in terms of urinary continence of Z-shaped ileal neobladder performed in a single center. ... INTRODUCTION AND OBJECTIVES: Radical cystectomy. (RC) after ...
Vol. 183, No. 4, Supplement, Monday, May 31, 2010
# of Patients
Table 1. Montie Cecchi Ugyur Fontana (1996) (1997) (2000) (2004) 19 14 30 50
THE JOURNAL OF UROLOGY姞
760 Abreu (2006) 3
Totals 116
CYSTECTOMY AFTER HIGH DOSE PELVIC RADIATION: DOES TYPE OF URINARY DIVERSION AFFECT LATE COMPLICATIONS? Manuel Eisenberg*, Ryan Dorin, Georg Bartsch, Jie Cai, Gus Miranda, Eila Skinner, Los Angeles, CA
Pouch Type
W
W
U
Y
U
Absorbable?
Yes
Yes
Yes
No
No
Median Creation Time (minutes)
20
20
15
20
40
Median Follow-Up (months)
15
18
26
20
3
16.4
Mean Pouch Capacity (mL)*
526
377
521
390
322
427.2
23
Mean End-Filling Pressure (cm H2O)
23***
23.8
30**
18
Not Done
20.9
Pouch Stones
0/19
0/14
0/30
3/50
0/3
3/116
Daytime Incontinence
8/19
1/14
1/30
10/50
0/3
20/116
Ureteroneobladder Anastomotic Stricture
0/19
1/14
1/30
2/50
0/3
4/116
Neobladder Anastomotic Leak 0/19 0/14 1/30 0/50 1/3 2/116 *As determined by measurement at last follow-up by urodynamic evaluation **Individual pressures not listed in study but all pressures reported as less than 30 cm H2O ***7/19 patients had pressures above 40 cm H20 prior to end filling; Average listed is for the remaining 12 patients
Source of Funding: None
759 URINARY CONTINENCE AFTER ORTHOTOPIC BLADDER REPLACEMENT USING Z-SHAPED ILEAL NEOBLADDER IN A SERIES OF 321 PATIENTS Henry Botto*, Yann Neuzillet, Laurent Yonneau, Jean-Marie Herve, Pierre-Marie Lugagne, Thierry Lebret, Suresnes, France INTRODUCTION AND OBJECTIVES: To evaluate the results in terms of urinary continence of Z-shaped ileal neobladder performed in a single center. METHODS: 321 consecutive patients, 27 women (8%) and 294 men (92%) who had an orthotopic bladder replacement using Z-shaped ileal neobladder between May 1990 and January 2009. 68 patients received adjuvant chemotherapy. RESULTS: The mean age of the patients was 63.4⫾11.8 years. The mean follow-up was 59.4 ⫾ 55.5 months. The surgical indications were bladder tumors in 315 (98.2%) cases and non-oncological in 6 (1.8%) cases. Perfect daytime urinary continence was achieved in 81% of patients (83% for men vs 56% for women, p⫽0.0007) and 91% (92% for men vs 79% for women, p⫽0.02) of patients did not require more than one pad during the day. Daytime continence was obtained within, on average, 6.8⫾15.8 months (9.4⫾18.2 months for completely continent patients). The interval between each daytime urination was 2.6⫾0.7 hours (median ⫽ 2.5 (1-5) hours). Perfect nocturnal urinary continence was achieved in 62% (62% for men vs 70% for women, p⬎0.05) of patients and 86% (87% for men vs 75% for women, p⬎0.05) of patients did not require more than one pad during the night. Nighttime continence was obtained within, on average, 10.8 ⫾ 22.1 months (14.9 ⫾ 22.2 months for completely continent patients). Obtaining the daytime and night-time continence was independent of age and are not related with use of chemotherapy. Hyper-continence with subsequent need for CISC was observed in 13 (4%) out of 294 men, and 9 (33%) out of 27 women. CONCLUSIONS: In our series of 321 patients, Z-shaped ileal neobladder allowed acceptable daytime and night-time continence in nine out of ten patients. Source of Funding: None
e297
INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) after pelvic radiation therapy (XRT) is complicated by impaired wound healing potentially predisposing to stricture, wound breakdown, and other late complications. The rate and severity of late complications are currently undefined in this population. Also unknown is how complication rates are affected by the type of urinary diversion (UD) performed. In this study we describe late complications in the largest reported series to date of patients undergoing RC and UD after high dose pelvic XRT. METHODS: Inclusion criteria were preoperative ⱖ60Gy XRT to the pelvis for any indication, RC with UD performed, and follow-up data ⬎90 days after surgery. From 1983 to 2008, 133 patients met inclusion criteria. Each patient’s medical record was retrospectively reviewed and complications were graded by 3 independent, blinded reviewers according to the 2004 “Clavien-Dindo” classification system. Any complication related to surgery occurring ⬎90 days after RC was recorded as a late complication. RESULTS: UD performed were ileal conduit (IC) in 61 patients (45.9%), continent cutaneous (CC) pouch in 29 (21.8%), and orthotopic neobladder (ON) in 43 (32.3%). Patient sex, ASA, radiation to surgery interval, total XRT dose, indication for XRT, and prior abdominopelvic surgery rates were similar between UD types. Median patient age by diversion was 76 for IC, 73 for CC, and 73 for ON (P⫽0.0019). Median follow up by diversion was 3yrs (0.3-15.2yrs) for IC, 16.9yrs (0.321.1yrs) for CC, and 6.6yrs (0.3-14.9yrs) for ON (P⫽0.009). A total of 195 late complications were recorded, with 173 (88.7%) occurring within the first 5yrs. Further analysis was restricted to the first 5yrs after surgery to account for the difference in follow-up between UD types. The number of late complications per patient and the highest grade complication were significantly related to UD type with a higher quantity and grade of complications seen in patients with CC and ON. (Table 1) Increased operative time was also significantly related to late complication grade (P⫽0.014). CONCLUSIONS: Late complications are common in patients undergoing radical cystectomy after high dose pelvic XRT. Late complication rate and severity are significantly related to the type of urinary diversion performed. All Patients 133
N
Ileal Conduit 61
Continent Orthotopic Cutaneous Neobladder P value 29 43
Late Complications per patient
0.0028
0
64 (48.1%) 38 (62.3%)
9 (31.0%) 17 (39.5%)
1
32 (24.1%) 14 (23.0%)
7 (24.1%) 11 (25.6%)
2
13 (9.8%)
4 (6.6%)
2 (6.9%)
7 (16.3%)
3
10 (7.5%)
1 (1.6%)
4 (13.8%)
5 (11.6%)
4
6 (4.5%)
1 (1.6%)
5 (17.2%)
0
ⱖ5
8 (6.0%)
3 (4.9%)
2 (6.9%)
3 (7.0%)
Highest Grade Late Complication
0.0018
Grade 0 (None)
64 (48.1%) 38 (62.3%)
Low Grade (1-2)
34 (25.6%) 17 (27.9%)
High Grade (3-5)
35 (26.3%)
6 (9.8%)
Source of Funding: None
9 (31.0%) 17 (39.5%) 8 (27.6%)
9 (20.9%)
12 (41.4%) 17 (39.5%)
