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Neobladder Construction using Completely Detubularized Sigmoid Colon after Radical Cystoprostatectomy
0022-534 7/91/1462-0311$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 146, 311-315, August 1991
Printed in U.S.A.
NEOBLADDER CONSTRUCTION USING COMPLETELY DETUBULARIZED SIGMOID COLON AFTER RADICAL CYSTOPROSTATECTOMY KUANG-KUO CHEN, LUKES. CHANG AND MING-TSUN CHEN From the Division of Urology, Department of Surgery, Veterans General Hospital-Taipei and National Yang-Ming Medical College, Taipei, Taiwan, Republic of China
ABSTRACT
To improve the quality of life of the patient we used completely detubularized sigmoid colon for bladder reconstruction along with radical cystoprostatectomy in 6 men with invasive bladder cancer. Followup was 8 to 20 months. Postoperatively, all of the patients were continent during the day but only 4 (66.7%) were continent at night, although they had to awaken twice to remain dry. N eocystourethroscopy in 4 of the 6 patients revealed no tumor and no stricture at the urethrocolonic anastomosis. However, a stone in the neobladder was found in 1 patient. Urodynamic study of the neobladder showed a low pressure (mean 16.7 cm. water) at the filling phase of water cystometry and an adequate maximal urethral closure pressure (mean 52.0 cm. water) and functional profile length (mean 3.8 cm.). The uroflow rate in all patients was good (1 patient even had a maximal uroflow rate of 31 ml. per second). There was no reflux in any patient. One patient had intestinal obstruction 5 months postoperatively and died 5 months later of widespread metastasis. The remaining 5 patients are alive with a satisfactory quality of life. In conclusion, use of completely detubularized sigmoid colon may be an ideal operation for neobladder construction after radical cystoprostatectomy. KEY WORDS: urinary diversion, bladder neoplasms, sigmoid, colon
Continent supravesical bowel urinary diversion has been considered to be a widely accepted operation among urologists and patients. Different segments of the bowel can be used to construct a reservoir (Kock pouch,1-5 Rowland pouch,6 Mainz pouch,7 Camey reservoir8 and sigmoid colon reservoir9 ) for bladder replacement after radical cystoprostatectomy in pa tients with invasive bladder cancer. Self-catheterization through an abdominal stoma to empty the urine from the reservoir was necessary in some patients who underwent uri nary diversion. -6 These stomal continent urinary diversions cause not only inconvenience but also psychological depression owing to a disfigured body image. Although anastomosis of a loop of bowel to the membranous urethra avoids the disadvan tages of an abdominal stoma and catheterization, a high inci dence of high pressure bowel contractions still may occur in these tubularized bowel segments, which may result in urinary frequency, and nocturnal and diurnal incontinence. 10• To im prove further the quality of life after radical cystoprostatec tomy, we used a segment of completely detubularized sigmoid colon to reconstruct a neobladder. The preliminary results are promising. We report this new alternative of continent urinary diversion. 1
11
PATIENTS AND METHODS
From June 1988 to February 1989, 6 men 40 to 69 years old (mean age 56. 7 years) underwent neobladder construction using completely detubularized sigmoid colon along with radical cys toprostatectomy for invasive bladder cancer. Preoperatively, excretory urography (IVP) showed normal upper urinary tracts and a filling defect in the bladder in all 6 patients. Sonography and computerized tomography (CT) demonstrated that the tumors were still within the bladder. Furthermore, a CT scan revealed no enlargement of the pelvic lymph nodes. Cystoure throscopy with biopsy of the bladder tumor and prostatic ure thra revealed transitional cell carcinoma without involvement Accepted for publication December 14, 1990.
of the prostatic urethra in all 6 patients. Colonoscopy also revealed normal sigmoid colon in all 6 patients. Surgical technique. After the peritoneal cavity is entered through a midline abdominal incision from the symphysis pubis to 2 inches above the umbilicus, formal bilateral pelvic lymph adenectomy is performed followed by standard radical cysto prostatectomy. The prostate is severed at its apex and a speci men of urethral stump is sent for frozen section. A segment of redundant sigmoid colon approximately 30 to 35 cm. long is mobilized out of the descending colon and sigmoid colon to construct the neobladder after frozen section reveals no malig nancy in the urethral stump. A 2-layer closure is made for continuity of the colon. The isolated segment of sigmoid colon is irrigated clean, and then folded in a U shape and distended with normal saline (fig. 1, A). Each ureter is implanted into each corresponding limb of the U-shaped sigmoid colon through a 5 cm. seromuscular incision at the lateral taenia. Then, the entire U-shaped sigmoid colon is completely detubularized through an incision made along the entire length of the medial taenia (fig. 1, B). The 2 medial side walls of the U-shaped detubularized sigmoid colon are approximated with 1 layer of a 3-zero polyglactin continuous suture as the posterior wall of the future neobladder. A 3-zero polyglactin suture is placed to the 2 lateral side walls 1.5 cm. away from the midpoint of the bottom of the U-shaped detubularized sigmoid colon to create an opening for urethral anastomosis (fig. 1, C). Each of the 2 ureters is splinted with a 7F x 90 cm. single J stent. The 2 lateral side walls of the incised sigmoid colon are further approximated with 3-zero polyglactin continuous suture from bottom upward until the half-way point of the anterior wall of the almost-formed reservoir (fig. 1, D ). The colourethral anas tomosis is made around a 20F Foley catheter with 6 interrupted sutures of 2-zero polyglactin. A 22F Foley catheter is inserted into the reservoir through an abdominal stab wound. The 2 single J stents are brought out of the abdominal skin at each side of the abdominal incision through the anterior wall of the sigmoid colon reservoir. The remaining upper half of the an terior wall of the reservoir is closed and the completely detu-
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B
A
D
E
FIG. 1. Completely detubularized sigmoid colon neobladder procedure. A, 30 to 35 cm. segment of sigmoid colon is isolated and folded into U shape. Dotted line indicates incision for complete detubularization. B, each ureter is implanted through lateral taenia at each limb of U segment. Segment of sigmoid colon is completely detubularized along medial taenia. Two medial side walls of detubularized sigmoid colon are approximated. C, 3-zero polyglactin suture is placed to 2 lateral side walls at 1.5 cm. from midpoint of bottom of U detubularized sigmoid colon to create opening for urethral anastomosis. D, each ureter is stented. Lower half of 2 lateral side walls of detubularized sigmoid colon is further sutured as anterior wall of reservoir. E, cola-urethral anastomosis is made on 20F Foley catheter. 22F Foley catheter is inserted into reservoir through abdominal wall. Rest of upper unsutured anterior wall is closed and completely detubularized sigmoid colon neobladder is accomplished.
bularized sigmoid colon neobladder is constructed (fig. 1, E). Two catheters are inserted into the pelvic cavity for drainage. Postoperatively, the drainage catheters are removed when a minimal amount of fluid is drained, usually after 4 to 6 days. The bilateral single J stents are removed at 10 days and the urethral Foley catheter is removed 2 weeks postoperatively. Cystography is performed through the abdominal Foley cathe ter to evaluate reflux or leakage. When neither leakage nor reflux is demonstrated, the abdominal catheter is clamped and the patient is instructed to attempt urethral voiding by abdom inal strain to increase the intra-abdominal pressure. The ab dominal catheter is removed when residual urine is not signif icant, usually 1 month postoperatively. The 6 patients were followed every 1 to 2 months. At fol lowup, a detailed continence history was taken, including the frequency of urination to ensure continence during the day and night, the sign or sensation of bladder fullness, and the neces sity of any protection to remain dry. IVPs and voiding cysto urethrography were done in all 6 patients initially at 4 to 6 months postoperatively and then every year. Serum creatinine, blood urea nitrogen (BUN) and electrolytes (chloride, sodium and potassium) were examined every 3 to 6 months. A urody namic study, including slow-filling (10 ml. per minute) water cystometry, urethral pressure profile and uroflowmetry, was performed in all 6 patients at 3 to 10 months postoperatively. During water cystometry the infusion was discontinued when the patient felt discomfort or when the saline leaked out around the catheter. The total infused volume of saline at this point was defined as the functional bladder capacity. The peak pres sure amplitude on the cystometric recording was defined as maximal intravesical pressure. The pressure at water filling to
half of the amount of functional bladder capacity was defined as filling intravesical pressure. Neocystourethroscopy with bi opsy at the urethrocolonic anastomosis was done every 6 months in 4 patients. A urine specimen was collected for routine analysis and bacterial study at each followup visit. RESULTS
There was no operative mortality. Postoperative followup ranged from 8 to 20 months (mean 14.6 months). Early com plications consisted of 1 patient with deep vein thrombosis of the left lower leg, which was managed with anticoagulant therapy, and the symptoms and signs resolved 2 months later. Late complications included intestinal obstruction caused by an adhesional band 5 months postoperatively in 1 patient and a 1.0 X 0.6 cm. stone in the neobladder 6 months postoperatively in 1. Lysis of the fibrotic band relieved the intestinal obstruc tion. Electrohydraulic lithotripsy was used to remove the stone. Analysis of the stone revealed struvite as the major component. A recurrent stone (4 x 3 mm.), formed around a suture and adherent to the wall of the neobladder, was noted 6 months later and it was removed neocystoscopically. All of our 6 patients were continent during the day within 1 month after they began urethral voiding. They voided urine every 2 to 4 hours. Usually, a vague feeling of low abdominal discomfort or a false feeling of a drop of urine at the urethral meatus was the sign to empty the neobladder. Of the 6 patients 4 (66%) were continent at night: 2 had to awaken twice during the night to remain dry, while the other 2 could remain conti nent at night even without awakening to void if they only drank little water before sleep. The remaining 2 patients were incon-
313
COMPLETELY DETUBULARIZED SIGMOID COLON NEOBLADDER tinent at night because they did not attempt to awaken to void (they used 1 to 2 diapers at night). The postoperative IVP showed no obstructive uropathy in any patient (fig. 2, A). The voiding cystourethrogram also demonstrated no reflux from the neobladder to the upper urinary tract in any patient (fig. 2, B). Serum BUN, creatinine and electrolytes were within normal limits in the 6 patients during the postoperative followup. Neocystourethroscopy re vealed no tumor in the neobladder and no stricture at the urethrocolonic anastomosis in all 4 patients. Biopsy at the urethrocolonic anastomosis showed no recurrent tumor as well. Urodynamic study of the neobladder was performed in all 6 patients 3 to 10 months postoperatively (see table). The pres sure at the filling phase of cystometry was low and there were no involuntary pressure spikes on water cystometry in all 6 patients (fig. 3, A). Uroflowmetry revealed a good maximal flow rate and minimal residual urine (fig. 3, B). The urethral pres sure profile showed an adequate maximal urethral closure pres sure and functional profile length (fig. 3, C). One patient suffered intestinal obstruction 5 months postoperatively and died 5 months later of widespread metastasis. The remaining 5 patients are alive with satisfactory quality of life. Although the urine in the neobladder contained pieces of whitish mucus, the patients never suffered urinary obstruction. Urine culture yielded intermittent growth of bacteria (Proteus mirabilis, Morganella morganii and Enterobacter cloacae) in 4 of the 6 patients. No patient had a symptomatic urinary tract infection.
A
Volune (ml)
Voided volume: Maximal flow rate: Mean flow rate: B Residual urine:
420 ml 21 ml/sec 9e1 ml/sec 15 ml
DISCUSSION
Continent urinary diversion via catheterization through an abdominal stoma has been considered to be one of the ideal
Length (cm)
C
FIG. 2. A, IVP shows normal upper urinary tract in patient 6 months after construction of completely detubularized sigmoid colon neoblad der. B, voiding cystourethrogram shows no reflux in patient 6 months postoperatively. Urodynamic studies in 6 patients
Cystometry: Filling intravesical pressure (cm. water)
Maximal intravesical pressure
(cm. water) Functional bladder capacity (ml.) Urethral pressure profile: Maximal urethral closure pressure (cm. water) Functional profile length (cm.) Uroflowmetry: Voidedv�l. (ml.) Mean flow rate (ml./sec.) Maximal flow rate (ml./sec.)
Mean± Standard Deviation
Range
16.7± 6.2
14-28
49.0± 9.7
26-60
310.0± 61.3
220-460
52.0± 16.8
22-66
3.8± 0.9
2.5-4.5
279.2 7.5 18.5
113.4 5.0 7.1
200-450 3.0-16 10-31
Maximal urethral closure pressure: 62 cm H20 Functional profile length: 2.5 cm
FIG. 3. Urodynamic study of completely detubularized sigmoid co lon neobladder. A, water cystometry shows low pressure and no invol untary pressure spikes in patient 4 months postoperatively. B, uroflow metry shows good mean and maximal uroflow rate 6 months postop eratively. C, urethral pressure profile demonstrates adequate maximal urethral closure pressure and functional profile length 6- months post operatively. procedures for bladder reconstruction. Although the patient need not carry an external collecting device for urine, an abdominal stoma as a disfigurement of the body usually has a negative psychological impact. In addition, intermittent cath eterization still is inconvenient in daily life. For most patients, a nonstomal bowel urinary reservoir with connection to the urethra may provide catheterization-free urination via the nat ural urine pathway, the urethra. 7-9• 11• 12 Therefore, the quality of life may be much improved. An ideal urinary reservoir or neobladder should meet several requirements, including a low intraluminal pressure, provision of continence, prevention of reflux and preservation of renal function, as well as no metabolic or nutritional problems and least compromised quality of life. To construct a urinary reservoir to replace the bladder a tubularized or detubularized segment of intestine could be used. Schmidbauer et al reported a higher intraluminal pressure in the tubular ilea! segment than the detubularized ileum in an animal study. 1 :i The Camey ilea! neobladder, using a tubular
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CHEN, CHANG AND CHEN
segment of ileum, had a high pressure in the reservoir. 1 ° Chen et al reported involuntary pressure spikes on water manometry of the Kock pouch in 25 % of their patients.14 Reddy and Lange also found high pressure contractions in a tubular segment of sigmoid colon used for bladder reconstruction. 11 These high pressure contractions were considered to endanger the upper urinary tract because of impeding urine drainage into the reservoir. In addition, these pressure spikes would result in frequency and urgency of urination in patients with neobladder construction.10• 11 In regard to the nutritional status, although the ileocecal valve was preserved during construction of the Kock pouch or Camey ileal reservoir, the long-term effect of the possible metabolic change and a deficiency of reabsorption of vitamin B12, folic acid and bile salt using a long segment of terminal ileum for urinary diversion still is a concern.4• 15 Reddy reported a sigmoid colon reservoir for bladder replace ment.9 Most of the U-shaped sigmoid colon was detubularized and a short bottom segment remained nondetubularized. The concern is that this short nondetubularized segment of sigmoid colon may have some impact on the production of bowel con tractions. Also, the tubular segment at the urethrocolonic anas tomosis may cause a direct resistance encountered at this anastomotic site during subsequent urethral catheterizations or cystourethroscopy. This resistance would make urethral catheterization difficult and even dangerous. We used a seg ment of completely detubularized sigmoid colon to construct a neobladder after radical cystoprostatectomy. In our patients, performance of neocystourethroscopy is as easy and safe as conventional cystourethroscopy in a bladder. When a male patient suffered from invasive bladder cancer without involvement of the prostatic urethra and with a normal sigmoid colon, we would consider construction of a completely detubularized sigmoid colon neobladder along with radical cys toprostatectomy. However, technically, this neobladder recon struction is not feasible in all patients. When the length of the sigmoid colon available is not long enough (less than 30 cm.) we would not consider use of the sigmoid colon for neobladder construction. Instead, small bowel would be used. During the same period we changed to use of ileum for construction of a detubularized neobladder after radical cystoprostatectomy be cause of inadequate length of the sigmoid colon in 2 patients. Although the surgical technique of construction of a com pletely detubularized sigmoid colon neobladder is simple, and no colon leakage has been noted in any of our 6 patients for 8 to 20 months, we would suggest that care be taken during ligation of the lateral pedicle to the bladder and during isolation of the sigmoid colon to avoid compromising the vascular supply to the distal rectum, which would potentially result in colon leakage because of ischemia at the anastomosis. Electrolyte abnormality due to reabsorption is of great con cern because of the bowel used to construct a urinary reservoir. In the completely detubularized sigmoid colon neobladder that we describe this probably will not be a problem because the urine will not reflux up the remainder of the colon. In all of our 6 patients the serum electrolytes were within normal limits during the postoperative followup. Urodynamic study showed a low intraluminal pressure during water filling of this completely detubularized sigmoid colon neobladder and an adequate maximal urethral closure pressure in all of our patients. In addition, no involuntary pressure spikes were recorded on cystometry. This low intravesical pres sure and high urethral resistance may provide for good daytime continence without frequency or urgency of urination. Uroflow metry showed a good maximal flow rate in 5 of our 6 patients. This finding may be attributed to appropriate abdominal strain ing and no urethral stricture at the colourethral anastomosis, which occurred in 4 patients who underwent neocystourethros copy. Most patients who underwent bowel neobladder reconstruc tion achieved daytime urinary continence.7-9' 11• 12 All of our 6
patients also achieved satisfactory continence during the day. Usually, a vague feeling of abdominal discomfort or of a drop of urine at the urethral meatus was the warning sign to void. However, 2 of our 6 patients were incontinent at night. This nocturnal urinary incontinence also has been reported to be present in other types of bowel neobladder.8-12 Normally, a physiological simultaneous increase in activity of the external sphincter would occur during filling of the bladder with saline. The increased urethral resistance may prevent urine leakage. In the bowel neobladder this continence mechanism might be ineffective and was considered to be a possible cause of the nocturnal urinary incontinence.16 When urinary incontinence persists implantation of an artificial sphincter around the bul bous urethra may provide continence.7• 17• 18 Some investigators reported stone formation in some patients who underwent Kock pouch urinary diversion.4• 15• 19 Stone for mation was considered to be related to the metal staples used. Although we did not use metal staples during construction of the detubularized sigmoid colon neobladder, 1 of our patients had a suture-centered stone in the neobladder. Because there was no urethral stricture, we believe that the suture may act as a nidus and become incrusted with struvite due to urease secreting bacteria (P. mirabilis) in the urine of the neobladder. In this sigmoid colon neobladder we applied electrohydraulic lithotripsy to fragment the stone ( 1.0 X 0.6 cm.), and removed the stone fragments easily and safely. Although 4 patients had intermittent growth of bacteria in the urine, they were free of symptoms of urinary tract infection. This finding may be attributed to prevention of reflux. Accord ingly, renal function also was preserved. In conclusion, our preliminary experience reveals that the completely detubularized sigmoid colon neobladder can provide the patient with continent urination through the urethra with a good urinary stream during the day. The method avoids a stoma over the abdomen. The patients need not carry an external appliance for collection of urine and quality of life is much improved. In male patients with invasive bladder cancer and an intact prostatic urethra construction of the completely detubularized sigmoid colon neobladder may be an ideal oper ation for bladder substitution after radical cystoprostatectomy. Larger patient numbers and longer followup are necessary to evaluate further this new procedure for bladder replacement. Miss Kai-Chi Fong provided the schematic illustrations. REFERENCES 1. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ilea! reser voir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 2. Kock, N. G., Norlen, L., Philipson, B. M. and Akerlund, S.: The continent ilea! reservoir (Kock pouch) for urinary diversion. World J. Urol., 3: 146, 1985. 3. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ilea! reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 4. Skinner, D. G., Lieskovsky, G. and Boyd, S.: Continent urinary diversion. J. Urol., 141: 1323, 1989. 5. Chen, K.-K., Chang, L. S., Chen, M.-T., Huang, J.-K., Yin, J.-H. and Lin, S.-N.: Clinical experience of Kock pouch continent urinary diversion. Urology, 35: 317, 1990. 6. Roland, R. G., Mitchell, M. E., Bihrle, R., Kahnoski, R. J. and Piser, J. E.: Indiana continent urinary reservoir. J. Urol., 137: 1136, 1987. 7. Thuroff, J. W., Alken, P., Riedmiller, H., Engelmann, U., Jacobi, G. H. and Hohenfellner, R.: The Mainz pouch (mixed augmen tation ileum and cecum) for bladder augmentation and continent diversion. J. Urol., 136: 17, 1986. 8. Camey, M.: Bladder replacement by ileocystoplasty following rad ical cystectomy. World J. Urol., 3: 161, 1985. 9. Reddy, P. K.: Detubularized sigmoid reservoir for bladder replace ment after cystoprostatectomy. Preliminary report of new con figuration. Urology, 29: 625, 1987. 10. Goldwasser, B., Rife, C. C., Benson, R. C., Jr., Furlow, W. L. and
COMPLETELY DETUBULARIZED
11. 12. 13. 14. 15.
Barrett, D. M.: Urodynamic evaluation of patients after the Camey operation. J. UroL, 138: 832, 1987. Reddy, P. K and Lange, P. H.: Bladder replacement with sigmoid colon after radical cystoprostatectomy. Urology, 29: 368, 1987. Ghoneim, M.A., Kock, N. G., Lycke, G. and Shehab El-Din, A. B.: An appliance-free, sphincter-controlled bladder substitute: the urethral Kock pouch. J. Urol., 138: 1150, 1987. Schmidbauer, C. P., Chiang, H. and Raz, S.: The impact of detu bularization on ilea! reservoirs. J. Urol., 138: 1440, 1987. Chen, K-K., Chang, L. S. and Chen, M.-T.: Urodynamic and clinical outcome of Kock pouch continent urinary diversion. J. Urol., 141: 94, 1989. Kock, N. G., Norlen, L. J. and Philipson, B. M.: Management of
smivi:orn 16. 17. 18. 19.
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complications after construction of a continent ileal reservoir for urinary diversion. World J. UroL, 3: 152, 1985. Lytton, B. and Green, D. F.: Urodynamic studies in patients undergoing bladder replacement surgery. J. Urol., 141: 1394, 19890 Reddy, P. K., Lange, P.H. and Fraley, E. E.: Bladder replacement after cystoprostatectomy: efforts to achieve total continence. J. Urol., 138: 495, 1987. Light, J. K. and Scott, F. B.: Total reconstruction of the lower urinary tract using bowel and the artificial urinary sphincter. J. Urol., 131: 953, 1984. Chen, K. K., Chang, L. S., Chen, M. T. and Lee, Y. H.: Electro hydraulic lithotripsy for stones in Kock pouch. Eur. Urol., 16: 110, 1989.
Vol. 146, 311-315, August 1991
Printed in U.S.A.
NEOBLADDER CONSTRUCTION USING COMPLETELY DETUBULARIZED SIGMOID COLON AFTER RADICAL CYSTOPROSTATECTOMY KUANG-KUO CHEN, LUKES. CHANG AND MING-TSUN CHEN From the Division of Urology, Department of Surgery, Veterans General Hospital-Taipei and National Yang-Ming Medical College, Taipei, Taiwan, Republic of China
ABSTRACT
To improve the quality of life of the patient we used completely detubularized sigmoid colon for bladder reconstruction along with radical cystoprostatectomy in 6 men with invasive bladder cancer. Followup was 8 to 20 months. Postoperatively, all of the patients were continent during the day but only 4 (66.7%) were continent at night, although they had to awaken twice to remain dry. N eocystourethroscopy in 4 of the 6 patients revealed no tumor and no stricture at the urethrocolonic anastomosis. However, a stone in the neobladder was found in 1 patient. Urodynamic study of the neobladder showed a low pressure (mean 16.7 cm. water) at the filling phase of water cystometry and an adequate maximal urethral closure pressure (mean 52.0 cm. water) and functional profile length (mean 3.8 cm.). The uroflow rate in all patients was good (1 patient even had a maximal uroflow rate of 31 ml. per second). There was no reflux in any patient. One patient had intestinal obstruction 5 months postoperatively and died 5 months later of widespread metastasis. The remaining 5 patients are alive with a satisfactory quality of life. In conclusion, use of completely detubularized sigmoid colon may be an ideal operation for neobladder construction after radical cystoprostatectomy. KEY WORDS: urinary diversion, bladder neoplasms, sigmoid, colon
Continent supravesical bowel urinary diversion has been considered to be a widely accepted operation among urologists and patients. Different segments of the bowel can be used to construct a reservoir (Kock pouch,1-5 Rowland pouch,6 Mainz pouch,7 Camey reservoir8 and sigmoid colon reservoir9 ) for bladder replacement after radical cystoprostatectomy in pa tients with invasive bladder cancer. Self-catheterization through an abdominal stoma to empty the urine from the reservoir was necessary in some patients who underwent uri nary diversion. -6 These stomal continent urinary diversions cause not only inconvenience but also psychological depression owing to a disfigured body image. Although anastomosis of a loop of bowel to the membranous urethra avoids the disadvan tages of an abdominal stoma and catheterization, a high inci dence of high pressure bowel contractions still may occur in these tubularized bowel segments, which may result in urinary frequency, and nocturnal and diurnal incontinence. 10• To im prove further the quality of life after radical cystoprostatec tomy, we used a segment of completely detubularized sigmoid colon to reconstruct a neobladder. The preliminary results are promising. We report this new alternative of continent urinary diversion. 1
11
PATIENTS AND METHODS
From June 1988 to February 1989, 6 men 40 to 69 years old (mean age 56. 7 years) underwent neobladder construction using completely detubularized sigmoid colon along with radical cys toprostatectomy for invasive bladder cancer. Preoperatively, excretory urography (IVP) showed normal upper urinary tracts and a filling defect in the bladder in all 6 patients. Sonography and computerized tomography (CT) demonstrated that the tumors were still within the bladder. Furthermore, a CT scan revealed no enlargement of the pelvic lymph nodes. Cystoure throscopy with biopsy of the bladder tumor and prostatic ure thra revealed transitional cell carcinoma without involvement Accepted for publication December 14, 1990.
of the prostatic urethra in all 6 patients. Colonoscopy also revealed normal sigmoid colon in all 6 patients. Surgical technique. After the peritoneal cavity is entered through a midline abdominal incision from the symphysis pubis to 2 inches above the umbilicus, formal bilateral pelvic lymph adenectomy is performed followed by standard radical cysto prostatectomy. The prostate is severed at its apex and a speci men of urethral stump is sent for frozen section. A segment of redundant sigmoid colon approximately 30 to 35 cm. long is mobilized out of the descending colon and sigmoid colon to construct the neobladder after frozen section reveals no malig nancy in the urethral stump. A 2-layer closure is made for continuity of the colon. The isolated segment of sigmoid colon is irrigated clean, and then folded in a U shape and distended with normal saline (fig. 1, A). Each ureter is implanted into each corresponding limb of the U-shaped sigmoid colon through a 5 cm. seromuscular incision at the lateral taenia. Then, the entire U-shaped sigmoid colon is completely detubularized through an incision made along the entire length of the medial taenia (fig. 1, B). The 2 medial side walls of the U-shaped detubularized sigmoid colon are approximated with 1 layer of a 3-zero polyglactin continuous suture as the posterior wall of the future neobladder. A 3-zero polyglactin suture is placed to the 2 lateral side walls 1.5 cm. away from the midpoint of the bottom of the U-shaped detubularized sigmoid colon to create an opening for urethral anastomosis (fig. 1, C). Each of the 2 ureters is splinted with a 7F x 90 cm. single J stent. The 2 lateral side walls of the incised sigmoid colon are further approximated with 3-zero polyglactin continuous suture from bottom upward until the half-way point of the anterior wall of the almost-formed reservoir (fig. 1, D ). The colourethral anas tomosis is made around a 20F Foley catheter with 6 interrupted sutures of 2-zero polyglactin. A 22F Foley catheter is inserted into the reservoir through an abdominal stab wound. The 2 single J stents are brought out of the abdominal skin at each side of the abdominal incision through the anterior wall of the sigmoid colon reservoir. The remaining upper half of the an terior wall of the reservoir is closed and the completely detu-
311
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CHEN, CHANG AND CHEN
B
A
D
E
FIG. 1. Completely detubularized sigmoid colon neobladder procedure. A, 30 to 35 cm. segment of sigmoid colon is isolated and folded into U shape. Dotted line indicates incision for complete detubularization. B, each ureter is implanted through lateral taenia at each limb of U segment. Segment of sigmoid colon is completely detubularized along medial taenia. Two medial side walls of detubularized sigmoid colon are approximated. C, 3-zero polyglactin suture is placed to 2 lateral side walls at 1.5 cm. from midpoint of bottom of U detubularized sigmoid colon to create opening for urethral anastomosis. D, each ureter is stented. Lower half of 2 lateral side walls of detubularized sigmoid colon is further sutured as anterior wall of reservoir. E, cola-urethral anastomosis is made on 20F Foley catheter. 22F Foley catheter is inserted into reservoir through abdominal wall. Rest of upper unsutured anterior wall is closed and completely detubularized sigmoid colon neobladder is accomplished.
bularized sigmoid colon neobladder is constructed (fig. 1, E). Two catheters are inserted into the pelvic cavity for drainage. Postoperatively, the drainage catheters are removed when a minimal amount of fluid is drained, usually after 4 to 6 days. The bilateral single J stents are removed at 10 days and the urethral Foley catheter is removed 2 weeks postoperatively. Cystography is performed through the abdominal Foley cathe ter to evaluate reflux or leakage. When neither leakage nor reflux is demonstrated, the abdominal catheter is clamped and the patient is instructed to attempt urethral voiding by abdom inal strain to increase the intra-abdominal pressure. The ab dominal catheter is removed when residual urine is not signif icant, usually 1 month postoperatively. The 6 patients were followed every 1 to 2 months. At fol lowup, a detailed continence history was taken, including the frequency of urination to ensure continence during the day and night, the sign or sensation of bladder fullness, and the neces sity of any protection to remain dry. IVPs and voiding cysto urethrography were done in all 6 patients initially at 4 to 6 months postoperatively and then every year. Serum creatinine, blood urea nitrogen (BUN) and electrolytes (chloride, sodium and potassium) were examined every 3 to 6 months. A urody namic study, including slow-filling (10 ml. per minute) water cystometry, urethral pressure profile and uroflowmetry, was performed in all 6 patients at 3 to 10 months postoperatively. During water cystometry the infusion was discontinued when the patient felt discomfort or when the saline leaked out around the catheter. The total infused volume of saline at this point was defined as the functional bladder capacity. The peak pres sure amplitude on the cystometric recording was defined as maximal intravesical pressure. The pressure at water filling to
half of the amount of functional bladder capacity was defined as filling intravesical pressure. Neocystourethroscopy with bi opsy at the urethrocolonic anastomosis was done every 6 months in 4 patients. A urine specimen was collected for routine analysis and bacterial study at each followup visit. RESULTS
There was no operative mortality. Postoperative followup ranged from 8 to 20 months (mean 14.6 months). Early com plications consisted of 1 patient with deep vein thrombosis of the left lower leg, which was managed with anticoagulant therapy, and the symptoms and signs resolved 2 months later. Late complications included intestinal obstruction caused by an adhesional band 5 months postoperatively in 1 patient and a 1.0 X 0.6 cm. stone in the neobladder 6 months postoperatively in 1. Lysis of the fibrotic band relieved the intestinal obstruc tion. Electrohydraulic lithotripsy was used to remove the stone. Analysis of the stone revealed struvite as the major component. A recurrent stone (4 x 3 mm.), formed around a suture and adherent to the wall of the neobladder, was noted 6 months later and it was removed neocystoscopically. All of our 6 patients were continent during the day within 1 month after they began urethral voiding. They voided urine every 2 to 4 hours. Usually, a vague feeling of low abdominal discomfort or a false feeling of a drop of urine at the urethral meatus was the sign to empty the neobladder. Of the 6 patients 4 (66%) were continent at night: 2 had to awaken twice during the night to remain dry, while the other 2 could remain conti nent at night even without awakening to void if they only drank little water before sleep. The remaining 2 patients were incon-
313
COMPLETELY DETUBULARIZED SIGMOID COLON NEOBLADDER tinent at night because they did not attempt to awaken to void (they used 1 to 2 diapers at night). The postoperative IVP showed no obstructive uropathy in any patient (fig. 2, A). The voiding cystourethrogram also demonstrated no reflux from the neobladder to the upper urinary tract in any patient (fig. 2, B). Serum BUN, creatinine and electrolytes were within normal limits in the 6 patients during the postoperative followup. Neocystourethroscopy re vealed no tumor in the neobladder and no stricture at the urethrocolonic anastomosis in all 4 patients. Biopsy at the urethrocolonic anastomosis showed no recurrent tumor as well. Urodynamic study of the neobladder was performed in all 6 patients 3 to 10 months postoperatively (see table). The pres sure at the filling phase of cystometry was low and there were no involuntary pressure spikes on water cystometry in all 6 patients (fig. 3, A). Uroflowmetry revealed a good maximal flow rate and minimal residual urine (fig. 3, B). The urethral pres sure profile showed an adequate maximal urethral closure pres sure and functional profile length (fig. 3, C). One patient suffered intestinal obstruction 5 months postoperatively and died 5 months later of widespread metastasis. The remaining 5 patients are alive with satisfactory quality of life. Although the urine in the neobladder contained pieces of whitish mucus, the patients never suffered urinary obstruction. Urine culture yielded intermittent growth of bacteria (Proteus mirabilis, Morganella morganii and Enterobacter cloacae) in 4 of the 6 patients. No patient had a symptomatic urinary tract infection.
A
Volune (ml)
Voided volume: Maximal flow rate: Mean flow rate: B Residual urine:
420 ml 21 ml/sec 9e1 ml/sec 15 ml
DISCUSSION
Continent urinary diversion via catheterization through an abdominal stoma has been considered to be one of the ideal
Length (cm)
C
FIG. 2. A, IVP shows normal upper urinary tract in patient 6 months after construction of completely detubularized sigmoid colon neoblad der. B, voiding cystourethrogram shows no reflux in patient 6 months postoperatively. Urodynamic studies in 6 patients
Cystometry: Filling intravesical pressure (cm. water)
Maximal intravesical pressure
(cm. water) Functional bladder capacity (ml.) Urethral pressure profile: Maximal urethral closure pressure (cm. water) Functional profile length (cm.) Uroflowmetry: Voidedv�l. (ml.) Mean flow rate (ml./sec.) Maximal flow rate (ml./sec.)
Mean± Standard Deviation
Range
16.7± 6.2
14-28
49.0± 9.7
26-60
310.0± 61.3
220-460
52.0± 16.8
22-66
3.8± 0.9
2.5-4.5
279.2 7.5 18.5
113.4 5.0 7.1
200-450 3.0-16 10-31
Maximal urethral closure pressure: 62 cm H20 Functional profile length: 2.5 cm
FIG. 3. Urodynamic study of completely detubularized sigmoid co lon neobladder. A, water cystometry shows low pressure and no invol untary pressure spikes in patient 4 months postoperatively. B, uroflow metry shows good mean and maximal uroflow rate 6 months postop eratively. C, urethral pressure profile demonstrates adequate maximal urethral closure pressure and functional profile length 6- months post operatively. procedures for bladder reconstruction. Although the patient need not carry an external collecting device for urine, an abdominal stoma as a disfigurement of the body usually has a negative psychological impact. In addition, intermittent cath eterization still is inconvenient in daily life. For most patients, a nonstomal bowel urinary reservoir with connection to the urethra may provide catheterization-free urination via the nat ural urine pathway, the urethra. 7-9• 11• 12 Therefore, the quality of life may be much improved. An ideal urinary reservoir or neobladder should meet several requirements, including a low intraluminal pressure, provision of continence, prevention of reflux and preservation of renal function, as well as no metabolic or nutritional problems and least compromised quality of life. To construct a urinary reservoir to replace the bladder a tubularized or detubularized segment of intestine could be used. Schmidbauer et al reported a higher intraluminal pressure in the tubular ilea! segment than the detubularized ileum in an animal study. 1 :i The Camey ilea! neobladder, using a tubular
314
CHEN, CHANG AND CHEN
segment of ileum, had a high pressure in the reservoir. 1 ° Chen et al reported involuntary pressure spikes on water manometry of the Kock pouch in 25 % of their patients.14 Reddy and Lange also found high pressure contractions in a tubular segment of sigmoid colon used for bladder reconstruction. 11 These high pressure contractions were considered to endanger the upper urinary tract because of impeding urine drainage into the reservoir. In addition, these pressure spikes would result in frequency and urgency of urination in patients with neobladder construction.10• 11 In regard to the nutritional status, although the ileocecal valve was preserved during construction of the Kock pouch or Camey ileal reservoir, the long-term effect of the possible metabolic change and a deficiency of reabsorption of vitamin B12, folic acid and bile salt using a long segment of terminal ileum for urinary diversion still is a concern.4• 15 Reddy reported a sigmoid colon reservoir for bladder replace ment.9 Most of the U-shaped sigmoid colon was detubularized and a short bottom segment remained nondetubularized. The concern is that this short nondetubularized segment of sigmoid colon may have some impact on the production of bowel con tractions. Also, the tubular segment at the urethrocolonic anas tomosis may cause a direct resistance encountered at this anastomotic site during subsequent urethral catheterizations or cystourethroscopy. This resistance would make urethral catheterization difficult and even dangerous. We used a seg ment of completely detubularized sigmoid colon to construct a neobladder after radical cystoprostatectomy. In our patients, performance of neocystourethroscopy is as easy and safe as conventional cystourethroscopy in a bladder. When a male patient suffered from invasive bladder cancer without involvement of the prostatic urethra and with a normal sigmoid colon, we would consider construction of a completely detubularized sigmoid colon neobladder along with radical cys toprostatectomy. However, technically, this neobladder recon struction is not feasible in all patients. When the length of the sigmoid colon available is not long enough (less than 30 cm.) we would not consider use of the sigmoid colon for neobladder construction. Instead, small bowel would be used. During the same period we changed to use of ileum for construction of a detubularized neobladder after radical cystoprostatectomy be cause of inadequate length of the sigmoid colon in 2 patients. Although the surgical technique of construction of a com pletely detubularized sigmoid colon neobladder is simple, and no colon leakage has been noted in any of our 6 patients for 8 to 20 months, we would suggest that care be taken during ligation of the lateral pedicle to the bladder and during isolation of the sigmoid colon to avoid compromising the vascular supply to the distal rectum, which would potentially result in colon leakage because of ischemia at the anastomosis. Electrolyte abnormality due to reabsorption is of great con cern because of the bowel used to construct a urinary reservoir. In the completely detubularized sigmoid colon neobladder that we describe this probably will not be a problem because the urine will not reflux up the remainder of the colon. In all of our 6 patients the serum electrolytes were within normal limits during the postoperative followup. Urodynamic study showed a low intraluminal pressure during water filling of this completely detubularized sigmoid colon neobladder and an adequate maximal urethral closure pressure in all of our patients. In addition, no involuntary pressure spikes were recorded on cystometry. This low intravesical pres sure and high urethral resistance may provide for good daytime continence without frequency or urgency of urination. Uroflow metry showed a good maximal flow rate in 5 of our 6 patients. This finding may be attributed to appropriate abdominal strain ing and no urethral stricture at the colourethral anastomosis, which occurred in 4 patients who underwent neocystourethros copy. Most patients who underwent bowel neobladder reconstruc tion achieved daytime urinary continence.7-9' 11• 12 All of our 6
patients also achieved satisfactory continence during the day. Usually, a vague feeling of abdominal discomfort or of a drop of urine at the urethral meatus was the warning sign to void. However, 2 of our 6 patients were incontinent at night. This nocturnal urinary incontinence also has been reported to be present in other types of bowel neobladder.8-12 Normally, a physiological simultaneous increase in activity of the external sphincter would occur during filling of the bladder with saline. The increased urethral resistance may prevent urine leakage. In the bowel neobladder this continence mechanism might be ineffective and was considered to be a possible cause of the nocturnal urinary incontinence.16 When urinary incontinence persists implantation of an artificial sphincter around the bul bous urethra may provide continence.7• 17• 18 Some investigators reported stone formation in some patients who underwent Kock pouch urinary diversion.4• 15• 19 Stone for mation was considered to be related to the metal staples used. Although we did not use metal staples during construction of the detubularized sigmoid colon neobladder, 1 of our patients had a suture-centered stone in the neobladder. Because there was no urethral stricture, we believe that the suture may act as a nidus and become incrusted with struvite due to urease secreting bacteria (P. mirabilis) in the urine of the neobladder. In this sigmoid colon neobladder we applied electrohydraulic lithotripsy to fragment the stone ( 1.0 X 0.6 cm.), and removed the stone fragments easily and safely. Although 4 patients had intermittent growth of bacteria in the urine, they were free of symptoms of urinary tract infection. This finding may be attributed to prevention of reflux. Accord ingly, renal function also was preserved. In conclusion, our preliminary experience reveals that the completely detubularized sigmoid colon neobladder can provide the patient with continent urination through the urethra with a good urinary stream during the day. The method avoids a stoma over the abdomen. The patients need not carry an external appliance for collection of urine and quality of life is much improved. In male patients with invasive bladder cancer and an intact prostatic urethra construction of the completely detubularized sigmoid colon neobladder may be an ideal oper ation for bladder substitution after radical cystoprostatectomy. Larger patient numbers and longer followup are necessary to evaluate further this new procedure for bladder replacement. Miss Kai-Chi Fong provided the schematic illustrations. REFERENCES 1. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ilea! reser voir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 2. Kock, N. G., Norlen, L., Philipson, B. M. and Akerlund, S.: The continent ilea! reservoir (Kock pouch) for urinary diversion. World J. Urol., 3: 146, 1985. 3. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ilea! reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 4. Skinner, D. G., Lieskovsky, G. and Boyd, S.: Continent urinary diversion. J. Urol., 141: 1323, 1989. 5. Chen, K.-K., Chang, L. S., Chen, M.-T., Huang, J.-K., Yin, J.-H. and Lin, S.-N.: Clinical experience of Kock pouch continent urinary diversion. Urology, 35: 317, 1990. 6. Roland, R. G., Mitchell, M. E., Bihrle, R., Kahnoski, R. J. and Piser, J. E.: Indiana continent urinary reservoir. J. Urol., 137: 1136, 1987. 7. Thuroff, J. W., Alken, P., Riedmiller, H., Engelmann, U., Jacobi, G. H. and Hohenfellner, R.: The Mainz pouch (mixed augmen tation ileum and cecum) for bladder augmentation and continent diversion. J. Urol., 136: 17, 1986. 8. Camey, M.: Bladder replacement by ileocystoplasty following rad ical cystectomy. World J. Urol., 3: 161, 1985. 9. Reddy, P. K.: Detubularized sigmoid reservoir for bladder replace ment after cystoprostatectomy. Preliminary report of new con figuration. Urology, 29: 625, 1987. 10. Goldwasser, B., Rife, C. C., Benson, R. C., Jr., Furlow, W. L. and
COMPLETELY DETUBULARIZED
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complications after construction of a continent ileal reservoir for urinary diversion. World J. UroL, 3: 152, 1985. Lytton, B. and Green, D. F.: Urodynamic studies in patients undergoing bladder replacement surgery. J. Urol., 141: 1394, 19890 Reddy, P. K., Lange, P.H. and Fraley, E. E.: Bladder replacement after cystoprostatectomy: efforts to achieve total continence. J. Urol., 138: 495, 1987. Light, J. K. and Scott, F. B.: Total reconstruction of the lower urinary tract using bowel and the artificial urinary sphincter. J. Urol., 131: 953, 1984. Chen, K. K., Chang, L. S., Chen, M. T. and Lee, Y. H.: Electro hydraulic lithotripsy for stones in Kock pouch. Eur. Urol., 16: 110, 1989.