Comparison of open and intracorporeal modified ureterosigmoidostomy (Mainz II) after laparoscopic radical cystectomy with bladder cancer.

OBJECTIVE: To compare perioperative and oncologic outcomes of open modified ureterosigmoidostomy urinary diversion (OMUUD) and intracorporeal modified ureterosigmoidostomy urinary diversion (IMUUD) following laparoscopic radical cystectomy (LRC). PATIENTS AND METHODS: We retrospectively reviewed our single institutional collected database patients undergoing LRC from October 2011 to October 2019. The perioperative characteristics were compared between OMUUD and IMUUD, and overall survival (OS) and progression-free survival (PFS) were evaluated by the Kaplan-Meier method. RESULTS: Overall, 84 patients were included. OMUUD and IMUUD were performed in 63 (75%) and 21 (25%) patients, respectively. IMUUD patients demonstrated shorter postoperative length of stay (16.24 ± 3.91 days vs. 18.98 ± 7.41 days, P = 0.033), similar operation time (498.57 ± 121.44 vs. 462.24 ± 99.71, P = 0.175), similar estimated blood loss [400 (200-475) ml vs. 400 (200-700) ml, P = 0.095], and similar overall complication rate within 30 days (19.05% vs. 25.40%, P = 0.848) and 90 days (23.81% vs. 17.46%, P = 0.748). Complete urinary control rate was 87.3% (55/63) in the OMUUD group. In IMUUD, the complete urinary control rate was 90.5% (19/21). There was no significant difference in OS (χ2 = 0.015, P = 0.901) and PFS (χ2 = 0.107, P = 0.743) between the two groups. CONCLUSION: IMUUD postoperative recovery is faster; other perioperative outcomes and oncology results are not significantly different with OMUUD. It is indicated that IMUUD can be utilized safely and effectively in the urinary diversion after LRC.

An unusual diverticulum adjacent to two large colonic polyps; a case report.

BACKGROUND: Adenocarcinomas can arise in a variety of circumstances in which intestinal segments have been used for urinary diversions. Whereas ureterosigmoidostomy is the oldest and simplest form of continent urinary diversion it also seems to be the most dangerous in this regard. Herein we present a case of colonic neoplasia complicating a non-functioning ureterosigmoidostomy after 55 years; the longest latent period documented to date. CASE PRESENTATION: A 56-year-old lady born with congenital bladder exystrophy and who had a functional ileal conduit presented to us with a 6 month history of change in bowel habit and rectal bleeding. Prior to this she had had multiple abdominal surgeries as a child and had suffered from lifelong recurrent urinary tract infections. Colonoscopy revealed the presence of two large sessile polyps in close proximity to a diverticulum-like structure that after surgical resection turned out to be a non-functioning ureterosigmoidostomy from when she was an infant. CONCLUSIONS: Our case highlights the importance of enrolling patients with ureterosigmoidostomies into long-term colonoscopic surveillance programmes. This is also true for those patients who undergo revisional surgery but have preserved ureteric stumps. Endoscopists should be aware of the varied endoscopic appearances of the anastamosis in order to be able to recognise these structures when present.

Our Experience of Laparoscopic Anterior Exenteration in Locally Advanced Cervical Carcinoma.

STUDY OBJECTIVE: To show the feasibility, technique, and results of laparoscopic anterior exenteration in selected patients. DESIGN: A retrospective cohort study. SETTING: Galaxy Care Laparoscopy Institute, Pune, India. PATIENTS: Seventy-four of 85 patients who underwent laparoscopic anterior exenteration for stage IVA carcinoma of the cervix from January 2005 to January 2015 were analyzed; the median follow-up was 30 months. Contrast-enhanced computed tomographic imaging of the abdomen and pelvis was performed for all patients. INTERVENTIONS: The same surgeon and team performed all the operations for uniformity in 10 operative steps. MEASUREMENTS AND MAIN RESULTS: The mean operative time was 180 minutes, and the mean blood loss was 160 mL. The mean hospital stay was 6 days. The average number of lymph nodes removed was 21.4. Surgical margins were negative in all patients. Forty-two patients had positive lymph nodes. Chemoradiation was given to those with positive lymph nodes. Perioperative complications occurred in 15 (20.27%) patients including deep vein thrombosis, urinary tract infection, ureterosigmoid leak (n = 2/74), and so on. Positron emission tomographic imaging and computed tomographic scanning were performed at 6 months after surgery and 6 months after adjuvant therapy in those with positive lymph nodes. There was no immediate postoperative mortality. The overall survival rate at 5 years was 25%. CONCLUSION: Laparoscopic anterior exenteration is feasible in cases of advanced carcinoma of the cervix. Results have shown that in selected patients this procedure is associated with good long-term survival.

Asynchronous bilateral anastomosis site sigmoid colon cancer after ureterosigmoidostomy: a case report.

BACKGROUND: We present a case of asynchronously occurring adenocarcinomas 29 and 36 years after ureterosigmoidostomy for bladder cancer, respectively, at both anastomosis sites. CASE PRESENTATION: A colonoscopy that was performed on a 69-year-old man because of bloody stool and an elevated carcinoembryonic antigen (CEA) level revealed a polypoid lesion at the right ureterosigmoid anastomosis site 29 years after the patient's ureterosigmoidostomy. Endoscopic resection was performed, and the lesion was diagnosed as adenocarcinoma. Seven years later (36 years after ureterosigmoidostomy), an elevated lesion was detected at the left ureterosigmoid anastomosis site by colonoscopy performed after detection of high CEA levels. Biopsy revealed an adenocarcinoma that was immunohistologically positive for CDX2; sigmoidectomy and ureterectomy were subsequently performed. The pathological diagnosis of the second tumor was adenocarcinoma arising in the ureterosigmoid anastomosis site and invading the left ureter. CONCLUSIONS: Diligent long-term follow-up of patients who underwent ureterosigmoidostomy is essential.

Carcinoma arising in enteric diversion or rectal neobladder for bladder exstrophy.

Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.

[Ureterosigmoidostomy with the formation of low pressure reservoir: history or operation of choice? 15 years of experience].

AIM: To examine the long-term outcomes of Mainz Pouch II ureterosigmoidostomy with the formation of a submucosal and extramural by Hassan (Hassan Abol-Enein) tunnels. MATERIALS AND METHODS: Mainz Pouch II ureterosigmoidostomies with the formation a submucosal tunnel (open-end technique) comprised group 1 (n=17) and with the formation of extramural ureteral implantation by Hassan - group 2 (n=15). The mean age of patients was 58+/-6.0 years, ranging from 16 to 76 years; among them there were 22 (68.8%) men and 10 (31.2%) women. Average follow-up was 14.7+/-6.0 years. All patients were continent during the daytime and at nighttime. Reservoir-ureteral reflux was detected in 2.4% (5 RU) observations and the obstruction only 1.4% (2 RU). Chronic pyelonephritis in the postoperative period was observed in 3 (9.75%) patients, whereas before surgery in 20 (62.5%) patients. The both modifications of the operation did not impair renal secretory function postoperatively in the majority of patients; in 2 of them its improvement was noted. Two patients experienced a decrease in the renal secretory function due to inadequate formation of extramural anastomosis. CONCLUSION: Mainz Pouch II and Hassan operations enable maintaining normal urination, optimize antireflux protection and are technically simple, provided the indications are carefully observed. The low incidence of complications of ureterosigmoidostomy, both in the immediate and in the long term implies that these operations may be the method of choice for continent bladder replacement in selected patients.

Laparoscopic anterior exenteration with intracorporeal uretero-sigmoidostomy.

STUDY OBJECTIVE: To demonstrate the feasibility of laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy. DESIGN: After Institutional Review Board approval was obtained, patients who had undergone laparoscopic anterior exenteration with intracorporeal ureterosigmoidostomy were analyzed. PATIENTS AND METHODS: Fifty-seven patients with advanced cervical carcinoma, stage IV A, since 2005 were analyzed retrospectively. The preoperative workup was done with contrast-enhanced computed tomography abdomen-pelvis and positron emission tomography (PET) scans. Patients were analyzed for operative time, blood loss, and complications. Patient follow-up was done monthly for the first 3 months, every 3 months for 1 year, and then every 6 months for 3 years. Postoperative follow-up was done with PET scans. SETTING: Galaxy Care Laparoscopic Institute, Pune, India. INTERVENTIONS: Operative steps were as follows: MEASUREMENTS AND RESULTS: The mean operative time was 180 minutes (range, 140-240 minutes), and mean blood loss was 100 mL (range, 50-200 mL), as measured by the amount of blood in the suction machine. The median duration of hospital stay was 4 days (range, 3-7 days). The mean number of lymph nodes retrieved was 12 (range, 9-21). Surgical margins were negative in all patients with a lateral margin >2 cm. Twenty-eight patients had positive lymph nodes. Chemoradiotherapy was given to the patients with positive lymph nodes. Minor leak was present in 11 patients in the immediate postoperative period, for which no active intervention was required. Hyperchloremic metabolic acidosis which was seen on biochemical parameter but clinically patient have no manifestation and was treated with sodium bicarbonate. A postoperative PET scan was done at 6 months after the completion of adjuvant therapy in lymph node-positive patients and 6 months after surgery in node-negative patients. CONCLUSION: Exenteration has a definitive role in the treatment of advanced cervical cancer. Results have demonstrated the feasibility of this procedure [1-4].

Squamous cell carcinoma at bladder exstrophy site after early cystectomy.

Patients with bladder exstrophy-epispadias complex (BEEC) are at risk for bladder cancer, usually this presents as adenocarcinoma (Smeulders "BJU Int" 87:623-628, 2001). Squamous cell carcinoma (SCC) is rare, with only 13 documented case reports. This is a case of SCC in a 78-year-old man with BEEC who underwent cystectomy and ureterosigmoidostomy in childhood.

Exstrophy epispadias complex- Issues beyond the initial repair.

Despite advances in the management of exstrophy epispadias complex (EEC), the quality of life of these patients is far from good. The post-operative period is complicated by numerous and variable events - infection, dehiscence, upper tract dilatation with deterioration, fistulas, stone formation and incontinence to name a few of the major complications. Redo surgery for bladder closure, bladder neck reconstruction, epispadias repair and closure of fistulas are frequently required. The current focus is on limiting the frequency and morbidity of the reconstructive procedures. A successful initial closure and early satisfactory cosmetic and functional results are gratifying for the family and the health care team, but this is only the beginning of the lifelong care necessary for bladder exstrophy (BE) patients. In this article, the long-term outcome of various treatment options and the continent procedures in BE has been reviewed, tracing the journey of these patients into adolescence and adulthood.

Synchronous enteroid adenocarcinoma at the ureteral implantation site after ureterosigmoidostomy.

Ureterosigmoidostomy is considered to be the oldest urinary diversion technique performed for the first time in the 19th Century in patients with urinary malformations. However, the high rate of complications as well as the significant risk of developing tumors in the colonic portion of the ureteral anastomosis have given rise to other new intestinal urinary diversion techniques. We present the case of a patient with two synchronous enteroid adenocarcinomas, with a latency period of 66 years, at the site of both ureterocolonic anastomoses after ureterosigmoidostomy performed during childhood owing to bladder exstrophy.

Detubularized Ureterosigmoidostomy for the Creation of Continent Neobladder in Children: Cases Report and Review of the Literature.

Introduction: To report our experience in continent urinary diversions, we describe two cases we treated performing detubularized ureterosigmoidostomy. In children, in the case of malformations or neoplastic diseases affecting the bladder, the need for a cystectomy is not so frequent. When cystectomy becomes mandatory, there is a need to create a continent bladder diversion. Mainz pouch II and Cologne pouch are procedures that utilize a detubularized sigma as a reservoir in order to build up a continent neo-bladder. Materials and methods: This is a retrospective study performed at the Pediatric Surgical Unit of the Salesi Children's Hospital. In this work, we reviewed data about two patients who underwent surgery for the creation of a sigmoid neo-bladder by the Mainz pouch II and Cologne pouch techniques. Results: In our experience, we treated a girl who was affected by a bladder's rabdomiosarcoma and a girl born with a bladder exstrophy and treated at birth abroad. In both patients, a complete cystectomy was performed and a continent neo-bladder was created by a detubularized ureterosigmoidostomy. In the first case, we performed the Mainz pouch II technique and in the second, the Cologne pouch technique. Discussion: Different techniques have been developed with the main goal of the creation of an orthotopic neo-bladder, which has to be a low pressure reservoir with a continent sphincteric mechanism. Detubularized ureterosigmoidostomy is a good choice in pediatric patients. Our study, according to other works, shows that these procedure are safe with good long-term outcomes.

Transrectal Ureteroscopic Stone Management in a Patient with Ureterosigmoidostomy.

Background: Published case reports on the management of ureteral stones in patients with prior ureterosigmoidostomy have described the challenges of direct retrograde access to the ureter using standard endourologic instruments. In light of these challenges, reported effective techniques have involved either (1) direct retrograde access utilizing sigmoid endoscopy with air insufflation or (2) percutaneous antegrade access. We report the first experience of effective retrograde ureteroscopy utilizing traditional endourologic instruments in a patient without percutaneous access. Case Presentation: The patient is a 70-year-old man born with bladder exstrophy who underwent end colostomy and ureterosigmoidostomy as a child. He presented with a symptomatic 6 mm stone at the right ureterosigmoid junction. A trial of spontaneous passage failed because of persistent pain. Treatment options were limited by the patient's recent history of coronary stent placement, requiring uninterrupted antiplatelet therapy with clopidogrel. As such, we attempted retrograde ureteroscopy through a transrectal approach. Anticipating some difficulty in the identification of the ureteral orifices, we administered methylene blue at the time of induction. After placing the patient in lithotomy position, we advanced a flexible cystoscope to the rectosigmoid junction where we identified a ureteral orifice. Guidewire access was obtained and we confirmed right-sided laterality with fluoroscopic imaging. A semirigid ureteroscope was passed to the ureterosigmoid junction where the stone was encountered and retrieved intact using a basket. A 6 × 26 Double-J stent was placed with a string to facilitate removal 5 days later. The postoperative course was unremarkable. Conclusion: Despite the previously reported challenges of the approach, retrograde ureteroscopy without percutaneous access represents a viable treatment option for ureteral stones in patients with ureterosigmoidostomy.

Secondary Tumors After Urinary Diversion.

It has been known that urinary diversions juxtaposing the urinary and intestinal tracts lead to increased incidence of secondary malignancies. Although tumorigenesis in ureterosigmoidostomies follows the typical course from adenomas to adenocarcinomas, secondary malignancies arising from isolated intestinal diversions are much more heterogeneous. Research over the last half century has unveiled patterns of incidence and progression, while also uncovering possible mechanisms driving the neoplastic changes. In this review, we summarize the current understanding of these unique tumors, with the hope that the knowledge gained may shed light on the etiologies of other cancers arising from the urinary and intestinal tracts.

Intermittent hyperammonemic encephalopathy after ureterosigmoidostomy: spontaneous onset in the absence of hepatic failure.

Intermittent hyperammonemic encephalopathy after ureterosigmoidostomy is a rare, but if unrecognized, potentially lethal condition. Ureterosigmoidostomy was performed in a male patient with bladder extrophy. After 35 years, he developed hyperammonemic encephalopathy. Diagnostic procedures did not reveal hepatic nor metabolic disorders. Despite administration of preventive medical treatment, several episodes recurred. A durable prevention was finally achieved by conversion into an ileal conduit. Intermittent hyperammonemic encephalopathy can occur decades after ureterosigmoidostomy. In the case of absence of metabolic disorders and resistance to medical treatment, conversion into a urinary diversion using an ileal segment constitutes an effective ultima ratio.

Clinical evaluation of patients treated with a detubularised isolated ureterosigmoidostomy diversion after radical cystectomy.

OBJECTIVES: To assess the emptying pattern and patient satisfaction after constructing a detubularised isolated ureterosigmoidostomy (DIUS) following a cystectomy, introduced to overcome the poor outcome of conventional ureterosigmoidostomy, to improve the emptying pattern and accordingly patients' quality of life. PATIENTS AND METHODS: The study included 122 patients who were treated with a DIUS diversion after cystectomy. The minimum follow-up of the patients was 6 months. The frequency of emptying and continence during the day and night were recorded. The ability of the patients to discriminate between urine and stool was assessed. The patients' overall satisfaction with the outcome was categorised as fully satisfied, moderately satisfied or not satisfied. RESULTS: In all, 95 patients were available for this evaluation; all patients were completely continent during the day and night. The mean emptying frequency was 3.9 during the day and 1.7 during the night. All patients were able to feel the desire to empty and the mean holding time was 35 min. Fifty-two patients (55%) could pass solid stools once per day, with minimal urine at the end of voiding, and the remaining evacuations were of clear urine only. Thirty-two patients (34%) were able to differentiate between urine and stool sensation before emptying. For satisfaction, 82 patients reported full satisfaction, 13 were moderately satisfied, and none regretted the diversion. CONCLUSIONS: The DIUS diversion provides continence during the day and night, with a satisfactory emptying habit. Patients with a DIUS diversion can tolerate a full pouch comfortably, with no leakage, and they can discriminate between urine and stool evacuations.

Recto sigmoid bladder reservoir for patients with exstrophy: three dimensional evaluation for outcome analysis.

OBJECTIVE: To report the results of recto sigmoid bladder reservoir (RSBR), a variant of ureterosigmoidostomy (US) in patients with bladder exstrophy (BE) using a three dimensional evaluation system. PATIENTS AND METHODS: This was a predominantly retrospective evaluation for all patients of BE undergoing RSBR who had completed minimum of 1 year follow-up. The patients were evaluated using a three dimensional system which included evaluation of urinary continence per rectally, status of upper tracts and health related quality of life (HRQOL). RESULTS: A total of 19 patients (four females) were evaluated. Mean age was 8.4 years, and mean duration of follow-up was 3.4 years. Mean age at RSBR was 5.1 years. Ten patients had good rectal continence. There was occasional minimal urine leak while passing flatus or on straining in nine. All patients had preserved renal function except one. The mean HRQOL score was 129.7 out of maximum of 150.. CONCLUSIONS: RSBR gives marked improvement in quality of life in patients of BE. In the literature there is a non-uniformity in the results reporting outcome of US. The presented three dimensional assessment provides a comprehensive way to report the results in the short/long term. If used by other surgeons it would make comparison across centers feasible.

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients.

OBJECTIVES: To assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy. PATIENTS AND METHODS: The study included 10 patients (mean age 61.8 years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student's t-test. RESULTS: Nine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3-5) and the mean night-time frequency was 0.5 (0-1). Before and after surgery, the respective mean resting anal pressure was 71 and 74 cm H2O (P = 0.004), the volume at first desire to defecate was 54 and 72 mL (P = 0.004) and the maximum tolerable volume was 140 and 160 mL (P < 0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0-10) cmH2O, and the end pressure was 13.2 (4.42, 9-20) cmH2O. CONCLUSION: Although the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients' quality of life.

Coronary artery bypass graft surgery in a patient with ureterosigmoidostomy.

A 75-year-old male patient had stable angina pectoris. After coronary angiography we decided to perform a coronary artery bypass graft surgery. Twenty years ago the patient underwent radical cystectomy and bilateral ureterosigmoidostomy because of bladder cancer. After that, his micturition was via the rectum. We did not experience that before. As is known, monitoring of urine output is very important after cardiac surgery. The patient was consulted with an urologist for how to monitor urine output in him. Transrectal catheterization was recommended for our follow-up, but before the catheterization bowel cleansing is necessary. Four-vessel on-pump coronary artery bypass graft surgery was performed without any problem. Peroperative urine volume and arterial blood gas results were normal. Urine output is a sensitive variable reflecting the patient's effective blood volume and tissue perfusion. Urinary catheterization is a standard for all cardiac surgeries, and it allows the patients' urine to drain freely from the bladder for collection. Monitoring of urine output in patients with ureterosigmoidostomy is impossible by standard urinary catheterization method. In this case we performed transrectal catheterization for Urine flow follow-up. Urine flow follow-up is essential after the open-heart surgery and it can be measured in different ways, as in our case.

Adenocarcinoma of the Ileal Conduit in a Patient Born With Classic Bladder Exstrophy.

Bladder exstrophy is a rare birth defect that typically requires patients to undergo multiple surgical procedures throughout the course of their childhood. Many ultimately undergo operations that use segments of bowel for the reconstruction and/or augmentation of the urinary tract, which imparts an increased risk of malignancy in these patients. We present the case of a 59-year-old man with a history of bladder exstrophy managed with ureterosigmoidostomies revised to an ileal conduit who developed a large adenocarcinoma in the ileal conduit that extended into small bowel, sigmoid colon, and ureter.