Urinary diversion
N
Comment
Ileal-conduit
345 (69 %)
Most commonly used
Ureterocutanostomy
10 (2 %)
In selected cases (ie. single kidney), old patients
Mainz- Pouch II
8 (2 %)
Mainly in women
Orthotopic neobladder
128 (25 %)
Mainly in male patients
Continent pouch (Kock, Indiana)
12 (2 %)
Mainly in women
Whereas an ileal conduit can be performed in almost every patient, ileal (sigmoid) neo-bladder requires some preliminaries: (i) the tumor has not infiltrated the bladder neck, (ii) the patient is able to manage the use of the neo-bladder including possibility to self-catheterize. A pouch can be also created is almost all situation, however, it represents a complex procedure and requires also the ability to self-catheterize [1].
Patients have to be informed about all variations of urinary diversion. For this purpose, we administer an enema of 300 cc of physiologic sodium chloride solution transanally and record the time, patients can hold this in the rectum. If the holding time is below 60 min, the patient should not undergo a continent diversion using a sigmoid pouch (i.e. Mainz-Pouch II). The use of ureterosigmodostomy without pouch has been abandoned. Additionally, we place a urostoma bag filled with 200 cc of normal saline on the right side of the body to check the appropriate position of the stoma of an ileal conduit (Fig. 69.1). Since the rate of hypercontince of a neobladder in women may reach up to 30 %, women should be mentatlly and physically able to perform self-catheterization.
Figure 69.1
Port placement for laparoscopic anterior exenteration – the right medial trocar entrance is used for the urostoma (black circle)
Patient Preparation
Initially, bowel preparation included oral self-administration of 2 liters of electrolyte lavage solution during 2 days before the surgical procedure. However, we have changed this to a only administration of laxatives the day before surgery. It is important to hydrate the patient adequately during the preoperative night (i.e. 1500 ml electrolyte solution i.v.).
Antibiotic prophylaxis with a cephalosporin (2 × 2 g) and metimazole (3 × 500 mg) is initiated intraoperatively for 5 days and low molecular weight heparin (4000 units) is administered preoperatively and until the postoperative day 15.
Technique of Urinary Diversion
Equipment
The technique is challenging, requiring state-of-the art laparoscopic or robot-assisted infrastructure and expertise (Table 69.2). We use a five- or six-port transperitoneal approach (Fig. 69.1). Standard laparoscopic surgical equipment with few special instruments is required (Table 69.3), including an endoscopic stapler (i.e. Endo-GIA) for control of the pedicles of the bladder and eventually for the intracorporeally performed intestinal anastomosis. At the « left Mac Burney » point a 12 mm diameter port is used, which can also be used to ease the retrieval of pelvic lymph nodes after dissection. At the true right Mac Burney point, another 12 mm trocar is placed to accept larger instruments (i.e. 10 mm-clip-applicator, right-angle dissector, needle with reducer-sheath, Endoscopic stapler) if necessary. Two 5 mm trocars are placed at the horizontal level of the navel, lateral to the 10/12 mm trocars.
Table 69.2
Laparoscopic urinary diversion – technical steps and options
Operative step | Options | Comments |
|---|---|---|
Transposition of ureter | Ileal-Conduit | Not for sigmoid-bladder or ureterosigmoidectomy |
Ileal-Neobladder (Studer-technique). | Not for Ileal-Neobladder (Hautmann-technique, Y-bladder) | |
Creation of reservoir | Intracorporeally | Technically difficult |
Stapler for GI-Anastomosis | ||
V-lock for neo-bladder | ||
Extracorporeally | Via mid-line incision | |
Open technique | ||
Ileal-conduit | Intracorporeally | Stapler for GI-Anastomosis |
Laparoscopic suture | ||
Extracorporeally (lap-assisted) | Via mid-line incision | |
Open technique | ||
Ureteral anastomosis | Intracorporeally | Sigmoid/Ileal-neobladder |
Sigmoid-pouch | ||
Ileal conduit | ||
Extracorporeally | Ileal neobladder (Studer) | |
Ileal-pouch | ||
Urethral anatomosis | Intracorporeally | All continent diversions (as first step) |
After re-insufflation (as last step) | ||
Extracorporeally | With laparoscopic pre-placed stitches |
Table 69.3
Laparoscopic pelvic anterior exenteration – equipment
Standard laparoscopic equipment | |
High flow insufflator/Air Seal | 1 |
300 W Xenon light fountain | 1 |
HD-camera (Karl Storz) | 1 |
10 mm 30° laparoscope | 1 |
Trocars | |
10–12 mm trocars | 2–3 |
5 mm trocars (reusable trocars preferred) | 3 |
Instruments | |
Laparoscopic Metzenbaum scissors, 5 mm | 1 |
Laparoscopic bipolar forceps, 5 mm | 1 |
Laparoscopic endo-dissectors, 5 mm | 2 |
Laparoscopic right-angle-dissector, 10 mm | 1 |
Laparoscopic atraumatic prehension forceps | 2 |
Laparoscopic suction irrigation canula | 1 |
Laparoscopy bags (i.e. Storz-Extraction Bag, 800 cc) | 1 |
Surgical endoscopy 5–10 mm clips appliers | 1 |
Needle-holder (i.e. Duffner, Storz), for both hands | 2 |
Endo-GIA30-stapler (i.e. Covedien) | |
Optional: | |
Harmonic scalpel (i.e. Ultracision, Ethicon), 10 mm device
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