Continent urostomy: a clinical experience in 20 patients

Urinary diversion via a continent ileal reservoir (modified Kock's procedure) was performed in 20 patients. Primary continent urostomy construction was carried out in 6 patients. Previous urinary diversion was present in 12 patients. Two patients were referred to us because a previous attempt to construct a continent reservoir urostomy had failed. There was no operative mortality. Three early complications occurred in 3 patients. Leakage from a uretero-enteric anastomosis in one patient and necrosis of a continence-providing valve in another patient necessitated reoperation. Late complications causing malfunction of the nipple valves required revisional surgery in 2 patients. Stoma stricture developed in 1 patient after 5 months and could be corrected surgically. The functional results were excellent. Continence was achieved without reflux to the upper urinary tract. Instead of a Kock pouch, an S-pouch was used. The continence and antireflux-providing valves were stapled to the reservoir wall. Slippage of the nipple valves did not occur. All our patients had consistently positive urine cultures and were without complaints. In a few cases, stone formation was observed usually on the staples at the tip of the valve. The stones were removed by forceps during endoscopy of the reservoir.     

Continent urinary diversion using a pre-peritoneal ileal graft and Benchekroun's hydraulic valve

The authors describe the creation of a continent pre-peritoneal ileal urinary reservoir with Benchekroun's valve. This system, performed on 10 occasions with no postoperative complications and currently perfect results, has the following advantages: decreased risk of distension of the reservoir because of its pre-peritoneal position, protection of Benchekroun's valve due to its distance from the reservoir at the end of the antiperistaltic loop, the great ease of creation of the diversion and the superficial situation facilitating any subsequent surgical revisions.     

Continent urinary diversion: review of the intussuscepted ileal valve

Summary Widespread use of the continent ileostomy and continent ileal pouch for urinary diversion stimulated renewed interest in the intussuscepted ileal valve first described by Perl in 1949. The historical review shows the results of several animal experiments and clinical experiences with the intussussepted ileal valve during the last five decades. The more recent results of pressure studies, prevention of germ ascension, the construction technique, and dynamic behaviour of the intussusception valve are reported and considered as the bases for succesfull use of the continent ilealpouch urinary diversion to day.     

Rome pouch: pre-peritoneal continent ileal reservoir with hydraulic valve.

We present our experience with a modified technique for constructing a continent ileal reservoir, using the terminal ileum in a pre-peritoneal position. The ureters were implanted using the Le Duc-Camey technique; the Benchekroun valve was used as a continence mechanism. This technique was used in 18 patients and its advantages and complications are discussed.     

Wall-incorporated antireflux valve in ileal bladder substitutes: first clinical experience in 17 patients

Objectives. To report on the initial clinical results of a novel technique of a wall-incorporated antireflux valve in ileal urinary reservoirs.Methods. Forty-five centimeters of the terminal ileum were isolated. A double-folded pouch was created using the distal 42 cm, of which the distal 35 cm was detubularized and the proximal 7 cm was left intact to act as a valve. Suturing at the borders of the valve was performed so that the valve formed part of the pouch wall. The technique was carried out in 17 patients. The mean follow-up period was 24 months (range 12 to 44). The patients were evaluated clinically and radiologically. Endoscopic examination was carried out in 3 patients.Results. None of 17 patients showed reflux on ascending cystography. Excretory urography revealed stable or improved upper tracts in 33 renal units. Hydroureteronephrosis was found in one unit because of ureteroileal stenosis that required operative correction. All patients were continent during the day. Night wetting occurred in 2 patients; imipramine hydrochloride therapy resulted in a complete response in 1 patient and partial improvement in the other.Conclusions. The preliminary results of wall-incorporated antireflux valve are encouraging. It is technically simple and easy. It is not time consuming and requires a shorter ileal segment than that required for the intussuscepted valve. Staples are not used. The vascular pedicle is not manipulated. The wall-incorporated valve is suitable for the normal, dilated, or short ureter. Despite limited clinical experience, the valve may provide a reliable technique for reflux prevention in bladder substitutes.     

The Z-shaped ileal neobladder after radical cystectomy: an 18 years experience with 329 patients

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

OBJECTIVE

To evaluate the results in terms of functional results and morbidity of Z‐shaped ileal neobladder performed in a single center.

PATIENTS AND METHODS

329 consecutive male patients who had an orthotopic bladder replacement using the Z‐shaped ileal neobladder between May 1990 and January 2009.

RESULTS

The mean age of the patients was 64.4 ± 9.6 years, with a mean follow‐up of 59.4 ± 55 months. Eighty‐three early complications in 80/294 patients (27.2%) occurred. The average Clavian rate of these early complications was 2.24. Among these, 12 complications in 12 patients (4.1%) were pouch‐related, and 3 reoperations were required. Two patients died from cardiac complications. Sixty‐three late complications in 60/294 patients (20.4%) were recorded. The average Clavian rate of these late complications was 2.98. Among these, 47 complications in 45/294 patients (15.3%) were pouch‐related, and 18 reoperations were required, essentially for ureteral anastomosis stricture. Satisfactory daytime urinary continence was achieved in 92% of patients. Daytime continence was obtained within, on average, 6.8 ± 16.4 months. The interval between each daytime urination was 2.6 ± 0.8 h (median = 2.5 [1–5] h). Forty‐four (15%) patients developed metabolic acidosis which only required oral medication. Satisfactory nocturnal urinary continence was achieved in 87% of patients. Night‐time continence was obtained within, on average, 10.8 ± 22.4 months. Hyper‐continence with subsequent need for CISC was observed in 4%.

CONCLUSION

In our series of 329 patients, compared with the other techniques, the Z‐shaped ileal neobladder had an ‘expected’ complication rate for this high risk surgery with satisfactory daytime and night‐time continence in nine out of ten patients.     

Ganglioglioma: 13 years of experience.

A 13-year retrospective review of 17 patients with gangliogliomas treated at the University of Iowa was conducted to investigate the association between tumor location, extent of resection, pathological findings, and patient prognosis. Thirteen were in the cerebral hemispheres and 4 in the midline. The mean ages at diagnosis and symptom onset were 16 and 8.8 years, respectively. The most common presenting symptom was seizures (11 patients); focal neurological deficit was seen in 5 patients and headache in 1. Patients with hemispheric tumors had an older age at time of diagnosis and a longer duration of symptoms. Pathologically, they had more microcalcifications, lymphocytic infiltration, microcystic degeneration, and eosinophilic bodies. Cerebral hemispheric tumors were more amenable to total resection than midline neoplasms, 77% versus 25%, respectively. In the patients with hemispheric tumors, 10 patients were tumor-free after total resection. Two of the 3 patients with partial resection had stable residual tumors. The third died of tumor progression. In the 4 patients with midline neoplasms, one was tumor-free after total resection. The other 3 had subtotal resection and radiation therapy. Two died within 2 years; the third is still alive with progressive tumor. Five of 9 patients who had seizure disorders and who underwent total tumor removal were seizure-free postoperatively. The other 4 patients and the 2 with partial surgical resection continued to have seizures.     

Continent ileostomy in dogs. An experimental study of ileal pouches using a simple prosthetic valve

This study in dogs evaluated a simple prosthetic valve constructed of fine Silastic tubing on the efferent limb of a modified Kock reservoir which was defunctionalized by diversion of the alimentary stream around the pouch by ileoileostomy. Pouches were studied at operation and postoperatively to determine the pressure of the valve and the pouch at the point of incompetency. In all 12 experiments a competent valve was constructed. Four early postoperative deaths were due to peritonitis, two associated with suture line leaks. The other animals were followed for 4 to 25 weeks. Competency of the valve was observed with leak pressures of 15 to 90 mm Hg, and most valve pressures were in the range of 100 to 400 mm Hg. Variable degrees of chronic fibrosis and migration of valve elements were noticed at autopsy.     

Continent cutaneous ileal pouch using the serous lined extramural valves. The Mansoura experience in more than 100 patients

PURPOSE: We report on the functional results of continent ileal reservoir using serous lined extramural valves for reflux prevention and continent urinary outlet. MATERIALS AND METHODS: The procedure was performed in 109 patients (68 men, 27 women and 14 children). The operation was indicated as a primary procedure in 93 patients and for conversion in 16. The technique entailed construction of a detubularized W-shaped ileal reservoir in which 2 serous lined troughs were created. Two tapered ileal segments were used, 1 for reflux prevention and the other as a continent outlet. The appendix was used for the construction of the outlet in 44 patients. RESULTS: Two patients died in the hospital of pulmonary embolism. A total of 22 early complications were observed in 18 patients (16.5%). None of the patients required operative intervention. A total of 93 patients were evaluable with a mean followup of 36.6 +/- 25.4 months. All evaluable patients but 5 were continent day and night. Mean time for catheterization was 4 to 5 hours. There were 14 late complications reported in 11 patients (11.8%), including pouch stones in 5, stomal stenosis in 5, failure to catheterize in 2, parastomal hernia in 1 and adhesive bowel obstruction in 1. Upper urinary tract was stable or improved in 94.8% of the renal units. Clinical acidosis did not develop in any of the patients. CONCLUSIONS: Serous lined unidirectional valves are reliable. They provide a versatile surgical technique suitable for urinary diversion or conversion procedures. The operation is associated with an acceptable complication rate and is followed by good functional results.     

Continent ileal bladder: an experimental study in dogs.

A method for constructing a continent ileal bladder has been tested in dogs. The requirements for a continent ileal bladder: continence, reservoir function, prevention of reflux, could be fulfilled in our experimental study.     

Evolution of outcomes with the ileal hydraulic valve continent diversion: reevaluation of the Benchekroun catheterizable stoma

Summary Initial reports with limited follow-up suggested that the ileal hydraulic valve was a satisfactory approach to continent urinary diversion that was associated with acceptable early complication rates and uniform efficacy in achieving continence. We sought to evaluate the later outcomes of patients with this form of continent urinary diversion. An average extended follow-up of 5 years was available on 11 patients who had undergone ileal hydraulic valve diversion. Although only 13% of patients had complications requiring surgical revision at 18 months of follow-up, at the 5-year follow-up, 91% had developed complications requiring surgical revision. Of these, 64% entailed major revision of the urinary diversion. The most common late complication was stomal stenosis (73%); calculus formation (36%) and devagination (36%) were also common. Although in some cases, stomal stenosis was successfully managed by superficial revision with skin flaps and grafts, most cases required complete replacement of the efferent limb. Use of the devaginated or stenosed ileal hydraulic valve to construct a flap-valve efferent limb based on the Mitrofanoff principal succeeded in salvaging the continent urinary diversions in these patients. Novel forms of urinary diversion require extended follow-up for accurate assessment of their feasibility and efficacy. Attentive surveillance with surgical revision as necessary in such cases is mandatory for the preservation of continence and renal function.     

The orthotopic T pouch ileal neobladder: experience with 209 patients

PURPOSE: A serous lined extramural ileal flap valve technique called the T limb was developed to prevent reflux of urine in an orthotopic bladder substitute called the T pouch. We evaluate our intermediate clinical and functional experience with the orthotopic T pouch ileal neobladder. MATERIALS AND METHODS: From November 1996 through May 2000, 209 patients (169 men [80%], 40 women), with a mean age of 69 years (range 33 to 93) underwent construction of an orthotopic T pouch ileal neobladder after cystectomy. The indication for cystectomy included bladder cancer in 198 patients (95%). Median followup for the entire cohort was 33 months (range 0 to 69). Data were analyzed according to perioperative mortality, early (within 3 months) and late diversion related and diversion unrelated complications, radiographic evaluation of the upper urinary tract and urinary reservoir, and determination of renal function. RESULTS: Three patients (1.4%) died perioperatively. A total of 63 (30%) early complications occurred, 53 (25%) diversion unrelated and 10 (5%) diversion related. The most common early diversion unrelated complication was dehydration (10 patients). The most common early diversion related complication was urine leak in 6 patients. There were no early complications directly related to the antirefluxing T limb. Late complications occurred in 68 (32%) patients including 30 (14%) diversion unrelated and 38 (18%) diversion related. The most common late diversion unrelated complication was incisional hernia in 16 patients. Of the 38 late diversion related complications the most common were pouch calculi in 17 and ureteroileal obstruction in 9 patients. The only late complication directly related to the T limb was stenosis in 4 patients, 3 of whom received adjuvant pelvic radiation. A total of 181 patients had radiographic evaluation of the upper urinary tract including 162 (90%) with a normal radiographic study or evidence of postoperative decompression. An abnormal upper tract study was seen in 18 patients (10%) including 9 with ureteroileal obstruction and 4 with afferent T limb stenosis. Gravity cystography of the neobladder was normal in 143 of 158 (90%) evaluable patients. Reflux was seen in 15 patients (10%). Renal function as determined by serum creatinine was stable or improved in 96% of patients. Good daytime and nighttime continence was reported in 87% and 72% of evaluable patients, respectively. Overall 75% of patients complete void while 25% required some form of intermittent catheterization to empty the neobladder completely including 20% of men and 43% of women. CONCLUSIONS: With intermediate followup the functional results of the T pouch ileal neobladder are acceptable. The antirefluxing T limb provides unobstructed urinary flow in 95% and reflux prevention in 90% of patients. Although these results are encouraging, further followup is required to assess the long-term results of the T pouch ileal neobladder.     

尿路造口患者自我感受负担的质性研究

目的了解膀胱全切尿路造口术后患者自我感受负担的心理体验及影响因素,为针对性干预提供参考。方法采用一对一式半结构访谈法,对12例尿路造口患者进行深入访谈和资料分析。结果提练出5个主题:担心照顾者身体透支;担心家庭经济负担过重;担心自护能力不足引起造口并发症;内疚感负荷过重;自卑感充斥内心。结论尿路造口患者术后经历了艰难的心理体验,自我感受负担较重,护理人员应重视患者因自我感受负担引起的一系列心理问题,及时提供住院期间的个性化健康教育及出院后的延续护理,呼吁家庭及社会支持系统给予患者更多关爱与支持。