Stones in enterocystoplasties.

OBJECTIVES: To assess the aetiology of stones which occur in enterocystoplasties and continent diversions, generally attributed to the presence of foreign material, e.g. staples, or to recurrent urinary infection, in patients with augmented or substituted bladders. PATIENTS AND METHODS: The study comprised 467 patients who had undergone reconstruction of the lower urinary tract and had been followed up for at least 3 years using videourodynamics and ultrasonography. RESULTS: Stones were found in 42 patients (9%); 50% were found incidentally and the remaining patients presented with symptomatic infections (27%) or deterioration in urinary continence (23%). Stones occurred in 6% of patients with augmentation, in 7% of those with substitution cystoplasty and in 22% of patients with continent diversions. Most patients with stones (88%) used clean intermittent self-catheterization (CISC). Stones were 5-10 times commoner in patients using CISC than in patients voiding spontaneously. CONCLUSION: Urinary stasis was a more important cause of stone formation than was bacteriuria in patients with cystoplasty. The presence of mucus and bacteriuria are presumed to be contributory. To reduce the risk of stone formation, orthotopic cystoplasty and spontaneous voiding are to be preferred to continent diversion and CISC. Periodic bladder washouts may be an alternative solution.

Malignant change in enterocystoplasty: a histochemical assessment.

Increasing numbers of cases of malignant tumours occurring in enterocystoplasties are being reported. Material from five cases of adenocarcinoma arising in such patients were studied using standard mucin and carbohydrate lectin staining methods. Sections from the tumour and adjacent and distant mucosa were stained to determine the pattern of histochemical changes. The abnormal staining patterns seen suggest that the adenocarcinomata arising at the enterovesical anastomosis are of intestinal origin. A hypothesis is advanced to explain the pathogenesis of these tumours.

Relative indications for orthotopic lower urinary tract reconstruction, continent urinary diversion and conduit urinary diversion.

Continent urinary diversion has become increasingly popular in the last few years and there are now several situations in which ileal conduit diversion, continent diversion and orthotopic reconstruction of the lower urinary tract are equally valid options. This review was intended to determine specific indications for each. Of 513 patients treated for severe lower urinary tract problems in the last 10 years, 399 underwent orthotopic reconstruction, 68 underwent continent diversion and 46 had an ileal conduit. Problems occurred 2 to 3 times more commonly in the continent diversion group than in either of the other groups. Given a free choice, most patients would choose an orthotopic reconstruction and this should probably be regarded as the gold standard. Continent diversion is specifically indicated in male patients who require a total cystourethrectomy for bladder cancer, in severe post-radiotherapy problems, and in patients with neuropathic bladder dysfunction in whom, for various reasons, self-catheterisation is impossible. Ileal conduit diversion remains the simplest and safest technique in high-risk patients and does not preclude a subsequent continent diversion or orthotopic reconstruction.

Cystoprostatectomy and substitution cystoplasty for locally invasive bladder cancer.

The results and long-term follow-up of 48 patients undergoing cystoprostatectomy and substitution cystoplasty for T2/3, M0 transitional cell carcinoma of the bladder are reported. There was no operative mortality but 1 early death from thromboembolic disease. Thirty-six patients are alive with a mean follow-up of 57 months (range 12-120). Eleven patients died of disseminated disease. Thirty-one patients (64%) regained normal continence by day and night and a further 8 were dry by day but incontinent at night; 9 patients underwent further surgery for incontinence and this was successful in 8, giving an overall continence rate of 79% and a day-time continence rate of 98%. Of the 38 patients claiming to be potent pre-operatively, 24 (63%) were potent post-operatively. Nerve-sparing cystoprostatectomy and substitution cystoplasty is a safe alternative to a "standard" cystectomy and ileal conduit diversion in a selected group of men undergoing radical surgery for invasive bladder cancer and it achieves its aims of preserving continence and potency in the majority of patients.

Calcium balance, growth and skeletal mineralisation in patients with cystoplasties.

Twelve adult female patients and 16 children who had undergone augmentation cystoplasty at least 2 years previously were studied to assess calcium balance and skeletal mineralisation. The serum and 24-h urinary calcium levels were measured and arterial blood gas analysis was performed in all patients. In children, skeletal mineralisation was assessed by serial study of their growth charts, comparing their growth centiles before and after cystoplasty. In adults, skeletal mineralisation was assessed by dual photon absorptiometry (DPA). As previously reported, all patients had a metabolic acidosis, usually with respiratory compensation. Serum and 24-h urinary calcium levels were all within the normal range. Growth charts of the 6 children with colocystoplasties showed an average of 20% reduction in growth potential in 3 of them. Growth charts in the 10 children with ileocystoplasties did not show any change in growth pattern. DPA bone scans in adults were all normal. These results suggest that if calcium is mobilised from bone in patients with a cystoplasty as a result of the metabolic acidosis, then it is reabsorbed from the bladder by the gut segment after an ileocystoplasty; colonic segments are less efficient than ileal segments, however, so that after a colocystoplasty skeletal demineralisation or a reduction in growth potential is more likely.

Role of the artificial urinary sphincter in the treatment of stress incontinence in women.

The artificial urinary sphincter (AUS) is rarely indicated in the treatment of women with stress incontinence because most of these women have deficient urethral support rather than pure sphincter weakness and the AUS is a treatment specifically for pure sphincter weakness. The procedure is contraindicated after pelvic radiotherapy and after previous sling surgery because of the high incidence of cuff erosion. Otherwise the artificial sphincter gives excellent results comparable to those seen in men with post-prostatectomy incontinence and much better than in neuropathic bladder dysfunction.

Problems in the surgical treatment of interstitial cystitis.

Two series of patients with histologically proven interstitial cystitis that was unresponsive to hydrostatic bladder distension and intravesical chemotherapy with dimethyl sulfoxide have been studied. In the first series 24 patients were treated by subtotal cystectomy and substitution cystoplasty without further consideration; 8 of these 24 patients had persistent frequency due to active disease in the remaining trigone and/or urethra and in 2 cases this was severe. Because of this experience the second group of patients had routine biopsy of the trigone and assessment of urethral sensation as part of the initial assessment. In those in whom the trigone was unaffected, treatment was unchanged. If the trigone was affected, total cystourethrectomy was performed with substitution cystourethroplasty unless the patient chose or was advised to avoid surgery altogether or to have a simpler option such as conduit or continent urinary diversion. Trigonal biopsies should be part of the routine assessment of all patients being considered for surgery, since residual active disease is a major cause of dissatisfaction after subtotal cystectomy and substitution cystoplasty.

The effect of cromakalim on the normal and hyper-reflexic human detrusor muscle.

Cromakalim is a benzopyran derivative which relaxes smooth muscle, probably by opening membrane potassium channels. This study tested the effect of cromakalim on spontaneous, electrically induced and pharmacologically induced contractile activity of normal and hyper-reflexic human detrusor muscle samples. All 3 types of contractile activity were reduced in the presence of cromakalim. A preliminary clinical trial of cromakalim was conducted, the results of which also suggest that this type of drug may have a significant role in the treatment of detrusor instability and hyper-reflexia.

Lower urinary tract reconstruction in patients with bladder exstrophy after failed primary treatment in early childhood.

The results of neonatal surgery for bladder exstrophy are not very satisfactory. A significant percentage of patients present in later childhood or adolescence for correction of their residual deformities. We have reconstructed 26 patients, correcting their entire urogenital and cosmetic deformity in a one-stage procedure. The results show that one-stage total reconstruction is possible and is preferable to serial correction of the various individual abnormalities. The principles of surgical reoperation in adolescence are the same as those now established for the primary correction in neonatal life.

Surgical management of the congenital neuropathic bladder.

We have previously described 3 types of lower urinary tract dysfunction in the congenital neuropathic bladder--contractile, intermediate and acontractile--accounting for 35, 40 and 25% of patients respectively. Subsequent urodynamic and surgical experience has shown that the intermediate type is commoner and the acontractile type less common than was thought. The contractile group accounts for 31% of patients and rarely requires surgery (a "clam" ileocystoplasty). The acontractile group accounts for only 9% but more commonly requires surgical treatment, usually the implantation of an artificial urinary sphincter (AUS). The intermediate group accounts for 60% of patients and usually requires surgery. If there is no significant sphincter weakness incontinence, a "clam" ileocystoplasty alone is performed; if there is sphincter weakness, a "clam and a cuff" procedure is performed with implantation of the remainder of the AUS at a later date, if required.

Assessment of the malignant potential of cystoplasty.

The study group comprised 34 patients with either an ileal augmentation cystoplasty or a colonic substitution cystoplasty. The histological appearance of the intestinal segment, suture line, bladder remnant and bacterial colonisation of the urine and urinary nitrosamine levels were recorded. There was a high incidence of histological abnormalities, the more significant of which correlated with heavy mixed bacterial growth on urine culture and with high levels of urinary N-nitrosamines. This group of compounds is thought to act as carcinogens in both bladder and bowel under certain circumstances. It was concluded that patients undergoing lower urinary tract reconstruction using intestinal segments should be considered at risk of developing malignant change either in the intestinal segment or in the bladder remnant. Close long-term follow-up of these patients is essential.

Metabolic complications of cystoplasty.

A series of 48 patients with intestinal segments incorporated into the urinary tract underwent assessment of acid-base and electrolyte balance. All patients had abnormal blood gas analyses, usually a metabolic acidosis with respiratory compensation; 33% had hyperchloraemia. Radioisotope studies using sodium, potassium and bromine showed that all were absorbed and that absorption was unaffected by renal function. The results suggest that all such patients, but particularly women and children, may be at risk of the secondary effects of chronic acidosis, especially skeletal demineralisation, unless some compensatory mechanism is working to offset the effects of the acidosis.

The problems of substitution cystoplasty.

Substitution cystoplasty was performed in 157 patients aged 4 to 71 years; 62% suffered no post-operative complication. The commonest complication was sphincter-weakness incontinence, found in 18%, mainly in patients having a cystoplasty for interstitial cystitis; it was rare for the patient to complain of this incontinence. Ten per cent suffered incontinence due to colonic overactivity and this occurred in patients with neuropathic sphincter-weakness incontinence or an artificial sphincter; all of these patients complained of their incontinence. This was corrected by "patching" in all cases. Voiding difficulties requiring clean intermittent self-catheterisation occurred in 15%. More worrying was the universal finding, when looked for by blood gas analysis, of a metabolic acidosis with respiratory compensation. It was concluded that in the absence of neuropathy, sphincter weakness or an artificial sphincter, an unmodified ileocaecal segment substitution cystoplasty is adequate; in the presence of neuropathy, sphincter weakness or an artificial sphincter, a "pouch" type of substitution cystoplasty should be performed. All patients should have blood gas analyses from time to time as part of their routine post-operative follow-up.

One hundred artificial sphincters.

One hundred patients with urinary incontinence of various aetiologies underwent implantation of an artificial urinary sphincter (AUS). In 40 patients various reconstructive procedures of the lower urinary tract were carried out at the same time. In 93 patients the results were successful and they are continent. Six are incontinent and 4 of these await AUS replacement. One patient has had a urinary diversion with the sphincter still in situ and functioning. The complication rate was 45% (of which 29% were designated "sphincter-related"). Half of these were accounted for by two complications: one was a change in bladder behaviour in patients with neuropathic bladders and the other was stress incontinence as a direct result of implanting low pressure devices. If these two factors and the "sphincter-unrelated" problems are discounted, the complication rate was 13%. The AUS is a satisfactory and successful method of treatment for sphincter weakness incontinence regardless of aetiology and the results suggest no contraindication to implantation at the same time as reconstructive surgery of the lower urinary tract.

Detrusor behaviour following implantation of the Brantley Scott artificial urinary sphincter for neuropathic incontinence.

During a 3-year period, 102 Brantley Scott artificial urinary sphincters were implanted to control urinary incontinence. Nineteen patients underwent endoscopic sphincterotomy and artificial sphincter implantation for the control of sphincter weakness incontinence due to congenital neuropathic bladder dysfunction. None had previous augmentation or substitution procedures. Nine patients (47%) subsequently showed a deterioration in detrusor function, resulting in either recurrent incontinence or upper tract dilatation. Eight of these (89%) had previously been shown to have an intermediate pattern of neuropathic bladder abnormality. All patients implanted with an AUS require long-term surveillance including videourodynamic studies, and patients with intermediate neuropathic bladders should be considered for augmentation or substitution at the time of implantation.

Clam enterocystoplasty in the neuropathic bladder.

Clam enterocystoplasty has proved to be the most effective treatment for severe detrusor instability resistant to conservative treatment (Bramble, 1982; Mundy and Stephenson, 1985). More recently it has become the procedure of choice in patients with neuropathic bladders with hyper-reflexia or severely impaired compliance, provided that the bladder is of reasonable size and that gross fibrosis and/or diverticular formation of the bladder wall has not occurred. Fifty-nine patients have undergone the clam procedure as part or all of their reconstruction in the past 4 years. Although uncontrolled incontinence was the commonest indication, impaired renal function was the indication in 14 patients and need for undiversion in seven. Currently all but four are voiding satisfactorily or are on intermittent self-catheterisation, though six have significant stress incontinence. The clam procedure is easier, quicker and as satisfactory as substitution cystoplasty in selected cases.

Secreto-motor function of intestinal segments used in lower urinary tract reconstruction.

Mucus excretion, sialic acid excretion and secretory IgA (sIgA) production from patients with a substitution caecocystoplasty (20), augmentation "clam" ileocystoplasty (20) or ileal conduit (10) were measured. Significant amounts of all of these substances were present in the urine of reconstructed patients and showed no evidence of diminution with time. Motility was studied by videocystourethrography. In patients with a neuropathic aetiology the amplitude of contractions was significantly increased and produced incontinence. The results demonstrate that intestinal secreto-motor function in gut segments incorporated into the lower urinary tract continues normally and must be taken into account when considering the long-term management of these patients.

Complex urinary undiversion.

Thirty-one previously diverted patients with various complex lower urinary tract problems have been undiverted with simultaneous reconstruction of the anorectum and vagina when these structures were also affected. No patient was denied undiversion on the basis of pelvic pathology. The only contraindications were a lack of motivation and when the patient's general condition, intelligence and mobility made it an unrealistic proposition.

Continence and potency preserving cystoprostatectomy and substitution cystoplasty for patients with bladder cancer.

Fifteen potent men with T3 M0 transitional cell carcinoma of the bladder underwent a technique for cystoprostatectomy designed to preserve the innervation of the distal sphincter mechanism and the corpora cavernosa, and substitution cystoplasty. All patients had previously had radiotherapy. When the neurovascular bundles were seen to be preserved all patients were continent by day (although one had objectively demonstrable stress incontinence) and 60% were potent. Damage to the neurovascular bundles was usually associated with impotence and a degree of stress incontinence, although the latter was correctable by implantation of an artificial sphincter. Cystectomy need not necessarily lead to an abdominal stoma or to impotence.