Indications For Urinary Diversion Research Articles

Imaging in nephroureterolithasis

In the acute diagnostics of a suspected nephroureterolithiasis, ultrasonography should be the examination modality of choice. In cases of suspected urolithiasis, unclear flank pain with fever or in cases of asolitary kidney, anoncontrast computed tomography (CT) scan should always subsequently be performed. If the sonography findings are inconclusive in pregnant women a magnetic resonance imaging (MRI) examination can be considered. If there are indications for urinary diversion, aretrograde imaging study should be performed as part of the urinary diversion. This or CT imaging is also suitable for preinterventional imaging before shock wave lithotripsy, percutaneous nephrolithotomy or ureteroscopy. Postinterventional imaging is not always necessary and sonography is often sufficient. In aconservative treatment approach an abdominal plain X‑ray can be used for follow-up assessment.

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.

Yang-Monti’s Catheterizable Stoma in Children

BackgroundIn 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization.ObjectivesWe report on our experience from the use of Monti’s procedure in children at our center.Patients and MethodsChildren < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti’s procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence.ResultsDuring the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti’s catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter.ConclusionsAlthough the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.

Diagnostische Nierenbeckenpunktion

There are individual cases especially of elderly or palliative patients with hydronephrosis and non-specific fever where a urinary diversion should be avoided in favor of quality of life. For these purposes this study presents the method and the results obtained with a diagnostic puncture of the renal pelvis. Demographic data, indications for urinary diversion and the disease leading to hydronephrosis were retrospectively recorded from the operation reports of all percutanous nephrostomy procedures from 2007 to 2012. All cases in which a diagnostic puncture of the renal pelvis was conducted to potentially avoid placing a nephrostomy tube were considered separately. From January 2007 to May 2012 a total of 476 percutanous nephrostomies were accomplished in this department. The most frequent indication for nephrostomy was acute renal failure in 55.3% of cases followed by septic laboratory constellations (33.1%) and colic (10.9%). Of the 148 cases of hydronephrosis combined with sepsis, a diagnostic puncture of the renal pelvis was accomplished in 20.1%. In these cases the hydronephrosis had an underlying urological origin in 71.0%, reaching statistical significance with reference to the complete collective (p=0.034). In 21 out of 34 nephrology units (61.8%) it was possible to avoid nephrostomy due to clear urine and immediate urinanalysis without any evidence for infection. In the other cases a nephrostomy tube was placed. Using a diagnostic puncture of the renal pelvis a nephrostomy could be avoided in over 50% of cases with a combination of hydronephrosis and non-specific fever in favor of quality of life.

V1709 ROLE OF LAPAROSCOPY IN URINARY DIVERSION IN CHILDREN: DESCRIPTION OF DIFFERENT URETEROSTOMY TECHNIQUES

You have accessJournal of UrologyPediatrics & Reconstruction1 Apr 2011V1709 ROLE OF LAPAROSCOPY IN URINARY DIVERSION IN CHILDREN: DESCRIPTION OF DIFFERENT URETEROSTOMY TECHNIQUES Yaser El-Hout, Tarek H. El-Ghazaly, and Walid A. Farhat Yaser El-HoutYaser El-Hout Toronto, Canada More articles by this author , Tarek H. El-GhazalyTarek H. El-Ghazaly Toronto, Canada More articles by this author , and Walid A. FarhatWalid A. Farhat Toronto, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.2034AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In pediatric urology, upper tract urinary diversion in the form of cutaneous ureterostomy may be clinically indicated as a temporizing procedure whenever the definitive reconstructive surgery has to be delayed for technical or clinical considerations. With expansion of the application of pediatric minimally invasive approaches, performing laparoscopic urinary diversion is an attractive alternative, owing to better visualization and limited dissection, hence a perceived decreased adhesions in the secondary definitive reconstruction. Herein, we describe two cases of laparoscopic ureterostomy, performed through different approaches:retroperitoneal and transperitoneal. METHODS This is a single center case study that reports on the clinical presentation, indications for urinary diversion, and description of surgical technique and short-term postoperative outcome on two pediatric patients that underwent retroperitoneoscopic unilateral cutaneous end ureterostomy and laparoscopic bilateral loop ureterostomies. RESULTS Retroperitoneal approach is ideal for unilateral ureterostomy creation, as it allows for direct access to the ureter along its entire course on the psoas. Transperitoneal approach is beneficial for bilateral creation, or whenever a diagnostic laparoscopy is clinically desired. In our reported patients, no intraoperative complications were encountered. Ultrasound and physical examination at three months follow-up confirmed upper tract decompression, stable renal function and patent stomas. CONCLUSIONS When indicated,minimally invasive urinary diversion, in the form of ureterostomies, is a feasible alternative in the pediatric population. Owing to the rarity of this entity, pediatric urologists may opt for this alternative in select patients. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e687 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yaser El-Hout Toronto, Canada More articles by this author Tarek H. El-Ghazaly Toronto, Canada More articles by this author Walid A. Farhat Toronto, Canada More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Laparoscopic Ureterocutaneostomy for Urinary Diversion in Selected Infants

Primary surgical correction has obviated the need for urinary diversion in many fields of pediatric obstructive and refluxive uropathy. However, a small number of children are not suitable for primary surgical correction and require temporary diversion. We present a small series of infants who underwent minimally invasive ureterocutaneostomy. Four infants (age 1-13 months) underwent laparoscopic ureterocutaneostomy. The indication for urinary diversion was a primary obstructive megaureter in 2 patients, deterioration of kidney function due to a posterior urethral valve in 1, and refluxive uropathy of a dysplastic single kidney in another. Laparoscopic ureteral diversion was performed using a 3 trocar technique. In 3 patients, both ureters were identified above the crossing of the iliac vessels and exteriorized through the right and left trocar incision respectively. A loop ureterocutaneostomy was performed in 3, and an end ureterocutaneostomy in 1 patient. Laparoscopic ureterocutaneostomy was feasible and there were no complications in any of the infants. The mean duration of operation was 111 minutes (range 85 to 145). Isotope renography after a mean follow-up of 11 months (range 2 to 16) revealed improved renal drainage in 3 infants, while 1 required kidney transplantation due to progressive renal insufficiency. Laparoscopic ureterocutaneostomy in infants is feasible. It may be considered in a selected group of patients with obstructive or refluxive uropathy in whom urinary diversion is required.

Mainz Pouch II technique: 10 years' experience.

To report the long-term results with the Mainz Pouch II procedure. Between 1990 and 2000 a Mainz Pouch II ureterosigmoidostomy was used in 123 patients (49 females and 74 males, mean age 43.6 years, range: 1-73). The indications for urinary diversion were cystectomy for bladder cancer in 92 patients, bladder exstrophy and/or incontinent epispadias in 26, irreparable traumatic loss of the sphincteric urethra in four and cloacal malformation (sinus urogenitalis) in one. In all, 102 patients with a follow-up of >/= 12 months were evaluated (mean 46.2 months). Day- and night-time continence rates were 97% and 95%, respectively. The remaining patients occasionally lose some drops of urine during coughing or straining, or reported minimal soiling of undergarments during the night. The mean voiding frequency was six during the day and once at night. There were 14 ureteric implantation stenoses (7.2% of 194 evaluated reno-ureteric units) and they were treated successfully by open repair (13) or antegrade balloon dilation (one). For metabolic disturbances, 69% of the patients had a capillary base excess of <-2.5 mmol/L and use oral alkalinizing drugs to prevent hyperchloraemic acidosis. There was no clinically evident metabolic acidosis. Applying the principles of detubularization and spherical reconfiguration to create a low-pressure reservoir and stratifying ureteric implantation between submucosal and serous-lined extramural tunnel techniques succeeded in giving better continence rates and long-term preservation of the upper urinary tract than a classical ureterosigmoidostomy. The Mainz Pouch II ureterosigmoidostomy is simple and reliable as a viable alternative for continent urinary diversion in selected patients.

Physiological principles for surgical correction of detrusor dysfunction.

Urinary incontinence may be the result of various forms of detrusor overactivity. Several surgical therapies have been devised, but with the exception of procedures to relieve urethral obstruction, none abolishes the overactivity or restores normal micturition. In general, ablative neurosurgery is considered only in patients with chronic neurologic disease. Bladder augmentation is useful in selected patients. The indications for urinary diversion in patients with detrusor overactivity and urge incontinence are quite limited.

Continent diversion with the Mainz pouch.

From 1983 until July 1994, 561 patients in 2 urology departments (Mainz and Wuppertal) underwent a Mainz pouch 1 procedure. The Mainz pouch 1 was used for bladder augmentation in 60 patients, for orthotopic bladder substitution in 61 patients, and for continent cutaneous urinary diversion in 440 patients. In the group of continent cutaneous urinary diversion, the continence mechanism applied was an ileal intussusception nipple in 270 patients, an appendix stoma in 146 patients, a submucosal seromuscular bowel-flap tube in 14 patients, and a submucosal full-thickness bowel-flap tube in 10 patients. Indications for urinary diversion were bladder cancer in 339 patients, anatomical or functional loss of bladder capacity in 179 patients, and other primary or secondary malignancies of the bladder or true pelvis in 43 patients. After a mean follow-up period of 57 months (range, 3-127 months), early and late complications were encountered in 12% and 37% of the patients, respectively. In the bladder-augmentation group, 93% of the patients are completely continent day and night. All but three patients, who empty their reservoir by intermittent self-catheterization (CIC), void spontaneously by abdominal straining. In the orthotopic bladder-substitution group, 95% of the patients are continent during the daytime. To prevent urinary leakage, 13% have to empty their reservoirs regularly at 4-h intervals and 13% have to perform CIC to avoid residual urine. Among the patients treated with continent cutaneous urinary diversion, stoma failure occurred in 11%, stoma stenosis was encountered in 13% and required open revision in 2%, endoscopical incision in 10%, and conservative treatment (dilation) in 1% of cases.

Current indications for cutaneousureterostomy

Objective To assess the current indications for cutaneous ureterostomy in children. Method A total of 32 children underwent cutaneous ureterostomy at Texas Children'sHospital from 1975 to 1990. Medical records were reviewed to determine the urologic diagnosis, the indication for urinary diversion, the type of ureterostomy performed, and the outcome for each patient. Results Twenty patients underwent loop cutaneous ureterostomy (LCU) or pyelostomy and 12 patients underwent end cutaneous ureterostomy (ECU). The main indication for LCU was obstructive uropathy unresponsive to lower urinary tract drainage, and the most common cause was posterior urethral valves. Other indications for LCU included obstruction requiring delayed surgical correction, high-grade reflux into a solitary kidney, and obstruction with infection. The children who required ECU were an older, more diverse group than those who underwent LCU. The main indication for ECU was poor bladder function secondary to a variety of congenital anomalies, including prune-belly syndrome, posterior urethral valves, bladder exstrophy, and urogenital sinus defect. Conclusion LCU is easy to perform and is an excellent method for achieving temporaryupper urinary tract drainage. ECU is suited for long-term or permanent urinary diversion in children with at least one dilated ureter, and can provide a socially acceptable stoma when delayed reconstruction is necessary. Many children who were “permanently” diverted by ECU may be undiverted using newer reconstructive techniques.

Pediatric urinary diversion: review and own experience.

New insights into the diseases of childhood, profound improvements and new developments in surgical techniques as well as the knowledge gained from long-term follow-up have altered the strategies and indications for urinary diversion in childhood. Continent urinary diversion is generally the method of choice. We are able to construct high capacity, low pressure reservoirs to protect the upper urinary tract and achieve continence. Nowadays, there is hardly any indication for permanent cutaneous urinary diversion. Temporary and intermediate cutaneous diversion are used only when serious conditions such as renal function deterioration occur. The possibility to convert any incontinent form of urinary diversion into a continent form changed the status of intermediate diversion. The indications for urinary diversion, the procedures available, the operative technique, a literature review, our own experience, contemporary strategies and controversies are described and discussed.

Ileal and Jejunal Conduit Urinary Diversion

The indications for urinary diversion have changed in recent years, and it is most often required in association with radical surgery for pelvic malignancies. Many patient with lower urinary tract dysfunction can be managed satisfactorily without diversion by use of intermittent catheterization, administration of specific pharmacologic agents, and, when necessary, implantation of artificial sphincters. For patients who require urinary diversion, the ureteroileal conduit remains the standard by which other methods should be judged. If satisfactory results are to be obtained, it is clear that meticulous attention to indications, operative technique, and careful follow-up are essential. As many of these patients have other disabilities, the management of the urinary tract must be integrated with other aspects of patient care. The introduction of the colonic conduit and recently the continent types of urinary diversion represent a search for the ideal method that has yet to be achieved.

Fallbericht: Perkutane Nephrostomieund und instrumentelle Steinentfernung in Lokalanästhesie

Percutaneous nephrostomy under ultrasonic guidance is a reliable method for suprapublic urinary diversion with a low complication rate. Indications are acute or chronic obstruction of the upper urinary tract from the intravesical ureter to the neck of renal calyx. Etiology of the obstruction may be a renal or ureteral calculus, an intrinsic or extrinsic (radiogenic, inflammatory, tumorous) stenosis of the ureter or a functional ureteral obstruction (megaureter, reflux). In the reported case of an ultrasonically guided percutaneous nephrostomy, the indication for urinary diversion was blocking renal calculus with urosepsis. Any operative procedure was contraindicated because of several internal disease. With sufficient urinary drainage, fever subsided and gradual dilatation of the nephrostomy channel with instrumental extraction of the calculus could be performed under local anesthesia. Percutaneous nephrostomy is recommended for urinary diversion in cases of blocking renal calculi with infection if an operation cannot be performed. This approach bears the option of a later cure by intrumental extraction, litholypaxy or chemical dissolution of the stone.

Urinary continence in open myelomeningocele.

In a consecutive series of 200 neonates having undergone surgery for open myelomeningocele, 24 of the 106 survivors at 10 to 12 years of age proved to be continent of urine. These figures included 11 children who had considerable neurological involvement. 4 children did not acquire urinary control until after the age of 5 years. Therefore, we consider early urinary diversion in children with myelomeningocele, even in the presence of neurological deficit, to be indicated only for the prevention of progressive deterioration in renal function. Incontinence of urine itself is not an indication for urinary diversion in the first decade of life.

Urinary Diversion and Undiversion in Children

The indications for urinary diversion have decreased in the past few years since other alternatives have developed. Long-term observation will show the non-refluxing colon conduit to be better than the ileal loop, although 15 years must pass to be certain of that.

Indications for Diversion of the Urinary Stream

Diversion of the urinary stream is required when the bladder has to be removed, usually for cancer, or is unable to function as an adequate urinary reservoir. The lesions which call for diversion fall into three categories: Malignant Disease.—Total cystectomy for bladder cancer necessitates urinary diversion. Diversion may also prove a useful palliative for patients with advanced inoperable bladder cancer suffering intolerable frequency and strangury. Other indications are as follows: when cystectomy is needed because of severe and persistent bladder hemorrhage after x-ray therapy and when uncontrollable irradiation cystitis follows x-ray therapy to the uterine cervix, for carcinoma of the female urethra prior to irradiation or surgical extirpation, as a palliative for malignant rectovesicovaginal fistula, and for ureteric obstruction due to pelvic malignancy Congenital Anomalies.—Ectopic vesicae continue to be dominant indications for urinary diversion, as plastic procedures have so far yielded only minimum success in providing

Indications for urinary diversion in children.

Indications for urinary diversion in children.

Palliative urinary diversion in patients with advanced carcinoma of the cervix.

During a 10-year period 47 of 222 patients with advanced carcinoma of the cervix admitted to the Francis Delafield Hospital had ureteral obstruction on initial admission. All but 3 of the 47 patients were treated with roentgen rays and/or radium; the exceptions underwent radical surgery. Twelve patients underwent palliative urinary diversion. There was no statistical significant difference in the survival rates of the patients who underwent urinary diversion and those who did not, irrespective of the stage of the disease and whether one or both ureters were involved; however, 8 of the 12 patients who underwent urinary diversion had partial relief of their symptoms. The indications for urinary diversion followed by the authors are ennumerated.