Urinary diversion

Urinary Diversion

1. URINARY DIVERSION Dr. Rojan Adhikari FCPS II resident Urology

2. INTRODUCTION URINARY DIVERSION Diversion of urinary pathway from its natural path Types: Temporary/Permanent External /Internal Continent / Incontinent Definitive/Palliative Orthotopic / Heterotopic

3. HISTORY First attempted urinary diversion by Simon in 1852 Ureterosigmoidostomy is the oldest Zaayer in 1911 started ileal conduit and it was gold standard through 1990’s 1950 (Bricker): eastablish ileal conduit as first choice

4.  In 1979, Camey and Le Duc reported their pioneer othrotopic neobladder Kock and associates reintroduced continent cutaneous diversion in 1982

5. IDEAL URINARY DIVERSION Undisturbed Body Image Natural Micturation Continence Safe Upper Urinary Tract Non Refluxing Low Pressure

6. GOAL OF URINARY DIVERSION To provide the best local cancer control. To reduce potential range of complications. To guarantee the best quality of life for the patient.

7. PREFERABLE DIVERSION Continent reservior connected to urethra Ileal segments (lower pressure peaks and ease of surgical handling)

8. PRINCIPLE OF URINARY DIVERSION A reservoir in which to store urine in low pressure A conduit through which the urine is conducted to the surface A continence mechanism

9. BLADDER RESERVOIR Able to retent 500-1000ml of fluid Maintenance of low pressure after filling Elimination of intermittant pressure spikes True continence Ease of catheterization and emptying Prevention of reflux

10. CLASSIFICATION OF DIVERSION ORTHOTOPIC: Orthotopic bladder substitution HETEROTOPIC 1. Continent : Cutaneous 2. Non-continent: Ileal conduit / colonic conduit Cutaneous ureterostomy 3.Diversion to GIT: Uretero-sigmoidostomy / rectal bladder

11. NON CONTINENT DIVESION NON CONTINENT DIVERSION involve a wide stoma and an external appliance to collect the urine. TYPE 1.Ileal Conduit 2.Colonic Conduit 3.Jejunal Conduit

12. CONTINENT URINARY DIVERSION Heterotopic Continent Diversion It’s a catheterizable stoma on the abdominal wall to empty an intra abdominal neobladder TYPE 1. Right Colonic Pouches The Indiana Pouch , The Florida Pouch The Miami Pouch ,The Penn Pouch 2. Ileal Pouches The Kock Pouch The Mainz Pouch

13. CONTINENT URINARY DIVERSION Orthotopic Continent Diversion It creates a pelvic neobladder that is anastomosed to urethra TYPE 1.Studder neobladder 2.Hautmann neobladder 3. Mainz neobladder

14. PRINCIPLE OF ANASTOMOSIS Adequate exposure Ensure good blood supply Control spillage Accurate apposition of serosa to serosa Ensure tight Realignment of the mesentery

15. TEMPORARY DIVERSION Nephrostomy Pyelostomy or ureterostomy Suprapubic cystostomy

16. NEPHROSTOMY

17. NEPHROSTOMY

18. URETEROSTOMY

19. SUPRA PUBIC CYSTOSTOMY

20. Indications For Permanent Diversion After radical cystectomy in a case of muscle invasive bladder tumor, along with radical prostatectomy Neurogenic bladder dysfunction due to congenital or acquired disorders in case of neural tube defect and spinal cord injury. Severe idiopathic detrusor overactivity Chronic inflammatory conditions like interstitial cystitis, Tuberculosis, schistosomiasis and post radiation bladder contraction

21. As a palliative diversion in case of irremovable obstruction in the bladder & distal to bladder Severe hemorrhagic cystitis Ectopic vesicle Incurable vesico - vagina fistula

22. SELECTION OF TYPE OF DIVERSION Age/ Survival rate Co morbidities Oncological Extent of disease Renal and Hepatic functional status Bowel condition Patient’s preferences Available expertise Mental status

23. ILEAL CONDUIT

24. PRE OPERATIVE PREPARATION Mechanical bowel preparation Whole gut irrigation with poly ehylene glycol and enema Pre-op antibiotic: cephalosporin + metronidazole Stoma site assessment Well informed consent

25. INDICATION After a cystectomy dysfunctional bladders persistent bleeding, obstructed ureter , poor compliance with upper tract deterioration, inadequate storage with total urinary incontinence

26. CONTRAINDICATION Short bowel syndrome Inflammatory small bowel disease Pelvic irradiation

27. ILEAL CONDUIT 10-12cm ileal segment isolated 20cm proximal to IC valve Short straight conduit without kinking Continuity of small bowel re-established Mesenteric window closed Ileum in isoperistaltic fashion

28. Isolated segment flushed with warm saline till return of clear fluid Left ureter brought beneath the sigmoid mesocolon (inferior to IMA ) Ureteroenteric anastomosis

29. ILEAL CONDUIT After single J ureteral stent is placed in both ureter Distal end of ileal segment fashioned as end ileostomy in RLQ A Rutzen bag/ stoma bag can be applied to the stoma on the fifth or sixth postoperative day with complete comfort for the patient

30. ILEAL CONDUIT ADVANTAGES Technically simple surgery Few complication No bladder retaining No nocturnal incontinence Dwayne Tun Soong Chang Published in Urology annals 2015, DOI: 10.4103/0974-7796.148553

31. ILEAL CONDUIT DISADVANTAGES Risk of stomal complication eg : parastomal hernia or stenosis Urinary incontinance Increased long term expenses of stoma care Dwayne Tun Soong Chang Published in Urology annals 2015, DOI: 10.4103/0974-7796.148553

32. COLONIC CONDUIT Indication 1. Extensive pelvic irradiation 2. When the middle and distal ureter are absent. Containdication 1. Inflammatory large bowel disease 2. Severe chronic diarrhoea

33. INDIANA POUCH Right colon pouch with tapered ileum as efferent limb

34. INDIANA POUCH A segment of terminal ileum approximately 10 cm in length along with the entire right colon is isolated. An appendectomy is performed, and the appendiceal fat pad obscuring the inferior margin of the ileocecal junction is removed by cautery . The entire right colon is opened along its antimesenteric border.

35. INDIANA POUCH Interrupted Lembert sutures are taken over a short distance (3 to 4 cm) in two rows for the double imbrication of the ileocecal valve. Application of opposing Lembert sutures on each side of the terminal ileum Excess ileum can be tapered by stapling technique.

36. INDIANA POUCH ADVANTAGES Potential for normal or near normal urinary continence No nocturnal incontinence No need for a stoma bag The small stoma can be easily covered with bandage that is less effect on physical image vs ileal conduit Dwayne Tun Soong Chang Published in Urology annals 2015, DOI: 10.4103/0974-7796.148553

37. INDIANA POUCH DISADVANTAGES Technically more difficult procedure Complication associated with intermittent catherization Potential complications from urinary waste product reabsorption Risk of stomal complication eg : parastomal hernia or stenosis

38. Neobladder The clinical goal of most neobladders is to allow volitional voiding 4 - 6 times per day capacity range of 400 to 500 mL of urine at low pressures (>15 cm H2O ) Two important criteria No compromise of oncological outcomes by reconstruction at the urethroenteric anastomosis Rhabdosphincter mechanism must remain intact to provide continent

39. Types of Neobladder Camey I & II Hautman Kock Mainz T-Pouch , Florida, UCLA, S pouch, Le bag Studer (most common)

40. STUDER NEOBLADDER Designated segments of terminal ileum for construction of neobladder . Note that the distal mesenteric division is made between the ileocolic and terminal branches of the superior mesenteric artery, which extends into the avascular plane of the mesentery. In addition, a small window of mesentery and a 5-cm segment of proximal small bowel are discarded to allow mobility to the pouch and small bowel anastomosis .

41. Contra-indication of O rthotopic Neobladder Compromised renal function Severe hepatic dysfunction Compromised intestinal function Positive urethral margin

42. Mental impairment Pre-existing incontinence Pelvic radiation (increased complications ) Recurrent urethral stricture disease AGE NOT CONTRAINDICTION!!

43. COMPLICATION RELATED WITH URINARY DIVERSION

44. Metabolic Problems Electrolyte Abnormalities Abnormal drug metabolism Osteomalacia and growth retardation Infections Formation of renal and reservoir calculi Renal deterioration Development of urothelial or intestinal cancer

45. Metabolic Problems Due to continued solute transport by interposed segment The factors that influence Segment of bowel used Surface area of the bowel The amount of time the urine is exposed The concentration of solutes in the urine Renal function The pH of the fluid

46.   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. Infection An increased incidence of bacteriuria , bacteremia , and septic episodes occurs in patients with bowel interposition Incidence : 10% to 17% with colon and ileal conduits Patients with continent diversions also have a significant incidence of bacteriuria and septic episodes

48. Stones Most are infection stone Structural or metabolic cause Major risk: hyperchloremic metabolic acidosis Colon conduits : 3% to 4% Ileal conduits : 10% to 12% Continent cecal reservoirs : 20%

49. Short bowel and nutritional problem Significant loss of ileum Vit B12 malabsorption : megaloblastic anemia Malabsorption of bile salts: diarrhea Malabsorption of fat: fatty diarrhea

50. References Campbell and Walsh Urology 10 th edition Bailey and love 27 th edition

51. THANK YOU