Le bag: total replacement of the bladder using an ileocolonic pouch

Creation of an ileocolonic pouch for total bladder replacement is described in 4 patients, resulting in a highly compliant, low pressure bladder. Previous experience with bowel segments for bladder augmentation and replacement have been plagued by unpredictable bowel contractions with urinary incontinence as well as potential for renal damage. A reliable method to achieve a highly compliant, low pressure system requires disruption of directional bowel peristalsis, which this technique has succeeded in achieving. The operative technique, bowel dynamics, renal status and clinical results are described. The ileocolonic pouch offers a low pressure reservoir for total replacement of the bladder in selected patients.     

Total replacement of the urinary bladder using an ileal pouch bladder

We have used the continent ileal bladder as a bladder replacement after radical cystectomy. The ileal bladder is an ileal pouch which is anastomosed to the urethral stumps. The ureters are implanted by a free end ureteroileostomy. The long term results with 26 patients who underwent this procedure are reported. In the early postoperative period, urodynamic and radiographic studies revealed small capacity and high intravesical pressure of the ileal bladder. However, it became a low pressure reservoir with increased capacity gradually. The average bladder capacity was about 250 ml and average residual urine was 30 ml. Most of the patients were continent in the daytime if the voiding intervals were less than 3 hours at night, some patients were incontinent. Urinary leakage was the most frequent complication. VUR and hydronephrosis were still the problems to be solved. The ileal pouch bladder is a valuable procedure in properly selected cases.     

Total bladder replacement using detubularized sigmoid colon: technique and results

We performed total bladder replacement with a detubularized segment of sigmoid colon in patients after cystoprostatectomy. The surgical technique and long-term results in 27 patients are reported. This neobladder configuration compared favorably with other neobladder types regarding ease of construction. The surgical complications were acceptable. Initial reservoir function was good but improved further with time. After 1 year the capacity averaged 600 cc, pressures during filling and at capacity were low (average 12 and 16 cm. water) and emptying was satisfactory (residual urine 4 to 80 cc). All patients were continent during the day and 67% were continent at night without excessive voiding habits. Nighttime incontinence was further resolved in 2 patients by using the AMS 800 artificial sphincter around the bulbous urethra. The detubularized sigmoid is an excellent neobladder configuration after cystoprostatectomy.     

Total replacement of bladder and urethra by cecum and appendix in bladder exstrophy

The first case of total bladder and urethral replacement by cecoappendiceal unit was achieved in a five-year-old boy born with bladder exstrophy. Residual vesical and prostatic tissue was utilized to provide continence successfully.     

(iv) Total knee replacement

Total knee arthroplasty is today a successful procedure in relieving pain and functional restoration of patients with advanced knee disease. Our knowledge on indications, surgical technique and prosthetic design have evolved over the past years to such an extent that a consistent and durable outcome can be obtained in the majority of cases. Some controversies that were debated in the past have today been resolved; others are still open for discussion.In this paper, a general overview on the current ‘state of the art’ in primary knee arthroplasty is given.     

无性别差异假体全膝关节置换术后的疗效分析

目的 探讨采用无性别差异假体行全膝关节置换术后男性患者与女性患者的疗效差异.方法 回顾性分析2001年1月至2004年12月行全膝关节置换患者的临床资料.病例入选标准:手术时年龄在53～77岁之间,屈曲畸形＜40°,内、外翻畸形＜20°,单侧膝关节置换,符合骨关节炎诊断标准,膝关节局部无手术史.用随机数字表法选取40例...     

经尿道手术治疗神经性排尿功能障碍

目的 总结经尿道手术治疗神经性排尿障碍的疗效及适应证.方法 神经性排尿功能障碍患者41例.男13例,女28例.年龄12～43岁,平均27岁.其中骶椎裂36例、骶脊膜膨出术后2例、骶神经瘤切除术后1例、腰椎外伤术后2例.临床表现为排尿困难、尿线细.B超检查提示膀胱残余尿及双肾输尿管积水,尿动力学检查提示神经原性膀胱.手术采用局麻,女性患者在5、6、7点电切膀胱颈至环状纤维;男性患者在11、1点垂直部分切断外括约肌.结果 41例均获随访,平均随访85(2～252)个月.手术成功36例(88%),患者排尿通畅,尿流率增加>10 ml/s,肾输尿管积水减少或消失.无效5例(12%).结论 经尿道电切治疗骶神经损伤所致下尿路排尿功能障碍方法简便易行、费用低、效果好.     

Total replacement of ureter with a segment of ileum

Replacement of ureter with a segment of ileum was successfully performed in two patients. One had ureteral cancer and the other recurrent calculi due to cystinuria. The first patient had only one kidney. In the second both ureters were replaced with ileum. Formation of a papilla at the distal end of the ileal segment in the bladder may reduce the risk of vesico-ileal reflux.     

环形乙状结肠全膀胱置换术

为了寻求更理想的膀胱替代术式，１９９０年１月至１９９５年１２月，自行设计并施行２２例环形乙状结肠全膀胱置换术。取乙状结肠３０～３５ｃｍ，无水乙醇灭活肠粘膜功能细胞，对端缝合做成环形与尿道对接。术后５５天内，清醒状态下尿自控１００％，睡眠状态下尿自控９５４％。随访６～７２个月，２０例新膀胱有足够的容量，良好的顺应性和控尿机能。手术操作简单，并发症少，是理想的膀胱替代术式。     

Experience with a detubularized right colonic segment for bladder replacement

A detubularized right colonic segment was used as bladder substitute in ten men who underwent cystoprostatectomy for carcinoma of the bladder. Postoperative complications unrelated to the replacement procedure occurred in three cases. Stricture of the urethrocaecal anastomosis developed during follow-up in one case. Day-time continence with convenient micturition intervals was achieved in all cases. Nocturnal continence was also maintained if the patients awoke once or twice to void. Urodynamic studies revealed adequate capacity, little or no residual urine and pressure waves of low amplitude at high-level filling. The technique employed for creation of a bladder substitute offers the advantage of technical simplicity. The bowel it utilizes is of secondary importance for intestinal absorption, and the result is a low-pressure, capacious neobladder.     

Prevention of chronic urinary retention in orthotopic bladder replacement in the female

OBJECTIVE: Chronic urinary retention is a frequent complication after orthotopic bladder replacement. Herein a new technical modification to avoid voiding dysfunction is described. METHODS: Between January 1995 and January 2004, 62 women had orthotopic bladder replacement after radical cystectomy. From November 1998 on, 35 patients were operated using a new technical modification, consisting in the fixation of a large and thick flap of peritoneal and extraperitoneal tissue deriving from the posterior wall of the vagina to the edges of endopelvic fascia to create a resistant hammock under the reservoir. RESULTS: 25 women have a follow-up longer than 12 months, range 12-56, and are considered in this study. Only one, out of 25 patients, still has occasionally stress incontinence but she did not need to use pads. Two patients are incontinent at night. None of 25 patients has a residual urine volume greater than 100 ml or needed intermittent catheterization. Median bladder capacity is 350 ml, range 280-430 ml. Median creatinine level is 1.1 mg/dl, range 0.7-1.2 mg/dl. CONCLUSION: The creation of a posterior support to the neobladder, by harvesting a thick flap, has, in our series, completely avoided the occurrence of chronic urinary retention, which is the most common long-term complication of bladder replacement in the female. Our series is sufficiently large to exclude serendipity and to be compared with other series in the literature.     

人工全髋关节置换术治疗发育性髋关节发育不良

目的 :探讨髋关节发育不良髋臼假体选择和骨缺损的修补方法。方法 :人工全髋关节置换术治疗 18例髋关节发育不良 ,其中骨水泥型 11例 ,非骨水泥型 7例 ,年龄 43～ 76岁。术前用标准模板重叠法测量轻、中、重度骨缺损 ,术中利用股骨头股骨距致密骨块 ,用反转方式植骨使骨块股骨距坚硬部分修补外上方承重区骨缺损 ,以防止骨块吸收或塌陷影响假体臼的稳定性。分别用三种方式固定髋臼假体 ,15例植骨。结果 :随访l～ 8年植骨块完全愈合 ,无植入骨块吸收和假体臼松动病例 ,骨水泥型和非骨水泥型假体与骨床结合稳定。结论 :股骨距骨块反转植骨同时具有修补骨缺损和骨支撑作用 ,是防止骨块吸收和稳定髋臼假体的好办法     

Cystourethrometric findings in patients with detubularized right colonic segment for bladder replacement

Urodynamic evaluation was performed in 13 men 4 to 18 months after cystoprostatectomy and bladder replacement using a detubularized right colonic segment. All patients are continent by day and only 3 are incontinent during the night to a degree that necessitates use of a condom catheter. Two patients awaken every 2 to 3 hours to void and the remainder have nocturia comparable to normal men of their age. The residual volume was 0 to 70 ml. The urethral closure pressure was normal, and in 3 patients studied preoperatively and postoperatively no significant change was observed other than shortening of the profile length. Maximal flow rates were normal although the pattern was intermittent. In 2 patients no cystoplasty contractions were recorded and in all but 2 patients the amplitude of the contractions was less than 40 cm. water. Simultaneous bladder and urethral pressure recordings during bladder filling demonstrated no change in urethral pressure in 10 patients. Although creation of a reservoir with a low pressure and careful preservation of the infraprostatic urethra are important for continence in these patients, we believe that the absence of normal sacral route reflexes after cystoprostatectomy is an important contributing cause to nocturnal incontinence.     

A simple modification using the appendix as efferent limb in ileocolonic reservoir (Mainz pouch)

The appendix was used as an efferent limb of the ileocolonic pouch (Mainz pouch) in two patients who underwent radical cystectomy for invasive bladder cancer. The pouch has a low pressure character and sufficient capacity as well as complete continence. This procedure is relatively simple to perform and considered to be a useful modification of ileocolonic pouch.