Search

To evaluate three subtypes of continent-cutaneous urinary diversion (CCUD); Indiana pouch (IP), right colon pouch with appendico-umbilicostomy (AU), and right colon pouch with neo-appendico-umbilicostomy (NAU), by investigating diversion-specific complications and quality-of-life outcomes.A retrospective review of an IRB-approved database was conducted for perioperative and outcome data. The EORTC QLQ-C30 questionnaire was used to assess quality of life; all responses were obtained 6 months after diversion.Fifty-eight patients who underwent a CCUD at our institution from 2010 to 2016 (33 IP by two surgeons, 15 AU and ten NAU by third surgeon) were identified for this study. Higher age and Charlson Comorbidity Index (CCI) ≥ 3 were seen in the AU cohort when compared to the IP cohort (P = 0.02 and 0.02, respectively). NAU group were also older when compared to the IP group (P = 0.02). After a median follow-up of 21 months (range: 0.8-81.0), more high-grade diversion-related complications were reported for AU and NAU patients comparing to the IP group (P 0.01 and P = 0.02, respectively). More stoma complications were also reported for the NAU cohort than the IP cohort (70% vs 30%, P = 0.03). In all groups, 60% of stoma complications occurred at the skin or fascia level. In the 90-day postoperative period, a higher continence rate was reported for the IP cohort, and this difference was significant when compared to the NAU cohort (P = 0.04). Length of stay after surgery and revision rates were not significantly different. For all groups, the majority of patients reported little-to-no disturbance of daily functions and rated overall quality of life as good-to-excellent.Urinary diversion using the Indiana pouch and right colon pouch with appendico/neo-appendico-umbilicostomy are all associated with high rates of continence and patient satisfaction. When compared to IP, AU and NAU patients had higher rates of high-grade diversion-related complications and NAU patients had a higher stoma complications with lower 90-day continence rate.

This report presents our experience in performing prolapse repair after anterior exenteration. The patient had a history of invasive bladder cancer and underwent a robotically assisted laparoscopic anterior exenteration with extended bilateral pelvic lymph node dissection and creation of an Indiana pouch continent diversion. Her pelvic organ prolapse progressed over time despite multiple pessary fittings. She eventually decided to proceed with pelvic reconstructive surgery 6 years after her cancer surgery. She underwent a successful vaginal native tissue reconstruction with uterosacral ligament suspension, posterior repair and reconstruction of the anterior compartment. The patient has been followed for 16 months without recurrent prolapse. Vaginal native tissue pelvic reconstruction is feasible in a patient with a history of pelvic exenteration.

The primary objective of urinary diversion is to allow low-pressure storage and efficient drainage of urine in patients with bladder cancer or severe lower urinary tract dysfunction. Continent urinary diversion, although more challenging to construct and less commonly performed than non-continent diversion, offers the advantages of an intra-corporeal pouch for urinary storage and a concealed stoma for evacuation. Minimally, invasive approaches to the creation of continent urinary diversions have emerged over the last 20 years and may limit the morbidity of these procedures by potentially allowing shorter hospitalization, earlier recovery, and improved postoperative pain control. We review the various advances in minimally invasive approaches to continent urinary diversion.

Techniques for continent cutaneous urinary diversion (CCD) have evolved considerably over the last 65 years. The Indiana pouch (IP) was initially described in the 1980s and has gained wide acceptance among urologists. For patients who desire continent urinary diversion, many clinical scenarios and individual preferences continue to make the IP an excellent option for appropriately selected patients. Continence rates for the IP are generally satisfactory and compare favorably with orthotopic neobladder. Unfortunately, radical cystectomy with urinary diversion is associated with a high complication rate. We discuss short-term (

KEYWORDSIleocecal bladder;Indiana pouch;Continence;Radical cystectomyAbstract One of the commonest forms of orthotopic bladder substitution for bladder cancer sur-vivors, used in our institute, is the use of ileocecal segment. Sometimes, the need for Indiana pouchheterotropic continent diversion arises.Aim: To compare the long-term effect of orthotopic ileocecal bladder and heterotropic Indianapouch following radical cystectomy in bladder cancer patients.Patients and methods: Between January 2008 and December 2011, 91 patients underwent radicalcystectomy/anterior pelvic exentration and orthotopic ileocecal bladder reconstruction (61 patients)and Indiana pouch (30 patients), when orthotopic diversion could not be technically or oncologi-cally feasible.Results: Convalescence was uneventful in most patients. All minor and major urinary leakagecases, in both diversions groups, where successfully conservatively treated. Only one patient inthe ileocecal group with major urinary leak required re-exploration with successful revision of uret-ro-colonic anastomosis. Only one patient in the Indiana pouch group had accidentally discoveredsub-centimetric stone, which was simply expelled. The overall survival proportion of ileocecal groupwas 100% compared to 80% in the Indiana pouch group (p < 0.001). The disease free survival pro-portion of ileocecal group was 90.8% compared to 80% in the Indiana pouch group (p = 0.076).Effective comparative daytime and nighttime urinary continence as well as renal function deterio-ration were not statistically significant between both reconstruction types.Conclusion: Both ileocecal bladder and Indiana pouch are safe procedures in regard to long-termeffects over kidney function following radical cystectomy.a 2013 National Cancer Institute, Cairo University. Production and hosting by Elsevier B.V.All rights reserved.

Continent cutaneous urinary diversion can be employed after cystectomy when orthotopic diversion is not appropriate and a continent diversion is desired. It is a technically challenging operation and requires careful pre-operative and intra-operative planning as well as an experienced surgeon and ancillary staff. Overall, continent cutaneous diversion (CCD) carries a high rate of long-term continence and patient satisfaction, and is an important and widely accepted part of the urologist’s armamentarium. Many different types of CCD and efferent channels have been described with variable success. Complications are largely related to the stoma and catheterizable channel. These complications can usually be managed outside of the operating room although occasionally re-operation is required.

Background: When urinary diversion began in the past century, urine was diverted to the intestine (internal diversion) and emptying was controlled by the anal sphincter. Later ureterosigmoidostomies became the method of choice. However, despite simplicity of the technique metabolic side effects such as hyperchloremic metabolic acidosis, urinary infection and frequent deterioration of renal function urged the need for new ways of bladder replacement. Methods: Diversions to the skin (external diversion) could avoid to a large extent these drawbacks. In fact, urinary diversion to the skin via an ileal conduit(Bricker) is the most frequently used technique. Recently continent diversions to the urethra (orthotopic pouch) have seen renewed interest. Results: Tunneled implantation of the ureters into the small bowel prevented reflux and recurrent infection. Further, less electrolyte imbalances were noted due to little electrolyte absorption. Since quality of life of the affected individual has become an important issue, continent external diversions are often offered to the young patient, using mostly cecum (or colon) as an internal collecting reservoir and a short segment of ileum for connecting the reservoir to the skin (Indiana pouch, Mainz pouch I). Similarly, orthotopic urinary diversion, connecting the reservoir (pouch) to the urethra has been employed. Frequently the ileum is used to create an ileum neobladder with connection to the urethra (modified Kock pouch, Hautmann bladder and Studer bladder). However, disadvantages of continent diversions are mainly the need for intermittent self catheterization and in case of orthotopic replacements night time incontinence. Nevertheless, the overall goal in the construction of continent reservoirs is the storage of large amounts of urine for a reasonable time period under low pressure conditions (

A variety of plastic surgical techniques may be used in the repair of vesicovaginal fistulas. The indication for their use include: (a) diameter greater than 4 cm; (b) involvement of the bladder neck/proximal urethra; (c) radiation-induced fistulas; and (d) previous failed repair(s). In the developing world the vast majority of complex fistulas are caused by obstetric trauma; elsewhere they occur mainly following radiotherapy or radical surgery for gynecologic malignancy. The majority of complex fistulas requiring tissue donation may be effectively treated using a vaginal approach and a modified Martius graft. There is probably little or no advantage in encorporating bulbocavernosus muscle fibers in this graft. Although some concern exists regarding the long-term viability of these grafts in radiation-induced fistulas, in view of the relatively simple operative technique, together with the low associated morbidity, modified Martius grafts may be deemed suitable for first-time repairs. The gracilis muscle graft should be considered next in cases of exclusive transvaginal repair. The omental graft is undoubtedly the most versatile: it can be used in both abdominal and combined abdominovaginal procedures. The recently described posterosuperior sliding bladder flaps warrant further evaluation. For most fistulas involving the bladder neck/proximal urethra, there is no clear advantage in bladder flap reconstruction over vaginal flap reconstruction, the latter being augmented by an anti-stress incontinence procedure were appropriate. When continent urinary diversion is required, the Indiana pouch appears preferable to the Kock pouch; ureterosigmoidostomy is, however, technically and culturally more acceptable in these circumstances in the developing world.

The exact role of the ileocecal valve (ICV) at the junction of small and large bowel is not well understood. Bowel segments used for the construction of urinary reservoirs incorporate the ICV. In the Indiana pouch its natural continence is used as one principle for achieving continence of the efferent limb. Motor activity and pressure in the ICV, the ileum and colon were registered in eight dogs. Myogenic activity of the bowel consisted of slow waves, irregular spontaneous contractions and superimposed spikes. Pressures of 7.2 +/- 0.3 cmH2O were recorded in the ileum and of 5.6 +/- 0.4 cmH2O in the colon. The pressure in the ICV was 12.7 +/- 0.4 cmH2O rising to 26.4 +/- 2.2 cmH2O during spontaneous depolarization. Balloon dilatation of the ileum resulted in relaxation of the ICV in 76% of experiments, whereas colonic distension was followed by a pressure increase in the ICV region in 80% of experiments. In 16% of cases a relaxation of the ICV area and a weaker response after repeated dilatation was noted. These findings make the ICV an unreliable continence mechanism as its long-term continence can not be predicted despite intraoperative evaluation. Additional measures to ensure consistent continence at the ICV (e.g. electric stimulation) need to be studied.

The Indiana pouch is a large capacity, lowpressure continent urinary reservoir. The mechanism of continence in the Indiana pouch has been shown to be the result of several factors, including the natural resistance of the ileocecal valve, resistance produced by the plication or tapering of the ileal efferent limb, and peristalsis of the ileum. Continence in urinary diversions is reviewed with special emphasis on the mechanisms of continence in the Indiana pouch.

Objective To investigate the indications, operation techniques and clinical effects of a modified technique of Indiana pouch.

Experience with the Kock pouch prompted us to develop a new form of continent urinary reservoir. This is a composite structure using ileum and cecum. Tunnelled ureteral implantations along the tenia of the cecum provide the antireflux mechanism, while the ileocecal valve and plicated terminal ileal segment provide continence. An ileal patch on the cecum helps overcome the intermittent incontinence that can occur and is presumed to be due to a bolus contraction of the cecum. The cecoileal continent urinary reservoir offers the flexibility of either abdominal or pelvic placement.