Urinary diversion following

cystectomy
Dr. Edmond Wong
 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
 Now
• Preferably:
o Continent reservior connected to urethra
o Ileal segments (lower pressure peaks and
ease of surgical handling)
 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
o Uretero-sigmoidostomy/ rectal bladder
 Factors influencing complication
• Patient Factors
• Bowel Factors
 Patient Factors
• Performance Status/ Co-morbidities
• Patient /Caretaker compliance to CISC
Mobility
• Previous RT
• Renal function
• Liver function
• Body Habitus/BMI
 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
Which Gastrointestinal segments?
• Stomach
• Ileum
• Colon
• Appendix
 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
 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
 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
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
 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)
 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)
 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
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
 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)
 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.
 Jejunum
• Indication : nil

• Not usually employed due to severe electrolyte

imbalance
– Hyponatremia
– Hyperkalemic / hypo K
– Hypochloremia
– metabolic acidosis
• Excissive loss of NaCl  Severe dehydration
 Appendix
• Useful for catheterizable nipple for
continuent cutaneous diversion
• If appendix not available Monti pouch
with ileal segments
 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.
 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
 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
 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)
 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
 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
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
 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
 (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
 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
 Preparation of ureter
• Preserve blood supply: periureteral
adventitial tissue (reduce ischemia and
stricture
• Left ureter moved across retroperitoneum
above level of IMA
 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
Bricker
Wallace
 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
 Complications
• Madersbacher 2003
– 131 patient
– Overallcomplication rate: 66%
• Intestinal anastomosis:
1. Ileus /Bowel obstruction (10%)
2. Leakage (2%)
3. Sepsis
4. Hemorrhage
5. Intestinal stenosis
6. Pseudo-obstruction
7. Conduit elongation or stenosis
 Complications of intestinal stomas &
conduit
1. Bowel necrosis
2. Dermatitis
3. Stomal stenosis 20%
4. Stomal retraction
5. Stomal Prolapse
6. Parastomal hernia
7. Obstruction
8. Conduit varice (due to portal HT)  torrential
bleeding
9. Ureteroenteric complication
– Anastomotic stricture
– Leakage
 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)
 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)
 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
 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)
 Open exploration
• Mayo clinic experience
• OT time: 320 min
• Patency rate: 86% at 3 years
 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)
 Acuise cutting balloon
• Success rate: 30-68%
• Risk of injury to surrounding ( ureteroenteric
fistula , iliac artery injury)
 Cold knife endoureterotomy
• Patency rate: 65 % at 3 years
• Multiple incision made circularly around the
stenotic segment (3-6)
• Flexible wire-mounted cold-knife
 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
 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)
 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
 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
 Entero-conduit fistulae
• Rare
• Risk factor:
– Bowel anastomotic leak
– Poor external drainage post-op
– UE anastomosis close to bowel anastomosis
• Mx: TPN 2 weeks, continue external drainage,
Re-exploration if failed
Continent cutaneous urinary
diversion
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
 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
 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
 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
 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
 Sphincteric compression

As in Indianan pouch
Nipple valve
Flap Valve mechanism
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
 When is Mitrofanoff indicated?
• For continent urinary diversion when a
patient has no usable urethra or urethral
sphincter
 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
 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
 Complications
• Re-operation rate: 22-49%
• Stoma stenosis: 4-15%
• Incontinence rate: 3.2%
• Ureteral stenosis : 8%
• Metabolic (if IC valve & terminal ileum):
diarrhoea, hyperchloraemic acidosis ,
malabsorbtion
Orthotopic neobladder
 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
 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
CI to neobladder
Neobladder construction
• 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
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
 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
 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
Complications
 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)
 What is a Kock Pouch?
• Nils Kock 1982
• A continent nonrefluxing urostomy
 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]
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
 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