2004 Part VIII: Nongastrointestinal Transabdominal Surgery will be done and the left ureter won’t be

brought to the right side as is done in the ileal

Fig. 4. Turnbull loop stoma. A: The distal end of the conduit is closed. The loop should
protrude 3 to 4 cm and be secured to the fascia. The loop is opened across the nonfunctional
segment. B: The stoma is maturated with interrupted sutures, including the skin, the
seromuscular layer of the conduit, and the edge of the mucosa. C: Stoma after maturation.
The combination of unirradiated bowel
and unirradiated ureters and the absence
of ure-teral mobilization optimizes
success in the high-risk radiation patient.
It is important to mobilize the hepatic
and splenic flexures of the colon. For this
reason it is frequently necessary to extend
the abdominal incision to the xiphoid. The
middle colic artery is easily identified. The
entire transverse colon is isolated and di-
vided as described above for the ileal con-
duit. While the segment will seem long, the
length is necessary in order to reach both
upper ureters as no ureteral mobilization
conduit. Depending on the preference of the
surgeon, the transverse colon can be brought
intraperitoneal or extraperitoneal. If
intraperitoneal, the colon is brought into
continuity above the colon conduit, as de-
scribed for the ileal conduit. The ureters are
brought through windows in the left and right
colonic mesentery, avoiding injury to the
inferior mesenteric vein on the left side.
Small enterotomies are made in the portion
of the colon adjacent to each ureter. We avoid
the tenia coli when performing re-fluxing
anastomosis. In this case, the mu-cosa is
matured, the anastomosis is per-formed, and
stents are placed as described for the ileal
conduit earlier. Because tun-neled
anastomoses are usually reserved for cases in
which fecal contamination raises concern for
pyelonephritis, we will reserve discussion of
these techniques until the section on
ureterosigmoidostomy.
Because the intraperitoneal approach to
the transverse colon conduit can be diffi-
cult in a patient with (a) very short ureters
or a planned anastomosis to the renal pel-
vis, (b) a thick fatty colonic mesentery, or
(c) an edematous mesentery after a long
operation, we frequently prefer the alterna-
tive retroperitoneal approach. In this case
the bowel is brought into continuity below
the conduit and the conduit is stretched
across the retroperitoneum, from kidney to
kidney. The upper ureters or renal pelvis
can then be anastomosed to the bowel as
described above. Regardless of the ap-
proach, bringing the stents through the ter-
minal end of the conduit can be difficult
due to the long length of the conduit, rela-
tive to an ileal conduit. This sometimes re-
quires using a flexible cystoscope to pass a
wire first or making a small colotomy mid-
way through the conduit to help guide the
stents through with a long clamp.

Continent Diversions
Continent diversions work best when fash-
ioned as a pouch. These include rectal di-
version, relying on the anal sphincter for
continence; orthotopic diversion, relying
on the external urinary sphincter for conti-
nence; and heterotopic pouches, relying on
a catheterizable segment for continence.
The first such continent diversions used
nondetubularized segments of intestine such
as the ureterosigmoidostomy or the Camey
pouch. However, the trend has been toward
creating pouches that rely on a de-tubularized
Fig. 5. Loopgram of a transverse colon conduit. X-ray demonstrates the utility of the segment of bowel refashioned in a spherical
transverse colon in reaching the upper ureters and renal pelves. Also shown is how long a shape in order to minimize pressure and
segment of transverse colon is required to traverse the retroperitoneum and reach the skin. metabolic complications.