Urinary Diversion Following Cystectomy

Udo Nagele
*
, Karl-Dietrich Sievert, Axel S. Merseburger,
Aristotelis G. Anastasiadis, Arnulf Stenzl
Department of Urology, University of Tuebingen, Hoppe-Seyler-Str. 3, Tuebingen 72076, Germany
Abstract
Urinary diversion is an essential component of the surgical procedure after cystectomy. Replacement with an
orthotopic ileal neobladder should be the rst choice if external urethral sphincter sparing surgery is possible,
offering good long-term function, quality of life and patients acceptance with few complications.
The possible use of a variety of alternative intestinal segments widen the horizon of the reconstructive surgeon,
allowing him or her to be prepared for unusual cases.
Contraindications for orthotopic neobladder reconstruction include tumour location, reduced renal, liver,
intestinal function, intellectual ability and physical handicaps.
It is therefore important to customtailor the appropriate mode of diversion for individual patients with a variety of
options available, including ureterocutaneous stomas, intestinal conduits and continent catheterizable reservoirs and
orthotopic neobladders. All these techniques require detailed knowledge of the possible metabolic problems
encountered by using gastrointestinal segments and how they react in contact with urine. Modern surgical
techniques such as nerve sparing surgery have the ability to preserve postoperative continence with voluntarily
micturition as well as sexual function. In addition, preliminary experimental data hold great promise that the off
shelf bladder substitute may become a technique of choice in the future, avoiding common problems encountered
using current technqiues.
# 2005 Elsevier B.V. All rights reserved.
Keywords: Urinary diversion; Bladder substitute; Conduit; Neobladder; Continent catheterizable reservoir
1. History
In 1852, Simon rst reported a urinary diversion
using intestinal segments [26]. In 1888, the rst ortho-
topic diversion in an animal study was performed by
Tizzoni and Foggi [39]. Coffey introduced uretreosig-
moidostomy in 1911, which became the standard tech-
nique, although the ileal conduit was reported by Zaayer
in the same year [22]. It took another 40 years, in which
many patients died because of hyperchloremic acidosis
(suffered by 80%of all patients with ureterosigmoidost-
omy) until Bricker established the ileal conduit as a
diversion of rst choice in 1950 [5].
The rst use of detubularized recongured ileal
segments in bladder augmentation as a low pressure
reservoir was described by Goodwin 1959. This tech-
nique was able to increase bladder capacity with
minimal pressure peaks [10,11].
Since then, many different continent catheterizable
reservoirs and neobladders were introduced. However,
urologists have not been able to overcome problems
related to the use of bowel such as resorption of urinary
contents, mucus production, and abnormal peristalsis
instead of detrusor-like contractions. In many centers
of excellence worldwide, a continent reservoir, pre-
ferably connected to the urethra is the urinary diversion
of choice today. For the creation of such reservoirs,
ileal segments are preferred, because of their lower
intraluminal pressure peaks, and their ease of surgical
handling.
EAU
Update Series
EAU Update Series 3 (2005) 129137
* Corresponding author. Tel. +49 7071 2986615;
Fax: +49 7071 2985092.
E-mail address: Udo.Nagele@med.uni-tuebingen.de (U. Nagele).
1570-9124/$ see front matter # 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.euus.2005.07.003
2. Urinary reservoirs - which
gastrointestinal segment?
2.1. Stomach
Metabolic acidosis and its related adverse effects are
seen with ileal and colonic diversions, especially
among younger patients. Gastric reservoirs have been
recommended by several authors with a variety of
outcomes [14,21]. Short term follow-up demonstrated
favourable results [24,27] with reduced mucus produc-
tion and prevention of hyperchloremic acidosis by the
acidic milieu of the urine. To overcome the disadvan-
tages of haematuria-dysuria syndrome, a so-called
composite urinary reservoir, combining gastric
and ileal or colonic segments were favoured [4,6].
The idea is to combine a segment with proton secretion
with an absorbing one. Therefore, metabolic acidosis
and its sequelae, which are inherent to ileal and colonic
segments, can be prevented. Furthermore, composite
reservoirs may be an option in patients with renal
insufciency, which is a relative contraindication to
continent urinary diversion. However, our knowledge
of ion interactions of the gastric and lower intestinal
segments remains limited [29].
2.2. Ileum
The authors of the largest series of continent urinary
diversion prefer a re-congured low-pressure ileal reser-
voir, according to the principle of the Goodwin cup
patchtechnique [28,37]. Goodmediumtermresults with
acceptable ileum-related morbidity continue to be
reported among those using the ileal low pressure
reservoir [37]. The ileum is important for vitamin B
12 and bile acid absorption. Resection of up to 60 cm
does appear to cause signicant side-effects regarding
absorption, if the terminal ileum is preserved. Fat-solu-
ble vitamin malabsorbtion, biliary salt loss and
increased oxalate absorption are of major concern, if
over 100 cmof ileumare resected, but in the majority of
cases a 4060 cm long segment is adequate.
Using ileumas urinary diversion causes a impairment
in renal acid and salt regulation. Hyperkalaemic, hypo-
chloraemic acidosis, and osteoporosis and osteomalacia
can occur in the long term. Mild acidosis is common
postoperatively and can be controlled with administra-
tion of oral sodiumbicarbonate. The absorptive capacity
of the bowel segment decreases 8-fold with time, result-
ing in less re-absorption and metabolic problems [15].
2.3. Ileocoecal valve
The ileocaecal valve is important for controlling the
transport of ileal contents into the colon. Resection of
the valve with the terminal ileum may lead to rapid
bowel propulsion, resulting in soft stools, diarrhoea
and malabsorbtion [3].
In a group of patients with a Mainz pouch, using the
ileocaecal valve and terminal ileum, 32% and 11% of
patients demonstrated decreased vitamin B
12
and folic
acid levels respectively. More than 30% of this cohort
had a metabolic acidosis, in addition to an increased
risk of developing renal, and/or gallbladder stones [37].
2.4. Colon
The sigmoid colon is redundant in many patients.
With its large diameter compared to the small bowel and
its relative mobility, it can easily be brought down to the
urethra and allows a relatively easy anti-reux ureteral
implantation. VitaminB
12
malabsorbtionandbiliarysalt
loss are minor compared to the terminal ileum. Despite
these advantages and even after detubularization and
reconguration, patients with a sigmoid colon neoblad-
der have a more frequent night-time voiding pattern.
This may be due to enhanced peristaltic activity and
higher pressure of the large bowel [12]. Initially reported
results suggest a high acceptance rates by patients, but
long-term follow-up, especially regarding the upper
urinary tract is warranted and the technique requires
further evaluation [9].
2.5. Appendix
The appendix is routinely removed during anterior
exenteration in some centres. However, it might be
quite useful to create a catheterizable nipple for a
continent cutaneous diversion. Some surgeons use
the appendix as the intestinal segment of choice in
forming a continence mechanism [8]. Surprisingly, a
continent ileocaecal diversion can be achieved with an
unaltered appendix conduit [7,25] and obviating more
complicated tunnelling techniques. Whenever the
appendix is not present or is inadequate, transversely
tubularized ileal segments by using the Monti principle
may be used as an alternative to create the efferent
continence mechanism of urinary pouches [38].
3. Preparationof the ureters for urinary
diversion
Irrespective of the type of urinary diversion used,
postoperative ureteral anastomotic stricture is a recog-
nised complication. Ischemia of the distal ureter is
avoidable, by taking note of its vascular supply with its
common variations [32] and preserving the periureteral
adventitial tissue - even below the level of ureteral
dissection. This reduces the risk of ischemia and
strictures. The left ureter should be moved across
U. Nagele et al. / EAU Update Series 3 (2005) 129137 130
the retroperitoneum above the level of the inferior
mesenteric artery to the contralateral retroperitoneal
space in order to maximise length and avoid unneces-
sary kinking (Fig. 1).
4. Incontinent urinary diversion
4.1. (Transuretero-) Ureterocutaneostomy
Cutaneous ureterostomy is the least desirable formof
urinary diversion, but despite its disadvantages it is a
valid option in selected cases, e.g. after palliative
cystectomy in elderly frail patients, in patients with
incurable malignancies or pelvic complications, as
(temporary) diversion in situations when gastrointest-
inal diversion is not possible or whenever the bladder
needs to be diverted because of stulae or haemorrhage.
The ureters are carefully mobilised to the bladder,
with minimal disruption to their blood supply, ligated
and divided. After creating a retroperitoneal tunnel
cranial to the inferior mesenteric artery, the less dilated
left or right ureter is transposed to the contralateral
side. A V- or U- shaped skin incision is made in the
skin, and a track is developed through the abdominal
wall in the most direct line. The ureter with the largest
diameter is pulled through the track without tension
and angulations and spatulated. A4/0 or 5/0 absorbable
suture is placed through the apex of the skin ap into
the apex of the ureteral spatulation.
The dilated ureter is then incised longitudinally for
approximately 2 cm and anastomosed to the other
ureter without any tension, using and end-to-side con-
guration to complete the transureteroureterostomy.
An omental ap can be used to secure both anasto-
moses and the abdominal tunnel.
4.2. Ileal and colonic conduits
In contrast to a cutaneous stoma, the ileal conduit
has no risk of stenosis at the skin level, because of the
short gut segment interposed between the skin and the
ureters. Usually, a 1012 cmsegment of terminal ileum
approximately 20 cm proximal of the ileocecal valve is
used. For a low pressure diversion it is important to pay
caution to a short, straight conduit without kinking and
a sufcient wide fascial opening (usually x-type inci-
sion). The segment is used in an isoperistaltic fashion.
Ureteric implantation can be carried out in three
ways:
A: The Bricker and Nesbit technique: Both ureters are
implanted individually in an end-to-side technique
[5].
B: Wallace 66 parallel oriented ureters; both spatu-
lated at the distal end for a distance slightly longer
than the diameter of the ileum. The posterior plate
is sutured and anastomosed in a side-to-end fashion
to the ileal stump [41] (Fig. 5).
C: Wallace 69 - end to end oriented ureters; both
spatulated and sutured to a ureteral plate anasto-
mosed in a side-to-end fashion to the ileal stump.
Of greatest importance is the position of the stoma.
Improper preoperative selection for the stoma location
causes urinary leakage underneath the stomal plate
because of skin folds or interference with the waist
belt. The location should be above or below the waist-
band and not too close to the umbilicus, the edge of the
rectus muscle, a bony prominence or a scar, and must
be tested with the patient and marked pre-operatively.
For decades the ileal conduit has been the procedure
of choice for urinary diversion. It remains a valid
option or even a better alternative than a continent
urinary diversion in many cases. The short gut segment
limits metabolic changes and is therefore recom-
mended in patients with renal insufciency (creatini-
ne > 2 mg/dl) or severe hepatic dysfunction, and when
a postoperative radiation might be necessary. Contra-
indications, among others, are short bowel syndrome,
radiation disease of the terminal ileum and ascites. In
cases of severe radiation disease in the pelvis, a
transverse colon conduit may be an alternative option.
5. Continent urinary diversion
5.1. Reservoir construction
The reservoir is a compromise between good capa-
city, low pressure storage and metabolic issues, par-
tially caused by the re-absorptive surface of the pouch.
U. Nagele et al. / EAU Update Series 3 (2005) 129137 131
Fig. 1. Anatomical specimen of a female pelvis outlining the arterial
vascularization of the distal ureter. The arrow depicts a common iliac
arterial branch which, apart from the vesical arteries, is the only other major
supply of the distal ureter.
A spherical reservoir stands for maximum volume
and minimum re-absorptive surface. To minimize pres-
sure peaks caused by coordinated bowel contractions,
detubularization of the used bowel segment is manda-
tory. In addition, according to Laplaces law (pressur-
e = tension/radius) a spherical reservoir has a low end-
lling pressure with maximum radius. Despite the
mathematical advantages of an M or a W folded
reservoir, we prefer a cross folded U [11] because of
its simplicity, and its documented low intraluminal
pressures due to the so called wind chamber effect.
5.2. Continent catheterizable reservoir
A catheterizable reservoir is indicated whenever
external urethral sphincter sparing surgery is not pos-
sible, or in patients with urethral malformations, spinal
injuries or other complex neurological defects. Patient
compliance is of outmost importance because of the
need for regular intermittent self-catheterisation. How-
ever, due to the lack of an overow valve there is a
certain danger that catheterisation difculties may lead
to perforation and even bladder rupture, if regular
reservoir evacuation is delayed. Several different con-
tinence mechanisms have been described. Nowadays
mostly the appendix, tapered ileum, or intussucepted
ileal nipples are used.
The catheterizable stoma is the main source of pro-
blems and complications in these patients. The reported
re-operation rate varies from 22% to 49 % [30] with
stomal stenosis ranging from 4% to 15% [23,37], an
overall incontinence rate of 3,2% [37], and ureteral
stenosis in 8%of patients [2]. Using the ileocaecal valve
and terminal ileum for a continent catheterizable reser-
voir carries the potential risks of diarrhoea, hyperchlor-
aemic acidosis and malabsorbtion. Metabolic and
clinical work-up, with regular check-up of serum para-
meters for inammation, renal and hepatic function,
metabolic acidosis, electrolyte disorders and hydration
is important. Adequate oral sodiumbicarbonate supple-
mentation is often necessary.
5.3. Orthotopic neobladder
The orthotopic neobladder continues to gain popu-
larity. Quality of life issues including physical integ-
rity, near normal voiding and continence are important
factors that many patients consider important, after
cure from their cancer. Contraindications are listed in
Table 1. The patients continence and external urethral
sphincter must be intact pre-operatively. To rule out
cancer inltration and possibly positive margins, pre-
operative cystoscopic biopsies of the bladder neck/
prostatic urethra as well as intraoperative frozen sec-
tions of the resected margins are mandatory.
From the oncological standpoint there are no sig-
nicant differences in cancer-specic survival between
ileal conduits and contemporary bladder substitutes
[42]. The low local tumor recurrence rate of 11%
and the recurrence rate of 25% in the urethra support
the trend towards orthotopic urinary diversion [13,18]
and demonstrate that safe patient selection for an
orthotopic neobladder is possible.
After decades of searching for the ideal gastro-
intestinal segment, many surgeons favour nowadays
the ileal neobladder, because of easy harvesting and
handling as well as low intraluminal pressures [15,36].
Approximately 40 cm of ileum are necessary to create
an adequate volume reservoir. Key points with every
neobladder are the connections cranially to the ureters
and caudally to the urethra.
5.3.1. Afferent anastomosis: Reux prevention how
and when to do it
5.3.1.1. Technique of reux prevention
5.3.1.2. Camey - Le Duc. A channel is created on the
posterior intestinal wall by incising the mucosa long-
itudinally for 33.5 cm all the way to the muscularis.
At the proximal end, the obliquely cut the ureter
penetrates into the lumen of the neobladder and is
xed at the distal end of the channel. The Camey-Le
Duc ureteroileal anastomosis must be considered his-
torical now. It has been widely abandoned due to its
high complication rate.
5.3.1.3. Intussusceptive ileal nipple.The Hemi-Kock
type of intussusceptive ileal nipple with both ureters
implanted at the proximal end of the nipple creates a
good intraluminal valve, but there is considerable risk
of long-term obstruction (Fig. 2).
5.3.1.4. Serosa-lined extramural tunnel implanta-
tion (Abol-Enein, Stein). After detubularization, the
ileum it is arranges as a W, M, or double-folded
U. Nagele et al. / EAU Update Series 3 (2005) 129137 132
Table1
General contraindications to continent urinary diversions
1. Chronic renal failure with serum creatinine exceeding 2 mg/dl
without acute hydronephrosis. In doubtful cases percutaneous
drainage is indicated preoperatively in an attempt to normalise
renal function.
2. Severe hepatic failure.
3. Compromised intestinal function especially caused by radiation
or inammatory bowel disease.
4. The presence of histologically proven cancer at the prostatic
apex (male) or bladder neck (female)
5. Lack of patient motivation and/or intellect to follow a strict
postoperative voiding regime, to accept possible incontinence
(mainly nocturnal) in the early post-operative phase and
sometimes in the long-term.
6. Pelvic oor disorders such as detrusor sphincter dis-synergia
or neurourological diseases.
U. The serosa is anastomosed approximately 2 cm
from the medial edges of the cut aps on each wing
with running sutures, thus forming two troughs. The
spatulated and joined ureters or a tapered 1012 cm
segment of ileum to which the ureters are anastomosed
proximally, placed into the trough and anastomosed to
the bowel mucosa at the distal end (Fig. 3). The tunnel
is closed above the ureters by a running suture forming
an extramural serosa lined tunnel which serves as a
volume dependent antireux mechanism.
5.3.1.5. Isoperistaltic tubular limb. Ureters are
implanted in an end-to-side fashion into the proximal
end of a 15 to 20 cm long afferent tubular segment,
where antireux protection is achieved by coordinated
peristalsis [19].
5.3.2. Efferent anastomosis
Good voiding function is mandatory to achieve good
quality of life with an orthotopic neobladder substitu-
tion. In recently reported series, daytime and night time
continence range between 87% and 98%, and 72% and
95% respectively [1,16,17,20,40]. Incomplete bladder
emptying with the need to perform intermittent self
catheterisation is seen in up to 15% of females [35] and
in 4% of male patients [13].
Precise preparation of the urethra is essential. Ure-
thro-ileal anastomosis is performed at the most caudal
point of the neobladder (determined digitally), either
by leaving a small opening at the end of the ventral
suture line forming a spout (our preferred technique in
male patients) (Fig. 5) or by making a 0.5 cm opening
into the ileal wall close to the mesentery (female
patients). It is important in female patients not to
U. Nagele et al. / EAU Update Series 3 (2005) 129137 133
Fig. 3. Serosa-lined extramural tunnel implantation with tapered ileum.
Fig. 4. Preparation of the ileal segment.
Fig. 2. The Herni-Kock intussusceptive ileal nipple.
Fig. 5. Wallace 66 ureteral anastomosis.
use the corner of the pouch, as this may lead to kinking
later on and difculties with voiding.
5.3.3. Neobladder
The neobladder described here appears to be eco-
nomic with regards to bowel length utilisation, ef-
cient in reux protection of the upper urinary tract, and
less time consuming than other methods. The left ureter
is transposed as mentioned above. Both ureters are
spatulated and conjoined to a ureteral plate.
40 cm of terminal ileum (Fig. 4) are isolated and
the ileal tube is arranged as a U. Starting 23 cm
from the endings, a running seromuscular suture of
approximately 10 cm at the mesenterial insertion
forms a so called ileal trough (Fig. 6). The ileum
is opened at its antimesenteric border in its entire
length. The conjoined ureters are placed into the ileal
trough, sutured to the distal end of the trough and
buried by closing the ileal aps over both ureters.
Two mono-J stents are placed into the ureters, the
ileal bladder is completed with a running suture line,
cross folded, and closed on the left side. The mono-J
stents are brought through the side wall of the neo-
bladder (Fig. 7).
In male patients the right side is closed leaving a
small opening at the distal end where the bladder is
anastomosed with the urethra with 6 stay sutures over a
2022 Fr catheter (Figs. 8 and 9).
In female patients the right side is closed comple-
tely and a small separate opening serves as the neo-
bladder neck where the urethra is anastomosed with 6
sutures.
At the end of the procedure, a J-shaped omentum
ap is brought down and led around the bottom part of
the pouch. Alternatively, portions of the ileal bladder
are xed to the pelvic wall, obstruction caused by ileal
U. Nagele et al. / EAU Update Series 3 (2005) 129137 134
Fig. 6. U-shaped isolated ileum segment with ileal trough.
Fig. 7. Detubularised neobladder with afferent anastomosis, during cross-
folding.
Fig. 8. Reconstructed neobladder with spout shaped afferent opening.
Fig. 9. Neobladder in situ.
folds and a pouchocele = descent can thus be
avoided in addition to securing the urethrointestinal
junction [31,33]. Advantages, postoperative follow-up
and illustrations of the technique are shown in Table 2
and Fig. 10, respectively.
5.4. Uretero (ileo-) sigmoidostomy
Ureterosigmoidostomy, though still performed, has
been largely replaced by other techniques because of
metabolic acidosis, renal failure, and tumourigenesis
typically with adenocarcinoma at the site of the ana-
stomosis years after implantation [9] (Fig. 11). By
detubularisation of the sigmoid, ileal interposition,
and antireux implantation of the ureters, some of
the complications of this technique can be reduced.
Major disadvantages are bacterial reux causing pye-
lonephritis and stenosis of the ureteral implantation,
which causes considerable renal damage, leading to re-
operation. In contrast to the ileal neobladder, reabsorb-
tion and metabolic problems are higher, result in an
increased need for permanent sodium bicarbonate
substitution and, interference with future systemic
chemotherapy. 6. Conclusion
In the 21st century, in both male and female patients
with bladder cancer requiring cystectomy, an orthoto-
pic bladder substitution should be the rst choice of
urinary diversion whenever the urethra can be spared
safely, without compromising the oncological aim of
the procedure. Renements of surgical techniques such
as autonomic nerve preservation and improved afferent
(ureteral) and efferent (urethral) anastomoses result in
excellent functional outcomes and improved quality of
life. Understanding the structural transformation of the
ileal mucosa and metabolic changes as well as the
functional principle of the neobladder results in a
structured follow-up, and avoids postoperative com-
plications. Other types of continent and incontinent
urinary diversion remain valid and time-tested options,
whenever an orthotopic bladder replacement is not
possible. Using careful selection criteria, the type of
U. Nagele et al. / EAU Update Series 3 (2005) 129137 135
Table 2
Advantages of the orthotopic technique described
1. Economic with regards to bowel length utilised.
2. Cross folded U (Goodwins cup-patch principle) combines low
pressure with simplicity and short suture lines.
3. Serosa lined extramural tunnel implantation achieves an antireux
mechanism with volume depended closure and has a low
stricture rate.
4. Wallace implantation in the middle of the posterior neobladder
wall facilitates endourological, especially ureteroscopic
procedures and follow up if necessary.
Fig. 10. Bladder replacement: postoperative management.
Fig. 11. Ureteroileorectosigmoidostomy.
urinary diversion used does not appear to impact on
cancer specic survival.
Future concepts, including tissue engineering tech-
niques, show promising results in the laboratory. This
is however outside the scope of the current article,
and several hurdles need to be overcome before the
rst off-the-shelf neobladder can be used in our
patients.
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