Complications associated with urinary diversion

Radical cystectomy (RC) with subsequent urinary diversion has been assessed to be the most difficult surgical procedure in the field of urology. No randomized trials have been performed to compare the outcomes of noncontinent conduit diversion, neobladder construction and continent cutaneous diversion. Almost all studies are of level 3 evidence, meaning the recommendations given in this Review are of grade C only. Until recently, significant disparity in the quality of surgical complication reporting, as well as the lack of universally accepted reporting guidelines, definitions and grading systems, have made it impossible to compare the surgical morbidity and outcomes of RC. There is a clear case for the standardized reporting of complications. The Clavien system is a straightforward and validated instrument that has already been successfully adopted by several urological centers. Surgical morbidity following RC is significant and, when strict reporting guidelines are incorporated, much higher than previously published. Complications can occur up to 20 years after surgery, emphasizing the need for more long-term studies to determine the full morbidity spectrum. In general, renal function after construction of continent detubularized reservoirs compares favorably with ileal conduit diversion, although the literature is insufficient to recommend one over the other. The challenge of optimum care for elderly patients with comorbidities is best mastered at a high-volume hospital by a high-volume surgeon

Nerve-sparing Radical Cystectomy: A New Technique

Background: The results of post-radical cystectomy (RC) erectile function are notoriously disappointing, except when a prostate-sparing technique is used. However, valid concerns regarding oncologic safety still predominate, and protocols for patient selection and technique are not well defined. Objective: We describe a new technique for nerve-sparing RC and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, and neurovascular bundles (NVB). No prostatic tissue is left behind, thus eliminating the risk of local recurrence from bladder cancer (BCa) as well as de novo prostate cancer. Design, setting, participants: Between March 2008 and October 2009, nine patients with intact erectile function and non-muscle-invasive bladder cancer (NMIBC) or stage ≤pT3a away from the trigone underwent this type of procedure. Prostatic carcinoma was excluded by normal digital rectal examination (DRE) and transurethral ultrasound (TRUS), a prostate-specific antigen (PSA) value ≤4.0 ng/ml, and a free-to-total PSA ratio >20%. Intervention: The procedure starts as a standard nerve-sparing radical prostatectomy (RP). After transection of the urethra with Denonvillier's fascia still intact, vasa deferentia and seminal vesicles are transected at the base of the prostate, and the trigone is undermined to the space of Douglas. The cystectomy is completed in ascending or preferably descending fashion. Measurements: Patients were evaluated pre- and postoperatively using the International Index of Erectile Function (IIEF) questionnaire. Patients were followed up regularly at 2 mo, 6 mo, and 12 mo. Results and limitations: Four out of nine patients maintained spontaneous complete tumescence, and five patients had partial tumescence using sildenafil as a successful erectogenic aid. PSA was <0.1 ng/ml in all cases. All patients showed no evidence of disease (NED). Conclusion: With correct patient selection, excellent functional results can be obtained. © 2010 European Association of Urology.Article in Pres