Modified ureterosigmoidostomy (Mainz Pouch II) urinary diversion: 10 years experience and follow-up

Abstract

Objective To report 10 years experience in modified ureterosigmoidostomy (Mainz Pouch Ⅱ) urinary diversion and evaluate its long-term outcome. Methods From October 2004 to December 2014, 248 patients , including 205 men and 43 women, had underwent Mainz Pouch Ⅱ urinary diversion at 26 institutions in Gansu Province, China.The median age at surgery was 61 years, ranged from 15 to 79 years, Among those patients, 239 patinets were diagnosed as bladder invasive urothelial carcinoma, including urothelial carcinoma in 230, squamous cell carcinoma in 6, adenocarcinoma in 2 and leiomyosarcoma in 1. 200 male patients underwent the radical vesico-prostsectomy. 39 female patients underwent the exenteration of total pelvis with bilateral pelvic lymadenectomy. For one paitent with urethral squamous cell carcinoma, exenteration of total pelvis, urethra resection and bilateral pelvic lymadenectomy were performed at the same time. Simple cystectomy were performed in 5 patients, including bladder retraction as a consequence of urinary tuberculosis, exstrophy bladder, interstitial cystitis, glandular cystitis and refractory vesicovaginal fistula. Bricker ileal conduit urinary diversion was transformed to Mainz Pouch Ⅱ in three patients. Clinical data and early complications were retrospective analysis. Data on long-term complications, continent status, urinary frequency and patient's quality of life were investigated by follow-up. Results The median operative time for urinary diversion is 120 minutes (ranging from 90 to 150 minutes). The median estimated blood loss was 800 ml (ranging from 400 to 2 500 ml). Seven patients (7/248, 2.8%) died in the perioperative period. Early complications were noticed in 66 patients (66/248, 26.6%), such as intestinal fistula(6/248, 2.4%), pulmonary infection(5/248, 2.0%), ileal obstruction (4/248, 1.6%), pyelonephritis(4/248, 1.6%), deep venous thrombosis(2/248, 0.8%), pelvic infection(2/248, 0.8%), wound dehiscence (10/248, 4.0%), superficial wound infections (30/248, 12.1%), hemorrhagic shock(1/248, 0.4%), myocardial infarction (1/248, 0.4%) and rectovaginal fistula (1/248, 0.4%). Thirty-seven patients (15.4%, 37/241) were lost during follow-up and eighty-five (41.7%, 85/204) passed away. 119 patients were followed from 7 to 126 months (mean 46 months). Late complications occurred in 29.4% of patients (60/204), including uretero-intestinal anastomotic stricture (20/204, 9.8%, 24 of 400 renoureteric units, 6.0%), recurrent pyelonephritis (12/204, 5.9%), delayed ileal obstruction (11/204, 5.4%), symptomatic metabolic acidosis (11/204, 5.4%), incisional hernia (5/204, 2.5%), pelvic infection (1/204, 0.5%). The overall quality of life was described as 'fully satisfied' by 20 patients (20/119, 16.8%), 'moderately satisfied' by 87 patients (87/119, 73.1%) and 'Poorly satisfied' by 12 patients (12/119, 10.1%). At the end of follow-up, three patients were excluded due to conversion to permanent nephrostomy. The other patients were continent at day time. Completely continence was achieved in 92 of 116 (79.3%) patients during the day and night. Conclusions Mainz Pouch Ⅱ is a simple and feasible procedure to achieve continent urinary diversion, with excellent continence rate and good quality of life. When the patient refused to have an incontinent urinary diversion, it may be used as a convenient and satisfactory alternative for cystectomized patients who are not suitable for orthotopic urinary diversion due to bladder cancer invasion into prostate or urethra. Key words: Ureterosigmoidostomy; Urinary diversion; Mainz Pouch Ⅱ; Surgical complications; Follow up