The Hautmann neobladder with a chimney: a versatile modification

PURPOSE

We describe a modification to the popular Hautmann ileal neobladder comprised of a chimney for the ureterointestinal anastomosis in order to enhance its flexibility, reduce its pitfalls and hence make more patients candidates for this type of diversion.

MATERIALS AND METHODS

The Hautmann ileal neobladder is prepared in the standard fashion except that an additional 5 to 10 cm. (or more if needed in the case of a short ureter) of small bowel are selected to be added for either a left or right "chimney" (depending on which side the ureter may be shorter or if there is a solitary kidney). The V segment of the W which will be anastomosed to the urethra is made longer than the contralateral V segment. A neobladder neck is created by sewing together the cut edges of a 5 cm. lip in the lowermost W configuration of the neobladder, allowing an end-to-end urethrointestinal anastomosis.

RESULTS

Between March and October 1996, 3 patients have undergone this procedure at the University of Virginia. Two had right chimneys and 1 had a left chimney. Followup is short, but there have been no complications except for a transient postoperative partial small bowel obstruction in 1 patient. Two patients have no urinary incontinence, the third has only occasional nocturnal incontinence.

CONCLUSIONS

This modification of the Hautmann ileal neobladder provides greater versatility for short ureters, minimizes tension from the mesentery on the urethrointestinal anastomosis, simplifies the ureterointestinal anastomosis and provides easy postoperative access for ureterointestinal anastomosis revision or resection in case of recurrent disease.

Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap

This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so-formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder-like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder-like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap.

Metabolic complications secondary to obstruction of a Kock pouch afferent limb

Metabolic complications are frequently seen following urinary diversion with an intestinal segment. Afferent limb complications are noted in 10% of patients undergoing continent Kock urinary diversion. We present a patient with cloacal exstrophy with developed significant hypocalcemic tetany and metabolic acidosis related to a nondraining afferent limb of a Kock pouch created to achieve continence.

Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 34 patients

PURPOSE

Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction at our institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients.

MATERIALS AND METHODS

Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70).

RESULTS

There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%) and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming.

CONCLUSIONS

The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy.

Stomach versus sigmoid colon in children undergoing major reconstruction of the lower urinary tract

A review of 50 patients who underwent intestinocystoplasty (ICP) or gastrocystoplasty (GCP) replacement at our department during an 8-year period is presented. The most common diagnoses were neurogenic bladder and bladder exstrophy. A total of 48 patients underwent augmentation cystoplasty and 2 had total bladder replacement. Mean follow-up time was 42 months. The clinical and metabolic aspects of the two types of ICP are reported. Hyperchloremic acidosis requiring therapy was not encountered, although mild degrees were seen after sigmoid augmentation in 36% of patients. A dysuria-hematuria syndrome (DHS) was seen in 50% of the patients who underwent GCP. Operative mortality rate was nil. Significant surgical complications occurred in 36% of the patients. The overall success rate for ICP and GCP in this series was 79.15%. ICP gives effective results when used to increase the compliance of the lower urinary tract, but problems related to electrolyte absorption, stones, and mucus production are often encountered. In GCP electrolyte absorption is practically eliminated, so that this technique can be used in patients with renal damage. In addition, patients with a normal bladder plate (bladder exstrophy) can achieve normal voiding with time. The authors believe that patients must be made aware of the possibility of DHS and that this syndrome needs further investigation.

[The Indiana pouch: a technic for simple continent urinary diversion]

OBJECTIVE

Description of the Indiana pouch, a continent urinary diversion after cystectomy for urogenital tumours, and for the sequelae of neurogenic and traumatic bladders.

MATERIAL AND METHOD

This was a retrospective study of 16 patients undergoing, between June 1991 and March 1995, cutaneous urinary diversion by ileocaecal graft, detubularized in the colonic segment, with continence ensured by the ileocaecal valve. The postoperative follow-up (4 to 36 months) was performed at 3, 6 and 12 months (abdominal ultrasonography alternating with abdominopelvic CT scan), then annually (CT scan). Finally, a urodynamic assessment was performed in 7 patients.

RESULTS

No early complications related to the reservoir were observed. Late complications of the diversion were related to the uretero-colonic anastomosis with 3 dilated renal subunits. Continence was achieved in 12 out of 15 patients, while one patient finally refused self-catheterization. In the patients in whom a urodynamic assessment was performed, the mean capacity of the reservoir was 671.4 +/- 273.9 mL for a filling pressure of between 3.7 +/- 1.6 and 11 +/- 2.5 cm H2O and an ileocaecal valve closure pressure of 97.9 +/- 117.1 cm H2O (full reservoir).

CONCLUSION

The Indiana pouch is a useful urinary diversion as it is simple to perform and is associated with a low revision rate, while ensuring low-pressure continence.

Diagnosis and management of high-pressure peristaltic contractions in cystoplasties

OBJECTIVE

To define the aetiology of and therapeutic strategy for high-pressure peristaltic contractions within colo- and caecocystoplasties associated with symptoms of frequency, urgency and urge incontinence.

PATIENTS AND METHODS

In a series of over 150 subtotal supratrigonal colo- and caeco-cystoplasties, nine patients were identified with such symptoms. These patients underwent videocystometrography (VCMG) confirming the presence of phasic peristaltic contractions of > 35 cmH2O.

RESULTS

In three cases, there was urodynamic evidence of outlet obstruction and symptoms resolved when the obstruction was surgically relieved. In the other six cases, high-pressure peristaltic contractions were present without bladder outlet obstruction. The symptoms did not respond to anticholinergic medication. Three of the six patients had tolerable symptoms which did not warrant further intervention. The other three cases had disabling urge incontinence and underwent ileal patch cystoplasty. The symptoms resolved in all three cases, although later recurred in one patient, probably due to incomplete division of the taenia coli during ileal patch cystoplasty.

CONCLUSION

It appears that colonic smooth muscle can develop high-pressure contractions in response to neobladder outlet obstruction. Relieving the obstruction ameliorates symptoms associated with these contractions and reduces the magnitude of the peristaltic waves. Symptoms related to high-pressure peristaltic contractions without neobladder outlet obstruction do not respond to anticholinergic medication but can be successfully treated by ileal patch cystoplasty.

Double folded rectosigmoid bladder with a new ureterocolic antireflux technique

PURPOSE

We present a new method of urinary diversion to the rectum.

MATERIALS AND METHODS

Between 1992 and 1995 a new surgical procedure was used in 32 women, 20 men and 12 children 3 to 60 years old (mean age plus or minus standard deviation 35.4 +/- 2.2). The main indication for diversion was invasive bladder carcinoma. Surgery entailed creation of an S-shaped double folded rectosigmoid reservoir with implantation of the ureters via an extramural serous lined antireflux technique.

RESULTS

One patient died of a massive pulmonary embolism postoperatively. Followup ranged from 6 to 36 months (mean 19.2 +/- 7.0). During the observation period 6 patients died of local recurrence and/or distant metastasis within 8 months. Of the patients 57 are currently evaluable. All patients are continent during the day with an emptying frequency of 2 to 4 times. Nocturnal enuresis was observed in 4 children who responded favorably to imipramine hydrochloride therapy. Upper urinary tract function was maintained or improved in 95% of the patients. No clinical evidence of acidosis was observed, since all patients were kept on prophylactic oral alkalization.

CONCLUSIONS

The procedure can circumvent some of the inherent disadvantages of ureterosigmoidostomy and is a good alternative to orthotopic bladder substitution when the urethra cannot be used.

[Orthotopic bladder replacement: II. Functional results and complications in patients with Studer-type ileal neobladder]

OBJECTIVE

Since 1988, 100 Studer ileal low pressure urinary reservoirs have been performed at our institution. The functional results and the complications observed in these patients are presented.

METHODS

Patients submitted to radical cystectomy and lower urinary tract reconstruction with the Studer technique from 1988 to 1994 were retrospectively studied. All patients were males, their mean age was 60 years (37-75) and the mean follow-up was 18 months (6-72). The isoperistaltic ileal segment as antireflux mechanism was utilized in 97 cases and intussusception of the ileal segment to which the ureters were anastomosed in 3 cases. Reinsertion of the ureter was done using the Wallace technique in 90 cases and by direct fixation according to a personal technique (H.V.) in 10 cases. Anastomosis of the neobladder and the urethra was done with the end of the second suture of the orthotopic reservoir. The neurovascular bands were preserved in 21 patients less than 60 years old with tumor stage T2-T3a, according to the technique described by Walsh and Mostwin (1984).

RESULTS

One patient died early postoperatively from sepsis. The early complications included urinoma (4%), urinary fistula (3%), intestinal fistula (2%), pulmonary complications (4%), pelvic hematoma (1%) and intestinal obstruction (3%). Only 4 of these patients required surgical resolution of the complication. The late complications included stricture of neobladder-urethra anastomosis (6%), lithiasis in neobladder (4%), ureteroileal stricture (8%), 5 renal units were lost, chronic urinary retention (5%), symptomatic metabolic acidosis (1%) and urinary infection (14%). Thirteen of these patients with late complications required surgery. At 6 months' minimum follow-up, 90% of the patients were continent during the day and 60% during the night. Overall, 36% of the patients recovered erection postoperatively; 76% of the patients with preserved neurovascular bands recovered erection. Forty-four percent of the patients claimed they had a satisfactory sexual activity postoperatively.

CONCLUSION

The Studer neobladder permits voiding through the urethra, preservation of the upper urinary tract, the urinary infection rate is acceptable, the complication rate is low and it offers patients continence rates that allow them to have a good quality of life.

Application of the Mitrofanoff principle in children with severe impairment of bladder function

Treatment of children with severe impairment of bladder function requires a large-volume, low-pressure reservoir combined with a continent, easily catheterizable valve. The Mitrofanoff principle (MP) appears to meet these requirements. Between 1986 and 1993, the MP was applied in 15 children (4 girls) aged 4 to 14 years. The primary diagnosis was bladder exstrophy in 8 (2 girls), neuropathic bladder in 3 (2 girls), urethral valves in 2, and rhabdomyosarcoma (RMS) in 2. In 10 patients bladder augmentation with an intestinal patch was performed in addition to a Mitrofanoff procedure; in 5 a neobladder and continent appendicostomy were made. One boy with RMS died of distant metastases with a well-functioning appendicostomy and adequate renal function. At 2 to 9 years follow-up of the other 14 patients, 12 have a good result defined as: (1) adequate reservoir capacity; (2) continence; (3) normal renal function; and (4) no hydronephrosis. In 1 exstrophy patient with pre-existing impairment of renal function, further deterioration necessitated frequent catheterization and additional medical treatment. In 1 boy with fulgurated urethral valves, spontaneous micturition became subsequently possible, allowing closure of his appendicovesicostomy. Complications occurred in 10 patients, necessitating reintervention in 7. The MP in combination with the creation of an adequate reservoir gives good results in children with severe impairment of bladder function. Careful attention should be given to patient education regarding emptying of the reservoir. Long-term follow-up of renal function is mandatory.

Continent urinary diversion: the Children's Hospital experience

PURPOSE

Continent urinary diversion has become increasingly important for treating childhood urinary tract pathology that cannot be managed by direct reconstructive techniques. We review our 9-year experience with continent diversion.

MATERIALS AND METHODS

Since 1986 continent diversions were created in 74 patients 3 to 38 years old (mean age 13.7). The underlying pathological condition was the exstrophy/epispadias complex in 34 patients, neurological disorders in 23, malignancy in 13 and other congenital anomalies in 4. Followup averaged 5.2 years after the last procedure. Nonbladder reservoirs in 39 patients (53%) were fashioned from ileocolic (17), colic (7), gastrocolic (6), sigmoid (3), gastrosigmoid (2), ileosigmoid (2), ileal (1) and gastroileac (1) segments. When possible, the native bladder was incorporated into the reconstructive strategy. A total of 26 patients underwent bladder augmentation with intestine or stomach, including ileal (11), gastric (8), sigmoid (3), gastroileac (2) and ileocolic (2) segments. Nine other patients did not require bladder augmentation. Continence mechanisms were a flap valve (Mitrofanoff principle) in 50 patients, nipple valve in 15 and ileal plication (Indiana pouch) in 9. When the Mitrofanoff principle was used with a native bladder reservoir in 30 cases, outlet resistance was altered by bladder neck division (15), fascial sling placement (6) or Young-Dees-Leadbetter bladder neck reconstruction (2). In the remaining 7 patients the bladder neck remained intact.

RESULTS

Excellent continence was obtained. The Mitrofanoff principle initially provided continence in 41 patients (82%). Six of the 9 incontinent patients were dry after a single revision. A total of 13 patients (87%) with nipple valves and 7 (78%) with Indiana pouches were dry, and the remaining 5 were cured after a single revision. Ultimately continence was achieved in 71 of the 74 patients (96%) after a maximum of 2 operations. Of the 48 complications in 29 patients the most common were difficulty in catheterizing (11), stones (11), infection (8) and upper tract deterioration (4).

CONCLUSIONS

Many options exist for reconstructing complex anomalies. Choices must be individualized based on patient anatomy. The dry state may be achieved in most cases without resorting to a bag on the abdomen.

Long-term results of lower urinary tract reconstruction with the ceco-appendiceal unit

PURPOSE

We report long-term results in 11 patients born with bladder exstrophy who underwent lower urinary tract reconstruction using a ceco-appendiceal unit.

MATERIALS AND METHODS

Four boys and 2 girls underwent lower urinary tract reconstruction using an unaltered ceco-appendiceal unit. In 2 boys and 1 girl the bladder was replaced with a reservoir of terminal ileum, cecum and ascending colon, and the appendix was used as an orthotopic neourethra. In another 2 boys and 1 girl the bladder was augmented, while the appendix was used to create a stoma to the umbilicus. In 5 patients in whom the ceco-appendiceal junction was incompetent the cecum was plicated over the base of the appendix to reinforce the sphincteric mechanism. Four patients underwent augmentation with the appendix brought out as an umbilical stoma, and in 1 the bladder was replaced and the appendix was used as a neourethra.

RESULTS

Six patients in whom the ceco-appendiceal junction was unaltered and 5 in whom it was plicated remain continent 5 to 11 and 2 to 7 years postoperatively, respectively. In the initial patient urinary incontinence developed due to high intraluminal pressure, which resolved after detubularization of the urinary reservoir. Another patient underwent revision of the abdominal stoma.

CONCLUSIONS

The ceco-appendiceal unit may be used for continent lower urinary tract reconstruction. Ceco-appendiceal junction competence can be tested intraoperatively and the sphincteric mechanism may be reinforced as necessary. The appendix may be ectopically or orthotopically placed and used for intermittent catheterization.

[Orthotopic bladder substitution: II. Types and complications]

OBJECTIVE

In the last two decades, attention has been focused on the design of continent urinary diversion and orthotopic neobladder in an attempt to find the ideal bladder substitute. The more commonly utilized techniques of orthotopic bladder replacement are described and the urodynamic aspects and complications are analyzed.

METHODS

The series of Studer, Hautmann, Kock, Pagano, Thuroff (Mainz Pouch) and Goldwasser and the relevant literature on this subject were reviewed.

RESULTS/CONCLUSION

To date, similar functional results have been achieved by the different techniques of bladder substitution, although different intestinal segments are utilized. A longer follow-up is warranted to determine which is the ideal technique of bladder substitution.

[Orthotopic bladder replacement: I. Physiopathology of orthotopic bladder replacement with intestine]

OBJECTIVE

To analyze the physiopathological principles of utilizing the bowel for orthotopic bladder substitution and their effects on metabolism, function and continence.

METHODS

The world literature is reviewed and our experience of 100 cases is described in the third part of this study.

RESULTS/CONCLUSION

To reduce the metabolic changes, utilization of colonic or ileal segments with a maximum length of about 40 cm is advocated. This length of detubulized intestinal segment permits creating an ample, low pressure reservoir with an antireflux mechanism. The precise incidence of neoplastic degeneration of the ileal and colonic reservoirs is not known, but appears to be lower for the ileal neobladder.

A simplified method for detubularization in the construction of a continent ileocolic reservoir (Miami pouch)

The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient's colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients.

Urinary diversion in children and young adults using the Mainz Pouch I technique

OBJECTIVES

To determine the late complications and consequences for renal function, vitamin and acid-base metabolism after application of the Mainz Pouch I (MZP-I) technique in children and young adults.

PATIENTS AND METHODS

To November 1994, the MZP-I procedure was carried out in 463 patients at our institution, 91 of whom were children and adolescents (< or = 20 years old) using bladder augmentation in 21 and a continent cutaneous stoma in 70. A minimum follow-up of 1 year was possible in 87 patients or 163 renal units (RUs) with a mean of 5.5 years (range 1-10.5).

RESULTS

At the last examination, 23 of 55 (42%) preoperatively dilated RUs had improved. 131 of the 163 RUs (80%) were stable and nine RUs (5.5%) showed a slight clinical asymptomatic increase in the upper tract dilatation. Through an extraperitoneal flank incision, 11% of the RUs which developed stenosis at the ureterocolic anastomosis were successfully reimplanted (16% in patients with neurogenic disorders, 17% with pre-operative irradiation and 5% in the remaining patients). Two of 32 patients with an intussuscepted and invaginated ileal nipple required re-operation due to incontinence, but none of the patients with an appendiceal stoma were incontinent. Open revision of a stomal stenosis was performed in three and endoscopic treatment in nine patients. In 54 patients, the levels of vitamins A, B1, B2, B6, E, folic and bile acid were within normal ranges. There was no significant decrease in vitamin B12 levels after operation. In none of the patients with normal pre-operative creatinine values had the levels increased and none developed severe acidosis or bowel neoplasm.

CONCLUSION

The MZP-I is recommended as a technique for bladder augmentation or continent urinary diversion in children and young adults, with an acceptable complication rate which offers long-term protection of the upper urinary tract.

Orthotopic bladder substitution in women following cystectomy for bladder cancer

The feasibility of orthotopic substitution of the bladder after cystectomy for cancer has been realized. One must be careful about two potential drawbacks that may appear. Cases must be selected carefully and followed up to ensure that the adoption of such a procedure does not increase the risk of local recurrences. In the long term, if overcontinence proves to be a problem among a significant proportion of such cases, the logic of and the need for orthotopic substitution are lost. One then has to reconsider that intermittent catheterization of a continent cutaneous stoma provides a better alternative.

Results of the Mitrofanoff procedure in urinary tract reconstruction in children

OBJECTIVES

To evaluate the success and long-term complications associated with the use of continent catheterizable conduits based on the Mitrofanoff principle in children.

PATIENTS AND METHODS

The records of 43 patients (21 female and 22 male) who underwent the construction of a continent catheterizable stoma based on the Mitrofanoff principle between 1987 and 1996 were reviewed retrospectively. The mean age at surgery was 10 years (range 3-21) and the mean follow-up was 3 years (range 0.5-6.5). Twenty-eight of the 43 children underwent augmentation cystoplasty in conjunction with the Mitrofanoff procedure, using ileum in 17, sigmoid in seven, caecum in two and stomach in one; detrusormyectomy was performed in one child. Fifteen patients had only a continent catheterizable stoma formed. The most common type of conduit was appendicovesicostomy (36 of 43 children): other conduits were constructed with ureter (four), tapered ileum (two) and fallopian tube (one).

RESULTS

Stomal continence was achieved in 42 of 43 patients (98%). The most common late complication was difficulty in catheterization, which occurred in 14 patients (32%). Stomal prolapse requiring revision occurred in one patient (2%). Conduit dilatation was initially attempted in all patients with difficult catheterization, although it failed in 11 who then required surgical revision. Therefore, the overall revision rate was 28% (12 of 43). The site of stomal placement (umbilical or abdominal) did not significantly influence the risk of difficulty with catheterization.

CONCLUSION

The Mitrofanoff procedure can simplify catheterization in children who are dependent upon intermittent catheterization. The vermiform appendix appears to be the best source for constructing the conduit. While stomal continence is excellent, conduit stenosis remains a frequent complication regardless of stomal location.

Continent cystostomy (Mitrofanoff's procedure) for neurogenic bladder in children and adolescent (56 cases: long-term results)

Between 1978 and 1991 we made a continent cystostomy according to Mitrofanoff's technique in 56 patients - children or adolescents - with a neurogenic bladder. We study the complications and the long-term results (follow-up ranging from 3 to 17 years - average 10 years). One patient died from a urological complication, another one died 2 years after from a neurological complication. Two patients were lost to follow-up after 3 years. Among the other patients 36 i.e. 64.3% have had urological complications. Analysis of these complications and their treatment demonstrates that most could now be avoided. At the present time the continent cystostomy with an appendicular or ureteral conduit is the safest and most comfortable way to treat the incontinence of wheel-chair bound patients who cannot or do not wish to use transurethral catheterisation.

[The use of a continent urinary stoma in complex reconstructions of the lower urinary tract in children]

Since its description in 1980, the Mitrofanoff principle has become a widely utilized and successful technique for the management of patients with a variety of urological disorders. We report our experience with this procedure in 14 patients (10 M, 4 F). The age range was 3.5 years to 17 years (average 12 y) and follow-up was from 6 months to 3 years (average 1.7 y). Patients were classified in 2 groups: I) When this procedure was done because of the patient was unable to perform urethral catheterization (8p). II) Concomitant bladder neck transection and Mitrofanoff diversion (6p). The appendice was used in 9p, ileum in 1 and ureter in 4. Bladder augmentation was performed with ureter in 2p and colon sigmoid in 4. In 1p, ileo-cecal segment and in other colon+ileum, were used to replace the bladder. All patients catheterize the Mitrofanoff channel easily, there were no case of stomal stenosis and the conduit was continent in all. We consider that Mitrofanoff principle is a very successful technique and it can be used as the primary continence mechanism or as an adjunct of major urinary tract reconstruction, to ensure complete bladder emptying, in patients unable to perform urethral catheterization.

Ureteral anastomosis in the orthotopic ileal neobladder: comparison of 2 techniques

PURPOSE

The functional results and complications of 2 different ureteroileal anastomoses were evaluated in patients with bladder cancer undergoing radical cystectomy and orthotopic ileal bladder substitution.

MATERIALS AND METHODS

Between 1989 and 1995, 102 patients underwent creation of a low pressure neobladder. In the first 50 cases the ureteroileal anastomosis was created with a split-cuff nipple technique as an additional antireflux mechanism. In the next 52 cases the ureteroileal anastomoses were constructed via the direct end-to-side technique counting on the antireflux protection of the afferent tubular limb.

RESULTS

Stenosis occurred in 7 of the 100 ureters (6 patients) treated with the split-cuff nipple technique and 7 of 104 treated with a direct end-to-side anastomosis. This complication occurred more commonly in the left ureter (11 of 14 patients). Reflux was noted at cystography in 10 cases with the split-cuff nipple method and 12 with end-to-side anastomoses, and was symptomatic in only 3 patients. Four ureteral strictures were treated successfully with primary open repair. Percutaneous dilation and stenting were performed for 8 ureteral strictures: 2 cases were successful, 3 failed and 3 are unresolved.

CONCLUSIONS

We observed no differences between the antireflux split-cuff and end-to-side anastomoses with regard to stricture formation or ureteral reflux. Therefore, we do not believe that there is a need to create antireflux ureteral anastomoses due to the tubular afferent ileal segment and given that the reflux is asymptomatic in most patients. Strictures may be treated with percutaneous balloon dilation and stenting but open repair appeared to be more effective.

Mitrofanoff principle for continent urinary diversion

In 1980 Mitrofanoff described a method to achieve continent urinary diversion by surgically closing the bladder neck and creating a continent catheterizable stoma from the appendix which had been implanted in a nonrefluxing manner into the bladder or from a nonrefluxing distal ureter. The Mitrofanoff principle (MP) serves well as a continence mechanism for either the native bladder or intestinal reservoirs. We review 17 patients, including 10 children, who were treated with the MP and received a continent catheterizable channel. For the MP, appendix was used in 16 patients and ureter in 1. The continuity between the urinary reservoir and urethra was maintained wherever possible. Bladder neck suspension was preferred to bladder neck closure in incontinent females and boys. Complications and their management have been discussed at length. Stable renal functions, ease of catheterization and urinary continence were achieved in 93.8% of the patients.

Bladder replacement with modified Studer pouch using absorbable staples

The use of absorbable staples may allow to reduce the operating time of orthotopic bladder replacement. We report our experience in 14 patients with a modification of the Studer technique using absorbable PolyGIA instruments. The technique has been shown to be simple and quick to perform (time for pouch creation 15-40 minutes, mean 16 minutes) with no significant intraoperative difficulties. Urodynamic data and continence are satisfactory and seem comparable to different procedures and not related to staples' use. The main question remains if the reduced operating time equalizes the high cost of staple devices.

Clinical experience with the detubularized ileocecal reservoir and continent appendicoumbilical stoma in urinary diversion

OBJECTIVE

To obtain clinical experience of a reservoir using a detubularized ileocecal segment (Mainz pouch) and continent appendiceal stoma connected to the umbilicus.

METHODS

The operation was performed in 23 patients. The submucosally placed in situ appendix was connected to the umbilicus acting as the continence mechanism and route for self-catheterization. The follow-up period was 8-62 months.

RESULTS

No operative mortality occurred. In 2 patients the postoperative period was complicated by catheter perforation of the appendix. In 4 patients stomal stenosis required excision of the stricture and reanastomosis. All patients are completely continent and catheterization is easy.

CONCLUSION

Both functional and cosmetic results are very satisfactory.

New techniques for construction of efferent conduits based on the Mitrofanoff principle

Presently, urinary diversion with continence mechanisms based on the Mitrofanoff principle is frequently used. For its construction, the critical issue is related to the choice of efferent conduit; the most widely used are the appendix and the tapered ileum. Here, we present two alternative techniques for construction of tubes applicable to the same function. Ten dogs underwent operations with two different types of tubes constructed through transversal tubularization of small segments of ileum. These tubes were implanted in the bladder. The dogs were followed up for 30 days, during which all were continent. Their tubes were easily catheterized. The techniques described met the criteria defined for an efferent tube to be used according to the Mitrofanoff principle.

Cystoplasty in pigs: a suitable model for the functional and morphological examination of urinary diversion

Although in the last years surgery for urinary diversion became routine in clinical practise, various problems have to be solved. Therefore, a safe, universal animal model is necessary. An ileal pouch anastomosed to the subtotally resected urinary bladder was formed in 6 domestic pigs. Ureters remained untouched and the reservoir was not drained by any tubes. Animals were followed up for 3 months, every 3-4 weeks blood was drawn for electrolytes, renal and hepatic function and blood gas analysis. The animals were sacrificed after 3 months and a thorough pathohistological examination of the reservoir was performed. No intraoperative or operation-related postoperative complications were seen. Laboratory parameters were stable and no micturition problems appeared. Upper urinary tract was normal. The animal model presented is safe with regard to inflammatory or metabolic side effects and to disturbances of supravesical urinary tract. Therefore, this model is suitable to serve for short- as well as long-term studies of various forms of urinary diversions.

Continent gastric tube: new techniques and long-term followup

PURPOSE

The successful use of stomach for bladder augmentation and substitution is well documented. Gastric tissue has been used more recently to create continent catheterizable tubes. We describe 2 new techniques of gastric tube construction, and report our long-term followup of catheterizable gastric tubes in children and adults undergoing complex urinary tract reconstruction.

MATERIALS AND METHODS

A retrospective chart review of 6 male and 4 female patients 5 to 43 years old was done. Primary diagnoses included bladder exstrophy, cloacal exstrophy, rhabdomyosarcoma and neurogenic bladder. Five patients underwent gastrocystoplasty with simultaneous creation of a continent gastric tube from the anterior gastric flap. In 2 patients who had undergone previous gastrocystoplasty a continent gastric tube was created from an anterior flap raised from the existing gastric bladder. Isolated gastric tubes were constructed in 3 patients.

RESULTS

Followup ranged from 2 to 9 years (median 3.5). All patients demonstrated easy reliable catheterization. One patient required revision of the proximal end of the tube for incontinence. At followup all tubes were continent. Complications occurred only in flush or protuberant stomas, and resolved after stomal revision with recessed skin flaps.

CONCLUSIONS

Several techniques can be used to create a continent gastric tube. Long-term followup reveals reliable catheterization and good continence rates. Recession of the gastric tube stoma with a skin flap prevents peristomal complications.

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.

Management of bladder exstrophy and incontinent epispadias: 25 years of experience with urinary diversion

OBJECTIVES

Achieving complete urinary continence with preservation of the upper urinary tract in the exstrophy-epispadias complex must be the primary aim. To determine the optimal surgical approach, we reviewed the records of patients treated at our institution.

METHODS

During the last 26 years, 95 patients with bladder exstrophy and 20 with incontinent epispadias were operated upon at our department. For this retrospective study a total of 102 patients could be interviewed. Mean followup after the first operation was 16.7 years. Of the 102 patients, in 43 primary treatment was performed at our institution (urinary diversion n = 39, modified Young Dees n = l, sling plasty n = 3). A further 59 patients were referred to our institution for secondary treatment, 34 of whom after primary bladder closure and/or bladder neck reconstruction (urinary diversion n = 27, modified Young Dees n = 7).

RESULTS AND CONCLUSION

Of the 8 patients with modified Young Dees, 5 required conversion to a Mainz Pouch I due to obstruction of the reconstructed bladder neck or incontinence. Continence rates are 96% for the rectal reservoirs, 97% for the Mainz Pouch I and 67% for the modified Young Dees procedure. Presently, none of the 102 patients has deterioration of the upper urinary tract or has renal insufficiency; none has developed severe metabolic complications or bowel neoplasms. The physical, social and psychological development of the patients treated at our institution appears to be comparable to that of the general population. All children over 6 years of age attend elementary school, most of the adults are, well-educated, only three are unemployed and one lives in a therapeutic center as a result of multiple physical problems. Rectal reservoirs are the urinary diversion of choice at our institution in patients with bladder exstrophy or incontinent epispadias. When the upper urinary tract has deteriorated, a colon conduit is created with the option of conversion to a continent form of diversion as soon as renal and ureteral functions have recovered. In patients with failed urinary tract reconstruction/insufficient anal sphincter function, we prefer the Mainz Pouch 1.

Intussuscepted partial-thickness ileal valve in continent urinary diversion

OBJECTIVE

This study was undertaken to ascertain the feasibility of fashioning a nipple valve from partial-thickness ileum and to assess the competence and durability of that valve. The approach employed was designed to circumvent the necessity for considerable lengths of bowel to be committed to valve formation and to avoid the tendency for desusception, present with other forms of nipple valves.

METHODS

A technique in which a subterminal segment of partial-thickness ileum was 'skinned' circumferentially of serosa and muscularis propria and then intussuscepted to form a continent nipple-valve mechanism was studied for up to 4 months in 10 dogs. The intussuscepted partial-thickness ileal valve was in continuity with a terminal ileal segment sutured flush with skin and, internally, with another segment laid open and anastomosed to the bladder.

RESULTS

All valves were competent, withstanding intravesical pressures up to 90 cm H2O. Six dogs were catheterized, without difficulty, twice daily up to 104 days. The valve mucosal surfaces were smooth due to a loss of plicae circulares, and, between 'back-to-back' submucosal layers, a fine stroma developed.

CONCLUSIONS

This simple technique, which is frugal in its use of bowel, provided a robust and effective ileal continence mechanism. Furthermore, because of denervation and interposing fibrous tissue, this nipple valve is considered most unlikely to desuscept subsequently. The intussuscepted partial-thickness ileal valve approach is recommended now for clinical evaluation.

Early clinical experience with continent urinary diversion

BACKGROUND

Alternatives to cutaneous diversion have included continent urinary diversion and replacement cystoplasty. Five-year experience with continent diversion is reported.

METHODS

Between 1989 and 1994, 29 patients underwent continent urinary diversion. Of these, 24 patients underwent Indiana pouch procedures and five patients had a Mitrofanoff-type procedure. All have now been followed up for at least 12 months.

RESULTS

The continence rate for the Indiana pouch group was 23/24 (96%) and the mean capacity was 648 mL (range 300-1400). There were nine (37.5%) early postoperative complications, only three of which (12.5%) required surgical revision. The late complication rate was 35.5% (7/22), and 18.2% (4/22) of the patients underwent re-operation. Stomal stenosis occurred in two patients in whom the stoma was situated in the right iliac fossa, whereas all 12 stomas sited at the umbilicus had no stomal problem. Four of the five patients having Mitrofanoff procedures were continent, but these patients had higher rates of early and late complications.

CONCLUSIONS

From this experience, the Indiana pouch urinary diversion appears to be superior to the Mitrofanoff procedure when continent diversion is indicated. An umbilical stoma site is optimal.

Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: long-term results of a prospective randomized trial

PURPOSE

Intestinal low pressure orthotopic bladder substitutes have no major coordinated contractions during micturition. Therefore, the importance and type of reflux prevention were assessed in a prospective randomized study.

MATERIALS AND METHODS

A total of 70 patients with an ileal low pressure bladder substitute was randomized to receive a nipple valve or an isoperistaltic afferent ileal tubular segment for reflux prevention.

RESULTS

After median observation times of 57 and 45 months, respectively, the results regarding functional reservoir capacity, incidence of infected urine, urinary continence, voiding habits and serum electrolytes, urea and creatinine were similar in both groups. Severe upper tract dilatation due to ureteroileal or nipple stenosis occurred in 9 of 67 evaluable reno-ureteral units (13.5%) in patients with antireflux nipples and in 2 of 69 (3%) in patients with an afferent tubular segment. This difference in favor of the latter cases is significant (Fisher's exact test p < 0.03). Video urodynamics did not show reflux of contrast medium during voiding in either group. A simultaneous intravesical, intra-abdominal and intrapelvic pressure increase was noted during the Valsalva maneuver.

CONCLUSIONS

While long-term upper tract preservation by an afferent tubular ileal segment must be confirmed in larger patient series with longer followup, our results indicate that reflux prevention in patients with orthotopic low pressure bladder substitutes is not a major concern and does not justify the use of antireflux mechanisms with a high complication rate.

Long-term renal morphology and function following enterocystoplasty (refluxing or anti-reflux anastomosis): an experimental study

OBJECTIVE

To study the morphology and function of the upper urinary tract over the long-term in dogs with an enterocystoplasty and a refluxing or anti-refluxing uretero-intestinal anastomosis.

MATERIALS AND METHODS

Subtotal cystectomy and "cup" ileocystoplasty were performed in 13 dogs. The right ureter was implanted into the cystoplasty with a refluxing technique in seven and with an anti-reflux procedure in six dogs. The left renal unit acted as an intact control in 11 dogs, while in two the intramural part of the left ureter was incised to produce reflux. Thus, of the 26 renal units, nine had a refluxing junction (anastomosis), six were anti-refluxing and 11 served as intact controls. Total and separate glomerular filtration rates (GFRs) were measured preoperatively and regularly thereafter, and cystometry, urography and ascending enterocystography were performed. At necropsy, urine was obtained for culture from the cystoplasty and renal pelves, and both kidneys were examined histologically.

RESULTS

The cystometric pressure was low in 12 of the 13 dogs: urography showed no obstruction. The fall in separate GFR did not differ significantly among the groups (with and without reflux protection, and control units). Reflux was detected in three of nine renal units with refluxing anastomosis and in three of 11 control units. Bacteriuria was found in the cystoplasty in all dogs; the incidence in the upper urinary tract was seven of eight renal units with a refluxing anastomosis, one in five of those with an anti-refluxing anastomosis and three of nine control units. Pyelonephritis was found in none of the control kidneys, in six of nine kidneys with a refluxing and in two of six with an anti-refluxing anastomosis: it was less severe in the latter.

CONCLUSION

Refluxing ureteric implantation in a low-pressure enterocystoplasty was commonly associated with bacteriuria in the upper urinary tract and with pyelonephritis. Thus, anti-reflux implantation was beneficial for renal preservation in this setting.

Mainz pouch with appendix-umbilical stoma using catheterizable conduit elongated with continuous cecal segment: a case report

The Mainz pouch with appendix-umbilical stoma is a very stable method for continent, self-catheterizable urinary reservoir in the presence of a healthy appendix. If the appendix is too short or an unexpected stenosis is seen at its distal portion, the elongation of the conduit using a part of the cecum and the implantation of the conduit to the pouch by the Mitrofanoff method can be a good alternative procedure. We herein report our experience in a 53-year-old male with high grade, invasive bladder tumor, who underwent cystourethrectomy and appendix Mainz pouch operation using the above technique.

[Orthotopic ileal neobladder of the Emikock type: technical points and functional results]

Ileal orthotopic neobladder represents, nowadays, the best urinary diversion after cystectomy. Emikock procedure was performed, in our institution, in 26 patients with bladder cancer T2-T4. At 6-60 months of follow-up 3 pts were died with local or at distance neoplastic recurrence, 2 were alive with neoplasms and 21 were NED. Nocturnal continence was good in 22 cases (88%) and only 3 patients were obstructed because of pseudodyssynergia in 2 and stricture in 1. Emikock neobladder even if needs a longer surgical time than other procedure and a long ileal tract is almost free from severe metabolic disorders. This technique offers a good protection of high urinary tract because of antireflux nipple and avoid the uretero-intestinal stricture. It not feasible, now, to know the functional trend of this reservoir on the long term. Adequate postoperative training is recommended to avoid the pseudodyssynergia and functional obstruction of reservoir.

Continent cutaneous urinary diversion using the full-thickness bowel flap tube as continence mechanism: a simplified tunneling technique

PURPOSE

We present a time and labor saving embedding technique for a full-thickness bowel flap tube used as a continent outlet.

MATERIALS AND METHODS

In 17 patients the bowel flap tube was extramurally embedded instead of being submucosally tunneled. The reservoir was attached to the abdominal wall to reinforce the continence mechanism and prevent the tunnel from opening.

RESULTS

All 17 patients are completely continent and 14 of 16 evacuate urine easily with a 14F catheter. Due to recurrent stomal stenosis 1 patient with severe diabetes has undergone incontinent diversion.

CONCLUSIONS

Our described tunneling procedure for the full-thickness bowel flap tube is easy to perform and provides excellent continence.

Continent small-intestine reservoir construction: a tapered intussusceptum promotes sustained continence

Developed for the study of dialysis in the continent jejunal reservoir (CJR), a novel, uncomplicated approach to achieve continence in construction of a small-bowel reservoir is presented. We utilize a technique of constructing a continent nipple valve, which entails the reduction or tapering of the intussusceptum prior to invagination into the reservoir. We have thus far performed the procedure successfully in 21 dogs. All animals have achieved absolute continence. Complications have occurred in two animals, neither complication involving the nipple valve. Pressure-volume cytometry in nine animals demonstrates continence in the awake animal at pressures of up to 40 cm H2O (volumes being limited by animal discomfort due to reservoir distention). In postmortem studies, reservoir capacities of > 1000 ml and pressures of > 70 cm H2O have been attained without loss of continence or prolapse of the nipple valve. Continence is sustained even when the reservoir and nipple valve are subjected to high intraluminal pressures. Incorporating a tapered intussusceptum, the continent reservoir provides absolute continence without the use of cumbersome mesh fixation or lithotropic intraluminal staples.

Kock versus right colon continent urinary diversion: comparison of outcome and reoperation rate

OBJECTIVES

To compare one surgeon's sequential experience with two types of continent cutaneous diversion; namely, the Kock pouch (KP) and the right colon pouch (RCP).

METHODS

Outcomes for the final 30 KP patients seen during the period 1989 to 1992 and the initial 30 RCP patients seen between 1992 and 1995 were analyzed retrospectively. Patients differed in median age (KP 52.5, RCP 63.5 years), in number in whom malignancy was the reason for diversion (KP 18, RCP 25), and median follow-up period (KP 50, RCP 16 months).

RESULTS

No intraoperative complications or perioperative deaths occurred. Immediate postoperative complications were mild and self-limited in both groups, with the exception of 1 RCP patient who developed life-threatening hemorrhage from a ruptured splenic artery aneurysm. KP patients had a statistically higher (P < 0.05) surgical revision requirement (16 patients, 26 revisions) than RCP patients (4 patients, 4 revisions). The majority of KP revisions were for efferent limb problems. Of the 14 KP patients not requiring revision, 4 have mild incontinence not warranting surgery. Three renal units showed new mild hydronephrosis (2 KP, 1 RCP) and are being observed. Prolonged diarrhea was present in 1 patient in each group, and vitamin B12 supplementation was required in 1 KP and 2 RCP patients.

CONCLUSIONS

The markedly higher rate of surgical revision with the Kock pouch has led to our change in practice in favor of the right colon pouch for continent cutaneous urinary diversion.

Comparison between results of ileal conduit and continent ileal bladder (VIP), after radical cystectomy

OBJECTIVES

The aim of the present study is to analyze the results achieved with the ileal bladder according to the VIP (vescica ileale Padovana) procedure.

METHODS/RESULTS

We compared the results obtained in 31 patients with invasive bladder cancer who underwent radical surgery (22 underwent the ileal conduit procedure and 9 were treated by orthotopic bladder substitution) and analyzed the early complications, long-term results and physiological data of the group submitted to the VIP procedure. In the patient group submitted to the VIP procedure, there was only one case who required removal of the new bladder due to an enteroneovesical fistula. Another case developed medium serrate anular stricture of the bulbar urethra about 8 months postoperatively and was treated by endoscopic urethrotomy. The uroradiologic and urodynamic evaluations confirmed urinary tract stability integrity of renal function and good adaptation of the new reservoir. The andrological studies showed complete sexual potency in 2 of 9 patients.

CONCLUSIONS

The VIP procedure appears to be a good technique, with complications no greater than those of traditional urinary diversion, and improves the quality of life of patients undergoing radical surgery for invasive bladder cancer.

The effects of detubularization and outflow competence in substitution cystoplasty

OBJECTIVE

To assess the effects of detubularization and outflow competence on the clinical and urodynamic results of patients undergoing substitution cystoplasty.

PATIENTS AND METHODS

The study included 142 patients undergoing orthotopic substitution cystoplasty, of whom 85 underwent a 'straight' and 57 a detubularized substitution cystoplasty using the ileo-colonic segment. All were assessed clinically and by video-urodynamic studies before and after surgery.

RESULTS

In patients voiding spontaneously, detubularization produced a capacity 38% greater than that found with a 'straight' cystoplasty, but there was no difference in the contractility of the substitute bladder between the groups. In patients requiring clean intermittent self-catheterization to empty, outflow competence was a more important factor in increasing capacity and reducing contractility.

CONCLUSIONS

Detubularization produces a modest increase in bladder capacity but far less than that predicted by mathematical models. It has no substantial effect on contractility when compared with straight substitution cystoplasty. The effects of detubularization on both capacity and contractility are less than the 'chronic retention' effect produced by increasing outflow competence. Detubularization is therefore only one of several factors that influence the results of substitution cystoplasty.

[A continent urinary diversion with a detubularized rectum and sigmoid (sigmo-rectal pouch)]

BACKGROUND

The continent reservoir is an ideal urinary diversion in patients after cystectomy. The artificial closing mechanism construction in these reservoirs is rather complicated and the results are uncertain. The objective of the present work is to assess own experience with a relatively simple rectosigmoid reservoir created by a method described by M. Fisch.

METHODS AND RESULTS

Since 1992 till 1995 the sigma-rectum detubularized reservoir was performed in 30 patients. The intricating bladder cancer was an indication for the operation in 27 patients and the other bladder diseases in 3 patients. The patients age ranged from 18 to 75 years. Diurnal continence was achieved in all 30 patients. 12 of them have to awake during the night to evacuate the reservoir 1 to 3 times.

CONCLUSIONS

Sigma-rectum pouch is a good form of cintinent diversion in such patient, which are not suitable for orthoscopic neobladder because of oncologic limitation or bad general conditions. The patients tolerate the procedure very well, heal and adapt quickly to new evacuating mechanisms.

The continent sigmoid urinary reservoir--an experimental study in pigs

OBJECTIVE

To evaluate the function of a continence mechanism in combination with a colonic urinary reservoir in a pig model.

MATERIALS AND METHODS

A colonic urinary reservoir was constructed as a bladder augmentation in six domestic pigs. The pouch was connected to a narrowed and tunnelled ileal tube as a continence mechanism. The closure pressure was measured intra-operatively and 3 months post-operatively.

RESULTS

The mean difference between the pressure in the continence mechanism and in the reservoir was 74 cmH2O (range 50-100). Continence was complete both intra-operatively and 3 months post-operatively.

CONCLUSION

The modified narrowed and tunnelled ileal tube is a safe continence mechanism when combined with a colonic urinary pouch.

[Barcelona pouch. An external continent urinary diversion]

OBJECTIVES

To describe a new technique for external continent urinary diversion based on the Vesica Ileale Padovana technique (VIP) with a continent hydraulic valve, which obviates the need for external permanent collecting urinary systems.

METHODS

An ileal neobladder was created following the VIP technique to which we added a modified Benchekroun continent hydraulic valve utilizing mechanical sutures.

RESULTS

A continent heterotopic neobladder was achieved. The technique was easy to perform and permitted preservation of the upper urinary tract due to the pouch's low internal pressures.

CONCLUSIONS

In our view, this technique is a valid alternative in patients unamenable to orthotopic diversion and are able to perform self-catheterization.

Detubularized isolated ureterosigmoidostomy: description of a new technique and preliminary results

PURPOSE

A technique is described to improve the evacuation pattern and, accordingly, the life-style of patients with ureterosigmoidostomy.

MATERIALS AND METHODS

An inverted U-shaped sigmoid colon is detubularized, and the left colon is fixed in continuity to the posterior wall of the rectal ampulla in line with the anorectal canal. The ureters are reimplanted into the sigmoid pouch using the nipple technique.

RESULTS

All 15 patients followed for 3 to 18 months postoperatively passed clear urine and solid feces separately, with good anal control and at convenient periods (urine 3 to 6 times and solid feces once daily). Urographic studies showed stabilization of renal morphology in 26 units, improved function in 3 and deterioration in 1. Dynamic study of the rectum in 3 patients showed a capacious rectosigmoid reservoir with low pressure.

CONCLUSIONS

The technique of detubularized isolated ureterosigmoidostomy has important advantages over conventional ureterosigmoidostomy. Patients pass urine and feces separately and at convenient intervals with good anal control. The upper urinary tract is well preserved, and there is potentially less risk of colonic carcinogenesis.

The Kock ileal neobladder: updated experience in 295 male patients

PURPOSE

Since 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993.

MATERIALS AND METHODS

Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence was individually evaluated via a detailed patient questionnaire.

RESULTS

The pouch related early and late complication rates were 7.2 and 11.6%, respectively, and pouch related abdominal reoperation rates were 0.0 and 1.4%, respectively. Analysis of late pouch related complications revealed 4.1% stone formation and 2.4% afferent nipple stenosis rates, and only 1 case (0.3%) of ileal urethral anastomotic stricture. Of the patients 87 and 86% reported good or satisfactory daytime and nighttime continence, respectively. With regard to age, while overall continence was similar, a significantly greater percentage of patients younger than 70 years experience good daytime and nighttime continence relative to the older counterparts. Of the patients 5% perform regular intermittent catheterization and 2.7% required an artificial urinary sphincter due to unacceptable continence.

CONCLUSIONS

The Kock orthotopic ileal neobladder can be constructed with minimal morbidity and extraordinary functional results. We strongly advocate its use when possible.

Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of continence results and fluorourodynamic findings

OBJECTIVES

To update continence results and present fluorourodynamic data in 17 female patients undergoing orthotopic lower urinary tract reconstruction with the Kock ileal urethrostomy following cystectomy.

METHODS

Continence results, voiding pattern, and overall patient satisfaction were evaluated by means of patient survey. Fluorourodynamic data and abdominal leak point pressures were obtained in 6 patients.

RESULTS

Complete daytime urinary continence was reported in 93% of patients, whereas complete nighttime continence was reported by 87% of patients. Fluorourodynamic studies demonstrated excellent neobladder capacity with low reservoir pressure in all cases. Abdominal leak point pressure measurements confirmed normal urethral sphincter function.

CONCLUSIONS

Excellent results with respect to urinary continence, voiding pattern, patient satisfaction, and reservoir function can be expected in women undergoing orthotopic lower urinary tract reconstruction.