Surgical procedures

Patient preparation

Together with the stomal therapist, the urologist should mark the site of the stoma prior to surgery. It should be placed in an area free of scars and skin folds. Most often the site will be slightly below a line between the umbilicus and the anterior superior iliac spine. The adhesive portion of the bandage is usually a quadrant with the side 7-8cm, which will influence position. The patient should wear the appliance for a day or two pre-operatively.

There are many suggestions of how to prepare the bowel. In Lund, the patient drinks four litres of polyethyleneglycol in the afternoon and evening before surgery. Two hours before the bowel is opened 2g of cefoxitin is given.

Non-continent urinary diversion

Although continent reconstruction has become the first option in many centres, non-continent diversion still seems to be the most commonly employed technique in conjunction with cystectomy. Thus, in Sweden, 63% of all patients undergoing radical cystectomy in 2000 received a non-continent type of diversion (Swedish National Register of Urinary Bladder Cancer). The last decades have seen considerable improvements in the quality of the necessary appliances. Equally or more important is the fact that enterostomal therapy has developed into a specific field of its own. These factors, together with more close follow-up of the patients with early interventions should complications occur, are reasons for less dismal results today than were reported in the 1970s and 80s of non-continent diversion (Figure 3).

Cutaneous ureterostomy

The main indication for this procedure is palliation in patients with advanced bladder cancer. It is performed less often today, due to the introduction of percutaneous nephrostomy and double-J stents. Stricture of the cutaneous stoma is a well-known complication, which more or less limits its use to cases with dilated ureters. If there is a non-dilated ureter, a Z-incision of the skin and suturing of the skin flaps into the spatulated ureter may lower the risk of stenosis. In certain cases, cutaneous ureterostomy can be combined with a transuretero-ureterostomy. The procedure, however, has a poor reputation. One risk is urine pendulating from one ureter up into the other, the 'yo-yo phenomenon', due to disrupted ureteric peristalsis. The recipient ureter therefore should be mobilized only to the level where the anastomosis will be performed.54 The end of the non-dilated donor ureter is cut obliquely and sutured without tension end-to-side to the recipient ureter, which is usually dilated. The ureter below the anastomosis may

Cutaneous Ureterostomy
Figure 3: Urostomist with ideal position of stoma for optimal fitting of the appliance.

suffer stricture due to ischaemia. This complication was one of the few ones in a large series of transuretero-ureterostomy but without cutaneous diversion.55 It is a valuable procedure in some cases of lower urinary tract reconstruction.

Conduit diversion

Conduits can be constructed from jejunum, ileum and colon. Of these, jejunum is seldom used because of the risk of specific electrolyte disorders; 'the jejunal conduit syndrome' (see below). Although ileum is most often used, there are two important indications for a colonic conduit. One is in children in whom an intermediate diversion is necessary, awaiting continent reconstruction at a higher age. Several reports during the 1980s testify to the poor outcome ofileal conduit diversion in children. Anti-reflux ureteric implantation is necessary in this group of patients and this may be more easily accomplished with the colon. Excellent long-term results have been published using the colon, most often the sigmoid colon.56

Another indication for the use of this procedure is patients who have received high-dose pelvic irradiation (see above).

In constructing the conduit, it is important to create a spout at least 2cm in length. The more obscene it may look, the better. This will decrease the risk of parastomal complications. The appliance will fit much better and there will be less risk of urine leakage. The spout should protrude into the appliance bag. Peristomal dermatitis with risk of hyperkeratosis and fungal infection is almost always caused by urine between skin and appliance and is often a consequence of retracted stoma or ill-fitting appliance. Stomal and peristomal complications reached 50% in some old series and even recently published series present figures around 30% (Figures 4 and 5).57,58

Perastomal hernia is seen in 5-15% and may occur also after continent cutaneous diversion (Figure 6). They are large rather than small and although the majority of patients are asymptomatic, some need surgery. A high recurrence of cases requiring re-operation is seen.57 For first-time parastomal hernia repairs, stoma relocation may be superior to fascial repair.59 We have seen infections with erosion and fistulas using synthetic mesh, which is usually employed in recurrent hernia repair. Newer techniques with the incision placed lateral and far away from the stoma, with closure of the fascial defect and using mesh material as onlay, have been reported as yielding good results.60,61

Pictures Bladder MeshSevere Candida
Figure 5: Severe peristomal candida infection because of poorly fitting appliance.
Colon Bladder Fistula Repair

Figure 7: Ileal conduit 11 years after construction. Shrunken, thick-walled conduit with ulcerated and inflammed mucosa.

Radical Cystectomy With Ileal Conduit

Figure 7: Ileal conduit 11 years after construction. Shrunken, thick-walled conduit with ulcerated and inflammed mucosa.

Conduit stenosis is a condition affecting ileal conduits. It has never been described in colonic conduits, indicating fundamental but unknown differences between ileum and colon in resistance to urine exposure. The whole, or part of the conduit, is transformed into a thick-walled tube without peristaltic activity (Figure 7). The pathogenesis of this disorder, which manifests late after diversion, is obscure. The clinical picture is colicky flank pain and/or fever and is produced by upper tract obstruction. Treatment is by removal of the conduit or partial resection with or without ureteric re-implantation.62

A recent report underlines the need for close indefinite follow-up of patients with conduit diversion.66 Complications related to ileal conduit developed in 2 of3 patients and almost 40% needed surgical re-intervention. The authors raise the provocative question of whether the ileal conduit really is a "gold standard".

Continent reconstruction

Whether for continent diversion or orthotopic substitution, three parts are essential in the construction; the pouch, the inlet and the outlet. The issue of how to fashion the first two in an optimal way are common to both types of reconstructive procedure.

The pouch

Large capacity and storage under low pressure in the pouch are essential requirements of continent reconstruction. This is achieved through detubularization and the dynamic behaviour of such pouches has been explained in general and in biomechanical terms (Figure 8).63,64 No proper prospective study has been performed to elucidate if any bowel segment is superior to others in terms of urodynamic behaviour. One study indicates superiority of ileum over colon, but functional differences may only be minor, if any.66,67 A prospective multi-centre study comparing ileum and colon has now started in Scandinavia.

Pharmacological attempts to reduce intra-reservoir pressure using anticholinergics and alfa- and beta-adrenoceptor agonists have had little clinical success. Potential interesting agents in this context are opiod-receptor agonists, calcium antagonists, potassium-channel openers and nitric oxide donors.

For colonic segments, surgical measure as multiple taeniamyotomies has been suggested for reducing intra-luminal pressure.68

Late complication is stone formation, the incidence of which appears to increase with longer follow-up (Figure 9). Use of staples exposed to urine in the pouch or in the outlet should be abandoned, as they will serve as nidus for stone formation (Figure 10). Mucus and residual urine may contribute. Eight out of 64 patients operated with right colonic neo-bladder in the years 1987-99 and followed for a mean of 71 months formed one or more stones, although staples were not used.13 Of these, seven could be removed endoscopically. Regular irrigation has been suggested to lower the risk of stone formation, but its true value remains unclear.69

Ileal Reservoir

Figure 8: Volumes of different types of ileal reservoirs, each calculated as a function of the length of bowel used for construction.

Figure 8: Volumes of different types of ileal reservoirs, each calculated as a function of the length of bowel used for construction.

Figure 9: Giant stone in a continent right colonic reservoir with ileal nipple valve outlet.

Figure 9: Giant stone in a continent right colonic reservoir with ileal nipple valve outlet.

Nipple Delay Procedure

A more serious, potentially lethal complication, is rupture/perforation of the pouch. The incidence seems to be 1-2%, but may increase the longer the follow-up. In a survey among 1,700 patients operated upon in the Scandinavia, 20 episodes occurred in 18 patients.70 Aetiology can be trauma from catheterization, but several cases were spontaneous, often occurring with a full pouch. Noticeable findings were long delay to treatment and that investigational procedures, such as enterocystoscopy, enterocystography and CT were seldom employed. This complication should always be suspected when a patient with a continent reservoir for urine is admitted with abdominal pain. The risk is much higher after continent cutaneous

What Cutaneous Diversion Procedure

diversion than after bladder substitution, when the urethral sphincter will yield to too high pressure.

How should the ureters be implanted - with or without reflux protection?

This is a never-ending issue of discussion, partly due to the fact that prospective studies that have tried to measure GFR accurately are rare. Such measurement is necessary if one would like to answer the question. Many reports have revealed a high incidence (13-41%) of renal deterioration associated with refluxing ileal conduit, as evaluated using serum creatinine and urography.56,71,72 Dilatation of the upper tract is a common finding, but it does not necessarily signify obstruction or renal deterioration.57

In a prospective, randomized study on the fate of separate GFR after ileal conduit urinary diversion, no difference was noted between units with or without anti-refluxing ureteroileal anastomosis, but severe renal scarring was more common on the side with refluxing anastomosis.73,74

There is presently a trend towards using refluxing techniques when implanting ureters into orthotopic neo-bladders.75-78 The proponents give several rationales:

1 Anti-refluxing anastomosis is associated with higher incidence of stenosis than refluxing anastomosis.

2 Intraluminal pressure is low.

3 Urine is sterile.

The common denominators in these reports are that follow-up is short and that renal function is evaluated by serum creatinine and urography only.

The critical factors with regard to renal function in the presence of reflux are pressure and infection, making refluxing anastomosis not recommended for patients with continent cutaneous diversion as intermittent very high pressure can be achieved and urine is always heavily colonized. The decrease in renal function that has been noted after ileal conduits with refluxing ureters have been converted into continent pouches with abdominal stoma testifies to the danger.79

However, intraluminal pressure can be substantial in orthotopic bladder substitutes and the expression 'low pressure reservoir' is clearly unsuitable, as evidenced by the report of pressure up to 150cm H2O, the mean being 77cm H2O, during voiding in patients with ileal neo-bladders.80 Obstruction of the urethrointestinal anastomosis is one risk factor for high pressure. It is also important to remember, contrary to general belief, that urine in orthotopic bladder substitutes is often not sterile.81,82 Bacteriuria is a common phenomenon, although the heavy colonization after continent cutaneous diversion is usually not seen. However, CISC, common in some series, will increase the microbial burden, with consequent risk for the upper tracts in case of reflux and high pressure.12 Therefore there are reasons for the statement 'conventional wisdom suggests that unless an anti-reflux technique is used during construction of a urinary reservoir, deleterious effects on renal function might be expected'.83

The question cannot be solved without a prospective study employing accurate measures of renal function. We suggest that this should be done by implanting one ureter with and the other without anti-refluxing technique in a randomized fashion, studying separate GFR pre-operatively and at follow-up. This is also the only way to find out if anti-refluxing anastomosis are associated with higher risk of stricture than refluxing anastomosis.

At present the most commonly used methods for anti-reflux ureteric implantation into ileal pouches are the Le Duc technique, the afferent ileal loop, as in the Studer pouch, and the serous-lined extramural tunnel (Abol-Enein technique) (Figure 11).47,84,85 The afferent nipple valve, as used in the Kock pouch, will probably disappear, some instead using a variation, although rather complicated, of the Abol-Enein principle, as in the T-pouch.86 For colonic pouches, the submucous tunnel and the Le Duc technique are used.87

Figure 11: Spatulated ureters in serous-lined intestinal troughs, which are transformed into tunnels by closing the intestinal mucosa over the implanted ureters; the Abol-Enein technique.

Abol Enein Serous Extramural Tunnel

Continent cutaneous diversion

In Lund, as in most other centres, continent cutaneous diversion is the second choice after orthotopic bladder substitution, and offered if urethrectomy has to be performed in conjunction with cystectomy. The success or failure of continent cutaneous diversion stands or falls with the outlet. However compliant the reservoir, the outlet must have an effective leakage-prevention mechanism that also permits easy catheterization. Furthermore, it must be easy to construct. The advice by Albert Einstein that 'everything should be made as simple as possible, but not simpler' is certainly applicable in this context. Numerous methods have been designed, reported once but not reappeared in the literature, most often probably due to high complexity. The most commonly used methods among urologists have been the Kock pouch, the Indiana pouch, or variation thereof, and pouches employing the appendix as outlet. The stoma is usually placed in the right lower quadrant or in the umbilicus, which may have aesthetic advantage (Figure 12).

The Kock pouch

This was the first method for continent cutaneous diversion that was accepted by the urological community after description by Kock (Figure 13) and then refined by Skinner's group.88,89

The method uses a long ileal segment that is detubularized, and reflux protection and outlet is by intussuscepted ileal nipple valves. Skinner's modifications were stapling of the valves, creation of a mesenteric window, and using synthetic mesh around the nipple base for stabilization of the intussusception and for fixation of the nipple base to the abdominal wall. Continence is achieved by the combination of intraluminal pressure equilibrium and intraluminal flap valve.63

Urological departments worldwide adopted the technique, but it was soon obvious that the technique was complicated and time-consuming, requiring meticulous attention to detail. The learning curve was also long. Fatty mesentery can cause difficulties in fashioning the nipple valve and fixation of the nipple base to the abdominal wall may present problems. Erosion by the mesh, pin-hole fistula, stenosis or even sloughing of the valves, as well as prolapse and sliding of the valve may occur, with consequent urine leakage and/or difficulties in catheterization (Figures 14, 15 and 16).

Figure 12: Concealed appendiceal stoma of continent reservoir.

Continent Vesicostomy Kock Pouch

Figure 13: Continent ileal reservoir for urine; the Kock pouch.

Figure 12: Concealed appendiceal stoma of continent reservoir.

Kock Pouch

Figure 13: Continent ileal reservoir for urine; the Kock pouch.

Kock Pouch AfferentIleal Conduit

Figure 14: Difficult catheterization through detachment of ileal nipple base from the abdominal wall.

Figure 14: Difficult catheterization through detachment of ileal nipple base from the abdominal wall.

Cancer Holes Nipple
Figure 15: Fistula through ileal nipple valve.
Photos Nipple Cancer

Figure 16: Prolapse of ileal nipple valve.

Outlet revision rate up to 50% has been reported.90 Also, with the wide experience of this technique in Skinner's department, the outlet failure rate after introducing several modifications was still as high as 15% in their last operated 239 patients.8 To this problem should be added the one of stone formation on exposed staples.92 In the most recent long-term follow-up of Kock reservoir patients from Gothenburg it is noted that all the first-operated 25 patients were re-operated. Of the patients operated on since 1984, 31% had outlet revision; this figure dropping to 21% in those operated on since 1993.93 Ninety percent of all surviving patients received a well-functioning reservoir. Despite this, it seems that the ileal nipple valve in most centres has been abandoned due to the high technical complexity and the high revision rate. Time will tell if the flap valve known as the T-mechanism, which has replaced the nipple valve in a few centres, represents improvements in this regard.86

The Indiana pouch

Described by Rowland et al. from Indiana in 1987, this type of diversion uses the detubularized right colon or the ascending colon patched with an ileal segment, outlet being a 10cm-long plicated or stapled ileal segment (Figure 17).94

Figure 17: The classical Indiana pouch.

Figure 17: The classical Indiana pouch.

Steps Studer Pouch ProcedureIndiana Pouch
Figure 18: The Lundiana pouch.

In the last report from the group, only one of 81 patients needed outlet revision due to urine leakage.95 The advantage with the technique is that it is simple, the disadvantage that the outlet lacks an intra-luminal closure mechanism. Instead, continence is achieved by extra-luminal 'sphincteric' compression, which might be less reliable, although proper studies to elucidate that have not been commissioned. Many modifications of the technique has been described. One is by incorporating the ileocaecal valve that is diminished in diameter and fixed to the caecal wall as a small flap valve; the Lundiana outlet (Figure 18). In a comparative study, this outlet proved equally effective as the intussuscepted ileal nipple valve. However, the urodynamic characteristics were not as optimal as those of the nipple valve.96

We have now analysed our series of Lundiana pouches operated from 1992 to 1999 and followed to December 2001.13 Of 97 patients, six underwent revision of outlet due to leakage (two revisions in one, three revisions in two). Six patients needed revision of the stoma due to stenosis (two revisions in two, three revisions in one) and one had dilatation due to stenosis. Inability to catheterize a full reservoir necessitated percutaneous puncture in two patients. Augmentation for an inadequate pouch capacity was done in two patients. Four patients never achieved continence and in two of these the pouch was continuously drained due to rapidly recurring cancer. Studies comparing the Kock pouch with the Indiana pouch have reported less need of surgical revision in the latter.90,97,98

Appendicial outlet

The use of the appendix as a catheterizable continent outlet for vesicostomy was described by Mitrofanoff and later by Riedmiller et al. for continent cutaneous diversion.99,100 Several techniques for the use of the appendix as continent outlet have been described, but the most popular seems to be

Figure 19: The appendix is positioned in a seromuscular trough and this layer is then closed over the appendix with interrupted sutures through the windows in the mesoappendix.

Figure 19: The appendix is positioned in a seromuscular trough and this layer is then closed over the appendix with interrupted sutures through the windows in the mesoappendix.

Vesicostomy Nach Mitrofanoff

the embedded appendix as it is used in the Mainz pouch I, and excellent results have been reported (Figure 19).101 Apart from three out of 118 patients who suffered ischaemic necrosis of the appendix and needed reoperation because of complete incontinence, no other patients underwent revision due to incompetence of the outlet. The main problem is the tendency towards stomal stenosis, causing difficult catheterization and in the above-mentioned series revision for that reason was necessary in 19 patients.

The advantages of using the appendix are that it is 'ready-made' and that a smaller amount of bowel is needed for the diversion. Disadvantages are that it is sometimes missing or too tiny to use. Familiarity with some other method for continent diversion is therefore necessary.

Other types of outlets

There are some other outlets that it is important to know about as they can be used as 'salvage' methods. One is the 'Monti technique', or the transverse retubularized ileum.102,103 Two to three centimetres of ileum are isolated, opened close to the mesenteric attachment and then closed transversely, creating a small-bore tube that can be handled like an appendix. So far experience of this is limited. It is simple, but there is probably the same risk as with the appendix as regards stenosis.

Other possible outlets are the tunnelled bowel flap tubes, one being a seromuscular tube and the other, seemingly more useful, a full thickness bowel flap tube.104

Continent anal urinary diversion

There is in the literature a large number of reports on complications of ureterosigmoidostomy, and this type of diversion was therefore abandoned in most centres due to the problems of ascending infections, loss of renal function, metabolic acidosis and the possibility of secondary malignancy. However, there are also series showing that the clinical results can be favourable, with high continence rate, if the operation is performed in childhood.105,106 The concept of detubularization with creation of rectosigmoid pouches may have lead to a revival of interest in anal diversion and different techniques have been described.107,108 Although excellent functional results have been published, it seems that acceptance by Western urologists has been low, presumably due mainly to instinctive mental reservations and the contemporary enthusiasm for orthotopic reconstruction.107-109

Orthotopic bladder substitution

Although first performed 50 years ago, the impetus to widespread use and acceptance of this type of reconstruction came with the report by Lilien and Camey in 1984 on the Camey bladder.110 Today it is first option in most centres for reconstruction in conjunction with radical cystectomy, and also in female patients. The majority of bladder substitutes are constructed from detubularized ileal segments, most commonly those described by Studer (Figure 20), Hautmann (Figure 21), Abol-Enein, and Pagano (Figure 22).47,85,111,112 Goldwasser and Reddy have described the use of right colonic segment and sigmoid segment for this purpose (Figure 23).113,114 Yet another possibility is to construct an ileocaecal pouch.115

The main problem after neo-bladder construction is voiding dysfunction, i.e. urine leakage and retention. Due to considerable variance between the multitude of series now published, it is impossible to claim superiority of one type of neo-bladder over another. Not only may patient age and follow-up vary, but the technique of performing the cystectomy and the type, length and detubularization of the intestinal segment may

Figure 20: The detubularized ileal neo-bladder with an afferent tubular segment; the Studer pouch.

Figure 20: The detubularized ileal neo-bladder with an afferent tubular segment; the Studer pouch.

Studer Pouch Definition
Figure 21: The ileal W neo-bladder; the Hautmann pouch.
Studer Hautmann

Figure 22: The

Padova ileal neo-bladder; the VIP pouch. The ureters are implanted using the Abol-Enein technique.

Figure 22: The

Padova ileal neo-bladder; the VIP pouch. The ureters are implanted using the Abol-Enein technique.

Ileal NeobladderStuder PouchStuder Pouch
Figure 23: The detubularized right colonic segment for orthotopic neo-bladder; the Goldwasser pouch.

be different. Semantics also differ. Thus, continence has been described as 'continence', 'good continence', 'satisfactory continence' and 'social continence', with definitions that vary widely. As has been pointed out, neo-bladder function has rarely been assessed using validated outcome instruments and/or voiding diaries.116 Good clinical research within this field is clearly needed.

In a recent review paper, daytime incontinence in published series varied between 0% and 67%, with a mean of 13%, and the corresponding figures for night-time incontinence were 7%, 70% and 29%.115 Between 4% and 44% of neo-bladder patients need intermittent self-catheterization.12,116

Introduction of bladder substitution in females was late, due to fear of compromising continence and radicality at cystectomy. It has since been established that female continence after cystectomy is through the rhabdosphincter in the distal half of the urethra, innervated by the pudendal nerve which, due to its course, is not likely to be damaged during surgery.117,118 There is an ongoing debate regarding the importance of preserving the autonomic nerves during cystectomy. Proponents for this measure argue that sacrificing the nerves increases the risk of urine retention as nerves sprout from adjacent adrenergic neurons into the denervated urethra.118-120 Other authors claim these nerves to be insignificant with regard to emptying.121,122 This latter view is supported by a recent experimental study showing that autonomic denervation resulted in a moderately reduced pressure in proximal urethra, no fibrosis and caused no residual urine.123 The functional results obtained in men and women seem equivalent.

Our results from use of the Goldwasser technique for orthotopic substitution are not encouraging. In 64 patients with mean follow-up of 71 months, stenosis of the urethrocolonic anastomosis occurred in three patients. AUS was required in three patients, two needed augmentation of the neo-bladder and conversion to ileal conduit was necessary for one patient. Twenty-six patients used CISC. The continence situation is not as good as for patients with a Lundiana pouch.

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