[Urinary diversion with continent umbilical stoma: Which techniques are suitable for which patients?]. / Harnableitung mit kontinentem Nabelstoma: Welche Patienten und welche Techniken sind geeignet?

BACKGROUND: Continent cutaneous diversions play a secondary role even in many centers for urinary diversion. The result is that knowledge about, indications and operation technique does not exist in many clinics. RESULTS: The general complication rates of the various forms of urinary diversion are not significantly different. There is no quality of life study showing a significant advantage for either form of urinary diversion. The functional results of neobladders in females with up to 70% hypercontinence are worse than in men, resulting in 2.4-fold more continent urinary diversions in men compared to women. The complication rates of the various forms of continent cutaneous pouches are different. CONCLUSION: Continent cutaneous pouches are an option for all patients with non-existing or functionally unusable urethra and as primary indication in all women with bladder cancer, consulting in very good quality of life and perfect body image. Age (<75 years), manual skills and psychological ability are selection criteria. As far as the results and complication rates are concerned the ileocecal pouch with an appendix umbilical stoma is the best option. In cases of non-existing appendix, alternatives are a neoappendix, serosal lined tapered ileum and ileal invagination nipple.

[W enterocystoplasty with resorbable staples: technic and functional results. Preliminary study]. / Entérocystoplastie en W aux agrafes résorbables: technique et résultats fonctionnels. Etude préliminaire.

INTRODUCTION: The use of absorbable staples for enterocystoplasty allows a marked reduction of the operating time. The long-term results on continence need to be evaluated at result term before adopting this technique. METHODS: Eight patients underwent "W" enterocystoplasty performed with absorbable staples according to the so-called "Detroit" technique, with direct uretero-ileal anastomosis. The continence of these patients was evaluated by clinical follow-up and urodynamic assessment (3 patients). Quality of life was studied by a questionnaire sent to the patient. RESULTS: The mean operating time was 5 hours 20 minutes, the plasty was performed in 25 to 35 minutes. The mean follow-up was 18.7 months, during which two uretero-ileal strictures were diagnosed. 7 of the 8 patients have a good diurnal continence (no leaks) and 1 patient has moderate continence (1 protection). Nocturnal continence was considered to be good in 3 cases, moderate in 2 cases and poor in 3 cases (> 1 protection). Four of the patients evaluated by questionnaire reported urinary disorders. CONCLUSION: The use of absorbable staples allows a definite reduction of the operating time, for a modes excess cost and satisfactory functional results.

Functional outcome and late complications in patients with continent urinary reservoirs.

BACKGROUND: We reviewed the functional outcome and late complication of continent urinary reservoirs (CUR) constructed with a cecocolonic segment, including the Indiana pouch, in 37 patients treated in our clinic. METHODS: The CUR procedure was performed on 37 patients, creating partially detubularized (PD) reservoirs in 9 patients, totally detubularized (TD) reservoirs in 16 patients and reservoirs with an ileal patch (IP) in 12 patients. Continence was achieved by the nipple valve in 10 patients and by ileal plication in 27 patients. The mean follow-up period was 46 months (range, 15 to 87 months). The function of the reservoir was evaluated by measurement of the intrareservoir pressure. RESULTS: Patients with the TD reservoir had less frequent appearance of involuntary, phasic elevation of the intrareservoir pressure (30.8%) than those with the PD reservoir (62.5%). In contrast, this phasic elevation was found in only 1 patient with an IP reservoir. The IP reservoir had the largest capacity accompanied by the lowest maximum intrareservoir pressure. Total incontinence was observed in 2 patients with ileal plication due to disruption of the plicated sutures on the terminal ileum. Frequent difficulty in catheterizing the reservoir was found in 2 patients, and reservoir-ureter reflux was found in 3 renal units. The serum chloride level was significantly elevated after surgery, however, in most patients the levels remained within normal limits. CONCLUSION: Our experience of the outcome and late complications of reservoirs indicates that the cecocolonic reservoir with an ileal patch and stapled ileal plication, i.e., the Indiana pouch, is a better choice for continent urinary diversion for patients who need a cystectomy.

Continent urinary diversion and the ileal cecal pouch with appendostomy: a review with nursing care.

Creation of a continent urinary reservoir has become the procedure of choice when the bladder is removed for either malignant or nonmalignant disease. The continent urinary reservoir provides the patient with a manageable and socially acceptable bladder replacement. It is important for the ET nurse to have a basic understanding of the surgical principles of continent urinary diversion, including the antireflux and continence mechanism, and segment of bowel used. Such an understanding facilitates competent patient care and appropriate instruction, both before and after operation. The basic principles of continent urinary diversion are discussed in this article, along with a brief description of the most common continent urinary reservoirs. In addition, a recent form of urinary diversion, the ileocecal pouch with appendostomy, is described, and relevant preoperative and postoperative care is outlined.

Orthotopic neobladder reconstruction after radical cystectomy.

Urinary diversion with continent urinary reservoirs to the urethra offer major advantages to patients with invasive bladder carcinoma. Multiple configurations for pouch creation have been described, however, there are unifying concepts between all types of continent diversions which should be adhered to in order to optimize outcome. These general concepts are discussed and the author's technique for small and large intestinal neobladder construction is presented. Perioperative management is delivered using a collaborative care critical pathway technique and has resulted in excellent outcomes.

[Bladder replacement and continent diversion: what about metabolic complications?]. / Remplacement de vessie et dérivation continente: qu'en est-il des complications métaboliques?

During the past several years there has been increasing interest in refunctionalizing patients who have undergone radical extirpative surgery for pelvic malignancies and patients with dysfunctional bladders. To accomplish this, intestinal segments have been successfully employed in a variety of configurations. Independent of their optimal urosurgical implementation these procedures are not without potential complications, a significant portion of which involve metabolic derangements. Besides first follow-up results of patients with bladder substitution or continent urinary diversion, analysis of experimental investigations and functionally comparable clinical conditions enables an insight into potential following physiopathological interrelationships. These concern, besides the problem of chronic metabolic acidosis, disorders of bile acid and vitamin B12 metabolism as well as the potential induction of a secondary hyperoxaluria with subsequent oxalate concrement diathesis. Furthermore, there may be a malabsorption of calcium and vitamin D with development of intestinal osteopathy due to the reduction of absorptive surface. Apart from these problems of enteral loss and deficiency manifestations, several case reports and investigations suggest that bone demineralization can occur as a consequence of chronic metabolic acidosis and patients are at risk of skeletal demineralization. The pathogenesis of this association has yet to be clarified. These physiopathological interrelationships must be considered in medical attendance of patients with intestinal substitute bladders and continent supravesical pouch systems over many years. As these procedures become more popular, it becomes important to identify any metabolic changes that may occur as their consequence.