Elsevier

European Urology

Volume 69, Issue 2, February 2016, Pages 247-253
European Urology

Platinum Priority – Bladder Cancer
Editorial by Fiona C. Burkhard on pp. 254–255 of this issue
Robotic Intracorporeal Orthotopic Neobladder: Urodynamic Outcomes, Urinary Function, and Health-related Quality of Life

https://doi.org/10.1016/j.eururo.2015.06.041Get rights and content

Abstract

Background

Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required.

Objective

To evaluate urodynamic features of iONB and bladder cancer–specific and general health-related quality-of-life (HRQOL) outcomes.

Design, setting, and participants

We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures.

Outcome measurements and statistical analysis

iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score.

Results and limitations

The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p < 0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p < 0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm3 (range 339–1001). BCI mean scores for urinary function (p = 0.58) and urinary bother (p = 0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs 19%; ≤2 pads 84% vs 79%), as reflected by total pad usage (p = 0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group.

Conclusions

iONB had adequate UDS characteristics and comparable bladder cancer–specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up.

Patient summary

We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group.

Introduction

There is significant uptake of robotic radical cystectomy (RRC) in the treatment of muscle-invasive bladder cancer. In appropriately selected patients, creation of an orthotopic neobladder (ONB) is the preferred urinary diversion at our center. Robotic creation of an intracorporeal ONB (iONB) has been demonstrated and adopted as part of a completely robotic cystectomy procedure [1]. Although there are data on the technical efficiency and complications related to robotic iONB, urodynamic functional assessments of intracorporeally constructed neobladders are lacking [2]. It remains to be seen whether entirely robotic creation of iONBs has comparable functional metrics and general and health-related quality of life (HRQOL) scores specifically related to orthotopic substitution, such as pad use.

The primary objective of this study was to report quantifiable urodynamic parameters to assess whether robotically created iONBs behave as low-pressure, high-volume reservoirs. As a secondary aim, validated instruments were used to compare continence outcomes and general and HRQOL scores related to orthotopic bladder substitution between robotic and open approaches.

Section snippets

Study subjects

Consenting patients who underwent RRC and iONB were prospectively followed in a database approved by the institutional review board (IRB). Inclusion criteria included male patients, no technical complications directly related to neobladder that could impact neobladder function, and completion of at least 3-mo follow-up after surgery. We identified 39 patients who underwent robotic iONB creation between January 2012 and October 2013 by one of three robotic surgeons (M.A, M.D, or I.S.G). Three

Results

A total of 28/32 (88%) eligible male patients who underwent robotic iONB completed follow-up questionnaires. Of these 28 patients, 12 (43%) agreed to undergo multichannel UDS measurement. The mean preurodynamic PVR was 82 cm3 (range 0–325 cm3). None of the 12 patients exhibited detrusor (neobladder) overactivity during the cystometry filling phase. The average compliance was normal (mean 33 ml/cm H2O, range 13–74) and nine of the 12 patients had compliance >30 ml/cm H2O. The mean cystometric

Discussion

To the best of our knowledge, this is the first study to assess UDS characteristics and orthotopic diversion-specific and generic HRQOL together with pertinent functional outcomes (patterns of pad use) following robotic iONB creation. UDS parameters confirmed that the robotic procedure created a low-pressure, high-volume ONB. BCI urinary function and bother scores were comparable between the open and robotic cohorts. Worse BCI scores were associated with diabetes, but not the surgical technique

Conclusions

Our UDS data confirm that robotic iONB creation recapitulates the necessary characteristics of a high-volume, low-pressure reservoir. Robotic iONB appears to display comparable health states to open diversion using a multidimensional measure of bladder cancer–specific HRQOL. However, given that pad size and daytime wetness were worse, ongoing follow-up and prospective comparison are required to assess long-term urinary continence rates.

References (29)

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