Keys to Successful Orthotopic Bladder Substitution

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Urs E. Studer
Editor

Keys to Successful
Orthotopic Bladder
Substitution
Editor
Urs E. Studer
Department of Urology
University Hospital Bern Inselspital
Bern
Switzerland

Videos to this book can be accessed at http://springerimages.com/videos/978-3-319-12381-3

ISBN 978-3-319-12381-3 ISBN 978-3-319-12382-0 (eBook)

DOI 10.1007/978-3-319-12382-0
Springer Cham Heidelberg New York Dordrecht London

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Foreword

Radical cystectomy with pelvic lymphadenectomy followed by orthotopic recon-

struction is established as the gold standard treatment of bladder cancer invading the
bladder muscle and of treatment-refractory, non-muscle-invasive bladder cancer.
The procedure is known to carry significant perioperative morbidity because of
oncological risk factors, the complexity of the required surgical skills, and the com-
paratively high postoperative complication rate. Ninety-day complication rates as
high as 60–70 % have been described using standardized reporting. It is imperative,
therefore, that attempts to improve the quality of care in radical cystectomy should
focus on perfecting the surgical techniques by enhanced surgeon training, improved
technology, and better anesthetic support.
The present handbook is designed to be the most comprehensive and informative
book possible on the operative management of the patient undergoing radical cys-
tectomy and orthotopic reconstruction. It originates from one of the very few insti-
tutions to have pioneered this procedure at its inception three decades ago and has
remained at the forefront of its continued refinement ever since.
The individual chapters focus on aspects of radical cystectomy with orthotopic
reconstruction such as indications, preparation of the patient, the procedure itself,
and precautions to be taken in the immediate postoperative period. Each chapter
includes a short bibliography for further reading.
This book is the result of a philosophy that emphasizes an individualized
approach to radical cystectomy and the need to combine that procedure with conti-
nent orthotopic diversion to maximize oncological safety with minimum avoidable
side effects. The highest good of this philosophy, the goal toward which all efforts
strive, is the maximization of the patient’s post-radical cystectomy quality of life.
This handbook should be of particular utility to the resident in training; it is also
well suited to provide the experienced urologist with ideas that can be incorporated
into an already established surgical armamentarium.

v
vi Foreword

Among its many possible uses, this handbook can be used

I. As a handy synopsis for quick review to refresh and update one’s knowledge just
before beginning the procedure.
II. As a guide for improving existing ways of performing radical cystectomy, thus
expanding surgical horizons.

Each chapter contains suggestions and precautions against potential pitfalls, with
tips on solving imminent problems before they become insoluble.

Ulm, Germany Richard E. Hautmann

Contents

Part I Key Tips and What to Avoid Before, During and After Surgery

1 Checklists: Key Tips and What to Avoid . . . . . . . . . . . . . . . . . . . . . . . . . 3

Urs E. Studer

Part II Specific Points of Interest

2 Landmarks in History of Continent Urinary Diversion . . . . . . . . . . . . 53

Urs E. Studer
3 Optimized Anesthesia During Cystectomy Improves
Postoperative Outcome: A Review of the Key Points . . . . . . . . . . . . . . 63
Patrick Y. Wuethrich
4 Why Attempt a Nerve-Sparing Cystectomy? . . . . . . . . . . . . . . . . . . . . . 75
Bastian Amend and Arnulf Stenzl
5 Seminal Vesicle-Sparing Cystoprostatectomy:
What Can Be Expected?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Frédéric D. Birkhäuser
6 Pelvic Lymph Node Dissection and Different Templates. . . . . . . . . . . . 93
Pascal Zehnder
7 Physical and Physiological Considerations
for Reservoir Construction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Beat Roth
8 Bowel Segments in the Urinary Tract:
Metabolic Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Robert Mills

vii
viii Contents

9 Preservation of Renal Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Fiona C. Burkhard
10 Quality of Life with Orthotopic Bladder Substitution:
Use of Validated Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Martin Spahn
11 Ileal Orthotopic Bladder Substitute with an Afferent
Isoperistaltic Tubular Segment: Key Operative Steps. . . . . . . . . . . . . 129
Ramesh Thurairaja
Introduction

To preserve patients’ physical integrity and quality of life, ileal orthotopic bladder
substitution is a form of urinary diversion that provides excellent long-term func-
tional outcomes. Since the ileal orthotopic bladder substitute is not particularly
more surgically challenging than an ileal conduit, many urologists once offered
this procedure to patients but subsequently gave up due to poor functional results
and complications. The key to success with consistently good functional and
long-term results is dependent on close attention to an array of little details such
as restrictive patient selection before surgery, adherence to specific surgical details
during surgery, and, probably most importantly, meticulous postoperative instruc-
tion and follow-up of the patient learning to cope with an orthotopic bladder
substitute.
Based on the results of previously published prospective randomized trials and
on 30 years of personal experience, this pocket guide attempts to bring together
the essential steps for achieving consistently good results with ileal orthotopic
bladder substitution in such a manner that any experienced urologist and mainly
those who wish to introduce the use of new modalities (laparoscopic/robotic sur-
gery) should be able to achieve consistently good results, thus allowing their
patients to return to a close-to-normal, if not normal, life after radical cystectomy.
The nonsurgical sections such as those on “proactive postoperative management”
or “trouble shooting” may be of particular interest to specialized nursing person-
nel and patients as well.
In the first section, essential steps to be observed before, during, and after sur-
gery as well as diagnostic algorithms for the management of specific problems or
complications are presented in the form of checklists in order to provide clear and
concise information to the reader. Certain important points appear in more than one
checklist, and where needed, individual points include brief explanations. In the
second part, specific aspects of nerve-sparing cystectomy and ileal orthotopic blad-
der substitution are presented in a more detailed fashion.
Many figures instead of descriptive text should make the seemingly complicated
techniques more easily comprehensible. In addition, essential surgical steps of a

ix
x Introduction

pelvic lymph node dissection, nerve-sparing cystectomies in female and male

patients, as well as construction of an ileal orthotopic bladder substitute are pre-
sented in four videotapes. Another unique feature of this paperback is that it includes
a summary of key messages in Mandarin (Chinese language) to facilitate the use of
this paperback in certain countries that have made enormous progress in medicine
in recent decades.
We perceive that if the indication is correct, ileal orthotopic bladder substitu-
tion will become the urinary diversion of choice for patients undergoing
cystectomy.

Bern, Switzerland Urs E. Studer

 Part I
Key Tips and What to Avoid Before,
During and After Surgery
Checklists: Key Tips and What to Avoid
1
Urs E. Studer

1.1 Before Surgery – Patient Selection and

Preoperative Management

This section presents key points for patient selection and preoperative management
relevant to all forms of orthotopic bladder substitution by intestinal segments.
• Exclusion of lymph node or distant metastasis from bladder cancer.
• The primary tumour must be resectable without risking positive margins.
• Negative biopsies (preferably cold cup biopsy under local anaesthesia) from the
distal prostatic urethra (male patients) or from the bladder neck (female patients).
The biopsy forceps must grasp the tissue deeply, be closed firmly and advanced
into the bladder rather than being pulled outwards to avoid damage to the sphinc-
ter mucosa.
Why not use intraoperative frozen sections?
– perioperative frozen sections from the urethral margin may be false negative
in up to 50 % of cases [1, 2]
– positive margin with urothelial cancer must be avoided to prevent local tumor
recurrence
– may unnecessarily shorten the urethra
– the surgeon should be clear, and the patient should be well informed prior to
surgery if the cystectomy is to be combined with an en bloc urethrectomy and
which form of urinary diversion the patient would be consigned to live with

Electronic supplementary material

Supplementary material is available in the online version of this chapter at 10.1007/978-3-319-12382-
0_1. Videos can also be accessed at http://www.springerimages.com/videos/978-3-319-12381-3.
U.E. Studer
Department of Urology, University Hospital Bern Inselspital, Bern, Switzerland
e-mail: [email protected]

© Springer International Publishing Switzerland 2015 3

U.E. Studer (ed.), Keys to Successful Orthotopic Bladder Substitution,
DOI 10.1007/978-3-319-12382-0_1
4 U.E. Studer

• Exclusion of urethral strictures and urinary incontinence. Urethral pressure pro-

file in females.
Why? Urinary continence depends on length of the functional urethra and the
closing urethral pressure [3, 4].
• Must be physically and mentally able to adapt to and function with an orthotopic
bladder substitute.
• Elderly patients (age >75 years) should not be excluded but must be physi-
cally fit and be informed that achieving urinary continence might take several
months [5, 6].
• Must be willing and able to participate in an active postoperative re-education
program and adhere to a strict follow-up protocol.
• Normal or slightly impaired renal function (serum creatinine ≤150 μmol/l,
GFR >50 ml). Reversible renal impairment due to obstruction may be taken into
account and may be considered.
Why? Severely impaired renal function would not allow for compensation of
the metabolic acidosis following incorporation of bowel in the urinary tract,
with consecutively long-term risk of osteoporosis and osteomalacia.
For further details, see Chapter 8, page 105.
• Normal liver function.
Why? Should the urine in the orthotopic bladder substitute become infected,
an increased ammonia load is consequently delivered to the liver.
For further details, see Chapter 8, page 105.
• No previous major bowel resection in the ileocaecal area.
Why? Risk of vitamin B 12 deficiency, risk of bile acid loss resulting in hyp-
eroxaluria and diarrhoea.
For further details, see Chapter 8, page 105.
• No antegrade bowel preparation, except for a laxative or enema to clear the
large bowel, meal rich in carbohydrate without fibre on the evening before
surgery.
• No instructions on how to perform clean intermittent catheterisation (CIC) is
required.
Why? All men and women voiding normally before surgery should be able to
void spontaneously postoperatively – it may take a few attempts – if there is
no mechanical outlet obstruction from the reservoir, e.g. kinking of a funnel-
shaped reservoir outlet, residual prostatic tissue or kinking of a denervated
hypotonic proximal female urethra. CIC could promote bacteriuria that pro-
vokes increased mucus production and intermittent urinary incontinence due
to hyperactivity of the reservoir wall. CIC may still be instructed later on in
the small number of female patients who have failed all other postoperative
measures. Instructing CIC preoperatively would be useless for more than
90 % of the patients and could even deter many patients from choosing an
ileal orthotopic diversion.
• Low molecular heparin on the evening before surgery in the arm and not in the thigh.
Why? To prevent lymphoceles in the pelvis after lymphadenectomy.
Subcutaneously injected substances are channelled by lymphatic vessels from
the thigh to the pelvis.
1 Checklists: Key Tips and What to Avoid 5

1.2 How to Perform a Nerve-Sparing Cystectomy

The patient must be offered the best possible cancer surgery, but that surgery must
also avoid unnecessary comorbidities. Preservation of the autonomic innervation to
the urethra (hypogastric nerve, pelvic plexus, paraprostatic neurovascular bundle,
paravaginal nerve plexus) is possible at least on the non-tumour bearing side in most
cystectomy cases and must always be attempted if the cystectomy is to be followed
by an orthotopic continent diversion.
Why? The autonomic nerves control the urethral closing pressure at rest and
are essential to maintain good urinary continence, the ability for residual-free
urination, sexual function in males and females as well as coordinated rectal/
anal function. In patients with tumours at the bladder dome, anterior wall or
multifocal T1G3 urothelial cancers even bilateral nerve sparing may be
considered.
For further details, see Chapters 4, page 75, and 5, page 85.

The individualised cystectomy is performed according to the following steps:

• Administration of antibiotics, including metronidazole.
• Insertion of a balloon catheter on continuous drainage.
• In female patients, insertion of a long clamp with a rounded tip into the vagina.
Why? To facilitate the localisation of the vaginal vault during surgery. This helps
to avoid unnecessary damage to autonomic nerve fibres located around the uterine
cervix.
• The operating table is flexed at the level of the hips, the legs are horizontally
positioned and the patient is in a 30° Trendelenburg position (Fig. 1.1).
Why? Flexing the table at the level of the hips and not the lumbar spine
avoids neuropraxia resulting in postoperative neurological deficits in the
legs. The 30° Trendelenburg position assures good venous return back to the
heart, lowers the intrapelvic venous pressure and facilitates bowel loops to
remain out of the surgical field without forcing the need for retention devices
which might compress the vena cava [7].

Fig. 1.1 The operating table should be flexed at the level of the hips and not the lumbar spine, and
the legs must be positioned horizontally to prevent venous stasis, while the abdomen/chest is in a 30°
Trendelenburg position to reduce pelvic venous pressure and assure good cardiac venous preload
6 U.E. Studer

• Anaesthesia combined with continuous norepinephrine and low intravenous fluid.

Why? Norepinephrine counteracts the vasodilation caused by the anaesthet-
ics and analgesics and thus reduces the need for compensatory IV fluid sup-
plementation. This helps to maintain a low intrapelvic venous pressure
resulting in better visibility within the surgical field, reduced blood loss and
fewer postoperative complications [7].
For further details, see Chapter 3 page 63.
• Incision of the peritoneum from the umbilicus to the internal iliac artery along
the obliterated umbilical arteries.
Why? For oncological safety, all tissue between these 2 ligaments is resected
en bloc with the bladder. In doing so, this facilitates identification of the inter-
nal iliac arteries and allows for the preservation of a larger peritoneal flap
between the obliterated umbilical arteries and the lateral pelvic walls than if
the peritoneum were incised over the external iliac arteries during pelvic
lymph node dissection. The larger peritoneal flap facilitates reperitonealisa-
tion, which in turn can significantly improve postoperative recovery of bowel
function [8].
• A meticulous extended pelvic lymphadenectomy is performed bilaterally along
the external, internal and common iliac vessels up to the point where the retracted
ureters cross the vessels (corresponding to the proximal/middle third of the com-
mon iliac vessels) (Fig. 1.2).
Why? Lymphadenectomy in the area of the aortic bifurcation may damage
the sympathetic fibres which are relevant for urinary continence.
For further details, see Chapters 4, page 75 and 6, page 93.

Fig. 1.2 Template for bilateral pelvic lymph node dissection along the external, internal and com-
mon iliac vessels, which avoids the area around the aortic bifurcation in order to preserve the
hypogastric nerves (Modified from: Thurairaja et al. [23])
1 Checklists: Key Tips and What to Avoid 7

• On the side(s) of attempted unilateral/bilateral nerve sparing, only the superior and
inferior vesicle vessels are transected and ligated along the internal iliac artery,
leaving the prostatic/vaginal and rectal vessels intact (arrows in Figs. 1.3 and 1.4).
Why? To preserve the blood supply to the pelvic plexus and the autonomic nerves
of the paraprostatic/paravaginal neurovascular bundles. The preceding lymphad-
enectomy aids in the recognition of the branches of the internal iliac vessels.
• Before transecting the dorsomedial bladder pedicles in men, the endopelvic fas-
cia is freed from all fatty tissue and incised obliquely and cephalad to the tendi-
nous arc. The puboprostatic ligament is not detached from the pubic bone. The
periprostatic fascia (or levator fascia) must also be incised above the ventral part
of the prostate in order to allow the detachment of the neurovascular bundle
along the prostatic capsule (Fig. 1.5).
• Santorini’s plexus is ligated (Fig. 1.6).
Why? Exposure of the prostate helps prevent unintentional/accidental dam-
age to the autonomic nerves, namely, within the critical angle between the
seminal vesicle, bladder and base of the prostate when transecting the dorso-
medial bladder pedicle. The lateral access to the apex of the prostate facili-
tates the recognition of the urethra, minimises bleeding from Santorini’s
plexus and avoids destabilisation of the sphincter mechanism by leaving the
pubourethral ligaments intact.

Fig. 1.3 On the side of the attempted left-sided nerve sparing of a female patient, only the vessels
of the bladder are transected along the internal iliac vessels, and the vessels more distally are left
intact (see arrows) to preserve the blood supply to the pelvic plexus and neurovascular bundles
(Modified from: Kessler et al. [24])