The Effect of Nerve Sparing Cystectomy Technique on Postoperative Continence After Orthotopic Bladder Substitution (original) (raw)
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BJU international, 2018
To analyse urinary continence in long-term survivors after radical cystectomy (RC) and orthotopic bladder substitution (OBS) according to attempted nerve-sparing (NS) status. We analysed 180 consecutive patients treated at our department between 1985 and 2007, who underwent RC with OBS, and survived ≥10 years after RC. We stratified patients by attempted NS status and evaluated continence outcomes using descriptive statistics and Cox proportional hazards regression models. A secondary analysis evaluated erectile function as a quality control for attempted NS. The median (interquartile range [IQR]) age at RC was 62 (57-71) years. Of 180 patients, attempted NS status was none in 24 (13%), unilateral in 100 (56%), and bilateral in 56 (31%). After a median (IQR) follow-up of 169 (147-210) months, 160 (89%) patients were continent during daytime and 124 (69%) during night-time. In multivariable analysis, any degree of attempted NS was significantly associated with daytime continence (odd...
Orthotopic ileal bladder substitute after radical cystectomy: Urodynamic features
Neurourology and Urodynamics, 1994
Urc~lynamic investigation wa\ pcrlormcd in I 2 men. 3 t o H months after cystoprostatectomy for hladdcr cancer and hladdcr whstitution. using a dctuhulariml ileal scgnient a\ described hy Studer-Zingg. All patients underwent a standard urodynamic evaluation and extramural amhulatory urtdynamic monitoring (c.a.111.). Ten patients were continent by day and 3 were incontinent during the night t o a degree that necessitated use o f a condom catheter. Three patient5 awakened every 3 hour\ t o void and h had t o void 1-2 times nightly. The residual urine w;is over I00 nil in 3 patients: it was low or absent in the rcniainder. Micturition was achicvcd by straining. with a maxiniuni flow rate of 13 nil pc" second or greater. cxccpt in 1 patients. I n 2 patient5 il urethral narrowing was found at the urethro-ileal ana\tonio\i\. and in I o f them an inctx)rdination bctwccn the ncohladdcr and the pelvic floor required the use of a urethral catheter and a subsequent protocol of pelvic floor rehahilitation. The incidence o f nocturnal incontinence was Sh.h%. I n 2 patients urethral prc\surc profile revealed hypotonia. with a maximum urethral closure pressure f MUCP) < 45 cni H,O. During c.;i.iii. \tudy pressure values i n the ncohladdcr u5ually ranged helow 15 ciii H , O and cxcccilcd 35 cni H,O in only I patient who complained ot daytime and ntwturnal incontinence. Ncohladdcr compliance was normal in a l l case\ In order to achieve a complete rchabilitatit)n after opcration. the patient \hould hc instructed t o I'ollow a careful training in order t o prevent overdistention ol the ncohladdcr by voiding at regular Intervals and t o obtain continence.
Patients with an Orthotopic Low-Pressure Bladder Substitute Enjoy Long-Term Good Function
The Journal of urology, 2016
Orthotopic bladder substitution (OBS) has been performed on a regular basis for over 30 years. Yet data on long-term functional outcomes are still lacking. A total of 200 patients (181 men, 19 women) who underwent radical cystectomy (RC) and urinary diversion with ileal OBS from 1985 to 2004 and who had ≥10-year follow-up were evaluated. Median age at RC was 63 years (interquartile range [IQR] 57-69 years). Median follow-up was 167 months (IQR 137-206 months). Both daytime and nighttime continence rates peaked at 24 months postoperatively and decreased slightly thereafter over almost two decades; at 10, 15 and 20 years daytime continence rates were 92%, 90% and 79%, respectively, nighttime continence rates were 70%, 65% and 55%. During the day and at night fewer than 3% and 10% of patients, respectively, had a urine loss of ≥100ml at any time ≥10 years following surgery. At 10 and 20 years, 11/200 (6%), and 1/29 (3%) of patients, respectively, had to perform clean intermittent self-...
Urodynamic evaluation of sacral neuromodulation for urge urinary incontinence
Bju International, 2008
OBJECTIVETo evaluate the urodynamic data before and 6 months after implantation of sacral neuromodulation (SNM, an established treatment for voiding dysfunction, including refractory urge urinary incontinence, UI) and to assess the correlation between the urodynamic data and clinical efficacy in patients with UI.To evaluate the urodynamic data before and 6 months after implantation of sacral neuromodulation (SNM, an established treatment for voiding dysfunction, including refractory urge urinary incontinence, UI) and to assess the correlation between the urodynamic data and clinical efficacy in patients with UI.PATIENTS AND METHODSIn all, 111 patients with a >50% reduction in UI symptoms during a percutaneous nerve evaluation test qualified for surgical implantation of SNM. Patients were categorized in two subgroups, i.e. those with UI with or without confirmed detrusor overactivity (DO) at baseline. At the 6-month follow-up all patients had a second urodynamic investigation, with the stimulator switched on.In all, 111 patients with a >50% reduction in UI symptoms during a percutaneous nerve evaluation test qualified for surgical implantation of SNM. Patients were categorized in two subgroups, i.e. those with UI with or without confirmed detrusor overactivity (DO) at baseline. At the 6-month follow-up all patients had a second urodynamic investigation, with the stimulator switched on.RESULTSAt baseline, there was urodynamically confirmed DO in 67 patients, while 44 showed no DO. A review of filling cystometry variables showed a statistically significant improvement in bladder volumes at first sensation of filling (FSF) and at maximum fill volume (MFV) before voiding for both UI subgroups, compared with baseline. In 51% of the patients with UI and DO at baseline, the DO resolved during the follow-up. However, those patients were no more clinically successful than those who still had DO (P = 0.73). At the 6-month follow-up, 55 of 84 implanted patients showed clinical benefit, having a ≥50% improvement in primary voiding diary variables. Patients with UI but no DO had a higher rate of clinical success (73%) than patients with UI and DO (61%), but the difference was not statistically significant.At baseline, there was urodynamically confirmed DO in 67 patients, while 44 showed no DO. A review of filling cystometry variables showed a statistically significant improvement in bladder volumes at first sensation of filling (FSF) and at maximum fill volume (MFV) before voiding for both UI subgroups, compared with baseline. In 51% of the patients with UI and DO at baseline, the DO resolved during the follow-up. However, those patients were no more clinically successful than those who still had DO (P = 0.73). At the 6-month follow-up, 55 of 84 implanted patients showed clinical benefit, having a ≥50% improvement in primary voiding diary variables. Patients with UI but no DO had a higher rate of clinical success (73%) than patients with UI and DO (61%), but the difference was not statistically significant.CONCLUSIONThese urodynamic results show a statistically significant improvement in FSF and MFV in patients with UI with or with no DO after SNM. Although there was a urodynamic and clinical improvement in both groups, patients with UI but no DO are at least as successful as patients with UI and DO. Therefore in patients with UI, DO should not be a prerequisite selection criterion for using SNM.These urodynamic results show a statistically significant improvement in FSF and MFV in patients with UI with or with no DO after SNM. Although there was a urodynamic and clinical improvement in both groups, patients with UI but no DO are at least as successful as patients with UI and DO. Therefore in patients with UI, DO should not be a prerequisite selection criterion for using SNM.
BJU International, 2008
To describe the development of screening tests and to identify re-operation rates after the permanent implant phase, and its characteristics, of the Interstim (Medtronic, Inc., Minneapolis, MI, USA) device for sacral nerve stimulation (SNS). We retrospectively reviewed the charts of women who had SNS between January 1998 and December 2005; their demographic, clinical and surgical information was abstracted. Descriptive statistics, chi-square and analysis of variance were used to compare the results. In all, 95 patients had 105 test procedures; 30 peripheral nerve evaluation (PNE) and 75 staged tined leads. Response rates were lower in the PNE than in the tined lead (40% vs 67%, P = 0.01). The indication for SNS was associated with the response rate, with urinary retention having the highest response (71%, P = 0.01). For the 55 implanted devices, there were 18 revisions (33%) and eight explants (15%). The main reasons for revision or explants were loss of efficacy (16/26) and pain at the implant site (six of 26). The median (range) time to intervention after implantation was 17 (1.2-75.0) months, and this was significantly associated with the indication. Revisions due to pain at the implant site were within the first year, and re-operations due to loss of efficacy after 1-2 years, whereas battery replacement was required on average 4 years after initial implantation. This study confirms the higher response rates of the tined-lead staged technique over PNE. Unobstructive urinary retention had the highest response rates. The reason for revision appeared to be largely predicted by the length of time since implantation.
Neural Stimulation for Chronic Voiding Dysfunctions
Journal of Urology, 1994
Neural stimulation of the sacral nerve roots could become an acceptable and prom1smg modality in controlling variable forms of difficult voiding dysfunctions. A total of 50 patients who presented with various forms of voiding dysfunction underwent initial screening by percutaneous nerve evaluation of the 83 nerve root guided by movements of the levator ani and toes. Only 17 patients demonstrated a satisfactory response to percutaneous nerve evaluation and subsequent subchronic wire testing for 4 to 5 days, and they were eligible to enter the study. The studied patients (13 women and 4 men) were classified into 2 groups according to presentation. Group 1 included 8 patients who presented mainly with nonobstructive chronic urinary retention. All 8 patients were on intermittent self-catheterization except 1 with a suprapubic tube. The 9 patients in group 2 mainly presented with other forms of voiding dysfunctions, including pain (suprapubic and perineal), frequency and/or urgency. All patients were neurologically free, and had failed pharmacological and surgical attempts to correct the problems. In both groups radiological and ultrasound evaluations of the urinary tract as well as cystourethroscopy were within normal limits. Urodynamic studies were performed preoperatively and postoperatively. Unilateral 83 foramen implantation was performed on the selected side in all patients. Followup ranged from 3 to 52 months. All patients were followed preoperatively and postoperatively by voiding and itemized symptom score diary as well as a quality oflife questionnaire. Each symptom and question were given certain grades that reflect the severity or importance to the patient. The symptom scores and the quality of life questionnaires were analyzed preoperatively and postoperatively. In group 1 voided volume (expressed as a percentage of total bladder capacity) was significantly increased at 6 months (23 ± 7.5% preoperatively versus 81.9 ± 7.7% postoperatively, p <0.05) and, accordingly, residual volume (also expressed as a percentage of total bladder capacity) was significantly decreased. The maximum flow rate increased to 18.0 ± 2.6 ml. per second postoperatively compared to 7.8 ± 3.1 ml. per second preoperatively. The number of intermittent self-catheterizations per day decreased to 1.3 ± 0.8 compared to 4.2 ± 0.6 preoperatively (p <0.05). Uninhibited bladder contractions with vesicosphincteric dyssynergia disappeared in 1 patient, while they persisted in 1 for up to 6 months. In group 2 the average improvement in pain and difficulty to start voiding was 85%, frequency improved by 37%, urgency by 42%, and leaking episodes and number of diapers per day decreased by 50%. Uninhibited bladder contractions disappeared in 1 patient within 6 months. No significant difference was observed in any of the other urodynamic parameters. The impact of voiding problem on patient activities and quality of life was considerably improved. The appliance was well tolerated with no serious complication. The prosthesis was removed in 1 patient due to local pain at the site of the pulse generator. We believe that neural stimulation is a valid option in treating select cases of voiding dysfunction.
Nerve Sparing Open Radical Retropubic Prostatectomy—Does It Have an Impact on Urinary Continence?
The Journal of Urology, 2006
We prospectively assessed the role of nerve sparing surgery on urinary continence after open radical retropubic prostatectomy. Materials and Methods: We evaluated a consecutive series of 536 patients who underwent open radical retropubic prostatectomy with attempted bilateral, unilateral or no nerve sparing, as defined by the surgeon, without prior radiotherapy at a minimum followup of 1 year with documented assessment of urinary continence status. Because outlet obstruction may influence continence rates, its incidence and management was also evaluated. Results: One year after surgery 505 of 536 patients (94.2%) were continent, 27 (5%) had grade I stress incontinence and 4 (0.8%) had grade II stress incontinence. Incontinence was found in 1 of 75 (1.3%), 11 of 322 (3.4%) and 19 of 139 patients (13.7%) with attempted bilateral, attempted unilateral and without attempted nerve sparing, respectively. The proportional differences were highly significant, favoring a nerve sparing technique (p Ͻ0.0001). On multiple logistic regression analysis attempted nerve sparing was the only statistically significant factor influencing urinary continence after open radical retropubic prostatectomy (OR 4.77, 95% CI 2.18 to 10.44, p ϭ 0.0001). Outlet obstruction at the anastomotic site in 33 of the 536 men (6.2%) developed at a median of 8 weeks (IQR 4 to 12) and was managed by dilation or an endoscopic procedure. Conclusions: The incidence of incontinence after open radical retropubic prostatectomy is low and continence is highly associated with a nerve sparing technique. Therefore, nerve sparing should be attempted in all patients if the principles of oncological surgery are not compromised.