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innovative surgeons have sought the best method to replace the original bladder when it must be removed because of either benign or malignant disease. The objective of bladder substitution is to allow volitional voiding through the urethra while eliminating the need for a cutaneous urinary stoma or intermittent catheterization.
He attempted a ureterosigmoidostomy in an exstrophy patient by bringing the ureters into the rectum with the use of needles and suture to create a fistula. Although the patient died of sepsis 12 months later, this marked the first reported attempt at some form of urinary diversion (Simon, 1852) Over the following 100 years the evolution of urinary diversion was marked by a continued search for better methods and techniques to reconstruct the lower urinary tract.
In the male patient involvement of the prostatic urethra is associated with a higher risk of subsequent urethral recurrence. Some evidence indicates that orthotopic diversion itself may provide some protection against urethral recurrence.
The ureteroileal anastomosis is then performed via a Le Duc technique. The reservoir is completed by folding the ileal plate and suturing with a running absorbable suture. The ends of the U are anchored to the pelvic floor to reduce tension (Fig. 99-4). A modification of the Camey II has been described by Barre and colleagues (1996). This places the ileum in a Z configuration and reportedly has the advantages of shorter length requirements, improved reservoir capacity, and potentially improved functional (continence) results (Barre et al, 1996).
Construction of the modified Camey II. A, The ileal loop is folded three times (Z shaped) and incised on the antimesenteric border. B, The reservoir is closed with a running suture to approximate the incised ileum. C, The urethral anastomosis is performed, and the ureters are implanted using a Le Duc antireflux technique.
Construction of the Kock ileal reservoir. A, A total of 61 cm of terminal ileum is isolated. Two 22-cm segments are placed in a U configuration and opened adjacent to the mesentery. The more proximal 17-cm segment of ileum will be used to make the afferent intussuscepted nipple valve. B, The posterior wall of the reservoir is then formed by joining the medial portions of the U with a continuous running suture. C, A 5- to 7-cm antireflux valve is made by removing the mesentery under that segment and then intussuscepting the afferent limb with the use of Allis forceps clamps. D, The afferent limb is fixed with two rows of staples placed within the leaves of the valve. E, The valve is then fixed to the back wall from outside the reservoir with additional surgical staples. F, After completion of the nipple valve, the reservoir is completed by folding the ileum on itself and closing it, leaving the most dependent end of the suture line open for the urethral anastomosis.
Construction of the Hautmann ileal neobladder. A, A 70-cm portion of terminal ileum is selected. The isolated segment of ileum is incised on the antimesenteric border. B, The ileum is arranged into an M or W configuration with the four limbs sutured to one another. C, After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethral anastomosis is performed. The ureteral anastomoses are performed using a Le Duc technique or direct implantation and are stented, and the reservoir is then closed in a side-to-side manner. As an alternative, the two ends of the W may be left slightly longer as a short chimney on either side for implantation of the ureters.
A, B, C, D, E1,
Construction of the Mainz ileocolonic orthotopic reservoir. A, An isolated 10 to 15 cm of cecum in continuity with 20 to 30 cm of ileum are isolated. B, The entire bowel segment is opened along the antimesenteric border. An appendectomy is performed. C, The posterior reservoir is closed by joining the opposing three limbs together with a continuous running suture. D, An antireflux implantation of the ureters through a submucosal tunnel is performed and stented. E, A buttonhole incision in the dependent portion of the cecum is made to provide for the urethral anastomosis. F, The reservoir is closed side to side with a cystostomy tube and the stents exiting.
Construction of Le Bag (ileocolonic) orthotopic reservoir. A, A total of 20 cm of ascending cecum and colon, with a corresponding length of adjacent terminal ileum, is isolated. The bowel is opened along the entire antimesenteric border, and the two incised segments are then sewn to each other. This forms the posterior plate of the reservoir. B, This reservoir is folded and rotated 180 degrees into the pelvis with the most proximal portion of the ileum (2 cm nondetubularized) anastomosed to the urethra. C, Modification is performed with complete detubularization of the bowel segment, which is then anastomosed to the urethra. (Copyright Baylor College of Medicine.)
These concepts are the cornerstone of current cutaneous and orthotopic reservoirs.
Dr Prateek Laddha
HISTORY OF ORTHOTOPIC URINARY DIVERSION
• Since the early 1900s
• Ureterosigmoidostomy is the oldest form of urinary diversion.
• 1st reported urinary diversion into a segment of bowel Simon in 1852.
• A number of technical modifications of the ureterosigmoidostomy ensued,
particularly related to the ureteral implantation technique (Hinman and
• (Leadbetter, 1951; Goodwin et al, 1953). introduction of an antireflux
tunneled anastomosis of the ureter into the sigmoid colon
• rates of obstruction and
• ascending pyelonephritis in patients with ureterosigmoidostomy
• Ureterosigmoidostomy remained the diversion of choice until the
• but long-term electrolyte imbalance,
• upper tract obstruction and infection, and
• secondary malignant neoplasms arising at the ureteral implantation site were
• In 1950 Bricker refined and popularized ileal conduit form of
• building on an original description by Zaayer in 1911 (Zaayer, 1911; Bricker,
• The ileal conduit is a technically simple, reliable form of urinary
diversion that became widely accepted and became the gold standard
to which other types of urinary diversion were compared until the
• It continues to be by far the most common form of urinary diversion
performed throughout the world today for patients undergoing
• Long-term complications with the [1970s].
• hyperchloremic metabolic acidosis and
• pyelonephritis were substantially less common than in patients with
• all patients who undergo radical cystectomy may be considered at
least potential candidates for orthotopic urinary diversion.
• Factors can be divided into cancer-related factors and patient factors.
Risk of Urethral Recurrence in Men
• Primary oncologic contraindication for orthotopic diversion is the
presence of urothelial carcinoma at the urethral margin on
intraoperative frozen section at the time of cystectomy.
• It has been a practice to counsel patients with documented
• prostatic mucosal,
• ductal, or
• stromal invasion about the increased risk of urethral recurrence if the urethra
is left in situ,
• weigh that risk against any perceived advantage of an orthotopic
Risk of Urethral Recurrence in Women:
• Risk factors for urethral involvement included
• increased grade,
• stage, and
• lymph node involvement, but the presence of CIS did not predict urethral
• Vaginal wall involvement was also a major risk factor for urethral
• The urethra can be safely preserved in selected female cystectomy patients
provided that neither preoperative biopsy specimens of the bladder neck
nor intraoperative frozen section specimens of the proximal urethra
demonstrate any tumor or atypia.
• However, approximately half of patients with bladder neck tumors
had a normal (tumor-free) proximal urethra.
• In all cases, intraoperative frozen-section analysis of the proximal
urethra correlated with and was correctly confirmed by final
• These results suggest that one may depend on the intraoperative
frozen section to determine the feasibility of orthotopic diversion.
Locally Advanced Tumor Stage
• Many urologists are hesitant to perform continent orthotopic
diversion in patients with locally extensive disease. This is based on
(1) concern about the possible impact of local recurrence on the neobladder
(2) a belief that these patients are doomed to suffer distant recurrence and
have a shortened life expectancy and will not benefit from the neobladder.
• If local tumor recurrence does develop in patients with an orthotopic
diversion, only a minority will develop problems related to the urinary
• most patients could anticipate normal neobladder function even in
the presence of locally recurrent disease.
• The low risk of local recurrence showed that in this cohort of patients
the oncologic efficacy of the operation was not compromised include
• patient’s general health and social circumstances,
• baseline renal function,
• presence of a healthy urethra and functioning sphincter muscle,
• manual dexterity, and
• previous treatments including pelvic radiation,
• prostate surgery, or
• bowel resection.
• The clear consensus is that chronologic age alone is not a contraindication
for continent diversion and that options should be considered for each
patient on the basis of other factors
• Renal Function
• One of the most important contraindications for continent neobladder
reconstruction is compromised renal function.
• In patients with compromised renal function, hyperchloremic metabolic
acidosis can develop along with worsening dehydration, uremia, nausea,
and bone loss.
• Serum creatinine level of < 1.7 to 2.2 mg/ dL (150 to 200 μmol/L) or an
estimated CC of greater than 35 to 40 mL/min is recommended for
patients considering continent diversion
• Obesity is not a contraindication
• Placing the urethral sutures and working with the thick bowel
mesentery may be challenging.
• An obese patient may be better served with orthotopic diversion
because of the difficulty constructing a functional conduit stoma
with a very thick abdominal wall.
• Manual Dexterity and Willingness to Do Self-Catheterization
• Urethral Stricture Disease or External Sphincter Damage
• Severe urethral stricture disease in men and women is a contraindication for
• Prior Pelvic Radiation
• Patients with prior radiation are at increased risk of several complications,
even with an ileal conduit diversion.
• Orthotopic lower urinary tract reconstruction can be performed after
definitive, full-dose pelvic irradiation.
• careful intraoperative tissue assessment and determination of the condition
of the urethra, ureters, and bowel must be performed to make a final
decision about the feasibility of orthotopic diversion
Prior Prostate Surgery or Bowel Resection
• Prior abdominal or pelvic surgery may also present challenges for the
surgeon performing orthotopic diversion. Patients who have had a
prior radical prostatectomy may have a particularly difficult dissection
around the proximal urethra at the prior vesicourethral anastomosis.
• Short bowel syndrome
SURGICAL TECHNIQUES FOR CONTINENCE
PRESERVATION DURING RADICAL CYSTECTOMY
• Anterior Apical Dissection in the Male Patient
• Attention to anatomic and surgical detail is important to optimize
functional and clinical outcomes in patients undergoing orthotopic
diversion. Minimal manipulation of the muscle fibers of the
rhabdosphincter, fascial attachments, and corresponding innervation is
essential to providing optimal urinary continence
• If a nerve-sparing approach is planned, the urethra may be divided after
the lateral pedicles are taken down to the bladder (anterior branches of
the internal iliac vessels) before the posterior dissection is performed. The
prostate is then dissected in a retrograde fashion off the rectum and
bilateral neurovascular bundles, and the posterior pedicles are divided last.
• Care should be taken to avoid deep suture bites into the complex or
levator muscles, which could injure the continence mechanism.
• Frozen-section analysis of the circumferential distal urethral mucosal
margin (prostatic apex) on the cystectomy specimen is performed to
exclude tumor involvement. If there is no evidence of tumor,
orthotopic reconstruction may be performed. If there is tumor at the
prostatic apex, the urethral stump can be excised or a total
urethrectomy may be performed at this time to obtain a negative
margin, and a cutaneous diversion constructed.
Preservation of the Urethra in the Female Patient
• A standard female cystectomy includes removal of the uterus, cervix,
and ovaries (anterior exenteration). However, in selected females
with clinically lower-stage disease, a number of authors have
advocated preservation of the uterus and ovaries.
• Whether the uterus is removed or not, whenever possible the
bladder is dissected completely off the anterior vaginal wall rather
than excising it. However, a deeply invasive tumor on the posterior
bladder or trigone may necessitate excision of a portion of the
anterior vaginal wall.
• A patient with a significant tumor at the bladder neck or with
palpable extension into the vaginal wall is a poor candidate for
neobladder and should undergo en bloc urethrectomy and
• Preparation of the female
urethra for an orthotopic
neobladder. The fatty tissue
overlying the anterior urethra is
swept off the endopelvic fascia
and the vesicourethral junction
is carefully identified by
positioning the Foley catheter
at the bladder neck. Note that
the endopelvic fascia and
periurethral tissue anteriorly
are not disturbed.
• Regardless of the form of vaginal
reconstruction, a well-vascularized
omental pedicle graft should be
placed between the reconstructed
vagina and the neobladder and
secured to the endopelvic fascia at
either side of the urethral stump to
separate the suture lines and
prevent fistula formation between
the vaginal and urethral
anastomosis, which may help
support the pouch posteriorly.
TECHNIQUES FOR ORTHOTOPIC
• Choice of Bowel Segment
• excellent functional and clinical outcomes with voiding can be
achieved regardless of the segment of bowel chosen as long as the
principles of preservation of the rhabdosphincter as a continence
mechanism and construction of an adequate capacity, low-pressure
reservoir are maintained
• Reservoirs made of detubularized ileum or ileum and colon together
appear to have the greatest compliance and lowest likelihood of
generating intermittent high-pressure contractions.
• The primary disadvantage of using distal ileum lies in the potential
loss of absorption of vitamin B12.
• Isolation of the segment of bowel to be used for the diversion must
be performed carefully to preserve blood supply to the pouch, as well
as to the bowel anastomosis.
Need to Prevent Reflux:
• It is clear that any mechanism introduced to prevent reflux may also
potentially cause upper tract obstruction.
General Perioperative Management
• Ileal Reservoirs
• ileal reservoirs use from 60 to 75 cm of terminal ileum, which is
detubularized and folded in a variety of ways to attempt to create a
• The use of nonabsorbable suture and metal staples should be
avoided because of the potential for stone formation.
• two most popular configurations around the world are the Hautmann
W-neobladder (and its various modifications) and the Studer pouch
• The Camey II orthotopic substitute is a modification of the original
Camey bladder substitute, which was a simple segment of ileum
anastomosed to the ureters and urethra.
• The modification includes detubularization and folding to eliminate
• A fingertip opening is made in the preselected area for the
ileourethral anastomosis, the entire ileal plate is brought down to the
pelvis, and the urethral anastomosis is performed.
Ileal Neobladder (Hautmann Pouch)
• This neobladder is an intentionally large-capacity, spheric (W
configuration) ileal reservoir that is constructed in an attempt to
optimize initial volume and potentially reduce nighttime
Construction of the Studer neobladder
• Designated segments of terminal
ileum for construction of the
orthotopic Studer pouch ileal
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
• The Studer pouch is constructed
from an isolated 44-cm ileal
segment (placed in an inverted U
configuration), which forms the
reservoir portion of the pouch,
and a proximal 15-cm segment of
ileum to form the afferent limb.
The two 22-cm ileal segments are
opened 2 cm adjacent to the
mesentery beginning at the apex
and carried upward to the ostium
of the afferent segment.
• The previously incised ileal
mucosa is then oversewn with
two layers of a running 3-0
polyglycolic acid suture starting
at the apex and running upward
to the afferent limb. The
reservoir is then closed by
folding it in half in the opposite
direction to which it was
• Construction of the antireflux
mechanism in the T pouch. The ileum is
divided between the proximal afferent
ileal segment and the 44-cm segment.
The dotted line depicts the incision line
on the U limbs. Mesenteric windows of
Deaver are opened between the vascular
arcades adjacent to the serosa.
Placement of small Penrose drains
through each mesenteric window helps
facilitate passage of sutures. The distal 3
to 4 cm of the afferent ileal segment is
anchored into a serosal-lined ileal trough
formed by the base of the two adjacent
22-cm ileal segments, using 3-0 silk
• The previously anchored distal
3- to 4-cm afferent ileal
segment is tapered over a 30-Fr
catheter on the antimesenteric
border. The incision of the
bowel provides wide flaps of
ileum that covers the tapered
distal afferent ileal segment to
form the antireflux mechanism
in a flap-valve technique.
• A mucosa-to mucosa
anastomosis is performed
between the ostium of the
afferent segment and the edges
of the ileal flaps using
interrupted 3-0 polyglycolic acid
suture. The mucosal edges of
the ileal flaps are brought over
the tapered distal portion of the
afferent ileal segment and sewn
using a continuous 3-0
polyglycolic acid suture.
• Once the reservoir is folded in
half, the anterior wall is closed
with a two-layer 3-0 polyglycolic
acid suture that is watertight.
Note that the anterior suture line
is stopped just short of the
(patient) right side to allow
insertion of an index finger, which
will become the neobladder neck.
Conversely a new buttonhole can
be created at the most dependent
portion of the pouch.
• Each ureter is spatulated and a
standard bilateral end-to-side
ureteroileal anastomosis is
performed using interrupted 4-
0 polyglycolic acid suture.
• The reservoir is anastomosed to
the urethra using the previously
placed urethral sutures.
Colon and Ileocolic Pouches
Orthotopic Mainz Pouch (Mainz III)
• late complications with the ileal conduit such as
• peristomal hernia
• stomal stenosis
• kidney stones
• ureteral obstruction
• renal deterioration became more apparent with longer follow-up
• These clinical sequelae
• the high-pressure reflux of infected urine or
• obstruction of the upper urinary tract.
• It was postulated that the addition of an antireflux technique to a
conduit form of diversion could help diminish the problems of reflux
and renal deterioration in these patients.
• Unfortunately, with longer follow-up, similar complications with
nonrefluxing colon conduits were observed.
• One of the earliest continent cutaneous diversions in humans was described by
Gilchrist and colleagues in 1950.
• This form of urinary reconstruction incorporated a cecal reservoir with the
ileocecal valve as the continence mechanism and the distal ileum as a
• The concept of a continent cutaneous diversion was subsequently reintroduced
by Kock and colleagues in 1982 with a technique that was originally developed
for a continent ileostomy after colectomy for inflammatory bowel disease.
• It incorporated an intussuscepted nipple valve to maintain continence and avoid
reflux. In animal experiments and then in humans, Kock demonstrated the
importance of complete detubularization of the bowel segment and the
double-folding technique that creates the most spheric shape possible.
• After Kock described his results in his initial 12 patients, Skinner
began performing this diversion in adults undergoing cystectomy for
bladder cancer in 1982.
• Although this form of urinary diversion required catheterization of an
abdominal stoma, it eliminated the need for an external urostomy
• The biggest challenge in the development of continent cutaneous
diversion has been the design of a reliable, durable, efferent
continence mechanism that is easily catheterizable.
• difficulty in catheterizing,
• peristomal hernias, and
• the development of leakage are potential problems with all of them, often
necessitating open surgical revision
• Today, several different reliable techniques are available to create a
continent cutaneous urinary diversion, including the Indiana pouch and
various other forms of right colon pouches.
• These forms of diversion can potentially offer an advantage to patients
over an ileal conduit, but these operations remain technically challenging
and are not widely used.
Early and Late Complications
Both early and late complications may also be influenced by other
factors such as
- prior radiation therapy,
- diabetes, and
- other comorbidities.
- Late complications are also influenced by tumor recurrence and the
use of adjuvant or salvage systemic chemotherapy or radiation, and
these causes may be difficult to separate out from causes related to
• Late complications not
• directly related to the diversion include bowel obstruction, ventral
• hernia, thrombotic events, and cardiovascular problems common
• to patients in this age group.
• Ventral hernias are quite common and may be in part related to the
need for increased abdominal pressure to empty the neobladder. The
poor fascial strength associated with advanced age and smoking
undoubtedly contributes to this risk as well.
• primary late complications of orthotopic diversion that are directly
related to the diversion itself include
• urinary tract infection,
• ureteroileal or afferent limb obstruction,
• urethral stricture,
• upper tract and pouch stones,
• vaginal fistula, and pouch rupture.
• Other than incontinence, these complications tend to be less common in
orthotopic diversion than in continent cutaneous diversion, and many if
not most can be managed by endoscopic procedures and rarely require
open surgical revision
• Pouch perforation is rare in continent diversion in general, especially
in orthotopic diversion because outlet resistance is usually low. The
risk may be increased in patients who have had previous radiation
therapy. It is a potentially life-threatening complication when it
• The direct end-to-side Leadbetter or the combined Wallace
anastomoses with interrupted fine absorbable sutures have been
shown to have the lowest risk of stricture, approximately 3% to 6%.
Obstruction from an antireflux valve has been seen in both hemi-
Kock pouches and in the extraserosal tunneled afferent limb of the T
• CT scans will often be misinterpreted by radiologists or urologists
unfamiliar with the anatomy and/or the specific type of neobladder.
• Pouch stones were very commonly seen in the Kock neobladder
because of the use of surgical staples to maintain the intussuscepted
nipple valve, with the incidence increasing steadily with time. Stones
have been rare in the Studer and Hautmann neobladders, which are
made entirely with absorbable suture.
• Pouch-vaginal fistula is a unique complication of orthotopic
neobladder in women that can be quite difficult to repair.
• Prevention methods include
• leaving the vagina intact whenever it is safe from an oncologic standpoint,
• careful watertight closure of the vaginal cuff when it is opened, and
• placement of an omental flap between the vagina and neobladder, secured
to the perivaginal tissue on either side of the urethral anastomosis
• The evaluation and management of urinary incontinence after
orthotopic diversion should be delayed until the neobladder has had
time to expand.
Follow up: NO CONSENSUS
• Early evaluation (first 4 months) to identify early ureteroileal anastomotic
strictures caused by technical difficulties or poorly vascularized distal
• Middle period (4 months to 3 years) primarily focused on detecting cancer
recurrence. This is best managed with CT or other cross-sectional imaging,
which also allows evaluation of the upper tracts and reservoir for stones or
• The frequency of the follow-up can be risk-adapted according to the
pathologic findings at the time of cystectomy and the risk of subsequent
• Long-term follow-up (beyond 3 years) to detect pouch stones, late upper
tract obstruction, and urothelial carcinoma arising in the urethra or upper
QUALITY OF LIFE AFTER
• Most quality-of-life studies that have evaluated and compared
patients undergoing various forms of urinary diversion have been
criticized for methodologic problems that limit their conclusions.
• The current body of published literature is insufficient to conclude
that any form of urinary diversion is superior to another on the basis
of health-related quality of life outcomes.