BLADDER SUBSTITUTION AND URINARY DIVERSION

DR NAUMAN KHALID

INDICATIONSABNORMALITIES OF BLADDER FUNCTIONAL e.g. Small capacity bladder

ANATOMICAL Mallignant diseases of pelvis

FIRST ANASTMOSIS SMITH 1878

PYELONEPHRITIS PERITONITS STRICTURING OF URETERAL ANASTOMOSIS

TYPE OF PROCEDURE NEEDS AND PRIORITIES OF PATIENT FOR FUNCTIONAL OR MALLIGNANT PROBLEM GENERAL STATE OF PATIENT IRRADIATION GUT DISEASE SURGERY ON GUT

CHARACTERS OF IDEAL DIVERSIONAPPROXIMATES NORMAL BLADDER NON REFLUXING LOW PRESSURE CONTINENT NON ABSORPTIVE

CLASSIFICATION

TYPE OF INTESTINE CONTINENT OR CONDUIT

COUNSELLING OF PATIENT AVAILABLE OPERATIVE OPTIONS OBJECTIVES LIFESTYLE SEXUAL LIFE PLACE OF STOMA POTENTIAL COMPLICATIONS OF EACH METHOD

PREPARATION CAREFULL HISTORY CBC SERUM ELECTROLYTES UREA NITROGEN AND CREATININE UPPER TRACT IMAGING(USG,IVU,CT) CONTRAST IMAGING OF BOWEL SEGMENT COLONOSCOPY BLEEDING DISORDERS

BOWEL PREPARATIONPreoperative Day 3 Diet Low residue plus supplements 2 Low residue plus supplements 1 Clear liquids 45 mL Fleet Phospho-Soda at 7 AM and 1 PM Conventional Cathartic Diet

(MECHANICAL)

Polyethylene Glycol Electrolyte SolutionsPolyethylene Glycol

Regular plus supplements Low residue plus supplements Clear liquids 2 to 4 liters (adults) or 25 mL/kg/hr 2 (children)

BOWEL PREPARATION(Antibiotic)Preoperative Day 3 Kanamycin 1 g kanamycin orally every 1 hour 4, then 4 times/day 1 g kanamycin orally 4 times/day 1 g neomycin 4 times/day plus 750 mg metronidazole 4 times/day 1 g erythromycin base 1 g neomycin 4 plus 1 g neomycin at 1 times/day plus 750 PM, 2 PM, 11 PM mg metronidazole 4 times/day Neomycin plus Erythromycin Base Neomycin plus Metronidazole

2

1

1 g kanamycin orally 4 times/day

CAUTION Whole-gut irrigation is contraindicated in patients with an unstable cardiovascular system, patients with cirrhosis, patients with severe renal disease, patients with congestive heart failure, or those with an obstructed bowel.

Diversion Options Ileal Conduit Urostomy Continent Diversion Heterotopic Cutaneous continent catheterizable urinary reservoir

Orthotopic neobladder

Indications for Orthotopic Reconstruction No disease at prostate apex/bladder neck Adequate bowel segment available Adequate urinary sphincter in situ No compromise to cancer control

Patient Selection Willing and able, highly motivated Able to self catheterize prior to surgery Good renal function Serum creatinine should be less than 2.0

Age/obesity are NOT contraindications

Surgical Considerations Cancer control is paramount All patients should be marked and consented for an ileal conduit should disease dictate more resection

Urologic Anatomy

Abdominal Anatomy

Figure 80-4 Connell suture. The suture traverses the bowel from serosa to mucosa and then from mucosa to serosa on the same side of the anastomosis. The suture is then placed on the opposite side of the anastomosis outside in inside out. The sequence is repeated until the two segments are approximated

Heterotopic Continent Cutaneous Reservoir

Orthotopic Urinary Diversion

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

Hautman

Figure 1083. Creation of the Hautmann ileal neobladder. A, A 70-cm 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 side-to-side manner. Copyright 2003, Elsevier Science (USA). All rights reserved.

Studer

Figure 1084. Creation of the ileal neobladder (Studer pouch) with an isoperistaltic afferent ileal limb. A, A 60- to 65-cm 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 end-to-side 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 closure, a buttonhole opening is made in the most dependent (caudal) portion of the reservoir. E, The urethroenteric anastomosis is performed. F, A cystostomy tube is placed, and the reservoir is closed complete

Kock

Figure -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

MAINZFigure 108 8. 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

Ureterointestinal anastmoses Combined Technique of Leadbetter and Clarke Transcolonic Technique of Goodwin Strickler Technique Pagano Technique

Leadbetter-Clarke ureterointestinal anastomosis. A, Injection of the submucosal tissues with saline facilitates the dissection. B, A linear incision is made in the taenia, the taenia is raised, and the mucosa is identified. A small button of mucosa is removed, and the ureter is spatulated and then sutured to the mucosa with 5-0 PDS. The seromuscular layer is sutured over the ureter, with care taken not to compromise or occlude the ureter.

Transcolonic technique of Goodwin

Transcolonic technique of Goodwin. A, The bowel is opened on its anterior surface; a small rent in the mucosa is made; and with a mosquito hemostat, the mucosa is raised from the submucosa extending laterally. A 3- to 4-cm tunnel is made before the clamp exits the serosal wall. The ureter is grasped and pulled into the submucosal tunnel. B, Both ureters have been drawn into the bowel through their submucosal tunnels before each is spatulated and circumferentially sutured to the mucosa. These sutures should also incorporate a portion of the muscularis for security. Where the ureter enters the colonic sidewall adjacent to the mesentery, the adventitia of the ureter is secured to the colonic serosa with interrupted 5-0 PDS sutures.

Strickler Technique

Strickler Technique Strickler ureterointestinal anastomosis. A, A small linear incision is made in the taenia, and the submucosa is dissected from the mucosa laterally. After a distance of 3 to 4 cm is achieved, a small hole is made in the serosa and the ureter is drawn through. B, A button of mucosa is excised, and the ureter is spatulated and sutured to the mucosa with 5-0 PDS. The rent in the taenia is closed with interrupted sutures, and an adventitial suture at the ureter's entrance point into the colon secures it to the serosa of the colon

Pagano Technique

Pagano Technique Pagano ureterointestinal anastomosis. A, A linear incision is made in the taenia between 4 and 5 cm in length. B, The submucosa is dissected from the mucosa laterally on both sides to the level of the mesentery. The ureters are drawn into the submucosal tunnel distally and sutured to the mucosa with 5-0 PDS suture proximally. C, The serosa is reapproximated, with incorporation of the mucosa in the midline

Small Bowel Anastomoses Bricker ureterointestinal Bricker Anastomosis anastomosis. A, The adventitia of the ureter is sutured to the serosa of the bowel. A small fullthickness serosal and mucosal plug is removed. Interrupted 5-0 PDS suture approximates the ureter to the full thickness of the mucosa and serosa. B, The anterior layer is completed by interrupted sutures placed through the adventitia of the ureter and the serosa of the small bowel.

Wallace TechniqueWallace ureterointestinal anastomosis. A, Both ureters are spatulated and laid adjacent to each other. B, The apex of one ureter is sutured to the apex of the other ureter with 5-0 PDS. The posterior medial walls of both ureters are then sutured together with interrupted or running 5-0 PDS, the knots tied to the outside. The lateral ureteral walls are then sutured to the intestine. C, A Y-type anastomosis is formed by completing the anterior row of the anterior lateral ureteral walls of the ureters as shown in B and then suturing the ends of the ureters directly to the intestine. D, The head-to-tail anastomosis involves suturing the apex of one ureter to the end of the other. The posterior medial walls are sewn together, and then the ends and lateral walls are sewn to the intestine

Tunneled Small Bowel AnastomosisTunneled small bowel anastomosis. A small transverse incision is made in the small bowel, and a second transverse incision 3 cm lateral to it is also made. The submucosal tunnel is made, a button of mucosa is removed, and the ureter is drawn through the tunnel and sutured directly to the mucosa. The rent in the serosa is closed, and an adventitial ureteral suture is placed and secured to the serosa at the ureter's entrance to the small bowel.

Split-Nipple Technique

This method attempts to establish a nonrefluxing anastomosis by employing a nipple mechanism. It may be applied to either small or large bowel. This technique was described by Griffiths and involves formation of a nipple in the ureter and implantation into the small bowel

Split-Nipple Technique

Split-nipple technique. The ureter is spatulated and turned back on itself, and the end of the ureter is secured to the adventitia of the ureter with interrupted 5-0 PDS suture

Le Duc TechniqueLe Duc ureterointestinal anastomosis. A, The small bowel is opened for approximately 4 to 5 cm. A longitudinal rent in the mucosa is made and the mucosa raised. B, At the distal end of the mucosal rent, a hole is made in the serosa, and the ureter is then drawn through. The entrance of the ureter through the serosa should be at least 2 cm proximal to the cut end of the bowel to allow sufficient bowel length to close the end. C, The ureter is spatulated and sutured to the mucosa and muscle layers. The mucosa is not reapproximated over the top of the ureter but rather sutured to the side of it.

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

Table 80-4 -- Complications of Ureterointestinal AnastomosesProcedure Colon Leadbetter-Clark [2][3] [4] [5]

No. of Patients

Stricture (%)

Leakage (%)

Reflux (%)

Strickler[5] Pagano[6] Small Bowel Bricker [8] [9] Wallace-Y [10] [11] [12][18]

127 28 63 1809 129 37 10 82

14 14 7 7 3 8 10 18

3

4 6

4 2 17 0 2 13

Nipple[8] Serosal tunnel[12] Le Duc [14] [15] [16] [17][18]

PostopDay 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), SP Cathetre out at 8 weeks

COMPARISON OF ORTHOTOPIC SIGMOID AND ILEAL NEOBLADDERS SN 85% daytime continence 9% nighttime continence

IN 90% daytime continence 60% nighttime continence

Complications Urethral Recurrence 10%

Hydronephrosis loss of renal unit Stones

Long Term Complications Metabolic Renal Failure Acidosis Osteoporosis B12 deficiency Urinary lithiasis

Metabolic Complications of Urinary Diversion

Electrolyte abnormalities Hepatic metabolism Abnormal drug metabolism Calculus formation Nutritional disturbance Glucose metabolism Bone disease Cancer

Cancer 11% of patients with ureterosignoidostomy, cancer occurring at ureterointestinal anastomosis. 10-20 yrs delay before the cancer becomes manifest. 500-fold increase in incidence of cancer is reported. The tumor invariably appear close to the anastomotic site of the ureters to the colon. Includes adenocarcinoma, signet ring carcinoma, adenomatous polyps, sarcoma, transitional cell carcinoma and undifferentiated carcinoma.

Possible etiology of cancer development Catelysed by fecal bacteria, production of carcinogenic nitrosamines from nitrites and secondary amines in the urine. Transitional/ intestinal epithelium metaplasia, dysplasia and carcinogenesis. Yearly sigmoidoscopy starting five years after procedure or altered bowel habits or gross GI bleeding.

CT Urography of Urinary Diversions63-year-old man with ileal conduit urinary diversion. Coronal maximumintensity-projection CT image shows ileal conduit (IC) after cystectomy for bladder cancer. Ureteroenteric anastomosis (arrows) is end-to-side, refluxing Bricker type.

71-year-old man with right colonic pouch urinary diversion after cystoprostatectomy. RCP = right colonic pouch. Coronal maximum-intensityprojection CT image shows RCP. Distal left ureteral segment (arrows) is not opacified.

66-year-old man with orthotopic neobladder urinary diversion after cystectomy for bladder cancer. NB = neobladder. Coronal maximum-intensityprojection CT image of patient with orthotopic NB. Ureteroenteric anastomosis (arrowhead) is refluxing Wallace-type anastomosis

69-year-old man with recurrent pelvic tumor after cystectomy. NB = neobladder Oblique coronal maximumintensity-projection CT image shows afferent limb (arrowheads) and reservoir of NB. Tight stricture (arrow) can be identified where tumor is encasing distal aspect of afferent limb of NB.

54-year-old man with ileal conduit (IC) urinary diversion and distal right ureteral stricture after cystectomy for bladder cancer. Coronal maximum-intensityprojection CT image shows distal right ureteral stricture (arrow). Surgical revision of distal right ureter confirmed benign stricture. IC = ileal conduit

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