This document outlines indications and techniques for radical cystectomy in the treatment of bladder cancer. It indicates radical cystectomy involves removal of the bladder and adjacent organs. Lymphadenectomy is also performed to remove pelvic lymph nodes. The extent of lymphadenectomy is controversial but removal of more than 15 nodes may provide prognostic benefits. Post-cystectomy urinary diversion options include abdominal conduits, orthotopic neobladders using bowel segments, and rectosigmoid diversions. Patient selection factors and oncologic outcomes are discussed.

2. Indications
1. Patientswith muscle-invasivebladder cancer T2-T4a, N0-Nx, m0
2. high-risk and recurrent superficialtumours, BCG-resistant Tis, T1G3
3. extensive papillary diseasethat cannot be controlled with TUR and intravesical
therapy alone
4. Salvage cystectomy is indicated for non-respondersto conservativetherapy,
5. recurrences after bladder sparing treatments,
6. non-urothelial carcinomas(these tumours respond poorly to chemo- and radiotherapy,
7. a purely palliativeinterventionfor e.g. fistulaformation, pain or recurrent
macrohaematuria

3. Technique and extent
 Radical cystectomyincludes the removal of the bladder and adjacent organs, that is
prostate and seminal vesiclesin men, and uterus and adnexa in women.
 The inclusion of the entire prostatein male patients,and the extent of urethrectomy and
vaginal resectionin female patients,however, has recentlybeen questioned

4.  A randomised study comparing patients with and without remnant portions of the
prostate is lacking and will be difficult to perform.
 Autopsy studiesas well as studieslooking at the unsuspectedincidence of prostate
cancer in cystoprostatectomy specimenssuggest that in approximately23-54% of
patientsa prostate cancer is found in the cystoprostatectomy specimen.
 Up to twenty-nine percent of these cancersmay be clinicallysignificant,locally
recurrent or even metastaticin patientswith prostatic tissue preserving radical
cystectomy.

5. Extent of lymphadenectomy
 Yet, data regarding its clinical significanceare controversial.
 In retrospective studies extended lymphadenectomy (removal of the obturator, internal,
external,common iliac and presacral nodes as well as nodes at the aortic bifurcation) has
been reported to improve survival in patientswith muscle-invasivebladder cancer.
 The curative value of lymph node dissection,however, is still unknown and a
standardised lymph node dissectionhas yet to be defined.

6.  There are several localisation studieswith regards to lymphadenectomy which
demonstratedboth retrospectivelyand prospectivelythat lymph nodes in bladder cancer
patientsare not found outside the pelvis if the pelvic lymph nodes are free of tumour.
 Furthermore progression free survivalas well as overall survival might be correlated
with the amount of lymph nodes removed during surgery. removal of more than 15
lymph nodes has been postulatedto be both sufficient for the evaluationof the lymph
node statusas well as beneficialfor overall survival in retrospective studies.

7.  A distal ureteral segment (length not specified)should be resected and in case of
bladder CIS a frozen section for evaluationof the surgicalmargins should be performed.

8.  Urethrectomy is recommended if
1. there are positive margins at the level of urethral dissection,
2. positive margins anywhere on the bladder specimen (in both sexes),
3. if the primary tumour is located at the bladder neck or in the urethra (in women), or
4. if tumour extensivelyinfiltratesthe prostate

9. Surgical boundaries of radical
cystectomy in a man. The specimen
includes the bladder, the prostate,
and the seminal vesicles
Surgical boundaries of radical
cystectomy in a woman. The
specimen includes the bladder
and entire urethra, uterus, ovaries,
fallopian tubes, and the anterior
wall of the vagina

10. MAIN STEPS
 POSITION
 INCISION
 ABDOMINAL EXPLORATION
 BOWEL MOBILIZATION
 URETERAL DISSECTION
 PELVIC LYMPHADENECTOMY
 LIGATION OF LATERAL VASCULAR PEDICLE
 LIGATION OF POSTERIOR VASCULAR PEDICLE
 ANTERIOR APICAL DISSECTION

11. Position
 The patient is placed in the hyperextended supine
position with the iliac crest located just below the
fulcrum of the operating table .
 The legs are slightly abducted so that the heels are
positioned near the corners of the foot of the table.
 In the female patient considering orthotopic diversion,
the modified frogleg or lithotomy position is employed
allowing access to the vagina.

12. Incision
 A vertical midline incision is made extending from the
pubic symphysis to the cephalad aspect of the epigastrium.
 The incision should be carried lateral to the umbilicus on
the contralateral side of the marked cutaneous stoma site.
 When considering the umbilicus as the site for a
catheterizable stoma, the incision should be directed 2 to 3
cm lateral to the umbilicus at this location.
 While opening the posterior rectus sheath , care should be
taken to remove the urachus en bloc with bladder.

13. Abdominal exploration
 Look for extent and resectability
 Hepatic metastasis
 Gross regional and retroperitoneal lymphadenopathy

14. Ureteral resection
 The ureters are most easily identified in the retroperitoneum just
cephalad to the common iliac vessels.
 They are dissected into the deep pelvis (several centimeters beyond the
iliac vessels) and divided between two large hemoclips.
 A section of the proximal cut ureteral segment (distal to the proximal
hemoclip) is then sent for frozen section analysis to ensure the absence
of carcinoma in situ or overt tumor.
 The ureter is then mobilized cephalad and tucked under therolled
towel to prevent inadvertent injury.
 Leaving the proximal hemoclip on the divided ureter during the
exenteration allows for hydrostatic ureteral dilation and facilitates the
ureteroenteric anastomosis.
 In women, the infundibulopelvic ligaments are ligated and divided at
the level of the common iliac vessels.

15. lymphadenectomy
 The “standard” dissection
 genitofemoral nerve- lateral limit of the node dissection.
 The entire external iliac artery and vein are dissected up to the
bifurcation of the common iliac artery, which is the cephalad
limit of the dissection.
 The caudal limit of the dissection is the endopelvic fascia. The
lymphatic package is then dissected free of the iliac vessels and
extended medially into the obturator fossa .
 The medial limit of the dissection is the bladder.
 Care is taken to avoid tearing an accessory obturator vein, which
is present frequently. The obturator nerve is visualized. The node
of Cloquet is mobilized at the junction of the femoral canal, and
a clip is applied to the lymphatic package in this area before
lymphatics are divided.
 The nodes are then dissected from the hypogastric artery and
vein.

16.  The distal limits of the dissection are then identified: the
circumflex iliac vein crossing anterior to the external iliac artery
distally, the genitofemoral nerve laterally, and the lymph node of
Cloquet medially.
 The “extended” lymphadenectomy includes the tissue
along the common iliacs up to the aortic bifurcation, but
some would also include the presacral nodes or carry the
dissection up to the inferior mesenteric artery.
 The extended lymphadenectomy has been shown to
improve survival in patients with both lymph node–
negative and limited lymph node metastatic disease ( Herr
et al, 2002 ). The lymph node yield is increased more than
threefold by dissecting and submitting separate lymph
node packets compared with an en bloc resection (
Bochner et al, 2001 ).

17. Pelvic dissection
 At the time of the dissection of the hypogastric vessels, the
obliterated umbilical and superior vesical arteries are
divided.
 Branches of the hypogastric artery are divided, but the
hypogastric artery is not ligated to avoid potential
compromise of blood flow to the internal pudendal artery
and possible vasculogenic impotence .
 The retrovesical cul-de-sac is exposed, and the posterior
peritoneum is incised . A plane between the bladder and
the rectum is then developed.
 This dissection can usually proceed under direct vision,
and the bladder and prostate can be separated from the
rectum. The seminal vesicles can then be visualized
posteriorly.

19. Nerve-Sparing Approach
 Once a retrograde dissection is initiated, the endopelvic fascia is
incised, and the puboprostatic ligaments are divided.
 The dorsal vein complex is divided and oversewn.
 The urethra is then divided. If a urethrectomy is to be performed,
the urethra is dissected under the symphysis so that the perineal
dissection is facilitated.
 If a continent urinary diversion is being considered, frozen-
section analysis of the prostatic urethra and the apex of the
prostate is performed to verify that there is no carcinoma at the
urethral margin.
 The neurovascular bundle is dissected off the prostate, and the
remainder of the pedicles are ligated and divided.
 A heavy ligature tied around the urethra at the level of the apex
of the prostate may prevent leakage of urine after division of the
urethra.

21. Survival after Radical Cystectomy
Pathologic Stage
Disease-Specific Survival
(%) Overall Survival (%)
pTa, Tis, T1 with high risk
of progression
82
Organ confined, negative
nodes (pT2, pN0)
73 49
Nonorgan confined (pT3-4a
or pN0)
33 23
Lymph node-positive (any
T, pN1-2)
28, 34 21

22. Urinary diversion after radical
cystectomy
 From an anatomicalstandpoint three alternativesare presentlyused after cystectomy:
1. Abdominal diversion such as uretherocutaneostomy,ileal or colonic conduit, and
various forms of a continent pouch
2. Urethral diversion which includesvarious forms of gastrointestinalpouches attached
to the urethra as a continent, orthotopic urinary diversion (neobladder,orthotopic
bladder substitution)
3. Rectosigmoid diversions,such as uretero(ileo-)rectostomy.
 Different types of segments of the intestinaltract have been used to reconstruct the
urinary tract, including the stomach,ileum, colon, and the appendix.

23.  Patientsundergoing continent urinary diversion have to be motivated both to learn about
their diversion and to be manually skilful in manipulatingtheir diversion.
 contra-indications to more complex forms of urinary diversion include:
1. Debilitating neurologicaland psychiatricillnesses.
2. Limited life expectancy.
3. Impaired liver or renal function.
4. Transitionalcell carcinoma of the urethral margin or other surgical margins

24.  relative contraindicationsspecific for an orthotopic neobladder are
1. high-dose preoperativeradiation therapy,
2. complex urethral stricture disease,and
3. severe urethral sphincter-relatedincontinence

25. Conduits
 Ileal conduit:
 A segment 10 to 15 cm in length is selected 10 to 15
cm from the ileocecal valve. The cecum and ileal
appendage (i.e., that portion of the distal ileum
fixed to the retroperitoneum) are mobilized.
 The ileal mesentery is transilluminated and a
major arcade identified to the segment selected

28. CONTRAINDICATION
 Because of refractory metabolic abnormalities, jejunal segments should be used only in
the absence of another acceptabletype of bowel segment.
 Bowel abnormalitiessuch as
IBD
IBS precludesuse of
Fat malabsorption lengthy bowel

30. Colonic conduit
 The segment may be isolated on the right or
middle colic arteries.
 The gastrocolic ligament is taken down and the
omentum dissected from the portion of colon
that is to be isolated.
 The splenic and hepatic flexures should be
mobilized next.
 The proper length of segment is determined by
taking into consideration the desired location of
the stoma and the length of available ureters. In
general, a length of 15 cm is sufficient.

31.  It is important not to isolate a segment that is too short and therefore
incapable of reaching the retroperitoneum in such a position that a
tension-free ureterocolonic anastomosis may be performed and
retroperitonealized.
 The segment is isolated between bowel clamps, and a two-layer
colocolostomy or stapled anastomosis is performed. The segment is
placed caudad to the anastomosis. If a colopyelostomy is to be
performed, the segment should be placed cephalad to the bowel
anastomosis.
 The isolated segment is irrigated with copious amounts of saline until
the effluent is clear. The proximal end is closed with a running Connell
suture of 3-0 chromic and a second layer of Lembert sutures of 3-0 silk.
The ureterocolic anastomoses are then performed, and the end is
anchored to the retroperitoneum close to the midline.
 The stoma is usually placed in the right upper quadrant but may be
placed anywhere in the abdomen if indicated.

32.  Other conduits
 Jejunal
 Combined ileo-caecal
 Sigmoid
 Ileo-vesicostomy- suited for neurogenic bladder

33. Continent urinary diversion
 Continent diversion may be further categorized into 3
types:
(1) Rectal - bowel
(2) Continent catheterizable diversion, and
(3) Orthotopic or neobladder diversion

34. RECTAL – BLADDER ( CONTINENT )
 Ureterosigmoidostomy
 Folded Rectosigmoid Bladder
 Augmented Valved Rectum
 Hemi-Kock Procedures with Valved Rectum
 Sigma Rectum Pouch, Mainz II

35. Mainz pouch II

36. Modified Mainz pouch II

38. Continent urinary diversion
 Bowel segments
- either ileum or a combination of terminal ileum and
ascending colon.
 High storage and voiding pressures ultimately cause high-
pressure reflux nephropathy and may result in renal failure
 Therefore, all bowel segments used for continent diversion
are initially detubularized.
 Refashioned in a more spherical shape,
- which increases capacity and decreases luminal
pressure.

39.  Catheterizable stoma have a one-way valve mechanism
fashioned at the insertion site that leads into the
urinary storage system.
 Mechanisms for continence of the efferent limb
include a flap valve, nipple valve, pressure
equilibration, or combinations of thereof.

40. Continent Catheterizing Pouches
 Kock Pouch - The Kock pouch consists of a reservoir
constructed from the small intestine, and a nipple
valve.
 Complications
- Nipple valve slips - can result in difficulties inserting
the tube, and eventually, incontinence.
- Pouchitis - Symptoms include loose stools and
sometimes bleeding.
- Pouchitis is treated with antibiotics, and the
symptoms usually disappear within a week.

42. Continent Catheterizing Pouches
 T-Pouch
 Mainz Pouch - 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 , with care taken to
preserve the ileocecal valve .

43. Indiana Pouch Reservoir
 A reservoir (pouch) is constructed out of the right colon (large
intestine) and a small segment of ileum (small intestine).
 Advantages:
- Urine is kept inside the body until it is ready to be emptied
- No bag necessary
- No odor
- Small stoma which can be covered by a bandage.
 Disadvantages:
- Longer surgery time
- Need for intermittent catheterization

44.  Penn Pouch - the appendix serves as the continence
mechanism.
 Benchekroun Hydraulic Ileal Valve creating an ileal
hydraulic valve .The premise was that as the reservoir
filled, the pressure within the valve would also
increase, thereby creating continence.
 Gastric Pouches

46. Orthotopic neobladder
 The terminal ileum is the gastrointestinal segment mostoften used for bladder substitution and
there is less experience with ascendingcolon, including caecum, and the sigmoid.
 The emptying of the reservoir anastomosed to the urethra requiresabdominal straining,
intestinal peristalsisand sphincterrelaxation.
 Early and late morbidity in up to 22% of the patientsis reported.
 Two important criteria
- rhabdosphincter mechanism must remain intact to
provide a continent means of storing urine.
- Under no circumstance should the cancer operation be
compromised

47.  Advantages:
- The patient is able to empty the reservoir (pouch) of urine in a manner similar to the
normal voiding pattern
- No stoma is required
- No cathetersrequired
 Disadvantages:
- Slightly longer surgery time
- Potentialfor temporary or permanent incontinencein a small percentage of patients.
- Some patientsmay have to perform intermittentcatheterization

48. Camey II

49. S Bladder
 A 75-cm segment of ileum is isolated,arranged in the shape of an S, and opened on the
antimesenteric border while the distal 5 cm and proximal 15 cm are kept intact.
 The corresponding antimesenteric borders are sutured together to form an intestinal
plate.
 The proximal 15 cm is transformed into an afferent antireflux Kock nipple as described
by Skinner and colleagues ( 1984 ) .
 The ureters are spatulated and anastomosed to the proximal portion of the antireflux
nipple. The distal ileum is tapered down to the size of the urethra.

50. Ileal Neobladder (Hautmann )

51. Studer Ileal Bladder Substitute

52.  Construction of the ileal neobladder (Studer pouch) with an
isoperistaltic afferent ileal limb.
 A 60- to 65-cm distal ileal segment is isolated (approximately 25 cm
proximal to the ileocecal valve) and folded into a U configuration. Note
that the distal 40 cm of ileum constitutes the U shape and is opened on
the antimesenteric border; the more proximal 20 to 25 cm of ileum
remains intact (afferent limb).
 The posterior plate of the reservoir is formed by joining the medial
borders of the limbs with a continuous running suture. The ureteroileal
anastomoses are performed in a standard end-to-side technique to the
proximal portion (afferent limb) of the ileum. Ureteral stents are used
and brought out anteriorly through separate stab wounds.
 The reservoir is folded and oversewn (anterior wall).
 Before complete closure, a buttonhole opening is made in the most
dependent (caudal) portion of the reservoir.
 The urethroenteric anastomosis is performed.
 A cystostomy tube is placed, and the reservoir is closed completely.

53. Orthotopic Kock Ileal Reservoir

54.  Construction of the Kock ileal reservoir.
 A total of 61 cm of terminal ileum is isolated. Two 22-cm segments are
placed in a U configuration and opened adjacent to the mesentery. Note
that the more proximal 17-cm segment of ileum will be used to make the
afferent intussuscepted nipple valve.
 The posterior wall of the reservoir is then formed by joining the medial
portions of the U with a continuous running suture.
 A 5- to 7-cm antireflux valve is made by intussusception of the afferent
limb with the use of Allis forceps clamps.
 The afferent limb is fixed with two rows of staples placed within the
leaves of the valve.
 The valve is fixed to the back wall from outside the reservoir.
 After completion of the afferent limb, the reservoir is completed by
folding the ileum on itself and closing it (anterior wall). Note that the
most dependent portion of the reservoir becomes the neourethra. The
ureteroileal anastomosis is performed first, and the urethroenteric
anastomosis is completed in a tension-free, mucosa-to-mucosa fashion

55. T Pouch Ileal Neobladder

57. Ileocolonic (Le Bag ) Pouch

58. sigmoid (Reddy ) neobladder

59. Ureterocolonic diversion
 The oldest and most common form was primarily a refluxive and later an antirefluxive
connection of ureters into the intact rectosigmoideum (uretero[recto]sigmoidostomy) .
 most of the indicationsfor this procedure have become obsolete due to a high incidence
of upper urinary tract infectionsand the long-term risk of developing colon cancer .
 Bowel frequency and urge incontinence were additional side-effectsof this type of
urinary diversion.
 however, it may be possibleto circumvent the above-mentionedproblems by interposing
a segment of ileum between ureters and rectum or sigmoid in order to augment capacity
and to avoid a direct interactionbetween urothelium, colonic mucosa, together with
faeces and urine .

61. Short-Term Complications after
Cystectomy and Urinary Diversion
Complication Percent
Acute acidosis requiring therapy 16
Urine leak 3 - 16
Bowel obstruction 5
Fecal leak 5
Pyelonephritis 5 - 15
Sepsis 5 - 15

62. Long-Term Complications after
Cystectomy and Urinary Diversion
Complication Percent
Ureteral intestinal obstruction 15
Renal deterioration 15
Renal failure 7
Stoma problems 15
Intestinal stricture 10
Bowel obstruction 5

63. Metabolic Complications
1. electrolyteabnormalities,
2. altered sensorium,
3. abnormal drug metabolism,
4. osteomalacia,
5. growth retardation,
6. persistentand recurrent infections,
7. formation of renal and reservoir calculi,
8. problems ensuing from removal of portions of the gut from the intestinaltract, and
9. development of urothelial or intestinalcancer.

64.  Many of these complications are a consequenceof altered solute absorption acrossthe
intestinalsegment.
 The factors that influence the amount of solute and type of absorptionare
1. the segment of bowel used,
2. the surface area of the bowel,
3. the amount of time the urine is exposed to the bowel,
4. the concentrationof solutes in the urine,
5. the renal function, and
6. the pH of the fluid.

65. Electrolyte Abnormalitiesare different, depending on the segment of bowel
used.
Syndrome Segment Symptoms Associated Abnormalities
Syndrome of severe metabolic
alkalosis
Stomach Lethargy, muscle weakness,
respiratory insufficiency,
seizures, ventricular
arrhythmia
Elevated aldosterone,
hypochloremia, hypokalemia
Syndrome of hyperkalemia,
hypochloremia, metabolic
acidosis
Jejunum Lethargy, nausea, vomiting,
dehydration, muscle weakness
Elevated renin, angiotensin
Syndrome of hyperchloremia,
metabolic acidosis
Ileum, colon Fatigue, anorexia, lethargy,
weakness
Total-body potassium
depletion, hypocalcemia

66. Metabolic Acidosis
 Best recognized sign -Kussmaul respiration (deliberate, slow, deep
breathing)
 Occurs through 2 mechanisms:
(1)The intestinal mucosa has an apical Cl-/ HCO3
- exchanger. When urine is
diverted to a loop , the Cl- in the urine is exchanged for HCO3
-. Significant
loss of HCO3
- increase in serum Cl- concentration.
(2)Intestinal mucosa reabsorbs urinary NH4
+, metabolized in the liver to
NH3 and H+.
This occur if
 Urine contact time with the intestinal mucosa is prolonged, as when a
long loop of bowel is used
 When the stoma is obstructed
 When sigmoid rather than ileal loop is used
 A low serum HCO3
- and a pH < 7.40 upon ABG analysis confirm
metabolic acidosis

67. Long term complications of meta. acidosis
 Bone disease (osteomalacia and osteopenia) caused by continual
buffering of H+ ions.
 Chronic metabolic acidosis increases the rate of skeletal muscle
breakdown; this high catabolic state may contribute to loss of body
mass and muscle weakness.

68. Treatment
 Alkalinization with oral sodium bicarbonate is effective in restoring
normal acid-base balance. Oral administration of bicarbonate may not be
tolerated particularly well, however, because it can produce considerable
intestinal gas.
 An effective alternative is sodium citrate and citric acid solution (Bicitra or
Shohl's solution) used together.
 Potassium citrate, sodium citrate, and citric acid solution (Polycitra) may be
used instead if excessive sodium administration is a problem because of
cardiac or renal disease and if potassium supplementation is desirable or at
least not harmful.

69.  Chlorpromazineand nicotinic acid inhibit cyclic adenosine monophosphate and
thereby impede chloride transport.
 those patients in whom persistent hyperchloremic metabolic acidosisoccurs and in
whom excessivesodium loads are undesirable,chlorpromazineor nicotinic acid may be
used to limit the degree of the acidosis.
 Chlorpromazine may be given in a dose of 25-50 mg three times a day
 s/e-tardive dyskinesia
 Nicotinic acid may be given in a dose of 400 mg three or four times a day
 s/e-exacerbation of liver dysfunction,exacerbation of peptic ulcer disease, headaches,
and double vision.

70. Hypokalemia
 Hypokalemia and total-body depletionof potassium may occur in patientswith urinary intestinal
diversion.This is more common in patients with ureterosigmoidostomies than it is in patients
who have other types of urinaryintestinal diversion.
 The potassium depletionis probablydue to renal potassium wasting as a consequence of renal
damage, osmotic diuresis, and gut loss through intestinal secretion.
 The last-mentioned(probablyquantitatively) playsa relativelyminor role. Indeed, it has been
shown that ileal segments exposed to high concentrationsof potassium in the urine reabsorb
some of the potassium, whereas colon is less likelyto do so .
 In treatingthese patients,one must rememberthat if the hypokalemiais associatedwith severe
hyperchloremicmetabolicacidosis, treatment must involve both replacement ofpotassium and
correction ofthe acidosiswith bicarbonate. If the acidosisis corrected without attentionto
potassium replacement, severe hypokalemiamay occur, marked flaccid paralysis may develop

71.  (C) Hypocalcaemia –
consequence of depleted body calcium stores and excessive renal
wasting.
(1) The chronic acidosis is buffered by carbonate from the bone with
subsequent release of calcium into the circulation, which is then
cleared by the kidney and results in a gradual decrease in body calcium
stores.
(2) An impairment of renal tubule calcium reabsorption also occurs.
 Leads to- Osteomalacia – adults
rickets - children

72. Altered Sensorium
 as a consequence of
1. magnesium deficiency,
2. drug intoxication, or
3. abnormalities in ammonia metabolism.
 Patients who develop magnesium deficiency do so either secondary to
nutritional depletion or in relation to magnesium wasting by the kidney in
much the same way that calcium wasting occurs

73. Abnormal Drug Absorption
 Drugs more likely to be a problem are those that are absorbed by the gastrointestinal
tract and excreted unchanged by the kidney.
 Thus, the excreted drug is re-exposed to the intestinalsegment, which then reabsorbs it,
and toxic serum levels develop. This has been reported for phenytoin (Dilantin) and has
been seen for certain antibioticsthat are excretedunchanged.
 A more recent study suggests that in patientswith normal renal function, both those with
and without continentdiversionstolerate chemotherapy well.
 in patientswith continentdiversionswho are receiving chemotherapy,consideration
should be given to draining the pouch during the time the toxic drugs are being
administered.

74. Osteomalacia
 Osteomalacia in urinary intestinal diversion may be due to
1. persistent acidosis,
2. vitamin D resistance, and
3. excessive calcium loss by the kidney.
 Patients who develop osteomalacia generally complain of lethargy; joint
pain, especially in the weight-bearing joints; and proximal myopathy.
 Analysis of serum chemistries reveals that the calcium concentration is
either low or normal. The alkaline phosphatase level is elevated, and the
phosphate level is low or normal

75. Rx
 correction of the acidosis and
 dietary supplementation of calcium.
 If this does not result in remineralization of the bone, the active form of
vitamin D may be administered.
 If this is not successful, the more active metabolite of vitamin D3, 1α-
hydroxycholecalciferol, should be administered.

76. Infection
 An increased incidence of bacteriuria, bacteremia, and septic episodes occurs
in patients with bowel interposition.
 Incidence of sepsis is 13%
 Etiology
1. transmucosal translocation of bacteria.
2. diminished antibacterial activity of the intestinal mucosa.
3. the intestine may make the urine less bacteriostatic and thereby promote
the growth of bacteria

77.  Many of patients with bacteruria, however, show no untoward effects and
seem to do well with chronic bacteriuria.
 of the upper tracts is more likely when the culture becomes dominant for
Proteus or Pseudomonas.
 Thus, patients with relatively pure cultures of Proteus or Pseudomonas
should be treated, whereas those with mixed cultures may generally be
observed, provided they are not symptomatic.

78. Stones
 the great majority of stones formed in patients with urinary intestinal
diversions are composed of calcium, magnesium, and ammonium phosphate.
 The incidence of renal stones is 3% to 4% in patients with colon conduits
and 10% to 12% in those with ileal conduits.
 Those most susceptible to development of renal calculi are patients who
have hyperchloremic metabolic acidosis, preexisting pyelonephritis, and
urinary tract infection with a urea-splitting organism

79.  A major cause of calculus formation in conduits and pouches is a foreign
body, such as staples or nonabsorbable sutures, on which concretions form.
 In intestinal reservoirs, alterations in bowel mucosa may also serve as a
nidus for stone formation.
 Finally, alterations in intestinal mucus, particularly in the presence of
infection or obstruction, may serve as a nidus or more importantly may
interfere with emptying and thereby exacerbate infection and stone
formation

80. Short Bowel, and Nutritional
Problems
 In patientswith a significantloss of ileum,vitamin B12 malabsorption has been reported
and results in anemia and neurologic abnormalities.
 Loss of significantportions of ileum also resultsin malabsorption of bile salts.Because
the ileum is the major site of bile salt reabsorption,the lack of reabsorption allows bile
salts entry into the colon, which causesmucosal irritation and diarrhea.
 Also, loss of the ileum resultsin the loss of the “ileal break.” The ileal break is a
mechanism whereby gut motility is reduced when lipids come in contact with the ileal
mucosa so that increasedabsorption can occur. With the loss of ileum, the lipid does not
result in decreased motility and is presented unmetabolized to the colon, which may
result in fatty diarrhea.

81.  Loss of the ileocecal valve may have a number of untoward effects.Because of the loss of the
valve, reflux of large concentrationsof bacteria into the ileum may occur, which results in small
intestinal bacterial overgrowth. This may result in nutritional abnormalities that involve
interferencewith fatty acid reabsorption and bile salt interaction.
 With the lack of absorption of fats and bile salts, these are presentedto the colon and result in
diarrhea.
 Moreover, reflux of bacteria into the small bowel may result in bile salt deficiency.Also, the
lack of fat absorptionmay result in deficienciesof the fat-soluble vitaminA, osteomalacia due
to lack of vitamin D, and complexing of calcium with the fats to form soaps and thus lack of its
absorption.
 Loss of a significant portion of jejunum may result in malabsorptionof fat, calcium, and folic
acid

82. Cancer
 with ureterosigmoidostomy 6% - 29% .
 10- to 20-year delay before the cancer manifest.
 Histologically, adenocarcinoma, adenomatous polyps, sarcomas, and transitional
cell carcinoma.
 Anaplastic carcinomas and adenomatous polyps have been reported in patients
with ileal conduits.
 The etiologic mechanism of the development of the carcinoma is not understood.
Whether the tumor arises from transitional epithelium or colonic epithelium is
unclear.
 The highest incidence of cancer occurs when the transitional epithelium is

83. neuromechanical complications
 Two types:
- atonic, resulting in an atonic segment with urinary retention, and upper
tract deterioration
- hyperperistaltic contractions , relevant in continent diversions as this may
result in incontinenceand a low-capacity reservoir.

84. Surgical Complications
 Complications that occur following any major surgical procedure
- thrombophlebitis,
- pulmonary embolus,
- wound dehiscence,
- pneumonia,
- atelectasis.

85. THANK YOU