Continent Cutaneous Reservoir Research Articles

Microbial Trends in Infection-related Readmissions Following Radical Cystectomy for Bladder Cancer

To report microbial pathogens detected at infection-related readmissions, including their susceptibility to antimicrobials. A retrospective review of 785 patients who underwent radical cystectomy for bladder cancer at a tertiary center in Denmark between 2009 and 2019. All patients received prophylactic cefuroxime preoperatively and pivmecillinam at stent- or catheter removal. Data were collected through the national medical records and microbiology database. The primary outcome was readmission rate and pathogens detected at infection-related readmissions. Univariable and multivariable regression analyses were carried out to identify risk factors of readmission. Within 90days of surgery, 225 (29%) patients experienced at least one infection-related readmission. The most common pathogen identified was Enterococcus spp (24% of all positive samples). In blood cultures, the most dominant species were Escherichia coli (29%) and Staphylococcus spp (26%). Due to the heterogeneity in microbial species identified, more than one-third of the bacteria where mecillinam was tested showed resistance. Most isolates were susceptible to piperacillin+tazobactam. Orthotopic neobladder and continent cutaneous reservoir were associated with the highest risk of infection-related readmission compared to ileal conduit (odds ratios 2.78 [95%CI 1.66;4.65] and 3.08 [95%CI 1.58;5.98], respectively). Patients with diabetes had an increased risk of infection-related readmission compared to patients without diabetes (odds ratio 1.67 [95%CI 1.02;2.73]). Nearly one-third of all patients experienced at least one postoperative infection-related readmission with a wide range of microbial etiologies. Generalizability of our results is uncertain, but the data can be used to plan interventional trials of antibiotic prophylaxis.

Hospitalisation and readmission costs after radical cystectomy in a nationally representative sample: does urinary reconstruction matter?

To investigate the impact of continent urinary diversion on readmissions and hospital costs in a nationally representative sample of radical cystectomies (RCs) performed in the USA. The 2010-2014 Nationwide Readmissions Database was queried for patients with a diagnosis of bladder cancer who underwent RC. We identified patients undergoing continent (neobladder or continent cutaneous reservoir) or incontinent (ileal conduit) diversions. Multivariable logistic regression models were used to identify predictors of 90-day readmission, prolonged length of stay, and total hospital costs. Amongst 21 126 patients identified, 19 437 (92.0%) underwent incontinent diversion and 1 689 (8.0%) had a continent diversion created. Continent diversion patients were younger, healthier, and treated at high-volume metropolitan centres. Continent diversions resulted in fewer in-hospital complications (37.3% vs 42.5%, P = 0.02) but led to more 90-day readmissions (46.5% vs 39.6%, P = 0.004). In addition, continent diversion patients were more often readmitted for infectious complications (38.7% vs 29.4%, P = 0.004) and genitourinary complications (18.5% vs 13.0%, P = 0.01). On multivariable logistic regression, patients with a continent diversion were more likely to be readmitted within 90 days (odds ratio [OR] 1.55, 95% confidence interval [CI]: 1.28, 1.88) and have increased hospital costs during initial hospitalisation (OR 1.99, 95% CI: 1.52, 2.61). Continent diversion led to a $4 617 (American dollars) increase in initial hospital costs ($36 640 vs $32 023, P < 0.001), which was maintained at 30 days ($48 621 vs $44 231, P < 0.001) and at 90 days ($56 380 vs $52 820, P < 0.001). In a nationally representative sample of RCs performed in the USA, continent urinary diversion led to more frequent readmissions and increased hospital costs. Interventions designed to address specific outpatient issues with continent diversions can potentially lead to a significant decrease in readmissions and associated hospital costs.

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

ABSTRACTStandard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome.This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula.In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

MP04-11 OBESITY MAY BE A RISK FACTOR FOR URETEROENTERIC ANASTOMOTIC STRICTURES AFTER RADICAL CYSTECTOMY WITH URINARY DIVERSION

You have accessJournal of UrologyBladder Cancer: Epidemiology & Evaluation I1 Apr 2017MP04-11 OBESITY MAY BE A RISK FACTOR FOR URETEROENTERIC ANASTOMOTIC STRICTURES AFTER RADICAL CYSTECTOMY WITH URINARY DIVERSION Belinda Li, Robert H. Blackwell, Bethany K. Burge, Elizabeth L. Koehne, and Marcus L. Quek Belinda LiBelinda Li More articles by this author , Robert H. BlackwellRobert H. Blackwell More articles by this author , Bethany K. BurgeBethany K. Burge More articles by this author , Elizabeth L. KoehneElizabeth L. Koehne More articles by this author , and Marcus L. QuekMarcus L. Quek More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.149AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureteroenteric anastomotic strictures (UAS) are a known long-term complication of radical cystectomy with urinary diversion (RCUD). Often a silent process, UAS can be associated with progressive renal function decline, and often require additional procedures. We assessed our series of RCUD to determine predictors of UAS. METHODS We completed a retrospective review of consecutive patients who underwent RCUD between 2005-2015 by a single surgeon. All ureteroenteric anastomoses were performed in a freely-refluxing end-to-side fashion over an 8Fr feeding tube. Kaplan-Meier time-to-event analysis was performed to estimate the cumulative incidence of UAS, with patients censored at last follow-up or death. Univariable and multivariable logistic regression were performed to identify predictors of UAS. The final multivariable model was selected using Akaike Information Criterion to optimize model parsimony and fit. RESULTS RCUD was performed in 286 bladder cancer patients, with a median age of 69.9 years (IQR 62.8-76.2) and median follow-up of 21.4 months (IQR 8.9-42.3). Urinary diversions included ileal conduit (164, 57.3%), orthotopic ileal neobladder (114, 39.9%), and continent cutaneous reservoir (8, 2.8%). UAS developed in 29 patients (10.1%), at a median of 6.4 months (IQR 4.4-8.8) postoperatively. The cumulative incidence of UAS was 12.5% (95% CI 8.7-17.7) at 24 months. UAS patients had higher rates of obesity (72.4% vs 28.0%, p<0.001), were younger (66.4 vs 70.3 years, p=0.003), and had a longer median follow-up (34.0 vs 20.2 months, p=0.04). There was no difference in preoperative radiation in the UAS group (3.5% vs 10.3%, p=0.2). On time-to-event analysis, obese (BMI ≥30) patients had a higher cumulative incidence of stricture than non-obese (25.2% vs 5.9%, p<0.001) at 24 months (Figure). On multivariate analysis, only obesity was an independent predictor of UAS (OR 6.4, 95%CI 2.6-156; p<0.001). CONCLUSIONS Ureteroenteric anastomotic strictures are often a silent event arising within the first year of radical cystectomy with urinary diversion. Obese patients are at a significantly increased risk of stricture development, regardless of urinary diversion type or oncologic characteristics. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e32 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Belinda Li More articles by this author Robert H. Blackwell More articles by this author Bethany K. Burge More articles by this author Elizabeth L. Koehne More articles by this author Marcus L. Quek More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Socioeconomic status is associated with urinary diversion utilization after radical cystectomy for bladder cancer.

To assess socioeconomic disparities in urinary diversion utilization in a contemporary American cohort. In the National Cancer Database, we identified 4538 patients who underwent cystectomy with urinary diversion for clinical T1-2N0M0 bladder cancer from 2010 to 2013. Multivariable logistic regression was used to identify predictors of urinary diversion type: ileal conduit (IC), continent cutaneous reservoir (CCR), or orthotopic neobladder (ON). Covariates included age, gender, race, income, Charlson score, clinical T stage, hospital cystectomy volume, teaching status, and surgical approach. Subgroup analysis by hospital volume (low, intermediate, or high) and teaching status (academic or non-academic) was performed to ascertain the impact of regionalization on urinary diversion use. The final cohort included 4066 (89.6%) patients with IC, 292 (6.4%) with CCR, and 180 (4.0%) with ON. On multivariable analysis, younger age (p<.01), higher income (p<.01), and high cystectomy volume predicted increased use of CCR and ON. Female gender predicted increased use of CCR versus IC (p<.01), and academic hospital status predicted increased use of ON versus IC (p=.04). On subgroup analysis, after further adjustment for hospital volume and teaching status, higher income remained an independent predictor of ON use. Despite regionalization of care, higher income patients are more likely to receive complex urinary diversions after radical cystectomy. Other related socioeconomic factors, especially patient education, may influence this practice pattern.

Complete resection of a primitive neuroectodermal tumour arising in the bladder of a 31-year-old female after neoadjuvant chemotherapy.

Primitive neuroectodermal tumours (PNET) that arise in the urinary bladder are an extremely rare occurrence. Very few cases have been reported so far in the literature1-13 and we report another case here in a 31-year-old-female. The patient presented with polyuria, gross hematuria, followed by development of anuria, and was discovered to have a 9.4 cm mass arising in the posterolateral aspect of the bladder. Histologically, the tumour showed small, round, blue cells. Further analysis using break-apart fluorescent in situ hybridization (FISH) revealed non-random chromosomal translocations of the ews gene suggestive of Ewing sarcoma (ES)/PNET. The patient completed seven cycles of neoadjuvant chemotherapy, which significantly reduced the size of the lesion. Due to the location of the lesion, surgical resection of the entire bladder and urethra with use of a continent cutaneous reservoir was performed. Here, the management of a 31-year-old female with ES/PNET arising from the bladder is reported.

Long-term follow-up after ileocaecal continent cutaneous urinary diversion (Mainz I pouch): A retrospective study of a monocentric experience

ObjectiveTo assess the long-term follow-up after ileocaecal continent cutaneous reservoir (ICCR) and to review the late complications. Patients and methodsIn all, 756 patients underwent an ICCR in our department, with long-term follow-up data available in 50 patients. The inclusion criterion was ICCR regardless of the indication and the exclusion criteria were orthotopic neobladder or other continent urinary diversions not performed with the ileocaecum. Patients were followed to record primary outcomes and late complications. Complications were stratified according to the Clavien–Dindo classification. ResultsThe mean patient age was 44years and pelvic malignancies were the first indication for urinary diversion. The mean (range) follow-up was 19 (9–36)years. A stoma stenosis was the most frequent outlet-related complication requiring re-intervention, followed by ischaemic outlet degeneration, and stoma incontinence. Six renal units (RUs) developed obstruction at the anastomotic site and were managed by open surgery. Three RUs had to be removed due to deterioration. A dederivation was necessary in three patients (6%). ConclusionThe ICCR is a safe and established technique when an orthotopic pouch is impossible. The long-term follow-up shows acceptable complication rates and satisfactory continence conditions. However, large population studies are necessary to confirm this observation.

The Impact of Transtomal Rigid Endoscopy in Continent Cutaneous Urinary Diversions

To determine if transtomal rigid endoscopy damages the continence mechanism of continent cutaneous reservoirs. We report the largest and longest series to date from a single institution demonstrating the safety of transtomal rigid endoscopy. We conducted an institutional review board-approved retrospective review of a prospectively accrued database of all patients with urinary diversions that underwent rigid endoscopic procedures for various reasons between 2000 and 2013. Pre- and postoperative continence, difficulty with catheterization, and need for surgical revision post procedure were evaluated. From 2000 to 2013, 71 patients with continent cutaneous diversions underwent 191 endoscopic procedures by a single surgeon. Mean follow-up was 603 days. Mean age was 58.4 years. The mean number of procedures per patient was 2.7 (1-7). All procedures were performed by gaining access through the stoma with an offset rigid nephroscope and a 28-30Fr access sheath. Two patients reported incontinence postoperatively; 1 patient was treated conservatively by way of indwelling catheter for 1 week and full continence returned. The second patient had small-volume incontinence preoperatively that worsened postoperatively. The procedure uncovered an existing efferent limb-cutaneous fistula. Patients undergoing repeated procedures were not at any higher risk of incontinence. There were no patients that had difficulty with catheterization postoperatively. No surgical revisions were required for worsened continence postoperatively. Transtomal rigid endoscopic procedures do not negatively affect the continence mechanism in continent cutaneous diversions. Transtomal rigid endoscopy allows for safe endoscopic access in these difficult to treat patients.

Continent urinary diversion following anterior exenteration

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options. To critically review the peer-reviewed literature on the function and oncological outcomes, complications, and factors influencing choice of procedure with urinary diversion after RC for bladder carcinoma. A Medline search was conducted to identify original articles, review articles, and editorials on urinary diversion in patients treated with RC. Searches were limited to the English language. Keywords included: 'bladder cancer', 'cystectomy', 'diversion', 'neobladder', and 'conduit'. The articles with the highest level of evidence were selected and reviewed, with the consensus of all of the authors of this paper. Both continent and incontinent diversions are available for urinary reconstruction after RC. In appropriately selected patients, an orthotopic neobladder permits the elimination of an external stoma and preservation of body image without compromising cancer control. However, the patient must be fully educated and committed to the labour-intensive rehabilitation process. He must also be able to perform self-catheterisation if necessary. When involvement of the urinary outflow tract by tumour prevents the use of an orthotopic neobladder, a continent cutaneous reservoir may still offer the opportunity for continence albeit one that requires obligate self-catheterisation. For patients who are not candidates for continent diversion, the ileal loop remains an acceptable and reliable option. Both continent and incontinent diversions are available for urinary reconstruction after RC. Orthotopic neobladders optimally preserve body image, while continent cutaneous diversions represent a reasonable alternative. Ileal conduits represent the fastest, easiest, least complication-prone, and most commonly performed urinary diversion.

Ileal Urinary Reservoir in Pediatric Population: Objective Assessment of Long-term Sequelae With Time-to-event Analysis

To evaluate the long-term outcomes of an ileal urinary reservoir in children. This was a longitudinal study of pediatric patients who had undergone total ileal substitution of the bladder. Continence status was assessed, and all patients were evaluated for kidney function and biochemical profile. Standardized growth charts were used to assess linear growth. To assess bone mineral density, dual-emission x-ray absorptiometry scanning was performed. Clavien's scale was used to report and grade the long-term complications and their timing. We used a simple quality of life questionnaire to assess the effect of the procedure on the quality of life of the growing child. A total of 17 patients were included; 3 with orthotopic and 14 with continent cutaneous reservoirs. After a mean follow-up of 87.3 months, all patients were voiding with clean intermittent catheterization, with a 94% final continence rate. Two patients (11.7%) had an estimated glomerular filtration rate of ≤ 45 mL/min/1.73 m(2) at the last follow-up examination. However, no clinically manifest metabolic acidosis was detected. No anemia or neurologic deficit was detected, with a low-normal serum level of vitamin B(12) in 2 patients (11.7%) and a low level in 1 patient (5.7%). One patient (5.7%) had chronic diarrhea. Low bone mineral density was found in 4 patients (22.8%), with 3 patients (17.1%) not exceeding the fifth percentile of height for age. High-grade complications (grade 3a-5) represented 64.5% of the complications, and the need for reintervention occurred late in the follow-up period. A high level of quality of life satisfaction was reported (88.5%). Ileal neobladder construction allows child to pass into adolescence dry with more confidence and self-esteem, with no external urine collection set. However, long-term follow-up is mandatory to maintain the positive outcome.

25 Years of Experience With 1,000 Neobladders: Long-Term Complications

We analyzed the long-term complications (greater than 90 days postoperatively) in a large, single center series of patients who underwent cystectomy and substitution with an ileal neobladder. A total of 1,540 radical cystectomies were performed at our center between January 1986 and September 2008. Of the patients 1,013 received an ileal neobladder. Only the 923 patients with followup longer than 90 days (median 72 months, range 3 to 267) were included in analysis. All long-term complications were identified. The complication rate was calculated using the Kaplan-Meier method. The overall survival rate was 65.5%, 49.8% and 28.3% at 5, 10 and 20 years, respectively. The overall long-term complication rate was 40.8% with 3 neobladder related deaths. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish urinary tract infection were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients, respectively, 20 years postoperatively. Subneovesical obstruction in 3.1% of cases was due to local tumor recurrence in 1.1%, neovesicourethral anastomotic stricture in 1.2% and urethral stricture in 0.9%. Chronic diarrhea was noted in 9 patients. Vitamin B12 was substituted in 2 patients. Episodes of severe metabolic acidosis occurred in 11 patients and 307 of 923 required long-term bicarbonate substitution. Rare complications included cutaneous neobladder fistulas in 2 cases, and intestinal neobladder fistulas, iatrogenic neobladder perforation, spontaneous perforation and necrotizing pyocystis in 1 each. Even in experienced hands the long-term complication rate of radical cystectomy and neobladder formation are not negligible. Most complications are diversion related. The challenge of optimum care for these elderly patients with comorbidities is best mastered at high volume hospitals by high volume surgeons.

Continent Catheterizable Pouches for Urinary Diversion

Context Catheterizable pouches represent a good alternative in patients with continent urinary diversion (CUD) when neobladder reconstruction is contraindicated. Objective This review summarizes the different techniques, indications and contraindications, functional results, outcomes, and complications of continent catheterizable pouches. Evidence acquisition A PubMed Medline database research was performed, identifying publications of CUD using a catheterizable pouch after radical cystectomy for treatment of bladder cancer. Evidence synthesis In some patients with infiltrating bladder cancer, a continent cutaneous diversion is indicated when the urethra is involved. Some authors also recommend a catheterizable pouch in patients with carcinoma in situ and in female patients. Different bowel segments have been used to build the reservoir: ileocecum, colon, and ileum. Especially in patients with previous pelvic irradiation, the transverse colonic pouch represents a feasible urinary diversion. Reservoirs with high volume and low pressures can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. The need for antirefluxive ureteral implantation is questioned and there is a trend towards refluxive implantation. Simple and reproducible techniques (eg, appendix stoma, flap-valve T mechanism, serosa-lined extramural tunnel) have been developed for creation of a continence mechanism. Satisfactory continence rates >90% are reported for most techniques and quality of life is comparable with orthotopic continent diversion. The overall incidence of complications varies from 28–57%. However, most urinary tract complications (eg, pouch calculi, ureteroenteric anastomotic strictures, efferent limb strictures, mucous retention) are corrected by endoscopic means. Open surgery is mainly performed in strictures of the afferent limb. Conclusions Cutaneous catheterizable pouches represent an established and good opportunity for CUD after radical cystectomy for treatment of bladder cancer. Most of the problems that occurred during creation of continent cutaneous reservoirs in the past have been solved. Long-term data of different surgical techniques show excellent continence and acceptable complication rates.

Application of the Yang-Monti Channel in Adult Continent Cutaneous Urinary Diversion

To report 8 cases using the Yang-Monti channel with ileum for adult continent cutaneous urinary diversion. From 2004 to 2006, 108 patients underwent urinary diversion, 8 of whom had a continent cutaneous reservoir using the Yang-Monti principle. Channels were created by transversely retubularizing 2 to 3 cm of ileum. Indications, technique, complications, and outcomes, such as continence and ease of channel catheterization, are reported. Five patients underwent a right colon reservoir urinary reconstruction after extirpative surgery. Orthotopic neobladders were not performed, owing to anatomic or oncologic concerns. Two additional patients underwent an augmentation, with 1 undergoing an Indiana pouch revision. All urinary reservoirs but 1 were connected to the umbilicus. Two strictures occurred, which were treated with in-office dilation. Incontinence was identified in 2 patients and successfully treated with dextran microspheres injections. All patients were continent at final follow-up. Seven patients continue to perform intermittent catheterization, and 1 patient is managed with an indwelling catheter, owing to comorbidities. The Yang-Monti channel using ileum is an alternative as a neo-appendicoumbilicostomy in construction of continent cutaneous urinary diversion. The channel is surgically versatile and can be used in the creation of a right colon pouch when the appendix is unavailable.

Urinary Diversion: Options, Patient Selection, and Outcomes

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d’Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of “conventional” antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

277: Long Term Complications of Continent Cutaneous Ileocolonic Reservoir

277: Long Term Complications of Continent Cutaneous Ileocolonic Reservoir

Luminal Nitric Oxide in Ileal Reservoirs for Continent Cutaneous Diversion or Orthotopic Bladder Reconstruction

Objectives: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. Methods: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. Results: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. Conclusions: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.

Continent right colon reservoir using a cutaneous appendicostomy

Introduction Although orthotopic reconstruction has become the preferred form of lower urinary tract reconstruction after cystectomy there remains a select group of patients who are not appropriate for an orthotopic neobladder substitute. A continent cutaneous reservoir provides an alternative means to store urine and protect the upper urinary tract without the need for a urostomy appliance. We report our surgical technique of a continent cutaneous right colon reservoir using a catheterizable submucosally embedded appendicostomy. Technical considerations The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy incorporates the ascending and proximal transverse colon, which are detubularized and folded to form the reservoir component of the urinary diversion. The terminal ileum acts as the afferent limb, with the intact native ileocecal valve providing the antireflux mechanism. The continence catheterizable mechanism incorporates the submucosally tunneled appendix with preservation of the mesentery in a flap-valve technique. Conclusions The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present, with good functional results and excellent continence.

PURE LAPAROSCOPIC ENTEROCYSTOPLASTY

The realm of laparoscopic surgery has expanded from simple extirpative operations to more complicated reconstructive procedures, such as dismembered pyeloplasty and ileal conduit creation. There has been recent interest in using laparoscopic techniques to augment the bladder with bowel.1, 2 To date only 1 case of enterocystoplasty, using the stomach, has been accomplished entirely by laparoscopy.3 To our knowledge we report the first case of ileal enterocystoplasty performed completely by laparoscopy. CASE REPORT A 31-year-old paraplegic woman with a C6 spinal cord injury developed worsening voiding dysfunction during the 2 years preceding presentation. She had managed previously with clean intermittent catheterization every 4 hours and remained dry. Video urodynamic studies demonstrated detrusor instability at bladder volumes of 40 to 50 ml. and a maximum bladder capacity of 85 ml. The patient did not desire urinary diversion or a continent cutaneous reservoir, and opted instead for laparoscopic ileal bladder augmentation. Mechanical and antibiotic bowel preparation was performed, and externalized ureteral stents were initially placed. The remainder of the operation duplicated open augmentation cystoplasty using an ileal segment. Briefly, 5 ports were used and the ileum was identified 15 cm. from the ileocecal valve. An endoscopic gastrointestinal anastomosis stapler was used to isolate a 15 to 20 cm. segment of ileum, and the mesentery was incised with ultrasonic coagulating shears. Bowel continuity was restored in a side-to-side fashion using a gastrointestinal anastomosis stapler, with the enterotomy closed in a single layer with interrupted 2-zero silk Lembert sutures. Monopolar electrocautery was used to remove the staples from both ends of the isolated ileal segment and detubularize it on its antimesenteric border. The ileum was sutured into a U-shaped configuration using a single layer of running 3-zero polyglactin sutures prior to mid sagittal cystotomy. The ileal patch was sutured to the bladder in quadrants using running 3-zero polyglactin sutures. Drainage was provided by a 20Fr urethral catheter and a 10 mm. Blake drain brought out through a lateral port site. No suprapubic catheter was placed. Watertight closure was confirmed by intraoperative irrigation of the bladder. Estimated blood loss was 100 ml. and there were no intraoperative complications. On the third postoperative day the drain was removed and the patient resumed liquid intake. However, she remained hospitalized due to prolonged ileus for 13 days. She returned to work and normal activity 1 week after being discharged. A cystogram performed 4 weeks postoperatively, at the time of catheter removal, demonstrated a bladder capacity of at least 250 ml. (see figure). Presently, the patient is continent between catheterizations with urinary volumes approximating 400 ml. DISCUSSION