Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 1. Glomerular filtration rate and patency of uretero-intestinal anastomosis

Outcome of patients with continent urinary reconstruction and a solitary functioning kidney

OBJECTIVE

To evaluate the outcome of patients with continent urinary diversions who had a solitary functioning kidney at the time of surgery.

PATIENTS AND METHODS

In all, 62 patients with continent urinary reservoirs and a solitary functioning kidney were reviewed (51 men and 11 women). The indications for surgery were bladder cancer in 54 and a contracted bladder in eight. The surgical procedures included an orthotopic ileal neobladder in 36 patients, a continent cutaneous ileal reservoir in 13 and rectal diversion in 13. Kidneys were evaluated using serum creatinine level, ultrasonography, intravenous urography and other radiological studies.

RESULTS

The follow-up was 6-173 months; 44 renal units (71%) remained stable during this period. Serum creatinine was increased in four patients with an orthotopic neobladder, with no evidence of obstruction or reflux, in one with preoperative renal impairment and one with voiding dysfunction, reflux and bacteriuria. Six renal units deteriorated because of uretero-intestinal strictures; of these patients, two were treated endoscopically, two with open ureteric reimplantation, one with conversion from a rectal reservoir to an ileal loop conduit, and one was maintained on JJ stenting. Six patients with a rectal diversion had renal deterioration because of chronic pyelonephritis.

CONCLUSIONS

A regular follow-up of renal function is mandatory in patients with a continent urinary diversion. Rectal diversion is associated with a higher risk of renal deterioration (54%) than are orthotopic (28%) and cutaneous reservoirs (8%).

[Uretero-intestinal anastomosis. Our experience. The simpler... the better]

INTRODUCTION

There are many techniques describe for ureteroenteric anastomoses. We present our experience with three of them inorder to reduce the stenosis rate.

METHOD AND MATERIAL

We have done radical cystectomy in 77 patients. Urinary diversion with small bowel in 20 patients (Paduana ileal neobladder) and dstubulized ureterosigmoidostomy (MainzII) in 55. Initially, we used Le Duc technique, afterward Ricard technique and actually bivalva technique (direct).

RESULTS

We have performed Le Duc in 38%, Ricard in 31% and "bivalva" in 27%. Median follow-up are 37.7 months, 19.9 months and 10 months respectively. Stenosis: 16.7% with Le Duc; 20.5% with Ricard and 9.1% with bivalva technique. Renal anulation: 10.4% with Le Duc; 10.3% with Ricard and 0% with bivalva (p .000).

CONCLUSIONS

In our experience, the less stenosant anastomose is BivalvaIn one. The simpliest technique, the best results. The rate of stenosis is higher when the upper urinary tract is dilatated pre-surgery, independently of the anastomosis technique.

Continent urinary tract reconstruction - the Lund experience

The Department of Urology in Lund, Sweden, has a long association with innovations in reconstructive urology. The authors from that department describe their experience over a long period with orthotopic bladder substitution and continent cutaneous urinary diversion. They conclude that continent urinary tract reconstruction is associated with a high incidence of early and late complications. They also found that for storage and emptying, their Lundiana pouch was superior to the Goldwasser neobladder.

OBJECTIVE

To assess the early and late complications and functional results in patients undergoing continent reconstruction of the urinary tract, i.e. orthotopic bladder substitution (OBS) or continent cutaneous diversion (CCD).

PATIENTS AND METHODS

The medical records of all patients undergoing OBS (Goldwasser technique) or CCD ('Lundiana' technique) for malignant or benign disease during 1987-1999 and followed to December 2001 were reviewed. There were 67 patients with neobladders, 77 with a Lundiana pouch who had undergone radical cystectomy and 22 with a Lundiana pouch operated for benign disorders.

RESULTS

Early complications requiring reoperation occurred in 12% of the cystectomy group, with no difference with type of reconstruction, and in 10% with benign diseases. Four patients (3%) undergoing radical cystectomy died from early cardiovascular complications, two after surgery for intra-abdominal complications. Intestinally related complications and wound dehiscence requiring re-operation occurred in nine and six patients, respectively. The incidence of late complications requiring open surgery was 22% and 23% after cystectomy with OBS and CCD, respectively. The value in patients with benign diseases undergoing CCD was also 23%. Stone formation in the pouch was common, occurring in 12% in patients with OBS and in 10% after CCD. The pouch perforated or ruptured in four patients. The incidence of uretero-intestinal stricture using the Le Duc technique was 2.4% and renal function was well preserved. The incidence of revisional surgery of the Lundiana pouch outlet for incontinence was low and all patients but four were continent. The functional outcome in patients with OBS was less good; some needed pouch augmentation or an artificial urinary sphincter. Most patients used incontinence products and many needed clean intermittent self-catheterization.

CONCLUSION

Continent urinary tract reconstruction is associated with a high incidence of early and late complications. For storage and emptying, the CCD Lundiana pouch is superior to the OBS of Goldwasser.

Long-term outcome of ileal conduit diversion

PURPOSE

Ileal conduit is considered a safe procedure and the gold standard to which newer forms of urinary diversion should be compared, although few long-term results are known. We analyzed a consecutive series of patients who lived a minimum of 5 years after ileal conduit diversion.

MATERIALS AND METHODS

A total of 412 patients underwent ileal conduit diversion between 1971 and 1995 at our institution. We analyzed all conduit related complications occurring later than 3 months after surgery in 131 long-term survivors (survival 5 years or greater).

RESULTS

Median followup was 98 months (range 60 to 354). Overall 192 conduit related complications developed in 87 of 131 (66%) patients. The most frequent complications were related to kidney function/morphology in 35 patients (27%), stoma in 32 (24%), bowel in 32 (24%), symptomatic urinary tract infection (including pyelonephritis) in 30 (23%), conduit/ureteral anastomosis in 18 (14%) and urolithiasis in 12 (9%). Within the first 5 years complications developed in 45% of patients. This percentage increased to 50%, 54% and 94% in those surviving 10, 15 and longer than 15 years, respectively. In this last group 50% had upper urinary tract changes and 38% had urolithiasis, for which the respective numbers after 5 years were 12% and 17%.

CONCLUSIONS

This study demonstrates a high conduit related complication rate in long-term survivors and underlines the need for vigorous long-term followup. Only studies lasting more than 1 decade cover the entire morbidity spectrum.

Valor del renograma isotópico diurético en el seguimiento de la vía urinaria superior tras cistectomía y derivación urinaria con intestino

INTRODUCTION

In our experience we often observe urinary upper tract dilatation after urinari diversion with bowel. To spare useful approaches and therapeutics we have used diuretic renogram.

MATERIAL AND METHOD

26 patients with urinary diversion (Mainz II or Paduana ileal neobladder). We performance ultrasound, urography and diuretic renogram.

RESULTS

Follow-up is between 1 y 4 years. After urinary diversion, 54% of the upper tracts are dilated but only 39.3% of them are obstructed in the diuretic renogram. Normal urographic tracts are normal or have good response in the diuretic renogram. Results goes on in the time.

CONCLUSIONS

Diuretic renogram is a useful tool in the diagnosis of upper urinary tract obstruction after urinary diversion.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group's specialised register (3 May 2001), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2001), MEDLINE (1966 to May 2001), PREMEDLINE (4 June 2001), Dissertation Abstracts (18.6.2001) and the reference lists of relevant articles. Date of most recent search: June 2001.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for methodological quality by the reviewers. Three reviewers were involved in the data extraction. The data collected was then analysed for statistical significance.

MAIN RESULTS

Two trials met the inclusion criteria with a total of 164 participants. These trials addressed only four of the 14 comparisons pre-specified in the protocol. There were no statistically significant differences found in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. There was no evidence of a difference in incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions. The confidence intervals were all wide, however, and did not rule out important differences. There was some limited evidence that use of the more complex nipple valve at the ureteroileal anastomosis was more likely to lead to upper tract deterioration than implantation into a non-detubularised, isoperistaltic ileal afferent limb.

REVIEWER'S CONCLUSIONS

The evidence from the included trials was very limited. Only two studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

A nonrefluxing, serous lined extramural tunnel for ureteroileal anastomosis in ileal conduit urinary diversion: first clinical experience in 10 patients

PURPOSE

We report the surgical technique and functional outcome of a new application for serous lined, anti-refluxing ureteroileal anastomosis in ileal conduit urinary diversion. Reflux prevention relies on the construction of a serous lined extramural ileal tunnel.

MATERIALS AND METHODS

A 25 cm. distal ileal segment was isolated. The proximal 7 cm. of the ileal segment was folded and the 2 proximal 7 cm. segments were joined by seromuscular sutures. The antimesenteric borders of these 7 cm. segments were incised and the medial edges of each ureter were joined. A mesenteric window was opened at the level of ileal folding and the ureters were passed through it. They were inlaid within the trough and the conjoined ureteral end were anastomosed to the intestinal mucosa. The tunnel was then closed over the implanted ureters. The lateral limbs of the detubularized ileal segment were then joined. The technique was performed in 10 patients with a mean followup of 9.9 months (range 3 to 19). The patients were evaluated clinically and radiologically.

RESULTS

None of the 10 patients had reflux on x-ray of the loop. One patient had previously undergone unilateral nephrectomy. Excretory urography showed a stabilized or improved upper tract in 18 renal units. Left ureterohydronephrosis was present in 1 renal unit because of ureteroileal stenosis.

CONCLUSIONS

The initial clinical results of the serous lined extramural ileal tunnel technique for ureteroileal anastomosis in ileal conduit cases are promising. The technique appears effective and reliable.

Orthotopic bladder substitution after radical cystectomy: 5 years of experience with a novel personal modification of the ileal s pouch

PURPOSE

We report a 5-year experience with 52 patients who underwent radical cystoprostatectomy for bladder cancer and orthotopic bladder substitution using a novel personal modification of the S pouch.

MATERIALS AND METHODS

From September 1995 to December 1999, 52 men 36 to 72 years old (mean age 63) underwent bladder substitution with an S pouch. They were followed until September 2000. The pouch was constructed with a 36 cm. segment of ileum with the whole length used for the reservoir. The ureters were directly anastomosed with one above the other in the mid segment of the pouch without any antireflux procedure. Complications were documented and classified as early or up to 3 months postoperatively and late, and further subdivided by the relationship to neobladder construction. Continence and voiding pattern were evaluated by personal interview and neobladder function was urodynamically assessed. Mean followup in our patients was 30 months.

RESULTS

The most common of the 5 early and 9 late neobladder related complications were persistent urine leakage and reflux, respectively. There was no reflux greater than grade III in the 4 patients with reflux (5 refluxing ureters) and no functional disorders. We observed 12 early and 5 late complications unrelated to the neobladder. Open reoperation was required in 5 cases. Good or satisfactory daytime and nighttime continence was reported by 95% and 88% of our patients, respectively. By year 1 postoperatively 91% of our patients voided at an interval of 3 to 5 hours during the day. Mean maximum neobladder capacity was 672 ml. and mean post-void residual was 30 ml. by year 3 postoperatively. Two patients required self-catheterization once daily and mild hyperchloremia without acidosis developed in 2.

CONCLUSIONS

The advantages of our modified S pouch are technical simplicity, substantially shorter operative time and decreased bowel length required. It is associated with an acceptable complication rate and functional parameters with subsequent patient satisfaction and good quality of life.

Continent urinary diversion in preparation for renal transplantation: a staged approach

BACKGROUND

We prospectively assessed the safety of kidney transplantation into continent urinary intestinal reservoirs as a planned two-stage procedure in patients with absent or dysfunctional lower urinary tract.

METHODS

Between November 1990 and June 1999, 12 patients have undergone renal transplantation into continent urinary reservoirs, and a further patient with a diversion is awaiting transplantation. This was part of a larger series of 356 patients who had undergone continent diversions during that period. A further 174 patients (33%) had diversions into ileal conduits.

FINDINGS

Within a mean follow-up of 26.1 months (5-72) after transplantation renal function was stable with serum creatinine values ranging from 0.9 to 1.8 mg/dl. There were 5 reoperations in the 12 patients (40%). Two patients needed their continence mechanism replaced. One had renal vein thrombosis with loss of the transplant. The cause for this was unknown but it had been speculated that it could have been caused by graft/body size disproportion. A second kidney was successfully transplanted after 12 months. Two further revisions were required for ureteric kinking and lymphocele. The patient with orthotopic substitution voids to completion. The other patients are continent day and night with easy catheterization.

INTERPRETATION

This is one of the largest single series reported to date of renal transplantation into continent urinary diversions, and we commend the approach in carefully selected patients, but the difficulties must not be underestimated and the specific problems of intestinal urinary reservoirs have to be reckoned with. These procedures should be confined to centers with considerable experience with this type of surgery and its complications. Lifelong close surveillance is critical for the success of this concept.

The effect of intestinal urinary reservoirs on renal function: a 10-year follow-up

OBJECTIVE

To study the effect of the storage of urine in intestinal reservoirs on long-term renal function and the possible causes of deterioration.

PATIENTS AND METHODS

Eighty-seven patients (aged 4-35 years) with bladder exstrophy who underwent reconstruction of the lower urinary tract using a bowel segment were enrolled in a prospective protocol. The glomerular filtration rate (GFR) was measured before and after surgery at 1, 2, 5 and 10 years using 51Cr-ethylenediamine tetra-acetic acid. Patients with a decline in GFR of > 5% were investigated to identify the cause.

RESULTS

Of 58 patients with a follow-up of > or = 10 years, 53 were evaluable, four having been lost to follow-up and one refusing to accept the protocol. In these 53 patients, the mean (SD) GFR decreased from 97. 9 (20.4) to 92.9 (23.6) mL/min/1.73 m2 (P = 0.24). However, this decrease was accounted for by 10 patients (19%) whose GFR fell by > or = 20% over the 10 years. The causes of renal deterioration in these 10 patients were; chronic retention and/or infection caused by inadequate catheterization in poorly compliant patients (five), uretero-ileal stenosis (one), a high-pressure reservoir (one) and uncertain causes (three).

CONCLUSIONS

For 80% of the patients, the storage of urine in intestinal reservoirs did not change renal function for at least 10 years. However, approximately 20% of patients had some deterioration in renal function during the 10-year follow-up, usually from identifiable and remediable causes. The storage of urine in bowel does not appear to be inherently damaging to kidney function. Patients with an enterocystoplasty need regular monitoring of renal function; when deterioration is detected the urinary tract must be functionally assessed.

Ureteroenteric anastomosis in continent urinary diversion: long-term results and complications of direct versus nonrefluxing techniques

PURPOSE

Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion.

MATERIALS AND METHODS

Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months.

RESULTS

Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia.

CONCLUSIONS

Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.

A study of reflux in patients with an ileal orthotopic bladder

OBJECTIVE

To determine whether there is vesico-ureteric reflux during voiding in patients who had undergone an ileal bladder substitution after cystectomy.

PATIENTS AND METHODS

The study comprised 15 patients (13 men and two women) who had undergone radical cystectomy and construction of a Studer ileal neobladder. At 1-24 months (median 4) after the operation indirect radionuclide cystography (IRC) was performed after isotopic renography (using 99m-technetium mercapto-acetyltriglycine) and voiding cysto-urethrography (VCUG).

RESULTS

None of the patients had reflux during voiding, either on IRC or on VCUG. Renal function and morphology remained stable in all patients. Despite bacteriuria occurring in four patients, no episode of pyelonephritis was reported.

CONCLUSION

There was no vesico-ureteric reflux during voiding in patients with a Studer ileal bladder substitution. However, long-term follow-up is needed to finally determine whether an antirefluxive ureteric implantation is required to protect the upper urinary tract in patients with ileal low-pressure bladder substitutions.

Reflux, stricture and glomerular filtration rate after two antireflux techniques in continent urinary reconstruction using the right colon

In the present study the incidence of reflux, stricture formation and changes in glomerular filtration rate in patients with the submucosal tunnel or the Camey-Le Duc technique of ureteric implantation into the caecum/detubularized right colon used for continent cutaneous diversion/orthotopic bladder substitution was investigated. Reflux was found in two renal units and ureterointestinal stenosis occurred in five renal units after submucosal tunnel ureteric implantation. After Camey-Le Duc ureteric implantation, one renal unit showed reflux and none had stenosis of the ureterointestinal anastomosis during follow-up. Mean glomerular filtration rate (ml/min/1.73 m2) fell from 98 to 85 in the submucosal tunnel group and from 88 to 81 in the Camey-Le Duc group after mean follow-ups of 9 and 5 years, respectively. Both methods of ureteric implantation in this study were effective in preventing reflux, and renal function was well preserved in both groups. The absence of ureterointestinal strictures in the Camey-Le Duc group is encouraging and indicates that this is a reliable method for reflux prevention.

Twenty-year experience with jejunal conduits

OBJECTIVES

To assess the results of jejunal conduit urinary diversion, with particular attention to electrolyte imbalance and long-term renal function.

METHODS

From 1976 to 1994, 50 patients underwent urinary diversion using a short jejunal loop (10 to 12 cm) placed transperitoneally. Of these patients, 18 received pelvic irradiation before diversion. Renal function and configuration of the upper urinary tract were assessed by creatinine clearance and excretory urography.

RESULTS

Median follow-up was 26 months (3 to 204). Of 50 patients, 22 had a follow-up more than 5 years later (median 86 months). Eight patients (16%) underwent 10 revision procedures postoperatively. Late complications related to urinary diversion included renal calculi (12%), parastomal hernia (6%), pyelonephritis (4%), ureterojejunal obstruction (4%), and stomal prolapse (2%). Electrolyte imbalance occurred in 2 patients (4%) and was easily corrected by 4 g sodium bicarbonate. No significant decrease in creatinine clearance (P = 0.6) was found in 22 patients with a follow-up of more than 5 years; however, of these patients, 2 had a decrease in creatinine clearance of greater than 20%, due to ureterojejunal obstruction. Of 42 ureterorenal units, hydronephrosis occurred and increased in 1 and 2 cases, respectively, and renal scarring occurred and progressed in 2 and 2 cases, respectively.

CONCLUSIONS

Urinary diversion using a short length of jejunum placed transperitoneally is a reliable procedure and gives good long-term renal function. Electrolyte imbalances are rare. Moreover, jejunal conduit can be used in almost all situations, especially after pelvic irradiation.

Renal function up to 16 years after conduit (refluxing or anti-reflux anastomosis) or continent urinary diversion. 2. Renal scarring and location of bacteriuria

OBJECTIVE

To evaluate the importance of refluxing versus anti-reflux ureteric implantation for the development of renal scarring in patients with a conduit or continent urinary diversion and for the incidence of bacteriuria in the upper urinary tract of patients with a conduit.

PATIENTS AND METHODS

Renal scintigraphy using 99mTc-dimercaptosuccinic acid was performed on 32 of 37 evaluable patients from a prospective, randomized study at a mean of 150 months (range 102-198) after urinary diversion. In five patients with a conduit diversion and unilateral renal scarring, urine was samples for culture from the proximal end of the conduit and from both renal pelvices by direct percutaneous aspiration.

RESULTS

Of 35 renal units (18 patients), studied after conduit diversion, scarring was found in 11 (two grade I, six grade II and three grade III) of 17 with refluxing anastomosis and in six (one grade I, four grade II and one grade III) of 18 with anti-reflux anastomosis (P = 0.06). Of 25 renal units (14 patients) after continent diversion, 16 showed scarring (seven grade I and nine grade II). Bacteriuria was found in four of five upper urinary tracts with a refluxing anastomosis, but in only one of five with an anti-reflux anastomosis. In these five patients scarring was present in all kidneys with refluxing anastomosis.

CONCLUSION

Anti-reflux ureteric anastomosis seems to be important for preventing scarring and bacteriuria in the upper urinary tract of patients with a conduit urinary diversion. Despite the anti-reflux technique of ureteric implantation, most patients with a continent reservoir had renal scarring, though it was generally less severe than in patients with a conduit urinary diversion.