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      Orthotopic MAINZ pouch bladder substitution – long-term follow-up

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          Abstract

          Introduction

          After radical cystectomy, orthotopic neobladder is one surgical strategy for urinary diversion. To assess the usefulness of an operation, long-term data are essential. We examined long-term complications and continence rates of orthotopic ileocecal (MAINZ pouch) bladder substitution.

          Material and methods

          Between 1986 and 2011, 193 patients underwent orthotopic MAINZ pouch bladder substitution. Until July 2000, ureter implantation was performed into the ascending colon through a submucosal tunnel technique (Goodwin-Hohenfellner). After July 2000, ureters were implanted into the terminal Ileum using the ileocecal valve to prevent reflux: the left spatulated ureter by an end-to-end (Wallace) and the right ureter by an end-to side technique (Nesbit). Surgical and medical follow-up reports were evaluated and a recent follow-up was obtained by a questionnaire.

          Results

          Median follow-up in 183 patients was 72 months (1–336). A total of 74 patients (38%) died during the follow-up. A surgical intervention was required in 26 out of 193 patients with early complications while 45 out of 183 patients had late and 17 patients had both, early and late complications. Ureteral stenosis was found in 13% of submucosal implanted ureters, 13% with the Wallace technique, and 3.6% with the Nesbit technique. In total, 66 patients responded to the questions concerning long-term continence (minimal follow-up >2 years). Overall, 84.8% were completely continent, 1.6%, reported grade I and 9.8% grade II stress incontinence.

          Conclusions

          The long-term continence and complication rates are comparable to those of other types of orthotopic bladder substitution. Orthotopic MAINZ pouch procedure can be considered as one of the options for orthoptic diversion, which stands the test of time.

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          Most cited references20

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          Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients.

          D Thangathurai, Fady M Mikhail, D. Raghavan … (2001)
          To evaluate our long-term experience with patients treated uniformly with radical cystectomy and pelvic lymph node dissection for invasive bladder cancer and to describe the association of the primary bladder tumor stage and regional lymph node status with clinical outcomes. All patients undergoing radical cystectomy with bilateral pelvic iliac lymphadenectomy, with the intent to cure, for transitional-cell carcinoma of the bladder between July 1971 and December 1997, with or without adjuvant radiation or chemotherapy, were evaluated. The clinical course, pathologic characteristics, and long-term clinical outcomes were evaluated in this group of patients. A total of 1,054 patients (843 men [80%] and 211 women) with a median age of 66 years (range, 22 to 93 years) were uniformly treated. Median follow-up was 10.2 years (range, 0 to 28 years). There were 27 (2.5%) perioperative deaths, with a total of 292 (28%) early complications. Overall recurrence-free survival at 5 and 10 years for the entire cohort was 68% and 66%, respectively. The 5- and 10-year recurrence-free survival for patients with organ-confined, lymph node-negative tumors was 92% and 86% for P0 disease, 91% and 89% for Pis, 79% and 74% for Pa, and 83% and 78% for P1 tumors, respectively. Patients with muscle invasive (P2 and P3a), lymph node-negative tumors had 89% and 87% and 78% and 76% 5- and 10-year recurrence-free survival, respectively. Patients with nonorgan-confined (P3b, P4), lymph node-negative tumors demonstrated a significantly higher probability of recurrence compared with those with organ-confined bladder cancers (P <.001). The 5- and 10-year recurrence-free survival for P3b tumors was 62% and 61%, and for P4 tumors was 50% and 45%, respectively. A total of 246 patients (24%) had lymph node tumor involvement. The 5- and 10-year recurrence-free survival for these patients was 35%, and 34%, respectively, which was significantly lower than for patients without lymph node involvement (P <.001). Patients could also be stratified by the number of lymph nodes involved and by the extent of the primary bladder tumor (p stage). Patients with fewer than five positive lymph nodes, and whose p stage was organ-confined had significantly improved survival rates. Bladder cancer recurred in 311 patients (30%). The median time to recurrence among those patients in whom the cancer recurred was 12 months (range, 0.04 to 11.1 years). In 234 patients (22%) there was a distant recurrence, and in 77 patients (7%) there was a local (pelvic) recurrence. These data from a large group of patients support the aggressive surgical management of invasive bladder cancer. Excellent long-term survival can be achieved with a low incidence of pelvic recurrence.
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            Twenty years experience with an ileal orthotopic low pressure bladder substitute--lessons to be learned.

            Urs E Studer, Fiona Burkhard, Martin Schumacher … (2006)
            We present the long-term results of a large consecutive series of patients undergoing ileal orthotopic bladder substitution following radical cystectomy. Between April 1985 and 2005 orthotopic bladder substitution with an ileal low pressure reservoir was performed in 482 patients (including 40 women) after radical and, if possible, nerve sparing cystectomy. In 447 cases the procedure was combined with an afferent ileal isoperistaltic tubular segment. The patients were followed prospectively. In the 482 patients 61 early (less than 30 days) diversion related complications requiring prolonged hospital stay or readmission were noted and 115 late complications required treatment. At 1 year continence was good in 92% of patients during the day and in 79% at night. At last followup 93% of patients could void spontaneously. Of 442 evaluable men 99 (22.4%) reported having erections without and 68 (15.4%) with medical assistance. Ureteroileal stenosis was observed in 12 of 447 (2.7%) patients. Urethral recurrence was detected in 25 of 482 (5%) patients. A total of 15 (5%) patients received vitamin B12 substitution. Renal parenchyma decreased only in patients with preoperative or postoperative ureteral obstruction. After 10 years patients with normal renal function had no long-term acidosis and in 20 patients the incidence of osteoporosis resembled that of the normal population. Ileal orthotopic bladder substitution combined with an afferent ileal tubular segment allows for good long-term functional results provided patients are restrictively selected, postoperative instructions are followed carefully, and typical complications such as outlet obstruction and hernias are treated early.
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              Long-term results of standard procedures in urology: the ileal neobladder.

              Urs E Studer, B. Volkmer, J Gschwend … (2006)
              Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2-3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1-2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11-12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cent European J Urol
                Journal ID (iso-abbrev): Cent European J Urol
                Journal ID (publisher-id): CEJU
                Title: Central European Journal of Urology
                Publisher: Polish Urological Association
                ISSN (Print): 2080-4806
                ISSN (Electronic): 2080-4873
                Publication date (Electronic): 19 April 2021
                Publication date (Print): 2021
                Volume: 74
                Issue: 2
                Pages: 235-240
                Affiliations
                [1 ]Department of Urology and Pediatric Urology, University Medical Center Mainz, Germany
                [2 ]Department of Urology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
                [3 ]Department of Pediatric, Adolescent and reconstructive Urology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
                Author notes
                Corresponding author Saskia Bröder, University Medical Center Mainz, Department of Urology and Pediatric Urology, 1 Langenbeckstr., 553131 Mainz, Germany. phone: +49 621 383 113. Saskia.Broeder@ 123456yahoo.de
                Article
                Publisher ID: 0275.R2
                DOI: 10.5173/ceju.2021.0275.R2
                PMC ID: 8318017
                PubMed ID: 34336244
                SO-VID: 51cd7cd6-a946-46f3-9b9f-3ca12d2e2394
                Copyright © Copyright by Polish Urological Association
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.

                History
                Date received : 29 September 2020
                Date revision received : 22 March 2021
                Date accepted : 29 March 2021
                Categories
                Subject: Original Paper

                Keywords: orthotopic bladder substitution,long-term results,bladder cancer,urinary diversion
                Data availability:
                Keywords: orthotopic bladder substitution, long-term results, bladder cancer, urinary diversion

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