TRANSVERSE RETUBULARIZED SIGMOIDOVESICOSTOMY CONTINENT URINARY DIVERSION TO THE UMBILICUS

PURPOSE: The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus. METHODS AND METHODS: In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipation and overflow fecal incontinence secondary to neurogenic bowel. Laparoscopy was performed to mobilize the appendix in patients who requested a low Pfannenstiel incision for better cosmesis. Additional procedures included the pubovaginal sling placement and sigmoid colocystoplasty. RESULTS: Mean length of the sigmoidovesicostomy, which was equal to the circumference of the sigmoid before retubularization, was 13 cm. (range 10 to 15). This sigmoid conduit reached the umbilicus easily in all cases. All sigmoidovesicostomies were easily catheterized and all were continent. One patient with morbid obesity (body mass index 40.4) had a mucocutaneous anastomotic breakdown 3 months postoperatively. Minimum followup was 1 year (mean 1.5). CONCLUSIONS: Transverse retubularized sigmoidovesicostomy is effective for creating a continent urinary diversion to the umbilicus in patients with neurogenic bladder secondary to spina bifida. Dilating the sigmoid colon from neurogenic bowel creates a long conduit based on the Yang-Monti principle and 2 ileal segments with an anastomosis are not required. Additional benefits are that the sigmoid colon is readily accessible via a low Pfannenstiel incision and may also be used for augmentation in select cases.     

Reconstruction of previously diverted urinary tract in children.

We tried to reconstruct partly or completely the urinary tract in nine patients who underwent, some years before, attempts at urinary diversion, for severe urinary tract diseases, using the intestine as an ureteral or a bladder subtitute. Our aim was to do a two-stage procedure, trying to reconstruct one normal side without the use of bowel, then within 6 mo to reevaluate the reconstructed side and, if correct, to do a transureteroureterostomy from the diverted side into the reconstructed side. Two patients were operated on this way and cured. We then advanced to a more aggressive approach with a one-stage procedure. Two more patients were operated on and cured. We then attempted reconstruction in patients when the ureter was no longer available. Two patients were operated on using a tapered and reimplanted piece of small bowel in the bladder and cured. Next we came to the patients in whom neither ureter nor bladder was available. Two patients were undiverted from an ileal loop and transformed into an ureterosigmoidostomy with transureterostomy, with achievement of continence. Finally, when neither ureter, nor bladder, nor even rectum was available, one patient on hemodialysis for a nonfunctioning Duhamel rectal bladder was converted into a functioning ileal loop and freed from dialysis. Technical points are discussed, focused on a two-stage procedure with one reimplantation and a transureteroureterostomy. When a permanent diversion must be done, today, for rare indications, we prefer to perform a sigmoid conduit.     

Intestinal reconstruction of the lower urinary tract as a prerequisite for renal transplantation

OBJECTIVE

To report a two‐stage protocol for children in whom bladder reconstruction was followed by kidney transplantation, as about a quarter of children requiring a kidney transplantation show significant lower urinary tract dysfunction, and consequently their bladder is unsuitable for a kidney transplant.

PATIENTS AND METHODS

Twelve children (median age 9.5 years, range 4.2–16.8) with end‐stage renal disease had a lower urinary tract reconstruction before kidney transplantation. The cause of bladder dysfunction and renal failure included posterior urethral valves in five, neuropathic bladder in two, prune‐belly syndrome in two, anal‐rectum and urethral atresia syndrome in one, primary obstructive uropathy in one and caudal regression syndrome in one. Two children were diverted with an ileal conduit; four had a bladder augmentation, and four had a bladder augmentation with additional continent cutaneous stoma. A continent urinary reservoir was constructed in one boy, and one boy had a Mitrofanoff‐only procedure. Subsequently, 11 children were transplanted.

RESULTS

The graft survival rate was 11 of 12 at 1 year and eight of 12 at 5 years. No patient lost the graft related to the reconstructed lower urinary tract. During the median (range) follow‐up of 5.4 (1.6–12.5) years all but one child had free drainage of the upper urinary tract. All 10 children who did not have an ileal conduit are continent.

CONCLUSION

Reconstruction of the lower urinary tract followed by renal transplantation is a safe and efficient approach. It has the advantage of restoring the lower urinary tract before immunosuppressive therapy, and supplies the best possible reservoir for a transplanted kidney.     

The expanded role of transureteroureterostomy in pediatric urology

Transureteroureterostomy was used in 31 patients as a component in urinary undiversions, salvage procedures for failed reimplants/reconstructions and diversions with a sigmoid antirefluxing conduit or end cutaneous ureterostomy, as well as an adjunct to reimplantation procedures complicated by an abnormal bladder that precluded reimplantation of more than 1 ureter. Reconstruction in 29 patients involved procedures that changed the drainage of the recipient ureters for various reasons, including obstruction, reflux, undiversion and diversion. A neurogenic bladder was present in 26 patients and an additional 4 patients had a significant bladder pathological condition. Both ureters were dilated in 17 patients, while 1 was dilated in another 6. This series illustrates the versatility and confirms the success of transureteroureterostomy in high risk, complicated reconstructive urological procedures in children.     

Reconstruction of urinary tract combined with surgical management of locally advanced non-urological cancer involving the genitourinary organs

INTRODUCTION: The objective of this study was to review our experience with urinary reconstruction in patients undergoing surgical management for locally advanced pelvic cancer, and to evaluate the role of urologists in these procedures. MATERIALS AND METHODS: This study included a total of 37 patients undergoing some type of urinary reconstruction due to invasion of the urological organs by locally advanced pelvic cancers, including 17 rectal cancers, 9 cervical cancers, 4 sigmoid cancers, 4 retroperitoneal sarcomas, 2 ovarian cancers and 1 appendiceal cancer. Among these 37, 18 were recurrent cancers following initial surgery for primary tumors. The clinical outcomes of these approaches were retrospectively analyzed. RESULTS: Of the 37 patients, 9 underwent cystectomy (group A) with the following urinary diversions: ileal neobladder in 3, ileal conduit in 5 and colon conduit in 1, and 12 underwent partial cystectomy (group B), among whom 11 received additional urinary reconstruction as follows: bladder flap repair in 5, psoas hitch in 2, ileal ureter in 2, bladder augmentation in 1 and ureteroureterostomy in 1, while the remaining 16 (group C), in whom complete bladder preservation was possible, underwent the following types of urinary reconstruction: bladder flap repair in 6, psoas hitch in 3, en bloc removal of the rectum with prostate in 3, ileal ureter in 2, and ureteroureterostomy in 2. There were 10 early urological complications, including leakage of urine in 7 and acute pyelonephritis in 3. As a late urological complication, hydronephrosis was observed in 8 patients, but ureteral stent was not required in any of these 8. There were no significant differences in the incidence of postoperative complications, the status of surgical margin and the survival among groups A-C. CONCLUSION: Our experience with extended surgical management of non-urological pelvic cancer with reconstruction of the urinary tract suggests that the urological portion of this procedure can be performed with acceptable morbidity, and that the role of the urological surgeon during this procedure is potentially important.     

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.     

Statistics on operations in the Department of Urology, Kobe University School of Medicine (January, 1976 to December, 1980)

Statistical observations on operations performed in our department from 1976 to 1980 were reviewed, especially in comparison with the statistics for the preceding 10 years. Operations on the kidney were the most frequent, as they were in the preceding 10 years, but operations on the bladder have increased remarkably, in 1980 accounting for more than those on the kidney. During this period, operations for benign diseases such as lithotomy of the upper urinary tract and prostatectomy tended to decrease. On the other hand, operations for malignant diseases of kidney, bladder and scrotal contents steadily increased. Transurethral operations are still increasing, especially for bladder tumors. It has been established that bladder tumors should be treated by either TUR-BT or total cystectomy and not by partial cystectomy. As to urinary diversion, ileal conduit was the main procedure used during this 5-year period instead of cutaneous ureterostomy.     

Hemi-T pouch modification for pediatric urinary diversion

PURPOSE: When the appendix is unavailable, there are limited reliable methods for continent urinary diversion. After successful application of double-T pouch urinary diversion in adults we modified the technique for bladder augmentation and continent diversion. MATERIALS AND METHODS: A 10-year-old male underwent bladder augmentation and continent urinary diversion with a hemi-T augment. Modifications of the T pouch technique are described in detail. We also reviewed the literature on tapered ileal diversions, such as the Yang-Monti procedure. RESULTS: One year after surgery the patient was continent. He was free of infection and bilateral hydronephrosis resolved. Urodynamics demonstrated a continent 350 ml reservoir without reflux. CONCLUSIONS: For patients who require concomitant bladder augmentation and continent diversion a hemi-T augment is a suitable option when the appendix is unavailable. It is especially true when there is minimal bladder available for implantation of a Yang-Monti conduit.     

Primary intestinal type adenocarcinoma of the urinary bladder: a case report]

A 43-year-old man was referred to our hospital with complaints of macroscopic hematuria, micturition pain, and pollakisuria. Cystoscopy revealed a papillary broad-based tumor of 4 cm in diameter at the posterior wall and trigone of the urinary bladder. A punch biopsy specimen was diagnosed histopathologically as adenocarcinoma mimicking colorectal cancer. Computed tomographic (CT) scan demonstrated a large tumor involving both the urinary bladder and the rectum. Total cystoprostatectomy and low anterior resection following colorectal anastomosis, double barreled colostomy, and ileal conduit urinary diversion were performed. The tumor was diagnosed histopathologically as primary intestinal type adenocarcinoma of the urinary bladder infiltrating the sigmoid colon and the small intestine. The patient died 12 months after the operation due to peritonitis carcinomatosa.     

A case of urinary undiversion from ileal loop conduit

A seventeen-year-old girl, who had had an ileal conduit urinary diversion at 5 years of age, underwent a urinary undiversion 12 years after the initial operation. She has been suffering from recurrent episodes of urinary tract infection with fever. The preoperative evaluation revealed dilatation of the bilateral pelvis and ureters on an excretory urography. Ileal conduitgraphy revealed urinary reflux from the ileal loop to the bilateral upper urinary tracts. Cyclic bladder hydrodilatation through a suprapubic cystostomy was performed and a precise urodynamic study was done on the lower urinary tract. The vesical capacity increased from 40 ml to 300 ml in a month. Cystometry and urethral pressure profile revealed a stable bladder with good detrusor contraction and preserved urethral continence. Voiding status was satisfactory with only a small amount of residue. The undiversion was undertaken as follows. The ureters were once isolated from the ileal loop and their distal ends were everted in length of 5 mm to be nipples in shape. The ureters were reanastomosed to the proximal end of the ileal loop with submucosal tunnels of 2 cm. The ileal loop was then tapered and implanted to the bladder with a submucosal tunnel of 5 cm. Eight months after the undiversion, she enjoys good urination, free from urinary tract infection. Although moderate hydronephrosis remains bilaterally, renal function is stable.     

Sigmoid conduit urinary diversion.

The courses of 11 patients with sigmoid conduit urinary diversion following total pelvic exenteration were reviewed in detail and the results presented. The sigmoid conduit appears to be a safe alternative to the ileal conduit for urinary diversion, and offers in addition the possible advantage of an effective antirefluxing ureterocolic anastomosis.     

Ileal substitute of ureter with reflux-plasty by terminal intussusception of bowel Animal experiments and clinical experience

The conflicting results reported after substitution of the ureter by isolated bowel segments suggest that the procedure is still hazardous. This induced us to check experimentally the performance of the ileal ureter with antireflux-plasty before using it clinically. The antireflux mechanism is constructed by intussuscepting the terminal 8 cm. of an isolated ileal segment into each other thus forming a nipple. After vesicoileostomy the nipple protrudes into the urinary bladder. In the pig vesicoileorenal reflux was prevented, and anterograde urinary flow from the kidney through the ileal ureter into the bladder was unobstructed. Finally, the case of a patient is recorded who was submitted to the same procedure successfully.     

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.     

Clinical study of radical cystectomy and urinary reconstruction in elderly patients with bladder cancer

We compared the clinical and functional results of radical cystectomy and urinary reconstructions performed on 19 elderly bladder cancer patients over 75 years old to those on 22 younger patients to determine whether age was one of the critical points for the application of this type of surgery. Between January 1992 and January 1998, bladder substitution was performed after cystectomy using either the Hautmann, Studer or Reddy procedure in 9 of the 19 elderly patients. Urinary diversion was performed after cystectomy using ileal conduit and ureterocutaneostomy procedures in the rest of the patients. On the other hand, bladder substitutions were performed in 11; urinary diversions with continent urinary reservoir in 6 and with ileal conduit in 4 of the 22 younger patients. Neither prolongation of the operation time, nor increase in the amount of bleeding or prolongation of the post-operative hospitalization period was observed in any procedure used for elderly patients in comparison with younger ones. In elderly patients, the average operation time of radical cystectomy with bladder substitution was slightly longer than that of total cystectomy with ileal conduit or ureterocutaneostomy. The post-operative hospitalization period in the case of bladder substitution was similar to that for ileal conduit and ureterocutaneostomy with the difference of only 5 days on average. There were no peri-operative deaths, and early post-operative complications were observed in 3 of 9 cases of the bladder substitution, in 4 of 10 cases of ileal conduit or ureterocutaneostomy. Five cases of bladder substitution maintained their comfortable voiding urine comfortably, while 4 had dysuria and/or urinary incontinence. Over all, late complications occurred in 10 of the elderly patients. The rate and types of complications in the elderly patients were not different from those in the younger patients. The cause-specific survival rate and overall survival rates of the elderly patients were similar to those of the younger patients. In conclusion, indication of cystectomy and selection of urinary reconstruction procedure are not dependent on patient's age, Orthotopic urinary reservoir was found to be useful for even an elderly patient.     

Augmentation ileocystoplasty and ileal ureter replacement for distal ureteral cancer in a patient with a contracted bladder

BACKGROUND: A male patient with a solitary kidney and contracted bladder due to urinary tuberculosis presented ureteral obstruction caused by primary lower ureteral cancer. METHODS: Distal ureterectomy and urinary tract reconstruction consisting of ileal bladder augmentation and ileal ureter replacement with an antireflux procedure was performed. RESULTS/CONCLUSIONS: Postoperatively satisfactory voiding without residual urine was achieved.     

膀胱全切不同尿流改道术后生活质量评估分析

目的:评估膀胱全切术后4种常见尿流改道术患者的生活质量(HRQOL)差异情况,为尿流改道术式的选择提供临床依据。方法:回顾性分析我院1995年1月~2009年6月共101例膀胱癌患者行全膀胱切除后尿流改道术的临床资料,即原位回肠新膀胱术(IN)28例、原位乙状结肠膀胱术(SN)22例、输尿管皮肤造口术(CU)20例、回肠膀胱术(IC)31例。IN和SN采用原位膀胱重建,属新膀胱组(NB)。用膀胱癌患者生活质量量表(FACT-BL)和国际前列腺症状评分(IPSS)作为调查工具,比较分析生活质量及排尿功能变化情况。结果:成功随访78例。4组尿流改道术式在男性人数、年龄、文化程度、城镇人数等方面差异无统计学意义(P0.05)。而NB组手术时间及术后住院天数明显长于经皮肤尿流改道组(CU和IC)。4组尿流改道HRQOL差异未见统计学意义,但FACT-BL躯体功能得分NB组高于CU组及IC组(P0.05)。结论:4组膀胱全切尿流改道术后总体生活质量相当,但原位新膀胱在躯体形象恢复方面优于不可控性经皮肤尿流改道术。     

Urinary undiversion with implantation of an artificial urethral sphincter

Urinary undiversion was performed in a 21-year-old man with a contracted flaccid bladder. The steps of the procedure were: bladder dilatation; antireflux implantation of an ileal conduit into the bladder; external sphincterotomy, and implantation of an artificial urethral sphincter. The patient is continent and has a good bladder capacity and emptying. In many patients with urinary ileal conduit diversion, upper urinary tract and stomal problems develop after some years. In these patients urinary undiversion must be considered but, so far, evaluation showing a high risk of postoperative incontinence has been regarded as a contraindication to urinary undiversion. However, the introduction of artificial urethral sphincters has made it possible to perform undiversion procedures in many of these patients in whom the bladder capacity and bladder emptying is acceptable, if a nonobstructed outlet is secured. We describe the findings and procedures in a patient undergoing urinary undiversion with implantation of an artificial sphincter 8 years after urinary diversion due to neurological disorders caused by a myelomeningocele.     

Total replacement of the urinary bladder using an ileal pouch bladder

We have used the continent ileal bladder as a bladder replacement after radical cystectomy. The ileal bladder is an ileal pouch which is anastomosed to the urethral stumps. The ureters are implanted by a free end ureteroileostomy. The long term results with 26 patients who underwent this procedure are reported. In the early postoperative period, urodynamic and radiographic studies revealed small capacity and high intravesical pressure of the ileal bladder. However, it became a low pressure reservoir with increased capacity gradually. The average bladder capacity was about 250 ml and average residual urine was 30 ml. Most of the patients were continent in the daytime if the voiding intervals were less than 3 hours at night, some patients were incontinent. Urinary leakage was the most frequent complication. VUR and hydronephrosis were still the problems to be solved. The ileal pouch bladder is a valuable procedure in properly selected cases.     

Management of tuberculous-contracted bladder with bilateral duplex collecting system: a case report with modified robotic urinary tract reconstructive surgery

Tuberculous bladder contracture with a bilateral duplicated collecting system is rare. According to anatomic variation, the surgical treatment strategy is highly individualized. We illustrate our robotic technique of urinary tract reconstruction. A 19-year-old girl with a history of pulmonary tuberculosis (TB) as a young child presented with a complaint of increasing frequency of micturition, nocturia, urgency, and urge incontinence starting at the age of 17. Clinical and imaging examinations demonstrated tuberculous contracted bladder with a bilateral duplex collecting system. The patient underwent a robot-assisted Institute of Urology Peking University (IUPU) orthotopic ileal neobladder reconstruction. This is a modified urinary tract reconstructive method, including resection of the end of the duplex ureters and diseased contracted bladder with preservation of the proximal urethra and bladder neck, ileal harvesting and IUPU strategy to reconstruct an ileal neobladder, uretero-ileal anastomosis and neobladder-bladder neck anastomosis. The patient remained symptom-free without recurrence of TB and had improved renal function during the one-year follow-up after surgery. Thus, our robot-assisted IUPU orthotopic ileal neobladder reconstruction method is an effective approach for this benign case. It can effectively increase bladder capacity, reduce intravesical pressure, and improve symptoms such as urination frequency and urgency.