radical cystectomy ( rc ) remains the standard of care for locally advanced , muscle - invasive and recalcitrant high - grade non - muscle invasive bladder cancer . a significant portion of morbidity following rc is associated with the choice of urinary diversion . although orthotopic neobladder ( onb ) has the advantage of preserving body image , improvements in quality of life over ileal conduit have been hard to demonstrate . one factor that may be associated with a decreased quality of life is continence status , both incontinence as well as hypercontinence or urinary retention . a number of factors have been purported to influence continence , including gender , nerve sparing , length of bowel segment and vaginal or uterine sparing in females . although the onb may be the preferred method for diversion , particularly for younger patients , improved quality of life may not be realized when the patients experience significant long - term voiding dysfunction . urodynamic studies in patients with ileal neobladder substitution have shown that good voiding habits are dependent on the ability to perform effective straining and the location of the neobladder . the ability to empty a neobladder has been shown to be dependent on bladder compliance in urodynamic studies . the dynamic mechanism of voiding in patients after neobladder construction have also been evaluated with interactive magnetic resonance imaging , showing that the movements are very different than in nave bladders . when counseling patients regarding the potential advantages and disadvantages of the different types of urinary diversion , it is critical to mention the possible need for long - term clean intermittent catheterization ( cic ) with onb . many patients are resistant to the idea of long - term cic and may choose a different diversion option when presented with the risk . thus , it is critical to understand and define the peri - operative factors that may be associated with a patient 's risk for requiring cic for long - term management of their onb . herein , we identify the peri - operative clinicopathologic factors associated with the need for long - term cic following onb . our study protocol received full approval from the institutional review board in compliance with the health insurance portability and accountability act ( hipaa ) . we conducted a retrospective review of our electronic medical record , identifying all patients between july 2004 and february 2013 who underwent a rc and onb . all radical cystectomies were performed by one of two fellowship trained urologic oncologists at the institution . for patients to be considered for an onb diversion , they must have a good performance status with an eastern cooperative oncology group ( ecog ) score of 02 . all patients underwent creation of onb as originally described by studer and had approximately 60 cm of distal ileum utilized for neobladder construction . men who were potent and sexually active prior to surgery had a nerve - sparing procedure completed with special attention to avoid damage to the neurovascular bundles on that lateral portion of the prostate . women who were sexually active had a vaginal - sparing surgery where the anterior vaginal wall was left intact and not resected along with the posterior bladder wall . patients had externalized ureteral stents and a urethral and suprapubic catheter immediately post - operatively . the ureteral stents were removed once the patients were tolerating a regular diet prior to discharge . patients returned to the clinic with a cystogram prior to neobladder activation ( catheter removal ) at 3 weeks post - operatively . all patients were placed on a strict voiding schedule after catheter removal , which included instructions to void every 2 h and to perform cic twice a day to check for residual urine . after 1 month , if patients had residuals less than 50 ml , they were instructed to stop cic . in addition , all patients had routine post - void residuals obtained at each clinic visit , and patients with > 150 ml of residual were instructed to perform cic for complete emptying . peri - operative clinical and pathologic data on all patients was obtained by chart review and utilized for the analysis of risk factors for the need to perform cic . the last follow - up appointment is where the catheterization status of the patient was determined . the date of this follow - up was different for each patient depending on the date of their neobladder construction . if a patient required catheterization post - operatively but then resolved prior to their latest visit , they were not considered hypercontinent , requiring cic . variables analyzed included age , body mass index ( bmi ) , gender , clinical and pathological stage , presence of diabetes mellitus , administration of neoadjuvant chemotherapy , history of previous abdominal surgeries and anterior vaginal or nerve - sparing procedures in females and males , respectively . previous surgeries included were any prior abdominal and pelvic procedures ; ventral and incisional hernia repairs of the abdomen were also included . the bmi of the patients used for this study was that recorded on the morning of surgery . bmi ( kg / m ) was stratified into three groups , including < 30 , 3039 and > 40 . clinical stage was based on the pathology report from the last transurethral resection and examination under anesthesia prior to cystectomy and pathological stage was divided into t0/tis / ta / t1 , t2 , t3 or t4 . an independent t - test was performed for the continuous variables and a chi - square test was used for the categorical variables . a multivariate forward stepwise logistic regression analysis was then used for all variables to determine which ones remained significant for the need to catheterize after neobladder urinary diversion . a p value of < 0.05 was considered significant . there were 114 patients from july 2004 to february 2013 who underwent rc with onb urinary diversion . age at the time of surgery ranged from 30 to 80 years , with a median age of 61 years . of this group , 15 were female ( 13% ) and 99 were male ( 87% ) . the bmi range at the time of surgery was 18.2160.5 kg / m , with an overall mean of 29 + 6.9 kg / m . patient characteristics of the 114 patients , 84 ( 73.7% ) did not require cic for emptying of their neobladder at the last follow - up , while 30 ( 26.3% ) reported having to catheterize at least once a day for completely emptying their onb . patients who reported requiring cic underwent office - based cystoscopy to rule out bladder neck contracture as a cause of the incomplete emptying , and none of the patients included in this group were reported to have a bladder neck contracture at the time of follow - up . it was found that five patients ( all male ) who required cic for emptying had ventral incisional hernias identified presumably from abdominal straining for neobladder emptying . on univariate analysis , three factors were statistically significant predictors for the need for cic and included younger age , higher bmi and undergoing non - conservative surgery ( non - nerve sparing in males and non - vaginal sparing in females ) , table 2 . when age is evaluated as a continuous variable , the mean age in those who required long - term cic was 62 years compared with 57 years in those who required cic ( p = 0.026 ) . when bmi was used as a continuous variable , patients who performed cic had a mean bmi of 31.7 versus 28.1 for those who did not catheterize ( p = 0.013 ) . forty - four ( 39% ) patients had a conservative procedure , and only six ( 20% ) of these reported catheterizing while 24 ( 80% ) patients who did not have vaginal- or nerve - sparing procedures required catheterization . because of the small numbers of patients , we combined males who had nerve sparing and females who had anterior vaginal wall sparing , including them as conservative surgical treatment . as shown in table 2 , all other variables were not significant on univariate analysis . univariate analysis comparing the use of cic and patients clinicopathological characteristics when these factors were used in a multivariable logistic regression analysis , we found that conservative procedure and age were the only two factors that were significant for increased need for cic . table 3 demonstrates that males who underwent a nerve - sparing procedure and females with vaginal sparing had a significantly decreased risk of requiring long - term cic ( odds ratio [ or ] 0.20 , p < 0.01 ) . surprisingly , older age was associated with a decreased risk of cic ( or 0.92 , p < 0.01 ) . patients < 50 years of age were more likely to catheterize than those 50 years of age , with an or of 6.4 ( 95% confidence interval [ ci ] 1.0638 , p = 0.042 ) . multivariate logistic regression analysis of clinicopathological variables and need to perform cic the analyses were completed on patients catheterization status at their last follow - up appointment , with a median of 39 months in the study . table 4 shows a breakdown of those requiring catheterization and those not requiring catheterization for onb emptying based on length of follow - up since rc with onb reconstruction . the onb has been considered a major advantage over ileal conduit urinary diversion , in that it allows individuals to void per urethra thus preserving body image and obviating the need for an external appliance . however , this improved quality of life may fail to be realized by the patient in whom significant voiding dysfunction occurs . voiding dysfunction is divided into the failure to empty or the failure to store urine . in our report , we examine the rate of urinary hypercontinence following onb and peri - operative clinicopathologic risk factors associated with the need for cic . previous studies have reported that between 4% and 25% of patients must perform intermittent self - catheterization due to incomplete emptying of the neobladder . although speculative , we suggest that this may be due to continued , long - term follow - up ( median 39 months ) in our patient population and the routine usage of post - operative measurements of post - void residuals in asymptomatic patients in addition to clinical diagnosis in those with symptoms . surprisingly , our analyses demonstrated that younger age was a risk factor for needing long - term cic . this is clearly of importance , as younger patients are frequently considered the ideal candidates for onb . interestingly , of the 18 patients > 70 years of age , only five ( 28% ) were reported to require long - term cic . our findings are contradictory to other reports that have demonstrated no appreciable differences in voiding function following onb in the elderly . theoretically , this may be a result of younger patients being more physically and mentally capable of long - term cic compared with elderly patients , who may demonstrate less compliance . younger patients may have higher expectations and desire to remain completely dry , which may lead them to catheterize as a precautionary tool to keep their bladder empty and prevent incontinence . perhaps it is the higher rate of incontinence in the elderly that may lead to a decreased need for cic , both potential explanations for this result . those patients who underwent nerve sparing or vaginal sparing were less likely to perform cic . it is important to make this clear to patients when educating and when seeing patients during follow - up visits . we found in this study that the overall rate of cic for emptying was 33% , with a median follow - up of 39 months . when separated by length of follow  up , it appears that catheterization may be required more often within the first year after surgery ( 60% ) and then decrease over time to a rate of 28% in those patients with follow - up times longer than 5 years since onb creation . many factors have been postulated for the precise pathogenesis of urinary retention and elevated residual urine after onb . voiding after neobladder often requires a combination of valsalva voiding and pelvic floor relaxation . in this study population , we found five patients who developed incisional ventral hernias after onb , and all these patients were male and had hypercontinence requiring cic . the hernia may be related to the abdominal straining required to empty after onb , but then the presence of the hernia traps urine causing retention to result without the use of catheterization . urodynamic studies after onb have demonstrated that patients with poor emptying ability ( defined as residual urine > 150 ml ) had increased compliance and capacity ( 1067 ml versus 623 ml ) compared with those with a good emptying ability . studies using urodynamic studies in neobladders have shown a wide range of cystometric capacities ( 3661370 ml ) . in one study , it was found that even with hypercontinent patients , the mean pressure of contractions was < 40 cm of water . other hypotheses of voiding difficulty after onb also include the inability to relax the external urethral sphincter , inadequate valsalva and anatomical factors including smooth continuity of the bladder neck to the urethra and appropriate bladder neck funneling . although we did not find any significant difference in cic rates between males and females , studies have consistently found that women are more likely to develop urinary retention than men . this may be due to the fact that in this study there were only a small number of female patients that underwent rc and onb . even though the exact mechanism of emptying and sensation is not known in patients with ileal neobladder , clearly , prevention of overdistention is of utmost importance to prevent dilatation of the upper urinary tract . as with any surgery , those individuals choosing to undergo onb for urinary diversion should be educated on the risk of urinary incontinence as well as urinary retention with the potential need for self - catheterization , even in the long - term setting . patients should understand the post - operative rehabilitation necessary to train the bladder substitute to meet their needs and expectations . quality of life studies have shown that those with onb had improved quality of life with regard to mental , physical and social functioning in daily life compared with ileal conduit . first , our study includes patient 's self - reporting of performing cic for neobladder emptying , which may not represent the true rate of hypercontinence . however , at our institution , we routinely performed post - void residual bladder scan on all patients with onb at every follow - up visit and we frequently reiterate to patients the importance of compliance . second , bmi was assessed on the day of surgery and not at the time of follow - up appointment when the report of cic was determined post - operatively . furthermore , long - term cic was not correlated to major changes in bmi post - operatively , a common consequence of rc . third , information on subsequent surgeries that may affect continence and emptying , such as urethral bulking injections , were not included in our report . on the other hand , patients with long - term retention were routinely ruled out for bladder neck contractures with office - based cystoscopy . in this study , we have only a small number of female patients ; therefore , this may not be representative of females undergoing onb . those males who underwent nerve sparing and females who had vaginal sparing surgery were combined and analyzed together as conservative management . there is also no patient - reported quality of life assessment at these follow - up time points to determine patient 's feelings toward this need for cic even at long time intervals after surgery . regardless of the limitations , it is quite clear that adequate patient counseling regarding choice of urinary diversion is imperative . furthermore , factors that may portent an increased risk of long - term cic following onb should be considered when discussing options . furthermore , patient characteristics associated with increased risk include non - conservative ( non - nerve sparing and non - vaginal sparing ) surgery , younger age and higher bmi .
introduction : we aimed to identify peri - operative and pathologic characteristics that may predict the need for clean intermittent catheterization ( cic ) following radical cystectomy ( rc ) with orthotopic neobladder ( onb ) in order to improve patient counseling on choice of urinary diversion.materials and methods : between july 2004 and february 2013 , all patients who underwent rc with onb were identified . 
 peri - operative clinical and pathological features were evaluated and correlated with patients reported need for cic . the independent t - test 
 was performed for continuous variables and chi - square test was performed for categorical variables . 
 multivariate forward stepwise logistic regression analysis was used to identify variables that correlated with need for cic after onb.results:during the study period , 114 patients underwent rc with onb creation . 
 on univariate analysis , patients with higher body mass index , younger age , and non - vaginal or non - nerve - sparing procedures were more likely to require catheterization for complete emptying . 
 multivariate analysis demonstrates that conservative surgery ( nerve sparing in males or vaginal sparing in females ) was associated with a significantly lower rate of requiring cic ( odds ratio [ or ] 0.20 , p < 0.01 ) . 
 surprisingly , older age was also associated with a slightly lower , but statistically significant , rate of requiring cic ( or 0.92,p < 0.01).conclusions : when counseling patients regarding the different types of diversions after rc , the potential need for long - term cic after onb must be discussed . 
 the clinical factors that appear to increase the need for cic include non - conservative rc ( non - nerve sparing in males and non - vaginal sparing in females ) and , to a certain degree , younger age .