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At least 19 recordsLinked to original sources

PubMed2000

A continence index predicts the early return of urinary continence after radical retropubic prostatectomy.

PURPOSE: We evaluated the ability of a newly developed continence index to predict the return of urinary continence 3 months after radical retropubic prostatectomy. MATERIALS AND METHODS: We developed and used a continence index to determine continence level after removal of the urinary catheter on postoperative day 15 in 145 men. A total of 20 patients were evaluated independently by 2 nurse specialists to assess continence index reliability. We evaluated continence level, pad use and degree of bothersomeness due to incontinence 3 months after catheter removal. The association of continence score with outcome variables was calculated using the Mantel-Haenszel trend test and the predictive ability of the continence score was determined by logistic regression to produce cumulative odds ratios. RESULTS: The intraclass correlation coefficient was 0.995 for the independently assessed continence index ratings and the Cronbach coefficient alpha was 0.65 for the 5 continence index parameters. Complete continence or continence with heavy activity but not always was achieved by 96%, 85% and 68% of the men in tertiles 1 (continence score 18), 2 (continence score 15 to 17) and 3 (continence score 14 or less), respectively. The cumulative odds ratio of 2.9 (95% confidence interval [CI] 1.9 to 4. 6) per tertile indicated a 2.9-fold increased chance of incontinence for each successively lower tertile. In addition, 96%, 82% and 68% of the men in tertiles 1 to 3, respectively, required no or 1 small pad daily. The cumulative odds ratio for pad use was 2.3 (95% CI 1.5 to 3.5) per tertile. Of the patients in tertiles 1 to 3 100%, 97% and 80%, respectively, had no or slight bothersomeness due to urinary incontinence. The cumulative odds ratio for bothersomeness level was 2.7 (95% CI 1.7 to 4.3) per tertile. The Mantel-Haenszel trend test showed a significant association of continence score with all 3 outcome variables (p < or =0.001). CONCLUSIONS: Our continence index is a simple and reliable instrument that provides useful prognostic information on the early return of continence after radical retropubic prostatectomy.

Adult↗

PubMed1998

Leak point pressure use for intraoperative adjustment of the continence mechanism in patients undergoing continent cutaneous urinary diversion.

OBJECTIVES: Failure of the continence mechanism is the most common cause of unsatisfactory results and the need for revision in patients with continent cutaneous urinary diversion. We believed that incontinence in these patients could be eliminated or minimized by using the concept of leak point pressure intraoperatively to make appropriate adjustments and thus ensure adequate continence postoperatively. METHODS: The appropriate ileocolonic bowel segment for continent urinary diversion was isolated. Whenever the appendix was available, the unaltered or minimally altered appendicocolic junction was used for continence. In the absence of an appendix, the tapered distal ileum and reinforced ileocecal valve were used. Intraoperative leak point pressure (pressure at which leakage occurs) was measured before detubularization using a simple standing column manometer and arterial line tubing. Whenever leakage occurred at pressure less than 75 to 80 cm H2O, adjustment of the continence mechanism was performed and leak point pressure measurement was repeated to ensure adequate continence. RESULTS: Seventy-seven patients had long-term follow-up (30 to 100 months). These included 41 in whom the native appendix was used and 36 in whom the terminal ileum and ileocecal valves were used. Adjustment of the continence mechanism was required in 32 of the 41 patients in whom the native appendicocolic junction was used and in all 36 patients in whom the tapered ileum and ileocecal valve were used. After adjustment, all patients attained leak pressures over 80 cm H2O. At the last follow-up visit, all 77 patients were continent on intermittent catheterization every 3.5 to 6 hours. None has required revision of the continence mechanism. CONCLUSIONS: Intraoperative measurement of leak point pressure is valuable in predicting the need for adjusting the continence mechanism and eliminating or substantially minimizing the need for subsequent revision.

Follow-Up Studies↗

PubMed1996

Continent small-intestine reservoir construction: a tapered intussusceptum promotes sustained continence.

Developed for the study of dialysis in the continent jejunal reservoir (CJR), a novel, uncomplicated approach to achieve continence in construction of a small-bowel reservoir is presented. We utilize a technique of constructing a continent nipple valve, which entails the reduction or tapering of the intussusceptum prior to invagination into the reservoir. We have thus far performed the procedure successfully in 21 dogs. All animals have achieved absolute continence. Complications have occurred in two animals, neither complication involving the nipple valve. Pressure-volume cytometry in nine animals demonstrates continence in the awake animal at pressures of up to 40 cm H2O (volumes being limited by animal discomfort due to reservoir distention). In postmortem studies, reservoir capacities of > 1000 ml and pressures of > 70 cm H2O have been attained without loss of continence or prolapse of the nipple valve. Continence is sustained even when the reservoir and nipple valve are subjected to high intraluminal pressures. Incorporating a tapered intussusceptum, the continent reservoir provides absolute continence without the use of cumbersome mesh fixation or lithotropic intraluminal staples.

Animals↗

PubMed1999

Continence and urodynamic parameters of continent urinary reservoirs: comparison of gastric, ileal, ileocolic, right colon, and sigmoid segments.

OBJECTIVES: To compare the urodynamic parameters and continence rates among five different continent urinary reservoirs. METHODS: Continent urinary reservoirs were constructed in 40 patients with an average age of 60 years (range 23 to 81). Twenty-three had orthotopic neobladders ("neobladders"), and in 17 the reservoirs exited by way of an abdominal wall stoma as "stomal urinary reservoirs." In the neobladders, the detubularized segment was ileum (Hautmann) in 5, ileocecal (Mainz) in 8, sigmoid in 4, and gastric in 6. In the stomal urinary reservoirs, the segment was ileocecal in 11 (Mainz) and right colon in 6 (Indiana). Urodynamic studies were performed at a mean of 9.1 months. RESULTS: Stomal urinary reservoirs had the best continence rates (Indiana pouch 100%, Mainz pouch 91%). Neobladder continence rates were as follows: Hautmann, 80%; Mainz, 75%; sigmoid, 50%; and gastric, 33%. Day and night incontinence rates were nearly identical. Compared with the other pouches, gastric and sigmoid reconstructions had the smallest capacity, were the least compliant, and were the most contractile. CONCLUSIONS: Stomal urinary reservoirs using ileocecal valve and right colon, with or without an overlying patch of ileum, provide similar excellent results. Continence approached 100% in compliant patients without the need for revision. Patients with neobladders were less continent, although those with ileal or ileocecal configurations still had very good continence rates. Neobladders of sigmoid or stomach can be used when necessary, but with greater incontinence rates. This poorer continence can be explained by the decreased capacity, decreased compliance, and a tendency toward high pressure spikes despite detubularization.

Adult↗

PubMed2001

The Hadera continent reservoir: a new appendico-umbilical continent stoma mechanism for urinary diversion.

PURPOSE: Creating a reliable continence mechanism for a continent reservoir is a great challenge. We describe an easily formed mechanism for allowing complete continence in such patients. MATERIALS AND METHODS: The native appendix attached to a detubularized right colonic reservoir was used as the catheterizable efferent limb. The continence mechanism was created by crossing 2 nondetached right rectus muscle strips around the appendix. RESULTS: At a mean followup of 32 months (range 4 to 52) in 17 patients complete continence was obtained between 2 to 4-hour self-catheterizations in all positions and even during straining. CONCLUSIONS: This continence mechanism is easy to construct and creates a reliable continent stoma in all patients who are not candidates for orthotopic bladder replacement and who retain the native appendix. In patients who have undergone appendectomy an alternate method is to create a small caliber efferent limb from a tailored terminal ileum and build the continence mechanism around it.

Aged↗

PubMed1998

Preservation of putative continence nerves during radical retropubic prostatectomy leads to more rapid return of urinary continence.

OBJECTIVES: Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control. METHODS: Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy. RESULTS: At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o'clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o'clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92. 1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence. CONCLUSIONS: During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.

Cadaver↗

PubMed1989

[Improving anal continence performance by intensive continence training].

Ten children of six to sixteen years with anal incontinence following anal atresia were treated with a conservative intensive continence training programme for a period of 6 to 18 months. The continence efficiency distinctly improved by an optic and acoustic biofeedback conditioning, transcutaneous electrostimulation of the pelvic muscles, by physical examinations and a sensibility training, as well as by contraction exercises. Not only the partial continence ability with low atresia but also the incontinence with high anal atresia could be improved to a level of continence, especially short-time continence. The essential success is based on an improvement of the strength and duration of the muscle contraction, of the sensible perception and of the nerval coordination of the pelvic muscles. After two weeks of therapy, 90% of the possible maximum increase had already been achieved. Thus, an evaluation of the training success was possible. This continence training programme proved an ideal supplement to surgical therapy. Even if other methods of therapy are exhausted, continence training is indicated for the improvement of anal sphincter function.

Adolescent↗

PubMed1999

Urinary continence after staged bladder reconstruction for cloacal exstrophy: the effect of coexisting neurological abnormalities on urinary continence.

PURPOSE: We determined whether there is a difference in the incidence of urinary continence in cloacal and classic bladder exstrophy after staged bladder neck reconstruction using the Young-Dees-Leadbetter technique. MATERIALS AND METHODS: We reviewed the records of patients with cloacal and classic bladder exstrophy who underwent staged bladder neck reconstruction from 1971 to 1997. RESULTS: The Young-Dees-Leadbetter bladder neck reconstruction was completed in 23 patients with cloacal exstrophy, of whom 5 (22%) became continent and 18 (78%) have persistent incontinence. A clinically apparent neurological abnormality significantly hindered the achievement of continence. Specifically 1 of the 13 children (7%) with versus 4 of the 10 (40%) without a neurological abnormality became continent (p <0.05). In contrast, staged reconstruction of classic bladder exstrophy resulted in urinary continence in 67 of the 82 patients (82%). Of the 67 continent patients 23 (34%) cannot void and require intermittent catheterization. None of the patients with classic exstrophy had a neurological deficit. CONCLUSIONS: The ability of the Young-Dees-Leadbetter bladder neck reconstruction to result in urinary continence significantly differs in the cloacal and classic bladder exstrophy populations (22 versus 82%, p <0.001). Our findings also suggest that a coexisting neurological abnormality significantly hinders the ability to reconstruct a functional bladder in patients with cloacal exstrophy.

Bladder Exstrophy↗

PubMed2000

Modified seromuscular tube: serosa lined bowel wall imbrication as a continent outlet for continent cutaneous urinary diversion.

PURPOSE: We created a simplified modification of the seromuscular tube technique for continent cutaneous urinary diversion. MATERIALS AND METHODS: We applied a simplified modification of our seromuscular tube technique in 1 woman and 2 men with a mean age of 53 years in whom outlet failure developed after continent cutaneous urinary diversion, and in whom adiposity and postoperative adhesions rendered revision difficult. We constructed a continent outlet conduit by imbricating the whole bowel wall and suturing it into a tube. RESULTS: At a followup of 4 to 13 months (mean 7) all 3 patients are completely continent without leakage. Catheterization is performed at 3 to 5-hour intervals (mean 4) with 14 to 16Fr catheters. CONCLUSIONS: The wall imbrication technique involves the flap valve principle, as does the seromuscular tube, and it is easy to perform. To date followup is too short for judging the long-term reliability of this continence mechanism. If the outcome stands the test of time in this series, which represents the worst case scenario, application of this technique may be extended to continent cutaneous urinary diversion.

Adult↗

PubMed1996

Appendiceal continence mechanisms in continent urinary diversion.

The creation of a safe, reliable, and easy-to-perform continence mechanism remains one of the most important problems during continent urinary diversion. The advent of the use of the appendix as an efferent segment brought through the umbilicus has greatly facilitated surgical procedures with very favorable results. Our experience with the insitu appendix as an efferent segment during continent cutaneous urinary diversion using the Mainz-pouch I technique over the past 6 years revealed a markedly decreased complication rate of 3.2% as compared with 7.2% in patients who received an ileocecal intussusception nipple. The routine use of the appendix as a continence mechanism during continent urinary diversion has proved to be a most valuable addition to our surgical armentarium.

Appendix↗

PubMed1993

Characteristics and use of the in situ appendix as a continent catheterization stoma for continent urinary diversion in adults.

Use of the in situ appendix to provide continence was evaluated in 21 adults undergoing continent urinary diversion. The appendix with minimal or no manipulation was used in 20 of the 21 adults to provide the continence mechanism. Our findings indicate that in the majority of adults with no prior appendectomy the unaltered or minimally altered appendix is suitable to provide continence, and that dilating a narrow appendix is safe, effective and compatible with providing an adequate continence mechanism.

Adult↗

PubMed1996

The choice of continence mechanism in continent (supra)vesical urinary diversion.

By creating continent supravesical diversions or continent vesicostomies, various methods of continence mechanism can be distinguished. They all are based on the principle that the pressure in the conduit is higher than in the reservoir. Twenty-eight patients with various urinary diversions and different continence mechanisms were followed up by clinical investigation, questioning and urodynamic evaluation. The latter showed similar results with regard to efferent loop pressure. The best results concerning easy catheterization and safe continence are reached by appendix stoma and tapered ileum.

Adolescent↗

PubMed1989

Functional characteristics of the continent ileocecal urinary reservoir: mechanisms of urinary continence.

We evaluated urodynamically 14 patients with a continent ileocecal urinary reservoir. Reservoirs were constructed of detubularized right colon alone (4 patients), or augmented with ileum (2) or with a U-shaped ileal patch (8). All reservoirs were placed in the abdomen and used plicated terminal ileum as the efferent continence mechanism. Twelve patients are completely continent with intermittent catheterization at 4 to 8-hour intervals. Two patients suffer mild nighttime incontinence. Mean reservoir volume was 675 ml. Intermittent intestinal contractions were noted in the plicated ileal segment and reservoir but they occurred more frequently in the former and were either synchronous with or preceded those in the reservoir. Mean and maximal contraction pressures were 24 and 47 cm. water, respectively, in the reservoir and 40 and 151 cm. water, respectively, in the plicated ileal segment (p equals 0.043 and less than 0.001, respectively). The highest reservoir contractions occurred in the 2 patients with nocturnal incontinence. The method of construction bore no consistent correlation with mean or maximal contraction pressures, contraction frequency or continence. Careful urodynamic assessment suggests that the ileocecal urinary reservoir is a relatively low pressure, nonrefluxing and continent bladder substitute. The plicated terminal ileal segment acts as an effective sphincter that responds to pressure elevations in the reservoir. Its simple construction and easy catheterization make it an attractive alternative to intussuscepted ileal segments.

Adult↗

PubMed1989

[The continent urostomy. 12 years' experience with the continent ileocecal bladder].

The ileo-caecal continent urostomy was first described in 1975. It is a combination between an ileo-caecal reservoir and an ileal hydraulic valve. From 1973 to 1986 we performed 107 such operations (41 for vesicovaginal fistula, 40 for bladder tumor, 26 for bladder exstrophy, neurogenic bladder and miscellaneous). Continence was obtained in 100 patients (80 at the first operation and 20 after operation). The follow up was 3 to 146 months (average 37) in 82 patients 74 of whom had conserved good continence. In cases with failure of continence, repair was obtained by reinvagination of the same valve or by creating a new valve. Only 2 cases of metabolic disorders in the form of acute pyelonephritis are reported. The continent urostomy provides a better quality of life for patients requiring a urinary diversion. The psychosocial and economic impact is very important.

Adolescent↗

PubMedDate not supplied

Differences in coping strategies among community-residing older adults with functional urinary continence, dysfunctional urinary continence and actual urinary incontinence.

With a prevalence of urinary incontinence in the community of approximately 30 percent for older adults, and mixed findings on the relationship between psychosocial effects and bladder patterns, it is important to understand the effective (functional) and ineffective (dysfunctional) coping mechanisms older adults use to confront incontinence. This study examined 117 participants who were mentally competent, able to communicate in English, not confined to bed, and residing in the community. Ages ranged from 58 to 93 years with a mean of 75.6. Participants were distributed into three groups: dysfunctional continence (28.2%), functional continence (32.5%) and urinary incontinence (39.2%). A self-reporting, 4-point, Likert-like scale was used to determine coping methods. The functional continence group varied significantly from the dysfunctional continence and actual incontinence groups. Chi-square analysis indicated significant differences between the two groups in four items regarding the use of fluid restriction, management of odor, attitude, and the influence of age. There were significant differences in coping scores and gender, with women scoring higher. Finally, 73 to 85 percent of the dysfunctional continence and actual incontinence groups never talked to any healthcare provider about their urinary concerns. These high percentages emphasize that nurses must actively seek ways to open communication and discuss sensitive topics with older clients.

Adaptation, Psychological↗

PubMed2004

The continent bladder: indications and techniques for the continent catheterizable segment.

PURPOSE OF REVIEW: Continent catheterizable segments are a substantial part of the urologist's armamentarium for providing bladder drainage. It is used for a myriad of indications, and there are multiple techniques currently used for its formation. Despite refinements in these techniques significant complications still occur, and there is continued advancement and ongoing investigation. This review examines the current status of the continent catheterizable segment with regard to indications for its use, techniques in its formation, discussion of complications, and ongoing and future directions in research. RECENT FINDINGS: The continent catheterizable segment is indicated when it is not feasible to use the urethra for evacuation (e.g. bladder exstrophy, neurogenic bladder, radiation injury, and marked urethral dysfunction) or to facilitate catheterization. Compliance with catheterization and irrigation regimens is essential in patient selection. Multiple methods exist for its formation, either with or without the need for bladder augmentation. Although Mitrofanoff techniques with multiple applications predominate, "hemi" augments with efferent limbs also play a significant role. Stoma placement should be performed to best facilitate catheterization. Complications relating to catheterizable segments mainly pertain to continence, stenosis, and ability to catheterize, with more significant morbidity relating to the bladder augmentation. Ongoing research to develop more physiologic tissue substitutes and less invasive techniques may hopefully be superseded by prevention of the underlying lower urinary tract pathology. SUMMARY: Catheterizable segments allow the patient to control bladder evacuation, and continue to be refined by ongoing investigations in terms of indication and technique, with attendent decreasing morbidity.

Humans↗

PubMed1996

Continent cutaneous urinary diversion using the full-thickness bowel flap tube as continence mechanism: a simplified tunneling technique.

PURPOSE: We present a time and labor saving embedding technique for a full-thickness bowel flap tube used as a continent outlet. MATERIALS AND METHODS: In 17 patients the bowel flap tube was extramurally embedded instead of being submucosally tunneled. The reservoir was attached to the abdominal wall to reinforce the continence mechanism and prevent the tunnel from opening. RESULTS: All 17 patients are completely continent and 14 of 16 evacuate urine easily with a 14F catheter. Due to recurrent stomal stenosis 1 patient with severe diabetes has undergone incontinent diversion. CONCLUSIONS: Our described tunneling procedure for the full-thickness bowel flap tube is easy to perform and provides excellent continence.

Follow-Up Studies↗

PubMedDate not supplied

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. IX. Single loop continence: a new theory of the mechanism of anal continence.

The role of the external and internal anal sphincters in the mechanism of anal continence is presented. The external sphincter induces continence by 1) preventing internal sphincter relaxation, what I have called the "voluntary inhibition action," and 2) mechanical compression of the rectal neck and anal canal proper. The mechanism of both actions is described. The internal sphincter plays a significant role not only in involuntary, but also in voluntary, continence. The importance of this role in the correction of anal incontinence is clarified. "Stress defecation," a condition which follows internal sphincter damage, is discussed. A "single loop continence" theory is presented, based on the fact that each of the three loops of the external sphincter has its own innervation, attachment, and direction of muscle bundles; each loop thus acts as a separate sphincter. The clinical application of this theory is presented.

Anal Canal↗