Continent urinary diversion

Transcription

1 Critical Reviews in Oncology/Hematology 57 (2006) Continent urinary diversion Fiona C. Burkhard, Thomas M. Kessler, Rob Mills, Urs E. Studer Department of Urology, University of Bern, 3010 Bern, Switzerland Accepted 3 June 2005 Contents 1. Introduction Patient selection criteria Absolute and relative contraindications Patient associated factors Important aspects of surgical technique Nerve sparing (Figs. 1 3) Reservoir construction Reservoir shape Reservoir size Metabolic aspects of continent urinary diversion Consequences of resection/malabsorption Consequences of urine in contact with bowel Reflux prevention Follow up after continent urinary diversion Results Impact on survival Impact on quality of life Impact on sexual function Urinary continence after continent urinary diversion Urinary continence after orthotopic bladder substitutes Urinary continence after continent catheterisable reservoirs Summary Reviewers References Biography Abstract During the last decade continent urinary diversion, especially orthotopic bladder substitution has become increasingly popular following radical cystectomy for bladder cancer. In general, if sphincter sparing surgery is possible, orthotopic bladder substitution is performed, if not then continent catheterisable reservoirs are a viable option. Strict patient selection criteria and improved surgical technique have had a positive influence on outcome, not only on survival but also on quality of life issues. It is becoming increasingly obvious, that a nerve sparing surgical technique not only improves sexual function but also continence. In addition, the length of the intestinal segment has an influence on continence and the degree of metabolic consequences, which are discussed in detail. Postoperative surveillance and instruction of patients is of utmost value for good functional results. Overall patient satisfaction and quality of life seem comparable in the various types Corresponding author. Tel.: ; fax: /91. address: urs.studer@insel.ch (U.E. Studer) /$ see front matter 2005 Elsevier Ireland Ltd. All rights reserved. doi: /j.critrevonc

2 256 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) of continent urinary diversions, and improved when compared to a urinary stoma. Continent urinary diversion offers a good quality of life with few long-term complications and should be considered the treatment of choice in the majority of patients, independent of sex Elsevier Ireland Ltd. All rights reserved. Keywords: Transitional cell carcinoma; Cystectomy; Continent urinary diversion; Orthotopic bladder substitution 1. Introduction Cystectomy is the gold standard for the treatment of certain forms of bladder cancer with the best chances of survival. Acceptance of cystectomy and the resulting need for urinary diversion is easier for both patients and doctors if the problem of an extracorporeal urine sack and lost sexuality can be avoided. Self-esteem and health related quality of life issues have been reported to be improved following continent urinary diversion [1]. Today there are excellent options for urinary diversion such as an orthotopic bladder substitute, the preferred method of bladder substitution, or catheterisable continent reservoirs. These, combined with more refined nerve sparing surgical techniques, allow patients an almost completely normal, socially integrated lifestyle. In addition, improved surgical technique and modern perioperative care have lowered the complication rates from 35 to 10% and operative mortality rates from almost 20% to less than 2% [2,3]. Most of the consequences or potential surgical complications associated with continent urinary diversion are similar independent of the type of diversion and have to do with the use of bowel and the creation of a an ureteroenteric anastomosis. However, outcome after cystectomy and continent urinary diversion is not only dependent on surgical technique, restrictive patient selection and expert patient management after surgery are of equal importance. 2. Patient selection criteria Preoperative checklist: 1. [Urinary continence] 2. [No tumour in the urethra, paracollicular (male) or bladder neck region (female)] 3. Serum creatinine 150mmol/L 4. Adequate liver function 5. Adequate bowel function 6. Adequate intellectual capacity, dexterity and mobility 7. Patient agreement to indefinite follow-up with in [] are only applicable for orthotopic diversion All patients in whom oncologically the indication for cystectomy is given, who have no clinical or radiological evidence (computed tomographic scans, CT or magnetic resonance imaging, MRI) of disease where it is doubtful whether complete en bloc resection is possible, signs of pelvic lymphadenopathy or distant metastasis (biplanar chest radiography or CT, abdominal CT and nuclear bone scan) are candidates for continent urinary diversion. For orthotopic bladder substitution intact urethral function preoperatively and sphincter sparing surgery are absolute prerequisites. In men, we recommend biopsies from the prostatic urethra bilaterally at the level of the verumontanum and evidence of invasive cancer or CIS in the biopsy is considered a contraindication for orthotopic bladder substitution. We prefer preoperative biopsies to intraoperative frozen sections, as the reliability of paraffin embedded sections is higher and because preoperative knowledge of the type of urinary diversion planned minimizes patients insecurity. This also allows specific in-depth information and explanation of the surgery and postoperative management without having to explain all possible alternatives and overwhelming patients with information. In women with transitional cell carcinoma biopsies are taken from the bladder neck and the trigone and more than a 1 cm margin from the bladder neck should be free of tumour and/or carcinoma in situ. This is due to the fact, that the distance between the male bladder neck and the sphincter is approximately 4 cm, whereas in women these structures are continuous and a strong association between occurrence at the bladder neck and tumour in the anterior vaginal wall or in the urethra has been described [4]. In addition, it has been shown that most invasive tumours in female patients are in the trigonal area. This necessitates resecting the anterosuperior vaginal wall and wide excision of the dorsomedial bladder pedicle in the paravaginal region (Figs. 1 and 2). This is indisputably close to the sphincter apparatus and its nerves. However, if no evidence of tumor is found at the bladder neck, then urethral sparing surgery and orthotopic bladder substitution is now considered the treatment of choice. In the remaining patients a continent catheterisable reservoir is a good option Absolute and relative contraindications Compromised kidney function, due to chronic renal failure or long-term obstruction, with a serum creatinine over mol/l is generally considered an absolute contraindication for continent diversion of any type [5]. However, patients with bladder tumours leading to ureteral obstruction and as a result significant creatinine elevations may recover sufficient kidney function to allow diversion, once the obstruction is relieved. A percutaneous nephrostomy tube, placed prior to surgery may give better indication of true renal function. Another absolute contraindication is severe hepatic dysfunction as reabsorption of ammonium can lead

3 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) Fig. 1. Innervation of the pelvic organs in the female. The arrow indicates the line of dissection on the non-tumor bearing side when performing nerve sparing cystectomy. to hyperammonemia. The reason that both renal and hepatic insufficiency are considered contraindications is that in these patients the metabolic consequences of continent urinary diversion cannot be adequately compensated. Chronologic age or prior radiation therapy are not absolute contraindications, but time needed to recover and regain urinary continence is longer than in younger patients [6]. In patients with prior pelvic irradiation complications are likely to be more prevalent, but in theory if sphincter function is intact these patients may be managed by orthotopic reconstruction. One exception may be women with prior excessive radiation to the urethra. In the case of impaired intestinal function, particularly due to inflammatory bowel disease or prior radiation therapy the patient may be better served by a short bowel conduit, where less intestinum is needed for urinary diversion. Lymph nodes found to be positive during surgery are also not considered an absolute contraindication for continent urinary diversion Patient associated factors In continent urinary diversion the most important factor determining successful outcome is that patients have the intellectual capacity to understand their new bladder and how it works and are willing to comply meticulously to instructions concerning bladder function postoperatively. If these prerequisites are not given, an alternative urinary diversion should be considered as not the surgery itself, but the postoperative management of patients with bladder substitutes and continent catheterisable reservoirs is the most important factor determining long-term outcome. 3. Important aspects of surgical technique There are two important surgical aspects influencing functional outcome in patients after radical cystectomy and continent urinary diversion. Nerve and sphincter sparing surgical technique has a relevant impact on quality of life factors, such as sexual function and urethral function, which maintains continence. The length of intestinal segment used is an act of balance between reservoir size, metabolic complications (the smaller the intestinal segment the less metabolic complications, the more likely incontinence) and continence. For example, the longer the bowel segment used, the better the capacity and pressure characteristics, but the more likely metabolic complications and risk of infected residual urine Nerve sparing (Figs. 1 3) Mixed sympathetic and parasympathetic fibers pass from the pelvic plexus to supply the pelvic viscera with a dual autonomic innervation. The pelvic plexus consists of a variable network of both sympathetic (T10 L2) and parasympathetic (S2 S4) fibers and is located lateral to the rectum, bladder, seminal vesicles and prostate/vagina. Somatic motor innervation passes from Onuf s nucleus in the anterior horn of the sacral segments S2 S4 and travels to the external urethral sphincter mainly via an extrapelvic, but also via an intrapelvic branch of the pudendal nerve. Intact sympathetic innervation is paramount for competent proximal urethral function and ejaculation in men. Parasympathetic innervation is responsible for erection, vascular engorgement of clitoris and vagina as well as lubrication. Coordination of sexual response, pelvic floor function and external urethral function are dependent on intact somatic innervation from the pudendal nerve. Considering the functional consequences of damage to these nerves we believe that nerve sparing cystectomy should always be attempted if radical tumor resection is not compromised. Nerve sparing is not only of advantage in patients undergoing ileal orthotopic bladder substitution. Patients with other forms of urinary diversion and intact

4 258 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) Fig. 2. In women, the dissection extends no further than the 2 or 10 o clock position on the non-tumor bearing side (A) preserving the autonomic nerves (C) and extends as far as the pararectal region on the tumor bearing side (B). sexual function preoperatively may also profit from nerve sparing. Unilateral nerve sparing is attempted on the non-tumor bearing side in patients with unilateral tumors. On the tumor bearing side, no nerve sparing is attempted as the dorsomedial pedicle of the bladder is resected along the pararectal/presacral plane to remove the lymphatics draining the bladder base (Figs. 1 3). In patients with tumors located at the bladder dome, the anterior bladder wall or in patients with multifocal T1 G3 bladder cancer with or without carcinoma in situ bilateral nerve sparing can be attempted Reservoir construction Reservoir shape There is general consent, that orthotopic bladder substitutes should have a good capacity with low pressure characteristics and at the same time a minimal reabsorptive surface. Therefore, urodynamic and metabolic factors dictate that the intestinal bladder substitute should be spherical. When using ileum this is probably best achieved by making the reservoir from four sections. Advantages of the spherical reservoir are (Fig. 4): (1) a maximum volume to surface area ratio, with maximal volume and minimal reabsortive surface area; (2) detubularization and cross-folding of the bowel segment render coordinated contractions impossible and minimize the development of high pressure peaks; (3) a spherical reservoir results in a maximum radius and according to Laplace s law (pressure = tension/radius) this larger radius provides for a lower end-filling pressure and (4) with maximum radius, wall tension is also maximal and thus a sensation of filling is more likely. If the reservoir is made from four transected crossfolded segments, it depends on the surgeons preference which

5 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) Fig. 3. Innervation of the pelvic organs in the male. The arrow indicates the line of dissection on the non-tumor bearing side when performing nerve sparing cystectomy. technique is applied, but it is irrelevant whether the segments are folded as an M, a W or as a cross-folded U (Goodwin s cup-patch principle), which we prefer for its simplicity [7] Reservoir size Viscoelasticity of the bowel wall and modulation of the smooth muscle tone by its nerve supply influence function of the bladder substitute, and are factors that cannot be influenced by the surgeon. Volume of the reservoir, however, plays an important role and is dictated by surgical technique. When using ileum, we recommend to use a segment of cm for the reservoir (Fig. 4), with an additional cm for the afferent tubular segment. This is little and initially results in a small volume, high-pressure reservoir. Therefore, it is of utmost importance to actively expand the reservoir by a patient guided process. Under the guidance of the urologist or a specially trained nurse, patients are instructed to gradually increase their micturition intervals up to 4 h. When complaining of leakage, they are encouraged to adhere to the micturition interval, as leakage is a sign of elevated Fig. 4. A spheroidal reservoirs volume and surface do not change in parallel. The amount of bowel to be used is limited as is shown theoretically in this figure. The example is based on the clinical experience, that 40 cm of bowel can be used for a reservoir with a volume of 500 ml (centre). If twice the amount of bowel is used, the reabsorptive surface doubles and the storage time is almost tripled (3-fold increase in volume) (right). On the other hand a reservoir made from 20 cm of bowel (left) would be too small and the pressure too high when filled to capacity. pressure, which is required to expand the reservoir. Making the reservoir from a larger segment of bowel, e.g. 60 cm appears enticing, as with a 50% increase in bowel surface almost double the capacity can be obtained. Initially results do appear better with longer micturition intervals and better postoperative continence. However, the advantage is only temporary and a floppy bag may develop with increased risk of chronically infected residual urine and the need for lifelong intermittent self-catheterisation Metabolic aspects of continent urinary diversion Consequences of resection/malabsorption Metabolic consequences of using bowel to form a new bladder are related mainly to bowel type and length [8]. Patients with malabsorption due to bowel resection may have troublesome symptoms without long-term nutritional consequences or, remain asymptomatic until serious complications prevail. Therefore, if possible the ileocoecal valve and the terminal ileum should be retained in order to avoid longterm complications [10]. Special attention should be paid to patients with previous radiotherapy as bowel resection following radiotherapy increases the risk of malabsorption due to the reduced ability of the remaining gut to compensate. As ileum is now most commonly used for bladder reconstruction, it is the only gut segment discussed here. The ileum is the sole site of Vitamin B12 and of bile acid absorption. Resection of up to 60 cm of ileum in patients who retain their terminal ileum and ileocoecal valve is generally well tolerated. A resection of cm may reduce bile acid reabsorption, but increased hepatic production maintains the overall bile acid pool [9]. Vitamin B12 absorption should remain normal if the terminal ileum is not affected. If more than 100 cm of ileum is resected, lipid malabsorption is virtually inevitable and there is also fat-soluble Vitamin (A, D, E und K) malabsorption. Oxalate absorption

6 260 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) is increased, because the unabsorbed fat saponifies with calcium, which is no longer available to form a chelate with oxalate. This raises serum and urinary oxalate levels and urinary stones may result. The altered bile acid metabolism reduces the solubility of cholesterol in bile and cholesterol biliary stones may result. Cholestyramine can bind malabsorbed bile acids and treat the cathartic diarrhea, but the other consequences of bile acid malabsorption are not corrected and the chronic use of cholestyramine should be avoided. The ileocoecal valve plays an important role in controlling the rate of delivery of ileal contents as well as limiting reflux of colonic contents into the terminal ileum and the ileocoecal valve should be preserved or consideration should be given to reconstruction in all cases to avoid diarrhea. In patients with a Mainz pouch, which involves resection of the ileocoecal valve and terminal ileum 32% were found to have Vitamin B12 and 11% folic acid levels below normal, approximately 10% gallbladder or kidney stones and more than one third chronic acidosis [10] Consequences of urine in contact with bowel The main goal of this intestinal segment is to produce isoosmotic contents. For this reason it has the ability to rapidly absorb or secrete sodium and chloride ions in response to the osmolarity of its contents. This can result in a counteraction to the renal regulation of body sodium and acid base balance and particularly patients with renal impairment are at great risk of metabolic complications. When long or proximal ileal segments are used salt loss can also occur, mainly early after surgery when the patient is encouraged to drink a lot of liquid and therefore produces hypotonic urine. The ileal segment then secretes sodium and chloride to try to restore urinary osmolality. Unless the patient takes sufficient extra salt, a salt-losing hypovolemic state can occur. Potassium absorption from the reservoir, in exchange for sodium, saturates the renal exchange mechanism and reduces hydrogen ion excretion and thus a hyperkalemic, hypochloremic acidosis ensues. Further sodium secreted into the reservoir lumen is compensated by the uptake of protons from the urine if this does not contain sufficient sodium. This results in acidosis, which is further enhanced by absorbed ammonium ions. This in turn affects bone metabolism through a decrease in calcium reabsorption and impaired Vitamin D metabolism. The resulting chronic acidosis may produce osteoporosis or osteomalacia. Mild metabolic acidosis can be expected in up to 50% of patients, particularly in the early postoperative phase after continent urinary diversion using an ileal segment and may also depend on renal function. Later than 3 months postoperatively, only patients with impaired renal function require sodium bicarbonate supplementation if the reservoir is constructed from 40 to 45 cm of intestine. Shorter ileal segments may reduce acidosis but at the price of lesser capacity and increased early postoperative continence. These two factors need to be balanced against each other when performing continent urinary diversion Reflux prevention Reflux prevention in orthotopic bladder substitutes remains a controversial issue and although excellent longterm results have been described without antireflux procedures, many surgeons continue to perform antirefluxive procedures. Although not confirmed by clinical studies, experiments in animals have revealed, that both reflux and urinary tract infections are required to develop reflux nephropathy [11]. For reflux to occur the pressure in the bladder must be higher than in the ureters, this is the state in normal, contractile bladders. Orthotopic bladder substitutes are low-pressure reservoirs, as detubularized bowel segments are incapable of coordinated contraction and pressure generation. Micturition is initiated by relaxation of the bladder outlet and an increase in abdominal pressure throughout the abdomen, resulting in identical pressure in both the bladder and the ureters, making reflux impossible. In addition, urine in the bladder substitute is sterile. In the event of major pressure peaks in the reservoir, exceeding urethral closure pressure, the external urethral sphincter acts as a safety valve and urinary leakage occurs. In addition, the afferent tubular segment itself has certain dynamic antirefluxive properties due to coordinated peristalsis [12]. In a prospective randomized trial in 70 patients we compared a flap valve type of antireflux procedure (intussuscepted ileal nipple or split cuff nipples) with a cm long afferent tubular segment with the ureters implanted open end-to-side similar to the Nesbit technique [13,14]. After a median observation time of several years functional results and serum values were comparable. Severe obstruction was found in 13% (9/67) of renal units with antireflux nipples and 3% (2/70) of renal units with afferent tubular segments, resulting in a statistically significant difference. Overall a significantly higher complication rate was found in patients with antireflux nipples. In our opinion possible minimal benefit from preventing the radiographic finding of reflux must be carefully weighed against the higher complication rate. While the possible damage to the kidneys by reflux in a low pressure system is still under debate, there is no doubt that ureteric obstruction due to scarring of an antireflux valve can lead to irreversible kidney damage. Reflux prevention in continent catheterisable reservoirs is generally considered to be necessary. As the urine in the continent catheterisable reservoir is often colonized by bacteria and there is no safety valve as in the orthotopic bladder, most surgeons feel that the ureteroenteric anastomosis should be non-refluxing. Here again one must weigh the risk of ureteroenteric stricture against the benefit of preventing reflux and consecutive pyelonephritis and decline of renal function. In most cases we perform an anti refluxive procedure as described by Abol-Enein [15]. However, in cases of preexisting dilated ureters with a potential loss of ureteral peristalsis and potentially a higher risk of obstruction a simple end-to-side implantation may be of benefit to the patient.

7 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) Overall the risk of stenosis is independent of the type of continent diversion and ranges from 2 to 9% [16 18], depending on the technique. The more complicated the surgery, the higher the stenosis rate. 4. Follow up after continent urinary diversion Meticulous postoperative surveillance and instruction of the patient are of utmost importance for good long-term results. After catheter removal, any bacteriuria must be treated until the urine is sterile. Causes of bacteriuria, e.g. incomplete emptying, strictures, hernia etc. should be recognized and treat accordingly. Initially patients with orthotopic bladder substitutes should be instructed to void every 2 h, first while sitting by relaxing the pelvic floor and if necessary, by abdominal straining without pressing downwards. Body weight and blood gases are regularly examined following catheter removal, to identify potential fluid and electrolyte alterations. It is important to recognize the clinical signs of metabolic acidosis, such as nausea, lack of appetite, fatigue, weakness and ultimately vomiting. Particularly, during the early postoperative recovery phase, supplement of sodium bicarbonate should be generous (2 6 g per day). Patients without or after compensation of metabolic disturbances, are instructed to retain urine for 3 h and then 4 h (even if they become incontinent earlier) to achieve a maximal voiding volume of 500 ml. This is essential to gain continence, especially at night. If patients try to avoid losing urine by voiding more frequently, they may indeed stay continent during day time, but they maintain a low capacity reservoir with high pressure characteristics, which will inevitably lead to nocturnal and sometimes also diurnal incontinence. Furthermore, as explained earlier the lacking sensation of fullness (high pressure but low wall tension) further supports incontinence. Alcohol and sleeping pills should be avoided as they relax the pelvic floor, which in turn leads to incontinence. In general postoperative surveillance is the same for any form of continent diversion. Patients with continent catheterisable reservoirs are also instructed to gradually increase catheterization intervals, however due to the lack of an overflow valve capacity can be increased more rapidly. They should also empty the reservoir after approximately 4 h and not exceed a volume of around 500 ml. 5. Results 5.1. Impact on survival The choice of urinary diversion should not have a major impact on survival, as nerve sparing is only attempted if reasonable from the oncological standpoint. Yossepowitch et al. examined the impact of orthotopic bladder substitutes on outcome after cystectomy [19]. There was no significant difference in cancer specific survival between contemporary orthotopic bladder substitutes and ileal conduits. The low local recurrence rate of 11% was confirmed by our larger series of 500 patients [20]. Urethral recurrence is rare and occurs in between 2 and 5% of patients, the highest risk is in patients with multifocal primary tumors or concomitant carcinoma in situ [21]. In the case of urethral recurrence transurethral resection or instillation therapy is feasible [22] Impact on quality of life Next to survival, patients sense of well being is influenced by long-term, treatment induced changes. There does not appear to be any relevant differences in postoperative quality of life between orthotopic bladder substitutes and continent catheterisable reservoirs and quality of life is generally considered good [23 25]. The lack of differences may, at least in part, be due to rather non-specific QoL questionnaires, which did not focus on the specific problems of patients after radical cystectomy, living with one or the other form of urinary diversion. Causes of distress in patients after cystectomy and continent urinary diversion are compromised sexual (especially in men), urinary and to a lesser extent bowel function [26]. In a study by Mansson et al. validated questionnaires were sent to patients by the institute where the surgery was performed or an independent institute [27]. Patients reported a significantly increased incidence of bowel problems, when questioned by an independent institution. This may exemplify a potential weaknesses of subjective outcome studies in general. Gratitude for a life saving operation or the need to remain in continuous follow up may influence patients statements. Nonetheless cystectomy with a continent urinary diversion is a major surgical intervention with the typical consequences on sexual, urinary and bowel function to which patients do need to adapt postoperatively Impact on sexual function Sexual function after surgery is not influenced by the type of continent urinary diversion, at least not objectively. Although awareness of pelvic organ innervation and nerve sparing surgical techniques is increasing, literature concerning the effect of nerve sparing on sexual function and continence is sparse. Recovery rates of erectile function range from 33 to 100% with or without sparing of the prostate (Table 1). It seems that various factors influence the effect of nerve sparing surgery. In a multivariate analysis of factors influencing erectile function we found that a nerve sparing cystectomy technique and younger age were independently associated with more frequent recovery of erectile function [6]. Not surprisingly the best results were found after bilateral preservation of the neurovascular bundles. Zippe et al. [28] investigated sexual dysfunction in men after radical cystectomy using the validated abridged five-item International

8 262 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) Table 1 Reported recovery of erectile/sexual function after nerve sparing cystectomy Authors Erectile/sexual function recovery Nerve sparing Time point of evaluation Schoenberg et al. [47] 42% (33/78) Yes 1 year Vallancien et al. [30] 82% (50/61) Yes a 1 year Meinhardt and Horenblas [31] 79% (19/24) Yes a 1 year Colombo et al. [32] 100% (27/27) Yes a 1 year Muto et al. [33] 95% (58/61) Yes a 6 months Terrone et al. [34] 93% (26/28) Yes a 2 months Kessler et al. [6] 60% (38) b Bilateral 2 years b 33% (218) b Unilateral 13% (75) b No Zippe et al. [28] 50% (8/16) Yes 1 year 3% (1/33) No a Prostate sparing. Kaplan Meier method. Index of Erectile function and found that fifty percent of the men with nerve sparing surgery remained potent, whereas only 3% of the men without nerve sparing retained sexual function. Several authors reported excellent results regarding sexual function with a seminal vesicle and prostate sparing cystectomy [29 34]. If prostate sparing cystectomy with subsequent orthotopic bladder substitution is attempted, then preoperative TUR-P or adenoma enucleation during cystectomy is mandatory not only to exclude transitional cell carcinoma but also to avoid outlet obstruction by prostatic tissue and subsequent post void residuals. Although the results of prostate sparing cystectomy in carefully selected patients suggest no adverse effects on cancer management, further experience especially in the long-term is required before recommending this type of procedure as a valid option in the management of muscle invasive bladder cancer, which is most frequently situated in the trigonal area. In the female, data concerning the effect of radical cystectomy on sexual function is rare. Volkmer et al. [35] reported that all aspects of female sexuality may remain unchanged following non-nerve sparing cystectomy and ileal orthotopic bladder substitution as long as sexual activity is not impaired for other reasons. However, these results are hampered by the retrospective study design where preoperative sexual function was evaluated 1 17 years following cystectomy. In addition, even though no attention was paid to nerve sparing, in some cases nerve sparing may have been performed inadvertently. In a recent prospective investigation [28] using the Index of Female Sexual Function (IFSF) questionnaire only about half of the 27 patients were able to have successful vaginal intercourse following non-nerve sparing radical cystectomy. The most common symptoms reported by these patients included diminished sexual desire, decreased vaginal lubrication, dyspareunia, and diminished ability or inability to achieve orgasm. This could be due to a non-nerve sparing technique since autonomic nerve damage may result in insufficient lubrication causing vaginal dryness and dyspareunia [36] Urinary continence after continent urinary diversion Urinary continence after orthotopic bladder substitutes Daytime and nighttime continence rates after orthotopic bladder substitutes range, independent of nerve sparing surgery, from 87 to 98% and 72 to 95%, respectively [6,16,17,27,30]. Various factors are likely to influence these results, one being that in many patients the nerves are, at least partially, inadvertently spared. Differences in the patient populations, risk factors, selection criteria, length of follow-up, definition of continence and statistical methods also make it difficult to compare results. In a recently published study from our institution using multivariate analysis to assess factors independently influencing continence after cystectomy and orthotopic bladder substitution daytime continence was better and achieved earlier in patients with preservation of both or one neurovascular bundle than in those without nerve sparing [6]. In women, the role of nerve sparing on voiding function following orthotopic bladder substitution is of intense debate. In our small series using a nerve sparing technique we observed a daytime and nighttime continence of 100 and 89%, respectively assessed by questionnaire after a median followup of 19 months [37]. Excellent results were also reported in other series where no special attention was paid to nerve sparing [38,39]. However, Stenzl et al. [40] reported a considerably higher catheterization rate of 72% without nerve sparing compared to 0 9% when preservation of the nerves was attempted Urinary continence after continent catheterisable reservoirs The incidence of incontinence after continent catheterisable reservoirs is difficult to determine due to a lack of standard terminology, the use of non-validated questionnaires and retrospective evaluation. In a review by Rowland et al. an overall incontinence rate of 3.2% was found [41].

9 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) This rate varied among the different continence mechanisms. Of patients with intussucepted nipples 5.8%, with tunneled appendix 3% and with stapled plicated ileocecal valves 0.6% were incontinent. Other reported incontinence rates in larger series range from 6.7% (Florida pouch) [42] and 28% (Indiana pouch) [43]. In a recent large series Abol-Eneim et al. reported a 94.6% day- and nighttime continence [44]. Patients catheterized at four to five hourly intervals during the day and one to two times at night. They also found 12% long-term complications, including difficult catheterisation in 5 and 2% retention. In Rowland s review these problems occurred in 8% of patients, once again with differences between the tunnelled appendix (18%), the intussuscepted valve (9%) and the stapled plicated vlave (3%). Stomal problems are one of the most common problems in this type of urinary diversion, with reported reoperation rates ranging from 22 to 49% [45]. In two recent large series with a long-term follow up stomal stenosis was reported in 4 and 15% with difficulty catheterising in 1.5 and 10% [42,43]. These complications can be minimized at the time of surgery by avoiding kinking of the continence mechanism, creating a tension free muco-cutaneous anastomosis and by fixing and stabilizing the continence mechanism [46]. In the case of incontinence further evaluation is needed to determine the cause. Potential reasons being uninhibited reservoir contractions, a low compliance high-pressure reservoir, an incompetent continence mechanism or a via falsa. In this setting urodynamics and cystoscopy can be helpful to determine the underlying cause, which then needs to be treated, respectively. 6. Summary Today most patients considered candidates for cystectomy, independent of sex are candidates for orthotopic bladder substitution. Intact urethral function is an absolute prerequisite for orthotopic bladder substitution, otherwise a continent catheterisable reservoir is a valid alternative. Increasing attention to surgical technique, such as nerve sparing procedures has resulted in improved functional outcome and quality of life. Meticulous follow up and attention to detail is a prerequisite for good results. If attention is paid to these factors, continent urinary diversion following cystectomy has low short- and long-term complications and offers the best quality of life. Reviewers Prof. Dr. med. Daniel Ackermann, Facharzt FMH für Urologie, Hirslanden Klinik Aarau, Schänisweg, 5001 Aarau, Switzerland. Prof. Dr. med. Jürgen Gschwend, Leitender Oberarzt, Urologische Universitätsklinik Ulm, Klinik für Urologie und Kinderurologie, Prittwitz-Strasse 43, D Ulm, Germany. Prof. Dr. med. Arnulf Stenzl, Ärztlicher Direktor/Chairman, Klinik für Urologie/Department of Urology, Hoppe-Seyler-Str. 3, D Tuebingen, Germany. References [1] Hobisch A, Tosun K, Kinzl J, et al. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol 2000;18: [2] Gschwend JE, Fair WR, Vieweg J. Radical cystectomy for invasive bladder cancer: contemporary results and remaining controversies. Eur Urol 2000;38: [3] Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001;19: [4] Coloby PJ, Kakizoe T, Tobishu K, Sakamoto M. Urethral involvement in female bladder cancer patients: mapping of 47 consecutive cysto-urethrectomy specimens. J Urol 1994;152: [5] Skinner DG, Studer UE, Okada K, et al. Which patients are suitable for continent urinary diversion or bladder substitution following cystectomy or other definitive local treatment. 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10 264 F.C. Burkhard et al. / Critical Reviews in Oncology/Hematology 57 (2006) [21] Gschwend JE. Bladder substitution. Curr Opin Urol 2003;13: [22] Varol C, Thalmann GN, Burkhard FC, Studer UE. Treatment of urethral recurrence following radical cystectomy and ileal bladder substitution. J Urol 2004;172: [23] Mansson A, Davidsson T, Hunt S, Mansson W. The quality of life in men after radical cystectomy with a continent cutaneous diversion or orthotopic bladder substitution: is there a difference? BJU Int 2002;90: [24] Hart S, Skinner EC, Meyerowitz BE, Boyd S, Lieskovsky G, Skinner DG. Quality of life after radical cystectomy for bladder cancer in patients with an ileal conduit, cutaneous or urethral kock pouch. J Urol 1999;162: [25] Kitamura H, Miyao N, Yanase M, et al. Quality of life in patients having an ileal conduit, continent reservoir or orthotopic neobladder after cystectomy for bladder carcinoma. Int J Urol 1999;6: [26] Henningsohn L, Wijkstrom H, Dickman PW, Bergmark K, Steineck G. Distressful symptoms after radical cystectomy with urinary diversion for urinary bladder cancer: a Swedish population-based study. Eur Urol 2001;40: [27] Mansson A, Henningsohn L, Steineck G, Mansson W. Neutral third party versus treating institution for evaluating quality of life after radical cystectomy. Eur Urol 2004;46: [28] Zippe CD, Raina R, Massanyi EZ, et al. Sexual function after male radical cystectomy in a sexually active population. Urology 2004;64:682 5, discussion [29] Spitz A, Stein JP, Lieskovsky G, Skinner DG. Orthotopic urinary diversion with preservation of erectile and ejaculatory function in men requiring radical cystectomy for nonurothelial malignancy: a new technique. J Urol 1999;161: [30] Vallancien G, Abou El Fettouh H, Cathelineau X, Baumert H, Fromont G, Guillonneau B. Cystectomy with prostate sparing for bladder cancer in 100 patients: 10-year experience. J Urol 2002;168: [31] Meinhardt W, Horenblas S. Sexuality preserving cystectomy and neobladder (SPCN): functional results of a neobladder anastomosed to the prostate. Eur Urol 2003;43: [32] Colombo R, Bertini R, Salonia A, et al. Overall clinical outcomes after nerve and seminal sparing radical cystectomy for the treatment of organ confined bladder cancer. J Urol 2004;171: , discussion [33] Muto G, Bardari F, D Urso L, Giona C. Seminal sparing cystectomy and ileocapsuloplasty: long-term followup results. J Urol 2004;172: [34] Terrone C, Cracco C, Scarpa RM, Rossetti SR. Supra-ampullar cystectomy with preservation of sexual function and ileal orthotopic reservoir for bladder tumor: twenty years of experience. Eur Urol 2004;46:264 9, discussion [35] Volkmer BG, Gschwend JE, Herkommer K, Simon J, Kufer R, Hautmann RE. Cystectomy and orthotopic ileal neobladder: the impact on female sexuality. J Urol 2004;172: [36] Keating JP. Sexual function after rectal excision. ANZ J Surg 2004;74: [37] Mills RD, Studer UE. Female orthotopic bladder substitution: a good operation in the right circumstances. J Urol 2000;163: [38] Ali-El-Dein B, Gomha M, Ghoneim MA. Critical evaluation of the problem of chronic urinary retention after orthotopic bladder substitution in women. J Urol 2002;168: [39] Lee CT, Hafez KS, Sheffield JH, Joshi DP, Montie JE. Orthotopic bladder substitution in women: nontraditional applications. J Urol 2004;171: [40] Stenzl A, Jarolim L, Coloby P, et al. Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors. Cancer 2001;92: [41] Rowland RG. The long-term study of continent cutaneous urinary reservoirs and neobladders. J Urol 1996;155:1217. [42] Webster C, Bukkapatnam R, Seigne JD, et al. Continent colonic urinary reservoir (Florida pouch): long-term surgical complications (greater than 11 years). J Urol 2003;169: [43] Holmes DG, Thrasher JB, Park GY, Kueker DC, Weigel JW. Longterm complications related to the modified Indiana pouch. Urology 2002;60: [44] Abol-Enein H, Salem M, Mesbah A, et al. Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients. J Urol 2004;172: [45] Skinner DG, Lieskovsky G, Boyd S. Continent urinary diversion. J Urol 1989;141: [46] Farnham SB, Cookson MS. Surgical complications of urinary diversion. World J Urol 2004;22: [47] Schoenberg MP, Walsh PC, Breazeale DR, Marshall FF, Mostwin JL, Brendler CB. Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup. J Urol 1996;155: Biography Professor U.E. Studer is Director of the Department of Urology at the University Hospital in Bern, Switzerland. He is an internationally renowned expert in urologic oncology and urinary diversion.