DETUBULARIZED SIGMOID COLON FOR BLADDER REPLACEMENT AFTER RADICAL CYSTECTOMY LUIGI F. DA POZO, RENZO COLOMBO, PAOLO POMPA, FRANCESCO MONTORST, VALERIO DI GIROLAMO skp PATRIZIO RIGATTL Prom he Departmen of Urogy, Seti Ite Safi, Mien, Hay During the last 6 yoars 24 sigmoid colon neobladders were constructed at our institute sceording Uo a surgival technique that provides Tor an optimal spherial configuration of the orthotopic reservoir. All pationts undorwent radealeystectomy fr locally advanced or superficie recurrent bladder cancer. The surgical complication rate was minimal, Mean followup was 38.3 months (range 7 to 70). Patients wore evaluated at 9 and 18 months vith urodynamic tests Daytime continence as achieved in 20 of 21 (95.2%) and in 16 of 17 (94.1%) patient, respec: tively: Nocturnal inemtinence was noted in 9 of 21 42.8%) and 6 of 17 (29.4%) patients, The ‘mean neobladder cepacty” ws “414 ce and 492 cc, respectively. Endoluminal prossure at the maximum reservoir capacity was 31 em. water range 23 Vo f4) and this did not change significantly at 18 nonthe. Minimal post‘voiding residual volume was evidenced all but 1 Ditient and was maintained at 18 months. Our modified sigmold colon neobladder fs an easy ‘Surgical procedure tat provides satisfactory otal bladder replacement in sleet patients, Ker Wane alder dass, Haderurtary dives emo, pcm Radical cystectomy i the treatment of choice for loa, savanced or saperical recurret and multi ladder can ‘uy, Tho procedure io aratve in high perestage of t= oe Patients with along hie expetancy should have an fcceptable quality of ie. Nerve spesng rica cystectomy” ‘and total bladder sobetitation niques have been sues {ely developed daring the Int deesde Inconnent tute ue urinary divers or uretcurgmniostnay cates be funaldered the gold sandard afar radia eystectomy, Ort topic reserves are currently preferred to eminent st lina aversion among male andiates be normal mcsurion ean he folic and alie™ sozments have been propre ladder sasttation, However de Heal fthatpaeocrva thas yet be determined. Nocti incontinence the art. ‘mien und mast deabling ermpliestion reported in the Imajority of series, Delobulnriong techniques Riarantee Aigmal continence in almost allease ‘We describe a aurea prcednre,snilrto that reported by Reddy to obtain an amos spenealpthotpi reser ‘oir fom a detabularivad test of siguoid alow, We a asses the long-term ficay four medi sigma elon cbr il aor racer ater aa feet, with parcular regard patient compliance int fel roots and urodynamic data, From January 1987 19 Febratry 1990, 24 male patios uundorvent ttl adder saben with « dtnbularced Staront of mold colon, perfumed alr cna! ang fot Foctly advanced tctages 2 to SNOMO, grades 2 to 3h or Stperialeurront (tage TANCMO, grade) bladder cancer ‘ot involving the tgune and prot uetira, One patient ‘ith clinical stage TAN bladdereancer underwent eablad Aer conatrseton due to hie retusa ef anyother type or ary diversion Chinical sting of only advaned bladder earinom i cluded eansurethral seoeetion of bladder cancer (IT pe Sens); eystacopy with eal-eupbipeiee ofthe tomor (2), trigone and prostate urethra, sxeretry aropranhy VP); coped for pabbeatin March 25198 ‘compterized tomography magnetic resonance imaging, and tne can. The intestinal rat wae investigstd by bar um nem or colonoscopy. Multipe sigmoid dverGeala {olen pats wer onsdered » contrsndieaton fr the us of the sigmoid colon sn total bladder eubtitution. In 2 cases a Elgmaid colon seblndder wan constructed even with ov ‘ence of sporadic diverticla of the destending clon In 2 ‘ther casos nical preoperative downstaging ofthe disase ‘was obtained ater 3 eels of neosdhorat patio, mete {remate and vinblastine chemcherapy. Mean patent age was [5.1 years (range 46 to 68 years Patents alder thas 70 years wre not considered candies for total Mader sub 2 satiactory performance status was reqiced (perfor. mance sats Ota 2) a well a uncompressed rena kane tion tereatnine less than 2 mg o eeatnie senrance seater than 70 por minute coveted Yo 173 m= surace ren) Posile completion f total arthotoie Nader a> Sttution, with parueulae regard to transitory or portant ‘nuess, were fully explained tothe patents who gave i Fiend consent. Candidates were nelected fr taal blader substittion oly they hod etal payehonaal abate ad {program of sal'ethetornation was eosdered fensble "The sural technique sloped mas tmilr to that de serbed by Reddy." with a few iieatons. An sinost. Spherical nosbledder configuration was obtained with folds ther a 30 em. tse of detubularizd enon (fg. 1). Peli Ipmphadensctomy is Use fest surgical sep Proven sections othe ph nodes are examined for tumor fetastses aod Cont bladder ubstetion i done in patente wi ange odes Blade subetitation was dan in oly I pation wi Boake des who prenperavely red ay her tye uf ‘Radealeytoprostaectomy is performed in the standard Iahlon. Tae prota aretha ie carefulydiseted and Vide ai: the pratate apex to avoid postoperative incon ‘ence, Frozen cetons af surreal marine sre sxaited for ‘ecidual mor segment ofa leat cm. of sigmoid clon {sitolated and postuoned in aU ahape athe ladder nite ig 1,4}-A compete detubuleraaton slong the medial tna perfrmed. Asal sion is ade in the lost part thesa10 ‘no, Simo son baer: reer 30m rca imi son ita tone in J shape de sang eaten ra a (apes leu ares shape yaa phralenigurten shaped colon and the cdlonle mucose Is advanced over {he external adventitia in preparation forthe urethro-olone ‘anastomosis. The preterer edges of te colon are then re- signed with adobe absrtable setae (ig. 1B). Urete- Colon anastomosis So performed and the ureters are rel planted in the poster aver 9 the future neablader with fa antreftx technique through a submucosal tunnel. Ure- ents are posittned, The anterior ayer ofthe noble Alera then sutured in a ¥ shape (Ag. C snd D) "The described tripe folding ofthe dtubularzed sigmoid colon provides the neabaddr an optimal spherieal configu {tion that can be domonateated alae on IVP (Og 2) A208 ‘eabladdar catheter is kept indwelling for 10 dave postop ‘tively. Daly irrigaions are performed to Keep the neoblad der ive of accumulating mucus. The ureteral stents are ‘emaved on day or 8 Te indweing eather x removed on {dy 10 aera ystgram has born performed, "ellewup evaluation incledee linia examination Hood chemistry studies and blood gas analy every 8 month fr ‘yearend thon every 6 months, sonography every 6 mot, INP alter 6 months and thea yearly, eytoarethrgraphy fer 6 montha, and urodynamic testing st 9 and 18 mothe pstoperatively, ere lel cl ea Ue complications incuded transient leakage atthe sto of {he uretirocolenic snastomenis 4 patent 10) who were treated conservatively leaving the catheter indwelling for a Tenger interval range 15 to 32 days) A secondary operation ‘wes necatsry in I patient due to leakage st the enon ‘emo colon anastomors Pleat empyems csarred in | Daten One patient ied of a massive tri sree in the arly postoperative stage Leto complications are roporte. Utrasound guided drain. sage of on ntcod lpmiphocsl wes necessary 3 month poet Speraively in 1 patient. Tw cases (9.6%) of stenosis ofthe ‘steal the reimplantaiien ste ecurred at6 and 14 months ostperaively, respectively In Tease hiateralstenasle was occnally treated eonservatively by antegrade balloon d= lation. No sanosis recurred ser 18 months, One patent refined any typeof editional treatment and ie presently Ssymptamat: with @ nonfunctioning Kidney. Symplomatiece unilateral nebladder ureteral refx was dingnoed in 1p ‘ent (7) at 24 months and be has not yet wn treated “The disease was pathological wage BIND grade 3m 8 canon pIBND grader 3 to in 10, ptuND grader to in 8 that ie onthe. Patients were instructed aboat timed voiding. The maxi mum suggested intaval between mictueions was 4 hours Dastine emtinence was ochioved in 20021 patients (95.2%) ab8 months. Of thee patients 4 wore a small pad inside the Shorts, mainly fr peyehological Teains, but they did tot ‘ed fo change during the day sinc they roparod sea ‘Sonal and minimal leakage of urine daring events of highly levatedinrs-abdominal rescue Toough, Inugh and 0 {orth One patient complained uf severe rea incontinene. OOF the If patient evtusted 18 months postoperatively 16 (9418) had diana continence. Patents were considered {continent during tho night when ttl involuntary enureris Gr more than 2 awekeningr were reported, or when they ‘ied the clthee during the nighe Nocturnal continence wa feportd in 12 of 21 GEE) and AB of 17 (109%) patent ot STand 18 month, respectively. Theve patients eperted ‘roved nvtumal continence batween the 2 encounters: ‘Uredynamic data at9 and 18 months were compared to linia results (se table) -A functional eaputy af more han 550 er a 9 months oceured in only I patent in whut a uu capecity necbladder (600 ce) was constructed, Minimal ‘angos in maximal nobladde capeciy were observed ater 18 months. Five patients underwent urodynamic tste at 8 longer followup range 26 to 39 month) and stable parame ters were recurded compared with the previous test. Chronic sodium bicarbonate uptake (600mg times daly) wan maggested teal patents and compliance was 68-1 (5 W121 Ne severe roetabalie eter or serum chcralyte tangas were diagnosed even in patents tho refed lke Tnatien. Cheonie symptematic urinary infestion requiring treatment with antics oceuered in patient wih large apultynowbladder and a lage post yond residual (300 2). ses production roquired temporary iergations uf the weo Uden 2 patente'afow dae aftr they were discharged fom te hota “Tumor recurred in 2 patent a 46 and 37 months, expec tively in patent local recurrence at the uretho-clonic tnastomosls required catanoousundiveraon of the neon der after urethrecomy, The patient was disease a 6 ‘months. One patent died ef'metaraic Ulsdder cancer at SS momihe ‘Total blader substation with bowel after rae eyetec: taniy has gained incresing poplar among arog rons dating the lat decode, Orthoiope neobladers are Fvtior soped by patients than incontinent or continent ‘ataneous Urinary diversions, tainly for peyehologea re Sons. Almost every bowel segent hat bre sed for total Bladder substitution and a varety of pcbladdery have been proposed in the recent tera lea and saoslonie Frecereirs are presently the most popular options fer ftal Tider subtiuton, We describ ou experince ith bad Ser replacement using a detubulerized regent of sigmoid ‘ion, he toe ofthe et clon for nena sonfgursion tras advocated in the aralgieal erate by Reddy aad ore recent by others “The ehoice ofthe lef soln for oa badder eubstittin in ‘oar exparonce was not seriously in sence by anderying ‘diseacs ofthe sigosdteact:Only 1 patent of 20 elected, had'to be excluded doe te the sabitized chronic sigs of progressive seue diverclis Rare and small diverttula of ‘hele colon were not considered set cntrandeations in 2 patente Due tothe relatively small numberof atnts ‘onsidered in our report, ii hued for us to sate precisely Fw many patients would have hewn exsded in argo propeleret pe borage onan better apericlconSiguration ofthe rnoryir and, hun bo ter clini and uredynarsie parameters. Thi configuration fan be cbtaied by means ofa trp ding of tae detabu Tarze tract of colon au deseribedpreviouniy. Due te a ‘ral pelvic position, the sgn con san be easly pulled ‘down to the urethral seam fr anastomosis, and the aire flax ureteral reimplantation ss particularly simple and rel able Early tnd late compleatons were acteptabe and si Tae’ to" thowe described for other neobindders Severea2 stable acidosis, malabsorption or dare did ot cecur nour patents ‘Total bladder sabetation was satisfactory in terms of clinical results and patent compliance Good near cx pacity moan 413 oo to ebained within 1 Year potopet [ively end doet oot sem to Inresse at hong-term fllewsp. Wertieve that br hs reason, patients eth a sigmoid colon ‘pablaas donot tend to have cbrnie urinary cetention {ren at lng-term foleep, nr oosrs in wore seri of eal Sd locolonie reserve, Sovere poe oid residual volume ‘500 ce easing symgtomate urinary ifetion ecsred only in pationt in whom 1 large eaoacty reervate (300 ce) he entrance,“ unary icons tore hot n problems nthe emeining patients and chronic Snibisde propa to prowndy not rewmmended our {Uhely afer total badder aubatttion a our nail "Total diurnal continenos wat ebieved in lmost all pa- tients in the early potoperative months. All but 1 patent ‘were sutified withthe esbladder nnd reported no changee In lietyle Theres, diamol cootineno can be expected fer total bladder substitution with the sigmoid colon x ‘Tih other detubulazed intestinal segment: Noctarea a Continence occured in 428% of ovr patonts a 9 months and {his incidence decreased slightly @047 after 18 months “Enuresa iba commen complication reported fer all orthotopic ‘oiding procedures and appears be les frequent with the Teal mesbindder 720 01%) Lose af the external spine time reesitment trough the spinal reese to bladder {ling seme tou be aot mportanteniee*® Our definition for gintoral contionce has ready been adopted by th. (co flowever a standard defini for nolarnal ariaary ‘ontiaence afer tral Winder sbtttson nas no et bean proposed. Therefore, more ojsctve goantieation of tbe Fienomenon is unovalable, Kaur serie patesta who had to {raken more dhen tice Were considered incontinent Taree Datentr who complained of nocturnal ieantnence at 9 enw ced cet o 18 mgt a hey ‘uowed changed wrodynamie parameters Tee dieu to {fine how much chenges inthe eens nits scheduled ffvakenings and Into Dotime) ifiyenced thee Judgment ‘None of ou ineontinent patients underwent implantation af fan arial sphincter analy, we have nol noticed any di {oranesn diarnl sed nocturnal oatinencebeteen younger find alder patient. must be noted, however, hat patients {nour series ere felavelySomg ngan age 98 year range {Gee coanderng the mean mow of patente who ender ‘ytectomy in the general rclogiea practice in or aries most patents sth igmatd colon neoblad- er urinate mhen tte ira seneaton of hypozastre fullness te dicomfor, whieh generally refered to ae eset of new ‘Ghinary etimltwandeceurs after an inveral claw to and not ‘aceeding the mani suggested 4 hours between mictar {loon Aue urinary stile smart the pysalogieal type wns opera nS eases We donot know exactly how to ‘he phenomenon that haw already been desesbed In the past afer igmold coan Bader augmentation = "Theseletion entena adopted fr otal ladda setitation vwore once In-eur eqpersnce ely 1 male patient among 12 SIGMOID COLON NEOBLADDEH AFTER KADICAL CYSTECTOMY requiring radical ctectomy underwent emetuction of Desbladder. ong ie expectancy Yeas especialy requir for {otal bladder stitution Age feos than 70 yeare ane low ‘stage bladder cancer Were cmsidored mandatory seletion itera Foe these reasons, mont of ur patients were ealue ‘Sicat iangterm flwop, Due tothe lw inidance of con Blisatione of the posodare and patent compliance, we have ‘Begun recently to perform total bladder substation even ftrer a noncuratie radial catectomy’ in cule patients 1. Bhi JP Skinner, D, Gan Konan JJ: Radel tec “omy lr carn of tho ade Te year of expres. tral ge raeibt. 2. whilmars Py Jind Batata, MA: Stato niga trednin snd ney ba ne Ci 4 Selig 3 and Wal. Newranatomi appro toe Uaise targa * «adem M6; Mil MOH an Rl, B= Gata nisin cease gat the pede forge ‘rt thn sever compromae point Cs, Tories 19 5. Wenrth UK, Badu, Egat G, Hedner, Dy ir apa hatnana The al ener ape fetta tn i cnn ee 1 Glam, A Keck N.C, yeh, 094 Shbab Din. AB. ‘Anappiaaeee spinircontsled nade atte: the ‘rar Kk po Url ie 19, 18 ‘obeker 100 eis wf Mag ph omni op ‘ence apd eatin JU Mh 8,188 9, Gaderer Mt Beni eC de: Bader titan and hc ee 10, Ry, PKs Dtabulariand sigma renee fr Mae fe hasan ater terse, Urls, 38625 18 11. hm Krk, Chang Sand Chen BT” Nene pst “eng empl lad pee arm 12 Mer, YF a Ste, U. Be Dine Sb made of ‘rabid um Sond Ua Nepal pls ee 10, 18 Jala, H, Stren, Stn, B, Rarho,P. n Ha T. ‘Pathan of src ry icons ner ne ‘al blsder replacement Conse erm of tea ‘Sette preceding sep: Br Ur 6 16, sas Sri AOR? Tad Mabe: ‘al ea, ras are ators J Ura 15, Kini ES Kantor M: Function of the atta abst uted ade Sein. Urol Nerd le 1 198 16, Kosta, Me Halen, B Ay Tonia. Le and takin, A: Cnoctoplay forthe weument of vere stented It 480,138,