Mainz Pouch Research Articles

A Propensity Score-Based Comparison regarding Renal, Functional, and Surgical Outcome of Continent Cutaneous Urinary Diversions in Patients with Benign Chronic Bladder Diseases and Patients with Bladder Cancer.

Continent cutaneous urinary diversion post-cystectomy is an established approach addressing both oncological and functional indications. However, there is a noticeable gap of evidence when it comes to comparing outcomes between these indications, especially concerning the technique of Mainz pouch I (MPI). This study aimed to close the gap by analyzing the long-term functional and renal outcomes of patients with MPI after cystectomy due to both benign and malign bladder pathologies. In this retrospective study, we examined 173 patients, who underwent MPI surgery between 2000 and 2022. Patients were categorized into a study group (benign conditions, n = 26) and a control group (bladder cancer, n = 52) using propensity score matching. Clinical demographics, surgical outcomes, and functional/renal parameters were analyzed using unpaired t tests and χ2 tests. Patients undergoing cystectomy with MPI due to benign bladder pathologies were significantly younger and had a lower comorbidity burden compared to those with bladder cancer. In contrast to a significantly higher incidence of chemotherapy in the oncological cohort, the long-term renal function was comparable between both populations. Surgical outcomes, revisions, and postoperative complications did not differ significantly between both groups. Nearly 90% of patients in both groups showed full continence. This study demonstrates the efficacy and safety of MPI surgery in both benign and malignant conditions, proving favorable long-term renal and functional outcomes.

Multicenter evaluation of complex urinary diversion for renal transplantation: outcomes of complex surgical solutions

PurposeAn abnormal lower urinary tract poses significant challenges for transplant surgeons. Besides the ureteral anastomosis to an ileal conduit, there are diverse complex reconstructive solutions. Due to its rarity, standardization and teaching of complex urinary diversion is extremely difficult.MethodsThe indications and outcomes of complex urinary diversions after kidney transplantation (KT) were retrospectively investigated at eight urologic transplant centers including a current follow-up.ResultsOf 37 patients with 21 (56%) males, vesicoureteral reflux (24%), spina bifida (22%), and glomerulonephritis (12%) were the most common causes of terminal renal failure. In 30 (81%) patients, urinary diversion was performed before KT, at a median of 107.5 (range, 10; 545) months before. Transplantations were held at a median patient age of 43 (10; 68) years, including six (16%) living donations. Urinary diversion was modified during 12 (32%) transplantations. After KT, the ileal conduit was the most common incontinent urinary diversion in 25 (67%) patients; a Mainz pouch I and bladder augmentation were the most frequent continent diversions (each n = 3). At a median follow-up of 120 months (range 0; 444), 12 (32%) patients had a graft failure with a 5-year graft survival of 79% (95%CI 61; 90). The median overall survival was 227 months (168; 286) and the 5-year overall survival 89% (69.3; 96.4).ConclusionThe mid-term kidney transplant function with complex urinary diversion appears to be comparable to transplants with regular urinary diversions. Hence, complex urinary diversion should always be considered as a surgical option, even during transplantation, if necessary.

Perioperative outcomes and continence following robotic-assisted radical cystectomy with mainz pouch II urinary diversion in patients with bladder cancer

PurposeTo present the widely unknown perioperative outcomes and continence status of bladder cancer patients following robotic-assisted radical cystectomy (RARC) with Mainz pouch II urinary diversion (UD).Materials and methodsFrom November 2020 to December 2023, 37 bladder cancer patients who underwent RARC with Mainz pouch II UD were retrospectively assessed (ChiCTR2300070279). The results, which included patient demographics, perioperative data, continence, and complications (early ≤ 30 days and late ≤ 30 days) were reported using the RC-pentafecta criteria. RC-pentafecta criteria included ≥ 16 lymph nodes removed, negative soft tissue surgical margins, absence of major (Grade III–IV) complication at 90 days, absence of clinical recurrence at ≤ 12 months, and absence of long-term UD-related sequelae. A numeric rating scale assessed patient satisfaction with urinary continence 30 days after surgery. The validated Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire was used to evaluate bowel function. The Kaplan-Meier curve was used to evaluate overall survival (OS).ResultsOf the 37 patients evaluated over a median (range) follow-up period of 23.0 (12.0-36.5) months. The median (range) age was 65 (40–81) years. The median (range) time to urinary continence after surgery was 2.3 (1.5-6) months. Of the 37 patients, 31 (83.8%) were continent both during the day and at night, 34 (91.9%) were continent during the day, 32 (86.5%) were continent at night, 35 (94.6%) were satisfied with their urinary continence status, and 21 (56.8%) were very satisfied. The mean (range) voiding frequency was 6 (4–10) during the day and 3 (2-5.5) at night. The mean (range) PAC-SYM total score was 9.50 (4.00–15.00). In 12 (32.4%) of the patients, RC-pentafecta was achieved, and achieving RC-pentafecta was linked to better satisfaction scores (7.3 vs. 5.5, p = 0.034). There was no significant difference between RC-pentafecta and No RC-pentafecta groups in terms of OS (25.6 vs. 21.5 months, p = 0.16). 7 (19.4%) patients experienced late complications.ConclusionsMainz pouch II UD following RARC in bladder cancer patients results in a satisfactory continence rate. Achieving RC-pentafecta was correlated with better satisfaction scores. The intracorporeal approach to Mainz pouch II UD is beneficial for female patients due to its reduced invasiveness.Trial registrationChiCTR2300070279; Registration: 07/04/2023, Last updated version: 01/06/2023. Retrospectively registered.

The effect of urinary diversion on renal function after cystectomy for bladder cancer: comparison between ileal conduit, orthotopic ileal neobladder, and heterotopic ileocecal pouch.

To explore the impact of ileal conduit (IC), orthotopic ileal neobladder, and MAINZ Pouch I on renal function (RF) over time. We performed a retrospective, cohort study including consecutive patients who underwent open radical cystectomy due to bladder cancer from November 2013 to June 2022. RF deterioration was calculated based on the estimated glomerular filtration rate (eGFR) through the CKD-EPI creatinine equation. A linear mixed-effects model was constructed, adjusting for multiple risk factors. The probability of achieving an eGFR reduction greater than 25% compared to baseline among different urinary diversion techniques was assessed using a Kaplan-Meier curve. Overall, 107 patients received IC, 28 neobladder, and 20 MAINZ Pouch I. Those receiving IC were older and displayed more comorbidities. At follow-up, eGFR was lower by 0.09mL/min/1.73m2 (confidence interval -5.87 to 5.69, p = 0.975) in patients receiving neobladder compared to those receiving IC. Similarly, eGFR was higher by 4.64mL/min/1.73m2 (confidence interval -1.57 to 10.85, p = 0.143) in patients receiving pouch compared to those receiving IC. Accordingly, patients with higher preoperative eGFR (p < 0.001), lower age (p = 0.048), non-T4 histological tumor (p = 0.027) and absence of septicemia at follow-up (p = 0.002) presented higher eGFR values at follow-up. The three UD techniques did not differ significantly in the time-to-event analysis (log-rank test = 0.29). A substantial proportion of patients undergoing urinary diversion with IC, orthotopic ileal neobladder, or MAINZ Pouch I develop RF deterioration at follow-up. No significant differences were observed among the three UD techniques in terms of eGFR decline in the long-term.

Outcomes of Cystectomy with MAINZ Pouch II and Epispadias Repair in Exstrophy Epispadias Complex in Adults: A Single-centre Experience from Pakistan.

To evaluate surgical outcomes and renal functions after cystectomy + MAINZ Pouch II and epispadias repair as a staged procedure in adult patients with exstrophy epispadias complex (EEC). Descriptive study. Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2004 to December 2020. A total of 33 patients with EEC were treated. Out of which, 20 underwent cystectomy + MAINZ Pouch II with epispadias repair as a staged procedure. Out of these, 17 had a follow-up period of more than a year and were included in the study. The patients were followed up after 6 weeks of surgery, at 6 months, one year, and at the end of follow-up. The assessed variables included the patients' renal function tests, malignancy potential, morning erections, ejaculations, night emissions, day-and-night-time urinary frequency, and overall happiness of patients at the end of follow-up. The mean age was 25.1 ± 7.5 years and mean follow-up duration was 7.8 ± 5.2 years. Postoperatively, there was a rise in blood urea from 27.8 to 35.08 mg/dl with a concurrent fall in serum bicarbonate from a mean of 23.5 to 20.2 mEq/dl. All patients were continent during the day-time postoperatively; whereas, two patients experienced nocturnal enuresis. All male patients exhibited good erections and ejaculations, but there was persistence of dorsal chordae in 4 (23.3%) patients. All were delighted, happy and pleased with the surgical outcomes and had returned to normal life. No rectal or sigmoid malignancy was observed. In adult EEC patients, cystectomy + MAINZ Pouch II and epispadias repair is safe and effective. Key Words: Adults, Exstrophy epispadias complex, MAINZ pouch II, Pakistan.

Orthotopic MAINZ pouch bladder substitution - long-term follow-up.

IntroductionAfter radical cystectomy, orthotopic neobladder is one surgical strategy for urinary diversion. To assess the usefulness of an operation, long-term data are essential. We examined long-term complications and continence rates of orthotopic ileocecal (MAINZ pouch) bladder substitution.Material and methodsBetween 1986 and 2011, 193 patients underwent orthotopic MAINZ pouch bladder substitution. Until July 2000, ureter implantation was performed into the ascending colon through a submucosal tunnel technique (Goodwin-Hohenfellner). After July 2000, ureters were implanted into the terminal Ileum using the ileocecal valve to prevent reflux: the left spatulated ureter by an end-to-end (Wallace) and the right ureter by an end-to side technique (Nesbit). Surgical and medical follow-up reports were evaluated and a recent follow-up was obtained by a questionnaire.ResultsMedian follow-up in 183 patients was 72 months (1–336). A total of 74 patients (38%) died during the follow-up. A surgical intervention was required in 26 out of 193 patients with early complications while 45 out of 183 patients had late and 17 patients had both, early and late complications. Ureteral stenosis was found in 13% of submucosal implanted ureters, 13% with the Wallace technique, and 3.6% with the Nesbit technique. In total, 66 patients responded to the questions concerning long-term continence (minimal follow-up >2 years). Overall, 84.8% were completely continent, 1.6%, reported grade I and 9.8% grade II stress incontinence.ConclusionsThe long-term continence and complication rates are comparable to those of other types of orthotopic bladder substitution. Orthotopic MAINZ pouch procedure can be considered as one of the options for orthoptic diversion, which stands the test of time.

A new index (A/G) associated with early complications of radical cystectomy and intestinal urinary diversion

ObjectivesTo put forward a new index (A/G, the postoperative ratio of albumin to blood glucose) associated with complications occurring within 30-day of radical cystectomy and intestinal urinary diversion (RC-IUD). Patients and methodsThe charts of 565 patients undergoing RC-IUD at our single center between 2008 and 2018 were reviewed. All baseline information and perioperative data were collected. We finally picked up 360 of them with complete postoperative laboratory test results to find a new index. Early complications (within 30-day) after surgery were graded using the standardized Clavien-Dindo scale. Single and multivariate logistic regression determined the association between perioperative variables and post RC-IUD complications. ResultsA total of 485 men and 80 women with a median age of 61 years and BMI of 24.8 were included. As for intestinal urinary diversion, most patients (n = 513, 90.8%) received ileal conduits, 47 (8.3%) received Ileal orthotopic neobladders and 5 received Mainz pouch bladders (0.9%). Robotic surgeries were conducted in 311(55.0%) patients and other 254 (45.0%) accepted laparoscopic surgeries. Available laboratory markers were obtained from 359 cases. Postoperative complications occurred in 129 patients (22.8%), including 117 (90.7%) Minor (Clavien I or Clavien II events) complications, and 12 (9.3%) major (Clavien III or greater events) complications. A single logistic regression identified 4 variables associated with postoperative complications, including hypertension, surgical procedures, postoperative A/G, operating time, and blood loss. A further multivariate logistic regression identified 2 significant indices: operating time and postoperative A/G. Moreover, we built a receiver operating characteristic curve of A/G to identify a threshold of 3.65 as a new indicator of postoperative complication. ConclusionsWe put forward a new index named A/G associated with complications after radical cystectomy, not singular considering albumin or blood glucose any more. This novel related index may provide an early alert for RC-IUD patients thus aiding in directing individual rehabilitation and improving postoperative outcomes after RC-IUD.

Kidney transplantation using a colon pouch (Mainz pouch III): a case report

Kidney transplantation is the most efficient method of renal replacement therapy. When this method is performed, native urinary bladder is the preferred urinary reservoir. However, in some patients with an anatomically and functionally abnormal lower urinary tract, the urinary bladder cannot be used for transplantation. In these patients, urinary diversion should be performed before kidney transplantation. We present a case of a 32-year-old male patient with orthotopic kidney transplantation performed using a colon pouch (Mainz-pouch III). He was born with severe anomalies including sacral agenesis, anorectal atresia, and hypospadias, which were corrected during childhood. Neurogenic bladder with severe vesicoureteral reflux led to end-stage renal disease. This dysfunctional bladder was unsuitable for kidney transplantation, and a staged approach for future transplantation was chosen. The first step was the creation of urinary diversion. Due to a short appendix, we created a continent, colon pouch (Mainz pouch III). Two years later, orthotopic kidney transplantation was performed using a right cadaveric kidney. The renal vessels were anastomosed to the aorta and inferior vena cava and the pyelon to the native ureter. Four years after transplantation, the patient has stable renal function without any complications. This is the first documented case of using Mainz-pouch III as a reliable option for kidney transplantation in selected patients.

Total intracorporeal robot-assisted laparoscopic Mainz II rectosigmoid pouch

Objective To report the surgical techniques and results of robot-assisted laparoscopic radical cystectomy (RRC) with bilateral pelvic lymphadenectomy and the Sigma rectum pouch (Mainz II) performed with an intracorporeal robotic technique at our center. Methods There was 1 female 63 years old with organ confined, muscle invasive transitional cell carcinoma of the bladder who underwent completely robot assisted surgery. The procedure included pelvic lymph node dissection, radical cystectomy with uterus and tubal structures, creation of the rectal sigmoid pouch and bilateral stented antireflux implantation of the ureters into the pouch. A 20 cm segment of the sigmoid was isolated. The posterior wall of the pouch were anastomosed side-to-side. And a nipple was formed by suturing the mucosa over the ureters to accomplish an antireflux mechanism. The F8 mono-pigtail ureteral stents were led out through the rectum, and a F26 Foley catheter was placed transanally for pouch drainage. Finally the anterior wall of the pouch was closed two layers. Results Operating time was 470 min and blood loss was 600 ml. The rectal tube was removal on the 9d postoperative day and the ureteral stents were removed 11 d and 12 d postoperatively. No intraoperative or postoperative complications were observed. The patients were followed up for 2 years, urinating 4-5 times per day and 1-2 times at night, CO2CP is 17.8mmol/L. The patient showed no upper urinary occlusion, reflux or urine incontinence. Conclusion To our knowledge, this is the first robotic radical cystectomy with intracorporeal continent urinary diversion (Mainz Ⅱ), RRC with the Mainz Pouch Ⅱ may become a simple and effective alternative surgical method for treating select patients with localized muscle invasive bladder cancer. Key words: Bladder cancer; Robot-assisted laparoscopic surgery; Radical cystectomy; Controlled urinary diversion

Continent versus incontinent diversion for obstetric fistula.

The plight of women who develop obstetric fistula in poor countries is especially dire. The constant leakage of urine and sometimes faeces leads to social isolation, poor nutrition, chronic medical problems and depression, often leading to early death. Although there have been several reports of improvement in quality of life (QoL) after repair of obstetric fistula, there are few data on the QoL or survival of women with unrepairable fistulas (persistent fistula-related disorder). Despite the severe disability of these women, urinary diversion has been used infrequently as it has been perceived as too complicated and dangerous to be performed in these countries. Despite this, many of the same countries, working with foreign experts, have developed programmes in open heart surgery, ophthalmic surgery and correction of congenital defects to mention a few. Part of the inertia to doing these procedures is that many gynaecologists who manage these patients do not have expertise in advanced urological techniques and the urology community in general has not shown enthusiasm for dealing with this problem. Arguments have been made that diversion is not ‘culturally acceptable’, but this ignores the fact that we have hard evidence that constant leakage of urine from the vagina is not culturally acceptable. If urinary diversion is to be performed, a major question is what type. In general there are three choices, the incontinent ileal conduit, a continent catherisable pouch made of ileum or colon or a continent ureterosigmoidostomy, most commonly the detubularised Mainz pouch II. The incontinent ileal conduit has the least complications but has commonly been considered a poor choice because of the appearance and cost of external appliances. The largest series of continent diversions use the Mainz pouch II and there is low perioperative mortality and manageable morbidity (Kirschner et al. Int Urogynecol J 2016;27:865–70). The only series with significant follow up, from Eritrea (Morgan et al. Int Urogynecol J 2009;20:1163–8), had no perioperative mortality and good satisfaction but no formal QoL instrument was used. In women with severe childbirth trauma, some degree of anorectal dysfunction would be expected and night-time incontinence was seen in about 30% of these women. Although it would seem obvious that a continent diversion would be superior to an incontinent diversion with regards to QoL, studies in the developed world have not clearly confirmed this (Evans et al. Curr Opin Urol 2010;20:421–5). Now we have a series from the developing world where women with an incontinent urinary diversion have an excellent QoL and, importantly, re-integration (Walker et al BJOG 2018;125:616–22). A randomised trial comparing QoL of women with persistent fistula-related disorder treated with continent or incontinent diversion is unlikely to be performed in the near future. However, an effort should be made in all centres who perform these procedures to collect and report this information so that a baseline estimate of the effect on QoL for each approach can be established. The procedure to be performed will be dependent on the results and resources of the countries performing them and preferences may vary by location. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Technique and results in total laparoscopic radical cystectomy with sigmoidorectal pouch (Mainz pouch II) - an initial experience.

We used laparoscopic radical cystectomy (LRC) with urinary diversion for muscle-invasive bladder cancer. A series of total LRC is presented with Mainz pouch II after we had gained experience of nearly 200 open radical cystectomy and 23 LRC. Since from October 2010 to April 2012, we performed totally LRC in 5 patients with muscle-invasive bladder cancer with Mainz pouch II as a urinary diversion. We analyzed age, pathological staging, continence, operative time, blood loss, blood transfusion volume, and complications. The mean age of the patients was 58.8±7.6 years (range, 49–69 years), and the follow-up time was 15.4±4.72 months. The mean operative time was 577.0±126.4 min for total LRC, with a mean blood loss of 280.0±130.38 ml and a mean hospital stay of 29.4±9.2 days. Blood transfusion was required in two cases, and immediate and late complications were observed in 2 cases. In conclusion, total LRC with urinary diversion is feasible for the management of muscle-invasive bladder cancer, by experienced surgeons, and despite the high level of difficulty of these procedures.

Long-term outcome after urinary diversion using the ileocecal segment in children and adolescents: Complications of the efferent segment

Long-term outcomes are of special concern in children after urinary diversion. In a single institution study we evaluated retrospectively the long-term outcomes of urinary diversion in children, in whom the ileocecal segment had been used, in respect to complications of the efferent segment. The Mainz pouch was used in 107 children for continent urinary diversion. Indications were neurogenic bladder (53%, 57/107), exstrophy-epispadias complex (25%, 27/107), malignancy (13%, 14/107), and others (9%, 9/107). Continent cutaneous diversion was performed in 95 patients, and 12 patients received bladder augmentation/substitution with a continent cutaneous stoma. As efferent segment, we used the in situ submucosally embedded appendix in 55/107, and an intussuscepted ileal nipple valve in 45/107 patients, other in seven patients. Complication rates and degree of satisfaction with urinary diversion were evaluated by assessing medical records and using follow-up questionnaires. The median follow-up time was 15.9 years (0.4-27.6 years). There was a significant difference between the stenosis rates of appendical stoma and the intussuscepted ileal nipple valve. In general, 38% of patients (41/107) with a continent cutaneous stoma developed a stoma stenosis at the skin level, with 41% (17/41) of those having recurrent stenoses (2-6×). Of the patients with an appendix stoma, 49% (27/55) developed a stenosis, compared with 20% (9/45) of those with an intussuscepted ileal nipple valve (p<0.001). In an attempt to reduce the incidence of stenosis, we implemented use of the ACE stopper during the last 2 years, but whether this is successful is subject to further investigations. For surgical treatment of stoma stenosis, reanastomosis of the efferent segment to the skin (n=37, re-stenosis rate 37%, [14/37]) was superior to endoscopic scar incision (n=44, re-stenosis rate 59% [26/44], OR 2.4). The overall continence rate was 85% (91/107). At the latest follow-up, 89% (49/55) of patients with an appendix stoma and 82% (37/45) of those with an intussuscepted ileal nipple valve were completely continent. The in situ submucosally embedded appendix and the intussuscepted ileal nipple valve are reliable continence mechanisms in the long-term median follow-up of nearly 16 years. The stomal stenosis rate is approximately double for the submucosal appendix, likely because of its smaller diameter in comparison with the ileal valve. Although we encountered a high overall rate of complications, the satisfaction rate with the diversion was high (99% [88/89] satisfied or very satisfied patients).

Modified ureterosigmoidostomy (Mainz Pouch II) urinary diversion: 10 years experience and follow-up

Objective To report 10 years experience in modified ureterosigmoidostomy (Mainz Pouch Ⅱ) urinary diversion and evaluate its long-term outcome. Methods From October 2004 to December 2014, 248 patients , including 205 men and 43 women, had underwent Mainz Pouch Ⅱ urinary diversion at 26 institutions in Gansu Province, China.The median age at surgery was 61 years, ranged from 15 to 79 years, Among those patients, 239 patinets were diagnosed as bladder invasive urothelial carcinoma, including urothelial carcinoma in 230, squamous cell carcinoma in 6, adenocarcinoma in 2 and leiomyosarcoma in 1. 200 male patients underwent the radical vesico-prostsectomy. 39 female patients underwent the exenteration of total pelvis with bilateral pelvic lymadenectomy. For one paitent with urethral squamous cell carcinoma, exenteration of total pelvis, urethra resection and bilateral pelvic lymadenectomy were performed at the same time. Simple cystectomy were performed in 5 patients, including bladder retraction as a consequence of urinary tuberculosis, exstrophy bladder, interstitial cystitis, glandular cystitis and refractory vesicovaginal fistula. Bricker ileal conduit urinary diversion was transformed to Mainz Pouch Ⅱ in three patients. Clinical data and early complications were retrospective analysis. Data on long-term complications, continent status, urinary frequency and patient's quality of life were investigated by follow-up. Results The median operative time for urinary diversion is 120 minutes (ranging from 90 to 150 minutes). The median estimated blood loss was 800 ml (ranging from 400 to 2 500 ml). Seven patients (7/248, 2.8%) died in the perioperative period. Early complications were noticed in 66 patients (66/248, 26.6%), such as intestinal fistula(6/248, 2.4%), pulmonary infection(5/248, 2.0%), ileal obstruction (4/248, 1.6%), pyelonephritis(4/248, 1.6%), deep venous thrombosis(2/248, 0.8%), pelvic infection(2/248, 0.8%), wound dehiscence (10/248, 4.0%), superficial wound infections (30/248, 12.1%), hemorrhagic shock(1/248, 0.4%), myocardial infarction (1/248, 0.4%) and rectovaginal fistula (1/248, 0.4%). Thirty-seven patients (15.4%, 37/241) were lost during follow-up and eighty-five (41.7%, 85/204) passed away. 119 patients were followed from 7 to 126 months (mean 46 months). Late complications occurred in 29.4% of patients (60/204), including uretero-intestinal anastomotic stricture (20/204, 9.8%, 24 of 400 renoureteric units, 6.0%), recurrent pyelonephritis (12/204, 5.9%), delayed ileal obstruction (11/204, 5.4%), symptomatic metabolic acidosis (11/204, 5.4%), incisional hernia (5/204, 2.5%), pelvic infection (1/204, 0.5%). The overall quality of life was described as 'fully satisfied' by 20 patients (20/119, 16.8%), 'moderately satisfied' by 87 patients (87/119, 73.1%) and 'Poorly satisfied' by 12 patients (12/119, 10.1%). At the end of follow-up, three patients were excluded due to conversion to permanent nephrostomy. The other patients were continent at day time. Completely continence was achieved in 92 of 116 (79.3%) patients during the day and night. Conclusions Mainz Pouch Ⅱ is a simple and feasible procedure to achieve continent urinary diversion, with excellent continence rate and good quality of life. When the patient refused to have an incontinent urinary diversion, it may be used as a convenient and satisfactory alternative for cystectomized patients who are not suitable for orthotopic urinary diversion due to bladder cancer invasion into prostate or urethra. Key words: Ureterosigmoidostomy; Urinary diversion; Mainz Pouch Ⅱ; Surgical complications; Follow up

Predictors for morbidity of radical cystectomy and different types of urine derivation: 20-year experience of a surgery center

Background. Most of serious complications of radical cystectomy (RCE) should be associated with the comorbidity of patients and the interintestinal anastomoses designed with urinary reservoirs rather than with RCE. It is relevant to identify and assess the role of predictors for morbidity of RCE and urine derivation. Objective: to search for risk factors for complications after RCE with different types of urine derivation. Subjects and methods. The immediate and late results of RCE and urine derivation were studied in 350 patients with bladder cancer. Sequential postoperative complications were additionally analyzed in chronological order in all the patients, including non-cancer ones (n = 43). Results. 43.9% of the patients had postoperative complications, if a surgeon had sufficient surgical experience; there was a preponderance of patients with mild-to-moderate complications (Clavien-Dindo grade I-II, 37.8%) unassociated with urine derivation. The patients with severe postoperative complications were 16.3%; mortality was 3.1%, which significantly correlated with surgical experience. Late (3-18 month) postoperative complications were detected in 21.4% of the patients with a preponderance of those with urine derivation-related complications (19.4). The frequency of complications due to extraintestinal versus intestinal urine derivations was significantly higher (68.1 and 49.8% (p &lt; 0.05). During two-step surgical treatment, the patients demonstrated higher morbidity and worse survival. Extraintestinal urine derivations, continuous urinary intestinal diversion determine a less favorable prognosis compared with one-stage ortho- and heterotopic procedures. The type of urine derivation and the experience of a surgeon performing RCE are valid predictors for postoperative morbidity and independent prognostic factors of overall and cancer-specific survival, respectively. 150 operations are needed for achieving optimal surgical experience. Discussion. It is appropriate to increase the time of research reports on the results of urine derivation up to 12-18 months of a postoperative follow-up. In practice, the routine use of two-step RCE and final urine derivation and internal and/or external urine ones should be abandoned; preference should be, when possible, given to single-stage ortho- and/or heterotopic urine derivations rather than to the former. Conclusion. Extraintestinal (percutaneous puncture nephrostomy, ureterocutaneostomy), and internal (ureterosigmoanastomosis, ureterosigmorectoanastomosis, Mainz pouch II) urine derivations, two-step surgical treatment, and a surgeon’s insufficient experience are predictors for high morbidity and poor prognostic factors for survival after RCE and urine derivation.

Ethical and well-constructed research into the surgical management of obstetric fistula: a distant hope or a real possibility?

The number of women presenting with new obstetric fistulae at the Hamlin Fistula Hospital in Addis Ababa, Ethiopia, has fallen from 492 to 329 in the 3 year period from January 2011 to December 2014, representing a drop of 33% (personal audit of Hamlin Fistula Ethiopia operating theatre records, JW 2015). Although this is clearly good news, as it suggests improvements in maternal health are being made, residual urinary incontinence following primary surgery still remains a problem. In a series of 390 women attending for urinary fistula repair, 240 returned for follow-up, of whom 123 (51%) remained incontinent (BJOG 2008;115:1564–9). In the past, urethral buttressing procedures, such as the use of Martius or pubococcygeus grafts, have been tried, but with limited success (BJOG 2004;111:357–61). It is tempting for both resident and visiting surgeons to try more invasive procedures, such as the use of abdomino-urethral slings, bladder augmentation, and urinary diversion; however, we need to remember that treatments now being considered for women with continuing urinary incontinence following fistula repair have largely been abandoned in high-income countries because of their ineffectiveness. For example, bladder augmentation is highly morbid and is rarely performed because of the need for self-catheterization, and urinary diversion is largely only performed for malignancy in aged patients. Whereas these operations may offer hope for women with urinary incontinence following fistula surgery, women need to be informed of the risks and possible, often unknown, benefits, not least of all because the surgery is not easily reversible, and any resulting morbidity will remain for the rest of their lives. Defecation in excess of six times a night is common following a Mainz pouch, and little is known about the long-term effects for these young women. Moreover, a urinary diversion cannot be reversed, but leaves women to cope with many challenges of stoma care within a rural environment where there may be no running water or adequate sanitation. It is therefore imperative that these procedures are trialled in a logical, well-documented, and ethical way, ensuring adequate consent about treatment options and the risks that must be faced. Informed consent, in the true sense, however, is not widely practiced in countries where obstetric fistulae are prevalent, and visiting surgeons need to ensure that they do not compromise their ethical standards simply because they are working out of their familiar context. Unlike clinical trials of medical therapy, new surgical procedures are not subject to ethical scrutiny or rigorous assessment of their efficacy and impact on quality of life. Indeed, many new surgical procedures are introduced without even a rudimentary assessment of patient satisfaction. For our putative patient with a Mainz pouch described above, her continued dribbling urinary incontinence and normal bowels may be a better option than radical surgery that leaves her socially isolated and unable to return to her community. Once surgery is performed, however, there is no turning back. These operations can be done, but should they be done? And if they are to be done, should they not at least be subjected to rigorous assessment of patient-reported outcomes, such as quality of life? None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

AB052. Modified ureterosigmoidostomy (Mainz Pouch II) urinary diversion: 10 years’ experience and follow-up.

ObjectiveTo report 10 years’ experience with Mainz Pouch II urinary diversion and to analyze its outcome.Materials and MethodsFrom October 2004 to December 2014, 248 patients 205 men and 43 women (age range, 15 to 79 years, mean 59.85±10.76) had underwent Mainz Pouch II urinary diversion at 26 institutions in Gansu Province, China. The indications for urinary diversions were invasive urothelial carcinoma of the urinary bladder in 239 cases, squamous cell carcinoma of urethra in one and unoncological reasons in 8 cases. Clinical data and early complications were retrospective analysis. Data on long-term complications, continence behaviour, urinary frequency and patient’s assessment of the quality of life were investigated by follow-up.ResultsThe median operative time for urinary diversion 120 minutes (range, 90-150 minutes), with a median estimated blood loss of 800 mL (range, 400-2,500 mL). Seven patients (2.82%) died in the perioperative period. Early complications were noticed in 66 patients (26.61%), such as intestinal fistula (6, 2.42%), pulmonary infection (5, 2.02%), ileus (4, 1.61%), pyelonephritis (4, 1.61%), deep venous thrombosis (2, 0.81%), pelvic infection (2, 0.81%), wound dehiscence (10, 4.03%), superficial wound infections (30, 12.10%), hemorrhagic shock (1, 0.40%), myocardial infarction (1, 0.40%) and rectovaginal fistula (1, 0.40%). Thirty-seven patients (n=241, 15.35%) were lost at follow-up and 204 patients were followed from 2 to 126 months (mean 47.93±29.26 months). Eighty-five (n=204, 41.67%) passed away. Late complications occurred in 29.41% of patients (60/204), including uretero-intestinal anastomotic stricture (20, 9.80%, 24 of 400 renoureteric units, 6.00%), recurrent pyelonephritis (12, 5.88%), prolonged ileus (11, 5.39%), metabolic acidosis (11, 5.39%), incisional hernia (5, 2.45%), pelvic infection (1, 0.49%).ConclusionsMainz Pouch II is a simple and easy to mastered form of continent urinary diversion, with excellent continence rate and good quality of life. When the patient refused to have a incontinent urinary diversion, it may be used as a convenient and satisfactory alternative for cystectomized patients who are not suitable for orthotopic urinary diversion due to bladder cancer invasion of prostate or urethra.

Sigma-rectum pouch (Mainz Pouch II)

The Mainz pouch II is a well tolerated form of continent urinary diversion in terms of morbidity, protection of the upper urinary tract and continence rate, even in patients aged > 65 years. Mainz pouch II was described by Fisch and Hohenfellner in 1991. They viewed the simplicity and reproducibility of the operation as one of its major advantages. A good continence rates between 93%-100% after this procedure has been shown in previous studies. The longer follow up will show whether these high rates of continence can be maintained with increasing age. The Mainz Pouch II serves as a satisfying continent urinary diversion for both sexes in selected patients in terms of quality of life. Evaluation of overall quality of life in patients with Mainz pouch II urinary derivation has given encouraging results. Compliance and cooperation of the patients, together with preoperative tests for anal competence, are mandatory to avoid complications. The Mainz group reported that the overall complication rate was low and comparable with other techniques of continent urinary diversion. During the past years modifications of the original technique have been described. These represent an increasing interest in the procedure. Today, the techniques of low-pressure and reservoirs have completely replaced classical ureterosigmoidostomy. In this review article the main focus is aimed at history, complications, continence and quality of life of patients with Mainz pouch II.

Complications of Camey-Le Duck ureteral reimplantation technique in modified ureterosigmoidostomy (Mainz pouch II) urinary diversion

to analyze complications and clinical outcome of Camey-Le Duck ureteral reimplantation technique in modified Mainz pouch II urinary diversion. this retrospective study included a total of 110 patients (101 male and 9 female, mean age 59.2 years, SD = 10.2), who had underwent a modified Mainz pouch II urinary diversion with Camey-Le Duck ureteral reimplantation technique, following total cystectomy, during the period 1995-2014. The mean follow-up, available for 90 (82%) patients period was 19 (1-74) months. Early and late postoperative complications were analyzed. early complications developed in 22 (20%) patients as follow: unilateral ureterohydronephrosis in 8 (7%) patients, bilateral ureterohydronephrosis in one (1%)-two RU (renoureteral units), urinary leakage in 8 (7%), and pyelonephritis in 5 (5%) patients. Late complications developed in 28 (25%) patients: pyelonephritis in 17 (15%), and ureteral reimplantation site stenosis in 11 (10%) patients with 12 RU. Balloon dilatation procedure was applied in all 12 RU, with additional metallic Strecker stent insertion in 5 RU. At 24-month follow-up, all patients with metallic Strecker stent had normal results of serum biochemistry, blood gas analysis and renal ultrasound. In the rest of six patients with 7RU, balloon dilatation has failed and restenosis of ureteral reimplantation site with consequent ipsilateral hydronephrosis was verified. In these patients, permanent percutaneous nephrostomy catheter was applied. Camey-Le Duck ureteral reimplantation technique following Mainz pouch II urinary diversion is simple, reliable and durable. It enables well upper urinary tract protection and is associated with relatively low major complication rates.

Cistectomía radical laparoscópica: técnica y resultados en 100 pacientes consecutivos

Radical laparoscopic cystectomy. Experience in 100 patients Background: Laparoscopic cystectomy is a less invasive alternative than traditional surgery. Aim: To report our experience with laparoscopic radical cystectomy, the technique, results and complications. Material and Methods: During a 10-year period, 100 consecutive laparoscopic cystectomies for bladder cancer were carried out. The procedures performed were 57 radical cystoprostatectomies, 27 pelvic exenterations, 14 cystectomies with prostate preservation and seven radical cystectomies. An extracorporeal urinary diversion was performed in 92% of cases. Results: The age of patients ranged from 29 to 83 years and the male/female ratio was 3:1. As urinary diversion, an orthotopic reservoir was used in 49 patients, and ileal conduit in 32, Indiana continent reservoir in 10 and intracorporeal Sigma-rectum pouch (Mainz pouch II) in 9 patients. All Mainz II pouches were constructed laparoscopically. Mean operative time and blood loss were 279 minutes (range 180 to 375) and 436 ml (range 50 to 1.500) respectively. Eight patients (11%) had perioperative complications: five had vascular lesions, two had eviscerations and two had septicemia. Delayed complications were observed in seven cases (9%). Three patients had a urinary sepsis, one had a ureteral stenosis, two had spontaneous ruptures of a continent reservoir and one had an intestinal fistula. Mean hospital stay was 8.8 days (range de 4 to 28). One patient died due to an intestinal fistula and secondary peritonitis. Mean followup was 18 months (range 2 to 68 months). Ten patients (13%) had disease progression and died in long-term follow up. Conclusions: Laparoscopic radical cystectomy is associated with a reduced operative bleeding, a short hospital stay and acceptable morbidity.

Quality of life after radical cystectomy for bladder cancer in men with an ileal conduit or continent urinary diversion: A comparative study

Aim:To investigate quality of life (QoL) domains with three forms of urinary diversions, including ileal conduit, MAINZ pouch, and orthotopic ileal neobladder after radical cystectomy in men with muscle-invasive bladder cancer.Materials and Methods:In a prospective study, 149 men underwent radical cystectomy and urinary diversion (70 ileal conduit, 16 MAINZ pouch, and 63 orthotopic ileal neobladder). Different domains of QoL, including general and physical conditions, psychological status, social status, sexual life, diversion-related symptoms, and satisfaction with the treatment were assessed using an author constructed questionnaire. Assessment was performed at three months postoperatively.Results:In questions addressing psychological status, social status, and sexual life, patients with continent diversion had a more favorable outcome (P = 0.002, P = 0.01, and P = 0.002, respectively). The rate of erectile dysfunction did not differ significantly between the three groups (P = 0.21). The rate and global satisfaction was higher with the MAINZ pouch (68.7%) and ileal neobladder (76.2%) as compared with the ileal conduit group (52.8%) (P = 0.002).Conclusion:Continent urinary diversion after radical cystectomy provides better results in terms of QoL as compared with ileal conduit diversion.