Sigmoid Conduit Research Articles

An extremely rare case of multiple recurrences of urothelial carcinoma in an ileal neobladder: a case report and review of the literature

In up to 18% of patients, recurrence is observed after curative radical cystectomy. Tumour recurrence occurs in most cases in the locoregional lymph node, as well as in the remaining urinary tract, but very rarely in the orthotopic neobladder. We report a case of multiple recurrence of urothelial carcinoma solely in the orthotopic neobladder of a male patient, 10 years after surgery, without involvement of the urethra or upper urinary tract. Therefore, the patient underwent resection of the neobladder with conversion to a sigmoid conduit. Nevertheless approximately 6 months later the patient developed widespread metastases and died a few months later. Currently, no guidelines are available for the treatment of these rare cases. We present our experience, together with revision of the current literature on this issue.

Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center.

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Non-obstructive, non-refluxing uretero-colonic anastomosis by colonic sero-muscular excision and extra mural peri-ureteric wrap – A new technique in 17 children

Uretero-enteric anastomosis with concomitant neobladder/augmentation/conduit becomes necessary when the bladder is unavailable or unfit for reimplantation or the ureters are short after high diversion or resection of lower ureteric pathology. Aiming to prevent both obstruction and reflux, we report a novel technique of sero-muscle denuded extra mural uretero-colic anastomosis. (Fig 1) The ureter was brought through the colonic mesentery. An adjacent zone of colon "abcd" was chosen to receive the ureter and colonic sero-muscular layer was excised from this zone. The ureter was placed on the raw area and uretero-colic anastomosis was done (a-d).The edges of the sero-muscular layer (ab and cd) were sutured over the ureter to complete a submucosal tunnel. The augmentation/neo bladder was completed such that the implanted ureter lay within it between two regions of re-configured bowel, this adding to the anti-reflux mechanism created by the extra mural peri-ureteric wrap. Surgical audit of this technique. 17 children (exstrophy - 8, ectopic ureter with bladder agenesis/hypoplasia - 3, prune belly - 2, neurogenic bladder -2, eosinophilic cystitis -1 and posterior urethral valve -1) underwent colonic implantation of 23 ureters while 6 ureters were drained via a trans uretero-ureterostomy into the reimplanted ureter. Nine augmentation, seven neo bladders and one sigmoid conduit was performed. The colon was available for ureteric re-implant in all patients. Pre-operatively 21 had hydroureteronephrosis. The bladder was agenetic/hypoplastic, small and fibrosed or poorly compliant. Eleven ureters had been diverted. Post operatively (mean follow up - 3.4 years) 16 of 30 renal units were normal, 11 had mild and three had moderate residual hydronephrosis, with no new hydronephrosis. Cystogram showed no reflux in 14 children and unilateral reflux in three (one re-diverted). Of 29 renal units drained directly or via trans uretero-ureterostomy by the uretero-colic reimplantation, none are obstructed, 26 have no vesico-ureteric reflux while three (10%) have reflux. We report results comparable to other extra mural techniques into the bowel, mainly from adult literature. Pediatric refluxing ureters are often large megaureters with or without preliminary diversions. The technique described avoids obstruction although having a slightly higher incidence of recurrent VUR. The ureters with recurrent reflux were massively dilated preoperatively and showed decrease in ureteric diameter postoperatively. The wrap, made for a larger ureter could have become too roomy and allowed reflux. This technique of non refluxing non obstructive uretero-colonic anastomosis has proven useful in selected situations.

PD28-10 RACIAL AND ETHNIC DISPARITIES IN MAJOR UROLOGIC ONCOLOGIC PROCEDURES

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety II1 Apr 2018PD28-10 RACIAL AND ETHNIC DISPARITIES IN MAJOR UROLOGIC ONCOLOGIC PROCEDURES Melody Chen, Anand Patel, and Carvell Nguyen Melody ChenMelody Chen More articles by this author , Anand PatelAnand Patel More articles by this author , and Carvell NguyenCarvell Nguyen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1373AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous research has demonstrated significant racial disparities in post-operative care in major surgical procedures. We sought to evaluate the relationship between race and perioperative outcomes in major urologic surgery in the United States. We hypothesized that there would not be a significant difference between races in perioperative outcomes for major urologic surgery. METHODS We utilized the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify 31,755 patients who underwent major urologic surgery between 2005 and 2011. Major urologic surgeries included open or laparoscopic nephrectomy, laparoscopic, retropubic or perineal prostatectomy, as well as cystectomy with ileal or sigmoid conduit or neobladder. RESULTS Overall, 75% of the cohort was white, with 8% black patients, and 16% categorized as other, including Hispanic and Asian minorities. Black patients were found more likely to have totally dependent functional status (p < 0.05) than their counterparts. Using multivariate analyses, non-white patients were not more likely to experience post-operative complications compared with white patients. The rates of complications including cardiac events, infections, readmission rates and return to the operating room were found to be equal. Blacks were found to have greater odds of progressive renal failure requiring dialysis and post-operative acute kidney injury (OR= 1.9, CI 1.3-2.5, p < 0.05). Additionally, non-white and non-blacks were found to be more likely to have >30-day length of stay (OR 4.2, CI 3.3-5.4, p <0.05). CONCLUSIONS In major urologic surgery, there was no demonstrated difference in post-operative complications or mortality between races and ethnicities. Black patients were more likely to develop post-operative acute kidney injury after major urologic surgery, however after stratifying the types of surgery this difference was not identified. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e566 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Melody Chen More articles by this author Anand Patel More articles by this author Carvell Nguyen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Total Pelvic Exenteration With Intracorporeal Sigmoid Conduit and Colostomy: Step-by-Step Technique

To describe our technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit and colostomy using the da Vinci Si robot. Three 8-mm robotic ports and two 12-mm laparoscopic ports are placed in a "W" configuration, approximately 2-3 cm more cephalad than for radical prostatectomy (Fig.1). The robot is docked between the legs with the patient in steep Trendelenburg. The ureters are dissected out from the iliac vessels to the rectovesical pouch, where they are clipped and transected. The sigmoid colon is stapled across at the rectosigmoid junction and reflected into the abdomen. A posterior plane is developed below the rectum (Fig.2A), if space allows, or through the rectum. The endopelvic fascia is exposed and incised bilaterally. After sequentially controlling the bladder and prostatic pedicles (Fig.2B) using the Harmonic scalpel, the urethra is transected at the prostatic apex, and the anterior rectal wall is incised (Fig.2C). Any remaining attachments are divided, the rectal remnant is excised, and the specimen is bagged and extracted (Fig.2D). Adjacent segments of left and sigmoid colon are harvested for the conduit and colostomy, avoiding a bowel anastomosis. The ureters are anastomosed to the conduit, maintaining separation between the gastrointestinal and the urinary systems. The conduit and left end colostomy are matured (Fig.3). The technique is performed entirely intracorporeally with specimen extraction through the anus, avoiding a large open incision. We present the case of a high-functioning (Eastern Cooperative Oncology Group performance status 1) 73-year-old man with metastatic castrate-resistant prostate cancer following failed primary brachytherapy. Despite a good systemic response to chemotherapy and complete androgen blockade, his prostate-specific antigen level continued to rise (to 33 ng/mL) because of an enlarging prostatic pelvic mass. He suffered from progressive local symptoms, including intractable pelvic pain, obstructive uropathy, and impending rectal obstruction. The indication for pelvic exenteration was local palliation. Total robotic time was 5.4 hours. The perioperative course was complicated by disseminated intravascular coagulation secondary to metastatic prostate cancer, which resulted in a transient ischemic attack. The disseminated intravascular coagulation resolved with blood product transfusion, and the patient recovered well without permanent disability. In-patient length of stay was 8 days. Complete local palliation was achieved until the patient's death from prostate cancer 5 months later. We demonstrate our step-by-step technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit.

Urological reconstruction after pelvic oncological surgery: A single institution experience

In locally advanced pelvic malignancies, there is often involvement of urological organs, necessitating resection and reconstruction, which can be associated with significant complications. We retrospectively reviewed 20 patients undergoing urological reconstructions during pelvic oncological surgeries from January 2004 to December 2013. All patients had imaging-proven involvement of at least one urological organ preoperatively. Primary outcome was urological complication rate. Secondary outcomes were nonurological complication, recurrence rate, and overall survival. Median age of presentation was 51 years. Six and 14 patients underwent resections for primary and secondary tumors, respectively. Colorectal tumors were the most common, followed by gynecological cancers. The ureter was the most common urological organ involved, followed by the bladder, prostate, and seminal vesicles. Reconstructive procedures included ileal and sigmoid conduits, ureteroneocystostomies, Boari flap, transureteroureterostomies (TUUs) and direct ureteroureterostomies. Six patients developed major urological complications, requiring endoscopic and surgical reinterventions. The follow-up time was 34 months. Thirteen patients developed recurrence, associated with higher tumor grade and lymphovascular invasion, and occurred at a median time of 10 months. These patients had an overall survival of 20 months, compared to 45 months in patients without recurrence. Careful patient selection in pelvic oncological surgeries can significantly prolong survival. Recurrent tumors and greater intraoperative blood loss are associated with higher urological complications. A limited pelvic exenteration and lower radiation doses can reduce complication rates. If higher doses are necessary, conformal techniques and hyperfractionated radiotherapy should be explored. Urological reconstruction should be individualized, according to the extensiveness of urological involvement and exposure of radiation.

V4-04 ROBOTIC TOTAL PELVIC EXENTERATION WITH INTRACORPOREAL SIGMOID CONDUIT AND COLOSTOMY: FIRST CLINICAL REPORT

You have accessJournal of UrologyRobotics – Prostate/Novel Imaging1 Apr 2016V4-04 ROBOTIC TOTAL PELVIC EXENTERATION WITH INTRACORPOREAL SIGMOID CONDUIT AND COLOSTOMY: FIRST CLINICAL REPORT Matthew J. Maurice, Daniel Ramirez, Catherine M. Seager, and Georges-Pascal Haber Matthew J. MauriceMatthew J. Maurice More articles by this author , Daniel RamirezDaniel Ramirez More articles by this author , Catherine M. SeagerCatherine M. Seager More articles by this author , and Georges-Pascal HaberGeorges-Pascal Haber More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1808AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Total pelvic exenteration may offer durable palliation in the setting of locally advanced pelvic cancer, but traditionally its morbidity has limited widespread use. We intend to demonstrate the feasibility of robotic total pelvic exenteration with completely intracorporeal sigmoid conduit and colostomy for locally advanced prostate cancer. METHODS We present the case of a 73-year-old man with metastatic castrate-resistant prostate cancer after primary brachytherapy who suffered from progressive local symptoms due to an enlarging pelvic mass. Despite treatment with complete androgen blockade and docetaxel, he progressed locally with worsening pelvic pain, bladder outlet obstruction, bilateral hydronephrosis requiring nephrostomy tubes, and impending rectal obstruction. Despite stable bony metastases, death from bowel obstruction was imminent without intervention. After extensive discussion and counseling, the patient elected to proceed with total pelvic exenteration. Surgery was performed via 5 ports in the standard “W” configuration with the patient in lithotomy and steep Trendelenburg position. RESULTS The total robotic time was 5.4 hours. Estimated blood loss was 100 ml. There were no surgical complications. The sigmoid conduit and colostomy were harvested intracorporeally, and the specimen was extracted via the anus, avoiding the need for an open incision. The use of sigmoid colon for the conduit avoided a bowel anastomosis. The perioperative course was complicated by disseminated intravascular coagulation, a known complication of metastatic prostate cancer, which resolved with the transfusion of blood products and intensive care monitoring. Due to abnormal clotting associated with this pathological condition, the patient suffered an ischemic stroke perioperatively. Length of stay was 8 days. The patient was cognitively intact and had regained gross motor function on the affected side within 1 month of surgery. CONCLUSIONS Robotic total pelvic exenteration with intracorporeal sigmoid conduit is technically feasible. By minimizing surgical morbidity, this approach may allow more patients to benefit from local surgical palliation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e517-e518 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Matthew J. Maurice More articles by this author Daniel Ramirez More articles by this author Catherine M. Seager More articles by this author Georges-Pascal Haber More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Short-term outcomes after incontinent conduit for gynecologic cancer: Comparison of ileal, sigmoid, and transverse colon

ObjectiveThe aim of this study is to estimate the overall rates of significant incontinent conduit-related complications and compare rates between conduit types. MethodsThis was a retrospective review of 166 patients who underwent incontinent urinary diversion from April 1993 through April 2013.Patients were categorized by conduit type—ileal, sigmoid colon, and transverse colon. Significant conduit-related complications were assessed at 30 and 90days after surgery. Significant conduit-related complication was defined as any of the following: ureteral stricture, conduit leak, conduit obstruction, conduit ischemia, ureteral anastomotic leak, stent obstruction requiring intervention via interventional radiology procedure or reoperation, and renal failure. ResultsA total of 166 patients underwent formation of an incontinent urinary conduit, most commonly during exenteration for gynecologic malignancy. There were 129 ileal, 11 transverse colon, and 26 sigmoid conduits. The overall significant conduit-related complication rate within 30days was 15.1%. Complication rates for ileal, transverse and sigmoid conduits were 14.7%, 0%, and 23.1%, respectively (Fisher's exact test, p=0.24). By 90days, the Kaplan–Meier estimated rates of significant complications were 21.8% overall, and 22.3%, 0%, and 28.9%, respectively, by conduit type (log-rank test, p=0.19). The most common significant conduit-related complications were conduit or ureteral anastomotic leaks and conduit obstructions. By 1 and 2years following surgery, the Kaplan–Meier estimated overall rate of significant conduit-related complication increased to 26.5% and 30.1%, respectively. ConclusionsOur study suggests that there are multiple appropriate tissue sites for use in incontinent conduit formation, and surgical approach should be individualized. Most significant conduit-related complications occur within 90days after surgery.

Vaginal malformations: a proposed classification based on embryological, anatomical and clinical criteria and their surgical management (an analysis of 167 cases)

Although it is virtually impossible to formulate a scheme that can satisfactorily collect all different types of vaginal malformations, a simple classification would be of a considerable value and would permit logical operative decisions. Many classifications of anomalies of uterus and vagina have been proposed: we find them unsatisfactory and confusing, being either too simple or too complex. We propose a new classification, focused only on vagina and based on embryological, anatomical, clinical and surgical criteria. In over 30years, 167 females with vaginal malformations have been observed in our department. Intersex cases were excluded. The encountered anomalies have been divided into six types and ten subtypes: type I vaginal agenesis (IA associated with uterine agenesis/17 Pts, IB isolated/1 Pt); type II vaginal atresia (IIA proximal/1 Pt, IIB distal/4 Pts); type III vaginal atresia with urethrovaginal fistula-urogenital sinus (IIIA proximal fistula-high sinus/42 Pts, IIIB distal fistula-low sinus/55 Pts); type IV vaginal atresia with transverse septum (IVA transverse septum/6 Pts, IVB imperforate hymen/17 Pts); type V disorders of müllerian ducts fusion (VA vaginal duplication/4 Pts, VB longitudinal septum/4 Pts); type VI cloaca/16 Pts. Of each type and subgroup of malformation the appropriate surgical correction is reported. Types of malformation and surgical treatment are analysed: IA vaginal reconstruction using a sigmoid conduit, IB vaginal reconstruction using a sigmoid conduit, atresic cervical resection and uterus-new vagina anastomosis according to Schmid; II perineal vaginal pull-through; IIIA anterior sagittal transanorectal vaginal pull-through, IIIB perineal flap vaginoplasty; IVA excision with abdominovaginal approach, IVB hymen incision; VA tubularization, VB septectomy via perineal approach; VI posterior sagittal anorectal-vaginal-urethroplasty. Most of the patients had good aesthetic and functional results. Type III showed relatively more complications: four redo operations (IIIA), four revisions of the vaginoplasty (IIIB). One patient is still waiting for definitive surgical correction. An early diagnosis is desirable to correct adequately vaginal malformations, which becomes mostly evident around puberty. The better timing for surgery is early age, to obtain better results and to avoid many of the psychological problems that arise at a later age.

Indications for Cutaneous Diversion in Modern Paediatric Urology

PURPOSE The aim of this study was to describe patient demographics of children undergoing cutaneous diversion, the types of surgery performed, the indications and complications. MATERIAL AND METHODS A retrospective cohort study was performed from 1995 to 2007. Our Hospital Trust database, Nurse Specialist records and the Spina Bifida registry identified children having undergone cutaneous diversion. Case note review was carried out to identify patient demographics, type of operation and indications for surgery and complications. RESULTS Thirty-nine patients were identified; 22(56%) male and 17(44%) female. Underlying medical conditions were neuropathic bladder 29 (74%)); bladder exstrophy 5 (13%)) and bladder outlet obstruction 5 (13%)). Median age at operation was 7 years with a range of 4 days to 19.75 years. Thirty children (77%) underwent ileal conduit formation. Ureterostomy and sigmoid conduits were formed in 6 (15%) and 2 (5%) respectively. The table below shows indications for surgery. One patient died in the immediate peri-operative period. Two patients required major re-operative surgery for bowel obstruction and nephro-enteric fistula. Twenty per cent of patients experienced difficulties using appliances. Table 1 Social Psychological Improved quality of life Failure of previous surgery Deteriorating renal function Reconstructive surgery not possible 5 10 5 4 13 1 CONCLUSIONS Cutaneous diversion continues to be a useful strategy in the management of selected patient groups with urinary problems.

Transverse retubularized sigmoidovesicostomy continent urinary diversion to the umbilicus.

The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus. In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipation and overflow fecal incontinence secondary to neurogenic bowel. Laparoscopy was performed to mobilize the appendix in patients who requested a low Pfannenstiel incision for better cosmesis. Additional procedures included the pubovaginal sling placement and sigmoid colocystoplasty. Mean length of the sigmoidovesicostomy, which was equal to the circumference of the sigmoid before retubularization, was 13 cm. (range 10 to 15). This sigmoid conduit reached the umbilicus easily in all cases. All sigmoidovesicostomies were easily catheterized and all were continent. One patient with morbid obesity (body mass index 40.4) had a mucocutaneous anastomotic breakdown 3 months postoperatively. Minimum followup was 1 year (mean 1.5). Transverse retubularized sigmoidovesicostomy is effective for creating a continent urinary diversion to the umbilicus in patients with neurogenic bladder secondary to spina bifida. Dilating the sigmoid colon from neurogenic bowel creates a long conduit based on the Yang-Monti principle and 2 ileal segments with an anastomosis are not required. Additional benefits are that the sigmoid colon is readily accessible via a low Pfannenstiel incision and may also be used for augmentation in select cases.

Comparative study of two sites of colonic conduit placement in the treatment of constipation due to rectal evacuatory disorders.

Chronic constipation may be treated by antegrade colonic irrigation via a colonic conduit. Two alternative sites of colonic conduit construction were evaluated for their effect on the symptoms of 21 consecutive women with intractable constipation primarily due to rectal evacuatory disorders. The conduit was constructed in the sigmoid colon in the first 11 patients and in the transverse colon in the subsequent ten. Symptomatic outcome was evaluated clinically and by questionnaires, with a prospective quality of life assessment in the transverse group. During a median follow-up of 12 (range 6-60) months, reflux or stenosis necessitated revision or dilatation in six patients. Irrigation with a median of 1.3 (0.8-2.0) litres of water achieved evacuation in all patients. Improvements in abdominal pain and bloating were reported by seven of the ten patients in the transverse conduit group, but benefit was found in only three of 11 in the sigmoid group. There was no significant improvement in quality of life scores. In the medium term, seven patients retained a transverse conduit compared with three with a sigmoid conduit. The transverse colonic conduit offers better relief from the symptoms of constipation due to rectal evacuatory dysfunction than the sigmoid conduit.

Transitional cell carcinoma of the distal portion of ureter protruding into the sigmoid conduit six years after cystoprostatectomy

Bladder tumors develop after the diagnosis of upper urinary tract carcinoma in approximately 20% of cases, whereas the incidence of upper urinary tract tumor after the diagnosis of bladder cancer is low, approximately 2%. In a 64-year-old man who had undergone cystoprostatectomy treatment of bladder carcinoma 6 years previously, with the sigmoid conduit used for supravesicle diversion, a transitional cell carcinoma that developed in the conduit was not revealed with intravenous pyelography at regular follow-up intervals. The patient had only hematuria. After an obstructed left kidney, left ureteral stricture, and a filling defect in the conduit were observed radiologically and biopsy revealed a transitional cell carcinoma at the ureterosigmoid junction, the patient underwent left nephroureterectomy, partial resection of a third of the sigmoid conduit, and right ureteral reimplantation. The occurrence of upper urinary tract carcinoma after treatment of bladder cancer should be considered even in light of intravenous pyelography that shows no abnormality; and when such carcinomas occur in this situation, disease involving the conduit should be ruled out.

Continent Urinary Diversion Using an Artificial Urinary Sphincter

Summary— We report a new and simplified method of continent urinary diversion employing a modified AMS 800 artificial urinary sphincter (AUS). Our aim in using this artificial valve is to make a stoma continent, while allowing intermittent catheterisation. The AMS 800 pump is replaced by a subcutaneous injection port. This allows, by direct puncture, the accurate setting of the closing pressure by varying the volume of the intra‐prosthetic liquid, with subsequent adjustment of this pressure as necessary. The cuff is placed on the subcutaneous part of the intestinal loop diversion. The pressure‐regulating balloon is implanted within the area of abdominal pressure, retroperitoneally.After first confirming the efficacy of the system in 3 dogs, the device was placed in 2 patients. The first had a neuropathic bladder treated initially by enterocystoplasty with an appendicocutaneous stoma. Secondary leakage was subsequently controlled by placement of the device, with continuing excellent results at 32 months. The second patient was a girl in whom a urogenital rhabdomyosarcoma had been treated by anterior exenteration, radiotherapy and a sigmoid conduit diversion. This was subsequently converted to a continent reservoir by simple augmentation of the conduit and placement of the device, with a good result being maintained after a follow‐up of 20 months.These two cases illustrate the best indications for this procedure, namely primary or secondary leakage from a supposedly continent urinary diversion, and conversion of a freely draining conduit into a continent reservoir.Although long‐term results are still pending, our experience thus far encourages us to recommend this technique as a simple means of achieving a continent urinary diversion.

Continent Appendicocolostomy: A Variation of the Mitrofanoff Principle in Pediatric Urinary Tract Reconstruction

There are numerous options for continent urinary reconstruction in children. If the appendix is available and the bladder capacity is satisfactory, a Mitrofanoff procedure may be performed using the appendix as a catheterizable tube implanted into the bladder. However, in many patients the bladder is absent or too small for this type of reconstruction. An alternative technique, termed appendicocolostomy, is to implant the appendix under the tenia of a detubularized patch of cecum or sigmoid colon, which becomes part of a continent neobladder or is attached to the bladder itself. This procedure has been used in 12 children and 1 adult undergoing continent reconstruction. Urological diseases included bladder exstrophy (10 patients) and a neuropathic bladder (3). Two patients underwent undiversion of a sigmoid conduit, while in 7 of the remaining patients the bladder was included in the reservoir. In 1 patient histological examination of the tip of the appendix revealed an incidental invasive carcinoid tumor necessitating appendectomy and revision of the reconstruction. Otherwise, no complications have occurred. Three adults were scheduled for this procedure but the appendix was diseased and an alternative form of diversion was necessary. Followup ranged from 2 months to 4 years. All patients are totally dry with a capacity of 300 to 750 cc (mean 475 cc). The appendicocolostomy is a superior form of conduit reconstruction that should be considered when the appendix is available during continent reconstruction. However, in adults the appendix may be fibrotic, precluding its use. Because most boys with exstrophy and a small bladder capacity requiring augmentation cystoplasty must perform intermittent catheterization, attachment of the appendix to the reservoir is an alternative that allows for easier and less painful intermittent catheterization than catheterization of the reconstructed epispadiae penis.

Conversion from External Appliance Wearing or Internal Urinary Diversion to a Continent Urinary Reservoir (Florida Pouch I and II): Surgical Technique, Indications and Complications

A total of 20 patients with diversion requiring an external appliance or internal urinary diversion underwent conversion to a continent urinary reservoir (Florida pouch I or II). All patients subsequently reported an improvement in the quality of life and expressed satisfaction with the new urinary diversion procedure. Of the patients 15 (75%) previously had an ileal conduit, while 1 (5%) had undergone ureterosigmoidostomy, 1 (5%) had cutaneous ureterostomy, 1 (5%) had a suprapubic tube, 1 (5%) had a sigmoid conduit and 1 (5%) had a cecal conduit. After the original diversion 3 patients (15%) had recurrent urinary infections, 3 had complications related to the stoma and external appliance (stenosis and skin dermatitis) and 5 (25%) had ureteral obstruction in 7 ureters. A total of 17 patients with conduits (85%) underwent conversion via different surgical technical aspects depending on the status of the intestinal segment from the conduit and the function of the ureteral reimplantation: in 14 the conduit was discarded or was used only to patch the newly created Florida I colonic pouch, while in 6 the conduit was preserved and 9 ureterointestinal reimplantations were left undisturbed (Florida pouch II). Among 7 ureters preoperatively obstructed (original diversion), reimplanting them into the pouch failed to prevent further renal damage in 5 (71%). Three renal units required nephrectomy, 2 kidneys deteriorated and 2 recovered renal function after percutaneous balloon dilation and stenting. Among 31 preoperatively nonobstructed renoureteral units (original diversion), 22 were reimplanted into the colonic reservoir. One of these units (4.2%) became obstructed postoperatively and 3 (13.5%) presently have reflux. The 10 reimplantations left undisturbed in the detubularized conduit drain satisfactorily without postoperative obstruction and in 6 reflux has not been demonstrated. Renal function (serum creatinine) is preserved in all patients but 15 (75%) have hyperchloremia of mild degree. Two patients (10%) have acidosis and 1 (5%) of these had low red blood cell folic acid. Conversion of an external or internal diversion to a continent colonic urinary reservoir (Florida pouch I or II) can be successful and improve the quality of life of the patient. The functioning renal units that were preoperatively obstructed were associated with a high failure rate (71%) after reimplantation. Metabolic alterations will require long-term followup, and are particularly worrisome in children and young adults.

Pyelotransverse Pyelocolostomy: An Alternative Method for High Urinary Diversion in Patients with Extended Bilateral Ureter Damage

After previous radiation due to pelvic malignoma or after multiple operations, the ileal conduit as well as sigmoid conduit are associated with an increased rate of complications. In these patients, the middle and distal ureter often cannot be considered for reimplantation due to fibrosis. High anastomosis to a bowel segment which is undamaged proves favorable. The transverse colon, conveniently situated in the cranial abdomen, is close enough to the kidneys for such a high anastomosis and is mostly spared from irradiation. In cases where severely damaged ureters forbid connection to a normal transverse conduit, we performed a pyelotransverse pyelocolostomy with high anastomosis of the bowel to both renal pelves or ureteropelvic junctions. 7 patients have been treated in this way and the follow-up of these patients ranges between 14 and 24 months. Postoperatively increased renal function was found in 6 renal units, stable function in 6 renal units, and only 1 patient showed a functional ureteropelvic stenosis. 4 months after the operation 1 patient died of sepsis caused by recurrent urinary tract infections due to recurrent stone disease as a consequence of immobilization in myelomeningocele. In patients with nearly total loss of ureters the pyelotransverse conduit is an effective surgical solution and may prove more comfortable to the patient than bilateral percutaneous nephrostomies.

Treatment of iatrogenic functional or morphologic bladder loss

From 1984 to 1986, six children from 4 to 13 years of age, received a bladder augmentation by ileocecal cystoplasty (Mainz-pouch technique) because of an iatrogenic functional or morphologic bladder loss. Indications for operation were incontinence due to the low bladder capacity or threat to the upper urinary tract due to ureteral obstruction or vesicorenal reflux. Two of the children had already undergone supravesical urinary diversion by sigmoid conduit. After a follow-up period of 2 to 19 months, (mean 11 months), five of the six children are completely continent. One boy with a known weak sphincter still has slight, but decreasing, enuresis nocturna in periods of complete filling of the pouch, 1 month after the operation. All children are able to void their augmented bladders without residual urine.

Urinary diversion with use of ileal and sigmoid conduits

Two hundred eighteen patients underwent urinary diversion: 156 with ileal and 62 with sigmoid conduits. There were no significant differences between the two groups regarding frequency of conduit morbidity or patient survival. The ileal conduit is preferred for urinary diversion with anterior exenteration, whereas the sigmoid conduit is preferable for urinary diversion with total exenteration.

Urinary diversion in patients undergoing pelvic exenteration

Between October, 1969, and April, 1981, gynecologic oncologists at the University of Alabama Medical Center in Birmingham have performed 119 pelvic exenterations. One hundred fifteen of these patients had a concurrent supravesical urinary diversion. Fifty-six patients (48.7%) had an anterior exenteration and 59 patients (51.3%) had a total exenteration. An ileal segment was used as a conduit in 97 patients while the segment of transverse colon was used in 16 patients. Two patients had sigmoid conduits. Eighty-five patients (73.9%) had the intestinal anastomosis and conduit constructed with gastrointestinal staplers. Stapler use shortened the mean operating time for the exenterative procedure by approximately 30%. No increase in postoperative gastrointestinal complications was noted. Urinary diversion preformed as part of a pelvic exenteration has been associated with short- and long-term complications. The use of ureteral stents and the gastrointestinal staplers shortens the procedure without predisposing the patient to major urologic complications. The use of a segment of unirradiated bowel (transverse colon) in conjunction with these techniques constitutes the preferred method of supravesical urinary diversion in patients undergoing a pelvic exenteration.