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Continent Cutaneous Urinary
Diversion inWomen
JakobKlemm, MalteW.Vetterlein,
andMargitFisch
15
Introduction
To reestablish urinary passage after removal of
the bladder, there are various options for urinary
diversion (UD), including conduits, cutaneous
ureterostomy, orthotopic neobladder, and continent cutaneous urinary diversion (CCUD). Aside
from bladder cancer, which represents a common
malignancy with an incidence rate of
2.4/100,000 in women worldwide in 2020 [1],
UD is also used in the management of advanced
or recurrent pelvic malignancies, as well as for
benign indications as a salvage treatment strategy
[2–4]. However, radical cystectomy, which is the
standard of care for nonmetastatic muscleinvasive bladder cancer, is associated with signicant perioperative morbidity and is the most
common indication for UD [5, 6]. In general,
incontinent UDs are used more frequently with
an increasing trend in recent years [7]. An ileal
conduit is the most common form of incontinent
UD across both genders, whereas an orthotopic
neobladder is the most frequent variant of continent UD [8, 9]. Although it has been shown that
an orthotopic neobladder is feasible in women
under certain conditions, it is performed signicantly more often in men [10]. For this reason,
J. Klemm · M. W. Vetterlein · M. Fisch (*)
Department of Urology, University Medical Center
Hamburg-Eppendorf, Hamburg, Germany
e-mail: j.klemm@uke.de; m.vetterlein@uke.de;
m.sch@uke.de
CCUD represents an important alternative, particularly in women, offering the benet of
patients being dry immediately after surgery [11,
12]. In this chapter, we aim to provide a compre-
hensive overview of the history, different techniques, outcomes, and complications of CCUDs
in women.
History, Techniques, andOutcomes
forCCUD Reservoirs
Many of the earliest descriptions of various
CCUD techniques date back to the years
1890–1920. However, due to high complication
rates and poor functional outcomes, these
approaches were abandoned [11]. Decades later,
the techniques were revived and rened as a
result of progressive medical advancements, particularly the advent of antimicrobial treatment
and antacids [11].
In general, all techniques involve a reservoir
into which the ureters are implanted, as well as an
efferent segment with a continence mechanism
that connects the reservoir to the skin. The reservoir is emptied intermittently by selfcatheterization through the efferent segment. In
the following, we provide a brief overview of the
history, techniques, and outcomes of the most
common surgical approaches for CCUDs.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_15
145
146
dcba
J. Klemm et al.
Ileocecal Reservoirs
The rst descriptions of an ileocecal reservoir
were published between 1900 and 1910 for an
orthotopic bladder replacement without achieving continence [13, 14]. The next descriptions of
ileocaecal reservoirs followed in the 1950s by
Gilchrist, who successfully developed the technique for a continent orthotopic reservoir.
However, their approach was not reproducible by
others [15].
In the 1970s, the rst heterotopic continent
ileocecal reservoir-based UDs were reported
[16–18].
This period also marks the beginning of the
“Lundiana pouch” with the use of a cecal reservoir and an ileal intussusception nipple as a continence mechanism [19]. After later modications,
the rst clinical results were published in 1990
[20]. A recent publication with the largest cohort
on the Lundiana pouch, including 64 women
among 198 patients mostly operated for malignant indications, has reported continence rates of
91% and difculties with catheterization in 5.3%
of patients at a median follow-up of 13 years.
Reoperations were performed at least once during follow-up in 54% of the patients, with 15%
for uretero-intestinal stenoses, 14% for pouch
stones, 8% for outlet revision, 8% for stomal stenosis, 5% for pouch perforation, and 2% for para-
stomal hernia. Overall, 25% of the patients had a
major complication within 90 days of surgery
[21].
The Mainz pouch I (mixed augmentation ileum
and cecum) was rst described in 1983, initially
for bladder substitution in benign diseases, and,
3years later, the rst results of 11 bladder substitutions and 12 CCUDs were published [22]. Later
publications included larger cohorts and different
modications [23–25]. The classical Mainz pouch
I is created by antimesenteric opening and reconguration of the ileocecum (Fig. 15.1) and two
ileal loops plus an additional 8–10-cm ileum left
intact for the efferent segment. Subsequently, ureters are implanted with an anti-reux technique
using a submucosal tunnel or a serosa-lined extramural tunnel. The invaginated efferent segment
xated with staplers serves as the continence
mechanism. Additional modications in the following years included the appendix stoma, further
developments of the ileum invagination nipple,
and modications of the efferent segment [23–26].
Moreover, antireuxive techniques were abandoned over time based on the idea that in a lowpressure reservoir, reux is less hazardous than
implantation stenosis. The largest cohort on the
Mainz pouch I was published in 2006 including
977 patients from Mainz and Würzburg who were
treated with different techniques for ureter
implantation and the continence mechanism
Fig. 15.1 Key steps of the Mainz pouch I with a
Mitrofanoff nipple: (a) An antimesenteric longitudinal
incision is made. (b) Detubularization and ureteral
implantation are performed. (c) The appendix is folded
cranially and sutures are placed. (d) After sutures are
knotted, a segment of the appendix is placed
submucosally
15 Continent Cutaneous Urinary Diversion inWomen
(mostly appendix stomas, n=419, intussuscepted
ileal nipple valves, n=491, and 1470 renal units
with uretero- intestinal anastomosis via the submucosal tunnel and 136 ureter implantations
using a serosa-lined extramural tunnel). At a mean
follow-up of 7.5years, continence was reported
by 96% of the patients with an appendix stoma
and by 90% of the patients with an intussuscepted
ileal nipple. Reoperations concerning the efferent
segment occurred mainly due to stoma stenosis
(24% of the patients with an appendix stoma and
15% with an intussuscepted ileal nipple) and calculus formation (5.6% of patients with an appendix stoma and 11% with an intussuscepted ileal
nipple) as well as incontinence (1.5 vs. 5.2% for
appendix stoma vs. intussuscepted ileal nipple,
respectively). Overall, 6.5% of renal units undergoing uretero-intestinal reimplantation via the
submucosal tunnel developed uretero-intestinal
stenosis, compared to 5% of renal units with
uretero- intestinal reimplantation via the serosalined extramural tunnel [26].
The Indiana pouch was developed and
described in the 1980s by Rowland et al. [27]
Herein, ureters are implanted along the tenia
libera into an ileocecal reservoir using the ileocecal valve and the tapered terminal ileum as the
continence mechanism (Fig.15.2) [28]. The largest single-center Indiana pouch cohort was published in 2022 including 55 women among 137
patients, mostly undergoing radical cystectomy
UD for bladder cancer. Herein, the authors report
an overall complication rate of 39% within 1year
(Clavien–Dindo grades II–V only) and a major
complication rate of 23% [29]. Continence rates
for Indiana pouch vary from 72% at a mean follow- up of 41months to 100% at a median follow up of 21 months in smaller cohorts (n < 100)
[30–32]. Reoperation rates vary from 7.3%
within 90 days of surgery and 8% beyond
90 days, to 52% at a median follow-up of
41months [29, 32–34].
The Florida pouch was developed in 1987 and
comprises the ascending colon and the right exure adjacent to the ileocecal segment. Ureters
were rst implanted directly and later according
to Le Duc, and the continence mechanism was
147
Fig. 15.2 Fundamental steps of the Indiana pouch procedure: After longitudinal detubularization, the colon segment is downfolded to form the pouch. For establishing
the continence mechanism, the terminal ileum undergoes
a reduction in diameter. Subsequently, a 12-Fr catheter is
accurately positioned within the efferent segment.
Concluding the procedure, imbricating seromuscular
stitches are applied with nonabsorbable suture material,
fortifying the ileocecal valve and thereby enabling
continence
composed of the ileocecal valve and a double
plication of the efferent segment [35]. In 2003,
the largest Florida pouch cohort, which included
74 patients and 36 females, reported a continence rate of 93%. UD-related complications
were grouped by etiology, resulting in 6.3% of
ureteral obstruction, 5.5% of severe acidosis,
5.4% of reservoir stones, and 4% of parastomal
hernia [36]. The initial series on the Florida
pouch reports a reoperation rate of 5% (bowel
obstruction, bilateral ureteral reimplantation,
anti-incontinence segment replication, and
abdominal wall closure) [35].
148
J. Klemm et al.
The Miami pouch was rst described in 1988
and utilizes the same bowel components as the
Florida pouch; ureters are implanted using a
modied Le Duc technique, and the continence
mechanism involves the terminal ileum, which is
tapered and reinforced with three proximal
sutures [37, 38]. The largest Miami pouch cohort
consists of 90 patients from the Miami gynecology department, who underwent Miami pouch
UD mostly due to pelvic malignancies with total
pelvic exenteration in 79% of cases. Of note,
91% of these patients received prior pelvic radiotherapy. The continence rate was reported to be
92% at last follow-up after three open surgical
revisions. Overall, 76% of the patients experienced non-UD-related complications within
60days of surgery, including a mortality rate of
11% (mostly due to sepsis). UD-related complications during follow-up occurred in 53% of the
patients, with ureteral obstruction in 20% and
anastomotic leak in 14% of the patients [39].
Other series with small urological cohorts including women and using Clavien–Dindo grades for
complication reporting show a 30-day overall
complication rate of 93% with a 30-day major
complication rate of 13% vs. 14% and continence
rates ranging from 79% to 100% [37, 38, 40, 41].
The Rome pouch, a simplication of an ileocecal reservoir, was rst described in 2006.
Through transverse taeniamyotomies, detubularization of the colonic segment can be omitted
[42]. This technique was previously described for
orthotopic neobladders and showed sufcient
capacity [43]. Ureteral implantation and the continence mechanism are based on the Miami
pouch technique [42]. The Rome pouch series
with the largest cohort size was published in 2011
and included 62 patients who underwent radical
cystectomy mostly for bladder cancer but also for
gynecological tumors. After the procedure, the
continence rate for appendicostomies was 94%
during the day and 88% during the night, while
the continence rate for ileostomies was 90% during the day and 85% during the night. Forty-eight
months after surgery, the Rome pouch appeared
to have a median capacity of 607ml [44]. In a
gynecology-only cohort, late complications
occurred in 32% and 24% of patients at 3 and
12 months, respectively, following surgery
mostly due to stomal stenosis or ureteral stenosis
[45]. These results match the reported complication rates for urological cohorts (30% long-term
complications at a mean onset of 13months postoperatively, mostly concerning the efferent limb)
[46]. Notably, all publications on the Rome
pouch originate from no more than three hospitals in Rome.
The most recently developed technique is the
Turin pouch, which was rst described in 2013
for patients with a prior appendectomy and consists of an ileocecal reservoir with 10cm of the
terminal ileum and 40 cm of the right colon,
folded to obtain a U-shaped pouch via stapler
detubularization, followed by the creation of an
articial efferent limb through stapler separation
of a 5-cm tubularized ap of the colonic wall.
Ureter implantation is performed according to
the Nesbit technique into the preserved terminal
ileum [47]. The largest and most recent cohort of
Turin pouch, published in 2021, consisted primarily of females (79%) and bladder cancer
patients and reported an approximate 90% daytime continence rate. In all, 24% of patients experienced stone formation within the pouch; 18%
reported catheterization difculties; 11% had
efferent limb stenosis; and 10% observed ureteral
stenosis and complicated urinary tract infection
at their last follow-up. These numbers are roughly
consistent with those of the initial series [47, 48].
In conclusion, ileocecal reservoirs provide
good capacity with sufcient continence rates
across all techniques and subtle differences
regarding postoperative complications. However,
due to mainly small cohorts as well as heterogeneous reporting of functional and objective outcomes, comparisons can often only be made with
reservations.
Colonic Reservoirs
Irradiation of the pelvis compromises the use of
ileocecal reservoirs; hence, a transverse colonic
pouch using a transverse and upper ascending or
descending colon was developed in 2000. The
continence mechanism consisted of a narrowed
15 Continent Cutaneous Urinary Diversion inWomen
149
colon segment that was incorporated into the
anterior pouch wall [49]. In 2000, the largest
cohort of Mainz pouch III patients was reported
from Mainz, including 44 previously irradiated
female patients. The continence rate was to be
reported at 100% after two open revisions, with
no early UD-related postoperative complications.
However, 18% of patients developed late
UD-related complications, mostly stoma stenosis. Each of the late complications required a
reoperation. The median pouch capacity was
found to be 480 ml [49]. A later publication
described the use of Mainz pouch III also in nonirradiated patients and reported a continence rate
of 83% for a small cohort of 24 patients, with 4%
of them suffering from an early UD-related complication and late UD-related complications
occurring in 8% of patients [50].
Ileal Reservoirs
The development of continent ileostomy and
later the ileum reservoir for UD is attributed to
Kock [51]. Nevertheless, other authors have also
described the use of ileum reservoirs in the late
1940s and 1950s and also in the 1970s [52–56].
Kock worked intensively on how to create a lowpressure pouch that would enable continence,
and he recognized the relevance of antimesenteric opening and reconguration of the bowel in
a way that peristalsis would counteract itself and
no increase in pressure would occur [51]. Kock
presented the rst clinical results on his pouch in
1982. The continence mechanism and the implantation site of the ureters were formed by two separate ileum intussusception nipples, which were
reinforced by Marlex tapes and connected by the
ileum reservoir [57]. The largest cohort of
patients undergoing the Kock pouch dates back
to 1989, when 489 patients received a continent
cutaneous Kock pouch, predominantly for malignant causes. Due to several modications over
the years, late complication rates and incontinence rates decreased from above 40% and 20%
to 22% and 15%, respectively. Early complications were reported in 16% of patients [58].
Several series reported signicantly elevated
reoperation rates for Kock pouch (38% and 53%)
compared to other CCUDs [34, 59].
A few years later in 1998, Bochner, Stein, and
Skinner published a novel antireuxive valve
mechanism and created the T-pouch [60]. Another
modication was made by Abol-Enein, who
implanted both ureters and the efferent segment
into the W-shaped ileum reservoir using “serosalined extramural tunnels,” also named the double
T-pouch [11, 61]. This technique continues to be
used in ileal reservoirs to date [62].
Outcomes, Complications,
andGender
To assess the functional and objective outcomes
after establishing UD, authors have used a variety
of study protocols, resulting in heterogeneous
reporting over time. In addition, there is lack of
evidence regarding the effect of gender on outcomes following CCUD, particularly as the overall rate of continent UDs decreases [7–9]. Few
studies compared outcomes by gender for different types of UDs, including CCUD and/or ileal
conduit and orthotopic neobladder and found
that, in general, there were no signicant differences. Yet, statistical power is consistently limited due to the small cohort sizes [63–67].
However, prior irradiation signicantly increases
the risk of both postoperative and UD-related
complications [68, 69]. Unfortunately, pelvic
irradiation is commonly indicated for gynecological malignancies.
Continence is an integral part of functional
outcomes. However, authors have used different
denitions of continence and reported data with
varying levels of accuracy, making comparability
impossible.
Postoperative complications are commonly
divided into very early (≤30 days), early
(≤90 days), and late complications. Overall,
instruments for standardized reporting are rarely
applied. In many cases, a rate of major complications is reported rather than an overall complication rate (major complications: grade IIIa and
higher according to the Clavien–Dindo classication). Moreover, complications are sometimes
150
J. Klemm et al.
divided into UD-related and UD-unrelated complications or into complications concerning the
efferent or afferent limb.
The Eerent Segment
To ensure continence and feasible selfcatheterization in CCUDs, many different techniques and modications of the efferent segment
have been described and published. Some of
them can be applied to different reservoirs. In
general, these techniques can be divided into different principles; the ap valve principle, the
nipple valve principle, hydraulic valves, and articial valves using tissue engineering [70].
The most common technique is probably the
ap valve principle included in the Mitrofanoff
procedure (Fig. 15.1), which uses the tunneled
appendix to create the efferent segment. The largest published series for in situ appendix in the
context of Mainz pouch I reports continence in
96% of patients and a stenosis rate of 24% [26].
If the appendix is not available, the Mitrofanoff
principle can be applied according to Monti and
Yang using a short section of the small intestine,
which is antimesenterically detubularized and
then transversally re-tubularized to create a nar-
rower and longer tunnel [71, 72]. The largest
series in children comparing Monti channels with
appendicovesicostomy was published in 2015
and reported similar rates of stomal stenosis and
incontinence (7.4% vs. 7.5% and 3.4% vs. 0.9%,
respectively). However, the primary subfascial
revision rate was signicantly higher in Monti
channels (16.6% vs. 6.5%, p=0.001) [73]. Other
techniques use a tapered ileum, stomach, ureter,
fallopian tube, vas deferens, or skin as the efferent limb [74]. Serosa-lined extramural tunnels
(Fig. 15.3), primarily described by Abol-Enein,
also represent a common type of the ap valve
principle. In 2004, Abol-Enein published a series
featuring 93 patients, with a continence rate of
95%, stomal stenosis in 5%, and a failure to catheterize in 2% of patients over a mean follow-up
period of 37months [61].
The Kock pouch employs the nipple valve
principle using an intussuscepted ileal nipple.
The largest Kock pouch series reported an early
complication rate of 17% and a late complication
rate of 22%. Leakage was the leading cause of
late complications in up to 15% of patients,
whereas the stenosis rate was lower in 2.6% of
patients compared to ap valves [70]. An
intussuscepted ileal nipple is also described for
Mainz pouch I (Fig.15.4) and continues to be an
Fig. 15.3 Crafting a serous-lined extramural tunnel for
ileal pouch continence. A 40-cm terminal ileum segment
is partitioned into 30-cm oral and 10-cm caudal lengths.
The oral segment is shaped into an “S,” and its distal limbs
is joined with a 4/0 seromuscular silk suture. The antimes-
enteric border is incised to form an ileal tunnel. The short
caudal segment is adjusted around a 14-Fr catheter at its
proximal two-thirds and is then implanted within the ileal
tunnel
YZ
15 Continent Cutaneous Urinary Diversion inWomen
151
ba
5 cm
X
5 cm 2 cm
dc
fe
Fig. 15.4 Constructing an ileal intussusception nipple
for a Mainz pouch 1 reservoir. (a) The intact proximal
12-cm ileum attached to the pouch is prepared for the
nipple. The ileum’s mesentery is separated 5cm beyond
the rst arcade for easy intussusception. (b) Dimensions
of the nipple segments are depicted: the mesenterial
exclusion (5cm over the nipple tip), the nipple tip (Y), the
outer layer (X–Y), and the inner layer (Y–Z). The proximal 2cm is reserved for umbilicus anastomosis. (c) Allis
clamps grasp the ileal wall, inserted through the ileocecal
valve, establishing the isoperistaltic nipple. (d) A completed 5-cm isoperistaltic nipple, pulled through the ileocecal valve with Allis clamps. (e) A nipple xed to the
ileocecal valve by three staple rows: two from inside the
pouch and one from outside. (f) Closure of the nipple’s
mesenterial slit using several 3/0 polypropylene nonabsorbable sutures
152
L
anastomosis
anastomosis
J. Klemm et al.
option for patients without an appendix. The largest series of intussuscepted ileal nipple valves in
Mainz pouch I included 491 patients, of whom
90% reported continence. The rate of stenosis
was determined to be 15%, which was lower than
the rate of stenosis for appendix stomas (24%)
[26].
Benchekroun et al. described a hydraulic
valve technique using a 14-cm ileal segment
including its mesentery and creating a continence mechanism by folding the ileal segment
inward so that the increase in pressure due to
urine lling between the outer and inner parts of
the folded ileum segment causes the inner canal
to collapse and ensures continence [18]. The initial continence rates were described to be 75%
at a median follow-up of 38 months [18]
However, at 5years’ follow-up, 91% of patients
had undergone surgical revision with stomal stenosis being the most common complication in
73% of patients [75].
To date, neither the articial urinary sphincter
system nor tissue engineering has been established in the context of CCUDs [70].
The Aerent Segment
Controversies regarding the use of antireuxive or
reuxive ureteral implantation techniques persist
to date. While antireuxive techniques are more
likely to cause ureteral stenosis, reuxive techniques may cause reux into the kidneys with
subsequent upper urinary tract problems.
However, higher rates of reux with reuxive
techniques do not appear to be associated with a
reduction in renal function [76]. Given the context
of a low-pressure reservoir and a higher risk of
ureteral implantation stenosis with antireuxive
ureteral implantation techniques, some authors
increased utilization of reuxive ureteral anastomoses in continent cutaneous urinary diversions
over time [77, 78]. Well-known reuxive ureteral
implantation techniques include Nesbit, Bricker,
and Wallace (Fig. 15.5) [79–81]. The predominantly used antireuxive implantation techniques
include Leadbetter, Le Duc, the submucosal tunnel (Fig.15.6), the serosa-lined extramural tunnel,
the split-cuff nipple, and the intussuscepted ileal
nipple [61, 82–85].
R
Bricker
Fig. 15.5 Reuxive uretero-intestinal anastomosis techniques. In the Bricker method, spatulated ureters are individually anastomosed to the ileal segment. In the Wallace
R
L
Wallace
method, spatulated ureters are anastomosed along their
medial walls, with the resultant conjoined ureters subsequently anastomosed to the ileal loop
15 Continent Cutaneous Urinary Diversion inWomen
153
ba
dc
1. 5cm
0.5cm
fe
Fig. 15.6 A modied Le Duc submucosal tunnel. (a) The
ureter is introduced 2 cm into the ileal lumen following
saline injection. (b) A 2-cm full-thickness ileal mucosal
sulcus is created. (c) The submucosal space is undermined,
forming mucosal aps. (d) The terminal ureter is spatulated
for 5 mm, anchored, and the ureteral adventitia and ileal
serosa are sutured. (e) A 1.5-cm non-spatulated ureter is
concealed by mucosal aps. (f) A ureteral stent is inserted
154
J. Klemm et al.
Conclusions
A variety of techniques exist for creating the reservoir, as well as the afferent and efferent segments, some of which can be combined in
different ways. Mainz pouch I and Indiana pouch
are among the most widely used CCUDs with
excellent outcomes when performed by experienced surgeons and represent a valid alternative
when an orthotopic neobladder is not feasible.
However, careful patient selection is key to
enable the best possible outcome.
Conict of Interest None.
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