Continent substitution enterocystoplasty using a low-pressure detubularized ileal reservoir

Abstract

The rate of enuresis after tubular substitution enterocystoplasty is well over 70%. Incontinence is partly due to the persistence of peristaltic activity in the isolated intestinal segment that generates high-pressure waves of over 40 cm H2O, even at low urinary volumes, which can overcome the distal urethral sphincter mechanism. The use of detubularized intestinal segments has been shown to reduce dramatically these high-pressure waves, secure diurnal continence, and reduce nocturnal leakage. The detubularized ileal low-pressure reservoir, easy to construct, provides continence rates identical to those secured by more complicated pouches. A 30-cm ileal loop, open on its antimesenteric border, is folded in a U shape. Its medial and lateral borders are then sutured so as to form a pouch, the apex is anastomosed to the urethral stump, the ureters are reimplanted on the upper aspect of each limb, and the pouch is closed. This procedure was used in ten patients after radical cystoprostatectomy for infiltrating bladder cancer, seven of whom were submitted to a thorough clinical radiologic and urodynamic evaluation, with a minimum follow-up of 5 months. All seven are continent during the day, with no residual urine, and have a mean flow rate of 15 ml/s. Cystometrograms taken at full bladder capacity failed to demonstrate pressure waves of over 25 cm H2O. Four patients are continent at night; three are enuretic and await further treatment. A reasonable alternative to other types of substitution enterocystoplasty, the low-pressure detubularized ileal reservoir provides excellent diurnal continence but cannot secure nocturnal continence in more than 50% of incontinent patients. However, the absence of high-pressure peristaltic waves may allow the use of an artificial urinary sphincter activated at night for the patient who remains incontinent.