Continent Urostomy Research Articles

Adenocarcinoma mucinosum of extrophy bladder: A rare case report.

IntroductionBladder exstrophy is a rare congenital anomaly while, bladder adenocarcinoma mucinous type is a rare type of bladder cancer, with aggressive behavior and inadequate response to radiation and chemotherapy. In extremely rare cases, untreated bladder exstrophy could transform into bladder mucinous adenocarcinoma.Case presentationWe report a case of a 41-year-old male with untreated bladder exstrophy that transformed into mucinous adenocarcinoma. The patient also had epispadias and a right inguinal hernia. Joint procedures were conducted to perform radical cystectomy, total penectomy and W-Pouch continent urostomy, inguinal hernia repair, osteotomy, and keystone and scrotal flap by split-thickness skin graft (STSG) for wound closure. The patient progressed well after surgery, two months after initial procedure, nephrostomies were conducted due to pouches stenosis. Due to the government's limited transportation and lockdown policy, as the Covid-19 pandemic occurred, the patient could not come to the hospital for routine follow-up and died nine-month after surgery.Clinical discussionBladder exstrophy is one of the risk factors of bladder cancer. Transformation of bladder exstrophy into mucinous adenocarcinoma is extremely rare, as the case is the first case to be discovered in Indonesia. Surgery, followed with a strict follow-up regime, is mainstay of treatment in this type of malignancy.ConclusionAdenocarcinoma of mucinous type is a scarce type of bladder exstrophy malignancies. A multidiscipline approach is mandatory in these cases. Strict and regular follow up are suggested for these cases.

Sleep Disturbances Decrease Self-Assessed Quality of Life in Individuals Who Have Undergone Cystectomy

The best possible urinary diversion after cystectomy, if any, is yet to be defined to our knowledge. Therefore, we investigated nocturnal urinary disturbances and quality of life in individuals who have undergone cystectomy with urinary diversion for bladder cancer. All patients 30 to 80 years old who had undergone cystectomy with urinary diversion at 7 urological centers in Sweden were included in the study. Sleep disturbances, nocturnal urinary leakage and urine evacuation frequency, as well as their effect on self-assessed quality of life variables were measured with a study specific questionnaire. We received the questionnaire from 452 (92%) of 491 identified individuals. Outcome variables were dichotomized and the results are presented as relative risks. Those individuals with an orthotopic neobladder had an increased risk of nocturnal urinary leakage and/or urine evacuation frequency compared to those with a noncontinent urostomy or cutaneous continent reservoir. Of the patients with an orthotopic neobladder 37% reported negative effects on nocturnal sleep compared to 22% and 14% of those with a noncontinent or continent urostomy, respectively. Of those patients reporting that the urinary diversion had a negative effect on nocturnal sleep 88% had a decreased quality of life vs 65% of those who stated that the urinary diversion had no or little influence on nocturnal sleep. Nocturnal urinary problems are of great concern for individuals with urinary diversion, especially those with an orthotopic neobladder. Regular disruption of sleep decreases quality of life.

Tumeurs infiltrantes de vessie : étude rétrospective à propos de 225 cas

The authors report a retrospective serial of 225 patients presenting an infiltrating bladder tumor. The infiltrating tumors represent 29.2% of bladder tumors. The middle age of our patients is 59 years with a sex-ratio of 7.3. In the histology, 80% of the tumors are a cell transitionnal carcinoma and 65% of the patients are classified stage T3T4. The surgical treatment has could be achieved at 73.3% of the cases and 66.7% of the patients had a radical cystectomy. The urinary diversion was essentially an continent urostomy using Benchekroun’s hydraulic valve. At 28 months mean follow-up, a locoregional recurrence has been noted from 18% of the Tur achieved alone and 4% of the radical cystectomy. A metastasis has been noted from 18% of the patients and this in a mean delay of 12 months.

Laparoscopic Management of Urolithiasis in a Continent Urostomy

Background. Urinary calculi formation is an infrequent but challenging late complication of continent urostomy. Percutaneous endoscopic management of two patients with symptomatic pouch urolithiasis is described.Cases. A 48-year-old woman with a history of cervical squamous cell carcinoma (SCC) treated with primary chemoradiotherapy presented with recurrent pain and urinary tract infections (pouchitis). She had undergone continent urostomy 4 years previously for management of a vesicovaginal fistula. A 59-year-old woman following exenteration with continent diversion for recurrent cervix SCC had a 6-month history of refractory pouchitis. In both women, multiple pouch urinary calculi were identified. Their continent reservoirs were, in part, created using titanium staplers. Percutaneous CO2 endoscopy afforded identification and removal of their stones and staples without complication.Conclusion. Successful treatment of continent urostomy urolithiasis is accomplished by percutaneous endoscopy.

Choices in Creating Continent Urostomies Following Pelvic Exenteration for Gynecologic Malignancies

Objective. The purpose of this report was to describe a rationale for choosing from a variety of techniques to construct continent urinary diversions for patients who undergo pelvic exenterations. Moreover, this report evaluated the technique and utility of a continent urostomy created from a supracecal segment of colon.Methods. The charts from patients who underwent pelvic exenterations and urinary diversions by DFS between September 1999 and December 2000 were reviewed after institutional review board approval. Data were recorded and evaluated.Results. Four patients underwent total pelvic exenterations and one received an anterior exenteration. Recurrent vulvar, vaginal, and cervical cancers were diagnosed in one, one, and two of the patients. One patient had an unknown primary squamous cell carcinoma in the pelvis. Four of the five received prior pelvic radiotherapy either in the neoadjuvant setting or as treatment for their primary disease. All five patients chose to have continent urostomies constructed. One Kock (ileal) pouch, one Miami (iliocolonic) pouch, and three supracecal colonic continent urostomies (SCCCU) were built. All five maintained continence over the follow-up period (mean follow-up time = 8.2 months). No complications related to the urostomies required reoperation. A new technique to for the construction of a SCCCU is described.Conclusion. With a variety of procedures established to build continent urostomies, the choice of which to use should be individualized to the patient's situation as well as to the surgeon's experience. The use of a SCCCU requires moderately complex manipulations of the colon (described in the text) and a slight increase in the operative time; however, it results in successful continence and avoids complications related to radiation-injured bowel. It may be considered the procedure of choice for patients who have received prior radiation therapy. Long-term follow-up is needed.

Urolithiasis Following Formation of a Continent Urostomy: Case Report and Review of the Literature

Background. Formation of urinary stones in a continent urostomy (Indiana pouch) has been described as a late complication. Management of a patient with symptomatic multiple large stones and review of the literature are outlined.Case report. A 32-year-old woman presented with recurrent urinary tract infections and pyelonephritis 6 years after a total pelvic exenteration and creation of a continent urostomy for central recurrent carcinoma of the cervix after radical pelvic radiation. Multiple large stones were found to be the underlying etiology. Laparotomy, enterocystotomy, and removal of stones were performed without apparent complication.Conclusion. It is recommended that for single calculi or multiple small stones, electroshock wave lithotripsy or the percutaneous endoscopic approach be considered. For larger stones the use of laparotomy and enterocystostomy may be appropriate.

Effect of Urinary Intestinal Diversion on Urinary Risk Factors for Urolithiasis

We investigated the effect of urinary intestinal diversion on risk factors for calcium urolithiasis, such as calcium, phosphate, magnesium, uric acid, oxalate and citrate, in 3 groups of patients (Kock pouch, Indiana pouch and ileal conduit). Mean urinary volume was not significantly different among the 3 groups. Mean serum creatinine and 24-hour creatinine clearance in the continent reservoir group were better than in the ileal conduit group. Mean urinary excretion of calcium, phosphate and magnesium was significantly greater in the continent reservoir group than in the ileal conduit group. Although calcium excretion had a positive correlation with 24-hour creatinine clearance, calcium excretion per ml. per minute creatinine clearance still showed a significant difference. Increased calcium excretion is considered to reflect metabolic disturbances resulting from reabsorption of urinary solutes through the intestinal segments. Overall, there was no significant difference in the urinary parameters between the Kock and Indiana pouch groups. While mean urinary oxalate and citrate were within the normal range in all 3 groups, more than a third of the patients in each group were hypocitraturic (less than 100 mg. per day). In none of the 3 groups did the levels of urinary calcium, phosphate and magnesium, as well as other urinary risk parameters show any correlation with the duration of diversion. In summary, our study indicated that the continent urinary reservoir causes a long-term increase in urinary excretion of calcium, phosphate and magnesium. These urinary metabolic alterations might promote the formation of calcium urolithiasis as well as infectious stones. The degree of metabolic alterations may be greater with a continent reservoir than with an ileal conduit.

Recent advances in surgical reconstruction of the gynecologic cancer patient

Despite significant advances in radiation oncology and chemotherapy, radical en bloc resection of pelvic tissue remains an important part of the armamentarium of the gynecologic oncologist. Total pelvic exenteration can be the only hope of women who failed more conservative therapy. The time has come where it is appropriate to employ temporary techniques in the discipline of reconstructive surgery to restore these women to an acceptable quality of life. It may be the next challenge for the pelvic surgeon to participate in such surgical reconstruction. This challenge is becoming an active part of the oncologic surgical practice in head and neck surgery, and in breast surgery. Reconstructive surgery of the vulva has been well described in the literature with the use of cutaneous and myocutaneous flaps, and it is beyond the scope of this paper to recount them here. This paper reviews the techniques that are available for reconstruction of a functional vagina, restoration of a functional rectum with elimination of colostomy, and reconstruction of a continent urostomy that will allow better physiologic protection of the upper renal tracts and improve the aesthetics of a urine ostomy bag.

Correction of incontinent ileocolic urostomy with Kock's nipple valve

Continent urostomy procedures may be replacing the incontinent ileal or colon conduit as the preferred method of urinary diversion in gynecologic cancer patients. One method of continent urinary diversion utilizes the detubularized ascending and transverse colon as a reservoir with a tapered segment of distal ileum as the stoma through which the patient catheterizes the pouch (Miami pouch). Failures of this procedure have been reported. A case report of such a failure is presented. This patient was managed by replacing the tapered ileal stoma with a Kock intussuscepted nipple valve made from proximal ileum. The patient is now continent. This technique warrants further investigation as a method of treating patients with continent urostomies of various types (Kock, Indiana, Miami, Mainz) that become partially or completely incontinent.

A Troublesome Urostomy Treated with Liposuction

A case is reported in which a fat deposit in a patient who had had a continent urostomy fashioned by Kock's technique, caused skin problems and made catheterisation Kock's technique, caused skin problems and made catheterisation difficult. The condition was successfully treated with liposuction around the stoma.

Construction of a stable nipple valve with processed dermal sheep collagen for continent ileostomy and urostomy

Complications of the nipple valve system used for continent urostomy and ileostomy basically consist of incomplete (or complete lack of) adhesion of the invaginated serosal surfaces of the valve. A novel concept in fixation of the valve by means of the intussusception of a newly developed biomaterial (processed dermal sheep collagen; PDSC) was tested. The implanted PDSC is characterized by induction of fibroblast invasion and formation of new collagen fibers, initial high tensile strength, bio-inertion and (slow) biodegradation. It was implanted between the serosal surfaces of the invagination in 14 dogs without the application of the commonly used staples and synthetic mesh. Good permanent fixation was obtained in all cases after the PDSC had been sutured in place. As the observation time advanced up to 2 years, an increased amount of newly formed collagen was seen anchoring the serosal surfaces firmly together via the implanted PDSC with apparent slow degradation. In none of the test animals did complications occur. The first clinical trial was successful.

Application of the Invaginated Sleeve Technique to Form a Continent Ileal Urostomy

The invaginated sleeve technique has been adapted to produce a continent urostomy, able to be catheterised, from a length of canine ileum measuring less than 10 cm. Of the 4 dogs catheterised twice daily up to 13 weeks, narrowing was present in the extra-ileal segment in 2, but all intra-ileal double-barrelled lumina remained healthy with preservation of bowel mucosa.

Continent Urostomy with Hydraulic Ileal Valve in 136 Patients: 13 Years of Experience

The hydraulic ileal valve, which we developed in 1975, ensures continence by adapting to 5 different urinary reservoirs. The valve is made by isolating a 14cm. long intestinal loop with the mesentery. The isolated ileal segment then is folded inward on itself throughout its entire length. We performed 136 continent urostomies with this hydraulic valve. An ileocecal reservoir was used in 122 patients, ileum in 8, sigmoid in 1, rectum in 1 and bladder (continent cystostomy) in 4. Indications for continent urostomy were bladder tumor in 55 patients, complex vesicovaginal fistulas in 5, neurogenic bladder in 13, vesical exstrophy in 12 and miscellaneous reasons in 5.Of the patients 103 (75 per cent) were continent immediately. Continence was obtained after repair of the valve in 24 patients (17.6 per cent). Therefore, 127 patients over-all were continent. Mean followup of our patients was 38 months (range 3 to 154 months). Continence remained excellent with self-catheterization performed easily in 88.3 per cent of the patients. Over-all, all of our continent urostomies were well tolerated biologically and radiologically.

Quality of Life Survey of Urinary Diversion Patients: Comparison of Ileal Conduits versus Continent Kock Ileal Reservoirs

There has been a recent marked increase in interest in continent urinary diversions. While considerable time has been spent on the technical aspects of these diversions the psychological impact has not yet been fully explored. We describe an extensive survey that was conducted among 100 consecutive adults (87 respondents) who had undergone urinary diversion via an ileal conduit and 100 consecutive adults (85 respondents) in whom a continent Kock ileal reservoir was created during the last 3 to 5 years at our university by the same surgeons. The Kock pouch patients were stratified further into 63 with primary diversion and 22 who underwent conversion from previous conduit diversions. The survey consisted of a questionnaire that included a social and sexual survey, the Beck Depressive Inventory, the Profile of Mood States and a physical impact study. The results revealed that all patients surveyed generally were satisfied with the diversions and they had adapted reasonably socially, physically and psychologically. The key to adaptation seemed to be a detailed, realistic preoperative education about the type of diversion used. Patients with ileal conduit diversions had the lowest expectations of the form of diversion as defined by the preoperative awareness of the need to wear an external ostomy appliance with its associated inconveniences and change in the external body image. Postoperatively, ileal conduit patients also had the poorest self images as defined by a decrease in sexual desire and in all forms of physical contact (sexual and nonsexual). The subset of patients who underwent conversion from conduit diversions to Kock pouches, however, were statistically the most satisfied, and they were the most physically and sexually active. We conclude that the Kock continent urostomy offers an important alternative to noncontinent forms of diversion.

An Update on the Kock Pouch for Continent Urinary Diversion

The authors continue to feel, based on a 4 1/2 year clinical experience in more than 400 patients, that the Kock continent urostomy offers an important alternative to noncontinent forms of diversion. Not only can it provide an improved body image, but the Kock pouch can also help to salvage, both physically and emotionally, those patients with unsatisfactory results from conduit diversion.

Drainage of the upper urinary tract as recorded with renography in patients with a continent urostomy (Kock pouch). An experimental study with various degrees of reservoir filling.

The drainage from the upper urinary tract was studied by the use of renography in thirteen patients with well functioning continent ileal reservoirs for urinary diversion (Kock-pouch). Renography was performed with empty reservoir and with submaximal or maximal filling of the reservoir. The reservoir pressure was continuously recorded when renography was performed with a full reservoir. When the reservoir was empty renography showed normal drainage in all patients. When the reservoir was full the renography was normal in eight patients, these having a mean reservoir volume of 715 ml but showed a delay in five patients, these having a mean reservoir volume of 930 ml. When the renography was repeated in the latter group of patients with submaximal filling (mean reservoir volume 544 ml) there was no delay of the drainage phases on the renograms. In these five patients the considerable "over-filling" of the reservoir had resulted in volumes greatly exceeding the previously recorded maximal reservoir capacity and also in pressures exceeding considerably those usually recorded in ileal reservoirs. These results show that the pressure in the bladder substitute is of great significance for the drainage from the upper urinary tract and that the low pressure ileal reservoir under ordinary circumstances does not obstruct the flow from the upper urinary tract.

Continent urostomy: a clinical experience in 20 patients.

Urinary diversion via a continent ileal reservoir (modified Kock's procedure) was performed in 20 patients. Primary continent urostomy construction was carried out in 6 patients. Previous urinary diversion was present in 12 patients. Two patients were referred to us because a previous attempt to construct a continent reservoir urostomy had failed. There was no operative mortality. Three early complications occurred in 3 patients. Leakage from a uretero-enteric anastomosis in one patient and necrosis of a continence-providing valve in another patient necessitated reoperation. Late complications causing malfunction of the nipple valves required revisional surgery in 2 patients. Stoma stricture developed in 1 patient after 5 months and could be corrected surgically. The functional results were excellent. Continence was achieved without reflux to the upper urinary tract. Instead of a Kock pouch, an S-pouch was used. The continence and antireflux-providing valves were stapled to the reservoir wall. Slippage of the nipple valves did not occur. All our patients had consistently positive urine cultures and were without complaints. In a few cases, stone formation was observed usually on the staples at the tip of the valve. The stones were removed by forceps during endoscopy of the reservoir.

Volume Capacity and Pressure Characteristics of the Continent Ileal Reservoir Used for Urinary Diversion

AbstractThe volume capacity and the pressure characteristics of the continent ileal reservoir for urinary diversion were studied at specific intervals postoperatively in 26 patients. The reservoir volume increased during the first year postoperatively from approximately 100ml. at operation to a mean of 735ml. and then remained stable during an observation period of up to 7 years. The basal pressure increased during filling from 0 to about 10cm. water. During physiological conditions, that is when the reservoir was filled by diuresis, the basal pressure was equal to those pressures measured during saline infusion at corresponding reservoir volumes. Calculation of the magnitude of motor activity by 2 different methods showed a significant decrease in activity at 12 months compared to at 2 months after construction of the reservoir. Data from the continent urostomy reservoir were compared to corresponding data from the continent ileostomy and cecal reservoirs for fecal diversion, these being obtained in previous studies in our laboratory. The ileal reservoirs used for fecal or urinary diversion were practically identical with regard to volume capacity, basal pressure and motor activity. However, the cecal reservoir had a significantly lower volume capacity and higher basal pressure at corresponding reservoir volumes, while the motor activity was approximately 10 times greater than in the ileal reservoir. The results indicate that with regard to volume capacity and pressure characteristics the ileal reservoir is superior to the cecal reservoir as a receptacle for urine.

Ultrastructural and histochemical changes in ileal reservoir mucosa after long-term exposure to urine. A study in patients with continent urostomy (Kock pouch).

Mucosal biopsy specimens were obtained from ileal reservoirs used for urinary collection in patients with continent urostomy. Shortly after construction of the reservoir there was a reduction in villous height and an increase in crypt depth. After 2 to 3 years of observation, avillous areas were noted in the reservoir mucosa, mixed with islets of villous mucosa. Specimens from the avillous areas showed a marked decrease in height of superficially located enterocytes, with loss of microvilli and a reduction in cell organelles. The histochemically demonstrable activity of oxidative enzymes was significantly reduced in the epithelial cells. There was an increase in the number of goblet cells and autonomic nerve fibres in the crypt layer. The constant exposure to urine led to significant alterations of the ileal mucosa resulting in avillous areas mixed with villous remnants in which many of the intestinal characteristics both structurally and functionally disappear.

Morphologic changes in ileal reservoir mucosa after long-term exposure to urine. A study in patients with continent urostomy (Kock pouch).

In patients with supravesical urinary diversion, continent ileal reservoirs utilized for urinary collection were examined by endoscopy at intervals of 1 month to 9 years after surgical construction, and biopsy specimens were obtained for light microscopy and morphometry. The gross appearance of the mucosa showed alterations in the shape of the shorter and broader finger-like villi during the first postoperative month to the subsequent very low ridges and convolutions or, in some instances, flat mucosa devoid of individual villi. Starting between 1 and 3 years after the surgical construction, endoscopically smooth areas were encountered in caudal areas of the reservoir, and the areas were mixed with islands of villous mucosa. Microscopically and morphometrically, the specimens from villous areas confirmed reduction in villous height and increase in crypt depth, whereas no changes were seen in the epithelial mitotic frequency. The number of mucus-storing goblet cells increased already within 1 month after construction. Specimens obtained from smooth areas showed alterations in the intestinal structure, with reduction of crypts, decreased height of epithelial cells, and occasional epithelial denudation. No signs of fibrosis, foreign-body reaction, or dysplasia were encountered. The constant exposure to urine leads to adaptive changes of the reservoir mucosa, resulting in a true atrophy of villi, crypts, and individual epithelial cells.