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24 October 2003
Continent Urinary Diversion
Phichaya Sujijantararat
24 October 2003
24 October 2003
Continent Urinary Diversion
• A system created to collect and store urine before it is removed from the body.
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Urinary Diversion
Classification:
1. Orthotopic (emptied through urethra )
vs non-orthotopic
2. Continent vs non-continent
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Who need it ?
1. Congenital anomalies eg. Exstrophy- Epispadias Complex , Cloacal exstrophy, Bilateral Single Ectopic Ureters 2. Neuropathic bladder 3. Bladder loss eg. Pelvic malignancy 4. Radiation damage 5. Urethral loss
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Continent Urinary Diversion
Adult
Restoration of
previously existing
state
Child
Dawn of the new life
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Patient selection
- ability to self catheterize
r/o quadriplegia, multiple sclerosis
- highly motivated & intelligence
- renal impairment
Cr < 1.8 mg% or Ccr > 60 ml/min
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Continent Urinary Diversion
Three basic components:
1. Reservoir to store urine
2. Continent mechanism to retain urine
3. Channel or tunnel + catheterizable
stoma to let the urine out
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Continent Urinary Diversion
Types of reservoir
1. Native bladder
2. Augmented bladder
3. New constructed pouch or reservoir
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Reservoir requirements
1. Low pressure
< 40 cm.H2O ( McGuire 1981 )
2. Adequate capacity
> 4 hourly emptying
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Bowel as a pouch, not a conduit
1. Detubularize to abolish peristalsis
2. Reconfiguration to increase capacity
3. Anti-reflux to prevent renal damage
4. Continence mechanism
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The effect of using different lengths of ileal segment
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Reconfiguration
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Reconfiguration
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Continence mechanisms
1. Flap valve eg. Mitrofanoff, Monti
2. Nipple valve eg. Kock nipple
3. Hydraulic valve eg. Benchekroun
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Kock Nipple
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Bencekroun Hydraulic Valve
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Bencekroun Hydraulic Valve
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Types of channel or tunnel
1. Appendix
2. Ileum
3. Colon
4. Ureter
5. Fallopian tube
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Mitrofanoff
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Mitrofanoff
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Monti tube (1)
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Monti tube (2)
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Monti tube (3)
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Monti tube (4)
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Modified Monti technique
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Modified Monti technique
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Modified Monti technique
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Anti-reflux techniques
1. Flap valve ( submucosal tunnel )
2. Split cuff nipple
3. Serosal lined extramural tunnel
4. Le Duc ( mucosal trough )
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Flap valve principle
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Split Cuff Nipple
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Le Duc (Mucosal trough)
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Anti-reflux techniques
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Post-operative care (1)
- flush stomal & pouch catheters 2/day
- remove ureteric stents on day 7
- leave stomal & pouch catheters for 3 wks
- cystogram or pouchogram
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Post-operative care (2)
- re-admission 6th wk - clamp & release stomal catheter at 2 – 3 hour interval - After the pouch expands to 300-500 ml, remove stomal catheter - start self catheterization - remove pouch catheter
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Advantages
1. No cost for expensive external appliance
2. Maintain body image
3. No psychologic impact
4. Socially acceptable
5. Maintain sex performance ?
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Urogenital sinus
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Pippi-Salle (1)
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Pippi-Salle (2)
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Future aspects
1. More than 40 variants of continent diversion, no single best technique
2. Which bowel segment ?3. Which continent technique ?4. Which anti-reflux technique ? Only long term follow up can answer
these questions
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Thank you
