Michael Waldner

Risk of Bowel Dysfunction with Diarrhea After Continent Urinary Diversion with Ileal and Ileocecal Segments

PURPOSE In a retrospective study we evaluated the risk of diarrhea after continent urinary diversion using ileal and ileocecal segments. MATERIALS AND METHODS We interviewed 100 patients of whom 65 underwent ileal and 35 underwent ileocecal resection. RESULTS Of the 65 patients who underwent ileal resection 7 (11%) and of the 35 who underwent ileocecal resection 8 (23%) reported chronic diarrhea of greater than 6 months in duration, which subsided spontaneously in 2 patients in each group. In each group 3 patients responded well to cholestyramine treatment and 3 responded to loperamid or psyllium. Two patients with ileocecal resection failed to respond to drug therapy. CONCLUSIONS The risk of diarrhea after ileocecal resection seems to be twice as high as after ileal resection. Most patients responded to symptomatic drug therapy. Alternative surgical therapies should be considered when risk factors are present.

ILEAL URETERAL SUBSTITUTION IN RECONSTRUCTIVE UROLOGICAL SURGERY: IS AN ANTIREFLUX PROCEDURE NECESSARY?

PURPOSE Whether antireflux implantation techniques are necessary in adults who undergo ileal ureteral substitution is controversial. We prospectively evaluated the correlation between reflux and renal function in 19 patients who underwent ileal ureteral substitution with no antireflux implantation technique. MATERIALS AND METHODS Followup included clinical evaluation, serum creatinine, blood gasses, excretory urogram, cystogram and dynamic selective renographic clearance on technetium mercaptotriglycine renal scans. All patients were followed for a minimum of 4 years except 2 who died 26 and 43 months postoperatively. Mean followup was 57 months (range 48 to 72). RESULTS Despite reflux, renal scans indicated a significant increase in renal function in all patients. Vesico-ileal reflux was present in 9 cases and reflux in the renal pelvis occurred in only 3. Reflux occurred in only 3 of 10 patients with ileal segments longer than 15 cm., and did not reach the renal pelvis. CONCLUSIONS Reflux appears to have no detrimental effect on renal function in adults with ileal ureters and, therefore, an antireflux procedure is unnecessary. In addition, an ileal segment longer than 15 cm. appears to safeguard the renal pelvis against visible reflux stemming from pro-grade intestinal peristalsis.

RECONSTRUCTION OF URETER WITH TRANSVERSE RETUBULARIZED COLON SEGMENTS

PURPOSE We present a technique in which colon segments are reconfigured as substitutes for ureteral defects. MATERIALS AND METHODS Via a flank incision a 3 cm. segment was obtained from the ascending or descending colon and reconfigured into a well vascularized tube. In 2 patients a single retubularized colon segment was interposed into an extensive defect of the upper and mid ureter, respectively. In an additional 2 patients 2 combined anastomosed reconfigured colon segments were used for pyelo-colo-cutaneostomy. RESULTS At a followup of 9 to 27 months (mean 15), no complications related to the reconfigured colon segments were noted. One patient died of progressive disease 9 months postoperatively but with no evidence of ureteral substitute malfunction. CONCLUSIONS Reconfigured colon segments may be used successfully to reconstruct extensive ureteral defects. Access is via a flank or pararectal incision and intraperitoneal surgery is minimal. The colon segments are obtained immediately proximal to the ureteral defect, necessitating little mobilization of the mesenteric pedicle. Metabolic consequences should be absent or low since only minimal amounts of intestine are isolated. In patients with renal insufficiency or a history of irradiation this technique may be superior to the use of ileum.

Preputial flap for primary closure after excision of tumors on the glans penis

In patients with large defects of the glans penis consequent to organ-preserving tumor excision, we describe a vascularized flap formed from the outer preputial leaf for primary defect coverage. We have used this successfully in 3 men in whom both erections and penile length have been preserved.

A SURGICAL TECHNIQUE COMBINING CONTINENT CUTANEOUS URINARY DIVERSION AND COMPLETE ILEAL URETERAL REPLACEMENT

PURPOSE Defects of the entire urinary tract are sometimes so extensive that a colonic conduit appears to be the only viable therapeutic option. However, if an incontinent diversion is unacceptable, an alternative must be found. MATERIALS AND METHODS We report on a new technique for achieving a continent diversion in which ileocecal intestinal segments are used as a continent reservoir and substitute for both ureters. RESULTS At 2-year followup excellent results were achieved in terms of renal function, continence and quality of life as confirmed by symptomatic evaluation and radiographic investigations. CONCLUSIONS We demonstrate the feasibility of reconstruction of the entire urinary tract with a continent reservoir using intestinal segments with a pure colonic pouch and prevalvular ileal segment as a substitute for both ureters.

Revision of nonfunctioning kock pouch efferent limb: continent, tissue preserving technique.

PURPOSE Despite extensive surgical experience with the intussuscepted efferent nipple of the Kock pouch, complications are not unusual. Although most repairs are relatively simple, the use of intestinal segments is necessary for reconstruction of the complete efferent limb in cases of severe stenosis, pre-stenotic diverticular enlargement or partial necrosis. We describe the tissue preserving transformation of an inadequate efferent Kock pouch outlet into a flap-valve continence mechanism. MATERIALS AND METHODS In 5 women a new efferent limb for the Kock pouch was created by transverse retubularization of the short intact ileal segment of the original limb. Continence was preserved through the construction of a Mitrofanoff-like flap valve, created by embedding the new ileal tube in an extramural trough. RESULTS At followup ranging from 6 to 28 months all patients were continent and experienced no problems with catheterization. CONCLUSIONS This technique of transverse retubularization of the inadequate efferent ileal limb and creation of a flap valve has obvious advantages. No new small bowel segments are required, thereby simplifying and shortening the procedure. The newly created ileal tube is wide (16 to 18Fr) and easy to catheterize. The mucosal folds are longitudinal and do not impede catheterization. The remaining thin layer of mesentery is set in the center of the tube and permits construction of a straight extramural tunnel.

RETROVESICAL HEMATOMA SECONDARY TO CLEAN INTERMITTENT SELF-CATHETERIZATION

A 36-year-old man presented with massive hematuria after performing self-catheterization with a 14Fr catheter while intoxicated with alcohol and cocaine. Since early childhood, he had suffered from incomplete spastic paraplegia and neurogenic bladder dysfunction consequent to spinal cord trauma. However, for the last 10 years he had successfully performed intermittent self-catheterization, only recently having had to use force because of an approximately 8 cm. long stricture of the penile and bulbar urethra. On physical examination and abdominal ultrasound the bladder was filled with blood clots and a 7 cm. retrovesical mass, consistent with hematoma, was present. The bladder was evacuated with a 20Fr hematuria catheter and a 3-way irrigation catheter were inserted. Cystography showed perforation of the bladder (fig. 1). After conservative treatment with antibiotics and catheter drainage for 7 days, repeat cystography demonstrated closure of the perforation site. The patient resumed intermittent self-catheterization and was discharged from the hospital. The patient returned to the hospital 8 days later with persistent lower abdominal pain and subfebrile temperatures (37.5C). Computerized tomography demonstrated a 10 cm. retrovesical mass (fig. 2). The abdomen was surgically explored via a lower abdominal midline incision and approximately 500 cc of retrovesical hematoma were evacuated. The patient declined concomitant bladder augmentation with continent vesicostomy. Convalescence was uneventful.

Surgical Anatomy and Physiology of the Small and Large Bowel Continent Reservoirs

Two aspects must be respected in the selection of bowel type and length: the metabolic impact on the urinary tract and the risk of malabsorption when intestinal segments are resected from the normal nutritional passage. Most of the data addressing physiology, resorption areas, and malabsorption after resection have been obtained from animal studies or from studies on patients with bowel disease. The results may not be completely transferable to patients with continent urinary diversion. The physiology of intestinal segments differs in animals, and in patients with bowel disease, the intestinal segments remaining after resection likely do not retain normal function. Additionally, resection of comparable amounts of bowel can have differing metabolic impacts in different patients. The total length of human bowel varies widely. The length of the small bowel measured in vivo ranges from 240 cm to 440 cm, the colon from 90 cm to 130 cm.4,10,12 Taking into account the length of the small intestine, the folds of the surface plicae, and, at the light microscopic level, the additional surface of the villi and microvilli, the small intestine has an enormous surface area.

Blutstillung, Vena cava

Temporare Blutstillung bei grosen intraoperativen Defekten der Vena cava oder der Aorta abdominalis.

Katheterismus, Via falsa

Erleichterung schwieriger transurethraler Kathetereinlagen mit Hilfe der flexiblen Zystoskopie und eines hydrophilen Fuhrungsdrahtes.