Urinary Diversio 385i16

CONTINENT URINARY DIVERSION

Continent Urinary Diversion • Urinary diversion is indicated when bladder can no longer safely function as a reservoir. • People are performing the diversion for past 150 year.

HISTORICAL MILESTONES Extrophy. 1878- Ureterosigmoiodostomy {Direct anastomosis) {Smith} 1898- Rectal Bladder {Gersuny} 1950- Ileal Loop {Bricker} 1959- Ileal Neo Bladder {Camay} 1851- Ureteroproctostomy by Simon on a patient with 1970- Koch Pouch 1980- Indiana Pouch 1980- Ortotobic, Diversion

Non Continent Diversion •

Diversion into a non continent conduit

•

Require a segment of bowel {ileum, colon, least common

jejunum} •

Mobilized on a vascular pedicle

•

One end anastomosed with ureter {proximal end}

•

Other end used for stoma formation over which collecting device {urostomy appliances} are required

Advantage and disadvantage • Less technically demanding • Low complications

• Low incidence of metabolic, nutritional complications • Disadvantages are poor quality of life , life long stoma appliances & complications, low self esteem

Continent urinary diversions • Widely accepted by urologist and patients • Technically challenging • Associated with more complications • With advent of stapler , absorbable clips the construction of pouch has become easier • The basic principle is to configurate a spherical reservoir. • Should able to store urine at low pressure • Should be continent ; either catheterisable or neo bladder

Indication of urinary diversion Ca bladder requiring cystectomy

Dysfunctional bladder {secondary to radiation, neurogenic bladder resulting in persistent bleeding , obstructed ureter, poor compliance , upper tract deterioration , inadequate storage , total urinary incontinence Intractable incontinence in female

Principle of continent urinary diversion Patient must be skillful , good hand eye coordination {CIC} Serum creatinine < 2 mg/dl or creatinine clear > 60ml/min If functions are borderline , otherwise good candidate for diversion (gastric pouch is appropriate, excretion of HCl – Beneficial) physiological age- less than 70 Obesity relative C/I- sometimes better as appliances are difficult to manage in fatty patients Advanced stage of ca bladder – not absolute c/I {significant number of patients has good life expectancy}

Critical to successful is large volume , low pressure reservoir without reflux or absorption of urinary constituents

Patient selection Honest , informed consent Aim should be free from cancer, During neo bladder formation,consent for cutaneous diversion/stoma should be obtained Radiological evaluation of bowel , rhabdosphincter should be intact. Distal urethral margin should be free from cancer.

Work up General physical examination Assessment renal function S Creatinine < 2 mg/dl, Creatinine clearance > 60 ml/min CBC, BUN, Urine R/M & C/S ABG Radiology: USG :for upper tract anatomy , PCS, calculus, mass lesion IVP: anatomical , functional status of kidney DTPA: assessing renal function ( contrast allergy) , drainage assessment {Lasix} CT: NCCT- for stone CECT- for primary disease , assessment of diversion , fistula MRI: if USG , CT findings are unequivocal urodynamic

Type of continent urinary diversion 1. Ureterosigmoidostomy 2. Continent catheterisable pouch 3. Orthotopic urinary diversion or neo bladder

Ureterosigmoidostomy • Original continent urinary diversion {1850 by Simon} • Direct anastomosis of ureter into sigmoid • Simplest. • pre op workup- r/o diverticulitis , IBD ,integrity of sphincter •

patient must be able to hold enema 400-500ml for 1 hour.

• Increased chance of carcinoma & metabolic complications • Patient with dilated ureter, neurogenic bladder, renal insufficiencies, extensive pelvic radiotherapy, hepatic dysfunction

are not candidates. • Almost obsolete.

Ureterosigmoidostomy

Other continent diversion requiring intact anal sphincter •

Folded recto sigmoid bladder { s shape sigmoid}

•

Augmented valved rectum – stoma appliance not available

•

Hemi Koch & T pouch procedure with valved rectumdilated ureter may be accommodated

•

Sigma rectum pouch- Mainz II- low pressure recto sigmoid

NON ORTHOTOPIC 

CATHTERISABLE STOMA {CIC}

EVACUATION Ureterosigmoidostomy



Folded Recto sigmoid bladder [with ureter anastomosis antiserosal trough]



Augmented Valved Rectum {with using ileal patch}



Hemi Kock & T Pouch Procedure with valved rectum in c/o dilated ureter without cannot be brought between intussuscepted sigmoid {less chance of malignancy}



Sigma Rectum Pouch {Mainz II}

   

Appendix IC valve with proximal tapered ileum Nipple Valve Hydraulic valve

Pouches

Continent catheterizing pouches Pouches which requires intermittent self catheterization dementia, quadriplegia, neurologic disorder multiple

sclerosis should not be offered this treatment Technically demanding. More complication rate

CONTINENT CATHETERIZING POUCHES

STOMA 1} Rt. colon pouches- appendiceal techniques, psuedo appendiceal tubes, ilieo caecal valve 2} tapered or ileo caecal valve 3}use of intussuscepted valve,flap valve {avoid need of intussusceptions} 4}Hydraulic valve as in Benchekroun nipple.

POUCH Bowel pouch

Ileal with leaving IC valve  Kock pouch  T pouch

Using IC valve

 MAINZ(tapered ileum)  Indiana (using IC valve )  Rt colon pouch with intussusceptions ileum (UCLA, DUKE, LE BAG)

Appendix serving continence  PENN POUCH

Gastric pouch

Appendiceal continence techniques • Simplest & effective

• Draw back- sometimes absent • Appendiceal stump may be too short to reach anterior abdominal wall • sometimes difficulty in irrigation & removal of mucus. • only small lumen catheter can be ed

2nd continent mechanism – Use of tapered or imbricated or both terminal ileum & ileocaecal valve – Loss of ileocaecal valve, associated with bowel irregularity

3rd continent mechanism is use of intussuscepted nipple valve/Flap valve – Most demanding technically – Highest complication & re-operation – Removal of mesenteric attachment from middle 6-8 cm of bowel reduces the effacement of intussusceptions. – 2nd attachment of valve with reservoir it self. – Potential for stone formation on exposed staple.

4th mechanism is hydraulic valve (Benckeroun nipple) – Small bowel segment is isolated & reverse intussusception. – Largely abandonned.

GENERAL METHODS OF CONTINENT DIVERSION

• Pouch is constructed meticulously [Reservoir] • Should be checked for ease of catheterization intra op. • Pouch is filled with saline and examined for leakage and test the efficacy of continence • Postop pouch should be irrigated with large bore catheter 4hourly • Contrast study is performed on 7th pod, thereafter stent can be removed.

ADVISE FOR CIC • • • • • •

For appendix –no 14,16 coude tip catheter Ileo-caecal plication – no 22 to no 24f coude tip Nipple valve – straight ended no 22 to 24 Carry the catheter in zipper bag To clean the stoma with benzalkonuim chloride wipe To lubricate the catheter by inserting the tip into foil pack . • Cover the stoma with adhesive bandage • Catheter cleaning with tap water

Common Complication with Pouch 1.

Pouch hyper contractility- require antibiotic therapy for at least 10 days ( if P.N then for longer Time)

2.

Pouch urinary retention- true emergency coud tip catheter is helpful ,if not possible than flexible cystoscopy. Intra peritoneal rupture of catherisable pouch – more common is neurological patient – require contrast study If leak is small – catheter drainage & antibiotics may suffice for larger one exploration is required.

3.

4.

Gastric pouches – Indication: compromised renal function metabolic acidosis H/o radiation to pelvic & small gut Pediatric age( low metabolic complication) Benefit : less mucus production less chance of infection due to low pH Secretes HCL which is beneficial for patient of CRF complications: hematuria Dysuria Hypochloraemia Hypokalemia Metabolic alkalosis Skin ulceration at stoma site

Orthotopic urinary diversion Basic principle, preparations are same Beside these, following criteria should be met. - Rhadosphincture must be intact -cancer operation should not be compromised -Meticulous dissection of pelvic floor -frozen section analysis of distal urethral margins is mandatory

Techniques of neobladder CAMEY II ORTHOTOPIC SUBSTITUTE

modification of Camey I 65 cm long ileum arranged in transverse u shaped detubularization & reconfiguration uretero-ileal anastomosis by Le duc technique PADOVA – modification of camey II - more spherical (vesical ileal pouch) S BLADDER ileum is configurted in S shaped rest all is same as above

HAUTMANN’ S ILEAL NEO BLADDER : 70cm of ileum.

W shaped configuration of ileum. large capacity & spherical . Uretero ileal anastomosis by le duc techniques STUDER ILEAL NEOBLADDER

ileal neo bladder with long afferent , isoperistaltic ,tubular ileal segment ORTHOTOPIC KOCK’S ILEAL RESERVOIR: obsolete T POUCH ILEAL NEO BLADDER – same as kock ileal neo bladder . defers in anti reflux technique . maintenance of vascular arcades by opening the window of Daever.

STUDER ILEAL NEOBLADDER

Complications – Metabolic

- Surgical - Neuromechanical Metabolic complications • electrolyte abnormality • Altered sensorium • Abnormal drug metabolism • Osteomalacia • Growth retardation {nutritional deficiencies} • Persistent & recurrent infections • Stone formation

• Development of cancer

Metabolic disturbances associated with diversions Bowel

Na+

K+

Cl-

HCO3- C/F

Comment

Jejunum

Low

High

Low

Low

Lethargy, Vomiting, weakness, dehydration

Refractory hyperkalemia with lack of efficacy of aldosteron {rarely used}

Ileum Colon

Low/ normal

Normal

Elevated Low

Anorexia, weight loss, polydipsia, fatigue

Oral salt replacement, BI corbs supplementation

Segment

Surgical complications – – – – – – – – – – – – –

Ileus bowel obstruction entero cutaneous fistula ureteral stricture Para stomal hernia stomal stenosis urine leak wound dehiscence acute pyelonephritis abdominal abscess GI bleeding Retention in the continent reservoir Volvulus/rupture of reservoir

Cancer more common in uretero sigmoidostomy because of intestinal mucosa is bathed in urine largely abandoned the uretero sigmoidostomy

FUTURE AND CONTROVERSY -OUD has gained popularity- refined, better body image . No adverse effect on survival. Recurrent cancer also do well. -Cellular matrix graft will be used as a substitute to bowel or urethra. -sexual dysfunction is emerging as bigger issue and nerve sparing surgeries are getting preferences. -OUD in females is gaining greater acceptance as fewer contraindication exist nowadays.

THANKS

Continent Catheterizing Pouches – – – – – – – –

Continent ileal reservoir {kock pouch] T pouch Mainz pouch Rt. colon pouches with intussuscepted terminal ileum. Indiana pouch UCLA pouch Penn Pouch Benckeroun hydraulic valve pouch