Le Duc-Camey antireflux ureteroileal reimplantation for continent ileal reservoir]

Le Duc-Camey antireflux ureteroileal reimplantation was used on 15 patients with 30 ureters reimplanted into the ileum as part of a bladder substitution procedure (Kock pouch or ileal neobladder: U-bladder) or augmentation cystoplasty (Goodwin ileocystoplasty). In our experience, no reflux was observed, while hydronephrosis was identified in one ureter of ileal neobladder (4%). Le Duc-Camey antireflux ureteroileal reimplantation is suitable for reconstruction with the ileal reservoir.     

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.     

Clinical, urodynamic and endoscopic characteristics of the Stanford pouch ileal neobladder constructed with absorbable staples

PURPOSE: The clinical, urodynamic and endoscopic aspects of the Stanford pouch ileal neobladder formed with absorbable staples were investigated. METHODS: A Stanford pouch ileal neobladder was formed using absorbable staples after radical cystoprostatectomy in 30 male patients with the diagnosis of muscle invasive carcinoma of the bladder between 1995 and 1998. The mean age of the patients was 62 (range 41-70) years. Patients were followed with arterial blood gas, serum biochemistry, pouch cystography, urodynamic tests and endoscopy. RESULTS: Five (16.7%) patients had early postoperative complications and three were related to the neobladder. One year postoperatively, low grade (I, II) vesicoureteral reflux was present in five (16.7%) cases. The mean preoperative and 6 months postoperative serum creatinine levels were 1.07+/-0.3 mg/dL and 1.2+/-0.4 mg/dL, respectively, but the difference was not statistically significant (P=0.1). Six months postoperatively the mean serum chloride level was 109+/-4.5 (range 100-113) mmol/L and the mean arterial blood pH was 7.37+/-0.2 (range 7.3-7.4). Two (6.7%) patients required oral alkaline supplementation because of high chloride levels. All the patients except one were continent throughout the day after 1 year. However, nocturnal enuresis was present in 25 (83.3%) cases. The pouch capacity was increased gradually up to 12 months postoperatively and the mean pouch capacity 12 months postoperatively was 460+/-95.8mL. Micturition occurred spontaneously in most patients while some needed abdominal straining. None of the patients had a residual urine of more than 60 mL. The mean maximum flow rate 6 months postoperatively was 9.8 (range 5.4-15.0) mL/s. After 6 months the stapled edge was noticed as a nodular line. One year postoperatively only a white scar could be observed at the suture line. CONCLUSION: The Stanford pouch ileal neobladder constructed using absorbable staples was able to provide a good capacity low pressure reservoir with a low rate of complications.     

Early experiences with continent bladder substitution

Since January 1987 a total of 14 patients have undergone continent bladder replacement procedure. The bladder substitute was constructed of ileum (ileal neobladder) in three patients, of an ileocaecal segment (Mainz pouch) in five patients while in six patients a segment of ascending colon (Mayo pouch) was used. Nine male patients underwent a complete bladder substitution after cystoprostatectomy. In five patients a bladder augmentation was performed. Four of these patients were female. They were subjected to subtotal cystectomy which left only one cm of the bladder neck, while the ureters were reimplanted into the pouch. Seven of the nine patients with total bladder substitution are continent during the day and seven at night. All patients in the bladder augmentation group are continent day and night, but one of them has to empty his bladder by intermittent catheterization. Because of stenosis at the ureterocolonic anastomosis, reoperation was performed on two patients more than one year after the primary operation. Except for these two patients, who required surgical revision, the initial results are encouraging and patient acceptance has been excellent.     

Tumor recurrence in the remnant urothelium of females undergoing radical cystectomy for transitional cell carcinoma of the bladder: long-term results from a single center

PURPOSE: We analyzed the risk factors and incidence of secondary TCC of the remnant urothelium in women following radical cystectomy for TCC of the bladder. MATERIALS AND METHODS: A total of 85 women with a mean age of 64.5 years with clinically localized TCC of the bladder underwent radical cystectomy between 1992 and 2004. Orthotopic bladder substitution was performed in 46 females, while 39 underwent nonorthotopic urinary diversion. Of the entire cohort 22 (26%) patients underwent cystectomy for multifocal or recurrent TCC. Followup examinations were performed at 6-month intervals. RESULTS: Mean followup in the entire cohort was 49.8 months (median 42). Intraoperative frozen sections obtained from the urethra and distal ureters were negative for TCC and CIS in all patients. Four women (4.7%) had TCC in the remnant urothelium at a mean of 56 months postoperatively. These patients had undergone cystectomy for multifocal or recurrent TCC (4 of 22 or 18%). No secondary TCC was seen in the 63 patients with solitary invasive or nonrecurrent bladder cancer (p <0.05). Urethral recurrence was found in 2 patients (4.3%) 65 and 36 months after orthotopic neobladder surgery, respectively. In the orthotopic group 1 patient (2.1%) had an upper urinary tract tumor 76 months after surgery, while in the nonorthotopic group 1 (2.5%) was found to have an upper urinary tract tumor 48 months postoperatively. CONCLUSIONS: Recurrent or multifocal TCC may represent a risk factor for secondary TCC of the remnant urothelium after cystectomy. In our series all recurrent tumors were late recurrences (more than 36 months postoperatively). Because the rate of urethral recurrence in the current series corresponds to that reported in men (2% to 6%), urethra sparing cystectomy with orthotopic bladder replacement does not appear to compromise the oncological outcome in women.     

Evaluation of direct versus non-refluxing technique and functional results in orthotopic Y-ileal neobladder after 12 years of follow up

OBJECTIVES: We report on the long-term functional results of the orthotopic Y-ileal neobladder and compare the outcome of the antireflux technique for ureteral implantation versus direct anastomosis. PATIENTS AND METHODS: Between 1990 and 2002, 120 patients underwent cystoprostatectomy and orthotopic Y-shaped ileal neobladder for invasive bladder carcinoma. The direct Nesbit technique for ureteral reimplantation was applied in 58 patients (group 1) and in 62 patients the ureters were reimplanted using the Le Duc antirefluxing technique (group 2). The mean follow-up period was 72 months (range, 36-144 months). RESULTS: Of 62 patients who underwent the Le Duc technique, six (9.7%) had unilateral uretero-ileal anastomotic stricture and four (6.5%) had reflux. Of 58 patients who underwent direct anastomosis, six (10.3%) patients had unilateral reflux, four of them had dilated ureters preoperatively and no patient had uretero-ileal anastomotic stricture. The incidence of stricture formation in the Le Duc technique is significantly higher than direct anastomosis (P = 0.04). There was no significant difference in the overall incidence of reflux in both groups. However, the incidence of reflux in preoperatively dilated ureters was significantly higher in direct ureteral anastomosis than Le Duc technique (40% in group 1 vs 16.7% in group 2; P = 0.045). The incidence of stone formation, azotemia, pyelonephritis and bacteriuria was comparable in both groups. The urodynamic findings showed a mean increase in the neobladder capacity at 6 and 18 months after surgery by 340 and 560 mL, respectively. The mean of the maximum pressure was 22 +/- 10 cm H2O, 18 months after surgery. Daytime and nighttime continence was good or satisfactory in 93.3% and 85.5% of the patients, respectively, after 3 years of follow-up. CONCLUSIONS: The functional and voiding results of a Y-shaped neobladder pouch using 40 cm of ileum are similar to the more sophisticated larger pouches. Direct uretero-ileal anastomosis in orthotopic bladder replacement is more reasonable than the Le Duc antireflux technique in non-dilated ureters. The benefit of the antireflux technique has been overestimated despite of the frequency of stricture formation.     

Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures.

A urethral controlled bladder substitute was constructed from a detubularized, double folded ileal segment in 40 male patients following cystoprostatectomy for bladder cancer. For reflux prevention patients were prospectively randomized to receive either an intussuscepted nipple valve or the ureters were implanted by the Le Duc mucosal trough technique. All patients had normal upper tracts preoperatively. Mean patient age, performance status and stage of cancer were comparable in both groups. Patients were evaluated 6 to 18 months postoperatively. In addition to history taking, assessment included excretory urography, ascending cystography and voiding cystourethrography. During the observation period all patients with nipple valves had normal radiographic appearance of the upper tracts without evidence of reflux. On the other hand, following the Le Duc procedure 12 of 38 renal units (31%) showed evidence of radiographic dilatation. Of the 12 units 11 had stenotic ureters and 1 had reflux. We conclude that nipple valves are more effective in reflux prevention and protection of the upper urinary tract in patients for whom an ileal neobladder is indicated.     

The ileal neobladder

Currently we are witnessing an increase of interest in bladder substitution enterocystoplasty. The goal of this presentation is to describe operative technique and first clinical results of a ileal neobladder for total bladder replacement. Creation of a ileal neobladder for total bladder replacement is described in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressures lower than 30 cm water and no reflux. Eight of the 11 patients with the neobladder are completely dry day and night. Three are stress incontinent grade I. All 11 patients developed recognizable sensations of bladder distension closely simulating those of their earlier bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers a stoma free alternative to urinary diversion resulting in a highly compliant low pressure bladder. A urodynamic comparison between the most recent developments (Kock-pouch, Camey, Mainz-pouch, "Le Bag") is made and this clearly shows the ileal neobladder to have several distinct advantages: the ileocolonic junction and the terminal ileum are saved; the operative technique is safe, simple and reliable (no Kock valve, no 180 degree rotation of the reservoir, simple antireflux technique); development of recognizable sensations of bladder filling in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

The ileal neobladder

An ileal neobladder for total bladder replacement was created in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm. ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to the method of Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressure lower than 30 cm. water and no reflux. Of the 11 patients with the neobladder 8 are completely dry day and night, while 3 have grade I stress incontinence. All 11 patients had recognizable sensations of bladder distension closely simulating those of normal bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers an alternative free of a stoma to urinary diversion, resulting in a highly compliant, low pressure bladder.     

Long-term results of orthotopic neobladder reconstruction after radical cystectomy

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.     

保留勃起和射精功能的改良全膀胱切除术的临床应用

目的探讨保留勃起和射精功能的改良全膀胱切除术在膀胱良、恶性病变患者的临床应用价值。方法本组18例男性患者,年龄18~38岁,平均30.5岁。结核性挛缩膀胱4例,腺性膀胱炎5例,晚期神经原性膀胱5例,复发的多发性非肌层侵犯膀胱移行细胞癌4例,均需行全膀胱切除术,但患者强烈希望保留勃起和生育功能。行改良单纯性全膀胱切除术,保留输精管、精囊、前列腺和双侧神经血管束,以回肠新膀胱(13例)或回结肠新膀胱(5例)替代。结果平均手术时间350min,术中平均出血量420ml,7例患者输血。1例发生尿漏,无其他围手术期并发症。拔除导尿管后均能自行排尿,每次尿量300~500ml,剩余尿量25~65ml。2例神经源性膀胱患者需间歇自家导尿。白天无尿失禁,3例患者晚上有遗尿。平均随访46个月(18~68个月)。17例(94.4%)患者术后阴茎勃起功能恢复良好,均有遗精(未婚者)或顺行射精。尿路造影上尿路功能和新膀胱形态良好,1例轻度肾积水。肿瘤患者无复发。结论对选择性膀胱良、恶性病变患者行保留勃起和射精功能的改良全膀胱切除和原位膀胱术,安全有效,效果满意。尿动力学检查对神经源性膀胱患者的选择至关重要。     

Results of chimney modification technique in ureterointestinal anastomosis of Hautmann ileal neobladder in bladder cancer

BACKGROUND: To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. METHODS: Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. RESULTS: At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. CONCLUSION: New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.     

Ileal Neobladder for Bladder Substitution after Radical Cystectomy

Background: Studer's ileal neobladder is technically simple, and favorable clinical results have been reported. However, there have been only a few follow-up studies on this type of ileal neobladder. We reviewed the clinical outcomes of patients who received Studer's ileal neobladder, with a minor modification, in our institution.
Methods: Twenty-five men underwent bladder reconstruction with Studer's ileal neobladder after radical cystectomy. The function of the ileal neobladder and voiding status were evaluated during follow-up. The follow-up period ranged from 3 to 42 months (mean, 24 months).
Results: The ileal neobladder achieved a large capacity at a low basal pressure, associated with a relatively low complication rate directly related to the neobladder. At 12 months after surgery, daytime and nighttime continence rates were 90|X% and 74|X%, respectively. In 5 patients who were incontinent, the maximal urethral closure pressure was statistically lower than in patients with continence.
Conclusion: Studer's ileal neobladder is an easy operative procedure for bladder substitution, and has a relatively low complication rate directly related to the neobladder. Good compliance ofthe pouch and preservation of the external sphincter mechanism are the most important factors for achieving urinary continence, after construction of the ileal neobladder.     

Clinical experience with the N-shaped ileal neobladder: assessment of complications, voiding patterns, and quality of life in our series of 58 patients

PURPOSE: The purpose of this retrospective study was to assess complications, voiding patterns, and quality of life in patients with an orthotopic bladder substitution, using an N-shaped ileal neobladder. MATERIALS AND METHODS: Between May 1996 and December 2002, 58 patients (52 men and 6 women) underwent an orthotopic ileal neobladder reconstruction after radical cystectomy. The mean age was 47 for the female and 60 for the male patients. In all patients an N-shaped ileal pouch was constructed. This pouch has not yet been described in the literature before. All procedures were performed by the same surgeon (HVP) and the mean follow-up was 38 months. Complications were registered as early (occurring within 3 months) or late (occurring after 3 months), and as pouch-related and non-pouch-related. The patients took part in a pelvic floor re-education programme for as long as they were incontinent. All patients completed a retrospective Quality of Life questionnaire, based on the QLQ-C30 questionnaire, which was validated by the EORTC's Study Group on Quality of Life. RESULTS: In 38% of the patients, early complications occurred, whereas 48% had late complications. The most frequent early complications were diarrhea (24%) and pyelonephritis (9%). Diarrhea was again the most frequently mentioned non-pouch-related complication (19%). The most frequently observed pouch-related late complication was ileo-urethral stenosis. This occurred in five patients. All of these 5 patients were re-operated using a minimally invasive approach. Daytime continence was achieved in 95% of patients and nighttime continence in 66%. Hyper-continence with subsequent need for CISC was observed in 5 out of 6 women (83%) and 0 out of 52 men (0%). The retrospective QoL questionnaire learned that the impact of bladder removal and orthotopic bladder substitution has acceptable impact on patient's everyday life. Diarrhea was mentioned as being the most discomforting complication by most of the patients. CONCLUSIONS: We describe a modified orthotopic ileal neobladder: the ileal N-pouch. The functional results with this pouch are good. Complication rates and QoL are comparable with the larger series published by other authors, using different ileal neobladder reconstructions.     

Experimental and clinical results with the ileum pouch as a continence-preserving replacement bladder

Clinical use of the ileum-pouch for bladder reconstruction without stoma and direct anastomosis to the urethra is mandatorily based upon the three following conditions: sufficient capacity, low pressure values and protection of reflux in the neobladder. In an experimental study, we constructed a U-pouch with anastomosis to the urethra and implantation of both ureters into a cranial ileum horn. Already six weeks postoperatively an optimal capacity and real low pressure conditions of the neobladder have been achieved. Without any ileoileal invagination as antirefluxive procedure simple ureter-nippling provides a highly efficient protection against renal reflux in the so constructed neobladder. Our first clinical results do confirm our experimental data, demonstrating no reflux and almost total continence.     

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE: A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure. MATERIALS AND METHODS: Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases. RESULTS: Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully. CONCLUSIONS: The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.     

改良原位螺旋构型回肠新膀胱术32例报告

目的 评价原位螺旋构型回肠新膀胱术的疗效.方法 1998-2008年对32例男性膀胱癌患者行原位螺旋构型回肠新膀胱术.采用40～45 cm回肠新建储尿囊,去管后用无水乙醇擦拭以清除、破坏黏液细胞,螺旋状构型缝合成低压储尿囊.两侧输尿管末端袖口状整形后分别行原位"插入式"置入新膀胱(Split-Cuff术式).新建储尿囊采用"四针法"低位与尿道缝合.结果 本组平均手术时间(281.2±48.7)min;平均失血量(545.4±181.9)ml,术中输血20例,平均输血(430.8±235.9)ml;平均住院时间(26.8±9.7)d.白天控尿良好30例(93.7%),夜间控尿良好26例(81.3%).23例于术后6个月复查尿动力学提示新膀胱初始尿意容量为270～420(315.0±33.4)ml,最大膀胱容量350～600(490.3±39.7)ml,充盈压(22.5±11.8)cm H2O,最大排尿压(78.3±14.7)cm H2O,最大尿流率(16.5±5.9)ml/s.术后随访22～132个月,平均58.4个月,术后2年内死于肿瘤转移4例.结论 原位螺旋形回肠新膀胱具有容量大、相对低压、顺应性好、肠管利用率高、消化道干扰小和术后排尿、控尿功能更接近正常生理等特点.新膀胱经无水乙醇处理后减少了分泌吸收功能,降低了尿路梗阻和代谢紊乱发生率.输尿管新膀胱Split-Cuff乳头"插入式"吻合可有效防止尿液反流,且方法简单,不易引起管口狭窄,有效地保护了肾功能.尿道以"四针法"吻合简单、实用,可减少吻合口狭窄的发生率.改良螺旋构型回肠新膀胱术是一种较为合理的原位膀胱替代方法.

Abstract：

Objective To assess the outcomes of modified spiral ileal orthotopic neobladder.Methods From January 1998 to January 2008, 32 patients (all male) underwent radical cystectomy and spiral ileal orthotopic substitution for muscle invasive bladder cancer. A segment of 40 to 45 cm ileal loop was isolated, detubularized, and reconfigured in spiral shape to form a pouch. Bilateral ureters were reimplanted by inserting the 1 cm distal segment into the pouch to form a Split-Cuff nipple.The bottom of the pouch was opened and anastomosed with the urethra (4 stitches). Results There were no perioperative deaths. The mean operative time was 281.2±48.7 min. Blood loss was 545.4±181.9 ml. Twenty cases required a blood transfusion, the mean volume of intraoprative blood transfusion was 430.8±235.9 ml. The average hospital stays were 26.8±9. 7 days. Rate of daytime continence was 93. 7% (30/32) while nighttime continence was 81.3% (26/32). Urodynamic studies were carried out in 23 cases 6 months after surgery. Neobladder capacity at first desire to urinate was 315.0± 33.4 ml(270-420 ml). The maximum neobladder capacity was 490. 3±39.7 ml(350-600 ml).The maximum flow rate (Qmax) was 16.5 ± 5.9 ml/s. Full resting pressure was 22. 5 ± 11.8 cm H2O. Peak voiding pressure was 78.3 ± 14.7 cm H2O. After mean 58. 4 months' follow up (range 22 to 132), 4 cases died of metastasis of bladder cancer. Conclusion Modified spiral ileal orthotopic neobladder is a reasonable option for treating invasive bladder cancer.     

Continent urinary tract reconstruction - the Lund experience

The Department of Urology in Lund, Sweden, has a long association with innovations in reconstructive urology. The authors from that department describe their experience over a long period with orthotopic bladder substitution and continent cutaneous urinary diversion. They conclude that continent urinary tract reconstruction is associated with a high incidence of early and late complications. They also found that for storage and emptying, their Lundiana pouch was superior to the Goldwasser neobladder. OBJECTIVE: To assess the early and late complications and functional results in patients undergoing continent reconstruction of the urinary tract, i.e. orthotopic bladder substitution (OBS) or continent cutaneous diversion (CCD). PATIENTS AND METHODS: The medical records of all patients undergoing OBS (Goldwasser technique) or CCD ('Lundiana' technique) for malignant or benign disease during 1987-1999 and followed to December 2001 were reviewed. There were 67 patients with neobladders, 77 with a Lundiana pouch who had undergone radical cystectomy and 22 with a Lundiana pouch operated for benign disorders. RESULTS: Early complications requiring reoperation occurred in 12% of the cystectomy group, with no difference with type of reconstruction, and in 10% with benign diseases. Four patients (3%) undergoing radical cystectomy died from early cardiovascular complications, two after surgery for intra-abdominal complications. Intestinally related complications and wound dehiscence requiring re-operation occurred in nine and six patients, respectively. The incidence of late complications requiring open surgery was 22% and 23% after cystectomy with OBS and CCD, respectively. The value in patients with benign diseases undergoing CCD was also 23%. Stone formation in the pouch was common, occurring in 12% in patients with OBS and in 10% after CCD. The pouch perforated or ruptured in four patients. The incidence of uretero-intestinal stricture using the Le Duc technique was 2.4% and renal function was well preserved. The incidence of revisional surgery of the Lundiana pouch outlet for incontinence was low and all patients but four were continent. The functional outcome in patients with OBS was less good; some needed pouch augmentation or an artificial urinary sphincter. Most patients used incontinence products and many needed clean intermittent self-catheterization. CONCLUSION: Continent urinary tract reconstruction is associated with a high incidence of early and late complications. For storage and emptying, the CCD Lundiana pouch is superior to the OBS of Goldwasser.     

The serous-lined tunnel principle for urinary reconstruction: a more rational method.

OBJECTIVE: To examine the feasibility of using the serous-lined-tunnel principle for orthotopic neobladder, continent cutaneous diversion and ureteric replacement by an intestinal segment. Patients and methods We created: (i) an orthotopic ileal neobladder using the serous-lined technique for antirefluxing ureteric implantation in 16 patients; (ii) a continent ileal pouch, adopting the principle for continent-valve construction and for ureteric implantation, in 10 patients (another patient with a failed continent valve underwent revision using an adaptation of this principle; and (iii) by applying the same principle an ileal ureter with a proximal antirefluxing mechanism was constructed in two patients (with lower ureteric cancer), and total replacement of the ureter by a tubular segment of the colon in association with a continent transverse colon pouch in one irradiated patient. RESULTS: In all, 52 ureters implanted into ileal neobladders or continent pouches functioned well, with neither obstruction nor reflux; 11 continent valves functioned well with no incontinence. Two patients with ileal ureters showed no ileo-ureteric reflux and had less hydronephrosis than before surgery. The tubularized ureter provided a unidirectional flow into the pouch. Conclusion Ureteric reimplantation and continent valve formation achieved by adopting the serous-lined tunnel principle provided satisfactory results. The versatility of the principle is apparent in the present experience and the creative application of the serous-lined tunnel principle should be possible in urinary reconstruction.     

A novel antireflux technique using an intussuscepted ileal segment

A novel surgical technique of antireflux with an ileal conduit for urinary diversion is presented with our early results. The mid 8-cm portion of an isolated terminal ileum is intussuscepted. After skeletonization of the mesenterial vasculature, 3 rows of 4 mattress seromuscular silk sutures are placed on the ileum. By tying the sutures successively, the ileum is intussuscepted and the resultant nipple is secured simultaneously between its outer and inner layers. The outer nipple layer and the recipient ileal layer are further fixed as a whole by placing 3 rows of metal staples. The nipple base is secured by interrupted silk sutures and the mesenterial defect is closed. This technique was applied to 30 patients undergoing rectosigmoidal bladder procedure, a modified ileocecal rectal bladder, in which the antireflux conduit was interposed between the ureters and the rectosigmoidal pouch. Ureteral reflux was observed in none of the patients during a mean follow-up period of 29.9 months. Of the 60 renal units, 53 (88.3%) had normal pyelography and 7 (12.7%) showed mild hydronephrosis at 3-6 months postoperatively. This antireflux technique is simple and reliable, and can be applied to other urinary diversion/reconstruction surgeries, such as the continent reservoir, orthotopic neobladder, and/or bladder augmentation.