Transverse colon-gastric tube composite reservoir

Transverse colon for continent urinary diversion: experimental study comparing two techniques

OBJECTIVES

Patients who have undergone pelvic radiotherapy can develop urinary complications such as actinic cystitis or fistulas and ultimately need urinary diversion, for which several techniques have been described. The purpose of this experimental study was to compare 2 different types of continent urinary diversion with the colonic pouch.

METHODS

Sixteen dogs of both sexes, weighing 20-25 kg were divided into 3 groups: the pilot group consisted of 6 dogs used to standardize the technique. Group 1 consisted of 5 dogs that underwent the Monti technique to construct the conduit and the Abol-Eneim technique to promote continence. The final group, group 2, consisted of 5 dogs that underwent the intussusception technique for continence. In both techniques the same length of colon was used (20 cm). Urodynamic evaluation was performed at postoperative day 30.

RESULTS

The compliance of the reservoir was similar among the groups. The capacity of the reservoir was greater and the continence mechanism was more effective in group 1. The length of the conduit was also longer in group 1. In group 2, the intussusception's mechanism was totally lost in 1 dog and partially in 2.

CONCLUSIONS

The technique performed in group 1 allowed for the construction of a reservoir with greater capacity and the continence mechanism proved to be more efficient than in group 2. The length of the conduit was significantly greater in group 1.

Isolated isoperistaltic gastric tube interposition for esophageal replacement in children

Various surgical procedures are used for esophageal substitution in children. With the gastric tube (GT) esophagoplasty procedures, main complications in the long term are related to gastric content reflux and acid production from the GT itself. A case of children operated on with a new procedure of isoperistaltic isolated GT interposition with favorable short- and long-term functional results is presented.

Clinical applications of the Monti procedure as a continent catheterizable stoma

OBJECTIVES

Monti et al. recently described a technique for the construction of a continent catheterizable conduit using short segments of small bowel in a canine model. We review our experience with 25 adult and pediatric patients in whom the Monti procedure was used in their reconstructive efforts.

METHODS

Since October 1995, 25 patients (13 males and 12 females), aged 4 to 67 years (median 29), underwent the construction of 29 catheterizable stomas with a short (2.5 cm) segment of bowel following the Monti technique. Twenty-seven tubes were created as urinary stomas and two as part of the Malone antegrade continent enema procedure (MACE). Continence is based on the Mitrofanoff flap valve mechanism. Tubes were created when the appendix was unavailable as part of urinary reconstructive efforts or after exenterative oncologic surgery of the lower urinary tract. Tubes were created using ileum (24) and sigmoid colon (5). Ten tubes (34.5%) were done in combination with a simultaneous bowel patch in the same pedicle for bladder augmentation. Tubes were implanted in the ileum (13), bladder (9), sigmoid colon (3), stomach (1), and descending colon (1). The two tubes created to do a MACE procedure were anastomosed into the cecum. Double tubes were necessary in 7 adult patients for adequate length. The length of the tubes varied from 6 to 14 cm.

RESULTS

Follow-up ranged between 3 and 26 months (mean 13). One adult patient (4%) with bladder cancer died of myocardial infarction 14 days postoperatively. Three patients (12%) received a new Monti tube because of ischemic stenosis of the tube. All of them were continent at a follow-up of 1, 6, and 20 months, respectively. Two patients (8%) experienced leakage through the stoma, requiring additional procedures and pharmacologic manipulation to become continent. All patients used intermittent catheterization through the stoma without problems.

CONCLUSIONS

Although the appendix remains the tissue of choice, the Monti procedure has substantial advantages over other efferent catheterizable tubes, including the need for a very short segment of bowel (2.5 cm), adequate lumen size (16F to 18F), length, reliable blood supply, and the versatility to combine with a simultaneous bowel patch in the same pedicle for bladder augmentation.

The Mitrofanoff principle in continent urinary reconstruction

Continent urinary diversion has increasingly become important for treating children and adults with urinary tract pathology that cannot be managed by direct reconstructive techniques. The Mitrofanoff principle, a term that has become synonymous with the flap valve mechanism for promoting the unidirectorial flow of a fluid medium, is a recapitulation of nature's design for the competent ureterovesical junction. Construction of a catheterizable channel using this principle can be performed with a variety of tissues and serves well as a continence mechanism for either the native bladder or intestinal reservoirs. In addition to its utility in managing urinary incontinence, implantation of a catheterizable channel into the cecum can be used to manage fecal incontinence in patients with neurogenic bowel dysfunction.

Outcome analysis of Mitrofanoff principle applications using appendix and ureter to umbilical and lower quadrant stomal sites

PURPOSE

We compared the indications for and results of application of the Mitrofanoff principle using appendix and ureter to umbilical and lower quadrant stomal sites.

MATERIAL AND METHODS

We created continent catheterizable conduits in 60 patients 3 days to 20 years old (mean age 8.8 years). The primary indication was refractory urinary incontinence associated with bladder or cloacal exstrophy, or anomalies in 31 cases. We constructed 38 umbilical (all appendix) and 22 lower quadrant (10 appendix and 12 ureter) stomas. Mean followup was 3 years.

RESULTS

We preferred the umbilicus as a stomal site for its cosmetic value. The most common indication for a lower quadrant stomal site was preservation of the retroperitoneal course of the ureter. The stomal stenosis rate was 13 and 4% in patients with umbilical and lower quadrant stomas, respectively. We preferred the appendix as a conduit due to availability. Indications for the ureter as a catheterizable conduit were absence of an adequate appendix or presence of a healthy ureter after nephrectomy. The appendiceal and ureteral conduits were catheterizable in 94 and 84% of patients, respectively, and continence was achieved in 97%.

CONCLUSIONS

In a complex group of patients with incontinence application of the Mitrofanoff principle yielded good results for either combination of stomal site or catheterizable conduit. Appendicovesicostomy to the umbilicus remains our preferred procedure.

Gastropyeloplasty: an alternative procedure in reconstruction of the renal pelvis

We report our first experience with the use of a small gastric patch for reconstruction of the renal pelvis. We performed left gastropyeloplasty based on the right gastroepiploic artery in 1 patient suffering from recurrent urinary tract infections and renal stones, and moderate renal failure. The use of a gastric patch for reconstruction of the renal pelvis prevented the recurrence of calculi and bacterial infections, and produced an improvement in renal function. We confirm the feasibility of the use of a small gastric patch in reconstruction of the renal pelvis and we argue that there are several possible ways to use stomach in upper urinary tract reconstruction.

The gastric augment single pedicle tube catheterizable stoma: a useful adjunct to reconstruction of the urinary tract

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Perioperative care protocols for a canine model of a new gastrocolonic pouch for continent urinary diversion

Traditionally, in continent urinary diversion (CUD), the ileum, ascending colon, or sigmoid colon is utilized to construct a urinary reservoir with a continence mechanism. When CUD was performed in women who had undergone extensive pelvic irradiation therapy for gynecologic cancer, the complication rate was exceedingly high due to the poor vascularity of the irradiated bowel incorporated in the reservoir. In order to avoid this very high complication rate, an animal study was conducted to test the feasibility of constructing a CUD utilizing nonradiated stomach, transverse colon, and proximal ureters. The development of this model in the canine necessitated prolonged abdominal surgery involving both the gastrointestinal and urinary systems. The immediate postoperative challenge included the need for continuous intravenous fluid infusion, maintenance of patent renal stents and neobladder stomal catheters, prevention of hypothermia and hypokalemia, and reduction of postoperative discomfort. Re-establishing an adequate plane of nutrition, preventing colonic ulceration from gastric secretions in the pouch, monitoring renal function, maintaining a patent stoma during healing, and managing the gradual expansion of the pouch were among the chronic care considerations. This procedure required the institution of unique and intensive perioperative care protocols. Using the methods discussed in this paper, three of four dogs in a pilot study survived the procedure and were included in an ongoing study of the new gastrocolonic continent urinary diversion.

Choice of gastroepiploic vessels for gastrocystoplasty

Use of vascularized gastric segments for augmentation cystoplasty and for construction of a continent urinary diversion depends on adequate blood supply via the right or left gastroepiploic vessels. Inadequate gastroepiploic vessels on 1 side may not be apparent without intraoperative testing for their patency. We recommend routine testing for the patency of the left and right gastroepiploic vessels before selecting the side to be used as a pedicle for the gastric segment.

Conversion of an ileal conduit to a continent catheterizable stoma

A technique is described by which a previously constructed ileal conduit is used as an efferent limb of a continent urinary reservoir. The ileal segment is tapered; 1 end is tunneled submucosally into a reconfigured colonic reservoir and the other end is brought to the skin as a catheterizable stoma. This modification of the Mitrofanoff principle provides a highly continent stoma that is easily catheterized, and allows for preservation of the terminal ileum and ileocecal valve within the gastrointestinal tract.