Serous-lined extramural tunnel technique for uretero-ileal implantation in urinary diversion

Orthotopic ileal W-shaped neobladder: functional results and oncological outcome

INTRODUCTION

There still exists an ongoing debate regarding the optimal method of ureterointestinal reimplantation in continent urinary diversion. The main objectives of the present study was to analyze the long-term functional results and the oncological outcome after the construction of orthotopic ileal neobladders, based on the antireflux serous-lined extramural tunnel technique.

MATERIALS AND METHODS

A total of 32 bladder cancer patients (30 males and 2 females, mean age 588 years), who underwent between 1/9/1996 and 1/9/2006 extended pelvic lymphadenectomy and radical cystectomy, followed by the construction of orthotopic W-shaped ileal neobladder, entered the study. All ureters were reimplanted via serous-lined extramural tunnels for reflux prevention. Adjuvant systemic chemotherapy with gemcitabine plus cisplatin was applied in 17 cases. All patients were evaluable for follow up (mean follow up - 53.938 months). Evaluation included clinical, radiographic and urodynamical studies to determine functional and oncological outcomes.

RESULTS

None of the patients died in the hospital. Various early and late complications occurred in 18.8% and 21.9% of the patients, respectively. The overall incidence of day- and nighttime continence was 93.8% and 78.1%. Stenosis at the anastomotic site occurred in 2 uretero-ileal anastomoses (3.2%), while none of the patients showed evidence of pouchoureteral reflux. Renal function was stabilized or improved in 96.8% of the reimplanted renal units. Eight oncological failures were observed during follow-up: 1 local tumor recurrence and 7 metastatic tumor spreads. The overall and disease-specific patient survival was 72% and 81%, resp.

CONCLUSION

The serous-lined extramural tunnel technique provides an effective and safe ureteroileal anastomosis, achieving nonobstructed unidirectional flow of urine. The results are durable and sustained with time. Therefore, this technique should be recommended whenever a construction of a continent intestinal urinary reservoir is considered.

Results of the ureteral reimplantation with serous-lined extramural tunnel in orthotopic ileal W-neobladder

BACKGROUND

Our experience in uretero-ileal anastomosis using the serous-lined extramural tunnel in orthotopic ileal W-neobladder is presented.

METHODS

Between June 1998 and November 2001, 42 patients (40 men and two women) underwent radical cystectomy and orthotopic ileal neobladder for invasive bladder cancer. The ureters were reimplanted into serous-lined extramural tunnels as described by Abol-Enein and Ghoneim. However, we made minor modifications during the ureteral reimplantation in cases that necessitated distal ureteral excision and with grossly dilated ureters. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes.

RESULTS

There was no operative mortality. The mean follow-up period was 28 months (range 12-52). Early complications occurred in four patients (9.5%). An endarterectomy for acute popliteal arterial embolism, the excision of the pouchointestinal fistula and a temporary colostomy were performed in two of these four patients. The other two patients were treated conservatively. Late complications occurred in eight patients (19%). Reflux was observed in three renal units (3.7%), ureterointestinal strictures in another three renal units (3.7%) and urethroileal stenosis in two patients (4.8%). In all cases, stabilization or improvement of renal function was achieved. No metabolic complications were observed.

CONCLUSIONS

Ileal W-neobladder with a serous-lined extramural tunnel is a safe, reliable form of lower urinary tract reconstruction. The method can be carried out with equal ease in grossly dilated ureters and in cases that necessitate distal ureteral excision.

Comparison of clinical and urodynamic outcome in orthotopic ileocaecal and ileal neobladder

OBJECTIVE

Aim of this study was to evaluate the clinical and urodynamic results in patients who had undergone orthotopic bladder substitution with ileocaecal (Mainz pouch procedure) or ileal (Abol-Enein and Ghoneim procedure) segments and who had a minimum follow-up of 12 months.

METHODS

Mainz pouch procedure (MP) was performed in 19 patients (mean age 62.4 years, median follow-up 36 months) and Abol-Enein and Ghoneim procedure (AG) in 36 patients (mean age 64.3 years, median follow-up 31 months). Complications and urodynamic findings were compared in both groups.

RESULTS

Complications related to the pouch were (MP and AG groups, respectively) ureterointestinal anastomotic stenosis (10.5% versus 5.7%), poucho-urethral anastomosis stenosis (5.3% versus 5.5%), poucho-ureteral reflux (7.9% versus 4.2%), and pyelonephritis (15.8% versus 13.8%). At 12 months postoperatively, daytime incontinence rates were 5.3% versus 5.5% and nighttime incontinence (twice weekly or more) rates were 21% versus 8.4% in MP and AG groups. In urodynamic evaluation, which was performed in 39 patients at 12 months postoperatively, both groups showed adequate bladder capacity, the mean values of which were 426 +/- 34 ml in MP group and 442+/-27 ml in AG group (p > 0.05). The mean value of maximal flow rate was 19.6 +/- 3.7 ml/s in MP group and 16 +/- 6.1 ml/s in AG group (p > 0.05). The mean residual urinary volume was 37 +/- 8.2 ml in MP group and 45 +/- 7.1 ml in AG group (p > 0.05).

CONCLUSION

The comparison between two types of bladder substitution, namely ileocaecourethrostomy (Mainz pouch procedure) and ileal reservoir (Abol-Enein and Ghoneim procedure) has demonstrated that urodynamic findings showed no significant difference between two groups.

Fate of tetraplegic patients managed by ileal conduit for urinary control: long-term follow-up

BACKGROUND

A study was conducted to evaluate our experience of ileal-conduit formation in tetraplegic patients with special reference to late complications due to upper urinary tract stones and pyocystis.

METHODS

Ileal-conduit formation was performed in 16 patients with tetraplegia to improve urinary management. The mean age at operation was 46 years (range 19-70) and the mean follow-up period was 8.7 years (range 2-17). We evaluated the results retrospectively from patients' medical records.

RESULTS

Two patients died 2 years after the procedure and one patient died 8 years after the ileal-conduit formation. Five patients suffered from repeated renal or ureteral stone. In three of these cases, serious urinary tract infections developed whenever the stone caused an obstruction. Three patients received a cystectomy at the time of the ileal-conduit formation. Eight patients suffered from empyema of the bladder and in two of these cases a subsequent cystectomy was required.

CONCLUSIONS

Ileal-conduit formation should be cautiously considered as an option in the urinary management of tetraplegic patients, particularly when more conservative management strategies have proved unsuccessful. However, an antirefluxing mechanism for the ileal conduit may be necessary, and a simultaneous cystectomy may improve the results.

The serous-lined tunnel principle for urinary reconstruction: a more rational method

OBJECTIVE

To examine the feasibility of using the serous-lined-tunnel principle for orthotopic neobladder, continent cutaneous diversion and ureteric replacement by an intestinal segment. Patients and methods We created: (i) an orthotopic ileal neobladder using the serous-lined technique for antirefluxing ureteric implantation in 16 patients; (ii) a continent ileal pouch, adopting the principle for continent-valve construction and for ureteric implantation, in 10 patients (another patient with a failed continent valve underwent revision using an adaptation of this principle; and (iii) by applying the same principle an ileal ureter with a proximal antirefluxing mechanism was constructed in two patients (with lower ureteric cancer), and total replacement of the ureter by a tubular segment of the colon in association with a continent transverse colon pouch in one irradiated patient.

RESULTS

In all, 52 ureters implanted into ileal neobladders or continent pouches functioned well, with neither obstruction nor reflux; 11 continent valves functioned well with no incontinence. Two patients with ileal ureters showed no ileo-ureteric reflux and had less hydronephrosis than before surgery. The tubularized ureter provided a unidirectional flow into the pouch. Conclusion Ureteric reimplantation and continent valve formation achieved by adopting the serous-lined tunnel principle provided satisfactory results. The versatility of the principle is apparent in the present experience and the creative application of the serous-lined tunnel principle should be possible in urinary reconstruction.