Continent Cutaneous Urinary Diversion

Fig. 4.1

Isolation of the ileal-colonic segment used for the Indiana pouch [17]

Bowel continuity is restored in a side-to-side fashion using a bowel stapler. The mesenteric defect is closed using a running 3-0 polyglactin suture.

The colonic segment is opened using electrocautery along its antimesenteric border beginning at the excised distal staple line to the base of the appendix, which is also excised (Fig. 4.2).

Fig. 4.2

The colonic segment has been opened along its antimesenteric border down to the base of the appendix. The red robinson catheter is shown traversing the ileocecal valve

The ileal segment is then tapered. A 12 French catheter is placed into the ileum and passed through the ileocecal valve. Allis clamps are placed along the antimesenteric side of the ileum (Fig. 4.3).

Fig. 4.3

A 12Fr red robinson catheter and a series of allis clamps are used to facilitate ileal tapering

A stapler passed under the Allis clamps and the bowel lumen is narrowed (Fig. 4.4a, b). The stapler is pressed down against the red Robinson catheter to taper the lumen as narrow as possible. Redundancy can create difficulty in catheterizing stoma. Two or three staple loads are usually required to complete tapering of the 15-cm segment of ileum. Care must be taken to ensure the stapler stays completely antimesenteric so as not to include the mesentery in the staple line.

Fig. 4.4

(a, b) Multiple loads of a GIA stapler are utilized to taper the ileal segement down to the base of the ileocecal valve

The final 1–2 cm near the ileocecal valve is not stapled. Instead, imbricating sutures are placed to taper the lumen at this level (Fig. 4.5). This is performed with interrupted 3-0 silk Lembert sutures at the superior, anterior, and inferior base of the ileocecal valve. Once this is completed, one should demonstrate that a 16Fr red Robinson catheter passes easily through the ileal segment and ileocecal valve.

Fig. 4.5

3-0 Silk imbricating sutures are placed at the base of the ileocecal valve

The colonic pouch is then closed by folding the appendiceal edge of the cecum up to the distal colonic edge. This allows of the ileal segment to face anteriorly. This is closed with a running 3-0 polyglactin suture.

Once the pouch is closed, the right end/corner of the colonic suture line has a natural tendency to rotate 90° counterclockwise toward the pelvis. With the pouch in this final resting position, the appropriate site for ureteral anastomosis is selected and performed. The colonic suture line acts as a longitudinal median determining right and left. The left ureter is anastomosed to the antimesenteric portion of colon pouch inferiorly and left of the suture line. The right ureter is anastomosed to an antimesenteric portion of colon pouch inferiorly and right of the suture line. Putting the pouch into this natural position for the ureteral anastomosis sites prevents sharp angles to the anastomosis, which can occur if the ureteral anastomosis is performed prior to rotating the pouch into the appropriate location.

A number of ureterocolonic anastomoses have been described for colonic pouches. At our institution, we perform a direct, end-to-side, spatulated freely refluxing anastomosis. We use interrupted 4-0 polyglactin sutures using a cutting needle. Our ureteral anastomoses also utilize four 4-0 chromic mucosal-everting sutures at the enterotomy in the colon. We believe this facilitates a better mucosa-to-mucosa re-approximation. The anastomoses are stented with 7Fr single J urinary diversion stents that are brought out through a small opening on the right side of the pouch (secured with a purse-string plain gut suture) and exit the skin through a small 5-mm incision inferior to the stoma location. This stent location should be well below the stoma to accommodate an external appliance bag that is used to collect the urine from the stents.

Once the ureteral anastomoses are complete, a pouchostomy tube site is selected in the right upper portion of the pouch. Using a 24F Foley or Malecot catheter, we bring the tube from outside through the abdominal wall and into the pouch where it is secured with two sets of concentric 2-0 polyglactin purse-string sutures. The purpose of the catheter is primary drainage of the pouch until the patient begins catheterizing pouch 3 weeks postoperatively.

A 1-cm ellipse of skin is removed at the desired stoma location. A tunnel is made through the subcuticular fat, fascia, and peritoneum. The tapered ileum is passed through the defect and pulled through as much as possible to limit redundant length to the limb. Once the limb has been pulled through as much as possible, the excess ileum is resected leaving 1 cm above the skin level, and the cutaneous stoma is matured at the skin with interrupted 2-0 polyglactin sutures. The shorter limb will result in fewer long-term catheterization issues.

Extracorporeal Variation for Indiana Pouch in Robotic Radical Cystectomy

If cystectomy is performed in a laparoscopic or robot-assisted laparoscopic fashion, the left ureter is tunneled under the sigmoid mesentery, and the left and right ureters are tagged with 9-in. polyglactin sutures for identification. Using the existing robotic ports, laparoscopic mobilization of the ascending colon and the hepatic flexure is performed. Alternatively, the low midline specimen extraction incision can be made, and a Gelport® (Applied Medical, Rancho Santa Margarita, USA) can be used to perform a hand-assisted colon mobilization. The existing robotic ports are utilized so no new port sites are placed. Once the specimen is retrieved, an Alexis wound protector (Applied Medical, California, USA) is placed into the wound. The ureters labeled with preplaced dyed and undyed polyglactin are oriented at the wound, and ileal-colonic segment is delivered through the wound. The Indiana pouch is then constructed as described previously.

Right Colon Pouch

A common approach for surgeons who feel strongly about the need for a non-refluxing continent cutaneous urinary diversion is the use of a right colon pouch where the ileocecal valve remains intact and the distal 10–15-cm segment of terminal ileum is used as the afferent limb where the ureters are anastomosed. The anti-reflux mechanism is the native ileocecal valve originally described by Zinman [11]. The common choice of continence mechanism in this setting is utilizing the Mitrofanoff principle using the appendix or a Yang-Monti channel. Stein et al. reported continence rates with right colon pouches to be 100% [12].

The right colon pouch with embedded appendix in the submucosa has been well described in the literature as an alternative to the Indiana pouch. Several modifications have been described leading to the following technique as described by Stein et al. [12] In this technique the procedure is initiated in a similar fashion to the Indiana pouch with complete mobilization of the small bowel, cecum, and ascending and transverse colon. This can be performed laparoscopically if indicated. Thirty to forty centimeters of ascending and transverse colon is isolated, along with 5–10 cm of the terminal ileum.

The ileal mesenteric division is made at the avascular plane of Treves between the terminal branches of the ileum and the ileocolic artery. Minimal distal colonic mesenteric division is necessary.

The appendix is then assessed for suitability as an efferent catheterizable limb. Generally, the appendix must be 5–6 cm in length and should accommodate a 12 Fr catheter. If the appendix is deemed appropriate, the appendix and mesoappendix are carefully mobilized in order to preserve blood supply. The distal edge of the appendix is incised and cannulated with a 12 Fr catheter.

Several mesenteric windows are created through the appendiceal mesentery adjacent to the serosa of the appendix. Care is taken to avoid injuring the blood supply to the appendix. Next, a 4–5-cm longitudinal incision is made through the anterior tenia of the cecum to the level of the mucosa, allowing the mucosa to bulge into the incision without violating the mucosa. This provides the channel in which the appendix will rest (Fig. 4.6).

Fig. 4.6

A channel in the tenia of the cecum is created that will hold the proximal appendix [12]

The appendix is then flipped into the channel, and 3-0 silk sutures are used to re-approximate the lateral edges of the incised tenia passing each suture through the mesenteric windows that were previously created in a U-stitch fashion. Using a Penrose drain passed through the mesenteric window will facilitate passage of the suture (Fig. 4.7).