Bladder carcinoma- surgery- substitution

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

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

Three Alternatives after Cystectomy
• Abdominal diversion
• Urethral diversion
Gastrointestinal pouches attached to the urethra
• Rectosigmoid diversions
3
Dept of Urology, GRH and KMC, Chennai.

Ureteral diversion to the abdominal wall
Simplest form of cutaneous diversion.
Safe procedure ; Preferred in older and compromised.
High rate of stomal stenosis
4

5

• AVAILABLE OPERATIVE OPTIONS
• OBJECTIVES
• LIFESTYLE
• SEXUAL LIFE
• PLACE OF STOMA
• POTENTIAL COMPLICATIONS OF EACH
METHOD
6

• Serum creatinine < 2 mg/dL
• Urine pH of 5.8 or less after an ammonium
chloride load
• Urine osmolality of 600 mOsm / kg or greater
in response to water deprivation
• GFR > 35 mL / min
• Minimal protein in the urine
7

Small bowel --
Large bowel --
Conduits made of stomach
Described but are rarely indicated
Difficult problems of stomal maintenance.
Each type of conduit specific Indications
Advantages
Complications. 8

Portion of distal ileum
Simplest type of conduit diversion ; Fewest intraoperative and
immediate postoperative complications.
Avoided in
Short bowel syndrome,
Inflammatory small bowel disease,
Extensive irradiation for Pelvic malignant neoplasm.
Complications:
Early ( 48%) -- Urinary tract infections, Pyelonephritis,
Uretero-ileal leakage
Late (24%) -- Stomal complications
Functional and / or Morphological changes of the
upper urinary tract in up to 30% . 9

The isolated segment of ileum is placed
caudal to the ileoileostomy.
The stoma is formed first before
anastomosing the ureters to allow
them to be inserted in an
optimal position.
10

Low rate of acceptance-- Electrolyte abnormalities
Renal calculi
Parastomal hernia
Pyelonephritis
Advantage : Avoids irradiated bowel and ureter.
Contraindications
Severe bowel nutritional disorders
Presence of another acceptable segment.
11

Transverse , Sigmoid, and ileocecal.
The transverse colon -- Extensive pelvic irradiation.
Less prone for stomal
stenosis
The sigmoid conduit -- Pelvic exenteration with colostomy.
 No bowel anastomosis .
 Allows non refluxing submucosal reimplantation
 Provides for an easily placed left sided stoma
Contraindications :
Inflammatory Diseases
Hypogastric arteries have been ligated 12

13

14

Advantages :
 Long segment of ileum for ureter replacement
 Provides colon for the stoma.
 Ileocecal valve reinforced to prevent reflux.
Contraindications
* Inflammatory bowel disease
* Severe chronic diarrhea.
15

Anastomoses stented with Silastic stents.
Removed individually on the fourth to sixth postoperative days.
Ureterointestinal anastomosis retroperitonealized,
Suturing the posterior peritoneum to the serosa of the conduit
above the ureterointestinal anastomosis.
Jackson- Pratt closed-suction drain laid in the retroperitoneum
3 to 4 cm away from the anastomosis.
The peritoneal cavity should not be drained.
16

 Nil Oral until bowel function returns.
 NGT decompression - FOR / AGAINST
 A progressive diet after confirmation of bowel activity.
 Severe respiratory disease  Consider performing a
Gastrostomy.
 Prophylaxis for DVT / Pulmonary embolus.
Compression boots
Use of Heparin or warfarin (Coumadin)
17

Electrolyte abnormalities
Altered sensorium,
Abnormal drug metabolism,
Osteomalacia,
Growth Retardation,
Persistent and recurrent infections,
Formation of renal and reservoir calculi,
Problems ensuing from removal of portions of the gut
Development of urothelial or intestinal cancer.
18

Altered solute absorption across the intestinal
segment.
Factors influencing the amount of solute and type
of absorption
 Segment of bowel used
 Surface area of the bowel
 Amount of time the urine is exposed to the
bowel
 Concentration of solutes in the urine
 Renal function
 pH of the fluid.
19

• Stomach
• Jejunum
• Colon / Ileum
Electrolyte Disturbances
Hyperammonemia
Hypomagnesemia
Hypocalcemia 20

21

Hypomagnesemia
Renal loss , Chronic diarrhea , Decreased absorption
Cardiac arrhythmias , Tremor , Tetany, Seizures
Magnesium Replacement
Ammonia Encephalopathy
Typically in pre-existing or acquired liver disease
Ureterosigmoidostomy > Colon or ileal conduits
Restlessness , Sleep disturbance , Impaired intellectual
abililites, Asterixis , Stupor, Coma
Lactulose , Neomycin/tetracycline, Arginine glutamate 22

Mineralized component of bone is replace with osteoid
Renal failure and Chronic untreated metabolic acidosis
• Vit. D resistance – Less Ca absorption by GIT
• Vit . D deficiency – Acidosis limits Vit. D production
Treatment of underlying metabolic acidosis
• Vit .C
• Activated Vit. D metabolite- 1-alpha-
hydroxycholecalciferol
• Ca supplementation
23

• A, D ,E, K – Fat soluble ; Lost in malabsorption of fat
• Vit . B12 – absorbed in distal ileum
Increased risk with Continent diversion
Larger bowel segment used
TI / IC junction resection
Resection of > 50cm
Replace with 100 ug cobalamin IM monthly
starting 1 year after surgery if > 50cm ileum resected
24

Early
 Wound Infection
 Intra abdominal abscess
 Pyelonephritis
 Hemorrhage
 Urine leak / Fistula
 Bowel leak / Fistula
 Ileus
 Bowel Obstruction
25

• Late
 Wound hernia or Dehiscence
 Bowel obstruction
 Ureteral stricture
 UTI / Pyelonephritis
 Urinary stones
 Renal deterioration
 Hematuria - Dysuria Syndrome
26

• Early
 Bleeding
 Necrosis
• Late
 Dermatitis
 Retraction
 Prolapse
 Parastomal hernia
 Stenosis
27

28

Cystourethrectomy when preservation of the sphincter
and urethra are not possible
Positive urethral biopsies
Positive intraoperative surgical margins.
Incontinent patient - Urethral sphincter incompetence.
Motivated , compliant with manual dexterity to
perform self-catheterization
29

Avoided in
• Quadriplegic individuals
• Very frail or mentally impaired
• Impaired Renal and hepatic function
• Previous irradiation
• Inflammatory bowel diseases
Postoperative Care
•Requires round-the-clock attention
•Hyperalimentation
•Late malignancy
•Routine colonoscopy 30

• “Best” continent diversion yet to be devised.
• Procedures with lower early and late
complication
• Apropriate bowel segment chosen –
Detubularised to avoid peristaltic activity
• Best techniques for urinary continence, and
prevention of reflux
31

Two major categories
 Ileocecal sigmoidostomy
 Rectal bladder
 Sigmoid hemi-Kock operation with proximal
colonic intussusception
Allow for excretion of urine by means of evacuation.
Requiring clean intermittent catheterization for urine
drainage at standard intervals.
32

33

Ureters are transplanted in to the rectal stump.
Proximal sigmoid colon is managed by
Terminal sigmoid colostomy or,
by bringing the sigmoid to the perineum
Uses the anal sphincter to achieve both bowel and urinary
control.
Large bowel studied for pre-existing disease
Anal sphincteric integrity testing
Not well accepted
Combined urinary and fecal incontinence,
Damage to the anal sphincter mechanism during the dissection processes
34

Rectal bladder with terminal colostomy
(Mauclaire)
Rectal bladder with perineal colostomy
(Lows
35

36

37

-- Pseudoappendiceal
tubes
For right colon pouches ; Fashioned from ileum or
right colon with ileocecal valve plication
38

Imbrication or plication of the ileocecal valve region along
with tapering of the more proximal ileum
39

which avoids the need for intussusception.
Most technologically demanding
Highest complication and reoperation rates.
40

Small bowel segment is isolated, and
reversely intussuscepted that effectively
apposes the mucosal surfaces of the
segment.
Tacking sutures are placed on a portion
of the circumference of the intussuscepted
segment in order to stabilize the nipple
valve
Allows urine to flow freely between the
leaves of apposed ileal mucosa.
As the pouch fills, hydraulic pressure
closes the leaves, thereby ensuring
continence.
41

Creation of a high-capacity and low-pressure
reservoir
Easily be emptied by intermittent self-
catheterization
Provides continence by its specific outlet.
Intraoperative testing for pouch integrity
Continence mechanism tested for ease of catheterization,
as well as continence -- Filling with saline
Secure the reservoir to the anterior abdominal wall in a
manner that prevents the reservoir from migrating. –
Prevent the development of a false passage or a kink
42

Larger bore catheter for drainage
Irrigated at frequent intervals to prevent mucous obstruction.
Performed at 4-hour intervals by simple irrigation with
45 to 50 mL of saline.
7TH POD  Contrast study performed to ensure pouch integrity.
Removal of Ureteral stents , Suction drain , Suprapubic tube
Patient taught to irrigate the tube traversing
the continence mechanism
43

12–15 cm of terminal ileum
used for construction of the
intussuscepted ileal nipple valve.
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.
44

Intact ileum is intussuscepted, and
two rows of staples are taken on
the intussuscipiens itself
The intussuscipiens is led through the
intact ileocecal valve, and a third row
of staples is taken to stabilize the
nipple valve to the reservoir
45

A buttonhole of skin is removed from the
depth of the umbilical funnel and the ileal
terminus is directed through this buttonhole
A fourth row of staples is taken
inferiorly, securing the inner leaf of
the intussusception to the ileal wall.
46

• Most reliable.
• Involves 20 – 35 cm colon and 10cm terminal ileum.
• Appendix removed.
• 30cm ascending colon detubularised.
• Cephalic end folded caudally and sutured to
antimesentric border.
47

10 cm of terminal ileum tapered over 12fr catheter.
Ileocecal plication narrow the valve.
Lembert sutures in terminal ileum to create continence.
Excess ileum tapered.
48

Similar to Indiana pouch except appendix used based on Mitrofanoff
principle as a continence mechanism .
The appendix is left attached to the cecum and buried in to the adjacent cecal taenia by
rolling it back on to itself
49

The entire ascending colon and the right third
or half of the transverse colon is isolated along
with 10 to 12 cm of ileum
Upper extremity of the large bowel is
mobilized laterally in the fashion of an
inverted U. The medial limbs of the
U are sutured after the bowel is
spatulated.
The bowel plate is then closed side to side.
50

Clinical episodes of Pyelonephritis
Prevented by effective antireflux mechanism
Antibiotic treatment instituted.
Recurrent episodes evaluated with radiography
Failure of the antireflux mechanism or
Upper tract stone formation.
“Pouchitis” -- Pain in the region of the pouch along with
increased pouch contractility.
Temporary failure of the continence mechanism
Sudden explosive discharge of urine through the
continence mechanism (rather than dribbling incontinence)
Longer periods of antibiotic therapy 51

Infrequent ; Most commonly seen with nipple valve.
Immediate catheterization and drainage by experienced personnel
Coudé tipped catheter
Rarely, flexible cystoscope
Catheter left indwelling for 3 to 5 days to allow the edema
and trauma to the catheterization portal to resolve.
Before discharge, patient should be observed to successfully
self-catheterize on multiple occasions.
52

More common in the neurologic patient -- Sensation of pouch
fullness may be less distinct
Associated with mild abdominal trauma
Immediate pouch decompression and radiographic pouch studies.
Large defects  Surgical exploration and pouch repair
Amount of urinary extravasation is small,
No evidence of peritonitis  Catheter drainage and antibiotic
administration
53

54

• No disease at prostate apex / bladder neck
• Adequate bowel segment available
• Adequate urinary rhabdosphincter in situ
• Adequate renal function
• No compromise to cancer control
55

• Willing and able, Highly motivated
• Able to self catheterize prior to surgery
• Good renal function
Serum creatinine level of less than 1.7 to 2.2 mg/dL
(150 to 200 μmol/L) or
Creatinine clearance of greater than 35 to 40 mL/min
56

• Age (elderly patients) – absent manual dexterity
• Mental impairment
• Severe and complex Urethral stricture disease
• Neurogenic bladder
• External sphincter dysfunction
• High-dose preoperative radiation therapy
57

 Adequate external sphincter function to maintain
continence.
 Reservoir must be sufficiently compliant to
maintain a low pressure throughout the filling
phase.
Bowel segment detubularized and reconstructed in to a spherical
shape.
 Ultimate storage volume - at least 400 to 500 mL at
low pressure.
58

Type Cms Configuration Volume
Pressure
Camey II 60-70 U single fold 500 < 40
Kock 60 U double fold 700 < 40
Hautmann 60-80 W 500-700 25-30
Studer 60 U double fold 400-600 15-20
T Pouch 40-50 V
59

Type Cm Config. Volume
Pressure
Mainz 20/30+10/15 W 500-700 15-17
Le Bag 20+20 U
Reddy 35 U 500-600 13-31
Sigmoid
60

Common Orthotopic Diversions
Large capacity, spherical configuration with “W”
of ileum
Ileal with long afferent limb
Intussuscepted afferent limb
61

A 70-cm portion of terminal
ileum is selected
The ileum is arranged in to an M or W
configuration with the four limbs
sutured to one another.
Buttonhole of ileum is removed on
an antimesenteric portion of the
ileum, and the urethroenteric
anastomosis is performed.
62

An ileal segment of approximately 55 cm length is
isolated about 25 cm from the ileocecalvalve.
63

The distal 44 cm of the ileal segment are
opened
along the antimesenteric border.
64

End-to-side anastomosis of the ureters to the
unopened part of the tubular segment. 65

Oversewing of the two distal antimesenteric borders of the
opened ileum to create neobladder 66

61 cm of terminal ileum is isolated.
Two 22-cm segments are placed
in a U configuration and
opened adjacent to the mesentery.
Posterior wall of the reservoir formed
by joining the medial portions of
the U with a continuous running
suture.
67

A 5- to 7-cm antireflux valve is made by
intussuscepting 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. 68

The valve is then fixed to the back
wall from outside the reservoir
with additional surgical staples.
Reservoir is completed by folding
the ileum on itself and closing.
Dependent end of the suture line left
open for the urethral anastomosis.69

An isolated 10 to 15 cm of cecum in
continuity with 20 to 30 cm of
ileum is isolated.
The entire bowel segment is opened along
the antimesenteric border.
An appendectomy is performed.
70

Posterior plate of the reservoir is
constructed by joining the opposing
three limbs together with a
continuous running suture.
An antireflux implantation of the ureters
through a submucosal tunnel is performed
and stented.
71

A buttonhole incision in the dependent
portion of the cecum made to provide
for urethral anastomosis.
The reservoir is closed side to side with
a cystostomy tube and the stents exiting.
72

Ureteral Catheters
Suprapubic Catheter
Foley Urethral Catheter 73

74

• Overall complications are similar to those
related to ileal conduit
• Complications are comparable for different
types of neobladders
• Ventral incisional hernia, Neobladder
fistulas are the specific complications
75

Orthotopic neobladder relies on the rhabdosphincter for
continence
Most patients are continent and able to void to completion
without the need for intermittent catheterization.
is common  20%
to 50% continue to improve beyond 12 months from
surgery.
Factors influencing continence rates --
Age, Intestinal segment
used,
Application of a nerve sparing technique.
Evaluation and management should be delayed until the 76

Physical therapy with biofeedback focused on the pelvic
floor muscles
Male
Transurethral Bulking agents
Artificial Urinary Sphincter
Female
Bulking agents
Pubo vaginal slings
77

• Failure to empty or urinary retention reported in
4% to 25%
• Risk factors
Use of excessive intestinal length (> 60 cm of
ileum),
Following prostate / nerve-sparing surgical
procedures
Abdominal wall or incisional hernias
postoperatively.
• Urinary retention is best managed by intermittent self-
78

• A unique voiding dysfunction in women
undergoing orthotopic reconstruction is
• Videourodynamics showed that retention
appeared to be mechanical in nature due to the
Pouch's falling back in the wide pelvic cavity,
resulting in acute angulation of the posterior
pouch–urethral junction
79

Mostly struvite stones
Causes: Chronic Bacteriuria,
Urinary stasis,
Mucous ,
Metabolic
abnormalities,
Staples / sutures.
Prevention:
Treatment of symptomatic
infection, Irrigation
80

1-8%
 Uninhibited pouch contractions
 Tx: Anticholinergics
Tx: Augmentation
Rare but potentially fatal
Risk increased with previous radiation therapy
81

Reported incidence in larger series is 5% to 10%,
Risk Factors : Portion of the anterior vaginal wall excised
Irradiated patients
PREVENTION :
Careful watertight closure of the vaginal cuff
Placement of an omental flap between the vagina and neobladder
Evaluated with a lateral cystogram before removal of the catheter.
Repair may be attempted transvaginally, ; Success rate varies
Transabdominal exploration or even conversion to a cutanous
form of diversion.
82

Every 4 Months First Year, Then
Every 6 Months up to 3 Years, Then
Annually
Physical examination including pelvic/rectal examination
Blood chemistries and Complete blood count
Annual Visits Only
Voided urine Cytology
Urethral wash (if carcinoma in situ on pathology)
Vitamin B12 level
Prostate-specific antigen (if prostate cancer on pathology)
83

> pT2 or N+:
CECT abdomen and pelvis and chest radiograph
each visit
≤ pT2:
CECT or intravenous urography and chest radiograph
at 4 and 12 months, then
annually up to 5 years, then
every 2 years thereafter
84

85

Bladder carcinoma- surgery- substitution

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