SCLENTI[FICARTICLES
CONTINENTURINARYDIVERSIONUSING CUTANEOUSILEOCECOCYSTOPLASTY MICHAEL F. SAROSDY, M.D. From the University of Texas Health Science Center, San Antonio, Texas ABSTRACT-We have employed a technique of continent urinary diversion that uses ileocecocystoplasty to incorporate native bladder into the urinary reservoir. This allows creation of a reservoir in selected patients using less complicated surgery than complete replacement of the bladder and avoids ureteralintestinal anastomoses. Early results are promising for this simplified means of continent diversion.
Continent urinary diversion utilizing bowel to replace the urinary bladder functionally recently has gained widespread acceptance.i4 Such diversion usually follows removal of the bladder in the course of treating malignancy either in the bladder or in other pelvic organs, but may be used to treat congenital or acquired functional or anatomic conditions. While the latter conditions do not necessarily require removal of the bladder, most forms of continent diversion employ bladder replacement rather than utilization of what functional bladder may be present. Increasingly, we are encountering patients with differing causes of bladder dysfunction who require urinary diversion to better manage their urinary drainage. Two recent patients possessed intact functional storage capability, but not continence and were not candidates for more conventional methods of restoring continence. A modification of continent diversion combining the continence mechanism of the Indiana reservoir with cutaneous ileocecocystoplasty allowed for continent diversion using a much less extensive and less risky surgical procedure than complete bladder replacement, with gratifying results and satisfied patients. Preoperative evaluation and preparation of the patient is performed as for any continent diversion. Included are mechanical and antibiotic bowel preparation and sterile urine is as-
sured. Through a midline laparotomy incision, the lower abdomen and pelvis are exposed, including the bladder. The bladder is prepared for enterocystoplasty in the usual fashion by a midline cystotomy extending just to the bladder neck or through it, depending on the anatomic problem being addressed (Figs. 1 and 2). Attention is then turned to the ileocecal portion of the large bowel. The right lateral colic gutter is incised sufficiently to allow mobilization of the cecum. An appendectomy is performed if not done previously. Using an overhead surgical light to transilluminate the mesentery, blood vessels to the ileocecal segment are identified. The mesentery is incised on either side of the ileocolic artery, to a point 8-10 cm distal to the ileocecal valve on the colon and to a point 12-15 cm proximally on the ileum (Fig. 3A). Division is accomplished in the standard fashion by incising the peritoneum, doubly clamping and dividing small blood vessels, and ligating these with 4-O silk suture. Both colon and ileum are transsected between bowel clamps, and an ileocolonic anastomosis is then performed to re-establsh intestinal tract continuity. Our preference is to use a two-layer closure consisting of a running 3-O chromic mucosal closure with interrupted 3-O silk seromuscular sutures. Alternately, division and reanastomosis may be accomplished satisfactorily using stapling techniques. The defect in the mesentery is closed using running 3-O chromic suture.
102
UROLOGY
Surgical Technique
I
AUGUST
1992
/ VOLUME
40, NUMBER 2
FIGURE 1.
Case 1. (A) Line extending of cystotomy through scarred bladder neck anastomoand UTethTOvesiCd sis which was resected. (B) Bladder opened. Similar cystotomy could be used in jemale patient undergoing such diversion.
FIGURE 2. Case 2. Anterior cystotomy just to anterior bladder neck.
extending
(A) L ines of incision of ileocolonic segment and its mesentery; length of colon segment which is isolated varies according to need to augment bladder versus simply provide access to it. (B) Ileal limb has already been reduced, in this case by use of GIA stapling technique; anastomosis of colonic segment to bladder is begun. (C) Malecot catheter is inserted when anterior half of both sides have been closed; ajter placement of catheter, postetier halves of each side are then closed starting at posterior apex. (Final appearance before con&UCtion of the cutaneous stoma.). FIGURE 3.
UROLOGY
/
AUGUST1992
/ VOLUME40,NUMBER2
The clamps are then removed from both ends of the pedicled ileocecal segment and it is irrigated with saline until clean. A catheterizable continence limb is then created by placing a 12F red rubber catheter through the ileal limb. Plication of this limb is then performed as described by Rowland and associates5 using interrupted 3-O silk sutures with a reinforcing second layer of running 3-O silk. Alternately, this reduction in caliber may be accomplished by holding the antimesenteric edges of the ileum in a GIA stapler and stapling and trimming redundant bowel as described by Bejany and Politano.6 In the latter maneuver, five to six plicating sutures are placed at the ileocecal valve to reinforce it as a continence valve.
After the catheterizable limb has been created, the remaining cecal segment is trimmed to a size compatible with the cystotomy and appropriate to the goal of the surgical procedure. Enterocystoplasty is performed using a double layer closure of running 4-O polyglycolic acid suture (Fig. 3B). We find it helpful to place two sutures at both ends of the cystotomy and perform the anastomosis in quarters. The right and left anterolateral quarters are closed first, including both layers. At this time a 22F Malecot catheter is brought through either the bladder or the cecum below the ileocecal valve, according to whichever is more convenient and simple. It is anchored in place with 2-O chromic if the bladder is chosen as the site, or 30 silk if the cecum is the site. The right and left posterolateral quarters of the enterocystoplasty are then closed as above (Fig. 3C). A site is then chosen for the cutaneous stoma. Since the course of the ileal limb is determined by its mesentery, this is usually in the left lower quadrant. The premarked site is circumscribed using a scalpel and the piston of a 10 mL syringe. A core of subcutaneous fat is removed down to the rectus muscle and the anterior rectus fascia is incised. The rectus muscle is bluntly pierced and the surgeon’s finger used to enlarge the opening in the muscle. Importantly, the course of the tunnel through both the subcutaneous fat and the muscle should not be perpendicular to the abdominal wall, but should be angled toward the bladder and the ileocecal valve to more easily allow an atraumatic passage of a catheter during intermittent catheterization. Four to six sutures of 3-O polyglycolic acid are placed in the rectus fascia, one at either apex of the incision and one or two more on each side. The needles are left on tbe sutures, the catheterizable limb is brought through the fascia, and the six sutures are used to anchor the limb to the fascia. Care is taken to avoid injury to the mesentery. The stomal enterocutaneous closure is performed with interrupted 4-O polyglycolic acid suture. The pelvis is then thoroughly irrigated and drains are placed. The Malecot catheter is brought through the abdominal wall at a suitable location. If the Malecot catheter site chosen is cecum, this is fixed to the overlying rectus muscle using two interrupted 3-O silk sutures. No such fixation is used if the bladder is the site of the Malecot catheter. The abdominal incision is closed using the suture of the surgeon’s choice, and a sterile dressing is applied. The
Case 1 A fifty-seven-year-old man had undergone pelvic lymphadenectomy and radical retropubit prostatectomy elsewhere for clinical Stage B carcinoma of the prostate in 1986. He was found to have Stage C disease, pathologically, with a positive margin and received adjunctive radiotherapy (5,500 rad) beginning six weeks postoperatively. A severe stricture subsequently developed, and he underwent transurethral resection on two occasions. He was referred to us and had two additional extensive transurethral resections over a twelve-month period with prompt stricture recurrence after each procedure. Three years after radical prostatectomy, he underwent ileocecocystoplasty and continent diversion as described. The surgical procedure included complete takedown of the vesicourethral anastomosis and cystotomy through the bladder neck down to the trigone (Fig. 1). Ureteral stents were placed to aid in identification of the intramural ureters during the enterocystoplasty. Cystography revealed complete healing of the enterocystoplasty by day 12, and the patient began intermittent catheterization, with removal of the Malecot catheter on day 14. Except for a prolonged ileus, he did well postoperatively and was discharged on the twentieth postoperative day. A cutaneous scar developed at the stomal site, requiring resection four months postoperatively. Importantly, vascularity of the catheterizable limb appeared to be good and no revision of the limb or bowel portion of the stoma was performed. He continues to do well twenty-six months after diversion with complete continence and no upper tract infections. Urography at six months showed no change in the upper urinary tracts.
104
UROLOGY
Malecot catheter is left to drainage, and no catheter is left in the catheterizable limb. Postoperatively, care is routine as for an enterocystoplasty patient. Daily irrigation is performed to evacuate mucus if necessary. Drains are removed as allowed, and a cystogram is performed on or about postoperative day 10. If no extravasation is seen, the Malecot catheter is clamped and the patient begins intermittent catheterization via the cutaneous stoma. If no problems are encountered, the Malecot catheter is removed the next day. Case Reports
/
AUGUST 1992
I
VOLUME 40, NUMBER 2
Case 2 A nineteen-year-old man was rendered partially paraplegic in a motor vehicle accident in which he sustained a pelvic fracture and lifethreatening hemorrhage in addition to his spinal injury. Emergency laparotomy with bilateral internal iliac artery ligation, repair of bladder lacerations, and insertion of a suprapubic catheter had followed pelvic arterial embolization attempts. He recovered from his injuries and was left with a complete prostatomembranous urethral stricture, a large capacity flaccid neurogenic bladder, and complete erectile impotence. The length of the strictured urethra was estimated to be approximately 2 cm by radiographic studies. Pelvic arteriography six months after his injury demonstrated no reconstitution of internal pudendal blood flow on either side. Due to the high risk of failure of any attempt at surgical restoration of urethral continuity because of ischemia’ combined with his flaccid neurogenic bladder, it was decided that continent diversion using a catheterizable cutaneous stoma might provide most likelihood of success and least risk of failure. He underwent the diversion outlined above eight months after his initial injury. Two differences from the procedure used in Case 1 should be noted: (1) The amount of cecum added to the bladder was minimal, as this patient did not require any degree of augmentation cystoplasty in order to obtain a large capacity, low pressure reservoir. (2) The anterior cystotomy used to create the site for enterovesical anastomosis extended only down to the anterior bladder neck, leaving alone the prostate and the prostatic urethra proximal to the stricture (Fig, 2). Postoperatively, he did well. Cystography showed no extravasation on postoperative day 9; intermittent catheterization was begun and the Malecot catheter removed. He was discharged from the hospital on postoperative day 11. The patient is now twenty months from the time of surgery, having satisfactory erections with self-injection therapy of prostaglandin El (PGEr), and complete day and nighttime continence. He has had no symptomatic bacteriuric episodes. Urography at six months demonstrated completely normal upper urinary tracts. Comment Satisfactory urinary diversion to correct anatomic or functional abnormalities of the lower
UROLOGY
/ AUGUST1992
/ VOLUME40,NUMBER2
urinary tract may be accomplished through a variety of surgical techniques. Of prime importance in the selection of the method used are the long-term success rates and the ability of the urologic surgeon to perform such diversion. An integral concept in such an approach is the use of surgical techniques with which the surgeon has the most familiarity and avoidance of seldomly used procedures. The surgical technique outlined above allows adaptation of two procedures which should be familiar to most reconstructive urologists, namely enterocystoplasty and creation of a continent catheterizable limb and valve. Many urologists appear to be using some form of Indiana reservoir for patients undergoing continent urinary diversion.5sQ The creation of the catheterizable limb by either plication or stapling works well, and we have personally had no problems requiring reoperation in more than 20 cases using the Indiana reservoir. Enterocystoplasty for bladder augmentation is a common procedure in centers with large pediatric practices and spinal cord units, and its use should be well known. Diversion of the fashion we have described includes the catheterizable portion of the Indiana reservoir. While we have no experience doing so, we would expect that similar portions of the Kock pouch or other reservoirs could be used to provide similar bladder diversion. The key is that the urologist performing this diversion use what works well in his or her experience. The ability to utilize a patient’s native bladder for much of the reservoir allows the avoidance of having to create nonrefluxing ureteralreservoir anastomoses as well as the need to reconfigure a large segment of bowel, thus shortening operative time considerably. The risk of long-term complications with the ureteral-reservoir anastomoses likewise is avoided altogether. For patients who have normal bladder volume and in whom augmentation is not required, two other procedures for continent diversion using the bladder may also be employed. First is cutaneous ureterostomy to access the bladder through the distal ureter, with ipsilateral transureteroureterostomy.‘O Secondly, the Mitrofanoff procedure allows transcutaneous vesical access through the appendix.” Both procedures might be reasonable in selected patients. The former obviously puts both renal units at some risk. The latter procedure
105
has been reported to have only a 50 percent success rate initially, with augmentation required at a later time in most of the failures. now recommend that Duckett and SnydeP bladder augmentation be strongly considered in all patients undergoing the Mitrofanoff procedure. The need to augment would, therefore, seem to offset any advantage of the Mitrofanoff procedure over the technique which we report. Longer follow-up is clearly required to verify our early satisfactory results. However, this technique provides a simple straightforward method for creation of a catheterizable, nonintubated urinary reservoir in patients who might otherwise be required to undergo ileal conduit diversion or chronic suprapubic cystostomy drainage. In the short term, this urinary diversion has been readily accepted by patients and showed minimal morbidity. 7703 Floyd Curl Drive San Antonio, Texas 78284-7845 (DR. SAROSDY)
106
References 1. Kock NG, et al: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients, J Urol 128: 469 (1982). 2. Skinner DG, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, J Urol 132: 1101 (1984). 3. Lilien OM, and Camey M: Impotence following radical prostatectomy: insight into etiology and prevention, J Urol 128: 492 (1984). 4. Thuroff JW, et al: The MAINZ-pouch (mixed augmentation ileum ‘n cecum) for bladder augmentation and continent diversion, J Urol 136: 17 (1986). 5. Rowland RG, Mitchell ME, and Bihrle R: The cecoileal continent urinary reservoir, World J Uro13: 185 (1985). 6. Bejany DE, and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir, J Urol 140: 191 (1988). 7. Jordan GH: Personal communication, 1999. 8. Mitrofanoff P: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques, Chir Pediatr 21: 297 (1980). 9. Lockhart J, et al: A continent colonic urinary reservoir: the Florida pouch, J Urol 144: 864 (1999). 10. Mitchell ME: Personal communication, 1996. 11. Monfort G, Guys JM, and Lacombe GM: Appendicovesicostomy: an alternative urinary diversion in the child, Eur Urol 10: 361 (1984). 12. Duckett JW, and Snyder HM: Use of the Mitrofanoff principle in urinary reconstruction, World J Urol3: 191 (1985).
UROLOGY
/
AUGUST 1992
I VOLUME 46, NUMBER 2
CONTINENTURINARYDIVERSIONUSING CUTANEOUSILEOCECOCYSTOPLASTY MICHAEL F. SAROSDY, M.D. From the University of Texas Health Science Center, San Antonio, Texas ABSTRACT-We have employed a technique of continent urinary diversion that uses ileocecocystoplasty to incorporate native bladder into the urinary reservoir. This allows creation of a reservoir in selected patients using less complicated surgery than complete replacement of the bladder and avoids ureteralintestinal anastomoses. Early results are promising for this simplified means of continent diversion.
Continent urinary diversion utilizing bowel to replace the urinary bladder functionally recently has gained widespread acceptance.i4 Such diversion usually follows removal of the bladder in the course of treating malignancy either in the bladder or in other pelvic organs, but may be used to treat congenital or acquired functional or anatomic conditions. While the latter conditions do not necessarily require removal of the bladder, most forms of continent diversion employ bladder replacement rather than utilization of what functional bladder may be present. Increasingly, we are encountering patients with differing causes of bladder dysfunction who require urinary diversion to better manage their urinary drainage. Two recent patients possessed intact functional storage capability, but not continence and were not candidates for more conventional methods of restoring continence. A modification of continent diversion combining the continence mechanism of the Indiana reservoir with cutaneous ileocecocystoplasty allowed for continent diversion using a much less extensive and less risky surgical procedure than complete bladder replacement, with gratifying results and satisfied patients. Preoperative evaluation and preparation of the patient is performed as for any continent diversion. Included are mechanical and antibiotic bowel preparation and sterile urine is as-
sured. Through a midline laparotomy incision, the lower abdomen and pelvis are exposed, including the bladder. The bladder is prepared for enterocystoplasty in the usual fashion by a midline cystotomy extending just to the bladder neck or through it, depending on the anatomic problem being addressed (Figs. 1 and 2). Attention is then turned to the ileocecal portion of the large bowel. The right lateral colic gutter is incised sufficiently to allow mobilization of the cecum. An appendectomy is performed if not done previously. Using an overhead surgical light to transilluminate the mesentery, blood vessels to the ileocecal segment are identified. The mesentery is incised on either side of the ileocolic artery, to a point 8-10 cm distal to the ileocecal valve on the colon and to a point 12-15 cm proximally on the ileum (Fig. 3A). Division is accomplished in the standard fashion by incising the peritoneum, doubly clamping and dividing small blood vessels, and ligating these with 4-O silk suture. Both colon and ileum are transsected between bowel clamps, and an ileocolonic anastomosis is then performed to re-establsh intestinal tract continuity. Our preference is to use a two-layer closure consisting of a running 3-O chromic mucosal closure with interrupted 3-O silk seromuscular sutures. Alternately, division and reanastomosis may be accomplished satisfactorily using stapling techniques. The defect in the mesentery is closed using running 3-O chromic suture.
102
UROLOGY
Surgical Technique
I
AUGUST
1992
/ VOLUME
40, NUMBER 2
FIGURE 1.
Case 1. (A) Line extending of cystotomy through scarred bladder neck anastomoand UTethTOvesiCd sis which was resected. (B) Bladder opened. Similar cystotomy could be used in jemale patient undergoing such diversion.
FIGURE 2. Case 2. Anterior cystotomy just to anterior bladder neck.
extending
(A) L ines of incision of ileocolonic segment and its mesentery; length of colon segment which is isolated varies according to need to augment bladder versus simply provide access to it. (B) Ileal limb has already been reduced, in this case by use of GIA stapling technique; anastomosis of colonic segment to bladder is begun. (C) Malecot catheter is inserted when anterior half of both sides have been closed; ajter placement of catheter, postetier halves of each side are then closed starting at posterior apex. (Final appearance before con&UCtion of the cutaneous stoma.). FIGURE 3.
UROLOGY
/
AUGUST1992
/ VOLUME40,NUMBER2
The clamps are then removed from both ends of the pedicled ileocecal segment and it is irrigated with saline until clean. A catheterizable continence limb is then created by placing a 12F red rubber catheter through the ileal limb. Plication of this limb is then performed as described by Rowland and associates5 using interrupted 3-O silk sutures with a reinforcing second layer of running 3-O silk. Alternately, this reduction in caliber may be accomplished by holding the antimesenteric edges of the ileum in a GIA stapler and stapling and trimming redundant bowel as described by Bejany and Politano.6 In the latter maneuver, five to six plicating sutures are placed at the ileocecal valve to reinforce it as a continence valve.
After the catheterizable limb has been created, the remaining cecal segment is trimmed to a size compatible with the cystotomy and appropriate to the goal of the surgical procedure. Enterocystoplasty is performed using a double layer closure of running 4-O polyglycolic acid suture (Fig. 3B). We find it helpful to place two sutures at both ends of the cystotomy and perform the anastomosis in quarters. The right and left anterolateral quarters are closed first, including both layers. At this time a 22F Malecot catheter is brought through either the bladder or the cecum below the ileocecal valve, according to whichever is more convenient and simple. It is anchored in place with 2-O chromic if the bladder is chosen as the site, or 30 silk if the cecum is the site. The right and left posterolateral quarters of the enterocystoplasty are then closed as above (Fig. 3C). A site is then chosen for the cutaneous stoma. Since the course of the ileal limb is determined by its mesentery, this is usually in the left lower quadrant. The premarked site is circumscribed using a scalpel and the piston of a 10 mL syringe. A core of subcutaneous fat is removed down to the rectus muscle and the anterior rectus fascia is incised. The rectus muscle is bluntly pierced and the surgeon’s finger used to enlarge the opening in the muscle. Importantly, the course of the tunnel through both the subcutaneous fat and the muscle should not be perpendicular to the abdominal wall, but should be angled toward the bladder and the ileocecal valve to more easily allow an atraumatic passage of a catheter during intermittent catheterization. Four to six sutures of 3-O polyglycolic acid are placed in the rectus fascia, one at either apex of the incision and one or two more on each side. The needles are left on tbe sutures, the catheterizable limb is brought through the fascia, and the six sutures are used to anchor the limb to the fascia. Care is taken to avoid injury to the mesentery. The stomal enterocutaneous closure is performed with interrupted 4-O polyglycolic acid suture. The pelvis is then thoroughly irrigated and drains are placed. The Malecot catheter is brought through the abdominal wall at a suitable location. If the Malecot catheter site chosen is cecum, this is fixed to the overlying rectus muscle using two interrupted 3-O silk sutures. No such fixation is used if the bladder is the site of the Malecot catheter. The abdominal incision is closed using the suture of the surgeon’s choice, and a sterile dressing is applied. The
Case 1 A fifty-seven-year-old man had undergone pelvic lymphadenectomy and radical retropubit prostatectomy elsewhere for clinical Stage B carcinoma of the prostate in 1986. He was found to have Stage C disease, pathologically, with a positive margin and received adjunctive radiotherapy (5,500 rad) beginning six weeks postoperatively. A severe stricture subsequently developed, and he underwent transurethral resection on two occasions. He was referred to us and had two additional extensive transurethral resections over a twelve-month period with prompt stricture recurrence after each procedure. Three years after radical prostatectomy, he underwent ileocecocystoplasty and continent diversion as described. The surgical procedure included complete takedown of the vesicourethral anastomosis and cystotomy through the bladder neck down to the trigone (Fig. 1). Ureteral stents were placed to aid in identification of the intramural ureters during the enterocystoplasty. Cystography revealed complete healing of the enterocystoplasty by day 12, and the patient began intermittent catheterization, with removal of the Malecot catheter on day 14. Except for a prolonged ileus, he did well postoperatively and was discharged on the twentieth postoperative day. A cutaneous scar developed at the stomal site, requiring resection four months postoperatively. Importantly, vascularity of the catheterizable limb appeared to be good and no revision of the limb or bowel portion of the stoma was performed. He continues to do well twenty-six months after diversion with complete continence and no upper tract infections. Urography at six months showed no change in the upper urinary tracts.
104
UROLOGY
Malecot catheter is left to drainage, and no catheter is left in the catheterizable limb. Postoperatively, care is routine as for an enterocystoplasty patient. Daily irrigation is performed to evacuate mucus if necessary. Drains are removed as allowed, and a cystogram is performed on or about postoperative day 10. If no extravasation is seen, the Malecot catheter is clamped and the patient begins intermittent catheterization via the cutaneous stoma. If no problems are encountered, the Malecot catheter is removed the next day. Case Reports
/
AUGUST 1992
I
VOLUME 40, NUMBER 2
Case 2 A nineteen-year-old man was rendered partially paraplegic in a motor vehicle accident in which he sustained a pelvic fracture and lifethreatening hemorrhage in addition to his spinal injury. Emergency laparotomy with bilateral internal iliac artery ligation, repair of bladder lacerations, and insertion of a suprapubic catheter had followed pelvic arterial embolization attempts. He recovered from his injuries and was left with a complete prostatomembranous urethral stricture, a large capacity flaccid neurogenic bladder, and complete erectile impotence. The length of the strictured urethra was estimated to be approximately 2 cm by radiographic studies. Pelvic arteriography six months after his injury demonstrated no reconstitution of internal pudendal blood flow on either side. Due to the high risk of failure of any attempt at surgical restoration of urethral continuity because of ischemia’ combined with his flaccid neurogenic bladder, it was decided that continent diversion using a catheterizable cutaneous stoma might provide most likelihood of success and least risk of failure. He underwent the diversion outlined above eight months after his initial injury. Two differences from the procedure used in Case 1 should be noted: (1) The amount of cecum added to the bladder was minimal, as this patient did not require any degree of augmentation cystoplasty in order to obtain a large capacity, low pressure reservoir. (2) The anterior cystotomy used to create the site for enterovesical anastomosis extended only down to the anterior bladder neck, leaving alone the prostate and the prostatic urethra proximal to the stricture (Fig, 2). Postoperatively, he did well. Cystography showed no extravasation on postoperative day 9; intermittent catheterization was begun and the Malecot catheter removed. He was discharged from the hospital on postoperative day 11. The patient is now twenty months from the time of surgery, having satisfactory erections with self-injection therapy of prostaglandin El (PGEr), and complete day and nighttime continence. He has had no symptomatic bacteriuric episodes. Urography at six months demonstrated completely normal upper urinary tracts. Comment Satisfactory urinary diversion to correct anatomic or functional abnormalities of the lower
UROLOGY
/ AUGUST1992
/ VOLUME40,NUMBER2
urinary tract may be accomplished through a variety of surgical techniques. Of prime importance in the selection of the method used are the long-term success rates and the ability of the urologic surgeon to perform such diversion. An integral concept in such an approach is the use of surgical techniques with which the surgeon has the most familiarity and avoidance of seldomly used procedures. The surgical technique outlined above allows adaptation of two procedures which should be familiar to most reconstructive urologists, namely enterocystoplasty and creation of a continent catheterizable limb and valve. Many urologists appear to be using some form of Indiana reservoir for patients undergoing continent urinary diversion.5sQ The creation of the catheterizable limb by either plication or stapling works well, and we have personally had no problems requiring reoperation in more than 20 cases using the Indiana reservoir. Enterocystoplasty for bladder augmentation is a common procedure in centers with large pediatric practices and spinal cord units, and its use should be well known. Diversion of the fashion we have described includes the catheterizable portion of the Indiana reservoir. While we have no experience doing so, we would expect that similar portions of the Kock pouch or other reservoirs could be used to provide similar bladder diversion. The key is that the urologist performing this diversion use what works well in his or her experience. The ability to utilize a patient’s native bladder for much of the reservoir allows the avoidance of having to create nonrefluxing ureteralreservoir anastomoses as well as the need to reconfigure a large segment of bowel, thus shortening operative time considerably. The risk of long-term complications with the ureteral-reservoir anastomoses likewise is avoided altogether. For patients who have normal bladder volume and in whom augmentation is not required, two other procedures for continent diversion using the bladder may also be employed. First is cutaneous ureterostomy to access the bladder through the distal ureter, with ipsilateral transureteroureterostomy.‘O Secondly, the Mitrofanoff procedure allows transcutaneous vesical access through the appendix.” Both procedures might be reasonable in selected patients. The former obviously puts both renal units at some risk. The latter procedure
105
has been reported to have only a 50 percent success rate initially, with augmentation required at a later time in most of the failures. now recommend that Duckett and SnydeP bladder augmentation be strongly considered in all patients undergoing the Mitrofanoff procedure. The need to augment would, therefore, seem to offset any advantage of the Mitrofanoff procedure over the technique which we report. Longer follow-up is clearly required to verify our early satisfactory results. However, this technique provides a simple straightforward method for creation of a catheterizable, nonintubated urinary reservoir in patients who might otherwise be required to undergo ileal conduit diversion or chronic suprapubic cystostomy drainage. In the short term, this urinary diversion has been readily accepted by patients and showed minimal morbidity. 7703 Floyd Curl Drive San Antonio, Texas 78284-7845 (DR. SAROSDY)
106
References 1. Kock NG, et al: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients, J Urol 128: 469 (1982). 2. Skinner DG, Boyd SD, and Lieskovsky G: Clinical experience with the Kock continent ileal reservoir for urinary diversion, J Urol 132: 1101 (1984). 3. Lilien OM, and Camey M: Impotence following radical prostatectomy: insight into etiology and prevention, J Urol 128: 492 (1984). 4. Thuroff JW, et al: The MAINZ-pouch (mixed augmentation ileum ‘n cecum) for bladder augmentation and continent diversion, J Urol 136: 17 (1986). 5. Rowland RG, Mitchell ME, and Bihrle R: The cecoileal continent urinary reservoir, World J Uro13: 185 (1985). 6. Bejany DE, and Politano VA: Stapled and nonstapled tapered distal ileum for construction of a continent colonic urinary reservoir, J Urol 140: 191 (1988). 7. Jordan GH: Personal communication, 1999. 8. Mitrofanoff P: Cystostomie continente trans-appendiculaire dans le traitement des vessies neurologiques, Chir Pediatr 21: 297 (1980). 9. Lockhart J, et al: A continent colonic urinary reservoir: the Florida pouch, J Urol 144: 864 (1999). 10. Mitchell ME: Personal communication, 1996. 11. Monfort G, Guys JM, and Lacombe GM: Appendicovesicostomy: an alternative urinary diversion in the child, Eur Urol 10: 361 (1984). 12. Duckett JW, and Snyder HM: Use of the Mitrofanoff principle in urinary reconstruction, World J Urol3: 191 (1985).
UROLOGY
/
AUGUST 1992
I VOLUME 46, NUMBER 2
