The Oncologic and Functional Results of the Ileal W-neobladder with a Serous-lined Extramural Tunnel / 대한비뇨기과학회지

PURPOSE: We wanted to analyze the oncologic and functional outcomes of radical cystectomy and creation of an orthotopic ileal neobladder with a serous-lined extramural tunnel. MATERIALS AND METHODS: There were 110 patients and 101 patients were male(mean age: 58.7 years, age range: 35-78 years). All these patients underwent radical cystectomy and creation of a ileal W-shaped neobladder with a serous-lined extramural tunnel, and all the procedures were done by one surgeon. The median period of follow-up was 28.9(range: 6-95) months. The Assessing the patients' clinical history, physical examinations, complete laboratory tests, CT scans and bone scans were performed postoperatively for the evaluation of recurrence and complications. The voiding patterns of 77 patients of the 110 patients were surveyed. RESULTS: Five-year-overall survival was 56% and the median survival period was 66.1 months. The tumor recurrence rate was 39.1%(43 patients) and 21(19.1%) patients died due to progression of cancer. The daytime and nighttime urinary continence rates at postoperative 1 year were 87% and 79%, respectively. Sixty three(81%) patients among the 77 patients had no voiding problems after the procedures. Nine patients still had severe incontinence and 5 patients still suffered from voiding difficulty. Renal functional deterioration developed in 3 patients(2.8%); however, no patients were on dialysis. Acute pyelonephritis was observed in 12 patients and recurrent pyelonephritis occurred in 6 patients. Ureter-ileal anastomosis site stricture was occurred in 5 renal units. No reflux from the ileal bladder into the ureter was observed. CONCLUSIONS: Radical cystectomy and an orthotopic ileal neobladder using a serous-lined extramural tunnel for patients with invasive bladder cancer were effective and durable procedures in terms of the oncologic and functional outcomes.

Polypoid Cystitis Managed by Bladder Substitution / 대한비뇨기과학회지

Polypoid cystitis is an unusual benign lesion characterized by the edema, congestion and inflammation elevating the vesical mucosa into papillary projections. It is rare in the absence of one of the following 3 recognizable causes: indwelling catheters, vesical fistula or chronic bladder irritation. We report a case of a rapidly growing, huge polypoid cystitis without identifiable cause in a 17-year-old female, who was managed by cystectomy with uterus preservation and orthotopic bladder substitution.

Ileal W-Neobladder in Women with Bladder Cancer: Early Experience / 대한비뇨기과학회지

PURPOSE: The anatomical and voiding functional outcomes of orthotopic neobladders in women with bladder cancer were investigated. MATERIALS AND METHODS: Since July, 1998, 5 women (median age 64.8) underwent an orthotopic bladder substitution following a radical cystectomy for bladder cancer. The median follow-up was 19.6 months (range 12 to 35). After urethral sparing cystectomy, an ileal W-neobladder was constructed and supported by an omental flap. Both the early and late complications were analyzed. A pressure flow study was performed to evaluate the voiding function, and a radiologic study including a MRI was performed to observe the anatomy. RESULTS: There were no perioperative deaths and no early and late complications related to the surgery except for acute pyelonephritis, which occurred in one patient 22 months after surgery. Four patients were continent day and night and one patient had nighttime incontinence. MRI showed that the urethra was connected to the dependent portion of the neobladder, which was supported by an omental flap in all patients. No recurrence of cancer in the native urethra was noted. All patients were satisfied postoperatively. CONCLUSIONS: Orthotopic bladder substitution after a standard radical cystectomy in women provides satisfactory anatomical and functional outcomes. An omental flap could improve the voiding function by supporting the neobladder and making a urethroneobladder junction located in the dependent portion of the neobladder.

Computed Tomographic Appearance of Orthotopic Neobladder: Correlation with Voiding Pattern / 대한비뇨기과학회지

PURPOSE: To define computed tomographic (CT) appearance according to voiding patterns and to evaluate the significance of CT in patients with voiding dysfunction after orthotopic bladder substitution following radical cystectomy. MATERIALS AND METHODS: We evaluated a total of 50 male patients in whom 25 had undergone an ileocolic and 25 had undergone an ileal neobladder. We performed uroflowmetry, postoperative voiding cystourethrography (VCUG) and CT for evaluation of configuration of neobladder according to voiding pattern. We defined a good voider (n=37) as the patients with maximum flow rate greater than 15 ml/sec and postvoid residual urine amount less than 200ml and a poor voider (n=13) as those with less than 15 ml/sec or greater than 200ml. RESULTS: Voiding cystourethrography revealed that the neobladder outlet was well funneled and wide open at the most dependent portion of the neobladder in good voider group. However, in poor voider group, the neobladder outlet was not funneled or deviated from its caudal location. CT revealed that the neobladder was symmetric in 28 cases (75.7%) and had soft tissue density in the neobladder base in 9 cases (24.3%) of good voider group. However, neobladder was asymmetric in 8 cases (61.5%) and had soft tissue density in the neobladder base in 8 cases (61.5%) of poor voider group. CONCLUSIONS: The asymmetry of neobladder and soft tissue density around base of neobladder on CT may be associated with the deviated neobladder outlet. This CT finding might be useful to presume the cause of voiding pattern.

A review of the use of bowel in bladder enlargement and substitution (with case reports of two colocystoplasties)

The various bladder enlargement and substitution procedures using different segments of the intestinal tract have been reviewed and their merits and disadvantages presentedTwo female patients with contracted bladders due to chronic interstitial cystitis, where successful colocystoplasties were performed, are presented. (Summary)

Voiding Patterns of the Orthotopic Neobladder: Clinical, Urodynamic and Radiographic Analysis / 대한비뇨기과학회지

PURPOSE: We evaluated voiding patterns and voiding dysfunction after orthotopic bladder substitution in patients with bladder cancer. MATERIALS AND METHODS: We examined a total of 40 male patients of whom 25 had undergone an ileocolic and 15 had undergone an ileal neobladder. We interviewed the patients and obtained 3-day voiding diary in all patients and performed urodynamic study and voiding cystourethrography. RESULTS: When a good voider is defined as the patient with maximum flow rate of 15ml/sec or more and a poor voider is less than 15ml/sec, mean maximum flow rate in good voiders was 20.4+/-4.2ml/sec compared with 8.2+/-3.1ml/sec in poor voiders. Maximum bladder capacity, vesical opening pressure, and vesical pressure at the maximum flow rate were not different significantly between the two groups. All patients voided by abdominal straining and relaxing the pelvic floor musculature in pressure-flow study. However, voiding patterns revealed differences between good and poor voiders. In good voiders, a single long-lasting abdominal straining achieved a smooth voiding, while in poor voiders, short-lasting frequent abdominal strainings resulted in interrupted and obstructive urine flow. Good continence during day and night was achieved in 90.6% and 81.3% of the good voiders and 87.5% and 87.5% of the poor voiders. The maximum urethral closure pressure and the functional urethral length decreased in incontinent patients. Voiding cystourethrography revealed that the reservoir was symmetric and its outlet was well funnelled and wide open at the most dependent portion of the reservoir in good voiders. However, in poor voiders, the reservoir revealed asymmetric configuration and its outlet did not funnel or deviated from its caudal location. CONCLUSIONS: Neobladder patients void by abdominal straining in coordination with the relaxation of pelvic floor musculature. Correct location of the neobladder outlet, minimum injury to the urethral anastomosis, and maximum preservation of the proximal urethra are required to the neobladder patients to obtain good voiding and continence.

Complications of the Ileal W-neobladder with Serous-lined Extramural Tunnel / 대한비뇨기과학회지

PURPOSE: Radical cystectomy has been a standard method in the treatment for invasive bladder cancer. Recently the orthotopic substitutions have been generally performed for urinary diversion. Ghoneim introduced a new method for orthotopic substitution which has used relatively short segment of ileum, and the method is regarded to have few complications. We performed this method for our study and analyzed the results and complications. MATERIALS AND METHODS: Among total 29 patients underwent ileal W-neobladder with serous-lined extramural tunnel, 27 patients had invasive bladder cancer and the remaining two patients had contracted bladder with vesicoureteral reflux. There were 25 male patients with the mean age of 59.2 years(45-70) and 4 female patients with 61.8 years(51-68). Mean follow-up period for the entire group was 8.4 months(3?17 month). History taking, physical examination, and complete laboratory tests were performed postoperatively and IVP or CT scan was taken at 3 month and 9 month after the operation for the evaluation of recurrence and upper tract change. RESULTS: The average operating time was 8 hours 35 minutes(420-670 min). Paralytic ileus developed in two patients and wound dehisced in 4. In all 29 patients, vesicoureteral reflux was not detected. Stricture of ureteroileal anastomosis was observed in 4 left renal units. We performed percutaneous nephrostomy and antegrade double J stenting on all the patients with stricture primarily, but one patient underwent neoureteroileostomy because of the failure of the primary management. Four patients complained enuresis, but no daytime incontinence was observed. There were no clinical symptoms of complications in all 29 patients and no metabolic acidosis was observed in laboratory tests. CONCLUSIONS: Serous-lined extramural tunnel method of orthotopic substitution showed an acceptable and safe reservoir with a large capacity at low pressure and absence of reflux with relatively short segment of ileum.

Change of the Upper Urinary Tracts and Occurrence of Metabolic Acidosis after Three Different Orthotopic Bladder Substitutions / 대한비뇨기과학회지

PURPOSE: Orthotopic neobladder following radical cystectomy are currently preferred to the other urinary diversions. We have compared three different ureteroenteric anastomoses regarding change of the upper urinary tracts and evaluated correlation between the length of bowel used for bladder reconstruction and metabolic acidosis. MATERIALS AND METHODS: Between Sep. 92 and Jul. 97, 37 patient(range 34-69 yrs) with bladder cancer underwent an orthotopic Mainz pouch with antireflux submucosal tunnel(n=10), an ileal low-pressure bladder substitute with direct ureteroileal anastomosis(Stuffier, n=15) and an ileal W-neobladder with serouslined ertramural tunnel(Ghoneim, n=12) following radical cystectomy Mean follow up was 22 months(7-64 twos). IVP and VCUG were performed at 6, 12 months postoperatively and annually thereafter. The measurement of serum electrolyte and/or arterial blood gas analysis were carried out every 3-6 months. RESULTS: The vesicoureteral reflux occurred in 37%(11/30 renal unit) with Stuffier pouch, 10%(2/20) with Mainz pouch, and none with Ghoneim(p=0.01). Moderate to severe hydronephrosis resulting from reflux was noted in 4 renal units with Stuffier pouch, while an atrophic kidney due to obstruction at ureteroenteric anastomosis was noted with each Mainz pouch and Ghoneim. Metabolic acidosis was identified in 5 patients(33%) with an Stuffier pouch whereas it was noted in less than 10% with Mainz pouch and Ghoneim(p=0.07). Two patients with deteriorated renal function need bicarbonate replacement therapy for correction of metabolic acidosis. CONCLUSIONS: Although most patients with direct ureteroileal anastomosis preserved renal function, antireflux ureteroenteric anastomosis using submucosal tunnel or serous-lined extramural tunnel is better in terms of occurrence of hydronephrosis and vesicoureteral reflux. The length of bowel less than 45cm used for bladder reconstruction may avoid metabolic acidosis

Studer's Pouch: Clinical Experience and Evaluation / 대한비뇨기과학회지

Studer's pouch was evaluated clinically and urodynamically. The pouch was constructed for bladder substitution in 18 and for bladder augmentation in 2 from July 1990 to November l995. Three patients of substitution were not included in this review because of operation related death in 1 case and short period(<6 months) of follow-up in 2 cases. Mean age is 53.2(range: 22-69) years. Mean follow-up period is 22.2(range: 2-64) months. Mean cystometric capacity was 445 ml, mean intraluminal pressure at 200 ml and 400 ml filled was 12.8(range: 5-30) and 23.7(range: 5-45) cmH2O, respectively. Maximal urethral closure pressure was 54.3(range: 18-112) cmH2O in bladder substitution cases. Maximal flow rate was 19.1(range: 12.9-26.0) ml/sec. Mean residual urine was 37.8(range: 0-80) ml. Reflux into ileal limb occurred in all patient at mean volume of 227(range : 30-400) ml. Reflux into kidney occurred in 20 of 24 renal units at mean volume of 291(range : 50-450) ml, but it drained completely and rapidly in all cases. No pelvocalyceal ectatic changes were seen. Urine was sterilized in 9 patients. Recurrent bacteriuria occurred in 6 patients. All of them had been controlled by parenteral antibiotic therapy. All of 15 substitution patients were completely continent during daytime. Two had mild daytime stress incontinence in early postoperative period, but which is improved as time passing. Three of them have nighttime incontinence. One of three has intermittent incontinence and is using a diaper for prevention from bed wetting. Two have total nighttime incontinence using a kismo every night. Though longer follow-up should be needed to confirm the safety of upper tract, we think that Studer's pouch seems not only to guarantee the continence but to be rather simple and easy to perform.

Continent Ileal Reservoir / 대한비뇨기과학회지

A new method of urinary diversion via Skinner`s modification of Koch continent ileal reservoir was tried. With this method continence with storage of urine under low pressure is well maintained so that no external applicances are necessary. Ileorenal reflux is also prevented with this nipple forming technique. From May l986 to September l986, 4 patients underwent urinary diversion that included creation of a modified Koch pouch by Skinner. Previous urinary diversion was by ureterocutaneous diversion in 1 patient. A total of 3 patients underwent radical cystectomies for bladder cancer In 1 patient, simultaneous urethrectomy was done because of carcinoma in situ in the urethra. There were no operative mortalities. All patients are continent and without reflux to the upper urinary tract. The volume capacity of pouch is more than 400ml. The pouch is emptied by self-catheterization every 4 to 6 hours during the day and once at night. Postoperative follow-up presently is short and it is impossible to check late complications. Although preliminary, this clinical trial suggests that the quality of life for patients can be improved markedly by the modified Koch continent ileal reservoir.

Clinical Observation on Substitute Bladders Replaced with Isolated Intestinal Segments / 대한비뇨기과학회지

Physiologic micturition has been observed in 3 patients with vesical tumors who underwent total cystoprostatovesicutectomy, followed by construction of substitute bladders from isolated bowel segments (an ileal segment in 1 case and sigmoid segments in 2 cases) anastomosed to the urethra. The 2 patients of advanced vesical carcinoma died 8 and 18 months postoperatively, but the remaining one of multiple papillomatosis has been alive up to date 8 years postoperatively. It suggests that the sigmoid bladder is a useful method at the present time for urinary reconstruction following total cystectomy in certain selected cases to adapt them to the social life with "dry" condition, especially expecting competent uretero-sigmoid anastomosis.