Use of Intestinal segments in urinary diversion

DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITAL
KILPAUK MEDICAL COLLEGE
CHENNAI
Use of Intestinal
Segments in Urinary
Diversion
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MODERATORS:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI. 2

SURGICAL ANATOMY
STOMACH:
 The stomach blood supply primarily from the celiac trunk
 Three branches of the celiac axis
 1. left gastric (coronary) artery arises directly from the celiac axis and supplies the lesser curvature.
 2. hepatic artery - right gastric artery - supplies the lesser curve of the stomach
gastroduodenal artery - supplies the antrum and duodenum before giving off the right
gastroepiploic artery.
 3. splenic artery - vasa brevia (short gastrics), - supply the fundus and cardia, and the left gastroepiploic artery.
 The right gastroepiploic artery meets with the left gastroepiploic artery; thus both supply collateral flow to the
greater curve of the stomach.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

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 By use of the gastroepiploic vessels, a pedicle of stomach may be mobilized as far as the pelvis.
 pedicle may consist of the entire antrum pylori or a wedge of the fundus
 The blood supply is based on either the left or right gastroepiploic artery, depending on the portion of
stomach used.
 On occasion, the left GEA is atreticat some point in its course and does not provide an adequate blood
supply. then the right GEA must be used.
 When a wedge of fundus is used,
it should not include a significant portion of the antrum
never extend to the pylorusor all the way to the lesser curve of the stomach.
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 When the blood supply is based on the left GEA, the short gastric vessels that course from the gastroepiploic artery
to the stomach are ligated along the greater curvature proximal to the pedicle to the origin of the gastroepiploic
artery.
 The omentum is left attached to the gastroepiploic vessels and support them.
 for proper pedicle mobility, detach the omentum from the colon along the avascular plane located at the point of its
attachment to the transverse colon.
 If an antrectomy is performed, a Billroth I anastomosis reconstitutes gastrointestinal continuity.
 The stomach has a thick seromuscular layer, easily separated from the mucosa should a submucosal ureteral
reimplantation be necessary.
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SMALL BOWEL
 two-fifths of the small bowel is jejunum, distal three-fifthsis ileum.
 Ileum - distal in location, smaller diameter,multiple arterial arcades, and the vessels in the arcades are
smaller than those in the jejunum.
 ileal mesentery is also thicker than the jejunal one.
 The arcades anastomose one with another and give off straight vessels, which enter the bowel and form an
anastomoticnetwork within the bowel wall
 up to 15 cm of small bowel can survive laterally to a straight vessel.
 Thus, the mesentery could be cleared from the small bowel for a length of 15 cm without necrosis of the end.
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 however, it is unwise to assume that more than 8 cm of small bowel will survive away from a straight vessel.
 The arcades receive their blood from the SMA.
 When segments of jejunum or ileum are isolated, the mesentery should be transected in such a way that the
isolated intestinal segment receives its blood supply from an arcade supplied by a palpable artery of substance that
courses through the base of the mesenteric pedicle.
 Two portions of the small bowel may lie within the pelvis and may be exposed to pelvic irradiation and pelvic
disease: ( AVOID THEM!!)
1) last 2 inches of the terminal ileum, which is fixed in the pelvis by ligamentous attachments
2) 5 feet of small bowel beginning approximately 6 feet from the ligament of Treitz, the mesentery of which is the
longest of the entire small bowel.
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COLON
 cecum, In general, is fixed in the right lower quadrant.
 on rare occasion, may lie free within the abdominal cavity with great mobility.
 Two accessory peritoneal bands bind the cecum and distal ileum to the retroperitoneum and
lateral abdominal wall. - One band arises from the distal ileum, attaches to the cecum, and is
fixed to the retroperitoneum.
- second band arises from the cecum and fixes the cecum to the posterior abdominal wall
laterally.
 Remaining ascending colon is fixed to the right posterior abdominal wall at the level of the hepatic
flexure,
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 transverse colon lies free within the abdominal cavity
 The descending colon is fixed to the lateral abdominal wall;
 sigmoid colon may or may not lie free within the abdominal cavity.
 rectosigmoid colon’s cephalad portion is intraperitoneal, and at distal - retroperitoneal and finally
subperitoneal.
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 colon receives its blood supply from - SMA, IMA, IIA
 The major arteries supplying the colon and rectum - ileocolic, right colic, middle colic, left colic,
sigmoid, superior hemorrhoidal, middle hemorrhoidal, and inferior hemorrhoidal arteries.
 These arteries anastomose to form the arc of Drummond and leeway in mobilizing the colon.
 The middle colic artery arises from the first portion of the SMA (ascends the transverse mesocolon
to the right of midline.)
 The right colic artery usually arises just below the MCA from SMA.
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 The ileocolic artery is the terminal portion of SMA and supplies the last 6 inches of ileum and
ascending colon.
 The left colic artery arises from the IMA
 then the IMA gives off four to six sigmoid branches, the last of which becomes the superior
hemorrhoidal artery.
 This anastomoses with the middle hemorrhoidal artery, a branch of the internal iliac artery, which,
in turn, anastomoses with the inferior hemorrhoidal artery, the terminal branch of the internal
pudendal artery.
 The middle sacral artery, which originates directly from the aorta, may supply the posterior aspect
of the rectum.
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WATERSHED AREAS
 These are regions of the colon that receive dual blood supply from the most distal branches of two larger arteries.
 Due to small diameter of these distal branches - vulnerable to ischemia during hypotension or thromboembolic
event.
 Griffith’s point- the collateral communication between the MCA and the ascending LCA
important for perfusion of the splenic flexure and descending colon.
 Sudeck’s point - between the junction of the last sigmoid branch and superior hemorrhoidal artery,
near the rectosigmoid junction.
 Although anastomoses here usually heal well provided the principles of proper technique are followed
 but it is wise to select an area for the anastomosis to one side of these points, where the feeding arteries have a
larger diameter.
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MOBILIZATION
 ascending colon is mobilized by transecting the cecal and distal ileal fibrous attachments to the lateral abdominal
wall and retroperitoneum
then by detaching it from the lateral abdominal wall along the avascular line of Toldt.
 The transverse colon is mobilized by,
- dividing the gastrocolic omentum (along the avascular plane of its attachment to the colon)
- hepatocolic ligament (which may have some small vessels coursing through it),
- phrenocolic ligament.
 descending colon is mobilized by incision of the avascular line of Toldt .
 Further mobility is gained by isolating a pedicle of the intestinal segment on the basis of one of the major arterial
vessels.
15

SELECTING THE SEGMENT OF INTESTINE
STOMACH:
 The advantages of the stomach - less permeable to urinary solutes,
it has a net excretion of chloride and protons rather than a net absorption of them
produces less mucus.
Urodynamically, it behaves as other intestinal segments do.
electrolyte imbalance rarely ensues in patients with normal renal function,
(although hypochloremic metabolic alkalosis possible)
 there is no difference in bacteriuria among any of the segments.
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 The urine, which usually has a pH of 6 to 7, does not typically result in an increased peristomal
skin problems.
 Serum gastrin levels are usually normal or minimally elevated, depending on what portion of the
stomach is used and how much.
 antral exclusion may result in elevated circulating gastrin levels, leading to intestinal ulcerative
problems
 Long-term histamine (H2 receptor) antagonist or PPI should be considered for these patients.
 The antrum should not be used if the fundus is available.
 If the antrum is used, reconstitution is generally by a Billroth I anastomosis.
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stomach for urinary intestinal diversion may be considered in,
 severe renal dysfunction who don’t tolerate metabolic acidosis
 risk of short gut syndrome,
 In severe abdominal adhesions - stomach is, in general, adhesion free and easily
mobilized.
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Early complications ,
 gastric retention - atony of the stomach or edema of the anastomosis
 Hemorrhage - from the anastomotic site;
 hiccups secondary to gastric distention;
 pancreatitis - intraoperative injury;
 duodenal leakage.
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Delayed complications
 dumping syndrome,
 steatorrhea,
 small stomach syndrome,
 increased intestinal transit time,
 bilious vomiting, afferent loop syndrome, hypoproteinemia
 megaloblastic or iron deficiency anemia.
 bowel obstruction - upto 10%
 Gastroduodenal and gastroureteral leaks
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specific complications
1) hematuria-dysuria syndrome
 in approximately 24% cases
 Symptoms - bladder spasms; suprapubic, penile, periurethral pain;
gross hematuria without infection;
skin excoriation
dysuria without infection
 symptoms are typically intermittent and self-limiting, and can usually be controlled with H2 blockers.
 due to acid by the gastric segment,
2) Severe metabolic alkalosis associated with respiratory distress
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Jejunum
 usually not used due to severe electrolyte imbalance - hyperkalemia.
 Used when diseases that would make the ileum inappropriate
 When it is the only segment available.
 as distal a segment of jejunum as possible should be used.
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Ileum
 used most often for urinary tract reconstruction
 mobile and of small diameter, has a constant blood supply
used in ureteral replacement and the formation of conduits.
 Loss of significant portions of the ileum results - vitamin B12 def, diarrhea due to lack of bile salt reabsorption, and
fat malabsorption.
 Sometimes mesenteric fat is excessive, making mobility and anastomosis difficult.
 mesentery may be so short that it is difficult to mobilize the ileum into the deep pelvis.
 Postoperative bowel obstruction occurs in up to 10% of patients
23

Colon
 requires mobilization from its fixed positions to give it the mobility.
 easily mobilized into any area of the abdomen or pelvis.
 In pelvic irradiated cases, portions of the right, transverse, and descending colon may be used
 fewer nutritional problems compared to that of ileum(provided the ileocecal valve is not violated)
 bowel obstruction 5%,
 electrolyte imbalance – same as of ileum, type and frequencies.
 antireflux ureterointestinal anastomosis by the submucosal tunnel technique is easier to perform with use of the colon.
ILEUM VS COLON - does not argue strongly for the selection of one over the other except under
special circumstances.
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BOWEL PREPARATION
 two aspects : mechanical and antibiotic.
 Mechanical preparation reduces the amount of feces (and therefore the total
number of bacteria)
 antibiotic preparation reduces the bacterial count per gram of feces
(concentration).
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HISTORY
 Ureterosigmoidostomy is the oldest form of urinary diversion. The first reported urinary diversion into a segment of
bowel was by Simon in 1852. (in exstrophy)
 In 1950, Bricker refined and popularized the ileal conduit form of urinary diversion, (original description by Zaayer in
1911)
 Thomas smith (1898) – first direct Ureterointestinal implantation
 Coffey (1911) – first successful anti-reflux Ureterointestinal implantation
 earliest continent cutaneous diversions in humans was described by Gilchrist et al. in 1950
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 In 1982, Kock et al. subsequently reintroduced the concept of a continent cutaneous diversion with a technique
that was originally developed for a continent ileostomy after colectomy .
(skinner done in cystectomy pts)
 Kock demonstrated the importance of complete detubularization of the bowel segment and the double-folding
technique that creates the most spherical shape possible.
 orthotopic diversion,
Tizzoni and Pogg(1888) – in dogs
Lemoine(1913) – in human (during undiversion of ureterosigmoidostomy)
Camey and LeDuc (1979) – pioneering clinical experience
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URINARY DIVERSION
 Urinary diversion refers to the diversion of the urine from its natural path.
INDICATIONS
 Prostatic hypertrophy
 Injury to urethra
 Birth defects of the urinary tract, kidney or ureter
 Bladder stones
 Tumors of the genitourinary tract or adjacent tissues and organs
 Conditions causing external pressure to the urethra or one or both ureters
 Bladder cancer patients undergoing radical cystectomy
 Malfunctioningbladder
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CHARACTERISTICS OF AN IDEAL URINARY DIVERSION:
It should provide,
1.Undisturbed body image
1.Natural way of micturition
Continence of urine
Safe upper urinary tract
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CLASSIFICATION OF URINARY DIVERSION TECHNIQUES:
SUBTYPES:
1. Temporary/Permanent
2. External/Internal
3. Continent/Incontinent
4. Definitive/Palliative
5. Orthotopic/HeterotopicSubstitution
BASED ON THE TECHNIQUES,
1. Intubated diversion
2. Ureterocutaneous
3. Ureterointestinal
4. conduits
5. Continent reservoir
6. Bladder substitution/ Orthotopic
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TEMPORARY DIVERSION
1. Nephrostomy
- open
- percutaneous
2. Internal Ureteral stents
3. Suprapubic cystostomy (SPC)
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PERMANENT DIVERSION,
1. Urostomy or Noncontinenturinary diversion
- Intestinal Conduits
- cutaneous ureterostomy
2. Continenturinary diversion.
- Uretero-intestinaldiversion (Eg. Ureterosigmoidostomy)
- cutaneous
- orthotopic
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CUTANEOUS URETEROSTOMY / PYELOSTOMY
 as a temporary diversion to manage the infant with severe hydroureteronephrosisin anticipation of future
reimplant.
 Due to the high rate of stomal stenosisnot suitable for long term.
 High degree of ureter mobilization >> devascularisationand stenosisin approximately 60%.
 In order to avoid two stomas it is customary to perform a double barrelureterostomy.
 Stomal stenosismay be minimized by eversion of the ureters into a rosebud and by incorporatinga V shaped
skin flap into each ureterostomy.
 It is usually done when the bowel cannot be used - like in cases of Crohn’s disease or in radiation enteritis.
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INTESTINAL ANASTOMOSES
Surgical Principles
 adequate exposure
 maintain a good blood supply to the severed ends of the bowel.
 prevention of local spillage of enteric contents.
 accurate apposition of serosa to serosa of the two segments of bowel
 not to tie the sutures so tightly that the tissue is strangulated
 realignment of the mesentery of the two segments of bowel to be joined
41

STOMA
 Two types – 1) flush with the skin and
2) protrude (nipple or rosebud)
 The flush stoma is preferable for the continent type of diversion in which intermittent catheterization is carried out.
 Protruding stoma is preferable when a collection device is worn.
 two types of protruding stomas:
- end stoma
- loop end ileostomy.
 site - done by marking the stomal site with the patient in the sitting and supine position;
 over the rectus muscle at least 5 cm away from the planned incision line.
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 well away from skin creases, scars, the umbilicus, belt lines, and bone prominences.
 radiotherapy injured area should be avoided.
 placed through the belly of the rectus muscle and be located at the peak of the infra-umbilical fat
roll.
 bowel should traverse the abdominal wall perpendicular to the peritoneal lining (i.e., it should
come straight out).
 avoid trimming fat or epiploic appendages from around the margin of the stoma
 Loop End Ileostomy is preferred in obese – Obese patients have a thick abdominal wall and often
a thick, short ileal mesentery. This makes construction of an end ileal stoma extremely difficult.
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URETEROINTESTINAL ANASTOMOSES
 refluxing or non-refluxing anastomosis.
 Regardless of type of diversion, renal failure has been seen in 12.5%
 Deterioration of the upper tracts is due to - lack of ureteral motility, infection, or stones and less
commonly caused by obstruction at the ureteral-intestinal anastomosis.
 many have suggested that a non - refluxing anastomosis would minimize the incidence of renal
deterioration
 It does not appear that conduit pressures are transmitted to the renal pelvis
 successful construction of an anti-refluxing anastomosis does not prevent bacterial colonization of
the renal pelvis.
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 Only as much ureter as needed should be mobilized - no redundancy or tension
on the anastomosis.
 Do not strip the ureter of its periadventitial tissue.
 ureter should be cleared of its adventitial tissue only for 2 to 3 mm at its most
distal portion
 fine absorbable sutures, watertight mucosa-to-mucosa apposition.
 bowel should be brought to the ureter and not vice versa
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 bowel should be fixed to the abdominal cavity, preferably adjacent to the site of the
ureterointestinal anastomosis.
 anastomosis should be retroperitonealized or a pedicle flap of peritoneum should be placed over
the anastomosis.
 modern soft Silastic stents are effective in reducing the leak rate, subsequent stricture formation
 For submucosal tunnel in nonrefluxing anastomosis - inject saline with a 25-gauge needle
submucosally to raise the mucosa away from the seromuscular layer.
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colonic:
1) Non - Refluxing
 Leadbetter-Clarke
 transcolonic technique of Goodwin
 Strickler
 Pagano
2) Refluxing
 Nesbit
 Cordonnier
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Small bowel:
1) Refluxing:
 Bricker
 Wallace
 Ureteral dipping
2) Non-refluxing:
 Tunneled (submucosal)
 Split-Nipple
 Serosal compression of extra-mural ureter
 Le Duc
 Hammock
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COMBINED
TECHNIQUE OF
LEADBETTER AND
CLARKE
• nonrefluxing ureterocolonic
anastomosis by using a
submucosal tunnel.
• it combines the
ureterocolonic anastomosis
of Nesbit, which is a refluxing
elliptical anastomosis to the
intestine, with the tunneled
technique of Coffey.
51

TRANSCOLONIC
TECHNIQUE OF
GOODWIN
• nonrefluxing
• construction of a submucosal
tunnel
• the anastomosis is performed
from within the bowel
52

STRICKLER
TECHNIQUE
• nonrefluxing
• construction of submucosal
tunnel
• Advantage - taeniae do not
need to be aligned, one can
form the tunnel according to
the normal course of the
ureter and avoid angulation.
• reliably prevents reflux
• stricture rate of approximately
14%
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PAGANO TECHNIQUE
• nonrefluxing
• construction of a
submucosal tunnel
• low complication rate.
• leakage rate is 3%
• stricture rate is 6%
• reflux rate is 6%
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Cordonnier and Nesbit Techniques
 use no tunnel
 direct refluxing anastomoses of the ureter to the colon
 not desirable for ureterosigmoidostomies.
 performed in much the same way as a Bricker anastomosis in the small bowel
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Small Bowel Anastomoses
 two basic types: end to side, and end to end.
 The end-to-side anastomoses - refluxing or nonrefluxing manner.
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BRICKER
ANASTOMOSIS
• refluxing
• end-to-side
• simple and low complication
rate
• originally described for the
small bowel, it may be used
in any suitable intestinal
segment
• stricture rate - 6%
• leak rate is 3% in the
absence of stents
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WALLACE TECHNIQUE
• A frequently used , refluxing .
• end of the intestine is sutured to the end of the
ureter
• used with either small bowel or colon.
• three basic types of anastomoses
• lowest complication rate
• Stricture- 3%, of deterioration of the upper tracts -
4%, and leakage - 2%
• Historically, it was not recommended for patients
who have extensive carcinoma in situ or a high
likelihood of recurrent tumor in the ureter - that a
recurrence of tumor at the anastomotic line in one
ureter would block both ureters. This, however,is
exceedingly rare.
• It is actually be easier to survey endoscopically
because both ureters can be easily found next to
each other at the most proximal portion of the loop.
• lower rate of obstruction than a Bricker
anastomosis
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TUNNELED SMALL
BOWEL
ANASTOMOSIS
• nonrefluxing
• construction of a submucosal
tunnel
• Not widely used
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SPLIT-NIPPLE
TECHNIQUE
(GRIFFITHS)
• Non-refluxing
• using a nipple mechanism
• applied to either the small or
large bowel.
• formation of a nipple in the
ureter and implantation into
the small bowel
• Stricture – 7%
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LE DUC METHOD
• nonrefluxing
• laying the ureter onto the interior of
the bowel wall,
• eventually resulting in a submucosal
tunnel when it is re-epithelialized
• Stricture – 5%
• Leak – 2%
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Hammock Anastomosis
 conjoining the ureters and implanting them into the small bowel in a nonrefluxing manner.
 The small bowel is closed at its proximal end
 three 10-cm longitudinal incisions separated by 1 to 2 mm are made through the seromuscular layer to the mucosa
 These incisions are cross-hatched by multiple incisions. This serves as a hammock.
 The ureters are conjoined as in the Wallace technique and sutured to the intestinal mucosa.
Ureteral Dipping Technique
 simple to perform and has excellent success
 form the neobladder, and then make a small opening in the small bowel wall.
 ureter is “dipped” approximately 1 cm into the bladder cavity and then secured to the seromuscular portion of the
bowel.
 No mucosal anastomosis is performed.
62

Ureter–Small Bowel
Anastomosis Using
Serosal Compression of
the Extramural Ureter as
an Anti-reflux Mechanism
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INTESTINAL ANTIREFLUX VALVES
 Another technique for preventing reflux into the ureter
 involves construction of an antireflux mechanism with bowel distal to the ureterointestinal
anastomosis.
 ureter is sutured by the technique of either Bricker or Wallace to the end of the bowel
 Then the bowel is used to make a one-way valve.
 when these valves fail or stenose, both kidneys are affected.
 Three basic types,
ileocecal intussusception
ileoileal intussusception
ileal nipple valve placed into colon.
64

INTUSSUSCEPTED
ILEOCECAL VALVE
valve has a moderate tendency
to fail because the
intussusception has a significant
chance of reduction
65

INTUSSUSCEPTED
ILEAL VALVE
• Complication rate – 10%
• modification - T pouch
• When the pouch is closed, a
nipple valve is constructed.
• concept - as pressure in the
pouch increases, the walls of
the tapered nipple valve are
compressed, thus preventing
reflux.
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NIPPLE VALVE
simplest intestinal antireflux
valve with use of ileum
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CONDUITS
 two types of conduits: (1) those using the small bowel, which includes the jejunum or ileum (2)
large bowel.
 Conduits using stomach - difficult problems of stomal maintenance.
 indications for a conduit are the need for urinary diversion:
- after a cystectomy; because of a diseased bladder;
- before transplantation in a patient who has a bladder that cannot adequately receive the
transplant ureter;
- dysfunctional bladders that result in persistent bleeding, obstructed ureters, poor compliance
with upper tract deterioration
- inadequate storage with total urinary incontinence.
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Management Common to All Conduits:
 All anastomoses are stented with Silastic stents.
 Stents removed individually on the fourth to sixth postoperative days.
 All conduits are retroperitonealized, with the ureterointestinal anastomosis being placed in the
retroperitoneum.
 Jackson-Pratt or Blake closed-suction drain laid in the retroperitoneum 3 to 4 cm away from the
anastomosis.
 The peritoneal cavity should not be drained.
70

ILEAL CONDUIT
 most common form of urinary diversion performed throughout the world today for
patients undergoing cystectomy
 distal ileum is chosen.
 simplest type of conduit diversion
 ureteral devascularization and the risk of stomal stenosis is minimized because the
intestine is brought to the ureters rather than mobilizing the ureters to the skin.
 fewest intraoperative and immediate postoperative complications.
 C/I - short bowel syndrome, inflammatory small bowel disease, and extensive
irradiation. 71

 10-12cm ileal segment isolated 20 cm proximal to IC
valve
 Short straight conduit without kinking
 Continuity of small bowel re-established
 Mesenteric window closed
 Ileum in isoperistaltic fashion
 Isolated segment flushed with warm saline till return
of clear fluid 72

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Left ureter brought to RLQ beneath the sigmoid mesocolon
(inferior to IMA)
Ureteroenteric anastomosis
After single J ureteral stent is placed in both ureter
Distal end of ileal segment fashioned as end ileostomy in RLQ
ARutzen bag can be applied to the stoma on the fifth POD.
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COLONIC CONDUITS
1) Sigmoid colon conduit
2) Ileocaecal conduit
3) Tranverse colon conduit.
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 colon conduit is essential in cases of long segment ureteral stricture or radiation ureteritis.
 Unlike the ileal conduit, it is not necessary to pass the left ureter across to the right side,
 Once the sigmoid colon mesentery is mobilized the two ureters can be brought toward the
midline or the colon can be stretched across the retroperitoneum.
 Because the transverse colon and its middle colic artery originate in the upper abdomen
this segment can be anastomosed to the upper one third of the ureter or even directly to the
renal pelvis.
76

Ileal Vesicostomy
 spatulated ileum and a generous transverse cystotomy to decompress the bladder and to allow an appliance to be used on
the abdomen.
 Indications,
- to spinal cord injury patients or neurologic disease. (easier job of caring for themselves with an abdominal stoma)
- detrusor–external sphincter dyssynergia
- detrusor hyperreflexia, particularly women, with increased incidence of incontinence.
 Done by spatulating an ileal segment >> performing a generous transverse cystotomy.
 distal segment is brought to the abdominal wall by fashioning a rosebud stoma.
 low-pressurereservoir.
 Its appeal is that if indicated at a later date, the patient’s anatomy can be converted back to normal 77

METABOLIC AND NEUROCHEMICAL PROBLEMS OF URINARY
INTESTINAL DIVERSION
 Electrolyte Abnormalities
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RENAL DETERIORATION
 There is significant and progressive deterioration in renal function in the majority of patients independent of the
type of urinary diversion
 18% of patients who have ileal conduits show progressive deterioration versus 13% who have nonrefluxing colon
conduits.
 In patients with ileal conduits, about 6% ultimately die of renal failure
 The amount of renal function required to effectively blunt the reabsorption of urinary solutes by the intestinal
segment and to prevent serious metabolic side effects depends on the type of urinary intestinal diversion
constructed
 i.e, the amount of bowel to be used and the length of time the urine is exposed to the intestinal mucosa
 Thus, greater degree of renal function is necessary for retentive (continent) diversions than for short conduit
diversions.
80

 In general, patients who have GFR on average above 40 mL/min tolerate a continent diversion
reasonably well.
 patients with normal urine protein content who have a serum creatinine concentration below 2.0
mg/dL do well with intestine interposed in the urinary tract
 At creatinine below 2 mg/dL, renal blood flow, GFR, tubule transport, and concentrating and
diluting ability are relatively well preserved.
 When creatinine exceeds 2 mg/dL and still being considered for retentive diversion or in whom
long segments of intestine will be used, a more detailed analysis of renal function is necessary,
- If the patient can achieve a urine pH of 5.8 or less after an ammonium chloride load,
- has a urine osmolality of 600 mOsm/ kg or higher in response to water deprivation,
- has a GFR that exceeds 35 mL/min
- minimal protein in the urine
81

 Alteration of the sensorium may occur as a consequence of magnesium deficiency, drug intoxication, or
abnormalities in ammonia metabolism.
 Abnormal Drug Absorption- Drug intoxication; problematic are those absorbed by the gastrointestinal tract and
excreted unchanged by the kidney
 Osteomalacia – acidosis, vit D resistance
 detrimental effect on growth and development.
 Stones - calcium, magnesium, and ammonium phosphate. (met acidosis, Urine alkaline pH)
 Intestinal Motility, Short Bowel, and Nutritional Problems
82

Cancer
 The highest incidence of cancer occurs when the transitional epithelium is juxtaposed to the colonic epithelium and
both are bathed by feces.
 Ureterosigmoidostomies (2.6%), cystoplasties (1.6%), and orthotopic (ileo)colonic neobladders (1.3%) have got
highest risk for malignancy.
 regular endoscopic evaluation beginning 5 years postoperatively for these patients
 Not needed for ileal neobladders (0.05% risk) and ileal conduits
83

NEUROMECHANICAL ASPECTS OF INTESTINAL SEGMENTS
 goal in reconfiguring the bowel is to achieve a sphericalstorage vessel.
 Sphere shape has the most volume for the least surface area.
 By increasing the volume, it has been suggested that pressure relationships within the confines of the intestine are
reduced.
 This is based on Laplace’s law – “for a sphere, the tension of its wall is proportional to the product of the radius and
pressure.”
 Helps to prevent deterioration of the upper tracts or incontinence.
 Over time, the volume capacity of segments increases.
 In ileal pouches - capacity increases sevenfold after 1 year
 significant increase in smooth muscle thickness of the bowel wall
 volume decreases with time if they are nonfunctional
84

Motor activity
 When the bowel wall is split on its antimesenteric border and reconfigured, acutely there is a marked interruption of
coordinated activity fronts
 which over a period of 3 months return to their normal coordinated state
 Intra pouch(ileum, caecum) pressures 40 to 60 cm H2O .
85

86

 Continent, non-orthotopic urinary diversions - two major categories.
1) variations of ureterosigmoidostomy
- ileocecal sigmoidostomy,
- rectal bladder
> hemi-Kock and T pouch operation with valved rectum > folded rectosigmoid bladder
> augmented valved rectum > sigma rectum (Mainz II)
2) continent catheterizing pouches
Kock pouch, Double T pouch , Mainz pouch I, Indiana Pouch, Florida pouch, Penn pouch.
Right colon pouches with Intussuscepted Terminal ileum – UCLA pouch, Duke pouch, Le Bag pouch
Gastric pouches – Adams pouch, Lockhart pouch
 many of the procedures are simple modifications of parent operations
 procedures using a right colon reservoir with some form of appendiceal continence mechanism are the fastest,
most reliable, and easiest to perform.
87

PATIENT SELECTION
 patient must be assessed for the ability to care for himself or herself
 multiple sclerosis, quadriplegic individuals, and very frail or mentally impaired patients are poor candidates for
CCUD
88

PATIENT PREPARATION
 Renal and hepatic function must be reviewed
 reabsorption and recirculation of urinary constituents and other metabolites require that liver function be normal.
 creatinine clearance should be at least 60 mL/ min.
 In the case of hydronephrosis, the upper urinary tract(s) should be decompressed with ureteral stenting or
percutaneous nephrostomy,
with subsequent reevaluation of renal function before consideration for a CCUD.
 Procedures that require the use of the colon should always be preceded by a colonoscopic assessment of the entire
large intestine.
 preop assessment of the colon is not mandatory but remains prudent if continent urinary diversion using small
intestine is planned.
89

POSTOPERATIVE CARE AND COMMENTS
 MALIGNANCY may develop from the urothelial component and not as a result of urine affecting
intestinal mucosa.
 So urinary cytology should be performed for all patients undergoing a continent urinary diversion,
 When the ureters are directed into the fecal stream, routine colonoscopy should also be
performed.
 Latency periods as short as 5 years have been reported for malignancy
 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 because of resulting renal insufficiency
90

RECTAL BLADDER URINARY DIVERSION
 separating the fecal and urinary streams, while still employing the principles of
ureterosigmoidostomy.
 Anal sphincteric tone must be judged competent before these operations are selected
 ureters are transplanted into the rectal stump.
 The proximal sigmoid colon is managed by terminal sigmoid colostomy or by bringing the sigmoid
to the perineum, thereby using the anal sphincter to achieve bowel and urinary control.
 Chance of combined urinary and fecal incontinence
 Dilated ureters, extensive pelvic irradiation, renal insufficiency pts are not candidates
91

1) FOLDED RECTOSIGMOID BLADDER
 A modification of the ureterointestinal anastomosis
 a folded rectosigmoid bladder with anastomosis of the ureters via serosa-lined tunnels (anti reflux) rather than into
the taenia coli.
 This reimplantation technique was first described by Abol-Enein and Ghoneim
 advantage - larger sigmoid reservoir, anti - reflux
 Complications ,
hyperchloremic acidosis (Rx- bicarbonate replacement)
hypokalemia ( Rx – Oral potassium citrate)
92

 Routine nightly insertion of a rectal tube for drainage is advocated especially patient who cannot maintain
electrolyte homeostasis
 Follow up,
- annual colonoscopy after 5 yrs
- Barium enemas are relatively contraindicated because reflux into the kidneys
- evaluation of stool for blood
- cytologic examination of the mixed urine and feces specimen
93

2) AUGMENTED VALVED RECTUM
 By Kock (1988)
 used when stoma appliances were not available.
 This 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.
 the rectum is patched with ileum to improve the urodynamic properties of the rectum.
94

3) HEMI-KOCK AND T POUCH PROCEDURES WITH VALVED RECTUM
 By stein and skinner
 It is a type of ileo-anal reservoir
 It is the improve on the intussuscepted Kock continence mechanism (Augmented Valved Rectum)
 It 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.
95

APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR
T implant
T patch
96

 Advantages,
- transitional ureteral epithelium is not in contact with colonic epithelium, there may be a reduced
risk colonic malignancy.
- proximal colonic intussusception used in this procedure decreases the contact between urine and
colonic epithelium
>> low risk of hyperchloremic acidosis.
 suited for the younger exstrophy patient
97

4) SIGMA-RECTUM POUCH / MAINZ II
 A variation of ureterosigmoidostomy
 by Fisch and Hohenfellner in 1991
 a low-pressure rectosigmoid reservoir of increased capacity due to partial reconfiguration of the rectosigmoid junction.
 simple and reproducibile
 Postop Mx,
- rectal tube is removed on the 3-5th POD
- ureteral stents are removed around 8th POD.
- IVU On the 15th POD to assess the upper tracts and the sigma-rectum pouch construction.
- Radiography of the pouch is performed on the 17th POD
98

CONTINENT CATHETERIZING POUCHES
two favorite sites for
(1) at the umbilicus
 preferred for individual confined to a wheelchair , paraplegics
 lower incidence of stomal stenosis (especially with appendiceal stoma)
(2) in the lower quadrant of the abdomen
 through the rectus bulge and below the “bikini line.
 conceals stoma.
99

NEOURETHRA
 construction of a neourethra to the introitus is feasible (in females)
 provided there is no substantial difficulty in the catheterizing process.
 it is difficult to direct a catheter through the “chimney” of an intussuscepted nipple valve,
 the imbricated and tapered ileal segment leading to an Indiana pouch is relatively easier to catheterize and can be
used for orthotopic catheterizing diversion
 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
100

FOUR GENERAL TECHNIQUES HAVE BEEN EMPLOYED TO CREATE A DEPENDABLE,
CATHETERIZABLE CONTINENCE ZONE
 1) For right colon pouches, appendiceal tunneling procedures are the simplest of
all to perform and established
 2) major type of continence mechanism used in right colon pouches is the
tapered and/or imbricated terminal ileum and ileocecal valve
 3) use of the intussuscepted nipple valve or the flap valve, which avoids the need
for intussusception.
 4) provision of a hydraulic valve (reverse intussusception), as in the Benchekroun
nipple
101

MANAGEMENT OF CONTINENT POUCHES
 continence mechanism is catheterized to ensure ease of catheter passage in later period.
- all redundancy should be removed from the continence mechanism.
- secure the reservoir to the anterior abdominal wall - prevents reservoir migration, kink
 larger-bore catheter used for drainage of the pouch - irrigated at 4-hour intervals with 45 to 50 mL of saline.
 as soon as possible the patient be taught how to self-irrigate
 If the patient is on a positive nitrogen balance (i.e., eating a regular diet), a contrast study is performed on the 7th
POD to ensure pouch integrity.
 If no leaks are noted, ureteral stents removed.
102

 If ureteral anastomoses and pouch are intact - suction drain is removed.
 Teach to irrigate the tube traversing the continence mechanism at 4-hour intervals or intra-abdominal pressure or
discomfort is experienced.
 Once trained – pt is discharged, usually at hospital days 6 to 8
 catheter type?
- For nipple valves - straight-ended 22- to 24-Fr tube;
- ileocecal plication - 20- to 22-Fr coudé tipped catheter
- appendiceal sphincters - 14- to 16-Fr coudé-tipped catheter
 catheter care - reusable catheter can be placed in a zipper-locked bag that can be placed in a women’s purse or a
man’s coat pocket. •
103

 cleaning the stoma - With a topical antiseptic wipe (e.g., with benzalkonium chloride),
 lubricate the catheter - foil pack of water-soluble lubricant or self-lubricating single-use
packaging.
 Cover stoma with a bandage - mucosal soiling.
 cleaning catheter - By rinsing with ordinary tap water - inside channel and outer surface
 smaller capacity pouches (ileal) managed best with indwelling catheterization during
sleep
- ileal pouch initial capacity - low - 150 mL
- right colon pouch initial capacity - in excess of 300 mL.
104

CONTINENT ILEAL
RESERVOIR (KOCK
POUCH)
• 50 cm of distal ileum is separated.
• The two 22 cm central segments are
anastomosed to each other on their
serosal surfaces
• limbs are opened along their
antimesenteric border.
• Nipple valves, afferent and efferent
are constructed.
• PGS mesh strip is used to further
stabilize the nipple.
• pouch is closed by folding up the
bottom half.
• Ureteroileal anastomosis is
• The efferent limb is used to create
the abdominal stoma.
105

DOUBLE T POUCH
• A 70-cm segment of terminal ileum
is isolated 15 to 20 cm from the
ileocecal valve
• proximal 10-cm segment is isolated
and rotated toward what will
become the reservoir in an
isoperistaltic direction.
• distal 12 to 15 cm is rotated
toward the reservoir in an
antiperistaltic direction.
• Mesentry windows of Deaver are
opened to allow the walls of the W
reservoir to be apposed behind the
valve mechanisms
• Continent mechanisms are tapered
(Flap vlve)
‘T’ limbs
106

MAINZ POUCH I
• 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.
• A portion of the intact proximal ileal
terminus is freed of its mesentery for
a distance of 6 to 8 cm.
• 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 are sutured to one
another to form a broad posterior
plate
• The intact ileum is intussuscepted,
• The intussuscipiens is led through the
intact ileocecal valve
• Ureterocolonic anastomoses are
created at the apex of the reservoir,
• ileal terminus is directed through this
umbilical buttonhole
107

RIGHT COLON POUCHES WITH INTUSSUSCEPTED TERMINAL ILEUM
 Use nipple valve technology for the continence mechanism
 These are variations on the continent cecal reservoir
 These three pouches are the UCLA pouch , the Duke pouch, and Le Bag
 These surgeries differ from one another by mainly related to the technique employed for stabilizing
the nipple valve
108

• concept - using the buttressed
ileocecal valve as a dependable
continence mechanism that can
withstand the trauma of CIC
• Rowland(1987) of Indiana
University
• reliable continence,least
technicallydemanding
• Initial large capacity
INDIANA POUCH
109

…INDIANA POUCH
• segment of terminal ileum
approximately 10 cm in length
along with the entire right colon
is isolated.
• Appendectomy is performed,
• entire right colon is opened
along its antimesentericborder
• double imbrication of the
ileocecal valve
• Excess ileum can be tapered by
stapler
• pouch is then closed in a
Heineke-Mikulicz configuration
• bring the ileal neourethra to
stoma site
110

PENN POUCH
• first continent diversion employing
the Mitrofanoff (1980) principle, in
which the appendix served as the
continence mechanism
• by Duckett and Snyder (1986)
• ileocecal pouch is created
• These two structures are
marsupialized on the antimesenteric
borders and sutured to one another in
the form of a neotubularized pouch.
• A button of cecum surrounding the
origin of the appendix is circumcised
• resulting cecal aperture is closed.
• appendix is then reversed
- cecal button > abdominal wall
- tail of the appendix > taenia of the
colon
111

GASTRIC POUCH
• prefered in renal insufficiency
and children
• 11-cm segment of stomach is
isolated on the right
gastroepiploic blood supply
• 22-cm segment of ileum is then
isolated, opened along its
antimesenteric border, and
refashioned in a U shape.
• edges of the stomach are then
sutured to edges of the ileum with
- reservoir.
• ureters are tunneled into the
stomach
• Mitrofanoff continence
mechanism is created with a
tapered segment of ileum
112

ORTHOTOPIC URINARY DIVERSION
 orthotopic neobladder allows for volitional
voiding, avoids the need for an appliance
 requires self-catheterization in a minority of
patients.
 80% to 90% of males and 75% of females
undergoing cystectomy are potential
candidates for orthotopic reconstruction.
113

114

TECHNIQUES FOR CONTINENCE PRESERVATION
 rhabdosphincter muscle fibers and associated innervation from the pudendal nerve are
concentrated in the area anterior and lateral to the proximal urethra in both males and females.
 In males,
- obtain careful control of the DVC
- avoidance of deep suture bites into the pelvic floor muscles
 In females
- endopelvic fascia and levator muscles should not be disturbed.
- bladder is dissected completely off the anterior vaginal wall rather than excising it.
115

TYPES
 Ileal Reservoirs
- Camey II
- Orthotopic Kock Ileal Reservoir (Hemi-Kock)
- Serous-Lined Extramural Tunnel
- Ileal Neobladder (Hautmann Pouch)
- Studer pouch
- T Pouch Modification (of Studer pouch)
 Colon and Ileocolic Pouches
- Orthotopic Mainz Pouch (Mainz III)
- Right colon pouch
- Padua Pouch (Vesica Ileale Padovana) or VIP pouch
- Sigmoid pouch / Reddy Pouch (Reddy and Lange)
116

 two most popular configurations - Hautmann W-neobladder and the Studer pouch
 Both are relatively simple and lowest stricture rate
 allow direct ureteroileal anastomosis.
 T pouch and extraserosal tunnel techniques both provide an antireflux
mechanism
117

CAMEY II
 original Camey - a simple segment of
ileum anastomosed to the ureters and
urethra
 modification - detubularization and
folding to eliminate peristaltic activity.
 A total of 65 cm of ileum is isolated
 The ileal loop is folded three times (Z
shaped) and incised on the
 The reservoir is closed
 urethral anastomosis done
 ureters implanted - Le Duc antireflux
technique.
original
Modified / Camey II
118

HAUTMANN ILEAL NEOBLADDER
 large-capacity, reduced nighttime incontinence
 A 70-cm portion of terminal ileum taken
 isolated segment of ileum is incised on the
antimesenteric border, leaving 5 cm on each end
intact.
 ileum is arranged into a W configuration
 four limbs sutured to one another.
 buttonhole of ileum is removed and urethral
anastomosis is performed.
 ureteral anastomoses are performed by direct
implantation
119

STUDER POUCH
 pouch is created from 40 to 44 cm of distal ileum with
each limb of the U measuring 20 to 22 cm
 proximal 15-cm segment of ileum used as the
afferent limb.
 ureteral length is short or compromised, a longer
afferent ileal segment is used.
 ureters anastomosed afferent ileal segment.
 dependent portion of the pouch is then anastomosed
to the urethra
 Advantages:
1. Useful in short ureters.
2. Can be used in females.
Original Studer
T – modification
(flap valve)
120

ORTHOTOPIC ILEOCOLONIC MAINZ POUCH (MAINZ III)
 Mainz (“mixed augmented ileum and zecum”)
 initially described as a continent catheterizable
reservoir
 isolated 10 to 15 cm of cecum in continuity with
20 to 30 cm of ileum are isolated.
 entire bowel segment is opened along the
 appendectomy is performed.
 posterior reservoir is closed by joining the
opposing three limbs together.
 antireflux implantation of ureters (submucosal
tunnel)
121

SIGMOID NEOBLADDER / REDDY POUCH
 35-cm segment of descending and sigmoid colon is
isolated and folded into a U shape.
 The colon is incised along the medial taenia
 tunneled ureterocolonic anastomosis is performed.
 medial portions of the U are sewn together
 buttonhole in the caudal portion anastomosed to urethra.
 colonic pouch is closed
 Adv - sigmoid easily reaches the urethra
 Concern,
- compromise of the vasculature of the distal colon segment during
cystectomy (IIA)
- frequent stools or rectal urgency after sigmoidectomy
122

123

TISSUE-ENGINEERED AUTOLOGOUS BLADDERS
 created with autologous cells
seeded on collagen-polyglycolic
acid scaffolds,and wrapped in
omentum after implantation
124

125

Use of Intestinal segments in urinary diversion

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