Changes in the upper urinary tract after radical cystectomy and urinary diversion: a comparison of antirefluxing and refluxing orthotopic bladder substitutes and the ileal conduit

PURPOSE: We evaluated and compared the effects of different types of urinary diversion on functional and radiographic changes in the upper urinary tract. MATERIALS AND METHODS: We analyzed data on 275 patients who underwent radical cystectomy and urinary diversion for bladder cancer and were observed at least 12 months. Of the patients 197 received an orthotopic bladder substitute, including antirefluxing ureteral anastomoses in 111 (group 1) and refluxing ureteral anastomoses in 86 (group 2). Ileal conduits were created in 78 patients (group 3). Serial serum Cr, radiographic changes in the upper urinary tract after diversion and the number of episodes of APN were compared by diversion method. Mean followup was 52 months (range 12 to 174 months) with no difference among the groups. RESULTS: Compared with group 3 patients in groups 1 and 2 demonstrated a significantly higher incidence of moderate to severe hydronephrosis (p = 0.001) but the incidence was similar between groups 1 and 2 (6.3%, 8.3% and 1.4% of the renal units in groups 1 to 3, respectively). Stabilized postoperative Cr did not differ among the groups. CRF, defined as Cr 3.0 mg/dl or greater, occurred in 2.7% of the patients in group 1 and in 3.5% of those in group 2 but in none in group 3. APN was noted in 3.3%, 4.4% and 0.4% of patients in groups 1 to 3, respectively (p = 0.012). CONCLUSIONS: An ileal conduit with a lower rate of diversion related hydronephrosis, CRF and morbidity associated with APN was superior to orthotopic bladder substitutes. Between the refluxing and antirefluxing types of orthotopic bladder substitutes no significant difference in functional or radiographic changes was noted.     

Ileal ureteric replacement in complex reconstruction of the urinary tract

OBJECTIVE: To report 10 years' experience with ileal ureteric replacement as a last resort in complex reconstruction of the urinary tract. PATIENTS AND METHODS: From March 1991 to February 2002 ileal segments were used for partial or total substitution of the ureter in 43 patients (mean age 45.6 years) with structural or functional ureteric loss secondary to irradiation, surgical complications or various other pathological conditions. Ileum was either implanted into the native urinary bladder (in 14) or an intestinal reservoir (in 29). In the latter group the technique was used at the time of primary urinary diversion in eight, in a secondary approach for treating early or late complications in nine and in undiversion or conversion procedures in 12. The ileal ureter was implanted into the urinary reservoir using a serous-lined extramural tunnel or distal intussusception for reflux prevention (in 31). All patients were followed prospectively according to a standardized protocol. RESULTS: There were no perioperative deaths; the mean (range) follow-up was 40.8 (1.5-109.5) months. In 41 patients with dilatation of the upper urinary tract before surgery there was a significant improvement radiographically in 34, no change in five and deterioration in two. The serum creatinine level decreased or remained stable in all. Reflux occurred in the 12 cases without and in three with an antireflux mechanism. Shortening of an elongated kinking ileal ureter became necessary because of recurrent severe metabolic acidosis and mucus obstruction in two; in one case mucus obstruction was treated endoscopically. There was pyelonephritis only in three patients with refluxing implantation into an intestinal reservoir. CONCLUSION: Ileal ureteric replacement is a safe and reliable last resort even in difficult cases. Whenever feasible, antirefluxing implantation into intestinal urinary reservoirs is recommended.     

Bowel dysfunction after transposition of intestinal segments into the urinary tract: 8-year prospective cohort study

PURPOSE: Bowel function may be disturbed after intestinal segments are transposed into the urinary tract to reconstruct or replace the bladder. In 1997 our group was the first to report major bowel dysfunction in a cohort of such patients. Up to 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively including explosive diarrhea, nocturnal diarrhea, fecal urgency, fecal incontinence and flatus leakage. We now describe bowel symptoms in this same cohort 8 years later (2005). MATERIALS AND METHODS: A total of 116 patients were evaluable. Of the remaining 37 from the original study 30 had died, 5 no longer wished to be involved and 2 could not be located. Patients were asked to complete postal questionnaires identical to those used in the first followup, assessing the severity of bowel symptoms and quality of life using 2 validated instruments. Responses were compared with those from the original study. The Nottingham Health Profile quality of life scores were also compared to age and sex matched norms. RESULTS: There were 96 patients (83%) who completed 8-year followup questionnaires, including 43 after ileal conduit diversion (group 1), 17 after clam enterocystoplasty for overactive bladder (group 2), 18 after bladder reconstruction for neurogenic bladder dysfunction (group 3) and 18 with bladder replacement for nonneurogenic causes (group 4). High prevalence rates of bowel symptoms persisted with no statistically significant differences between the 2 times. Of those with symptoms in 2005, approximately 50% had reported similar symptoms in 1997. Patients treated with clam enterocystoplasty (group 2) still reported the highest prevalence (59%) of troublesome diarrhea with 1 in 2 on regular antidiarrheal medication. They also had high rates of fecal incontinence (47%), fecal urgency (41%) and nocturnal bowel movement (18%), and a large number reported a moderate or severe adverse effect on work (36%), social life (50%) and sexual activity (43%). High rates were also reported by patients with neurogenic bladder dysfunction, including 50% with troublesome diarrhea. This symptom was reported by 19% after ileal conduit and by 17% after bladder replacement for nonneurogenic causes. The impact of bowel symptoms on everyday activities and quality of life persisted, remaining most severe after clam enterocystoplasty, with 24% regretting undergoing the procedure because of subsequent bowel symptoms. CONCLUSIONS: After more than 8 years, operations involving transposition of intestinal segments continue to be associated with high rates of bowel symptoms which impact everyday activities. These are particularly troublesome following enterocystoplasty for overactive bladder and bladder reconstruction for neurogenic bladder dysfunction. These risks should influence patient selection and potential patients should be warned before undergoing surgery.     

Secondary malignancies in different forms of urinary diversion using isolated gut

PURPOSE: Tumor development following ureterosigmoidostomy is a worldwide accepted late complication. In contrast, tumor risk in other forms of urinary diversion with the separation of urine and feces is still unclear. We present a complete and detailed analysis of all reported tumors following urinary diversions using isolated gut segments in the literature. We estimated the tumor risk in comparison to ureterosigmoidostomies and to the general population. MATERIALS AND METHODS: We reviewed the world literature up to April 2003 via MEDLINE for secondary tumors in urinary diversions using isolated intestinal segments. RESULTS: We found 81 tumor case reports following urinary diversion using isolated intestinal segments. Tumors developed in 18 conduits, 45 cystoplasties, 5 rectal bladders, 3 neobladders, 6 colonic pouches and 4 ileal ureter replacements. CONCLUSIONS: All urinary diversions using bowel with or without separation of urine and feces carry a significantly higher tumor risk for intestinal tumor development compared to the general population. The tumor spectrum and tumor location in isolated gut segments are different than tumors following ureterosigmoidostomies but the total tumor risk is probably similar. The latency period depends on the initial diagnosis with malignant diseases leading to a shorter induction time. Concerning etiology, many theories exist but the exact mechanism remains unclear. Regular endoscopic control beginning with postoperative year 3 for early detection of secondary malignancies is mandatory.     

Enhanced continent mechanism of tapered ileum by extramural support from the pouch and abdominal walls: a preliminary report of a clinical study

PURPOSE: We constructed a reliable continent tube that is easy to catheterize and surgically simple. MATERIALS AND METHODS: Eight patients with bladder cancer underwent a procedure in which ileal segment was tapered as an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. Urodynamic and radiological studies were done postoperatively in 7 cases. RESULTS: The stoma was easily catheterized with a 16Fr catheter in all cases. One patient died of heart disease 55 days postoperatively, while 6 of the remaining 7 were completely continent day and night. Urodynamic study of the efferent tubes showed that maximum close pressure with the pouch full was significantly higher than with the pouch empty (p <0.001). Retrograde radiography of the efferent tubes demonstrated perfect canalization without stenosis. CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by fixing it between the abdominal and pouch walls. This maneuver also provides easy catheterization and surgical simplicity.     

Fate of the leftover bladder after supravesical urinary diversion for benign disease

PURPOSE: We studied the fate of the leftover bladder in patients who underwent supravesical urinary diversion without cystectomy for benign pathology. MATERIALS AND METHODS: This retrospective study was performed in 9 males and 15 females with a median age of 59 years in whom supravesical urinary diversion was performed for various benign conditions from 1996 to 2004. These conditions were incontinence, acontractile bladder, radiation and/or hemorrhagic cystitis, and neuropathic bladder. Median followup was 48 months. RESULTS: Of the patients 13 (54%) experienced problems with the retained bladder, 2 (8%) presented with urethral bleeding, which resolved by conservative means, and 11 (46%) had infective complications, which resolved with expectant treatment in 3 (12%). However, 8 patients (33%) had frank pyocystis and 3 (12%) were treated with the Spence procedure, which alleviated symptoms in only 1. Six patients (25%) required cystectomy. CONCLUSIONS: In patients undergoing supravesical urinary diversion for benign disease in whom the bladder remains in situ the risks of complications related to the defunctionalized bladder are more than 50% and 25% of patients subsequently need cystectomy. These patients should be offered primary cystectomy at urinary diversion.     

回肠膀胱腹壁造瘘术与Bricker术的疗效对比

目的分别对全膀胱切除术后行回肠膀胱腹壁造瘘术、Bricker术的膀胱尿路上皮癌患者进行长期随访,评价两种尿流改道术式的临床疗效。方法 2010年1月至2019年4月,我科共行98例全膀胱切除术,其中57例行回肠膀胱腹壁造瘘术(造瘘术组),41例行Bricker术(Bricker术组),比较两种不同术式患者的一般资料、围手术期情况、术后并发症等。结果两组一般临床资料比较,差异无显著统计学意义(P>0.05);造瘘术组平均手术时间(4.4±0.3)h,显著低于Bricker术组(5.8±0.3)h(P<0.05),但两组在术中出血、术后住院时间、术后拔除盆腔引流管时间、术后拔除输尿管支架时间等方面无统计学差异(P>0.05);造瘘术组术后总肾功异常发生率(2.0%vs.11.2%)、造瘘口周围皮炎及疤痕发生率(0.0%vs.10.2%)均显著低于Bricker术组(P<0.05)。此外,两组患者在随访时间、术后TNM分期、漏尿、肠梗阻、肾积水、膀胱结石、回肠造瘘口坏死或狭窄等方面均无统计学差异(P>0.05)。结论与Bricker术相比,回肠膀胱腹壁造瘘术临床疗效可靠,手术疗效无明显差别,但手术时间更短,术后总肾功异常发生率更低、造瘘口并发症更少,可弥补Bricker术的不足,有望成为更加理想的尿流改道术式。     

Hygiene and urinary tract infections after cystectomy in 452 Swedish survivors of bladder cancer

Study Type – Symptom prevalence (retrospective cohort)
Level of Evidence 2b

OBJECTIVES

To determine whether or not an improved hygiene can lessen the incidence of symptomatic urinary tract infections (UTIs) in patients treated by cystectomy for urinary bladder cancer.

PATIENTS AND METHODS

We attempted to contact during their follow‐up all men and women aged 30–80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified hygienic measures and included them in a study‐specific questionnaire. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results presented as relative risks (RR) with 95% confidence interval.

RESULTS

We received the questionnaire from 452 (92%) of 491 identified patients. The proportion of patients who had a symptomatic UTI in the previous year was 22% for orthotopic neobladder and cutaneous continent reservoir, and 23% for non‐continent urostomy diversion. The RR for a UTI was 1.1 (0.5–2.5) for ‘never washing hands’ before handling with catheters or ostomy material. Patients with diabetes mellitus had a RR of 2.1 (1.4–3.2) for having a symptomatic UTI.

CONCLUSIONS

We could not confirm lack of hygiene measures as a cause of UTI for men and women who had a cystectomy with urinary diversion. Patients with diabetes mellitus have a greater risk of contracting a UTI.     

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.     

Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era

PURPOSE: We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible. MATERIALS AND METHODS: A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined. RESULTS: A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively. CONCLUSIONS: In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.     

Neovesical-urethral anastomotic stricture after orthotopic urinary diversion: presentation and management

OBJECTIVE

To assess the frequency, presentation, treatment, and outcomes of bladder neck contractures (BNCs) among patients who had an orthotopic urinary diversion after radical cystectomy.

PATIENTS AND METHODS

We retrospectively examined our single‐institution database of 788 patients who had a radical cystectomy from 1 January 1996 to 4 January 2006 for BNC; variables evaluated included presentation, degree of stricture/contracture, clinical management, and outcomes after management.

RESULTS

Of the 374 patients who had an orthotopic urinary diversion, 11 (2.9%) men developed BNC; four BNCs were between 17 F and 22 F, six were <17 F, and one was pinhole‐sized. Nine of the 11 patients presented with voiding difficulties, one in complete retention after complicated urinary tract infection, and one with new‐onset nocturnal urinary incontinence. The treatment of BNC included cystoscopic dilatation in the clinic in six and under anaesthesia in three, and transurethral incision with a Collins knife or holmium laser in seven. After treatment, all patients were instructed to use continuous intermittent catheterization (CIC). Ten patients had follow‐up data available after the intervention, with a mean (range) follow‐up of 40.6 (10.6–98.0) months. Six patients were stricture‐ free for a mean period of 35.4 (10.6–98.0) months, while four patients had a recurrence within a mean of 7.4 (1.3–17.1) months. At the last follow‐up, nine of the 10 patients were using CIC. No patient had significant daytime or night‐time incontinence after treatment.

CONCLUSION

BNC develops in a small proportion of patients undergoing orthotopic urinary diversion, with most patients presenting with voiding difficulty. Most will require transurethral incision rather than an office‐based dilatation. After endoscopic incision to correct BNC, we recommend CIC to ensure complete emptying and to maintain the patency of the anastomotic stricture.     

Continent lower urinary tract reconstruction in the cervical spinal cord injured population

PURPOSE: Patients with cervical spinal cord injury and upper extremity dysfunction are treated primarily with indwelling or condom catheters. We present our experience with a select group of patients with limited upper extremity function to determine long-term success and patient satisfaction after lower urinary tract reconstruction. MATERIALS AND METHODS: Between May 1988 and November 1996, 28 patients with cervical spinal cord injury underwent lower urinary tract reconstruction. Postoperative information was obtained on 21 patients. Charts were reviewed and patients were contacted by an independent reviewer to ascertain patient satisfaction and quality of life. Patient age was 17 to 51 years (average 34.6). Reconstructive procedures requiring catheterization included augmentation ileocystoplasty in 4 patients plus Mitrofanoff appendicovesicostomy in 7, a Kock ileal reservoir in 8 and an Indiana pouch in 2. RESULTS: Catheterization was regularly performed by 20 of the 21 patients (95%). A total of 12 patients (60%) performed self-intermittent catheterization and 8 (40%) relied on an attendant or family member. Of the patients 80% reported improved quality of life since reconstruction, citing such reasons as lack of a need for urinary drainage bags, increased freedom and an improved sense of body image. Using a visual analog scale to grade satisfaction from 1 to 10 (1-extremely unsatisfied to 10-extremely satisfied) 14 patients (67%) reported a score of 8 or more. CONCLUSIONS: With appropriate preoperative selection of the cervical spinal cord injured patient intermittent catheterization is successfully maintained in the long term, allowing greater flexibility in choice, and a resultant high level of patient satisfaction and improved quality of life.     

Critical evaluation of the problem of chronic urinary retention after orthotopic bladder substitution in women

PURPOSE: We studied the possible causes of chronic retention after radical cystectomy and orthotopic bladder substitution in women. MATERIALS AND METHODS: Between January 1995 and January 2001, 136 women with a mean age plus or minus standard deviation of 52 +/- 8 years underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Videourodynamics, pelvic floor electromyography, pelvic floor magnetic resonance imaging and pan-endoscopy were done. In the last 37 cases some technical modifications were adopted to circumvent the development of chronic urinary retention. RESULTS: One woman died postoperatively of massive pulmonary embolism. Of the 100 patients evaluable at a mean followup of 36 months 95 were continent in the daytime, 86 were continent at night, 2 were completely incontinent and 16 were in chronic retention. Videourodynamics showed that retention was mechanical in nature due to the pouch falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction. In addition, herniation of the pouch wall through the prolapsed vaginal stump was observed in most cases. Pelvic floor electromyography demonstrated complete pelvic floor silence during voiding. No abnormality of the pelvic floor or rhabdosphincter was noted on magnetic resonance imaging. Pan-endoscopy showed a normal urethra with no urethroileal stricture. A 4 mg. dose of the alpha1-adrenergic blocker doxazosin daily was ineffective, excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal urethral muscles may have been the cause of this problem. After omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at cystectomy the incidence of chronic retention decreased from 18.7% (14 of 75 cases) before to 8% (2 of 25) after modifications. Furthermore, after vaginal wall descent was mechanically corrected by a pessary there was significant improvement in evacuation. CONCLUSIONS: Strong evidence was provided that chronic urinary retention after orthotopic substitution is due to anatomical rather than to functional or neurogenic reasons. Modifications to increase back support of the pouch with ventral suspension near its dome and support the vaginal stump are recommended to avoid this complication.     

Early and late urodynamic assessment of ileal orthotopic bladder substitutes combined with an afferent tubular segment

PURPOSE: Limited information is available concerning changes in the urodynamic characteristics of orthotopic bladder substitutes with time. Therefore, we compared early and late urodynamic results in patients with an ileal orthotopic bladder substitute combined with an afferent tubular segment. MATERIALS AND METHODS: Of 139 patients surviving at least 5 years after cystoprostatectomy and ileal orthotopic bladder substitution with an afferent tubular segment 119 underwent urodynamic assessment, including 66 at a median of 9 months (early) and 77 at a median of 62 months (late). Of these patients 24 were assessed at each time point. Simultaneously all patients were asked to complete a bladder diary and questionnaire regarding continence for at least 3 days in the week preceding the urodynamic study. RESULTS: Urodynamic parameters were comparable in patients who were evaluated early and late postoperatively. In addition, median values at early and late urodynamic evaluation in the 24 patients with the 2 examinations showed no statistically significant differences for volume at first desire to void (300 vs 333 ml, p = 0.85), pressure at first desire to void (12 vs 13 cm H2O, p = 0.57), maximum cystometric capacity (450 vs 453 ml, p = 0.84), end filling pressure (19 vs 20 cm H2O, p = 0.17), reservoir compliance (25 vs 28 ml/cm H2O, p = 0.58) or post-void residual urine volume (5 vs 15 ml, p = 0.27). CONCLUSIONS: Urodynamic results after 5 years of living with an ileal orthotopic bladder substitute with an afferent tubular segment show grossly unchanged urodynamic characteristics. Patients maintain a reservoir capacity and micturition pattern consistent with a normal life-style. Reservoir pressure remained low, thereby protecting and preserving upper tract function. To achieve these results patients must be regularly followed, and the causes of bacteriuria, increased post-void residual urine and bladder outlet obstruction must be recognized and dealt with accordingly.     

Urinary diversion: ileal conduit to neobladder

PURPOSE: The goals of urinary diversion have evolved from simply diverting the urine through a conduit to orthotopic reconstruction, which provides a safe and continent means to store and eliminate urine with efforts to provide an improved quality of life. We address meaningful points that may help optimize clinical results in patients with an orthotopic bladder substitute. MATERIALS AND METHODS: The review involved an objective evaluation of the basic science literature of functional, structural and physiological characteristics of gastrointestinal tissue as a substitute for bladder. Potential problems that may be associated with particular parts of the gut for use in reconstruction are discussed. We also summarize the clinical results and complications of orthotopic reconstruction. RESULTS: In the last 10 years the paradigm for choosing urinary diversion has changed substantially: In 2002 all patients undergoing cystectomy were neobladder candidates. It is critically important to understand the phenomenon of maturation. The motor and pharmacological response of the implanted gut changes dramatically toward that of the bladder. Structural and ultrastructural changes in the ileal mucosa lead to a primitive epithelium similar to urothelium. The need for reflux prevention is not the same as in ureterosigmoidostomy conduit or continent diversion. Reflux prevention in neobladders is even less important than in a normal bladder. When using nonrefluxing techniques, the risk of obstruction is at least twice that after direct anastomosis. Kidney function is not impaired by diversion if stenosis is recognized and managed. Patient health status is more influenced by underlying disease than by diversion. Complications of neobladders are actually similar to or lower than the true rates after conduit formation, in contrast to the popular view that conduits are simple and safe. Some degree of nocturnal leakage is a consistent finding in most reports despite a technically sound operation. The precise pathogenesis of urinary retention requiring clean intermittent catheterization remains uncertain. There are new complications, such as neobladder rupture and mucous tamponade. CONCLUSIONS: Orthotopic reconstruction has passed the test of time. In these patients life is similar to that in individuals with a native lower urinary tract. Until a better solution is devised orthotopic bladder reconstruction remains the best option for patients requiring cystectomy.     

原位回肠膀胱对上尿路功能影响的临床研究

目的 探讨膀胱癌行膀胱全切原位回肠膀胱术后,新膀胱对上尿路功能的影响.方法 评估2006年3月-2010 年6月陕西省核工业二一五医院泌尿外科收治的28例肌层浸润性膀胱尿路上皮癌行膀胱全切W形原位回肠代膀胱患者的上尿路功能,所有病例随访2年以上.评估项目包括肌酐测定、泌尿系B超测定膀胱残余尿量及肾积水量、膀胱造影明确有无尿液反流.结果 术后4周拔除导尿管之前行膀胱造影检查,未发现明显造影剂外溢,术后3个月轻度肾积水8例(28.6％),其中2例(7.1％)术前即合并有肾积水,x2 =0.49 (P ＞0.05),差异无统计学意义.术后2年轻度肾积水5例(17.9％),与术前比较,x2 =0.22(P ＞0.05)差异无统计学意义.术前血肌酐(72.92±14.58) mmol/L,术后3个月血肌酐(83.42±15.18) mmol/L,t=-6.43(P ＜0.05),手术前后血肌酐均值均在正常值范围,术后2年血肌酐(82.50±14.39) mmol/L,与术前比较,t=-4.67 (P＜0.05),但均在正常范围,无临床意义.术后3个月膀胱容量(160±23) mL,残余尿量(58.7 ±9.7) mL,术后2年膀胱容量(430±21) mL,残余尿量(61.3 ±37.1)mL,t=-0.37(P＞0.05),差异无统计学意义.结论 原位W型回肠膀胱可作为膀胱全切术后较为理想的待膀胱术式,对上尿路功能影响较轻.     

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.     

Ileal Pouch with an Umbilical Stoma: A Continent Mechanism Created by the Extramural Tunnel Technique

We present an initial experience of creating an extramural continent valve in the ileal pouch in 4 patients who required continent urinary diversion. Using the appendix or a tapered ileal segment, the continent valve was created by the extramural tunnel technique along the anterior suture line of the pouch to facilitate the umbilical anastomosis. All patients were continent postoperatively with easy catheterization. This technique can provide a simple and effective continent pouch formed entirely from the ileum.