Continent urinary reservoirs

Experience with the Mainz modification of ureterosigmoidostomy

BACKGROUND

The purpose of this study was to report experience with the revived surgical concept of ureterosigmoidostomy in its low pressure modification and to discuss its value within the current spectrum of urinary diversion.

METHODS

Between February 1992 and September 1997 modified ureterosigmoidostomy (rectosigmoid pouch; Mainz pouch II) was performed in 34 patients aged 1.9-76.9 (mean 55.8) years as a primary urinary diversion after radical cystectomy for bladder cancer (n = 30) and benign conditions (bladder exstrophy, three patients; intractable urinary incontinence, one). All patients were followed prospectively according to a standard protocol including assessment of continence, renal function and acid-base balance.

RESULTS

There were no perioperative deaths. In one patient dislocation of a ureteral stent in the early postoperative course required insertion of a percutaneous nephrostomy. All patients were continent during the day. One patient experienced night-time incontinence but rejected a conversion procedure. In one case ureterosigmoidostomy was replaced by an ileal conduit after several episodes of septicaemia. One nephrectomy was performed for ureterointestinal obstruction. Mild hyperchloraemic acidosis was seen in two patients.

CONCLUSION

Bowel frequency and urge incontinence, the major weaknesses of classical ureterosigmoidostomy, can be overcome by detubularization of the rectum. As the modified procedure is quick, safe and easy to perform with highly satisfactory results, the rectosigmoid pouch has potential in reconstructive urology.

Complications related to different continence mechanisms in ileocecal reservoirs

PURPOSE

We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir.

MATERIALS AND METHODS

From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus.

RESULTS

In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple.

CONCLUSIONS

In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Quality of life after cystectomy and urinary diversion: results of a retrospective interdisciplinary study

PURPOSE

Now that creation of continent urinary reservoirs has become a standardized and clinically well established surgical technique with known morbidity and mortality rates, we reassessed the psychological and social aspects of this treatment compared with wet urostomy.

MATERIALS AND METHODS

We developed a questionnaire (102 items) addressing general aspects of quality of life, disease related social support, coping strategies and stoma related issues. It was mailed to 600 patients with ileal conduits and 130 with continent reservoirs. Final analysis was restricted to 192 patients operated upon within the last 5 years (mean followup 2.7 years).

RESULTS

The resulting groups were matched and paralleled regarding most treatment related and sociodemographic data. Final analysis did not reveal differences between the groups in disease related social support, coping strategies or quality of life when expressed as a total score. We found statistically significant superiority of continent reservoirs regarding all stoma related items, patient global self-assessment of their quality of life (single item, p < 0.005), physical strength, mental capacity, leisure time activities and social competence (p < 0.05).

CONCLUSIONS

Continent diversion is clearly advantageous with respect to all items directly related to the stoma. The significant superiority of continent diversion in patient global self-assessment of their quality of life reflects the highly subjective dimension of the concept. Superiority in self-ratings of physical strength, mental capacity, leisure time activities and social competence could be interpreted as indicators of enhanced vitality in those patients, thus, supporting our understanding that women and men who actively participate in life have a special benefit from continent reservoirs.

Ureteral anastomosis in the orthotopic ileal neobladder: comparison of 2 techniques

PURPOSE

The functional results and complications of 2 different ureteroileal anastomoses were evaluated in patients with bladder cancer undergoing radical cystectomy and orthotopic ileal bladder substitution.

MATERIALS AND METHODS

Between 1989 and 1995, 102 patients underwent creation of a low pressure neobladder. In the first 50 cases the ureteroileal anastomosis was created with a split-cuff nipple technique as an additional antireflux mechanism. In the next 52 cases the ureteroileal anastomoses were constructed via the direct end-to-side technique counting on the antireflux protection of the afferent tubular limb.

RESULTS

Stenosis occurred in 7 of the 100 ureters (6 patients) treated with the split-cuff nipple technique and 7 of 104 treated with a direct end-to-side anastomosis. This complication occurred more commonly in the left ureter (11 of 14 patients). Reflux was noted at cystography in 10 cases with the split-cuff nipple method and 12 with end-to-side anastomoses, and was symptomatic in only 3 patients. Four ureteral strictures were treated successfully with primary open repair. Percutaneous dilation and stenting were performed for 8 ureteral strictures: 2 cases were successful, 3 failed and 3 are unresolved.

CONCLUSIONS

We observed no differences between the antireflux split-cuff and end-to-side anastomoses with regard to stricture formation or ureteral reflux. Therefore, we do not believe that there is a need to create antireflux ureteral anastomoses due to the tubular afferent ileal segment and given that the reflux is asymptomatic in most patients. Strictures may be treated with percutaneous balloon dilation and stenting but open repair appeared to be more effective.

Studio delle alterazioni metaboliche dei pazienti sottoposti a neovescica ortotopica di sostituzione e reservoir urinario

Urine exposed to intestinal mucosa changes its composition, as some substances are absorbed and others are secreted. Metabolic effects in 57 patients who underwent bladder substitution, augmentation cystoplasty or continent reservoir, were reviewed in our institute. Hyperchloraemic metabolic acidosis was the most common effect. Even if the consequences are often limited by the body's compensatory response, the risk of long-term complications is always present and a close metabolic follow-up is mandatory.