Continent Ileal Reservoir Research Articles

Successful Treatment of Prepouch Ileitis with Oral Mesalamine in Barnett Continent Ileal Reservoir

Barnett Continent Ileal Reservoir is rarely performed in patients with ulcerative colitis who require colectomy. Prepouch ileitis occasionally occurs in patients with ileal pouches. The role of oral mesalamine in the treatment of prepouch ileitis has not been established. We describe a case in which prepouch ileitis in Barnett Continent Ileal Reservoir was successfully treated with oral mesalamine. This is the first case in the literature showing that mesalamine is safe and effective in the treatment of prepouch ileitis in a patient with a continent ileostomy.

Long-term Outcomes of Cystectomy and Crossfolded Ileal Reservoir Combined with an Afferent Tubular Segment for Heterotopic Continent Urinary Diversion: A Longitudinal Single-centre Study

BackgroundThe crossfolded ileal reservoir combined with an afferent tubular isoperistaltic segment for heterotopic continent urinary diversion has been performed on a regular basis for over 20 years. Yet data on long-term-outcomes remain sparse. ObjectiveTo report long-term functional and oncological outcomes, gastrointestinal and metabolic disturbances, urinary tract infections (UTIs), and quality of life. Design, setting, and participantsLong-term functional and oncological outcomes of a consecutive series of 118 patients undergoing cystectomy and construction of a continent cutaneous crossfolded ileal reservoir from 2000 to 2018 were evaluated. InterventionPatients underwent cystectomy and construction of a continent cutaneous crossfolded ileal reservoir according to the Studer technique for bladder reconstruction. Outcome measurements and statistical analysisPre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. Self-reported questionnaires regarding quality of life, patient satisfaction, and difficulty in catheterisation were sent to patients preoperatively; after 3, 6, 12, and 24 mo; and at last follow-up, and were then manually entered in the departmental database. Results and limitationsThe median follow-up was 7.8 (interquartile range 3–12.7) yr. Patient satisfaction was high in 77.4% and moderate in 16.9%. Serum creatinine and estimated glomerular filtration rate remained stable during follow-up. Of all patients, 81% (96/118) had at least one UTI during follow-up. Recurrent UTIs occurred in 67% (79/118) of patients. Urolithiasis was found in 12% (14/118), with 6% (7/118) having a single and 6% a recurrent event. Of all stone formers, 79% (11/14) had recurrent UTIs. In oncological patients, 12.5% (10/79) developed a local recurrence. Cancer-specific survival and overall survival were 90% and 88%, and 68% and 56% after 1 and 10 yr, respectively. A limitations is the retrospective analysis from prospectively assessed data. ConclusionsA high satisfaction level, stability of kidney function, and low rates of urolithiasis in patients with a heterotopic continent ileal reservoir can be achieved, provided that close attention is paid to intra- and postoperative details. Regular lifelong follow-up is essential for timely detection and treatment of complications. Oncological outcome is not affected by the urinary diversion. Patient summaryIn patients with a continent cutaneous ileal reservoir, good quality of life and a high satisfaction rate are possible provided that patients adhere to regular lifelong follow-up.

Effectiveness and Complications of Augmentation Cystoplasty with or without Nonrefluxing Ureteral Reimplantation in Patients with Bladder Dysfunction: A Single Center 11-Year Experience.

We reviewed our experience with the effectiveness and complications of augmentation cystoplasty with or without nonrefluxing ureteral reimplantation in adult patients with long-standing bladder dysfunction. We retrospectively reviewed the records of 173 patients who underwent augmentation cystoplasty with or without ureteral reimplantation at our center from July 2005 to July 2016. Clinical data, and magnetic resonance urography and videourodynamic parameters were collected. Upper urinary tract dilatation and vesicoureteral reflux grading systems were used to evaluate upper urinary tract function. Postoperative complications were evaluated. Ureteral reimplantation was performed in 160 patients (266 ureteral units) and 120 ureteral units were simultaneously managed by tailoring and/or ureterolysis. Mean followup was 44.4 months (range 3 to 108). Mean maximum bladder capacity and bladder compliance significantly increased (p <0.0001), and maximum detrusor pressure and serum creatinine decreased compared with preoperative levels (p <0.05). Upper urinary tract dilatation and vesicoureteral reflux significantly improved after surgery. Postoperative complications included persistent vesicoureteral reflux in 1 patient (0.6%), anastomotic stricture in 14 ureteral units (5.3%), bowel dysfunction in 11 patients (6.4%), a need for laparotomy in 4 (2.3%), urinary tract stone in 15 (8.7%) and deteriorating renal function in 9 (5.2%). This retrospective study indicates that ureteral reimplantation concomitant with augmentation cystoplasty may be beneficial in patients with low pressure or high grade vesicoureteral reflux, ureterovesical junction obstruction or ureteral tortuosity, and adhesions and/or severe upper urinary tract dilatation, especially in those with a long medical history.

Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center

BackgroundThere are no published studies comparing pouch configurations and long-term adverse outcomes. AimTo evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI). MethodsWe conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses. ResultsFourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups. ConclusionsPatients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.

Bowel Function Remains Subjectively Unchanged After Ileal Resection for Construction of Continent Ileal Reservoirs

BackgroundConstruction of a continent catheterizable urinary reservoir or an orthotopic bladder substitute requires substantial bowel resection, which can cause changes in bowel transit time. The reported incidence of chronic diarrhea after ileocecal resection is about 20%. Studies assessing bowel function after resection of 55–60cm of ileum without compromising the ileocecal valve are scarce, and long-term results have not been reported. ObjectiveProspective assessment of possible changes in bowel function (eg, stool frequency, diarrhea) and the potential impact on quality of life in patients with resection of small bowel for urinary diversion. Design, setting, and participantsA total of 82 patients who underwent radical cystectomy, extended lymph node dissection, orthotopic ileal bladder substitution, or heterotopic continent cutaneous urinary diversion with a follow-up >1 yr after surgery were prospectively evaluated. Patients who had a neurogenic bladder disorder, had undergone previous radiotherapy, or had not completed the questionnaire were excluded from the study. The validated Gastrointestinal Quality of Life Index was completed by the patients preoperatively and at 3, 12, and 24 mo postoperatively. Five points concerning bowel function (frequent bowel movement, urgent bowel movement, diarrhea, constipation, or uncontrolled stool loss) were assessed, and the median scores were compared pre- and postoperatively. Results and limitationsMost patients (≥80%) were rarely or never troubled by frequent or urgent bowel movements, diarrhea, constipation, or uncontrolled stool loss preoperatively. In the case of stool frequency, a remarkable shift from rarely to never was observed postoperatively at 3, 12, and 24 mo. Scores for constipation and uncontrolled stool loss remained unchanged throughout the whole time period. For urgent bowel movements the median preoperative score of 4 decreased to 3 at 3 mo and 12 mo and returned to 4 at 24 mo. For diarrhea the preoperative score of 4 decreased to 3 at 3 mo and 24 mo and remained at 4 after 12 mo. ConclusionsNo relevant changes in bowel movements were found after resection of 55–60cm of ileum if the terminal ileum and the ileocecal valve were left intact.

Catheterizable Serous Lined Urinary Outlet in Children and Adolescents: A Choice When Other Treatments Fail

We evaluated the functional outcome of continent catheterizable outlet using the serous lined extramural tunnel technique as a continence mechanism in children and adolescents. We retrospectively studied all patients who underwent continent catheterizable stoma using the serous lined extramural technique between May 1993 and March 2008. Patient records were reviewed for age, sex, indication for surgery, surgical details and postoperative course. All patients were evaluated for continence with emphasis on frequency of clean intermittent catheterization. Urodynamic evaluation was done for patients with leaking stoma. Stoma related complications were also recorded. A total of 37 boys and 23 girls 3 to 18 years old underwent continent catheterizable stoma using the serous lined extramural technique. Total bladder substitution was performed in 13 patients using continent ileal W-shaped reservoir, and 47 patients underwent augmentation ileocystoplasty mounted with serous lined outlet. The outlet channel was appendix in 39 patients (65%), tapered ileal segment in 13 (21.5%) and Monti ileal tube in 8 (13.5%). After a median followup of 43 months (range 10 to 180) 55 patients (91.6%) achieved continence, with catheterization frequency of 3 to 5 times during the daytime and 1 to 2 times at night. Stoma related complications were leaking stoma in 5 patients (8.4%), stomal stenosis in 6 (10%), parastomal hernia in 2 (3.3%) and reservoir stones in 8 (13.3%). Reoperation rate was 18.3% (11 patients). The serous lined continent outlet seems to be a durable and efficient technique for treating children with incontinence, with an acceptable complication rate.

Incidence of New Onset Metabolic Acidosis Following Enteroplasty for Myelomeningocele

Extant literature is mixed regarding risk of metabolic acidosis after enteroplasty for myelomeningocele. This study is the first known attempt to describe the pattern of developing metabolic acidosis in a group of children who underwent enteroplasty and served as their own controls. Multiple preoperative and postoperative laboratory measures for each child were obtained for comparison. This retrospective cohort study allowed participants to serve as their own controls for pre-intervention and post-intervention analysis. The setting was a tertiary, university affiliated, interdisciplinary spina bifida program. All patients followed in the spina bifida program who had undergone ileal or colonic enteroplasty were included for review (total 113). Strict exclusion criteria were preoperatively diagnosed renal insufficiency, preexisting metabolic acidosis consistent with renal tubular acidosis (pH less than 7.35, bicarbonate 20 mmol/l or less) and history of augmentation using gastric or ureteral tissue. Final analysis included 71 children who met inclusion criteria. Children in our spina bifida program periodically undergo routine laboratory evaluation of electrolytes, blood urea nitrogen, creatinine, blood count, and venous blood gases including pH, bicarbonate and partial pressure of carbon dioxide. Primary outcome measures were comparative shifts in blood gases and electrolytes that would confirm the new onset of metabolic acidosis after enteroplasty. Changes in electrolytes and serum creatinine were secondary outcome measures to identify potential markers for postoperative effects. With each child as his/her own control, analysis included paired t tests. No statistically significant differences (p <0.05) were found when comparing laboratory values before and after bladder augmentation, including pH, bicarbonate, partial pressure of carbon dioxide and electrolytes. No child had metabolic acidosis based on the aforementioned criteria. Followup ranged from 1 to 138 months after enteroplasty (mean 46.8). Respiratory compensation was considered in the analysis, and no difference in partial pressure of carbon dioxide following surgery was noted (p = 0.65). To our knowledge no previous study has examined the matched paired results of before and after development of metabolic acidosis among children (serving as their own controls) with myelomeningocele undergoing ileal or colonic enteroplasty. The negative statistical results in this controlled cohort are clinically significant. If a child with myelomeningocele has metabolic acidosis after enteroplasty, other clinical reasons beyond the effects of surgery warrant careful consideration.

18 IMPACT OF STAGE MIGRATION ON THE PREVALENCE OF PELVIC LYMPH NODE METASTASES IN PATIENTS UNDERGOING EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: A 23-YEAR SINGLE INSTITUTION EXPERIENCE

INTRODUCTION AND OBJECTIVE: Locally recurrent gynecological malignancys generally have a poor prognosis and therapeutic optins are limited. We evaluated a series of women undergoing exenterative surgery and urinary diversion for gynecological malignancy. METHODS: All patients who underwent pelvic exenteration for recurrent gynecological malignancy between 1989 and 2001 at Bern University Hospital or Karlsruhe Medical Center were evaluated. Variables assessed included time to recurrence, type of exenteration and urinary diversion, pathological stage, postoperative complications and survival. Cox proportional hazard analysis and Kaplan-Meier survival method and subgroup analysis were performed. RESULTS: Initial therapy prior to recurrence in the 43 evaluated patients was surgery only in 19/43 (44%), in 16/43 (37%) patients surgery was combined with either radiation therapy (23%), chemotherapy (5%) or radio-chemotherapy (9%). Of the remaining 8 patients 5/43 (12%) underwent radiation therapy only and 3/43 (7%) underwent combined radio-chemotherapy. Anterior exenteration was performed in 37 (86%) patients and total exenteration in 6 (14%). Half of the women underwent additional procedures. A continent urinary diversion was constructed in 16 (4 ileal orthotopic bladder substitutes, 2 continent ileal reservoirs, 10 continent ileocecal reservoirs (Mainz-pouch I) and an ileal conduit in 27 patients. The majority of the early postoperative complications were minor and only 2 patients required additional surgical intervention. Four intestinal fistulas were succesfully treated conservatively. Late complications were mainly tumor related. Complication rates related to the urinary diversion were low and there was no difference in complications between continent and incontinent diversion. Overall disease specific 5 year survival rate after exenteration was 33.9 %. This correlated significantly with surgical margin status. CONCLUSIONS: In patients with completely resectable (R0) recurrent cervical cancer of the pelvis, exenteration is a viable option with 5 year survival rates of approx. 43%. Continent urinary diversion did not show higher complication rates than an ileal conduit and should be considered an option even in irradiated patients. This may be of greater significance in younger patients where an intact body image may play an important role on quality of life.

Gastrointestinal function and metabolic control after construction of an orthotopic ileal neobladder in bladder cancer

To investigate the effects of ileum resection in orthotopic neobladder construction on gastrointestinal function and metabolic control. We included 28 patients who underwent radical cystectomy and construction of an orthotopic neobladder or continent ileal reservoir for bladder cancer. As controls, 10 patients endoscopically treated for non-invasive bladder cancer (TaG2) were enrolled. Gastrointestinal symptoms, enterohepatic bile salt circulation, gastric emptying and gastrointestinal hormones involved in metabolic control were monitored. Of the cystectomy patients, 25% experienced daily diarrhoea and faecal urgency due to bile acid malabsorption, compared to 0% of the controls (p = 0.013). The cystectomy patients experienced faster gastric emptying and had higher levels of peptide YY. Plasma concentrations of insulin, glucagon-like peptide-1 and glucose were unchanged. Using the distal ileum for orthotopic neobladder construction causes bowel disorders in a quarter of cystectomy patients. Diarrhoea and faecal urgency are probably caused by decreased reabsorption of bile and are not due to changes in gastrointestinal hormones. A sizeable proportion of patients develop bile salt-induced diarrhoea, which can be relieved by treatment with cholestyramine.

Interindividual variability in the absorption of ciprofloxacin and hydrocortisone from continent ileal reservoir for urine

The neobladder created with a detubularized segment of ileum as standard treatment for the transitional cell carcinoma of the bladder may permit absorption of drugs. As a consequence, on the one hand the elimination of drugs excreted in the urine may be delayed and a change of dosage may be required, and on the other hand the intravesical administration of a drug may produce blood levels capable of inducing unwanted systemic effects. The purpose of the present study was to explore the possibility of drug absorption from a continent ileal reservoir for urine. The possibility of drug re-absorption from a continent ileal reservoir for urine was studied in 12 patients with well functioning reservoirs after a time interval of 3 months from surgery and also, in 7 of them, 6 months later. Saline solutions of ciprofloxacin or hydrocortisone were instilled and maintained in the reservoir for 2 h, and drug concentrations in plasma were measured 1 and 2 h after instillation. Both ciprofloxacin and to a lower extent hydrocortisone were adsorbed from the reservoir, but with large interindividual variability. A comparison of the plasma concentrations produced by the two drugs 3 and 9 months after creation of the new bladder revealed that after 9 months the absorption was decreased in 3 patients, substantially unchanged in 2, and increased in 2. The results of this study show that both ciprofloxacin, chosen for its use as possible radiosensitizing agent in bladder cancer patients, and hydrocortisone, chosen as an example of lypofilic endogenous compound, can be absorbed through the intestinal mucosa of a continent ileal reservoir, but to a different extent and with high interindividual variability.

Clinical Experience of Laparoscopic-Assisted Radical Cystectomy with Continent Ileal Reservoir

Introduction: Laparoscopic-assisted radical cystectomy with continent ileal reservoir reconstruction is a challenging procedure. We report our experience learned from a hand-assisted laparoscopic technique in our transition to a pure laparoscopic approach. Materials and Methods: Eighteen consecutive patients underwent laparoscopic-assisted radical cystectomy with continent ileal reservoir. Hand-assisted laparoscopy was used for the first 11 patients and pure laparoscopy was performed for the subsequent 7 patients in radical cystectomy. Continent ileal reservoir reconstruction was performed extracorporeally via the hand port wound or trocar extension wound. Surgical outcome was analyzed in a retrospective review of the medical records. Results: In the hand-assisted and pure laparoscopic groups, the mean operative time for cystectomy was 2.5 and 2.3 h, for continent ileal reservoir reconstruction it was 4.0 and 3.7 h, and for bilateral lymph node dissection it was 0.8 and 0.6 h, respectively. Mean intraoperative blood loss was 286 ml for the hand-assisted and 179 ml for the pure laparoscopic group. There were no major intraoperative complications nor need for conversion in any of the procedures. Bowel movement was regained in a mean of 3 days and the mean length of postoperative hospital stay was 7 days. Conclusions: The hand-assisted laparoscopic experience of radical cystectomy learned from the initial 11 patients effectively helped us in the transition to a pure laparoscopic approach. A comparable surgical outcome was found in both groups of patients.

Urinary diversion via a continent ileal reservoir: clinical results in 12 patients

Urinary diversion via a continent ileal reservoir: clinical results in 12 patients

CONTINENT CUTANEOUS ILEAL POUCH USING THE SEROUS LINED EXTRAMURAL VALVES. THE MANSOURA EXPERIENCE IN MORE THAN 100 PATIENTS

We report on the functional results of continent ileal reservoir using serous lined extramural valves for reflux prevention and continent urinary outlet. The procedure was performed in 109 patients (68 men, 27 women and 14 children). The operation was indicated as a primary procedure in 93 patients and for conversion in 16. The technique entailed construction of a detubularized W-shaped ileal reservoir in which 2 serous lined troughs were created. Two tapered ileal segments were used, 1 for reflux prevention and the other as a continent outlet. The appendix was used for the construction of the outlet in 44 patients. Two patients died in the hospital of pulmonary embolism. A total of 22 early complications were observed in 18 patients (16.5%). None of the patients required operative intervention. A total of 93 patients were evaluable with a mean followup of 36.6 +/- 25.4 months. All evaluable patients but 5 were continent day and night. Mean time for catheterization was 4 to 5 hours. There were 14 late complications reported in 11 patients (11.8%), including pouch stones in 5, stomal stenosis in 5, failure to catheterize in 2, parastomal hernia in 1 and adhesive bowel obstruction in 1. Upper urinary tract was stable or improved in 94.8% of the renal units. Clinical acidosis did not develop in any of the patients. Serous lined unidirectional valves are reliable. They provide a versatile surgical technique suitable for urinary diversion or conversion procedures. The operation is associated with an acceptable complication rate and is followed by good functional results.

Diagnosis and management of pouchitis

Diagnosis and management of pouchitis

Urinary diversion via a continent ileal reservoir: Clinical results in 12 patients

Urinary diversion via a continent ileal reservoir has been performed in 12 patients. An isolated ileal reservoir was constructed using the technique described for patients with a continent ileostomy. The ureters were implanted into an afferent segment provided with a reflux-preventing nipple valve. There were few operative complications and no operative mortality. Late complications involving malfunction of the nipple valves occurred in 8 patients and were corrected surgically. Postoperative followup presently is between 9 months and 6 1/2 years. Two patients have died: 1 in an accident and i of metastatic bladder carcinoma. The remaining 10 patients are continent and without reflux to the upper urinary tract. The reservoir generally is emptied by intermittent self-catheterization between 3 to 6 times daily. The volume capacity of the reservoir is more than 500 ml. Urinary cultures have been constantly negative in 7 patients and the contents of the reservoir more or less permanently contained bacteria in 5. Dilatation of the upper urinary tracts, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are satisfied with this type of urinary diversion, especially those who have undergone other types of diversion previously.

Health-related quality of life after 5-12 years of continent ileal urostomy (Kock reservoir) in children and adolescents.

To assess quality of life after continent ileal reservoir diversion in children and adolescents. Nine boys and 9 girls (10.8-18 years old at surgery) were operated with a Kock reservoir and followed for 5-12 years. They participated in an interview using a questionnaire based on the Swedish self-esteem inventory, "I think I am". The questionnaire consisted of 76 questions that covered medical, physical, psychological, social, body image and sexual aspects. Six of 18 patients had some difficulties on catheterization. Five complained of pain or bleeding during evacuation. Two patients had slight urinary leakage between evacuations and 6 had mucus secretion. Ten patients had diarrhea with different frequencies. Physical activities were not hampered by the operation in any patient. Instead, activities such as full day outside home, friend at home overnight, using all types of clothes, and participation in camps were increased in 8, 6, 5 and 5 patients, respectively. All patients but 2 had an excellent relation with friends and family members. More than half of patients had excellent positive self-esteem and body image and the rest had very good self-esteem. However, some patients were concerned about how they looked and felt that life was unfair to them. The patients were satisfied with their operation. They were physically active and declared a positive perspective regarding self-esteem and body image. The medical problems related to the operation did not have any negative influence on the self-esteem or body image. The choice of the operation can only be determined on the basis of an attentive dialogue between surgeon, child and parents.

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

FUNCTIONAL RESULTS OF ORTHOTOPIC ILEAL NEOBLADDER WITH SEROUS-LINED EXTRAMURAL URETERAL REIMPLANTATION: EXPERIENCE WITH 450 PATIENTS

We report functional results of the orthotopic ileal neobladder using a serous-lined extramural tunnel as an antireflux procedure. One-stage radical cystectomy and orthotopic ileal W-shaped neobladder creation were performed in 353 male and 97 female patients for invasive bladder cancer. The ureters were reimplanted using a serous-lined extramural tunnel for reflux prevention. Of the patients 344 were evaluable at a mean followup plus or minus standard deviation of 38 +/- 25 months. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. Four patients (0.8%) died in the hospital. Early complications in 42 patients (9%) were treated conservatively but 3 women underwent vaginal repair of a pouch-vaginal fistula. During the observation period there were 90 oncological failures, of which 3 were isolated urethral recurrence. Late complications included pouch stones in 10 cases, outflow obstruction in 11, mucous retention in 2, adhesive bowel obstruction in 3 and hypercontinence in 9 females. The incidence of daytime and nighttime continence was 93.3% and 80%, respectively. The upper tracts remain unchanged or improved in 96.2% of the reimplanted renal units, while reflux was observed in 3%. The serous-lined extramural tunnel has proved its efficiency and durability as an antireflux technique.

THE ORTHOTOPIC KOCK ILEAL NEOBLADDER: FUNCTIONAL RESULTS, URODYNAMIC FEATURES, COMPLICATIONS AND SURVIVAL IN 166 MEN

We report our experience with 166 patients who underwent radical cystectomy and orthotopic bladder substitution with the ileal Kock neobladder between February 1990 and January 1999. We classified complications as early (3 months or less postoperatively) and late. Continence was assessed by patient interview, the need to use protective devices and provocative incontinence testing. Neobladder function was evaluated by uroflowmetry, post-void residual urine volume measurement and enterocystometry, and renal function was assessed by 51creatinine ethylenediaminetetraacetic acid clearance. There were no perioperative deaths. However, 52 early complications developed in 39 patients (23.5%) and 73 late complications in 62 (37.4%). The rate of early and late complications associated with the urinary tract was 11.5% and 23.5% with abdominal reoperation rates of 1.8% and 2.4%, respectively, due to these complications. At 3 and 5 years the risk of stone formation on the metallic staples was 18% and 34%, and the risk of B12 deficiency was 30% and 33%, respectively. One patient (0.6%) underwent reoperation for ureteral anastomotic stricture. Anterior urethral stricture in 5 cases (3%) was caused by recurrence in 1 and urethral anastomotic stricture in 1 also resulted from recurrent disease. Daytime continence was reported by 97% and 100% of our patients at 1 and 5 years, respectively. Provocative incontinence testing confirmed this level of daytime continence. Overall 75% of patients reported nighttime continence at 1 year and 94% at 5 years. The need for a nighttime protective device decreased with time. At 1 versus 3 years 39.8% versus 45.9% of patients used no protection, 29.7% versus 39.2% used a sanitary pad and 30.5% versus 14.9% used a condom device. Enterocystometric capacity and subtracted maximum reservoir pressure remained remarkably uniform at 456 versus 411 ml. and 47 versus 50 cm. water 6 months and 5 years postoperatively, respectively. Nevertheless, median post-void residual urine volume increased from 20 ml. at 6 months to 40 ml. at 5 years with an increased prevalence of patients requiring intermittent catheterization due to post-void residual urine greater than 100 ml. from 16% at 6 months to 44% at 5 years. 51Creatinine ethylenediaminetetraacetic acid clearance remained unchanged. There was a substantial 5-year survival advantage for the subpopulation with stage pT3a or less, pN0 tumors (94% versus 51%, p <0.001). Radical cystectomy and orthotopic bladder substitution with the Kock ileal neobladder may be performed with an acceptable complication rate and good functional results. The probability of survival was considerably higher for patients with tumor confined to the bladder. Consequently we believe that early aggressive treatment should be considered in those with invasive disease, and reconstruction with orthotopic bladder substitution may encourage patients to accept radical surgery.

Effect of Increased Intrareservoir Pressure on Upper Urinary Tract Function in Continent Urinary Diversion PatientsAssessed by Radioisotope Renography

To assess upper urinary tract function and determine an ideal continent reservoir capacity, we investigated the relationship between intrareservoir pressure and functional parameters using radioisotope renography. Forty-three patients for whom ileal reservoir construction was performed by Kock pouch (n = 33) or Hautmann’s ileal neobladder (n = 14) approaches between November 1984 and September 1996 were studied. After the reservoir contents were catheterized, ^99mTc-MAG 3 renoscintigraphy was carried out and time activity curves in the kidney (renogram) and reservoir (reservoirgram) were recorded, while saline solution was poured into the reservoir for monitoring of intrareservoir pressure. Three basic abnormal curves were noted in the excretory phase on renograms: a normal downward curve followed by an upward curve, a continuous upward curve associated with or without a sharp decline after the catheterization of the reservoir contents, and episodes of spike waves. Based on these curves, renograms were classified into five types: normal, high pressure, retention, obstruction, and reflux. Abnormal types were noted with 51 of 65 renal units (78.5%) in the Kock pouch group and 15 of 25 renal units (60.0%) in the neobladder group. This examination method may be useful for evaluating urodynamics in the upper urinary tract of patients with a continent ileal reservoir and provide data on adequate voiding volumes for the individual patient.