British Journal of Urology (1991), 68,376-379
01991 British Journal of Urology
Role of Continent Suprapubic Diversion in Pelvic Cancer J. S. K. GELISTER and C. R. J. WOODHOUSE Department of Urology, Royal Marsden Hospital, London
Summary-Seventeen patients with either current (n = 14) or previous (n =3) pelvic malignant disease underwent continent urinary diversion using the Mitrofanoff principle in 16 and a Kock pouch in 1. Eight patients had bladder carcinoma, 6 had gynaecological malignancy, 2 had rectal cancers and 1 had a squamous cell carcinoma of the perineum. Fourteen underwent synchronous exenterative surgery and continent suprapubic diversion; plastic reconstructive procedureswere required in 4. There were 2 post-operative deaths and 5 patients have developed further tumour recurrence. Continence was satisfactory in all patients with a median interval of intermittent selfcatheterisation of 4 h.
The standard method of urinary diversion following cystectomy remains the ileal conduit. Alternatives to cutaneous diversion include the construction of a neobladder from an intestinal segment which is drained either via the urethra or via a continent suprapubic diversion. Inadequate emptying and enuresis, particularly at night, are not uncommon following anastomosis of such a neobladder to the urethra. After cystourethrectomy, continent suprapubic diversion is the only real alternative to an incontinent stoma and bag other than ureterosigmoidostomy with its widely acknowledged complications. Various techniques of continent suprapubic diversion have been described. The principal methods depend either on the formation of a nipple valve (Kock, 1969), utilisation of the ileocaecal valve (Gilchrist etal., 1950),or on the anti-refluxing implantation of a small calibre tube such as appendix into a urinary reservoir (Mitrofanoff, 1980). This report details our experience of continent suprapubic diversion in patients with pelvic malignant disease using the Mitrofanoff principle. Read at the 46th Annual Meeting of the British Association of Urological Surgeons in Scarborough, July 1990
Patients and Methods Seventeen patients with a current or previous history of pelvic cancer underwent continent or suprapubic diversion. Their median age was 59 years (range 27-72) and the underlying pathology is summarised in Table 1. They were selected from patients presenting with pelvic cancer who required radical surgery and were deemed physically and emotionally fit for major reconstruction. All were counselled preoperatively regarding the pros and cons of an incontinent versus a continent stoma. All were Table 1 Underlying Pathology in Patients undergoing Continent Suprapubic Diversion No. of Pathology
patients
Transitional cell carcinoma of bladder (T3, G3 in 4;extensive carcinoma in situ superficial disease in 3) Squamous cell carcinoma of the bladder Carcinoma of cervix (Squamous cell in 3, adenosquamous in 1, adenocarcinoma in 1) Adenocarcinoma of rectum Adenocarcinoma of vagina Squamous cell carcinoma of urethra
376
+
I 1 5
2 1 1
ROLE OF CONTINENT SUPRAPUBIC DIVERSION IN PELVIC CANCER
extensively investigated and staged pre-operatively . This always included computed tomography, an assessment of renal function and an examination under anaesthesia (EUA). Where appropriate, preoperative consultation was sought with gynaecological, plastic and/or general surgical teams and if necessary a combined EUA was performed. Fourteen patients underwent continent suprapubic diversion and cancer-clearing surgery with curative intent concurrently. Four patients also underwent concurrent plastic reconstructive procedures including myocutaneous flap grafting and/ or vaginoplasty. Details of the operations performed concurrently with continent suprapubic diversion are summarised in Table 2. Eight patients underwent radical cystourethrectomy (7 for transitional cell and 1 for squamous cell carcinoma). Seven of them had a Mitrofanoff reconstruction and 1 underwent construction of a Kock pouch. Two women underwent synchronous anterior exenteration and a Mitrofanoff reconstruction for locally recurrent carcinoma of cervix. One woman with extensive intra-epithelial carcinoma of cervix who had previously had a hysterectomy, laser therapy and radiotherapy underwent vulvocolpectomy and because of bladder involvement a cystectomy. Reconstruction was by means of a rectus abdominis flap, ileovaginoplasty and a Mitrofanoff procedure. Another woman with adenocarcinoma of the vagina who had persisting disease despite radiotherapy underwent hysterocolpectomy, urethrectomy and a partial cystectomy. The reconstruction included ureteric reimplantation, colovaginoplasty and a Mitrofanoff procedure in which appendix was implanted into the bladder remnant. A further woman had a local recurrence of a rectal carcinoma involving the vagina 2 years
377
after abdominoperineal resection. This persisted despite radiotherapy and she therefore underwent a pelvic clearance, reconstruction being by means of a rectus flap, ileovaginoplasty and a Mitrofanoff procedure. A male patient with an ulcerating squamous cell carcinoma in the perineum underwent radical excision of the penis, urethra and perineal ulcer. Reconstruction included a rectus flap and a Mitrofanoff procedure. A further 3 patients who had had previous treatment for pelvic malignancy underwent continent suprapubic diversion. All were reassessed and considered to be free of recurrent disease. In 2 women with cervical cancer, treatment had included external beam and intracavity radiotherapy. Both had been disease-free for 3 years but had developed severely contracted bladders, 1 with intractable incontinence and the other with bilateral ureteric obstruction. The third patient had undergone abdominoperineal resection for a rectal cancer 13 years previously. She had persistent urinary incontinence despite endoscopic and open colposuspensions. The urinary reservoir was constructed from detubularised caecum and ascending colon in 13 patients. In each case the appendix was mobilised on its pedicle, reimplanted into the caecum and brought to the skin surface as previously described (Woodhouse et al., 1989). In 3 patients bladder was available. In 2 of them ureter was used as a catheterisable conduit with an associated transuretero-ureterostomy as previously described (Woodhouse et al., 1989). In the third patient appendix was implanted into the bladder and brought to the surface as a continent catheterisable vesicostomy. The seventeenth patient had a conventional Kock pouch.
Table 2 Operations performed concurrently with Continent Urinary Diversion and Details of Previous Surgery and Radiotherapy No. ofputients -~~~~ ~~
~
~
~
Bladder cancer Radical cystourethrectomy (pre-operative deep X-ray therapy in 1) Other pelvic malignancy Anterior exenteration (previous deep X-ray therapy in 2, previous hysterectomy in 1) Vulvo-colpectomy, cystectomy, rectus flap and ileo-vaginoplasty (previous hysterectomy and deep X-ray therapy) Hystero-colpectomy, urethrectomy, partial cystectomy, ureteric reimplantation and colo-vaginoplasty (previous deep X-ray therapy) Pelvic exenteration, rectus flap and ileo-vaginoplasty (previous A-P resection and deep X-ray therapy) Radical excision of penis, urethra and perineal ulcer rectus flap
+
8
2 1
1 1 1
378
Results There were 2 post-operative deaths. In the patient who had excision of an ulcerating perineal tumour the rectus abdominis flap necrosed and this was replaced with a groin flap but this also failed. Renal and multi-organ failure followed. In the second patient an acute abdomen and signs of sepsis necessitated re-exploration 1 week after radical cystourethrectomy and a Mitrofanoff reconstruction. The patient had a fatal myocardial infarct after this operation. These 2 patients were the second and third oldest in the series. The median follow-up in the remaining patients was 24 months (range 6-36). All of these patients achieved continence, though 1 required revision of the appendix conduit to do so. Patients selfcatheterise at intervals of 4 to 5 h and occasionally at night. One patient required dilatation of an appendiceal conduit. Another had difficulty catheterising a ureteric conduit and ultimately required conversion to a Kock nipple. One patient had minor leakage in association with urinary infection which required more frequent catheterisation. A further patient who had received radiotherapy developed a stricture at the site of ureteric reimplantation into the neobladder. This was initially dilated percutaneously but ultimately required open revision because of upper tract deterioration. There were no other upper tract complications and no significant metabolic complications were encountered. Tumour recurrence has occurred in 5 patients. Three are alive with distant metastases which presented 5, 6 and 17 months following radical cystourethrectomy for bladder cancer (squamous cell in 1 and transitional cell in 2). The women with cervical and vaginal carcinoma respectively developed local recurrence 8 and 6 months after combined exenterative surgery and reconstruction. Both underwent further extensive pelvic surgery with reconstruction of a neobladder in 1. The continent diversion was preserved in both, but they died from widespread disease at 12 and 16 months respectively. One of these women presented with difficulty in self-catheterisation which was found to be due to tumour recurrence around the Mitrofanoff appendix.
Discussion Although the ileal conduit remains the standard method of urinary diversion after cystectomy and other ablative pelvic operations, efforts to avoid a
BRITISH JOURNAL OF UROLOGY
wet stoma and bag have been intensified in recent years. Carney and Le Duc (1979) first popularised anastornosing an intestinal neobladder to the urethra and numerous variations on this theme have followed. These procedures are not uncommonly complicated by inadequate emptying and enuresis, particularly at night, necessitating intermittent self-catheterisation and in some cases an artificial sphincter. After cystectomy, therefore, continent suprapubic diversion (particularly with a discrete stoma) is an attractive alternative to procedures in which a neobladder is anastomosed to the urethra. Following cystourethrectomy and other procedures which remove or destroy the continence mechanisms, continent suprapubic diversion is in our view the only realistic alternative to an incontinent stoma. Skinner e l af. (1987) have popularised the use of the Kock pouch after radical cystourethrectomy. However, we have not found the Kock pouch easy to construct and even in the hands of enthusiasts there is a significant rate of revisional surgery (Cumming et al., 1987). We have previously reported our early experience of continent suprapubic diversion employing the Mitrofanoff principle in younger patients who had originally undergone urinary diversion in childhood (Woodhouse et af.,1989). In some of these patients native bladder was available, but following cystectomy we have found detubularised caecum and ascending colon to be the most satisfactory arrangement for the reservoir with appendix as the catheterisable conduit. The present series comprised a relatively high risk group of patients in so far as 6 of them had had previous radiotherapy and/or previous primary surgical treatment for their underlying disease (Table 2). The combination of a radical pelvic cancer exenteration with a concurrent complex reconstruction of a continent suprapubic diversion in an older, less fit patient is a different prospect from performing this type of diversion alone in an otherwise healthy young adult. In the younger group we have now performed over 40 continent diversions with no mortality. Of the 2 deaths in this series 1 resulted from failed plastic surgical reconstruction in the patient with a fungating perineal squamous cell tumour. The second death, however, emphasises the increased risks of performing this type of reconstruction concurrent with radical cystourethrectomy for bladder cancer. This patient did have evidence of cardiovascular disease preoperatively and was therefore a relatively high risk. We are now more critical in evaluating patients
ROLE OF CONTINENT SUPRAPUBIC DIVERSION IN PELVIC CANCER
pre-operatively and in those patients keen to avoid a bag but considered unfit for a synchronous continent diversion we offer to construct a colon conduit with the option of a later conversion to a continent suprapubic diversion. Women with cervical cancer constituted the second largest group in the present series. Patients with central recurrences and no evidence of distant disease following previous radiotherapy are offered anterior exenteration with the possibility of a continent suprapubic diversion. If there is any evidence of pelvic sidewall or iliac or para-aortic lymph node involvement on per-operative frozen section, an ileal conduit is constructed instead of the more complicated procedure. Continent suprapubic diversion also has a place in the reconstruction of the lower urinary tract in patients who have radiation damage following previous treatment of pelvic cancers, as in 2 of the women with cervical cancer in the present series. In some of these patients substitution cystoplasty may be feasible. However, in those with sphincteric damage and in those with severe radiation fibrosis, continent suprapubic diversion may be preferable. Two patients in this series had colostomies. We do not regard this as a contraindication to continent urinary diversion. Many patients prefer to have 1 bag rather than 2. Continent urinary diversion has a wide range of application in patients with pelvic malignant disease. We prefer the Mitrofanoff method of reconstruction. In the elderly, less fit patient typical of those requiring cystectomy for bladder cancer, great care must be taken in selection as the concurrent construction of a continent suprapubic
379
diversion confers additional risks on an already major procedure.
References Camey, M. and Le DUC,A. (1919). L’entkrocystoplastie apres cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13,114-123. Cumming, J., Worth, P. H. L. and Woodhouse, C. R. J. (1987). The choice of suprapubic continent catheterisable stoma. Br. J . Urol., 60,221-230. Gilchrist, R. K., Merricks, J. W., Hamlin, H. H. er al. (1950). Construction of a substitute bladder and urethra. Surg. Gynecol. Obstet., 90, 752-760. Kock, N. G. (1969). Intra abdominal reservoir in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal continence in five ileostomy patients. Arch. Surg., 99,223-231. Mitrofanoff, P. (1980). Cystostomie continente transappendiculaire dans le traitement des vessies neurologiques. Chir. Pediatr., 21,297-305. Skinner,D. G.,Lieskowski,G. andBoyd,S. D. (1987).Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases. J . Urol., 137, 1140-1 145. Woodhouse, C. R. J., Malone, P. R., Cumming, J. et al. (1989). The Mitrofanoff principle for continent urinary diversion. Br. J . Urol.,63, 53-51.
The Authors J . S. K. Gelister, MS, FRCS, Senior Urological Registrar, Royal Marsden Hospital. C. R. J . Woodhouse, FRCS, Consultant Urologist and Senior Lecturer, St Peter’s, St George’s and Royal Marsden Hospitals, London. Requests for reprints to: J . S. K. Gelister, Department of Urology, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 IAA.
01991 British Journal of Urology
Role of Continent Suprapubic Diversion in Pelvic Cancer J. S. K. GELISTER and C. R. J. WOODHOUSE Department of Urology, Royal Marsden Hospital, London
Summary-Seventeen patients with either current (n = 14) or previous (n =3) pelvic malignant disease underwent continent urinary diversion using the Mitrofanoff principle in 16 and a Kock pouch in 1. Eight patients had bladder carcinoma, 6 had gynaecological malignancy, 2 had rectal cancers and 1 had a squamous cell carcinoma of the perineum. Fourteen underwent synchronous exenterative surgery and continent suprapubic diversion; plastic reconstructive procedureswere required in 4. There were 2 post-operative deaths and 5 patients have developed further tumour recurrence. Continence was satisfactory in all patients with a median interval of intermittent selfcatheterisation of 4 h.
The standard method of urinary diversion following cystectomy remains the ileal conduit. Alternatives to cutaneous diversion include the construction of a neobladder from an intestinal segment which is drained either via the urethra or via a continent suprapubic diversion. Inadequate emptying and enuresis, particularly at night, are not uncommon following anastomosis of such a neobladder to the urethra. After cystourethrectomy, continent suprapubic diversion is the only real alternative to an incontinent stoma and bag other than ureterosigmoidostomy with its widely acknowledged complications. Various techniques of continent suprapubic diversion have been described. The principal methods depend either on the formation of a nipple valve (Kock, 1969), utilisation of the ileocaecal valve (Gilchrist etal., 1950),or on the anti-refluxing implantation of a small calibre tube such as appendix into a urinary reservoir (Mitrofanoff, 1980). This report details our experience of continent suprapubic diversion in patients with pelvic malignant disease using the Mitrofanoff principle. Read at the 46th Annual Meeting of the British Association of Urological Surgeons in Scarborough, July 1990
Patients and Methods Seventeen patients with a current or previous history of pelvic cancer underwent continent or suprapubic diversion. Their median age was 59 years (range 27-72) and the underlying pathology is summarised in Table 1. They were selected from patients presenting with pelvic cancer who required radical surgery and were deemed physically and emotionally fit for major reconstruction. All were counselled preoperatively regarding the pros and cons of an incontinent versus a continent stoma. All were Table 1 Underlying Pathology in Patients undergoing Continent Suprapubic Diversion No. of Pathology
patients
Transitional cell carcinoma of bladder (T3, G3 in 4;extensive carcinoma in situ superficial disease in 3) Squamous cell carcinoma of the bladder Carcinoma of cervix (Squamous cell in 3, adenosquamous in 1, adenocarcinoma in 1) Adenocarcinoma of rectum Adenocarcinoma of vagina Squamous cell carcinoma of urethra
376
+
I 1 5
2 1 1
ROLE OF CONTINENT SUPRAPUBIC DIVERSION IN PELVIC CANCER
extensively investigated and staged pre-operatively . This always included computed tomography, an assessment of renal function and an examination under anaesthesia (EUA). Where appropriate, preoperative consultation was sought with gynaecological, plastic and/or general surgical teams and if necessary a combined EUA was performed. Fourteen patients underwent continent suprapubic diversion and cancer-clearing surgery with curative intent concurrently. Four patients also underwent concurrent plastic reconstructive procedures including myocutaneous flap grafting and/ or vaginoplasty. Details of the operations performed concurrently with continent suprapubic diversion are summarised in Table 2. Eight patients underwent radical cystourethrectomy (7 for transitional cell and 1 for squamous cell carcinoma). Seven of them had a Mitrofanoff reconstruction and 1 underwent construction of a Kock pouch. Two women underwent synchronous anterior exenteration and a Mitrofanoff reconstruction for locally recurrent carcinoma of cervix. One woman with extensive intra-epithelial carcinoma of cervix who had previously had a hysterectomy, laser therapy and radiotherapy underwent vulvocolpectomy and because of bladder involvement a cystectomy. Reconstruction was by means of a rectus abdominis flap, ileovaginoplasty and a Mitrofanoff procedure. Another woman with adenocarcinoma of the vagina who had persisting disease despite radiotherapy underwent hysterocolpectomy, urethrectomy and a partial cystectomy. The reconstruction included ureteric reimplantation, colovaginoplasty and a Mitrofanoff procedure in which appendix was implanted into the bladder remnant. A further woman had a local recurrence of a rectal carcinoma involving the vagina 2 years
377
after abdominoperineal resection. This persisted despite radiotherapy and she therefore underwent a pelvic clearance, reconstruction being by means of a rectus flap, ileovaginoplasty and a Mitrofanoff procedure. A male patient with an ulcerating squamous cell carcinoma in the perineum underwent radical excision of the penis, urethra and perineal ulcer. Reconstruction included a rectus flap and a Mitrofanoff procedure. A further 3 patients who had had previous treatment for pelvic malignancy underwent continent suprapubic diversion. All were reassessed and considered to be free of recurrent disease. In 2 women with cervical cancer, treatment had included external beam and intracavity radiotherapy. Both had been disease-free for 3 years but had developed severely contracted bladders, 1 with intractable incontinence and the other with bilateral ureteric obstruction. The third patient had undergone abdominoperineal resection for a rectal cancer 13 years previously. She had persistent urinary incontinence despite endoscopic and open colposuspensions. The urinary reservoir was constructed from detubularised caecum and ascending colon in 13 patients. In each case the appendix was mobilised on its pedicle, reimplanted into the caecum and brought to the skin surface as previously described (Woodhouse et al., 1989). In 3 patients bladder was available. In 2 of them ureter was used as a catheterisable conduit with an associated transuretero-ureterostomy as previously described (Woodhouse et al., 1989). In the third patient appendix was implanted into the bladder and brought to the surface as a continent catheterisable vesicostomy. The seventeenth patient had a conventional Kock pouch.
Table 2 Operations performed concurrently with Continent Urinary Diversion and Details of Previous Surgery and Radiotherapy No. ofputients -~~~~ ~~
~
~
~
Bladder cancer Radical cystourethrectomy (pre-operative deep X-ray therapy in 1) Other pelvic malignancy Anterior exenteration (previous deep X-ray therapy in 2, previous hysterectomy in 1) Vulvo-colpectomy, cystectomy, rectus flap and ileo-vaginoplasty (previous hysterectomy and deep X-ray therapy) Hystero-colpectomy, urethrectomy, partial cystectomy, ureteric reimplantation and colo-vaginoplasty (previous deep X-ray therapy) Pelvic exenteration, rectus flap and ileo-vaginoplasty (previous A-P resection and deep X-ray therapy) Radical excision of penis, urethra and perineal ulcer rectus flap
+
8
2 1
1 1 1
378
Results There were 2 post-operative deaths. In the patient who had excision of an ulcerating perineal tumour the rectus abdominis flap necrosed and this was replaced with a groin flap but this also failed. Renal and multi-organ failure followed. In the second patient an acute abdomen and signs of sepsis necessitated re-exploration 1 week after radical cystourethrectomy and a Mitrofanoff reconstruction. The patient had a fatal myocardial infarct after this operation. These 2 patients were the second and third oldest in the series. The median follow-up in the remaining patients was 24 months (range 6-36). All of these patients achieved continence, though 1 required revision of the appendix conduit to do so. Patients selfcatheterise at intervals of 4 to 5 h and occasionally at night. One patient required dilatation of an appendiceal conduit. Another had difficulty catheterising a ureteric conduit and ultimately required conversion to a Kock nipple. One patient had minor leakage in association with urinary infection which required more frequent catheterisation. A further patient who had received radiotherapy developed a stricture at the site of ureteric reimplantation into the neobladder. This was initially dilated percutaneously but ultimately required open revision because of upper tract deterioration. There were no other upper tract complications and no significant metabolic complications were encountered. Tumour recurrence has occurred in 5 patients. Three are alive with distant metastases which presented 5, 6 and 17 months following radical cystourethrectomy for bladder cancer (squamous cell in 1 and transitional cell in 2). The women with cervical and vaginal carcinoma respectively developed local recurrence 8 and 6 months after combined exenterative surgery and reconstruction. Both underwent further extensive pelvic surgery with reconstruction of a neobladder in 1. The continent diversion was preserved in both, but they died from widespread disease at 12 and 16 months respectively. One of these women presented with difficulty in self-catheterisation which was found to be due to tumour recurrence around the Mitrofanoff appendix.
Discussion Although the ileal conduit remains the standard method of urinary diversion after cystectomy and other ablative pelvic operations, efforts to avoid a
BRITISH JOURNAL OF UROLOGY
wet stoma and bag have been intensified in recent years. Carney and Le Duc (1979) first popularised anastornosing an intestinal neobladder to the urethra and numerous variations on this theme have followed. These procedures are not uncommonly complicated by inadequate emptying and enuresis, particularly at night, necessitating intermittent self-catheterisation and in some cases an artificial sphincter. After cystectomy, therefore, continent suprapubic diversion (particularly with a discrete stoma) is an attractive alternative to procedures in which a neobladder is anastomosed to the urethra. Following cystourethrectomy and other procedures which remove or destroy the continence mechanisms, continent suprapubic diversion is in our view the only realistic alternative to an incontinent stoma. Skinner e l af. (1987) have popularised the use of the Kock pouch after radical cystourethrectomy. However, we have not found the Kock pouch easy to construct and even in the hands of enthusiasts there is a significant rate of revisional surgery (Cumming et al., 1987). We have previously reported our early experience of continent suprapubic diversion employing the Mitrofanoff principle in younger patients who had originally undergone urinary diversion in childhood (Woodhouse et af.,1989). In some of these patients native bladder was available, but following cystectomy we have found detubularised caecum and ascending colon to be the most satisfactory arrangement for the reservoir with appendix as the catheterisable conduit. The present series comprised a relatively high risk group of patients in so far as 6 of them had had previous radiotherapy and/or previous primary surgical treatment for their underlying disease (Table 2). The combination of a radical pelvic cancer exenteration with a concurrent complex reconstruction of a continent suprapubic diversion in an older, less fit patient is a different prospect from performing this type of diversion alone in an otherwise healthy young adult. In the younger group we have now performed over 40 continent diversions with no mortality. Of the 2 deaths in this series 1 resulted from failed plastic surgical reconstruction in the patient with a fungating perineal squamous cell tumour. The second death, however, emphasises the increased risks of performing this type of reconstruction concurrent with radical cystourethrectomy for bladder cancer. This patient did have evidence of cardiovascular disease preoperatively and was therefore a relatively high risk. We are now more critical in evaluating patients
ROLE OF CONTINENT SUPRAPUBIC DIVERSION IN PELVIC CANCER
pre-operatively and in those patients keen to avoid a bag but considered unfit for a synchronous continent diversion we offer to construct a colon conduit with the option of a later conversion to a continent suprapubic diversion. Women with cervical cancer constituted the second largest group in the present series. Patients with central recurrences and no evidence of distant disease following previous radiotherapy are offered anterior exenteration with the possibility of a continent suprapubic diversion. If there is any evidence of pelvic sidewall or iliac or para-aortic lymph node involvement on per-operative frozen section, an ileal conduit is constructed instead of the more complicated procedure. Continent suprapubic diversion also has a place in the reconstruction of the lower urinary tract in patients who have radiation damage following previous treatment of pelvic cancers, as in 2 of the women with cervical cancer in the present series. In some of these patients substitution cystoplasty may be feasible. However, in those with sphincteric damage and in those with severe radiation fibrosis, continent suprapubic diversion may be preferable. Two patients in this series had colostomies. We do not regard this as a contraindication to continent urinary diversion. Many patients prefer to have 1 bag rather than 2. Continent urinary diversion has a wide range of application in patients with pelvic malignant disease. We prefer the Mitrofanoff method of reconstruction. In the elderly, less fit patient typical of those requiring cystectomy for bladder cancer, great care must be taken in selection as the concurrent construction of a continent suprapubic
379
diversion confers additional risks on an already major procedure.
References Camey, M. and Le DUC,A. (1919). L’entkrocystoplastie apres cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13,114-123. Cumming, J., Worth, P. H. L. and Woodhouse, C. R. J. (1987). The choice of suprapubic continent catheterisable stoma. Br. J . Urol., 60,221-230. Gilchrist, R. K., Merricks, J. W., Hamlin, H. H. er al. (1950). Construction of a substitute bladder and urethra. Surg. Gynecol. Obstet., 90, 752-760. Kock, N. G. (1969). Intra abdominal reservoir in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal continence in five ileostomy patients. Arch. Surg., 99,223-231. Mitrofanoff, P. (1980). Cystostomie continente transappendiculaire dans le traitement des vessies neurologiques. Chir. Pediatr., 21,297-305. Skinner,D. G.,Lieskowski,G. andBoyd,S. D. (1987).Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update after 250 cases. J . Urol., 137, 1140-1 145. Woodhouse, C. R. J., Malone, P. R., Cumming, J. et al. (1989). The Mitrofanoff principle for continent urinary diversion. Br. J . Urol.,63, 53-51.
The Authors J . S. K. Gelister, MS, FRCS, Senior Urological Registrar, Royal Marsden Hospital. C. R. J . Woodhouse, FRCS, Consultant Urologist and Senior Lecturer, St Peter’s, St George’s and Royal Marsden Hospitals, London. Requests for reprints to: J . S. K. Gelister, Department of Urology, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 IAA.
