Form Of Urinary Diversion Research Articles

Radical cystectomy in octogenarians

This retrospective study evaluates the morbidity and outcome of cystectomy and urinary diversion in octogenarians with invasive bladder cancer. Records of all patients older than 80 years who underwent cystectomy during the last 10 years were analyzed retrospectively. Among 565 cystectomies, 11(< 2%) patients were identified and evaluated for intraoperative and postoperative complications and mortality post surgery. The median age was 82 years. One female and ten male patients were selected. Eight patients were hypertensive, three were diabetic, one had coronary artery disease, two had chronic lung disease and one had depression. Seven patients presented with hematuria, two had lower urinary tract symptoms and two presented with renal failure who were optimized for renal function. All patients had ileal conduit as the form of urinary diversion. Simultaneous urethrectomy was done in two patients. Median surgical time was 5 h. Median hospital stay after surgery was 10 days. Four patients had pneumonitis and one patient developed hemiplegia, but all patients were eventually discharged. One patient expired due to stent septicemia within one month after discharge. Follow-up ranged from four months to five years. Three patients expired three years after surgery—one due to disease recurrence and the other two due to unrelated cause. One patient was lost to follow-up and six patients are doing well. Our results support the use of cystectomy in octogenarians with invasive bladder cancer, which has acceptable morbidity and mortality, and offers the best chance for sustained disease-free quality survival.

Screening for Malignancy After Augmentation Cystoplasty in Children With Spina Bifida: A Decision Analysis

Augmentation cystoplasty is the mainstay of surgical treatment for medically refractory neurogenic bladder in patients with spina bifida. Concerns regarding an increased risk of malignancy have prompted many centers to consider routine postoperative screening. We examine the potential cost-effectiveness of such screening. A Markov model was used to compare 2 screening strategies among patients with spina bifida after cystoplasty, namely annual screening cystoscopy and cytology and usual care. Model parameters were informed via a systematic review of post-augmentation malignancy and cost estimates from published reports or government sources. In a hypothetical cohort the individual increase in life expectancy for the entire cohort was 2.3 months with an average lifetime cost of $55,200 per capita, for an incremental cost-effectiveness ratio of $273,718 per life-year gained. One-way and two-way sensitivity analyses suggest the screening strategy could be cost effective if the annual rate of cancer development were more than 0.26% (12.8% lifetime risk) or there were a greater than 50% increase in screening effectiveness and cancer risk after augmentation. After adjusting for multiple levels of uncertainty the screening strategy had only an 11% chance of being cost effective at a $100,000 per life-year threshold or a less than 3% chance of being cost effective at $100,000 per quality adjusted life-year. Annual screening for malignancy among patients with spina bifida with cystoplasty using cystoscopy and cytology is unlikely to be cost effective at commonly accepted willingness to pay thresholds. This conclusion is sensitive to a higher than expected risk of malignancy and to highly optimistic estimates of screening effectiveness.

Serum carcino-embryonic antigen (CEA) and its possible use as tumor marker for secondary tumors in urinary intestinal reservoirs

ObjectivesSerum carcino-embryonic antigen (CEA) has become a useful tumor marker in patients with colorectal adenocarcinoma. Patients who undergo uroenteric reconstruction, such as urinary diversion (UD), have an increased risk of developing malignant changes in their UD. We compared serum CEA levels in patients with different types of UD, evaluating long-term CEA changes and assessing its potential for use as a tumor marker of malignant transformation in the UD. Materials and methodsSerum CEA was evaluated 3 to 122 months after surgery in 177 patients with different types of UD and retrospectively analyzed. The normal range for CEA was 0.2–3.4 μg/l. No patient had a history of colorectal cancer. ResultsA total of 443 CEA samples from 177 patients were evaluated. CEA was elevated (up to 32 μg/l) in 122 samples (27.5%) from 59 patients (33.3%). Patients with Mainz Pouch II had significantly higher CEA levels (P = 0.037) than patients with other forms of UD. CEA levels increased significantly in the study population during follow-up (P = 0.0000007). Five of the patients (2.8%) developed a secondary neoplasm, 4 of whom had elevated CEA. Three neoplasms (urothelial cancer) were located outside the UD. Only 2 tumors were actually located in the UD: an urothelial cancer at the uretero-colonic anastomosis of the UD with normal CEA levels, and a colonic adenoma at the bottom of the UD with elevated CEA levels. No patient had adenocarcinoma in the UD. ConclusionElevated serum CEA is a common finding in patients with UD using bowel segments (33.3%), especially in patients with rectal reservoirs. Serum CEA has a tendency to increase over time in patients with UD but is not a valuable marker of secondary neoplasms in these patients.

Tumor Growth in Urinary Diversion: A Multicenter Analysis

BackgroundThe risk estimation of secondary tumors after different types of urinary diversion with intestinal segments is possible only for ureterosigmoidostomy owing to the lack of follow-up studies of other forms of urinary diversions. ObjectiveWe calculated the prevalence of secondary tumors associated with different forms of urinary diversion, relating the number of reported tumors to the number of performed diversions in German clinics. Design, setting, and participantsWe analyzed the operative records of 44 German clinics for urinary diversions performed from 1970 to 2007 and registered all reported secondary tumors up to 2009. MeasurementsFor statistical comparison of the different tumor prevalences, Fisher exact test was used. Additionally, we compared tumor locations and latency periods in different forms of urinary diversions. Results and limitationsIn 17 758 urinary diversions, 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (2.58%) and cystoplasty (1.58%) was significantly higher than in other continent forms of urinary diversion (p<0.0001). The risk in orthotopic (ileo-)colonic neobladders (1.29%) was significantly higher (p=0.0001) than in ileal neobladders (0.05%). The difference between ileocecal pouches (0.14%) and ileal neobladders was not significant (p=0.46), and the tumor risk with ileal conduits was minimal (0.02%). ConclusionsUreterosigmoidostomies, cystoplasties, and probably orthotopic (ileo-)colonic neobladders bear a significantly increased tumor risk compared with the general population and necessitate regular endoscopic evaluation from at least the fifth postoperative year. Regular endoscopy is not imperative after ileal neobladders and conduits, but with catheterizable ileocecal pouches, it is recommended in the presence of symptoms such as hydronephrosis, chronic urinary infection, and hematuria.

Radical cystectomy and urinary diversion in women: Impact on sexual function

The aim of this study was to assess the impact of radical cystectomy and different forms of urinary diversion on female sexual function. Seventy-three consecutive patients were included in the study. The mean age was 52.3 ± 6.5 years. All of them had undergone non-nerve-sparing radical cystectomy and urinary diversion for invasive bladder cancer. Patients were questioned about their current general relations with their husbands in comparison to the preoperative status. The Female Sexual Function Index (FSFI) was used to assess libido, lubrication, orgasm, satisfaction and painful sexual dysfunction. Patients were asked about any urinary complaints during or after sexual intercourse. Twenty-nine patients (39%) reported worsening relations with their husbands. The mean frequency of sexual relations was 2.3 ± 2.3/month; however, sexual relations had ceased completely in 19 patients (26%). Overall satisfaction among sexually active women worsened in 32 (59.2%) and was completely lost in eight patients (14.8%). Absent libido, difficult intromission, dyspareunia, lack of orgasm and sexually related urinary complaints were reported in 89%, 63%, 48%, 63% and 63% of patients, respectively. The mean FSFI score dropped significantly from 18.3 ± 5.1 to 11.3 ± 7.4 postoperatively (p < 0.001). FSFI scores were significantly higher among patients with orthotopic versus non-orthotopic forms of diversion and also higher among patients with no stoma versus those with stomal forms of diversion. Radical cystectomy and urinary diversion have deleterious impacts on all domains of female sexual function. Female patients with orthotopic and non-stomal diversions had better sexual functions than those with stomal diversions.

Improving selection of appropriate urinary diversion following radical cystectomy for bladder cancer

Radical cystectomy represents the gold-standard of treatment for invasive bladder cancer. Following cystectomy, various options for urinary diversion may be offered to patients. This article represents an overview of the history of urinary diversion, explains the current selection criteria used at one of the most experienced bladder cancer centers worldwide, and provides an update on the current understanding of continence mechanisms. Furthermore, we review the current literature on quality of life for patients with different forms of urinary diversion. Excellent functional results can be achieved with continent forms of urinary diversion. It is important to consider the relative and absolute contraindications when choosing any form of urinary diversion. Proper patient selection and thorough standardized preoperative counseling is critical in achieving optimal results.

1250 FLUORESCENT CYSTOSCOPY WITH HEXAMINOLEVULINATE: DIAGNOSTIC ACCURACY FOR NON MUSCLE INVASIVE BLADDER CANCER

INTRODUCTION AND OBJECTIVES: The risk estimation of secondary tumors following different kinds of urinary diversion using intestinal segments has only been possible for ureterosigmoidostomies yet due to the lack of follow-up studies. METHODS: We analyzed the operation records of 44 German clinics for all kinds of urinary diversion operated from 1970–2007 and registerated all reported secondary tumors of these clinics up to 2009. RESULTS: In 17.758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomies (2,58%) and cystoplasties (1,58%) is significantly higher than in other continent forms of urinary diversion (p 0,0001). The tumor risk in orthotopic (ileo-) colonic neobladders (0,97%) is significantly (p 0,0001) higher than in ileal neobladders (0,05%). The difference between ileocoecal pouches (0,18%) versus ileal neobladders is not significant (p 0,46). The tumor risk following ileal conduits is minimal (0,02%). CONCLUSIONS: Ureterosigmoidostomies, cystoplasties and probably orthotopic (ileo-)colonic neobladders bear a significantly increased tumor risk compared to the general population with necessity of regular endoscopic controls at least from the 5th postoperative year on. Following ileal neobladders, conduits and probably catheterizable ileocoecal pouches regular endoscopic controls are not necessary.

Endoscopic management of lower ureteric stone after ureterosigmoidostomy

Ureterosigmoidostomy is one of the oldest technique for continent urinary diversion. Though less common nowadays, it is still a useful form of urinary diversion; simple to perform, offers good continence with minimal interference with life style. It still has a major role in conditions like ectopia vesicae and post-radical cystectomy for bladder carcinoma. We present a case of 33 years lady who underwent ureterosigmoidostomy at the age of 10 years for ectopia vesicae and later developed left pyonephrosis due to distal ureteric calculus. Left sided PCN was done and successful antegrade endoscopic removal of calculus relieved her symptoms.

Endoscopic management of lower ureteric stone after ureterosigmoidostomy

Ureterosigmoidostomy is one of the oldest technique for continent urinary diversion. Though less common nowadays, it is still a useful form of urinary diversion; simple to perform, offers good continence with minimal interference with life style. It still has a major role in conditions like ectopia vesicae and post-radical cystectomy for bladder carcinoma. We present a case of 33 years lady who underwent ureterosigmoidostomy at the age of 10 years for ectopia vesicae and later developed left pyonephrosis due to distal ureteric calculus. Left sided PCN was done and successful antegrade endoscopic removal of calculus relieved her symptoms.DOI: http://dx.doi.org/10.3126/joim.v32i1.4004Journal of Institute of Medicine, April, 2010; 32:1 pp.46-49

Long‐term outcome of ureterosigmoidostomy: an analysis of patients with &gt;10 years of follow‐up

Therapy (case series). 4. To examine our long-term experience with ureterosigmoidostomy (USS) to evaluate its potential applicability in the treatment of benign and malignant conditions of the urinary bladder, as USS has been largely disregarded recently, secondary to concerns of long-term complications, but has had a resurgence of interest due to its potential applicability to newer minimally invasive surgical techniques. We identified 51 patients who had USS from 1956 to 2006 at our institution and with >10 years of follow-up. The patients were followed retrospectively by a chart review. Patient data were analysed in a multifaceted fashion, paying particular attention to metabolic abnormalities, early (< or =30 days) and late (>30 days) complication rates, continence rates, imaging changes, and the rate of repeat surgical intervention. The median (range) follow-up was 15.7 (10.0-45.4) years and the median age at surgery was 58.8 (0.4-79.0) years; 40 (79%) patients had the procedure for malignancy and 11 (22%) for benign disease. Six patients (12%) had at least one early complication, including one wound dehiscence and one pulmonary embolus. In all, 22 patients (43%) had at least one late complication, with anastomotic stricture being the most common (11/51, 22%). This was followed by recurrent pyelonephritis in eight patients (16%), stones in five (10%), chronic renal insufficiency in three (6%) and severe intractable acidosis in two (4%). A repeat surgical intervention was required in 19 (37%) patients. In all, 94% (48) reported complete continence. No patient developed colonic malignancy during the course of this study. USS is associated with long-term complications. While this complication rate might not be acceptable for all patients, some might be willing to undergo the procedure as the primary method of urinary diversion. When designing newer minimally invasive techniques for the treatment of benign and malignant conditions of the bladder, consideration could be given to USS as a form of urinary diversion in highly selected patients.

How to Obtain Good Results with Orthotopic Bladder Substitution: The 10 Commandments

The orthotopic neobladder has not only withstood the test of time but is increasingly becoming a more desirable method of urinary diversion. Complementing orthotopic neobladder features with adequate training allows patients to return to a urinary routine that is close to, if not completely, normal. The preconditions, indications, and contraindications as well as the key points of the surgical technique will be presented by researchers who pioneered this operation. Experience with and long-term follow-up of orthotopic reconstruction is presented by surgeons at institutions that pioneered orthotopic reconstruction during the last 25 yr with a high surgical volume of radical cystectomy (RCX) and any form of urinary diversion (particularly orthotopic reconstruction). Ten commandments were developed for achieving good results with orthotopic bladder substitution: (1) The procedure should be performed by a high-volume surgeon; (2) do not overextend the indication; (3) experience with nerve-sparing radical prostatectomy and bowel surgery is mandatory; (4) use ileum whenever possible; (5) maximum detubularisation is a must; (6) use a stented, freely refluxive ileoureterostomy; (7) the low-pressure, compliant, freely refluxive reservoir is standard; (8) be aware of myriad potential complications; (9) a full armamentarium of diversion techniques must be available; and (10) meticulous follow-up must be guaranteed. Continence and voiding function following orthotopic bladder substitution are determined primarily by characteristics of the reservoir and by a preserved, innervated outlet mechanism. The reservoir should be detubularised and compliant with a low end filling pressure. Ileum seems to be superior to sigmoid or stomach, which can be used when necessary but with higher incontinence rates. Reflux prevention is not a major concern and does not justify the use of an antireflux mechanism with a high complication rate. This paper outlines 10 commandments for obtaining good results with orthotopic bladder substitution.

Terminal Patients With Urinary Diversion

To investigate the treatment and nursing care problems related to the type of urinary diversion in terminal patients experienced by the primary healthcare sector. A questionnaire about treatment and nursing care problems related to urinary diversion was sent to general practitioners (GPs) and district nurse units (DNUs) that had been in contact with 1 of 71 patients who died following cystectomy in a 5-year period. The patients had 1 of 3 types of urinary diversion: ileal conduit (IC), Indiana pouch (IP), or Hautmann orthotopic neobladder (NB). Both GPs and DNUs reported significant difference in problems associated with the 3 types of urinary diversion favoring the IC (P = .049 and .025, respectively). However, clinical decisions about urinary diversion types are often based on incontinent versus continent diversions. When divided into continent versus incontinent diversions, the analysis revealed no differences in the number of problems (P = .31 and .052, respectively). Comparing IC and NB alone made the difference even less significant (P = .82 and .23, respectively). It seems that there are no major disadvantages with one type of urinary diversion when compared to the other as perceived by primary healthcare providers. Relevant and thorough information should be provided to GPs and DNUs in order to minimize problems with all forms of urinary diversion.

LONG-TERM OUTCOMES OF ORTHOTOPIC NEOBLADDER RECONSTRUCTION AFTER RADICAL CYSTECTOMY FOR BLADDER CANCER IN JAPANESE MEN: ASSESSMENT OF COMPLICATIONS, VOIDING PATTERNS AND QUALITY OF LIFE

You have accessJournal of Urology1 Apr 2009LONG-TERM OUTCOMES OF ORTHOTOPIC NEOBLADDER RECONSTRUCTION AFTER RADICAL CYSTECTOMY FOR BLADDER CANCER IN JAPANESE MEN: ASSESSMENT OF COMPLICATIONS, VOIDING PATTERNS AND QUALITY OF LIFE Hideaki Miyake, Junya Furukawa, Atsushi Takenaka, Sadao Kamidono, and Masato Fujisawa Hideaki MiyakeHideaki Miyake More articles by this author , Junya FurukawaJunya Furukawa More articles by this author , Atsushi TakenakaAtsushi Takenaka More articles by this author , Sadao KamidonoSadao Kamidono More articles by this author , and Masato FujisawaMasato Fujisawa More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)60809-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "LONG-TERM OUTCOMES OF ORTHOTOPIC NEOBLADDER RECONSTRUCTION AFTER RADICAL CYSTECTOMY FOR BLADDER CANCER IN JAPANESE MEN: ASSESSMENT OF COMPLICATIONS, VOIDING PATTERNS AND QUALITY OF LIFE." The Journal of Urology, 181(4S), p. 284 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 284 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Hideaki Miyake More articles by this author Junya Furukawa More articles by this author Atsushi Takenaka More articles by this author Sadao Kamidono More articles by this author Masato Fujisawa More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term follow up (37–69years) of patients with bladder exstrophy treated with ureterosigmoidostomy: Uro-nephrological outcome

To describe the urological and nephrological long-term outcome of patients born with classical bladder exstrophy treated with bilateral ureterosigmoidostomies in early childhood. Out of 42 patients born with bladder exstrophy in Switzerland between 1937 and 1968, 25 participated in this study; seven had died, seven were lost to follow up and three refused consent. Assessment included chart review, clinical examination, and assessment of renal function and morphology. After a follow-up period of 37-69 years ((mean 50 years), 13 of the 25 participants (52%) had their ureterosigmoidostomy still in place. All others had different forms of urinary diversions. Fifteen (60%) patients had normal renal function or mild chronic kidney disease as assessed by estimated glomerular filtration rate. Three patients were on renal replacement therapy. MRI (n=16) showed 10 morphologically normal kidneys. One patient suffered from adenocarcinoma of the colon, five had benign colonic polyps, one urethral papillary carcinoma and 18 no evidence of tumor. The majority of our patients have normal or mildly impaired renal function and a well functioning ureterosigmoidostomy. This is remarkable, given the fact that ureterosigmoidostomies are considered to be refluxing high-pressure reservoirs at risk of renal injury and malignancy.

Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders

Orthotopic neobladder reconstruction has become a standard form of urinary diversion in many centers for patients undergoing radical cystectomy for bladder cancer. There is still controversy about the best technique for construction of the neobladder, and especially whether it is necessary to include an antireflux mechanism. We designed a prospective randomized clinical trial comparing two forms of ileal neobladder: the Studer pouch and the T-pouch. The latter includes an extraserosal tunneled afferent limb which prevents reflux from the pouch to the kidneys. The primary endpoint of the study is renal function and anatomy at 3 years following surgery, with secondary endpoints including early and late postoperative complications, renal infections and need for secondary procedures. To date we have randomized 462 patients over approximately 6 years, with a planned full enrollment of 550 patients. Ten percent of patients have been withdrawn because they did not undergo the planned orthotopic diversion due to a positive urethral margin on frozen section. We expect approximately 70% of patients to be alive and available for follow-up at 3 years, which will give us ample power to detect clinically meaningful differences in the outcome of these two diversions. This trial has been feasible and randomization has been acceptable to most patients. Long-term follow-up of the patients on this trial should be able to definitively answer the question of the importance of an antireflux mechanism in the orthotopic neobladders construction.

Change of Ureteral Submucosal Anti-reflux Implantation into an Intussuscepted Ileal Nipple Valve as Reflux Protection in Ureterosigmoidostomy

After submucosal implantation of the ureters in ureterosigmoidostomy failed for different reasons, urologists are confronted with the task of creating a new form of urinary diversion. Therefore, the implantation site of the ureters must be removed because of the risk of secondary malignancy with the consequences of a large colonic defect. Here we describe a technique for reimplantation of both ureters with an intussuscepted ileal nipple in ureterosigmoidostomy with three advantages for the patient in situations in which classical submucosal implantation failed after several years. We were able to avoid conversion into another form of incontinent or continent urinary diversion. To prevent the development of colonic tumors at the implantation site where urothelial meets colonic epithelium, we interposed an ileal segment which avoids this epithelial contact. We were also able to cover a large colonic defect which was mandatory to receive a negative surgical margin when the tumor was resected. This technique of using an ileal nipple as reflux protection in ureterosigmoidostomy allows the patient to keep the form of urinary diversion he is used to live with, for many decades.

Reconstruction of urethral injuries

To highlight the complexity of urethral injuries and to emphasise their prevention. A retrospective study. Coast Province General Hospital, Mombasa, Kenya. Twenty two male patients operated between 1997 and 2007. Surgery for urethral injuries was done on 22 patients; 16 were of the posterior urethra, five bulbar urethra and one proximal penile urethra. The posterior urethral injuries were due to: pelvic fracture in 14, penetrating stick in one, and one animal injury by a buffalo. The bulbar urethral injuries were due to straddle injuries in four and one gunshot injury. The penile urethral injury was by compression of the subject by a motor vehicle against a wall. Anastomotic urethroplasty was performed in 20 patients, of whom 16 had complete recovery. Surgery for all bulbar and the penile urethral injuries was successful. Failure of repair with restenosis occurred in four patients with posterior urethral injuries. Bouginage was done in one patient who subsequently required no further treatment. Eventual total obliteration occurred in three patients. Reoperation was done in two of these with complete recovery in one and failure in the other who had two further urethroplasties, optical urethrotomy and is currently on clean intermittent self catheterisation. The fourth patient awaits reoperation. Sutureless membranous urethroplasty was done in two patients with posterior urethral injuries in whom sutures could not be inserted into the proximal prostatic urethra. One developed stenosis a year later, had optical urethrotomy and commenced on clean intermittent self catheterisation for a while, without further trouble. The other developed total obliteration. At repeat surgery enhanced scarring with urethral shortening were found and the operation was abandoned. The Mitrofanoff principle was applied with an appendicovesicostomy; one form of urinary diversion with a continent catheterisable conduit. On follow up, now nine years, the diversion is continent, has no catheterisation difficulties, and no urinary calculi. Urethral injuries are difficult to manage. A two pronged approach is advanced; prevention and competent repair. Surgeons managing these injuries are encouraged to acquire the needed reconstruction skills. Emphasis on prevention is paramount. Appropriate road, industrial and occupational safety measures should be enforced. Iatrogenic injuries can be avoided by due care during catheterisation and urethral instrumentation.

Formen der operativen Harnableitung: Methoden und bildgebende Diagnostik

After cystectomy two principal types of urinary diversion are used for the surgical reconstruction of the urinary tract: incontinent and continent. In the continent type of urinary diversion, a differentiation must be made between those with and without catheterization for voiding. Besides urothelial cancer other reasons for urinary diversion include neurogenic bladder palsy (connatal or acquired) due to meningomyelocele or connatal diseases like bladder exstrophy. The main objective of the clinical urologist when selecting urinary diversion are to achieve continence and to preserve upper urinary tract function. Knowledge of the different forms of urinary diversion is critical for the exact interpretation of the images. This review presents the typical imaging techniques after a description of the basic surgical features of urinary diversion. CT urography and MR urography are becoming increasingly important as further imaging tools for controlling urinary diversions.

Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer

Radical cystectomy with an appropriate lymph node dissection and an appropriate form of urinary diversion is the standard treatment for muscle-invasive transitional cell carcinoma of the bladder. Optimal outcomes following radical cystectomy require an extended lymph node dissection, negative surgical margins, and a continent urinary diversion. There has been an increasing number of reports describing initial experiences with laparoscopic radical cystectomy. Intermediate and long-term oncologic outcomes with laparoscopic radical cystectomy remain undefined, and appropriate lymph node dissections laparoscopically have not been uniformly performed. Furthermore, the long-term functional outcomes associated with laparoscopically performed urinary diversions also remain undefined. There appears to be a recent trend toward performing the urinary diversion portion of the procedure extracorporeally, after laparoscopic removal of the bladder. Some studies suggest a decrease in postoperative analgesic requirements and quicker recovery of bowel function in those undergoing laparoscopic radical cystectomy, but these observations have not been corroborated by others. In the absence of long-term functional and oncologic outcome data, laparoscopic radical cystectomy should be considered an investigative technique, and potential candidates for this operation should be appropriately counseled.

Clinical outcome of tubeless cutaneous ureterostomy by the Toyoda method

Cutaneous ureterostomy is the least invasive method of urinary diversion, but it carries a risk of stomal stenosis. We retrospectively examined the long-term outcome of tubeless cutaneous ureterostomy by the Toyoda method. Since 1983, the Toyoda cutaneous ureterostomy has been performed in 97 patients (169 renal units) with a minimum follow up of 3 months. The ureteral patency rate was reviewed according to whether the stomal type was single (one ureter, one stoma) or double-barrel (two ureters, one stoma). After a median follow up of 23 months (range 3 to 169), a tubeless condition was achieved in 102 (82%) of 124 renal units associated with double-barrel stoma and in 35 (78%) of 45 renal units associated with single stoma. Although mild to moderate hydronephrosis was observed in 19% of patients, serum creatinine levels did not change after a minimum of 12 months after surgery (median 35). A high ureteral patency rate was achieved with cutaneous ureterostomy using the Toyoda method. This procedure, especially double-barrel stomal creation, is a reasonable alternative to other forms of urinary diversion in patients at high risk.