Lower Urinary Tract Reconstruction Research Articles

Pregnancy After Lower Urinary Tract Reconstruction in Women

Purpose We determined if pregnant women with reconstructed lower urinary tracts experience complications related to the urological reconstruction. Materials and Methods A total of 27 women (34 pregnancies) with reconstructed lower urinary tracts underwent regular urinalysis, blood biochemistry studies and ultrasound examinations during pregnancy and for a minimum of 1 year after delivery. Results There were 28 normal, full-term vaginal deliveries without complication. a total of 6 patients underwent cesarean section, with injury to the vascular pedicle of the cystoplasty without sequelae occurring in 1. Temporary postpartum incontinence occurred in 6 patients. Conclusions Patients with reconstructed lower urinary tracts can experienced normal deliveries but require close surveillance. The route of delivery should be determined by obstetrical indications.

Indications for Lower Urinary Tract Reconstruction in Women After Cystectomy for Bladder Cancer

Indications for Lower Urinary Tract Reconstruction in Women After Cystectomy for Bladder Cancer

Stomach in Combination with Other Intestinal Segments in Pediatric Lower Urinary Tract Reconstruction

Stomach in Combination with Other Intestinal Segments in Pediatric Lower Urinary Tract Reconstruction

The social implications of lower urinary tract reconstruction performed during childhood

To compare the social effects of urinary diversion, undiversion and orthotopic bladder reconstruction performed during childhood. Of 99 patients treated at the Wessex Centre for Paediatric Surgery between 1960 and 1993, 46 (16 with a urinary diversion, eight with an undiversion and 22 with bladder reconstruction) were interviewed using a standardized questionnaire. Information was collected about the types and results of surgery, the medical support received and the social effects of the different treatments. By day, continence or only occasional wetting was achieved in 13 patients with diversions, all those with undiversions and 16 of those with reconstructions. At night, 13 patients with diversions, seven with undiversions and 18 with reconstructions were dry or only occasionally wet. Re-operation rates were higher in those with reconstruction and undiversion. Only five of the diversion group were satisfied with their management compared to all patients in the other two groups. The social effects in terms of employment, schooling, independence, body image and social interactions were also better in those with undiversions and reconstructions. The social effects of undiversion and bladder reconstruction were better than those following urinary diversion despite the higher re-operation rates and the need for a rigid regimen of post-operative care. However, the need for continuing medical support in this group of patients cannot be over emphasized, and the vital role of the urological nurse specialist is stressed.

Experience in 100 Patients with an Ileal Low Pressure Bladder Substitute Combined with an Afferent Tubular Isoperistaltic Segment

Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an afferent ileal tubular segment. The early complication rate was 11 percent, including 2 postoperative deaths due to septicemia. After a median followup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor recurrence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urinary continence. After 1 year 92 percent of the patients were continent by day and after 2 years 80 percent were continent at night. Upper tract surveillance with excretory urography, renal ultrasound and serum creatinine estimation has shown 4 left ureteral strictures but no significant upper tract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder, no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pressure reservoir with an afferent isoperistaltic ileal segment and an open end-to-side ureteroileal anastomosis allows for radical cancer surgery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional peristalsis of the ureters and the afferent tubular ileal segment seem to protect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are comparable to other similar reservoir techniques, provided that the patients are carefully selected, well rehabilitated and meticulously followed.

Radical Cystectomy and Lower Urinary Tract Reconstruction After Cardiac Allograft Transplantation

The risk of a malignancy developing as a consequence of long-term immunosuppression after allograft transplantation is well documented. To our knowledge we report on the first cardiac allograft recipient to undergo radical cystectomy with lower urinary tract reconstruction using a continent Kock ileal reservoir with bilateral ureteroileal urethrostomy for squamous cell carcinoma that developed 4 years after transplantation.

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.

Lower Urinary Tract Reconstruction Following Cystectomy In Women Using The Kock Ileal Reservoir With Bilateral Ureteroileal Urethrostomy: Initial Clinical Experience

Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.

Clinical experience of lower urinary tract reconstruction using a urethral Kock pouch.

The operative procedure used in the present series involved a nerve-sparing radical cystectomy, with anastomosis of the urethra using a pouch made of detubularized ileum. The 36 patients who underwent this operation were all male with an average age of 58. No deaths resulted from the operation. As far as late complications were concerned, malfunction of the antireflux nipple valve was noted in 1 patient and stenosis occurred between the urethra and pouch in 2. One patient was found to have multiple stones in the pouch and reservoir decompensation was recognized in 2. Thus, the late complication rate was 17%. There were no cases of total incontinence, but nocturnal incontinence appeared in 11 out of 31 (35%). A total of 20 out of 25 patients (80%) recovered their erectile function during the postoperative follow-up period and the disease-free survival rate at 5 years was 78%. Therefore, the urethral Kock pouch combined with nerve-sparing cystectomy has proved to be a useful procedure as far as the quality of life is concerned.

New Intra-Ureteral Stent for Use during Reconstructive Surgery

This paper describes a stent which has been specifically designed to facilitate the identification of the ureters during lower urinary tract reconstruction. It has semi-rigid limbs which allow easy ureteric identification and a soft central portion which lies across the trigone without traumatising the ureteric orifices.

Lower urinary tract reconstruction using stomach and the artificial sphincter : G.S. Ganesan, D.H. Nguyen, M.C. Adams, et al. J Urol 149:1107–1109, (May), 1993

Lower urinary tract reconstruction using stomach and the artificial sphincter : G.S. Ganesan, D.H. Nguyen, M.C. Adams, et al. J Urol 149:1107–1109, (May), 1993

The Mitrofanoff principle for urethral failure.

To assess the outcome of surgery for urethral failure. Patients undergoing lower urinary tract reconstruction are recorded prospectively by protocol. Thirty-four are presented whose urethra had failed as a conduit; in 23 the urethra was incontinent and in 11 it was spastic causing chronic retention. The incontinent patients had failed a variety of reconstructions, in five including insertion of an artificial sphincter. Those with chronic retention were unable to self-catheterize the urethra. A continent supra-public diversion using the Mitrofanoff principle was performed. In two patients a new technique was used in which a detrusor tube formed the continent conduit. Ninety-four per cent of patients were continent. Two patients voided to completion, the remainder emptied by self-catheterization. Five minor revisions were required to allow easy catheterization. There was one death. The complication rate was 17%. This type of reconstruction is preferable to the formation of an ileal conduit in this difficult group of patients.

Yang Needle Tunneling Technique in Creating Antireflux and Continent Mechanisms

A total of 7 patients underwent cystectomy due to bladder malignancy and the ileum was used for lower urinary tract reconstruction (5 underwent bladder substitutions, 1 an internal ileal reservoir and 1 ileal conduit diversion). Antireflux mechanisms were created by submucosally tunneled ureters and in 1 case the continent mechanism was created by a submucosally tunneled ileal tube. In all cases the Yang needle was used, which consists of a needle portion and a forceps portion. The selected position of the ileum for ureteral and ileal tube implantation is injected with normal saline submucosally to form a wheal. The Yang needle is introduced submucosally, guided under the wheal for a certain distance and then directed through the ileal wall. Smooth dilation of the tunnel is achieved with the dilated portion of the needle without laceration of the mucosa. The needle portion is then removed. The ureter or ileal tube is grasped by the forceps portion of the needle and brought through the tunnel to the mucosal side of the ileal plate, followed by mucosa-to-mucosa anastomosis.For all 14 ureteral implantations only 1 ureter had reflux on postoperative radiographic studies and only 1 of 4 hydroureters remained. No additional obstructive lesions or pyelonephritis was noted postoperatively. The patient whose continent mechanism is formed by the submucosal tunneled ileal tube method is continent and free of an appliance. The Yang needle tunneling technique may be a choice in the creation of antireflux and continent mechanisms.

The Ileal Neobladder: 6 Years of Experience with more than 200 Patients

Between April 1986 and April 1992, 211 consecutive men underwent lower urinary tract reconstruction by means of the ileal neobladder. There have been 5 perioperative deaths for an operative mortality rate of 2.4%. The early complication rate for issues not directly related to the neobladder was 7.5% compared to a 6.5% directly neobladder-related early reoperation rate. Neobladder-related late complications requiring rehospitalization or reoperation have been acceptable, including ileus (2%), abscess (1%), colon-reservoir fistula (1.5%), hydronephrosis (1%), ureteral stenosis (3.6%) and transurethral incision of the urethroileal anastomosis (7%). Overall, only 29.3% of our patients had no complication, whereas 32% suffered significant problems requiring rehospitalization or reoperation. The remainder of the patients suffered minor but not negligible problems.Excellent continence was achieved early and increased with time: 85% of the patients were perfectly dry night and day by 3 years. At this date only 5.5% of the patients had nighttime incontinence, while 6% wear protection for occasional accidents. Intermittent catheterization is necessary in 3.5% of the patients because of the inability to void or maintain a post-void residual volume of less than 100ml. Despite the fact that some price must be paid for excellent continence, natural voiding and undisturbed body image, the ileal neobladder continues to be our procedure of choice for male patients after cystectomy provided there is no evidence of prostatic or urethral involvement. Our results should stimulate earlier patient and physician acceptance of cystectomy.

Lower Urinary Tract Reconstruction Using Stomach and the Artificial Sphincter

We implanted the artificial urinary sphincter at gastrocystoplasty in 13 male and 5 female patients. The diagnoses were classical bladder exstrophy (8 patients), myelodysplasia (8), cloacal exstrophy (1) and bilateral ectopic ureters (1). Mean patient age was 14.3 years (range 7 to 32.5). Six patients (5 with bladder exstrophy and 1 with cloacal exstrophy) had failed bladder neck continence procedures, 3 myelodysplastic patients had failed artificial urinary sphincter placement, and 1 exstrophy patient had failed a Young-Dees bladder neck repair and artificial urinary sphincter placement. The sphincter cuff was placed around the reconstructed bladder neck in these patients, while in the remainder the artificial urinary sphincter was placed around the intact bladder neck. Mean followup was 20.3 months (range 1 to 5). Of the patients 16 (88%) are continent day and night, while 2 are wet. A total of 11 patients (61%) use Valsalva’s maneuver alone for voiding and the remainder use Valsalva’s maneuver and/or clean intermittent catheterization for bladder evacuation. Complications related to the artificial urinary sphincter were recurrent pump erosion requiring conversion to a Mitrofanoff continent stoma in 1 patient, and mechanical dysfunction requiring pump cuff and reservoir replacement in 3. There were no complications due to infection. Our report demonstrates that the combination of augmentation gastrocystoplasty and an artificial urinary sphincter leads to urinary continence and can allow for spontaneous urination. The rate of infectious complications is not increased when the 2 procedures are combined simultaneously.

Vitamin B12 Deficiency in Patients with Ileocolic Neobladders

The terminal ileum is widely used for reconstruction of the lower urinary tract. Since the terminal ileum exclusively absorbs vitamin B12, removal of ileum from the gastrointestinal tract for use in lower urinary tract reconstruction may predispose patients to vitamin B12 deficiency. In a prospective study serial vitamin B12 levels were obtained postoperatively in 24 patients who underwent cystectomy for malignancy and ileocolic neobladder urinary diversion with a mean followup of 25 months (range 6 to 53). Any patient who had a low vitamin B12 serum level (less than 200pg./ml.) underwent a Schilling test to confirm malabsorptive vitamin B12 deficiency. Six patients (25%) had low serum vitamin B12 levels, of whom 3 (13%) had an abnormal Schilling test. No patient had megaloblastic anemia. One patient with malabsorptive vitamin B12 deficiency had neurological symptoms 53 months postoperatively. We conclude that vitamin B12 deficiency can occur following ileocolic neobladder reconstruction. Patients with true vitamin B12 deficiency should be identified and placed on lifelong parenteral vitamin B12.

Lower urinary tract reconstruction in young patients.

Lower urinary tract reconstruction in young patients.

Reconstruction of the lower urinary tract for neurogenic bladder: lessons from the adolescent age group.

Of 42 adolescents with neurogenic bladder who presented for lower urinary tract reconstruction, 4 patients with severe spina bifida were unfit for major surgery. Five patients had a simple undiversion; 4 of these had a poor outcome because of unpredicted sphincter incontinence (1 patient) or instability (3). A total of 26 patients had an enterocystoplasty. All 7 patients who had a substitution cystoplasty had a good result, as did 3 males with a clam cystoplasty. Nine of 16 females had a poor result from a clam procedure. In 3 the problem lay with self-catheterisation difficulties. One each had persistent hyper-reflexia and sphincter incontinence. Four had hyper-reflexia on sexual intercourse. Overall, 42% of females had problems from the retained bladder segment. Seven patients had continent urinary diversions. The results were good, although 2 Kock nipples required revision. Surgery was well tolerated. There was a 21% re-operation rate for complications. Pre-operative investigation correctly predicted sphincter competence and the need for self-catheterisation in 79 and 86% respectively.

Surgical management of duplex ureteroceles

We reviewed the cases of 95 children with duplex ureteroceles treated in this department over an 18-year period. There were 101 ureteroceles (6 bilateral). Diagnosis and treatment were analyzed. Special attention was paid to newborns screened in utero. We always strove to preserve functional renal tissue whenever possible. In keeping with this goal, three surgical techniques were used: (1) upper pole heminephrectomy; (2) ureterocele excision, bladder neck reconstruction, and ureter reimplantation with or without cutaneous ureterostomy of the upper pole ureter; and (3) endoscopic ureterocele incision. Follow-up studies using x-ray and radionuclide imaging demonstrated satisfactory renal function in 86.6% of patients. These findings support a conservative approach to ureteroceles using endoscopic ureterocele incision as the primary treatment. Lower urinary tract reconstruction may be associated in cases involving urinary tract infection, obstruction or incontinence. Upper pole heminephrectomy should be performed only after functional evaluation following ureterocele incision or cutaneous ureterostomy.

Lower Urinary Tract Reconstruction following Cystectomy: Experience and Results in 126 Patients using the Kock Ileal Reservoir with Bilateral Ureteroileal Urethrostomy

Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patient acceptance with few late complications or need for reoperation.