The late symptomatic and functional results of enterocystoplasty

Metabolic complications of the urinary intestinal diversion: ileo-caecal bladder compared with ileal conduit

Five patients with an ileal conduit and 5 with an ileo-caecal bladder substitute have been studied metabolically. All had undergone cystectomy for infiltrating carcinoma and they formed 2 homogeneous groups in terms of age and follow-up. Function in both groups was within normal limits but closer examination of patients with an ileo-caecal bladder revealed mild functional damage as shown by reduced creatinine secretion, a lower level of bicarbonate and lower urinary acid valency secretion. It was concluded that the ileal conduit is more satisfactory from a metabolic point of view than the ileo-caecal bladder, which requires closer follow-up and treatment with bicarbonates if necessary.

Metabolic complications of cystoplasty

A series of 48 patients with intestinal segments incorporated into the urinary tract underwent assessment of acid-base and electrolyte balance. All patients had abnormal blood gas analyses, usually a metabolic acidosis with respiratory compensation; 33% had hyperchloraemia. Radioisotope studies using sodium, potassium and bromine showed that all were absorbed and that absorption was unaffected by renal function. The results suggest that all such patients, but particularly women and children, may be at risk of the secondary effects of chronic acidosis, especially skeletal demineralisation, unless some compensatory mechanism is working to offset the effects of the acidosis.

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.

Augmentation cystoplasty in the treatment of neurogenic bladder dysfunction

We report on the role of augmentation cystoplasty in the treatment of 18 patients with neurogenic bladder dysfunction and associated symptoms of severe urinary urgency, frequency and urinary incontinence. All patients failed to obtain any symptomatic improvement with a variety of treatments, including intermittent self-catheterization and pharmacologic manipulation. Preoperative evaluation helped segregate the patients into 3 groups: 1) those with extremely poor bladder wall compliance, 2) those with severe detrusor hyperreflexia and 3) those with a combined problem of poor bladder wall compliance and hyperreflexia. Bladder augmentation involved cecocystoplasty in 15 cases and ileocystoplasty in 3. In 5 patients an artificial urinary sphincter cuff was placed in an attempt to improve continence. Followup ranging from 12 to 120 months (mean 38 months) was available in 17 patients. An excellent surgical result was obtained in 82 per cent of the patients who became asymptomatic and continent after augmentation cystoplasty. Augmentation cystoplasty is a therapeutic modality that should be considered a viable treatment option in selected patients with neurogenic bladder dysfunction.