Technique For Urinary Diversion Research Articles

Robotic-assisted total intracorporeal ileal loop urinary diversion

The ileal loop urinary diversion procedure is an integral part of surgical treatment for central recurrent cervical cancer requiring pelvic exenteration. The procedure is typically performed via open laparotomy, which often is associated with significant blood loss, increased morbidity, and prolonged recovery. Thus, it would be ideal to perform the ileal loop urinary diversion via a minimally invasive surgical approach that is either laparoscopic or robotic-assisted. A major limitation of traditional laparoscopic-assisted urinary diversion is the inability to perform ureteroileal anastomosis, which requires fine sewing. A detailed technique of robotic-assisted complete intracorporeal ileal loop urinary diversion is described.

Double-barreled colon conduit and colostomy for simultaneous urinary and fecal diversions: long-term follow-up.

Best strategies for simultaneous urinary and stool diversion remain indeterminate. Here we present what is to our knowledge the longest outcome data on double-barreled colon conduit and colostomy (DBCCC) in a cohort of patients needing simultaneous urinary and fecal diversion. We identified 9 patients who underwent DBCCC between March 2002 and March 2013. Nine patients who underwent separate urinary and fecal diversion (colostomy plus percutaneous nephrostomy or ureterocutaneostomy) served as the control group. We compared demographics, comorbidities, follow-up morbidities, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-item questionnaire in the two groups. The preservation of renal function was better in the DBCCC group. There were significant improvements in global state of health, fatigue, insomnia, appetite, bowel habit, and social function in the DBCCC group. In comparison with the separate urinary and fecal diversion group, the patients in the DBCCC group had statically significant improvement in global health status, functional scales, and symptom scales. Compared with the separate urinary and fecal diversion technique, DBCCC provides preservation of renal function, easy stoma bag care, better quality of life, and improved body image for patients who need simultaneous urinary and fecal diversion.

V9 Robot-assisted intracorporeal ileal neobladder: Simplified step-by-step technique and surgical outcomes

have described our experience with intracorporeal urinary diversions, including orthotopic ileal neobladder and ileal conduit. Intracorporeal urinary diversion remains an advanced technique focused in centers of excellence. To our knowledge, there have been no previous reports of robotic intracorporeal continent cutaneous diversion. Herein, we provide the first description of our technique of robotic intracorporeal continent cutaneous urinary diversion (Indiana pouch) following robotic cystectomy, including the results of our initial experience. METHODS: We perform a robotic cystoprostatectomy using a standard 6-port transperitoneal technique, as previously described. We provide a step-by-step illustration of our intracorporeal approach to right colonic mobilization, bowel segmentation, ileocolonic anastomosis, ureterocolonic anastomoses, and creation of a hand-sewn Indiana pouch continent cutaneous urinary diversion. We describe optimization of port utilization and technique for robot positioning. Tapering of the catheterization channel and reinforcement of ileocecal valve are performed via the standard extraction incision. RESULTS: Robotic intracorporeal Indiana pouch was successfully performed following robotic cystoprostatectomy. Only 2 additional port incisions were necessary to complete the diversion. Operative time for intracorporeal diversion was 180 minutes, with negligible blood loss, and without any intra-operative complications. Post-operative care followed a standardized clinical care pathway. Length of stay was 7 days. There were no major (Clavien 3-5) 90-day complications observed. Externalized ureteral stents are removed at 2 weeks. At 3 weeks post-operatively, a pouchgram is performed. The malecot drain is capped, and the patient begins catheterizing via the cutaneous stoma. The malecot is subsequently removed. CONCLUSIONS: We demonstrate robotic intracorporeal continent cutaneous urinary diversion following robotic cystectomy is technically feasible and safe. Early functional results are promising. To our knowledge, this is the first description of completely intracorporeal continent cutaneous diversion.

Robotic radical cystectomy and intracorporeal urinary diversion: The USC technique.

Introduction:Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results.Materials and Methods:Specific descriptions for preoperative planning, surgical technique, and postoperative care are provided. Demographics, perioperative and 30-day complications data were collected prospectively and retrospectively analyzed. Learning curve trends were analyzed individually for ileal conduits (IC) and neobladders (NB). SAS® Software Version 9.3 was used for statistical analyses with statistical significance set at P < 0.05.Results:Between July 2010 and September 2013, RRC and lymph node dissection with ICUD were performed in 103 consecutive patients (orthotopic NB=46, IC 57). All procedures were completed robotically replicating the open surgical principles. The learning curve trends showed a significant reduction in hospital stay for both IC (11 vs. 6-day, P < 0.01) and orthotopic NB (13 vs. 7.5-day, P < 0.01) when comparing the first third of the cohort with the rest of the group. Overall median (range) operative time and estimated blood loss was 7 h (4.8-13) and 200 mL (50-1200), respectively. Within 30-day postoperatively, complications occurred in 61 (59%) patients, with the majority being low grade (n = 43), and no patient died. Median (range) nodes yield was 36 (0-106) and 4 (3.9%) specimens had positive surgical margins.Conclusions:Robotic radical cystectomy with totally ICUD is safe and feasible. It can be performed using the established open surgical principles with encouraging perioperative outcomes.

Which urinary diversion is best after radical cystectomy? The case for “incontinent” diversion

Which urinary diversion is best after radical cystectomy? The case for “incontinent” diversion

Renal Transplantation into a Diverted Urinary System—Is it Safe in Children?

Historically surgeons caring for children with urinary diversion for bladder outlet obstruction have routinely performed undiversion before renal transplantation. We hypothesized that patients undergoing transplantation into a diverted system would have outcomes similar to those undergoing transplantation into a normal bladder. We review the outcomes of patients with and without diversion undergoing kidney transplantation at our institution. We retrospectively studied a cohort of children undergoing renal transplant between 1993 and 2006. Patients whose etiology of end-stage renal disease was either obstructive uropathy or renal dysplasia were included. Patients with less than 5 years of followup were excluded from the analysis. Four groups were assembled, ie controls with renal dysplasia and no history of obstructive uropathy undergoing transplant (group 1), patients with obstructive uropathy not diverted at transplant (group 2), patients with obstructive uropathy diverted at transplant (group 3) and patients with obstructive uropathy augmented before transplant (group 4). The groups were compared for outcomes of frequency of urinary tract infection, renal graft function and graft loss. Of the 80 subjects eligible based on diagnostic criteria 43 had completed 5 years of followup. There was no significant difference between groups based on age (p = 0.508), renal function as measured by glomerular filtration rate (p = 0.526) or creatinine (p = 0.612), or frequency of urinary tract infections (p = 0.083). Only 1 patient in the cohort suffered graft loss. Based on frequency of urinary tract infection, renal function and graft loss 5 years after transplant, there appears to be no added risk to transplanting a kidney into a diverted system.

Cystostomies continentes : expérience monocentrique

To evaluate the feasibility, the efficiency, the results of continent cystostomy in adult population. Retrospective study of patients who underwent a continent cystostomy between 1987and 2011. Forty-three patients underwent a continent cystostomy (13men and 30women). The mean age at surgery was 53.4±14.6years. The mean BMI was 25kg/m(2). No death in relation with the cystostomy was reported. Thirty-two patients had a neurological pathology (74.4%), 11a pathology other than neurological (25.6%). A retention bladder was reported for 12patients (27.9%), 17 (39.5%) were incontinent, and 14 (32.6%) had a mixed symptomatology. All patients had urodynamics and an evaluation of the urinary tract. Nineteen appendicovesicostomy were made, 15double Monti-procedure, six simple Monti-procedure, three channels were made of an association of ileon and appendix. Seventeen patients underwent an augmentation cystoplasty in combination with the continent catheterizable conduit. The mean follow-up was 47.6±29months. Continence was achieved in 37patients (86%), two patients underwent a Bricker. Stomal stenosis occurred in eight patients (18.6%), with a median time of 16.1±20.4months. Leakage occurred after bladder neck closure for two patients (4.6%). Clean intermittent catheterization were performed by 30patients, catheterization by a care giver for four patients, seven did not use their stomy because of the evolution of their causal pathology, or because of an intercurrent pathology. No difference between the channels (Mitrofanoff versus Monti) was reported. Continent catherizable cystostomy were a feasible method of continent urinary diversion in an adult population. This study demonstrated their feasibility in an adult population and their long-term efficiency with a mean follow-up of 47.6months and 127months for one of them. With a rate of continence upper than 80%, it was an effective technique of urinary diversion associated with intermittent catheterization.

A Modified Ureteroileal Anastomosis Technique for Bricker Urinary Diversion

Up to 10% of patients who have undergone the Bricker ileal conduit urinary diversion may develop ureteroileal anastomotic complications that are more frequently associated with the left side ureter. We have therefore modified the standard Bricker ileal conduit technique to minimize the anastomotic complications associated with the left side ureter. In our modification, the proximate end of the ileal conduit was brought from the right side to the left under the mesosigmoid in an isoperistaltic fashion. The left ureter that remained in the natural extraperitoneal location was anastomosed to the ileal segment in the usual end-to-side fashion without the need of extensive ureteral dissection. A series of 42 patients have undergone ileal conduit urinary diversion using this modified technique. During a median follow-up period of 18.6 months, this technique was found to have no associated major perioperative complications and early- and intermediate-term ureteroileal anastomotic complications from both sides of the ureters. Our modified ileal conduit diversion technique was easy and safe to perform, and may serve as an alternative technique for the standard Bricker ileal conduit urinary diversion, especially when the left distal ureter was involved extensively with urothelial carcinoma.

Does intubated uretero-ureterocutaneostomy provide better health-related quality of life than orthotopic neobladder in patients after radical cystectomy for invasive bladder cancer?

Ileal orthotopic neobladder (ONB) has not proved to provide better health-related quality of life (HRQoL) than other urinary diversion techniques after radical cystectomy. The aim of the study is to compare HRQoL assessed by four questionnaires between ONB and uretero-ureterocutaneostomy (UUC). Thirty-nine patients (35 men and 4 women) aged 66.95 ± 8.18 years old underwent radical cystectomy due to invasive bladder cancer and urinary diversion. Patients randomized to ileal ONB and UUC groups, except if certain limitations did not allow performing an ONB. Patients were interviewed face-to-face 7-84 months (median 17) after the operation and completed the Functional Assessment of Cancer Therapy Scale-General (FACT-G), the FACT Vanderbilt Cancer Index (FACT-VCI), the Beck Depression Index (BDI), and the generic RAND 36-item Health Survey Short Form (SF)-36 questionnaire, to asses HRQoL. Comparing the two groups there were no statistically significant differences for the scores of FACT-G, FACT-VCI, and BDI. For VCI score there was a borderline nonsignificant difference (P = 0.051). No statistically significant differences were noticed also from the comparison of SF-36 subgroups for the two groups except SF. Role emotional subgroup on behalf of UUC (P = 0.022). Patients with UUC surprisingly presented at least equal quality of life than the presumably less debilitating and more recent ONB. This could be explained due to lower complication rate and to lower expectations of the UUC group. UUC is a considerable option for urinary diversion after radical cystectomy in the era of HRQoL for selected patients.

Laparoscopic pelvic exenteration for gynaecological malignancy: Is there any advantage?

Introduction Pelvic exenteration (PE) remains one of the most mutilating surgical procedures with important postoperative morbidity. Laparoscopic approach has emerged in an attempt to reduce postoperative complications. The aim of the present study was to compare outcomes between laparoscopic pelvic exenteration combined with a vaginal or perineal approach, versus classical approach. Methods A cohort study was performed by identifying patients who underwent laparoscopic pelvic exenteration, and retrospectively comparing data with open cases from the same period of time, from 2000 to 2008. Results Fourteen patients underwent laparoscopic PE and 29 patients underwent an open exenterative procedure. All patients except one (97.6%) had received prior radiotherapy. Eighteen patients (41.9%) underwent total PE, 17 anterior PE (39.5%), and 8 posterior PE (18.6%). Urinary diversion (UD) technique consisted of 24 Miami pouch (68.6%), 9 Bricker diversion (25.7%), 1 Kock pouch (2.9%), and 1 ureterostomy (2.9%). Most frequent postoperative complications were related to the urinary diversion (45%) and bowel reconstruction (27.9%). Median estimated blood loss for the laparoscopy and laparotomy group was 400 ml (range 200–700 ml) and 875 ml (range 200–1600 ml), respectively. Transfusion rate was also significantly higher in the laparotomy group. Operative time, margin status, length of hospital stay, operative and postoperative morbidity, and disease and overall survival were not significantly different between both groups. Conclusions Laparoscopic PE is feasible with curative intent to selected patients. Potential postoperative advantages of laparoscopic approach when compared to classical approach, oncological safety of the procedure, and QOL considerations need to be further investigated.

Endoscopic management of lower ureteric stone after ureterosigmoidostomy

Ureterosigmoidostomy is one of the oldest technique for continent urinary diversion. Though less common nowadays, it is still a useful form of urinary diversion; simple to perform, offers good continence with minimal interference with life style. It still has a major role in conditions like ectopia vesicae and post-radical cystectomy for bladder carcinoma. We present a case of 33 years lady who underwent ureterosigmoidostomy at the age of 10 years for ectopia vesicae and later developed left pyonephrosis due to distal ureteric calculus. Left sided PCN was done and successful antegrade endoscopic removal of calculus relieved her symptoms.

Endoscopic management of lower ureteric stone after ureterosigmoidostomy

Ureterosigmoidostomy is one of the oldest technique for continent urinary diversion. Though less common nowadays, it is still a useful form of urinary diversion; simple to perform, offers good continence with minimal interference with life style. It still has a major role in conditions like ectopia vesicae and post-radical cystectomy for bladder carcinoma. We present a case of 33 years lady who underwent ureterosigmoidostomy at the age of 10 years for ectopia vesicae and later developed left pyonephrosis due to distal ureteric calculus. Left sided PCN was done and successful antegrade endoscopic removal of calculus relieved her symptoms.DOI: http://dx.doi.org/10.3126/joim.v32i1.4004Journal of Institute of Medicine, April, 2010; 32:1 pp.46-49

Lebensqualität nach radikaler Zystektomie – Übersicht und Analyse einer aktuellen Serie

Published evidence does not support a clear advantage in quality of life for continent versus incontinent urinary diversion or vice versa. We retrospectively assessed 61 patients after radical cystectomy with the EORTC-QLQ-C30 and -BLM30 instruments. Analysis was performed in dependence of age, sex, technique of urinary diversion and time-course of therapy. 36 patients had an incontinent and 20 patients a continent urinary diversion. Younger patients (p = 0.001) and those with a continent urinary diversion (p = 0.03) were found to have a statistically significant higher incidence of financial problems. Also patients with continent urinary diversion had significantly (p = 0.032) more problems in social integration. Furthermore, there were significant differences in social integration (p = 0.03) and emotional ability (p = 0.008) in the age-dependent analysis. Patients with a continent diversion had significantly more meteoristic problems (p = 0.007). This study also could not demonstrate any clear differences in dependence on the technique of urinary diversion. A good postoperative quality of life seems possible independent of age.

Ureteral Obstruction by the Vas Deferens after Urostomy

A male patient with spina bifida and paraplegia, born in 1968, underwent urostomy in 1973. In 1999, he developed urine infections. Intravenous urography showed bilateral hydronephrosis and hydroureter. This patient continued to get recurrent urine infections. In 2009, computed tomography of the abdomen revealed dilatation of the ureters, but the ureters reverted to normal calibre as they passed forward through the anterior abdominal wall. The vas deferens on either side was crossing and kinking the ureter. Magnetic resonance imaging of the abdomen confirmed that the level of obstruction in both ureters was at the site where the vas deferens crossed the ureter and kinked it. While performing urostomy, the ureters below the crossover by the vas deferens were detached from the bladder and attached to the skin for urinary diversion, thus causing the vas deferens to hook the lower end of the ureters. As the patient gained height and weight, thereby increasing abdominal girth, kinking of the ureters by the vas deferens was accentuated. In hindsight, bilateral midline cutaneous urostomy using the ureters below the crossover by the vas deferens represents a poor surgical technique for urinary diversion.

Ureteroileocecal Appendicostomy Based Urinary Reservoir in Irradiated and Nonirradiated Patients

The ureteroileocecal appendicostomy reservoir is designed to potentially decrease the morbidity of continent diversion, particularly in previously irradiated patients. We report our experience with this reservoir to compare complications in irradiated and nonirradiated patients. The records of 52 consecutive patients who underwent ureteroileocecal appendicostomy diversion between March 2001 and January 2008 were evaluated. Outcomes were analyzed according to whether patients received radiation therapy to the pelvis. Complications were reported as early (within 90 days of surgery) or late. Overall 29 patients received radiation therapy. The incidence of early complications requiring operative intervention was 14%, including 2 patients (9%) with and 5 (17%) without radiation (p = 0.68). All except 1 reoperation was done to revise the stoma. Early urinary tract infections developed in 17% of nonirradiated and 28% of irradiated patients (p = 0.51). The most common late complication was stomal stenosis requiring dilation on an outpatient basis, which occurred in 21% of patients, including 4 with (17%) and 7 without (24%) radiation (p = 0.74). Late ureteral complications requiring intervention were reported in 15% of renal units, including 2 of 44 without (5%) and 6 of 56 with (11%) radiation (p = 0.21). Ureteroileocecal appendicostomy is a safe, effective technique for continent cutaneous urinary diversion in heavily irradiated patients. Complication rates did not significantly differ between irradiated and nonirradiated patients, and appear improved compared to those in previous reports.

Endoscopic treatment of benign ureterointestinal anastomotic strictures in patients with urinary diversion

Objective To evaluate the clinical efficacy of endourologic treatment of benign uret-erointestinal anastomotic strictures in patients with urinary diversion. Methods Nine cases of benign ureterointestinal anastomotic strictures with a length of 1-3 cm following radical cystectomy and uri-nary diversion accepted endourologic treatment. 8 cases were treated by antegrade percutaneous ap-proach, 1 case by retrograde ureteroscopic approach. The strictures received balloon dilation, and ure-teral stents indewelled. Results In a follow up of 0.5-5.0 years, 1 case received percutaneous ne-phrostomy for complete ureterointestinal anastomotic atresia and refused to open operation reconstruc-tion. 5 cases had no recurrence after 2-3 endoscopic sessions. 3 cases needed long time ureteral stents indwelled. Conclusion Endourological technique for ureterointestinal strictures following urinary di-version avoided the disadvantages of open operation. Key words: Urinary diversion; Stomas strictures; Endoscopic; Surgical procedures

Current developments for pelvic exenteration in gynecologic oncology

The present review aims to update new techniques of pelvic exenteration including minimal invasive surgery, and discuss other aspects of this radical surgery, including worldwide differences. Major advances are made since the first description of pelvic exenteration and the operation is still under evolution. Explorative laparoscopy prior to exenteration is a valuable alternative to laparotomy to elect candidates for pelvic exenteration. There are considerable differences with respect to indications, contraindications, preoperative staging and adjuvant therapy after exenteration in different countries. Advances in laparoscopic instruments also led to the laparoscopic exenteration. The main limiting step of the operation is urinary diversion. New techniques of laparoscopic-assisted and robotic-assisted techniques of urinary diversion have been reported that decrease the operation time. Vascularized muscle flaps are preferred by many surgeons to fill the empty pelvis and provide an acceptable vaginal reconstruction. J-pouch seems to be a safer technique than end-to-end coloanal anastomosis for bowel reconstruction. Developments in the bioengineering tissue for pelvic reconstruction are required. Laparoscopy has the advantages of decreased blood loss, improved convalescence, lower incidence of wound infection and incisional hernia, short recovery periods, rapid return of bowel function, better pain control and improved cosmetics compared with laparotomy for pelvic exenteration. Magnification and improved visualization permits en-bloc dissection of tumor and good anastomosis technique. New techniques of urinary diversion, orthotopic neobladder and coloanal are promising.

Harnableitungsformen

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Outcome and quality of life in patients operated on with radical cystectomy and three different urinary diversion techniques

To assess outcome and quality of life (QoL) aspects among patients treated with three different diversion techniques: Bricker, Studer or Hemi-Kock, after radical cystectomy. Thirty-seven patients with Bricker conduit, 19 with Studer neobladder and 16 with Hemi-Kock neobladder answered a questionnaire concerning QoL, general health, relationship with partner, sexual function, satisfaction with information and follow-up, etc. Response rates were 79% (37/47), 100% (18/18) and 86% (19/22), in Bricker, Studer and Hemi-Kock patients respectively. Medical records were reviewed to assess cancer type, grade and stage. Both Studer and Bricker patients reported a high mean value of QoL (p>0.05). QoL was not influenced by tumour stage (pTa-T2 versus pT3-4) (p>0.05). After surgery, more Studer patients (78%) experienced practical problems compared with Bricker patients (40%) (p=0.01). Studer patients reported a higher influence on the everyday life compared with Bricker and Hemi-Kock patients (p<0.01 and p=0.05, respectively). Leakage in day-time was reported by 53% of Studer patients and 16% of Hemi-Kock patients (p=0.03). Moreover, all Studer patients had leakage at night compared with 58% of Hemi-Kock (p<0.01). The follow-up time after surgery was 56 months for Hemi-Kock patients compared with 26 months for Studer patients. Erectile dysfunction was reported by 81% of the men, with no difference between the methods of diversion. Patients in all diversion groups rated their QoL as high. Type of urinary diversion was not associated with any statistically significant difference in QoL outcome. However, Studer patients reported less favourable outcome regarding urinary continence compared with Hemi-Kock patients, probably owing to factors as shorter follow-up and surgical skill and experience. The results regarding urinary continence may explain why Studer patients reported more practical problems and a higher influence on their everyday life than Bricker and Hemi-Kock patients.

Cutaneous calicostomy for salvage urinary diversion

Objective We describe a salvage technique for urinary diversion in the face of an obstructed, undilated upper urinary tract utilized in the management of a premature newborn infant with bilateral renal candidiasis, namely cutaneous calicostomy. Methods An 850-g 24 weeks' gestation premature male infant developed obstructive nephropathy as a result of renal candidiasis. Systemic therapy with bilateral nephrostomy drainage and amphotericin B irrigations was repeatedly unsuccessful in eradicating the candiduria and fungal balls. Underlying bilateral proximal collecting system obstructions complicated the situation by rendering ureterostomy or pyelostomy impossible. Subsequent flank exploration was performed bilaterally, and bilateral cutaneous calicostomies were performed. Results The patient's urinary tract was successfully diverted and the fungal balls eradicated. Renal ultrasounds and antegrade nephrostograms through the cutaneous calicostomy stomas revealed the procedure to be successful. Unfortunately, the patient eventually died from overwhelming non-urologic sepsis approximately 3 months postoperatively. Conclusions Although systemic antifungal therapy with bilateral nephrostomy drainage has been shown to be successful in the treatment of obstructive uropathy due to renal candidiasis, surgical intervention is necessary when recurrent sepsis with candiduria persists. In the event that underlying collecting system obstruction is also present, cutaneous calicostomy is an option to consider in the treatment of this disease.