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Objective To characterize the health-related quality of life reported by patients who received an ileal conduit (IC), Indiana pouch, or neobladder urinary diversion after radical cystectomy. Materials and Methods The Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index survey was administered to patients with bladder cancer undergoing radical cystectomy and urinary diversion from 2015-2018. Surveys were completed prior to radical cystectomy and then longitudinally throughout the postoperative course. Results A total of 146 patients completed questionnaires over a median of 12.3 months, 83 (56.8%) received an IC, 31 (21.2%) an Indiana pouch, and 32 (21.9%) an orthotopic neobladder. There were no significant differences in health related quality of life among urinary diversion groups considering the Trial Outcome Index scores, general overall FACT-G assessment, or total Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index instruments. Patients who received IC were older and had higher Charlson Comorbidity Index scores (p Conclusions To our knowledge this is the first and largest quality of life analysis comparing all three methods of urinary diversion in a longitudinal fashion utilizing a standardized, validated, treatment-specific health survey. Proper preoperative counseling is critical to ensure understanding of the benefits of available urinary diversion.

Objective To review surgical outcomes in urinary undiversions and describe short and long-term complications. Methods Retrospective review of patients who underwent urinary undiversion in our institution between May 2010 and May 2016. Complications were graded according to the Clavien classification. All patients completed the Patient Global Impression of Improvement questionnaire to indicate overall satisfaction with urinary undiversion. Results Median time from the cystectomy to undiversion was 29 months (range 11-53 months). Five patients (55%) reported significant distress related to the ileal conduit and were undiverted into an orthotopic neobladder. A female patient with an orthotopic neobladder and severe urinary incontinence received neobladder neck closure and catheterizable channel. Another female patient with an orthotopic neobladder was undiverted into an Indiana Pouch. Complications during the first 60 days were mostly minor, Clavien I (1 patient), 5 patients Clavien II, and a patient with Clavien IIIb. Patient Global Impression of Improvement questionnaire scores showed that 6 patients (67%) felt “Very much better” and 3 patients (33%) felt “Much better” after urinary undiversion 60%. Conclusion After urinary undiversions, minor complication rate is high, and major complication rate is considerable. Urinary undiversions are a highly complex, yet feasible procedure, which requires experienced multidisciplinary teams and demands appropriate patient selection. Patients, after undiversions show a high degree of satisfaction with long-term satisfactory outcomes, which points out the need for consideration for these procedures once the oncologic disease is controlled.

To evaluate the long-term (5 years) health-related quality of life (HRQOL) outcomes following radical cystectomy, comparing Indiana pouch (IP), neobladder (NB), and ileal conduit (IC).The departmental radical cystectomy database was queried to identify patients who underwent radical cystectomy and urinary diversion for bladder cancer between 1991 and 2009 and had not died. Three hundred patients were identified and sent the validated Bladder Cancer Index instrument.A total of 128 (43%) patients completed the survey. When adjusted for gender, age at surgery, surgeon, and time since surgery, IC and IP patients had significantly better urinary function than NB patients (P = .0013). Sexual bother was less in NB than IP (P = .0387). Among men ≥65 years of age, IC patients had significantly better urinary function (P = .0376) than NB patients (91.6 vs 49.4, respectively). Among men 65 years of age, IC and IP patients (76.0 and 82.8, respectively) had significantly better urinary function than NB patients (50.7) (P = .0199). Among women greater than 65 years, bowel bother was significantly better (P = .0095) for IC patients than IP patients (44.8 vs 69.5, respectively).Urinary diversion type after radical cystectomy affects HRQOL differently in long-term survivors. Age and gender at surgery influenced HRQOL based on diversion procedure. Urinary function but not urinary bother was significantly better in IC and IP compared to NB diversions. Prospective longitudinal studies using validated HRQOL tools will further help guide preoperative diversion choice decisions between patient and surgeon.

Introduction Continent catheterizable diversions can exhibit long-term complications such as high pressures and involuntary unit contractions within the urinary reservoir, rendering them similar to neurogenic bladders. Given the similarity of these issues to neurogenic detrusor overactivity, the use of Botox injections is a logical treatment option to explore. Technical Considerations A patient with a contracted Indiana pouch continent catheterizable diversion was treated with intra-pouch Botox injections after failing maximal doses of oral anticholinergic medications. This patient underwent four consecutive percutaneous Botox pouch injections every 11-12 months under general anesthesia. Flexible cystoscope via the catch stoma was attempted first on the first two surgeries, but the scope could not reach the majority of the pouch. Thus, percutaneous access was obtained under fluoroscopic guidance, and the injections were performed through a suprapubic tube access sheath. Two hundred to four hundred units of Botox (stained with methylene blue) were visually injected in 20-40 separate injection sites. Of note, the initial dose used was 200 units and was increased to 300 units then 400 units on subsequent treatments to improve results and durability. After each round of Botox injections, the patient noted resolution of her symptoms. Postinjection urodynamic studies showed normal filling with no evidence of muscularis overactivity, even at high volumes of 600 cc. Conclusion Botox injections may be an excellent long-term treatment option for contracted continent catheterizable diversions, or at least used as a temporizing measure before surgical augmentation. Further studies are needed to verify the durability, complications, and long-term outcomes of this procedure.

Colonic adenocarcinoma of a urinary diversion is rare. We report a case of a 70 year-old woman who developed such a malignancy 12 years after creation of an Indiana pouch urinary diversion for treatment of urothelial carcinoma of the bladder cancer.

Introduction Radical pelvic surgery requires continent or incontinent urinary diversion. There are many techniques, but the orthotopic neobladder is the most used. A continent catheterizable urinary reservoir is sometimes a good alternative when this derivation is not possible or not indicated. This paper has aimed to present our experience with the Indiana pouch continent urinary reservoir. Materials and methods The series is made up of 85 patients, 66 women and 19 men, with a mean age of 56 years (31–77 years). Variables analyzed were operating time, estimated blood loss, transfusion rate, hospital stay and peri-operatory complications. Results The main indication in 49 cases was resolution of complications related to the treatment of cervical cancer. Average operation time was 110.5 minutes (range 80–130 minutes). Mean blood loss was 450 cm3 (100–1000 cm3). Immediate postoperative complications, all of which were treated medically, occurred in 16 patients (18.85%). One patient suffered anastomotic leakage. Hospital stay was 19 days (range 5–60 days) and there was no mortality in the series. Late complications occurred in 26 patients (32%), these being ureteral anastomotic stenosis in 11 cases, cutaneous stoma stenosis in 9 cases and reservoir stones in 6 cases. Conclusion The Indiana continent catheterizable urinary reservoir is a valid option for the treatment of both urological and gynecological malignancies as well as for the management of pelvic morbidity related to the treatment of pelvic cancers.

Introduction and Objective Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly utilized approach to treating various bladder pathologies requiring extirpation. As surgeons have become more experienced with ICUD, especially with lesser-used diversions such as continent cutaneous reservoirs, the technique has evolved. Methods We describe our technique and recent advances in the practical creation of robotic ICUD with a continent catheterizable pouch (CCP) built upon the open principles of the previously described “Indiana Pouch,” which uses the distal ileum and right colon. Modifications in anatomic mobilization and exposure, bowel segmentation using novel robotic bowel staplers, catheterizable channel creation, and addition of ileal chimney for uretero-enteric anastomoses are highlighted. The addition of the ileal chimney allows for ease of reconstruction in a fashion familiar to surgeons accustomed to performing intracorporeal ileal conduit and, therefore, may result in lower ureteroenteric stricture rates. Table 1 demonstrates the supplies used intraoperatively. Use of indocyanine green to assess vascularity in bowel and ureter intraoperatively is demonstrated. The port configurations are demonstrated using the DaVinci ® Xi platform. Also described are short-term outcomes of our initial experience. Results Eleven consecutive patients (5 female) who have undergone ICUD with CCP were included. Of the eleven, seven had malignant indications (bladder or urethral cancer) while 4 were for benign causes (2 radiation cystitis, 2 interstitial cystitis). Mean blood loss was 235cc (range 100–500cc) and mean operative time was 8.5 h (range 7–13). There were no conversions to an open procedure and no patient required a blood transfusion. Hospital stay was 7.2 days on average (range 4–18) with no 30-day post-discharge readmissions. One patient had a Clavien grade 3 or greater complication at 30 days (Table 2). No urine leaks or bowel leaks were observed and no patient experienced stomal stenosis or uretero-enteric stenosis. At three months follow up, all patients were continent and satisfied with their diversion. Conclusions RARC with CCP ICUD is a safe and effective approach to bladder removal and reconstruction. As more surgeons utilize RARC, growing attention to techniques of intracorporeal reconstruction will allow further implementation of this technique to cystectomy patients. Patients with adequate renal function (glomerular filtration rate of 40 mL/min or greater) and hepatic function, who understand the requirement for regular clean-intermittent-catheterization and who possess mental acuity and manual dexterity to empty their pouch 4–6 times daily should be offered CCP ICUD as a reconstructive option following RARC.

Objective To evaluate the functional outcomes and complications for patients with bladder cancer undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion. Methods From February 2004 to March 2010, 34 patients underwent robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction. After surgery, the complications were identified, categorized, and graded using an established 5-grade modification of the original Clavien grading system, and continence was assessed. Descriptive statistics were used in evaluating the outcomes. Fischer's exact test was used in the comparison of early and late Clavien grade III complications. Results Overall, 175 (123 early and 52 late) complications after surgery were reported in 32 (94%) of 34 patients. Within 90 days of surgery, 31 (91%) of 34 patients experienced ≥1 early complication. Of 34 patients, 15 (44%) reported ≥1 late complications (>90 days). Most (85% and 69%, respectively) early and late complications were graded as minor (grade II or less). Fewer patients with early complications required an additional intervention (grade III) compared with patients with late complications (14% vs 31%; P = .116). The most common complication in both intervals was infection, reported in 22% and 37% of patients with early and late complications, respectively. The continence data for 31 patients at a mean follow-up of 20.1 months (median 12.0) showed that all but 1 patient (97%) had daytime and nighttime continence. Conclusion Patients undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction have comparable complication rates and functional outcomes compared with patients in the open series.

Purpose We present a single institute experience of the four most widely used diversions after cystectomy in 281 patients, with an evaluation of the association between clinical factors, complication rates, functional results, and metabolic complications. Materials and methods Between 1990 and 2005, 281 consecutive cystectomies were performed at our institute. Four different diversions were offered: an ileal conduit according to Bricker (IC; 118 patients), an Indiana pouch (IP; 51 patients), and orthotopic diversions after cystectomy/neobladder (N; 62 patients), or sexuality-preserving cystectomy and neobladder (SPCN; 50 patients). Results Forty-four percent developed early complications: IC 48%, IP 43%, N 42%, and SPCN 38%. High ASA score was the only variable significantly associated with early major complications (ASA 1 vs. 3: HR, 0.32; 95%CI, 0.14–0.72). Late complication rate was 51% with fewer complications in the IC group, IC 39%, IP 63%, N 59%, and SPCN 60% (HR, 0.32; 95%CI, 0.14–0.72), which was explained by fewer uncomplicated urinary tract infections (one third of all late complications) in the IC group. There were no differences in experienced late major complications. We found no significant association between tumour stage, ASA, age, preoperative radiotherapy, gender, and diversion-related complication rates. Complete daytime and nighttime continence, respectively, was achieved in 96% and 73% after IP, 90% and 67% after neobladder, and 96% and 67% after SPCN. Metabolic changes were found in 24% of the patients: 21% after IC, 26% after IP, and 28% after orthotopic diversion (neobladder and SPCN combined); low vitamin B12 was measured in 23%, 15%, and 15% respectively. Conclusions Cystectomy with any subsequent diversion remains a procedure with considerable morbidity. High ASA score was associated with more early complications. Orthotopic diversions provide good functional results, but at the cost of more late complications compared with ileal conduits. We found no evidence that age, ASA score, positive lymph nodes, extravesical tumour growth, or previous radiotherapy were contraindications per se for any diversion.

Pediatric extrarenal malignant rhabdoid tumors (MRTs) are rare and aggressive (20% 5-year survival). Only 2 cases of bladder MRTs have been published. We report on a 9-year-old boy presenting with gross hematuria, palpable pelvic mass, and an obstructed, nonfunctional kidney. Evaluation was consistent with a 9.7 cm extrarenal MRT invading the bladder and prostate. He underwent a cystoprostatectomy, Indiana pouch continent urinary reservoir creation, and a left nephroureterectomy. A discrete 2.5 cm focus of renal MRT was found. To our knowledge, this is the first case of simultaneous perivesical and renal MRT. We review the current management of pediatric extrarenal MRTs.

To evaluate the effects of ileal bladder substitution or colonic Indiana pouch on skeletal bone density and various biochemical parameters related to bone metabolism.In 27 patients with urinary diversion and 14 controls with benign urologic disease, bone mineral density (BMD), assessed by dual-photon absorptiometry; serum electrolyte, creatinine, alkaline phosphatase and parathyroid hormone levels were determined, and capillary blood gas analysed. BMD was measured in the lumbar spine and the femur neck. The mean time since surgery was 33.6+/-10.1 months in 17 patients with an ileal bladder substitution and 56+/-9.1 months in 10 patients with a colonic Indiana pouch (p=0.001).Although BMD did not change in the colonic Indiana pouch group, it was reduced in the patients with ileal bladder substitution compared to control group. The mean pH value was not statistically significant different in the both groups from the control group (p0.2). The mean base excess value reduced in the substitution group (p0.01). While alkaline phosphatase levels increased in both groups compared to control group (p0.05), the mean parathyroid hormone level decreased only in the patients with ileal bladder substitution (p0.05). The other biochemical parameters were similar in patients and control subjects. There was a statistically significant correlation between the base excess values and BMD values of the patients in both groups.Although there is decreased BMD in patients with an ileal bladder substitute, there is no change in BMD in the patients with Indiana pouch. Alkaline phosphatase levels increased in both patient groups indicating increased bone turnover.

Background. Formation of urinary stones in a continent urostomy (Indiana pouch) has been described as a late complication. Management of a patient with symptomatic multiple large stones and review of the literature are outlined. Case report. A 32-year-old woman presented with recurrent urinary tract infections and pyelonephritis 6 years after a total pelvic exenteration and creation of a continent urostomy for central recurrent carcinoma of the cervix after radical pelvic radiation. Multiple large stones were found to be the underlying etiology. Laparotomy, enterocystotomy, and removal of stones were performed without apparent complication. Conclusion. It is recommended that for single calculi or multiple small stones, electroshock wave lithotripsy or the percutaneous endoscopic approach be considered. For larger stones the use of laparotomy and enterocystostomy may be appropriate.

The right colon reservoir using a stapled plicated ileal efferent limb (Indiana continent urinary reservoir) has been demonstrated to be a reproducible durable form of continent diversion. The overall day and nocturnal continence rate of 94% compares favorably with all other forms of continent cutaneous diversion. Carefully following the technique of stapling and plicating the ileal efferent limb and ileocecal valve as described in this article nearly ensures adequate competence of the outlet valve. In the rare case in which incontinence occurs, it is almost always on the basis of high-pressure unit contractions of the reservoir. On occasion, patients who develop incontinence are observed to have high pressures within the reservoir despite complete detubularization of the right colon segment. When this problem is encountered it can be corrected successfully by adding an ileal patch augmentation to the previously detubularized reservoir. The issue of ureteral implantation in continent urinary diversions is as yet unsettled. Many authors have not used ureteral tenial tunnels and have reported a reflux rate of < 13%. Furthermore, these patients have not developed any long-term sequelae of their reflux. Although favorable results have been obtained without creating tunneled tenial reimplantation, we believe that continent cutaneous reservoirs are almost always colonized with bacteria, and an antireflux mechanism may offer protection against subsequent pyelonephritis. Closure of the reservoir traditionally has been conducted by hand at our institution; however, the development of smaller absorbable gastrointestinal anastomosis stapling devices offers the theoretic advantage of shortening the operative time. We anxiously await follow-up, including larger patient numbers and longer term follow-up of the absorbable staple technique. The use of continent cutaneous urinary diversion clearly has decreased as bladder replacement has become a more viable procedure over the past decade. Despite this, the urologic reconstructive surgeon must maintain the ability to perform continent cutaneous diversion in patients who are unwilling to accept the potential for nocturnal incontinence observed in all forms of bladder replacement as well as the patients who have ineffective sphincter mechanism or who need a urethrectomy due to their primary disease.

A short ureteral length can preclude the use of a continent urinary diversion during urinary tract reconstruction after bladder removal. We present a surgical technique using the in situ appendix to provide length to a shortened left ureter, thus allowing formation of a continent ileocecal urinary diversion.

Pelvic exenteration for treatment of malignant gynecologic disease is most often done for recurrent cervical cancer, although cytologic screening has substantially decreased the number of patients considered for the operation. The authors prefer the Indiana pouch for urinary diversion, and all patients in whom it has been used in the past 2 years have achieved continence. To avoid reoperation, a diverting, rather than a protective, colostomy is constructed during the exenteration. Postoperative management of fistulae may include the use of somatostatin analog and percutaneous nephrostomy. Survival depends on the extent of resection and various clinical and pathological factors. Newer techniques for delivering additional radiation to recurrent tumors may increase the number of patients eligible for curative exenteration.

have described our experience with intracorporeal urinary diversions, including orthotopic ileal neobladder and ileal conduit. Intracorporeal urinary diversion remains an advanced technique focused in centers of excellence. To our knowledge, there have been no previous reports of robotic intracorporeal continent cutaneous diversion. Herein, we provide the first description of our technique of robotic intracorporeal continent cutaneous urinary diversion (Indiana pouch) following robotic cystectomy, including the results of our initial experience. METHODS: We perform a robotic cystoprostatectomy using a standard 6-port transperitoneal technique, as previously described. We provide a step-by-step illustration of our intracorporeal approach to right colonic mobilization, bowel segmentation, ileocolonic anastomosis, ureterocolonic anastomoses, and creation of a hand-sewn Indiana pouch continent cutaneous urinary diversion. We describe optimization of port utilization and technique for robot positioning. Tapering of the catheterization channel and reinforcement of ileocecal valve are performed via the standard extraction incision. RESULTS: Robotic intracorporeal Indiana pouch was successfully performed following robotic cystoprostatectomy. Only 2 additional port incisions were necessary to complete the diversion. Operative time for intracorporeal diversion was 180 minutes, with negligible blood loss, and without any intra-operative complications. Post-operative care followed a standardized clinical care pathway. Length of stay was 7 days. There were no major (Clavien 3-5) 90-day complications observed. Externalized ureteral stents are removed at 2 weeks. At 3 weeks post-operatively, a pouchgram is performed. The malecot drain is capped, and the patient begins catheterizing via the cutaneous stoma. The malecot is subsequently removed. CONCLUSIONS: We demonstrate robotic intracorporeal continent cutaneous urinary diversion following robotic cystectomy is technically feasible and safe. Early functional results are promising. To our knowledge, this is the first description of completely intracorporeal continent cutaneous diversion.

Studer neobladder (N1⁄43), Indiana pouch (n1⁄42), and ureteroileal diversion (N1⁄41). Ten patients had undergone urological surgery for transitional cell carcinoma, one for trauma, and one for neurogenic bladder. Seven strictures were left-sided and five were on the right. PCBU balloon sizes ranged from 5to 8-mm. Immediately following each PCBU, ureteric patency was assessed and percutaneous nephroureteral stents were placed. Follow-up antegrade nephrostograms were performed at 4-6 weeks intervals. Based upon the nephrostogram and clinical findings, patients underwent either conversion to nephrostomy, repeat dilatation and catheter exchange, or catheter removal. Technical success was defined as the ability to inflate the PCB to profile during the ureteroplasty. Clinical success was defined as attainment of tube-free existence. Failure time was defined as the interval between PCBU and the point at which the stenosis recurred and required re-intervention (surgery or repeat dilation) Results: Immediate technical success of PCBU was 100%. No deaths, or bleeding requiring transfusion or surgery occurred. A single patient was lost to follow-up. Clinical success was achieved in 8 /11 (73%) of the patients available for follow-up. The median failure time of PCBU for all patients, including those without clinical success, was 28 months (95% CI [0,52]. Of patients who achieved clinical success, the median failure time was 40 months (95% CI [5, na]). In addition, for those who achieve clinical success, failure rate was estimated at 33% at 25 months and 73% at 52 months. Conclusion: PCBU can to be a safe and effective treatment alternative to surgery in patients with uretero-enteric anastomotic strictures. Patients that achieve clinical success will generally achieve 3 or more years of tube free existence.

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.