Modification of the Indiana Pouch Ileo-Caecal Cutaneous Continent Urinary Diversion: Tubular Ileal Afferent Limb for Ureteral Anastomosis Has Low Stricture Rate and Allows Ileal Ureter Replacement

<b><i>Objective:</i></b> The aim of the study was to introduce our new modification of the Indiana pouch with a refluxing ureteral anastomosis in a tubular afferent ileal segment of the ileo-caecal urinary reservoir. <b><i>Patients and Methods:</i></b> Between February 2008 and December 2020, we performed a total of 37 modified continent ileo-caecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby, we modified the Indiana pouch procedure with a new refluxing end-to-end ureteral anastomosis into an 8-cm afferent tubular ileal segment. <b><i>Results:</i></b> We performed the modified Indiana pouch in 27 women (73%) and 10 men (27%). The median age of the patients at time of operation was 64 years (43–80 years). To date, the average follow-up is 69 months (3–156 months). In 32/37 cases, we performed the new pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1/37 cases after radical cystectomy for locally advanced prostate cancer. In 4 cases, the procedure was performed after total exenteration of the pelvis due to locally advanced bladder, colorectal, or gynaecological cancers. Ureteral anastomotic strictures were seen in 2/37 patients (5.4%) or 2/72 (2.8%) of renal units. <b><i>Conclusions:</i></b> Our modification of the Indiana pouch cutaneous continent urinary diversion with the ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening, the afferent tubular ileal segment, it additionally allows easy ureteral replacement.

Primary antiphospholipid antibody syndrome presenting as acute superior mesenteric vein thrombosis

Antiphospholipid antibody syndrome (APS) is an autoantibody mediated thrombophilia characterised by recurrent arterial or venous thrombosis and/or pregnancy morbidity. APS presenting as thrombosis in mesenteric venous system is relatively uncommon (10%). Here, we present a case of primary APS presenting as acute superior mesenteric vein (SMV) thrombosis in a 38-year-old female. She was admitted with the complaints of abdominal pain and constipation for five days. Her abdomen was distended with sluggish bowel sounds. Her abdominal contrast enhanced computed tomography revealed thrombosis of SMV, splenic vein and portal vein. She was initially kept on conservative management and started on anticoagulants. Her coagulation work-up revealed that she was positive for anticardiolipin antibody and therefore, the diagnosis of APS was made. She was continued on conservative management and anticoagulants. On the tenth day of admission, after starting oral diet, she developed severe abdominal pain and abdominal signs of peritonitis. She was then taken up for emergency laparotomy. Intraoperatively; there was 100 cm of gangrenous ileal segment, about 60 cm from ileocecal junction and 160 cm from duodenojejunal flexure. The gangrenous ileal segment was resected and a double barrel ileostomy was constructed. She had an uneventful postoperative recovery and was started on lifelong anticoagulants.

Post traumatic ureteral defect brigded with ileal segment (Yang-Monti) for inferior ureterocalycostomy: a rare case report with review of literature

Ureteric substitution using the Yang-Monti principle was reported as a modification of simple ileal ureter replacement. A patient underwent ileal ureteral substitution using a reconfigured ileal segment of Yang-Monti principle in our clinical centre. Authors report a case of a 41year old male involved in a homicidal stab injury with isolated renal pelvis injury underwent Thompson’s renal capsular flap repair. After 6 weeks, double J (DJ) stent was removed and following that patient developed urinoma. Percutaneous drain was placed to drain urinoma on emergency basis and again 6 Fr DJ stent was inserted but patient had recurrent fever and chills. On CECT evaluation authors noticed that DJ stent was outside the upper urinary tract. And then patient was re-explored where authors found 6 cm stricture of the proximal left ureter. A reconfigured small bowel tube was interposed between inferior calyx and proximal ureteral stumps. This technique offers certain distinct advantages. A short ileal segment is included with the consequent absence of metabolic complications. Yang-Monti Principle is a safer and efficient technique for clinical partial and complete ureteral defects with sustained, good, long-term results. Yang-Monti reconfigured tube seems to be promoted an equally efficient urine transport mechanism that persists unaltered for long periods if patients and potential risks could be well prepared.

Modified orthotopic ileal neobladder - surgical technique and initial results

Introduction/Objective. Vesica ileale Padovana is the surgical technique for reconstruction of lower urinary tract following radical cystectomy using isolated ileal segment. This operative technique requires dissection of both ureters in full length, that can?t be possible in some cases. The paper is aimed to present our experience with modified surgical technique of vesica ileale Padovana using 40 cm of an isolated ileal segment and initial results. Methods. 10 male patients received modified ileal neobladder following radical cystectomy at our institution during the period 2008 to 2011. The mean age of patients was 59 years (45-70). Median follow-up was 76 months (62-93). Patients were monitored cautiously for functional outcome, local recurrence, and distant progression. Results. Perioperative, early and late postoperative mortality have not been noticed. There were only 2 major complications: prolonged postoperative ileus and prolonged urinary leakage requiring percutaneous nephrostomy and subsequent ureteral reimplantation due to stenosis of ureterovesical anastomosis in 1 patient (10 %), respectively. Average ileal neobladder capacity was 450 ml. Daytime and night continence were achieved in 9 (90%) and 7 (70%) of patients, respectively. Conclusion. This modification of orthotopic ileal neobladder has not been difficult to perform in our hands. Modified technique provides a clear advantage in easier ureteral implantation more proximally than in the original technique, requiring less length of ureters. Initial encouraging results should be confirmed in further clinical practice.