Continent urinary diversion: review of the intussuscepted ileal valve

The uretero-ileoceco-proctostomy (ileocecal rectal bladder): early experiences in 18 patients

With the current practice of continent urinary diversion the patient still has a cutaneous stoma and must perform intermittent catheterization. To circumvent these problems we devised the uretero-ileoceco-proctostomy (ileocecal rectal bladder), in which the intussuscepted ileocecal segment is interposed between the ureters and rectum, the rectal capacity is augmented by side-to-side anastomosis to the cecal limb of the segment and continence is controlled by the anal sphincter. The interposed segment prevents reflux of the urine-fecal mixture to the upper urinary tract and may decrease the risk of carcinoma at the ureteroileal anastomosis. The intussusception is stabilized without opening the recipient bowel (cecal limb), thus simplifying the subsequent ceco-proctostomy with automatic suture technique. Our preliminary experience in 18 patients with this new technique is encouraging with respect to voiding, preservation of renal function and quality of life.

The functional rectal bladder--prevention of hyperchloremic acidosis following vesico-sigmoidostomy in dogs

Urinary diversion by a vesico-sigmoidostomy was performed in fourteen dogs. The animals were randomly divided into two groups. Group 1 had an isoperistaltic intussusception of the sigma proximal to the vesico-sigmoidostomy. Group 2 was used as control without intussusception. In the postoperative course, serum creatinine, chloride, pH, bicarbonate, base-excess were controlled over a period of four months twice weekly. Additionally, IVPs were taken in all dogs and rectograms performed in the intussuscepted group. While IVPs and creatinine values demonstrated normal postoperative kidney function in all dogs of both groups, acidbase parameters including chloride were significantly (p less than 0.001, Wilcoxon test) better in group 1. Intussusception of the sigmoid colon is a reliable operative way to significantly reduce hyperchloremic acidosis in the course of urinary diversion into the sigmoid colon, while the fecal stream remains undisturbed.

Urodynamic and clinical outcome of Kock pouch continent urinary diversion

Urodynamic studies of the Kock pouch were conducted in 20 patients 3 to 36 months after radical cystectomy and urinary diversion for invasive bladder cancer. Functional pouch capacity, intrapouch pressure, maximal nipple pressure, maximal nipple closure pressure and functional nipple length with the pouch filled to capacity were measured. Intermittent involuntary pressure spikes resembling bowel peristaltic waves occurred in 5 patients (25 per cent). The mean functional pouch capacity was 280.0 +/- 119.2 ml. (standard deviation) and mean maximal intra-pouch pressure was 41.0 +/- 11.0 cm. water in patients with involuntary pressure spikes. In patients without involuntary pressure spikes these values were 332.7 +/- 114.5 ml. and 11.6 +/- 4.8 cm. water, respectively. For all patients the mean maximal nipple pressure was 72.1 +/- 24.6 cm. water, the mean maximal nipple closure pressure was 58.8 +/- 23.1 cm. water and the mean functional nipple length was 3.4 +/- 0.9 cm. A functional nipple length of less than or equal to 2.5 cm. and/or a low maximal nipple closure pressure (less than 40 cm. water) correlated with a small functional pouch capacity (less than 200 ml.) in 5 patients. Clinically, these 5 patients also required frequent catheterization to provide continence. A maximal nipple closure pressure greater than 60 cm. water and an adequate functional nipple length (greater than 3.0 cm.) correlated with a rather large functional pouch capacity (more than 350 ml.). The degree of continence provided by the Kock pouch appeared to be determined by functional nipple length, maximal nipple closure pressure, functional pouch capacity and maximal intrapouch pressure.