[Total replacement of the bladder with an intestinal pouch for normal micturition after cystectomy]

Abstract

Patients who have undergone cystectomy require some form of urinary diversion, an ileal conduit being the most common. A disadvantage of a conduit, however, is that it necessitates wearing an external appliance. A continent ileal urinary reservoir (Kock pouch) has recently been introduced to overcome the ileal conduit problem. Certain problems arising with a Kock pouch, however, are the presence of stoma that must be intermittently self-catheterized, the technical difficulty of the operation and the possible failure of the efferent nipple valve to function. Another method of urinary diversion is ureterosigmoidostomy which initially seemed a safe, simple operation that ensured urinary continence. Serious problems of electrolyte imbalance, urinary tract infections, formation of renal calculi and so forth, however, have caused many urologists to abandon this procedure. A third method is the construction of an internal reservoir from an intestinal segment anastomosed to the urethra, thus avoiding any stoma. Between May 1987 and August 1989, 15 male patients aged 36-69 years underwent an operation for total replacement of the bladder with an intestinal pouch for normal micturition after cystectomy. Of these 13 patients, the detubularized ileocecocolic segment was used as the internal reservoir and, in the other two, the ileum or the sigmoid colon was used because of severe adhesion of the ascending colon due to previous surgery. Three months after surgery, most patients had a vesical capacity of 300 ml or more and could excrete a maximum 200-300 ml urine at one voiding. Daytime continence was achieved in 14 patients in three months, and nighttime continence in 11 patients in six months. No abnormalities in serum electrolytes except mild hyperchloremia in one patient, acid-base balance or renal function were observed during follow-up periods of 2-27 months. The patients were enthusiastic about this procedure. The follow-up periods have been short, but this method seems promising as a new internal diversion.