Urinary Reservoirs. In: Ashken MH, editor. Urinary Diversion. London: Springer; 1982. pp. 112-39. [DOI: 10.1007/978-1-4471-1320-1_6]

Relative indications for orthotopic lower urinary tract reconstruction, continent urinary diversion and conduit urinary diversion

Continent urinary diversion has become increasingly popular in the last few years and there are now several situations in which ileal conduit diversion, continent diversion and orthotopic reconstruction of the lower urinary tract are equally valid options. This review was intended to determine specific indications for each. Of 513 patients treated for severe lower urinary tract problems in the last 10 years, 399 underwent orthotopic reconstruction, 68 underwent continent diversion and 46 had an ileal conduit. Problems occurred 2 to 3 times more commonly in the continent diversion group than in either of the other groups. Given a free choice, most patients would choose an orthotopic reconstruction and this should probably be regarded as the gold standard. Continent diversion is specifically indicated in male patients who require a total cystourethrectomy for bladder cancer, in severe post-radiotherapy problems, and in patients with neuropathic bladder dysfunction in whom, for various reasons, self-catheterisation is impossible. Ileal conduit diversion remains the simplest and safest technique in high-risk patients and does not preclude a subsequent continent diversion or orthotopic reconstruction.

Clam ileocystoplasty

Clam enterocystoplasty has been used successfully in the treatment of refractory urge incontinence. We report 31 patients who underwent ileocystoplasty between 1982 and 1989. The majority of patients were pleased with the outcome of the operation. The main post-operative complication was voiding dysfunction due to relative bladder outflow obstruction. Urinary tract infection and mucus production were significant long-term problems.

Secreto-motor function of intestinal segments used in lower urinary tract reconstruction

Mucus excretion, sialic acid excretion and secretory IgA (sIgA) production from patients with a substitution caecocystoplasty (20), augmentation "clam" ileocystoplasty (20) or ileal conduit (10) were measured. Significant amounts of all of these substances were present in the urine of reconstructed patients and showed no evidence of diminution with time. Motility was studied by videocystourethrography. In patients with a neuropathic aetiology the amplitude of contractions was significantly increased and produced incontinence. The results demonstrate that intestinal secreto-motor function in gut segments incorporated into the lower urinary tract continues normally and must be taken into account when considering the long-term management of these patients.

Urodynamic aspects of continent urinary diversion. Review

Continence following urinary diversion depends on factors related to the reservoir and outlet. The reservoir should possess good compliance and no or atmost low pressured phasic contractions. The outlet should provide adequate outflow resistance to allow expulsion of urine under voluntary control and at convenient intervals. Overcoming high intra-reservoir pressures by producing high outlet resistance may endanger the upper urinary tracts. There is evidence that a low pressure reservoir may be constructed from any part of the bowel as long as detubularization of the segment is performed. All types of intussuscepted valves possess an inherent tendency to dessuscept despite various techniques which are employed to stabilize them. The causes are discussed and a recently described technique to overcome this problem is reviewed.

Dynamics of a continent caecal reservoir for urinary diversion

Motor activity of the caecal reservoir for urine, and of the intussuscepted nipple valve in the ileal outlet, was studied in seven continent and two incontinent patients by means of a catheter equipped with two microtransducers. The basal pressure was low in the reservoir even at large-volume filling. In the continent patients the basal pressure was always higher in the ileal outlet than in the reservoir. No high-pressure zone was present in the outlet in the incontinent patients. Intermittent pressure waves occurred in the reservoir, and they increased in frequency, duration and amplitude with increasing filling. Pressure waves with higher amplitude arose simultaneously in the outlet. Increasing time from construction of the reservoir was accompanied by decreasing amplitude of the pressure waves, indicating adaptation towards the larger functional capacity of the reservoir. The recorded dynamics seemed to reflect the functional state of the reservoir.

Continent caecal reservoir in urinary diversion

Construction of a continent urinary reservoir was attempted in 18 patients with carcinoma of the bladder. The caecum was used as the reservoir and an intussuscepted ileal nipple was created to provide continence. Fifteen patients are alive and have been observed for 7 to 68 months. The most common complication was malfunction of the nipple valve with urinary leakage and/or difficulty in catheterisation. Revision of the outlet was performed one or more times in 11 cases. The technique of nipple valve construction was successively evolved, with improvement in the functional results. Stricture of one uretero-intestinal anastomosis occurred in three patients. Construction of a continent caecal reservoir is a complex procedure and the problem of a stable, continence-ensuring mechanism in the outlet has not been conclusively solved. The enhanced quality of life offered by a successful continent reservoir nevertheless warrants continued clinical trials in selected patients.

[Bladder replacement by a continent ileocolonic intestinal reservoir wih antireflux-plasty--experimental study in the dog]

The purpose of this experimental study was to try to develop a continent appliance-free urinary diversion with a non-refluxing urinary reservoir to be emptied by intermittent catheterization. A reliable antireflux plasty can be performed only on the large bowel wall. Continence can only be achieved using small bowel. For these reasons an ileo-colic urinary reservoir was conceived and experienced in 20 beagle dogs of both sexes. The posterior wall of the reservoir is formed by an intestinal plate constructed with two ileal loops. Continence is achieved by intussuscepting the terminal ileum in a retrograde fashion into the reservoir for a distance of 5 cm, thus creating a competent nipple valve between the pouch and the ileostoma. The anterior wall of the reservoir is formed using a colonic plate obtained by dividing the excluded sigmoid colon at the antimesenteric border. A long submucuous tunnel is created in the colon in which to lay the ureter. Thus renal infection and chronic pyelonephritis are avoided. Continence of the stoma is both socially and economically acceptable and improves the quality of life.

Renal function after urinary diversion. A study of continent caecal reservoir, ileal conduit and colonic conduit

Total and separate renal function, renal parenchymal thickness and dilatation of the upper urinary tract were studied in 40 patients preoperatively and 24 to 67 months after urinary diversion, using 51Cr-EDTA clearance test, scintillation camera renography and urography. In ten patients a continent caecal reservoir was used for diversion. In the other patients, an ileal or a colonic conduit (15 patients with each method) was used, one ureter being implanted with an anti-reflux method and the other with direct technique. Renal function following urinary diversion showed little or no deterioration in most patients. The functional outcome was not related to the method of diversion or, in the conduit groups, to the mode of ureteral implantation. Serum creatinine tests and urography were not adequate for determining loss of renal function. Radionuclide studies proved to be valuable for assessing renal function after urinary diversion.