Choice of therapy
Only about 20% of bladder cancers are at the time of initial diagnosis in the advanced stage, in involving the muscle layer of the bladder wall. These are – deeply infiltrating bladder cancer – called. Here, the following therapeutic options are available:
The cystectomy (bladder removal):
This is a complete surgical removal of the bladder, the seminal vesicles and prostate in men, followed by the same time or bladder replacement. This can be regarded as the best method by which the highest absolute chances of a cure can be achieved and which has the highest survival rate (about 70-80% at 5 years) for the person concerned.
In the woman’s womb, the fallopian tubes and the ovaries are having the bladder removed by default, and often part of the vagina. Again, can be created by means of intestinal segments during surgery a bladder replacement.
Not regress In large superficial tumors (T1 G3), which even after several scrapes (transurethral resection, TUR-B) and drug treatments or grow again, a bladder removal may be necessary for such tumors take the further course of disease often to malignancy and can then also the lymph nodes and form metastases. Even with a carcinoma in situ (CIS), a bubble removal in strong expansion in the bladder wall are necessary because these tumors must be counted among the high-risk tumors, which often tend to infiltrate deep into the bladder wall.
Simultaneously with the operative bladder removal, the new way for the urinary diversion is created, either with a urostomy, a Mainz Pouch, where the urinary diversion by means of self-catheterisation, or neobladder, where the urinary diversion is carried out on natural route via the urethra.
When choosing one of the featured here urinary diversion systems should be used with addition to disease-related conditions and the physiological age of the patient and his or her individual circumstances.
Under a urostomy is understood the derivation of urine through a surgically created opening in the body skin of the abdomen. Possible causes for applying urostomates can congenital developments, atresia, stenosis of the urinary tract, nerve damage, as well as acquired causes such as be by irradiation damage, tumors or injuries. Here one distinguishes several variants:
Nephrostomy, ureterocutaneostomy, TUUC (Transuretero-Ureterocutane-ostomy), ileal conduit (Bricker-bladder) and colonic conduit. The ileal conduit is nowadays the most commonly used for applying urostomates.
Because a urostomy is an incontinent Harnableitungsform and constantly leak urine can from the skin opening, it is necessary to permanently carry a bag which is stuck to the skin.
A urostomy is the simplest form of urinary diversion and for many patients because of the lower complication rate compared to the other systems and the most comfortable.
In an ileal conduit, also called Bricker-bladder, the ureter in a 15 to – 20 cm long isolated small intestine piece implanted, which is discharged to the skin and this mushroom-shaped surmounted (stoma). The urine with the aid of an adhesive bag which is attached to the skin around the stoma, and the collected urine bag emptied by the patient in a toilet. With this system, patients are largely independent again and can go about their normal activities.
In a colonic conduit for discharging a piece of large intestine (colon) is used. The urine flows continuously from the two ureters via the switched bowel segment and the stoma to the outside (artificial output).
It is collected in a bag system. The bag system is stuck as in the ileal conduit on the abdominal wall and covers the stoma. The supply of the bag system can perform independently of the stoma after some time. For advice and support those affected specially trained nurse and nurse (stoma) should stand aside.
The Mainz-Pouch I
The pouch is made of thick and about 1/3 to 2/3 of the small intestine. He can hold a large volume without the pressure in the reservoir is too large and urine leaking (long capacity low pressure reservoir).
The bladder substitute is with the navel by a piece of the small intestine, or – connected appendicitis – if still available. It is a continent stoma. By this, the patient can drain the Mainz-Pouch I with a catheter. This type of urinary diversion is in a variety of diseases in which the bladder is not created by birth, severely impaired in their function or must be removed because of a tumor disease, a very convenient solution.
Preparation for surgery
This includes the clarification of the colon by colonic enema and / or colonoscopy. Furthermore, a representation of the urinary tract necessary (Infusion pyelogram).
To reduce the risk of infection during the surgery, the intestine must be completely cleaned. This requires prior to surgery as long as a particular liquid to be drunk within a short time (usually 2-4 liters within 3 – 6 hours) until it is clear again excreted. Alternatively, the intestine via a, inserted through the nose, stomach tube can be purged. The aim of both options is a complete cleaning of the intestine.
During surgery, it may turn out that the installation of a Mainz-pouch is not possible or does not make sense. The urinary diversion should take place over a wet stoma, a so-called Conduit in the small or large intestine.
Before the operation, the marking of the stoma output is necessary. By a qualified caregiver 1-2 points are marked on the abdomen to allow the location of the stoma in a good position. Before the start of the operation is set to ensure adequate hydration and nutrition for the following postoperative days by the anesthetist, a central venous catheter.
Construction of the Mainz-Pouch I
The two loops of small bowel are opened longitudinally and then joined together side-to-side. After opening of the colon, the urethra can be implanted through a tunnel underlying the mucosa into the colon part.
If the appendix is not to be used, or been removed, further 8-10 cm ileum are required.These small intestine is invaginated into himself.
This tunnel prevents the reflux of urine into the kidney. The large intestine part is combined with the small intestine plate already formed.The ureters are temporarily splinted with thin catheters (known as splints).
After closure of the pouch to fix the „continence nipple“ at the lowest point of the navel occurs. In addition to the Harnleitersplints a balloon catheter (silicone catheter) are performed by the Nabelstoma and an additional thinner catheter (Pouchostomie) for drainage of the pouch discharged from the skin. Most have one or two drainages are inserted.
If the appendix (appendix) has not been removed in a previous operation, and it shows itself during the operation in good condition, so it is used as a continence mechanism. It is embedded in the pouch and connected to the navel funnel. This continence mechanism is called appendiceal stoma.
After the operation
Following the surgery, the patient is laid on a guard or ICU. There the heart and circulation are monitored by monitors.
In addition to the infusion lines and a stomach tube or – in adult patients – usually a gastrostomy (a tube that is discharged directly through the abdominal wall from the stomach) to be maintained the above mentioned catheters and wound drains.
The following days are general recovery and mobilization. The wound drains after about 5 to 8 days, depending on the wound secretion, successively removed. Skin staples after about 8 to 10 days, the gastric tube usually removed a few days after surgery, the gastrostomy after about 10 to 14 days.
Between the 10th and 12th day pulling out the Harnleitersplints done. Dragging is painless. After the removal of the urinary tract by intravenous Pyelogramms (IVP) is checked the next day. Are the inspections of the urinary tract and the control of blood values discreetly, the patient can be discharged with a well-matched bags supply to the left in the umbilical silicone catheter temporarily in the home environment.
The catheter should be left for at least 3 weeks and not disconnected. So a good healing of the pouch is ensured. Patients will be instructed by trained personnel to flush the catheter by means of a saline solution, as this can lead to clogging of the catheter through the mucus of the intestine.
Use the silicone catheter
Three to four weeks after surgery blood tests including a blood gas analysis be carried out in the renewed hospitalization. This is necessary to check the acid-base balance (see later explanation).A radiological control of the pouch is performed using contrast medium is filled via the silicone catheter in the Pouch until a certain Füllungsmaß is felt. It is checked whether the pouch is „waterproof“ healed.
The silicone catheter is pulled. Now the moment has come in which the patient must learn to deal with the Pouch. After abundant hydration to Pouch empty it after about 2 hours under professional guidance itself.
The Pouch emptying should be done in about 4-6-hour intervals. The discharged amount of urine (Pouch filling) should not exceed 600 ml. By overstretching of the pouch stability can be endangered. The capacity can be checked with a urine bag.
The first part massively encountered amounts of mucus in the urine can be reduced by increased fluid intake.
Due to the off parts of the intestine may initially diarrhea occur that are easy to fix by dietary measures. It should „constipating“ foods such as bananas are eaten. However, if no improvement is reached, may also be a drug (eg Avatar Alan ® help).
Cause of the diarrhea is the decreased absorption of bile acids in the small intestine shortened.The Avatar Alan ® binds them. Otherwise, it requires no special diet. Mainz-Pouch- carrier should pay attention to a sufficient amount of liquid, ie drink so much that you have at least one excretion of 3 liters in 24 hours. The more the better.
Vitamin C acidifies the urine and reduces a strong germ multiplication. Canned fruit juices, and fruit juice concentrates, alkalize the urine and promote bacterial growth. They should be avoided if possible.
The power-intestinal still absorbed substances from the urine, which acidify the blood. This is checked by means of the „Blood gas analysis“. If the base excess more than -2.5, so Uralyt U should® or similar substances are ingested. The required amount depends on the respective base excess.
Now close monitoring is necessary in order for the personal need for Uralyt U ® or a similar substance can be identified. This reduced most in the coming years.
In addition to the control of the acid-base balance must be regularly carried out an ultrasound inspection of the kidneys, as it may cause a damming of the kidneys. A slight extension of the renal cavity system is completely normal for a Mainz-Pouch.
It also controls the transition from ureter to Pouch, as this can lead to growths here.
When the blood tests a check of electrolytes (blood salts), the urinary metabolites (creatinine, urea), liver function tests (AST, ALT and AP) and vitamin levels should (especially vitamin B 12) are carried out at intervals of 1 year. The remaining follow-up examinations are determined by the respective underlying disease.
Within the first two years of these inspections at intervals of 3 months, up to the 5th year should then be able to control every 6 months, a year later, are performed.
An endoscopic mirroring the pouch should be done annually from the fifth year after Pouch conditioning once.
Due to lack of fluid intake can also lead to infections, increased mucus production, and possibly to the formation of stones. Occasionally have the metal braces that stabilize the continents stoma, leading to urine contact and can be used as focal points for stone formation. The stones do not cause symptoms and are usually discovered during the inspection sonography. To prevent growth and possible problems or complications, they should be crushed and filtered off with suction endoscopically with ultrasonic waves. In most cases this can be done on an outpatient basis without anesthesia.
After a few years, it can also lead to metabolic changes, such as a lowering of the vitamin B 12 levels. This would have to be compensated under certain circumstances.
In the area of the transition from the navel to the pouch, it can lead to scarring. The patient noted that the catheterization is more difficult and you have to use a thinner catheter. If this is the case and takes the narrowing too quickly, this can be easily treated on an outpatient basis through a slit.A surgical removal of the latter part of the stoma and reconnection between the stoma and the navel is required only in exceptional cases.
inpatient treatment measures
In rare cases it can lead to incontinence of the stoma once. This would then be surgically corrected under certain circumstances.
At the junction of the ureter and Pouch can cause scarring with narrowing of the urethra. Should the urine flow from the kidney to be severely hampered, so this needs to be corrected surgically.
Usually complications can be detected early through a careful follow-up and easily remedied. For this reason it is very important that patients regularly take the opportunity to follow-up.
Occupation, Recreation and Sports
Sports and Recreation should take the same value as before the operation.
But sports that lead to overuse of the abdominal muscles (weight lifting, rowing, martial arts, and the like) should be avoided. Lifting loads over 10 kg should be avoided.
Restrictions in the workplace are to reconsider a case by case and to decide.
In principle, by the Mainz-Pouch I the plant no impairment in professional life. The family life can be resumed in full.
After this rather extensive surgery, a follow-up treatment is recommended. They should be started in the next few weeks after hospitalization. Preparations for this place during the stay in the hospital by the social workers and ideally before the surgery.
The ureters are implanted here (rectum) in the expanded Sigma and the urine is emptied along with the chair over the anus. This presupposes a good function of the sphincter, which is checked pre-operatively accordingly.
This method of urinary diversion is now used only rarely because of a high complication rate.
Author: Detlef Höwing
Prof. Dr. med. Manfred Beer, Chief of Urology of the Franziskus-Krankenhaus Berlin,
Dr. med. Jörg Neymeyer, OA Urogynecology the Franziskus-Krankenhaus Berlin,
Dr. med. Gerson Liidecke, Consultant Urologist, Giessen,
Dr. med. Frank King, FEBU, Berlin,
PD Dr. med. Frank Christoph, FEBU, OA of the Department of Urology at the Charité Berlin,