BLADDER SUBSTITUTION AND

URINARY DIVERSION

DR NAUMAN KHALID
 INDICATIONS

ABNORMALITIES OF BLADDER
• FUNCTIONAL
• e.g. Small capacity bladder

• ANATOMICAL
• Mallignant diseases of pelvis
 FIRST ANASTMOSIS
SMITH 1878

• PYELONEPHRITIS
• PERITONITS
• STRICTURING OF URETERAL ANASTOMOSIS
 TYPE OF PROCEDURE
• NEEDS AND PRIORITIES OF PATIENT
• FOR FUNCTIONAL OR MALLIGNANT PROBLEM
• GENERAL STATE OF PATIENT
• IRRADIATION
• GUT DISEASE
• SURGERY ON GUT
CHARACTERS OF IDEAL DIVERSION
APPROXIMATES NORMAL BLADDER
• NON REFLUXING
• LOW PRESSURE
• CONTINENT
• NON ABSORPTIVE
 CLASSIFICATION

• TYPE OF INTESTINE
• CONTINENT OR CONDUIT
 COUNSELLING OF PATIENT
• AVAILABLE OPERATIVE OPTIONS
• OBJECTIVES
• LIFESTYLE
• SEXUAL LIFE
• PLACE OF STOMA
• POTENTIAL COMPLICATIONS OF EACH
METHOD
 PREPARATION
• CAREFULL HISTORY
• CBC
• SERUM ELECTROLYTES
• UREA NITROGEN AND CREATININE
• UPPER TRACT IMAGING(USG,IVU,CT)
• CONTRAST IMAGING OF BOWEL SEGMENT
• COLONOSCOPY
• BLEEDING DISORDERS
 BOWEL PREPARATION (MECHANICAL)

Polyethylene Glycol–Electrolyte Solutions

Preoperative Diet Conventional Diet Polyethylene

Day Cathartic Glycol
3 Low residue Regular plus
plus
supplements supplements

2 Low residue Low residue

plus plus
supplements supplements

1 Clear liquids 45 mL Fleet Clear liquids 2 to 4 liters

Phospho-Soda (adults) or 25
at 7 AM and 1 mL/kg/hr × 2
PM (children)
 BOWEL PREPARATION(Antibiotic)
Preoperative Kanamycin Neomycin plus Neomycin plus
Day Erythromycin Base Metronidazole
3 1 g kanamycin orally
every 1 hour × 4, then 4
times/day

2 1 g kanamycin orally 4 1 g neomycin 4

times/day times/day plus 750
mg metronidazole
4 times/day
1 1 g kanamycin orally 4 1 g erythromycin base 1 g neomycin 4
times/day plus 1 g neomycin at times/day plus 750
1 PM, 2 PM, 11 PM mg metronidazole
4 times/day
 CAUTION

• Whole-gut irrigation is contraindicated in

patients with an unstable cardiovascular
system, patients with cirrhosis, patients with
severe renal disease, patients with
congestive heart failure, or those with an
obstructed bowel.
 Diversion Options
• Ileal Conduit – Urostomy

• Continent Diversion
– Heterotopic
• Cutaneous continent catheterizable urinary reservoir
– Orthotopic
• “neobladder”
 Indications for Orthotopic
Reconstruction

• No disease at prostate apex/bladder neck

• Adequate bowel segment available

• Adequate urinary sphincter in situ

• No compromise to cancer control

 Patient Selection
• Willing and able, highly motivated

• Able to self catheterize prior to surgery

• Good renal function

– Serum creatinine should be less than 2.0

• Age/obesity are NOT contraindications

 Surgical Considerations
• Cancer control is paramount

• All patients should be marked and consented

for an ileal conduit should disease dictate
more resection
Urologic Anatomy
Abdominal Anatomy
 Figure 80-4  Connell suture. The suture traverses the bowel from serosa to mucosa and then from mucosa to serosa on the
same side of the anastomosis. The suture is then placed on the opposite side of the anastomosis “outside in–inside out.” The
sequence is repeated until the two segments are approximated
Heterotopic Continent Cutaneous
Reservoir
Orthotopic Urinary Diversion
 Types of Common Orthotopic
Diversions
• Hautman
– Large capacity, spherical configuration with “W” of
ileum
• Studer
– Ileal with long afferent limb
• Kock
– Intessuscepted afferent limb
• T-Pouch
• MAINZ Pouch
 Hautman

Figure 108–3. Creation of the Hautmann ileal neobladder. A, A 70-cm portion of terminal ileum is selected. Note that the isolated segment of ileum
is incised on the antimesenteric border. B, The ileum is arranged into an “M” or “W” configuration with the four limbs sutured to one another. C,
After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethroenteric anastomosis is performed. The ureteral
implants (Le Duc) are performed and stented, and the reservoir is then closed in a side-to-side manner.

Copyright © 2003, Elsevier Science (USA). All rights reserved.

Studer
Figure 108–4. Creation of the ileal neobladder (Studer pouch) with an
isoperistaltic afferent ileal limb. A, A 60- to 65-cm distal ileal segment is
isolated (approximately 25 cm proximal to the ileocecal valve) and folded
into a “U” configuration. Note that the distal 40 cm of ileum constitutes
the U shape and is opened on the antimesenteric border while the more
proximal 20 to 25 cm of ileum remains intact (afferent limb). B, The
posterior plate of the reservoir is formed by joining the medial borders of
the limbs with a continuous, running suture. The ureteroileal
anastomoses are performed in a standard end-to-side technique to the
proximal portion (afferent limb) of the ileum. Ureteral stents are used and
brought out anteriorly through separate stab wounds. C, The reservoir is
folded and oversewn (anterior wall). D, Before complete closure, a
buttonhole opening is made in the most dependent (caudal) portion of
the reservoir. E, The urethroenteric anastomosis is performed. F, A
cystostomy tube is placed, and the reservoir is closed complete
Kock
• Figure -Kock ileal reservoir. A, A total of 61 cm of terminal ileum is
isolated. Two 22-cm segments are placed in a “U” configuration and
opened adjacent to the mesentery. Note that the more proximal 17-cm
segment of ileum will be used to create the afferent intussuscepted nipple
valve. B, The posterior wall of the reservoir is then created by joining the
medial portions of the U with a continuous running suture. C, A 5- to 7-cm
antireflux valve is created by intussusception of the afferent limb with the
use of Allis forceps clamps. D, The afferent limb is fixed with two rows of
staples placed within the leaves of the valve. E, The valve is fixed to the
back wall from outside the reservoir. F, After completion of the afferent
limb, the reservoir is completed by folding the ileum on itself and closing
it (anterior wall). Note that the most dependent portion of the reservoir
becomes the neourethra. The ureteroileal anastomosis is performed first,
and the urethroenteric anastomosis is completed in a tension-free,
mucosa-to-mucosa fashion.
T-Pouch
 MAINZ
Figure 108–8. Creation of the Mainz ileocolonic
orthotopic reservoir. A, An isolated 10 to 15
cm of cecum in continuity with 20 to 30 cm of
ileum are isolated. B, The entire bowel
segment is opened along the antimesenteric
border. Note that an appendectomy is
performed. C, The posterior plate of the
reservoir is constructed by joining the
opposing three limbs together with a
continuous running suture. D, An antireflux
implantation of the ureters via a submucosal
tunnel is performed and stented. E, A
buttonhole incision in the dependent portion
of the cecum is made that provides for the
urethroenteric anastomosis. Note that the
ureterocolonic anastomoses are performed
before closure of the reservoir. F, The
reservoir is closed side to side with a
cystostomy tube and the stents exiting.
 Neobladder – “Tubes and Drains”

Suprapubic Catheter

Ureteral Catheters

Foley Urethral Catheter

 Ureterointestinal anastmoses
• Combined Technique of Leadbetter and Clarke
• Transcolonic Technique of Goodwin
• Strickler Technique
• Pagano Technique
 Leadbetter-Clarke
ureterointestinal anastomosis.
A, Injection of the submucosal
tissues with saline facilitates
the dissection. B, A linear
incision is made in the taenia,
the taenia is raised, and the
mucosa is identified. A small
button of mucosa is removed,
and the ureter is spatulated
and then sutured to the
mucosa with 5-0 PDS. The
seromuscular layer is sutured
over the ureter, with care
taken not to compromise or
occlude the ureter.
Transcolonic technique of Goodwin
• Transcolonic technique of Goodwin. A, The bowel is opened on its
anterior surface; a small rent in the mucosa is made; and with a
mosquito hemostat, the mucosa is raised from the submucosa
extending laterally. A 3- to 4-cm tunnel is made before the clamp
exits the serosal wall. The ureter is grasped and pulled into the
submucosal tunnel. B, Both ureters have been drawn into the
bowel through their submucosal tunnels before each is spatulated
and circumferentially sutured to the mucosa. These sutures
should also incorporate a portion of the muscularis for security.
Where the ureter enters the colonic sidewall adjacent to the
mesentery, the adventitia of the ureter is secured to the colonic
serosa with interrupted 5-0 PDS sutures.
Strickler Technique
 Strickler Technique
• Strickler ureterointestinal anastomosis. A, A small linear incision is
made in the taenia, and the submucosa is dissected from the
mucosa laterally. After a distance of 3 to 4 cm is achieved, a small
hole is made in the serosa and the ureter is drawn through. B, A
button of mucosa is excised, and the ureter is spatulated and
sutured to the mucosa with 5-0 PDS. The rent in the taenia is
closed with interrupted sutures, and an adventitial suture at the
ureter's entrance point into the colon secures it to the serosa of
the colon
Pagano Technique
 Pagano Technique
• Pagano ureterointestinal anastomosis. A, A linear incision is made
in the taenia between 4 and 5 cm in length. B, The submucosa is
dissected from the mucosa laterally on both sides to the level of the
mesentery. The ureters are drawn into the submucosal tunnel
distally and sutured to the mucosa with 5-0 PDS suture proximally.
C, The serosa is reapproximated, with incorporation of the mucosa
in the midline
Bricker Small Bowel Anastomoses
ureterointestinal Bricker Anastomosis
anastomosis. A, The
adventitia of the
ureter is sutured to
the serosa of the
bowel. A small full-
thickness serosal and
mucosal plug is
removed. Interrupted
5-0 PDS suture
approximates the
ureter to the full
thickness of the
mucosa and serosa.
B, The anterior layer
is completed by
interrupted sutures
placed through the
adventitia of the
ureter and the serosa
of the small bowel.
 Wallace Technique
Wallace ureterointestinal anastomosis.
A, Both ureters are spatulated and laid
adjacent to each other. B, The apex of
one ureter is sutured to the apex of the
other ureter with 5-0 PDS. The posterior
medial walls of both ureters are then
sutured together with interrupted or
running 5-0 PDS, the knots tied to the
outside. The lateral ureteral walls are
then sutured to the intestine. C, A Y-
type anastomosis is formed by
completing the anterior row of the
anterior lateral ureteral walls of the
ureters as shown in B and then suturing
the ends of the ureters directly to the
intestine. D, The head-to-tail
anastomosis involves suturing the apex
of one ureter to the end of the other.
The posterior medial walls are sewn
together, and then the ends and lateral
walls are sewn to the intestine
 Tunneled Small Bowel Anastomosis

Tunneled small bowel

anastomosis. A small transverse
incision is made in the small
bowel, and a second transverse
incision 3 cm lateral to it is also
made. The submucosal tunnel is
made, a button of mucosa is
removed, and the ureter is
drawn through the tunnel and
sutured directly to the mucosa.
The rent in the serosa is closed,
and an adventitial ureteral
suture is placed and secured to
the serosa at the ureter's
entrance to the small bowel.
 Split-Nipple Technique

This method attempts to establish a nonrefluxing anastomosis

by employing a nipple mechanism. It may be applied to either
small or large bowel. This technique was described by
Griffiths and involves formation of a nipple in the ureter and
implantation into the small bowel
 Split-Nipple Technique

Split-nipple technique. The ureter is

spatulated and turned back on itself,
and the end of the ureter is secured to
the adventitia of the ureter with
interrupted 5-0 PDS suture
 Le Duc Technique
Le Duc ureterointestinal
anastomosis. A, The small bowel is
opened for approximately 4 to 5
cm. A longitudinal rent in the
mucosa is made and the mucosa
raised. B, At the distal end of the
mucosal rent, a hole is made in the
serosa, and the ureter is then
drawn through. The entrance of the
ureter through the serosa should be
at least 2 cm proximal to the cut
end of the bowel to allow sufficient
bowel length to close the end. C,
The ureter is spatulated and
sutured to the mucosa and muscle
layers. The mucosa is not
reapproximated over the top of the
ureter but rather sutured to the side
of it.
 Further Considerations
• Continence
– Preserve sphincter beyond prostate apex in males
– Suspend reconstructed vagina via sacrocolpopexy
or Burch procedure in females

• Refluxing versus nonrefluxing

– Nonrefluxing with decreased rates of
pyelonephritis
– However, higher rates of obstruction and
technically more challenging
Table 80-4   -- Complications of Ureterointestinal Anastomoses

Procedure No. of Patients Stricture (%) Leakage (%) Reflux (%)

Colon

Leadbetter-Clark [2]
[3] [4] [5]
127 14 3 4
Strickler[5] 28 14 — —
Pagano[6] 63 7 — 6
Small Bowel
Bricker [8] [9] 1809 7 4 —
Wallace-Y [10] [11] [12]
[18]
129 3 2 —
Nipple[8] 37 8 — 17

Serosal tunnel[12] 10 10 — 0

Le Duc [14] [15] [16] [17] [18] 82 18 2 13

 Postop
• Day 1-3: Fluids, Diet, ambulate
• Day 3: Passive Irrigation SPT and Foley: 30cc each
• Day 4: Daily Active Irrigation SPT/Foley: 60cc TID
• Day 5: Antibiotics and Pull Right (red) Ureteral
Catheter
• Day 6: Antibiotics and Pull Left (Blue), Teach SPT
Irrigation – 60cc TID
• Day 7: Discharge, plan foley d/c 14 days (cystogram),
SP Cathetre out at 8 weeks
 COMPARISON OF ORTHOTOPIC SIGMOID AND
ILEAL NEOBLADDERS
• SN
– 85% daytime continence
– 9% nighttime continence
• IN
– 90% daytime continence
– 60% nighttime continence
 Complications
• Urethral Recurrence
– 10%
• Hydronephrosis – loss of renal unit

• Stones
 Long Term Complications
• Metabolic
– Renal Failure
– Acidosis
– Osteoporosis
– B12 deficiency
– Urinary lithiasis
Metabolic Complications of Urinary Diversion

• Electrolyte abnormalities
• Hepatic metabolism
• Abnormal drug metabolism
• Calculus formation
• Nutritional disturbance
• Glucose metabolism
• Bone disease
• Cancer
 Cancer
• 11% of patients with ureterosignoidostomy, cancer
occurring at ureterointestinal anastomosis.
• 10-20 yrs delay before the cancer becomes manifest.
• 500-fold increase in incidence of cancer is reported.
• The tumor invariably appear close to the
anastomotic site of the ureters to the colon.
• Includes adenocarcinoma, signet ring carcinoma,
adenomatous polyps, sarcoma, transitional cell
carcinoma and undifferentiated carcinoma.
Possible etiology of cancer development
• Catelysed by fecal bacteria, production of
carcinogenic nitrosamines from nitrites and
secondary amines in the urine.
• Transitional/ intestinal epithelium
metaplasia, dysplasia and carcinogenesis.
• Yearly sigmoidoscopy starting five years
after procedure or altered bowel habits or
gross GI bleeding.
CT Urography of Urinary Diversions

63-year-old man with ileal conduit

urinary diversion. Coronal maximum-
intensity-projection CT image shows
ileal conduit (IC) after cystectomy for
bladder cancer. Ureteroenteric
anastomosis (arrows) is end-to-side,
refluxing Bricker type.
71-year-old man with
right colonic pouch
urinary diversion after
cystoprostatectomy.
RCP = right colonic
pouch. Coronal
maximum-intensity-
projection CT image
shows RCP. Distal left
ureteral segment
(arrows) is not
opacified.
66-year-old man with
orthotopic neobladder
urinary diversion after
cystectomy for bladder
cancer. NB =
neobladder. Coronal
maximum-intensity-
projection CT image of
patient with orthotopic
NB. Ureteroenteric
anastomosis
(arrowhead) is refluxing
Wallace-type
anastomosis
69-year-old man with
recurrent pelvic tumor
after cystectomy. NB =
neobladder Oblique
coronal maximum-
intensity-projection CT
image shows afferent
limb (arrowheads) and
reservoir of NB. Tight
stricture (arrow) can be
identified where tumor
is encasing distal
aspect of afferent limb
of NB.
54-year-old man with ileal
conduit (IC) urinary
diversion and distal right
ureteral stricture after
cystectomy for bladder
cancer. Coronal
maximum-intensity-
projection CT image
shows distal right ureteral
stricture (arrow). Surgical
revision of distal right
ureter confirmed benign
stricture. IC = ileal conduit
THANK YOU