URINARY DIVERSIONS. Winter 2016 Dr P. O Malley

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1 URINARY DIVERSIONS Winter 2016 Dr P. O Malley

2 OVERVIEW Who gets diversions? What s involved with cystectomy? What are the different types of diversions? What are the problems with various diversions? How do we choose which diversion? Post-op management

3 PATIENTS WITH DIVERSIONS Radical Cystectomy Invasive UCC (including into prostate) Palliation in metastatic disease Early cystectomy for UCC Urethral carcinoma much less common Simple Cystectomy essentially non-oncological IC Crippled bladder post radiation, neurogenic Hemorrhagic cystitis Severe incontinence

4 WHY CAN T WE LEAVE BLADDER? In non-oncologic cases why can t we leave bladder? Pyocystitis Hemorrhage Sepsis Pain Fistula Malignancy

5 WHAT S INVOLVED IN THE SURGERY Radical Cystectomy - bladder, prostate, seminal vesicles, lymph nodes - bladder, urethra, +/- vaginal cuff, uterus, ovaries Simple Cystectomy - bladder, +/- prostate, seminal vesicles, No lymph nodes - bladder, +/- urethra, vaginal cuff, uterus, ovaries

6 TYPES OF DIVERSIONS Stomach, jejunum, ileum, & colon are possible Goals of Diversion: Adequate capacity, low-pressure No fecal contamination Complete & voluntary emptying No reflux No electrolyte reabsorption Not completely necessary

7 TYPES OF DIVERSIONS Incontinent Ileal conduit (most common) + Cutaneous Ureterostomy Continent Continent cutaneous - Indiana Orthotopic Studer/Hautman Rectal Mainz II

8 ILEAL CONDUIT Simple, lowest complication rate CI: Short bowel syndrome, radiation, IBD Uses terminal ileum

9 ILEAL CONDUIT Bowel re-anastamosed using stapler Ureter(s) anastamosed to conduit segment

10 ILEAL CONDUIT Pink-red, moist, slightly everted 1-2 ureteric stents Red - Right, blue-left +/- multi-eye catheter (Remove POD3-5)

11 STOMAL COMPLICATIONS Seperation of mucocutaneous junction Stomal Retraction Stomal Prolapse Parastomal hernia Can also have significant peri-stomal lesions: Candidiasis, Folliculitis, Dermatitis, Pseudoverrucous, etc..

12 STOMAL APPLIANCES 1 piece vs 2 piece 1 piece Easier for those with less dexterity and skill Patients with lower cognition Lower profile Costs less Easier for pts with hernia 2 piece Rotation of pouch Better fit Can change bag without changing wafer Adhesive & mechanical varieties

13 CUTANEOUS URETEROSTOMY Historically plagued by high stenosis rate Method to decrease morbidity of cystectomy and diversion in unhealthy or older patients Obviates requirement for bowel division & reanastamosis OR time Recovery time Complication rate Post-op ileus, anastamotic leak Many times ureteric stents will be changed periodically but left in place permanently SKIN

14 CUTANEOUS URETEROSTOMY Was a thing of the past but several people have started doing them again

15 TYPES OF DIVERSIONS So why do we have different types. Vanity? Or as we like to call it Preference or Quality of Life

16 TYPES OF DIVERSIONS Complications Dexterity required Cognition & Med literacy Time & Energy required Investment Quality of Life??

17 INDIANA POUCH Contra-Indications (same for neobladders) Renal impairment Urethral UCC (pre-op) Margin (+)ve (intra-op) Radiation (extensive) Age or limited life expectancy, poor cognition IBD Dexterity issues Short bowel Liver Failure

18 INDIANA POUCH There are several continent cutaneous diversions: Indiana, Reverse Indiana, Penn, R colon, Kock, Mainz No one really uses any except Indiana Capacity, initially is cc Continent, low-pressure, +/- anti-reflux Ileum + Ascending Colon Can be brought to umbilicus or abdominal wall

19 INDIANA POUCH Ascending colon & TI Opened and de-tubularized TI is narrowed down and imbricated for continence

20 INDIAN POUCH - DRAINS 1-2 Ureteric stents to bag, D/C POD3-5 1 Malecot to bag, D/C POD21 1 red rubber to bag, Cap POD2-3, D/C POD14 1 JP D/C <D/C Irrigation: some surgeons do from POD0 some start POD 3-5 -I do POD3 unless low Uo

21 INDIANA POUCH At D/C POD 5-7 D/C ureteric stents and JP Capped Red Rubber Malecot to SD One bag at this point POD 14 D/C Red rubber Start CIC of stoma, first time in clinic if there is an issue we can problem solve it Malecot is capped but they record residual after each CIC Thus we can be confident they can empty POD 21 D/C Malecot CIC Q3H Q4-5H as reservoir expands Irrigate PRN NS to flush mucous

22 ILEAL NEOBLADDER STUDER Similar contraindications to Indiana Number of types but Studer used almost universally

23 ILEAL NEOBLADDER Isoperistaltic limb Continence dependent on sphincteric preservation IE similar post-op issue with leakage to prostatectomy

24 ILEAL NEOBLADDER 1-2 Ureteric stents Malecot Foley JP drain Ureteric Stent x2 Malecot Irrigate α Surgeon

25 ILEAL NEOBLADDER POST-OP At D/C POD 5-7 D/C ureteric stents and JP Foley to SD Malecot capped One bag at this point POD 14 D/C Foley TOV Timed voiding Q2H, Malecot is safety valve and measure residual after each voiding POD 21 D/C Malecot Voiding Q3H Q4-5H as reservoir expands Irrigate via CIC PRN w/ NS to flush mucous if needed

26 ISSUES AFTER URINARY DIVERSION Stomal Stenosis Ileal Conduits very rare Cutaneous ureterostomy very common, need stents Indiana pouch not uncommon, more so with umbilical Incontinence Indiana Pouch % Ileal Neobladder 4-13% UTI Indian Pouch 7% Ileal Neobladder %

27 ISSUES AFTER URINARY DIVERSION Complications related to using ileum Hyperchloremic metabolic acidosis Hypokalemia Altered sensorium Disorders of liver metabolism Vit B12 deficiency Bone demineralisation Mucous production UTI Treat if symptomatic and positive C/S Dipstick may normally show LE and nitrites (bowel)

28 ISSUES AFTER URINARY DIVERSION Anastomotic leak (urine) Indiana 2-10% Ileal NB % Anastomotic stricture Indiana 4-7% Ileal NB % Incomplete Emptying Ileal NB 4-25%

29 SO WHICH DIVERSION Multifactorial decision Patient factors Underlying medical/psychosocial issues Disease factors Patient preference Perceived Actual System factors

30 SOME ISSUES TO CONSIDER Body habitus - NS has average higher BMI more leakage with a NB Geography remote regions = less access to tertiary care in both ER and OP setting Dexterity/cognition if either issue do NOT do neobladder or Indiana pouch Older people = usually less vain, more practical They have higher QOL scores with conduits Younger people tend to have higher QOL with continent diversions No real validated questionnaire to compare the different types of diversions though

31 WHICH WOULD YOU CHOOSE? A. Cutaneous Ureterostomy B. Ileal Conduit C. Indiana Pouch Depends what you re looking for? D. Ileal Neobladder

32 HELPFUL RESOURCES Bladder Cancer Canada (Canada) & Bladder Cancer Advocacy Network (US) Canadian Urological Association: k/25-bladder_cancer_when_it_invades_the_muscle.pdf European Association of Urology: European Association of Urology Nurses: American Nurses Credentialing Center s Commision on Accreditation OEBPS/Text/Section0003.html

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