Bladder reconstruction: a critical reappraisal

Retrograde ureteroscopy in patients with orthotopic ileal neobladder urinary diversion

PURPOSE

We assess the feasibility, technique, complications and clinical outcomes of retrograde ureteroscopy in patients with orthotopic ileal neobladder.

MATERIALS AND METHODS

We retrospectively reviewed our ureteroscopy experience to identify procedures performed in patients who had previously undergone cystectomy with orthotopic ileal neobladder urinary diversion. These procedures were reviewed and data collected regarding patient characteristics, indication for endoscopic evaluation, surgical technique, findings, complications and followup.

RESULTS

Eight patients with neobladder diversion were taken for 9 sessions in the cystoscopy suite for attempted retrograde ureteroscopy on 13 renal units. The indication for ureteroscopy was an upper tract filling defect, positive cytology or calculi. The ureter and renal pelvis were successfully accessed and visualized in 10 of 13 renal units. The cause of failure in the 3 unsuccessful procedures was inability to access the ureteral orifice. Mean operative time +/- SD was 78 +/- 34 minutes. Urothelial abnormalities were identified in 4 patients, extrinsic compression in 2 and stones in 3. In 1 patient postoperative hematuria developed, which spontaneously resolved. Fluoroscopy was essential to identify the afferent limb of the reservoir, and a directional guide wire was helpful in engaging the ureteral orifice.

CONCLUSIONS

Ureteroscopic evaluation and treatment of upper tract abnormalities are feasible and practical in most patients with orthotopic neobladder urinary diversion. Identification of the ureteral orifice is challenging but can be accomplished with a combination of endoscopic and fluoroscopic techniques. This procedure avoids the morbidity of percutaneous access, and complications are minimal.

Perimesenteric detubularization of ileum for ileocystoplasty improves compliance and increases capacity

OBJECTIVE

To describe a modified form of detubularization using a perimesenteric incision of the ileal segment, which increases the capacity of the neobladder and reduces the length of the ileal segment required.

PATIENTS AND METHODS

From February 1993 to November 1999, ileocystoplasty was undertaken in 20 patients (mean age 8.4 years, range 4-16). Six had myelodysplasia, four had primary epispadias, five had bladder exstrophy, three had post-traumatic lesions and two had cloacal exstrophy. The patients were divided into two groups; in the first (eight patients, mean age 9.6 years, range 5-15) the ileal segment was opened along the antemesenteric border and in the second (12 patients, mean age 7.7 years, range 4-16) the ileal segment was opened adjacent to the mesentery, perimesenterically. Each segment was then folded and the perimesenteric edges sutured to form the pouch.

RESULTS

The patients were assessed at 1 year after surgery; the neobladder capacity was evaluated as ((neobladder capacity - bladder capacity)/body weight), which shows the relative increase of bladder capacity after enterocystoplasty per unit of weight. There was a statistically significant increase in neobladder capacity in group 2 (perimesenteric transection; Kruskal-Wallis chi-square, P = 0.005; Mann-Whitney U-test, P = 0.006).

CONCLUSION

These results indicate that augmentation can be carried out by perimesenteric transection of the intestinal segment, which improves compliance and increases capacity of the neobladder.