A continent colonic urinary reservoir: the Florida pouch

Long-term follow-up after ileocaecal continent cutaneous urinary diversion (Mainz I pouch): A retrospective study of a monocentric experience

OBJECTIVE

To assess the long-term follow-up after ileocaecal continent cutaneous reservoir (ICCR) and to review the late complications.

PATIENTS AND METHODS

In all, 756 patients underwent an ICCR in our department, with long-term follow-up data available in 50 patients. The inclusion criterion was ICCR regardless of the indication and the exclusion criteria were orthotopic neobladder or other continent urinary diversions not performed with the ileocaecum. Patients were followed to record primary outcomes and late complications. Complications were stratified according to the Clavien-Dindo classification.

RESULTS

The mean patient age was 44 years and pelvic malignancies were the first indication for urinary diversion. The mean (range) follow-up was 19 (9-36) years. A stoma stenosis was the most frequent outlet-related complication requiring re-intervention, followed by ischaemic outlet degeneration, and stoma incontinence. Six renal units (RUs) developed obstruction at the anastomotic site and were managed by open surgery. Three RUs had to be removed due to deterioration. A dederivation was necessary in three patients (6%).

CONCLUSION

The ICCR is a safe and established technique when an orthotopic pouch is impossible. The long-term follow-up shows acceptable complication rates and satisfactory continence conditions. However, large population studies are necessary to confirm this observation.

De Castro technique used to create neophallus: a case of aphallia

We report on a rare case of aphallia in an X, Y-born male treated at our institution. The child underwent phalloplasty at 5 years of age using the De Castro phalloplasty technique and an abdominal skin flap. Although moderate distal necrosis was seen, the overall immediate and 12-month postoperative results were highly encouraging for our patient. Thus, this technique should be seen as a temporizing reconstructive option for patients with aphallia. Long-term follow-up is necessary to determine whether the neophallic size augments with axial growth and the need for additional intervention to facilitate onset of sexual activity.

Urinary diversion after cystectomy: An Indian perspective

Radical cystectomy remains the standard treatment for muscle-invasive carcinoma bladder. Various methods have been described for the urinary diversion. In the last 150 years urinary diversion has evolved from cutaneous ureterostomy to the orthotopic neobladder. Especially during the last 20 years, much advancement has been made. We hereby have reviewed the current approaches being used at different centers in India. We have also analyzed the evolution of diversion from conduit to the orthotopic substitution at our center.

The efferent segment in continent cutaneous urinary diversion: a comprehensive review of the literature

OBJECTIVE

To critically assess the biophysical properties and current status of outlet formation in heterotopic intestinal urinary diversion. As despite three decades of clinical experience with continent cutaneous urinary diversion through bowel segments, no consensus has been reached for the optimal efferent segment although its function largely determines patient satisfaction.

METHODS

A comprehensive Medline literature search using the Medical Subject Headings database (search terms: continent urinary diversion followed by either efferent segment, nipple, Mitrofanoff, Yang-Monti, Benchekroun, tapered ileum, intussuscepted ileum, Kock pouch, T-valve, or Ghonheim) was conducted to identify all full-length original articles addressing the various principles and techniques of outlet formation as well as their outcomes and complications. Examined series were published in English between 1966 and 2010. All studies were systematically evaluated using a checklist (study design, number of patients, etc.) and rated according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence (LoE).

RESULTS

While there was a continuous flow of publications over the last three decades, the vast majority of studies were retrospective case series with numerous confounding factors and poorly defined, non-standardized outcomes (LoE, 3). Only a few investigations compare different efferent segments (LoE, 2a). No randomized studies exist. The major biophysical principles are based on the use of flap, nipple, and hydraulic valves. Vermiform appendix, intussuscepted ileal nipple, and the Yang-Monti tube are the most popular techniques and have well-established data on outcomes, complications, and failure rates. Artificial sphincter systems and tissue engineering have provided disappointing results thus far. Most reconstructive strategies are subject to a process of on-going improvement.

CONCLUSIONS

The continuous quest for optimization has not led to a single universally applicable efferent segment in continent cutaneous urinary diversion. While all techniques have their unique set of advantages and disadvantages, they will always remain a compromise. Success depends on selecting the optimal strategy for individual patients. A major change in principles in the near future is unlikely.

[Development of continent reservoirs]

Continent reservoirs represent an alternative to urostomy. Various operation techniques are available and the historical development will be described here with respect to the use of different parts of the intestine.

Long-Term Multi-Institutional Evaluation of Charleston Pouch I Continent Cutaneous Urinary Diversion

PURPOSE

Charleston pouch I continent cutaneous urinary diversion has been used since 1989. We evaluated the long-term results of this procedure in 201 consecutive patients.

MATERIALS AND METHODS

The records of patients treated with the Charleston pouch I between 1989 and 2005 at 3 university hospitals were reviewed. Available data on age, sex, indications for diversion, comorbidity, followup duration, continence status, short-term and long-term complications, quality of life issues, and laboratory, radiological and urodynamic data were recorded. Patients were followed at 6-month intervals.

RESULTS

Followup was 14 to 136 months. Seven adults died in the 90-day postoperative period, and 21 (10.8%) and 51 (26%) patients had early and late complications, respectively. The interval between clean intermittent catheterizations was 2 to 8 hours. Mean capacity was 470 ml (range 250 to 1,300). At 12 months diurnal continence was achieved in 98% of the patients. A total of 98 patients (50.5%) needed night catheterization to stay dry. Of 342 ureters 17 (5%) became obstructed, requiring open or endoscopic management. Urolithiasis developed in 16 patients (8%). Vesicoureteral reflux was noted in 15 renal units (4.4%). Stomal complications developed in 8.2% of cases. Modest vitamin B12 supplementation was empirically used to avoid long-term deficiency. No detrimental effects on vitamin B12 concentrations were noted for up to 10 years.

CONCLUSIONS

Long-term multi-institutional followup of the classic Charleston pouch I reveals that it provides adequate continence with an acceptable complication rate and satisfactory patient acceptance.

Continent cutaneous urinary diversion: long-term follow-up of more than 800 patients with ileocecal reservoirs

We report the clinical outcome of more than 800 patients, who underwent continent cutaneous urinary diversion with an ileocecal reservoir (Mainz-pouch I) in two urological tertiary referral centers at a mean follow-up of 7.6 years. Complications related to the continence mechanism (intussuscepted ileal nipple vs. submucosally embedded in situ appendix) and the antirefluxive uretero-intestinal anastomosis (submucosal tunnel vs. serosa-lined extramural tunnel) were recorded retrospectively. Stomal stenosis was observed in 23.5% of the patients with appendix stoma and in 15.3% of the patients with intussuscepted ileal nipple. The incidence of calculi was 10.8% in reservoirs with intussuscepted ileal nipple and 5.6% in reservoirs with appendix stoma. Eleven patients (eight with appendix, three with ileal nipple) required reoperation because of ischemic degeneration of the continence mechanism. The overall continence rate (day and night) was 92.8%. Anastomotic strictures of the afferent limb occurred in 6.5% of renal units (RUs) with a submucosal tunnel and in 5.0% of RUs with a serosa-lined extramural tunnel. Continent cutaneous urinary diversion with an ileocecal pouch is a highly satisfactory and safe option for patients, in whom orthotopic urinary diversion is impossible or contraindicated.

Total pelvic exenteration: The Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003)

OBJECTIVE

To review the trends, modifications and results of 103 consecutive total pelvic exenterations (TPE) performed at the Montefiore Medical Center and Albert Einstein College of Medicine from 1987 to 2003.

METHODS

All patients who underwent TPE from January 1987 to December 2003 were included. The medical record, complications, follow-up, clinical status and demographic information were entered in a database. The procedure performed, the method of urinary diversion, colonic diversion, pelvic floor support and vaginal reconstruction were documented. Surviving patients were surveyed regarding their satisfaction with the urinary diversion, the vaginal reconstruction and their sexual function since the surgery.

RESULTS

103 pts were identified. Indications for TPE were recurrent cancers of the cervix (95), endometrium (2), colon and rectum (5), vulva (1). Overall 5-year survival was 47%. 5-year survival for pts with recurrent cervix cancer was 48%. Six pts (6%) recurred >5 years after the TPE. 14 pts (14%) had ureteral anastomotic leaks (no difference between ileal conduit 9/65 (14%) versus 5/38 (13%) continent conduit (P = 0.92). 34 pts (89%) with continent conduits were "continent." 14 pts (17%) had wound complications. 4 pts (4%) had parastomal hernias. 5/11 (46%) pts who had a low rectal reanastomosis developed recurrence in the pelvis. 21/39 (54%) of pts with continent conduits would choose an ileal conduit if they had the option again. Long-term renal function was similar in pts with ileal and continent conduits. Mesh of any type for pelvic floor reconstruction is associated with infection and bowel/urinary fistulas. VRAM flaps for neovagina fill the pelvic dead space, reduce the risk of fistulas and 20/36 pts (55%) are sexually active.

CONCLUSIONS

Our overall 5-year survival is encouraging, and modifications in surgical technique have improved the reconstructive phase. Low rectal anastomoses at TPE adversely affects survival. Many of our pts with continent urinary diversions would not choose this method again. Mesh of any type is associated with sepsis and bowel/urinary fistulas. VRAM for neovagina reduces fistula rate and are functional in >55% of pts. TPE remains a potentially curative option for these pts.

CONVERSION FROM COLONIC OR ILEAL CONDUIT TO CONTINENT CUTANEOUS URINARY DIVERSION

PURPOSE

After ileal or colonic conduit diversion some patients, particularly adolescents, desire conversion to a continent diversion to improve quality of life. We report our long-term results on conversion from conduit diversion to continent cutaneous diversion.

MATERIALS AND METHODS

Between 1986 and 2001, 39 patients (mean age 24 years, range 6 to 49) underwent conversion from a colonic (21) or ileal conduit (18) to an ileocecal pouch (Mainz pouch I) with a mean followup of 102 months (range 18 to 192). Conversion was performed after a mean of 11 years (range 1 to 36) of conduit urinary diversion by incorporating the preexisting colonic/ ileal conduit and the ileocecal pouch.

RESULTS

A total of 21 patients (54%) experienced complications requiring surgical intervention including stoma stenosis (13%), pouch calculi (31%) and ureteral stenosis (6 of 75 renoureteral units, 8%). Continence was achieved in 95% of patients. Defecation was unchanged in 72% of patients without treatment. In 21% fecal frequency was medically controlled (cholestyramine, loperamide) and 8% of patients had fecal frequency. During followup early substitution of alkali was performed and in 19 patients (49%) the venous base excess was less than -2.5 mmol/l to prevent hyperchloremia and acidosis.

CONCLUSIONS

The inclusion of a preexisting colonic or ileal conduit decreases resection length of bowel for continent cutaneous diversion. Acceptable complication rates, stable renal function and satisfaction of patient expectations support conversion from a conduit into a Mainz pouch I as a safe and viable option in the long run.

Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years

OBJECTIVE

A patient with a recurrent central pelvic malignancy after radiation will require urinary diversion as part of the reconstructive phase of the pelvic exenteration. The aim of our study was to assess the result of our 15-year experience with a continent ileocolonic urinary reservoir, which is known as the Miami pouch.

STUDY DESIGN

Since 1988, all patients who received a continent ileocolonic urinary reservoir in the Division of Gynecologic Oncology, University of Miami School of Medicine, were included in the study. Parameters that were evaluated during the study period include functional outcomes, early and late perioperative complications, and their treatment.

RESULTS

A total of 90 patients were identified from February 1988 to December 2002. Seventy-eight patients (87%) had a recurrent central pelvic malignancy, and 82 patients (91%) received radiation before the Miami pouch procedure. The non-reservoir-related morbidities were fever (76%), wound complication (30%), pelvic collection (12%), ileus/small bowel obstruction (12%), and postoperative death (11%). The most common reservoir-related complications were urinary infection (40%), ureteral stricture (20%), and difficulty with self-catheterization (18%). In our study, the overall complication rate that was related directly to the Miami pouch was 53%. Conservative treatment resolved>80% of these cases. The rate of urinary continence that was achieved in our patients was 93% during our 15-year experience with the Miami pouch.

CONCLUSION

The Miami pouch is a good alternative for continent urinary diversion during exenteration or radiation-induced damage. The rate of major complications that require aggressive surgical intervention is acceptable. Most postoperative complications (80%) can be corrected with the use of conservative techniques that are associated with fewer deaths than reoperation and thus should be used first. The technique is simple and effective in women who are at high risk, who have undergone previous radiation therapy, and who have a high rate of functional success and is a profound advantage for a woman's psychosocial well-being.

Pelvic exenteration and reconstruction

For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.

Continent colonic urinary reservoir (Florida pouch): long-term surgical complications (greater than 11 years)

PURPOSE

We analyzed the long-term results (greater than 10 years) of a continent cutaneous colonic urinary reservoir (Florida pouch), focusing primarily on the incidence of significant complications.

MATERIALS AND METHODS

Between January 1986 and October 1991, 179 patients underwent continent cutaneous colonic urinary reservoir construction. Of these patients 105 died of primary disease or were lost to followup, leaving 38 males and 36 females with a mean followup of 133 months with adequate data for analysis who are the subject of this report. The surgical technique has been previously reported. Briefly, a detubularized right colonic segment forms the reservoir, a tapered external limb reinforced at the ileocecal valve level allows continent catheterization and the ureters are directly anastomosed to the pouch. The diseases that prompted urinary diversion included bladder cancer in 28 cases, conversion from another diversion in 12, neurogenic bladder in 11, interstitial cystitis in 10, crippling incontinence in 4, radiation cystitis in 6, hemorrhagic cystitis in 1, exstrophy in 1 and colon cancer in 1. A total of 146 direct ureterocolonic reimplantations were performed.

RESULTS

Complications were grouped by etiology and the number of patients, including abdominal wall (peristomal hernia in 3 patients or 4%), external limb (incontinence in 5 or 6.7%, stomal stenosis in 3 or 4% and difficult catheterization in 1 or 1.4%), reservoir stones (4 or 5.4%), ureteral obstruction (primary reimplantation in 7 of 108 or 6.3%, repeat reimplantation in 4 of 24 or 16.4% and radiated ureters in 4 of 14 or 28.4%) and metabolic (persistent diarrhea in 2 or 2.7%, renal failure in 2 or 2.7% and low vitamin B12 in 3 or 4%). Severe acidosis developed in 4 individuals (5.5%). Of the 12 patients who underwent conversion from another type of diversion 7 (58%) experienced metabolic alterations.

CONCLUSIONS

In the long term continent colonic reservoirs have an acceptable complication rate. The most common problem is ureteral obstruction, especially in patients who have previously undergone irradiation (28.4% versus 6.3%, Fisher's test p = 0.02). Patients in whom longer bowel segments were resected, such as those with conversion from another type of diversions, experienced a greater number of complications, especially ureteral obstruction associated with repeat reimplantation (16.4% versus 6.3%, Fisher's test p = 0.23) and metabolic derangements (58% versus 6.4%, Fisher's test p = 0.0001).

Stomal construction, complications, and reconstruction

This article reviews stomal complications and their management. To accomplish this goal, the authors review techniques used for planning and creating the stomas for both continent reservoirs and incontinent conduits.

Bladder Replacement and Urinary Diversion After Radical Cystectomy

BACKGROUND: The optimal mode of urinary tract reconstruction following cystectomy continues to challenge the urologic surgeon. Disadvantages with bowel conduits have prompted the search for better techniques to improve patient outcomes. METHODS: The development of urinary tract reconstruction is reviewed, and results from several forms of continent urinary diversion and bladder replacement construction are presented. The authors report on their experience in creating continent reservoirs or neobladders in over 400 patients. RESULTS: Several surgical approaches are now available for continent urinary diversion. Metabolic and nutritional abnormalities, stone formation, infection, and cancer formation are potential complications. CONCLUSIONS: Advances in surgical techniques, an understanding of the physiology of isolated bowel segments, and improvements in pre- and post-operative care have altered the field of urinary reconstruction after cystectomy for bladder cancer. Most patients can expect minimal morbidity and mortality.

The ileal neobladder--updated experience with 306 patients

From April 1986 through May 1995, 306 men with primary urothelial carcinoma underwent radical cystoprostatectomy and orthotopic bladder substitution via the ileal neobladder. Altogether, 7.5% of the patients suffered general early complications, including thrombosis, embolism, wound infection, and pneumonia. Specific early complications directly related to formation of the neobladder and requiring surgery included ileus (4%), abscess drainage (2%), and leakage of the ileal anastomosis (0.5%). The early reoperation rate was 6.5%. Early complications that required temporary percutaneous drainage were lymphocele formation (3%) or ureteral obstruction (6%). In all, 9% of our patients required prolonged catheter drainage for leakage of the ileouretheral anastomosis. Late complications requiring reoperation were ileus (2%), abscess drainage (1%), neobladder fistula to the colon (1.5%), ureteral reimplantation because of obstruction (3.6%), and nephrectomy for hydronephrosis (1%). A transurethral incision of the ileouretheral anastomosis was necessary in 7% of cases. Continence was separately addressed by sending each patient and his home physician a detailed questionnaire: Using our criteria (no diapers, no awakenings) the night and day continence rate increased from 67% at 6 months, to 72% at 1 year to 85% at 2 years, finally reacting 90% after 4 years. In part II of this presentation we address the question as to whether the option of orthotopic bladder replacement has any impact on the patient's and physician's decision toward earlier cystectomy. We compared our ileal neobladder cohort with a group of 137 patients that had been operated on during the same time span by the same group of surgeons. There was no negative selection with regard of the tumor stage of our patients. However, as compared with the conduit group, the neobladder cohort had a significantly improved survival rate. This phenomenon is explainable by the significantly lower number of previous transurethral resections of the bladder (TUR-Bs) performed in the neobladder group. The time span between primary diagnosis and cystectomy was 10 months in the neobladder group as compared with 18 months in the conduit patients. These data reinforce our belief that orthotopic bladder replacement using the ileal neobladder yields an extraordinary functional result that can be accomplished with a high degree of patient satisfaction and minimal complication. The availability of orthotopic bladder replacement does indeed stimulate the physicians and patients decision toward earlier cystectomy.

Serous-lined extramural ileal valve as a new continent cutaneous urinary outlet: an experimental study in dogs

A new technique for the construction of a cutaneous continent catheterizable outlet suitable for urinary reservoirs is presented. The technique entails the creation of an ileal reservoir outlet by implantation of a tapered ileal segment into a serous-lined extramural tunnel. The procedure was carried out in eight experimental dogs, and the results were compared with a control group of five dogs for which a nontunnelled tapered ileal outlet draining a similar reservoir was constructed. Clinical, radiological and urodynamic evaluation provided evidence that this new outlet is easily catheterizable. Its continence mechanism is more reliable than that of a simple tapered outlet.

Special considerations in the endourologic management of stones in continent urinary reservoirs

To various degrees, all continent pouch designs are subject to stones, which often are infected. We report on the endourologic management of large stone burdens in three types of continent reservoirs. Stone in a UCLA and a Kock pouch were managed endoscopically, and stones in an augmented pouch with a Mitrofanoff valve were managed percutaneously. Recommendations are made with regard to the optimal endourologic management of significant stone burdens in each of the common continent urinary reservoirs.

Study of the unaltered in situ appendix as a native continence mechanism: cadaveric and clinical correlation

The past decade has seen intense efforts to develop the ideal pouch for use in continent diversion and bladder substitution. The aspect that has been singularly the most difficult to perfect has been the continence mechanism. In recent years much has been reported on the use of the vermiform appendix as a continence mechanism following one or more surgical manipulations. It was the aim of this study to determine whether the in situ appendix, without any surgical manipulation, could provide a native continence mechanism. Studies were carried out using (1) five cadaver subjects and (2) eight patients undergoing cystoprostatectomy in whom the distal tip of the appendix was removed and an ileocecal pouch was filled with irrigant until leakage was noted from the appendix. The pressure within the pouch at the time of leakage was defined as the appendiceal leak pressure. Mean appendiceal leak pressure was 50.6 cm H2O with a range from 21 to 86 cm H2O. These studies indicate that at the pressure being maintained in most continent pouches as constructed today, the in situ unmanipulated appendix would, in some cases, provide adequate continence. In others only minimal reinforcement is required to maintain continence.

Urinary undiversion in adults with myelodysplasia: long-term followup

A total of 14 women and 6 men 19 to 39 years old (mean age 27 years) with myelodysplasia underwent undiversion 8 to 29 years (mean 16) after ileal conduit diversion. The main reasons for diversion were incontinence in 17 patients and failed ureteral reimplants in 3, and those for undiversion were a desire for an improved quality of life in 16, increasing hydronephrosis in 4 and stomal problems in 3. Preoperative assessment included upper and lower tract imaging, and video urodynamics. Operations on the ureters included reimplantation into an intussuscepted nipple valve in 8 patients, tunneled reimplants into a sigmoid augmentation in 3 and the ureters joined to either the bladder or lower ureter without interposing bowel in 9. All reimplantations were done with nonrefluxing techniques. A total of 18 patients underwent bladder augmentation and 2 women in whom cystectomy was performed for pyocystis underwent substitutions. Simultaneous continence procedures in 18 patients included trigonal tubularization in 2, artificial sphincter implantation in 2, a bladder neck sling in 5 or bladder neck tapering and a sling in 9. The patients were followed for a mean of 69 months (range 21 to 133). Eight patients required reintervention within 1 year for problems, such as anastomotic leak in 1, bladder neck obstruction in 1, incontinence in 1, artificial urinary sphincter revisions in 1 and bladder stones in 1. One patient had a recurrent renal calculus 10 years after undiversion. All patients experienced either persistence of normal upper tract appearance or improvement and/or stabilization of hydronephrosis. Mean bladder capacity was 77 cc preoperatively and 480 cc postoperatively, while mean pressure at capacity decreased from 50 to 14 cm. water with detubularized augmentation. Of the patients 17 are completely dry, 2 wear 1 pad per day and 1 has enuresis. All but 1 patient who voids with straining are on intermittent self-catheterization. All patients, on followup interviews, reported an improved quality of life without a stoma. We conclude that undiversion provides an improved quality of life and an acceptable morbidity rate. The choice of operation depends on the anatomy of the patient. We prefer a nonprosthetic type of incontinence procedure when intermittent self-catheterization is to be done. No long-term morbidity has yet been noted.

Primary adenocarcinoma of the vermiform appendix associated with transitional cell carcinoma of the bladder

A case of primary adenocarcinoma of the vermiform appendix coexisting with transitional cell carcinoma (TCC) of the bladder is presented. The patient was a 74-year-old male who underwent radical cystectomy with continent urinary diversion using the Florida pouch. Two different cancers were found, TCC of the bladder and mucinous adenocarcinoma of the appendix. To our knowledge, this is the only such case reported in the medical literature.

Experimental investigation of an infolded bowel segment as an anti-incontinence mechanism without interposing the ileo-cecal valve

A technique for using bowel segment as an anti-incontinence mechanism was developed in an animal model and evaluated urodynamically. Variously modified bowel segments were investigated alone and later attached to a colonic reservoir to establish their value in preventing urinary incontinence while allowing easy catheterization. Using careful surgical technique, intussuscepted, tapered and plicated bowel segments were constructed. The maximum segmental closure pressure and functional length were evaluated in all preparations. The three bowel segments remained continent during slow filling and up to reservoir capacity. The recordings demonstrated both highest maximal closure pressure and longest functional length in the plicated system when evaluated both alone and following reservoir attachment. These recording differences occurred both with the reservoir full and empty. These results demonstrate the value of a plicated bowel segment in the maintenance of urinary continence when attached to a compliant urinary reservoir without using the ileo-cecal valve in this model.

La Nostra Esperienza con la Tasca Ileo-Colica Continente (Indiana Modificata): Note di Tecnica

The ileo-colic continent pouch in a modified Indiana version has been used in our Unit for some years now on those patients where an orthotopical neo-bladder is impossible. This technique exploits the ileocecal valve's characteristics of continence. The operative stages are indicated, highlighting the main characteristics and unusual technical aspects. We usually use the ascending colon section with supply from ileo-colic artery to obtain a small pouch, which is then enlarged with a 25 cm long detubulised ileal section. The uretero-ileal anastomosis is made by sub-mucosal anti-reflux tunnel. The terminal ileus, which will act as a duct, is anastomised to the umbilical skin, keeping it straight. The choice of umbilical site for the anastomy is excellent for easy self-catheterisation and external appearance. Couch capacity is immediately 600 cc. Urodynamic evaluation shows low pressure in all stages of filling (up to 900 cc) without pressure peaks due to peristaltic contractions.

Alternatives to urinary diversion with a bag: results in 100 patients

One hundred patients underwent surgery to free them from a cutaneous urinary diversion (n = 59) or to avoid having one (n = 41). The reconstruction was tailored to the needs of the patient: 7 had a simple undiversion, 35 a complex undiversion and 58 a continent suprapubic diversion. The outcome was satisfactory in 97%. Two patients were rediverted to an ileal conduit. The simpler the reconstruction the lower the re-operation rate: simple undiversion 0%, complex undiversion 20%, Mitrofanoff 42%, Kock pouch 69%. In spite of the high complication rate, there is a strong demand for such reconstructions and a high satisfaction rate amongst patients.

Direct (nontunneled) ureterocolonic reimplantation in association with continent reservoirs

A total of 190 patients underwent continent urinary diversion using the Florida pouch. Direct mucosa-to-mucosa ureterocolonic reimplantation was used in 165 patients (326 ureters). Of the first 30 ureters in patients who underwent antireflux tunneled reimplantation obstruction occurred in 4 (13.3%). Obstruction developed directly in 16 of the ureters reimplanted (4.9%), and 3 of the 6 plicated and reimplanted megaureters (50%). Among the obstructed units 3 (13%) were treated unexpectedly by autonephrectomy, while the other 20 units (87%) were treated with percutaneous balloon dilation and internal stenting for 6 to 8 weeks. In the latter group 12 units (60%) recovered function, 3 (15%) had pyelonephritis requiring nephrectomy and 5 (25%) stabilized following a new reimplantation. Reflux was demonstrated in 23 units (7%). All units with reflux are being followed conservatively and renal deterioration has not been demonstrated. The incidence of ureteral obstruction with direct reimplantation is lower compared to a tunneled technique. This reimplantation procedure is technically simpler than others and is safe in adults when performed in association with a large volume, continent colonic reservoir.

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

We report on 6 patients who underwent a new type of continent urinary diversion: the gastroileoileal reservoir. These are a select group of patients who presented with the short bowel syndrome, acidosis, borderline diarrhea and/or severe pelvic radiation, which precluded the use of terminal ileum and the ileocecal segment. Considering these factors, and based on the different functional properties of the stomach as well as the need for a large reservoir, a segment of stomach and proximal ileum was used to construct the reservoir. Four patients have been followed for at least 6 months, with the longest followup being 12 months. Temporary dysphagia requiring hydrogen blockers developed in 1 patient. Results indicate excellent function of the continent urinary system, lack of metabolic complications, absent diarrhea and excellent patient tolerance. This procedure could be a useful alternative in some difficult clinical situations when continent urinary diversion is desirable.

New continent ileocolonic urinary reservoir: Charleston pouch with minimally altered in situ appendix stoma

A new continent urinary reservoir that utilizes minimally altered in situ appendix stoma is described. The reservoir was constructed from segments of terminal ileum and ascending colon which were detubularized and reorientated to provide maximum reduction in filling pressures. The in situ appendix was utilized to provide a continent catheterizable stoma. Appendicular leak pressures were measured intraoperatively to determine the need, if any, for augmentation. Minimal reinforcement of the appendiculo-colonic junction with two or three sutures was performed in most patients. Preliminary experience with 16 patients who had the Charleston pouch with an appendicular stoma as described herein is reviewed.

Appendicovesicostomy (and variations) in bladder reconstruction

Bladder reconstruction using bowel segments was advanced when intermittent catheterization proved so acceptable. Access to the reservoir by way of the urethra is often not possible in children, especially boys. Implantation of the isolated appendix into the bladder remnant or colon segment similar to a ureteral reimplant provides a continence mechanism with ready catheter access (the Mitrofanoff principle). Since 1982 we have applied this principle in 41 pediatric cases of bladder reconstruction (64% boys). Primary diagnoses included bladder exstrophy (46%) and myelomeningocele (34%). Extending the concept of a flap valve continence channel with a narrow tube into the reservoir, segments of tapered ileum and ureters were also used (appendix 61%, ileum 12%, ureter 27%). Results of continence (100%) and uncomplicated catheterization (93%) have been satisfactory. Unfortunately, the longer the experience (average 3.2 years of followup), the more stone formation we experienced (32%), which is due to mucus production and bacteriuria as the stone nidus. There were 2 deaths, including 1 from a renal stone obstructing the ureter with sepsis and 1 a likely suicide. Reoperation was required for 3 stomal revisions, 2 bowel obstructions and 7 stone removals in 3 of the 6 cases in which the bladder neck was closed. Unique aspects of these reconstructions are presented, such as our current preference to bury the stoma in the umbilicus (7 cases), placement of the ureteral segment into the perineum as a neourethra and an unusual conjoined twin reconstruction.

Continent urinary diversion using cutaneous ileocecocystoplasty

We have employed a technique of continent urinary diversion that uses ileocecocystoplasty to incorporate native bladder into the urinary reservoir. This allows creation of a reservoir in selected patients using less complicated surgery than complete replacement of the bladder and avoids ureteral-intestinal anastomoses. Early results are promising for this simplified means of continent diversion.

Complications of the Miami pouch

The Miami pouch, a continent colonic urinary reservoir, was constructed in 75 patients after cystectomy for invasive bladder tumor (44), gynecological tumor (25), neurogenic bladder (4) and conversion of an ileal conduit (2). Continence was achieved by tapering the distal ileum over a 14F catheter and reinforcing the ileocecal valve with 3 circumferential silk sutures in a pursestring fashion. Ureterocolonic anastomosis was performed in a nontunneled fashion. There were 5 perioperative deaths. One or more early (perioperative) complications occurred in 19 patients (26%). Late complications (beyond 6 weeks) were found in 16 patients (23%). Total continence rate was 98.6% and the success rate of the ureterocolonic anastomosis was 90%. Followup was 7 to 69 months. We present a review of the technical aspects of the construction of the Miami pouch, and the early and late complications associated with this procedure.

Conversion from external appliance wearing or internal urinary diversion to a continent urinary reservoir (Florida pouch I and II): surgical technique, indications and complications

A total of 20 patients with diversion requiring an external appliance or internal urinary diversion underwent conversion to a continent urinary reservoir (Florida pouch I or II). All patients subsequently reported an improvement in the quality of life and expressed satisfaction with the new urinary diversion procedure. Of the patients 15 (75%) previously had an ileal conduit, while 1 (5%) had undergone ureterosigmoidostomy, 1 (5%) had cutaneous ureterostomy, 1 (5%) had a suprapubic tube, 1 (5%) had a sigmoid conduit and 1 (5%) had a cecal conduit. After the original diversion 3 patients (15%) had recurrent urinary infections, 3 had complications related to the stoma and external appliance (stenosis and skin dermatitis) and 5 (25%) had ureteral obstruction in 7 ureters. A total of 17 patients with conduits (85%) underwent conversion via different surgical technical aspects depending on the status of the intestinal segment from the conduit and the function of the ureteral reimplantation: in 14 the conduit was discarded or was used only to patch the newly created Florida I colonic pouch, while in 6 the conduit was preserved and 9 ureterointestinal reimplantations were left undisturbed (Florida pouch II). Among 7 ureters preoperatively obstructed (original diversion), reimplanting them into the pouch failed to prevent further renal damage in 5 (71%). Three renal units required nephrectomy, 2 kidneys deteriorated and 2 recovered renal function after percutaneous balloon dilation and stenting. Among 31 preoperatively nonobstructed renoureteral units (original diversion), 22 were reimplanted into the colonic reservoir. One of these units (4.2%) became obstructed postoperatively and 3 (13.5%) presently have reflux. The 10 reimplantations left undisturbed in the detubularized conduit drain satisfactorily without postoperative obstruction and in 6 reflux has not been demonstrated. Renal function (serum creatinine) is preserved in all patients but 15 (75%) have hyperchloremia of mild degree. Two patients (10%) have acidosis and 1 (5%) of these had low red blood cell folic acid. Conversion of an external or internal diversion to a continent colonic urinary reservoir (Florida pouch I or II) can be successful and improve the quality of life of the patient. The functioning renal units that were preoperatively obstructed were associated with a high failure rate (71%) after reimplantation. Metabolic alterations will require long-term followup, and are particularly worrisome in children and young adults.

Correction of incontinent ileocolic urostomy with Kock's nipple valve

Continent urostomy procedures may be replacing the incontinent ileal or colon conduit as the preferred method of urinary diversion in gynecologic cancer patients. One method of continent urinary diversion utilizes the detubularized ascending and transverse colon as a reservoir with a tapered segment of distal ileum as the stoma through which the patient catheterizes the pouch (Miami pouch). Failures of this procedure have been reported. A case report of such a failure is presented. This patient was managed by replacing the tapered ileal stoma with a Kock intussuscepted nipple valve made from proximal ileum. The patient is now continent. This technique warrants further investigation as a method of treating patients with continent urostomies of various types (Kock, Indiana, Miami, Mainz) that become partially or completely incontinent.