SlideShare a Scribd company logo
1 of 55
Download to read offline
URINARY DIVERSION
Dr. Rojan Adhikari
FCPS II resident
Urology
INTRODUCTION
• URINARY DIVERSION
Diversion of urinary pathway from its natural
path
Types:
• Temporary/Permanent
• External /Internal
• Continent / Incontinent
• Definitive/Palliative
• Orthotopic / Heterotopic
HISTORY
• First attempted urinary diversion by Simon in
1852
• Ureterosigmoidostomy is the oldest
• Zaayer in 1911 started ileal conduit and it was
gold standard through 1990’s
• 1950 (Bricker): eastablish ileal conduit as first
choice
• In 1979, Camey and Le Duc reported their
pioneer othrotopic neobladder
• Kock and associates reintroduced continent
cutaneous diversion in 1982
IDEAL URINARY DIVERSION
1. Undisturbed Body Image
2. Natural Micturation
3. Continence
4. Safe Upper Urinary Tract
5. Non Refluxing
6. Low Pressure
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.
PREFERABLE DIVERSION
• Continent reservior connected to urethra
• Ileal segments (lower pressure peaks and ease
of surgical handling)
PRINCIPLE OF URINARY DIVERSION
• A reservoir in which to store urine in low
pressure
• A conduit through which the urine is conducted
to the surface
• A continence mechanism
BLADDER RESERVOIR
• Able to retent 500-1000ml of fluid
• Maintenance of low pressure after filling
• Elimination of intermittant pressure spikes
• True continence
• Ease of catheterization and emptying
• Prevention of reflux
CLASSIFICATION OF DIVERSION
• ORTHOTOPIC:
Orthotopic bladder substitution
• HETEROTOPIC
1. Continent : Cutaneous
2. Non-continent: Ileal conduit / colonic conduit
Cutaneous ureterostomy
3.Diversion to GIT: Uretero-sigmoidostomy/
rectal bladder
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
CONTINENT URINARY DIVERSION
• 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
CONTINENT URINARY DIVERSION
• Orthotopic Continent Diversion
It creates a pelvic neobladder that is anastomosed
to urethra
TYPE
1.Studder neobladder
2.Hautmann neobladder
3. Mainz neobladder
PRINCIPLE OF ANASTOMOSIS
• Adequate exposure
• Ensure good blood supply
• Control spillage
• Accurate apposition of serosa to serosa
• Ensure tight
• Realignment of the mesentery
TEMPORARY DIVERSION
• Nephrostomy
• Pyelostomy or ureterostomy
• Suprapubic cystostomy
NEPHROSTOMY
NEPHROSTOMY
URETEROSTOMY
SUPRA PUBIC CYSTOSTOMY
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
• As a palliative diversion in case of irremovable
obstruction in the bladder & distal to bladder
• Severe hemorrhagic cystitis
• Ectopic vesicle
• Incurable vesico- vagina fistula
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
ILEAL CONDUIT
PRE OPERATIVE PREPARATION
• Mechanical bowel preparation
Whole gut irrigation with poly ehylene glycol and
enema
• Pre-op antibiotic: cephalosporin + metronidazole
• Stoma site assessment
• Well informed consent
INDICATION
• After a cystectomy
• dysfunctional bladders
 persistent bleeding,
 obstructed ureter,
 poor compliance with upper tract deterioration,
 inadequate storage with total urinary
incontinence
CONTRAINDICATION
• Short bowel syndrome
• Inflammatory small bowel disease
• Pelvic irradiation
ILEAL CONDUIT
• 10-12cm ileal segment isolated 20cm 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
• Left ureter brought beneath the sigmoid
mesocolon (inferior to IMA)
• Ureteroenteric anastomosis
Urinary diversion
ILEAL CONDUIT
• After single J ureteral stent is placed in both ureter
• Distal end of ileal segment fashioned as end
ileostomy in RLQ
• A Rutzen bag/ stoma bag can be applied to the
stoma on the fifth or sixth postoperative day with
complete comfort for the patient
ILEAL CONDUIT
• ADVANTAGES
Technically simple surgery
Few complication
No bladder retaining
No nocturnal incontinence
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
ILEAL CONDUIT
• DISADVANTAGES
Risk of stomal complication eg: parastomal
hernia or stenosis
Urinary incontinance
Increased long term expenses of stoma care
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
COLONIC CONDUIT
• Indication
1. Extensive pelvic irradiation
2. When the middle and distal ureter are
absent.
• Containdication
1. Inflammatory large bowel disease
2. Severe chronic diarrhoea
INDIANA POUCH
• Rightcolon pouch with tapered ileum as
efferent limb
INDIANA POUCH
• A segment of terminal ileum approximately 10
cm in length along with the entire right colon is
isolated.
• An appendectomy is performed, and the
appendiceal fat pad obscuring the inferior margin
of the ileocecal junction is removed by cautery.
• The entire right colon is opened along its
antimesenteric border.
INDIANA POUCH
• Interrupted Lembert sutures are taken over a
short distance (3 to 4 cm) in two rows for the
double imbrication of the ileocecal valve.
• Application of opposing Lembert sutures on
each side of the terminal ileum
• Excess ileum can be tapered by stapling
technique.
Urinary diversion
INDIANA POUCH
• ADVANTAGES
Potential for normal or near normal urinary
continence
No nocturnal incontinence
No need for a stoma bag
The small stoma can be easily covered with
bandage that is less effect on physical image vs
ileal conduit
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
INDIANA POUCH
• DISADVANTAGES
Technically more difficult procedure
Complication associated with intermittent
catherization
Potential complications from urinary waste
product reabsorption
Risk of stomal complication eg: parastomal hernia
or stenosis
Neobladder
• The clinical goal of most neobladders is to
– allow volitional voiding 4 - 6 times per day
– capacity range of 400 to 500 mL of urine at low
pressures (>15 cm H2O)
• Two important criteria
– No compromise of oncological outcomes by
reconstruction at the urethroenteric anastomosis
– Rhabdosphincter mechanism must remain intact
to provide continent
Types of Neobladder
• Camey I & II
• Hautman
• Kock
• Mainz
• T-Pouch, Florida, UCLA, S pouch, Le bag
• Studer (most common)
STUDER NEOBLADDER
• Designated segments of terminal ileum for
construction of neobladder.
• Note that the distal mesenteric division is made
between the ileocolic and terminal branches of
the superior mesenteric artery, which extends
into the avascular plane of the mesentery.
• In addition, a small window of mesentery and a
5-cm segment of proximal small bowel are
discarded to allow mobility to the pouch and
small bowel anastomosis.
Urinary diversion
Contra-indication of Orthotopic
Neobladder
• Compromised renal function
• Severe hepatic dysfunction
• Compromised intestinal function
• Positive urethral margin
• Mental impairment
• Pre-existing incontinence
• Pelvic radiation (increased complications)
• Recurrent urethral stricture disease
• AGE NOT CONTRAINDICTION!!
COMPLICATION RELATED WITH
URINARY DIVERSION
Metabolic Problems
• Electrolyte Abnormalities
• Abnormal drug metabolism
• Osteomalacia and growth retardation
• Infections
• Formation of renal and reservoir calculi
• Renal deterioration
• Development of urothelial or intestinal cancer
Metabolic Problems
• Due to continued solute transport by interposed
segment
• The factors that influence
– Segment of bowel used
– Surface area of the bowel
– The amount of time the urine is exposed
– The concentration of solutes in the urine
– Renal function
– The pH of the fluid
Urinary diversion
• stomach: a hypochloremic hypokalemic metabolic
alkalosis may occur
• jejunum – hyponatremia, hyperkalemia, and
metabolic acidosis occur.
• ileum or colon – hyperchloremic metabolic acidosis
ensues.
• Other electrolyte abnormalities – hypokalemia,
hypomagnesemia, hypocalcemia, hyperammonemia,
and elevated blood urea nitrogen and creatinine.
Infection
• An increased incidence of bacteriuria, bacteremia,
and septic episodes occurs in patients with bowel
interposition
• Incidence : 10% to 17% with colon and ileal
conduits
• Patients with continent diversions also have a
significant incidence of bacteriuria and septic
episodes
Stones
• Most are infection stone
• Structural or metabolic cause
• Major risk: hyperchloremic metabolic acidosis
• Colon conduits : 3% to 4%
• Ileal conduits : 10% to 12%
• Continent cecal reservoirs : 20%
Short bowel and nutritional problem
• Significant loss of ileum
Vit B12 malabsorption : megaloblastic
anemia
Malabsorption of bile salts: diarrhea
Malabsorption of fat: fatty diarrhea
References
• Campbell and Walsh Urology 10th edition
•
• Bailey and love 27th edition
THANK YOU

More Related Content

What's hot

Principles of Endourology
Principles of EndourologyPrinciples of Endourology
Principles of EndourologyEko indra
 
Use of Intestinal segments in urinary diversion
Use of Intestinal segments in urinary diversion Use of Intestinal segments in urinary diversion
Use of Intestinal segments in urinary diversion GovtRoyapettahHospit
 
Open Ureterolithotomy
Open UreterolithotomyOpen Ureterolithotomy
Open UreterolithotomyEko indra
 
Whipple's procedure - Indications, Steps, Complications
Whipple's procedure - Indications, Steps, ComplicationsWhipple's procedure - Indications, Steps, Complications
Whipple's procedure - Indications, Steps, ComplicationsVikas V
 
urinary diversions in bladder cancer
urinary diversions in bladder cancerurinary diversions in bladder cancer
urinary diversions in bladder cancerDrAyush Garg
 
PCNL - the Perfect Puncture
PCNL - the Perfect PuncturePCNL - the Perfect Puncture
PCNL - the Perfect PunctureSiewhong Ho
 
Laparoscopic Cholecystectomy
Laparoscopic CholecystectomyLaparoscopic Cholecystectomy
Laparoscopic CholecystectomyDr. Shouptik Basu
 
Laparoscopic splenectomy
Laparoscopic splenectomyLaparoscopic splenectomy
Laparoscopic splenectomypiyushpatwa
 
Urethroplasty Treatment
Urethroplasty TreatmentUrethroplasty Treatment
Urethroplasty TreatmentDrGautamBanga
 
Lt hemicolectomy - Surgical Approach, Complications.
Lt hemicolectomy - Surgical Approach, Complications.Lt hemicolectomy - Surgical Approach, Complications.
Lt hemicolectomy - Surgical Approach, Complications.Vikas V
 
Principles of urethral reconstructive surgery
Principles of urethral reconstructive surgeryPrinciples of urethral reconstructive surgery
Principles of urethral reconstructive surgeryAhmed Eliwa
 
Bile duct injuries.slideshare
Bile duct injuries.slideshareBile duct injuries.slideshare
Bile duct injuries.slidesharedrksreenath
 

What's hot (20)

Principles of Endourology
Principles of EndourologyPrinciples of Endourology
Principles of Endourology
 
urinary diversion
urinary diversionurinary diversion
urinary diversion
 
Use of Intestinal segments in urinary diversion
Use of Intestinal segments in urinary diversion Use of Intestinal segments in urinary diversion
Use of Intestinal segments in urinary diversion
 
Cutaneous urinary Stoma
Cutaneous urinary StomaCutaneous urinary Stoma
Cutaneous urinary Stoma
 
Stoma management
Stoma managementStoma management
Stoma management
 
Urethral trauma
Urethral traumaUrethral trauma
Urethral trauma
 
Open Ureterolithotomy
Open UreterolithotomyOpen Ureterolithotomy
Open Ureterolithotomy
 
Whipple's procedure - Indications, Steps, Complications
Whipple's procedure - Indications, Steps, ComplicationsWhipple's procedure - Indications, Steps, Complications
Whipple's procedure - Indications, Steps, Complications
 
Lap pyeloplasty
Lap pyeloplastyLap pyeloplasty
Lap pyeloplasty
 
urinary diversions in bladder cancer
urinary diversions in bladder cancerurinary diversions in bladder cancer
urinary diversions in bladder cancer
 
PCNL - the Perfect Puncture
PCNL - the Perfect PuncturePCNL - the Perfect Puncture
PCNL - the Perfect Puncture
 
Laparoscopic Cholecystectomy
Laparoscopic CholecystectomyLaparoscopic Cholecystectomy
Laparoscopic Cholecystectomy
 
Laparoscopic splenectomy
Laparoscopic splenectomyLaparoscopic splenectomy
Laparoscopic splenectomy
 
LAPAROSCOPIC UROLOGY PPT. DR SREEJOY PATNAIK
LAPAROSCOPIC UROLOGY PPT. DR SREEJOY PATNAIKLAPAROSCOPIC UROLOGY PPT. DR SREEJOY PATNAIK
LAPAROSCOPIC UROLOGY PPT. DR SREEJOY PATNAIK
 
Right hemicolectomy
Right hemicolectomyRight hemicolectomy
Right hemicolectomy
 
Hypospadias
HypospadiasHypospadias
Hypospadias
 
Urethroplasty Treatment
Urethroplasty TreatmentUrethroplasty Treatment
Urethroplasty Treatment
 
Lt hemicolectomy - Surgical Approach, Complications.
Lt hemicolectomy - Surgical Approach, Complications.Lt hemicolectomy - Surgical Approach, Complications.
Lt hemicolectomy - Surgical Approach, Complications.
 
Principles of urethral reconstructive surgery
Principles of urethral reconstructive surgeryPrinciples of urethral reconstructive surgery
Principles of urethral reconstructive surgery
 
Bile duct injuries.slideshare
Bile duct injuries.slideshareBile duct injuries.slideshare
Bile duct injuries.slideshare
 

Similar to Urinary diversion

Radical cystectomy
Radical cystectomyRadical cystectomy
Radical cystectomyBright Singh
 
Etiopathogenesis, Evaluation & Management of Posterior Urethral Valve
Etiopathogenesis, Evaluation & Management of Posterior Urethral ValveEtiopathogenesis, Evaluation & Management of Posterior Urethral Valve
Etiopathogenesis, Evaluation & Management of Posterior Urethral ValveShubham Lavania
 
oshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxoshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxahmed eshiba
 
Colonic diverticulosis neo
Colonic diverticulosis neoColonic diverticulosis neo
Colonic diverticulosis neoNawin Kumar
 
RTC PANCREATIC INJURY.pptx
RTC PANCREATIC INJURY.pptxRTC PANCREATIC INJURY.pptx
RTC PANCREATIC INJURY.pptxssuser789c6b
 
Gall bladder & Bile duct diseases.pptx
Gall bladder & Bile duct diseases.pptxGall bladder & Bile duct diseases.pptx
Gall bladder & Bile duct diseases.pptxJwan AlSofi
 
Congenital conditions of the male genital urinary tract
Congenital conditions of the male genital urinary tractCongenital conditions of the male genital urinary tract
Congenital conditions of the male genital urinary tractMunyagaByanjo
 
Urinary diversion
Urinary diversion Urinary diversion
Urinary diversion drswati2002
 
Urethral stricture
Urethral strictureUrethral stricture
Urethral strictureoletty01
 
Azhar kappil tumer bla and kid
Azhar kappil tumer bla and kidAzhar kappil tumer bla and kid
Azhar kappil tumer bla and kidazharkappil
 
Disorders of Gu system by Abhi
Disorders of Gu system by AbhiDisorders of Gu system by Abhi
Disorders of Gu system by AbhiAbhishek Joshi
 
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...Sean M. Fox
 

Similar to Urinary diversion (20)

Radical cystectomy
Radical cystectomyRadical cystectomy
Radical cystectomy
 
Ureteric injury (1)
Ureteric injury (1)Ureteric injury (1)
Ureteric injury (1)
 
Etiopathogenesis, Evaluation & Management of Posterior Urethral Valve
Etiopathogenesis, Evaluation & Management of Posterior Urethral ValveEtiopathogenesis, Evaluation & Management of Posterior Urethral Valve
Etiopathogenesis, Evaluation & Management of Posterior Urethral Valve
 
oshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxoshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptx
 
Renal stone.pptx
Renal stone.pptxRenal stone.pptx
Renal stone.pptx
 
Colonic diverticulosis neo
Colonic diverticulosis neoColonic diverticulosis neo
Colonic diverticulosis neo
 
LIVER INFECTIONS.pptx
LIVER INFECTIONS.pptxLIVER INFECTIONS.pptx
LIVER INFECTIONS.pptx
 
Orthotopic neobladder
Orthotopic neobladderOrthotopic neobladder
Orthotopic neobladder
 
Urolithiasis
Urolithiasis Urolithiasis
Urolithiasis
 
RTC PANCREATIC INJURY.pptx
RTC PANCREATIC INJURY.pptxRTC PANCREATIC INJURY.pptx
RTC PANCREATIC INJURY.pptx
 
Gall bladder & Bile duct diseases.pptx
Gall bladder & Bile duct diseases.pptxGall bladder & Bile duct diseases.pptx
Gall bladder & Bile duct diseases.pptx
 
Biliary tract interventions
Biliary tract interventionsBiliary tract interventions
Biliary tract interventions
 
Congenital conditions of the male genital urinary tract
Congenital conditions of the male genital urinary tractCongenital conditions of the male genital urinary tract
Congenital conditions of the male genital urinary tract
 
Urinary diversion
Urinary diversion Urinary diversion
Urinary diversion
 
Urethral stricture
Urethral strictureUrethral stricture
Urethral stricture
 
Hydronephrosis.pptx
Hydronephrosis.pptxHydronephrosis.pptx
Hydronephrosis.pptx
 
Stomas
StomasStomas
Stomas
 
Azhar kappil tumer bla and kid
Azhar kappil tumer bla and kidAzhar kappil tumer bla and kid
Azhar kappil tumer bla and kid
 
Disorders of Gu system by Abhi
Disorders of Gu system by AbhiDisorders of Gu system by Abhi
Disorders of Gu system by Abhi
 
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...
Drs. Penzler, Ricker, and Ahmad’s CMC Abdominal Imaging Mastery Project: June...
 

More from Rojan Adhikari

Urinary bladder carcinoma
Urinary bladder carcinoma Urinary bladder carcinoma
Urinary bladder carcinoma Rojan Adhikari
 
Locally advanced renal cell carcinoma RCC
Locally advanced renal cell carcinoma RCCLocally advanced renal cell carcinoma RCC
Locally advanced renal cell carcinoma RCCRojan Adhikari
 
Nmibc, NON MUSCLE INVASIVE BLADDER CANCER
Nmibc, NON MUSCLE INVASIVE BLADDER CANCERNmibc, NON MUSCLE INVASIVE BLADDER CANCER
Nmibc, NON MUSCLE INVASIVE BLADDER CANCERRojan Adhikari
 
Metabolic evaluation of stone
Metabolic evaluation  of stoneMetabolic evaluation  of stone
Metabolic evaluation of stoneRojan Adhikari
 
anatomy of Prostate and prostate carcinoma
anatomy of Prostate and prostate carcinomaanatomy of Prostate and prostate carcinoma
anatomy of Prostate and prostate carcinomaRojan Adhikari
 
Urolithiasis epidemology and pathogenesis
Urolithiasis epidemology and pathogenesisUrolithiasis epidemology and pathogenesis
Urolithiasis epidemology and pathogenesisRojan Adhikari
 
Renal trauma kidney injury
Renal trauma kidney injuryRenal trauma kidney injury
Renal trauma kidney injuryRojan Adhikari
 
Approach to a_child_with_rash[1]
Approach to a_child_with_rash[1]Approach to a_child_with_rash[1]
Approach to a_child_with_rash[1]Rojan Adhikari
 
Postoperative pain management
Postoperative pain managementPostoperative pain management
Postoperative pain managementRojan Adhikari
 
Inguinal hernia repair
Inguinal hernia repairInguinal hernia repair
Inguinal hernia repairRojan Adhikari
 

More from Rojan Adhikari (18)

Urinary bladder carcinoma
Urinary bladder carcinoma Urinary bladder carcinoma
Urinary bladder carcinoma
 
Renal cell carcinoma
Renal cell carcinoma Renal cell carcinoma
Renal cell carcinoma
 
imaging in RCC
imaging in RCCimaging in RCC
imaging in RCC
 
Locally advanced renal cell carcinoma RCC
Locally advanced renal cell carcinoma RCCLocally advanced renal cell carcinoma RCC
Locally advanced renal cell carcinoma RCC
 
Intravesical bcg
Intravesical bcgIntravesical bcg
Intravesical bcg
 
Nmibc, NON MUSCLE INVASIVE BLADDER CANCER
Nmibc, NON MUSCLE INVASIVE BLADDER CANCERNmibc, NON MUSCLE INVASIVE BLADDER CANCER
Nmibc, NON MUSCLE INVASIVE BLADDER CANCER
 
Metabolic evaluation of stone
Metabolic evaluation  of stoneMetabolic evaluation  of stone
Metabolic evaluation of stone
 
anatomy of Prostate and prostate carcinoma
anatomy of Prostate and prostate carcinomaanatomy of Prostate and prostate carcinoma
anatomy of Prostate and prostate carcinoma
 
Research
ResearchResearch
Research
 
Urolithiasis epidemology and pathogenesis
Urolithiasis epidemology and pathogenesisUrolithiasis epidemology and pathogenesis
Urolithiasis epidemology and pathogenesis
 
Thulium vs holmium
Thulium vs holmiumThulium vs holmium
Thulium vs holmium
 
Renal trauma kidney injury
Renal trauma kidney injuryRenal trauma kidney injury
Renal trauma kidney injury
 
Embryology of kidney
Embryology of kidneyEmbryology of kidney
Embryology of kidney
 
Hydatid cyst
Hydatid cystHydatid cyst
Hydatid cyst
 
Approach to a_child_with_rash[1]
Approach to a_child_with_rash[1]Approach to a_child_with_rash[1]
Approach to a_child_with_rash[1]
 
Postoperative pain management
Postoperative pain managementPostoperative pain management
Postoperative pain management
 
Inguinal hernia repair
Inguinal hernia repairInguinal hernia repair
Inguinal hernia repair
 
Esophageal cancer
Esophageal cancerEsophageal cancer
Esophageal cancer
 

Recently uploaded

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 

Recently uploaded (20)

AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 

Urinary diversion

  • 1. URINARY DIVERSION Dr. Rojan Adhikari FCPS II resident Urology
  • 2. INTRODUCTION • URINARY DIVERSION Diversion of urinary pathway from its natural path Types: • Temporary/Permanent • External /Internal • Continent / Incontinent • Definitive/Palliative • Orthotopic / Heterotopic
  • 3. HISTORY • First attempted urinary diversion by Simon in 1852 • Ureterosigmoidostomy is the oldest • Zaayer in 1911 started ileal conduit and it was gold standard through 1990’s • 1950 (Bricker): eastablish ileal conduit as first choice
  • 4. • In 1979, Camey and Le Duc reported their pioneer othrotopic neobladder • Kock and associates reintroduced continent cutaneous diversion in 1982
  • 5. IDEAL URINARY DIVERSION 1. Undisturbed Body Image 2. Natural Micturation 3. Continence 4. Safe Upper Urinary Tract 5. Non Refluxing 6. Low Pressure
  • 6. 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.
  • 7. PREFERABLE DIVERSION • Continent reservior connected to urethra • Ileal segments (lower pressure peaks and ease of surgical handling)
  • 8. PRINCIPLE OF URINARY DIVERSION • A reservoir in which to store urine in low pressure • A conduit through which the urine is conducted to the surface • A continence mechanism
  • 9. BLADDER RESERVOIR • Able to retent 500-1000ml of fluid • Maintenance of low pressure after filling • Elimination of intermittant pressure spikes • True continence • Ease of catheterization and emptying • Prevention of reflux
  • 10. CLASSIFICATION OF DIVERSION • ORTHOTOPIC: Orthotopic bladder substitution • HETEROTOPIC 1. Continent : Cutaneous 2. Non-continent: Ileal conduit / colonic conduit Cutaneous ureterostomy 3.Diversion to GIT: Uretero-sigmoidostomy/ rectal bladder
  • 11. 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
  • 12. CONTINENT URINARY DIVERSION • 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
  • 13. CONTINENT URINARY DIVERSION • Orthotopic Continent Diversion It creates a pelvic neobladder that is anastomosed to urethra TYPE 1.Studder neobladder 2.Hautmann neobladder 3. Mainz neobladder
  • 14. PRINCIPLE OF ANASTOMOSIS • Adequate exposure • Ensure good blood supply • Control spillage • Accurate apposition of serosa to serosa • Ensure tight • Realignment of the mesentery
  • 15. TEMPORARY DIVERSION • Nephrostomy • Pyelostomy or ureterostomy • Suprapubic cystostomy
  • 20. 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
  • 21. • As a palliative diversion in case of irremovable obstruction in the bladder & distal to bladder • Severe hemorrhagic cystitis • Ectopic vesicle • Incurable vesico- vagina fistula
  • 22. 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
  • 24. PRE OPERATIVE PREPARATION • Mechanical bowel preparation Whole gut irrigation with poly ehylene glycol and enema • Pre-op antibiotic: cephalosporin + metronidazole • Stoma site assessment • Well informed consent
  • 25. INDICATION • After a cystectomy • dysfunctional bladders  persistent bleeding,  obstructed ureter,  poor compliance with upper tract deterioration,  inadequate storage with total urinary incontinence
  • 26. CONTRAINDICATION • Short bowel syndrome • Inflammatory small bowel disease • Pelvic irradiation
  • 27. ILEAL CONDUIT • 10-12cm ileal segment isolated 20cm proximal to IC valve • Short straight conduit without kinking • Continuity of small bowel re-established • Mesenteric window closed • Ileum in isoperistaltic fashion
  • 28. • Isolated segment flushed with warm saline till return of clear fluid • Left ureter brought beneath the sigmoid mesocolon (inferior to IMA) • Ureteroenteric anastomosis
  • 30. ILEAL CONDUIT • After single J ureteral stent is placed in both ureter • Distal end of ileal segment fashioned as end ileostomy in RLQ • A Rutzen bag/ stoma bag can be applied to the stoma on the fifth or sixth postoperative day with complete comfort for the patient
  • 31. ILEAL CONDUIT • ADVANTAGES Technically simple surgery Few complication No bladder retaining No nocturnal incontinence Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
  • 32. ILEAL CONDUIT • DISADVANTAGES Risk of stomal complication eg: parastomal hernia or stenosis Urinary incontinance Increased long term expenses of stoma care Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
  • 33. COLONIC CONDUIT • Indication 1. Extensive pelvic irradiation 2. When the middle and distal ureter are absent. • Containdication 1. Inflammatory large bowel disease 2. Severe chronic diarrhoea
  • 34. INDIANA POUCH • Rightcolon pouch with tapered ileum as efferent limb
  • 35. INDIANA POUCH • A segment of terminal ileum approximately 10 cm in length along with the entire right colon is isolated. • An appendectomy is performed, and the appendiceal fat pad obscuring the inferior margin of the ileocecal junction is removed by cautery. • The entire right colon is opened along its antimesenteric border.
  • 36. INDIANA POUCH • Interrupted Lembert sutures are taken over a short distance (3 to 4 cm) in two rows for the double imbrication of the ileocecal valve. • Application of opposing Lembert sutures on each side of the terminal ileum • Excess ileum can be tapered by stapling technique.
  • 38. INDIANA POUCH • ADVANTAGES Potential for normal or near normal urinary continence No nocturnal incontinence No need for a stoma bag The small stoma can be easily covered with bandage that is less effect on physical image vs ileal conduit Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553
  • 39. INDIANA POUCH • DISADVANTAGES Technically more difficult procedure Complication associated with intermittent catherization Potential complications from urinary waste product reabsorption Risk of stomal complication eg: parastomal hernia or stenosis
  • 40. Neobladder • The clinical goal of most neobladders is to – allow volitional voiding 4 - 6 times per day – capacity range of 400 to 500 mL of urine at low pressures (>15 cm H2O) • Two important criteria – No compromise of oncological outcomes by reconstruction at the urethroenteric anastomosis – Rhabdosphincter mechanism must remain intact to provide continent
  • 41. Types of Neobladder • Camey I & II • Hautman • Kock • Mainz • T-Pouch, Florida, UCLA, S pouch, Le bag • Studer (most common)
  • 42. STUDER NEOBLADDER • Designated segments of terminal ileum for construction of neobladder. • Note that the distal mesenteric division is made between the ileocolic and terminal branches of the superior mesenteric artery, which extends into the avascular plane of the mesentery. • In addition, a small window of mesentery and a 5-cm segment of proximal small bowel are discarded to allow mobility to the pouch and small bowel anastomosis.
  • 44. Contra-indication of Orthotopic Neobladder • Compromised renal function • Severe hepatic dysfunction • Compromised intestinal function • Positive urethral margin
  • 45. • Mental impairment • Pre-existing incontinence • Pelvic radiation (increased complications) • Recurrent urethral stricture disease • AGE NOT CONTRAINDICTION!!
  • 47. Metabolic Problems • Electrolyte Abnormalities • Abnormal drug metabolism • Osteomalacia and growth retardation • Infections • Formation of renal and reservoir calculi • Renal deterioration • Development of urothelial or intestinal cancer
  • 48. Metabolic Problems • Due to continued solute transport by interposed segment • The factors that influence – Segment of bowel used – Surface area of the bowel – The amount of time the urine is exposed – The concentration of solutes in the urine – Renal function – The pH of the fluid
  • 50. • stomach: a hypochloremic hypokalemic metabolic alkalosis may occur • jejunum – hyponatremia, hyperkalemia, and metabolic acidosis occur. • ileum or colon – hyperchloremic metabolic acidosis ensues. • Other electrolyte abnormalities – hypokalemia, hypomagnesemia, hypocalcemia, hyperammonemia, and elevated blood urea nitrogen and creatinine.
  • 51. Infection • An increased incidence of bacteriuria, bacteremia, and septic episodes occurs in patients with bowel interposition • Incidence : 10% to 17% with colon and ileal conduits • Patients with continent diversions also have a significant incidence of bacteriuria and septic episodes
  • 52. Stones • Most are infection stone • Structural or metabolic cause • Major risk: hyperchloremic metabolic acidosis • Colon conduits : 3% to 4% • Ileal conduits : 10% to 12% • Continent cecal reservoirs : 20%
  • 53. Short bowel and nutritional problem • Significant loss of ileum Vit B12 malabsorption : megaloblastic anemia Malabsorption of bile salts: diarrhea Malabsorption of fat: fatty diarrhea
  • 54. References • Campbell and Walsh Urology 10th edition • • Bailey and love 27th edition