Bladder Substitution in Children

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.

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.

Ileocecal ureterosigmoidostomy: an alternative to conventional ureterosigmoidostomy

We describe a 1-stage procedure that involves use of the ileocecal segment as an intervening urine conduit to the large bowel to achieve a continent diversion. The ureters are anastomosed end to end to the terminal ileum that is intussuscepted into the cecum. The cecum then is joined to the lower sigmoid by an end-to-side anastomosis. Mixed urine and feces are eliminated through the rectum. The results in 5 patients with exstrophy and 1 with epispadias between 5 months and 13 years old are reported. Ureteral reflux was not observed. Urinary tract infection developed in 2 patients. Ileocecal ureterosigmoidostomy is a reasonable alternative to intact ureterosigmoidostomy that may reduce the risk of development of cancer.

Urinary tract reconstruction in children

The successful introduction of clean intermittent catheterization and increased awareness of urinary tract physiology and urodynamics have been the basis for recent major advances in urinary tract reconstructive surgery. Surgical techniques are now available to manage anatomical and functional deficiencies of any isolated or combined components of the urinary tract. The high incidence of unsatisfactory long-term results with ileal conduit diversion has led to increased popularity in urinary tract undiversion and greater utilization of reconstructive principles. As with any new surgical field of endeavour, new operative techniques are appearing at a rapid rate. In particular, there has been a recent proliferation of surgical procedures that provide a continent, low pressure, catheterizable reservoir for urine storage. Most children with major urinary tract deficiencies can now be offered socially and cosmetically unobtrusive surgical solutions without jeopardizing renal function.

Experiences with bladder reconstruction in children

The results in 56 children (28 with neurogenic bladder dysfunction) undergoing enterocystoplasty between 1981 and 1985 are presented. Ileal, ileocecal, right colon and sigmoid segments were used in tubular and opened configurations. Our experience leads us to recommend opened ileal segment reconstruction in neurogenic bladder patients and those with weak anal sphincters generally, and open ileocecal or open right colon segments in patients with other etiologies. Continence was achieved in 53 patients, although secondary procedures, particularly at the bladder outlet, were required in 13. When ureteral reimplantation was required we achieved excellent success with normal-sized or mildly dilated ureters regardless of the operative technique used. Initial failures to prevent reflux in the face of marked ureterectasis using the ileocecal valve have been resolved by a modified technique of intussusception and fixation. An over-all favorable experience is reported, which we believe permits us to formulate certain rules that will improve the acceptability and success of bladder reconstruction in general.