e. refer for physical therapy for pelvic floor strengthening.

Answers

1.b. Demonstration in cystectomy specimens that urethral involvement was rare in the absence of tumor at the bladder neck. The two findings that paved the way for orthotopic diversion in women were retrospective pathologic studies showing that urethral involvement was rare in the absence of bladder neck involvement (in other words, “skip lesions” were rarely seen, suggesting oncologic safety) and studies showing that women could be continent without an intact bladder neck (previously thought to be required).

2.a. Prostatic stromal invasion. Two large studies have demonstrated conclusively that urethral recurrence in men is associated with prostatic stromal invasion in the cystectomy specimen.

3.b. Older patients take longer to regain continence than younger patients.

Older men regain continence more slowly than younger men, but the majority of fit older men will ultimately have good control, especially in the daytime. Older men often have difficulty becoming independent in managing an ileal conduit, and in a man living alone a neobladder may actually be simpler.

4.e. A 58-year-old woman with palpable induration of the anterior vaginal apex. Women with palpable invasion of the anterior vaginal wall have a high risk of urethral tumor and should not undergo orthotopic diversion.

5.c. The bowel used should be detubularized and fashioned into a spherical shape. Orthotopic diversions can be made from small or large bowel. The key to obtaining a low-pressure reservoir with good volume is to detubularize the segment and reconfigure it into a spherical shape.

6.d. Preservation of the uterus. Late urinary retention ("hypercontinence") in women appears to be primarily due to posterior displacement of the pouch into the vagina resulting in a kinking at the urethral anastomosis.

A number of maneuvers have been suggested such as sacroculpopexy, but preservation of the uterus appears to be the most promising.

7.b. Avoid excess dissection anterior to the urethra. In preserving the urethra for an orthotopic bladder in males, one should be careful of the dorsal venous complex and avoid deep bites into the pelvic floor, especially anterior to the urethra where the rhabdosphincter is the most developed.

8.d. Complete the cystectomy and neobladder and refer for adjuvant

chemotherapy. Patients with node-positive disease have a poor prognosis, but up to 30% may be long-term survivors, especially with adjuvant chemotherapy. Orthotopic diversion should not impact survival, and if a patient is highly motivated to avoid a stoma, this option can still be pursued.

9.b. Evaluation of renal function. In order to be considered a candidate for a continent diversion, a patient must have a glomerular filtration rate (GFR) in

excess of 35 mL/min, and the kidneys must be capable of concentrating and acidifying the urine.

.d. Pudendal nerve. The rhabdosphincter is innervated by the pudendal somatic nerve. The contribution to continence from the pelvic autonomic plexus is uncertain, although some nonrandomized studies suggest that preserving the neurovascular bundle posterolateral to the prostate may

improve continence.

.d. The staples become a nidus for stone formation. Metallic staples have a high association with subsequent stone formation, as was seen in the longterm experience with the hemi-Kock pouch. Recent efforts to perform intracorporeal neobladder using minimally invasive techniques have advocated using GIA staplers, but early results have suggested a high risk of stones.

.e. Systemic chemotherapy with or without external beam radiation. Local recurrence of urothelial cancer will not usually impact the neobladder function. Rarely, direct invasion of the reservoir will cause bleeding or outlet obstruction. Prognosis is poor, and local resection is rarely successful in eradicating the tumor, so primary treatment should be systemic chemotherapy and possibly radiation (which can be safely applied around a neobladder).

.c. Does not generally require treatment. In patients with orthotopic bladders, approximately one quarter have asymptomatic bacteriuria.

After the initial 6 months it is rare for patients to have symptomatic infections or pyelonephritis, and bacteriuria does not require treatment.

.c. Check postvoid residual. Patients who have a change in their continence after initial good function should be evaluated for possible urinary retention. This is often the first sign of incomplete emptying. Urodynamics are not necessary unless the pouch is made from colon, because ileal neobladders are very reliably low-pressure with good compliance.

.a. Teach the patient intermittent catheterization. All patients who are considered for a continent diversion should be willing and able to perform self-catheterization. The likelihood of needing self-catheterization

is lower in men than in women, with reported rates of 10% to 40% in most series.

.d. Have often been underpowered or affected by selection bias. Quality-of- life surveys have not shown one type of urinary diversion to be superior over another, though the vast majority of studies have serious methodological flaws. Obviously, randomized studies in this area have been impossible. Most patients are reasonably well adapted socially, physically, and psychologically to their diversion. The key to this adaptation is

appropriate and realistic preoperative education.

.d. Percutaneous drainage of the fluid collection. If a patient has an undrained urine leak postoperatively, percutaneous drainage is the first step. Nephrostomy tubes can be placed if a large urine leak does not respond

to percutaneous drainage with optimal catheter drainage. Open surgical repair should be avoided if possible because the complication rate is high and success in closing the leak in the face of acute postsurgical inflammation is low.

.c. Evaluate for possible vesicovaginal fistula. A woman with persistent incontinence should be evaluated for a pouch vaginal fistula. This is most common when the anterior vaginal wall is removed with the specimen. It is best prevented by interposition of an omental pedicle but still can occur. Evaluation is easily performed with a speculum exam with methylene blue in the bladder.

. e. Renal ultrasound and vitamin B12 level every 1 to 2 years. Long-term risks in diversion patients include late ureteral stricture, stones, decreased bone density, and vitamin B12 deficiency. All of these can be silent, so long-term routine follow-up is required. Most primary care physicians are not familiar with this.

.d. Continuous IV narcotics to optimize pain management. New ERAS protocols have resulted in shorter hospital stay. Avoidance of bowel prep and

the use of the μ opioid inhibitor alvimopan have been proven effective in randomized trials.

.b. Stenosis of the afferent nipple valve. Afferent nipple stenosis is a welldocumented late complication of the classic hemi-Kock pouch with an intussuscepted nipple valve antireflux mechanism. Treatment includes nephrostomy tube placement and endoscopic incision of the valve mechanism.

.d. The surgery can be performed through a smaller incision. A large series of patients undergoing robotic-assisted cystectomy with extracorporeal

diversion showed no decrease in hospital stay or early or late complications compared with open series, and this was confirmed in one recent randomized trial from Memorial Sloan-Kettering. Oncologic efficacy appears to be similar, but long-term results are not yet available.

.e. Cystoscopy and extraction of the stone. Stones can occur in all types of continent diversions. These stones should be removed endoscopically while

they are still small.

.a. Reassurance that the nighttime continence will likely improve with more time. Patients typically attain nighttime continence more slowly than daytime, with patients reporting improvement out to 1 to 2 years.

Early on there is an obligate nocturnal diuresis from the pouch that aggravates this. If the patient has good daytime control, further efforts to strengthen the sphincter are unlikely to help the nighttime continence. There is no role for anticholinergics or urodynamics in this setting.

Chapter review

1.The volume of the reservoir generally increases over time. Reservoirs constructed from ileum generally have a greater increase in volume over time than pouches constructed with colon.

2.The risk factors in women that are most predictive of urethral cancer developing are vaginal wall invasion or bladder neck involvement of transitional cell carcinoma.

3.The majority of patients who have a urethral recurrence are symptomatic on presentation. A urinary cytology has a variable rate of yield but is generally low in this group of patients.

4.When orthotopic bladders are constructed in elderly patients, there is a slower time to achieve continence, an increased rate of stress incontinence, and an increased incidence of nighttime incontinence when compared with younger patients.

5.In order to consider a patient a candidate for a continent diversion, he or she must have a glomerular filtration rate (GFR) in excess of

60 mL/min, and the kidneys must be capable of concentrating and acidifying the urine. A minimum GFR of 35 mL/min is required for a conduit diversion if metabolic problems are to be manageable.

6.All patients who are considered for a continent diversion should be willing and able to perform self-catheterization, although for selected patients this may not be necessary.

7.In preserving the urethra for an orthotopic bladder in males, one should be careful of the dorsal venous complex, preserve the puboprostatic ligaments, and avoid deep bites into the pelvic floor. In females, the endopelvic fascia and levator muscles should be preserved.

8.In patients with orthotopic bladders, approximately one quarter have asymptomatic bacteriuria.

9.The need to perform an antireflux mechanism for the ureters in an orthotopic urinary diversion is unproved.

10.If there is any suggestion that a nerve-sparing technique might result in a positive surgical margin, the nerve should be sacrificed. This does not mean that the diversion cannot be successfully performed or that the patient will not be continent.

11.Nighttime incontinence occurs in approximately 25% to 75% of patients.

12.Urinary retention following orthotopic urinary diversion occurs in 10% to 25% of patients and is more common in women than in men.

13.It may take 3 to 6 months for daytime continence to develop in many patients. Nocturnal continence may take more than a year after surgery.

14.If a patient has an undrained urine leak postoperatively, percutaneous drainage and/or nephrostomy is preferable to open surgical repair because the latter is extremely difficult and the complication rate is high.

15.Obstruction from an antireflux valve may be clinically silent, and patients may present with hydronephrosis and/or renal failure.

16.A pouch vaginal fistula is a morbid complication in female patients and is most likely to occur when the anterior vagina is removed along with the bladder. It is best prevented by interposition of an omental pedicle.

17.Quality-of-life surveys have not shown one type of urinary diversion to be superior over another. Most patients are reasonably well adapted socially, physically, and psychologically to their diversion. The key to this adaptation is appropriate and realistic preoperative education.

18.Preserving the uterus and vagina and their supporting structures limits the risk of a vaginal fistula, improves sexual function, and may decrease urinary retention in women who undergo a continent diversion.

19.The absence of the guarding reflex and increased volume output at night due to secretion of fluid by the bowel and the physiologic diuresis that occurs in older patients in the supine position contributes to nighttime incontinence.

20.In women, one fourth will have daytime leakage, one third will have

nighttime leakage, and two thirds will require self-catheterization at least once a day.

21.Women with palpable invasion of the anterior vaginal wall have a high risk of urethral tumor and should not undergo orthotopic diversion.

22.Long-term risks in diversion patients include late ureteral stricture, stones, decreased bone density, and vitamin B12 deficiency.