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PubMed2001

Determinants of continence in the bladder exstrophy population: predictors of success?

OBJECTIVES: To delineate factors that may predict eventual urinary continence after bladder neck reconstruction (BNR) in the bladder exstrophy population. METHODS: The records of 65 patients who underwent all phases of bladder exstrophy reconstruction at our institution between 1975 and 1997 with greater than 1-year follow-up were reviewed and data analyzed. RESULTS: Fifty patients (77%) are continent day and night and voiding per urethra without need for augmentation or intermittent catheterization. Nine (14%) patients have social continence, dry for more than 3 hours during the day. Two patients required continent diversion for continence after failed BNR. Four patients are completely incontinent. The mean age of BNR was 4 years with a mean and median capacity of 93 and 85 cc (range 45 to 175). Analysis of bladder capacity measurements prior to BNR revealed that patients with a bladder capacity greater than 85 cc median capacity at the time of BNR had better outcomes. No correlation was found between the age of BNR and obtaining eventual continence. The mean time to daytime continence was 14 months (range 4 to 21) and the mean time to nighttime continence was 22 months (range 11 to 33). CONCLUSIONS: Determinants of continence in the bladder exstrophy population are multifactorial. In our experience, 77% of patients are completely dry, day and night, and 91% can achieve social continence, being dry for at least 3 hours. However, with careful evaluation of bladder capacity and bladder growth, urinary continence may be improved in this population with better patient selection.

Bladder Exstrophy↗

PubMed1996

Improved continence with tubularized bladder neck reconstruction following radical retropubic prostatectomy.

OBJECTIVES: Incontinence after radical retropubic prostatectomy remains a common problem. This study determines the efficacy of a tubularized bladder neck reconstruction for improving the time to continence and also the total rate of continence following radical retropubic prostatectomy. METHODS: Tubularized bladder neck reconstruction was performed in 29 patients by creating a trapezoidal-shaped anterior bladder flap and performing tubularization over a 30 F red rubber catheter prior to urethrovesical anastomosis. This flap measured approximately 5 cm at its base and 3 cm at its apex. Continence rates of these patients were compared to results of 30 randomly selected patients in whom a bladder flap was not used. RESULTS: Seven of 29 (24%) patients with tubularized bladder neck reconstruction were fully continent within 24 hours of catheter removal and 27 of 29 (93%) were fully continent by 3 months follow-up. An additional patient was continent at 6 months for a total continence rate of 28 of 29 (97%). These continence rates were significantly higher at all follow-up times than for patients in whom an anterior bladder flap was not used. One patient developed a bladder neck contracture and was successfully managed with visual urethrotomy. He is fully continent. CONCLUSIONS: Tubularized bladder neck reconstruction following radical prostatectomy may both increase the successful achievement of postoperative continence and decrease the time needed to achieve full continence without increasing morbidity.

Aged↗

PubMed2000

Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.

PURPOSE: The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix. MATERIALS AND METHODS: A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum. RESULTS: The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years. CONCLUSIONS: The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.

Adolescent↗

PubMed2006

Orthotopic bladder substitution in men revisited: identification of continence predictors.

PURPOSE: We determined the impact of the functional characteristics of the neobladder and urethral sphincter on continence results, and determined the most significant predictors of continence. MATERIALS AND METHODS: A total of 88 male patients 29 to 70 years old underwent orthotopic bladder substitution with tubularized ileocecal segment (40) and detubularized sigmoid (25) or ileum (23). Uroflowmetry, cystometry and urethral pressure profilometry were performed at 13 to 36 months (mean 19) postoperatively. The correlation between urinary continence and 28 urodynamic variables was assessed. Parameters that correlated significantly with continence were entered into a multivariate analysis using a logistic regression model to determine the most significant predictors of continence. RESULTS: Maximum urethral closure pressure was the only parameter that showed a statistically significant correlation with diurnal continence. Nocturnal continence had not only a statistically significant positive correlation with maximum urethral closure pressure, but also statistically significant negative correlations with maximum contraction amplitude, and baseline pressure at mid and maximum capacity. Three of these 4 parameters, including maximum urethral closure pressure, maximum contraction amplitude and baseline pressure at mid capacity, proved to be significant predictors of continence on multivariate analysis. CONCLUSIONS: While daytime continence is determined by maximum urethral closure pressure, during the night it is the net result of 2 forces that have about equal influence but in opposite directions, that is maximum urethral closure pressure vs maximum contraction amplitude plus baseline pressure at mid capacity. Two equations were derived from the logistic regression model to predict the probability of continence after orthotopic bladder substitution, including Z1 (diurnal) = 0.605 + 0.0085 maximum urethral closure pressure and Z2 (nocturnal) = 0.841 + 0.01 [maximum urethral closure pressure - (maximum contraction amplitude + baseline pressure at mid capacity)].

Adult↗

PubMed1995

Continence mechanism of the orthotopic neobladder: urodynamic analysis of ileocolic neobladder and external urethral sphincter functions.

BACKGROUND: The main objectives of bladder substitution are the preservation of the upper urinary tract and maintenance of urinary continence. Orthotopic bladder substitution makes it possible to achieve urinary continence as well as normal passage of urine through the urethra. Creation of a low pressure reservoir and careful preservation of the distal sphincter mechanism are considered to be of utmost importance for the maintenance of urinary continence after orthotopic bladder substitution. However, sphincter behavior after orthotopic bladder substitution has not been fully elucidated. The purpose of this study was to evaluate the vesicourethral continence mechanism after orthotopic bladder substitution in male patients. METHODS: Urodynamic evaluation was performed in 14 male patients after cystoprostatectomy for bladder cancer and an ileocolic neobladder using a cecourethral anastomosis. RESULTS: Good continence was achieved in 86% (12/14) of the patients during the day and in 79% (11/14) at night. On cystometry, maximum capacity of the neobladders was 434 +/- 21 ml (mean +/- SEM), and basal pressure at maximum capacity was 15.6 +/- 0.9 cm water. Phasic neobladder contraction with amplitudes ranging from 14 to 40 (26.6 +/- 2.7) cm water were noted in 11 of 14 patients. Sphincter electromyography demonstrated an increase in the frequency of action potentials of the external urethral sphincter during neobladder filling from empty to 80% of capacity (from 8.9 +/- 1.6 to 14.6 +/- 2.1 spikes per second; mean percentage increase, 64%, in patients with daytime continence). Maximum urethral closure pressure on urethral pressure profile was 49.9 +/- 3.5 (range, 30 to 64) cm water in patients with daytime continence, while in two patients who were incontinent during the day and at night maximum urethral closure pressure was lower (16 and 24 cm water) and the recruitment of action potentials of the external urethral sphincter during neobladder filling was impaired (percentage increase, 15% and 20%). CONCLUSIONS: An ileocolic neobladder has characteristics of a low pressure reservoir with a satisfactory continence rate. The vesicourethral continence reflex is well preserved in patients with continence after orthotopic bladder substitution.

Cecum↗

PubMed1997

Transanal ultrasound and anorectal physiology findings affecting continence after sphincteroplasty.

PURPOSE: This study was undertaken to evaluate endosonographic and physiologic determinants of fecal continence after sphincteroplasty. METHODS: Sixteen female patients with severe fecal incontinence were treated with overlapping sphincteroplasty. Mean postoperative follow-up was 12 (range, 3-48) months. All patients underwent preoperative and postoperative transanal endosonography and anal manometry. Bilateral pudendal nerve terminal motor latency determinations were performed in each patient. A physiologic continence score was used to assess stool control. RESULTS: Postoperatively, continence was worse, unchanged, and improved in one, five, and ten patients, respectively. An inverse correlation was noted between endosonographic sphincter discontinuity postoperatively, in degrees, and the change in fecal continence after overlapping sphincteroplasty (r = -0.51; P = 0.04). Postoperative increases in sphincter resting (r = 0.6; P = 0.02) and squeeze (r = 0.54; P = 0.03) pressures correlated with improved fecal continence. Mean pudendal nerve terminal motor latency (r = -0.34; P = 0.20) and changes in anal sphincter length at rest (r = 0.41; P = 0.11) and squeeze (r = 0.33; P = 0.20) after sphincteroplasty did not significantly correlate with the change in continence. Patients with intact endosonographic anatomy postoperatively and bilateral, unilateral, or no evidence of pudendal neuropathy had a mean change in continence score of 0.5, 1.8, and 2.2, respectively (P = 0.48). CONCLUSIONS: Endosonography after sphincteroplasty can identify residual sphincter defects that are significant in terms of fecal continence. Restoration of anal canal resting and squeeze pressures was related to improved fecal control after overlapping sphincteroplasty. Mean pudendal nerve terminal motor latency was not significantly related to poor postoperative continence. A trend toward less improvement in fecal continence was noted with bilateral pudendal neuropathy.

Adult↗

PubMed2000

[Can continence function after rectal resection be prognostically estimated?].

AIM: To determine clinical and physiologic parameters enabling the prognosis of continence after protective ileostomy closure secondary to rectal resection for rectal cancer. METHODS: Patients who had undergone rectal resection (n = 65, of whom 24 had had radiochemotherapy) were evaluated by clinical examination, anorectal manometry and orthograde contrast enema before ileostomy closure. Continence was evaluated by clinical findings 91 +/- 52 weeks after stoma closure with the help of standardized questionnaires and classified according to the Wexner continence score. The relationship between findings before stoma closure and continence score was calculated with Pearson's correlation coefficient. RESULTS: Correlations were found to be significant between the continence score and the level of anastomosis (r = -0.58, p < 0.001), median resting pressure (r = -0.52, p < 0.001), rectal compliance (r = -0.43, p < 0.001). Additionally, radiochemotherapy impairs continence (p = 0.0001). Correlations were not significant between continence and functional sphincter length, squeeze pressure, threshold for perception, urge and maximal tolerable volume, and continence for semiliquid contrast medium. CONCLUSION: Incontinence after rectum resection is multifactorial: the level of anastomosis, resting pressure, rectal compliance and radiochemotherapy all play a dominant role. Based on these findings, the continence score can be calculated before closure of a diverting ileostomy by applying multivariate analysis with the help of the following formula: Continence score = 18.23 - 0.94 x level of anastomosis - 0.18 x resting pressure + 3.72 x radiochemotherapy.

Adult↗

PubMed2002

Long-term followup and outcome of continent catheterizable vesicocstomy using the Rink modification.

PURPOSE: Multiple techniques have been described to create a Mitrofanoff channel in the pediatric population. A small subset of patients only requires creation of a catheterizable channel without bladder augmentation. These patients are ideal candidates for a procedure that avoids the use of intestine, especially in the absence of a suitable appendix. We used a modification of the Casale vesicostomy, as described by Rink, to create a continent vesicostomy in these children. We report our long-term experience with this technique. MATERIALS AND METHODS: We retrospectively reviewed the medical records of all patients who underwent continent vesicostomy at our institution between 1992 and 2000. Patient diagnosis, stomal site, associated bladder procedures, stomal continence, followup and complications associated with continent vesicostomy were documented. RESULTS: Of the 31 patients who underwent continent vesicostomy, as described by Rink, 14 were female and 17 were male. Average age was 9 years (range 2.5 to 22). Primary diagnosis included neuropathic bladder in 15 cases, the prune-belly syndrome in 6, cloacal exstrophy/anomaly in 5 and other in 5. The stoma was placed in the lower abdomen in 17 patients, in the umbilicus in 7 and in a neoumbilicus in 7. Simultaneous procedures included ureteral reimplantation in 8 cases, bladder augmentation in 5, bladder neck surgery in 4 and reduction cystoplasty in 2. Mean followup was 41 months. All patients achieved excellent stomal continence. Complications included stomal stenosis requiring revision in 14 cases (45%). Stenosis developed in 60% of the patients with neuropathic bladder and in 86% with an umbilical stoma. Eventually 6 patients underwent conversion to an alternative catheterizable channel. CONCLUSIONS: Continent vesicostomy can be performed successfully when there is any underlying bladder pathology with 100% stomal continence. Despite the higher rate of stomal problems with this type of Mitrofanoff channel we think that continent vesicostomy is a reasonable alternative in patients with a large bladder requiring only catheterizable channel creation. Because of the excellent results reported with the Monti-Yang technique, we would currently recommend this procedure over continent vesicostomy when bowel is used for bladder reconstruction.

Adolescent↗

PubMed1997

Urinary continence after radical retropubic prostatectomy. Analysis and synthesis of contributing factors: a unified concept.

OBJECTIVE: To assess the effects of three types of apical dissection on urinary continence after radical retropubic prostatectomy and to evaluate possible contributing factors, e.g. preservation of the bladder neck and preprostatic sphincter, age, anastomotic strictures, previous transurethral resection and nerve-sparing surgery. PATIENTS AND METHODS: Having undergone one of three types of apical dissection, 280 patients were evaluated: in Group 1 (sphincter-damaging) 134 patients underwent the original technique of ligating and transecting the venous complex; in Group 2 (sphincter-repairing), 76 patients had the venous complex with part of striated sphincter incorporated within anastomotic suture(s); and in Group 3 (sphincter-preserving), 70 patients had the venous complex alone ligated using the 'bunching' technique of Myers. The outcome was analysed for the number becoming continent and the time to continence. RESULTS: Continence was achieved in 93% overall, with 90%, 93% and 99% achieving continence in Groups 1, 2 and 3, respectively. The mean time to continence was 68 days overall, taking 100, 52 and 30 days for the respective groups. Twenty patients (7%) did not achieve full continence; 15 had minor incontinence and five severe, with none of the latter being in Group 3. The group (preservation of external sphincter), age and freedom from development of anastomotic strictures were the most important factors both in regaining continence and decreasing the time to continence. CONCLUSIONS: Preservation of as much as possible of the normal anatomy of the sphincter mechanisms and their nerve supplies results in an excellent return to continence after radical retropubic prostatectomy.

Aged↗

PubMed2004

Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy.

OBJECTIVE: To report our experience of the influence of bladder neck preservation on patient continence. MATERIAL AND METHODS: Radical retropubic prostatectomy with bladder neck preservation was performed in 131 patients (age range 48-73 years; mean 64.5 years). Urinary continence was evaluated using a validated questionnaire at follow-up visits and telephone interviews. All patients reporting incontinence were studied using a pad test and urodynamics. RESULTS: After a mean follow-up period of 21.7 months (range 4-47 months), 115 patients were continent (87%) and 16 incontinent. According to the International Continence Society criteria, three had severe, three moderate and 10 mild incontinence. Urodynamics revealed sphincter deficiency in 15 cases, which was associated with decreased bladder compliance in four, while decreased compliance was the only abnormality in one. Continence was recovered 0-27 months after surgery (mean 3.2 months): 40% of men were continent within the first month and 74% within the third. Histopathology revealed positive margins in 30/131 patients (22%), but exclusively at the bladder neck level in only seven (5%), and two also had positive nodes. Six patients (4.5%) presented bladder neck stenosis requiring transurethral incision. No statistically significant differences were found between the ages of continent and incontinent men or between the time to continence recovery with two different techniques of retropubic hemostasis; however, use of a nerve-sparing technique significantly reduced the time to continence recovery. CONCLUSIONS: Bladder neck preservation during radical retropubic prostatectomy does not improve the long-term results of urinary continence but does contribute substantially to its earlier recovery, thus improving the quality of life. With proper patient selection the risk of positive margins at the bladder neck level only is reasonably low.

Age Factors↗

PubMed1997

The effect of nerve sparing cystectomy technique on postoperative continence after orthotopic bladder substitution.

PURPOSE: Continence after orthotopic bladder substitution may be influenced by characteristics of the reservoir and of the sphincter mechanism. Autonomic innervation probably contributes to pressure generation by the sphincter mechanism at rest. We therefore examined the effect of nerve sparing cystectomy technique on continence in 165 consecutive men who underwent cystectomy and construction of an ileal low pressure reservoir and were followed regarding continence for at least 3 months postoperatively. MATERIALS AND METHODS: Nerve sparing was attempted bilaterally in 20 men, unilaterally in 96 and not at all in 49. Patients were followed prospectively and completed regular voiding diaries, including details of continence. Postoperative sexual potency was ascertained by questionnaire. The effects of attempted nerve sparing and of age on continence were examined in Kaplan-Meier models and in Cox's proportional hazards models. RESULTS: Median times to continence during the day and at night for all men were 3 and 9 months, respectively. Continence differed significantly between patients with attempted nerve sparing and no attempt at nerve sparing (day, p = 0.003 and night, p = 0.001, log rank test) and between men less than 65 years old and those older than 65 (day, p = 0.037 and night, p = 0.005, log rank test). In the multivariate analysis, attempted nerve sparing was significantly associated with improved continence by day (t = 1.96) and by night (t = 1.98). CONCLUSIONS: These data suggest that attempted nerve sparing is associated with improved urinary continence after orthotopic bladder substitution.

Adult↗

PubMed1999

Enhanced continent mechanism of tapered ileum by extramural support from pouch-abdominal wall: an experimental study in dogs.

PURPOSE: To construct a reliable continent tube, which is easy to catheterize, we created and evaluated a new continent cutaneous diversion using a tapered ileum combined with extramural support from the pouch-abdominal wall. MATERIALS AND METHODS: Six dogs underwent a procedure in which two ileal segments were tapered and anastomosed to the ileal pouch. One of the segments (continent) was placed between the back surface of the rectus muscle and the wall of the ileal pouch creating a continent tube. The other segment (control) was brought out into the abdominal skin directly without any support from the pouch-abdominal wall. Urodynamic and radiological studies were carried out postoperatively in all dogs. RESULTS: In the continent tubes, the maximum closure pressure with a full pouch was significantly higher than those with an empty pouch (p<0.01). The maximum closure pressures of the continent tubes were significantly higher than those of the control tubes when the pouch was empty (p<0.01). The leak point pressures of the continent tubes were significantly higher than those of the control tubes (p<0.001). In all dogs, the retrograde radiogram of the continent tubes showed perfect canalization without stenosis. CONCLUSION: This study suggests that the continent mechanism of tapered ileum can be greatly enhanced by fixing it between the abdominal and pouch walls, also allowing easy catheterization in contrast to the submucosal tunnel technique.

Abdominal Muscles↗

PubMed1991

The effect of posterior rectopexy on fecal continence. A prospective study.

Twenty-three patients with rectal prolapse or intussusception were studied to specifically focus on the effect of posterior rectopexy on fecal continence, anal pressure, and rectal capacity. Before operation, five patients were fully continent (A), 10 were continent for solid stools (B) and eight patients were fully incontinent (C). Group A remained fully continent; continence was regained nine times in group B and in group C, three patients regained full continence, two became continent for solid stools, three patients remained incontinent. Other symptoms such as constipation, false urgency, and a feeling of incomplete evacuation were not beneficially influenced by rectopexy. The patients' continence status was correlated to anorectal manometry and rectal capacity measurement. In group B, incremental pressure (P = squeeze - basal P) increased significantly (P less than 0.02) as well as incremental volume (V = maximum tolerated volume - volume of first sensation) (P less than 0.05). We conclude that, by an increase of incremental anal pressure and incremental rectal volume, posterior rectopexy offers an 83 percent chance of regaining full continence, or a major improvement, and a 17 percent chance of stabilization of fecal incontinence.

Adult↗

PubMed1995

Endosonography of the anal sphincter after ileal pouch-anal anastomosis. Relation with anal manometry and fecal continence.

PURPOSE: The aim of the present study was to visualize supposed defects of the internal anal sphincter after ileal pouch-anal anastomosis (IPAA) by anal endosonography and to relate these findings with anal manometry and fecal continence. METHODS: We investigated 23 patients, visualized the sphincter complex by anal endosonography, and quantified the anatomic changes of the sphincter. Anal resting and squeezing pressures as well as length of the anal canal were determined by anal manometry. Continence was objectively scored by an observer not involved in treatment of patients and subjectively by patients themselves. RESULTS: At anal endosonography, the mean thickness of the internal anal sphincter was 1.16 mm (95 percent confidence interval, 0.98-1.33), which is significantly less than in normal volunteers. Tapering of the internal anal sphincter only occurred in six patients (of whom two had a gap in the internal sphincter). In 17 patients endosonography showed a thin internal anal sphincter without essential variation in thickness over the complete circumference. Approximately eight weeks after ileostomy closure following IPAA, maximum resting pressure (MRP) and length of the anal canal appeared to be significantly decreased compared with values before IPAA (P = 0.001 and 0.002, respectively). These differences were less striking (P = 0.05 and 0.04, respectively) when measured six or more months after ileostomy closure. The extent of reduction of the MRP and thickness of the internal anal sphincter were not correlated with grade of continence or with subjectively scored continence. CONCLUSIONS: IPAA leads to a reduction of thickness of the internal anal sphincter and reduction of the MRP. Tapering or gaps in the internal anal sphincter are probably caused by direct trauma to this sphincter because of mucosectomy, whereas in cases of circular reduction of thickness of the internal anal sphincter without tapering or gaps, direct trauma is an unlikely explanation; this reduction is probably caused by denervation. IPAA compromises continence to a variable degree in 18 of 23 patients. No correlations were found between the extent of reduction of the MRP and the extent of reduction in internal anal sphincter thickness or between these two parameters and objectively or subjectively scored continence. Difficulties in obtaining reliable information on continence may be a causal factor. A striking discrepancy was noticed among objective, scored disturbances in continence, and overall satisfaction concerning level of continence by patients themselves.

Adenomatous Polyposis Coli↗

PubMed2005

Continent ileostomy: current experience.

PURPOSE: This study was designed to review our recent experience with continent ileostomies and evaluate patient outcomes. METHODS: Retrospective chart reviews and phone interviews of patients who underwent a continent ileostomy operation from 1993 to 2003 at the Ochsner Clinic Foundation were performed. RESULTS: Twenty-four patients (19 females; age range, 22-73 years) had construction of continent ileostomies (modified Kock pouch). There were no intraoperative mortalities or stoma-related deaths. The mean operating room time for primary construction was 3.9 +/- 0.57 hours with a mean length of stay of 7 +/- 2 days. The average follow-up period was 66 (range, 6-134) months. The most common underlying indication for the construction of a continent ileostomy was ulcerative colitis (71 percent). Thirteen patients had a continent ileostomy created for conversion of a Brooke ileostomy and seven for a failed ileoanal pouch. Other indications included colonic inertia and incontinence in three patients and one patient who had failed multiple operations for Hirschsprung's disease. A total of 28 revisions were performed in 14 patients (58 percent). Six patients required multiple procedures. Operative revisions included 12 skin level revision for stenosis, 11 operations for valve repairs, and 1 each for peristomal hernia repair, stomal relocation, and pouch repair for fistulas. Two patients had their pouches removed (Crohn's disease and inability to manage pouch). The need for revision by 12 months was 29 percent, and the average time period before the first revision was 24 months (range, 4 days to 109 months). The overall failure rate (converted to conventional ileostomy) was only 8.3 percent. Ninety percent of the patients have continent pouches and are satisfied with their pouch function. CONCLUSIONS: Continent ileostomies continue to have a high rate of reoperations, reasonable functional results, and are a viable option for failed ileal pouch-anal pouch patients. Surgeons electing to perform continent ileostomies must carefully select their patients and advise them of the high potential for reoperations. Despite a high reoperation rate, patients are pleased with their continent ileostomies.

Adult↗

PubMed2006

Impact of pre-operative MRI-measured membranous urethral length on urinary continence after radical cystectomy and orthotopic substitution: clinical and urodynamic evaluation.

PURPOSE: We aimed to determine the impact of membranous urethral length as measured by preoperative magnetic resonance imaging (MRI) upon continence following radical cystectomy and orthotopic substitution. MATERIALS AND METHODS: A total of 40 male patients (mean age 55.7 +/- 7 years) were subjected to radical cystectomy and orthotopic ileal substitution for bladder cancer. Membranous urethral length was measured by preoperative MRI utilizing coronal oblique high resolution T2 weighted images. In all evaluable patients, day and night continence statuses as well as time to stable continence were recorded. Urodynamic assessment included medium fill pouchometry and urethral pressure profilometry. RESULTS: Of all patients 10 were non-evaluable. Mean follow-up period was 8.1 +/- 1.9 months. All the evaluable patients were continent by daytime. On the other hand, 13 were continent by night (43.3%), 13 showed occasional enuresis (43.3%) and 4 were nightly enuretic (13.4%). Mean membranous urethral lengths were 14 +/- 1.9, 13.8 +/- 1.9 and 12.8 +/- 1.7 mm in the three groups, respectively (P = 0.51). Mean time to reach stable postoperative daytime continence was 5.4 +/- 4.6 whilst it was 12.5 +/- 7.4 weeks for nighttime continence. There was no significant correlation between preoperative membranous urethral length and time to stable day or night continence (R = -0.11, -0.08, respectively). Moreover, such correlation was not observed with postoperative urethral pressure profilometry parameters including maximum urethral pressure, maximum urethral closure pressure or functional urethral length (R = -0.33, -0.38, -0.16, respectively). CONCLUSION: Preoperative MRI-measured membranous urethral length has no value for judgment of postoperative continence status following radical cystectomy and ileal bladder substitution.

Cystectomy↗

PubMed2001

Predicting continence following radical prostatectomy.

Stress urinary incontinence is a recognized complication following radical prostatectomy. Fortunately, in the hands of experienced surgeons, the overwhelming majority of men ultimately regain urinary continence following the procedure. Most men regain urinary continence 3 to 12 months after the prostatectomy. We have developed and validated a continence index that is administered at the time of catheter removal after radical prostatectomy. This index identifies those men who rapidly regain continence and men who will have permanent incontinence after prostatectomy. The study population was stratified into tertile groups based on the continence scores. At 3 months, 96%, 82%, and 68% of men in the highest, mid, and lowest tertile groups reported using no pads or one small pad. Based on these observations, we recommend initiating biofeedback immediately postoperatively in men with continence scores of 14 or less. At 1 year, 100%, 98%, and 87% of the men in the highest, mid, and lowest tertile group reported using no pads or only one small pad. Men who have continence scores greater than 14 can be assured that they will regain urinary continence within 1 year. To our knowledge, this index is the only validated instrument that predicts the return of urinary continence after radical prostatectomy.

Humans↗

PubMed2006

A new postoperative predictor of time to urinary continence after laparoscopic radical prostatectomy: the urine loss ratio.

OBJECTIVES: To assess the correlation of a newly defined parameter, "urine loss ratio" (ULR), with the time to continence and probability for incontinence after laparoscopic radical prostatectomy (LRP). MATERIALS AND METHODS: A standardized "micturition protocol" that uses 24-h pad testing to objectively quantify urine loss after removal of the catheter was obtained from 939 patients who underwent LRP and were provided complete follow-up regarding continence. ULR was defined as the weight of urine loss in the pad divided by daily micturition volume, distinguishing between ULR on the first day after catheter removal and the last day of hospital stay. The time to continence was classified as early (0-3 mo), midterm (4-12 mo), and late continence (13-24 mo). RESULTS: Early continence was attained in 69.8% (n=655) of patients, midterm continence in 18.4% (n=173), and late continence in 3.5% (n=33). Of 939 patients in whom first-day ULR was quantified, 495 patients were not discharged immediately and their last-day ULR was quantified (2.3 d following catheter removal). There was a linear correlation between time to continence and ULR, which was more significant for last- than first-day ULR (p<0.001). A cutoff point of more than 15% of urine loss indicates a high risk of incontinence (ie, 8-fold for first-day ULR, 55-fold for last-day ULR). CONCLUSION: ULR predicts the time to continence and may be used to select patients for specific rehabilitation programs and early adjuvant medical therapy, particularly when urine loss exceeds 15%.

Adult↗