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248 Stern and Dalton
ostium, it is extended cephalad to the base of the ileal segment and directly
lateral to the antimesenteric border of the ileum. This incision provides
wide flaps of ileum that will eventually be brought over the tapered afferent
ileal segment to create the antireflux mechanism in a flap-valve technique
(Fig. 26E).
As described by Skinner, the previously incised ileal mucosa is then
oversewn with a running absorbable suture starting at the apex and running
upward to the afferent limb (Fig. 26F). Once the ostium of the afferent
limb is reached, an interrupted mucosa-to-mucosa anastomosis is completed
between the ostium of the afferent ileal limb and the incised intestinal ileal
flaps with absorbable sutures. The mucosal edges of the ileal flaps are then
approximated over the tapered portion of the afferent ileal limb (3 to 4 cm)
with a running suture. The suture line finalizes the posterior wall of the
reservoir and produces the serous-lined ileal antireflux mechanism (Fig.
26G).
Finally, the reservoir is closed by folding the ileum in half in the
opposite direction to which it was opened, similar to formation of the Kock
pouch. The anterior wall is closed (Fig. 26H). This anterior suture line is
stopped before the end of the right side to allow introduction of an index
finger. This is the most mobile and dependent portion of the reservoir and
will be anastomosed to the urethra (Fig. 26I). Once the pouch has been
closed, each ureter is spatulated, and a standard bilateral end-to-side ureter-
oileal anastomosis is performed to the proximal afferent ileal segment (Fig.
26).
COMPLICATIONS AND RESULTS
Stein and associates [76] reviewed their results in 40 patients who under-
went this procedure with mean follow-up of 10.5 months. They report one
perioperative death and 5 early complications, all unrelated to urinary di-
version, with no late complications. Their belief is that the intraluminal
serosa-lined ileal antireflux mechanism will eliminate complications asso-
ciated with the intussuscepted nipple valve technique. Fifteen of the 20
patients who were alive at 10 months follow-up had complete daytime con-
tinence, and 4 reported daytime incontinence with a minor effort only.
Complete nighttime continence was reported by 13 patients.
QUALITY OF LIFE IN URINARY DIVERSION
Gburek and associates [77] compared the clinical outcomes of the Studer
neobladder with those of an ileal conduit diversion and found that the peri-
operative and long-term morbidity to be comparable to that of an ileal con-
duit diversion. Similarly, Hart and associates [78] compared patients with
Methods of Urinary Diversion 249
Figure 26 The T-Pouch Ileal Neobladder.
ileal conduit, cutaneous diversion, and urethral Kock pouch and found that
the type of diversion did not affect quality of life.
LAPAROSCOPIC DIVERSION
Finally, we would be remiss without at least paying homage to the newly
developing technique of laparoscopic diversion. While currently performed
only by laparoscopic pioneers, both laparoscopic ileal conduits [79,80] and
neobladders [81] have been described.
250 Stern and Dalton
Figure 26 Continued
SUMMARY
Improvements in techniques of urinary diversion continue, to the benefit of
patients requiring these procedures. The ileal conduit is losing its place as
the “gold standard” in adult patients. Continent urinary diversion and ortho
Methods of Urinary Diversion 251
Figure 26 Continued
topic bladder substitutions continue to grow in popularity and have become
the procedures of choice in many clinical situations. Laparoscopic surgery
promises to provide even newer horizons as the story of urinary diversion
continues to evolve.
252 Stern and Dalton
Figure 26 Continued
Methods of Urinary Diversion 253
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