RECONSTRUCTIVE UROLOGY

Comparison of clinical and urodynamic outcome in orthotopic ileocaecal and ileal neobladder
Bedük Y, Türkölmez K, Baltac S, Goegues C
Department of Urology, Ankara University, School of Medicine, Ankara, Turkey
J Urol. 2003; 169:1379-83

• Objective: Aim of this study was to evaluate the clinical and urodynamic results in patients who had undergone orthotopic bladder substitution with ileocaecal (Mainz pouch procedure) or ileal (Abol-Enein and Ghoneim procedure) segments and who had a minimum follow-up of 12 months.
• Methods: Mainz pouch procedure (MP) was performed in 19 patients (mean age 62.4 years, median follow-up 36 months) and Abol-Enein and Ghoneim procedure (AG) in 36 patients (mean age 64.3 years, median follow-up 31 months). Complications and urodynamic findings were compared in both groups.
• Results: Complications related to the pouch were (MP and AG groups, respectively) ureterointestinal anastomotic stenosis (10.5% versus 5.7%), pouch-urethral anastomosis stenosis (5.3% versus 5.5%), pouch-ureteral reflux (7.9% versus 4.2%), and pyelonephritis (15.8% versus 13.8%). At 12 months postoperatively, daytime incontinence rates were 5.3% versus 5.5% and nighttime incontinence (twice weekly or more) rates were 21% versus 8.4% in MP and AG groups. In urodynamic evaluation, which was performed in 39 patients at 12 months postoperatively, both groups showed adequate bladder capacity, the mean values of which were 426 ± 34 ml in MP group and 442 ± 27 ml in AG group (p > 0.05). The mean value of maximal flow rate was 19.6 ± 3.7 ml/s in MP group and 16 ± 6.1 ml/s in AG group (p > 0.05). The mean residual urinary volume was 37 ± 8.2 ml in MP group and 45 ± 7.1 ml in AG group (p > 0.05).
• Conclusion: The comparison between two types of bladder substitution, namely ileocaecourethrostomy (Mainz pouch procedure) and ileal reservoir (Abol-Enein and Ghoneim procedure) has demonstrated that urodynamic findings showed no significant difference between two groups.
  
• Editorial Comment
  Several papers have tried to compare different gastrointestinal segments with regards to their use and possible complications in orthotopic neobladders. In this paper a group actually not so experienced with the technique of orthotopic neobladders as some centers of excellence have demonstrated that in their hands no real difference with regards to the outcome after a minimum follow up of 12 months could be detected. It is notable, however, that the incidence of ureterointestinal anastomotic stenoses was lower in patients with a sub-serosal technique. There was also a lower incidence of pouch-ureteral reflux with the ileal subserosal technique. The value of anti-refluxing techniques in orthotopic low pressure reservoirs is still under discussion. What we can learn from this paper is the fact that submucosal embedding of ureters is not only a more difficult way of inserting ureters but it is also probably more prone to complications. This may especially be true in those centers where the numbers of orthotopic neobladder procedures are not extremely high (1). Nevertheless, we must also consider other factors that are important to diminish a stenosis or stricture rate in ureterointestinal anastomosis such as the length of mobilized ureters, handling of the ureters during dissection, preservation of periureteral tissue and thus vascular anastomosis etc.
  The last issue is also how we prepare ourselves for future instrumentation of the upper urinary tract in orthotopic neobladders. The location and angle at which ureters insert into the pouch may be factors for an easy or difficult access from below.

Reference
1. Stenzl A, Hobisch A, Strasser H, Bartsch G: Ureteroileal anastomosis in orthotopic urinary diversion: how much or how little is necessary? Tech Urol. 2001; 7: 188-95.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany