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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
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
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
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
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
Ureterosigmoidostomy
NON ORTHOTOPIC
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}
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.
MAINZ(tapered ileum) Indiana (using IC valve ) Rt colon pouch with intussusceptions ileum (UCLA, DUKE, LE BAG)
Gastric pouch
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.
2.
3.
4.
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.
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
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
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 KOCKS 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.
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
Jejunum
Low
High
Low
Low
Ileum Colon
Low/ normal
Normal
Elevated Low
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