In an effort to preserve an antireflux mechanism but avoid the potential long-term complications seen with the Kock nipple valve, the T pouch was developed via a modification of Ghoneim and Abol-Enein’s serous-lined ureteral tunnel [9]. Similar to the Studer neobladder, the T pouch contains a 15 cm antirefluxing afferent limb. The ileum is divided between the proximal afferent ileal segment and the 44-cm segment, and the antireflux mechanism is created by anchoring the distal 3–4 cm of the 15 cm afferent ileal segment into the serosal-lined ileal trough formed by the base of the two adjacent 22-cm ileal segments. Mesenteric windows are opened between the vascular arcades on the T-limb (Fig. 2.4a). A series of 3-0 silk sutures are then used to approximate the serosa of the two adjacent 22-cm ileal segments at the base of the “U” with the sutures being passed through the previously opened windows of Deaver to anchor the afferent limb. Initial descriptions of the T pouch included tapering the distal portion of the afferent segment after it had been fixed into the tunnel to decrease its diameter and decrease the risk of reflux. However, these efforts appeared to be associated with occasional late stenosis of the end of the afferent valve. In 2004 we stopped tapering the distal afferent limb with improved results. When the incision in the “U” limb of reservoir reaches the level of the afferent ostium, it is extended directly lateral to the antimesenteric border of the ileum and carried upward (cephalad) to the base of the ileal segment. This incision provides wide flaps of ileum that are brought over the afferent ileal segment and sutured in two layers to create the antireflux mechanism in a flap-valve technique (Fig. 2.4b). An interrupted mucosa-to-mucosa anastomosis is then performed between the ostium of the afferent ileal limb and the incised intestinal ileal flaps with 3-0 polyglycolic acid sutures (Fig. 2.4c). The rest of the neobladder is constructed in the same fashion as the Studer pouch.

Once the reservoir is folded in half, the anterior wall is closed with a two-layer 3-0 polyglycolic acid suture that is watertight. Note that the anterior suture line is stopped just short of the (patient) right side to allow insertion of an index finger, which will become the neobladder neck (Fig. 2.5). Conversely, a new hole can be created at the most mobile and dependent portion of the reservoir as originally described by Studer. Although thought to decrease folding that can occur at the neck of the bladder leading to functional obstruction, urinary retention rates appear to be similar with both techniques [10]. Each ureter is spatulated and a standard bilateral end-to-side ureteroileal anastomosis is performed using interrupted 4-0 polyglycolic acid suture (Fig. 2.6). The reservoir is anastomosed to the urethra using the previously placed urethral sutures (Fig. 2.7).

Radical cystectomy and urinary diversion remains one of the most complex urologic operations. Most patients are elderly and have significant comorbidities including long-term tobacco use. Thorough preoperative evaluation and counseling is critical in ensuring optimal outcomes and reducing complications. Many patients will require cardiac clearance particularly if there is a significant smoking history. We adhere to the principles of enhanced recovery after surgery (ERAS) and have implemented a postoperative pathway that has led to a dramatic decrease in hospital length of stay to a median of 4 days [11]. We no longer recommend mechanical or antibiotic bowel preparation which leads to dehydration, alteration of normal bowel flora and electrolyte disturbances. Patients undergoing a preoperatively planned continent cutaneous reservoir using the colon however are given a mechanical bowel preparation in order to decrease the amount of stool present in the colonic segment being used. Several studies have shown no benefit to bowel preparation prior to radical cystectomy including gastrointestinal complications [12]. A meta-analysis on the utility of bowel preparation prior to colorectal surgeries showed no difference in rates of wound infection, peritonitis, re-operation, or mortality [13]. In same token, nasogastric tube decompression is not necessary and in fact may increase complication rates rather than prevent aspiration or bowel leak [14]. In one study Inman et al. showed NGT decompression was actually associated with a prolonged time to gastrointestinal recovery and length of hospital stay [15]. Other studies have confirmed these findings, and in high volume centers, it is generally accepted that bowel resection can be safely performed without the use of postoperative nasogastric tube decompression [16, 17]. The meta-analysis performed by Cheatham et al. over 20 years ago confirmed the same findings in over 4000 and actually demonstrated a higher incidence of pulmonary complications with no clinical benefit [18]. Fasting and adhering to a clear liquid diet prior to surgery has again been the dogmatic approach to patients undergoing bowel resection and urinary diversion. Fasting however leads to insulin resistance and dehydration and in fact can increase postoperative complication rates. In fact evidence suggests that preoperative carbohydrate loading plays an important role in decreasing hospital stay by reducing insulin resistance [19]. We recommend use of high-protein, high-carbohydrate liquid drinks starting a few days prior to surgery. A regular diet is continued up until the night prior to surgery as per routine non-bowel surgery. Patients are directed toward a preoperative “cystectomy class” whereby they learn more about managing the various aspects of their upcoming surgery. Nurse specialists are involved and may be able to detect psychosocial barriers that may impede early recovery.

Patients are given alvimopan in the preoperative holding area about 1 h prior to surgery. Alvimopan is a mu opioid receptor antagonist that has been shown in multiple randomized trials to accelerate the return of bowel function following bowel resection. There are 5 multicenter double-blind randomized placebo-controlled trials including 1877 patients which have shown a decreased time to bowel function and hospital length of stay [20]. In patients undergoing radical cystectomy and urinary diversion a phase IV double-blind, placebo-controlled study again demonstrated the same benefit in decreasing time to bowel recovery leading to shorter hospital length of stay with a significant decrease in rates of ileus in the Alvimopan group (8.4% vs 29.1%; p < 0.001) [21].

Patients are also given subcutaneous heparin starting preoperatively in order to reduce the risk for venous thromboembolism. Patients are maintained on thrice daily subcutaneous heparin during the postoperative period and then discharged on prophylactic low molecular weight heparin. Intraoperatively, fluid intake is minimized and judicious use of colloids helps maintain intravascular volume. Every effort is made to minimize time under anesthesia and to decrease intraoperative blood loss including use of tissue sealants and fibrin products. Patients are given intravenous acetaminophen acetate as well as ketorolac (if adequate renal function) and opioid use is kept to a minimum. At the conclusion of the case, patients are transferred to a ward on telemetry unless there is an indication for admission to the ICU.

As previously mentioned we have adopted and evidence-based multimodal postoperative care pathway (enhanced recovery after surgery – ERAS) aimed at decreasing gastrointestinal complication rates and hospital length of stay. The pathway focuses on carbohydrate loading preoperatively, no bowel preparation, no postoperative nasogastric tube, focus on non-narcotic pain management, peripheral mu receptor opioid antagonist (alvimopan), use of neostigmine, and early feeding and ambulation. Sips of liquids (including high-carbohydrate, high-protein fluids) are started early on the afternoon or evening of surgery if tolerated up to a limit of 500 cc. Patients are started on a regular diet on postoperative day one provided they have no nausea, vomiting, or abdominal distention regardless of gas passage or bowel movement. Our “cystectomy diet” is designed for patients to improve tolerance post-surgery and to provide a high level of nutrients for healing. Foods known to cause bloating such as milk, raw fruits and vegetables, and high-fat foods are not included. Alvimopan is continued postoperatively and neostigmine and bisacodyl suppositories are administered to facilitate bowel function recovery. All of these medications are discontinued once the patient has a bowel movement. Additionally, a magnesium-based lactulose is started if there is no bowel function recovery by postoperative day 3. Proton pump inhibitor and H2 receptor blockers are used routinely for stress ulcer prevention and ondansetron and/or metoclopramide is administered for nausea and vomiting prophylaxis. Patients are asked to ambulate three times a day starting on postoperative day one.

If the patient has small volume emesis but is otherwise clinically stable and non-distended, we continue the same regimen but ask the patient to decrease their oral intake. Nasogastric tube decompression is only used for large volume, or repeated emesis or significant distention. If the patient is not tolerating oral food by 1 week postoperatively and/or there is no bowel activity, parenteral nutrition is considered.

Patients are given ketorolac (if renal function allows) and acetaminophen intravenously intraoperatively at the conclusion of the case. Para-incisional subfascial catheters are placed intraoperatively by the surgeon (positioned between the rectus muscle and the posterior rectus sheath) with constant local anesthetic (0.2% ropivacaine) release. Intramuscular ketorolac and oral acetaminophen are continued postoperatively for 48 h with opioid medication given for breakthrough pain. Use of postoperative opioids is minimized (while maintaining adequate pain control to reduce the chance of ileus). Opioid receptors are distributed throughout the gastrointestinal tract, and most opiates have mu receptor activity that inhibits gut motility and delays emptying [22]. As previously mentioned alvimopan helps to block these mu receptors and decrease ileus rates. We do use oral opioid pain medications starting postoperative day 1 with most patient being transitioned to oral analgesics only by POD 3–4.

Discharge criteria include bowel activity, adequate pain control with oral medication, ability to ambulate, normal electrolytes, and adequate oral intake of at least 1 l in 24 h. Prophylactic antibiotics are also used for 3 weeks postoperatively although there is a lack of evidence for their efficacy. Patients are discharged on oral sodium bicarbonate replacement if there are signs of early hyperchloremic metabolic acidosis. Patients are generally sent home with the catheter and the drain with instructions to irrigate the catheter 3–4 times a day. They have a schedule postoperative follow-up 7–10 days following discharge for a check-up and laboratories. In order to ensure adequate hydration during the early post-discharge period and to decrease readmission for dehydration and electrolyte abnormalities, we arrange for patients to receive 1 l of intravenous fluid therapy at home through a short peripherally inserted central line. All patients are seen at 3 weeks postoperatively for removal of catheters, drains and stents, and pouch training.