The mechanisms of continence in the Indiana pouch: a video-urodynamic study

Functional outcomes and complications in patients with bladder cancer undergoing robotic-assisted radical cystectomy with extracorporeal Indiana pouch continent cutaneous urinary diversion

OBJECTIVE

To evaluate the functional outcomes and complications for patients with bladder cancer undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion.

METHODS

From February 2004 to March 2010, 34 patients underwent robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction. After surgery, the complications were identified, categorized, and graded using an established 5-grade modification of the original Clavien grading system, and continence was assessed. Descriptive statistics were used in evaluating the outcomes. Fischer's exact test was used in the comparison of early and late Clavien grade III complications.

RESULTS

Overall, 175 (123 early and 52 late) complications after surgery were reported in 32 (94%) of 34 patients. Within 90 days of surgery, 31 (91%) of 34 patients experienced ≥ 1 early complication. Of 34 patients, 15 (44%) reported ≥ 1 late complications (>90 days). Most (85% and 69%, respectively) early and late complications were graded as minor (grade II or less). Fewer patients with early complications required an additional intervention (grade III) compared with patients with late complications (14% vs 31%; P = .116). The most common complication in both intervals was infection, reported in 22% and 37% of patients with early and late complications, respectively. The continence data for 31 patients at a mean follow-up of 20.1 months (median 12.0) showed that all but 1 patient (97%) had daytime and nighttime continence.

CONCLUSION

Patients undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction have comparable complication rates and functional outcomes compared with patients in the open series.

Evaluation of flap valve as an alternative continence mechanism in the Florida pouch

OBJECTIVES

To evaluate urodynamic findings in a successful flap valve (FV) continence mechanism in association with a continent colonic urinary reservoir (Florida pouch) and to compare the urodynamic findings of the FV mechanism with the doubly plicated (PI) standard anti-incontinence segment in the same reservoir.

METHODS

Thirteen patients who successfully received the Florida pouch between 1988 and 1996 agreed to undergo urodynamic evaluation as part of a pilot study. Eight patients had a PI continence mechanism and a mean time from surgery of 51 months; 5 had a FV continence mechanism and a mean time from surgery of 14 months. Enterocystometry was performed with a trans-stomal Bard triple channel 7F catheter. Volume and pressure at first desire to empty (VFDE, PFDE), as well as maximal enterocystometric capacity and pressure (VMEC, PMEC), were recorded. Maximal outlet pressure (MOP) was recorded using the catheter withdrawal technique.

RESULTS

PI and FV groups demonstrated the following mean values respectively: VFDE, 692.7 and 403 mL; PFDE, 19.5 and 19.2 cm H2O; VMEC, 876.5 and 515 mL; PMEC, 25.9 and 24.6 cm H2O; MOP, 57.5 and 51.2 cm H2O (reservoir empty) and 50.5 and 52.6 cm H2O (reservoir full); and functional length of outlet, 24.3 and 24.6 cm. MOP measurement demonstrated greater variability in the PI than in the FV group.

CONCLUSIONS

Urodynamic comparison of these mechanisms reveals that MOP measurement was closer to the mean among FV than PI patients. In addition, the mean VFDE (692.7 mL for PI versus 403 mL for FV, P < 0.05) and the mean VMEC (876.5 mL for PI versus 515 mL for FV, P < 0.05) were significantly less in the FV group. Lower VMEC and less variability in MOP indicate that continence may be more dependent on MOP in the FV mechanism. A longer follow-up time and a larger number of patients will be of assistance in clarifying these findings.

Ileocecal valve resistance augmentation using glutaraldehyde cross-linked collagen: a canine model for endoscopic salvage of the leaking Indiana reservoir

PURPOSE

Periurethral injection of glutaraldehyde cross-linked collagen is a well-established modality for the treatment of patients with incontinence caused by structural defects at the bladder outlet. Little is known about the potential usefulness of this approach to the nonfunctioning continence mechanism of a leaking continent urinary reservoir. An animal model of an incontinent Indiana reservoir was created using the naturally incompetent canine ileocecal valve. The effectiveness and feasibility of endoscopic submucosal injection of glutaraldehyde cross-linked collagen into the ileocecal valve to increase resistance were examined.

MATERIALS AND METHODS

Seven beagle dogs underwent isolation of the ileocecal segment. The right colon and ileum were brought to the skin as 2 stomas. Baseline leak point pressures of the ileocecal valve were determined while infusing contrast material into the right colon. The leak point was observed fluoroscopically, and the pressure at which contrast material crossed the valve was measured. Glutaraldehyde cross-linked collagen, 4 to 10 ml., was injected endoscopically into the valve in a circumferential pattern. Leak point pressures were measured immediately, 1 month after injection and 3 months after injection.

RESULTS

An average of 7.1 gm. (range, 4.1 to 10.1 gm.) was required to create an endoscopically "closed" ileocecal valve. Leak point pressure increased from a mean 3.8 mm. water (range, 2.5 to 6.0 mm. water) at baseline to mean 35.7 mm. water after injection (range, 22.0 to 57.0 mm. water). At 1 month, mean leak point pressure decreased slightly to 26.7 mm. water. This pressure stabilized at 3 months at 29.5 mm. water.

CONCLUSIONS

Endoscopic delivery of glutaraldehyde cross-linked collagen into the ileocecal valve consistently enhanced resistance as measured by leak point pressure. This effect was durable over a 3-month period of observation. Admittedly, this period of observation is relatively short. Longer followup may have demonstrated significant diminution of collagen migration or resorption. However, this feasibility study demonstrates that collagen injections may provide a minimally invasive means of treating the incontinent continent urinary reservoir.

Morpho-functional follow-up of modified Indiana Pouch

— Between November ‘90 and August ‘94, 55 patients underwent modified Indiana Pouch. Our modifications include the isolation of 20 cm of right colon, the creation of a 15 cm long ileal patch, taeniotomies of partial detubularized cecum, Le Duc ureterocolic anastomosis and umbilical stomal positioning. An orthotopic reservoir was constructed in 2 young exstrophic patients. The ileal limb was anastomosed to the introitus vaginalis in a female and by an original, staged operation to the epispadic urethral plate in a male. The continence rate was 91%. The mean pouch capacity was 500 ± 40 cc, the filling pressure was 10 ± 2 cm H2O and the ileocecal valve resistance was 85 ± 6 cm H2O. 12 late complications were reported (4 stomal stenoses, 3 parastomal hernias, 1 severe ureteral stenosis, 2 high pressure pouches, 2 decompensated reservoirs). No ureteral reflux renal function decrease, metabolic acidosis or vitamin B12 reduction was observed. We conclude that modified Indiana Pouch is a reliable, reproducible, easy-to-perform technique with an acceptable complication rate. On the other hand it has to be reserved for compliant patients.

Evolving experience with continent urinary diversion using the Indiana pouch

The Indiana continent urinary reservoir procedure for urinary diversion was performed in 46 patients. After the first 8 cases several modifications were made to the Indiana pouch. These modifications include complete detubularization of the colonic segment, construction of the pouch augmented with a U-shaped patch of ileum and, more recently, the use of stapled plication. The mean postoperative follow-up period was 46 mo (range 4.5-74.1 mo). There was 1 perioperative death and this case was excluded from the follow-up study. Late complications related to the urinary reservoir occurred in 12 (26.7%) of the 45 patients. Stone formation was observed in 5 patients. Out of 45 patients, 42 achieved complete urinary continence while 2 suffered mild nocturnal incontinence and 1 had significant leakage. Three had unilateral hydronephrosis due to ureteroanastomotic stricture. Reservoirgraphy demonstrated no reflux into the upper urinary tract in all of the follow-up cases. Loopography of the efferent limb showed that a staple-plicated ileum functions better than a suture-plicated one in terms of reliability of the continence mechanism and ease of catheterization. The Indiana pouch should be considered for any patient requiring cutaneous urinary diversion because it is technically easy to perform and it has a low revision and high continence rate.

Closure pressure studies of the tapered ileal segment and reinforced ileocecal valve in continent urinary diversion

OBJECTIVE

To evaluate the function of the continent segment, a tapered terminal ileum with reinforced ileocecal valve, utilized in continent colonic urinary reservoir.

METHODS

Closure pressure study of the continent mechanism was performed in 20 patients with the colonic reservoir empty and at maximum capacity.

RESULTS

Maximum pressure within the tapered ileum was recorded at the reinforced ileocecal valve and was recorded when the reservoir was full. Pressure ranged between 60 and 200 cm water (mean, 139.5 cm H2O). The pressure within the reinforced segment exceeded the pressure within the reservoir at all times.

CONCLUSIONS

When properly reinforced, the ileocecal valve is able to maintain a closing pressure above that of the detubularized urinary reservoir, making it a reliable continent mechanism.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

A simplified technique for continent urinary diversion: an all-stapled colonic reservoir

A simple continent colonic reservoir was constructed in its entirety with the aid of surgical stapling techniques in 17 men and 10 women. In 5 men an orthotopic pouch was created and in the rest a continent stoma was designed. Detubularization of the entire colonic segment assures a low pressure system with disruption of directional peristaltic activity. The ureters are implanted by simply burying them in a mucosal furrow. Operative time required for the creation of the reservoir (excluding time for cystectomy) has ranged between 70 and 140 minutes (mean 95.4 minutes). With a followup of 9 to 60 months (mean 22.8 months) continence has been achieved in all but 1 patient with no ureteral reflux or obstruction. Urodynamically the pouch has achieved a large capacity (mean 750 cc) with low filling pressures (8.1 cm. water) because of technical ease of construction together with a shortened operative time due to the stapling techniques. This form of bladder replacement offers an option for select patients in whom continent urinary diversion is contemplated.