Use of sigmoid colon in orthotopic neobladder reconstruction: Long-term results: Beyond the Abstract

We started using sigmoid colon for orthotopic neobladder reconstruction in the early 1990s. [1] Initally we, as other surgeons, were using the ileum, but our patients were developing complications such as dilation of the reservoir (which then requires intermittent self-catheterization), absorption defects and deterioration of renal function. [2-4] Our initial experience with sigma showed satisfactory results, and, since then, orthotopic sigmoid neobladder (SN) represents the first choice at our institution after radical cystectomy in patients selected for neobladder reconstruction. 

The aim of the study was to present our experience with a completely detubularized 20–25-cm segment of sigmoid colon always remodeled in the same fashion into a continent orthotopic reservoir of spheroidal shape, to assess functional and oncological outcomes, and to describe complications. 

We retrospectively evaluated the functional and oncological outcomes of 160 patients who underwent orthotopic SN reconstruction. [5] Inclusion criteria were: bladder cancer muscle-invasive and non-muscle-invasive at high risk of progression, good performance status, and adequate sigmoid length. Absolute exclusion criteria were: colonic pathologies, chronic hepatitis or impaired liver function or renal impairment (creatinine >1.5 mg/dL), diabetes, severe comorbidities, distant metastasis and urethral or trigonal invasion. Female patients with severe urinary incontinence and/or pelvic organ prolapse (stage III or more) and significant PVR (>200 mL) were informed about the risk of incontinence or of chronic urinary retention and were excluded from neobladder reconstruction program. 

Regarding the surgical technique, the sigmoidal segment is detubularized by cutting its anti-mesenteric taenia, it then becomes a rectangle, its shorter sides are sutured to form a cylinder. We start to suture the posterior circumference longitudinally to seal the rear wall of the neobladder, where the ureters will be implanted. Finally, the anterior edge is sewn longitudinally to close the anterior wall leaving the lowest 2cm open for anastomosis to the urethral stump. 

Each of our patients was evaluated every 3 months the first year, every 6 months for the next 4 years and annually thereafter. Urodynamic studies of all consenting patients were carried out after 6 months, and 2, 5 and 10 years. We used the log–rank test, Cox regression models and Kaplan–Meier survival analysis. The ANOVA test was used to compare urodynamic findings over time. 

Mean follow up was 6.8 years (range 0.65–21.7 years). Overall survival was 58.1% at 5 years, and 47.1% at 10 years. Early complications occurred in 36 patients (22.6%); late complications in 40 (25%). Stage V chronic kidney disease developed in two patients (1.3%). Complete (daytime and night-time) continence, defined as no need for pads or condom devices, was achieved by 45% of patients at 5 years, daytime continence only, was achieved by 36% of patients; both were unchanged at 10 years. At 5 years 3.7% of our patients performed clean intermittent self-catheterization (CIC). We did not include patients who perform CIC among continents, in fact, in our opinion, they represent a distinct group with distinct functional outcome. Concerning neobladder functional parameters, a significant difference emerged in maximal neobladder capacity and post-void residual values between 6 months and 2 years, and between 2 and 5 years (P < 0.01 and P = 0.03, respectively). 

SNs have been criticized in the past, but in experienced hands SN represent a good alternative for urinary diversion, especially in young patients due to the long-term functional stability. [6] Characteristics of a SN are: low tendency to hyperdilation, due to sigmoidal wall thickness; good filling sensation, due to the common nerve pathways of bladder and sigma; good continence rates; negligible metabolic imbalance, due to the storage properties rather than absorptive ones; and no deleterious effect on upper urinary tract function. 

We would like to underline that a standardized definition of continence in patients with a neobladder hasn’t yet been introduced [6, 7] and patients who perform CIC have been included among continents by other Authors.

Written by: Alberto Martini, Donata Villari, Giulio Nicita, Department of Urology, University of Florence, Careggi Hospital, Florence, Italy.

References
  1. Martini A,  Villari D,  Filocamo MT, et al. MP56-13 orthotopic sigmoid reservoir: more than twenty years experience. J Urol. 2016; 195: e749-e750
  2. Jentzmik F, Schrader AJ, de Petriconi R et al. The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome. World J Urol. 2012; 30: 733–9. 
  3. Ahmadi H, Skinner EC, Simma-Chiang V et al. Urinary functional outcome following radical cystoprostatectomy and ileal neobladder reconstruction in male patients. J Urol. 2013; 189: 1782-8
  4. Kristjansson A, Mansson W. Renal function in the setting of urinary diversion. World J Urol. 2004; 22: 172–7 
  5. Nicita G, Martini A, Filocamo MT, et al. Use of sigmoid colon in orthotopic neobladder reconstruction: Long-term results. Int J Urol. 2016; 23: 984-990.
  6. Martini A, Villari D, Nicita G. Editorial comment to: Ileal versus sigmoid neobladder as bladder substitute after radical cystectomy for bladder cancer: A meta-analysis. Int J Surg. 2017; 37: 13-14
  7. Nicita G, Martini A, Filocamo MT, et al. Response to Editorial Comment to Use of sigmoid colon in orthotopic neobladder reconstruction: Long-term results. Int J Urol. 2016; 23: 991.

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