Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy

Background Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments. Objectives To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease. Search methods We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. Selection criteria All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract. Data collection and analysis Trials were evaluated for appropriateness for inclusion and for risk of bias by the review authors. Three review authors were involved in the data extraction. Data were combined in a meta-analysis when appropriate. Main results Five trials met the inclusion criteria with a total of 355 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, uretero-intestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. A meta-analysis of two trials showed no statistically significant difference in daytime or nocturnal incontinence amongst participants who were randomised to ileocolonic/ileocaecal segment bladder replacement compared to an ileal bladder replacement. However, one small trial suggested that bladder replacement using an ileal segment compared to using an ileocolonic segment may be better in terms of lower rates of nocturnal incontinence. There were no differences in the incidence of dilatation of upper tract, daytime urinary incontinence or wound infection using different intestinal segments for bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis. Authors' conclusions The evidence from the included trials was very limited. Only five studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The clinical significance of data from one small trial suggesting that bladder replacement using an ileal segment compared to using an ileocolonic segment is better in terms of lower rates of nocturnal incontinence is uncertain. The small amount of usable evidence for this review suggests that collaborative multi centre studies should be organised, using random allocation where possible. This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2012, Issue 2. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.</p

Urological cancer care pathways: development and use in the context of systematic reviews and clinical practice guidelines

Background: Making healthcare treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health professionals, clinical practice guideline developers and funders of healthcare. Methods: This paper presents a review of a methodology for the development of urological cancer care pathways (UCAN care pathways), which reflects an appreciation of this broad stakeholder base. The methods section includes an overview of the steps in the development of the UCAN care pathways and engagement with clinical content experts and patient groups. Results: The development process is outlined, the uses of the urological cancer care pathways discussed and the implications for clinical practice highlighted. The full set of UCAN care pathways is published in this paper. These include care pathways on localised prostate cancer, locally advanced prostate cancer, metastatic prostate cancer, hormone-resistant prostate cancer, localised renal cell cancer, advanced renal cell cancer, testicular cancer, penile cancer, muscle invasive and metastatic bladder cancer and non-muscle invasive bladder cancer. Conclusion: The process provides a useful framework for improving urological cancer care through evidence synthesis, research prioritisation, stakeholder involvement and international collaboration. Although the focus of this work is urological cancers, the methodology can be applied to all aspects of urology and is transferable to other clinical specialties.11 page(s

Antegrade repositioning of Memokath stent in malignant ureteroileal anastomotic stricture

Ureteric strictures are common and can be due to benign or malignant causes. Various surgical treatments can be used from minimally invasive endoscopic retrograde JJ stent insertion, balloon dilatation, ureterolithotomy, to open surgical exploration and repair. Memokath 051 stent is a metallic stent designed for long-term ureteral stenting in the management of ureteral strictures. The insertion of this device is usually a straightforward procedure performed endoscopically in a retrograde fashion via cystoscopy. However, this procedure can be difficult in complicated scenarios when the bladder has been removed with neoureteral reimplantations or high-grade strictures. Here, we report a case of Memokath stent insertion complicated by placement difficulties in a lady with ileal conduit due to previous ovarian cancer complicated by vesicovaginal fistula, who presented with malignant stricture of the ureteroileal anastomosis. We describe a simple yet effective antegrade technique to precisely reposition the malpositioned Memokath stent, along with illustrations

Relationships between apparent fecundity and the best-supported rainfall block spanning conception months for each ungulate species for the early wet (Nov-Dec), late wet (Jan-June) and dry (Jul-Oct) seasons of conceptions for a) topi, b) warthog, c) hartebeest and d) impala.

<p>Relationships between apparent fecundity and the best-supported rainfall block spanning conception months for each ungulate species for the early wet (Nov-Dec), late wet (Jan-June) and dry (Jul-Oct) seasons of conceptions for a) topi, b) warthog, c) hartebeest and d) impala.</p

Relationships between a) early births (August-October), b) modal births (November-December), c) late births (January-March) and e) annual fecundity and early rainfall (September-February) in the current year; d) late births and late rainfall (March-June), f) annual fecundity and g) juvenile survival and annual rainfall (Nov-Jun) in the current year; h) juvenile survival and i) yearling survival and early rainfall in the preceding year for topi.

<p>The patterns for topi well illustrate those for the other species.</p