The concept of functional preservation after orthotopic neobladder construction has gradually attracted attention. Reconstruction of urine storage and voiding is the basic function preservation of orthotopic neobladder. Clinical exploration mainly focuses on the optimization of neobladder reconstruction methods and procedures, and there is still a lack of summary of existing surgical characteristics and high-quality functional comparative studies. For strictly selected patients, on the basis of tumor control and standardized postoperative rehabilitation guidance, most patients with preserved nerve can retain satisfied sexual function after surgery. The protection of neurovascular bundle and ancillary structures combined with postoperative exercise is crucial to the improvement of urinary continence. According to the characteristics of patients, choosing the appropriate urinary diversion methods and function preserving can help patients establish a normal life style after surgery and improve their self-image and quality of life.
Humans ; Urinary Reservoirs, Continent/physiology* ; Cystectomy/methods* ; Urinary Bladder Neoplasms/surgery* ; Quality of Life ; Urinary Diversion/methods*

BACKGROUNDFor muscle invasive bladder cancer, radical cystectomy is the most effective treatment now and urinary diversion is often necessary. The use of intestinal tissue for urinary diversion is frequently associated with complications. In this study, we aimed to make a tissue-engineered conduit (TEC) using bladder epithelial cells and bladder acellular matrix (BAM) for urinary diversion in rabbits.

METHODSBladder epithelial cells of rabbit were cultivated and expanded in vitro, then seeded on BAM, and cultured for 7 days. Then cell-seeded graft was used to make TEC. In the experimental group, most of bladder of the rabbit was removed while bladder trigone was retained. The proximal end of TEC was anastomosed with bladder trigone and the distal end was anastomosed with the abdominal stoma. In the control group, TEC was made using unseeded BAM. Haematoxylin and eosin staining was conducted, respectively, at 1, 2, 4, and 8 weeks postoperatively. Immunohistochemistry was performed 8 weeks postoperatively. Intravenous urography, retrograde pyelography, and cystoscopy of TEC were made at 12 weeks postoperatively.

RESULTSAll animals were alive in the experimental group. Haematoxylin and eosin staining showed epithelial coverage in TEC. Immunohistochemistry showed anti-cytokeratin AE(1)/AE(3) antibody and anti-ZO1 antibody positive, confirming there were mature and functional epithelial cells on the lumen of TEC. Retrograde pyelography and intravenous urography showed that TEC developed well and that there was no obstruction. In the control group, four rabbits were dead within 2 weeks and scar formation, atresia, and severe hydronephrosis were found.

CONCLUSIONSWe successfully made TEC using BAM and bladder epithelial cells for urinary diversion in rabbits. The lumen of this new TEC covered mature epithelial cells and could prevent urinary extravasation.

Animals ; Epithelial Cells ; cytology ; Male ; Rabbits ; Tissue Engineering ; methods ; Urinary Bladder ; cytology ; Urinary Diversion ; methods

Cystectomy ; methods ; Humans ; Laparoscopy ; Urinary Bladder Neoplasms ; surgery ; Urinary Diversion ; methods

BACKGROUNDContinent cutaneous diversion (CCD) has been widely used in almost any lower urinary reconstruction. We have been continually trying to modify this procedure because of the high complications rate, especially as they relate to the efferent tube. In this study, we reported a modified procedure with a tapered ileum wrapped by the rectus abdominalis flap (RAMF) and assessed the feasibility of this new technique to achieve urinary continence.

METHODSA procedure in which two ileal segments were tapered and connected to a U-shaped reservoir was performed in ten dogs. A RAMF with its blood supply was wrapped around one of the tapered ileum. In control groups, the tapered ileum was brought to the abdominal skin. Urodynamic studies were conducted In the 1st, 3rd and 6th months post-operatively. The data of maximum inner pressure (MIP) and functional pressure length (FPL) in every group at each phase were recorded. Retrograde radiograms of the efferent limbs were performed before sacrifice.

RESULTSMIP in the study group was significantly higher than that in the control group at each phase (P < 0.05). However, no significant differences in MIP or FPL were found in the study group between an empty and full reservoir. In the control group, MIP increased (P < 0.05) and FPL decreased significantly (P < 0.05) compared with an empty and full reservoir. Retrograde radiograms confirmed that efferent limbs were positioned straigh beneath the abdominal wall. Histological examination of the study group demonstrated a layer of striated muscle around the outside surface of the ileum.

CONCLUSIONThe continent mechanism of tapered ileum can be enhanced by extra support from wrapped RAMF.

Animals ; Dogs ; Female ; Ileum ; surgery ; Male ; Urinary Diversion ; methods ; Urinary Reservoirs, Continent ; Urodynamics

OBJECTIVETo investigate the effect of extramural support from the pouch and abdominal wall to enhance the continent mechanism of tapered ileum.

METHODSA total of 24 patients underwent a procedure in which an ileal segment was tapered into an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. A urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 24 months postoperatively.

RESULTSOne patient died of heart disease 55 days postoperatively, while 22 of the remaining 23 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes demonstrated that the maximum closure pressure with a full pouch was 46 - 124 cmH(2)O (91.26 +/- 15.71 cmH(2)O) and with an empty pouch was 34 - 84 cmH(2)O (67 +/- 10.60 cmH(2)O). The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -11.78 and P = 0.00001). At 6 to 24 months, a second urodynamic study was performed on 18 cases, demonstrating a reservoir capacity of 420 to 750 ml (481.67 +/- 78.83 ml). Reservoir pressure was 6 to 9 cmH(2)O (7.17 +/- 1.17 cmH(2)O) when the pouch was filled to 50 ml, and 16 to 35 cmH(2)O (24.12 +/- 5.61 cmH(2)O) when it was filled to maximum capacity. There was no contractive wave during the filling in any patient. Maximum closure pressure in the efferent tube was 80 to 194 cm H(2)O (98.89 +/- 26.34 cmH(2)O) when the pouch was filled with saline, and 64 to 128 cmH(2)O (74.78 +/- 14.54 cmH(2)O) when the pouch was empty. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -7.58 and P = 0.00003).

CONCLUSIONSThis study indicates that the continent mechanism of tapered ileum may be greatly enhanced by extramural support from the abdominal and pouch walls.

Adult ; Aged ; Female ; Humans ; Ileum ; surgery ; Male ; Middle Aged ; Urinary Diversion ; methods ; Urinary Reservoirs, Continent ; Urodynamics

BACKGROUNDAn important milestone in the area of urinary diversion was the advent of a series of orthotopic bladder substitution (OBS). However, reconstruction of OBS by the traditional hand suture method (THSM) is a time-consuming process. Stapling techniques are considered to be inferior to hand-sewn methods. We report our experience and functional results in patients with W-ileal neobladder by a hand-assisted-drawing-needle running suture (HADNRS).

METHODSBetween April 1993 and December 2011, 347 patients (338 men and 9 women) aged 28 - 77 years (median age: 59 years) underwent radical cystectomy, followed by the creation of a modified W-ileal neobladder by HADNRS with a curved needle. A total of 347 (20 patients in 2003) were evaluated by urodynamic tests.

RESULTSThe operative time ranged from 110 to 310 minutes (mean 148 minutes), and the mean time of reconstruction by HADNRS, excluding ureterointestinal and ileouretral anastomosis, was (20.2 ± 4.3) minutes. Histopathological analysis of removed specimens showed that 317 patients had transitional cell bladder carcinoma. Of these 317 patients, 19 also had squamous carcinoma and 13 had adenocarcinoma. Glandularis and prostate cancer occurred in 16 and 14 patients, respectively. Three patients (0.8%) had neobladder abdominal fistula. No other early complications or injury to the surgeon's hands occurred due to HADNRS. Of the 20 cases with urodynamic examinations in 2003, two suffered from daytime incontinence and six had nocturnal incontinence. The maximum capacity of the neobladder was (492.9 ± 177.8) ml, and the maximum pressure within the reservoir at the end of filling was (32.1 ± 8.6) cmH2O.

CONCLUSIONReconstruction of W-ileal neobladder by HADNRS is effective and economical.

Adult ; Aged ; Cystectomy ; methods ; Female ; Humans ; Male ; Middle Aged ; Treatment Outcome ; Urinary Diversion ; methods ; Urinary Reservoirs, Continent

OBJECTIVETo present the technique and experience of robotic-assisted laparoscopic radical cystectomy (RARC) by da Vinci surgical system.

METHODSFrom December 2007 to September 2008, 4 patients underwent RARC and urinary diversion. The age of patients was 44 to 63 years old. The body mass index was 22.8 to 27.7. All their clinical stages were lower than T2N0M0. The technique for RARC involving ureters dissection, posterior dissection, lateral pedicle control, anterior dissection, dorsal vein complex control, neurovascular bundles sparing, lymphadenectomy, ureter-ileal anastomosis, urethra-neobladder anastomosis to either ileal conduit urinary diversion or neobladder reconstruction performed extracorporeally.

RESULTSAll the operations were accomplished successfully. The urinary diversion of 2 case was ileal conduit and others was ileal orthophoria neobladder. The operation time was 300 to 450 min. The time of radical cystectomy was 150 to 180 min. The estimated blood loss was 100 to 500 ml. The postoperative hospital stay was 9 to 35 d. The bed rest time was 4 to 9 d. There was 1 patients who had incomplete intestinal obstruction at 8th postoperative day cured by conservative therapy. The patients were followed up for 3 to 12 months, all patients survived without tumor recurrence. The patients have satisfied urinary continence and normal renal functions without hydronephrosis after the operation.

CONCLUSIONSRARC is small incision and safe, the results are definite. It is one of the direction of minimally invasive urologic surgery.

Adult ; Cystectomy ; methods ; Follow-Up Studies ; Humans ; Laparoscopy ; methods ; Male ; Middle Aged ; Retrospective Studies ; Robotics ; Urinary Diversion ; methods

BACKGROUNDWe presented the technique and outcomes of laparoscopic radical cystectomy performed in 28 patients with bladder cancer to evaluate its clinical efficacy and feasibility.

METHODSAmong the 28 patients, aged from 58 to 73 years (mean 68.5 years), 26 were transitional cell carcinoma grads II - III and 2 squamous carcinoma. Laparoscopic radical cystectomy plus bladder reconstruction was performed in all cases, among them 15 with ileum, 10 with rectum pouch, and 3 with ureterostomy. The operating time, the blood loss, the intestine function and the complications were observed.

RESULTSAll procedures were successful. The operating times were 7 - 10 hours, the blood loss was 400 - 1500 ml (mean 850 ml), the intestine function recovered at 72 hours after operation, and all ureteral catheters were removed at 2 weeks after surgery. The results of intravenous urography were normal at 3-month, 1-year, and 2-year follow-up after surgery.

CONCLUSIONSLaparoscopic radical cystectomy for invasive bladder cancer is safe and efficient, with good operating field, reliable hemostasis, mini-invasion, less celiac complications, and rapid recovery. This surgery is worth being extended.

Aged ; Carcinoma, Transitional Cell ; surgery ; Cystectomy ; methods ; Humans ; Ileum ; surgery ; Laparoscopy ; methods ; Male ; Middle Aged ; Urinary Bladder Neoplasms ; surgery ; Urinary Diversion ; methods ; Urinary Reservoirs, Continent

BackgroundRobot-assisted/laparoscopic intracorporeal ileal conduit (ICIC) has been reported in many experienced centers. Whether laparoscopic ICIC is superior to extracorporeal ileal conduit (ECIC) and whether laparoscopic ICIC should be promoted is still controversial. The aim of the study was to compare surgical and early oncological outcomes between patients undergoing laparoscopic radical cystectomy (LRC) with ICIC and ECIC.

MethodsFrom January 2011 to June 2016, a total of 45 patients with bladder cancer underwent LRC with ileal conduit at our department, of whom 20 patients underwent LRC with ECIC and 25 patients underwent LRC with ICIC. Data of each patient's characteristics, surgical outcomes, and short-term oncological outcomes were collected and analyzed.

ResultsLRC with ileal conduit was performed successfully on all 45 patients. There were no significant differences in patients' characteristics, mean total operative time, and mean estimated blood loss between the ICIC and ECIC groups. Median time of flatus and oral intake was shorter in the ICIC group compared with the ECIC group (3 vs. 5 days, P = 0.035; 4 vs. 5 days, P = 0.002). The complications rates did not show significant difference between the two groups within the first 90 days postoperatively (P = 0.538). Cancer staging showed 45% of patients in the ECIC group and 36% in the ICIC group had a pathologic stage of T3 or T4, and 50% of patients in the ECIC group and 44% in the ICIC group had a pathologic stage of N1 or N1+. Kaplan-Meier analysis showed no significant difference in overall survival at 24 months (60% vs. 62%, P = 0.857) between the ECIC and ICIC groups.

ConclusionsICIC after LRC may be successful with the benefits of faster recovery time. No significant difference was found in complications and oncological outcomes between ICIC and ECIC. However, larger series with longer follow-up are needed to validate this procedure.

Aged ; Cystectomy ; methods ; Female ; Humans ; Laparoscopy ; methods ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome ; Urinary Bladder ; surgery ; Urinary Bladder Neoplasms ; surgery ; Urinary Diversion ; methods

OBJECTIVETo evaluate the elective method and the clinical experience of using appendix in situ in continent urinary diversion.

METHODS26 continent urinary diversions have been performed since 1990. Among them, 11 cases underwent the intussuscepted technique and other 15 cases underwent embedded technique.

RESULTSThe continent rate was 100% at the daytime among all the case, while intermittent incontinence occurred in 3 cases at night, which happened in the intussuscepted group. Other complications included catheterization difficulty in 3 cases, appendix perforation in 1 case, which happened in the embedded group, traction of the appendix into abdominal cavity in 1 case, and prolapse of the intussusepted appendix in 3 cases.

CONCLUSIONSThe embedded technique shows better results than the intussuscepted technique in term of continence. The embedded technique, using appendix in situ as an efferent loop, shows the advantages of easily performing, timesaving, better outcome in continence and less complication. We believe the technique of appendix in situ as an efferent loop is an ideal modality in urinary diversion operation.

Adult ; Aged ; Appendix ; surgery ; Cystectomy ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Urinary Bladder Neoplasms ; surgery ; Urinary Bladder, Neurogenic ; surgery ; Urinary Diversion ; methods ; Urinary Reservoirs, Continent