100 cases of Mainz pouch: continuing experience and evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.     

Urinary diversion in children and adolescents with neurogenic bladder: the Mainz experience

After failure of conservative treatment of neurogenic bladders (deterioration of the upper urinary tract/incontinence) continent cutaneous diversion has to be considered in those patients with irreparable urethral sphincter defects or those who are unable to perform trans-urethral self-catheterization. In this second part of the study we investigated the long-term safety of using the Mainz pouch I with regard to protecting the upper urinary tracts and to provide urine continence. Between 1985 and 2002, operations to form an ileocaecal pouch with umbilical stoma (Mainz pouch I) were performed on 70 children and adolescents of median age 15.3 years (range 5.7-20 years). During the follow-up period five patients died 2.4-14 years postoperatively of causes not related to urinary diversion. A follow-up period of 8.7 years (0.9-18) was achieved in 65 patients with 118 renal units (RUs). As compared to preoperatively, the upper urinary tracts had remained stable or improved in 113/118 RUs (95.8%) at the latest follow-up. Complete continence was achieved in 97% of patients with a continent cutaneous diversion. Surgical revisions were required for: incontinence of the outlet mechanism in 9%, stoma prolapse in 2%, stoma stenosis in 23%, pouch calculi in 15%, symptomatic reflux in 1%, ureter stenosis in 16% of the RUs with submucosal tunnel and in 3% of the RUs with an extramural tunnel. We conclude that, in patients with irreparable sphincter defect and those who are unable to perform urethral self-catheterization, continent cutaneous urinary diversion with the Mainz pouch I provides a high continence rate with preservation of the upper urinary tracts in the long run. In patients with dilated ureters, the extramural tunnel technique results in a lower complication rate.     

Urinary diversion and orthotopic bladder substitution in children and young adults with neurogenic bladder: a safe option for treatment?

PURPOSE: Combined pharmacotherapy, clean intermittent catheterization and infection prophylaxis is currently the gold standard of treatment for neurogenic bladder. However, as the adolescent gains independence from parental supervision, the intervals of clean intermittent catheterization compliance with medical treatment and regularity of followup examinations may decrease, and neurological and/or orthopedic status may change. This situation sometimes leads to failure of conservative treatment, resulting in incontinence and/or deterioration of the upper urinary tract. A multidisciplinary team was established at our institution 30 years ago to assess all aspects of care for patients with neurogenic bladder, of which urological function is just 1 aspect of the complex problem. Patient desires and essential medical goals, such as preservation of renal function, are considered by this team. An adequate compromise is sought and achieved in some cases by urinary diversion. We investigated the long-term safety of urinary diversion in these patients and its ability to protect the upper urinary tract. MATERIALS AND METHODS: Between 1967 and 1997 urinary diversion was performed in 149 patients with neurogenic bladder. Mean followup was 11.8 years (range 0.8 to 28.5) in 129 cases. Mean patient age at surgery was 12.1 years (range 0.8 to 20). A colonic conduit was created in 59 patients, mainly before the era of clean intermittent catheterization and continent diversion, while orthotopic bladder substitution was performed in 12 and continent urinary diversion (Mainz pouch I) in 58, of whom 50% were wheelchair bound. RESULTS: The upper urinary tract improved or remained stable in 97% of the renal units in patients with a colonic conduit or Mainz pouch I, and in 95% of the renal units in those with orthotopic bladder substitution. All patients with bladder substitution were continent during the day, 1 required occasional pads at night and 7 of 12 performed clean intermittent catheterization. Complete continence was achieved in 98% of those with a continent stoma. CONCLUSIONS: After failure of conservative treatment in patients with neurogenic bladder urinary diversion represents a safe long-term compromise. Daytime and nighttime continence is provided by the Mainz pouch bladder substitution and urinary diversion, while the upper urinary tract is protected by antireflux ureteral implantation.     

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.     

The Mainz pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent urinary diversion

A new technique for fashioning an ileocecal pouch, applicable for both bladder augmentation and continent urinary diversion, is described. A low pressure reservoir is achieved by antimesenteric longitudinal transsection of ileum and cecum and formation of a pouch from the cecum and two ileal loops. The antireflux procedure consists of submucosal tunnel implantation of the ureters into the cecum. Clinical application of the operative technique in 4 cases for bladder augmentation and in another 6 cases for urinary diversion has proven the validity of our functional concept: all patients with Mainz pouch bladder augmentation are completely dry day and night with normal intervals of bladder evacuation. Of the 6 patients with Mainz pouch urinary diversion, 2 rely on a an all alloplastic stomal prosthesis for continence, another 2 have achieved continence with isoperistaltic ileo-ileal invagination, and the remainder are awaiting implantation of a sphincteric device.     

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

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

Colon pouch (Mainz III) for continent urinary diversion

OBJECTIVE: To evaluate the use of a continent cutaneous pouch made exclusively of colon (Mainz pouch III), as excellent results with the Mainz pouch III in irradiated patients suggested that the indication for this type of urinary diversion could be extended. PATIENTS AND METHODS: The outcome of 24 patients with continent cutaneous urinary diversions using colon segments (Mainz pouch III) was investigated retrospectively. Overall, 22 of the patients had a malignant disease and two a benign disease; 16 had a hysterectomy and pelvic exenteration for gynaecological tumours; two men with a rhabdomyosarcoma of the prostate had a radical cystoprostatectomy; one woman had pelvic exenteration for bladder cancer; one man had a simultaneous rectum resection due to infiltrating rectal cancer, and another a left nephrectomy with cystectomy for concomitant kidney and bladder tumour. Benign indications were hyper-reflexive bladder after polytrauma and two cases of neurogenic bladder dysfunction. Eighteen patients had radiotherapy (32-48 Gy) before the urinary diversion. RESULTS: The mean (range) follow-up was 35 (12-65) months. The mean pouch capacity was 293.8 mL. Three patients died during the follow-up (two from disease progression and one suicide); 20 patients were fully continent, four with reduced pouch capacity (<300 mL) had slight incontinence and are wearing a protective pad (band-aid at the umbilicus). All patients use intermittent self-catheterization (mean catheterization frequency 6.8/day, range 6-12). Complications related to the pouch were one outlet stenosis that required revision. Postoperative pouchograms showed asymptomatic reflux in four patients. None of the patients developed metabolic acidosis or diarrhoea. CONCLUSIONS: The Mainz pouch III is an alternative to other types of continent urinary diversion.     

Preliminary Report of a Modified Continent Appendix Stoma in a Sigmoid Urinary Reservoir Pouch

Background:
The application of an appendix stoma in a Mainz urinary reservoir pouch is an established procedure and assures good continence. We modified this method for use with a sigmoid pouch.
Methods:
In each of 3 men with bladder carcinoma, an appendix with a blood supply was prepared and anastomosed to the detubularized sigmoid pouch with a 3-cm submucosal tunnel.
Results:
In all 3 patients, this procedure was performed successfully, and the pouch was completely continent. Self-catheterization could be performed without difficulty by 2 patients, and with slight resistance in the remaining patient. The patients are satisfied with their quality of life.
Conclusions:
We conclude, based on our findings and these preliminary observations, that this procedure is a potentially good alternative for the placement of continent stoma in continent urinary reservoir surgery.     

Blasenaugmentation und -ersatz bei Kindern und Jugendlichen

Background

In children and adolescents, the indication for continent urinary diversion or bladder augmentation is rare. Today, for most patients with a neurogenic bladder, conservative treatment (clean intermittent catheterization [CIC] and pharmacotherapy) is the method of choice, while for patients with bladder exstrophy-epispadias complex (BEEC), primary reconstruction is recommended. Only after failure of conservative treatment or primary reconstruction should bladder augmentation or urinary diversion be considered. Other rare indications include patients with malignant tumor involving the lower urinary tract (e.?g., rhabdomyosarcoma).

Discussion

In patients with a hyperreflexive, small capacity, and/or low compliance bladder with a normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. For those unable to perform CIC via the urethra, a continent cutaneous stoma should be offered. In patients with irreparable sphincter defects and normal renal function, a continent cutaneous diversion is an option and in those with a competent anal sphincter the rectosigmoid pouch can be offered.

Conclusion

In this review, surgical options with their advantages and disadvantages are discussed.

     

Long-term results of ileocecal continent urinary diversion in patients treated with and without previous pelvic irradiation

PURPOSE: Patients who receive pelvic irradiation may require urinary diversion to manage complications resulting from progressive malignancy or radiotherapy. The choice of urinary diversion is an important issue and remains controversial. We characterized the long-term outcome of urinary diversion with a continent ileocecal reservoir in patients who received pelvic irradiation versus those who underwent urinary diversion without previous irradiation. MATERIALS AND METHODS: Continent urinary diversion with an ileocecal reservoir (Mainz pouch 1) was performed in 36 irradiated patients in a 9-year period. Morbidity, mortality, the reoperative rate and parameters associated with the surgical procedure were determined at a median followup of 57 months. Results were compared with those in 385 nonirradiated patients who received the same type of continent diversion after cystectomy for bladder cancer. RESULTS: Irradiated patients had a significantly higher rate of serious complications after ileocecal urinary diversion than nonirradiated controls. Continence mechanism failure occurred in 25% of patients in the irradiated group and 5.7% in nonirradiated patients, stomal complications were noted in 38.8% and 10.6%, and ureteral complications developed in 22.2% and 6.5%, respectively. CONCLUSIONS: In patients who have received pelvic radiotherapy, ileocecal Mainz pouch 1 continent urinary diversion is associated with a high rate of serious complications and should be avoided.     

Bowel-flap tubes for continent cutaneous urinary diversion

The appendix stoma for Mainz-pouch continent cutaneous urinary diversion is reliable and easy to perform. Two new continence mechanisms were developed for patients in whom the appendix is not available or usable. A seromuscular tube was used in 27 patients (12 women, 15 men, mean age 63 years) and a bowel-wall tube was used in 24 patients (13 women, 11 men, mean age 57 years) as the continence mechanism for continent cutaneous urinary diversion. At a mean follow-up of 32 months (range 2–68 months), 93% of patients with a seromuscular tube and 92% of those with a bowel-wall tube are continent day and night. Four early and nine late stoma-specific complications have occurred, requiring seven open surgical revisions. Thus far, both techniques have fulfilled all requirements as continence mechanisms for continent cutaneous urinary diversion. However, the reliability, advantages, and disadvantages of these techniques have to be confirmed in further long-term studies.     

Long-term follow-up of submucosal tunnel and serosa-lined extramural tunnel ureter implantation in ileocaecal continent cutaneous urinary diversion (Mainz pouch I)

OBJECTIVE: To assess upper urinary tract complications and renal function in patients with a submucosal tunnel and serosa-lined extramural tunnel ureter implantation during the long-term follow-up of ileocaecal continent cutaneous urinary diversion (Mainz pouch I). PATIENTS AND METHODS: In all, 458 patients who had diversion with the ileocaecal pouch were analysed in a retrospective follow-up study. Uretero-intestinal implantation was done using a submucosal tunnel (ST) in 809 reno-ureteric units (RUs) and by the serosa-lined extramural tunnel (ET) technique in 74 RUs. The median age of the patients at the time of surgery was 47.1 years, and the median follow-up was 89.0 months. RESULTS: For the ST, there was anastomotic obstruction in 59 RUs (7.3%) at a median of 16.8 months after diversion; the obstruction-free intervals at 1, 5 and 10 years were 97%, 93% and 91%, respectively. Obstruction rates were 13.9% for previously dilated upper tracts and 17.1% in patients with a neurogenic bladder. Serum creatinine levels were < or =1.6 mg/dL in 97% of the patients at the latest follow-up. For ET, there was anastomotic obstruction in three RUs (4.1%) at a median of 17.2 months after diversion. Obstruction-free intervals at 1, 5 and 10 years were 100%, 96% and 96%. Preoperative dilation of the upper tracts did not reduce the obstruction rate (3.1%), but it was 7.1% in patients with a neurogenic bladder. Serum creatinine levels were < or =1.6 mg/dL in 98% of the patients at the latest follow-up. CONCLUSIONS: The ET gives lower obstruction rates than the ST, especially when upper tracts are dilated and in patients with a neurogenic bladder. Renal function remained stable with both techniques in the long term.     

EARLY CLINICAL EXPERIENCE WITH CONTINENT URINARY DIVERSION

Background : Alternatives to cutaneous diversion have included continent urinary diversion and replacement cystoplasty. Fiveyear experience with continent diversion is reported. Methods : Between 1989 and 1994. 29 patients underwent continent urinary diversion. Of these, 24 patients underwent Indiana pouch procedures and five patients had a Mitrofanoff-type procedure. All have now been followed up for at least 12 months. Results : The continence rate for the Indiana pouch group was 23/24 (96%) and the mean capacity was 648 mL (range 300–1400). There were nine (37.5%) early postoperative complications, only three of which (12.5%) required surgical revision. The late complication rate was 35.5% (7/22), and 18.2% (4/22) of the patients underwent re-operation. Stomal stenosis occurred in two patients in whom the stoma was situated in the right iliac fossa, whereas all 12 stomas sited at the umbilicus had no stomal problem. Four of the five patients having Mitrofanoff procedures were continent, but these patients had higher rates of early and late complications. Conclusions : From this experience, the Indiana pouch urinary diversion appears to be superior to the Mitrofanoff procedure when continent diversion is indicated. An umbilical stoma site is optimal.     

Surgical complications of urinary diversion

We comprehensively reviewed the published literature on urinary diversion, specifically examining the surgical complications associated with conduit, continent cutaneous diversion and orthotopic urinary diversion. Appropriate patient selection and adherence to proper surgical technique are of paramount importance in preventing surgical complications of urinary diversion. Complications can be broadly divided into those related to bowel, conduit or reservoir, stoma and ureterointestinal anastomosis. Each type of urinary diversion has unique characteristics predisposing to certain surgical complications as well as similarities related to intestinal surgery. With conduit urinary diversions, problems related to the stoma such as stomal stenosis and parastomal hernia present not uncommonly. With continent cutaneous diversion, complications include difficulties with catheterizing of the efferent limb, formation of pouch stones and urinary leakage. With orthotopic neobladder formation, voiding dysfunction manifesting as incontinence or hypercontinence may present unique challenges in patient management. Increased surgical experience and technical refinements have led to decreasing surgical complication rates for all types of diversion in contemporary series.     

Rectosigmoid pouch (Mainz Pouch II) in children

PURPOSE: Continent anal urinary diversion is a therapeutic option in bladder exstrophy. We report our long-term results with the rectosigmoid pouch (Mainz pouch II), a modification of the classic ureterosigmoidostomy. MATERIALS AND METHODS: A total of 38 children with a mean age of 5 years (range 0.5 to 17) underwent a Mainz pouch II procedure between 1991 and 2004. Most patients (33) had bladder exstrophy or incontinent epispadias. In 14 children (37%) urinary diversion was performed after failed primary reconstruction. In 6 children conversion was performed from an incontinent type of urinary diversion. Renal function, continence and metabolic changes were analyzed. A total of 35 children were followed for a mean of 112 months (range 5 to 147). RESULTS: All children were continent during the daytime but 3 (8.6%) suffered from nighttime incontinence requiring pads. With respect to the upper urinary tract, 6 children (15.8%) had development of pyelonephritis, mostly with stenosis of the ureterointestinal anastomosis. Reimplantation of the ureter was required in 10 of 69 RU (14.5%), of which 7 (10.1%) were due to ureterointestinal stenosis and 3 (4.3%) were due to reflux. Serum creatinine was within normal limits in all children. During followup acid-base balance was monitored, and early alkali supplementation was initiated in 24 of 35 children (69%) when the base excess was less than -2.5 mmol/l. One child had development of clinical acidosis requiring hospitalization. After followup of more than 10 years annual rectosigmoidoscopy was performed in 16 children/young adults without pathological findings. CONCLUSIONS: The Mainz pouch II procedure for children with genitourinary anomalies promises excellent continence rates. However, periodic followup studies are important to check the upper urinary tract and prevent metabolic acidosis. Due to the risk of malignancy at the ureterointestinal anastomosis, endoscopy should be performed annually beginning at postoperative year 10. The Mainz pouch II procedure is safe in the long term. Without stoma, appliance or catheterization this type of continent urinary diversion is specifically suitable for children.     

Continent cutaneous urinary diversion in children: experience with Charleston pouch I

PURPOSE: Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. MATERIALS AND METHODS: A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long-term functional status. RESULTS: Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory. CONCLUSIONS: Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable.     

Early experience with an ileocolic bladder substitution (Mainz pouch) in 11 cases

In the last decade, many continent urinary diversions have been developed for the cystectomy patients. Mainz pouch, which seems to be a sophisticated one without using an alloplastic prosthesis, was adopted in our clinic. We preliminarily report our result in 11 patients who underwent a Mainz pouch procedure in the last 2 years: 1 for bladder augmentation, 5 for total bladder substitution after cystoprostatectomy and 5 (including 2 females) for continent urinary diversion. The mean age of them was 54 years old and the follow up periods ranged from 6 to 24 months. The antimesenteric longitudinal incision of the ileum and cecum and their sutures were performed similarly to the usual detubularized intestinal pouch. The ureteral reimplantation to the colonic segment was accomplished by the submucosal tunnel method. Although the ureteral hiatus was initially positioned at the anal edge of the colon, a new hiatal creation by stabbing the more oral portion of the colon according to the Goodwin's ureterocolic anastomosis was subsequently employed to avoid the trouble of closure of this portion. When the urethral anastomosis was achieved by 4-5 interrupted sutures between the most dependent portion of the cecum and the urethral stump after cystoprostatectomy, the mucosa was everted to the colonic serosa to prevent the stricture. The continent stoma was created by an intussusception of the proximal ileum, which was stabilized by the seromuscular stripping and 2-3 rows of external metal staples. Complication of the alimentary system occurred in 6 of 11 cases (55%), though they were successfully treated by an appropriate conservative management except one who suffered an ileostomy and nephrostomy because of severe panperitonitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Continent Catheterizable Pouches for Urinary Diversion

ContextCatheterizable pouches represent a good alternative in patients with continent urinary diversion (CUD) when neobladder reconstruction is contraindicated.ObjectiveThis review summarizes the different techniques, indications and contraindications, functional results, outcomes, and complications of continent catheterizable pouches.Evidence acquisitionA PubMed Medline database research was performed, identifying publications of CUD using a catheterizable pouch after radical cystectomy for treatment of bladder cancer.Evidence synthesisIn some patients with infiltrating bladder cancer, a continent cutaneous diversion is indicated when the urethra is involved. Some authors also recommend a catheterizable pouch in patients with carcinoma in situ and in female patients. Different bowel segments have been used to build the reservoir: ileocecum, colon, and ileum. Especially in patients with previous pelvic irradiation, the transverse colonic pouch represents a feasible urinary diversion. Reservoirs with high volume and low pressures can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. The need for antirefluxive ureteral implantation is questioned and there is a trend towards refluxive implantation. Simple and reproducible techniques (eg, appendix stoma, flap-valve T mechanism, serosa-lined extramural tunnel) have been developed for creation of a continence mechanism. Satisfactory continence rates >90% are reported for most techniques and quality of life is comparable with orthotopic continent diversion. The overall incidence of complications varies from 28–57%. However, most urinary tract complications (eg, pouch calculi, ureteroenteric anastomotic strictures, efferent limb strictures, mucous retention) are corrected by endoscopic means. Open surgery is mainly performed in strictures of the afferent limb.ConclusionsCutaneous catheterizable pouches represent an established and good opportunity for CUD after radical cystectomy for treatment of bladder cancer. Most of the problems that occurred during creation of continent cutaneous reservoirs in the past have been solved. Long-term data of different surgical techniques show excellent continence and acceptable complication rates.     

Ileal T-pouch as a urinary continent cutaneous diversion: clinical and urodynamic evaluation

OBJECTIVE: To report the functional results of continent cutaneous urinary diversion with ileum, using the serous-lined extramural valve and Mitrofanoff procedure for the continence mechanism. PATIENTS AND METHODS: From April 1999 to October 2001, 18 patients (mean age 68 years) underwent radical cystectomy for invasive bladder cancer involving the bladder neck, urethra or prostate; they then had an ileal continent cutaneous T pouch constructed. The mean (range) follow-up was 12 (4-20) months. The first five patients had reconstructions using the original orthotopic T-pouch configuration, but in subsequent patients the technique was simplified, reducing the ileal segments. The ureteric-intestinal anastomosis was made using a split-cuff nipple technique. RESULTS: All patients were continent day and night, and there were no late complications. All cutaneous continent T pouches had a good capacity and low pressure, with no urinary reflux. No catheterization difficulties were reported and the evacuation intervals were approximately 4 h. CONCLUSIONS: This ileal cutaneous continent diversion is a versatile technique; the T-valve can be used successfully as a continent mechanism, ensuring continence day and night. The simplified technique maintains a reservoir of good capacity and compliance, thus preserving approximately 13 cm of ileal tract. The ureteric intestinal anastomosis by the split-cuff nipple technique is suitable in undilated and peristaltic ureters.     

The Mainz pouch. Ileocecal reservoir, Mainz pouch

The surgical technique for creation of the Mainz-pouch uses 12cm of cecum and ascending colon and 2 ileal loops of the same length for construction of an urinary reservoir, which has proven to be applicable for bladder augmentation, bladder substitution as well as for continent urinary diversion. For the creation of a continent nipple in urinary diversion 6cm of ileum in addition are necessary. As a modification we use the non-infected submucosal imbedded appendix as continence mechanism. Since 1986 a total of 247 patients underwent a Mainz-pouch procedure: 54 for bladder augmentation, 27 for bladder substitution and 166 for continent diversion. The appendix as continence mechanism was used in 30. Postoperative mortality rested under 1%, early complications have been observed in 4.4% and late complications in 13.7% (mean follow-up of 35 months). In the bladder augmentation group 52 patients are completely dry, 2 patients have urge and frequency and 5 patients are on intermittent self catheterisation to avoid residual urine. In the bladder substitution group all patients are continent at daytime. At nighttime 3 patients have leakage if they don't empty their bladder all 4 hours. In the urinary diversion group all but 3 are completely dry and are on intermittent catheterization. The main problem of our initial series was prolapse of the continent nipple which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve or by using the submucosal imbedded appendix.