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The objective was to evaluate the long-term results after the construction of a continent catheterizable urinary conduit in adults. We retrospectively reviewed the charts of 41 adults who received a continent catheterizable urinary conduit and extracted indications and complications (29/41 women, average age 32, median follow-up durations 52 months, 48% ≥1 reoperation). Patients who were still using the conduit during this research (n = 32) were sent a questionnaire about their impression of improvement, continence and catheterization problems. 24 patients completed the questionnaire and on average reported a ‘much better’ situation. In conclusion, the construction of a continent catheterizable urinary conduit in adults is associated with a high complication and reoperation rate. Nevertheless, patients perceive improvement compared to before the construction of the stoma.

ZusammenfassungWir berichten über einen 84-jährigen Patienten mit der seltenen Diagnose eines Volvulus eines Sigmakonduits nach radikaler Zystoprostatektomie bei Harnblasenkarzinom. Unseres Wissens handelt es sich um den ersten in der Literatur beschriebenen Fall.

Intestinal segments are currently used in reconstructive urology to create urinary diversion after cystectomy. Ileal conduit (IC) is the dominant type of urinary diversion. Nevertheless, IC is not an ideal solution as the procedure still requires entero-enterostomy to restore the bowel continuity. This step is a source of relevant complications that might prolong recovery time. Fabrication of artificial urinary conduit is a tempting idea to introduce an alternative form of urinary diversion which might improve cystectomy outcomes.The aim of this review is to discuss available research data about artificial urinary conduit and identify major challenges for future studies.Fabrication of artificial urinary conduit is in range of current tissue engineering technology but there are still many challenges to overcome. There is an urgent need for studies to be conducted on large animal models with long follow up to expose the limitation of experimental strategies and to gather data for translational research.

Urinary diversion after cystectomy has been a historical standard for the treatment of numerous benign and malignant diseases of the bladder. Since the first published description in the early 1900s, improvements in surgical technique and a better understanding of the metabolic sequelae postoperatively have greatly enhanced patient outcomes. Both continent and incontinent diversions are available to patients after cystectomy. In appropriately selected patients, orthotopic neobladder reconstruction can offer preservation of body image and continence, and continent cutaneous diversions represent a reasonable alternative. Conduit diversion, which remains the most commonly performed diversion technique, is ideal for patients who would benefit from a less morbid surgical procedure that negates the need for self-catheterization. This installment of the Core Curriculum in Nephrology outlines numerous aspects of urinary diversion, in which a multidisciplinary approach to postoperative management at the intersection of nephrology and urology is required to effectively optimize patient outcomes. This article includes a discussion of the various reconstructive options after cystectomy as well as a comprehensive review of frequently encountered short-term and long-term metabolic abnormalities associated with altered electrolyte and acid-base homeostasis.

Decellularized tissues have been increasingly popular for constructing scaffolds for tissue engineering applications due to their beneficial biological compositions and mechanical properties. It is therefore natural to consider decellularized trachea for construction of tissue-engineered trachea, as well as other tubular organs. A Neo-Urinary Conduit (NUC) is such a tubular organ that works as a passage for urine removal in bladder cancer patients who need a urinary diversion after their diseased bladder is removed. In this study, we report our findings on the feasibility of using a decellularized trachea for NUC applications. As a NUC scaffold, decellularized trachea provides benefits of having not only naturally occurring biological components but also having sufficient mechanical properties and structural integrity. We, therefore, decellularized rabbit trachea, evaluated its mechanical performance, and investigated its ability to support in vitro growth of human smooth muscle cells (hSMCs) and human urothelial cells (hUCs). The decellularized trachea had appropriate biomechanical properties with ultimate tensile strength of ∼0.34 MPa in longitudinal direction and ∼1.0 MPa in circumferential direction and resisted a radial burst pressure of155 mm Hg. Cell morphology study by scanning electron microscopy further showed that hUCs grown on decellularized trachea adopted a typical flatten and interconnected network structure in the lumen of the scaffold, while they formed a round spherical shape and did not spread on the outer surfaces. SMCs, on the other hand, spread well throughout the scaffold. The gene expression analysis by real time quantitative polymerase chain reaction (RT-qPCR) and immunofluorescence studies further confirmed scaffold's ability to support long-term growth of hSMCs. Since uroepithelium has been shown to regenerate itself over time in vivo, these findings suggest that it is possible to construct a NUC from decellularized trachea without any preseeding of UCs. In future, we plan to translate decellularized trachea in a preclinical animal model and evaluate its biological performance.

It has been known that urinary diversions juxtaposing the urinary and intestinal tracts lead to increased incidence of secondary malignancies. Although tumorigenesis in ureterosigmoidostomies follows the typical course from adenomas to adenocarcinomas, secondary malignancies arising from isolated intestinal diversions are much more heterogeneous. Research over the last half century has unveiled patterns of incidence and progression, while also uncovering possible mechanisms driving the neoplastic changes. In this review, we summarize the current understanding of these unique tumors, with the hope that the knowledge gained may shed light on the etiologies of other cancers arising from the urinary and intestinal tracts.

Radical cystectomy (RC) with urinary diversion is associated with significant morbidity, much of which arises from the interposition of bowel segments in the urinary system. A tissue-engineered alternative for urinary diversion could dramatically reduce the perioperative and long-term morbidity associated with RC. Attempts at developing a tissue-engineered incontinent urinary conduit (TEUC) have involved mechanical scaffolds and promoting tissue growth within them. Despite some preclinical success, significant obstacles remain before a TEUC is ready for clinical use. A further understanding of tissue and materials engineering may help overcome these obstacles or help to develop a new approach to tissue engineering entirely.

Objectives: To evaluate the long-term results after the construction of a Continent Catheterizable Urinary Conduit (CCUC) in adults.Methods: This study retrospectively reviewed the charts of 41 adults from two tertiary centers who received a CCUC. The demographics, underlying diseases, indications for a CCUC and outcomes such as the reoperation rate and the occurrence of complications were extracted. The patient reported outcome was measured with the Patient Global Impression of Improvement (PGI-I) scale and four additional questions about continence, leakage and stomal problems. Results: Twenty-nine patients were women. The median age at surgery was 32 years, with a median follow-up of 52 months. Twenty-six patients had a neurogenic bladder. The reoperation rate was 48.8%, with a median of 10.5 months after constructing the CCUC. Superficial stomal stenosis was the most common registered complication (20 times) and stoma revision was the most often performed reoperation (12 times). Twenty-four patients completed the PGI-I; the mean improvement rating was 2 (=much better).Conclusion: The construction of a CCUC in adults is associated with a high complication and reoperation rate. The high reoperation rate is in accordance with the sparse literature. Despite this, patients reported 'much better' on the PGI-I.

Tissue engineering is focusing research effort on search for new biomaterials that might be applied to create artificial urinary conduit. Nevertheless, the demanding biomechanical characteristics necessary for proper conduit function is difficult to be replicated. In this study, we are introducing novel marine biomaterial obtained by decellularization of squid mantle derived from Loligo vulgaris. Squid mantles underwent decellularization according to developed dynamic flow two-staged procedure. Efficacy of the method was confirmed by computational dynamic flow analysis. Subsequently Decellularized Squid Mantle (DSM) underwent extensive histological analysis and mechanical evaluation. Based on gained biomechanical data the computational modelling using finite element method was utilized to simulate behavior of DSM used as a urinary conduit. Taking into account potential application in reconstructive urology, the DSM was then evaluated as a scaffold for urothelial and smooth muscle cells derived from porcine urinary bladder. Conducted analysis showed that DSM created favorable environment for cells growth. In addition, due to polarized structure and natural external polysaccharide layer, it protected seeded cells from urine.

Item does not contain fulltext PURPOSE: A readily available artificial urinary conduit might be substituted for autologous bowel in standard urinary diversions and minimize bowel associated complications. However, the use of large constructs remains challenging as host cellular ingrowth and/or vascularization is limited. We investigated large, reinforced, collagen based tubular constructs in a urinary diversion porcine model and compared subcutaneously pre-implanted constructs to cell seeded and basic constructs. MATERIALS AND METHODS: Reinforced tubular constructs were prepared from type I collagen and biodegradable Vicryl(R) meshes through standard freezing, lyophilization and cross-linking techniques. Artificial urinary conduits were created in 17 female Landrace pigs, including 7 with a basic untreated construct, 5 with a construct seeded with autologous urothelial and smooth muscle cells, and 5 with a free graft formed by subcutaneous pre-implantation of a basic construct. All pigs were evaluated after 1 month. RESULTS: The survival rate was 94%. At evaluation 1 basic and 1 cell seeded conduit were occluded. Urinary flow was maintained in all conduits created with pre-implanted constructs. Pre-implantation of the basic construct resulted in a vascularized tissue tube, which could be used as a free graft to create an artificial conduit. The outcome was favorable compared to that of the other conduits. Urinary drainage was better, hydroureteronephrosis was limited and tissue regeneration was improved. CONCLUSIONS: Subcutaneous pre-implantation of a basic reinforced tubular construct resulted in a vascularized autologous tube, which may potentially replace bowel in standard urinary diversions. To our knowledge we introduce a straightforward 2-step procedure to create artificial urinary conduits in a large animal model.

Introduction Incontinent urinary diversion using an ileal conduit is the most popular method used by urologists after bladder cystectomy resulting from muscle invasive bladder cancer. The use of gastrointestinal tissue is related to a series of complications with the necessity of surgical procedure extension which increases the time of surgery. Regenerative medicine together with tissue engineering techniques gives hope for artificial urinary conduit construction de novo without affecting the ileum. Material and methods In this review we analyzed history of urinary diversion together with current attempts in urinary conduit construction using tissue engineering methods. Based on literature and our own experience we presented future perspectives related to the artificial urinary conduit construction. Results A small number of papers in the field of tissue engineered urinary conduit construction indicates that this topic requires more attention. Three main factors can be distinguished to resolve this topic: proper scaffold construction along with proper regeneration of both the urothelium and smooth muscle layers. Conclusions Artificial urinary conduit has a great chance to become the first commercially available product in urology constructed by regenerative medicine methods.

A tissue-engineered product needs to be properly characterized in order to be used in vivo. Many methods can be used to characterize a scaffold during creation of a tissue-engineered product. This chapter looks at the mechanical (tensile testing) and biological characterization (cell viability and proliferation) of a polyglycolic acid-based scaffold used to tissue engineer a Neo-Urinary Conduit™. Such methods are more broadly applicable to characterization of other neo-organ product candidates.

The Neo-Urinary Conduit™ is a tubular neo-organ composed of native-like urinary tissue mediating efflux of urine from the body in patients requiring urinary diversion. Its development from concept to clinical trials is presented here as an illustrative example highlighting issues common to bioprocess development of novel TE/RM products based on cell/biomaterial composite constructs.

The author outlines the procedures involved in creating a Mitrofanoff pouch as an alternative to urinary conduit. Patients who have such a procedure must learn to alter their lifestyles and acquire skills such as self-catheterisation, but early results suggest that they find the procedure acceptable and preferable to other options.

Objectives. To review the literature regarding ileovesicostomy and evaluate our patient population for clinical characteristics.Methods. Various surgical reconstructive techniques allow management of difficult clinical scenarios involving patients with neurogenic bladder, irretraceable lower urinary tract symptoms, lower urinary tract disaster, and urethrocutaneous fistulae. One such reconstructive technique employed is the ileovesicostomy. This procedure provides patients with a low-pressure urinary conduit utilizing the ileum and native bladder that empties without catheterization. We describe our patient population who underwent ileovesicostomy for 5 consecutive years ending 2007 at Detroit Receiving Hospital.Results. Most common diagnosis was neurogenic bladder secondary to spinal cord injury. Our population and clinical outcomes are similar to those previously reported in the literature.Conclusions. Based on our experience, we suggest that patients with severe lower urinary tract symptoms and who are unable to perform clean intermittent catheterization and/or refractory to medical therapy ileovesicostomy should be the procedure of choice.

Placing of ileal conduit at the time of pelvic exenteration in combination with a same-side vertical rectus abdominis myocutaneous flap is controversial. We report our experience with the placement of the ileal conduit at the same side as the donor site of the vertical rectus abdominis myocutaneous flap in 12 patients and describe our technical approach.

Regeneration of the urinary conduit, using engineered autologous material, could have many clinical implications. The urinary system is composed of a three-layered wall consisting of different cell types. In this study we investigated the possibility to coculture these components in vitro into a continuous sheet for total autologous regeneration. To address this issue, human urothelial cells, fibroblasts, and smooth muscle cells were isolated separately and expanded in vitro. Cells were then cocultured by seeding them in layers in a "sandwich model." After coculturing the material was investigated histologically and with immunoassays. The different cells could be cocultured after being isolated and expanded separately in vitro. The cells formed a continuous sheet that could be enzymatically detached and that sustained mechanical handling. The morphology of different cell layers and the reaction to immunostaining indicated their preserved individual phenotype. In conclusion, we showed that human urothelial cells, fibroblasts, and smooth muscle cells can be expanded in vitro and cocultured to form a continuous cellular sheet consisting of three distinct layers of different types of cells. This could provide the surgeon with autologous tissue for urogenital reconstructive purposes.

A simplified procedure for constructing a urinary conduit is described in patients who have already undergone fecal diversion with colostomy. Two patients are described in whom this method was utilized to create a urinary conduit without the need for an intestinal anastomosis. This procedure is especially suited to high-risk surgical candidates with comorbid medical conditions, multiple previous surgical procedures or prior pelvic radiotherapy in whom avoiding an intestinal anastomosis can significantly reduce postoperative morbidity. This simplified method for creating a urinary conduit is described in two patients and discussed as related to alternative methods for establishing supravesicular urinary diversion.

In 4 patients with cutaneous urinary diversion who underwent percutaneous ureteral stone removal, similar ureteral complications developed as a result of severe ureteritis at the site of the stone. Ureteral narrowing occurred within days of percutaneous ureteral stone removal, progressing to complete occlusion in 2 cases. These complications led to prolonged hospitalization and additional procedures for each patient. One patient with an occluded ureter was lost to followup. Two patients responded satisfactorily to repeated ureteral dilations and prolonged stenting. One patient underwent excision of the affected ureteral segment. The average interval between tube placement and removal of tubes and stents was 15 weeks in 4 patients. The average inpatient period was 24 days. Patients with a cutaneous urinary conduit diversion may be at increased risk for complications following percutaneous treatment of ureteral stones. This risk may be secondary to an intense inflammatory response due to infection and other local factors.

This communication describes two patients in whom the appendix was used to extend the ureters to the skin surface for cutaneous diversion. The advantages and the disadvantages of the procedure are discussed and brief review of the literature is included.

Surgical stapling devices to close the proximal end of the isolated loop of an ileal urinary conduit have been used since the early 1970s (Assadnia et al, 1972). However, the occasional development of calculi forming around the metal staples has deterred uniform acceptance of this technique in spite of its advantages of speed and decreased post-operative morbidity (Assadnia et al, 1972; Bergman et al, 1978). We describe two patients who presented to this hospital in recent months, in whom surgical staples migrated proximally into the renal pelvis, becoming the nidus for stone formation in one of the patients.

Background: Continent urinary diversion may be necessary in range of urological abnormalities. In circumstances where the standard techniques are not possible, alternative innovative techniques may be used. Methods: In female patient with bladder exstrophy, continent diversion was recommended. The appendix was not available, the ureters were not suitable and continent stoma was fashioned from an isolated segment of colon. Results: The stoma proved to be continent, although it was somewhat stenotic. However, clean intermittent catheterization maintained its patency. Conclusions: A continent catheterizable stoma may be constructed from segment of colon. The technique may be considered when other well recognized methods are not feasible.

Fifteen patients with incurable gynecological cancers, all primary radiation treated and all having severe urinary discomfort due to urinary tract injuries were retrospectively examined after urinary conduit diversion. All have been followed-up until termination or until all survivors had lived for 6 months after the operation. Twelve of the 15 were discharged from the hospital, 10 of whom survived the first 6 months. Of those discharged 82% of the cumulated sum of postoperative observations days was spent out of the hospital. At the end of the observation period nine patients had been supplied with a colostomy as well, thus having double stomas. All six patients still alive declared in retrospect that given the choice again, they would still be willing to undergo the operation.

The need for urinary diversion is widespread for both benign and malignant disease and for patient of all ages. In the past 25 years, the urinary conduit concept of diversion has been the most widely practiced modality and has produced results that have been gratifying and acceptance, though not perfect. It is doubtful that a "perfect" solution to bladder substitution will ever be found, i.e., a solution without complications and without risk to long-term renal function. Of the various conduit operations, ileal conduit has been the one most widely employed. This procedure has produced a lower incidence of pyelonephritis and hyperchloremic acidosis than any method of diversion prior to 1950. However, it has been associated with significant complications and a threat to long-term renal function is now being recognized. Various efforts at improving these results are under way, aimed chiefly at avoiding the effects of ureteral anastomosis to irradiated bowel and at the development of non-refluxing ureteral anastomoses. Only time and careful study will determine the results of these efforts. We should adopt standardized parameters in the next 25 years in order to make meaningful comparisons possible. The parameters of greatest importance are a definition of complications clearly resulting from the diversion, a definition of pyelonephritis, and an agreement on a standard definition of "renal deterioration".

The records of 246 gynecologic cancer patients who received urinary conduit diversions at the M. D. Anderson Hospital and Tumor Institute between the years of 1954 and 1969 were reviewed. Indications for diversion were for treatment of pelvic malignancy and treatment of urologic complications of cancer therapy. Postoperative and urologic complications in the short- and long-term follow-up periods were evaluated and related to multiple preoperative factors. In critically analyzing these data, an attempt was made to answer the following questions: Do patients benefit from urinary diversion? Does significant harm come to patients with conduit diversion?

Difficult ureteral stent manipulations often can be performed under fluoroscopic guidance, eliminating the need for cystoscopy. The three illustrative cases involved an inconveniently placed nephrostomy tract, an occluded stent in a patient with recurrent rectal carcinoma, and an obstructed stent in a patient with a urinary conduit.

Summary Exenteration, or complete excision of the pelvic viscera, is an ultra-radical surgical procedure intended for curative treatment of the patient with advanced pelvic malignancy—primary or recurrent. At the time of introduction of this procedure, enthusiasm for its use was marred by the high incidence of serious surgical morbidity and mortality, which approached the five-year survival rate. With more careful physiological and psychological selection of patients, concentration of this kind of procedure in centres familiar with its use, improved urinary conduit techniques and careful attention to covering the pelvic floor with omentum and/or synthetic materials, the morbidity and mortality rate has been significantly reduced thus making exenteration a more acceptable treatment option to a wider spectrum of patients. More sophisticated haemodynamic monitoring, both intra- and postoperatively, intravenous hyperalimentation, prophylactic antibiotics and low-dose heparin are undoubtedly important adjuncts to the improvements in surgical technique and judgment. Psychosexual ‘rehabilitation' in the broadest sense must be an integral part of patient care for those undergoing exenteration and in most instances necessitates involvement of the patient's partner. Exenteration has only a very limited role in palliation and all attempts should be made to avoid this procedure when cure is clearly not a possibility.

Nine patients previously treated by pelvic irradiation underwent a urinary diversion procedure, four as part of total pelvic exenteration. The automatic surgical staplers used in these procedures, the gastrointestinal anastomosis device, and ligation and division stapler, greatly reduced operating time while preserving a better blood supply to the anastomotic site. The method of use and advantages of the autosuture instruments in urinary diversions are discussed.