Continent urinary diversion

From August 1982 through March 1988, 531 patients have undergone continent urinary diversion using an ileal reservoir constructed according to the method of Kock. For the last 18 months we have used the principle of Kock reservoir construction for primary lower urinary tract reconstruction after cystectomy in 39 highly selected male patients by means of a ureteroileal urethrostomy. Early complications occurred in 86 of 531 patients (16.2 per cent), resulting in an operative mortality rate of 1.9 per cent (10 of 531). The early complication rate was 16.5 per cent among patients undergoing 1-stage cystectomy and Kock pouch construction, and 15.2 per cent among patients undergoing Kock pouch conversion. Late complications have been analyzed in 489 patients who have undergone Kock cutaneous diversion. The complications unique to continent urinary diversion, their incidence and the effect of technical modifications in reducing the number of late complications are shown. Note that since the last modification in July 1985 the over-all incidence of late complication has decreased to 22 per cent. Based on this ongoing experience we conclude that the continent ileal reservoir, as conceived by Kock, remains the ideal internal reservoir for bladder replacement in terms of volume accommodation with the lowest internal pressures, and the intussuscepted ileal nipple valve mechanism is a reproducible, highly effective mechanism that prevents reflux and pyelonephritis in greater than 95 per cent of the patients and produces excellent continence. Our enthusiasm remains tempered by the need for reoperation in approximately 10 to 15 per cent of the patients, usually due to a pinhole fistula or false passage at the base of the efferent nipple valve mechanism. Electrolyte abnormalities rarely occur and in the absence of radiation gastrointestinal dysfunction is unusual. Continent urinary diversion is a viable concept that provides a real alternative in terms of quality of life and self-image for the patient who requires urinary diversion for any reason.     

Orthotopic urinary diversion

Internal reservoirs constructed from segments of stomach, ileum, the ileocecal region, and the sigmoid colon provide a reliable form of continent diversion.     

Continent urinary diversion

Continent urinary diversion has evolved from an investigational method of urinary tract reconstruction to an accepted, and in many instances preferred, option for men and women facing radical cystectomy. Over the last 15 years, we have learned much about the different procedures, their durability, and their success rates. This article reports on the procedures that the authors believe are associated with the highest success rates and the lowest complication rates. At this time, continent diversion should be offered to all appropriate candidates, and these procedures should be considered a part of the standard urologic armamentarium.     

可控性尿流改道

当膀胱或尿道病变不能正常储尿及排尿而手术 又无法修复时,需做膀胱重建及尿流改道。1852年 Simon将输尿管吻合于乙状结肠,尿虽可控,却发生 了严重电解质紊乱,或伴肾功能受损,威胁患者生命 以后Bricker用回肠作储尿及输出道,但需配带尿 袋,无法防止尿液渗湿衣裤。1950年Rem     

Laparoscopic urinary diversion

Urinary diversion, in conjunction with cystectomy or as an isolated procedure, has traditionally been performed using open surgical technique. Laparoscopic urinary diversion has only recently been reported. We review the available literature on laparoscopic urinary diversion and present some of the experimental and clinical studies that have attempted to overcome the technical difficulties of the procedure. In addition, the indications, results, and future directions of laparoscopic urinary diversion are discussed.     

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.     

Use of single J urinary diversion stents in intestinal urinary diversion

A review of the past twenty months of intestinal-urinary diversion with use of the single J urinary diversion stents at Albany Medical Center Hospital and the Albany Veterans Administration Medical Center resulted in no ureteroileal anastomotic fistulas. Thirty-seven stented anastomoses were performed in 19 patients.     

The selection of the method for urinary diversion in children]

Ninety-five urinary fistulas have been produced at various urinary tract levels in 62 infants and children, aged 20 days to 13 years, for uni- or bilateral megaureter and hydronephrosis 14 days to 16 months prior to major reconstructive-plastic surgery. Efficacy of draining (21 cystostomies, ureterostomies and nephropyelostomies) and nondraining (74 ureterocutaneostomies) techniques was evaluated 2-6 months or later using clinical, laboratory, X-ray, tracer and urologic cinematographic studies. Fistula application and removal maneuvers and complications are described. The draining techniques were found to be inefficient in prolonged preliminary urinary diversion and to be associated with frequent infection relapses and less satisfactory results of plastic surgery. Ureterocutaneostomy proved to be the most reliable and convenient method of prolonged drainage even though it required additional operations to replace the patent ureters. The drainage should be prolonged to 12-16 months if the urinary tract deteriorates, especially in young children.     

Continent urinary diversion using the appendix as a catheterizable stoma]

Two patients with bladder cancer underwent construction of continent urinary reservoir using the in situ appendix as a catheterizable stoma after total cystectomy. Urodynamic study revealed that the reservoir had a large capacity of 500-800 ml and low pressure without the involuntary pressure spikes was maintained. X-rays of the reservoir showed no reflux. The patients achieved complete day and night-time continence.     

Sigmoid conduit urinary diversion

Sigmoid conduit urinary diversion represents a step forward in the evolution of urinary diversion. The rigid test of time, however, is necessary to decide the fate of this form of urinary diversion. Although far from ideal, the nonrefluxing colon conduit represents a useful tool in the urologist's armamentarium for select patients.     

Pregnancy and urinary diversion

In most children or premenopausal women who need urinary diversion, the underlying disease is benign. After the problems associated with urinary incontinence have been resolved, and patients have reached puberty, sexuality and fertility become more significant. In women with urinary diversion, numerous influencing factors exist, including, but not limited to, the underlying disease and form of urinary diversion. The authors' center has a large expertise in urinary diversion, although the number of cases with pregnancies is limited. This article uses this prior experience and data from a literature review to provide guidance for urologists, obstetricians, general practitioners, and patients to aid decision making in pregnancies after urinary diversion.     

Follow-up after urinary diversion

With modern forms of urinary diversion being widely employed during recent years, the awareness of possible complications and appropriate follow-up strategies gains rising importance and current follow-up strategies are reviewed herewith. Follow-up investigations after urinary diversion have to address possible surgical complications, metabolic changes as well as the risk of secondary malignancies in the incorporated bowel segments. The most important and possible deleterious surgical complication is upper tract dilation and obstruction following ureteroenteric anastomotic stenosis and occurs in 2-30% depending on the surgical technique and evaluated series. The most appropriate follow-up study to detect upper tract dilation is ultrasonography while the associated obstructional component can best be estimated by functional renographic studies (MAG(3) renal scan). The significance of reflux associated with urinary diversion remains controversial although experimental studies and clinical observations suggest a risk of renal functional deterioration associated with reflux which is certainly true in ureterosigmoidostomy following pyelonephritic changes. Possible metabolic changes include hyperchloremic metabolic acidosis and problems related to malabsorption due to bowel resection and incorporation of bowel segments into the urinary tract. The incidence of hyperchloremic acidosis is related to the form of urinary diversion, being higher in continent forms than in incontinent diversions, while hyperchloremic metabolic acidosis is most frequently encountered in ureterosigmoidostomy. While acute complications of metabolic acidosis may encompass hyperventilation as well as severe changes of serum electrolytes and acid base balance leading to cardiac arrhythmias necessitating immediate hospital treatment with intravenous alkalinizing, chronic acidosis may lead to osteopenia through hypocalcemia and stimulation of osteoclastic activity. Metabolic acidosis can be best detected by regular blood gas analysis. To prevent these complications prophylactic administration of alkalinizing agents (e.g. potassium citrate) should be readily performed. Malabsorption of bile acid strongly correlates with the length of ileum resected and can induce both chologenic diarrhea and malabsorption of liposoluble vitamins (A, D, E, K). Vitamin B(12) is exclusively absorbed in the distal ileum, serum levels therefore may be reduced following resection of distal ileum. This will not occur during the first 3-5 years following diversion because B(12) deposits usually will last for this period. Later, however, serum levels of vitamin B(12) should be checked annually while others favor routine substitution of this vitamin. The incidence of cancer occurring at the ureterointestinal anastomosis seems to be highest in patients with ureterosigmoidostomy varying between 2 and 29% with polypoid benign lesions being more frequent. The most common type of tumor is adenocarcinoma which has also been reported in colonic and ileal conduits as well as augmentation cystoplasty using either colon or ileum. Since the time interval between surgery and cancer occurrence is longer than 10 years, the newer forms of continent diversion theoretically also inherit the risk of tumor formation, which, however, has yet to be established because these diversions are only in wide use since 10 years. Currently, annual endoscopic controls are recommended in those patients with diversions where feces and urine are in contact with urothelium starting 5 years after surgery. Although formal guidelines for follow-up after urinary diversion have not yet been established by the working group on oncology of the German urological association, this paper suggests a follow-up strategy addressing surgical complications, metabolic changes and the risk of secondary malignancies. Copyright Copyright 1999 S. Karger AG, Basel