Simplified Uretero-Intestinal Implantation in Continent Cutaneous Urinary Diversion Using Ileovalvular Segment as Afferent Loop and Appendix as Continent Outlet

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

Technique of Suprafascial Anastomosis With Reduced Risk of Stenosis of the Efferent Outlet in Continent Catheterizable Urinary Diversion

OBJECTIVE

To describe our technique and long-term experience with a technique of a suprafascial anastomosis for the efferent continent segment in continent cutaneous urinary diversion, which aims to reduce the rate of stomal strictures.

MATERIALS AND METHODS

Between 1998 and 2013, up to 191 patients underwent continent cutaneous urinary diversion with a suprafascial anastomosis technique at our institution. A complete follow-up was achievable in 82 patients. The retrospective analysis included continence rates, stomal complications, and other complications related to the urinary diversion such as anastomotic insufficiencies, fistulas, or hernias.

RESULTS

The study population consisted of 82 patients with 67 (82%) women and 15 (18%) men with a median age of 58 years. The median length of follow-up was 82 months (range 13-203) with a median survival time of 46 (range 13-193) months. At the time of the analysis, 46 patients (57%) were still alive. Five out of 82 patients (6%) presented with a relevant stenosis in umbilical stoma that required surgical revisions. Nine patients (12%) with functional stenosis could be treated conservatively. Continence was achieved in 74 of 82 patients (90%). Only 8 patients reported some degree of incontinence.

CONCLUSION

The technique of a suprafascial stoma is a simple and safe technique that may help prevent the incidence of stomal complications.

[Urinary diversion with continent umbilical stoma: Which techniques are suitable for which patients?]

BACKGROUND

Continent cutaneous diversions play a secondary role even in many centers for urinary diversion. The result is that knowledge about, indications and operation technique does not exist in many clinics.

RESULTS

The general complication rates of the various forms of urinary diversion are not significantly different. There is no quality of life study showing a significant advantage for either form of urinary diversion. The functional results of neobladders in females with up to 70% hypercontinence are worse than in men, resulting in 2.4-fold more continent urinary diversions in men compared to women. The complication rates of the various forms of continent cutaneous pouches are different.

CONCLUSION

Continent cutaneous pouches are an option for all patients with non-existing or functionally unusable urethra and as primary indication in all women with bladder cancer, consulting in very good quality of life and perfect body image. Age (<75 years), manual skills and psychological ability are selection criteria. As far as the results and complication rates are concerned the ileocecal pouch with an appendix umbilical stoma is the best option. In cases of non-existing appendix, alternatives are a neoappendix, serosal lined tapered ileum and ileal invagination nipple.

[Follow-up care - consequences of urinary diversion after bladder cancer]

Radical cystectomy is the standard of care for muscle-invasive bladder cancer. Continent urinary diversions utilizing both small and large bowel are becoming more prominent: therefore, the postoperative follow-up has to focus on different aspects. In the first instance after radical cystectomy functional issues with respect to potential stenosis, post-void residual urine and micturition disorders are important. In the early phase the oncological follow-up aims to detect local, urethral and systemic recurrences and new data show the importance of the first 3 years after surgery. Long-term follow-up focuses on metabolic aspects, such as cobalamin or bile acid deficits, acidosis and disorders of calcium and bone metabolism. Follow-up care should consider specific complications of different types of urinary diversions; however to date standardized follow-up guidelines are lacking.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations

In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal. After failure of conservative treatment (clean intermittent catheterisation and pharmacotherapy) urinary diversion should be considered. In this review, the surgical options with their advantages and disadvantages are discussed. In patients with a hyper-reflexive, small-capacity and/or low-compliance bladder with normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. To those who are unable to perform clean intermittent catheterisation via urethra, a continent cutaneous stoma can be offered. In patients with irreparable sphincter defects a continent cutaneous diversion is an option. For patients who are not suitable for a continent diversion (incompliant±chronic renal failure), a colonic conduit for incontinent diversion is preferred. Surgical complications specific to urinary diversion include: ureterointestinal stenosis, stomal stenosis, stone formation, bladder perforation, and shunt infection and obstruction. Surgical revision is required in around one third of patients. Careful lifelong follow-up of these patients is necessary, as some of these complications can occur late.

Serosa lined and tapered ileum as primary and secondary continence mechanism for various catheterizable pouches

PURPOSE

Incontinence of catheterizable ileocecal pouches with an umbilical stoma using the original Mainz pouch technique can be repaired by a secondary ileal intussusception nipple fixed in the ileocecal valve. In cases of a modified Mainz pouch with ureteral anastomosis to the prevalvular ileal segment another form of troubleshooting is necessary.

MATERIALS AND METHODS

In 4 of 112 patients (3.6%) with the modified Mainz pouch described by Roth incontinence or stenosis of the catheterizable stoma occurred. A 24 to 30 cm segment of ileum was isolated. The proximal 8 to 10 cm were tapered and seroserosally embedded in the U-shaped 2 x 8 to 10 cm long remainder of the segment. After excising the insufficient efferent limb this ileal segment was anastomosed to the pouch and the umbilicus with tapered ileum acting as the continence mechanism. In a fifth patient such a segment was used for ileocystoplasty with an umbilical stoma after bladder neck closure.

RESULTS

At a median followup of 6 months (range 5 to 64) all 5 patients were fully continent with regular, easy self-catheterization via the umbilicus.

CONCLUSIONS

The introduced method seems to be a promising continence mechanism for various forms of catheterizable pouches, not only for troubleshooting.

Techniques for uretero-intestinal reimplantation

PURPOSE OF REVIEW

Uretero-intestinal reimplantation is a crucial component of urinary diversion. Several techniques for refluxing and nonrefluxing uretero-intestinal reimplantation have been established and modified to minimize anastomotic complications and preserve renal function. We review current experience with uretero-intestinal reimplantation in different types of urinary diversion.

RECENT FINDINGS

The basic principles of uretero-intestinal reimplantation are still controversially discussed. Several studies have focused on complications of urinary reflux from direct end-to-side or end-to-end anastomosis, such as pyelonephritis and calculus formation. Strictures at the anastomotic site of nonrefluxing tunneled ureteral reimplantation resulting in hydronephrosis and renal deterioration have led some to question the need for an antirefluxive anastomosis, at least in "low pressure urinary diversion". Alternative surgical procedures aim to avoid reflux and minimize the risk for anastomotic strictures by direct ureteral reimplantation into an intact isoperistaltic afferent ileal segment or the prevalvular ileum, with the ileocaecal valve functioning as an antireflux mechanism.

SUMMARY

A "gold standard" for uretero-intestinal anastomosis in urinary diversion does not yet exist. Further prospective randomized studies are required to identify the best anastomotic techniques for different types of urinary diversion.

Continent right colon reservoir using a cutaneous appendicostomy

INTRODUCTION

Although orthotopic reconstruction has become the preferred form of lower urinary tract reconstruction after cystectomy there remains a select group of patients who are not appropriate for an orthotopic neobladder substitute. A continent cutaneous reservoir provides an alternative means to store urine and protect the upper urinary tract without the need for a urostomy appliance. We report our surgical technique of a continent cutaneous right colon reservoir using a catheterizable submucosally embedded appendicostomy.

TECHNICAL CONSIDERATIONS

The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy incorporates the ascending and proximal transverse colon, which are detubularized and folded to form the reservoir component of the urinary diversion. The terminal ileum acts as the afferent limb, with the intact native ileocecal valve providing the antireflux mechanism. The continence catheterizable mechanism incorporates the submucosally tunneled appendix with preservation of the mesentery in a flap-valve technique.

CONCLUSIONS

The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present, with good functional results and excellent continence.

Urologic intestinal reservoirs: the continent outlet

General use of standardized terminology and assessment of functional characteristics suggested by the International Continence Society will enable better comparison of the results and technical specifications of different continent outlets. According to the basic functional principle, continence mechanisms can be classified into extraluminally and intraluminally located continent outlets. Extraluminal continent outlets are easy to construct, but are associated with the risk of overflow incontinence. The use of invagination or intussusception nipple valves is associated with a long learning curve, tedious surgical technique and high complication rate. There is an increasing tendency to use the flap valve principle for construction of continent outlets, which guarantee a high rate of complete continence with an acceptable complication rate.