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Incorporation and adaptation of intestinal segments into the urinary tract

Inkorporation und Adaptation von Darmsegementen in den Urogenitaltrakt

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Summary

Background: When urinary diversion began in the past century, urine was diverted to the intestine (internal diversion) and emptying was controlled by the anal sphincter. Later ureterosigmoidostomies became the method of choice. However, despite simplicity of the technique metabolic side effects such as hyperchloremic metabolic acidosis, urinary infection and frequent deterioration of renal function urged the need for new ways of bladder replacement.

Methods: Diversions to the skin (external diversion) could avoid to a large extent these drawbacks. In fact, urinary diversion to the skin via an ileal conduit(Bricker) is the most frequently used technique. Recently continent diversions to the urethra (orthotopic pouch) have seen renewed interest.

Results: Tunneled implantation of the ureters into the small bowel prevented reflux and recurrent infection. Further, less electrolyte imbalances were noted due to little electrolyte absorption. Since quality of life of the affected individual has become an important issue, continent external diversions are often offered to the young patient, using mostly cecum (or colon) as an internal collecting reservoir and a short segment of ileum for connecting the reservoir to the skin (Indiana pouch, Mainz pouch I). Similarly, orthotopic urinary diversion, connecting the reservoir (pouch) to the urethra has been employed. Frequently the ileum is used to create an ileum neobladder with connection to the urethra (modified Kock pouch, Hautmann bladder and Studer bladder). However, disadvantages of continent diversions are mainly the need for intermittent self catheterization and in case of orthotopic replacements night time incontinence. Nevertheless, the overall goal in the construction of continent reservoirs is the storage of large amounts of urine for a reasonable time period under low pressure conditions (<40 cm H2O).

Conclusions: From this perspective, the majority of patients undergoing cystectomy for invasive bladder cancer can be offered bladder substitutes providing continence and easy emptying while avoiding external collecting devices.

Zusammenfassung

Grundlagen: Die Harnableitung als Ersatz für eine operativ entfernte oder funktionsgestörte Blase wurde schon im letzten Jahrhundert im Sinne einer Ableitung über den Darm (innere Ableitung) durchgeführt. Die Miktionskontrolle erfolgte dabei über den Analsphinkter. Als Beispiel dafür wurde die Uretersigmoidostomie häufig durchgeführt. Trotz der technischen Simplizität, kam es zu berträchtlichen Nebenerscheinungen wie z. B. hyperchlorämischen, metabolischen Azidosen, rezidivierenden Harnwegsinfektionen und zur Beeinträchtigung des oberen Harntraktes. Diese gaben auch den Anstoß zur Entwicklung neuer Opertionsverfahren.

Methodik: Harnableitungen zur Haut über zwischengeschaltete Dick- oder Dünndarm- (Ileum-Conduit, Bricker-Blase) Anteile (äußere Ableitung) wurden und werden vielfältig eingesetzt.

Ergebnisse: Die antirefluxive Implantation des Harnleiters in den Dünndarm konnte hierbei den häufig auftretenden Reflux und rezidivierende Harnwegsinfekte vermeiden. Auch die Rückresorption der im Harn vorhandenen Harnstoff- und Chlorid-Ionen konnte gesenkt und dadurch metabolische Komplikationen großteils verhindert werden. Im Gegensatz zum Dickdarm, neigen Patienten mit zwischengeschaltetem Dünndarm zu normochlorämischen Azidosen. Der Einsatz kontinenter Harnableitungen, im besonderen orthotoper Reservoirs, hat auch bezüglich der Lebensqualität der Patienten vieles verbessert. Dafür wird häufig Dünndarm (modifizierter Kock-Pouch, Studer-Blase) oder Dickdarm oder aber Anteile der Ileozäkalregion (Mainz-Pouch) verwendet. Auch in diesen Fällen können Komplikationen auftreten: So z. B. die Salzretention bei Kolon-Ersatzblasen und die Hypovolämie beim Dünndarmreservoir. Weiters klagen Patienten mit orthotopen Ableitungen häufig über eine vorwiegend nächtliche Inkontinenz. Trotzdem bleibt Ziel jeder Ableitung die Schaffung eines Niederdruckreservoirs mit ausreichender Kapazität.

Schlußfolgerungen: Zusammenfassend kann dem Patienten, bei dem aus onkologischen oder funktionellen Gründen eine Zystektomie durchgeführt wird, ein Blasenersatz angeboten werden, der ihm Kontinenz und eine regelrechte Entleerung (und somit Lebensqualität) ermöglicht.

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References

  1. Akerland S, Berglund B, Kock NG, et al: Voiding pattern, urinary volume, composition and bacterial contamination in patients with urinary diversion via a continent ileal reservoir. Br J Urol 1989;63:619–623.

    Google Scholar 

  2. Allen TD, Roehrborn CG, Peters PC: Long term follow-up of patients after cystectomy and urinary diversion via ileal loop (IL) versus ureterosigmoidostomy (US). J. Urol 1989;141:350A.

    Google Scholar 

  3. Bergman B, Kaijser B, Nilson AE: Conduit urinary diversion and urinary-tract infection. I. Serum antibody titers against Escherichia coli and Proteus mirabilis in relation to urographic findings. Scand J Urol Nephrol 1979;13:65.

    PubMed  CAS  Google Scholar 

  4. Bissada NK, Morcos RR, Morgan WM, Hanash KA: Ureterosigmoidostomy: is it a viable procedure in the age of continent urinary diversion. J Urol 1995;153:1439–1430.

    Article  Google Scholar 

  5. Boyd SD, Schiff WM, Skinner DG, et al: Prospective study of metabolic abnormalities in patient with continent Kock pouch urinary diversion. Urology 1989;33:85–88.

    Article  PubMed  CAS  Google Scholar 

  6. Bruce AW, Reid G, Chan RCY, et al: Bacterial adherence in the human ileal conduit: A morphological and bacteriological study. J Urol 1984;132:184–188.

    PubMed  CAS  Google Scholar 

  7. Chan RCY, Reid G, Bruce AW, et al: Microbial colonization of human ileal conduits. Appl Environ Microbiol 1984;48:1159–1165.

    PubMed  CAS  Google Scholar 

  8. Cunningham J, Bikle DD, Avioli LV: Acute but not chronic metabolic acidosis disturbs 25-hydroxy vitamin D3 metabolism. Kidney Int 1984;25:47–52.

    Article  PubMed  CAS  Google Scholar 

  9. D’Agostino A, Leadbetter WF, Schwartz WB: Alterations in the ionic composition of isotonic saline solution instilled into the colon. J Clin Invest 1953;32:444.

    PubMed  CAS  Google Scholar 

  10. Devaskar U, Montgomery W: Urinary lactic dehydrogenase isoenzyme IV and V in the differential diagnosis of cystitis and pyelonephritis. J Pediatr 1978;93:789–791.

    Article  PubMed  CAS  Google Scholar 

  11. Diamond DA, Blight A, Samuell CT, et al: Ammonia levels in paediatric ureterosigmoidostomy patients: a screen for hyperammonaemia? Br J Urol 1991;67:541–544.

    PubMed  CAS  Google Scholar 

  12. Duckett JW, Lotfi AH: Appendicovesicostomy (and variations) in bladder reconstruction. J Urol 1993;149:567.

    PubMed  CAS  Google Scholar 

  13. Ferris DO, Odel HM: Electrolyte pattern of the blood after bilateral ureterosigmoidostomy. JAMA 1950;192:600.

    Google Scholar 

  14. Fisch M, Wammack R, Muller SC, et al: The Mainz pouch II (Sigma Rectum Pouch), J Urol 1993;149:258–263.

    PubMed  CAS  Google Scholar 

  15. Gafter U, Kraut JA, Lee DBN, et al: Effect of metabolic acidosis on intestinal absorption of calcium and phosphorus. Am J Physiol 1980;239:6480.

    Google Scholar 

  16. Goldwasser B, Madgar I, Hanani Y: Urodynamic aspects of continent urinary diversion. Rev Scand J Urol Nephrol 1987;21:245–253.

    CAS  Google Scholar 

  17. Goodwin WE: Open, transcolonic ureterintestinal anastomosis. Surg Gynecol Obstet 1953;97:295–300.

    PubMed  CAS  Google Scholar 

  18. Grossfeld GD, Bennett CJ, Bennett JK, Martins F, Apaydin F, Green BG: The non-refluxing ileal conduit: a new form of urinary diversion. J Urol 1995;154:981–984.

    Article  PubMed  CAS  Google Scholar 

  19. Guinan PD, Moore RH, Neter E, et al: The bacteriology of ileal conduit urine in man. Surg Gynecol Obstet 1972;134:78–82.

    PubMed  CAS  Google Scholar 

  20. Hall MC, Koch MO, McDougal WS: Metabolic consequences of urinary diversion through intestinal segments. Urol Clin North Am 1991;18:725–735.

    PubMed  CAS  Google Scholar 

  21. Hall MC, Koch MO, McDougal WS: Mechanism of ammonium transport by intestinal segments following urinary diversion: Evidence for ionized NH4+ transport via K+-pathways. J Urol 1992;148:453–457.

    PubMed  CAS  Google Scholar 

  22. Hassan ST, Coorsh J, Tapson JS: Use of bendrofluazide in the management of recurrent jejunal conduit syndrome. Br J Urol 1994;73:101–102.

    Google Scholar 

  23. Hautmann RE: The ileal neobladder. Acta Urol Belg 1991;59:227–240.

    PubMed  CAS  Google Scholar 

  24. Hindle W, Code CF: Some differences between duodenal and ileal absorption. Am J Physiol 1962;203:215–220.

    PubMed  CAS  Google Scholar 

  25. Jahnson S, Pedersen J: Cystectomy and urinary diversion during twenty years: complications and metabolic implications. Eur Urol 1993;24:343–349.

    PubMed  CAS  Google Scholar 

  26. Jacobsen H, Steven K, Stigsby B, et al: Pathogenesis of nocturnal urinary incontinence after ileocecal bladder replacement. Br J Urol 1987;59:148–152.

    Google Scholar 

  27. Kaveggia FF, Thompson JS, Schafer EC, et al: Hyperammonemic encephalopathy in urinary diversion with urea-splitting urinary tract infection. Arch Intern Med 1990;150:2389–2392.

    Article  PubMed  CAS  Google Scholar 

  28. Kennedy HA, Adams MC, Mitchell ME, et al: Chronic renal failure and bladder augmentation: stomach versus sigmoid colon in the canine model. J Urol 1988;140:1138–1140.

    PubMed  CAS  Google Scholar 

  29. Kiker JD, Woodside JR, Reed WP, et al: Urinary lactic dehydrogenase and serum Creative protein as means of localizing the site of urinary tract infection in patients with ileal conduits. J Urol 1982;128:749–751.

    PubMed  CAS  Google Scholar 

  30. Klein EA, Montie JE, Montague DK, et al: Jejunal conduit urinary diversion. J Urol 1986;135:244–246.

    PubMed  CAS  Google Scholar 

  31. Koch MO, McDougal WS: Chlorpromazine: adjuvant therapy for the metabolic derangements created by urinary diversion through intestinal segments. J Urol 1985;134:165–169.

    PubMed  CAS  Google Scholar 

  32. Koch MO, McDougal WS: Nicotinic acid: treatment for the hyperchloremic acidosis following urinary diversion through intestinal segments. J Urol 1985;134:162–164.

    PubMed  CAS  Google Scholar 

  33. Koch MO, McDougal WS, Reddy PK, et al: Metabolic alterations following continent urinary diversion through colonic segments. J Urol 1991;145:270–273.

    PubMed  CAS  Google Scholar 

  34. Koch MO, McDougal WS, Thompson CO: Mechanisms of solute transport following urinary diversion through intestinal segments: An experimental study with rats. J Urol 1991;146:1390–1394.

    PubMed  CAS  Google Scholar 

  35. Koch MO, McDougal WS, Hall MC, et al: Long-term metabolic effects of urinary diversion: A comparison of myelomeningocele patients managed by clean intermittent catheterization and urinary diversion. J Urol 1992;147:1343–1347.

    PubMed  CAS  Google Scholar 

  36. Koch MO: Orthotopic neobladder reconstruction after radical cystectomy. Tech Urol 1995;1:197–203.

    PubMed  CAS  Google Scholar 

  37. Lapides J: Mechanism of electrolyte imbalance following ureterosigmoid transplantation. Surg Gynecol Obstet 1951;93:691.

    PubMed  CAS  Google Scholar 

  38. Leong CH, Ong GG: Gastrocystoplasty in dogs. Aust N Z J Surg 1972;41:272–279.

    PubMed  CAS  Google Scholar 

  39. Light JK, Marks JL: Total bladder replacement in the male and female using the ileocolonic segment (LeBag). Br J Urol 1990;65:467–472.

    PubMed  CAS  Google Scholar 

  40. Lim STK, Lam SK, Lee NW, et al: Effects of gastrocystoplasty on serum gastrin levels and gastric acid secretion. Br J Surg 1983;70:275–277.

    Article  PubMed  CAS  Google Scholar 

  41. Lockhart JL, Davies R, Persky R, Figueroa TE, Ramirez G: Acid-bases changes following urinary tract reconstruction for continent diversion and orthotopic bladder replacement. J Urol 1994;152:338–342.

    PubMed  CAS  Google Scholar 

  42. Magnus RV: Pressure studies and dynamics of ileal conduits in children. J Urol 1977;118:406–407.

    PubMed  CAS  Google Scholar 

  43. Månsson W, Colleen S, Low K, et al: Immunoglobulins in urine from patients with ileal and colonic conduits and reservoirs. J Urol 1985;133:713–716.

    PubMed  Google Scholar 

  44. Månsson W, Colleen S, Mårdh P-A: The microbial flora of the continent cecal urinary reservoir, its stoma and the peristomal skin. J Urol 1986;135:247–250.

    PubMed  Google Scholar 

  45. Marshall FF, Mostwin JL, Radebaugh LC, et al: Ileocolic neobladder post-cystectomy: continence and potency. J Urol 1991;145:502–504.

    PubMed  CAS  Google Scholar 

  46. Martinez-Pimeiro L, Mateos F, Montero A, Madero R, Martinez-Pimeiro JA: Urinary solute transport by ileal segments. Effects of nicotinic acid. Br J Urol 1993;72:851–857.

    Google Scholar 

  47. Mayo ME, Chapman WH: Management of ileal conduit stomal obstruction: a urodynamic study. J Urol 1981;125:828–829.

    PubMed  CAS  Google Scholar 

  48. McDougal WS, Koch MO: Effects of sulfate on calcium and magnesium homeostasis following urinary diversion. Kidney Int 1989;35:105–115.

    Article  PubMed  CAS  Google Scholar 

  49. McDougal WS, Stampfer DS, Kirley S, Bennett PM, Lin CW: Intestinal ammonium transport by ammonium and hydrogen exchange. J Am Coll Surg 1995;181:241–248.

    PubMed  CAS  Google Scholar 

  50. Mitrofanoff P: Cystotomie continentetrans-appendiculaire dans le traitement des vessies neurologique. Chirurgie pedriatique. 1980;21:297.

    CAS  Google Scholar 

  51. Needham RN, Smith MM, Matsen JM: Differences in the bacteriology of intestinal loop urinary diversion. J Urol 1970;104:831–833.

    PubMed  CAS  Google Scholar 

  52. Ngan JHK, Lau JLT, Lim STK, et al: Long-term results of antral gastrocystoplasty. J Urol 1993;149:731–734.

    PubMed  CAS  Google Scholar 

  53. Nurmi M, Puntala P: Evaluation of upper and lower urinary tracts after Camey operation. Scand J Urol Nephrol 1989;23:275–277.

    Article  PubMed  CAS  Google Scholar 

  54. Odel HM, Ferris DO, Priestly JT: Further observations on the electrolyte pattern of the blood after bilateral ureterosigmoidostomy. J Urol 1951;65:1013–1020.

    PubMed  CAS  Google Scholar 

  55. Olivo G, Biasioli S, Bonciarelly M, Noto L: Metabolic complications of the urinary intestinal diversion: ileo-caecal bladder compared with ileal conduit. Br J Urol 1993;71:172–175.

    PubMed  CAS  Google Scholar 

  56. Parmeggiani PL: Autonomic nervous system in sleep. Exp Brain Res Suppl 1984;8:39.

    Google Scholar 

  57. Perry W, Allen LN, Stamp TCB, et al: Vitamin D resistance in osteomalacia after ureterosigmoidostomy. N Engl J Med 1977;297:1110–1112.

    Article  PubMed  CAS  Google Scholar 

  58. Rabbani GH, Bardham PK, Butler T, et al: Reduction of fluid-loss in cholera by nicotinic acid: a randomized controlled trial. Lancet 1983;2:1439–1442.

    Article  PubMed  CAS  Google Scholar 

  59. Rangel DM, Yakeishi Y, Stevens GH, et al: Absorption of urinary contents from isolated segments of jejunum and ileum. Surg Gynecol Obstet 1969;129:1189–1198.

    PubMed  CAS  Google Scholar 

  60. Reddy PK, Lange PH, Fraley EE: Total bladder replacement using detubularized sigmoid colon: technique and results. J Urol 1991;145:51–55.

    PubMed  CAS  Google Scholar 

  61. Richie JP: Intestinal loop urinary diversion in children. J Urol 1974:111:687–689.

    PubMed  CAS  Google Scholar 

  62. Richie JP, Skinner DG, Waisman J: The effect of reflux on the development of pyelonephritis in urinary diversion. An experimental study. J Surg Res 1974;16:256–261.

    Article  PubMed  CAS  Google Scholar 

  63. Roehrborn CG, Teigland CM, Sagalowsky AI: Functional characteristics of the Camey ileal bladder. J Urol 1987;138:739–742.

    PubMed  CAS  Google Scholar 

  64. Rosenberg ML: The physiology of hyperchloremic acidosis following ureterosigmoidostomy: A study of urinary reabsorption with radioactive isotopes. J Urol 1953;70:569–580.

    PubMed  CAS  Google Scholar 

  65. Schiff SF, Lytton B: Incontinence after augmentation cystoplasty and internal diversion. Urol Clin North Am 1991;18:383–392.

    PubMed  CAS  Google Scholar 

  66. Schiller LR, Walsh JH, Feldman M: Distention-induced gastrin release. Gastroenterology 1980;78:912–917.

    PubMed  CAS  Google Scholar 

  67. Schilling A, Friesen A: Transprostatic selective cystectomy with an ileal bladder. Eur Urol 1990;18:253–257.

    PubMed  CAS  Google Scholar 

  68. Schreiter F, Noll F: The S-bladder, an ileal bladder substitution. Acta Urol Belg 1991;59:251–264.

    PubMed  CAS  Google Scholar 

  69. Sidi AA, Reinberg Y, Gonzales R: Influence of intestinal segment and configuration on the outcome of augmentation enterocystoplasty. J Urol 1986;136:1201–1204.

    PubMed  CAS  Google Scholar 

  70. Siklos P, Davie M, Jung RT, et al: Osteomalacia in ureterosigmoidostomy: healing by correction of the acidosis. Br J Urol 1980;52:61–62.

    PubMed  CAS  Google Scholar 

  71. Sinaiko E: Artificial bladder from segment of stomach and study of effect of urine on gastric secretion. Surg Gynecol Obstet 1956;102:433–438.

    PubMed  CAS  Google Scholar 

  72. Skinner DG, Boyd SD, Lieskovsky G, et al: Lower urinary tract reconstruction following cystectomy: experience and results in 126 patients using the Kock ileal reservoir with bilateral ureteroileal urethrostomy. J Urol 1991;146:756–760.

    PubMed  CAS  Google Scholar 

  73. Specht EE: Rickets following ureterosigmoidostomy and chronic hyperchloremia. J Bone Joint Surg 1969;49:1422–1430.

    Google Scholar 

  74. Steiner MS, Morton RA, Marshall FF: Vitamin B12 deficiency in patients with ileocolic neobladders. J Urol 1993;149:255–257.

    PubMed  CAS  Google Scholar 

  75. Stewart WW, Cass AW, Matsen JM: Bacteriuria with intestinal loop urinary diversion in children. J Urol 1979;122:528–535.

    PubMed  CAS  Google Scholar 

  76. Stöckle M, Becht E, Voges G, et al: Ureterosigmoidostomy: an outdated approach to bladder exstrophy? J Urol 1990;143:770–774.

    PubMed  Google Scholar 

  77. Studer UE, Ackermann D, Casanova GA, et al: Three year’s experience with an ileal low pressure bladder substitute. Br J Urol 1989;63:43–52.

    Article  PubMed  CAS  Google Scholar 

  78. Sumfest JM, Burns MW, Mitchell ME: The mitrofanoff principle in urinary reconstruction. J Urol 1993;150:1875–1877.

    PubMed  CAS  Google Scholar 

  79. Thüroff JW, Alken P, Riedmiller H, et al: 100 cases of Mainz pouch: continuing experience and evolution. J Urol 1988;140:283–288.

    PubMed  Google Scholar 

  80. Wammack R, Burger R, Fisch M: The appendix as a continence mechanism. In Wammack R, Hohenfellner R (eds): Continent Urinary Diversion. London, Churchill Livingstone, 1992, p 159.

    Google Scholar 

  81. Whiting SJ, Draper HH: Effects of a chronic acid load as sulfate or sulfur amino acids on bone metabolism in adult rats. J Nutr 1981;111:1721–1726.

    PubMed  CAS  Google Scholar 

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  1. Department of Urology, University of Vienna, Währinger Gürtel 18-20, A-1090, Vienna

    B. Djavan

  2. Department of Surgery, Division of Urology, University of Texas, Southwestern Medical Center, Dallas, Texas, USA

    C. G. Roehrborn

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Djavan, B., Roehrborn, C.G. Incorporation and adaptation of intestinal segments into the urinary tract. Acta Chir Austriaca 30, 227–234 (1998). https://doi.org/10.1007/BF02620211

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