BACKGROUND AND PURPOSE: The storage and drainage of urine after total cystectomy for bladder cancer has been a problem that has not been satisfactorily resolved. There is a wide range of clinical disciplines related to urinary diversion and bladder reconstruction, and the characteristics of the various procedures vary, making it difficult to choose a commonly used and standard alternative bladder procedure. This study attempted to summarize the 8-year follow-up results of the two most commonly used alternative bladder procedures (Bricker’s procedure and Studer’s in situ cystectomy) in our department and to evaluate the clinical outcomes of both procedures in total cystectomy for bladder cancer.
DATA AND METHODS: The follow-up data of patients undergoing total cystectomy for bladder cancer from April 2005 to August 2013 were collected, and the results of general tumor status, intravenous pyelogram, and electrolytes of liver and kidney function were recorded in patients undergoing Bricker; the results of general tumor status, urinary flow rate, cystoscopy, intravenous pyelogram, electrolytes of liver and kidney function, and urinary routine in patients undergoing Studer; and statistical Statistical analysis was performed.
Results: 266 cases in the Bricker operation group, mean age 72 years, 179 men and 87 women; 97 cases in the Studer in situ cystectomy, mean age 56 years, 94 men and 3 women. There was no one death in this group due to surgery and two deaths due to metastasis (both in the Bricker operation group). In the early postoperative period, incomplete intestinal obstruction occurred in 3 cases in the Bricker group and 1 case in the Studer group; intestinal fistula, 1 case (occurred in the Bricker group). Late complications, Bricker group: ureteral anastomotic stricture, 1 case; Studer group: new bladder neck and urethral anastomotic stricture, 1 case. urination in Studer group: all had varying degrees of urinary incontinence in the early postoperative period and urinary control was restored after 1 week. The new bladder volume was 100~200ml in the first 3 months, 200~350ml 6 months after surgery, 350~500ml after 1 year, average 450ml. residual urine was 10~100ml, average 30ml. 1 patient had hypokalemic walking weakness, which improved after potassium supplementation. the rest of the patients had normal renal function, no acidosis manifestation, no upper urinary tract dilatation, and no ureteral reflux apparent on cystography. Cystoscopy did not show urethral and neobladder implantation metastases.
CONCLUSION: Complications of bowel surgery may be related to the general condition of patients such as age; Bricker procedure can protect renal function, has a low complication rate, has a relatively wide range of indications, and remains a common method for clinical urinary diversion. Compared to the Bricker procedure, Studer in situ cystectomy has certain requirements for patient cognition and bladder-spreading muscles, and is a bladder reconstruction procedure with relatively high quality of life and low complication rate that can be chosen first.
Keywords: ileal cystectomy, in situ neocystectomy, total cystectomy, follow-up, urinary diversion
Radical total cystectomy is the treatment of choice for muscle-invasive bladder cancer and some high-risk superficial bladder cancers. The storage and drainage of urine after total cystectomy has been a problem that has not been satisfactorily resolved. There is a wide range of clinical disciplines related to urinary diversion and bladder reconstruction, and the characteristics of the various procedures vary, making it difficult to choose a commonly used and standard alternative cystectomy. In this study, we attempted to summarize the 8-year follow-up results of the two most commonly used alternative bladder procedures (Bricker procedure and Studer in situ cystectomy) and evaluate the clinical outcomes of both procedures in total cystectomy for bladder cancer.
1.Objects and methods
1.1 Subjects: Clinical data and postoperative follow-up data of patients who underwent total cystectomy (including Bricker’s and Studer’s in situ cystectomies) from April 2005 to August 2013 were collected.
1, 2 METHODS: The general tumor status, follow-up intravenous pyelogram, liver and kidney function electrolytes and other results of patients undergoing Bricker are to be recorded; the general tumor status and follow-up urinary flow rate, cystoscopy, intravenous pyelogram, liver and kidney function electrolytes, urinary routine and postoperative urinary flow rate of patients undergoing Studer are to be recorded.
1, 3 Statistical analysis: Using SPSS 11.5 software package, data were expressed as x±s, and survival rate was calculated using Kaplan-Meier method.
2, Results
The clinical data and follow-up specific results were as follows: 266 cases in the Bricker operation group, mean age 72 years, 187 men and 79 women; 97 cases in the Studer in situ cystectomy, mean age 50 years, 94 men and 3 women; the median patients were followed up for more than 3 years, and there was no one death due to surgery and 2 deaths due to metastasis during the follow-up period (both in the Bricker operation group). Early postoperatively (within one month), incomplete bowel obstruction occurred in 3 cases in the Bricker group and 1 case in the Studer group; intestinal fistula, 1 case (only in the Bricker group). Late complications, Bricker group: 1 case of ureteral anastomotic stricture; Studer group: 1 case of neobladder neck and urethral anastomotic stricture. urination in Studer group: all had varying degrees of urinary incontinence in the early postoperative period and gradually regained urinary control after 1 week. The follow-up ultrasound indicated that the new bladder volume was 100-200ml in the first 3 months, 200-350ml six months after surgery, 350-500ml after 1 year, with an average of 450ml; residual urine was 10-100ml, with an average of 30ml. only 1 patient had hypokalemic walking weakness during the follow-up period, which improved after potassium supplementation. the rest of patients had normal renal function on laboratory tests, no acidosis manifestation, and ultrasound indicated no upper The rest of the patients had normal renal function and no acidosis. Postoperative cystoscopy every 3 months did not reveal urethral and neocystic implantation metastases.
3. Discussion
Total cystectomy is still the gold standard of treatment for invasive bladder tumors. Improvements in follow-up search techniques and follow-up modalities have greatly improved the survival of patients with invasive bladder cancer, and the perioperative mortality rate for total cystectomy is approximately 1,8% to 3,0%, with the major causes of death being cardiovascular complications, sepsis, pulmonary embolism, liver failure, and hemorrhage [1]. The overall 5-year survival rate of patients is 54, 5% to 68%, and the 10-year survival rate is also 66% [2]. The biggest problem after radical cystectomy is the lower urinary tract reconstruction, which directly affects the quality of survival of patients. To date, there are more than 100 reconstruction methods, but there is no definitive ideal method.
3.1 Bricker ileocecal cystectomy
To establish a satisfactory ileocecal bladder urinary diversion, an ideal stoma site, a papillary ectopic stoma, and a reliable uretero-ileal anastomosis are necessary. Since Bricker’s successful ileal cystic diversion in 1951, ileal bladder drainage has been smooth and metabolites and electrolytes are less absorbed, resulting in few upper urinary tract infections and electrolyte disturbances because of the unidirectional peristalsis of the ileal bladder and the assistance of abdominal pressure to facilitate urinary evacuation in the ileum. The Bricker procedure was once the gold standard for urinary diversion after total cystectomy and is still a classic, simple, safe, and effective uncontrolled urinary diversion procedure, with the main disadvantage of requiring an abdominal wall stoma and a lifelong urinary bag. Early complications reported in the foreign literature can reach 48%, including urethral infection, pyelonephritis, and uretero-ileal anastomotic leak or stricture [3]; long-term follow-up results suggest that anastomotic stricture and functional and morphological changes in the upper urinary tract are the most common, at 24% and 30%, respectively [4]. The national literature, on the other hand, reported 135 patients with ileal cystectomy followed for 1 to 15 years, with a mean of 6, 6 years. The survival rates at 5, 10, and 15 years after surgery were 66, 2% (47/ 71), 36, 7% (11/ 30), and 25, 0% (1/ 4), respectively. There were 10 cases (7, 4%) of long-term complications, including 4 cases of adhesive bowel obstruction, 1 case of ileostomy stenosis, 2 cases of ileal bladder stones, 3 cases of ileal ureteral anastomosis stenosis with upper urinary tract stones, fluid accumulation and chronic renal insufficiency, and no ileal bladder tumor was found. Postoperative urethral tumors occurred in 14 cases (10, 4 %) [5]. Combined with the data of 66 patients with this procedure in our department, early complications were more common in incomplete intestinal obstruction and intestinal fistula, but the total number of cases of the former was 3 cases and the latter only 1 case, which is roughly the same as the results of other centers in China and abroad, while considering our short follow-up time and also the small number of patients, further follow-up data are yet to be perfected.
3,2 Studer’s in situ ileal cystectomy
In the last 20 years Studer’s invention of in situ ileal cystoplasty has become a popular procedure for urinary diversion after total cystectomy. Studer himself in 2006 made a summary of more than 20 years of performing this procedure, the total number of cases was 482, including 40 female patients, and at the time of the literature analysis, 52% of the patients were still alive, most of the patients died because of tumor. The most common late complications were intestinal obstruction and lymphatic cysts, and deep vein thrombosis was also common, and he also noted that 12 patients, or 2.5%, had reoperation for ileal cystectomy [6]. A recent collaborative review analyzed the multicenter experience of performing this procedure, with similar clinical follow-up data published by each center and no significant differences in oncologic outcomes compared to other urinary diversion modalities. In particular, the most troubling postoperative complication for patients is urinary incontinence, which can reach 85-90% during the day and 60-80% at night with this procedure, and some means of pharmacological treatment (promethazine, oxybutynin, verapamil, etc.) are given [7]. Other complications include electrolyte disturbances, sensory abnormalities, retention of bowel mucus, rupture of the pronephric bladder, as well as urinary tract infections and impaired upper urinary tract function. A national study on urinary control after neobladder surgery included 20 patients for 6-44 months follow-up to assess changes in functional bladder capacity, residual urine volume, maximum urinary flow rate, and incontinence at 6, 12, 24, and 36 months postoperatively; there were no significant changes in functional bladder capacity, maximum urinary flow rate, and an increase in residual urine volume during the follow-up period, and the main complications were hydronephrosis, renal atrophy, urinary tract infection and persistent and intermittent hematuria [8]. As a center for prostate cancer diagnosis and treatment in Shanghai, our center has a better mastery of radical prostate surgery and thus has more mature surgical skills for radical cystectomy, fewer postoperative complications and relatively better urinary control than other centers.
3.3 Comparison of two surgical procedures
Both domestic and international comparisons of these two surgical approaches have been made, including the comparison of surgery-related recent and long-term complications, patient survival prognosis, and quality of life. In China, Zhuang Wei et al. compared the general intraoperative and postoperative conditions, recent and long-term complications, and tumor recurrence in two groups of patients who underwent these two surgeries, respectively. All urinary fistulas were cured by conservative treatment. Intraoperative blood loss, time to recovery of bowel function, incidence of bowel obstruction and other complications, and perioperative mortality were similar, with no statistically significant differences [9]. While scholars such as Gburek from the renowned foreign mayo clinic also compared the perioperative and late complications of the two groups of patients in their treatment centers in the JU journal, the final results showed that patients who underwent in situ cystectomy did not have increased surgical risk and hospital stay in the compared items.1 And given the current severe medical situation in China, our patients usually have longer hospital stays than those abroad, in terms of our medical experience, there was no increase in the incidence of related complications except for urinary incontinence of the neobladder, which was more common at night than during the day [10]. Another comparison of the postoperative quality of life of patients undergoing Studer ileal in situ cystectomy with Bricker and Kock in situ cystectomies pointed out that urinary incontinence was the biggest problem plaguing patients undergoing Studer cystectomy [11], and our experience was that encouraging patients to lift the anus to exercise the pelvic floor muscles and increase abdominal pressure to drain the urine each time usually resulted in a satisfactory quality of life after 3 months.
4, Conclusion
Complications of bowel surgery may be related to the general condition of patients such as age; the Bricker procedure can protect renal function, has a low complication rate, has a relatively wide range of indications, and remains a common method for clinical urinary diversion. Compared to the Bricker procedure, Studer in situ cystectomy has certain requirements for patient cognition and bladder-spreading muscles, and is a relatively high quality of life, low complication rate, and may be the first choice for bladder reconstruction.