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A Novel Uretero-Ileal Reimplantation Technique: The Serous Lined Extramural Tunnel. A Preliminary Report
HASSAN
A.
AND
From the Urology and Nephrology Center, Mansoura, Egypt
ABSTRACT
A novel.,...n.(1)Ih,,..,,lI . . .,lIlItOt. for an anti-refluxing uretero-ileal reimplantation entailing creation of 2 serous lined tunnels in a detubularized ileal is presented. The operation was done on 12 whom an orthotopic bladder substitute was indicated. Mean followup was 18 that this method could a nonobstructed unidirectional flow of renal units. M:'t71ri1Qln,(1)Q
.. .,..,.
.("\11 ..
.n,n..,..n.rfI
,..'YI-"1I'V\1I.,..,.""rlI
KEY WORDS:
urinary diversion, bladder diseases, bladder neoplasms, cystectomy
The importance of incorporation of an anti-reflux mechanism with orthotopic bladder substitutes does not need emphasis. These systems are frequently infected, at least initially, and regurgitation of the contents could be deleterious to renal function. 1 Furthermore, absence of reflux would allow progressive enlargement and maturation of the pouch, otherwise it remains small with a limited 2 rn"I'"TI"a,..,.f-II-':T used for reflux Several operative te(~hnllqlles Dr~ev~~nt~loll.3-6 In our constructed the best functional Skinner outcome. 7 Similar observations were also et al. 8 Nevertheless, creation of an afferent valve requires use of an extra 15 cm. of bowel. Metallic staples are necessary for valve stability, which act as a nidus for stone formation in approximately 15 % of the cases. 9 In a series of animal experiments a new technique for an anti-refluxing ureteroileal anastomosis was developed and evalan extra length of uated. 10- 12 The method does not bowel for construction or for stability. In view of the technical and functional the ation was in the clinical We our clinical in 12 who underwent cystectomy for bladder cancer. iCllVlI"tliCll1"",oll"U"iCll
nl'f"\niClll'hT
MATERIALS AND METHODS cv~,topr()statE~ctorrlV
is must be to of these success of ortho-
VIJ'-,.LUlI.LV.L.lI.
lI,..,.1-Art'"Tt'lI1--':T
-t-" ....'.ro1-,IA,..,...., I
control of the pe(11C,Les, on of the prostate is of scissors. A right-angled the fascia the venous then it is further incised medially puboprostatic ligaments are reached. These ligaments are carefully severed at the point of their insertion in the bone. The venous plexus is controlled by 1 or 2 suture ligatures 3-zero polyglactin just distal to the vesico-prostatic junction. A transverse incision is made proximal to these sutures and extended by sharp dissection with scissors towards the apex of the prostate. The catheter is palpated in the urethra, the anterior wall of which is then incised just distal to the prostatic apex. The exposed Foley catheter is transected and held for traction. At this point 3 stay sutures of 4-zero polyglactin are placed through the urethra at the 3, 9 and 12 o'clock positions, incorporating the mucosa as Accepted for publication October 29, 1993. * Requests for reprints: Urology and Nephrology Center, Mansoura, Egypt.
well as the periurethral musculature. These sutures prevent retraction of the urethra following its complete transection and may be used later for the urethro-ileal anastomosis. The posterior urethral wall is then incised to expose the dorsal fibrous raphe formed by the fascia of Denonvillier, which is lifted from the anterior surface of the rectum by a right-angled clamp and divided. The divided fascia is then included in 2 stay sutures at the 5 and 7 o'clock positions for its later tion in the urethro-intestinal anastomosis. According to this step results return of continence postoperatively. Intestinal pouch. A 40 cm. long segment is isolated from the distal ileum and arranged in a W -shaped configuration (fig. 1, a). The antimesenteric border of intestine is incised using a diathermy knife (fig. 1, b). The edges of the medial flaps are joined by a running through-and-through suture of 3-zero polyglactin. On either side, the 2 lateral flaps are joined together by a seromuscular continuous suture of 3-zero silk. The result is the creation of 2 serous lined intestinal troughs (fig. 1, c). Each ureter is laid down in its corresponding trough. A mucosato-mucosa anastomosis between the stented spatulated end of the ureter and the intestinal mucosa of the distal end of the trough is then performed. The mucosal edges on each side are approximated over the reimplanted ureter using interrupted 4zero sutures. In this manner, each trough is transan extramural serous lined tunnel 1, d). The anterior wall of the is then closed. suture line of the most the in close . . . . . r" ...r .. '''''''' .. the for a distance of is maintained 2 sutures stump is anastomosed lr1f-a"l""'·""ln.f-nrl 4-zero DOJlVE:,lactln sutures. After the row of sutures has been a the urethra and the balloon catheter is inserted The anterior sutures are applied using the stay sutures, which were holding the urethral stump (fig. 1, e). Two tube drains are placed in the pelvic cavity and brought out through separate incisions in the abdominal wall. Gravity drainage only is used. Intravenous alimentation is necessary until normal bowel function resumes. Prophylactic antibiotics are routinely administered. The tube drains are removed once fluid drainage has ceased and the ureteral stents are removed after 10 days. The urethral catheter is retained for 3 weeks. Evaluation. Evaluation of the 12 patients included a symptom analysis for daytime continence, enuresis and voiding frequency. Excretory urography (IVP) was done when the patient was discharged from the hospital, 3 months postoperatively and every 6 months thereafter to evaluate the configuration of the upper tract and to obtain a rough appraisal of the renal function. Ascending radiography was done to assess the config-
1193
lnf"'A-rnA'l'Q_
i- .. T
............, v..................
1194
URETERO-ILEAL REIMPLANTATION TECHNIQUE: SEROUS LINED EXTRAMURAL TUNNEL
FIG. 1. a, 40 em. long segment from distal ileum is isolated and arranged in W-shaped configuration. b, antimesenteric border is incised. c, 2 lateral ileal flaps are joined together by seromuscular continuous suture to create 2 serous lined intestinal troughs. d, spatulated ureter is anastomosed to intestinal mucosa and tunnel is then closed over implanted ureter. e, closure of ileal reservoir after urethro-ileal anastomosis.
uration and capacity of the pouch, and the efficiency of the reflux preventing system. Voiding was studied under fluoroscopy and the potential residual urine volume was estimated. RESULTS
There was no postoperative mortality or gross morbidity. All patients were followed for a minimum of 1 year (range 12 to 24 months). Continence. All patients are continent during the day and 9 are dry at night without medication. Three patients suffer from a variable degree of bed-wetting and they each had an excellent response to imipramine hydrochloride (25 mg. at bedtime). Upper urinary tract. The configuration and function of the upper urinary tract as evaluated by an IVP revealed that all renal units were stable or showed evidence of decompression (fig. 2). Ascending and micturition studies. A typical study demonstrates a nonrefluxing reservoir with adequate capacity (fig. 3). The urethro-ileal anastomosis is smooth, funneled and patent with a minimal amount of residual urine on the post-evacuation film.
Other studies. Ascending radiography of the pouch using air and contrast medium combined with an IVP serves to delineate the pathway of the ureter through the intestinal wall (fig. 4). The opacified ureters are clearly visualized passing through a well identified ileal trough of adequate length and caliber. Computerized spiral scanning with contrast medium was also obtained. The study illustrates the 3-dimensional topographic profile of the ureters inside the tunnels. The submucous, extramural location of the ureters is well outlined in the axial section (fig. 5, a), while the functional length of the tunnel is noted in the reformatted sagittal section (fig. 5, b). With this method of construction, the neo-bladder lends itself to all types of endoscopic procedures. The ureteral orifices are well visualized. Ureteral catheterization, retrograde studies and/or ureteroscopy is feasible (fig. 6). DISCUSSION
A unidirectional nonobstructed flow of urine is the ultimate goal of any sound uretero-ileal anastomosis. Currently, it appears that the best functional yield is obtained following construction of an intussuscepted nipple valve with a wide spatu-
eX1JerleUlce,7 as rate is aplJrOXluaately 20 to 30% as stenosis. evidence has that the of the intestinal been mucosa over the in the DrE~Se]aCe of urine. The is an process scar formation. 10, 11 Creation of an extramural serous lined tunnel provides several advantages. An extra segment of bowel is not Accordingly, a 40 cm. long segment of bowel only is -rnr~lIl1l1"lI"nrl which is shorter than the critical length beyond metabolic complications resulting from reabsorption or malabsorption are to be expected. 6 Metallic or materials from interare not required. Thus, the The serous action of a foreign material urine are lined tunnel protects the implanted portion of the ureter from exposure to urine so that sound healing without scarring is ensured. this technique is versatile and applicable to ureters of different calibers. One may tailor the length and the cross section of the tunnel according to the clinical needs. The use of this technique requires construction of an ileal Hautmann et al. 15 bladder as originally described Ur()d.~Tn2Lm]LC characteristics are similar to those of the Kock both are based on the same prllnClples, is detubularization and double a with a at low prE~SSlLlre eXr)erlen(~e has all types of prC)CelClUI'es, ureteroscopy. The exact role of novel judged by increasing the number of cases as as a observation time. A prospective randomized trial this newly proposed technique versus the Intus~:;USiCelJted valve is currently under way. cOlnpjllciltlc~n
IT'T'£1>.nMlll!o-r
"Tt'nrnllll'lI"nrl
FIG. 2. a, preoperative IVP. b, postoperative IVP shows maintained upper tract configuration.
lated uretero-ileal anastomosis. 7,8 Nevertheless this tec:hnlQtle to ensure entails the use of an extra 15 cm. of bowel and for stone stability of the The latter may act as a formation. 9 afferent segStuder et al6 may cause some COJmpI!lcatlons, which may be to excessive Tl'O~~ from the reservoir and!or deficiencies from exclusion of a segment of bowel. Furthermore, the efficiency of this concept in reflux prevention and preservation of renal function is questionable in the long term. hCIATI'"n1""lArIi
Tl'OC:
OYl'..... AC..... ""'1n,1I....
r>n.l'Y"1n.QTI'llrliO"
FIG. 3. Ascending and micturition study demonstrates nonrefluxing reservoir with adequate capacity, smooth funneled urethro-ileal anastomosis and minimal residual urine in post-evacuation film.
1196
URETERO-ILEAL REIMPLANTATION TECHNIQUE: SEROUS LINED EXTRAMURAL TUNNEL
FIG. 4. Ascending radiograph of pouch using air and contrast medium in combination with IVP shows opacified ureters passing through subserous tunnels.
FIG. 6. Bilateral retrograde uretero-pyelogram
2.
3. 4. 5.
6. 7. FIG. 5. Computerized spiral scanning with contrast medium. a, submucous, extramural location of ureters in axial section. b, functional length of tunnel in sagittal plane.
REFERENCES 1. Akerlund, S., Delin, K., Kock, N. G., Lycke, G., Philipson, B. M. and Volkmann, R.: Renal function and upper urinary tract configuration following urinary diversion to a continent urinary
8. 9. 10.
reservoir (Kock pouch): a prospective 5 to II-year followup after reservoir construction. J. Urol., 142: 964, 1989. Kock, N. G., Ghoneim, M. A., Lycke, K. G. and Mahran, M. R.: Replacement of the bladder of the urethral Kock pouch: functional results, urodynamics and radiologic features. J. Urol., 141: 1111, 1989. Kock, N. G., Nilson, A. E., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir: clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1982. Le-Duc, A., Carney, M. and Teillac, P.: An original antireflux ureteroileal implantation technique: long-term followup. J. Urol., 137: 1156, 1987. Melchior, H., Spehr, C., Knop-Wagemann, 1., Persson, M. C. and Juenemann, K. P.: The continent ileal bladder for urinary tract reconstruction after cystectomy: a survey of 44 patients. J. Urol., 139: 714, 1988. Studer, U. E., Gerber, E., Springer, J. and Zingg, E. J.: Bladder reconstruction with bowel after radical cystectomy. World J. Urol., 10: 11, 1992. Shaaban, A. A., Gaballah, M. A., EI-Diasty, T. A. and Ghoneim, M. A.: Urethral controlled bladder substitution: a comparison between the intussuscepted nipple value and the technique of Le Due as antireflux procedures. J. Urol., 148: 1156,1992. Skinner, D. G., Lieskovsky, G. and Boyd, S. D.: Continent urinary diversion. J. Urol., 141: 1323, 1989. Ghoneim, M. A., Shaaban, A. A., Mahran, M. R. and Kock, N. G.: Further experience with the ureth~al Kock pouch. J. Urol., 147: 361,1992. Abol Enein, H., EI-Baz, M. and Ghoneim, M. A.: Optimization of uretero-intestinal anastomosis in urinary diversion: an experi-
Urol. Res., 11. Abol Enein, EI-Baz M. and Ghoneim, M. Optimization of uretero-intestinal anastomosis in urinary diversion: an experimental study in dogs. II. Influence of exposure to urine on the healing of the ureter and ileum. Urol. Res., 131, 1993. 12. Abol Enein, H. and Ghoneim, M. A.: Optimization of ureterointestinal anastomosis in urinary diversion: an experimental study in dogs. III. new antireflux technique for uretero-ileal
13.
Urol.,
14. prc)C€~du.re: prE~llrnnlaIY
A. I. and .H.oc~hrlborn. C.: results in 11 patients.
J. Urol., 15. Hautmann, R. E., Frohneberg, D. and Miller, ileal neobladder. 39, 1988. 16. Catalona, W.J.: Personal communication.
The
A.
AND
From the Urology and Nephrology Center, Mansoura, Egypt
ABSTRACT
A novel.,...n.(1)Ih,,..,,lI . . .,lIlItOt. for an anti-refluxing uretero-ileal reimplantation entailing creation of 2 serous lined tunnels in a detubularized ileal is presented. The operation was done on 12 whom an orthotopic bladder substitute was indicated. Mean followup was 18 that this method could a nonobstructed unidirectional flow of renal units. M:'t71ri1Qln,(1)Q
.. .,..,.
.("\11 ..
.n,n..,..n.rfI
,..'YI-"1I'V\1I.,..,.""rlI
KEY WORDS:
urinary diversion, bladder diseases, bladder neoplasms, cystectomy
The importance of incorporation of an anti-reflux mechanism with orthotopic bladder substitutes does not need emphasis. These systems are frequently infected, at least initially, and regurgitation of the contents could be deleterious to renal function. 1 Furthermore, absence of reflux would allow progressive enlargement and maturation of the pouch, otherwise it remains small with a limited 2 rn"I'"TI"a,..,.f-II-':T used for reflux Several operative te(~hnllqlles Dr~ev~~nt~loll.3-6 In our constructed the best functional Skinner outcome. 7 Similar observations were also et al. 8 Nevertheless, creation of an afferent valve requires use of an extra 15 cm. of bowel. Metallic staples are necessary for valve stability, which act as a nidus for stone formation in approximately 15 % of the cases. 9 In a series of animal experiments a new technique for an anti-refluxing ureteroileal anastomosis was developed and evalan extra length of uated. 10- 12 The method does not bowel for construction or for stability. In view of the technical and functional the ation was in the clinical We our clinical in 12 who underwent cystectomy for bladder cancer. iCllVlI"tliCll1"",oll"U"iCll
nl'f"\niClll'hT
MATERIALS AND METHODS cv~,topr()statE~ctorrlV
is must be to of these success of ortho-
VIJ'-,.LUlI.LV.L.lI.
lI,..,.1-Art'"Tt'lI1--':T
-t-" ....'.ro1-,IA,..,...., I
control of the pe(11C,Les, on of the prostate is of scissors. A right-angled the fascia the venous then it is further incised medially puboprostatic ligaments are reached. These ligaments are carefully severed at the point of their insertion in the bone. The venous plexus is controlled by 1 or 2 suture ligatures 3-zero polyglactin just distal to the vesico-prostatic junction. A transverse incision is made proximal to these sutures and extended by sharp dissection with scissors towards the apex of the prostate. The catheter is palpated in the urethra, the anterior wall of which is then incised just distal to the prostatic apex. The exposed Foley catheter is transected and held for traction. At this point 3 stay sutures of 4-zero polyglactin are placed through the urethra at the 3, 9 and 12 o'clock positions, incorporating the mucosa as Accepted for publication October 29, 1993. * Requests for reprints: Urology and Nephrology Center, Mansoura, Egypt.
well as the periurethral musculature. These sutures prevent retraction of the urethra following its complete transection and may be used later for the urethro-ileal anastomosis. The posterior urethral wall is then incised to expose the dorsal fibrous raphe formed by the fascia of Denonvillier, which is lifted from the anterior surface of the rectum by a right-angled clamp and divided. The divided fascia is then included in 2 stay sutures at the 5 and 7 o'clock positions for its later tion in the urethro-intestinal anastomosis. According to this step results return of continence postoperatively. Intestinal pouch. A 40 cm. long segment is isolated from the distal ileum and arranged in a W -shaped configuration (fig. 1, a). The antimesenteric border of intestine is incised using a diathermy knife (fig. 1, b). The edges of the medial flaps are joined by a running through-and-through suture of 3-zero polyglactin. On either side, the 2 lateral flaps are joined together by a seromuscular continuous suture of 3-zero silk. The result is the creation of 2 serous lined intestinal troughs (fig. 1, c). Each ureter is laid down in its corresponding trough. A mucosato-mucosa anastomosis between the stented spatulated end of the ureter and the intestinal mucosa of the distal end of the trough is then performed. The mucosal edges on each side are approximated over the reimplanted ureter using interrupted 4zero sutures. In this manner, each trough is transan extramural serous lined tunnel 1, d). The anterior wall of the is then closed. suture line of the most the in close . . . . . r" ...r .. '''''''' .. the for a distance of is maintained 2 sutures stump is anastomosed lr1f-a"l""'·""ln.f-nrl 4-zero DOJlVE:,lactln sutures. After the row of sutures has been a the urethra and the balloon catheter is inserted The anterior sutures are applied using the stay sutures, which were holding the urethral stump (fig. 1, e). Two tube drains are placed in the pelvic cavity and brought out through separate incisions in the abdominal wall. Gravity drainage only is used. Intravenous alimentation is necessary until normal bowel function resumes. Prophylactic antibiotics are routinely administered. The tube drains are removed once fluid drainage has ceased and the ureteral stents are removed after 10 days. The urethral catheter is retained for 3 weeks. Evaluation. Evaluation of the 12 patients included a symptom analysis for daytime continence, enuresis and voiding frequency. Excretory urography (IVP) was done when the patient was discharged from the hospital, 3 months postoperatively and every 6 months thereafter to evaluate the configuration of the upper tract and to obtain a rough appraisal of the renal function. Ascending radiography was done to assess the config-
1193
lnf"'A-rnA'l'Q_
i- .. T
............, v..................
1194
URETERO-ILEAL REIMPLANTATION TECHNIQUE: SEROUS LINED EXTRAMURAL TUNNEL
FIG. 1. a, 40 em. long segment from distal ileum is isolated and arranged in W-shaped configuration. b, antimesenteric border is incised. c, 2 lateral ileal flaps are joined together by seromuscular continuous suture to create 2 serous lined intestinal troughs. d, spatulated ureter is anastomosed to intestinal mucosa and tunnel is then closed over implanted ureter. e, closure of ileal reservoir after urethro-ileal anastomosis.
uration and capacity of the pouch, and the efficiency of the reflux preventing system. Voiding was studied under fluoroscopy and the potential residual urine volume was estimated. RESULTS
There was no postoperative mortality or gross morbidity. All patients were followed for a minimum of 1 year (range 12 to 24 months). Continence. All patients are continent during the day and 9 are dry at night without medication. Three patients suffer from a variable degree of bed-wetting and they each had an excellent response to imipramine hydrochloride (25 mg. at bedtime). Upper urinary tract. The configuration and function of the upper urinary tract as evaluated by an IVP revealed that all renal units were stable or showed evidence of decompression (fig. 2). Ascending and micturition studies. A typical study demonstrates a nonrefluxing reservoir with adequate capacity (fig. 3). The urethro-ileal anastomosis is smooth, funneled and patent with a minimal amount of residual urine on the post-evacuation film.
Other studies. Ascending radiography of the pouch using air and contrast medium combined with an IVP serves to delineate the pathway of the ureter through the intestinal wall (fig. 4). The opacified ureters are clearly visualized passing through a well identified ileal trough of adequate length and caliber. Computerized spiral scanning with contrast medium was also obtained. The study illustrates the 3-dimensional topographic profile of the ureters inside the tunnels. The submucous, extramural location of the ureters is well outlined in the axial section (fig. 5, a), while the functional length of the tunnel is noted in the reformatted sagittal section (fig. 5, b). With this method of construction, the neo-bladder lends itself to all types of endoscopic procedures. The ureteral orifices are well visualized. Ureteral catheterization, retrograde studies and/or ureteroscopy is feasible (fig. 6). DISCUSSION
A unidirectional nonobstructed flow of urine is the ultimate goal of any sound uretero-ileal anastomosis. Currently, it appears that the best functional yield is obtained following construction of an intussuscepted nipple valve with a wide spatu-
eX1JerleUlce,7 as rate is aplJrOXluaately 20 to 30% as stenosis. evidence has that the of the intestinal been mucosa over the in the DrE~Se]aCe of urine. The is an process scar formation. 10, 11 Creation of an extramural serous lined tunnel provides several advantages. An extra segment of bowel is not Accordingly, a 40 cm. long segment of bowel only is -rnr~lIl1l1"lI"nrl which is shorter than the critical length beyond metabolic complications resulting from reabsorption or malabsorption are to be expected. 6 Metallic or materials from interare not required. Thus, the The serous action of a foreign material urine are lined tunnel protects the implanted portion of the ureter from exposure to urine so that sound healing without scarring is ensured. this technique is versatile and applicable to ureters of different calibers. One may tailor the length and the cross section of the tunnel according to the clinical needs. The use of this technique requires construction of an ileal Hautmann et al. 15 bladder as originally described Ur()d.~Tn2Lm]LC characteristics are similar to those of the Kock both are based on the same prllnClples, is detubularization and double a with a at low prE~SSlLlre eXr)erlen(~e has all types of prC)CelClUI'es, ureteroscopy. The exact role of novel judged by increasing the number of cases as as a observation time. A prospective randomized trial this newly proposed technique versus the Intus~:;USiCelJted valve is currently under way. cOlnpjllciltlc~n
IT'T'£1>.nMlll!o-r
"Tt'nrnllll'lI"nrl
FIG. 2. a, preoperative IVP. b, postoperative IVP shows maintained upper tract configuration.
lated uretero-ileal anastomosis. 7,8 Nevertheless this tec:hnlQtle to ensure entails the use of an extra 15 cm. of bowel and for stone stability of the The latter may act as a formation. 9 afferent segStuder et al6 may cause some COJmpI!lcatlons, which may be to excessive Tl'O~~ from the reservoir and!or deficiencies from exclusion of a segment of bowel. Furthermore, the efficiency of this concept in reflux prevention and preservation of renal function is questionable in the long term. hCIATI'"n1""lArIi
Tl'OC:
OYl'..... AC..... ""'1n,1I....
r>n.l'Y"1n.QTI'llrliO"
FIG. 3. Ascending and micturition study demonstrates nonrefluxing reservoir with adequate capacity, smooth funneled urethro-ileal anastomosis and minimal residual urine in post-evacuation film.
1196
URETERO-ILEAL REIMPLANTATION TECHNIQUE: SEROUS LINED EXTRAMURAL TUNNEL
FIG. 4. Ascending radiograph of pouch using air and contrast medium in combination with IVP shows opacified ureters passing through subserous tunnels.
FIG. 6. Bilateral retrograde uretero-pyelogram
2.
3. 4. 5.
6. 7. FIG. 5. Computerized spiral scanning with contrast medium. a, submucous, extramural location of ureters in axial section. b, functional length of tunnel in sagittal plane.
REFERENCES 1. Akerlund, S., Delin, K., Kock, N. G., Lycke, G., Philipson, B. M. and Volkmann, R.: Renal function and upper urinary tract configuration following urinary diversion to a continent urinary
8. 9. 10.
reservoir (Kock pouch): a prospective 5 to II-year followup after reservoir construction. J. Urol., 142: 964, 1989. Kock, N. G., Ghoneim, M. A., Lycke, K. G. and Mahran, M. R.: Replacement of the bladder of the urethral Kock pouch: functional results, urodynamics and radiologic features. J. Urol., 141: 1111, 1989. Kock, N. G., Nilson, A. E., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir: clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1982. Le-Duc, A., Carney, M. and Teillac, P.: An original antireflux ureteroileal implantation technique: long-term followup. J. Urol., 137: 1156, 1987. Melchior, H., Spehr, C., Knop-Wagemann, 1., Persson, M. C. and Juenemann, K. P.: The continent ileal bladder for urinary tract reconstruction after cystectomy: a survey of 44 patients. J. Urol., 139: 714, 1988. Studer, U. E., Gerber, E., Springer, J. and Zingg, E. J.: Bladder reconstruction with bowel after radical cystectomy. World J. Urol., 10: 11, 1992. Shaaban, A. A., Gaballah, M. A., EI-Diasty, T. A. and Ghoneim, M. A.: Urethral controlled bladder substitution: a comparison between the intussuscepted nipple value and the technique of Le Due as antireflux procedures. J. Urol., 148: 1156,1992. Skinner, D. G., Lieskovsky, G. and Boyd, S. D.: Continent urinary diversion. J. Urol., 141: 1323, 1989. Ghoneim, M. A., Shaaban, A. A., Mahran, M. R. and Kock, N. G.: Further experience with the ureth~al Kock pouch. J. Urol., 147: 361,1992. Abol Enein, H., EI-Baz, M. and Ghoneim, M. A.: Optimization of uretero-intestinal anastomosis in urinary diversion: an experi-
Urol. Res., 11. Abol Enein, EI-Baz M. and Ghoneim, M. Optimization of uretero-intestinal anastomosis in urinary diversion: an experimental study in dogs. II. Influence of exposure to urine on the healing of the ureter and ileum. Urol. Res., 131, 1993. 12. Abol Enein, H. and Ghoneim, M. A.: Optimization of ureterointestinal anastomosis in urinary diversion: an experimental study in dogs. III. new antireflux technique for uretero-ileal
13.
Urol.,
14. prc)C€~du.re: prE~llrnnlaIY
A. I. and .H.oc~hrlborn. C.: results in 11 patients.
J. Urol., 15. Hautmann, R. E., Frohneberg, D. and Miller, ileal neobladder. 39, 1988. 16. Catalona, W.J.: Personal communication.
The