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The Mainz Pouch (Mixed Augmentation Ileum and Cecum) for Bladder Augmentation and Continent Diversion
0022-534'/ /86/1361-0017$02.00/0 THE JOURNAL OF UROLOGY
Copyright@ 1986 by The Williams & Wilkins Co.
THE MAINZ POUCH (MIXED AUGMENTATION ILEUlVi AND CECUM) FOR BLADDER AUGMENTATION AND CONTINENT DIVERSION J. W. THUROFF,* P. ALKEN, H. RIEDMILLER, U. ENGELMANN, G. H. JACOBI
AND
R. HOHENFELLNER From the Department of Urology, Johannes Gutenberg University, Medical School, Mainz, Federal Republic of Germany
ABSTRACT
The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: 1) creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, 2) antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and 3) in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis. In 1912 Lemoine anastomosed the rectum to the urethra for total bladder replacement, with voluntary control of micturition by the urethral sphincter and end-to-end anastomosis of the sigmoid colon to the anal sphincter. 10 In 1950 Couvelaire reported bladder augmentation using cecum,1 1 and since then there have been numerous reports on the use of cecum for bladder augmentation12- 22 or complete bladder replacement. 13• 23 An isolated ileocecal segment also has been applied for bladder augmentation, in some cases combined with ureteral replacement22 • 24- 33 or for complete bladder replacement. 34, 35 Stoeckel introduced use of a segment of sigmoid colon for bladder augmentation in 1918. 36 Mathisen used a sigmoid patch for the same purpose in 1955. 37 Total bladder replacement by sigmoid colon anastomosed to the urethra after cystectomy was performed experimentally by Bisgard in 1943 38 and was applied clinically Gil Vernet. 39 In 1908 Verhoogen experimentally used cecum and appendix for supravesical urinary diversion. 40 This was applied Makkas in 1910. Attempts to successfully in a patient achieve continence in supravesical urinary diversion by ~se of the ileocecal segment were abandoned Bricker in 195042 in favor of the simpler technique of ileal loop diversion. Gilchrist and associates also used an ileocecal segment for continent supravesical diversion with the cecum as reservoir and the ileocecal valve in conjunction with the ileal peristalsis as a continence providing mechanism for the ilea! stoma. 43 Excellent results regarding continence were reported, 44 • 45 while other reports were not so favorable. 46 · 47 In 1969 Kock devised a continent ileostomy reservoir for proctocolectomized patients 48 and it was used first in 1975 for continent supravesical urinary diversion. 49 In this ileal pouch the mechanism for continence as well as for prevention of ureteral reflux is based on an ileal intussusception valve as devised by Perl in 1949. 50 Based on experiments by Basso, 51 Smith and Hinman first used an ileal intussusception valve in the urinary tract of dogs for continent ileocystostomy. 52 Others have reported on continent ileal pouch urinary diversion with a technique similar to that devised by
For successful restoration of function, surgical construction of a bladder from bowel must fulfill the requirements of 1) creation of a low pressure reservoir of adequate capacity, 2) antirefluxing ureteral implantation that avoids obstruction and 3) reliable control of continence with easy emptying of the reservoir. Enterocystoplasty can be criticized as a tedious, time-con suming operation, with unreliable functional results regarding residual urine, vesicoureteral reflux and continence-the latter especially when the bladder is replaced completely by boweL 1 Furthermore, there are objections against enterocystoplasty for bladder replacement after cystectomy in bladder cancer or for complete bladder replacement in women. 1 Nevertheless, there is enormous interest on the part of patients to avoid a urinary stoma and they are willing to undergo reconstruction of the urinary tract to achieve normal functional control of urine storage and emptying. If a stoma cannot be avoided, patients prefer continent urinary diversion to a wet stoma with external ~ollecting devices. Patient acceptance of the principle of continent diversion seems to be dramatic, even if difficulties are experienced and reoperation sometimes is required. 2 For bladder augmentation, small bowel was used first experimentally in 1888 by Tizzoni and Foggi, who anastomosed an ileal loop to the bladder neck of dogs after cystectomy. 3 In 1899 Mikulicz reported enlarging the bladder of a patient by the use of an ileal loop, one end of which was anastomosed to the bladder dome. 4 In the same year Rutkowski used an ileal patch for bladder augmentation, 5 and Tasker fashioned an ileal pouch in 1953. 6 Complete bladder replacement by an ilea! loop anastomosed to the urethra after cystectomy for cancer treatment was reported in 1951 by Couvelaire 7 and since then it has been popularized as the Camey operation. 8 ' 9 Accepted for publication January 31, 1986. Read at annual meeting of American Urological Association, Atlanta, Georgia, May 12-16, 1985. * Requests for reprints: UCSF Urinary Stone Center, 505 Parnassus Ave., M-418, San Francisco, California 94143.
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Kock. 53 - 55 After the followup study of 12 patients reported on by Kock and associates in 1982, 56 Skinner and associates directed attention toward and popularized this technique. 57 After the report of Gilchrist and associates, 43 various other attempts were made to use the cecum as a reservoir. Ashken devised an ileal spout valve as a sphincter mechanism for the cecal reservoir, 58 which later was changed to an ileal flutter valve. 59 Benchekroun used a reversed ileal intussusception ("ink-well" valve) for continent closure of the ileocecal reservoir,60·61 while Zingg and Tscholl, 62 and Mansson and Sundin63 used intussusception of the terminal ileum into the cecum, both of which failed owing to sliding of the intussusception. 59· 64 Later, Mansson changed the technique into an ileoileal intussusception of the terminal ileum with much better results. 64 ln 1984 Lamesch and Dociu reported animal experiments for construction of a continent pouch from sigmoid colon and 2 ileal loops with an ileal intussusception valve for continent closure. 65 Since 1983 we have used a technique to construct a pouch from cecum, ascending colon and 2 ileal loops (mixed augmentation ileum and cecum, Mainz pouch), 66 which combines some of the surgical features of the reviewed techniques, and is applicable for bladder augmentation, continent urinary diversion and complete bladder replacement. MATERIAL AND METHODS
Since 1983 reconstruction of a urinary reservoir using a Mainz pouch was performed on 23 patients, 3 of whom were children (12 female and 11 male patients between 5 and 64 years old, with a mean age of 36 years). The Mainz pouch was used for bladder augmentation in 11 patients (for undiversion in 5). Previous urinary diversion consisted of ureterosigmoidostomy in 1 patient, ileal conduit in 1, bilateral percutaneous nephrostomy in 1 and sigmoid conduit in 2. Indications for bladder augmentation were contracted bladders of various etiology: iatrogenic in 3 patients, neurogenic in 2, tuberculosis in 3 and interstitial cystitis in 3. The Mainz pouch was used for urinary diversion in 12 patients. Indications for urinary diversion were radical cystoprostatectomy for treatment of bladder cancer (8 patients) and neurogenic bladder dysfunction (4). Surgical technique. After appendectomy, the cecum and ascending colon are mobilized up to the right colic flexure. For bladder augmentation, 10 to 15 cm. of cecum and ascending colon, and 2 terminal ileal segments of equal length are outlined by stay sutures (fig. 1, A). For continent urinary diversion the same segments are used to fashion the pouch but 20 to 25 cm. of ileum also must be isolated proximally for ileoileal intussusception (fig. 1, B). After isolation of the ileocecal segment, bowel continuity is restored by an ileocolostomy, which is
accomplished either by single row sutured end-to-end anastomosis after antimesenteric spatulation of the ileum for adjustment of bowel diameter (fig. 2, A and B), or by mechanical end-to-side anastomosis of ileum to ascending colon with the EEA-stapler and the TA 55 stapler for closure of the ascending colon (fig. 2, C and D). The ascending colon, cecum and both terminal ileal segments are split open at their antimesenteric borders (fig. 3, A). For urinary diversion the third proximal ileal segment remains intact (fig. 3, B). The posterior wall of the pouch is completed by side-to-side anastomosis of the ascending colon with the terminal ilea! loop, and of the latter with the next proximal ileal segment (fig. 3, C and D). After a comparison of different techniques of side-to-side anastomosis, including absorbable staples, 66 we found single-row through-and-through running sutures (4-zero polyglyconate, straight needle) to be the most time-saving. For bladder augmentation, the bladder is resected subtotally, with the resection line just below the ureteral orifices, leaving a bladder neck cuff of approximately the size of a silver dollar. If the mesentery is sufficiently long the still open pouch is slid into the small pelvis for anastomosis with the posterior bladder wall (fig. 4, A). If the mesentery is too short the pouch is rotated 180 degrees counterclockwise for an anastomosis free of tension with the posterior wall of the bladder (fig. 4, B). The anastomosis is accomplished by single row through-and-through interrupted sutures of 3 or 4-zero polyglyconate. Since both ureters then are implanted into the large bowel segment, the contralateral ureter must be pulled through retroperitoneally. Ureters are implanted from the open end of the large bowel via a 5 cm. long submucosal tunnel (fig. 4, A and B). The ureters are anchored with 2, 5-zero polyglyconate sutures to the muscle of the bowel wall and the neo-orifices are established by 6-zero ureteral mucosal sutures. The anastomosis with the anterior bladder wall is completed by single row through-and-through interrupted sutures. Closure of the anterior wall of the pouch is accomplished by single row throughand-through running sutures but at the site ofureteral implantation the pouch is closed solely by interrupted mucosa! sutures to prevent ureteral obstruction (fig. 4, C and D). For urinary diversion, the technique basically is the same with ureteral implantation into the ascending colon (fig. 5). As a continence-providing mechanism, isoperistaltic ileoileal intussusception of the antiperistaltic draining loop has been performed in 6 patients. The ileal mesentery is divided directly at the ilea! wall for about 6 cm. for mesenteric exclusion from intussusception (fig. 6, A). To achieve ileoileal intussusception, the mesenteric division should be done 9 cm. away from the pouch. The serosa of the ileum is scarified by electric cautery
B
FIG. 1. Intestinal segment to be isolated. A, Mainz pouch bladder augmentation. B, Mainz pouch continent urinary diversion
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THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
A
B
'///)////• /
C
D
FIG. 2. A and B, single row sutured end-to-end ileocolostomy. C, mechanical end-to-side anastomosis of ileum to ascending colon with EEAstapler. D, blind closure of ascending colon by TA 55 stapler.
over the entire length of intussusception (fig. 6, A to C). Two Allis clamps are introduced into the ileum through the open pouch to grasp the ileal wall at the middle of the mesenteric division (fig. 6, A and B) for stepwise isoperistaltic intussusception. Each step of about 1 cm. of intussusception is secured by a row of 5 to 6 interrupted 4-zero silk serornuscular sutures (fig. 6, B). Alternatively, the intussusception has been stapled with the TA 55 instrument to the intussuscepting ileal wall using 3 to 4 rows of 4.8 mm. metal staples (fig. 6, C). A 1.5 cm. wide fascia! strip is excised from the anterior rectus fascia and wrapped around the base of the intussusception. The fascial strip is anchored to the base of the intussusception as well as to the stomal segment of ileum by multiple interrupted sutures (fig. 6, B). The skin for the stoma is excised in the right hypogastrium and the base of the intussusception is anchored within the abdominal wall by 5 to 6 interrupted sutures connecting the fascial sling around the base of the intussusception and the external abdominal fascia (fig. 6, B and D). As an alternative for sphinteric control, an alloplastic stomal prosthesis for simple mechanical closure has been implanted in 4 patients (fig. 6, E). This specially designed prosthesis 67 consists of a titanium barrel coated with expanded microporous polytetrafluoroethylene (Teflon). Details of design and function of the prosthesis will be reported separately. The pouches are drained by a 26F Foley balloon catheter
and, in cases of bladder augmentation, by an additional 15F cystostomy tube for easy control of residual urine after removal of the transurethral catheter. Two 20F silicone drains are placed, 1 in the small pelvis and 1 at the ureteral implantation site. Ureters are stented for 10 days and pouch catheters are removed after 14 days. At removal the patients are instructed in intermittent catheterization or are asked to void spontaneously, respectively. All 8 patients with bladder cancer underwent simultaneous bilateral pelvic iliac lymph node dissection, radical cystectomy and Mainz pouch urinary diversion. RESULTS
We encountered no operative mortality and 3 major complications. A jejunocutaneous fistula that was caused by faulty placement of a tension suture during closure of the abdominal wall closed spontaneously after removal of the suture. A 9-yearold boy had to be reoperated on 9 days postoperatively for an ileal intussusception ileus, which occurred away from the anastomotic site. Convalescence was complicated further by thrombosis of the upper vena cava secondary to a catheter in the right jugular vein, which was managed conservatively. The third patient (with continent diversion) suffered bleeding into the pouch 5 days postoperatively during a hypertensive crisis in which blood pressure increased to 230/130 mm. Hg. The bleed-
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THUROFF AND ASSOCIATES
C
FIG. 3. Antimesenteric splitting of intestine for bladder augmentation (A) and urinary diversion (B). Side-to-side anastomosis of ascending colon and terminal ilea! segment, and of latter with next proximal loop in bladder augmentation (C) and urinary diversion (D).
ing caused recurrent tamponade of the pouch, which had to be evacuated instrumentally 3 times between 5 and 9 days postoperatively. The patient required 6 units of blood and bleeding finally stopped after continuous rinsing of the pouch via a separately introduced small catheter. Infection of an alloplastic stomal prosthesis finally resulted in removal of the prosthesis after 3 months. The patient was left with the free draining reservoir and is awaiting continent closure by an intussusception valve. Followup ranged from 1 to 20 months, with a mean of 4.8 months. Of the 11 patients in the bladder augmentation group 1 with myelomeningocele had a low bladder capacity of 250 ml. 6 weeks postoperatively, compared to a mean capacity of 528 ml. for the entire group (see table). This patient remains dry only as long as she empties the reservoir every 2 hours by intermittent catheterization. All other patients are completely dry day and night. Both patients with myelomeningocele and bladder augmentation empty the bladder by intermittent catheterization, while all other patients void spontaneously at normal intervals without significant residual urine. Urodynamic studies performed 4 to 8 weeks postoperatively revealed mean resting pressures of 34 cm. water with a half full bladder and 45 cm. water with a full bladder (see table). During urodynamic provocative filling (80 ml. per minute), contractions started at a filling volume of 60 per cent of bladder capacity and peaked at a mean maximum pressure of 60 cm. water (see table) but subsided immediately if the inflow was stopped. All patients voided by abdominal straining and ureteral reflux did not occur (fig. 7). Excretory urography (IVP) revealed the upper tracts either to have remained undilated or else the previous dilatation had improved (fig. 7). In the urinary diversion group 2 patients with Mainz pouch urinary diversion without a continence mechanism, who are awaiting implantation of an alloplastic stomal prosthesis, and 1 patient whose prosthesis was removed because of infection
use the regular external bags for urine collection. All other patients with an alloplastic stomal prosthesis (3) and intussusception valve (6) are continent. Including the incontinent diversion patients, the 4 to 8-week postoperative urodynamic investigations revealed a mean pouch capacity of 467 ml. and all other urodynamic findings in this group closely resembled those in the bladder augmentation group (see table). Ureteral reflux did not occur (figs. 8 and 9). The IVP showed bilateral grade I dilatation of the upper tract 12 weeks postoperatively in 1 patient, bilateral grade II dilatation 4 weeks postoperatively in 1 and unobstructed upper tracts in the remainder (figs. 8 and 9). All patients primarily needed alkalizing drugs to balance hyperchloremic acidosis but, with an increasing followup period, 8 currently are stable without any alkalizing drugs. DISCUSSION
Preliminary results of our operative technique indicate that all requirements for the reconstruction of a urinary reservoir are fulfilled. A low pressure reservoir of adequate capacity is achieved by dissection of circular and spiral muscle fibers of bowel when the intestine is split longitudinally at its antimesenteric border, and by opposing large and small bowel to each other within 1 pouch. This is the same principle as used for ileum alone in the Kock pouch, 48 • 49 • 56 which has been proved functionally to be a low pressure reservoir. 68 Since cecum alone, if used as a reservoir, reveals intraluminal pressures comparable to the Kock pouch, 69 we did not expect adverse effects regarding pressure and capacity from combining it with small bowel. Nevertheless, as seen under fluoroscopic control, contractions of the Mainz pouch derive from the large bowel segment and are dampened or canceled by the small bowel segments of the reservoir. Easy and reliable antirefluxing implantation of ureters was the rationale for adding cecum to the intestinal pouch, as was done in the animal model of Lamesch and Dociu, 65 who added
THE flJ'.AKNZ POUCH FOR BLADDER AUGM:ENTATION AND DIVERSWN
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B
/
/
I I
I
I
I
I I
Vi/
FIG. 4. Anastomosis of posterior wall of pouch to subtotally resected bladder and antirefluxing implantation of ureters without rotation of intestine (A) and after 180-degree counterclockwise rotation of intestine for anastomosis free of tension with short mesentery (B). Operative appearance after complete closure of bladder augmentation without rotation of pouch (C) and after 180-degree rotation of pouch (D).
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THUROFF AND ASSOCIATES
hyperreflexia and a partially denervated sphincter. After undiversion she is continent for up to 2 hours and empties the bladder with intermittent catheterization. All of the remaining patients had urodynamically proved normal sphincteric control, are completely dry day and night after bladder augmentation, and empty the bladder without significant residual urine. The advantages of the Mainz pouch over the conventional methods of bladder augmentation, which obviously have only partially satisfactory results regarding nocturnal continence, residual urine and ureteral reflux, 1 seem first to be the pouch technique and second the antirefluxing implantation of the ureters into the pouch, which allows subtotal cystectomy. This is particularly important in cases of interstitial cystitis and detrusor hyperreflexia. Which method of continence control for Mainz pouch supravesical diversion will be preferable cannot be determined to date. Our type of intussusception valve as devised by Mansson64 is an isoperistaltic intussusception comparable to the antireflux valve of the Kock pouch, which reportedly caused fewer problems than the antiperistaltic continence valve. 49• 56• 57 Compared to the intussusception nipple valves protruding into the reservoir, 49·53-57· 62 the ileoileal type of intussusception can be fixed easily to the intussuscepting ileal wall by sutures or staples, if the well known complication of devagination of these valves 49 •56•58•63 • 64 should occur. The disadvantage of this continence mechanism is that catheterization is the only means to evacuate the reservoir but this has not been a problem in any of our patients to date. Nevertheless, the alloplastic stomal prosthesis as devised by Riedmiller67 has the advantage that sphincteric control is based on a simple, reliable mechanical fC:=:::::.Principle of closure and that emptying of the reservoir is possible without insertion of a catheter deep in the reservoir. Furthermore, implantation of the prosthesis is easy and timeFIG. 5. Mainz pouch urinary diversion with antirefluxing implansaving. Nevertheless, the risk of infection of alloplastic material tation of ureters into ascending colon. Proximal ilea! loop remains is a drawback of this closure mechanism, which necessitated intact for ileoileal intussusception valve. removal of the prosthesis in 1 case. Even if patient acceptance of a continent stoma is superior to any other method of diversion, 2• 56•57 avoidance of an abdomMainz pouch for bladder augmentation (9 patients) and supravesical inal stoma is preferable. 2 This can be achieved by further urinary diversion (10 patients) applications of the Mainz pouch, including anastomosis to the Supravesical Bladder Diversion* membranous urethra after cystoprostatectomy, if necessary Augmentation Mean (range) Mean (range) combined with implantation of a bulbar urethral Scott pros467 {350-1,000) 528 (250-1,000) Capacity (ml.) thetic sphincter (fig. 10, A), or a perineal ot vestibular stoma 30 (0-80) Residual urine (ml.)t after cystectomy and urethrectomy with use of a Scott prosReservoir pressure (cm. water): thetic sphincter at the bowel (fig. 10, B), as investigated for 25 (15-35) 34 (30-40) At 50% capacity this purpose by Engelmann and associates. 71 Nevertheless, our 39 (20-60) At 100% capacity 45 (40-50) 283 (150-450) main concern regarding use of this alloplastic sphincteric cuff 317 (130-570) Filling volume at start of peristaltic contractions (ml.) on bowel tissue in humans was the incidence of infection, 63 (45-90) 60 (50-70) Maximum reservoir pressure durerosion and reduction of bowel diameter under the cuff during ing contraction (cm. water) long-term use, which we found in our animal experiments.71
Urodynamic studies were performed with patient in sitting position 4 to 8 weeks postoperatively. * Of these patients 8 had continent and 2 incontinent urinary diversion. t Two patients on intermittent catheterization were not included.
sigmoid colon to an ileal pouch for antirefluxing ureteral implantation. The disadvantage of the latter pouch is that 2 intestinal anastomoses for restoration of ileal and sigmoid continuity are needed. Indeed, the standard submucosal tunnel technique for antirefluxing ureteral implantation as used for urinary diversion with large boweF 0 was successful in all of our cases without any operative or perioperative complications, and with a low incidence of upper tract dilatation. Continence depends on a low pressure reservoir with adequate capacity and competent sphincteric control. In the bladder augmentation group 2 patients with myelomeningocele had abnormal sphincteric function preoperatively. One patient had bladder hyperreflexia and detrusor-sphincter dyssynergia. Postoperatively, she is completely continent but relies on intermittent catheterization for bladder evacuation. The second patient, who previously had ileal conduit diversion, had bladder
REFERENCES
1. Winter, C. C.: Overview: caution needed in cystoplasty. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter. Philadelphia: Harper & Row Publishers, part 24, p. 837, 1984. 2. Olsson, C. A.: Continent urinary diversion. J. Urol., 132: 1157, 1984. 3. Tizzoni, G. and Foggi, A.: Die Wiederherstellung der Harnblase. Experimentelle Untersuchungen. Zentralbl. Chir., 15: 921, 1888. 4. Mikulicz, J.: Zur Operation der angeborenen Blasenspalte. Zentralbl. Chir., 26: 641, 1899. 5. Rutkowski, M.: Zur Methode der Harnblasenplastik. Zentralbl. Chir., 26: 473, 1899. 6. Tasker, J. H.: Ileo-cystoplasty: a new technique. An experimental study with report of a case. Brit. J. Urol., 25: 349, 1953. 7. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie totale chez l'homme. J. d'Urol., 57: 408, 1951. 8. Camey, M. and Le Due, A.: L'entero-cystoplastie apr.es cystoprostatectomie totale pour cancer de vessie. Indications, technique operatoire, surveillance et resultats sur quatre-vingt-sept cas. Ann. Urol., 13: 114, 1979.
THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
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A
FIG. 6. Ileoileal intussusception technique. A, division of 6 cm. of mesentery for mesenteric exclusion from intussusception valve. B, completed intussusception, secured by several rows of interrupted seromuscular sutures and fascia! strip around base of intussusception. C, alternative fixation of intussusception valve to intussuscepting ilea! wall with 4 rows of staples. D, completed continent stoma. Fascia! strip around base of intussusception is sutured to abdominal fascia to anchor base of intussusception within abdominal wall. E, alloplastic stomal prosthesis for continent closure of Mainz pouch, as developed by Riedmiller. 67
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THUROFF AND ASSOCIATES
FIG. 7. M. W., 34-year-old woman with total loss of bladder capacity after multiple operations elsewhere, had bilateral grade IV reflux and underwent bilateral nephrostomy urinary diversion. A, nephrostogram shows bilateral dilatation of upper tract. B, bladder was filled by nephrostogram and had capacity less than 20 ml. Endoscopically, both ureters can be engaged easily with 23.5F cystoscope. C, IVP 2 months after Mainz pouch bladder augmentation. D, cystogram 2 months after bladder augmentation shows capacity of 600 ml. (residual urine 20 ml.). Patient is completely dry day and night with normal intervals of voiding.
9. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Urol., 132: 886, 1984. 10. Lemoine, G.: Creation d'une vessie nouvelle par un procede personnel apres cystectomie totale pour cancer. J. d'Urol. Med. Chir., 4: 367, 1913. 11. Couvelaire, R.: La "petite vessie" des tuberculeux genito-urinaires. Essai de classification, place et variantes des cysto-intestinoplasties. J. d'Urol., 56: 381, 1950. 12. Menville, J. G., Nix, J. T. and Pratt, A. M., II: Cecocystoplasty. J. Urol., 79: 78, 1958. 13. Turner-Warwick, R. T. and Handley-Ashken, M.: The functional results of partial, subtotal and total cystoplasty with special reference to uretercaecocystoplasty, selective sphincterotomy and cystocystoplasty. Brit. J. Urol., 39: 3, 1967. 14. Kuss, R., Bitker, M., Camey, M., Chatelain, C. and Lassau, J.P.: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. J. Urol., 103: 53, 1970. 15. Smith, R. B., Van Cangh, P., Skinner, D. G., Kaufman, J. J. and Goodwin, W. E.: Augmentation enterocystoplasty: a critical review. J. Urol., ll8: 35, 1977. 16. Shirley, S. W. and Mirelman, S.: Experiences with colocystoplasties, cecocystoplasties and ileocystoplasties in urologic surgery: 40 patients. J. Urol., 120: 165, 1978.
17. George, N. J. R., Dunn, M., Dounis, A., Abrams, P.H. and Smith, P. J. B.: The late symptomatic and functional results of enterocystoplasty. Brit. J. Urol., 50: 517, 1978. 18. Zinman, L. and Libertino, J. A.: Ileocecal conduit for temporary and permanent urinary diversion. J. Urol., 113: 317, 1975. 19. Chan, S. L., Ankenman, G. J., Wright, J.E. and McLaughlin, M. G.: Cecocystoplasty in the surgical management of the small contracted bladder. J. Urol., 124: 338, 1980. 20. Freiha, F. S., Faysal, M. H. and Stamey, T. A.: The surgical treatment of intractable interstitial cystitis. J. Urol., 123: 632, 1980. 21. Kass, E. J. and Koff, S. A.: Bladder augmentation in the pediatric neuropathic bladder. J. Urol., 129: 552, 1983. 22. Abel, B. J. and Gow, J. G.: Results of caecocystoplasty for tuberculous bladder contracture. Brit. J. Urol., 50: 511, 1978. 23. Hradec, E. A.: Bladder substitution: indications and results in 114 operations. J. Urol., 94: 406, 1965. 24. Adan, R.: Etude descriptive d'une nouvelle technique concernant le traitement chirurgical de la petite vessie et de l'ureterite tuberculeuses dans un cas de rein unique. J. d'Urol., 62: 491, 1956. 25. Gil-Vernet, J. M. and Gosalvez, R.: Ileocystoplastie ou colocystoplastie? J. d'Urol., 63: 466, 1957. 26. Dretler, S. P., Hendren, W. H. and Leadbetter, W. F.: Urinary tract reconstruction following ilea! conduit diversion. J. Urol., 109: 217, 1973. 27. Wallack, H., Lome, L. G. and Presman, D.: Management of interstitial cystitis with ileocecocystoplasty. Urology, 5: 51, 1975. 28. Hendren, W. H.: Some alternatives to urinary diversion in children. J. Urol., ll9: 652, 1978. 29. Dounis, H., Abel, B. J. and Gow, J. G.: Cecocystoplasty for bladder augmentation. J. Urol., 123: 164, 1980. 30. Skinner, D. G.: Further experience with the ileocecal segment in urinary reconstruction. J. Urol., 128: 252, 1982. 31. Linder, A., Leach, G. E. and Raz, S.: Augmentation cystoplasty in the treatment of neurogenic bladder dysfunction. J. Urol., 129: 491, 1983. 32. Whitmore, W. F., III and Gittes, R. F.: Reconstruction of the urinary tract by cecal and ileocecal cystoplasty: review of a 15year experience. J. Urol., 129: 494, 1983. 33. Light, J. K., Flores, F. N. and Scott, F. B.: Use of the AS792 artificial sphincter following urinary undiversion. J. Urol., 129: 548, 1983. 34. Gil-Vernet, J.M., Jr.: The ileocolic segment in urologic surgery. J. Urol., 94: 418, 1965. 35. Khafagy, M., El-Bolkainy, M. N., Barsoum, R. S. and El-Tatawy, S.: The ileocecal bladder: a new method for urinary diversion after radical cystectomy (a preliminary report). J. Urol., 113: 314, 1975. 36. Stoeckel, W.: Demonstration eines Falles von Maydl'scher Operation bei tuberkuliiser Schrumpfblase. Zentralbl. Gyniik., 42: 720, 1918. 37. Mathisen, W.: Open-loop sigmoido-cystoplasty. Acta Chir. Scand., llO: 227, 1955. 38. Bisgard, J. D.: Substitution of the urinary bladder with a segment of sigmoid. An experimental study. Ann. Surg., 117: 106, 1943. 39. Gil""'Vernet, J. M.: Technique for construction of a functioning artificial bladder. J. Urol., 83: 39, 1960. 40. Verhoogen, J.: Neostomie uretero-caecale. Formation d'une nouvelle poche vesicale et d'un nouvel metre. Ass. Franc. d'Urol., 12: 362, 1908. 41. Makkas, M.: zur Behandlung der Blasenektopie. Umwandlung des ausgeschalteten Coecum zur Blase und der Appendix zur Urethra. Zentralbl. Chir., 37: 1073, 1910. 42. Bricker, E. M.: Bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 43. Gilchrist, R. K., Merricks, J. W., Hamlin, M. H. and Rieger, I. T.: Construction of a substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950. 44. Merricks, J. W. and Gilchrist, R. K.: Follow-up on operation for urinary bladder substitution. Arch. Surg., 74: 780, 1957. 45. Sullivan, H., Gilchrist, R. K. and Merricks, J. W.: Ileocecal substitute bladder: long-term followup. J. Urol., 109: 43, 1973. 46. Harper, J. G. M., Berman, M. H., Hertzberg, A. D., Lerman, F. and Brendler, H.: Observations on the use of the cecum as a substitute urinary bladder. J. Urol., 71: 600, 1954. 47. Wells, C. A.: The use of the intestine in urology. Omitting ureterocolic anastomosis. Brit. J. Urol., 28: 335, 1956.
THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
25
FIG. 8. J. P., 22-year-old woman, had anal atresia, urogenital sinus and right solitary kidney with reflux. Several operations were done for reflux, urethral reconstruction and vesicovaginal fistula repair. A, preoperative IVP. B, IVP 3 months after continent Mainz pouch urinary diversion. C, radiograph of pouch shows capacity of 350 ml., no ureteral reflux and complete continence with ileoileal intussusception.
FIG. 9. A. W., 56-year-old man. A, IVP 2 months after radical cystoprostatectomy for high grade invasive bladder cancer and Mainz pouch urinary diversion. B, radiograph of pouch reveals capacity of 400 ml., no ureteral reflux and complete continence with alloplastic stomal prosthesis.
48. Kock, N. G.: Intra-abdominal "reservoir" in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal "continence" in five ileostomy patients. Arch. Surg., 99: 223, 1969. 49. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir: clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1978. 50. Perl, J. I.: Intussuscepted conical valve formation injejunostomies. Surgery, 25: 297, 1949. 51. Basso, D. E.: The efficacy and applicability of an intussuscepted conical valve in preventing regurgitation and leakage of intestinal contents. Ann. Surg., 133: 477, 1951. 52. Smith, G. I. and Hinman, F., Jr.: The intussuscepted ileal cystostomy. J. Urol., 73: 261, 1955. 53. Leisinger, H.J., Schauwecker, H., Schmucki, 0., Hauri, D., Mayor, G. and Siiuberli, H.: Continent ileal bladder: an experimental study in dogs. Eur. Urol., 1: 103, 1975.
54. Leisinger, H. J., Siiuberli, H., Schauwecker, H. and Mayor, G.: Continent ileal bladder: first clinical experience. Eur. Urol., 2: 8, 1976. 55. Madigan, M. R.: The continent ileostomy and the isolated ileal bladder. Ann. Roy. Coll. Surg. Engl., 58: 62, 1976. 56. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 57. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ileal reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 58. Ashken, M. H.: An appliance-free ileocaecal urinary diversion: preliminary communication. Brit. J. Urol., 46: 631, 1974. 59. Ashken, M. H.: Urinary reservoirs. In: Urinary Diversion. New York: Springer-Verlag, chapt. 6, pp. 112-139, 1982. 60. Benchekroun, A.: Continent caecal bladder. Eur. Urol., 3: 248, 1977.
26
THUROFF AND ASSOCIATES
A
FIG. 10. A, anastomosis of Mainz pouch to membranous urethra after cystoprostatectomy. Optional bulbar urethra Scott sphincter prosthesis. B, perineal/vestibular stoma after cystectomy and urethrectomy, and Scott sphincter prosthesis wrapped around ileum for control of continence.
61. Benchekroun, A.: Continent caecal bladder. Brit. J. Urol., 54: 505, 1982. 62. Zingg, E. and Tscholl, R.: Continent cecoileal conduit: preliminary report. J. Urol., 118: 724, 1977. 63. Miinsson, W. and Sundin, T.: Experience with a continent caecal reservoir in urinary diversion. Scand. J. Urol. Nephrol., suppl., 48: 4, 1978. 64. Miinsson, W.: The continent caecal reservoir for urine. Thesis. Scand. J. Urol. Nephrol., suppl., 85: 1, 1984. 65. Lamesch, A. and Dociu, N.: Blasenersatz durch ein kontinentes ileocolisches Darmreservoir mit Antirefluxplastik-experimentelle Studie am Hund. Langenbeck Arch. Chir., 363: 57, 1984. 66. Thiiroff, J. W., Alken, P., Engelmann, U., Riedmiller, H., Jacobi, G. H. and Hohenfellner, R.: The MAINZ pouch (mixed augmentation ileum 'n zoecum) applicable for bladder augmentation and continent urinary diversion. Akt. Urol., 16: 1, 1985. 67. Riedmiller, H.: Alloplastische Stomaprothese zur kontinenten supravesikalen Harnableitung. Eine tierexperimentelle Studie. Thesis. Mainz, 1984. 68. Norlen, L. and Trasti, H.: Functional behaviour of the continent ileum reservoir for urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl., 49: 33, 1978. 69. Hedlund, H., Lindstrom, K. and Miinsson, W.: Dynamics of a continent caecal reservoir for urinary diversion. Scand. J. Urol. Nephrol., suppl., 85: 61, 1984. 70. Wilbert, D. M. and Hohenfellner, R.: Colonic conduit. Preoperative requirements, operative techniques, postoperative management. World J. Urol., 2: 159, 1984. 71. Engelmann, U. H., Felderman, T. P and Scott, F. B.: The use of the AMS-AS800 artificial sphincter for continent urinary diversion. I. Investigations, including pressure-flow studies, using rabbit intestinal loops. J. Urol., 134: 183, 1985.
Copyright@ 1986 by The Williams & Wilkins Co.
THE MAINZ POUCH (MIXED AUGMENTATION ILEUlVi AND CECUM) FOR BLADDER AUGMENTATION AND CONTINENT DIVERSION J. W. THUROFF,* P. ALKEN, H. RIEDMILLER, U. ENGELMANN, G. H. JACOBI
AND
R. HOHENFELLNER From the Department of Urology, Johannes Gutenberg University, Medical School, Mainz, Federal Republic of Germany
ABSTRACT
The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: 1) creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, 2) antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and 3) in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis. In 1912 Lemoine anastomosed the rectum to the urethra for total bladder replacement, with voluntary control of micturition by the urethral sphincter and end-to-end anastomosis of the sigmoid colon to the anal sphincter. 10 In 1950 Couvelaire reported bladder augmentation using cecum,1 1 and since then there have been numerous reports on the use of cecum for bladder augmentation12- 22 or complete bladder replacement. 13• 23 An isolated ileocecal segment also has been applied for bladder augmentation, in some cases combined with ureteral replacement22 • 24- 33 or for complete bladder replacement. 34, 35 Stoeckel introduced use of a segment of sigmoid colon for bladder augmentation in 1918. 36 Mathisen used a sigmoid patch for the same purpose in 1955. 37 Total bladder replacement by sigmoid colon anastomosed to the urethra after cystectomy was performed experimentally by Bisgard in 1943 38 and was applied clinically Gil Vernet. 39 In 1908 Verhoogen experimentally used cecum and appendix for supravesical urinary diversion. 40 This was applied Makkas in 1910. Attempts to successfully in a patient achieve continence in supravesical urinary diversion by ~se of the ileocecal segment were abandoned Bricker in 195042 in favor of the simpler technique of ileal loop diversion. Gilchrist and associates also used an ileocecal segment for continent supravesical diversion with the cecum as reservoir and the ileocecal valve in conjunction with the ileal peristalsis as a continence providing mechanism for the ilea! stoma. 43 Excellent results regarding continence were reported, 44 • 45 while other reports were not so favorable. 46 · 47 In 1969 Kock devised a continent ileostomy reservoir for proctocolectomized patients 48 and it was used first in 1975 for continent supravesical urinary diversion. 49 In this ileal pouch the mechanism for continence as well as for prevention of ureteral reflux is based on an ileal intussusception valve as devised by Perl in 1949. 50 Based on experiments by Basso, 51 Smith and Hinman first used an ileal intussusception valve in the urinary tract of dogs for continent ileocystostomy. 52 Others have reported on continent ileal pouch urinary diversion with a technique similar to that devised by
For successful restoration of function, surgical construction of a bladder from bowel must fulfill the requirements of 1) creation of a low pressure reservoir of adequate capacity, 2) antirefluxing ureteral implantation that avoids obstruction and 3) reliable control of continence with easy emptying of the reservoir. Enterocystoplasty can be criticized as a tedious, time-con suming operation, with unreliable functional results regarding residual urine, vesicoureteral reflux and continence-the latter especially when the bladder is replaced completely by boweL 1 Furthermore, there are objections against enterocystoplasty for bladder replacement after cystectomy in bladder cancer or for complete bladder replacement in women. 1 Nevertheless, there is enormous interest on the part of patients to avoid a urinary stoma and they are willing to undergo reconstruction of the urinary tract to achieve normal functional control of urine storage and emptying. If a stoma cannot be avoided, patients prefer continent urinary diversion to a wet stoma with external ~ollecting devices. Patient acceptance of the principle of continent diversion seems to be dramatic, even if difficulties are experienced and reoperation sometimes is required. 2 For bladder augmentation, small bowel was used first experimentally in 1888 by Tizzoni and Foggi, who anastomosed an ileal loop to the bladder neck of dogs after cystectomy. 3 In 1899 Mikulicz reported enlarging the bladder of a patient by the use of an ileal loop, one end of which was anastomosed to the bladder dome. 4 In the same year Rutkowski used an ileal patch for bladder augmentation, 5 and Tasker fashioned an ileal pouch in 1953. 6 Complete bladder replacement by an ilea! loop anastomosed to the urethra after cystectomy for cancer treatment was reported in 1951 by Couvelaire 7 and since then it has been popularized as the Camey operation. 8 ' 9 Accepted for publication January 31, 1986. Read at annual meeting of American Urological Association, Atlanta, Georgia, May 12-16, 1985. * Requests for reprints: UCSF Urinary Stone Center, 505 Parnassus Ave., M-418, San Francisco, California 94143.
17
18
THUROFF AND ASSOCIATES
Kock. 53 - 55 After the followup study of 12 patients reported on by Kock and associates in 1982, 56 Skinner and associates directed attention toward and popularized this technique. 57 After the report of Gilchrist and associates, 43 various other attempts were made to use the cecum as a reservoir. Ashken devised an ileal spout valve as a sphincter mechanism for the cecal reservoir, 58 which later was changed to an ileal flutter valve. 59 Benchekroun used a reversed ileal intussusception ("ink-well" valve) for continent closure of the ileocecal reservoir,60·61 while Zingg and Tscholl, 62 and Mansson and Sundin63 used intussusception of the terminal ileum into the cecum, both of which failed owing to sliding of the intussusception. 59· 64 Later, Mansson changed the technique into an ileoileal intussusception of the terminal ileum with much better results. 64 ln 1984 Lamesch and Dociu reported animal experiments for construction of a continent pouch from sigmoid colon and 2 ileal loops with an ileal intussusception valve for continent closure. 65 Since 1983 we have used a technique to construct a pouch from cecum, ascending colon and 2 ileal loops (mixed augmentation ileum and cecum, Mainz pouch), 66 which combines some of the surgical features of the reviewed techniques, and is applicable for bladder augmentation, continent urinary diversion and complete bladder replacement. MATERIAL AND METHODS
Since 1983 reconstruction of a urinary reservoir using a Mainz pouch was performed on 23 patients, 3 of whom were children (12 female and 11 male patients between 5 and 64 years old, with a mean age of 36 years). The Mainz pouch was used for bladder augmentation in 11 patients (for undiversion in 5). Previous urinary diversion consisted of ureterosigmoidostomy in 1 patient, ileal conduit in 1, bilateral percutaneous nephrostomy in 1 and sigmoid conduit in 2. Indications for bladder augmentation were contracted bladders of various etiology: iatrogenic in 3 patients, neurogenic in 2, tuberculosis in 3 and interstitial cystitis in 3. The Mainz pouch was used for urinary diversion in 12 patients. Indications for urinary diversion were radical cystoprostatectomy for treatment of bladder cancer (8 patients) and neurogenic bladder dysfunction (4). Surgical technique. After appendectomy, the cecum and ascending colon are mobilized up to the right colic flexure. For bladder augmentation, 10 to 15 cm. of cecum and ascending colon, and 2 terminal ileal segments of equal length are outlined by stay sutures (fig. 1, A). For continent urinary diversion the same segments are used to fashion the pouch but 20 to 25 cm. of ileum also must be isolated proximally for ileoileal intussusception (fig. 1, B). After isolation of the ileocecal segment, bowel continuity is restored by an ileocolostomy, which is
accomplished either by single row sutured end-to-end anastomosis after antimesenteric spatulation of the ileum for adjustment of bowel diameter (fig. 2, A and B), or by mechanical end-to-side anastomosis of ileum to ascending colon with the EEA-stapler and the TA 55 stapler for closure of the ascending colon (fig. 2, C and D). The ascending colon, cecum and both terminal ileal segments are split open at their antimesenteric borders (fig. 3, A). For urinary diversion the third proximal ileal segment remains intact (fig. 3, B). The posterior wall of the pouch is completed by side-to-side anastomosis of the ascending colon with the terminal ilea! loop, and of the latter with the next proximal ileal segment (fig. 3, C and D). After a comparison of different techniques of side-to-side anastomosis, including absorbable staples, 66 we found single-row through-and-through running sutures (4-zero polyglyconate, straight needle) to be the most time-saving. For bladder augmentation, the bladder is resected subtotally, with the resection line just below the ureteral orifices, leaving a bladder neck cuff of approximately the size of a silver dollar. If the mesentery is sufficiently long the still open pouch is slid into the small pelvis for anastomosis with the posterior bladder wall (fig. 4, A). If the mesentery is too short the pouch is rotated 180 degrees counterclockwise for an anastomosis free of tension with the posterior wall of the bladder (fig. 4, B). The anastomosis is accomplished by single row through-and-through interrupted sutures of 3 or 4-zero polyglyconate. Since both ureters then are implanted into the large bowel segment, the contralateral ureter must be pulled through retroperitoneally. Ureters are implanted from the open end of the large bowel via a 5 cm. long submucosal tunnel (fig. 4, A and B). The ureters are anchored with 2, 5-zero polyglyconate sutures to the muscle of the bowel wall and the neo-orifices are established by 6-zero ureteral mucosal sutures. The anastomosis with the anterior bladder wall is completed by single row through-and-through interrupted sutures. Closure of the anterior wall of the pouch is accomplished by single row throughand-through running sutures but at the site ofureteral implantation the pouch is closed solely by interrupted mucosa! sutures to prevent ureteral obstruction (fig. 4, C and D). For urinary diversion, the technique basically is the same with ureteral implantation into the ascending colon (fig. 5). As a continence-providing mechanism, isoperistaltic ileoileal intussusception of the antiperistaltic draining loop has been performed in 6 patients. The ileal mesentery is divided directly at the ilea! wall for about 6 cm. for mesenteric exclusion from intussusception (fig. 6, A). To achieve ileoileal intussusception, the mesenteric division should be done 9 cm. away from the pouch. The serosa of the ileum is scarified by electric cautery
B
FIG. 1. Intestinal segment to be isolated. A, Mainz pouch bladder augmentation. B, Mainz pouch continent urinary diversion
19
THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
A
B
'///)////• /
C
D
FIG. 2. A and B, single row sutured end-to-end ileocolostomy. C, mechanical end-to-side anastomosis of ileum to ascending colon with EEAstapler. D, blind closure of ascending colon by TA 55 stapler.
over the entire length of intussusception (fig. 6, A to C). Two Allis clamps are introduced into the ileum through the open pouch to grasp the ileal wall at the middle of the mesenteric division (fig. 6, A and B) for stepwise isoperistaltic intussusception. Each step of about 1 cm. of intussusception is secured by a row of 5 to 6 interrupted 4-zero silk serornuscular sutures (fig. 6, B). Alternatively, the intussusception has been stapled with the TA 55 instrument to the intussuscepting ileal wall using 3 to 4 rows of 4.8 mm. metal staples (fig. 6, C). A 1.5 cm. wide fascia! strip is excised from the anterior rectus fascia and wrapped around the base of the intussusception. The fascial strip is anchored to the base of the intussusception as well as to the stomal segment of ileum by multiple interrupted sutures (fig. 6, B). The skin for the stoma is excised in the right hypogastrium and the base of the intussusception is anchored within the abdominal wall by 5 to 6 interrupted sutures connecting the fascial sling around the base of the intussusception and the external abdominal fascia (fig. 6, B and D). As an alternative for sphinteric control, an alloplastic stomal prosthesis for simple mechanical closure has been implanted in 4 patients (fig. 6, E). This specially designed prosthesis 67 consists of a titanium barrel coated with expanded microporous polytetrafluoroethylene (Teflon). Details of design and function of the prosthesis will be reported separately. The pouches are drained by a 26F Foley balloon catheter
and, in cases of bladder augmentation, by an additional 15F cystostomy tube for easy control of residual urine after removal of the transurethral catheter. Two 20F silicone drains are placed, 1 in the small pelvis and 1 at the ureteral implantation site. Ureters are stented for 10 days and pouch catheters are removed after 14 days. At removal the patients are instructed in intermittent catheterization or are asked to void spontaneously, respectively. All 8 patients with bladder cancer underwent simultaneous bilateral pelvic iliac lymph node dissection, radical cystectomy and Mainz pouch urinary diversion. RESULTS
We encountered no operative mortality and 3 major complications. A jejunocutaneous fistula that was caused by faulty placement of a tension suture during closure of the abdominal wall closed spontaneously after removal of the suture. A 9-yearold boy had to be reoperated on 9 days postoperatively for an ileal intussusception ileus, which occurred away from the anastomotic site. Convalescence was complicated further by thrombosis of the upper vena cava secondary to a catheter in the right jugular vein, which was managed conservatively. The third patient (with continent diversion) suffered bleeding into the pouch 5 days postoperatively during a hypertensive crisis in which blood pressure increased to 230/130 mm. Hg. The bleed-
20
THUROFF AND ASSOCIATES
C
FIG. 3. Antimesenteric splitting of intestine for bladder augmentation (A) and urinary diversion (B). Side-to-side anastomosis of ascending colon and terminal ilea! segment, and of latter with next proximal loop in bladder augmentation (C) and urinary diversion (D).
ing caused recurrent tamponade of the pouch, which had to be evacuated instrumentally 3 times between 5 and 9 days postoperatively. The patient required 6 units of blood and bleeding finally stopped after continuous rinsing of the pouch via a separately introduced small catheter. Infection of an alloplastic stomal prosthesis finally resulted in removal of the prosthesis after 3 months. The patient was left with the free draining reservoir and is awaiting continent closure by an intussusception valve. Followup ranged from 1 to 20 months, with a mean of 4.8 months. Of the 11 patients in the bladder augmentation group 1 with myelomeningocele had a low bladder capacity of 250 ml. 6 weeks postoperatively, compared to a mean capacity of 528 ml. for the entire group (see table). This patient remains dry only as long as she empties the reservoir every 2 hours by intermittent catheterization. All other patients are completely dry day and night. Both patients with myelomeningocele and bladder augmentation empty the bladder by intermittent catheterization, while all other patients void spontaneously at normal intervals without significant residual urine. Urodynamic studies performed 4 to 8 weeks postoperatively revealed mean resting pressures of 34 cm. water with a half full bladder and 45 cm. water with a full bladder (see table). During urodynamic provocative filling (80 ml. per minute), contractions started at a filling volume of 60 per cent of bladder capacity and peaked at a mean maximum pressure of 60 cm. water (see table) but subsided immediately if the inflow was stopped. All patients voided by abdominal straining and ureteral reflux did not occur (fig. 7). Excretory urography (IVP) revealed the upper tracts either to have remained undilated or else the previous dilatation had improved (fig. 7). In the urinary diversion group 2 patients with Mainz pouch urinary diversion without a continence mechanism, who are awaiting implantation of an alloplastic stomal prosthesis, and 1 patient whose prosthesis was removed because of infection
use the regular external bags for urine collection. All other patients with an alloplastic stomal prosthesis (3) and intussusception valve (6) are continent. Including the incontinent diversion patients, the 4 to 8-week postoperative urodynamic investigations revealed a mean pouch capacity of 467 ml. and all other urodynamic findings in this group closely resembled those in the bladder augmentation group (see table). Ureteral reflux did not occur (figs. 8 and 9). The IVP showed bilateral grade I dilatation of the upper tract 12 weeks postoperatively in 1 patient, bilateral grade II dilatation 4 weeks postoperatively in 1 and unobstructed upper tracts in the remainder (figs. 8 and 9). All patients primarily needed alkalizing drugs to balance hyperchloremic acidosis but, with an increasing followup period, 8 currently are stable without any alkalizing drugs. DISCUSSION
Preliminary results of our operative technique indicate that all requirements for the reconstruction of a urinary reservoir are fulfilled. A low pressure reservoir of adequate capacity is achieved by dissection of circular and spiral muscle fibers of bowel when the intestine is split longitudinally at its antimesenteric border, and by opposing large and small bowel to each other within 1 pouch. This is the same principle as used for ileum alone in the Kock pouch, 48 • 49 • 56 which has been proved functionally to be a low pressure reservoir. 68 Since cecum alone, if used as a reservoir, reveals intraluminal pressures comparable to the Kock pouch, 69 we did not expect adverse effects regarding pressure and capacity from combining it with small bowel. Nevertheless, as seen under fluoroscopic control, contractions of the Mainz pouch derive from the large bowel segment and are dampened or canceled by the small bowel segments of the reservoir. Easy and reliable antirefluxing implantation of ureters was the rationale for adding cecum to the intestinal pouch, as was done in the animal model of Lamesch and Dociu, 65 who added
THE flJ'.AKNZ POUCH FOR BLADDER AUGM:ENTATION AND DIVERSWN
21
B
/
/
I I
I
I
I
I I
Vi/
FIG. 4. Anastomosis of posterior wall of pouch to subtotally resected bladder and antirefluxing implantation of ureters without rotation of intestine (A) and after 180-degree counterclockwise rotation of intestine for anastomosis free of tension with short mesentery (B). Operative appearance after complete closure of bladder augmentation without rotation of pouch (C) and after 180-degree rotation of pouch (D).
22
THUROFF AND ASSOCIATES
hyperreflexia and a partially denervated sphincter. After undiversion she is continent for up to 2 hours and empties the bladder with intermittent catheterization. All of the remaining patients had urodynamically proved normal sphincteric control, are completely dry day and night after bladder augmentation, and empty the bladder without significant residual urine. The advantages of the Mainz pouch over the conventional methods of bladder augmentation, which obviously have only partially satisfactory results regarding nocturnal continence, residual urine and ureteral reflux, 1 seem first to be the pouch technique and second the antirefluxing implantation of the ureters into the pouch, which allows subtotal cystectomy. This is particularly important in cases of interstitial cystitis and detrusor hyperreflexia. Which method of continence control for Mainz pouch supravesical diversion will be preferable cannot be determined to date. Our type of intussusception valve as devised by Mansson64 is an isoperistaltic intussusception comparable to the antireflux valve of the Kock pouch, which reportedly caused fewer problems than the antiperistaltic continence valve. 49• 56• 57 Compared to the intussusception nipple valves protruding into the reservoir, 49·53-57· 62 the ileoileal type of intussusception can be fixed easily to the intussuscepting ileal wall by sutures or staples, if the well known complication of devagination of these valves 49 •56•58•63 • 64 should occur. The disadvantage of this continence mechanism is that catheterization is the only means to evacuate the reservoir but this has not been a problem in any of our patients to date. Nevertheless, the alloplastic stomal prosthesis as devised by Riedmiller67 has the advantage that sphincteric control is based on a simple, reliable mechanical fC:=:::::.Principle of closure and that emptying of the reservoir is possible without insertion of a catheter deep in the reservoir. Furthermore, implantation of the prosthesis is easy and timeFIG. 5. Mainz pouch urinary diversion with antirefluxing implansaving. Nevertheless, the risk of infection of alloplastic material tation of ureters into ascending colon. Proximal ilea! loop remains is a drawback of this closure mechanism, which necessitated intact for ileoileal intussusception valve. removal of the prosthesis in 1 case. Even if patient acceptance of a continent stoma is superior to any other method of diversion, 2• 56•57 avoidance of an abdomMainz pouch for bladder augmentation (9 patients) and supravesical inal stoma is preferable. 2 This can be achieved by further urinary diversion (10 patients) applications of the Mainz pouch, including anastomosis to the Supravesical Bladder Diversion* membranous urethra after cystoprostatectomy, if necessary Augmentation Mean (range) Mean (range) combined with implantation of a bulbar urethral Scott pros467 {350-1,000) 528 (250-1,000) Capacity (ml.) thetic sphincter (fig. 10, A), or a perineal ot vestibular stoma 30 (0-80) Residual urine (ml.)t after cystectomy and urethrectomy with use of a Scott prosReservoir pressure (cm. water): thetic sphincter at the bowel (fig. 10, B), as investigated for 25 (15-35) 34 (30-40) At 50% capacity this purpose by Engelmann and associates. 71 Nevertheless, our 39 (20-60) At 100% capacity 45 (40-50) 283 (150-450) main concern regarding use of this alloplastic sphincteric cuff 317 (130-570) Filling volume at start of peristaltic contractions (ml.) on bowel tissue in humans was the incidence of infection, 63 (45-90) 60 (50-70) Maximum reservoir pressure durerosion and reduction of bowel diameter under the cuff during ing contraction (cm. water) long-term use, which we found in our animal experiments.71
Urodynamic studies were performed with patient in sitting position 4 to 8 weeks postoperatively. * Of these patients 8 had continent and 2 incontinent urinary diversion. t Two patients on intermittent catheterization were not included.
sigmoid colon to an ileal pouch for antirefluxing ureteral implantation. The disadvantage of the latter pouch is that 2 intestinal anastomoses for restoration of ileal and sigmoid continuity are needed. Indeed, the standard submucosal tunnel technique for antirefluxing ureteral implantation as used for urinary diversion with large boweF 0 was successful in all of our cases without any operative or perioperative complications, and with a low incidence of upper tract dilatation. Continence depends on a low pressure reservoir with adequate capacity and competent sphincteric control. In the bladder augmentation group 2 patients with myelomeningocele had abnormal sphincteric function preoperatively. One patient had bladder hyperreflexia and detrusor-sphincter dyssynergia. Postoperatively, she is completely continent but relies on intermittent catheterization for bladder evacuation. The second patient, who previously had ileal conduit diversion, had bladder
REFERENCES
1. Winter, C. C.: Overview: caution needed in cystoplasty. In: Current Operative Urology, 2nd ed. Edited by E. D. Whitehead and E. Leiter. Philadelphia: Harper & Row Publishers, part 24, p. 837, 1984. 2. Olsson, C. A.: Continent urinary diversion. J. Urol., 132: 1157, 1984. 3. Tizzoni, G. and Foggi, A.: Die Wiederherstellung der Harnblase. Experimentelle Untersuchungen. Zentralbl. Chir., 15: 921, 1888. 4. Mikulicz, J.: Zur Operation der angeborenen Blasenspalte. Zentralbl. Chir., 26: 641, 1899. 5. Rutkowski, M.: Zur Methode der Harnblasenplastik. Zentralbl. Chir., 26: 473, 1899. 6. Tasker, J. H.: Ileo-cystoplasty: a new technique. An experimental study with report of a case. Brit. J. Urol., 25: 349, 1953. 7. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie totale chez l'homme. J. d'Urol., 57: 408, 1951. 8. Camey, M. and Le Due, A.: L'entero-cystoplastie apr.es cystoprostatectomie totale pour cancer de vessie. Indications, technique operatoire, surveillance et resultats sur quatre-vingt-sept cas. Ann. Urol., 13: 114, 1979.
THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
23
A
FIG. 6. Ileoileal intussusception technique. A, division of 6 cm. of mesentery for mesenteric exclusion from intussusception valve. B, completed intussusception, secured by several rows of interrupted seromuscular sutures and fascia! strip around base of intussusception. C, alternative fixation of intussusception valve to intussuscepting ilea! wall with 4 rows of staples. D, completed continent stoma. Fascia! strip around base of intussusception is sutured to abdominal fascia to anchor base of intussusception within abdominal wall. E, alloplastic stomal prosthesis for continent closure of Mainz pouch, as developed by Riedmiller. 67
24
THUROFF AND ASSOCIATES
FIG. 7. M. W., 34-year-old woman with total loss of bladder capacity after multiple operations elsewhere, had bilateral grade IV reflux and underwent bilateral nephrostomy urinary diversion. A, nephrostogram shows bilateral dilatation of upper tract. B, bladder was filled by nephrostogram and had capacity less than 20 ml. Endoscopically, both ureters can be engaged easily with 23.5F cystoscope. C, IVP 2 months after Mainz pouch bladder augmentation. D, cystogram 2 months after bladder augmentation shows capacity of 600 ml. (residual urine 20 ml.). Patient is completely dry day and night with normal intervals of voiding.
9. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Urol., 132: 886, 1984. 10. Lemoine, G.: Creation d'une vessie nouvelle par un procede personnel apres cystectomie totale pour cancer. J. d'Urol. Med. Chir., 4: 367, 1913. 11. Couvelaire, R.: La "petite vessie" des tuberculeux genito-urinaires. Essai de classification, place et variantes des cysto-intestinoplasties. J. d'Urol., 56: 381, 1950. 12. Menville, J. G., Nix, J. T. and Pratt, A. M., II: Cecocystoplasty. J. Urol., 79: 78, 1958. 13. Turner-Warwick, R. T. and Handley-Ashken, M.: The functional results of partial, subtotal and total cystoplasty with special reference to uretercaecocystoplasty, selective sphincterotomy and cystocystoplasty. Brit. J. Urol., 39: 3, 1967. 14. Kuss, R., Bitker, M., Camey, M., Chatelain, C. and Lassau, J.P.: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. J. Urol., 103: 53, 1970. 15. Smith, R. B., Van Cangh, P., Skinner, D. G., Kaufman, J. J. and Goodwin, W. E.: Augmentation enterocystoplasty: a critical review. J. Urol., ll8: 35, 1977. 16. Shirley, S. W. and Mirelman, S.: Experiences with colocystoplasties, cecocystoplasties and ileocystoplasties in urologic surgery: 40 patients. J. Urol., 120: 165, 1978.
17. George, N. J. R., Dunn, M., Dounis, A., Abrams, P.H. and Smith, P. J. B.: The late symptomatic and functional results of enterocystoplasty. Brit. J. Urol., 50: 517, 1978. 18. Zinman, L. and Libertino, J. A.: Ileocecal conduit for temporary and permanent urinary diversion. J. Urol., 113: 317, 1975. 19. Chan, S. L., Ankenman, G. J., Wright, J.E. and McLaughlin, M. G.: Cecocystoplasty in the surgical management of the small contracted bladder. J. Urol., 124: 338, 1980. 20. Freiha, F. S., Faysal, M. H. and Stamey, T. A.: The surgical treatment of intractable interstitial cystitis. J. Urol., 123: 632, 1980. 21. Kass, E. J. and Koff, S. A.: Bladder augmentation in the pediatric neuropathic bladder. J. Urol., 129: 552, 1983. 22. Abel, B. J. and Gow, J. G.: Results of caecocystoplasty for tuberculous bladder contracture. Brit. J. Urol., 50: 511, 1978. 23. Hradec, E. A.: Bladder substitution: indications and results in 114 operations. J. Urol., 94: 406, 1965. 24. Adan, R.: Etude descriptive d'une nouvelle technique concernant le traitement chirurgical de la petite vessie et de l'ureterite tuberculeuses dans un cas de rein unique. J. d'Urol., 62: 491, 1956. 25. Gil-Vernet, J. M. and Gosalvez, R.: Ileocystoplastie ou colocystoplastie? J. d'Urol., 63: 466, 1957. 26. Dretler, S. P., Hendren, W. H. and Leadbetter, W. F.: Urinary tract reconstruction following ilea! conduit diversion. J. Urol., 109: 217, 1973. 27. Wallack, H., Lome, L. G. and Presman, D.: Management of interstitial cystitis with ileocecocystoplasty. Urology, 5: 51, 1975. 28. Hendren, W. H.: Some alternatives to urinary diversion in children. J. Urol., ll9: 652, 1978. 29. Dounis, H., Abel, B. J. and Gow, J. G.: Cecocystoplasty for bladder augmentation. J. Urol., 123: 164, 1980. 30. Skinner, D. G.: Further experience with the ileocecal segment in urinary reconstruction. J. Urol., 128: 252, 1982. 31. Linder, A., Leach, G. E. and Raz, S.: Augmentation cystoplasty in the treatment of neurogenic bladder dysfunction. J. Urol., 129: 491, 1983. 32. Whitmore, W. F., III and Gittes, R. F.: Reconstruction of the urinary tract by cecal and ileocecal cystoplasty: review of a 15year experience. J. Urol., 129: 494, 1983. 33. Light, J. K., Flores, F. N. and Scott, F. B.: Use of the AS792 artificial sphincter following urinary undiversion. J. Urol., 129: 548, 1983. 34. Gil-Vernet, J.M., Jr.: The ileocolic segment in urologic surgery. J. Urol., 94: 418, 1965. 35. Khafagy, M., El-Bolkainy, M. N., Barsoum, R. S. and El-Tatawy, S.: The ileocecal bladder: a new method for urinary diversion after radical cystectomy (a preliminary report). J. Urol., 113: 314, 1975. 36. Stoeckel, W.: Demonstration eines Falles von Maydl'scher Operation bei tuberkuliiser Schrumpfblase. Zentralbl. Gyniik., 42: 720, 1918. 37. Mathisen, W.: Open-loop sigmoido-cystoplasty. Acta Chir. Scand., llO: 227, 1955. 38. Bisgard, J. D.: Substitution of the urinary bladder with a segment of sigmoid. An experimental study. Ann. Surg., 117: 106, 1943. 39. Gil""'Vernet, J. M.: Technique for construction of a functioning artificial bladder. J. Urol., 83: 39, 1960. 40. Verhoogen, J.: Neostomie uretero-caecale. Formation d'une nouvelle poche vesicale et d'un nouvel metre. Ass. Franc. d'Urol., 12: 362, 1908. 41. Makkas, M.: zur Behandlung der Blasenektopie. Umwandlung des ausgeschalteten Coecum zur Blase und der Appendix zur Urethra. Zentralbl. Chir., 37: 1073, 1910. 42. Bricker, E. M.: Bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 43. Gilchrist, R. K., Merricks, J. W., Hamlin, M. H. and Rieger, I. T.: Construction of a substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950. 44. Merricks, J. W. and Gilchrist, R. K.: Follow-up on operation for urinary bladder substitution. Arch. Surg., 74: 780, 1957. 45. Sullivan, H., Gilchrist, R. K. and Merricks, J. W.: Ileocecal substitute bladder: long-term followup. J. Urol., 109: 43, 1973. 46. Harper, J. G. M., Berman, M. H., Hertzberg, A. D., Lerman, F. and Brendler, H.: Observations on the use of the cecum as a substitute urinary bladder. J. Urol., 71: 600, 1954. 47. Wells, C. A.: The use of the intestine in urology. Omitting ureterocolic anastomosis. Brit. J. Urol., 28: 335, 1956.
THE MAINZ POUCH FOR BLADDER AUGMENTATION AND DIVERSION
25
FIG. 8. J. P., 22-year-old woman, had anal atresia, urogenital sinus and right solitary kidney with reflux. Several operations were done for reflux, urethral reconstruction and vesicovaginal fistula repair. A, preoperative IVP. B, IVP 3 months after continent Mainz pouch urinary diversion. C, radiograph of pouch shows capacity of 350 ml., no ureteral reflux and complete continence with ileoileal intussusception.
FIG. 9. A. W., 56-year-old man. A, IVP 2 months after radical cystoprostatectomy for high grade invasive bladder cancer and Mainz pouch urinary diversion. B, radiograph of pouch reveals capacity of 400 ml., no ureteral reflux and complete continence with alloplastic stomal prosthesis.
48. Kock, N. G.: Intra-abdominal "reservoir" in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal "continence" in five ileostomy patients. Arch. Surg., 99: 223, 1969. 49. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir: clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1978. 50. Perl, J. I.: Intussuscepted conical valve formation injejunostomies. Surgery, 25: 297, 1949. 51. Basso, D. E.: The efficacy and applicability of an intussuscepted conical valve in preventing regurgitation and leakage of intestinal contents. Ann. Surg., 133: 477, 1951. 52. Smith, G. I. and Hinman, F., Jr.: The intussuscepted ileal cystostomy. J. Urol., 73: 261, 1955. 53. Leisinger, H.J., Schauwecker, H., Schmucki, 0., Hauri, D., Mayor, G. and Siiuberli, H.: Continent ileal bladder: an experimental study in dogs. Eur. Urol., 1: 103, 1975.
54. Leisinger, H. J., Siiuberli, H., Schauwecker, H. and Mayor, G.: Continent ileal bladder: first clinical experience. Eur. Urol., 2: 8, 1976. 55. Madigan, M. R.: The continent ileostomy and the isolated ileal bladder. Ann. Roy. Coll. Surg. Engl., 58: 62, 1976. 56. Kock, N. G., Nilson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 57. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ileal reservoir for urinary diversion. J. Urol., 132: 1101, 1984. 58. Ashken, M. H.: An appliance-free ileocaecal urinary diversion: preliminary communication. Brit. J. Urol., 46: 631, 1974. 59. Ashken, M. H.: Urinary reservoirs. In: Urinary Diversion. New York: Springer-Verlag, chapt. 6, pp. 112-139, 1982. 60. Benchekroun, A.: Continent caecal bladder. Eur. Urol., 3: 248, 1977.
26
THUROFF AND ASSOCIATES
A
FIG. 10. A, anastomosis of Mainz pouch to membranous urethra after cystoprostatectomy. Optional bulbar urethra Scott sphincter prosthesis. B, perineal/vestibular stoma after cystectomy and urethrectomy, and Scott sphincter prosthesis wrapped around ileum for control of continence.
61. Benchekroun, A.: Continent caecal bladder. Brit. J. Urol., 54: 505, 1982. 62. Zingg, E. and Tscholl, R.: Continent cecoileal conduit: preliminary report. J. Urol., 118: 724, 1977. 63. Miinsson, W. and Sundin, T.: Experience with a continent caecal reservoir in urinary diversion. Scand. J. Urol. Nephrol., suppl., 48: 4, 1978. 64. Miinsson, W.: The continent caecal reservoir for urine. Thesis. Scand. J. Urol. Nephrol., suppl., 85: 1, 1984. 65. Lamesch, A. and Dociu, N.: Blasenersatz durch ein kontinentes ileocolisches Darmreservoir mit Antirefluxplastik-experimentelle Studie am Hund. Langenbeck Arch. Chir., 363: 57, 1984. 66. Thiiroff, J. W., Alken, P., Engelmann, U., Riedmiller, H., Jacobi, G. H. and Hohenfellner, R.: The MAINZ pouch (mixed augmentation ileum 'n zoecum) applicable for bladder augmentation and continent urinary diversion. Akt. Urol., 16: 1, 1985. 67. Riedmiller, H.: Alloplastische Stomaprothese zur kontinenten supravesikalen Harnableitung. Eine tierexperimentelle Studie. Thesis. Mainz, 1984. 68. Norlen, L. and Trasti, H.: Functional behaviour of the continent ileum reservoir for urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl., 49: 33, 1978. 69. Hedlund, H., Lindstrom, K. and Miinsson, W.: Dynamics of a continent caecal reservoir for urinary diversion. Scand. J. Urol. Nephrol., suppl., 85: 61, 1984. 70. Wilbert, D. M. and Hohenfellner, R.: Colonic conduit. Preoperative requirements, operative techniques, postoperative management. World J. Urol., 2: 159, 1984. 71. Engelmann, U. H., Felderman, T. P and Scott, F. B.: The use of the AMS-AS800 artificial sphincter for continent urinary diversion. I. Investigations, including pressure-flow studies, using rabbit intestinal loops. J. Urol., 134: 183, 1985.