Urinary diversion for refractory female SUI

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.

1) When should urinary diversion be considered as an option? There is no clear recommendation regarding when and how to perform UD for the management of complex or refractory SUI in female patients. This is in contrast from refractory idiopathic overactive bladder syndrome, where UD is clearly recommended. [1]

The EAU has recently released new guidelines on non-neurogenic female LUTS. They state that patients with intractable UI related to multiple pelvic surgeries, radiotherapy and other pelvic pathologies which ultimately lead to intrinsic sphincter deficiency or fistulae may be offered reconstructive options such as non-continent UD (for example ileal conduit) or neobladder (orthotopic or heterotopic) with continent catheterisable conduit. [1]

It was reported that UD may be an option in case of failure of surgical curative options for female SUI.

In a paper by Nadeau et al. reviewing recurrent stress incontinence following sling implantation, the authors consider UD as the most invasive intervention for SUI. They claim it should be used as the last resort in this indication. [2] They highlight the importance of counselling patients on the significant risk of complications and the need for life-long monitoring.

A recently published French study from Tricard et al. reported the outcomes of 111 patients who underwent an artificial urinary sphincter (AUS) for SUI. [3] Over a period of 26 years, 29 patients required 35 explantations. Among them, 4 patients were managed with urinary diversions (three cystectomies and one neck bladder closure with continent UD). 13 AUS were reimplanted in 11 patients, with 6 patients (46%) finally requiring UD (continent with bladder neck closure, or non-continent UD) because of urethral perforation or device infection. 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.

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]

In a systematic review recently published by Dobberfuhl, on the management of female SUI after pelvic radiotherapy, the author advocates that UD is the standard care for female patients suffering from refractory SUI after failed bladder outlet procedures with devastated bladder neck/urethra. An example of this is a procedure after a long-term indwelling urethral catheter. [4] Whatever the mechanism in these cases of devastated bladder neck/urethra, UD (continent or non-continent) may be proposed as a first line option. The author also suggests not to prescribe long-term indwelling catheter, to avoid any severe complications such as iatrogenic hypospadias, intrinsic sphincter deficiency, bladder neck injury or urethro-cutaneous fistulae, in both non-neurogenic and neurogenic female patients. [4,5] In patients not willing to undergo a UD or who have contra-indications to this surgery, a suprapubic catheter may be offered in carefully selected patients with a certain degree of persistent urethral continence. [4]

In the particular case of vesico-vaginal fistulae after radiation therapy, the EAU guidelines on nonneurogenic female LUTS report that modified surgical techniques are often required as standard techniques may be at higher risk of failure or poorer results. [1] Temporary or permanent UD may be proposed in these particular cases. [1] However, the type of diversion (continent or non-continent) is not specified.

2) When indicated, how to choose between continent and non-continent urinary diversion? As reported in the EAU guidelines, there is insufficient evidence in the literature to comment on which procedure offers the best outcomes, in particular for quality of life. [1]

In case of non-devastated bladder neck/urethra, when urethral continence wants to be achieved, or can be 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).

Regarding the technical aspect of performing a non-continent diversion such as ileal conduit, preserving the bladder appears to be a poor strategy, because of the high risk of pyocysts. In a paper published in 2002 by Chartier-Kastler, 33 patients with neurogenic bladders who underwent non-continent UD, the rate of non-concomitant cystectomies was 63%, and a high rate of pyocysts was observed (21%). [7] This rate can reach 50% in the literature, and the International Consultation in Incontinence recommends to systematically remove the bladder during the procedure. [8]

3) Long-term outcomes and complications after urinary diversion for female SUI A few studies have been published reporting outcomes of UD in females with refractory SUI.

Cox and Worth reported their outcomes after a minimum of 1-year follow-up in 18 female patients who underwent non-continent UD (ileal conduit) for refractory SUI. [8] 8 required revisions of their stomas and 13 developed complications related to persistent discharge from the bladder. A further 8 patients required a secondary cystectomy.

In the paper published by Tricard et al., patients who underwent UD after AUS explantation were described as satisfied and reported an improvement in quality of life at last follow-up. [3]

In his review of UD in women after radiotherapy, excluding fistulae, Dobberfuhl states that in the case of a devastated outlet, UD remains a standard treatment option, provided that the quality of life benefits are carefully weighed against a reported 65-83% postoperative complication rate. [4] In the same review, the rate of patients improved after UD was 66%. However, these results are difficult to extrapolate specifically in patients with refractory SUI, as they included female patients who had undergone UD after radiotherapy in various conditions, including bladder or cervical cancer. [4] 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.

References

1. Harding C, Lapitan MC, Arlandis Guzman S, Bo K,

Costantini E, Groen J, et al. EAU Guidelines on

Management of Non-Neurogenic Female Lower Urinary

Tract Symptoms (LUTS) 2021 [Available from: https:// uroweb.org/wp-content/uploads/EAU-Guidelines-on-Non-

Neurogenic-Female-LUTS-2021.pdf. 2. Nadeau G, Herschorn S. Management of recurrent stress incontinence following a sling. Curr Urol Rep. 2014;15(8):427. 3. Tricard T, Al Hashimi I, Schroeder A, Munier P, Saussine C.

Real-life outcomes after artificial urinary sphincter explantation in women suffering from severe stress incontinence. World J Urol. 2021;39(10):3891-6. 4. Dobberfuhl AD. Evaluation and treatment of female stress urinary incontinence after pelvic radiotherapy. Neurourol

Urodyn. 2019;38 Suppl 4:S59-S69. 5. Gambachidze D, Lefevre C, Chartier-Kastler E, Perrouin

Verbe MA, Kerdraon J, Egon G, et al. Management of urethrocutaneous fistulae complicating sacral and perineal pressure ulcer in neurourological patients: A national multicenter study from the French-speaking Neuro-urology

Study Group and the Neuro-urology committee of the

French Association of Urology. Neurourol Urodyn. 2019;38(6):1713-20. 6. Basavaraj DR, Harrison SC. The Mitrofanoff procedure in the management of intractable incontinence: a critical appraisal. Curr Opin Urol. 2006;16(4):244-7. 7. Chartier-Kastler EJ, Mozer P, Denys P, Bitker MO, Haertig A,

Richard F. Neurogenic bladder management and cutaneous non-continent ileal conduit. Spinal Cord. 2002;40(9):443-8. 8. Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D,

Brubaker L, et al. 6th International Consultation on

Incontinence. Recommendations of the International

Scientific Committee: Evaluation and treatment of urinary incontinence, pelvic organ prolapse and faecal incontinence. Neurourol Urodyn. 2018;37(7):2271-2. 9. Cox R, Worth PH. Ileal loop diversion in women with incurable stress incontinence. Br J Urol. 1987;59(5):420-2.

Refractory female SUI/ Failure of cura4ve op4ons

Non devastated urethra/ Bladder neck

Prior radiotherapy

No

Urinary diversion

may be an op3on, the non-con3nent diversion being proposed in pa3ent who are not able to self-catheterise Yes

Non con4nent urinary diversion 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

Con4nent urinary diversion s4ll feasible

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 ?

Devastated urethra/ bladder neck

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