There are several aspects that have to be carefully reviewed when recommending to a patient the most optimal method for urinary tract reconstruction in conjunction with cystectomy.
■ Risk of urethral recurrence
■ Previous pelvic irradiation
■ Renal function
■ Physical status
■ Mental constitution.
High age is a relative contra-indication to continent reconstruction, which requires an active and alert attitude with regard to body functions. The patient must be able to recognize the symptoms of a full pouch and understand the importance of regular emptying. S/he must be able to carry out intermittent self-catheterization, a requirement that might occur not only after continent cutaneous diversion. In one series of patients followed for five years after ileal neo-bladder construction, 44% were on clean intermittent self-catheterization (CISC).12 In our own series of colonic neo-bladders, this was used by 37% of the patients.13
Another problem clearly related to age is incontinence after orthotopic bladder substitution. The older the patient, the poorer the result with regard to continence.14-16 Although a permanent catheter may solve the problem in the short term, an indwelling catheter may give rise to severe complications, such as septicaemia, stone formation, retention due to mucous plug and rupture of the pouch. Such potential problems form the basis for our reluctance to perform continent reconstruction in the octogenarian and in fact many patients above the age of 70, after being thoroughly informed, settle for an ileal conduit. At the same time we realize that there may be single individuals in excellent condition at high age in whom continent reconstruction is justified, indicating that it is the patient's biological age that is the determining factor.
Advanced disease is, in our opinion, another relative contra-indication to continent reconstruction. If grossly enlarged positive lymph nodes ('bulky disease') are found at exploration, we usually perform an ileal conduit. Patients are informed about this possibility before surgery. Our main reason is that we want as short and as smooth post-operative course as possible. We think that conduit diversion is associated with less risk of early and late problems than continent reconstruction, enabling the patient to commence adjuvant chemotherapy early and spend as little time as possible in hospital. Although some series during the last decade have shown five-year survival in the range of 20-30% in node-positive disease, for most patients survival is short and the majority of them will succumb within one or two years. In this situation, most patients will change priorities in life and the issue of type of reconstruction will be of secondary importance. On the other hand, it can be argued that an ileal conduit with the external collection device might be an additional burden on a patient already mentally distressed by advanced malignancy. This issue is to a large extent a philosophical question.
In patients with one or a few small positive nodes we usually proceed with the planned type of reconstruction. In patients with neo-bladders who suffer pelvic recurrence, several reports, however, have shown that complications from the pouch are rare, that neo-bladder function has been maintained and that the patients have been able to undergo adjuvant chemotherapy.17-20
This is a major issue when contemplating orthotopic bladder substitution. The risk of urethral recurrence after cystoprostatectomy and urinary diversion is around 10%, classical risk factors being multiplicity of the bladder tumour, wide-spread carcinoma in situ, bladder neck tumour and prostatic involvement, the latter usually considered to be present in 10-20% of patients undergoing radical cystectomy.21 However, it seems that prostatic involvement in TCC of the bladder is more common than has previously been thought. Two studies employing whole mount technique in studying the prostate of the cystoprostatectomy specimen showed prostatic involvement in 43%.22,23 We used longitudinal whole mount sectioning and found TCC in 30%.24 With regard to prostatic involvement, ductal and particularly stromal growth have been associated with highest risk of urethral recurrence.25,26 Common practice, therefore, has been to rule out such engagement by performing deep transurethral resection biopsies of the prostate, preferably at the 5 and 7 o'clock position at the level of the verumontanum pre-operatively.27 In many centres, patients with positive biopsies and those with widespread carcinoma in situ have been recommended prophylactic urethrectomy.
In the surge of the current interest in orthotopic bladder substitution, the reliability of the pre-operative transurethral resection biopsies and the impact of prostatic involvement for urethral recurrence have been challenged by several groups.28-31 Donat et al. found sensitivity and specificity of the biopsies for stromal invasion to be only 53% and 77% respectively, and many centres today have abandoned these biopsies, relying only upon frozen section of the urethral margin obtained at surgery, and accepting all patients for orthotopic reconstruction providing the frozen sections are negative.28-31 In the study by Lebret et al., all 106 patients with negative margin were without recurrence, contrary to the experience by Donat et al.28,29 It is thus obvious that we are today lacking optimal instruments for correct assessment of the prostatic urethra/prostate. Some patients with prostatic involvement will be at risk of developing urethral recurrence after bladder substitution, but we have difficulties in correctly identifying them pre-operatively.
Although the incidence of urethral recurrences after neo-bladder construction is lower than reported for diversion with retained urethra, one has to remember that follow-up in some series is still short. The calculated five-year recurrence rate with any prostatic involvement was 5% after ileal neo-bladder construction.30 The true incidence may prove to be even higher. In one series, an overall incidence of urethral recurrence of 6% was reported, increasing to 12% in those followed for five years, the majorities being carcinoma in situ.32,33 These figures certainly provoke reflection and it is obvious that great care has to be exercised in recommending patients for orthotopic substitution.
In studies of female cystectomy specimen, the incidence of urethral tumour has been reported to be around 10%, with the main risk factors being bladder neck tumour, but also widespread carcinoma in situ and vaginal wall involvement.34-37 It was demonstrated that providing the bladder neck was free of tumour, there was no tumour in the urethra.36 Thus, pre-operative bladder neck biopsies should be obtained. However, the occurrence of urethral tumour without bladder neck involvement has been described.35
In a few centres, radiotherapy is still the treatment of choice for invasive bladder cancer. Usually 60-70 Gy is delivered. Today there is a growing interest in chemo-radiotherapy following aggressive TUR ('bladder-sparing treatment modality'). In most schemes, a break with assessment of the bladder is made after 40-45 Gy and if no tumour is noted, consolidating radiotherapy up to a total dose of65-70 Gy is given. Some patients will not be rendered free of tumour or they will have recurrence with remaining treatment option being 'salvage cystectomy'.
Several reports confirm an increased risk of early as well as late complications in irradiated patients following cystectomy and ileal conduit diversion.38,39 The same holds true for continent cutaneous diversion, in which the risk of outlet malfunction was greater in irradiated patients with a Mainz pouch or a Kock pouch than in non-irradiated patients.39,40
Neo-bladders have also been constructed in full-dose irradiated patients, but the procedure was reported 'more challenging than is usual'.41 Not surprisingly, early complications have been reported more commonly in irradiated patients with intestinal obstruction and delayed healing of the anastomosis to the urethra.42 Late complications, such as bowel perforation and fistula formation from the neo-bladder, and poor functional results, further emphasize the risk the urologist is taking when anastomosing tissues within a previous radiation field.41,43 If such surgery is contemplated, large experience in reconstructive urology, correct intraoperative assessment of the intestine and the ureters and a well-informed patient are necessary components. If any of the above are lacking, the result can be disastrous.
The governing rule should be to use non-irradiated tissue; the 'stay away' principle. Ureters should be divided high. If conduit diversion is the most suitable alternative for the patient, a transverse colonic conduit is usually the best choice.44,45 Continent cutaneous diversion can also
Construction of a Mainz III pouch from the left colonic flexure. The oral end is tapered and the rest of the colonic segment is detubularized and mesenteric windows created. Ureters are implanted with anti-refluxing technique, the pouch closed and the efferent segment embedded by serosa-to-serosa sutures placed through the mesenteric windows.
successfully be performed using the transverse colon, as in the Mainz pouch III, with low reported incidence of early and late complications (Figure 2).39
The issue of renal function is of importance in the choice between continent reconstruction and conduit diversion. For a given glomerular filtration rate (GFR), the risk of hyperchloremic metabolic acidosis, with possible risk of defect bone mineralization in the long run, will be higher after continent reconstruction, due to more extensive contact between urine and intestinal mucosa. Different upper limits of serum creatinine for accepting patients for continent reconstruction are given in the literature; 250 u-mol/l by Skinner's group, 200 by Hautmann's group and 150 by Studer's group.2,46,47 However, these values all signify considerably reduced renal function with risk of acidosis. We have studied two groups of patients after continent diversion using the right colon; one group with a mean GFR of 100 ml/min and another with a mean GFR of 55 ml/min.48 Although there was a tendency towards statistically significant
difference in acid-base balance, the values were within normal limits in both groups. Nor was there any difference in the ability to handle an acute acid load. However, in the group with reduced GFR, ionized calcium was significantly lower than in the other group, probably an expression of increased calcium release from the bone with subsequent loss in urine. It is our opinion that continent urinary reconstruction should not be performed in individuals with GFR below 40 ml/min.
Is continent reconstruction associated with higher risk of complications than the ileal conduit? In comparisons, a common problem is that case series are not really comparable due to differences in age and, particularly, in co-morbidity. Some studies have tried to properly answer the question by stratifying the patients to levels of co-morbidity. Thus, using a 'fitness score', no significant differences were found between the two groups with regard to operative mortality or morbidity.49 The Charlson co-morbidity index was applied in a study comparing ileal neo-bladder patients and ileal conduit patients.50 No differences were noted in post-operative complications and hospital stay, but there were more late complications among neo-bladder patients. Although one would expect that patients with co-morbidity would do worse than those without, no differences with regard to complications, length of hospitalization and re-admission rate were found in patients undergoing radical cystectomy and bladder substitution when stratified with the Charlson co-morbidity index.51 Although these studies do not support major differences between methods for reconstruction, nor between patients with different physical status, clinical experience nevertheless has taught most of us that there are correlations between outcome and physical status as well as surgical intricacy. The major impact on the patient is probably the cystectomy trauma, but it is of course impossible to separate the effects of the cystectomy from those of the reconstruction.52 The risk of late complications with need of revisional procedures of the urinary tract is definitely higher after continent reconstruction than after conduit diversion.
Although little studied, this subject is ofimportance, especially with regard to post-operative adjustment. In the clinical setting it is the delicate task of the urologist to try to understand the personality of the patient; therefore the need of repeat communications with the patient pre-operatively.
Although orthotopic substitution is usually the first option for reconstruction, this procedure may not be ideal if the patient finds the prospect of urine leakage repugnant. A highly nervous patient may not be the ideal candidate for continent cutaneous diversion, after which difficult catheterization is a possible complication. The patient's coping ability is a complex issue, but important for post-operative rehabilitation. Instruments like questionnaires may be of importance in this context. We studied the influence of psychological defensive strategies, by which the patient was assigned to a 'risk' or a 'non-risk' group with regard to expected post-operative difficulties after cystectomy.53 Men using primitive strategies such as projection seemed to run a long-term risk for poor psychosocial adaptation, while those with sensitivity were at risk relatively early in the rehabilitation period. However, we know little or nothing with regard to the importance of such strategies in relation to different modes of reconstruction.
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