Continent Urinary Reservoir with Intussuscepted Valve Mechanism: How I Do It?
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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.
KeywordsBladder cancer Cystectomy Continent reservoir Urine diversion
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.
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 .
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.
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 . Indiana pouch was then emerges using ileocecal junction with the ileal segment acting as the afferent limb . 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.
Double-walled intussuscepted ileum is a safe and reproducible technique to create the valve mechanism of continent urinary reservoir.
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.