Long-term followup of augmentation enterocystoplasty and continent diversion in patients with benign disease

PURPOSE: We evaluated long-term outcomes in patients undergoing augmentation enterocystoplasty (AC) (with or without an abdominal stoma) or continent urinary diversion in patients with benign urological disorders. MATERIALS AND METHODS: This was a retrospective study of 76 consecutive adults who underwent AC (with or without an abdominal stoma) or continent urinary diversion because of benign urological conditions. The outcomes assessed were a patient satisfaction questionnaire, continence status, catheterization status, bladder capacity, bladder compliance, detrusor instability, maximum detrusor pressure, upper tract status, significant postoperative morbidity, need for reoperation, persistent diarrhea and vitamin B12 deficiency. RESULTS: The 76 patients (18 men and 58 women) were 19 to 80 years old (mean age 49). Followup was 1 to 19 years (mean 8.9). Preoperative diagnoses were neurogenic bladder in 41 patients, refractory detrusor overactivity in 9, interstitial cystitis in 7, end stage bladder disease in 7, radiation cystitis in 3, exstrophy in 3, postoperative urethral obstruction in 3 and low bladder compliance in 3. A total of 50 patients underwent simple AC, 15 underwent AC with an abdominal stoma and 11 underwent continent supravesical diversion. Of the 71 evaluable patients 49 (69%) considered themselves cured, 14 (20%) considered themselves improved and 8 (11%) considered treatment to have failed. All 7 patients with interstitial cystitis had failed treatment. Mean bladder capacity increased from 166 to 572 ml and mean maximum detrusor pressure decreased from 53 to 14 cm H2O. Serum creatinine improved or remained normal in all patients. Five patients experienced persistent diarrhea requiring intermittent antispasmodics but none had vitamin B12 deficiency, pernicious anemia or malabsorption syndrome. Long-term complications were stomal stenosis or incontinence in 11 of 26 patients (42%) with stomas, de novo bladder and renal stones in 2 of 71 (3%) and 1 of 71 (1%), respectively, and recurrent bladder stones in 6%. Small bowel obstruction occurred in 5 of 71 patients (7%), requiring surgical exploration in 4 (6%). CONCLUSIONS: AC and urinary diversion provide a safe and effective long-term therapy in patients with refractory neurogenic bladder but stomal problems in patients with continent diversion continue to be a source of complications.     

Long-term multi-institutional evaluation of Charleston pouch I continent cutaneous urinary diversion

PURPOSE: Charleston pouch I continent cutaneous urinary diversion has been used since 1989. We evaluated the long-term results of this procedure in 201 consecutive patients. MATERIALS AND METHODS: The records of patients treated with the Charleston pouch I between 1989 and 2005 at 3 university hospitals were reviewed. Available data on age, sex, indications for diversion, comorbidity, followup duration, continence status, short-term and long-term complications, quality of life issues, and laboratory, radiological and urodynamic data were recorded. Patients were followed at 6-month intervals. RESULTS: Followup was 14 to 136 months. Seven adults died in the 90-day postoperative period, and 21 (10.8%) and 51 (26%) patients had early and late complications, respectively. The interval between clean intermittent catheterizations was 2 to 8 hours. Mean capacity was 470 ml (range 250 to 1,300). At 12 months diurnal continence was achieved in 98% of the patients. A total of 98 patients (50.5%) needed night catheterization to stay dry. Of 342 ureters 17 (5%) became obstructed, requiring open or endoscopic management. Urolithiasis developed in 16 patients (8%). Vesicoureteral reflux was noted in 15 renal units (4.4%). Stomal complications developed in 8.2% of cases. Modest vitamin B12 supplementation was empirically used to avoid long-term deficiency. No detrimental effects on vitamin B12 concentrations were noted for up to 10 years. CONCLUSIONS: Long-term multi-institutional followup of the classic Charleston pouch I reveals that it provides adequate continence with an acceptable complication rate and satisfactory patient acceptance.     

The Boari bladder flap: an effective continent stoma for the high‐compliance neurogenic bladder

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine if a continent urinary stoma can be created effectively using a Boari bladder flap (BBF) technique.

PATIENTS AND METHODS

Selected patients (15, eight women and seven men) with a neurogenic bladder and a bladder compliance of >20 mL/cmH₂O had a procedure to create a BBF continent urinary stoma. The technique consisted of tubularising a trapezoidal, full‐thickness detrusor flap 10 cm long, 5–6 cm wide at the base and 2 cm at the tip, over a 12 F catheter, and plication of detrusor muscle around the stomal base. Outcomes after surgery were assessed by reviewing stomal continence, stomal patency, and stability of the upper urinary tract.

RESULTS

Ten BBF procedures were performed using native detrusor muscle, four with enterocystoplasty tissue and one in a defunctionalized bladder. Over a mean follow‐up of 13 months, 11 patients had functioning stomas and 10 of these reported complete stomal continence. The mean change in serum creatinine level from the preoperative baseline for all patients was 0.1 mg/dL. The odds ratio for procedural failure, defined as a stoma unusable for self‐catheterization, was 7.5 (P = 0.04) when the BBF was created from augmented or defunctionalized bladder tissue, compared to native high‐compliance detrusor.

CONCLUSION

A BBF can be used to create a viable, functional stoma in the high‐compliance neurogenic bladder, although the rate of stomal complications is high when the BBF is created from enterocystoplasty tissue.     

Long-term followup of patients after redo bladder neck reconstruction for bladder exstrophy complex

PURPOSE: The aim of this study was to determine whether redo bladder neck reconstruction is effective in achieving continence after a failed bladder neck reconstruction procedure. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients with bladder exstrophy who had undergone redo bladder neck reconstruction. There were 30 patients in the study, including 20 boys and 10 girls. Mean patient age at redo bladder neck reconstruction was 9.3 years (range 3.2 to 15.5). The patients were divided into 3 groups on the basis of the preoperative pattern of incontinence--incomplete wetters, complete wetters and those on continuous suprapubic drainage. Of the patients 15 already had undergone bladder augmentation, 12 had undergone a Mitrofanoff procedure and 12 had been treated with bulking agents injected in the bladder neck in an attempt to achieve continence. Four patients had undergone more than 1 bladder neck procedure. The patients were investigated with a combination of noninvasive urodynamics, cystoscopy, cystogram and ultrasound. All patients underwent Mitchell's modification of Young-Dees-Leadbetter bladder neck reconstruction. Additional procedures performed included augmentation cystoplasty and Mitrofanoff formation. RESULTS: Mean followup was 6.9 years (range 1.2 to 15.5). Postoperatively 28 patients were using clean intermittent catheterization to empty the bladder (5 per urethra, 23 via Mitrofanoff). Two patients remained on continuous suprapubic catheter drainage. A total of 18 patients (60%) were dry postoperatively (80% of girls and 50% of boys). Among dry patients only 3 were performing clean intermittent catheterization per urethra and 15 via a Mitrofanoff channel. No patient was able to void per urethra without the need for clean intermittent catheterization. The 2 patients on continuous suprapubic catheter drainage continued to remain so. At night only 50% of the patients were dry (5 on free drainage, 4 on clean intermittent catheterization, 6 not on any drainage). Those patients who did not respond satisfactorily to redo bladder neck reconstruction underwent subsequent additional procedures, which included injection of bulking agents (3 patients), insertion of an artificial urinary sphincter (1), Mitrofanoff formation (2) and bladder augmentation plus Mitrofanoff channel (1). Postoperative complications included difficulty with clean intermittent catheterization (8 patients), perivesical leak (1), recurrent epididymo-orchitis (1), upper urinary tract dilatation (2) and incisional hernia (1). Bladder neck closure was being considered in 5 patients. CONCLUSIONS: In our experience redo bladder neck reconstruction cannot achieve continence with volitional voiding per urethra. Although redo bladder neck reconstruction can render a significant number of patients dry, it is only effective if performed in conjunction with augmentation. Failure of the initial bladder neck reconstruction may be a reflection of a bladder that is of inadequate capacity and/or compliance. Therefore, bladder augmentation should be considered in all patients requiring redo bladder neck reconstruction. Bladder neck closure may be a better alternative to redo bladder neck reconstruction.     

Lessons learned from stomal complications in children with cutaneous catheterizable continent stomas

OBJECTIVE: To evaluate the impact of various factors that might ultimately influence the stoma complication rate associated with the construction of a continent catheterizable urinary (CCU) and Malone antegrade colonic enema (MACE) stoma in children. PATIENTS AND METHODS: Retrospectively, we reviewed our experience in patients who had a CCU and/or MACE stoma reconstructed at our institution from 1992 to 2003. Diagnosis, type of stoma constructed (CCU vs MACE), single vs dual stomas, stomal site, conduit material (appendix, split appendix, Monti-Yang or ureter), sex, age, patient mobility and body mass index, race and concomitant surgery (e.g. bladder augmentation with or without bladder neck reconstruction) were evaluated for stoma-related complications. In all, 109 patients (64 males and 45 female), with a mean (sd, range) age of 8.6 (5.7, 2-37) years, had 151 stomas constructed during the period of analysis, comprising 56 CCU only, 11 MACE only and 42 (84 stomas) both simultaneously. RESULTS: The mean (range) follow-up was 48 (6-144) months. The primary diagnoses were neurogenic bladder in 60 (55%), bladder exstrophy/epispadias in 17 (16%) and posterior urethral valves in 11 (9%) patients. The umbilicus was the primary site for the CCU stoma in 88 of 98 (90%) cases, while the right lower quadrant was the primary site for MACE in 46 of 53 (87%). After surgery complete stomal continence was provided in 95 of 98 (97%) CCU stoma, whereas the MACE was successful in 52 of 53 (99%). The stoma-related complications included stenosis in 27, leakage in eight, false passage in four, atrophy in two, keloid in one, and breakdown of the stoma in two. Individually, only greater age and a primary diagnosis of neurogenic bladder were independent risk factors associated with an increased rate of stomal complications and higher incidence of revision (P < 0.05). CONCLUSION: Stomal complications are extremely common whether CCU or MACE stomas are constructed individually or together. Nevertheless, despite the need for revision, the high stoma continence rate supports their use. Greater age at surgery and a primary diagnosis of neurogenic bladder were associated with a significant increase in the stoma-related complications and the need for revision.     

The continent, catheterizable abdominal conduit in adult urological practice

OBJECTIVE

To report a large, single‐centre experience with a continent, catheterizable abdominal conduit in adult patients.

PATIENTS AND METHODS

We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13‐year period. Data on surgical procedure, complications and final outcome were collected and analysed.

RESULTS

The mean age of the patients was 38.4 years and mean follow‐up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent.

CONCLUSIONS

Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long‐term follow‐up.     

可控性尿流改道与原位肠代膀胱的临床应用研究

目的:为膀胱全切术后的患者提供更好的控尿术式。方法:回顾性分析1998～2010年间28例可控性尿流改道(可控性回结肠膀胱)和21例原位肠代膀胱的并发症发生率及其对患者生活质量的影响。可控性回结肠膀胱组前9例行Indiana术式,后19例行改良的Indiana术式。原位肠代膀胱组采用乙状结肠或"W"形回肠纵行剖开制成贮尿囊。结果:本研究组49例均获得随访,随访时间6个月～12年。可控性回结肠膀胱组28例自行清洁导尿,间隔时间90～270min,平均240min。原位肠代膀胱组21例在腹压的辅助下自行排尿,排尿间隔时间150～240min,平均195min。可控性回结肠膀胱组中22例感觉生活满意或基本满意(78.6%),6例感觉生活不便(21.4%);9例出现并发症(32.1%)。原位肠代膀胱组中19例患者感觉生活满意(90.5%),2例感觉不满意(9.5%),均为压力性尿失禁;3例出现并发症(14.3%)。结论:原位肠代膀胱患者的生活质量优于可控性回结肠膀胱,术后并发症方面,原位肠代膀胱组患者并发症明显小于可控性回结肠膀胱组。     

回肠壁叠盖式可控输出道的实验研究

目的 探讨经皮可控性尿流改道术中一种新型输出道的控尿能力及应用价值。方法 采用配对比较,在同一段回肠的两端分别缝制肠壁叠盖式输出道和套叠乳头式(Kock)输出道。以整个肠管作为贮尿囊并注入生理盐水,观察贮尿囊压力和肠壁叠盖式输出道中点压力的变化关系,并且测定两种输出道的失控压力。结果 肠壁叠盖式输出道中点压力与贮尿囊压力呈正相关性。其直线回归方程为:输出道中点压力(cmH2O)=18.71+0.95×贮尿囊压力。肠壁叠盖法失控压力明显高于套叠乳头法(P<0.01)。结论 肠壁叠盖法输出道操作简单,控尿能力强,需要的肠管少,适用性广,是一种值得进一步研究的可控性输出道制作法。     

Long-term results of ileocecal continent urinary diversion in patients treated with and without previous pelvic irradiation

PURPOSE: Patients who receive pelvic irradiation may require urinary diversion to manage complications resulting from progressive malignancy or radiotherapy. The choice of urinary diversion is an important issue and remains controversial. We characterized the long-term outcome of urinary diversion with a continent ileocecal reservoir in patients who received pelvic irradiation versus those who underwent urinary diversion without previous irradiation. MATERIALS AND METHODS: Continent urinary diversion with an ileocecal reservoir (Mainz pouch 1) was performed in 36 irradiated patients in a 9-year period. Morbidity, mortality, the reoperative rate and parameters associated with the surgical procedure were determined at a median followup of 57 months. Results were compared with those in 385 nonirradiated patients who received the same type of continent diversion after cystectomy for bladder cancer. RESULTS: Irradiated patients had a significantly higher rate of serious complications after ileocecal urinary diversion than nonirradiated controls. Continence mechanism failure occurred in 25% of patients in the irradiated group and 5.7% in nonirradiated patients, stomal complications were noted in 38.8% and 10.6%, and ureteral complications developed in 22.2% and 6.5%, respectively. CONCLUSIONS: In patients who have received pelvic radiotherapy, ileocecal Mainz pouch 1 continent urinary diversion is associated with a high rate of serious complications and should be avoided.     

APPENDICOVESICOSTOMY AND NEWER ALTERNATIVES FOR THE MITROFANOFF PROCEDURE: RESULTS IN THE LAST 100 PATIENTS AT RILEY CHILDREN′S HOSPITAL

PURPOSE: We present our experience using the various Mitrofanoff techniques to create a continent catheterizable stoma as an adjunct to continent urinary tract reconstruction in children and young adults. MATERIALS AND METHODS: Between 1990 and 1998 a Mitrofanoff procedure was performed at our institution in 55 male and 45 female patients with a mean age of 10.5 years. The etiology of incontinence was diverse but more than 90% of the patients had neurogenic bladder, the epispadias-exstrophy complex or a cloacal anomaly. Surgery included appendicovesicostomy in 57 cases, a Yang-Monti ileovesicostomy in 21, continent vesicostomy in 21 and formation of a tapered ileal segment as a catheterizable channel in 1. Simultaneously bladder augmentation was performed in 52 patients, bladder neck reconstruction was done in 48 and a Malone antegrade colonic enema stoma was constructed for fecal incontinence in 17. RESULTS: The abdominal stoma is continent in 98 of our 100 patients. Mean followup is 2 years (range 2 months to 8 years) with the longer followup in the appendicovesicostomy group. One patient with stomal incontinence who underwent revision is now dry. Postoperative complications requiring an additional procedure developed in 20 patients, including stomal stenosis in 12. Continent vesicostomy was most prone to stomal problems (6 of 21 patients, 29%). CONCLUSIONS: The Mitrofanoff procedure is a reliable technique for creating a continent catheterizable urinary stoma. Appendicovesicostomy continues to be our first option for this procedure, although we have also had good results with the Yang-Monti ileovesicostomy and continent vesicostomy. These newer options have allowed preservation of the appendix for the Malone antegrade colonic enema stoma procedure in patients with urinary and fecal incontinence.     

Seminal sparing cystectomy and ileocapsuloplasty: long-term followup results

PURPOSE: The efficacy of nerve sparing techniques to save potency in cystoprostatectomy is about 50%. This radical surgery may be proposed to young men with normal sexual function. We report the results of a 13-year experience with our innovative seminal sparing cystectomy and bladder replacement to maintain sexual function in such patients. MATERIALS AND METHODS: Seminal sparing cystectomy is a modification of standard radical cystectomy in which the posterior bladder dissection is anterior to the seminal vesicle plane to preserve the vasa deferens, seminal vesicles, prostatic capsule and neurovascular bundles. Ablation of the whole bladder and the prostatic urothelium with surrounding hypertrophic tissue is guaranteed, and injury to the pelvic nerve plexus that provides autonomic innervation to the corpora cavernosa is avoided. From April 1990 to December 2002 we performed 68 procedures in 63 patients (7 of whom were lost to followup) with superficial bladder cancer resistant to conservative therapies (18 patients with stage T1G2 disease, 13 TaG2, 11 T1G3 and 14 TaG3) and in 5 patients with invasive bladder cancer (T2G3) which was monofocal and away from the bladder neck. All patients had normal sexual function. A complete clinical evaluation (with prostate specific antigen [PSA], digital rectal examination and transrectal ultrasound) to exclude concomitant prostate cancer was performed. Average patient age was 49 years and mean followup was 68 months. RESULTS: Normal erectile function was preserved in 58 patients (95%). Complete daytime continence was reached in 58 patients (95%) and nighttime continence was reached in 19 patients (31%). The early postoperative complication rate was 18% and the delayed complication rate was 26.2%. A total of 55 patients (90.2%) are alive and 6 patients (9.8%) died, 5 of cancer progression. High grade prostatic intraepithelial neoplasia was noticed in prostatic specimens in 3 patients and prostatic cancer was noted in 1 patient. These patients had a normal PSA before operation and a serum PSA less than 0.2 ng/ml at a mean followup of 19 months. No positive margins were identified on permanent histological analysis of the specimens, nor were local pelvic recurrences observed. CONCLUSIONS: Our innovative technique is safe, effective and easy to perform. The oncological and functional results obtained with a long followup justify seminal sparing cystectomy as an excellent surgical procedure which can be proposed to some oncological and nononcological cases.