Complications of bladder substitution and continent urinary diversion

Human umbilical mesenchymal stem cells-seeded bladder acellular matrix grafts for reconstruction of bladder defects in a canine model

Background

The goal of this study was to explore the feasibility of utilizing human umbilical mesenchymal stem cells (HUMSCs)-seeded Bladder acellular matrix graft (BAMG) for bladder reconstruction in a canine model.

Methodology/Principal Findings

HUMSCs were isolated from newborn umbilical cords and identified by flow cytometry. Partial cystectomy was performed in the experimental and control group. Bladder defects were repaired with HUMSCs-BAMG in the experimental group and repaired with unseeded-BAMG in control group. The implanted grafts were harvested after surgery. H&E and immunohistochemistry staining were performed to evaluate the regeneration of the bladder defect. Primary cultured HUMSCs displayed typical fibroblast morphology with spindle-shaped. Flow cytometry indicated that these cells were positive for CD105 (97.3%) and CD44 (99%), but negative for CD34 (2.8%), CD31 (2.1%), and CD45 (1.7%). Immunohistochemistry staining showed that a multilayered urothelium and well-developed smooth muscle were observed at 12 weeks in experiment group. In contrast, multilayered urothelial tissues were also observed at 12 weeks in group B, but well-developed smooth muscle bundles were observed.

Conclusions/Significance

Our preliminary results demonstrate that UMSC-seeded BAMGs are superior to unseeded BAMGs to promote the regeneration of bladder defects. Our findings indicated that HUMSCs may be a potential cell source for bladder tissue engineering.

Use of nonabsorbable staples for urinary diversion: a step in the wrong direction

BACKGROUND

The use of bowel segments incorporated into the urinary tract is well established in urological surgery.

OBJECTIVE

To describe and compare the use of absorbable and nonabsorbable staples for creation of a urine reservoir after radical cystectomy.

MATERIALS AND METHODS

This review is based on a systematic Medline search assessing the period 1950-2010.

RESULTS

Use of the autosuture stapling device for the construction of the urinary diversion significantly reduces operating time. Johnson and Fuerst reported its use for the first time to construct a ureteroileocutaneous urinary diversion in 1973. However, many studies demonstrated that exposed metal staples represent a nidus for stone formation when they are in direct contact with urine, particularly in urinary diversions such as Kock pouch and ileal conduit. Stone formation has been attributed in part to the use of nonabsorbable artificial materials, such as metal staples and Marlex mesh, strictures of the pouch and accumulation of mucus. The treatment options for pouch calculi include observation for spontaneous passage, extracorporeal shockwave lithotripsy, percutaneous or endoscopic lithotripsy/lithotomy.

CONCLUSIONS

Historically, the mean time to stone formation with nonabsorbable material (staples, Marlex mesh) is 34 months. None of the studies on use of nonabsorbable staples in urinary diversion has such a long follow-up. Until further studies with more appropriate observation time are completed, the use of nonabsorbable staples for continent and noncontinent urinary diversion should be discouraged.

[Multiple stones in atypical heterotopic reservoir in a patient with renal transplant: endourologic resolution]

BACKGROUND

Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity.

INTRODUCTION

Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence.

MATERIALS AND METHODS

We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones.

SURGICAL TECHNIQUE

preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted.

RESULTS

No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported.

CONCLUSIONS

In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Large orthotopic reservoir stone burden: Role of open surgery

PURPOSE

To present our experience in open poucholithotomy as a primary management of large orthotopic reservoir stone burden and discuss different management options.

MATERIALS AND METHODS

Records of men underwent radical cystectomy and orthotopic urinary diversion were retrospectively reviewed as regards pouch stone formation. Patients with large reservoir stone burden managed by open poucholithotomy were further selected.

RESULTS

Large reservoir stone burden was encountered in 12 post radical cystectomy men. All underwent open poucholithotomy as a primary management of their reservoir stones. Median age at cystectomy was 46 (range: 32-55) years with a median total follow up period of 214.15 (range: 147-257) months and a median interval to stone detection of 99 (range: 63-132) months. The median stone burden was 5260 (range: 3179-20410) mm(2). All patients were continent during the day while 5 showed nocturnal enuresis; 2 of them became continent after removal of the stones. Post poucholithotomy, all patients had sterile urine cultures except one who showed occasional colonization. None of the 12 patients showed stone recurrence after poucholithotomy. Two patients underwent revision of a dessuscepted nipple valve in association with stone removal.

CONCLUSIONS

Open poucholithotomy for large reservoir stone burden is a feasible and safe option. It saves the reservoir mesentery and adjacent bowel. It allows complete removal of the stone(s) leaving no residual fragments. Furthermore, it permits correction of concomitant reservoir abnormalities.

Effect of stanford pouch and ileal conduit urinary diversions on bone mineral density and metabolism

After urinary-intestinal diversions metabolic complications may occur in long term follow up. We aimed to evaluate bone metabolism changes in urinary diverted patients. Nineteen patients with urinary diversions (11 Stanford pouch and 8 ileal conduit) performed with diagnosis of locally invasive bladder cancer and 19 age-sex matched healthy subjects were enrolled in the study. Bone mineral density (BMD), arterial blood pH, bicarbonate and base excess as well as bone mineralisation parameters at urine and serum were evaluated for all groups. For statistical evaluation, nonparametric comparisons between groups were used. Comparison of ileal conduit and control groups displayed higher alkaline phosphatase and parathormone levels in the patient group though the difference was not significant. The mean BMD values of ileal conduit group were osteopenic, revealing a significant difference with the control group. Statistically significant differences between alkaline phosphatase, parathormone levels of Stanford pouch and control groups were apparent whereas BMD values were not significantly different. When the two patient groups were compared with each other, no difference in BMD or bone metabolism parameter values could be observed. Patients with urinary diversions are under risk of bone demineralisation and must be followed by BMDs, arterial blood analysis and bone mineral metabolism parameters.

Comparison of Orthotopic Sigmoid and Ileal Neobladders: Continence and Urodynamic Parameters

OBJECTIVES

The objective this of the study was to compare continence rates and urodynamic parameters among patients who had undergone orthotopic bladder substitution with sigmoid or ileal segments.

METHODS

Continent urinary reservoirs were constructed in 112 patients. Fifty patients received a sigmoid neobladder (SN) and 62 patients an ileal neobladder (IN). Thirty-four patients with an SN (mean age 64.4 years), and 20 with an IN (mean age 57.8 years) agreed to postoperative urodynamic evaluation at a median time after surgery of 18 and 37 months, respectively. Continence and urodynamic parameters were compared in both groups.

RESULTS

The average reservoir capacity of the SN (296 ml) was lower than the IN (546 ml). The majority of patients voided by the Valsalva maneuver and achieved good peak flow rates [SN group 16.6 (range 7-32) ml/s, IN group 25.5 (range 5-35) ml/s]. Of the patients with an SN 26 (76%) and with an IN 15 (75%) emptied to near completion with a post-void residual (PVR) of less than 100 ml. Daytime continence was achieved in 90% of IN patients and 85% of SN patients. Only 9% of patients with an SN and 60% of patients with an IN were continent at night.

CONCLUSION

A neobladder constructed from detubularized ileum or sigmoid achieves adequate capacity with a satisfactory daytime continence rate. Nighttime incontinence in patients with IN can be at least partly explained by periods of high pressure due to neobladder contractions in combination with a relaxed sphincter during sleep. The low nighttime continence rate of the SN is probably related to its small functional capacity.

22 week assessment of bladder acellular matrix as a bladder augmentation material in a porcine model

Previous studies on the reconstruction of porcine bladder using bladder acellular matrix allograft (BAMA) have indicated positive preliminary results with respect to graft shrinkage and cellular repopulation. The current study was conducted to investigate the feasibility of using BAMA in a similar model of bladder reconstruction out to longer time frames (22 weeks). At predetermined time points, the macroscopic, histological and mechanical properties of explanted native and BAMA tissues were evaluated and compared. Macroscopically, contracture of the BAMA was observed. The peripheral regions of the grafts experienced extensive cellular repopulation. Towards the centre however, all grafts were consistently devoid of organized smooth muscle bundles and a well-developed urothelium. An alteration in both the amount and organization of collagen was also observed within this region. Significant differences (p < 0.05) in the rupture strain and the elastic modulus of the BAMA compared to native bladder tissue appear to correlate with macroscopic graft contracture as well as the fibroproliferative tissue response of the matrix.

Regeneration of functional bladder substitutes using large segment acellular matrix allografts in a porcine model

PURPOSE

We previously reported on the short-term (4 weeks) morphometric analysis of a large bladder acellular matrix allograft used as a bladder bioprosthesis (average size 24 cm.2). We demonstrated cellular repopulation through the entire thickness of the graft. We now present the long-term (12 weeks) morphometric results of graft regenerated porcine bladders using segments measuring an average of 40 cm.2.

MATERIALS AND METHODS

Bladders harvested from pigs were subjected to detergent and enzymatic extractions to render them acellular. Partial cystectomy was performed in 21 pigs and the defect was repaired with a bladder acellular matrix allograft (average size 40.52 cm.2). Of the animals 8 were sacrificed at 1, 2 and 4 weeks and 13 were sacrificed at 8 and 12 weeks. To evaluate cellular repopulation and matrix reorganization the native bladder and graft were analyzed using standard histological and immunofluorescent techniques. To evaluate for calcium deposits in the grafts a radiological evaluation of the graft was performed after explantation.

RESULTS

All animals survived the surgical procedure and there were no significant urinary leaks. No stones were noted in any of the bladders. At 1 week there was a diffuse infiltration with acute inflammatory cells. At 2 weeks the luminal surface of the graft was lined with a single layer of urothelium, and there was stromal infiltration with unorganized smooth muscle cells and angiogenesis. At 4 weeks the urothelium was multilayered with organizing groups of smooth muscle cells and angiogenesis. At 8 and 12 weeks there was repopulation throughout the bladder acellular matrix allograft implant with all native cellular components participating.

CONCLUSIONS

We present evidence that large patch bladder acellular matrix allograft implantation is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. Its advantages may include the potential for complete and functional regeneration of a bladder substitute.

Acellular bladder matrix allografts in the regeneration of functional bladders: evaluation of large-segment (> 24 cm) substitution in a porcine model

OBJECTIVES

To evaluate the use of a large-segment (> 24 cm2) bladder substitution with porcine bladder acellular matrix allograft (BAMA) in a large animal model. Materials and methods Bladders were harvested from pigs at the time of necropsy and subjected to detergent and enzymatic extractions to render them acellular. The BAMA produced had the surgical handling and suture-retaining properties of normal bladder tissue. Six pigs had BAMA segments implanted under general anaesthesia, through a low midline abdominal incision and after partial cystectomy. The defect was repaired with a BAMA patch (mean size 43.88 cm2, range 12-72), with no urinary diversion. Two animals each were then killed at 9, 16 and 30 days and the bladders explanted. The native bladder and BAMA patch were analysed morphometrically to evaluate cellular re-population and matrix re-organization.

RESULTS

All animals survived surgery; there were no urinary leaks and no stones detected in any of the bladders. At 9 days there was a diffuse infiltration with acute inflammatory cells, but no areas of necrosis. There were isolated areas of smooth muscle cell (SMC) infiltration of the BAMA. At 16 days the luminal surface was lined with a single layer of urothelium, there was stromal infiltration with disorganized SMC and angiogenesis, with mature vessels in the BAMA patch. At 30 days the urothelium was multilayered with organizing groups of SMCs and angiogenesis. The highest cell density was at the periphery of the repopulated BAMA patch, decreasing towards the centre.

CONCLUSIONS

The implantation of large patches of BAMA is technically feasible and may prove to be a viable surgical alternative to bladder augmentation with intestinal segments. The advantages of BAMA include the potential for complete and functional regeneration of a bladder substitute. This model provides a tool with which to obtain a better understanding of the cellular and molecular aspects of matrix re-population.

A prospective randomized study comparing absorbable and nonabsorbable staples in constructing antireflux valves of urethral hemi-Kock pouches

OBJECTIVE

To determine the long-term complications associated with constructing an antireflux nipple valve using absorbable or nonabsorbable staples in the urethral hemi-Kock pouch.

PATIENTS AND METHODS

Fifty patients (all men, median age 47 years, range 28-73) undergoing construction of a urethral hemi-Kock pouch were randomized prospectively into two equal groups. In group 1, absorbable (polyglyconate) staples were used for the construction, and in group 2 nonabsorbable (metal) staples were used but omitting the staples applied at the tip of nipple valve. Assessment during the follow-up of 6-88 months comprised urine analysis, culture and sensitivity, measurement of serum creatinine, electrolytes and blood gases, and plain abdominal radiography, intravenous urography and micturating pouchography.

RESULTS

In group 1, 21 patients were evaluable; a pouch stone was detected in one, extussusception of the valve in one and valve stenosis in one. In group 2, 20 patients were evaluable; pouch stones were detected in six, extussusception of the valve in three and valve stenosis in one.

CONCLUSION

Compared with nonabsorbable (metal) staples, the use of absorbable (polyglyconate) staples significantly decreased the incidence of pouch stone formation and improved valve stability in patients with a urethral hemi-Kock pouch.

Bladder augmentation with different forms of intestinal grafts: an experimental study in the pig

OBJECTIVE

To create an experimental animal model to examine changes in bladder volume and histology after bladder augmentation in growing individuals and from the model, evaluate a method using demucosalized intestinal grafts and short-term bladder drainage.

MATERIALS AND METHODS

The study comprised 21 piglets: in group 1, seven underwent a sham operation; in group 2, seven piglets underwent bladder augmentation with full-thickness caecum after a major bladder resection; in group 3 seven underwent the same procedure but with demucosalized caecum. The bladder volume and area of the intestinal segment were measured peroperatively and when the animals were killed 2 months later. Bladder specimens were taken for histological examination.

RESULTS

The mean preoperative bladder volumes were similar among the groups; in the control group, volumes increased from 58 to 165 mL and in group 2 from 63 to 255 mL, with an increase in area of the intestinal segment from 59 to 138 cm2. In group 3 the volume was unchanged, from 63 to 71 mL, with a decrease in area from 58 to 5 cm2. Control bladders showed normal urothelium with neutral mucins and sialomucins. In group 2, there was metaplasia in the border between urothelium and colonic epithelium, with enhancement of sialo- and sulphomucins. Demucosalization resulted in extensive fibrosis, with a monolayer of urothelial cells showing metaplasia.

CONCLUSIONS

The experimental model was successful; the observed changes in bladder volume correlated well with the fate of the intestinal implant, because the bladder resection was major. This is essential, as the bladder remnant has some growth potential. Full-thickness grafts grew faster than the normal bladder. Mechanical demucosalization, including submucosa, results in shrinkage despite short-term drainage. Glandular metaplasia, with production of sialomucins and sulphomucins, occurs at the junction between bladder and colon, irrespective of mucosal removal.

In vitro functional properties of the rat bladder regenerated by the bladder acellular matrix graft

PURPOSE

To assess the response of rat urinary bladder regenerated by the homologous bladder acellular matrix graft (BAMG) to in vitro electrical and pharmacologic stimuli.

MATERIALS AND METHODS

In Sprague-Dawley rats, partial cystectomy (>50%) was performed, followed by BAMG augmentation cystoplasty. After 4 months, organ bath studies of tissue strips in 10 were used to compare the contractility of the BAMG regenerates and the corresponding host detrusor smooth muscle.

RESULTS

The BAMG regenerates exhibited contractile activity to electrical field stimulation and a qualitatively identical pattern of response to muscarinic, purinergic, alpha- and beta-adrenergic drug administration and nitric oxide. At 4 months after surgery, the maximum forces of contraction of the BAMG regenerates to carbachol stimulation amounted to close to 80% of the host bladder response. With electrical field stimulation, they equaled 44% and 62% of the host bladder response after 2.5 and 4 months, respectively. Histological and immunohistochemical studies confirmed the presence of receptors for neurotransmitters that these functional in vitro studies implied.

CONCLUSIONS

The present study provides further evidence that augmentation cystoplasty with the BAMG leads to functional regeneration of the rat bladder detrusor smooth muscle.

Functional rat bladder regeneration through xenotransplantation of the bladder acellular matrix graft

OBJECTIVE

To determine the decreased antigenicity of the bladder acellular matrix graft (BAMG) through xenotransplantation and to assess the in vivo and in vitro functional properties of the rat urinary bladder thus regenerated.

MATERIALS AND METHODS

After partial cystectomy (> 50%), BAMGs prepared from hamster, rabbit and dog urinary bladders were grafted to male and female Sprague-Dawley rats; 10 control rats underwent partial cystectomy only. Urinary storage and voiding function were monitored in 15 animals using a specially designed 'micturition cage' and cystometry. After 4 months, organ-bath studies and histological techniques were used to evaluate bladder regeneration in vitro in the grafted animals.

RESULTS

Clinically relevant antigenicity was not evident; no animal died from rejection and all bladder wall components regenerated in all BAMG xenografts. However, the degree and quality of regeneration varied. Muscularization, peak pressure, and bladder capacity were higher in the hamster BAMG-grafted animals, whereas in vitro contractility and compliance were best in the dog BAMG-regenerated bladders. All grafted bladders had significantly better capacity and compliance than the autoregenerated bladders after partial cystectomy alone.

CONCLUSIONS

The present in vivo and in vitro studies show that BAMG-augmentation cystoplasty can lead to morphological and functional regeneration of the rat bladder, preserving its low-pressure reservoir function. Because BAMG-regenerated bladders show functional innervation that is similar to normal bladders, they can work in coordination with the host bladder components, thus generating adequate intravesical pressure to produce sustained voiding. The decreased antigenicity makes heterologous BAMG transplants feasible without immunosuppression.

No evidence of osteopenia 5 to 8 years after ileal orthotopic bladder substitution

PURPOSE

The use of bowel segments as bladder substitutes may result in chronic, impaired vitamin D and calcium metabolism, and ultimately in bone demineralization.

MATERIALS AND METHODS

Bone metabolism was examined in 14 patients who lived for 5 to 8 years with an ileal low pressure bladder substitute after radical cystectomy for bladder cancer. Bone mineral density was measured using dual energy x-ray absorptiometry of the total skeleton, lumbar spine, femoral neck, and tibial epiphysis and diaphysis. Laboratory studies included serum levels of 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D, intact parathyroid hormone, plasma alkaline phosphatase, electrolytes, creatinine and blood gas analysis.

RESULTS

Bone mineral density was normal in all patients. There was no evidence of deficient vitamin D stores. There was a tendency toward slightly elevated serum creatinine values in patients with preexisting impaired renal function, including 1 who also had slight acidosis. No patient had hyperchloremia.

CONCLUSIONS

We found no evidence of osteomalacia, osteoporosis or significant metabolic acidosis in 14 patients with an ileal bladder substitute for 5 to 8 years. However, it is not known whether the absence of osteopenia would also apply to patients with poor renal function, to those not followed meticulously and, thus, at risk for major long-term functional or metabolic disturbances from the ileal bladder substitute or to patients with orthotopic bladder substitutes made from longer or other bowel segments than we used.

Urinary immunoglobulins in patients with continent urinary reservoirs and ileal conduits

BACKGROUND

Although bowel segments are commonly used for reconstructing the urinary tract, a high incidence of bacteriuria is observed in patients with urinary intestinal diversion. The normal gastrointestinal tract possesses a potent mucosal immune system characterized by secretory immunoglobulin A (sIgA) as the major humoral defense factor. However, the significance of urinary IgA secretion as the mucosal defense mechanism in patients with urinary intestinal diversion has remained obscure. In this study, urinary levels of sIgA as well as serum-type IgA were measured in patients with continent urinary reservoirs (Kock and Indiana pouches) and ileal conduits.

METHODS

Twenty-four-hour urine samples were collected in a total of 80 patients with urinary intestinal diversion (22 Kock pouch patients, 21 Indiana pouch patients and 37 ileal conduit patients). The amount of sIgA and serum-type IgA were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Urinary IgA levels showed great inter- and intra patient variability in all three groups. Indiana reservoir urine contained significantly greater amounts of sIgA (mean 32.0 mg/24 hrs) than Kock reservoir urine (11.9 mg) and conduit urine (4.9 mg), whereas Kock reservoir urine contained significantly more sIgA than conduit urine. However, the corresponding difference was not observed in regard to serum-type IgA. In none of the three modes of urinary diversion did 24-hour sIgA excretion show any correlation with the length of time after surgery.

CONCLUSIONS

Since the amounts of sIgA in these patients were much greater than reported in urinary tract infection as well as in normal subjects, the major portion of urinary sIgA seemed to be secreted by the intestinal segments. Long-term sIgA secretion in urinary intestinal diversion, especially continent urinary reservoirs, may be an important host defense system.

Effect of urinary intestinal diversion on urinary risk factors for urolithiasis

We investigated the effect of urinary intestinal diversion on risk factors for calcium urolithiasis, such as calcium, phosphate, magnesium, uric acid, oxalate and citrate, in 3 groups of patients (Kock pouch, Indiana pouch and ileal conduit). Mean urinary volume was not significantly different among the 3 groups. Mean serum creatinine and 24-hour creatinine clearance in the continent reservoir group were better than in the ileal conduit group. Mean urinary excretion of calcium, phosphate and magnesium was significantly greater in the continent reservoir group than in the ileal conduit group. Although calcium excretion had a positive correlation with 24-hour creatinine clearance, calcium excretion per ml. per minute creatinine clearance still showed a significant difference. Increased calcium excretion is considered to reflect metabolic disturbances resulting from reabsorption of urinary solutes through the intestinal segments. Overall, there was no significant difference in the urinary parameters between the Kock and Indiana pouch groups. While mean urinary oxalate and citrate were within the normal range in all 3 groups, more than a third of the patients in each group were hypocitraturic (less than 100 mg. per day). In none of the 3 groups did the levels of urinary calcium, phosphate and magnesium, as well as other urinary risk parameters show any correlation with the duration of diversion. In summary, our study indicated that the continent urinary reservoir causes a long-term increase in urinary excretion of calcium, phosphate and magnesium. These urinary metabolic alterations might promote the formation of calcium urolithiasis as well as infectious stones. The degree of metabolic alterations may be greater with a continent reservoir than with an ileal conduit.

Second stage reconfiguration of Camey I ileal bladder improves its urodynamic and clinical characteristics

Second stage reconfiguration of Camey I neobladder with intact ileal loop was performed in 3 patients due to poor functional results and associated complications requiring reintervention. Neoblasdder capacity increased from a mean volume of 240 to 593 mL, maximum endoluminal pressure decreased from a mean value of 86 to 29 mm water, and night-time incontinence uniformly disappeared. Loop detubularization and reconfiguration, therefore, results in marked improvement of the clinical and urodynamic characteristics of Camey I ileal neobladder.

Minimally invasive endourologic management of calculi in continent urinary reservoirs

This study was done to determine whether minimally invasive endourologic management of calculi in continent reservoirs can be done effectively without compromise of urinary continence. Four patients with continent urinary diversions (1 Indiana pouch and 3 Kock pouches) were managed with trans-stomal pouchoscopic ultrasonic lithotripsy (n = 2), prone position extracorporeal shock wave lithotripsy (n = 1), or a "sandwich" combination of these (n = 1) for stone burdens up to 20 cm2. Total hospital stay ranged from one to four (mean = 2.6) days. All 4 patients were initially rendered stone free, and, with follow-up as long as twenty-five months, only 1 has had a recurrence. No patient experienced stomal leakage or other complications. This study suggests that minimally invasive endourologic management of calculi in continent urinary reservoirs can be done safely and effectively to obviate the need for more invasive percutaneous approaches or open surgery, even for some patients with large stone burdens.

Urolithiasis in children following augmentation cystoplasty

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Neobladder after cystectomy: an Indian experience

A continent urinary reservoir was constructed from an ileocolonic segment and anastomosed to the urethra in 30 males after radical cystectomy for infiltrating bladder cancer. A small cuff of the prostate was retained for anastomosis with the reservoir and ureteric anastomosis was done from within the reservoir by the "pull through" method. Complete continence was achieved in 29 patients, all of whom had an adequate reservoir capacity exceeding 400 ml; they were able to empty the reservoirs satisfactorily as judged by the residual urine (< 50 ml). Urodynamic study revealed an intra-abdominal pressure < 30 cm of water at rest and at reservoir capacity of 500 ml. Early post-operative complications included urinary leaks in 3 patients, intestinal obstruction in 3 and a faecal fistula in 1. Deterioration of the upper tracts was noted in 5 cases. Twenty-seven patients are alive after a mean follow-up of 36 months.

Percutaneous access to a continent urinary reservoir for removal of intravesical calculi: a case report

Stone formation within urinary reservoirs is a well recognized problem. Various endourological techniques have been used to treat these stones. We report a case in which reservoir calculi were removed via a percutaneous approach.

Sequelae of treatment in 109 patients followed for 5 to 15 years after diagnosis of sarcoma of the bladder and prostate. A report from the Intergroup Rhabdomyosarcoma Study Committee

BACKGROUND

As increasing numbers of young patients with cancer survive, interest in the late effects of therapy is rising.

METHODS

The sequelae of treatment were reviewed after a minimum of 5 years of observation in 109 surviving patients with sarcoma of the bladder or prostate who were enrolled in the Intergroup Rhabdomyosarcoma Studies I and II (1972-1984). The 82 male and 27 female patients were 3 weeks to 19 years of age when the diagnosis was made (median, 2 years) and were 5-29 years of age at last contact (median, 11 years). Treatment consisted of chemotherapy with vincristine, dactinomycin, and cyclophosphamide and bladder irradiation in nearly all patients.

RESULTS

Fifty-four patients underwent total cystectomy, and 10 had a partial cystectomy. Of the 55 patients with bladder preservation, 1 had a urinary conduit with a nonfunctioning bladder. Thus, 54 bladders (50% of the total) remained in place as part of the urinary tract. There was no information regarding bladder function in two patients. Satisfactory bladder function was found in 38 patients (73%), 9 were incontinent, and 5 had urinary frequency with or without nocturia. Posttherapy hematuria was detected in 29% of patients. Nine of the 31 patients (29%) with follow-up renal imaging studies had a structural abnormality, chiefly hydronephrosis, which was more frequent in those with urinary diversion. Positive urine cultures were found mainly among those with enteric urinary conduits, but only two cases of pyelonephritis were documented. Abnormalities of irradiated bone and bowel were observed infrequently. Only one patient had a significantly elevated blood urea nitrogen or serum creatinine value, and only one patient was hypertensive. Most patients were still prepubertal at last follow-up. Of 24 patients who were intrapubertal or postpubertal, 7 (29%) were receiving sex hormone replacement because of delayed pubertal development. Height was decreased by 25% or more in 11 patients, as confirmed by growth chart analysis. Secondary surgical procedures other than repeat biopsy or cystectomy consisted primarily of urinary conduit revisions and repair of bowel adhesions or fistulous tracts. Information about psychosocial status was limited.

CONCLUSIONS

Overall, 50% of the patients retained their bladders, and 73% of them had satisfactory bladder function. Renal function was preserved in nearly every patient.

Delayed spontaneous rupture of an ileocolonic neobladder

A case of delayed spontaneous rupture of an ileocolonic neobladder and subsequent peritonitis 4 years after the initial operation is reported. Many of the features of this case are similar to those noted in recent reports of spontaneous rupture of an augmented bladder and it is postulated that the etiology is the same.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

Biodegradable pericardial implants for bladder augmentation: a 2.5-year study in dogs

Bladder augmentation using biodegradable pericardial tissue was evaluated in canine bladders. Acetic acid and acetic anhydride treated pericardial tissue grafts were stored in 75% ethanol for 18 to 27 months before implant. Ten dogs weighing 20 to 25 kg. were subjected to a 50% partial cystectomy. After careful separation of the mucosa, bladder muscle and adventitial layers a pericardial graft volumetrically equivalent to the portion of the bladder removed was sutured to the bladder remnant in 2 layers. In 1 control dog the bladder was opened, 50% of the bladder was removed and the bladder was closed primarily. In another control dog the excised bladder was replaced with fresh chemically treated patch material that was never subjected to ethanol storage. Excretory urography and cystography were performed on all dogs. Urodynamics with filling pressures and bladder volumes measured before and after the operation at intervals of up to 36 months confirmed that adequate bladder capacity was achieved. There were no operative complications. Postmortem histological evaluations revealed a smooth epithelialized inner surface with no traces of any surface irregularities or suture lines. The bladder apex showed an intact epithelium and the absence of a smooth muscle layer. The biodegradable acetylated tissue provides an intact structural reservoir for urine and serves as a template for epithelial regeneration. This permits volumetric bladder enlargement while the graft is progressively reabsorbed with time.

An unusual complication of high dose infusion computerized tomography in a patient with a continent diversion

We describe a myelodysplastic woman with a Kock continent ileal reservoir who suffered parastomal herniation of the pouch following high dose infusion computerized tomography. Prophylactic indwelling catheterization in patients with continent diversion undergoing procedures that induce significant diuresis or involve prolonged distension of the reservoir is probably indicated.

Management of upper tract calculi in patients with tubularized urinary diversions

In a retrospective review of patients with urinary diversion who presented to our stone center during a 3.5-year period 9 underwent 20 procedures for suspected stone episodes. Eventual outcome was excellent in all but 1 patient. In particular, all attempts at retrograde trans-stomal manipulation were successful. We present our cases, and note the technical considerations and management principles. Frequently, these patients are best served by a combination of percutaneous antegrade, trans-stomal retrograde and/or extracorporeal shock wave lithotripsy.