Urinary diversion for refractory female SUI An overview of indications and considerations In the particular case of previous pelvic radiotherapy, bladder outlet procedures are at higher risk of failure, regardless of the type of procedure (synthetic slings, colposuspension, artificial urinary sphincter). [4] There is also a higher rate of complications, in particular device exposure. [4] Patients should be informed and made aware of these complications before undergoing continence surgeries, especially when prosthetic devices are implanted.
Dr. Marie-Aimée Perrouin Verbe Dept. of Urology Nantes Hôtel-Dieu Hospital Nantes (FR) marieaimeeperrouin@ me.com In some complex cases of female refractory stress urinary incontinence (SUI), or after failure of surgical curative options, urinary diversion (UD) may be considered. However, the optimum timing and the type of UD (continent UD or non-continent UD) may be challenging due to the scarcity of data in the literature. Moreover, performing these surgeries may also prove challenging as the patients have frequently undergone previous SUI procedures or pelvic radiation therapy.
Moreover, with pelvic radiotherapy sometimes leading to detrusor overactivity and poor bladder compliance, bladder outlet procedures may also be at risk of de novo or increased storage symptoms as well as high-pressure bladder. [4] In these cases, urodynamic studies are mandatory to assess bladder dysfunction, and if necessary, a concomitant augmentation cystoplasty can be performed alongside bladder outlet surgery. The UD (continent or non-continent) is an alternative option to discuss in these cases; the non-continent diversion is proposed to patient who are not able to self-catheterise. [4]
achieved with a concomitant bladder neck closure or obstructive surgery (autologous fascial sling, bladder neck aponeurotic sling), a continent UD can be proposed, in patients willing and/or able to selfcatheterise. [6] However, in cases of devastated bladder neck/ urethra, there is a substantial risk of persistent urethral incontinence with continent UD. This risk is enhanced in case of prior radiation therapy, as there is a higher risk of poor wound healing, placing patients at elevated risk of failure after continent urinary diversion. [4] Finally, as previously mentioned, radiation therapy may also lead to poor bladder compliance, with a risk of high bladder pressure and urethral incontinence. In these situations, a non-continent UD may be proposed as first option (see Fig. 1).
4) Conclusion/implication for practice There is limited published data in the literature evaluating the treatment of refractory stress urinary incontinence in females whilst considering factors such as multiple pelvic surgeries, radiotherapy and other pelvic pathologies leading to intrinsic sphincter deficiency. UD has been described without consensus as an option of last resort, when previous curative options have failed, and is probably the best option in case of devastated bladder neck/urethra. There is no data to help us choose the type of UD according to the situation. However, when the chances of achieving urethral continence are limited, or after radiotherapy, non-continent UD seems to be the best option to consider to limit complications and achieve quality of life. The optimum timing for re-intervention is even more controversial. Patient’s counselling is mandatory to best guide them in their choice of treatment and type of UD.
Regarding the technical aspect of performing a non-continent diversion such as ileal conduit, preserving the bladder appears to be a poor strategy, 1) When should urinary diversion be considered as because of the high risk of pyocysts. In a paper References an option? 1. Harding C, Lapitan MC, Arlandis Guzman S, Bo K, In a systematic review recently published by published in 2002 by Chartier-Kastler, 33 patients with Costantini E, Groen J, et al. EAU Guidelines on There is no clear recommendation regarding when and Dobberfuhl, on the management of female SUI after neurogenic bladders who underwent non-continent how to perform UD for the management of complex or pelvic radiotherapy, the author advocates that UD is the UD, the rate of non-concomitant cystectomies was 63%, Management of Non-Neurogenic Female Lower Urinary refractory SUI in female patients. This is in contrast from standard care for female patients suffering from Tract Symptoms (LUTS) 2021 [Available from: https:// and a high rate of pyocysts was observed (21%). [7] refractory idiopathic overactive bladder syndrome, uroweb.org/wp-content/uploads/EAU-Guidelines-on-Nonrefractory SUI after failed bladder outlet procedures This rate can reach 50% in the literature, and the where UD is clearly recommended. [1] Neurogenic-Female-LUTS-2021.pdf. with devastated bladder neck/urethra. An example of International Consultation in Incontinence recommends 2. Nadeau G, Herschorn S. Management of recurrent stress this is a procedure after a long-term indwelling urethral to systematically remove the bladder during the The EAU has recently released new guidelines on incontinence following a sling. Curr Urol Rep. catheter. [4] Whatever the mechanism in these cases of procedure. [8] non-neurogenic female LUTS. They state that patients 2014;15(8):427. devastated bladder neck/urethra, UD (continent or with intractable UI related to multiple pelvic surgeries, 3. Tricard T, Al Hashimi I, Schroeder A, Munier P, Saussine C. non-continent) may be proposed as a first line option. 3) Long-term outcomes and complications after radiotherapy and other pelvic pathologies which Real-life outcomes after artificial urinary sphincter The author also suggests not to prescribe long-term urinary diversion for female SUI ultimately lead to intrinsic sphincter deficiency or explantation in women suffering from severe stress indwelling catheter, to avoid any severe complications A few studies have been published reporting outcomes fistulae may be offered reconstructive options such as incontinence. World J Urol. 2021;39(10):3891-6. such as iatrogenic hypospadias, intrinsic sphincter of UD in females with refractory SUI. non-continent UD (for example ileal conduit) or 4. Dobberfuhl AD. Evaluation and treatment of female stress deficiency, bladder neck injury or urethro-cutaneous neobladder (orthotopic or heterotopic) with continent urinary incontinence after pelvic radiotherapy. Neurourol fistulae, in both non-neurogenic and neurogenic Cox and Worth reported their outcomes after a catheterisable conduit. [1] Urodyn. 2019;38 Suppl 4:S59-S69. female patients. [4,5] In patients not willing to undergo minimum of 1-year follow-up in 18 female patients who 5. Gambachidze D, Lefevre C, Chartier-Kastler E, Perrouin a UD or who have contra-indications to this surgery, a underwent non-continent UD (ileal conduit) for It was reported that UD may be an option in case of Verbe MA, Kerdraon J, Egon G, et al. Management of suprapubic catheter may be offered in carefully selected refractory SUI. [8] 8 required revisions of their stomas failure of surgical curative options for female SUI. urethrocutaneous fistulae complicating sacral and perineal patients with a certain degree of persistent urethral and 13 developed complications related to persistent pressure ulcer in neurourological patients: A national continence. [4] discharge from the bladder. A further 8 patients In a paper by Nadeau et al. reviewing recurrent stress multicenter study from the French-speaking Neuro-urology required a secondary cystectomy. incontinence following sling implantation, the authors Study Group and the Neuro-urology committee of the In the particular case of vesico-vaginal fistulae after consider UD as the most invasive intervention for SUI. French Association of Urology. Neurourol Urodyn. radiation therapy, the EAU guidelines on nonIn the paper published by Tricard et al., patients who They claim it should be used as the last resort in this 2019;38(6):1713-20. neurogenic female LUTS report that modified surgical underwent UD after AUS explantation were described indication. [2] They highlight the importance of techniques are often required as standard techniques as satisfied and reported an improvement in quality of 6. Basavaraj DR, Harrison SC. The Mitrofanoff procedure in counselling patients on the significant risk of the management of intractable incontinence: a critical may be at higher risk of failure or poorer results. [1] life at last follow-up. [3] complications and the need for life-long monitoring. appraisal. Curr Opin Urol. 2006;16(4):244-7. Temporary or permanent UD may be proposed in these 7. Chartier-Kastler EJ, Mozer P, Denys P, Bitker MO, Haertig A, particular cases. [1] However, the type of diversion In his review of UD in women after radiotherapy, A recently published French study from Tricard et al. Richard F. Neurogenic bladder management and (continent or non-continent) is not specified. excluding fistulae, Dobberfuhl states that in the case reported the outcomes of 111 patients who underwent cutaneous non-continent ileal conduit. Spinal Cord. of a devastated outlet, UD remains a standard an artificial urinary sphincter (AUS) for SUI. [3] Over a 2002;40(9):443-8. 2) When indicated, how to choose between continent treatment option, provided that the quality of life period of 26 years, 29 patients required 35 8. Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D, and non-continent urinary diversion? benefits are carefully weighed against a reported explantations. Among them, 4 patients were managed Brubaker L, et al. 6th International Consultation on As reported in the EAU guidelines, there is insufficient 65-83% postoperative complication rate. [4] In the with urinary diversions (three cystectomies and one Incontinence. Recommendations of the International evidence in the literature to comment on which same review, the rate of patients improved after UD neck bladder closure with continent UD). 13 AUS were Scientific Committee: Evaluation and treatment of urinary procedure offers the best outcomes, in particular for was 66%. However, these results are difficult to incontinence, pelvic organ prolapse and faecal reimplanted in 11 patients, with 6 patients (46%) finally quality of life. [1] extrapolate specifically in patients with refractory SUI, requiring UD (continent with bladder neck closure, or incontinence. Neurourol Urodyn. 2018;37(7):2271-2. as they included female patients who had undergone 9. Cox R, Worth PH. Ileal loop diversion in women with non-continent UD) because of urethral perforation or In case of non-devastated bladder neck/urethra, when UD after radiotherapy in various conditions, including incurable stress incontinence. Br J Urol. 1987;59(5):420-2. device infection. urethral continence wants to be achieved, or can be bladder or cervical cancer. [4]
Refractory female SUI/ Failure of cura4ve op4ons
Non devastated urethra/ Bladder neck
Devastated urethra/ bladder neck
Prior radiotherapy
Yes
No
Urinary diversion may be an op3on, the non-con3nent diversion being proposed in pa3ent who are not able to self-catheterise
Non con4nent urinary diversion
Con4nent urinary diversion s4ll feasible
to be discussed as first op3on as prior radiotherapy may lead to poorer results on urethral con3nence and poor bladder compliance in case of con3nent diversion
if the pa3ent is able/willing to self catheterise but must be aware of poorer results on urethral con3nence++ risk of poor bladder compliance: concomitant augmenta3on cystoplasty ?
Non con4nent urinary diversion to be discussed as first op3on as devastated urethra may lead to recurrent urethral incon3nence also to be discussed as first op3on in case of prior radiotherapy
Con4nent urinary diversion with bladder neck closure pa3ent must be informed of the risk of recurrent urethral incon3nence
Fig. 1: Treatment options for refractory female SUI
22
European Urology Today
March/May 2022
