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Urologic procedures
Published in J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan, An Atlas of Gynecologic Oncology, 2018
Padraic O’Malley, Peter N. Schlegel
The Indiana pouch is made up of the terminal 10 cm of ileum and the ascending colon. Whether the pouch is constructed intracorporeally or extracorporeally during robotic cases, it is less laborious to mobilize the ascending colon beyond the hepatic flexure while using the robot or laparoscopic. Once the colon and terminal ileum have been divided to isolate the ascending colon and terminal ileum, a side-to-side anastomosis is performed between the ileum and transverse colon. The colonic segment is then detubularized by incision along the taenia. It is then folded and reconstituted in a more spherical fashion (Figure 30.5A). No further attempts are needed to create a spherical reservoir, as the colon has a larger diameter than the ileum. However, of note, rupture is a higher risk among colonic pouches than among ileal reservoirs (Mansson et al. 1997). The ureter is then re-anastomosed using an intra-reservoir technique. The appendix must be removed, although some surgeons have removed it and used it as the efferent limb owing to its inherently smaller lumen than the terminal ileum. Generally speaking, continence of the pouches arises from two features, the presence of the ileocecal valve and tapering of this junction and the efferent ileal limb.
Urinary diversion
Published in Jacques Corcos, David Ginsberg, Gilles Karsenty, Textbook of the Neurogenic Bladder, 2015
Sender Herschorn, Greg G. Bailly
Unlike the Indiana pouch, the Kock pouch maintains the ileocecal valve and uses only small bowel to create a low-pressure reservoir.44 Continence of urine and prevention of reflux to the upper tracts are achieved by constructing nipple valves (Figure 50.10). It has been criticized for being technically difficult and is associated with a high complication rate. As such, it has been abandoned by many urologists. However, the Kock limb (nipple valve) remains an important procedure as a means for constructing a continent catheterizable stoma, such as with the hemi-Kock augmentation cystoplasty.
Malignant Neoplasms of the Rectum
Published in Philip H. Gordon, Santhat Nivatvongs, Lee E. Smith, Scott Thorn Barrows, Carla Gunn, Gregory Blew, David Ehlert, Craig Kiefer, Kim Martens, Neoplasms of the Colon, Rectum, and Anus, 2007
In their review of pelvic exenteration for recurrent colorectal carcinoma, Yeung et al. (564) noted that after they combined a series of 13 reports in the literature, the incidence of pelvic recurrence by Dukes’ staging was 11%, 23%, and 35% for Dukes’ A, B, and C, respectively, with an overall recurrence rate of 25%. It is very clear that the incidence of recurrence is dependent on the length of follow-up, but approximately 70% of failures occur within two years of treatment. A significant portion of patients with local recurrence have disease confined to the pelvis without distant metastases. Faced with the problem of isolated pelvic recurrence, complete extirpation may have a chance of cure or at least good palliation. Elements of the procedure consist of a composite that in women are radical hysterectomy, total cystectomy, and abdominoperineal resection; and in men total cystectomy, radical prostatectomy, and abdominoperineal resection. More radical resection may include sacrectomy. In their series of 43 patients ranging in age from 31 to 77 years, the median duration from the time of the initial operation to exenteration was 39.7 months. Of the patients studied, 60% had received radiotherapy. Internal iliac vessels were ligated, but involvement of common and external iliac vessels implied inoperability. The most popular form of urinary diversion was the ileal conduit. In their series of 43 patients, 26 had ileal conduits, six had colonic conduits, and 11 had wet colostomies. Among the different constructions of a continent reservoir, the ileal colonic (Indiana) pouch was attractive because it utilized the least amount of ileum along with the ascending colon, which has the greatest likelihood of not being exposed to pelvic radiation. The learning curve for this procedure is steep with high postoperative morbidity and mortality rates. Cited operative mortality rates fell from 13% to 20% to from 2% to 7% as experience accumulated. Complication rates range from 30% to 75%. Types of complications included enteric fistula, conduit leak and/or fistula, bowel obstruction, pelvic hemorrhage/abscess, urosepsis, renal failure, wound infection, deep venous thromboses/pulmonary embolus, myocardial infarction/cardiac arrest, cerebrovascular accident, sepsis (nonpelvic), gastrointestinal hemorrhage, prolonged ileus, and hernia. The reoperation rate was high among this group of patients in whom the complication rate was even higher. These sobering statistics mandate that a careful patient selection process was undertaken prior to embarking on this procedure. Survival rates following this procedure have not been overly encouraging. Reported rates of recurrence range from 40% to 70% and overall five-year survival rates from 10% to 20%. However, this should be compared to a 2% to 3% five-year survival rate for untreated disease. Even in a palliative setting, symptomatic improvement is often prompt and long-standing. Up to 89% of patients with curative intent have significant palliation from pain. Moreover, some of these patients achieve remarkable psychological improvement and an enhanced quality of life.
Factors influencing decisions about neurogenic bladder and bowel surgeries among veterans and civilians with spinal cord injury
Published in The Journal of Spinal Cord Medicine, 2023
Denise G. Tate, Edward J. Rohn, Martin Forchheimer, Suzanne Walsh, Lisa DiPonio, Gianna M. Rodriguez, Anne P. Cameron
Overall QOL ratings were lower (7.65) than ratings of satisfaction with decisions (8.75). Decision outcomes about SP surgeries and overall QOL were rated very similarly (averaging 8.50 versus 8.16) as were decision regarding bladder augmentation and nephrectomy surgeries and related QOL ratings (9.75; 9). Greater disparity in satisfaction ratings were noted for those who underwent ileal conduits, Mitrofanoff catheterizable channel and Indiana pouch procedures. These were rated higher (8.50) than respective QOL ratings (6.80). For decisions about colostomies, satisfaction ratings averaged 5.50 while QOL ratings averaged 5.62. Those with ileostomies rated satisfaction with decisions higher (9.75) and QOL (8.25) accordingly. Those who had hemorrhoidectomies reported the highest satisfaction, with both providing ratings of 10 for satisfaction and 9 for QOL.
Robot-assisted radical cystectomy with intracorporeal urinary diversion – The new ‘gold standard’? Evidence from a systematic review
Published in Arab Journal of Urology, 2018
Niyati Lobo, Ramesh Thurairaja, Rajesh Nair, Prokar Dasgupta, Muhammad Shamim Khan
Continent cutaneous ICUDs have also been shown to be feasible, although the technique is still in its early stages. Goh et al. [31] were the first to perform a totally intracorporeal modified Indiana pouch UD, reporting a 3 h UD operative time. There were no perioperative complications and, at the 1-year follow-up, the patient was reported to be doing well. Desai et al. [32], at the University of Southern California, have since published a limited series of 10 cases in which they report a median total operating time of 6 h and a mean hospital stay of 10 days. Early complications (Clavien–Dindo grade I–II) were observed in 30%, and 20% developed uretero-enteric anastomotic strictures. At the 1-year follow-up, all patients (with the exception of one who requested conversion to an ileal conduit) were fully continent and catheterising without difficulty.
Radical cystectomy or bladder preservation with radiochemotherapy in elderly patients with muscle-invasive bladder cancer: Retrospective International Study of Cancers of the Urothelial Tract (RISC) Investigators
Published in Acta Oncologica, 2018
Jihane Boustani, Aurélie Bertaut, Matthew D. Galsky, Jonathan E. Rosenberg, Joaquim Bellmunt, Thomas Powles, Federica Recine, Lauren C. Harshman, Simon Chowdhury, Guenter Niegisch, Evan Y. Yu, Sumanta K. Pal, Ugo De Giorgi, Simon J. Crabb, Matthieu Caubet, Loïc Balssa, Matthew I. Milowsky, Sylvain Ladoire, Gilles Créhange
Between 1988 and 2015, 164 patients with non-metastatic MIBC were included: 92 (56.1%) underwent RC and 72 (43.9%) had RCT. Flow charts are shown in Figure 1. Patients’ characteristics were comparable between RC and RCT groups (Table 1). Median age was 82 years (range, 80–100) in the RC group and 83 years (range, 80–93) in the RCT group. The majority of tumors were T2–T3 (91.5%) and N0 − Nx (92.7%). There were significantly more women in the RCT group (p = .01). Severe comorbidities were less frequent in patients treated with RCT (non-adjusted CCI ≥ 3: 22.2% versus 43.5%, p = .004). Eight (8.7%) patients had neoadjuvant chemotherapy before surgery. In the RCT group, 91.7% of patients received concurrent carboplatin or cisplatin alone and only two patients in association with 5 fluorouracil. Three patients were treated with paclitaxel and three other with gemcitabine (Table 2). The total radiation dose to the bladder is shown in Table 3. Data were missing in two patients. The majority of patients in the surgery group had open RC (89.1%), four (4.3%) had laparoscopic cystectomy and six (6.5%) had robotic cystectomy. The type of surgery was unknown in one patient. Urinary diversion types were ileal conduit, neobladder and Indiana pouch reservoir in 78 (84.8%), 7 (7.6%) and 2 (2.2%) patients, respectively. It was unknown in five cases.