Mainz Pouch II technique: 10 years’ experience

Perioperative outcomes and continence following robotic-assisted radical cystectomy with mainz pouch II urinary diversion in patients with bladder cancer

PURPOSE

To present the widely unknown perioperative outcomes and continence status of bladder cancer patients following robotic-assisted radical cystectomy (RARC) with Mainz pouch II urinary diversion (UD).

MATERIALS AND METHODS

From November 2020 to December 2023, 37 bladder cancer patients who underwent RARC with Mainz pouch II UD were retrospectively assessed (ChiCTR2300070279). The results, which included patient demographics, perioperative data, continence, and complications (early ≤ 30 days and late ≤ 30 days) were reported using the RC-pentafecta criteria. RC-pentafecta criteria included ≥ 16 lymph nodes removed, negative soft tissue surgical margins, absence of major (Grade III-IV) complication at 90 days, absence of clinical recurrence at ≤ 12 months, and absence of long-term UD-related sequelae. A numeric rating scale assessed patient satisfaction with urinary continence 30 days after surgery. The validated Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire was used to evaluate bowel function. The Kaplan-Meier curve was used to evaluate overall survival (OS).

RESULTS

Of the 37 patients evaluated over a median (range) follow-up period of 23.0 (12.0-36.5) months. The median (range) age was 65 (40-81) years. The median (range) time to urinary continence after surgery was 2.3 (1.5-6) months. Of the 37 patients, 31 (83.8%) were continent both during the day and at night, 34 (91.9%) were continent during the day, 32 (86.5%) were continent at night, 35 (94.6%) were satisfied with their urinary continence status, and 21 (56.8%) were very satisfied. The mean (range) voiding frequency was 6 (4-10) during the day and 3 (2-5.5) at night. The mean (range) PAC-SYM total score was 9.50 (4.00-15.00). In 12 (32.4%) of the patients, RC-pentafecta was achieved, and achieving RC-pentafecta was linked to better satisfaction scores (7.3 vs. 5.5, p = 0.034). There was no significant difference between RC-pentafecta and No RC-pentafecta groups in terms of OS (25.6 vs. 21.5 months, p = 0.16). 7 (19.4%) patients experienced late complications.

CONCLUSIONS

Mainz pouch II UD following RARC in bladder cancer patients results in a satisfactory continence rate. Achieving RC-pentafecta was correlated with better satisfaction scores. The intracorporeal approach to Mainz pouch II UD is beneficial for female patients due to its reduced invasiveness.

TRIAL REGISTRATION

ChiCTR2300070279; Registration: 07/04/2023, Last updated version: 01/06/2023. Retrospectively registered.

N. D, R. M, K. S. S, Ali M. Bilateral ureteral ectopia with duplex collecting system and hypoplastic bladder: a rare variant

Background

Bilateral single system ectopic ureter is a rare congenital anomaly, but bilateral ureteral ectopia with duplex collecting system with bladder hypoplasia is even rarer. Urinary incontinence in such cases is dealt with various reconstructive procedures.

Case presentation

A 20-year-old female presented with continuous urinary incontinence without normal voiding since birth. Imaging revealed bilateral duplex collecting system with ectopic ureter draining into the vestibule, and hypoplastic bladder. The patient was managed with Mainz-II pouch creation with serous lined extramural ureteral reimplantation technique with complete resolution of incontinence.

Conclusion

Our article highlights the challenges in surgical planning, treatment and the patient perspectives for this rare congenital malformation presenting with incontinence.

Robot-assisted radical cystectomy with intracorporeal Mainz Ⅱ rectosigmoid pouch for muscle-invasive bladder cancer

BACKGROUND

To report the surgical techniques and results of robot-assisted radical cystectomy (RARC) with intracorporeal Mainz Ⅱ rectosigmoid pouch at our centre.

METHODS

Two female patients were treated with this procedure. Construction of the pouch was divided into four main steps: incision of the rectum and sigmoid colon, closure of the posterior wall of the pouch, reimplantation of the ureters at the bottom of pouch in an anti-reflux manner, and closure of the anterior wall. Surgical results and perioperative complications were assessed.

RESULTS

The operations were performed completely intracorporeally. No perioperative complications were observed. Postoperatively, high-grade invasive urothelial carcinoma was detected. On postoperative day 60, no bilateral ureteral dilation was detected. Two patients demonstrated total continence. Clinical recurrence was not observed during the follow-up period.

CONCLUSIONS

With careful patient selection, robot-assisted intracorporeal Mainz Ⅱ rectosigmoid pouch might be a simple minimally invasive surgical technique to be evaluated in repeated applications.

Continent diversion: five decades of developments and evolution

OBJECTIVE

To provide a chronological overview of the evolution of continent urinary diversion (CUD) over the last 50 years and to highlight important milestones.

METHODS

We performed an extensive literature review and analysed different forms of urinary diversion worldwide. After the evaluation of surgical techniques, we assessed the advantages and disadvantages of assorted CUD approaches based on published long-term follow-up data.

RESULTS

A wide variety of surgical options for CUD is available and feasible to date, although consensus among urologists regarding the 'gold standard' is still lacking. Several forms of orthotopic bladder substitutes and continent cutaneous urinary reservoirs have been shown to provide excellent long-term results.

CONCLUSION

The last 50 years of CUD have seen constant evolution and refinement of techniques, but the best surgical approach remains unclear and there is no 'one-size-fits-all' option, but rather tailor-made approaches are necessary to ensure patient satisfaction.

Laparoscopic Mainz II Approach for Single System Ectopic Ureter with Bladder Agenesis

Solitary renal unit with ectopic ureter with bladder agenesis is a rare congenital anomaly. Urinary incontinence in such cases is dealt with various continent and noncontinent procedures. We report a case of 20-year-old female patient who presented with continuous leakage of urine. Examination and investigations revealed an absence of right kidney, bladder agenesis, ectopic ureter opening into the vestibule, and multiple bony abnormalities. She was managed effectively by laparoscopic Mainz II with serous lined extramural ureteral reimplantation technique.

The Cologne pouch procedure for continent anal urinary diversion in children with bladder exstrophy-epispadias complex

INTRODUCTION

In children who remain incontinent after reconstruction of bladder exstrophy-epispadias complex (BEEC), continent anal urinary diversion (CAD) is one option to achieve continence. Known problems after CAD are an increased stool frequency and ureterointestinal stenosis. We devised a new surgical technique of CAD that we named the "Cologne pouch procedure" (CPP) that renders the possibility of separate evacuation of urine and feces. Furthermore, we connect the bladder plate to the rectosigmoid pouch instead of performing a ureterosigmoidostomy to reduce the rate of ureterointestinal stenosis. In this study, we want to introduce the CCP and critically evaluate our results.

STUDY DESIGN

In CPP a detubularized sigmoid-bladder pouch is created, which is naturally connected to the rectum. A retrospective study was performed including all patients with BEEC and CPP treated in our hospital between January 1, 2007, and December 31, 2016. Epidemiological and surgical key data, complications, and the need for alkaline supplementation were assessed. At follow-up examinations, we evaluated continence, ability of independent urine and feces evacuation, need for bicarbonate supplementation, status of the upper urinary tract, and complications such as urinary tract infections or urolithiasis.

RESULTS

In total, 29 patients with BEEC and CPP were included. The mean age at surgery was 4.2 ± 3.3 years (range 0.1-12.7 years). Overall, 14 short-term complications occurred in nine patients. Postoperatively, all patients were continent for urine and feces during daytime and only one child occasionally lost small portions of urine at night. An independent evacuation of urine and feces was accomplished in 22 patients (81.5%). Continued bicarbonate supplementation was necessary in 15 patients (55.6%). During the follow-up period six patients (22.2%) had a single urinary tract infection and four patients (14.8%) calculi of the urinary tract. No urinary tract abnormalities-especially no vesicoureteral reflux (VUR) or stenosis-were detected during follow-up ultrasound examination. In two children, a preoperatively known hydronephrosis decreased after CPP.

CONCLUSION

CPP is a novel technique that yields excellent results concerning continence. In contrast to other forms of rectosigmoid urinary diversion, functional separation of defecation and urination can be achieved in most patients.

Continent Anal Urinary Diversion in Classic Bladder Exstrophy: 45-Year Experience

OBJECTIVE

To evaluate the long-term outcomes in patients with classic bladder exstrophy and continent anal urinary diversion (CAD) for continence, upper urinary tract status, secondary malignancies, and sexual function.

PATIENTS AND METHODS

The medical records of 82 exstrophy patients having undergone CAD in our department between 1970 and 2015 were reviewed. Patients were invited for follow-up examinations and asked to complete validated questionnaires relating to sexual function.

RESULTS

Thirty-two of 57 eligible patients with a median follow-up of 23.9 years were included in the study. Ninety-seven percent of patients were fully continent during daytime. Upper urinary tract and renal function remained stable in 75% and 87%, respectively. Five patients developed secondary malignancies originating from the rectal reservoir. Forty-one percent received prophylactic alkaline substitution. Sexual function as measured by the Female Sexual Function Index and the International Index on Erectile Function was negatively affected in all domains in both genders. Eighty-six percent of patients had a stable relationship and 35% were married. Five women conceived a total of 6 healthy children. Paternity rate was 40%.

CONCLUSION

CAD constitutes an effective treatment option with acceptable long-term outcomes in exstrophy patients in whom all attempts at restoring the lower urinary tract have failed. Long-term follow-up of the upper urinary tract, assessment of acid-base balance, and endoscopy of the rectosigmoid reservoir are paramount for the safety of this type of management. Evaluation of sexual dysfunction should be an active part of follow-up.

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients

OBJECTIVES

To assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy.

PATIENTS AND METHODS

The study included 10 patients (mean age 61.8 years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student's t-test.

RESULTS

Nine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3-5) and the mean night-time frequency was 0.5 (0-1). Before and after surgery, the respective mean resting anal pressure was 71 and 74 cm H2O (P = 0.004), the volume at first desire to defecate was 54 and 72 mL (P = 0.004) and the maximum tolerable volume was 140 and 160 mL (P < 0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0-10) cmH2O, and the end pressure was 13.2 (4.42, 9-20) cmH2O.

CONCLUSION

Although the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients' quality of life.

Dilatation and curettage of urinary bladder: A rarity

Twenty-eight-year-old female while undergoing a medical termination of pregnancy (MTP) encounter complete urethral loss and massive bladder curettage. After resuscitation, she developed continuous urinary leakage followed by progressive decline in urine output. Case is highlighted here because of the massive vesico-urethral trauma because of MTP, leading to permanent urinary diversion.

Urinary diversion--approaches and consequences

BACKGROUND

Bladder cancer is not a rare disease: In 2010, there were more than 70 000 affected patients in the United States. Radical cystectomy for the treatment of muscle invasive bladder cancer necessitates urinary diversion.

METHODS

We present the current options for urinary diversion and their different indications on the basis of a selective search for pertinent literature in PubMed and our own clinical experience.

RESULTS

When bladder cancer is treated with curative intent, continence-preserving orthotopic urinary bladder replacement is preferred. For heterotopic urinary bladder replacement, a reservoir is fashioned from an ileal or ileocecal segment. Urine is diverted to the rectum by way of the sigmoid colon. When bladder cancer is treated with palliative intent, non-continence-preserving cutaneous urinary diversion is usually performed: The creation either of a renal-cutaneous fistula or a self-retaining ureteral stent is a purely palliative procedure. In these interventions, the resorptive surface of the bowel segment used can no longer play its original physiological role in the gastrointestinal tract, even though its absorptive and secretory functions are still intact. This has metabolic consequences, because the diverted urine here comes into contact with a large area of bowel epithelium. Early preventive treatment must be provided against potentially serious complications such as metabolic acidosis and loss of bone density. The resection of ileal segments can also lead to malabsorption. The risk of secondary malignancy is elevated after either continence-preserving anal urinary diversion (>2%) or bladder augmentation (>1%).

CONCLUSION

There are four options for urinary diversion after cystectomy that can be performed when surgery is performed with either curative or palliative intent. There are also a number of purely palliative interventions.

Bladder exstrophy in adulthood

Background

We report our experience with the treatment of classic exstrophy of the bladder in a small series of seven adult males. There are very few documented cases of adults presenting with exstrophy of bladder in literature.

Materials and Methods

Adult males presenting with classic exstrophy of the bladder and complete epispadias underwent detailed evaluation including psychological assessment and counseling. All were explained regarding the surgical procedure and informed about the need for self-catheterization. Prior to 2002 all patients underwent cystectomy of the existing bladder plate, with creation of catheterizable modified Mainz pouch. Since 2002 patients were assessed for bladder reconstruction with augmentation ileocystoplasty, bladder neck reconstruction, and abdominal wall closure.

Results

Seven adult males with classic exstrophy of the bladder and complete epispadias who had not received any previous treatment presented to us during the period 1991-2006. Five of these underwent cystectomy with continent pouch and the remaining two underwent bladder reconstruction. All have been doing well with improved self-esteem and social interaction. Two of these have married and leading a satisfactory sexual relationship.

Conclusions

Surgical correction in adults with exstrophy of the bladder greatly improves self-esteem, confidence, and social relationship.

Clinical experience in a modified Roux-Y-shaped sigmoid neobladder: assessment of complications and voiding patterns in 43 patients

OBJECTIVE

To evaluate the complications and urinary voiding patterns in patients with a new Roux-Y-shaped continent neobladder, using a modified sigmoid pouch.

PATIENTS AND METHODS

Between June 2003 and July 2008, 43 patients (26 men and 17 women, mean age 69.5 years) underwent a modified Roux-Y-shaped sigmoid continent neobladder reconstruction after radical cystectomy. The surgical procedures involved the construction of a Roux-Y-shaped sigmoid pouch, making an antifeces-refluxing valve into the sigmoid urine reservoir and ureterosigmoidostomy using the Leadbetter method. This pouch method has not been described before. The patients' clinical, biochemical, radiological and urodynamic variables were assessed.

RESULTS

During the mean (range) follow-up of 24 (6-65) months, there were no deaths related to the procedure. In 16% of the patients, early complications occurred, whereas 12% had late complications. There were no cases with local recurrence and metastasis. Routine electrolyte evaluation revealed a slight metabolic acidosis in six patients (14%). Hypovitaminosis B(12) did not occur in any patients. All patients were continent in the daytime and night-time continence was poor in eight patients (19%). The mean (sd, range) neobladder capacity and residual urine volume was 330 (110, 120-410) mL and 48 (26, 25-80) mL, respectively. Moreover, the maximum urinary flow rate was 9.2-25.3 mL/s.

CONCLUSION

The modified Roux-Y-shaped sigmoid neobladder replacement provides a new simple surgical procedure with low complication rates. The procedure offers comparatively satisfactory daytime continence with low postvoid residual urine volumes and voiding patterns. This technique is a valid alternative to continent urinary diversion.

[The history of ureterosigmoidostomy]

Congenital anomalies like bladder exstrophy were the indication in 1821 to implant the ureters into the sigmoid colon for the first time. In 1894 the Maydl technique was used more frequently with a postoperative mortality rate of 31%. The most important impact for ureterosigmoidostomy came from Robert Coffey in 1911. Obstruction at the ureterocolic anastomosis, inflammatory complications together with severe acidosis, renal insufficiency, and high mortality rates however gave way in 1950 to the worldwide success of Bricker's ileal conduit although at the same time the technique of ureterosigmoidostomy was perfected by Leadbetter, Goodwin, and Hohenfellner. About 25 years later, when the high late complication rate of ileal conduits was obvious, the advantages of ureterosigmoidostomy were reconsidered and the technique was refined using valuable principles of pouch surgery. Today modified ureterosigmoidostomy has a strong place among the possibilities of urinary diversion.

Complications of treatment of obstetric fistula in the developing world: gynatresia, urinary incontinence, and urinary diversion

OBJECTIVE

To provide a comprehensive review of the pathophysiology, evaluation, and treatment of gynatresia and urinary incontinence, 2 conditions that can arise following the repair of obstetric fistulas. The article discusses relevant issues with respect to urinary diversion in the treatment of obstetrical fistula and associated urinary incontinence.

METHODS

A review was conducted of the existing literature and of the expert recommendations issued at the Gates Institute fistula meeting held in July 2005 at the Johns Hopkins Bloomberg School of Public Health.

RESULTS

Gynatresia and urinary incontinence develop in approximately 10% and 16% of patients, respectively, after the first repair. Urinary diversion may be necessary when fistulas cannot be closed vaginally or in cases of severe urinary incontinence following successful closure. Gynatresia, urinary incontinence, and urinary diversion are all associated with morbidity, and they require surgical and nonsurgical expertise for proper management.

CONCLUSIONS

Closing the anatomical fistula is not always sufficient, and treatment paradigms must shift toward the prevention and repair of gynatresia and urinary incontinence at the time of the primary operation.

Long-term follow-up of submucosal tunnel and serosa-lined extramural tunnel ureter implantation in ileocaecal continent cutaneous urinary diversion (Mainz pouch I)

OBJECTIVE

To assess upper urinary tract complications and renal function in patients with a submucosal tunnel and serosa-lined extramural tunnel ureter implantation during the long-term follow-up of ileocaecal continent cutaneous urinary diversion (Mainz pouch I).

PATIENTS AND METHODS

In all, 458 patients who had diversion with the ileocaecal pouch were analysed in a retrospective follow-up study. Uretero-intestinal implantation was done using a submucosal tunnel (ST) in 809 reno-ureteric units (RUs) and by the serosa-lined extramural tunnel (ET) technique in 74 RUs. The median age of the patients at the time of surgery was 47.1 years, and the median follow-up was 89.0 months.

RESULTS

For the ST, there was anastomotic obstruction in 59 RUs (7.3%) at a median of 16.8 months after diversion; the obstruction-free intervals at 1, 5 and 10 years were 97%, 93% and 91%, respectively. Obstruction rates were 13.9% for previously dilated upper tracts and 17.1% in patients with a neurogenic bladder. Serum creatinine levels were < or =1.6 mg/dL in 97% of the patients at the latest follow-up. For ET, there was anastomotic obstruction in three RUs (4.1%) at a median of 17.2 months after diversion. Obstruction-free intervals at 1, 5 and 10 years were 100%, 96% and 96%. Preoperative dilation of the upper tracts did not reduce the obstruction rate (3.1%), but it was 7.1% in patients with a neurogenic bladder. Serum creatinine levels were < or =1.6 mg/dL in 98% of the patients at the latest follow-up.

CONCLUSIONS

The ET gives lower obstruction rates than the ST, especially when upper tracts are dilated and in patients with a neurogenic bladder. Renal function remained stable with both techniques in the long term.

A modified sigma-rectum pouch (Mainz pouch II) technique: analysis of outcomes and complications on 220 patients

OBJECTIVE

To evaluate the safety and efficacy of a modified technique for a sigma-rectum pouch (Mainz pouch II).

PATIENTS AND METHODS

Between October 1994 and March 2003, a modified Mainz pouch II was constructed in 220 patients (153 men and 67 women, mean age 56.7 years) in a multicentre prospective study. The median follow-up (177 patients, 81%) was 21 (1-84) months.

RESULTS

There were no peri-operative deaths; there were early complications in 24 patients, including prolonged ileus in six, pyelonephritis in 17, unilateral ureterohydronephrosis in 11, bilateral ureterohydronephrosis in two, and incipient renal failure in five. Late complications included ureteric implantation-site stenosis (unilateral in eight patients and bilateral in three). In all, 92 patients (52%) needed oral alkalizing medications and potassium supplementation because of hyperchloraemic metabolic acidosis. All but three patients (99%) were continent by day and at night. The mean (sd) voiding frequency was 4.2 (1.6) voids by day and 2.1 (0.5) at night.

CONCLUSION

The Mainz pouch II is a simple and reproducible surgical technique, with good results in terms of mortality, morbidity, continence and overall quality of life. The main limitation is malignant transformation of the uretero-intestinal anastomosis. For selected cases, the technique is a good alternative to other types of continent urinary diversion.

Rectosigmoid pouch (Mainz Pouch II) in children

PURPOSE

Continent anal urinary diversion is a therapeutic option in bladder exstrophy. We report our long-term results with the rectosigmoid pouch (Mainz pouch II), a modification of the classic ureterosigmoidostomy.

MATERIALS AND METHODS

A total of 38 children with a mean age of 5 years (range 0.5 to 17) underwent a Mainz pouch II procedure between 1991 and 2004. Most patients (33) had bladder exstrophy or incontinent epispadias. In 14 children (37%) urinary diversion was performed after failed primary reconstruction. In 6 children conversion was performed from an incontinent type of urinary diversion. Renal function, continence and metabolic changes were analyzed. A total of 35 children were followed for a mean of 112 months (range 5 to 147).

RESULTS

All children were continent during the daytime but 3 (8.6%) suffered from nighttime incontinence requiring pads. With respect to the upper urinary tract, 6 children (15.8%) had development of pyelonephritis, mostly with stenosis of the ureterointestinal anastomosis. Reimplantation of the ureter was required in 10 of 69 RU (14.5%), of which 7 (10.1%) were due to ureterointestinal stenosis and 3 (4.3%) were due to reflux. Serum creatinine was within normal limits in all children. During followup acid-base balance was monitored, and early alkali supplementation was initiated in 24 of 35 children (69%) when the base excess was less than -2.5 mmol/l. One child had development of clinical acidosis requiring hospitalization. After followup of more than 10 years annual rectosigmoidoscopy was performed in 16 children/young adults without pathological findings.

CONCLUSIONS

The Mainz pouch II procedure for children with genitourinary anomalies promises excellent continence rates. However, periodic followup studies are important to check the upper urinary tract and prevent metabolic acidosis. Due to the risk of malignancy at the ureterointestinal anastomosis, endoscopy should be performed annually beginning at postoperative year 10. The Mainz pouch II procedure is safe in the long term. Without stoma, appliance or catheterization this type of continent urinary diversion is specifically suitable for children.

Techniques for uretero-intestinal reimplantation

PURPOSE OF REVIEW

Uretero-intestinal reimplantation is a crucial component of urinary diversion. Several techniques for refluxing and nonrefluxing uretero-intestinal reimplantation have been established and modified to minimize anastomotic complications and preserve renal function. We review current experience with uretero-intestinal reimplantation in different types of urinary diversion.

RECENT FINDINGS

The basic principles of uretero-intestinal reimplantation are still controversially discussed. Several studies have focused on complications of urinary reflux from direct end-to-side or end-to-end anastomosis, such as pyelonephritis and calculus formation. Strictures at the anastomotic site of nonrefluxing tunneled ureteral reimplantation resulting in hydronephrosis and renal deterioration have led some to question the need for an antirefluxive anastomosis, at least in "low pressure urinary diversion". Alternative surgical procedures aim to avoid reflux and minimize the risk for anastomotic strictures by direct ureteral reimplantation into an intact isoperistaltic afferent ileal segment or the prevalvular ileum, with the ileocaecal valve functioning as an antireflux mechanism.

SUMMARY

A "gold standard" for uretero-intestinal anastomosis in urinary diversion does not yet exist. Further prospective randomized studies are required to identify the best anastomotic techniques for different types of urinary diversion.

Laparoscopic radical cystectomy with continent urinary diversion (rectosigmoid pouch) performed completely intracorporeally: An intermediate functional and oncologic analysis

OBJECTIVES

To present our experience with the first series of rectosigmoid pouch creation performed completely laparoscopically for continent urinary diversion after radical cystectomy to treat transitional cell carcinoma of the bladder. We evaluated the intermediate functional and oncologic outcomes.

METHODS

Between April 2000 and January 2004, 20 patients underwent laparoscopic radical cystectomy with urinary diversion for transitional cell carcinoma at the Department of Urology, Charite Hospital, Campus Mitte. Of the 20 patients, 12 received a rectosigmoid pouch for urinary diversion. The procedures were performed completely laparoscopically, including free-hand laparoscopic suturing and in situ knot tying techniques. The mobilized specimens were removed in an endoscopy bag by way of the rectum or vagina.

RESULTS

All operations were completed laparoscopically by two surgeons without conversion to open surgery. The median operating time was 485 minutes. One patient needed a blood transfusion of 2 U. All specimens had negative surgical margins. Two patients required reoperation. The median follow-up was 33 months. All patients were continent during the day, and 11 patients were continent at night. One patient developed unilateral hydronephrosis with loss of kidney function. No patient developed local recurrence, but 3 patients had systemic progression. Two of the three died of metastatic disease.

CONCLUSIONS

This is the first series of laparoscopic radical cystectomy using an intracorporeal rectosigmoid pouch. Our functional data for continence and upper urinary tract obstruction were comparable with those of open rectosigmoid pouch studies. We were able to demonstrate an oncologic outcome similar to that achieved by the open surgical approach.

[Urinary diversion after cystectomy]

Urinary diversions become necessary in cases of a tumor-bearing urinary bladder requiring cystectomy or a nonfunctioning urinary bladder, e.g., due to neurogenic disorders. In order to choose the ideal urinary diversion, long-term function as well as complication rates, quality of life issues, and patient's acceptance become matters of debate. In this regard, orthotopic diversions are usually the first choice. However, there are contraindications for an orthotopic bladder substitute and sometimes the decision has to be made intraoperatively. Therefore, urinary diversions should only be offered by uro-oncological centers that are capable of performing different kinds of diversions. For many decades incontinent diversions have been the standard of care and for 20 years different kinds of cutaneous and orthotopic continent reservoirs have been performed. Bladder substitutes by means of tissue engineering, however, are still experimental.