Indications and early and late results of intestino-cystoplasty: a review of 185 cases

Experiences with bladder reconstruction in children

The results in 56 children (28 with neurogenic bladder dysfunction) undergoing enterocystoplasty between 1981 and 1985 are presented. Ileal, ileocecal, right colon and sigmoid segments were used in tubular and opened configurations. Our experience leads us to recommend opened ileal segment reconstruction in neurogenic bladder patients and those with weak anal sphincters generally, and open ileocecal or open right colon segments in patients with other etiologies. Continence was achieved in 53 patients, although secondary procedures, particularly at the bladder outlet, were required in 13. When ureteral reimplantation was required we achieved excellent success with normal-sized or mildly dilated ureters regardless of the operative technique used. Initial failures to prevent reflux in the face of marked ureterectasis using the ileocecal valve have been resolved by a modified technique of intussusception and fixation. An over-all favorable experience is reported, which we believe permits us to formulate certain rules that will improve the acceptability and success of bladder reconstruction in general.

Bladder replacement after cystoprostatectomy: efforts to achieve total continence

Total bladder replacement with tubular sigmoid colon and detubularized ileocecal bowel segments was performed on 17 patients after cystoprostatectomy for bladder cancer. There were few complications and patient acceptance was excellent. Daytime continence was achieved in most patients but voiding patterns were superior with detubularized segments. However, enuresis was common with both segment types. Total urinary continence (day and nighttime continence) was achieved in 7 patients with an artificial urinary sphincter that was activated only at night. Total bladder replacement is an acceptable form of urinary diversion after cystoprostatectomy in appropriate patients.

Intestinocystoplasty and total bladder replacement in children and young adults: followup in 129 cases

A review of 129 consecutive young patients (average age 13.4 years) who underwent intestinocystoplasty or total bladder replacement during a 6 1/2-year period at our institution is presented. The most common diagnosis was myelodysplasia and the average followup was 44 months. The clinical and urodynamic aspects of 4 types of intestinocystoplasty (ileocecal, tubular sigmoid, sigmoid patch and ileal patch) are presented. All 4 operations resulted in a significant increase in bladder volume, with a decrease in filling pressure and, thus, improved vesical compliance. In combination with clean intermittent catheterization renal function was maintained or improved in 91 per cent and urinary continence was achieved in 82 per cent of the patients. Hyperchloremic acidosis requiring therapy was noted only in patients with pre-existing renal insufficiency, although mild hyperchloremia after cystoplasty was seen with all 4 types of cystoplasty. There were no operative mortalities. Significant surgical complications occurred in 36 per cent of the patients, the most common of which was vesicoureteral reflux in the ileocecal cystoplasty. Mass unit peristaltic contractions occurred in 34 per cent of the tubular-shaped bowel segments compared to only 10 per cent of the patch segments. These peristaltic contractions contributed to the greater postoperative morbidity noted in the tubular large bowel cystoplasties. The over-all success rate for intestinocystoplasty in this series was 84 per cent. Intestinocystoplasty is an effective procedure when used to increase the compliance of the lower urinary tract. In combination with clean intermittent catheterization it can be applied successfully to patients with neurogenic bladder dysfunction. Large and small bowel seem to have similar clinical and urodynamic properties. The type of intestinal segment used for intestinocystoplasty seems to be of less importance than the size and configuration. Large bowel in its native tubular configuration should be avoided.

Detubularized sigmoid reservoir for bladder replacement after cystoprostatectomy. Preliminary report of new configuration

A technique for total bladder replacement using a detubularized sigmoid segment is described. The procedure is technically straightforward and results in a highly compliant, low-pressure reservoir that allows both day and night-time continence.

Continent urinary diversion using a sigmoid reservoir

Continent urinary diversions are now accepted procedures for selected patients undergoing cystoprostatectomy. We describe a procedure in which a segment of sigmoid colon is used as a continent reservoir. Effective ureteral antireflux procedures have protected the upper tracts. All patients have good daytime urinary control with some night-time urinary incontinence controlled by condom drainage.

Bladder replacement with sigmoid colon after radical cystoprostatectomy

Sigmoid colon was used to replace the bladder after radical cystoprostatectomy in 10 patients with bladder cancer. A U- or J-shaped segment of the sigmoid colon was anastomosed at the most dependent portion to the urethral stump. The ureters were implanted in each end of the loop via an antireflux tunneling technique. There was no operative mortality, and the complications associated with this form of bladder replacement were minimal. All 10 patients had sensations of filling, and 8 of 10 achieved full daytime continence with complete voluntary emptying. Enuresis was present in all patients and required condom catheters during sleep, which were well tolerated. We believe that a tubular sigmoid segment is an acceptable alternative to tubular ileum or cecum for total bladder replacement.

Sigmoidocystoplasty after total cystectomy for bladder cancer: a follow-up study

Data on 47 patients who underwent sigmoidocystoplasty after total cystectomy for bladder cancer from 1960 to 1979 are presented. The overall survival rates were 53.3 per cent at 5 years and 41.3 per cent at 10 years, respectively. The urethral recurrence of cancer occurred in 8 (17 per cent) patients with bladder neck or multiple cancers. Long-term follow-up studies revealed that hydronephrosis with vesico-ureteral reflux and mild acidosis occurred in some patients, but severe deterioration of renal function was nil. We emphasize that sigmoidocystoplasty should widely be considered for patients with extratrigonal bladder cancers infiltrating but not extending beyond the muscle layer.

Pediatric applications of augmentation cystoplasty: the Johns Hopkins experience

Since 1976, 23 children with bladder or cloacal exstrophy, meningomyelocele, sacral agenesis, the prune belly syndrome and noncompliant bladders associated with urethral valves or prior diversion underwent augmentation cystoplasty. Of these procedures 7 were combined with some type of urinary undiversion. Bowel segments used for augmentation included ileum alone in 10 patients, ileocecal segments in 4, a sigmoid patch in 8 and a hindgut patch in 1. An artificial urinary sphincter was placed at the time of bladder augmentation in 3 patients. There were no urinary fistulas or cases of urinary rediversion. Two patients required oral alkalizing agents as a result of persistent systemic acidosis. One patient required reoperation twice for ureteral obstruction, 1 had removal of the sphincter device secondary to erosion, 1 required reinforcement of the ileocecal valve owing to persistent reflux and 1 required reoperation for small bowel obstruction. Other complications included a superficial wound infection and 5 urinary tract infections, all of which were managed easily. Three patients were voiding and continent, 18 were dry with intermittent self-catheterization, 1 had giggle incontinence and 1 remained incontinent after sphincter removal. Augmentation cystoplasty appears to offer a reliable alternative to urinary diversion in the reconstructive management of children with small capacity bladders.

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.

Intestinocystoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction

Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.

Ileocaecocystoplasty in urinary tract reconstruction in children

Ten children have undergone lower urinary tract reconstruction by ileocaecocystoplasty. Four patients had previously been diverted and the other six were reconstructed because of intractable incontinence or deteriorating renal function. Continence was primarily achieved in eight patients and renal function improved or remained stable in all 10. Reflux was prevented by a plicated ileocaecal valve in five of eight patients. Continued pharmacological manipulation, intermittent self catheterisation and secondary surgical intervention were frequently necessary in these patients who required careful counselling and follow-up.

Transpubic cystectomy and ileocecal bladder replacement after preoperative radiotherapy for bladder cancer

Radical cystectomy was modified by leaving the apical prostatic capsule to facilitate anastomosis of the isolated ileocecal segment to the urethra and to preserve erectile potency. The transpubic approach was used to increase the exposure, and to facilitate dissection and anastomosis. A total of 15 patients with stages T1 to T4 bladder tumors underwent the operation: 13 after preoperative radiotherapy with 4,000 rad and 2 had salvage cystectomy after 6,000 rad. One patient died postoperatively. The remaining 14 patients underwent urodynamic evaluation 3 to 6 months postoperatively. The maximum urine flow rates were almost normal and none of the patients had significant residual urine. Daytime urinary continence was satisfactory in 13 patients and 1 was moderately incontinent. All of the patients were incontinent at night, probably owing to peristaltic contractions in the intestinal bladder and relaxation of the pelvic floor muscles. Preoperatively, 8 patients experienced erections and 7 had intercourse. Postoperatively, erectile potency was preserved in 4 patients and 3 had sexual function. No orthopedic disability occurred postoperatively. The median followup was 20 months, with a range of 3 to 30 months. There have been no local recurrences. A year postoperatively 6 of 9 patients had sterile urine. This technique makes it possible to avoid a urinary stoma, to obtain satisfactory voiding and urinary continence in almost all cases, and to preserve sexual function in some patients after cystectomy.

Nonrefluxing ureteroileal cystoplasty for bladder augmentation or replacement of ureters: long-term results of own technique

The technique of a nonrefluxing end-to-end ureteroileal anastomosis is described. The conjoined ends of both ureters are formed into a 4 to 5 cm. long ureteral tube that is placed loosely into the bowel lumen. Increased intraluminal pressure during micturition closes the valve by compressing the ureter wall from outside, thus, preventing reflux. An end-to-end enteroureteral anastomosis has been used in 32 ileal or colon conduits and in 6 patients with ureteroileal cystoplasty. The followup (range 1 to 15 years) of these 6 patients who underwent bladder augmentation or ureteral replacement is presented. Based on this experience, this type of anastomosis appears to be fast and safe, without urine leakage, stenosis or reflux. The nonrefluxing safety valve mechanism makes this anastomosis applicable for bladder augmentation, with no ill-effects and good long-term function.

Augmentation ileocystoplasty in neuropathic bladder

Augmentation cystoplasty is a viable treatment modality in patients with neuropathic bladder. Indications include incontinence despite pharmacologic manipulation, persistent hydroureteronephrosis, vesicoureteral reflux, and propantheline bromide intolerance. Eight patients have had augmentation cystoplasties, with all obtaining normal bladder capacity, intravesical pressure, and voiding frequency. Reflux and hydronephrosis have been eliminated or significantly reduced in those patients who had experienced those problems prior to augmentation. Four cases are presented.

Bladder augmentation in the pediatric neuropathic bladder

Augmentation enterocystoplasty was used as an aid to reconstruction of the urinary tract and undiversion in 14 children with neurogenic bladder dysfunction. The long-term results have been excellent in children in whom an effective program of clean intermittent catheterization has been possible. The elements and the importance of the preoperative evaluation are discussed.

Bladder reconstruction in rabbits with glutaraldehyde-stabilized amniotic membranes

Glutaraldehyde-treated human amniotic membranes were used to repair rabbit bladders after supratrigonal cystectomies. The membranes maintained the integrity of the bladders until healing and reepithelialization occurred. There was no significant loss of bladder capacity or decreased renal function postoperatively. Calcification did not occur on the membranes but was noted on chromic sutures retaining the membranes in 7 of 27 bladders. These findings suggest that glutaraldehyde-stabilized amnion is well tolerated by the urothelium and may serve as a suitable material for replacement of genitourinary tissues.

Function of the intestinal substituted bladder

Bladder function of 15 patients treated with total cystectomy, subtotal cystectomy or bladder resection, combined with sigmoidal, caecal or ileal cystoplasty, was evaluated with synchronous bladder pressure-flow-electromyography studies. Micturition was good or satisfactory in 14 patients. Eight patients had nocturnal incontinence. Bladder-sphincter dyssynergia of varying degree impaired the function of the intestinal substituted bladder in 9 patients. However, in selected cases intestinal cystoplasty is the best solution for retaining the normal way of voiding. After total cystoprostatectomy it is possible to replace the motor function of the bladder with sigmoidal cystoplastic substitution of the bladder. Patients with sigmoidal bladders also gradually developed sensations of fullness closely simulating those of their earlier bladders.

Evolution of the rectal bladder as a method for urinary diversion

A critical analysis of previous reports reveals 2 main drawbacks of the rectal bladder: 1) recurrent pyelonephritis with subsequent loss of renal function (30 per cent) and 2) nocturnal urinary leakage (40 per cent). In a randomized prospective study the role of a submucosal tunnel for prevention of reflux was evaluated. We demonstrated objectively that this technique could provide a patent unidirectional flow of urine in the majority of cases (82.5 per cent). Urodynamic measurements, including flowmetry, rectal pressure and anal electromyography activities, indicated that the driving force for voiding is the voluntary increase of the intra-abdominal pressure rather than the intrinsic contractions of the smooth muscles of the rectum. Accordingly, attempts at control of nocturnal urinary leakage were directed towards increasing the resistance offered by the pelvic floor. The efficiency of imipramine hydrochloride to achieve this goal was tested against a placebo in a clinical trial performed in a prospective randomized fashion. This treatment was effective in the control of enuresis in a significant number of patients (75 per cent). We conclude that the rectal bladder with a terminal colostomy is a highly recommended method for permanent urinary diversion when these 2 modifications are used.

The role of bladder augmentation in undiversion

Twenty-nine pediatric patients underwent bladder augmentation as part of their urinary undiversion. Indications included spina bifida deformity, contracted small bladder, and extrophy. Cecal and sigmoid segments were used. Prior diversion included ureterointestinal conduits, vesicostomies, ureterostomies, and suprapubic catheter drainage. In most cases the renal function was normal. Intermittent catheterization is used in almost every cases. Several illustrative cases are shown.

Urinary tract diversion and undiversion in the pediatric age group

Undiversion is an interesting phenomenon but may in part be self-limiting. As the experience with techniques in reconstruction increases, the need for diversion may give way to that of earlier correction of the original pathology, Thus, reversal of diversion by offering a wealth of experience in reconstruction may well lead to its own demise. Nevertheless, even with newer reconstructive techniques, there is, to date, a definite place for diversion of the urinary tract in the pediatric age group and there are now many pediatric patients still to be considered candidates for undiversion

Dynamics of obstruction in acontractile bladder: attempt at management

Five patients with acontractile bladders were observed during lateral voiding cystourethrography in the resting and straining states. Two abnormalities were noted: (1) posterior displacement of the bladder with closure of the posterior vesicourethral angle on straining, and (2) plication of the bladder over the symphysis pubis, resulting in the formation of an anterior pseudodiverticulum. Two other abnormalities are discussed: closure of the anterior vesicourethral angle, and descent of the bladder and prostate in flaccid paraplegia, causing plication at the prostatic apex. Surgical techniques for the correction of the abnormalities are described.

Undifferentiated sarcoma arising in an augmented ileocystoplasty patch

We report an unusual case of a sarcoma at the patch site of an ileocystoplasty. The tumor proved to be an aggressive neoplasm that metastasized widely. The literature is reviewed concerning neoplasms occurring in urinary diversion procedures.

Cecocystoplasty for bladder augmentation

Augmentation of the bladder by cecocystoplasty has been studied in 37 patients during a 15-year period. The indications for an operation were a small contracted bladder secondary to tuberculosis in 31 cases, interstitial cystitis in 5 and carcinoma of the bladder in 1. Results were studied by the assessment of symptomatic improvement, the effect on renal function, urinary tract infection and the postoperative complications. Urodynamic studies also were done on 23 patients with tuberculosis of the renal tract and the results are discussed. Azotemia was not a contraindication to an operation but patients with enuresis or those who have evidence of psychiatric disturbance should be assessed carefully.

"Undiversion" with colocystoplasty for neurogenic bladder. A report of 2 cases

The encouraging success of partial replacement of the bladder for interstitial cystitis and for contracted bladder due to tuberculosis, and the relative success of total bladder replacement for carcinoma, prompted an attempt to reconstruct a bladder in 2 patients with neuropathic bladders, who had problems with their ileal conduit and, thus, "undivert" them. Bladder reconstruction in these patients was performed using a modified technique of colocystoplasty. One of the patients has had 2 normal pregnancies since colocystoplasty.

Bladder augmentation--a long-term review

Fifty-nine patients who had undergone augmentation cystoplasty were studied over a period of 18 years. The indications for the operation were a tuberculous contracted bladder in 51, interstitial cystitis in 7 and carcinoma in 1. The ileum was used in one patient, the colon in 16 and the caecum in 42. The results did not seem to be influenced by the segment of bowel and the long-term results of using the colon as bladder substitute were similar to those achieved by using the caecum. An excellent result has been achieved in 78% of the 49 surviving patients. Operative mortality was 5.1% (3 patients). Contraindications include progressive severe renal failure, enuresis and a history of previous psychiatric disturbance.

Results of caecocystoplasty for tuberculous bladder contracture

The results of caecocystoplasty for tuberculous bladder contracture in 30 patients over a 15-year period are presented. The operative mortality was 3.3%. Poor renal function was not a contraindication to surgery. The results indicate that caecocystoplasty provided relief of symptoms in over 90% of patients. Renal function was preserved and associated obstructive uropathy was usually relieved. Efficient cystoplasty emptying was observed in 80% of patients if detrusor resection was kept to the minimum consistent with a wide caecovesical anastomosis.

Experiences with colocystoplasties, cecocystoplasties and ileocystoplasties in urologic surgery: 40 patients

During the last 16 years (1960 to 1976) we have treated 78 patients with a contracted bladder syndrome, 40 of whom have been treated surgically by replacing part or all of the bladder with an isolated segment of rectosigmoid, cecum or ileum. The series is a combination of 30 patients treated by Shirley in the United States and 10 patients by Mirelman in South America. Chronic interstitial cystitis (26 cases) and chronic radiation cystitis (4 cases) have been the primary causes for surgical treatment of the contracted bladder in the United States, whereas tuberculosis of the urinary tract was the primary etiologic factor for those treated in South America. The results have been gratifying, with 50 per cent excellent and 30 per cent good. Only 3 patients have had to be diverted to and outside colon or ileal conduit. Generally, our results with each type segment of large and small bowel have been satisfactory by the choice of segment must depend on the degree of bladder disease, and the medical and urologic condition of the patient.

Partial replacement of urinary bladder by autologous gallbladder

In an effort to find a more suitable method of partial urinary bladder replacement for those patients with either a damaged or contracted bladder, the use of the autologous gallbladder was studied. The urinary bladders of 6 female dogs were partially resected, and the defective portions were replaced by autologous gallbladder transplants. After six weeks, the gallbladder mucosa showed evidence of squamous cell metaplasia progressing toward transitional cell epithelium with minimal necrosis. The muscular layer showed extensive granulation tissue and revascularization. No changes were detected in the upper urinary tracts. No mortality or detectable morbidity was associated with the procedure. It appears that the gallbladder may have a role to play in partial urinary bladder replacement.

Augmentation enterocystoplasty: a critical review

Augmentation cystoplasty appears to offer a successful long-term solution for patients with small contracted bladders of almost any etiology. If proper indications are observed the procedure is well tolerated. With refined urodynamic diagnostic techniques our over-all failure rate of 35 per cent can be expected to decrease. Contraindications of the procedure include azotemia (creatinine clearance less than 40 cc per minute), vesical malignancy, neurogenic bladder with spastic pelvic floor (that cannot be modified) and young boys (mucus problems). In addition, patients with a strong psychiatric history should be approached with caution. The non-functional contracted bladder in which the cause of prior diversion is unclear or was performed because of an apparent outflow obstruction that spontaneously has been corrected by rest during the period of supravesical diversion also should be approached with care.

Final results of Coffey's ureterosigmoidostomy in noncarcinomatous diseases

The present report on 67 patients, in whom a ureterosigmoidostomy was performed on the ground of a benign indication, is to take a critical attitude towards ureterosigmoidostomy. In about 60 per cent of the cases satisfactory or good results can be achieved. Final comparisons with other methods of derivation cannot be made, since a sufficiently great number of late results is not yet available. In our opinion, it is doubtful if there will ever be an alternative. The operator's judgment and experience will always play an important role. Certainly the results can be improved by a lifelong close observation of the patients.

Blow out of a colocystoplasty loop owing to bladder neck obstruction

A case of blowout of the colonic segment of a colocystoplasty at its free end owing to late development of bladder neck obstruction is described. Prostatitis and secondary bladder neck contracture provided further hindrance to the already inefficient voiding mechanism and predisposed to the rupture of the decompensated bowel loop. This is an extreme example of proof that the colonic loop, except as an improved substitute for an ileal segment, cannot withstand high intraluminal pressures generated in the presence of bladder outlet obstruction.

Experience with the ileal ureter

The isolated ileal loop often provides a satisfactory solution to the problem of extensive ureteric defects. Our experience in 18 cases of diseased ureters partially or totally replaced by isolated ileal loops is presented. The indications for the operation and important operative and preoperative details are discussed. The operation presents a definite method for renal conservation in many cases in which nephrectomy would otherwise have been unavoidable.

Ureteroileourethrostomy: 16-year followup

Ureteroileourethrostomy has been abandoned at our institution for replacement of the bladder because: 1) it compromised the cancer operation and 2) upper urinary deterioration forced conversion to ureteroileocutaneous diversion in 2 of 3 patients. The ureteroileourethrostomy may have future application if all of the prostate is removed when cystectomy is necessary for bladder cancer. The urinary retention can be satisfactorily managed with clean, intermittent self-catheterization. The hyperchloremic metabolic acidosis can be satisfactorily managed by reducing residual urine and potassium citrate administration. The upper urinary tract changes can be partially or wholely prevented with antirefluxing ureteroileal anastomoses.