The gastroileoileal pouch: an alternative continent urinary reservoir for patients with short bowel, acidosis and/or extensive pelvic radiation

Gastric neobladders: surgical outcomes of 91 cases using different techniques

Introduction:

We report on the surgical results of a series of 91 patients who received gastric neobladders as urinary diversion after radical cystectomies performed for the treatment of muscle-invasive bladder cancers.

Materials and Methods:

We report on a retrospective case series of 91 patients who received gastric neobladders as urinary diversion after radical cystectomies performed for the treatment of muscle-invasive bladder cancers. Different techniques of gastric neobladders were employed from 1988 to 2013 at a university hospital in the South of Brazil.

Results:

Initial outcomes utilizing Leong (Antral) and Nguyen-Mitchell (Wedge) technique were unsatisfactory, yielding high pressure, low capacity reservoirs. Further developments of these techniques, with the detubularized gastric neobladder and the “spherical” gastric neobladders resulted in low pressure, high capacity reservoirs, with better surgical and urodynamic outcomes. Complication and perioperative mortality rates of our series of gastric neobladders were significantly higher than historical results of techniques using ileum or colon.

Conclusions:

Stomach is an exceptional option for the creation of neobladders after radical cystectomies, but due to the increased complication rates it should be reserved for specific situations (e.g., renal insufficiency, previous pelvic/abdominal radiotherapy, short bowel syndromes).

Long-term follow-up of composite bladder augmentation incorporating stomach in a multi-institutional cohort of patients with cloacal exstrophy

INTRODUCTION

Composite bladder augmentation, incorporating gastric and bowel segments, has the theoretical advantage of metabolic neutrality while potentially avoiding the morbidities of gastrocystoplasty, such as hematuria-dysuria syndrome. The most common indication for this operation is a paucity of bowel, such as in cloacal exstrophy. Despite several early descriptive studies of this technique, there are no reports, to date, of long-term follow-up in this population.

OBJECTIVE

To describe the outcomes of composite bladder augmentation utilizing stomach in a cohort of cloacal exstrophy patients.

MATERIALS AND METHODS

A retrospective review of cloacal exstrophy patients who underwent composite bladder augmentation from 1984 to 2006 at two institutions was performed. The incidence of mortality and morbidities related to augmentation was evaluated.

RESULTS

Eleven patients with cloacal exstrophy underwent composite bladder augmentation. Median age at initial augmentation was 6.4 years (interquartile range (IQR) 4.4-9.1). Median follow-up was 13.2 years (IQR 11.2-24.6). The Summary table describes the types of composite bladder augmentations. Of the three patients with pre-operative metabolic acidosis, two improved with composite bladder augmentation and one developed metabolic alkalosis. Three developed hematuria-dysuria syndrome: one improved with staged ileocystoplasty, and two had persistent symptoms successfully treated with H2 receptor blockers. Two of 11 developed symptomatic bladder stones. There were no reported bladder perforations, bladder malignancies, conversions to incontinent urinary diversions, or deaths.

CONCLUSION

With long-term follow-up, very few patients developed metabolic acidosis/alkalosis after composite bladder augmentation. The composite bladder augmentation will continue to be used in patients with cloacal exstrophy, in order to minimize the impact on the pre-existing short gut in these patients.

Combining gastric and ileal segments, does it overcome segment-related complications? An experimental study on rats

Bladder augmentation has revolutionized the care of children with neurogenic bladder but it is associated with certain short- and long-term complications. Using the combination of gastric and ileal segments to balance effects of these segments might be a solution for complications. A total of 39 female Spraque-Dawley rats randomly divided into four groups: ileocystoplasty (11), gastrocystoplasty (9), ileogastrocystoplasty (11) and control (8). Serum/urine electrolytes and pH values, and serum creatinine levels and urine mucus concentration were measured. Kruskal-Wallis non-parametric variance analysis was performed to compare the groups and p < 0.05 was accepted as significant. Metabolic alkalosis with significantly lower urine pH was observed in gastrocystoplasty group. Gastroileal group showed similar results with the ileal group in all parameters. No stone formation was detected in the sham and gastric cystoplasty groups. Metaplastic and hyperplastic changes were observed in all segments surrounding urothelium. In conclusion, combination of gastric and ileal segments does not significantly reduce the rate of metabolic impairments, stone and mucus formation. Besides it is not associated with significant improvement in histological outcome since urine is still in contact with the gastrointestinal mucosa.

Urinary diversion: options, patient selection, and outcomes

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer.

Experience With Coapted Gastric Tube Outlet and Composite Gastrointestinal Reservoir for Continent Cutaneous Urinary Diversion

PURPOSE

Established techniques for urinary diversion are not ideal for certain patients such as those with extensive pelvic irradiation, metabolic acidosis, short bowel syndrome or renal insufficiency. In a multi-institutional study a gastrointestinal reservoir was previously found to provide metabolic balance in such patients. We used a coapted gastric tube as the continent outlet in patients undergoing gastrointestinal urinary diversion. We evaluate the long-term functional results of the gastric tube to provide continence and report our long-term followup results.

MATERIALS AND METHODS

A composite reservoir was constructed from gastric and transverse colon or ileal segments. In addition, a gastric strip, in continuity with the gastric segment of the composite reservoir, was tubularized and coapted to provide the continence mechanism.

RESULTS

A total of 19 patients with a gastrointestinal reservoir and coapted gastric tube outlet were followed for 24 to 101 months, of whom 18 are continent day and night on intermittent catheterization every 3 to 8 hours. Four of 34 ureters (12.5%) became obstructed. One patient had significant preoperative renal insufficiency, which progressed to end stage renal disease. Another patient had slow progression of renal insufficiency. In the remaining 17 patients mean serum creatinine did not change significantly while serum chloride and bicarbonate improved or remained normal.

CONCLUSIONS

A coapted gastric tube functions well as the continence mechanism in patients with a gastrointestinal urinary reservoir. We also confirm the metabolic advantages of a composite gastrointestinal urinary reservoir. Gastrointestinal cutaneous urinary diversion can be an alternative to incontinent diversion in select patients who are not suitable for other forms of diversion.

Advances in bladder augmentation

Over the past 20 years, rapid advances have been made in bladder augmentation due to the introduction of clean intermittent catheterization, the use of intestinal segments interposed into the urinary tract, and the development of tissue expansion. The particular augmentation method selected from the multiple methods currently available is an individualized process that takes into account both patient factors and potential complications. Exciting new techniques, such as tissue engineering, may change the face of lower urinary tract reconstruction.

Multi-institutional experience with the gastrointestinal composite reservoir

PURPOSE

We evaluated multi-institutional experience with the gastrointestinal composite reservoir in patients with metabolic acidosis, the short bowel syndrome, severe pelvic radiation and/or renal insufficiency.

MATERIALS AND METHODS

At 4 institutions 33 patients underwent construction of a gastrointestinal composite reservoir, including 19 with the short bowel syndrome, 13 with metabolic acidosis and 7 who also had renal insufficiency. A total of 16 patients underwent conversion of a previous diversion and the remaining 17 received new urinary diversion. Charts were reviewed for the metabolic impact of the gastrointestinal reservoir as well as any long-term sequelae.

RESULTS

At a mean followup of 54 months there was a significant (p < or =0.05) improvement in mean preoperative and postoperative serum chloride (106 versus 102 mEq./l.), serum bicarbonate (23.3 versus 25 mEq./l.) and serum pH (7.36 versus 7.4). Mean serum creatinine did not significantly differ during followup in patients with normal renal function or renal insufficiency. Complications were not different than those of standard intestinal or gastric reservoirs.

CONCLUSIONS

The gastrointestinal reservoir has provided an excellent metabolic balance in a large series of compromised patients with few side effects. We believe that the gastrointestinal composite reservoir represents the urinary diversion of choice when standard intestinal urinary reservoirs cannot be created in the setting of metabolic acidosis, the short bowel syndrome and severe pelvic radiation. However, the value of the gastrointestinal composite in the setting of renal insufficiency remains undetermined.

The gastrointestinal composite urinary reservoir in patients with myelomeningocele and exstrophy: long-term metabolic followup

PURPOSE

We investigated the long-term metabolic effects of gastrointestinal composite urinary reservoirs in patients with myelomeningocele or exstrophy.

MATERIALS AND METHODS

Seven patients with myelomeningocele or exstrophy who required complex urinary reconstruction in the setting of metabolic acidosis or the short bowel syndrome underwent construction of a gastrointestinal composite reservoir, including a staged and a single procedure in 3 and 4, respectively. Preoperatively and postoperatively serum electrolytes were measured, and urinalysis and urine cultures were performed in all patients. In 5 patients serum pH was compared preoperatively and postoperatively, and in all serum gastrin was measured postoperatively.

RESULTS

At an average followup of 62 months (range 52 to 87) serum chloride and bicarbonate significantly normalized (p <0.05) in all 7 patients with bladder exstrophy or myelomeningocele. Serum pH also significantly normalized (p <0.05) in 5 patients at long-term followup. Serum gastrin and creatinine were normal and urinary pH fluctuated insignificantly throughout followup. None of the patients had urolithiasis or symptoms of the hematuria-dysuria syndrome. Periodic symptomatic urinary tract infections developed but none required chronic antibiotic therapy.

CONCLUSIONS

Gastrointestinal composite urinary reservoirs appear to be beneficial for patients with myelomeningocele or exstrophy who have preexisting metabolic acidosis or the short bowel syndrome. Serum electrolyte neutrality is achieved during long-term followup. No patient had the hematuria-dysuria syndrome or urolithiasis.

The gastrointestinal composite urinary reservoir in patients with myelomeningocele and exstrophy: long-term metabolic followup

PURPOSE

We investigated the long-term metabolic effects of gastrointestinal composite urinary reservoirs in patients with myelomeningocele or exstrophy.

MATERIALS AND METHODS

Seven patients with myelomeningocele or exstrophy who required complex urinary reconstruction in the setting of metabolic acidosis or the short bowel syndrome underwent construction of a gastrointestinal composite reservoir, including a staged and a single procedure in 3 and 4, respectively. Preoperatively and postoperatively serum electrolytes were measured, and urinalysis and urine cultures were performed in all patients. In 5 patients serum pH was compared preoperatively and postoperatively, and in all serum gastrin was measured postoperatively.

RESULTS

At an average followup of 62 months (range 52 to 87) serum chloride and bicarbonate significantly normalized (p <0.05) in all 7 patients with bladder exstrophy or myelomeningocele. Serum pH also significantly normalized (p <0.05) in 5 patients at long-term followup. Serum gastrin and creatinine were normal and urinary pH fluctuated insignificantly throughout followup. None of the patients had urolithiasis or symptoms of the hematuria-dysuria syndrome. Periodic symptomatic urinary tract infections developed but none required chronic antibiotic therapy.

CONCLUSIONS

Gastrointestinal composite urinary reservoirs appear to be beneficial for patients with myelomeningocele or exstrophy who have preexisting metabolic acidosis or the short bowel syndrome. Serum electrolyte neutrality is achieved during long-term followup. No patient had the hematuria-dysuria syndrome or urolithiasis.

Long-term metabolic advantages of a gastrointestinal composite urinary reservoir

PURPOSE

We investigated the long-term metabolic impact of gastrointestinal composite reservoirs.

MATERIALS AND METHODS

Nine patients underwent construction of a gastroileal (7) or gastrocolonic (2) reservoir for continent urinary diversion. Four cases of metabolic acidosis were converted from a preexisting conduit and the other 5 patients had diversion for either preexisting metabolic acidosis or the short bowel syndrome. All were reconstructed using a medium sized gastric segment (8 x 4 cm.) from the greater curvature of the stomach. The anti-incontinence segment was constructed from a tapered and reimplanted ileal segment. All patients underwent preoperative and postoperative measurements of serum pH, serum electrolytes, and urinalysis. Serum gastrin was measured in all patients postoperatively. Followup from surgery ranged from 47 to 61 months (mean 54.4).

RESULTS

All 9 patients demonstrated electrolyte neutrality in serum on long-term followup. Postoperative serum pH (mean 7.40) was significantly different (p < 0.01) from preoperative serum pH (mean 7.36) and serum bicarbonate was also significantly different (p < 0.01) preoperatively versus postoperatively (mean 22.3 versus 25.14). Urine pH values were not significantly different throughout the study. One patient with mildly acidic urinary pH (6.0 to 6.5) had ulcerative skin changes at the stoma site. Three patients had elevated serum gastrin levels on short-term followup but all patients had normal serum gastrin levels on long-term followup. One patient, with persistent alkaline urine, had urolithiasis and symptomatic urinary tract infections.

CONCLUSIONS

Our results demonstrate that a composite urinary reservoir constructed using gastric and intestinal segments achieved serum electrolyte neutrality on long-term followup. These results indicate a long-term metabolic advantage over other intestinal reservoirs associated with hyperchloremic metabolic acidosis and may be beneficial in patients compromised by either preexisting metabolic acidosis or the short bowel syndrome.

The failed anti-incontinence mechanism: a flap valve or cecal wrap for surgical reconstruction

PURPOSE

On a long-term basis patients with continent urinary diversions may have an acceptable number of complications, such as urinary incontinence. We report on a new surgical technique for treatment of the incompetent anti-incontinence segment.

MATERIALS AND METHODS

Seven patients presented with a large capacity, low pressure reservoir and an incompetent anti-incontinence mechanism. The original anti-incontinence mechanism consisted of an intussuscepted reimplanted appendix (Mitrofanoff) in 2 patients, tapered ileum and reinforced ileocecal valve in 3, and tapered and reimplanted ileal segment in 2. Surgical reconstruction involved 2 stages: stage 1 - lengthening and tubularizing the cecum with the anti-incontinence segment and stage 2 - creation of the flap valve mechanism. Stage 2 required intraoperative modification when abundant peri-reservoir fibrosis, a thin-walled reservoir (cecal wrap) or an excessive thickened mesentery was encountered.

RESULTS

After a mean followup of 7 months 6 of 7 patients performed catheterization every 4 hours and were continent. Several patients required a concomitant procedure with the incontinence revision.

CONCLUSIONS

We describe a 2-stage technique for correction of a variety of untoward anatomical conditions related to a failed anti-incontinence segment with continent urinary reservoirs. Concomitant repair of other coexisting structural abnormalities related to the continent reservoir may also be necessary.

Metabolic complications of urinary diversions: an overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

The gastric augment single pedicle tube catheterizable stoma: a useful adjunct to reconstruction of the urinary tract

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Acid-base changes following urinary tract reconstruction for continent diversion and orthotopic bladder replacement

A prospective determination of serum electrolytes, arterial blood gases, urinalysis and urine cultures was done in 31 patients who underwent a successful continent urinary reservoir or orthotopic bladder replacement. The patients who underwent reconstruction with a long detubularized intestinal segment (group 1-50 cm. long) demonstrated the greatest tendency for metabolic hyperchloremic acidosis (35.2%). In group 2 (patients with an orthotopic bladder replacement) only 1 individual (16.7%) had hyperchloremia, which proved to be the sole metabolic derangement encountered. In group 3 (individuals with a continent gastroileac reservoir) 2 patients (25%) had a slight tendency for compensated and asymptomatic alkalosis. Urinalyses and urine cultures in groups 1 and 2 demonstrated a trend toward urine alkalinity (52.1%) and asymptomatic bacteriuria (74%), respectively. On the contrary, among the patients undergoing a gastroileac reservoir (group 3), mild urinary acidity (pH between 5 and 6) was demonstrated in 4 (50%), while asymptomatic bacteriuria was present in 3 (37.5%). In this group symptomatic urinary acidity and/or ulceration of the ileal component has not occurred to date. Metabolic hyperchloremic acidosis predominates when longer colonic segments are used for reservoir construction. This abnormality is magnified in patients in whom an accessory small bowel was resected. The majority of the gastroileac reservoir patients showed electrolytic neutrality. With our surgical technique, the gastric secretory properties predominate over those of the ileum. The differences in homeostatic findings with the use of these varieties of bowel segments suggest that we could modify the final electrolytic environment by using different combinations of bowel and bowel length.

The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results

Ten patients with a urethra that could not be catheterized and with absent appendixes underwent neobladder construction using an ileal segment fashioned to serve as the anti-incontinence mechanism. The latter was tapered and reimplanted following the guidelines of the Mitrofanoff procedure. Urinary reservoirs were constructed from detubularized segments of right colon, sigmoid colon and composite gastro-ileal combinations. Followup ranged from 9 to 21 months (mean 14.5). All patients presently catheterize the reservoir satisfactorily and are free of urinary leakage. Three patients (30%) experienced initial catheterization difficulties: 2 required endoscopic procedures and insertion of a stent, and 1 with stomal stenosis was successfully treated with a Y-V stoma plasty. One patient (10%) required a repeat ileal segment reimplantation due to urinary incontinence. The higher reoperation rate and the increased surgical complexity of this procedure compared with reconstructions using the ileocecal valve as part of the anti-incontinence mechanism make this operation a less attractive alternative in the creation of a continent urinary reservoir. However, with comprehension of the need for careful and detailed surgical technique in its creation, the tapered and reimplanted ileal segment is a successful choice as an alternative for the creation of an abdominal wall stoma when the appendix is unavailable.