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Keywords:

  • bladder carcinoma;
  • ileal neobladder;
  • Stanford pouch;
  • urodynamics

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Abstract Purpose The clinical, urodynamic and endoscopic aspects of the Stanford pouch ileal neobladder formed with absorbable staples were investigated.

Methods A Stanford pouch ileal neobladder was formed using absorbable staples after radical cystoprostatectomy in 30 male patients with the diagnosis of muscle invasive carcinoma of the bladder between 1995 and 1998. The mean age of the patients was 62 (range 41–70) years. Patients were followed with arterial blood gas, serum biochemistry, pouch cystography, urodynamic tests and endoscopy.

Results Five (16.7%) patients had early postoperative complications and three were related to the neobladder. One year postoperatively, low grade (I, II) vesicoureteral reflux was present in five (16.7%) cases. The mean preoperative and 6 months postoperative serum creatinine levels were 1.07 ± 0.3 mg/dL and 1.2 ± 0.4 mg/dL, respectively, but the difference was not statistically significant (P = 0.1). Six months postoperatively the mean serum chloride level was 109 ± 4.5 (range 100–113) mmol/L and the mean arterial blood pH was 7.37 ± 0.2 (range 7.3–7.4). Two (6.7%) patients required oral alkaline supplementation because of high chloride levels. All the patients except one were continent throughout the day after 1 year. However, nocturnal enuresis was present in 25 (83.3%) cases. The pouch capacity was increased gradually up to 12 months postoperatively and the mean pouch capacity 12 months postoperatively was 460 ± 95.8 mL. Micturition occurred spontaneously in most patients while some needed abdominal straining. None of the patients had a residual urine of more than 60 mL. The mean maximum flow rate 6 months postoperatively was 9.8 (range 5.4–15.0) mL/s. After 6 months the stapled edge was noticed as a nodular line. One year postoperatively only a white scar could be observed at the suture line.

Conclusion The Stanford pouch ileal neobladder constructed using absorbable staples was able to provide a good capacity–low pressure reservoir with a low rate of complications.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

The introduction of ileal bladder substitution by Couvelaire1 has provided a continent diversion that has decreased the morbidity of radical cystectomy considerably. Since then, different types of neobladder have been described and each technique has certain advantages and disadvantages. The complications of intestinal bladder substitution are mainly related to the length and type of the intestinal segment used; the length of the proximal limb where the ureters are anastomosed; and the technique itself.2 We have been forming Stanford pouch ileal neobladders using absorbable staples since 1995. Radical cystectomy plus lymph node dissection plus construction of a neobladder is a lengthy procedure and the invention of automatic surgical staplers loaded with absorbable staples has considerably decreased the operation time as well as simplifying the procedure. The objective of the present study was to present the clinical, urodynamic and endoscopic aspects of the Stanford pouch ileal neobladder formed with absorbable staples in a series of 30 patients.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Patients

A Stanford pouch ileal neobladder was formed using absorbable staples after radical cystoprostatectomy in 30 male patients with the diagnosis of muscle invasive carcinoma of bladder between 1995 and 1998. The mean age of the patients was 62 (range 41–70) years and all the patients were operated on by the same surgical team. Patients were followed with arterial blood gas, serum biochemistry, urinalysis and urine culture 3 weeks postoperatively and at 3-month intervals thereafter. In addition, pouch cystography, intravenous pyelography, urodynamic tests and endoscopy were performed at 6-month intervals. A brief voiding history was also obtained for each patient at every visit. Patients were accepted as continent when they leaked less than half a pad of urine through the day.

Urodynamic tests were performed using the Synectics AB (Stockholm, Sweden) device. A 3-channel Bard catheter was used in cystometry and the pouch was filled with physiological saline at 20°C at a rate of 30–50 mL/min. The end-filling pressure was determined as the pressure at the point of leakage or when the patient felt considerable abdominal discomfort (maximum capacity). Uroflowmetry followed cystometry and finally residual urine was determined with a small calibre catheter.

Statistical analysis was done using the paired t-test.

Surgical technique

The surgical technique is shown in Fig. 1.

image

Figure 1. Surgical technique for the construction of the Stanford pouch ileal neobladder. (a) A 40 cm segment of ileum is isolated and the proximal 10 cm is left as the afferent limb. The rest of the segment is folded over itself to form the shape of a ‘U’ and two enterotomies are performed cranially and caudally. (b) The stapler is inserted from the caudal enterotomy and operated. (c) The other stapler is put through the cranial enterotomy and operated. (d) The enterotomies and the distal end of ileum are closed and the ureters are anastomosed to the proximal limb.

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A 40 cm segment of ileum was isolated 20 cm proximal to the ileocecal valve. The continuity of the bowel was then restored by the automatic GIA and TA staplers (Autosuture, US Surgical, Norwalk, CT, USA). The proximal 10 cm of the isolated bowel segment was left as the afferent limb and the rest of the segment was folded over to form the shape of ‘U’ with the help of stay sutures. Two enterotomies were performed cranially and caudally to the folded segment for insertion of the staplers. The automatic poly GIA 75 mm stapler loaded with absorbable staples (Autosuture, US Surgical) was inserted from the caudal enterotomy and operated. The other stapler was then put through the cranial enterotomy and operated. These staplers provided simultaneous detubularization and closure of the pouch. Sometimes the length of the staplers was insufficient so that the septum left in the middle of the pouch had to be divided by scissors and the minute opening created on both sides of the pouch was then closed manually. The distal ileal end and the cranial enterotomy were closed either by absorbable poly TA 55 mm staples (Autosuture, US Surgical) or manually. The ureters were anastomosed to the proximal limb by the Wallace method and 6–8 F feeding tubes were used as stents.3 An urethral catheter was inserted and the urethra was anastomosed to the caudal enterotomy with 2.0 polyglactin sutures. All patients were drained with a 20 F sump drain. Standard bowel preparation was done in all patients at the preoperative period and broad spectrum antibiotics were started 1 day before surgery and continued until the removal of the ureteral catheters. The ureteral catheters were removed postoperativly days 5–7 and the drain at 8 days. A pouch cystography was obtained 21 days postoperatively and in the absence of leakage the urethral catheter was removed. Patients were instructed to void at 2–3 h intervals.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

The use of absorbable staples considerably decreased the operation time and the construction of the pouch took no longer than 15 min in any patient. The mean follow-up period was 26 (range 6–42) months. Tumour recurrence occurred in seven (23.3%) patients and four cycles of combination chemotherapy were administered, including cisplatinum, methotexate, epirubicine and vinblastine. None of these patients experienced chemotherapy-related side-effects. Despite treatment, three (10%) patients died of metastatic disease.

Complications

Five (16.7%) patients had early postoperative complications. Three (10%) complications were related to the ileal neobladder. One patient had unresolved bacteriuria despite antibiotic treatment. His urine culture was positive for Pseudomonas aureginosa. Antibiotic therapy was changed according to antibiotic sensitiv-ity results and the infection was eradicated. Persistent urinary leakage was present in another patient and bilateral percutaneous nephrostomy was performed. Anterograde pyelography revealed obstruction of the right lower ureter and ileoureteral revision was considered. Right to left transureteroureterostomy was performed as there was ischemia of the right lower ureter and the left ureter was reanastomosed to the pouch. One patient pulled out his urethral catheter in the first week postoperatively during a psychotic episode. During surgical exploration the ileourethral anastomosis was found to be totally disrupted and reanastomosis was done. Unfortunately that patient became totally incontinent. There were two (6.7%) neobladder-unrelated complications. One patient died of pulmonary embolism and another had wound infection. Ureterointestinal stenosis did not occur in any patient.

Pouch cystography obtained 3 weeks postoperatively revealed vesicoureteral reflux (VUR) of various degrees (International Classification System) in 21 (70%) patients. At 1 year postoperatively, only low grade (I,II) VUR was present in five (16.7%) cases. Pouch cystography of a patient with reasonable capacity is shown in Fig. 2.

image

Figure 2. Cystography of a patient at 6 months postoperatively.

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Renal function and acid–base status

The mean preoperative and 6 months postoperative creatinine measurements were 1.07 ± 0.3 mg/dL and 1.2 ± 0.4 mg/dL, respectively, and the difference was not statistically significant (P = 0.1). Six months postoperatively, the mean serum chloride level was 109 ± 4.5 (range 100–113) mmol/L and the mean arterial blood pH was 7.37 ± 0.2 (range 7.3–7.4). Two (6.7%) patients required oral alkaline supplementation because of high chloride levels.

Continence

The patient who pulled out the catheter was totally incontinent. All other patients were continent throughout the day after 1 year. However, there was nocturnal enuresis in 25 (83.3%) patients. Four (13.3%) patients were totally continent.

Urodynamic tests

The pouch capacity was increased gradually up to 12 months postoperatively. The mean postoperative pouch capacities at 3 weeks, 6 months, 12 months and 24 months are shown in Table 1. There was a statistically significant increase between each successive measurement except after 12 months. In other words, we did not observe any significant change in pouch capacity after 12 months postoperatively. Six months postoperatively the Stanford pouch neobladder provided good capacity and the end-filling pressure did not exceed 30 cm H2O in any case thereafter. There was a steady increase in bladder pressure with increase in bladder volume (Fig. 3). None of the patients could achieve a true sense of bladder fullness. Most cases experienced abdominal discomfort when the bladder was full. The micturition occurred spontaneously in most patients while some needed abdominal straining. In the present series no case had a residual urine of more than 60 ml. The mean maximum flow rate calculated 6 months postoperatively was 9.8 (range 5.4–15.0) mL/s and the typical voiding pattern is shown in Fig. 4. Voiding was initiated with pelvic muscle relaxation and abdominal straining. Table 2 shows a typical voiding pattern analysis.

Table 1.  Mean bladder capacity with regard to postoperative time
Time postoperativelyMean ± SD pouch capacity (mL)Significance of the difference from the previous measurement
3 weeks259.3 ± 40.2
6 months391 ± 76.5P = 0.0001
12 months460 ± 95.8P = 0.016
24 months520.8 ± 91P = 0.11
image

Figure 3. Cystometry of a case with a Stanford pouch ileal neobladder at 6 months postoperatively. There is a slow increase in intravesical pressure (Pves) with increase in bladder volume. The maximum bladder capacity is 371 mL and the intravesical pressure at maximum capacity is 17.7 cmH2O. InfVol, infused volume; Pabd, abdominal pressure; Pdet, detrusor pressure.

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image

Figure 4. Voiding pattern of a patient with a Stanford pouch ileal neobladder 6 months postoperatively. (a) Flow/time; (b) volume/time.

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Table 2.  Typical voiding pattern analysis
Uroflowmetry analysisValue
PositionStanding
Subjective gradingNormal
Residual urine (mL)
Voided volume (mL)469
Bladder capacity (mL)469
Maximum flow [QMax] (mL/s)8.8
Average flow (mL/s)3.2
Voiding time (s)140.5
Flow time (s)135.1
Time to maximum flow (s)6.0
Volume at maximum flow (mL)59
Flow index (1/s)0.3

Endoscopic appearance

After 6 months, the stapled edge was noticed as a nodular line. One year postoperatively, only a white scar could be observed as the suture line.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Many different techniques have been described for orthotopic neobladders using different gastrointestinal segments. The incorporation of intestinal segments into the bladder is known to cause problems such as malabsorption and metabolic disturbances.2 We prefer to use the Stanford pouch ileal neobladder as it requires the use of only 40 cm of ileum and it is technically simple.4 A disadvantage of this pouch may be an increase in pressure according to the La Place law (pressure = tension/radius); however, this does not seem to be applicable because of the inherent capacity of intestine to distend.5 It is shown that the Stanford pouch could provide a good capacity without an increase in pressure.5,6 In our patients the capacity of ileal neobladder was found to increase gradually in time up to 12 months postoperatively. The mean pouch capacity at that time reached 460 mL and no significant change occurred thereafter. Urodynamic tests performed in 28 patients with a Stanford pouch by Iwakiri et al. also confirmed good reservoir characteristics with an average capacity of 699 mL at an average follow-up of 18 months.6 In the same series, mean post voiding residual urine was reported as 137 mL. Considering their high neobladder capacity when compared to our patients, it is not surprising that none of our patients had a residual urine more than 60 mL.

Good compliance is probably the most important factor for the maintenance of continence in ileal neobladder patients.5,6 As a result of good compliance, 93% of patients in the report by Iwakiri et al. were continent throughout the day. All our cases except the one who pulled out his catheter were also day-time continent (96.7%). Night-time continence was achieved in 61% of patients of Iwakiri et al. and was reported to be 84% by Boyd et al.7 and 92% by Miller et al.8 When compared to these reports the incidence of nocturnal incontinence was considerably higher (83.3%) in our patients, but this rate represents night-time incontinence when the patient did not wake up for voiding. This could also be partly attributed to relatively lower pouch capacity and shorter follow-up period during which the patients were instructed to void at set times also during the night. As the pouch capacity increases with time, the frequency of night-time voids should be individualized for each patient. Our final impression is that most cases could achieve night-time continence by waking up at least twice per night after 1 year from the operation. Similarly, the average time to achieve night-time continence was found to be 8 (range 2–24) months in the series of Iwakiri and Freiha.5 They observed that 78% of their cases needed to void at least once to stay dry at night and the average number of voids/night to maintain continence was two. The authors found no significant difference in basal neobladder pressure, phasic contraction pressure and maximum urethral closure pressure between night-time continent and incontinent patients. However, a significant difference was present with regard to compliance between day-time continent and incontinent cases.

Another disadvantage of the Stanford pouch is the high rate of vesicoureteral reflux. Vesicoureteral reflux was present in 62% of Iwakiri and Freiha's cases; however, this neither produced any detrimental effect on renal function nor resulted in febrile urinary tract infections.5 We observed that 3 weeks postoperatively, 71% of the patients had various degrees of reflux which was decreased to 16.7% after 1 year and no febrile urinary tract infections occurred. The increase in pouch capacity with time and good plication of the afferent limb were possibly the important factors to decrease the rate of reflux.

All of the patients in our series could urinate spontaneously with a mean maximum flow rate of 9.8 mL/s. The physiology of micturition in the ileal neobladder is rather different than the native bladder as the intestine has no voluntary motor innervation. The ileal neobladder depends on the pressure generated in the reservoir upon filling for the evacuation of the bladder.9 When the patient desires to void, the outlet resistance is decreased by pelvic floor relaxation and voiding occurs. However, some patients may need abdominal straining to provide extra pressure to facilitate voiding.9,10 As the patient lost the afferent feedback between the detrusor and central nervous system, a rise in ileal neobladder pressure upon filling may cause leakage of the urine.9,10 Therefore patients must learn how to relax and contract their pelvic muscles to provide both continence and successful voiding process, which takes time. Problems can arise due to insufficient relaxation of the pelvic musculature because of residual urine, namely overdistention, infection and calculus formation.6,11 Chronic overdistention of the reservoir also increases the risk of metabolic abnormalities because of increased contact time.2,9 The Stanford pouch is a good type of ileal neobladder in this regard as it utilizes a short segment of bowel and produces a relatively small but sufficient reservoir capacity as in our study. Mikuma et al. stated that voiding dysfunction in ileal neobladder could be a result of incorrect location of the bladder outlet,12 which emphasizes the importance of good surgical technique. The early complication rate (16.7%) in our series is similar to previous reports; however, as the follow-up period is short, long-term complication rates are not available.5 Recently, Hautmann et al. published the long-term complications and functional results of the Hautmann pouch ileal neobladder in 363 patients.11 The early and late complication rates were 39% and 32%, respectively, but the Hautmann pouch utilized a longer segment of ileum and was constructed by a different technique.

The ileal neobladder was also found to be safe with regard to acid–base balance. We observed hyperchloremic acidosis in only two (6.7%) patients who promptly responded to the treatment. Similarly, Racioppi et al. recently reported the incidence of hyperchloremic acidosis as 7.9% in patients with ileal and ileocecal neobladder and found no difference between the two techniques with regard to acid–base imbalance.13 Preservation of renal function; villous atrophy and decrease in absorptive capacity with time; the use of a short segment of ileum; and low amount of residual urine are probably the most important advantages of the Stanford pouch which protects the patient from metabolic disturbances. It was shown that the length of the ileum resected correlated with absorption capacity, and 50 cm was the critical margin for vitamin B12 absorption from the ileum.14,15 Accordingly, patients with the Stanford pouch ileal neobladder would probably have a lower risk for vitamin B12 malabsorption.

An important technical point in our series is the use of automatic staplers loaded with absorbable staples for the construction of the pouch. Radical cystectomy and construction of the ileal neobladder is a lengthy and technically demanding procedure. The use of automatic staplers and absorbable staples not only shortens the operation time but simplifies the procedure as well. The invention of absorbable staples has led to more widespread use of continent reservoirs because of technical simplicity. Montie et al. compared the ‘W’ stapled ileal reservoir with hand sewn reservoirs and reported that 32% of the cases in stapler group had poor reservoir characteristics.16 They suggested that the ischemia of the anterior ileal segment between adjacent stapler lines might be the cause of fibrosis and poor distention of the reservoir. They also observed that septations persisted in the reservoir at sites where adjacent limbs were not anastomosed entirely. Probably, the ‘W’ configuration and the technique were the main problems in that series. However, Paolini et al.17 and Altugˇet al.18 used the automatic staplers for the construction of ileal neobladders with good functional results. Other authors also showed the utility of GIA absorbable staples in the construction of Indiana pouches and ileocecal reservoirs.19,20 We did not face any problems in pouch capacity and compliance due to the use of absorbable staples. This may partly be related to the rather simple configuration of the Stanford pouch. The main disadvantages of absorbable staples are the need to divide the septum with scissors when the length of the staplers is insufficient for the construction of the whole pouch and the rigidity of the suture line. After 1 year, we observed only a white scar at the suture line endoscopically.

In conclusion, the Stanford pouch ileal neobladder constructed with absorbable staples was able to provide a good capacity–low pressure reservoir with a low rate of complications. The use of absorbable staples not only shortens the operation time but also simplifies a technically demanding procedure. Short-term results with regard to renal function and acid–base status are also encouraging. However, the patients must be instructed to void at set times during the day and also at night to achieve continence. As the pouch capacity increases with time, the frequency of night-time voids should be individualized for each patient.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  • 1
    Couvelaire R. Le reservoir ileale de substitution après la cystectomie total chez l'homme. J. Urol. (Paris) 1951; 57: 408.
  • 2
    Stamfer DS & McDougal WS. Metabolic and nutritional complications. Urol. Clin. N. Amer. 1997; 24: 71522.
  • 3
    Wallace DM. Uretero-ileostomy. Br. J. Urol. 1970; 42: 52934.
  • 4
    Freiha FS. Treatment options for patients with invasive bladder cancer. In: Stamey TA (ed.). Monographs in Urology. Vol. 11, No. 3. Medical Directions, Montverde, 1990; 3347.
  • 5
    Iwakiri J & Freiha F. Stanford pouch ileal neobladder: Clinical, radiologic and urodynamic follow-up. Urology 1993; 41: 51722.
  • 6
    Iwakiri J, Gill H, Anderson R & Freiha F. Functional and urodynamic characteristics of an ileal neobladder. J. Urol. 1993; 149: 10726.
  • 7
    Boyd SD, Leiskovsky G & Skinner DG. Kock pouch bladder replacement. Urol. Clin. N. Amer. 1991; 18: 6418.
  • 8
    Miller K, Wenderoth UK, De Petriconi R, Kleinschmidt K & Hautmann R. The ileal neobladder: Operative technique and results. Urol. Clin. N. Amer. 1991; 18: 62330.
  • 9
    Turner WH, Mills MD & Studer UE. What you can expect regarding patient voiding following orthotopic reconstruction. Contemp. Urol. 1998; 10: 3340.
  • 10
    Koraitim MM, Atta MA & Foda MK. Desire to void and force of micturition in patients with ileal neobladders. J. Urol. 1996; 155: 12146.
  • 11
    Hautmann RE, De Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R & Paiss T. The ileal neobladder: Complications and functional results in 363 patients after 11 years of followup. J. Urol. 1999; 161: 4228.
  • 12
    Mikuma N, Hirose T, Yokoo A & Tsukamoto T. Voiding dysfunction in ileal neobladder. J. Urol. 1997; 158: 13658.
  • 13
    Racioppi M, D'addesi A & Fanasca A et al. Acid–base and electrolyte balance in urinary intestinal orthotopic reservoir: Ileocecal neobladder compared with ileal neobladder. Urology 1999; 54: 62935.DOI: 10.1016/s0090-4295(99)00317-9
  • 14
    Pannek J, Haupt G, Schulze H & Senge T. Influence of continent ileal urinary diversion on vitamin B12 absorption. J. Urol. 1996; 155: 12068.
  • 15
    Racioppi M, D'addesi A & Fanasca A et al. Vitamin B12 and folic acid plasma levels after ileocecal and ileal neobladder reconstruction. Urology 1997; 50: 88892.
  • 16
    Montie JE, Pontes JE & Powell IJ. A comparison of the W-stapled ileal reservoir with hand-sewn reservoirs for orthotopic bladder replacement. Urology 1996; 47: 47681.
  • 17
    Paolini R, Viggiani F, Bragaglia A & Costantini FM. The ileal neobladder: Simple detubularization technique using automatic surgical staplers and absorbable staples. Br. J. Urol. 1996; 77: 7478.
  • 18
    Altugˇ U, Uygur MC, Yaman I. & Erol D. A novel continent cutaneous reservoir: Application of appendiceal Mitrofanoff principle to Stanford pouch. Tech. Urol. 1997; 3: 20912.
  • 19
    Kirsch AJ, Hensle TW & Olsson CA. Rapid construction of right colon pouch: Initial clinical experience. Urology 1994; 43: 22834.
  • 20
    Rowland RG. Present experience with the Indiana pouch. World J. Urol. 1996; 14: 928.