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Intestinocystoplasty in treatment of interstitial cystitis
INTESTINOCYSTOPLASTY OF INTERSTITIAL
J. M. SEDDON, L. BEST,
IN TREATMENT
CYSTITIS
M.D.
M.D.
A. W. BRUCE,
M.D.
From the Department of Urology, Kingston, Ontario, Canada
Queen’s
University,
ABSTRACT - Nine cases of interstitial cystitis treated by intestinocystoplasty are reviewed. The longest follow-up is seventy-eight months. Two patients have since died of unrelated causes. The results reveal seven symptomatic cures and two failures. Long-term renal and vesical function have been well maintained.
The etiology of interstitial cystitis remains obscure although an autoimmune phenomenon is suggested. Ever since Hiinner’ originally described the condition, it has remained a perplexing management problem. The number of surgical and medical treatments advocated attest to the urologist’s inability to deal successfully with the disease. This relatively rare condition principally affects middle-aged females although recently the diagnosis has been made in a much younger age group.’ The patient presents with frequency, nocturia, dysuria, and severe suprapubic pain only minimally relieved by voiding. Urgency and urgency incontinence may be present and hematuria invariably occurs. The urine is stated to be characteristically sterile, and a cystometrogram reveals a bladder of small capacity but with a normal filling curve.3 Cystoscopic examination reveals areas of blanched mucosa or actual ulceration, and with mild distention, petechia and linear splits may appear in the bladder mucosa. The trigone is usually normal. Pathologic examination of the bladder shows chronic inflammation and fibrosis affecting the submucosal and muscular layers of the bladder with or without ulceration of the bladder mucosa. The chronic inflammatory cell infiltrate is said to show a high proportion of mast cells.4’5
UROLOGY
I
NOVEMBER
1977
I
VOLUME
X, NUMBER 5
The patient shows symptomatic improvement after forced distention of the bladder under anesthesia. However, this improvement is only temporary, the symptoms usually returning within six months. In cases in which the bladder capacity has been markedly reduced, little benefit is to be expected from repeated hydrodistention, fulguration and resection of ulcers, or cystolysis.3 In such cases intestinocystoplasty appears to be the procedure of choice as suggested by results in recent series.3*6 Material
and Methods
Nine patients, 8 females and 1 male, underwent intestinocystoplasty for interstitial cystitis over a ten-year period (1965 to 1975). The average age of the patients was fifty-six years, the youngest being twenty-two. The longest time period between the date of diagnosis and the undertaking of intestinocystoplasty was eight years and eleven months. The average time period between diagnosis and surgery was two years. All patients complained of gross frequency and nocturia, the latter being of the order of 8 to 10 times per night (Table I). The next most common symptoms were hematuria and dysuria. Urgency and urgency incontinence were a significant problem in 5 patients, and
431
TABLE I.
Preoperative
Symptoms
Symptoms Case Number
5 6 7 8 9*
Age (Years)
Date of Diagnosis
Frequency Nocturia
57 57 49 22
3167 8174 11/69 9165
+++ +++ +++ +++
+ + +
55 45 50 57 65
10169 8174 lo/67 l/70 4l69
+++ +++ +++ +++ +++
-
Hematuria
Dysuria
+ + + +
Suprapubic Pain
Incontinence
_ _
-
-
+ + +
+ -
+ + + _
-
_
+ +
+ -
+
+
+ +
+ +
+
Urinary Tract Infections . . . . . + 9ii5’ + 2166 . . . Numerous + lo/67 Numerous + 8168
*Only male patient in series.
TABLE II.
Instrumentation
Cystoscopic Findings Case Number
Ulcers
Inflammation
Splits
Capacity (Ml.)
1
+
+
+
120
2 3 4
+
+ + +
+ + +
180 400 150
5
-
+
+
280
6 7
+
+ +
+
100 200
8
+
+
_
350
9*
+
+
+
150
Dates of Hvdrodistention 1 l/67 8168 5169 3170 8174 11/65 2166 2167 2168 4l70 7170 at71 2172
3169 2170 8171 7172 5172
10167 12!67 2168 l/70 9170 2171 4169 8169 10169
’ ’’
12173
*Only male patient in series.
surprisingly, in only 5 patients was pelvic discomfort a major complaint. Urinary tract infections were documented on at least one occasion in 5 patients preoperatively, and were a significant recurrent problem in 2 of these patients (Table I). Only 2 patients had preoperative cystometrograms. In both cases the bladder was noted to have a markedly reduced capacity and the filling curve showed uninhibited contractions.
432
Preoperative intravenous pyelography revealed normal upper tracts in 7 patients. One patient had upper tract changes on intravenous pyelogram indicative of chronic pyelonephritis of the right kidney. The other patient showed evidence of right ureteric dilatation suggestive of megaureter. Voiding cystourethrography was performed on only 1 patient preoperatively. In this instance minimal right ureteric reflux was noted.
UROLOGY
i
NOVEMBER
1977
/
VOLUME
X, NUMBER
5
Cystoscopic cally inflamed
examination revealed a chronibladder in all cases. Typical
ulcers were seen in 5 patients and splitting of the mucosa on distention in 7. Bladder capacity was reduced in all cases except one (Case 3). Diagnosis in most cases was based on the classic cystoscopic appearance with biopsy confirmation. A number of the patients were treated initially with hydrodistention therapy (Table II). Long-term antibiotics and antispasmodics were also employed. Dissatisfaction with the results from such therapy led to intestinocystoplasty. In the most recent cases surgery was undertaken more readily and conservative therapy was not prolonged.
TABLE
III. Pathology
Category
Number of Patients
A
6
B
1
Results There were no operative mortalities nor significant morbidity in the immediate postoperative period. One patient had a wound infection which settled with drainage. As expected when large bowel is approximated to the urinary tract and catheter drainage is maintained for a considerable time postoperatively, urinary tract infection is inevitable and occurred in all patients. However, 3 patients had sterile urine at the time of discharge from hospital and none showed evidence of renal involvement in the infective process. Two patients have since died of unrelated causes, one five years postoperatively and one eighteen months postoperatively (Table IV). All other patients have been followed to the
UROLOGY
/ NOVEMBER1977
/ VOLUMEX,
NUMBER5
Pathology Loss of mucosa; chronic inflammatory cell infiltrate of submucosa and muscularis, lymphocytes and plasma cells predominating; and edema and fibrosis of submucosa/muscularis As in category A plus in-
creased numbers of eosinophils in cellular infiltrate; adenomatous metaplasia of epithelium where present
Surgery Colocystoplasty of the patch type using the sigmoid colon was performed in 8 patients.7 In one patient the mobilized segment of large bowel was found to contain a polyp which had not been demonstrated on preoperative barium enema. The polyp was excised and pathologic examination showed it to be benign. The segment of bowel was used with no ill effects. One patient had an ileocystoplasty performed of the U-type (Case 2). A preoperative barium enema had revealed diverticulosis of the sigmoid colon thus excluding the large bowel as a source for the patch. In all patients at the time of surgery the bladder was resected down to within 1 cm. of the trigone. The pathologic reports on the excised specimens are summarized in Table III. It is noteworthy that in only 2 patients was there evidence of mast cells within the chronic cellular infiltrate.
of excised bladder tissue
C
1
D
1
As in category A plus increased numbers of eosinophils and mast cells in cellular infiltrate As in category A plus increased numbers of mast cells in cellular infiltrate; adenomatous metaplasia of epithelium where present
present time. The longest follow-up has been seventy-eight months and the shortest eighteen months, the average being forty-one months. Six patients have had complete elimination of symptoms, and this has been maintained during the follow-up period (Table IV). One patient still suffers from frequency and nocturia (three times) although her previous symptom of hematuria has been completely relieved and the degree of frequency and nocturia is much less than was the case preoperatively. We consider these 7 patients symptomatic cures. Two patients are considered failures in this small series. One patient had return of all her symptoms three months postoperatively (Case 8). She later died of unrelated causes. One patient (Case 6) had return of symptoms six months postoperatively. Cystoscopic examination at this time revealed ulceration on the trigone. Fulguration and resection of the ulcer was carried out, and the patient has been relatively asymptomatic since. However, as far as this series is concerned we have regarded this case as a failure. Four patients continued to have problems with recurrent infection. In 1 patient (Case 3) this problem persisted for the first year after surgery and has since disappeared. The other 3 patients had a history of recurrent infection
433
TABLE
IV.
Postoperative symptoms
Symptoms Case Number
Date of Last Follow-up
1 2
S/76 10176
3
4176
4
St76
1 year, 9 months
5
5176
6
6176
7
4l73 Dead s/75 Dead 4l76
3 years, 6 months I year, 10 months 5 years
8 9*
Suprapubic Urinary Tract Infection Pain
Total Follow-up
Frequency Nocturia
Dysuria
Incontinence
Hematuria
6 years 1 year, 6 months 3 years
++ -
-
-
-
-
. . . . . .
-
-
-
-
-
-
-
-
-
-
5173 6173 10173 10/74 10175 3176 11/74 5175 . . .
++
-
-
-
-
-
-
-
-
-
+++
+
+
+
+
El75 l/76 3171 l/73 . . .
-
-
-
-
-
. . .
I year, 8 months 6 years, 6 months
*Only male patient in series.
but he has a large residual and an atonic type curve. The other 5 patients have normal cystometrograms. Bladder capacities are reasonable (350 to 500 ml.), residuals are less than 50 ml., and the filling curves are normal (Table V). Intravenous pyelography was performed on 8 of the patients postoperatively. In 7 patients the examination was normal or unchanged from the preoperative examination. In 1 case bilateral hydronephrosis was noted initially postoperatively, but this has since disappeared.
preoperatively, one having changes on intravenous pyelography suggestive of chronic pyelonephritis. These x-ray changes, however, were present preoperatively. All 7 living patients have had recent cystometrograms (Table V). The 1 patient whom we
regard as a symptomatic failure had a bladder capacity of 255 ml. with a normal filling curve. The male patient in the series (Case 9) has recently shown increasing signs of prostatism; his cystometrogram reveals a bladder of normal capacity, TABLE V.
Cystometrogram Residual
Postoperative investigations
Case Number
Capacity
1 2 3
350 400 400
20 20 35
Normal Normal Normal
4
500
30
Normal
5 6 7 8 9f
400 255 . . .
25 10 ...
iii
io0
Normal Normal . . . . . . Atonic
grade I (minimal reflux in lower third of ureter tOnly male patient in series.
*GI =
434
Intravenous Pyelogram
Curve
only);
Voiding Cystourethrogram Reflux: right, GI;* left, GI Normal Reflux: right, GII; left, GI
Normal Normal Bilateral hydronephrosis settling Right chronic pyelonephritis unchanged Normal Normal Normal
Small diverticulum
Reflux: right, GII; left, GII Reflux: right, GI unchanged Reflux: right, GII; left, GI Normal Large postvoid residual
Normal ’ ’
GII =
grade II (reflux extending
UROLOGY
to renal pelvis with no dilatation).
/ NOVEMBER1977
/ VOLUMEX,
NUMBER5
All 9 patients have had voiding cystourethrograms postoperatively. Two are normal, and 5 show varying degrees of reflux - in 1 case unchanged in degree from the preoperative examination. In 1 case a small diverticulum has been visualized, and in the male patient inadequate bladder emptying has been demonstrated. Comment All patients in this series presented with the classic symptoms of interstitial cystitis, and the majority showed ulcers and mucosal splitting on cystoscopic examination. The patients did not necessarily have sterile urines and pathologic examination did not always reveal the mast cells said to be pathognomonic of this disease. 5 We believe it would be unreasonable to expect middle-aged females, with deficient bladder defenses against infection due to ulceration and edema of the mucosa, to maintain a sterile urine. In view of the gross frequency and nocturia it is surprising that more were not infected preoperatively.’ A possible explanation for this discrepancy is the fact that many of these patients were on long-term antimicrobial therapy. Unfortunately, cystometrograms were performed preoperatively on only 2 patients, and those patients were the failures in the series. Both filling curves revealed uninhibited contractions. This finding is not in agreement with previous reports.3 Review of our results suggest that intestinocystoplasty is an excellent form of management for this disease especially when it has progressed to the contracted bladder stage. One patient (Case 3) had a normal bladder capacity and perhaps, retrospectively, cystolysis would have sufficed.3 The reason for the two failures is not apparent at the present time. It is noteworthy that these 2 patients (Cases 6 and 8) had a significant problem with recurrent infection preoperatively. This may have contributed in some way to the unsuccessful outcome.
UROLOGY
1
NOVEMBER
1977
i
VOLUME X, NUMBER 5
Vesical function postoperatively has been maintained. The importance of keeping the bladder neck unobstructed as noted by Worth and Turner-Warwick3 is well illustrated by our 1 male patient. Only 1 patient showed any significant deterioration in renal status, and this was of a temporary nature. Excluding the immediate postoperative period, urinary tract infection has not been a problem. In only I patient who was free of infection preoperatively did susceptibility develop postoperatively, and this disappared after one year. The other 3 patients with postoperative infection had evidence of this prior to surgery. Voiding cystourethrograms performed during the follow-up period have revealed reflux in the majority. This may be due to extensive resections of bladder tissue, and it may be that reflux could be avoided by leaving a larger margin of bladder tissue around each ureteric orifice.3 However the reflux does not appear to have produced any significant renal deterioration to the present time. Diverticulum formation in the patch of intestine has not been a problem. Kingston, Ontario, Canada K7L (DR.
3N6
BRUCE)
References 1. Hiinner GL: A rare type of bladder ulcer in women, Tr. South. Surg. Gynecol. Assoc. 27: 247 (1914). 2. Lapides J: Observations on interstitial cystitis, Urology 5: 610 (1975). 3. Worth PHL, and Turner-Warwick II: The treatment of interstitial cystitis by cystolysis with observations on cystoplasty, Br. J. Urol. 45: 65 (1973). 4. Smith BH, and Dehner LP: Chronic ulcerating interstitial cystitis (Hiinner’s ulcer), Arch. Pathol. 93: 76 (1972). 5. Jacob0 E, Stamler FW, and Culp DA: Interstitial cystitis followed by total cystectomy, Urology 3: 481 (1974). 6. Duff FA, O’Grady JF, and Kelly DG: Colocystoplasty. A review of 10 cases, Br. J. Urol. 42: 794 (1970). 7. Riches E: Colocystoplasty, Proc. R. Sot. Med. 53: 1029 (196% 8. Seddon JM, Bruce AW, Chadwick P, and Carter D: Introital bacterial flora effect of increased frequency of micturition, Br. J. Urol. 48: 211 (1976).
43s
J. M. SEDDON, L. BEST,
IN TREATMENT
CYSTITIS
M.D.
M.D.
A. W. BRUCE,
M.D.
From the Department of Urology, Kingston, Ontario, Canada
Queen’s
University,
ABSTRACT - Nine cases of interstitial cystitis treated by intestinocystoplasty are reviewed. The longest follow-up is seventy-eight months. Two patients have since died of unrelated causes. The results reveal seven symptomatic cures and two failures. Long-term renal and vesical function have been well maintained.
The etiology of interstitial cystitis remains obscure although an autoimmune phenomenon is suggested. Ever since Hiinner’ originally described the condition, it has remained a perplexing management problem. The number of surgical and medical treatments advocated attest to the urologist’s inability to deal successfully with the disease. This relatively rare condition principally affects middle-aged females although recently the diagnosis has been made in a much younger age group.’ The patient presents with frequency, nocturia, dysuria, and severe suprapubic pain only minimally relieved by voiding. Urgency and urgency incontinence may be present and hematuria invariably occurs. The urine is stated to be characteristically sterile, and a cystometrogram reveals a bladder of small capacity but with a normal filling curve.3 Cystoscopic examination reveals areas of blanched mucosa or actual ulceration, and with mild distention, petechia and linear splits may appear in the bladder mucosa. The trigone is usually normal. Pathologic examination of the bladder shows chronic inflammation and fibrosis affecting the submucosal and muscular layers of the bladder with or without ulceration of the bladder mucosa. The chronic inflammatory cell infiltrate is said to show a high proportion of mast cells.4’5
UROLOGY
I
NOVEMBER
1977
I
VOLUME
X, NUMBER 5
The patient shows symptomatic improvement after forced distention of the bladder under anesthesia. However, this improvement is only temporary, the symptoms usually returning within six months. In cases in which the bladder capacity has been markedly reduced, little benefit is to be expected from repeated hydrodistention, fulguration and resection of ulcers, or cystolysis.3 In such cases intestinocystoplasty appears to be the procedure of choice as suggested by results in recent series.3*6 Material
and Methods
Nine patients, 8 females and 1 male, underwent intestinocystoplasty for interstitial cystitis over a ten-year period (1965 to 1975). The average age of the patients was fifty-six years, the youngest being twenty-two. The longest time period between the date of diagnosis and the undertaking of intestinocystoplasty was eight years and eleven months. The average time period between diagnosis and surgery was two years. All patients complained of gross frequency and nocturia, the latter being of the order of 8 to 10 times per night (Table I). The next most common symptoms were hematuria and dysuria. Urgency and urgency incontinence were a significant problem in 5 patients, and
431
TABLE I.
Preoperative
Symptoms
Symptoms Case Number
5 6 7 8 9*
Age (Years)
Date of Diagnosis
Frequency Nocturia
57 57 49 22
3167 8174 11/69 9165
+++ +++ +++ +++
+ + +
55 45 50 57 65
10169 8174 lo/67 l/70 4l69
+++ +++ +++ +++ +++
-
Hematuria
Dysuria
+ + + +
Suprapubic Pain
Incontinence
_ _
-
-
+ + +
+ -
+ + + _
-
_
+ +
+ -
+
+
+ +
+ +
+
Urinary Tract Infections . . . . . + 9ii5’ + 2166 . . . Numerous + lo/67 Numerous + 8168
*Only male patient in series.
TABLE II.
Instrumentation
Cystoscopic Findings Case Number
Ulcers
Inflammation
Splits
Capacity (Ml.)
1
+
+
+
120
2 3 4
+
+ + +
+ + +
180 400 150
5
-
+
+
280
6 7
+
+ +
+
100 200
8
+
+
_
350
9*
+
+
+
150
Dates of Hvdrodistention 1 l/67 8168 5169 3170 8174 11/65 2166 2167 2168 4l70 7170 at71 2172
3169 2170 8171 7172 5172
10167 12!67 2168 l/70 9170 2171 4169 8169 10169
’ ’’
12173
*Only male patient in series.
surprisingly, in only 5 patients was pelvic discomfort a major complaint. Urinary tract infections were documented on at least one occasion in 5 patients preoperatively, and were a significant recurrent problem in 2 of these patients (Table I). Only 2 patients had preoperative cystometrograms. In both cases the bladder was noted to have a markedly reduced capacity and the filling curve showed uninhibited contractions.
432
Preoperative intravenous pyelography revealed normal upper tracts in 7 patients. One patient had upper tract changes on intravenous pyelogram indicative of chronic pyelonephritis of the right kidney. The other patient showed evidence of right ureteric dilatation suggestive of megaureter. Voiding cystourethrography was performed on only 1 patient preoperatively. In this instance minimal right ureteric reflux was noted.
UROLOGY
i
NOVEMBER
1977
/
VOLUME
X, NUMBER
5
Cystoscopic cally inflamed
examination revealed a chronibladder in all cases. Typical
ulcers were seen in 5 patients and splitting of the mucosa on distention in 7. Bladder capacity was reduced in all cases except one (Case 3). Diagnosis in most cases was based on the classic cystoscopic appearance with biopsy confirmation. A number of the patients were treated initially with hydrodistention therapy (Table II). Long-term antibiotics and antispasmodics were also employed. Dissatisfaction with the results from such therapy led to intestinocystoplasty. In the most recent cases surgery was undertaken more readily and conservative therapy was not prolonged.
TABLE
III. Pathology
Category
Number of Patients
A
6
B
1
Results There were no operative mortalities nor significant morbidity in the immediate postoperative period. One patient had a wound infection which settled with drainage. As expected when large bowel is approximated to the urinary tract and catheter drainage is maintained for a considerable time postoperatively, urinary tract infection is inevitable and occurred in all patients. However, 3 patients had sterile urine at the time of discharge from hospital and none showed evidence of renal involvement in the infective process. Two patients have since died of unrelated causes, one five years postoperatively and one eighteen months postoperatively (Table IV). All other patients have been followed to the
UROLOGY
/ NOVEMBER1977
/ VOLUMEX,
NUMBER5
Pathology Loss of mucosa; chronic inflammatory cell infiltrate of submucosa and muscularis, lymphocytes and plasma cells predominating; and edema and fibrosis of submucosa/muscularis As in category A plus in-
creased numbers of eosinophils in cellular infiltrate; adenomatous metaplasia of epithelium where present
Surgery Colocystoplasty of the patch type using the sigmoid colon was performed in 8 patients.7 In one patient the mobilized segment of large bowel was found to contain a polyp which had not been demonstrated on preoperative barium enema. The polyp was excised and pathologic examination showed it to be benign. The segment of bowel was used with no ill effects. One patient had an ileocystoplasty performed of the U-type (Case 2). A preoperative barium enema had revealed diverticulosis of the sigmoid colon thus excluding the large bowel as a source for the patch. In all patients at the time of surgery the bladder was resected down to within 1 cm. of the trigone. The pathologic reports on the excised specimens are summarized in Table III. It is noteworthy that in only 2 patients was there evidence of mast cells within the chronic cellular infiltrate.
of excised bladder tissue
C
1
D
1
As in category A plus increased numbers of eosinophils and mast cells in cellular infiltrate As in category A plus increased numbers of mast cells in cellular infiltrate; adenomatous metaplasia of epithelium where present
present time. The longest follow-up has been seventy-eight months and the shortest eighteen months, the average being forty-one months. Six patients have had complete elimination of symptoms, and this has been maintained during the follow-up period (Table IV). One patient still suffers from frequency and nocturia (three times) although her previous symptom of hematuria has been completely relieved and the degree of frequency and nocturia is much less than was the case preoperatively. We consider these 7 patients symptomatic cures. Two patients are considered failures in this small series. One patient had return of all her symptoms three months postoperatively (Case 8). She later died of unrelated causes. One patient (Case 6) had return of symptoms six months postoperatively. Cystoscopic examination at this time revealed ulceration on the trigone. Fulguration and resection of the ulcer was carried out, and the patient has been relatively asymptomatic since. However, as far as this series is concerned we have regarded this case as a failure. Four patients continued to have problems with recurrent infection. In 1 patient (Case 3) this problem persisted for the first year after surgery and has since disappeared. The other 3 patients had a history of recurrent infection
433
TABLE
IV.
Postoperative symptoms
Symptoms Case Number
Date of Last Follow-up
1 2
S/76 10176
3
4176
4
St76
1 year, 9 months
5
5176
6
6176
7
4l73 Dead s/75 Dead 4l76
3 years, 6 months I year, 10 months 5 years
8 9*
Suprapubic Urinary Tract Infection Pain
Total Follow-up
Frequency Nocturia
Dysuria
Incontinence
Hematuria
6 years 1 year, 6 months 3 years
++ -
-
-
-
-
. . . . . .
-
-
-
-
-
-
-
-
-
-
5173 6173 10173 10/74 10175 3176 11/74 5175 . . .
++
-
-
-
-
-
-
-
-
-
+++
+
+
+
+
El75 l/76 3171 l/73 . . .
-
-
-
-
-
. . .
I year, 8 months 6 years, 6 months
*Only male patient in series.
but he has a large residual and an atonic type curve. The other 5 patients have normal cystometrograms. Bladder capacities are reasonable (350 to 500 ml.), residuals are less than 50 ml., and the filling curves are normal (Table V). Intravenous pyelography was performed on 8 of the patients postoperatively. In 7 patients the examination was normal or unchanged from the preoperative examination. In 1 case bilateral hydronephrosis was noted initially postoperatively, but this has since disappeared.
preoperatively, one having changes on intravenous pyelography suggestive of chronic pyelonephritis. These x-ray changes, however, were present preoperatively. All 7 living patients have had recent cystometrograms (Table V). The 1 patient whom we
regard as a symptomatic failure had a bladder capacity of 255 ml. with a normal filling curve. The male patient in the series (Case 9) has recently shown increasing signs of prostatism; his cystometrogram reveals a bladder of normal capacity, TABLE V.
Cystometrogram Residual
Postoperative investigations
Case Number
Capacity
1 2 3
350 400 400
20 20 35
Normal Normal Normal
4
500
30
Normal
5 6 7 8 9f
400 255 . . .
25 10 ...
iii
io0
Normal Normal . . . . . . Atonic
grade I (minimal reflux in lower third of ureter tOnly male patient in series.
*GI =
434
Intravenous Pyelogram
Curve
only);
Voiding Cystourethrogram Reflux: right, GI;* left, GI Normal Reflux: right, GII; left, GI
Normal Normal Bilateral hydronephrosis settling Right chronic pyelonephritis unchanged Normal Normal Normal
Small diverticulum
Reflux: right, GII; left, GII Reflux: right, GI unchanged Reflux: right, GII; left, GI Normal Large postvoid residual
Normal ’ ’
GII =
grade II (reflux extending
UROLOGY
to renal pelvis with no dilatation).
/ NOVEMBER1977
/ VOLUMEX,
NUMBER5
All 9 patients have had voiding cystourethrograms postoperatively. Two are normal, and 5 show varying degrees of reflux - in 1 case unchanged in degree from the preoperative examination. In 1 case a small diverticulum has been visualized, and in the male patient inadequate bladder emptying has been demonstrated. Comment All patients in this series presented with the classic symptoms of interstitial cystitis, and the majority showed ulcers and mucosal splitting on cystoscopic examination. The patients did not necessarily have sterile urines and pathologic examination did not always reveal the mast cells said to be pathognomonic of this disease. 5 We believe it would be unreasonable to expect middle-aged females, with deficient bladder defenses against infection due to ulceration and edema of the mucosa, to maintain a sterile urine. In view of the gross frequency and nocturia it is surprising that more were not infected preoperatively.’ A possible explanation for this discrepancy is the fact that many of these patients were on long-term antimicrobial therapy. Unfortunately, cystometrograms were performed preoperatively on only 2 patients, and those patients were the failures in the series. Both filling curves revealed uninhibited contractions. This finding is not in agreement with previous reports.3 Review of our results suggest that intestinocystoplasty is an excellent form of management for this disease especially when it has progressed to the contracted bladder stage. One patient (Case 3) had a normal bladder capacity and perhaps, retrospectively, cystolysis would have sufficed.3 The reason for the two failures is not apparent at the present time. It is noteworthy that these 2 patients (Cases 6 and 8) had a significant problem with recurrent infection preoperatively. This may have contributed in some way to the unsuccessful outcome.
UROLOGY
1
NOVEMBER
1977
i
VOLUME X, NUMBER 5
Vesical function postoperatively has been maintained. The importance of keeping the bladder neck unobstructed as noted by Worth and Turner-Warwick3 is well illustrated by our 1 male patient. Only 1 patient showed any significant deterioration in renal status, and this was of a temporary nature. Excluding the immediate postoperative period, urinary tract infection has not been a problem. In only I patient who was free of infection preoperatively did susceptibility develop postoperatively, and this disappared after one year. The other 3 patients with postoperative infection had evidence of this prior to surgery. Voiding cystourethrograms performed during the follow-up period have revealed reflux in the majority. This may be due to extensive resections of bladder tissue, and it may be that reflux could be avoided by leaving a larger margin of bladder tissue around each ureteric orifice.3 However the reflux does not appear to have produced any significant renal deterioration to the present time. Diverticulum formation in the patch of intestine has not been a problem. Kingston, Ontario, Canada K7L (DR.
3N6
BRUCE)
References 1. Hiinner GL: A rare type of bladder ulcer in women, Tr. South. Surg. Gynecol. Assoc. 27: 247 (1914). 2. Lapides J: Observations on interstitial cystitis, Urology 5: 610 (1975). 3. Worth PHL, and Turner-Warwick II: The treatment of interstitial cystitis by cystolysis with observations on cystoplasty, Br. J. Urol. 45: 65 (1973). 4. Smith BH, and Dehner LP: Chronic ulcerating interstitial cystitis (Hiinner’s ulcer), Arch. Pathol. 93: 76 (1972). 5. Jacob0 E, Stamler FW, and Culp DA: Interstitial cystitis followed by total cystectomy, Urology 3: 481 (1974). 6. Duff FA, O’Grady JF, and Kelly DG: Colocystoplasty. A review of 10 cases, Br. J. Urol. 42: 794 (1970). 7. Riches E: Colocystoplasty, Proc. R. Sot. Med. 53: 1029 (196% 8. Seddon JM, Bruce AW, Chadwick P, and Carter D: Introital bacterial flora effect of increased frequency of micturition, Br. J. Urol. 48: 211 (1976).
43s