urinary diversion

44
URINARY DIVERSION – A REVIEW SRIVATHSAN.R

Upload: minnalesri

Post on 10-Apr-2015

792 views

Category:

Documents


5 download

TRANSCRIPT

Page 1: Urinary Diversion

URINARY DIVERSION ndash A

REVIEWSRIVATHSANR

URINARY DIVERSION External (ileal conduit) Internal(ureterosigmoidostomy)

Temporary (pediatric second look ) Permanent

BRIEF HISTORY OF DIVERSION

Ureterosigmoidostomy1048708 First form of continent diversion1048708 Reported by Simon in 1852 (bladder

exstrophy)1048708 Complications sigmoid cancer fecal

leak pyelonephritisureteral strictureIleal Conduit1048708 Described by Bricker in 19501048708 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 Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 2: Urinary Diversion

URINARY DIVERSION External (ileal conduit) Internal(ureterosigmoidostomy)

Temporary (pediatric second look ) Permanent

BRIEF HISTORY OF DIVERSION

Ureterosigmoidostomy1048708 First form of continent diversion1048708 Reported by Simon in 1852 (bladder

exstrophy)1048708 Complications sigmoid cancer fecal

leak pyelonephritisureteral strictureIleal Conduit1048708 Described by Bricker in 19501048708 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 Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 3: Urinary Diversion

BRIEF HISTORY OF DIVERSION

Ureterosigmoidostomy1048708 First form of continent diversion1048708 Reported by Simon in 1852 (bladder

exstrophy)1048708 Complications sigmoid cancer fecal

leak pyelonephritisureteral strictureIleal Conduit1048708 Described by Bricker in 19501048708 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 Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 4: 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 Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 5: Urinary 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 Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 6: Urinary Diversion

DIVERSION OPTIONS- COMPLETE Incontinent Ileal Conduit ndash Urostomy

Continent DiversionHeterotopic

Cutaneous continent catheterizable urinary reservoir

Non continent cutaneous Diversion to GIT

Orthotopic ldquoneobladderrdquo

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 7: Urinary Diversion

PARTIAL BLADDER SPARING

Ileovesicostomy Appendicovesicostomy or catheterizable

vesicostomy

The bladder sparing ones donrsquot 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 ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 8: Urinary Diversion

URETEROSIGMOIDOSTOMY Of historical significance ndash gone into

void Anal tone to be determined To be avoided in

1 liver disease2 primary diseases of colon3 pelvic irradiation

ldquoantirefluxing techniquerdquolsquoAdenocarcinoma at the site of

anastomosisrsquoYearly sigmoidoscopy from 5yrs after

surgery

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 9: Urinary Diversion

ILEAL CONDUIT 15-20 cm loop 30cm from IC Jn Wallace technique

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 10: Urinary Diversion

STOMAL STENOSIS

1048708 Very common complication1048708 Need for surgical intervention unless theconduit is not drainingOperative Options1048708 Revise the stoma1048708 Replace the conduit1048708 Conservative Options1048708 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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 11: Urinary Diversion

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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 12: Urinary Diversion

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 lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 13: Urinary Diversion

ALTERED SENSORIUM Increased ammonia absorption Decreased Mg(renal lossdiarrhea

decreased absorption) Drug reabsorption

(dilantinMTXChemotheophyllinebetalactamsnitrofurantoinaminogycosides)

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 14: Urinary Diversion

TREATMENT Drain urine Limit protein Treat Infection Lactulose Neomycintetracycline arginine glutamate

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 15: Urinary Diversion

COMPONENTS OF A CONTINENTDIVERSION

Low-pressure reservoir (inc volume dec pressure) detubulurisation of the gut to decrease the peristalsis

1048708 Volume 400-500 mlUreteral anastomosis 1048708 Refluxing or non-refluxingContinent Outlet 1048708 Catheterizable limb with a continence

mechanism(Mitrofanoff Principle) 1048708 Native urethra with sufficient

sphincteric function

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 16: Urinary Diversion

PATIENT FACTORS INFLUENCINGDIVERSION SELECTION Renal function ndash Creatinine lt 18 - 20mgdl GFR gt 40 mlmin 1048708 Age (relative) 1048708 Pre-operative urinary continence 1048708 Manual dexterity hand-eye coordination ndash for catheterizable diversions 1048708 Pelvic Radiation ndash bowel segment selection (transverse colon) 1048708 Primary tumor type ndash stage and location(Kristjansson A et al J Urol 1572099ndash2103

1997)

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 17: Urinary Diversion

CONTINENT CATHETERIZABLE CONDUITS Mitrofanoff Principle(Chir Pediatr 21 297

1980) 1048708 Appendix 1048708 Ureter (Ashcraft

J Pediatr Surg211042 1986)

1048708 Fallopian tube (Woodhouse1991)

1048708 Tapered ileum

Monti construction 1048708 2-25 cm segment

of ileum- tubularised 1048708 opened along

antimesenteric border 1048708 Reconstructed over

a 12-14 Fr catheter 1048708 Mesentery centered 1048708 Yields 6-8 cm

segment

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 18: Urinary Diversion

Name Bowel segment

Continence mechanism

Primary complication

Koch Ileum Nipple valve Incontinence

Indiana Ileocaecal Tapered ileal segment

Stones B12 deficiency

Mainz ileum IntussusceptedIleal nipple

Nipple valvemalfunction

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 19: Urinary Diversion

INDIANA POUCH

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 20: Urinary Diversion

HETEROTOPIC CONTINENT CUTANEOUS RESERVOIR

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 21: Urinary Diversion

INDICATIONS FOR ORTHOTOPIC RECONSTRUCTION

No disease at prostate apexbladder neck

Urethra free of disease

Adequate nondiseased 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 and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 22: Urinary Diversion

PATIENT SELECTION Willing and able highly motivated

Able to self catheterize prior to surgery

Good renal function and LFTsSerum creatinine should be less than 20

Ageobesity 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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 23: Urinary Diversion

SURGICAL CONSIDERATIONS Cancer control is paramount

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

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 24: Urinary Diversion

ORTHOTOPIC URINARY DIVERSION

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 25: Urinary Diversion

BOWEL SEGMENTS UTILIZED FORNEOBLADDER RECONSTRUCTION

1048708 Stomach1048708 Small intestine ndash primarily ileum rarely

jejunum1048708 Ileocecal1048708 Colon Right and transverse colon Sigmoid

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 26: Urinary Diversion

TYPES OF COMMON ORTHOTOPIC DIVERSIONS

HautmanLarge capacity spherical configuration with ldquoWrdquo of

ileum Studer

Ileal with long afferent limb Kock

Intessuscepted afferent limb T-Pouch MAINZ Pouch

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 27: Urinary Diversion

HAUTMAN

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 ldquoMrdquo or ldquoWrdquo 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 copy 2003 Elsevier Science (USA) All rights reserved

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 28: Urinary Diversion

STUDER

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 ldquoUrdquo 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 completely

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 29: Urinary Diversion

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 ldquoUrdquo 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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 30: Urinary Diversion

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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 31: Urinary Diversion

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 ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 32: Urinary Diversion

NEOBLADDER ndash ldquoTUBES AND DRAINSrdquo

Ureteral Catheters

Suprapubic Catheter

Foley Urethral Catheter

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 33: Urinary Diversion

POSTOP Day 1-3 Fluids Diet ambulate Day 3 Passive Irrigation SPT and Foley

30cc each Day 4 Daily Active Irrigation SPTFoley

60cc TID Day 5 Antibiotics and Pull Right (red)

Ureteral Catheter Day 6 Antibiotics and Pull Left (Blue)

Teach SPT Irrigation ndash 60cc TID Day 7 Discharge plan foley dc 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 nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 34: Urinary Diversion

FURTHER CONSIDERATIONS Continence

Preserve sphincter beyond prostate apex in males

Suspend reconstructed vagina via sacrocolpopexy or Burch procedure in females

Refluxing versus nonrefluxingNonrefluxing with decreased rates of

pyelonephritisHowever higher rates of obstruction and

technically more challenging

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 35: Urinary Diversion

SPHINCTERIC INCONTINENCE AFTERORTHOTOPIC 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 MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 36: Urinary Diversion

OPTIONS FOR SPHINCTER DEFICIENCY MALES1048708 Injectable Agents (collagen)1048708 Male Sling1048708 Artificial Urinary Sphincter

FEMALES1048708 Injectable Agents1048708 Female Sling

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 37: Urinary Diversion

URODYNAMIC EVALUATION OFNEOBLADDERS

1048708 Urodynamic evaluation of pouch withmultichannel system1048708 Assessment of capacity compliance

amplitude of contractions1048708 Pressure in pouch at time of leakage1048708 Confirmation of high pressure zone at

the junction between catherizable limb and pouch

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 38: Urinary Diversion

EXPECTED URODYNAMIC POUCHPARAMETERS Capacity 400-500 ml 1048708 Compliance gt 40 mlcm H2O 1048708 Pouch contractions 1048708 Small bowel 5-10 cm H2O 1048708 Right colon 20-25 cm H2O 1048708 Sigmoid lt 40 cm H2O

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 39: Urinary Diversion

OUTCOMES

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 40: Urinary Diversion

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

bull SNndash 85 daytime continencendash 9 nighttime continence

bull INndash 90 daytime continencendash 60 nighttime continence

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 41: Urinary Diversion

COMPLICATIONS Urethral Recurrence

10 Hydronephrosis ndash loss of renal unit

Stones

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications
Page 42: Urinary Diversion

LONG TERM COMPLICATIONS Metabolic

Renal FailureAcidosisOsteoporosisB12 deficiencyUrinary lithiasis

  • URINARY DIVERSION ndash A REVIEW
  • Urinary diversion
  • Brief History of Diversion
  • Slide 4
  • Slide 5
  • Diversion Options- complete
  • Partial bladder sparing
  • ureterosigmoidostomy
  • Ileal Conduit
  • Stomal Stenosis
  • Slide 11
  • Other conduits
  • Altered sensorium
  • treatment
  • Components of a Continent Diversion
  • Patient factors influencing diversion selection
  • Continent catheterizable conduits
  • Slide 18
  • Indiana pouch
  • Heterotopic Continent Cutaneous Reservoir
  • Indications for Orthotopic Reconstruction
  • Patient Selection
  • Surgical Considerations
  • Orthotopic Urinary Diversion
  • Bowel Segments Utilized for Neobladder Reconstruction
  • Types of Common Orthotopic Diversions
  • Hautman
  • Studer
  • Kock
  • T-Pouch
  • MAINZ
  • Neobladder ndash ldquoTubes and Drainsrdquo
  • Postop
  • Further Considerations
  • Sphincteric Incontinence after Orthotopic Diversion (Studer)
  • Options for Sphincter Deficiency
  • Urodynamic Evaluation of Neobladders
  • Expected urodynamic pouch parameters
  • Outcomes
  • Slide 40
  • Slide 41
  • Slide 42
  • Complications
  • Long Term Complications