Selection of the type of urinary diversion in conjunction with radical cystectomy

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients

OBJECTIVES

To assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy.

PATIENTS AND METHODS

The study included 10 patients (mean age 61.8 years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student's t-test.

RESULTS

Nine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3-5) and the mean night-time frequency was 0.5 (0-1). Before and after surgery, the respective mean resting anal pressure was 71 and 74 cm H2O (P = 0.004), the volume at first desire to defecate was 54 and 72 mL (P = 0.004) and the maximum tolerable volume was 140 and 160 mL (P < 0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0-10) cmH2O, and the end pressure was 13.2 (4.42, 9-20) cmH2O.

CONCLUSION

Although the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients' quality of life.

Clinical and urodynamic efficacy of oxybutynin and verapamil in the treatment of nocturnal enuresis after formation of orthotopic ileal neobladders. A prospective, randomized, crossover study

OBJECTIVE

To evaluate the efficacy of two drugs: the anticholinergic agent oxybutynin (Ditropan) and the calcium channel blocker verapamil (Isoptin) in the management of nocturnal enuresis in patients with orthotopic ileal reservoirs.

MATERIAL AND METHODS

The study population comprised 20 male enuretic patients who had undergone radical cystoprostatectomy and formation of an orthotopic ileal reservoir (hemi-Kock or W-neobladder). All patients were clinically evaluated regarding their continence state. Basal medium-fill enterocystometry was performed for every patient. The patients were randomized on entry into one of the two arms of the study: oxybutynin followed by verapamil (n =10); or verapamil followed by oxybutynin (n = 10). Each group received both drugs for a period of 2 weeks each. After administration of each drug, patients were re-evaluated both clinically and urodynamically.

RESULTS

Oxybutynin and verapamil improved continence status in 70% and 55% of the patients, respectively. Both drugs significantly increased the bladder volume at first desire, at normal desire and at the maximum enterocystometric capacity. The maximum enterocystometric capacity increased from 585+/-148.6 ml at baseline to 667.5+/-180.8 and 621.05+/-170.5 ml after administration of oxybutynin and verapamil, respectively. Despite this, there was no significant change in any of the pressure parameters with the exception of the basal pressure at maximum enterocystometric capacity, which decreased significantly from 20.1+/-8.3 cmH2O at baseline to 16.07+/-5.1 cmH2O after administration of verapamil. The number of uninhibited contractions in the last 5 min of filling decreased significantly from 3.6+/-0.7 at baseline to 1.9+/-1.2 after administration of oxybutynin and to 2.1+/-1.26 after administration of verapamil. The amplitude of maximum uninhibited contraction decreased from 41.15+/-9.1 cmH2O at baseline to 34.95+/-12.77 and 33.25+/-11.52 cmH2O after treatment with oxybutynin and verapamil, respectively. Neither drug significantly changed the initial, late or total compliance of the pouch. No significant side-effects occurred with either drug.

CONCLUSIONS

Both drugs used in this study had beneficial effects on the continence status of our patients, with minimal side-effects. Both drugs clinically improved nocturnal incontinence after radical cystoprostatectomy and formation of orthotopic ileal reservoirs, which was verified by the associated improvements in urodynamic characteristics.

Noncontinent urinary diversion

When the need for urinary diversion arises, whether from carcinoma of the urinary tract, malfunction, or malformation, a decision must be made about the type of diversion to be performed. Currently, the patient and surgeon must decide on continent versus noncontinent versus neobladder, and on the type of intestinal segment to be used.

Bladder Replacement and Urinary Diversion After Radical Cystectomy

BACKGROUND: The optimal mode of urinary tract reconstruction following cystectomy continues to challenge the urologic surgeon. Disadvantages with bowel conduits have prompted the search for better techniques to improve patient outcomes. METHODS: The development of urinary tract reconstruction is reviewed, and results from several forms of continent urinary diversion and bladder replacement construction are presented. The authors report on their experience in creating continent reservoirs or neobladders in over 400 patients. RESULTS: Several surgical approaches are now available for continent urinary diversion. Metabolic and nutritional abnormalities, stone formation, infection, and cancer formation are potential complications. CONCLUSIONS: Advances in surgical techniques, an understanding of the physiology of isolated bowel segments, and improvements in pre- and post-operative care have altered the field of urinary reconstruction after cystectomy for bladder cancer. Most patients can expect minimal morbidity and mortality.

Analysis of continent versus standard urinary diversion

The seemingly high complication and re-operation rates associated with continent urinary diversion have led some to criticize its morbidity and question its role in reconstructive urological surgery. We therefore reviewed our experience with all patients undergoing either continent or standard urinary diversion performed by 3 urological surgeons during a specified 3-year period. In 73 consecutive patients (22 continent urinary diversion, 51 standard urinary diversion), no significant difference was demonstrated with respect to the number of post-operative in-hospital days, complication rate, re-operation rate and operative mortality rate between the 2 groups. While those undergoing continent diversion were on average younger and healthier than their counterparts receiving standard diversion, stratification of patients in each group according to age and a pre-operative "fitness" score showed no significant difference in operative mortality or major morbidity between comparable patients in each group. The mean post-operative length of hospital stay was, however, 3 days shorter for the youngest and fittest patients receiving standard versus continent urinary diversion.

Ileal conduit in era of systemic chemotherapy

The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.