Stephan Roth

DOES THE SUCCESS OF URETEROINTESTINAL IMPLANTATION IN ORTHOTOPIC BLADDER SUBSTITUTION DEPEND MORE ON SURGEON LEVEL OF EXPERIENCE OR CHOICE OF TECHNIQUE

PURPOSE We attempted to determine the relative risk of ureterointestinal anastomosis using 2 antireflux techniques of orthotopic bladder substitution, and we assessed the degree to which success is determined by surgeon experience. MATERIALS AND METHODS A total of 120 patients underwent surgery, including 74 with the Hautmann (Le Duc) technique and 46 with a somewhat modified Studer (Nesbit/Studer) technique. The urologists who performed the operations were classified as expert, skilled and learner. Evaluation was done retrospectively. All patients in the Studer group, except 3 who died and 1 who was lost to followup, were monitored a minimum of 12 months. RESULTS There was a 20.4% rate of nonneoplastic obstructions in the 142 ureters reimplanted with the Le Duc technique (Hautmann group). The variation in obstruction rates of 16.7, 18.2 and 25%, respectively, for expert, skilled and learning surgeons was statistically insignificant. Only 3 nonneoplastic obstructions (3.6%) developed in the 83 ureters reimplanted with the Nesbit/ Studer technique (Studer group). The variation in obstruction rates of 5.1, 0 and 3.6%, respectively, for expert, skilled and learner surgeons was statistically insignificant. CONCLUSIONS The Nesbit/Studer technique results in a generally lower rate of ureterointestinal anastomotic stricture than the Le Duc technique. Using the Le Duc technique there was no statistically significant correlation between incidence of obstruction and surgeon level of experience, indicating that obstruction with this technique probably arises from other factors.

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.

Simplified Uretero-Intestinal Implantation in Continent Cutaneous Urinary Diversion Using Ileovalvular Segment as Afferent Loop and Appendix as Continent Outlet

PURPOSE We performed continent cutaneous urinary diversion with implantation of ureters as in ileal loop diversion to reduce the risk of ureterointestinal implantation stricture. MATERIALS AND METHODS Four patients underwent colonic pouch and 11 underwent ileocecal continent urinary diversion the ileocecal segment used as an afferent loop and the sphincter-like function of the ileocecal valve used as an antireflux mechanism. RESULTS All preoperatively undilated renal units (26 of 30) remained postoperatively undilated. Of the 4 preoperatively dilated renal units 3 also showed postoperatively improvement (mean followup 8 months). However, after 3 to 14 months transient reflux occurred during contraction waves in the reservoir in 6 renal units. CONCLUSIONS Our modified technique simplifies ureteral reimplantation and appears to diminish the postoperative complication of anastomotic structure. The solution to the problem of occasional reflux may be reinforcement of the ileocecal valve.

Continent cutaneous urinary diversion using the full-thickness bowel flap tube as continence mechanism : A simplified tunneling technique

PURPOSE We present a time and labor saving embedding technique for a full-thickness bowel flap tube used as a continent outlet. MATERIALS AND METHODS In 17 patients the bowel flap tube was extramurally embedded instead of being submucosally tunneled. The reservoir was attached to the abdominal wall to reinforce the continence mechanism and prevent the tunnel from opening. RESULTS All 17 patients are completely continent and 14 of 16 evacuate urine easily with a 14F catheter. Due to recurrent stomal stenosis 1 patient with severe diabetes has undergone incontinent diversion. CONCLUSIONS Our described tunneling procedure for the full-thickness bowel flap tube is easy to perform and provides excellent continence.

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.