KÄLBLE ET AL.
Surgery Illustrated – Surgical Atlas
BJUI
Serosa-lined and tapered ileum as primary and
secondary continence mechanism for various
catheterizable pouches
BJU INTERNATIONAL
Tilman Kälble, Petra Anheuser* and Joachim Steffens*
Department of Adult and Pediatric Urology, Hospital Fulda, Fulda; and *Department of Adult and Pediatric
Urology, St.-Antonius-Hospital Eschweiler, Eschweiler, Germany
T.K. and P.A. contributed equally to the completion of this study
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
INTRODUCTION
20 cm
The Mitrofanoff principle was introduced by
Riedmiller et al. [1] with the Mainz-Pouch-1
procedure in 1990. The method is commonly
accepted and used as a reliable continence
mechanism for catheterizable pouches [2].
However, there is little consensus about
other options for the efferent segment,
which has the greatest influence on patient
satisfaction [3]. Flap and nipple valves are
mostly used, and continence rates are
generally high [3]. The two main problems
with continent catheterizable stomas are
stenosis and leakage. Stimulated by
Abol-Enein et al. [4], Kälble and Roth [5]
used serosa-lined and tapered ileum
embedded in a short segment of ileum as
troubleshooting for incontinence. The
procedure was established for cases with an
absent or unsuitable appendix for Mainz
pouch and in cases of a failed continence
mechanism without the possibility of using
the ileocaecal valve with a secondary ileal
intussusception nipple [5].
a
10 cm
b
The good results of the serous lined
extramural ileal valve as a continent urinary
outlet stimulated Kälble and Roth [5] to use
this revision technique also as a continence
mechanism for bladder augmentation after
bladder neck closure in patients with
recurrent incontinence and stenosis of the
vesicourethral anastomosis after radical
prostatectomy. In addition, patients with
persistent incontinence caused by an
incompetent sphincter after a surgical
procedure or cases with a bladder outlet
syndrome in connection with a neurological
disease are often associated with a reduced
capacity of the bladder volume. The
procedure of serosa-lined and tapered ileum
embedded in a short segment of ileum
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requires a bladder neck closure and allows
the use of capacity-reduced bladder for
ileocystoplasty [5]. In contrast, the
application of an artificial sphincter requires
adequate bladder capacity and the patients
request for an alternative procedure should
be considered [6].
Although the number of such operations is
still small, the described method is a safe
and reproducible continence mechanism for
various forms of catheterizable pouches
[5,7].
PATIENT SELECTION
Appropriate selection of patients is essential
for the success of this surgical procedure.
An inevitable requirement is appropriate
patient compliance to perform regular clean
intermittent self-catheterisation. Sufficient
dexterity is necessary but it can be restricted
by neurological and/or muscular diseases.
Age and previous irradiation are not
absolute contraindications but can be
limitations to the procedure.
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INDICATIONS
• Ileocaecal pouch incontinence or therapy
refractory stenosis.
• Persistent urinary incontinence or BOO
due to incompetent external urethral
sphincter and/or recurrent bladder neck
stenosis after radical prostatectomy or TURP,
neurogenic bladder
SPECIAL INSTRUMENTS AND MATERIALS
• Allis clamps
• Long bipolar tweezers
• 18 F central open-end balloon catheter
for placement in the catheterizable efferent
ileum segment
• Polyurethane/polypropylene ureteric
stents
• 3/0 polyglactin polyfilament (Vicryl®)
absorbable sutures for closing the
mesenterial incision
• 3/0 or 4/0 polypropylene monofilament
(Prolene®) nonabsorbable sutures for
fixation of the U-shaped bowel that means
creating the back wall of the sero-serosal
tunnel.
• 4/0 polydioxanone monofilament (PDS)
absorbable sutures for closure of the
tapered ileum and connection of its distal
aperture with the U-shaped ileum segment
and for anastomosis of the efferent segment
with the umbilical skin
• 4/0 polydioxanone monofilament
(PDS) absorbable sutures for closing
the inner margins of the U-shaped ileum
segment over the embedded tapered
ileum segment and for incorporation
of the U-shaped segment with the
embedded tapered ileum segment into
the pouch
• 4/0 polyglytone monofilament rapidly
absorbable sutures for fixation of stents,
pouchostomy
Special cleaning of the bowel is not
necessary before surgery. Obstipation
should be excluded. The patient is placed
on the table with about 15-grade
overextension.
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SURGICAL STEPS
Figure 1
A midline abdominal incision is made with
a left-sided semi-circumcision of the
umbilicus. The length of the incision
depends on individual conditions. Generally,
it extends from the symphysis up to some
centimetres above the umbilicus. It should
allow mobilisation of the ascending colon.
a
b
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Figures 2 and 3
After adhesiolysis, the pouch is completely
detached from the abdominal wall, the
insufficient stoma is resected and the pouch
is opened at the anti-mesenteric site.
Thereafter, 30-cm ileum is isolated and
bowel continuity is restored by ileoileostomy. The oral 10 cm of the isolated
ileum segment are separated from the distal
part of the segment and tapered over an
18 F open-end catheter (4/0 PDS).
20 cm
10 cm
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Figures 4 and 5
The distal 20 cm of the isolated ileum
segment are opened antimesenterically and
configured in a U-shape. The two limbs of
the ‘U’ are sewn together by running
seromuscular sutures (3/0 or 4/0 nonabsorbable polypropylene monofilament
sutures, e.g. Prolene®) near the mesentery of
each side.
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Figure 6
In this sero-serosal bed the tapered ileum is
placed and anastomosed to the inner part of
the ‘U’. At the entrance of the ‘U’ the distal
opening of the tapered segment is fixed
with the free margins of the inner bowel
segments (4/0 PDS). The sero-serosal tunnel
is then closed by interrupted running
sutures (3/0 or 4/0 PDS).
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POUCH CONTINENCE MECHANISM
Figure 7
This U-shaped segment with the embedded
tapered ileum is then sutured to the opened
pouch by running sutures again (4/0 PDS).
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Figure 8
Before complete closure of the pouch, a
pouchostomy is inserted through the
abdominal wall into the pouch. The catheter
is brought through the umbilicus and the
distal part of the tapered ileum is
anastomosed end-to-end to the umbilicus.
The pouch is reattached to the abdominal
wall by some single nonabsorbable sutures.
The umbilical continent stoma is created.
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CLOSURE OF THE BLADDER NECK,
OMENTOPLASTY AND CONTINENT
ILEOCYSTOPLASTY
Figure 9
After adhesiolysis the bladder neck is
transected from the urethra and closed in
two layers using absorbable monofilament
sutures (3/0 and 4/0 Vicryl). Before closure
ureteric splints are inserted to avoid damage
to the ureteric orifices.
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Figure 10
To prevent urinary leakage an omentum
majus flap is interposed between bladder
neck and urethra.
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Figure 11
The bladder is opened at the dorsocranial
aspect. Thereafter, the ileal ‘U’ with
sero-serosally embedded and tapered ileum
is created as described and then sutured to
the opening of the bladder, as an
ileocystoplasty (3/0 PDS).
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Figure 12
The efferent ileum-segment is placed at the
lower abdominal quadrant (4/0 PDS). The
stoma location depends on its length and
mobility. It should be carefully planned to
allow easy access by the patient, preferably
with the dominant hand. For tension-free
channel fixation, a circumferential incision is
made to minimise the stricture risk. The skin
flaps are mobilised down to the rectus fascia
and sutured with the stoma margins with
single sutures (4/0 PDS).
a
b
c
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POSTOPERATIVE CARE
Antibiotics (cefuroxime and metronidazole)
are started before surgery and continued for
5 days.
For drainage of the stomach a nasogastric
tube is placed during the operation. It will
be removed after 1–2 days, after reflux is
excluded. Patients are mobilised as early as
the first postoperative day.
Drains are placed behind the pouch and
into the small pelvis, if cystectomy was
performed. They will be removed as soon
as the delivery rate falls below 50 mL/24h.
The ureteric stents are extracted after
8–10 days, at which time the rapidly
absorbable polyglycone sutures for fixation
of the stents are partially dissolved and
breakable. The day thereafter the upper
urinary tract is checked using
ultrasonography.
At discharge from the hospital the
pouchostomy catheter is left indwelling on
continuous urinary drainage for 4 weeks.
The patient is instructed to irrigate the
pouch with 50 mL saline once or twice a
day. After 4 weeks a pouchogram is
performed to exclude extravasation. The
patient is instructed to perform intermittent
self-catheterisation.
FROM SURGEON TO SURGEON
The procedure needs special attention to the
construction of the catheterizable efferent
segment. This continent outlet allows the
catheterisation of the pouch and requires an
adequate orifice. For this function a
sufficient length and vascularity of the
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embedded ileum is necessary to create a
tension-free abdominal stoma.
The assembly of the inner parts of the
configured ileum segments requires
particular attention. The inner margins of
the antimesenterically opened ileum parts
are closed over the tapered ileum segment.
The surgeon must ensure the right breadth
depending on the thickness of the
mesenterium and the diameter of the
tapered ileum segment. This step is
important for an undisturbed perfusion of
the continence mechanism. If it is difficult
to wrap the detubularised bowel around the
tapered ileum, the tunnel is closed by
several transverse running sutures between
adapting sutures.
If postoperatively the pouchostomy is
inadvertently lost, reinsertion is usually
possible without major problems. In difficult
cases, reinsertion of a catheter is
recommended to be done under fluoroscopic
control with a coaxial technique. In this way
a guidewire is inserted first, over which a
ureteric catheter (5–6 F) is passed into the
pouch. The correct position can be
controlled under injection of contrast dye.
Using the ureteric catheter as a guide, a
central open-end balloon catheter (16 F) is
now used for coaxial placement.
An extravasation from the pouch after
removal of the catheter at 4 weeks is
treated by reinserting the catheter for about
10–14 days. Water tightness should be
tested before its removal.
Leakage from the bladder neck requires
drainage of the pouch/augmented bladder. A
pouchogram should be done after 2 weeks.
If there is persistent leakage, a catheter
should be placed and checked at an interval
of 2 weeks. A surgical re-intervention for
persisting leakage is rarely indicated.
REFERENCES
1
2
3
4
5
6
7
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Thüroff JW, Riedmiller H, Fisch M,
Stein R, Hampel C, Hohenfellner R.
Mainz pouch continent cutaneus
diversion. BJU Int 2010; 106: 1830–54
Ardelt PU, Woodhouse CRJ, Riedmiller
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Abol Enein H, Salem M, Mesbah A
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Pfalzgraf D, Beuke M, Isbarn H et al.
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Anheuser P, Kranz J, Fechner G et al.
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preparation
Correspondence: Prof. Dr. T. Kälble, Klinik für
Urologie und Kinderurologie, Klinikum Fulda,
Pacelliallee 4, 36043, Fulda, Germany.
e-mail: [email protected]
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