Energy balance of voiding after cecal cystoplasty

Using porcine acellular collagen matrix (Pelvicol®) in bladder augmentation: experimental study

PURPOSE

Evaluate the rabbit augmented bladder with Pelvicol.

MATERIALS AND METHODS

Twenty New Zealand rabbits were divided into 4 groups. Bladder augmentation was performed using a 10 x 10 mm sized porcine acellular collagen matrix. The material was placed on the dome of the bladder wall as a patch with 5-0 polyglycolic sutures. The bladder was resected on the 7th, 14th day, 30th and 90th days, and processed for histological analysis.

RESULTS

No stone formation was found in the first, second and fourth weeks. In the first week, there was inflammatory appearance and roughness in the reconstructed area when compared to other sites on the bladder wall. The material could not be seen in some bladders because of acute inflammatory reaction. The normal bladder epithelium was found on the part of the bladder wall that follows the surface of the eroded material. In the second week, edema was observed through the bladder wall. Perivesical fat tissue increased and it was not easy to distinguish it from the surrounding area. In the fourth week, the bladder wall was thickened and there was a sensation of hardness present. The inner and outer surface of the material was darker than in the other bladders. In the third month, there was no inflammatory reaction; however, there was micro calcification and irregular detrusor regeneration.

CONCLUSIONS

Pelvicol cannot be suitable material for bladder augmentation because of the resultant micro calcification, thickening of the bladder wall and irregular development of detrusor regeneration.

Bladder calculi in children who perform clean intermittent catheterization

OBJECTIVE

To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients.

PATIENTS AND METHODS

The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed.

RESULTS

Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months.

CONCLUSION

These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.

The use of polytetrafluoroethylene (Gore-Tex) grafts in reconstruction of the urinary bladder

The safety and histopathologic effects of polytetrafluoroethylene (Gore-Tex) grafts in reconstruction of the urinary bladder were examined. Following partial excision of the bladder Gore-Tex was placed, and the rats were sacrificed at days 7, 14 and 30. Gore-Tex did not cause urine infection, and there was no peritonitis or sepsis in any of the rats. Inflammation around the Gore-Tex diminished after four weeks. Some mononuclear cells and exudate were observed on the inner surface of the Gore-Tex. There was no inflammation or fibrosis in the mucosa and muscular layers of the remaining bladder. In this study the Gore-Tex graft was found to be an infection resistant, urine impermeable material, with no adverse effects on the urinary bladder. Gore-Tex is suggested as a safe material for the reconstruction of the urinary bladder.

Bladder augmentation. Options, outcomes, future

Remarkable progress has been made in lower urinary tract reconstruction in children. Nowhere is this more valuable than in augmentation cystoplasty, where there are several available options. This article discusses the current techniques and the benefits and limitations of these procedures. A section on tissue regeneration techniques and the author's current recommendations are included.

Lower urinary tract reconstruction using stomach and the artificial sphincter

We implanted the artificial urinary sphincter at gastrocystoplasty in 13 male and 5 female patients. The diagnoses were classical bladder exstrophy (8 patients), myelodysplasia (8), cloacal exstrophy (1) and bilateral ectopic ureters (1). Mean patient age was 14.3 years (range 7 to 32.5). Six patients (5 with bladder exstrophy and 1 with clocal exstrophy) had failed bladder neck continence procedures, 3 myelodysplastic patients had failed artificial urinary sphincter placement, and 1 exstrophy patient had failed a Young-Dees bladder neck repair and artificial urinary sphincter placement. The sphincter cuff was placed around the reconstructed bladder neck in these patients, while in the remainder the artificial urinary sphincter was placed around the intact bladder neck. Mean followup was 20.3 months (range 1 to 5). Of the patients 16 (88%) are continent day and night, while 2 are wet. A total of 11 patients (61%) use Valsalva's maneuver alone for voiding and the remainder use Valsalva's maneuver and/or clean intermittent catheterization for bladder evacuation. Complications related to the artificial urinary sphincter were recurrent pump erosion requiring conversion to a Mitrofanoff continent stoma in 1 patient, and mechanical dysfunction requiring pump cuff and reservoir replacement in 3. There were no complications due to infection. Our report demonstrates that the combination of augmentation gastrocystoplasty and an artificial urinary sphincter leads to urinary continence and can allow for spontaneous urination. The rate of infectious complications is not increased when the 2 procedures are combined simultaneously.

Augmentation cystoplasty and closure of the urethra for the destroyed lower urinary tract

Five paraplegic patients with pressure ulceration complicated by incontinence related to fistula formation were treated by deliberate closure of the urethra and augmentation cystoplasty with a continent stoma. This procedure is similar in scope to urinary diversion but preserves a low-pressure reservoir and obviates the use of tubes for drainage of urine. Overall outcome was excellent. Valvular failure occurred in one patient and required revision. The follow-ups range from 1 to 5 years, with a mean of 24 months. One patient developed reservoir calculi as a late complication, necessitating removal with flexible endoscopy via the continent conduit. All patients have preserved normal upper tracts. Augmentation cystoplasty with closure of the urethra is a reasonable procedure in such patients providing for low-pressure urinary storage and permitting secondary or simultaneous plastic surgical procedures on perineal pressure ulceration and osteomyelitis.

Pediatric urinary diversion and undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.

Radical cystectomy and ileocaecal bladder reconstruction for carcinoma of the urinary bladder. A study of 130 patients

One hundred and thirty patients underwent radical cystectomy and ileocaecal bladder reconstruction for carcinoma of the urinary bladder. The actuarial 5-year survival rate was 45%. Local pelvic recurrence was noted in 26.3% of patients. Most of those in the series (81.9%) had perfect control of micturition. Intravenous urography performed up to 10 years post-operatively showed preservation of renal configuration in 92.2%. The normal flow curves recorded showed that it was possible to achieve a balanced vesicourethral unit. Ileocaecal bladder reconstruction is less disabling than urinary diversion after radical cystectomy.

Intestinocystoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction

Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.

Use of the AS792 artificial sphincter following urinary undiversion

Reconstruction of the urinary tract after diversion has been successful in patients with normal innervation of the lower tracts. However, the possibility of urinary incontinence after such major surgical procedures has dissuaded many surgeons from attempting urinary undiversion in patients in whom the continence status cannot be determined accurately before the operation or who were known to be incontinent before the original diversion. For this reason, the presence of neuropathic bladder dysfunction has been considered a relative contraindication to urinary undiversion unless it can be established preoperatively that the patient will obtain urinary continence. Eight patients are reported who had successful outcome with the use of the AS792 artificial urinary sphincter to control incontinence after urinary undiversion. Because of this successful experience it is now believed that patients with neuropathic bladder dysfunction or anatomically abnormal lower tracts are no longer precluded from urinary undiversion. A variety of methods has been used to reconstruct the urinary tract, including total reconstruction of the bladder and urethra with the sigmoid colon in 1 case. In the latter case the artificial sphincter was placed around the bowel segment to provide continence. The use of the artificial sphincter around a bowel segment offers many possibilities for reconstructive procedures involving bowel in the future.

Evolution of the rectal bladder as a method for urinary diversion

A critical analysis of previous reports reveals 2 main drawbacks of the rectal bladder: 1) recurrent pyelonephritis with subsequent loss of renal function (30 per cent) and 2) nocturnal urinary leakage (40 per cent). In a randomized prospective study the role of a submucosal tunnel for prevention of reflux was evaluated. We demonstrated objectively that this technique could provide a patent unidirectional flow of urine in the majority of cases (82.5 per cent). Urodynamic measurements, including flowmetry, rectal pressure and anal electromyography activities, indicated that the driving force for voiding is the voluntary increase of the intra-abdominal pressure rather than the intrinsic contractions of the smooth muscles of the rectum. Accordingly, attempts at control of nocturnal urinary leakage were directed towards increasing the resistance offered by the pelvic floor. The efficiency of imipramine hydrochloride to achieve this goal was tested against a placebo in a clinical trial performed in a prospective randomized fashion. This treatment was effective in the control of enuresis in a significant number of patients (75 per cent). We conclude that the rectal bladder with a terminal colostomy is a highly recommended method for permanent urinary diversion when these 2 modifications are used.

The role of bladder augmentation in undiversion

Twenty-nine pediatric patients underwent bladder augmentation as part of their urinary undiversion. Indications included spina bifida deformity, contracted small bladder, and extrophy. Cecal and sigmoid segments were used. Prior diversion included ureterointestinal conduits, vesicostomies, ureterostomies, and suprapubic catheter drainage. In most cases the renal function was normal. Intermittent catheterization is used in almost every cases. Several illustrative cases are shown.

Urinary tract diversion and undiversion in the pediatric age group

Undiversion is an interesting phenomenon but may in part be self-limiting. As the experience with techniques in reconstruction increases, the need for diversion may give way to that of earlier correction of the original pathology, Thus, reversal of diversion by offering a wealth of experience in reconstruction may well lead to its own demise. Nevertheless, even with newer reconstructive techniques, there is, to date, a definite place for diversion of the urinary tract in the pediatric age group and there are now many pediatric patients still to be considered candidates for undiversion

Cecocystoplasty in the surgical management of the small contracted bladder

Preliminary results have been reviewed for 17 patients with a small contracted bladder from chronic inflammatory disease who underwent cecocystoplasties. Except for 1 patient who was lost to followup results were considered excellent in 11, good in 2 and a failure in 3. The amount of diseased bladder resected and the configuration of the cecal segment used did not seem to bear any relationship to the surgical outcome. The importance of a concurrent Y-V plasty is emphasized. No case of significant electrolyte imbalance has been encountered. Results can be gratifying in selected patients after detailed voiding pattern documentation and thorough urological study ahve been completed.

The late symptomatic and functional results of enterocystoplasty

A symptomatic and, where possible, urodynamic assessment has been made in 19 patients undergoing enterocystoplasty over a 16-year period. It is suggested that this operation should be considered in those cases of interstitial cystitis and irritable bladder syndrome in which all recognised medical and surgical treatment has failed.

Blow out of a colocystoplasty loop owing to bladder neck obstruction

A case of blowout of the colonic segment of a colocystoplasty at its free end owing to late development of bladder neck obstruction is described. Prostatitis and secondary bladder neck contracture provided further hindrance to the already inefficient voiding mechanism and predisposed to the rupture of the decompensated bowel loop. This is an extreme example of proof that the colonic loop, except as an improved substitute for an ileal segment, cannot withstand high intraluminal pressures generated in the presence of bladder outlet obstruction.

Urodynamics

The urinary tract is a hydrodynamic system whose components are in precise balance with each other and whose functioning depends on mechanical equilibrium. Alteration of the delicate balance between bladder and urethra means dysfunction in voiding or continence. Of greatest clinical interest at present is the bladder-urethra matching mechanism, which controls normal or abnormal voiding or continence. Since the matching combination of bladder and urethra must obey the same hydrodynamic laws that govern all fluid systems, it is obvious that measurement of fluid quantities and fluid porperties should correlate with function and dysfunction in the system. Urodynamics is the art of developing standard fluid-mechanical techniques that will be useful in routine clinical evaluation. Increasing experience with diagnostic urodynamic tests nurtures non-invasive, precise diagnosis of voiding dysfunction. Inexpensive, readily available and convenient techniques have been developed and are in clinical use. We can look forward to many more.