Reconstruction of the lower urinary tract: observations on bowel dynamics and the artificial urinary sphincter

In 14 patients the lower urinary tract was reconstructed using bowel and the artificial urinary sphincter. Of these patients 11 underwent augmentation cystoplasty. The ileocecal segment was used in 4, cecum in 4 and ileum in 3. Total reconstruction of the lower urinary tract was done using the sigmoid colon in 2 patients and an ileocecocolonic segment in 1. Significant bowel contractions were seen in all segments of the large bowel, including the ileocecal segment, which resulted in urinary incontinence in 3 patients with the artificial urinary sphincter and reflux in 3. The ileal cup-patch technique consistently produced low bladder pressures with excellent compliance and an adequate volume. Because of the unpredictable bowel contractions observed in the ileocecal, sigmoid and cecal segments we recommend that augmentation cystoplasty be performed using the cup-patch technique. This procedure will ensure the virtual absence of bowel contractions, and is associated with excellent compliance and capacity.     

Intestinocystoplasty and total bladder replacement in children and young adults: followup in 129 cases

A review of 129 consecutive young patients (average age 13.4 years) who underwent intestinocystoplasty or total bladder replacement during a 6 1/2-year period at our institution is presented. The most common diagnosis was myelodysplasia and the average followup was 44 months. The clinical and urodynamic aspects of 4 types of intestinocystoplasty (ileocecal, tubular sigmoid, sigmoid patch and ileal patch) are presented. All 4 operations resulted in a significant increase in bladder volume, with a decrease in filling pressure and, thus, improved vesical compliance. In combination with clean intermittent catheterization renal function was maintained or improved in 91 per cent and urinary continence was achieved in 82 per cent of the patients. Hyperchloremic acidosis requiring therapy was noted only in patients with pre-existing renal insufficiency, although mild hyperchloremia after cystoplasty was seen with all 4 types of cystoplasty. There were no operative mortalities. Significant surgical complications occurred in 36 per cent of the patients, the most common of which was vesicoureteral reflux in the ileocecal cystoplasty. Mass unit peristaltic contractions occurred in 34 per cent of the tubular-shaped bowel segments compared to only 10 per cent of the patch segments. These peristaltic contractions contributed to the greater postoperative morbidity noted in the tubular large bowel cystoplasties. The over-all success rate for intestinocystoplasty in this series was 84 per cent. Intestinocystoplasty is an effective procedure when used to increase the compliance of the lower urinary tract. In combination with clean intermittent catheterization it can be applied successfully to patients with neurogenic bladder dysfunction. Large and small bowel seem to have similar clinical and urodynamic properties. The type of intestinal segment used for intestinocystoplasty seems to be of less importance than the size and configuration. Large bowel in its native tubular configuration should be avoided.     

Indiana continent urinary reservoir

Cecoileal reservoirs were created in 29 patients. Tunneled ureteral implantations along the tenia of the cecum provided the antireflux mechanism. Plication or tapering of the terminal ileal segment along with the ileocecal valve provided the continence mechanism. The tubular configuration of the cecum was disrupted with either an ileal or sigmoid patch, or it was re-configured in a Heineke-Mikulicz type of closure to avoid bolus (unit) contractions. Short-term followup examination with excretory urography showed no upper tract obstruction. X-rays of the pouch showed no reflux and interviews revealed satisfactory continence in 93 per cent of the patients.     

Bladder replacement after cystoprostatectomy: efforts to achieve total continence

Total bladder replacement with tubular sigmoid colon and detubularized ileocecal bowel segments was performed on 17 patients after cystoprostatectomy for bladder cancer. There were few complications and patient acceptance was excellent. Daytime continence was achieved in most patients but voiding patterns were superior with detubularized segments. However, enuresis was common with both segment types. Total urinary continence (day and nighttime continence) was achieved in 7 patients with an artificial urinary sphincter that was activated only at night. Total bladder replacement is an acceptable form of urinary diversion after cystoprostatectomy in appropriate patients.     

Enterocystoplasty in the management and reconstruction of the pediatric neurogenic bladder

Eighteen children and young adults with neurogenic bladder underwent enterocystoplasty as part of urinary undiversion or for treatment of incontinence associated with reduced bladder compliance or detrusor sphincter dyssynergia. In 12, tubular sigmoid enterocystoplasty with transureteroureterostomy was performed with the smaller diameter ureter implanted into the bowel tenia. In two patients the ileocecal segment was used to augment the bladder, and the ureters were anastomosed to the ileum. In four patients the cecum or a patch of sigmoid colon was used to augment the bladder. Young-Dees bladder neck reconstruction was performed on eight patients at the time of surgery; one later required bladder neck reconstruction, and two later required an artificial sphincter. After a mean follow-up of 20 months, 16 of the 17 available for follow-up are continent with clean intermittent catheterization every 3 to 4 hours. Nine patients require anticholinergic or smooth muscle relaxing medication to increase functional bladder capacity. Most of the patients need chronic antimicrobial treatment to control bacteriuria.     

Ileal bladder substitute: antireflux nipple or afferent tubular segment?

Spheroidal bladder substitutes made from double-folded ileal segments, similar to Goodwin's cup-patch technique, are devoid of major coordinated wall contractions. This, together with the reservoir's direct anastomosis to the membranous urethra, prevents major intraluminal pressure peaks and assures a residue-free voiding of sterile urine. In order to determine whether, under these conditions, an afferent tubular isoperistaltic ileal segment of 20-cm length protects the upper urinary tract as efficiently as an antireflux nipple, 60 male patients who were subjected to radical cystectomy were prospectively randomised to groups in which a bladder substitute was formed together with either of these 2 antireflux devices. An analysis of the results obtained in 20 patients from each group who could be followed for more than 1 year (median observation time 30 and 36 months) showed no differences between the groups in metabolic disturbances, kidney size, reservoir capacity, diurnal and nocturnal urinary continence, the incidence of urinary tract infection or episodes of acute pyelonephritis. Later than 1 year postoperatively, intravenous urograms of the renoureteral units of 25% of the patients with antireflux nipples showed persistent but generally slight dilatation of the upper urinary tracts. This observation was significantly more frequent than it was in patients with afferent tubular segments. Urodynamic and radiographic studies showed that the competence of the antireflux nipples was secured by the raised surrounding intravesical pressure. This, however, also resulted in a transient functional obstruction, and a gradual rise of the basal pressure in the upper urinary tracts was recorded. In patients with afferent ileal tubular segments, contrast medium could be forced upwards into the renal pelvis when the bladder substitutes were overfilled. However, despite raised intravesical pressures, peristalsis in the isoperistaltic afferent tubular segment gradually returned contrast medium back to the reservoir. Our results suggest that the combination of an ileal low-pressure reservoir together with an afferent tubular isoperistaltic limb is at least as good as an antireflux nipple valve. Moreover, the use of the afferent ileal limb makes it possible to resect the distal and often diseased ureters together with the paraureteric lymphatics at a safe distance from the bladder tumor. This avoids also distal ischemic ureteric stenosis and makes possible a simple end-to-side ureterointestinal anastomosis with a small complication rate.     

Bladder replacement with sigmoid colon after radical cystoprostatectomy

Sigmoid colon was used to replace the bladder after radical cystoprostatectomy in 10 patients with bladder cancer. A U- or J-shaped segment of the sigmoid colon was anastomosed at the most dependent portion to the urethral stump. The ureters were implanted in each end of the loop via an antireflux tunneling technique. There was no operative mortality, and the complications associated with this form of bladder replacement were minimal. All 10 patients had sensations of filling, and 8 of 10 achieved full daytime continence with complete voluntary emptying. Enuresis was present in all patients and required condom catheters during sleep, which were well tolerated. We believe that a tubular sigmoid segment is an acceptable alternative to tubular ileum or cecum for total bladder replacement.     

Antireflux ureteroileal reimplantation: an alternative for urinary diversion

Direct antireflux ureteroileal reimplantation with a short (2 to 2.5 cm.) intraintestinal ureteral segment was used in 14 patients with 26 ureters reimplanted into the ileum as part of a bladder augmentation procedure, substitution cystoplasty or continent supravesical diversion. Our incidence of reflux was 3.8 per cent (1 ureter), while ureteroileal obstruction occurred in 11.4 per cent (3 ureters). The over-all short-term technical success (maximum 18 months) with this operation was 84.8 per cent. These encouraging results make antireflux ureteroileal reimplantation an attractive alternative for its use in urinary tract reconstruction with ileal reservoirs.     

Bladder substitution in children

In spite of all the difficulties, cystoplasty, particularly with the ileocecal segment, has proved rewarding. Undiversion is easily accomplished in this way. Most patients are outwardly well and happy. Reflux usually does no harm in the near term, especially if infection can be prevented, and bladder pressures are not elevated. However, we believe that we are close to being able to prevent reflux in a reliable manner. If this is the case, the ileocecal segment or hemi-Kock pouch may clearly become the optimal choice for bladder substitution in patients with reflux or ureteral obstruction, as well as those with short ureters or very small bladders, or as a standard method of undiversion. We have also employed the intussuscepted ileum as the antireflux mechanism in patients undergoing bladder substitution using a patch of small bowel as in the hemi-Kock. This technique allows one to leave the cecum and ileocecal valve in situ, reducing the risk of chronic postoperative diarrhea. In addition, small bowel is proving to be more compliant on the average than large bowel segments when used in bladder reconstruction. Whether the ileocecal segment or the hemi-Kock cystoplasty has a permanent place in undiversion and in the treatment of chronic or pharmacoresistant noncompliant bladder, neuropathic or otherwise, the techniques learned are making total replacement of the bladder with bowel segments a more attractive and feasible undertaking. The pool of patients susceptible to such maneuvers is a large one.     

Review of a 14-year experience of augmentation enterocystoplasty. Observations on bowel dynamics

Fifteen patients with low compliance bladder of varying etiologies (neurogenic bladder, radiation induced contracted bladder after radical hysterectomy, bladder tuberculosis and interstitial cystitis) underwent augmentation enterocystoplasty. The ileocecal tubular segment was used in 12 patients, ileal-patch in 2 and ileal-cup patch in 1. In all patients in whom partial reconstruction was done, the functional bladder capacity satisfactorily increased and the maximum detrusor pressure was low. The upper urinary tract did not deteriorate in 12 patients. Three died from recurrence of uterine or bladder cancer. Five neurogenic patients were managed by intermittent self-catheterization postoperatively. Another 10 patients was dry without voiding difficulty. Of 18 ureteral reimplantations in ileocecal cystoplasty, 13 had reflux without resultant progressive hydronephrosis. In 3 patients ureteral reimplantation was not required without reflux after ileal-patch and ileal-cup patch cystoplasty.     

Continent urostomy with hydraulic ileal valve in 136 patients: 13 years of experience

The hydraulic ileal valve, which we developed in 1975, ensures continence by adapting to 5 different urinary reservoirs. The valve is made by isolating a 14 cm. long intestinal loop with the mesentery. The isolated ileal segment then is folded inward on itself throughout its entire length. We performed 136 continent urostomies with this hydraulic valve. An ileocecal reservoir was used in 122 patients, ileum in 8, sigmoid in 1, rectum in 1 and bladder (continent cystostomy) in 4. Indications for continent urostomy were bladder tumor in 55 patients, complex vesicovaginal fistulas in 5, neurogenic bladder in 13, vesical exstrophy in 12 and miscellaneous reasons in 5. Of the patients 103 (75 per cent) were continent immediately. Continence was obtained after repair of the valve in 24 patients (17.6 per cent). Therefore, 127 patients over-all were continent. Mean followup of our patients was 38 months (range 3 to 154 months). Continence remained excellent with self-catheterization performed easily in 88.3 per cent of the patients. Over-all, all of our continent urostomies were well tolerated biologically and radiologically.     

Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir

A continent colonic urinary reservoir was created in 10 patients who had undergone anterior exenteration for invasive bladder carcinoma. A tapered distal ileal segment with a catheterizable abdominal stoma provided full continence in all 10 patients. Tapering of the terminal ileum was achieved with a gastrointestinal anastomosis stapler in 5 patients or with a bowel clamp in 5 others. Three purse-string sutures of 2-zero silk were placed on the tapered ileal segment to increase the intraluminal pressure. A nontunneled ureterocolonic anastomosis was performed in all 20 ureters. No obstruction or reflux was noted in 19 ureters (95 per cent). Hydronephrosis at the anastomotic site was noted in 1 ureter and was successfully dilated percutaneously.     

Non-stomal continent reservoir: use of detubularized ileal segment for bladder replacement

Summary Total bladder replacement after cystoprostatectomy was performed in 2 patients using a detubularized segment of ileum to construct a continent urinary reservoir. A small part of the segment remained tubular for anastomosis to the urethra. The ureters were implanted into the reservoir using an antireflux technique. There were no complications associated with the procedure. Continence was maintained by the patients' external urethral sphincter. Two bowel configurations in 2 patients are described. The preliminary results with both configurations have been encouraging, with 1 patient achieving total continence. The detubularized ileal reservoir appears to offer technical and functional advantages over other tubular and detubularized bowel segments used for bladder replacement.     

Vesical neck reconstruction in patients with epispadias-exstrophy

Vesical neck reconstruction was performed in 50 male and 12 female patients with the epispadias-exstrophy complex. Of these patients 45 had epispadias and 17 had classical exstrophy. Patient age ranged from 3 to 27 years, with a mean age of 12.6 years. Followup after vesical neck reconstruction averaged 11.6 years. Of the 45 patients with epispadias 35 (78 per cent) and of the 17 with bladder exstrophy 13 (76 per cent) are continent, for an over-all continence rate of 77 per cent. An adequate bladder capacity was one of the most important determinants of continence. In 11 patients with a small capacity or poorly compliant bladder augmentation cystoplasty was combined with vesical neck reconstruction to increase vesical capacity and to produce complete urinary continence.     

Functional characteristics of the continent ileocecal urinary reservoir: mechanisms of urinary continence

We evaluated urodynamically 14 patients with a continent ileocecal urinary reservoir. Reservoirs were constructed of detubularized right colon alone (4 patients), or augmented with ileum (2) or with a U-shaped ileal patch (8). All reservoirs were placed in the abdomen and used plicated terminal ileum as the efferent continence mechanism. Twelve patients are completely continent with intermittent catheterization at 4 to 8-hour intervals. Two patients suffer mild nighttime incontinence. Mean reservoir volume was 675 ml. Intermittent intestinal contractions were noted in the plicated ileal segment and reservoir but they occurred more frequently in the former and were either synchronous with or preceded those in the reservoir. Mean and maximal contraction pressures were 24 and 47 cm. water, respectively, in the reservoir and 40 and 151 cm. water, respectively, in the plicated ileal segment (p equals 0.043 and less than 0.001, respectively). The highest reservoir contractions occurred in the 2 patients with nocturnal incontinence. The method of construction bore no consistent correlation with mean or maximal contraction pressures, contraction frequency or continence. Careful urodynamic assessment suggests that the ileocecal urinary reservoir is a relatively low pressure, nonrefluxing and continent bladder substitute. The plicated terminal ileal segment acts as an effective sphincter that responds to pressure elevations in the reservoir. Its simple construction and easy catheterization make it an attractive alternative to intussuscepted ileal segments.     

Use of the ileocecal segment for bladder substitution or continent urinary diversion

Urinary reservoirs constructed from the ileocecal segment conform generally to the principles of an ideal bladder substitute. They have psychological and functional advantages for selected patients who require urinary diversion. The reservoir can easily be placed in the pelvis attached to the urethra. Alternatively, an extremely efficient efferent continence mechanism that is both easy to catheterize and to construct can be made from tapered terminal ileum and an intact ileocecal valve.     

Rectosigmoidal bladder utilizing intussuscepted ileal segment: A surgical technique for urinary diversion and experiences in 30 patients

BACKGROUND: We previously reported that the ileocecal rectal bladder consists of interposition of an intussuscepted ileocecal segment between the ureters and the rectum for those in whom the urethra is not available. Although the ileocecal rectal bladder has been well accepted by most patients, it requires an extensive preparation along the ascending colon. We present a modified operation technique (rectosigmoidal bladder) by using the ileal segment alone as an interposing antireflux component and by using the sigmoidal segment to augment the rectal capacity. METHODS: From February 1993 to July 2002, 30 patients with a median age of 64 years underwent construction of a rectosigmoidal bladder. Median follow-up period was 26 months (range, 13-125). The follow up was carried out using clinical and functional assessments such as evacuation status, serum chemistry and radiographic evaluation of the upper urinary tracts and rectosigmoidal pouch. To assess the postoperative health-related quality of life, we carried out a survey comparison of the ileocecal rectal bladder patients and the rectosigmoidal bladder patients. RESULTS: No operative or urinary diversion-related postoperative mortality was encountered. All rectosigmoidal bladders had sufficient capacity, with no evidence of urinary reflux or daytime incontinence. When compared with our previous procedure, the ileocecal rectal bladder, the present procedure had advantages with respect to complications with urine-fecal leak and acidosis. There were no differences in mean operation time, or in the health-related quality of life survey, between the two procedures. CONCLUSIONS: Our experience showed that this technique should be considered for those in whom the urethra is not available.     

Replacement bladder constructed with the aid of a folded ileum segment

An internal urinary diversion after radical cystoprostatectomy has been performed in 70 male patients. The bladder substitute was made from an ileal segment, opened along its antimesenteric border and folded twice, according to Goodwin's "cup-patch technique". After an observation time of 6 months to 6 years, the results are in general good: The initial capacity of the pouch made from only 40 cm of ileum (in order to avoid metabolic disturbances) increases to a functional capacity of 500 ml within the first postoperative weeks. The increase of the bladder substitute's capacity is parallel to the improvement of urinary continence. In general, the latter is achieved after 1-3 months during the day, and after 3-6 months during the night. However, loss of a few drops of urine may occur, reason why half of our patients wear a safety pad later than 6 months after surgery, at least during the night. There was no significant difference between those patients with an antireflux nipple and those patients having an ileal tubular afferent segment.     

Concealed umbilical stoma: long-term evaluation of stomal stenosis

PURPOSE: The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis. MATERIALS AND METHODS: We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty. RESULTS: At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis. CONCLUSIONS: The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.     

Pediatric applications of augmentation cystoplasty: the Johns Hopkins experience

Since 1976, 23 children with bladder or cloacal exstrophy, meningomyelocele, sacral agenesis, the prune belly syndrome and noncompliant bladders associated with urethral valves or prior diversion underwent augmentation cystoplasty. Of these procedures 7 were combined with some type of urinary undiversion. Bowel segments used for augmentation included ileum alone in 10 patients, ileocecal segments in 4, a sigmoid patch in 8 and a hindgut patch in 1. An artificial urinary sphincter was placed at the time of bladder augmentation in 3 patients. There were no urinary fistulas or cases of urinary rediversion. Two patients required oral alkalizing agents as a result of persistent systemic acidosis. One patient required reoperation twice for ureteral obstruction, 1 had removal of the sphincter device secondary to erosion, 1 required reinforcement of the ileocecal valve owing to persistent reflux and 1 required reoperation for small bowel obstruction. Other complications included a superficial wound infection and 5 urinary tract infections, all of which were managed easily. Three patients were voiding and continent, 18 were dry with intermittent self-catheterization, 1 had giggle incontinence and 1 remained incontinent after sphincter removal. Augmentation cystoplasty appears to offer a reliable alternative to urinary diversion in the reconstructive management of children with small capacity bladders.