Bladder substitutes controlled by the anal sphincter: a comparison of the different absorption potentials

Clinical evaluation of patients treated with a detubularised isolated ureterosigmoidostomy diversion after radical cystectomy

OBJECTIVES

To assess the emptying pattern and patient satisfaction after constructing a detubularised isolated ureterosigmoidostomy (DIUS) following a cystectomy, introduced to overcome the poor outcome of conventional ureterosigmoidostomy, to improve the emptying pattern and accordingly patients' quality of life.

PATIENTS AND METHODS

The study included 122 patients who were treated with a DIUS diversion after cystectomy. The minimum follow-up of the patients was 6 months. The frequency of emptying and continence during the day and night were recorded. The ability of the patients to discriminate between urine and stool was assessed. The patients' overall satisfaction with the outcome was categorised as fully satisfied, moderately satisfied or not satisfied.

RESULTS

In all, 95 patients were available for this evaluation; all patients were completely continent during the day and night. The mean emptying frequency was 3.9 during the day and 1.7 during the night. All patients were able to feel the desire to empty and the mean holding time was 35 min. Fifty-two patients (55%) could pass solid stools once per day, with minimal urine at the end of voiding, and the remaining evacuations were of clear urine only. Thirty-two patients (34%) were able to differentiate between urine and stool sensation before emptying. For satisfaction, 82 patients reported full satisfaction, 13 were moderately satisfied, and none regretted the diversion.

CONCLUSIONS

The DIUS diversion provides continence during the day and night, with a satisfactory emptying habit. Patients with a DIUS diversion can tolerate a full pouch comfortably, with no leakage, and they can discriminate between urine and stool evacuations.

Ureterorectostomy as a continent urinary diversion for complicated bladder exstrophy in children by using a modified Duhamel procedure: a case series

INTRODUCTION

Whatever the method and timing of surgery, a high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence. They face the options of urinary diversion to an external stoma or construction of a neobladder from bowel. This study describes a modified Duhamel's rectal pouch with a ureterorectostomy was carried out on 11 children who had a failed repair of bladder exstrophy.

MATERIALS AND METHODS

Ten boys and one girl, aged from 4 to 7 years (mean 5.5), had several unsuccessful operations for bladder exstrophy. All selected to have good renal function and no other anomalies, but were incontinent of urine and had a small contracted or prolapsed bladder. They underwent urinary diversion to the rectum using the Duhamel pullthrough technique, where the sigmoid colon was opened into the back of the anal canal above the dentate line, creating a rectal bladder and making use of the anal sphincter to control urine and stool. All were followed up for 24 months (18-27 months).

RESULTS

In this selected group of patients there were no major operative or postoperative complications. Follow-up for 2 years revealed no deterioration in renal function, or electrolytes disturbance. They can hold up to 300 ml of urine and all patients are continent during the daytime with an emptying frequency of 3-5 times. Nocturnal wetting occur some 4-8 times per month with significant decrease with time. Two cases developed pyelonephritis but this was controlled with medical treatment.

CONCLUSION

Eleven children achieved effective urinary continence by ureteric diversion to the rectum using a modified Duhamel pullthrough technique. Two years follow up showed no complications, except bed wetting, but long term assessment is warranted.

A comparative study of the effects of a colorectal valve on the oro-anal transit time in patients with an augmented and valved rectum for urinary diversion

OBJECTIVES

To evaluate the effect of the interposed colorectal valve on the flow of the proximal colonic contents to the rectum in patients with a valved urinary diversion to the rectum.

PATIENTS AND METHODS

The oro-anal transit time (OATT) and segmental colonic transit time (SCTT) were estimated in two groups of 15 patients each (10 women and five men). In group 1, patients had a colorectal valve and in group 2 (control) they had no valve in the rectosigmoid area. The OATT and SCTT were evaluated using the 7-day method, whereby each patient swallowed 10 ring-shaped radio-opaque markers daily for 6 days, and a single abdominal radiograph was taken on day 7. The OATT and SCTT were then estimated as the number of retained markers divided by the daily dose of markers.

RESULTS

The mean (sd) OATT was not significantly different (P=0.185), at 1.85 (1.21) days in group 1 and 2.49 (1.38) days in group 2. There were no sex differences in the values between the groups. The SCTT in the four areas of the colon again showed no significant differences within or between groups (P>0.05).

CONCLUSION

Using a colorectal valve to functionally isolate the urinary rectal reservoir and thus reduce the high incidence of metabolic acidosis has no significant effect on intestinal transit times.

Evaluation of the functional significance of the colorectal valve used in rectal urinary diversion in children: a comparative study between cases with and without the valve

OBJECTIVES

To study the long-term impact of functional isolation of rectal reservoirs on the blood chemistries and acid-base balance of children who underwent this type of urinary diversion.

METHODS

A retrospective evaluation of 63 children with rectal reservoirs was performed. Of these, 40 had a colorectal valve and 23 had double-folded rectal reservoirs without a functional isolation valve. Evaluation included serum chemistry and arterial blood sample analysis to verify the impact of the created valve on homeostasis.

RESULTS

There was a statistically significant difference between the two groups relative to the value of pH, P(CO2), bicarbonate, base excess, and chloride in favor of those having a colorectal valve. Reduction of the absorptive surface area of the colon is presumably the cause in view of the functional isolation created by the colorectal valve.

CONCLUSIONS

In children, the long life expectancy and the benign condition for which they have diversion require the incorporation of the colorectal valve in any form of continent rectal diversion. Prophylactic alkalinization with strict follow-up is a must in those having no valve.

Rectosigmoid urinary diversion: the functional significance of creating an intussuscepted colorectal valve

PURPOSE

We assess the functional importance of a colorectal valve in patients with rectal urinary diversion.

MATERIALS AND METHODS

A retrospective evaluation of 87 patients with an anal sphincter controlled bladder substitute was performed. Of these patients 42 had colorectal valves and 45 did not. Evaluation included serum chemistry studies and arterial blood samples to study the impact of the colorectal valve on homeostasis.

RESULTS

There was a statistically significant difference between the 2 groups in pH, carbon dioxide partial pressure, bicarbonate, base excess and chloride in favor of patients with a colorectal valve.

CONCLUSIONS

The difference between the groups was reduction of the surface area available for reabsorption when a valve is constructed. This finding is of particular importance among patients with a long life expectancy. Prophylactic alkalization is necessary in cases without valve reconstruction.

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 modified rectal bladder (the augmented and valved rectum) for urine diversion in children

OBJECTIVES

Urinary diversion is usually the procedure of choice for children having complicated primary closure for bladder exstrophy. We introduce the modified rectal bladder as a low pressure and functionally isolated rectal reservoir as a bladder substitute for these cases.

METHODS

Modified rectal bladder urinary diversion was done on 15 children as a low pressure and functionally isolated rectal reservoir via the adoption of sigmoid intussuscepted valve and the rectal patching with detubularized sheet of ileum. Fourteen of these children are currently evaluable, with follow-up ranging from 16 to 72 months (median 55 months). All of them are subjected to thorough history-taking, clinical examination, laboratory and radiologic investigations, and urodynamic study.

RESULTS

A high rate of urinary continence was achieved and so far the upper urinary tract and the metabolic status were preserved. Reflux to the colon and kidneys was prevented. Urine samples from the renal pelvis through percutaneous needle aspiration revealed sterile cultures in 82% of the renal units (23 of 28).

CONCLUSIONS

Our results demonstrate the distinct advantages of the modified rectal bladder over the conventional methods of urinary diversion to the rectum or the abdominal reservoirs coupled to the skin via continent catheterizable stomas.

Radionuclide evaluation of the uretero-ileoceco-proctostomy (ileocecal rectal bladder)

Technetium 99m diethylenetriaminepentaacetic acid renoscintigraphy was applied to 14 patients to obtain comprehensive information on the kidney and urinary tract 12.6 +/- 8.8 months (mean +/- SD) after uretero-ileoceco-proctostomy (ileocecal rectal bladder) diversion. The total glomerular filtration rate (GFR) was within the normal range in all patients, and the diuretic renogram was normal in 19 of 28 kidneys, dilated-nonobstructive in 7 and obstructive-intermediate in 2. The mean colonic reflux was 16.6 +/- 18.4% of total excretion and the mean total residual in the colon and rectum was 38.8 +/- 15.5%. In the second study, performed 12.4 +/- 3.5 months later in 9 patients, the GFR of bilateral and individual kidneys remained stable, 17 of 18 kidneys were normal as judged by both renography and pyelography, and the occurrence and degree of colonic reflux decreased. There was a tendency for the rectal capacity to increase, while the total residual tended to decrease solely due to the decrease in colonic residual. These results indicate that the ileocecal rectal bladder functions well as an internal continent reservoir and that radionuclide investigation is a valuable and cost-beneficial means of follow-up of urinary diversions.

The application of the modified rectal bladder in management of the compromized urethral damage

Failure to repair the traumatic injuries of the lower urinary tract with loss of urethral sphincteric function usually puts forward the subject of urinary diversion. Ten males and five females presented with extensive urethral damage and with or without vesical fistulas. All attempts of repair were exhausted before the decision of diversion was planned. Continent urinary diversion using the modified rectal bladder (the augmented and valved rectum) was utilized. The procedure entailed functional isolation of the rectum without terminal colostomy and depended on colorectal intussuscepted valve. All the patients are currently evaluated with follow up periods ranging 10-56 months. Evidences proved the effectiveness of the colorectal valve in providing non impeded fecal stream to the functionally isolated rectal reservoir. Continent status is attributed to the ileal patching that produces a low pressure reservoir against the effective high anal resistance. The results support the distinct superiority of the modified rectal bladder to either the conventional methods of urinary diversion to the rectum or the abdominal reservoir with continent catheterizable stomas.

The valved S-shaped rectosigmoid pouch for continent urinary diversion

Continent urinary diversion to the valved S-shaped rectosigmoid pouch was performed in 9 female and 6 male patients 12 to 65 years old (mean age 51 years). The pouch was constructed by detubularization and S-shaped reconfiguration of 30 cm. of the intact rectum and sigmoid colon. The ureters were reimplanted into the pouch using antireflux techniques. Reflux of urine from the pouch to the proximal colon was prevented by fashioning an intussusception valve. The construction was protected by a transverse colostomy for 6 to 8 weeks. With a followup of 3 to 24 months (mean 11 months), all patients are continent during the day and also at night with evacuation intervals of 3 to 6 hours. There have been no cases of symptomatic urinary tract infection. Only 1 patient had mild hyperchloremic acidosis. No patient complained of abdominal distention or constipation. Contrast study via the anus (radiography of the pouch) showed that the intussusception valve was competent in all but 1 patient in whom reflux to the proximal colon was noted due to sliding of the nipple valve, which was revised successfully. Urodynamic studies (cystometry of the pouch) showed a capacity of 400 to 900 ml. (mean 600) with an intraluminal pressure of 22 cm. water (range 10 to 34) at maximal filling. The valved S-shaped rectosigmoid pouch is a faster and simpler surgical procedure compared with the modified rectal bladder (valved rectum augmented with ileum). It also results in a smooth postoperative course, since an intestinal anastomosis proximal to the colostomy is avoided.

Further experience with the modified rectal bladder (the augmented and valved rectum) for urine diversion

Continent diversion with the modified rectal bladder was done in 83 patients and 65 are currently evaluable with followup ranging from 6 to 36 months. There was no postoperative mortality and the morbidity rate was acceptable. Renal function and configuration were maintained in most patients (91%). Dessusception of the colorectal valve was observed in 7.6% of the patients. Evidence was provided that this valve is effective in prevention of regurgitation of the rectal contents to the proximal colon. All patients were continent during the day. Enuresis was noted in 6 patients and all of them responded to imipramine hydrochloride therapy. The results support earlier observations that the procedure offers distinct advantages over ureterosigmoidostomy and the simple rectal bladder.