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A SURGICAL TECHNIQUE COMBINING CONTINENT CUTANEOUS URINARY DIVERSION AND COMPLETE ILEAL URETERAL REPLACEMENT
00~-5347/98/1605-1784$03.00/0
VOI. 160,1784-1786,November 1998 Printed in V.S.A.
TKEJOURNAL OF UROLOGY Copyright 0 1998 by AMERICAN UROLOGICAL ASSOCIA~ON,hC.
A SURGICAL TECHNIQUE COMBINING CONTINENT CUTANEOUS URINARY DIVERSION AND COMPLETE ILEAL URETERAL REPLACEMENT MICHAEL WALDNER, LOTHAR HERTLE
AND
STEPHAN ROTH"
From the Department of Urology, University of Munster, Munster, and Department of Adult and Pediatric Urology, University of Witten, Herdecke Medical School, Klinikum Barmen, Wuppertal, Germany
ABSTRACT
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. KEYWORDS: urinary diversion; ureteral obstruction; ureter; intestines; urinary reservoirs, continent
The replacement of the ureter with an ileal segment and urinary diversion with continent cutaneous outlet are well known procedures. However, in some cases reconstruction of the entire urinary tract (bladder and both ureters) with a continent reservoir is required. We describe a technique for complete reconstruction of the urinary tract with continent cutaneous urinary diversion. CASE HISTORY
A 57-year-old, severely uremic woman presented in 1995 with contracted bladder and ureters 6 months in duration. Creatinine was 5.2 mg./dl. (normal 0.5 to 1.1).The renal pelvis of both kidneys was dilated and bladder capacity was approximately 100 ml. Except for acute recurring cystitis she had no history of urological disease, malignancy or radiation therapy. However, the patient had a long history of alcohol abuse, which resolved at age 42 years. Within 7 days after percutaneous nephrostomy creatinine reverted to normal. Bilateral antegrade pyelography revealed nearly complete stricture of both ureters along the entire length as well as a contracted bladder with marked surface irregularities (fig. 1).Histological analysis of multiple bladder biopsies showed chronic granulating pseudopolypoid urocystitis with no signs of malignant, infectious or other disease. The inflammatory process also extended to the bladder neck and urethra. Urodynamic investigations demonstrated a low urethral closure pressure, indicating stress incontinence. Computerized tomography showed no signs of periureteral inflammation or malignancy. Administration of antibiotics and anti-inflammatory drugs for 8 weeks were ineffective. For quality of life reasons a continent cutaneous diversion with complete substitution of both ureters was performed following complete normalization of kidney function. The bladder was left in place as multiple bladder biopsies had Accepted for publication May 15,1998. * Requests for re rints: Department of Adult and Pediatric urology, University of &itten, Herdecke Medical School, Klinikum Barmen, Heusnerstr. 40,42283 Wuppertal, Germany.
FIG. 1. Antegrade filling through nephrostomytubes shows plete stricture of both ureters as well as contracted bladder.
ruled out malignant disease. In addition, surgery would have been unduly and unnecessarily prolonged had the bladder been removed. h ileocecal intestinal segment consisting of 50 cm. of terminal ileum plus the ascending colon and right
1784
URINARY DIVERSION AND ILEAL URETERAL REPLACEMENT
colic flexure was used. Construction of the colonic reservoir and substitution of both ureters are shown in figures 2 and 3. Continence was ensured with modified embedding of the bowel flap tube in a n extramural trough and attachment of the reservoir to the abdominal wall as described previously by Rothl and Lampe12 et al. In accordance with another previously described technique whereby a 15 cm. prevalvular afferent loop was used to simplify ureterointestinal implant a t i ~ n a, ~50 cm. prevalvular ileal segment was used to replace both ureters simultaneously. The intact ileocecal sphincter (valvula ileocaecalis) was used as a natural antireflw mechanism to prevent reflux into the afferent loop. This continent cutaneous diversion with bilateral ureteral replacement was drained with 2 ureteral stents, and stomal and transmural catheters. The ureteral stents were removed 14 days postoperatively, and the stomal and transmural catheters were removed after 4 weeks (fig. 4). Radiography of the pouch 4 weeks and 2 years postoperatively showed a capacity of approximately 250 and 500 ml., respectively. Radiography revealed no reflux into the tubular ileal segments. To date there have been no signs of pyelonephritis. At 2 years postoperatively serum creatinine is normal and dynamic radionuclide renography shows no signs of outflow obstruction or decrease in renal function. Mild metabolic acidosis is being successfully treated with oral alkalization. The patient is completely continent. Catheterization of the pouch is performed without difficulty 5 times daily with a 14F catheter. NOlubricant is used for catheterization.
1785
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FIG. 3, Reservoir is closed transversally, bowel flap tube is sutured to umbilicus, 20 cm. distal prevalvular segment is used to reDlace right ureter and 30 cm. s e m e n t is used as substitute for left ureter. Proximal segment is anast&nosed at its proximal open end to pyelon, while distal end of segment is joined to ileal segment of right ureter substitute 10 cm. above ileocecal sphincter.
i FIG. 4. Continent cutaneous urinary diversion and complete ileal ureter replacement 14 days postoperatively.
Interruption of the continuity of the intestine with long segments of ileum and colon for urinary diversion has not resulted in diarrhea.* FIG. 2. Construction of continent cutaneous urinary diversion and complete ileal ureter replacement. Colon is divided between right and middle colic arteries. Two further incisions are made to obtain 2 ileal segments (used later as ureteral substitutes). First incision is made between ileal arcade of ileocolic artery and terminal branches of superior mesenteric artery 20 cm. proximal to ileocecal valve. Shorter second incision is made 30 cm. proximally. Full thickness bowel flap tube (used later as efferent outlet) is constructed from 3 cm. X 7 cm. cecal segment using 18F nephrostomy catheter. Flap tube is folded over and laid on lateral tenia, and extramural tunnel is created by wrappin wall of reservoir around tube (A). Lon .tudi nd incision of tenia &era of colon ascendens and right collc 8 , x u r i 1s made.
DISCUSSION
This patient presented with a high creatinine level, which we at first thought ruled out continent urinary diversion as urine resorption at creatinine levels of approximately 2.5 mg./dl. would have led to a decrease in renal function. However, bilateral nephrostomy resulted in complete and rapid normalization of creatinine, which indicated the presence of acute ureteral stricture with no impairment of renal function. This finding enabled us to use long intestinal segments
1786
URINARY DIVERSION AND ILEAL URETERAL REPLACEMENT
for reconstruction of the complete urinary tract below the pyelon. To our knowledge only 2 cases of subtotal bladder replacement combined with subtotal replacement of both ureters have been described previously.5.6 In both of these cases ileal bladder augmentation and partial replacement of both ureters with ileum were performed. In our patient the 2 different bladder substitution procedure options were orthotopic reconstructionhladder augmentation and simultaneous bladder neck suspension (due to stress incontinence) or a colonic pouch with umbilical stoma and ureteral substitution with ileum. We decided against orthotopic reconstruction and augmentation because of inflammation had already spread to the bladder neck and urethra, uncertainty of the origin of the disease and how it would develop in the future, and severe stress incontinence. Moreover, the patient rejected this option because of the risk of urethral obstruction and reluctance to perform selfcatheterization through the urethra. Another option would have been to use a 30 cm. colonic segment (right flexure and colon ascendens) to bridge the distance between the renal pelves with left end-to-end anastomosis and right end-to-side anastomosis to create a classical ileocecal pouch. We elected a pure colonic pouch as the urinary reservoir and prevalvular, tubular ileum as the ureteral substitute. This procedure has several advantages. The prevalvular ileal segment is suitable for ureteral substitution, irrespective of the length of the deficient ureter and even if the ureter is completely deficient, as in our patient. Anastomosis of the intestine to the pyelon of both kidneys can be easily performed without recourse to laborious mesenterial mobilization. The detubularized pure colonic pouch attains sufficient capacity without ileal augmentation. Other reasons why we chose the pure colonic pouch were our extensive experience performing the procedure and the excellent long-term results obtained using ileovalvular ileal segment as afferent loop in combination with an ileocolic or colonic pouch, and appendix as a continent ~ u t l e tHowever, .~ for routine urinary diversion with an umbilical stoma we use a short afferent ileal loop, since complete ureteral substitution is not necessary in such cases. Moreover, the long, isoperistaltic ileal segment in combination with a low pressure reservoir helps to prevent reflux and supports the natural antireflux function of the ileocecal sphincter, irrespective of the latter interindividual variability. There is some controversy regarding the necessity for performing antireflux implantation techniques in adults. The use of ileal segments for ureteral substitution has been described by several authors. Retrospective long-term investigations revealed no serious decrease in renal function, despite reflux into the ileal ureter.7-9 Our own prospective investigation of 20 patients with a followup of 4 to 6 years with potentially refluxing ileal ureter anastomosis is in accordance with these results. In contrast, Shokeir and Ghoneim performed a prospective, randomized trial on 50 patients to compare renal function with or without antireflux
implantation technique following ileal ureter substitution.^^ They concluded that reflux prevention is of central importance for the preservation of renal function. They also stated that renal function was comparable among patients in both treatment groups. Thus, the issue of whether reflux prevention in low pressure bladder is necessary remains unresolved. However, the substitution of both ureters with ileum is a simple procedure that can be performed regardless of interindividual anatomical features found intraoperatively . Alternative techniques for ureter replacement exist, such as the reconfigured colon substitute which replaces a section of 1 ureter.” However, this procedure would not have been feasible in our patient because both ureters had to be completely replaced. In conclusion, 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. Robert Nusbaum assisted with writing and Angela Haas provided the drawings. REFERENCES
1. Roth, S., Weining, C. and Hertle, L.: Continent cutaneous urinary diversion using the full-thickness bowel flap tube as
continence mechanism: a simplified tunneling technique, J. Urol., 156 1922, 1996. 2. Lampel, A., Hohenfellner, M., Schultz-Lampel,D. and Thiiroff, J. W.: In situ tunneled bowel flap tubes: 2 new techniques of a continent outlet for Mainz pouch cutaneous diversion.J. Urol., 153:308, 1995. 3. Roth, S., Weining, C. and Hertle, L.: Simplified ureterointestinal implantation in continent cutaneous urinary diversion using ileovalvular segment as afferent loop and appendix as continent outlet. J. Urol., 155 1200, 1996. 4. Roth, S.,Semjonow, A., Waldner, M. and Hertle, L.: Risk of bowel dysfunction with diarrhea after continent urinary diversion with ileal and ileocecal segments. J. Urol., 154: 1696, 1995. 5. Carl, P. and Stark, L.: Ileal bladder augmentation combined
with ileal ureter replacement in advanced urogenital tuberculosis. J. Urol., 151: 1345, 1994. 6. Hubmer, G. and Ring, E.: Bladder augmentation and synchronous bilateral replacement of the ureter by an upsilon-shaped ileal segment. Akt. Urol., 19 297, 1988. 7. Goodwin, W. E., Winter, C. C. and Turner, R. D.: Replacement of ureter by small intestine: clinical application and results of the “ileal ureter.” J. Urol., 81: 406, 1959. 8. Salem, C. E., Huffman, J. L., Lieskovsky, G., Boyd, S. D. and Skinner, D. G.: Long term clinical success for ileal ureteral substitution. J. Urol., part 2, 153 347A, abstract 474, 1995. 9. Boxter, R. J., Fritzsche, P., Skinner, D. G., Kaufman, J. J., Belt, E., Smith, R. B. and Goodwin, W. E.: Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J. Urol., 121: 728, 1979. 10. Shokeir, A. A. and Ghoneim, M. A.: Further experience with the modified ileal ureter. J. Urol., 154: 45, 1995. 11. Pope, J. and Koch, M. 0.:Ureteral replacement with reconfigured colon substitute. J. Urol., 155 1693, 1996.
VOI. 160,1784-1786,November 1998 Printed in V.S.A.
TKEJOURNAL OF UROLOGY Copyright 0 1998 by AMERICAN UROLOGICAL ASSOCIA~ON,hC.
A SURGICAL TECHNIQUE COMBINING CONTINENT CUTANEOUS URINARY DIVERSION AND COMPLETE ILEAL URETERAL REPLACEMENT MICHAEL WALDNER, LOTHAR HERTLE
AND
STEPHAN ROTH"
From the Department of Urology, University of Munster, Munster, and Department of Adult and Pediatric Urology, University of Witten, Herdecke Medical School, Klinikum Barmen, Wuppertal, Germany
ABSTRACT
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. KEYWORDS: urinary diversion; ureteral obstruction; ureter; intestines; urinary reservoirs, continent
The replacement of the ureter with an ileal segment and urinary diversion with continent cutaneous outlet are well known procedures. However, in some cases reconstruction of the entire urinary tract (bladder and both ureters) with a continent reservoir is required. We describe a technique for complete reconstruction of the urinary tract with continent cutaneous urinary diversion. CASE HISTORY
A 57-year-old, severely uremic woman presented in 1995 with contracted bladder and ureters 6 months in duration. Creatinine was 5.2 mg./dl. (normal 0.5 to 1.1).The renal pelvis of both kidneys was dilated and bladder capacity was approximately 100 ml. Except for acute recurring cystitis she had no history of urological disease, malignancy or radiation therapy. However, the patient had a long history of alcohol abuse, which resolved at age 42 years. Within 7 days after percutaneous nephrostomy creatinine reverted to normal. Bilateral antegrade pyelography revealed nearly complete stricture of both ureters along the entire length as well as a contracted bladder with marked surface irregularities (fig. 1).Histological analysis of multiple bladder biopsies showed chronic granulating pseudopolypoid urocystitis with no signs of malignant, infectious or other disease. The inflammatory process also extended to the bladder neck and urethra. Urodynamic investigations demonstrated a low urethral closure pressure, indicating stress incontinence. Computerized tomography showed no signs of periureteral inflammation or malignancy. Administration of antibiotics and anti-inflammatory drugs for 8 weeks were ineffective. For quality of life reasons a continent cutaneous diversion with complete substitution of both ureters was performed following complete normalization of kidney function. The bladder was left in place as multiple bladder biopsies had Accepted for publication May 15,1998. * Requests for re rints: Department of Adult and Pediatric urology, University of &itten, Herdecke Medical School, Klinikum Barmen, Heusnerstr. 40,42283 Wuppertal, Germany.
FIG. 1. Antegrade filling through nephrostomytubes shows plete stricture of both ureters as well as contracted bladder.
ruled out malignant disease. In addition, surgery would have been unduly and unnecessarily prolonged had the bladder been removed. h ileocecal intestinal segment consisting of 50 cm. of terminal ileum plus the ascending colon and right
1784
URINARY DIVERSION AND ILEAL URETERAL REPLACEMENT
colic flexure was used. Construction of the colonic reservoir and substitution of both ureters are shown in figures 2 and 3. Continence was ensured with modified embedding of the bowel flap tube in a n extramural trough and attachment of the reservoir to the abdominal wall as described previously by Rothl and Lampe12 et al. In accordance with another previously described technique whereby a 15 cm. prevalvular afferent loop was used to simplify ureterointestinal implant a t i ~ n a, ~50 cm. prevalvular ileal segment was used to replace both ureters simultaneously. The intact ileocecal sphincter (valvula ileocaecalis) was used as a natural antireflw mechanism to prevent reflux into the afferent loop. This continent cutaneous diversion with bilateral ureteral replacement was drained with 2 ureteral stents, and stomal and transmural catheters. The ureteral stents were removed 14 days postoperatively, and the stomal and transmural catheters were removed after 4 weeks (fig. 4). Radiography of the pouch 4 weeks and 2 years postoperatively showed a capacity of approximately 250 and 500 ml., respectively. Radiography revealed no reflux into the tubular ileal segments. To date there have been no signs of pyelonephritis. At 2 years postoperatively serum creatinine is normal and dynamic radionuclide renography shows no signs of outflow obstruction or decrease in renal function. Mild metabolic acidosis is being successfully treated with oral alkalization. The patient is completely continent. Catheterization of the pouch is performed without difficulty 5 times daily with a 14F catheter. NOlubricant is used for catheterization.
1785
-
FIG. 3, Reservoir is closed transversally, bowel flap tube is sutured to umbilicus, 20 cm. distal prevalvular segment is used to reDlace right ureter and 30 cm. s e m e n t is used as substitute for left ureter. Proximal segment is anast&nosed at its proximal open end to pyelon, while distal end of segment is joined to ileal segment of right ureter substitute 10 cm. above ileocecal sphincter.
i FIG. 4. Continent cutaneous urinary diversion and complete ileal ureter replacement 14 days postoperatively.
Interruption of the continuity of the intestine with long segments of ileum and colon for urinary diversion has not resulted in diarrhea.* FIG. 2. Construction of continent cutaneous urinary diversion and complete ileal ureter replacement. Colon is divided between right and middle colic arteries. Two further incisions are made to obtain 2 ileal segments (used later as ureteral substitutes). First incision is made between ileal arcade of ileocolic artery and terminal branches of superior mesenteric artery 20 cm. proximal to ileocecal valve. Shorter second incision is made 30 cm. proximally. Full thickness bowel flap tube (used later as efferent outlet) is constructed from 3 cm. X 7 cm. cecal segment using 18F nephrostomy catheter. Flap tube is folded over and laid on lateral tenia, and extramural tunnel is created by wrappin wall of reservoir around tube (A). Lon .tudi nd incision of tenia &era of colon ascendens and right collc 8 , x u r i 1s made.
DISCUSSION
This patient presented with a high creatinine level, which we at first thought ruled out continent urinary diversion as urine resorption at creatinine levels of approximately 2.5 mg./dl. would have led to a decrease in renal function. However, bilateral nephrostomy resulted in complete and rapid normalization of creatinine, which indicated the presence of acute ureteral stricture with no impairment of renal function. This finding enabled us to use long intestinal segments
1786
URINARY DIVERSION AND ILEAL URETERAL REPLACEMENT
for reconstruction of the complete urinary tract below the pyelon. To our knowledge only 2 cases of subtotal bladder replacement combined with subtotal replacement of both ureters have been described previously.5.6 In both of these cases ileal bladder augmentation and partial replacement of both ureters with ileum were performed. In our patient the 2 different bladder substitution procedure options were orthotopic reconstructionhladder augmentation and simultaneous bladder neck suspension (due to stress incontinence) or a colonic pouch with umbilical stoma and ureteral substitution with ileum. We decided against orthotopic reconstruction and augmentation because of inflammation had already spread to the bladder neck and urethra, uncertainty of the origin of the disease and how it would develop in the future, and severe stress incontinence. Moreover, the patient rejected this option because of the risk of urethral obstruction and reluctance to perform selfcatheterization through the urethra. Another option would have been to use a 30 cm. colonic segment (right flexure and colon ascendens) to bridge the distance between the renal pelves with left end-to-end anastomosis and right end-to-side anastomosis to create a classical ileocecal pouch. We elected a pure colonic pouch as the urinary reservoir and prevalvular, tubular ileum as the ureteral substitute. This procedure has several advantages. The prevalvular ileal segment is suitable for ureteral substitution, irrespective of the length of the deficient ureter and even if the ureter is completely deficient, as in our patient. Anastomosis of the intestine to the pyelon of both kidneys can be easily performed without recourse to laborious mesenterial mobilization. The detubularized pure colonic pouch attains sufficient capacity without ileal augmentation. Other reasons why we chose the pure colonic pouch were our extensive experience performing the procedure and the excellent long-term results obtained using ileovalvular ileal segment as afferent loop in combination with an ileocolic or colonic pouch, and appendix as a continent ~ u t l e tHowever, .~ for routine urinary diversion with an umbilical stoma we use a short afferent ileal loop, since complete ureteral substitution is not necessary in such cases. Moreover, the long, isoperistaltic ileal segment in combination with a low pressure reservoir helps to prevent reflux and supports the natural antireflux function of the ileocecal sphincter, irrespective of the latter interindividual variability. There is some controversy regarding the necessity for performing antireflux implantation techniques in adults. The use of ileal segments for ureteral substitution has been described by several authors. Retrospective long-term investigations revealed no serious decrease in renal function, despite reflux into the ileal ureter.7-9 Our own prospective investigation of 20 patients with a followup of 4 to 6 years with potentially refluxing ileal ureter anastomosis is in accordance with these results. In contrast, Shokeir and Ghoneim performed a prospective, randomized trial on 50 patients to compare renal function with or without antireflux
implantation technique following ileal ureter substitution.^^ They concluded that reflux prevention is of central importance for the preservation of renal function. They also stated that renal function was comparable among patients in both treatment groups. Thus, the issue of whether reflux prevention in low pressure bladder is necessary remains unresolved. However, the substitution of both ureters with ileum is a simple procedure that can be performed regardless of interindividual anatomical features found intraoperatively . Alternative techniques for ureter replacement exist, such as the reconfigured colon substitute which replaces a section of 1 ureter.” However, this procedure would not have been feasible in our patient because both ureters had to be completely replaced. In conclusion, 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. Robert Nusbaum assisted with writing and Angela Haas provided the drawings. REFERENCES
1. Roth, S., Weining, C. and Hertle, L.: Continent cutaneous urinary diversion using the full-thickness bowel flap tube as
continence mechanism: a simplified tunneling technique, J. Urol., 156 1922, 1996. 2. Lampel, A., Hohenfellner, M., Schultz-Lampel,D. and Thiiroff, J. W.: In situ tunneled bowel flap tubes: 2 new techniques of a continent outlet for Mainz pouch cutaneous diversion.J. Urol., 153:308, 1995. 3. Roth, S., Weining, C. and Hertle, L.: Simplified ureterointestinal implantation in continent cutaneous urinary diversion using ileovalvular segment as afferent loop and appendix as continent outlet. J. Urol., 155 1200, 1996. 4. Roth, S.,Semjonow, A., Waldner, M. and Hertle, L.: Risk of bowel dysfunction with diarrhea after continent urinary diversion with ileal and ileocecal segments. J. Urol., 154: 1696, 1995. 5. Carl, P. and Stark, L.: Ileal bladder augmentation combined
with ileal ureter replacement in advanced urogenital tuberculosis. J. Urol., 151: 1345, 1994. 6. Hubmer, G. and Ring, E.: Bladder augmentation and synchronous bilateral replacement of the ureter by an upsilon-shaped ileal segment. Akt. Urol., 19 297, 1988. 7. Goodwin, W. E., Winter, C. C. and Turner, R. D.: Replacement of ureter by small intestine: clinical application and results of the “ileal ureter.” J. Urol., 81: 406, 1959. 8. Salem, C. E., Huffman, J. L., Lieskovsky, G., Boyd, S. D. and Skinner, D. G.: Long term clinical success for ileal ureteral substitution. J. Urol., part 2, 153 347A, abstract 474, 1995. 9. Boxter, R. J., Fritzsche, P., Skinner, D. G., Kaufman, J. J., Belt, E., Smith, R. B. and Goodwin, W. E.: Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J. Urol., 121: 728, 1979. 10. Shokeir, A. A. and Ghoneim, M. A.: Further experience with the modified ileal ureter. J. Urol., 154: 45, 1995. 11. Pope, J. and Koch, M. 0.:Ureteral replacement with reconfigured colon substitute. J. Urol., 155 1693, 1996.