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Urinary diversion via a continent ileal reservoir: Clinical results in 12 patients
0022-5347/0Z/1672-1153/0 Tile JOURNALOF UROLOG~ Copyright© 2002 by A.~mRICA.~UROLOGICAL ASSOCtA~O~,INC.®
Vol. 167, 1153-1159,February 2002
Printed in U.S.A.
URINARY DIVERSION VIA A CONTINENT ILEAL RESERVOIR: CLINICAL RESULTS IN 12 PATIENTS N. G. KOCK,* A. E. NILSON, L. O. NILSSON, L. J. NORL]~N AND B. M. PHILIPSON From the Departments of Surgery II, Urology and Roentgenology, Section of Uroradiology, Sahlgren's Hospital, University of G6teborg, G6teborg, Sweden (Reprinted from J Urol, 128: 469-475, 1982)
ABSTRACT
Urinary diversion via a continent ileal reservoir has been performed in 12 patients. An isolated ileal reservoir was constructed using the technique described for patients with a continent ileostomy. The ureters w e r e implanted into an afferent segment provided with a refluxpreventing nipple valve. There were few operative complications and no operative mortality. Late complications involving malfunction of the nipple valves occurred in 8 patients and were corrected surgically. Postoperative followup presently is between 9 months and 6½ years. Two patients have died: 1 in an accident and i of metastatic bladder carcinoma. The remaining 10 patients are continent and without reflux to the upper urinary tract. The reservoir generally is emptied by intermittent self-catheterization between 3 to 6 times daily. The volume capacity of the reservoir is more than 500 ml. Urinary cultures have been constantly negative in 7 patients and the contents of the reservoir more or less permanently contained bacteria in 5. Dilatation of the upper urinary tracts, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are satisfied with this type of urinary diversion, especially those who have undergone other types of diversion previously. For many years the ileal conduit has been regarded as the best over-all method for permanent supravesical urinary diversion. Because of loss of continence and storage capacity of the lower urinary tract patients with an ileal conduit must use external appliances permanently. Despite improvements in surgical technique for construction of the stoma and the development of modern appliances, the ileal conduit is a poor substitute for the lower urinary tract and the situation of patients with this type of urinary diversion is far from satisfactory with respect to quality of life. 1 Many attempts have been made to develop a continent urinary diversion procedure. In the beginning the complex surgical procedures involved and the inability to control infection resulted in prohibitive mortality and, in addition, disappointing results in regard to continence. Medical advances have changed the premises for construction of continent supravesical urinary Wiversion systems and renewed interest has been expressed for development of continent urinary diversion procedures. In 1950 Bricker isolated an ileocecal segment, implanted the ureters into the cecum and advanced the ileal segment through the abdominal wall for :onstruction of a stoma. 2 The ileocecal valve was used to prevent leakage of urine. This principle for urinary diversion has been modified more recently, with the construction of a :ontinence-providing nipple valve. 3-s Encouraging results with a continent ileal reservoir in patients after proctocolectomy6 and the excellent long-term Functional results after ileocystoplastyv prompted us to study ~xperimentally the continent ileal reservoir for urinary di}ersion. s After successful animal experiments a clinical trial ,vas begun and the first patient was operated upon in 1975. 9 [Jsing the same principles Madigan, lo and Leisinger and tssociates ix reported on a few patients in whom a continent leal reservoir had been constructed for urinary diversion. We
herein present our clinical experience with 12 patients who received a continent ileal reservoir for urinary diversion. MATERIAL Urinary diversion was done in 12 patients via a continent ileal reservoir. Age and sex of the patients, and the date of operation together with the diagnoses, type of previous urinary diversion and reason for diversion via a continent ileal reservoir are shown in table 1. In 5 patients the urinary diversion was a primary procedure, mainly because of incontinence and/or retention, while it was combined with cystectomy in 4 and with extirpation of a malfunctioning cecocystoplasty in 1. One patient with a ureterosigmoidostomy and 1 with an isolated rectal bladder were severely incapacitated by rectal frequency. One patient with a cutaneous ureterostomy and 4 with ileal conduit diversion were converted because of considerable problems related to the stoma and appliances. SURGICAL PROCEDURE
The abdominal cavity was explored through a low midline incision. A 60 to 70 cm. small bowel segment was isolated from the intestinal canal approximately 50 cm. proximal to the ileocecal valve and used for construction of the ileal reservoir (fig. 1). Then, 12 to 15 cm. of the distal portion of the isolated loop were preserved for the outlet and for construction of the continence-providing nipple valve. Proximal to this segment 40 cm. of ileum were folded into a U shape with the terminal segment directed towards the cranium and the bottom of the U to the left side of the patient. This positioning of the gut is important for the later maneuvers that allow the pouch to be positioned in the lower part of the abdominal cavity. The legs of the U (each 20 cm. long) were sutured together at the antimesenteric border with continuous 3-zero Accepted for publication November 20, 1981. * Requests for reprints: Department of Surgery II, Sahlgren's Hos- polyglycolic acid (fig. 2, A). The intestine then was split open at the antimesenteric border and the incision was made 3 cm. pital, University o f GSteborg, S-413 45 Gtiteborg, Sweden. 1153
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1154 Pt.--Sex--Age No. 1--F--28 2--F---34 3--M--52 4--F----46 5--F---44 6--F--63 . 7--M--43 8--F--20 9--F---37 lO---M--51 11--M--36 12--F--20 _
TABLE 1. Data concerning 12 patients with urinary diversion via continent ileal reservoir Previous Type of Urinary Indications for Continent Ileal Diagnosis Diversion Reservoir Neurogenic bladder Neurogenic bladder Bladder Ca Urinary retention plus incontinence Ca of cervix uteri Interstitial cystitis Neurogenic bladder, bladder Ca Bladder exstrophy Neurogenic bladder Chronic prostatis, urinary incontinence Chronic prostatis, urinary incontinence Bladderexstrophy
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Ileal conduit Ureterosigmoidostomy Isolated rectal bladder -Ileal conduit -Cutaneous ureterostomy -Ileal conduit Ileal conduit
Stoma problems Rectal frequency Rectal frequency Incontinence Stoma problems Malfunctioning cecocystoplasty Incontinence Stoma problems Incontinence Incontinence Stoma problems Stoma problems
Yr. of Operation 1975 1975 1976 1978 1979 1979 1979 1979 1980 1980 1980 1980
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FIG. 1. Bowel segment measuring 60 to 70 cm. is isolated approximately 50 cm. from ileocecal valve and positioned as U with terminal end directed towards cranium of patient and bottom of U to left side of patient.
longer i n the proximal leg to separate the outlet from the i n l e t w h e n the reservoir was closed. The mucous m e m b r a n e of the legs of the U t h e ~ v a s sutured, also with c o n t i n u o u s polyglycolic acid (fig. 2, B). Openings were m a d e close to the i n t e s t i n a l wall i n the m e s e n t e r y supplying the f u t u r e bases of the nipple valves, the continence-providing valve a t the outlet a n d the reflux-protecting valve at the inlet. Approxim a t e l y 1.0 cm. wide strips of fascia from the a n t e r i o r rectus sheet or of Marlex mesh, shaped as i l l u s t r a t e d i n figure 2, B, t h e n were b r o u g h t t h r o u g h the openings for l a t e r application a r o u n d the base of the nipple valves. The strips h a d been soaked i n a solution c o n t a i n i n g doxycycline. The i n t u s s u s c e p t e d valves t h e n were constructed. The bowel wall was grasped t h r o u g h the open l u m e n a n d the u n s p l i t ileal segments were i n t u s s u s c e p t e d p a r t l y into the l u m e n of the future reservoir (fig. 3, A). The i n t u s s u s c e p t e d nipple valves were approximately 5 cm. long. T h e nipple position was m a i n t a i n e d with a s t a p l i n g i n s t r u m e n t u s i n g special staple cartridges t h a t h a d no knife (fig. 3, B). Four such applications were performed, 2 of t h e m p a r t l y involving the mesentery. However, i n p a t i e n t s 1 to 3 no s t a p l i n g ins t r u m e n t n o r Marlex m e s h was used b u t the n i p p l e valves were constructed according to a n earlier method described by Kock a n d associates. 9 I n 5 p a t i e n t s a strip of fascia was used i n s t e a d of the Marlex mesh.
FIG. 2. A, legs of U are united at antimesenteric border with continuous 3-zero polyglycolic acid. Intestine is split open along suture line and incision is continued for 3 cm. on afferent limb. B, mucous membrane is sutured with continuous 3-zero polyglycolic acid. Openings are made in mesentery supplying future base of nipple valves.
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Fro. 3. A, intussuscept.ion at parts of afferent and efferent segments into future reservom B, fixation of nipple valves with stapling instruments.
1155
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR The intestinal plate then was folded and the reservoir was :losed with 2 continuous inverting 3-zero polyglycolic acid ~utures (fig. 4). The corners of the reservoir were pushed ~ownwards between the mesenteric leaves so that the posterior aspect of the reservoir was brought anteriorly (fig. 5). this maneuver allowed the pouch to be positioned in the pelvic cavity when the reservoir was secured later to the inner surface of the abdominal wall. The Marlex mesh or fascia was positioned as a cylinder around the base of the outlet and inlet, respectively, including the major part of the mesentery supplying the valve, and the ends of the strips were sutured together with 3 to 4 nylon sutures. Approximately half of the cylinder then was embedded between the intestinal walls by suturing the reservoir ~vall up to the cylinder with a few isolated polyglycolic acid sutures (figs. 5, C and 6). When this step was completed the length of the nipple valve measured approximately 5 cm. Care was taken not to make the cylinder too tight around the outlet and inlet. The ureters were implanted into the inlet segment with an open technique and splinted with soft polyethylene catheters. The proximal end of the inlet segment was closed with 2 rows of polyglycolic acid sutures (fig. 7). An opening then was made in the abdominal wall for the outlet of the reservoir. The peritoneum around the inner opening of the channel was excised and the rectus muscle was split at the cranial side of the opening to make room for the mesentery supplying the nipple valve and the outlet (fig. 7). Interrupted nonabsorbable sutures were placed from the lateral aspect of the Marlex mesh or fascia cylinder to the anterior rectus sheet. After the outlet of the reservoir had been pulled through the channel in the abdominal wall the medial aspect of the cylinder was secured with isolated sutures to the medial part of the anterior rectus sheath. A fiat stoma was constructed (fig. S). A urostomy catheter was positioned through the stoma for drainage of the reservoir. The reservoir procedure has been described in detail previously. 12 When an ileal conduit was converted into an ileal reservoir diversion the conduit with the previous ureteral implantations was connected to the inlet segment of the reservoir. In 2 patients the conduit was used for construction of the refluxprotecting valve and then connected via a short inlet to the reservoir. A catheter was inserted into the previous ileal conduit for postoperative drainage in these patients.
FIG. 4. Closure of reservoir with 2 continuous inverting 3-zero polyglycolieacid sutures.
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FIo. 5. Reservoir is brought into final position by pushing corners of reservoir downwards between mesenterie leaves.
Postoperative management. General principles for postoperative management were followed. The ureteral catheters
Fro. 6. Fascia or Marlex mesh encircles base of nipple valve and ends are united with 3 to 4 nonabsorbable sutures. Reservoir wall is sutured to cylinder with isolated 3-zero polyglycolicacid sutures.
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1156
were removed a f t e r 10 days b u t t h e reservoir cathet d r a i n e d c o n t i n u o u s l y for 14 days. A f t e r this period the cat e t e r was c l a m p e d i n t e r m i t t e n t l y for 1 h o u r d u r i n g the thi: w e e k a n d for 2 h o u r s d u r i n g t h e fourth week. The reserv¢ c a t h e t e r t h e n was r e m o v e d and the p a t i e n t w a s i n s t r u c t e d e m p t y t h e r e s e r v o i r e v e r y 3 hours a t first and t h e n le frequently. The p a t i e n t s used clean b u t not sterile cathete for this purpose. T h e s t o m a w a s covered b y a s m a l l pad.
RESULTS
FiG. 7. Cylinder at efferent segment is attached to opening in anterior rectus sheath by use of nonabsorbable sutures.
-
:17 FIa. 8. Completed ileal reservoir in situ
Pt. No. 1 2 3 4 5 6 7 8 9 10 11 12
Early complications. T h e r e w a s no o p e r a t i v e m o r t a l i t y (t ble 2). L e a k a g e of u r i n e because of insufficient s u t u r e s led r e o p e r a t i o n a n d r e p a i r 7 days p o s t o p e r a t i v e l y in 1 patier T h e r e were no f u r t h e r complications r e l a t e d to t h e diversi( procedure in this p a t i e n t . In a n o t h e r p a t i e n t t h e vascul~ s u p p l y of t h e i n l e t s e g m e n t h a d been i m p a i r e d d u r i n g t] operation a n d r e o p e r a t i o n was n e c e s s a r y a few d a y s posto e r a t i v e l y for construction of a new i n l e t segment. Convale cence was uneventful in the r e m a i n i n g 10 p a t i e n t s . Late complications. Malfunction of t h e continenc providing valve n e c e s s i t a t i n g a revisional operation dev( oped after a few m o n t h s in 7 p a t i e n t s . Of these 7 p a t i e n t s corrective o p e r a t i o n for malfunction of t h e nipple valve w~ n e c e s s a r y twice before p e r m a n e n t continence was achiew in 2, sliding of t h e reflux-protecting valve n e c e s s i t a t e d su gical correction in 3 a n d a stricture a t t h e site of t h e u r e t e r i m p l a n t a t i o n w a s corrected surgically in 1. In t h e patie: who u n d e r w e n t r e o p e r a t i o n because of g a n g r e n e of t h e affe e n t s e g m e n t t h e volume capacity of t h e reservoir remain, s m a l l a n d a n a u g m e n t a t i o n p l a s t y w a s performed. I n S e p t e m b e r 1981 t h e histories a n d c u r r e n t s t a t u s of p a t i e n t s w e r e e v a l u a t e d with r e s p e c t to functional result u r i n a r y infections, r e n a l function, metabolic s t a t u s , morph( ogy of t h e mucosa and q u a l i t y of life. P a t i e n t 2 died in accident 6 m o n t h s a f t e r construction of the" continent ile reservoir a n d p a t i e n t 7 died 8 m o n t h s p o s t o p e r a t i v e l y m e t a s t a t i c b l a d d e r carcinoma. Thus, 10 p a t i e n t s w e r e e w u a t e d 9 m o n t h s to 6V2 y e a r s (mean 32 months) postoper tively. Continence w a s achieved in all p a t i e n t s , a l t h o u g h a re~ sional operation w a s n e c e s s a r y in 7 owing to malfunction t h e continence-providing valve. I n t e r m i t t e n t e m p t y i n g of t| reservoir w i t h a c a t h e t e r g e n e r a l l y is done easily w i t h i n 3 4 m i n u t e s . B e t w e e n e m p t y i n g s t h e p a t i e n t s w e a r a small p~ over the stoma. Of 10 p a t i e n t s 8 e m p t y the reservoirs 3 to t i m e s d u r i n g the d a y a n d g e n e r a l l y not a t all at night. Ho~ ever, 2 p a t i e n t s e m p t y more frequently, 5 to 7 t i m e s daft a n d 1 uses a n i n d w e l l i n g c a t h e t e r a t night. All p a t i e n t s h a v e been examined r e g u l a r l y by urograpl a n d "reservoirography" to test t h e competence of t h e nipp valves. P l a i n r a d i o g r a p h s after the reservoirs w e r e emptfi by c a t h e t e r i z a t i o n disclosed no r e s i d u a l u r i n e in a n y patie: (fig. 9). T h e volume c a p a c i t y of the r e s e r v o i r h a s been r
TABLE 2. Complications in 12 patients with urinary diversion via continent ileal reservoir Nipple Valve Complications Operative Complications Other Complications Incontinence Reflux Anastomotie leak
Surgical correction 2 times
Surgical correction
Surgical correction Surgical correction Gangrene of afferent segment
Surgical correction Surgical correction -Surgical correction 2 times Surgical correction
Insufficient volume capacity of reservoir Surgical correction Surgical correction
Ureteral implantation stenosis
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1157
FIG. 9. A, reservoir filled with 300 ml. contrast medium through catheter. No reflux to afferent loop or upper urinary tract is noted. B, no 'etention is noted after reservoir is emptied through catheter.
Fro. 10. Urography 3 years postoperatively in patient 4. A, visualization of upper urinary tract, afferent loop (single arrow) and reservoir :double arrows). There is no dil~ation at any level. B, reservoir with marked prominence of afferent nipple (arrowheads).
corded regularly and after 3 months the capacity generally is >500 ml. without any inconvenience to the patient. In 3 patients incompetence of the reflux-protecting valve was found and 1 of these patients also had stenosis at the ureteral implantation into the inlet segment. However, these problems were corrected by a revisional operation. No progressive dilatation of the upper urinary tract or pyelonephritic changes of the kidneys were observed (fig. 10). Quantitative urine cultures have been done regularly in all patients. In 7 patients the cultures have been negative constantly and no prophylactic antibacterial therapy has been given, while in the remaining 5 the contents of the reservoir more or less permanently contained bacteria and only occasionally have the urine cultures been negative. However, symptomatic urinary infections have not been encountered. Acute pyelitis occurred in the patient with stenosis at the ureteral implantation before reimplantation was performed. Radioisotope renograms, 51chromium-ethylenediaminetetraacetic acid clearance, excretory urography as well as serum creatinine concentrations have remained unchanged during
followup. Serum concentration of electrolytes and the arterial acid-base status also have been normal. No signs of hematological or liver function disturbances were found. Biopsies obtained by endoscopy from the mucosa of the reservoir at regular intervals were studied by light and electron microscopy. A rapid continuous decrease in villous height leading to an almost flat mucosa was noted during the first 12 months postoperatively. There also was an increase of the crypt layer but normal mitotic frequency. Endoscopy 3 years postoperatively revealed a bladder-resembling surface with areas of intestinal appearance. Microscopically, the bladder-resembling surface showed few crypts and no villi, whereas the intestinal areas were similar to specimens obtained during the first year. Electron microscopy of the epithelium revealed regressive changes at the subcellular level. The morphological studies have been described in detail previously. 13 All patients are satisfied with this type of urinary diversion. The patients with previous types of urinary diversions were much relieved after conversion to the continent ileal
1158
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
reservoir and the elimination of external appliances was of great benefit. For those patients who were disabled seriously by other types of diversion conversion made rehabilitation possible. Stomal or parastomal skin problems have not occurred in any of the patients. A most significant gain with the operation was the confidence in the stoma, which allowed the patients to abandon previous restrictions in their social and vocational activities owing to incontinence and stomal problems. DISCUSSION
To accomplish continent supravesical urinary diversion an appropriate continence-providing principle must be found and the integrity of the upper urinary tract and renal parenchyma should not be endangered. The ideal method should ensure that 1) there is an intra-abdominal low pressure reservoir for collection and storage of urine, 2) the storage of urine in the reservoir should not result in disturbing shifts of water and solutes across the wall of the receptacle, 3) ascending urinary infections owing to reflux from the reservoir to the upper urinary tracts must be avoided and 4) the reservoir should be provided with an outlet valve that prevents involuntary expulsion of the contents but allows emptying when convenient. The continent ileal reservoir used in our study seems to meet these requirements. The ileal reservoir provides adequate low pressure volume capacity for collection and storage of urine, 14 and adapts to increasing volumes by enlargement, thereby allowing convenient intervals between emptyings. Because of the low pressure in the reservoir it does not obstruct urinary flow from the upper urinary tract. Consequently, progressive ureteral dilatation was not noted on urography at regular intervals. Large shifts of water and solutes occur across the normal intestinal mucosa and it is a well known problem inherent in the use of intestinal reservoirs for urine that these shifts may lead to metabolic disturbances and increased risk of water deprivation. Although long-term studies after ileocystoplasty indicate that metabolic disturbances o~ving to shifts of water and solutes across the ileal mucosa are not to be expected, v all patients were studied carefully with respect to this possibility. The transmucosal shifts in the reservoir were not of the magnitude to harm the patients and were compensated for easily by the kidneys. This is in accordance with a previous report in which 2 patients with normal renal function and urinary diversions via a continent ileal reservoir were studied even under loadin~ conditions, ls Furthermore, the transmucosal shifts may diminish with time parallel to the morphological adaptation of the mucous membrane. 'a,'s Reflux of the contents of the reservoir to the upper urinary tracts was prevented by the nipple valve constructed at the inlet segment. "Reservoirography" showed sliding of the reflux-protecting nipple valve and consequent reflux in 3 patients that was corrected surgically. By improved surgical technique in construction of the valve it should be possible to avoid incompetence of the reflux-protecting valve. This is of the utmost importance, since the contents of the reservoir was infected in 5 patients. In an experimental study on urinary diversion via a continent ileal reservoir without protection against reflux of infected contents from the reservoir,. the upper urinary tracts became dilated and rapid pyelonephritic renal deterioration ensued, s There also is experimental and clinical evidence indicating a relationship between reflux of bacteria-containing urine and progressive pyelonephritic renal deterioration after ileal conduit diversion. '7,'s Thus, the continent ileal reservoir, with its reflux protection, may at least theoretically be superior to the ileal conduit diversion with regard to deterioration of renal function. Despite the fact that the patients use clean but not sterile
catheters at emptying 7 had permanently negative urinary cultures. The complete emptying of the reservoirs by catheterization, which was confirmed by radiography of the reservoir, probably is important for this favorable finding. The ultimate goal of this procedure, to achieve complete voluntary control over the expulsion of the contents of the reservoir without the need for external appliances, was attained in all 12 patients although a revisional operation was necessary in 7 to achieve permanent continence. Malfunction of the continence-providing valve has been a major problem in patients with continent ileostomy after proctocolectomy and a corrective operation is necessary in up to 50 per cent of the patients. However, by modification of the technique for construction of the valve this late complication in patients with ileostomy more recently has been almost eliminated. 12,19 In the future, by adapting the modified technique for construction of the nipple valve to the urinary diversion procedure one may expect this distressing complication to be largely avoided. In comparison to techniques using an ileocecal segment for continent urinary diversion, the continent ileal reservoir involves a more complex, time-consuming surgical procedure. Furthermore, the use of a considerable length of small bowel for construction of the reservoir could interfere with absorption of bile salts and vitamin B12. However, if the terminal ileum is not used these consequences should be avoided. On the other hand, the advantage over the ileocecal reservoir is the low pressure in the reservoir and its adaptation to increasing volumes, which should eliminate the risk for obstruction against the urinary flow from the upper urinary tract and allow longer intervals between emptyings. Furthermore, the adaptation of the ileal mucosa to prolonged exposure to urine, resulting in villous atrophy and possibly diminished absorptive capacity, favors the present method. Our results indicate that urinary diversion via a continent ileal reservoir offers the patient a quality of life much superior to that with conventional urinary diversion procedures. The excellent functional results and the absence of harmful side effects in patients presently observed for up to 6½ years postoperatively justify continued clinical trial with this method. REFERENCES 1. Tilma, A., Christensen, T. B. and Fuglsang, E.: Tilvaerelsen efter Bricker-operation. Ugeskr. Laeger., 135: 2812, 1973. 2. Bricker, E. hi.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Ashken, hi. H.: An appliance-free ileocaecal urinary diversion; preliminary communication. Brit. J. Urol., 46: 631, 1974. 4. Ashken, hi. H.: Continent ileocaecal urinary reservoir. J. Roy. Soc. Med., 71: 357, 1978. 5. Zingg, E. and Tscholl, R.: Continent cecoileal conduit: preliminary report. J. Urol., 118: 724, 1977. 6. Kock, N. G.: Continent ileostomy. Prog. Surg., 12: 180, 1973. 7. Fax6n, A., Kock, N. G. and Sundin, T.: Long-term functional results after ileocystoplasty. Scand. J. Urol. Nephrol., 7: 127, 1973. 8. Kock, N. G., Nilson, A. E., Norl6n, L., Sundin, T. and Trasti, H.: Changes in renal parenchyma and the upper urinary tracts followingurinary diversion via a continent ileum reservoir. An experimental study in dogs. Scand. J. Urol. Nephrol., suppl. 49" 11, 1978. 9. Kock, N. G., Nilson, A. E., NorI~n, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir. Clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1978. 10. Madigan, hi. R.: The continent ileostomy and the isolated ileal bladder. Ann. Roy. Coll. Surg. Engl., 58: 62, 1976. 11. Leisinger, H. J., Schauwecker, H. and S/iuberli, H.: Dynamics of the continent ileal bladder. An experimental study in dogs. Invest. Urol., 15: 49, 1977. 12. Kock, N. G., Myrvold, H. E., Nilsson, L. O. and Ahr4n, C.:
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
13.
14.
15.
16.
17. 18.
19.
Construction of a stable nipple valve for the continent ileostomy. Ann. Chir. Gynaec., 69: 132, 1980. Philipson, B. M., Nilsson, L. O., Norldn, L., Kock, N. G. and ./kt{ris, C.: Mucosal adaptation in ileum after long time exposure to urine. In: Mechanisms of Intestinal Adaptation, MTM Press Ltd., p. 613, 1982. Norl~n, 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. Jagenburg, R., Kock, N. G., Norl~n, L. and Trasti, H.: Clinical significance of changes in composition of urine during collection and storage in continent ileum reservoir urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl. 49: 43, 1978. Hansson, H.-A., Kock, N. G., Norl~n, L., Philipson, B., Trasti H. and .$thr~n, C.: Morphological observations in pedicled ileal grafts used for construction of continent reservoirs for urine. Scand. J. Urol. Nephrol., suppl., 49: 49, 1978. Richie, J. P., Skinner, D. G. and Waisman, J.: The effect of reflux on the development of pyelonephritis in urinary diversion: an experimental study. J. Surg. Res., 16: 256, 1974. Bergman, B., Kaijser, B. and Nilson, A. E.: Conduiturinary diversion and urinary-tract infection. I. Serum antibody titers against Escherichia coli and Proteus mirabilis in relation to urographic findings. Scand. J. Urol. Nephrol., 13: 65, 1979. Kock, N. G., Myrvold, H. E., Nilsson, L. O. and Philipson, B. M.: Continent ileostomy. An account of 314 patients. Acta Chir. Scand., 147: 67, 1981.
1159
EDITORIAL COMMENT This article on urinary diversion with a continent ileal reservoir is a classic advance in urological surgery. The authors clearly and beautifully describe their results in 12 patients, including the complications, and the results are stunningly good. They have adapted our ileocystoplasty technique1 and added the principle of intussusception to prevent reflux and maintain continence.2.3 Their results are excellent and my belief is that this advance in urological cutaneous urinary diversion will, in the near future, become the method of choice for most urinary cutaneous diversions. The idea of having a continent cutaneous diversion is an old one in urological surgery but this is the first one that I know of that can be called a real success. We look forward to further advances in this field.
Willard E. Goodwin Department of Surgery University of California School of Medicine Los Angeles, California 1. Goodwin, W. E., Winter, C. C. and Barker, W. F.: "Cup-patch" technique ofileocystoplasty for bladder enlargement or partial substitution. Surg., Gynec. & Obst., 108: 240, 1959. 2. Grey, D. N., Flynn, P. and Goodwin, W. E.: Experimental methods of ureteroneocystostomy: experiences with the ureteral intussusception to produce a nipple or valve. J. Urol., 77: 154, 1957. 3. Smith, G. I. and Hinman, F., Jr.: The intussuscepted ileal cystostomy. J. Urol., 73: 261, 1955.
Vol. 167, 1153-1159,February 2002
Printed in U.S.A.
URINARY DIVERSION VIA A CONTINENT ILEAL RESERVOIR: CLINICAL RESULTS IN 12 PATIENTS N. G. KOCK,* A. E. NILSON, L. O. NILSSON, L. J. NORL]~N AND B. M. PHILIPSON From the Departments of Surgery II, Urology and Roentgenology, Section of Uroradiology, Sahlgren's Hospital, University of G6teborg, G6teborg, Sweden (Reprinted from J Urol, 128: 469-475, 1982)
ABSTRACT
Urinary diversion via a continent ileal reservoir has been performed in 12 patients. An isolated ileal reservoir was constructed using the technique described for patients with a continent ileostomy. The ureters w e r e implanted into an afferent segment provided with a refluxpreventing nipple valve. There were few operative complications and no operative mortality. Late complications involving malfunction of the nipple valves occurred in 8 patients and were corrected surgically. Postoperative followup presently is between 9 months and 6½ years. Two patients have died: 1 in an accident and i of metastatic bladder carcinoma. The remaining 10 patients are continent and without reflux to the upper urinary tract. The reservoir generally is emptied by intermittent self-catheterization between 3 to 6 times daily. The volume capacity of the reservoir is more than 500 ml. Urinary cultures have been constantly negative in 7 patients and the contents of the reservoir more or less permanently contained bacteria in 5. Dilatation of the upper urinary tracts, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are satisfied with this type of urinary diversion, especially those who have undergone other types of diversion previously. For many years the ileal conduit has been regarded as the best over-all method for permanent supravesical urinary diversion. Because of loss of continence and storage capacity of the lower urinary tract patients with an ileal conduit must use external appliances permanently. Despite improvements in surgical technique for construction of the stoma and the development of modern appliances, the ileal conduit is a poor substitute for the lower urinary tract and the situation of patients with this type of urinary diversion is far from satisfactory with respect to quality of life. 1 Many attempts have been made to develop a continent urinary diversion procedure. In the beginning the complex surgical procedures involved and the inability to control infection resulted in prohibitive mortality and, in addition, disappointing results in regard to continence. Medical advances have changed the premises for construction of continent supravesical urinary Wiversion systems and renewed interest has been expressed for development of continent urinary diversion procedures. In 1950 Bricker isolated an ileocecal segment, implanted the ureters into the cecum and advanced the ileal segment through the abdominal wall for :onstruction of a stoma. 2 The ileocecal valve was used to prevent leakage of urine. This principle for urinary diversion has been modified more recently, with the construction of a :ontinence-providing nipple valve. 3-s Encouraging results with a continent ileal reservoir in patients after proctocolectomy6 and the excellent long-term Functional results after ileocystoplastyv prompted us to study ~xperimentally the continent ileal reservoir for urinary di}ersion. s After successful animal experiments a clinical trial ,vas begun and the first patient was operated upon in 1975. 9 [Jsing the same principles Madigan, lo and Leisinger and tssociates ix reported on a few patients in whom a continent leal reservoir had been constructed for urinary diversion. We
herein present our clinical experience with 12 patients who received a continent ileal reservoir for urinary diversion. MATERIAL Urinary diversion was done in 12 patients via a continent ileal reservoir. Age and sex of the patients, and the date of operation together with the diagnoses, type of previous urinary diversion and reason for diversion via a continent ileal reservoir are shown in table 1. In 5 patients the urinary diversion was a primary procedure, mainly because of incontinence and/or retention, while it was combined with cystectomy in 4 and with extirpation of a malfunctioning cecocystoplasty in 1. One patient with a ureterosigmoidostomy and 1 with an isolated rectal bladder were severely incapacitated by rectal frequency. One patient with a cutaneous ureterostomy and 4 with ileal conduit diversion were converted because of considerable problems related to the stoma and appliances. SURGICAL PROCEDURE
The abdominal cavity was explored through a low midline incision. A 60 to 70 cm. small bowel segment was isolated from the intestinal canal approximately 50 cm. proximal to the ileocecal valve and used for construction of the ileal reservoir (fig. 1). Then, 12 to 15 cm. of the distal portion of the isolated loop were preserved for the outlet and for construction of the continence-providing nipple valve. Proximal to this segment 40 cm. of ileum were folded into a U shape with the terminal segment directed towards the cranium and the bottom of the U to the left side of the patient. This positioning of the gut is important for the later maneuvers that allow the pouch to be positioned in the lower part of the abdominal cavity. The legs of the U (each 20 cm. long) were sutured together at the antimesenteric border with continuous 3-zero Accepted for publication November 20, 1981. * Requests for reprints: Department of Surgery II, Sahlgren's Hos- polyglycolic acid (fig. 2, A). The intestine then was split open at the antimesenteric border and the incision was made 3 cm. pital, University o f GSteborg, S-413 45 Gtiteborg, Sweden. 1153
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1154 Pt.--Sex--Age No. 1--F--28 2--F---34 3--M--52 4--F----46 5--F---44 6--F--63 . 7--M--43 8--F--20 9--F---37 lO---M--51 11--M--36 12--F--20 _
TABLE 1. Data concerning 12 patients with urinary diversion via continent ileal reservoir Previous Type of Urinary Indications for Continent Ileal Diagnosis Diversion Reservoir Neurogenic bladder Neurogenic bladder Bladder Ca Urinary retention plus incontinence Ca of cervix uteri Interstitial cystitis Neurogenic bladder, bladder Ca Bladder exstrophy Neurogenic bladder Chronic prostatis, urinary incontinence Chronic prostatis, urinary incontinence Bladderexstrophy
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Ileal conduit Ureterosigmoidostomy Isolated rectal bladder -Ileal conduit -Cutaneous ureterostomy -Ileal conduit Ileal conduit
Stoma problems Rectal frequency Rectal frequency Incontinence Stoma problems Malfunctioning cecocystoplasty Incontinence Stoma problems Incontinence Incontinence Stoma problems Stoma problems
Yr. of Operation 1975 1975 1976 1978 1979 1979 1979 1979 1980 1980 1980 1980
//
"
'%..
.~,1
FIG. 1. Bowel segment measuring 60 to 70 cm. is isolated approximately 50 cm. from ileocecal valve and positioned as U with terminal end directed towards cranium of patient and bottom of U to left side of patient.
longer i n the proximal leg to separate the outlet from the i n l e t w h e n the reservoir was closed. The mucous m e m b r a n e of the legs of the U t h e ~ v a s sutured, also with c o n t i n u o u s polyglycolic acid (fig. 2, B). Openings were m a d e close to the i n t e s t i n a l wall i n the m e s e n t e r y supplying the f u t u r e bases of the nipple valves, the continence-providing valve a t the outlet a n d the reflux-protecting valve at the inlet. Approxim a t e l y 1.0 cm. wide strips of fascia from the a n t e r i o r rectus sheet or of Marlex mesh, shaped as i l l u s t r a t e d i n figure 2, B, t h e n were b r o u g h t t h r o u g h the openings for l a t e r application a r o u n d the base of the nipple valves. The strips h a d been soaked i n a solution c o n t a i n i n g doxycycline. The i n t u s s u s c e p t e d valves t h e n were constructed. The bowel wall was grasped t h r o u g h the open l u m e n a n d the u n s p l i t ileal segments were i n t u s s u s c e p t e d p a r t l y into the l u m e n of the future reservoir (fig. 3, A). The i n t u s s u s c e p t e d nipple valves were approximately 5 cm. long. T h e nipple position was m a i n t a i n e d with a s t a p l i n g i n s t r u m e n t u s i n g special staple cartridges t h a t h a d no knife (fig. 3, B). Four such applications were performed, 2 of t h e m p a r t l y involving the mesentery. However, i n p a t i e n t s 1 to 3 no s t a p l i n g ins t r u m e n t n o r Marlex m e s h was used b u t the n i p p l e valves were constructed according to a n earlier method described by Kock a n d associates. 9 I n 5 p a t i e n t s a strip of fascia was used i n s t e a d of the Marlex mesh.
FIG. 2. A, legs of U are united at antimesenteric border with continuous 3-zero polyglycolic acid. Intestine is split open along suture line and incision is continued for 3 cm. on afferent limb. B, mucous membrane is sutured with continuous 3-zero polyglycolic acid. Openings are made in mesentery supplying future base of nipple valves.
k_.-
Fro. 3. A, intussuscept.ion at parts of afferent and efferent segments into future reservom B, fixation of nipple valves with stapling instruments.
1155
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR The intestinal plate then was folded and the reservoir was :losed with 2 continuous inverting 3-zero polyglycolic acid ~utures (fig. 4). The corners of the reservoir were pushed ~ownwards between the mesenteric leaves so that the posterior aspect of the reservoir was brought anteriorly (fig. 5). this maneuver allowed the pouch to be positioned in the pelvic cavity when the reservoir was secured later to the inner surface of the abdominal wall. The Marlex mesh or fascia was positioned as a cylinder around the base of the outlet and inlet, respectively, including the major part of the mesentery supplying the valve, and the ends of the strips were sutured together with 3 to 4 nylon sutures. Approximately half of the cylinder then was embedded between the intestinal walls by suturing the reservoir ~vall up to the cylinder with a few isolated polyglycolic acid sutures (figs. 5, C and 6). When this step was completed the length of the nipple valve measured approximately 5 cm. Care was taken not to make the cylinder too tight around the outlet and inlet. The ureters were implanted into the inlet segment with an open technique and splinted with soft polyethylene catheters. The proximal end of the inlet segment was closed with 2 rows of polyglycolic acid sutures (fig. 7). An opening then was made in the abdominal wall for the outlet of the reservoir. The peritoneum around the inner opening of the channel was excised and the rectus muscle was split at the cranial side of the opening to make room for the mesentery supplying the nipple valve and the outlet (fig. 7). Interrupted nonabsorbable sutures were placed from the lateral aspect of the Marlex mesh or fascia cylinder to the anterior rectus sheet. After the outlet of the reservoir had been pulled through the channel in the abdominal wall the medial aspect of the cylinder was secured with isolated sutures to the medial part of the anterior rectus sheath. A fiat stoma was constructed (fig. S). A urostomy catheter was positioned through the stoma for drainage of the reservoir. The reservoir procedure has been described in detail previously. 12 When an ileal conduit was converted into an ileal reservoir diversion the conduit with the previous ureteral implantations was connected to the inlet segment of the reservoir. In 2 patients the conduit was used for construction of the refluxprotecting valve and then connected via a short inlet to the reservoir. A catheter was inserted into the previous ileal conduit for postoperative drainage in these patients.
FIG. 4. Closure of reservoir with 2 continuous inverting 3-zero polyglycolieacid sutures.
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,"; .... i
FIo. 5. Reservoir is brought into final position by pushing corners of reservoir downwards between mesenterie leaves.
Postoperative management. General principles for postoperative management were followed. The ureteral catheters
Fro. 6. Fascia or Marlex mesh encircles base of nipple valve and ends are united with 3 to 4 nonabsorbable sutures. Reservoir wall is sutured to cylinder with isolated 3-zero polyglycolicacid sutures.
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1156
were removed a f t e r 10 days b u t t h e reservoir cathet d r a i n e d c o n t i n u o u s l y for 14 days. A f t e r this period the cat e t e r was c l a m p e d i n t e r m i t t e n t l y for 1 h o u r d u r i n g the thi: w e e k a n d for 2 h o u r s d u r i n g t h e fourth week. The reserv¢ c a t h e t e r t h e n was r e m o v e d and the p a t i e n t w a s i n s t r u c t e d e m p t y t h e r e s e r v o i r e v e r y 3 hours a t first and t h e n le frequently. The p a t i e n t s used clean b u t not sterile cathete for this purpose. T h e s t o m a w a s covered b y a s m a l l pad.
RESULTS
FiG. 7. Cylinder at efferent segment is attached to opening in anterior rectus sheath by use of nonabsorbable sutures.
-
:17 FIa. 8. Completed ileal reservoir in situ
Pt. No. 1 2 3 4 5 6 7 8 9 10 11 12
Early complications. T h e r e w a s no o p e r a t i v e m o r t a l i t y (t ble 2). L e a k a g e of u r i n e because of insufficient s u t u r e s led r e o p e r a t i o n a n d r e p a i r 7 days p o s t o p e r a t i v e l y in 1 patier T h e r e were no f u r t h e r complications r e l a t e d to t h e diversi( procedure in this p a t i e n t . In a n o t h e r p a t i e n t t h e vascul~ s u p p l y of t h e i n l e t s e g m e n t h a d been i m p a i r e d d u r i n g t] operation a n d r e o p e r a t i o n was n e c e s s a r y a few d a y s posto e r a t i v e l y for construction of a new i n l e t segment. Convale cence was uneventful in the r e m a i n i n g 10 p a t i e n t s . Late complications. Malfunction of t h e continenc providing valve n e c e s s i t a t i n g a revisional operation dev( oped after a few m o n t h s in 7 p a t i e n t s . Of these 7 p a t i e n t s corrective o p e r a t i o n for malfunction of t h e nipple valve w~ n e c e s s a r y twice before p e r m a n e n t continence was achiew in 2, sliding of t h e reflux-protecting valve n e c e s s i t a t e d su gical correction in 3 a n d a stricture a t t h e site of t h e u r e t e r i m p l a n t a t i o n w a s corrected surgically in 1. In t h e patie: who u n d e r w e n t r e o p e r a t i o n because of g a n g r e n e of t h e affe e n t s e g m e n t t h e volume capacity of t h e reservoir remain, s m a l l a n d a n a u g m e n t a t i o n p l a s t y w a s performed. I n S e p t e m b e r 1981 t h e histories a n d c u r r e n t s t a t u s of p a t i e n t s w e r e e v a l u a t e d with r e s p e c t to functional result u r i n a r y infections, r e n a l function, metabolic s t a t u s , morph( ogy of t h e mucosa and q u a l i t y of life. P a t i e n t 2 died in accident 6 m o n t h s a f t e r construction of the" continent ile reservoir a n d p a t i e n t 7 died 8 m o n t h s p o s t o p e r a t i v e l y m e t a s t a t i c b l a d d e r carcinoma. Thus, 10 p a t i e n t s w e r e e w u a t e d 9 m o n t h s to 6V2 y e a r s (mean 32 months) postoper tively. Continence w a s achieved in all p a t i e n t s , a l t h o u g h a re~ sional operation w a s n e c e s s a r y in 7 owing to malfunction t h e continence-providing valve. I n t e r m i t t e n t e m p t y i n g of t| reservoir w i t h a c a t h e t e r g e n e r a l l y is done easily w i t h i n 3 4 m i n u t e s . B e t w e e n e m p t y i n g s t h e p a t i e n t s w e a r a small p~ over the stoma. Of 10 p a t i e n t s 8 e m p t y the reservoirs 3 to t i m e s d u r i n g the d a y a n d g e n e r a l l y not a t all at night. Ho~ ever, 2 p a t i e n t s e m p t y more frequently, 5 to 7 t i m e s daft a n d 1 uses a n i n d w e l l i n g c a t h e t e r a t night. All p a t i e n t s h a v e been examined r e g u l a r l y by urograpl a n d "reservoirography" to test t h e competence of t h e nipp valves. P l a i n r a d i o g r a p h s after the reservoirs w e r e emptfi by c a t h e t e r i z a t i o n disclosed no r e s i d u a l u r i n e in a n y patie: (fig. 9). T h e volume c a p a c i t y of the r e s e r v o i r h a s been r
TABLE 2. Complications in 12 patients with urinary diversion via continent ileal reservoir Nipple Valve Complications Operative Complications Other Complications Incontinence Reflux Anastomotie leak
Surgical correction 2 times
Surgical correction
Surgical correction Surgical correction Gangrene of afferent segment
Surgical correction Surgical correction -Surgical correction 2 times Surgical correction
Insufficient volume capacity of reservoir Surgical correction Surgical correction
Ureteral implantation stenosis
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
1157
FIG. 9. A, reservoir filled with 300 ml. contrast medium through catheter. No reflux to afferent loop or upper urinary tract is noted. B, no 'etention is noted after reservoir is emptied through catheter.
Fro. 10. Urography 3 years postoperatively in patient 4. A, visualization of upper urinary tract, afferent loop (single arrow) and reservoir :double arrows). There is no dil~ation at any level. B, reservoir with marked prominence of afferent nipple (arrowheads).
corded regularly and after 3 months the capacity generally is >500 ml. without any inconvenience to the patient. In 3 patients incompetence of the reflux-protecting valve was found and 1 of these patients also had stenosis at the ureteral implantation into the inlet segment. However, these problems were corrected by a revisional operation. No progressive dilatation of the upper urinary tract or pyelonephritic changes of the kidneys were observed (fig. 10). Quantitative urine cultures have been done regularly in all patients. In 7 patients the cultures have been negative constantly and no prophylactic antibacterial therapy has been given, while in the remaining 5 the contents of the reservoir more or less permanently contained bacteria and only occasionally have the urine cultures been negative. However, symptomatic urinary infections have not been encountered. Acute pyelitis occurred in the patient with stenosis at the ureteral implantation before reimplantation was performed. Radioisotope renograms, 51chromium-ethylenediaminetetraacetic acid clearance, excretory urography as well as serum creatinine concentrations have remained unchanged during
followup. Serum concentration of electrolytes and the arterial acid-base status also have been normal. No signs of hematological or liver function disturbances were found. Biopsies obtained by endoscopy from the mucosa of the reservoir at regular intervals were studied by light and electron microscopy. A rapid continuous decrease in villous height leading to an almost flat mucosa was noted during the first 12 months postoperatively. There also was an increase of the crypt layer but normal mitotic frequency. Endoscopy 3 years postoperatively revealed a bladder-resembling surface with areas of intestinal appearance. Microscopically, the bladder-resembling surface showed few crypts and no villi, whereas the intestinal areas were similar to specimens obtained during the first year. Electron microscopy of the epithelium revealed regressive changes at the subcellular level. The morphological studies have been described in detail previously. 13 All patients are satisfied with this type of urinary diversion. The patients with previous types of urinary diversions were much relieved after conversion to the continent ileal
1158
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
reservoir and the elimination of external appliances was of great benefit. For those patients who were disabled seriously by other types of diversion conversion made rehabilitation possible. Stomal or parastomal skin problems have not occurred in any of the patients. A most significant gain with the operation was the confidence in the stoma, which allowed the patients to abandon previous restrictions in their social and vocational activities owing to incontinence and stomal problems. DISCUSSION
To accomplish continent supravesical urinary diversion an appropriate continence-providing principle must be found and the integrity of the upper urinary tract and renal parenchyma should not be endangered. The ideal method should ensure that 1) there is an intra-abdominal low pressure reservoir for collection and storage of urine, 2) the storage of urine in the reservoir should not result in disturbing shifts of water and solutes across the wall of the receptacle, 3) ascending urinary infections owing to reflux from the reservoir to the upper urinary tracts must be avoided and 4) the reservoir should be provided with an outlet valve that prevents involuntary expulsion of the contents but allows emptying when convenient. The continent ileal reservoir used in our study seems to meet these requirements. The ileal reservoir provides adequate low pressure volume capacity for collection and storage of urine, 14 and adapts to increasing volumes by enlargement, thereby allowing convenient intervals between emptyings. Because of the low pressure in the reservoir it does not obstruct urinary flow from the upper urinary tract. Consequently, progressive ureteral dilatation was not noted on urography at regular intervals. Large shifts of water and solutes occur across the normal intestinal mucosa and it is a well known problem inherent in the use of intestinal reservoirs for urine that these shifts may lead to metabolic disturbances and increased risk of water deprivation. Although long-term studies after ileocystoplasty indicate that metabolic disturbances o~ving to shifts of water and solutes across the ileal mucosa are not to be expected, v all patients were studied carefully with respect to this possibility. The transmucosal shifts in the reservoir were not of the magnitude to harm the patients and were compensated for easily by the kidneys. This is in accordance with a previous report in which 2 patients with normal renal function and urinary diversions via a continent ileal reservoir were studied even under loadin~ conditions, ls Furthermore, the transmucosal shifts may diminish with time parallel to the morphological adaptation of the mucous membrane. 'a,'s Reflux of the contents of the reservoir to the upper urinary tracts was prevented by the nipple valve constructed at the inlet segment. "Reservoirography" showed sliding of the reflux-protecting nipple valve and consequent reflux in 3 patients that was corrected surgically. By improved surgical technique in construction of the valve it should be possible to avoid incompetence of the reflux-protecting valve. This is of the utmost importance, since the contents of the reservoir was infected in 5 patients. In an experimental study on urinary diversion via a continent ileal reservoir without protection against reflux of infected contents from the reservoir,. the upper urinary tracts became dilated and rapid pyelonephritic renal deterioration ensued, s There also is experimental and clinical evidence indicating a relationship between reflux of bacteria-containing urine and progressive pyelonephritic renal deterioration after ileal conduit diversion. '7,'s Thus, the continent ileal reservoir, with its reflux protection, may at least theoretically be superior to the ileal conduit diversion with regard to deterioration of renal function. Despite the fact that the patients use clean but not sterile
catheters at emptying 7 had permanently negative urinary cultures. The complete emptying of the reservoirs by catheterization, which was confirmed by radiography of the reservoir, probably is important for this favorable finding. The ultimate goal of this procedure, to achieve complete voluntary control over the expulsion of the contents of the reservoir without the need for external appliances, was attained in all 12 patients although a revisional operation was necessary in 7 to achieve permanent continence. Malfunction of the continence-providing valve has been a major problem in patients with continent ileostomy after proctocolectomy and a corrective operation is necessary in up to 50 per cent of the patients. However, by modification of the technique for construction of the valve this late complication in patients with ileostomy more recently has been almost eliminated. 12,19 In the future, by adapting the modified technique for construction of the nipple valve to the urinary diversion procedure one may expect this distressing complication to be largely avoided. In comparison to techniques using an ileocecal segment for continent urinary diversion, the continent ileal reservoir involves a more complex, time-consuming surgical procedure. Furthermore, the use of a considerable length of small bowel for construction of the reservoir could interfere with absorption of bile salts and vitamin B12. However, if the terminal ileum is not used these consequences should be avoided. On the other hand, the advantage over the ileocecal reservoir is the low pressure in the reservoir and its adaptation to increasing volumes, which should eliminate the risk for obstruction against the urinary flow from the upper urinary tract and allow longer intervals between emptyings. Furthermore, the adaptation of the ileal mucosa to prolonged exposure to urine, resulting in villous atrophy and possibly diminished absorptive capacity, favors the present method. Our results indicate that urinary diversion via a continent ileal reservoir offers the patient a quality of life much superior to that with conventional urinary diversion procedures. The excellent functional results and the absence of harmful side effects in patients presently observed for up to 6½ years postoperatively justify continued clinical trial with this method. REFERENCES 1. Tilma, A., Christensen, T. B. and Fuglsang, E.: Tilvaerelsen efter Bricker-operation. Ugeskr. Laeger., 135: 2812, 1973. 2. Bricker, E. hi.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Ashken, hi. H.: An appliance-free ileocaecal urinary diversion; preliminary communication. Brit. J. Urol., 46: 631, 1974. 4. Ashken, hi. H.: Continent ileocaecal urinary reservoir. J. Roy. Soc. Med., 71: 357, 1978. 5. Zingg, E. and Tscholl, R.: Continent cecoileal conduit: preliminary report. J. Urol., 118: 724, 1977. 6. Kock, N. G.: Continent ileostomy. Prog. Surg., 12: 180, 1973. 7. Fax6n, A., Kock, N. G. and Sundin, T.: Long-term functional results after ileocystoplasty. Scand. J. Urol. Nephrol., 7: 127, 1973. 8. Kock, N. G., Nilson, A. E., Norl6n, L., Sundin, T. and Trasti, H.: Changes in renal parenchyma and the upper urinary tracts followingurinary diversion via a continent ileum reservoir. An experimental study in dogs. Scand. J. Urol. Nephrol., suppl. 49" 11, 1978. 9. Kock, N. G., Nilson, A. E., NorI~n, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir. Clinical experience. Scand. J. Urol. Nephrol., suppl., 49: 23, 1978. 10. Madigan, hi. R.: The continent ileostomy and the isolated ileal bladder. Ann. Roy. Coll. Surg. Engl., 58: 62, 1976. 11. Leisinger, H. J., Schauwecker, H. and S/iuberli, H.: Dynamics of the continent ileal bladder. An experimental study in dogs. Invest. Urol., 15: 49, 1977. 12. Kock, N. G., Myrvold, H. E., Nilsson, L. O. and Ahr4n, C.:
URINARY DIVERSION VIA CONTINENT ILEAL RESERVOIR
13.
14.
15.
16.
17. 18.
19.
Construction of a stable nipple valve for the continent ileostomy. Ann. Chir. Gynaec., 69: 132, 1980. Philipson, B. M., Nilsson, L. O., Norldn, L., Kock, N. G. and ./kt{ris, C.: Mucosal adaptation in ileum after long time exposure to urine. In: Mechanisms of Intestinal Adaptation, MTM Press Ltd., p. 613, 1982. Norl~n, 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. Jagenburg, R., Kock, N. G., Norl~n, L. and Trasti, H.: Clinical significance of changes in composition of urine during collection and storage in continent ileum reservoir urinary diversion. An experimental and clinical study. Scand. J. Urol. Nephrol., suppl. 49: 43, 1978. Hansson, H.-A., Kock, N. G., Norl~n, L., Philipson, B., Trasti H. and .$thr~n, C.: Morphological observations in pedicled ileal grafts used for construction of continent reservoirs for urine. Scand. J. Urol. Nephrol., suppl., 49: 49, 1978. Richie, J. P., Skinner, D. G. and Waisman, J.: The effect of reflux on the development of pyelonephritis in urinary diversion: an experimental study. J. Surg. Res., 16: 256, 1974. Bergman, B., Kaijser, B. and Nilson, A. E.: Conduiturinary diversion and urinary-tract infection. I. Serum antibody titers against Escherichia coli and Proteus mirabilis in relation to urographic findings. Scand. J. Urol. Nephrol., 13: 65, 1979. Kock, N. G., Myrvold, H. E., Nilsson, L. O. and Philipson, B. M.: Continent ileostomy. An account of 314 patients. Acta Chir. Scand., 147: 67, 1981.
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EDITORIAL COMMENT This article on urinary diversion with a continent ileal reservoir is a classic advance in urological surgery. The authors clearly and beautifully describe their results in 12 patients, including the complications, and the results are stunningly good. They have adapted our ileocystoplasty technique1 and added the principle of intussusception to prevent reflux and maintain continence.2.3 Their results are excellent and my belief is that this advance in urological cutaneous urinary diversion will, in the near future, become the method of choice for most urinary cutaneous diversions. The idea of having a continent cutaneous diversion is an old one in urological surgery but this is the first one that I know of that can be called a real success. We look forward to further advances in this field.
Willard E. Goodwin Department of Surgery University of California School of Medicine Los Angeles, California 1. Goodwin, W. E., Winter, C. C. and Barker, W. F.: "Cup-patch" technique ofileocystoplasty for bladder enlargement or partial substitution. Surg., Gynec. & Obst., 108: 240, 1959. 2. Grey, D. N., Flynn, P. and Goodwin, W. E.: Experimental methods of ureteroneocystostomy: experiences with the ureteral intussusception to produce a nipple or valve. J. Urol., 77: 154, 1957. 3. Smith, G. I. and Hinman, F., Jr.: The intussuscepted ileal cystostomy. J. Urol., 73: 261, 1955.