urinary diversion urology

1. Dr Burhan ( R3 S/C )
Dr Jitendra ( R3 S/C )
Ref:from
Campbell Urology
Smith Urology
Fischer Master Of Surgery
Bailey & Love Practice Of Surgery
URINARY
DIVERSION

2. CONTENT OF SEMINAR
1. INTRODUCTION
2. HISTORY
3. CLASSIFICATION
4. NON CONTINENT DIVERSION
5. HETEROTOPIC CONTINENT DIVERSION
6. URETEROSIGMOIDOSTOMY
7. ORTHOTOPIC CONTINENT DIVERSION
8. COMPLICATION OF URINARY DIVERSION

3. INTRODUCTION
URINARY DIVERSION
Diversion of urinary pathway from its natural path
Types:
Temporary/Permanent
External /Internal
Continent / Incontinent
Definitive/Palliative
Orthotopic / Heterotopic

4. HISTORY
First attempted urinary diversion by Simon in 1852
Uretero sigmoidostomy is the oldest
Zaayer in 1911 started ileal conduit and it was gold
standard through 1990’s
 1911 (Coffey): ureterosigmoidostomy
 1950 (Bricker): eastablish ileal conduit as first choice

5.  In 1979, Camey and Le Duc reported their pioneer
othrotopic neobladder
Kock and associates reintroduced continent cutaneous
diversion in 1982

6. IDEAL URINARY DIVERSION
1. Undisturbed Body Image
2. Natural Micturation
3. Continence
4. Safe Upper Urinary Tract
5. Non Refluxing
6. Low Pressure

7. GOAL OF URINARY DIVERSION
To provide the best local cancer control.
To reduce potential range of complications.
To guarantee the best quality of life for the patient.

8. PREFERABLE DIVERSION
1.Continent reservior connected to urethra
2.Ileal segments (lower pressure peaks and ease of
surgical handling)

9. PRINCIPLE OF URINARY DIVERSION
1. A reservoir in which to store urine in low pressure
2. A conduit through which the urine is conducted to the
surface
3. A continence mechanism

10. BLADDER RESERVOIR
1. Able to retent 500-1000ml of fluid
2. Maintenance of low pressure after filling
3. Elimination of intermittant pressure spikes
4. True continence
5. Ease of catheterization and emptying
6. Prevention of reflux

11. CLASSIFICATION OF DIVERSION
1.ORTHOTOPIC:
Orthotopic bladder substitution
2.HETEROTOPIC
1.Continent
Cutaneous
2.Non-continent
Ileal conduit / colonic conduit
Cutaneous ureterostomy
3.Diversion to GIT
Uretero-sigmoidostomy/ rectal bladder

13. NON CONTINENT DIVESION
NON CONTINENT DIVERSION involve a wide
stoma and an external appliance to collect the urine.
TYPE
1.Ileal Conduit
2.Colonic Conduit
3.Jejunal Conduit

14. CONTINENT URINARY DIVERSION
1.Heterotopic Continent Diversion
It’s a catheterizable stoma on the abdominal wall to
empty an intra abdominal neobladder
TYPE
1.Right Colonic Pouches
The Indiana Pouch , The Florida Pouch
The Miami Pouch ,The Penn Pouch
2. Ileal Pouches
The Kock Pouch
The Mainz Pouch

15. 2.Orthotopic Continent Diversion
Its creat a pelvic neobladder that is anastomosed to
urethra
TYPE
1.Studder neobladder
2.Hautmann neobladder
3. Mainz neobladder

17. PRINCIPLE OF ANASTOMOSIS
Adequate exposure
Ensure good blood supply
Control spillage
Accurate apposition of serosa to serosa
Ensure tight
Realignment of the mesentery

18. Uretero Intestinal Anastomosis
PRINCIPLE
Refluxing Vs Antirefluxing
Only needed ureter is mobilized
Shouldn’t strip the peri advential tissue
Bowel should be brought to the ureter not vice versa
Water tight mucosa to mucosa anastomosis
Anastomosis should be retroperitonealised
Soft silastic stent can be used to avoid stricture at
anastomatic site

19. TEMPORARY DIVERSION
Nephrostomy
Pyelostomy
or
ureterostomy
Suprapubic
cystostomy

20. NEPHROSTOMY

21. URETEROSTOMY

22. SUPRA PUBIC CYSTOSTOMY

23. Indications For Permanent Diversion
After radical cystectomy in a case of muscle invasive
bladder tumor , along with radical prostatectomy.
Neurogenic bladder dysfunction due to congenital or
acquired disorders in case of neural tube defect and
spinal cord injury. Severe idiopathic detrusor
overactivity
Chronic inflammatory conditions like interstitial
cystitis, Tuberculosis, schistosomiasis and post
radiation bladder contraction

24. As a palliative diversion in case of irremovable
obstruction in the bladder & distal to bladder
Severe hemorrhagic cystitis
 Ectopic vesicae
Incurable vesico- vagina fistula

25. PRE PROCEDURE COUNSELLING
Selection based on Clinical factors
Inform and honest discussion
Long and short term risks and benefits
Intergroup talk
Possibility of change in diversion method
Stoma therapist

26. SELECTION OF TYPE OF DIVERSION
Age/ Survival rate
Co morbidities
Oncological Extent of disease
Renal and Hepatic functional status
Bowel condition
Patient’s preferences
Available expertise
Mental status

27. PRE OPERATIVE PREPARATION
1. Mechanical bowel preparation
1. 3 days of fluid diet
2. Whole gut irrigation with poly ehylene glycol
3. enema
2. Pre-op antibiotic : cephalosporin + kanamycin +
metronidazole
3. Stoma site assessment
4. Well informed consent

28. Non Continent Urinary Diversion
1.Ileal
Conduit
3.Colonic
Conduit
2.Jejunal
Conduit

29. ILEAL
CONDUIT

30. INDICATION
After a cystectomy
Associated with medical co morbidities
dysfunctional bladders
persistent bleeding,
obstructed ureters,
poor compliance with upper tract deterioration,
 inadequate storage with total urinary incontinence

31. CONTRAINDICATION
 Short bowel syndrome
 Inflammatory small bowel disease
 Pelvic irradiation

32. ILEAL CONDUIT
 10-12cm ileal segment isolated 20 proximal to IC valve
 Short straight conduit without kinking
 Continuity of small bowel re-established
 Mesenteric window closed
 Ileum in isoperistaltic fashion
 Isolated segment flushed with warm saline till return
of clear fluid

34. Left ureter brought to RLQ beneath the sigmoid mesocolon
(inferior to IMA)
Ureteroenteric anastomosis
After single j ureteral stent is placed in both ureter
Distal end of ileal segment fashioned as end ileostomy in RLQ
A Rutzen bag can be applied to the stoma on the fifth or sixth
postoperative day with complete comfort for the patient

35. URETERIC IMPLANTATION
1.Bricker and Nesbit:
Both ureter implant individually in an end-to-side
2.Wallace
End to end oriented ureter
Spatulated at distal end and suture
end-to-end fashion to ileal stump

36. BRICKER
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 sutures
approximate 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.

37. WALLACE
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 The
posterior medial walls of both
ureters are then sutured together
The lateral ureteral walls are then
sutured to the intestine.

38. 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.

39. LE DUC
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.

40. TUNNELED METHOD
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

41. BROOKE ROSE BUD STOMA
A and B, Nipple stoma. Five
to 6 cm of intestine are
brought through the
abdominal wall. The serosa
is scarified, and
quadrant 3-0 vicryl are
placed through the full
thickness of the distal end
of the intestine. Each
suture is placed in the
seromuscular layer 3 cm
proximal and then secured
to the dermis before it is
tied

42. TURNBULL LOOP STOMA
A After the distal end of the loop is closed and
the bowel is drawn through the rent in the
abdominal wall, the bowel is held in place by a
rod passed through the mesentery. The
mesentery is realigned, and the peritoneum is
sutured to the serosa of the bowel
circumferentially.
B A transverse incision is made in the bowel
four fifths of the loop distance cephalad.
C The cephalad portion of the stoma is simply
sutured to the dermal layer of skin with
interrupted 3-0 vicryl
D On the inferior aspect of the incision, 3-0
chromic sutures are placed through the full
thickness of the cut edge, then through the
seromuscular layer, and then through the
dermis. This everts the caudal portion of the
stoma

43. COLONIC CONDUIT
Indication
1. Extensive pelvic irradiation
2. When the middle and distal ureter are absent.
Conta indication
1. Inflammatory large bowel disease
2. Severe chronic diarrhoea

44. COLONIC CONDUIT

45. HETEROTOPIC
URINARY
DIVERSION

46. PRINCIPLE
1. Good Reservoir
 Good capacity
 Lower pressure storage
 Low metabolic issue
2. Catheterizable efferent limb
3. Continence mechanism
 Spherical reservoir: low end-filling pressure with
maximum radius

47. INDICATION
 External urethral sphincter sparing surgery
impossible
 Urethral malformations
 Spinal injury or complex neurological defects

48. CONTRAINDICATION
Impaired renal function
Impaired hepatic function
Inadequate intellectual capacity
Unmotivated patient

49. Detubularisation & Reconfiguration
To increase geometric capacity of reservoir ,
maximising the volume achievable for a given surface
area of intestine
To decrease storage pressure , improving overall
compliance
To interrupt the normal higher pressure contraction of
the intact intestine

50. CONTINENCE MECHANISM
1.Sphincteric Compression:
 La Place Law : T = P x r
 Intraluminal pressure inversely proportional to the
radius of the reservoir
 Narrowing of efferent limb (decrease r )  increase
resistance to urinary leakage
 Constructed by plicating , tapering or
intussuscepting a limb of bowel
 Ex. Indiana pouch

51. Sphincteric Compression

52. 2. Peristalsis:
 When ileum is use as efferent limb, preceding
peristalsis of the ileum to that of colon server as a
counteractive force to overcome leakage
 Ileal contraction is earlier with higher contraction
pressure
 Ex. Mainz pouch

53. 3. Nipple-valve: equilibrating pressure
 Invagination of the efferent limb into the pouch
result in nipple-valve
 Equivalent pressure inside the reservoir will be
reflected on the outlet  prevent leakage
 Construction of nipple valve is most technical
demanding and asso with high complication
 E.g Kock pouch

54. NIPPLE VALVE

55. Nipple valve. Approximately 8 cm
of mesentery are cleaned from the
distal end of the ileum, and the
serosa is scarified and then turned
back on itself to form a nipple of
approximately 4 cm in length. The
end of the ileum is sutured to itself
with interrupted 4-0 PDS. A rent is
made in the colon through a
taenia, and the nipple valve is
placed through the rent and
secured with circumferential
interrupted 4-0 PDS through the
full thickness of the colon and the
seromuscular layer of the ileum.

56. 4. Flap valve mechanism:
 Construction of part of the efferent limb
within the reservior against a fixed wall
 So that intraluminal pressure of the pouch
wound compression onto the efferent limb
during filling phase

57. FLAP VALVE

58. Mitrofannoff Principle
The construction of a catheterisable conduit to a low
pressure urinary reservoir
With a continent and catheterisable cutaneous stoma
Mitrofanoff 1980
Require a narrow tube , buried in the wall of the
conduit in a tunnel about 5cm long
About 90% are continent

59. Choice Of Efferent Limb
1.Appendix (Mitrofanoff)
2.Reconstructed ileal tube (Monti)
2-3cm ileum isolated
Open longitudinally and anti-mesenteric border
Close over a Fr 10 catheter along the new long axis
Adv: bring bulky mesentry to the middle and facilate
implantation of the bilateral end
3.Tapered ileum:
Plicated with rows of Lembert suture of stapler
4.Others: ureter, fallopian tube

61. Example Of Cutaneous Continent
Diversion
Indiana pouch:
Rt colon pouch with tapered ileum as efferent limb
Penn pouch:
Ileocolonic pouch using the appendix as the efferent limb
T- Pouch:
Ileal pouch with antireflux mechanism
Mainz pouch :
Ileaoceacal pouch with intussuscepted ileal segment as efferent
limb

63. 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

66. INDIANA POUCH
A. A segment of terminal ileum approximately 10 cm in
length along with the entire right colon is isolated.
 B. An appendectomy is performed, and the appendiceal fat
pad obscuring the inferior margin of the ileocecal junction
is removed by cautery.
C. The entire right colon is opened along its antimesenteric
border.
 D. Interrupted Lembert sutures are taken over a short
distance (3 to 4 cm) in two rows for the double imbrication
of the ileocecal valve
E. Application of opposing Lembert sutures on each side of
the terminal ileum .
 F. Excess ileum can be tapered by stapling technique.

68. FLORIDA &MIAMI POUCH
A, The entire ascending colon and the right third or half of the transverse colon is
isolated along with 10 to 12 cm of ileum.
B, The entire upper extremity of the large bowel is mobilized laterally in the
fashion of an inverted U. The medial limbs of the U are sutured after the bowel is
spatulated.
C, The bowel plate is then closed side to side

69. PENN POUCH
A to C, The appendix is left attached to the cecum and buried into the adjacent cecal
taenia by rolling it back onto itself. A wide tunnel is created, extending 5 to 6 cm from the
base of the appendix. 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.

70. URETERO
SIGMOIDOSTOMY

71. The first direct anastomosis of the ureter into intact colon
was first performed by smith in 1878.
No collection apparatous is required .
STEP
Right paramedian incision was kept
Patient is placed in the trendelenberg position
Right ureter is found and an incision is made over
peritoneum medial side of ureter.

72. Ureter is dissected from its bed and cleared till its
entry into the bladder.
The sigmoid colon is now taken out.
Uretro sigmoid anastomosis is done.
 Similar manner the left ureter is implanted little
above the right ureter .
 foley catheter is introduced into ractal ampulla.
 Catheter is removed at 3rd day.

73. Leadbetter & clarke ( Extra Colonic )
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.

74. Goodwin ( Transcolonic )
. 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.

75. STRICKLER
. 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 polydioxanone
sutures. 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.