Sigmoid neobladder in women after radical cystectomy

PURPOSE: Neobladder reconstruction using an intestinal segment is the common procedure of choice in men after cystectomy. Recently this procedure has been extended to women. We present our surgical and functional experience with the sigmoid neobladder in women. MATERIALS AND METHODS: A total of 11 women 49 to 74 years old (mean age plus or minus standard deviation 60 +/- 8.5) with transitional cell carcinoma of the bladder underwent lower urinary tract reconstruction with a modified sigmoid neobladder after nerve and urethral support sparing cystectomy. After at least 3 months voiding pattern and continence status were evaluated. Pressure flow studies and uroflowmetry were performed, the urethral pressure profile and neocystourethral angle were measured, and blood chemistry was analyzed. RESULTS: After at least 3 months complete daytime continence was achieved in 2 patients, while 8 had mild stress incontinence. At night 8 of the 11 women (72.7%) were continent with or without voiding at regular intervals. All except 1 patient voided to completion. Of the 2 patients with complete continence 1 needed clean intermittent catheterization 4 months postoperatively. Mean maximal urinary flow was 19.9 +/- 10.5 ml. per second. Excluding the woman who required catheterization mean residual urine volume was 15 +/- 13.7 ml. Postoperatively maximal urethral pressure was slightly lower and functional urethral length was about 10 mm. shorter than preoperatively. The mean neocystourethral angle was 131.9 +/- 21.7 degrees. Mean pH, bicarbonate and base excess were 7.38 +/- 0.03, 23. 48 +/- 2.34 mmol./l. and -0.92 +/- 2.50, respectively. CONCLUSIONS: After nerve and urethral support sparing cystectomy a modified sigmoid neobladder may be constructed in women to obtain satisfactory continence and voiding results.     

女性保留内生殖器膀胱全切原位回肠新膀胱尿流改道术的临床疗效

目的:探讨女性保留内生殖器膀胱全切患者行原位回肠新膀胱尿流改道术的临床疗效。方法:回顾性分析我院2005年7月~2012年5月48例女性膀胱肿瘤患者的临床资料,均采取保留内生殖器的膀胱全切术并行原位回肠新膀胱尿流改道术。48例患者中移行细胞癌46例,腺癌2例;原发肿瘤32例,复发性肿瘤16例;多发性非肌层侵犯肿瘤17例,肌层浸润性膀胱肿瘤31例。结果:48例患者的平均手术时间260(210~360)min,平均输血量280(0~1200)ml。术后47例患者获得随访,随访6~84个月,平均36个月。术后12个月白天控尿率为97.9%(46/47),夜间控尿率为93.6%(44/47)。新膀胱尿道吻合口漏3例。术后6个月IVU检查输尿管狭窄2例。无子宫、子宫附件及阴道转移复发。结论:对于符合适应证的女性膀胱癌患者,保留内生殖器、阴道前壁、自主神经及完整尿道,行膀胱全切并行原位回肠新膀胱尿流改道术,临床疗效满意,术后患者生活质量高,可作为广泛开展的术式。     

保留部分前列腺外科包膜对原位新膀胱功能的影响

目的　探讨全膀胱切除术中保留远端部分前列腺外科包膜及其周围横纹括约肌对原位新膀胱功能的影响。　方法　对 2 3例男性膀胱癌患者行全膀胱切除并肠道原位新膀胱术。分两组 :①改良手术组 :13例 ,在膀胱切除时保留远端部分前列腺外科包膜及其周围横纹括约肌 ,新膀胱与残留前列腺包膜连续缝合 ;②常规手术组 :10例 ,行常规全膀胱切除 ,新膀胱与后尿道间断缝合。对两组新膀胱术后的控尿和排尿功能进行随访和比较。　结果　术后病理分期 :T2aN0 M0 13例 ,T2bN0 M0 6例 ,T1N0 M0 1例 ,T3aN0 M0 1例 ,T3bN1M0 1例和T4aN0 M0 1例。术后随访 3～ 4 0个月。改良手术组无瘤生存 11例 ;带瘤生存 2例 ,其中 1例为低分化移行细胞癌 ;另 1例为低分化腺癌。 13例新膀胱排尿良好 ,剩余尿 0～ 70ml;完全控尿 12例 ,夜间尿失禁 1例。常规手术组 10例均无瘤生存 ,7例排尿好 ,剩余尿 10～ 10 0ml,3例剩余尿 10 0～ 2 5 0ml,需要不定期间歇导尿 ;完全控尿 7例 ,昼夜尿失禁 1例 ,夜间尿失禁 2例。　结论　保留部分前列腺外科包膜及其周围横纹括约肌可改善原位新膀胱术后患者的排尿和控尿功能。     

Neobladder with prostatic capsule and seminal-sparing cystectomy for bladder cancer: a step in the wrong direction

A laudable trend in urologic surgical oncology is to minimize operative morbidity by anatomic and functional organ preservation without compromising radicality. An increasing number of authors have taken advantage of the sexual-function-preserving cystectomy for bladder cancer. The modified procedure includes cystectomy with sparing of prostate, vasa deferens, seminal vesicles, and resection of a prostatic adenoma to avoid bladder outlet obstruction and bladder reconstruction with an orthotopic reservoir. This article focuses on studies from the last 15 years and includes the results from 13 centers worldwide. Many of them report a pattern of failure (local versus distant) that is highly unusual. Although a local recurrence rate of 7 of 252 patients is to be expected in this combined series the distant failure rate of 34 of 252 patients is at least twice as high as expected for the given series of superficial or organ-confined TCC. The observed distant failure rate of sexuality-preserving cystectomy in this potentially lethal disease is more than 5% higher as compared with standard radical cystectomy. The precise underlying mechanism of this unexpected pattern of failure following sexuality-sparing cystectomy is not fully understood. Furthermore, surgeons considering procedures that preserve a portion of the prostatic urethra, the prostatic capsule, or the entire prostate should recognize a 6% risk of significant prostatic cancer in any residual tissue, and the potential risk of urethral tumor involvement with TCC. Daytime continence following radical versus sexuality-sparing cystectomy is identical. Data on nighttime continence of sexuality-sparing cystectomy are inconclusive. The continuous intermittent catheterization rate following sexuality-sparing cystectomy, however, seems to be higher than after standard cystectomy. The only advantage sexuality-preserving cystectomy has is indeed preservation of these functions in a much higher percentage than following standard or nerve-sparing cystectomy. This is at the cost of radicality, however, and results in a 10% to 15% higher oncologic failure rate. Consequently, sexuality-sparing cystectomy for bladder cancer is a step in the wrong direction and should be abandoned.     

Pubovaginal slings for stress urinary incontinence following radical cystectomy and orthotopic neobladder reconstruction in women

PURPOSE: We evaluated the clinical efficacy of pubovaginal slings for new onset stress urinary incontinence following radical cystectomy and orthotopic lower urinary tract reconstruction in women. MATERIALS AND METHODS: Between June 1990 and July 2002, 101 female patients with primary transitional cell carcinoma of the bladder were treated with radical cystectomy and orthotopic ileal neobladder reconstruction. Four patients 61 to 73 years old underwent pubovaginal slings (autologous rectus fascia in 2 and dermal graft in 2) for stress urinary incontinence persisting 9 to 20 months following reconstruction with a Studer (2) or T pouch (2) ileal neobladder. Pre-cystectomy continence was excellent in 3 patients, while 1 had mild stress incontinence. All patients had high grade, muscle invasive transitional cell carcinoma and/or carcinoma in situ with negative urethral margins and 3 of the 4 had lymph node negative disease on pathological examination. Two patients were treated with transurethral bulking material 4 to 5 months prior to the sling procedure without noticeable improvement. RESULTS: Two patients who underwent autologous pubovaginal slings had significant complications arising from dissection in the retropubic space, including 1 entero-pouch fistula and 1 enterotomy resulting in an enterocutaneous fistula, sepsis and subsequent death. These 2 patients had persistent stress incontinence despite the sling procedures and they ultimately underwent conversion to continent cutaneous urinary diversions. Two patients were treated with a dermal graft sling using infrapubic bone anchors through a transvaginal approach, obviating the need to enter the pelvis. These patients had uneventful postoperative courses and they are currently hypercontinent, performing intermittent catheterization with complete daytime continence and only occasional nighttime leakage 3 and 9 months following sling surgery. CONCLUSIONS: Pubovaginal sling procedures for incontinence following orthotopic neobladder reconstruction in women may be complicated due to extensive pelvic surgery. Dissection in the retropubic space should be avoided because potentially fatal complications may occur. Slings using infrapubic bone anchors may provide the best option in such patients in whom conservative management has failed because the pelvis need not be violated.     

女性原位回肠代膀胱术的临床应用

目的:总结女性膀胱全切患者行原位回肠代膀胱术的临床疗效。方法:回顾性分析1998年1月～2006年2月36例女性膀胱全切,原位回肠代膀胱患者的临床资料。36例患者,年龄48～65岁,平均56岁。其中移行细胞癌34例,腺癌2例。原发肿瘤22例,复发性肿瘤14例。多发性非肌层侵犯肿瘤(Ta～T1)12例,浸润性膀胱肿瘤(T2～T3)24例。结果:36例手术平均时间270min(210～330min),输血量平均400ml(0～1000ml)。术后随访6～72个月,平均26个月。术后6个月昼夜控尿率分别为94%(34/36)和92%(33/36)。2例排尿可控过度,需间歇导尿。术后6个月IVU检查无输尿管狭窄和反流。血电解质和肾功能正常,无尿道残端肿瘤复发。结论:原位回肠代膀胱术治疗女性膀胱癌患者临床疗效满意,可作为广泛开展的术式。     

Causes and treatment of residual urine volume after orthotopic bladder replacement in women

OBJECTIVES: Intact innervation of the female urethra is conditional for normal urination. In the past, urethrectomy was performed as part of cystectomy. After intense anatomical studies of the female pelvis, urethral-function-sparing cystectomy was developed. METHODS: Our clinical group consists of 41 female patients who were operated from 1993 to 1998 for bladder cancer, utilizing cystectomy with orthotopic bladder replacement. RESULTS: In 28 patients, complete daytime continence was restored and in 13 patients, daytime continence was socially satisfactory (1-2 pads were used due to mild stress incontinence). The drawback of orthotopic replacements in females is the frequent development of serious residual volume, which was seen in one third of the 41 patients. The functional results of orthotopic neobladders and therapy of residual urine volume were documented using urodynamic studies. CONCLUSIONS: Postvoiding residual volume may be caused by isolated dysfunction of the urethra and can be treated with clean intermittent self-catheterization or with alpha-blockers, which improve evacuation of the neobladder.     

Impact of Pre-operative MRI-measured Membranous Urethral Length on Urinary Continence after Radical Cystectomy and Orthotopic Substitution: Clinical and Urodynamic Evaluation

Purpose We aimed to determine the impact of membranous urethral length as measured by preoperative magnetic resonance imaging (MRI) upon continence following radical cystectomy and orthotopic substitution. Materials and methods A total of 40 male patients (mean age 55.7 ± 7 years) were subjected to radical cystectomy and orthotopic ileal substitution for bladder cancer. Membranous urethral length was measured by preoperative MRI utilizing coronal oblique high resolution T2 weighted images. In all evaluable patients, day and night continence statuses as well as time to stable continence were recorded. Urodynamic assessment included medium fill pouchometry and urethral pressure profilometry. Results Of all patients 10 were non-evaluable. Mean follow-up period was 8.1 ± 1.9 months. All the evaluable patients were continent by daytime. On the other hand, 13 were continent by night (43.3%), 13 showed occasional enuresis (43.3%) and 4 were nightly enuretic (13.4%). Mean membranous urethral lengths were 14 ± 1.9, 13.8 ± 1.9 and 12.8 ± 1.7 mm in the three groups, respectively (P = 0.51). Mean time to reach stable postoperative daytime continence was 5.4 ± 4.6 whilst it was 12.5 ± 7.4 weeks for nighttime continence. There was no significant correlation between preoperative membranous urethral length and time to stable day or night continence (R = −0.11, −0.08, respectively). Moreover, such correlation was not observed with postoperative urethral pressure profilometry parameters including maximum urethral pressure, maximum urethral closure pressure or functional urethral length (R = −0.33, −0.38, −0.16, respectively). Conclusion Preoperative MRI-measured membranous urethral length has no value for judgment of postoperative continence status following radical cystectomy and ileal bladder substitution.     

保留性神经的膀胱全切除原位回肠膀胱术34例临床分析

目的研究保留性神经的膀胱全切除原位回肠膀胱术在年轻膀胱癌患者中的临床疗效,为临床诊治提供依据.方法选取1998年 l 月至2010年6月我院诊治的年轻膀胱癌患者34例,平均(37．0±2．4)岁.患者入选条件：肿瘤均未侵袭膀胱颈、后尿道、前列腺,无合并前列腺癌,且患者均行保留性神经的膀胱全切除原位回肠膀胱术治疗,实现原位尿流改道.观察入选患者手术成功率、手术时间、随访情况并采用男性性功能量表(BMSFI)进行术后调查.结果34例手术均成功,手术时间280~410 min,平均(310．0±10．2)min.随访6~80个月,34例均存活,无尿道复发,无转移.术后2个月20例(58．8％)有晨间自发性阴茎勃起现象.治疗后28例(82．4％)可有性生活.结论年轻膀胱癌患者采用保留性神经的膀胱全切除原位回肠膀胱术治疗效果理想,能维持患者勃起功能,改善患者生活质量,值得推广应用.     

腹腔镜膀胱癌根治—原位回肠新膀胱术(附5例报告)

目的探讨腹腔镜膀胱癌根治—原位回肠新膀胱术的临床疗效。方法 2008年11月至2011年4月,采用5点穿刺经腹入路,先行腹腔镜下膀胱癌根治,继而体外构建回肠新膀胱,最后腹腔镜下行新膀胱尿道吻合,实施腹腔镜膀胱癌根治—原位回肠新膀胱术5例。皆为男性,平均年龄67岁。结果手术时间420～600min,平均480min,术中失血量350～800ml,平均400ml。术后淋巴结及手术切缘均阴性。随访3～24个月,除1例有轻度夜间尿失禁外,其余患者均昼夜控尿良好。代膀胱充盈良好,容量200～350ml,平均270ml。平均最大尿流率12ml/s。1例出现勃起功能障碍。结论腹腔镜膀胱癌根治—原位回肠新膀胱术创伤小、出血少、并发症少且疗效满意。     

Bladder Substitution in Women

Although numbers are still small and follow-up is often limited, female orthotopic bladder reconstruction has been shown to provide excellent, near-normal voiding and storage function in selected patients, and its popularity has been growing over the last decade. The true role of this form of surgery, however, is not yet fully established. This paper discusses the indications for patient selection, operative technique and outcome of female bladder substitution. Outcome is equivalent to that seen in male patients, although in some series there is a higher rate of voiding dysfunction requiring intermittent self-catheterization. Although further data regarding urethral recurrence rates are awaited, it would seem that with careful patient selection and operative technique, cancer surgery may not be compromised. Functional results have been excellent and patient satisfaction is very high. Provided there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.     

腹腔镜保留前列腺尖部包膜根治性膀胱切除W形回肠新膀胱术尿控和勃起功能研究

目的探讨腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术的临床疗效。 方法回顾性分析2019年1月至2021年12月行腹腔镜根治性膀胱切除W形回肠原位新膀胱术的43例男性膀胱癌患者的临床资料。分为保留前列腺尖部包膜组20例（观察组）和非保留前列腺尖部包膜组23例（对照组）。观察组在距前列腺尖部1.0 cm处切开前列腺包膜,剜除前列腺,保留部分前列腺包膜的腹腔镜膀胱根治切除。对照组采用常规腹腔镜膀胱根治切除。两组W形回肠新膀胱制作方法相同。术后3周拔除导尿管,每３个月定期复查,收集所有患者的临床资料和完整随访信息。 结果所有患者均顺利完成手术。术后随访6~40个月无肿瘤复发。两组患者在术前人口学资料、膀胱肿瘤分期、手术时间、术中出血量、术中并发症、90 d内并发症发生率和术后6个月新膀胱残余尿量差异均无统计学意义（P>0.05）。术后6个月尿控率和勃起功能（IIEF-5评分）实验组优于对照组,日间尿控率分别为85.0%和52.2%（P<0.05）,夜间尿控率分别为65.0%和34.8%（P<0.05）,IIEF-5评分分别为[8（6,9）]分和[3（2,5）]分（P<0.05）。 结论腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术有利于尿控和勃起功能保护,不会影响肿瘤控制效果,值得临床推广应用。     

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.     

Continence mechanism of the ileal neobladder in women: a urodynamics study

We undertook this study to evaluate the mechanism of continence in women who underwent modified radical cystectomy and creation of an ileal neobladder. Our surgical technique was modified in accordance with detailed anatomic dissection of female pelvises with attention to the innervation of the pelvic musculature and urethral sphincter. Ten women aged 41–71 years (mean 64.3 years) underwent nerve-sparing radical cystectomy and creation of an orthotopic neobladder with detubularized ileum. Videourodynamic evaluation was performed 6 months postoperatively to evaluate sphincteric and reservoir function. Seven of the ten patients were totally continent after the procedure, requiring no protective pad. Of these, one requires intermittent self-catheterization. Videourodynamic evaluation revealed a low-pressure reservoir with a mean capacity of 467 ml, and leakage did not occur during Valsalva maneuver. Three patients reported significant incontinence (more than one pad per day) after orthotopic reconstruction. These patients demonstrated intrinsic sphincteric deficiency with a low mean abdominal leak-point pressure of 48.3 cmH₂O. Two of these women had stress incontinence preoperatively. In conclusion, continence can be preserved in most women after modified radical cystectomy and orthotopic bladder replacement. Success results from preservation of the intrinsic sphincteric mechanism and the creation of a low-pressure, compliant reservoir. A history of stress incontinence preoperatively appears to predispose to sphincteric weakness postoperatively.     

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.     

Orthotopic urethral substitution in female patients using the mitrofanoff principle

PURPOSE: We present our experience with orthotopic urethral substitution in female patients using the Mitrofanoff principle. MATERIALS AND METHODS: We performed orthotopic urethral substitution using the Mitrofanoff principle in 18 female patients 1 to 29 years old (mean age 10). The conduit was constructed with appendix in 13 cases, tapered ileum in 4 and fallopian tube in 1. The etiology of incontinence included exstrophy in 8 patients, neurogenic bladder in 3, urogenital sinus in 3, and bilateral ectopic ureter, ectopic ureterocele, the prune-belly syndrome and post-cystectomy undiversion in 1 each. RESULTS: Mean followup was 29 months (range 9 to 72). A total of 16 patients achieved continence following a program of clean intermittent catheterization. There were 2 unsuccessful operations. In 1 case the appendix become ischemic and in 1 a vesicoperineal fistula developed. One patient catheterizes every 2 hours to avoid leakage. Catheterization was temporarily difficult in 5 patients, of whom 2 had an appendiceal and 3 had a tapered ileal conduit. Two patients with an ileal conduit have had chronic difficult catheterization. CONCLUSIONS: Orthotopic replacement of the urethra using the Mitrofanoff principle is suitable in highly select female patients who need continent diversion or a catheterizable conduit but who will not accept an abdominal stoma. It is particularly suited to patients in whom exstrophy reconstruction has failed.     

改良膀胱全切新回肠膀胱术治疗男性浸润性膀胱癌

目的 探讨根治性全膀胱切除术中保留远端的前列腺包膜及精囊对原位新膀胱功能及勃起功能的影响。方法 对24例男性浸润性膀胱癌患者施行改良根治性全膀胱切除及原位回肠膀胱术：保留远端的前列腺外科包膜及精囊，新回肠膀胱与残留前列腺包膜连续缝合；对术后新膀胱的储尿、排尿、控尿功能及患者的勃起功能进行随访和比较。结果 术后病理分期：T2aN0M0 5例，T2bN0M0 9例，T3aN0M0 7例，T3bN1M0 3例。术后随访3—24个月，平均12．7月。无瘤生存22例；带瘤生存2例。新膀胱容量（385±68）mL，最大充盈压（24±16）cmH2O。排尿良好，最大尿流率（18±5）mL／s，剩余尿（35±16）mL；完全控尿22例，夜间尿失禁2例；21例术前勃起功能正常者术后2例发生勃起功能障碍。结论 在改良根治性膀胱全切术中保留远端的前列腺外科包膜及精囊，可明显改善患者术后的储尿、排尿、控尿功能和勃起功能，同时可有效防止新膀胱一尿道吻合口狭窄的发生。     

原位肠代膀胱术远期疗效评价(附266例报告)

目的 总结评价原位肠代膀胱术的远期临床效果。方法 对1991-2003年266例因膀胱癌行膀胱全切手术患者资料进行分析。Hautmann回肠原位代膀胱术206例，Reddy原位结肠代膀胱术60例。131例患者在原标准术式基础上作了手术技术改进。总结手术改进前后患者控尿率和并发症发生率等。结果 获完整随访患者225例。回肠代膀胱术改进前后男性平均随访时间62（44-146）个月和38（4-67）个月；结肠原位代膀胱手术改进前后患者平均随访时间为62（51-131）个月和34（5-67）个月。手术改进可提高男性术后夜间可控率（P〈0．05），女性改善不明显（P〉0．05），总的近期和远期并发症发生率为13．8％和19．6％。男性肿瘤尿道复发9例（4％），女性无复发。结论 原位尿流改道术的远期临床疗效满意，并发症发生率低。手术技术改进可提高男性患者的夜间控尿率。     

Surgical management of incontinence in bladder exstrophy.

Between 1978 and 1990, 86 patients with previously closed classical bladder exstrophy and 10 patients seeking undiversion have presented for continence management and have undergone selective reconstruction designed for voiding and/or intermittent urethral catheterisation. The reconstruction in these 96 patients has been reviewed. Eight of the 10 patients undergoing undiversion achieved a satisfactory state of continence but 4 required Mitrofanoff procedures to enable catheterisation. Of the other 86 patients, 2 reached a satisfactory state of continence without further surgery; 79 underwent bladder neck surgery for continence either without augmentation (n = 32) or with augmentation (n = 47). Twenty of the 32 patients who were treated by bladder neck reconstruction alone were later found to require augmentation. Five patients had very early augmentation either to facilitate neonatal closure or on account of severe upper tract dilatation. Of these, 1 became continent without further surgery and 4 demonstrated the need for bladder neck reconstruction. Thus 12 children achieved successful continence (n = 6) or are evolving satisfactorily with potential success (n = 6) as a result of bladder neck reconstruction. Of the 71 patients requiring bladder neck reconstruction and augmentation, 68 have completed their surgery. The current status of these patients is: satisfactory in 57 (80%) (42 void/urethral clean intermittent catheterisation (CIC), 7 waiting to learn CIC, 5 Mitrofanoff, 3 artificial urinary sphincter (AUS]. Of the remaining 11 patients (20%), 8 are unsatisfactory to varying degrees and the status of the other 3 is unknown.     

Bladder replacement by entero-cystoplasty after radical cystectomy for bladder cancer--the urethral Kock pouch

From September 1989 to March 1990, 6 male patients with invasive bladder cancer, 49 to 70 years old in age, underwent bladder replacement with the ileum (the urethral Kock pouch) after radical cystectomy. Follow up ranged between 3 and 9 months. Urodynamic evaluation showed the ileal bladder to be a low pressure reservoir with a capacity that increased to more than 250 ml. The ileal bladder was emptied by straining without significant residual urine in all patients except one who was performing intermittent self-catheterization. All patients were continent in the daytime. However, all patients required pads at night because of occasional loss of a little urine. Excretory urograms revealed excellent upper tract function. The procedure is suitable whenever the urethra can be preserved after cystectomy for cancer.