Malignancy associated with the use of intestinal segments in the urinary tract

Use of intestinal segments for urinary tract reconstruction has become widespread. In these patients, urologists are increasingly encountering malignancies that may be a direct result of this altered milieu. This review attempts to summarize the current literature on cancer in patients with intestinal segments in their urinary tracts. Although the exact etiology for this increased risk of malignancy is still unclear, several theories have been proposed. Many investigators now recommend annual screening in patients who have intestinal segments in contact with urine beginning 10 years after the initial surgery.     

Management of the Recurrent Male Urethral Stricture

Urethral stricture disease negatively impacts quality of life and leads to significant urologic pathology including lower urinary tract symptoms, recurrent urinary tract infections, and potentially more severe sequelae such as detrusor dysfunction, renal failure, urethral carcinoma, and Fournier’s gangrene. Open urethral reconstruction is considered a durable and definitive treatment for urethral stricture with lifetime success rates ranging from 75–100 %; however, strictures do recur up to 10 years after surgery. Recurrence rates vary by repair type. There also is no agreed-upon modality for recurrence surveillance, but there are many modalities with varying degrees of invasiveness. Recurrent strictures may be managed endoscopically or via open repair. We review stricture recurrence rates, surveillance modalities, risk factors, and management options.     

Urinary diversion: ileal conduit to neobladder

PURPOSE: The goals of urinary diversion have evolved from simply diverting the urine through a conduit to orthotopic reconstruction, which provides a safe and continent means to store and eliminate urine with efforts to provide an improved quality of life. We address meaningful points that may help optimize clinical results in patients with an orthotopic bladder substitute. MATERIALS AND METHODS: The review involved an objective evaluation of the basic science literature of functional, structural and physiological characteristics of gastrointestinal tissue as a substitute for bladder. Potential problems that may be associated with particular parts of the gut for use in reconstruction are discussed. We also summarize the clinical results and complications of orthotopic reconstruction. RESULTS: In the last 10 years the paradigm for choosing urinary diversion has changed substantially: In 2002 all patients undergoing cystectomy were neobladder candidates. It is critically important to understand the phenomenon of maturation. The motor and pharmacological response of the implanted gut changes dramatically toward that of the bladder. Structural and ultrastructural changes in the ileal mucosa lead to a primitive epithelium similar to urothelium. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is more influenced by underlying disease than by diversion. Complications of neobladders are actually similar to or lower than the true rates after conduit formation, in contrast to the popular view that conduits are simple and safe. Some degree of nocturnal leakage is a consistent finding in most reports despite a technically sound operation. The precise pathogenesis of urinary retention requiring clean intermittent catheterization remains uncertain. There are new complications, such as neobladder rupture and mucous tamponade. CONCLUSIONS: Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.     

Primary urethral reconstruction: the cost minimized approach to the bulbous urethral stricture

PURPOSE: Treatment for urethral stricture disease often requires a choice between readily available direct vision internal urethrotomy (DVIU) and highly efficacious but more technically complex open urethral reconstruction. Using the short segment bulbous urethral stricture as a model, we determined which strategy is less costly. MATERIALS AND METHODS: The costs of DVIU and open urethral reconstruction with stricture excision and primary anastomosis for a 2 cm bulbous urethral stricture were compared using a cost minimization decision analysis model. Clinical probability estimates for the DVIU treatment arm were the risk of bleeding, urinary tract infection and the risk of stricture recurrence. Estimates for the primary urethral reconstruction strategy were the risk of wound complications, complications of exaggerated lithotomy and the risk of treatment failure. Direct third party payer costs were determined in 2002 United States dollars. RESULTS: The model predicted that treatment with DVIU was more costly (17,747 dollars per patient) than immediate open urethral reconstruction (16,444 dollars per patient). This yielded an incremental cost savings of $1,304 per patient, favoring urethral reconstruction. Sensitivity analysis revealed that primary treatment with urethroplasty was economically advantageous within the range of clinically relevant events. Treatment with DVIU became more favorable when the long-term risk of stricture recurrence after DVIU was less than 60%. CONCLUSIONS: Treatment for short segment bulbous urethral strictures with primary reconstruction is less costly than treatment with DVIU. From a fiscal standpoint urethral reconstruction should be considered over DVIU in the majority of clinical circumstances.     

Missed diagnosis of complete urethral transection after sling: the case for translabial ultrasound

ABSTRACT: Patients with complications of urethral sling placement for stress urinary incontinence are often treated for recurrent symptoms for years after initial reassuring evaluation. Translabial ultrasound is a noninvasive modality with minimal risks that can clearly diagnose urethral mesh complications. We present a 47-year-old premenopausal woman referred for treatment of urethral stricture and diverticulum 8 years after mesh sling placement. The diagnosis was made at an outside institution by voiding cystourethrogram and cystoscopy. However, translabial ultrasound confirmed the diagnosis of complete urethral transection, and the patient underwent a complex urethral reconstruction. Ultrasound should be used to evaluate patients with a history of urethral sling and persistent lower urinary tract symptoms. Referral to a center with advanced pelvic reconstruction services may be required.     

The urological care and outcome of pregnancy after urinary tract reconstruction

OBJECTIVE: To assess the obstetric and urological outcomes during and after pregnancy following urinary tract reconstruction, as pregnancies after such surgery can have a significant effect on the function of the reconstructed urinary tract, and the reconstruction can significantly affect the delivery of the fetus. PATIENTS AND METHODS: We retrospectively reviewed the obstetric and urological history of 11 patients (12 pregnancies; 10 singletons and one twin) with previous urinary reconstruction, delivered between 1989 and 2003. Antepartum and postpartum urological function and obstetric outcomes were investigated. RESULTS: All the patients had some difficulty with clean intermittent catheterization (CIC) during pregnancy, and four needed continuous indwelling catheters. During pregnancy 10 women had several bladder infections and all received antibiotic suppression. There were eight Caesarean sections, two vaginal deliveries and one combined delivery. Six Caesareans were elective and three were emergent. The use of CIC returned to normal in all patients after delivery. CONCLUSIONS: Women with a urinary reconstruction can have successful pregnancies. The complexity of the surgery and the concern for possible emergency Caesarean section resulted in most patients having an elective Caesarean delivery before term. Antibiotic prophylaxis is recommended and patients may require indwelling dwelling catheters while pregnant but normal CIC can be resumed after delivery.     

Bowel function after urinary diversion

Removal of bowel segments for the purposes of urinary diversion may have a significant effect on bowel function. The remaining bowel may not be able to fulfill its normal role, resulting in not only malabsorption syndromes, but also dysfunctional defecation. Provided, however, care is taken in selecting patients and the bowel segments for such procedures and follow-up is vigilant, complications should be minimal. There appears to be a significant risk of developing symptoms of increased bowel frequency following urinary diversion and reconstruction. Patients need to be counselled regarding this prior to surgery, however, further data needs to be collected to accurately quantify the risk and the effect it has on quality of life.     

Management of the devastated posterior urethra and bladder neck: refractory incontinence and stenosis

Stricture of the proximal urethra following treatment for prostate cancer occurs in an estimated 1-8% of patients. Following prostatectomy, urethral reconstruction is feasible in many patients. However, in those patients with prior radiation therapy (RT), failed reconstruction, refractory incontinence or multiple comorbidities, reconstruction may not be feasible. The purpose of this article is to review the evaluation and management options for patients who are not candidates for reconstruction of the posterior urethra and require urinary diversion. Patient evaluation should result in the decision whether reconstruction is feasible. In our experience, risk factors for failed reconstruction include prior radiation and multiple failed endoscopic treatments. Pre-operative cystoscopy is an essential part of the evaluations to identify tissue necrosis, dystrophic calcification, or tumor in the urethra, prostate and/or bladder. If urethral reconstruction is not feasible it is imperative to discuss options for urine diversion with the patient. Treatment options include simple catheter diversion, urethral ligation, and both bladder preserving and non-preserving diversion. Surgical management should address both the bladder and the bladder outlet. This can be accomplished from a perineal, abdominal or abdomino-perineal approach. The devastated bladder outlet is a challenging problem to treat. Typically, patients undergo multiple procedures in an attempt to restore urethral continuity and continence. For the small subset who fails reconstruction, urinary diversion provides a definitive, “end-stage” treatment resulting in improved quality of life.     

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 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.     

Urinary tract infection after vaginal repair surgery

Catheter drainage of the bladder is commonly used after vaginal repair surgery to avoid urinary retention. Catheter use is the main risk factor for postoperative urinary tract infection, and the risk increases with the duration of catheterization. The risk is reduced with closed collecting systems and with suprapubic drainage. Prophylactic use of antimicrobial drugs may also reduce the risk, but the most important point is to keep the catheter time down. The article reviews the various aspects of asymptomatic bacteriuria and urinary tract infection after vaginal repair surgery and provides recommendations.     

Onkologische Beckenchirurgie unter urologischen Gesichtspunkten

The aim of the treatment of invasive bladder cancer with radical cystectomy and subsequent urinary diversion is to combine a safe oncological procedure with a satisfactory quality of life. Radical cystectomy is the treatment of choice for all patients with recurrent or multifocal high grade T1 bladder cancer, T1 tumors with high risk of progression, failure of Bacillus Calmette-Guérin treatment and muscle-invasive bladder cancer. Radical cystectomy offers excellent recurrence-free and cancer-specific survival rates as well as local tumor control in patients with organ-confined and node-negative diseases. Tumor control in non-organ-confined tumors is still satisfactory with long term recurrence-free survival (RFS) rates of about 50%. Nerve-sparing cystectomy is of importance for lower urinary tract function, including continence rates after orthotopic urinary diversion and for sexual function in males and females. Orthotopic urinary reconstruction using a neobladder achieves good continence rates. Overall quality of life after radical cystectomy remains good in most patients irrespective of the type of urinary diversion.     

Preventing reservoir calculi after augmentation cystoplasty and continent urinary diversion: the influence of an irrigation protocol

OBJECTIVE: To evaluate the influence of an irrigation protocol in preventing reservoir calculi forming after augmentation cystoplasty and continent urinary diversion. PATIENTS AND METHODS: Between 1985 and 1995, 91 patients had an augmentation cystoplasty and/or continent urinary diversion (group 1; 54 females and 37 males, mean age 11.1 years, range 1-31); these patients were not routinely instructed to use irrigation after surgery. The segments used included ileum (44), colon (36), stomach (eight) and ureter (three). Between 1995 and 2000, 42 patients (group 2) underwent urinary reconstruction (22 females and 20 males, mean age 14.8 years, range 4-27), the segment used being ileum (30), colon (five), ureter (five) and stomach (two) but in contrast to group 1 they then were placed on a standard prophylactic irrigation protocol. The occurrence of stones in the reservoir was then assessed. RESULTS: Thirty-nine of the 91 patients (42.8%) in group 1 presented with reservoir calculi after reconstruction and 22 had several episodes. The mean time to presentation was 30 months. The incidence of stone formation by underlying diagnosis included: myelomeningocele, 32/48 (66%), exstrophy five/25 (25%), posterior urethral valves two/20 (10%) and rhabdomyosarcoma, none of three. Fifty of the 91 patients had an abdominal stoma, with stone formation in 33 (66%), while 41 used the native urethra, with stone formation in six (15%). Three (7%) of the 42 patients in group 2 developed reservoir calculi after reconstruction, two in patients with myelomeningocele and one in a trauma patient who had residual bone spicules in the bladder; the mean time to presentation was 26.5 months. CONCLUSIONS: These data suggest that the irrigation protocol used in group 2 significantly reduced the number of reservoir calculi after urinary tract reconstruction when bowel was used as part of the reconstruction (43% vs. 7%). The most calculi in both groups were in immobile patients with sensory impairment. Also, patients with an abdominal stoma had a greater risk of reservoir calculi (66%) than those using the native urethra (15%).     

Update of urethra-sparing approaches in cystectomy in women

Summary The emerging experience in urethra-sparing cystectomy in women undergoing subsequent orthotopic lower-urinary-tract reconstruction with regard to the anatomy of the remnant urethra, patient selection, refinements of the surgical technique, the patients' outcome with respect to the underlying disease, the risk for tumor recurrence, and postoperative urodynamics are the main focus of this report. In the present study, 30 carefully selected female patients underwent orthotopic reconstruction of the lower urinary tract. Surgical variations emerging from the first learning curve, including nerve-sparing anterior exenteration, vaginal reconstruction, omental support of the neobladder floor, and ureterointestinal anastomosis, were applied in 21 patients with lower-urinary-tract reconstruction. Of 24 patients followed for more than 6 months, 21 (87.5%) are continent at daytime, 19 (79%) have nocturnal continence, and only 1 (4%) requires self-catheterization; 3 patients with urinary retention were successfully treated for obstructed ileal valves. After a follow-up period of 2–41 (mean 15.4) months one patient each developed local recurrence (uterine adenosarcoma) after 13 months and distant metastasis transitional-cell cancer of the bladder after 3 months; all other patients are currently free of disease. Urethra-sparing surgery has established itself in selected women with bladder cancer. Refinements in the technique of radical cystectomy and orthotopic creation of a neobladder to the urethra may improve the continence, spontaneous micturition, and surgical oncological outcome of these patients.     

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PURPOSE: As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. RESULTS: Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. CONCLUSIONS: Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.     

The frequency of histopathological abnormalities in incidental appendectomy in urological patients: the implications for incorporation of the appendix in urinary tract reconstruction.

In 1980 Mitrofanoff described the use of the isolated appendix as an intermittent catheterization route to empty a continent urinary reservoir. The procedure was popularized and numerous variations on the same principle were reported. Presence of histopathological abnormalities in the appendix may limit its suitability for reconstructive purposes. We studied the frequency of incidental histopathological abnormalities in appendixes removed electively in 122 urological patients during a radical pelvic operation. The implications for incorporation of the appendix in urinary tract reconstruction are evaluated. A total of 38 patients (31.1%) had notable histological abnormalities of the appendix: 35 had fibrous obliteration of the lumen, 2 had carcinoid tumor and 1 had a mucocele of the appendix. The rate of abnormal appendixes was significantly higher in elderly patients (more than 70 years old). Incidental pathology of the appendix is a frequent finding that may affect the immediate results and the late outcome of urinary tract reconstruction using the appendix. When such strategy of urinary tract reconstruction is considered, potential histopathological abnormalities should be anticipated. The patients should be informed and aware of possible unexpected changes in the preplanned procedure, while the surgeon must be familiar with these alternative reconstructive methods.     

Treatment of bladder exstrophy. Reconstruction or urinary diversion]

Bladder exstrophy is seen in 1 of 30,000-40,000 live births, and is seldom treated in many urological departments. Treatment options for children with exstrophy are upper urinary tract diversion or reconstruction of the bladder and plastic surgery of the bladder neck to gain urinary continence by the age of 4-7 years. Historical reviews report continence rates of 10-30% after a staged approach with primary reconstruction and secondary bladder neck repair. This formerly meant upper urinary tract diversion as a third stage in 70-90%. Multiple operative procedures could be avoided when primary diversion was done. The best results were reported following antirefluxive implantation of ureters into the sigmoid colon (ureterosigmoidostomy). In boys, the base of the bladder was removed, leaving a small residual bladder which together with the reconstructed epispadias served as a "seminal tract". Total removal of the bladder was performed in girls. Long-term follow up of upper urinary tract diversion showed disturbances of serum electrolytes, urinary tract infections and stone formation, and after ureterosigmoidostomies an increased rate of colon carcinomas was documented. These results led to renewed interest in reconstruction. The technique of bladder neck reconstruction was changed, resulting in a higher rate of late urinary continence: augmentation cystoplasties, clean intermittent catheterization and the artificial sphincter help to achieve a continence rate of more than 90%. This goal was reached only after multiple operations and without knowledge of the long-term sequelae of augmentation cystoplasties. The years to come will show whether new concepts of ureterosigmoidotomies, such as the sigma-rectum pouch, will be preferable, or a late urinary tract diversion after failed reconstruction. Most centers are now agreed that primary reconstruction of bladder exstrophy should be attempted in the newborn child.     

Adjustable continence therapy for the treatment of urinary incontinence after radical cystectomy and orthotopic neobladder in women

The management of urinary incontinence after radical cystectomy and orthotopic neobladder reconstruction is a very challenging situation. We report on a patient that developed a neobladder–urethro–vaginal fistula successfully treated but resulting in severe urinary incontinence that was cured after the periurethral insertion of adjustable silicone balloons.     

Primary neuroendocrine carcinoma of the urethra

We present a rare case of a primary neuroendocrine carcinoma of the urethra after radical cystectomy and orthotopic urinary reconstruction for transitional cell carcinoma of the urinary bladder.     

Surgery for invasive bladder tumors: technique and outcome

The operative management of invasive transitional cell carcinoma has advanced significantly in the past year, particularly with respect to continent urinary diversion. The long term safety and efficacy of this form of urinary reconstruction is being established in terms of both operative and metabolic complications. The availability of continent diversion can decrease the interval to cystectomy and therefore may impact positively on survival. It has also been shown that continent diversion can safely be offered to patients at high risk for local recurrence. The importance of urethral sensory threshold on postoperative continence is being established. These findings and others continue to enhance the survival and quality of life of patients undergoing cystectomy for invasive bladder cancer.     

Orthotopic ileocolic neobladder reconstruction following radical cystectomy: history, technique and results of the Johns Hopkins experience, 1986-1998

Reconstruction of the lower urinary tract using intestinal segments has become a standard component of the treatment of patients with bladder cancer. A variety of intestinal segments can be successfully used for this purpose. Between 1986 and 1998, the authors have used a composite ileocolic segment for neobladder reconstruction in patients desiring orthotopic reconstruction of the lower urinary tract. The early and late complication rates are 11% and 30%, respectively. Forty-five percent of men are potent postoperatively. Seventy-six percent of patients are continent both day and night. Three percent of our patients experience nocturnal enuresis, and 15% perform clean intermittent catheterization. Bothersome daytime stress urinary incontinence occurs in 3% of patients evaluated for this report. Although no contemporary studies demonstrate the superiority of a particular bowel segment for lower urinary tract reconstruction, the authors' long-term experience with the ileocolic neobladder suggests that this composite segment provides excellent results for lower urinary tract reconstruction after radical cystectomy.