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 urethrao Ileal segments (lower pressure peaks and

ease of surgical handling)

Classification of Diversion• Orthotopic:

• Orthotopic bladder substitution• Heterotopic

o Continent cutaneousoNon-continent Cutaneous

o Ileal conduit / colonic conduito Cutaneous ureterostomy

oDiversion to GIToUretero-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 infection4. 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 endo Posterior plate suture o Side-to-end fashion to ileal stump

• Wallace 69: o End to end oriented uretero Spatulated and sutureo Side-to-end fashion to ileal stump

Bricker

Wallace

Pros and Cons• Advantage:

o Short segment use limited metabolic changeo Suitable in renal or hepatic insufficencyo Use when post-op radiation necessary

• Contraindications: o Short bowel syndromeo Radiation to terminal ileumo 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 stenosis6. Pseudo-obstruction7. Conduit elongation or stenosis

Complications of intestinal stomas & conduit

1. Bowel necrosis2. Dermatitis3. Stomal stenosis 20%4. Stomal retraction5. Stomal Prolapse6. Parastomal hernia7. Obstruction8. Conduit varice (due to portal HT) torrential

bleeding9. 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 mechanism1. 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 Duco Intussuceptive ileal nipple (Hemi-Kock)o Abol-Enein, Stein : Serosa-lined extramural

tunnel implantationo 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