Cutaneous Continent Urinary Diversion

GENERAL CONSIDERATIONS

Continent urinary diversion is widely accepted by both urologist and patient alike as an

acceptable form of urinary reconstruction after cystectomy. Orthotopic urethral anastomotic

procedures and continent catheterizable stomal reservoirs have stood the test of time, and

both procedures should always be considered for all appropriate patients. Orthotopic

continent diversion and the metabolic consequences of continent urinary diversion are

covered in separate chapters. In this chapter the focus is on the continent cutaneous diversion

surgeries associated with the highest success rates. Over the past 25 years the design of the

reservoir has not substantially changed. However, an evolution has occurred in the techniques

used to create antireflux and continence mechanisms in order to make them more effective

and reliable. In addition, attention is given to the long-term quality of life outcomes of

continent cutaneous reservoirs, as well as to the newer laparoscopic approaches used to create

such reservoirs.

Despite the considerable enthusiasm for continent urinary diversion operations, those

procedures requiring the use of external urinary collecting appliances remain more common.

Although continent urinary diversion is certainly appropriate in selected patients, the

procedures are technically more challenging and associated with higher short-term and long-

term complication rates than those that use external collecting devices. However, the

operating time associated with these more complex procedures has been significantly reduced

by the widespread use of absorbable and metal staples in the construction of the reservoirs

and limbs. These techniques are discussed in detail later. Also, as experience with continent

urinary diversion has grown, complication rates have decreased dramatically. As a result, in

some centers continent diversions are now more commonly employed than conduit

diversions.

Patient Selection

Because the ability to self-catheterize is essential to the patient undergoing continent

diversion, the patient must be assessed for the ability to care for himself or herself.

Consultation between an enterostomal therapist and the patient is extremely helpful in this

regard because the patient may be at greater ease with the therapist and more willing to

express any concerns. Certain patients may not be able to comprehend the strict flushing and

catheterization regimens that must be followed after continent urinary diversion or may lack

the motor skills to independently perform self-care. Patients with multiple sclerosis,

quadriplegic individuals, and frail or mentally impaired patients will at some point in their

lives require family or visiting nurses for basic care and are therefore viewed as poor

candidates for any form of continent diversion. Indeed, these patients may also require

assistance with external appliances, but the degree of time and expertise required is much less

burdensome on the care provider and the health care system. On the contrary, continent

catheterizable diversion requires continuous attention and may limit patient and family

options when determining long-term care needs.

Patient Preparation

All patients undergoing anticipated continent urinary diversion should be prepared for the

possibility that a traditional ileal conduit might be performed. Although it is rare to abandon a

continent diversion owing to unanticipated problems, this always remains a possibility.

Therefore before starting the operation, the site for an external stoma should be selected with

extreme care. In general, the location must be free from fat creases in both the standing and

sitting position and it should not be close to prior abdominal scars that may interfere with

proper adherence of an external appliance. Here, again, the aid of an enterostomal therapist is

helpful. In general, the stoma should be brought through the right (or left) lower quadrant of

the abdomen on a line extending from the umbilicus to the anterior superior iliac spine. The

stoma should be as far lateral from the midline as possible, but the site selected should ensure

that the bowel segment comprising the stoma traverses the rectus muscle. Failure to adhere to

this rule increases the risk of parastomal hernias. The selected site for the stoma should be

marked with an X scratched onto the anterior abdominal wall. Marking the stoma site with

ink should be avoided because it may be washed away during the antiseptic preparation of the

skin.

The surgeon undertaking continent urinary diversion should be familiar with more

than one type of continent diversion technique. Although it is uncommon to have to abandon

a given bowel segment for the reservoir, it is not uncommon to have to modify the antireflux

or continence mechanism. In these circumstances, it is essential that the surgeon be able to

select an alternate form of continent diversion from what was originally intended. Renal and

hepatic function must be reviewed carefully in the patient selected for continent diversion

(Mills and Studer, 1999). The reabsorption and recirculation of urinary constituents and other

metabolites require that liver function be normal and that serum creatinine levels be within

normal range, or certainly below the level of 1.8 mg/dL. In cases in which renal function is

borderline, creatinine clearance should be measured. A minimal level of 60 mL/min should

be documented before deeming the patient an appropriate candidate for continent diversion.

In patients with bilateral hydronephrosis in whom renal functional improvement might be

anticipated on relief of the ureteral obstruction, the upper urinary tract should first be

decompressed with either ureteral stenting or percutaneous nephrostomy(ies). Subsequent

reevaluation of renal function should be performed before undertaking a continent diversion.

Procedures that will require use of the colon should always be preceded by a colonoscopic

assessment of the entire large intestine. Performing only a sigmoidoscopy for a procedure that

will use only this segment of the large bowel is insufficient because disease proximal to the

resected segment may leave the patient with short colon syndrome. The preoperative

assessment of the colon is not necessary if continent urinary diversion using small intestine is

planned. Healthy patients undergoing radical cystectomy can be admitted to the hospital on

the day of surgery. A mechanical bowel preparation is administered after a liquid dinner on

the night before surgery. The patient is instructed to drink copious amounts of water, and at 8

PM and 10 PM the patient is administered oral metronidazole (500 mg). In addition, the

patient should receive cefoxitin (1 gm) intravenously 1 hour before the skin incision.

Cystectomy

All operations described require a midline incision, skirting the umbilicus to the side opposite

the selected stoma site. The incision for a right colon pouch usually extends from the pubis to

a point midway between the umbilicus and the xiphoid. The cranial extent of the incision is

governed by the hepatic flexure, which must be divided to obtain sufficient colonic length

and to allow for the right colon to easily fold on itself. On some occasions, the incision will

be extended to the xiphoid. The incision for procedures using only the ileum should extend to

just below the umbilicus. The cystectomy procedure is covered elsewhere in this text, and

only those points germane to continent diversion are covered here.

After abdominal exploration, the ureters are isolated, transected, and transposed to an

appropriate place for subsequent diversion. The right retroperitoneum is first opened over the

iliac artery to expose the right ureter. In the typical circumstance of conduit diversion, the

right ureter is transected below the common iliac artery. For all continent diversions, both

ureters are transected as low as possible and shortened to the appropriate length once the final

anatomy is determined. The sigmoid colon is freed from its lateral peritoneal attachments by

incising along the line of Toldt. A wide tunnel is created by blunt finger dissection ventral to

the aorta and common iliac arteries and caudal to the inferior mesenteric artery. This affords

left ureteral access to the previously exposed right retroperitoneum. In cases of uroepithelial

malignancy it is prudent to evaluate the margin status of the most distal portion of both

ureters using frozen section analysis. In situations where substantial ureteral length is

removed to obtain negative surgical margins, extension of the afferent limb mechanism may

be necessary to allow tension-free ureteral intestinal anastomoses. All sutures used in the

urinary tract should be absorbable. The individual surgeon’s preference will dictate the

caliber and type of suture material used. When carrying out bowel surgery for continent

urinary diversions, stapling is the preferred method for division of the bowel segment, as well

as for reconstruction of bowel continuity. This technique shortens operative times greatly and

affords safe and reliable bowel anastomosis. Suturing is not necessary with the exception of

placing two silk Lembert sutures at the apex of side-to-side stapled bowel anastomoses in

order to prevent tension on the staple line. To avoid stone formation on the stapled proximal

bowel segments, oversewing the stapled end of the conduit with absorbable material isolates

the metal staple line from urinary contact within the lumen. In constructing a nonappendiceal

continent urinary diversion stoma, a skin button matching the diameter of the structure to be

used in the diversion is resected. Cutaneous tissues are separated down to the level of the

anterior rectus fascia, where a circle of similar diameter is excised from this fascia or,

alternatively, the fascia is incised in a cruciate fashion. In carrying out this maneuver, it is

essential that the fascia and skin are properly aligned in order to avoid angulation. Rectus

muscle fibers are separated bluntly and an instrument passed through the posterior fascia and

peritoneum. For appendiceal stomas, we prefer to perform a Y-shaped cutaneous incision that

allows for a YV-type plasty incision between the appendiceal limb and the skin (Fig. 86–1).

This will decrease the likelihood of subsequent stomal stenosis. Alternatively, the appendix

lends itself to an umbilical stoma (Bissada, 1993; Gerharz et al, 1997). Favorable results with

this appendiceal YV plasty technique to the umbilical site have been reported (Bissada,

1998). It is standard procedure to use long, end-hole single J–type diverting stents in all

continent cutaneous urinary diversions. These stents drain urine externally, ensuring that

urine is safely diverted beyond any anastomotic site during the early healing period. They can

also be safely manipulated or exchanged if necessary. The end hole allows for the passage of

a straight wire through the stent, which decreases the likelihood of anastomotic trauma at the

time of stent removal. The authors advocate the use of closed suction drains in all cases of

urinary diversion. Soft silicone Jackson-Pratt closed suction drains are preferred because they

have less potential for tissue damage or migration into pouches. Abdominal closure is

performed according to the surgeon’s preference. In general a single-layer closure, using No.

2 nylon, Surgilene, or Prolene taken through all layers of fascia and muscle provides a rapid

and secure abdominal closure in the majority of patients. In obese patients, those with tissues

of poor quality, or nutritionally depleted patients, through-and-through stay sutures are also

used. Ureteral stents are always brought through separate abdominal stab wounds, sutured to

the anterior abdominal wall, and directed into separate drainage bags to monitor urine output.

Even at this early stage it is important to ensure adequate drainage of the reservoir in order to

prevent pouch rupture should the ureteral stents be displaced. In the case of limited pouch

access such as with an appendiceal stoma, a Malecot tube should be placed directly into the

reservoir and secured to the skin. The reservoir is sutured to the abdominal wall to prevent

urine leakage

into the peritoneal cavity when the tube is removed. This maneuver also helps to prevent

migration and angulation of the reservoir, which could result in incontinence or

catheterization difficulties.

Postoperative Care and Comments

Paralytic ileus is a common complication following urinary diversion procedures. Gastric

decompression should be maintained until extubation. This can be achieved in the majority of

patients by means of nasogastric intubation. However, certain patients may be managed best

by formal gastrostomy decompression inserted intraoperatively. These individuals include

those with multiple prior abdominal procedures in whom prolonged ileus is more likely. If

the patient is nutritionally depleted preoperatively, hyperalimentation has been suggested to

be of value if initiated during the preoperative interval (Hensle, 1983; Askanazi et al, 1985).

Ureteral stents are usually removed 1 week after surgery. Before any manipulation, a

urine sample from each stent should be sent for culture and sensitivity testing. Before stent

removal, radiographs of the pouch are obtained to ensure that the pouch is intact. Radiologic

contrast studies are performed to ensure against ureteral anastomotic leakage. Each stent is

injected with contrast agent in a search for extravasation; if none is seen, guidewires are

advanced to each kidney and the stents removed. If there is any question of extravasation,

stents can be advanced over the wires, positioned fluoroscopically, and left in situ for re-

evaluation after additional healing has taken place. Late malignancy has been reported in all

bowel segments exposed to the urinary stream, whether or not there is a commingling with

feces (Filmer and Spencer, 1990; Shokeir et al, 1995). A study by Gitlin and colleagues

(1999) suggests that the malignancy may develop from the urothelial component and not as a

result of urine affecting intestinal mucosa. As a result, urinary cytology should be performed

in all patients undergoing a continent urinary diversion whether or not the diversion was

performed secondary to a urothelial malignancy. When the ureters are directed into the fecal

stream, routine colonoscopy should also be performed. Latency periods have been reported as

short as 5 years, so all patients developing gross or microscopic hematuria should be fully

evaluated (Golomb et al, 1989). If an anastomotic transitional cell cancer is discovered, the

patient should be fully evaluated with upper tract imaging and ureteroscopy if possible.

Antegrade ureteropyeloscopy can be employed if necessary. For an isolated anastomotic

recurrence, distal ureterectomy and reimplantation may be appropriate. If

nephroureterectomy is necessary, some patients may require removal of their continent

diversion due to resulting renal insufficiency.

CONTINENT URINARY DIVERSION

Continent, nonorthotopic urinary diversion can be divided into two major categories. First,

the variations of ureterosigmoidostomy such as ileocecal sigmoidostomy, rectal bladder, and

the sigmoid hemi-Kock operation with proximal colonic intussusception are discussed. These

techniques allow for excretion of urine by means of evacuation. Second is the large category

of continent diversions requiring clean intermittent catheterization of the constructed pouch

for urine drainage at standard intervals.

The concept of refashioning bowel so that it serves as a urinary reservoir rather than a

conduit has become universally accepted. This concept is based on original pioneering

observations by Goodwin and colleagues in the development of the cystoplasty augmentation

procedure (Goodwin et al, 1958). The destruction of peristaltic integrity and refashioning of

bowel has led to the development of many innovative urinary reservoirs constructed from

bowel. Several antireflux procedures have evolved to avoid upper tract urinary damage by

sepsis or reflux, while other surgical techniques have been devised to achieve urinary

continence.

Because there are numerous variants of continent urinary diversion used worldwide, a

complete review of all operative techniques is beyond the scope of this or any chapter.

However, many of these procedures are simple modifications of parent operations. In this

chapter we describe in detail each parent operation, as well as major modifications. The fact

that there are many continent urinary diversion procedures described reveals an obvious

corresponding fact: the “best” continent diversion has yet to be devised. There is, to date, no

consensus that would indicate one continent cutaneous diversion is superior to another, but it

is becoming apparent that certain procedures are associated with lower early and late

complication rates. Points of controversy include which bowel segment is most appropriate

for fashioning into a urinary reservoir, the best techniques to use for achieving urinary

continence, and the best technique for prevention of urine reflux into the upper tracts. There

are now various continence mechanisms that appear reliable. In the authors’ experience,

procedures using a right colon reservoir with some form of appendiceal continence

mechanism are the fastest and easiest to perform.

It should be re-emphasized that all continent diversions will allow for substantial

reabsorption of urinary constituents that will place an increased workload on the kidneys

(Mills and Studer, 1999). No patient with substantial renal impairment should be considered

for any of these procedures. The long-term sequelae of continent urinary diversion are well

understood and, unfortunately, commonly involve significant renal damage. Although it has

been suggested that the absence of reflux into the upper urinary tracts in catheterizable

pouches may reduce the longterm impact of continent diversion procedures on renal function,

it should be cautioned that long-term 15-year data are now available and, in some instances,

antireflux procedures are associated with a higher risk of obstruction due to anastomotic

stricture (Kristjansson et al, 1995). In addition to increased stricture rates, it is not clear

whether antirefluxing mechanisms actually esult in improved preservation of the upper tracts

(Pantuck et al, 2000).

Multiple international studies have suggested an improved psychosocial adjustment of

patients undergoing continent urinary and fecal diversion compared with those patients with

diversions requiring collecting appliances (Gerber, 1980; McLeod and Fazio, 1984; Boyd et

al, 1987; Salter, 1992a, 1992b; Bjerre et al, 1995; Filipas et al, 1997; Hart et al, 1999;

McGuire et al, 2000). Although this is indeed true and is best exemplified by the individual

with a conduit who desires conversion to a continent procedure, it is also true that many

individuals seem to adjust well to wearing external appliances. The sense of body image is a

remarkably personal and subjective parameter that varies greatly from patient to patient. In

fact, the majority of patients are satisfied with their choice of urinary diversion, whether it is

continent or not. The process of patient counseling that we employ always refers to ileal

conduit diversion as the gold standard against which the newer, more complex operations

must be compared. The patient should be advised that continent diversion is, all other

considerations being equal, associated with a longer hospital stay, higher complication rates,

and greater potential for requiring reoperative surgery. However, it should be noted that an

extensive review from our institution has demonstrated no statistically significant difference

in reoperations, mortality, or hospital stay in patients undergoing continent diversion versus

conduit diversion by the same three surgeons over a 3-year period (Benson et al, 1992).

Analysis of the two patient groups, on the other hand, showed that, in general, those selected

for continent diversion were 12 years younger and four times less likely to have significant

concurrent illness. What this review suggests is that, with proper patient selection, continent

diversion operations can be safely conducted with results similar to those for conduit

diversion. To determine if continent diversion could be safely performed in selected elderly

patients, Navon and colleagues (1995) compared the clinical course of 25 patients older than

the age of 75 years undergoing a modified Indiana reservoir to a cohort of 25 randomly

selected patients younger than 75. The mean age of the first group was 78.5 years, and the

mean age of the second was 59.3 years. The complication rates between the two groups were

acceptably low and surprisingly similar. Navon and colleagues concluded that age alone

should not be a contraindication to continent diversion and that the Indiana reservoir can be

successfully performed in elderly patients.

Rectal Bladder Urinary Diversion

Various innovative surgical techniques have been advocated for separating the fecal and

urinary streams, while still employing the principles of ureterosigmoidostomy. These

operations can generally be discussed together as rectal bladder urinary diversions. In each of

these operations the ureters are transplanted into the rectal stump. The proximal sigmoid

colon is managed by terminal sigmoid colostomy or, more commonly, by bringing the

sigmoid to the perineum, thereby using the anal sphincter to achieve both bowel and urinary

control. Although these operations continue to be commonly performed, they have never

been well accepted in the United States. The principal reason is the potential for the

calamitous complication of combined urinary and fecal incontinence, presumably occurring

as a consequence of damage to the anal sphincter mechanism during the dissection processes

(Culp, 1984). If the urologist selects one of these procedures, the preoperative evaluation

should include all of the caveats of ureterosigmoidostomy. Dilated ureters are not acceptable.

Patients with extensive pelvic irradiation are not candidates, and neither are those with

existing renal insufficiency. Anal sphincteric tone must be judged competent before electing

these operations. Our preference has been to use a 400- to 500-mL thin mixture of oatmeal

and water that the patient is asked to retain for 1 hour in the upright position (Spirnak and

Caldamone, 1986). Finally, colonoscopy must be carried out before the procedure to rule out

pre-existing colorectal disease, as well as after the procedure to guard against the potential

development of colonic cancer. Procedures that separate the fecal and urinary streams but

drain both through the rectal sphincter are not described here. Those wishing a detailed

description of these procedures can find them in prior editions of this chapter. The following

is a brief description of more modern surgical procedures that use the intact anal sphincter for

urinary and fecal continence. However, the surgical techniques for these procedures will

likewise not be discussed in this edition.

Folded Rectosigmoid Bladder

A modification of the ureterointestinal anastomosis was described by a group from

Mansoura, Egypt (Hafez et al, 1995; El-Mekresh et al, 1997). This procedure creates a folded

rectosigmoid bladder with anastomosis of the ureters via serosa-lined tunnels rather than into

the taenia coli. This procedure has the advantage of a larger sigmoid reservoir, as well as the

prevention of reflux by creating the above serous-lined tunnel for the anastomosis. This

reimplantation technique was first described by Abol-Enein and Ghoneim (1993) and appears

to have a lower complication rate than direct taenial implantation (Hafez et al, 1995).

Postoperative Care and Comments. Patients undergoing this procedure must be

closely monitored for the development of hyperchloremic acidosis. This will occur in the

majority of cases, and it is wise to initiate a bicarbonate replacement program following the

operation. Because hypokalemia is also a feature of ureterosigmoidostomy, replacement of

potassium along with bicarbonate may be achieved with oral potassium citrate. Routine

nightly insertion of a rectal tube is advocated in the long-term care of the patient. However,

many patients will reject this practice as uncomfortable and unappealing. Nighttime urinary

drainage should be mandated in any patient who cannot maintain electrolyte homeostasiswith

oral medication. Bissada and colleagues (1995) reported that 30 of 61 patients were able to

stay dry during the night without awakening. The other 31 required two or more awakenings

to remain dry overnight. Hyperchloremic acidosis was reported in 4 of 61 noncompliant

patients.

In 1997 El-Mekresh and colleagues (1997) reported on 64 patients (32 women, 20

men, and 12 children) who underwent their rectosigmoid bladder procedure between 1992

and 1995. Follow-up ranged from 6 to 36 months. Functional results were assessable in 57

patients: 1 died of a postoperative pulmonary embolism and 6 died from their disease. All

patients were continent during the day with two to four emptyings, whereas all butfour

remained dry at night with zero to two emptyings. Four children experienced enuresis that

responded to 25 mg of imipramine at bedtime. Importantly, upper urinary tract function was

maintained or improved in 95% of patients. However, six renal units (5.3%) developed

obstructive hydronephrosis secondary to ureterocolic anastomotic strictures. Two were

remedied by antegrade dilation, one was repaired by open revision, and one nonfunctioning

renal unit was removed. The fate of the remaining two units was not specified. No patient in

this series developed a postoperative metabolic acidosis. However, all patients were

maintained on prophylactic oral alkalinization.

Obviously, all patients undergoing these procedures have exposure of the urinary tract

to fecal flora. Most authors would advocate chronic administration of an antibacterial agent in

all patients (Duckett and Gazak, 1983; Spirnak and Caldamone, 1986). Ureteral strictures

require reoperative surgery and are experienced in 26% to 35% of cases over time (Williams

et al, 1969; Duckett and Gazak, 1983).

Because of the concern for development of rectal cancer anywhere between 5 and 50

years (average 21 years) after ureterosigmoidostomy (Ambrose, 1983), it is suggested that

patients with long-term ureterosigmoidostomy undergo annual colonoscopy (Filmer and

Spencer, 1990). Barium enemas are relatively contraindicated because reflux of this material

into the kidneys (if the antireflux procedure fails) can result in dire consequences (Williams,

1984). Additional methods for colon carcinoma screening in this population are the

evaluation of stool for blood, and the attempted cytologic examination of the mixed urine and

feces specimen (Filmer and Spencer, 1990).

Augmented Valved Rectum

Kock developed this technique to be used in locales where stoma appliances were not

readily available (Kock et al, 1988). This operation is similar to standard

ureterosigmoidostomy except that a proximal intussusception of the sigmoid colon confines

the urine to a smaller surface area, thus minimizing the problems of electrolyte imbalance.

Additionally the rectum is patched with ileum to improve the urodynamic properties of the

rectum as a urinary reservoir. Preoperative evaluation is similar to that used in

ureterosigmoidostomy. The large bowel must be studied for pre-existing disease, and anal

sphincteric integrity must be tested before surgery.

Hemi-Kock and T Pouch Procedures with Valved Rectum

In his description of the augmented valved rectum procedure, Kock described the use of a

foreshortened hemi-Kock pouch to be used as a rectal patch when the ureters were too dilated

to bring down between the leaves of the intussuscepted sigmoid (Kock et al, 1988). Skinner

then modified this procedure by using an entire hemi-Kock segment to augment the rectum

after sigmoid intussusception (Skinner et al, 1989).

After extensive experience with the Kock ileal reservoir, the group at the University

of Southern California has attempted to improve on the intussuscepted Kock continence

mechanism. The result has been the modification of the T pouch to serve as an ileal anal

reservoir (Stein et al, 1999a). The technique consists of the construction of a hemi-Kock or T

pouch employing doubly folded, marsupialized ileum and a proximal continence mechanism

to prevent pouch-ureteral reflux. This pouch is then anastomosed to the rectum directly as a

patch. Contact of urine with the proximal colon can be avoided by the intussusception of the

sigmoid colon proximal to the anastomotic site (Fig. 86–2).

Postoperative Care and Comments. Postoperative management and complications associated

with this operation are similar to those that might be experienced after any procedure that

directs the urinary stream into the rectum. Radiologic studies of the stents are carried out on

the seventh postoperative day. Before conducting stent studies, a Gastrografin enema may be

performed through the rectal tube to ensure that the region of ureterocolonic anastomosis is

intact. Follow-up films are taken to ensure prompt drainage of the upper urinary tracts into

the rectosigmoid region. The rectal tube may be removed at this point, but some believe that

it is advisable to have it reinserted for evening drainage over the forthcoming week. The

patient is instructed to empty the colon at intervals of no more than every 2 hours,

particularly in the early postoperative period.

When the rectal tube is removed, as in other situations when the urinary tract is

diverted to the rectum, the patient must be closely monitored for the development of

hyperchloremic acidosis. Because hypokalemic metabolic acidosis often occurs after

ureterosigmoidostomy, bicarbonate replacement with oral potassium citrate should begin in

the immediate postoperative setting. Longterm care should include nightly insertion of a

rectal tube despite the uncomfortable and unappealing nature of the process. In addition,

nighttime urinary drainage is necessary in patients who cannot maintain electrolyte

homeostasis with oral medication.

The hemi-T procedure with valved rectum has one theoretical advantage over the

valved rectum operation itself: Because

Figure 86–2. A, A 30-cm segment of ileum is selected, the first 10 cm for the T implant and the distal 20 cm for the patch. The 20-cm segment is folded into a U and opened as shown. The medial borders are closed with running absorbable sutures. B, The ostium of the T is secured to the walls of the ileum with interrupted absorbable sutures. The wall of the ileum is closed over the T mechanism with a running absorbable suture. C, The ureters are anastomosed to the top of the T in the usual end-to-side fashion. The T patch is then secured to the 15-cm proctotomy with a two-layer closure. (From Stein JP, Buscarini M, DeFilippo RE, Skinner DG. Application of the T pouch as an ileo-anal reservoir. J Urol 1999;162:2052–3.)

transitional ureteral epithelium is not in contact with colonic epithelium, there may be a

reduced risk of developing colonic malignancy. As in the augmented valved rectum, the

proximal colonic intussusception used in this procedure decreases the contact between urine

and colonic epithelium, thereby potentially decreasing the risk of hyperchloremic acidosis.

Nevertheless, attention should be paid to electrolyte levels after removal of stents and rectal

tubes. Skinner and colleagues reported on the results of the hemi-Kock procedure in 15

patients between 1987 and 1991 (Simoneau and Skinner, 1995). Four patients had prior

bladder exstrophy and were converted to an ileoanal reservoir, and 11 patients underwent the

procedure as a form of primary diversion after cystectomy. At the time of the report 10

patients were still alive and could be evaluated. Early postoperative complications occurred

in three patients (20%): a colocutaneous fistula in two patients, urine leak in one, and deep

venous thrombosis in another. Late complications included partial small bowel obstruction in

four patients (with two requiring surgery), urinary retention requiring surgery in two patients,

and metabolic acidosis in five patients. Two of the 11 patients undergoing primary

construction never achieved continence; both were older than 68 years. The authors

summarized their experience by concluding that the operation is best suited for the younger

exstrophy patient and that it is essential to avoid colonic redundancy distal to the reservoir.

The use of the T pouch as an ileoanal reservoir has been reported in one former exstrophy

patient (Stein et al, 1999a), with no reported postoperative complications.

Sigma-Rectum Pouch, Mainz II

A variation of ureterosigmoidostomy was described by Fisch and Hohenfellner in 1991 and

updated in 1996 (Fisch and Hohenfellner, 1991; Fisch et al, 1996). This operation, which they

termed the sigma rectum or the Mainz II pouch, creates a low-pressure rectosigmoid reservoir

of increased capacity. They viewed the simplicity and reproducibility of the operation as one

of its major advantages.

Postoperative Care and Comments. The rectal tube is removed on the third to fifth

postoperative day, and the ureteral stents are removed around the eighth day. On the 15th

postoperative day the Mainz group performs an intravenous pyelogram to assess the upper

tracts and the sigma rectum pouch construction. Radiography of the pouch is performed on

the 17th postoperative day.

The results of the Mainz II pouch were reported by Fisch and colleagues in 1997.

Between 1990 and 1993, 73 patients (59 adults and 14 children) underwent the Mainz II

pouch procedure. Early complications were encountered in 5 of 73 patients (6.8%). These

included single examples of a dislodged ureteral stent, pneumonia, pulmonary embolism,

wound dehiscence, and ileus necessitating surgical intervention. There were eight (10.9%)

late complications that required surgery: ureteral stenosis occurred in five patients (6.8%);

one patient with nephrolithiasis was treated with extracorporeal shockwave lithotripsy; one

patient with rupture of the anterior suture line required temporary colostomy; and one patient

experienced perianal bleeding after chemotherapy that required endoscopic coagulation. Six

patients presented with pyelonephritis (8.2%) and were treated with antibiotics. Daytime and

nighttime continence were reported as 94.5% and 98.6%, respectively. Oral alkalinization to

prevent metabolic acidosis was used in 49 of 73 patients (67.1%). Two patients who refused

any oral medication developed metabolic acidosis. The Mainz group concluded that the

overall complication rate was low and comparable with other techniques of continent urinary

diversion. Woodhouse and Christofides (1998) reported on their experience with the Mainz II

pouch in 15 primary cystectomy patients and 4 patients with prior standard

ureterosigmoidostomy who were incontinent. They reported excellent results: 14 of 15

(93.3%) of the primary patients achieved documented daytime and nighttime urinary control,

while the remaining patient refused follow-up but reported continence. The four patients

undergoing a salvage procedure fared less well. Only two patients became continent, while

the remaining two were found to be in chronic retention. Their failed continence was believed

to be secondary to inadequate pouch emptying. Similarly, excellent results have been

achieved by Venn and Mundy (1999). They reported full daytime and nighttime urinary

continence in 14 of 14 patients and no major postoperative complications.

Bastian and colleagues (2004) have reported on the healthrelated quality of life in 83

patients undergoing Mainz II urinary diversion. They found that quality of life was similar to

that of age-matched controls except for diarrhea symptoms, with 100% daytime continence.

There appears to be no metabolic advantage to this procedure because the need for

oral alkalinization is similar to standard ureterosigmoidostomy. In fact, the only difference

between this operation and standard ureterosigmoidostomy is the partial reconfiguration of

the rectosigmoid junction. It does appear that the reduced intracolonic pressures that result

from the partial reconfiguration increases the sigmoid capacity and results in better daytime

and nighttime continence. Whether the increased capacity and lower pressure of this pouch

will decrease the incidence of upper tract complications remains to be determined by longer

follow-up.

Continent Catheterizing Pouches

Numerous operative techniques have been developed for continent diversion wherein urine is

emptied at intervals by clean intermittent self-catheterization. Many of these operations are

described in this chapter, although certain pioneering procedures that used intact bowel (e.g.,

those of Gilchrist and colleagues [1950], Ashken [1987], Mansson and colleagues [1984,

1987], Benchekroun [1987]) are not. This is not to discredit the pioneers in the field but

simply to allow this chapter to focus on those pouches that incorporate modern principles that

attempt to achieve a spherical configuration and disruption of peristalsis.

In continent urinary diversion, the two favorite sites for stomal location are (1) at the

umbilicus and (2) in the lower quadrant of the abdomen, through the rectus bulge and below

the “bikini” line. This location is often preferred because it affords both men and women the

opportunity to conceal the stoma. The umbilicus is a preferred location for the individual

confined to a wheelchair and has been reported to have a lower incidence of stomal stenosis,

especially when fashioning an appendiceal stoma. The umbilical location is also far easier for

the paraplegic individual to catheterize without the need for chair transfer and disrobing. In

individuals with a recessed umbilicus, the umbilical location of a stoma is barely perceptible

from a normal umbilical dimple. Generally, the stoma site is covered with a gauze pad or

square bandage to avoid mucous soiling of clothing. Patients undergoing continent urinary

diversion to an umbilical location should be advised to wear a medical alert bracelet that

informs the examiner of the umbilical stoma.

Before the extension of orthotopic neobladder construction to women, there was some

enthusiasm for the orthotopic placement of a catheterizing portal. This procedure has been

carried out in certain female patients with success. The construction of a neourethra to the

introitus is attractive, provided there is no substantial difficulty in the catheterizing process.

Because it can be difficult to direct a catheter through the “chimney” of an intussuscepted

nipple valve, those continent diversions employing nipple valves are not particularly

adaptable to orthotopic location, although they have been performed with success in a small

number of patients (Olsson, 1987). In contrast, the imbricated and tapered ileal segment

leading to an Indiana pouch is relatively easier to catheterize and can be used for orthotopic

catheterizing diversion (Rowland et al, 1987). However, it may be difficult to obtain

sufficient mesenteric length in some patients. The appendix can also be used as a neourethra,

in which case mesenteric length should become less of a problem (Hubner and Pfluger,

1995).

Four general techniques have been employed to create a dependable, catheterizable

continence zone. For right colon pouches, appendiceal techniques, pseudoappendiceal tubes

fashioned from ileum or right colon, and the ileocecal valve plication are applicable.

Appendiceal tunneling procedures are the simplest of all to perform because they use

established surgical techniques already present in the urologic armamentarium. The in situ or

transposed appendix is tunneled into the cecal taenia in a fashion similar to ureterocolonic

anastomosis. Appendiceal continence mechanisms have been criticized for three general

reasons. First, the appendix may be unavailable in some patients because of prior

appendectomy. For those individuals, techniques have been developed that allow for the

construction of a similar tube fashioned from ileum (Woodhouse and MacNeily, 1994) or

from the wall of the right colon (Lampel et al, 1995a). Second, the appendiceal stump may be

too short to reach the anterior abdominal wall or umbilicus while still maintaining sufficient

length for tunneling. This criticism has been addressed by an operative variation described by

Mitchell, in which the appendiceal stump can be lengthened by the inclusion of a tubular

portion of proximal cecum (Burns and Mitchell, 1990) (Fig. 86–3). This lengthening

procedure has the added advantage of allowing for a slightly larger stoma made of cecum that

is less prone to stomal stenosis. Appendiceal continence mechanisms share the feature of

allowing only small-diameter (14- to 16-Fr) catheters to be used for intermittent

catheterization, whereas the large amount of mucus produced by an intestinal reservoir is

more easily emptied or irrigated using a 20- to 22-Fr catheter. We believe that these

criticisms are more theoretical and that the appendiceal or pseudoappendiceal continence

mechanism remains an attractive and reliable continence mechanism.

The second major type of continence mechanism used in right colon pouches is the

tapered and/or imbricated terminal ileum and ileocecal valve. Here again the technology is

rather simple, with imbrication or plication of the ileocecal valve region along with tapering

of the more proximal ileum in the fashion of a neourethra (Rowland et al, 1985; Lockhart,

1987; Bejany and Politano, 1988). These techniques afford a reliable continence mechanism.

One feature of right colon pouches that has been criticized is the loss of the ileocecal

valve. Although this does result in an

Figure 86–3. A, The appendiceal stump is lengthened by the inclusion of a tubular portion of

proximal cecum by the application of the gastrointestinal anastomosis (GIA) stapler to the

terminal cecum. A window is made in the mesoappendix, and the blade of the GIA stapler is

advanced through the window. This maneuver ensures that the blood supply is not

inadvertently damaged. B, The added length is demonstrated. The appendix is rotated and

implanted into the taenia; the cecal tube serves as the stoma. (From Burns MW, Mitchell ME.

Tips on constructing the Mitrofanoff appendiceal stoma. Contemp Urol 1990;May:10–2.)

increased frequency of bowel movements for some patients in the short term, the majority

will experience bowel regularity either through intestinal adaptation or with the use of

pharmacologic therapy. However, some patients have developed rather striking

diarrhea/steatorrhea after the loss of the ileocecal valve. This may be particularly true in

pediatric patients in whom there is neurogenic bowel dysfunction (e.g., myelomeningocele).

The third surgical principle used in constructing the continence mechanism is the use

of the intussuscepted nipple valve or, more recently, the flap valve, which avoids the need for

intussusception. The creation of nipple valves is by far the most technologically demanding

of all the continence mechanisms, and it is associated with the highest complication and

reoperation rates. There exists a significant learning curve before the surgeon achieves

reproducible and dependable results. For this reason, nipple valve construction should

probably not be chosen by the surgeon carrying out occasional construction of continent

pouches. Furthermore, it should be noted that in the past 2 decades we have seen the

introduction of numerous modifications of the original technique of Kock for construction of

a stable nipple valve. The singular reason for all of these modifications is the rather

disappointing long-term stability of the nipple valve in some patients. As a result, the group

at the University of Southern California has developed the T pouch, which uses a flap valve

(Stein et al, 1998). This procedure, which appears much simpler than the intussuscepted

nipple valve, has been used to create both a continence and an antireflux mechanism. Nipple

valve failure from slippage or valve effacement can be anticipated in 10% to 15% of cases

even in the hands of the best and experienced surgeons. In addition to slippage, nipple valves

are subject to ischemic atrophy. When this occurs, a new nipple valve must be fashioned

from a new bowel segment.

A final feature of stapled nipple valves is the potential for stone formation on exposed

staples. This was greatly lessened by the omission of staples at the tip of the intussuscepted

nipple valve, as suggested by Skinner and colleagues (1984). However, more proximal

staples occasionally erode into the pouch and serve as a nidus for stone formation. These

stones are usually manageable endoscopically with forceps extraction or else with

electrohydraulic or ultrasonic disintegration of the stone with subsequent forceps extraction

of the staple. Although exposed staples may serve as a nidus for stone formation, continent

urinary diversion in and of itself results in more urinary excretion of calcium, magnesium,

and phosphate as compared with ileal conduit diversion (Terai et al, 1995). Thus all patients

undergoing continent diversion are at an increased risk for the formation of reservoir stones.

The fourth major technique of continence mechanism construction is the provision of

a hydraulic valve, as in the Benchekroun nipple (1987). In this procedure a small bowel

segment is isolated, with subsequent reversed intussusception 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 while

allowing urine to flow freely between the leaves of apposed ileal mucosa. As the pouch fills,

hydraulic pressure closes the leaves, thereby ensuring continence. The premise of this

technique is that as the reservoir fills, the pressure within the valve would also increase,

resulting in continence. Concerns regarding stomal stenosis, especially in children, and nipple

destabilization have resulted in this procedure being largely abandoned (Sanda et al, 1995).

As a result, it is not discussed in this chapter.

General Procedural Methodology

During construction of the pouch, intraoperative testing for pouch integrity should always be

performed. The continence mechanism is also tested for ease of catheterization, as well as

continence after the pouch construction has been completed. The pouch is filled with saline,

the continence mechanism catheter is removed, and the pouch is compressed lightly to look

for points of leakage and to test the continence mechanism for its ability to contain urine.

Thereafter, the continence mechanism is catheterized to ensure ease of catheter passage. This

is an extremely important and crucial maneuver because the inability to catheterize is a

serious complication that will often result in the need for reoperation. In general, all

redundancy should be removed from the continence mechanism. It is often useful to secure

the reservoir to the anterior abdominal wall in a manner that prevents the reservoir from

migrating. This can prevent the development of a false passage or a kink, thereby facilitating

catheterization.

Postoperatively, the larger-bore catheter used for drainage of the pouch should be

irrigated at frequent intervals to prevent mucous obstruction. This can be performed at 4-hour

intervals by simple irrigation with 45 to 50 mL of saline. Less frequent intervals of irrigation

can be employed when the urine is totally diverted from the kidneys by means of long

indwelling stents. It is essential that as soon as possible the patient be taught how to self-

irrigate and what kind of regimen is required. This is performed to familiarize the patients

with the catheterization process, to reduce the work burden on the nursing staff, and to allow

for earlier discharge.

On the seventh postoperative day, a contrast study is performed to ensure pouch

integrity. Thereafter, ureteral stents may be removed if no leaks are demonstrated by imaging

studies. When it has been ascertained that the ureteral anastomoses and pouch are intact, the

suction drain is removed. The suprapubic tube (if employed) can also be removed at this

time, or it can be left in place until the patient is confident with self-catheterization. The

patient is taught to irrigate the tube traversing the continence mechanism at 4-hour intervals

and whenever any episode of intraabdominal pressure or discomfort is experienced. Once

these procedures are mastered and the patient is tolerating a regular diet, the patient can be

discharged. This usually occurs between hospital days 6 and 8.

The following represents a summary of common patient questions and everyday solutions:

What kind of catheter do I use? For nipple valves, a straightended 22- to 24-Fr tube;

for ileocecal plication, a 20- to 22-Fr coudé tip catheter; and for appendiceal

sphincters, a 14- to 16-Fr coudé tip 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

benzalkonium chloride wipe, which can be purchased in individual foil-wrapped

packets.

How do I lubricate the catheter? By tearing off the end of an individual-use foil pack

of 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 ordinary tap water

through the inside channel and over the outside surface before replacing it in its

zipper-locked bag.

In the case of ileal pouches, pouch capacity will initially be low (150 mL). Therefore the

frequency of catheterization will have to be significantly different in these individuals

compared with those with right colon pouches in which initial comfortable capacities will be

in excess of 300 mL. To ensure restful sleep, the smaller-capacity pouches may be managed

best with indwelling catheterization during sleeping hours.

General Care

Because all patients with catheterized pouches will have chronic bacteriuria, the problem of

antibiotic management should be discussed. Most authors would suggest that bacteriuria in

the absence of symptomatology does not warrant antibiotic treatment (Skinner et al, 1987).

The construction of an effective antireflux mechanism in these pouches may help protect

against clinical episodes of pyelonephritis, in contrast to patients with freely refluxing

conduits. Obviously, if clinical pyelonephritis does occur, antibiotic treatment should be

instituted. Episodes of recurrent pyelonephritis should be evaluated with radiography of the

pouch in order to diagnose failure of the antireflux mechanism or upper tract stone formation.

A condition termed “pouchitis” is manifested by pain in the region of the pouch along

with increased pouch contractility. It should be mentioned that this condition, although

infrequent, may result in temporary failure of the continence mechanism because of the

hypercontractility of the bowel segment employed for construction of the pouch. The patient

typically presents with a history of sudden explosive discharge of urine through the

continence mechanism (rather than dribbling incontinence), along with discomfort in the

region of the pouch. Appropriate antibiotic therapy will usually result in resolution of these

symptoms. It has been our experience that short courses of antibiotics are not usually

successful when treating pouch infections. This may be due to the larger amount of foreign

material in the form of mucus and sediment within intestinal pouches as opposed to the

bladder. Intestinal crypts may also serve as bacterial sanctuaries. Therefore whenever a pouch

infection is diagnosed, antibiotic therapy should be continued for at least 10 days.

Pyelonephritis will, of course, require longer courses of therapy.

Urinary retention is an infrequent but serious occurrence in catheterizable pouches. It

is most commonly seen with pouches whose continence mechanism consists of a nipple

valve. In these circumstances, when the chimney of the nipple valve is not near the

abdominal surface, the catheter may be misdirected into folds of bowel rather than into the

nipple valve proper, resulting in urinary retention. Pouch urinary retention represents a true

emergency, and the patient must seek immediate attention so that catheterization and

drainage by experienced personnel can be achieved promptly. The use of a coudé tipped

catheter may be helpful. Rarely, a flexible cystoscope will be necessary. After the immediate

problem has been resolved by emptying the pouch, a catheter should be left indwelling for 3

to 5 days to allow the edema and trauma to the catheterization portal to resolve. Before

discharge, the patient should be observed to successfully self-catheterize on multiple

occasions. The appropriate angle of entry should be taught to the patient until he or she is

comfortable with the use of the new catheter. In fact, the authors prefer to routinely use coudé

catheters with non–nipple valve pouches.

Intraperitoneal rupture of catheterizable pouches has been reported (Kristiansen et al,

1991; Thompson and Kursh, 1992; Watanabe et al, 1994). In general, these episodes are more

common in the neurologic patient when sensation of pouch fullness may be less distinct

(Hensle, personal communication; Mitchell, personal communication). Ruptures may also be

associated with mild abdominal trauma, such as a fall. In general, these patients require

immediate pouch decompression and radiographic pouch studies. For patients with large

defects, surgical exploration and pouch repair are required. If the amount of urinary

extravasation is small, and the patient does not have evidence of peritonitis, catheter drainage

and antibiotic administration may suffice in treating an intraperitoneal rupture. Patients

managed with this conservative approach require careful monitoring. If there is any sign of

progressive peritonitis, surgical exploration and repair is imperative. The authors have

successfully employed this nonoperative approach on patients with ruptured right colon

pouches.

Continent Ileal Reservoir (Kock Pouch)

This operation was first reported for use in urinary diversion by Kock and colleagues in 1982.

This report was singularly responsible for the renewed interest in continent diversion

procedures at that time. An outgrowth of the Kock procedure for continent ileostomy (Kock,

1971), the Kock pouch combined reasonably dependable techniques for ensuring urinary

continence and preventing reflux to the upper urinary tracts (nipple valves) with carefully

refashioned bowel that provided a lowpressure urinary reservoir. This procedure and the

similarly constructed T pouch are the only catheterizable continent diversions that preserve

the ileocecal valve. Skinner and his colleagues (1989, 1992) have carefully studied and

improved the technique over the years while amassing a prodigious experience with the

operation and its variants. The high complication rate and the technical difficulties involved

with constructing this reservoir have resulted in the procedure being abandoned by most

individuals. As a result, this procedure is not discussed further in this edition. Those

interested in a more detailed description should refer to previous editions of this text.

However, the construction of a Kock limb remains an important procedure for use in

repairing failed continence or reflux mechanisms and, as such, is described in more detail. It

is Skinner’s operative description that will be followed closely in this chapter.

Procedure. A 15- to 20-cm length of ileum is selected for creating the intussuscepted nipple

valve. The proximal 10 cm serve as the valve, and the distal 5 to 10 cm serve as the patch

(Fig. 86–4A). The distal length is chosen on the basis of the volume lost after resection of the

failed mechanism. Only 5 cm are necessary for the patch, but on some occasions the reservoir

itself may require augmentation. The middle 6 to 8 cm of the 10-cm segment are denuded of

mesentery by electrocoagulation. An Allis or Babcock clamp is advanced into the ileal

terminus, grasping the full thickness of the intussusceptum and inverting the ileum into the

pouch (see Fig. 86–4B). Using the TA-55 stapler, three rows of 4.8-mm staples are applied to

the intussuscepted nipple valve (see Fig. 86–4C). The distal six staples from each cartridge

are removed before staple application to ensure that the tip of the valve is free of staples.

Most authors suggest that the pin of the stapling instrument should always be kept in place so

that staple misalignment does not occur. This will result in a pinhole puncture site at the base

of the nipple valve that should be oversewn with absorbable suture material to prevent fistula

formation after staple application is complete. The nipple valve is then fixed to the back wall

of the patch by one of two stapling techniques (Skinner et al, 1984). A small buttonhole may

be made in the back wall of the ileal plate so that the anvil of the stapler can be passed

through the buttonhole and advanced into the nipple valve before application of the fourth

row of staples (see Fig. 86–4D). If this is carried out, the buttonhole is oversewn afterward

with absorbable material. Alternatively, the anvil of the stapler can be directed between the

two leaves of the intussuscipiens and the fourth row of staples used to fix the inner leaf of the

nipple valve to the pouch wall (see Fig. 86–4E).

Some authors including Skinner and colleagues (1989) suggest the use of an

absorbable mesh collar to anchor the base of the nipple valve. If a collar is used, a 2.5-cm

wide strip of absorbable mesh is placed through an additional window of Deaver at the base

of the nipple valve. The mesh strip is fashioned into a collar and sewn to the base of the patch

with seromuscular sutures of absorbable material (see Fig. 86–4F and G). The patch is then

sewn to the reservoir.

Double T Pouch

As indicated earlier, many surgeons have abandoned the Kock pouch largely due to the

technical difficulties of creating the continence and antireflux mechanisms, as well as the

high complication rates associated with them. This should not be viewed as a condemnation

of the pioneering work of Kock and his colleagues. Without their initial efforts, many of the

procedures described in this chapter would never have come into being. Rather, this

represents the natural evolution of surgical techniques.

The group at the University of Southern California modified a technique described by

Abol-Enein and Ghoneim (1993, 1994) to create a novel continence mechanism created

entirely from ileum (Bochner et al, 1988). Abol-Einein and Ghoneim described a technique

that created an extramural serosal tunnel into which the ureters were implanted. This

extramural trough created a pseudotunnel that prevents reflux but in theory is associated with

a lower risk of obstruction than either the Goodwin (1958), Leadbetter (1961), or LeDuc and

colleagues’ (1987) techniques of direct transmural ureteral implantation. Stein and colleagues

(1998) first reported on the use in a neobladder of a tapered ileal segment implanted into a

serosal trough as the antireflux mechanism. In 1999 they reported on their adaptation of the

technique to the ileal-anal reservoir, and in 1999 they presented their early experience with a

double T pouch as a replacement for the Kock pouch at the meeting of the American

Urological Association (Stein et al, 1999a). It was published elsewhere (Stein and Skinner,

2001) and is the technique presented in this section.

Procedure. A 70-cm segment of terminal ileum is isolated 15 to 20 cm from the

ileocecal valve at the line of Treves. The proximal isoperistaltic 10- to 12-cm segment is

isolated and will serve as the antireflux mechanism. The distal 12- to 15-cm segment is

isolated and rotated in an antiperistaltic fashion and will create the cutaneous continence

mechanism (Fig. 86–5A and B). A short 2- to 3-cm mesenteric incision is made to isolate the

proximal limb, and a 4-cm incision is made for the distal limb, thereby preserving the major

vascular arches. The proximal and distal segments can vary in length, depending on ureteral

length and the thickness of the anterior abdominal wall. The middle 44 cm of ileum are

folded in a W with each limb measuring 11 cm.

The afferent antireflux mechanism is created by opening the windows of Deaver

between the vascular arcades along the distal 3 to 4 cm. The efferent continence mechanism

is created by opening the proximal 7 to 8 cm of vascular arcades (antiperistaltic) (see Fig. 86–

5C). One-fourth-inch Penrose drains are then placed in each window of Deaver to facilitate

passage of the 3-0 silk horizontal mattress sutures that are used to approximate the serosa of

the corresponding 11-cm limbs of the W (see Fig. 86–5D). The 3- to 4-cm anchored portion

of the proximal limb is then tapered over a 30-Fr catheter, and the 7- to 8-cm anchored

portion of the efferent limb is tapered over a 16-Fr catheter. In both instances, tapering is

performed with a gastrointestinal anastomosis (GIA) stapler (the staples will not be in contact

with urine). Care must be taken in the efferent limb to create a gradual taper so that the

catheter does not hit a false cul-de-sac (see Fig. 86–5E). The portions of the 11-cm W limbs

not forming the troughs are then sutured together with a running 3-0 polyglycolic acid

(PGA). The bowel is now incised along its antimesenteric border in the portion where the

serosal trough exists and in close proximity to the medial PGA suture lines when beyond the

two limbs

Figure 86–4. A, A 15-cm segment of terminal ileum is isolated and opened along its antimesenteric wall. The proximal 10 cm will serve asthe continent intussusception and the distal 5 to 10 cm, the patch. The size of the patch will vary according to the size of the excisedsegment. B, An Allis or Babcock clamp is advanced into the ileal terminus, the full thickness of the intussuscipiens is grasped, and it isprolapsed into the pouch. C, Three rows of 4.8-mm staples are applied to the intussuscepted nipple valve using the TA-55 stapler. D, Asmall 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 intothe nipple valve. A fourth row of staples is applied. The figure shows two valve mechanisms, but in this instance there would be only one.E, The anvil of the stapler can be directed between the two leaves of the intussuscipiens and the fourth row of staples applied in thismanner. Two valve mechanisms are shown, but in this instance there would be only one. F, A 2.5-cm wide strip of absorbable mesh isplaced through additional windows of Deaver at the base of each nipple valve. The mesh strips are fashioned into collars. G, The collarsare sewn to the base of the pouch and the ileal terminus with seromuscular sutures. (A, From Ghoneim MA, Lock NG, Lycke G, El-Din AB.An appliance-free, sphincter-controlled bladder substitute. J Urol 1987;138:1150–4; B to G, from Hinman F Jr. Atlas of urologic surgery.Philadelphia: WB Saunders; 1989.)

Figure 86–5. 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 isisolated and rotated toward what will become the reservoir in an isoperistaltic direction. The distal 12 to 15 cm is rotated toward thereservoir in an antiperistaltic direction. C, The windows of Deaver are opened to allow the walls of the W reservoir to be apposed behindthe valve mechanisms. Penrose drains are passed to guide suture passage. D, Horizontal mattress sutures of 3-0 silk are passed througheach window. The distal continence mechanism is longer than the proximal antireflux mechanism. E, The proximal and distal mechanismsare tapered with a metal gastrointestinal anastomosis stapler. F, The bowel is incised along its antimesenteric border, where it will overliethe 2 Ts. Distal to the Ts, the bowel is incised close to the approximated limbs of the reservoir.

Figure 86–5, cont’d.G, The ostia of the valves are secured to the bowel wall with interrupted absorbable sutures. The two flaps of ileumare closed over the Ts with running absorbable sutures. H, The back wall of the reservoir is closed with running absorbable sutures. I, Thelateral walls are folded medially, and the construction is completed with running absorbable sutures. (From Stein JP, Buscarini M, DeFilippoRE, Skinner DG. Application of the T pouch as an ileo-anal reservoir. J Urol 1999;162:2052–3.)

see Fig. 86–5F). The incised mucosa is then closed in two layers with a running suture of 3-0

PGA. The incised intestinal flaps (antimesenteric incision) are then sutured to each ostium

with interrupted sutures of 3-0 PGA, and the two ileal flaps are sutured over each segment

with a running suture of 3-0 PGA (see Fig. 86–5G). The reservoir is then closed side to side

in two layers with 3-0 PGA, thereby completing its construction (see Fig. 86–5H and I). The

ureters are anastomosed end to side over stents to the proximal limb, which has been closed

with a running absorbable Parker-Kerr suture. The efferent limb is then brought to the

abdominal wall stoma site, and redundant ileum is resected. The stoma is then matured with

the reservoir lying immediately adjacent to the anterior abdominal wall.

Postoperative Care and Comments. Postoperative care is similar to that for any

continent reservoir. Stein and colleagues (1999b) initially reported on nine patients, seven of

whom could be evaluated for continence and long-term complications and two of whom died

of disease during follow-up. All seven patients achieved immediate continence on catheter

removal. However, two patients later became incontinent, with one requiring surgical

revision. None of the nine patients experienced an early postoperative complication. One

patient developed a reservoir stone 9 months after surgery that was removed endoscopically

without sequelae. Pouch capacity was excellent: 400 to 700 mL (average 500 mL). There was

no radiographic evidence of reflux in any patient, and there was no upper tract deterioration.

This operative procedure appears to have many advantages over the Kock pouch, and good

long-term continence results have been reported. Marino and colleagues (2002) reported on

18 patients with 1-year follow-up with 100% day and night continence and no delayed

complications. Seifert and colleagues (2008) recently published their results on 19 patients

who underwent ileal double T pouch construction between 1998 and 2006. Five patients

(26%) had complications related to the diversion, some of which required surgical revision.

Three patients (16%), all of whom had body mass indices of greater than 30, suffered

necrosis of the efferent loop and subsequent cutaneous fistulas. Sixteen (84%) eventually

developed both daytime and nighttime continence. Although a mild acidosis was common in

this group, no urinary reflux was detected and no patients suffered significant upper tract

deterioration or pyelonephritis.

Mainz Pouch I

The catheterizable Mainz pouch has undergone considerable modification over the years

(Thuroff et al, 1985; Stein et al, 1995; Lampel et al, 1996; Gerharz et al, 1997). The main

impetus for these changes has been the difficulty encountered with the nipple valve

mechanism. The operative technique has now been modified to use the intact ileocecal valve

as a means of further stabilizing the intussusception (Thuroff et al, 1988). This procedure is

described here without further reference to earlier prototypes.

Procedure. The catheterizable Mainz pouch varies somewhat from the orthotopic, voiding

Mainz pouch. First, a longer segment of bowel is used. A 10- to 15-cm portion of cecum and

ascending colon is isolated along with two separate, equally sized limbs of distal ileum and

an additional portion of ileum measuring 20 cm (Fig. 86–6A). The entire colon and distal

segments of ileum are spatulated, taking care to preserve the ileocecal valve. These three

bowel segments are folded in the form of an incomplete W and their posterior aspects sutured

to one another to form a broad posterior plate (see Fig. 86–6B). A portion of the intact

proximal ileal terminus is freed of its mesentery for a distance of 6 to 8 cm, and

intussusception of the segment is achieved. Two rows of staples are applied on the

intussusceptum itself (see Fig. 86–6C).

Thereafter, the intussusceptum is led through the intact ileocecal

Figure 86–6. A, A 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. B, A portion of the intact proximal ileal

terminus is freed of its mesentery for a

distance of 6 to 8 cm. C, The intact ileum is intussuscepted, and two rows of staples are taken

on the intussuscipiens itself. D, The

intussuscipiens is led through the intact ileocecal valve, and a third row of staples is taken to

stabilize the nipple valve to the ileocecal

valve. E, A fourth row of staples is taken inferiorly, securing the inner leaf of the

intussusception to the ileal wall. F, A button of skin is

removed from the depth of the umbilical funnel, and the ileal terminus is directed through this

buttonhole. Excess ileal length is resected,

and the ileum is sutured at the depth of the umbilical funnel. (A, From Thuroff JW, Alken P,

Hohenfellner R. The MAINZ pouch [mixed

augmentation with ileum ‘n’ cecum] for bladder augmentation and continent diversion. In:

King LR, Stone AR, Webster GD, editors. Bladder reconstruction and continent urinary

diversion. Chicago: Year Book Medical Publishers; 1987. p. 252; B to F, from Thuroff JW,

Alken P, Riedmiller H, et al. 100 cases of MAINZ pouch: continuing experience and

evolution. J Urol 1988;140:283–8.)

valve and a third row of staples is applied to stabilize the nipple valve to the ileocecal valve

(see Fig. 86–6D). Finally, a fourth row of staples is applied inferiorly, securing the inner leaf

of the intussusception to the ileal wall (see Fig. 86–6E).

Ureterocolonic anastomoses are created at the apex of the reservoir, which is then folded on

itself in a side-to-side fashion to complete pouch construction. The entire pouch is rotated

cephalad so as to bring the ileal terminus to the region of the umbilicus. A small button of

skin is removed from the depth of the umbilical funnel, and the ileal terminus is directed

through this buttonhole (see Fig. 86–6F). The pouch is secured to the posterior fascia with

interrupted absorbable sutures, and the ileal terminus is sewn similarly to anterior fascia.

Excess ileal length is resected, and the ileum is sutured at the depth of the umbilical funnel

with interrupted absorbable sutures.

Postoperative Care and Comments. No specific differences in postoperative care or

complications associated with the Mainz pouch need to be addressed. Initial pouch capacities

are higher than in the Kock or T pouch. Final mean capacity averaging greater than 600 mL

has been reported. Pouch pressures are 23 cm H2O at half capacity and 31 cm H2O when the

pouch is full. Contraction waves beginning at 50% pouch fullness can be recorded at an

amplitude of 12 cm H2O. Thus this pouch seems to produce a reasonably low-pressure

urinary reservoir, although the pressures are not as low as those achieved with the use of

small bowel alone.

Recently, the 10- and 12-year experiences with the Mainz pouch and the variations created by

its developers were presented (Stein et al, 1995; Lampel et al, 1996). Between 1983 and

1994, 440 patients underwent a Mainz I operation in two urology departments, Mainz and

Wuppertal. Continence mechanisms varied: in 146 cases the appendix was used as the

continence mechanism; in 270 patients the intussuscepted nipple was used as the continent

stoma; in 14 patients a submucosal, seromuscular bowel flap was employed; and in 10

patients a submucosal full-thickness bowel flap was used. The early complication rate was

12% and included mechanical ileus requiring open revision in 9 patients (1.6%), pouch

leakage requiring revision in 5 patients (0.9%), wound dehiscence in 4 patients (0.7%), and

fatal pulmonary emboli in 4 patients (0.7%).

The late complication rate was 37% and was predominantly attributable to the pouch. Stomal

failure requiring open revision occurred in 45 patients (8%) and was directly related to the

continence mechanism. Only 2 of 146 patients (1.4%) with an appendiceal continence

mechanism were incontinent, but stomal stenosis occurred in 21%. The developers of this

procedure were innovative in their attempts to bring the incontinence rate down to an

acceptable level. To this end they tried multiple techniques, with variable success: an

alloplastic stoma (4/4 incontinent); sutured intussusception (8/8 incontinent); stapled

intussusception (5/22, 23% incontinent); and stapled ileocecal intussusception (10/204, 4.9%

incontinent). The stapled ileocecal intussusception described previously is the current

recommendation, and the long-term incontinence rate among the patients undergoing the

stapled nipple valves was reduced to 10%. Other late complications included the need for

ureteral reimplantation in 28 patients (4.9%) and stomal stenosis in 29 patients with an ileal

nipple (11.7%) and in 17 patients with an appendiceal stoma (14.7%).

Calculus formation in the pouch occurred in 38 patients (6.8%), resulting in 36 percutaneous

procedures. Despite the loss of the terminal ileum, no significant decrease in serum vitamin

B12 levels has been reported and no patient has developed a macrocytic anemia or neurologic

symptoms. However, 25% of patients are on oral alkalinization to avoid metabolic acidosis.

Since its inception, the overall complication rate for this procedure has been considered high

(31%). However, as Stein and colleagues (1995) pointed out, 50% of the complications were

manageable with percutaneous techniques. Additionally, since 1988 the incontinence rate has

been only 3.2% and less than 2% in patients with an appendiceal mechanism. Gerharz and

colleagues (1997) from Marburg, Germany, reported their single-institution experience with

the Mainz I ileocecal pouch. From 1990 to 1996, 202 consecutive patients underwent

continent diversion, 96 with a submucosally embedded in-situ appendix and 106 with an

intussuscepted ileal nipple. All patients had an umbilical stoma. In 172 of 200 patients (85%),

no stomal complications occurred. In 17 of 96 patients (18%) with an appendiceal stoma, 23

revisions were performed for stomal stenosis. In contrast, only 13 of 106 patients (12%) with

an intussuscepted ileal nipple developed problems with their stoma.

However, these patients required more invasive, major procedures for correction, whereas

those with an appendiceal stenosis could usually be repaired with a minor procedure. Three

patients with an ileal nipple (3%) developed pouch calculi, whereas none of the patients with

an appendiceal continence mechanism developed stones. As a result, the authors concluded

that the appendix, when available, should be the intestinal continence mechanism

of choice.

We share the enthusiasm for the use of the appendix as a continence mechanism. In our

experience it has also been a reliable technique that is easy to perform. It has been our

tendency in constructing right colon pouches employing an appendiceal continence

mechanism to use the entire right colon inclusive of the hepatic flexure to form the reservoir,

thereby preserving more terminal ileum. This has the theoretical advantage of fewer

metabolic complications, but the Mainz group has not reported significant metabolic

problems.

The introduction of the more reliable appendiceal continence mechanism has greatly

increased the acceptance of the Mainz I procedure. The Mainz group has also developed two

new techniques for construction of a Mitrofanoff, or appendiceal, type tube for use in patients

whose appendix is either unsuitable or absent (Lampel et al, 1995a, 1995b; Lampel and

Thurhoff, 1998). Both techniques use a small-caliber conduit fashioned from the large

intestine in the region of the cecum. One technique uses a fullthickness tube lined by mucosa

(Fig. 86–7) and the other a seromuscular tube lined by serosa (Fig. 86–8). Both techniques

appear to be successful, although the full-thickness tube was associated with a lower

complication rate and a higher success rate in their initial report (Lampel et al, 1995b). With

longer follow-up, the authors have observed a similar success rates with both tubes; 93% of

the patients (25 of 27) with a seromuscular tube and 92% of the patients (22 of 24) with a

bowel wall tube were continent day and night (Lampel and Thurhoff, 1998). The authors

believed that either tube was reliable and that each had its own unique advantages and

disadvantages. In general, the full-thickness bowel wall tube was more adaptable, owing to

the ability to create a longer tube. However, this came at the expense of a more tenuous blood

supply. The decreased distal blood supply might be improved by creating a wider base on the

tube. This could, however, make taenial implantation more difficult. The seromuscular tube

was equally reliable but could only be anastomosed to the umbilicus, owing to the short adit

tube. Either tube was believed to be indicated as a continence mechanism in the Mainz I

pouch when the appendix was not available or as a continence mechanism for reservoirs

created from other large intestinal segments. Either

Figure 86–7. A to C, A full-thickness tube lined by mucosa is fashioned over an 18-Fr Foley

catheter for tunneled reimplantation. The tube

is closed with a running 3-0 absorbable suture. For longer tubes, the authors advise a wider

base to prevent distal ischemia. The continence

mechanism is created by placing the tube into the adjacent taenial trough. (From Lampel A,

Hohenfellner M, Schultz-Lampel D, Thuroff JW. In-situ tunneled bowel flap tubes: two new

techniques of a continent outlet for Mainz pouch cutaneous diversion. J Urol 1995;153:308–

15.)

technique could be used as a salvage procedure when another primary continence mechanism

had failed. Another novel Mitrofanoff continence mechanism was described by Montie

(1997), who conceived of a procedure in which a 2- to 3-cm segment of terminal ileum is

isolated on its blood supply (Fig. 86–9A). The width of the segment was chosen to

correspond to the circumference of the tube to be created. Once isolated, the segment is

opened near one of its mesenteric junctions to create a longitudinal reconfiguration (see Fig.

86–9B and C). The tube is then closed with a running 3-0 absorbable suture (see Fig. 86–9D).

It can now be used for a Mitrofanoff implant. When longer tubes are necessary, two adjacent

segments can be isolated, reconfigured, and joined together (see Fig. 86–9E and F).

Although originally described in dogs, the authors have used this technique in humans

without complication. Montie (1997) reported on a high rate of stomal stenosis in dogs, but

this may have been secondary to infrequent catheterizations. Stomal stenosis has not occurred

in our limited series of patients. Other groups have used tapered ileum to create a tunneled

access into the right colon (Fig. 86–10) (Woodhouse and MacNeily, 1994; Hampel et al,

1995). Using tapered ileum for this purpose has the advantage of a blood supply independent

of the reservoir and no length restrictions while having the disadvantage of further limiting

intestinal absorptive surface.

Wiesner and colleagues (2007) recently compared their longterm results in 458

patients who underwent Mainz I pouch construction. The anastomosis was made using a

submucosal tunnel in 809 renal-ureteric units and using a serosa-lined extramural tunnel in 74

units. At 17 months postoperatively they found a significantly higher occurrence of

anastomotic obstruction in the submucosal tunnel group compared with the extramural group

(7.3% vs. 4.1%, respectively). Importantly, they found a much higher rate of obstruction in

patients with previously dilated upper tracts (14%) or with a history of neurogenic bladder

(17%). No significant deterioration of the upper tracts was identified. In another comparison

of patients with a Mainz I pouch, Wiesner and colleagues (2006) reported on 800 patients

with almost 8 years of follow-up. Overall continence was approximately 93%. Stomal

stenosis occurred in 23.5% of patients with a submucosally embedded in-situ appendix,

whereas stenosis was reported in 15.3% of patients with intussuscepted ileal nipple valves.

Rates of calculi formation were the reverse: 10.8% incidence in patients with an ileal nipple

valve and only in 5.6% of patients with an appendix stoma. Ischemic degeneration of the

continence mechanism occurred almost three times more often in the appendiceal group.

Right Colon Pouches with

Intussuscepted Terminal Ileum Additional pouches using nipple valve technology for the

continence mechanism include those right colon pouches in which intussusception of the

terminal ileum and ileal cecal valve is employed. As such, they are variations on the

continent cecal reservoir initially described by Mansson (1987) that employ an intact cecal

segment. These three pouches are the Le Bag (Light and Scardino, 1986), Duke pouch

(Webster and King, 1987), and UCLA pouch (Raz, personal communication, 1989). These

surgeries differ from each other only by a few features mainly related to the technique

employed for stabilizing the nipple valve. Unless the appendix is being used as a continence

mechanism, appendectomy must be performed in all cases because an in-situ appendix would

serve as a nidus for infection and abscess formation. These operations were described in

detail in the prior edition of this text. Since then, no new modifications to these procedures

have been reported, and they are not further described here. The reader is referred to the prior

edition of this text for an in-depth description of these operations.

Indiana Pouch

The 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. This operation, which involved the partial

spatulation of the cecal segment and attachment of an ileal patch, represented major

contributions to the original ileocecal reservoir as described by Gilchrist and colleagues

(1950), in which the intact bowel reservoir was employed and no attempt was made to

strengthen the ileocecal valve. Originally, strengthening the ileocecal valve consisted of a

double row of imbricating sutures taken to the entire ileal segment (Rowland et al, 1985,

1987). It soon became apparent that this was necessary only in the region of the

ileocecal valve. “Neourethral” pressure profiles showed that the continence zone was

confined to the region of the reconfigured ileocecal valve (Bejany and Politano, 1988). The

remaining “neourethra” could be tapered and brought through an abdominal or perineal

stoma. At Indiana University, as well as other institutions, it became clear that the concept of

marsupializing only a portion of the ascending colon segment left enough peristaltic integrity

in the cecal region to generate pressures sufficiently high to overcome the continence

mechanism in some patients. A number of groups contributed to the concept of using the

entire right colon or more, marsupializing the entire structure and refashioning it in a

Heineke-Mikulicz configuration (Lockhart, 1987; Bejany and Politano, 1988; Benson et al,

1988; Rowland, personal communication, 1989). These variations have been entitled the

Florida pouch (Lockhart, 1987) and the University of Miami pouch

(Bejany and Politano, 1988). However, they represent relatively minor variations on the

theme of the Indiana pouch.

Procedure. The Indiana pouch, in its present form, involves isolating a segment of terminal

ileum approximately 10 cm in length along with the entire right colon to the junction of the

right and middle colic artery blood supplies (Fig. 86–11A). After bowel continuity is re-

established, appendectomy is performed and the appendiceal fat pad obscuring the inferior

margin of the ileocecal junction is removed by cautery (see Fig. 86–11B). The entire right

colon is opened along its antimesenteric border, and ureteral-taenial implants are fashioned

(see Fig. 86–11C). The ileocecal junction is buttressed according to various reported

techniques. Using nonabsorbable sutures, interrupted Lembert sutures are taken over a

distance of 3 to 4 cm in two rows for the double imbrication of the ileocecal valve as

described at Indiana University (see Fig. 86–11D). The second row of sutures should attempt

to bring the opposite mesenteric edges of ileum together, usually over a 12- to 14-Fr catheter.

These two rows of sutures should be placed approximately 8 mm from one another, and the

initial suture in each row may be taken in a purse-string fashion around the cecal margin as

well. Alternatively, the University of Miami group suggests placing purse-string sutures in

the same ileal region (Bejany and Politano, 1988). Finally, the Tampa group suggests

placement of apposing Lembert sutures on each side of the terminal ileum (see Fig. 86–11E).

The remaining ileum can be tapered over the catheter and excess ileum removed with a

stapling technique (see Fig. 86–11F).

It is important to carry out the imbrication while the cecal reservoir is still open (Rowland,

1996) so that the gradual closure of the ileocecal valve can be closely observed. The pouch is

then closed in a Heineke-Mikulicz configuration with a running absorbable suture. Ureteral

stents and a suprapubic tube are taken through a stab wound in the pouch and led through the

right lower abdominal quadrant. The pouch is rotated so as to bring the ileal neourethra as

close as possible to the selected stoma site. A fingerbreadth-width skin button is transected

along with a similar button from the anterior and posterior fascia. The ileal neourethra is

advanced between bundles of the rectus muscle through the stoma, and excess ileum is

transected. The ileal edges are sewn to skin with interrupted sutures so as to create a flush

stoma. In addition to the differences in the technique of ileocecal valve imbrication, both the

University of Miami and the Florida pouches differ in the amount of colon used. The entire

ascending colon and the right third or half of the transverse colon is isolated along with 10 to

12 cm of ileum. The entire upper extremity of the large bowel is mobilized laterally in the

fashion of an inverted U (Fig. 86–12A). The medial limbs of the U are sutured to one another

after the bowel is spatulated (see Fig. 86–12B). The bowel plate is then closed side to side

(see Fig. 86–12C). This inverted-U closure, however, is exactly the same as a Heineke-

Mikulicz reconfiguration.

Recent modifications to the Indiana reservoir allow for more rapid construction and a lower

complication rate (Rowland, 1996). The modifications incorporate the use of metal staples to

create the efferent limb and absorbable staples to fashion the reservoir. The concept of using

a metal GIA stapler to fashion the efferent limb was first introduced by Bejany and Politano

(1988). Carroll and Presti (1992) reported on the urodynamic features of the stapled and

plicated terminal ileum and found that the stapled limb performed equally well and was easier

to construct. The use of absorbable staples to create this and other types of reservoirs is

described later in the chapter.

Postoperative Care and Comments. The postoperative care of the patient with an Indiana

pouch or its variants is not substantially different from that used in patients with other right

colon catheterizable diversions. In early reports, Rowland recommended discharging the

patient with the suprapubic tube in place until readmission to the hospital 3 weeks later for

tube removal and instruction in self-catheterization. In the current medical climate, which

places a premium on outpatient procedures, tube removal and catheterization instruction is

now an ambulatory procedure at most institutions including Indiana University (Bihrle,

1997).

Average pouch capacities of 400 to 500 mL have been reported by the Indiana group

(Rowland et al, 1987). Combining the partially and totally spatulated bowel procedures, this

group reports a reoperation rate of 26%. Overall continence rates of 93% were achieved.

Elegant urodynamic studies were conducted in Indiana pouch variants by Carroll and

colleagues (1989). They found only 86% of patients totally continent in a small series.

However, their pouch capacities exceeded 650 mL, and peak contractions of 47 cm H2O

were recorded at capacity. The last 81 patients operated on by Rowland underwent

construction of a stapled efferent limb, and, in the last 20, the reservoir was created with

absorbable staples (Rowland, 1996). The results in this group of patients were extremely

favorable.

Early pouch-related complications occurred in only three patients (3.7%). Two patients

experienced a pouch leak that was managed conservatively, and one patient required open

revision of the efferent limb owing to difficulty with catheterization.

Early complications not directly attributable to the pouch occurred in seven patients (8.6%).

Transient small bowel obstruction was the most common complication, occurring in four

patients (4.9%). One patient developed a superficial wound infection, and one patient

developed an abdominal abscess requiring surgery (1.2%). Late complications associated

with the reservoir occurred in 23 patients (28.4%). Incontinence occurred in six patients

(7.4%): In five patients it occurred secondary to high pouch pressures, whereas in the

remaining patient it was due to failure of the efferent limb. One of the former and the latter

patient underwent reoperation. Three patients (3.7%) developed stomal stenosis, and three

had parastomal hernias; all six underwent surgery. Pouch stones occurred in three patients:

One underwent open removal, and two had endoscopic extraction. Acute pyelonephritis was

seen in four patients (4.9%). The most common late complication not related to the pouch

was small bowel obstruction; this was seen in six patients and managed conservatively

in five. In summary, the early reoperation rate was 2.5% and the late reoperation rate 14.8%.

At 1 year, daytime and nighttime dry intervals of 4 hours or greater were achieved

in 98% of patients. Eighty-four percent of patients stated they slept through the night without

the need to awake for catheterization.

Similarly excellent results in the last 150 patients, 50 with at least 2.5-year follow-up, were

reported by Birhle (1997). The Florida pouch has been performed in more than 190 patients

(Helal et al, 1993). In 165 patients involving 326 ureters, no attempt was made to create a

tunneled reimplantation. This approach was adopted owing to the high incidence of ureteral

obstruction encountered in the first 30 ureters that were tunneled into a Florida pouch (4

patients, 13.3%). In the last 165 patients, 16/326 ureters (4.9%) developed primary

obstruction and were treated by percutaneous balloon dilation, nephrectomy, or observation.

Although no attempt is made to create an antirefluxing anastomosis, only 7.1% of the ureters

implanted demonstrated reflux. All are being followed conservatively, and no renal

deterioration has been demonstrated. In the initial 100 patients, a 7.2% reoperation rate was

reported (Lockhart, 1987). Although hyperchloremia was noted in 70% of patients, only four

patients (including those who had pre-existing renal disease) required treatment. Reservoir

capacities ranged from 400 to 1200 mL, and maximal reservoir pressures at capacity ranged

from 18 to 55 cm H2O (Lockhart, 1987). The reason why these authors experienced

such a high incidence of ureteral obstruction with both nontunneled and tunneled ureteral

colonic anastomoses is not clear. It is also surprising that only 23 of 326 ureters that were

anastomosed end to side had reflux.

The University of Miami group has reported on its results in 75 patients. Early complications

occurred in 19 patients (25%). Sixteen patients (21%) experienced late complications. The

success rate of the ureterocolonic anastomosis was 90%, and total continence occurred in

98.6% of patients. Average pouch capacities were 750 mL or higher, and end filling pressures

of 20 cm H2O were reported. No patient required alkali therapy.

The Indiana pouch remains one of the most reliable of all catheterizable reservoirs. It is

among the easiest to construct and has low short-term and long-term

complications.

Penn Pouch

The Penn pouch was the first continent diversion employing the Mitrofanoff (1980) principle

in which the appendix served as the continence mechanism. As mentioned earlier, this

operation enjoys the singular feature of affording a catheterizable continent diversion that can

be performed using techniques already present in the urologic armamentarium.

Procedure. Two techniques of appendiceal continence mechanisms have been reported.

Mitrofanoff reported excising the appendix with a button of cecum and reversing it on itself

before tunneled reimplantation (Mitrofanoff, 1980; Duckett and Snyder, 1986). Alternatively,

Riedmiller and colleagues (1990) left the appendix attached to the cecum and buried it into

the adjacent taenia by rolling it back onto itself. A wide tunnel is created in the taenia

extending 5 to 6 cm from the base of the appendix (Fig. 86–13). Windows are created in the

mesoappendix between blood vessels. The appendix is folded cephalad into the tunnel, and

seromuscular sutures are placed through the mesoappendix windows to complete the

tunneling. The tip of the appendix is amputated and brought to the selected stoma site. As

described by Duckett and Snyder (1986), an ileocecal pouch is created by isolating a segment

of cecum up to the junction of the ileocolic and middle colic blood supplies along with a

similar length of terminal ileum. These two structures are marsupialized on the

antimesenteric borders and sutured to one another in the form of a neotubularized pouch. The

superior margin of the pouch is sutured in a transverse fashion (all sutures being of

absorbable material). A button of cecum surrounding the origin of the appendix is

circumcised, and the resulting cecal aperture is closed with running absorbable suture. The

mesentery of the appendix is dissected carefully from the base of the cecum, thereby

preserving its blood supply. The appendix is then reversed on itself so that the cecal button

can reach the anterior abdominal wall and the tail of the appendix can be directed to the

taenia of the colon (Fig. 86–14). The appendiceal tip is obliquely transected and may be

spatulated. Then a tunneled appendiceal-taenial implantation is carried out. If additional

appendiceal length is required, the variation proposed by Burns and Mitchell (1990) of

creating a tube from the base of the cecum can be employed (see Fig. 86–3). Instead of

simply removing the appendix with a button of cecum before preparing it for tunneling, the

entire base of the cecum leading to the appendix can be resected in continuity with the

appendix by the application of the GIA stapler. The authors have found it helpful to spatulate

the distal tip of the appendix until it accommodates a catheter at least 12- to 14-Fr in

diameter.

Postoperative Care and Comments. Although not shown in Duckett’s surgical drawings, the

authors would suggest that a large-bore suprapubic tube be used to drain the pouch in the

early postoperative interval. The size of the catheter admitted by the appendiceal stump is

insufficient to allow for the passage of ureteral stents along with the 12- to 14-Fr catheter. In

addition, safe irrigation of mucous debris is best managed by a larger-bore catheter.

Many groups have used the Mitrofanoff principle owing to the simplicity and reliability of

the continence mechanism (Burger et al, 1992; Bissada, 1993; Sumfest et al, 1993;

Woodhouse and MacNeily, 1994; Hampel et al, 1995). Woodhouse and MacNeily (1994)

reported on a series of 100 patients who underwent surgery between 1985 and 1993. They

employed seven different catheterizable conduits into six different types of reservoirs.

Although they found the Mitrofanoff principle to be versatile and associated with a high

success rate (91% continence), the reoperation rate for tube complications was 33%. Sumfest

and colleagues (1993) affirmed the use of the appendix as the Mitrofanoff segment of choice.

They reported a continence rate of 96%. In their hands, late complications included difficulty

with catheterization in 10.6% and stomal stenosis in 19.1%. Urodynamic properties and

pouch capacities will be a function of the reservoir constructed. Most often, the appendix is

used in situ (Burger et al, 1992), and the right colon, either alone or with associated terminal

ileum (Mainz), serves as the reservoir. We have used the in-situ appendix with a

detubularized right colon reservoir and the native ileocecal valve as an antireflux mechanism

(refluxing ureters implanted end to side into terminal ileum). In our hands this has resulted in

an excellent success rate with no upper tract problems. The adequacy of the ileocecal valve as

an antireflux mechanism was also reported by Alcini and colleagues (1994). In their series,

however, the reservoir was not always detubularized and, as expected, upper tract

complications ensued owing to high reservoir pressures. This procedure is uniquely capable

of affording continent cutaneous diversion to the patient with short ureters because the

terminal ileum can be left long enough to reach high into the retroperitoneum.

Gastric Pouches

Pioneering animal experimentation demonstrated the feasibility of employing stomach as a

bladder patch or urinary reservoir (Sinaiko, 1956; Rudick et al, 1977; Leong, 1978). The use

of the stomach to create a urinary reservoir has theoretical and real advantages (Adams et al,

1988). First, electrolyte reabsorption would be greatly diminished by using this bowel

segment in the reservoir. This would potentially make the stomach the selected reservoir for

individuals with pre-existing metabolic acidosis or renal insufficiency. Hyperchloremic

acidosis would not be an anticipated problem; in fact, in addition to presenting a barrier

against the absorption of chloride and ammonium, the gastric mucosa secretes chloride ions

(Piser et al, 1987). Furthermore, in patients in whom shortening of the bowel may be

expected to lead to some degree of malabsorption, the use of stomach is an attractive

alternative.

The acid pH of the urine may also reduce the risk of bacterial colonization. Finally, when the

entire lower bowel has been irradiated, stomach tissue may provide healthy nonirradiated

tissue for use in performing continent diversion. Given these theoretical advantages, a

number of groups have initiated trials with gastric pouches and composite reservoirs in both

pediatric (Adams et al, 1988) and adult populations (Lockhart et al, 1993; Austin et al, 1997).

Procedure. A wedge-shaped segment of stomach with maximal width of 7 to 10 cm is

fashioned from the greater curvature. Care is taken not to extend the wedge through to the

lesser curvature to preserve vagal innervation and normal gastric emptying. The left

gastroepiploic artery is preferentially used as the blood supply for the isolated gastric wedge,

dividing the short gastric vessels from the more proximal artery up to the gastric fundus.

Alternatively, if there is a problem with the left artery, the right gastroepiploic vessel may be

employed, dividing the short gastric vessels to the level of the pylorus (Fig. 86–15A and B).

The stomach is then closed according to the surgeon’s preference. Neither

gastroduodenostomy nor gastrojejunostomy is mandatory unless the antrum of the stomach

has been used. The isolated wedge is refashioned into nearly a sphere by folding it back on

itself and suturing the edges together with running absorbable material.

Before pouch closure, one ureter is tunneled into the reservoir according to the surgeon’s

preferred antireflux technique. Contralaterally, proximal transureteroureterostomy is

performed. The contralateral distal ureter is used to create the continence mechanism.

The distal ureter is tunneled into the reservoir in a fashion similar to an appendiceal implant.

The free portion of the ureter can then be brought to the skin or to the introitus (or urethral

stump in males) to serve as a catheterization portal (see Fig. 86–15C). Alternatively, the

wedge of stomach can be incorporatedinto a reservoir composed of detubularized ileum

(Lockhart et al, 1993). In this procedure, an 11-cm long segment of stomach is isolated on the

right gastroepiploic blood supply (Fig. 86–16A). A 22-cm segment of ileum is then isolated,

opened along its antimesenteric border, and refashioned in a U shape (see Fig. 86–16B).

The edges of the stomach are then sutured to edges of the ileum with a running absorbable

suture of 2-0 PGA. This completes the reservoir. The ureters are tunneled into the stomach,

and a Mitrofanoff continence mechanism is created according to the preference of the

surgeon. For example, the group from the University of South Florida employs a tapered

segment of ileum (see Fig. 86–16C).

Postoperative Care and Comments. Adams and colleagues (1988) report mean pouch

capacities of 245 mL and end filling pressures averaging 35 cm H2O in a small patient

sample. Combining their experience of gastric continent diversion and gastrocystoplasty,

they report minimal mucus production: Only 3 of 13 patients required any irrigations, and the

majority maintained sterile urine. Urine pHs have ranged from 4 to 7, but no introital

ulceration from acid urine was reported. Three patients had minor elevations of serum

gastrin, and none of the continent divisions required reoperation. Leong (1978) has used

similar concepts in gastric pouch construction and has alluded to the creation of a voiding

pouch created from stomach as well.

The construction of reservoirs entirely from stomach has not seen widespread

acceptance. Rather, there has been greater use of stomach segments either for bladder

augmentation or as a portion of a reservoir (composite) either alone or with an in-situ

catheterizable tube fashioned from a portion of the stomach (Gosalbez et al, 1994; Carr and

Mitchell, 1996).

Goslabez and colleagues (1994) reported on 15 patients who received a gastric tube as

part of a composite gastric patch. Complications associated with the gastric patch and in-situ

tube included one each of early traumatic perforation of the tube, distal tube stenosis, and

mucosal redundancy. Two of these patients required reoperation. Peristomal skin irritation

from acid secretion occurred in two patients but was not considered severe. This is a more

frequent complication in other reports and has resulted in skin breakdown in some instances.

Over a 10-year period from January, 1985, to June, 1995, Carr and Mitchell (1996)

reported on the use of stomach in 12 patients. Seven had urinary reservoirs totally constructed

from stomach, whereas five had composite reservoirs. They report continence in all patients

but that the continence mechanisms have often required revision. Average bladder capacity

was 309 mL, and average compliance was 12.9 mL/cm H2O. When stomach is used as a

bladder augment or as a portion of a neobladder, a dysuria and hematuria syndrome has been

reported (Nguyen et al, 1993).

Austin and colleagues (1997) reported on nine adult patients with a mean follow-up of

54 months who underwent construction of a continent composite reservoir that was

gastroileal in seven and gastrocolonic in two. All nine patients had either preexisting

metabolic acidosis or a short bowel syndrome. All nine patients achieved electrolyte

neutrality, and postoperative serum pH was significantly improved (P < .01). Three patients

had a short-term serum gastrin elevation, which returned to normal during follow-up. One

patient developed skin ulceration at the stoma site.

The use of stomach has particular appeal in the pediatric population in which the

stomach’s unique acidbase properties can be used to not only reconstruct but also help correct

the metabolic problems that are often associated with the need for pediatric urinary

reconstruction (Carr and Mitchell, 1996). Although experience with use of the stomach

remains small, its various unique intrinsic properties as a reservoir suggest that its use will

continue in selected clinical situations.

QUALITY OF LIFE ASSESSMENTS

Extraordinarily few well-designed, prospectively conducted studies using validated

instruments exist to assess quality of life after continent cutaneous urinary diversion. In fact,

no randomized prospective trial has ever been conducted to compare the quality of life after

continent cutaneous diversion with either orthotopic continent diversion or incontinent

urostomy urinary diversion. Of those studies performed, there appear to be common flaws in

the study design and methods used that make any direct comparisons between continent and

incontinent diversions difficult (Gerharz et al, 2005).

In general, most quality of life studies show similar results between patients

undergoing both ileal conduit and cutaneous continent diversion, with the latter being

associated with improvements in stomal and urinary quality of life scores. In one of the few

prospective studies to compare quality of life after continent cutaneous and ileal conduit

diversion, Hardt and colleagues (2000) followed patients from the preoperative setting until 1

year after surgery. Using validated instruments tested for reliability, they found life

satisfaction improved over time in patients with continent cutaneous diversion, whereas it

worsened during the first year after ileal conduit construction. Using the Beck Depression

Inventory and Profile of Mood States in adults, Boyd and colleagues (1987) found that

patients choosing ileal conduit diversion had the lowest expectations of their quality of life.

Interestingly, they found the highest overall satisfaction among patients undergoing

conversion from ileal conduit to Kock cutaneous pouch diversion.

Mansson and colleagues (2002) found no difference in overall quality of life in men

undergoing continent cutaneous diversion when compared with orthotopic neobladder using

the FACT-BL and Hospital Anxiety and Depression Scale. In specific questions concerning

intestinal, urinary, and sexual function, patients with cutaneous reservoirs experienced less

difficulty with incontinence and emptied less frequently. Sexual function appeared better in

patients undergoing orthotopic bladder substitution, likely due to urethral preservation.

VARIATIONS IN OPERATIVE TECHNIQUE

Minimally Invasive Continent Cutaneous Diversion With

recent improvements in both laparoscopic and roboticassisted laparoscopic techniques,

radical cystectomy can now be performed in selected centers using these minimally invasive

techniques. The vast majority of centers performing minimally invasive cystectomy and

continent cutaneous diversion perform the urinary diversion via standard open techniques.

Turk has reported on an initial series of five patients who have undergone radical cystectomy

with bilateral pelvic lymphadenectomy and continent urinary diversion using a rectosigmoid

pouch performed with an intracorporeal laparoscopic technique. A bilateral stented antireflux

ureteral reimplantation was used, and laparotomy was not performed. Operative time was 7.4

hours with minimal blood loss and a mean hospital stay of 10 days. No intraoperative or

postoperative complications were encountered.

The complex nature of minimally invasive reconstructive surgery necessary in

continent cutaneous diversion has limited these procedures to select centers. In addition,

because of the prolonged time for return of postoperative bowel function, the benefits in

hospital stay routinely encountered after laparoscopic nephrectomy do not seem to exist when

urinary diversion is performed.

Conduit Conversion to a Continent Reservoir

The major indication for conversion of a functioning conduit to a continent urinary reservoir

is the patient’s desire for improved quality of life. Pow-Sang and colleagues (1992) reported

on conversion in 20 patients. Fifteen were converted from an ileal conduit, and one each from

a cecal conduit, ureterosigmoidostomy, cutaneous ureterostomy, sigmoid conduit, and a

suprapubic tube. In 14 of the 20 patients the conduit was discarded or used only as a patch to

a colonic reservoir. Renal units that were obstructed preoperatively were associated with a

71% failure rate. Metabolic acidosis was seen in 15 (75%) but was believed to be mild.

Pouch-related complications are, in general, a function of the reconstruction selected and

should not necessarily be higher in this setting. However, patient selection is important in

determining appropriate candidates for conversion.

The authors prefer to use the conduit in some form whenever possible. This strategy

was supported in a report on two patients by Oesterling and Gearhart (1990). The use of an

existing bowel segment has the potential to diminish metabolic sequelae and may result in a

lower complication rate. The form of continent reconstruction chosen will have to depend on

intraoperative findings, and no one procedure is more amenable than another. Before

undertaking conversion, the patient should be fully evaluated for disease recurrence, renal

functional status, urinary anatomy, hydronephrosis, intestinal length, and intestinal health.

Pahernik and colleagues (2004) have described the long-term outcomes of conversion

of 39 patients from conduit diversion to Mainz I pouch diversion. With a mean follow-up of

102 months, the most common complications were stomal stenosis and pouch calculi. Long-

term continence was achieved in 95% of patients.

Absorbable Stapling Techniques in Continent Urinary Diversion

The principle of bowel detubularization to increase reservoir capacity and diminish

the effects of peristalsis is a fundamental principle of all contemporary continent urinary

diversions. The process of detubularization and refashioning of the spatulated bowel segment

consumes at least 1 hour of operating time and is by far the most time-consuming and tedious

aspect of pouch construction. The use of absorbable staples has substantially reduced the time

required to fashion bowel reservoirs and has demonstrated short-term and long-term

reliability with respect to reservoir integrity and volume.

Bonney and Robinson (1990) first demonstrated the potential use of absorbable

staplers to substitute for conventional suturing of bowel reservoirs. These authors used a

bulky absorbable stapler (Polysorb staples in a TA Premium 55 stapler [US Surgical,

Norwalk, CT]) to construct an S pouch configuration in a canine ileal urinary pouch model.

Although the same stapler was used in humans by the authors in 1992 and by Cummings in

1995, its clinical use was never widely adopted because the bulky staple configuration

destroyed a significant portion of the bowel diameter, particularly when applied to the small

intestine. The fact that up to 20 costly staple cartridges were required to complete the closure

of a bowel reservoir further reduced the potential benefits of absorbable pouch construction.

A 75-mm GIA instrument (PolyGIA [US Surgical, Norwalk, CT]) that incorporates

substantially smaller absorbable staples was made available for clinical use in 1992. The

stapler delivers four rows of absorbable polylactic acid and PGA blend copolymer staples,

dividing the bowel between the second and third rows. Thus each staple line of the pouch has

a double, staggered, stapled closure. This device has enabled both the refashioning and

closure of bowel pouches to be performed with fewer staple applications and is strong and

watertight. Finally, the width of bowel sacrificed with the new instrument is appreciably less

than that with the older staple device. Several investigators have subsequently used the new

“absorbable” GIA stapler to construct catheterizable pouches and neobladders (Olsson et al,

1993; Montie et al, 1994, 1995; Olsson and Kirsch, 1995). However, it is important to note

that the absorbable PolyGIA staples must not overlap because this will result in the failure of

the staples to lock together. This is in direct contrast to metal staples, which are meant to

overlap to create anastomotic integrity. As a result of the need to prevent overlap of

absorbable staples, the reservoir construction procedures must be varied when using such

staples, as described next.

Surgical Techniques

Right Colon Pouch

In 1993 the authors described a technique using the absorbable GIA staplers to fully

detubularize and refashion large bowel (Olsson et al, 1993). The technique of colon pouch

construction described here incorporates the principles of bowel detubularization and

refashioning using absorbable staplers in a

simple “one-step” process.

The right colon and 10 cm of terminal ileum are mobilized by incising the peritoneum

along the white line of Toldt and along the base of the mesentery and are isolated using metal

GIA staplers (Fig. 86–17A). After bowel continuity is restored with standard metal GIA and

TA staplers, the distal staple line of the right colon is excised and the bowel lumen is irrigated

to remove residual enteric contents. Using electrocautery, a small opening (2 cm) is created

on the antimesenteric border of the cecum to fit the absorbable stapler. The distal open end of

the colon is aligned with the cecostomy by folding the right colon on itself, as depicted in

Figure 86–17B. The limbs of the absorbable GIA stapler are inserted into the distal open end

and into the cecostomy, and the stapler is fired along the antimesenteric line of the apposed

folded bowel (see Fig. 86–17C). It is necessary to evert the bowel to continue subsequent

staple applications. This may be achieved by placing Babcock clamps on each side of the

distal staple line (see Fig. 86–17D). A small incision at the junction of each staple line is

made to prevent overlap of the absorbable staple rows and to allow for the next staple

application. Because of this incision, there is often a short unstapled area at the junction

between each application of the stapler, requiring one or two simple figure-of-eight sutures of

2-0 absorbable material at each of these points. The last staple application traverses the apex

of the fold of bowel. In adults, three to four applications of the stapling device have been

required to construct the right colon pouch, whereas in children two to three staples suffice.

The appearance of the nearly completed pouch is illustrated in Figure 86–17E.

Once the generic right pouch has been fashioned, several options exist for ureteral

anastomosis and formation of a sphincter mechanism. These maneuvers may be approached

through the coalesced distal colon opening and cecostomy, which accesses

the interior of the pouch (see Fig. 86–17E). The opening permits appropriate stent placement

or inspection of a buttressed ileocecal valve. Any of the Mitrofanoff techniques described in

conjunction with the Mainz I procedure can be employed. Likewise, the terminal ileum can

be either stapled or plicated to create a continence mechanism. Once construction of a

continence mechanism and ureteral anastomoses has been performed, the opening can be

closed with a running 2-0 absorbable suture or the application of an absorbable TA stapler of

appropriate length.

Continent diversion procedures commonly employ the right colon or the cecum and

terminal ileum. The array of right colon pouches that can be facilitated by this technique

include all of the reservoirs described previously. Reservoirs using terminal ileum and cecum

such as the Penn Pouch and the Mainz Pouch can also be fashioned in this manner.

Stapled Sigmoid Reservoir

The same stapling maneuvers can be applied to create a reservoir constructed from the

sigmoid colon (Olsson and Kirsch, 1995). A portion of the sigmoid and descending colon

measuring approximately 35 cm is mobilized by incising the peritoneum along the white line

of Toldt. Once mesenteric windows have been created, the segment of colon is isolated using

metal GIA staplers (Fig. 86–18A). Restoration of bowel continuity is achieved with either

GIA, TA, or EEA staple devices.

Each of the metal stapled ends of the isolated colon are excised, and the bowel lumen

is irrigated. The isolated sigmoid is folded on itself in a U configuration, aligning both open

ends (see Fig. 86–18B). The absorbable GIA stapler is inserted into the open bowel ends and

fired along the antimesenteric line of the folded bowel (see Fig. 86–18C). Following the

procedure for bowel eversion as described earlier completes the reservoir. Again, usually two

or three applications of the stapler are required to complete the pouch, cutting each staple line

tip to avoid staple overlap.

After bowel reinversion, ureteral implants into the taenia can be carried out, using the

residual colon opening to assist stent passage. These stents and a suprapubic tube are led

through a separate stab wound in the pouch and brought through a lower abdominal wall stab

incision. A continence mechanism employing one of the Mitrofanoff variations is then

performed.

W-Stapled Reservoir

Montie and colleagues (1994) used the absorbable GIA stapler to construct ileal neobladders

in patients undergoing cystoprostatectomy.

A segment of ileum measuring 50 cm is divided with a standard metal GIA stapler 20 cm

from the ileocecal valve. The terminal ends of each limb of the isolated ileal segment are

closed with an absorbable TA-55 stapler, and the metal staple line is resected. The bowel is

aligned in a W configuration, and an enterotomy is made 10 cm from each end (Fig. 86–

19A). To assist

To assist closure of the enterotomy with a TA instrument (see Fig. 86–19, inset), the

enterotomy must be made midway between the mesentery and antimesenteric border. The

absorbable GIA device is inserted through the enterotomy and is activated. This maneuver

adjoins the two adjacent bowel segments. The enterotomy may be closed with the absorbable

TA-55 instrument or running absorbable suture, completing the distal segment of the W. The

middle and proximal segments are constructed similarly (see Fig. 86–19B).

Montie stresses that the segments of the W must be offset to avoid staple lines that overlap

each other. Exceeding a 3 to 6 cm overlap may result in bowel ischemia.

Postoperative Care and Comments

In the first 50 adult patients to undergo our absorbable stapling technique in right colon

pouch construction, with at least 7 years of follow-up, there have been no complications

attributable to absorbable staples. Similar results have been reported by Rowland (1996). In

the pediatric population, we have applied the absorbable stapler to continent urinary

diversion, as well as to bladder augmentation (Hensle et al, 1995). In the first 18 children

observed for up to 3 years, there have been no instances of pouch perforation or inadequate

pouch capacity and, to date, only one of the\ patients has developed a reservoir calculus.

Montie and colleagues (1994) used absorbable staplers to create W-stapled ileal

neobladders in 25 patients. Ileal pouch construction was performed in approximately 20

minutes, and functional aspects were comparable with bowel reservoirs constructed by

conventional suturing. Urodynamic evaluation at 6 months, however, documented a small-

capacity reservoir requiring augmentation enterocystoplasty in 3 of 25 patients (12%). Montie

and colleagues attributed this complication to either the size of the staples or reservoir

fibrosis secondary to foreign body reaction. It is conceivable that a similar situation would

arise when constructing a W-stapled T pouch.

The authors have used the absorbable stapler to construct both large and small bowel

reservoirs. In our experience, colonic pouches appear better suited for construction with the

absorbable stapler because of their relatively larger lumen. The introduction of stapling

devices delivering still smaller staples and automatic staple line sealing devices may prevent

the problems presently seen when ileal pouches are constructed with current technology.

SUMMARY

In summary, continent urinary diversion is now an accepted part of the urologic surgical

armamentarium. A wide array of surgical techniques exists to accomplish the desired goal of

creating a continent, stomal-free, nonrefluxing pouch. A paucity of long-term quality of life

studies exists to compare outcomes between continent cutaneous urinary diversion and ileal

conduit urinary diversion. Surgeons contemplating these forms of urinary diversion should

familiarize themselves with several of the techniques and the management of the most

common complications.