EXPERIENCE IN 100 PATIENTS WITH AN ILEAL LOW-PRESSURE BLADDER SUBSTITUTE COMBINED WITH AN AFFERENT TUBULAR ISOPERISTALTIC SEGMENT

Between April 1985 and April 1993, 100 consecutive men underwent lower urinary tract reconstruction after cystectomy. An ileal low pressure reservoir using the Goodwin cup-patch principle was combined with an a fferent ileal tubular segment. The early complication rate was 11%, in cluding 2 postoperative deaths due to septicemia. After a median follo wup of 27 months (range 3 to 96) 14 patients required surgery for late complications (intestinal obstruction, urethral stricture or tumor re currence, hernia or ureteral stenosis). A total of 32 patients died of metastatic bladder cancer and 7 died of other causes. The functional capacity of the bladder substitute was increased to the desired 450 to 500 ml. after 3 to 12 months, which was paralleled by improving urina ry continence. After 1 year 92% of the patients were continent by day and after 2 years 80% were continent at night. Upper tract surveillanc e with excretory urography, renal ultrasound and serum creatinine esti mation has shown 4 left ureteral strictures but no significant upper t ract deterioration or ureteral recurrence. Significant reflux was not observed during video urodynamics unless the reservoir was overfilled. During voiding, by outlet relaxation and straining if necessary, the intra-abdominal pressure increase with straining acted equally on the reservoir and ureters. Therefore, unlike voiding with a normal bladder , no isolated intravesical pressure increase occurred and, thus, there was no reflux from the reservoir. The combination of an ileal low pre ssure reservoir with an afferent isoperistaltic ileal segment and an o pen end-to-side ureteroileal anastomosis allows for radical cancer sur gery with resection of the ureters where they cross the iliac vessels and minimizes the risk of ureteral stenosis. The unidirectional perist alsis of the ureters and the afferent tubular ileal segment seem to pr otect the upper urinary tract sufficiently. The surgical technique is straightforward and allows for later conversion to an ileal conduit if necessary. The functional results of the bladder substitute are compa rable to other similar reservoir techniques, provided that the patient s are carefully selected, well rehabilitated and meticulously followed .