Orthotopic neobladder (ONB) is the preferred urinary diversion after radical cystectomy (RC) with the main advantage of body image preservation, although its quality-of-life improvements are still under discussion. The principal factors associated with decrease in quality of life are continence status (both incontinence as well as urinary retention) and urinary tract infections (UTIs). The aim of this study is to investigate whether early clean intermittent catheterization (CIC) might improve functional outcomes, continence status, and reduce the incidence of UTIs.

In this prospective randomized study patients were divided in two groups: group A with standard postoperative approach, and group B consisting of patients who started CIC within the first post-operative month. The CIC was introduced at the time of indwelling catheter and stents removal after ONB reconfiguration.
All patients were studied postoperatively at 1, 3, 6, and 9 months after ONB. Inclusion criteria were the ability to both perform self-catheterization and empty the neobladder using abdominal straining. The CIC was executed 4 times/daily after each voluntary micturition. Exclusion criteria were diabetes mellitus, neurological conditions, cognitive impairment, and urethral strictures. The postoperative evaluation included: post-void residual volume (PVR), urine analysis and culture, number of pads/days and the self-administrated questionnaire International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF).

From September 2017 to March 2021, 39 male and 8 female patients underwent laparoscopic or robot assisted RC with totally intracorporeal ONB (37 U shaped and 10 Padua reconstructions). All patients completed the nine months follow-up (mean 9.2 months; range 6-13 months). At the first follow up all patients were able to do self CIC. At this time mean PVR was 116.5 mL, ICIQ-UI SF mean score was 16, mean no. of pads/day was 3, 14 patients reported 3 episodes of symptomatic UTIs (Escherichia coli was the most common pathogen). At 3, 6 and 9 months follow up after surgery the PVR and the ICIQ-UI SF scores were significantly improved. The number of pads decreased to 2 pads/day at 3 months, and only one safety pad at 6 and 9 months. The episodes of UTIs significantly decreased over the time with only 8 patients at 3 months (reporting 4 symptomatic episodes), and 4 and two patients at 6 and 9 months, respectively.

The findings of our study strongly indicate the important role of postoperative counselling and education for correct ONB emptying and support the early introduction of CIC with the aim to reduce the incidence of febrile UTI episodes, as observed in our study. The continence status reported in our study was in line with data in literature, as we observed a urinary continence improvement through the time.

This study confirmed that PVR is one of the most important parameters related with episodes of symptomatic UTIs, pads use and continence status. The data reported supports the early introduction of self CICs in patients with OIN after RC. Self CIC in these patients was significantly associated with quality-of-life improvement related to the continence status and the reduction of UTIs episodes.

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Kretschmer A, Grimm T, Buchner A, et al. Prognostic Features for Objectively Defined Urinary Continence after Radical Cystectomy and Ileal Orthotopic Neobladder in a Contemporary Cohort. J Urol. 2017;197(1):210-215.