urinary diversion
TRANSCRIPT
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-