Laparoscopic radical cystectomy with ileal conduit urinary diversion

OBJECTIVE: To report on the surgical technique of laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion. METHODS: A 79 years old man with histologically proven transitional cell carcinoma of the bladder stageT 2b NxMx underwent a laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion. The cystoprostatectomy was performed with laparoscopic technique. Creation of the ileal conduit and the stoma were performed through a mini-laparotomy. Specific technical aspects are described. RESULTS: The procedure was completed laparoscopically. The creation of the ileal conduit and stoma were performed through a mini-laparotomy. The surgical margins were free of disease. There were no intra or postoperative complications. The operative time was 290 min. Estimated blood loss was 380 mL. Hospital stay was 6 days. At 3 months there is no evidence of disease. The patient resumed his normal activity. CONCLUSION: Laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion is a feasible option for organ-confined carcinoma of the bladder. The procedure is technically demanding and should be performed in centers with large experience in laparoscopic surgery.     

Bricker's ileal conduit urinary diversion with a simple non-refluxing uretero ileal anastomosis

Fifty consecutive patients had ileal conduits constructed with a technically and quick simple antireflux ureteroileal anastomosis. Complications related to the ureteral implantation were studied retrospectively, and at follow-up (8 months-12 years later, median 3 years) conduit dysfunction and ureteral reflux were assessed in 18 patients out of the 25 patients who were still alive. Early complications and signs of late upper urinary tract deterioration were similar to those found after other operative techniques had been used. One patient had a postoperative urinary leak from the uretero ileal anastomosis. which was treated successfully by two weeks drainage. Hydronephrosis deteriorated in 18 (26%) of the renal units, remained unchanged in 39 (57%) and improved in 11 (16%). Increases in plasma creatinine concentrations up to 200 mumol/l were found in eight patients, and in one patient it increased from 300 to 420 mumol/l. Partial ureteral reflux was present in three (2 patients) of 33 ureters studied and minimal conduit dysfunction was found in 8 patients. In conclusion we find this method of urinary diversion to be quick, easy, and safe.     

Comparison of ileal conduit and transureteroureterostomy with ureterocutaneostomy urinary diversion

INTRODUCTION: We compare the postoperative early and late complications of patients who had undergone ileal conduit (IC) urinary diversion and transureteroureterostomy (TUU) with ureterocutaneostomy (UC) urinary diversion during the same interval and by the same surgeons. MATERIALS AND METHODS: Between 1992 and 2004, we performed TUU with UC urinary diversion in 27 men and 7 women (group I) and ileal conduit urinary diversion in 57 men and 10 women (group II). The mean age of the TUU with UC diversion and the ileal conduit patients was 57+/-11.2 (range 51-76) and 64+/-12.6 (range 54-76) years, and the mean follow-up was 37 (range 14-52) and 56 (range 14-72) months, respectively. The 6F or 8F stents were used routinely. RESULTS: Of 34 TUU with UC cases 8 (23.52%) had early postoperative complications and 2 (5.88%) had early reoperation rates, whereas 11 (16.42%) of 67 ileal conduit cases had early postoperative complications and 4 (5.97%) had early reoperation. The mean hospital stay was 7 (range 5-25 day) and 11 (range 7-34 day) days for each group, respectively. Of the TUU and UC cases, 6 (17.64%) had late complications and 3 had (8.82%) late reoperation, whereas 14 conduit cases (20.89%) had late complications and 6 had (8.9%) late reoperation. Early postoperative complications were defined as those that occurred before hospital discharge or within 30 days from the date of surgery and late complications were defined as those occurring greater than 30 days from the date of surgery as previously described. In group I, the mean operative time was 170 min (range 120-325) compared with 260 min (range 170-473) in group II. The mean blood loss in group I was 474 ml (range 250-1,400) and 589 ml (range 300-1,700) in group II (p>0.05). CONCLUSIONS: Our results suggest that patients undergoing a TUU and UC diversion have no additional risk of reoperation and the TUU with UC urinary diversion is a safe procedure with postoperative early and late complications.     

Lethal complications of standard self-retaining ureteral stents in patients with ileal conduit urinary diversion

While standard commercially available pigtail ureteral stents are used commonly in the obstructed patient, particularly when metastatic disease has been identified, our recent experience suggests caution in the use of such stents for patients with ileal conduits. Rapid obstruction of these stents occurs with unacceptable frequency, which has resulted in urosepsis and death, and they do not appear to be cost-effective even for palliation. Although these standard pigtail stents have physical properties that allow easy placement by angiographic wire guidance, they are not to be recommended. Safe internal ureteral diversion in patients with an ileal conduit awaits further evolution in stent technology.     

Laparoscopic hand assisted radical cystectomy with ileal conduit urinary diversion

PURPOSE: Hand assisted laparoscopy was originally described in the early 1990s. Since then many studies have shown that hand assisted techniques have the same advantages of laparoscopy including decreased need for postoperative narcotics and rapid return to routine activities. Laparoscopic techniques are advancing rapidly and intracorporeal laparoscopic cystectomy is reported. To our knowledge we report the first case of hand assisted, laparoscopic radical cystectomy with ileal conduit urinary diversion. MATERIALS AND METHODS: A 68-year-old male with rapidly recurring grade III transitional cell carcinoma elected to undergo hand assisted radical cystectomy. We performed a radical cystectomy with bilateral pelvic lymph node dissection removing the specimen through the hand port site. The ileal loop urinary diversion was constructed by pulling the small bowel through the hand port incision. We made another separate hole for the stoma and a drain was placed through a port site. The incisions were closed in the standard fashion.RESULTS: Operative time was 7 hours with 750 cc of blood loss and no complications. All surgical margins were negative. The patient did well and was discharged from the hospital on postoperative day 7 with return to normal activity without limitations at 4 weeks. CONCLUSIONS: To our knowledge this is the first reported case of hand assisted laparoscopic radical cystectomy with ileal loop diversion. Hand assistance facilitated this technically demanding surgery resulting in a good outcome without significant added operative time.     

The management of pyocystis following ileal conduit urinary diversion in children.

27 cases of pyocystis following ileal conduit urinary diversion are discussed. In those cases not responding to medical treatment, vagino-vesicostomy is recommended as an alternative to cystectomy. The operation of prophylactic vagino-vesicostomy at the time of the original diversion is discussed.     

The long-term results of ileal conduit urinary diversion in children

Sixty-seven children undergoing urinary diversion by ileal conduit tolerated this procedure well. The initial results were most satisfying, but late complications occurred in 55 children (82%), and this is a cause for concern. Even when the surgical complications were avoided, it seemed important to consider carefully the psychological problems that these children with ileal loop diversion could develop as they advanced into adult life.     

Ileo-ureteral reflux after urinary diversion through an ileal conduit

The authors made a comparative study (intravenous urography, loopography and loopomanometry) between patients with inverted antireflux anastomosis, as proposed by Melchior, and 12 patients with classical uretero-ileostomy (Bricker bladder). Inverting the anastomosis results in greater incidence of obstruction, while less complications were seen using the classical technique. The importance of reflux in ileal loops and the validity of the classical and manometry loopogram is discussed. Antireflux procedure is only indicated in cases with dilated ureters.     

Bowel function in patients with urinary diversion: a gender-matched comparison of continent urinary diversion with the ileocecal pouch and ileal conduit

Purpose

To evaluate stool habits and associated quality of life (QoL) in a matched pair analysis of patients who underwent continent cutaneous diversion using the ileocecal segment [Mainz pouch I (MzPI)] with an intussuscepted ileal nipple as efferent segment with those receiving an ileal conduit (IC) after radical cystectomy.

Methods

We identified 250 patients who underwent radical cystectomy and urinary diversion (UD) with either MzPI with an ileal nipple or IC in our database. A detailed history of stool habits using the modified Wexner score was obtained, and questions addressing general lifestyle, comparison of symptom differences before and after surgery considering bowel function as well as bowel-associated QoL were assessed.

Results

Forty-five age- and sex-matched pairs could be compared. Overall, stool incontinence (p = 0.481) and the Wexner score (p = 0.464) revealed no differences between both groups. However, patients with MzPI as compared to those with IC had significant higher rates of stool frequency (53 vs 31 %), softer stool consistencies (60 vs 13 %), diarrhea (62 vs 20 %) and a lower rate of constipation (4 vs 22 %). Patients with MzPI had a trend toward lower bowel-associated QoL compared with patients with IC. Similarly, the MzPI group reported a significantly impaired overall postoperative QoL (51 %) compared to the IC group (29 %) (p = 0.024).

Conclusions

Patients following UD by MzPI have an increased stool frequency and softer stool consistency. However, there is no difference between both groups in terms of de novo stool incontinence. Change in bowel habits should be part of preoperative informed consent in any kind of UD. Careful patient selection is of paramount importance.

     

Modified autosuture technique for ileal conduit construction in urinary diversion

The autosuture stapling technique in ileal conduit formation is modified to exclude the proximal staple line from the urinary stream, so as to prevent calculus encrustation on the staples. We have also selected the open-lumen technique of bowel anastomosis, rather than the closed-lumen technique, and have found no increase in complications with this method. In particular, no problems with excessive faecal contamination were encountered.