Ureterocystoplasty: importance of the proximal blood supply

Modified Tubeless Ureterocutaneostomy in High-Risk Patients After Radical Cystectomy and its Long-Term Clinical Outcomes

OBJECTIVES

This work aimed to prevent stoma stenosis and achieve tubeless cutaneous ureterostomy in elderly and high-risk patients with our modified cutaneous ureterostomy.

METHODS

We retrospectively analyzed 40 and 49 patients (176 renal units) who underwent Toyoda (group 1) and modified cutaneous ureterostomy (group 2) between 2012 and 2021. The average follow-up period was 44 months. The primary results of our study were the catheter-free rate and clinical outcomes, especially renal function and urinary diversion-related complications. Significant differences in catheter-free rate and urinary diversion-related complications were found between our modified method and the Toyoda technique.

RESULTS

A total of 56 (71.8%) of 78 renal units in group 1 and 89 (90.8%) of 98 renal units in group 2 remained catheter free. Compared with group 1, group 2 had a higher catheter-free rate (P = .001). Multivariate analysis indicated that the surgical procedure (HR = 0.268; P = .001) and body mass index (HR = 3.127; P = .002) were the predictors independently associated with catheter insertion. During follow-up, renal deterioration was observed in 32 (36.0%) patients. Patients with catheter insertion were more likely to suffer from renal deterioration (P < .001), postoperative pyelonephritis (P < .001), and urolithiasis (P < .001) than their counterparts.

CONCLUSION

Our modified cutaneous ureterostomy method may provide an effective and simple approach to tubeless cutaneous ureterostomy in elderly and high-risk patients.

Revascularized Pyelo-Uretero-Cystoplasty in Patients with Chronic Bladder Outlet Obstruction Due to Ectopic Ureterocele: A Safe Surgical Technique with Superior Continence Outcomes

PURPOSE

To present the outcomes of revascularized pyeloureterocystoplasty with ureterocele unroofing in end stage bladder patients with duplex system and ureterocele.

METHODS

Thirteen patients with obstruction of intrauterine outlet from an ectopic obstructive ureterocele were included. Fourteen units of duplex systems underwent upper pole partial nephrectomy in conjunction with augmentation revascularized pyeloureterocystoplaty and ureterocele unroofing. The anterior and lateral walls of the ureterocele were excised before cystoplasty, and the resultant edges of the posterior wall were sutured to the bladder epithelium. Anastomosis of the upper pole vein and artery to the inferior iliac artery and the common iliac vein was performed. Detubularization of the whole ureter was performed with exception of the intramural ureteric part that kept tubularized for 'jet/turbulent' occurrence. Five patients (control group) underwent pyeloureterocystoplasty without revascularization. Patients underwent several evaluations in long-term follow-up.

RESULTS

Patients were all dry by day and night in our long-term follow-up. Urinary incontinence improved in patients with no need for re-augmentation technique. Vesicoureteral reflux subsided in all patients postoperatively except one, who was asymptomatic. After five years, median bladder capacity rose from 128.5 ml to 395 ml and bladder compliance showed significant improvement from 15 ml/cm H₂O to 29 ml/cm H₂O, in experimental group and remained stable for 24-36 months. Median bladder capacity did not rise significantly in control group.

CONCLUSION

Pyeloureterocystoplasty is an efficient choice in this type of patients, which may prevent the recurrence of hypocompliant bladders and prevent ischemia and subsequent fibrosis.

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.

Prerequisite for successful surgical outcome in urothelium lined seromuscular colocystoplasty

PURPOSE

Urothelium lined seromuscular colocystoplasty is an ideal method of augmentation cystoplasty that avoids various complications caused by the use of gastrointestinal segments. We reviewed the long-term outcomes using this technique at a single institution.

MATERIALS AND METHODS

We retrospectively analyzed 34 patients who underwent urothelium lined seromuscular colocystoplasty between January 1996 and December 2007. A total of 33 patients, excluding 1 who had previously undergone artificial urinary sphincter implantation, were included in the study. Changes in urodynamic parameters, duration of anticholinergic use, incontinence and surgical complications were analyzed.

RESULTS

Mean±SD age at surgery was 10.0±5.7 years (range 3.0 to 26.0) and duration of followup was 6.0±2.3 years (2.7 to 13.4). A total of 17 patients (51.5%) underwent simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty. Mean bladder capacity increased by a factor of 2.96 and mean percentage of expected bladder capacity for age increased by a factor of 1.96 postoperatively. Of patients who underwent anti-incontinence surgery 4 of 10 whose abdominal leak point pressure was less than 40 cm H2O required additional surgery, whereas none whose abdominal leak point pressure was 40 to 60 cm H2O required reoperation. Two of 16 patients who did not undergo anti-incontinence surgery eventually required continence surgery. A total of 13 patients (39.4%) were able to discontinue anticholinergics at 47.3 months postoperatively. There were no bladder perforations, bowel obstructions or metabolic abnormalities.

CONCLUSIONS

Urothelium lined seromuscular colocystoplasty can be primarily considered in patients without prior bladder mucosal injury. Constant high bladder outlet pressure to facilitate adhesion of bladder mucosa and seromuscular patch is critical for the best results. We recommend abdominal leak point pressure 60 cm H2O or less as an indication for simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty.

[Ureterocystoplasty: functional results and possible problem areas]

Surgical procedures such as ileal augmentation cystoplasties are often necessary in neurogenic low-compliance bladders. Whenever possible one should avoid using segments of the GI tract in the urinary tract and preferably use the patient's own ureter for augmentation cystoplasty. This procedure includes transperitoneal nephrectomy of a nonfunctioning kidney with preservation of the renal pelvis and the megaureter, followed by detubularization of the ureter and its integration into the opened urinary bladder. We performed this procedure on four patients, two boys and two girls (aged 6-13 years). In the long-term follow-up they all had good rehabilitation results for their lower urinary tracts with an increase of the storage volume and normalization of their reduced compliance. No deterioration of the remaining upper urinary tract was found. Complications such as partial ureteral necrosis have to be taken into consideration when the vascularization of the ureter is compromised, for example, by multiple prior antireflux procedures.

Dysfunction of the lower urinary and distal gastrointestinal tracts in pediatric patients with known spinal cord problems

Destruction of the urinary tract in children with elimination, storage, and holding dysfunction of the lower urinary and the distal GI tracts is caused primarily by high intravesical pressure. UTI accelerates this process. The LPP and the status of the urethral control mechanism and its relationship to the detrusor are the primary determinants of intravesical pressure. Intravesical pressures of more than 40 cm H2O are dangerous because they cause a pressure gradient that is transmitted proximally to the renal papillae, which results in the cessation of renal blood flow and a loss of renal function over time. Hydroureteronephrosis, VUR, UTI, urinary incontinence, and calculi formation also may occur. If these dangerously high intravesical pressures remain untreated, renal failure is likely to occur over time. These children then require dialysis or renal transplantation to survive, which is tragic and represents an enormous economic cost to society. Renal failure and upper urinary tract damage is nearly 100% preventable with early and appropriate evaluation and treatment. CIC is a crucial part of the management of these children and has been shown to be safe and effective, even in newborn boys. The use of the Credé maneuver (i.e., manual compression) to empty the bladder is obsolete and should be abandoned. The distal GI tract is inseparable from the lower urinary tract and must be treated simultaneously. Failure to treat the distal GI tract yields poor clinical results and much patient dissatisfaction and makes it difficult or impossible to treat the child's urinary tract problem successfully. Bowel-management programs must include daily high water and fiber intake, together with digital perianal stimulation or fecal extraction. Neuropathic bladder and bowel problems that are intractable to conservative medical and mechanical (i.e., CIC and digital perianal stimulation or fecal extraction, respectively) management almost always can be corrected surgically with high success rates in cooperative patients. Finally, neuropathic bladder and bowel problems can be extremely isolating and debilitating problems. Psychologic counseling and emotional support must be provided as needed. The care that these patients receive must be organized, comprehensive, and correlated with these patients' lifestyles. If these children are evaluated and treated early, they have the potential to live long, healthy, and productive lives.

Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation

PURPOSE

Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients.

MATERIALS AND METHODS

Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter.

RESULTS

Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty.

CONCLUSIONS

Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.

Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation

PURPOSE

Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients.

MATERIALS AND METHODS

Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter.

RESULTS

Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty.

CONCLUSIONS

Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.

Augmentation ureterocystoplasty with ipsilateral renal preservation in the management of patients with compromised renal function secondary to dysfunctional voiding

We evaluated the role of ureterocystoplasty with ipsilateral renal preservation in the management of patients with neurovesical dysfunction and impaired renal function. The procedure was carried out on 6 patients with a mean age of 8.5 years. All patients had vesicoureteric reflux (VUR) secondary to neuropathic bladders, recurrent urinary tract infections, day time incontinence, impaired and deteriorating renal function. All patients were followed up with a mean of 22.5 months (range 6-30). Renal function stabilized in 4 patients and improved in 2 patients. Adequate urinary bladder capacity was achieved in all patients. Bladder volume increased from a mean of 210+/-71 to 382+/-66, this increase was statistically significant (p<0.001). All patients were dry by day including the children who at presentation were in diapers. We conclude that the results of this operative intervention are satisfactory and promising in the management of this difficult group of patients while avoiding the side effects of enterocystoplasty procedures.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue

PURPOSE

Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy.

MATERIALS AND METHODS

During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed.

RESULTS

We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date.

CONCLUSIONS

There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Clinical and urodynamic evaluation after ureterocystoplasty with different amounts of tissue

PURPOSE

Ureter is one of the best tissues for bladder augmentation. The amount of ureteral segment available is extremely variable among patients. We compared results in patients who underwent ureterocystoplasty with 2 ureters, 1 complete ureter or a distal segment only after transureteroureterostomy.

MATERIALS AND METHODS

During a 6-year period we performed 32 ureterocystoplasties at 2 pediatric centers in Argentina (16) and Chile (16). Median patient age at surgery was 9 years (range 4 months to 20 years). Clinical presentation included urinary infection, hydronephrosis, incontinence and undiversion. The diagnosis was neurogenic bladder in 20 cases, infravesical obstruction in 7, massive reflux in 3 and ureterocele in 2. All patients had poor bladder compliance and vesicoureteral reflux. We used different options to augment the bladder, including 2 ureters in 5 patients, bilateral nephrectomy in 3, a complete duplex system in 1 and a bilateral partial ureter in 1 (group 1); a complete ureter in 14 (group 2), and a distal segment of ureter with transureteroureterostomy in 13 (group 3). When transureteroureterostomy was performed, a suprapubic tube remained indwelling for 2 weeks and a Double-J stent was placed for 1 month. Median followup was 16 months (range 4 months to 6 years). Clinical and radiological evaluations, including ultrasound, cystography, urodynamics, renal scan and renal function measurement, were done 4 months postoperatively and twice yearly thereafter as needed.

RESULTS

We noted no significant difference in bladder capacity when 1 or 2 ureters were used. Median increase in bladder capacity in groups 1 and 2 was 375% (range 80 to 800). All patients who received a complete segment of ureter had clinical improvement, decreased hydronephrosis and resolution of reflux with improved bladder compliance. When a partial segment of ureter was used median capacity increased 230% (range 40 to 400) with clinical improvement in 12 patients (92.3%). Compliance improved, which led to longer intervals between clean intermittent catheterizations. No patient has needed repeat augmentation to date.

CONCLUSIONS

There is a difference in median increased bladder capacity when a segment of distal ureter is used to augment the bladder versus 1 or 2 whole ureters. However, the use of distal ureter still represents a safe alternative for augmenting the bladder and simultaneously resolving massive reflux. Ureterocystoplasty is an excellent choice for increasing bladder capacity and improving bladder compliance despite the different amounts of tissue available.

Extraperitoneal ureterocystoplasty with transureteroureterostomy

Ureterocystoplasty enables the bladder to be reliably enlarged and the resultant neobladder to be lined by urothelium. Many techniques have been described for the operative management of the lower ureter, and a number of alternatives have been suggested for reconstruction of the upper renal tract and bladder. This report describes a new approach that allows renal preservation, transureteroureterostomy, and ureterocystoplasty through an extraperitoneal approach.

Tandem ureterocystoplasty

BACKGROUND

Bladder augmentation may be undertaken by using various gastrointestinal segments but their use is associated with a multitude of well-recognized complications. The mega-ureter has proven to be a satisfactory alternative; in patients with bilateral mega-ureters, both ureters may be used for this purpose.

METHODS

Seventeen patients had augmentation ureterocystoplasty, including three in whom both distal ureters were used in tandem. The latter included two patients with neurogenic bladder and one with bladder exstrophy.

RESULTS

Satisfactory augmentation was achieved in all patients undergoing tandem ureterocystoplasty. The neurogenic bladder patients are managed by urethral clean intermittent catheterization (CIC) and the exstrophy patient is managed by CIC of an appendicovesicostomy (Mitrofanoff). All are continent.

CONCLUSIONS

The mega-ureter provides an excellent source of augmentation material in patients with small non-compliant bladders. In those with bilateral mega-ureters, consideration should be given to using both ureters in tandem to achieve the maximum possible bladder capacity.