Urinary Diversion

Urinary Diversion

Kawa Omar1, Nawal Shamim Khan2, Shahrokh F. Shariat3, Johannes Alfred Witjes4, and Muhammad Shamim Khan5,6,7

1 Department of Urology, Guy’s & St Thomas’ Hospital, NHS Foundation Trust, London, UK

2 Final Year Medical Student, Oradea University, Oradea, Romania

3 Department of Urology, Medical University of Vienna, Vienna, Austria

4 Department of Urology, Radboud University Medical Center, Nijmegen, Netherlands

5 Guy’s & St Thomas’ Hospital, NHS Foundation Trust, King’s College, London, UK

6 MRC Centre for Transplantation, King’s College London, King’s Health Partners, London, UK

7 Department of Urology, Guy’s & St. Thomas’ Hospital, NHS Foundation Trust, London, UK


Urinary Diversions

Urinary diversion involves rerouting of urinary drainage to outside of the body. These procedures can be performed either as a temporising measure or a permanent solution. The most common reason for a permanent urinary diversion is after ablative surgery for malignancy of the urinary bladder or other pelvic organs. However, it can be performed for functional and anatomical abnormalities of the urinary tract. Urinary diversions can be classified as percutaneous, continent, or incontinent.

The majority of diversions involve incorporating a segment of bowel in to the urinary tract to either create a conduit or a reservoir. An ideal diversion is one with low pressure, no reflux in to the upper tract, spontaneous and controlled emptying, maintains body image, and is of no functional consequences. However, at present an ideal urinary diversion does not exist. Choice of a urinary diversion depends mainly on the underlying pathology, patient’s compliance and dexterity, renal function, presence of bowel disease, previous bowel surgery, and patient’s preference.

All types of diversions have certain advantages and disadvantages. As most types of diversions include change in the body image and lifelong commitment to diversion care, patients need to be appropriately counselled prior to operations as to what the operation might entail. In addition, long‐term monitoring of renal function and metabolic and nutritional status are required. In this chapter, we discuss common types of urinary diversion, indications, contraindications, and pros and cons of each.

Keywords: urinary diversions; nephrostomy; cystostomy; continent or incontinent urinary diversions; ileal conduit; Mitrofanoff; Bricker; Wallace; Mainz II; Studer pouch; orthotopic bladder substitution

22.1 Urinary Diversions

22.1.1 History

The long history of urinary diversion begins, it is said, with Franco, who created an artificial urinary fistula in 1556 [1]. Later Petit (1770) made a nephrostomy for calculous pyonephrosis [1]. Any kind of external fistula requires either an indwelling tube or a suitable external collecting appliance, and none were really suitable until the invention of the adhesive bag in 1950. The most extreme example of an external fistula was exstrophy, for which life with collecting devices was so miserable that it led Simon to attempt the first ureterosigmoidostomy; he was led to this bold step by the consideration that: ‘patients whose bladder, after the operation of lithotomy, opens into the rectum, acquire a certain control over the fluid contents of that bowel, by means of both sphincters ani’ [2]. Using special catheters armed with sharp stylets, he passed seton sutures from ureters into the rectum and tied them tightly. His patient became dry, but within a year both ureters became ‘choked with calculous concretions’ [3] and he died. Shortly afterwards, in 1851, Lloyd attempted the same procedure, but perforated the peritoneum and the patient died 10 days later [4]. These two complications were to bedevil urinary diversion for another century.

22.1.2 Nephrostomy

Nephrostomy is one of the most common procedures employed by interventional radiologists, especially in emergency obstructive uropathy scenarios. Inserted under local anaesthetic percutaneously, nephrostomies can be temporary, or in certain cases, permanent, requiring regular changes.

Nephrostomy can allow for antegrade studies to be carried out as well as procedures such as ureteric dilation or stent insertion. If a percutaneous nephrolitholapaxy is to be carried out for a large renal stone, the nephrostomy can be used as the tract site for dilation intraoperatively.

Complications include infection, bleeding, and pain most commonly. Inadvertent renal vessel cannulation, atrioventricular (AV) fistulation, and ureteric or renal pelvic perforation are more severe but rare.

22.1.3 Suprapubic Cystostomy

The simplest and most useful temporary diversion is the suprapubic percutaneous cystoscopy better known as suprapubic catheterisation (SPC). SPC is commonly used in retention of urine where a urethral catheter is difficult to pass. The technique is simple (Figure 22.1). Local anaesthetic is given with a large‐bore needle. A small 1‐ to 1.5‐cm incision is made about two fingerbreadths above the symphysis pubis. A long needle is directed into the bladder. A rigid guidewire inserted and needle removed. A dilator is railroaded over the guidewire and a catheter is inserted through the dilator sheath.

3 Illustrations depicting suprapubic cystostomy.

Figure 22.1 (a–c) Suprapubic cystostomy.

SPC insertions can be done in an emergency scenario, or more commonly, electively. It can be carried out percutaneously with blind insertion, or using the aid of an ultrasound to ensure the bladder is cannulated. Alternatively, under flexible or rigid cystoscopic guidance. Indications of SPC Insertion [5]

  • Acute or chronic urinary retention
  • Neurological disorders (i.e. multiple sclerosis or patients with spinal cord injuries)
  • For patients requiring long‐term catheterisation (i.e. patients who are frail or elderly)
  • Urinary incontinence
  • Postoperative
  • Trauma settings Contraindications of SPC Insertion [5]

  • Bladder cancer
  • Patients with bleeding diathesis or use of anticoagulation or antiplatelets
  • Previous abdominal surgery, higher risk of bowel damage
  • Previous vascular surgery where subcutaneous vascular graft is present Complications [5]

  • Bleeding
  • Infection
  • Bladder discomfort or pain,
  • Urine leakage from around the catheter
  • Stone and debris formation which can block the catheter
  • Injury to the bowel (see figure in Chapter 23)

In rare cases, an open cystostomy might be required, especially if the bladder cannot be palpated, or there is a high risk of bladder injury. Such cases are nearly always men who have undergone previous surgery when the peritoneum is apt to be stuck to the symphysis, and great care is needed in finding the bladder (Figure 22.2).

4 Illustrations depicting formal open cystostomy, with peritoneum displaced upwards (a), bladder opened between stay sutures (b), and catheter lying in a long oblique tunnel, well away from the symphysis (c and d).

Figure 22.2 Formal open cystostomy. After (a) separating the recti, the peritoneum is displaced upwards and (b) the bladder is opened between stay sutures. (c and d) The catheter lies in a long oblique tunnel, well away from the symphysis.

22.2 Bladder Urinary Diversion

Urinary diversions may be incontinent or continent. The ideal reservoir should have a low‐pressure system, store a functional amount of urine, and be reliable in maintaining continence either through natural orifices or through appliances with voluntary control of voiding and no absorption of urinary wastes. In Table 22.1, the characteristics of an ideal reservoir are shown. Unfortunately, such a reservoir does not exist, and the aim of fashion urinary diversion is to achieve as close as possible to these characteristics. Selection of any type of urinary diversion are determined by a number of factors which are presented in Table 22.2.

Table 22.1 Ideal characteristics of a urinary reservoir.

Characteristic Comments
Low pressure system Higher internal pressure in the reservoir may overcome the external sphincter mechanisms that maintain continence
Stores a functional amount of urine (approximately 500 ml)
Reliable, complete continence Detubularisation of intestinal segments limits the ability to generate a peristaltic pressure wave. These waves can contribute to incontinence.
Complete voluntary control of voiding
No absorption of urinary waste products by the reservoir walls Minimises the likelihood of metabolic complications

Table 22.2 Issues affecting urinary diversion selection.

Cancer Control General Health Technical Quality of Life
Risk of local recurrence Functional status Functioning urethra Compliance
Previous pelvic radiation Previous surgeries Tumour location Sexual function
Need for adjuvant therapy Renal or hepatic function Ability to catheterize Body image
Secondary malignancies Medical comorbidities Mesentery length Urinary function
Urethral or bladder neck involvement Status of gastrointestinal tract Bowel condition Family support

Body habitus Operative time Daily maintenance

22.2.1 Incontinent Urinary Diversion

The incontinent urinary diversion options include cutaneous ureterostomy, or more commonly, intestinal conduit urinary diversion. Although technically less demanding, these entail application of an external appliance and hence cosmetically are less pleasing. Cutaneous Ureterostomy

Ureterostomy is also a method of diversion, rarely used, and usually only as a last resort. Cutaneous ureterostomy involves direct drainage of urine from the ureters to an appliance over the abdominal wall. The most suitable patients for this kind of urinary diversion are:

  • High‐risk patients with symptomatic bladder cancer combined with palliative cystectomy.
  • Diversion in patients with urinary fistula.
  • Salvage procedures.

This type of diversion should not be considered in patients with following clinical situations:

  • Patients who are obsess.
  • After radiotherapy.
  • Short ureteric stumps.
  • Poorly vascularized ureters.

Technique: when the ureter is wide it can be split, everted, and brought to the skin like an ileostomy (Figure 22.3). For ureters of more normal calibre, there is a tendency for the stoma to undergo stenosis, which a double‐Z plasty may partly avoid (Figure 22.4).

Illustration depicting ureterostomy when ureter dilated.

Figure 22.3 Ureterostomy when the ureter is dilated.

3 Illustrations depicting double-Z plasty for ureterostomy with an undilated ureter.

Figure 22.4 Double‐Z plasty for ureterostomy with an undilated ureter. Intestinal Conduit

Originally described by Zaayer in 1911, intestinal conduit is now the most frequently performed diversion. It is a passive conduit for urine to drain into an appliance. Most commonly, a segment of ileum is used to construct the conduit, although a colonic segment may be used as alternative in cases of previous pelvic radiation.

The ileal conduit was developed in occupied France during World War II. The French surgeons were glad to explain their new techniques to the surgeons in the liberating forces. The technique did not gain wide acceptance until an effective adhesive appliance for ileostomy was introduced in 1950. The operation was first described in the English literature by Bricker [6] (sadly, without any acknowledgement of priority to the French). The ileal conduit soon replaced the now historic ureterosigmoidostomy.

There are a number of useful simplifications of the original French/Bricker method of making an ileal conduit, notably, the simple anastomosis of Wallace [7]. Using this technique, the ileal loop became the diversion of choice.

After bowel preparation, a length of ileum with a good blood supply, from an unirradiated area (Figure 22.5), is selected. Having isolated the loop, an end‐to‐end anastomosis is performed (the Wallace technique; Figure 22.6). The ureters are spatulated and anastomosed together to form a common stoma which is then sewn to the open end of the bowel (Figure 22.7). In the Bricker technique, each ureter is spatulated and anastomosed to the bowel separately. It saves anxiety if the ureters are stented for a few days and an intra‐abdominal drain left in situ.

3 Illustrations depicting the mesentery viewed with transmitted light (a), with the mesenteric vessels ligated to isolate the loop (b and c).

Figure 22.5 (a) The mesentery is viewed with transmitted light. (b and c) The mesenteric vessels are ligated to isolate the loop.

4 Illustrations depicting the ends of the ileum anastomosed together.

Figure 22.6 (a–d) The ends of the ileum are anastomosed together.

4 Illustrations depicting the ends of the ureters spatulated and sewn together and anastomosed to one end of isolated ileal loop (a and b). The other end is brought out on the skin as an ileostomy (c and d).

Figure 22.7 (a) The ends of the ureters are spatulated and sewn together and anastomosed to one end of the isolated ileal loop (b). The other end is brought out on the skin as an ileostomy (c and d).

Early Complications [8, 9]:

  • Ischemia
  • Ileus
  • Bowel anastomotic leak
  • Urinary leak
  • Bowel obstruction

Delayed Complications [8, 9] :

  • Parastomal hernia
  • Stomal retraction or stenosis
  • Renal impairment (with up to 6% dying from end‐stage renal failure)
  • Urinary tract infection (UTI)
  • Stomal stenosis
  • Bowel complications
  • Stomal bleeding
  • Uretero‐ileal obstruction or stenosis
  • Redundant loop
  • Stones
  • Incisional hernia
  • Metabolic disorders
  • Psychological disorders

As much care should be given in choosing the right site for the appliance as is given to the operation itself. The site of the stoma is chosen after the patient has worn an appliance, filled with water, when sitting, lying down, and with his or her clothes on. Care must be taken to avoid placing the site of the stoma on a scar, skin crease, or where the belt is usually tightened.

From time to time it is convenient to make a conduit out of a suitable length of the large bowel (e.g. the sigmoid after pelvic exenteration); these are known as colonic conduits. Exactly the same principles are used. There are no special advantages or disadvantages in using large rather than small bowel. Urinary absorption and the risk of reflux is identical.

The follow‐up of patients with either type of intestinal conduit should include regular monitoring of their electrolytes, especially when there is already some impairment of renal function. In addition, ultrasound or urography is necessary to detect dilatation of the loop or of the upper tracts. Stones are a frequent long‐term complication of intestinal conduits. The indications and metabolic consequences of each part of the gastrointestinal tract are presented in Table 22.3.

Table 22.3 Primary indications and metabolic consequences for use of bowel segments.

Bowel Segment Primary Indication Metabolic Consequences Clinical Symptoms

  • Children requiring diversion (exstrophy, pelvic radiation)
  • Renal insufficiency
Metabolic alkalosis
(↓ K and Cl, hypergastrinemia)

  • Haematuria‐dysuria syndrome
  • Dehydration, lethargy, seizures, respiratory distress

  • Pelvic radiation
  • Deficient ureteral length
  • Compromised viability of other small or large bowel
Metabolic acidosis
(↓ Na and Cl, ↑ K, azotaemia)

  • Dehydration, nausea/vomiting, weakness, lethargy, seizures
Ileum or ileal‐colic reservoirs

  • Malignancies requiring removal of the bladder
  • Severe haemorrhagic cystitis
  • Incontinence
Metabolic acidosis
(↑ Cl, ↓ bicarbonate, azotaemia)

  • Fatigue, anorexia, weight loss, diarrhoea, polydipsia
  • B12 and fat soluble vitamin deficiency
  • Diarrhoea, urinary calculi, cholelithiasis
Colon (ureterosigmoidostomy)

  • Children requiring diversion (exstrophy, pelvic radiation)
  • No other bowel segment alternative
Metabolic acidosis
(↑ Cl, ↓ bicarbonate, azotaemia)

  • Fatigue, anorexia, weight loss, diarrhoea, polydipsia
  • Pyelonephritis
  • Adenocarcinoma at anastomotic site
Transverse colon conduit

  • Malignancies requiring removal of the bladder
  • Small bowel not practical
Metabolic acidosis
(↑ Cl, ↓ bicarbonate, azotaemia)

  • Fatigue, anorexia, weight loss, diarrhoea, polydipsia
  • Pyelonephritis
  • Adenocarcinoma at anastomotic site

Cl, chlorine; K, potassium; NA, sodium.

22.2.2 Continent Urinary Diversions

Despite the safety of the ileal conduit, many patients disliked their urinary stoma, and however good the appliance, it was always likely to leak or come unstuck at the least convenient moment.

The options include:

  1. Orthotopic substitution
  2. Continent pouches and bladder augmentation
  3. Natural evacuation urinary diversion (ureterosigmoidostomy) Orthotopic Bladder Substitution (Neobladder)

Although there is no ideal urinary diversion, this option is closest to the native bladder because patients opting for this type may void spontaneously, be continent, and also maintain the body image. A variety of techniques have been described, but currently the most widely used is the Studer technique [10]. The techniques all essentially involve a reservoir fashioned from bowel and a neo‐sphincter mechanism or catheterisable conduit. Contraindications of a continent urinary diversions are summarised in Table 22.4. In general, the continent urinary diversions be it neobladder or catheterisable pouches are associated with early and long‐term complications; the complications and their rate are shown in Table 22.5 [11, 12].

Table 22.4 Absolute and relative contraindications for continent cutaneous or orthotopic neobladder urinary diversions.

Absolute contraindications
Impaired renal function: serum creatinine values >2.0–2.5 mg dl−1 or 1.5 μmol l−1 or eGFR <40 ml min−1/1.73 m2
Impaired hepatic function
Physical or mental impairment to perform self‐catheterization
Positive apical urethral margin (for neobladder)
Unmotivated patient
Relative contraindications
Associated comorbid conditions
Advanced age
Need for adjuvant chemotherapy
Prior pelvic radiation
Bowel disease
Urethral pathology
Extensive local disease with soft tissue extension and high risk of local recurrence

eGFR, estimated glomerular filtration rate.

Table 22.5 Early versus late complications of continent urinary diversions.

Complication Type Early
(within 30 days)
% Long Term
(30 days to death)
Reservoir‐related Urinary leak 1.8–10

Pyelonephritis 0.9–13 Pyelonephritis 3–10

Upper tract calculi 3

Pouch calculi 5–35
Anastomosis‐related Ureteral obstruction 0–6.3 Ureteral obstruction or stricture 2–30

Urethral or stomal stricture 2–14.3 Renal deterioration 0.4–10.5

Ureteral reflux <2
Bowel‐related Faecal leak 1–2 Metabolic abnormalities 15–50

Prolonged ileus 2–11 Bowel obstruction 4–8
Other Wound infection 5

Wound dehiscence 5 Incisional hernia 0–10

Deep venous thrombosis 2–2.7 Deep venous thrombosis 0–6.3

Loss of continence mechanism 15–20

Hypercontinence (male vs. female) 3–9 vs. 10–50 Contraindications to Neobladder Formation

  • Poor mental capacity
  • Poor manual dexterity (unable to perform self‐catheterisation)
  • Prostate or bladder neck cancer involvement
  • Estimated glomerular filtration rate (eGFR) <35 ml min−1
  • Severe gastrointestinal disease (e.g. inflammatory bowel, history of bowel cancer, radiotherapy to the bowel)
  • Unmotivated poor compliant patient

Complications of bladder substitute include:

  • Urinary incontinence and nocturnal enuresis
  • Mucus production (could be more than 3–5 g daily requiring regular catheterisation or washouts)
  • Urinary leakage and peritonitis
  • Abscess
  • Stones
  • UTIs
  • Late onset neobladder rupture Continent Pouches and Bladder Augmentation

There were attempts by the turn of the century to use the bowel as a reservoir for urine. Bricker, Eiseman, Gilchrist, and Merricks [1315] developed a technique that was claimed to give a capacious reservoir with a continent ileal stoma which could be emptied by periodic intermittent self‐catheterization (Figure 22.8). Couvelaire was critical of the method ‘Elle n’a rien d’une vessie, ni la continence, ni la miction[16]. Nor was it free from the complications of acidosis, ascending infection, and calculus formation.

3 Illustrations depicting Merricks–Gilchrist ileocaecal reservoir featuring the ileocaecal segment (left), ileocaecal valve (right), and ureters, ileostomy, and ileocaecal valve (bottom).

Figure 22.8 Merricks–Gilchrist ileocaecal reservoir.

More recently, a continent pouch is fashioned from about 60 cm of detubularised ileum rather than colon but employs the same principles. The ureters are anastomosed to the pouch with an anti‐reflux submucosal tunnel. A catheterisable stoma is brought out in the right iliac fossa.

In 1980 Mitrofanoff first described a continent supravesical catheterisable channel, using appendix on vascular pedicle [17]. In patients who have either lost an appendix at operation or do not have suitable lumen or length, alternatives have been used including small bowel [18, 19], ureter, Fallopian tube, colon, vas deferens, or even stomach [2024].

The earliest attempts to enlarge the bladder with bowel were performed for bladders that had undergone contracture from tuberculosis or interstitial cystitis. Different segments of intestine were used, including colon, small intestine, and caecum (Figure 22.9). Spontaneous contractions of the bowel, especially the caecum, would result in incontinence of urine especially at night, but a more serious consequence of these uninhibited contractions was that they generated such a high pressure that there would be ureteric reflux and obstructive nephropathy.

3 Illustrations depicting ileum (left), colon (middle), and caecum with ureters and ileum (right). The latter has remnant of bladder or ureters.

Figure 22.9 A simple length of ileum, colon, or ileum and colon were added onto the trigone after subtotal cystectomy.

These could be avoided if the bowel were ‘detubularised’ (i.e. opened out and sewn into the bladder as a flat patch). The uncoordinated bowel contractions would not generate any pressure; indeed, such a patch could be used in ‘clam cystoplasty’ to overcome deliberately raised bladder pressure in patients with vesical detrusor instability (Figure 22.10) [2528].

3 Illustrations depicting clam cystoplasty, with bladder opened in the coronal plane and length of ileum isolated (a). The ileum is opened and sewn into the bladder (b) to give extra volume and lower the pressure (c).

Figure 22.10 Clam cystoplasty. (a) The bladder is opened in the coronal plane and a length of ileum is isolated. (b) The ileum is opened and sewn into the bladder (c) to give extra volume and lower the pressure.

As a result of this discovery, it became possible to devise a new kind of pouch or bladder enlargement with a very low pressure – so low indeed that it would not take much pressure on the outlet to maintain continence (Figure 22.11). Continence was usually at the expense of needing self‐catheterization and occasional spontaneous rupture [29].

Image described by caption.

Figure 22.11 Kock’s pouch. (a) A 45‐cm length of ileum is isolated, and (b) the middle 20 cm opened out. (c–e) The ileum at each end is intussuscepted to form an anti‐reflux nipple, which is secured with staples. (f) One end forms the stoma, and the other is anastomosed to the ureters. The middle portion is formed into a reservoir.

Although Kock had first developed this pouch as a faecal reservoir for patients undergoing colectomy for ulcerative colitis, the idea was quickly adapted as a urinary reservoir. At first, the stoma was led out on the skin, later, it was anastomosed to the urethra as a true substitute for the bladder [30]. Because only a very low pressure was needed to keep in the urine, one could make use of an artificial sphincter, a loop of ileum, plicated ileum, or the appendix.

The ingenuity of its enthusiasts knew no bounds, and every conceivable permutation and combination of every part of the gastrointestinal tract was used to provide low‐pressure continent substitutes for the bladder (Figure 22.12) [3134]. The multiplicity of these techniques and their innumerable modifications shows that none of them are yet perfect. Preoperative radiation to the bowel rules them out.

5 Illustrations depicting ureters implanted with long submucosal tunnels (a), window in mesentery (b), intact ileocaecal valve (c), ileum intussuscepted and staples (d), and nipple brought to ileocaecal valve (e).

Figure 22.12 (a–f) The Mainz pouch. A 30‐cm length of ileum and caecum are isolated. One end of the ileum is intussuscepted and brought through the ileocaecal valve as a long anti‐reflux nipple. The ureters are implanted into the caecum with long submucosal tunnels. The rest of the ileum is sewn onto the caecum to give a low‐pressure reservoir. The pouch may be joined to the skin or to the urethra.

The two problems that remain a challenge are how to prevent reflux up the ureters and how to maintain continence. In the Kock pouch, reflux from the reservoir to the ureters is prevented by an ileal intussusceptum which forms a long nipple‐like valve. Continence of urine is achieved by a second intussusceptum valve on the efferent limb of ileum.

In a Camey technique, reflux is prevented by a submucosal tunnel similar to the classical Leadbetter valve in ureterocolic anastomosis (Figure 22.13) [35]. Mitrofanoff [34, 36] uses the appendix, where present, as a long narrow stoma, joining it to the skin or the urethra. At the umbilicus, it is invisible [37]. Others use plicated ileum to provide continence [38].

Illustration depicting camey operation with parts labeled antireflux anastomosis, ileal loop, and urethra.

Figure 22.13 Camey operation. The ureters are anastomosed through a long submucosal tunnel to each end of the loop of ileum which is anastomosed to the stump of the urethra after cystectomy.

Complications of continent pouches [3941] include:

  • Mortality
  • Small bowel obstruction
  • Ischaemic necrosis of channel
  • Peristomal abscess
  • Stones
  • Renal impairment
  • Catheterisation difficulties
  • Revision rate
  • Stenosis
  • Prolapse
  • Reservoir rupture
  • UTIs
  • Metabolic disorders
  • Malignancy

As mentioned previously, the choice of continent or conduit urinary diversions is based on a number of factors, but there are a number of studies which have reported the rate of complications of either type in the early postoperative period or in the long term. The studies with their number of patients, duration of follow up, and rate complications are tabulated in Table 22.6.

Table 22.6 Comparison of complications: ileal conduits versus continent diversions.

Type of Diversion Year Series No. of Patients Time From Surgery (months) % Complications
Ileal conduit 2000 Parekh, et al. 81 19 22

1998 Gburek, et al. 66 20 18

2003 Studer, et al. 131 98 66
Continent diversion 2000 Parekh, et al. 117 20 12

1998 Gburek, et al. 66 17 18

1999 Shimogaki, et al. 8 59.9 0

2000 Mills, et al. 15 19 13

1999 Ali‐el‐dein, et al. 60 20.2 13

1999 Hautmann, et al. 363 57 15.4–23.4a

2000 Steven, et al. 166 32 23.5–37.4a

1997 Studer, et al. 200 30–134 12–22a

a Early (within 90 days) vs. late (>90 days) complications. Natural Evacuation Urinary Diversion Ureterosigmoidostomy

The first type of urinary diversion applied in 1852 by Simon had significant morbidities and mortality due to obstruction and sepsis. Innumerable techniques were devised for performing the ureterosigmoidostomy, but it was not until a direct elliptical mucosal anastomosis was combined with an anti‐reflux tunnel that the ascending infection complication was reduced, but remained significant. However, metabolic complications were significant. Physiologists had long been aware that if enough urine was absorbed by the intestine, it could eventually lead to renal tubular damage [42, 43], but the complication was thought to be very rare [44, 45]. Then, in 1950 Ferris and Odel published their long‐term follow‐up of 124 patients and found that no fewer than 62% had developed severe acidosis [46].

The biochemical changes were due to two factors: first and foremost was absorption of urine. Since normal urine is acidotic to the plasma by one‐third too much chloride, this absorption at a milliequivalent for milliequivalent rate can cause hypochloraemia, and the real problem is how much absorption occurs [47]. The second factor was renal function. If renal tubular function was perfect, it could cope with the acidosis. But when continued absorption of urine or damage from ascending infection and obstruction began to impair tubular function, acidosis would appear. This explained why it took so long for acidosis to develop in patients who started off with good kidneys [48].

Once the hazards of acidosis were appreciated, surgeons welcomed other alternatives to ureterosigmoidostomy. Nevertheless, the method still has a place (e.g. when the patient has a good anal control, good renal function, and a relatively short life expectancy) [49]. The Leadbetter tunnelled anti‐reflux technique reduced infection rates; however, high intrarectal pressures led to persistent infection as well as incontinence (Figure 22.14). The Mansoura and Mainz II techniques were devised to reduce intrarectal pressures.

3 Illustrations depicting the ureter brought between layers of mesosigmoid (a), tunnel made for ureter through muscle of colon (b), and elliptical anastomosis made between spatulated ureter and colonic mucosa (c).

Figure 22.14 Leadbetter technique of ureterosigmoidostomy. (a) The ureter is brought between the layers of the mesosigmoid. (b) A tunnel is made for the ureter through the muscle of the colon. (c) An elliptical anastomosis is made between the spatulated ureter and colonic mucosa. The muscle is closed over the ureter; to prevent closing it too tightly, a catheter is placed alongside the ureter while the stitches are tied. The Mansoura Diversion

In Egypt as well as many countries where the poor and low socioeconomic uneducated class are prevalent, incontinence means social ostracism, and adhesive appliances are expensive and unreliable in the hot climate. Ghoneim, working with Kock, devised an ingenious modification of a historical urinary diversion technique the Mauclaire’s operation, which offers the patient a capacious urinary reservoir, prevents reflux of urine even in ureters that have been damaged by bilharziasis, and employs an intussusception valve which keeps the urine in the rectum and out of the rest of the colon (so it limits the absorbent surface area; Figure 22.15). The sigmoid colon is intussuscepted to prevent reflux and Kock ureteric anastomosis fashioned, an ileal augmentation of the sigmoid reduces intraluminal pressures.

3 Illustrations depicting Mansoura diversion, with intussuscepted sigmoid (a), ureters led down between layers of intussuscepted bowel (b), and isolated patch of ileum added to rectosigmoid (c).

Figure 22.15 The Mansoura diversion. (a) The sigmoid is intussuscepted to form a nonreturn valve. (b) The ureters are led down between the layers of the intussuscepted bowel to prevent reflux. (c) An isolated patch of ileum is added to the rectosigmoid to give extra capacity. Mainz II Diversion

It is a type of continent urinary diversion in which a pouch is created from rectosigmoid. A length of 15–20 cm of the sigmoid is opened on the antimesentric side and closed side to side to form a pouch. The ureters are then implanted in a 3.5‐cm submucosal tunnel to act as an anti‐reflux mechanism. A well‐functioning anal sphincter is essential for patients selected for this procedure. In patients requiring urethrectomy, or those live in hot climates or developing countries where acquiring and maintaining external appliance might be difficult, it is the diversion of choice.

Contraindications for a Mainz II diversion include poor anal sphincter function, pelvic radiotherapy, and diverticulosis.

Complications of a Mainz II diversion are:


  • Urinary or bowel leak
  • Bowel obstruction


  • Metabolic disturbances
  • Incontinence
  • Renal function deterioration
  • UTIs
  • Diarrhoea
  • Ureterosigmoid cancer

22.3 Functional Follow‐Up

Resection of a part of subterminal ileum for construction of ileal conduit predisposes patients to vitamin B12 deficiency. The body has a large reserve of vitamin B12; therefore, levels may decrease after three years. These patients will be at risk of megaloblastic anaemia and subacute combined degeneration of spinal cord. Once a diagnosis of vitamin B12 deficiency is made, supplementation is indicated. Monitoring of vitamin B12 levels should be checked at follow‐up every 6–12 months [50].

Metabolic hyperchloraemic acidosis can occur in up to 15% patients after a radical cystectomy and ileal conduit and up to 50% of patients with continent diversions [51]. It is less likely in patients with normal renal function (eGFR >60 ml min−1 as can compensate). These patients require regular monitoring for metabolic abnormalities every 6–12 months and generous supplementation with sodium bicarbonate if found to have metabolic acidosis. Metabolic follow‐up should continue up to 15 years after cystectomy [52]. If left uncorrected can lead to bone demineralization and osteomalacia.

Adenocarcinoma may develop in the ileal conduit or neobladder in the long term (15–20 years) in 5% of patients. This is due to the carcinogenic bacterial metabolism of urinary nitrosamines; there is a risk of cancer in the long term. It took 20 years of experience with ureterosigmoidostomy before the risk of colonic cancer came to light [53]. Therefore, annual cystoscopy is recommended on a long‐term basis.

22.4 Quality of Life Urinary Diversion after Cystectomy

It is obvious that radical cystectomy is a major surgery and also involves structural changes. With treatments aiming to prolong life in bladder cancer, there has also been increasing interest in the quality of life (QoL) after cystectomy [54]. There have been questions regarding the social aspects of life, sexual function, adaptation to the new body image, and new appliances. Efforts have been made to produce relevant validated tools for evaluation of QoL that reflects QoL in patients with bladder cancer [55, 56].

To date, there are no randomised controlled studies to support superiority of QoL in continent diversions in comparison with conduit diversions and studies show varying outcomes. Some studies have shown that global QoL is better with orthotopic neobladder compared to ileal conduit [57], whilst others have failed to report a better QoL in continent, incontinent, or orthotopic neobladders [5860]. Orthotopic neobladder is associated with a marginally better QoL [54].

However, improvement in surgical techniques has been shown to affect the aspects of QoL, especially in nerve‐sparing surgery. Impaired sexual function, altered bowel function, and urinary function have been found to be causes of concern with continent neobladders [61]. In nerve‐sparing surgeries, erectile function was improved, but better outcomes are seen in patients who are younger [6265]. Similarly, sexual function is affected in females after cystectomy, and nerve‐sparing cystectomy in females has also been shown to have superior sexual function recovery [66, 67].

Despite the approach of surgery, appropriate preoperative counselling about the type of the urinary diversions and its impact on the functional status and body image remains important [68]. The operation, the side effects, and outcomes have to be appropriately explained to patients, and patients should also be counselled before the operation about the operation might entail.

Aug 6, 2020 | Posted by in UROLOGY | Comments Off on Urinary Diversion

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