Lester Persky

A continent colonic urinary reservoir : the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.

Acid-Base Changes Following Urinary Tract Reconstruction for Continent diversion and Orthotopic Bladder replacement

A prospective determination of serum electrolytes, arterial blood gases, urinalysis and urine cultures was done in 31 patients who underwent a successful continent urinary reservoir or orthotopic bladder replacement. The patients who underwent reconstruction with a long detubularized intestinal segment (group 1-50 cm. long) demonstrated the greatest tendency for metabolic hyperchloremic acidosis (35.2%). In group 2 (patients with an orthotopic bladder replacement) only 1 individual (16.7%) had hyperchloremia, which proved to be the sole metabolic derangement encountered. In group 3 (individuals with a continent gastroileac reservoir) 2 patients (25%) had a slight tendency for compensated and asymptomatic alkalosis. Urinalyses and urine cultures in groups 1 and 2 demonstrated a trend toward urine alkalinity (52.1%) and asymptomatic bacteriuria (74%), respectively. On the contrary, among the patients undergoing a gastroileac reservoir (group 3), mild urinary acidity (pH between 5 and 6) was demonstrated in 4 (50%), while asymptomatic bacteriuria was present in 3 (37.5%). In this group symptomatic urinary acidity and/or ulceration of the ileal component has not occurred to date. Metabolic hyperchloremic acidosis predominates when longer colonic segments are used for reservoir construction. This abnormality is magnified in patients in whom an accessory small bowel was resected. The majority of the gastroileac reservoir patients showed electrolytic neutrality. With our surgical technique, the gastric secretory properties predominate over those of the ileum. The differences in homeostatic findings with the use of these varieties of bowel segments suggest that we could modify the final electrolytic environment by using different combinations of bowel and bowel length.

The overlooked, retained double J stent

A series of 4 patients with long overlooked, retained ureteral stents is presented to illustrate the variable, unpredictable, and at times, hazardous course of such patients. These cases are cited to re-emphasize the need for careful documentation, observation, and follow-up of patients in whom stents are placed.

LONG-TERM METABOLIC ADVANTAGES OF A GASTROINTESTINAL COMPOSITE URINARY RESERVOIR

PURPOSEnWe investigated the long-term metabolic impact of gastrointestinal composite reservoirs.nnnMATERIALS AND METHODSnNine patients underwent construction of a gastroileal (7) or gastrocolonic (2) reservoir for continent urinary diversion. Four cases of metabolic acidosis were converted from a preexisting conduit and the other 5 patients had diversion for either preexisting metabolic acidosis or the short bowel syndrome. All were reconstructed using a medium sized gastric segment (8 x 4 cm.) from the greater curvature of the stomach. The anti-incontinence segment was constructed from a tapered and reimplanted ileal segment. All patients underwent preoperative and postoperative measurements of serum pH, serum electrolytes, and urinalysis. Serum gastrin was measured in all patients postoperatively. Followup from surgery ranged from 47 to 61 months (mean 54.4).nnnRESULTSnAll 9 patients demonstrated electrolyte neutrality in serum on long-term followup. Postoperative serum pH (mean 7.40) was significantly different (p < 0.01) from preoperative serum pH (mean 7.36) and serum bicarbonate was also significantly different (p < 0.01) preoperatively versus postoperatively (mean 22.3 versus 25.14). Urine pH values were not significantly different throughout the study. One patient with mildly acidic urinary pH (6.0 to 6.5) had ulcerative skin changes at the stoma site. Three patients had elevated serum gastrin levels on short-term followup but all patients had normal serum gastrin levels on long-term followup. One patient, with persistent alkaline urine, had urolithiasis and symptomatic urinary tract infections.nnnCONCLUSIONSnOur results demonstrate that a composite urinary reservoir constructed using gastric and intestinal segments achieved serum electrolyte neutrality on long-term followup. These results indicate a long-term metabolic advantage over other intestinal reservoirs associated with hyperchloremic metabolic acidosis and may be beneficial in patients compromised by either preexisting metabolic acidosis or the short bowel syndrome.

Tunica vaginalis flap for the management of disabling Peyronie's disease: surgical technique, results, and complications.

OBJECTIVESnTo discuss the surgical technique for tunica vaginalis flap (TVF) in the management of disabling Peyronies disease and to evaluate the results and complications.nnnMETHODSnTwelve patients underwent the TVF technique. Through a scrotal incision, the most dependent part of the tunica was dissected from the testicle and epididymis. The flap measured at least 4 cm in width and its upper extremity was left attached to the cremasteric muscle. Subsequently, the flap was brought underneath a groin skin bridge to cover the dorsal penile defect.nnnRESULTSnAll patients were pain free. Seven patients (58.3%) were able to achieve a satisfactory erection with good vaginal penetration. Five patients (41.7%) were unable to perform sexually secondary to disabling chordee in 3 patients, glanular hypoesthesia in 1 patient, and venous leakage in 1 patient.nnnCONCLUSIONSnTVF is an adequate alternative for correction of distortions of Peyronies plaque in patients with disabling disease. TVF is at present our first choice in the management of this disease. If penetration is still impaired following recurrent curvature, a Nesbit ventral plication can be used as a secondary procedure.

Evaluation and management of parastomal hernia in association with continent urinary diversion.

PURPOSEnWe discuss the incidence and diagnosis of parastomal hernias in association with continent urinary reservoirs. We also present a surgical technique appropriate for correction of this complication.nnnMATERIALS AND METHODSnWe evaluated 21 patients with parastomal hernia after construction of a continent urinary reservoir. The hernia developed secondary to diversion with an ileocecal segment in 19 patients and a Kock procedure in 2. Subsequent to development of the parastomal hernia 13 patients (61.9%) had simultaneous urinary incontinence, 2 (9.5%) had difficulty catheterizing the reservoir and 4 (19.047%) had associated pain over the stomal area. Evaluation was primarily by physical examination. However, 2 patients (9.5%) required abdominal computerized tomography to confirm the diagnosis of parastomal hernia. Surgical repair was recommended for all patients, and 19 underwent repair with or without revision of the anti-incontinence segment. Reconstruction included transabdominal takedown of the anti-incontinence segment from the abdominal wall with parastomal hernia closure through a midline incision, external reinforcement of the hernia opening with Marlex mesh when the diameter exceeded 6 cm., revision of the anti-incontinence mechanism when simultaneous urinary incontinence existed preoperatively and repositioning of the stoma site through a new selected area in the abdominal wall.nnnRESULTSnThe success rate (mean followup 23.4 months) with this surgical approach was 89.5%. Incontinence due to failure of the anti-incontinence mechanism was successfully corrected in 13 patients (100%).nnnCONCLUSIONSnLong-term followup of continent urinary reservoirs is often associated with development of parastomal hernia. This complication can be associated with urinary incontinence, peristomal pain and difficult catheterization. Evaluation is primarily by physical examination but selected clinical situations require abdominal computerized tomography to confirm the diagnosis. The surgical technique following the steps described has been associated with minimal morbidity and has provided excellent surgical results (89.5% success rate).

Intermittent Catheterization the Right Way! (Volume vs. Time-Directed)

Intermittent catheterization (ICP) is a well-proven effective means of urologic management for spinal cord diseased (SCD) persons who meet the following criteria: adequate low pressure bladder capacity (350-400 cc minimum), adequate hand function, unobstructed urethra and compliant, understanding, continent, cooperative patients. Time-directed (Q4 H-Q6 H), ICP-obtained volumes on twenty-one patients revealed a majority of early, unnecessary as well as some late over-distended bladder catheterizations. The PCI 5000 or Bladder Manager, a miniaturized ultrasonic bladder volume measuring device developed by Diagnostic Ultrasound of Seattle, was evaluated. It allowed the patients to perform volume-directed ICP which results in less frequent catheterizations and prevents bladder overdistension.

Conversion from external appliance wearing or internal urinary diversion to a continent urinary reservoir (Florida pouch I and II): surgical technique, indications and complications.

A total of 20 patients with diversion requiring an external appliance or internal urinary diversion underwent conversion to a continent urinary reservoir (Florida pouch I or II). All patients subsequently reported an improvement in the quality of life and expressed satisfaction with the new urinary diversion procedure. Of the patients 15 (75%) previously had an ileal conduit, while 1 (5%) had undergone ureterosigmoidostomy, 1 (5%) had cutaneous ureterostomy, 1 (5%) had a suprapubic tube, 1 (5%) had a sigmoid conduit and 1 (5%) had a cecal conduit. After the original diversion 3 patients (15%) had recurrent urinary infections, 3 had complications related to the stoma and external appliance (stenosis and skin dermatitis) and 5 (25%) had ureteral obstruction in 7 ureters. A total of 17 patients with conduits (85%) underwent conversion via different surgical technical aspects depending on the status of the intestinal segment from the conduit and the function of the ureteral reimplantation: in 14 the conduit was discarded or was used only to patch the newly created Florida I colonic pouch, while in 6 the conduit was preserved and 9 ureterointestinal reimplantations were left undisturbed (Florida pouch II). Among 7 ureters preoperatively obstructed (original diversion), reimplanting them into the pouch failed to prevent further renal damage in 5 (71%). Three renal units required nephrectomy, 2 kidneys deteriorated and 2 recovered renal function after percutaneous balloon dilation and stenting. Among 31 preoperatively nonobstructed renoureteral units (original diversion), 22 were reimplanted into the colonic reservoir. One of these units (4.2%) became obstructed postoperatively and 3 (13.5%) presently have reflux. The 10 reimplantations left undisturbed in the detubularized conduit drain satisfactorily without postoperative obstruction and in 6 reflux has not been demonstrated. Renal function (serum creatinine) is preserved in all patients but 15 (75%) have hyperchloremia of mild degree. Two patients (10%) have acidosis and 1 (5%) of these had low red blood cell folic acid. Conversion of an external or internal diversion to a continent colonic urinary reservoir (Florida pouch I or II) can be successful and improve the quality of life of the patient. The functioning renal units that were preoperatively obstructed were associated with a high failure rate (71%) after reimplantation. Metabolic alterations will require long-term followup, and are particularly worrisome in children and young adults.

Penile ecthyma gangrenosum: Complication of drug addiction

We present a case of ecthyma gangrenosum involving the penis in an IV drug abuser probably resulting from direct arterial septic embolization from a femoral injection site. An increased awareness of this condition is essential because misdiagnosis has been reported in up to 100 percent of cases. Prompt diagnosis is essential to begin appropriate therapy.

Evaluation and management of mechanical dysfunction in continent colonic urinary reservoirs

PURPOSEnWe analyze a group of patients who presented with mechanical dysfunction of the reservoir and/or efferent limb of a continent colonic urinary diversion, and establish an evaluation and management algorithm.nnnMATERIALS AND METHODSnA total of 16 patients with a mean age of 58 years and 1 or more symptoms related to continent colonic urinary diversion were evaluated. Presenting symptomatology included difficult catheterization in 8 cases (50%), disabling incontinence in 8 (50%) and recurrent urinary tract infections in 6 (37.5%). All patients had normal, nonobstructed, nonrefluxing upper tracts and none presented with stone disease. Urological evaluation consisted of catheterization, fluoroscopy and urography of the pouch, retrograde urography of the external limb and urodynamics (enterocystometrogram and outlet pressure profilometry).nnnRESULTSnOf the 8 patients with difficulty with catheterization 4 had stomal stenosis, 2 had an elongated and redundant external limb, and 2 had a false passage. Diagnosis was established by the inability to catheterize, fluoroscopy of the pouch and retrograde urography. Disabling incontinence occurred in 8 patients, including 7 who presented with an incompetent outlet and 2 with high pressure intestinal contractions of the reservoir. The aforementioned abnormalities were diagnosed by a combination of retrograde urography, urography of the pouch and urodynamics. Recurrent symptomatic urinary infections were observed in 5 patients of the previous groups and in another with an hourglass reservoir, which was primarily diagnosed by urography of the pouch. Surgical correction in 15 patients included outlet reinforcement, reservoir revision, stomal or external limb revision and conversion to a urinary conduit. Surgical treatment was successful in 14 of 15 patients (93%).nnnCONCLUSIONSnCatheterization difficulty requires retrograde urography to define possible anatomical abnormalities (false passage, conduit elongation) if catheterization and fluoroscopy of the pouch do not demonstrate stomal stenosis. Urinary incontinence benefits from enterocystometry and outlet pressure measurement to determine reservoir and external limb function. Recurrent urinary tract infections not related to ureteral obstruction or reflux requires fluoroscopy of the pouch and external limb to determine abnormalities in patients with detubularization and localization of areas of urine pooling.