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Objective: To evaluate the functional outcomes and complications for patients with bladder cancer undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion., Methods: From February 2004 to March 2010, 34 patients underwent robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction. After surgery, the complications were identified, categorized, and graded using an established 5-grade modification of the original Clavien grading system, and continence was assessed. Descriptive statistics were used in evaluating the outcomes. Fischer's exact test was used in the comparison of early and late Clavien grade III complications., Results: Overall, 175 (123 early and 52 late) complications after surgery were reported in 32 (94%) of 34 patients. Within 90 days of surgery, 31 (91%) of 34 patients experienced ≥ 1 early complication. Of 34 patients, 15 (44%) reported ≥ 1 late complications (>90 days). Most (85% and 69%, respectively) early and late complications were graded as minor (grade II or less). Fewer patients with early complications required an additional intervention (grade III) compared with patients with late complications (14% vs 31%; P = .116). The most common complication in both intervals was infection, reported in 22% and 37% of patients with early and late complications, respectively. The continence data for 31 patients at a mean follow-up of 20.1 months (median 12.0) showed that all but 1 patient (97%) had daytime and nighttime continence., Conclusion: Patients undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction have comparable complication rates and functional outcomes compared with patients in the open series., (Copyright © 2012 Elsevier Inc. All rights reserved.) more...

The efficacy of a new continent outlet mechanism using a simple ileal valve in a continent cutaneous urinary diversion was evaluated. In eight mongrel dogs, a 50 cm distal ileal segment was isolated. The distal 41 cm of the isolated segment was opened along the antimesenteric border while the proximal 9 cm was not detubularized. The distal 6 cm part of the non-detubularized segment was tapered over a 30 F catheter and closed with continuous 3/0 polyglactin sutures. In order to create a valve, this 6 cm tapered ileal segment was wrapped anteriorly by the most distal part of the detubularized ileal segment. The remaining part of the detubularized ileal segment was folded into a U configuration. The posterior plate was completed by joining the limbs of the U with running absorbable sutures. Afterwards, the reservoir was closed by folding the ileal plate in half in the opposite direction to which it was opened. The intact proximal 3 cm part of the isolated ileal segment was brought out to the abdominal skin. A pouchogram of the reservoir and video-urodynamic studies were performed to evaluate the efficacy of the continent outlet 18-20 weeks after surgery. Video-urodynamic studies and pouchograms of the reservoirs revealed no leakage from the continent outlet in any dog. Reservoirs had a mean capacity of 413 +/- 51 ml (range 356-447 ml). When the reservoir was filled to maximum capacity, the average total reservoir pressure was 29 +/- 4.7 cm H2O (range 21-45). This procedure, using a single ileal segment for construction of the continent cutaneous urinary diversion, is simple and safe. The ileal valve mechanism serves as a reliable continent outlet system. more...

Background: The ileocecal rectal bladder (IRB) after cystectomy has been devised, in which continence is controlled by the anal sphincter. To assess how this procedure influences postoperative health-related quality of life (QOL), IRB patients were compared with ileal conduit (IC) patients using a questionnaire mail-out., Methods: The questionnaire consisted of 35 questions. The questions were multiple choice and the answers were rated on a Linkert rank-type four-point scale. The IRB operation was performed on 29 patients between March 1990 and July 1998. The questionnaire was mailed to 21 of 29 IRB and 34 IRC patients, who underwent either operation during the same period abd had no persistent or recurrent tumor. Statistical analysis was performed by Mann-Whitney U-test., Results: All 21 IRB patients (100%) and 24 IC patients (71%) responded to the questionnaire. The mean age and follow-up time of both groups were not significantly different. The IRB group had better scores in many items, especially, in those of self-care, turning over freely during sleep,and tension. However, 43% of IRB patients used pads for small amounts of incontinence (spotting) and worried about flatus., Conclusion: These findings show that many functional and symptomatic health related QOL scores are better after IRB and support the use of this procedure of urinary diversion for selected patients. more...

The aim of this study was the metabolic evaluation of 10 patients with 2 different types of urinary diversions, after cystectomy for infiltrating carcinoma. The patients were divided into two groups, homogeneous for age and follow up, according to the type of urinary diversion: group A (5 patients with ileo-cecal bladder) and group B (5 patients with ileal conduit). The follow up duration was 16.8 +/- 7.3 months in group A and 25.4 +/- 7.8 months, in group B. Even though the glomerular filtration rate (GFR) in both groups was within the normal limits, however - on closer evaluation - patients of A group revealed a slight functional damage, shown by reduced creatinine secretion, lower bicarbonatemia and lower urinary acid secretion when compared with ileal conduit patients. According to this study, the ileal conduit seems to be associated with a fairly good metabolic status while the ileo-cecal bladder could require closer clinical-metabolic follow up and bicarbonate supplementation. more...

Immobilization and subsequent sacral decubitus or pressure sore formation is a danger faced by the paraplegic. We report on 4 patients treated with non-healing pressure sores. Three male patients had decubiti eroding into the posterior urethra and bladder neck area. One female patient had bladder neck and urethral loss secondary to Foley catheter erosion and a sacral pressure sore. All 4 had non-healing decubiti secondary to urinary contamination and, in addition, gross fecal contamination in the male patients. All patients failed previous muscular flaps and urinary diversion per suprapubic tube. In the male patients, suprapubic continent urinary diversion included bladder neck mobilization, closure of the distal urethra by oversewing and patching with bovine dura, and augmentation of the bladder with a Miami pouch. Fecal diversion was provided with a sigmoid colostomy. In the female patient, continent diversion was performed by forming a Miami pouch. Total diversion allowed healing of the pressure sores and provided a simpler method of personal hygiene. Details of the diversion and case studies will be presented. more...

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 ureteral-intestinal anastomoses. Early results are promising for this simplified means of continent diversion. more...

Urinary reservoirs constructed from the ileocecal segment conform generally to the principles of an ideal bladder substitute. They have psychological and functional advantages for selected patients who require urinary diversion. The reservoir can easily be placed in the pelvis attached to the urethra. Alternatively, an extremely efficient efferent continence mechanism that is both easy to catheterize and to construct can be made from tapered terminal ileum and an intact ileocecal valve. more...

We have described herein a simple pressure transducer system which helps the surgeon to tailor suture placement and achieve a continent ileocecal reservoir. It seems that fewer Lembert sutures than previously recommended are necessary to create a continent reservoir, although further study is needed. more...

Eighteen patients with cancer of the urinary bladder underwent cystectomy with formation of a large intestinal reservoir for urine. The terminal large intestinal portion, 15-20 cm, the cecum, the ascending colon, and the hepatic angle of the colon were excluded to produce a reservoir from the intestinal tube. Appendectomy was performed. The continuity of the intestinal tube was restored via ileotransversostomy. The ureters were retroperitoneally grafted into the cecum by using antireflux and antistricture techniques. The ileocecal valve was clinico-anatomically examined. A device restraining urine was formed on an individual basis in relation to the function of Bauhin's valve. Cutaneous urinostoma ("dry") was formed epicutaneously in the right iliac region below the umbilicus. Three patients died in the postoperative period. Complete urine keeping was observed in 14 of 15 patients. The maximal capacity of the reservoir is 500 ml, the pressure is 30-40 cm H2O. Homeostasis and intestinal function were found to be normal. more...

Patients requiring bladder removal for malignant disease have undergone continent urinary diversion employing the ileocecal segment, using the cecum to construct a reservoir and an intussuscepted ileocecal valve as the continence mechanism. Five of these patients have been studied urodynamically and radiographically in the postoperative period. Incontinence was found to be minimal and related only to a prolonged catheterization interval. Passive filling pressure and peristaltic pressure remained low in all patients and was lower than the nipple valve pressure in 4 of 5 patients. A transient increase in reservoir pressure at capacity with peristalsis exceeded the nipple peristaltic pressure in 1 patient and was associated with a small volume of incontinence. This resolved with a shortened catheterization interval. Reflux was not found in any subject studied. These studies indicate that the cecal segment can be used to construct a continent urinary reservoir that provides satisfactory function for the patient while maintaining an acceptable pressure volume relationship. more...

The ileocecal reservoir (Indiana pouch) is a large volume, low pressure continent reservoir well suited for urinary diversion. The mechanism of continence is believed to be the result of several factors, including the natural ileocecal valve resistance, resistance produced by the plication of the ileal segment and normal peristalsis of the ileum. We report the results of a video-urodynamic study in patients with an Indiana pouch, aimed at establishing the factors that contribute to continence and their relative significance. Video-urodynamic studies clearly demonstrate that continence in this type of urinary reservoir is dependent upon a synergism of the aforementioned factors in combination with the low intraluminal pressure of the detubularized bowel. Video-urodynamic studies offer an objective demonstration of the reservoir dynamics and its continence mechanisms, and provide an insight into the possible etiology of incontinence. Such studies also offer an objective means for critical comparison of the different continent urinary reservoirs. more...

One of the major limitations of continent intestinal reservoirs currently in use is failure of the efferent continence mechanisms. Unsatisfactory results have been reported in the literature in up to 40% of cases. While progress has been made toward better continence in urinary diversions, evolution of the actual continence mechanisms has been along two rather distinct paths: those with a valve mechanism placed inside the pouch (either by intussusception or surgical insertion), and those with the valve outside to the pouch (by imbrication of an externally located ileal segment). A canine experimental model was used to investigate a type of intraluminal continence mechanism and to compare it to an extraluminal imbricated ileocecal valve. In eight mongrel dogs a reservoir was made out of ascending and transverse colon with two different valve mechanisms--one intraluminal and one extraluminal--connected via separate stomas to the skin. Radiographic, sonographic, endoscopic and urodynamic studies of the pouch and its outlets were performed. Results showed that, in contrast to the extraluminal valve, continence in the intraluminal valve was volume dependent. The valve closing pressure of the intraluminal continence mechanism increased far beyond the values of the extraluminal valve (50.38 vs. 30.12 cm. H2O) at maximum pouch filling. Leakage of the intraluminal valve was observed at significantly higher pouch volumes than in the extraluminal valve (348 cc vs. 215 cc). In view of these results, the volume dependent intraluminal valve mechanism appears superior to an extraluminal type, especially at higher pouch volumes. more...

We report a case of intermittent difficulty with catheterization of an Indiana continent urinary reservoir. Management was with the flexible ureteroscope. A possible explanation for this problem is proposed. more...

Construction of a continent urinary reservoir was attempted in 18 patients with carcinoma of the bladder. The caecum was used as the reservoir and an intussuscepted ileal nipple was created to provide continence. Fifteen patients are alive and have been observed for 7 to 68 months. The most common complication was malfunction of the nipple valve with urinary leakage and/or difficulty in catheterisation. Revision of the outlet was performed one or more times in 11 cases. The technique of nipple valve construction was successively evolved, with improvement in the functional results. Stricture of one uretero-intestinal anastomosis occurred in three patients. Construction of a continent caecal reservoir is a complex procedure and the problem of a stable, continence-ensuring mechanism in the outlet has not been conclusively solved. The enhanced quality of life offered by a successful continent reservoir nevertheless warrants continued clinical trials in selected patients. more...

Five patients in whom isolated ileal or ileocecal segments had been incorporated into the urinary tract suffered complications that ended in excision of the bowel segment. A bowel segment functions if it does not meet resistance or increased intraluminal pressures. In a closed system these 2 evils are working constantly against the loop of bowel, subjecting it to growing distension, dilatation and redundancy and, inevitably, residual urine, urinary tract infection, stone formation, electrolyte imbalance and progressive deterioration of the upper urinary tract ensue. What was initially meant to save kidney function causes instead renal damage and eventually total loss of function. more...

Creation of a continent low pressure urinary reservoir was attempted in 33 patients: 11 with a supravesical diversion, 6 with a vesicostomy, 9 treated by catheter drainage and 7 with end stage bladder disease. The common problems were poor urine storage associated with bladder fibrosis, defunctionalization and decentralization or spinal cord injury coupled with a poorly functional urethral continence mechanism. The over-all outcome at a mean of 21 months (range 4 months to 11 years) was excellent in terms of upper tract function, reservoir capability and continence. more...

Construction of a continent ileal urinary reservoir is associated with a high incidence of late complications because of malfunction of the nipple valve. Three important modifications in the operative procedures for the construction of the nipple valve were developed with significant improvements in late complication rates and end results. First is the use of Dacron (polyester fiber) fabric as a collar instead of Marlex mesh (polypropylene), which frequently causes erosion. The second is treatment of the mesentery using a CUSA (Cavitron Ultrasonic Surgical Aspirator) (Cavitron Co. Ltd.) instead of making Deaver's windows, thus preserving the blood supply to the nipple valves. Third is anchoring of the nipple valves to the anterior wall of the reservoir, preventing prolapse, the most frequent malfunction of the nipple valve. The incidence of malfunction of the nipple valve and the end results of this innovative urinary diversion using an internal reservoir were analyzed in relation to these modifications of the operative technique among 71 patients. To date, with an established mode of operation, the success rate is more than 95 per cent. more...

A continent ileocecal reservoir was created as an alternative to ileal loop urinary diversion in 7 patients. In 3 patients the bladder neck was closed, the in situ bladder was augmented and a continent stoma was formed by intussusception of the ileocecal valve. In the remaining 4 patients an isolated cecal reservoir with a continent stoma replaced the bladder. Creation of a stoma that was continent and easy to catheterize was achieved by intussusception of the ileocecal valve with stabilization of the intussuscepted nipple using a Marlex collar. In most cases the cecal segment was hyperactive but this was controlled with anticholinergic medication. All 7 patients have a satisfactory capacity and a continent stoma without significant catheterization difficulties. more...

We tried the new method of urinary diversion via a continent ileal reservoir, reported by Kock in 1982, and now being accepted with great enthusiasm and satisfaction not only by doctors, but also by patients in Europe and in the United States. With this method, continency with storage of urine under low pressure is well maintained so that no external appliances are necessary. Ileorenal reflux is also prevented with this nipple valve forming technique, minimizing impairment of renal function. We report for the first time in Japan 13 cases, in which this method of innovative urinary diversion was used, with special attention paid to its demanding surgical technique and early results with its complications. From November, 1984 to August, 1985, we performed urinary diversion via the Kock pouch in 13 cases: 10 males and 3 females, from 35 to 67 years old (mean age 49 years), 11 bladder cancer patients, and 2 rectal cancer patients. The 2 patients with rectal cancer died from cancer and 1 bladder cancer patient with psychosis died from mental crisis 4 months after the operation. Of the 10 cases followed up long enough, 7 cases were in excellent condition with complete continence, 2 cases were in good condition with minor leak due to intermittent prolapse of the nipple valve, and in one case with failure, due to the postoperative ileus and eversion of the nipple valve, which made it difficult to catheterize into the pouch. Excision of the pouch and conversion to the standard ileal conduit was performed by reoperation.(ABSTRACT TRUNCATED AT 250 WORDS) more...

A boy presenting with a small bladder and refluxing blind-ending ureteral stumps following multiple attempts at ureteral reimplantation and supravesical diversion with a high left-to-right transureteroureterostomy and right cutaneous ureterostomy underwent successful undiversion. Surgery consisted of bilateral ureterectomy and ileocecocystoplasty, with intussusception of the ileocecal valve and anastomosis of the ileal tail to the right renal pelvis. more...

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve. more...

Ileocecal conduit urinary diversion was performed on 18 patients. Over-all surgical complications were few. Creation of a sutured ileal intussusception across the ileocecal valve prevented reflux in 9 of 12 patients (75 per cent) followed for 8 to 25 months. A stapling technique prevented reflux in all 5 patients followed for 8 to 12 months. These modifications may allow chronically reliable nonrefluxing urinary diversion along with the previously recognized advantages of the ileocecal segment. more...

Since 1976, 23 children with bladder or cloacal exstrophy, meningomyelocele, sacral agenesis, the prune belly syndrome and noncompliant bladders associated with urethral valves or prior diversion underwent augmentation cystoplasty. Of these procedures 7 were combined with some type of urinary undiversion. Bowel segments used for augmentation included ileum alone in 10 patients, ileocecal segments in 4, a sigmoid patch in 8 and a hindgut patch in 1. An artificial urinary sphincter was placed at the time of bladder augmentation in 3 patients. There were no urinary fistulas or cases of urinary rediversion. Two patients required oral alkalizing agents as a result of persistent systemic acidosis. One patient required reoperation twice for ureteral obstruction, 1 had removal of the sphincter device secondary to erosion, 1 required reinforcement of the ileocecal valve owing to persistent reflux and 1 required reoperation for small bowel obstruction. Other complications included a superficial wound infection and 5 urinary tract infections, all of which were managed easily. Three patients were voiding and continent, 18 were dry with intermittent self-catheterization, 1 had giggle incontinence and 1 remained incontinent after sphincter removal. Augmentation cystoplasty appears to offer a reliable alternative to urinary diversion in the reconstructive management of children with small capacity bladders. more...

We report on 11 patients who in 1980-1982 had bladder reconstruction, after cystectomy for bladder cancer, utilizing the ileocecal valve as an antireflux mechanism and a direct urethrocecal anastomosis. They received preoperative irradiation (2,000 rad) and had some early complications such as pelvic abscesses and temporary urinary fistulas. We have since omitted preoperative radiation on cases performed in 1984-1987 and they did not have these complications. more...

A plicated ileocecal segment was used to construct an antirefluxing urinary conduit in 3 patients. Each patient had markedly dilated or shortened ureters that prevented conventional Leadbetter ureteral reimplantation into a colon conduit. Ascending colon was brought out as a cutaneous stoma, the ureters were anastomosed to ileum, and an antireflux mechanism was created from plicated terminal ileum and the native ileocecal valve. Significant reflux was prevented in all 3 patients. This technique provides a means to prevent urinary reflux into short or dilated ureters, and increases the versatility of the ileocecal segment for use in diversion and urinary tract reconstruction. more...