可控性回结肠膀胱术远期疗效的临床研究

目的 对可控性回结肠膀胱术的远期疗效进行评价。方法 对23例回结肠膀胱术术后患者的可控性尿动力学、血清电解质、肾功能等进行随访观察。结果 23例随访4～126个月，平均59个月。白天可控率为100％，夜问可控率96％。贮尿囊容量350～640ml，平均560ml，贮尿囊内压力9．30～32，08cmH2O（1cmH2O=0．098kPa），平均19．20cmH2O。B超、静脉肾盂造影（IVP）及贮尿囊造影显示：单侧输尿管狭窄并肾积水1例。贮尿囊结石2例。血清电解质及肾功能正常。结论 可控性回结肠膀胱术远期疗效可靠、并发症少，是一种较理想的尿路分流术式。     

原位阑尾输出道的可控性回结肠膀胱术（附16例报告）

为更好地解决膀胱癌患膀胱全切后的储尿问题，采用原位阑尾造口作输出道的可控性回结肠膀胱术治疗１６例膀胱癌患。其方法是用末段回肠、盲肠及升结肠作储尿囊，原位阑尾翻转１８０°粘膜下隧道埋藏，行右下腹壁或部造口作输出道。结果：除１例患有间歇性少量漏尿外，其余均可安全控制尿液。储尿囊内压低，可控效果佳，并发症少，中对手术技巧进行了详细讨论，认为此法基本上满足了理想的可控性膀胱的要求。     

可控性回结肠膀胱术远期疗效观察

评价可控性回结肠膀胱手术的远期疗效。方法对２０例回结肠膀胱术术后病人的可控性、尿动力学、血清电解质、肾功能等进行随访观察。结果２０例随访６－１１８个月，平均６２个月。白天可控率１００％，夜间可控率９５％。贮尿囊容量３８０－６６０ｍｌ，平均５８０ｍｌ。     

阑尾与尿道吻合的回盲肠代膀胱手术远期疗效观察(附11例报告)

目的　评价阑尾与尿道吻合的回盲肠代膀胱手术远期疗效。　方法　应用回盲肠作贮尿囊 ,阑尾代后尿道原位排尿的方法治疗膀胱肿瘤病人 5 6例。　结果　 11例病人术后获 10年以上随访。其中白天完全自控排尿 10例 ,夜间完全自控排尿 8例。伴后尿道假性瓣膜 2例 ,贮尿囊内继发结石 1例 ,后尿道狭窄 1例 ,无输尿管返流 ,无高氯性酸中毒。贮尿囊容量 2 90～ 5 2 0ml,平均 388ml,压力 2 3～ 36cmH2 O(1cmH2 O =0 .0 98kPa) ,平均 2 8cmH2 O。平均尿流率 9.6ml/s。　结论　阑尾与尿道吻合的回盲肠代膀胱术式具有贮尿囊内压低 ,容量大 ,可控性和原位排尿的优点 ,是一种较理想的尿流改道方式。     

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。     

改良低压可控性回结肠膀胱术

目的 建立一种更接近生理的回结肠代膀胱术。方法 1991年10月至1996年10月实施8例全膀胱切除回结肠膀胱与尿道吻合,由外括约肌控制,经尿道排尿的新手术方法。结果 术后随访8个月～9年8个月,平均5年3个月。至随访日全部无吻合口狭窄,排尿通畅,无肾盂积水,肾功能正常。结论 该术式具有贮尿囊内压低(12～20 cmH_2O)、容量适中(300～460 ml,一年后400～700 ml)、可控性和原位排尿的优点,操作简单、并发症少,且无电解质紊乱和肾功能损害,是一种较好的尿流改道方式。     

可控性回结肠膀胱阑尾腹壁造口术五例报告

可控性回结肠膀胱阑尾腹壁造口术五例报告杨远清，顾明祥，杨燮樵，周毅１９８９年１０月至１９９２年７月，我们根据Ｉｓｓａ等（Ｉｓ－ｓａＭＭ，ｅｔａｌ；ＪＵｒｏｌ，１９８９，１４１：１３８５）的报告，对５例膀胱癌患者行膀胱全切。可控性回结肠膀胱阑尾腹壁造口...     

以阑尾为流出道的可控性回盲肠膀胱术远期疗效观察

目的 评价以阑尾为流出道的可控性回盲肠膀胱手术的远期疗效。方法 应用回盲肠及部分升结肠作储尿囊，以阑尾为流出道腹壁造口术治疗膀胱肿瘤患者46例，采用尿动力学方法随访5年以上21例。男15例，女6例，平均年龄57岁。G212例，G39例。T3aN0M011例，T3bN0M0 5例，T3bN1M03例，T3bN0M02例。结果 21例患者中能控尿者19例(95％)。白天导尿4～5次，夜间1～2次，每次量250～400ml。膀胱初始感觉压力平均28cmH2O，最大充盈压36cmH2O，储尿囊容量分别为265ml、450ml。阑尾流出道闭合压力45cmH2O。1例患者出现肺转移行手术切除，1例出现肝转移死亡。无输尿管返流，无高氯血性酸中毒。结论 以阑尾为流出道的回盲肠膀胱术储尿囊内压低、容量大、可控性好，是一种较理想的尿流改道方式。     

阑尾原位脐部造口的可控性回结肠膀胱术

目的尝试根据Ｍｉｔｒｏｆａｎｏｆｆ原理，将阑尾不加任何处理直接从脐孔穿出，构成可控性回结肠膀胱的排出管道。方法 选取末段回肠和肓肠升结肠各约２０ｃｍ，保留阑尾，沿肠系膜对侧缘纵行劈开肠管，远近端对折缝合形成囊袋。双侧输尿管与囊袋以粘膜下隧道法吻合，阑尾末端开放，并直接从脐部戳孔引出固定，形成可控性回结肠膀胱。结果 ８例患者术后随访１０￣３０个月，回结肠膀胱脐部阑尾排出道控尿能力满意，患者自行插管排     

阑尾原位经脐造口的可控性回结肠膀胱术(附32例报告)

目的 探讨无处理阑尾脐部造口可控性回结肠膀胱术的临床效果。方法 回、结肠各约２０ｃｍ,纵形剖开、拼接形成囊袋。采用未经处理的阑尾由脐部直接引出造口。共为３１例膀胱肿瘤和１例间质性膀胱炎患者实施了膀胱全切、无处理阑尾经脐造口的可控性回结肠膀胱术。结果 新膀胱容量３００～５００ｍｌ,内压达４０ｃｍＨ２Ｏ无尿溢出。患者可自我导尿,造口勿需覆盖,不影响任何活动。随访６个月至５年,临床效果满意。结论 无处理     

CONTINENT ILEOCECAL DIVERSION WITH AN UNALTERED IN SITU APPENDIX CONDUIT

Purpose

We performed continent urinary diversion using an unaltered, in situ appendix to decrease the risk of appendicocolic manipulation.

Materials and Methods

Since September 1994, 19 patients a mean of 46.5 years old underwent continent urinary diversion with an ileocecal segment and an unaltered, in situ appendiceal conduit. In 1 case of a permanent colostomy we performed simple transposition of the appendix on the ileal pouch as a conduit, which to our knowledge is the first reported case.

Results

During the 4 to 24-month followup (mean 12) 17 patients were continent day and night, defined as being completely dry for 3 to 5 hours. Two patients were occasionally incontinent at night. One patient with a history of multiple operations who was completely incontinent achieved complete continence with endoscopic polytetrafluoroethylene (Teflon) injection at the appendicocecal junction.

Conclusions

This unaltered in situ appendix technique is timesaving, safe, effective and comparable with other methods that provide urinary continence.     

Conversion from colonic conduit into recto-sigmoid pouch (Mainz pouch II)

OBJECTIVE: To report our long-term results of conversion from conduit conversion into a continent anal urinary diversion, as after conduit urinary diversion in childhood, some patients wish to have a later conversion to a continent diversion to avoid external appliances and to improve their quality of life. PATIENTS AND METHODS: Between 1992 and 2003, 139 patients had a urinary diversion with a recto-sigmoid pouch (Mainz pouch II), of whom four had a conversion from a colonic conduit diversion to a recto-sigmoid pouch. The mean (range) age at conduit diversion was 5.5 (3-14) years and the mean interval between conduit diversion and conversion to a continent anal diversion was 8 (4-18) years. The mean age at conversion into a Mainz pouch II was 13 (8-32) years and the follow-up afterward was 11.5 (1-13) years. The conversion was done by incorporating the pre-existing colonic conduit into the recto-sigmoid pouch with no ureteric reimplantation. RESULTS: There were no early complications; one nephrectomy was required 5 years after conversion because of uretero-intestinal obstruction and pyelonephritis. All other reno-ureteric units remained stable and renal function was maintained. All patients are continent day and night; three require substitution with alkali at a base excess of < -2.5 mmol/L to prevent hyperchloraemia and acidosis. CONCLUSION: The recto-sigmoid pouch is a therapeutic option when patients desire conversion from an incontinent type of urinary diversion to a continent type.     

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.     

Urinary Reconstruction Using Appendix as a Urinary and Catheterizable Conduit in 12 Patients

Background The appendix vermiformis can. provide an excellent urinary conduit or a catheterizable outlet in continent urinary reservoirs in selected cases. We report our clinical experience using the appendix in urinary reconstruction in adult patients.
Methods A total of 12 patients underwent urinary reconstruction using the appendix. The indications were pelvic malignancies except for 1 patient with neurogenic bladder and difficulty in self-catheterization via urethra. The appendix was used as a catheterizable conduit in 8 patients, and as a urinary conduit in 4 patients. The in situ submucosally embedded method was used in 6 patients and the Mitrofanoff method was used in 2 patients. Follow-up ranged from 3 to 41 months (mean, 22).
Results Early complications occurred in 3 patients (wound infection, false passage and intestinal anasotomotic leak). Late complications occurred in 3 (slight hydronephrosis, ileus, stomal stenosis). Emergent colostomy and pouchstomy with resection of the appendix was performed in the patient with anastomotic leak. The isoperistaltic Kock nipple valve was reconstructed for continence in this case. Prolonged ileus in 1 patient was treated by open surgery. Other complications were managed conservatively. End results were excellent in 8 patients, good in 3, and poor in 1.
Conclusions The appendix can be used advantageously as an outlet of continent urinary reservoirs or for a urinary conduit when the ureter is too short to reach the skin. Complete continence and easy catheterization can be obtained, and the appendix construction can be used as a urinary conduit instead of the ileal conduit in poor risk patients.     

Long-term followup of the intussuscepted ileal nipple and the in situ, submucosally embedded appendix as continence mechanisms of continent urinary diversion with the cutaneous ileocecal pouch (Mainz pouch I)

PURPOSE: We analyzed stoma related complications and continence rates in patients who underwent continent urinary diversion with the cutaneous ileocecal pouch (Mainz pouch I). We compared the intussuscepted ileal nipple and in situ, submucosally embedded appendix as continence mechanisms. MATERIALS AND METHODS: A total of 401 patients were included in a retrospective followup study. Continence mechanisms were the intussuscepted ileal nipple in 205 patients and the in situ, submucosally embedded appendix in 196. RESULTS: A total of 144 patients (36%) required intervention for a stomal complication. Of patients who received an intussuscepted ileal nipple 34 (17%) had stomal stenosis at a mean time to first stenosis of 43.8 months, 41 (20%) had stones at a mean interval to the first stone of 62.8 months, 12 underwent reoperation for stomal incontinence, including 1 because of nipple necrosis, and 82% were completely continent. Of patients who received an in situ, submucosally embedded appendix 63 (32%) had stomal stenosis at a mean time to first stenosis of 31.4 months, 20 (10%) had stones at a mean interval to the first stone of 47.5 months, 3 underwent reoperation for stomal incontinence, 4 had appendiceal necrosis and 92% were completely continent. CONCLUSIONS: Of stomal complications 63% were treated endoscopically. The higher rate of stomal stenosis with the appendiceal stoma is most likely due to the smaller diameter of the appendix. The higher rate of stone formation in patients with the intussuscepted ileal nipple is related to metal staples. Continence rates of the 2 outlets are good with somewhat larger amounts of mucous secretion from the larger stoma of the intussuscepted ileal nipple.     

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.     

Conversion from external appliance wearing or internal urinary diversion to a continent urinary reservoir (Florida pouch I and II): surgical technique, indications and complications.

A total of 20 patients with diversion requiring an external appliance or internal urinary diversion underwent conversion to a continent urinary reservoir (Florida pouch I or II). All patients subsequently reported an improvement in the quality of life and expressed satisfaction with the new urinary diversion procedure. Of the patients 15 (75%) previously had an ileal conduit, while 1 (5%) had undergone ureterosigmoidostomy, 1 (5%) had cutaneous ureterostomy, 1 (5%) had a suprapubic tube, 1 (5%) had a sigmoid conduit and 1 (5%) had a cecal conduit. After the original diversion 3 patients (15%) had recurrent urinary infections, 3 had complications related to the stoma and external appliance (stenosis and skin dermatitis) and 5 (25%) had ureteral obstruction in 7 ureters. A total of 17 patients with conduits (85%) underwent conversion via different surgical technical aspects depending on the status of the intestinal segment from the conduit and the function of the ureteral reimplantation: in 14 the conduit was discarded or was used only to patch the newly created Florida I colonic pouch, while in 6 the conduit was preserved and 9 ureterointestinal reimplantations were left undisturbed (Florida pouch II). Among 7 ureters preoperatively obstructed (original diversion), reimplanting them into the pouch failed to prevent further renal damage in 5 (71%). Three renal units required nephrectomy, 2 kidneys deteriorated and 2 recovered renal function after percutaneous balloon dilation and stenting. Among 31 preoperatively nonobstructed renoureteral units (original diversion), 22 were reimplanted into the colonic reservoir. One of these units (4.2%) became obstructed postoperatively and 3 (13.5%) presently have reflux. The 10 reimplantations left undisturbed in the detubularized conduit drain satisfactorily without postoperative obstruction and in 6 reflux has not been demonstrated. Renal function (serum creatinine) is preserved in all patients but 15 (75%) have hyperchloremia of mild degree. Two patients (10%) have acidosis and 1 (5%) of these had low red blood cell folic acid. Conversion of an external or internal diversion to a continent colonic urinary reservoir (Florida pouch I or II) can be successful and improve the quality of life of the patient. The functioning renal units that were preoperatively obstructed were associated with a high failure rate (71%) after reimplantation. Metabolic alterations will require long-term followup, and are particularly worrisome in children and young adults.     

Surgical complications of urinary diversion

We comprehensively reviewed the published literature on urinary diversion, specifically examining the surgical complications associated with conduit, continent cutaneous diversion and orthotopic urinary diversion. Appropriate patient selection and adherence to proper surgical technique are of paramount importance in preventing surgical complications of urinary diversion. Complications can be broadly divided into those related to bowel, conduit or reservoir, stoma and ureterointestinal anastomosis. Each type of urinary diversion has unique characteristics predisposing to certain surgical complications as well as similarities related to intestinal surgery. With conduit urinary diversions, problems related to the stoma such as stomal stenosis and parastomal hernia present not uncommonly. With continent cutaneous diversion, complications include difficulties with catheterizing of the efferent limb, formation of pouch stones and urinary leakage. With orthotopic neobladder formation, voiding dysfunction manifesting as incontinence or hypercontinence may present unique challenges in patient management. Increased surgical experience and technical refinements have led to decreasing surgical complication rates for all types of diversion in contemporary series.