Fiona C. Burkhard

The orthotopic neobladder.

The orthotopic neobladder has not only withstood the test of time, but is increasingly becoming a more desirable method of urinary diversion [1,2]. This transition has been due to the increasing importance of providing patients with a favourable cosmetic outcome and the best quality of life after cystectomy. The orthotopic bladder shares many similar features with the original bladder, including a continent low-pressure reservoir of adequate capacity [3]. Complementing orthotopic neobladder features with adequate training allows patients to return to a close to if not normal urinary routine. Developing techniques, e.g. the nerve-sparing approach, further result in excellent functional outcomes in terms of continence, spontaneous voiding and normal erectile function.

Bladder substitution in women.

Abstract: Although numbers are still small and follow-up is often limited, female orthotopic bladder reconstruction has been shown to provide excellent, near-normal voiding and storage function in selected patients, and its popularity has been growing over the last decade. The true role of this form of surgery, however, is not yet fully established. This paper discusses the indications for patient selection, operative technique and outcome of female bladder substitution. Outcome is equivalent to that seen in male patients, although in some series there is a higher rate of voiding dysfunction requiring intermittent self-catheterization. Although further data regarding urethral recurrence rates are awaited, it would seem that with careful patient selection and operative technique, cancer surgery may not be compromised. Functional results have been excellent and patient satisfaction is very high. Provided there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.

Stenting Prior to Cystectomy is an Independent Risk Factor for Upper Urinary Tract Recurrence.

Purpose: Patients with bladder cancer who present with hydronephrosis may require drainage of the affected kidney before receiving further cancer treatment. Drainage can be done by retrograde stenting or percutaneously. However, retrograde stenting carries the risk of tumor cell spillage to the upper urinary tract. The aim of this study was to evaluate whether patients with bladder cancer are at higher risk for upper urinary tract recurrence if retrograde stenting has been performed prior to radical cystectomy. Materials and Methods: We retrospectively analyzed the records of 1,005 consecutive patients with bladder cancer who underwent radical cystectomy at our department between January 2000 and June 2016. Negative intraoperative ureteral margins were mandatory for study inclusion. Patients received regular followup according to our institutional protocol, including imaging of the upper urinary tract and urine cytology. Results: Preoperative drainage of the upper urinary tract was performed in 114 of the 1,005 patients (11%), including in 53 (46%) by Double‐J® stenting and in 61 (54%) by percutaneous nephrostomy. Recurrence developed in the upper urinary tract in 31 patients (3%) at a median of 17 months after cystectomy, including 7 of 53 (13%) in the Double‐J group, 0% in the nephrostomy group and 24 of 891 (3%) in the no drainage group. Multivariate regression analysis revealed a higher risk of upper urinary tract recurrence if patients underwent Double‐J stenting (HR 4.54, 95% CI 1.43–14.38, p = 0.01) and preoperative intravesical instillations (HR 2.94, 95% CI 1.40–6.16, p = 0.004). Conclusions: Patients who undergo Double‐J stenting prior to radical cystectomy are at higher risk for upper urinary tract recurrence. If preoperative upper urinary tract drainage is required, percutaneous drainage might be recommended.