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Objective: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD)., Patients and Methods: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations., Results: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%)., Conclusion: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Objective: To report the long-term outcomes of ileal ureteric replacement (IUR) in complex reconstruction of the urinary tract., Patients and Methods: From 1991 to 2016, IUR was performed in 157 patients with structural or functional ureteric loss. In 52 patients, bilateral IUR became necessary. Implantation sites where either the native urinary bladder (n = 79) or intestinal reservoirs (n = 78). In the latter group, the technique was used at the time of primary urinary diversion (n = 34), in a secondary approach (n = 29), and in undiversion or conversion procedures (n = 15). Anti-refluxive implantation was performed in 37 patients. In eight patients the ileal ureter was implanted into the cutis as an ileal conduit. All patients were followed prospectively according to a standardised protocol., Results: The mean follow-up was 54.1 months. In 114 patients with dilatation of the upper urinary tract before surgery a significant improvement of the dilatation was confirmed in 98 patients. Serum creatinine levels decreased or remained stable in 147 of the 157 patients. Reflux was present in all cases without and in six cases with an anti-reflux mechanism. In six patients, operative revision became necessary because of severe metabolic acidosis, mucus obstruction or stenosis of the ileal ureter., Conclusions: To our knowledge, this is the world's largest single-centre series of IUR reported to date. Long-term follow-up confirms that this approach is a safe and reliable solution, even under complex conditions. Anti-refluxive implantation is recommended for intestinal reservoirs, whereas reflux prevention seems to be of minor importance when the native bladder is chosen as the site of implantation., (© 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Objective: To describe our, step-by-step, technique for robotic intracorporeal neobladder formation., Patients and Methods: The main surgical steps to forming the intracorporeal orthotopic ileal neobladder are: isolation of 65 cm of small bowel; small bowel anastomosis; bowel detubularisation; suture of the posterior wall of the neobladder; neobladder-urethral anastomosis and cross folding of the pouch; and uretero-enteral anastomosis. Improvements have been made to these steps to enhance time efficiency without compromising neobladder configuration., Results: Our technical improvements have resulted in an improvement in operative time from 450 to 360 min., Conclusion: We describe an updated step-by-step technique of robot-assisted intracorporeal orthotopic ileal neobladder formation., (© 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.)

Objectives: To develop and report our initial experience with a novel antirefluxing technique for segmental ileal ureteric replacement for the treatment of long ureteric strictures., Patients and Methods: Between January 2000 and January 2007, 12 cases of ureteric strictures (nine bilateral and three unilateral) were treated using a novel surgical technique in which the ureter was replaced with a segment of ileum using an end-to-side anastomosis. An antireflux valve was constructed by fixing the distal part of upper ureter (4 cm) between the psoas muscle and ileal segment (the ileo-psoas tunnel technique). The distal ileum was connected to the urinary bladder with an end-to-side anastomosis., Results: The 12 cases were followed-up for a mean (range) of 39.42 (12-64) months. There were no cases of pyelonephritis or signs of renal failure after surgery. There was dramatic improvement in hydronephrosis, as assessed by intravenous urography, in the 4-9 months after surgery. Cystography showed no evidence of ileo-ureteric reflux. Mild hyperchloraemic acidosis was detected in two patients and was successfully treated with oral alkalization., Conclusions: In our initial experience, ileal ureteric replacement combined with the ileo-psoas tunnel antirefluxing technique is a highly effective procedure for the treatment of ureteric strictures.

Objective: To assess the extent and mechanism of renal reabsorption and excretion in patients with an ileal neobladder, as mild metabolic acidosis cause by proton reabsorption is common after such surgery, and long-term pharmacological correction is often necessary., Patients and Methods: The study comprised 30 patients (29 men and one woman) with ileal neobladders after oncological surgery; before surgery all had normal retention values. Before and after withdrawing the transurethral catheter, serum creatinine and urea were analysed and used to assess the effect of the neobladder on retention values, expressed as the percentage change from baseline (Delta creatinine and urea)., Results: There was a significant correlation between the Delta-creatinine and Delta-urea values (P < 0.001; r = 0.66); 15 patients (50%) showed resorption of creatinine and urea, eight (27%) excreted creatinine into the neobladder and resorbed urea from it at the same time, and three (10%) showed the reverse response, i.e. creatinine resorption and urea excretion. Interestingly, four patients (13%) excreted both creatinine and urea into the neobladder., Conclusions: We assume that there was both a resorptive and excretory function. Probably the metabolic state (resorption or secretion) of the neobladder depends on its mucus production and on the internal surface, or on diuresis. Further investigation is required to characterize these different influences.

Objective: To assess the feasibility and intermediate-term outcome of laparoscopic radical cystectomy (LRC) with ileal conduit urinary diversion in patients with organ-confined muscle-invasive carcinoma of the urinary bladder, the entire procedure undertaken intracorporeally only using laparoscopic techniques., Patients and Methods: Five patients (four men and one woman) underwent LRC with intracorporeal ileal conduit diversion in February 2000, using a six-port transperitoneal technique. LRC, ileal conduit exclusion, restoration of ileo-ileal continuity, and bilateral stented uretero-ileal anastomoses were completed intracorporeally in all patients. The follow-up data up to 2 years are reported., Results: All procedures were completed laparoscopically with no open conversion or intraoperative complications. The mean duration of surgery was 7.5 h; the blood loss was 360 mL and no patient required perioperative blood transfusion. The mean (range) hospital stay was 7 (6-22) days; the specimen weight was 225-400 g. The surgical margins of the bladder specimen were negative in each patient. One patient developed intestinal obstruction after surgery, requiring a diverting ileostomy for 12 weeks. At a follow-up of 2 years, two patients died, both from unrelated causes (myocardial infarction and septicaemia from pulmonary infection in one each). The three surviving patients are asymptomatic with normal upper tracts and no evidence of local recurrence or metastatic disease., Conclusion: LRC with ileal conduit diversion undertaken completely intracorporeally is a feasible option for muscle-invasive organ-confined carcinoma of the urinary bladder, with good outcomes over a 2-year follow-up.

Objective: To assess the use of demucosalized ileum for bladder augmentation, following the same principles previously used with the sigmoid colon., Patients and Methods: Eleven patients with bladder exstrophy or a neurogenic bladder had their bladders augmented with demucosalized ileum instead of the sigmoid colon, but following the same technique. The use of a Foley catheter with an inflated balloon greatly facilitated the dissection of the mucosa from the muscle. A silicone model, inserted in the bladder, was used to avoid shrinkage of the patch. An animal model was also used for total bladder replacement following the same principle., Results: The mean (range) follow-up was 15.4 (2-25) months. There was a significant increase in bladder compliance in all patients. A bladder of good shape and compliance was obtained in the animal model, with epithelial growth detected in all cases., Conclusions: Demucosalized ileum can be used safely for bladder augmentation in the same way as with the sigmoid colon. The distension of the isolated patch greatly facilitates dissection between the mucosa and muscle. The animal model supported this method of bladder replacement.

Objective: To describe a modified form of detubularization using a perimesenteric incision of the ileal segment, which increases the capacity of the neobladder and reduces the length of the ileal segment required., Patients and Methods: From February 1993 to November 1999, ileocystoplasty was undertaken in 20 patients (mean age 8.4 years, range 4-16). Six had myelodysplasia, four had primary epispadias, five had bladder exstrophy, three had post-traumatic lesions and two had cloacal exstrophy. The patients were divided into two groups; in the first (eight patients, mean age 9.6 years, range 5-15) the ileal segment was opened along the antemesenteric border and in the second (12 patients, mean age 7.7 years, range 4-16) the ileal segment was opened adjacent to the mesentery, perimesenterically. Each segment was then folded and the perimesenteric edges sutured to form the pouch., Results: The patients were assessed at 1 year after surgery; the neobladder capacity was evaluated as ((neobladder capacity - bladder capacity)/body weight), which shows the relative increase of bladder capacity after enterocystoplasty per unit of weight. There was a statistically significant increase in neobladder capacity in group 2 (perimesenteric transection; Kruskal-Wallis chi-square, P = 0.005; Mann-Whitney U-test, P = 0.006)., Conclusion: These results indicate that augmentation can be carried out by perimesenteric transection of the intestinal segment, which improves compliance and increases capacity of the neobladder.

Objective: To compare, in a dog model, the properties of a reconstructed bladder (peristalsis, histological changes and absorption) using an autotransplanted ileal segment with standard enterocystoplasty., Materials and Methods: Female beagle dogs were divided into two groups. In group 1 (autotransplantation, six dogs), a Heineke-Mikulicz-type pouch was constructed using autotransplanted terminal ileum. The artery and vein of the terminal ileum were anastomosed to the iliac artery and vein, respectively. The pouch was anastomosed to the bladder remnant immediately above the vesical triangle. In group 2 (control, five dogs) the same type of bladder reconstruction using terminal ileum was undertaken but with no vessel anastomosis. Bladder function in these two groups was then compared for peristalsis (by monitoring intravesical pressure), histological changes (by microscopy) and glucose reabsorption (by measuring the amount of glucose remaining in the reconstructed bladder). The mean (range) follow-up was 11 (7-18) months for group 1 and 9.2 (7-12) months for group 2; the recovery time before examination was 4.6 (2-7) months for group 1 and 4.0 (2-6) months for group 2., Results: In group 1, there were no major complications in five dogs after the procedure and they survived for > 7 months; the autotransplant became necrotic in one dog where the arterial diameter was < 1 mm. In the control group, all five dogs survived for > or = 7 months after surgery. Intestinal peristalsis was inhibited in group 1 but not in group 2. The bladder was oval/spherical in group 1 and elongated in group 2, with a thinner epithelium and fewer goblet cells in the latter. Glucose reabsorption was greater in group 2 than in group 1., Conclusion: Bladder reconstruction using autotransplanted terminal ileum in dogs is technically feasible. For bowel peristalsis and reabsorption of glucose, autotransplanted ileum may have functional advantages over a standard enterocystoplasty.

Objective: To assess the effect of patient position (supine, sitting or standing) on ileo-ureteric reflux in patients with an ileal conduit urinary diversion, in whom such reflux is normally detected when they are supine during a retrograde loopogram., Patients and Methods: The study included 10 patients with an ileal conduit as a primary urinary diversion; a loopogram was obtained with the patient upright or supine and a further film taken with the patient supine but at 45 degrees to the ground., Results: When supine, free ileo-ureteric reflux occurred into both ureterorenal units in eight patients. The remaining two patients, who had previously undergone unilateral nephrectomy, also had reflux into their existing renal units. Of the 18 units, 15 had grade III and three had grade IV reflux. In the upright and 45 degrees position, reflux still occurred in al ureterorenal units. The patient's position did not affect the degree of reflux in 16 units, but in one unit with grade IV reflux and another with grade III reflux, the reflux was one grade less severe., Conclusions: Ileo-ureteric reflux is common after ileal conduit diversion and may contribute to the likelihood of renal deterioration. The presence and/or degree of reflux is generally not affected by the position of the patient.

Objective: To describe a new continent valve incorporated as part of the wall of a urinary reservoir constructed from bowel., Materials and Methods: The technique was evaluated experimentally in 12 dogs; 40 cm of the distal ileum were isolated and the proximal 30 cm detubularized. The adjacent distal 7 cm of the intact ileum (valvular segment) was tailored around an 18 F catheter. The opened ileum plus the valve were doubly folded to form a pouch and the valvular segment incorporated as part of the pouch wall. The pouch was anastomosed to the trigone after subtotal cystectomy; the ureters were not manipulated. The pressure profile of the valve and ascending cystography were assessed 20 weeks after surgery and the inner layer of the valve examined histopathologically after the animals were killed., Results: None of the 12 dogs showed leakage through the valve at maximum filling on ascending cystography. The urodynamic assessment verified the reliability of the valve in maintaining continence and there were no problems catheterizing the valve. The histopathological examination showed that the valve was covered by intestinal mucosa. The new continent valve is technically easy to construct: the procedure is not time-consuming. staples are unnecessary and the mesenteric vascular pedicle is not manipulated. A shorter ileal segment is used in constructing this valve than is required for the intussuscepted valve. The wall-incorporated valve seems to provide a reliable and easily catheterizable continent stoma.

Objective: To determine the ultrastructural changes in the mucosa of intestinal segments used as a neobladder., Materials and Methods: Biopsy specimens from the ileal neobladders of eight men (mean age 62 years, range 52-68) who had undergone radical cystectomy were assessed by light and electron microscopy from 1 month to 5 years after operation. The morphology was compared with that in control specimens obtained from three patients of similar age during construction of an ileal neobladder after radical cystectomy., Results: Light microscopy showed shorter mucosal villi and fewer goblet cells. Marked oedema was found in all ileal neobladder walls. Electron microscopy revealed fewer and shorter microvilli and fewer filamentous core rootlets; cell borders were irregular, there were few senile cells in the tip of the villi and more desmosomes., Conclusions: The absorptive and secretory function of the intestinal mucosa was probably decreased; the oedema of transferred ileal mucosa seemed to be associated with an inflammatory cell reaction. The cellular dynamics of the mucosa of the ileal neobladder changed with time, thus the ileal mucosa in the substitute bladder apparently adapted well to the new environment, i.e. urine retention, and neobladder expansion and contraction.

Objective: To evaluate the impact of the modified ileal neobladder reconstruction on lifestyle, voiding habits and functional outcome in Asian patients., Patients and Methods: Twenty-seven Asian patients (25 men and two women, mean age 59 years, range 41-76) underwent modified ileal neobladder reconstruction after radical cystectomy for carcinoma of the bladder. The mean (range) follow-up was 21 (3-75) months. All patients were evaluated retrospectively using case notes, reviews, interviews and voiding charts; 18 patients underwent urodynamic studies., Result: Twenty-five patients (93%) achieved diurnal and 23 (85%) nocturnal continence within 6 months. Of the 19 patients who were in employment before surgery, 15 continued to be economically active afterward; 26 patients (96%) reported no change in their daily living activities. Of 16 men who reported being potent pre-operatively only four retained some residual erectile function. Twenty-three patients were interviewed about their voiding habits and satisfaction with the outcome of surgery. Fourteen patients had no sensation of reservoir fullness and of the 21 men, 13 had to squat or sit to void effectively. The mean (range) voiding frequency was 5 (4-8) during the day and 2 (0-4) during sleep. Twenty-two patients were satisfied with the overall outcome., Conclusions: The modified ileal bladder provides a high urinary continence rate with minimal changes in daily living activities and occupational status. The functional outcome was very satisfactory and accepted well, despite some changes in reservoir sensation, voiding posture and erectile function. The method is a viable option for reconstruction after cystectomy in Asian patients.

Objective: To assess the long-term (3-9 years) results of augmentation ileocystoplasty for non-neurogenic female urge incontinence in terms of continence, the need for intermittent self-catheterization and the need for additional or auxiliary treatment, to define the long-term complications and to assess the patients' satisfaction with the outcome., Patients and Methods: The study comprised 51 women who underwent augmentation ileocystoplasty for non-neurogenic urge incontinence between November 1987 and December 1993; 27 patients had associated interstitial cystitis. All patients had exhausted conservative methods, with an unsatisfactory outcome. All patients were interviewed about the results of the procedure, and their charts reviewed and updated with relevant information., Results: Within a mean (range) follow-up of 75.4 (36-109) months, 27 patients (53%) were completely continent, 13 (25%) had occasional leaks and nine (18%) continued to have disabling urge incontinence frequently requiring pads. Regular self-catheterization was needed by 20 (39%) patients while the rest emptied adequately with no or minimal residual volumes. Additional pharmacotherapy had to be used by 12 (24%) patients. Three patients later developed stress urinary incontinence and were managed with fascial sling procedures. The patch was revised in two patients and excised from four others because they had high residual volumes and uncontrollable infections. Two patients had an ileal conduit diversion for persistent incontinence. The most common complication was recurrent urinary tract infections, seen in 22 patients using intermittent self-catheterization. Mucus retention occurred regularly in 10 patients, six had chronic diarrhoea, four had latent bowel obstruction, one developed a bladder stone, one an incisional hernia and one developed patch necrosis and perforation. Twenty-seven patients (53%) were happy with the outcome of the procedure while 20 (39%) were not; four patients were unsure whether a change had occurred., Conclusion: Augmentation ileocystoplasty is a valuable alternative for women with intractable urge incontinence. However, these patients and their physicians should be aware of its limitations, specifically the possibility that incontinence may persist and the high probability of the need for self-catheterization, with potential subsequent urinary tract infection.

Objective: To determine whether the distension of bowel-augmented bladders during filling and urine storage stimulates gastrointestinal peristalsis, resulting in diarrhoea and increased bowel frequency., Patients and Methods: Five patients with symptomatic diarrhoea occurring after enterocystoplasty were studied; all had undergone bladder augmentation using ileum or colon at least 6 months previously. Using bowel frequency charts and colonic transit-time studies, their bowel function was assessed over 6 days while patients self-catheterized 4-hourly. This was repeated when the patient's bladders were decompressed with an indwelling catheter, and the results before and after bladder decompression compared., Results: One patient showed a significant increase in colonic transit time, from 44.4 to 57.6 h, a decrease in the percentage of liquid motions from 50% to 42.8% and a corresponding small decrease in bowel frequency with bladder decompression. One patient reported an increase in liquid stools, but there was a minor decrease in colonic transit time. The remaining three patients showed no improvement with bladder decompression. When data were combined and analysed using Student's paired t-test, there were no significant changes in colonic transit time, bowel frequency and diarrhoea stools with bladder decompression., Conclusions: Eliminating bladder distension and hence distension of the incorporated bowel segment in reconstructed bladders has no impact on bowel motility.

Objective: To investigate the efficacy of the reversed ileal seromuscular enterocystoplasty (RISMEC) technique and assess the urodynamic findings., Materials and Method: A large bladder defect was created in 12 New Zealand White rabbits: in six the bladder was closed primarily (control group) and in the remaining six the bladder was augmented using the RISMEC technique combined with omentoplasty. The results were assessed using intravenous pyelography (IVP), voiding cysto-urethrography (VCUG), histopathological investigations and urodynamic studies after 4 and 12 weeks., Results: The IVP and VCUG revealed an apparently normal urinary system and voiding pattern in both groups. Histopathologically, in all rabbits undergoing RISMEC, the serosal surface of the reversed ileum was lined with transitional urinary epithelium; there was no evidence of severe fibrosis, inflammation, stone or mucus-production. Urodynamic studies showed a significant decrease in the mean bladder capacity in the controls, but no significant change in the RISMEC group. The mean bladder compliance decreased from 5.85 to 1.36 mL/cmH2O in the controls (P < 0.02) but there was no significant decrease in compliance in the RISMEC group., Conclusion: The results suggest that in this rabbit model, the RISMEC technique combined with omentoplasty increases bladder capacity with minimal graft shrinkage; the peritoneal surface is rapidly covered with transitional epithelium and the integrity of the kidneys preserved. Urodynamic investigations showed neobladders with adequate storage capacity, low intravesical pressures and improved compliance rates.

Objective: To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement., Patients and Methods: Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation., Results: All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred., Conclusions: The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

Objective: To present the long-term results of the interposition of ileum in the ureter., Patients and Methods: An ileal loop was interposed to replace a long defect of the upper ureter, with preservation of lower ureteric continuity, in nine patients (mean age 35 years, range 18-58). Patients were followed regularly for a mean of 5.2 years (range 2-7) and assessed using renal ultrasonography, isotopic renography and intravenous urography., Results: Urinary drainage was satisfactory and renal function and configuration were improved. None of the patients experienced metabolic acidosis or electrolyte disturbances despite receiving no medication., Conclusion: These results were encouraging and further clinical experience is needed to confirm that ileal interposition of the ureter is a safe and effective procedure.

Objectives: To document the changes in bowel habit in patients who have undergone enterocystoplasty., Patients and Methods: Sixty-nine patients with neuropathic (NP) and 44 with non-neuropathic (NNP) bladder dysfunction (mean age 26 years, range 13-61, 93.6% socially continent), followed for at least 36 months after cystoplasty, were assessed using a questionnaire addressing faecal frequency, consistency, method of evacuation and incontinence episodes before and after surgery., Results: Of the patients with NP bladder dysfunction, 26 (38%) had more and seven (10%) less frequent bowel action after surgery, with 36 (52%) unchanged; 38 (55%) of patients had unchanged consistency, 26 (38%) were looser and five (7%) more constipated; 41 (59%) opened their bowels as before, 16 (23%) needed more help and 12 (17%) less help to evacuate; 16 (23%) patients had more and 17 (25%) less episodes of incontinence; 21 (30%) patients felt their bowels had not become normal after their operation and only 24 (35%) that they had returned to normal within 3 months of their operation. The bowel segment used was ileum in 44 patients, ileocaecal in 11 and sigmoid cystoplasty in 14. Patients with intact ileum did not have the same degree of diarrhoea, with only three of the 14 patients with a sigmoid cystoplasty being adversely affected. Of the patients with NNP bladder dysfunction, 18 patients (41%) had a more and five (11%) a less frequent bowel action; 20 (46%) had more loose and five (11%) less loose bowel action; similar numbers (five and four) needed either an increase or a decrease in laxatives or enemata: surprisingly, 12 patients (27%) felt they had an increase in the episodes of incontinence; 17 (39%) patients felt their bowels returned to normal within 3 months of surgery and 30% felt their bowels had not become normal after surgery. Only one patient in this group had a sigmoid cystoplasty and she did not find that the operation interfered with her bowel function., Conclusions: Ileal resection results in malabsorption of bile acids, maldigestion of fat and an imbalance of water and electrolytes. Patients with neurogenic bladders are finely balanced between acceptable bowel function and choas, and surgery often tips this balance the wrong way. In 30% of the present patients, bowel problems persisted after surgery, with 38% having increased frequency. 38% having looser consistency and 23% more incontinence episodes following surgery. More surprisingly, a high percentage of NNP patients had bowel problems after cystoplasty.

Objective: To study the morphology and function of the upper urinary tract over the long-term in dogs with an enterocystoplasty and a refluxing or anti-refluxing uretero-intestinal anastomosis., Materials and Methods: Subtotal cystectomy and "cup" ileocystoplasty were performed in 13 dogs. The right ureter was implanted into the cystoplasty with a refluxing technique in seven and with an anti-reflux procedure in six dogs. The left renal unit acted as an intact control in 11 dogs, while in two the intramural part of the left ureter was incised to produce reflux. Thus, of the 26 renal units, nine had a refluxing junction (anastomosis), six were anti-refluxing and 11 served as intact controls. Total and separate glomerular filtration rates (GFRs) were measured preoperatively and regularly thereafter, and cystometry, urography and ascending enterocystography were performed. At necropsy, urine was obtained for culture from the cystoplasty and renal pelves, and both kidneys were examined histologically., Results: The cystometric pressure was low in 12 of the 13 dogs: urography showed no obstruction. The fall in separate GFR did not differ significantly among the groups (with and without reflux protection, and control units). Reflux was detected in three of nine renal units with refluxing anastomosis and in three of 11 control units. Bacteriuria was found in the cystoplasty in all dogs; the incidence in the upper urinary tract was seven of eight renal units with a refluxing anastomosis, one in five of those with an anti-refluxing anastomosis and three of nine control units. Pyelonephritis was found in none of the control kidneys, in six of nine kidneys with a refluxing and in two of six with an anti-refluxing anastomosis: it was less severe in the latter., Conclusion: Refluxing ureteric implantation in a low-pressure enterocystoplasty was commonly associated with bacteriuria in the upper urinary tract and with pyelonephritis. Thus, anti-reflux implantation was beneficial for renal preservation in this setting.

Objective: To develop and improve the technique of bladder replacement with ileum in patients with interstitial cystitis., Patients and Methods: A consecutive series of 27 patients (23 women and four men, median age 61 years, range 40-79) with chronic severe interstitial cystitis refractory to conservative therapies underwent cystectomy and bladder replacement using an ileal pouch. The relief of pain was assessed over a median follow-up of 30 months (range 2-48)., Results: Pain relief was complete in all patients and the median neo-bladder capacity was 520 mL (range 350-700). Only four patients required intermittent self-catheterization to drain post-micturition residual urine. Bladder calculi formed in two patients and were removed successfully at cystoscopy., Conclusion: Bladder replacement with ileum in the form of the Kock pouch is an effective surgical treatment for intractable interstitial cystitis.

Objectives: To evaluate the intestinal mucosal permeability in continent reservoirs for urine., Patients and Methods: The mucosal permeability in continent urinary reservoirs, constructed either from an ileal or a colonic segment (six patients each), was assessed by analysing serial samples of plasma, after instilling the reservoir with 51Cr-ethylene diaminetetra-acetic acid (51Cr-EDTA), and serum, after instillation with polyethylene glycol (PEG 400)., Results: There was no or negligible permeation of 51Cr-EDTA and PEG 400 in either type of reservoir, as there was no significant increase of the markers in plasma and serum, respectively., Conclusion: The intestinal barrier to medium-sized hydrophilic molecules seems intact in continent urinary reservoirs. The lack of significant permeation of 51Cr-EDTA confirms the usefulness of a single injection of 51Cr-EDTA for the determination of glomerular filtration rate in patients with intestinal urinary diversion.

Objective: To compare two methods of connecting the ureters to an ileocystoplasty., Patients and Methods: Eighteen men with bladder cancer underwent radical cystoprostatectomy and a further two had a subtotal cystectomy, all with immediate orthotopic bladder replacement by ileocystoplasty. In 10 patients, the ureters were connected to the neobladder by a length of ileum with an inverted nipple valve, while in the other 10 the ureters were implanted directly using a serosal tunnel. Post-operatively, the upper tracts were examined by intravenous urography and the neobladder by cystography before removal of the catheter., Results: The direct implantation technique used 15 cm less ileum and took a mean of 1 h less operating time to complete. The kidneys and ureters remained normal in all patients except one, who had a subtotal cystectomy and developed severe hydronephrosis and hydroureter with acute renal failure when the inverted nipple valve became everted., Conclusions: Whilst both techniques gave satisfactory results, direct implantation is more economical in the length of ileum used and in operating time.

Objective: To evaluate the results obtained with a technique of bladder replacement using a detubularized ileal tract, developed by the authors., Patients and Methods: Since 1983, 34 patients have undergone an orthotopic bladder replacement using 35-40 cm of ileum, detubularized and shaped into an 'S' to create a neobladder with a capacity of 100-120 mL. The ureters were anastomosed directly to a 10 cm long intact afferent loop which serves as an anti-reflux mechanism, while a 2 cm long efferent, spatulated loop was used for urethral anastomosis. The mean (SD) follow-up was 32 (33) months., Results: All the patients were continent during the day, with socially convenient intervals between voids; 3 years after the operation, 10 of 12 patients were continent during the night, with intervals of 2-4 h between voids. The mean post-void residual urine volume was 41 mL and no patient required self-catheterization. There were no derangements of the metabolic status of patients., Conclusion: This technique was applied knowing that a detubularized intestinal loop has the remarkable ability to increase in capacity over time. Therefore, to maintain the reservoir in good condition over a long period it is important to construct it with an intra-operative capacity of < 120 mL, thus reducing the length of intestine required. This may explain the satisfactory metabolic status of these patients. Moreover, the triplication of the mesentery helps to maintain the sphericity of the neobladder and provides support for the neobladder in the lower pelvis, where it retains the same position as a normal bladder.

Objective: To determine if the bowel dysfunction that develops in approximately 12% of patients after a clam enterocystoplasty is due to disruption of the enterohepatic circulation of bile acids., Patients and Methods: Fourteen symptomatic patients (mean age 36 years, range 21-65) who had undergone clam enterocystoplasty were investigated by bowel frequency charts, hydrogen breath tests of expired air and the retention of radioactive 75Se-labelled homocholic acid-taurine (SeHCAT), a synthetic bile acid. Patients with abnormal results were commenced on anion-exchange resins and the symptoms evaluated 6 weeks later., Results: The interruption of bile acid circulation, as estimated by SeHCAT, occurred in most of the patients studied and was due to surgical resection of the terminal ileum. All hydrogen breath tests were normal, excluding bacterial overgrowth as a cause of diarrhoea. Bowel frequency correlated well with the percentage of SeHCAT retained. Anion-exchange resins were successful in relieving the symptoms if patients complied well with the treatment., Conclusions: After clam enterocystoplasty, some patients have bowel dysfunction caused by the interruption of the enterohepatic circulation of bile acids. These patients can be identified using bowel frequency charts and treated by anion-exchange resins.

Objective: To provide a stable continence mechanism in patients with urinary diversion by creating a flap valve from the ileal wedge, sutured into the grooves of the reservoir mucosa., Patients and Methods: The valve's efficacy and stability were confirmed previously in an experimental study using five dogs. The valve was used in 22 patients with ileocaecal pouches and as a continence mechanism for cystostomy in two paraplegic women., Results: Continence was achieved in all but two patients. In these exceptions the valve was found to be abnormally short (only 2 cm). Re-operation restored one patient to continence but the second patient refused further surgery. There were no problems with either catheterization of the valve or with epithelialization of the serosal surface of the valve., Conclusion: The valve is easy to construct and requires only a small intestinal segment; it has long-term mechanical and functional stability and can be easily catheterized. The valve provides continence even with increasing reservoir content and will accept a large catheter, which seems to be important in preventing lithiasis.

Twenty-three patients with an ileal bladder substitute formed after cystectomy for invasive bladder cancer were evaluated clinically and urodynamically between 3 and 38 months post-operatively. The urodynamic measurements were compared with the clinical findings. After re-education of the patients' voiding habits the mean voiding volumes of the bladder substitutes stabilised 6-9 months post-operatively at 350 ml. The frequency of micturition was 3 to 5 times during the day and once or twice at night. The maximum functional capacity (maximum voiding volume) was about 490 ml. Ninety-one per cent of the patients were continent during the day 18 months after the operation and 82% were continent during the night. Micturition was problem-free with an average maximum flow of 25 ml/s and an average micturition time of 50 s. The mean voiding volume of ileal bladder substitutes was 50% of the measured cystometric capacity; the maximum functional capacity (= max. micturition volume) was 80% of the cystometric capacity. The average basal pressure was < 20 cm H2O from the third post-operative month onwards. Eleven of the 23 patients had contractions in the bladder substitute (average at 30 cm H2O) at 55-76% of the maximum cystometric capacity or at approximately 90% of the maximum functional capacity. Such spike waves had no clinical or radiological consequences. If the patients were shown how to increase the functional capacity of a reservoir made from only 40 cm of ileum, the clinical results were excellent.

Five patients with an ileal conduit and 5 with an ileo-caecal bladder substitute have been studied metabolically. All had undergone cystectomy for infiltrating carcinoma and they formed 2 homogeneous groups in terms of age and follow-up. Function in both groups was within normal limits but closer examination of patients with an ileo-caecal bladder revealed mild functional damage as shown by reduced creatinine secretion, a lower level of bicarbonate and lower urinary acid valency secretion. It was concluded that the ileal conduit is more satisfactory from a metabolic point of view than the ileo-caecal bladder, which requires closer follow-up and treatment with bicarbonates if necessary.

We present our experience with a modified technique for constructing a continent ileal reservoir, using the terminal ileum in a pre-peritoneal position. The ureters were implanted using the Le Duc-Camey technique; the Benchekroun valve was used as a continence mechanism. This technique was used in 18 patients and its advantages and complications are discussed.

A group of 66 patients (40 males, 26 females) underwent an ileal conduit urinary diversion because of bladder cancer (44 patients) or incontinence/bladder dysfunction (22). They were questioned about pre- and post-operative sexual function and activity and it was found that 90% of the males (26/29) who were sexually active before surgery lost the ability to achieve erection following radical cystectomy. Although they were unable to achieve penile erection, 41% were able to experience orgasm by means of masturbation. Five of the 29 males received penile implants. Five of the 6 females treated by cystectomy, who were sexually active before the operation, reported either a decrease or cessation of sexual activity (i.e. coitus) post-operatively. The main problems were a decrease in sexual desire, dyspareunia and vaginal dryness. One women reported the inability to experience orgasm after surgery. Compared with women with bladder cancer, those with incontinence/bladder dysfunction were more likely to have an active sexual life after urostomy surgery. Seven females in this group, of whom 4 were sexually inactive before surgery, increased their sexual activity after the operation. For these women the conduit operation removed the need to use incontinence pads or indwelling catheters.

Bladder augmentation has a role in the management of patients with neuropathic bladder dysfunction and in urinary undiversion. Several reports attest to its clinical value, but there have been few detailed urodynamic studies of its effects. We have carried out a prospective review over a 4-year period of 25 patients undergoing bladder augmentation or substitution assessed by conventional and ambulatory urodynamic studies. All patients had a detubularised reservoir made of ileum in 6, and of the ileocaecal segment in the remainder. Six patients also had an artificial sphincter fitted and 2 underwent colposuspension. There was no mortality. After operation, bladder capacity increased from 122 +/- 91 ml to 659 +/- 431 ml and there were significant decreases in the pressure rise during filling and increases in bladder compliance. Hyper-reflexia was present in 74% before operation and 23% after operation. Regular phasic activity was observed in 77% of patients at the end of filling after operation, probably due to bowel activity despite detubularisation. Four patients described urge incontinence associated with this activity. After operation, one man had persistent major stress incontinence. He has since undergone insertion of an artificial urinary sphincter (AUS) and is now completely dry. Of the remainder, 10 patients had minor, infrequent defects in continence, 9 patients with leakage when the bladder was full and 4 with occasional leakage at night. With the exception of the patient with major stress incontinence, all but one felt the operation had been worthwhile--40% reporting complete success and 52% excellent improvement. Reconstruction of the neuropathic lower urinary tract is a major surgical procedure, but the final clinical outcome is very satisfactory.

Previous studies on substitution or augmentation cystoplasty have highlighted the profusion of surgical techniques available, but there is disagreement as to which is the best. We established an animal model to compare various types of cystoplasties, tubularised and detubularised, using ileum and caecum. Detubularisation did not abolish intrinsic bowel contractions but delayed their onset. No differences were noted in the frequency and amplitude of such contractions after detubularisation or between large and small bowel cystoplasties. Although intravenous urography did not demonstrate any abnormality in upper tract anatomy, a significant number of animals had some functional disturbance of the kidney after cystoplasty demonstrable on isotope renography, irrespective of the surgical technique. It may be possible to prevent these contractions with their associated harmful effects by preventing the bladder volume from building up excessively.

Total substitution of both ureters in 5 patients with advanced obstructive uropathy due to extensive ureteric bilharziasis is described. It is recommended that ureteric replacement in the presence of marked obstructive uropathy should not be undertaken without preliminary renal drainage. An open through-and-through nephrostomy is recommended for this purpose. It is suggested that this approach will help to minimise the incidence of nephrectomy in areas of endemic urinary bilharziasis.

Clam enterocystoplasty has proved to be the most effective treatment for severe detrusor instability resistant to conservative treatment (Bramble, 1982; Mundy and Stephenson, 1985). More recently it has become the procedure of choice in patients with neuropathic bladders with hyper-reflexia or severely impaired compliance, provided that the bladder is of reasonable size and that gross fibrosis and/or diverticular formation of the bladder wall has not occurred. Fifty-nine patients have undergone the clam procedure as part or all of their reconstruction in the past 4 years. Although uncontrolled incontinence was the commonest indication, impaired renal function was the indication in 14 patients and need for undiversion in seven. Currently all but four are voiding satisfactorily or are on intermittent self-catheterisation, though six have significant stress incontinence. The clam procedure is easier, quicker and as satisfactory as substitution cystoplasty in selected cases.

One hundred and thirty patients underwent radical cystectomy and ileocaecal bladder reconstruction for carcinoma of the urinary bladder. The actuarial 5-year survival rate was 45%. Local pelvic recurrence was noted in 26.3% of patients. Most of those in the series (81.9%) had perfect control of micturition. Intravenous urography performed up to 10 years post-operatively showed preservation of renal configuration in 92.2%. The normal flow curves recorded showed that it was possible to achieve a balanced vesicourethral unit. Ileocaecal bladder reconstruction is less disabling than urinary diversion after radical cystectomy.

Mucus excretion, sialic acid excretion and secretory IgA (sIgA) production from patients with a substitution caecocystoplasty (20), augmentation "clam" ileocystoplasty (20) or ileal conduit (10) were measured. Significant amounts of all of these substances were present in the urine of reconstructed patients and showed no evidence of diminution with time. Motility was studied by videocystourethrography. In patients with a neuropathic aetiology the amplitude of contractions was significantly increased and produced incontinence. The results demonstrate that intestinal secreto-motor function in gut segments incorporated into the lower urinary tract continues normally and must be taken into account when considering the long-term management of these patients.