Continent Catheterizable Pouches for Urinary Diversion

Continent Catheterizable Pouches for Urinary Diversion

Michael Rink *, Luis Kluth, Eike Eichelberg, Margit Fisch, Roland Dahlem

Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

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Article info

Keywords:

Continent urinary diversion

Continent cutaneous diversion

Pouch

Bladder cancer

Continence mechanism

Complications

Abstract

Context: Catheterizable pouches represent a good alternative in patients with

continent urinary diversion (CUD) when neobladder reconstruction is contraindi-

cated.

Objective: This review summarizes the different techniques, indications and con-

traindications, functional results, outcomes, and complications of continent cathe-

terizable pouches.

Evidence acquisition: A PubMed Medline database research was performed, iden-

tifying publications of CUD using a catheterizable pouch after radical cystectomy

for treatment of bladder cancer.

Evidence synthesis: In some patients with infiltrating bladder cancer, a continent

cutaneous diversion is indicated when the urethra is involved. Some authors also

recommend a catheterizable pouch in patients with carcinoma in situ and in female

patients. Different bowel segments have been used to build the reservoir: ileoce-

cum, colon, and ileum. Especially in patients with previous pelvic irradiation, the

transverse colonic pouch represents a feasible urinary diversion. Reservoirs with

high volume and low pressures can be fashioned by antimesenteric opening and

spherical reconfiguration of the bowel. The need for antirefluxive ureteral implan-

tation is questioned and there is a trend towards refluxive implantation. Simple

and reproducible techniques (eg, appendix stoma, flap-valve T mechanism, serosa-

lined extramural tunnel) have been developed for creation of a continence mecha-

nism. Satisfactory continence rates >90% are reported for most techniques and

quality of life is comparable with orthotopic continent diversion. The overall

incidence of complications varies from 28–57%. However, most urinary tract

complications (eg, pouch calculi, ureteroenteric anastomotic strictures, efferent

limb strictures, mucous retention) are corrected by endoscopic means. Open

surgery is mainly performed in strictures of the afferent limb.

Conclusions: Cutaneous catheterizable pouches represent an established and good

opportunity for CUD after radical cystectomy for treatment of bladder cancer. Most

of the problems that occurred during creation of continent cutaneous reservoirs in

the past have been solved. Long-term data of different surgical techniques show

excellent continence and acceptable complication rates.

# 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Urology, University Medical Centre Hamburg-Eppendorf,Martinistr. 52, D-20246 Hamburg, Germany. Tel. +49 40 74105 3442; Fax: +49 40 74105 2444.E-mail address: [email protected] (M. Rink).

1569-9056/$ – see front matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eursup.2010.09.003

http://dx.doi.org/10.1016/j.eursup.2010.09.003

mailto:[email protected]

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E U R O P E A N U R O L O G Y S U P P L E M E N T S 9 ( 2 0 1 0 ) 7 5 4 – 7 6 2 755

[()TD$FIG]

Fig. 1 – The Lundiana pouch is built from the ileocaecal segment with anintussuscepted ileal nipple, including the ileocaecal valve as efferentsegment [4].

1. Introduction

Urothelial carcinoma of the bladder (UCB) is an important

cause of morbidity and mortality [1], as well as the main

indication for urinary diversion. Radical cystectomy is the

gold-standard treatment for muscle-invasive and recurrent

high-risk UCB [2]. Safe long-term oncologic outcome,

reasonable functional results, as well as an easy adjustment

to patients’ lifestyle and recovering the quality of life are the

major goals of contemporary surgical approaches in

patients receiving radical cystectomy for treatment of

UCB. Orthotopic neobladder reconstruction currently repre-

sents the primary modality for continent urinary diversion

(CUD) in patients with infiltrating UCB at most institutions

[3]. However, when the urethra is involved, continent

cutaneous diversion (CCD) is indicated. Some authors also

recommend CCD in patients with carcinoma in situ [4] and

in female patients, since long-term follow-up has shown

that clean intermittent catheterization to empty the

neobladder is required in a significant number of patients

[5]. Furthermore, nononcologic indications for CCD are

present in patients with irreversible lower urinary tract

dysfunction.

The initial description of many CUD techniques dates

back to the period between 1890 and 1920. Due to high

complication and low success rates in these early years, the

number of patients treated remained small. Several decades

later, interest in CUD was renewed. Improvements in

surgical techniques, new instruments, as well as suture

materials and the availability of antibiotics and alkalinizing

drugs succeeded in tremendously reducing intra- and

postoperative complications.

For continent cutaneous urinary diversion (CCUD), crea-

tion of a reservoir, ureteral implantation, and a continent

stoma are required. Different bowel segments have been

used to build the reservoir: ileocecum, colon (ascending,

transverse, and descending), and ileum. Techniques already

established for ureteral implantation in ureterosigmoidos-

tomy were simply transferred to CCUD. Creation of a safe

continence mechanism was a main challenging intent.

This review article provides a literature overview of the

history and types of CCUD, clinical implications, and results

of the most important techniques used for CCD, including

complications and outcome, with focus on standard

techniques performed today in patients with infiltrating

bladder cancer.

2. Evidence acquisition

Publications relating to CUD using a catheterizable pouch

after radical cystectomy for treatment of bladder cancer

were identified by searching the PubMed Medline database.

Search terms were: bladder cancer, continent urinary

diversion, pouch, continent cutaneous diversion, conti-

nence mechanism and complication. Language was not a

specific search parameter; therefore, papers in English,

French, and German were identified and selected for this

review article. There was no time limit in the Medline

search; however, publications presented in this review

were selected because they were the most recent and

contained the most relevant supportive and conclusive

information regarding continent catheterizable pouches.

3. Evidence synthesis

3.1. History, types, and techniques

Over the last century, many different continent catheteriz-

able reservoirs for urinary diversion were described. First

reports by Verhoogen [6] and Makkas [7] were published

1908 and 1910, respectively. However, in these first reports

on reconstructive urinary diversion using a reservoir, no

real continence mechanism was created. Since the 1950 s,

due to surgical improvements, the ‘‘burden of care and

discomfort because of incontinence,’’ as described by

Hinman and Weyrauch [8], was solved when the first

continent reservoirs were built. The different variants of

continent catheterizable reservoirs can be divided by the

bowel segment (ileocecum, colon, and ileum) that is used.

Therefore, we used this structure to describe the different

types and techniques.

3.1.1. Ileocecal reservoirs

In 1950, Gilchrist and colleagues [9] were the first to describe

the successful use of the ileocecal segment for CUD with

excellent results. Gilchrist rotated the segment by 908 and

applied a submucosal Coffey II implantation of the ureters.

The natural antireflux mechanism of the ileocecal valve and

the peristalsis of the prevalvular ileal segment, which was

used as the efferent segment, served as the continence

mechanism. However, the excellent results were not

reproducible by others and therefore other techniques were

needed.

In 1977, the first descriptions of the Lundiana pouch

(Fig. 1) were published [10] and Mansson et al reported

clinical results after several modifications in 1990 [11]. The

[()TD$FIG]

Fig. 2 – The original Mainz pouch I: (a) Intraoperative view showing the intussuscepted terminal ileum serving as continence mechanism, and (b) uretersare implanted using submucosal tunnels as antireflux mechanism [13,53].


original reservoir consisted of a detubularized segment of

ascending colon with the ureters being implanted through

submucosal tunnels. An ileal nipple fixed by staples and

sutured to the rectus fascia served as the continence

mechanism. At the same time, Benchekroun developed his

inkwell valve and reported results on 33 patients in 1980

[12].

In 1983, the Mainz pouch was developed for orthotopic

bladder substitution in benign diseases. In 1986, first clinical

results with CCD using this technique in 12 patients were

published [13]. The reservoir was created by antimesenteric

opening and spherical reconfiguration of the ileocecal

segment. Ureters were implanted using submucosal tunnels

as an antireflux mechanism. The intussuscepted terminal

ileum fixed by staples served as continence mechanism

(Fig. 2). A modification was reported in 1992 by Riedmiller

and colleagues [14], using the appendix as a stoma. In that
[()TD$FIG]
Fig. 3 – (a) The appendix vermiformis is used as a stoma in the modified Mainz[13,14].

report, the appendix vermiformis was in situ submucosally

embedded into the caecal pole as a continence mechanism

(Fig. 3). Other modifications of the efferent segment (eg, in

situ tunneled bowel-flap tubes) were described over the

years [15,16].

Rowland et al [17] described the Indiana pouch technique

in 1985 and presented first clinical results of 29 patients in

1987 [18]. Compared to the Mainz pouch, this technique was

a modification using the ileocecal segment with the ureters

being implanted along the tenia libera. The tapered ileal

segment, together with the natural antireflux mechanism of

the ileocecal valve, served as a continence mechanism.

Furthermore, continence was improved by plication sutures.

In 1987, the Florida pouch was introduced by Lockhart

[19]. The reservoir consisted of cecum and ascending colon,

including the right colonic flexure, with the ureters

implanted using the Le Duc technique at first, and later

pouch I. (b) The appendix is submucosally embedded into the cecal pole


by direct refluxing anastomosis. Using the antireflux

mechanism of the ileocecal valve and a double plication

of the efferent segment, continence is accomplished with

this technique.

The Miami pouch was introduced in 1988 [20]. The same

segments for reservoir creation as the Florida pouch were

used. They were opened antimesenterically and reconfi-

gured in a U-shape. Ureters were implanted using a

modified Le Duc technique. The terminal ileum, serving

as efferent segment, was tapered and reinforced by three

proximal sutures.

3.1.2. Colonic reservoirs

As previously mentioned, the Florida and the Miami

pouches were constructed using the cecum and ascending

colon including the right colonic flexure. Some authors also

might classify these reservoirs as colonic.

Another colonic reservoir was first described by Leissner

and colleagues [21] in 2000. The transverse pouch (Mainz

Pouch III) consists of transverse and upper ascending or

descending colon to create an upside-down U-shaped

reservoir (Fig. 4). A tailored bowel segment incorporated

into the anterior pouch wall serves as a continence

mechanism. As the bowel segments in this reservoir type

are outside the irradiation field in patients with previous

pelvic irradiation, this cutaneous urinary diversion was

developed for those patients [21–24].

3.1.3. Ileal reservoirs

The most common continent ileostomy for urinary diver-

sion is the Kock pouch. Kock first reported this reservoir for
[()TD$FIG]
Fig. 4 – The Mainz pouch III is built from 30–40 cm of nonirradiated transversesegment serves as continence mechanism in the U-shaped reservoir. (b) A reflu

urinary diversion in 1975 [25]. However, when using this

reservoir for urinary diversion, Kock transferred his work on

‘‘ileal low pressure pouches’’ in patients with proctoco-

lectomy, published in 1969 [26], to the urinary tract. The

ureters were implanted using an intussuscepted ileal nipple

as the antireflux mechanism (afferent segment). Another

intussuscepted ileal nipple served as the efferent segment.

Both were reinforced by Marlex tapes. Clinical results on

this technique were published in 1982 [27].

Further work on continent ileal reservoirs was reported

by Leisinger et al [28] and Madigan [29] in 1976. Over 20 yr

after introduction of the Kock pouch, a new technique of an

antirefluxive valve mechanism was described and named

the T-pouch [30]. Due to significant improvements with

fewer complications using the continent T-pouch compared

to the Kock pouch, this new technique replaced the

traditional one.

Another modification of the continent ileal reservoir was

described by Abol-Enein [31] in 2004 (Fig. 5). He used a

serosa-lined extramural valve as a continence mechanism.

Ureters were implanted into a W-shaped ileal reservoir

through serosa-lined extramural tunnels.

3.2. Indications for continent pouches in urinary diversion

In patients with infiltrating bladder cancer and in need of a

radical cystectomy, one question is uppermost in patients’

minds: ‘‘Which type of urinary diversion can I receive?’’

Over the last decades, a substantial change in the

paradigm of urinary diversion has been reported. The

number of patients receiving an orthotopic neobladder is

colon and either ascending or descending colon. (a) A tailored bowelxing anastomosis is used for ureterointestinal implantation [23].

[()TD$FIG]

Fig. 5 – The Mansoura pouch. A continent cutaneous ileal reservoir isconstructed from a detubularized ileal segment. Two tapered bowelsegments are embedded and fixed within serous-lined troughs and theappendix vermiformis can serve as efferent limb [30].


steadily increasing [3,32] and today potentially all cystec-

tomy patients are suggested to be candidates for a

neobladder [32]. Nevertheless, there are still absolute and

relative contraindications for orthotopic and continent

urinary diversion. Therefore, it is important to identify

patients who are candidates for CUD, but less ideal for

orthotopic urinary diversion.

3.2.1. Patient selection

CCD is indicated when the urethra is involved and a

simultaneous urethrectomy is indicated on the basis of the

tumour. An orthotopic diversion in these candidates is

absolutely contraindicated [33].

Some authors also recommend CCD in patients with

carcinoma in situ (CIS), especially at the bladder neck or

prostatic urethra [4], as it has been shown that patients with

concomitant CIS are at increased risk of urethral transitional

cell carcinoma involvement [34] and therefore a urethrect-

omy might be discussed.

Furthermore, some authors suggest performing CCD in

female patients, since functional long-term results have

shown that clean, intermittent, self-catheterization is

needed in up to 40% of these patients to empty the

neobladder [4,5]. Even with technical improvements in

surgical strategies, rates of self-catheterization in female

neobladder patients is still high (>30%) [35]. Catheteriza-

tion through a continent abdominal stoma is easy to

perform; specifically, it is easier than self-catheterization

through the urethra, especially for obese patients.

Baseline external sphincter function is essential for

continence mechanism after surgery. Therefore, patients

with known external sphincter dysfunction might be

compromised by orthotopic diversion and benefit from

cutaneous diversions. Likewise, patients with recurrent

urethral strictures benefit from this diversion type as

complications and recurrent surgery are more frequent in

these patients.

3.2.2. Absolute contraindications

If renal function is compromised (ie, serum creatinin level

>150–200 mmol/l) due to chronic renal failure or urinary

tract obstruction, continent diversion of any type is

absolutely contraindicated. Similarly, in case of severe

hepatic dysfunction, incontinent diversion is recommended

[36].

3.2.3. Relative contraindications

Selection criteria for continent cutaneous reconstruction

are age, and mental and health status. The upper age limit is

usually 75–80 yr. The patient should be compliant and

mentally capable of performing self-catheterization and

correctly interpreting the symptoms of a full reservoir.

Patients with an advanced disease will most likely not

benefit from CUD with respect to quality of life (QoL). Even

patients with compromised intestinal function, particularly

inflammatory bowel disease, may benefit from an inconti-

nent conduit.

3.3. Functional results and outcome analysis

3.3.1. Continence

Excellent continence rates are achieved with all CCD types.

Data on continence rates are summarized in Table 1.

Continence rates vary from 72% to 98%. Mansson et al

reported continence rates of 94% for the Lundiana pouch [4].

Similar results were reported in studies by Abol-Enein [31]

for the Mansoura ileal pouch (94.6%) and Webster et al [37]

for the Florida pouch. Wiesner and colleagues reported an

overall continence rate of 92.8% for the Mainz pouch I

reservoir. However, in their large series of 977 patients,

continence rates were dependent on the type of efferent

limb: appendix stoma (96%) versus intussuscepted nipple

(89.5%) [38]. Lower continence rates (83% and 72%) were

reported by Stolzenburg et al and Holmes et al for the

transverse (Mainz III) and Indiana pouches, respectively

[24,39]. In general, continence rates of cutaneous cathe-

terizable pouches are higher than those for orthotopic

neobladders.

3.4. Quality of life

Easy adjustment of urinary diversion to patients’ lifestyle

after radical cystectomy leads to a major improvement in

recovering QoL. To evaluate QoL, well established, disease-

specific, validated questionnaires are used (QLQ-C30, QLQ-

BLM30, QLQ-BLS24). Different studies have analysed the

QoL difference between CCD and orthotopic neobladder,

conduit diversion, or both.

For comparison of QoL between CCD and orthotopic

neobladder, only retrospective studies exist. In these, no

differences were noted comparing both diversion types

[35,40,41]. In the analysis of Pazooki et al, the majority of

the patients were satisfied or very satisfied with their

diversion, but more patients were troubled by leakage in the

orthotopic bladder group [41]. In a recently published

study, Large et al identified 92 women who either received

an orthotopic neobladder (n = 47) or an Indiana pouch

Table 1 – Overview of continence rates and common, specific complications in different cutaneous pouch techniques

Pouch technique [reference](bowel segment)

Year ofpublication

Patients infollow-up, no.

Continencerates, %

Complications

Stoma/nipplestenosis, %

Uretero-intestinalstenosis, %

Pouchcalculi, %

Indiana pouch [39] (ileocaecum) 2002 125 72.0 15.2 7.2 10.4

Lundiana pouch [4] (ileocaecum) 2003 77 93.7 7.1 2.4 10.0

Florida pouch [37]

(caecum plus colon ascendens)

2003 179 93.3 4.0 6.3 5.4

Mansoura pouch [31] (ileum) 2004 93 94.6 5.4 5.2 5.4

Mainz pouch I [38] (ileocaecum) 2006 839 92.8 (overall) 6.5 (submucosal tunnel)

With appendix stoma 96.0 23.5 5.0 (serosa-lined

extramural tunnel)

5.6

With intussuscepted nipple 89.5 15.3 10.8

Mainz pouch III [24]

(colon transversum including flexure)

2007 24 83.8 4.2 – –

Charlston pouch I [47] (ileocaecum) 2007 194 98.0 8.2 8.2 5.0


(n = 45) diversion [35]. No significant differences were

noted with regard to physical, social, emotional, functional,

and specific health-related QoL [5]. Somani et al analysed

the QoL and body image in a prospective cohort study and

also performed a systematic review of 40 studies. Compar-

ing CCD to orthotopic bladder substitutions or conduit

diversions, similar results were obtained between all

groups. QoL in favour of neobladder diversion was only

reported to be slightly better in two studies [42]. In a

prospective study initiated by Hardt et al, a similar high

satisfaction was noted for both CCD and conduit diversion.

Most patients reported they would choose the same mode

of diversion again [43]. It has been suggested that body

image is not an important determination for patients’ QoL

after urinary diversion [40,42].

3.5. Renal function

Renal function is an important requirement for reconstruc-

tive surgery and published literature offers many clinical

reports. However, most of them have a retrospective

character with a limited level of evidence. Furthermore,

the number of reports on catheterizable pouches are limited

as well. As previously described, baseline renal function

remains an important factor for CUD. Therefore, comparison

of reports on renal function in continent and incontinent

diversion types is difficult [44].

In an important, randomized, controlled study (level of

evidence: 2), Kristjansson et al compared the renal function

by glomerular filtration rate (GFR) in patients with ileal or

colonic conduit (refluxing or antirefluxing uretero-intesti-

nal anastomosis) and CCD. Within a mean follow-up of 10

yr, no statistically significant GFR deterioration was found

between these groups [44]. In a large cohort of 883 renal

units, Wiesner et al [45] compared the submucosal tunnel

and the serosa-lined extramural tunnel in uretero-intestinal

implantations in Mainz pouch I reservoirs, retrospectively.

Serum creatinine levels were �1.6 mg/dl in 98% of the

patients and renal function remained stable with both

techniques in long-term follow-up. Similar results were

reported by Abol-Enein and colleagues [31] with evidence

of improvement or stabilization in 162 of 171 renal units

(94.8%). In a case study by Jonsson et al, however, patients

with continent cutaneous Kock reservoirs showed a

significant reduction of GFR in the long-term follow-up.

However, this GFR deterioration partly resembled the

decrease of renal function in an expected control population

due to increased age [44]. Therefore, catheterizable pouches

do not seem to impair renal function in long-term follow-up

in carefully selected patients for CUD.

3.6. Complications

Various complications in patients with catheterizable

pouches for CUD have been reported [4,21,24,31,37,38,46–

52]. Basically, cutaneous pouch-related complications may

be divided into early and late complications according to the

time of occurrence, and as general or specific. General

complications are mainly based on the nature of the CUD

using a bowel segment. It has been reported that general

complications are comparable in patients with orthotopic

neobladder and continent catheterizable pouch reconstruc-

tions [36]. Specific complications are mainly based on the

nature of the catheterizable cutaneous reservoir (ie, the

afferent or efferent segment). Meanwhile, long-term follow-

up results are available for specific complications [37,38,

46,48,51–53]. The number of complications arising with an

increasing follow-up is significant: Overall complication

rates range between 28% and 57% [53]. It appears that

complication rates are comparable for different types of

different cutaneous continent pouches. Excluding those with

a transverse pouch [24], irradiated patients show a signifi-

cantly higher number of complications [48,52]. An overview

of common pouch-specific complications is displayed in

Table 1. However, especially in comparison to orthotopic

neobladder reconstruction, no differences have been ob-

served in the number of complications between orthotopic

and CCD in contemporary series [4,35].

3.6.1. General complications

Patients with CUD are at risk for metabolic complications,

which may have serious consequences, especially if they are

not recognized and corrected. Due to the use of ileal or colic

segments for the reservoir construction, electrolyte shift


and reabsorption are feasible; electrolyte abnormalities like

hypokalemia, hyperchloremic acidosis, and absorption of

ammonia have been reported [36]. According to the bowel

segment used to build the reservoir, different electrolyte

abnormalities may occur more frequently. For example,

ileal segments absorb more potassium, whereas colic

segments may absorb more sodium and chloride, with an

increased possibility of hyperchloremic acidosis [36].

Furthermore, chronic acidosis may affect the skeleton in

different ways. Therefore, long-term changes in acid–base

balance may represent an important factor for bone

demineralization after urinary intestinal diversion [54].

Acid–base abnormalities in patients presenting with

osteomalacia should be corrected first, as this might lead

to remineralisation. Further, treatment with activated

vitamin D and calcium supplements are recommended.

The use of ileum and, less often, the ileocecal segment

may also lead to chronic vitamin B12 deficiency in some

patients as vitamin B12 absorption occurs primarily in the

terminal ileum. Age, renal function, and baseline level may

play an important role in vitamin B12 absorption and

development of clinical symptoms. As depletion of body

stores of vitamin B12 requires 3 to 5 yr, symptoms may be

delayed. However, chronic deficiency may result in

irreversible neurologic and hematologic sequelae [55,56].

Bowel mucosa secretes mucous and patients with CUDs

produce about 35 g/d of mucus. Whether long-term

adaptation of bowel mucosa incorporated into urinary

diversion leads to decreased mucous production is still

under debate. After exposure to urine, ileal mucosa appears

to atrophy over the time. On the other hand, colonic mucosa

seems to be preserved and retains its mucous and

immunoglobulin secretory abilities [36]. Incomplete emp-

tying of the pouch during catheterization may lead to

mucous retention and may increase the hazard of acute

urinary retention. To prevent initial mucous build-up

within the pouch, careful irrigation through the indwelling

catheter should be performed in the early postoperative

period [4]. Patients with continuously high secretion of

mucous may receive a recurrent intermittent irrigation of

their pouch during self-catheterization. Furthermore, in

these patients, local use of mucolytic agents (N-acetylcys-

teine or urea) during irrigation might be beneficial [56].

Another general problem in patients with continent

diversions is chronic bacteriuria. Rates of positive urine

cultures range between 50% and 90% [57,58]. In most cases,

however, bacteriuria is asymptomatic [58] without clini-

cally significant signs of a urinary tract infection (UTI).

Recently it has been reported that only 22% of patients with

cutaneous continent reservoirs or orthotopic neobladder

exhibit symptomatic UTIs in 1 yr [59]. A lack of hygiene does

not seem to be the reason for UTI after urinary diversion in

patients with self-catheterization [59]. Still, the reasons for

the increased incidence of bacteriuria remains unclear. It

has been suggested that the intestine, in contrast to the

urothelium, is incapable of inhibiting bacterial proliferation

[36]. Patients with asymptomatic bacteriuria without

clinical or laboratory signs of a UTI do not regularly require

antibiotic treatment [60].

3.6.2. Specific complications

Early pouch-related complications are rare. In contempo-

rary publications, specific complications occur in <20% of

nonirradiated patients [31,46,47]. Early complications in

patients with CCUD are urinary leakage from the uretero-

intestinal anastomosis or partial pouch necrosis/perfora-

tion, early uretero-intestinal anastomotic stricture, and

pyelonephritis [4,31,47]. The incidence of early complica-

tions requiring operative intervention is <10% [47]. A

conservative approach with a prolonged indwelling cathe-

ter is feasible in case of urinary leakage. For treatment of

strictures in the early postoperative period, balloon

dilatation or less-invasive endoscopic treatment can be

used [31,47].

Substantial, catheterizable pouch-related, late complica-

tions include catheterizing difficulties, stoma stenosis,

stones in the reservoir, incontinence, and stenosis of the

uretero-intestinal implantation. Most complications were

apparent in the first 3 yr postoperatively [38,46].

Catheterizing difficulties are mainly based on stomal

stenoses a few years after urinary diversion. Stenoses rates in

the efferent limb range from 4% to 36% [4,24,32,35–39,46,51].

In a large series of 977 patients with Mainz pouch diversion,

published by Wiesner et al, significantly higher incidence of

stomal stenosis was observed for the appendiceal stoma

compared with the intussuscepted ileal nipple (23% vs 15%)

[38]. The median duration to appearance of stoma stenoses

was significantly shorter for appendiceal stoma compared

with the intussuscepted ileal nipple (22 vs 34 mo) [51].

Abdallah et al reported a stenosis rate of only 8% for the

Charleston pouch I with appendix for continent outlet [46].

The incidence of stoma stenosis was 5% in the Mansoura ileal

reservoir with the serosa-lined extramural valve [31] and 4%

in patients with Florida pouches [37]. The smaller the

diameter of the efferent segment, the higher the incidence of

stenosis [51]. Treatment options include endoscopic

approaches, buccal or tongue mucosa grafts, YV plasty, and

complete stoma revisions [31,37,38,46,52,61]. However,

endoscopic treatment by incision is most common and

performed with high success rates. An acknowledged

disadvantage of the endoscopic incision is the higher

recurrence rate of stenoses [31,46,51].

The incidence of pouch calculi is remarkable (5–42%)

with a significant number of endoscopic (15–76%) and open

surgical interventions (17–80%) [4,31,37–39,46,51,58].

Pouch stones can grow to the considerable size of 20 cm

[37]. Treatment options are primarily influenced by the

number and size of stones. The greater the number or size of

stones, the more frequently open surgical revisions are used

[37]. Frequent and complete catheterization of the pouch

[37,46,62], as well as avoiding metal staples in surgery may

lower the risk of stone formation [58]. A clear relationship

between urinary bacteriology and calculus formation was

not established [58]; however, urinary infections and

metabolic factors seem to play an important role in stone

formation [62].

As previously discussed, incontinence rates with cuta-

neous pouches are low (2–16%) [24,38,46]. Reported

continence rates are marginally superior for the appendix


stoma and the ileocecal valve as compared with the

intussuscepted ileal nipple [38,63]. One reason might be

the larger diameter of the intussuscepted nipple. Further

reasons are urinary retention due to less frequent catheter-

ization, efferent limb insufficiency, and damage of the

efferent limb due to catheterization.

The incidence of uretero-intestinal obstruction depends

on the technique used for ureteric implantation. Overall rates

range from 2.4% in nonirradiated to 42% in irradiated patients

[4,24,31,37,38,46,48,51,52,64]. In their previously men-

tioned, large, Mainz pouch I series, Wiesner and colleagues

compared 1422 renal units with uretero-intestinal reim-

plantation by the submucosal tunnel with 121 renal units

with the serosa-lined extramural tunnel reimplantation

technique. Obstruction rates were 6.5% and 5.0%, respectively

[38]. Abol-Enein et al reported a stenosis rate of 5.2% with the

serosa-lined extramural tunnel [31]. Mansson et al [4] and

Stein et al [64] reported stenoses rates of 2.4% and 4% for the

antirefluxive Le Duc technique in the Lundiana pouch and in

the afferent antirefluxive nipple of the Kock pouch,

respectively. However, a trend towards direct refluxing

implantation has been reported, as complications caused by

reflux seem to be less harmful than those caused by

obstruction. As the typical patient with bladder cancer is

generally older and has limited life expectancy, reflux of the

uretero-intestinal anastomosis might not be of clinical

relevance [53]. Furthermore, especially in patients with

irradiated ureters, high obstruction rates of 11–42% have

been reported [47,48,52]. Although obstruction rates of the

afferent limb have decreased, they are still significantly

higher than nonirradiated ureters, according to more recent

publications [47]. However, only in irradiated patients

receiving the transverse colonic pouch were obstruction

rates comparable to nonirradiated patients (4%) [24].

Treatment of strictures is most commonly performed with

open revision, which has low restenosis or reoperation rates.

In case of endoscopic balloon dilatation, incision with a knife

or laser and ureter stent implantation are used [37,38].

4. Conclusions

Cutaneous catheterizable pouches represent an established

and good opportunity for CUD after radical cystectomy for

treatment of bladder cancer. Many techniques have been

developed and significantly improved over the last half

century. Technical feasibility and surgical versatility have

been proven. Reservoirs with high volume and low pressure

can be fashioned by antimesenteric opening and spherical

reconfiguration of the bowel. Different simple and repro-

ducible mechanisms offer highly satisfactory continence

rates. Long-term data on different surgical techniques are

comparable regarding functional outcome and QoL. The

incidence of complications is acceptable and most compli-

cations can be treated endoscopically.

Conflicts of interest

The authors have nothing to disclose.

Funding support

None.

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Continent Catheterizable Pouches for Urinary Diversion