Continent urostomy with hydraulic ileal valve in 136 patients: 13 years of experience.

The hydraulic ileal valve, which we developed in 1975, ensures continence by adapting to 5 different urinary reservoirs. The valve is made by isolating a 14 cm. long intestinal loop with the mesentery. The isolated ileal segment then is folded inward on itself throughout its entire length. We performed 136 continent urostomies with this hydraulic valve. An ileocecal reservoir was used in 122 patients, ileum in 8, sigmoid in 1, rectum in 1 and bladder (continent cystostomy) in 4. Indications for continent urostomy were bladder tumor in 55 patients, complex vesicovaginal fistulas in 5, neurogenic bladder in 13, vesical exstrophy in 12 and miscellaneous reasons in 5. Of the patients 103 (75 per cent) were continent immediately. Continence was obtained after repair of the valve in 24 patients (17.6 per cent). Therefore, 127 patients over-all were continent. Mean followup of our patients was 38 months (range 3 to 154 months). Continence remained excellent with self-catheterization performed easily in 88.3 per cent of the patients. Over-all, all of our continent urostomies were well tolerated biologically and radiologically.

[The continent urostomy. 12 years' experience with the continent ileocecal bladder]. / Urostomie continente. Douze années d'expérience avec la vessie iléo-caecale continente.

The ileo-caecal continent urostomy was first described in 1975. It is a combination between an ileo-caecal reservoir and an ileal hydraulic valve. From 1973 to 1986 we performed 107 such operations (41 for vesicovaginal fistula, 40 for bladder tumor, 26 for bladder exstrophy, neurogenic bladder and miscellaneous). Continence was obtained in 100 patients (80 at the first operation and 20 after operation). The follow up was 3 to 146 months (average 37) in 82 patients 74 of whom had conserved good continence. In cases with failure of continence, repair was obtained by reinvagination of the same valve or by creating a new valve. Only 2 cases of metabolic disorders in the form of acute pyelonephritis are reported. The continent urostomy provides a better quality of life for patients requiring a urinary diversion. The psychosocial and economic impact is very important.

[Urodynamic study of urinary incontinence in women. For what purpose?]. / L'exploration urodynamique des incontinences urinaires de la femme. Pour quoi faire?

Based on considerable personal experience and a rigorous and critical analysis of case-reports, a highly polemic subject is discussed. This fundamental article, prepared after deliberation and with discernment, is liable to close a debate by sweeping aside certain simplest principles established on bases supposedly scientific to the detriment of clinical observation. Recognition of bladder instability appears to be much more the domain of the an amnesis than of cystometry; transmission failure is a true myth confirmed neither by clinical or surgical findings, and is therefore of no utility for the surgical decision; incontinence due to urgency is perhaps less of an absolute contraindication to surgery than previously considered. It appears artificial to analyze a complex symptom such as urinary incontinence on results of urodynamic data alone, each women possessing a different balance. In contrast, knowledge of certain urodynamic parameters of this balance (particularly closure pressure) can assist prediction of chances of success of surgery. Opponents and proponents of urodynamic exploration of women with urinary incontinence should find in these comments a matter of reflection.

[Vesicovaginal fistula. Apropos of 600 cases]. / Les fistules vésico-vaginales. A propos de 600 cas.

A personal series of 600 cases of vesicovaginal fistula is reviewed. Patients could be classified as a function of site of fistula into 3 groups: I. urethrovaginal fistula (31%); II. cervicovaginal fistula (22%); III. vesicovaginal fistula (46%). Etiology was mainly obstetrical (94%), as was multiparity (69%). An associated lesion was detected in 11% of cases (uterine, ureteral and rectal). Surgery was performed after a minimum period of 3 months with the following results. Type I fistulae, using a low approach and requiring urethral refection, showed good results in only 53% of cases. Type II fistulae, usually treated through a low approach (80%), were relieved in 80% of cases, with the reservation that reinforcement of bladder neck was often necessary. Type III fistulae, treated by a high (60%) or low (40%) approach were nearly always corrected (98%). In 2 cases of destroyed urethra unable to benefit from urethral plastic surgery, bladder repositioning with continent cystostomy was satisfactory. 72 cases with irrecuperable destroyed bladder received definitive high diversion: 34 Coffey, 5 Bricker, and since 1975, 33 continent ileocecal bladders using Benchekrouns' technique.

[How to examine an non-contractile bladder]. / Comment explorer une vessie acontractile.

Bladder contractility is dependent on the quality of the detrusor muscle and its innervation, and acontractility can therefore result from muscular or neurologic dysfunction. Etiologic factors involved in this functional disorder include collagen overload of the bladder wall and/or denervation or inhibition phenomena. Cystometric conditions necessary and sufficient for recognition of the disorder are indicated, the stop-test being an indispensable exploration to establish diagnosis. The Lapidès test is reliable when peripheral neurologic lesions are involved but the lesion must be complete; for incomplete lesions greater sensitivity is obtained with electrophysiologic tests such as analytic electromyography, sacral evoked potentials or rapid cystometry. Tests using an alpha-blocker allow recognition and lifting of reflex inhibition, particularly in neurologic patients with high level lesions. Proof of the psychogenic nature of the retention in hysterical patients is more difficult to obtain, and a specific test is not available, apart from histology, for diagnosis of bladder collagenosis.

[Hydatid cyst of the kidney. Apropos of 30 cases]. / Le kyste hydatique du rein. A propos de 30 cas.

Symptomatology in thirty patients with hydatid cyst of kidney treated in the Urologic Clinic, UHC, Avicenne, Rabat, was florid (83% with pain and 43% with a mass in the flank) and sometimes specific (27% of cases). Associated hypertension was an exceptional finding. Preoperative diagnostic investigations included ultrasound and CT scan imaging, replacing arteriography to a great extent. Approach to surgical treatment was usually by a lombotomy (64%) or even a Baraya incision (23%), followed by treatment of the renal cyst itself (a case of silent kidney on IVU treated by resection of a protruding dome). Nephrectomy was frequently necessary (47%) for renal lesions. When conservative therapy appeared sufficient the only procedure adopted, apart from specific cases, was resection of a protruding dome even when the hydatid cyst was discharging into excretory pathways. Splenectomy was sometimes necessary (2 of 22 cases) for hydatid cyst of left kidney. This series emphasizes the safety of surgery for hydatid cyst of kidney since the only death reported occurred 2 months after operation in a patient with an associated renal sarcoma.