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Cutaneous Continent Urinary Diversion
GENERAL CONSIDERATIONS
Continent urinary diversion is widely accepted by both urologist and patient alike as an
acceptable form of urinary reconstruction after cystectomy. Orthotopic urethral anastomotic
procedures and continent catheterizable stomal reservoirs have stood the test of time, and
both procedures should always be considered for all appropriate patients. Orthotopic
continent diversion and the metabolic consequences of continent urinary diversion are
covered in separate chapters. In this chapter the focus is on the continent cutaneous diversion
surgeries associated with the highest success rates. Over the past 25 years the design of the
reservoir has not substantially changed. However, an evolution has occurred in the techniques
used to create antireflux and continence mechanisms in order to make them more effective
and reliable. In addition, attention is given to the long-term quality of life outcomes of
continent cutaneous reservoirs, as well as to the newer laparoscopic approaches used to create
such reservoirs.
Despite the considerable enthusiasm for continent urinary diversion operations, those
procedures requiring the use of external urinary collecting appliances remain more common.
Although continent urinary diversion is certainly appropriate in selected patients, the
procedures are technically more challenging and associated with higher short-term and long-
term complication rates than those that use external collecting devices. However, the
operating time associated with these more complex procedures has been significantly reduced
by the widespread use of absorbable and metal staples in the construction of the reservoirs
and limbs. These techniques are discussed in detail later. Also, as experience with continent
urinary diversion has grown, complication rates have decreased dramatically. As a result, in
some centers continent diversions are now more commonly employed than conduit
diversions.
Patient Selection
Because the ability to self-catheterize is essential to the patient undergoing continent
diversion, the patient must be assessed for the ability to care for himself or herself.
Consultation between an enterostomal therapist and the patient is extremely helpful in this
regard because the patient may be at greater ease with the therapist and more willing to
express any concerns. Certain patients may not be able to comprehend the strict flushing and
catheterization regimens that must be followed after continent urinary diversion or may lack
the motor skills to independently perform self-care. Patients with multiple sclerosis,
quadriplegic individuals, and frail or mentally impaired patients will at some point in their
lives require family or visiting nurses for basic care and are therefore viewed as poor
candidates for any form of continent diversion. Indeed, these patients may also require
assistance with external appliances, but the degree of time and expertise required is much less
burdensome on the care provider and the health care system. On the contrary, continent
catheterizable diversion requires continuous attention and may limit patient and family
options when determining long-term care needs.
Patient Preparation
All patients undergoing anticipated continent urinary diversion should be prepared for the
possibility that a traditional ileal conduit might be performed. Although it is rare to abandon a
continent diversion owing to unanticipated problems, this always remains a possibility.
Therefore before starting the operation, the site for an external stoma should be selected with
extreme care. In general, the location must be free from fat creases in both the standing and
sitting position and it should not be close to prior abdominal scars that may interfere with
proper adherence of an external appliance. Here, again, the aid of an enterostomal therapist is
helpful. In general, the stoma should be brought through the right (or left) lower quadrant of
the abdomen on a line extending from the umbilicus to the anterior superior iliac spine. The
stoma should be as far lateral from the midline as possible, but the site selected should ensure
that the bowel segment comprising the stoma traverses the rectus muscle. Failure to adhere to
this rule increases the risk of parastomal hernias. The selected site for the stoma should be
marked with an X scratched onto the anterior abdominal wall. Marking the stoma site with
ink should be avoided because it may be washed away during the antiseptic preparation of the
skin.
The surgeon undertaking continent urinary diversion should be familiar with more
than one type of continent diversion technique. Although it is uncommon to have to abandon
a given bowel segment for the reservoir, it is not uncommon to have to modify the antireflux
or continence mechanism. In these circumstances, it is essential that the surgeon be able to
select an alternate form of continent diversion from what was originally intended. Renal and
hepatic function must be reviewed carefully in the patient selected for continent diversion
(Mills and Studer, 1999). The reabsorption and recirculation of urinary constituents and other
metabolites require that liver function be normal and that serum creatinine levels be within
normal range, or certainly below the level of 1.8 mg/dL. In cases in which renal function is
borderline, creatinine clearance should be measured. A minimal level of 60 mL/min should
be documented before deeming the patient an appropriate candidate for continent diversion.
In patients with bilateral hydronephrosis in whom renal functional improvement might be
anticipated on relief of the ureteral obstruction, the upper urinary tract should first be
decompressed with either ureteral stenting or percutaneous nephrostomy(ies). Subsequent
reevaluation of renal function should be performed before undertaking a continent diversion.
Procedures that will require use of the colon should always be preceded by a colonoscopic
assessment of the entire large intestine. Performing only a sigmoidoscopy for a procedure that
will use only this segment of the large bowel is insufficient because disease proximal to the
resected segment may leave the patient with short colon syndrome. The preoperative
assessment of the colon is not necessary if continent urinary diversion using small intestine is
planned. Healthy patients undergoing radical cystectomy can be admitted to the hospital on
the day of surgery. A mechanical bowel preparation is administered after a liquid dinner on
the night before surgery. The patient is instructed to drink copious amounts of water, and at 8
PM and 10 PM the patient is administered oral metronidazole (500 mg). In addition, the
patient should receive cefoxitin (1 gm) intravenously 1 hour before the skin incision.
Cystectomy
All operations described require a midline incision, skirting the umbilicus to the side opposite
the selected stoma site. The incision for a right colon pouch usually extends from the pubis to
a point midway between the umbilicus and the xiphoid. The cranial extent of the incision is
governed by the hepatic flexure, which must be divided to obtain sufficient colonic length
and to allow for the right colon to easily fold on itself. On some occasions, the incision will
be extended to the xiphoid. The incision for procedures using only the ileum should extend to
just below the umbilicus. The cystectomy procedure is covered elsewhere in this text, and
only those points germane to continent diversion are covered here.
After abdominal exploration, the ureters are isolated, transected, and transposed to an
appropriate place for subsequent diversion. The right retroperitoneum is first opened over the
iliac artery to expose the right ureter. In the typical circumstance of conduit diversion, the
right ureter is transected below the common iliac artery. For all continent diversions, both
ureters are transected as low as possible and shortened to the appropriate length once the final
anatomy is determined. The sigmoid colon is freed from its lateral peritoneal attachments by
incising along the line of Toldt. A wide tunnel is created by blunt finger dissection ventral to
the aorta and common iliac arteries and caudal to the inferior mesenteric artery. This affords
left ureteral access to the previously exposed right retroperitoneum. In cases of uroepithelial
malignancy it is prudent to evaluate the margin status of the most distal portion of both
ureters using frozen section analysis. In situations where substantial ureteral length is
removed to obtain negative surgical margins, extension of the afferent limb mechanism may
be necessary to allow tension-free ureteral intestinal anastomoses. All sutures used in the
urinary tract should be absorbable. The individual surgeon’s preference will dictate the
caliber and type of suture material used. When carrying out bowel surgery for continent
urinary diversions, stapling is the preferred method for division of the bowel segment, as well
as for reconstruction of bowel continuity. This technique shortens operative times greatly and
affords safe and reliable bowel anastomosis. Suturing is not necessary with the exception of
placing two silk Lembert sutures at the apex of side-to-side stapled bowel anastomoses in
order to prevent tension on the staple line. To avoid stone formation on the stapled proximal
bowel segments, oversewing the stapled end of the conduit with absorbable material isolates
the metal staple line from urinary contact within the lumen. In constructing a nonappendiceal
continent urinary diversion stoma, a skin button matching the diameter of the structure to be
used in the diversion is resected. Cutaneous tissues are separated down to the level of the
anterior rectus fascia, where a circle of similar diameter is excised from this fascia or,
alternatively, the fascia is incised in a cruciate fashion. In carrying out this maneuver, it is
essential that the fascia and skin are properly aligned in order to avoid angulation. Rectus
muscle fibers are separated bluntly and an instrument passed through the posterior fascia and
peritoneum. For appendiceal stomas, we prefer to perform a Y-shaped cutaneous incision that
allows for a YV-type plasty incision between the appendiceal limb and the skin (Fig. 86–1).
This will decrease the likelihood of subsequent stomal stenosis. Alternatively, the appendix
lends itself to an umbilical stoma (Bissada, 1993; Gerharz et al, 1997). Favorable results with
this appendiceal YV plasty technique to the umbilical site have been reported (Bissada,
1998). It is standard procedure to use long, end-hole single J–type diverting stents in all
continent cutaneous urinary diversions. These stents drain urine externally, ensuring that
urine is safely diverted beyond any anastomotic site during the early healing period. They can
also be safely manipulated or exchanged if necessary. The end hole allows for the passage of
a straight wire through the stent, which decreases the likelihood of anastomotic trauma at the
time of stent removal. The authors advocate the use of closed suction drains in all cases of
urinary diversion. Soft silicone Jackson-Pratt closed suction drains are preferred because they
have less potential for tissue damage or migration into pouches. Abdominal closure is
performed according to the surgeon’s preference. In general a single-layer closure, using No.
2 nylon, Surgilene, or Prolene taken through all layers of fascia and muscle provides a rapid
and secure abdominal closure in the majority of patients. In obese patients, those with tissues
of poor quality, or nutritionally depleted patients, through-and-through stay sutures are also
used. Ureteral stents are always brought through separate abdominal stab wounds, sutured to
the anterior abdominal wall, and directed into separate drainage bags to monitor urine output.
Even at this early stage it is important to ensure adequate drainage of the reservoir in order to
prevent pouch rupture should the ureteral stents be displaced. In the case of limited pouch
access such as with an appendiceal stoma, a Malecot tube should be placed directly into the
reservoir and secured to the skin. The reservoir is sutured to the abdominal wall to prevent
urine leakage
into the peritoneal cavity when the tube is removed. This maneuver also helps to prevent
migration and angulation of the reservoir, which could result in incontinence or
catheterization difficulties.
Postoperative Care and Comments
Paralytic ileus is a common complication following urinary diversion procedures. Gastric
decompression should be maintained until extubation. This can be achieved in the majority of
patients by means of nasogastric intubation. However, certain patients may be managed best
by formal gastrostomy decompression inserted intraoperatively. These individuals include
those with multiple prior abdominal procedures in whom prolonged ileus is more likely. If
the patient is nutritionally depleted preoperatively, hyperalimentation has been suggested to
be of value if initiated during the preoperative interval (Hensle, 1983; Askanazi et al, 1985).
Ureteral stents are usually removed 1 week after surgery. Before any manipulation, a
urine sample from each stent should be sent for culture and sensitivity testing. Before stent
removal, radiographs of the pouch are obtained to ensure that the pouch is intact. Radiologic
contrast studies are performed to ensure against ureteral anastomotic leakage. Each stent is
injected with contrast agent in a search for extravasation; if none is seen, guidewires are
advanced to each kidney and the stents removed. If there is any question of extravasation,
stents can be advanced over the wires, positioned fluoroscopically, and left in situ for re-
evaluation after additional healing has taken place. Late malignancy has been reported in all
bowel segments exposed to the urinary stream, whether or not there is a commingling with
feces (Filmer and Spencer, 1990; Shokeir et al, 1995). A study by Gitlin and colleagues
(1999) suggests that the malignancy may develop from the urothelial component and not as a
result of urine affecting intestinal mucosa. As a result, urinary cytology should be performed
in all patients undergoing a continent urinary diversion whether or not the diversion was
performed secondary to a urothelial malignancy. When the ureters are directed into the fecal
stream, routine colonoscopy should also be performed. Latency periods have been reported as
short as 5 years, so all patients developing gross or microscopic hematuria should be fully
evaluated (Golomb et al, 1989). If an anastomotic transitional cell cancer is discovered, the
patient should be fully evaluated with upper tract imaging and ureteroscopy if possible.
Antegrade ureteropyeloscopy can be employed if necessary. For an isolated anastomotic
recurrence, distal ureterectomy and reimplantation may be appropriate. If
nephroureterectomy is necessary, some patients may require removal of their continent
diversion due to resulting renal insufficiency.
CONTINENT URINARY DIVERSION
Continent, nonorthotopic urinary diversion can be divided into two major categories. First,
the variations of ureterosigmoidostomy such as ileocecal sigmoidostomy, rectal bladder, and
the sigmoid hemi-Kock operation with proximal colonic intussusception are discussed. These
techniques allow for excretion of urine by means of evacuation. Second is the large category
of continent diversions requiring clean intermittent catheterization of the constructed pouch
for urine drainage at standard intervals.
The concept of refashioning bowel so that it serves as a urinary reservoir rather than a
conduit has become universally accepted. This concept is based on original pioneering
observations by Goodwin and colleagues in the development of the cystoplasty augmentation
procedure (Goodwin et al, 1958). The destruction of peristaltic integrity and refashioning of
bowel has led to the development of many innovative urinary reservoirs constructed from
bowel. Several antireflux procedures have evolved to avoid upper tract urinary damage by
sepsis or reflux, while other surgical techniques have been devised to achieve urinary
continence.
Because there are numerous variants of continent urinary diversion used worldwide, a
complete review of all operative techniques is beyond the scope of this or any chapter.
However, many of these procedures are simple modifications of parent operations. In this
chapter we describe in detail each parent operation, as well as major modifications. The fact
that there are many continent urinary diversion procedures described reveals an obvious
corresponding fact: the “best” continent diversion has yet to be devised. There is, to date, no
consensus that would indicate one continent cutaneous diversion is superior to another, but it
is becoming apparent that certain procedures are associated with lower early and late
complication rates. Points of controversy include which bowel segment is most appropriate
for fashioning into a urinary reservoir, the best techniques to use for achieving urinary
continence, and the best technique for prevention of urine reflux into the upper tracts. There
are now various continence mechanisms that appear reliable. In the authors’ experience,
procedures using a right colon reservoir with some form of appendiceal continence
mechanism are the fastest and easiest to perform.
It should be re-emphasized that all continent diversions will allow for substantial
reabsorption of urinary constituents that will place an increased workload on the kidneys
(Mills and Studer, 1999). No patient with substantial renal impairment should be considered
for any of these procedures. The long-term sequelae of continent urinary diversion are well
understood and, unfortunately, commonly involve significant renal damage. Although it has
been suggested that the absence of reflux into the upper urinary tracts in catheterizable
pouches may reduce the longterm impact of continent diversion procedures on renal function,
it should be cautioned that long-term 15-year data are now available and, in some instances,
antireflux procedures are associated with a higher risk of obstruction due to anastomotic
stricture (Kristjansson et al, 1995). In addition to increased stricture rates, it is not clear
whether antirefluxing mechanisms actually esult in improved preservation of the upper tracts
(Pantuck et al, 2000).
Multiple international studies have suggested an improved psychosocial adjustment of
patients undergoing continent urinary and fecal diversion compared with those patients with
diversions requiring collecting appliances (Gerber, 1980; McLeod and Fazio, 1984; Boyd et
al, 1987; Salter, 1992a, 1992b; Bjerre et al, 1995; Filipas et al, 1997; Hart et al, 1999;
McGuire et al, 2000). Although this is indeed true and is best exemplified by the individual
with a conduit who desires conversion to a continent procedure, it is also true that many
individuals seem to adjust well to wearing external appliances. The sense of body image is a
remarkably personal and subjective parameter that varies greatly from patient to patient. In
fact, the majority of patients are satisfied with their choice of urinary diversion, whether it is
continent or not. The process of patient counseling that we employ always refers to ileal
conduit diversion as the gold standard against which the newer, more complex operations
must be compared. The patient should be advised that continent diversion is, all other
considerations being equal, associated with a longer hospital stay, higher complication rates,
and greater potential for requiring reoperative surgery. However, it should be noted that an
extensive review from our institution has demonstrated no statistically significant difference
in reoperations, mortality, or hospital stay in patients undergoing continent diversion versus
conduit diversion by the same three surgeons over a 3-year period (Benson et al, 1992).
Analysis of the two patient groups, on the other hand, showed that, in general, those selected
for continent diversion were 12 years younger and four times less likely to have significant
concurrent illness. What this review suggests is that, with proper patient selection, continent
diversion operations can be safely conducted with results similar to those for conduit
diversion. To determine if continent diversion could be safely performed in selected elderly
patients, Navon and colleagues (1995) compared the clinical course of 25 patients older than
the age of 75 years undergoing a modified Indiana reservoir to a cohort of 25 randomly
selected patients younger than 75. The mean age of the first group was 78.5 years, and the
mean age of the second was 59.3 years. The complication rates between the two groups were
acceptably low and surprisingly similar. Navon and colleagues concluded that age alone
should not be a contraindication to continent diversion and that the Indiana reservoir can be
successfully performed in elderly patients.
Rectal Bladder Urinary Diversion
Various innovative surgical techniques have been advocated for separating the fecal and
urinary streams, while still employing the principles of ureterosigmoidostomy. These
operations can generally be discussed together as rectal bladder urinary diversions. In each of
these operations the ureters are transplanted into the rectal stump. The proximal sigmoid
colon is managed by terminal sigmoid colostomy or, more commonly, by bringing the
sigmoid to the perineum, thereby using the anal sphincter to achieve both bowel and urinary
control. Although these operations continue to be commonly performed, they have never
been well accepted in the United States. The principal reason is the potential for the
calamitous complication of combined urinary and fecal incontinence, presumably occurring
as a consequence of damage to the anal sphincter mechanism during the dissection processes
(Culp, 1984). If the urologist selects one of these procedures, the preoperative evaluation
should include all of the caveats of ureterosigmoidostomy. Dilated ureters are not acceptable.
Patients with extensive pelvic irradiation are not candidates, and neither are those with
existing renal insufficiency. Anal sphincteric tone must be judged competent before electing
these operations. Our preference has been to use a 400- to 500-mL thin mixture of oatmeal
and water that the patient is asked to retain for 1 hour in the upright position (Spirnak and
Caldamone, 1986). Finally, colonoscopy must be carried out before the procedure to rule out
pre-existing colorectal disease, as well as after the procedure to guard against the potential
development of colonic cancer. Procedures that separate the fecal and urinary streams but
drain both through the rectal sphincter are not described here. Those wishing a detailed
description of these procedures can find them in prior editions of this chapter. The following
is a brief description of more modern surgical procedures that use the intact anal sphincter for
urinary and fecal continence. However, the surgical techniques for these procedures will
likewise not be discussed in this edition.
Folded Rectosigmoid Bladder
A modification of the ureterointestinal anastomosis was described by a group from
Mansoura, Egypt (Hafez et al, 1995; El-Mekresh et al, 1997). This procedure creates a folded
rectosigmoid bladder with anastomosis of the ureters via serosa-lined tunnels rather than into
the taenia coli. This procedure has the advantage of a larger sigmoid reservoir, as well as the
prevention of reflux by creating the above serous-lined tunnel for the anastomosis. This
reimplantation technique was first described by Abol-Enein and Ghoneim (1993) and appears
to have a lower complication rate than direct taenial implantation (Hafez et al, 1995).
Postoperative Care and Comments. Patients undergoing this procedure must be
closely monitored for the development of hyperchloremic acidosis. This will occur in the
majority of cases, and it is wise to initiate a bicarbonate replacement program following the
operation. Because hypokalemia is also a feature of ureterosigmoidostomy, replacement of
potassium along with bicarbonate may be achieved with oral potassium citrate. Routine
nightly insertion of a rectal tube is advocated in the long-term care of the patient. However,
many patients will reject this practice as uncomfortable and unappealing. Nighttime urinary
drainage should be mandated in any patient who cannot maintain electrolyte homeostasiswith
oral medication. Bissada and colleagues (1995) reported that 30 of 61 patients were able to
stay dry during the night without awakening. The other 31 required two or more awakenings
to remain dry overnight. Hyperchloremic acidosis was reported in 4 of 61 noncompliant
patients.
In 1997 El-Mekresh and colleagues (1997) reported on 64 patients (32 women, 20
men, and 12 children) who underwent their rectosigmoid bladder procedure between 1992
and 1995. Follow-up ranged from 6 to 36 months. Functional results were assessable in 57
patients: 1 died of a postoperative pulmonary embolism and 6 died from their disease. All
patients were continent during the day with two to four emptyings, whereas all butfour
remained dry at night with zero to two emptyings. Four children experienced enuresis that
responded to 25 mg of imipramine at bedtime. Importantly, upper urinary tract function was
maintained or improved in 95% of patients. However, six renal units (5.3%) developed
obstructive hydronephrosis secondary to ureterocolic anastomotic strictures. Two were
remedied by antegrade dilation, one was repaired by open revision, and one nonfunctioning
renal unit was removed. The fate of the remaining two units was not specified. No patient in
this series developed a postoperative metabolic acidosis. However, all patients were
maintained on prophylactic oral alkalinization.
Obviously, all patients undergoing these procedures have exposure of the urinary tract
to fecal flora. Most authors would advocate chronic administration of an antibacterial agent in
all patients (Duckett and Gazak, 1983; Spirnak and Caldamone, 1986). Ureteral strictures
require reoperative surgery and are experienced in 26% to 35% of cases over time (Williams
et al, 1969; Duckett and Gazak, 1983).
Because of the concern for development of rectal cancer anywhere between 5 and 50
years (average 21 years) after ureterosigmoidostomy (Ambrose, 1983), it is suggested that
patients with long-term ureterosigmoidostomy undergo annual colonoscopy (Filmer and
Spencer, 1990). Barium enemas are relatively contraindicated because reflux of this material
into the kidneys (if the antireflux procedure fails) can result in dire consequences (Williams,
1984). Additional methods for colon carcinoma screening in this population are the
evaluation of stool for blood, and the attempted cytologic examination of the mixed urine and
feces specimen (Filmer and Spencer, 1990).
Augmented Valved Rectum
Kock developed this technique to be used in locales where stoma appliances were not
readily available (Kock et al, 1988). This operation is similar to standard
ureterosigmoidostomy except that a proximal intussusception of the sigmoid colon confines
the urine to a smaller surface area, thus minimizing the problems of electrolyte imbalance.
Additionally the rectum is patched with ileum to improve the urodynamic properties of the
rectum as a urinary reservoir. Preoperative evaluation is similar to that used in
ureterosigmoidostomy. The large bowel must be studied for pre-existing disease, and anal
sphincteric integrity must be tested before surgery.
Hemi-Kock and T Pouch Procedures with Valved Rectum
In his description of the augmented valved rectum procedure, Kock described the use of a
foreshortened hemi-Kock pouch to be used as a rectal patch when the ureters were too dilated
to bring down between the leaves of the intussuscepted sigmoid (Kock et al, 1988). Skinner
then modified this procedure by using an entire hemi-Kock segment to augment the rectum
after sigmoid intussusception (Skinner et al, 1989).
After extensive experience with the Kock ileal reservoir, the group at the University
of Southern California has attempted to improve on the intussuscepted Kock continence
mechanism. The result has been the modification of the T pouch to serve as an ileal anal
reservoir (Stein et al, 1999a). The technique consists of the construction of a hemi-Kock or T
pouch employing doubly folded, marsupialized ileum and a proximal continence mechanism
to prevent pouch-ureteral reflux. This pouch is then anastomosed to the rectum directly as a
patch. Contact of urine with the proximal colon can be avoided by the intussusception of the
sigmoid colon proximal to the anastomotic site (Fig. 86–2).
Postoperative Care and Comments. Postoperative management and complications associated
with this operation are similar to those that might be experienced after any procedure that
directs the urinary stream into the rectum. Radiologic studies of the stents are carried out on
the seventh postoperative day. Before conducting stent studies, a Gastrografin enema may be
performed through the rectal tube to ensure that the region of ureterocolonic anastomosis is
intact. Follow-up films are taken to ensure prompt drainage of the upper urinary tracts into
the rectosigmoid region. The rectal tube may be removed at this point, but some believe that
it is advisable to have it reinserted for evening drainage over the forthcoming week. The
patient is instructed to empty the colon at intervals of no more than every 2 hours,
particularly in the early postoperative period.
When the rectal tube is removed, as in other situations when the urinary tract is
diverted to the rectum, the patient must be closely monitored for the development of
hyperchloremic acidosis. Because hypokalemic metabolic acidosis often occurs after
ureterosigmoidostomy, bicarbonate replacement with oral potassium citrate should begin in
the immediate postoperative setting. Longterm care should include nightly insertion of a
rectal tube despite the uncomfortable and unappealing nature of the process. In addition,
nighttime urinary drainage is necessary in patients who cannot maintain electrolyte
homeostasis with oral medication.
The hemi-T procedure with valved rectum has one theoretical advantage over the
valved rectum operation itself: Because
Figure 86–2. A, A 30-cm segment of ileum is selected, the first 10 cm for the T implant and the distal 20 cm for the patch. The 20-cm segment is folded into a U and opened as shown. The medial borders are closed with running absorbable sutures. B, The ostium of the T is secured to the walls of the ileum with interrupted absorbable sutures. The wall of the ileum is closed over the T mechanism with a running absorbable suture. C, The ureters are anastomosed to the top of the T in the usual end-to-side fashion. The T patch is then secured to the 15-cm proctotomy with a two-layer closure. (From Stein JP, Buscarini M, DeFilippo RE, Skinner DG. Application of the T pouch as an ileo-anal reservoir. J Urol 1999;162:2052–3.)
transitional ureteral epithelium is not in contact with colonic epithelium, there may be a
reduced risk of developing colonic malignancy. As in the augmented valved rectum, the
proximal colonic intussusception used in this procedure decreases the contact between urine
and colonic epithelium, thereby potentially decreasing the risk of hyperchloremic acidosis.
Nevertheless, attention should be paid to electrolyte levels after removal of stents and rectal
tubes. Skinner and colleagues reported on the results of the hemi-Kock procedure in 15
patients between 1987 and 1991 (Simoneau and Skinner, 1995). Four patients had prior
bladder exstrophy and were converted to an ileoanal reservoir, and 11 patients underwent the
procedure as a form of primary diversion after cystectomy. At the time of the report 10
patients were still alive and could be evaluated. Early postoperative complications occurred
in three patients (20%): a colocutaneous fistula in two patients, urine leak in one, and deep
venous thrombosis in another. Late complications included partial small bowel obstruction in
four patients (with two requiring surgery), urinary retention requiring surgery in two patients,
and metabolic acidosis in five patients. Two of the 11 patients undergoing primary
construction never achieved continence; both were older than 68 years. The authors
summarized their experience by concluding that the operation is best suited for the younger
exstrophy patient and that it is essential to avoid colonic redundancy distal to the reservoir.
The use of the T pouch as an ileoanal reservoir has been reported in one former exstrophy
patient (Stein et al, 1999a), with no reported postoperative complications.
Sigma-Rectum Pouch, Mainz II
A variation of ureterosigmoidostomy was described by Fisch and Hohenfellner in 1991 and
updated in 1996 (Fisch and Hohenfellner, 1991; Fisch et al, 1996). This operation, which they
termed the sigma rectum or the Mainz II pouch, creates a low-pressure rectosigmoid reservoir
of increased capacity. They viewed the simplicity and reproducibility of the operation as one
of its major advantages.
Postoperative Care and Comments. The rectal tube is removed on the third to fifth
postoperative day, and the ureteral stents are removed around the eighth day. On the 15th
postoperative day the Mainz group performs an intravenous pyelogram to assess the upper
tracts and the sigma rectum pouch construction. Radiography of the pouch is performed on
the 17th postoperative day.
The results of the Mainz II pouch were reported by Fisch and colleagues in 1997.
Between 1990 and 1993, 73 patients (59 adults and 14 children) underwent the Mainz II
pouch procedure. Early complications were encountered in 5 of 73 patients (6.8%). These
included single examples of a dislodged ureteral stent, pneumonia, pulmonary embolism,
wound dehiscence, and ileus necessitating surgical intervention. There were eight (10.9%)
late complications that required surgery: ureteral stenosis occurred in five patients (6.8%);
one patient with nephrolithiasis was treated with extracorporeal shockwave lithotripsy; one
patient with rupture of the anterior suture line required temporary colostomy; and one patient
experienced perianal bleeding after chemotherapy that required endoscopic coagulation. Six
patients presented with pyelonephritis (8.2%) and were treated with antibiotics. Daytime and
nighttime continence were reported as 94.5% and 98.6%, respectively. Oral alkalinization to
prevent metabolic acidosis was used in 49 of 73 patients (67.1%). Two patients who refused
any oral medication developed metabolic acidosis. The Mainz group concluded that the
overall complication rate was low and comparable with other techniques of continent urinary
diversion. Woodhouse and Christofides (1998) reported on their experience with the Mainz II
pouch in 15 primary cystectomy patients and 4 patients with prior standard
ureterosigmoidostomy who were incontinent. They reported excellent results: 14 of 15
(93.3%) of the primary patients achieved documented daytime and nighttime urinary control,
while the remaining patient refused follow-up but reported continence. The four patients
undergoing a salvage procedure fared less well. Only two patients became continent, while
the remaining two were found to be in chronic retention. Their failed continence was believed
to be secondary to inadequate pouch emptying. Similarly, excellent results have been
achieved by Venn and Mundy (1999). They reported full daytime and nighttime urinary
continence in 14 of 14 patients and no major postoperative complications.
Bastian and colleagues (2004) have reported on the healthrelated quality of life in 83
patients undergoing Mainz II urinary diversion. They found that quality of life was similar to
that of age-matched controls except for diarrhea symptoms, with 100% daytime continence.
There appears to be no metabolic advantage to this procedure because the need for
oral alkalinization is similar to standard ureterosigmoidostomy. In fact, the only difference
between this operation and standard ureterosigmoidostomy is the partial reconfiguration of
the rectosigmoid junction. It does appear that the reduced intracolonic pressures that result
from the partial reconfiguration increases the sigmoid capacity and results in better daytime
and nighttime continence. Whether the increased capacity and lower pressure of this pouch
will decrease the incidence of upper tract complications remains to be determined by longer
follow-up.
Continent Catheterizing Pouches
Numerous operative techniques have been developed for continent diversion wherein urine is
emptied at intervals by clean intermittent self-catheterization. Many of these operations are
described in this chapter, although certain pioneering procedures that used intact bowel (e.g.,
those of Gilchrist and colleagues [1950], Ashken [1987], Mansson and colleagues [1984,
1987], Benchekroun [1987]) are not. This is not to discredit the pioneers in the field but
simply to allow this chapter to focus on those pouches that incorporate modern principles that
attempt to achieve a spherical configuration and disruption of peristalsis.
In continent urinary diversion, the two favorite sites for stomal location are (1) at the
umbilicus and (2) in the lower quadrant of the abdomen, through the rectus bulge and below
the “bikini” line. This location is often preferred because it affords both men and women the
opportunity to conceal the stoma. The umbilicus is a preferred location for the individual
confined to a wheelchair and has been reported to have a lower incidence of stomal stenosis,
especially when fashioning an appendiceal stoma. The umbilical location is also far easier for
the paraplegic individual to catheterize without the need for chair transfer and disrobing. In
individuals with a recessed umbilicus, the umbilical location of a stoma is barely perceptible
from a normal umbilical dimple. Generally, the stoma site is covered with a gauze pad or
square bandage to avoid mucous soiling of clothing. Patients undergoing continent urinary
diversion to an umbilical location should be advised to wear a medical alert bracelet that
informs the examiner of the umbilical stoma.
Before the extension of orthotopic neobladder construction to women, there was some
enthusiasm for the orthotopic placement of a catheterizing portal. This procedure has been
carried out in certain female patients with success. The construction of a neourethra to the
introitus is attractive, provided there is no substantial difficulty in the catheterizing process.
Because it can be difficult to direct a catheter through the “chimney” of an intussuscepted
nipple valve, those continent diversions employing nipple valves are not particularly
adaptable to orthotopic location, although they have been performed with success in a small
number of patients (Olsson, 1987). In contrast, the imbricated and tapered ileal segment
leading to an Indiana pouch is relatively easier to catheterize and can be used for orthotopic
catheterizing diversion (Rowland et al, 1987). However, it may be difficult to obtain
sufficient mesenteric length in some patients. The appendix can also be used as a neourethra,
in which case mesenteric length should become less of a problem (Hubner and Pfluger,
1995).
Four general techniques have been employed to create a dependable, catheterizable
continence zone. For right colon pouches, appendiceal techniques, pseudoappendiceal tubes
fashioned from ileum or right colon, and the ileocecal valve plication are applicable.
Appendiceal tunneling procedures are the simplest of all to perform because they use
established surgical techniques already present in the urologic armamentarium. The in situ or
transposed appendix is tunneled into the cecal taenia in a fashion similar to ureterocolonic
anastomosis. Appendiceal continence mechanisms have been criticized for three general
reasons. First, the appendix may be unavailable in some patients because of prior
appendectomy. For those individuals, techniques have been developed that allow for the
construction of a similar tube fashioned from ileum (Woodhouse and MacNeily, 1994) or
from the wall of the right colon (Lampel et al, 1995a). Second, the appendiceal stump may be
too short to reach the anterior abdominal wall or umbilicus while still maintaining sufficient
length for tunneling. This criticism has been addressed by an operative variation described by
Mitchell, in which the appendiceal stump can be lengthened by the inclusion of a tubular
portion of proximal cecum (Burns and Mitchell, 1990) (Fig. 86–3). This lengthening
procedure has the added advantage of allowing for a slightly larger stoma made of cecum that
is less prone to stomal stenosis. Appendiceal continence mechanisms share the feature of
allowing only small-diameter (14- to 16-Fr) catheters to be used for intermittent
catheterization, whereas the large amount of mucus produced by an intestinal reservoir is
more easily emptied or irrigated using a 20- to 22-Fr catheter. We believe that these
criticisms are more theoretical and that the appendiceal or pseudoappendiceal continence
mechanism remains an attractive and reliable continence mechanism.
The second major type of continence mechanism used in right colon pouches is the
tapered and/or imbricated terminal ileum and ileocecal valve. Here again the technology is
rather simple, with imbrication or plication of the ileocecal valve region along with tapering
of the more proximal ileum in the fashion of a neourethra (Rowland et al, 1985; Lockhart,
1987; Bejany and Politano, 1988). These techniques afford a reliable continence mechanism.
One feature of right colon pouches that has been criticized is the loss of the ileocecal
valve. Although this does result in an
Figure 86–3. A, The appendiceal stump is lengthened by the inclusion of a tubular portion of
proximal cecum by the application of the gastrointestinal anastomosis (GIA) stapler to the
terminal cecum. A window is made in the mesoappendix, and the blade of the GIA stapler is
advanced through the window. This maneuver ensures that the blood supply is not
inadvertently damaged. B, The added length is demonstrated. The appendix is rotated and
implanted into the taenia; the cecal tube serves as the stoma. (From Burns MW, Mitchell ME.
Tips on constructing the Mitrofanoff appendiceal stoma. Contemp Urol 1990;May:10–2.)
increased frequency of bowel movements for some patients in the short term, the majority
will experience bowel regularity either through intestinal adaptation or with the use of
pharmacologic therapy. However, some patients have developed rather striking
diarrhea/steatorrhea after the loss of the ileocecal valve. This may be particularly true in
pediatric patients in whom there is neurogenic bowel dysfunction (e.g., myelomeningocele).
The third surgical principle used in constructing the continence mechanism is the use
of the intussuscepted nipple valve or, more recently, the flap valve, which avoids the need for
intussusception. The creation of nipple valves is by far the most technologically demanding
of all the continence mechanisms, and it is associated with the highest complication and
reoperation rates. There exists a significant learning curve before the surgeon achieves
reproducible and dependable results. For this reason, nipple valve construction should
probably not be chosen by the surgeon carrying out occasional construction of continent
pouches. Furthermore, it should be noted that in the past 2 decades we have seen the
introduction of numerous modifications of the original technique of Kock for construction of
a stable nipple valve. The singular reason for all of these modifications is the rather
disappointing long-term stability of the nipple valve in some patients. As a result, the group
at the University of Southern California has developed the T pouch, which uses a flap valve
(Stein et al, 1998). This procedure, which appears much simpler than the intussuscepted
nipple valve, has been used to create both a continence and an antireflux mechanism. Nipple
valve failure from slippage or valve effacement can be anticipated in 10% to 15% of cases
even in the hands of the best and experienced surgeons. In addition to slippage, nipple valves
are subject to ischemic atrophy. When this occurs, a new nipple valve must be fashioned
from a new bowel segment.
A final feature of stapled nipple valves is the potential for stone formation on exposed
staples. This was greatly lessened by the omission of staples at the tip of the intussuscepted
nipple valve, as suggested by Skinner and colleagues (1984). However, more proximal
staples occasionally erode into the pouch and serve as a nidus for stone formation. These
stones are usually manageable endoscopically with forceps extraction or else with
electrohydraulic or ultrasonic disintegration of the stone with subsequent forceps extraction
of the staple. Although exposed staples may serve as a nidus for stone formation, continent
urinary diversion in and of itself results in more urinary excretion of calcium, magnesium,
and phosphate as compared with ileal conduit diversion (Terai et al, 1995). Thus all patients
undergoing continent diversion are at an increased risk for the formation of reservoir stones.
The fourth major technique of continence mechanism construction is the provision of
a hydraulic valve, as in the Benchekroun nipple (1987). In this procedure a small bowel
segment is isolated, with subsequent reversed intussusception that effectively apposes the
mucosal surfaces of the segment. Tacking sutures are placed on a portion of the
circumference of the intussuscepted segment in order to stabilize the nipple valve while
allowing urine to flow freely between the leaves of apposed ileal mucosa. As the pouch fills,
hydraulic pressure closes the leaves, thereby ensuring continence. The premise of this
technique is that as the reservoir fills, the pressure within the valve would also increase,
resulting in continence. Concerns regarding stomal stenosis, especially in children, and nipple
destabilization have resulted in this procedure being largely abandoned (Sanda et al, 1995).
As a result, it is not discussed in this chapter.
General Procedural Methodology
During construction of the pouch, intraoperative testing for pouch integrity should always be
performed. The continence mechanism is also tested for ease of catheterization, as well as
continence after the pouch construction has been completed. The pouch is filled with saline,
the continence mechanism catheter is removed, and the pouch is compressed lightly to look
for points of leakage and to test the continence mechanism for its ability to contain urine.
Thereafter, the continence mechanism is catheterized to ensure ease of catheter passage. This
is an extremely important and crucial maneuver because the inability to catheterize is a
serious complication that will often result in the need for reoperation. In general, all
redundancy should be removed from the continence mechanism. It is often useful to secure
the reservoir to the anterior abdominal wall in a manner that prevents the reservoir from
migrating. This can prevent the development of a false passage or a kink, thereby facilitating
catheterization.
Postoperatively, the larger-bore catheter used for drainage of the pouch should be
irrigated at frequent intervals to prevent mucous obstruction. This can be performed at 4-hour
intervals by simple irrigation with 45 to 50 mL of saline. Less frequent intervals of irrigation
can be employed when the urine is totally diverted from the kidneys by means of long
indwelling stents. It is essential that as soon as possible the patient be taught how to self-
irrigate and what kind of regimen is required. This is performed to familiarize the patients
with the catheterization process, to reduce the work burden on the nursing staff, and to allow
for earlier discharge.
On the seventh postoperative day, a contrast study is performed to ensure pouch
integrity. Thereafter, ureteral stents may be removed if no leaks are demonstrated by imaging
studies. When it has been ascertained that the ureteral anastomoses and pouch are intact, the
suction drain is removed. The suprapubic tube (if employed) can also be removed at this
time, or it can be left in place until the patient is confident with self-catheterization. The
patient is taught to irrigate the tube traversing the continence mechanism at 4-hour intervals
and whenever any episode of intraabdominal pressure or discomfort is experienced. Once
these procedures are mastered and the patient is tolerating a regular diet, the patient can be
discharged. This usually occurs between hospital days 6 and 8.
The following represents a summary of common patient questions and everyday solutions:
What kind of catheter do I use? For nipple valves, a straightended 22- to 24-Fr tube;
for ileocecal plication, a 20- to 22-Fr coudé tip catheter; and for appendiceal
sphincters, a 14- to 16-Fr coudé tip catheter.
How do I carry my catheter? In a zipper-locked bag that can be placed in a women’s
purse or a man’s coat pocket.
How do I clean the stoma before catheterizing in a public facility? With a
benzalkonium chloride wipe, which can be purchased in individual foil-wrapped
packets.
How do I lubricate the catheter? By tearing off the end of an individual-use foil pack
of water-soluble lubricant and inserting the tip of the catheter into the pack.
What do I do with the stoma after catheterizing? Cover it with a bandage.
How do I clean my catheter after draining my pouch? By rinsing ordinary tap water
through the inside channel and over the outside surface before replacing it in its
zipper-locked bag.
In the case of ileal pouches, pouch capacity will initially be low (150 mL). Therefore the
frequency of catheterization will have to be significantly different in these individuals
compared with those with right colon pouches in which initial comfortable capacities will be
in excess of 300 mL. To ensure restful sleep, the smaller-capacity pouches may be managed
best with indwelling catheterization during sleeping hours.
General Care
Because all patients with catheterized pouches will have chronic bacteriuria, the problem of
antibiotic management should be discussed. Most authors would suggest that bacteriuria in
the absence of symptomatology does not warrant antibiotic treatment (Skinner et al, 1987).
The construction of an effective antireflux mechanism in these pouches may help protect
against clinical episodes of pyelonephritis, in contrast to patients with freely refluxing
conduits. Obviously, if clinical pyelonephritis does occur, antibiotic treatment should be
instituted. Episodes of recurrent pyelonephritis should be evaluated with radiography of the
pouch in order to diagnose failure of the antireflux mechanism or upper tract stone formation.
A condition termed “pouchitis” is manifested by pain in the region of the pouch along
with increased pouch contractility. It should be mentioned that this condition, although
infrequent, may result in temporary failure of the continence mechanism because of the
hypercontractility of the bowel segment employed for construction of the pouch. The patient
typically presents with a history of sudden explosive discharge of urine through the
continence mechanism (rather than dribbling incontinence), along with discomfort in the
region of the pouch. Appropriate antibiotic therapy will usually result in resolution of these
symptoms. It has been our experience that short courses of antibiotics are not usually
successful when treating pouch infections. This may be due to the larger amount of foreign
material in the form of mucus and sediment within intestinal pouches as opposed to the
bladder. Intestinal crypts may also serve as bacterial sanctuaries. Therefore whenever a pouch
infection is diagnosed, antibiotic therapy should be continued for at least 10 days.
Pyelonephritis will, of course, require longer courses of therapy.
Urinary retention is an infrequent but serious occurrence in catheterizable pouches. It
is most commonly seen with pouches whose continence mechanism consists of a nipple
valve. In these circumstances, when the chimney of the nipple valve is not near the
abdominal surface, the catheter may be misdirected into folds of bowel rather than into the
nipple valve proper, resulting in urinary retention. Pouch urinary retention represents a true
emergency, and the patient must seek immediate attention so that catheterization and
drainage by experienced personnel can be achieved promptly. The use of a coudé tipped
catheter may be helpful. Rarely, a flexible cystoscope will be necessary. After the immediate
problem has been resolved by emptying the pouch, a catheter should be left indwelling for 3
to 5 days to allow the edema and trauma to the catheterization portal to resolve. Before
discharge, the patient should be observed to successfully self-catheterize on multiple
occasions. The appropriate angle of entry should be taught to the patient until he or she is
comfortable with the use of the new catheter. In fact, the authors prefer to routinely use coudé
catheters with non–nipple valve pouches.
Intraperitoneal rupture of catheterizable pouches has been reported (Kristiansen et al,
1991; Thompson and Kursh, 1992; Watanabe et al, 1994). In general, these episodes are more
common in the neurologic patient when sensation of pouch fullness may be less distinct
(Hensle, personal communication; Mitchell, personal communication). Ruptures may also be
associated with mild abdominal trauma, such as a fall. In general, these patients require
immediate pouch decompression and radiographic pouch studies. For patients with large
defects, surgical exploration and pouch repair are required. If the amount of urinary
extravasation is small, and the patient does not have evidence of peritonitis, catheter drainage
and antibiotic administration may suffice in treating an intraperitoneal rupture. Patients
managed with this conservative approach require careful monitoring. If there is any sign of
progressive peritonitis, surgical exploration and repair is imperative. The authors have
successfully employed this nonoperative approach on patients with ruptured right colon
pouches.
Continent Ileal Reservoir (Kock Pouch)
This operation was first reported for use in urinary diversion by Kock and colleagues in 1982.
This report was singularly responsible for the renewed interest in continent diversion
procedures at that time. An outgrowth of the Kock procedure for continent ileostomy (Kock,
1971), the Kock pouch combined reasonably dependable techniques for ensuring urinary
continence and preventing reflux to the upper urinary tracts (nipple valves) with carefully
refashioned bowel that provided a lowpressure urinary reservoir. This procedure and the
similarly constructed T pouch are the only catheterizable continent diversions that preserve
the ileocecal valve. Skinner and his colleagues (1989, 1992) have carefully studied and
improved the technique over the years while amassing a prodigious experience with the
operation and its variants. The high complication rate and the technical difficulties involved
with constructing this reservoir have resulted in the procedure being abandoned by most
individuals. As a result, this procedure is not discussed further in this edition. Those
interested in a more detailed description should refer to previous editions of this text.
However, the construction of a Kock limb remains an important procedure for use in
repairing failed continence or reflux mechanisms and, as such, is described in more detail. It
is Skinner’s operative description that will be followed closely in this chapter.
Procedure. A 15- to 20-cm length of ileum is selected for creating the intussuscepted nipple
valve. The proximal 10 cm serve as the valve, and the distal 5 to 10 cm serve as the patch
(Fig. 86–4A). The distal length is chosen on the basis of the volume lost after resection of the
failed mechanism. Only 5 cm are necessary for the patch, but on some occasions the reservoir
itself may require augmentation. The middle 6 to 8 cm of the 10-cm segment are denuded of
mesentery by electrocoagulation. An Allis or Babcock clamp is advanced into the ileal
terminus, grasping the full thickness of the intussusceptum and inverting the ileum into the
pouch (see Fig. 86–4B). Using the TA-55 stapler, three rows of 4.8-mm staples are applied to
the intussuscepted nipple valve (see Fig. 86–4C). The distal six staples from each cartridge
are removed before staple application to ensure that the tip of the valve is free of staples.
Most authors suggest that the pin of the stapling instrument should always be kept in place so
that staple misalignment does not occur. This will result in a pinhole puncture site at the base
of the nipple valve that should be oversewn with absorbable suture material to prevent fistula
formation after staple application is complete. The nipple valve is then fixed to the back wall
of the patch by one of two stapling techniques (Skinner et al, 1984). A small buttonhole may
be made in the back wall of the ileal plate so that the anvil of the stapler can be passed
through the buttonhole and advanced into the nipple valve before application of the fourth
row of staples (see Fig. 86–4D). If this is carried out, the buttonhole is oversewn afterward
with absorbable material. Alternatively, the anvil of the stapler can be directed between the
two leaves of the intussuscipiens and the fourth row of staples used to fix the inner leaf of the
nipple valve to the pouch wall (see Fig. 86–4E).
Some authors including Skinner and colleagues (1989) suggest the use of an
absorbable mesh collar to anchor the base of the nipple valve. If a collar is used, a 2.5-cm
wide strip of absorbable mesh is placed through an additional window of Deaver at the base
of the nipple valve. The mesh strip is fashioned into a collar and sewn to the base of the patch
with seromuscular sutures of absorbable material (see Fig. 86–4F and G). The patch is then
sewn to the reservoir.
Double T Pouch
As indicated earlier, many surgeons have abandoned the Kock pouch largely due to the
technical difficulties of creating the continence and antireflux mechanisms, as well as the
high complication rates associated with them. This should not be viewed as a condemnation
of the pioneering work of Kock and his colleagues. Without their initial efforts, many of the
procedures described in this chapter would never have come into being. Rather, this
represents the natural evolution of surgical techniques.
The group at the University of Southern California modified a technique described by
Abol-Enein and Ghoneim (1993, 1994) to create a novel continence mechanism created
entirely from ileum (Bochner et al, 1988). Abol-Einein and Ghoneim described a technique
that created an extramural serosal tunnel into which the ureters were implanted. This
extramural trough created a pseudotunnel that prevents reflux but in theory is associated with
a lower risk of obstruction than either the Goodwin (1958), Leadbetter (1961), or LeDuc and
colleagues’ (1987) techniques of direct transmural ureteral implantation. Stein and colleagues
(1998) first reported on the use in a neobladder of a tapered ileal segment implanted into a
serosal trough as the antireflux mechanism. In 1999 they reported on their adaptation of the
technique to the ileal-anal reservoir, and in 1999 they presented their early experience with a
double T pouch as a replacement for the Kock pouch at the meeting of the American
Urological Association (Stein et al, 1999a). It was published elsewhere (Stein and Skinner,
2001) and is the technique presented in this section.
Procedure. A 70-cm segment of terminal ileum is isolated 15 to 20 cm from the
ileocecal valve at the line of Treves. The proximal isoperistaltic 10- to 12-cm segment is
isolated and will serve as the antireflux mechanism. The distal 12- to 15-cm segment is
isolated and rotated in an antiperistaltic fashion and will create the cutaneous continence
mechanism (Fig. 86–5A and B). A short 2- to 3-cm mesenteric incision is made to isolate the
proximal limb, and a 4-cm incision is made for the distal limb, thereby preserving the major
vascular arches. The proximal and distal segments can vary in length, depending on ureteral
length and the thickness of the anterior abdominal wall. The middle 44 cm of ileum are
folded in a W with each limb measuring 11 cm.
The afferent antireflux mechanism is created by opening the windows of Deaver
between the vascular arcades along the distal 3 to 4 cm. The efferent continence mechanism
is created by opening the proximal 7 to 8 cm of vascular arcades (antiperistaltic) (see Fig. 86–
5C). One-fourth-inch Penrose drains are then placed in each window of Deaver to facilitate
passage of the 3-0 silk horizontal mattress sutures that are used to approximate the serosa of
the corresponding 11-cm limbs of the W (see Fig. 86–5D). The 3- to 4-cm anchored portion
of the proximal limb is then tapered over a 30-Fr catheter, and the 7- to 8-cm anchored
portion of the efferent limb is tapered over a 16-Fr catheter. In both instances, tapering is
performed with a gastrointestinal anastomosis (GIA) stapler (the staples will not be in contact
with urine). Care must be taken in the efferent limb to create a gradual taper so that the
catheter does not hit a false cul-de-sac (see Fig. 86–5E). The portions of the 11-cm W limbs
not forming the troughs are then sutured together with a running 3-0 polyglycolic acid
(PGA). The bowel is now incised along its antimesenteric border in the portion where the
serosal trough exists and in close proximity to the medial PGA suture lines when beyond the
two limbs
Figure 86–4. A, A 15-cm segment of terminal ileum is isolated and opened along its antimesenteric wall. The proximal 10 cm will serve asthe continent intussusception and the distal 5 to 10 cm, the patch. The size of the patch will vary according to the size of the excisedsegment. B, An Allis or Babcock clamp is advanced into the ileal terminus, the full thickness of the intussuscipiens is grasped, and it isprolapsed into the pouch. C, Three rows of 4.8-mm staples are applied to the intussuscepted nipple valve using the TA-55 stapler. D, Asmall buttonhole is made in the back wall of the ileal plate to allow the anvil of the TA-55 stapler to be passed through and advanced intothe nipple valve. A fourth row of staples is applied. The figure shows two valve mechanisms, but in this instance there would be only one.E, The anvil of the stapler can be directed between the two leaves of the intussuscipiens and the fourth row of staples applied in thismanner. Two valve mechanisms are shown, but in this instance there would be only one. F, A 2.5-cm wide strip of absorbable mesh isplaced through additional windows of Deaver at the base of each nipple valve. The mesh strips are fashioned into collars. G, The collarsare sewn to the base of the pouch and the ileal terminus with seromuscular sutures. (A, From Ghoneim MA, Lock NG, Lycke G, El-Din AB.An appliance-free, sphincter-controlled bladder substitute. J Urol 1987;138:1150–4; B to G, from Hinman F Jr. Atlas of urologic surgery.Philadelphia: WB Saunders; 1989.)
Figure 86–5. A, A 70-cm segment of terminal ileum is isolated 15 to 20 cm from the ileal cecal valve. B, A proximal 10-cm segment isisolated and rotated toward what will become the reservoir in an isoperistaltic direction. The distal 12 to 15 cm is rotated toward thereservoir in an antiperistaltic direction. C, The windows of Deaver are opened to allow the walls of the W reservoir to be apposed behindthe valve mechanisms. Penrose drains are passed to guide suture passage. D, Horizontal mattress sutures of 3-0 silk are passed througheach window. The distal continence mechanism is longer than the proximal antireflux mechanism. E, The proximal and distal mechanismsare tapered with a metal gastrointestinal anastomosis stapler. F, The bowel is incised along its antimesenteric border, where it will overliethe 2 Ts. Distal to the Ts, the bowel is incised close to the approximated limbs of the reservoir.
Figure 86–5, cont’d.G, The ostia of the valves are secured to the bowel wall with interrupted absorbable sutures. The two flaps of ileumare closed over the Ts with running absorbable sutures. H, The back wall of the reservoir is closed with running absorbable sutures. I, Thelateral walls are folded medially, and the construction is completed with running absorbable sutures. (From Stein JP, Buscarini M, DeFilippoRE, Skinner DG. Application of the T pouch as an ileo-anal reservoir. J Urol 1999;162:2052–3.)
see Fig. 86–5F). The incised mucosa is then closed in two layers with a running suture of 3-0
PGA. The incised intestinal flaps (antimesenteric incision) are then sutured to each ostium
with interrupted sutures of 3-0 PGA, and the two ileal flaps are sutured over each segment
with a running suture of 3-0 PGA (see Fig. 86–5G). The reservoir is then closed side to side
in two layers with 3-0 PGA, thereby completing its construction (see Fig. 86–5H and I). The
ureters are anastomosed end to side over stents to the proximal limb, which has been closed
with a running absorbable Parker-Kerr suture. The efferent limb is then brought to the
abdominal wall stoma site, and redundant ileum is resected. The stoma is then matured with
the reservoir lying immediately adjacent to the anterior abdominal wall.
Postoperative Care and Comments. Postoperative care is similar to that for any
continent reservoir. Stein and colleagues (1999b) initially reported on nine patients, seven of
whom could be evaluated for continence and long-term complications and two of whom died
of disease during follow-up. All seven patients achieved immediate continence on catheter
removal. However, two patients later became incontinent, with one requiring surgical
revision. None of the nine patients experienced an early postoperative complication. One
patient developed a reservoir stone 9 months after surgery that was removed endoscopically
without sequelae. Pouch capacity was excellent: 400 to 700 mL (average 500 mL). There was
no radiographic evidence of reflux in any patient, and there was no upper tract deterioration.
This operative procedure appears to have many advantages over the Kock pouch, and good
long-term continence results have been reported. Marino and colleagues (2002) reported on
18 patients with 1-year follow-up with 100% day and night continence and no delayed
complications. Seifert and colleagues (2008) recently published their results on 19 patients
who underwent ileal double T pouch construction between 1998 and 2006. Five patients
(26%) had complications related to the diversion, some of which required surgical revision.
Three patients (16%), all of whom had body mass indices of greater than 30, suffered
necrosis of the efferent loop and subsequent cutaneous fistulas. Sixteen (84%) eventually
developed both daytime and nighttime continence. Although a mild acidosis was common in
this group, no urinary reflux was detected and no patients suffered significant upper tract
deterioration or pyelonephritis.
Mainz Pouch I
The catheterizable Mainz pouch has undergone considerable modification over the years
(Thuroff et al, 1985; Stein et al, 1995; Lampel et al, 1996; Gerharz et al, 1997). The main
impetus for these changes has been the difficulty encountered with the nipple valve
mechanism. The operative technique has now been modified to use the intact ileocecal valve
as a means of further stabilizing the intussusception (Thuroff et al, 1988). This procedure is
described here without further reference to earlier prototypes.
Procedure. The catheterizable Mainz pouch varies somewhat from the orthotopic, voiding
Mainz pouch. First, a longer segment of bowel is used. A 10- to 15-cm portion of cecum and
ascending colon is isolated along with two separate, equally sized limbs of distal ileum and
an additional portion of ileum measuring 20 cm (Fig. 86–6A). The entire colon and distal
segments of ileum are spatulated, taking care to preserve the ileocecal valve. These three
bowel segments are folded in the form of an incomplete W and their posterior aspects sutured
to one another to form a broad posterior plate (see Fig. 86–6B). A portion of the intact
proximal ileal terminus is freed of its mesentery for a distance of 6 to 8 cm, and
intussusception of the segment is achieved. Two rows of staples are applied on the
intussusceptum itself (see Fig. 86–6C).
Thereafter, the intussusceptum is led through the intact ileocecal
Figure 86–6. A, A 10- to 15-cm portion of cecum and ascending colon is isolated along with
two separate equal-sized limbs of distal ileum
and an additional portion of ileum measuring 20 cm. B, A portion of the intact proximal ileal
terminus is freed of its mesentery for a
distance of 6 to 8 cm. C, The intact ileum is intussuscepted, and two rows of staples are taken
on the intussuscipiens itself. D, The
intussuscipiens is led through the intact ileocecal valve, and a third row of staples is taken to
stabilize the nipple valve to the ileocecal
valve. E, A fourth row of staples is taken inferiorly, securing the inner leaf of the
intussusception to the ileal wall. F, A button of skin is
removed from the depth of the umbilical funnel, and the ileal terminus is directed through this
buttonhole. Excess ileal length is resected,
and the ileum is sutured at the depth of the umbilical funnel. (A, From Thuroff JW, Alken P,
Hohenfellner R. The MAINZ pouch [mixed
augmentation with ileum ‘n’ cecum] for bladder augmentation and continent diversion. In:
King LR, Stone AR, Webster GD, editors. Bladder reconstruction and continent urinary
diversion. Chicago: Year Book Medical Publishers; 1987. p. 252; B to F, from Thuroff JW,
Alken P, Riedmiller H, et al. 100 cases of MAINZ pouch: continuing experience and
evolution. J Urol 1988;140:283–8.)
valve and a third row of staples is applied to stabilize the nipple valve to the ileocecal valve
(see Fig. 86–6D). Finally, a fourth row of staples is applied inferiorly, securing the inner leaf
of the intussusception to the ileal wall (see Fig. 86–6E).
Ureterocolonic anastomoses are created at the apex of the reservoir, which is then folded on
itself in a side-to-side fashion to complete pouch construction. The entire pouch is rotated
cephalad so as to bring the ileal terminus to the region of the umbilicus. A small button of
skin is removed from the depth of the umbilical funnel, and the ileal terminus is directed
through this buttonhole (see Fig. 86–6F). The pouch is secured to the posterior fascia with
interrupted absorbable sutures, and the ileal terminus is sewn similarly to anterior fascia.
Excess ileal length is resected, and the ileum is sutured at the depth of the umbilical funnel
with interrupted absorbable sutures.
Postoperative Care and Comments. No specific differences in postoperative care or
complications associated with the Mainz pouch need to be addressed. Initial pouch capacities
are higher than in the Kock or T pouch. Final mean capacity averaging greater than 600 mL
has been reported. Pouch pressures are 23 cm H2O at half capacity and 31 cm H2O when the
pouch is full. Contraction waves beginning at 50% pouch fullness can be recorded at an
amplitude of 12 cm H2O. Thus this pouch seems to produce a reasonably low-pressure
urinary reservoir, although the pressures are not as low as those achieved with the use of
small bowel alone.
Recently, the 10- and 12-year experiences with the Mainz pouch and the variations created by
its developers were presented (Stein et al, 1995; Lampel et al, 1996). Between 1983 and
1994, 440 patients underwent a Mainz I operation in two urology departments, Mainz and
Wuppertal. Continence mechanisms varied: in 146 cases the appendix was used as the
continence mechanism; in 270 patients the intussuscepted nipple was used as the continent
stoma; in 14 patients a submucosal, seromuscular bowel flap was employed; and in 10
patients a submucosal full-thickness bowel flap was used. The early complication rate was
12% and included mechanical ileus requiring open revision in 9 patients (1.6%), pouch
leakage requiring revision in 5 patients (0.9%), wound dehiscence in 4 patients (0.7%), and
fatal pulmonary emboli in 4 patients (0.7%).
The late complication rate was 37% and was predominantly attributable to the pouch. Stomal
failure requiring open revision occurred in 45 patients (8%) and was directly related to the
continence mechanism. Only 2 of 146 patients (1.4%) with an appendiceal continence
mechanism were incontinent, but stomal stenosis occurred in 21%. The developers of this
procedure were innovative in their attempts to bring the incontinence rate down to an
acceptable level. To this end they tried multiple techniques, with variable success: an
alloplastic stoma (4/4 incontinent); sutured intussusception (8/8 incontinent); stapled
intussusception (5/22, 23% incontinent); and stapled ileocecal intussusception (10/204, 4.9%
incontinent). The stapled ileocecal intussusception described previously is the current
recommendation, and the long-term incontinence rate among the patients undergoing the
stapled nipple valves was reduced to 10%. Other late complications included the need for
ureteral reimplantation in 28 patients (4.9%) and stomal stenosis in 29 patients with an ileal
nipple (11.7%) and in 17 patients with an appendiceal stoma (14.7%).
Calculus formation in the pouch occurred in 38 patients (6.8%), resulting in 36 percutaneous
procedures. Despite the loss of the terminal ileum, no significant decrease in serum vitamin
B12 levels has been reported and no patient has developed a macrocytic anemia or neurologic
symptoms. However, 25% of patients are on oral alkalinization to avoid metabolic acidosis.
Since its inception, the overall complication rate for this procedure has been considered high
(31%). However, as Stein and colleagues (1995) pointed out, 50% of the complications were
manageable with percutaneous techniques. Additionally, since 1988 the incontinence rate has
been only 3.2% and less than 2% in patients with an appendiceal mechanism. Gerharz and
colleagues (1997) from Marburg, Germany, reported their single-institution experience with
the Mainz I ileocecal pouch. From 1990 to 1996, 202 consecutive patients underwent
continent diversion, 96 with a submucosally embedded in-situ appendix and 106 with an
intussuscepted ileal nipple. All patients had an umbilical stoma. In 172 of 200 patients (85%),
no stomal complications occurred. In 17 of 96 patients (18%) with an appendiceal stoma, 23
revisions were performed for stomal stenosis. In contrast, only 13 of 106 patients (12%) with
an intussuscepted ileal nipple developed problems with their stoma.
However, these patients required more invasive, major procedures for correction, whereas
those with an appendiceal stenosis could usually be repaired with a minor procedure. Three
patients with an ileal nipple (3%) developed pouch calculi, whereas none of the patients with
an appendiceal continence mechanism developed stones. As a result, the authors concluded
that the appendix, when available, should be the intestinal continence mechanism
of choice.
We share the enthusiasm for the use of the appendix as a continence mechanism. In our
experience it has also been a reliable technique that is easy to perform. It has been our
tendency in constructing right colon pouches employing an appendiceal continence
mechanism to use the entire right colon inclusive of the hepatic flexure to form the reservoir,
thereby preserving more terminal ileum. This has the theoretical advantage of fewer
metabolic complications, but the Mainz group has not reported significant metabolic
problems.
The introduction of the more reliable appendiceal continence mechanism has greatly
increased the acceptance of the Mainz I procedure. The Mainz group has also developed two
new techniques for construction of a Mitrofanoff, or appendiceal, type tube for use in patients
whose appendix is either unsuitable or absent (Lampel et al, 1995a, 1995b; Lampel and
Thurhoff, 1998). Both techniques use a small-caliber conduit fashioned from the large
intestine in the region of the cecum. One technique uses a fullthickness tube lined by mucosa
(Fig. 86–7) and the other a seromuscular tube lined by serosa (Fig. 86–8). Both techniques
appear to be successful, although the full-thickness tube was associated with a lower
complication rate and a higher success rate in their initial report (Lampel et al, 1995b). With
longer follow-up, the authors have observed a similar success rates with both tubes; 93% of
the patients (25 of 27) with a seromuscular tube and 92% of the patients (22 of 24) with a
bowel wall tube were continent day and night (Lampel and Thurhoff, 1998). The authors
believed that either tube was reliable and that each had its own unique advantages and
disadvantages. In general, the full-thickness bowel wall tube was more adaptable, owing to
the ability to create a longer tube. However, this came at the expense of a more tenuous blood
supply. The decreased distal blood supply might be improved by creating a wider base on the
tube. This could, however, make taenial implantation more difficult. The seromuscular tube
was equally reliable but could only be anastomosed to the umbilicus, owing to the short adit
tube. Either tube was believed to be indicated as a continence mechanism in the Mainz I
pouch when the appendix was not available or as a continence mechanism for reservoirs
created from other large intestinal segments. Either
Figure 86–7. A to C, A full-thickness tube lined by mucosa is fashioned over an 18-Fr Foley
catheter for tunneled reimplantation. The tube
is closed with a running 3-0 absorbable suture. For longer tubes, the authors advise a wider
base to prevent distal ischemia. The continence
mechanism is created by placing the tube into the adjacent taenial trough. (From Lampel A,
Hohenfellner M, Schultz-Lampel D, Thuroff JW. In-situ tunneled bowel flap tubes: two new
techniques of a continent outlet for Mainz pouch cutaneous diversion. J Urol 1995;153:308–
15.)
technique could be used as a salvage procedure when another primary continence mechanism
had failed. Another novel Mitrofanoff continence mechanism was described by Montie
(1997), who conceived of a procedure in which a 2- to 3-cm segment of terminal ileum is
isolated on its blood supply (Fig. 86–9A). The width of the segment was chosen to
correspond to the circumference of the tube to be created. Once isolated, the segment is
opened near one of its mesenteric junctions to create a longitudinal reconfiguration (see Fig.
86–9B and C). The tube is then closed with a running 3-0 absorbable suture (see Fig. 86–9D).
It can now be used for a Mitrofanoff implant. When longer tubes are necessary, two adjacent
segments can be isolated, reconfigured, and joined together (see Fig. 86–9E and F).
Although originally described in dogs, the authors have used this technique in humans
without complication. Montie (1997) reported on a high rate of stomal stenosis in dogs, but
this may have been secondary to infrequent catheterizations. Stomal stenosis has not occurred
in our limited series of patients. Other groups have used tapered ileum to create a tunneled
access into the right colon (Fig. 86–10) (Woodhouse and MacNeily, 1994; Hampel et al,
1995). Using tapered ileum for this purpose has the advantage of a blood supply independent
of the reservoir and no length restrictions while having the disadvantage of further limiting
intestinal absorptive surface.
Wiesner and colleagues (2007) recently compared their longterm results in 458
patients who underwent Mainz I pouch construction. The anastomosis was made using a
submucosal tunnel in 809 renal-ureteric units and using a serosa-lined extramural tunnel in 74
units. At 17 months postoperatively they found a significantly higher occurrence of
anastomotic obstruction in the submucosal tunnel group compared with the extramural group
(7.3% vs. 4.1%, respectively). Importantly, they found a much higher rate of obstruction in
patients with previously dilated upper tracts (14%) or with a history of neurogenic bladder
(17%). No significant deterioration of the upper tracts was identified. In another comparison
of patients with a Mainz I pouch, Wiesner and colleagues (2006) reported on 800 patients
with almost 8 years of follow-up. Overall continence was approximately 93%. Stomal
stenosis occurred in 23.5% of patients with a submucosally embedded in-situ appendix,
whereas stenosis was reported in 15.3% of patients with intussuscepted ileal nipple valves.
Rates of calculi formation were the reverse: 10.8% incidence in patients with an ileal nipple
valve and only in 5.6% of patients with an appendix stoma. Ischemic degeneration of the
continence mechanism occurred almost three times more often in the appendiceal group.
Right Colon Pouches with
Intussuscepted Terminal Ileum Additional pouches using nipple valve technology for the
continence mechanism include those right colon pouches in which intussusception of the
terminal ileum and ileal cecal valve is employed. As such, they are variations on the
continent cecal reservoir initially described by Mansson (1987) that employ an intact cecal
segment. These three pouches are the Le Bag (Light and Scardino, 1986), Duke pouch
(Webster and King, 1987), and UCLA pouch (Raz, personal communication, 1989). These
surgeries differ from each other only by a few features mainly related to the technique
employed for stabilizing the nipple valve. Unless the appendix is being used as a continence
mechanism, appendectomy must be performed in all cases because an in-situ appendix would
serve as a nidus for infection and abscess formation. These operations were described in
detail in the prior edition of this text. Since then, no new modifications to these procedures
have been reported, and they are not further described here. The reader is referred to the prior
edition of this text for an in-depth description of these operations.
Indiana Pouch
The concept of using the buttressed ileocecal valve as a dependable continence mechanism
that can withstand the trauma of intermittent catheterization was first reported by Rowland
and colleagues (1987) from Indiana University. This operation, which involved the partial
spatulation of the cecal segment and attachment of an ileal patch, represented major
contributions to the original ileocecal reservoir as described by Gilchrist and colleagues
(1950), in which the intact bowel reservoir was employed and no attempt was made to
strengthen the ileocecal valve. Originally, strengthening the ileocecal valve consisted of a
double row of imbricating sutures taken to the entire ileal segment (Rowland et al, 1985,
1987). It soon became apparent that this was necessary only in the region of the
ileocecal valve. “Neourethral” pressure profiles showed that the continence zone was
confined to the region of the reconfigured ileocecal valve (Bejany and Politano, 1988). The
remaining “neourethra” could be tapered and brought through an abdominal or perineal
stoma. At Indiana University, as well as other institutions, it became clear that the concept of
marsupializing only a portion of the ascending colon segment left enough peristaltic integrity
in the cecal region to generate pressures sufficiently high to overcome the continence
mechanism in some patients. A number of groups contributed to the concept of using the
entire right colon or more, marsupializing the entire structure and refashioning it in a
Heineke-Mikulicz configuration (Lockhart, 1987; Bejany and Politano, 1988; Benson et al,
1988; Rowland, personal communication, 1989). These variations have been entitled the
Florida pouch (Lockhart, 1987) and the University of Miami pouch
(Bejany and Politano, 1988). However, they represent relatively minor variations on the
theme of the Indiana pouch.
Procedure. The Indiana pouch, in its present form, involves isolating a segment of terminal
ileum approximately 10 cm in length along with the entire right colon to the junction of the
right and middle colic artery blood supplies (Fig. 86–11A). After bowel continuity is re-
established, appendectomy is performed and the appendiceal fat pad obscuring the inferior
margin of the ileocecal junction is removed by cautery (see Fig. 86–11B). The entire right
colon is opened along its antimesenteric border, and ureteral-taenial implants are fashioned
(see Fig. 86–11C). The ileocecal junction is buttressed according to various reported
techniques. Using nonabsorbable sutures, interrupted Lembert sutures are taken over a
distance of 3 to 4 cm in two rows for the double imbrication of the ileocecal valve as
described at Indiana University (see Fig. 86–11D). The second row of sutures should attempt
to bring the opposite mesenteric edges of ileum together, usually over a 12- to 14-Fr catheter.
These two rows of sutures should be placed approximately 8 mm from one another, and the
initial suture in each row may be taken in a purse-string fashion around the cecal margin as
well. Alternatively, the University of Miami group suggests placing purse-string sutures in
the same ileal region (Bejany and Politano, 1988). Finally, the Tampa group suggests
placement of apposing Lembert sutures on each side of the terminal ileum (see Fig. 86–11E).
The remaining ileum can be tapered over the catheter and excess ileum removed with a
stapling technique (see Fig. 86–11F).
It is important to carry out the imbrication while the cecal reservoir is still open (Rowland,
1996) so that the gradual closure of the ileocecal valve can be closely observed. The pouch is
then closed in a Heineke-Mikulicz configuration with a running absorbable suture. Ureteral
stents and a suprapubic tube are taken through a stab wound in the pouch and led through the
right lower abdominal quadrant. The pouch is rotated so as to bring the ileal neourethra as
close as possible to the selected stoma site. A fingerbreadth-width skin button is transected
along with a similar button from the anterior and posterior fascia. The ileal neourethra is
advanced between bundles of the rectus muscle through the stoma, and excess ileum is
transected. The ileal edges are sewn to skin with interrupted sutures so as to create a flush
stoma. In addition to the differences in the technique of ileocecal valve imbrication, both the
University of Miami and the Florida pouches differ in the amount of colon used. The entire
ascending colon and the right third or half of the transverse colon is isolated along with 10 to
12 cm of ileum. The entire upper extremity of the large bowel is mobilized laterally in the
fashion of an inverted U (Fig. 86–12A). The medial limbs of the U are sutured to one another
after the bowel is spatulated (see Fig. 86–12B). The bowel plate is then closed side to side
(see Fig. 86–12C). This inverted-U closure, however, is exactly the same as a Heineke-
Mikulicz reconfiguration.
Recent modifications to the Indiana reservoir allow for more rapid construction and a lower
complication rate (Rowland, 1996). The modifications incorporate the use of metal staples to
create the efferent limb and absorbable staples to fashion the reservoir. The concept of using
a metal GIA stapler to fashion the efferent limb was first introduced by Bejany and Politano
(1988). Carroll and Presti (1992) reported on the urodynamic features of the stapled and
plicated terminal ileum and found that the stapled limb performed equally well and was easier
to construct. The use of absorbable staples to create this and other types of reservoirs is
described later in the chapter.
Postoperative Care and Comments. The postoperative care of the patient with an Indiana
pouch or its variants is not substantially different from that used in patients with other right
colon catheterizable diversions. In early reports, Rowland recommended discharging the
patient with the suprapubic tube in place until readmission to the hospital 3 weeks later for
tube removal and instruction in self-catheterization. In the current medical climate, which
places a premium on outpatient procedures, tube removal and catheterization instruction is
now an ambulatory procedure at most institutions including Indiana University (Bihrle,
1997).
Average pouch capacities of 400 to 500 mL have been reported by the Indiana group
(Rowland et al, 1987). Combining the partially and totally spatulated bowel procedures, this
group reports a reoperation rate of 26%. Overall continence rates of 93% were achieved.
Elegant urodynamic studies were conducted in Indiana pouch variants by Carroll and
colleagues (1989). They found only 86% of patients totally continent in a small series.
However, their pouch capacities exceeded 650 mL, and peak contractions of 47 cm H2O
were recorded at capacity. The last 81 patients operated on by Rowland underwent
construction of a stapled efferent limb, and, in the last 20, the reservoir was created with
absorbable staples (Rowland, 1996). The results in this group of patients were extremely
favorable.
Early pouch-related complications occurred in only three patients (3.7%). Two patients
experienced a pouch leak that was managed conservatively, and one patient required open
revision of the efferent limb owing to difficulty with catheterization.
Early complications not directly attributable to the pouch occurred in seven patients (8.6%).
Transient small bowel obstruction was the most common complication, occurring in four
patients (4.9%). One patient developed a superficial wound infection, and one patient
developed an abdominal abscess requiring surgery (1.2%). Late complications associated
with the reservoir occurred in 23 patients (28.4%). Incontinence occurred in six patients
(7.4%): In five patients it occurred secondary to high pouch pressures, whereas in the
remaining patient it was due to failure of the efferent limb. One of the former and the latter
patient underwent reoperation. Three patients (3.7%) developed stomal stenosis, and three
had parastomal hernias; all six underwent surgery. Pouch stones occurred in three patients:
One underwent open removal, and two had endoscopic extraction. Acute pyelonephritis was
seen in four patients (4.9%). The most common late complication not related to the pouch
was small bowel obstruction; this was seen in six patients and managed conservatively
in five. In summary, the early reoperation rate was 2.5% and the late reoperation rate 14.8%.
At 1 year, daytime and nighttime dry intervals of 4 hours or greater were achieved
in 98% of patients. Eighty-four percent of patients stated they slept through the night without
the need to awake for catheterization.
Similarly excellent results in the last 150 patients, 50 with at least 2.5-year follow-up, were
reported by Birhle (1997). The Florida pouch has been performed in more than 190 patients
(Helal et al, 1993). In 165 patients involving 326 ureters, no attempt was made to create a
tunneled reimplantation. This approach was adopted owing to the high incidence of ureteral
obstruction encountered in the first 30 ureters that were tunneled into a Florida pouch (4
patients, 13.3%). In the last 165 patients, 16/326 ureters (4.9%) developed primary
obstruction and were treated by percutaneous balloon dilation, nephrectomy, or observation.
Although no attempt is made to create an antirefluxing anastomosis, only 7.1% of the ureters
implanted demonstrated reflux. All are being followed conservatively, and no renal
deterioration has been demonstrated. In the initial 100 patients, a 7.2% reoperation rate was
reported (Lockhart, 1987). Although hyperchloremia was noted in 70% of patients, only four
patients (including those who had pre-existing renal disease) required treatment. Reservoir
capacities ranged from 400 to 1200 mL, and maximal reservoir pressures at capacity ranged
from 18 to 55 cm H2O (Lockhart, 1987). The reason why these authors experienced
such a high incidence of ureteral obstruction with both nontunneled and tunneled ureteral
colonic anastomoses is not clear. It is also surprising that only 23 of 326 ureters that were
anastomosed end to side had reflux.
The University of Miami group has reported on its results in 75 patients. Early complications
occurred in 19 patients (25%). Sixteen patients (21%) experienced late complications. The
success rate of the ureterocolonic anastomosis was 90%, and total continence occurred in
98.6% of patients. Average pouch capacities were 750 mL or higher, and end filling pressures
of 20 cm H2O were reported. No patient required alkali therapy.
The Indiana pouch remains one of the most reliable of all catheterizable reservoirs. It is
among the easiest to construct and has low short-term and long-term
complications.
Penn Pouch
The Penn pouch was the first continent diversion employing the Mitrofanoff (1980) principle
in which the appendix served as the continence mechanism. As mentioned earlier, this
operation enjoys the singular feature of affording a catheterizable continent diversion that can
be performed using techniques already present in the urologic armamentarium.
Procedure. Two techniques of appendiceal continence mechanisms have been reported.
Mitrofanoff reported excising the appendix with a button of cecum and reversing it on itself
before tunneled reimplantation (Mitrofanoff, 1980; Duckett and Snyder, 1986). Alternatively,
Riedmiller and colleagues (1990) left the appendix attached to the cecum and buried it into
the adjacent taenia by rolling it back onto itself. A wide tunnel is created in the taenia
extending 5 to 6 cm from the base of the appendix (Fig. 86–13). Windows are created in the
mesoappendix between blood vessels. The appendix is folded cephalad into the tunnel, and
seromuscular sutures are placed through the mesoappendix windows to complete the
tunneling. The tip of the appendix is amputated and brought to the selected stoma site. As
described by Duckett and Snyder (1986), an ileocecal pouch is created by isolating a segment
of cecum up to the junction of the ileocolic and middle colic blood supplies along with a
similar length of terminal ileum. These two structures are marsupialized on the
antimesenteric borders and sutured to one another in the form of a neotubularized pouch. The
superior margin of the pouch is sutured in a transverse fashion (all sutures being of
absorbable material). A button of cecum surrounding the origin of the appendix is
circumcised, and the resulting cecal aperture is closed with running absorbable suture. The
mesentery of the appendix is dissected carefully from the base of the cecum, thereby
preserving its blood supply. The appendix is then reversed on itself so that the cecal button
can reach the anterior abdominal wall and the tail of the appendix can be directed to the
taenia of the colon (Fig. 86–14). The appendiceal tip is obliquely transected and may be
spatulated. Then a tunneled appendiceal-taenial implantation is carried out. If additional
appendiceal length is required, the variation proposed by Burns and Mitchell (1990) of
creating a tube from the base of the cecum can be employed (see Fig. 86–3). Instead of
simply removing the appendix with a button of cecum before preparing it for tunneling, the
entire base of the cecum leading to the appendix can be resected in continuity with the
appendix by the application of the GIA stapler. The authors have found it helpful to spatulate
the distal tip of the appendix until it accommodates a catheter at least 12- to 14-Fr in
diameter.
Postoperative Care and Comments. Although not shown in Duckett’s surgical drawings, the
authors would suggest that a large-bore suprapubic tube be used to drain the pouch in the
early postoperative interval. The size of the catheter admitted by the appendiceal stump is
insufficient to allow for the passage of ureteral stents along with the 12- to 14-Fr catheter. In
addition, safe irrigation of mucous debris is best managed by a larger-bore catheter.
Many groups have used the Mitrofanoff principle owing to the simplicity and reliability of
the continence mechanism (Burger et al, 1992; Bissada, 1993; Sumfest et al, 1993;
Woodhouse and MacNeily, 1994; Hampel et al, 1995). Woodhouse and MacNeily (1994)
reported on a series of 100 patients who underwent surgery between 1985 and 1993. They
employed seven different catheterizable conduits into six different types of reservoirs.
Although they found the Mitrofanoff principle to be versatile and associated with a high
success rate (91% continence), the reoperation rate for tube complications was 33%. Sumfest
and colleagues (1993) affirmed the use of the appendix as the Mitrofanoff segment of choice.
They reported a continence rate of 96%. In their hands, late complications included difficulty
with catheterization in 10.6% and stomal stenosis in 19.1%. Urodynamic properties and
pouch capacities will be a function of the reservoir constructed. Most often, the appendix is
used in situ (Burger et al, 1992), and the right colon, either alone or with associated terminal
ileum (Mainz), serves as the reservoir. We have used the in-situ appendix with a
detubularized right colon reservoir and the native ileocecal valve as an antireflux mechanism
(refluxing ureters implanted end to side into terminal ileum). In our hands this has resulted in
an excellent success rate with no upper tract problems. The adequacy of the ileocecal valve as
an antireflux mechanism was also reported by Alcini and colleagues (1994). In their series,
however, the reservoir was not always detubularized and, as expected, upper tract
complications ensued owing to high reservoir pressures. This procedure is uniquely capable
of affording continent cutaneous diversion to the patient with short ureters because the
terminal ileum can be left long enough to reach high into the retroperitoneum.
Gastric Pouches
Pioneering animal experimentation demonstrated the feasibility of employing stomach as a
bladder patch or urinary reservoir (Sinaiko, 1956; Rudick et al, 1977; Leong, 1978). The use
of the stomach to create a urinary reservoir has theoretical and real advantages (Adams et al,
1988). First, electrolyte reabsorption would be greatly diminished by using this bowel
segment in the reservoir. This would potentially make the stomach the selected reservoir for
individuals with pre-existing metabolic acidosis or renal insufficiency. Hyperchloremic
acidosis would not be an anticipated problem; in fact, in addition to presenting a barrier
against the absorption of chloride and ammonium, the gastric mucosa secretes chloride ions
(Piser et al, 1987). Furthermore, in patients in whom shortening of the bowel may be
expected to lead to some degree of malabsorption, the use of stomach is an attractive
alternative.
The acid pH of the urine may also reduce the risk of bacterial colonization. Finally, when the
entire lower bowel has been irradiated, stomach tissue may provide healthy nonirradiated
tissue for use in performing continent diversion. Given these theoretical advantages, a
number of groups have initiated trials with gastric pouches and composite reservoirs in both
pediatric (Adams et al, 1988) and adult populations (Lockhart et al, 1993; Austin et al, 1997).
Procedure. A wedge-shaped segment of stomach with maximal width of 7 to 10 cm is
fashioned from the greater curvature. Care is taken not to extend the wedge through to the
lesser curvature to preserve vagal innervation and normal gastric emptying. The left
gastroepiploic artery is preferentially used as the blood supply for the isolated gastric wedge,
dividing the short gastric vessels from the more proximal artery up to the gastric fundus.
Alternatively, if there is a problem with the left artery, the right gastroepiploic vessel may be
employed, dividing the short gastric vessels to the level of the pylorus (Fig. 86–15A and B).
The stomach is then closed according to the surgeon’s preference. Neither
gastroduodenostomy nor gastrojejunostomy is mandatory unless the antrum of the stomach
has been used. The isolated wedge is refashioned into nearly a sphere by folding it back on
itself and suturing the edges together with running absorbable material.
Before pouch closure, one ureter is tunneled into the reservoir according to the surgeon’s
preferred antireflux technique. Contralaterally, proximal transureteroureterostomy is
performed. The contralateral distal ureter is used to create the continence mechanism.
The distal ureter is tunneled into the reservoir in a fashion similar to an appendiceal implant.
The free portion of the ureter can then be brought to the skin or to the introitus (or urethral
stump in males) to serve as a catheterization portal (see Fig. 86–15C). Alternatively, the
wedge of stomach can be incorporatedinto a reservoir composed of detubularized ileum
(Lockhart et al, 1993). In this procedure, an 11-cm long segment of stomach is isolated on the
right gastroepiploic blood supply (Fig. 86–16A). A 22-cm segment of ileum is then isolated,
opened along its antimesenteric border, and refashioned in a U shape (see Fig. 86–16B).
The edges of the stomach are then sutured to edges of the ileum with a running absorbable
suture of 2-0 PGA. This completes the reservoir. The ureters are tunneled into the stomach,
and a Mitrofanoff continence mechanism is created according to the preference of the
surgeon. For example, the group from the University of South Florida employs a tapered
segment of ileum (see Fig. 86–16C).
Postoperative Care and Comments. Adams and colleagues (1988) report mean pouch
capacities of 245 mL and end filling pressures averaging 35 cm H2O in a small patient
sample. Combining their experience of gastric continent diversion and gastrocystoplasty,
they report minimal mucus production: Only 3 of 13 patients required any irrigations, and the
majority maintained sterile urine. Urine pHs have ranged from 4 to 7, but no introital
ulceration from acid urine was reported. Three patients had minor elevations of serum
gastrin, and none of the continent divisions required reoperation. Leong (1978) has used
similar concepts in gastric pouch construction and has alluded to the creation of a voiding
pouch created from stomach as well.
The construction of reservoirs entirely from stomach has not seen widespread
acceptance. Rather, there has been greater use of stomach segments either for bladder
augmentation or as a portion of a reservoir (composite) either alone or with an in-situ
catheterizable tube fashioned from a portion of the stomach (Gosalbez et al, 1994; Carr and
Mitchell, 1996).
Goslabez and colleagues (1994) reported on 15 patients who received a gastric tube as
part of a composite gastric patch. Complications associated with the gastric patch and in-situ
tube included one each of early traumatic perforation of the tube, distal tube stenosis, and
mucosal redundancy. Two of these patients required reoperation. Peristomal skin irritation
from acid secretion occurred in two patients but was not considered severe. This is a more
frequent complication in other reports and has resulted in skin breakdown in some instances.
Over a 10-year period from January, 1985, to June, 1995, Carr and Mitchell (1996)
reported on the use of stomach in 12 patients. Seven had urinary reservoirs totally constructed
from stomach, whereas five had composite reservoirs. They report continence in all patients
but that the continence mechanisms have often required revision. Average bladder capacity
was 309 mL, and average compliance was 12.9 mL/cm H2O. When stomach is used as a
bladder augment or as a portion of a neobladder, a dysuria and hematuria syndrome has been
reported (Nguyen et al, 1993).
Austin and colleagues (1997) reported on nine adult patients with a mean follow-up of
54 months who underwent construction of a continent composite reservoir that was
gastroileal in seven and gastrocolonic in two. All nine patients had either preexisting
metabolic acidosis or a short bowel syndrome. All nine patients achieved electrolyte
neutrality, and postoperative serum pH was significantly improved (P < .01). Three patients
had a short-term serum gastrin elevation, which returned to normal during follow-up. One
patient developed skin ulceration at the stoma site.
The use of stomach has particular appeal in the pediatric population in which the
stomach’s unique acidbase properties can be used to not only reconstruct but also help correct
the metabolic problems that are often associated with the need for pediatric urinary
reconstruction (Carr and Mitchell, 1996). Although experience with use of the stomach
remains small, its various unique intrinsic properties as a reservoir suggest that its use will
continue in selected clinical situations.
QUALITY OF LIFE ASSESSMENTS
Extraordinarily few well-designed, prospectively conducted studies using validated
instruments exist to assess quality of life after continent cutaneous urinary diversion. In fact,
no randomized prospective trial has ever been conducted to compare the quality of life after
continent cutaneous diversion with either orthotopic continent diversion or incontinent
urostomy urinary diversion. Of those studies performed, there appear to be common flaws in
the study design and methods used that make any direct comparisons between continent and
incontinent diversions difficult (Gerharz et al, 2005).
In general, most quality of life studies show similar results between patients
undergoing both ileal conduit and cutaneous continent diversion, with the latter being
associated with improvements in stomal and urinary quality of life scores. In one of the few
prospective studies to compare quality of life after continent cutaneous and ileal conduit
diversion, Hardt and colleagues (2000) followed patients from the preoperative setting until 1
year after surgery. Using validated instruments tested for reliability, they found life
satisfaction improved over time in patients with continent cutaneous diversion, whereas it
worsened during the first year after ileal conduit construction. Using the Beck Depression
Inventory and Profile of Mood States in adults, Boyd and colleagues (1987) found that
patients choosing ileal conduit diversion had the lowest expectations of their quality of life.
Interestingly, they found the highest overall satisfaction among patients undergoing
conversion from ileal conduit to Kock cutaneous pouch diversion.
Mansson and colleagues (2002) found no difference in overall quality of life in men
undergoing continent cutaneous diversion when compared with orthotopic neobladder using
the FACT-BL and Hospital Anxiety and Depression Scale. In specific questions concerning
intestinal, urinary, and sexual function, patients with cutaneous reservoirs experienced less
difficulty with incontinence and emptied less frequently. Sexual function appeared better in
patients undergoing orthotopic bladder substitution, likely due to urethral preservation.
VARIATIONS IN OPERATIVE TECHNIQUE
Minimally Invasive Continent Cutaneous Diversion With
recent improvements in both laparoscopic and roboticassisted laparoscopic techniques,
radical cystectomy can now be performed in selected centers using these minimally invasive
techniques. The vast majority of centers performing minimally invasive cystectomy and
continent cutaneous diversion perform the urinary diversion via standard open techniques.
Turk has reported on an initial series of five patients who have undergone radical cystectomy
with bilateral pelvic lymphadenectomy and continent urinary diversion using a rectosigmoid
pouch performed with an intracorporeal laparoscopic technique. A bilateral stented antireflux
ureteral reimplantation was used, and laparotomy was not performed. Operative time was 7.4
hours with minimal blood loss and a mean hospital stay of 10 days. No intraoperative or
postoperative complications were encountered.
The complex nature of minimally invasive reconstructive surgery necessary in
continent cutaneous diversion has limited these procedures to select centers. In addition,
because of the prolonged time for return of postoperative bowel function, the benefits in
hospital stay routinely encountered after laparoscopic nephrectomy do not seem to exist when
urinary diversion is performed.
Conduit Conversion to a Continent Reservoir
The major indication for conversion of a functioning conduit to a continent urinary reservoir
is the patient’s desire for improved quality of life. Pow-Sang and colleagues (1992) reported
on conversion in 20 patients. Fifteen were converted from an ileal conduit, and one each from
a cecal conduit, ureterosigmoidostomy, cutaneous ureterostomy, sigmoid conduit, and a
suprapubic tube. In 14 of the 20 patients the conduit was discarded or used only as a patch to
a colonic reservoir. Renal units that were obstructed preoperatively were associated with a
71% failure rate. Metabolic acidosis was seen in 15 (75%) but was believed to be mild.
Pouch-related complications are, in general, a function of the reconstruction selected and
should not necessarily be higher in this setting. However, patient selection is important in
determining appropriate candidates for conversion.
The authors prefer to use the conduit in some form whenever possible. This strategy
was supported in a report on two patients by Oesterling and Gearhart (1990). The use of an
existing bowel segment has the potential to diminish metabolic sequelae and may result in a
lower complication rate. The form of continent reconstruction chosen will have to depend on
intraoperative findings, and no one procedure is more amenable than another. Before
undertaking conversion, the patient should be fully evaluated for disease recurrence, renal
functional status, urinary anatomy, hydronephrosis, intestinal length, and intestinal health.
Pahernik and colleagues (2004) have described the long-term outcomes of conversion
of 39 patients from conduit diversion to Mainz I pouch diversion. With a mean follow-up of
102 months, the most common complications were stomal stenosis and pouch calculi. Long-
term continence was achieved in 95% of patients.
Absorbable Stapling Techniques in Continent Urinary Diversion
The principle of bowel detubularization to increase reservoir capacity and diminish
the effects of peristalsis is a fundamental principle of all contemporary continent urinary
diversions. The process of detubularization and refashioning of the spatulated bowel segment
consumes at least 1 hour of operating time and is by far the most time-consuming and tedious
aspect of pouch construction. The use of absorbable staples has substantially reduced the time
required to fashion bowel reservoirs and has demonstrated short-term and long-term
reliability with respect to reservoir integrity and volume.
Bonney and Robinson (1990) first demonstrated the potential use of absorbable
staplers to substitute for conventional suturing of bowel reservoirs. These authors used a
bulky absorbable stapler (Polysorb staples in a TA Premium 55 stapler [US Surgical,
Norwalk, CT]) to construct an S pouch configuration in a canine ileal urinary pouch model.
Although the same stapler was used in humans by the authors in 1992 and by Cummings in
1995, its clinical use was never widely adopted because the bulky staple configuration
destroyed a significant portion of the bowel diameter, particularly when applied to the small
intestine. The fact that up to 20 costly staple cartridges were required to complete the closure
of a bowel reservoir further reduced the potential benefits of absorbable pouch construction.
A 75-mm GIA instrument (PolyGIA [US Surgical, Norwalk, CT]) that incorporates
substantially smaller absorbable staples was made available for clinical use in 1992. The
stapler delivers four rows of absorbable polylactic acid and PGA blend copolymer staples,
dividing the bowel between the second and third rows. Thus each staple line of the pouch has
a double, staggered, stapled closure. This device has enabled both the refashioning and
closure of bowel pouches to be performed with fewer staple applications and is strong and
watertight. Finally, the width of bowel sacrificed with the new instrument is appreciably less
than that with the older staple device. Several investigators have subsequently used the new
“absorbable” GIA stapler to construct catheterizable pouches and neobladders (Olsson et al,
1993; Montie et al, 1994, 1995; Olsson and Kirsch, 1995). However, it is important to note
that the absorbable PolyGIA staples must not overlap because this will result in the failure of
the staples to lock together. This is in direct contrast to metal staples, which are meant to
overlap to create anastomotic integrity. As a result of the need to prevent overlap of
absorbable staples, the reservoir construction procedures must be varied when using such
staples, as described next.
Surgical Techniques
Right Colon Pouch
In 1993 the authors described a technique using the absorbable GIA staplers to fully
detubularize and refashion large bowel (Olsson et al, 1993). The technique of colon pouch
construction described here incorporates the principles of bowel detubularization and
refashioning using absorbable staplers in a
simple “one-step” process.
The right colon and 10 cm of terminal ileum are mobilized by incising the peritoneum
along the white line of Toldt and along the base of the mesentery and are isolated using metal
GIA staplers (Fig. 86–17A). After bowel continuity is restored with standard metal GIA and
TA staplers, the distal staple line of the right colon is excised and the bowel lumen is irrigated
to remove residual enteric contents. Using electrocautery, a small opening (2 cm) is created
on the antimesenteric border of the cecum to fit the absorbable stapler. The distal open end of
the colon is aligned with the cecostomy by folding the right colon on itself, as depicted in
Figure 86–17B. The limbs of the absorbable GIA stapler are inserted into the distal open end
and into the cecostomy, and the stapler is fired along the antimesenteric line of the apposed
folded bowel (see Fig. 86–17C). It is necessary to evert the bowel to continue subsequent
staple applications. This may be achieved by placing Babcock clamps on each side of the
distal staple line (see Fig. 86–17D). A small incision at the junction of each staple line is
made to prevent overlap of the absorbable staple rows and to allow for the next staple
application. Because of this incision, there is often a short unstapled area at the junction
between each application of the stapler, requiring one or two simple figure-of-eight sutures of
2-0 absorbable material at each of these points. The last staple application traverses the apex
of the fold of bowel. In adults, three to four applications of the stapling device have been
required to construct the right colon pouch, whereas in children two to three staples suffice.
The appearance of the nearly completed pouch is illustrated in Figure 86–17E.
Once the generic right pouch has been fashioned, several options exist for ureteral
anastomosis and formation of a sphincter mechanism. These maneuvers may be approached
through the coalesced distal colon opening and cecostomy, which accesses
the interior of the pouch (see Fig. 86–17E). The opening permits appropriate stent placement
or inspection of a buttressed ileocecal valve. Any of the Mitrofanoff techniques described in
conjunction with the Mainz I procedure can be employed. Likewise, the terminal ileum can
be either stapled or plicated to create a continence mechanism. Once construction of a
continence mechanism and ureteral anastomoses has been performed, the opening can be
closed with a running 2-0 absorbable suture or the application of an absorbable TA stapler of
appropriate length.
Continent diversion procedures commonly employ the right colon or the cecum and
terminal ileum. The array of right colon pouches that can be facilitated by this technique
include all of the reservoirs described previously. Reservoirs using terminal ileum and cecum
such as the Penn Pouch and the Mainz Pouch can also be fashioned in this manner.
Stapled Sigmoid Reservoir
The same stapling maneuvers can be applied to create a reservoir constructed from the
sigmoid colon (Olsson and Kirsch, 1995). A portion of the sigmoid and descending colon
measuring approximately 35 cm is mobilized by incising the peritoneum along the white line
of Toldt. Once mesenteric windows have been created, the segment of colon is isolated using
metal GIA staplers (Fig. 86–18A). Restoration of bowel continuity is achieved with either
GIA, TA, or EEA staple devices.
Each of the metal stapled ends of the isolated colon are excised, and the bowel lumen
is irrigated. The isolated sigmoid is folded on itself in a U configuration, aligning both open
ends (see Fig. 86–18B). The absorbable GIA stapler is inserted into the open bowel ends and
fired along the antimesenteric line of the folded bowel (see Fig. 86–18C). Following the
procedure for bowel eversion as described earlier completes the reservoir. Again, usually two
or three applications of the stapler are required to complete the pouch, cutting each staple line
tip to avoid staple overlap.
After bowel reinversion, ureteral implants into the taenia can be carried out, using the
residual colon opening to assist stent passage. These stents and a suprapubic tube are led
through a separate stab wound in the pouch and brought through a lower abdominal wall stab
incision. A continence mechanism employing one of the Mitrofanoff variations is then
performed.
W-Stapled Reservoir
Montie and colleagues (1994) used the absorbable GIA stapler to construct ileal neobladders
in patients undergoing cystoprostatectomy.
A segment of ileum measuring 50 cm is divided with a standard metal GIA stapler 20 cm
from the ileocecal valve. The terminal ends of each limb of the isolated ileal segment are
closed with an absorbable TA-55 stapler, and the metal staple line is resected. The bowel is
aligned in a W configuration, and an enterotomy is made 10 cm from each end (Fig. 86–
19A). To assist
To assist closure of the enterotomy with a TA instrument (see Fig. 86–19, inset), the
enterotomy must be made midway between the mesentery and antimesenteric border. The
absorbable GIA device is inserted through the enterotomy and is activated. This maneuver
adjoins the two adjacent bowel segments. The enterotomy may be closed with the absorbable
TA-55 instrument or running absorbable suture, completing the distal segment of the W. The
middle and proximal segments are constructed similarly (see Fig. 86–19B).
Montie stresses that the segments of the W must be offset to avoid staple lines that overlap
each other. Exceeding a 3 to 6 cm overlap may result in bowel ischemia.
Postoperative Care and Comments
In the first 50 adult patients to undergo our absorbable stapling technique in right colon
pouch construction, with at least 7 years of follow-up, there have been no complications
attributable to absorbable staples. Similar results have been reported by Rowland (1996). In
the pediatric population, we have applied the absorbable stapler to continent urinary
diversion, as well as to bladder augmentation (Hensle et al, 1995). In the first 18 children
observed for up to 3 years, there have been no instances of pouch perforation or inadequate
pouch capacity and, to date, only one of the\ patients has developed a reservoir calculus.
Montie and colleagues (1994) used absorbable staplers to create W-stapled ileal
neobladders in 25 patients. Ileal pouch construction was performed in approximately 20
minutes, and functional aspects were comparable with bowel reservoirs constructed by
conventional suturing. Urodynamic evaluation at 6 months, however, documented a small-
capacity reservoir requiring augmentation enterocystoplasty in 3 of 25 patients (12%). Montie
and colleagues attributed this complication to either the size of the staples or reservoir
fibrosis secondary to foreign body reaction. It is conceivable that a similar situation would
arise when constructing a W-stapled T pouch.
The authors have used the absorbable stapler to construct both large and small bowel
reservoirs. In our experience, colonic pouches appear better suited for construction with the
absorbable stapler because of their relatively larger lumen. The introduction of stapling
devices delivering still smaller staples and automatic staple line sealing devices may prevent
the problems presently seen when ileal pouches are constructed with current technology.
SUMMARY
In summary, continent urinary diversion is now an accepted part of the urologic surgical
armamentarium. A wide array of surgical techniques exists to accomplish the desired goal of
creating a continent, stomal-free, nonrefluxing pouch. A paucity of long-term quality of life
studies exists to compare outcomes between continent cutaneous urinary diversion and ileal
conduit urinary diversion. Surgeons contemplating these forms of urinary diversion should
familiarize themselves with several of the techniques and the management of the most
common complications.