Carcinogenesis. The fate of intestinal segments used in urinary reconstruction

A single centre experience on the formation of double barrelled uro-colostomy in pelvic exenteration surgery: a cohort study

BACKGROUND

Double barrelled uro-colostomy (DBUC) is an alternative to traditional ileal conduit (IC) and separate colostomy in patients requiring simultaneous urinary and faecal diversion for reconstruction in pelvic exenteration surgery (PES).

METHODS

This cohort study evaluated short- and long-term morbidity and mortality associated with DBUC formation in 20 consecutive adult patients undergoing PES in an Australian Complex Pelvic Surgical Unit. Data were obtained from a prospective database.

RESULTS

Mean age 59 years (range 27-76 years). PES was performed for malignant disease in 18 patients (curative intent in 17). Mean operative duration 11.8 h (range 7-17 h). Mean follow-up duration 29.1 months (range 2.6-90.1 months). Early DBUC-related complications occurred in four patients (20.0%): urinary tract infection (UTI)/urosepsis (n = 4) and early ureteric stenosis requiring intervention (n = 1). Late DBUC-related complications occurred in five patients (25.0%): recurrent UTI/urosepsis (n = 4), chronic kidney disease (n = 4), ureteric stenosis (n = 2) and parastomal hernia (n = 4). No mortality occurred secondary to a DBUC complication.

CONCLUSION

DBUC is a safe reconstructive option with acceptable morbidity profile in patients requiring simultaneous urinary and faecal diversion.

The double-barrel wet colostomy: An alternative for urinary diversion after pelvic exenteration

AIM

Pelvic exenteration is a radical procedure used to treat locally advanced and/or recurrent pelvic malignancies. Different reconstruction options exist, the most popular being the end colostomy with ileal conduit. The double barrel wet colostomy (DBWC) offers concomitant fecal and urinary diversion through a single stoma, but is infrequently utilized. We aim to review the evidence base of the postoperative complications, long-term oncologic risks and quality of life following creation of a double barrel wet colostomy.

METHODS

A narrative review of the literature was performed evaluating the DBWC. Patient demographics, perioperative complications, operative variables, long terms oncologic outcomes and quality of life data were extracted. Descriptive statistics were used to define the data.

RESULTS

Fourteen articles with a total of 300 patients undergoing DBWC following pelvic exenteration were selected. 41% of malignancies were gastrointestinal in origin while 41.7% were gynecologic and 5.3% genitourinary. 42% of patients experienced at least one complication within in 40 days of surgery, the most common being wound infection (8.7%) and urinary leak (8.3%). There was no evidence of malignancy within the DBWC during long-term surveillance. Quality of life following DBWC is comparable to other reconstructive methods.

CONCLUSION

The DBWC is a well described reconstructive method for urinary and fecal diversion utilizing a single stoma following pelvic exenteration. The short- and long-term outcomes following DBWC are comparable to other reconstructive methods and the quality of life with a DBWC is acceptable. DBWC should remain a readily available option for reconstruction following pelvic exenteration.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Application of Adult and Pluripotent Stem Cells in Interstitial Cystitis/Bladder Pain Syndrome Therapy: Methods and Perspectives

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a multifactorial, chronic disease without definite etiology characterized by bladder-related pelvic pain. IC/BPS is associated with pain that negatively affects the quality of life. There are various therapeutic approaches against IC/BPS. However, no efficient therapeutic agent against IC/BPS has been discovered yet. Urothelium dysfunction is one of the key factors of IC/BPS-related pathogenicity. Stem cells, including adult stem cells (ASCs) and pluripotent stem cells (PSCs), such as embryonic stem cells (ESCs) and induced PSCs (iPSCs), possess the abilities of self-renewal, proliferation, and differentiation into various cell types, including urothelial and other bladder cells. Therefore, stem cells are considered robust candidates for bladder regeneration. This review provides a brief overview of the etiology, pathophysiology, diagnosis, and treatment of IC/BPS as well as a summary of ASCs and PSCs. The potential of ASCs and PSCs in bladder regeneration via differentiation into bladder cells or direct transplantation into the bladder and the possible applications in IC/BPS therapy are described in detail. A better understanding of current studies on stem cells and bladder regeneration will allow further improvement in the approaches of stem cell applications for highly efficient IC/BPS therapy.

Our experience with ureterocystoplasty in bilateral functional kidneys

OBJECTIVE

We have reviewed the data of the patients in order to evaluate the effectiveness of our ureterocystoplasty technique in augmentation cystoplasty operation.

MATERIAL AND METHODS

Data of a total of 16 patients with bilateral functional kidneys who had undergone augmentation ureterocystoplasty between January 1995 and June 2018 which were retrieved during the retrospective archive scanning were included in the study. Ultrasonography (USG), serum blood urea nitrogen and creatinine values and Technetium-99 DTPA (Tc-99 DTPA) scan were used to evaluate the renal function of the patients. Intravenous pyelography (IVP) and USG were used to evaluate the ureters before surgery. Magnetic resonance (MR) urographies were performed in our center.

RESULTS

Of the total 16 patients, 10 were male and 6 were female, while ages ranged from 1 to 24 years. Among 16 patients, the most common cause of neurogenic bladder etiology was meningomyelocele. In the urodynamic studies performed before the operation, it was determined that the bladder capacities of the patients were between 40-180 mL and the bladder compliances were 1.0-4.0 cc/cmH₂O. At postoperative 3^rd months, it was determined that the bladder capacities of the patients were between 180-330 mL and the bladder compliances were between 6.0-24.0 cc/cmH₂O.

CONCLUSION

Augmentation ureterocystoplasty seems to be an appropriate technique in which successful results are obtained with appropriate patient selection. Besides, complications that may occur due to use of ileal segment are avoided.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

Pelvic exenteration with rectal resection for different types of malignancies at two tertiary referral centres

INTRODUCTION

Pelvic exenteration (PE) offers the best chance of cure for locally advanced primary or recurrent pelvic organ malignancies invading adjacent organs. The aims of this study were to analyse results for any pelvic exenteration that includes rectal resection and the analysis of results of fecal and urinary reconstruction.

METHOD

From January 2000 to April 2014, 111 PE with rectal resection for any pelvic cancer were analysed retrospectively at two national tertiary referral centers.

RESULTS

Thirty-six colorectal anastomosis were performed. Urologic reconstructions performed were 30 double barrelled wet colostomy (DBWC), 14 Bricker ileal conduit (BIC), and 2 ureterocutaneostomies. Postoperative complications occurred in 71 patients (64%). Six deaths (5.4%) occurred within 30 postoperative days. Five-year overall survival following R0 resection was 62.6%; R1: 42.7%; R2: 24.2% (P=.018). The resection margin status was associated with overall survival, local recurrence and distant recurrence.

CONCLUSION

Pelvic exenterations for any cause need to be performed in referral centers and by specialized surgeons. Anastomosis after modified supralevator pelvic exenteration for ovarian cancer, is safe. DBWC can be considered a valid option for urologic reconstruction. The most important prognostic factor after pelvic exenteration for malignant pelvic tumors is the status of surgical margins.

Renal Transplantation in the Setting of Prior Urinary Diversion: A Case of Poorly Differentiated Adenocarcinoma in an Ileal Conduit

Though rare, renal transplantation into a bowel containing urinary diversion is necessary in select clinical situations. Compared to renal transplant patients with functional native bladders, patients with urinary diversion have comparable long-term graft and patient survival rates. However, compounding the increased risk of malignancy in those on chronic immunosuppression are the inherent risks of urinary diversion. We present a case report of a high grade adenocarcinoma with neuroendocrine differentiation arising in an ileal conduit and discussion on the pathophysiology, management, and screening of this highly select population.

Tubular Adenoma in the Indiana Pouch of a Patient With a History of Bladder Exstrophy

An increased risk of neoplasm has been noted when bowel segments are used for urinary diversion. Particularly true for ureterosigmoidostomy, colonic adenocarcinoma has rarely been reported following Indiana Pouch diversion. This report describes a 42-year-old woman with a history of bladder exstrophy who developed a polyp in her Indiana Pouch 24 years after its creation. The polyp, found incidentally, was a tubular adenoma with high-grade dysplasia. Due to its malignant potential, the polyp was resected with preservation of the Indiana Pouch. This case highlights the need for lifetime surveillance in urinary reservoir patients who received diversions at a young age.

Double barreled wet colostomy: initial experience and literature review

Background. Pelvic exenteration and multivisceral resection in colorectal have been described as a curative and palliative intervention. Urinary tract reconstruction in a pelvic exenteration is achieved in most cases with an ileal conduit of Bricker, although different urinary reservoirs have been described. Methods. A retrospective and observational study of six patients who underwent a pelvic exenteration and urinary tract reconstruction with a double barreled wet colostomy (DBWC) was done, describing the preoperative diagnosis, the indication for the pelvic exenteration, the complications associated with the procedure, and the followup in a period of 5 years. A literature review of the case series reported of the technique was performed. Results. Six patients had a urinary tract reconstruction with the DBWC technique, 5 male patients and one female patient. Age range was from 20 to 77 years, with a medium age 53.6 years. The most frequent complication presented was a pelvic abscess in 3 patients (42.85%); all complications could be resolved with a conservative treatment. Conclusion. In the group of our patients with pelvic exenteration and urinary tract reconstruction with a DBWC, it is a safe procedure and well tolerated by the patients, and most of the complications can be resolved with conservative treatment.

The evolution of bladder augmentation: from creating a reservoir to reconstituting an organ

Bladder augmentation was first described in 1899. The goal at the time was to establish the ideal method to create a simple capacious reservoir for the safe storage of urine. That simple idea has over the last 100 years grown into one of the most dynamic areas in Pediatric Urology. Creative minds and hands from individuals in multiple disciplines have led us from creating a reservoir to the threshold of recreating a functional organ. In this review, we look at the historical evolution of bladder augmentation and how it exponentially grew in scope from those initial descriptions of intestinocystoplasty to the work being reported today in the field of tissue engineering.

Serum carcino-embryonic antigen (CEA) and its possible use as tumor marker for secondary tumors in urinary intestinal reservoirs

OBJECTIVES

Serum carcino-embryonic antigen (CEA) has become a useful tumor marker in patients with colorectal adenocarcinoma. Patients who undergo uroenteric reconstruction, such as urinary diversion (UD), have an increased risk of developing malignant changes in their UD. We compared serum CEA levels in patients with different types of UD, evaluating long-term CEA changes and assessing its potential for use as a tumor marker of malignant transformation in the UD.

MATERIALS AND METHODS

Serum CEA was evaluated 3 to 122 months after surgery in 177 patients with different types of UD and retrospectively analyzed. The normal range for CEA was 0.2-3.4 μg/l. No patient had a history of colorectal cancer.

RESULTS

A total of 443 CEA samples from 177 patients were evaluated. CEA was elevated (up to 32 μg/l) in 122 samples (27.5%) from 59 patients (33.3%). Patients with Mainz Pouch II had significantly higher CEA levels (P = 0.037) than patients with other forms of UD. CEA levels increased significantly in the study population during follow-up (P = 0.0000007). Five of the patients (2.8%) developed a secondary neoplasm, 4 of whom had elevated CEA. Three neoplasms (urothelial cancer) were located outside the UD. Only 2 tumors were actually located in the UD: an urothelial cancer at the uretero-colonic anastomosis of the UD with normal CEA levels, and a colonic adenoma at the bottom of the UD with elevated CEA levels. No patient had adenocarcinoma in the UD.

CONCLUSION

Elevated serum CEA is a common finding in patients with UD using bowel segments (33.3%), especially in patients with rectal reservoirs. Serum CEA has a tendency to increase over time in patients with UD but is not a valuable marker of secondary neoplasms in these patients.

Ileocystoplasty in rats: metabolic, renal and enteropatch changes in a mid- and long-term follow-up

INTRODUCTION

Bladder augmentation predisposes humans to many metabolic, renal and enteropatch changes. Our aim was to evaluate in a rat model of ileocystoplasty mid- and long-term urinary, metabolic, renal and graft changes.

MATERIALS AND METHODS

We performed an ileocystoplasty and a sham operation in 30 rats. Seven augmented rats and 3 sham-operated animals were euthanized after 1, 3 and 6 months. We performed urinalysis, urine culture and blood sampling for serum electrolytes and urea. Histopathological changes of the ileal patch and kidneys were also evaluated.

RESULTS

The urine cultures were positive in 14.3, 57 and 71%, respectively, 1, 3 and 6 months after surgery. Urinary pH, serum chloride and urea of the augmented group were significantly higher. Bladder calculi were formed in 23.8% of ileocystoplasty. Histopathological examination showed urothelialization of the graft with hyperplastic/metaplastic changes. The kidneys showed glomerular depletion and a marked distal tubular ectasia.

CONCLUSIONS

Our data showed that, in a mid- and long-term follow-up, rat bladders subjected to ileocystoplasty displayed hyperchloremic metabolic acidosis, electrolyte imbalance, enhanced serum blood urea levels and glomerular/tubular changes. Hyperplastic and/or metaplastic changes at the junctional zone were observed. Our experimental results suggest that frequent monitoring of renal function and surveillance of humans who have undergone ileocystoplasty are recommended.

Ultrastructural changes in colorectal mucosa after chronic contact with urine

Ultrastructural changes in the colorectal mucosa in response to chronic contact with the urine were demonstrated in outbred albino rat experiments. Oral correction with slightly alkaline sodium hydrocarbonate solution reduced the destructive effect of the urine on rat colorectal mucosa.

Long-term outcome of ureterosigmoidostomy: an analysis of patients with >10 years of follow-up

STUDY TYPE

Therapy (case series).

LEVEL OF EVIDENCE

4.

OBJECTIVE

To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques.

PATIENTS AND METHODS

We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention.

RESULTS

The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study.

CONCLUSIONS

USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

Tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty: report of a first case

Neoplasms of the urinary bladder following augmentation ileocystoplasty are rare. We present the case of a 39-year-old male with a tubular adenoma with high-grade dysplasia in the ileal segment 34 years after augmentation ileocystoplasty to enlarge a post-chemoradiation-induced shrunken bladder. He presented with gross hematuria. Cystoscopy revealed a papillary tumor at the site of ileovesical anastomosis, and transurethral resection was performed. Histologic examination revealed a tubular adenoma with high-grade dysplasia. There are only two previous reports of tubulovillous adenoma in ileal segment after ileocystoplasty, both without high-grade dysplasia. Our observation supports the hypothesis that an ileal neobladder may undergo all the morphologic and molecular changes observed in the development of gastrointestinal adenocarcinoma. Therefore, patients who had an ileal neobladder created should be closely followed.

Colonic adenocarcinoma in an Indiana pouch successfully treated by endoscopic mucosal resection

We report the case of a 76-year-old woman who developed a colonic adenocarcinoma and a stone in an Indiana pouch 15 years after the urinary diversion. The colonic adenocarcinoma was treated endoscopically and we were able to preserve the Indiana pouch. To our knowledge, this is the sixth case of colonic adenocarcinoma in an Indiana pouch.

Adenocarcinoma of ileal neobladder 20 years after cystectomy

We present the case of a 67-year-old man with adenocarcinoma of the ileal neobladder 20 years after radical cystoprostatectomy for Stage pT2 transitional bladder cell cancer. A MEDLINE research revealed 9 other cases of the development of a neoplasm in the ileal part of an ileocystoplasty. This observation supports the hypothesis that in an ileal neobladder morphologic and molecular changes can be observed similar to those in the development of colorectal carcinoma. Patients who had an ileal neobladder created are at risk of glandular malignancy and should be closely followed up.

Ureterosigmoidostomy and obstructive uropathy

BACKGROUND

A 19-year-old mentally retarded man with failed exstrophy repair and ureterosigmoidostomy urinary diversion presented with high fever, vomiting and right-flank pain of 2 days' duration. Past medical history was notable for a left nephrectomy to treat an infected staghorn calculus in a poorly functioning kidney. Physical examination revealed pyrexia and right-flank tenderness.

INVESTIGATIONS

Physical examination, renal function tests, electrolyte and metabolic assessment, urine and blood cultures, abdominal CT, ANTEGRADE PYELOURETEROGRAPHY, sigmoidoscopy and histopathology.

DIAGNOSIS

Ureterosigmoidostomy complicated by acute pyelonephritis, obstructive uropathy, recurrent urinary tract infections, renal impairment and the development of renal stones and metabolic acidosis.

MANAGEMENT

Fluids, intravenous antibiotics, bicarbonate and potassium supplementation, and rediversion of ureterosigmoidostomy to an ileal conduit.

SECONDARY MALIGNANCIES IN DIFFERENT FORMS OF URINARY DIVERSION USING ISOLATED GUT

PURPOSE

Tumor development following ureterosigmoidostomy is a worldwide accepted late complication. In contrast, tumor risk in other forms of urinary diversion with the separation of urine and feces is still unclear. We present a complete and detailed analysis of all reported tumors following urinary diversions using isolated gut segments in the literature. We estimated the tumor risk in comparison to ureterosigmoidostomies and to the general population.

MATERIALS AND METHODS

We reviewed the world literature up to April 2003 via MEDLINE for secondary tumors in urinary diversions using isolated intestinal segments.

RESULTS

We found 81 tumor case reports following urinary diversion using isolated intestinal segments. Tumors developed in 18 conduits, 45 cystoplasties, 5 rectal bladders, 3 neobladders, 6 colonic pouches and 4 ileal ureter replacements.

CONCLUSIONS

All urinary diversions using bowel with or without separation of urine and feces carry a significantly higher tumor risk for intestinal tumor development compared to the general population. The tumor spectrum and tumor location in isolated gut segments are different than tumors following ureterosigmoidostomies but the total tumor risk is probably similar. The latency period depends on the initial diagnosis with malignant diseases leading to a shorter induction time. Concerning etiology, many theories exist but the exact mechanism remains unclear. Regular endoscopic control beginning with postoperative year 3 for early detection of secondary malignancies is mandatory.

Tumour formation within intestinal segments transposed to the urinary tract

Patients and their urologists are quite rightly concerned about the possibility of neoplastic change within intestinal segments transposed to the lower urinary tract. This fear arises from the occurrence of latent adenocarcinoma arising from the urocolic anastomosis in approximately 10% of patients who underwent ureterosigmoidostomy in childhood. The present text provides an update of previous reviews and details work published since 1990 on epidemiological, experimental and clinical studies. Consideration of the collected evidence confirms the increased risk of colonic neoplasia following mixing of the faecal and urinary stream by ureterosigmoidostomy or its more recent variants. In contrast, the occurrence of tumours within transposed intestinal segments appears more likely to be related to the underlying urinary tract disease for which the surgery was performed rather than exposure of the intestinal mucosa to urine. This conclusion is, however, based on low level evidence and, despite the reassuring findings, caution is advised until more robust data are available to provide a confident risk assessment.

Autologous muscle transfer for reconstruction of the lower urinary tract

The recent experimental results of using functioning muscle transfer to the bladder have been shown to be useful for some clinical indications. LDDM proved to be a viable option for the treatment of patients with an acontractile bladder due to traumatic or congenital lower motor neuropathy. A logical development for complete bladder substitution would be to combine the well-vascularized and contractile latissimus dorsi muscle transplant with cultivated and expanded autologous urothelial cells. A scaffolding, such as bioabsorbable polymer, alginate, or small intestinal sumucosa, may be useful to convey the in vitro-created urothelial layer onto the muscle and to avoid osteogenesis. Experimental studies are necessary, however, to rule out whether these materials induce fibrosis, leading to stiffness of the neobladder wall, and thereby reducing contractile function and voiding capability of the transferred muscle.

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder]

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Early histological changes of ileal mucosa after augmentation cystoplasty

Segments of bowel are used routinely for transplantation in various pathological conditions such as contracted bladders or poorly compliant neuropathic bladders. However, little is known how these intestinal segments adopt to a toxic environment caused by urine. Therefore, the present study was performed to determine early histological changes of ileal mucosa after augmentation cystoplasty. Seven patients with augmentation cystoplasty underwent random cold-cup biopsies of ileal segments after a mean period of 14.4 months after cystoplasty and morphological changes were evaluated using light microscopy and transmission and scanning electron microscopy. Most pronounced features were varying degrees of villous atrophy, increased numbers of Paneth and goblet cells. Severity of atrophic villous changes were not related to the length of the interval between surgery and endoscopic biopsy. These findings may be explained as adaptations of bowel tissue to counteract noxious effects of urine and to maintain its epithelial function in the bladder.

Colonic adenocarcinoma occurring in an Indiana pouch: report of a case and review of the literature

Colonic adenocarcinoma has been frequently reported after ureterosigmoidostomy based on carcinogenic substances created when feces and urine are mixed. However, colonic adenocarcinoma has never been reported arising in an Indiana pouch after cystectomy. We report a case of adenocarcinoma arising in a urinary pouch after cystectomy for transitional cell cancer. We believe this to be caused by hereditary nonpolyposis colon cancer (an autosomal dominant syndrome that puts individuals at risk for genitourinary, colonic, and several other cancers) rather than carcinogenic effects of urine on colonic mucosa. When planning urinary reconstruction after cystectomy for malignancy, it is important to consider the possibility that an individual may suffer from hereditary nonpolyposis colon cancer before selecting the colon as a urinary reservoir.

What is new in urinary diversion

There have been some suggestions for changes in technique and investigations of the quality of life. As experience has grown, there have been increasing numbers of reports of complications. Careful attention to technique, especially in nerve-sparing cystectomy and orthotopic cystoplasty may reduce the rate of incontinence. Increasing awareness of quality of life issues should improve preoperative counselling of patients, especially those whose underlying condition is not life-threatening.

Bladder substitution

Preliminary data have shown that composite reservoirs consisting of gastric segments in combination with ileum or colon may reduce metabolic problems. Orthotopic neobladders are the most natural way to reconstruct the urinary bladder and are a safe option in selected male and female patients. Experimental and preliminary clinical data about new methods using autologous muscle transfer and tissue engineering are promising.