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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 2  |  Page : 81-85

Long-term satisfaction and complications in women with interstitial cystitis undergoing partial cystectomyand augmentation enterocystoplasty


1 Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
2 Department of Urology, Buddhist Tzu Chi General Hospital; School of Medicine, Tzu Chi University, Hualien, Taiwan

Date of Web Publication30-Apr-2018

Correspondence Address:
Hann-Chorng Kuo
Buddhist Tzu Chi General Hospital, Hualien
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_21_17

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  Abstract 

Objective: Interstitial cystitis (IC) is a chronic syndrome without effective definite treatment. Partial cystectomy with augmentation enterocystoplasty (AE) is considered a treatment of last resort for ulcer-type IC. This study investigated the long-term satisfaction and complications of IC patients undergoing AE. Methods: Fifteen IC (12 ulcer-type and 3 nonulcer-type) patients who underwent AE at a single medical center from 2010 to 2016 were retrospectively reviewed. The clinical symptoms and urodynamic study results of each patient were recorded before the operation. The long-term satisfaction of each patient was then evaluated using the global response assessment (GRA), and the postoperative symptoms were graded on a 4-point scale. The complications of AE were also recorded. Results: The mean age of the patients was 58.7 ± 12.7 years, and the mean follow-up period was 36.9 ± 23.1 months. The complications associated with AE included bladder stones, hydronephrosis, acute pyelonephritis, acute urinary retention, and recurrent bladder ulcers. The patients with ulcer-type IC who underwent AE reported better GRA results compared to those with nonulcer IC. The postoperative symptoms of bladder pain, dysuria, frequency, and urinary tract infection (UTI) were present in both groups of patients. No benefit was reported in all nonulcer IC patients. Conclusions: Although AE can improve bladder symptoms in ulcer-type IC patients, postoperative dysuria and UTI remain problems, and IC patients might have complications related to AE. Meanwhile, most of the patients with nonulcer IC reported no benefit from AE and hence AE should not be recommended.

Keywords: Augmentation enterocystoplasty, complication, interstitial cystitis, partial cystectomy, satisfaction


How to cite this article:
Wang HJ, Kuo HC. Long-term satisfaction and complications in women with interstitial cystitis undergoing partial cystectomyand augmentation enterocystoplasty. Urol Sci 2018;29:81-5

How to cite this URL:
Wang HJ, Kuo HC. Long-term satisfaction and complications in women with interstitial cystitis undergoing partial cystectomyand augmentation enterocystoplasty. Urol Sci [serial online] 2018 [cited 2018 May 24];29:81-5. Available from: http://www.e-urol-sci.com/text.asp?2018/29/2/81/231426


  Introduction Top


Interstitial cystitis/bladder pain syndrome (IC/BPS) is a condition involving chronic bladder pain or lower urinary tract symptoms that can have a profound detrimental impact on quality of life.[1],[2] The characteristics of these sensations are variable, but the most consistent features include frequency, urgency, dysuria, and pain in the lower abdomen, bladder, vagina, urethra, or perineum in the absence of bacterial infection.[3],[4] IC/BPS can be subdivided into two types, ulcerative-type and nonulcerative-type IC. Ulcer-type IC patients usually exhibit Hunner's lesions on cystoscopy and usually have a worse prognosis after treatment. Due to lack of a clear understanding of the etiology, there is no consensus regarding the optimal treatment approach for IC/BPS.[5]

Currently, there is no treatment that is consistently effective in providing relief for IC/BPS symptoms.[6] The American Urological Association (AUA) has, however, issued the clinical practice guidelines for the treatment of IC/BPS.[7] Progressive treatment is recommended, with the therapeutic sequence of IC/BPS treatment being based on the risks for the given patient. It is recommended that self-care and behavior modification are used as the first-line therapies, with other treatment options such as oral medications and surgical intervention following for those patients who do not respond to the conservative treatments.[8] Among all the medical and surgical treatments for IC/BPS, partial cystectomy with augmentation enterocystoplasty (AE) had been considered a treatment of last resort which might be used when other therapies such as cystoscopic hydrodistention, intravesical hyaluronic acid instillation, and intravesical botulinum toxin A injection cannot meet patients' expectations.

Partial cystectomy is a widely employed surgical procedure that has been used in the clinical practice since the late 19th century; it has been performed for various nonmalignant diseases including IC/BPS, neurogenic bladder, hemorrhagic/radiation cystitis, infectious diseases of the bladder, and other miscellaneous conditions such as bladder endometriosis and refractory total incontinence.[8] After partial cystectomy was performed for the bladder lesion, AE with an intestinal segment is usually performed to increase bladder capacity. However, AE is associated with high morbidity, which has many potential complications, with approximately half of the complications being considered major complications, including small bowel obstruction, bleeding requiring transfusion, fistula, bladder perforation, and recurrent urinary tract infection (UTI) or pyelonephritis.[7],[9] Hence, the pros and cons of AE in the treatment of refractory IC/BPS remain controversial. Due to its irreversibility, the AUA guidelines state that surgical treatment for IC/BPS is only appropriate after all conservative treatment options have been exhausted or if the patient is found to have a small fibrotic bladder.[7]

There is limited research regarding the long-term follow-up of patients with IC/BPS who have undergone AE. In addition, due to differences in medical environments, patient education, and home-care quality between Eastern and Western countries, the bladder management and complications of AE surgery for IC/BPS patients in different countries might be different. This study investigated the long-term satisfaction and urological complications of the patients with refractory IC/BPS who underwent partial cystectomy and AE. The results of the study could provide valuable information regarding the decision to use AE as a treatment for IC/BPS patients.


  Methods Top


We retrospectively reviewed the records of 15 patients with IC/BPS (12 ulcer-type patients and 3 nonulcer-type patients) who underwent partial cystectomy and AE. All of the patients were diagnosed at a single medical center and operated upon by a single surgeon (HCK) from 2010 to 2016. Before undergoing the operation, all of the patients had been treated conservatively with poor response. The patients were divided into two groups, those with ulcerative-type IC and those with nonulcerative-type IC. The initial clinical symptoms, urodynamic study results, and previous treatments were recorded.

The operation performed was supratrigonal partial cystectomy of the ulcer part of the bladder wall and augmented of the ileal neobladder. The ileal neobladder was constructed using a 40-cm segment of terminal ileum about 30 ml proximal to the ileocecal valve. The opened ileal segment was reconfigured into an M-shape pouch. The pouch was then anastomosed to opened bladder by double-layer sutures using 4-0 vicryl suture for the mucosal layer and 3-0 silk sutures for the seromuscular layers. For the nonulcer-type IC patients, about half of the bladder wall was resected and AE was performed using the same technique.

All of the patients in the ulcer-type IC group had been proven to have a contracted bladder with a portion of thickened bladder wall with multiple bladder ulcerations. The patients with nonulcer-type IC also had intractable bladder pain and small maximal bladder capacity under cystoscopic hydrodistention. The baseline symptoms of bladder pain, frequency, urgency, dysuria, nocturia, UTI episodes, and previous treatments were reviewed. IC symptom scores such as the IC symptom index (ICSI), IC problem index (ICPI), total O'Leary-Sant symptom score (OSS), and 10-scale visual analog score (VAS) for pain, as well as the urodynamic parameters, were recorded. After partial cystectomy and AE, the global response assessment (GRA) was used to assess the long-term satisfaction of each patient regarding the operation. The patients were asked to report the symptoms which would affect their quality of life, such as bladder pain, dysuria, and frequency; the frequency of UTI episodes after the AE operation was also recorded. The changes in the severity of symptoms and UTI frequency were graded on a 4-point scale (2: much improved, 1: mildly improved, −1: mildly worse, and −2: much worse). The complications after the operation were also recorded.

Detailed explanation was provided by a study assistant if the patients had any problems in completing the questionnaires. We compared the two groups in terms of the subjective questionnaire parameters and GRA using Fisher's exact test. All statistical analyses were performed using the statistical package SPSS (Version 20.0, SPSS Inc., Chicago, IL, USA).

The Ethics Committee of Buddhist Tzu Chi General Hospital approved this study (IRB registration number: TCGH IRB: 105-25-B). Written informed consent was obtained from all patients to enable their data to be used for research purposes. The study conformed to the provisions of the Declaration of Helsinki


  Results Top


A total of 15 female patients (ulcer-type, n = 12; nonulcer-type, n = 3) with partial cystectomy and AE were included. The mean age of the patients was 58.7 ± 12.7 years (ulcer-type group: 62.6 ± 11.1; nonulcer-type group, 43.3 ± 3.2), and the average follow-up period was 36.9 ± 23.1 months. The baseline symptoms of the ulcer-type and nonulcer-type IC/BPS patient groups were similar. More specifically, there were no significant differences in baseline ICSI, ICPI, OSS, VAS, detrusor pressure, volume, or postvoid residual between two groups at baseline. However, the baseline first sensation of filling, full sensation, bladder capacity, and maximum flow rate (Qmax) were significantly lower in the ulcer-type IC patients. All of the patients had received cystoscopic hydrodistention, and nearly all of the patients had undergone intravesical onabotulinum toxin A injection. Ten of the ulcer-type IC patients had also undergone electrocauterization many times for ablation of Hunner's lesions before undergoing the AE operation. In general, the ulcer-type IC patients had undergone more surgical intervention procedures than the nonulcer-type IC patients [Table 1].
Table 1: Baseline demographics of patients with interstitial cystitis undergoing partial cystectomy and augmentation enterocystoplasty

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A comparison of the GRA results after AE for the ulcer and nonulcer groups showed a high satisfaction rate among the ulcer-type IC patients but not the nonulcer-type IC patients. GRA ≥2 after AE was noted in 11 (91.7%) of the ulcer-type IC patients but only in 1 (33.3%) in the nonulcer-type IC patients (P = 0.024).

The questionnaire results regarding quality-of-life indicators including bladder pain, frequency, dysuria, and UTI also showed more improvement in the ulcer-type IC patients than in the nonulcer-type IC patients [Table 2]. Complications associated with partial cystectomy and AE including bladder stones, hydronephrosis, acute pyelonephritis, and occasional acute urinary retention were highly prevalent in both the nonulcer-type and ulcer-type IC patients. In addition, the recurrence of bladder ulcers was found in 5 (41.7%) of the patients with ulcer-type IC/BPS [Table 3].
Table 2: The bladder symptoms after augmentation enterocystoplasty in ulcer and nonulcer interstitial cystitis patients

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Table 3: Complications of augmentation enterocystoplasty in patients with interstitial cystitis/bladder pain syndrome

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  Discussion Top


To the best of our knowledge, this is the first study to focus on the long-term satisfaction and complications of women with refractory IC/BPS who have undergone partial cystectomy and AE in an Eastern country. The results of this study revealed that only the ulcer-type refractory IC/BPS patients who underwent AE had good subjective outcomes, while those with nonulcer-type IC/BPS did not. However, symptoms such as bladder pain, frequency, dysuria, and UTIs still bothered part of the ulcer-type IC patients even after AE, and the complication rate associated with AE was high. Meanwhile, no benefit of any kind from AE was noted for the nonulcer-type IC patients.

IC/BPS is a chronic pain syndrome, and its etiology is not well understood. Hence, it is not curable, and the goal of management is to provide relief of symptoms and achieve an adequate quality of life.[10] It has been estimated that there are 700,000 patients with IC/BPS in the United States, and about 90% of them are women.[11],[14] Conservative treatments with painkillers, antihistamines, amitriptyline, and repeated cystoscopic hydrodistention, as well as intravesical instillation of surface protectants, are usually recommended as the first- and second-line treatments for IC/BPS.[7] It is only after all the conservative treatments have failed that surgical treatment will be considered.

Cystourethrectomy with urinary diversion or partial cystectomy with AE bladder augmentation is the most aggressive treatment available but has been considered the ultimate option for the treatment of refractory IC/BPS, particularly in patients with intractable pain. However, some nonulcer-type IC patients might have intractable bladder pain and large bladder capacity. Lotenfoe et al. found a success rate of 88% in patients with bladder capacities <400 mL, but only 20% in patients with capacities over 400 mL. It is possible that the visceral pain in patients with a larger bladder capacity might originate from central sensitization rather than the bladder.[15] Trigone-sparing orthotopic cecocystoplasty was previously reported to be effective in intractable IC/BPS after a 9-year follow-up. However, problems with complications such as de novo clean intermittent self-catheterization, recurrent symptoms, and carcinoma remain unsolved.[16] In another study, 14 of 18 patients treated with trigone-sparing partial cystectomy and substitution enterocystoplasty were pain-free, 15 experienced resolution of their dysuria, and 12 could void spontaneously.[17]

In appropriately selected patients, AE can increase in bladder capacity and improvement in bladder compliance. In our study, the main efficacy of AE was high GRA and symptoms improvement, especially in ulcer-type IC patients. In long-term follow-up, only some minor complications were noted. Based on the improvement of GRA in ulcer-type IC/BPS patients, AE is one of the options for treating ulcer-type IC/BPS. However, some of the patients undergoing AE might have persistent bladder pain despite the surgical intervention.[18],[19] According to our results, partial cystectomy and AE is suitable only for ulcer-type IC but not for nonulcer-type IC. Moreover, even though the symptom of bladder pain was solved for most of the ulcer-type IC patients, many of those patients still suffered from persistent symptoms of frequency and dysuria, as well as recurrent UTIs. The residual portion of native bladder in both ulcer-type and nonulcer-type IC/BPS patients might be the source of these residual bladder symptoms. In one report regarding patients with refractory IC/BPS who received subtotal cystectomy and AE or supravesical urinary diversion with intact bladder, 13 of the patients later received total cystectomy due to persistent bladder pain 12 months after the primary procedure. Overall, 74% of those patients were free of pain, and 68% were satisfied with the end result.[20] In our study, 5 (41.7%) of the ulcer-type IC patients were found to have recurrent bladder ulcers. The bladder inflammation might involve more than what we observed during partial cystectomy; therefore, patients may have new Hunner's lesion eruptions later on. Total cystectomy or repeat electrocauterization of the new ulcers might be necessary to achieve a complete remission.

The advantages of AE include an increase in bladder capacity, improvement in bladder compliance, and protection of the upper urinary tract.[21] However, AE is also often accompanied by the numerous complications associated with small intestinal surgery.[22] Among our cases, bladder stones formation attached to the nonabsorbable serosal suture stitches in the surgery was common after partial cystectomy and AE. The reported rate of bladder stone formation after AE ranges from 3% to 40%.[23] Although the nonabsorbable sutures were adequately embedded into the anastomosis, some stitches still migrated out to the bladder lumen and resulted in stone formation. UTIs were also common among the patients in our series, and an occurrence may be related to poor self-care and clean intermittent self-catheterization skills.

Although our study showed that AE improved quality of life and provided long-term satisfaction for ulcer-type IC patients, these patients still experienced a high rate of minor complications, with these complications usually requiring surgical intervention. As such, with respect to treatment decisions, AE should be recommended with caution for patients who have had ulcer-type IC refractory to conservative treatment. In contrast, AE should not be suggested for patients with intractable bladder pain who have been proven to have nonulcer-type IC because the surgical outcomes are not likely to be good.

This study has several limitations. First, the number of patients in both groups was too small and the duration of the follow-up period was still too short. Although the case number of nonulcer IC patient was only 3, most of these patients had poor surgical outcome and complications. We honestly reported this result and also concluded that nonulcer-type IC should not be treated with AE because the bladder pain symptoms could not be eradicated and postoperative complications would bother them very much. Second, the patient population of this study was collected from our “real-world” clinical practice such that a high degree of selection bias might exist. A better prospective design with a randomized control group is thus needed.


  Conclusions Top


The results of this study revealed that among refractory IC/BPS patients undergoing AE, only those with ulcer type IC/BPS had good outcomes while those with nonulcer type IC/BPS did not. However, symptoms such as bladder pain, dysuria, frequency, and UTIs still existed among the ulcer-type IC/BPS patients even after they underwent AE. According to these results, patients with refractory IC/BPS should be carefully counseled before considering AE as the definite treatment option.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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