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.     

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.     

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.     

A new technique for the prevention of reflux in those undergoing bladder substitution or undiversion using bowel segments

Summary The use of small and large bowel segments in reconstruction of the bladder and in continent urinary diversion has become increasingly practical in recent years. Many of these patients are expected to achieve a near normal life and life expectancy as a result of such surgery. Reflux therefore represents a potential hazard to the upper tracts, especially when residual urine is present or the patient empties by intermittent catheterization, occasionally introducing bacteria. Various techniques to prevent reflux have been employed with varying degrees of success. We present our experience with seven patients undergoing undiversion or bladder substitution in whom a new technique for reflux prevention was employed. Of the seven patients, six are free of reflux at this time, and the technique seems applicable in several different clinical situations.     

Bladder augmentation in reconstruction of the urinary tract (1985-1997)

Bladder augmentation with intestinal or urinary segments has virtually replaced other treatments in the management of both neuropathic and no neuropathic bladder dysfunction that has not responded to pharmacotherapy nor other intervention. We present herein our experience in 55 patients who underwent augmentation cystoplasty. Their mean age were 12.2 years (range 2.5-22.8) and the mean follow-up time was 4 years (1-13.1). They were divided in three groups according to the diagnosis: vesical or cloacal exstrophy (14 patients), neuropathic bladder (36) and posterior urethral valves (5 patients). Indications were: 1) to get a low pressure, high volume reservoir and avoid upper urinary tract damage in low-compliance bladders (41 patients); 2) as an undiversion (8 patients), and 3) prior to renal transplantation. Cystoplasty was performed with bowel segments in 47 cases and ureter in 8, adding some other urological procedures in 22 patients. Mean bladder capacity after 1 year was 400 ml versus 112 as previous value. 52 out of the 55 patients are continent after augmentation. There was no impairment of the renal function in the 5 patients with prior renal failure who underwent cystoplasty. Vesicoureteral reflux disappeared in 78.6% of the patients after cystoplasty. The complications were urinary stones in 5 cases, upper urinary tract infections in 3, and spontaneous bladder perforation in 1 patient. Augmentation cystoplasty is the best choice to achieve a low pressure reservoir, to assure contingency and to avoid progressive damage of the upper urinary tract in neuropathic or no neuropathic pediatric bladder dysfunctions.     

The hemi-Kock ileocystoplasty: a versatile procedure in reconstructive urology.

The hemi-Kock system, constructed from approximately 40 cm. of terminal ileum, comprises a detubularized and remodeled ileal plate with a stapled ileoileal intussusception to form a 1-way valve. This system has been applied to reconstruct 30 varied cases in which the intussuscepted valve was used either for reflux prevention or as a continent stoma. The patients included 11 with intractable urinary incontinence and a devastated bladder outlet in whom the hemi-Kock pouch was anastomosed to the bladder after the bladder neck had been surgically closed, with the afferent limb of the nipple valve being routed through the abdominal wall as a continent stoma. In 9 patients who had previously undergone supravesical diversion, undiversion was accomplished with this system to augment the bladder, with the antireflux nipple being anastomosed to the prior ileal loop or ureters. In 5 patients in whom intractable bladder hyperactivity had led to devastated upper tracts with markedly dilated ureters this system was used for bladder augmentation, with the ureters being reimplanted into the afferent limb of the hemi-Kock system to prevent reflux. The final patients were those in whom the hemi-Kock pouch was converted into a complete reservoir and used for orthotopic bladder replacement. The hemi-Kock system proved to be successful in each of these roles. It created a capacious low pressure reservoir, protected the upper tracts from reflux and improved those that were previously dilated, and it proved to be a reliable continent stoma when applied to that use. The versatility of the hemi-Kock system in its application to a variety of reconstructive endeavors recommends it for use.     

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.     

Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty

The clinical and urodynamic results of enterocystoplasty were compared in 3 groups of patients in which the intact ileocecal segment (10 patients), tubular sigmoid segment (16) or sigmoid cup-patch segment (8) was used. In all 3 groups the upper urinary tract and renal function improved or remained stable, and the functional bladder capacity increased. All patients experienced involuntary, volume-dependent vesical contractions of comparable intensity 3 months postoperatively. After a mean followup of 19.4 +/- 8.9 months only 12 per cent of the patients with a cup-patch configuration demonstrated volume-dependent contractions, compared to all patients with ileocecal cystoplasty and 94 per cent with sigmoid tubular cystoplasty. The intensity of these contractions was significantly less in the cup-patch configuration group compared to the other groups. Patients with cup-patch cystoplasty achieved a significantly higher rate of urinary continence than those in the other 2 groups. It appears that the sigmoid cup-patch configuration may provide a lower pressure system and better continence compared to the intact ileocecal or tubular sigmoid segment, although the latter techniques have specific applications when confronted with a wide gap between the ureters and bladder or when dilated ureters require anastomosis to the bowel.     

Assessment of the malignant potential of cystoplasty

The study group comprised 34 patients with either an ileal augmentation cystoplasty or a colonic substitution cystoplasty. The histological appearance of the intestinal segment, suture line, bladder remnant and bacterial colonisation of the urine and urinary nitrosamine levels were recorded. There was a high incidence of histological abnormalities, the more significant of which correlated with heavy mixed bacterial growth on urine culture and with high levels of urinary N-nitrosamines. This group of compounds is thought to act as carcinogens in both bladder and bowel under certain circumstances. It was concluded that patients undergoing lower urinary tract reconstruction using intestinal segments should be considered at risk of developing malignant change either in the intestinal segment or in the bladder remnant. Close long-term follow-up of these patients is essential.     

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.     

Urodynamic evaluation and long-term results of the orthotopic gastric neobladder in men

PURPOSE: Orthotopic neobladders are most commonly formed from colon and/or small bowel segments. However, after excellent results were reported in children, we constructed gastric neobladders in select men who had undergone cystectomy. Although gastric neobladders in adults have been reported to have decreased capacity, to our knowledge neither long-term followup nor urodynamic parameters have been reported in these patients. MATERIALS AND METHODS: Gastric neobladder was performed in 8 patients following cystectomy for malignancy in 7 and undiversion in 1. Average followup was 43 months and all patients underwent urodynamic evaluations an average of 9.1 months after surgery. Patients also completed an incontinence questionnaire. The gastric neobladder group was compared to a similar group of patients who underwent neobladder construction from either small bowel (Kock/Hautmann/Studer) or ileocecal segments (Mainz). RESULTS: The gastric neobladder group had significantly reduced mean bladder capacity compared to the ileal or ileocecal neobladder group (309 versus 551 cc, respectively, t = 0.001), while compliance was similarly decreased (27 versus 59 cc/cm. H2O, respectively, t = 0.04). Incontinence rates were greater in the gastric neobladder group (63%) compared to the ileal or ileocecal neobladder group (8% to 23%, t = 0.02). Complication rates were comparable. Revision or removal was required in 3 (38%) patients for severe incontinence, intractable dysuria and ureterogastric anastomotic stricture, respectively. CONCLUSIONS: Adult gastric neobladders as currently constructed are associated with poor urodynamic parameters and high incontinence rates. Routine use of gastric neobladders in adults is not recommended. They may be appropriate, especially as composites, in select cases such as renal failure or inadequate bowel length. The reasons for success in some patients and not in others are unknown.     

Ileocecal bladder augmentation in myelodysplasia

We discuss 14 children and adolescents with myelodysplasia who underwent bladder augmentation with the ileocecal segment. The bowel was not detubularized nor was the ileocecal valve intussuscepted. Urodynamic evaluation was performed before and after the procedure in 13 patients with a followup of 1 to 8 years. Postoperative capacity and compliance were normal but cecal contractions occurred in 8 patients despite adequate doses of anticholinergics. Reflux was demonstrated at capacity with a cecal contraction in 4 patients but upper tract dilatation and infection were not clinical problems. Three patients required reoperation for complications owing to ureteroileal stenosis and/or urinary tract calculi. Although the clinical results were satisfactory, detubularized segments of bowel with intussuscepted afferent loop valves to prevent reflux may resolve these problems in the future.     

The hemi-Kock augmentation ileocystoplasty: a low pressure anti-refluxing system

Experiences with various methods of using intestinal segments for bladder augmentation and urinary undiversion, as well as with clinical applications of the Kock continent ileostomy for urinary diversion have led us to develop the hemi-Kock augmentation ileocystoplasty for selected patients requiring a nonrefluxing bladder augmentation. In 6 of 7 patients this bladder augmentation technique fulfilled the requirement for a low pressure nonrefluxing reservoir. Renal function has been preserved and electrolyte problems have not occurred. Nocturnal incontinence has been eliminated. Although 2 of 7 patients required surgical revision patient acceptance has been excellent. Prerequisites to implementing this approach are appropriate patient selection and familiarity with the surgical principles of the continent ileal reservoir.     

Reconstruction of the lower urinary tract for neurogenic bladder: lessons from the adolescent age group.

Of 42 adolescents with neurogenic bladder who presented for lower urinary tract reconstruction, 4 patients with severe spina bifida were unfit for major surgery. Five patients had a simple undiversion; 4 of these had a poor outcome because of unpredicted sphincter incontinence (1 patient) or instability (3). A total of 26 patients had an enterocystoplasty. All 7 patients who had a substitution cystoplasty had a good result, as did 3 males with a clam cystoplasty. Nine of 16 females had a poor result from a clam procedure. In 3 the problem lay with self-catheterisation difficulties. One each had persistent hyper-reflexia and sphincter incontinence. Four had hyper-reflexia on sexual intercourse. Overall, 42% of females had problems from the retained bladder segment. Seven patients had continent urinary diversions. The results were good, although 2 Kock nipples required revision. Surgery was well tolerated. There was a 21% re-operation rate for complications. Pre-operative investigation correctly predicted sphincter competence and the need for self-catheterisation in 79 and 86% respectively.     

Surgical management of intractable interstitial cystitis

Interstitial cystitis represents a diagnostic and therapeutic challenge. Most patients can be managed conservatively, but a small number of patients do not respond to conservative therapy and for them surgical treatment is indicated. This article reviews the historical and currently used surgical modalities. Enterocystoplasty is the surgical treatment of choice for intractable interstitial cystitis. The results of enterocystoplasty are satisfactory in approximately 80% of patients. However, no histological findings, such as mast cell density or degree of inflammation, can be used as a preoperative predictor of treatment results. The best results of cystoplasty seem to be achieved in patients who have a small bladder capacity, determined preoperatively under anesthesia. Approximately 10%–20% of patients may not be able to void spontaneously after surgery and require self-catheterization. Because of the unpredictable results, cystoplasty must be recommended with caution for certain patients. There is no evidence to indicate that a supratrigonal cystectomy and substitution cystoplasty offer a therapeutic advantage over augmentation cystoplasty alone. The choice of bowel segment does not affect the final outcome provided that it is tubularized and made spherical in configuration.     

The use of small intestine in bladder reconstruction

Reconstruction of the bladder is a treatment available to patients who have a diseased or damaged bladder, and small bowel is the most commonly used tissue. Augmentation cystoplasty increases the total bladder capacity, whereas substitution cystoplasty replaces the whole organ. This is either drained through a continent cutaneous stoma or is reanastomosed to the urethra as an orthotopic reconstruction. Although the treatment for invasive bladder cancer has not changed greatly in the last few decades, the use of orthotopic bladder reconstruction allows for a great improvement in the quality of life for patients who undergo cystectomy. These reconstructive techniques can also be offered to patients with other forms of pelvic malignancy that involve the bladder.     

Use of the AS792 artificial sphincter following urinary undiversion

Reconstruction of the urinary tract after diversion has been successful in patients with normal innervation of the lower tracts. However, the possibility of urinary incontinence after such major surgical procedures has dissuaded many surgeons from attempting urinary undiversion in patients in whom the continence status cannot be determined accurately before the operation or who were known to be incontinent before the original diversion. For this reason, the presence of neuropathic bladder dysfunction has been considered a relative contraindication to urinary undiversion unless it can be established preoperatively that the patient will obtain urinary continence. Eight patients are reported who had successful outcome with the use of the AS792 artificial urinary sphincter to control incontinence after urinary undiversion. Because of this successful experience it is now believed that patients with neuropathic bladder dysfunction or anatomically abnormal lower tracts are no longer precluded from urinary undiversion. A variety of methods has been used to reconstruct the urinary tract, including total reconstruction of the bladder and urethra with the sigmoid colon in 1 case. In the latter case the artificial sphincter was placed around the bowel segment to provide continence. The use of the artificial sphincter around a bowel segment offers many possibilities for reconstructive procedures involving bowel in the future.     

Kidney transplantation in children with reconstructed bladder

There is some controversy about the safety of renal transplantation in patients with an augmentation cystoplasty because of the possibility of urinary tract infection in immunosuppressed patients leading to pyelonephritis and graft loss. Nevertheless, it is now well known that in patients with a small volume and poorly compliant bladder, reconstructive bladder surgery (augmentation cystoplasty or continent reservoir) creates a low-pressure and compliant reservoir, which protects the upper urinary tract and restores a functional lower urinary tract. Graft survival is not adversely affected when a kidney transplant is drained into a reconstructed bladder. When bowel segments are used for augmentation, a voiding modality with clean intermittent self-catheterization does not increase the risk of urinary tract infections, even in immunosuppressed patients.     

Undiversion in patients with meningomyelocele

Since 1981, 12 patients with neurogenic bladder due to meningomyelocele who had had previous ileal conduit urinary diversions underwent assessment for undiversion. Two important criteria for undiversion were motivation and a reconstructable bladder. Four patients either did not fulfil these criteria or refused surgery. Eight patients (six females and two males) underwent undiversions. Uretero-ureteral anastomosis was achieved in 13 ureters and ureteroneocystostomy in 2; transureteroureterostomy was necessary in 1 ureter. Augmentation cystoplasty and vesicourethropexy were important in establishing continence postoperatively; these procedures were not performed in two patients whose undiversion failed early in the series. The evolution of an investigation protocol, surgical technique and final approach to this complex problem are discussed.     

Urinary undiversion by cecoileourethroplasty and pubovaginal sling operation

A continent urinary undiversion was performed on a woman who had previously had a cystectomy and ileal loop urinary diversion for intractable interstital cystitis. The first stage consisted of isolation of an ileocecal segment and detubularization to create a low-pressure reservoir. The ileocecal valve was then intussuscepted and and reinforced. The proximal ileum was tapered and anastomosed to the urethral stump. The second stage involved excision of the ileal loop stoma, creating a nipple in the distal ileal loop conduit, and anastomosing this nipple into the reservoir to prevent reflux. A pubovaginal sling was performed to prevent stress incontinence. The patient is continent and empties her bladder by intermittent self-catheterization. She is doing well 3 years after the operation.