CONTINENT

URINARY DIVERSION

Continent Urinary Diversion

• Urinary diversion is indicated when bladder can no longer safely function as a reservoir.

• People are performing the diversion for past 150 year.

HISTORICAL MILESTONES

Extrophy.

1878- Ureterosigmoiodostomy {Direct anastomosis) {Smith}

1898- Rectal Bladder {Gersuny}

1950- Ileal Loop {Bricker}

1959- Ileal Neo Bladder {Camay} 1851- Ureteroproctostomy by Simon on a patient with

1970- Koch Pouch

1980- Indiana Pouch

1980- Ortotobic, Diversion

Non Continent Diversion

• Diversion into a non continent conduit

• Require a segment of bowel {ileum, colon, least

common jejunum}

• Mobilized on a vascular pedicle

• One end anastomosed with ureter {proximal end}

• Other end used for stoma formation over which

collecting device {urostomy appliances} are

required

Advantage and disadvantage

• Less technically demanding

• Low complications

• Low incidence of metabolic, nutritional complications

• Disadvantages are poor quality of life , life long stoma appliances & complications, low self esteem

Continent urinary diversions• Widely accepted by urologist and patients• Technically challenging • Associated with more complications• With advent of stapler , absorbable clips the

construction of pouch has become easier• The basic principle is to configurate a spherical

reservoir.• Should able to store urine at low pressure • Should be continent ; either catheterisable or neo

bladder

Indication of urinary diversion

Ca bladder requiring cystectomy

Dysfunctional bladder {secondary to radiation,

neurogenic bladder resulting in persistent

bleeding , obstructed ureter, poor compliance ,

upper tract deterioration , inadequate storage ,

total urinary incontinence

Intractable incontinence in female

Principle of continent urinary diversionPatient must be skillful , good hand eye coordination {CIC}

Serum creatinine < 2 mg/dl or creatinine clear > 60ml/min

If functions are borderline , otherwise good candidate for

diversion (gastric pouch is appropriate, excretion of HCl –

Beneficial)

physiological age- less than 70

Obesity relative C/I- sometimes better as appliances are difficult

to manage in fatty patients

Advanced stage of ca bladder – not absolute c/I {significant

number of patients has good life expectancy}

Critical to successful is large volume , low pressure reservoir

without reflux or absorption of urinary constituents

Patient selection

Honest , informed consent

Aim should be free from cancer,

During neo bladder formation,consent for cutaneous diversion/stoma should be obtained

Radiological evaluation of bowel , rhabdosphincter should be intact.

Distal urethral margin should be free from cancer.

Work upGeneral physical examinationAssessment renal functionS Creatinine < 2 mg/dl, Creatinine clearance > 60 ml/minCBC, BUN, Urine R/M & C/SABG

Radiology: USG :for upper tract anatomy , PCS, calculus, mass lesionIVP: anatomical , functional status of kidneyDTPA: assessing renal function ( contrast allergy) ,

drainage assessment {Lasix}CT: NCCT- for stoneCECT- for primary disease , assessment of diversion ,

fistulaMRI: if USG , CT findings are unequivocalurodynamic

Type of continent urinary diversion

1. Ureterosigmoidostomy

2. Continent catheterisable pouch

3. Orthotopic urinary diversion or neo

bladder

Ureterosigmoidostomy

• Original continent urinary diversion {1850 by Simon}

• Direct anastomosis of ureter into sigmoid

• Simplest.

• pre op workup- r/o diverticulitis , IBD ,integrity of sphincter

• patient must be able to hold enema 400-500ml for 1 hour.

• Increased chance of carcinoma & metabolic complications

• Patient with dilated ureter, neurogenic bladder, renal

insufficiencies, extensive pelvic radiotherapy, hepatic

dysfunction are not candidates.

• Almost obsolete.

Ureterosigmoidostomy

Other continent diversion requiring intact anal Other continent diversion requiring intact anal sphinctersphincter

• Folded recto sigmoid bladder { s shape sigmoid}

• Augmented valved rectum – stoma appliance not

available

• Hemi Koch & T pouch procedure with valved

rectum- dilated ureter may be accommodated

• Sigma rectum pouch- Mainz II- low pressure recto

sigmoid

NON

ORTHOTOPIC EVACUATION Ureterosigmoidostomy

Folded Recto sigmoid bladder [with ureter anastomosis

antiserosal trough]

Augmented Valved Rectum {with using ileal patch}

Hemi Kock & T Pouch Procedure with valved rectum in c/o dilated ureter without cannot be brought between intussuscepted sigmoid {less chance of malignancy}

Sigma Rectum Pouch {Mainz II}

CATHTERISABLE STOMA {CIC}

Appendix IC valve with proximal tapered

ileum Nipple Valve Hydraulic valve

Pouches

Continent catheterizing pouches

Pouches which requires intermittent self

catheterization

dementia, quadriplegia, neurologic disorder multiple

sclerosis should not be offered this treatment

Technically demanding.

More complication rate

CONTINENT CATHETERIZING POUCHES

STOMA1} Rt. colon pouches-

appendiceal techniques, psuedo appendiceal tubes, ilieo caecal valve

2} tapered or ileo caecal valve

3}use of intussuscepted valve,flap valve {avoid need of intussusceptions}

4}Hydraulic valve as in Benchekroun nipple.

POUCHBowel pouchIleal with leaving IC

valve Kock pouch T pouch

Using IC valve MAINZ(tapered ileum)

Indiana (using IC valve ) Rt colon pouch with

intussusceptions ileum (UCLA, DUKE, LE BAG)

Appendix serving continence

PENN POUCH

Gastric pouch

Appendiceal continence techniques

• Simplest & effective

• Draw back- sometimes absent

• Appendiceal stump may be too short to reach

anterior abdominal wall

• sometimes difficulty in irrigation & removal of

mucus.

• only small lumen catheter can be passed

2nd continent mechanism– Use of tapered or imbricated or both terminal ileum &

ileocaecal valve – Loss of ileocaecal valve, associated with bowel irregularity

3rd continent mechanism is use of intussuscepted nipple valve/Flap valve– Most demanding technically – Highest complication & re-operation – Removal of mesenteric attachment from middle 6-8 cm of bowel reduces the effacement of intussusceptions.– 2nd attachment of valve with reservoir it self.– Potential for stone formation on exposed staple.

4th mechanism is hydraulic valve (Benckeroun nipple)– Small bowel segment is isolated & reverse intussusception.– Largely abandonned.

GENERAL METHODS OF CONTINENT DIVERSION

• Pouch is constructed meticulously [Reservoir]

• Should be checked for ease of catheterization intra op.

• Pouch is filled with saline and examined for leakage and test the efficacy of continence

• Postop pouch should be irrigated with large bore catheter 4hourly

• Contrast study is performed on 7th pod, thereafter stent can be removed.

ADVISE FOR CIC

• For appendix –no 14,16 coude tip catheter • Ileo-caecal plication – no 22 to no 24f coude tip• Nipple valve – straight ended no 22 to 24• Carry the catheter in zipper bag • To clean the stoma with benzalkonuim chloride

wipe • To lubricate the catheter by inserting the tip into

foil pack .• Cover the stoma with adhesive bandage • Catheter cleaning with tap water

Common Complication with Pouch1. Pouch hyper contractility- require antibiotic therapy for

at least 10 days ( if P.N then for longer Time)

2. Pouch urinary retention- true emergency coud tip catheter is helpful ,if not possible than flexible cystoscopy.

3. Intra peritoneal rupture of catherisable pouch – more common is neurological patient – require contrast study

4. If leak is small – catheter drainage & antibiotics may suffice for larger one exploration is required.

Gastric pouches – Indication: compromised renal function

metabolic acidosis H/o radiation to pelvic & small gut Pediatric age( low metabolic complication) Benefit : less mucus production less chance of infection due to low pH Secretes HCL which is beneficial for patient of

CRF

complications: hematuria Dysuria

Hypochloraemia Hypokalemia Metabolic alkalosis

Skin ulceration at stoma site

Orthotopic urinary diversionOrthotopic urinary diversion Basic principle, preparations are same

Beside these, following criteria should be met.

- Rhadosphincture must be intact -cancer operation should not be

compromised -Meticulous dissection of pelvic floor -frozen section analysis of distal urethral

margins is mandatory

Techniques of neobladderCAMEY II ORTHOTOPIC SUBSTITUTE modification of Camey I 65 cm long ileum arranged in transverse u shaped detubularization & reconfiguration uretero-ileal anastomosis by Le duc techniquePADOVA – modification of camey II - more spherical (vesical ileal pouch) S BLADDER ileum is configurted in S shaped rest all is same as above

HAUTMANN’ S ILEAL NEO BLADDER : 70cm of ileum. W shaped configuration of ileum. large capacity & spherical .

Uretero ileal anastomosis by le duc techniques

STUDER ILEAL NEOBLADDER

ileal neo bladder with long afferent , isoperistaltic ,tubular ileal

segment ORTHOTOPIC KOCK’S ILEAL RESERVOIR: obsoleteT POUCH ILEAL NEO BLADDER –

same as kock ileal neo bladder . defers in anti reflux technique .

maintenance of vascular arcades by opening the window of Daever.

STUDER ILEAL NEOBLADDER

Complications– Metabolic

- Surgical - Neuromechanical

Metabolic complications • electrolyte abnormality • Altered sensorium• Abnormal drug metabolism• Osteomalacia • Growth retardation {nutritional deficiencies} • Persistent & recurrent infections• Stone formation

• Development of cancer

Bowel Segmen

t

Na+ K+ Cl- HCO3- C/F Comment

Jejunum Low High Low Low Lethargy, Vomiting, weakness, dehydration

Refractory hyperkalemia with lack of efficacy of aldosteron {rarely used}

Ileum Colon

Low/normal

Normal

Elevated

Low Anorexia, weight loss, polydipsia, fatigue

Oral salt replacement, BI corbs supplementation

Metabolic disturbances associated with diversions

Surgical complications

– Ileus – bowel obstruction– entero cutaneous fistula– ureteral stricture– Para stomal hernia– stomal stenosis– urine leak– wound dehiscence – acute pyelonephritis – abdominal abscess– GI bleeding – Retention in the continent reservoir – Volvulus/rupture of reservoir

Cancer more common in uretero sigmoidostomy

because of intestinal mucosa is bathed in urine largely abandoned the uretero sigmoidostomy

FUTURE AND CONTROVERSYFUTURE AND CONTROVERSY

-OUD has gained popularity- refined, better body image .

No adverse effect on survival. Recurrent cancer also do well.

--Cellular matrix graft will be used as a substitute to bowel or urethra.

-sexual dysfunction is emerging as bigger issue and nerve sparing surgeries are getting preferences.

-OUD in females is gaining greater acceptance as fewer contraindication exist nowadays.

THANKS

Continent Catheterizing Pouches

– Continent ileal reservoir {kock pouch]– T pouch– Mainz pouch– Rt. colon pouches with intussuscepted terminal

ileum.– Indiana pouch– UCLA pouch– Penn Pouch– Benckeroun hydraulic valve pouch