SIMPLIFIED TECHNIQUE OF ILEAL CONDUIT CONVERSION TO INDIANA POUCH
REFERENCES
1431
assume that the ureters were originally implanted into the conduit
by the refluxing technique. At conversion a detubularized right co-
lonic segment was attached to the proximal part of the conduit. I
would be most concerned regarding the effect of intermittent high
intrareservoir pressure, which would occur although the colonic seg-
ment was detubularized. The situation is not at all analogous to that
of the Studer ileal neobladder, in which a 15 to 20 cm. afferent ileal
segment provides some protection against reflux from the neoblad-
der. Furthermore, urinary leakage develops when pressure in the
neobladder is too high, thus, providing an escape route for high
pressure. The apparently effective closure mechanism in the outlet of
the continent pouch used by these authors tolerates high pressure.
Also, although to my knowledge it has not been studied in detail to
date, colon may imply a risk of higher pressure in the pouch than
ileum. Thus, the risk of high pressure reflux of urine that is more or
less constantly heavily colonized with microorganisms is obvious.
The need for hospitalization because of pyelonephritis and increas-
ing serum creatinine postoperatively in some patients support such
events (fig. 3 in article). It seems that the increase in serum creati-
nine occurred mainly in patients who had the highest creatinine
levels before conversion, testifying to the vulnerability of kidneys
with preexisting functional damage. Why were loopograms per-
formed before conversion? If these authors were interested in know-
ing whether ureteral reflux was present, it obviously did not influ-
ence their approach to surgery.
1. Hovey, R. M. and Carroll P. R.: Noncontinent urinary diversion.
In: Urologic Oncology. Edited by J. E. Oesterling and J. P.
Richie. Philadelphia: W. B. Saunders Co., chapt. 22, pp. 323–
335, 1997
2. Pitts, R. W., Jr. and Muecke, E. C.: A 20-year experience with
ileal conduits: the fate of the kidneys. J Urol, 122: 154, 1979
3. Bjerre, B. D., Johansen, C. and Steven, K.: Health-related qual-
ity of life after cystectomy: bladder substitution compared with
ileal conduit diversion. A questionnaire survey. Br J Urol, 75:
200, 1995
4. Gerharz, E. W., Weinga¨rtner, K., Dopatka, T. et al: Quality of life
after cystectomy and urinary diversion: results of a retrospec-
tive interdisciplinary study. J Urol, 158: 778, 1997
5. Herschorn, S., Rangaswamy, S. and Radomski, S. B.: Urinary
undiversion in adults with myelodysplasia: long-term fol-
lowup. J Urol, 152: 329, 1994
6. Boyd, S. D., Esrig, D., Stein, J. P. et al: Undiversion in men
following prior cystoprostatectomy and cutaneous diversion. Is
it practical? J Urol, 152: 334, 1994
7. Rowland, R. G., Mitchell, M. E., Bihrle, R. et al: Indiana conti-
nent urinary reservoir. J Urol, 137: 1136, 1987
8. Ahlering, T. E., Weinberg, A. C. and Razor, B.: Modified Indiana
pouch. J Urol, 145: 1156, 1991
9. Wilson, T. G., Moreno, J. G., Weinberg, A. et al: Late complica-
tions of the modified Indiana pouch. J Urol, 151: 331, 1994
Another aspect of interest is the total length of bowel removed.
10. Struder, U. E., Danuser, H., Thalmann, G. et al: Antireflux Removing the right colon is usually well tolerated provided a sub-
nipples or afferent tubular segments in 70 patients with ileal
low pressure bladder substitutes: long-term results of a pro-
spective randomized trial. J Urol, 156: 1913, 1996
stantial length of ileum is not removed. In our experience when a
modification of the Indiana (Lundiana) pouch is used in which 10 cm.
of ileum are removed, patients admit to some changes in bowel
habits postoperatively but serious problems are rare. As in the cur-
rent technique, the loss of longer segments of the distal ileum sub-
stantially increases this risk. The authors mention that this increase
is most obvious in neuropathic groups and in those with previous
irradiation.
In addition, is better quality of life really achieved? The question is
certainly valid in view of the potential hazards of repeat, major
intra-abdominal surgery, the possible need for revision surgery
thereafter and the aforementioned problems. I would carefully re-
view these aspects with patients and would be reluctant to offer
conversion except to those who actively seek medical advice with this
purpose. Usually these patients have benign underlying disease. The
common view that continent reconstruction is superior to conduit
diversion in patients with bladder cancer with regard to postopera-
tive adjustment may be seriously questioned.1, 2 In the complexity of
individual life colored by personal values and existential experiences
it may well be that health status has a lesser role in quality of life
than we clinicians have believed.3
11. Pow-Sang, J., Helal, M., Figueroa, T. E. et al: Conversion from
external appliance wearing or internal urinary diversion to a
continent urinary reservoir (Florida pouch I and II): surgical
technique, indications and complications. J Urol, 147: 356,
1992
12. Goodwin, W. E., Turner, R. D. and Winter, C. C.: Results of
ileocystoplasty. J Urol, 80: 461, 1958
13. Sullivan, J. W., Grabstald, H. and Whitmore, W. F., Jr.: Com-
plications of uteteroileal conduit with radical cystectomy: re-
view of 336 cases. J Urol, 124: 797, 1980
14. Ahlering, T. E., Weinberg, A. C. and Razor, B.: A comparative
study of the ileal conduit, Kock pouch and modified Indiana
pouch. J Urol, 142: 1193, 1989
15. Rowland R. G.: Complications of continent cutaneous reservoirs
and neobladders: series using contemporary techniques. AUA
Update Series, lesson 25, vol. XIV, 1995
16. Helal, M., Austin, P., Spyropoulos, E. et al: Evaluation and
management of parastomal hernia in association with conti-
nent urinary diversion. J Urol, 157: 1630, 1997
17. Lockhart, J. L., Davies, R., Persky, L. et al: Acid-base changes
following urinary tract reconstruction for continent diversion
and orthotopic bladder replacement. J Urol, 152: 338, 1994
Wiking Mansson
Department of Urology
University Hospital
Lund, Sweden
EDITORIAL COMMENT
1. Månsson, Å. and Månsson, W.: When the bladder is gone: quality
of life following different types of urinary diversion. World
J Urol, 17: 211, 1999
2. Hart, S., Skinner, E. C., Mayerowitz, B. E. et al: Quality of life
after radical cystectomy for bladder cancer in patients with an
ileal conduit, or cutaneous or urethral Kock pouch. J Urol, 162:
77, 1999
These authors describe their experience with conversion of conduit
diversion to continent Indiana pouch cutaneous diversion. The na-
tive ureteral anastomoses to the conduit were preserved. Excellent
functional results are reported and the anticipated continent situa-
tion was achieved by all patients.
The important aspects of this type of surgery are the fate of renal
function, impact on intestinal function and possible changes in
health related quality of life. Although not specifically stated, I
3. Hunt, S. M.: The problem of quality of life. Qual Life Res, 6: 205,
1997