VOJNOSANITETSKI PREGLED

: Background/Aim: Orthotopic continent neobladder provides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency. Standard surgical techniques require usage of ileal segment in the length of 50-65 cm for neobladder creation, with favorable results. However, usage of long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications. Aim of this study was to analyze clinical outcomes of the Belgrade pouch orthotopic bladder replacement in female patients and to promote usage of shorter ileal segment for neobladder creation. Methods: A prospective study conducted in our institution during the period from 2009-2019 year included 37 female patients who underwent orthotopic bladder replacement according to “Belgrade pouch” technique with usage of shorter ileal segment average length of 28 cm for neobladder creation . Inclusion criteria were: female continent patients older than 18 yrs, organ confined muscle invasive bladder carcinoma and, ASA score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonal diseases, systemic illness and metabolic diseases which may have influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, pathohistological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two years period of follow up. Results: Average age voiding frequency, with adequate capacity, without urinary tract retention, and with the decrease of metabolic complications.


ABSTRACT:
Background/Aim: Orthotopic continent neobladder provides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency.
Standard surgical techniques require usage of ileal segment in the length of 50-65 cm for neobladder creation, with favorable results. However, usage of long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications.
Aim of this study was to analyze clinical outcomes of the Belgrade pouch orthotopic bladder replacement in female patients and to promote usage of shorter ileal segment for neobladder creation.
Methods: A prospective study conducted in our institution during the period from 2009-2019 year included 37 female patients who underwent orthotopic bladder replacement according to "Belgrade pouch" technique with usage of shorter ileal segment average length of 28 cm for neobladder creation . Inclusion criteria were: female continent patients older than 18 yrs, organ confined muscle invasive bladder carcinoma and, ASA score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonal diseases, systemic illness and metabolic diseases which may have influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, pathohistological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two years period of follow up.

INTRODUCTION:
Bladder tumor is the sixth most common malignancy in human population, and it appears 3,5-4 times rarely in female population (1). Despite the fact that this malignancy is not so frequent in females, bladder cancer in this subgroup of population is presented with more advanced disease and have worse survival rate. (2). In 25% of patients, bladder cancer appears in muscle-invasive form (3). Radical cystectomy (RC) is the gold standard management for muscle invasive bladder cancer (MIBC). RC in females includes removal of the bladder, anterior wall of vagina, uterus, ovary, fallopian tubes and regional lymph nodes. After RC, urinary diversion may be resolved through ureterocutaneostomy, ileal conduit or neobladder substitution.
AIM of this study is to present very first results of Belgrade pouch technique in females and to promote usage of shorter ileal segment for neobladder creation in females.

METHODOLOGY:
In prospective clinical study we included 37 female patients surgically treated between We did not noticed wound dehiscence, neither high body temperature during hospitalization.
In early postoperative period we reported one patient (2,7%) with paralytic ileus which was resolved conservatively within 8 days postoperatively with prokinetic drugs, correction of serum potassium concentration and prolonged nasogastric tube placement .
One (2,7%) patient had urinary fistula that appeared, two months following the surgery. In the youngest one patient, aged 32,the right ovary was preserved, and in another two patients aged 37 and 42, internal genital organs were preserved.   Patients sheduled for orthotopic urinary derivation are often younger, usually under the age of 65 (7). In this study cohort, the average age of the pts was 58, and the youngest one was at the age of just 32. Although age is not a contraindication for orthotopic diversion, thr majority of authors do not perform this kind of surgery in octogenarians (8,9).
The most common early complications in other studies were ileus up to 15% and wound infection up to 12% (10). In this study there was only one patient with paralitic ileus, and we did not report wound infection and dehiscence, but our results are probably associated with a smaller number of patients.
Referent studies reported that one-quarter to one-third of pts received blood transfusion intraoperatively, and similar results were reported in this study (11). Few percentage higher results in our study are in correlation with a higher percentage of preoperative anemia in patients.
Urinary fistula is uncommon, but possible complication. Carmel described their experience with this kind of complication and suggested that Martius or omental flap should be interposed between vagina and (neo)bladder, after excision of fistulous channel and closure of defect (12). The procedure using Martius flap , through transvaginal approach was done in our patient with excellent results.
Kretschmer reported 22,4% with TIS, 23,0% of pts in pT1 stage, 27,6% in pT2 stage, 18,4% in pT3 and 4,6% in pT4 stage , with missing data in 4% (13).The majority of patients in our study were in pT2 and pT3 stage. Some of them have unfavorable histopathological features of squamocellular or sarcomatoid components which may influence on treatment outcome as well as nodal involvement. Although we used the "Belgrade pouch" technique only in patients with malignancy, it is suitable also for patients with benign conditions requiring cystectomy.

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In the youngest patient, aged of 32 the right ovary was preserved. In another two patients aged 37 and 42 uterus and ovaries were preserved, on their own request. For selected patients, sparing of internal genitalia has proven to be oncologicaly safe, but still there are no strict recommendations for these cases (14). Pouch may became unnecessary large and become a reason for voiding problems and metabolic complications. Different studies reported daytime continence in range of 88-99%, and during the night level of continence is 10-20% lower (17,18) In 11 studies reported daytime and night-time continence rates were 58-100% and 42-100%, respectively and self-catheterisation rate was 9.5-78% (19 Reasons for ureterohydronephrosis appearance in patients after neobladder construction may be stricture on uretero-pouch anastomosis, urine reflux , calculosis of the renal pelvis or ureter , tumor in ureter or extraluminal compression on ureter. Early, postoperative transitional hydronephrosis may be caused by edema at anastomosis and reduced compliance and capacity of the neobladder (23). Ureterohydronephrosis rate in referent studies appears in 5-19% (23). In our study initially higher number of low grade bilateral hydronephrosis was caused by urine reflux during the period while neobladder is still with smaller capacity. This kind of hydronephrosis is transitional, and usually is not connected with renal deterioration and infection rate. On the other hand, in two years period of follow up we reported one patient with hydronephrosis grade III which was resolved by placing a percutaneous nephrostomic tube. The other patient was resolved through very complicated surgical procedure of reimplantation of both ureters in neobladder.
Vitamin B12 deficiency is more frequent in neobladders constructed of more than 60 cm of terminal ileum. Fujisawa reported 13,6% patients vitamin B12 deficiency, detected between 9 months and 3 years after surgery (24). In our study we did nor reported vitamin B12 deficiency.

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CONCLUSION: Orthotropic ileal neoblader created from shorter ileal segment "Belgrade pouch" provides high level of continence without significant increasing of voiding frequency, with adequate capacity, insignificant residual urine without urinary tract retention. We reported a small percentage of pouch calculosis without significant acidosis and without vitamin B12 deficiency in two years of follow up. Appearance of refluxive ureterohydronephrosis is transient, low grade and caused by smaller neobladder capacity in first months. Literature: