Modified ureterosigmoidostomy (Mainz Pouch II) in different age groups and with different techniques of ureteric implantation

OBJECTIVE: To examine the outcome of Mainz Pouch II urinary diversion in different age groups and with different techniques of ureteric implantation. PATIENTS AND METHODS: Between March 1995 and August 2002 a Mainz Pouch II was created in 41 patients (27 male and 14 female, median age 56.3 years, range 2-75) with 81 renal units (RU). For analysis, the patients were divided into 29 (70%) aged <65 years and 12 (30%) aged >65 years. Ureteric implantation with the Goodwin-Hohenfellner (GH) technique was used in 55 RU, with the Abol-Enein (AE) modification in 23 and Le-Duc procedure in three. The median (range) follow-up (available for 36 patients, 88%) was 19 (1-80) months. An unvalidated questionnaire was used to determine specific urinary diversion items. RESULTS: Early complications occurred in 7% of patients, none requiring surgical intervention. Pyelonephritis occurred in five of 36 patients and seven of 71 RU (14% of the patients, 10% of the RU); all patients were <65 years old. In five of seven RU pyelonephritis was caused by the development of upper urinary tract dilatation; none required surgical revision. Ureteric stenosis requiring reimplantation occurred in two RU (2%, one GH, one AE). All patients were continent in the daytime; all but one patient had to wake to urinate at night, with 36% having to do so more than six times. Of the patients, 63% were able to distinguish between stool and urine. Initially, alkalinizing drugs to prevent metabolic acidosis were taken by 30% of the patients. Of previously medicated patients with a follow-up of >1 year, 8% required oral alkalinizing medication. CONCLUSION: The Mainz Pouch II is a safe and reproducible urinary diversion, and serves as a satisfying alternative to other forms of continent urinary diversion in all age groups. The follow-up shows a low complication rate with good results in terms of continence. There were no significant differences in complication rates for the different ureteric implantation techniques. The long-term results remain to be evaluated.     

Sigmoidorectal (Mainz II) pouch for continent urinary diversion in bladder cancer

BACKGROUND: We aimed to assess the feasibility, safety, and outcome of the sigmoidorectal (Mainz II) pouch for urinary diversion in patients with invasive bladder cancer. METHODS: Twenty-nine patients (25 men and four women), aged 65-76 years, who had undergone radical cystectomy and the sigmoidorectal pouch procedure for invasive bladder cancer were included in this study. Postoperative evaluations included metabolic testing, standard laboratory screening, renal ultrasonography, pouchography, and intravenous urography or pouchoscopy when indicated. RESULTS: The median operative time was 175 min. Urine leakage was encountered in two patients (6.8%), deep vein thrombosis in one (3.4%), and ileus necessitating surgery in another one. Two patients developed pyelonephritis due to ureterocolonic stricture, which was treated with antegrade balloon dilatation. No local relapses of bladder cancer were found. All patients were continent during the day, but one patient was occasionally incontinent during the night. In the long term, six patients (20.6%) developed metastatic disease, and five patients (17.2%) died because of cancer-related causes. Overall survival was 100, 96 and 60% at 1, 2 and 3 years after the operation, respectively. The mean survival was 36.8 +/- 1.9 months, which was statistically significantly associated with the M stage (P < 0.001), but not with the T (P = 0.091) or N (P = 0.081) stages. CONCLUSIONS: The sigmoidorectal (Mainz II) pouch seems to be a feasible, safe and effective method for continent urinary diversion. It is able to provide good quality of life, and ensure good overall survival rates.     

Modified ureterosigmoidostomy (Mainz Pouch II): a nonrefluxing stented vs unstented laparoscopic porcine model

OBJECTIVE

To describe a rapid and reproducible pure laparoscopic cystectomy and nonrefluxing modified continent urinary diversion (Mainz Pouch II), and to determine whether ureteric stenting decreases ureteric obstruction after surgery.

MATERIALS AND METHODS

After institutional review and approval, six female pigs (51–55 kg) had a laparoscopic cystectomy and urinary diversion using a modified Mainz Pouch II. Imbricating bowel over the extra‐intestinal ureteric segment created the nonrefluxing mechanism. All pigs had the same bowel preparation before a standard four‐port transperitoneal laparoscopic procedure, but three pigs received bilateral J ureteric stents and three did not. Body weights, radiographic imaging, serum electrolytes and renal function were monitored during the 6‐week survival period.

RESULTS

One stented pig developed bilateral pyelonephritis, renal obstruction and was killed. Including this pig, four of 12 renal units were obstructed, occurring more often in the stented pigs. There were no significant differences between the serum electrolytes before and after surgery or between the stented or unstented pigs. The surgery was quicker as experience increased. No pig developed hyperchloraemic metabolic acidosis. The nonrefluxing modification appeared to be effective, as reflux was only present in one renal unit.

CONCLUSIONS

Laparoscopic ureterosigmoidostomy, specifically the modified Mainz Pouch II, represents a viable and reasonable continent urinary diversion. The results suggest that there was no benefit in stenting in this pig model.     

Mainz Pouch II technique: 10 years' experience

OBJECTIVE: To report the long-term results with the Mainz Pouch II procedure. PATIENTS AND METHODS: Between 1990 and 2000 a Mainz Pouch II ureterosigmoidostomy was used in 123 patients (49 females and 74 males, mean age 43.6 years, range: 1-73). The indications for urinary diversion were cystectomy for bladder cancer in 92 patients, bladder exstrophy and/or incontinent epispadias in 26, irreparable traumatic loss of the sphincteric urethra in four and cloacal malformation (sinus urogenitalis) in one. In all, 102 patients with a follow-up of >/= 12 months were evaluated (mean 46.2 months). RESULTS: Day- and night-time continence rates were 97% and 95%, respectively. The remaining patients occasionally lose some drops of urine during coughing or straining, or reported minimal soiling of undergarments during the night. The mean voiding frequency was six during the day and once at night. There were 14 ureteric implantation stenoses (7.2% of 194 evaluated reno-ureteric units) and they were treated successfully by open repair (13) or antegrade balloon dilation (one). For metabolic disturbances, 69% of the patients had a capillary base excess of <-2.5 mmol/L and use oral alkalinizing drugs to prevent hyperchloraemic acidosis. There was no clinically evident metabolic acidosis. CONCLUSION: Applying the principles of detubularization and spherical reconfiguration to create a low-pressure reservoir and stratifying ureteric implantation between submucosal and serous-lined extramural tunnel techniques succeeded in giving better continence rates and long-term preservation of the upper urinary tract than a classical ureterosigmoidostomy. The Mainz Pouch II ureterosigmoidostomy is simple and reliable as a viable alternative for continent urinary diversion in selected patients.     

A modified sigma-rectum pouch (Mainz pouch II) technique: analysis of outcomes and complications on 220 patients

OBJECTIVE: To evaluate the safety and efficacy of a modified technique for a sigma-rectum pouch (Mainz pouch II). PATIENTS AND METHODS: Between October 1994 and March 2003, a modified Mainz pouch II was constructed in 220 patients (153 men and 67 women, mean age 56.7 years) in a multicentre prospective study. The median follow-up (177 patients, 81%) was 21 (1-84) months. RESULTS: There were no peri-operative deaths; there were early complications in 24 patients, including prolonged ileus in six, pyelonephritis in 17, unilateral ureterohydronephrosis in 11, bilateral ureterohydronephrosis in two, and incipient renal failure in five. Late complications included ureteric implantation-site stenosis (unilateral in eight patients and bilateral in three). In all, 92 patients (52%) needed oral alkalizing medications and potassium supplementation because of hyperchloraemic metabolic acidosis. All but three patients (99%) were continent by day and at night. The mean (sd) voiding frequency was 4.2 (1.6) voids by day and 2.1 (0.5) at night. CONCLUSION: The Mainz pouch II is a simple and reproducible surgical technique, with good results in terms of mortality, morbidity, continence and overall quality of life. The main limitation is malignant transformation of the uretero-intestinal anastomosis. For selected cases, the technique is a good alternative to other types of continent urinary diversion.     

Long‐term outcome of ureterosigmoidostomy: an analysis of patients with >10 years of follow‐up

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

OBJECTIVE

To examine our long‐term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long‐term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques.

PATIENTS AND METHODS

We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow‐up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (≤30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention.

RESULTS

The median (range) follow‐up was 15.7 (10.0–45.4) years and the median age at surgery was 58.8 (0.4–79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study.

CONCLUSIONS

USS is associated with long‐term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.     

Treatment of incontinence in children with bladder exstrophy after rectal urinary diversion: the anal sling procedure

PURPOSE: An original technique for reinforcement of the anal sphincter using a sling prosthesis with a flexible fixing point that prevents incontinence and rectal prolapse is presented. MATERIALS AND METHODS: Of 43 patients with exstrophy who have undergone urinary rectal diversion between 1988 and 1997 incontinence was observed in 9 boys and 5 girls. From January 1993 to December 1998 these children were treated with an original method, the anal sling procedure. RESULTS: There were no postoperative complications. Investigations revealed no urinary or fecal incontinence after a mean followup of 3.2 years (range 6 months to 61/2 years). CONCLUSIONS: A short and simple operation eliminates incontinence after rectal urinary diversion in patients with bladder exstrophy. It can be used as an alternative to the formation of an isolated urinary reservoir.     

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.     

Enterocystoplasty in childhood: a second look at the effect on growth

OBJECTIVE: To re-evaluate the assumption that enterocystoplasty in children has a detrimental effect on linear growth (which is almost exclusively based upon a chance finding in a retrospective study 10 years ago) in a larger cohort and with a longer follow-up. PATIENTS AND METHODS: The original 12 children who had impaired linear growth in a previous study 10 years earlier were re-measured. A larger cohort was identified from the 242 children and adolescents who had undergone enterocystoplasty between 1982 and 1997. Patients with conditions involving organ systems apart from the urinary tract, and those with myelomeningocele, malignant diseases, reduced glomerular filtration rate and incomplete notes were excluded. In the definitive study cohort (123; mean age at operation 8.6 years; mean age at investigation 16.8 years) enterocystoplasty had been undertaken using colon in 70, ileum in 37, a combination of both in 11, ileocaecal segments in three and stomach in two patients. RESULTS: Of the original 12 patients, six had regained or surpassed their preoperative position on their growth charts. In all patients with a known target centile range the final height was within their genetic growth potential. In the cohort of 123 patients, 1215 height and weight measurements had been recorded. The distribution of percentile positions before and after enterocystoplasty showed a normal configuration, with 83% and 80% of patients growing within two standard deviations of the 50th percentile. After surgery, 85% either remained on the same or reached a higher centile. Nineteen (15.5%) were in a lower position, with a similar tendency in the weight centile. A clinically relevant growth disorder was recognized in four patients with a complete endocrinological evaluation; in none of these was enterocystoplasty thought to be a causal factor. CONCLUSIONS: It is very unlikely that the loss of the preoperative percentile position on the growth curve in 15% of children after enterocystoplasty is a consequence of the surgery. Rather it is a non-specific phenomenon that has to be considered in any clinical population of the same size and age distribution after the same length of time.     

Continent cutaneous urinary diversion in children: experience with Charleston pouch I

PURPOSE: Complete continent urinary diversion not incorporating the bladder is not commonly used in children. We evaluated the short and long-term outcome of a form of continent cutaneous urinary diversion (Charleston pouch I) in children. MATERIALS AND METHODS: A total of 17 children underwent Charleston pouch I continent cutaneous urinary diversion between 1988 and 2005. Patient records were reviewed for age, sex, indications for diversion, preoperative and postoperative laboratory and radiological studies, continence, patient and family acceptance, complications and long-term functional status. RESULTS: Patient age ranged from 6 to 16 years. The main indication for diversion was bladder exstrophy in 8 patients (47%), neurogenic bladder in 6 (35%) and cloacal abnormalities in 3 (18%). Mean followup was 87.5 months. One patient was lost to followup. With moderate fluid intake the other patients were dry with a mean catheterizing time of 3.4 hours (range 2 to 6). Catheterization intervals were adjusted for individual patients. Generally, the patients became damp or leaked if they did not catheterize at recommended intervals. Continence was achieved at variable postoperative intervals, with some patients attaining continence soon after and others at 3 to 12 months before pouch maturation. Patients irrigated the pouch a mean of 4 times weekly (range 0 to 14). Three patients (18%) had bladder stones. Ultrasound and/or other upper tract studies revealed no deterioration of the upper urinary system. No patient experienced clinical pyelonephritis or acidosis. Family and patient acceptance was satisfactory. CONCLUSIONS: Continent cutaneous urinary diversion with Charleston pouch I was satisfactory in this group of children. It provided preservation of the upper urinary tract, and achieved acceptable continence rates while allowing leakage when catheterization was not performed at recommended intervals. In addition, patient and parent acceptance was good, and complication rates were acceptable.     

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.     

Experience with the orthotopic ileal neobladder in women: a mid-term follow-up

OBJECTIVE: To report our experience with orthotopic bladder reconstruction in women, as currently the ileal orthotopic neobladder is the diversion of choice for women requiring a bladder substitute at our institution. PATIENTS AND METHODS: From February 1995 to March 2001, 29 women with muscle-invasive bladder carcinoma underwent a nerve-sparing radical cystectomy and had an orthotopic ileal neobladder reconstructed. The outcome was evaluated at 2 and 6 months and then yearly, by a clinical history, physical examination, voiding diary, stress test and estimate of functional neobladder capacity. RESULTS: All patients were followed for at least 14 months (mean 27.5); there were no major complications related to the surgery. The mean (range) neobladder capacity 2 months after surgery was 250 (190-320) mL; at 6 months it increased, remaining stable for the remaining follow-up, at 450 (350-700) mL. Four patients (14%) had nocturnal incontinence and one stress urinary incontinence, associated with using three pads per day. Three patients (10%) required catheterization for a postvoid urinary residual of >100 mL. Of the 29 patients, seven died with metastatic disease and three from causes unrelated to the reservoir or bladder cancer. Currently, 19 patients (65%) are alive and disease-free, with a mean follow-up of 35 months. CONCLUSION: Orthotopic neobladder reconstruction in women, using 40 cm of ileum, is safe and gives high continence and low urinary retention rates. Therefore, it should be advised as the first option in women with good renal function and a tumour-free bladder neck.     

The urethral Kock pouch: long-term functional and oncological results in men

OBJECTIVE: To evaluate our experience with men who underwent radical cystectomy and urethral Kock pouch construction between January 1986 and January 1996. PATIENTS AND METHODS: Complications were classified as early (within the first 3 months after surgery) or late. Continence was assessed by interviewing the patient; they were considered continent if they were completely dry with no need of protection by pads, condom catheter or medication. The patients were followed oncologically and Kaplan-Meier survival curves constructed. Urodynamic studies were used to define the possible causes of enuresis. RESULTS: Three patients died after surgery from pulmonary embolism. There were 67 early complications in 63 patients. The mean (SD) follow-up was 87.8 (49.1) months. There were 111 treatment failures from cancer; of these, four men only had an isolated local recurrence in the urethra. Late complications included 72 pouch stones in 55 patients, and 36 deteriorated renal units caused by reflux (17), uretero-ileal stricture (11), nipple valve eversion (four) or stenosis (four). Interestingly, 65 renal units that were dilated before surgery improved significantly afterward. Ileo-urethral strictures occurred in seven men and anterior urethral strictures in six. Nine patients were totally incontinent and two had chronic urinary retention. Daytime continence was complete in 94% of men, with nocturnal enuresis in 55; the latter had significantly more residual urine, and a higher amplitude and duration of phasic contractions. CONCLUSIONS: Orthotopic bladder substitution after cystectomy for cancer is feasible, with good functional and oncological outcomes in properly selected patients. Nevertheless, the use of a hemi-Kock pouch is associated with many valve-related complications.     

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.