Nonorthotopic Urinary Diversions

Incontinent ileovesicostomy providing low-pressure urinary storage and drainage was first introduced in 1994

to address the problems associated with conventional incontinent urinary diversions. Without ureteral mobilization or reimplantation, it decreases the operative time and avoids the risk for ureteral complications. Preserving the ureterovesical junction, it maintains the antireflux mechanism and lessens the risk for pyelonephritis. Furthermore, it does not require the use of any catheter or foreign material, either intermittently or chronically. These advantages, together with excellent renal function preservation and the low rate of complications, have been confirmed by several recent reports with long-term follow-up, and ileovesicos-tomy has been recommended as a better alternative to all other types of incontinent urinary diversion.

All ileovesicostomy procedures described to date have been performed in the conventional, open manner. The major surgical components of ileovesicostomy included the following: (a) bladder mobilization with cystotomy creation, (b) harvesting of a well-vascularized bowel segment, (c) establishment of bowel-to-bowel anastomosis with closure of mesenteric window, and (d) performance of full-thickness, mucosa-to-mucosa ileovesical anastomosis in a tension-free, watertight manner. The laparoscopic technique we have been using for this procedure has replaced the traditional open approach to accomplish these steps efficaciously [Figure 10-2.5(a)].

Augmentation cystoplasty with the right colon using a reinforced ileocecal valve catheterizable continence mechanism is another form of urinary diversion preferred for preservation of the bladder and upper urinary tract; a continent catheterizable access port to the bladder is needed as well [Figure 10-2.5(b)]. One hundred years have passed since the fundamental open technique for this procedure has become an established reconstructive technique, which we have been performing laparoscopically.12

We recently reported on a comparative study of nine cases of open versus nine cases of laparoscopic approaches

Figure 10-2.5. a, Laparoscopic ileovesicostomy formation. b, Laparoscopic augmentation cystoplasty with the right colon using a reinforced ileocecal valve continence mechanism that is catheterized through the umbilicus. (Reprinted with the permission of The Cleveland Clinic Foundation.)

to this complex reconstructive procedure. The mean operative time for the open approach was 278 versus 468 minutes for our initial cases using a laparoscopic approach (P < .001). There was no significant difference regarding the blood loss between the two approaches. Mean time necessary to meet discharge criteria was significantly shorter after the laparoscopic approach (2.8 days), than after the open approach (7.1 days). Mean hospital stay was significantly shorter with the laparoscopic approach (4.4 days) than with the open approach (8.2 days) (P < 0.001). There was significant improvement in validated outcomes of bladder function with no adverse effect on bowel function after both procedures.

For people with complex voiding dysfunction who need bladder drainage or access procedures as described above for evacuation disorders, using a laparoscopic approach for these traditional open procedures makes the selection of these options more of an attractive consideration. A clinically significant positive impact on their postoperative quality of life related to their bladder function compared with their preoperative status can be achieved using a laparoscopic approach. Furthermore, this benefit in their quality of life from improvement of their bladder function can be achieved without a negative impact on their bowel control.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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