Urinary Diversions in Management of Bladder

Cancer

Ayush GargPG JR I

Radiotherapy

SURGERY

1. Transurethral resection of bladder tumor(TURBT)

2. Partial Cystectomy

3. Radical Cystectomy

Modern Radical Cystectomy• Radical Cystectomy• Removal of bladder with surrounding fat• Prostate/seminal vesicles (males)• Uterus/fallopian tubes/ovaries/cervix (females)• + Urethrectomy

• Pelvic Lymphadenectomy• More is better

• Urinary Diversion• Ileal conduit• Continent cutaneous reservoir• Orthotopic neobladder

Urinary Diversion• Use of intestinal segment to bypass/ reconstruct/

replace the normal urinary tract

• Goals: • Storage of urine without absorption• Maintain low pressure even at high volumes to allow

unobstructed flow of urine from kidneys• Prevent reflux of urine back to the kidneys• Socially-acceptable continence• Empties completely

• “Ideal” diversion has yet to be discovered

Types of Urinary Diversion

ILEAL CONDUIT(incontinent

diversion to skin)

CONTINENT CUTANEOUS RESERVOIR

(continent diversion to skin)

ORTHOTOPIC NEOBLADDER

(continent diversion to urethra)

Ileal Conduit

• 18-20 cm of small intestine (ileum) is separated from the intestinal tract

Intestines are sewn back together (re-establish intestinal continuity)

Ureters are attached to one end of the segment of ileum

Stoma is constructed

Other end is brought out through an opening on the abdomen

Continent Cutaneous Reservoir• Many variations (same theme)

• Indiana Pouch, Penn Pouch, Kock Pouch…

• All use various parts of the intestine• Ileum, Right Colon most commonly

• Reservoir• “Detubularized” intestine- low pressure storage

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

• The surgeon takes a piece of bowel and makes it into a pouch inside the body. The pouch opens out from the abdomen through a stoma (like the urostomy).

• The urine doesn't leak out of the stoma. The stoma is made from the part of the bowel where the large and small bowel join and there is a natural valve that keeps the stoma closed. When patient wants to empty the pouch, he puts a thin tube (catheter) into the stoma and drain off the urine.

Continent Cutaneous ReservoirINDIANA POUCH

Appendix removed

Right colon and distal

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

Continent Cutaneous ReservoirINDIANA POUCH

RESERVOIREFFERENT LIMB

(to skin)

catheter

Ureters attached to back of reservoir (not shown)

Continence maintained by ileocecal valve

Orthotopic NeobladderWHAT IS AN ORTHOTOPIC NEOBLADDER?

“Orthotopic” means “in the same place” and “neobladder” means new bladder.

So an orthotopic neobladder is a substitute or “new” bladder that is placed in the same location as the “old” bladder.

HOW IS THE ORTHOTOPIC NEOBLADDER CONSTRUCTED?

The neobladder is made from loops of the intestine.

First, the surgeon removes a section of intestine.

He then reconnects the bowel so there are no changes in bowel function.

The piece of intestine that was removed is cut open to create a “flat piece” instead of a hollow tube.

The flat piece of intestine is sewn together to form a pouch. The ureters (kidney tubes) are connected to one end of this pouch, the other end of the pouch is connected to the urethra. Urine will drain from the kidneys through the ureters and into the new “bladder.”

The new bladder will store the urine and the individual will void through normal channels.

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

THANK YOU