Renal transplantation in patients with urinary diversion: a case-control study.
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BACKGROUND: Renal transplantation in Sweden in patients with ileal conduits or continent reservoirs was investigated in order to compare the outcome with regard to graft and patient survival as compared to controls. METHODS: Patient data from the four transplantation centres in Sweden were collected on: treatment prior to transplantation, time needed for the operative procedure, and postoperative care and outcome in terms of renal function as well as graft and patient survival at 1 and 5 years. The pattern of urinary tract infection was also investigated. Each case with urinary diversion was matched with two non-diabetic controls. RESULTS: Ten male and 12 female cases were found who had received 27 grafts between 1982 and 1996. Five patients had a Kock reservoir and 17 had a Bricker conduit. The time needed for the transplant procedure was significantly longer in the case group. After matching the case group with 54 controls, we found that the renal function was similar in both groups. Graft and patient survival was similar in both groups, over 90% after 1 year. Graft survival was about 70% after 5 years. Postoperative surgical complications in the case group were only seen in a few cases. The pattern of bacteria causing urinary tract infection was slightly different among the patients with ileal conduits or continent reservoirs. CONCLUSION: Patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted. There appears to be no indication for native nephrectomy, except in selected cases. The study did not show any advantage with regard to continent reservoirs vs ileal conduits. (+info)
Urodynamic study of enhanced continent mechanism using tapered ileum as continent urinary reservoir.
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OBJECTIVE: To investigate the effect of extramural support from the pouch and abdominal wall to enhance the continent mechanism of tapered ileum. METHODS: A total of 24 patients underwent a procedure in which an ileal segment was tapered into an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. A urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 24 months postoperatively. RESULTS: One patient died of heart disease 55 days postoperatively, while 22 of the remaining 23 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes demonstrated that the maximum closure pressure with a full pouch was 46 - 124 cmH(2)O (91.26 +/- 15.71 cmH(2)O) and with an empty pouch was 34 - 84 cmH(2)O (67 +/- 10.60 cmH(2)O). The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -11.78 and P = 0.00001). At 6 to 24 months, a second urodynamic study was performed on 18 cases, demonstrating a reservoir capacity of 420 to 750 ml (481.67 +/- 78.83 ml). Reservoir pressure was 6 to 9 cmH(2)O (7.17 +/- 1.17 cmH(2)O) when the pouch was filled to 50 ml, and 16 to 35 cmH(2)O (24.12 +/- 5.61 cmH(2)O) when it was filled to maximum capacity. There was no contractive wave during the filling in any patient. Maximum closure pressure in the efferent tube was 80 to 194 cm H(2)O (98.89 +/- 26.34 cmH(2)O) when the pouch was filled with saline, and 64 to 128 cmH(2)O (74.78 +/- 14.54 cmH(2)O) when the pouch was empty. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -7.58 and P = 0.00003). CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by extramural support from the abdominal and pouch walls. (+info)
Orthotopic ileal neobladder similar to original bladder.
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OBJECTIVE: To report the surgical techniques and results of an 8-year follow-up study of 42 patients with a modified orthotopic ileal neobladder restoring normal anatomical relationship. METHODS: Total cystoprostatectomy was performed extraperitoneally. A 45 - 50 cm segment of the ileal loop was isolated, detubularized, and reconfigured into an "M"-shape to form a pouch. Bilateral ureters were implanted by inserting 1 cm distal segment into the pouch. The bottom of pouch was opened and anastomosed with the urethra. RESULTS: Forty-two patients were followed up for 6 to 96 months,90.5% of whom were continent in the daytime, and 85.7% at night. Two patients had a difficulty in urination. The average volume of the pouch was (361 +/- 48) ml at 12 months postoperation. Urodynamic examination showed the average peak voiding pressure was (86.8 +/- 21.4) cm H(2)O. The average maximum flow rate (Qmax) was (18.4 +/- 6.1) ml/s. No remarkable ureter reflux and obstruction were found. No patient was detected to have urethral carcinoma. CONCLUSIONS: Extraperitoneal cystectomy can avoid the tumor contamination of the abdomen and intestinal interference of the operative field. The ureter-inserting implantation technique is a simple anti-reflux anastomosis method with less ureter stenosis rate. Isolating the neobladder and ureters from the peritoneal cavity can reduce the postoperative complications, such as adhesive ileus, internal hernia, and urine leakage into the peritoneal cavity. The neobladder is similar to the original bladder in position, volume, shape and anti-reflux ureter connection. (+info)
Comparison of three types of continent urinary diversions in a single center.
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The results including the complication and continence rates for 3 types of continent urinary diversion were evaluated. From 1992 to 1998 we performed 58 continent urinary diversions after radical cystectomy for invasive transitional cell carcinoma (TCC) of the urinary bladder. All three types of continent diversions and ileal loop procedures were discussed and patient preferences were determined. The patient preference rate for continent urinary diversion was 96.6%, and half of these patients wanted to be completely dry. Mean age of the patients was 58.2 years. Of the 58 patients, 9 (15.5%) had a Kock pouch, 15 (25.8%) had a Kock neobladder and 34 (58.6%) had sigmoidorectal pouch (Mainz-II pouch). Early and late complication rates of the three different continent diversions were evaluated. The number of complications, such as urine leakage, pyelonephritis, hydronephrosis, reflux and stone formation, were similar in all three types of diversions. Two (5.9%) Mainz pouch II patients who had stopped oral alkalinization demonstrated severe hyperchloremic acidosis. Spontaneous pouch rupture occurred in 1 of the Kock pouches. Reoperation rates were higher with the Kock pouch and Kock neobladder cases. Daytime continence rates for the Kock pouch, Kock neobladder and Mainz II pouch were 77.7%, 86.7% and 100% respectively. Even though complete dryness may not be achieved in every patient, orthotopic bladder substitution appears to be the best choice after radical cystectomy. Although it carries the risk of life-long oral alkalinization therapy, the Mainz pouch II is associated with an excellent continence rate and may be a good alternative for patients who desire to be dry. (+info)
Laparoscopic radical cystectomy with orthotopic ileal neobladder: report of 33 cases.
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BACKGROUND: The laparoscopic radical cystectomy (LRC) with orthotopic ileal neobladder is now applied to treat invasive bladder cancer, however, it has not been well codified and illustrated. We describe in this paper a technique step by step that we have developed in 33 patients and achieved excellent results. METHODS: The surgical procedure can be divided into eight steps: laparoscopic pelvic lymphadenectomy and mobilization of the distal ureters; exposing Denonvillier's space and the posterior aspect of prostate; exposing retropubic space and anterior surface of the bladder; dividing the lateral pedicles of the bladder and the prostate; dividing the apex of the prostate; extracorporeal formation of the ileal pouch; extracorporeal implantation of the ureters; and laparoscopic urethra-neobladder anastomosis. This operation was performed in 33 patients, 29 males and 4 females, with muscle invasive bladder cancer between December 2002 and September 2004. RESULTS: The operating time was 5.5-8.5 hours with an average of 6.5 hours; the estimated blood loss was 200-1000 ml with an average of 460 ml. The surgical margins of the bladder specimen were negative in all patients. There was no evidence of local recurrence at follow-up of 1-21 months in all the patients. However lymph node metastases were found in one case at 9 months postoperatively. Most of patients achieved urine control 1 to 3 months after surgery. The daytime continence rate was 94% (31 cases) and nighttime continence rate was 88% (29 cases). Urodynamic evaluation was performed between 3 and 6 months postoperatively for all cases. The mean value of neobladder capacity was (296 +/- 37) ml. The mean value of maximum flow rate was (18.7 +/- 7.1) ml/s. The mean residual urine volume was (32 +/- 19) ml. In all cases, excretory urography at 1 to 2 months postoperatively demonstrated slightly dilated upper urinary tracts without ureteral obstruction, which resolved at follow up. Cystography showed neobladders being similar in shapes to normal. Two small ureteral nipples with intermittently efflux of urine were observed at cystoscopy in most patients. Postoperative complications occurred in 6 of 33 patients (18%), including pouch leakage in 2 cases, pelvic infection in 1, partial small bowel obstruction in 2 and neobladder-vaginal fistula in 1. CONCLUSIONS: The LRC with orthotopic ileal neobladder is a feasible option for bladder cancer when radical cystectomy is indicated. The extracorporeal formation of the ileal pouch and ureteral implantation through a small lower midline incision can simplify the complexity of the procedures, shorten the duration of surgery and reduce the medical expenses. (+info)
Long-term functional outcome and late complications of Studer's ileal neobladder.
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OBJECTIVE: The purpose of this study was to evaluate the long-term functional outcome and late complications of Studer's ileal neobladder. METHODS: The study included 57 patients who underwent radical cystectomy and bladder reconstruction with Studer's ileal neobladder, and were followed-up for at least 3 months after surgery. The voiding and storage function, and late complications were evaluated. The times of evaluation after surgery were categorized into periods I (3-23 months), II (24-59 months), III (60-95 months) and IV (> or =96 months). RESULTS: Daytime and night-time continence rates were 95.6 and 88.6%, respectively. The averages of functional capacity (439 ml), maximum flow rate (15.7 ml/s) and residual urine (35 ml) evaluated in period I were maintained in period IV. Of the 57 patients, intermittent self-catheterization was needed in five (8.8%) due to incomplete emptying or urinary retention. Urethroileal anastomotic stricture was found in two patients (3.5%), who were successfully treated by transurethral intervention. Inguinal hernia was found in seven patients (12.8%), five of whom developed it within 2 years after surgery. CONCLUSIONS: Our results indicate that Studer's ileal neobladder had a favorable long-term functional outcome. Although late complication rates were low, the incidence of inguinal hernia was relatively high, and this was considered as a definite late complication in our study. (+info)
Stapleless laparoscopic assisted radical cystectomy with ileal neobladder in a male and with ileal loop in a female: initial report from Brazil.
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INTRODUCTION: Here, we report our initial experience with laparoscopic assisted radical cystectomy without the use of surgical staples. CASES REPORT: A 70 year old male and a 55 year old female were diagnosed to have T2G3 transitional cell carcinoma of the bladder with negative metastatic work-out. Both patients were scheduled and agreed to a laparoscopic assisted radical cystectomy. In both cases, urinary diversion (orthotopic ileal Studer neobladder in the male and ileal conduit in the female) was performed extracorporeally following radical cystectomy. In both cases control of the bladder vascular pedicle was accomplished with a combination of metallic and hem-o-lock clips. The total surgical time was 6.5 hours in both cases. Estimated intra-operative blood loss was 500 cc and 350 cc respectively, however both patients required postoperative blood transfusions. No intraoperative complications occurred. In both cases, pathology revealed negative surgical margins. CONCLUSIONS: Extracorporeal creation of urinary diversion decrease the overall operative time. Laparoscopic pelvic lymphadenectomy can be performed following the extended template. The use of surgical clips instead of vascular Endo-GIA titanium staples to control the bladder vascular pedicles is feasible and safe in selected patients, thus reducing intraoperative surgical costs. Considerable experience with laparoscopic radical prostatectomy is necessary before one attempts laparoscopic radical cystectomy. (+info)
Laparoscopic assisted radical cystoprostatectomy with Y-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples through a 5 cm Pfannensteil incision.
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INTRODUCTION: We performed a laparoscopic radical cystoprostatectomy followed by constructing a Y-shaped reservoir extra-corporeally with titanium staples through a 5-cm muscle-splitting Pfannenstiel incision. SURGICAL TECHNIQUE: Upon completion of the extirpative part of the operation, the surgical specimen was entrapped and removed intact through a 5-cm Pfannenstiel incision. Through the extraction incision, the distal ileum was identified and a 40 cm segment isolated. With the aid of the laparoscope, the ureters were brought outside the abdominal cavity and freshened and spatulated for approximately 1.5-cm. Bilateral double J ureteral stents were then inserted up to the renal pelvis and the ureters were directly anastomosed to the open ends of the limbs of the neobladder. Following this, the isolated intestinal segment was arranged in a Y shape with two central segments of 14 cm and two limbs of 6 cm. The two central segments were brought together and detubularized, with two sequential firings of 80 x 3.5 mm and 60 x 3.5 mm non-absorbable mechanical stapler (Multifire GIA--US Surgical) inserted through an opening made at the lowest point of the neobladder on its anti-mesenteric border. The neobladder was reinserted inside the abdominal cavity and anastomosed to the urethra with intracorporeal laparoscopic free-hand suturing. CONCLUSION: Although this procedure is feasible and the preliminary results encouraging, continued surveillance is necessary to determine the lithiasis-inducing potential of these titanium staples within the urinary tract. (+info)