Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
This is a detailed Presentation of the surgical procedure - Left Hemicolectomy. It deals with the Surgical anatomy, Indications, Surgical Steps, Complications of the Procedure
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Bladder injuries may result from blunt,Penetrating and Iatrogenic trauma.
Full bladder is more susceptible to injury than empty bladder.
Management varies from conservative to surgical aiming to directly repair the injury.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. HISTORY OF ORTHOTOPIC URINARY DIVERSION
• Since the early 1900s
• Ureterosigmoidostomy is the oldest form of urinary diversion.
• 1st reported urinary diversion into a segment of bowel Simon in 1852.
• A number of technical modifications of the ureterosigmoidostomy ensued,
particularly related to the ureteral implantation technique (Hinman and
Weyrauch, 1936).
• (Leadbetter, 1951; Goodwin et al, 1953). introduction of an antireflux
tunneled anastomosis of the ureter into the sigmoid colon
• rates of obstruction and
• ascending pyelonephritis in patients with ureterosigmoidostomy
3. • Ureterosigmoidostomy remained the diversion of choice until the
late 1950s,
• but long-term electrolyte imbalance,
• upper tract obstruction and infection, and
• secondary malignant neoplasms arising at the ureteral implantation site were
observed
• In 1950 Bricker refined and popularized ileal conduit form of
urinary diversion,
• building on an original description by Zaayer in 1911 (Zaayer, 1911; Bricker,
1950).
4. • The ileal conduit is a technically simple, reliable form of urinary
diversion that became widely accepted and became the gold standard
to which other types of urinary diversion were compared until the
1980s.
• It continues to be by far the most common form of urinary diversion
performed throughout the world today for patients undergoing
cystectomy.
• Long-term complications with the [1970s].
• hyperchloremic metabolic acidosis and
• pyelonephritis were substantially less common than in patients with
ureterosigmoidostomy,
5.
6. PATIENT SELECTION
• all patients who undergo radical cystectomy may be considered at
least potential candidates for orthotopic urinary diversion.
• Factors can be divided into cancer-related factors and patient factors.
7. Oncologic Factors
Risk of Urethral Recurrence in Men
• Primary oncologic contraindication for orthotopic diversion is the
presence of urothelial carcinoma at the urethral margin on
intraoperative frozen section at the time of cystectomy.
• It has been a practice to counsel patients with documented
• prostatic mucosal,
• ductal, or
• stromal invasion about the increased risk of urethral recurrence if the urethra
is left in situ,
• weigh that risk against any perceived advantage of an orthotopic
diversion.
8. Risk of Urethral Recurrence in Women:
• Risk factors for urethral involvement included
• increased grade,
• stage, and
• lymph node involvement, but the presence of CIS did not predict urethral
involvement.
• Vaginal wall involvement was also a major risk factor for urethral
involvement.
• The urethra can be safely preserved in selected female cystectomy patients
provided that neither preoperative biopsy specimens of the bladder neck
nor intraoperative frozen section specimens of the proximal urethra
demonstrate any tumor or atypia.
9. • However, approximately half of patients with bladder neck tumors
had a normal (tumor-free) proximal urethra.
• In all cases, intraoperative frozen-section analysis of the proximal
urethra correlated with and was correctly confirmed by final
permanent section.
• These results suggest that one may depend on the intraoperative
frozen section to determine the feasibility of orthotopic diversion.
10. Locally Advanced Tumor Stage
• Many urologists are hesitant to perform continent orthotopic
diversion in patients with locally extensive disease. This is based on
two factors:
(1) concern about the possible impact of local recurrence on the neobladder
itself and
(2) a belief that these patients are doomed to suffer distant recurrence and
have a shortened life expectancy and will not benefit from the neobladder.
• If local tumor recurrence does develop in patients with an orthotopic
diversion, only a minority will develop problems related to the urinary
diversion itself.
11. • most patients could anticipate normal neobladder function even in
the presence of locally recurrent disease.
12. • The low risk of local recurrence showed that in this cohort of patients
the oncologic efficacy of the operation was not compromised include
the
• patient’s general health and social circumstances,
• baseline renal function,
• presence of a healthy urethra and functioning sphincter muscle,
• manual dexterity, and
• previous treatments including pelvic radiation,
• prostate surgery, or
• bowel resection.
13. Patient-Related Factors
• Age
• The clear consensus is that chronologic age alone is not a contraindication
for continent diversion and that options should be considered for each
patient on the basis of other factors
• Renal Function
• One of the most important contraindications for continent neobladder
reconstruction is compromised renal function.
• In patients with compromised renal function, hyperchloremic metabolic
acidosis can develop along with worsening dehydration, uremia, nausea,
and bone loss.
• Serum creatinine level of < 1.7 to 2.2 mg/ dL (150 to 200 μmol/L) or an
estimated CC of greater than 35 to 40 mL/min is recommended for
patients considering continent diversion
14. Body Habitus
• Obesity is not a contraindication
• Placing the urethral sutures and working with the thick bowel
mesentery may be challenging.
• An obese patient may be better served with orthotopic diversion
because of the difficulty constructing a functional conduit stoma
with a very thick abdominal wall.
15. • Manual Dexterity and Willingness to Do Self-Catheterization
• Urethral Stricture Disease or External Sphincter Damage
• Severe urethral stricture disease in men and women is a contraindication for
orthotopic diversion.
• Prior Pelvic Radiation
• Patients with prior radiation are at increased risk of several complications,
even with an ileal conduit diversion.
• Orthotopic lower urinary tract reconstruction can be performed after
definitive, full-dose pelvic irradiation.
• careful intraoperative tissue assessment and determination of the condition
of the urethra, ureters, and bowel must be performed to make a final
decision about the feasibility of orthotopic diversion
16. Prior Prostate Surgery or Bowel Resection
• Prior abdominal or pelvic surgery may also present challenges for the
surgeon performing orthotopic diversion. Patients who have had a
prior radical prostatectomy may have a particularly difficult dissection
around the proximal urethra at the prior vesicourethral anastomosis.
• Short bowel syndrome
17. SURGICAL TECHNIQUES FOR CONTINENCE
PRESERVATION DURING RADICAL CYSTECTOMY
• Anterior Apical Dissection in the Male Patient
• Attention to anatomic and surgical detail is important to optimize
functional and clinical outcomes in patients undergoing orthotopic
diversion. Minimal manipulation of the muscle fibers of the
rhabdosphincter, fascial attachments, and corresponding innervation is
essential to providing optimal urinary continence
• If a nerve-sparing approach is planned, the urethra may be divided after
the lateral pedicles are taken down to the bladder (anterior branches of
the internal iliac vessels) before the posterior dissection is performed. The
prostate is then dissected in a retrograde fashion off the rectum and
bilateral neurovascular bundles, and the posterior pedicles are divided last.
18. • Care should be taken to avoid deep suture bites into the complex or
levator muscles, which could injure the continence mechanism.
• Frozen-section analysis of the circumferential distal urethral mucosal
margin (prostatic apex) on the cystectomy specimen is performed to
exclude tumor involvement. If there is no evidence of tumor,
orthotopic reconstruction may be performed. If there is tumor at the
prostatic apex, the urethral stump can be excised or a total
urethrectomy may be performed at this time to obtain a negative
margin, and a cutaneous diversion constructed.
19. Preservation of the Urethra in the Female Patient
• A standard female cystectomy includes removal of the uterus, cervix,
and ovaries (anterior exenteration). However, in selected females
with clinically lower-stage disease, a number of authors have
advocated preservation of the uterus and ovaries.
• Whether the uterus is removed or not, whenever possible the
bladder is dissected completely off the anterior vaginal wall rather
than excising it. However, a deeply invasive tumor on the posterior
bladder or trigone may necessitate excision of a portion of the
anterior vaginal wall.
20. • A patient with a significant tumor at the bladder neck or with
palpable extension into the vaginal wall is a poor candidate for
neobladder and should undergo en bloc urethrectomy and
cutaneous diversion.
21. • Preparation of the female
urethra for an orthotopic
neobladder. The fatty tissue
overlying the anterior urethra is
swept off the endopelvic fascia
and the vesicourethral junction
is carefully identified by
positioning the Foley catheter
at the bladder neck. Note that
the endopelvic fascia and
periurethral tissue anteriorly
are not disturbed.
22. • Regardless of the form of vaginal
reconstruction, a well-vascularized
omental pedicle graft should be
placed between the reconstructed
vagina and the neobladder and
secured to the endopelvic fascia at
either side of the urethral stump to
separate the suture lines and
prevent fistula formation between
the vaginal and urethral
anastomosis, which may help
support the pouch posteriorly.
23. TECHNIQUES FOR ORTHOTOPIC
BLADDER SUBSTITUTION
• Choice of Bowel Segment
• excellent functional and clinical outcomes with voiding can be
achieved regardless of the segment of bowel chosen as long as the
principles of preservation of the rhabdosphincter as a continence
mechanism and construction of an adequate capacity, low-pressure
reservoir are maintained
• Reservoirs made of detubularized ileum or ileum and colon together
appear to have the greatest compliance and lowest likelihood of
generating intermittent high-pressure contractions.
24. • The primary disadvantage of using distal ileum lies in the potential
loss of absorption of vitamin B12.
• Isolation of the segment of bowel to be used for the diversion must
be performed carefully to preserve blood supply to the pouch, as well
as to the bowel anastomosis.
Need to Prevent Reflux:
• It is clear that any mechanism introduced to prevent reflux may also
potentially cause upper tract obstruction.
25. General Perioperative Management
• Ileal Reservoirs
• ileal reservoirs use from 60 to 75 cm of terminal ileum, which is
detubularized and folded in a variety of ways to attempt to create a
spheric shape.
• The use of nonabsorbable suture and metal staples should be
avoided because of the potential for stone formation.
• two most popular configurations around the world are the Hautmann
W-neobladder (and its various modifications) and the Studer pouch
neobladder.
26. Camey II
• The Camey II orthotopic substitute is a modification of the original
Camey bladder substitute, which was a simple segment of ileum
anastomosed to the ureters and urethra.
• The modification includes detubularization and folding to eliminate
peristaltic activity.
• A fingertip opening is made in the preselected area for the
ileourethral anastomosis, the entire ileal plate is brought down to the
pelvis, and the urethral anastomosis is performed.
27.
28.
29. Ileal Neobladder (Hautmann Pouch)
• This neobladder is an intentionally large-capacity, spheric (W
configuration) ileal reservoir that is constructed in an attempt to
optimize initial volume and potentially reduce nighttime
incontinence.
30.
31. Construction of the Studer neobladder
(modified).
• Designated segments of terminal
ileum for construction of the
orthotopic Studer pouch ileal
neobladder. Note that the distal
mesenteric division is made
between the ileocolic and terminal
branches of the superior
mesenteric artery, which extends
into the avascular plane of the
mesentery. In addition, a small
window of mesentery and a 5-cm
segment of proximal small bowel
are discarded to allow mobility to
the pouch and small bowel
anastomosis.
32. • The Studer pouch is constructed
from an isolated 44-cm ileal
segment (placed in an inverted U
configuration), which forms the
reservoir portion of the pouch,
and a proximal 15-cm segment of
ileum to form the afferent limb.
The two 22-cm ileal segments are
opened 2 cm adjacent to the
mesentery beginning at the apex
and carried upward to the ostium
of the afferent segment.
33. • The previously incised ileal
mucosa is then oversewn with
two layers of a running 3-0
polyglycolic acid suture starting
at the apex and running upward
to the afferent limb. The
reservoir is then closed by
folding it in half in the opposite
direction to which it was
opened.
34. • Construction of the antireflux
mechanism in the T pouch. The ileum is
divided between the proximal afferent
ileal segment and the 44-cm segment.
The dotted line depicts the incision line
on the U limbs. Mesenteric windows of
Deaver are opened between the vascular
arcades adjacent to the serosa.
Placement of small Penrose drains
through each mesenteric window helps
facilitate passage of sutures. The distal 3
to 4 cm of the afferent ileal segment is
anchored into a serosal-lined ileal trough
formed by the base of the two adjacent
22-cm ileal segments, using 3-0 silk
sutures.
35. • The previously anchored distal
3- to 4-cm afferent ileal
segment is tapered over a 30-Fr
catheter on the antimesenteric
border. The incision of the
bowel provides wide flaps of
ileum that covers the tapered
distal afferent ileal segment to
form the antireflux mechanism
in a flap-valve technique.
36. • A mucosa-to mucosa
anastomosis is performed
between the ostium of the
afferent segment and the edges
of the ileal flaps using
interrupted 3-0 polyglycolic acid
suture. The mucosal edges of
the ileal flaps are brought over
the tapered distal portion of the
afferent ileal segment and sewn
using a continuous 3-0
polyglycolic acid suture.
37. • Once the reservoir is folded in
half, the anterior wall is closed
with a two-layer 3-0 polyglycolic
acid suture that is watertight.
Note that the anterior suture line
is stopped just short of the
(patient) right side to allow
insertion of an index finger, which
will become the neobladder neck.
Conversely a new buttonhole can
be created at the most dependent
portion of the pouch.
38. • Each ureter is spatulated and a
standard bilateral end-to-side
ureteroileal anastomosis is
performed using interrupted 4-
0 polyglycolic acid suture.
39. • The reservoir is anastomosed to
the urethra using the previously
placed urethral sutures.
42. • late complications with the ileal conduit such as
• peristomal hernia
• stomal stenosis
• pyelonephritis
• kidney stones
• ureteral obstruction
• renal deterioration became more apparent with longer follow-up
43. • These clinical sequelae
• the high-pressure reflux of infected urine or
• obstruction of the upper urinary tract.
• It was postulated that the addition of an antireflux technique to a
conduit form of diversion could help diminish the problems of reflux
and renal deterioration in these patients.
• Unfortunately, with longer follow-up, similar complications with
nonrefluxing colon conduits were observed.
44. • One of the earliest continent cutaneous diversions in humans was described by
Gilchrist and colleagues in 1950.
• This form of urinary reconstruction incorporated a cecal reservoir with the
ileocecal valve as the continence mechanism and the distal ileum as a
catheterizable stoma.
• The concept of a continent cutaneous diversion was subsequently reintroduced
by Kock and colleagues in 1982 with a technique that was originally developed
for a continent ileostomy after colectomy for inflammatory bowel disease.
• It incorporated an intussuscepted nipple valve to maintain continence and avoid
reflux. In animal experiments and then in humans, Kock demonstrated the
importance of complete detubularization of the bowel segment and the
double-folding technique that creates the most spheric shape possible.
45. • After Kock described his results in his initial 12 patients, Skinner
began performing this diversion in adults undergoing cystectomy for
bladder cancer in 1982.
• Although this form of urinary diversion required catheterization of an
abdominal stoma, it eliminated the need for an external urostomy
appliance.
• The biggest challenge in the development of continent cutaneous
diversion has been the design of a reliable, durable, efferent
continence mechanism that is easily catheterizable.
46. Problems
• stones,
• difficulty in catheterizing,
• peristomal hernias, and
• the development of leakage are potential problems with all of them, often
necessitating open surgical revision
• Today, several different reliable techniques are available to create a
continent cutaneous urinary diversion, including the Indiana pouch and
various other forms of right colon pouches.
• These forms of diversion can potentially offer an advantage to patients
over an ileal conduit, but these operations remain technically challenging
and are not widely used.
47. Early and Late Complications
Both early and late complications may also be influenced by other
factors such as
- prior radiation therapy,
- diabetes, and
- other comorbidities.
- Late complications are also influenced by tumor recurrence and the
use of adjuvant or salvage systemic chemotherapy or radiation, and
these causes may be difficult to separate out from causes related to
the surgery.
48. • Late complications not
• directly related to the diversion include bowel obstruction, ventral
• hernia, thrombotic events, and cardiovascular problems common
• to patients in this age group.
49. • Ventral hernias are quite common and may be in part related to the
need for increased abdominal pressure to empty the neobladder. The
poor fascial strength associated with advanced age and smoking
undoubtedly contributes to this risk as well.
50. • primary late complications of orthotopic diversion that are directly
related to the diversion itself include
• incontinence,
• urinary tract infection,
• ureteroileal or afferent limb obstruction,
• urethral stricture,
• upper tract and pouch stones,
• vaginal fistula, and pouch rupture.
• Other than incontinence, these complications tend to be less common in
orthotopic diversion than in continent cutaneous diversion, and many if
not most can be managed by endoscopic procedures and rarely require
open surgical revision
51. • Pouch perforation is rare in continent diversion in general, especially
in orthotopic diversion because outlet resistance is usually low. The
risk may be increased in patients who have had previous radiation
therapy. It is a potentially life-threatening complication when it
occurs.
• The direct end-to-side Leadbetter or the combined Wallace
anastomoses with interrupted fine absorbable sutures have been
shown to have the lowest risk of stricture, approximately 3% to 6%.
Obstruction from an antireflux valve has been seen in both hemi-
Kock pouches and in the extraserosal tunneled afferent limb of the T
pouch
52. • CT scans will often be misinterpreted by radiologists or urologists
unfamiliar with the anatomy and/or the specific type of neobladder.
• Pouch stones were very commonly seen in the Kock neobladder
because of the use of surgical staples to maintain the intussuscepted
nipple valve, with the incidence increasing steadily with time. Stones
have been rare in the Studer and Hautmann neobladders, which are
made entirely with absorbable suture.
53. • Pouch-vaginal fistula is a unique complication of orthotopic
neobladder in women that can be quite difficult to repair.
• Prevention methods include
• leaving the vagina intact whenever it is safe from an oncologic standpoint,
• careful watertight closure of the vaginal cuff when it is opened, and
• placement of an omental flap between the vagina and neobladder, secured
to the perivaginal tissue on either side of the urethral anastomosis
54. Incontinence:
• The evaluation and management of urinary incontinence after
orthotopic diversion should be delayed until the neobladder has had
time to expand.
55. Follow up: NO CONSENSUS
• Early evaluation (first 4 months) to identify early ureteroileal anastomotic
strictures caused by technical difficulties or poorly vascularized distal
ureters.
• Middle period (4 months to 3 years) primarily focused on detecting cancer
recurrence. This is best managed with CT or other cross-sectional imaging,
which also allows evaluation of the upper tracts and reservoir for stones or
obstruction
• The frequency of the follow-up can be risk-adapted according to the
pathologic findings at the time of cystectomy and the risk of subsequent
recurrence.
• Long-term follow-up (beyond 3 years) to detect pouch stones, late upper
tract obstruction, and urothelial carcinoma arising in the urethra or upper
tracts.
56.
57. QUALITY OF LIFE AFTER
URINARY DIVERSION
• Most quality-of-life studies that have evaluated and compared
patients undergoing various forms of urinary diversion have been
criticized for methodologic problems that limit their conclusions.
• The current body of published literature is insufficient to conclude
that any form of urinary diversion is superior to another on the basis
of health-related quality of life outcomes.
innovative surgeons have sought the best method to replace the original bladder when it must be removed because of either benign or malignant disease.
The objective of bladder substitution is to allow volitional voiding through the urethra while eliminating the need for a cutaneous urinary stoma or intermittent catheterization.
He attempted a ureterosigmoidostomy in an exstrophy patient by bringing the ureters into the rectum with the use of needles and suture to create a fistula. Although the patient died of sepsis 12 months later, this marked the first reported attempt at some form of urinary diversion (Simon, 1852)
Over the following 100 years the evolution of urinary diversion was marked by a continued search for better methods and techniques to reconstruct the lower urinary tract.
In the male patient involvement of the prostatic urethra is associated with a higher risk of subsequent urethral recurrence.
Some evidence indicates that orthotopic diversion itself may provide some protection against urethral recurrence.
The ureteroileal anastomosis is then performed via a Le Duc technique. The reservoir is completed by folding the ileal plate and suturing with a running absorbable suture. The ends of the U are anchored to the pelvic floor to reduce tension (Fig. 99-4). A modification of the Camey II has been described by Barre and colleagues (1996). This places the ileum in a Z configuration and reportedly has the advantages of shorter length requirements, improved reservoir capacity, and potentially improved functional (continence) results (Barre et al, 1996).
Construction of the modified Camey II. A, The ileal loop is folded three times (Z shaped) and incised on the antimesenteric border. B, The reservoir is closed with a running
suture to approximate the incised ileum. C, The urethral anastomosis is performed, and the ureters are implanted using a Le Duc antireflux technique.
Construction of the Kock ileal reservoir. A, 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. The more proximal 17-cm segment of ileum will be used to make the afferent intussuscepted nipple valve. B, The posterior wall of the reservoir is then formed by joining the medial portions of the U with a continuous running suture. C, A 5- to 7-cm antireflux valve is made by removing the mesentery under that segment and then intussuscepting the afferent limb with the use of Allis forceps clamps. D, The afferent limb is fixed with two rows of staples placed within the leaves of the valve. E, The valve is then fixed to the back wall from outside the reservoir with additional surgical staples. F, After completion of the nipple valve, the reservoir is completed by folding the ileum on itself and closing it, leaving the most dependent end of the suture line open for the urethral anastomosis.
Construction of the Hautmann ileal neobladder. A, A 70-cm portion of terminal ileum is selected. The isolated segment of ileum is incised on the antimesenteric border. B, The ileum is arranged into an M or W configuration with the four limbs sutured to one another. C, After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethral anastomosis is performed. The ureteral anastomoses are performed using a Le Duc technique or direct implantation and are stented, and the reservoir is then closed
in a side-to-side manner. As an alternative, the two ends of the W may be left slightly longer as a short chimney on either side for implantation of the ureters.
A, B, C, D, E1,
Construction of the Mainz ileocolonic orthotopic reservoir.
A, An isolated 10 to 15 cm of cecum in continuity with 20 to
30 cm of ileum are isolated. B, The entire bowel segment is opened
along the antimesenteric border. An appendectomy is performed.
C, The posterior reservoir is closed by joining the opposing three
limbs together with a continuous running suture. D, An antireflux
implantation of the ureters through a submucosal tunnel is performed
and stented. E, A buttonhole incision in the dependent portion
of the cecum is made to provide for the urethral anastomosis. F, The
reservoir is closed side to side with a cystostomy tube and the stents
exiting.
Construction of Le Bag (ileocolonic) orthotopic reservoir. A, A total of 20 cm of
ascending cecum and colon, with a corresponding length of adjacent terminal ileum, is isolated.
The bowel is opened along the entire antimesenteric border, and the two incised segments are
then sewn to each other. This forms the posterior plate of the reservoir. B, This reservoir is
folded and rotated 180 degrees into the pelvis with the most proximal portion of the ileum (2 cm
nondetubularized) anastomosed to the urethra. C, Modification is performed with complete
detubularization of the bowel segment, which is then anastomosed to the urethra. (Copyright
Baylor College of Medicine.)
These concepts are the cornerstone of current cutaneous and orthotopic reservoirs.