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SN Comprehensive Clinical Medicine

, Volume 1, Issue 11, pp 958–960 | Cite as

Continent Urinary Reservoir with Intussuscepted Valve Mechanism: How I Do It?

  • Doaa Attia
  • Asmaa Ismail
  • Mohamed Adel Atta
  • Mohamed Sharafeldeen
  • Ahmed Elabbady
  • Hazem Elmansy
  • Walid Shahrour
  • Owen Prowse
  • Ahmed KotbEmail author
Surgery
  • 114 Downloads
Part of the following topical collections:
  1. Topical Collection on Surgery

Abstract

The aim of our work was to show our new simple and reproducible technique of reconstructing the valve mechanism of continent urinary reservoir, as a possible safe alternative or additive to other techniques. Single 50 cm of ileum is isolate and folded into 3 segments; the afferent limb of which will be the one used for the valve mechanism and used for patients’ catheterization. Double-walled intussusception was used to create the valve mechanism. Our technique was easy and reproducible with no immediate postoperative complications. The pouch could be easily catheterizable by the patients with no daytime leak and minimal or no night time leak. Double-walled intussuscepted ileum is a safe and reproducible technique to create the valve mechanism of continent urinary reservoir.

Keywords

Bladder cancer Cystectomy Continent reservoir Urine diversion 

Introduction

Bladder cancer is the fourth most common cause of cancer, and radical cystectomy is considered the gold-standard treatment for muscle invasive bladder cancer. Continent urinary diversion is the preferred and widely used procedure by many surgeons to reconstruct the lower urinary tract following radical cystectomy for lower urinary malignancy [1, 2, 3].

There are many available techniques for reconstructing the valve mechanism for the continent reservoir and our aim was to show our new simple and reproducible technique of reconstructing the valve mechanism as a possible safe alternative or additive to other techniques.

Technique

We isolate 50 cm of ileum and fold it into 2 equal segments of 15 cm each and 20 cm afferent segment. The two equal segments will be detubularized and used for the pouch creation (Figs. 1, 2, and 3). The remaining 20-cm afferent segment will be divided into 3 parts. A transfixing stitch will pass between the distal and middle thirds which will be used to produce intussusception of the distal segment into the pouch; this will serve as the valve mechanism (Fig. 4). Vicryl 3/0 was used as the running suture for pouch creation and for intussuscepted valve suturing.
Fig. 1

A total of 50 cm of ileum was isolated and folded into 3 limbs

Fig. 2

Two limbs were detubularized and the posterior wall of the pouch was stitched

Fig. 3

The anterior wall of the pouch was closed halfway before we do ureteric reimplantation and then doing the valve mechanism.

Fig. 4

The distal 1/3 of the afferent limb was intussuscepted into the pouch using a transfixing stitch passing across the ileal circumference between the distal and middle thirds of the afferent limb then pulled into the pouch, creating the double-walled intussuscepted valve

Monopolar cautery will be used to create raw areas in the wall of the intussuscepted segment and the underlying pouch mucosa, then stitches will be used to fix both areas together using 3/0 Vicryl. Figures 1, 2, and 4 illustrate the continent reservoir reconstruction steps.

Both ureters were anastomosed using embedded nipple technique directly into the pouch wall [4].

Outcomes

Our technique was easy and reproducible with no immediate postoperative complications. The pouch could be easily catheterizable by the patients with no daytime leak and minimal or no night time leak. During several years applying this maneuver by two uro-oncologists on tens of patients; two patients had significant daytime urine leak few months after the surgery, and the cause was found to be contracted pouch requiring pouch augmentation, rather than an inherent problem in the valve mechanism. This is a novel technique that can be easily taught and done by reconstructive surgeons.

Discussion

Radical cystectomy requires a safe reconstruction of the lower urinary tract and the choice of the appropriate method for urinary diversion is very crucial and differs depending on patients’ circumstances and surgeon experience. Continent urine diversion is an attractive way for urine diversion that aims to create large volume pouch to store urine, with the creation of incontinence mechanism to avoid the use of appliances.

Koch introduced the idea of creating low-pressure ileal reservoir, for creating continuous cutaneous reservoir, and described his technique. Although the Koch pouch was a great renovation, it had a relatively high failure rate, risk of afferent limb ischemia, and used stapler [5]. Indiana pouch was then emerges using ileocecal junction with the ileal segment acting as the afferent limb [6]. Our technique is considered a modification to the Koch pouch, using an afferent limb with our modified intussusception technique, no efferent limb, but ureters, were implanted using nipple technique direct into the pouch wall and no stapler within the pouch.

Conclusion

Double-walled intussuscepted ileum is a safe and reproducible technique to create the valve mechanism of continent urinary reservoir.

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical approval and informed consent

No ethical approval or patients’ consent were obtained, as the procedure involves tips and tricks we are doing during reconstruction to improve the outcome and not a completely new procedure. No patients’ data were included in the study, but technique description.

References

  1. 1.
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    Abou Youssif TM, Fahmy A, Rashad H, et al. The embedded nipple: An optimal technique for re-implantation of primary obstructed megaureter in children. Arab J Urol. 2016;14(2):171–7.CrossRefGoogle Scholar
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    Kock NG, Nilson AE, Nilsson LO, et al. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol. 1982;128(3):469–75.CrossRefGoogle Scholar
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    Rowland RG, Mitchell ME, Bihrle R, et al. Indiana continent urinary reservoir. J Urol. 1987;137(6):1136–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Urology DepartmentAlexandria UniversityAlexandriaEgypt
  2. 2.Urology DepartmentNorthern Ontario School of MedicineThunder BayCanada

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