Reconstructive urology

Stenzl, Arnulf

doi:10.1590/S1677-55382004000600019

UROLOGICAL SURVEY

Reconstructive urology

Vaginal and penile reconstruction

Sievert KD

Department of Urology, University of Munster, Munster, Germany

Curr Opin Urol. 2003; 13: 489-94

PURPOSE OF REVIEW: Reconstructive surgery for patients with genital abnormalities or for patients who require reconstructive efforts is challenging. This review highlights those articles, which are outstanding among all those important papers, which have been published during the last year (2002-2003).

RECENT FINDINGS: A greater understanding of embryonal development improves the success of reconstructive surgery. Other factors, such as the patient's sex, influence the surgical technique used and the degree of invasiveness or complexity. In the adult the pressure to shorten hospital stays has played a big part in the continual modification and enhancement of surgical techniques. In addition to modified techniques, new off-the-shelf materials are introduced to the clinic, which seem to have the potential to improve the surgical outcome and shorten hospital stays.

SUMMARY: With the continued successful basic anatomy and basic research, reconstructive surgery brings higher success rates. Long-term results are still required to validate the reliability of these new surgical techniques and materials.

Editorial Comment

This paper nicely outlines the current status of reconstruction of male and female genitalia for a successful reconstruction in genital abnormalities a greater understanding of the embryonal development is advantages. Flap technology and prefabrication are the currently preferred methods for surgical success in transsexual patients. However, here again we are awaiting the clinical application of tissue-engineered segments for both the penile autologous prosthesis and vaginal cavity.

Dr. Arnulf Stenzl

Professor and Chairman of Urology

Eberhard-Karls-University Tuebingen

Tuebingen, Germany

Orthotopic bladder substitution in women: nontraditional applications

Lee CT, Hafez KS, Sheffield JH, Joshi DP, Montie JE

Department of Urology, University of Michigan, Ann Arbor, Michigan, USA

J Urol. 2004; 171: 1585-8

PURPOSE: Orthotopic urinary diversion is a feasible and optimal technique for many women undergoing cystectomy. Although successful outcomes have been achieved, groups at most centers have strict selection criteria. We evaluated our experience with female orthotopic diversion in traditional and nontraditional candidates.

MATERIALS AND METHODS: From September 1, 1995 to February 6, 2003 53 females with a mean age of 62 years underwent orthotopic bladder substitution. Median followup was 24 months. Clinicopathological parameters were evaluated in traditional and nontraditional patients. The nontraditional subset comprised 22 women older than 70 years (12) or had a history of pelvic radiation (2), neoadjuvant chemotherapy (6) or stress incontinence (2).

RESULTS: The entire group had a mean operative time, blood loss and hospital stay of 6.2 hours, 1,135 ml and 8.2 days, respectively. Tumor was organ confined in 38 and extravesical in 14 patients with bladder cancer. Complications were detected in 20 patients, including 9 who were traditional (23%) and 11 who were nontraditional (50%). Daytime and nighttime continence was reported by 46 (87%) and 45 (85%) patients, respectively, of whom 11 (21%) required intermittent catheterization. Of the patients with cancer 42 were disease-free, 2 were alive with disease and 6 died of disease. The nontraditional subset was older (p < 0.0003) and had shorter followup (p = 0.05), a higher American Society of Anesthesiologists score (p = 0.01) and a shorter overall survival (p = 0.001) than the traditional group. Continence was seen in 19 of 22 nontraditional patients (86%) and 4 (18%) required intermittent catheterization.

CONCLUSIONS: Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. A subset of less favorable candidates can also successfully undergo orthotopic substitution with a tolerable toxicity profile.

Editorial Comment

In this paper the authors confirm previous studies on a successful use of orthotopic neobladder in a wide range of female patients. Despite extravesical disease, an age older than 70 years, a history of pelvic radiation, neoadjuvant chemotherapy, or preoperative stress incontinence, these patients had a continence rate of 86% and an intermittent catheterization rate of 18%. None of the patients had a urethral recurrence after a median follow up of 24 months.

This study reinforces previous suggestions that an orthotopic bladder substitution in women undergoing radical cystectomy is not only feasible but also applicable to a majority with localized bladder tumors. Not everybody might agree with the technique of surgery by the authors, which might be the reason for a higher rate of urinary retention compared to other reports, but undoubtedly this paper shows that unfavorable factors must be a contraindication for an orthotopic neobladder.