2. History
• 1852 (Simon): report urinary diversion with
intestinal segments
• 1888 (Tizzoni): 1st
orthotopic diversion in
animal
• 1911 (Coffey): ureterosigmoidostomy
• 1911 (Zaayer): 1st
report ileal conduit
• 1950 (Bricker): eastablish ileal conduit as first
choice
• 1959 (Goodwin): 1st
ue of detubularized
reconfigureed ileal segments as low pressure
reservoir
3. Now
• Preferably:
o Continent reservior connected to urethra
o Ileal segments (lower pressure peaks and
ease of surgical handling)
4. Classification of Diversion
• Orthotopic:
• Orthotopic bladder substitution
• Heterotopic
o Continent cutaneous
o Non-continent Cutaneous
o Ileal conduit / colonic conduit
o Cutaneous ureterostomy
o Diversion to GIT
oUretero-sigmoidostomy/ rectal bladder
6. Patient Factors
• Performance Status/ Co-morbidities
• Patient /Caretaker compliance to CISC
Mobility
• Previous RT
• Renal function
• Liver function
• Body Habitus/BMI
7. Bowel/Technical Factors
• Type of intestinal segment used
• Length of intestinal segment
• Continent vs Continuously draining
• Method/ extent of detubularization
• Capacity
• Compliance
• Reflux or non-refluxing uretero-intestinal
anastomosis
• Type of diversion chosen
• Contact time with urine
9. Stomach
• Blood supply
– Usually use fundus
– Either left or right gastroepiploic artery with the omentum left
behind as support
• Indications:
– Borderline RFT
– Inflammatory bowel disease
• Advantage:
– Less permeable to urine solute & acidify urine with net HCL loss,
less acidosis be more suitable for impair RFT
– Locate at epigastrium with less affect by RT
– Lower incidence of bacteriuria
– Reduced mucus production stone formation
– Thick muscular backing easier antireflux ureteroenteric
anastomosis
10. Stomach
• Disadvantage:
– Hypokalemic Hypochloremic metabolic alkalosis
• Excessive secretion of HCL & absorption of HCO3
• Txn: H2 blocker
– Hematuria-dysuria syndrome (overcome with composite urinary
reservoir)
– Hyper-gastrinemia increase acid secretion
– Reduced intrinsic factor (paritetal cell) vitamin B12 deficiency
– Cx of gastrectomy: Dumping syndrome, steatorrhoea, bilious
vomiting, afferent loop syndrome
– Megaloblastic or iron deficiency anemia
– Bowel obstruction (10%)
– Gastric pouch ulceration
– Theoretical risk of bone demineralization
11. Post-gastrectomy syndrome
• Malnutrition:
– Malnutrition: small capacity, rapid gastric emptying,
rapid intestinal transit
– Fe def: acid convert Fe3+ to Fe 2+ (ferrous)
– B12 det: lack of intrinsic factor
• Dumping syndrome:
– Early (30min): gastric emptying to small bowel
osmotic load dizziness, palpitation
– Late : rapid swing in insulin secretion hypoglycemia
• Diarrhoea:
– rapid gastric emptying & hyperosmoler load in small
bowel
• Bilious vomiting :
– Loss of pylorous reflux of duodenal contents
12. Stomach complication (early)
• Gastric retention due to atony of the
stomach or edema of the anastomosis
• Hemorrhage (anastomotic site)
• Hiccups (gastric distention)
• Pancreatitis (intraoperative injury)
• Duodenal leakage
13. Ileum
• Advantage:
– Can be reconfigured as low-pressure reservoir
– Abundant supply , mobile with constant blood supply
– Away from RT field except last 2 inch of terminal ileum
• Disadvantage:
– HypoK, Hyperchloraemic metabolic acidosis
• Secret NaHCO3 & absorp NH4Cl
• NH4Cl NH3 + HCL
• Hypo K due to renal lekage, osmotic diuresis & gut loss
– Post op IO 10% (vs colon 4%)
– impaired Vit B12 and Bile acid absorption (if >60cm resected)
– Increased oxalate absorption stone formation
– Acidosis Osteoporosis and osteomalacia
– Bacteriuria + recurrent UTI
– Impair RFT
– Risk of malignancy (Nitrite + amine= carcinogen)
14. Txn in metabolic cx of Ileum
• Alkalizing agent:
– NaHCO3 900mg TDS
– Polycitra (K+/Na+ citrate in citric acid
solution)
• K supplement after acidosis corrected
• Chlorpromazine 25mg TDS (inhibit Cl
transport)
15. Ileocoecal valve
• Controlled transport of ileal content into colon
• Rapid bowel propulsion soft stools,
diarrhoea, malabsorption
• Decrease Vit B (32%)
• Decrease folic acid (11%)
• Metabolic acidosis (30%)
• Increase risk of renal and gall bladder stones
16. What happen after ileal resection?
• Vit B12 def :
– Vit B12 is absorbed in terminal ileum after
finding to intrinsic factor
• Decrease enterohepatic circulation:
– Increase bile salt in colon colonic
malignancy
– Decrease bile salt pool cholesterol gall
stones
17. Colon
• Advantage:
– Redundant sigmoid (easy to brought down)
– Larger diameter
– Less Vit B12 and bile salt absorption problem
– Less IO (4%)
• Disadvantage:
– Hyperchloremic hypokalemic Metabolic acidosis
– Frequent night time voiding (enhance peristalsis
+ higher pressure)
– Diarrhea (if ileum and right colon are resected)
18. Colon
• usually easily mobilized
• results in fewer nutritional problems
• If the ileocecal valve be used, diarrhea,
excessive bacterial colonization of the ileum
with malabsorption, and fluid and bicarbonate
loss may occur.
• incidence of postoperative bowel obstruction
with colon is 4%, less than that occurring with
ileum.
• An antireflux ureterointestinal anastomosis by
the submucosal tunnel technique is easier to
perform with use of colon.
19. Jejunum
• Indication : nil
• Not usually employed due to severe electrolyte
imbalance
– Hyponatremia
– Hyperkalemic / hypo K
– Hypochloremia
– metabolic acidosis
• Excissive loss of NaCl Severe dehydration
20. Appendix
• Useful for catheterizable nipple for
continuent cutaneous diversion
• If appendix not available Monti pouch
with ileal segments
21. Summary
• Stomach:
– Hypo K , Hypo Cl, Metabolic acidosis
• Jejunum
– Salt loss syndrome (dehydration, hyponatraemia,
hypochloraemia, hyperkalaemia, metabolic acidosis).
• lleum
– Salt loss syndrome
– Hypo K Hyperchloraemic acidosis.
• Colon
– Hypo K , Hyperchloraemic acidosis.
22. Other problem
• Altered sensorium
– Increase NH4 absorption
– Mg deficiency
– Txn: Lactulose 10mg BD , neomycin 1gm TDS
• Altered drug metabolism:
– Those excreted unchange in kidney and absorbed by GI tract
• Bone disease
– Due to metabolic acidosis
– Demineralization (long-term) osteomalacia
– Reduced growth (young patients).
– Increased fracture rate.
– Pain in weight-bearing joints
– Txn: Correct acidosis, Ca supplement, Vit D
23. Other problem
• Recurrent infection:
– Baterial colonization 25% with stomach , 80% with ileal or colonic
conduit
– 20% with acute pyelonephritis, 5% sepsis
– Patient with C/ST +ve for Proteus or Pseudomonas should be
actively treated
• Stone:
1. Increase urinary Ca excretion result in bone absorption (2nd
to
acidosis)
2. Decrease urine citrate secretion (acidosis)
3. Recurrent infection
4. Ileum : Disturbed bile salt + fat absorption Ca saponification with
fat cannot bind to oxalate increase oxalate absorption
hyperoxalouria
5. Urinary stasis or obstruction
24. Other problem
• Nutritional due to bowel resection:
– Vit B12 deficiency
– Bile salt and fatty acid malabosorption gall
stone formation
• Malignancy:
– >10yr, at site of anastomosis, Adeno Ca
– Due to bacteria in urine : Nitrate nitrite
– Nitrite + amine N-nitroasmine
(carcinogenic)
25. Patient preparation
• Mechanical bowel preparation
– 3 days of fluid diet
– Whole gut irrigation with polyehylene glycol
– Fleet enema
• Pre-op antibiotic : caphalosporin + flagyl
• Stoma site assessment by stoma nurse
• Well informed consent
26. Which type of Urinary diversion?
• Incontinent urinary diversion
– (Transuretero-) Ureterocutaneostomy
– Ileal and colonic conduits
• Continent urinary diversion
– Continent catheterizable reservoir
– Substitution cystoplasty / Orthotopic
neobladder
– Uretero (ileo-) sigmoidostomy/ rectal bladder
27. 3 Principles for lower urinary tract
reconstruction
• A reservoir in which to store urine in low
pressure
• A conduit through which the urine is
conducted to the surface
• A continence mechanism
28. Bladder reservoir must have:
• Able to retent 500-1000ml of fluid
• Maintenance of low pressure after filling
• Elimination of intermittency pressure
spikes
• True continence
• Ease of catheterization and emptying
• Prevention of reflux
• Skinner
29. (Transuretero-) Ureterocutaneostomy
• Indications:
– After palliative cystectomy in elderly frail pt
– Temporary divers when GI tract not possible
– Diversion for fistula or hemorrhage
• Procedure:
– Ureter mobolized to bladder ligated and divided
– V or U shaped skin incision
– Track throught abd wall in most direct line
– Ureter with largest diameter pulled thru track (spatulated
– Apex of skin flap to ureteral apex (4-5/0)
– The other ureter End-to-side to complete TUU
– Oemntal flap to secure anastomosis and abdominal tunnel
30. Ileal conduit: procedure
• 10-12cm ileal segment isolated 20 proximal to IC valve
• Short straight conduit without kinking
• Continuity of small bowel re-established
• Mesenteric window closed
• Ileum in isoperistaltic fashion
• Isolated segment flused with warm saline till return of clear fluid
• Left ureter brought to RLQ beneath the sigmoid mesocolon
(inferior to IMA)
• Ureteroenteric anastomosis
• Distal end of ileal segment fashioned as end ileostomy in RLQ
• Wide facial opening (x-type incision)
• Stoma site
– Above of below the waist band
– Not close to umbilicus , edge of rectus , bony prominence or scar
– Be test with patient and marked pre-op
31. Preparation of ureter
• Preserve blood supply: periureteral
adventitial tissue (reduce ischemia and
stricture
• Left ureter moved across retroperitoneum
above level of IMA
32. Ureteric implantation
• Bricker and Nesbit:
o Both ureter implant individually in an end-to-side
• Wallace 66:
o Paralllel orientated ureter
o Spatualted at distal end
o Posterior plate suture
o Side-to-end fashion to ileal stump
• Wallace 69:
o End to end oriented ureter
o Spatulated and suture
o Side-to-end fashion to ileal stump
35. Pros and Cons
• Advantage:
o Short segment use limited metabolic change
o Suitable in renal or hepatic insufficency
o Use when post-op radiation necessary
• Contraindications:
o Short bowel syndrome
o Radiation to terminal ileum
o Ascites
38. Complication
• Ureteric complication
– Upper ureteric obstruction esp over left side
• Excessive stripping f periureteral adventitial tissue
ischemic stricture
• Angulation of left ureter beneath mesosigmoid
colon (IMA)
• Upper tract damage:
– Pyelonephritis (10%)
– Hydronephrosis and deranged RFT (50% in
20yr)
39. Parastomal hernia
• Incidence: 10-15%
• Prevention : bring conduit through the rectus
muscle and attached to ant rectus shealth
• Can cause bowel obstruction + skin
• Surgical revision: stomal relocation ,direct
repair, avoid use of prosthetic graft (high
infection rate)
40. Stomal stenosis
• 6% (Switzerland series)
• Enough length for advancement new stoma
• Hyperkeratosis of peristomal skin and mucosa
– Excessive alkalinity of urine (infection by urea-
splitting organism)
– Txn: Vinegar on stoma surface, alkalinzation of
urine
41. Anastomoitic stricture
• 4-8%
• Early stricture: technical error
• Late stricture: ischemic ureter (ureteral dissection ,
tension , radiation)
• Txn:
– Open exploration with excision + reconstruction
– Bypass: side-to-side anastomosis, proximal ureter to
another site on loop
• Minimally invasive technique:
– Balloon dilatation
– Endoureterotomy (laser, cold-knife, electro-cautery)
43. Laser endoureterotomy
• Holmiun-YAG laser
• Thermal injury zone 0.5 to 1mm
• Direct observation of arterial pulse
• 365-micron fiber, 0.6 to 2.0 J, 8-15 Hz
• Incision made until retroperitoneal fat seen
• Stent place for 6 weeks
• Result: 70.8% patency rate (22.5m)
45. Cold knife endoureterotomy
• Patency rate: 65 % at 3 years
• Multiple incision made circularly around the
stenotic segment (3-6)
• Flexible wire-mounted cold-knife
46. Bowel problems
• Small bowel obstruction (12%)
• Cause
– Loop of small bowel stuck to raw pelvic surface/
LN dissection site
– Radiation of bowel
– Internal hernia (inadquate closure of small bowel
mesentry)
• 50% require operative adhesiolysis
47. UTI
• Colonization of ileal conduit is the rule
• Subtle sign : change of urine odor/color,
abd/loin pain , hematuria, increase mucus
• Urine collection: stoma clean with betadine,
sterile CSU send
• Ix: Loopogram (stone,urine stasis, stricture)
48. Metabolic derangement
• Related to length and type of bowel use
• HyperChloremic Metabolic Acidosis (10%)
• Secondary to RTA with derange RFT
• Txn: Oral sodium bicarbonate
• Cx: Bone demineralization
• Require high suspicious in pt with non specific
illness
49. Upper tract calculi
• Lift long risk : 9% (Studer)
• Risk increase with time from diversion
• Txn: ESWL, antegrade endoscopic technique
• Retrograde : easier in Wallace-type diversion
52. Continent cutaneous urinary diversion
1. Good Reservoir
– Good capacity
– Lower pressure storage
– Low metabolic issue
2. Catheterizable efferent limb
3. Continence mechanism
• Spherical reservoir: low end-filling
pressure with maximum radius
53. Continent cutaneous urinary diversion
• Indication:
– External urethral sphincter sparing surgery
impossibile
– Urethral malformations
– Spinal injury or complex neurological defects
• Patient compliance is of utmost importance
• Risk of perforation or bladder rupture
• Afferent (ureteroenteric) anastomosis
better have some reflux mechanism
54. Contraindications
• Absolute:
– Compromised RFT: Cr >150-200umol/L or GFR <
60ml/min
– Severe hepatic dysfunction: NH3
– Compromised intestinal function: IBD
• Relative:
– Frail patient with low motivation & hand eye
coordination
– Impossible for regular FU
– Advance age / short life expatancy
– Previous RT or need of adj RT
• In that case consider to use stomach
55. Continence mechanism
1. Sphincteric compression:
– La Place Law : T = P x r
– Intraluminal pressure inversely proportional to the radius of the
reservoir
– Narrowing of efferent limb (decrease r ) increase resistance
to urinary leakage
– Constructed by plicating , tapering or intussuscepting a limb of
bowel
– Contributed by : natural coaptation of mucosa, elasticity &
muscle tone
2. Peristalsis:
– When ileum is use as efferent limb, preceding peristalsis of the
ileum to that of colon server as a counteractive force to
overcome leakage
– Ileal contraction is earlier with higher contraction pressure
– E.g Maniz pouch
56. Continence mechanism
• 3. Nipple-valve: equilibrating pressure
– Invagination of the efferent limb into the pouch result in
nipple-valve
– Equivalent pressure inside the reservoir will be
reflected on the outlet prevent leakage
– Construction of nipple valve is most technical
demanding and asso with high complication
– E.g Kock pouch
• 4. Flap valve mechanism:
– Construction of part of the efferent limb within the
reservior against a fixed wall
– So that intraluminal pressure of the pouch wound
compression onto the efferent limb during filling phase
60. What is the Mitrofannoff Principle?
• The construction of a catheterisable conduit to
a low pressure urinary reservoir
• With a continent and catheterisable cutaneous
stoma
Mitrofanoff 1980
• Require a narrow tube , buried in the wall of the
conduit in a tunnel about 5cm long
• About 90% are continent
• 30% have conduit complication
61. When is Mitrofanoff indicated?
• For continent urinary diversion when a
patient has no usable urethra or urethral
sphincter
63. Choice of efferent limb
• Appendix (Mitrofanoff)
• Reconstructed ileal tube (Monti)
– 2-3cm ileum isolated
– Open longitudinally and anti-mesenteric border
– Close over a Fr 10 catheter along the new long axis
– Adv: bring bulky mesentry to the middle and facilate
implantation of the bilateral end
• Tapered ileum:
– Plicated with rows of Lembert suture of stapler
• Others: ureter, fallopian tube
65. Example of cutaneous continent
diversion
• Indiana pouch:
– Rt colon pouch with tapered ileum as efferent
limb
• Penn pouch:
– Ileocolonic pouch using the appendix as the
efferent limb
• T- Pouch:
– Ileal pouch with antireflux mechanism
70. Orthotopic neobladder
• A form of substitutional cystoplasty
• No oncological difference from conduit
• Consideration:
– EUS must be intact
– Local tumor recurrence: 11% (25% if prostate
involvement)
– To rule out cancer infiltration:
• Pre-op cystoscopy+ bx of BN/ Prostatic urethra
• Intra-op FS of resected margin or BN (F)
– CIS & multifocal disease, T & LN stage are not a CI
71. Advantage
1. No need for cutaneous stoma or collecting
device
2. Urinary continence rely on intact external
sphincter
3. Voiding by increase intraabdominal pressure
(valsalva’s maneuver) + relaxation of pelvic
floor muscle
4. Most retain urinary continence, void to
complete without the need of CISC
5. Improve self image and reduce psychological
truma
76. • Surface and volume does not change in parallel
• With 40cm length of bowel volume 500ml
• With double length volume 3x but pressure
almost same (radius increase by little)
• With 20cm volume too small
• Conclusion: 40ml is the ideal length
77. Methods to improve continence
• Preservation of rhabdosphincter:
– Avoid excessive apical dissection
– Avoid unnecessary suture btw DVC & sphincter
• Dissection of pelvic floor:
– Preserve branch of pundendal nerve below
endopelvic fascia
– Preserve muscuolofacial support of the pelvic floor
• Nerve sparing:
– Preservation of pelvic nerve and inferior hypogastric
nerve plexus
78. Afferent anastomosis
• Usually antireflux is not necessary in
orthotopic bladder
• Reflux prevention:
o Camey-Le Duc
o Intussuceptive ileal nipple (Hemi-Kock)
o Abol-Enein, Stein : Serosa-lined extramural
tunnel implantation
o Isoperistaltic tubular limb
79. Efferent anastomosis
• Day time continence: 87-98%
• Night time continence: 72-95%
• Need of CISC: M 4%, F 15%
• Precise preparation of urethra is essential
• Avoid conner of pouch to urethra
anastomosis kinking and difficulties with
voiding
86. Rectal bladder
• Hemi-Kock or T-pouch with valved rectum
• Depend on anal sphincter for continence
• Type:
– Ureterosigmoidosotomy
– Augmented valved rectum (sigmoid intussucept into rectum to
prevent back flow of urine)
• Largely replace by conduits, obsolete
• Main Disadvantages:
– Metabolic acidosis
– Renal failure
– Tumourigenesis (adenoCa) at site of anastomosis
– Bacterial reflux (Pyelonephritis and ureteric stenosis)
87. What is a Kock Pouch?
• Nils Kock 1982
• A continent nonrefluxing urostomy
88. Augmentation cystoplasty
• Indications:
– Improve or restore bladder capacity, adequate
to store urine for an acceptible time period (4
hr) – [Rink & Adams 1998]
– To decrease sustained bladder pressure (Pdet
> 40cmH2O) upper tract at risk [McGuire
1981]
89. Detubularisation & reconfiguration
• To increase geometric capacity of
reservoir , maximising the volume
achievable for a given surface area of
intestine
• To decrease storage pressure , improving
overall compliance
• To disrupt or blunt intestinal contraction
90. Pre-op preparation
• No test to ensure the patient will be able
to void spontaneously or empty well after
augmentation cystoplast
• All patient must be prepared to perform
CISC after cystoplasty
• Thus should learn and practice pre-
operatively