Evolution of the rectal bladder as a method for urinary diversion

Outcome of Mainz II Pouch Urinary Diversion after Radical Cystectomy in Patients with Muscle-invasive Bladder Cancer: Our Experience

Introduction:

Mainz II pouch urinary diversion in patients with muscle-invasive bladder cancer is one of the options of continent urinary diversion following radical cystectomy (RC). We aim to report our experience and the outcome of our patients who had this procedure.

Patients and Methods:

Patients who had RC and Mainz II pouch urinary diversion for muscle-invasive bladder cancer in our institution from 2007 to 2016 were evaluated. Variables analyzed included age, gender, stage of the disease, pathological grade and tumor types, complications, and survival status.

Results:

There were 11 patients who had Mainz II pouch urinary diversion after RC for bladder cancer over a 10-year period. Four (36%) were male and 7 (64%) were female. The mean age of the patients was 58.6 (range, 52–65) years. The diseases were pT2, pT3, and pT4 in 2 (18%), 7 (64%), and 2 (18%) patients, respectively. Four (36%) had pelvic nodal metastasis. Nine (82%) had a histological diagnosis of transitional cell carcinoma, and two (18%) were squamous cell carcinoma (SCC). Ten (91%) patients had high-grade disease, whereas only 1 (9%) patient had low-grade disease. Short-term morbidities were electrolytes derangement, hypokalemia, and acidosis in 2 (18%) patients and pyelonephritis in 2 (18%) patient. The two patients with invasive SCC had recurrence and death within 12 months of surgery. At present, four of the patients are alive, and seven are dead. Survival till date ranged from 8 to 120 months (mean survival time was 48 months). All patients achieved day and night time continence, and there was no significant long-term morbidity from the method of urinary diversion.

Conclusion:

Mainz II pouch urinary diversion is safe and acceptable to most of our patients with good long-term results.

Clinical evaluation of patients treated with a detubularised isolated ureterosigmoidostomy diversion after radical cystectomy

OBJECTIVES

To assess the emptying pattern and patient satisfaction after constructing a detubularised isolated ureterosigmoidostomy (DIUS) following a cystectomy, introduced to overcome the poor outcome of conventional ureterosigmoidostomy, to improve the emptying pattern and accordingly patients' quality of life.

PATIENTS AND METHODS

The study included 122 patients who were treated with a DIUS diversion after cystectomy. The minimum follow-up of the patients was 6 months. The frequency of emptying and continence during the day and night were recorded. The ability of the patients to discriminate between urine and stool was assessed. The patients' overall satisfaction with the outcome was categorised as fully satisfied, moderately satisfied or not satisfied.

RESULTS

In all, 95 patients were available for this evaluation; all patients were completely continent during the day and night. The mean emptying frequency was 3.9 during the day and 1.7 during the night. All patients were able to feel the desire to empty and the mean holding time was 35 min. Fifty-two patients (55%) could pass solid stools once per day, with minimal urine at the end of voiding, and the remaining evacuations were of clear urine only. Thirty-two patients (34%) were able to differentiate between urine and stool sensation before emptying. For satisfaction, 82 patients reported full satisfaction, 13 were moderately satisfied, and none regretted the diversion.

CONCLUSIONS

The DIUS diversion provides continence during the day and night, with a satisfactory emptying habit. Patients with a DIUS diversion can tolerate a full pouch comfortably, with no leakage, and they can discriminate between urine and stool evacuations.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for risk of bias by the review authors. Three review authors were involved in the data extraction. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Five trials met the inclusion criteria with a total of 355 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, uretero-intestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. A meta-analysis of two trials showed no statistically significant difference in daytime or nocturnal incontinence amongst participants who were randomised to ileocolonic/ileocaecal segment bladder replacement compared to an ileal bladder replacement. However, one small trial suggested that bladder replacement using an ileal segment compared to using an ileocolonic segment may be better in terms of lower rates of nocturnal incontinence. There were no differences in the incidence of dilatation of upper tract, daytime urinary incontinence or wound infection using different intestinal segments for bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis.

AUTHORS' CONCLUSIONS

The evidence from the included trials was very limited. Only five studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The clinical significance of data from one small trial suggesting that bladder replacement using an ileal segment compared to using an ileocolonic segment is better in terms of lower rates of nocturnal incontinence is uncertain. The small amount of usable evidence for this review suggests that collaborative multi centre studies should be organised, using random allocation where possible.

[Urinary diversion to the augmented and valved rectum: simplified technique]

OBJECTIVE

Description of the Ghoneim's low pressure rectal bladder, without colo-colic valve and colostomy.

METHOD

Thirty-six patients underwent this simplified technique.

RESULTS

The simplification of the technique did not increase the complication. The operating time has been lessened. The closing colostomy was avoided.

Mainz II and double folded rectosigmoid pouches. Experience with 95 patients

OBJECTIVES

We report a clinical case series for construction of Mainz II or double folded rectosigmoid pouch with suitable antireflux uretero-intestinal anastomosis.

MATERIALS AND METHODS

Ninety-five patients with invasive bladder carcinoma were treated by radical cystectomy and supravesical urinary shunt in form of either Mainz II {56 (58.9%)} or double folded {39 (41.1%)} rectosigmoid pouch. Antireflux techniques for uretero-intestinal anastomosis were subserosal extramural and submucosal tunnels for 122/190 (64.2%) dilated and 68/190 (45.8%) normal caliber ureters. All patients were kept on prophylactic alkalization. Evaluation included clinical, radiological, laboratory, and urodynamic evaluations. Mean follow-up was 40 months.

RESULTS

Early postoperative complications were reported in seven (7.4%) cases that were treated conservatively. All patients were continent day and night. Reflux was reported in 2/122 (1.6%) renal units (RU) with dilated ureters and in 1/68 (1.5%) RU with normal caliber ureter, that was managed conservatively. Stenosis at uretero-intestinal anastomosis was reported in 10 (5.3%) RU. Laboratory investigations were within normal. Pouchometry results were comparable in both Mainz II and double folded rectosigmoid pouches. Both were low-pressure good capacity reservoirs.

CONCLUSIONS

Mainz II pouch is indicated in cases of normal caliber, unilateral dilated, and some cases of bilateral dilated ureters, while double folded rectosigmoid pouch is optional in case of bilateral dilated ureters. Both have comparable low-pressure urodynamic features.

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

BACKGROUND

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

OBJECTIVES

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group's specialised register (3 May 2001), The Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2, 2001), MEDLINE (1966 to May 2001), PREMEDLINE (4 June 2001), Dissertation Abstracts (18.6.2001) and the reference lists of relevant articles. Date of most recent search: June 2001.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for appropriateness for inclusion and for methodological quality by the reviewers. Three reviewers were involved in the data extraction. The data collected was then analysed for statistical significance.

MAIN RESULTS

Two trials met the inclusion criteria with a total of 164 participants. These trials addressed only four of the 14 comparisons pre-specified in the protocol. There were no statistically significant differences found in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. There was no evidence of a difference in incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions. The confidence intervals were all wide, however, and did not rule out important differences. There was some limited evidence that use of the more complex nipple valve at the ureteroileal anastomosis was more likely to lead to upper tract deterioration than implantation into a non-detubularised, isoperistaltic ileal afferent limb.

REVIEWER'S CONCLUSIONS

The evidence from the included trials was very limited. Only two studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

Complete primary closure of bladder exstrophy. Epispadias and bladder exstrophy repair

Bladder exstrophy remains one of the most challenging problems in pediatric urology. Recent efforts have focused on primary reconstruction rather than urinary diversion to treat exstrophy. Complete primary closure appears to offer improved continence and decreases the number of surgical procedures required to treat exstrophy.

A simple technique for urinary diversion: the dismembered detubularized rectosigmoid bladder with distal colorectostomy

PURPOSE

A new modification for urinary diversion following cystectomy is presented.

MATERIALS AND METHODS

A total of 20 patients with bladder cancer who were treated with radical cystectomy underwent urinary diversion using a new technique. The sigmoid colon is dismembered approximately 30 cm. proximal to the peritoneal reflection and detubularized by anterior incision in its proximal two-thirds. Ureters are reimplanted by nipple or submucosal tunnel technique. The rectosigmoid sheet is folded on itself and closed to form a rectosigmoid pouch. The terminal colon is reanastomosed end to side to the anterior surface of the rectum just proximal to the peritoneal reflection.

RESULTS

During 4 to 36 months of followup all patients had complete daytime continence and only 2 had minimal nighttime fecal incontinence. The average daytime and nighttime evacuation frequency was 6 and 2 times, respectively. All patients were able to withhold voiding for an average of 30 minutes after maximum desire to void. Eight patients voided clear urine separated from stools in most instances while 12 voided mixtures of urine and stools. Postoperative excretory urogram revealed improvement of previously dilated systems in 8 renal units, deterioration in 4 and stable renal morphology in 28. An ascending pouchogram demonstrated good filling capacity in all cases. Urodynamic studies revealed low basic pressure within the pouch (mean 9.7 +/- 1.8 cm. water) with high compliance (mean 32.3 +/- 10).

CONCLUSIONS

This type of diversion provides a low pressure urine reservoir with satisfactory early results of preservation of the upper urinary tract and evacuation pattern.

The valved S-shaped rectosigmoid pouch for continent urinary diversion

Continent urinary diversion to the valved S-shaped rectosigmoid pouch was performed in 9 female and 6 male patients 12 to 65 years old (mean age 51 years). The pouch was constructed by detubularization and S-shaped reconfiguration of 30 cm. of the intact rectum and sigmoid colon. The ureters were reimplanted into the pouch using antireflux techniques. Reflux of urine from the pouch to the proximal colon was prevented by fashioning an intussusception valve. The construction was protected by a transverse colostomy for 6 to 8 weeks. With a followup of 3 to 24 months (mean 11 months), all patients are continent during the day and also at night with evacuation intervals of 3 to 6 hours. There have been no cases of symptomatic urinary tract infection. Only 1 patient had mild hyperchloremic acidosis. No patient complained of abdominal distention or constipation. Contrast study via the anus (radiography of the pouch) showed that the intussusception valve was competent in all but 1 patient in whom reflux to the proximal colon was noted due to sliding of the nipple valve, which was revised successfully. Urodynamic studies (cystometry of the pouch) showed a capacity of 400 to 900 ml. (mean 600) with an intraluminal pressure of 22 cm. water (range 10 to 34) at maximal filling. The valved S-shaped rectosigmoid pouch is a faster and simpler surgical procedure compared with the modified rectal bladder (valved rectum augmented with ileum). It also results in a smooth postoperative course, since an intestinal anastomosis proximal to the colostomy is avoided.

Bladder substitutes controlled by the anal sphincter: a comparison of the different absorption potentials

A comparative study of the absorption potentials of the simple rectal bladder (10 patients), modified rectal bladder (20) and ureterosigmoidostomy (10) was done with intrarectal instillation of 22sodium. Results indicate that absorption is significantly greater among patients with ureterosigmoidostomy. The emptying patterns of ureterosigmoidostomy and the modified rectal bladder were also studied by ascending scintigraphy with 99mtechnetium. Evidence was provided that in cases with ureterosigmoidostomy the isotope is distributed throughout the entire colon. These studies proved the role of the colorectal valve in preventing reflux of urine from the rectum to the proximal colon. Consequently, the surface area of colonic mucosa exposed to urine is decreased and the rate of reabsorption is limited.

Urinary diversion to the augmented and valved rectum: preliminary results with a novel surgical procedure

A new method for urinary diversion to the rectum was elaborated in animal experiments and currently has been used in 19 patients. Reflux of the rectal content to the colon and to the upper urinary tract is prevented by the fashioning of an intussusception valve at the rectosigmoid junction. The rectum is augmented by anastomosing an ileal patch to the anterior rectal wall. A transverse colostomy protects the construction for 6 to 8 weeks. Of the 19 patients 3 had local recurrence or metastasis within 6 months. Thus, 16 patients with a followup of 3 to 14 months are evaluable. All patients are continent during the daytime with an emptying frequency of 3 to 5 times and dry at night with a frequency of 0 to 2. In 3 patients partial sliding of the sigmoid intussusception valve occurred causing reflux of rectal contents to the sigmoid and to the right ureter in 1. Reflux to the upper urinary tract has not been revealed in any of the other patients. With 1 exception excretory urography has demonstrated either improvement or stabilization of the upper urinary tract post-operatively. The rectal capacity increased from 200 to 700 ml. after 6 months. With the reservoir full the mean basal pressure was 17 cm. water and the mean maximum pressure was 24 cm. water.

Urinary diversion to the augmented and valved rectum. An experimental study in dogs

A new model for diverting urine to the rectum was tried in dogs. An intussusception valve was constructed at the junction of the sigmoid colon and the rectum allowing passage only in aboral direction. The rectum was augmented by patching it with an opened and folded ileal segment. The ureters were implanted into the rectum by a new anti-reflux method. All three dogs survived the operation. The volume of the augmented rectum increased from 80-150 ml at operation to a maximum of 750 ml six months after the operation. The pressure in the rectum did not exceed 18 cm of water during maximal filling. No reflux to the bowel proximal to the intussusception valve or to the ureters could be observed even during maximal filling of the augmented rectum. No signs of obstruction of the fecal stream by the intussusception valve were seen. In three out of five implanted renal units strictures developed at the implantation sites and resulted in impaired renal function. In the two renal units without strictures, no impairment of kidney function was found. Involuntary leak from the anus was not observed and no masceration was found around the anus. These experiments are regarded as very encouraging an a clinical trial is now under way.

Bladder reconstruction following cystectomy by uretero-ileo-colourethrostomy

Five patients who had had the bladder removed underwent uretero-ileo-colourethrostomy construction to allow for urination in a physiological manner. All 5 patients void spontaneously and have daytime continence, while 1 requires intermittent catheterization twice daily and 1 has significant enuresis. This method is promising for reconstruction of the urinary tract following cystectomy for benign and malignant diseases.

Bladder reconstruction in the surgical management of bladder cancer

As the preceding discussion has demonstrated, a number of ingenious yet relatively practical approaches have been proposed for urinary reconstruction following partial or total cystectomy for bladder cancer. Ileal conduit diversion and ureterosigmoidostomy are the only procedures for which there is adequate clinical experience to judge their relative advantages and disadvantages. Neither is an ideal form of diversion but both are practical solutions to the problem of urinary drainage following radical cystectomy. Until effective alternatives are developed, these procedures will remain the standard therapies in the management of bladder cancer. The ideal bladder substitute which needs to be developed must be continent, able to evacuate completely, have minimal physiologic consequences, and be stomaless. Ureteroiliourethrostomy comes closest to fulfilling these criteria, but there is persistent skepticism about the ability of the ileal bladder to empty effectively. Further clinical trials of this procedure are necessary before any definitive statements are possible regarding its eventual role in patients with bladder cancer. The major consideration in urinary reconstruction in the management of bladder cancer is the possibility of tumor recurrence in an adjacent urinary segment. Partial rather than total bladder reconstruction is usually precluded by this factor, but may be feasible in carefully selected patients. Staged urinary reconstruction, such as initial conduit diversion and later reestablishment of urinary continuity once tumor recurrence has been ruled out, is an attractive but relatively untried solution to this problem. The quality of life of the patient must improve to an extent which warrants the operative risks involved. To minimize these risks, a flexible, reliable, and uncomplicated procedure must be developed and must withstand prolonged clinical scrutiny. Advances in urinary reconstruction in the management of bladder cancer are eagerly anticipated by surgeons and patients alike.