lleocecocystoplasty:

Some

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RAYMOND

A.

Radiolog

MADDOCKS’

AND

Ileocecocystoplasty was used in eight carefully selected patients to enlarge diseased urinary bladders. Postoperative radiologic evaluation often demonstrates bizarre findings, requiring knowledge of the surgically created anatomy and physiology of the ileocecal segment for accurate interpretation. Details of the surgical manipulations and pertinent radiographic observations following this operation are presented. lleocecocystoplasty which

is an

frequently

graphic

findings.

the radiologic ences with surgical logic

innovative

results

in

Finding

no

literature, the operation,

surgical

bizarre reports

on

we now describe offer drawings

manipulations,

and

review

subject

in

our expenioutlining the

associated

radio-

observations.

Use

of

the

ileal

segment

to

enlarge

eased bladders was first described [1], at about the same time Bnicker the

ileal

was

first

conduit

for

to describe

bladder

enlargement.

6]

described

have

enlarging

urinary the

use

Since

procedure by Gittes

1 -Surgical

result showing Received

dis-

Gil-Vernet

of the

ileocecal

then,

sporadic as by

July

Department Department

Am J Roentgenol

and

segment

for

reports

[4-

a means

After ably Two

for or

the

after

revision

Medical

Center

Medical

Center

isolated

October

Hospital

was

in

over

six

of

the

no further with extrophy

uretenal

patients

were

lengthening

procedures

ileocecocystoplasty,

needed

128:81-83,

January

1977

Hospital

surgery. incon[7]

done

additional

ileocecal

valve

at surgery;

segment cecum.

and

in the

no

at ileal

reinforcement

other,

therein

attempted

reinforce-

will be rotated Antireflux aspect

counterclockwise 1800 of procedure not shown.

05401

address:

B.

Final

surgical

1. 1976.

of Vermont,

Burlington.

Vermont

.

Present

106

Main

Street,

02571. of Radiology,

reason-

reconstructive and persistent

diversions. Two cases showed postoperative one, a preoperative barium enema showed

done

divided;

of ileum

requiring both

of

competent

and mesentery

and coaptation

procedure,

after

time

conduit neflux:

was that described by Gil-Vernet [4] (fig. 1 ). A segment of terminal

accepted

of Urology.

the

stable, patients,

tinence

in-

Methods

A. Ileocecal segment and ureteroileal anastamoses

1. 1976;

MINDELL2

Results

[3]

tuberculosis

procedure.

cecovesical

Massachusetts 2

replace

cystitis.

The surgical as modified

1

diversion.

contracted

Subjects

Fig.

or

J.

over 20 years ago [2] advocated using

ileocecocystoplasty

bladders

terstitial

[3]

radio-

this

HOWARD

ileum and cecum is isolated, rotated counterclockwise 1800, and anastamosed as shown (fig. 1B) to a prepared cuff of bladder. An antirefluxing mechanism may be provided by intussuscepting the terminal ileum into the cecum. Since 1969, eight patients with prior unsuccessful operative therapy for primary disease have undergone ileocecocystoplasty at our hospital. There were five females and three males; ages ranged from 5 to 60 years. Underlying problems included interstitial cystitis (three cases), bladder extrophy (contracted) with incontinence (two cases), and massive bilateral vesicorenal reflux with contracted bladder (three cases). Preoperative evaluation utilized urograms, void ing cystourethrograms, renal function tests, cystoscopy. and barium enemas (ileocecal valve competence). The major preoperative problem in all cases was a bladder with small capacity, either giving intolerable symptoms or making sungical reconstruction impossible.

procedure

postoperative

ic Observations

of Vermont,

Burlington.

81

Vermont

05401

.

Address

reprint

requests

to H. J. Mindell.

Wareham,

a

82

MADDOCKS

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r

AND

MINDELL

I

....‘

severe bilateral hydnoureteronephrosis, and voiding cystourethrography showed a bladder of small capacity with massive neflux. Ileocecocystoplasty was performed; urinary frequency

83

ILEOCECOCYSTOPLASTY

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and incontinence persisted postoperatively but gradually cleared over the subsequent 4 months. Serum creatinine was I .2 mg/dl. The postoperative cystogram revealed no reflux, and intravenous pyelognaphy demonstrated decreasing hydnoureteronephnosis (figs. 28 and 2C).

for

ileocecocystoplasty

have

been severe bladder contraction, interstitial or tuberculous cystitis, partial dude

cystectomy patients

for with

defunctionalization stenosing

with

radiologic

ordinarily

show

caliectasis

may

voiding

surgical

procedure

(figs.

1 and

7-10

days

and

procedure

may

be

required.

be

related

urogmay

to edema

cecovesical

studied

caution with

cystourethrography caliectasis,

Excretory

for

postoperatively,

Suspect

may

anasta-

with

retrograde

on overdistending excretory urography

after possible

3 months neflux,

the and

is suggested

and

emptying

of

reservoir. least

yearly.

anastamotic ileocecal on

radiologic Progressive

obstruction valve, or poor bladder

emptying

evaluation caliectasis

should may

be be

done due

to

(ureteroileal), reflux at the reservoir drainage. However, by

voiding

not

ings

include

upper

gram,

and

reasonable

tract

that

the

cecal

[8]. for nadiologic

have

yet

evaluation

evolved,

stability, emptying

desirable

no of

segment

reflux

the

on

newly

of findcysto-

created

reservoir.

We thank study these

Dr. Guy patients.

cystourethrog-

W.

Leadbetter,

ENT Jr.,

for

allowing

us to

REFERENCES

anastamosis. Severe hydnonephrosis within a month, since surgical inter-

exercising Reexamination

assess

check

this

distal

is needed

2).

account

ACKNOWLEDGM

after after

might also into temporary

reflux

(in all of our cases)

Postoperative at

the

extravasation

cystogram, new pouch.

the

with

done

ureteroileal repeat study

vention

to

associated

assessment

raphy,

mosis

or

into

by gravity standards

primarily

as might be seen bilharziasis, or

tumor. Candidates small bladders due

take

primarily precise

ureteritis.

Familiarity

at the needs

should

cecal-bladder

Discussion Indications

raphy empties While

1. Kuss R. Bitker M, Camey M, Chatelain C, Lassau JP: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. J Urol 103:53-63, 1970 2. Bnicken EM: Bladder substitution after pelvic evisceration. Sung C!in North Am 30:1511-1521, 1950 3. Gil-Vernet JM Jn: The ileocolic segment in urologic sungeny. J Unol 94:418-426. 1965 4. Gittes RF: Ileocecal cystoplasty: clinical and metabolic studies. Paper presented at the annual meeting of the American Urological Association, Philadelphia, May 1970 5. Skinner DG: Secondary urinary reconstruction: use of ileocecal segment. J Urol 112:48-51, 1974 6. Wallack HI, Lome LG, Presman D: Management of interstitial cystitis with ileocecocystoplasty. Urology 5:51-55, 1975 7. Leadbetter GW Jr: Surgical connection of total urinary incontinence. J Unol 91:261-266, 1964 8. Gleason DM, Gittes RF, Bottacinni MR. Byrne JC: Energy balance of voiding after cecal cysto7lasty. J Unol 108: 259-264,

1972