Rectal Bladder Research Articles

Replacement of the urinary bladder with rectum

The rectum can be used as a substitute for the urinary bladder such that the normal outlet for feces at the anus is left undisturbed and continent. Perfect and complete continence is achieved by creating a narrow neck of the rectal bladder with a sphincter around it and a narrow urinary outlet, a neourethra, also with a sphincter around it. Three different types of anomaly necessitating reconstruction of the urinary bladder were operated upon by this procedure. Three patients are doing well in respect to micturition and defacation, having achieved total continence for both.

RADIONUCLIDE EVALUATION OF THE URETERO‐ILEOCECO‐PROCTOSTOMY (ILEOCECAL RECTAL BLADDER)

Technetium 99m diethylenetriaminepentaacetic acid renoscintigraphy was applied to 14 patients to obtain comprehensive information on the kidney and urinary tract 12.6 +/- 8.8 months (mean +/- SD) after uretero-ileoceco-proctostomy (ileocecal rectal bladder) diversion. The total glomerular filtration rate (GFR) was within the normal range in all patients, and the diuretic renogram was normal in 19 of 28 kidneys, dilated-nonobstructive in 7 and obstructive-intermediate in 2. The mean colonic reflux was 16.6 +/- 18.4% of total excretion and the mean total residual in the colon and rectum was 38.8 +/- 15.5%. In the second study, performed 12.4 +/- 3.5 months later in 9 patients, the GFR of bilateral and individual kidneys remained stable, 17 of 18 kidneys were normal as judged by both renography and pyelography, and the occurrence and degree of colonic reflux decreased. There was a tendency for the rectal capacity to increase, while the total residual tended to decrease solely due to the decrease in colonic residual. These results indicate that the ileocecal rectal bladder functions well as an internal continent reservoir and that radionuclide investigation is a valuable and cost-beneficial means of follow-up of urinary diversions.

The Application of the Modified Rectal Bladder in Management of the Compromized Urethral Damage

Failure to repair the traumatic injuries of the lower urinary tract with loss of urethral sphincteric function usually puts forward the subject of urinary diversion. Ten males and five females presented with extensive urethral damage and with or without vesical fistulas. All attempts of repair were exhausted before the decision of diversion was planned. Continent urinary diversion using the modified rectal bladder (the augmented and valved rectum) was utilized. The procedure entailed functional isolation of the rectum without terminal colostomy and depended on colorectal intussuscepted valve. All the patients are currently evaluated with follow up periods ranging 10-56 months. Evidences proved the effectiveness of the colorectal valve in providing non impeded fecal stream to the functionally isolated rectal reservoir. Continent status is attributed to the ileal patching that produces a low pressure reservoir against the effective high anal resistance. The results support the distinct superiority of the modified rectal bladder to either the conventional methods of urinary diversion to the rectum or the abdominal reservoir with continent catheterizable stomas.

Continent urinary reservoirs

With the increasing incidence of bladder cancer, many different operations have been devised to reconstruct the lower urinary tract in a continent fashion. The incontinent type of urinary reservoir (ileal conduit) has been a surgical preference for many years. However, the continent urinary reservoir (CUR), neobladder, and rectal bladder offer the capable and motivated patient an alternative to an incontinent permanent stoma. Nursing management of patients requiring diversional surgery requires continual updating of these specialized surgical procedures and unique aspects of care.

The Valved S-Shaped Rectosigmoid Pouch for Continent Urinary Diversion

Continent urinary diversion to the valved S-shaped rectosigmoid pouch was performed in 9 female and 6 male patients 12 to 65 years old (mean age 51 years). The pouch was constructed by detubularization and S-shaped reconfiguration of 30cm. of the intact rectum and sigmoid colon. The ureters were reimplanted into the pouch using antireflux techniques. Reflux of urine from the pouch to the proximal colon was prevented by fashioning an intussusception valve. The construction was protected by a transverse colostomy for 6 to 8 weeks. With a followup of 3 to 24 months (mean 11 months), all patients are continent during the day and also at night with evacuation intervals of 3 to 6hours. There have been no cases of symptomatic urinary tract infection. Only 1 patient had mild hyperchloremic acidosis. No patient complained of abdominal distention or constipation. Contrast study via the anus (radiography of the pouch) showed that the intussusception valve was competent in all but 1 patient in whom reflux to the proximal colon was noted due to sliding of the nipple valve, which was revised successfully. Urodynamic studies (cystometry of the pouch) showed a capacity of 400 to 900ml. (mean 600) with an intraluminal pressure of 22cm. water (range 10 to 34) at maximal filling. The valved S-shaped rectosigmoid pouch is a faster and simpler surgical procedure compared with the modified rectal bladder (valved rectum augmented with ileum). It also results in a smooth postoperative course, since an intestinal anastomosis proximal to the colostomy is avoided.

The Uretero-Ileoceco-Proctostomy (Ileocecal Rectal Bladder): Early Experiences in 18 Patients

With the current practice of continent urinary diversion the patient still has a cutaneous stoma and must perform intermittent catheterization. To circumvent these problems we devised the uretero-ileoceco-proctostomy (ileocecal rectal bladder), in which the intussuscepted ileocecal segment is interposed between the ureters and rectum, the rectal capacity is augmented by side-to-side anastomosis to the cecal limb of the segment and continence is controlled by the anal sphincter. The interposed segment prevents reflux of the urine-fecal mixture to the upper urinary tract and may decrease the risk of carcinoma at the ureteroileal anastomosis. The intussusception is stabilized without opening the recipient bowel (cecal limb), thus simplifying the subsequent ceco-proctostomy with automatic suture technique. Our preliminary experience in 18 patients with this new technique is encouraging with respect to voiding, preservation of renal function and quality of life.

99mTechnetium-diethylenetriaminepentaacetic acid renoscintigraphy as a measure of renal function and urodynamics after uretero-ileoceco-proctostomy

Ten patients having a uretero-ileocecoproctostomy (ileocecorectal bladder) were evaluated by 99mtechnetium diethylenetriaminepantaacetic acid renoscintigraphy, which was repeated at an approximately 1 year interval in 7 patients. The computed total glomerular filtration rates at the 1st and 2nd surveys were 100 +/- 23.2 and 92.7 +/- 23.0 ml/min (mean +/- S.D.), respectively indicating a minimal change with no statistically significant difference. The normal or incompletely obstructive renogram patterns were consistent with the pyelographic findings in 27 of 28 renal units, and 5 of 6 renal units with dilated nonobstructive renograms subsequently became normal both on the renograms and pyelograms. Comparing the data in the 1st and 2nd surveys, the frequency of colonic reflux decreases from 8/10 to 3/7 of the patients, the rectal bladder capacity increased from 82 +/- 18.8% to 92 +/- 20.8% of the excreted urine, and the total residual urine rate decreased from 40.4 +/- 12.9% to 28.0 +/- 16.6% (p = 0.1298), respectively. The results indicate that the ileocecorectal bladder, though it has no antireflux mechanism against colonic regurgitation, well functions as an internal continent urinary reservoir. Also, since this comprehensive information is obtained by a single procedure, the radionuclide evaluation can be practiced as a cost-beneficial measure for follow-up of patients with urinary diversions.

Further Experience with the Modified Rectal Bladder (The Augmented and Valved Rectum) for Urine Diversion

Continent diversion with the modified rectal bladder was done in 83 patients and 65 are currently evaluable with followup ranging from 6 to 36 months. There was no postoperative mortality and the morbidity rate was acceptable. Renal function and configuration were maintained in most patients (91%). Dessusception of the colorectal valve was observed in 7.6% of the patients. Evidence was provided that this valve is effective in prevention of regurgitation of the rectal contents to the proximal colon. All patients were continent during the day. Enuresis was noted in 6 patients and all of them responded to imipramine hydrochloride therapy. The results support earlier observations that the procedure offers distinct advantages over ureterosigmoidostomy and the simple rectal bladder.

Induction of carcinoma at ureterosigmoid anastomosis--with and without faecal stream.

The induction of tumours at the site of uretero-intestinal anastomosis was investigated in Hannover: WISTAR rats. The rats were divided into 3 groups. In one group (n = 70) the ureter of the left kidney was implanted into the colon, using microsurgical techniques developed for humans. In 13% of the rats in this group benign tumours developed; in 16% malignant tumours occurred. In a second group (n = 76) the ureter was implanted into a rectal bladder; the faeces were excluded from the anastomosis by a descending colon anus praeter. In this group benign tumours developed in 17% and malignant tumours in 8%, all of them being situated at the site of the anastomosis. In a control group (n = 80) no colonic tumour could be identified.

Isolated Ureterosigmoidostomy and Isolated Vesicorectal Anastomosis: The Rectal Bladder

Our experience documents that an isolated internal urinary diversion and the requisite diverting colostomy offer an acceptable long-term method for establishing sphincteric urinary continence while preserving renal function and upper-tract morphology. This procedure has been widely accepted by those patients undergoing it.

Renal transplantation into abnormal lower urinary tract

Because doubts remain about the safety and efficacy of renal transplantation for patients with primary urological abnormalities, we have studied the outcome of transplantation in a large group of such patients. Between 1977 and 1989, 69 renal transplants were completed in 62 patients with abnormal lower urinary tracts (29 primary vesicoureteric reflux, 13 posterior urethral valves or bladder outflow obstruction, 6 vesicoureteric tuberculosis, 5 neuropathic bladders, and 9 miscellaneous causes). Graft survival in this urological group was similar to that in 150 allograft recipients (157 grafts) with end-stage renal failure of a non-urological cause. No aetiological subgroup had poorer graft survival than the others, although patients with recurrent urinary-tract infections and a history of outflow obstruction tended to have worse graft function. 9 patients (10 transplants) had renal transplantation into a urinary diversion (8 ileal conduits, 1 rectal bladder). These patients had graft survival and renal function comparable with those of the whole urological group. We found no effect of immunosuppressive treatment (cyclosporin or azathioprine), type of kidney donor (living or cadaveric), or donor or recipient age on graft survival time or renal function. Thus, renal transplantation in patients with abnormal lower urinary tracts is safe and effective; patients with ileal conduits do well and have few substantial difficulties. Preoperative assessment of bladder emptying and urodynamics are important in these patients.

Colonoscopic Control of Uretero‐enteric Anastomoses in Internal Urinary Diversion

Twenty-four patients with internal urinary diversion following total bladder ablation underwent colonoscopic control of the uretero-enteric anastomoses. The techniques performed were: rectal bladder with colostomy according to Mauclaire (11 patients); rectal bladder with abdomino-perineal pull-through according to Heitz-Boyer/Hovelacque (6); ureterosigmoidostomy (7). The uretero-enteric anastomoses were divided into 3 categories according to the colonoscopic appearance: "nipple-like", nearly flat and flat anastomosis. Urographic examinations were carried out in all patients and the results demonstrated that the "nipple-like" anastomosis was the most successful for the preservation of upper urinary tract integrity.

Bladder Substitutes Controlled by the Anal Sphincter: A Comparison of the Different Absorption Potentials

A comparative study of the absorption potentials of the simple rectal bladder (10 patients), modified rectal bladder (20) and ureterosigmoidostomy (10) was done with intrarectal instillation of 22sodium. Results indicate that absorption is significantly greater among patients with ureterosigmoidostomy. The emptying patterns of ureterosigmoidostomy and the modified rectal bladder were also studied by ascending scintigraphy with 99mtechnetium. Evidence was provided that in cases with ureterosigmoidostomy the isotope is distributed throughout the entire colon.These studies proved the role of the colorectal valve in preventing reflux of urine from the rectum to the proximal colon. Consequently, the surface area of colonic mucosa exposed to urine is decreased and the rate of reabsorption is limited.

Functional, Augmented Rectal Bladder: Early Clinical Experience

From August 1988 until March 1990, 10 female patients received an augmented, functional rectal bladder according to the technique first described by Kock. Indications were radical cystectomy in 8 and undiversion from a previously wet stoma in 2 patients. There was no perioperative mortality. Postoperative complications were: one obstructive pyelonephritis (treated with a temporary nephrostomy); one obstruction at the ileal intussusception (operative revision), and one slipping at the sigma nippel (no treatment). Intravenous pyelographies taken 2-3 months postoperatively, showed 13 normal and 5 slightly dilated renal units. All patients are completely continent by day, 7 are continent at night, 2 wear sanitary pads during the night due to occasional spotting. The preliminary experience with this new technique is encouraging and warrants further clinical application in patients in whom the external urethral sphincter is not available as continence organ.

Urinary incontinence in epispadias and bladder exstrophy with special reference to free autologous muscle transplantation

This is a report on 16 patients with epispadias of grades II to IV and on 35 patients with exstrophy of the bladder, grades III and IV. The following surgical treatment was carried out: in children with epispadias, simple closure of the urethra in one case, neck of the bladder plasty according to Young-Dees in two cases, the method after Thiersch-Duplay in three cases, whereas four patients were treated after Williams, five after Johnston and one patient after Ombrédanne in reverse. Seven additional operations were done mainly for prepuce correction and closure of fistula after urethroplasty. Three of the 16 patients were continent already before the operation. 4 children were partially continent. Two of these showed improved continence, thus achieving prolonged periods of dryness. 9 children remained incontinent. Hence, free muscle transplantation to the bladder was performed in four patients. A total of 45 operations were performed on children with exstrophy of the bladder. Of these, 12 concerned primary closure of bladder; in 13 cases, an ileum bladder was constructed, whereas cystosigmoideostomy was done in 5 times, uretersigmoideostomy 5 times, cutaneous ureterostomy once, rectum bladder once, and a colon conduit once. The postoperative continence performance of the 12 patients with primary bladder closure was unsatisfactory. Three children only attained periods of dryness up to two hours; 5 remained completely incontinent, whereas in 4 it was subsequently necessary to construct a urinary passage into the intestine by means of an ileum bladder in 2 cases, a colon conduit in one case, and ureterosigmoideostomy in one case. Free muscle transplantation to the bladder was performed in two patients. Free muscle transplants were also performed on 2 children, in one case after traumatic tearoff of the urethra and in one case after iatrogenic lesion of the musculus sphincter vesicae externus in adrenogenital syndrome (AGS) according to Prader III and IV. This means that a total of eight free muscle transplants were performed. All children were primarily incontinent. Postoperatively, complete continence could be achieved in four cases, once an improvement with dry periods up to 2 hours. The two patients with bladder exstrophy remain incontinent, in one patient with epispadias the postoperative interval has been too short so far to arrive at a final judgement. It follows from the examinations that free muscle transplantation is a good method for treating urinary incontinence, the suspension effect playing an important part. However, in patients with bladder exstrophy the indication should be considered with caution.

Abnormal patterns of colorectal mucin secretion after urinary diversion of different types: Histochemical and lectin binding studies

Clinical and experimental evidence indicates that ureterosigmoidostomy is associated with a high risk for the development of colonic cancer, while there is no reported evidence of increased risk in patients who undergo urinary diversion of other types. In the present study the histochemical and lectin binding characteristics of goblet cell mucin were investigated in biopsy specimens from patients who had undergone ureterosigmoidostomy and from patients who had undergone rectal bladder surgery. Specimens from transitional mucosa surrounding colonic cancers and from normal rectal mucosa were also studied. For histochemical studies the high iron diamine-Alcian blue method was used. FITC-conjugated Dolichus biflorus agglutinin (FITC-DBA) and Arachis hypogaea agglutinin (FITC-PNA) were used for the study of lectin binding characteristics. In contrast to the striking increase in numbers of sialomucin-containing goblet cells found in the patients who had undergone ureterosigmoidostomy, the mucin proved to be histochemically normal in the rectal bladder surgery group. Abnormal lectin binding patterns were observed in colorectal mucosa after urinary diversion of both types, with the abnormalities consisting of dramatic decreases in FITC-DBA labeling (compared with controls) and the appearance of substantial numbers of FITC-PNA-labeled goblet cells. These findings indicate that the pattern of mucin secretion is definitely abnormal in patients who have undergone urinary diversion. Whether this abnormality is an indicator of premalignant changes remains to be established. These data, however, confirm that endoscopic and histologic follow-up studies may be of value in assessing the risk for the development of cancer in these patients.

Evolution of the Rectal Bladder as a Method for Urinary Diversion

A critical analysis of previous reports reveals 2 main drawbacks of the rectal bladder: 1) recurrent pyelonephritis with subsequent loss of renal function (30 per cent) and 2) nocturnal urinary leakage (40 per cent). In a randomized prospective study the role of a submucosal tunnel for prevention of reflux was evaluated. We demonstrated objectively that this technique could provide a patent unidirectional flow of urine in the majority of cases (82.5 per cent). Urodynamic measurements, including flowmetry, rectal pressure and anal electromyography activities, indicated that the driving force for voiding is the voluntary increase of the intra-abdominal pressure rather than the intrinsic contractions of the smooth muscles of the rectum. Accordingly, attempts at control of nocturnal urinary leakage were directed towards increasing the resistance offered by the pelvic floor. The efficiency of imipramine hydrochloride to achieve this goal was tested against a placebo in a clinical trial performed in a prospective randomized fashion. This treatment was effective in the control of enuresis in a significant number of patients (75 per cent). We conclude that the rectal bladder with a terminal colostomy is a highly recommended method for permanent urinary diversion when these 2 modifications are used.

Potentiation of dimethylhydrazine bowel carcinogenesis in rats.

An animal model of organ-specific chemical carcinogenesis has been used to study environmental effects on the incidence of human colorectal adenocarcinoma. Wistar/Furth weanling rats underwent connection of their urinary and fecal streams (ureterosigmoidostomy), connection of their urinary and fecal streams with proximal fecal diversion (rectal bladder), or sham operations. Age-matched, unoperated control and operated animals then received either no carcinogen, 1,2-dimethylhydrazine (DMH) 20 mg/kg body weight, s.c. once weekly for 16 weeks, N-[4-(5-nitro-2-furyl)-2-thiazolylformamide (FANFT) 0.2% of the feed for 16 weeks, or DMH + FANFT concurrently. Thirty-three weeks after carcinogen exposure, surviving animals were killed and examined for bowel and urinary bladder tumors. The incidence of adenocarcinoma of the colon adjacent to the junction between bladder and bowel was significantly higher in animals after ureterosigmoidostomy compared with animals whose fecal stream had been proximally diverted (14/22 vs. 0/34, P less than 0.001). This effect was not dependent upon chemical carcinogen exposure. Nonexposed animals still developed a significantly higher incidence of colon adenocarcinomas adjacent to their bladder-bowel junctions as compared with animals with proximal fecal diversion (5/8 vs. 0/13, P less than 0.01). In unoperated or sham operated animals, adenocarcinomas of the bowel occurred in 33% of DMH-treated animals and transitional cell carcinomas of the urinary bladder in 33% of the FANFT-treated animals. After concurrent exposure to both carcinogens, no increased incidence of bladder tumors was noted when compared with FANFT treatment alone. However, the number of animals with one or more adenocarcinomas of the bowel (22/30 vs. 17/50, P less than 0.001), the mean number of tumors per animal (2.1 +/- 0.2 vs. 1.1 +/- 0.1, P less than 0.01), and the invasiveness of the tumors were all increased after DMH + FANFT as compared with DMH exposure alone. The carcinogenic potential of direct bladder to bowel connection with intact fecal and urinary streams, and the potentiation by FANFT of DMH-induced colon carcinogenesis may have implications in the genesis of human colorectal cancer.

Rectal Bladder

Experience is reported on more than 700 patients submitted to rectal bladder over the last 20 years. The main indications were total cystectomy due to bladder neoplasias and palliative surgery in patients in whom cystectomy was impossible. The rectal bladder, even of the Mauclaire type, is the most useful and best accepted urinary diversion. Separation of urine from faeces avoids serious ascending infections and involvement of renal function. These observations are supported by the long survival of patients submitted to derivative surgery in the absence of neoplastic disease.

Rectal Bladder in the Treatment of Bladder Exstrophy

Satisfactory results were obtained in 25 patients with bladder exstrophy treated by the Heitz-Boyer-Hovelacque operation.