The orthotopic Kock ileal neobladder: Functional results, urodynamic features, complications and survival in 166 men

Purpose: We report our experience with 166 patients who underwent radical c ystectomy and orthotopic bladder substitution with the ileal Kock neobladde r between February 1990 and January 1999. Materials and Methods: We classified complications as early (3 months or le ss postoperatively) and late. Continence was assessed by patient interview, the need to use protective devices and provocative incontinence testing. N eobladder function was evaluated by uroflowmetry, post-void residual urine volume measurement and enterocystometry, and renal function was assessed by (51)creatinine ethylenediaminetetraacetic acid clearance. Results: There were no perioperative deaths. However, 52 early complication s developed in 39 patients (23.5%) and 73 late complications in 62 (37.456) . The rate of early and late complications associated with the urinary trac t was 11.5% and 23.5% with abdominal reoperation rates of 1.8% and 2,4%, re spectively, due to these complications. At 3 and 5 years the risk of stone formation on the metallic staples was 18% and 34%, and the risk ofB12 defic iency was 30% and 338, respectively. One patient (0.6%) underwent reoperati on for ureteral anastomotic stricture. Anterior urethral stricture in 5 cas es (3%) was caused by recurrence in 1 and urethral anastomotic stricture in 1 also resulted from recurrent disease. Daytime continence was reported by 97%, and 100% of our patients at 1 and 5 years, respectively. Provocative incontinence testing confirmed this level of daytime continence. Overall 75 % of patients reported nighttime continence at 1 year and 94% at: 5 years. The need for a nighttime protective device decreased with time. At 1 versus 3 years 39.8% versus 45.9% of patients used no protection, 29.7% versus 39 .2% used a sanitary pad and 30.5% versus 14.9% used a condom device. Entero cystometric capacity and subtracted maximum reservoir pressure remained rem arkably uniform at 456 versus 411 mi. and 47 versus 50 cm. water 6 months a nd 5 years postoperatively, respectively. Nevertheless, median post-void re sidual urine volume increased from 20 mi. at 6 months to 40 mi. at 5 years with an increased prevalence of patients requiring intermittent catheteriza tion due to post-void residual urine greater than 100 mi, from 16% at 6 mon ths to 44% at 5 years. (51)Creatinine ethylenediaminetetraacetic acid clear ance remained unchanged. There was a substantial 5-year survival advantage for the subpopulation with stage pT,3a or less, pNO tumors (94% versus 51%, p (0,001). Conclusions: Radical cystectomy and orthotopic bladder substitution with th e Kock ileal neobladder may be performed with an acceptable complication ra te and good functional results. The probability of survival was considerabl y higher for patients with tumor confined to the bladder. Consequently we b elieve that early aggressive treatment should be considered in those with i nvasive disease, and reconstruction with orthotopic bladder substitution ma y encourage patients to accept radical surgery.