Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence following bladder surgery

Nabi G, Cody JD, Dublin N, McClinton S, N'Dow JMO, Neal DE, Pickard R, Yong SM

Published Online:

January 21, 2009

The normal urinary bladder is a hollow muscular organ that lies deep in the pelvis. It functions through the balanced activity of many inter-related nerves and muscles that contain or empty urine as needed. If the bladder has been damaged by disease, surgery can be performed to divert the urine from the bladder (urinary diversion), to reconstruct the bladder or to replace the bladder with intestinal segments. The review did not find enough evidence from trials to show which surgical options are the most effective. More research is needed to determine the most effective surgical methods for urinary diversion, reconstruction or replacement of the urinary bladder that has been damaged by disease.

Abstract (click to read)

Background:

Surgery performed to improve or replace the function of the diseased urinary bladder has been carried out for over a century. Main reasons for improving or replacing the function of the urinary bladder are bladder cancer, neurogenic bladder dysfunction, detrusor overactivity and chronic inflammatory diseases of the bladder (such as interstitial cystitis, tuberculosis and schistosomiasis). There is still much uncertainty about the best surgical approach. Options available at the present time include: (1) conduit diversion (the creation of various intestinal conduits to the skin) or continent diversion (which includes either a rectal reservoir or continent cutaneous diversion), (2) bladder reconstruction and (3) replacement of the bladder with various intestinal segments.

Objectives:

To determine the best way of improving or replacing the function of the lower urinary tract using intestinal segments when the bladder has to be removed or when it has been rendered useless or dangerous by disease.

Search strategy:

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 June 2007) and the reference lists of relevant articles.

Selection criteria:

All randomised or quasi-randomised controlled trials of surgery involving transposition of an intestinal segment into the urinary tract.

Data collection and analysis:

Trials were evaluated for appropriateness for inclusion and for methodological quality by the review authors. Three review authors were involved in the data extraction. The data collected was then analysed for statistical significance.

Main results:

Four trials met the inclusion criteria with a total of 284 participants. These trials addressed only five of the 14 comparisons pre-specified in the protocol. One trial reported no statistically significant differences in the incidence of upper urinary tract infection, ureterointestinal stenosis and renal deterioration in the comparison of continent diversion with conduit diversion. The confidence intervals were all wide, however, and did not rule out important clinical differences. In a second trial, there was no reported difference in the incidence of upper urinary tract infection and uretero-intestinal stenosis when conduit diversions were fashioned from either ileum or colon. Similarly, a third trial reported no differences in the incidence of dilatation of upper tract, urinary incontinence or wound infection using different intestinal segments for the bladder replacement. However the data were reported for 'renal units', but not in a form that allowed appropriate patient-based paired analyses. No statistically significant difference was found in the incidence of renal scarring between anti-refluxing versus freely refluxing uretero-intestinal anastomotic techniques in conduit diversions and bladder replacement groups. Again, the outcome data were not reported as paired analysis or in form to carry out paired analysis.

Authors' conclusions:

The evidence from the included trials was very limited. Only four studies met the inclusion criteria; these were small, of moderate or poor methodological quality, and reported few of the pre-selected outcome measures. This review did not find any evidence that bladder replacement (orthotopic or continent diversion) was better than conduit diversion following cystectomy for cancer. There was no evidence to suggest that bladder reconstruction was better than conduit diversion for benign disease. The small amount of usable evidence for this review suggests that collaborative multicentre studies should be organised, using random allocation where possible.

This record should be cited as:

Nabi G, Cody JD, Dublin N, McClinton S, N'Dow JMO, Neal DE, Pickard R, Yong SM. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003306. DOI: 10.1002/14651858.CD003306

Assessed as up to date:

June 19, 2007

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Primary Review Group:

Incontinence Group

Health topics:

Gynaecology > Urinary incontinence > Surgery

Urology > Incontinence > Surgery

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence following bladder surgery

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