Urinary Diversion in Urological Cancer J.Edson Pontes

Radical Cystectomy: Historical Perspective Radical Cystectomy in the 40s/50s was considered a major surgical procedure, done only in a few centers. The procedure was often done in 2 stages. The mortality associated with it was about 30%

Radical Cystectomy: Historical Perspective Advances in Antibiotic Therapy. Improvement in Nutrition. Improvement in Pre and post operative care. Resulted in decreased mortality to about 1-2% in modern series.

Urinary Diversion Most of the present techniques of continent urinary diversion, can be found in experimental procedures at the end of the 19th century. Ureterosigmoidostomy was used widely before the 50s. Metabolic problems, ascending urinary infections and sepsis drove the need for alternatives. The Gilcrest procedure and the ileal loop (Bricker) were developed therefore.

Continent Urinary Diversion Couvelaire in 1950, published the first case of a continent urinary diversion. Camey, made this procedure popular in France in the 60s/70s, and Lillien presented it to the AUA in the 80s. The concept of detubularization and low pressure reservoir consolidated this procedure.

Continent Urinary Diversion Does not affect the Outcome of the disease. The only Goal is improvement in Quality of life!

QUALITY OF LIFE IN NONCONTINENT UROSTOMIES FEAR OF STOMAL LEAKAGE ODOR LACK OF SEXUAL ATTRACTIVENESS AND PERFORMANCE

PATIENT SELECTION CRITERIA Clinically organ confined disease Serum creatinine < 2.5mg/dl High self motivation Adequate manual dexterity No significant comorbidity Low risk for urethral recurrence

CONTINENT URINARY RESERVOIR - GOALS GOOD CAPACITY AT LOW PRESSURE EMPTIES EASILY WITH NO OR LITTLE RESIDUAL PRESERVATION OF UPPER URINARY TRACT GOOD URINARY CONTROL LOW COMPLICATION RATE

CONTINENT CONTANEOUS URINARY DIVERSION CREATION OF CONTINENT NIPPLE VALVE KOCH POUCH MAINZ POUCH ILEOCOLONIC RESERVOIRS WITH PLICATED ILEAL SEGMENT MITROFANOFF PRINCIPLE

PHYSIOLOGICAL PRINCIPLES FOR CONTINENT RESERVOIR OUTLET RESISTANCE ON “INDIANA” POUCHES MAY BE DUE: REDUCED DIAMETER OF TERMINAL ILEUM, PHASIC AND TONIC CONTRACTIONS OF THE ILEUM, PASSIVE RESISTANCE AND ACTIVE CONTRACTION IN THE ILEOCECAL VALVE. P. CARROLL ET AL., J. UROL 1989

CONTINENT URINARY DIVERSION TO THE URETHRA ILEAL ILEO-CECAL LARGE BOWEL STOMACH

Commonly used Continent Reservoirs Camey 2 W Pouch(Studder) Le Bag Mainz Pouch Padova Neo bladder

Conclusions 1 Continent urinary diversion are now common place in bladder replacement. Continent reservoirs are now used in 60-70% of all patients in our Center. Despite the complexities of the procedure there only minimal increase complications Selection of patients and procedures are key to success.

Conclusion 2 Remember that no Neo Bladder can replace a Normal Bladder!