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Purpose: We provide the long-term results of renal transplantation into continent urinary intestinal reservoirs as a planned 2-stage procedure., Materials and Methods: Between November 1990 and January 2009, 18 patients underwent cadaveric or living related renal transplantation into continent urinary reservoirs (continent cutaneous diversion 16, orthotopic substitution 2). All patients were prospectively followed., Results: Of these patients 15 are currently free of dialysis. At a mean followup of 89.2 months (range 2 to 188) 13 patients had a serum creatinine ranging from 0.6 to 3.1 mg/dl (mean 1.49) after the first transplantation. Two patients underwent a second transplantation 12 and 122 months after loss of the transplant for renal vein thrombosis and chronic allograft dysfunction, respectively. Two additional patients had to resume hemodialysis 62 and 109 months after renal transplantation. The second transplantation was delayed mainly due to compliance problems. One patient died of fulminant septicemia after laparotomy elsewhere for bowel obstruction with normal renal function before that episode. The continence mechanism needed correction in 3 patients, and 2 further revisions were required for ureteral kinking and lymphocele. The patients with orthotopic substitution (2) voided to completion and showed complete continence. All patients with cutaneous diversion were continent day and night with easy catheterization., Conclusions: This study is among the largest single series to date of renal transplantation into continent urinary diversions. Long-term followup confirms that this approach is a safe and socially well accepted treatment option in carefully selected patients., (Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We critically examined the evidence supporting the widely accepted notion that patients undergoing continent urinary tract reconstruction after cystectomy experience superior quality of life outcomes than patients receiving a conduit., Materials and Methods: Based on a comprehensive MEDLINE literature search we retrieved and evaluated all full-length articles published in the English, French, German, Italian and Spanish languages comparing conduit diversion with continent cutaneous diversion and/or orthotopic bladder substitution with respect to quality of life or similar concepts. All studies were rated according to the International Consultation on Urological Diseases modification of Oxford Center for Evidence-Based Medicine levels of evidence., Results: The literature on quality of life after radical cystectomy for bladder cancer was rather extensive but generally of questionable quality. The main problems were flaws in the patient materials and methodologies used. To our knowledge not a single randomized, controlled study exists in the field. Because only few articles achieved a level of evidence better than III, the International Consultation on Urological Diseases rating system does not allow further differentiation among studies. Most studies showed that overall quality of life after cystectomy remained good in most patients irrespective of urinary diversion type., Conclusions: Existing studies are unable to prove that continent reconstruction after radical cystectomy is superior to conduit diversion. This review emphasizes the importance of performing well designed studies in the future.

Purpose: Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique., Materials and Methods: From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube., Results: Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization., Conclusions: With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.

Purpose: We compared the incidence, treatment and outcome of complications related to different continence mechanisms in a single institutional series of continent urinary diversions using an ileocecal reservoir., Materials and Methods: From November 1990 through October 1996 in 193 consecutive cases an ileocecal pouch (Mainz I) was used as a low pressure, high capacity reservoir. A submucosally embedded in situ appendix was used in 96 patients (mean age 57.2 years, mean followup 35.6 months) and an ileal intussusception valve was used in 106 (mean age 58.4, mean followup 33.1 months). Without exception the stoma was placed in the umbilicus., Results: In 172 patients (85.2%) no stoma related complication was observed. In 17 patients (17.7%) with appendix stoma 23 reinterventions were performed, for appendico-umbilical stenosis in all but 2 cases (15.6%), occurring after a mean of 20.4 months. Two complete appendix necroses required replacement by ileal nipple. Stomal stenoses could be corrected as minor outpatient procedures. In 13 of 106 patients (12.3%) with intussuscepted ileal nipple a second operation became necessary after a mean interval of 9.6 months (partial/complete necrosis of nipple in 4 cases, dislocation of nipple from ileocecal valve in 3, detachment from fascia in 4 and stomal stenosis in 2). Whereas no calculi were observed in the appendix group, stones had to be removed from 3 patients (2.8%) with ileal nipple., Conclusions: In situ appendix and intussuscepted ileal valve techniques are satisfactory in providing ileocecal reservoir continence. Besides the known advantages of the appendix as the primary reconstructive approach, the treatment of subsequent complications is simple. Therefore, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism.

Purpose: Now that creation of continent urinary reservoirs has become a standardized and clinically well established surgical technique with known morbidity and mortality rates, we reassessed the psychological and social aspects of this treatment compared with wet urostomy., Materials and Methods: We developed a questionnaire (102 items) addressing general aspects of quality of life, disease related social support, coping strategies and stoma related issues. It was mailed to 600 patients with ileal conduits and 130 with continent reservoirs. Final analysis was restricted to 192 patients operated upon within the last 5 years (mean followup 2.7 years)., Results: The resulting groups were matched and paralleled regarding most treatment related and sociodemographic data. Final analysis did not reveal differences between the groups in disease related social support, coping strategies or quality of life when expressed as a total score. We found statistically significant superiority of continent reservoirs regarding all stoma related items, patient global self-assessment of their quality of life (single item, p < 0.005), physical strength, mental capacity, leisure time activities and social competence (p < 0.05)., Conclusions: Continent diversion is clearly advantageous with respect to all items directly related to the stoma. The significant superiority of continent diversion in patient global self-assessment of their quality of life reflects the highly subjective dimension of the concept. Superiority in self-ratings of physical strength, mental capacity, leisure time activities and social competence could be interpreted as indicators of enhanced vitality in those patients, thus, supporting our understanding that women and men who actively participate in life have a special benefit from continent reservoirs.

Purpose: Pelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes in hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy., Materials and Methods: Standard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas., Results: The mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 +/- 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 +/- 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site., Conclusions: Approximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.