Thomas C. Krivak and Paniti Sukumvanich
The utilization of urinary diversion and creation of urinary conduits have been developed and modified with the principal of maintaining a quality of life in the patients undergoing radical surgery for treatment of recurrent gynecologic cancer or complications from previous therapy.1-5 Initially, Brunschwig used a “wet colostomy” (ie, an ureterosigmoidostomy) as a means to provide urinary diversion. This procedure unfortunately led to high rates of pyelonephritis and renal failure, which limited the utility of such a procedure. In subsequent years, Bricker described using the terminal ileum for diverting the urinary stream, whereas Rowland described using the large bowel as the reservoir for the urinary diversion. These 2 later techniques decreased the complication rate and had acceptable postoperative complications, thus making such procedures more widely used in patients undergoing pelvic exenteration.
Urinary diversions may be necessary in cases where there is obstruction of the ureters due to pelvic tumor growth or complications of radiation therapy (eg, radiation fibrosis or genitourinary fistula), or as part of a curative exenterative procedure. Depending on the clinical situation, the methods for urinary diversion may range from incontinent diversions, such as percutaneous nephrostomy tubes or ileal conduit, to continent urinary diversion, such as a large bowel continent urinary diversion.
The gynecologic oncology surgeon should carefully evaluate the clinical scenario in order to choose the most appropriate treatment, given the variety of methods available for urinary diversion. In cases where an exenteration is not being performed, one should also consider whether a nonpermanent diversion such as a percutaneous nephrostomy would suffice in place of permanent diversion. Another clinical scenario issue to consider is whether or not the procedure is for curative intent or palliation of symptoms. In cases where the procedure is needed as part of a pelvic exenteration procedure, the main point to consider is whether it should be a continent or incontinent urinary diversion. An example of a patient who would be an ideal candidate for continent colon urinary diversion would be a patient with an anterior cancer recurrence undergoing an anterior exenteration.6-12 A continent diversion in this case would provide the patient with a better cosmetic result because only a small ostomy for catheterization of the continent reservoir will be present on her abdomen. Conversely, in a patient with a central recurrence and distant disease who has a large vesicovaginal fistula requiring urinary diversion, one should consider a percutaneous nephrostomy placement or noncontinent small bowel conduit, because this may have a better impact on her quality of life. This chapter will focus on the various methods for urinary diversion and the management of complications that can ensue from such procedures.
Box 32B-1 Master Surgeon’s Corner
Avoid using any tissue that shows signs of significant radiation changes.
Obtain a mucosal-to-mucosal ureteroileal anastomosis to decrease risk of anastomotic leaks.
Obtain adequate spatulation with the ureteroileal anastomosis to decrease risk of strictures.
Be sure to have an adequate protrusion of the stoma above the abdominal wall skin level.
Ensure that the small bowel conduit is secured with the direction of bowel peristalsis toward the stoma.
PREOPERATIVE PREPARATION AND INDICATIONS
The 4 main issues to consider in the preoperative planning phase of the procedure are as follows:
1. Determining the degree of renal function
2. Determining the type of urinary diversion
3. Obtaining informed consent
4. Determining the location of the stoma
Determining the Degree of Renal Function
Prior to performing a procedure that can have significant long-term consequences, it is important to determine that the patient’s kidneys are indeed functional. Laboratory tests such as serum electrolytes, blood urea nitrogen (BUN), and creatinine levels should be obtained to assess baseline renal function. If there has been any evidence of long-term obstruction, then one should consider a renal ultrasound and nuclear renal scan. Radiographic studies, such as a radionucleotide or renal Lasix scan, are important to obtain because a normal BUN or creatinine level does not always imply that both kidneys are functional. This should be done to ensure that a urinary diversion is not performed on a nonfunctioning kidney. Generally, a nonfunctioning kidney is confirmed by a less than 5% total glomerular filtration rate of one kidney. When a nonfunctioning kidney is encountered, a nephrectomy should be taken considered as part of the surgical procedure to avoid chronic pyelonephritis.
Determining the Type of Urinary Diversion
Urinary diversions can be divided into 2 types: permanent and temporary (ie, percutaneous nephrostomy). In a patient who is a poor surgical candidate and in whom the goal of any surgical intervention is palliation, one should consider the placement of percutaneous nephrostomy tubes. Such a procedure can provide relief of symptoms due to obstruction and fistulas with a minimum of morbidity. This technique may also allow the patient to regain her renal function as well as undergo antegrade passage of stents at a later time. This may be a temporary or permanent type of diversion based on patient prognosis. Another indication for percutaneous nephrostomy tube placement is a patient with ureteral strictures, because such treatment may allow for passage of a ureteral stent as well as balloon catheters for dilatation. In a patient undergoing definitive treatment with a pelvic exenteration, a permanent urinary diversion such as an incontinent ileal conduit or continent conduit would be indicated. In general, a patient who is undergoing a total exenteration is a good candidate for an ileal conduit.12-14 Continent conduits can be considered for patients undergoing an anterior exenteration because the cosmetic result with a small stoma may be more appealing to the patient.
Obtaining Informed Consent
It is important to thoroughly explain the risks and benefits of any permanent urinary diversion procedure. Such counseling is often done in conjunction with the discussion on the expected outcomes, utility, and risks of the pelvic exenteration procedure. Patients have to be aware of the lifestyle changes that will be required, such as long-term care of the colostomy and urostomy or the care required for continent large bowel urinary diversion (self-catheterization). Complication rates reported in the literature for ileal conduits include a ureteral-ileal anastomosis postoperative leak rate of 5% to 10%, postoperative pyelonephritis risk of 5% to 20%, chronic pyelonephritis risk of 5% to 10%, parastomal hernia risk of less than 5%, stomal stenosis in continent conduits risk of 5% to 15%, nephrolithiasis risk of 5% to 10%, and a risk of chronic renal sufficiency.5,7,8,11,15
Determination of the Location of the Stoma
Determining the placement of the stoma will often depend on what other procedures are being done at the same time. It is recommended that the patient should have a preoperative consultation with an enterostomal therapist to help with markings for the stoma. It should be kept in mind that locations that are at the level of the umbilicus are not ideal, as the waistbands of women’s pants are often placed at that level. Any stoma should be placed at a least 8 to 10 cm away from the mid-line incision, either above or below the umbilicus, not in a skin crease and clear of any bony prominences. Patients should be evaluated while standing and supine to ensure the location is ideal in both positions.
Noncontinent Urinary Diversion: Ileal Conduit
Care should be taken with dissection of the ureters from the retroperitoneal space. Often, this dissection can be quite difficult due to radiation fibrosis. One should gently handle the ureters because they can easily be devascularized. In general, it is recommended to excise any portion of the ureter that shows signs of extensive radiation fibrosis and to use a portion of the ureter that is out of the radiated field. One should also try to conserve as much of the periureteral tissue as possible without completely stripping the ureter because this will also help to prevent devascularization of the ureter. Isolation of the ureters may begin with a pericolic gutter peritoneal incision in order to dissect from lateral to medial. This will allow for identification of the important vascular structures that are close to the ureter such as the infundibulopelvic ligament. The cecum and the ascending colon will also need to be mobilized as part of the right ureteral dissection. The left ureteral dissection can be done along with the rectosigmoid colon mobilization. The ileal conduit stoma is typically placed in the right lower quadrant. As such, the left ureter will need to be mobilized for a distance of approximately 15 cm to allow it to be brought underneath the inferior mesenteric artery and sigmoid colon mesentery to reach the conduit. Because the right ureter has a shorter path to travel to the conduit, it usually must be mobilized for a distance of 10 cm or so to ensure a tension-free anastomosis. One might need more or less dissection; the amount dissected should allow for a tension-free anastomosis to the conduit. Once the dissection has been performed, the ureters should be ligated with 2-0 silk ties. This will lead to dilatation of the ureters and will allow for easier placement of the ureteral stents, facilitating the ureteroileal anastomosis. The amount of time the ureters are ligated should be monitored, because the ureters cannot be ligated for longer than 3 to 4 hours due to the development of electrolyte abnormalities. The anesthesiologist should be notified of the ureteral ligation in order to allow for fluid optimization during this portion of the procedure.
Isolation of Small Bowel Segment
Once the ureters have been dissected and ligated, the next step is selecting the ileal segment to be used for the conduit. The ileal segment for the conduit should be at least 15 cm away from the ileocecal valve and should be a nonmottled, well-vascularized, healthy-appearing segment of bowel. Approximately 12 to 18 cm of bowel is typically required for an ileal conduit. The actual length required may depend on numerous factors such as whether a Turnbull loop will be needed or the segment is long enough to allow for a tension-free anastomosis with the ureters. The segment of ileum should not be too long, because redundancy can lead to postoperative electrolyte abnormalities from absorption of electrolytes from a long segment of ileum. Once the segment of ileum has been identified, one should ensure that there is adequate blood supply by elevating the distal ileum and transilluminating the mesentery. If good blood supply is identified, then a segment of ileum 15 cm away from the ileocecal valve is marked and tagged with a Penrose drain, and a proximal segment is measured between 12 and 20 cm in length for the proximal and distal ends of the ileal conduit. In an obese patient, an additional 5- to 10-cm segment should be considered to allow for the Turnbull loop. The Turnbull loop stoma allows for a longer segment of small bowel to traverse the abdominal wall without compromising vascular supply. Once the bowel has been marked and tagged with a Penrose drain, the proximal and distal portions may be isolated and divided using a GIA-60 stapler. A series of 3-0 silk horizontal mattress sutures are used to oversew the staple line at the proximal end of the conduit, where the ureters will be connected, in order to decrease contact of the staple line with urine and reduce the risk of nephrolithiasis.
Once the ileal loop has been isolated, the skin aperture is created, and the stoma is formed (Figure 32B-1). The layers that will need to be excised are the skin, the subcutaneous tissue, the anterior rectus sheath, the rectus muscle, the posterior rectus sheath, and the peritoneum. Ideally, the skin site will have been marked preoperatively to avoid any bony prominences, prior abdominal scars, and abdominal creases. Pulling up a piece of skin with a Kocher clamp and cutting across should result in a 2- to 2.5-cm small circumferential incision. Remove all the fatty tissue down to the anterior rectus sheath. Be sure to place tension on the anterior and posterior rectus sheath by pulling medially on the fascia through the midline incision, and then make a cruciate incision through the rectus sheath, rectus muscle, and underlying peritoneum using an electrosurgical unit (Bovie) device. The skin incision may need to be larger if a loop stoma (Turnbull loop) is going to be created. Care should be taken not to damage any of the surrounding structures, such as the inferior epigastric vessels, during this process. The aperture should accommodate 2 fingers to pass through easily. The distal end of the ileal conduit is then grasped by a Babcock clamp that has been passed through the aperture, and the conduit is then brought up to the skin. At this point, the surgeon must ensure that the bowel mesentery is not strangulated or twisted and that the direction of intestinal peristalsis is pointed toward the efferent limb of the conduit. Once the conduit has been safely pulled through the skin, Allis clamps are placed on the corners below the prior staple line. The staple line is excised, and copious irrigation should be performed to ensure that small bowel contents are removed completely. The ileal segment should be re-evaluated to ensure that there is adequate length for the ureteral-ileal anastomosis.
FIGURE 32B-1. Creation of the urinary conduit stoma. (A) Creation of the stoma aperature. (B), (C), (D) ‘Rosebud’ stoma creation.
Creation of the stoma is done by placing 4 equally spaced 3-0 Vicryl sutures first 1 cm from the skin edge, then approximately 4 cm from the stoma opening, and finally through the opening of the stoma to facilitate eversion (“rosebud”) of the stoma. It is extremely important to ensure that there is adequate eversion of the stoma, because low-profile stomas can make it very difficult for appliances to be placed around the stoma, thus allowing for caustic urinary leak on the skin. Care should also be taken not to ligate critical vascular supply within the mesentery so as not to devascularize the distal end of the conduit. The stoma should be pink and healthy and not blue with compromised blood supply. The ileal conduit is then fixed to the posterior rectus sheath using several 3-0 Vicryl sutures to decrease the risk of parastomal hernia.
The distal ureters should be incised and spatulated to allow for placement of the ureteral stent. Care should be taken not to make the opening too large because this can lead to reflux (the opening should be no larger than 1 cm). Once this has been completed, the screw-on tip of a metal Yankauer suction is removed, and it is then placed down through the stoma into the conduit to the location where the left ureter will be anastomosed to the conduit (Figure 32B-2). It is usually easiest to perform the left ureteral anastomosis first. A 1-cm incision is created with a #15 blade on ileum over the tip of the Yankauer to allow the suction tip to protrude. A guide wire is placed through the Yankauer and fed through the ureter. A single-J, 6- or 7-French ureteral stent is passed over the guide wire through the ureter into the kidney. Palpation of the ureter should be done while the stent is being passed to make sure the stent is placed up into the kidney. The ureter is then sutured into the conduit using a series of 5 to 8 interrupted 4-0 polydioxanone sutures on a vascular needle placed circumferentially. Care should be taken to go from the mucosa of the ureter to the mucosa of the ileum to achieve a mucosa-to-mucosa anastomosis. The ureter should be sutured in such a way that the knot is on the outside of anastomosis. The surgeon should be careful not to place too many sutures with this anastomosis, as this can compromise the blood flow and prevent adequate healing of the anastomotic site. The left ureter should not be kinked, and the anastomosis should be tension-free (Figure 32B-3). Once the left ureteral-ileal anastomosis is complete, a 1-0 chromic suture should be placed through-and-through the ileal conduit, piercing through the stent to prevent any stent migration during the immediate postoperative period. The procedure is repeated for the right ureter. Both anastomoses should be water-tight and tension-free without ureteral angulation, strictures, or twisting. A water-tight seal of the ureteral-ileal anastomosis can be confirmed by insufflating the conduit with a diluted indigo carmine blue solution. The stents should be flushed, and urine production from the stents should be confirmed. The distal ends of the ureteral stents emerging from the efferent end of the conduit should be trimmed to an appropriate length to fit within the urinary appliance and may be sutured to the peristomal skin as an additional measure to prevent migration during the postoperative period.
FIGURE 32B-2. Yankauer suction tip used to facilitate placing ureteral stent guide wire.
FIGURE 32B-3. Tension-free ureteroileal anastomosis.
Re-establish Intestinal Continuity
After completion of the conduit, intestinal continuity is re-established via a side-to-side functional end-to-end enteroenterostomy using the divided ends of ileum. The anastomosis is performed anterior to the ileal conduit. The anastomosis is done in the usual manner using GIA-60 and TA-60 stapling devices. The mesenteric defect is closed with a series of interrupted 3-0 Vicryl sutures to prevent an internal bowel hernia. When closing the mesenteric defect, avoid constricting the mesenteric blood supply to the ileal conduit. Finally, the proximal end of the conduit should be secured to the sacral promontory with several 2-0 or 3-0 delayed-absorbable sutures to prevent migration and creation of tension on the ureteral anastomoses (Figure 32B-4). A closed-suction drain (eg, Jackson-Pratt) is placed in the dependent pelvis. Postoperatively, an abdominal film should be obtained to confirm proper ureteral stent location.
FIGURE 32B-4. Completed ileal conduit.
Noncontinent Ileal Conduit: Alternatives and Modifications
Alternatives to the ileal conduit include a transverse colon conduit and a double-barrel wet stoma.16-21 An advantage of the transverse colon noncontinent conduit is that it provides a large-caliber segment of bowel that has not been irradiated and may be used when the small bowel has been heavily irradiated. The double-barrel wet colostomy (ureters implanted directly into an end colostomy segment) has the advantage of a single stoma but is less than ideal due to the risk of ascending kidney infections. This procedure may be a viable option for patients who may have difficulty with care of 2 stomal sites.
There are several modifications of the previously described ileal conduit construction. In the technique of Leadbetter, the proximal end of the conduit is sutured to the sacral promontory, and both ureters are brought to the midline for the anastomosis of the intestinal segment. This allows for a more vertically oriented ileal conduit than the transverse oriented conduit of the Bricker method.5,17 The Turnbull loop stoma can provide adequate blood supply and less compromise of the mesentery for patients who are obese or have had prior complications of ileal conduits such as stomal strictures.18-20
A modification of the ileal conduit to help reduce ureteral-ileal anastomotic complications has been described by Barbieri et al21 in which a small linear incision is made in the ileal segment and the ureteroileal anastomoses created under direct visualization. The reported stricture rate was less than 2%, and the complications from making a linear incision along the small bowel conduit were minimal.
Box 32B-2 Complications and Morbidity
Anastomotic leak (5%-10%)
Stoma retraction, necrosis
Low urine output
Ureteroileal anastomotic stenosis (10%-15%)
Stoma stenosis or hernia (5%-15%)
Chronic pyelonephritis (5%-10%)
The immediate postoperative period should be focused on detecting early complications related to the urinary conduit, such as ureteroileal anastomotic leak and complications with the stoma. Urine leak will be heralded by an increase in pelvic drainage output and a markedly elevated creatinine level in the drain effluent. Conservative management with percutaneous nephrostomy drainage is the preferred management and frequently allows spontaneous closure in the absence of severely irradiated tissues. Extensive necrosis of the stoma that extends below the skin line requires surgical revision. The differential diagnosis for low urine output includes insufficient volume replacement, ureteroileal anastomotic leak, a defect in the proximal conduit stump, ureteral obstruction (kinking, stent occlusion), and improper stent position. Persistently low urine output after volume repletion should be evaluated with a computed tomography (CT) uro-gram. The closed-suction pelvic drain should be left in place until the output is less than 50 to 100 mL per 24-hour period. The ureteral stents can be removed 6 to 12 weeks postoperatively after confirmation of anastomotic integrity by intravenous pyelogram or CT urogram. Long-term surveillance should include periodic renal ultrasound (or CT imaging) to evaluate for hydronephrosis and stone formation as well as regular renal function testing. Delayed ureteroileal anastomosis stenosis can often be managed by percutaneous balloon dilatation. Stomal stenosis or parastomal hernia will require conduit revision and/or relocation.
RIGHT COLON CONTINENT URINARY DIVERSION
Box 32B-3 Master Surgeon’s Corner
Appropriate patient selection and preoperative counseling should be done to ensure that the patient will be able to self-catheterize and flush the conduit in the immediate postoperative time frame.
Transilluminate the colonic mesentery to ensure adequate blood supply to the isolated bowel segment.
Test the “tightness” of the ileocecal valve placation before fixation of the conduit to the abdominal wall.
The ileal segment of the conduit should be as short as possible to avoid kinking and difficulty with catheterization.
There are a number of variations on the continent urinary conduit (pouch) using both large and small bowel segments. The most commonly used procedure in gynecologic oncology, and the focus of this section, uses a detubularized segment of right (ascending) colon and distal ileum, with the ileocecal valve serving as the continence mechanism. In most cases, a continent urinary diversion is chosen when the exenterative patient does not require concurrent diversion of the fecal stream (eg, end colostomy). Although formation of an end colostomy is not an absolute contraindication to continent urinary diversion, the cosmetic advantages are largely mitigated. Continent urinary diversions require more intensive maintenance and attention than their noncontinent counterparts. The ideal candidate would be a patient who requires an anterior exenteration or a total pelvic exenteration with a rectosigmoid resection than can have low anterior anastomosis accomplished safely. This will allow for the patient to have no appliances on the anterior abdominal wall.
Preoperative evaluation and counseling are similar to what has been described for incontinent small bowel urinary diversion. However, preoperative assessment for a continent urinary diversion must include detailed counseling and education regarding the care and maintenance of the urinary pouch as well as an appraisal of the patient’s ability and motivation for self-care. Any history of prior radiation therapy should be reviewed, with careful attention to the potential damage to the terminal ileum and/or ascending colon. Reconstruction of the urinary tract must consider the totality of the exenterative procedure, including the available length and viability of intestinal tract as well as modifications of the abdominal wall that may be required for vaginal reconstruction.
Preparation of the Right Colon
The most common bowel segment used for continent urinary diversion in gynecologic oncology surgery is the right colon with terminal ileum, with minor variations on this theme having been described as the “Miami pouch” or the “Indiana pouch.”22-26 The general principles of a typical right colon continent urinary diversion are described in this section.
After completion of the extirpative phase of the operation, the ureters are adequately mobilized as described previously for the ileal conduit. The small bowel is mobilized by incising the base of the small bowel mesentery up to the ligament of Treitz. The cecum, ascending colon, and transverse colon are mobilized by dividing along the white line of Toldt, taking down the hepatic flexure, and dividing the gastrocolic ligament. The mesenteric blood supply to the terminal ileum and proximal colon should be carefully preserved. In general, a 26- to 30-cm segment of colon is required to create the right colon pouch. The mesentery of the right colon and transverse colon is transilluminated to identify the right colic and middle colic vascular pedicles. The proximal transverse colon is divided using a GIA stapler just proximal to the middle colic vascular pedicle, and the mesentery is “back-cut” down to its base, proximal and parallel to the middle colic vascular pedicle, to achieve maximum mobility. The distal ileum is divided using a GIA stapler approximately 12 to 15 cm from the ileocecal valve.
The isolated segment of right colon is then detubularized by incising along the tenia omentalis (anterior-most tenia) from the proximal transverse colon down to the cecum using the electrosurgical unit, and the bowel lumen is copiously irrigated (Figure 32B-5). If not done previously, appendectomy should be performed. The segment of right colon is then folded over on itself to form a detubularized intestinal “pouch.” The posterior “wall” of the pouch is approximated using a 2-layer closure of running 3-0 Vicryl suture. It is often easiest to place the outer (imbricating) layer prior to the inner (full-thickness, mucosa-to-mucosa) layer. The anterior “wall” of the pouch is then approximated in a similar fashion, leaving a large enough opening in the cecum to facilitate constructing the ureterocolic anastomoses. For the anterior closure, the inner (mucosa-to-mucosa) layer should be placed first, followed by the outer (imbricating) layer.
FIGURE 32B-5. Detubularization of the right colon segment for construction of urinary pouch.
Creation of the Continence Mechanism
The distal ileal segment should be trimmed to a length 3 to 4 cm longer than the thickness of the abdominal wall to allow for “rosebudding” of the stoma with the ileocecal valve juxtaposed to the abdominal wall peritoneum. The ileal segment is then tapered to facilitate straight-line catheterization by placing a 14- or 16-French Robinson catheter into the lumen, grasping the mesenteric border with several Babcock clamps (incorporating the Robinson catheter), and firing 1 or 2 applications of the GIA stapling device along the antimesenteric border of ileum to excise the redundant lumen (Figure 32B-6). With the red Robinson catheter still in place, the ileocecal valve is then plicated using 3 or 4 imbricating stitches of 2-0 or 3-0 silk sutures placed along the antimesenteric border (Figure 32B-7). At this juncture, the Robinson catheter should be withdrawn and reinserted several times to ensure that the plicated ileocecal valve is tight enough to ensure continence yet still able to be easily intubated by the pliable Robinson catheter.
FIGURE 32B-6. Tapering of the ileal segment.
FIGURE 32B-7. Plication of the ileocecal valve continence mechanism.
Creation of Stoma Site
Maximum mobility of the right colon pouch should be confirmed, and an appropriate stoma site in the right lower quadrant should be selected that will allow a tension-free approximation of the distal ileal segment to the skin. The ileal segment is passed through the stoma aperture to test the “fit,” and then returned to the abdominal cavity. The stoma will be created in the same fashion as described earlier for an ileal conduit.
Ureterocolic Anastomosis and Closure of the Pouch
The base of the right colon pouch should lie tension-free in the right lower quadrant. The left ureter is mobilized above the pelvic brim and brought beneath the inferior mesenteric artery to reach the posterior wall of the pouch, generally the cecum or proximal ascending colon. The right ureter will be anatomically closer to the base of the pouch and requires less mobilization. It is easier to perform the right ureterocolic anastomosis first. An appropriate site is selected on the posterior wall of the pouch that will allow a tension-free anastomosis for the right ureter, and a small defect is created in the colonic wall at this site over a Mixter or tonsil clamp using the electrosurgical unit. The clamp is then used to grasp the suture on the ligated end of the right ureter, and the ureter is brought into the base of the pouch. The distal ureter is trimmed obliquely and spatulated, as previously described, and a 6- or 7-French double-J ureteral stent is passed up to the level of the renal pelvis. A direct mucosa-to-mucosa anastomosis is created using 6 to 8 interrupted stitches of 4-0 delayed-absorbable monofilament suture, and the stent is transfixed to the colonic mucosa using a through-and-through stitch of 1-0 chromic suture. A 3-0 delayed-absorbable monofilament suture is passed through the distal end of the double-J ureteral stent and passed down the ileal segment and out the efferent end to be used for later extraction of the stent. The same procedure is repeated for the left ureter (Figure 32B-8). It is advisable to use different color sutures passed through the distal ends of the right and left ureteral stents to facilitate accurate identification at the time of stent extraction. Alternatively, an antireflux mechanism can be constructed by tunneling the ureters under the muscularis of the colon for a distance of 2 cm and then placating over this with 4-0 Vicryl suture. Care must be taken when constructing this antireflux mechanism to ensure the ureters have adequate spatulation and opening so that there are no ureteral strictures.
FIGURE 32B-8. Ureteral anastomosis to the colonic urinary pouch.
The Robinson catheter should be replaced by a 14- or 16-French 3-way Foley catheter. The anterior closure of the pouch base is completed, and the efferent ileal segment (with Foley catheter and ureteral extraction sutures protruding) is brought through the abdominal wall to the stoma site (Figure 32B-9). The anterior wall of the pouch should be secured to the peritoneum of the anterior abdominal wall to ensure that the ileocecal valve continence mechanism is juxtaposed to the anterior abdominal wall and that redundancy of the ileal segment will not be created by the pouch “settling” into the pelvis. The “rosebud” stoma is created in the same fashion as for an ileal conduit. The pouch is filled with 400 to 500 mL of a dilute methylene blue solution, through the irrigating port of the 3-way Foley catheter, and inspected for any areas of leakage. The ureteral stent extraction sutures are secured to the skin 1 to 2 cm away from the stoma using a Mayo needle, and the Foley catheter is attached to drainage. Prior to closure of the abdomen, a closed-suction drain (eg, Jackson-Pratt) is placed in the dependent pelvis.
FIGURE 32B-9. Final stages of completing colonic urinary pouch.
Re-establish Intestinal Continuity
Intestinal continuity is re-established by creating a side-to-side functional end-to-end enterocolostomy between the distal ileum and midtransverse colon using the GIA and TA stapling devices. The intervening mesenteric defect is closed with a series of interrupted sutures, with care taken not to constrict the blood supply to the right colon urinary pouch.
Box 32B-4 Complications and Morbidity
Catheter obstruction from thick mucus
Difficulty catheterizing pouch
Anastomotic stricture, hydronephrosis
Chronic renal insufficiency
The management of a continent pouch postoperatively is more complex than managing a noncontinent ileal conduit. An abdominal film should be obtained in the postoperative period to confirm stent position, and stoma condition should be assessed daily. The 3-way Foley catheter should be irrigated with 60 to 120 mL of saline solution every 3 to 4 hours until mucus production decreases (usually 10-14 days). The Foley catheter is drained to gravity in between irrigations. The differential diagnosis of low urine output includes the same entities as for ileal conduit, as well as a blocked Foley catheter due to thick colonic mucus production. An abdominal ultrasound can detect an overdistended pouch. Increased frequency of irrigation should remedy this problem. The Foley catheter can be removed on postoperative day 10, and the patient is instructed in self-catheterization using an 18- to 22-French catheter. Self-catheterization should be performed every 4 hours initially, with frequent use of irrigation until mucus production subsides. The frequency of catheterization can gradually be decreased. Ideally, maximum pouch capacity will be at least 500 mL, and the patient should have to self-catheterize no more than 4 or 5 times per day, although this is highly individualized.
Three to 6 weeks postoperatively, an intravenous pyelogram or CT urogram should be obtained to confirm pouch integrity. Removal of the ureteral stents is accomplished by cutting the ureteral stent extraction sutures attached to the peristomal skin and pulling out one stent at a time. The same precautions and surveillance for long-term complications and electrolyte abnormalities observed for the ileal conduit apply to care of the continent colonic conduit.
A pouchogram should be ordered 4 to 5 weeks postoperatively and in 3 to 6 months to evaluate the size of the pouch. If there are any abnormalities noted or if the patient is having any difficulty with significant residual after catheterization, additional postoperative care should include evaluation with an intravenous pyelogram, pouchogram, serum electrolytes, and renal ultrasound and nuclear medicine scans to ensure that the pouch and renal function and upper urinary tracts stay within normal limits. It should also be noted that it is very difficult to assess urine culture status and that treatment of pyelonephritis would need to be based on clinical symptoms such as back pain, leukocytosis, and febrile episodes.
The complications are similar to those with an ileal conduit and can be divided into early complications and late complications. Complications include urinary leakage, low urine output, and small bowel obstruction similarly seen with other urinary diversion procedures. Ureteral anastomotic leaks may occur, as well as leaks from the pouch. Such complications should initially have nonsurgical interventions such as placement of drains via interventional radiology and percutaneous nephrostomy drainage to safely manage these complications because the ileal conduit will resolve and heal on its own.22-26 It should be noted that if there is urine extravasation on a pouchogram done within the early postoperative period, conservative management should be the initial treatment. Such treatment includes drainage with a Jackson-Pratt drain placed within the pelvis, percutaneous nephrostomy drainage, and continuation with ureteral stents. One should also make sure that a ureteral anastomotic leak is not present. Urinomas need to be not only diverted, but also drained to ensure adequate healing. With urinomas or pelvic abscesses, this acute inflammatory process will cause significant edema and inflammation and may lead to ureteral strictures. It is extremely important that the patient is able to self-catheterize and get good emptying of the pouch. The Malecot drain should stay in place until this has been demonstrated. Hyperchloremic metabolic acidosis is a complication that can be seen with continent urinary diversions, especially a large continent urinary diversion due to absorption of solute. If this occurs, depending on the severity of the issue, the patient may need to self-catheterize more often or be managed with sodium bicarbonate supplementation. If the problem continues, the patient may need a conversion to a noncontinent urinary diversion with placement of a catheter along with a stomal bag.
In a recent review by Ramirez et al7 from the MD Anderson Cancer Center, complications of continent urinary diversion using the ileal colonic segment were studied. The most common complications postoperatively included febrile episodes, pneumonia bacteremia, postoperative ileus, wound complications such as infections and wound disruption, prolonged intubations, anastomotic leak, pelvic abscess, and deep venous thrombosis. Complications related to the continent conduit reservoir included stomal strictures, acute renal failure, ureteral colonic anastomosis strictures, and anastomotic leaks. Late complications occurring after more than 60 days included chronic pyelonephritis, urinary stomal strictures, nephrolithiasis, the pouch basically being incontinent, ureteral strictures, acute renal failure, and fistula development. It should be noted that of the patients in this study, 18 were without evidence of disease at follow-up, 13 had died of disease, 7 had died from other causes, and 2 were alive with disease. In the patients who had long-term follow-up, 36 of 40 reported normal continent function after management of their complications.
It should be highlighted that these complications should be managed conservatively and reoperation is reserved for patients who fail conservative measures. Conservative management procedures include ureteral dilatation and percutaneous nephrostomy tube drainage for management of ureteral stenosis and urinary leaks. The need for reimplantation of ureters may be very challenging, and if the stricture is due to ischemia, reoperation with a radiated ureter again may lead to further stricture development. If there is an incompetent ileocecal valve, this incompetence results from high pressure spikes, and it may be necessary to consider reoperation for ureteral reimplantation and creation of a new pouch or conversion to a noncontinent diversion. An additional long-term complication may be the development of nephrolithiasis and pouch stones. The longer patients have these pouches, the more these complications may be seen, and management will depend on renal function and symptoms.
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