Comparison of Safety and Efficacy of Detaenial Sigmoid Neobladder and Ileal Neobladder

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Description

Surgical technique for Hautmann ileal neobladder: A 70-cm portion of terminal ileum is selected and incised on the antimesenteric border. The ileum is arranged into an M or W configuration with the four limbs sutured to one another. After a buttonhole of ileum is removed on an antimesenteric portion...

Surgical technique for Hautmann ileal neobladder: A 70-cm portion of terminal ileum is selected and incised on the antimesenteric border. The ileum is arranged into an M or W configuration with the four limbs sutured to one another. After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethral anastomosis is performed. The ureteral anastomoses are performed using a Le Duc technique or direct implantation, are stented, and the reservoir is then closed in a side-to-side manner. As an alternative, the two ends of the W may be left slightly longer as a short chimney on either side for implantation of the ureters. Surgical technique for detaenial sigmoid neobladder: After radical cystectomy, the sigmoid was brought out from a midline incision in the lower abdomen and a 15 to 25 cm segment was isolated. Intestinal continuity was restored using a circular stapler. Omental and free taeniae, and the serosal layer were incised deeply as far as the submucosal layer until the plane between smooth muscle and the submucosal layer could be identified clearly by scalpel dissection. The serosal layer with smooth muscle was then detached from the submucosal layer and removed continuously without difficulty. During this time, the operator could insert the finger in the sigmoid lumen and lift the sigmoid wall up for accurate dissection. Only the mucosal and submucosal layers were preserved. Approximately 2 to 3 cm of the taeniae and serosal layer were preserved to strengthen the urethra-neobladder anastomosis at the central portion of the isolated sigmoid and at the two ends for the ureter-neobladder anastomosis. The detaenial sigmoid was irrigated repeatedly by dilute iodine solution to eliminate impurities. Its capacity for enlargement and leak tightness were assessed at the end by filling with 300 to 400 ml iodine solution. Residual taeniae were identified and incised during this filling phase. The ureters were subsequently implanted in antirefluxing fashion in a submucosal tunnel with 4-zero poly glactin at the two ends of sigmoid. The ureter-neobladder anastomoses were protected with a 6Fr Single J® stent. Each stent was passed through the sigmoid wall and exteriorized. The two ends of the sigmoid were closed by 2-zero polyglactin with the embedded seromuscular layer. The central portion of the sigmoid was incised and a 22Fr 3-way catheter was inserted in neobladder. The neobladder was anastomosed to the urethra with 2-zero polyglactin. Followup: Each patient was evaluated at 3-month intervals for 1 year, at 6-month intervals for 2 to 5 years. Renal ultrasound, biochemical examination and urine culture were done every 3 to 6 months. Pelvic computerized tomography and retro-cystogram were performed 6 months postoperatively and annually thereafter. Urodynamic investigation and cystoscopic examination were done annually. Postoperative complications were classified as early (90 days or less) and late (greater than 90 days). Early and late complications were subdivided into those related and not related to the neobladder. Complication grade was classified according to the Clavien-Dindo system. Major complications were defined as grade III or higher. Daytime and nighttime continence levels were recorded postoperatively at patient interview. Continence was defined as complete if the patient was dry without a pad, satisfactory if no more than 1 pad was required and poor if the patient used more than 1 pad during the day or night. End points: The primary end point was change in renal function from baseline to 3 years. Secondary end points included changes in renal function from baseline to 6, 12 and 24 months, reduction in eGFR 10 ml/minute/1.73 m2 or greater, early (less than 90 days) and late (90 days to 3 years) complications, urinary tract infection that was symptomatic or was treated, any surgical re-intervention or urinary diversion related surgical re-intervention defined as an open or endoscopic procedure under anesthesia, cancer recurrence and overall survival. Renal function was assessed using the CKD-EPI equation. Complications were analyzed and graded by a blinded adjudicator using the modified Clavien complication grading system.

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