Comparative Study Between Ureterosigmoidostomy And Rectosegmoid Pouch In Urine Diversion After Cystectomy:

Mohammed Hashem Abd El-baky El-shareef

Although orthotopic substitution of the bladder is considered the optimal method of urinary diversion followingcystectomy, the procedure may not be applicable In asignificant proportion of cases : including patients with apathological condition of the urethra or a high Iikehoad ofurethral recurrence. In such circumstances an anal sphinctercontrolled bladder substitute provide a viable alternative.A multitude of techniques have been described to divertthe urinary stream to the rectum. It is clear that the overall goalof such procedure is the storage of urine under low pressureconditions. Unfortunately, the classical techniques ofureterosigmoidostomy as well as rectal bladder do not permitlow pressure storage because the intestine is left intact.In the present study 81 patients were undergone radicalcystectomy and two methods of diversion have been utilized,ureterosigmoidostomy and sigma rectum pouch.Ureterosigmoidostomy. group, the first group, included 42patients, 9.6% were females with mean age 57.17 + 8.009.The sigma pouch group, the second group, were 39patients, 20.5% were females with mean age 53.85 + 7.38 .Sigma pouch have been done by folding the sigmoidinto U shaped configuration or by double folding into N shapedconfiguration the ureters were implanted by the submucoustunnel technique in cases of ureterosigmoidostomy and in the Ushaped sigma pouch. Extramural serous lined tunnels techniquewere used in the double folded N shaped pouch.Mortality rate in the early post operative was 4.8% in theureterosigmoidostomy group and 5.1 % in the sigma pouchgroup. In the late post operative evaluation mortality was 22.5%in the first group and 11.4 % in the sigma pouch group. Tumourrecurrence was the main cause of death in the both groups.The major early complications reported In theureterosigmoidostomy group and the sigma pouch group wererespectively : urinary leakage 16.7 % and 10.3%, fecal leakage0% and 5.1 %, ureteric obstruction 9.5 % and 2.6%, uretericreflux 4.8 % and 0% ,acute episodes of pyelonephritis 11.9%and 5.1 % and wound infection was 19.% and 17.9 % .The late complications in the both groups were :ureterocolic obstruction 12.5% and 11.4 %, ureterocolic reflux5% and 8.6%, chronic pyelonephritis 17.5 % and 11.4% , renalfunction deterioration 10% and 5.7 % , tumour recurrence 15 %and 8.6 % , renal calculi 2.5 % and 5 %, lastly metabolicacidosis was 20 % in the first group and 0 % in the sigma group.Radiological reno-ureteral pattern was stabilized in73.75% in the ureterosigmoidostomy group and in 87% in thesigma pouch groupDaytime continence was achieved In 87.5%in theureterosigmoidostomy group and 100% in the second group.Night continence was 72.5% and 88.5% in the two groupsrespectively . Enuretic patients were 3 patients 7.5% in the firstgroup and in one patient 2.8% in the second group.Pouchmetry and pouchgram have been evaluated in sigmapouch group with mean capacity 656.206 cc + 120.9 and meanpressure 20.038 ern of water + 3.02 . There is no significantdifference among U shaped and N shaped double folded pouchconfiguration.The study of blood urea and serum creatinine in ureterosigmoidostomy group revealed that higher values will beresulted at prolonged time of evaluation and no significantdifference have been illustrated in the sigma pouch group .The sigma rectum pouch has many advantages over otherforms of continent urinary diversion. A reservoir capacity, safeand stable pouch fixation without the risk of damaging themesentry in the area of the promontory , guaranteeing a straightureteral path and low pressure even at high filling volumes makethe sigma rectum pouch a most attractive urinary diversion.Simple detubularization without the need for extensivebowel surgery or colostomy suffices to create a low pressurereservorr . With this technique even dilated ureter can beimplanted . This technique improves continence and protectingthe upper urinary tract . It is an elegant and simple method tocreate a low pressure reservoir.