The Surgeon
Volume 10, Issue 1 , Pages 33-35, February 2012

Review of continent urinary diversion in contemporary urology

Department of Urology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA

Received 27 June 2011; received in revised form 2 September 2011; accepted 6 September 2011. published online 17 October 2011.

Article Outline

Abstract 

Continent urinary diversion (CUD) continues to be widely accepted by both urologists and patients for urinary reconstruction after cystectomy and some complicated cases of urinary incontinence. Different operative techniques and modifications have been contributed in the last 3 decades. The advantages and disadvantages of each technique have long been debated. Ureterosigmoidostomy is the oldest form of CUD but has lost favor in recent decades. The other 2 broad categories of CUD are cutaneous and orthotopic CUD. This review presents and discusses the current common forms of continent urinary diversions.

Keywords: Continent, Urine diversion

 

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Introduction 

In 1852, Simon1 attempted the first urinary diversion known as ureterosigmoidostomy in a patient with bladder exstrophy. This technique was later improved by Coffey2 in 1911 and became the dominant procedure for many decades. Urinary diversion has evolved from a simple conduit (incontinent) form of diversion into continent cutaneous diversion and orthotopic urinary diversion. Continence being defined as the ability to retain a bodily discharge voluntarily. This offers a means of increasing quality of life by eliminating the social and emotional burden of urostomy appliances.

Continent Urinary diversion (CUD) can be discussed under:

1.Classic and modified ureterosigmoidostomy;

2.Continent cutaneous urinary diversion;

3.Orthotopic urinary diversion (Neobladder) to the native, intact urethra.

Although ureterosigmoidostomy is seldom utilized currently, it continues to have a limited role in select patients. Central to most other current continent urinary diversion procedures, a detubularized bowel segment is utilized to make a low pressure, high-compliance reservoir. The reservoir can be constructed from small bowel, colon, caecum, stomach or composite reservoirs. Different techniques are utilized to prevent reflux. The necessity of preventing reflux in CUD has also been debated.

In 1993, Bissada et al.3 highlighted the important goals of continent urinary diversions to include (1) construction of an adequate volume, low pressure reservoir with high compliance, (2) reliable continence mechanism, (3) prevention of intestinal ureteric reflux or stenosis, (4) simplicity in construction, (5) avoidance of use of synthetic material, (6) avoidance of the use of excessive lengths of bowel, (7) ease of catheterization, (8) avoidance of need for revision, and (9) good cosmetic appearance.

The objective of this review is to present and discuss the current status of continent urinary diversion techniques, their complications, and their quality of life status post cystectomy.

Ureterosigmoidostomy 

Ureterosigmoidostomy (US) is a continent rectal reservoir technique with storage and elimination of urine through the rectum. It was first performed by Simon in 1852.1 Simon’s technique was discouraged due to poor results, and in 1911 Coffey introduced the concept of tunneling the ureter into the bowel.2 This technique of continent urinary diversion dominated for several decades.4 However, due to complications such as ureterointestinal obstruction, significant metabolic consequences, and pyelonephritis, US has remained relatively unpopular at many centers. Bissada et al.5 performed a retrospective study of 63 patients who had undergone ureterosigmoidostomy in the modern era. All patients were maintained on adequate supplementation of bicarbonate and potassium to prevent hyperchloremic acidosis and/or hypokalemia respectively. Renal function had remained stable in 92% of patients. Radiographic deterioration occurred in 23% of the renal units. About 50% of patients were able to stay dry through the night without waking. The most worrisome complication of US is late development of adenocarcinoma of the colon. Mean latency is roughly 25 years, but has rarely been reported as early as 6 years. Yearly colonoscopies are recommended after 10 years post-operatively.

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Continent cutaneous reservoirs 

Although the design for continent reservoirs has not changed substantially over the past two decades, there are continual modifications of the techniques utilized to create a reliable continence mechanism. To date there are a variety of continent reservoirs made from the ileum, ileocecal, ascending colon, sigmoid colon, and transverse colon. Rowland popularized the Indiana pouch.6 Our group prefers the Charleston pouch. In the classic Charleston pouch I, the ileocaecal segment and the appendix are used to construct the reservoir and the continence outlets respectively.

Mainz I and Charleston pouch I CUD 

These two pouches were introduced simultaneously in 1989. The Mainz pouch I has undergone considerable modifications over the years due to problems with the nipple valve. The technique now uses the reinforced intact ileocecal valve for the continence mechanism.7 Reported early complications included mechanical ileus in requiring open revision, pouch leakage requiring revisions, wound dehiscence, and fatal pulmonary embolism. Late complication rate was 37% which was mainly pouch related. Late complications included stomal failure, problems related to ureteral re-implants, stomal stenosis of ileal nipple, pouch calculi and incontinence.7, 8

The Charleston pouch procedure was introduced by Bissada in 1989.9, 10, 11, 12 In this procedure the continent reservoir is constructed from segments of the terminal ileum and ascending colon, which are detubularized and reoriented to provide maximum reduction in filling pressures. The in-situ appendix is utilized to provide a continent catheterizable stoma.

Operative technique of the Charleston pouch involves isolation of 15–20 cm of the terminal ileum, caecum, appendix, and ascending colon with their blood supply.9, 12 The ileum and colon are detubularized to form an inverted “U” shaped patch and the two pieces are sutured together to form a globular reservoir. In the absence of an appendix, a short segment of tapered terminal ileum (neoappendix) is constructed.

A longterm follow up of 201 patients with the Charleston pouch was published in 2007.10 Early and late complications were 11% and 26%, respectively. The interval between clean intermittent catheterizations was 2–8 h. Mean pouch capacity was 470 ml. Diurnal continence was achieved in 98% of the patients. Fifty percent needed night catheterization to stay dry. Urolithiasis developed in 16 patients (8%) and vesicoureteral reflux was noted in 15 renal units (4.4%). Follow up at ten years demonstrated no detrimental effects on vitamin B12 levels.

Indiana pouch 

In 1987, Rowland and colleagues at the University of Indiana reported the first use of the ileocaecal valve as a dependable continence mechanism. This operation lead to the creation of other operative techniques using the same theme, but with minor variations.

The Indiana pouch involves isolating a 10 cm segment of terminal ileum and the entire right colon. The ascending colon is detubularized and an appendectomy is performed to down to the ileocecal valve. The ileum is then formed to create a neourethra which is then brought to the skin to construct a stoma.

Rowland et al. reported an average pouch capacity of 400–500 mL and the overall continence rates were 93%.13 In 1996, Rowland reported at 1 year follow up, day and night time dry intervals of 4 h or more were achieved in 98% of patients and 84% reported they slept through the night.14

Pure transverse colon pouch 

With pelvic radiation, a whole new dilemma ensues. Use of extensively radiated bowel is associated with unacceptably high rate of complications including fistulas, ureterointestinal stenosis, and poor healing. The radiation field for pelvic malignancy includes the ileum, caecum, sigmoid colon, and the lower ureters.15 To avoid the use of irradiated tissue in these patients, we used a pure transverse colon continent cutaneous urinary diversion.16 In this procedure, the transverse colon is harvested with its middle colic blood supply. A 2 cm segment from each side of this colonic segment is used to form two Monti tubes which are utilized to construct the continent catheterizable outlet and anti-reflux mechanisms. The rest of the colonic segment is then fashioned into an “M” shape and detubularized to form the reservoir.

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Orthotopic neobladder diversion to the native, intact urethra 

The orthotopic neobladder is formed from detubularized bowel segment which is anastomosed (connected) to the patient’s native urethra. This eliminates the need for a cutaneous stoma and a collection device.17, 18 The continence mechanism relies on an intact proximal urethra with its rhabdosphincter component. Voiding is accomplished by increasing intra-abdominal pressure (Valsalva) and relaxation of the pelvic floor muscles.

Like continent catheterizable pouches, the terminal ileum (Hautmann Studer, Kock, and T Pouch), caecum, ileocecal (Mainz) segment or the sigmoid colon have been used to construct the urinary reservoir. Personal preference and surgeon’s experience dictates the type of orthotopic neobladder used at different centers.

Quality of life after continent urinary diversion depends on many factors. Those with continent catheterizable diversions generally have better quality of life than patients with orthotopic neobladders. Nocturnal incontinence and sleep interruptions which have a negative affect on sleep are more common with orthotopic neobladders with secondary effects on total quality of life.19

Use of bowel in urinary diversion has many short term and long term risks and sequelae.20 Ideally, it should be undertaken by major centers with adequate resources and expertise to provide patients with necessary short and long term support.

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Summary 

Continent urinary diversion is a widely accepted and an ideal procedure in selected patients after cystectomy. However, the procedure is not widely adopted as about half of these patients are managed with continent diversion while the others usually get a standard ileal conduit. The patient’s preoperative medical condition and surgeon’s experience are important components of the choice for continent urinary diversion technique versus ileal conduit. Strict patient selection criteria, improved surgical techniques, meticulous operative, postoperative and long term follow up have all had a positive influence on the outcome and survival of patients. As experience grows and the complication rates continue to decrease, continent urinary diversion techniques will become a more common procedure. In this review, the various forms of continent urinary diversions including ureterosigmoidostomy, continent cutaneous diversion techniques, and orthotopic urinary diversions were discussed. These are major procedures with known risks and sequelae. The patients ultimate clinical course depends on many factors which include the surgeon’s skill and experience, pre-operative co-morbidities, and patients’ compliance with postoperative instruction and care. Overall, we believe that continent urinary diversion is a viable surgical option that provides an attractive alternative for suitable patients requiring urinary diversion for malignant or benign bladder problems.

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References 

  1. Simon J. Ectopia vesicae (absence of anterior walls of the bladder and pubic abdominal parietes); operation for directing the orifices of the ureters into the rectum; temporary success; subsequent death; autopsy. Lancet. 1852;2:568
  2. Coffey RC. Physiologic implantation of the severed ureter or common bile duct into the intestine. JAMA. 1911;56:397
  3. Bissada NK, Marshall IY, Kaczmarek A. Continent urinary diversion and bladder substitution. JSCMA. 1993;89:435–438
  4. Coffey RC. Transplantation of the ureters into large intestine. Submucous implantation method; personal studies and experience. Brit J Urol. 1931;3:353
  5. Bissada NK, Morcos RR, Morgan MW, Hanash KA. Ureterosigmoidostomy: is it a viable procedure in the age of continent urinary diversion and bladder substitution?. J Urol. 1995;153:1429–1431
  6. Rowland RG. Present experience with the Indiana pouch. World J Urol. 1996;14:92–98
  7. Thüroff JW, Alken P, Riedmiller H, Jacobi GH, Hohenfellner R. 100 cases of MAINZ pouch: continuing experience and evolution. J Urol. 1988;140:283–288
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  9. Bissada NK, Abdallah MM, Aaronson I, Hammouda HM. Continent cutaneous urinary diversion in children: experience with Charleston pouch I. J Urol. 2007;177:307–311
  10. Abdallah MM, Bissada NK, Hamouda HM, Bissada AN. Long-term multi-institutional evaluation of charlston pouch I continent cutaneous urinary diversion. J Urol. 2007;177:2217–2220
  11. Hammouda HM. Charleston pouch with in situ appendix and concealed abdominal stoma. Afr J Urol. 2003;9:176–181
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  14. Rowland . Rowland RG: Present experience with the Indiana Pouch. World J Urol. 1996;14:92–98
  15. Alfret HJ, Gillenwater JY. The consequences of ureteral irradiation with special reference to subsequent ureteral injury. J Urol. 1972;107:369–371
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  18. Stein JP, Cote RJ, Freeman JA, Esrig D, Elmajian DA, Groshen S. Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer. A pathological review of female cystectomy specimens. J Urol. 1995;154:1329–1333
  19. Thulin H, Kreicbergs U, Wijkstrom H, Steineck G, Henningsohn L. sleep disturbances decrease self assessed quality of Life in Individuals who have undergone cystectomy. J Urol. 2010 July;184:198–202
  20. Shokeir AA, Shamaa M, El-Mekresh MM, El-Baz M, Ghoneim MA. Late malignancy in bowel segments exposed to urine without fecal stream. Urology. 1995;46:657–661

PII: S1479-666X(11)00126-0

doi:10.1016/j.surge.2011.09.003

The Surgeon
Volume 10, Issue 1 , Pages 33-35, February 2012

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