Three years' experience with an ileal low pressure bladder substitute.

At the beginning of this century it was realised that peristalsis would cause incontinence if bowel was used for augmentation or substitution of the bladder. Trans-section of the antimesenteric border and cross-folding of the intestinal segments (Goodwin's cup-patch technique) is an efficient means of solving this problem and has been successfully used in the Kock pouch. We anastomosed the ileal low pressure reservoir to the membranous urethra in 22 male patients following radical cystoprostatectomy for bladder cancer. The mean observation time was 16 months (range 3-36). The capacity of the bladder substitute increased with time, the average being 450 ml after 6 months. In the first 4 patients with a short (2-5 cm) intestinal segment between the pouch and the urethra, micturition was prolonged, residual urine varied from 50 to 300 ml and bacteriuria was found. Occasional expulsions of several ml of urine were caused by peristalsis within this short tubular segment. In the following 18 patients, the low pressure reservoir was anastomosed directly to the membranous urethra. Micturition was good, with no notable residual urine, no bacteriuria and no paroxysmal urinary incontinence. However, a safety pad is used by half of the patients because once or twice a week, mainly at night, a few ml of urine may be lost. No significant changes in serum electrolytes, bicarbonate or creatinine were noted. With the three different antireflux techniques used, no obstructive or inflammatory changes in the upper urinary tracts were found, although no long-term antibiotic prophylaxis was given.