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Use of Intestinal segments in urinary diversion
1. DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITAL
KILPAUK MEDICAL COLLEGE
CHENNAI
Use of Intestinal
Segments in Urinary
Diversion
1
2. MODERATORS:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI. 2
3. SURGICAL ANATOMY
STOMACH:
The stomach blood supply primarily from the celiac trunk
Three branches of the celiac axis
1. left gastric (coronary) artery arises directly from the celiac axis and supplies the lesser curvature.
2. hepatic artery - right gastric artery - supplies the lesser curve of the stomach
gastroduodenal artery - supplies the antrum and duodenum before giving off the right
gastroepiploic artery.
3. splenic artery - vasa brevia (short gastrics), - supply the fundus and cardia, and the left gastroepiploic artery.
The right gastroepiploic artery meets with the left gastroepiploic artery; thus both supply collateral flow to the
greater curve of the stomach.
3
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
5. By use of the gastroepiploic vessels, a pedicle of stomach may be mobilized as far as the pelvis.
pedicle may consist of the entire antrum pylori or a wedge of the fundus
The blood supply is based on either the left or right gastroepiploic artery, depending on the portion of
stomach used.
On occasion, the left GEA is atreticat some point in its course and does not provide an adequate blood
supply. then the right GEA must be used.
When a wedge of fundus is used,
it should not include a significant portion of the antrum
never extend to the pylorusor all the way to the lesser curve of the stomach.
5
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
6. When the blood supply is based on the left GEA, the short gastric vessels that course from the gastroepiploic artery
to the stomach are ligated along the greater curvature proximal to the pedicle to the origin of the gastroepiploic
artery.
The omentum is left attached to the gastroepiploic vessels and support them.
for proper pedicle mobility, detach the omentum from the colon along the avascular plane located at the point of its
attachment to the transverse colon.
If an antrectomy is performed, a Billroth I anastomosis reconstitutes gastrointestinal continuity.
The stomach has a thick seromuscular layer, easily separated from the mucosa should a submucosal ureteral
reimplantation be necessary.
6
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
7. SMALL BOWEL
two-fifths of the small bowel is jejunum, distal three-fifthsis ileum.
Ileum - distal in location, smaller diameter,multiple arterial arcades, and the vessels in the arcades are
smaller than those in the jejunum.
ileal mesentery is also thicker than the jejunal one.
The arcades anastomose one with another and give off straight vessels, which enter the bowel and form an
anastomoticnetwork within the bowel wall
up to 15 cm of small bowel can survive laterally to a straight vessel.
Thus, the mesentery could be cleared from the small bowel for a length of 15 cm without necrosis of the end.
7
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
8. however, it is unwise to assume that more than 8 cm of small bowel will survive away from a straight vessel.
The arcades receive their blood from the SMA.
When segments of jejunum or ileum are isolated, the mesentery should be transected in such a way that the
isolated intestinal segment receives its blood supply from an arcade supplied by a palpable artery of substance that
courses through the base of the mesenteric pedicle.
Two portions of the small bowel may lie within the pelvis and may be exposed to pelvic irradiation and pelvic
disease: ( AVOID THEM!!)
1) last 2 inches of the terminal ileum, which is fixed in the pelvis by ligamentous attachments
2) 5 feet of small bowel beginning approximately 6 feet from the ligament of Treitz, the mesentery of which is the
longest of the entire small bowel.
8
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
9. COLON
cecum, In general, is fixed in the right lower quadrant.
on rare occasion, may lie free within the abdominal cavity with great mobility.
Two accessory peritoneal bands bind the cecum and distal ileum to the retroperitoneum and
lateral abdominal wall. - One band arises from the distal ileum, attaches to the cecum, and is
fixed to the retroperitoneum.
- second band arises from the cecum and fixes the cecum to the posterior abdominal wall
laterally.
Remaining ascending colon is fixed to the right posterior abdominal wall at the level of the hepatic
flexure,
9
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
10. transverse colon lies free within the abdominal cavity
The descending colon is fixed to the lateral abdominal wall;
sigmoid colon may or may not lie free within the abdominal cavity.
rectosigmoid colon’s cephalad portion is intraperitoneal, and at distal - retroperitoneal and finally
subperitoneal.
10
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
11. colon receives its blood supply from - SMA, IMA, IIA
The major arteries supplying the colon and rectum - ileocolic, right colic, middle colic, left colic,
sigmoid, superior hemorrhoidal, middle hemorrhoidal, and inferior hemorrhoidal arteries.
These arteries anastomose to form the arc of Drummond and leeway in mobilizing the colon.
The middle colic artery arises from the first portion of the SMA (ascends the transverse mesocolon
to the right of midline.)
The right colic artery usually arises just below the MCA from SMA.
11
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
12. The ileocolic artery is the terminal portion of SMA and supplies the last 6 inches of ileum and
ascending colon.
The left colic artery arises from the IMA
then the IMA gives off four to six sigmoid branches, the last of which becomes the superior
hemorrhoidal artery.
This anastomoses with the middle hemorrhoidal artery, a branch of the internal iliac artery, which,
in turn, anastomoses with the inferior hemorrhoidal artery, the terminal branch of the internal
pudendal artery.
The middle sacral artery, which originates directly from the aorta, may supply the posterior aspect
of the rectum.
12
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
13. WATERSHED AREAS
These are regions of the colon that receive dual blood supply from the most distal branches of two larger arteries.
Due to small diameter of these distal branches - vulnerable to ischemia during hypotension or thromboembolic
event.
Griffith’s point- the collateral communication between the MCA and the ascending LCA
important for perfusion of the splenic flexure and descending colon.
Sudeck’s point - between the junction of the last sigmoid branch and superior hemorrhoidal artery,
near the rectosigmoid junction.
Although anastomoses here usually heal well provided the principles of proper technique are followed
but it is wise to select an area for the anastomosis to one side of these points, where the feeding arteries have a
larger diameter.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
15. MOBILIZATION
ascending colon is mobilized by transecting the cecal and distal ileal fibrous attachments to the lateral abdominal
wall and retroperitoneum
then by detaching it from the lateral abdominal wall along the avascular line of Toldt.
The transverse colon is mobilized by,
- dividing the gastrocolic omentum (along the avascular plane of its attachment to the colon)
- hepatocolic ligament (which may have some small vessels coursing through it),
- phrenocolic ligament.
descending colon is mobilized by incision of the avascular line of Toldt .
Further mobility is gained by isolating a pedicle of the intestinal segment on the basis of one of the major arterial
vessels.
15
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
16. SELECTING THE SEGMENT OF INTESTINE
STOMACH:
The advantages of the stomach - less permeable to urinary solutes,
it has a net excretion of chloride and protons rather than a net absorption of them
produces less mucus.
Urodynamically, it behaves as other intestinal segments do.
electrolyte imbalance rarely ensues in patients with normal renal function,
(although hypochloremic metabolic alkalosis possible)
there is no difference in bacteriuria among any of the segments.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
17. The urine, which usually has a pH of 6 to 7, does not typically result in an increased peristomal
skin problems.
Serum gastrin levels are usually normal or minimally elevated, depending on what portion of the
stomach is used and how much.
antral exclusion may result in elevated circulating gastrin levels, leading to intestinal ulcerative
problems
Long-term histamine (H2 receptor) antagonist or PPI should be considered for these patients.
The antrum should not be used if the fundus is available.
If the antrum is used, reconstitution is generally by a Billroth I anastomosis.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
18. stomach for urinary intestinal diversion may be considered in,
severe renal dysfunction who don’t tolerate metabolic acidosis
risk of short gut syndrome,
In severe abdominal adhesions - stomach is, in general, adhesion free and easily
mobilized.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
19. Early complications ,
gastric retention - atony of the stomach or edema of the anastomosis
Hemorrhage - from the anastomotic site;
hiccups secondary to gastric distention;
pancreatitis - intraoperative injury;
duodenal leakage.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
20. Delayed complications
dumping syndrome,
steatorrhea,
small stomach syndrome,
increased intestinal transit time,
bilious vomiting, afferent loop syndrome, hypoproteinemia
megaloblastic or iron deficiency anemia.
bowel obstruction - upto 10%
Gastroduodenal and gastroureteral leaks
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
21. specific complications
1) hematuria-dysuria syndrome
in approximately 24% cases
Symptoms - bladder spasms; suprapubic, penile, periurethral pain;
gross hematuria without infection;
skin excoriation
dysuria without infection
symptoms are typically intermittent and self-limiting, and can usually be controlled with H2 blockers.
due to acid by the gastric segment,
2) Severe metabolic alkalosis associated with respiratory distress
21
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
22. Jejunum
usually not used due to severe electrolyte imbalance - hyperkalemia.
Used when diseases that would make the ileum inappropriate
When it is the only segment available.
as distal a segment of jejunum as possible should be used.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
23. Ileum
used most often for urinary tract reconstruction
mobile and of small diameter, has a constant blood supply
used in ureteral replacement and the formation of conduits.
Loss of significant portions of the ileum results - vitamin B12 def, diarrhea due to lack of bile salt reabsorption, and
fat malabsorption.
Sometimes mesenteric fat is excessive, making mobility and anastomosis difficult.
mesentery may be so short that it is difficult to mobilize the ileum into the deep pelvis.
Postoperative bowel obstruction occurs in up to 10% of patients
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
24. Colon
requires mobilization from its fixed positions to give it the mobility.
easily mobilized into any area of the abdomen or pelvis.
In pelvic irradiated cases, portions of the right, transverse, and descending colon may be used
fewer nutritional problems compared to that of ileum(provided the ileocecal valve is not violated)
bowel obstruction 5%,
electrolyte imbalance – same as of ileum, type and frequencies.
antireflux ureterointestinal anastomosis by the submucosal tunnel technique is easier to perform with use of the colon.
ILEUM VS COLON - does not argue strongly for the selection of one over the other except under
special circumstances.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
25. BOWEL PREPARATION
two aspects : mechanical and antibiotic.
Mechanical preparation reduces the amount of feces (and therefore the total
number of bacteria)
antibiotic preparation reduces the bacterial count per gram of feces
(concentration).
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
32. HISTORY
Ureterosigmoidostomy is the oldest form of urinary diversion. The first reported urinary diversion into a segment of
bowel was by Simon in 1852. (in exstrophy)
In 1950, Bricker refined and popularized the ileal conduit form of urinary diversion, (original description by Zaayer in
1911)
Thomas smith (1898) – first direct Ureterointestinal implantation
Coffey (1911) – first successful anti-reflux Ureterointestinal implantation
earliest continent cutaneous diversions in humans was described by Gilchrist et al. in 1950
32
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
33. In 1982, Kock et al. subsequently reintroduced the concept of a continent cutaneous diversion with a technique
that was originally developed for a continent ileostomy after colectomy .
(skinner done in cystectomy pts)
Kock demonstrated the importance of complete detubularization of the bowel segment and the double-folding
technique that creates the most spherical shape possible.
orthotopic diversion,
Tizzoni and Pogg(1888) – in dogs
Lemoine(1913) – in human (during undiversion of ureterosigmoidostomy)
Camey and LeDuc (1979) – pioneering clinical experience
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
34. URINARY DIVERSION
Urinary diversion refers to the diversion of the urine from its natural path.
INDICATIONS
Prostatic hypertrophy
Injury to urethra
Birth defects of the urinary tract, kidney or ureter
Bladder stones
Tumors of the genitourinary tract or adjacent tissues and organs
Conditions causing external pressure to the urethra or one or both ureters
Bladder cancer patients undergoing radical cystectomy
Malfunctioningbladder
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
35. CHARACTERISTICS OF AN IDEAL URINARY DIVERSION:
It should provide,
1.Undisturbed body image
1.Natural way of micturition
Continence of urine
Safe upper urinary tract
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
36. CLASSIFICATION OF URINARY DIVERSION TECHNIQUES:
SUBTYPES:
1. Temporary/Permanent
2. External/Internal
3. Continent/Incontinent
4. Definitive/Palliative
5. Orthotopic/HeterotopicSubstitution
BASED ON THE TECHNIQUES,
1. Intubated diversion
2. Ureterocutaneous
3. Ureterointestinal
4. conduits
5. Continent reservoir
6. Bladder substitution/ Orthotopic
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
37. TEMPORARY DIVERSION
1. Nephrostomy
- open
- percutaneous
2. Internal Ureteral stents
3. Suprapubic cystostomy (SPC)
37
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
39. CUTANEOUS URETEROSTOMY / PYELOSTOMY
as a temporary diversion to manage the infant with severe hydroureteronephrosisin anticipation of future
reimplant.
Due to the high rate of stomal stenosisnot suitable for long term.
High degree of ureter mobilization >> devascularisationand stenosisin approximately 60%.
In order to avoid two stomas it is customary to perform a double barrelureterostomy.
Stomal stenosismay be minimized by eversion of the ureters into a rosebud and by incorporatinga V shaped
skin flap into each ureterostomy.
It is usually done when the bowel cannot be used - like in cases of Crohn’s disease or in radiation enteritis.
39
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
41. INTESTINAL ANASTOMOSES
Surgical Principles
adequate exposure
maintain a good blood supply to the severed ends of the bowel.
prevention of local spillage of enteric contents.
accurate apposition of serosa to serosa of the two segments of bowel
not to tie the sutures so tightly that the tissue is strangulated
realignment of the mesentery of the two segments of bowel to be joined
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
42. STOMA
Two types – 1) flush with the skin and
2) protrude (nipple or rosebud)
The flush stoma is preferable for the continent type of diversion in which intermittent catheterization is carried out.
Protruding stoma is preferable when a collection device is worn.
two types of protruding stomas:
- end stoma
- loop end ileostomy.
site - done by marking the stomal site with the patient in the sitting and supine position;
over the rectus muscle at least 5 cm away from the planned incision line.
42
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
43. well away from skin creases, scars, the umbilicus, belt lines, and bone prominences.
radiotherapy injured area should be avoided.
placed through the belly of the rectus muscle and be located at the peak of the infra-umbilical fat
roll.
bowel should traverse the abdominal wall perpendicular to the peritoneal lining (i.e., it should
come straight out).
avoid trimming fat or epiploic appendages from around the margin of the stoma
Loop End Ileostomy is preferred in obese – Obese patients have a thick abdominal wall and often
a thick, short ileal mesentery. This makes construction of an end ileal stoma extremely difficult.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
46. URETEROINTESTINAL ANASTOMOSES
refluxing or non-refluxing anastomosis.
Regardless of type of diversion, renal failure has been seen in 12.5%
Deterioration of the upper tracts is due to - lack of ureteral motility, infection, or stones and less
commonly caused by obstruction at the ureteral-intestinal anastomosis.
many have suggested that a non - refluxing anastomosis would minimize the incidence of renal
deterioration
It does not appear that conduit pressures are transmitted to the renal pelvis
successful construction of an anti-refluxing anastomosis does not prevent bacterial colonization of
the renal pelvis.
46
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
47. Only as much ureter as needed should be mobilized - no redundancy or tension
on the anastomosis.
Do not strip the ureter of its periadventitial tissue.
ureter should be cleared of its adventitial tissue only for 2 to 3 mm at its most
distal portion
fine absorbable sutures, watertight mucosa-to-mucosa apposition.
bowel should be brought to the ureter and not vice versa
47
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
48. bowel should be fixed to the abdominal cavity, preferably adjacent to the site of the
ureterointestinal anastomosis.
anastomosis should be retroperitonealized or a pedicle flap of peritoneum should be placed over
the anastomosis.
modern soft Silastic stents are effective in reducing the leak rate, subsequent stricture formation
For submucosal tunnel in nonrefluxing anastomosis - inject saline with a 25-gauge needle
submucosally to raise the mucosa away from the seromuscular layer.
48
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
49. colonic:
1) Non - Refluxing
Leadbetter-Clarke
transcolonic technique of Goodwin
Strickler
Pagano
2) Refluxing
Nesbit
Cordonnier
49
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
50. Small bowel:
1) Refluxing:
Bricker
Wallace
Ureteral dipping
2) Non-refluxing:
Tunneled (submucosal)
Split-Nipple
Serosal compression of extra-mural ureter
Le Duc
Hammock
50
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
51. COMBINED
TECHNIQUE OF
LEADBETTER AND
CLARKE
• nonrefluxing ureterocolonic
anastomosis by using a
submucosal tunnel.
• it combines the
ureterocolonic anastomosis
of Nesbit, which is a refluxing
elliptical anastomosis to the
intestine, with the tunneled
technique of Coffey.
51
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
53. STRICKLER
TECHNIQUE
• nonrefluxing
• construction of submucosal
tunnel
• Advantage - taeniae do not
need to be aligned, one can
form the tunnel according to
the normal course of the
ureter and avoid angulation.
• reliably prevents reflux
• stricture rate of approximately
14%
53
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
54. PAGANO TECHNIQUE
• nonrefluxing
• construction of a
submucosal tunnel
• low complication rate.
• leakage rate is 3%
• stricture rate is 6%
• reflux rate is 6%
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
55. Cordonnier and Nesbit Techniques
use no tunnel
direct refluxing anastomoses of the ureter to the colon
not desirable for ureterosigmoidostomies.
performed in much the same way as a Bricker anastomosis in the small bowel
55
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
56. Small Bowel Anastomoses
two basic types: end to side, and end to end.
The end-to-side anastomoses - refluxing or nonrefluxing manner.
56
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
57. BRICKER
ANASTOMOSIS
• refluxing
• end-to-side
• simple and low complication
rate
• originally described for the
small bowel, it may be used
in any suitable intestinal
segment
• stricture rate - 6%
• leak rate is 3% in the
absence of stents
57
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
58. WALLACE TECHNIQUE
• A frequently used , refluxing .
• end of the intestine is sutured to the end of the
ureter
• used with either small bowel or colon.
• three basic types of anastomoses
• lowest complication rate
• Stricture- 3%, of deterioration of the upper tracts -
4%, and leakage - 2%
• Historically, it was not recommended for patients
who have extensive carcinoma in situ or a high
likelihood of recurrent tumor in the ureter - that a
recurrence of tumor at the anastomotic line in one
ureter would block both ureters. This, however,is
exceedingly rare.
• It is actually be easier to survey endoscopically
because both ureters can be easily found next to
each other at the most proximal portion of the loop.
• lower rate of obstruction than a Bricker
anastomosis
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
60. SPLIT-NIPPLE
TECHNIQUE
(GRIFFITHS)
• Non-refluxing
• using a nipple mechanism
• applied to either the small or
large bowel.
• formation of a nipple in the
ureter and implantation into
the small bowel
• Stricture – 7%
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
61. LE DUC METHOD
• nonrefluxing
• laying the ureter onto the interior of
the bowel wall,
• eventually resulting in a submucosal
tunnel when it is re-epithelialized
• Stricture – 5%
• Leak – 2%
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
62. Hammock Anastomosis
conjoining the ureters and implanting them into the small bowel in a nonrefluxing manner.
The small bowel is closed at its proximal end
three 10-cm longitudinal incisions separated by 1 to 2 mm are made through the seromuscular layer to the mucosa
These incisions are cross-hatched by multiple incisions. This serves as a hammock.
The ureters are conjoined as in the Wallace technique and sutured to the intestinal mucosa.
Ureteral Dipping Technique
simple to perform and has excellent success
form the neobladder, and then make a small opening in the small bowel wall.
ureter is “dipped” approximately 1 cm into the bladder cavity and then secured to the seromuscular portion of the
bowel.
No mucosal anastomosis is performed.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
64. INTESTINAL ANTIREFLUX VALVES
Another technique for preventing reflux into the ureter
involves construction of an antireflux mechanism with bowel distal to the ureterointestinal
anastomosis.
ureter is sutured by the technique of either Bricker or Wallace to the end of the bowel
Then the bowel is used to make a one-way valve.
when these valves fail or stenose, both kidneys are affected.
Three basic types,
ileocecal intussusception
ileoileal intussusception
ileal nipple valve placed into colon.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
65. INTUSSUSCEPTED
ILEOCECAL VALVE
valve has a moderate tendency
to fail because the
intussusception has a significant
chance of reduction
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
66. INTUSSUSCEPTED
ILEAL VALVE
• Complication rate – 10%
• modification - T pouch
• When the pouch is closed, a
nipple valve is constructed.
• concept - as pressure in the
pouch increases, the walls of
the tapered nipple valve are
compressed, thus preventing
reflux.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
69. CONDUITS
two types of conduits: (1) those using the small bowel, which includes the jejunum or ileum (2)
large bowel.
Conduits using stomach - difficult problems of stomal maintenance.
indications for a conduit are the need for urinary diversion:
- after a cystectomy; because of a diseased bladder;
- before transplantation in a patient who has a bladder that cannot adequately receive the
transplant ureter;
- dysfunctional bladders that result in persistent bleeding, obstructed ureters, poor compliance
with upper tract deterioration
- inadequate storage with total urinary incontinence.
69
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
70. Management Common to All Conduits:
All anastomoses are stented with Silastic stents.
Stents removed individually on the fourth to sixth postoperative days.
All conduits are retroperitonealized, with the ureterointestinal anastomosis being placed in the
retroperitoneum.
Jackson-Pratt or Blake closed-suction drain laid in the retroperitoneum 3 to 4 cm away from the
anastomosis.
The peritoneal cavity should not be drained.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
71. ILEAL CONDUIT
most common form of urinary diversion performed throughout the world today for
patients undergoing cystectomy
distal ileum is chosen.
simplest type of conduit diversion
ureteral devascularization and the risk of stomal stenosis is minimized because the
intestine is brought to the ureters rather than mobilizing the ureters to the skin.
fewest intraoperative and immediate postoperative complications.
C/I - short bowel syndrome, inflammatory small bowel disease, and extensive
irradiation. 71
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
72. 10-12cm ileal segment isolated 20 cm proximal to IC
valve
Short straight conduit without kinking
Continuity of small bowel re-established
Mesenteric window closed
Ileum in isoperistaltic fashion
Isolated segment flushed with warm saline till return
of clear fluid 72
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
74. Left ureter brought to RLQ beneath the sigmoid mesocolon
(inferior to IMA)
Ureteroenteric anastomosis
After single J ureteral stent is placed in both ureter
Distal end of ileal segment fashioned as end ileostomy in RLQ
ARutzen bag can be applied to the stoma on the fifth POD.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
76. colon conduit is essential in cases of long segment ureteral stricture or radiation ureteritis.
Unlike the ileal conduit, it is not necessary to pass the left ureter across to the right side,
Once the sigmoid colon mesentery is mobilized the two ureters can be brought toward the
midline or the colon can be stretched across the retroperitoneum.
Because the transverse colon and its middle colic artery originate in the upper abdomen
this segment can be anastomosed to the upper one third of the ureter or even directly to the
renal pelvis.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
77. Ileal Vesicostomy
spatulated ileum and a generous transverse cystotomy to decompress the bladder and to allow an appliance to be used on
the abdomen.
Indications,
- to spinal cord injury patients or neurologic disease. (easier job of caring for themselves with an abdominal stoma)
- detrusor–external sphincter dyssynergia
- detrusor hyperreflexia, particularly women, with increased incidence of incontinence.
Done by spatulating an ileal segment >> performing a generous transverse cystotomy.
distal segment is brought to the abdominal wall by fashioning a rosebud stoma.
low-pressurereservoir.
Its appeal is that if indicated at a later date, the patient’s anatomy can be converted back to normal 77
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
78. METABOLIC AND NEUROCHEMICAL PROBLEMS OF URINARY
INTESTINAL DIVERSION
Electrolyte Abnormalities
78
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
80. RENAL DETERIORATION
There is significant and progressive deterioration in renal function in the majority of patients independent of the
type of urinary diversion
18% of patients who have ileal conduits show progressive deterioration versus 13% who have nonrefluxing colon
conduits.
In patients with ileal conduits, about 6% ultimately die of renal failure
The amount of renal function required to effectively blunt the reabsorption of urinary solutes by the intestinal
segment and to prevent serious metabolic side effects depends on the type of urinary intestinal diversion
constructed
i.e, the amount of bowel to be used and the length of time the urine is exposed to the intestinal mucosa
Thus, greater degree of renal function is necessary for retentive (continent) diversions than for short conduit
diversions.
80
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
81. In general, patients who have GFR on average above 40 mL/min tolerate a continent diversion
reasonably well.
patients with normal urine protein content who have a serum creatinine concentration below 2.0
mg/dL do well with intestine interposed in the urinary tract
At creatinine below 2 mg/dL, renal blood flow, GFR, tubule transport, and concentrating and
diluting ability are relatively well preserved.
When creatinine exceeds 2 mg/dL and still being considered for retentive diversion or in whom
long segments of intestine will be used, a more detailed analysis of renal function is necessary,
- If the patient can achieve a urine pH of 5.8 or less after an ammonium chloride load,
- has a urine osmolality of 600 mOsm/ kg or higher in response to water deprivation,
- has a GFR that exceeds 35 mL/min
- minimal protein in the urine
81
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
82. Alteration of the sensorium may occur as a consequence of magnesium deficiency, drug intoxication, or
abnormalities in ammonia metabolism.
Abnormal Drug Absorption- Drug intoxication; problematic are those absorbed by the gastrointestinal tract and
excreted unchanged by the kidney
Osteomalacia – acidosis, vit D resistance
detrimental effect on growth and development.
Stones - calcium, magnesium, and ammonium phosphate. (met acidosis, Urine alkaline pH)
Intestinal Motility, Short Bowel, and Nutritional Problems
82
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
83. Cancer
The highest incidence of cancer occurs when the transitional epithelium is juxtaposed to the colonic epithelium and
both are bathed by feces.
Ureterosigmoidostomies (2.6%), cystoplasties (1.6%), and orthotopic (ileo)colonic neobladders (1.3%) have got
highest risk for malignancy.
regular endoscopic evaluation beginning 5 years postoperatively for these patients
Not needed for ileal neobladders (0.05% risk) and ileal conduits
83
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
84. NEUROMECHANICAL ASPECTS OF INTESTINAL SEGMENTS
goal in reconfiguring the bowel is to achieve a sphericalstorage vessel.
Sphere shape has the most volume for the least surface area.
By increasing the volume, it has been suggested that pressure relationships within the confines of the intestine are
reduced.
This is based on Laplace’s law – “for a sphere, the tension of its wall is proportional to the product of the radius and
pressure.”
Helps to prevent deterioration of the upper tracts or incontinence.
Over time, the volume capacity of segments increases.
In ileal pouches - capacity increases sevenfold after 1 year
significant increase in smooth muscle thickness of the bowel wall
volume decreases with time if they are nonfunctional
84
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
85. Motor activity
When the bowel wall is split on its antimesenteric border and reconfigured, acutely there is a marked interruption of
coordinated activity fronts
which over a period of 3 months return to their normal coordinated state
Intra pouch(ileum, caecum) pressures 40 to 60 cm H2O .
85
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
87. Continent, non-orthotopic urinary diversions - two major categories.
1) variations of ureterosigmoidostomy
- ileocecal sigmoidostomy,
- rectal bladder
> hemi-Kock and T pouch operation with valved rectum > folded rectosigmoid bladder
> augmented valved rectum > sigma rectum (Mainz II)
2) continent catheterizing pouches
Kock pouch, Double T pouch , Mainz pouch I, Indiana Pouch, Florida pouch, Penn pouch.
Right colon pouches with Intussuscepted Terminal ileum – UCLA pouch, Duke pouch, Le Bag pouch
Gastric pouches – Adams pouch, Lockhart pouch
many of the procedures are simple modifications of parent operations
procedures using a right colon reservoir with some form of appendiceal continence mechanism are the fastest,
most reliable, and easiest to perform.
87
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
88. PATIENT SELECTION
patient must be assessed for the ability to care for himself or herself
multiple sclerosis, quadriplegic individuals, and very frail or mentally impaired patients are poor candidates for
CCUD
88
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
89. PATIENT PREPARATION
Renal and hepatic function must be reviewed
reabsorption and recirculation of urinary constituents and other metabolites require that liver function be normal.
creatinine clearance should be at least 60 mL/ min.
In the case of hydronephrosis, the upper urinary tract(s) should be decompressed with ureteral stenting or
percutaneous nephrostomy,
with subsequent reevaluation of renal function before consideration for a CCUD.
Procedures that require the use of the colon should always be preceded by a colonoscopic assessment of the entire
large intestine.
preop assessment of the colon is not mandatory but remains prudent if continent urinary diversion using small
intestine is planned.
89
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
90. POSTOPERATIVE CARE AND COMMENTS
MALIGNANCY may develop from the urothelial component and not as a result of urine affecting
intestinal mucosa.
So urinary cytology should be performed for all patients undergoing a continent urinary diversion,
When the ureters are directed into the fecal stream, routine colonoscopy should also be
performed.
Latency periods as short as 5 years have been reported for malignancy
For an isolated anastomotic recurrence, distal ureterectomy and reimplantation may be
appropriate.
If nephroureterectomy is necessary, some patients may require removal of their continent
diversion because of resulting renal insufficiency
90
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
91. RECTAL BLADDER URINARY DIVERSION
separating the fecal and urinary streams, while still employing the principles of
ureterosigmoidostomy.
Anal sphincteric tone must be judged competent before these operations are selected
ureters are transplanted into the rectal stump.
The proximal sigmoid colon is managed by terminal sigmoid colostomy or by bringing the sigmoid
to the perineum, thereby using the anal sphincter to achieve bowel and urinary control.
Chance of combined urinary and fecal incontinence
Dilated ureters, extensive pelvic irradiation, renal insufficiency pts are not candidates
91
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
92. 1) FOLDED RECTOSIGMOID BLADDER
A modification of the ureterointestinal anastomosis
a folded rectosigmoid bladder with anastomosis of the ureters via serosa-lined tunnels (anti reflux) rather than into
the taenia coli.
This reimplantation technique was first described by Abol-Enein and Ghoneim
advantage - larger sigmoid reservoir, anti - reflux
Complications ,
hyperchloremic acidosis (Rx- bicarbonate replacement)
hypokalemia ( Rx – Oral potassium citrate)
92
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
93. Routine nightly insertion of a rectal tube for drainage is advocated especially patient who cannot maintain
electrolyte homeostasis
Follow up,
- annual colonoscopy after 5 yrs
- Barium enemas are relatively contraindicated because reflux into the kidneys
- evaluation of stool for blood
- cytologic examination of the mixed urine and feces specimen
93
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
94. 2) AUGMENTED VALVED RECTUM
By Kock (1988)
used when stoma appliances were not available.
This is similar to standard ureterosigmoidostomy,
except that a proximal intussusception of the sigmoid colon confines the urine to a smaller surface area, thus
minimizing the problems of electrolyte imbalance.
the rectum is patched with ileum to improve the urodynamic properties of the rectum.
94
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
95. 3) HEMI-KOCK AND T POUCH PROCEDURES WITH VALVED RECTUM
By stein and skinner
It is a type of ileo-anal reservoir
It is the improve on the intussuscepted Kock continence mechanism (Augmented Valved Rectum)
It consists of the construction of a hemi-Kock or T pouch employing doubly folded, marsupialized ileum and a
proximal continence mechanism to prevent pouch-ureteral reflux.
This pouch is then anastomosed to the rectum directly as a patch.
Contact of urine with the proximal colon can be avoided by the intussusception of the sigmoid colon proximal to the
anastomotic site.
95
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
96. APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR
T implant
T patch
96
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
97. Advantages,
- transitional ureteral epithelium is not in contact with colonic epithelium, there may be a reduced
risk colonic malignancy.
- proximal colonic intussusception used in this procedure decreases the contact between urine and
colonic epithelium
>> low risk of hyperchloremic acidosis.
suited for the younger exstrophy patient
97
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
98. 4) SIGMA-RECTUM POUCH / MAINZ II
A variation of ureterosigmoidostomy
by Fisch and Hohenfellner in 1991
a low-pressure rectosigmoid reservoir of increased capacity due to partial reconfiguration of the rectosigmoid junction.
simple and reproducibile
Postop Mx,
- rectal tube is removed on the 3-5th POD
- ureteral stents are removed around 8th POD.
- IVU On the 15th POD to assess the upper tracts and the sigma-rectum pouch construction.
- Radiography of the pouch is performed on the 17th POD
98
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
99. CONTINENT CATHETERIZING POUCHES
two favorite sites for
(1) at the umbilicus
preferred for individual confined to a wheelchair , paraplegics
lower incidence of stomal stenosis (especially with appendiceal stoma)
(2) in the lower quadrant of the abdomen
through the rectus bulge and below the “bikini line.
conceals stoma.
99
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
100. NEOURETHRA
construction of a neourethra to the introitus is feasible (in females)
provided there is no substantial difficulty in the catheterizing process.
it is difficult to direct a catheter through the “chimney” of an intussuscepted nipple valve,
the imbricated and tapered ileal segment leading to an Indiana pouch is relatively easier to catheterize and can be
used for orthotopic catheterizing diversion
it may be difficult to obtain sufficient mesenteric length in some patients.
The appendix can also be used as a neourethra, in which case mesenteric length should become less of a problem
100
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
101. FOUR GENERAL TECHNIQUES HAVE BEEN EMPLOYED TO CREATE A DEPENDABLE,
CATHETERIZABLE CONTINENCE ZONE
1) For right colon pouches, appendiceal tunneling procedures are the simplest of
all to perform and established
2) major type of continence mechanism used in right colon pouches is the
tapered and/or imbricated terminal ileum and ileocecal valve
3) use of the intussuscepted nipple valve or the flap valve, which avoids the need
for intussusception.
4) provision of a hydraulic valve (reverse intussusception), as in the Benchekroun
nipple
101
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
102. MANAGEMENT OF CONTINENT POUCHES
continence mechanism is catheterized to ensure ease of catheter passage in later period.
- all redundancy should be removed from the continence mechanism.
- secure the reservoir to the anterior abdominal wall - prevents reservoir migration, kink
larger-bore catheter used for drainage of the pouch - irrigated at 4-hour intervals with 45 to 50 mL of saline.
as soon as possible the patient be taught how to self-irrigate
If the patient is on a positive nitrogen balance (i.e., eating a regular diet), a contrast study is performed on the 7th
POD to ensure pouch integrity.
If no leaks are noted, ureteral stents removed.
102
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
103. If ureteral anastomoses and pouch are intact - suction drain is removed.
Teach to irrigate the tube traversing the continence mechanism at 4-hour intervals or intra-abdominal pressure or
discomfort is experienced.
Once trained – pt is discharged, usually at hospital days 6 to 8
catheter type?
- For nipple valves - straight-ended 22- to 24-Fr tube;
- ileocecal plication - 20- to 22-Fr coudé tipped catheter
- appendiceal sphincters - 14- to 16-Fr coudé-tipped catheter
catheter care - reusable catheter can be placed in a zipper-locked bag that can be placed in a women’s purse or a
man’s coat pocket. •
103
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
104. cleaning the stoma - With a topical antiseptic wipe (e.g., with benzalkonium chloride),
lubricate the catheter - foil pack of water-soluble lubricant or self-lubricating single-use
packaging.
Cover stoma with a bandage - mucosal soiling.
cleaning catheter - By rinsing with ordinary tap water - inside channel and outer surface
smaller capacity pouches (ileal) managed best with indwelling catheterization during
sleep
- ileal pouch initial capacity - low - 150 mL
- right colon pouch initial capacity - in excess of 300 mL.
104
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
105. CONTINENT ILEAL
RESERVOIR (KOCK
POUCH)
• 50 cm of distal ileum is separated.
• The two 22 cm central segments are
anastomosed to each other on their
serosal surfaces
• limbs are opened along their
antimesenteric border.
• Nipple valves, afferent and efferent
are constructed.
• PGS mesh strip is used to further
stabilize the nipple.
• pouch is closed by folding up the
bottom half.
• Ureteroileal anastomosis is
• The efferent limb is used to create
the abdominal stoma.
105
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
106. DOUBLE T POUCH
• A 70-cm segment of terminal ileum
is isolated 15 to 20 cm from the
ileocecal valve
• proximal 10-cm segment is isolated
and rotated toward what will
become the reservoir in an
isoperistaltic direction.
• distal 12 to 15 cm is rotated
toward the reservoir in an
antiperistaltic direction.
• Mesentry windows of Deaver are
opened to allow the walls of the W
reservoir to be apposed behind the
valve mechanisms
• Continent mechanisms are tapered
(Flap vlve)
‘T’ limbs
106
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
107. MAINZ POUCH I
• 10- to 15-cm portion of cecum and
ascending colon is isolated
• along with two separate equal-sized
limbs of distal ileum and an additional
portion of ileum measuring 20 cm.
• A portion of the intact proximal ileal
terminus is freed of its mesentery for
a distance of 6 to 8 cm.
• entire colon and distal segments of
ileum are spatulated, taking care to
preserve the ileocecal valve. These
three bowel segments are folded in
the form of an incomplete W, and their
posterior aspects are sutured to one
another to form a broad posterior
plate
• The intact ileum is intussuscepted,
• The intussuscipiens is led through the
intact ileocecal valve
• Ureterocolonic anastomoses are
created at the apex of the reservoir,
• ileal terminus is directed through this
umbilical buttonhole
107
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108. RIGHT COLON POUCHES WITH INTUSSUSCEPTED TERMINAL ILEUM
Use nipple valve technology for the continence mechanism
These are variations on the continent cecal reservoir
These three pouches are the UCLA pouch , the Duke pouch, and Le Bag
These surgeries differ from one another by mainly related to the technique employed for stabilizing
the nipple valve
108
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109. • concept - using the buttressed
ileocecal valve as a dependable
continence mechanism that can
withstand the trauma of CIC
• Rowland(1987) of Indiana
University
• reliable continence,least
technicallydemanding
• Initial large capacity
INDIANA POUCH
109
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110. …INDIANA POUCH
• segment of terminal ileum
approximately 10 cm in length
along with the entire right colon
is isolated.
• Appendectomy is performed,
• entire right colon is opened
along its antimesentericborder
• double imbrication of the
ileocecal valve
• Excess ileum can be tapered by
stapler
• pouch is then closed in a
Heineke-Mikulicz configuration
• bring the ileal neourethra to
stoma site
110
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
111. PENN POUCH
• first continent diversion employing
the Mitrofanoff (1980) principle, in
which the appendix served as the
continence mechanism
• by Duckett and Snyder (1986)
• ileocecal pouch is created
• These two structures are
marsupialized on the antimesenteric
borders and sutured to one another in
the form of a neotubularized pouch.
• A button of cecum surrounding the
origin of the appendix is circumcised
• resulting cecal aperture is closed.
• appendix is then reversed
- cecal button > abdominal wall
- tail of the appendix > taenia of the
colon
111
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112. GASTRIC POUCH
• prefered in renal insufficiency
and children
• 11-cm segment of stomach is
isolated on the right
gastroepiploic blood supply
• 22-cm segment of ileum is then
isolated, opened along its
antimesenteric border, and
refashioned in a U shape.
• edges of the stomach are then
sutured to edges of the ileum with
- reservoir.
• ureters are tunneled into the
stomach
• Mitrofanoff continence
mechanism is created with a
tapered segment of ileum
112
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113. ORTHOTOPIC URINARY DIVERSION
orthotopic neobladder allows for volitional
voiding, avoids the need for an appliance
requires self-catheterization in a minority of
patients.
80% to 90% of males and 75% of females
undergoing cystectomy are potential
candidates for orthotopic reconstruction.
113
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115. TECHNIQUES FOR CONTINENCE PRESERVATION
rhabdosphincter muscle fibers and associated innervation from the pudendal nerve are
concentrated in the area anterior and lateral to the proximal urethra in both males and females.
In males,
- obtain careful control of the DVC
- avoidance of deep suture bites into the pelvic floor muscles
In females
- endopelvic fascia and levator muscles should not be disturbed.
- bladder is dissected completely off the anterior vaginal wall rather than excising it.
115
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116. TYPES
Ileal Reservoirs
- Camey II
- Orthotopic Kock Ileal Reservoir (Hemi-Kock)
- Serous-Lined Extramural Tunnel
- Ileal Neobladder (Hautmann Pouch)
- Studer pouch
- T Pouch Modification (of Studer pouch)
Colon and Ileocolic Pouches
- Orthotopic Mainz Pouch (Mainz III)
- Right colon pouch
- Padua Pouch (Vesica Ileale Padovana) or VIP pouch
- Sigmoid pouch / Reddy Pouch (Reddy and Lange)
116
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117. two most popular configurations - Hautmann W-neobladder and the Studer pouch
Both are relatively simple and lowest stricture rate
allow direct ureteroileal anastomosis.
T pouch and extraserosal tunnel techniques both provide an antireflux
mechanism
117
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118. CAMEY II
original Camey - a simple segment of
ileum anastomosed to the ureters and
urethra
modification - detubularization and
folding to eliminate peristaltic activity.
A total of 65 cm of ileum is isolated
The ileal loop is folded three times (Z
shaped) and incised on the
antimesenteric border.
The reservoir is closed
urethral anastomosis done
ureters implanted - Le Duc antireflux
technique.
original
Modified / Camey II
118
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119. HAUTMANN ILEAL NEOBLADDER
large-capacity, reduced nighttime incontinence
A 70-cm portion of terminal ileum taken
isolated segment of ileum is incised on the
antimesenteric border, leaving 5 cm on each end
intact.
ileum is arranged into a W configuration
four limbs sutured to one another.
buttonhole of ileum is removed and urethral
anastomosis is performed.
ureteral anastomoses are performed by direct
implantation
119
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120. STUDER POUCH
pouch is created from 40 to 44 cm of distal ileum with
each limb of the U measuring 20 to 22 cm
proximal 15-cm segment of ileum used as the
afferent limb.
ureteral length is short or compromised, a longer
afferent ileal segment is used.
ureters anastomosed afferent ileal segment.
dependent portion of the pouch is then anastomosed
to the urethra
Advantages:
1. Useful in short ureters.
2. Can be used in females.
Original Studer
T – modification
(flap valve)
120
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121. ORTHOTOPIC ILEOCOLONIC MAINZ POUCH (MAINZ III)
Mainz (“mixed augmented ileum and zecum”)
initially described as a continent catheterizable
reservoir
isolated 10 to 15 cm of cecum in continuity with
20 to 30 cm of ileum are isolated.
entire bowel segment is opened along the
antimesenteric border.
appendectomy is performed.
posterior reservoir is closed by joining the
opposing three limbs together.
antireflux implantation of ureters (submucosal
tunnel)
121
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122. SIGMOID NEOBLADDER / REDDY POUCH
35-cm segment of descending and sigmoid colon is
isolated and folded into a U shape.
The colon is incised along the medial taenia
tunneled ureterocolonic anastomosis is performed.
medial portions of the U are sewn together
buttonhole in the caudal portion anastomosed to urethra.
colonic pouch is closed
Adv - sigmoid easily reaches the urethra
Concern,
- compromise of the vasculature of the distal colon segment during
cystectomy (IIA)
- frequent stools or rectal urgency after sigmoidectomy
122
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124. TISSUE-ENGINEERED AUTOLOGOUS BLADDERS
created with autologous cells
seeded on collagen-polyglycolic
acid scaffolds,and wrapped in
omentum after implantation
124
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