- Email: [email protected]
Simplified Indiana pouch with multiple teniamyotomies
ADULT UROLOGY
SIMPLIFIED INDIANA POUCH WITH MULTIPLE TENIAMYOTOMIES M. GALLUCCI, C. LEONARDO, S. GUAGLIANONE, A. ROCCHEGGIANI, A. ALCINI, G. P. FLAMMIA, AND E. FORESTIERE
ABSTRACT Objectives. To describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouch with multiple teniamyotomies without detubularization and reconfiguration. Methods. From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique using teniamyotomies without detubularization and reconfiguration. The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. The efferent tract of the reservoir was prepared using the appendix. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed. Results. The mean follow-up was 3 years (range 1 to 5). Continence was excellent for 40 patients (91%); in 4 patients (9%), daytime incontinence was reported. The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). Long-term complications occurred in 15 patients (34%), with a mean onset of 13.4 months postoperatively. Conclusions. Our experience showed that a modified Indiana pouch with multiple teniamyotomies has a good capacity with low internal pressure and good continence. Thus, even with the comparable results of other continent pouch models, our modified Indiana pouch is a valid alternative because of its simplicity to perform. UROLOGY 67: 93–96, 2006. © 2006 Elsevier Inc.
A
variety of detubularized bowel segments have been used to construct continent urinary reservoirs with the stoma on the abdominal wall. The major stomal urinary reservoirs have used detubularized ileum (Kock) and detubularized right colon with or without a patch of ileum (Mainz and Indiana). Since its introduction, the Indiana pouch has gained popularity as a form of continent urinary diversion. We describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouches with multiple teniamyotomies without detubularization and reconfiguration. Avoiding detubularization, sectioning the tenia improved the reservoir morphology and reduced internal pressure and wall distension, limiting the potential complications of the operation. From the Department of Urology, Regina Elena Cancer Institute, Rome, Italy Reprint requests: Costantino Leonardo, M.D., Department of Urology, Regina Elena Cancer Institute, Via Berengario 10, Rome 00162, Italy. E-mail: [email protected] Submitted: March 23, 2005, accepted (with revisions): July 27, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
MATERIAL AND METHODS From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique with teniamyotomies. The mean patient age was 40.7 years, and in this series all but one of the patients were women. The indications for surgery are presented in Table I. Preoperatively, patients underwent assessment of serum electrolytes and creatinine, cystoscopy, chest x-ray, excretory urography, computed tomography, or magnetic resonance imaging. Moreover, they underwent instruction for pouch training and care by an enterostomal nurse, including catheterization and irrigation protocols. Blood loss, operative time, hospitalization, and intraoperative mortality were evaluated for all patients. Patients were routinely evaluated at 4-month intervals for the first year, 6-month intervals in the second year, and yearly thereafter. Follow-up included a complete physical examination, serum electrolyte and creatinine assessment, and ultrasonography or computed tomography. Excretory urography and pouchography were performed 6 weeks postoperatively and yearly thereafter. Nine months after surgery, urodynamic studies were performed on 42 patients by the same investigator (A.R.) using a multichannel system (Urodesk 300, Siem, Milan, Italy). Before cystometry, the pouch was emptied through the stoma. The pouch was then filled with 20°C sterile water with a filling speed of 50 mL/min. The pouch was filled 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.07.054 93
TABLE I. Indications for surgery Diagnosis
Patients (n)
Gynecologic tumor Urethral tumor Bladder cancer Neurogenic bladder Exstrophic bladder
19 1 15 6 3
FIGURE 2. Intraoperative image of multiple teniamyotomies.
FIGURE 1. Multiple teniamyotomies.
until one of the following occurred: discomfort, leakage, or a volume of 600 mL was reached. The urodynamic variables analyzed included the pressure at 350 mL of capacity, pressure at maximal capacity, and closure pressure in the efferent tract. All patients completed a continence questionnaire. During urodynamic evaluation, continence was objectively assessed. Continence was strictly defined as complete dryness. After standard radical cystectomy, the reconstructive time started with the isolation of 8 to 10 cm of terminal ileum and 25 to 30 cm of cecum and ascending colon. The digestive tract was reconstructed with a terminal lateral ileocolostomy using a stapler device. Next, multiple transverse teniamyotomies were performed by scalpel (Figs. 1 and 2). The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. They were performed with the reservoir filled with about 100 mL of saline to allow good exposure of the submucosal layer. Five teniamyotomies were standard; however, in some patients, depending on their anatomic physiologic characteristics, more teniamyotomies (to a maximum of eight) were necessary to relax the wall successfully. The appendix was preferably used as a continence mechanism, and a ureteroileal anastomosis was performed as described by Wallace1 (Fig. 3). If it was unsuitable, a direct ureterocolic anastomosis was performed. The efferent tract of the reservoir was prepared using the appendix as shown in Figures 4 and 5. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed.
RESULTS In 25 patients, an efferent tract was created with the appendix and in 19 patients with ileum. The 94
FIGURE 3. Ureteroileal anastomosis as described by Wallace.
mean blood loss was 300 mL (range 150 to 500), mean operative time 180 minutes (range 150 to 220), mean operative reconstructive time 55 minutes (range 45 to 70), and mean hospitalization time 11.6 days (range 10 to 14). No intraoperative mortality occurred. The mean follow-up was 3 years (range 1 to 5). All the patients were available for follow-up. Continence was excellent for 40 patients (91%); in 4 patients, daytime incontinence was reported (9%). The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (range 400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). The closure pressure in the efferent tract was 90 cm H2O in the appendicostomy and 70 cm H2O in the ileostomy. Six patients affected by urinary tumor and five UROLOGY 67 (1), 2006
TABLE II. Long-term complications Complication
Patients (%)
Difficult catheterization Stomal stenosis Pouch stones Ureteral stricture Small bowel obstruction
5 (11) 2 (4.2) 3 (6.8) 2 (4.5) 1 (2.2)
value before surgery and at the last follow-up visit was 26.5 and 27.8 mmol/L, respectively. COMMENT
FIGURE 4. Appendix preparation.
FIGURE 5. Umbilical appendicostomy.
affected by gynecologic tumor developed metastatic progression resulting in death. Long-term complications occurred in 13 patients (30%), with a mean onset of 13.4 months postoperatively. Seven complications (16%) were due to the efferent limb, with difficult catheterization the most common (5 patients [11%]), followed by stomal stenosis in 2 patients (4.5%) that required reoperation. Three pouch-related problems that occurred were stones (6.8%), which were treated with a percutaneous approach. Ureteral anastomotic strictures were seen in 2 patients (4.5%) and required ureteroileal reimplantation. Small bowel obstruction occurred in 1 patient (2.2%). The long-term complications are summarized in Table II. The mean serum creatinine value before surgery and at the last follow-up visit was 87.4 and 87.6 mol/L, respectively. The mean serum bicarbonate UROLOGY 67 (1), 2006
Since its introduction by Rowland et al.,2 the Indiana pouch has gained popularity, and a few modifications have kept it relatively simple. Moreover, most series have reported few complications and a low revision rate.2,3 The technique used in the construction of the continent diversion is a critical element in the development of complications. For this reason, we have described our retrospective experience with 44 modified Indiana pouches with teniamyotomies. In 1997, Alcini et al.4 evaluated the results of long-term follow-up of ileocecal urethrostomy with multiple transverse teniamyotomies for bladder replacement. The method allowed an ileocecal segment to be used with no detubularization. The intestinal wall tension and internal pressure were reduced using transverse teniamyotomies of the cecum. On the basis of the theory that teniamyotomies can achieve the same goals as detubularization, we have performed the Indiana pouch since 1999, avoiding detubularization and sectioning the teniae to improve reservoir morphology and reduce internal pressure and wall distension, limiting the potential complications of the operation. Our overall continence rate of 91% is similar to that reported in other series.5,6 However, incontinence occurred in cases in which compliance with the catheterization schedule was a problem. Urodynamic data showed good capacity and pressure at maximal capacity. Most of the complications were related to the efferent limb, which is the most delicate part of the reconstruction. Difficulty with catheterization and stomal stenosis accounted for one half of the complications. Difficulty with catheterization, stomal stenosis, and pouch stones are complications that become more frequent with time. The development of pouch stones was the next most common complication. The presentation included pain, urinary tract infection, incontinence, and trouble catheterizing. The stones were often multiple, and some were quite large. The percutaneous approach was usually successful.7 Analysis 95
revealed compositions ranging from calcium apatite to struvite with a mucous nidus. Our ureteral anastomotic strictures rate of 4.5% is similar to the 7% reported by Holmes et al.6 CONCLUSIONS Our experience demonstrated that modified Indiana pouch creation with multiple teniamyotomies has good capacity with low internal pressure and good continence. When comparing the complications of our series with others, no appreciable difference was seen.6,8 –10 Thus, with comparable results to those of other continent pouch models, our modified Indiana pouch has proved a valid alternative because of the simplicity of performing the procedure and the reduced operating time. Verifying our findings with another cohort and long-term follow-up is necessary to assess the efficacy of this procedure. REFERENCES 1. Wallace DM: Ureteric diversion using a conduit: a simplified techique. Br J Urol 38: 522–527, 1966.
96
2. Rowland RG, Mitchell ME, and Bihrle R: Indiana continent urinary reservoir. J Urol 137: 1136 –1139, 1987. 3. Rowland RG, and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 152: 2247–2251, 1994. 4. Alcini E, Racioppi M, D’Addessi A, et al: The ileocaecourethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders—morphological, functional and metabolic results after 9 years’ experience. Br J Urol 79: 333–338, 1997. 5. Bihrle R: The Indiana pouch continent urinary reservoir. Urol Clin North Am 24: 773–779, 1997. 6. Holmes DG, Thrasher JB, Park GY, et al: Long-term complications related to the modified Indiana pouch. Urology 60: 603– 606, 2002. 7. Raso DM, Gallucci M, Leonardo C, et al: Urinary stones in Indiana pouch: a new endoscopic treatment. J Endourol 17(suppl 1): 275–276, 2003. 8. Wilson TG, Moreno JG, Weinberg A, et al: Late complications of the modified Indiana pouch. J Urol 151: 331–334, 1994. 9. Arai Y, Kawakita M, Terachi T, et al: Long-term followup of the Kock and Indiana pouch procedures. J Urol 150: 51–55, 1993. 10. Weijerman PC, Schurmans JR, Hop WC, et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology 51: 51– 56, 1998.
UROLOGY 67 (1), 2006
SIMPLIFIED INDIANA POUCH WITH MULTIPLE TENIAMYOTOMIES M. GALLUCCI, C. LEONARDO, S. GUAGLIANONE, A. ROCCHEGGIANI, A. ALCINI, G. P. FLAMMIA, AND E. FORESTIERE
ABSTRACT Objectives. To describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouch with multiple teniamyotomies without detubularization and reconfiguration. Methods. From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique using teniamyotomies without detubularization and reconfiguration. The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. The efferent tract of the reservoir was prepared using the appendix. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed. Results. The mean follow-up was 3 years (range 1 to 5). Continence was excellent for 40 patients (91%); in 4 patients (9%), daytime incontinence was reported. The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). Long-term complications occurred in 15 patients (34%), with a mean onset of 13.4 months postoperatively. Conclusions. Our experience showed that a modified Indiana pouch with multiple teniamyotomies has a good capacity with low internal pressure and good continence. Thus, even with the comparable results of other continent pouch models, our modified Indiana pouch is a valid alternative because of its simplicity to perform. UROLOGY 67: 93–96, 2006. © 2006 Elsevier Inc.
A
variety of detubularized bowel segments have been used to construct continent urinary reservoirs with the stoma on the abdominal wall. The major stomal urinary reservoirs have used detubularized ileum (Kock) and detubularized right colon with or without a patch of ileum (Mainz and Indiana). Since its introduction, the Indiana pouch has gained popularity as a form of continent urinary diversion. We describe a retrospective review of a single-institution, single-surgeon (M.G.) experience with 44 simplified Indiana pouches with multiple teniamyotomies without detubularization and reconfiguration. Avoiding detubularization, sectioning the tenia improved the reservoir morphology and reduced internal pressure and wall distension, limiting the potential complications of the operation. From the Department of Urology, Regina Elena Cancer Institute, Rome, Italy Reprint requests: Costantino Leonardo, M.D., Department of Urology, Regina Elena Cancer Institute, Via Berengario 10, Rome 00162, Italy. E-mail: [email protected] Submitted: March 23, 2005, accepted (with revisions): July 27, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
MATERIAL AND METHODS From April 1999 to May 2003, 44 patients underwent radical cystectomy and continent urinary diversion with a simplified Indiana pouch technique with teniamyotomies. The mean patient age was 40.7 years, and in this series all but one of the patients were women. The indications for surgery are presented in Table I. Preoperatively, patients underwent assessment of serum electrolytes and creatinine, cystoscopy, chest x-ray, excretory urography, computed tomography, or magnetic resonance imaging. Moreover, they underwent instruction for pouch training and care by an enterostomal nurse, including catheterization and irrigation protocols. Blood loss, operative time, hospitalization, and intraoperative mortality were evaluated for all patients. Patients were routinely evaluated at 4-month intervals for the first year, 6-month intervals in the second year, and yearly thereafter. Follow-up included a complete physical examination, serum electrolyte and creatinine assessment, and ultrasonography or computed tomography. Excretory urography and pouchography were performed 6 weeks postoperatively and yearly thereafter. Nine months after surgery, urodynamic studies were performed on 42 patients by the same investigator (A.R.) using a multichannel system (Urodesk 300, Siem, Milan, Italy). Before cystometry, the pouch was emptied through the stoma. The pouch was then filled with 20°C sterile water with a filling speed of 50 mL/min. The pouch was filled 0090-4295/06/$32.00 doi:10.1016/j.urology.2005.07.054 93
TABLE I. Indications for surgery Diagnosis
Patients (n)
Gynecologic tumor Urethral tumor Bladder cancer Neurogenic bladder Exstrophic bladder
19 1 15 6 3
FIGURE 2. Intraoperative image of multiple teniamyotomies.
FIGURE 1. Multiple teniamyotomies.
until one of the following occurred: discomfort, leakage, or a volume of 600 mL was reached. The urodynamic variables analyzed included the pressure at 350 mL of capacity, pressure at maximal capacity, and closure pressure in the efferent tract. All patients completed a continence questionnaire. During urodynamic evaluation, continence was objectively assessed. Continence was strictly defined as complete dryness. After standard radical cystectomy, the reconstructive time started with the isolation of 8 to 10 cm of terminal ileum and 25 to 30 cm of cecum and ascending colon. The digestive tract was reconstructed with a terminal lateral ileocolostomy using a stapler device. Next, multiple transverse teniamyotomies were performed by scalpel (Figs. 1 and 2). The tenia was sectioned across the whole width and deepened as far as the submucosal layer, with 2 to 3 cm between each teniamyotomy. They were performed with the reservoir filled with about 100 mL of saline to allow good exposure of the submucosal layer. Five teniamyotomies were standard; however, in some patients, depending on their anatomic physiologic characteristics, more teniamyotomies (to a maximum of eight) were necessary to relax the wall successfully. The appendix was preferably used as a continence mechanism, and a ureteroileal anastomosis was performed as described by Wallace1 (Fig. 3). If it was unsuitable, a direct ureterocolic anastomosis was performed. The efferent tract of the reservoir was prepared using the appendix as shown in Figures 4 and 5. If it was unsuitable, an ileum invagination nipple fixed in the ileocecal valve was constructed.
RESULTS In 25 patients, an efferent tract was created with the appendix and in 19 patients with ileum. The 94
FIGURE 3. Ureteroileal anastomosis as described by Wallace.
mean blood loss was 300 mL (range 150 to 500), mean operative time 180 minutes (range 150 to 220), mean operative reconstructive time 55 minutes (range 45 to 70), and mean hospitalization time 11.6 days (range 10 to 14). No intraoperative mortality occurred. The mean follow-up was 3 years (range 1 to 5). All the patients were available for follow-up. Continence was excellent for 40 patients (91%); in 4 patients, daytime incontinence was reported (9%). The urodynamic studies showed an average pressure at 350 mL of capacity of 19.6 cm H2O (range 15.1 to 25.5). The average pressure at maximal capacity (range 400 to 600 mL) was 32.3 cm H2O (range 28.5 to 35). The closure pressure in the efferent tract was 90 cm H2O in the appendicostomy and 70 cm H2O in the ileostomy. Six patients affected by urinary tumor and five UROLOGY 67 (1), 2006
TABLE II. Long-term complications Complication
Patients (%)
Difficult catheterization Stomal stenosis Pouch stones Ureteral stricture Small bowel obstruction
5 (11) 2 (4.2) 3 (6.8) 2 (4.5) 1 (2.2)
value before surgery and at the last follow-up visit was 26.5 and 27.8 mmol/L, respectively. COMMENT
FIGURE 4. Appendix preparation.
FIGURE 5. Umbilical appendicostomy.
affected by gynecologic tumor developed metastatic progression resulting in death. Long-term complications occurred in 13 patients (30%), with a mean onset of 13.4 months postoperatively. Seven complications (16%) were due to the efferent limb, with difficult catheterization the most common (5 patients [11%]), followed by stomal stenosis in 2 patients (4.5%) that required reoperation. Three pouch-related problems that occurred were stones (6.8%), which were treated with a percutaneous approach. Ureteral anastomotic strictures were seen in 2 patients (4.5%) and required ureteroileal reimplantation. Small bowel obstruction occurred in 1 patient (2.2%). The long-term complications are summarized in Table II. The mean serum creatinine value before surgery and at the last follow-up visit was 87.4 and 87.6 mol/L, respectively. The mean serum bicarbonate UROLOGY 67 (1), 2006
Since its introduction by Rowland et al.,2 the Indiana pouch has gained popularity, and a few modifications have kept it relatively simple. Moreover, most series have reported few complications and a low revision rate.2,3 The technique used in the construction of the continent diversion is a critical element in the development of complications. For this reason, we have described our retrospective experience with 44 modified Indiana pouches with teniamyotomies. In 1997, Alcini et al.4 evaluated the results of long-term follow-up of ileocecal urethrostomy with multiple transverse teniamyotomies for bladder replacement. The method allowed an ileocecal segment to be used with no detubularization. The intestinal wall tension and internal pressure were reduced using transverse teniamyotomies of the cecum. On the basis of the theory that teniamyotomies can achieve the same goals as detubularization, we have performed the Indiana pouch since 1999, avoiding detubularization and sectioning the teniae to improve reservoir morphology and reduce internal pressure and wall distension, limiting the potential complications of the operation. Our overall continence rate of 91% is similar to that reported in other series.5,6 However, incontinence occurred in cases in which compliance with the catheterization schedule was a problem. Urodynamic data showed good capacity and pressure at maximal capacity. Most of the complications were related to the efferent limb, which is the most delicate part of the reconstruction. Difficulty with catheterization and stomal stenosis accounted for one half of the complications. Difficulty with catheterization, stomal stenosis, and pouch stones are complications that become more frequent with time. The development of pouch stones was the next most common complication. The presentation included pain, urinary tract infection, incontinence, and trouble catheterizing. The stones were often multiple, and some were quite large. The percutaneous approach was usually successful.7 Analysis 95
revealed compositions ranging from calcium apatite to struvite with a mucous nidus. Our ureteral anastomotic strictures rate of 4.5% is similar to the 7% reported by Holmes et al.6 CONCLUSIONS Our experience demonstrated that modified Indiana pouch creation with multiple teniamyotomies has good capacity with low internal pressure and good continence. When comparing the complications of our series with others, no appreciable difference was seen.6,8 –10 Thus, with comparable results to those of other continent pouch models, our modified Indiana pouch has proved a valid alternative because of the simplicity of performing the procedure and the reduced operating time. Verifying our findings with another cohort and long-term follow-up is necessary to assess the efficacy of this procedure. REFERENCES 1. Wallace DM: Ureteric diversion using a conduit: a simplified techique. Br J Urol 38: 522–527, 1966.
96
2. Rowland RG, Mitchell ME, and Bihrle R: Indiana continent urinary reservoir. J Urol 137: 1136 –1139, 1987. 3. Rowland RG, and Kropp BP: Evolution of the Indiana continent urinary reservoir. J Urol 152: 2247–2251, 1994. 4. Alcini E, Racioppi M, D’Addessi A, et al: The ileocaecourethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders—morphological, functional and metabolic results after 9 years’ experience. Br J Urol 79: 333–338, 1997. 5. Bihrle R: The Indiana pouch continent urinary reservoir. Urol Clin North Am 24: 773–779, 1997. 6. Holmes DG, Thrasher JB, Park GY, et al: Long-term complications related to the modified Indiana pouch. Urology 60: 603– 606, 2002. 7. Raso DM, Gallucci M, Leonardo C, et al: Urinary stones in Indiana pouch: a new endoscopic treatment. J Endourol 17(suppl 1): 275–276, 2003. 8. Wilson TG, Moreno JG, Weinberg A, et al: Late complications of the modified Indiana pouch. J Urol 151: 331–334, 1994. 9. Arai Y, Kawakita M, Terachi T, et al: Long-term followup of the Kock and Indiana pouch procedures. J Urol 150: 51–55, 1993. 10. Weijerman PC, Schurmans JR, Hop WC, et al: Morbidity and quality of life in patients with orthotopic and heterotopic continent urinary diversion. Urology 51: 51– 56, 1998.
UROLOGY 67 (1), 2006