Conduit Diversion Research Articles

Long-term results of treatment for ureteroenteric strictures

Objectives. To review the long-term outcome for ureteroenteric stricture treatment. Methods. The ileal conduit diversions that formed ureteroenteric strictures from 1966 to 1999 were reviewed. The strictures were diagnosed radiographically, and malignancy was excluded. The treatment, location, length, diameter, and timing of stricture development after conduit creation was evaluated and compared regarding the time until stricture recurrence (failure). Success was defined as symptomatic improvement and radiologic evidence of patency. Results. Forty patients, after exclusions, returned for ureteroenteric stricture repair, comprising 79 procedures (27 open repairs and 52 balloon dilations). The open repair had a success rate at 1, 2, and 3 years of 92%, 87%, and 76%, respectively. Seven of the open cases were preceded by failed dilations. Balloon dilation had a success rate at 1, 2, and 3 years of 15%, 15%, and 5%, respectively ( P = 0.0001 versus open). Similar patency results for open versus balloon ( P = 0.0001) were noted with analysis restricted to each patient’s first stricture repair. Strictures greater than 1.0 cm were more likely to recur ( P = 0.03). All strictures forming within 6 months of the conduit creation were treated with dilation and failed within 1 year. Of note, 11 of the 40 patients were found to have less than 25% renal function on the strictured side. Conclusions. Open repair for ureteroenteric strictures offers excellent long-term patency (76% at 3 years, P = 0.0001). On review, balloon dilation appeared to have less successful patency rates and was often followed by open repair after failure. Patients with a history of anastomotic strictures should be closely monitored to avoid renal damage and failure.

ESTIMATED BLOOD LOSS AND TRANSFUSION REQUIREMENTS OF RADICAL CYSTECTOMY

Radical cystectomy has been associated with significant blood loss and/or transfusion requirement. We defined and characterized blood loss and transfusion parameters in this population. We reviewed the records of 304 consecutive patients who underwent radical cystectomy and urinary diversion between October 1995 and July 2000. Charts were examined, and univariate and multivariate logistic regression analysis was performed to evaluate estimated blood loss and the transfusion requirement. Complete blood loss data were available in 297 cases. Overall 45% of patients had anemia preoperatively. Median estimated blood loss was 600 ml. (range 100 to 3,000). On univariate analysis increased estimated blood loss was related to patient age, American Society of Anesthesiologists score, longer operative time and paralytic ileus. Overall transfusion was done in 88 of 297 cases (30%) with a median requirement of 2 units (range 1 to 10). The transfusion rate in male and female patients was 26% and 40%, respectively (p <0.05). On univariate analysis female gender, ileal conduit diversion and lower preoperative hematocrit correlated with transfusion need (p = 0.04, <0.001 and <0.001, respectively). On multivariate logistic regression analysis lower preoperative hematocrit, increased estimated blood loss, major complications and ileal conduit diversion type correlated with a higher transfusion rate (odds ratio 8.34, 5.88 and 4.60, respectively). Acute blood loss anemia is common in patients undergoing radical cystectomy, and predicting blood loss and transfusion requirements remains difficult. These data indicate the need for continued refinement in surgical techniques to decrease blood loss as well as for strategies designed to decrease the need for blood transfusion.

Estudio de la calidad de vida en pacientes sometidos a sustitución vesical ortotópica versus ileostomía cutánea

PurposeNowadays, pschycological and social aspects of treatment of urinary diversion after cystectomy, have become of utmost importance. Body image, potence, continence, emotional distress and dissatisfaction, functional and social activities are majors factors to improve quality of life after surgery. The aim of this study is to compare health-related quality of life after bladder substitution with ileal conduit diversion Material and methodsWe developed a questionnaire based upon a literature review, to compare health related quality of life between bladder substitution and ileal conduit (45 multiple choice mailed questionnaire). We examined functional and social activities, sexual dysfunction, urinary problems, and body image dissatisfaction Results78 male patients with bladder cancer, were interviewed. 91% of the questionnaires were answered, 48.7% by patients’ family and 42.3% by the patients themselves. 6 patients underwent ileal conduit and 27 underwent bladder substitution. Patients with ileal consuit presented higher body image dissatisfaction than those who underwerent bladder substitution. When urine leakageoccurred it caused more distress to the conduit patients, indicating urinary leakage as their main problem. Bladder substitution patients did not consider continence problems as very important, they had not interrupted social activities such as travelling or seeing friends. 100% of bladder substitution patients would not mind to undergo this operation again, while only 66% of ileal conduit patients would ConclusionsHealth-related quality of life is higher after bladder substitution. In our opinion we should use bladder substitution as the standard method of diversion after radical cystectomy for bladder cancer.

Tricuspid Atresia.

Untreated, the prognosis for patients with tricuspid atresia (TA) is poor. Recent advances in medical and surgical therapy, particularly the application of Fontan principle, have markedly improved the long-term outlook for children with this condition. Palliative procedures to normalize the pulmonary blood flow and to relieve interatrial or interventricular obstruction should be undertaken promptly. Staged total cavopulmonary connection to bypass the right atrium and right ventricle by an initial bidirectional Glenn procedure and followed by extracardiac conduit diversion of inferior vena caval flow into the pulmonary arteries appears to be the current procedure of choice in the surgical management of TA. Total cavopulmonary diversion appears to be superior to conventional Fontan-Kreutzer operations, but long-term follow-up results are needed to confirm this impression.

Paclitaxel-induced stomal neuropathy: a unique cause of pain in a patient with ileal conduit

We present a case of unusual chemotherapy-induced neurotoxicity in a patient who had undergone radical cystoprostatectomy and ileal conduit diversion for invasive bladder cancer. On routine computed tomography scan several years later, he was diagnosed with metastatic transitional cell carcinoma involving the retroperitoneal lymph nodes. The patient received systemic chemotherapy, including a combination of paclitaxel (Taxol) and gemcitabine (Gemzar). During this treatment, the patient developed spasmodic pain and dysesthesia in the stoma area, with no apparent skin irritation or any other local finding. These symptoms resolved about 3 months after completion of the therapy.

SIMPLE CYSTECTOMY IN PATIENTS REQUIRING URINARY DIVERSION

Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection. Ileal conduit or continent diversion and simple cystectomy were performed for crippling bladder symptoms secondary to neurogenic bladder, pelvic radiation, hematuria and/or severe incontinence in 12 women and 7 men with a mean age of 63 years. We performed urinary diversion and simple cystectomy only when all conservative means of treatment had failed. The majority of patients had multiple co-morbidities, previous surgeries and pelvic radiation. An average of 5 conservative procedures (range 2 to 10) had been done before simple cystectomy. None of these patients had urothelial malignancy. Simple cystectomy was done concomitantly with urinary diversion in 13 cases and later as a separate procedure in 6 due to complications of a retained nonfunctional bladder. Mean followup was 15 months. No mortality was associated with surgery. For simple cystectomy only mean operative time was 30 minutes and mean estimated blood loss was 300 cc. Median time from symptom presentation to cystectomy was 35 months and mean hospital stay was 7 days. In all cases symptoms were dramatically alleviated. No morbidity was directly attributable to simple cystectomy. Simple cystectomy is well tolerated and should be performed at urinary diversion to avoid later complications of the retained bladder. Technically this procedure is not demanding and is relatively easy to perform even after previous pelvic radiation.

Percutaneous incision of stenotic uroenteric anastomoses with a cutting balloon catheter: long-term results.

To describe the technique and results of incision of strictures in anastomotic urinary diversions with a commercially available cutting balloon catheter. Thirty-seven stenoses were treated in 32 patients. Most (28 [88%]) of the patients had undergone surgery for bladder cancer 17.7 months +/- 17.4 (SD) (range, 3-72 months) before incision. Thirteen patients had undergone ileal conduit diversion, and nineteen had undergone enterocystoplasty. All stenoses were shorter than 3 cm. The presence of adjacent ileal loops and/or iliac vessels was assessed with computed tomography before incision. The cutting wire was oriented anteriorly or anterolaterally, and the balloon was inflated with diluted contrast material during the incision. A Kaplan-Meier survival curve was constructed to illustrate the success rates over time. No major complications occurred. Twelve (32%) stenoses recurred in nine patients 15 months +/- 10 (range, 6-36 months) after stent removal; the failure rate was 53% (eight of 15 stenoses) for ileal conduits and 18% (four of 22 stenoses) for enterocystoplasties. Late failure (>12 months) was observed in four patients. The patency of the other 25 stenoses (23 patients) was checked 25 months +/- 11 after stent removal (range, 5-43 months). The actuarial patency rate was 77% at 1 year, 68% at 2 years, and 62% at 3 years. Cutting balloon incision is a safe and simple alternative to surgery, particularly when the urinary diversion is enterocystoplasty.

Incidence of urolithiasis in cystectomy patients after intestinal conduit or continent urinary diversion.

The purpose of this study was to determine the incidence of nephrolithiasis in radical cystectomy patients treated with either intestinal conduit or continent urinary diversion. The charts from 94 patients who had undergone radical cystectomy with urinary diversion at our institution from 1988 to 1998 were reviewed retrospectively for this study. Charts and radiographs from all patients were examined for renal function and evidence or urinary tract calculi. Two groups were compared: group I patients had undergone diversion with an intestinal conduit, and group II patients had received a continent diversion (primarily involving an Indiana pouch). Conduit diversions were typically done with a freely refluxing anastomosis (Bricker), whereas continent diversions were done with a nonrefluxing ureteral-intestinal anastomosis. Group I consisted of 54 patients who had undergone ileal conduit (50) or colon conduit (4) diversion with a mean follow-up of 2.5 years (range 0.6-7.0 years). Group II consisted of 40 patients who had undergone continent diversion (33 Indiana pouches, 7 orthotopic diversions) with a mean follow-up of 3.1 years (range 0.5-10.5 years). Laboratory studies of serum blood urea nitrogen, creatinine, and CO(2) were similar between the two groups. Six patients in group I developed urolithiasis, all in the upper tract. Stones developed at a mean of 3.1 years after urinary diversion. Three patients required operative intervention, whereas the others were managed expectantly. One patient in group II had an upper tract stone at the time of presentation for his bladder cancer, but no patient developed new upper tract stones during the present study period. Two patients in group II developed pouch calculi at a mean of 5 years after diversion; both required surgical intervention. In our study the risk for upper tract urolithiasis seemed higher in the intestinal conduit group (group I), with 11% of the patients developing stones. In the continent diversion group, no patient developed upper tract stones, although two patients (5%) developed pouch stones. Refluxing urine may contribute to an increased risk for stone formation after urinary diversion, whereas pouch stasis may contribute to stone formation in the continent diversion group.

When the bladder is gone: quality of life following different types of urinary diversion.

Methods aiming for continence after radical cystectomy for bladder cancer, e.g., continent cutaneous urinary diversion and orthotopic bladder substitution, have become clinically accepted alternatives to ileal conduit diversion in the past decade. The a priori assumption has been that improvement in the postoperative quality of life would be greater following the new methods than after ileal conduit diversion. Studies on the validity of this assumption have been hampered by a lack of consensus on what should be measured and how this should be done: in no two studies have identical test instruments been used. The frequent inclusion of patients with nonmalignant disease has also impeded comparative evaluation of reports. By and large, published studies do not seem to confirm that the new types of urinary tract reconstruction improve the quality of life of bladder cancer patients. Common for all methods are psychosocial and sexual problems.

MALIGNANT PERIPHERAL NERVE SHEATH TUMOR OF THE PROSTATE: A RARE MANIFESTATION OF NEUROFIBROMATOSIS TYPE 1

Malignant peripheral nerve sheath tumors of the prostate associated with neurofibromatosis are rare, with only 1 previous case reported in the medical literature. We report a case treated with radical cystoprostatectomy and low anterior resection with ileal conduit diversion.

STRATEGIES FOR RECONSTRUCTION AFTER UNSUCCESSFUL OR UNSATISFACTORY PRIMARY TREATMENT OF PATIENTS WITH BLADDER EXSTROPHY OR INCONTINENT EPISPADIAS

Purpose Following unsuccessful or unsatisfactory primary treatment in patients with the epispadias/exstrophy complex, the options for a surgical solution to preserve the upper urinary tract, to achieve complete continence, and to reconstruct the external and female internal genitalia are limited. We reviewed the records of the patients treated at our institution to determine a surgical compromise between ingenious operative constructions and patient desires, both of which are secondary to stabilization of renal function. Materials and Methods From 1967 to December 1997, 128 patients with bladder exstrophy/epispadias complex were treated, of 80 whom had received previous unsuccessful or unsatisfactory treatment. Of these patients 72 were followed for an average of 22.4 years after the first surgical intervention. There were 40 patients referred to our institution after primary bladder closure and bladder neck reconstruction, 10 after rectal bladder, 7 after ureterosigmoidostomy and 5 after incontinent diversion. Results At the latest followup 19 patients had a rectal reservoir, 38 an ileocecal pouch, 12 a conduit diversion and 3 an augmented Young-Dees procedure. The upper urinary tract remained stable in 95% of the renal units with rectal reservoir, 95% with ileocecal pouch, 96% with a colonic conduit and 100% with an augmented Young-Dees procedure. Day and night continence was achieved in 95% of the patients with a rectal reservoir and 97% of those with an ileocecal pouch were continent, whereas only 2 of the 3 patients with an augmented Young-Dees procedure were continent. Of the women 16 were satisfied with the cosmetic results and 6 delivered 8 children by cesarean section. Only 1 man was dissatisfied with the final cosmetic result. All adults but 1 engaged in sexual intercourse. Conclusions The first operative intervention in patients with bladder exstrophy/epispadias complex determines their fate. After failure of primary treatment, the upper urinary tract must be stabilized. In patients with severely impaired renal function the colonic conduit is our method of choice while in those with a normal or slightly dilated upper urinary tract and intact anal sphincter we performed a rectal reservoir. In the remaining patients an ileocecal pouch guarantees continence day and night. The results of genital reconstruction are satisfactory.

Long-Term Results and Complications of Augmentation Ileocystoplasty for Idiopathic Urge Incontinence in Women

Objective To assess the long-term (3–9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients’ satisfaction with the outcome. Patients and methods The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information. Results Within a mean (range) follow-up of 75.4 (36–109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred. Conclusion Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.

Sexological problems after cystectomy: bladder substitution compared with ileal conduit diversion. A questionnaire study of male patients

Correspondence to Mr Christopher R. Chapple, Urology Research Department, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK. Tel: +44 114 271 2791; fax: +44 114 279 8318 Royal Hallamshire Hospital, Sheffield, UK

Can preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction predict psychosocial adjustment after cystectomy in patients with bladder cancer?

To assess if there is relationship between: (i) preoperative psychological defensive strategies, mood and type of lower urinary tract reconstruction, and (ii) psychosocial adaptation after radical cystectomy for bladder cancer. Fifty-seven consecutive patients (44 men and 13 women, mean age 62 years, range 34-81) undergoing radical cystectomy (ileal conduit urinary diversion in 17, continent cutaneous diversion in 22 and orthotopic bladder replacement in 18) were assessed preoperatively using the meta-contrast technique (MCT), a projective test to reveal individual defensive strategies. From the results the patients were classified as hypothetical 'at risk' or 'no risk' patients for postoperative psychosocial complications. An 'at risk' patient was designated as one who showed neurotic defensive strategies in coping with threats, i.e. primitive, immature or regressive strategies or even lack of defence in connection with pronounced anxiety. All patients completed a questionnaire and were interviewed; 10 questions dealt with mood, five reflecting anxiety and five the depressive states. The questionnaire and the interview were repeated 3 and 12 months, and 5 years after surgery. The remembered difficulties during the first month after discharge from hospital differed between the 'risk' and 'no risk' groups after 1 and 5 years. On a visual analogue scale (VAS) the 'risk' patients had very low scores (less difficulty) or very high, while the 'no risk' patients had intermediate scores. VAS score were also higher, although not significantly so, in patients using primitive defence strategies. The psychosocial situation did not differ between the groups in the first year, but at 5 years there were differences in self-esteem and interpersonal contact-seeking. High depression scores before surgery were associated with high VAS scores at 3 months when recalling the first month after discharge, but the anxiety score was not predictive. Men with orthotopic bladder replacement adapted less well throughout the 5 year follow-up. Elderly patients with stereotypy (the commonest defensive strategy at these ages) adapted relatively well to ileal conduit diversion. About 20% of patients had difficulty in accepting the postoperative situation, regardless of urinary diversion modes. The combination of defensive strategies assessed using the MCT and selected on hypothetical grounds was less discriminatory than expected for those at risk of postoperative psychosocial problems. However, those with primitive strategies apparently had a long-term risk of poor adaptation. The search for an optimal instrument for the identification of patients at risk is warranted. In this study, patients with a 'wet' stoma did not seem to fare less well than those with a continent reconstruction.

COMPARISON OF STUDER ILEAL NEOBLADDER AND ILEAL CONDUIT URINARY DIVERSION WITH RESPECT TO PERIOPERATIVE OUTCOME AND LATE COMPLICATIONS

Purpose We compare the perioperative and long-term morbidity of a cohort of patients who had undergone Studer ileal neobladder urinary diversion with that of a similar cohort who had undergone ileal conduit urinary diversion during the same interval and by the same surgeons. Materials and Methods Between 1990 and 1996 we performed Studer ileal neobladder urinary diversion in 62 men and 4 women, and ileal conduit urinary diversion in 66 men. Mean age of the neobladder and conduit patients was 62 and 69 years, and mean followup was 17 and 20 months, respectively. Results Of 66 neobladder cases (18%) 12 had a total of 16 perioperative complications and a 5% reoperation rate, whereas 12 of 66 conduit cases (18%) had a total of 17 perioperative complications and a 6% reoperation rate. Mean hospital stay was 13 days for each group. Of the neobladder cases 14 (21%) had 14 late complications and an 11% reoperation rate, whereas 8 conduit cases (12%) had 9 late complications and an 8% reoperation rate. Conclusions The Studer ileal neobladder urinary diversion is a safe procedure with perioperative and long-term morbidity comparable to ileal conduit diversion at our institution.

DOES THE OPTION OF THE ILEAL NEOBLADDER STIMULATE PATIENT AND PHYSICIAN DECISION TOWARD EARLIER CYSTECTOMY?

Purpose The primary goal of bladder replacement is to attempt to improve patient quality of life, not to increase survival, affect cancer prognosis or decrease renal metabolic complications. Nevertheless, we retrospectively determined whether orthotopic bladder replacement has an impact on the decision to perform cystectomy. Materials and Methods From April 1986 to September 1994, 213 men a mean of 63 years old with stages pT2N0M0 to pT4N0M0 invasive bladder cancer were referred to our department for cystectomy. For 135 patients who underwent an ileal neobladder procedure and 78 who underwent conduit diversion median followup was 4.8 and 3.5 years, respectively. We evaluated the interval from the primary diagnosis of bladder cancer to cystectomy as well as the number of previous transurethral bladder resections. The 5-year cancer specific survival rates were calculated using the Kaplan-Meier method. The Wilcoxon and log rank tests, and the Cox proportional hazards model were used to determine statistical significance. Results In the neobladder and conduit groups an average of 2.1 (range 1 to 18) and 4.1 (range 1 to 15) transurethral bladder resections was performed, respectively. Interval from the primary diagnosis to cystectomy was 11.8 months in the neobladder and 16.7 months in the conduit group. Cystectomy was performed 4.1 months after the diagnosis of invasive cancer in the neobladder group, whereas radical surgery was delayed for 15.4 months in the conduit group. Cancer specific 5-year survival rates were 76.6 and 28.35% in the neobladder and conduit groups, respectively. After stratifying according to tumor stage the 5-year survival rate was significantly higher for all disease stages in the neobladder than in the conduit group. The proportional hazards model revealed that this difference was not due to patient age at disease stages pT3bN0 and pT4N0 or by American Society of Anesthesiologists score. Independent prognostic factors for survival were diversion type and age. Delayed cystectomy was a risk factor only in advanced disease stages. Conclusions These data suggest that the ileal neobladder may decrease physician reluctance to perform cystectomy early in the disease process, increasing the survival rate. They also demonstrate that the ileal neobladder option significantly affects an earlier patient and physician decision in favor of cystectomy.

BOWEL DYSFUNCTION AFTER BLADDER RECONSTRUCTION

Purpose Bowel function may be disturbed after intestinal segments are used in urinary reconstruction. The etiology of this condition and its incidence in different patient groups is unclear. We studied the incidence of bowel disturbance in patients who underwent bladder replacement, continent diversion, enterocystoplasty for idiopathic detrusor instability and ileal conduit diversion. Materials and Methods We evaluated 71 patients after ileal conduit diversion and 82 after bladder reconstruction, including clam enterocystoplasty for detrusor instability in 28, neurogenic bladder dysfunction in 26 and nonneuropathic conditions in 28. We noted the severity of symptoms, such as frequency of defecation, nocturnal diarrhea, flatus leakage, fecal urgency, fecal incontinence and explosive diarrhea, as well as quality of life. Results Of the patients who underwent bladder reconstruction 24% had symptoms of bowel dysfunction preoperatively and 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively. These symptoms were most common and severe in 54% of patients after clam enterocystoplasty for detrusor instability compared to 26% with neuropathy, 14% with a nonneuropathic condition and 15% with an ileal conduit. Compared to those in other groups patients who underwent enterocystoplasty for detrusor instability had a significantly higher incidence of nocturnal bowel movements (18 versus less than 4%, p <0.01), flatus leakage (29 versus less than 8%, p <0.01), fecal urgency (39 versus less than 12%, p <0.001) and fecal incontinence (32 versus less than 16%, p <0.001). The length of ileum used for clam enterocystoplasty was only slightly greater than that used for ileal conduit operations (25 versus 18 cm.). Of the patients who underwent enterocystoplasty for detrusor instability 29% regretted undergoing the procedure due to subsequent bowel symptoms. Conclusions After enterocystoplasty for detrusor instability patients are at risk of significant bowel symptoms. The development of new bowel symptoms was associated with poor patient satisfaction.

Long-term results and complications of augmentation ileocystoplasty for idiopathic urge incontinence in women.

To assess the long-term (3-9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients' satisfaction with the outcome. The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information. Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred. Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.

A Questionnaire Study of Sexological Problems Following Urinary Diversion in the Female Patient

A questionnaire study was conducted to evaluate the sexological problems after urinary diversion, using the continent Kock reservoir or the ileal conduit diversion. Thirty-seven female patients completed the questionnaire: 17 patients had a continent and 20 an ileal conduit diversion, with a median follow-up of 0.8 year (range 0.5-4.4) and 4.6 years (range 2.8-12.0), respectively. Data from only 33 patients were eligible for analysis, but no significant between-group differences were found. Coital frequency remained unchanged or increased among 44% of patients with a continent reservoir and among 18% of ileal conduit patients (p = 0.11). Among those reporting other than unchanged/increased activity almost one-third gave physical problems or decreased desire as the reason, and 30% felt less sexually attractive, with cystectomized patients reporting a higher percentage than others. A higher frequency of dyspareunia among patients with a continent reservoir was an unexpected finding (p = 0.06), and merits further investigation in a larger sample. Here it may be due to the shorter follow-up of these patients. Thirty per cent of all patients would have like more sexological counselling.

Carcinoma of the bladder in renal transplant patients

Bladder malignancy in the renal transplant recipient is an infrequent occurrence. The 11 previously reported cases reflect an aggressive tumor growth with invasion, requiring partial or complete cystectomy with or without conduit diversion. We report an additional case in a 40‐yr‐old woman with a living related renal transplant, who experienced rapid progression of her tumor over 3 wk from initial hematuria to a pelvic mass involving the anterior bladder. Her allograft ureter and native ureters, as well as her left iliac vein, became obstructed with tumor in another 2 wk. Biopsy showed poorly differentiated, invasive transitional carcinoma. Attempted resection was abandoned because of finding tumor involvement in most of the pelvis. Chemotherapy was not attempted. She died 2 wk after her attempted resection from tumor burden. Our report presents a collective review of these previously reported 11 cases plus our case. These bladder tumors demonstrate a rapid progression of invasive disease and respond poorly to chemotherapy. There is a possible association of bladder tumors with cyclophosphamide immunosuppression. An aggressive surgical approach should be followed, especially since these tumors present in a younger age group.