Presentation Authors: Rolf von Knobloch*, Wasim Abdul Samad, Monika Kibele, Marc Seybold, Kempten, Germany
Introduction: For more than two centuries it was mandatory to perform an anti-refluxive anastomosis in continent urinary reservoirs as in the Indiana-Pouch. Pouch procedures for continent urinary diversion have become a rare reconstructive technique. With a 10-year experience we here introduce our new modification of Indiana-Pouch with refluxive Wallace type I ureteral anastomosis in a tubular ileal segment of the ileocecal pouch leading to a lower anastomotic stricture rate.
Methods: Between February 2008 und October 2018 we performed a total of 30 continent ileocecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby we extensively modified the Indiana-Pouch procedure with a new refluxive end-to-side ureteral anastomosis into an 8 cm afferent tubular ileal segment (Wallace type I) of the ileocecal pouch. We can now report our experience with this new modification of the original Indiana-Pouch procedure rendering a low ureteral anastomotic stricture rate.
Results: We performed the modified Indiana ileocecal-pouch with a tubular afferent ileal loop for refluxive ureteral anastomosis in 21 women (70 %) and 9 men (30 %). The median age of the patients at time of operation was 64 years (43 to 80 years). To date the average follow-up is 54.5 months (1 to 129 months). In 25 cases we performed the new ileocecal-pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1 case after radical cystectomy for locally advanced prostate cancer. In 4 cases the new pouch procedure was performed after total exenteration of the pelvis due to locally advanced colorectal cancers invading the bladder. Ureteral anastomotic strictures were only experienced in 2 of 30 patients (6.7 %). Concerning renal units the ureteral anastomotic stricture rate was 2 of 59 (3.4 % of renal units). In one case ureteral anastomotic stricture had to be revised by open surgery 57 months after the pouch procedure.
Conclusions: After a more than 10-year experience with our new modification of the Indiana-Pouch continent urinary diversion we can report that the technique of ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening the afferent tubular ileal segment it additionally allows easy ureteral replacement if necessary. In young patients our new technique also effectively prevents the development of secondary carcinomas at the anastomic site.