How to Manage a Dysfunction of the Efferent Segment in Continent Cutaneous Urinary Diversion (Hydraulic Reservoir)? A Retrospective Study of 10 Cases

"Continent cutaneous reservoirs after cystectomy remain an invaluable treatment option for a well-defined subset of indications. The continence mechanism largely determines the treatment success in terms of patient satisfaction and quality of life. Any dysfunction is considered a failure by both patients and surgeons. A retrospective study was made from 2003 to 2013 (13 years) with the aim to characterize the hydraulic valve dysfunction in patients who underwent a cystectomy with continent urinary pouch. A total of ten patients were included in this study. The main age was 44 years. The indications of cystectomy were pelvic tumors (62%); vesico-vaginal fistulas (20%); bladder extrophy (10%); hypospadias (4%) and complicated uretral strictures (4%). An hydraulic continent valve according the Benchekroun process was made for all our patients. After a median follow-up of 36 months; the main related efferent segment complications were fistulas in the top of the valve or ""pinhole fistula"" in 25% of cases; the externalized prolapse of disinserted valve in 25% of cases; and the progressive desinvagination with urinary incontinence in 50% of cases Continent catheterizable urinary diversion remains a treatment option for a well-defined subset of indications. There is little consensus regarding the different options for the efferent segment; which has the greatest influence on patient satisfaction."

Disintegrating Perineal Disease in Patients with Urethral Stricture and HIV Infection: A Review of 12 Cases

The aim of this study was to define disintegrating perineal disease (DPD) and to determine whether the fulminating nature of the condition could be explained by urine and perineal swab microbiology or perineal histology. A retrospective study that included 12 male patients with urethral strictures and DPD was performed. DPD was defined as a chronic; destructive; purulent perineal inflammation with multiple fistulae or sinuses of the perineum; scrotum or penoscrotal area; which continued for more than six weeks despite a patent urethra after direct vision internal urethrotomy (DVIU) or urinary diversion by means of suprapubic cystostomy. The median patient age was 43.5 years (range of 22-68 years). The patients all tested positive for human immunodeficiency virus (HIV) infection. Their mean CD4 count was 340 cells/mm3 (range of 244-1 252 cells/mm3). Histology of the fistula tracts showed non-specific inflammation in 8 patients (66.7); tuberculosis in 2 (16.7); hydradenitis suppurativa in one (8.3); and squamous cell carcinoma in situ with condylomata acuminata in one patient (8.3). DVIU was performed in 10 patients. Patency of the urethra could be achieved in only three patients for more than six weeks. Perineal urethrostomy was completed in three patients after failed DVIU. Ileal conduit urinary diversion and simple cystectomy was carried out in three patients and curing the DPD was accomplished in two. DPD relates to urethral stricture disease in HIV-positive men with secondary infection as the initiating cause; but no predominant microorganism is responsible for the condition. Simple cystectomy with urinary diversion may be the only solution to treating this debilitating disease

Continent Cutaneous Urinary Conversion

Objectives: After ileal or colon conduit diversion some patients; in particular in adolescence; desire a conversion into a continent form of diversion thus removing external devices and improving the quality of life. We report our long-term results of conversion from conduits into a continent cutaneous diversion. Methods: Between July 1986 and February 2001; a total of 32 patients (mean age: 18 years; range 6 to 49 years) underwent conversion of a colon (n=19) or ileal conduit (n=13) into an ileo-caecal pouch with a mean follow-up of 97 months (range 11-185 months). Conversion was performed using a simplified technique incorporating the preexisting colon/ileal conduit into ileocaecal Mainz pouch I. The morphology of the upper urinary tract; renal function; con-tinence and metabolic changes were analyzed. Results: A total of 17 patients (53) showed complications requiring surgical intervention; these included stoma stenosis (13); pouch calculi (28) as well as ureteric stenosis in 4/61 RU (7). Continence was achieved in 97of patients. Faecal frequency was unchanged in 75of patients without treatment while the rest required medical therapy (cholestyramine; loperamide). During follow-up; early substitution of alkalizing agents was performed at a base excess of -2.0 mmol/l for 15 patients (47); thus preventing acidosis. The renal function remained stable during follow-up. All patients are completely satisfied; in particular as compared to the previous situation. Conclusion: The inclusion of the preexisting colon or ileal conduit facilitates continent cutaneous conversion and decreases bowel requirements. An acceptable complication rate; a stable renal function and the patient's comfort support the conversion of a conduit into Mainz Pouch I as a safe and viable option on the long run

The Impact of preservation of the prostatic apex on the urodynamic characteristics in different orthotopic ileal reservoirs

Objective This study was carried out to evaluate the urodynamic characteristics of the Camey II; Kock's and W-configured ileal reservoirs utilized for orthotopic urinary diversion. Patients and Methods Between January 2000 and 2002; 42 male patients prospectively underwent radical cystoprostatectomy for bladder cancer followed by orthotopic urinary diversion at the urology department of Cairo University hospitals. All cases were evaluated clinically; bacteriologically; radiologically and urodynamically including uroflowmetry; medium-fill and voiding enterocystometry and urethral pressure profilometry; which was done in the early and late postoperative period (at 3-6 months and 6-18 months). Patients were divided into four groups: Group I: 11 cases with preservation of the prostatic apex and creation of a W-neobladder. Group II: 11 cases without prostatic apex preservation and creation of a W-shaped ileal pouch. Group III: 12 cases without prostatic apex preservation and creation of a Camey II pouch. Group IV: 8 cases without prostatic apex preservation and creation of a Kock's pouch. Results The patients of Group I had a larger mean neobladder capacity (699 ml) and volume at which the first contraction occurred (315 ml) and a larger amount of residual urine (224 ml) as compared to Group II (511.1; 285 and 77.5 ml; respectively); Group III (375; 200 and 55 ml; respectively) and Group IV (563; 266 and 600 ml; respectively). Also Group I with a preserved prostatic apex had a higher mean intraluminal opening pressure (55 cm H2O) and a higher pressure at maximum flow (62.36 cm H20) as compared to the patients with complete prostatic resection. Conclusion We conclude that the patients with a preserved prostatic apex (Group I) had a statistically significant higher mean residual urine in the early and late postoperative period and a significantly higher mean maximum cystometric capacity in the late postoperative period as compared to those recorded in patients with complete prostatic resection (Groups II; III; IV). A higher incidence of upper tract deterioration was detected in Group I (35) vs. 4.6; 27.8and 12.5in Groups II; III and IV; respectively

Transerve colon pouch : an alternative to continent urinary diversion after pelvic irradiation

Objective Urinary diversion after pelvic irradiation is challenging. The use of irradiated bowel is mostly complicated and unsuccessful. Therefore; the use of an exclusively non-irradiated bowel segment; such as the transverse colon; is a good alternative in such situation. Patients and Methods Twenty-nine female patients who had received a high dose of irradiation underwent construction of a transverse colon reservoir as a primary form of urinary diversion. The indications were irreparable vesicovaginal fistula in 5; local recurrence of gynaecological tumors in 18 and invasive bladder carcinoma in 6 patients. They were followed up for a median of 5.6 (1-9) years. Results No pouch-related complications were observed. Hydronephrosis improved in 9 of 15 renal units that had preoperatively been dilated. Incontinence occurred in 3 patients due to an inefficient stoma that was revised; and all were continent thereafter. Conclusion The results suggest that the transverse colon reservoir in previously irradiated patients is safe and effective. It can; therefore; be recommended as the method of choice in this group of patients