Japanese Journal of Clinical Oncology Advance Access originally published online on June 27, 2006
Japanese Journal of Clinical Oncology 2006 36(7):418-424; doi:10.1093/jjco/hyl047
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© 2006 Foundation for Promotion of Cancer Research
Eight Year Experience with Studer Ileal Neobladder
Department of Urology, Iwate Medical University School of Medicine, Morioka, Japan
For reprints and all correspondence: Wataru Obara, Department of Urology, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka 020-8505, Japan. E-mail: watao{at}iwate-med.ac.jp
Received February 19, 2006; accepted April 1, 2006
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Abstract |
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Background: We reviewed our experience with orthotopic continent urinary reconstruction after radical cystectomy to assess the feasibility of Studer ileal neobladder for patients who are relatively advanced in age.
Methods: Between June 1997 and January 2005, 31 consecutive male patients (mean age: 64 years) underwent lower urinary tract reconstruction after radical cystoprostatectomy. Perioperative and late complications, functional outcome of the neobladder, urinary continence, upper urinary tract status and renal function with the metabolic balance were evaluated in all patients.
Results: There was no perioperative death, and perioperative and late complication rates were 22.8% and 3.3%, respectively. All 31 patients were able to void urine. Although the mean maximal functional capacity of the neobladder was 122 ml at 1 month after surgery, the mean capacities were increased to 247 ml at 6 months and 321 ml at 1 year after the operation. Urodynamic results at 3 years showed unchanged characteristics as to micturition pattern and volume of residual urine and neobladder pressure remained low. Of 31 patients, 29 (93.5%) showed excellent or good continent status during the daytime and 9 (29%) were completely dry at night in 6 months after surgery. Even at 3 years after the operation, only 1 patient out of 21 evaluated required single pad during nighttime. In a subgroup of five patients (24%) older than 70 years, the status of continence was satisfactory at 3 years after the reconstruction, and only one patient required a pad during the night at that point. Renal function levels and metabolic status were comparable before surgery and 3 years after surgery. Moreover, pyelography revealed normal condition of the upper urinary tract 1 month postoperatively in almost all cases.
Conclusions: These data provide evidence that Studer ileal neobladder is a satisfactory surgical technique for selected patients at our institute. Even for patients older than 70 years, this urinary diversion procedure is safe in terms of morbidity and efficacious as indicated by functional outcome.
Key Words: Studer ileal neobladder • orthotopic continent urinary reconstruction • bladder cancer
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INTRODUCTION |
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Urinary diversion has a history of nearly 150 years (1), and the ileal conduit has long been considered the gold standard for urinary diversion. Orthotopic substitution of the bladder following cystectomy is currently well established. This procedure, which requires a bowel segment, avoids an abdominal stoma and may offer an improved quality of life for patients undergoing radical cystectomy for bladder cancer (2–5). In 1989, Studer et al. (6) described low-pressure bladder substitution using a spherical reservoir consisting of four cross-folded ileal detubularized segments. This neobladder uses an afferent isoperistaltic ileal segment with direct ureteroileal anastomosis, which functions as an antireflex mechanism in order to protect the upper urinary tract.
Since 1997, we have adopted the Studer orthotopic bladder substitution following radical cystectomy in 31 male patients with invasive bladder cancer. In the present study, we reviewed the clinical outcomes of these patients to evaluate the relatively long-term results of this procedure, since there have been only a few long-term follow-up studies on this type of neobladder construction (7–9). The purpose of the study was to investigate whether Studer orthotopic bladder substitution is an ideal procedure with less complication, providing adequate pouch capacity, good continence and voluntary control of voiding without residual urine, and preservation of renal function.
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PATIENTS AND METHODS |
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PATIENTS
Between June 1997 and January 2005, 31 consecutive male patients underwent combined radical cystoprostatectomy and pelvic lymphadenectomy with urinary diversion by a Studer bladder substitute for the management of muscle invasive bladder cancer at our hospital and the affiliated hospitals. The ages at surgery ranged from 49 to 74 years with a mean age of 64 years. The mean follow-up period was 42 months (range 20–104 months). Before the operation, all patients received two or three courses of systemic chemotherapy consisting of a combination of methotrexate, vinblastine, adriamycin and cisplatin. The study of functional outcome was focused on 21 patients who remained cancer-free and were available for complete follow-up for at least 3 years after the surgery. The specific criteria for this selection are related to the disease stage, renal and liver function, and the patient's willingness to live with a neobladder and comply with the routine follow-up even in patients older than 70 years.
SURGICAL TECHNIQUE
The technique of the ileal bladder substitution has been described by Studer et al. (6,10). Briefly, an ileal segment 60 cm in length was isolated 
25 cm proximal to the ileocecal valve. The distal end of the ileal segment, 40–45 cm in length, was opened along its antimesenteric border. The afferent tubular ileal segment was 20 cm long initially and was later reduced to 14–16 cm. For the construction of the reservoir, the two medial borders of the opened U-shaped distal part of the ileal segment were oversewn with a single-layer seromuscular running suture. The bottom of the U was folded over onto the two ends of the U, thus producing a spherical reservoir consisting of four cross-folded ileal segments. Ureterointestinal anastomoses were performed by the Nesbit technique in an open end-to-side fashion at the proximal part of the ileal segment. After closing the lower half of the anterior wall and part of the upper half, the surgeon's finger was introduced through the ‘window’ to determine the most caudal part of the reservoir. A hole with a diameter of 5 mm was cut out of the pouch wall and four 2-0 polyglycolic acid seromuscular sutures were placed between the hole in the reservoir and the edge of the membranous urethra and a 18F silicone urethral catheter was inserted before tying the four sutures at 10, 2, 5 and 7 o'clock positions of the membranous urethra. Before completely closing the pouch, a ‘cystostomy’ tube using a 22F silicone catheter was placed into the reservoir.
On the 7th to 10th postoperative days, the ureteric stents were removed. After excluding fistula formation of the reservoir and leakage from the pouch–urethral anastomosis by ‘cystogram’ on the 14th day, the urethral catheter was removed. The patients were instructed to void every 2 h, first in a sitting position, by relaxing the pelvic floor and if necessary by abdominal straining (11). When the capacity of the reservoir had increased to over 100 ml, the ‘cystostomy’ tube was removed. In addition, bacteriuria if detected was treated until the urine was sterile. Complications were defined as perioperative if they occurred within 30 days after the operation and late if they occurred later than 30 days.
FOLLOW-UP
The patients were followed at regular intervals of 3 months for the first year and at least once a year thereafter. Of 31 patients, 21 were followed for more than 3 years. Lower urinary tract function and urinary continence were evaluated by interviews; post-void ultrasound of the reservoir to assess neobladder empting; and urodynamic studies including intrapouch pressure measurement, urethral pressure profilometry and uroflowmetry. Continence was strictly assessed and rated as excellent if the patient was completely dry at all times, good if there were occasional or sporadic episodes of leakage but no need for protection, fair if no more than a single pad was required in 24 h and unsatisfactory if more than 1 pad were required within 24 h. Incontinence was further divided into nocturnal or daytime (12). The status of the upper urinary tract was assessed by radiological assessment using intravenous pyeloureterography (IVP), and renal function with the metabolic status was also monitored by serum Urea nitrogen (normal: 9–20 ng/ml) and creatinine (normal: 0.4–1.1 mg/dl) with serum chloride (normal: 96–111 mEq/l) and arterial HCO3– (22–28 mEq/l). For IVP examination, 40 ml of nonionic contrast material was injected intravenously. Non-tomographic images of the abdomen and pelvis were obtained at 5, 15 and 30 min after administration of the contrast medium.
STATISTICAL ANALYSIS
Values are expressed as means plus or minus standard deviation (SD). Differences between means for the various group in the study were compared using the Student's t-test for independent population means and considered statistically significant when the P-values were <5%.
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RESULTS |
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In 31 patients, the mean time to perform the entire operation including radical cystoprostatectomy was 6 h and 22 min (SD: 1 h and 23 min). The mean blood loss was 1992 ml (SD: 671 ml).
PERIOPERATIVE AND LATE COMPLICATIONS
There was no perioperative death in 31 patients. Perioperative complications are shown in Table 1. Two patients (6.5%) had neobladder-unrelated and general early complications that can be expected from any major pelvic operation, including wound infection and rectal injury. One patient required ultrasound-guided drainage of the abscess. In another patient, a temporary colostomy was installed due to the rectal injury. Specific early complications directly related to the neobladder occurred in five patients (16.1%). Acute pyelonephritis (3 patients) was successfully managed with conventional antibiotic therapy. Stricture of the urethra–pouch anastomosis (1 patient) required temporary dilatation with the metal sounds. Hydronephrosis in a patient was confirmed on one side and was treated conservatively. Late complication occurred in only one patient. In this case, stricture of the urethral anastomosis was treated by transurethral incision of the urethra–pouch junction. No stone formation was observed in any patient (Table 1).
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FUNCTIONAL OUTCOME
All 31 patients were able to void urine, first in a sitting position and later in an upright position. The mean maximal functional capacity of the bladder substitute was 122 ml in the immediate postoperative period. Despite a small capacity in early postoperative period, the capacity increased gradually with time, reaching almost 250 ml and over 300 ml at 6 months and 1 year after the surgery, respectively, and was maintained almost constant thereafter (Fig. 1). At 6 months following the surgery, the volume of residual urine after voiding was <15 ml in all patients and it was maintained at
15 ml thereafter. There were also no significant differences of these parameters of the urodynamic study such as the maximum flow rate, average flow rate and pressure of maximum capacity in the postoperative periods. The mean maximum functional capacity was 374 ml and mean pouch-pressure of the capacity was 28.8 cm H2O at 3 years postoperatively. These values were almost the same as those during earlier postoperative periods.
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URINARY CONTINENCE
Table 2 shows urinary continence with time after surgery. At 6 months following the operation, 29 of 31 patients (94%) regained excellent or good urinary control and only 2 (6.5%) patients required a single protective pad during daytime. During nighttime, 9 out of 31 patients (29%) were completely dry, 14 (45%) had good control with sporadic episodes of minor leakage managed with timed voiding or fluid restriction, 6 (19%) had fair continence requiring only a single pad and 2 (6%) had unsatisfactory control requiring more than two pads. Both daytime and nocturnal urinary continence improved gradually with time after surgery. At 3 years after operation, all 21 patients had excellent or good continence and required no pad during the day; 20 (95.2%) had satisfactory control during nighttime and only one patient (4.8%) had nocturnal incontinence requiring a single pad to avoid leakage.
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Next, we evaluated the influence of patient's age at operation on the reservoir capacity, daytime frequency of urination, nocturia and continence rates (Table 3). During postoperative periods, there were no significant differences in reservoir capacity and the frequencies of urination during both daytime and nighttime among the aged groups. However, both daytime and nighttime continence rates were significantly lower in patients aged 70 years or older than in younger patients at 6 months, and the nighttime continence rates decreased significantly with aging at both 6 months and 1 year after operation. Furthermore, at 3 years after operation, the status of urinary continence was satisfactory in all 21 patients during daytime and only 1 patient required a pad during the night.
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UPPER URINARY TRACT STATUS
Clinically overt pyelonephritis with fever was diagnosed in 3 out of 31 patients in the first postoperative month. Since then, no episode of high fever due to bacteriuria was encountered. On IVP examination, dilatation of the upper urinary tract on the 30-min film was observed in 5 of 62 renoureteral units of 31 patients (16.1%) at 1 month after operation. Among all patients, unilateral hydroureteronephrosis was observed in only 1 renoureteral unit (3.2% of 31 patients), meanwhile the remaining 61 renoureteral units did not show any ectasia or obstruction during the entire IVP examination at 1 year after the surgery. In studies performed on 21 patients followed for over 3 years, none of the 42 units demonstrated dilatation or obstruction throughout the IVP examination from 1 year after surgery.
UREA NITROGEN AND CREATININE IN THE SERUM AND METABOLIC STATUS
Preoperative mean values of urea nitologen and creatinine were 18.7 mg/dl and 0.9 mg/dl, respectively, in 31 patients (Table 4). During follow-up, none of the patients demonstrated significant changes in serum urea nitrogen, creatinine and chloride levels in 3 years. None had hyperchloremic metabolic acidosis at 1 month after surgery.
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DISCUSSION |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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The requirements for an ideal intestinal bladder substitution are low pressure, adequate capacity and high compliance, which provide continence and voluntary control of voiding without residual urine. It is obvious that these factors facilitate a higher quality of life following orthotopic bladder substitution. The Studer orthotopic ileal neobladder has the advantages of satisfactory continence rate, absence of urinary leakage and freedom from intermittent catheterization (13). In addition, renal function is preserved, and intestinal malabsorption and fluid and electrolyte imbalances are avoided (5,9,10). These features have rendered the Studer bladder substitution one of the most ideal orthotopic urinary diversions. In the present study, we focused on the complication rate, functional outcome, continence rate and renal function level with the metabolic status of our experience of the Studer bladder substitute at our institution between 1997 and 2004.
The early and late complication rates in our series were 22.8 and 3.3%, respectively. These results are consistent with those of previously reported series, in which the perioperative complication rate ranged from 9 to 18% and the late complication rate ranged from 6 to 24%. Furthermore, there was no remarkable difference in types of complications between our cases and previously reported series (4–8).
The main mechanism for urinary control following radical cystectomy with orthotopic bladder substitution seems to be the same as that after radical prostatectomy, that is preservation of the periurethral sphincter mechanism and muscles of the pelvic floor (14). However, Parekh et al. (12) reported that patients with the bladder substitution achieve daytime control more rapidly than those undergoing radical prostatectomy, and stress urinary incontinence is rarely an issue. The intestinal neobladder has no detrusor sphincteric reflux that increases urethral closure pressure as bladder pressure increases (15). Also, unlike a normal bladder, there are no vesical sensory fibers allowing feedback to the brain to alert the patient when the reservoir is full, particularly at night (16). This point is further supported by our finding that after surgery at least 80% of our patients were completely dry or had leakage without need for protection during the day and night and consequently only one patient needed a pad during the night 3 years after operation.
Age has been proposed to be a risk factor for the development of daytime urinary incontinence in patients with neobladder substitution (12,17,18). Madersbacher et al. described that the continence status was achieved in 90% of patients older than 60 years at surgery while the percentage was elevated to 100% in those younger than 50 years, at a 5-year follow-up (9). However, in the report of Studer and Zingg, they emphasized that chronological age should not be considered as an absolute contraindication for the neobladder, but time for recovery and for achieving urinary continence tended to be longer than in younger patients (10). In our experience, we achieved 100% daytime continence at 3-year follow-up even in patients older than 70 years at surgery. Our success is probably attributed to careful selection of patients. In other words, we tried not to perform this type of urinary diversion in patients with poor incentive to learn a new voiding pattern such as timed voiding and voiding via abdominal straining after operation. The most important factor that induced the success of a bladder substitute was the mental capacity to understand the new bladder and how it functions, which was required even in patients older than 70 years.
The importance of an antireflux mechanism in patients undergoing orthotopic bladder substitution seems to be questionable, because the fate of the upper urinary tract depends on a combination of high bladder pressures, ureteric obstruction and chronically infected urine (16,19–21). Good long-term results have been reported for the isoperistatic long afferent segment known as the Studer's limb, where direct ureteroileal anastomosis was performed (9,22,23). When combining the Studer's limb with an ileal low-pressure neobladder substitution, there is no coordinated contraction of the reservoir to cause an isolated intra-reservoir pressure increase and possible reflux during micturition (18). Furthermore, the use of antireflux procedures such as nipples and tunneled ureters is not always justified because of the higher rate of low anastomotic stricture (20,22). Based on this fact, ileo-ureteral anastomosis using simple end-to-side technique is preferably adopted in our series.
Meanwhile, it is possible that prolonged urine storage leads to reabsorption of urinary solutes, resulting in hyperchloremic metabolic acidosis. Melchior et al. reported that 21 of 31 patients required treatment for persistent metabolic acidosis (17), and Hautmann et al. (18) also reported that 47% of 211 patients had metabolic acidosis. Racioppi et al. (24) reported that patients who were advised to avoid excessive dilatation of the neobladder had no symptomatic acidosis. In our patients, the serum bicarbonate was measured and no significant postoperative metabolic acidosis was observed compared with the preoperative level (Table 4). We believe that this favorable finding is attributed to the satisfactory neobladder functional outcome such as relatively low residual urine and low reservoir pressure as indicated in Table 2.
With regard to the upper urinary tract status demonstrated by IVP, dilatation of the upper tract was observed in the five renoureteral units (5 of 31 patients) at 1 month after operation. However, the rate of urinary ectasia in these patients decreased dramatically from 16.1 to 3.2% at 1 year after operation. This fact also seems to be reflected by the stable levels of serum urea nitrogen and creatinine levels. A true diagnosis of ureteral obstruction leading to renal damage cannot be made based on IVP findings alone. To avoid misinterpretation of IVP findings, both long-term radiography and serum creatinine monitoring are needed, along with serum pH check.
For appropriately selected patients, Studer urinary reconstruction offers a satisfactory quality of life compared with other urinary diversions. Our outcome study demonstrates that stable results can be obtained when the procedure is performed with proper precautions such as careful patient selection, preservation of the periurethral sphincter mechanism and maintenance of low-pressure reservoir. Review of our series also indicates that some complications mentioned above have no significant relation to the patient's age. Therefore, Studer ileal neobladder is feasible for selected patients over 70 years of age.
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CONCLUSIONS |
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TOPAbstractINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSReferences |
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Based on long-term follow-up for a maximum of 7 years, we conclude that our results with Studer ileal bladder substitution are promising in male patients requiring radical cystoprostatectomy, even in patients aged 70 years or older.
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References |
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