A simplified method for detubularization in the construction of a continent ileocolic reservoir (Miami pouch).

The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient's colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients.

[Current strategies in patients with urinary diversion, 2: Upper urinary tract]. / Aktuelle Strategien bei Patienten mit Harnableitung, Teil 2: Oberer Harntrakt.

Improved surgical methods and changed management of invasive bladder cancer lead to an increased number of patients with urostomies. The number of patients with internal stents is increasing, too. Numerous surgical options are currently available for both male and female patients. Lifestyle implications are as important as the selection of the adequate diversion such as ileal conduit, continent cutaneous diversions or orthotopic bladder replacement.

Stabilization of the nipple base with titanium rings when reoperating patients with continent urostomies for nipple dysfunction.

Nipple dysfunction in Kock reservoirs used for continent urinary diversion is usually caused by a flattening out of the intestinal nipple due to a lateral tore at the base of the nipple when the reservoir expands. This study describes a new method to repair dysfunctioning nipples based on the use of titanium rings applied outside the reservoir around the base of the nipple. Experiments on dogs and rats have shown that rings and plates of titanium rapidly attach to the serosal surface of ileum exposed to urine with only minor signs of inflammation. Ten patients with Kock reservoirs for urinary diversion have been reoperated for nipple dysfunction due to nipple sliding with elongation of the nipple and fixation of the nipple base with titanium rings. The functional result is excellent in 9 out of the 10 patients. No signs of erosion of the rings into the reservoirs have been noted. With this new method for nipple repair the need for using more intestine to construct a new nipple is eliminated.

Absorbable stapling techniques in continent urinary diversion.

The principle of bowel detubularization to decrease peristaltic pressure and increase reservoir capacity is applied in contemporary continent urinary diversions. The process of detubularization and refashioning of the spatulated bowel segment approximates 1 of operating time and is the most time-consuming aspect of pouch construction. The employment of devices applying absorbable staples ("absorbable staplers") has substantially reduced the time required to fashion bowel reservoirs. This article reviews the adaptation of the absorbable stapler to continent urinary diversion using small- and large-bowel segments.

[A continent urostomy. An ileal pouch and the Benchekroun valve]. / Urostomie continente. Poche iléale et valve de Benchekroun.

The authors reported their experience using detubularized ileal pouch and Benchekroun hydraulic valve. They obtain continence in all patients, and antireflux in only 12 of them. 30 patients were operated according to this technique from January 1986 to December 1992. The main indication was represented by vesical tumors, treated by cystoprostatectomy. 90% of the patients operated this way are continent, when 10% were reoperated to achieve continence. They point out in the follow-up the steady state of renal function, and radiologically, the improvement or at least the stabilization of pyelo-ureteral dilatation, and the absence of ureteral reflux, especially when antireflux system was performed using Benchekroun hydraulic valve.

The Mitrofanoff pouch: a continent urinary diversion.

1. Continent urinary diversions are an alternative diversion to urostomies. 2. Nurses must be aware of the intense preparation, high level nursing and continuous support needed by patients. 3. Patients and carers need to be made aware of the high complication rate of these operations. 4. Commitment to care of the diversion by the patient and a strict follow-up regimen are essential to ensure complications are avoided or dealt with early.

Simple detubularization technique for construction of continent colonic urinary reservoirs.

OBJECTIVES: Despite the advantages offered by continent urinary diversion techniques, wide acceptance of the procedure has been hampered by the length of time required to detubularize and suture the reconfigured bowel. With the purpose of simplifying the procedure, a linear stapler loaded with absorbable staples was used to accomplish simultaneous detubularization and closure of the reservoirs. METHODS: Six patients, 4 men and 2 women received a stapled detubularized reservoir following radical cystectomy. The male patients all had construction of a neobladder, whereas in the females a catheterizable continent stoma was designed. RESULTS: Operative time was shortened by an average of 30 to 45 minutes without technical difficulties. No postoperative complications related to the staple line occurred and with a follow-up of 6 months good functional results have been achieved, with no patient experiencing diurnal incontinence. CONCLUSIONS: This simple mechanical detubularization technique offers results similar to the hand suture method while at the same time shortening and simplifying the procedure.

Continent urinary reservoirs.

With the increasing incidence of bladder cancer, many different operations have been devised to reconstruct the lower urinary tract in a continent fashion. The incontinent type of urinary reservoir (ileal conduit) has been a surgical preference for many years. However, the continent urinary reservoir (CUR), neobladder, and rectal bladder offer the capable and motivated patient an alternative to an incontinent permanent stoma. Nursing management of patients requiring diversional surgery requires continual updating of these specialized surgical procedures and unique aspects of care.

Yang needle tunneling technique in creating antireflux and continent mechanisms.

A total of 7 patients underwent cystectomy due to bladder malignancy and the ileum was used for lower urinary tract reconstruction (5 underwent bladder substitutions, 1 an internal ileal reservoir and 1 ileal conduit diversion). Antireflux mechanisms were created by submucosally tunneled ureters and in 1 case the continent mechanism was created by a submucosally tunneled ileal tube. In all cases the Yang needle was used, which consists of a needle portion and a forceps portion. The selected position of the ileum for ureteral and ileal tube implantation is injected with normal saline submucosally to form a wheal. The Yang needle is introduced submucosally, guided under the wheal for a certain distance and then directed through the ileal wall. Smooth dilation of the tunnel is achieved with the dilated portion of the needle without laceration of the mucosa. The needle portion is then removed. The ureter or ileal tube is grasped by the forceps portion of the needle and brought through the tunnel to the mucosal side of the ileal plate, followed by mucosa-to-mucosa anastomosis. For all 14 ureteral implantations only 1 ureter had reflux on postoperative radiographic studies and only 1 of 4 hydroureters remained. No additional obstructive lesions or pyelonephritis was noted postoperatively. The patient whose continent mechanism is formed by the submucosal tunneled ileal tube method is continent and free of an appliance. The Yang needle tunneling technique may be a choice in the creation of antireflux and continent mechanisms.

[Surgical staplers. Urologic surgery with intestines]. / Suturas mecánicas. Cirugía urológica con empleo de intestino.

Since the late 1980s, different reservoirs and bladder substitution techniques have been added to the urological surgical armamentarium. The necessary use of an intestinal segment--generally detubularized--make these surgical procedures complicated and time-consuming. Furthermore, problems are encountered postoperatively due to the important morbidity arising from these procedures. The present article describes our experience with mechanical sutures and resorbable material. Although the results have not been analyzed, our initial experience at the Miguel Servet Hospital has shown that these devices significantly facilitate the operative procedure, thereby reducing the incidence of urinary and intestinal fistulas. Although there is an evident risk of calculi formation, complicated solutions are not required and the biological tolerance to the metal sutures is excellent.

[Endoscopic findings of nipple fixation in Kock pouch].

Fixing the nipple to the pouch wall is indispensable to reduce the incidence of late complications of the Kock pouch. We performed endoscopy of the Kock pouch in 28 patients to evaluate the nipple valve fixation. We carried out submucosal fixation of nipple in 17 patients, fixation using staples in 2 patients and full layer fixation in last 9 patients. On endoscopy, both efferent and afferent nipples were poorly fixed or completely detached in 8 of the 17 patients who underwent submucosal fixation. On the other hand, there were no patients in whom the nipple was poorly fixed or completely detached among the other 11 patients. We experienced nipple malfunction in only one of the last 9 patients. Based on endoscopic findings and clinical results, we concluded that full layer fixation was reliable and useful to reduce the incidence of nipple valve complications.

Lithiasis in the ileal conduit and the continent urinary pouch: two cases and a review.

We present 2 patients who developed stones (6 and 57 g) in the ileal conduit; the first stone was passed and the second required surgical removal; its nidus was a surgical staple. After a review of the literature which includes 25 other cases of stones in ileal conduits, as well as over 20 cases of stones in continent urinary pouches, it is concluded that the use of metallic staples in the construction of the ileal conduit or the continent urinary pouch should be abandoned.