Robotic-assisted laparoscopic catheterizable bladder augment: a novel approach to treat recurrent bladder neck contracture following radical prostatectomy

INTRODUCTION

Bladder neck contractures (BNC) are an uncommon complication following radical prostatectomy. Occasionally, BNCs can be refractory to endoscopic approaches. We describe the effectiveness of a novel robotic-assisted laparoscopic catheterizable bladder augment in treating recalcitrant BNCs.

MATERIALS AND METHODS

Patients undergoing robotic-assisted radical prostatectomy (RALP) between 2004-2014 who developed a postoperative BNC were identified. We documented our experience with robotic-assisted laparoscopic catheterizable bladder augment for recalcitrant BNCs. Total operative time, robotic time, estimated surgical blood, length of hospital stay, serum creatinine, complications, and postoperative course/upper tract imaging were recorded.

RESULTS

Thirty-six of 2002 RALP patients (1.8%) experienced a post-surgical BNC at 182 days post-surgery. Twenty-two (61.1%) underwent a single dilation and/or transurethral incision. Eleven (30.6%) required = 1 procedure. Three patients (8.3%) had recalcitrant BNCs. One patient with normal bladder capacity elected open urethroplasty. The remaining two had reduced bladder capacity, detrusor over-activity and failed multiple incisions and self-catheterization. In one patient, the stricture was complete. The other patient experienced urethral leakage requiring bladder neck closure. In both patients, a robotic approach, utilizing an ileal-cecal segment as a catheterizable augment, was performed. At 16 and 89 months follow up, both are continent, with stable renal function and normal upper tracts.

CONCLUSION

Robotic-assisted laparoscopic catheterizable bladder augment is a viable treatment for recurrent BNCs. This approach may be particularly well suited for patients with concurrent hyperreflexia or decreased bladder capacity.

Lymphotoxin regulates commensal responses to enable diet-induced obesity

Microbiota are essential for weight gain in mouse models of diet-induced obesity (DIO), but the pathways that cause the microbiota to induce weight gain are unknown. We report that mice deficient in lymphotoxin, a key molecule in gut immunity, were resistant to DIO. Ltbr(-/-) mice had different microbial community composition compared to their heterozygous littermates, including an overgrowth of segmented filamentous bacteria (SFB). Furthermore, cecal transplantation conferred leanness to germ-free recipients. Housing Ltbr(-/-) mice with their obese siblings rescued weight gain in Ltbr(-/-) mice, demonstrating the communicability of the obese phenotype. Ltbr(-/-) mice lacked interleukin 23 (IL-23) and IL-22, which can regulate SFB. Mice deficient in these pathways also resisted DIO, demonstrating that intact mucosal immunity guides diet-induced changes to the microbiota to enable obesity.

A new technique using free ileocaecal patch transplantation for secondary voice restoration after total laryngectomy

SUMMARY

We introduce our newly designed voice restoration technique, which uses free ileocaecal patch transplantation for patients who have undergone prior total laryngectomy. Two women received ileocaecal patch transplantation for secondary voice restoration after total laryngectomy. In order to make the tracheoesophageal shunt for speech, a new orifice on the anterior wall of the hypopharynx had to be opened, which was closed at the time of laryngectomy. The hypopharyngeal orifice was covered by a free caecal patch harvested from an ileocaecal segment. Then, a tracheoesophageal shunt was created by anastomosing the terminal ileum of the patch and the remnant of the cervical trachea. Expiratory air was diverted into the pharynx through the ileum of the transplanted graft when the tracheostoma was closed by digital occlusion. Aspiration through an oesophagotracheal shunt in swallowing was prevented by the ileocaecal valve on the patch. Both patients began to speak up to 4 weeks after surgery without requiring training or difficult practice to achieve initial phonation and to be able to swallow without aspiration. The advantages of our procedure are (1) it can be carried out at the time of laryngectomy and also at secondary voice restoration after earlier laryngectomy; (2) the graft contains an ileocaecal valve that prevents aspiration through the shunt and also functions as a vibrating device to produce voice; (3) our procedure can be adapted to individuals whose tracheostoma is detached from the oesophagus and becomes contraindicated for a voice prosthesis. We believe that our newly designed procedure is a unique and useful alternative, especially for secondary voice restoration after prior total laryngectomy.

Reconstruction of bladder and urethra using ileocecal segment and appendix in patients with exstrophy-epispadias complex: the first report of a new surgical approach

OBJECTIVE

We aimed to describe our experience in administering an innovative surgical technique to treat pediatric cases of exstrophy-epispadias complex.

MATERIAL AND METHODS

Between 1995 and 2004, seven consecutive patients (six males) with exstrophy-epispadias complex were treated using ileocecal segment for bladder augmentation and appendix for urethral reconstruction. In a single-stage operation, the exstrophied bladder was dissected- and a segment of cecum, ascending colon, terminal ileum, and the corresponding appendix were isolated. Using the opened colon to augment the bladder, the ileal segment was fashioned to skin as temporary stoma, and the appendix was laid in the urethral lumen as the neourethra following urethral demucosation. This technique was used as a secondary surgery in one case and as a primary surgery in six neonates. Evaluation of the urinary tract status was performed by cystograms and ultrasonograms.

RESULTS

Renal function was saved in all cases and continence was achieved by clean intermittent catheterization every two hours either via the neourethra (n = 6) or through the temporary stoma (n = 1). The patients did not experience any metabolic complications in their follow-ups. Moreover, no one had vesicourethral reflux, dehiscence, or fistula.

CONCLUSIONS

The technique was deemed safe with acceptable outcomes even when secondary repair of previously failed operation was intended. Experiencing the technique in larger cohorts as well as longer follow-ups might be necessary to assess probable long-term complications.

[Bladder augmentation cystoplasty with continent urinary diversion by ileo-caeco-appendicular graft in children]

OBJECTIVE

Description of augmentation cystoplasty combined with continent urinary diversion using an ileo-caeco-appendicular graft in children.

MATERIAL AND METHOD

Augmentation cystoplasty combined with Mitrofanoff appendicostomy and reimplantation of the ureters into the ileal stump was performed during a single operation in two patients (a 3-year-old girl and an 8-year-old boy). The indications were a pseudoneurogenic bladder with major dilatation of the upper tract due to high-grade reflux in one case and a small scarred bladder after repeated failure of repeated surgery for duplicated ureterocele in another case.

RESULTS

A bladder capacity of about 300 ml was obtained in the 2 children. Incontinence was managed by intermittent catheterization via the abdominal stoma. Upper urinary tract dilatation had resolved after one year.

CONCLUSION

This technique is useful in certain complex urological situations combining a small, poorly compliant bladder, destruction of continence and severe upper tract dilatation. In these situations, it constitutes a conservative alternative to salvage diversion.

Ileocecal with teniamyotomies and ileal detubularized neobladders: considerations about a videourodynamic study after a long-term follow-up

OBJECTIVE

To evaluate the functionality of ileal detubularized reservoir and ileocecal neobladder with multiple teniamyotomies after a long term follow-up.

MATERIAL AND METHODS

Eight patients with ileal detubularized reservoir (IR) and 10 with ileocecal neobladder with multiple teniamyotomies (ICUS) with an average follow-up of 95 months, were submitted to a videourodynamic digital fluorongiographic examination. The patients had the longest disease-free follow-up of our series.

RESULTS

Urodynamic data collected were almost good and comparable between IR and ICUS. Anyway the exams showed that the smooth intestinal muscles remain active both in non-detubularized and detubularized bladders even after years. Continence is mostly assured by the striated sphincter, which can withstand transient high pressure peaks but is less effective when facing prolonged pressure increases. While in some cases a valid micturition was achieved simply relaxing the perineal floor, in other cases micturition was obtained by an abdominal straining against the resistance of a contracted urethral sphincter/pelvic floor even after a long follow-up.

CONCLUSIONS

Detubularization and teniamyotomies can equally help the striated sphincter function by increasing the neobladder compliance. Moreover we observed that a non-spherical neobladder was compatible with good clinical results as well, proving that neobladder shape was less important in achieving good functional performance. Furthermore, in some cases the optimal relaxation of the perineal floor made abdominal straining superfluous especially when neobladders had physiological capacity. Thus a perineal floor musculature training and its co-ordination with abdominal muscles may improve the quality of micturition.

New Surgical Technique for Primary and Secondary Voice Restoration Using a Free Ileocecal Patch Graft After Total Laryngectomy

PURPOSE

We devised a new surgical technique to restore the voice after laryngectomy. This procedure is designed to repair the hypopharyngeal defect by using a free ileocecal patch for voice rehabilitation.

METHODS

We performed this procedure in seven patients; for primary voice restoration in six and for secondary voice restoration in one. The technique involved resecting an ileocecal segment containing the ileocecal valve and cutting a patch from the cecum, the size of which was equalized with the hypopharyngeal defect. After patch repair of the defect, the tracheopharyngeal shunt was completed by an anastomosis between the ileum and trachea.

RESULTS

One patient died from sudden rupture of the carotid artery, but all six survivors were able to speak and swallow without aspiration, achieving fair to good articulation.

CONCLUSIONS

The advantages of our method are as follows. (1) The operative procedure is simple and does not require complicated remodeling of the intestinal graft for voice production. (2) The ileocecal valve can prevent aspiration. (3) The patch expands the pharynx and prevents narrowing. (4) Using this procedure, it is possible to achieve voice restoration even in patients who have undergone total laryngectomy in the past.

Metabolic findings after colocystoplasty in children

OBJECTIVES

To investigate whether colocystoplasty has resulted in metabolic changes in the growing child during long-term follow-up according to whether cecum with ascending or sigmoid colon was used.

METHODS

Twenty-eight patients (mean age at surgery 11 years) were included in the study and divided into two groups: group 1, cystoplasty with cecum and ascending colon (12 patients) and group 2, sigmoid cystoplasty (16 patients). Patients' linear growth, body mass index, and the following parameters were estimated before surgery and at 3, 6, and 12 months, and then yearly after surgery: blood and urine electrolytes (sodium, potassium, chloride, calcium, phosphorus, magnesium), creatinine, urea, blood gases, blood pH, urine pH, and blood alkaline phosphatase (ALP). All the data were statistically analyzed.

RESULTS

In group 1, the blood ALP increased significantly (P = 0.026) during follow-up. Severe metabolic acidosis with or without hyperchloremia was found in 7 patients. In group 2, the serum sodium and serum calcium levels decreased significantly (P = 0.014 and P = 0.003, respectively); however, the blood ALP, urine sodium, and urine phosphorus levels increased significantly (P = 0.033, P = 0.027, and P = 0.026, respectively) during follow-up. A statistically significant decrease in blood pH (P = 0.022) was found after surgery. Severe metabolic acidosis with or without hyperchloremia was detected in 5 patients. The average linear growth decreased significantly (P = 0.001 and P = 0.016, respectively) 1 and 2 years postoperatively.

CONCLUSIONS

The statistically significant increase in blood ALP and decrease in serum calcium indicate bone demineralization after colocystoplasty. Our investigations in children suggest that bone demineralization is more frequent after sigmoid cystoplasty than after the use of cecum and ascending colon.

Bladder augmentation techniques in women

Augmentation cystoplasty is performed in women for a variety of indications, including neurogenic bladder dysfunction, inflammatory diseases, small fibrosed bladders, idiopathic urge incontinence and enuresis. The preoperative evaluation, surgical techniques and postoperative management are reviewed. Complications of stone formation, urinary tract infections, mucus production, metabolic disturbances, hematuria and dysuria syndrome, tumors and perforations are addressed. In addition, alternative techniques such as ureterocystoplasty, autoaugmentation, seromuscular cystoplasty and the future of augmentation of the bladder utilizing techniques of tissue engineering are discussed. The management of pregnancy in women who have previously undergone augmentation cystoplasty is also reviewed.

Intestinal bypass of the oesophagus: 117 patients in 28 years

This study includes 117 patients operated upon in the period from 1970 to 1999. Indications, surgical techniques, complications, and results are reviewed. Indications included: long-gap oesophageal atresia with or without fistula in 81 patients; peptic stenosis in 19; caustic stenosis in 12; oesophageal varices in 2; and 1 case each of oesophageal epidermolysis bullosa, total oesophageal leiomyomatosis, and a non-functioning antiperistaltic retrosternal colic graft operated upon in another hospital. A retrosternal bypass was performed 106 times: 98 first operations and 8 redos; the intrathoracic technique was used 19 times. The left transverse colon was used in 107 cases (85.6%), the right transverse colon in 8 (6.4%), and the ileocecum in 10 (8%). All the intestinal bypasses were placed in the isoperistaltic direction. There were 5 deaths in the first 11 years of our experience; no patient died from 1982 on. Ten complications were treated conservatively (8%): 2 wound infections healed with medical treatment, and 8 leaks of the cervical anastomosis closed spontaneously. The major surgical complications were 8 gangrenous bypasses (6.4%), removed and reoperated about 1 year later utilizing an ileocolic retrosternal graft. Three cases of peptic disease of the colic bypass (2.4%) were successfully treated with the author's technique. Nine patients had minor surgical complications (7.2%): 3 strictures of the oesophagocolic anastomosis in a retrosternal bypass (resected and reoperated) and 6 cases of adhesive occlusion. In our opinion, the best substitute of the oesophagus is the colon, particularly the left transverse segment, which may be placed behind the sternum or in the oesophageal bed, always in the isoperistaltic direction. The low mortality (4%), restricted to the early period of our experience, and few major surgical complications (6.4%) are acceptable considering the importance of the operation, and the long-term results may be considered very satisfactory.

Detection of adenocarcinoma by urinary microsatellite analysis after augmentation cystoplasty

Augmentation cystoplasty is associated with an increased risk of bladder cancer development between 10 and 20 years after augmentation. Using microsatellite analysis, we analyzed urine obtained before surgical resection of the malignant lesion from a patient who developed invasive adenocarcinoma after augmentation cystoplasty. Loss of heterozygosity was identified in both urine and tumor samples from this patient. This observation suggests that microsatellite urine analysis may be useful as a monitoring tool for patients after augmentation cystoplasty.

Clinical outcome and quality of life after gastric and distal esophagus replacement with an ileocolon interposition

Mainly because of the loss of reservoir function, loss of sphincter function, and exclusion of the duodenal route, patients who undergo gastrectomy suffer from many adverse effects postoperatively. The ileocecal interpositional graft is an attractive method to use as a gastric substitute after gastrectomy and distal esophagectomy. A pedunculated ileocecal graft is placed between the esophagus and the duodenum. The cecum acts as a reservoir while the ileocecal valve protects against enteroesophageal reflux. The duodenal passage is also preserved. Fourteen patients underwent this operation. The technique-related morbidity was low and the quality of life was good. During a mean follow-up of 6 months, no evidence of severe dumping syndrome or reflux esophagitis was observed. Further prospective randomized studies are warranted to compare this technique with the standard methods of gastric reconstruction.

[Ileo-cecal segment as stomach substitute]

In clinical practice a long Roux-en-Y reconstruction is most often used for gastric replacement. Among various postgastrectomy symptoms, alcaline reflux is the most disturbing. A great variety of different pouch reconstructions with or without duodenal bypass only control reflux in part. The ileocoecal interposition has been placed between the oesophagus and the duodenum as a gastric substitute in 14 patients without postoperative mortality. This preliminary series demonstrates an excellent control of alcaline reflux and a good quality of life, according to the Eypasch score. Dysphagia or stasis in the distal oesophagus are absent as is gas bloating. This type of reconstruction, which is simpler than some of the pouch reconstructions, probably deserves more attention and may perhaps be perfected by varying the length of ileum and volume of ascending colon to be interposed.

Bladder augmentation with different forms of intestinal grafts: an experimental study in the pig

OBJECTIVE

To create an experimental animal model to examine changes in bladder volume and histology after bladder augmentation in growing individuals and from the model, evaluate a method using demucosalized intestinal grafts and short-term bladder drainage.

MATERIALS AND METHODS

The study comprised 21 piglets: in group 1, seven underwent a sham operation; in group 2, seven piglets underwent bladder augmentation with full-thickness caecum after a major bladder resection; in group 3 seven underwent the same procedure but with demucosalized caecum. The bladder volume and area of the intestinal segment were measured peroperatively and when the animals were killed 2 months later. Bladder specimens were taken for histological examination.

RESULTS

The mean preoperative bladder volumes were similar among the groups; in the control group, volumes increased from 58 to 165 mL and in group 2 from 63 to 255 mL, with an increase in area of the intestinal segment from 59 to 138 cm2. In group 3 the volume was unchanged, from 63 to 71 mL, with a decrease in area from 58 to 5 cm2. Control bladders showed normal urothelium with neutral mucins and sialomucins. In group 2, there was metaplasia in the border between urothelium and colonic epithelium, with enhancement of sialo- and sulphomucins. Demucosalization resulted in extensive fibrosis, with a monolayer of urothelial cells showing metaplasia.

CONCLUSIONS

The experimental model was successful; the observed changes in bladder volume correlated well with the fate of the intestinal implant, because the bladder resection was major. This is essential, as the bladder remnant has some growth potential. Full-thickness grafts grew faster than the normal bladder. Mechanical demucosalization, including submucosa, results in shrinkage despite short-term drainage. Glandular metaplasia, with production of sialomucins and sulphomucins, occurs at the junction between bladder and colon, irrespective of mucosal removal.

Milking action: a new functional concept of a different orthotopic neobladder: 4-year followup

PURPOSE

We demonstrate how the combined use of detubularized and remodeled intestine with intact cecum in the construction of an orthotopic colonic neobladder determines different functioning.

MATERIALS AND METHODS

Since February 1993, 11 men who underwent radical cystectomy due to invasive bladder carcinoma have received a new bladder substitute consisting of an upper component of ascending colon and a detubularized and remodeled right half of transverse colon, and a lower component with intact cecum. During postoperative years 1 and 4 all patients were evaluated with urodynamics and cystography.

RESULTS

The detubularized upper component of the neobladder acts as a large capacity, low pressure filling reservoir, while the intact cecum with its haustral contractions (inverted milking action) contributes as an additional continence mechanism. The mass contractions (milking action) with abdominal wall tension actively collaborate to evacuate the reservoir completely.

CONCLUSIONS

This new structural concept of a neobladder constructed from detubularized and intact intestine has a different functional behavior than neobladders described in literature. This neobladder enables complete evacuation and total continence in the immediate postoperative period.

Bowel motility after enterocystoplasty

OBJECTIVE

To determine whether the distension of bowel-augmented bladders during filling and urine storage stimulates gastrointestinal peristalsis, resulting in diarrhoea and increased bowel frequency.

PATIENTS AND METHODS

Five patients with symptomatic diarrhoea occurring after enterocystoplasty were studied; all had undergone bladder augmentation using ileum or colon at least 6 months previously. Using bowel frequency charts and colonic transit-time studies, their bowel function was assessed over 6 days while patients self-catheterized 4-hourly. This was repeated when the patient's bladders were decompressed with an indwelling catheter, and the results before and after bladder decompression compared.

RESULTS

One patient showed a significant increase in colonic transit time, from 44.4 to 57.6 h, a decrease in the percentage of liquid motions from 50% to 42.8% and a corresponding small decrease in bowel frequency with bladder decompression. One patient reported an increase in liquid stools, but there was a minor decrease in colonic transit time. The remaining three patients showed no improvement with bladder decompression. When data were combined and analysed using Student's paired t-test, there were no significant changes in colonic transit time, bowel frequency and diarrhoea stools with bladder decompression.

CONCLUSIONS

Eliminating bladder distension and hence distension of the incorporated bowel segment in reconstructed bladders has no impact on bowel motility.

[Replacement of part of the bladder and ureter using an ileocecal segment for tubercular sclerosis]

Based on a series of 14 operated cases, the author describes augmentation of a fibrotic bladder and replacement of the stenotic ureter by an ileocaecal graft. The lesions were due to urinary tuberculosis. Good resumption of normal micturition was observed, with no cases of renal failure.

A case of non-functioning antiperistaltic retrosternal colic conduit replaced in situ and substituted with an isoperistaltic segment of ileum-caecum

The authors report the case of a female patient, affected by long-gap oesophageal atresia, who, at 5 months old, was operated on for retrosternal substitution with a right-transverse antiperistaltic colic segment, in her local district hospital. Due to the anomalous position the neooesophagus never worked, and the baby was seriously dysphagic and failed to thrive. For this reason, when she was 11 months old, she was reoperated in our department. Through a medium sternolaparotomy the antiperistaltic colon was removed and replaced between the left and right colon; reconstruction was carried out with a retrosternal and isoperistaltic segment of ileo-caecum. The reoperation resolved her problems. This case is reported to confirm the author's opinion that all intestinal conduits must be positioned in the isoperistaltic direction.

[The Indiana pouch: a technic for simple continent urinary diversion]

OBJECTIVE

Description of the Indiana pouch, a continent urinary diversion after cystectomy for urogenital tumours, and for the sequelae of neurogenic and traumatic bladders.

MATERIAL AND METHOD

This was a retrospective study of 16 patients undergoing, between June 1991 and March 1995, cutaneous urinary diversion by ileocaecal graft, detubularized in the colonic segment, with continence ensured by the ileocaecal valve. The postoperative follow-up (4 to 36 months) was performed at 3, 6 and 12 months (abdominal ultrasonography alternating with abdominopelvic CT scan), then annually (CT scan). Finally, a urodynamic assessment was performed in 7 patients.

RESULTS

No early complications related to the reservoir were observed. Late complications of the diversion were related to the uretero-colonic anastomosis with 3 dilated renal subunits. Continence was achieved in 12 out of 15 patients, while one patient finally refused self-catheterization. In the patients in whom a urodynamic assessment was performed, the mean capacity of the reservoir was 671.4 +/- 273.9 mL for a filling pressure of between 3.7 +/- 1.6 and 11 +/- 2.5 cm H2O and an ileocaecal valve closure pressure of 97.9 +/- 117.1 cm H2O (full reservoir).

CONCLUSION

The Indiana pouch is a useful urinary diversion as it is simple to perform and is associated with a low revision rate, while ensuring low-pressure continence.

Diagnosis and management of high-pressure peristaltic contractions in cystoplasties

OBJECTIVE

To define the aetiology of and therapeutic strategy for high-pressure peristaltic contractions within colo- and caecocystoplasties associated with symptoms of frequency, urgency and urge incontinence.

PATIENTS AND METHODS

In a series of over 150 subtotal supratrigonal colo- and caeco-cystoplasties, nine patients were identified with such symptoms. These patients underwent videocystometrography (VCMG) confirming the presence of phasic peristaltic contractions of > 35 cmH2O.

RESULTS

In three cases, there was urodynamic evidence of outlet obstruction and symptoms resolved when the obstruction was surgically relieved. In the other six cases, high-pressure peristaltic contractions were present without bladder outlet obstruction. The symptoms did not respond to anticholinergic medication. Three of the six patients had tolerable symptoms which did not warrant further intervention. The other three cases had disabling urge incontinence and underwent ileal patch cystoplasty. The symptoms resolved in all three cases, although later recurred in one patient, probably due to incomplete division of the taenia coli during ileal patch cystoplasty.

CONCLUSION

It appears that colonic smooth muscle can develop high-pressure contractions in response to neobladder outlet obstruction. Relieving the obstruction ameliorates symptoms associated with these contractions and reduces the magnitude of the peristaltic waves. Symptoms related to high-pressure peristaltic contractions without neobladder outlet obstruction do not respond to anticholinergic medication but can be successfully treated by ileal patch cystoplasty.

[Comparison of 2 types of experimental transplant in the treatment of lethal short bowel syndrome]

OBJECTIVE

To evaluate the functional response, morbidity and histostructural changes in rats enterectomized and without cecum using two types of syngenic enteral transplants.

MATERIAL AND METHODS

Controlled randomized surgical-therapeutic trial. Four groups of male Lewis rats 8-10 weeks old underwent the following procedures: 1. Lethal enteral resection (n = 10). 2. Lethal enteral resection + total yeyuno-ileal transplant (n = 28). 3. Lethal enteral resection + distal segmentary of 40% and cecum transplant (n = 32). 4. Control group (n = 10).

RESULTS

11% of the transplanted animals died due to technical failures; both transplanted groups had a similar proportion of late complications, mostly enteral obstruction. A persistent diarrhea was observed in 20% of the yeyuno-ileal transplanted group, but no significant differences were found between the two groups concerning survival, weight gain, protein and triglycerides serum levels, and a maltose absorption test; villus and crypt hypertrophy was observed in both grafts. The enteral graft integration was followed by structural changes similar to those found in intestinal remnants on deficit conditions after enteral resection.

CONCLUSION

The bowel distal segmentary transplant with ileocecal valve and cecum may be a good option in cases of irreversible enteral failure, as the functional response and morbidity are similar to those found with the standard total transplant.

Long-term results of lower urinary tract reconstruction with the ceco-appendiceal unit

PURPOSE

We report long-term results in 11 patients born with bladder exstrophy who underwent lower urinary tract reconstruction using a ceco-appendiceal unit.

MATERIALS AND METHODS

Four boys and 2 girls underwent lower urinary tract reconstruction using an unaltered ceco-appendiceal unit. In 2 boys and 1 girl the bladder was replaced with a reservoir of terminal ileum, cecum and ascending colon, and the appendix was used as an orthotopic neourethra. In another 2 boys and 1 girl the bladder was augmented, while the appendix was used to create a stoma to the umbilicus. In 5 patients in whom the ceco-appendiceal junction was incompetent the cecum was plicated over the base of the appendix to reinforce the sphincteric mechanism. Four patients underwent augmentation with the appendix brought out as an umbilical stoma, and in 1 the bladder was replaced and the appendix was used as a neourethra.

RESULTS

Six patients in whom the ceco-appendiceal junction was unaltered and 5 in whom it was plicated remain continent 5 to 11 and 2 to 7 years postoperatively, respectively. In the initial patient urinary incontinence developed due to high intraluminal pressure, which resolved after detubularization of the urinary reservoir. Another patient underwent revision of the abdominal stoma.

CONCLUSIONS

The ceco-appendiceal unit may be used for continent lower urinary tract reconstruction. Ceco-appendiceal junction competence can be tested intraoperatively and the sphincteric mechanism may be reinforced as necessary. The appendix may be ectopically or orthotopically placed and used for intermittent catheterization.

Bowel problems after enterocystoplasty

OBJECTIVES

To document the changes in bowel habit in patients who have undergone enterocystoplasty.

PATIENTS AND METHODS

Sixty-nine patients with neuropathic (NP) and 44 with non-neuropathic (NNP) bladder dysfunction (mean age 26 years, range 13-61, 93.6% socially continent), followed for at least 36 months after cystoplasty, were assessed using a questionnaire addressing faecal frequency, consistency, method of evacuation and incontinence episodes before and after surgery.

RESULTS

Of the patients with NP bladder dysfunction, 26 (38%) had more and seven (10%) less frequent bowel action after surgery, with 36 (52%) unchanged; 38 (55%) of patients had unchanged consistency, 26 (38%) were looser and five (7%) more constipated; 41 (59%) opened their bowels as before, 16 (23%) needed more help and 12 (17%) less help to evacuate; 16 (23%) patients had more and 17 (25%) less episodes of incontinence; 21 (30%) patients felt their bowels had not become normal after their operation and only 24 (35%) that they had returned to normal within 3 months of their operation. The bowel segment used was ileum in 44 patients, ileocaecal in 11 and sigmoid cystoplasty in 14. Patients with intact ileum did not have the same degree of diarrhoea, with only three of the 14 patients with a sigmoid cystoplasty being adversely affected. Of the patients with NNP bladder dysfunction, 18 patients (41%) had a more and five (11%) a less frequent bowel action; 20 (46%) had more loose and five (11%) less loose bowel action; similar numbers (five and four) needed either an increase or a decrease in laxatives or enemata: surprisingly, 12 patients (27%) felt they had an increase in the episodes of incontinence; 17 (39%) patients felt their bowels returned to normal within 3 months of surgery and 30% felt their bowels had not become normal after surgery. Only one patient in this group had a sigmoid cystoplasty and she did not find that the operation interfered with her bowel function.

CONCLUSIONS

Ileal resection results in malabsorption of bile acids, maldigestion of fat and an imbalance of water and electrolytes. Patients with neurogenic bladders are finely balanced between acceptable bowel function and choas, and surgery often tips this balance the wrong way. In 30% of the present patients, bowel problems persisted after surgery, with 38% having increased frequency. 38% having looser consistency and 23% more incontinence episodes following surgery. More surprisingly, a high percentage of NNP patients had bowel problems after cystoplasty.

The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years' experience

OBJECTIVE

To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement.

PATIENTS AND METHODS

Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation.

RESULTS

All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred.

CONCLUSIONS

The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

The Le Bag orthotopic urinary diversion

PURPOSE

We reviewed our experience with Le Bag orthotopic urinary diversion in 38 cases.

MATERIALS AND METHODS

Between April 1990 and January 1995, 38 men underwent radical cystectomy and Le Bag urinary diversion for treatment of bladder cancer. Approximately 20 cm. each of detubularized ileum and cecum were used to construct the pouch. A total of 22 pouches was fashioned with absorbable staples. In 21 cases freely refluxing Bricker ureterointestinal anastomoses were used.

RESULTS

There was no significant difference in major complication rates in the hand sewn versus stapled anastomosis groups, and there were no complications specifically related to the use of staples. There were 3 episodes of febrile urinary tract infection: 2 in the Bricker group and 1 in the tunneled anastomosis group. There was no significant difference between the 2 groups with respect to ureteral obstruction. The daytime continence rate was 91%, and 80% of the patients are completely dry or have only mild incontinence at night. Most patients had mild hyperchloremic metabolic acidosis postoperatively as evidenced by a decrease in median serum bicarbonate level (28 versus 24 mmol./l.). This difference appears to be related to pouch length (r = 0.58, p = 0.0002).

CONCLUSIONS

We conclude that the Le Bag technique is a technically feasible form of urinary diversion with functional results similar to other forms of orthotopic diversion. Use of absorbable staples simplifies pouch construction without increasing complications. This form of urinary diversion is associated with hyperchloremic metabolic acidosis, which is related to pouch length.

Human syngeneic intestinal transplantation: evaluation of enterocyte viability with serum levels of intestinal fatty acid binding protein

In a case of human syngeneic intestinal transplantation, the post-operative course was complicated by the Systemic Inflammatory Response System (SIRS). This syndrome was characterized by negative cultures and elevated levels of the pro-inflammatory cytokines, IL-1 beta, IL-6 and TNF. In keeping with current concepts of translocation across the enterocyte barrier as the etiology of SIRS, levels of intestinal fatty acid binding protein (I-FABP), an enterocyte-specific protein, also increased. These observations suggest that (i) a clinical syndrome consistent with translocation may occur in the absence of rejection in intestinal transplantation, and (ii) I-FABP may serve as a clinically relevant marker for enterocyte injury.

Relative microbial resistance of gastric, ileal and cecal bladder augmentation in the rat

PURPOSE

Bladder resistance to bacterial infection after gastrocystoplasty, ileocystoplasty and cecocystoplasty was investigated in the rat.

MATERIALS AND METHODS

Bladders were infected with Escherichia coli 6 to 13 months after augmentation and urine culture was obtained weekly for 3 months.

RESULTS

No differences were observed in the number of infected animals within each group or electrolyte data among groups. The number of animals infected after surgery but before E. coli challenge was lowest in the gastrocystoplasty group. Bladder stones formed only in ileocystoplasty and cecocystoplasty groups. No group had a change in urinary pH.

CONCLUSIONS

Gastrocystoplasty may be associated with a lower incidence of spontaneous infection and stone formation. An aggressive infection protocol may have masked differences in susceptibility to infection. Since urinary pH was unchanged after gastrocystoplasty, use of the rat may not be appropriate for augmentation studies.

Risk of bowel dysfunction with diarrhea after continent urinary diversion with ileal and ileocecal segments

PURPOSE

In a retrospective study we evaluated the risk of diarrhea after continent urinary diversion using ileal and ileocecal segments.

MATERIALS AND METHODS

We interviewed 100 patients of whom 65 underwent ileal and 35 underwent ileocecal resection.

RESULTS

Of the 65 patients who underwent ileal resection 7 (11%) and of the 35 who underwent ileocecal resection 8 (23%) reported chronic diarrhea of greater than 6 months in duration, which subsided spontaneously in 2 patients in each group. In each group 3 patients responded well to cholestyramine treatment and 3 responded to loperamid or psyllium. Two patients with ileocecal resection failed to respond to drug therapy.

CONCLUSIONS

The risk of diarrhea after ileocecal resection seems to be twice as high as after ileal resection. Most patients responded to symptomatic drug therapy. Alternative surgical therapies should be considered when risk factors are present.

[The continent ileocecal pouch. The Mainz pouch I]

Since 1993 to July 1994, 374 patients underwent a Mainz Pouch procedure in their hospital. The follow up is between 4.2 +/- 2.6 years. The authors used this technique as well for bladder augmentation, bladder substitution as continent diversion. If possible, the appendix will be used for creating the continence system.

Simple flap valve for continent urinary diversion

OBJECTIVE

To provide a stable continence mechanism in patients with urinary diversion by creating a flap valve from the ileal wedge, sutured into the grooves of the reservoir mucosa.

PATIENTS AND METHODS

The valve's efficacy and stability were confirmed previously in an experimental study using five dogs. The valve was used in 22 patients with ileocaecal pouches and as a continence mechanism for cystostomy in two paraplegic women.

RESULTS

Continence was achieved in all but two patients. In these exceptions the valve was found to be abnormally short (only 2 cm). Re-operation restored one patient to continence but the second patient refused further surgery. There were no problems with either catheterization of the valve or with epithelialization of the serosal surface of the valve.

CONCLUSION

The valve is easy to construct and requires only a small intestinal segment; it has long-term mechanical and functional stability and can be easily catheterized. The valve provides continence even with increasing reservoir content and will accept a large catheter, which seems to be important in preventing lithiasis.

Acid-base changes following urinary tract reconstruction for continent diversion and orthotopic bladder replacement

A prospective determination of serum electrolytes, arterial blood gases, urinalysis and urine cultures was done in 31 patients who underwent a successful continent urinary reservoir or orthotopic bladder replacement. The patients who underwent reconstruction with a long detubularized intestinal segment (group 1-50 cm. long) demonstrated the greatest tendency for metabolic hyperchloremic acidosis (35.2%). In group 2 (patients with an orthotopic bladder replacement) only 1 individual (16.7%) had hyperchloremia, which proved to be the sole metabolic derangement encountered. In group 3 (individuals with a continent gastroileac reservoir) 2 patients (25%) had a slight tendency for compensated and asymptomatic alkalosis. Urinalyses and urine cultures in groups 1 and 2 demonstrated a trend toward urine alkalinity (52.1%) and asymptomatic bacteriuria (74%), respectively. On the contrary, among the patients undergoing a gastroileac reservoir (group 3), mild urinary acidity (pH between 5 and 6) was demonstrated in 4 (50%), while asymptomatic bacteriuria was present in 3 (37.5%). In this group symptomatic urinary acidity and/or ulceration of the ileal component has not occurred to date. Metabolic hyperchloremic acidosis predominates when longer colonic segments are used for reservoir construction. This abnormality is magnified in patients in whom an accessory small bowel was resected. The majority of the gastroileac reservoir patients showed electrolytic neutrality. With our surgical technique, the gastric secretory properties predominate over those of the ileum. The differences in homeostatic findings with the use of these varieties of bowel segments suggest that we could modify the final electrolytic environment by using different combinations of bowel and bowel length.

Somatostatin analogue inhibits intestinal regeneration

Somatostatin analogue octreotide inhibits intestinal absorption and motility but its effect on epithelial cell migration and proliferation remains unclear. Our aim was to determine the effect of octreotide on parameters of intestinal regeneration, including epidermal growth factor (EGF)-induced changes. Thirty rabbits had full-thickness ileal defects patched with cecal serosa surface. Group 1 were controls. Groups 2 and 3 received 100 micrograms and 1000 micrograms, respectively, of subcutaneous octreotide daily. Group 4 received EGF at 1.5 micrograms/kg per hour via subcutaneous miniosmotic pump, and group 5 received both octreotide (1000 micrograms/d) and EGF (1.5 micrograms/kg per hour). Octreotide at 100 micrograms/d did not inhibit epithelial cell migration or proliferation at 7 days. Octreotide at 1000 micrograms/d inhibited normal but not EGF-stimulated cell migration. Octreotide decreased EGF-stimulated but not normal proliferation. Octreotide impairs epithelial cell migration in a dose-dependent manner. Octreotide inhibits EGF-stimulated proliferative activity but not EGF-stimulated migration. Prolonged administration of octreotide may adversely affect normal and adaptive intestinal regeneration by both direct and indirect effects.

[Further experience with the use of gastrointestinal segments in bladder reconstruction in the complex of exstrophy-epispadias]

It is a matter of discussion if bladder augmentation should or should not utilize in the treatment of exstrophy-epispadias complex. When staged functional bladder reconstruction is adopted in the most difficult cases, or when one desires to avoid early and/or subsequent urinary diversions, sometimes a bladder enhancement could be necessary. The indications should be: a progressive damage to the upper urinary tract, after bladder closure at birth, due to a very small, no compliant detrusor plate (this is a rare condition: only one case in our series); a bladder capacity < or = 80 mls at the time of bladder neck reconstruction (this is a frequent but questionable condition: three cases in our series); a progressive damage of the upper urinary tract after bladder neck reconstruction (this is an unexpected, but not rare condition: 3 cases in our series); during every undiversion procedure (bladder augmentation is nearly mandatory during undiversion in cloacal or bladder exstrophies previously diverted: 4 cases in our series). In our experience, 12 bladder augmentations (in 11 patients, over 85 cases we observed) were done at median age of 8 years and 5 months. Different intestinal segments have been used: the sigmoid colon, the ileo-cecal portion, an ileal tract and the stomach. Follow-up ranges from 11 years to 12 months; until now, we observed few surgical complications: a bowel obstruction in one patient, a left ureteral partial stenosis at level of the anastomosis with the gastric patch wall in another patient and bladder lithiasis in 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of a smooth muscle antagonist on contraction of patched intestinal defects

Growing new intestinal mucosa on serosal patches may potentially increase intestinal surface area but is limited by contraction of the serosal patch. Since this might be related to smooth muscle contraction or altered collagen metabolism, our aim was to determine whether the smooth muscle antagonist thiphenamil inhibits contraction. Fifty rabbits had two 2 x 5-cm full-thickness intestinal defects patched with adjacent cecum. Group I (n = 25) received saline and Group II (n = 25) 0.02 M thiphenamil at 10 cc/hr intraluminally. Animals were sacrificed at 1, 3, 5, 7, and 10 days. Group II had significantly less contraction of the proximal patch until the 10th day after patching (84 +/- 8 vs 66 +/- 20% Day 1, 67 +/- 4 vs 52 +/- 9% Day 5, 42 +/- 14 vs 42 +/- 7% Day 10). Epithelialization of patches was significantly less in Group II animals at 10 days (88 +/- 8 and 86 +/- 11% vs 47 +/- 20 and 50 +/- 16%, P less than 0.05) but crypt cell production rate and villus height were similar. The hydroxyproline content of regenerating tissue increased significantly 7 and 10 days after patching but was similar in the two groups (30.8 +/- 5.9 micrograms/mg tissue Day 10 vs 12.8 +/- 2.8 Day 1). Smooth muscle antagonism by thiphenamil inhibited contraction of serosal patches but had a deleterious effect on epithelialization and mucosal enzyme activity. The transient effect of thiphenamil and the associated increase of hydroxyproline content suggest that collagen may have the predominant role in contraction.

[Ileocecum with appendix in reconstruction of bladder and urethra]

New bladder and urethra were reconstructed by transplanting the ileocecum with appendix and part of the ascending colon. Ileocecal valve was used to prevent urine reflux into the ureters. The appendix and its seromuscular layer were used as "sphincter muscle" to prevent overflow of urine in the cecum. From March, 1988, to October, 1991, 38 cases of carcinoma of bladder were treated by this way. Follow-up for 0.5 to 3.5 years showed that the reconstructed bladder had large capacity, good urination function, no electrolyte disorder, urine reflux and infection of renal pelvis.

Cystoplasty: tubularisation or detubularisation?

Previous studies on substitution or augmentation cystoplasty have highlighted the profusion of surgical techniques available, but there is disagreement as to which is the best. We established an animal model to compare various types of cystoplasties, tubularised and detubularised, using ileum and caecum. Detubularisation did not abolish intrinsic bowel contractions but delayed their onset. No differences were noted in the frequency and amplitude of such contractions after detubularisation or between large and small bowel cystoplasties. Although intravenous urography did not demonstrate any abnormality in upper tract anatomy, a significant number of animals had some functional disturbance of the kidney after cystoplasty demonstrable on isotope renography, irrespective of the surgical technique. It may be possible to prevent these contractions with their associated harmful effects by preventing the bladder volume from building up excessively.

[Improvised reconstruction of the esophagus in concurrent atresia and nonrotation]

In the course of three years, 1985-1987, 21 children with congenital atresia of the oesophagus were operated, incl. four where the oesophagus had to be replaced by the large intestine. Each operation had unforeseen complications, all children survived, however, and are thriving. The authors describe the case of a girl with atresia type Vogt 1 who had moreover hypochromic anaemia, was a twin, premature, hypotrophic and had harelip. During the planned operation when the oesophagus was to be replaced by the large intestine at the age of 8 months, it was, however, revealed that the child has a narrow mesenterium commune with incomplete rotation. They had to perform a completely modific and improvised selection of the portion of the gut for transposition, a part of the ileum and caecum with another portion, as only that portion could be transplanted with preservation of the nurture. The gut could not be stretched because of the short mesentery. The child is now two years after the operation and development corresponds to age.

Ileocecal vaginal construction

In 10 patients, six with previously failed vaginal reconstruction of Mayer-Rokitansky syndrome, two with male pseudohermaphroditism, one with a history of Wertheim-Meigs operation followed by irradiation of the true pelvis, and one with vaginectomy caused by trauma, a neovagina was created out of cecal or ileocecal segments. Advantages of this technique are the excellent blood supply to the ileocecal region and the long vascular pedicle. The supplemental application of terminal ileum for prolongation of the cecal vaginoplasty allows for tensionless anastomosis between the neovagina and the vulva, even in patients with difficult anatomic conditions. A detailed description of the operative technique and indications for ileocecal and cecal vaginoplasty are presented, and the techniques in current use for vaginal replacement are reviewed and discussed.

[Bladder repair using an ileocecal segment]

Subtotal cystectomy and bladder replacement from shorted-out ileocecal segment as well as uretero-ileostomy was carried out in a 25-year-old woman because of a contracted urinary bladder, consequence of a developmental disorder, i.e. colonic-type mucous membrane of the bladder. The patient is continent passes urine every 3-4 hours without residuum.

Effect of liquid diphenoxylate hydrochloride and atropine sulfate (Lomotil) instillations on dynamics and function of continent cecal urinary reservoirs

We assessed the impact of twice daily instillations of 10 ml. liquid diphenoxylate hydrochloride and atropine sulfate (Lomotil) on the dynamics and function of continent urinary reservoirs constructed from intact cecum and ascending colon. Six patients were treated for 1 to 3 weeks at 3 to 8 months postoperatively. The treatments reduced the frequency of spontaneous reservoir contractions, as well as the basal and contraction pressures of the reservoirs. The reservoir capacities were increased modestly. These alterations in reservoir dynamics were accompanied by a decrease in the cramping characteristically associated with reservoir distension and increased intervals between reservoir catheterization. Two patients who had incontinence after initially successful operations regained continence during treatment. No systemic side effects were observed, although dilution of the drug may be required to prevent reservoir irritability. Diphenoxylate hydrochloride and atropine sulfate instillations may prevent acute and possibly long-term pressure-related complications of continent urinary reservoirs constructed from intact cecum and ascending colon.

Ileocecocystoplasty bladder augmentation and renal transplantation

In 4 patients with a small contracted bladder and end stage renal failure ileocecocystoplasty bladder augmentation was done in conjunction with renal transplantation. All 4 patients have stable renal and bladder function 13 to 46 months after transplantation. In carefully selected patients bladder augmentation may be an alternative to urinary diversion.

[The ileocecal vagina]

In 3 patients with vaginal aplasia respectively traumatic vaginal loss a neovagina was created out of the separated ileocecal segment. Advantages of this technique are the excellent blood supply of the ileocecal region and the long vascular pedicle. The additional application of terminal ileum for prolongation of the cecal vaginoplasty allows the tensionless anastomosis between neovagina and vulva even in patients with difficult anatomical conditions. The present paper gives a detailed description of the operative technique and the indications of the ileocecal vaginoplasty. Furthermore the common techniques for vaginal replacement are reviewed and discussed.

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.

Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty

The clinical and urodynamic results of enterocystoplasty were compared in 3 groups of patients in which the intact ileocecal segment (10 patients), tubular sigmoid segment (16) or sigmoid cup-patch segment (8) was used. In all 3 groups the upper urinary tract and renal function improved or remained stable, and the functional bladder capacity increased. All patients experienced involuntary, volume-dependent vesical contractions of comparable intensity 3 months postoperatively. After a mean followup of 19.4 +/- 8.9 months only 12 per cent of the patients with a cup-patch configuration demonstrated volume-dependent contractions, compared to all patients with ileocecal cystoplasty and 94 per cent with sigmoid tubular cystoplasty. The intensity of these contractions was significantly less in the cup-patch configuration group compared to the other groups. Patients with cup-patch cystoplasty achieved a significantly higher rate of urinary continence than those in the other 2 groups. It appears that the sigmoid cup-patch configuration may provide a lower pressure system and better continence compared to the intact ileocecal or tubular sigmoid segment, although the latter techniques have specific applications when confronted with a wide gap between the ureters and bladder or when dilated ureters require anastomosis to the bowel.

Ileocecal segment for temporary and permanent urinary diversion

The ileocecal conduit and its antirefluxing component have functioned well and have prevented many of the upper-tract complications associated with other forms of diversion. Its future role remains to be determined. Today, continent forms of diversion, such as the Koch pouch and the continent ileocecal reservoir, are being studied and are becoming popular. A continent antirefluxing form of urinary diversion is the ideal we are striving to achieve.