Urinary Diversion following Radical Cystectomy

1. URINARY DIVERSION
&
URINARY BLADDER SUBSITUTION
Bikash Bk. Thapa

2. Overview
• History n Types of urinary diversion
• Principle of surgical techniques
• Selection criteria
• Complications
• Modifications in conventional techniques
• Recent advances

3. Introduction
• Diversion of urinary pathway from its natural path
• Types:
– Temporary/Permanent
– External /Internal
– Continent / Incontinent
– Definitive/Palliative
– Orthotropic / Heterotropic subsitution

5. Evolution of urinary diversion

6. History
• First attempted urinary diversion by Simon in 1852
• Urterosigmoidostomy is the oldest
• Zaayer in 1911 started ileal conduit and it was gold
standard through 1990’s
• Kock and associates reintroduced continent cutaneous
diversion in 1982
• In 1979, Camey and Le Duc reported their pioneer
othrotopic neobladder

7. Limitation for selection
• Neobladder is most commonly used procedure -50%
• 40% don’t qualify for neobladder
• Ileal conduit is second choice-30%
• Anal and continent diversion with catheterizable
stoma -20%
• Richard E.Hautmann/J Uro,2003

8. Indications of permanent urinary diversion
• When the bladder has to be removed
• When the sphincters of the bladder & the detrusor muscle
damaged or have lost their normal neurological control
• When there is irremovable obstruction in the bladder & distal
• Ectopic vesicae
• Incurable vesico- vagina fistula

9. Urinary Diversion in Carcinoma Bladder
• Radical cystectomy
– muscle-invasive
– recurrent T1 disease or CIS
• Palliative therapy

10. Goal Directed Diversion
Maximal tumor control
Minimal complications
Best possible QOL

11. Ideal Urinary Diversion
Undisturbed body image
Natural micturation
Continence
Safe upper urinary tract

12. Pre-procedure counselling
Selection based on Clinical factors
Inform and honest discussion
Long and short term risks and benefits
Intergroup talk
Possibility of change in diversion method
Stoma therapist

13. Selection of Type of Diversion
Age/ Survival rate
Comorbidities
Oncological Extent of disease
Renal and Hepatic functional status
Bowel condition
Patient’s preferences
Available expertise

14. Choose the route of diversion
Intestinal Cutaneous Neobladder Palliative
Continent VS Incontinent

15. Use of Intestinal segment for diversion
• Surgical anatomy
• Selection of part of bowel
• Bowel preparation
• Intestinal anastamosis
• Ureterointestinal anastomosis

16. Anatomy

17. Selection of Bowel/Segment

18. • There are two portions of the small bowel that may
lie within the confines of the pelvis and as such may
be exposed to pelvic irradiation and pelvic disease:
the last 2 inches of the terminal ileum, which is often
fixed in the pelvis by ligamentous attachments;and 5
feet of small bowel beginning approximately 6 feet
from the ligament of Treitz, the mesentery of which is
the longest of the entire small bowel, and as such,
this portion of the small bowel can descend into the
pelvis. In a postirradiated patient, one should try to
avoid use of these two segments of the small
intestine in any reconstructive procedure

19. • The advantage of stomach over other intestinal
segments for urinary intestinal diversion is that it
is less permeable to urinary solutes, it has a net
excretion of chloride and protons rather than a
net absorption of them, and it produces less
mucus.
• The jejunum is usually not employed for
reconstruction of the urinary system because its
use may result in severe electrolyte imbalance

20. • The ileum and colon are used most often for urinary tract
reconstruction and have been employed in all types of
reconstructive procedures. The ileum is mobile and of small
diameter, has a constant blood supply, and serves well for ureteral
replacement and the formation of conduitsLoss of significant
portions of the ileum results in nutritional problems because of lack
of vitamin B12 absorption, diarrhea because of lack of bile salt
reabsorption, and fat malabsorption. On occasion, the mesenteric
fat is excessive, making mobility and anastomosis difficult. Also, the
mesentery may be so short that it is difficult to mobilize the ileum
into the deep pelvis. Postoperative bowel obstruction occurs in
about 10% of patients who have segments isolated from the ileum
for urinary tract reconstruction

23. Principle of Anastomosis
• Adequate exposure
• Ensure good blood supply
• Control spillage
• Accurate apposition of serosa to serosa
• Ensure tight
• Realignment of the mesentry

24. Intestinal anastomosis

26. Ureterointestinal Anastomosis
• Refluxing Vs Antirefluxing
• Only needed ureter is mobilized
• Shouldn’t strip the periadvential tissue
• Bowel should be brought to the ureter not vice
versa
• Watertight mucosa to mucaosa anastomosis
• Anastomosis should be retroperitonealised
• Soft silastic stent can be used to avoid stricture at

33. Complication of intestinal urinary
diversion

35. Urinary Diversion- Conduit
• After a cystectomy; because of a diseased
bladder
• Before transplantation in a patient who has a
bladder that cannot adequately receive the
transplant ureter;
• dysfunctional bladders
– persistent bleeding,
– obstructed ureters,
– poor compliance with upper tract deterioration,
– inadequate storage with total urinary incontinence

36. Ileal conduit
• In this procedure, a portion of distal ileum is chosen. It
is the simplest type of conduit diversion to perform
and is associated with the fewest intraoperative and
immediate postoperative complications.
• It is not advisable to use ileum for a conduit in patients
with a short bowel syndrome, in patients with
inflammatory small bowel disease, and in those whose
ileum has received extensive irradiation, often as a
consequence of prior radiation therapy for a pelvic
malignant neoplasm.

39. The early and long-term complications are similar
to those listed for ileal conduit except that the
electrolyte abnormality is a hyperkalemic,
hyponatremic metabolic acidosis instead of the
hyperchloremic metabolic acidosis of ileal diversion
( Table 80-6 ). The treatment of the jejunal
syndrome consists of administration of sodium
chloride and sodium bicarbonate. Thiazides may
also be used and are helpful in allaying the
hyperkalemia ( Hasan et al, 1994 ).

40. Colonic Conduit
• Three types of colon conduits are commonly used: transverse, sigmoid, and ileocecal. Each has
specific indications with advantages and disadvantages.
• The transverse colon is used when one wants to be sure that the segment of conduit employed
has not been irradiated in individuals who have received extensive pelvic irradiation. It is also an
excellent segment when an intestinal pyelostomy needs to be performed. The sigmoid conduit is
a good choice in patients undergoing a pelvic exenteration who will have a colostomy. Thus, no
bowel anastomosis needs to be made. It also allows nonrefluxing submucosal reimplantation and
provides for an easily placed left-sided stoma when that is desirable.
• The use of sigmoid colon is contraindicated with disease of this segment or when the hypogastric
arteries have been ligated and the rectum has been left in situ. The latter circumstance may result
in sloughing of the rectum or its mucosa because its blood supply of necessity is interrupted. It is
also unwise to use this segment in individuals with extensive pelvic irradiation because it has
probably been included in the radiation fields.
• An ileocecal conduit has the advantage of providing a long segment of ileum when long segments
of ureter need replacement as well as the advantage of providing colon for the stoma. It is also
used in situations in which free reflux of urine from the conduit to the upper tracts is thought to
be undesirable. Contraindications to the use of transverse, sigmoid, and ileocecal conduits
include the presence of inflammatory large bowel disease and severe chronic diarrhea

43. • Metabolic complications
– electrolyte abnormalities,
– altered sensorium,
– abnormal drug metabolism,
– osteomalacia, growth retardation,
– persistent and recurrent infections,
– formation of renal and reservoir calculi,
– problems ensuing from removal of portions of the gut
from the intestinal tract, and
– development of urothelial or intestinal cancer.
• .

44. • Many of these complications are a
consequence of altered solute absorption
across the intestinal segment. The factors that
influence the amount of solute and type of
absorption are the segment of bowel used,
the surface area of the bowel, the amount of
time the urine is exposed to the bowel, the
concentration of solutes in the urine, the renal
function, and the pH of the fluid.

45. • stomach
– a hypochloremic hypokalemic metabolic alkalosis may
occur.
• jejunum
– hyponatremia, hyperkalemia, and metabolic acidosis
occur.
• ileum or colon
– hyperchloremic metabolic acidosis ensues.
• Other electrolyte abnormalities
– hypokalemia, hypomagnesemia, hypocalcemia,
hyperammonemia, and elevated blood urea nitrogen and
creatinine.

47. • Alteration of the sensorium may occur as a consequence of
magnesium deficiency, drug intoxication, or abnormalities
in ammonia metabolism
• Osteomalacia in urinary intestinal diversion may be due to
persistent acidosis, vitamin D resistance, and excessive
calcium loss by the kidney. It appears that the degree to
which each of these contributes to the syndrome may
vary from patient to patient.
• Drugs more likely to be a problem are those that are
absorbed by the gastrointestinal tract and excreted
unchanged by the kidney. Thus, the excreted drug is re-exposed
to the intestinal segment, which then reabsorbs
it, and toxic serum levels develop

48. • An increased incidence of bacteriuria, bacteremia, and septic
episodes occurs in patients with bowel interposition
• Deterioration of the upper tracts is more likely when the culture
becomes dominant for Proteus or Pseudomonas. Thus, patients
with relatively pure cultures of Proteus or Pseudomonas should be
treated, whereas those with mixed cultures may generally be
observed, provided they are not symptomatic. Patients with
continent diversions also have a significant incidence of bacteriuria
and septic episodes
• the great majority of stones formed in patients with urinary
intestinal diversions are composed of calcium, magnesium, and
ammonium phosphate. Those most susceptible to development of
renal calculi are patients who have hyperchloremic metabolic
acidosis, preexisting pyelonephritis, and urinary tract infection
with a urea-splitting organism

49. • The incidence of cancer development in
patients with ureterosigmoidostomy varies
between 6% and 29%, with a mean of 11% (
Schipper and Decter, 1981 ; Stewart et al,
1982 ; Zabbo and Kay, 1986 ). There is
generally a 10- to 20-year delay before the
cancer becomes manifest. On histologic
examination, the tumors include
adenocarcinoma, adenomatous polyps,
sarcomas, and transitional cell carcinoma.

50. Diversion via Rectum
• ureterosigmoidostomy

51. Cutaneous Continent Urinary Diversion
• Patient selection
• Patient Preparation
– Stoma site marking
– Hepatic and renal function status
• 60ml/min
– Well versed with more than one type
– Consider sigmoidsotomy or colonoscopy
– Bowel Preparation

52. • Goodwin et al 1958
• Best continent is yet to be devised
• Considerable renal deterioration

53. • Rectal Bladder Urinary diversion
– Ureterosigmoidostomy
– Folded rectosigmoid bladder
– Agumented valved rectum
– Hemi-kock and T- kock procedure
– Sigma rectum pouch ( Mainz II)
• Continent Cathetersiation Pouches
– Continent ileal reservior (kock pouches)
– Double T- pouches
– Mainz I pouch
– Indiana pouch
– Rt colon pouch with intussuscepted terminal ileum
– Penn Pouch
– Gastric pouch

57. Orthotopic Urinary Diversion
• “Arguably, the orthotopic bladder substitute
has evolved into the most ideal form of
urinary diversion available today and should
be considered the true gold standard with
which other forms of diversion are
compared”.

58. Patient Selection
• Able to self cathetersie when needed
• Creatinine<2.0gm%
• CR clearance >60ml/min
• Gastric form of neobladder is appropiate for
borderline renal function
• Old age and obesity is not contraindication
• Accommodate a large volume of urine, under low
pressure, without the reflux or absorption of
urinary constituents.

59. Key points in orthotopic diversion
• The rhabdosphincter mechanism must
remain intact to provide a continent means
of storing urine.
• Under no circumstance should the cancer
operation be compromised by reconstruction
at the urethroenteric anastomosis, retained
urethra, or surgical margins.

60. • The innervation of the striated urethral
rhabdosphincter arises from the branches of the
pudendal nerve and is most important to
maintain continence in patients with an
orthotopic neobladder. ▪ Any pelvic surgery
intended to maintain the rhabdosphincter
function and innervation should avoid excessive
dissection along the pelvic floor where the
branches of the pudendal nerve course to
innervate the sphincter complex

61. Continence preservation
• The clinical goal of most orthotopic neobladders is to
allow volitional voiding every 3 to 4 hours with a
capacity range of 400 to 500 mL.
• Nocturnal incontinence is observed in approximately
28% of patients undergoing orthotopic diversion.
• Factors influencing continence rates include age,
intestinal segment used, and possibly the application
of a nerve-sparing technique.
• Failure to empty or urinary retention has been
reported in 4% to 25% of patients undergoing
orthotopic reconstruction and is more common in
women

62. Pelvic n Urethral recurrence
• The overall risk of a urethral recurrence of transitional cell
carcinoma after cystectomy is approximately 10% in men. ▪ The
two most important risk factors for a urethral tumor recurrence in
men are invasive prostatic tumor involvement and the form of
urinary diversion. ▪ The two most important risk factors in
women for urethral tumor recurrence are bladder neck
involvement and anterior vaginal wall involvement with
tumor. ▪ Intraoperative frozen-section analysis of the distal
surgical margin in men (apical prostatic urethra) and women
(proximal urethra) provides an accurate assessment of the urethra
and appropriately determines candidacy for orthotopic
diversion. ▪ A local pelvic recurrence rate of approximately 10%
is seen in patients undergoing radical cystectomy for bladder
cancer and rarely interferes with the function of the neobladder.

63. Refluxing or Anti-refluxing neobladder
• Neobladder accommodate large vol of urine in low
pressure system
• Urine constituents in neobladder is sterile
• Complete emptying is done with Valsalva maneuver
• Anti-refluxing mechanism is challenging and time
consuming
• Antireflux mechanism is assoc with high rate of
intestinal obstruction
• Good results have been observed with intermediate
follow-up with the isoperistaltic long afferent segment
of an ileal neobladder, known as the Studer pouch
• ( Studer et al, 1996b ; Thoeny et al, 2002

64. • The inclusion of an antireflux mechanism in
the chronically infected continent cutaneous
reservoir, requiring intermittent
catheterization, is important and is not a
source of significant debate

65. • camey II
• Vesical ileal pouch
• S-Bladder
• Ileal neo bladder (Hautmann)
• Studer ileal Bladder substitute
• Orthotropic kock’s ileal reservior
• T-pouch ileal neobladder
• Orthotropic Mainz Pouch
• Ileocolonic (leg Bag) pouch
• Right colon pouch
• Sigmoid Pouch

66. Camey II orthotopoic subsitute

67. Hautmann

68. Studer ileal bladder subsitute

70. • The appropriate use of catheters, stents, and drains is important in all patients undergoing
urinary diversion Judicious use of these surgical tools helps reduce perioperative morbidity. In our
experience, a 24 French Simplastic hematuria catheter has been an ideal urethral catheter. This
catheter allows excellent irrigation of mucus and blood clots and eliminates the need for a
cystostomy tube. Ureteral stents should extend from the ipsilateral renal pelvis across the
ureteroenteric anastomosis and may be either externalized to the skin or internalized and
anchored to the urethral catheter (our preference). Externalized ureteral stents can be removed 1
to 2 weeks postoperatively. However, stents that are anchored to the urethral catheter are
generally removed 3 weeks postoperatively when the urethral catheter is removed. All patients
should have a pelvic drain postoperatively. We advocate a 1-inch Penrose drain placed posterior
to the bladder substitute and brought out a separate stab wound lateral to the midline incision.
This Penrose drain prevents the accumulation of urine and serous fluid and is generally removed
after the urethral catheter is removed at 3 weeks postoperatively. A large suction Hemovac drain
is placed for the first 24 hours, allowing the evacuation of blood during the acute postoperative
period. Last, some authors advocate the placement of a tube gastrostomy that provides a simple
means to drain the stomach and obviates the need for an uncomfortable nasogastric tube while
the postoperative ileus resolves ( Buscarini et al, 2000 ).

71. • Although no strict guidelines are available regarding optimal timing of reservoir
catheter removal, it has been our practice for patients undergoing orthotopic and
continent cutaneous forms of diversion to wait until 3 weeks postoperatively.
When patients return at the 3-week postoperative mark, if there is minimal
drainage from the Penrose drain (less than 100 mL during 24 hours), the catheter
is removed, followed by the drain. Routine pouchograms or radiographic studies
of the neobladder are not routinely performed as suggested by Ankem and
associates (2004) unless a significant output from the drain is observed. In this
situation, conservative management (advancing the Penrose drain and ensuring
adequate reservoir drainage) is generally all that is necessary for the reservoir to
heal with time. In rare instances of persistent urinary drainage, proximal
diversion of the urinary system with bilateral nephrostomy tubes will help
resolve this problem. Open surgical intervention for a persistent urinary leak is
indicated only when a foreign body is present or if there is an undrained fluid
collection that cannot be managed with computed tomography–directed
placement of a drain. Obviously, these are general guidelines on the
management of the reservoir drains, and each case must be considered
individually to optimize clinical outcomes.

73. Pitcher Pot Ileal neobladder