Abdullah Alenizi R5, SFH

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

 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

 Incontinent diversion (Conduit)  Continent Diversion › Heterotopic  Cutaneous continent catheterizable reservoir › Orthotopic  “neobladder”

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

 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

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

 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

 Advantages › Abundant › Easily mobilized › Familiar to most urologist  Disadvantages › Vitamin B12 deficiency › Diarrhea › Fat malabsorption › Cannot be used after radiation

 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%

 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)

 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)

 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)

Contraindications of sodium phosphate: Renal insufficiency, Hyperphosphatemia, Hypocalcemia.

 Antibiotic prep. may result in pseudomembranous enterocolitis: abdominal pain and diarrhea No fever or chills Clostridium difficile is the causative organism

 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)

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

 End to end Two-Layer Suture Anastomosis

 End-to-Side Ileocolic Sutured Anastomosis

 Ileocolonic End-to-End Sutured Anastomosis with Discrepant Bowel Sizes

 Stapled circular anastomosis

 End-to-End Stapled Anastomosis: Ileal-Ileal or Ileocolonic Anastomosis

Complications 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

 Sitting & supine  Over the rectus muscle  Away from › Incision, ~ 5 cm › Bony prominences › Scars › Umbilicus › Belt line

 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

 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

 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

 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

 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

 Leadbetter and Clarke Technique :

 Transcolonic Technique of Goodwin

 Strickler Technique

 Pagano Technique

 Bricker Anastomosis - Refluxing end-to-side anastomosis - Simple to perform and has a low complication rate

 Wallace Technique

 Split-Nipple Technique In one series, this type of anastomosis prevented reflux in more than 50% of the patients

 Intussuscepted Ileocecal Valve

 Intussuscepted Ileal Valve

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

3- Pyelonephritis: occurs both in the early postoperative period and during the long term 4- Leakage 5- Deterioration of renal function

 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

 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

 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

 Metabolic Complications: Altered sensorium, abnormal drug metabolism, osteomalacia, growth retardation, formation of urinary calculi, electrolyte abnormalities : hyponatremia in jejunal diversions

 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)

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

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

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

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

Infection:  approximately 3/4 of ileal conduit urine specimens are infected ProteusPseudomonas  Deterioration of the upper tracts is more likely with Proteus or Pseudomonas  Pure cultures of Proteus or Pseudomonas should be treated, whereas those with mixed cultures may be observed, provided they are asymptomatic

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

Short 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

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

Chapter 81

Patient must be  Willing, able, highly motivated  Able to self catheterize  Good renal function › Serum creatinine should be less than 2.0

 Afferent limb  Reservoir  Efferent limb

 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)

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

catheter EFFERENT LIMB (to skin) Continence maintained by ileocecal valve RESERVOIR

 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.

 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

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

 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)

Chapter 82

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

 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

 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)

 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)

Suprapubic Catheter Ureteral Catheters Foley Urethral Catheter

 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

 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

Isolation of ileal segment 20 cm cm

Detubularization of ileum

Afferent Limb Reservoir Opening to urethra

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

 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