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Urinary Diversion
Abdullah Alenizi
R5, SFH
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Definition
Use of intestinal segment to bypass/ reconstruct/ replace the normal urinary tract
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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
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Options of diversions
Incontinent diversion (Conduit)
Continent Diversion› Heterotopic
Cutaneous continent catheterizable reservoir
› Orthotopic “neobladder”
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Types of Urinary Diversion
CONDUIT(incontinent
diversion to skin)
CONTINENT CUTANEOUS RESERVOIR
(continent diversion to skin)
ORTHOTOPIC NEOBLADDER
(continent diversion to urethra)
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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
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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
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Use of Intestinal Segments in Urinary Diversion
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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
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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
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Ilium
Advantages› Abundant› Easily mobilized› Familiar to most urologist
Disadvantages› Vitamin B12 deficiency› Diarrhea › Fat malabsorption› Cannot be used after radiation
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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%
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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)
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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)
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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)
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Cont.. Mechanical Preparation
Contraindications of sodium phosphate:
Renal insufficiency,
Hyperphosphatemia,
Hypocalcemia.
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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
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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)
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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
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Types of Intestinal Anastomoses
End to end Two-Layer Suture Anastomosis
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Types of Intestinal Anastomoses End-to-Side Ileocolic Sutured
Anastomosis
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Types of Intestinal Anastomoses Ileocolonic End-to-End Sutured
Anastomosis with Discrepant Bowel Sizes
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Types of Intestinal Anastomoses
Stapled circular anastomosis
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Types of Intestinal Anastomoses End-to-End Stapled Anastomosis: Ileal-Ileal or
Ileocolonic Anastomosis
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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
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Abdominal stoma
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Marking the site
Sitting & supine Over the rectus muscle Away from
› Incision, ~ 5 cm
› Bony prominences
› Scars
› Umbilicus
› Belt line
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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
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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
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Loop End Ileostomy
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V-Flap
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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
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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
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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
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Ureterocolonic Anastomoses Leadbetter and Clarke Technique :
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Ureterocolonic Anastomoses
Transcolonic Technique of Goodwin
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Ureterocolonic Anastomoses
Strickler Technique
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Ureterocolonic Anastomoses
Pagano Technique
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Small Bowel ureterointestinal
Anastomoses
Bricker Anastomosis - Refluxing end-to-side
anastomosis - Simple to perform and
has a low complication rate
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Small Bowel ureterointestinal Anastomoses
Wallace Technique
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Small Bowel ureterointestinal Anastomoses
Split-Nipple Technique In one series, this type
of anastomosis prevented reflux in more than 50% of the patients
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Intestinal Antireflux Valves Intussuscepted Ileocecal Valve
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Intestinal Antireflux Valves
Intussuscepted Ileal Valve
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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
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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
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Incontinent diversion (conduits)
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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
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Complications of ilial conduits
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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
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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
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Colon Conduit
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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CUTANEOUS CONTINENT URINARY DIVERSION
(HETEROTOPIC BLADDER)
Chapter 81
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Patient Selection
Patient must be Willing, able, highly motivated
Able to self catheterize
Good renal function› Serum creatinine should be less than 2.0
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Components
Afferent limb Reservoir Efferent limb
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Techniques to create a dependable, catheterizable continence zone
Appendiceal techniques Pseudoappendiceal tubes fashioned from
ileum or right colon Ileocecal valve plication
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Continence mechanism› Ileocecal valve (Indiana)› Flap valve (Penn, Lahey)› Intussuscepted nipple valve (Kock)
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Indiana pouch
Appendix removed
Right colon is opened lengthwise and folded down to create a sphere
Right colon and distal
ileum isolated
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Indiana pouch
catheter
EFFERENT LIMB(to skin)
Continence maintained by ileocecal valve
RESERVOIR
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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.
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Kock poch
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Kock poch
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Kock poch
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Kock poch
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Kock poch
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Kock poch
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Montie
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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
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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
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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)
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Orthotopic Urinary Diversion
Chapter 82
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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
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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
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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
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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)
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Techniques of orthotopic bladder substitutes
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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)
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Tubes and Drains
Suprapubic Catheter
Ureteral Catheters
Foley Urethral Catheter
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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
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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
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Studer pouch
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Studer pouch
Isolation of ileal segment
20 cm
20 cm
20-25 cm
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Detubularization of ileum
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Final shape of the studer pouch
Afferent Limb Reservoir
Opening to urethra
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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
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QoL
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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
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