Objective To report the functional results of continent cutaneous urinary diversion with ileum, using the serous-lined extramural valve and Mitrofanoff procedure for the continence mechanism.
Patients and methods From April 1999 to October 2001, 18 patients (mean age 68 years) underwent radical cystectomy for invasive bladder cancer involving the bladder neck, urethra or prostate; they then had an ileal continent cutaneous T pouch constructed. The mean (range) follow-up was 12 (4–20) months. The first five patients had reconstructions using the original orthotopic T-pouch configuration, but in subsequent patients the technique was simplified, reducing the ileal segments. The ureteric-intestinal anastomosis was made using a split-cuff nipple technique.
Results All patients were continent day and night, and there were no late complications. All cutaneous continent T pouches had a good capacity and low pressure, with no urinary reflux. No catheterization difficulties were reported and the evacuation intervals were ≈ 4 h.
Conclusions This ileal cutaneous continent diversion is a versatile technique; the T-valve can be used successfully as a continent mechanism, ensuring continence day and night. The simplified technique maintains a reservoir of good capacity and compliance, thus preserving ≈ 13 cm of ileal tract. The ureteric intestinal anastomosis by the split-cuff nipple technique is suitable in undilated and peristaltic ureters.
Since 1982 the Kock pouch has been the most frequently used continent cutaneous urinary diversion with an ileal tract. In this reservoir an intussuscepted nipple valve is used both for continent and antireflux procedures . Skinner et al.[2,3] modified the Kock pouch, using a Dexon collar fixation and three rows of staples to fix the valve. However, patients with a Kock pouch were significantly more likely to require surgical revision for three main complications, i.e. stenosis, calculi and prolapse of the ileal nipple [4–6].
Carr and Webster  compared the Kock pouch and a right colonic continent urinary diversion, concluding that the rate of surgical revision was much higher with the former, thus favouring the colonic pouch. The new continent urinary outlet proposed by Abol-Eneim and Ghoneim was used successfully in orthotopic and continent cutaneous urinary diversion [8,9]. Stein et al. used both a serous-lined extramural tunnel and the Mitrofanoff principle to construct an orthotopic T pouch. This T-valve procedure is used for the uretero-intestinal anastomosis with an antireflux technique.
We present an application of the T-valve procedure in continent cutaneous urinary diversion constructed using ileum, where the valve is used as a continence mechanism. The uretero-intestinal anastomosis is made using the split-cuff nipple technique, as described previously .
Patients and methods
Between April 1999 and October 2001 a continent catheterizable cutaneous diversion with a T-pouch procedure was used in 14 men and four women (mean age 67 years, range 53–78). All patients had undergone radical cystectomy and bilateral lymphadenectomy for bladder cancer involving the bladder neck and urethra in women, and urethra or prostatic stroma in men. Four woman and eight men underwent a simultaneous urethrectomy where the urethra or prostate were involved.
All patients were fully informed of the options and a continent cutaneous urinary diversion proposed as an alternative to an ileal conduit. Photographs and videotapes were used to better illustrate to the patients the self-catheterizable stoma. Although no specific age threshold was chosen, from experience we do not propose this continent cutaneous urinary diversion in all older patients, but decide using biological rather than chronological criteria.
The ileal continent cutaneous diversion uses the T-valve for the continence mechanism, with a pouch configured as described by Stein et al. in the orthotopic diversion. A 62-cm segment of distal ileum is isolated and the continuity of bowel re-established. The isolated bowel segment is subdivided into three sections; the first (distal 44 cm) is used for the reservoir, the second (intermediate 7 cm) is removed (to allow mobilization of the third) and the proximal tract (10 cm) used to create the outlet valve. The first segment is placed in a V configuration and fixed by 3/0 silk sutures (3 cm each) (Fig. 1a). After the first five patients were treated using this procedure, a technical modification was devised using only two ileal segments and the same configuration (Fig. 1b). The first is 40 cm long (for the reservoir), while the second is 10 cm long for the continence mechanism, with a long mesenteric incision between these segments to enable good mobilization of the afferent limb into the reservoir. The removal of the mesenteric fat gives good reservoir elasticity, maintaining good capacity and compliance.
Four mesenteric windows are created in the proximal tract to unite it to the first segment by 3/0 silk seromuscular sutures. The continence mechanism is then created, anchoring the terminal 5 cm of the afferent ileal segment into the serosal-lined trough that is fixed at the base of the two adjacent 20 cm ileal segments. The tract is then tapered around the 18 F Nelaton catheter using a gastrointestinal stapler. At the end of this tract the five metallic staples are omitted and sutured instead with polyglactin 3/0 to improve the continence mechanism. The antemesenteric border (V shaped) is incised by diathermy to create proximally two medial flaps, which are tubularized. The tapered segment is then embedded and fixed by polyglactin 3/0 in a serous-lined extramural trough with the mesentery behind the reservoir (Fig. 2). Each ureter is split and introduced into the upper tract of the reservoir. A circular tract of the reservoir is removed to avoid kinking of the ureteric implant. The uretero-intestinal anastomosis is made with the split-cuff nipple technique, using 4/0 single polyglactin sutures (Fig. 3). Stents are brought out through the T tunnel valve with a Nelaton catheter, and the reservoir folded and closed with a 3/0 polyglactin running suture.
On completion the system is tested hydraulically to check the water-tightness of the sutures. The proximal ileal tract lies just behind the midline of the rectal muscle tract and is then anastomosed to the skin of the umbilicus. The 18 F Nelaton catheter and the ureteric stents are passed outside and fixed to the skin by sutures. The reservoir is irrigated daily with warm saline solution to remove mucus.
Parenteral fluids were maintained until bowel function resumed and prophylactic antibiotics given routinely for 10 days. The Jackson Pratt drain was removed after a pouchgram confirmed watertight sutures. The stents were removed ≈ 12 days after the pouchgram. Patients were allowed home at 16–22 days with a 20 F Foley catheter. After 20 days the pouch was evaluated fluoroscopically with dilute contrast material and saline [1,4]. The pouch was kept drained for 15 days before training by intermittent clamping of the catheter. All patients start to self-catheterize ≈ 30 days after surgery and after 40 days patients evacuated the pouch every 4 h.
At 3 and 6 months the patients were assessed by fluoroscopy and urodynamics, with IVU at 6 months. The upper urinary tract was assessed every 2 months by renal ultrasonography, electrolyte values, analysis of blood gases, urine microscopy and urine culture. Patients were questioned to determine incontinence and other complaints, with continence evaluated as ‘excellent’ (no leakage and the patient satisfied), ‘good’ (with slight or moderate leakage needing one or more small pads, respectively, but the patient satisfied), or ‘incontinent’ (with more discomfort and needing many pads).
The mean range operative duration for complete en bloc radical cystectomy with bilateral pelvic lymphadenectomy and ileal continent cutaneous diversion was 5.3 (4–7) h. The mean (range) follow-up was 14 (4–20) months. There were no deaths during or after surgery, and no late complications or complications directly related to urinary diversion. Two patients had prolonged ileus which was treated conservatively. All patients were continent and there was no evidence of reflux in the upper urinary tract in all pouchgrams taken at 20 days and 6 months. IVU showed a normal upper tract in all patients. Two patients underwent adjuvant chemotherapy, for which the Foley catheter was left in situ, to avoid complications from over-absorption of the chemotherapy agents. On patients had adjuvant radiotherapy chemotherapy. Two patients died after 10 and 14 months from progressive disease. However, all patients were continent and able to self-catheterize; the urodynamic assessment at 3 and 6 months showed a mean (range) capacity of 400 (320–490) mL with a mean pressure of 16 (10–22) cmH2O.
Continent cutaneous urinary diversion is indicated for bladder cancer involving the bladder neck and prostate, neuropathic bladder, contracted bladder with sphincter deficiency after previous radiotherapy, urethral recurrence and in urinary conversion. Several intestinal tracts can be used to construct the diversion. An ileal segment is preferable as it preserves the ileal-caecal valve, avoiding the development of malabsorption and deficiency syndromes.
We have experience with the split-cuff nipple technique used as the uretero-intestinal anastomosis in the orthotopic reservoir with a Camey II procedure, and developed it further to reduce the rate of complications from ureteric kinking. Adding the serous-lined extramural tunnel allowed a continent urinary diversion to be constructed with ileum in a different configuration. Thus we used the T pouch configuration described by Stein et al. to construct the diversion and the valve for the continence mechanism in the first five patients but simplified the technique, reducing the use of intestine and maintaining the same urodynamic features. This system permits good mobilization of the ileal segment introduced into the reservoir for the continence mechanism and spares 10–13 cm of ileum. This reservoir incorporates an excellent valve for the continence mechanism and guarantees a good capacity, with low pressure. The continence mechanism is easy to catheterize; the umbilical stoma preserves the patient's body image and assists in maintaining their quality of life. The state of fullness of the reservoir can also be sensed by the patient. The ureteric intestinal anastomosis using the split-cuff nipple technique is easy to construct and suitable for this reservoir, providing excellent results in a normal upper urinary tract with peristaltic and undilated ureters. This urinary continent cutaneous diversion is now our choice of procedure after cystectomy for bladder cancer involving bladder neck, prostate or urethra. However, in those with dilated and atonic ureters we use a cutaneous continent pouch with ileum in an inverted W configuration, thus using the serous-lined extramural tunnel for the continence and antireflux mechanism.
A longer follow-up is required to evaluate fully the success of the present urinary diversion, but future developments of an artificial bladder could change these procedures and the present techniques, although the serous-lined extramural tunnel procedure must be considered a milestone in surgery for urinary tract reconstruction.
G. Marino, MD, Deputy Director.
M. Laudi, MD, Urologist.
G. Marino, Department of Urology, Mauriziano Hospital, Largo Turati 62, 10128 Turin, Italy. e-mail: email@example.com