Technique For Urinary Diversion Research Articles

Urinary diversion for incontinence in women.

Urinary incontinence is a common condition affecting up to 50% of the female population, but only a third seek medical help. Although the majority of these are satisfactorily managed with conservative or conventional surgical treatment, 10%-15% continue to remain incontinent despite intervention. Urinary diversion is a management option for this group. The different techniques of urinary diversion, their results, complications and long-term sequelae are discussed, with a review of the literature.

SEROUS LINED EXTRAMURAL ILEAL VALVE: A NEW CONTINENT URINARY OUTLET

Purpose We report the functional results following the use of serous lined extramural valve as an antireflux technique and urinary outlet for continent urinary diversion. Materials and Methods The procedure was performed in 18 men and 5 women. The technique entails fashioning 2 serous lined extramural troughs in a detubularized W-shape ileal reservoir. A tapered ileal segment is embedded in 1 trough as an antireflux valve and the ureters are anastomosed to its proximal end. Another tapered ileal segment or the appendix is embedded in the second trough and acts as a continent cutaneous outlet. Results No operative or postoperative mortality was observed. One patient had prolonged ileus which was treated conservatively. All patients were evaluable with a mean followup of 19 months. All patients but 1 were continent day and night. No catheterization difficulties were reported. Evacuation intervals were 4 to 5 hours. Radiographic evaluation demonstrated a continent complaint reservoir, stable and straight outlet, and absence of pouch and ureteral reflux. Conclusions This procedure is technically feasible, surgically versatile, applicable for urinary diversion or conversion and associated with satisfactory outcome.

Continent urinary diversion: Evolution of techniques

– The panel discussion is introduced with emphasis being placed on the continuing development of urinary diversion techniques, the history of which is briefly summarized. To date, indications for external continent diversion are limited. Women in particular, who have long been considered as ideal candidates for continent diversion, are now being submitted with increasing frequency to orthotopic bladder reconstruction to the urethra.

Urinary diversion in children and young adults using the Mainz Pouch I technique.

To determine the late complications and consequences for renal function, vitamin and acid-base metabolism after application of the Mainz Pouch I (MZP-I) technique in children and young adults. To November 1994, the MZP-I procedure was carried out in 463 patients at our institution, 91 of whom were children and adolescents (< or = 20 years old) using bladder augmentation in 21 and a continent cutaneous stoma in 70. A minimum follow-up of 1 year was possible in 87 patients or 163 renal units (RUs) with a mean of 5.5 years (range 1-10.5). At the last examination, 23 of 55 (42%) preoperatively dilated RUs had improved. 131 of the 163 RUs (80%) were stable and nine RUs (5.5%) showed a slight clinical asymptomatic increase in the upper tract dilatation. Through an extraperitoneal flank incision, 11% of the RUs which developed stenosis at the ureterocolic anastomosis were successfully reimplanted (16% in patients with neurogenic disorders, 17% with pre-operative irradiation and 5% in the remaining patients). Two of 32 patients with an intussuscepted and invaginated ileal nipple required re-operation due to incontinence, but none of the patients with an appendiceal stoma were incontinent. Open revision of a stomal stenosis was performed in three and endoscopic treatment in nine patients. In 54 patients, the levels of vitamins A, B1, B2, B6, E, folic and bile acid were within normal ranges. There was no significant decrease in vitamin B12 levels after operation. In none of the patients with normal pre-operative creatinine values had the levels increased and none developed severe acidosis or bowel neoplasm. The MZP-I is recommended as a technique for bladder augmentation or continent urinary diversion in children and young adults, with an acceptable complication rate which offers long-term protection of the upper urinary tract.

Subcutaneous Urinary Diversions for Palliative Treatment of Pelvic Malignancies

Purpose We developed 2 subcutaneous urinary diversion techniques, pyelovesical bypass and anterior cutaneous nephrostomy, to improve the quality of life of patients undergoing permanent palliative percutaneous nephrostomy. Materials and Methods A total of 21 patients underwent either pyelovesical bypass (19) or anterior cutaneous nephrostomy (13). Technically, the percutaneous nephrostomy tube is replaced by a self-retaining expanded polytetrafluoroethylene-silicone tube tunneled underneath the skin. The distal extremity can be either introduced into the bladder, creating a pyelovesical bypass, or brought out directly through a cutaneous orifice, creating an anterior cutaneous nephrostomy. Results No tube was dislodged and none became obstructed due to incrustation or angulation. Standard percutaneous nephrostomy was necessary in 1 patient in each group. Improvement in the quality of life was stressed by all patients. Pyelovesical bypass eliminates external drainage and anterior cutaneous nephrostomy performed when the bladder is no longer functional allows for the creation of a single, easily dressed anterior stoma. Conclusions Pyelovesical bypass and anterior cutaneous nephrostomy constitute valuable alternatives to standard permanent palliative percutaneous nephrostomy.

Techniques of internai urinary diversion without bowel interruption

Internai urinary diversions date back more than 100 years to when ureterosigmoidostomy was introduced by Simon. Urinary diversion to the rectum is a simple technique of continent urinary diversion but can cause troublesome complications such as electrolyte imbalance, pyelonephritis and renal function deterioration. Improvement of the techniques of internai urinary diversion have reduced the risk of such complications. When the urethra cannot be preserved, internai urinary diversion provides a viable alternative to external diversion.

External continent diversion. Technical aspects and development principles

The Authors briefly review the evolution of urinary diversion techniques. The introduction of the ileal conduit (Bricker) was the most important step to construction of continent pouches, both external and orthotopic, which share most surgical principles (intestinal detubularization, adequate capacity of the pouch, anti-reflux system for the ureters). External pouches present, as-an additional surgical challenge, the technical problems related to the construction of the continent valve at the stoma site: it is therefore not surprising that they are being performed with decreasing frequency. On the other hand there is increasing interest in the construction of an orthotopic neobladder also in the female patient, where such reconstructive surgery has traditionally been impaired by the anatomo-functional features of the female urethra. The Authors maintain that the following points should be considered with great attention: a) functional border between urethra and bladder neck; b) oncologic border between transitional and stratified epithelium; c) positioning of the pouch within the pelvis; d) trophic condition of the pelvic wall musculature.

Management of bladder cancer

Bladder cancer is a paradigm of malignancy, representing the spectrum from localized to metastatic disease, and manifesting varied histologic types, including transitional cell carcinoma, squamous cell carcinoma, and adenocarcinoma. Preclinical and clinical data suggest that a common stem cell of origin gives rise to the different histologic types and that these patterns are of clonal origin. Localized bladder cancer is managed optimally by transurethral resection, with or without adjuvant intravesical chemotherapy. Invasive cancer or relapsed superficial disease may require more radical surgery or radical radiotherapy. In recent years, the evolution of techniques of continent urinary diversion or of bladder replacement has revolutionized the management of invasive disease. However, the 5-year survival for invasive bladder cancer is still approximately 50%, and innovative strategies have been developed, combining definitive local treatment and systemic chemotherapy, in an attempt to improve survival. For patients with metastatic disease, the combination of methotrexate, vinblastine, doxorubicin, and cisplatin (the MVAC regimen) has achieved response rates as high as 70% but with a median survival of only 12 months. Until cure rates are improved, one of the hallmarks of effective management of metastatic disease will remain the provision of thorough and well-structured palliative treatment programs. Recently, the introduction of new agents (such as paclitaxel, gallium, ifosfamide, and gemcitabine) has led to promising response rates, and further clinical trials of these agents alone and in combination are in progress. In addition, an improved understanding of the mechanisms of resistance to treatment, including the implications of the expression of p-glycoprotein, p53 proteins, and other biochemical predictors of outcome, and of strategies to overcome such resistance, may lead to more effective management of advanced disease. Furthermore, real progress will be made only through the application of well-designed clinical trials to test the efficacy and toxicity of the new strategies of treatment.

The Double-Barreled Wet Colostomy: Long-term Experience with the First 11 Patients

We describe our experience with a technique for simultaneous urinary and fecal diversion using a single abdominal stoma. The procedure requires the construction of a diverting loop colostomy with division of the colon approximately 15cm. distal to the stoma. This distal segment of colon acts as a urinary conduit, and allows internal separation of the urine and fecal streams. The procedure has been used in patients without a prior stoma as well as those with existing loop and end colostomies. Unlike the watery diarrhea associated with the wet colostomy described previously, these patients experience a continuous urine output and intermittent semiformed bowel movements. Complications have been minimal: there have been no episodes of clinical pyelonephritis, no new electrolyte problems and no significant stomal complications. In 1 patient late radiographic evidence of hydronephrosis developed associated with advancing metastatic disease, while in another late bilateral ureterocolonic strictures developed. The majority of patients died of the underlying cancer but 1 died of a myocardial infarction 2 weeks postoperatively. This procedure has now been performed in 11 patients with followup from 0.5 to 80 months. The results are gratifying for a group of highly complex cases.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

Continent urinary diversion using cutaneous ileocecocystoplasty

We have employed a technique of continent urinary diversion that uses ileocecocystoplasty to incorporate native bladder into the urinary reservoir. This allows creation of a reservoir in selected patients using less complicated surgery than complete replacement of the bladder and avoids ureteralintestinal anastomoses. Early results are promising for this simplified means of continent diversion.

An approach to stoma-less continent urinary diversion by uretero-ileoceco-proctostomy (ileocecorectal bladder)

The current practice of continent urinary diversion still places the patients under the restraint of the stoma and intermittent catheterization. To overcome these problems, we developed a new technique of urinary diversion of which continent is controlled by the anal sphincter. The isolated ileocecal segment is intussuscepted and interposed between the ureters and the rectum. The conjoined ureters are anastomosed to the stump of the ileal limb, and the antimesenteric portion of the cecal limb is joined to the anterior wall of the rectum. The surgical procedure is simpler than that of the continent reservoirs currently employed. The intussuscepted ileocecal segment prevents fecal reflux to the upper urinary tract and may also inhibit carcinogenesis at the uretero-intestinal junction. Additionally, the rectal capacity is augmented by the side to side anastomosis between the cecal limb and the rectum. Our preliminary experience in 10 cases were satisfactory with respect to voiding function, antireflux mechanism of the intussuscepted ileocecal segment and quality of life. The results will justify further trials with this stomaless continent urinary diversion for those in whom the urethra cannot be used.

A Simplified Technique for Continent Urinary Diversion: An All-Stapled Colonic Reservoir

A simple continent colonic reservoir was constructed in its entirety with the aid of surgical stapling techniques in 17 men and 10 women. In 5 men an orthotopic pouch was created and in the rest a continent stoma was designed. Detubularization of the entire colonic segment assures a low pressure system with disruption of directional peristaltic activity. The ureters are implanted by simply burying them in a mucosal furrow. Operative time required for the creation of the reservoir (excluding time for cystectomy) has ranged between 70 and 140 minutes (mean 95.4minutes). With a followup of 9 to 60 months (mean 22.8 months) continence has been achieved in all but 1 patient with no ureteral reflux or obstruction. Urodynamically the pouch has achieved a large capacity (mean 750 cc) with low filling pressures (8.1cm. water) because of technical ease of construction together with a shortened operative time due to the stapling techniques. This form of bladder replacement offers an option for select patients in whom continent urinary diversion is contemplated.

Transureteroureterostomy and Terminal Loop Cutaneous Ureterostomy in Advanced Pelvic Malignancies

Transureteroureterostomy was combined with terminal loop cutaneous ureterostomy, without complications, in 8 patients with advanced pelvic malignancy and a poor prognosis. Urinary diversion was palliative in all patients and followed pelvic exenteration in 4, debulking of pelvic tumor in 2 and radical cystectomy in 1, while 1 had inoperable bladder cancer. All patients had at least unilateral hydroureteronephrosis preoperatively. In each case a postoperative excretory urogram revealed significant improvement of the hydroureteronephrosis and the serum creatinine improved or stabilized. No patient had ureteral stomal stenosis or retraction. Mean survival was 5 months, with the longest survival being 1 year. Transureteroureterostomy in conjunction with terminal loop cutaneous ureterostomy is an effective technique of urinary diversion in selected patients with a poor prognosis and advanced pelvic malignancy, decreasing operative time while avoiding the morbidity associated with a ureterointestinal operation or nephrostomy.

Camey Procedure: A Continent Urinary Diversion Technique

Camey Procedure: A Continent Urinary Diversion Technique

Bladder cancer

Bladder cancer is largely a preventable disease; epidemiologic studies indicate that the majority of cases occur as a result of cigarette smoking or occupational exposures. The impact of screening high-risk populations is uncertain, but prompt and early diagnosis is essential for optimal therapeutic results. The management of different stages of disease varies greatly and is currently in a state of evolution. The majority of cancers are superficial, of low malignant potential, and can generally be treated cystoscopically. Few studies have addressed whether intravesical therapy will prevent high-risk patients with superficial disease from developing muscle invasion or distant metastases. Controversy exists as to optimal management of patients with invasive cancers. Improvements in technique and methodologies of urinary diversion have made cystectomy more tolerable for patients. Although cystectomy remains the “gold standard,” probably not all patients require it. The careful selection of those patients whose bladders can be preserved is currently being evaluated. Combination chemotherapy for patients with metastatic bladder cancer is very active, appears to prolong survival, and may offer durable remissions to some patients. Whether chemotherapy will permit greater numbers of patients with invasive bladder cancer to be cured and bladders preserved remains to be determined.

Continent vesicocutaneostomy. Preliminary experiments on dogs

A new operative technique for continent urinary diversion was designed as a continent vesicocutaneostomy and preliminary experiments were performed on 7 dogs. A U-shaped flap of anterior bladder wall (30 X 20 X 30 mm) was created, which was then rolled and sutured to an efferent duct. One-half to two-thirds in length of the efferent duct was placed between the muscular layer and mucosa of the bladder, and the distal end of the efferent duct was anastomosed to the cutaneous stoma made at the suprapubic area. In this urinary diversion, excretion of urine from the bladder was done by intermittent catheterization from the stoma through the efferent duct. The operation was successful on all of the experimented dogs, continence of the stoma was preserved and catheterization through the stoma was achieved easily. Urodynamic assessment of the efferent duct was performed, being focused on the mechanism of continence, at 3 and 6 months after the operation. The length of continence zone and maximum closing pressure through the entire efferent duct were 23.2 +/- 4.5 mm and 41.2 +/- 14.7 cmH2O respectively with empty bladder (intravesical pressure = 0). When the bladder was full (intravesical pressure = 20-40 cmH2O), these parameters were 21.4 +/- 4.7 mm and 36.0 +/- 7.0 cmH2O respectively. The length of continence zone and maximum closing pressure of only the submucosal part of the efferent duct were 12.8 +/- 4.3 mm and 18.5 +/- 5.2 cmH2O with empty bladder, 13.3 +/- 2.9 mm and 22.0 +/- 9.9 cmH2O with full bladder.(ABSTRACT TRUNCATED AT 250 WORDS)

A New Technique for Continent Urinary Diversion

Canine experimental surgery was used to investigate the feasibility of creating a new continent urinary reservoir. Remodelled ileum was used to fashion this reservoir like the Kock pouch, but without either of the intussuscepted nipple valves which it uses. Ureters were implanted directly into the wall of the reservoir using a nonrefluxing technique. Continence was obtained by plication of a short limb of intact ileum exiting from the reservoir through which intermittent catheterization was performed. Three of four animals which remained infection-free had good to excellent results. Reservoir infection in four additional animals was associated with failure due to ureteral obstruction. The advantages of this reservoir include the use of ileum to achieve a low-pressure reservoir, the absence of the complex nipple valves of the Kock pouch, and the absence of foreign bodies such as staples and artificial sphincters. While the followup in this study is recognized as relatively short-term, the successes seen in this difficult-to-use animal model suggest that further evaluation of this simplified procedure is warranted.

Radical cystectomy--often too late?

From 1967 to 1985, 246 cystectomies for treatment of transitional cell carcinoma of the urinary bladder were performed. Perioperative mortality decreased from 15% in the early years to 0% in 1985. Preoperative radiotherapy was not given. Patients who underwent cystectomy immediately following the diagnosis of invasive bladder carcinoma had a significantly better prognosis than those having cystectomy after recurrence of a transurethrally resected invasive carcinoma in spite of identical G and T criteria. A total of 26 patients who were cystectomized because of tumor recurrence after definitive radiotherapy (salvage cystectomy) represented the group with the worst prognosis: they had a 5-year survival rate of less than 10%. It is concluded from these results that recurrence of an infiltrating bladder tumor is an indication of poor prognosis. Early cystectomy after diagnosis of tumor infiltration can improve survival rates. Transurethral resection without adjuvant therapy cannot be regarded as reliable curative treatment of bladder cancer infiltrating the lamina propria (pT1). Modern surgical techniques of continent urinary diversion or total bladder replacement combined with sparing of the pelvic nerves (and thus preservation of potency) reinforce our view that radical cystoprostatectomy need no longer be regarded as mutilating surgery.

Selective Urethrectomy Following Cystoprostatectomy for Bladder Cancer

The poor prognosis in patients who have symptomatic urethral carcinoma after cystoprostatectomy has prompted some investigators to recommend prophylactic urethrectomy. However, this approach subjects the majority of these patients (up to 90 per cent) to an operation for a disease that they might never have and precludes some innovative urinary diversion techniques. From June 1976 to July 1985 we performed 75 cystoprostatectomies for bladder cancer in men. Three patients underwent simultaneous urethrectomy because of tumor in the urethra. Of the remaining 72 patients who were followed by urethral wash cytology studies every 6 months 7 (10 per cent) had positive cytology studies during followup and underwent urethrectomy. Subsequent histological examination showed carcinoma in situ in all 7 specimens. To date 6 of the 7 patients are free of disease. One patient died 18 months after urethrectomy without evidence of transitional cell carcinoma. We have had no false positive urethral wash cytology studies and no patient has had local recurrence in the absence of a positive cytology study.