MILKING ACTION: A NEW FUNCTIONAL CONCEPT OF A DIFFERENT ORTHOTOPIC NEOBLADDER: 4-YEAR FOLLOWUP

Purpose

We demonstrate how the combined use of detubularized and remodeled intestine with intact cecum in the construction of an orthotopic colonic neobladder determines different functioning.

Materials and Methods

Since February 1993, 11 men who underwent radical cystectomy due to invasive bladder carcinoma have received a new bladder substitute consisting of an upper component of ascending colon and a detubularized and remodeled right half of transverse colon, and a lower component with intact cecum. During postoperative years 1 and 4 all patients were evaluated with urodynamics and cystography.

Results

The detubularized upper component of the neobladder acts as a large capacity, low pressure filling reservoir, while the intact cecum with its haustral contractions (inverted milking action) contributes as an additional continence mechanism. The mass contractions (milking action) with abdominal wall tension actively collaborate to evacuate the reservoir completely.

Conclusions

This new structural concept of a neobladder constructed from detubularized and intact intestine has a different functional behavior than neobladders described in literature. This neobladder enables complete evacuation and total continence in the immediate postoperative period.     

Perineal Cystoprostatectomy and Ureterosigmoidostomy for Invasive Bladder Cancer

Purpose

A technique for perineal cystoprostatectomy with ureterosigmoidostomy is described as a minimally invasive method to treat muscle invasive bladder cancer.

Materials and Methods

We performed 7 perineal cystoprostatectomies. In the most recent case ureterosigmoidostomy performed via the perineal approach was the definitive method of urinary diversion.

Results

The operation was well tolerated and minimally invasive.

Conclusions

Perineal cystoprostatectomy and ureterosigmoidostomy are effective and minimally invasive means of definitive therapy for muscle invasive bladder cancer.     

Urethral Lengthening With Anterior Bladder Wall Flap (Pippi Salle Procedure): Modifications and Extended Indications of the Technique

Purpose

We report a clinical case series of an innovative method of urethral reconstruction for the treatment of urinary incontinence. Modifications of our original technique are presented.

Materials and Methods

Bladder neck repair was done in 17 patients, mean age 9.3, with neurogenic incontinence (13) or exstrophy (4). Average followup is 25.6 months. Of the patients 9 with neurogenic bladder underwent the original procedure using a midline anterior bladder wall flap. In the 4 patients with exstrophy a modified procedure was done using an anterolateral bladder wall flap. In another 4 patients an extended flap of distal mucosa was used to avoid ureteral reimplantation. Augmentation was performed in 13 of the 17 cases (10 detubularized ileum and 3 detubularized colon).

Results

Continence (greater than 4 hours) was obtained in 12 of the 17 patients (70%), 2 are dry for 1 to 2 hours and 3 are incontinent. A urethrovesical fistula developed in 2 patients (1 closed successfully), and 3 patients have problems with catheterization.

Conclusions

Urethral lengthening with anterior bladder wall flap is a versatile alternative in the surgical treatment of urinary incontinence. Variations of the original technique resulted in an improved vascular supply and decreased the formation of fistula at the base of the flap. The modified technique was successful in patients with exstrophy, including those who had failed bladder neck surgery.     

Long-Term Results of Ureterosigmoidostomy in Children With Bladder Exstrophy

Purpose

We evaluated long-term results of patients with bladder exstrophy who underwent ureterosigmoidostomy.

Materials and Methods

Of 4 women and 23 men monitored at our institution 16 (59 percent) underwent primary diversion by ureterosigmoidostomy, while 11 (41 percent) underwent primary bladder closure or an ileal conduit procedure before conversion to ureterosigmoidostomy. Average followup after ureterosigmoidostomy was 17 years.

Results

Significant upper urinary tract changes developed in 18 percent of the patients. Metabolic acidosis was well compensated in most patients but 2 had problems with urinary retention leading to hyperammonemia and acidosis. Of the 19 patients monitored with biennial colonoscopy benign polyps were removed in 4. Daytime continence was achieved in 92 percent of cases and nighttime continence in 58 percent.

Conclusions

Our experience with ureterosigmoidostomy in children with bladder exstrophy has been favorable through long-term followup. With proper imaging, metabolic surveillance, biennial colonoscopy and nonsteroidal anti-inflammatory drugs we offer ureterosigmoidostomy as a viable alternative for patients with small bladders.     

Submucosal Hematoma of the Sigmoid Colon as a Complication of Anticoagulation Treatment

Background

Anticoagulation therapy after coronary stent implantation is necessary and crucial for patients with severe coronary heart disease. Submucosal bleeding of the colon is an infrequent complication of anticoagulants.

Methods

TWe present the case of a 70-year-old woman with spontaneous submucosal hematoma and active bleeding of her sigmoid colon due to anticoagulants after intracoronary stenting.

Results

This patient underwent a timely surgical operation. Treated by our experienced multidisciplinary team, her recovery was smooth without any other major complications.

Conclusions

Surgical intervention is an appropriate therapy for patients with intractable bleeding.

     

Giant sigmoid diverticulum: A rare entity of high clinical significance

Aim-Background

Affecting about 35% of patients above the age of sixty, diverticular disease represents a common entity. However, giant colonic diverticulum is a rare complication of this disease with variant clinical presentation and high complication rate. This report describes one such case and includes a short review of the literature.

Case report

An 83-year-old Caucasian man was transferred to our Unit after having been hospitalized in the Department of Internal Medicine for 15 days due to high fever with chills and vague left lower abdominal pain. The clinical examination was normal and showed no signs of peritonitis or palpable mass, other than a mild abdominal tenderness in the left iliac fossa. The patient’s medical history included diabetes mellitus, hyperlipidaemia, and distal arteriopathy. The patient had undergone endovascular repair of abdominal aortic aneurysm five years earlier. Blood tests indicated hypochromic anaemia and a hemoccult test was positive for haematochezia. Blood, urine, and faeces cultures were negative.

Results

Diverticulosis of the sigmoid colon was diagnosed by colonoscopy. The abdominal CT revealed a large air density mass adjacent to the sigmoid colon and diverticulosis of the sigmoid colon was diagnosed by colonoscopy. We performed sigmoid resection followed by end-to-end colorectal anastomosis with protective loop ileostomy so as to eliminate the risk of septic complications. A giant pseudodiverticulum was confirmed by histology.

Conclusion

Giant colonic diverticulum is a rare complication of colonic diverticular disease with unclear aetiology and variable clinical presentation. Due to the substantial risk of complications and the low mortality associated with surgical treatment, elective surgical therapy has been recommended. Conservative management of an asymptomatic giant colonic diverticulum should be reserved only for high-risk elderly patients who cannot tolerate surgery or who are unwilling to undergo surgery.     

VAGINAL CONSTRUCTION IN CHILDREN

Purpose

We evaluated outcomes in 20 patients 1 to 21 years old who underwent vaginal construction between 1980 and 1996.

Materials and Methods

A total of 21 vaginal constructions was performed in 20 children using ileum in 13, sigmoid colon in 6, bladder mucosa from a diverticulum in 1 and scrotal skin in 1. The diagnoses included the Mayer-Rokitansky syndrome in 6 cases, micropenis in 5, cloacal exstrophy in 3, penile agenesis in 3, and testicular feminization, classic bladder exstrophy and true hermaphroditism in 1 each.

Results

Patients treated with intestinal vaginoplasty had excellent cosmetic results without excessive mucous production or the need for routine dilation. The bladder mucosa vagina achieved good results with periodic dilation. Loss of depth developed in the scrotal skin vagina and it was converted to an ileal vagina. Stenosis at the mucocutaneous junction in 1 patient with a sigmoid and 1 with an ileal vagina was treated with Y-V plasty.

Conclusions

Vaginal construction may be performed using isolated bowel segments with excellent results and minimal morbidity. We have found ileum to be the segment of choice in younger patients, while sigmoid colon is preferred for vaginal construction in adolescents. Vaginal construction with isolated bowel segments provides a cosmetic, self-lubricating neovagina with low rates of failure and revision, and without the need for routine dilation.     

Feasibility of Single-Port Laparoscopic Surgery for Sigmoid Colon and Rectal Cancers and Preoperative Assessment of Operative Difficulty

Purpose

Single-port laparoscopic surgery is more difficult for sigmoid colon and rectal cancers than for right-sided colon cancer. We sought to analyze the feasibility of this procedure for sigmoid colon and rectal cancers and to estimate its difficulty.

Methods

We analyzed prospectively collected data from 63 consecutive patients with sigmoid colon or rectal cancers who underwent single-port laparoscopic surgery at our institution from June 2009 to December 2011. Patient and tumor characteristics, including patients’ pelvic anatomy which was assessed on CT scan imaging, were evaluated to elucidate what factors would affect the difficulty of the procedure and the necessity of using an additional trocar.

Results

Overall, the median operative duration was 190 min and blood loss was 20 ml, with no postoperative complications. The median number of lymph nodes harvested was 17 and the distal margin was 58 mm. The tumor was located significantly closer to the anus in cases in which an additional trocar was required in the right lower quadrant (9.5 vs 18 cm, p?<?0.0001). Procedural difficulty was significantly increased in cases in which the sacral promontory protruded ventrally (odds ratio 0.779 [95 % confidence interval 0.613 to 0.945], p?=?0.0236).

Conclusions

Depending on tumor location and sacral promontory shape, the introduction of an additional trocar might render single-port laparoscopic surgery feasible for sigmoid colon and rectal cancer resection.     

Total laparoscopic sigmoid and rectal surgery in combination with transanal endoscopic microsurgery: a preliminary evaluation in China

Background

This study was designed to evaluate the feasibility and safety of total laparoscopic sigmoid and rectal surgery without abdominal incision in combination with transanal endoscopic microsurgery (TEM).

Methods

From May 2010 to October 2011, 34 patients with colon and rectal tumors were treated by total laparoscopic surgery without abdominal incision, and the clinical data of these patients were reviewed.

Results

All operations could be successfully accomplished without conversion to open surgery. No diverting ileostomy was created. The average operative time was 151.60 (range, 125–185) minutes. The average blood loss was 200.20 (range, 55–450) ml. All resection margins were negative. Six patients developed postoperative anastomotic leakage. There were no reports of other complications in all patients.

Conclusions

This preliminary study indicated that total laparoscopic sigmoid and rectal surgery in combination with TEM was a safe, feasible, and minimally invasive technique. This advanced surgical technique was developed by combining laparoscopy with the concept of natural orifice transluminal endoscopic surgery.     

Desire to Void and Force of Micturition in Patients with Intestinal Neobladders

Purpose

We attempted to determine how patients with an orthotopic bladder perceive the desire to void and the force achieved to evacuate the bladder.

Materials and Methods

A total of 24 men who had undergone post-cystectomy bladder substitution (ileocecal in 12, sigmoid in 6 and ileal in 6) was evaluated subjectively and objectively by pressure-flow study 1 to 3 years postoperatively.

Results

Desire to void was felt at the base of the penis or in the perineum by 20 men (83 percent). Abdominal pressure contributed to intra-reservoir pressure by 51 to 54 percent in ileocecal, 20 to 24 percent in sigmoid and 23 to 25 percent in ileal neobladders.

Conclusions

Patients perceive the desire to void when drops of urine leak into the proximal urethra from an overfilled neobladder. Urine is evacuated mainly by abdominal straining for ileal neobladders, mainly by contraction for sigmoid neobladders, and by approximately equal contributions of contraction and straining for ileocecal neobladders.     

Transanal drainage tube placement to prevent anastomotic leakage following colorectal cancer surgery with double stapling reconstruction

Purpose

Anastomotic leakage (AL) is a critical complication of colorectal cancer surgery. The transanal drainage tube (TDT) is designed to prevent AL caused by decompression and stasis at the anastomosis. We conducted this study to investigate the feasibility of using the TDT to prevent AL following double-stapling technique reconstruction (DST).

Methods

The subjects of this study were 179 patients who underwent curative resection and DST reconstruction for sigmoid colon and rectal cancer in our institution between 2008 and 2013. We analyzed the effectiveness of the TDT for preventing AL.

Results

A TDT was placed in 78 patients (43.6 %, TDT group) and not placed in the remaining 101 patients (56.4 %, NTDT group). AL developed in 2 (2.6 %) patients from the TDT group and in 14 (13.9 %) patients from the NTDT group (p = 0.009). Univariate analysis revealed that AL was significantly correlated with tumor distance from the anal verge (AV), the number of staples, and TDT placement. Multivariate analysis revealed a significantly positive correlation between AL and AV [OR 0.877 (0.783–0.982) p = 0.023] and a significantly negative correlation between AL and TDT placement [OR 0.07 (0.013–0.374) p = 0.002].

Conclusions

Anastomotic decompression with TDT placement may prevent AL after colorectal cancer surgery with DST reconstruction.

     

The effect of Daikenchuto on postoperative intestinal motility in patients with right-side colon cancer

Purpose

Daikenchuto (DKT) has a stimulant effect on intestinal motility and reportedly has a positive effect on postoperative intestinal motility in patients with sigmoid colon cancer. In this study, we investigated the effects of DKT in patients with right-side colon cancer.

Methods

This retrospective study included 88 patients with right-side colon cancer. We orally administered 7.5 g of DKT in the DKT group and did not administer any DKT to patients in the no-DKT group. All patients ingested radiopaque markers 2 h before surgery, which were used to assess intestinal motility. The postoperative intestinal motility was radiologically assessed by counting the numbers of residual markers in the large and small intestines.

Results

The DKT and no-DKT groups showed no marked differences in the total number of residual markers or number of residual markers in the small intestine. However, in the elderly subgroup, the total number of residual markers in the DKT group was significantly less than in the no-DKT group.

Conclusion

Although DKT had some small effect on the postoperative intestinal motility for most patients, it may have positive effects in elderly patients.

     

Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis

Background

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described.

Methods

After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique.

Results

Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series.

Conclusions

The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).     

Facilitating Intracorporeal Colorectal Anastomoses

Background and Objectives:

An experimental study was undertaken to evaluate whether a previously described technique for laparoscopic sigmoid resection with intracorporeal resection-anastomosis and specimen removal via a suprapubic incision could be facilitated and applied to the rectum.

Methods:

Ten domestic pigs (median weight 41 kg) underwent low anterior resection of the rectum, which was transected with an articulating endoscopic stapler. Pursestring sutures were fashioned intracorporeally with a laparoscopic pursestring clamp. The anvil of a circular stapler was inserted through a 33 mm port into the colon and pursestring tied intracorporeally. A circular gun with a spike fixed to its shaft was introduced per anum and a double-stapled anastomosis performed.

Results:

Complete doughnuts were obtained in all cases and anastomoses were all methylene blue tight. All porcine subjects had an uneventful 5-week postoperative course. The median anastomotic level from the anal verge was 5.2 cm. Histology of colorectal anastomoses revealed healing mucosa.

Conclusions:

The use of articulating endoscopic stapler, laparoscopic pursestring clamp, and circular stapler with a spike fixed to its shaft seems to facilitate a previously described intracorporeal approach to sigmoid resection which was safely applied to the rectum in a porcine model.     

Outcomes following surgical repair using layered closure of unrepaired 4th degree perineal tear in rural western Uganda

Introduction

In many rural low-income countries, perineal tears at time of vaginal birth are not repaired at time of delivery. The aims of this study are to describe the surgical technique for management of the unrepaired 4th degree tear, performed without flaps, and short-term follow up on anal incontinence symptoms using a validated questionnaire.

Methods

Women presenting to fistula camps in western Uganda with unrepaired 4th degree tears were interviewed using the Cleveland Clinic Continence Score. Interviews were undertaken pre-operatively, at 4–6 weeks post-operatively and 12 months following surgery. Repair of the 4th degree tear was performed in layers, with an overlapping anal sphincter repair and reconstruction of the perineal body, without flaps. All women were examined prior to discharge.

Results

68 women completed pre-operative Cleveland Clinic Continence Scores. Prior to surgery, 59 % of women complained of daily incontinence to solid stools. Over 70 % of women complained of restriction to lifestyle due to the unrepaired 4th degree tear. About 50 % of the women are rejected by their husbands because of the condition. Only 1 woman had wound breakdown on Day 2. At 4 to 6 weeks follow-up, 61 women were contacted and all reported perfect continence.

Conclusion

This study highlights the hidden problem of unrepaired 4th degree tears in rural areas of low-income countries where most deliveries are undertaken in the village without professional health care workers. These tears have significant impact on quality of life and anal incontinence. Short-term outcomes following surgical repair using a layered closure are promising.

     

Feasibility of end-to-anterior wall anastomosis in conversion of the double-stapling technique during laparoscopically assisted surgery

Background

Double stapling technique (DST) is a physiological end-to-end anastomosis that is currently used widely in rectal surgery and also in sigmoidectomy. In laparoscopy-assisted sigmoidectomy, we occasionally encounter obstruction during insertion of the circular stapler device from the anus. In such cases, we used to cut the residual rectosigmoid colon additionally and to allow DST anastomosis. Here, we propose an alternative way to overcome this difficulty, that is to perform an anastomosis to the anterior wall of the rectosigmoid colon.

Methods

Between 2001 and 2007, we experienced the cases of 10 sigmoid colon cancer patients who underwent laparoscopic surgeries with a conversion from DST to end to side (anterior wall) anastomosis.

Results

None of the patients suffered from anastomosis leakage, and none had complained of their stool habits. Colonoscopy showed that anastomosis window is kept wide and that stool is not pooled in the blind pocket of the rectosigmoid colon, suggesting the passage is well preserved.

Conclusion

Our experience indicates that though several technical points should be noted, an end to anterior wall anastomosis procedure is easy and safe. This method is a useful alternative way when end-to-end DST anastomosis is not performed smoothly in laparoscopic surgery.     

Vaginal reconstruction with sigmoid colon in patients with congenital absence of vagina and menses retention: a report of treatment experience in 22 young women

Introduction and hypothesis

We evaluated the surgical feasibility, sexual satisfaction and complications of vaginal reconstruction with sigmoid colon in patients with congenital absence of vagina and menses retention.

Methods

Retrospective analysis of surgical techniques and long-term postoperative follow-up was performed for 22 patients who underwent vaginal reconstruction with sigmoid colon at a single hospital between 1977 and 2011 to treat congenital absence of vagina with menses retention.

Results

All patients achieved satisfactory sexual function after marriage. No patients experienced enterospastic abdominal pain during sexual intercourse. The neovaginas accommodated two or more fingers and had depths >10 cm. The mucous membranes were soft and flexible, and secretions of the sigmoid mucosa provided adequate and acceptable lubrication. No patient required vaginal stents, and none developed vaginal stenosis or reported pain with vaginal expansion. Fifteen of the 22 patients underwent hysterectomies due to cervical agenesis; seven retained their uterus and had onset of normal menses postoperatively. Two patients became pregnant 1 year after marriage; one achieved 38-week gestation, underwent cesarean section due to premature rupture of membranes, and delivered a healthy boy. The other experienced natural incomplete abortion and underwent curettage at her local hospital.

Conclusion

This study confirms that sigmoid colon vaginal reconstruction is a good choice for treating congenital absence of vagina and menses retention and results in the closest approximation to the physical function of a normal female vagina. Reproductive ability can be retained in many cases for patients with a well-developed uterus and cervix.     

Transabdominal sacrocolpopexy with autologous rectus fascia graft

Introduction and hypothesis

Extrusion and infection are potential postoperative complications when using synthetic mesh for abdominal sacrocolpopexy. Long-term follow-up in the Colpopexy and Urinary Reduction Efforts (CARE) trial revealed an estimated 9.9 % risk of mesh extrusion. There are 26 reports of spondylodiscitis after sacrocolpopexy with synthetic mesh. These surgical risks may be decreased by using autologous fascia. To date, there have been no reports of extrusion or spondylodiscitis after using autologous fascia for sacrocolpopexy.

Methods

This video demonstrates transabdominal sacrocolpopexy with an autologous rectus fascia graft. A 76-year-old woman with symptomatic stage 3 prolapse also had a history of diverticulitis and sigmoid abscess requiring sigmoid colectomy with end colostomy and incidental left ureteral transection with subsequent left nephrostomy tube placement. She presented for colostomy reversal, ureteral reimplantation, and prolapse repair. Given the need for concomitant colon and ureteral reconstruction, the risk of infection was potentially higher if synthetic mesh were used. The patient therefore underwent transabdominal sacrocolpopexy with autologous rectus fascia graft.

Results

At 4 months’ follow-up the patient reported resolution of her symptoms and on examination she had no pelvic organ prolapse.

Conclusion

Transabdominal sacrocolpopexy using autologous rectus fascia graft is a feasible option, especially in cases in which infection and synthetic mesh extrusion risks are potentially higher.

     

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”

Purpose

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS).

Materials and methods

Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis???loop ileostomy or a Hartmann’s procedure) after 24–48?h.

Results

Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n?=?17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n?=?5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).

Conclusion

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.