ABSTRACT
Introduction: There is a great debate about the cause of the higher incidence of hypercontinence in women undergoing orthotopic diversion after cystectomy in relation to men.
Methods: A total of 39 females with orthotopic diversion were studied: 21 from the Theodore Bilharz Research Institute (TBRI), and 18 from the University of South Florida at Tampa (USF). Nerve preservation was attempted in all cases. Cystectomy was done with a cut across the bladder neck in the TBRI cases, while the urethral cut in the USF cases was done across the proximal urethra.
Results: Hypercontinence was found in 38% (8 of 21) of TBRI patients and in 16% (3 of 18) of USF patients. Urodynamic evaluation was done in 10 of the TBRI cases, and it was comparable to other series regarding pouch capacity (mean = 500 ml), pouch pressure (mean = 17 cm H2O at capacity), maximum urethral pressure (mean = 67 cm H2O), and maximum urethral closure pressure (mean = 49.2 cm H2O).
Conclusion: The relaxation of the striated sphincter and the contraction of the longitudinal smooth muscle opens the way for micturition. The loss of this normal coordinated reflex leads to the presence of a urethra with a fixed tone that does not open with trials of evacuation. As men and women have an intact striated sphincter, the higher incidence of hypercontinence in females compared to males is due to the presence of the extra tone of the urethral smooth muscles. This study proves that the more urethral length left, the higher the incidence of hypercontinence because more smooth muscle tone is faced during micturition. Nerve preservation has no impact because the coordinated detrusor urethral smooth muscle action is lost.
Keywords: Women, Orthotopic diversion, Hypercontinence
Correspondence: Mohamed Ali A Ismail, Urology Department, Theodore Bilharz Research Institute, Giza, Egypt,
To Cite this Article: Ismail MAA, Wishahi MM, Elsherbeeny M, Sewallam TA, Lockhart J. Hypercontinence in Women after Orthotopic Neobladder Diversion. UIJ. In Press. doi:10.3834/uij.1944-5784.2008.12.05
Introduction
The first report of a successful neobladder was in 1888 by Guido Tizzoni and Alfonso Poggi of Bologna who performed a 2-stage technique using a small bowel in a female dog [1]. In 1979, Camay [2] proved that urinary continence is possible with a neobladder, but the procedure remained unpopular until the last 2 decades of the last century when orthotopic lower urinary tract reconstruction became the procedure of choice in select male patients undergoing cystectomy.
Different techniques and variations have been developed with the same concept of achieving a urinary diversion that physically, physiologically, and psychologically resembles the normal voiding pattern. The excellent clinical and functional results achieved in men stimulated efforts to provide women requiring lower urinary tract reconstruction with a similar form of diversion.
The application of orthotopic urinary diversion in women has been lagging behind because of the fear of compromising radicality by retaining the urethra and the fear of incontinence because of the lack of understanding the physiology and anatomy of female continence.
Many studies have provided the scientific basis and paved the way for orthotopic substitution in selected cases in women. From the oncological viewpoint, there was the general conviction that urethrectomy is a fundamental component of radicality. Reliable data on the development of synchronous or metasynchronous secondary urethral tumors has been collected in recent years and has found that the association of urethral tumor and bladder cancer is around 2% [3]. Regarding the functional viewpoint, an essential finding was that the continuity of the bladder and urethra is not essential for closure of the striated urethral sphincter [4]. Urethral continence in women who underwent cystectomy was attributed to the rhabdosphincter and the distal urethra with its somatic innervation derived from the pudendal nerve [5].
What is puzzling is that there is a 40% incidence of hypercontinence upon application of orthotopic diversion in women. This is much higher than the rate in men, and its cause still a matter of great debate.
Materials and Methods
We studied a total of 39 women who underwent orthotopic diversion. Of the cases, 21 were from the Theodore Bliharz Research Institute (TBRI) in Giza, Egypt, and 19 were from the University of South Florida at Tampa (USF) in Florida, USA.
Indications for orthotopic diversion were vesical malignancy in 37 cases, refractory interstitial cystitis in 1 case, and severe vesical trauma in 1 case. Patient selection and inclusion criteria are shown in Table 1, and both preoperative and intraoperative exclusion criteria are shown in Table 2.
Nerve preservation was attempted in all cases. Cystectomy was done in all TBRI cases with a cut across the bladder neck, while the urethral cut in USF cases was done across the proximal urethra. Diversion was done in the form of Hautmann neobladder in 26 patients, Camey Type II in 4 patients, Y neobladder in 7 patients, and colonic neobladder in 2 patients. Omental flap was introduced posterior to the pouch in all cases. Follow-up ranged between 0 and 190 months and was done every 3 months for the first year, every 6 months in the second year, and yearly thereafter.
Urodynamic evaluation was done for 10 cases from TBRI series* and included voiding cystometry, flowmetry, and both pre- and postoperative urethral pressure profile (UPP).
There is a complete breakdown of each case detailed in Data 1 and Data 2.
*Urodynamics was done for these first 10 patients in TBRI series as a routine during each visit. This was in addition to ascending and voiding pouchogram and other routine lab work but was found to be exhausting to the department’s resources. Therefore, we shifted to doing all the radiological and lab workup and only do urodynamics on a selective basis. This was in agreement with the USF policy, and included in this study are only the urodynamics of patients followed up with urodynamics on a regular basis.
Results
Hypercontinence, which is defined as either an inability to void or voiding with more than 150 ml residual urine, was found in 38% (8 of 21) of the TBRI patients and in 16% (3 of 18) of the USF patients. Clean intermittent bladder catheterization (CIC) was advised for all patients. Our study revealed that there is no correlation between the preoperative continence status and postoperative continence status, taking into consideration that there were no cases of Grade 3 stress incontinence included in our study. This makes sense because the bladder is replaced by an intestinal pouch and the urethra is fixed by fibrosis around the urethro-ileal anastomosis.
Urodynamic evaluation for the first 10 cases of the TBRI series was comparable to other series regarding pouch capacity (mean = 500 ml), pouch pressure (mean = 17 cm H2O at capacity), maximum urethral pressure (MUP) (mean 67 cm H2O), maximum urethral closure pressure (MUCP) (mean 49.2 cm H2O). There was no significant difference between both pre- and postoperative UPP. Complete results of the 10 urodynamic evaluations are shown in Data 3.
Urodynamics was done routinely for the first 10 TBRI cases, but thereafter it was not considered a part of the routine evaluation for cost-benefit considerations. It yielded comparable results with other series and there was no significant difference between the 4 hypercontinent patients and the others in this group, apart from pouch capacity.
Discussion
Contrary to the fear of compromising continence in women, hypercontinence is the main problem encountered with the application of orthotopic diversion. Its incidence ranged between 5% and 50% in different series [6-10], and the etiology has always been a point of debate. Different theories proposed include:
1. Urethral angulation with increased urethro-intestinal angle due to lack of the posterior support of the pouch:
This was supported by Ali-el-Dein et al. [6] who found the urethral angle to be acute (73º ± 14º) in patients with high residual urine (increasing during voiding), while it was obtuse (122º ± 21º degrees) in others. In later studies, Ali-el-Dein and Ghoneim [11] and Darson et al. [12] supported the placement of an omental flap posterior to the pouch for support.
2. Functional obstruction due to denervation of the urethral smooth muscles:
The series by Jarolim et al. [13] supported this idea, for which they recommended the use of alpha blockers in addition to CIC. This was debated by Ali-el-Dein et al. [6], Ali-el-Dein and Ghoneim [11], and Stein et al. [14], who did not recommend nerve sparing cystectomy in women. In an experimental study on female dogs, Ali-el-Dein and Ghoneim [11] reported a reduction of 46% to 48% in the MUP in the proximal urethra after autonomic denervation with no effect on the distal urethra and rhabdosphincter and that the proximal urethra remained patent with no fibrosis after autonomic denervation. Their conclusion was that preservation of 50% of the proximal urethral function and the whole distal urethra and rhabdosphincter function would be sufficient for maintaining continence after orthotopic bladder replacement following non-nerve sparing cystectomy.
3. The level of urethral resection:
Hautmann et al. [8,15] concluded that the higher up the urethral resection, the higher the incidence of hypercontinence. He found that in patients with bladder neck preservation, the incidence of hypercontinence was 40%, while it was only 15% in patients where the specimen was cut across the proximal urethra.
4. Ileal valve:
Stenzl et al. [16,17] found partially or completely obstructing ileal valve in 3 of 4 patients with hypercontinence. He followed up with TUR valve incision that led to complete resolution.
5. False voiding technique:
Mills et al. [18] added that the patient should understand that relaxing the pelvic floor is more important than abdominal straining during voiding. The pouch capacity is another factor, as he stated that large floppy bags will not empty well and need more straining with the risk of pouchocele formation.
Our experience with 39 patients with a follow-up from 3 to 190 months found that:
1. No case of pouchocele formation was found in our series. We don’t agree with the theory of mechanical obstruction.
2. Nerve preservation was attempted in all patients, yet we still got a high incidence of hypercontinence (30%).
3. No ileal valve was found in our cases either radiologicaly (pouchogram) or during follow-up cystoscopy for the hypercontinent patients.
The results of this study are compared to previous studies in Data 4.
The only significant factor contributing to hypercontinence in our work was the level of urethral resection. In the TBRI series, the specimen cut was across the bladder neck, and the hypercontinence rate was 38%. This is compared to the USF series where the specimen was cut across the proximal urethra and the hypercontience rate was 25%. A comparison of the 2 groups is shown in Figure 1.
Our explanation is that, in these patients, there is no coordination between the relaxation of the striated sphincter and the longitudinal smooth muscle contraction. Typically, this leads to the shortening and widening of the female urethra, and together with detrusor contraction, is the mechanism for micturition. However, the urinary stream of hypercontinent patients faces a urethra with a fixed tone that doesn’t open with trials of evacuation.
The significantly higher incidence in females compared to males needs explanation. We believe that, as both have an intact striated sphincter, the difference comes from the extra tone of the urethral smooth muscles left during surgery and that is faced during voiding.
Conclusions
The normal coordinated micturition reflex is the relaxation of the striated sphincter and contraction of the longitudinal smooth muscle. The loss of this reflex leads to the presence of a urethra with a fixed tone that doesn’t open with trials of evacuation. Because both have an intact striated sphincter, the higher incidence of hypercontinence in females compared to males is due to the presence of the extra tone of the urethral smooth muscles. This study proves that the more urethral length left, the higher the incidence of hypercontinence because more smooth muscle tone is faced during micturition. Nerve preservation has no impact, as the coordinated detrusor urethral smooth muscle action is lost.
No correlation was found in our study between the preoperative continence status and the postoperative continence condition. However, there were no cases of Grade 3 stress incontinence included in our study.
Acknowledgment
The authors acknowledge their deepest gratitude for Prof. Dr. Mohamed Helal from the Urology Department of the University of South Florida at Tampa (USF) for his sincere effort and participation in the completion of this work.
References
- Perez L, Webster G. History of urinary diversion techniques. In: Webster GD, Goldwater B, eds. Urinary Diversion: Scientific Foundations and Clinical Practice. 1st ed. Oxford, UK: Informa HealthCare; 1995:14-16.
- Camey M. Detubularized U-shaped cystoplasty. Curr Surg Tech Urology. 1980;3:1-8.
- Stein JP, Cote RJ, Freeman JA, Esrig D, Elmajian DA, Groshen S, Skinner EC, Boyd SD, Lieskovsky G, Skinner DG. Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens. J Urol. 1995 Oct;154(4):1329-33.
PubMed - CrossRef - Hübner WA, Trigo-Rocha F, Plas EG, Tanagho EA. Functional bladder replacement after radical cystectomy in the female: experimental investigation of a new concept. Eur Urol. 1993;23(3):400-4.
PubMed - Colleselli K, Strasser H, Moriggl B,et al. Hemi-Kock to the female urethra: Anatomical approach to the continence mechanism of the female urethra. J Urol. 1994;151(Pt. 2): 500 A; Abstract 1089.
- Ali-el-Dein B, el-Sobky E, Hohenfellner M, Ghoneim MA. Orthotopic bladder substitution in women: functional evaluation. J Urol. 1999 Jun;161(6):1875-80.
PubMed - CrossRef - Abol-Enein H, Ghoneim MA. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol. 2001 May;165(5):1427-32.
PubMed - CrossRef - Hautmann RE, Paiss T, de Petriconi R. The ileal neobladder in women: 9 years of experience with 18 patients. J Urol. 1996 Jan;155(1):76-81.
PubMed - CrossRef - Parra R, Berni K, Cummings J. Orthotopic bladder substitution in women with an ileocolonic pouch: functional and oncological outcome. Arch Esp Urol. 2004 Sep;57(7):769-74.
PubMed - Kochakarn W, Lertsithichai P, Pummangura W. Bladder substitution by ileal neobladder for women with interstitial cystitis. Int Braz J Urol. 2007 Jul-Aug;33(4):486-92; discussion 492.
PubMed - CrossRef - Ali-El-Dein B, Ghoneim MA. Effect of selective autonomic and pudendal denervation on the urethral function and development of retention in female dogs. J Urol. 2001 Oct;166(4):1549-54.
PubMed - CrossRef - Darson M, Blute M, Barrett D. Continent orthotopic urinary diversion in female patients. AUA update series. 2000;21(33):258-63.
- JarolÃÂm L, Babjuk M, Pecher SM, Grim M, Nanka O, Tichý M, Hanus T, Janský M. Causes and treatment of residual urine volume after orthotopic bladder replacement in women. Eur Urol. 2000 Dec;38(6):748-52.
PubMed - CrossRef - Stein JP, Grossfeld GD, Freeman JA, Esrig D, Ginsberg DA, Cote RJ, Skinner EC, Boyd SD, Lieskovsky G, Skinner DG. Orthotopic lower urinary reconstruction in women using the Kock ileal neobladder: updated experience in 34 patients. J Urol. 1997 Aug;158(2):400-5.
PubMed - CrossRef - Hautmann RE, de Petriconi R, Kleinschmidt K, Gottfried HW, Gschwend JE. Orthotopic ileal neobladder: Impact of the urethral resection line on functional results. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(4):224-9; discussion 230.
PubMed - CrossRef - Stenzl A, Colleselli K, Bartsch G. Update of urethra-sparing approaches in cystectomy in women. World J Urol. 1997;15(2):134-8.
PubMed - CrossRef - Stenzl A, Hobisch A, Strasser H, Bartsch G. Ureteroileal anastomosis in orthotopic urinary diversion: How much or how little is necessary? Tech Urol. 2001 Sep;7(3):188-95.
PubMed - Mills RD, Burkhard F, Studer UE. Bladder substitution in women. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(4):246-53.
PubMed - CrossRef