Ileocaecal vs ileal neobladder after radical cystectomy in patients with bladder cancer: a comparative study. A randomized study comparing an antireflux system with a direct ureteric anastomosis in patients with orthotopic ileal neobladders. Five-year followup of a prospective trial of radical cystectomy and neoadjuvant chemotherapy: Nordic Cystectomy Trial I. The Nordic Cooperative Bladder Cancer Study Group. Neorectal reservoir is not the functional principle of the colonic J-pouch: the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 1. Glomerular filtration rate and patency of uretero-intestinal anastomosis.
To compare an ileocaecal orthotopic bladder, (which has been the standard procedure in Egypt for >30 years) with the ileal neobladder, as there is no ideal continent orthotopic bladder replacement for patients after cystectomy for bladder cancer.
                Between June 1999 and December 2001, 60 patients with invasive bladder cancer were randomized into two groups. Group A comprised 29 patients who had radical cystectomy and reconstruction with an ileal neobladder (median age 50 years, 27 men and two women) and group B included 31 who had an ileocaecal bladder substitution after radical cystectomy (median age 51 years, 28 men and three women).
                The complication rate after surgery in group A was 17%, with two deaths, one from acute myocardial infarction and the other from haematemesis. In group B, the complication rate was 13%, with two deaths, one from a massive pulmonary embolism and the other from liver cell failure. Daytime continence was achieved in 93% of patients in group A and 90% in group B. The mean (sd) postvoid residual urine volume was larger in group A than group B, at 90 (72) vs 12 (20) mL. Acidosis and hyponatraemia were evident in the patients in group A but in none in group B (P < 0.05). The pelvicalyceal systems were preserved in 85% of patients in group A and 93% in group B during the 2-year follow-up. The mean (sd) renal cortical thickness was less in group A than in group B, at 1.8 (0.5) and 1.9 (0.2) cm, respectively. Although the cystometric capacity was greater and the basal pressure less in group A than B, these were not reflected in the degree of diurnal and nocturnal continence or back pressure on the renal units.
                Continence in both pouches was similar but the renal units were preserved better in the ileocaecal than in the ileal neobladder. Residual urine volume was greater in the ileal neobladder, with its potential complications of infection and stone formation, and acidosis was more evident. To assess the benefit of an antireflux system in patients with orthotopic ileal neobladders, as there is controversy about whether reflux prevention offers any advantages.
                We conducted a randomized prospective study between January 2002 and March 2004, on 60 patients (53 men and seven women) with a mean (sd) age of 52.7 (7.3) years, who were candidates for orthotopic neobladders. Patients with comorbidities were excluded. Preoperative evaluation included intravenous urography (IVU), cystoscopic biopsy and radioisotope renography to evaluate the differential glomerular filtration rates (GFRs). Cases with normal kidneys and ureters, and with similar GFRs, were enrolled. Surgery comprised a standard radical cystectomy with pelvic lymphadenectomy. The ureters were randomized to either a direct anastomosis into a 5-cm ileal chimney on one side, or to be implanted using the antireflux serous-lined extramural tunnel on the contralateral side in the same patient. Regular follow-up included IVU and renography every 6 months in cancer-free patients.
                The mean (sd) follow-up was 23 (9.6) months. There was prolonged urinary leak from a refluxing ureter in one patient that was treated with a temporary percutaneous nephrostomy. Symptomatic pelvic collections required tube drainage in six cases. Six ureters developed early anastomotic strictures (one direct and five antirefluxing), and were treated with endoscopic ureterotomy in three and open revision in three. Serum creatinine levels were normal in all patients throughout the observation period. GFRs were similar in the two groups. The mean GFRs before surgery and at 6, 12, 18, and 24 months after cystectomy were: 55.1, 50.7, 49.4, 52.2 and 53.9 mL/min for the direct side; and 56.1, 53, 52.4, 53.2 and 50.4 mL/min for renal units with antirefluxing implantation. There was a significant deterioration of the GFRs due to anastomotic strictures, from 48.6 (6.7) mL/min before surgery to 31.8 (15.9) mL/min after the revision (P = 0.01).
                The antireflux procedures were associated with a higher incidence of anastomotic strictures than the direct methods and there was a significant deterioration of renal function after obstruction. The long-term follow-up data are awaited. Chemotherapy is widely used in patients with locally advanced bladder cancer but until now there has been no conclusive evidence that this therapy improves survival. The Nordic Cooperative Bladder Cancer Study Group conducted a randomized phase III study to assess the possible benefit of neoadjuvant chemotherapy in patients with bladder cancer undergoing radical cystectomy after short-term radiotherapy.
                Our trial included 325 patients with locally advanced stage T1 grade 3 or stages T2 to T4aNXM0 bladder cancer allocated randomly into a chemotherapy or no chemotherapy group (control). The chemotherapy schedule consisted of 2 cycles of 70 mg./m.2 cisplatin and 30 mg./m.2 doxorubicin with a 3-week interval between the cycles.
                After 5 years the overall survival rate was 59% in the chemotherapy group and 51% in the control group (p = 0.1). The corresponding cancer specific survival rate was 64 and 54%, respectively. In regard to treatment, no difference was observed for stages T1 and T2 disease, while there was a 15% difference in overall survival for patients with stages T3 to T4a disease (p = 0.03). In a multivariate analysis only chemotherapy and T category emerged as independent prognostic factors. The relative death risk for patients who received chemotherapy was 0.69 (95% confidence interval 0.49 to 0.98) compared to the control group after adjustment for the other tested factors.
                Neoadjuvant chemotherapy seems to improve long-term survival after cystectomy in patients with stages T3 to T4a bladder carcinoma, while no survival benefit was found for stages T1 to T2 disease. Low anterior resection with coloanal anastomosis prevents a definitive stoma in patients with distal rectal cancer. However, imperative stool urge, stool fragmentation, prolonged stooling sessions, and minor problems of incontinence are frequently observed in the postoperative situation and negatively affect quality of life. Therefore, the colonic J-pouch was originally constructed to create a stool reservoir. In a randomized, prospective study, the short (5 cm) colonic J-pouch was tested for function and continence vs. straight coloanal anastomosis.
                Over a period of 30 months, 74 consecutive patients (55 males) with rectal cancer in the lower and middle third of the rectum were included and randomized into two groups. Anastomosis was performed either as a coloanal or a colon-pouch-anal anastomosis. The standardized surgical procedure included mobilization of the left hemicolon, central ligation of the inferior mesenteric artery and vein, preaortal lymph node dissection, autonomic nerve preservation, and total mesorectal excision. The anastomosis was performed at the upper anal canal or at the intersphincteric level. All patients were evaluated preoperatively and six months postoperatively for fecal continence, including sphincter manometry and defecation habits. In addition, quality of life was determined by use of a standardized questionnaire (European Organization for Research and Treatment of Cancer, EORTC-QLQ-C30).
                Thirty-seven patients were randomized into each group. In general, problems with continence for liquids or gas occurred less frequently in the colonic J-pouch group 6 months after surgery. The frequency of bowel movements was lower in the J-pouch group (2.5 per day) than in the coloanal group (4.7 per day). Importantly, in a manometric study at the same postoperative point, neorectal capacity was decreased to a similar degree in both groups compared with the preoperative rectal volume. Thus, the expected and postulated reservoir effect could not be achieved by forming a 5-cm colonic J-pouch.
                The colonic J-pouch was superior with regard to continence for gas and liquids compared with a straight coloanal anastomosis. Furthermore, stool frequency was significantly lower in the J-pouch group than in the coloanal reconstruction group. However, because neorectal capacity decreased equally in both groups, we speculate that the advantage of the colonic J-pouch is not in the creation of a larger neorectal reservoir but rather may be related to decreased motility. To evaluate the glomerular filtration rate (GFR) and incidence of anastomotic stenosis in patients with urinary diversion by ileal or colonic conduit (refluxing or anti-reflux uretero-intestinal anastomosis) or with a continent caecal reservoir.
                All conduit urinary diversions performed from 1977 to 1984 were randomized by type (ileal or colonic) and by the method of ureteric implantation (with or without anti-reflux technique). In continent caecal reservoirs anti-reflux implantation was used for both ureters. Total and separate GFR were measured pre-operatively and after a mean follow-up of 123 months (range 36-198) with 51Cr-EDTA and scintillation renography.
                Of the 56 evaluable patients, 18 had an ileal and 20 a colonic conduit, and 18 had a continent reservoir. The total mean GFR fell from 88 to 71 mL/min in the ileal group, from 84 to 65 mL/min in the colonic group and from 100 to 85 mL/min in the reservoir group. Separate GFR did not differ significantly between kidneys with and without reflux protection in the patients with a conduit diversion. Strictures occurred in 15 uretero-intestinal anastomoses and were unrelated to the mode of ureteric implantation (in the conduit groups). Renal function improved after ureteric reimplantation in six of seven kidneys, but after balloon dilatation in only one of five.
                GFR fell moderately in all three groups, with no significant intergroup difference, and the continent caecal reservoir compared favourably with conduit diversion. The fall in separate GFR did not differ significantly between kidneys with and without reflux protection. Surgical exploration of uretero-intestinal stenosis is recommended if renal function is threatened.
The evidence from the included trials was very limited. Only five studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The clinical significance of data from one small trial suggesting that bladder replacement using an ileal segment compared to using an ileocolonic segment is better in terms of lower rates of nocturnal incontinence is uncertain. The small amount of usable evidence for this review suggests that collaborative multi centre studies should be organised, using random allocation where possible.