This document discusses various urinary diversion procedures including continent pouches and orthotopic neobladders. It describes different types of pouches such as the Indiana pouch, Florida pouch, Penn pouch, Kock pouch, and T-pouch which are created using segments of the ileum, cecum or colon. The document outlines techniques for creating antirefluxing conduits and continent diversion mechanisms such as the use of an appendiceal tunnel or imbricated ileocecal valve. It also discusses postoperative care and complications of these urinary diversion procedures.

1. URINARY DIVERSION PROCEDURES -
CONTINENT POUCHES AND NEOBLADDER
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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. 1. Orthotopic
- Orthotopic neobladder
2. Heterotopic
a. Continent – cutaneous
b. Non continent – Ileal, jejunal, colonic conduit and cutaneous
ureterostomy
3. Diversion to GIT
- Ureterosigmoidostomy / rectal bladder
GENERAL OUTLINE - URINARY DIVERSION
3
Dept
of
Urology,
GRH
and
KMC,
Chennai.

4. Heterotopic continent diversion
A. Right colonic pouches
1.Indiana pouch 2. florida pouch
3. Penn pouch
B. Ileal pouches
1. kock 2.Mainz
4
Dept
of
Urology,
GRH
and
KMC,
Chennai.

5. Orthotopic neobladder
1. Studder
2. Hartmann
3. Mainz
5
Dept
of
Urology,
GRH
and
KMC,
Chennai.

6. URINARY DIVERSION BY POUCH
Fundamental principle
 Creation of low pressure reservoir -
Detubularise, cross folding into spherical shape
 Protect renal function
 Allows volitional voiding
 Socially acceptable continence 6
Dept
of
Urology,
GRH
and
KMC,
Chennai.

7. MAINTENANCE OF INTRINSIC CONTINENCE MECHANISM
 Central to successful outcome
 Meticulous dissection at apex during cystoprostatectomy
 Nerve sparing – sexual function and continence
 Maintain maximum functional urethral length
7
Dept
of
Urology,
GRH
and
KMC,
Chennai.

8. REFLUXING VS ANTIREFLUXING
 Ureter – colon : Antirefluxing
 Ureter to continent pouch / neobladder : refluxing
 Technically simpler
 No significant rate of renal deterioration
 Less chance of anastomotic stricture
8
Dept
of
Urology,
GRH
and
KMC,
Chennai.

9. PATIENT SELECTION
 Willing to follow a prescribed voiding time regimen
 Ability to generate adequate valsalva pressure to empty
 Ability to perform CSIC
 Normal renal function
9
Dept
of
Urology,
GRH
and
KMC,
Chennai.

10. CONTRAINDICATIONS
 Severe neurological illness
 Psychiatric patients
 IBD
 Ca involving Prostatic urethra, urethral stricture
 Abnormal RFT , Cr >2mg% & GFR<35ml/min
 Additional solute absorption - Dyselectrolytemia
 Additional water absorption
 Hyperammonia – liver dysfunction
10
Dept
of
Urology,
GRH
and
KMC,
Chennai.

11. Continent catheterizing pouches
Two favourable site for stoma
1. Umbilicus – Aged , Move in wheel chair
2. Lower abdominal quadrant – at rectus muscle bulge –
ambulant
11
Dept
of
Urology,
GRH
and
KMC,
Chennai.

12. General techniques - to create dependable, catheterizable continence zone
A. For right colon pouches – Appendiceal stump
- appendiceal tunneling procedures are the simplest
- in situ or transposed appendix is tunneled into the cecal taenia
Unfavourable situation
1. Appendix may be unavailable - prior appendectomy , construction of a similar tube fashioned
from ileum (Woodhouse and MacNeily) or from the wall of the right colon (Lampel)
2. Appendiceal stump may be too short to reach the anterior abdominal wall or umbilicus
 continence mechanism remains a very this attractive and reliable continence mechanism 12
Dept
of
Urology,
GRH
and
KMC,
Chennai.

13. 13
Dept
of
Urology,
GRH
and
KMC,
Chennai.

14. B. Tapered and/or imbricated terminal ileum and ileocecal valve
continence mechanism
- used in right colon pouches
- imbrication or plication of the ileocecal valve region along with tapering of
the more proximal ileum in the fashion of a neourethra
- afford a reliable continence mechanism
14
Dept
of
Urology,
GRH
and
KMC,
Chennai.

15. 15
Dept
of
Urology,
GRH
and
KMC,
Chennai.

16. C. Intussuscepted nipple valve or the flap valve continence
mechanism - which avoids the need for intussusception.
- creation of nipple valves - most technologically demanding
- highest complication and reoperation rate
- significant learning curve
- potential for stone formation on exposed staples / increased risk
for reservoir stone formation 16
Dept
of
Urology,
GRH
and
KMC,
Chennai.

17. 17
Dept
of
Urology,
GRH
and
KMC,
Chennai.

18. 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.
18
Dept
of
Urology,
GRH
and
KMC,
Chennai.

19. POUCHES
19
Dept
of
Urology,
GRH
and
KMC,
Chennai.

20. portion of intact terminal ileum freed
from mesentery for 6-8cm is
intussuscepted
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.
20
Dept
of
Urology,
GRH
and
KMC,
Chennai.

21. ILEUM 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
21
Dept
of
Urology,
GRH
and
KMC,
Chennai.

22. A buttonhole of skin is removed from
the depth of the umbilicus 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.
22
Dept
of
Urology,
GRH
and
KMC,
Chennai.

23.  Most reliable.
 concept of using the buttressed ileocecal valve as a dependable
continence mechanism that can withstand the trauma of
intermittent catheterization was first reported by Rowland and
colleagues (1987) from Indiana University
 Ureters anastomosed with pouch and terminal ileum as
neourethra
23
Dept
of
Urology,
GRH
and
KMC,
Chennai.

24. A segment of terminal ileum approximately 10 cm in length along with the entire right colon is
isolated. B, Appendectomy is performed and the appendiceal fat pad obscuring the inferior margin of
the ileocecal junction is removed by cautery. C, The entire right colon is opened along its
antimesenteric border
24
Dept
of
Urology,
GRH
and
KMC,
Chennai.

25. D, Interrupted Lembert sutures are taken over a short distance (3 to 4 cm) in two rows for the double
imbrication of the ileocecal valve E, Application of apposing Lembert sutures on each side of the terminal
ileum. F, Excess ileum can be tapered by stapling technique
25
Dept
of
Urology,
GRH
and
KMC,
Chennai.

26. 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
26
Dept
of
Urology,
GRH
and
KMC,
Chennai.

27. 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. 27
Dept
of
Urology,
GRH
and
KMC,
Chennai.

28. ILEAL POUCH - KOCK
28
Dept
of
Urology,
GRH
and
KMC,
Chennai.

29. ILEAL POUCH – KOCK
 A , 15-cm segment of terminal ileum is isolated and opened along its
antimesenteric wall.
 The proximal 10 cm will serve as the continent intussusception, and the
distal 5 to 10 cm as the patch. The size of the patch will vary according to
the size of the excised segment.
 B, An Allis or Babcock clamp is advanced into the ileal terminus; the full
thickness of the intussuscipiens is grasped, and it is prolapsed into the
pouch.
 C, Three rows of 4.8-mm staples are applied to the intussuscepted nipple
valve using the TA-55 stapler.
29
Dept
of
Urology,
GRH
and
KMC,
Chennai.

30. 30
Dept
of
Urology,
GRH
and
KMC,
Chennai.

31.  D, A small buttonhole is made in the back wall of the ileal plate to allow the
anvil of the TA-55 stapler to be passed through and advanced into the nipple
valve. The figure shows two valve mechanisms
 A 2.5-cm wide strip of absorbable mesh is placed through additional
windows of Deaver at the base of each nipple valve. The mesh strips are
fashioned into collars.
 G, The collars are sewn to the base of the pouch as well as to the ileal
terminus with seromuscular sutures.
31
Dept
of
Urology,
GRH
and
KMC,
Chennai.

32. T POUCH ILEAL NEOBLADDER
 Kock pouch + serous-lined ileal trough instead of intussuscepted nipple
valve
 less ileum required
 no nipple valve so less complications & no staples so less stones
 preserves blood supply so less ischemic stenosis of valve
 can overcome short ureters by harvesting longer afferent ileal limb
32
Dept
of
Urology,
GRH
and
KMC,
Chennai.

33. 33
Dept
of
Urology,
GRH
and
KMC,
Chennai.

34.  A, A 70-cm segment of terminal ileum is isolated 15 to 20 cm from the ileal cecal
valve.
 B, A proximal 10-cm segment is isolated and rotated toward what will become the
reservoir in an isoperistaltic direction. The distal 12 to 15 cm is rotated toward the
reservoir in an antiperistaltic direction.
 C, The windows of Deaver are opened to allow the walls of the W reservoir to be
apposed behind the valve mechanisms. Penrose drains are passed to guide suture
passage.
 D, Horizontal mattress sutures of 3-0 silk are passed through each window. The
distal continence mechanism is longer than the proximal antireflux mechanism.
34
Dept
of
Urology,
GRH
and
KMC,
Chennai.

35.  E, The proximal and distal mechanisms are tapered with a metal gastrointestinal anastomosis stapler.
 F, The bowel is incised along its antimesenteric border where it will overlie the two Ts.
 Distal to the Ts, the bowel is incised close to the approximated limbs of the reservoir 35
Dept
of
Urology,
GRH
and
KMC,
Chennai.

36.  G, The ostia of the valves are secured to
the bowel wall with interrupted
absorbable sutures. The two flaps of
ileum are closed over the Ts with
running absorbable sutures.
 H, The back wall of the reservoir is
closed with running absorbable sutures.
 I, The lateral walls are folded medially
and the construction is completed with
running absorbable sutures.
36
Dept
of
Urology,
GRH
and
KMC,
Chennai.

37. POST OP
 intraoperative testing for pouch integrity and continence
mechanism – to be tested
 The pouch is filled with saline, the continence mechanism catheter
is removed, and the pouch is compressed lightly to look for points
of leakage
 To test the continence mechanism for its ability to contain urine
 to ensure ease of catheter passage. 37
Dept
of
Urology,
GRH
and
KMC,
Chennai.

38.  Postoperatively, larger-bore catheter used for drainage of the pouch should be irrigated at
frequent intervals to prevent mucous obstruction
 performed at 4-hour intervals by simple irrigation with 45 to 50 mL of saline
 On 7th POD - contrast study to be performed to ensure pouch integrity. If no leaks are
noted, ureteral stents can be removed
 suction drain is removed
 The patient is taught to irrigate the tube traversing the continence mechanism at 4-hour
intervals and whenever any episode of intra-abdominal pressure or discomfort is
experienced.
 Once these procedures have been mastered and the patient is tolerating a regular diet, the
patient can be discharged 38
Dept
of
Urology,
GRH
and
KMC,
Chennai.

39. COMPLICATIONS
 2/3 of patients
experience at least
one complication
within the first 90
days after surgery
39
Dept
of
Urology,
GRH
and
KMC,
Chennai.

40. complications
Pyelonephritis
 Prevented by effective antireflux mechanism
 Antibiotic treatment instituted
 Recurrent episodes evaluated with radiography
 Failure of the antireflux mechanism or upper tract stone
formation 40
Dept
of
Urology,
GRH
and
KMC,
Chennai.

41. 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)
41
Dept
of
Urology,
GRH
and
KMC,
Chennai.

42. Urinary retention
 Infrequent ; Most commonly seen with nipple valve.
 Immediate catheterization and drainage by experienced personnel -
Coudé tipped catheter and 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
42
Dept
of
Urology,
GRH
and
KMC,
Chennai.

43. Intraperitoneal Rupture of catheterizable pouches
•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 enough
43
Dept
of
Urology,
GRH
and
KMC,
Chennai.

44. PATIENTS QUESTION
 What kind of catheter do I use?
For nipple valves, a straight-ended 22- to 24-Fr tube; for ileocecal plication, a 20- to 22-Fr
coudétipped catheter; and for appendiceal sphincters, a 14- to 16-Fr coudé-tipped
catheter
 How do I carry my catheter?
In a zipper-locked bag that can be placed in a women’s purse or a man’s coat pocket
 How do I clean the stoma before catheterizing in a public facility?
With a topical antiseptic wipe (e.g., with benzalkonium chloride)
44
Dept
of
Urology,
GRH
and
KMC,
Chennai.

45.  How do I lubricate the catheter?
water-soluble lubricant and inserting the tip of the catheter into the pack
 What do I do with the stoma after catheterizing?
Cover it with a bandage
 How do I clean my catheter after draining my pouch?
By rinsing with ordinary tap water through the inside channel and over the
outside surface before replacing the catheter in bag 45
Dept
of
Urology,
GRH
and
KMC,
Chennai.

46. 46
Dept
of
Urology,
GRH
and
KMC,
Chennai.

47. • No disease at prostate apex / bladder neck
• Adequate bowel segment available
• Adequate urinary rhabdosphincter in situ
• Adequate renal function
• No compromise to cancer control
47
Dept
of
Urology,
GRH
and
KMC,
Chennai.

48.  Age (elderly patients) – absent manual dexterity
 Mental impairment
 Severe and complex Urethral stricture disease
 Neurogenic bladder
 External sphincter dysfunction
 High-dose preoperative radiation therapy 48
Dept
of
Urology,
GRH
and
KMC,
Chennai.

49. ▪ 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.
49
Dept
of
Urology,
GRH
and
KMC,
Chennai.

50. 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 50
Dept
of
Urology,
GRH
and
KMC,
Chennai.

51. COMMON ORTHOTOPIC DIVERSIONS
Large capacity, spherical configuration with “W”of ileum
Ileal with long afferent limb
Intussuscepted afferent limb
51
Dept
of
Urology,
GRH
and
KMC,
Chennai.

52. 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.
52
Dept
of
Urology,
GRH
and
KMC,
Chennai.

53. An ileal segment of approximately 55 cm length is
isolated about 25 cm from the ileocecalvalve.
53
Dept
of
Urology,
GRH
and
KMC,
Chennai.

54. THE DISTAL 44 CM OF THE ILEAL SEGMENT ARE OPENED
ALONG THE ANTIMESENTERIC BORDER. 54
Dept
of
Urology,
GRH
and
KMC,
Chennai.

55. End-to-side anastomosis of the ureters to the
unopened part of the tubular segment.
55
Dept
of
Urology,
GRH
and
KMC,
Chennai.

56. OVERSEWING OF THE TWO DISTAL ANTIMESENTERIC BORDERS OF THE
OPENED ILEUM TO CREATE NEOBLADDER
56
Dept
of
Urology,
GRH
and
KMC,
Chennai.

57. 61 cm of terminal ileum is
isolated. Two 22-cm segments
are placed in a U
configuration and opened
Posterior wall of the reservoir
formed by joining the medial
portions of the U with a
continuous running suture.
57
Dept
of
Urology,
GRH
and
KMC,
Chennai.

58. 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.
58
Dept
of
Urology,
GRH
and
KMC,
Chennai.

59. The valve is then fixed to the
back wall from outside the
reservoir with additional surgical
Reservoir is completed by
folding the ileum on itself and
closing.
Dependent end of the suture line
59
Dept
of
Urology,
GRH
and
KMC,
Chennai.

60. 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.
60
Dept
of
Urology,
GRH
and
KMC,
Chennai.

61. Posterior plate of the reservoir
is constructed by joining the
opposing limbs together with a
An antireflux implantation of the
ureters through a submucosal tunnel is
performed and stented.
61
Dept
of
Urology,
GRH
and
KMC,
Chennai.

62. A buttonhole incision in the
dependent portion of the cecum
made to provide for urethral
The reservoir is closed side to side
with
a cystostomy tube and the stents
62
Dept
of
Urology,
GRH
and
KMC,
Chennai.

63. Ureteral Catheters
Suprapubic Catheter
Foley Urethral Catheter
63
Dept
of
Urology,
GRH
and
KMC,
Chennai.

64. • Overall complications are similar to those related to ileal
conduit
• Ventral incisional hernia, Neobladder fistulas are the specific
complications
64
Dept
of
Urology,
GRH
and
KMC,
Chennai.

65. •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 neobladder achieve
maximal capacity ( about 6 months)
65
Dept
of
Urology,
GRH
and
KMC,
Chennai.

66. •Physical therapy with biofeedback focused on the pelvic
floor muscles
Male
•Transurethral Bulking agents
•Artificial Urinary Sphincter
Female
•Bulking agents
•Pubo vaginal slings 66
Dept
of
Urology,
GRH
and
KMC,
Chennai.

67.  Failure to empty or urinary retention reported in 4% to
25%
 Risk factors
Use of excessive intestinal length (> 60 cm of ileum),
Abdominal wall or incisional hernias postoperatively.
 Urinary retention is best managed by intermittent self-
catheterization 67
Dept
of
Urology,
GRH
and
KMC,
Chennai.

68. Mostly struvite stones
Causes: Chronic Bacteriuria,
Urinary stasis, Mucous ,
Metabolic abnormalities,
Staples / sutures.
Prevention:
Treatment of symptomatic infection,
Irrigation
Treatment: Percutaneous vs Open
Extraction
68
Dept
of
Urology,
GRH
and
KMC,
Chennai.

69. Pouch Leakage : 1-8%
▪ Uninhibited pouch contractions
▪ Tx: Anticholinergics
Poorly compliant reservoir
Tx: Augmentation
Spontaneous Perforation of reservoir:
Rare but potentially fatal
Risk increased with previous radiation therapy
69
Dept
of
Urology,
GRH
and
KMC,
Chennai.

70. 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) 70
Dept
of
Urology,
GRH
and
KMC,
Chennai.

71. THANK YOU
71
Dept
of
Urology,
GRH
and
KMC,
Chennai.