Spectrum of imaging manifestations of tumour recurrences in orthotopic neobladder

Continent diversion with orthotopic neobladder is the most upcoming form of urinary diversion postradical cystectomy. This allows patients to void through the native urethra preserving the maximal quality of life. These patients with greater life expectancies increasingly present with a wide range of late complications, which also include local recurrences involving neobladder. Such presentations on surveillance scans can be challenging for radiologists unfamiliar with expected post-surgical anatomy and usual sites of local recurrences. Tumour in neobladder, although rare, has predilection concerning specific sites of involvement and few distinct histological types. Major subtypes of such recurrences with corresponding radiological features on multimodality imaging have been discussed in this article. Management of such cases with revision of diversions is challenging, and surgeons expect a meticulous read of such scans before contemplating pelvic clearance and secondary diversions. This pictorial review aims to appraise the literature related to various primary and secondary types of tumours involving reservoir and anastomotic sites in an orthotopic neobladder, their relative incidences and illustrate salient imaging points with case examples.

Long-Term Outcomes Following Surgical Management of Urethral Catheter Injuries in Men With Spinal Cord Injury

Objective: To evaluate the outcomes of surgical management of men with spina cord injury (SCI) with subsequent catheter damage to the urethra that prevents clean intermittent catheterization (CIC). Methods: We performed a retrospective analysis of male SCI individuals on CIC with catheter-induced urethral injuries who had undergone an operative intervention in the last 30 years at our institution. The offered surgical managements were direct vision internal urethrotomy (DVIU) or urethroplasty (UP). Continent diversion (CDIV) was indicated when reconstruction was not possible. Results: A total of 43 male SCI patients were identified. Median age was 50 years (IQR 41 to 57), and follow-up was 69 months (IQR 34 to 125). Inability to perform CIC was due to urethral stricture (25), false passages (11), fistula (4), diverticulum (2), and urethral erosion (1) . Primary intervention techniques were DVIU, UP, and CDIV. Overall primary success, defined by the ability to return to continent CIC, was 25/43 (58%); secondary surgery (10 CDIV, 3 UP, 1 DVIU) rescued 14/18 failures for a final 91% success rate. Conclusion: Urethral injuries in men with SCI are complex, but individualized continued surgical management can be successful in up to 90% of patients. Therefore, reconstruction should be considered in this population to restore continent intermittent catheterization.

Comparison of postoperative complications and quality of life between patients undergoing continent versus non-continent urinary diversion after pelvic exenteration for gynecologic malignancies

BackgroundPelvic exenteration and its reconstructive techniques have been associated with high postoperative morbidity and a negative impact on patient quality of life. The aim of our study was to compare postoperative complications and quality of life in patients undergoing continent compared with non-continent urinary diversion after pelvic exenteration for gynecologic malignancies.MethodsWe designed a multicenter study of patients from 10 centers who underwent an anterior or total pelvic exenteration with urinary reconstruction for histologically confirmed persistent or recurrent gynecologic malignancy after previous treatment with radiotherapy. From January 2005 to September 2008, we included patients retrospectively, and from September 2008 to May 2009, patients were included prospectively which allowed collection of quality of life data. Demographic, surgical, and follow-up data were analyzed. Postoperative complications were classified according to the Clavien–Dindo classification. Quality of life was assessed using the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C30 (V.3.0) and EORTC-QLQ-OV28 quality of life questionnaires. We compared patients who underwent a continent urinary diversion with those who underwent a non-continent reconstruction.ResultsWe included 148 patients, 92 retrospectively and 56 prospectively. Among them, 77.4% had recurrent disease and 22.6% persistent disease after the primary treatment. In 70 patients, a urinary continent diversion was performed, and 78 patients underwent a non-continent diversion. Median age of the continent and incontinent groups was 53.5 (range 33–78) years and 57 (26-79) years, respectively. There were no significant differences between the continent and non-continent groups in median length of hospitalization (28.5 vs 26 days, P=0.19), postoperative grade III–IV complications (42.9% vs 42.3%, P=0.95), complications needing surgical (27.9% vs 34.6%, P=0.39) or radiological (14.7% vs 12.8%, P=0.74) intervention, and complication type (digestive (23.2% vs 16.7%, P=0.32) and urinary (15.9% vs 16.7%, P=0.91)). There were no significant differences between the groups in global health, global quality of life, and body image perception scores 1 year after surgery.ConclusionContinent and incontinent urinary reconstructions are equivalent in terms of postoperative complications and quality of life scores.

30-day readmission after radical cystectomy: Identifying targets for improvement using the phases of surgical care

Introduction: Postoperative readmissions following radical cystectomy (RC) have gained attention in the past decade. Postoperative and post-discharge complications play a role in readmission rates; however, our ability to predict readmissions remains poor.Methods: Using the National Surgical Quality Improvement Program database, we identified patients with bladder cancer undergoing RC from 2013–2015. Complications were defined as postoperative and post-discharge. Outcomes were 30-day readmission, post-discharge complications, and post-discharge major complications. Patient, operative, and complication factors were assessed using multivariable logistic regression.Results: We identified 4457 patients who underwent RC; 9.2% of patients experienced a postoperative complication, 18.8% experienced a post-discharge complication, and 20.3% were readmitted. Overweight and obese body mass index (BMI), dependent functional status, chronic obstructive pulmonary disease (COPD), a continent diversion, and duration of operation were associated with post-discharge complications. Postoperative complications were not associated with post-discharge complications. Readmission was associated with Black race (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.0–2.1), overweight (OR 1.5; 95% CI 1.2–1.8) and obese BMI (OR 1.5; 95% CI 1.2–1.9), diabetes (OR 1.2; 95% CI 1.0–1.5), COPD (OR 1.4; 95% CI 1.0–1.8), steroid use (OR 1.5; 95% CI 1.0–2.2), a continent diversion (OR 1.4; 95% CI 1.1–1.7), duration of operation (OR 1.1; 95% CI 1.1–1.2), and postoperative complications (OR 1.5; 95% CI 1.2–2.0). The majority of readmissions experienced a post-discharge complication.Conclusions: Factors that span the preoperative, intraoperative, postoperative, and post-discharge phases of care were identified to increase readmission risk. To improve readmission rates, interventions will have to target factors across the surgical experience.

HETEROTOPIC CONTINENT OR INCONTINENT URINARY DIVERSION:MAKING THE OPTIMAL CHOICE

Introduction. Quality of life and survival rate of post-cystectomy patients depend on the urinary diversion methods [1,2].Purpose of the study. A comparison of morbidity, survival rate, and quality of life in patients after heterotopic continent or incontinent urinary diversions.Materials and methods. During the period from 1998 to 2016, 36 heterotopic intestinal diversions were performed using urine containment method according to the Kock pouch scheme in our modification, and 61 incontinent heterotopic intestinal Bricker diversions. We evaluated the comorbid conditions (Charlson comorbidity index), postoperative complications (acc. to Clavien-Dindo), survival rate (acc. to E.L. Kaplan, P. Meier), and the quality of life of patients (SF-36) using complex statistical analysis.Results. Early and late complications not related and related to urinary diversion prevailed in the group of patients after Bricker surgery without statistical significance. With longer postoperative monitoring periods the share of complications related to urinary diversion increases, while the frequency of delayed complications and survival rate show no statistical difference in both groups. No reliable differences were revealed in the quality of life in all cases of cutaneous urinary diversion.Discussion. 80% of patients after the Kock pouch surgery (mod.) throughout the medium follow-up period of over 5 years remain continent and enjoy high quality of life. It is necessary to develop and implement in clinical practice new and more advanced statistical tools for evaluation of the patients’ quality of life depending upon the type of urinary diversion after cystectomy.Conclusion. Heterotopic continent diversion (Kock pouch (mod.)) in comparison with the incontinent method (Bricker) does not increase morbidity or decrease the survival rate, and provides for higher quality of life.