Riedmiller H

The Buccal Mucosal Graft For Urethral Reconstruction: A Preliminary Report

Autologous buccal mucosa as a substitute for urethral epithelium was studied in 2 dogs and used in 6 patients with difficult urethral reconstruction problems. The indications for an operation in these patients were failed hypospadias repairs with limited skin in 3, severe structure disease after hypospadias repair in 1, a short urethra in 1 and epispadias in 1. Three urethral fistulas and 1 meatal stenosis occurred in 3 patients. No urethral stricture or diverticulum was noted, and the final outcome was good functionally and cosmetically in all patients. This technique is useful for urethral reconstruction when local skin is not available.

The Mainz Pouch (Mixed Augmentation Ileum and Cecum) for Bladder Augmentation and Continent Diversion

AbstractThe surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: 1) creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, 2) antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and 3) in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis.Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the rema...

The mainz-pouch (mixed augmentation ileum 'n zecum) for bladder augmentation and continent diversion

SummaryThe ideal urinary reservoir constructed from bowel material should be a low-pressure system with a high capacity, capable of preventing upper tract deterioration resulting from ureteral obstruction or reflux. It should achieve reliable control of continence and assure easy emptying of the reservoir. In the Mainz-pouch, the combination of cecum and ileum, the latter of which is able to absorb pressure waves created by the cecum, produces a low-pressure system with a high capacity immediately postoperatively. By incorporating large bowel in our pouch, ureteral implantation can be done using a simple and reliable standard antireflux technique with a submucosal tunnel. The Mainz-pouch has been done since 1983 in 26 patients. Of these 11 were for bladder augmentation after subtotal cystectomy and 15 for continent urinary diversion. All of the patients with bladder augmentation are completely dry day and night; 2 patients with myelomeningocele are on intermittent catheterization for bladder evacuation. The remainder void spontaneously without significant residual urine. Of 15 patients with Mainz-pouch urinary diversion, 4 had an alloplastic stomal prosthesis implanted for control of continence and 11 have isoperistaltic ileo-ileal invagination, where by the invagination valve can easily be fixed to the intussuscepting ileum by sutures or staples. Of the 4 alloplastic stomal prostheses, 2 have been removed because of infection. In 1 of these patients, an ileo-ileal invagination was performed in the same operation to achieve continent closure. All patients with the invagination valve, as well as the 2 patients with an alloplastic stomal prosthesis, are completely continent, but in 3 cases, revision of the ileo-ileal invagination became necessary due to prolapse of the valve.

Psoas-hitch ureteroneocystostomy: experience with 181 cases.

The operative technique, indications and results of the psoas-hitch ureteroneocystostomy in 181 patients are reported. The principles of this procedure are as follows. Dissection of the ureter under direct vision, fixation of the mobilized bladder to the psoas muscle, longitudinal opening of the bladder up to the point of fixation, implantation of the ureter in an immobile bladder portion using a long submucosal tunnel. The original course of the ureter is maintained and is identical to the axis of the fixed bladder part. The broad spectrum of indications includes the repair of distal ureteral defects due to iatrogenic lesion, radiotherapy or inflammation, correction of congenital ureteral anomalies as well as therapy of reflux in adulthood and complicated reflux in children. Especially in cases in which previous ureteroneocystostomy has failed, the psoas-hitch plasty is the method of choice. Contraindications are neurogenic bladder dysfunction and a highly reduced bladder capacity or the impossibility of bladder mobilization because of a frozen pelvis. The success rate of psoas-hitch ureteroneocystostomy performed in 181 cases was 96.7%. The preconditions for a successful ureteroneocystostomy are: tension-free anastomosis between ureter and bladder; antireflux implantation of the ureter through a long submucosal tunnel, and a straight course of the implanted ureter without kinking at the point of entrance into the bladder.

Ureterosigmoidostomy: An Outdated Approach to Bladder Exstrophy?

Long-term results among 46 children with ureterosigmoidostomy are presented. The indication for ureterosigmoidostomy had been bladder exstrophy in 40 patients, incontinent epispadias in 5 and neurogenic bladder dysfunction in 1. Of the 40 patients with bladder exstrophy 8 had undergone ureterosigmoidostomy after failure of other types of urinary tract reconstruction (6 had upper tract dilatation before ureterosigmoidostomy). Three patients with previously damaged upper urinary tracts required early postoperative conversion because of severely increasing kidney dilatation. Three other patients required conversion after a mean of 10 years to preserve kidney function. One patient died after 16 years of a cause not related to ureterosigmoidostomy. The remaining 39 patients were alive with a functioning ureterosigmoidostomy after a mean followup of 14.7 years. The daytime continence rate was 97.4% (38 of 39 patients) and the complete continence rate was 92.3% (36 of 39). Except for 1 tubular adenoma that was removed successfully during routine colonoscopy, no bowel neoplasia has been observed. None of the 45 living patients has renal insufficiency.

Urethral Tumor Recurrences after Radical Cystoprostatectomy: The Case for Primary Cystoprostatourethrectomy?

Of 273 male patients who underwent radical cystoprostatectomy between 1967 and 1987, 22 were regarded as at risk for urethral recurrence. These patients underwent simultaneous primary urethrectomy or urethrectomy shortly after cystectomy because of the histology of the cystectomy specimen. Of the remaining 251 patients a urethral recurrence was observed in 23 (9.2%). A patient with a urethral recurrence originally had undergone an operation at another hospital. The first urethral tumor recurrence was observed in 1977 but between October 1987 and May 1988, 7 patients were treated for an initial or secondary urethral recurrence. This finding suggests that the rate of urethral recurrence increases with improved survival rates after cystoprostatectomy and longer followup of these patients. Of the 24 patients who had urethral recurrence 21 showed multifocal tumor growth in the primary cystectomy specimen and 2 had unifocal tumors. The original histological status in the patient treated elsewhere is not known. The data suggest that primary simultaneous urethrectomy should be performed in all patients undergoing cystoprostatectomy for multifocal bladder tumors. Patients who retain the urethra require regular and life-long washout cytology studies of the urethra for early diagnosis of recurrent urethral tumor.

Mainz pouch continent cutaneous diversion.

Since the early 1980s, the ileocaecal segment has been used in the Mainz pouch technique not only for continent cutaneous urinary diversion but also for orthotopic bladder substitution [1–4]. Initially, the ileal intussusception nipple was the standard continence mechanism for the catheterizable efferent segment [1–3]. Since 1990, the submucosally embedded appendix, when available and useable, has become the standard catheterizable continent efferent segment [5] and the intussusception nipple remains a reserve technique after appendectomy. Both techniques are described in this article. Other catheterizable continent conduits have been developed [6] but are not described herein. The Mainz pouch offers a low-pressure reservoir with good capacity [7]. To date, > 1500 procedures have been performed at our institution.

Doppler and B-mode ultrasound for avascular nephrotomy.

Doppler sonography for intraoperative localization of the intrarenal arteries combined with B-scan sonography for intraoperative visualization of stones allows complete stone removal via small radial nephrotomies for which clamping of the renal artery is no longer necessary. Since September 1980 we used this technique on 35 patients with staghorn or recurrent calculi. The main advantages of this technique are exact and quick stone localization, minimal loss of renal function owing to preservation of the intrarenal vascular system, and no need for renal ischemia and cooling.

Ureterosciatic hernia: a rare cause of pyonephrosis

A female patient presented as an emergency case with pyonephrosis and septicemia as a result of ureterosciatic hernia. Septicemia was treated successfully by immediate percutaneous nephrostomy tubing. After complete disappearance of symptoms, the hernia was closed operatively. Topographic anatomy of ureterosciatic hernia is presented.

Doppler and real-time ultrasound in renal stone surgery.

In stone surgery the operative approach aims not only at complete removal of stones, but also at minimizing damage to the intrarenal arteries and parenchyma. In complicated staghorn or calyceal stones, our concept is to remove as many stones as possible through an extended pyelocalicotomy and the residual calyceal stones via minimal radial nephrotomies. To accomplish an atraumatic nephrotomy, the shortest transparenchymal route should be chosen, and damage to the intrarenal arteries must be avoided. Doppler sonography for intraoperative localization of the intrarenal arteries and combined B-scan sonography for intraoperative localization of stones allow an avascular, atraumatic nephrotomy, in which clamping of the renal artery and cooling are no longer necessary. In 35 operations with a total of 109 radial nephrotomies, clamping of the renal artery was required in only 2 cases. By comparing the preoperative and 6-week postoperative functional results, split 131I-hippuran clearance demonstrated only 7% loss of function of the operated kidneys.