Best evidence for rehabilitation management of urinary incontinence in patients with bladder cancer following orthotopic neobladder reconstruction

Abstract

Objective

This study aims to establish the best evidence for the rehabilitation management of urinary incontinence (UI) in patients with orthotopic neobladder (ONB) following radical cystectomy (RC) for bladder cancer, providing a theoretical foundation for clinical practice.

Methods

A systematic search was conducted across evidence-based databases, guideline networks, and professional association websites to identify relevant literature on rehabilitation management for patients with ONB after bladder cancer surgery. Studies published in both English and Chinese, up to May 8, 2024, were included. Trained researchers assessed the quality of the literature and summarized the evidence.

Results

Fourteen documents were included, consisting of eight guidelines, two clinical decision documents, and four expert consensus reports. A total of 43 pieces of evidence were identified, covering seven key areas: preoperative UI assessment and counseling, preventive measures, UI assessment and diagnosis, conservative treatments, selection and use of nursing equipment, evaluation of effectiveness, and follow-up care.

Conclusions

The best evidence for UI rehabilitation management after ONB for bladder cancer can help standardize patient care and clinical practices. Healthcare providers should adapt this evidence to their local healthcare settings, cultural contexts, barriers, and patient preferences.

Systematic review registration

This study was conducted following the evidence summary reporting specifications of the Fudan University Center for Evidence-Based Nursing (Registration No. ES20244165).

Introduction

Bladder cancer is a major health issue and the tenth most common cancer worldwide, with approximately 570,000 new cases and 210,000 deaths reported in 2020.¹ Clinically, bladder cancer is classified into muscle-invasive bladder cancer (MIBC) and non-MIBC (NMIBC), depending on the presence of muscle invasion. MIBC is characterized by high malignancy and recurrence rates and typically requires radical cystectomy (RC), pelvic lymph node dissection, and urinary diversion as standard treatments.²

Orthotopic neobladder (ONB) surgery uses organs such as the intestine to create a storage bladder, which is then anastomosed to the urethra, allowing the patient to urinate normally after cystectomy.³ This remains the preferred urinary diversion method as it preserves urinary control and avoids the psychosocial impact of a stoma.⁴ However, as a substitute, the neobladder does not function as effectively as the original bladder in many aspects.⁵ Urinary incontinence (UI) is a distressing and challenging condition in patients with neobladders, it often requires high-quality rehabilitation guidance and sometimes surgical intervention.⁶ Previous studies have reported that the incidence of daytime and nocturnal incontinence in patients with bladder cancer following ONB for RC is as high as 41% and 72%, respectively, at 3 months postoperatively,⁷ as the capacity and compliance of the neobladder increase, most patients improved urinary control 6–12 months postoperatively.⁸ However, a recent meta-analysis of 59 retrospective studies showed that daytime and nocturnal incontinence remained high at 15.8% and 38.3%, respectively, 12 months after ONB surgery.⁹

Although not life-threatening, UI following ONB in patients with bladder cancer significantly affects their quality of life (QOL). It can lead to loss of self-esteem, reduced sexual desire, and limitations in physical, social, and self-care activities.¹⁰ As incontinence worsens, patients may depend more on caregivers, which reduces their social interactions and independence. Moreover, UI management after ONB in patients with bladder cancer remains a significant challenge.¹¹

Evidence exists for managing various UI types in different populations,12, 13, 14, 15, 16 and interventions for urinary incontinence primarily include conservative therapy, pharmacologic, and surgical treatments,but they may not fully address the unique needs of bladder cancer patients with incontinence after ONB. Meanwhile, there are no comprehensive systematic guidelines for rehabilitation management of UI in patients with bladder cancer after ONB, and nursing practice lacks detailed guidance. This gap underscores the need for a summary of the best evidence to guide clinical practice effectively.

Therefore, researchers must build on the existing evidence to identify the most relevant data for managing UI rehabilitation in patients with bladder cancer after ONB, incorporating clinical experience and patient preferences. This study aimed to fill the gaps in the existing research by systematically identifying, evaluating, and synthesizing the best available evidence on UI rehabilitation after ONB in patients with bladder cancer. The goal was to provide a robust theoretical foundation to improve patient care, enhance clinical outcomes, and inform decision making. These findings can inform a standardized approach to UI rehabilitation care for patients with bladder cancer undergoing ONB to facilitate patient recovery and improve the overall quality of life and clinical outcomes.

Methods

Identification of the evidence-based issues

This study employed the PIPOST model developed by the JBI Evidence Center in Australia to identify evidence-based issues. P refers to the patient population (patients undergoing ONB for bladder cancer); I refers to interventions (assessment, diagnosis, rehabilitation, and treatment of UI after ONB); P refers to practitioners (clinicians, patients, and caregivers); O refers to outcomes (urination status, incontinence incidence, level of incontinence); S refers to settings (urology wards, outpatient clinics, communities, patient residences); and T refers to types of evidence (clinical guidelines, evidence summaries, expert consensus, systematic reviews/meta-analyses, high-quality randomized controlled trials (RCTs), quasi-experimental studies).

Literature retrieval strategy

Following the ‘6S’ evidence model,¹⁷ a top-down search was conducted across databases and professional sites, including UpToDate, BMJ Best Practice, PubMed, Cochrane Library, Embase, Science Direct, Scopus, Web of Science, BMJ Clinical Evidence, OVID Evidence-Based Database, Chinese Journal Full-text Database (CNKI), VIP Database, Chinese Wanfang Database, Chinese Biomedical Literature Database (CBM), International Guide Collaboration (GIN), Scottish Intercollegiate Guideline Network (SIGN), World Health Organization (WHO), National Institute for Health and Care Excellence (NICE), Registered Nurses Association of Ontario (RNAO), Medlive, National Comprehensive Cancer Network (NCCN), American Urological Association (AUA), American Society of Clinical Oncology (ASCO), Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU), British Association of Urological Surgeons (BAUS), European Society for Medical Oncology (ESMO), European Association of Urology (EAU), Wound, Ostomy, and Continence Nursing (WOCN), and International Continence Society (ICS).

A keyword-based search strategy was developed, with the search period covering each database from inception to May 8, 2024. The English search keywords included “urinary diversion” “orthotopic neobladder”and “urinary incontinence” “urinary control”, and “rehabilitation” “management”. The Chinese search terms included “尿流改道术”“膀胱癌根治术”“原位新膀”, and “尿失禁”“尿控”, and “康复” “管理” “干预”. The search period covered each database from inception until May 8, 2024.

Our search strategy for English databases, such as PubMed, which we developed based on a systematic review, as summarized in Table 1.

Table 1.

Keywords and search stratery

Database	No	Search strategy
PubMed	#1	"Rehabilitation" [Title/Abstract]OR "prevention"[Title/Abstract] OR "management"[Title/Abstract] OR "nursing"[Title/Abstract] OR "intervention" [Title/Abstract] OR "conservative therapy" [Title/Abstract]
	#2	"Urinary incontinence"[MeSH Terms] OR "urinary leakage" [Title/Abstract] OR "urinary control" [Title/Abstract]
	#3	"Urinary Bladder Neoplasms"[MeSH Terms] OR "bladder cancer" [Title/Abstract] OR "bladder carcinoma" [Title/Abstract] OR"bladder tumor" [Title/Abstract]);
	#4	"Urinary diversion" [MeSH Terms] OR"radical cystectomy" [Title/Abstract] OR"orthotopic neobladde" [Title/Abstract] OR"neobladder reconstruction" [Title/Abstract] OR "ileal substitute bladder" [Title/Abstract]
	#5	#3 OR #4
	#6	"Systematic review" [Title/Abstract] OR "meta-analysis" [Title/Abstract] OR "guideline" [Title/Abstract] OR "consensus" [Title/Abstract] OR "recommendation" [Title/Abstract] OR "evidence summary" [Title/Abstract] OR “randomized controlled trial” [Title/Abstract]
	#7	#1 AND #2 AND #5 AND #6

Literature inclusion and exclusion criteria

The inclusion criteria were as follows: studies that focused on patients who underwent ONB reconstruction for bladder cancer; studies that assessed the risk of incontinence development, prevention, evaluation, diagnosis, and various treatment approaches (conservative, pharmacological, and surgical). The outcome indicators included the incidence of incontinence and urine control; literature types included clinical decision-making papers, guidelines, expert consensus, evidence summaries, meta-analyses, and systematic reviews; Literature published in English or Chinese.

The exclusion criteria were as follows: lack of full-text availability; the study record was available as an abstract-only or translated version; publications through repeated publication. Presenting redundant information; following a thorough quality evaluation, the quality of the studies was deemed to be extremely low.

Literature quality evaluation

Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.¹⁸ Expert opinions, consensuses, quasi-experimental studies, randomized controlled trials, and cohort studies were evaluated using the Australian JBI Evidence-Based Health Care Center tool (2016).¹⁹ Meanwhile, because there were no recognized quality evaluation tools for the best-practice evidence, evidence summaries, and recommended practices, we judged the quality of these types of evidence by tracing back the original documents from which each source was derived, and then selecting the corresponding evaluation tools for quality evaluation. The quality of the systematic reviews was assessed using the AMSTAR 2 criteria.²⁰

Evidence summary and recommendation level

The 2014 version of the JBI Evidence Pre-grading System was used to classify evidence levels, and the JBI Evidence Rank System (2014) was used to categorise recommendation levels.²¹ Based on the study design, This system divided the evidence into five levels, from highest (Level 1) to lowest (Level 5). Evidence from the guidelines and summaries retained their original classifications. The highest evidence level was used to classify the evidence from multiple sources. Then, we classified the evidence into grade A (strongly recommended) or grade B (weakly recommended) according to the JBI feasibility, appropriateness, meaningfulness, and effectiveness (FAME) framework.²²

Literature evaluation quality process

Two authors (Xu and Chen) independently screened the titles and abstracts of all the records identified using the search strategy. The same authors independently retrieved and assessed the full text of potentially relevant articles based on the inclusion and exclusion criteria. Disagreements were resolved through discussion with the corresponding author (Chen).

Extraction and classification of evidence

Careful and thorough reading of the literature of the 14 included articles extracting, analyzing, and comparing evidence consistent with the research theme and objectives, synthesizing and categorizing similar and recurring evidence into dimensions, and finally, scrutinizing each piece of evidence through iterative discussions among the research team, with reference to similarly established frameworks in the field, in order to determine the final dimensions and entries.

Results

Baseline characteristics of the enrolled articles

A total of 1665 publications were initially identified. After removing duplicates and excluding those that did not meet the inclusion criteria based on the title, abstract, and full-text review, 14 publications were included. These consisted of eight guidelines, two clinical decision documents, and four expert consensus papers. The study selection process is shown in Fig. 1 and the basic characteristics of the included studies are summarized in Table 2.

Fig. 1.

Flow chart of literature retrieval and screening.

Table 2.

Characteristics of the included literature (N ​= ​14).

Author	Year	Article type	Article sources	Research subjects
Shariat et al.23	2024	Clinical decision	UpToDate	Urinary Diversion and Reconstruction After Cystectomy
Davila et al.24	2023	Clinical decision	BMJ BestPractise	Female UI
EAU25	2020	Guideline	EAU	Adult UI
WHO26	2017	Guideline	PubMe	Management of UI in the Elderly
Gacci et al.27	2022	Guideline	PubMed	Male UI
EAU28	2024	Guideline	EAU	Muscle-Invasive and Metastatic Bladder Cancer
NICE29	2021	Guideline	PubMed	Prevention and Non-Surgical treatment of Pelvic Floor Dysfunction
NICE30	2019	Guideline	PubMed	Management of Female UI and Pelvic Organ Prolapse
Stangel-Wojcikiewicz et al.31	2021	Guideline	PubMed	Management of Female Stress Urinary Incontinence
Huang et al.32	2022	Guideline	Medlive	Chinese Guidelines for the Diagnosis and Treatment of Urological and Male Diseases
Chinese Urological Association33	2018	Expert consensuses	Medlive	Enhanced Recovery Management for Radical Cystectomy and Urinary Diversion
Ding et al.2	2021	Expert consensuses	Medlive	Radical Cystectomy with Urinary Diversion
Zhang et al.8	2017	Expert consensuses	PubMed	Diagnosis and Treatment of UI after Orthotopic Ileal Neobladder in China
Gray et al.34	2018	Expert consensuses	PubMed	Assessment, Selection, Use, and Evaluation of Absorbent Products for Adult Incontinence Patients

UI, ​urinary incontinence.

Results of literature quality evaluation

Eight guidelines with a high inter-rater agreement were included in this study. Table 3 presents the standardized Scores in Various Domains and the overall quality evaluation of the guidelines. The first four guidelines had standardized scores greater than 60% in all areas and therefore received grade A recommendation, while the last four guidelines had achieved a standardized assessment score less than 60% in terms of applicability and editorial independence, therefore received a grade B recommendation. The two clinical decision documents were of high quality and were included. Four expert consensus studies were included in this study. Of these, three had all items evaluated as “Yes.” In Zhang et al.,⁸ the first five items were rated“Yes”, while the evaluation of item six was ‘unclear’. This consensus followed the evidence development process and the criteria for meeting the inclusion requirements of the study.

Table 3.

Methodological evaluation of the guidelines included in this study.

Study	Standardized Scores in Various Domains (%)						≥ 60%	≥ 30%	Quality Evaluation
	Domain 1: Scopes and objects	Domain 2: Stakeholder Participant	Domain 3: Rigour of development	Domain4: Clarity of guidelines	Domain 5: Applicability	Domain 6: Editorial Independence
EAU25	92.6%	88.9%	82.6%	74.1%	63.9%	66.7%	6	6	A
WHO26	87.0%	83.3%	80.1%	72.2%	80.5%	61.1%	6	6	A
Gacci et al.27	81.5%	79.6%	75.7%	77.8%	66.7%	75.0%	6	6	A
EAU28	94.4%	83.4%	79.2%	83.3%	81.9%	80.1%	6	6	A
NICE29	83.3%	63.0%	69.4%	77.8%	61.1%	55.6%	5	6	B
NICE30	88.9%	74.1%	70.1%	83.3%	66.7%	52.8%	5	6	B
Stangel-Wojcikiewic et al.31	64.8%	59.3%	62.5%	66.7%	69.4%	52.8%	4	6	B
Huang et al.32	87.0%	74.1%	87.5%	88.9%	47.2%	0	4	6	B

Summary and description of evidence

To standardize UI rehabilitation care for patients with bladder cancer undergoing ONB, this study identified 43 evidence entries categorized into seven dimensions: preoperative assessments and risk communication, preventive measures, UI assessment and diagnosis, conservative treatment, the selection and use of nursing equipment, and outcome evaluation and follow-up. This comprehensive evidence summary aims to facilitate patient recovery and improve their overall quality of life and clinical outcomes.

Evidence was extracted from the final selected literature and evaluated using the JBI evidence pre-grading and rank systems. The seven dimensions encompass key recommendations for UI rehabilitation management: (1) Conducting comprehensive preoperative assessments and communicating potential complications such as UI to patients and their families. (2) Providing preoperative health education and ensuring intraoperative protection of urinary control structures. (3) Implementing standardized assessment and diagnosis for UI following ONB. (4) Prioritizing conservative treatments, such as pelvic floor exercises and lifestyle modifications. (5) Selecting appropriate nursing equipment to enhance patient comfort and support. (6) Assessing treatment effectiveness. (7) Instructing patients on the importance of regular follow-ups. These findings are summarized in Table 4 to provide a clear and actionable framework for clinical practice.

Table 4.

Summary of best evidence for prevention and management of urinary incontinence after orthotopic neobladder.

Subject of evidence	Evidence content	Evidence level	Recommendation
Preoperative Assessment and Notification	1. Conduct a comprehensive preoperative assessment of the patient's condition, physical status, psychological state, and social support system23	1	A
	2. Inform the patient and their family about the potential perioperative complications associated with the surgical plan, as well as key points for postoperative care and rehabilitation2	5	A
	3. Patients should be thoroughly educated on the necessity of adhering to postoperative rehabilitation. Additionally, they should be equipped with sufficient practical skills to perform self-catheterization if required23	1	A
Preventive Measures for UI	4. Surgeons should focus on the design of the neobladder and meticulous surgical techniques to reduce the occurrence of urinary incontinence23	1	A
	5. Preoperative guidance on pelvic floor muscle rehabilitation and abdominal pressure training can help alleviate patient stress and enhance postoperative urinary control2,33	5	A
	6. Assess the strength and endurance of the pelvic floor muscles and their ability to contract during increased abdominal pressure. Even if control is present, patients should perform pelvic floor muscle rehabilitation exercises at least once daily8	5	A
	7. During surgery, ensure adequate and effective protection of urinary control structures such as the external sphincter, pelvic floor muscles, and ligaments. (1) strive to preserve the residual urethra; (2) De-tubularize or de-band the intestine to remove the segment's peristaltic contractions or reduce their intensity; (3) Select a sufficiently long intestinal segment to construct the neobladder2,23	1	B
Assessment and Diagnosis of UI	8. The assessment and classification of UI are the foundations for treatmen30	2	A
	9. The assessment of UI following orthotopic neobladder surgery should be delayed until bladder capacity stabilizes, which typically takes 6–12 months8	5	A
	10. The assessment includes medical history evaluation, physical examination, and laboratory tests8,27	5	A
	11. After determining the type of urinary incontinence, it is essential to assess each patient's treatment goals and expectations to help select the optimal treatment plan24	1	A
	12. The pad test can accurately diagnose UI and can also be used to quantify the presence and severity of UI27	3	A
	13. Specific symptom score questionnaires and voiding diaries are helpful for the screening and classification of UI27	3	A
	14. For standardized assessment, UI patients should be required to complete a voiding diary, using a clinically validated voiding diary25,32	3	A
	15. A 3–7 day voiding diary is a reliable tool for objectively measuring average voided volume, daytime and nighttime frequency, and the frequency of UI episodes25	2	A
	16. Do not use urethral pressure profilometry or leak point pressure measurement to assess the severity of urinary incontinence25	2	A
	17. If symptomatic urinary tract infection with UI occurs, the patient should be reassessed after treatment25	2	A
Conservative treatment for UI	18. Provide lifestyle recommendations that may improve UI: Encourage overweight and obese adults (BMI > 30 kg/m2) with UI to lose 5% of their body weight and maintain the weight loss25	1	A
	19. Provide patients with advice on how to avoid constipation25	3	A
	20. Offer smoking cessation support to smokers24,25	4	A
	21. There is conflicting evidence regarding whether restricting fluid intake improves UI25	2	B
	22. Reducing caffeine intake can only reduce UI when combined with behavioural therapy31	2	B
	23. Recommend regular toileting for UI patients, provide prompted voiding for adults with cognitive impairment who have urinary incontinence25,26	2	A
	24. Advise patients with nocturnal UI to restrict fluid intake for 3 hours before bedtime33	5	B
	25. For patients undergoing neobladder surgery, home pH management includes regular pH measurements and substituting sodium bicarbonate based on the results28	1	B
	26. For adult patients with urge UI or mixed UI, provide at least 6 weeks of bladder training as a first-line treatment26,30	1	A
	27. Pelvic floor muscle training should be offered as a first-line treatment for stress UI or mixed urinary incontinence25,30	1	A
	28. Pelvic floor muscle training should be recommended for at least 3 months and should be conducted under the supervision and guidance of a professional25,29,30	1	A
	29. Psychological intervention can improve the adherence and compliance of patients undergoing pelvic floor muscle training29	5	B
	30. Before using pelvic floor muscle training to treat urinary incontinence, the contraction function of the pelvic floor muscles should be assessed8,30	4	A
	31. Electrical stimulation can enhance the benefits of pelvic floor muscle training in the short term24,25,27	2	B
	32. If pelvic floor muscle training is beneficial, the exercise program should be continued30	2	A
	33. For UI caused by persistent urinary retention, provide intermittent catheterization and carefully consider the implications of long-term indwelling catheterization30,32	2	B
Selection and Use of Nursing Equipment	34. When selecting close-fitting absorbent products for incontinence patients, consider the condition of the skin around the genital area, fit, comfort, and skin barrier function34	1	A
	35. Using protective materials can improve the comfort of both short-term and long-term UI patients31	3	A
	36. For mild urinary incontinence, urinary pads are the preferred choice. For moderate to severe urinary incontinence, it is recommended to use diapers with super absorbent polymer technology34	2	A
	37. For patients with nocturnal urinary incontinence, it is recommended to use disposable absorbent products34	2	A
	38. Close-fitting absorbent underwear with spiral fibre design may reduce the occurrence of incontinence-associated dermatitis34	4	B
	39. Absorbent sealed products, handheld urinals, or elimination aids should not be offered for the treatment of urinary incontinence30	4	A
	40. The timing of absorbent product changes should be patient-centred and not based on routine or caregiver convenience8,34	2	A
Effectiveness Evaluation	41. Changes in leakage volume on the pad test can be used to measure treatment outcomes25	2	A
Follow-up	42. Follow-up schedule: Patients should be followed up at 3 months, 6 months, and 12 months postoperatively. In the second postoperative year, follow-up should be extended to every 6 months, and thereafter, consider annual follow-up8,32	5	A
	43. Follow-up content: Assess the frequency of urinary incontinence, urine volume, and quality of life scores. It is also recommended to perform an abdominal ultrasound along with a urinary tract examination to check the urinary tract and the pressure of the neobladder, as well as the stability and compliance of the neobladder. Urodynamic testing is advised if necessary. Other options include keeping a voiding diary, urinalysis, blood tests, and assessment of renal function and electrolytes8	5	A

UI, urinary incontinence.

Discussion

Health care providers should conduct thorough preoperative assessments and engage in effective risk communication, optimize care management strategies, strengthen interdisciplinary collaboration to accurately assess and diagnose UI, and enhance patients' physical and psychological recovery. By effectively utilizing health care resources and providing personalized multidisciplinary treatment and follow-up plans, patient outcomes and overall quality of life can be significantly improved.

Preoperative assessment and risk communication: essential for patients

Adequate preoperative assessment should focus on the patient's physical and mental health, and illness status. The potential risks, anesthesia tolerance, and surgical difficulty can be predicted by improving preoperative laboratory tests, imaging, and functional tests of vital organs. Therefore, a comprehensive survival, mortality, and perioperative complication assessment should be conducted.^35,36 For patients with poor surgical tolerance due to functional impairments of vital organs (heart, lungs, and kidneys), active communication with anesthesiology and other relevant departments is necessary to develop a joint diagnosis and treatment plan.³⁷ Factors such as age are critical because the incidence of postoperative UI is correlated with age. A previous study showed that at five years post-surgery, the incidence of UI was 19% in patients under 60 years of age compared to 35% in those over 70.³⁸ For older patients, postoperative survival time and life expectancy should be considered, whereas younger patients should receive aggressive treatment to prolong survival. Sex is another factor; women experience higher rates of UI due to voiding dysfunction, with 45% being unable to urinate unaided and two-thirds requiring urinary catheters to assist with neobladder voiding.³⁹ Therefore, a personalized treatment plan that considers the patient's tumor characteristics and individual needs is essential to minimize incontinence.

Collaborative interdisciplinary efforts are crucial for the successful implementation of preventive interventions.⁴⁰ Urologists should collaborate with anesthetists, urology nurses, clinical psychologists, oncologists, dietitians, sports psychologists, and other specialists in multidisciplinary teams to ensure perioperative patient safety. This multidisciplinary approach provided comprehensive preoperative education, rehabilitation measures, improved nutritional support, and adequate preoperative bowel preparation. Collectively, these interventions lay the foundation for a smooth surgery and optimal patient recovery.

Given the complexity and specificity of surgery, medical staff should thoroughly inform patients and their families about available treatment options, associated benefits and risks, potential perioperative complications, and key aspects of postoperative care and rehabilitation. This approach ensures maximum patient and family cooperation and understanding. Nurses must recognize the importance of family social support. First, nurses should enhance communication with patients and their families to build trust and cooperation and foster a harmonious nurse–patient relationship. Second, dynamic assessment of a patient's family social support should be conducted feasibly and appropriately. Finally, nurses should educate patients with weak family support and their families on the critical role of a strong social support system in surgical treatment and recovery. These positive effects should be reinforced during follow-up of patients with strong family support.

Preoperative and intraoperative attention to UI prevention

Long-term follow-up of patients with bladder cancer after ONB reconstruction has shown that outcomes are significantly improved in facilities with specialized teams dedicated to promoting postoperative recovery.⁴¹ Therefore, RC should be performed by experienced surgeons in high-volume hospitals because surgeons play a critical role. The prevention of UI after ONB requires meticulous surgical techniques. Surgeons must carefully design the neobladder and preserve continence structures, such as by using an adequate ileum length and creating an elliptical or spherical conformation, while also employing nerve preservation techniques and preventing pelvic floor injuries, which are key to reducing incontinence risk.⁴² Preoperative pelvic floor muscle training can significantly reduce the risk of postoperative incontinence by improving patient urination control. Thus, the medical staff should instruct patients to perform pelvic floor exercises preoperatively, alleviate stress, and improve postoperative urinary control. Clinicians should assess pelvic floor muscle strength, endurance, and contraction ability, particularly under increased abdominal pressure, and tailor the training regimen accordingly.

Accurate assessment and diagnosis: the foundation for treatment and rehabilitation

Accurate assessment and diagnosis are essential to guide UI treatment.³⁰ Health professionals should be proactive in asking patients about their incontinence symptoms. Patients with urinary incontinence should undergo a comprehensive and holistic assessment.⁴³ The assessment process, which includes a medical history review, physical examination, and laboratory tests, with history-taking as the cornerstone of accurate evaluation. A detailed history should include the patient's general condition, such as cognitive function, lifestyle habits, mobility, history of bladder cancer surgery and treatment, use of questionnaires and standardized voiding diaries to track UI onset, day and night distributions, associated symptoms, pain levels, nocturnal urination frequency, and urinary pad tests to quantify UI severity. A 3–7 day voiding diary is a reliable tool for objectively measuring the average urine output, daytime and nighttime frequency, and incontinence episodes.²⁵ Instructing patients to maintain a voiding diary helps them understand the importance of neobladder function training, identify training challenges, improve training effectiveness, and reduce the incidence of UI.⁴⁴ Physical examinations included general, full-body, specialist assessments, and special investigations. The laboratory tests included urodynamic studies, residual urine measurements, and blood tests. Accurately identifying the UI type helps set realistic treatment goals and expectations and helps patients select the most appropriate treatment plan.²⁴

UI following ONB reconstruction in patients with bladder cancer differs from general UI; however, in clinical practice, doctors often use common incontinence assessment tools such as urinary pad tests, scoring questionnaires, and standardized voiding diaries, as recommended by evidence. Therefore, specific assessment and diagnostic methods should be selected and applied appropriately based on the patient's condition and physician's clinical experience.

Conservative treatment of urinary incontinence: lifestyle changes, pelvic floor muscle training, and bladder training

Managing and rehabilitating UI after ONB reconstruction following RC is challenging and depends on accurately identifying the cause of leakage.⁴⁵ Among the conservative treatments, lifestyle modifications are commonly recommended. Lifestyle factors associated with UI, such as obesity, smoking, constipation, fluid intake, and caffeine intake, can be modified to improve the symptoms. Several studies have addressed these issues.

Behavioral and physical therapies, including bladder and pelvic floor muscle training (PFMT), are key first-line treatments for UI. However, combining these treatments with other options such as electrophysiological stimulation, percutaneous tibial nerve stimulation, and biofeedback has produced mixed and sometimes contradictory results. There is also ongoing research on developing educational materials and teaching procedures, combined with PFMT and voiding diaries, for the conservative treatment of UI.⁴⁶

Improving patient compliance and adherence to PFMT can lead to psychological benefits and better UI management. Intermittent catheterization may effectively manage UI caused by persistent urinary retention. However, clinicians must carefully weigh the potential risks associated with prolonged catheter use. Although large-scale clinical trials are lacking to determine the optimal combination of behavioral and physical therapies for UI, current evidence supports that effective multimodal prehabilitation interventions should at least include lifestyle changes, PFMT, and bladder training.

Patient-centred selection and use of nursing products

Despite advancements in incontinence treatment and rehabilitation management, evidence shows that incontinence products remain the most commonly used strategy for managing urinary and fecal incontinence among adults.^47,48 Selecting appropriate continence products is crucial for managing UI and enhancing patient comfort. Considerations for selecting close-fitting absorbent products include the condition of the perigenital skin, fit, comfort, and skin barrier function.³⁴ Protective materials should be used to improve the comfort of all patients with incontinence.³¹ It is also essential that the timing of absorbent product changes is patient-centred rather than based on routine or caregiver convenience.^8,33 Additionally, regular reassessment and customisation of continence care plans are necessary to address patients evolving needs over time.

Outcome evaluation and follow-up: ensuring the effectiveness of prevention and treatment

To detect and manage complications and improve the patient's quality of life, bladder function should be continuously monitored after ONB reconstruction following RC for bladder cancer.⁸ While no standard follow-up schedule exists for post-ONB care, regular follow-up is crucial for assessing the effectiveness of incontinence management and making the necessary adjustments. The incidence of UI decreased during follow-up.⁴⁹ UI assessments should be delayed until bladder capacity stabilizes, typically 6–12 months after ONB. Therefore, early follow-up is recommended at 3, 6, and 12 months after ONB, followed by annual assessment. Outcome evaluations should include incontinence frequency, quality of life assessments, and objective tests such as urodynamic studies, when indicated.⁸

Implications for nursing practice and research

This evidence can inform decisions regarding the management of incontinence rehabilitation in patients after ONB reconstruction following RC for bladder cancer. However, applying all evidence in clinical practice may not always be feasible. Health care professionals can focus on implementing more practical evidence to drive quality improvement projects, optimize care workflows, and develop clinical pathways according to specific contexts. The application should be guided by evidence-based practice models combined with clinical expertise while considering patient preferences, values, and ethical considerations. Involving patients in discussions and developing rehabilitation plans can foster their engagement.

Targeted strategies should address barriers to implementing incontinence rehabilitation care such as limited access to evidence, increased nurse workload, poor communication, and low acceptability. For example, setting realistic review indicators based on evidence and offering systematic training can improve its implementation. Strong leadership and facilitators should devise practical action strategies. Additionally, strengthening communication between doctors and nurses and encouraging patients to participate in rehabilitation management can enhance patient compliance and beliefs about recovery, even in cases of incontinence, leading to better adherence and improved recovery outcomes.

Strengths and limitations

This study has several strengths. First, all researchers underwent systematic evidence-based training to ensure standardization of research and operational processes. The research team achieved reliable results by systematically searching major databases and evaluating, classifying, and synthesizing evidence. Additionally, given the limited literature on the rehabilitation and management of postoperative UI in patients undergoing ONB after bladder cancer RC, this study provides valuable references for health care professionals involved in bladder cancer surgery by systematically integrating high-quality evidence. However, this study has some limitations. For instance, the 14 documents included only published in Chinese and English, potentially missing important evidence published in other languages. Moreover, owing to the specific nature of postoperative incontinence after ONB, further research on interventions for this type of incontinence is required to expand and enrich the current findings.

Conclusions

This study used an evidence-based approach to summarize 43 pieces of the best evidence for managing incontinence in patients undergoing ONB reconstruction after RC for bladder cancer. Evidence spanned seven key dimensions: preoperative assessment and communication, preventive measures for UI, UI assessment and diagnosis, conservative treatment, selection and use of nursing equipment, outcome evaluation, and follow-up. This provides a strong evidence base for health care professionals to implement incontinence rehabilitation. However, although the available evidence supports continence management in patients with ONB, there remains a need for high-quality evidence. Future research, particularly multicenter and large-sample studies on postoperative incontinence interventions, is needed to address the current gaps and provide more personalized rehabilitation guidance. Additionally, more studies are required to explore how best to translate and apply this evidence in clinical practice to improve the quality of life of patients following ONB for bladder cancer.

CRediT authorship contribution statement

Man Xu: Conceptualization, Methodology, Data curation, Investigation, Writing – Original draft. Shuhong Chen: Methodology, Data curation, Investigation, Writing – review & editing. Xiyuan Liu: Writing – Original draft preparation. Yuyi Luo: Data curation, Formal analysis. Di Wang: Writing – Original draft preparation. Huiming Lu: Conceptualization, Supervision, Project administration. Mengxiao Jiang: Methodology, Writing – review & editing. Xiaoping Chen: Conceptualization, Validation, Writing – review & editing, Supervision. All authors had full access to the data, reviewed, and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and no others meeting the criteria have been omitted.

Ethics statement

Not required.

Funding

This study was supported by the Guangdong Nurses Association (Grant No. gdshsxh2021b012) of Guangdong Province.The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Data availability statement

All evidence summarized in this study was derived from publicly available, peer-reviewed literature, which has been appropriately cited in the reference list. No additional data were generated or analyzed during this study.

Declaration of generative AI and AI-assisted technologies in the writing process

No AI tools/services were used during the preparation of this work.

Declaration of competing interest

The authors declare no conflict of interest.