Urinary Diversion

Abdullah Alenizi

R5, SFH

Definition

Use of intestinal segment to bypass/ reconstruct/ replace the normal urinary tract

EVOLUTION OF URINARY DIVERSION Ureterosigmoidostomy was

the diversion of choice until the late 1950s when electrolyte imbalances, renal problems, and secondary malignancies were found frequently

These significant complications led to invention of different forms of urinary diversion:

conduit continent cut. Diversion orthotopic neobladder

Options of diversions

Incontinent diversion (Conduit)

Continent Diversion› Heterotopic

Cutaneous continent catheterizable reservoir

› Orthotopic “neobladder”

Types of Urinary Diversion

CONDUIT(incontinent

diversion to skin)

CONTINENT CUTANEOUS RESERVOIR

(continent diversion to skin)

ORTHOTOPIC NEOBLADDER

(continent diversion to urethra)

Indications After cystectomy

Before transplantation in a patient with poorly functioning bladder (neurogenic, small capacity)

Dysfunctional bladders with persistent bleeding, obstructed ureters, poor compliance with upper tract deterioration

Preparation

All patients require a bowel preparation

Choice of Urinary Diversion

Disease Factors› Urethral margin

Patient Factors› Kidney function / liver function› Manual dexterity› Preoperative urinary continence/ urethral

strictures› Motivation

Surgeon Factors› Familiarity with various types of diversions

Use of Intestinal Segments in Urinary Diversion

SURGICAL ANATOMY

Small Bowel

Unlike jejunum, ileum has smaller diameter, multiple arterial arcades, thicker mesentery and the vessels in the arcades are smaller

Two portions of the small bowel may lie in the pelvis and can be affected by pelvic disease or radiation:

- last 2 inches of the terminal ileum

- 5 feet of bowel beginning 6 feet from the ligament

of Treitz

Stomach

Advantage:

1. Less permeable to solutes

2. Net excretion of chloride and

protons rather than a net

absorption

3. Less mucus

Disadvantage:

1- Hematuria-dysuria syndrome

2- Severe metabolic alkalosis

3- Megaloblastic/iron deficiency

anemia

Ilium

Advantages› Abundant› Easily mobilized› Familiar to most urologist

Disadvantages› Vitamin B12 deficiency› Diarrhea › Fat malabsorption› Cannot be used after radiation

Colon

Advantages

› Submucosal tunnel is easy to perform

Good for antireflux technique

› Can be utilized in case of pelvic irradiation

Disadvantage

› If ileucecal valve is removed, diarrhea & bacterial colonization with loss of fluid & bicarb result from rapid transit time

› Post op obstruction 4%

BOWEL PREPARATION

Early studies suggested that bowel prep. reduces rates of wound infection, intraperitoneal abscesses, and anastomotic dehiscence compared to those who had no bowel prep.

Irvin and Goligher, 1973 ; Dion et al, 1980

A meta-analysis of randomized clinical trials( Guenaga et al, 2003 ) showed no support that bowel prep. reduces anastomotic leak rates and other complications …. In fact it might increase the risk (same group,2005)

BOWEL PREPARATION

2 types of bowel prep:

mechanical and antibiotic

The mechanical prep. reduces the amount of feces, whereas the antibiotic prep. reduces the bacterial count (concentration)

Cont.. Mechanical Preparation

It can cause electrolyte disturbances No difference in complication rate bet. sodium

phosphate with polyethylene glycol Sodium phosphate is preferred by most surgeons

(better tolerated)

Cont.. Mechanical Preparation

Contraindications of sodium phosphate:

Renal insufficiency,

Hyperphosphatemia,

Hypocalcemia.

Cont.. Antibiotic Bowel Preparation

Antibiotic prep. may result in pseudomembranous enterocolitis:

abdominal pain and diarrhea No fever or chills Clostridium difficile is the causative organism

pseudomembranous enterocolitis

Diagnosis: is suspected by endoscopy and confirmed by cultures

Treatment: Stop all antibiotics

Administer vancomycin or flagyl

Pt. with pseudomembranous colitis can develop toxic megacolon,

mortality 15% to 20% treatment: subtotal colectomy ( life saving)

INTESTINAL ANASTOMOSES Principles of proper anastomoses: 1. Avoid irradiated bowel 2. Good blood supply to the severed ends of the bowel avoid: tension, excessive dissection & excessive use of electrocautery 3. Prevention of local spillage of enteric contents: 4. Mucosa to mucosa:

watertight, tension free 5. Realignment of the mesentery of the two

segments: ensure no twist on completion of the anastomosis 6. Closure of the mesenteric window

Types of Intestinal Anastomoses

End to end Two-Layer Suture Anastomosis

Types of Intestinal Anastomoses End-to-Side Ileocolic Sutured

Anastomosis

Types of Intestinal Anastomoses Ileocolonic End-to-End Sutured

Anastomosis with Discrepant Bowel Sizes

Types of Intestinal Anastomoses

Stapled circular anastomosis

Types of Intestinal Anastomoses End-to-End Stapled Anastomosis: Ileal-Ileal or

Ileocolonic Anastomosis

Intestinal AnastomosesComplications of

Intestinal Anastomoses:

Sepsis and Other Infectious Complications

Bowel Obstruction (10% in ilial and gastric diversions)

reduced by : using non-irradiated bowel,

well vascularized bowel, retroperitonealizing the segment, GI decompression, placing omentum

Fistulas ( 4-5%) Hemorrhage:

Either due to bad hemostasis or anastomotic ulcer

Intestinal Stenosis Pseudo-obstruction

Complications of the Isolated Intestinal Segment:

Intestinal Stricture Elongation of the

Segment Ureteral-intestinal

obstruction Pouch calculi Pyelonephritis Renal deterioration

Abdominal stoma

Marking the site

Sitting & supine Over the rectus muscle Away from

› Incision, ~ 5 cm

› Bony prominences

› Scars

› Umbilicus

› Belt line

Abdominal Stomas

Flush

› When CIC is planned

Protruding

› When stoma bag is going to be applied

› End stoma e.g. nipple stoma

› Loop end ileostomy

* All stomas should be placed through the belly of the rectus muscle and be located at the peak of the infraumbilical fat roll

* If placed lateral to rectus sheath, parastomal hernia is likely to occur

Nipple Stoma: “Rosebud”

bowel is grasped (babcock) and brought out for a distance of 5 to 6 cm to make a nipple of about 2 to 3 cm in length

Loop End Ileostomy

V-Flap

Complications of Intestinal Stomas Early complications: bowel necrosis, bleeding, dermatitis,

parastomal hernia, prolapse, obstruction, stomal retraction, and stomal stenosis

Stomal stenosis is 20% to 24% in ileal conduits and 10% to 20% in colon conduits

Parastomal hernias occur rarely (1% to 4%) with end stomas but are more likely to occur with loop stomas

URETEROINTESTINAL ANASTOMOSES Controversy…. refluxing or nonrefluxing

Antirefluxing anastomosis does not prevent bacterial colonization of the renal pelvis

Antireflux mechanism in the chronically infected continent cutaneous reservoir, requiring CIC, is important and is not debatable

Advantage of a refluxing anastomosis is that the upper tracts may be observed by periodic contrast study through the conduit

URETEROINTESTINAL ANASTOMOSES

Principles of anastomosis:

- Fine absorbable sutures

- Watertight, tension free

- Mucosa-to-mucosa

- stented

- Bowel should be brought to the ureter

and not vice versa Strictures are caused by ischemia, urine leak,

radiation, or infection

Ureterocolonic Anastomoses Leadbetter and Clarke Technique :

Ureterocolonic Anastomoses

Transcolonic Technique of Goodwin

Ureterocolonic Anastomoses

Strickler Technique

Ureterocolonic Anastomoses

Pagano Technique

Small Bowel ureterointestinal

Anastomoses

Bricker Anastomosis - Refluxing end-to-side

anastomosis - Simple to perform and

has a low complication rate

Small Bowel ureterointestinal Anastomoses

Wallace Technique

Small Bowel ureterointestinal Anastomoses

Split-Nipple Technique In one series, this type

of anastomosis prevented reflux in more than 50% of the patients

Intestinal Antireflux Valves Intussuscepted Ileocecal Valve

Intestinal Antireflux Valves

Intussuscepted Ileal Valve

Complications of Ureterointestinal

Anastomoses 1- Urinary Fistula : occur in the first 7-10 days postop. with an

incidence of 3% to 9% Markedly reduced by the use of soft Silastic stents

2- Stricture : Antirefluxing higher incidence of stricture Also occur away from the ureterointestinal

anastomosis commonly Lt. ureter as it crosses over aorta & below inferior mesenteric A

open repair has a success rate of approximately 75% at 3 years versus 15% for balloon dilation

Complications of Ureterointestinal Anastomoses

3- Pyelonephritis:

occurs both in the early postoperative period and during the long term

4- Leakage

5- Deterioration of renal function

Incontinent diversion (conduits)

Ileal Conduit

Simplest type diversions to perform

Fewest intraop. and immediate postop. Complications

Relatively contraindicated in:

- Short bowel syndrome

- Pts with inflammatory bowel disease

- Irradiated ilium

Complications of ilial conduits

Jejunal Conduit

Can lead to sever electrolyte imbalances Used only if extensive irradiation or severe adhesions

of the ileum and absence of the large bowel

Contraindications: severe bowel nutritional disorders and the presence of another acceptable segment.

Procedure: A 10- to 15-cm segment of jejunum is isolated 15 to 25 cm from the ligament of Treitz

Colon Conduit

Good option if extensive pelvic radiation

Sigmoid conduit is a good choice with pelvic exenteration And colostomy

Contraindications to the use of transverse, sigmoid, and ileocecal conduits include the presence of inflammatory large bowel disease and severe chronic diarrhea

Colon Conduit

METABOLIC PROBLEMS OF INTESTINAL

DIVERSION Metabolic Complications:

Altered sensorium, abnormal drug metabolism, osteomalacia, growth retardation, formation of urinary calculi, electrolyte abnormalities :

hyponatremia in jejunal diversions

Mechanism of electrolyte imbalance

Jejunum (hyponatremia, hypochloremia, hyperkalemia):

increased secretion of sodium and chloride with an increased reabsorption of potassium and hydrogen ions

Ilium & colon (hyperchloremic hypokalemic metabolic acidosis) :

ammonium chloride is absorbed across the lumen into the blood in exchange for carbonic acid (i.e., CO2 and water)

Metabolic Complications

Hypokalemia: Can happen with urinary diversion (commonly with

ureterosigmoidostomy) Caused by:

. Renal K+ wasting due to renal damage

. Osmotic diuresis

. GI loss through intestinal secretion

Treatment: replace K+ and treat acidosis with NaHco3

Metabolic Complications

Altered Sensorium: Results from: magnesium deficiency, drug

intoxication, or abnormalities in ammonia metabolism (most common)

Ammoniagenic coma: reported in those with cirrhosis, those with altered liver function without underlying chronic liver disease

Treatment: draining the urinary intestinal diversion. Neomycin is administered orally to reduce the ammonia load from the enteric tract

Metabolic Complications

Abnormal Drug Absorption:

Drugs more likely to be a problem are those that are absorbed by the gastrointestinal tract and excreted unchanged by the kidney

excreted drug is re-exposed to the intestinal segment,

reabsorbed, and toxic serum levels develop

For Pt. on chemo , the pouch should be drained during the administration

Metabolic Complications

Osteomalacia (renal rickets):

Happens when mineralized bone is reduced and the osteoid component becomes excessive

Causes:

persistent acidosis (most common), vitamin D def. , and excessive calcium loss by the kidney

Metabolic Complications

Infection: approximately 3/4 of ileal conduit urine specimens

are infected Deterioration of the upper tracts is more likely with ProteusProteus or PseudomonasPseudomonas

Pure cultures of Proteus or Pseudomonas should be treated, whereas those with mixed cultures may be observed, provided they are asymptomatic

Metabolic Complications

Stones: Majority composed of ca, mg, and ammonium

phosphate

patients who have hyperchloremic metabolic acidosis, preexisting pyelonephritis, and urinary tract infection with a urea-splitting organism are more susceptible to have stones

Metabolic ComplicationsShort Bowel, and Nutritional Problems: significant loss of ileum:

. Vit B12 malabsorption.. results in anemia

and neurologic abnormalities

. Malabsorption of bile salts.. Fat malabsorption (deficiency of fat soluble vit A, D)

Loss of the ileocecal valve:

Reflux of bacteria into the ileum, which results in small intestinal bacterial overgrowth…bile salt

malabsorption… Loss of jejunum may result in malabsorption of fat,

calcium, and folic acid

Metabolic Complications

Cancer: Histology: adenocarcinoma, adenomatous polyps,

sarcomas, and TCC

Because most tumors are adenoca , it has been assumed that the tumor arises from the intestinal epith.

There is high incidence of ca. in the transitional epith. juxtaposed to the colonic epith.

Because of high incidence in ureterosigmoidostomies, Pt. should have routine colonoscopies on a scheduled periodic basis

CUTANEOUS CONTINENT URINARY DIVERSION

(HETEROTOPIC BLADDER)

Chapter 81

Patient Selection

Patient must be Willing, able, highly motivated

Able to self catheterize

Good renal function› Serum creatinine should be less than 2.0

Components

Afferent limb Reservoir Efferent limb

Techniques to create a dependable, catheterizable continence zone

Appendiceal techniques Pseudoappendiceal tubes fashioned from

ileum or right colon Ileocecal valve plication

Continence mechanism› Ileocecal valve (Indiana)› Flap valve (Penn, Lahey)› Intussuscepted nipple valve (Kock)

Indiana pouch

Appendix removed

Right colon is opened lengthwise and folded down to create a sphere

Right colon and distal

ileum isolated

Indiana pouch

catheter

EFFERENT LIMB(to skin)

Continence maintained by ileocecal valve

RESERVOIR

Indiana pouch

It remains one of the most reliable of all catheterizable reservoirs.

It is among the easiest to construct,

and it has very low short-term and long-term complications.

Kock poch

Kock poch

Kock poch

Kock poch

Kock poch

Kock poch

Montie

General Care

Regarding ileal pouches, capacity will initially be low (150 mL): needs

More frequent cath. Than in colon pouches Indwelling over night drainage

All patients with catheterized pouches will have chronic bacteriuria but treatment is reserved only for symptomatic pt.

Pouch urinary retention (females) represents a true emergency that needs prompt drainage

Continent Cutaneous Reservoir

ADVANTAGES No external bag Stoma can be covered

with bandage

DISADVANTAGES Most complex Need for regular

intermittent catheterization

Potential complications:› Stoma stenosis› Stones› Urine infections

Conduit Conversion to a Continent Reservoir

Indication: The major indication is the patient's desire for improved

quality of life

Can discard the conduit or use it as a patch to a colonic reservoir (diminish metabolic sequelae and may result in a lower complication rate)

Orthotopic Urinary Diversion

Chapter 82

Patient selection

Patient must have Willingness, highly motivated

Good renal function› Serum creatinine should be < 175 mmol/l ( 2 mg/dl)

A minimum creatinine clearance of 60 mL/min

Intact ext. sphincter mechanism

Free urethral margin + absence of CIS

General considerations

Patients with bladder cancer that has extravesical extension and positive LN should, not necessarily be excluded from orthotopic reconstruction

In obese individuals, an orthotopic diversion may be preferred bec. Of the difficulty in urostomy care and self catheterization

CONTINENCE PRESERVATION Nocturnal incontinence (28%) is more commonly

observed than daytime incontinence

Evaluation and management of incontinence should be delayed until the neobladder has had time to enlarge (6-12/12)…. If continued UDS:

. If low valsalva LPP urethral bulking agent in

females or AUS in males

. If low capacity CIC

Failure to empty or urinary retention (females) has been reported in 4% to 25% CIC, r/o hernias

Urethral Recurrence in males: Overall risk is 10% Prostatic stromal invasion is the single

strongest pathologic predictor of

subsequent recurrence in the anterior

urethra (frozen section) Deep TUR Bx of the prostate (@ 5-,

7-o'clock positions at the level of the

verumontanum), may help identify

those with prostatic tumor

Monitoring the retained urethra for all patients after radical cystectomy is important:

annual cytology, urethroscopy (specially pt. with change in voiding pattern) Urethrectomy can be done during cystectomy or delayed

Urethral recurrence in females: Bladder neck involvement was

most significantly associated with secondary urethral tumor ( frozen section)

Techniques of orthotopic bladder substitutes

COMPONENTS:

Internal reservoir: detubularized ileum “Efferent limb” Connect to urethra

Urethral sphincter provides continence “Afferent Limb” – ureteral connection

› Antirefluxing (T-Pouch, Kock)› Low pressure isoperistaltic limb (Studer)

Tubes and Drains

Suprapubic Catheter

Ureteral Catheters

Foley Urethral Catheter

Tubes and Drains

Urethral cath.: 24 Fr

Can be removed in 3/52 Ureteral stents:

. Either externalized to the skin or internalized and anchored to the catheter

. Can be removed 1 to 2 weeks postoperatively A large suction Hemovac drain is placed for the first

24 hours

Types of Common Orthotopic Diversions

Hautman› Large capacity, spherical configuration with “W” of

ileum Studer

› Ileal with long afferent limb Kock

› Intessuscepted afferent limb T-Pouch MAINZ Pouch Camy II

Studer pouch

Studer pouch

Isolation of ileal segment

20 cm

20 cm

20-25 cm

Detubularization of ileum

Final shape of the studer pouch

Afferent Limb Reservoir

Opening to urethra

Orthotopic Neobladder

ADVANTAGES No external bag Urinate through

urethra May not need

catheterization

DISADVANTAGES Incontinence (10-

30%) Retention (5-20%) Risk of stones, UTI’s Need to “train”

neobladder

QoL

9 studies, all retrospective

1995 – 2004

Better QoL with ONB in 2 studies only (small N of pt.)

Conclusion:

No support for the advantages of 1 method over the other regarding QoL