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A recent systematic review sought to outline international practices for the treatment of urinary incontinence (UI) in patients who have undergone radical cystectomy (RC) and orthotopic neobladder (ONB) reconstruction. These findings were published in Nursing Open.
“There are no evidence-based guidelines for incontinence management after RC and ONB,” the researchers wrote in their report.
This systematic scoping review of the literature involved a search of multiple databases for published research regarding management of UI following radical cystectomy and ONB reconstruction. Studies were published between 1979 and 2022 and were not limited in terms of data sources or study design. For analyses, data extracted were patient demographics, presence or absence of preoperative incontinence, type of ONB surgery, outcomes related to postoperative incontinence and treatment responses, and other details.
Sixteen papers met the eligibility criteria for this review, most of which were published in the US or Europe. Of these, 11 were research articles, and 5 were clinical case reports. More male patients than female patients (283 vs 23) were involved across the studies.
A variety of factors can influence UI: surgical, patient, and postoperative. The type of bowel segment used for the neobladder influences voiding pressure and voiding pattern, as well as the risk of voiding dysfunction and choice of surgical technique.
Choice of surgical technique had an effect on patient quality of life. Open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) with intracorporeal (iN) or extracorporeal neobladder are surgical options reviewed. Another technique was intracorporeal urinary diversion (iUD) with ORC and RARC.
Voiding function is significantly affected by whether the technique used involved nerve sparing and organ preservation. Methods that seek to achieve nerve sparing and organ preservation can lead to improved incontinence and hypercontinence.
Patient factors were age, presence of diabetes or obesity, and trying nerve sparing on early continence. Younger patients may be better candidates for ONB reconstruction, as strict adherence to the new bladder training program is required. Age older than 65 years and preoperative urethral pressure curve were reported as factors that influence urinary control after radical cystectomy for orthotopic bladder substitution.
Overall, there appeared to be a lack of global guidance for managing UI following radical cystectomy and ONB reconstruction. However, the researchers noted that surgical treatment should be considered for patients who have low urethral closure pressure or peritoneal depression if conservative methods have not been effective.
The postoperative period also influences overall outcomes for patients. These studies reported improved continence over time. As the bowel stretches from the increase in volume and decrease in pressure, improved daytime incontinence control (59% at 3 months to 92% at 12 to 18 months postoperatively) and nocturnal abstinence (28% at 3 months to 51% at 18 to 36 months postoperatively) were reported.
“Patients must pay close attention to changes in voiding patterns after surgery because continence is a dynamic process that improves in many patients as the functional capacity of the neobladder increases over time,” the researchers concluded.
Based on this review, conservative therapy was determined to have limitations, pharmacologic interventions appear worthwhile. Invasive procedures for mild to moderate UI such as fillers appear outdated and sling procedures carry an increased risk of complications. They considered the use of an artificial urinary sphincter to represent a possible reference standard for male patients with severe UI.
Reference
Miao SY, He QW, Zhang YF, et al. Management of urinary incontinence after radical cystectomy and orthotopic neobladder: a scoping review of international practices. Nurs Open. 2023;10(10):6618-6634. doi:10.1002/nop2.1924
