100 Cases of Mainz Pouch: Continuing Experience and Evolution

Abstract

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.

Ten Years’ Experience with the Submucosally Embedded in situ Appendix in Continent Cutaneous Diversion

“…Apart from well–documented metabolic complications [15]the ‘price’ that a patient has to pay for avoiding a wet urostomy with its notorious drawbacks [16, 17]is either persistently liquid stools in revived and modified ureterosigmoidostomy [18], the risk of chronic urinary retention, stress and night time incontinence in orthotopic substitution [2, 3]or the total dependence on the strict ritual of intermittent catheterization in continent cutaneous diversion [4, 5, 6, 7, 8, 9, 10]. …”

“…In 262 patients, an ileocecal reservoir with umbilical stoma was created in a standardized fashion that has been described in detail elsewhere [4, 9, 10]. If present, the vermiform appendix was carefully inspected and dilated to accommodate a 16 to 18F catheter to ensure sufficient postoperative drainage of mucus (fig.…”

“…2, 3, 4). If the appendix had been removed beforehand or was inappropriate for use in reconstructive surgery additional 10 cm of ileum were excluded, intussuscepted and fixed in the ileocecal valve (141 patients) [9, 10]. The Yang–Monti technique (transversely retubularized ileum) [11, 12]and a Thüroff–Lampel tube (full–thickness bowel flap) [13]have been used in three salvage procedures with major loss of bowel in earlier operations.…”

“…With an increasing number of large institutional series and the availability of long–term follow–up the ‘true’ complication rates of the various techniques become evident defining the ‘price’ of continence in urinary diversion [2, 3, 4, 5, 6]. When Riedmiller et al [7]described the submucosally embedded appendix as in situ adaptation of the Mitrofanoff principle [8]to continent cutaneous diversion [9, 10]this simple maneuver was regarded as being a significant progress in the evolution of the ileocecal reservoir. We reevaluate this technique 10 years after its original description with special reference to changing indications, current alternatives, failures and pitfalls, their prevention and management.…”

Voiding Dysfunction of Sigmoid Neobladder in Women: A Comparative Study with Men

“…The mechanism of continence after construction of a neobladder has been extensively investigated. Avoidance of an excessive dissection of the urethra or of a disruption of the integrity of the pelvic floor support is important for maintaining continence, as is the construction of a reservoir with an adequate capacity [1, 4, 15]. While causes of voiding dysfunction have been examined by several investigators [1, 11, 13], voiding dysfunction in patients with neobladders remains incompletely understood.…”