The transverse colonic reservoir: the Unicamp technique

Transverse colon for continent urinary diversion: experimental study comparing two techniques

OBJECTIVES

Patients who have undergone pelvic radiotherapy can develop urinary complications such as actinic cystitis or fistulas and ultimately need urinary diversion, for which several techniques have been described. The purpose of this experimental study was to compare 2 different types of continent urinary diversion with the colonic pouch.

METHODS

Sixteen dogs of both sexes, weighing 20-25 kg were divided into 3 groups: the pilot group consisted of 6 dogs used to standardize the technique. Group 1 consisted of 5 dogs that underwent the Monti technique to construct the conduit and the Abol-Eneim technique to promote continence. The final group, group 2, consisted of 5 dogs that underwent the intussusception technique for continence. In both techniques the same length of colon was used (20 cm). Urodynamic evaluation was performed at postoperative day 30.

RESULTS

The compliance of the reservoir was similar among the groups. The capacity of the reservoir was greater and the continence mechanism was more effective in group 1. The length of the conduit was also longer in group 1. In group 2, the intussusception's mechanism was totally lost in 1 dog and partially in 2.

CONCLUSIONS

The technique performed in group 1 allowed for the construction of a reservoir with greater capacity and the continence mechanism proved to be more efficient than in group 2. The length of the conduit was significantly greater in group 1.

Colon pouch (Mainz III) for continent urinary diversion

OBJECTIVE

To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended.

PATIENTS AND METHODS

The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion.

RESULTS

The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea.

CONCLUSIONS

The Mainz pouch III is an alternative to other types of continent urinary diversion.

Technique for pure transverse colon continent cutaneous urinary diversion

We describe a new method for constructing a pure transverse colon reservoir with two short segments of transverse colon fashioned as Monti tubes that are placed in a serous-lined extramural tunnel for construction of the efferent segment and for ureteral reimplantation, respectively.

Pelvic exenteration for gynaecological tumours: achievements and unanswered questions

Pelvic exenteration has been used for 60 years to treat cancers of the lower and middle female genital tract in radiated pelves. The mainstay for treatment success in terms of locoregional control and long-term survival is resection of the pelvic tumour with clear margins (R0). New ablative techniques based on developmentally derived surgical anatomy and laterally extended endopelvic resection have raised the number of R0 resections done, even for tumours that extend to the pelvic side wall, which were traditionally judged a contraindication for exenteration. Although mortality has fallen to less than 5%, treatment-related severe morbidity of pelvic exenteration still exceeds 50%, possibly because of compromised healing of irradiated tissue and use of complex reconstructive techniques. The benefits of exenteration for patients who have advanced primary disease or recurrent tumours after surgery, versus those who have chemoradiotherapy, are not proven by results of controlled trials, but can be assumed from retrospective data. Comparative findings are missing, and arguments are unconvincing to favour pelvic exenteration over less extensive treatments and best supportive care for palliation of cancer symptoms in most patients.

Continent Urinary Diversion in Patients with Pelvic Irradiation: An Alternative Utilizing Transverse Colon Reservoir

The use of radiation therapy in pelvic malignancies increases the risk of urinary complications, sometimes being necessary urinary diversion. The risk of utilizing previously irradiated bowel should be avoided. The use of transverse colon is a safe and effective alternative. We present a heterotopic continent colonic reservoir with an easily catheterizable conduit.

Versatility of reconfigured-colon-segment technique for urinary reconstruction requiring use of tubular structures

INTRODUCTION

When a colon segment is used for urinary reconstruction and a tubular structure is necessary, the option for the tubular structures is limited. We prepared a short colon segment in advance for creating a reconfigured tube.

TECHNICAL CONSIDERATIONS

Short colon segments are separated beforehand from the edges of the main colon segment for a continent urinary reservoir or augmentation cystoplasty. The short segments are either reconfigured, if necessary, into tubular structures to produce a continent valve or to replace a ureteral defect or discarded if they prove not to be needed. The number of short segments can be predicted on the basis of the clinical situation before and during the operation.

CONCLUSION

Preparation of short colon segments is useful for urinary reconstruction using a colon segment that might require a number of tubular structures. The technique provides versatility and flexibility in difficult clinical conditions.

Vesico-vaginal fistula: new perspectives

The present review is based essentially on the literature relating to vesico-vaginal fistulae (VVF) published during the past 2 years. It highlights the major publications regarding aetiology, epidemiology, assessment and management, and indicates my opinions as to the significance of the various contributions. In particular, the route of repair, the value of interposition grafting and the place of diversionary procedures remain topical. Medico-legal aspects of the condition as it arises in the developed world and their impact on management strategies are also covered.

Colon pouch (Mainz pouch III) for continent urinary diversion after pelvic irradiation

OBJECTIVES

Urinary diversion after previous pelvic irradiation is challenging. The use of irradiated bowel in particular is associated with an increased rate of early and late complications. We therefore performed continent cutaneous urinary diversion using exclusively nonirradiated bowel segments in this group of patients.

METHODS

A continent colon pouch for urinary diversion was performed in 44 female patients after pelvic irradiation. The indications were irreparable vesical fistula in 20, local recurrence of gynecologic tumors in 22, and radical cystectomy for bladder cancer in 2 patients. Depending on the length of the nonirradiated bowel segment, a transverse-ascending colon pouch (n = 8) or transverse-descending colon pouch (n = 36) was performed. The efferent segment was created from a tapered bowel segment embedded in the pouch wall. The ureters were implanted using a submucosal (n = 67) or subserosal (n = 17) extramural tunnel.

RESULTS

No pouch-related complications were observed during the immediate postoperative period. In long-term follow-up (mean 52.2 months), upper urinary tract dilation was seen in five renal units. All five of these had been dilated preoperatively, and none required ureteral reimplantation. Incontinence occurred in 2 patients; both underwent reoperation with subsequent continence. Umbilical stoma stenosis was observed in 6 patients.

CONCLUSIONS

The technique of the colon pouch for continent urinary diversion in previously irradiated patients is safe and has a low complication rate. The use of nonirradiated bowel segments should be the method of choice in this group of patients.