Urinary diversion, defined as rerouting of urine from a normal intact urinary tract, can be classified as either incontinent or continent. Incontinent diversion allows for the free flow of urine outside of the body, which can be collected into an external ostomy appliance.^1,2 Incontinent urinary diversions are performed much more often than continent ones, particularly in patients with complex medical or surgical histories and/or those that have a history of previous radiotherapy.^3,4

Ureterosigmoidostomy, first performed in 1851 by John Simon, was the first widely used surgical technique for urinary diversion, providing an effective diversion that relied on the anal sphincter for continence. However, its usefulness is limited by deterioration of renal function over time, metabolic complications, and the increased risk for the development of secondary malignancies. Subsequently, substantial progress has been made by incorporating innovative techniques that use isolated bowel segments as either urinary conduits or continent reservoirs and effectively separates the fecal and urinary streams. In the 1950s Bricker used a segment of ileum to which the ureters were anastomosed and a stoma created in the right lower abdomen. The ileal conduit (IC) has subsequently become the gold standard for incontinent urinary diversion.^1,2 Cutaneous ureterostomy, which has been used sparingly in adults due to surgeon concern for ureteral obstruction,⁵ is the simplest method of all permanent urinary diversions. However, there are risks of stomal stenosis requiring intubation and pyelonephritis.^6,7

In this chapter, the most commonly used reconstructive options of incontinent urinary diversion will be discussed, as well as indications and clinical applications, anatomic considerations, surgical procedures, postoperative care, and long-term outcomes.

There are a variety of choices for incontinent urinary diversions (IC, colon conduit [CC], and cutaneous ureterostomy). The choice is determined by patient and medical criteria. Important patient criteria are patient preference, age, comorbidities, body mass index (BMI), and the ability and motivation to perform intermittent self-catheterization. Further considerations are the condition of the segment of bowel to be used, kidney function/upper urinary tract status, and the overall medical condition of the patient. The choice of urinary diversion still remains a very personal decision to be made between the patient, family members, and the physician.⁸

Ileal Conduit

IC urinary diversion remains the gold standard for incontinent urinary reconstruction. Although the introduction of continent urinary diversions has decreased the proportion of these procedures performed, they remain the most common form of urinary diversion.⁴ It is a procedure that is obligated for patients with a short life expectancy, reduced kidney function, and for those who cannot manage a continent diversion. Due to the relative ease of formation and shorter operative time, an IC is often used in patients with significant medical comorbidities in an attempt to minimize postoperative complications and the risk of reoperation.⁹

Cutaneous Ureterostomy

Although the IC is the accepted standard due to its safe, well-proven, and low-risk performance, nevertheless it does involve a small bowel resection and ureteroenteric anastomosis, which can lead to increased complications. The ureterocutaneostomy, consisting of direct routing of the ureters to the skin, is an easier alternative, which was initially shown to have a high rate of stomal stenosis. However, new data suggest that the stomal stenosis rate, measured by need for stent, is comparable to the IC. In addition, quality of life analyses show comparable results. Therefore, cutaneous ureterostomy should be considered as an option for urinary diversion in patients who are critically ill, those with significant previous intestinal surgery, or those with end-stage urinary obstruction, in whom neither cystectomy nor intestinal surgery may be advisable.^7,10,11,12 It can also be used as a temporary diversion in situations when gastrointestinal diversion is not possible or whenever the bladder needs to be diverted because of fistula or hemorrhage.¹³ In cases of failed IC urinary diversion, transureteroureterostomy with cutaneous ureterostomy can be used as a salvage measure.¹⁴ In those patients in whom intestine may not be available for reconstruction (eg, those with short bowel syndrome or Crohn disease), cutaneous ureterostomy remains an option to enable permanent diversion with or without cystectomy.¹¹

Colonic Conduit

Although controversial, some believe that the use of ileal segments or the ileocecal reservoir in patients who have been exposed to pelvic radiation may be associated with increased risk of early and late complications.¹⁵ In this circumstance, a colonic conduit, a loop of transverse colon with ureterocolonic anastomosis, is an option. The superior outcome of this urinary diversion is due to the use of nonirradiated segments of the colon and ureter in the radiated population.¹⁶ The transverse colon segment is also an option for salvage of problems related to ICs.¹⁷

Ureter

Complications due to ischemia of the distal ureter, ureteroenteric or stomal (in the case of cutaneous ureterostomy), are a recognized complication of any urinary diversion. Ischemia of the distal ureter is preventable, by taking note of its vascular supply with its common variations and preserving the periureteral adventitial tissue. This reduces the risks of urinary extravasation and ureteral strictures. Special care must be taken when translocating the left ureter across the retroperitoneum to the right; this should be done below the posterior peritoneum overlying the sigmoid colon above the level of the inferior mesenteric artery in order to maximize length and avoid kinking. Approximately 5 to 10 cm of well-vascularized ureter is usually left freely mobile for ureterointestinal anastomosis.

For cutaneous ureterostomy, the ureters are tunneled in an extraperitoneal fashion to bilateral abdominal or flank stomas. If a single stoma is required, then translocation of 1 ureter to the other side in a similar manner to translocating the left ureter to the right (as described above) with a subsequent transureteroureterostomy can be performed.

Bowel

As a general principle, any segment of bowel can be used to form a urinary diversion. However, there are metabolic consequences associated with the utilization of each segment based upon the absorptive function of bowel.^18,19,20 In addition, the length and location of bowel segment used can affect the patient’s postoperative bowel function. Conduits should be long enough to warrant an everted stoma and to allow a tension-free ureterointestinal anastomosis. The two types of bowel segment most commonly used for noncontinent urinary diversion are distal ileum and transverse colon.

For IC urinary diversion, the terminal 10 to 15 cm of ileum is typically preserved to maintain adequate absorption of bile salts, vitamin B12, and fat-soluble vitamins. Before deciding on the final limits of the segment, the associated vascular arcades are routinely inspected with translumination through the mesentery to ensure that at least 2 vascular arcades are present. The isolated loop is always left caudal and below the continuous small intestine after performing enteroenteric anastomosis.

Reconfigured colon segments can be used successfully to replace long ureteral defects. The advantages are use in patients with impaired renal function and lack of small intestine, proximity of the colon to the ureter, optimal cross-sectional diameter of the graft and less intraperitoneal surgical trauma than with ileal substitutes.²¹

Anastomosis

It is important to perform tension-free ureteroileal anastomoses and reduce manipulation of the conduit after completion of the ureteroileal anastomoses. There are multiple ureteroileal anastomotic variants. The Nesbit ureteral implantation technique, adopted and more commonly attributed to Bricker leaves the proximal end of the IC closed. The ureteral ends are spatulated and anastomosed directly via a refluxing technique and separated by about 1 to 3 cm from each other along the antimesenteric side of the conduit. The Wallace variant consists of anastomosing both spatulated ureters together—oriented “head to head” (Wallace I); or oriented in the opposite, “head to tail” direction (Wallace II)—and then directly anastomosing the combined complex to the proximal end of the IC segment.²² Although a Wallace type of anastomosis is technically simpler due to the creation of only one ureteroenteric anastomosis, complications at this anastomosis put both kidneys at risk for damage. Therefore, the Bricker anastomosis is currently the one more commonly performed.

Stoma

The preferred location of the ileal stoma is the right abdominal quadrant between the umbilicus and the anterior-superior iliac spine. The location should be above or below the waistband and not too close to the umbilicus, the edge of the rectus muscle, a bony prominence or a scar, and must be tested with the patient and preoperatively marked.^7,13,22

The presence of a stoma and appliance affects a patient’s body image. Typically, the ileal or transverse conduit stoma is a standard end ostomy. In patients who are obese, where a short bowel mesentery and thick abdominal wall may prevent the creation of an end-on stoma without undue tension, a loop type of stoma (Turnbull) is commonly advocated.²⁰

General

A complete preoperative anesthesiologic assessment, including cardiac testing, renal, and hepatic function, and correction of modifiable medical diseases, such as hypertension, cardiac arrhythmias, and anemia, should be completed in all candidates. Imaging studies of the ureters and kidneys to confirm presence of both kidneys is also required.

Limited bowel preparation has been recognized by many clinical studies as a promising approach in radical cystectomy, which require use of intestinal segments.^23,24 Despite this, the use of complete bowel preparation (polyethylene glycol or sodium phosphate oral solution) has long been advocated to reduce the incidence of postoperative ileus, wound infections, and anastomotic dehiscence.²⁵ However, recent reports show that preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion or colorectal surgery does not demonstrate any significant advantage in perioperative outcomes, including gastrointestinal complications.^24,26

The stoma site is usually marked on the skin by the urologist or stoma therapist. Patients should be fully informed about the risks and benefits of the urinary diversion procedure planned including possible surgical alternatives and sufficient time should be given to patients to understand the impact of everyday aspects related to the selected urinary diversion prior to obtaining informed consent. Patient or family counseling, with the aid of psychologists, oncology nurse specialists, or patients who have previously undergone the chosen procedure, is also helpful.²³

Ileal conduit

After entering the abdomen, a self-retaining retractor is positioned. The ureters are identified and ligated as distally as possible. Temporarily obstructing the ureter with a tie or clip allows for dilatation until it is time for the ureteroileal anastomosis. The ureters are dissected superiorly to the pelvic brim while preserving the adventitia.

Approximately 15 cm from the ileocecal valve, the distal margin of the proposed ileal segment is marked with a silk suture. The length required should be sufficient to span the distance from the stoma site to the sacral promontory. In some cases, a longer span may be needed to bridge the gap between ureter and skin. Mesenteric windows are formed by dividing the peritoneum, fat, and intervening blood vessels. This division can be performed using mosquito hemostats and ties, a stapler, or the monopolar cautery combined with the LigaSure device.⁷ A small bowel resection is then performed essentially by using a gastrointestinal anastomosis (GIA) 60/80 stapler. The bowel is put back in contiguity cephalad to the ileal loop using standard technique, specifically a GIA 60/80 stapler for a side-to-side ileal anastomosis and a thoracoabdominal (TA) 60/90 stapler to complete the anastomosis. The staple line is then oversewn using imbricating Lembert sutures of 3-0 silk. The rent in the mesentery is closed using 3-0 silk as well.

The left ureter is passed under the posterior peritoneum under the sigmoid colon mesentery, caudal to the inferior mesenteric artery toward the right side. Alternatively, the left ureter is brought through the sigmoid colon mesentery. With the proximal end of the loop positioned at the level of the sacral promontory, the ureteroileal anastomosis is performed in a standard end-to-side fashion after sharply debriding the distal ureter. A traction suture is placed at the apex of the spatulated ureter (Figure 11-1) to allow manipulation of the ureter during the anastomosis. A 1-cm enterotomy is next created (Figure 11-2), and ureteroileal anastomosis is commenced with absorbable 4-0 or 5-0 sutures in an interrupted fashion (Figures 11-3 and 11-4).^7,13,22,27 Prior to completing each anastomosis, a single J stent should be placed (Figure 11-5). The suture line can be reinforced with interrupted and ventitial sutures if desired (Figure 11-6). Confirmation of the closure is performed at this point by injecting saline using a bulb-irrigation syringe through the stomal end of the IC and confirming no extravasation at both ureteroenteric anastomotic sites. The stoma is created next. The plunger of a 20-mL syringe may be used as a guide for a circumferential skin incision at the stoma site.⁷ Fat is incised all the way down to the rectus fascia. A cruciate incision is made in the rectus fascia. A space is made through the rectus muscle and then an incision is made though posterior rectus sheath and anterior peritoneum. This should easily allow 2 fingerbreadths. A narrow transfascial passage increases the risk of fascial stenosis and retraction; conversely, a wide passage favors prolapses and parastomal hernias. The distal portion of the ileal loop is brought through the abdominal wall to the skin using an atraumatic clamp. The mesenteric pedicle should be inspected to make sure it is not twisted, as this can cause severe ischemic damage. The stoma is next matured by first placing 3 fascial sutures, followed by 4 quadrant sutures to rosebud the stoma, both of these are using 2-0 Vicryl sutures. The stoma is then matured by suturing the mucosa to the skin with multiple interrupted 3-0 Vicryl sutures. The ureteral stents are secured with a silk suture to the skin, and an external urine collection device is placed. A 22-French multieyed catheter may be placed in the ileal loop for extra drainage. The surgeon should verify that the ileocutaneous anastomosis is tension free; otherwise, he or she should not hesitate to redo it. Ureteroileal anastomosis is generally dropped back into the retroperitoneum by suturing the sutured end of the ileal loop to the cut end of the posterior peritoneum, effectively placing the proximal end of the IC and ureteroileal anastomoses in the retroperitoneum. The omentum, when available, is used to wrap the area. One suction drain should be placed in the pelvis. Irrigation of the abdominal cavity with normal saline solution is suggested.^7,13,22 Figure 11-7 shows a representative IC urinary diversion.