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238 Stern and Dalton
Figure 19 Example of use of a catheterizable appendiceal stoma (Mitrofanoff
principle) with a cecal reservoir.
KOCK POUCH
The continent ileostomy developed by Nils Kock is discussed in Chapter 10
[61]. This technique was modified for urinary diversion [62] and ushered in
the era of continent urinary diversion. Skinner and associates [63] at the
University of Southern California, popularized the procedure in the United
States. Their methods are summarized in the following discussion.
An ileal segment approximately 80 cm long is selected. The distal
margin should be approximately 20 cm proximal to the ileocecal valve. The
bowel and mesentery are divided, with close attention paid to maintaining
the blood supply. An ileoileostomy is performed according to the surgeon’s
preference.
The ileal segment is marked into four segments of 17, 22, 22, and 17
cm. The two 22-cm segments are placed side by side and opened along
their antimesenteric border (Fig. 22A), and the back walls are closed with
a continuous 3-0 Vicryl suture (Fig. 22B).
Construction of the nipple valves is the crux of the procedure, because
most reoperations are performed to repair them. The mesentery is separated
from the bowel closest to the reservoir for approximately 8 cm and the
bowel is intussuscepted. Boyd et al. currently place a 2-cm strip of Vicryl
mesh through a mesenteric window 2–3 cm away from the previously made
mesenteric opening. They also have begun using a GIA stapler to support
the valve by placing two rows of 3.5-mm staples. The distal six staples are
removed to prevent stone formation. The back wall of the valve is secured
Methods of Urinary Diversion 239
Figure 20 Benchekroun’s method of maintaining a continent stoma. A-B, Seg-
ment of ileum is inverted. C, Anterior walls of inverted ileum are approximated.
Posterior opening is left to allow urine to enter from the reservoir, thus “squeezing”
the inner chamber.
further to the reservoir with a TA-55 stapler, and the tips of the valves are
secured to the inside of the reservoir with 3-0 Vicryl suture. In a further
attempt to prevent loss of intussusception, the Vicryl mesh is secured to the
ileal limb and reservoir.
The pouch is closed in a watertight manner to provide a detubularized
pouch. End-to-side ureteroileostomies are constructed on the afferent lib
with the aid of stents. A flush stoma is constructed from the efferent lib in
a convenient location previously selected by an ET. An additional 1-cm
strip of Marlex mesh is used to secure further the mesenteric side of the
240 Stern and Dalton
Figure 21 Koff’s continent stoma. This method utilizes a separate ileal segment
attached to the reservoir and “wrapped” around the catheterizable terminal ileum.
efferent limb to the posterior rectus fascia. A 30F catheter is left in the
efferent lib to provide reservoir drainage, and a drain is placed.
As noted previously, frequent irrigation is necessary to avoid develop-
ment of a mucous plug. Instruction for self-catheterization is given at ap-
proximately 3 weeks.
The most recent data from the University of Southern California state
that 7% of patients have required endoscopic revision and 3.1% have required
open revision of afferent valve stenosis [64]. Skinner and associates had pre-
viously reported that 11% of patients required revision of the efferent lib to
maintain continence. Reflux or ureteroenteric strictures occurred only 2–3%
of the time. [65] Vitamin B
12
levels should be closely monitored.
SIMULTANEOUS DIVERSION OF URINARY
AND FECAL STREAM
The standard wet colostomy as described by Brunschwig and Daniel [66]
has been generally abandoned because of development of severe electrolyte
imbalance, pyelonephritis, and stoma complications. My colleagues and I
have introduced the procedure called the “double-barreled” wet colostomy
[46], which seems to have avoided the majority of these compli cat ion s. Fortu-
Methods of Urinary Diversion 241
Figure 22 Modification of Kock pouch for urinary diversion. Ureterocolosto-
mies are constructed on afferent limb, and efferent limb is used as a catheterizable
stoma. Most reoperations are performed to repair the efferent limb.
nately, patients needing this procedure are rare and usually have advanced
pelvic malignancies or severe radiation damage to the pelvic viscera.
If no colostomy exists, the sigmoid colon is mobilized, and an appro-
priate portion of the proximal sigmoid is selected as the stoma site (Fig.
23). We create the stoma first. A plug of skin and subcutaneous tissue is
removed from the left middle abdomen and the rectus fascia is opened in a
cruciate fashion as described previously. The muscle fibers are separated,
242 Stern and Dalton
Figure 23 Double-barreled wet colostomy.
and a loop of sigmoid colon is delivered. The colon is secured to the ante-
rior fascia to avoid retraction. The colon is opened, and the mucosa is se-
cured to the skin with 3–0 Vicryl suture. The colon is divided with a GIA
stapler approximately 15–20 cm distal to the stoma, thus forming a “urine
limb.” The staples are removed from the urine limb, and the colon is closed
in watertight fashion with 3-0 Vicryl suture. If severe ureteral dilation is
not present, nonrefluxing ureteroenterostomies are performed; otherwise an
end-to-side technique is used.
If a loop colostomy already exists, the urine limb is constructed and
ureterocolostomy is performed (see Fig. 23). If an end-sigmoid colostomy
is present, it is taken down and the colon and the splenic flexure are mobi-
lized. The procedure then proceeds as described previously.
Of the 10 patients operated on, 8 had advanced pelvic malignancies
and succumbed to their disease within 2
1
⁄
2
years. The two patients with
severe radiation damage to pelvic viscera are doing well after approxi-
mately 3 years. Upper tract function and/or radiographic appearance re-
mained stable or improved in 9 of 10 patients, with the remaining patient
developing malignant ureteral obstruction. There were no episodes of py-
elonephritis, but metabolic acidosis occurred in two patients with renal in-
sufficiency. Overall patient acceptance has been excellent.
ORTHOTOPIC URINARY DIVERSION
The first orthotopic reconstruction in a human was performed in 1913 by
Lemonie [67], in which he performed a cystectomy with ureteral reimplan-
Methods of Urinary Diversion 243
tation into the rectum. Camey and associates [68] first reported their experi-
ence with orthotopic diversion to the urethra in 1979. Prior to 1990, ortho-
topic reconstruction was reserved for male patients, as the female urethra
was considered necessary to provide an adequate cancer margin. In 1995,
however, Stein and associates [69] demonstrated the viability of the proce-
dure in women.
The advantage to the orthotopic neobladder is that it most closely
resembles the native bladder in both function and location. Moreover, it
obviates the need for a cutaneous stoma and collection appliance. The or-
thotopic neobladder relies on the intact rhabdosphincter continence mecha-
nism, thus eliminating the need for intermittent catheterization. The patient
voids by simultaneously performing Valsalva’s maneuver and relaxing the
pelvic floor musculature.
While performing the cystectomy, care is taken to preserve the conti-
nence mechanism. Tumor involvement of the distal surgical margin is ex-
cluded by frozen-section analysis. If there is no evidence of tumor, the
orthotopic diversion may be performed [70].
STUDER ILEAL BLADDER
Described by Studer in 1989 [71], this is a popular form of orthotopic
diversion (Fig. 24). Approximately 25 cm proximal to the ileocecal valve,
a portion of terminal ileum 54–60 cm long is isolated. Bowel continuity is
restored, and the ends of the isolated segment are closed with a running
absorbable suture. The distal 40-cm portion of ileum is placed in a U shape
and opened along the antimesenteric border (Fig. 24A). The ureters are then
split and anastomosed in an end-to-side fashion to the proximal, nonincised,
afferent tubular portion of ileum. The two medial borders of the U-shaped
ileum are oversewn with a running absorbable suture (Fig. 24B). The bot-
tom of the U is folded over between the two ends of the U (Fig. 24C). As
described by Studer, after part of the upper half and the lower half of the
anterior wall are closed, the surgeon’s finger is placed through the remain-
ing reservoir opening to in order to determine the most caudal part of the
neobladder. A hole is cut out in the dependent portion of ileum, away from
the suture line, allowing for urethral anastomosis (Fig. 24D). The ure-
throenteric anastomosis is then completed (Fig. 24E) and the remaining
portion of the reservoir closed (Fig. 24F).
COMPLICATIONS AND RESULTS
Complications of orthotopic neobladder are summarized in Table 3. Studer
reviewed his first 200 patients to undergo this procedure [72] and found
that 24 had early complications, none of which were directly related to the
244 Stern and Dalton
Figure 24 The Studer Ileal Bladder.
neobladder. One patient required conversion of the afferent tubular segment
to an ileal conduit secondary to partial pouch necrosis 3 months postopera-
tively. Two patients required conversion following urethral tumor recur-
rence. In all, 194 of the patients were able to void spontaneously.
KOCK ILEAL NEOBLADDER
The Kock ileal neobladder evolved from the Kock continent cutaneous ileal
reservoir described above, which uses intussuscepted nipple values for both
the afferent and efferent limbs. In the orthotopic modification, the afferent
intussuscepted limb was maintained to prevent reflux [73,74]. In total, 61
cm of terminal ileum is isolated. Two 22-cm segments are placed in a U
configuration and opened next to the mesentery. The more proximal 17-cm
segment of ileum is used to form the afferent intussuscepted nipple valve
Methods of Urinary Diversion 245
Table 3 Results From Orthotopic Neobladders Series
Compli-
cations* Continence
No. of Mean
Author Form patients Follow-up age Mortality Early Late Day Night IC Antireflux mechanism
Barre
82
Camey II-lleum 110 32 mo 62 years 1% — — 93% 74% 1% Le Duc
Elmajian
83
Kock-Ileum 295 42 mo 66 years 1% 7% 12% 87% 86% 8% Nipple valve
Steven
84
Kock-Ileum 166 32 mo 62 years 0% 12% 23% 98% 80% 32% Nipple valve
Hautmann
85
“W”-Ileum 363 57 mo 63 years 3% 15% 23% 96% 95% 6% Le Duc
Hollowell
91
“W”-Ileum 50 20 mo 62 years 2% 10% 20% 93% 86% 4% Isoperistaltic “chimney”
Stein
86
T-Pouch-Ileum 40 10 mo 67 years 2.5% 12% — 80% 65% 0% T-limb mechanism
Studer
87
Studer-Ileum 200 30 mo 64 years 2% — — 90% 80% 0.5% Isoperistaltic limb
Cancrini
88
Studer-Ileum 96 28 mo 60 years 6% 6% 24% 98% 83% — Isoperistaltic limb
Thuroff
89
Mainz-Ileocecal 61 46 mo — — 5% 18% 95% 86% 13% Submucosal tunnel
Koletlis
90
Ileocecal (Le Bag) 38 14 mo 61 years 0% 8% 8% 91% 80% 3% Le Duc and Bricker
*Complications reported related to urinary diversion.
IC, some form of intermittent catheterization to empty neobladder.
From Stein JP and Skinner DG: Orthotopic Urinary Diversion. In Walsh, Retik, Vaughan, Wein (eds.): Campbell’s Urology, 8th edition, Volume 4, 3861,
2002; with permission.
246 Stern and Dalton
(Fig. 25A). The posterior wall of the reservoir is then created by combining
the medial portions of the U with a continuous running suture (Fig. 25B).
Next a 5- to 7-cm antireflux valve is created by intussusception of the affer-
ent limb with the use of Allis forceps clamps (Fig. 25C). The afferent limb
is fixed with two rows of staples placed within the leaves of the valve (Fig.
25D), which is then fixed to the back wall from outside the reservoir (Fig.
25E). Finally, after completion of the afferent limb, the reservoir is final-
ized by folding the ileum into itself and closing it. The ureteroileal anasto-
mosis is completed first, and the ureteroenteric anastomosis is performed in
a tension-free mucosa-to-mucosa fashion (Fig. 25F).
COMPLICATIONS AND RESULTS
USC follow-up 295 male patients who underwent the Kock ileal neobladder
procedure [75] revealed early and late complication rates of 7.2 and 11.6%,
Figure 25 The Kock Ileal Neobladder.
Methods of Urinary Diversion 247
respectively. The complications were primarily related to the intussuscepted
antireflux afferent limb, including stone formation and afferent nipple ste-
nosis. Late pouch related abdominal reoperation rates were 1.4%, while
there were no early reoperations. Good or satisfactory daytime and night-
time continence was reported by 86 and 87% respectively, 5% perform
regular intermittent catheterization, and 2.7% require an artificial urinary
sphincter secondary to intolerable incontinence.
T POUCH ILEAL NEOBLADDER
More recently, the USC group has been performing the T Pouch neobladder
[76] in an attempt to prevent complications from the intussuscepted afferent
nipple. According to Skinner, the T pouch is created from 44 cm of distal
ileum placed in an inverted V configuration; each limb of the V measures
22 cm, and a proximal 8- to 10-cm segment of ileum (afferent limb) is used
to form the afferent antireflux mechanism. The ileum is then divided be-
tween the proximal afferent ileal segment and the 44-cm segment that will
form the reservoir. The proximal end of the isolated afferent ileal segment is
closed with a running absorbable suture. The isolated 44-cm ileal segment is
laid in an inverted V configuration, with the apex of the V lying caudally
and a suture marking a point between the two 22-cm adjacent segments of
ileum. The opened end of the V is directed cephalad (Fig. 26A).
The antireflux mechanism is then created by anchoring the distal 3–4
cm of the afferent ileal segment into the serous-lined ileal trough formed
by the base of the two adjacent 22-cm ileal segments. Mesenteric windows
of Deaver are opened between the vascular arcades 3 to 4 cm proximal to
the most distal portion of the isolated afferent segment (Fig. 26B).
With the sutures passed through the previously opened windows of
Deaver, a series of 3-0 silk sutures are used to approximate the serosa of
the two adjacent 22-cm ileal segments at the base of the V. This process is
repeated through each individual window of Deaver until the distal 3–4 cm
of the afferent segment is permanently fixed in the serous-lined ileal trough
(Fig. 26C).
The anchored portion of the afferent ileal segment (3–4 cm distal) is
then tapered on the antimesenteric border over a 30F catheter. Tapering this
portion of the afferent ileal segment merely reduces the bulk of the afferent
limb, facilitating later coverage of the anchored afferent limb with ileal
flaps (Fig. 26D).
The remaining portion of the adjacent 22-cm ileal segments is then
approximated with an absorbable suture after the distal 3–4 cm of the affer-
ent ileal segment has been tapered. Starting at the apex of the V, the bowel
is opened immediately adjacent to the serosal suture line and carried up-
ward to the afferent limb. As this incision reaches the level of the afferent