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AIMS Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion. METHODS Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes. RESULTS During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission. CONCLUSIONS Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

A 73-year-old man with lower abdominal pain was diagnosed at our hospital with sigmoid colon cancer. He had previously undergone radical cystectomy with Indiana pouch construction and gastrectomy to treat bladder cancer and gastric cancer, respectively. We performed a laparoscopic Hartmann's operation with Japanese D3 lymph node dissection. We observed severe adhesion in the abdominal cavity; adhesions between the urostomy and sigmoid colon were particularly severe. The tumor had invaded to the distal rectum, which had adhered to the pubic bone and the previously reconstructed urinary pouch. By performing careful and persistent laparoscopic dissection, we completed the operation without damaging the urostomy and with no remnant tumor tissue (R0). The postoperative course was uneventful, and the patient was doing well with no evidence of cancer recurrence 1 year after surgery.

BACKGROUND Urinary diversion specimens from patients who undergo radical cystectomy are often submitted for urine cytology to screen for recurrent urothelial carcinoma. The objective of the current study was to investigate the frequency and cytohistologic features of cancer recurrence in diversion urine specimens. METHODS A 10-year retrospective review of archival urinary diversion specimens was conducted. For abnormal cytology cases, cytology slides were reviewed, and their cytomorphology and available corresponding histopathology were documented. RESULTS In total, 679 diversion urine cytology specimens were identified, of which 39 specimens from 25 patients (5.7 %) had abnormal cytology diagnoses. Seven of 25 patients (28%) had postcystectomy surgical follow-up, and 5 of them manifested with local recurrence. Among the patients who had local recurrence, 3 (60%) developed lymph node and distant metastases and subsequently died. Sites of tumor recurrence included anastomoses in 4 of 5 patients and the penile urethra in 1 of 5 patients. The diversion urine cytology slides in patients who had carcinoma revealed scant, well preserved urothelial cells either alone or in clusters with high-grade features, including eccentrically located, enlarged, hyperchromatic nuclei; irregular nuclear borders; and high nuclear-to-cytoplasmic ratios. CONCLUSIONS The current data demonstrate that abnormal cytology in urinary diversion specimens is rare but, when present, can help to detect recurrent urothelial carcinoma. Careful examination of these specimens is warranted to screen for features of high-grade urothelial carcinoma among a degenerated cellular and sometimes inflammatory background. Cancer Cytopathol 2017;125:120–127. © 2016 American Cancer Society.

Study Type – Therapy (outcomes research) Level of Evidence 2c What’s known on the subject? and What does the study add? Continent urinary diversion represents a valid alternative to orthotopic reconstruction when this is unsuitable. Inclusion criteria for continent cutaneous diversion are strict and patients must be carefully selected. To date, several continent urinary diversions have been used such as Mainz, Indiana and Miami pouches. Simplified Indiana Pouch with multiple taeniamyotomies (SIPMT) represents a valid continent cutaneous urinary diversion with stable urodynamic features along 4 years. Appendicostomies guarantees better continence than ileostomies. In our series the EORTC QLQ-C30 and QLQ-BLM30 questionnaires showed a good health related quality of life. OBJECTIVE To compare the early and late urodynamic assessment of simplified Indiana pouch with multiple taeniamyotomies (SIPMT). PATIENTS AND METHODS Between April 1999 and May 2005, 62 consecutive patients underwent radical cystectomy (RC) and SIMPT. Cystometry and efferent tract pressure profilometry were performed at 12 (early) and 48 (late) months after RC in 32 patients. The efferent tract of the reservoir was the appendix in 62.5% of patients and an ileum invagination nipple in 37.5%. All patients were asked to complete questionnaires on HRQL: the European Organization for Cancer Research and Treatment of Cancer Quality of life Questionnaire version 3.0 (EORTC QLQ-C30) and the bladder cancer-specific module (EORTC QLQ-BLM30). RESULTS There was no significant change in cystometric capacity (median 627.5 vs 607.5 mL, P= 0.79), while end-filling pressure (median 28 vs 18 cmH2O) and amplitude of involuntary contractions (median 38 vs 32 cmH2O; both P < 0.001) decreased. Efferent tract-closing pressure increased in the appendicostomies (median 74.5 vs 91.0 cmH2O, P= 0.029) and decreased in the ileostomies (median 72.5 vs 63 cmH2O, P= 0.015), also the leakage rates during the pressure peaks decreased from 15% to 5% in appendicostomies, while there was no change in those with ileostomies (15%). At late evaluation, daytime and night-time continence rates were 94% and 88%, respectively, in patients with appendicostomies, and 90% and 85%, respectively, in those with ileostomies. A good HRQL was determined by the EORTC QLQ-C30 and QLQ-BLM30 questionnaires. CONCLUSIONS At 48 months after surgery SIPMT maintained an adequate capacity with low internal pressure, good continence rates and HRQL. When feasible, appendicostomy should be performed, as it was associated with better continence.

Background We report our technique for robotic-assisted laparoscopic radical cystoprostatectomy (RARCP) and extracorporeal urinary diversion and present their clinical outcomes. Methods Between October 2003 and December 2008 we performed 58 RARCPs with extracorporeal continent urinary diversion. Preoperative, operative and postoperative data was evaluated. Results Mean patient age was 68 (range 46–89) years, with an average American Society of Anesthesiologists classification of 2.9. Mean operative time was 8 (range 5–11) h. Median blood loss was 450 ml. Thirteen patients received intra-operative blood transfusions and 22 patients received peri-operative blood transfusions. Continent urinary diversions were performed by means of the Studer technique (n = 42) or Indiana pouch (n = 16). Mean number of lymph nodes examined on lymphadenectomy was 27 (range 0–52). Conclusions Our RARCP and continent diversion technique is a safe and feasible option for primary urothelial carcinoma of the bladder. Oncological and surgical outcomes are comparable to open cystectomy series. Copyright © 2010 John Wiley & Sons, Ltd.

Continent urinary diversion requires the creation of a reservoir, ureteric implantation and establishment of a continence mechanism in the efferent segment. This review is a short overview on the history of different techniques in current use. Reservoirs with high volume and low pressure can be fashioned by antimesenteric opening and spherical reconfiguration of the bowel. Previously, techniques for ureteric implantation were simply transferred to continent urinary diversion. Currently the need for antirefluxive ureteric implantation techniques is questioned and there is a trend towards refluxive implantation. To create a continence mechanism, simple and reproducible procedures. e.g. the incorporation of the efferent segment into the pouch wall (e.g. appendix stoma, flap valve T mechanism, serosal-lined extramural tunnel) have been developed. Long-term data for different surgical techniques show excellent continence and acceptable complication rates.

Background Because vitamin B12 is absorbed exclusively by the terminal ileum, we investigated vitamin B12 deficiency as a potential metabolic complication after urinary intestinal diversion. Methods We measured serum levels in patients with Kock pouches (n = 35); Indiana pouches (n = 27); and ileal conduits (n = 25). Serial determinations of serum B12 levels were obtained in 1 9 patients with Kock pouches and 14 patients with Indiana pouches. The dual-isotope Schilling test was performed in 9 patients with Kock pouches and 6 patients with Indiana pouches. Results No patient had an abnormally low serum B12 level (< 200 pg/mL). Mean (+ SD) serum B12 levels in patients with the Kock pouch (506 ± 202pg/mL) and the Indiana pouch (536 + 249pg/mL) were lower than that in patients with the ileal conduit (727 + 391 pg/mL). The mean serum B,2 level was not significantly different between patients with and without preoperative irradiation. Serial determinations showed that serum B12 levels in some patients with continent urinary reservoirs were persistently near the lower normal limit, or became progressively lower. Three of the 9 patients (33%) with Kock pouches and 4 of the 6 patients (67%) with Indiana pouches were B12 malabsorbers, although no patients had megaloblastic anemia or neurologic symptoms. Conclusions Some patients with continent urinary reservoirs are at risk for vitamin B12 deficiency due to malabsorption. Routine evaluation of serum B12 levels is recommended for all patients with continent urinary reservoirs, and a Schilling test for those with subnormal serum B12 levels.

Background: Continent urinary diversion (CUD) is performed on patients after total cystourethrectomy due to invasive bladder cancer or other diseases requiring urinary diversion. Since 1984, we have performed CUD using either the Kock pouch procedure or a modified Indiana pouch method. During the long-term follow-up, increasing numbers of late complications occurred, especially after the Kock pouch procedure. We summarized the frequency of postoperative complications, their management, and outcome of CUD using these 2 methods. Methods: Between 1984 and 1995, CUD using the Kock pouch method was performed on 102 patients, and on 61 patients using the Indiana pouch method, with a mean follow-up period of 83 and 50 months, respectively. The patients were between 24 and 82 years old, with a mean age of 59 years. In most patients, the Kock pouch was constructed according to the original method, except for the use of a Dacron fabric collar, and the Indiana pouch was made using the ileal patch method. Results: Of 95 patients followed up for more than 3 months after CUD using the Kock pouch method, efferent and afferent nipple valve malfunction occurred in 21 (22%) and 26 (27%) patients, respectively. Efferent complications occurred during the first year after surgery, whereas afferent complications occurred several years after surgery. Open repair surgery (excluding ileus) was necessary for 36 (38%) patients. Of 59 patients followed for more than 3 months after CUD using the Indiana pouch method, 7 patients with stomal stenosis, 2 patients with stomal prolapse, and 1 patient with stricture at the ureterocolonic anastomosis were treated surgically. An hourglass-like deformity of the pouch was seen in 2 patients, on whom the original Indiana pouch method was performed. As a whole, 13 patients (22%) were retreated with open surgery. Urinary calculi occurred in 42 (44%) patients after CUD using the Kock pouch method and in 11 patients (19%) using the Indiana pouch method. The outcome was excellent, good, fair, and poor in 31, 37, 24, and 8% of the patients after CUD using the Kock pouch method, and in 36, 17, 42, and 5% of the patients after CUD using the Indiana pouch method. Conclusions: We performed CUD using either the Kock pouch or the Indiana pouch method with a success rate of approximately 90%. The rates of revision, reoperation and stone formation were higher with the Kock pouch procedure than with the Indiana pouch procedure, while varying degrees of incomplete incontinence and difficulty in catheterization were seen more often in the latter.

Background: Although bowel segments are commonly used for reconstructing the urinary tract, a high incidence of bacteriuria is observed in patients with urinary intestinal diversion. The normal gastrointestinal tract possesses a potent mucosal immune system characterized by secretory immunoglobulin A (slgA) as the major humoral defense factor. However, the significance of urinary IgA secretion as the mucosal defense mechanism in patients with urinary intestinal diversion has remained obscure. In this study, urinary levels of slgA as well as serum-type IgA were measured in patients with continent urinary reservoirs (Kock and Indiana pouches) and ileal conduits. Methods: Twenty-four-hour urine samples were collected in a total of 80 patients with urinary intestinal diversion (22 Kock pouch patients, 21 Indiana pouch patients and 37 ileal conduit patients). The amount of slgA and serum-type IgA were measured by enzyme-linked immunosorbent assay (ELISA). Results: Urinary IgA levels showed great inter- and intra patient variability in all three groups. Indiana reservoir urine contained significantly greater amounts of slgA (mean 32.0 mg/24hrs) than Kock reservoir urine (11.9 mg) and conduit urine (4.9 mg), whereas Kock reservoir urine contained significantly more slgA than conduit urine. However, the corresponding difference was not observed in regard to serum-type IgA. In none of the three modes of urinary diversion did 24-hour slgA excretion show any correlation with the length of time after surgery. Conclusions: Since the amounts of slgA in these patients were much greater than reported in urinary tract infection as well as in normal subjects, the major portion of urinary slgA seemed to be secreted by the intestinal segments. Long-term slgA secretion in urinary intestinal diversion, especially continent urinary reservoirs, may be an important host defense system.

The Indiana continent urinary reservoir procedure for urinary diversion was performed in 46 patients. After the first 8 cases several modifications were made to the Indiana pouch. These modifications include complete detubularization of the colonic segment, construction of the pouch augmented with a U-shaped patch of ileum and, more recently, the use of stapled plication. The mean postoperative follow-up period was 46 mo (range 4.5-74.1 mo). There was 1 perioperative death and this case was excluded from the follow-up study. Late complications related to the urinary reservoir occurred in 12 (26.7%) of the 45 patients. Stone formation was observed in 5 patients. Out of 45 patients, 42 achieved complete urinary continence while 2 suffered mild nocturnal incontinence and 1 had significant leakage. Three had unilateral hydronephrosis due to ureteroanastomotic stricture. Reservoirgraphy demonstrated no reflux into the upper urinary tract in all of the follow-up cases. Loopography of the efferent limb showed that a staple-plicated ileum functions better than a suture-plicated one in terms of reliability of the continence mechanism and ease of catheterization. The Indiana pouch should be considered for any patient requiring cutaneous urinary diversion because it is technically easy to perform and it has a low revision and high continence rate.

The outcome of 15 children and young adults who underwent reconstruction of continent urinary reservoirs (CUR) from January 1987 to 1990 is presented. Ten patients were male and 5 female with an age range of 3 to 20 years. There were 13 patients with bladder exstrophy and 2 with incontinent epispadias. In 8 cases the urinary diversion was performed for an inadequate bladder capacity following successful closure (3), failed attempted closure (3), female epispadias (1) and following successful urethroplasty in 1 case of male epispadias. A tiny fibrotic bladder plate unsuitable for attempted closure was the indication for diversion in 3 patients. Faecal and urinary incontinence following ureterosigmoidostomy (2 patients) and trigonosigmoidostomy (2) was the reason to consider re-diversion in 4 previously diverted patients. In 10 patients an Indiana pouch was performed. The Mitrofanoff procedure was used in 5 cases with caecum (2), sigmoid colon (2) or transverse colon (1) as the urinary reservoir. All patients are continent on clean intermittent catheterisation with stable renal function. Three patients developed large stones within the reservoir and needed open cystolithotomy. This series supports the efficacy of CUR as an alternative procedure to traditional forms of urinary diversion in the management of selected patients with exstrophy/epispadias complex.

We present a case of a tubulovillous adenoma in an Indiana pouch managed by endoscopic resection. A 66-year-old male underwent a cystectomy with creation of an Indiana pouch urinary diversion for invasive small cell carcinoma of the bladder. Seven years following his initial surgery, the patient noted several episodes of gross hematuria. The evaluation revealed a 2.5 cm tubulovillous adenoma with high-grade dysplasia within the Indiana pouch. The patient had significant comorbidities precluding an open operative procedure. He underwent en endoscopic resection of the tumor, and subsequently has been managed with surveillance pouchoscopy, biopsies, and fulguration every 3 months.

We report the case of a 76-year-old woman who developed a colonic adenocarcinoma and a stone in an Indiana pouch 15 years after the urinary diversion. The colonic adenocarcinoma was treated endoscopically and we were able to preserve the Indiana pouch. To our knowledge, this is the sixth case of colonic adenocarcinoma in an Indiana pouch.

We report on a 63-year-old woman with adenocarcinoma and stones in an Indiana pouch. Adenocarcinoma of an Indiana pouch is extremely rare. To our knowledge, only four cases with adenocarcinoma in an Indiana pouch have been reported.

Continent urinary diversion has become a common form of bladder management for the female exstrophy patient in whom primary reconstruction has failed. Reported are the results of successful pregnancies in four young adult females, who had previously undergone a flap vaginoplasty as part of earlier management and more recently a continent right colonic urinary reservoir with a perineal stoma (Indiana pouch). Pregnancy in each of these patients was characterized by several urinary tract infections, cervical prolapse and mild to severe maternal hydronephrosis. All of the patients had some degree of difficulty with clean intermittent catheterization. One patient required an indwelling catheter with prolonged bed rest. Maternal hydronephrosis resolved after delivery in all instances. All four patients delivered their infants by way of cesarean section, either emergently for maternal or fetal distress or electively. Cervical prolapse did not resolve in three patients and will require surgical repair. After delivery, all patients returned to their previous pattern of clean intermittent catheterization without loss of continence. All the infants delivered were healthy with appropriate weights and high Apgar scores (more than 8). Orthotopic (perineal stoma) continent urinary diversion is not a contraindication to pregnancy. However, our experience mandates delivery by cesarean section with close monitoring for maternal or fetal distress during gestation.