Management of urinary incontinence after radical cystectomy and orthotopic neobladder: A scoping review of international practices

Abstract

Objectives

To identify and describe international practice in incontinence management after radical cystectomy and orthotopic neobladder.

Materials and Methods

A systematic scoping review following the methodology of the Joanne Briggs Institute was conducted in which the application searched 15 data sources to identify papers published in English, from 1979 to 2022.

Results

Of the 16 papers that met the eligibility criteria, articles in Eastern countries mainly focus on the effect of conservative treatment, while in Western countries, more attention is paid to the effect of surgical treatment. Clinical characteristics of patients included conservative treatment failure, duration of post-operative intervention and unique differential treatment of male and female patients. Reported factors influencing the achievement of urinary incontinence (UI) include lack of evidence to guide management practice, limited value of conservative treatment, high risk of surgical treatment and uncertainty of efficacy; currently, early behavioural research and multimodal rehabilitation training have good results.

Conclusions

UI in neobladder patients is a distressing condition that is difficult to treat and often requires high-quality rehabilitation guidance and surgical intervention. Further research to address current knowledge gaps is important to inform practice.

INTRODUCTION

Bladder cancer is among the top 10 most common cancer types in the world, with approximately 550,000 new cases annually (Richters et al., 2020). radical cystectomy (RC) is the gold-standard treatment option for muscle-invasive and metastatic bladder cancer (Perera et al., 2018). Although various urinary diversion procedures exist, orthotopic neobladder (ONB) may be the preferred option to support the use of this type of continental diversion (Studer et al., 2006). Importantly, ONB avoids the need for anostomy and the risk of stoma complications and associated physical and psychosocial impacts. ONB enables reconstructed patients to control themselves, maintain the integrity of image and allow them to control their urinary function and improve the quality of life (QoL) compared to other non-controlled procedures such as ileal catheter formation (Crozier et al., 2016; Ghosh & Somani, 2016). Ideally, the neobladder is a high-capacity, low-pressure reservoir; it has an average capacity of 400–500 mL of urine and is emptied; however, it is a bladder replacement, so in many ways it does not function as effectively as the original bladder (Herdiman et al., 2013).

The management of urinary incontinence (UI) after RC and ONB reconstruction is a very challenging situation (Riccetto et al., 2007). Treating incontinence in this population is difficult and depends on the correct identification of the cause of leakage (Bailey et al., 2016). The mechanisms of UI are complex and sometimes require corrective surgery to treat and may be difficult to treat (Jindal et al., 2013). Although some studies suggest that intra-operative nerve protection and sphincter function protection are related to improved continence (Stein et al., 2002), some centres have not noticed such differences (Wilson et al., 2004). However, there is a lack of guidelines for the assessment and management of UI after RC and ONB. Currently, there are no prospective randomized trials, very few retrospective studies or very small case reports with limited follow-up (Hautmann, 2012). Lack of standardization of incontinence definitions, different surgical techniques for neobladder reconstruction and differences in patient record keeping may also account for differences in incontinence rates between studies (Chang & Lawrentschuk, 2015). This scoping review addresses this current gap in knowledge by identifying and characterizing the current practice of managing UI after RC and ONB.

METHODS Review question

This paper presents a scoping review that aims to answer the following question: what is known in the international literature about the practice of UI management in patients after RC and ONB?

Review objectives

1. This review determines the patient characteristics and pathogenesis of post-operative UI.
2. This review presents the management measures for post-operative UI patients.
3. This review presents existing relevant research evidence and findings to help such patients achieve continence.

Review methodology

The scope review method applied the Joanna Briggs Institute (JBI) method and the Extended Scope Review (PRISMA-ScR) checklist (Peters et al., 2020; Tricco et al., 2018).

Study eligibility

According to the JBI Participant Conceptual Context (PCC) framework (Peters et al., 2020), the following criteria are used to determine eligibility included in this review: (1) participant: patients with ONB after RC for bladder cancer; (2) concept: a paper reporting on the treatment or management of UI after this procedure, including surgical treatment, conservative treatment, factors influencing the achievement of UI; (3) background: UI after this procedure from any country or region; (4) source: there are no restrictions on data sources or study design and (5) date range: the 1979 paper is eligible for inclusion as the first record (Lilien & Camey, 1984) of the procedure is in the literature published between 1979 and 2022.

Search strategy

Entered search terms (Table 1): MEDLINE (EBSCO), CINAHL, PsychINFO, Web of Science, Scopus, EMBASE, AMED, NICE, The Cochrane Library, The British Library, Open Grey and Google Scholar.

TABLE 1 Search strategy.

	Keywords or synonyms
P	Orthotopic neobladder, orthotopic ileal neobladder, neobladder, Radical cystectomy, cystectomy, bladder reconstruction after cystectomy, bladder replacement, neobladder reconstruction, orthotopic bladder substitution, orthotopic neobladder diversion, urinary bladder neoplasms
C	Bladder training, neobladder rehabilitation, conservative management, surgical management, drug, sling, surgical intervention, prostheses and implants, bulking, artificial sphincters
C	Urinary incontinence, incontinence, stress urinary incontinence, voiding dysfunction

Outcome of searches

Search results including paper selections are displayed in the PRISMA-ScR flow chart (Figure 1). The search yielded 324 records, which were imported into the Reference Manager software Endnote X9. Removed duplicates, filtered title and abstract for 200 records inclusion criteria and selected articles for SYM were discussed with YFZ and QWH. Screening excluded 158 papers, 42 papers were screened for full-text review. Sixteen papers met the inclusion criteria and were included in the final review.

FIGURE 1. PRISMA-ScR flow chart of evidence source selection.

Data extraction and charting

Evidence for each study was plotted into predesigned tables adapted from the Joanna Briggs Institute (JBI) Handbook (Peters et al., 2020). Tables list source details, study characteristics and results for each study. An example of data extraction is shown in Table 2. These include author, year and title, country of origin, purpose, study participants, patient characteristics, design/method, number of patients treated for UI and the type of treatment selected. Patient characteristics included gender, age, presence or absence of pre-operative incontinence, type of ONB surgery, duration of post-operative incontinence, response to treatment and curative effect.

TABLE 2 Data charting.

	County and setting	Design/methods	Aims	Study participants	Patient characteristics	Treatment of urinary incontinence after orthotopic neobladder surgery	The efficacy of treatment
Bailey, et al. (2016)	USA	Retrospective study	Empirically proposes a treatment algorithm for orthotopic neobladder female incontinence assessment and management	Total 12 Twelve women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014.	F: n = 12 Age (years): median age 64(56–68) Pre-operative urinary incontinence: Unspecified Duration of incontinence: median time 15 months (9.6–33.3), sphincter incontinence (n = 2), NVF (n = 5), Valsalva leak point <60 cm H2O(n = 4) Method of the neobladder procedure:ONBD Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	Bulking agent injections (n = 6) Transobturator slings、pubovaginal slings (n = 8)	The outcomes were continued dryness after one injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). One case (17%) was dry, and one case (17%) was improved. Of the 6 (50%) women with dryness or improvement, 2 (17%) achieved planned intermittent catheterization after surgery, and 2 (17%) underwent ileal catheter conversion.
Hashem, et al. (2021)	Egypt	Randomized Controlled Trial	To assess the effect of mebeverine in enhancing in situ bladder replacement continence.	Total 116 Exclude(n = 6) Did not meet inclusion criteria (n = 5) Refused to participate (n = 1)	M: n = 110 Age (years): Placebo Group: 60.4 ± 7.2; Mebeverine Group: 62.3 ± 6.9 Pre-operative urinary incontinence: Unspecified Duration of incontinence: Placebo Group:7 (3–10) months; Mebeverine Group: 6.5 (3–10) months Method of the neobladder procedure:Hautmann W-neobladder technique Intra-operative nerve preservation: N/A Types of urinary incontinence: Unspecified	Medical treatment: mebeverine	Short-term impact: mebeverine accelerates the development of continence in male ileal orthotopic bladder substitute patients in the first year after orthotopic bladder substitute construction
Jindal, et al. (2013)	India	CCR	To evaluate the efficacy of obturator tape (TOT)	Total 1	F: n = 1 Age (years): 58 Pre-operative urinary incontinence: continent and no history of pelvic organ prolapse Duration of incontinence: 4 months after surgery Method of the neobladder procedure:Studer orthotopic neobladder Reconstruction Intra-operative nerve preservation: N/A Types of urinary incontinence: Unspecified	Transobturator taping (TOT)	Seven months after TOT, there was a large amount of residual urine after voiding and clean intermittent catheterization was necessary to empty the bladder.
Wilson, et al. (2004)	USA	Retrospective study	To evaluate the clinical efficacy of transurethral fillers in women with new-onset urinary incontinence after radical cystectomy and in situ lower urinary tract reconstruction.	Total: (12/101;12%) received treatment for new-onset incontinence. Collagen (n = 11) Non-absorbable pyrolytic carbon-coated beads (n = 1)	F: n = 12 Age (years): average age: 75.4 years (66–86) Pre-operative urinary incontinence: No patients had stress or urge incontinence prior to cystectomy Duration of incontinence: average of 16 months (range 4–39) Method of the neobladder procedure:orthotopic ileal neobladder reconstruction: kock (n = 6), T-pouch (n = 3), Studer (n = 3) Intra-operative nerve preservation: N/A Types of urinary incontinence New-onset persistent SUI	Bulking agent injections	Although injectable urethral fillers are a minimally invasive treatment, long-term outcomes in severely ill patients have shown suboptimal durable responses for stress urinary incontinence after orthotopic neobladder reconstruction.
Kim, et al. (2020)	Korea	Qualitative study	To explore the adjustment experience of three Korean male bladder cancer survivors after neobladder reconstruction, including how to cope with post-operative urinary incontinence.	Total 3 Korean male bladder cancer survivors (n = 3)with a neobladder Purposive sampling	M: n = 3 Age (years): 54–59 Pre-operative urinary incontinence: Unspecified. Duration of incontinence: 9 (3–12) months Method of the neobladder procedure: ONBD Intra-operative nerve preservation: N/A Types of urinary incontinence: Unspecified	N/A	Frequency and volume of incontinence were reduced.
Riccetto, et al. (2007)	Brazil	CCR	Unspecified	Total 1	F: n = 1 Age (years): 55 Pre-operative urinary incontinence: Unspecified Duration of incontinence: 12 weeks; no detrusor contractions.;Valsalva leak-point pressure was 55 cm H2O. Method of the neobladder procedure:Studer technique Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	An adjustable silicone balloon inserted around the urethra(ACT™-Uromedica，Plymouth，MN, USA)	The patient was able to maintain control during the day but was incontinent at night.
Simma-Chiang, et al. (2012)	USA	Retrospective study	To examine the outcome of patients undergoing iatrogenic stress urinary incontinence after radical cystectomy (RC) and in situ neobladder (ONB) diversion in patients undergoing artificial urinary sphincter (AUS)	Total 12 (12/179; 6.7%); From 2002 to 2009, 263 eligible patients (RC with ONB transfer) received a questionnaire on incontinence; 179 of 263 patients returned the questionnaire, including 12 male patients (12/179; 6.7%) who had undergone AUS placement for post-operative SUI	M: n = 12 Age (years): average age: 72.9 (57–84) Pre-operative urinary incontinence: Pelvic floor biofeedback testing was performed, but SUI symptoms did not improve (n = 1). No other treatments were received (n = 11); no anticholinergics were administered; no patients reported urinary urgency (n = 12). Duration of incontinence: N/A Method of the neobladder procedure:random assignment accepts Studer (n = 3) and T-pouch technology (n = 9) Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	Artificial Urinary Sphincter (AUS) Placement	Post-AUS Continence (10/12 (83.3%) returned validated questionnaires): no pad/day (n = 5); 1 pad/day (n = 3); 2–3 pads/day (n = 2); AUS is a safe and effective abstinence procedure for male ONB patients
Tchetgen, et al. (2000)	USA	CCR	To determine the clinical efficacy of endoscopic collagen injection therapy	Total 3	F: n = 3 Age (years): 58–74 Pre-operative urinary incontinence: mild incontinence (n = 1) Continence (n = 2) Duration of incontinence: 14.7 (8–36) months Method of the neobladder procedure: orthotopic ileal neobladder Intra-operative nerve preservation: Not preserving nerves does not necessarily lead to incontinence Types of urinary incontinence: SUI	Bulking agent injections:endoscopically injected collagen	Urinary incontinence improved or became dry in all three women, but repeated injections were required to maintain continence.
Quek, et al. (2004)	USA	CCR	To evaluate the clinical efficacy of a pubovaginal sling for women with new-onset stress urinary incontinence after radical cystectomy and orthotopic neobladder	Total 4(4/101) From June 1990 to July 2002, 101 female patients with primary transitional cell carcinoma of the bladder underwent radical cystectomy and in situ ileal neobladder reconstruction, including four for persistent stress urinary incontinence pubovaginal slings.	F: n = 4 Age (years): 61–73 Pre-operative urinary incontinence: mild stress incontinence (n = 1), continence (n = 3); Transurethral bulking materials were given 4–5 months prior to the sling procedure with no significant improvement (n = 2) Duration of incontinence: 9–20 months Method of the neobladder procedure:Studer (n = 2), T-pouch (n = 2) Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	Pubovaginal slings: Autologous rectus fascia (n = 2), dermal graft (n = 2)	Dermal graft (n = 2): complete daytime continence and only occasional nighttime leakage. Autologous rectus fascia (n = 2): significant complications.
Xiao, et al. (2021)	China	Prospective cohort study	To evaluate the effect of action research on functional training of neobladder in patients with an orthotopic ileal neobladder.	Total:68 A control group (n = 31) and experimental group (n = 37)	M: n = 68 Age (years): a control group (50.1 ± 12.8) Experimental group (51.5 ± 13.9) Pre-operative urinary incontinence: Unspecified Duration of incontinence: N/A Method of the neobladder procedure:orthotopic ileal neobladder Intra-operative nerve preservation: N/A Types of urinary incontinence: Unspecified	A research approach to the spiral cycle of planning, action, observation and reflection: Action Research	In the experimental group, the urination interval and each urine volume increased (P < 0.05), the number of nocturia decreased (P < 0.05) and the daytime and nighttime continence rates increased (P < 0.05).
Erdogan et al., (2021)	Germany	Retrospective study	To assess early abstinence in patients undergoing inpatient rehabilitation after RC and ONB.	Total 283 Male patients treated at a specialized urological rehabilitation centre in Germany between January 2016 and July 2017 Purposive sampling	M: n = 283 Age (years): median (IQR) 63 (57–69) Pre-operative urinary incontinence: Cardiovascular disease (42.8%), diabetes (6.7%) Duration of incontinence: 50 days (IQR 46–56) Method of the neobladder procedure: N/A Intra-operative nerve preservation:n = 142 (50.2%) Types of urinary incontinence: Unspecified	Three weeks of multimodal continence therapy in a rehabilitation centre: Osteopathic physiotherapy Instruction on a selective urethral sphincter training Education on neobladder management and care	Urinary incontinence was significantly improved. Independent predictors of urinary loss: age, diabetes, obesity and NS
Grimm, et al. (2019)	Germany	A cross-sectional study in the form of questionnaire	To objectively quantify urinary incontinence rates and correlate them with health-related quality of life (HRQOL) after ONB.	Total 244 178 patients (73.0%) answered the QLQ-C30 questionnaire artificial urinary sphincter (n = 2), male sling (n = 1), chronic urinary retention (n = 7). Sampling: may be purposive sampling	M: n = 155 (87.1%) F: n = 23 (12.1%) Age (years): 65.3 ± 9.3 Pre-operative urinary incontinence: Unspecified Duration of incontinence: N/A Method of the neobladder procedure: Hautmann Orthotopic ileal neobladder Intra-operative nerve preservation: 97 (54.5%) (did not improve continence outcomes) Types of urinary incontinence: Unspecified	N/A	Independent predictors of HRQOL increase: pelvic floor muscle training
O'Connor et al., (2001)	USA	Retrospective study	To review the overall efficacy and safety of artificial urinary sphincter (AUS) in five male patients with stress urinary incontinence (SUI) after orthotopic ileal neobladder or cystoprostatectomy	Total 5	M: n = 5 Age (years): average age: 70.6 (67–74) Pre-operative urinary incontinence: Unspecified Duration of incontinence: 20.2 months (range 12–29) Method of the neobladder procedure:cystoprostatectomy with orthotopic ileal neobladder creation. Intraoperative nerve preservation: N/A Types of urinary incontinence: SUI	Artificial Urinary Sphincter Placement (AUS-AMS 800, American Medical Systems, Minnetonka, Minn)	5 (100%) and 2 (40%) of 5 men reported social continence (1 pad/day or less) and total continence (0 pad/day) respectively. No device (AUS)-related complications occurred
Schlenker, et al. (2006)	Germany	Prospective cohort study	To evaluate whether duloxetine is safe and effective for men with stress urinary incontinence after radical prostatectomy or cystectomy	Total 20 Radical prostatectomy (n = 15) Cystoprostatectomy with orthotopic ileal neobladder reconstruction (n = 5)	M: n = 20 Age (years): (average age: 65.8; range: 47–78) Pre-operative urinary incontinence: Unspecified Duration of incontinence: prostatectomy group (average: 90.1 weeks; range: 3–356 weeks) Cystoprostatectomy group (average: 22.3 weeks; range: 10–38 weeks) Method of the neobladder procedure:cystoprostatectomy with orthotopic ileal neobladder reconstruction Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	Medical treatment: duloxetine	Taking duloxetine regularly (n = 18/20) n = 15/18(83.33%) reported improvement in SUI with duloxetine, but the improved results can be attributed to pelvic floor training alone or a combination of duloxetine and pelvic floor training
Shigeru Minowada, Kano, & Okano, (1995)	Japan	CCR	Unspecified	Total 1	M: n = 1 Age (years): 62 Pre-operative urinary incontinence: Iatrogenic injury of external sphincter during surgery Duration of incontinence: 1 month Method of the neobladder procedure:ileal neobladder replacement (Melchior method) Intra-operative nerve preservation: N/A Types of urinary incontinence: Unspecified	Sling	Sling surgery is not the best option due to the very difficult separation of the pubic and ileal neobladder adhesions.
Vainrib, et al. (2013)	USA	Retrospective study	To review outcomes and complications in patients with artificial urinary sphincter (AUS) placement for SUI, assessing potential risk factors for AUS failure (PRF)	Total 64 Due to the retrospective nature of the study, 36 patients were evaluable and incontinence data were available for 29 patients	M: n = 36 Age (years): average age: 72 (58–79) Pre-operative urinary incontinence: Pre-AUS placement: total incontinence (n = 22); day-only incontinence (n = 3); night-only incontinence (n = 4) Duration of incontinence: 28 (2–120) months Method of the neobladder procedure: T-pouch (n = 25) Kock pouch to urethra (n = 3) Studer (n = 8) Intra-operative nerve preservation: N/A Types of urinary incontinence: SUI	Artificial Urinary Sphincter (AUS) Placement	Post-AUS placement Tota incontinence (n = 5); day-only incontinence (n = 1), night-only incontinence (n = 2), More than half of AUS patients after RC/ONB may require AUS revision for various reasons.

RESULTS

Achieving goal to (1) identify and report treatment/management measures for UI after RC and ONB, (2) determine the effectiveness of incontinence treatment/management, retrieved study data were plotted under the following headings: study participants, patient characteristics, design/method, number of patients treated for incontinence and type of treatment selected and (3) to analyse factors influencing the management of UI after orthotopic ileal neobladder.

Study design

Five clinical case reports (Jindal et al., 2013; Quek et al., 2004; Riccetto et al., 2007; Shigeru Minowada et al., 1995; Tchetgen, Sanda, Montie, & Faerber, 2000) and six carried out retrospective chart reviews or observational studies (Bailey et al., 2016; Erdogan, Berg, Noldus, & Muller, 2021; O'Connor et al., 2001; Simma-Chiang, Ginsberg, Teruya, & Boyd, 2012; Vainrib, Simma-Chiang, Boyd, & Ginsberg, 2013; Wilson et al., 2004), one cross-sectional study in the form of questionnaires (Grimm et al., 2019), one paper reporting on qualitative research (Kim, Ryu, & Kim, 2020), two prospective cohort studies (Schlenker et al., 2006; Xiao, Zhang, & Lin, 2021) and one randomized controlled trial study (Hashem et al., 2021) (Figure 2).

FIGURE 2. Research methods applied by the included literature. ACT‒, An adjustable silicone balloon inserted around the urethra; AUS, Artificial Urinary Sphincter; BA, bulking agent; TOS, transobturator sling; TOT, transobturator taping.

Country of origin

Of the 16 articles included after the search in this article, most of them were published in West, including Europe and the United States (n = 11) (Bailey et al., 2016; Erdogan et al., 2021; Grimm et al., 2019; Quek et al., 2004; O'Connor et al., 2001; Riccetto et al., 2007; Schlenker et al., 2006; Simma-Chiang et al., 2012; Tchetgen et al., 2000; Vainrib et al., 2013; Wilson et al., 2004). There are three papers published in East, including Korea (Kim et al., 2020), China (Xiao et al., 2021) and Japan (Shigeru Minowada et al., 1995) (Figure 3). Most of the post-operative treatments of UI reported in Western countries are invasive treatments and drug interventions, while the Asian reports to improve post-operative UI are mainly rehabilitation training.

FIGURE 3. The publication year and management method of the included literature. ACT™, An adjustable silicone balloon inserted around the urethra; AUS, Artificial Urinary Sphincter; BA, bulking agent; TOS, transobturator sling; TOT, transobturator taping.

Patient characteristics

All reports suggested that there are more male patients than female patients (283 males, 23 females), ranging in age from 47 to 86 years, reported six categories of factors associated with the current management of UI after ONB surgery: age, previous incontinence, method of the neobladder procedure, the duration of UI, the type of UI and the presence or absence of nerve retention during surgery. The general characteristics of patients with UI after treatment of ONB were shown. The median or mean age of patients selected for treatment was usually reported in retrospective studies over 63 years (Bailey et al., 2016; Erdogan et al., 2021; O'Connor et al., 2001; Simma-Chiang et al., 2012; Vainrib et al., 2013; Wilson et al., 2004), with 60% reporting mean age greater than 70 years (O'Connor et al., 2001; Simma-Chiang et al., 2012; Vainrib et al., 2013; Wilson et al., 2004), whereas the age of patients in prospective cohort studies was 50.1 ± 12.8 (Xiao et al., 2021). Most of the case reports focused on the presence or absence of pre-operative UI (Jindal et al., 2013; Quek et al., 2004; Tchetgen et al., 2000), two of which suggested mild incontinence before ONB surgery (Quek et al., 2004; Tchetgen et al., 2000). The average time span of post-operative patients choosing invasive UI treatment was 9–28 months (Bailey et al., 2016; Quek et al., 2004; O'Connor et al., 2001; Tchetgen et al., 2000; Vainrib et al., 2013; Wilson et al., 2004), and most of them were more than 12 months (Bailey et al., 2016; Quek et al., 2004; O'Connor et al., 2001; Tchetgen et al., 2000; Vainrib et al., 2013). Most of the categories of UI were classified as stress urinary incontinence (SUI) (Bailey et al., 2016; Quek et al., 2004; O'Connor et al., 2001; Riccetto et al., 2007; Schlenker et al., 2006; Simma-Chiang et al., 2012; Tchetgen et al., 2000; Vainrib et al., 2013; Wilson et al., 2004). Nerve sparing during cystectomy has been shown to be associated with an increased incidence of daytime and nocturnal incontinence, and post-operative radical nerve sparing was generally considered to contribute to early post-operative continence, but sympathetic nerves to the proximal urethra and associated smooth muscle tissue denervation did not necessarily lead to incontinence (Grimm et al., 2019; Hashem et al., 2021; Tchetgen et al., 2000). These findings contradicted previously reported that this autonomic innervation is essential for maintaining continence.

Current management of UI after RC and ONB

Synthesis of data-generated treatment options into two modules: conservative treatment and invasive treatment. Methods: action research method, multimodal continence therapy, drugs, slings (trans obturator slings, pubovaginal slings), transobturator taping (TOT), bulking agent injections (BA), artificial urinary sphincter (AUS) and adjustable silicone balloon (Figure 4).

FIGURE 4. Current management of UI after RC and ONB in different countries. ACT™, An adjustable silicone balloon inserted around the urethra; AUS, Artificial Urinary Sphincter; BA, bulking agent; TOS, transobturator sling; TOT: transobturator taping.

Conservation treatment Action research method

Xiao et al. (2021) applied the action research method to develop educational materials and standardized teaching procedures in a targeted manner, combined with pelvic floor muscle training, urination diary first-line conservative treatment of UI (Nambiar, 2018), through bladder filling and regular emptying, carry out step-by-step training, instruct patients to repeatedly contract and relax pelvic floor muscles, in order to improve the storage of the new bladder, urination and Urine control. They instructed patients to use the urination diary, understand and solve the practical problems encountered by patients in neobladder function training, to help them understand why they need training, improve the effect of patients' neobladder training, reduce the incidence of UI and improve the patient's performance (Elmer et al., 2017; Bradbury & Lifvergren, 2016).

Multimodal continence therapy

German social law entitled cancer patients to receive an average of 3 weeks of rehabilitation therapy to help patients reintegrate into society (032-045OL, A.-R, 2021). In view of this unique rehabilitation advantage, Erdogan et al., (2021) accepted a multimodal approach to inpatient rehabilitation of patients with early incontinence after orthotopic ileal neobladder surgery. Continence treatment, including (1) Neobladder management and nursing education. (2) Urethral sphincter training guidance and (3) Osteopathic physiotherapy. The research team dynamically tracked the recovery effect of patients and performed video-assisted biofeedback sphincter training through transurethral endoscopy for patients whose daytime UI did not improve within 2 weeks of treatment. The patient kept a voiding diary, and researchers instructed patients to empty the neobladder every 2–3 h during the day and night (by setting an alarm clock to wake up to urinate at night), carefully increase the neobladder capacity to achieve a sensitive neobladder capacity. Results showed that a rehabilitation programme with specific multimodal incontinence treatment in a specialized urological rehabilitation centre improved early incontinence after RC and ONB.

Drugs

Hashem et al. (2021) conducted a single-centre, parallel, double-blind, placebo-controlled randomized clinical trial to evaluate the efficacy of mebeverine in patients with UI in the first year after ONB surgery. Results in this trial, mebeverine enhanced daytime and nighttime urinary continence and improved their quality of life (QoL). In addition, other drug studies have shown that duloxetine, a combination serotonin (5-HT) and norepinephrine (NE) reuptake inhibitor, was beneficial in reducing radical prostatectomy or bladder medications for the degree of incontinence in patients after resection. Promoted incontinence recovery in patients who had previously performed pelvic floor exercises with poor results, however, one-third of patients reported intolerable side effects (such as nausea) and discontinued duloxetine. Use of tolterodine increased the number of sanitary pads used per night and decreased scores on the International Incontinence Counseling Module questionnaire, but discontinuation rates for anticholinergic ranged from 43% to 83% in the first 30 days, particularly adverse reactions such as dry mouth, constipation, headache and blurred vision in the elderly will continue to rise over time and should be used with caution (Schlenker et al., 2006; Zahran et al., 2019).

Invasive treatment

Surgery should be considered in patients with low urethral closure pressure or peritoneal depression when conservative interventions for UI are ineffective.

Slings

Among the articles included in this study, slings included the pubovaginal sling (PVS) and the transobturator sling (TOS). Although PVSs are the gold standard for the treatment of female internal sphincter defects, urologists have been hesitant to apply this technique to UI after neobladder reconstruction is mainly due to the risk of overcontinence or the cost of urinary tract obstruction. In a case report, two female patients underwent dermal graft sling and subpubic bone anchors, resulting in hypercontinence requiring periodic intermittent catheterization; two female patients underwent traditional autologous fascial sling, these patients subsequently developed complications related to retropubic space dissection (Quek et al., 2004). For UI after ONB in women, PVS surgery for incontinence in women after OBS can be complicated due to extensive pelvic surgery, and it is recommended that dissection in the retropubic space should be avoided. A retrospective study by Bailey et al. (2016) reported that two slings, including four PVS and four TOS, were placed in six patients, and all retropubic slings were placed subperiosteal to avoid damage to the neobladder. In four PVS patients, two received cadaveric PVS, two received autologous PVS and one received autologous PVS with the concurrent repair of post-neovesicovaginal fistula (post-NVF) dryness improved incontinence but required lifelong intermittent catheterization after surgery; of the four TOS, three were synthetic and one was autologous, of which two patients also received NVF repair when the autologous sling was placed, as a result of these six patients, only one patient remained dry after the autologous PVS was placed, and the remaining patients were in the sling. UI did not improve after placement (Bailey et al., 2016). More clinical studies are needed to confirm the efficacy of pubovaginal suspension for UI after orthotopic ileal neobladder surgery.

Bulking agent (BA)

Urethral injection is a minimally invasive surgical procedure for the treatment of female UI. The purpose of the procedure is to increase the closure of the internal opening of the urethra to achieve the effect of controlling urine. Currently, reported fillers include collagen, non-absorbable pyrolytic carbon-coated beads. The urethral injection can be repeated several times to achieve the effect of urinary control. It has been reported that the patient can improve UI after nine injections. For patients with mild to moderate UI, the cure rate is as high as 66%. The long-term results showed suboptimal durable responses. The long-term efficacy and management of transurethral collagen injections are unclear (Bailey et al., 2016; Tchetgen et al., 2000; Wilson et al., 2004). BAs most serious complication is urethrovaginal fistula, and the low morbidity of this minimally invasive procedure may also be an attractive treatment option for women with UI after ONB surgery (Bailey et al., 2016).

Artificial sphincter (AUS)

Since there have been few reports on the use of AUS in patients with UI after RC and ONB in the past, this study included three articles that showed that the use of AUS in patients with UI after ONB is a safe and effective method. O'Connor et al. (2001) published a cohort study, although only five patients were included, the results showed that AUS was well tolerated, safe and reliable and improved the QoL of patients. In 2012, Simma-Chiang et al. (2012) published the results of AUS placement in men after RC and OBS for UI (USC experience), although this was a small case series involving 12 patients with a mean age of 73.8 years and mean follow-up time. For 21.7 months, 90% of patients reported improvement in UI in the questionnaires sent, three patients deactivated their AUS during the day and activated it at night, in cohort the device did not corrosion or mechanical failure with satisfactory results (Simma-Chiang et al., 2012). Vainrib et al. (2013) conducted a retrospective review of 36 male patients with 76% of patients experienced improvement in incontinence symptoms. Overall, AUS is a safe and effective treatment with acceptable complication rates.

Transobturator taping (TOT)

Transobturator tape for the treatment of female UI is considered one of the standard treatments for UI and has shown good long-term results, but it is almost impossible to treat UI after ONB. Jindal et al. (2013) is the first to report the successful use of TOT with a simple Prolene mesh for the treatment of UI in a 58-year-old female patient after neobladder reconstruction, 3 months after post-operative pelvic floor training ineffective, and then performed TOT at the doctor's recommendation. At the 7-month follow-up post-operatively, she was continental but was unable to urinate normally, had a large amount of post-void residual urine and had to undergo clean intermittent catheterization to empty her bladder. The patient stated that she was satisfied with the results compared to UI.

Adjustable silicone balloon

There are case reports on the use of the Adjustable Continental Therapy Device (ACT™) periurethral implant for selective female incontinence and studies on the treatment of UI after prostatectomy. Significantly less used to treat UI after ONB (Hubner & Schlarp, 2005). This is the first case reported for the treatment of UI after ONB, describing a 55-year-old female patient who developed UI after undergoing RC and ileal neobladder reconstruction using the Studer technique. After using the device, UI during the day was possible, but UI was at night, and the device was free of infection (Riccetto et al., 2007).

Factors influencing UI Surgical factors

1. The type of bowel segment selected for the ‘neobladder’. Voiding pressure and voiding pattern depend on the type, length and configuration of the bowel segment collected. These variables also determine the risk of voiding dysfunction and the choice of surgical technique, With the RARC-iN being a challenging procedure. The potential impact of the learning curve on important outcomes, such as high-grade complications and positive surgical margins, has played a negative role in its widespread adoption (Lombardo et al., 2021). In addition, the age and gender of the patient. Although colonic, ileal, gastric and ileal neobladder are all considered acceptable, a spherical neobladder made from ileum is the most popular. The two most common types of neobladder are the Hautman method, which uses approximately 70 cm of ileum, and the Studer method, which uses approximately 60 cm of ileum. (Bailey et al., 2016; Grimm et al., 2019; Hashem et al., 2021; Jindal et al., 2013; Kim et al., 2020; Quek et al., 2004; O'Connor et al., 2001; Riccetto et al., 2007; Schlenker et al., 2006; Shigeru Minowada, 1995; Simma-Chiang et al., 2012; Tchetgen et al., 2000; Vainrib et al., 2013; Wilson et al., 2004; Xiao et al., 2021).
2. Utilization of surgical techniques. Open radical cystectomy (ORC) is still considered the reference approach for RC. Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder (iN) is a challenging procedure. There are few reports on RARC-iN, with the extracorporeal method being the most popular. An interim analysis of 1-year health-related quality of life (HRQoL) results from an ongoing randomized controlled study contrasting fully intracorporeal urinary diversion (iUD) with ORC and RARC was reported (Lombardo et al., 2021). Patient-reported QoL results showed RARC-iUD and ORC to be equivalent in all QoL areas, with the exception of two minor issues: sleeplessness and bloating and gas in the abdomen. Patients with RARC-iUD were more likely to report a significant increase in urinary tract symptoms and problems. Riccardo analysed 1-year data for health-related quality of life from an ongoing trial comparing open and robotic surgery for removal of the bladder in patients with bladder cancer. Robotic surgery seems to provide benefits for most QoL items on patient-reported questionnaires (Mastroianni, Tuderti, et al., 2022). He also reported the early outcomes of a single-centre randomized controlled trial between ORC and RARC-iUD (Mastroianni, Ferriero, et al., 2022). There were no differences in terms of daytime continence, while the open cohort showed a higher nighttime continence probability at 6 months.
3. Nerve-sparing (NS) and organ-preserving. Surgical technique is crucial to maximizing voiding function; it has been demonstrated that nerve-sparing and organ-preserving methods help to reduce incontinence and hypercontinence (Furrer et al., 2018). In the previously mentioned study by Anderson et al. that examined the severity of incontinence in females receiving ONB, the only predictor of daytime continence was prior hysterectomy. RC with genital preservation for women without high-risk features is also used in some medical centres (Hoy et al., 2017). Tuderti et al., (2020) reported on their technique of sex-sparing (SS) robot-assisted radical cystectomy (RARC) in 11 female patients receiving an iN. They highlighted differences with the standard technique and anatomical details of preservation of the inferior hypogastric plexus (IHP), which represented the cornerstone of a quick and effective recovery of physiological functions in terms of urinary continence and sexual activity. The findings demonstrated that sex-RARC-iN is a safe, oncologically procedure which might be provided to female patients who are motivated to preserve sexual function, with 1-year daytime and nighttime continence recovery probability are 90.9% and 86.4%. In a study by Furrer et al., (2018), which evaluated a large consecutive series of regularly followed long-term survivors with an orthotopic bladder substitution (OBS), They found that trying NS was associated with a higher likelihood of daytime and nocturnal urination compared to no NS. Importantly, the benefits of NS are not only maintained over time. As patients age and OBS develops, the benefits of NS become more apparent. The other component that causes incontinence after orthotopic diversion is a disturbance in the external sphincter's integrity. Age-related decline in urethral sphincter function is suggested to be one significant reason. Additionally, it has been suggested that decreased urethral sensitivity may be a cause of UI following RC and ONB (Gross, Meierhans Ruf, Meissner, Ochsner, & Studer, 2015).

Patient factors

The ONB remains an attractive option for younger patients and those with a strong desire to maintain abstinence, regardless of the specific neobladder or urinary diversion technique performed. A study by Erdogan et al., (2021) demonstrated a significant positive effect of being young, not diabetic or obese and trying NS on early continence. In addition, the surgeon must also consider the ability of the patient to adapt to the care and management of ONB requirements after surgery. Strict adherence to the new bladder training programme is required to help patients achieve the best QoL (Xiao et al., 2021). Age > 65 years and pre-operative urethral pressure curve have been reported (Gross et al., 2015; Rouanne et al., 2014; Steers, 2000a, 2000b) as factors influencing urinary control after RC for OBS.

Length of post-operative period

Recent studies have characterized continence as dynamic and improve over time, with a gradual increase in new bladder capacity from 150–200 to 400–500 mL in the long term (Herdiman et al., 2013; Steers, 2000a, 2000b). One reason for the improvement in continence over time is the increase in volume and decrease in pressure as the bowel stretches (Anderson et al., 2012). Clifford et al (2016) reported an increase in daytime incontinence control from 59% at 3 months to 92% at 12–18 months post-operatively. Nocturnal abstinence also increased from 28% at 3 months to 51% at 18–36 months post-operatively.

DISCUSSION

This review demonstrates a global lack of clinical and policy guidance for the management of UI after RC and ONB. It is worth noting that although there is more than one gold standard regimen in the treatment of UI, such as AUS is considered to be the gold standard for the treatment of iatrogenic UI in men after radical prostatectomy; PVS has long been the gold standard for treating internal sphincter defects (Hoy et al., 2017; Simma-Chiang et al., 2012). However, early reports on its use in post-ONB incontinence with significantly associated morbidity have been poor, and while technical details of various surgical interventions for women with post-ONB incontinence have been described, these reports are limited to small patient cohorts examining individual post-intervention outcomes, with no treatment regimen becoming the gold standard (Bailey et al., 2016; Jindal et al., 2013; Quek et al., 2004; Riccetto et al., 2007; Wilson et al., 2004). Therefore, the lack of guidance on the management of UI after RC and ONB and the low level of evidence reported in the literature are important gaps in the evidence base. Demonstrated that a key issue in managing UI after ONB surgery is the complexity and challenge of all reported post-operative UI interventions in such patients, as well as patient selection prior to such surgery. Crucially, including tumour, age, physical fitness and post-operative patients have high-quality care needs. Age > 65 years and pre-operative urethral pressure distribution have been factors that affect post-operative control after OBS, so careful pre-operative patient selection might improve prognosis (Gross et al., 2015; Rouanne et al., 2014; Veskimae et al., 2017).

The reported daytime incontinence rate after ONB ranges from 49% to 92% but can be as low as 49% in women. Nocturnal incontinence rates generally lag daytime incontinence rates, ranging from 28% to 75%, indicating unique differences between male and female patients. However, these literatures do not document patient-reported severity or incontinence over time (Anderson et al., 2012; Gross et al., 2015; Nam, Kim, Park, Lee, & Chung, 2013). Recovery of daytime urinary control usually occurs 6–12 months earlier than at night, with good functional results over a period of 12–18 months (Chang & Lawrentschuk, 2015; Hashem et al., 2021).

In female patients, after excluding vaginal fistulas as a source of incontinence, first-line treatment of poor pelvic floor function must include behaviour modification and pelvic floor reinforcement, and patients without fistulas and mild incontinence can receive adequate pelvic floor muscle intensive testing. This may produce slight improvements in some women. Many of them will be troubled by the extent of incontinence and the impact on QoL and will want additional treatment (Bailey et al., 2016). In male patients, the first step in diagnosis is still to exclude other causes of leakage, and once UI is confirmed, conservative measures should be taken to treat uncomplicated UI, including pelvic floor physiotherapy and lifestyle changes, some anticholinergic drugs such as oxybutynin and tolterodine. To improve OBS control, mebeverine accelerates the development of continence in male ONB substitute patients in the first year after ONB substitute construction (Hashem et al., 2021).

In terms of conservative treatment, the two retrospective studies included in this article explored the effects of behavioural mode intervention and multimodal rehabilitation mode intervention on post-operative abstinence and rehabilitation in ONB patients and achieved good results in the early post-operative period. Therefore, future multicentre, randomized, large-sample prospective studies to demonstrate that early multimodal functional exercise can effectively accelerate or improve post-operative UI are recommended. Allow patients to return to society as soon as possible after surgery. Additionally, lack of standardization in the definition of UI, the definition and measurement of UI should be based on a recognized scoring system, such as the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) scoring system. Patients are able to improve the accuracy of future studies by recording the frequency and severity of incontinence during the day and night, both as part of the new bladder training.

STUDY LIMITATIONS

This literature review has some limitations due to limitations in the inclusion and exclusion criteria. First, we do not publish recent conference papers that could be an important source of information. With the ever-changing nature of home care, clinicians and healthcare professionals may not have time to publish research findings and ethical discussions in a timely manner but simply share their thoughts at work and at conferences. Secondly, Asian people, especially those in East Asia, are influenced by Confucian culture and are afraid of undergoing surgery again after major surgery, not only because they do not want to add to the problems of their families, but also because of the shame and embarrassment of the patient. As a result, the majority of Easterners opt for conservative treatment compared to Westerners. These factors may also lead to selection bias.

CONCLUSION

There are no evidence-based guidelines for incontinence management after RC and ONB. 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 (Zahran et al., 2014). Conservative therapy is currently of limited value and pharmacological intervention appears to be worthwhile. In mild to moderate UI, the effects of all invasive procedures are of concern, the use of fillers appears to be outdated, and any form of sling system portends a high risk of complications; in severe UI, for male patients, AUS appears to be a viable reference standard. Early interventions with behavioural patterns and multimodal rehabilitation models appear to have good efficacy and need to be further validated in later studies.

AUTHOR CONTRIBUTIONS

SYM and WW designed the study; SYM, QWH and YFZ collected the data; SYM, QWH and YFZ analysed the data. All authors prepared the manuscript and approved the final version for submission.

ACKNOWLEDGEMENTS

The authors have no acknowledgements to make.

FUNDING INFORMATION

This work was supported by the Zhejiang Provincial Medical and Health Technology Project (grant no. 2021KY658).

CONFLICT OF INTEREST STATEMENT

There is no conflict of interest declared.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

ETHICS STATEMENT

None.