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Case Reports: Functional Replacement of Bladder and Urethra After Cystectomy for Bladder Cancer in a Female Patient
0022-5347/95/1533-1043$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROLOCICAL ASSOCIATION, INC.
Vol. 153,1043-1046,March 1995 Printed in U S A .
FUNCTIONAL REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY FOR BLADDER CANCER IN A FEMALE PATIENT WILHELM A. €#BNER*
AND
HEINZ PFLOGER
From the Department of Urology, Lainz Hospital, Vienna, Austria
ABSTRACT
We describe a new concept for female bladder replacement introducing a n ileocecal pouch with the intact appendix vermiformis used as a n orthotopic neourethra. Based upon the results of preceding experimental studies this procedure was performed on a woman with t h e diagnosis of focal invasive bladder cancer. Eight months after the operation the patient is completely contin e n t and back to work. This new type of urinary diversion with improved body image can be offered to female patients undergoing cystectomy for bladder cancer. KGI WORDS:bladder, urethra, cystectomy, appendix, female Prompted by the work of Kock and Skinner et al, great interest is being shown in bladder replacement with detubularized sections of The creation of a low pressure reservoir with sufficient capacity and anti-reflux implantation of the ureters into the pouch assure continence over longer periods without placing the upper urinary tract at risk.376.638-11For male cystectomy patients the goal of achieving continent, stoma-free drainage of urine has been realized by attaching low pressure intestinal pouches to the urethra."-ls In female patients too much of the intrinsic continence mechanism is removed at cystectomy to achieve reliable day and nighttime continence by simple attachment of a common pouch to the urethra. Therefore, subtotal cystectomy techniques (leaving behind parts of the original bladder neck) or implantation of an artificial sphincter is necessary to achieve a functional neobladder that enables the patient to void at convenient interval^.^^-^^ However, such concepts carry the risk of urethral tumor recurrence or complications arising from artificial sphincters placed around intestinal segments.2sz6 Since 1989 we have been working on a new concept for female bladder replacement using an ileocecal pouch with the intact appendix vermiformis in place to provide additional sphincter potency. This method involves the ceco-appendiceal junction as a neobladder neck and the appendix vermiformis as a neourethra.26-2s We present our first clinical application of this new concept. CASE REPORT
A 53-year-old white woman with the diagnosis of focal invasive stage T2NOMO grade 2 bladder cancer was selected for nerve sparing radical cystectomy and urine diversion by an orthotopic ileocecal neobladder with the in situ appendix serving as a neourethra. The upper urinary tract was normal on ultrasonography and excretory urography, and no nodal involvement was seen on computerized tomography. Blood parameters were within normal range. Bowel preparation was started with 3 1.20%mannitol given through a nasogastric tube, and 4 gm.cefotaxime, 240 mg. tobramycin and 1.5 gm. metronidazole were given on the day of operation. Pelvic lymphadenectomy revealed no nodal involvement at frozen section. A nerve sparing radical cystectomy was performed according to the findings of our anatomical studies. The fibers of the hypogastric plexus were easily identitied and preserved (fig. 1).After submucosal injection of saline the external urethral orifice was circumcised and the mucosa
was mobilized bluntly. The distal part of the mucosa was then fixed to a 16F Foley catheter with a ligature and stripped into the pelvis. The specimen was examined for completeness macroscopically. A neobladder was then constructed of cecum and 20 cm. of isolated ileum, and anti-reflux submucosal implantation of the ureters into the cecum was performed as described by Goodwin et al." The pouch was shifted into the true pelvis, and the appendix vermiformis was drawn through the urethral channel as a neourethra and fixed with 4-zero polyglycolic acid atraumatic mucocutaneous sutures. Because this was the first clinical case of this new technique, an additional continent safety nipple composed of tapered ileum was formed, and the stoma was positioned in the left lower side of the abdomen.6 Foley catheters were left through the neourethra and in the ileal stoma. Convalescence was uneventful. The catheters were removed 24 days postoperatively and a urodynamic study of the pouch is shown in figure 2. Initially retention occurred followed by temporary leakage from the urethra but after 4 weeks, during which vaginal cones were used for training the pelvic floor, the patient has been completely continent during the day and she awakens only once during a sleeping period of 7 hours. Urodynamic studies after 12 weeks revealed voiding volumes of up to 400 ml. at micturition pressures of 60 cm. water and a residual urine of 150 ml. Micturition is achieved by abdominal strain (fig. 3). Pouch contractions were observed resulting in pressure peaks of up to 60 cm. water. Continence is preserved up to a volume of 600 ml., and stress incontinence was not observed either clinically or during urodynamic studies (fig. 4). The safety stoma in the left lower side of abdomen was closed 7 months after the operation based on patient convenience. A recent urodynamic study &er closure of the stoma revealed low baseline pressures in a matured reservoir (fig. 5). However, pressure peaks of 50 cm. water are still observed. Micturition is initiated by abdominal strain and supported by a pouch contraction. Presently the patient is completely continent and back to work. The cosmetic result of the neourethral external orifice is pleasing. DISCUSSION
Great emphasis has been placed on the preservation of continence and erectile function in male patients undergoing . ~ became ~~~~ radical prostatectomy or c y s t o p r ~ s t a t e c t o m y It standard to attach intestinal pouches to the urethra, thus forming - a functional neobladder capable of urine storage as Accepted for publication August 12,1994. micturition in m&."-" * Requests for reprints: Department of Urology, Lainz Hospital, well as In women continence depends on the so-called mucosal Wolkersbergenstrasse 1, 1130 Vienna, Austria. 1043
REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
1044
RG.1. A. during cystectomy fibers of ri ht hypogastric plexus are identified and secured with vessel loops (M and right ureter ( U Iis pulled medially to facilitate preparation. distal stump of right ureter is drawn medially when preparation of lateral bladder wall is initiated. Nerve fibers leading to bladder must be transected and fibers traveling to urethra are left untouched.
8,
r Uara
t
t Pabd 31 cnHZO/Diu
FIG.3. Fluoroscopy reveals neourethra of orthotopic surrogate bladder during voluntary micturition (arrows).
Uura
288 n 1 4 i v 1 nin/Div
additional sphincteric strength. The 3 taeniae of the large bowel converge in the region of the ceco-appendiceal junction, pouch throu h safety stoma leads to ressure peaks of 90 cm. water whereby the circular muscle ring in this area is reinforced. at volume of200 ml. (investigation agandoned). Qura, uroflow. EM- Histological investigations on the ceco-appendiceal junction GAVE,electromyogra h of pelvic floor.Pdet, detrusorpressure.Pues, bladder pressure. Pa&, abdominal pressure (not measured). Vum. suggest the presence of a sphincter-like muscle ring in this region.2s Ceco-appendiceal junction and appendix vermiforvolume voided. mis, containing smooth muscle capable of long-term tonic contraction, have been known to generate pressures of 35 to ' . ~ urethral ~ pressures in our patient sphincter, bladder neck and urethra (smooth muscle), elastic 110 cm. ~ a t e r . ~ The fibers of the urethral wall, periurethral vascular plane and correspond well to these data, and in conjunction with the pelvic floor (striated m u ~ d e ) ? Since ~ - ~ ~the first 4 factors preserved function of the urethra baseline continence is that are responsible for baseline continence cease to apply achieved. Stress continence is preserved since the abdomino-urethral after conventional radical cystectomy in female patients, bladder replacement was only possible if the urethra and pressure transmission as well as the somatic neural pathparts of the bladder neck were left intact or if an artificial ways for contraction of the pelvic floor are left unsphincter was i ~ n p l a n t e d . ' ~ -However, ~ ~ * ~ ~ leaving behind t o u ~ h e d . ~ ~In- ~patients ' with a weak pelvic floor additional parts of the bladder neck is not advisable for patients under- colpo-suspension might be necessary to keep the bladder in going cystectomy for bladder cancer.23 Implantation of an the desired high position and assure abdomino-urethral presartificial sphincter around excluded bowel segments to sure transmission. achieve continence proved to carry a high risk of complicaIn men who have undergone bladder replacement micturitions, such as erosion of the cuff into the bowel l ~ m e n . ' ~ . ~tion ~ results from abdominal strain. Although the coordinated To our knowledge no consequent efforts have been under- micturition process no longer occurs after such operations, a taken to study the possible function of the female urethra certain learning process seems feasible, which is substantiand pelvic floor after radical cystectomy in humans. The ated by the extremely variable voiding pressures between 30 results of our animal studies revealed that dynamic function and 120 cm. water recorded in surrogate bladder^.'^-^".*^ can be preserved to a substantial extent. Prere uisite to that Comparable to male patients with neobladders it took our is maintenance of the responsible nerve With the patient 6 weeks to get used to the new voiding technique and technique described, parts of the intrinsic urethral closure regain continence. She is now completely dry with little or no mechanisms (particularly the outer circular fibers) as well as problem to initiate micturition. Apparently, conscious relaxthe urethrovaginal sphincter are left intact.33 The ceco- ation of the pelvic floor can reduce urethral resistance to such appendiceal junction and the appendix vermiformis provide an extent that sufficient urine flow occurs with abdominal
RG.2. Udynamic study
4 weeks after operation. Filling of
upp ply!^.^"
~
REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
lass behind the ureter with the posterior hypogastric vessels. 3bviously preservation of these nerve fibers was possible in )ur patient. The innervation of the somatic sphincter mechinism (pudendal nerve) is not at risk during radical cystec;omy. The anterior vaginal wall is excised only at the supraarethral portion. Leaving the distal portion of the vagina underlying the urethra intact results in preserving the integrity of the urethrovaginal sphincter muscle, which is an important factor in the complex striated urethral sphincter system in the female ~ a t i e n t . ~ ~ . ~ ~ Transposition of the pouch into the true pelvis was possible without difficulty, which corresponds to data in the literature concerning attachment of (ileo-) cecal pouches onto the membranous ~ r e t h r a . " . ~ ~ . 'Since ~ , ~ it . ~is~not necessaxy to perform a n anastomosis in the true pelvis when using this method, the procedure is surgically no more challenging than in male patients. In addition, the continence mechanisms of the pelvic floor are not affected by sutures and subsequent scarring.2s We believe the model described to be a viable approach towards orthotopic functional bladder replacement for female patients. "his new type of urinary diversion with improved body image can be offered to women undergoing cystectomy for bladder cancer.
PuraDif 38 cnH20/Div Pura 38 cnH20/Div Pves
38 cnH2O/Div
PB NU 78
3enu PE
a DANTEC FIG.4. Pressure profile of neourethra (appendix). PuruDif, closure pressure. Puru, urethral pressure. Pues, bladder pressure.
I
I I I I
Pura 5 nl/s/Diu
I
Pdet
t
-
:
38 cnH201Diu Pues
38 cnHlOiDiu
Pabd
28 cnH2O/Diu Uura 288 nliDiu I
Uinfus
I
288 nl/Diu
-
I I
L
I
I
I I I
1045
I
FIG.5. Urodynamic study after closure of safety stoma. Low intraluminal baseline pressure, eaks of up to 50 cm. water. Micturition is initiated by abdominafstrain (M) and supported by pouch contraction. Quru, uroflow. Pdet, detrusor pressure. Pues, bladder pressure. Pubd, abdominal pressure. Vuru, volume voided. Vinfus, filling volume.
straining. The micturition pressure of 50 to 60 cm. water as detected during postoperative urodynamic studies is acceptable. In regard to the appendiceal mucosa, no complications are anticipated. The mucosa of the appendix carries no significant risk for problems with recurrent or chronic contact with urine as described in several reports.8*9*32.35,42,43 In our opinion certain aspects of surgical technique must be emphasized at radical cystectomy to preserve function of the female pelvic floor and urethra. The fibers of the inferior hypogastric plexus supporting the urethra and vagina should remain intact at least on 1 ~ i d e . ' ~ , During ~' traditional radical cystectomy the autonomic nerve fibers are cut as thej
REFERENCES
1. Kock, N. G., Nilson, A. E., Nilsson, L. O., NorlBn, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128 469,1982. 2. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ileal reservoir for urinary diversion. J. Urol., 132 1101,1984. 3. Benchekroun, A., Essekalli, N., Faik, M., Marzouk, M., Hachimi, M. and Abakka, T.: Continent urostomy with hydraulic ileal valve in 136 patients: 13 years of experience. J. Urol., 142:46, 1989. 4. b a n , F., Jr.: Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J. Urol., 139 519,1988. 5. Kock,N. G., Ghoneim, M. A, Lycke, K G. and Mahran, M. R.: Replacement of the bladder by the urethral Kock pouch: functional results, urodynamics and radiological features. J . Urol., 141:1111, 1989. 6. Fbwland. R. G.. Mitchell. M. E.. Bihrle. R.. Kahnoski, R. J. and Piser, J. E.: Indiana continent urinary reservoir. J. Urol., 131: 1136,1987. 7. Thiiroff, J. W.,Alken, P., Riedmiller, H., Engelmann, U., Jacobi, G. H. and Hohenfeller, R.: The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J. Urol., 136 17,1986. 8. Issa, M. M., Oesterling, J. E., Canning, D. A. and Jeffs, R. D.: A new technique of using the in situ appendix as a catheterizable stoma in continent urinary reservoirs. J. Urol., 141: 1385, 1989. 9. Riedmiller, H. F., Muller, S., Thiiroff, J. and Hohenfeller, R.: Continent appendix stoma: a modification of the Mainz pouch technique. J. Urol., 143:1115,1990. 10. Lieskovsky, G., Boyd, S. D. and Skinner, D. G.: Management of late complications of the Kock pouch form of urinary diversion. J . Urol., 131: 1146,1987. 11. Skinner, D. G., Lieskovsky, G. and Boyd, S. D.: Continuing experience with the continent ileal reservoir (Kock pouch) as an alternative to cutaneous urinary diversion: an update aRer 250 cases. J . Urol., 131: 1140,1987. 12. MBnsson, W.,Davidsson, T. and Colleen, S.: The detubularized right colonic segment as urinary reservoir: evolution of technique for continent diversion. J. Urol., 144: 1359,1990. 13. Hautmann, R. E., Egghart, G., Frohneberg, D. and Miller, K: The ileal neobladder. J. Urol., 139 39, 1988. 14. Hautmann, R. E.,Egghart, G., Frohneberg, D. and Miller, K: Die Ileum-Neoblase. Urologe A, 2 6 67,1987. 15. Light, J. K. and Engelmann, U. H.: L=eBag: total replacement of the bladder using an ileocolonic pouch. J. Uml., 136 27, 1986. 16. Melchior, H., Spehr, C. and Person, M. C.: Die kontinente Ileum-Blase: ein erster Bericht uber 5 Patienten. Akt. U d . , 11:256. 1986.
1046
REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
17. Goldwasser, B. and Webster, G. D.: Augmentation and substitution enterocystoplasty. J. Urol., 135.215, 1986. 18. Melchior,H., Spehr, C., Knop-Wagemann, J., 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. 19. Tammela, T. L., Lindell, 0. I., Viitanen, J. K, Hellstrom, P. A., Kontturi, M. J. and Lukkarinen, 0. A.: Functional and urodynamic characteristics of bladder substitution with detubularised right colonic segment. Brit. J. Urol., 61:298,1991. 20. Light, J. K and Marks, J. L.: Total bladder replacement in the male and female using ileocolonic segment (LeBag). Brit. J. Urol., 66: 467, 1990. 21. Lindell, 0.: Early experiences with continent bladder substitution. Ann. Chir. Gynec., 78: 130,1989. 22. Tobisu, K, Coloby, P. J., Fujimoto,H., Mizutani,T. and Kakizoe, T.: An ileal neobladder for a female patient after a radical cystectomy to ensure voiding from the urethra: a case report. Jap. J . Clin. Oncol., 2 2 359,1992. 23. De Paepe, M.E., Andr6, R. and Mahadevia, P.: Urethral involvement in female patients with bladder cancer. A study of 22 cystectomy specimens. Cancer, 65:1237,1990. 24. Light, J. fl:Total vesicourethral replacement in the female-the case for artificial sphincter around bowel. Scand. J. Urol. N e p h l . , suppl., 142: 105,1992. 25. Burbige, K A., Reitelman, C. and Olsson, C. A.: Complicationsof artificial urinary sphincter around intestinal segments in reconstructed exstrophy patients. J. Urol., 138.1123,1987. 26. Hubner, W. A, Hartung, R., Asboth, F. and Porpaczy, P.: Caecoappendiceal junction: a urologically applicable sphincter mechanism? Akt. Urol., 2 2 20,1991. 27. Hubner, W. A., Trigo-Rocha, F., Plas, E. G. and Tanagho, E. A.: Functional bladder replacement after radical cystedomy in the female: experimental investigation of a new concept. Eur. J. Urol., 23: 400, 1993. 28. Hubner, W. A., Trigo-Rocha,F., Plas, E. G. and Tanagho, E. A,: Urethral function after cystedomy: a canine in vivo experiment. Urol. Res., 21: 45,1993. 29. Goodwin, W. E., Harris, A. P., Kaufman, J. J. andBeal, J. M.: Open, transcolonic ureterointestinal anastomosis: a new approach. Surg., Gynec. & Obst., 97:295,1953. 30. Walsh, P. C. and Mostwin, J. L.: Radical prostatedomy and cystoprostatedomy with preservation of potency. Results us-
ing a new nerve-sparing technique. Brit. J. Urol., 56: 694, 1984. 31. Walsh, P. C.: Radical retropubic prostatectomy. In: Campbell’s Urology, 5th ed. Edited by P. C. Walsh, R. F. Gittes, A. D. Perlmutter and T. A. Stamey. Philadelphia: W. B. Saunders Co., vol. 3,sect. XV, chapt. 76,pp. 2754-2775, 1986. 32. Tanagho, E.A.,Meyers, F. H. and Smith, D. R.: Urethral resistence: its components and implications. I. Smooth muscle component. Invest. Urol., 7: 136, 1969. 33. Oelrich, T. M.: The striated urogenital sphincter muscle in the female. Anat. Rec., 206 223, 1983. 34. Tanagho, E.A.,Meyers, F. H. and Smith, D. R.: Urethral resistence: its components and implications. 11. Striated muscle component. Invest. Urol., 1:195,1969. 35. Bissada, N.K.:Characteristics and use of the in situ appendix as a continent catheterization stoma for continent urinary diversion in adults. J. Urol., 160 151, 1993. 36. Bunne, G. and Obrink, A.: Urethral closure pressure with stress-a comparison between stress-incontinent and continent women. Urol. Res., 6 127,1978. 37. Tanagho, E. A.: Urodynamics of female urinary incontinence with emphasis on stress incontinence. J. Urol., 122 200,1979. 38. Constantinou, C.E.and Govan, D. E.: Spatial distribution and timing of transmitted and reflexly generated urethral pressures in healthy women. J. Urol., 121: 964,1982. 39. Heidler, H., Wolk, H. and Jonas, U.: Urethral closure mechanism under stress conditions. Eur. Urol., 6 110,1979. 40. Obrink, A.,Brunne, G. and Ingelman-Sundberg, A.: Pressure transmission to the pre-urethral space in stress incontinence. Urol. Res., 6 135,1978. 41. Persson, C. and Melchior, H.: Ileozystodynamik: urodynamische Untersuchungen der kontinenten Ileumblase. Urologe A, 2 6 259,1986. 42. Lipsky, H. and Melchior, H.: Ureterersatz durch Appendix. Verh. Dtsch. Ges. Urol., 40 56,1988. 43. Mtrofanoff, P.: Cystostomie continente trans-appendicularie dans le traitement des vessies neurologiques. Chir. Ped., 21: 297, 1980. 44. Goldwasser, B. and Webster, G. D.: Continent urinary diversion. J. Urol., 134:227,1985. 45. Gilchrist, R.K., Merricks, J . W., Hamlin, M. H. and Rieger, I. T.: Construction of a substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950.
Vol. 153,1043-1046,March 1995 Printed in U S A .
FUNCTIONAL REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY FOR BLADDER CANCER IN A FEMALE PATIENT WILHELM A. €#BNER*
AND
HEINZ PFLOGER
From the Department of Urology, Lainz Hospital, Vienna, Austria
ABSTRACT
We describe a new concept for female bladder replacement introducing a n ileocecal pouch with the intact appendix vermiformis used as a n orthotopic neourethra. Based upon the results of preceding experimental studies this procedure was performed on a woman with t h e diagnosis of focal invasive bladder cancer. Eight months after the operation the patient is completely contin e n t and back to work. This new type of urinary diversion with improved body image can be offered to female patients undergoing cystectomy for bladder cancer. KGI WORDS:bladder, urethra, cystectomy, appendix, female Prompted by the work of Kock and Skinner et al, great interest is being shown in bladder replacement with detubularized sections of The creation of a low pressure reservoir with sufficient capacity and anti-reflux implantation of the ureters into the pouch assure continence over longer periods without placing the upper urinary tract at risk.376.638-11For male cystectomy patients the goal of achieving continent, stoma-free drainage of urine has been realized by attaching low pressure intestinal pouches to the urethra."-ls In female patients too much of the intrinsic continence mechanism is removed at cystectomy to achieve reliable day and nighttime continence by simple attachment of a common pouch to the urethra. Therefore, subtotal cystectomy techniques (leaving behind parts of the original bladder neck) or implantation of an artificial sphincter is necessary to achieve a functional neobladder that enables the patient to void at convenient interval^.^^-^^ However, such concepts carry the risk of urethral tumor recurrence or complications arising from artificial sphincters placed around intestinal segments.2sz6 Since 1989 we have been working on a new concept for female bladder replacement using an ileocecal pouch with the intact appendix vermiformis in place to provide additional sphincter potency. This method involves the ceco-appendiceal junction as a neobladder neck and the appendix vermiformis as a neourethra.26-2s We present our first clinical application of this new concept. CASE REPORT
A 53-year-old white woman with the diagnosis of focal invasive stage T2NOMO grade 2 bladder cancer was selected for nerve sparing radical cystectomy and urine diversion by an orthotopic ileocecal neobladder with the in situ appendix serving as a neourethra. The upper urinary tract was normal on ultrasonography and excretory urography, and no nodal involvement was seen on computerized tomography. Blood parameters were within normal range. Bowel preparation was started with 3 1.20%mannitol given through a nasogastric tube, and 4 gm.cefotaxime, 240 mg. tobramycin and 1.5 gm. metronidazole were given on the day of operation. Pelvic lymphadenectomy revealed no nodal involvement at frozen section. A nerve sparing radical cystectomy was performed according to the findings of our anatomical studies. The fibers of the hypogastric plexus were easily identitied and preserved (fig. 1).After submucosal injection of saline the external urethral orifice was circumcised and the mucosa
was mobilized bluntly. The distal part of the mucosa was then fixed to a 16F Foley catheter with a ligature and stripped into the pelvis. The specimen was examined for completeness macroscopically. A neobladder was then constructed of cecum and 20 cm. of isolated ileum, and anti-reflux submucosal implantation of the ureters into the cecum was performed as described by Goodwin et al." The pouch was shifted into the true pelvis, and the appendix vermiformis was drawn through the urethral channel as a neourethra and fixed with 4-zero polyglycolic acid atraumatic mucocutaneous sutures. Because this was the first clinical case of this new technique, an additional continent safety nipple composed of tapered ileum was formed, and the stoma was positioned in the left lower side of the abdomen.6 Foley catheters were left through the neourethra and in the ileal stoma. Convalescence was uneventful. The catheters were removed 24 days postoperatively and a urodynamic study of the pouch is shown in figure 2. Initially retention occurred followed by temporary leakage from the urethra but after 4 weeks, during which vaginal cones were used for training the pelvic floor, the patient has been completely continent during the day and she awakens only once during a sleeping period of 7 hours. Urodynamic studies after 12 weeks revealed voiding volumes of up to 400 ml. at micturition pressures of 60 cm. water and a residual urine of 150 ml. Micturition is achieved by abdominal strain (fig. 3). Pouch contractions were observed resulting in pressure peaks of up to 60 cm. water. Continence is preserved up to a volume of 600 ml., and stress incontinence was not observed either clinically or during urodynamic studies (fig. 4). The safety stoma in the left lower side of abdomen was closed 7 months after the operation based on patient convenience. A recent urodynamic study &er closure of the stoma revealed low baseline pressures in a matured reservoir (fig. 5). However, pressure peaks of 50 cm. water are still observed. Micturition is initiated by abdominal strain and supported by a pouch contraction. Presently the patient is completely continent and back to work. The cosmetic result of the neourethral external orifice is pleasing. DISCUSSION
Great emphasis has been placed on the preservation of continence and erectile function in male patients undergoing . ~ became ~~~~ radical prostatectomy or c y s t o p r ~ s t a t e c t o m y It standard to attach intestinal pouches to the urethra, thus forming - a functional neobladder capable of urine storage as Accepted for publication August 12,1994. micturition in m&."-" * Requests for reprints: Department of Urology, Lainz Hospital, well as In women continence depends on the so-called mucosal Wolkersbergenstrasse 1, 1130 Vienna, Austria. 1043
REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
1044
RG.1. A. during cystectomy fibers of ri ht hypogastric plexus are identified and secured with vessel loops (M and right ureter ( U Iis pulled medially to facilitate preparation. distal stump of right ureter is drawn medially when preparation of lateral bladder wall is initiated. Nerve fibers leading to bladder must be transected and fibers traveling to urethra are left untouched.
8,
r Uara
t
t Pabd 31 cnHZO/Diu
FIG.3. Fluoroscopy reveals neourethra of orthotopic surrogate bladder during voluntary micturition (arrows).
Uura
288 n 1 4 i v 1 nin/Div
additional sphincteric strength. The 3 taeniae of the large bowel converge in the region of the ceco-appendiceal junction, pouch throu h safety stoma leads to ressure peaks of 90 cm. water whereby the circular muscle ring in this area is reinforced. at volume of200 ml. (investigation agandoned). Qura, uroflow. EM- Histological investigations on the ceco-appendiceal junction GAVE,electromyogra h of pelvic floor.Pdet, detrusorpressure.Pues, bladder pressure. Pa&, abdominal pressure (not measured). Vum. suggest the presence of a sphincter-like muscle ring in this region.2s Ceco-appendiceal junction and appendix vermiforvolume voided. mis, containing smooth muscle capable of long-term tonic contraction, have been known to generate pressures of 35 to ' . ~ urethral ~ pressures in our patient sphincter, bladder neck and urethra (smooth muscle), elastic 110 cm. ~ a t e r . ~ The fibers of the urethral wall, periurethral vascular plane and correspond well to these data, and in conjunction with the pelvic floor (striated m u ~ d e ) ? Since ~ - ~ ~the first 4 factors preserved function of the urethra baseline continence is that are responsible for baseline continence cease to apply achieved. Stress continence is preserved since the abdomino-urethral after conventional radical cystectomy in female patients, bladder replacement was only possible if the urethra and pressure transmission as well as the somatic neural pathparts of the bladder neck were left intact or if an artificial ways for contraction of the pelvic floor are left unsphincter was i ~ n p l a n t e d . ' ~ -However, ~ ~ * ~ ~ leaving behind t o u ~ h e d . ~ ~In- ~patients ' with a weak pelvic floor additional parts of the bladder neck is not advisable for patients under- colpo-suspension might be necessary to keep the bladder in going cystectomy for bladder cancer.23 Implantation of an the desired high position and assure abdomino-urethral presartificial sphincter around excluded bowel segments to sure transmission. achieve continence proved to carry a high risk of complicaIn men who have undergone bladder replacement micturitions, such as erosion of the cuff into the bowel l ~ m e n . ' ~ . ~tion ~ results from abdominal strain. Although the coordinated To our knowledge no consequent efforts have been under- micturition process no longer occurs after such operations, a taken to study the possible function of the female urethra certain learning process seems feasible, which is substantiand pelvic floor after radical cystectomy in humans. The ated by the extremely variable voiding pressures between 30 results of our animal studies revealed that dynamic function and 120 cm. water recorded in surrogate bladder^.'^-^".*^ can be preserved to a substantial extent. Prere uisite to that Comparable to male patients with neobladders it took our is maintenance of the responsible nerve With the patient 6 weeks to get used to the new voiding technique and technique described, parts of the intrinsic urethral closure regain continence. She is now completely dry with little or no mechanisms (particularly the outer circular fibers) as well as problem to initiate micturition. Apparently, conscious relaxthe urethrovaginal sphincter are left intact.33 The ceco- ation of the pelvic floor can reduce urethral resistance to such appendiceal junction and the appendix vermiformis provide an extent that sufficient urine flow occurs with abdominal
RG.2. Udynamic study
4 weeks after operation. Filling of
upp ply!^.^"
~
REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
lass behind the ureter with the posterior hypogastric vessels. 3bviously preservation of these nerve fibers was possible in )ur patient. The innervation of the somatic sphincter mechinism (pudendal nerve) is not at risk during radical cystec;omy. The anterior vaginal wall is excised only at the supraarethral portion. Leaving the distal portion of the vagina underlying the urethra intact results in preserving the integrity of the urethrovaginal sphincter muscle, which is an important factor in the complex striated urethral sphincter system in the female ~ a t i e n t . ~ ~ . ~ ~ Transposition of the pouch into the true pelvis was possible without difficulty, which corresponds to data in the literature concerning attachment of (ileo-) cecal pouches onto the membranous ~ r e t h r a . " . ~ ~ . 'Since ~ , ~ it . ~is~not necessaxy to perform a n anastomosis in the true pelvis when using this method, the procedure is surgically no more challenging than in male patients. In addition, the continence mechanisms of the pelvic floor are not affected by sutures and subsequent scarring.2s We believe the model described to be a viable approach towards orthotopic functional bladder replacement for female patients. "his new type of urinary diversion with improved body image can be offered to women undergoing cystectomy for bladder cancer.
PuraDif 38 cnH20/Div Pura 38 cnH20/Div Pves
38 cnH2O/Div
PB NU 78
3enu PE
a DANTEC FIG.4. Pressure profile of neourethra (appendix). PuruDif, closure pressure. Puru, urethral pressure. Pues, bladder pressure.
I
I I I I
Pura 5 nl/s/Diu
I
Pdet
t
-
:
38 cnH201Diu Pues
38 cnHlOiDiu
Pabd
28 cnH2O/Diu Uura 288 nliDiu I
Uinfus
I
288 nl/Diu
-
I I
L
I
I
I I I
1045
I
FIG.5. Urodynamic study after closure of safety stoma. Low intraluminal baseline pressure, eaks of up to 50 cm. water. Micturition is initiated by abdominafstrain (M) and supported by pouch contraction. Quru, uroflow. Pdet, detrusor pressure. Pues, bladder pressure. Pubd, abdominal pressure. Vuru, volume voided. Vinfus, filling volume.
straining. The micturition pressure of 50 to 60 cm. water as detected during postoperative urodynamic studies is acceptable. In regard to the appendiceal mucosa, no complications are anticipated. The mucosa of the appendix carries no significant risk for problems with recurrent or chronic contact with urine as described in several reports.8*9*32.35,42,43 In our opinion certain aspects of surgical technique must be emphasized at radical cystectomy to preserve function of the female pelvic floor and urethra. The fibers of the inferior hypogastric plexus supporting the urethra and vagina should remain intact at least on 1 ~ i d e . ' ~ , During ~' traditional radical cystectomy the autonomic nerve fibers are cut as thej
REFERENCES
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REPLACEMENT OF BLADDER AND URETHRA AFTER CYSTECTOMY
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