Urinary Diversion

URINARY DIVERSION – A REVIEW SRIVATHSAN.R

Urinary diversion  External

(ileal conduit)  Internal(ureterosigmoidostomy)  Temporary  Permanent

(pediatric / second look )

Brief History of Diversion Ureterosigmoidostomy First form of continent diversion Reported by Simon in 1852 (bladder exstrophy) Complications: sigmoid cancer, fecal leak, pyelonephritis,ureteral stricture Ileal Conduit Described by Bricker in 1950 Traditional gold standard for urinary diversion

 1851

- Ureteroproctostomy (Simon)  1878 - Ureterosigmoidostomy (direct anastomosis) (Smith)  1898 - Rectal bladder (Gersuny)  1950s - Ileal loop (Bricker)  1959 - Ileal neobladder (Camay)  1970s - Koch pouch  Early 1980s - Indiana pouch  Late 1980s - Orthotopic diversion

The most common indications for urinary system diversion are as follows:

 Bladder

cancer requiring cystectomy  Neurogenic bladder conditions that threaten renal function  Severe radiation injury to the bladder  Intractable incontinence in females

Diversion Options- complete  Incontinent:  Continent

Ileal Conduit – Urostomy

Diversion

 Heterotopic   

Cutaneous continent catheterizable urinary reservoir Non continent cutaneous Diversion to GIT

 Orthotopic 

“neobladder”

Partial bladder sparing  Ileovesicostomy  Appendicovesicostomy

vesicostomy.

or catheterizable

The bladder sparing ones don’t really have an application in patients with bladder cancer, although sometimes we use this in patients who have prostate cancer and need to have their prostate removed along with a portion of the bladder.

ureterosigmoidostomy  Of

historical significance – gone into void  Anal tone to be determined.  To be avoided in 1. liver disease 2. primary diseases of colon 3. pelvic irradiation “antirefluxing technique” ‘Adenocarcinoma at the site of anastomosis’ Yearly sigmoidoscopy from 5yrs after surgery

Ileal Conduit  15-20

cm loop  30cm from IC Jn.  Wallace technique:

Stomal Stenosis Very common complication Need for surgical intervention unless the conduit is not draining Operative Options Revise the stoma Replace the conduit Conservative Options Place catheter into the conduit

 Ileum:  hyperchloremic

metabolic acidosis  B12 , bile salt and fat malabsorption  Stomach:

Hypochloremic, hypokalemic metabolic alkalosis, hematuria dysuria syndrome, hypergastrinemia.  Colon-

hyperchloremic metabolic acidosis

Other conduits  Jejunal:

rare, if rest of bowel diseased/ irradiated.  Electrolyte imbalance are more  Hyponatremia  Hyperkalemic hypochloremic met acidosis  Severe dehydration

Altered sensorium  Increased

ammonia absorption.  Decreased Mg.(renal loss,diarrhea, decreased absorption)  Drug reabsorption (dilantin/MTX/Chemo/theophylline/betalacta ms/nitrofurantoin/aminogycosides).

treatment  Drain

urine  Limit protein  Treat Infection  Lactulose  Neomycin/tetracycline  arginine glutamate

Components of a Continent Diversion Low-pressure reservoir (inc volume /dec pressure) detubulurisation of the gut to decrease the peristalsis. Volume: 400-500 ml Ureteral anastomosis Refluxing or non-refluxing Continent Outlet Catheterizable limb with a continence mechanism(Mitrofanoff Principle) Native urethra with sufficient sphincteric function

Patient factors influencing diversion selection  Renal

function – Creatinine < 1.8 - 2.0mg/dl; GFR > 40 ml/min  Age (relative)  Pre-operative urinary continence  Manual dexterity, hand-eye coordination – for catheterizable diversions  Pelvic Radiation – bowel segment selection (transverse colon)  Primary tumor type – stage and location (Kristjansson A, et al J Urol 157:2099–2103, 1997)

Continent catheterizable conduits  Mitrofanoff

Principle (Chir Pediatr 21, 297: 1980) Appendix Ureter (Ashcraft, J Pediatr Surg21:1042, 1986) Fallopian tube (Woodhouse,1991) Tapered ileum

 Monti

construction  2-2.5 cm segment of ileum- tubularised  opened along antimesenteric border  Reconstructed over a 12-14 Fr catheter  Mesentery centered  Yields 6-8 cm segment

Indiana pouch

Heterotopic Continent Cutaneous Reservoir

Indications for Orthotopic Reconstruction  No

disease at prostate apex/bladder neck

 Urethra

free of disease

 Adequate

nondiseased bowel segment

 Adequate

urinary sphincter in situ

available

 No

compromise to cancer control

Patient Selection  Willing  Able

and able, highly motivated

to self catheterize prior to surgery

 Good

renal function and LFTs

 Serum

creatinine should be less than 2.0

 Age/obesity

are NOT contraindications

Surgical Considerations  Cancer  All

control is paramount

patients should be marked and consented for an ileal conduit should disease dictate more resection

Orthotopic Urinary Diversion

Bowel Segments Utilized for Neobladder Reconstruction Stomach Small intestine – primarily ileum, rarely jejunum Ileocecal Colon  Right and transverse colon  Sigmoid

Types of Common Orthotopic Diversions  Hautman  Large

capacity, spherical configuration with “W” of ileum

 Studer  Ileal

with long afferent limb

 Kock  Intessuscepted

 T-Pouch  MAINZ

Pouch

afferent limb

Creation of the Hautmann ileal neobladder. A, A 70­cm portion of terminal ileum is selected. Note that the isolated segment of ileum  is incised on the antimesenteric border. B, The ileum is arranged into an “M” or “W” configuration with the four limbs sutured to one  another. C, After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethroenteric anastomosis is  performed. The ureteral implants (Le Duc) are performed and stented, and the reservoir is then closed in a side­to­side manner.

Studer

. Creation of the ileal neobladder (Studer pouch) with an isoperistaltic afferent ileal limb. A, A 60­ to 65­cm distal ileal segment is isolated  (approximately 25 cm proximal to the ileocecal valve) and folded into a “U” configuration. Note that the distal 40 cm of ileum constitutes the U  shape and is opened on the antimesenteric border while the more proximal 20 to 25 cm of ileum remains intact (afferent limb). B, The  posterior plate of the reservoir is formed by joining the medial borders of the limbs with a continuous, running suture. The ureteroileal  anastomoses are performed in a standard end­to­side technique to the proximal portion (afferent limb) of the ileum. Ureteral stents are used  and brought out anteriorly through separate stab wounds. C, The reservoir is folded and oversewn (anterior wall). D, Before complete 

Kock

Creation of the Kock ileal reservoir. A, A total of 61 cm of terminal ileum is isolated. Two 22-cm segments are placed in a “U” configuration and opened adjacent to the mesentery. Note that the more proximal 17-cm segment of ileum will be used to create the afferent intussuscepted nipple valve. B, The posterior wall of the reservoir is then created by joining the medial portions of the U with a continuous running suture. C, A 5- to 7-cm antireflux valve is created by intussusception of the afferent limb with the use of Allis forceps clamps. D, The afferent limb is fixed with two rows of staples placed within the leaves of the valve. E, The valve is fixed to the back wall from outside the reservoir. F, After completion of the afferent limb, the reservoir is completed by folding the ileum on itself and closing it (anterior wall). Note that the most dependent portion of the reservoir becomes the neourethra. The ureteroileal anastomosis is performed first, and the urethroenteric anastomosis is completed in a tension-free, mucosa-to-mucosa fashion.

T-Pouch

MAINZ Creation of the Mainz ileocolonic orthotopic reservoir. A, An isolated 10 to 15 cm of cecum in continuity with 20 to 30 cm of ileum are isolated. B, The entire bowel segment is opened along the antimesenteric border. Note that an appendectomy is performed. C, The posterior plate of the reservoir is constructed by joining the opposing three limbs together with a continuous running suture. D, An antireflux implantation of the ureters via a submucosal tunnel is performed and stented. E, A buttonhole incision in the dependent portion of the cecum is made that provides for the urethroenteric anastomosis. Note that the ureterocolonic anastomoses are performed before closure of the reservoir. F, The reservoir is closed side to side with a cystostomy tube and the stents exiting.

Neobladder – “Tubes and Drains”

Suprapubic Catheter

Ureteral Catheters

Foley Urethral Catheter

Postop  Day

1-3: Fluids, Diet, ambulate  Day 3: Passive Irrigation SPT and Foley: 30cc each  Day 4: Daily Active Irrigation SPT/Foley: 60cc TID  Day 5: Antibiotics and Pull Right (red) Ureteral Catheter  Day 6: Antibiotics and Pull Left (Blue), Teach SPT Irrigation – 60cc TID  Day 7: Discharge, plan foley d/c 14 days (cystogram), SPT out at 8 weeks

Further Considerations  Continence  Preserve

sphincter beyond prostate apex in males  Suspend reconstructed vagina via sacrocolpopexy or Burch procedure in females  Refluxing

versus nonrefluxing

 Nonrefluxing

with decreased rates of pyelonephritis  However, higher rates of obstruction and technically more challenging

Sphincteric Incontinence after Orthotopic Diversion (Studer)  Voiding

accomplished by Valsalva

 Balance

between control of incontinence and  Obstruction  Options

same as incontinence without

 Cystectomy

(variation necessary

Options for Sphincter Deficiency  MALES

Injectable Agents (collagen) Male Sling Artificial Urinary Sphincter  FEMALES

Injectable Agents Female Sling

Urodynamic Evaluation of Neobladders Urodynamic evaluation of pouch with multichannel system Assessment of capacity, compliance, amplitude of contractions Pressure in pouch at time of leakage Confirmation of high pressure zone at the junction between catherizable limb and pouch

Expected urodynamic pouch parameters  Capacity:     

400-500 ml Compliance: > 40 ml/cm H2O Pouch contractions: Small bowel: 5-10 cm H2O Right colon: 20-25 cm H2O Sigmoid: < 40 cm H2O

Outcomes

50 pts Sigmoid Neobladder (SN) 62 pts with Ileal Neobladder (IN)

• •

•

SN – 85% daytime continence – 9% nighttime continence

Complications  Urethral

Recurrence

 10%

 Hydronephrosis  Stones

– loss of renal unit

Long Term Complications  Metabolic  Renal

Failure  Acidosis  Osteoporosis  B12 deficiency  Urinary lithiasis