Indications and early and late results of intestino-cystoplasty: a review of 185 cases

Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder

PURPOSE

We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up.

MATERIALS AND METHODS

We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function.

RESULTS

We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52 months (IQR 31-103 months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45 ml/min.

CONCLUSIONS

Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45 ml/min are at greater risk of a decline in renal function following reconstruction.

Long-term effectiveness and safety of bladder augmentation in spina bifida patients

AIMS

To establish the long-term efficacy and safety of bladder augmentation in spina bifida patients.

MATERIAL AND METHODS

Sixteen patients were operated on using the Bramble technique. Preoperative and postoperative evaluation included clinical history, blood tests, urine cultures, cystography, pyelography, ultrasound, and filling cystometry. In the final review a standardized quality of life questionnaire was applied.

RESULTS

Median follow-up was 20 years (15-26). Kidney function was stabilized except for one case that required a kidney transplant. Hydronephrosis disappeared or improved (p = 0.03). Vesicoureteral reflux grades I-II was cured without reimplantation and grades III-IV responded better with reimplantation than without (p = 0.03). Quality of life improved in all patients, with all stating they would undergo the procedure again. After surgery, 94% of the patients exhibited diurnal continence but 25% exhibited nocturnal incontinence. Pressure at capacity decreased and bladder capacity increased (p < 0.001). One patient presented ureteral fistula with another presenting hemorrhage. Both required immediate surgical review. Late complications included urinary sphincter cuff erosion, renal lithiasis, four instances of bladder lithiasis and repeated pyelonephritis in one 24-year-old patient. All required surgery. The mean of urinary infections fell, from 2.5 per year (0.7) to 1 (0.5) (p = 0.03).

CONCLUSION

Augmentation cystoplasty (AC) maintains its efficacy and improves quality of life in the long term. However, serious surgical complications can ensue, along with minor or major subsequent complications. This should be considered before surgery and makes lifelong monitoring of patients necessary.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance.

RECENT FINDINGS

Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

Can baseline serum creatinine and e-GFR predict renal function outcome after augmentation cystoplasty in children?

OBJECTIVE

To assess cut-off value of creatinine and glomerular filtration rate for augmentation cystoplasty (AC) in paediatric age-group.

MATERIALS AND METHODS

Data of all paediatric-patients (<18 years) with small capacity bladder, in whom AC was advised between 2005-2015 were reviewed. All patients were divided in two-groups, AC-group and control-group (without AC). Creatinine and e-GFR were assessed at the time of surgery, at 6 months and at last follow-up. Renal function deterioration was defined as increase in creatinine by ≥25% from baseline value or new-onset stage-3 CKD or worsening of CKD stage with pre-operative-CKD stage-3. ROCs were plotted using creatinine and e-GFR for AC.

RESULTS

A total of 94 patients with mean-age 8.9 years were included. The mean creatinine and e-GFR were 1.33mg/dL and 57.68mL/min respectively. Out of 94 patients, AC was performed in 45 patients and in the remaining 49 patients AC was not done (control-group), as they were not willing for the same. Baseline patient's characteristics were comparable in both Groups. 22 underwent gastro-cystoplasty (GC) and 25 underwent ileo-cystoplasty (IC). Decline in renal function was observed in 15 (33.3%) patients of AC-group and in 31 (63.3%) patients of control-group. Patients having creatinine ≥1.54mg/dL (P=0.004, sensitivity (S) 63.6% and specificity (s) 90.5%) at baseline and e-GFR ≤46mL/min (P=0.000, S=100% and s=85.7%) at the time of surgery had significantly increased probability of renal function deterioration on follow-up after AC.

CONCLUSION

e-GFR ≤46mL/min and creatinine ≥1.54mg/dL at time of surgery could serve as a predictor of renal function deterioration in AC in paediatric patients.

Factors Predicting Renal Function Outcome after Augmentation Cystoplasty

We determined the cause of renal deterioration after augmentation cystoplasty (AC). Twenty-nine adult patients with refractory bladder dysfunction and who underwent ileocystoplasty from 2004 to 2015 were studied. Patients with a decline in glomerular filtration rate (GFR) after augmentation were reviewed. The primary outcome was to determine the factors that might lead to deterioration of estimated GFR. Median follow-up was 7.0 ± 2.6 years. Significant bladder capacity, end filling pressure, and bladder compliance were achieved from median 114 ± 53.6 to 342.1 ± 68.3 ml (p = .0001), 68.5 ± 19.9 to 28.2 ± 6.9 cm H₂O (p = .0001), and 3.0 ± 2.1 to 12.8 ± 3.9 (p = .0001), respectively. Renal function remained stable and improved in 22 (76%) patients from median eGFR 135 ± 81.98 to 142.82 ± 94.4 ml/min/1.73 m² (p = .160). Significant deterioration was found in 7 (24%) patients from median eGFR 68.25 ± 42 to 36.57 ± 35.33 (p = .001). The causes of renal deterioration were noncompliance to self-catheterization (2 patients), posterior urethral valve/dysplastic kidneys (2 patients), and reflux/infection (2 patients). On multivariate analysis, recurrent pyelonephritis (OR 3.87, p = 0.0155) and noncompliance (OR 30.78, p = 0.0156) were significant. We concluded that AC is not the cause of progression to end-stage renal disease in patients with renal insufficiency.

Augmentation cystoplasty: Urodynamic and metabolic outcomes at 10-year follow-up

OBJECTIVE

To review the urodynamic outcomes, renal function and metabolic complications after augmentation cystoplasty with at least 10 years of follow-up.

METHODS

Augmentation cystoplasty performed in two tertiary referral centers from 1995 to 2004 were reviewed. Ten years or more postoperative course was studied by review of the clinical notes, urodynamic reports and laboratory results.

RESULTS

A total of 40 patients were included in this study. The mean age at surgery was 43 years, and 47.5% of patients were female. Median follow up was 13 years. Bladder capacity significantly increased from 283 ± 151 to 492 ± 123 mL (P < 0.01), with a percentage change of +130%. The compliance of the bladder was increased by 87%, and detrusor overactivity decreased by 54.2%. There were no significant changes in preoperative and postoperative estimated glomerular filtration rate (68.3 mL/min vs. 76.6 mL/min, P = 0.798). Three patients (7.5%) had more than one episode of symptomatic urinary tract infection per year.

CONCLUSION

The present study confirms the effectiveness of augmentation cystoplasty in increasing bladder capacity, improving bladder compliance and reducing detrusor overactivity. The preservation of renal function and low metabolic complication rate provide solid evidence for carrying out this time-honored procedure in patients with neurogenic or non-neurogenic bladder dysfunction.

Augmentation cystoplasty: Contemporary indications, techniques and complications

Augmentation cystoplasty (AC) has traditionally been used in the treatment of the low capacity, poorly compliant or refractory overactive bladder (OAB). The use of intravesical botulinum toxin and sacral neuromodulation in detrusor overactivity has reduced the number of AC performed for this indication. However, AC remains important in the pediatric and renal transplant setting and still remains a viable option for refractory OAB. Advances in surgical technique have seen the development of both laparoscopic and robotic augmentation cystoplasty. A variety of intestinal segments can be used although ileocystoplasty remains the most common performed procedure. Early complications include thromboembolism and mortality, whereas long-term problems include metabolic disturbance, bacteriuria, urinary tract stones, incontinence, perforation, the need for intermittent self-catheterization and carcinoma. This article examines the contemporary indications, published results and possible future directions for augmentation cystoplasty.

New therapies in the treatment of overactive bladder

INTRODUCTION

Overactive bladder (OAB) is a common condition which affects both men and women across many age groups with significant impact on quality of life. There is currently an armamentarium of treatment options available ranging from conservative, medical therapy to radical surgeries. Increasing understanding of OAB is resulting in the rapid development of new therapies today.

AREAS COVERED

The purpose of this article was to summarise the latest developments in non-neurogenic OAB treatment, discuss the evidence and results of current and new treatment modalities available through review of published data and results presented at recent international meetings.

EXPERT OPINION

The ultimate goal in OAB therapy is to provide good clinical efficacy, safe, non-invasive and easy to administer. There is definitely room for development of new therapies in OAB and current progress is encouraging.

The past, present and future of augmentation cystoplasty

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

Reconstructive bladder surgery in genitourinary tuberculosis

Genitourinary tuberculosis (GUTB) occurs in 15-20% cases of pulmonary tuberculosis with a prevalence of 400 per 100,000 population. Reconstructive surgery for GUTB is required for cases with grossly distorted and dysfunctional anatomy that are unlikely to regress with chemotherapy alone. In the recent past, there has been a tremendous increase in the variety of reconstructive procedures for the urinary bladder, used in the management of GUTB. Augmentation cystoplasty includes the goals of increasing bladder capacity, while retaining as much of bladder as possible. Various bowel segments (from the stomach to the sigmoid colon) have been used for bladder reconstruction. The choice of material for reconstruction is purely the surgeon's prerogative--his skill, the ease, the mobility and length of mesentery (allowing bowel to reach the bladder neck without tension and maintaining an adequate blood supply). The presence or absence of concomitant reflux is of considerable importance. In the former, an ileocystoplasty with implantation of ureter to the proximal end of the isolated ileal loop and anastomosis of the distal end of the ileal loop to the bladder neck and trigone is advocated. In the latter case, the ureterovesical valve is preserved and colocystoplasty is preferred, wherein the sigmoid colon on being opened along its antimesentric border is joined to the trigone and bladder neck and then to itself to form a capacious pouch. Gastrocystoplasty reduces the risk of acidosis but is associated with complications like hypochloremic alkalosis and ‘hematuria-dysuria’ syndrome. Orthotopic neobladder reconstruction is a feasible option, suitable in cases of tubercular thimble bladder with a markedly reduced capacity (as little as 15 ml), where an augmentation alone may be associated with anastomatic narrowing or poor relief of symptoms. In this article, we review the various bladder reconstruction options used for the surgical management of GUTB, along with their indications and complications.

Reconstructive surgery for tuberculous contracted bladder: experience of a center in northern India

OBJECTIVE

To document the management of tuberculous cicatrized urinary bladder by incorporating bowel segment and the long-term follow-up after the reconstructive surgery.

MATERIALS AND METHODS

Twenty-three patients (out of 28) were managed by augmentation cystoplasty (AC) and 5 by orthotopic neobladder (OTN) reconstruction. Sigmoidocystoplasty was performed in 11 cases, ileocystoplasty in 10 patients and ileocecocystoplasty in 2 patients. Ileal neobladder reconstruction was done in 2 patients, ileocecal neobladder reconstruction in 1 patient and sigmoid neobladder reconstruction in 2 patients, respectively. The patients were followed according to standard follow-up protocols.

RESULT

The mean age of patients who underwent AC was 32.5 years and of those who underwent OTN reconstruction was 31 years. The mean pre-operative bladder capacity in patients with AC was 70 ml (range 40-100 ml) and of patients with OTN reconstruction was 14 ml (range 10-20 ml). The mean postoperative bladder capacity at 3 months following AC was 427 ml (range 450-500 ml) and following OTN reconstruction it was 430 ml (range 350-450 ml). The mean follow-up in patients who underwent AC was 43.3 months (range 12-90 months) and in those who underwent OTN reconstruction it was 35.6 months (16-60 months). None of the patients had upper urinary tract deterioration following the reconstructive surgery.

CONCLUSION

Urinary bladder rehabilitation either by AC or OTN reconstruction increases the bladder capacity and storage time and also preserves the upper tracts.

Laparoscopy-assisted ileal ureter creation for multiple tuberculous strictures: report of two cases

We describe in detail the technique of laparoscopy-assisted ileal ureter creation for multiple tuberculous ureteral strictures in two patients. The proximal anastomosis included an ileocalicostomy in the first patient and an ileopyelostomy in the second patient. The first patient had bowel entrapment behind the mesentery of the ileal loop, but the second patient had an uneventful postoperative recovery. Short-term follow-up showed good patency of the ileal loop. The variations in the technique that can cause postoperative problems are discussed, and the future of this technique is postulated.

Preventing reservoir calculi after augmentation cystoplasty and continent urinary diversion: the influence of an irrigation protocol

OBJECTIVE

To evaluate the influence of an irrigation protocol in preventing reservoir calculi forming after augmentation cystoplasty and continent urinary diversion.

PATIENTS AND METHODS

Between 1985 and 1995, 91 patients had an augmentation cystoplasty and/or continent urinary diversion (group 1; 54 females and 37 males, mean age 11.1 years, range 1-31); these patients were not routinely instructed to use irrigation after surgery. The segments used included ileum (44), colon (36), stomach (eight) and ureter (three). Between 1995 and 2000, 42 patients (group 2) underwent urinary reconstruction (22 females and 20 males, mean age 14.8 years, range 4-27), the segment used being ileum (30), colon (five), ureter (five) and stomach (two) but in contrast to group 1 they then were placed on a standard prophylactic irrigation protocol. The occurrence of stones in the reservoir was then assessed.

RESULTS

Thirty-nine of the 91 patients (42.8%) in group 1 presented with reservoir calculi after reconstruction and 22 had several episodes. The mean time to presentation was 30 months. The incidence of stone formation by underlying diagnosis included: myelomeningocele, 32/48 (66%), exstrophy five/25 (25%), posterior urethral valves two/20 (10%) and rhabdomyosarcoma, none of three. Fifty of the 91 patients had an abdominal stoma, with stone formation in 33 (66%), while 41 used the native urethra, with stone formation in six (15%). Three (7%) of the 42 patients in group 2 developed reservoir calculi after reconstruction, two in patients with myelomeningocele and one in a trauma patient who had residual bone spicules in the bladder; the mean time to presentation was 26.5 months.

CONCLUSIONS

These data suggest that the irrigation protocol used in group 2 significantly reduced the number of reservoir calculi after urinary tract reconstruction when bowel was used as part of the reconstruction (43% vs. 7%). The most calculi in both groups were in immobile patients with sensory impairment. Also, patients with an abdominal stoma had a greater risk of reservoir calculi (66%) than those using the native urethra (15%).

[Ureteral stenosis of uretero-ileal anastomosis]

Replacement plasty allows to perform oncology surgery while maintaining body image and preserving renal function. Entero-ureteral anastomosis is a significant element in this procedure where the main responsible for the loss of renal function are stenosis, infection and reflux. Our group has performed 206 orthotopical vesical replacements (November 1981-November 1998), using a direct Wallace-type uretero-ileal anastomosis. An intussusception valve system was used as antireflux mechanism. The number of obstructions, rate of stenosis at the uretero-ileal junction and incidence of valve stenosis were all analyzed as part of the complications occurred over a follow-up period of 54 months (6-183). Findings included 6 stenosis at the uretero-intestinal junction and 2 at the intussusception valve. Two (3.8%) of the uretero-ileal stenosis were earlier and associated to fistula; one was treated with open surgery and one had a double J placed through antegrade percutaneous access. Of the remaining late four, only one was treated with a double J catheter while the other three had to be re-operated. Stenoses of the valvular system (1.2%) were solved with open surgery. From our experience, we believe that direct uretero-ileal implantation with scraping of the ureter is a safe technique with little risk for stenosis at the uretero-ileal junction. Intussusception was used a antireflux system in all cases.

Orthotopic neobladder in management of tubercular thimble bladders: initial experience and long-term results

OBJECTIVES

To describe the indications and long-term results of orthotopic bladder replacement for tubercular thimble bladders.

METHODS

Four patients (3 women, 1 man; mean age 32 years) presented with markedly contracted bladders of tubercular etiology. The patients had marked lower tract symptoms, and the mean bladder capacity was 15 mL. All 4 patients had associated upper tract pathology. Four-drug antitubercular treatment (ATT) was started in all 4 patients, and all 4 underwent surgery 4 weeks later. The procedure performed was a cystectomy and orthotopic bladder reconstruction using the ileocecal segment in 3 patients and the sigmoid colon in 1. The ureters were implanted into the taenia of the cecum or the sigmoid in an antireflux fashion. ATT was continued for a total of 9 months.

RESULTS

All patients had an uneventful postoperative course. After a follow-up period ranging from 22 to 54 months (mean 38), the average bladder capacity in the 4 patients was 450 mL (range 400 to 600). The mean maximal flow rate was 18.3 mL/s. Potency was preserved in the man and all patients were continent at last follow-up. The male patient had hypercontinence requiring clean intermittent catheterization for a period of 3 months. At last follow-up all patients had residual-free micturition. The female patients were able to void to completion with a Valsalva maneuver. No patient had symptomatic urinary infection or deterioration in renal function. No patient had persistent ureteral reflux or stricture.

CONCLUSIONS

Cystectomy with orthotopic bladder replacement offers an alternative to the urologist treating end-stage tubercular bladders (thimble bladders) with a capacity of less than 15 to 20 mL. This treatment removes the source of the symptoms, permits anastomosis to healthy tissue of the proximal urethra, and addresses lower ureteral pathology at the same time. The long-term results in these initial cases are encouraging; however, only a prospective, randomized trial can establish whether these advantages actually translate into long-term clinical benefit in this group of patients.

Management of complete ureteral replacement. Experiences and review of the literature

The common treatment for patients with extensive damage to the ureter is complete ureteral replacement, combining Boari flap-psoas bladder hitch and downward mobilization of the involved kidney, with complete ideal replacement of the ureter, renal autotransplantation, of elective nephrectomy. Three case reports serve to describe two options of reconstructive treatment for complete ureteral replacement. The operative techniques, their limits, their postoperative results, and the treatment alternatives are discussed with due regard to recent literature. In the case of ileal replacement we have used a very short ileal segment to reduce the absorption surface of the ileal mucosa. Reflux prevention of the ileal segment was performed by creating an invaginated distal ileum nipple which was additionally fixed at the Boari flap by a third stapler row (auto suture TASS) to prevent potential nipple-gliding.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

Photochemical ablation of intestinal mucosa for bladder augmentation

Complications associated with enterocystoplasty include mucus production, electrolyte abnormalities, infections, stones and cancer at the vesicoenteric anastomosis. Removal of the intestinal mucosa with subsequent urothelialization may obviate these problems. We describe a unique approach whereby photodynamic therapy is used to de-epithelialize an ileal segment before augmentation. Enterocystoplasty was performed in 32 female Fischer 344 rats using a 1.5 cm. patch of terminal ileum. Of the 32 rats 24 survived at least 6 weeks before euthanasia. The experimental group (10 rats) received hematoporphyrin derivative intravenously 24 hours before surgery. The ileal patch was treated with red light for 20 minutes and then used for augmentation. There were 3 control groups, including 1 group of 5 rats that underwent augmentation alone, while the other 2 groups were augmented but received either light treatment (4 rats) or hematoporphyrin derivative (5 rats). Histological analysis revealed urothelialization of the augments treated with hematoporphyrin derivative and light, which did not occur in the controls. The preoperative and postoperative bladder capacities increased substantially in all groups. Mucus production and bacterial colonization were reduced while stone formation increased in the treated animals.

Refluxes in orthotopic neobladders: can the ileocecal sphincter be considered an adequate antireflux mechanism?

OBJECTIVES

To evaluate the usefulness of the ileocecal sphincter in preventing ureteral refluxes in ileocecal orthotopic neobladder, thus avoiding the use of antireflux technique for ureteroileal anastomosis.

METHODS

From 1980 to 1992, 95 patients underwent orthotopic bladder substitution. In 30 our detubularized ileal reservoir was used and in 65 first only an integral ileocecal segment was used and subsequently multiple transverse teniamyotomies on the cecal portion to increase the capacity and reduce the pressure. The upper urinary tract was indirectly protected in the ileal reservoir technique by leaving an integral 8 to 10 cm long afferent segment folded behind the reservoir and in the ileocecal technique by the ileocecal sphincter, thus keeping the anastomosis between ureters and ileum simple and direct.

RESULTS

The mean follow-up of the 65 patients with ileocecourethrostomy is 37 +/- 33 months (range, 2 to 141 months); in 13.8% of the patients (9/65) monolateral refluxes appeared, but without any evident clinical consequences. The appearance of monolateral stenosis on the ureterointestinal anastomosis requiring treatment occurred in 4 patients (6%): 3 underwent an endoscopic treatment and 1 a surgical one. Modifications of renal function with respect to the preoperative status were not verified in any of the patients.

CONCLUSIONS

The ileocecal sphincter is an effective antireflux mechanism for an orthotopic neobladder in which multiple transverse teniamyotomies (5 to 7) increase the capacity of the neobladder itself, reduce its internal pressure, and confer a nearly spherical configuration. Moreover, a correct anastomosis between the cecum and membranous urethra decisively reduces the resistance to emptying of the neobladder, thus avoiding too strong pressures against the ileocecal sphincter. The integrity of the circular muscular layer maintains a healthy tonic wall: this fact, combined with the low peripheral resistances, ensures good emptying and a stable capacity. The procedure is easy to perform and not time-consuming; these considerations lead us to consider the ileocecal unit an excellent structure for bladder substitution.

Urolithiasis in children following augmentation cystoplasty

Until recently urolithiasis in children following augmentation cystoplasty was an infrequently noted problem. We examined our 10-year experience and found urinary calculi to form in 52% of children and young adults undergoing augmentation cystoplasty. Calculi formed at a median interval of 24.5 months after surgery, predominantly in the lower tract. Urinary tract infection was a statistically significant risk factor, while the use of absorbable staples, intestinal mucus and hypocitraturia were also implicated. Calculus composition was primarily a mixture of apatite, struvite and ammonium urate. Bladder calculi were effectively managed endoscopically in the majority of cases without complication. Upper tract calculi presented an endourological challenge.

Complications of enterocystoplasty

Bladder reconstruction, either by augmentation or substitution enterocystoplasty, is a safe alternative to supravesical urinary diversion providing careful attention to preoperative selection, surgical technique, and postoperative review is observed. However, under the most optimal conditions an untoward outcome may occur. We reviewed our series of 100 intestinocystoplasties to categorize the types of complications encountered, and to identify preoperative risk factors that could potentially develop into an unfavorable sequela. Twenty-seven patients required either early or late surgical intervention, while 30 were managed nonoperatively. In our review we identified two groups, those with myelodysplasia and those with a solitary functioning kidney, who are at a higher risk for an unfavorable outcome to develop.

Evaluation of augmentation cystoplasty for severe neuropathic bladder using the hostility score

In a retrospective study, the pre-operative urodynamic findings of 41 myelodysplastic patients who had undergone enterocystoplasty for intractable incontinence or deteriorating upper urinary-tracts were compared with findings from similar studies. An objective score combining five urodynamic parameters, the Hostility Score, was calculated before and after surgery to assess its clinical applicability in guiding and monitoring patient management. A score of greater than or equal to 5 should be avoided, if possible, as deleterious upper urinary-tract changes can occur even while on conservative management. In this series the mean pre-operative Hostility Score was 5.6, with 26 patients having a mean score of greater than or equal to 5. After surgery the mean score was reduced to 2.8, with no patient having a score of greater than 4. We conclude that the Hostility Score is a reliable tool for the management and follow-up of patients who have neurogenic bladder disease as a result of myelodysplasia.

Bladder augmentation and replacement. Urodynamic and clinical review of 25 patients

Bladder augmentation has a role in the management of patients with neuropathic bladder dysfunction and in urinary undiversion. Several reports attest to its clinical value, but there have been few detailed urodynamic studies of its effects. We have carried out a prospective review over a 4-year period of 25 patients undergoing bladder augmentation or substitution assessed by conventional and ambulatory urodynamic studies. All patients had a detubularised reservoir made of ileum in 6, and of the ileocaecal segment in the remainder. Six patients also had an artificial sphincter fitted and 2 underwent colposuspension. There was no mortality. After operation, bladder capacity increased from 122 +/- 91 ml to 659 +/- 431 ml and there were significant decreases in the pressure rise during filling and increases in bladder compliance. Hyper-reflexia was present in 74% before operation and 23% after operation. Regular phasic activity was observed in 77% of patients at the end of filling after operation, probably due to bowel activity despite detubularisation. Four patients described urge incontinence associated with this activity. After operation, one man had persistent major stress incontinence. He has since undergone insertion of an artificial urinary sphincter (AUS) and is now completely dry. Of the remainder, 10 patients had minor, infrequent defects in continence, 9 patients with leakage when the bladder was full and 4 with occasional leakage at night. With the exception of the patient with major stress incontinence, all but one felt the operation had been worthwhile--40% reporting complete success and 52% excellent improvement. Reconstruction of the neuropathic lower urinary tract is a major surgical procedure, but the final clinical outcome is very satisfactory.

Ileocecocystoplasty for the management of refractory neurogenic bladder: surgical technique and urodynamic findings

A total of 21 incontinent adults with a neurogenic bladder who were refractory to conservative management underwent a modified technique of ileocecocystoplasty. Followup ranged from 1 to 6 years (mean 3.1 years). To ensure a wide anastomosis the augmentation was accomplished by suturing a detubularized ileocecal patch to a large posterior based bladder flap anchored to the psoas muscles. Postoperatively 20 of 21 patients were continent. The remaining woman was cured after surgical correction of sphincteric incontinence. Mean bladder capacity increased from 185 +/- 17 to 595 +/- 43 ml. (standard error). Mean maximum detrusor pressure decreased from 53 +/- 6.3 to 16 +/- 2.3 cm. water (p less than 0.0001). Followup revealed a persistently large capacity, low pressure reservoir in all patients. No patient required anticholinergic medication. None experienced acid-base imbalance, tumors in the augmented bladder or upper tract deterioration. We conclude that this technique of ileocecocystoplasty is suitable for the management of patients with a refractory neurogenic bladder.

Ileal segment for ureteral substitution or for improvement of ureteral function

A total of 29 patients received an ileal segment interposition between the upper and lower urinary tract for partial or total ureteral substitution, or for ileal wrapping around a massively dilated, aperistaltic ureter. Indications for an operation included the presence of an extensively diseased or short ureter and an aperistaltic megaureter that had failed previous reconstructive attempts. Nine patients (group 1) underwent an ileal sleeve procedure in an attempt to increase the ureteral peristaltic activity and facilitate drainage. Among these patients 7 (78%) had a stable upper tract radiologically and normal serum creatinine (less than 1.6 mg./100 ml.), while 2 (22%) had deterioration of the renal function. Ten patients (group 2) had undergone a myriad of reconstructions that failed and then underwent complete ureteral substitution with ileum. Among them, renal function (as evidenced by excretory urography and serum creatinine) is stable in 7 (70%) and deteriorated in 3 (30%). In 10 patients (group 3) the ureters were partially replaced by ileum in addition to a bladder augmentation procedure. Of these patients 8 (80%) have stable renal function and 2 (20%) had renal failure. Over-all, 7 patients have different degrees of renal failure; among them 2 (6.9%) are on dialysis and 2 (6.9%) have received a transplanted kidney. In groups 2 and 3 the results with an antireflux operation indicated that among 6 ureteroileal reimplantations 5 (83%) were successful, among 12 intravesical intestinal nipples 6 (50%) failed to prevent reflux and there was no case of obstruction, while among 4 ileocecal intussusceptions 2 (50%) were successful and 2 failed. Mucous secretion produced temporary ureteral obstruction in 1 ureter (3.4%), which resolved without surgical intervention. Some of the aforementioned procedures were done in the past and in some situations a different reconstructive technique would be considered presently. The surgical complexity and magnitude of the procedures justify their performance only in difficult clinical situations as an alternative to urinary diversion or renal autotransplantation.

Bladder augmentation: experience with 129 children and young adults

From 1977 to 1989 bladder augmentation was performed in 56 male and 73 female patients from 1 to 35 years old (average age 12.7 years). In 59 cases augmentation was performed as part of an undiversion operation. Indications for augmentation included neurogenic bladder, severely scarred bladder from prior operations, noncompliant bladder after previous treatment of severe urethral valves, small bladder in former exstrophy patients, epispadias with a small bladder, cloacal exstrophy, and small, noncompliant bladder after therapy for cancer, trauma, cloaca and miscellaneous conditions. We used 145 bowel segments, since 16 patients had 2 bowel segments. Segments included cecum in 65 cases, sigmoid in 46, small bowel in 24, stomach in 4 and left colon in 1. The most common complication was stones. Detubularized bowel for augmentation of small noncompliant bladders allows functional reconstruction in a wide range of urological disorders that were formerly treated by diversion. Reconstruction is possible in many previously diverted patients if bladder augmentation is used.

Continent urinary reconstruction in ischiopagus tripus conjoined twins

The principle of the continent urinary reservoir involves use of a variety of intestinal segments providing continence, a mechanism of antireflux and a catheterizable stoma in either an abdominal or pelvic location. This concept was used to create a continent urinary reservoir in a 3-year-old former ischiopagus tripus conjoined twin. The solitary renal unit had been drained into a hydrocolpos with an antirefluxing ureteral reimplantation at separation. The patient remained incontinent through the urogenital sinus. At subsequent reconstruction the posterior aspect of the hydrocolpos was tubularized as a vagina, while the remainder of the hydrocolpos was augmented with ileum to create a urinary reservoir. The conduit was constructed with imbricated ileum, in which myectomy had been performed to allow for easier imbrication and tubularization for a narrow neourethra. A second set of conjoined twins have been separated similarly. Of these twins 1 will undergo creation of a continent urinary reservoir in an identical fashion. This represents the first report of the use of hydrocolpos in the creation of a urinary reservoir.

Glomerular filtration rate up to 10 years after urinary diversion of different types. A comparative study of ileal and colonic conduit, refluxing and antirefluxing ureteral anastomosis and continent caecal reservoir

To evaluate the influence of conduit type (ileal or colonic) and method of ureterointestinal anastomosis (refluxing or antirefluxing) on renal function in patients with urinary diversion, a prospective randomized trial was conducted in 1977-1984. During these years urinary diversion via a continent caecal reservoir emerged as an alternative to conduit diversion at our hospital, and these patients with continent reservoir were also included in the study. Total and separate glomerular filtration rate (GFR) were measured, the latter with scintillation camera renography, preoperatively and at follow-up in 70 patients. Measurements 2-10 years postoperatively showed slight to moderate decrease of GFR in all groups, with no significant difference between values according to conduit type or caecal reservoir or between refluxing and antirefluxing ureterointestinal anastomosis. Almost all of the anastomotic strictures involved the ureter that had been brought beneath the sigmoid mesentery, indicating that ischemia secondary to extensive ureteral mobilization is a likely cause of stricture in these cases.

Spontaneous bladder rupture following enterocystoplasty

We treated 2 male patients with spontaneous bladder rupture following enterocystoplasty. Both adolescents had neurogenic bladders that were managed with enterocystoplasty and an artificial urinary sphincter. With prompt aggressive therapy including intravenous antibiotics, laparotomy and closure of the perforation serious sequelae were averted. Cystography failed to demonstrate the lesion in either case. The failure of cystography to diagnose these ruptures is especially disturbing. These patients demonstrate that in augmented bladders a high index of suspicion may be necessary to diagnose ruptures clinically. Early diagnosis is critical so that aggressive therapy may be instituted.

Functional results after ileocystoplasty

The functional results after ileocystoplasty were studied in seven patients with interstitial cystitis, irradiated bladder and neurogenic bladder dysfunction. None of the patients had had symptomatic improvement by medical or surgical means. All patients were suffering from urinary frequency and five patients had severe urge incontinence or suprapubic pains. Postoperatively the patients were followed from 8 to 66 months and evaluated by urodynamic examinations and interviews. Urinary frequency was improved in all patients but one with interstitial cystitis who had persisting suprapubic pains. None had residual urine volume greater than 30 ml postoperatively. It is concluded that bladder augmentation by ileocystoplasty is an excellent method of treatment for patients with contracted bladder secondary to interstitial cystitis, irradiated bladder, and detrusor hyperreflexia and sphincter dyssynergia.

Treatment of iatrogenic functional or morphologic bladder loss

From 1984 to 1986, six children from 4 to 13 years of age, received a bladder augmentation by ileocecal cystoplasty (Mainz-pouch technique) because of an iatrogenic functional or morphologic bladder loss. Indications for operation were incontinence due to the low bladder capacity or threat to the upper urinary tract due to ureteral obstruction or vesicorenal reflux. Two of the children had already undergone supravesical urinary diversion by sigmoid conduit. After a follow-up period of 2 to 19 months, (mean 11 months), five of the six children are completely continent. One boy with a known weak sphincter still has slight, but decreasing, enuresis nocturna in periods of complete filling of the pouch, 1 month after the operation. All children are able to void their augmented bladders without residual urine.

Bladder reconstruction after cystectomy: use of ileocecal segment and three-loop ileal reservoir

We report on 11 patients who in 1980-1982 had bladder reconstruction, after cystectomy for bladder cancer, utilizing the ileocecal valve as an antireflux mechanism and a direct urethrocecal anastomosis. They received preoperative irradiation (2,000 rad) and had some early complications such as pelvic abscesses and temporary urinary fistulas. We have since omitted preoperative radiation on cases performed in 1984-1987 and they did not have these complications.

Pediatric urinary diversion and undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.