Three14 139 Use of intestinal segments in urinary diversion

  1. Bowel preparation in radical cystectomy?
    • A mechanical bowel prep decreases the amount of feces in the intestinal tract and therefore the absolute bacterial count.
    • • An antibiotic bowel prep decreases the concentration of bacteria per cubic centimeter of feces.
  2. Types of mechanical bowel preparation?
    • Conventional bowel preparation 
    • - 3-day preparation period of insufficient calorie intake
    • - exhaust the patient and exacerbate nutritional depletion 

    • Whole gut irrigation 
    • - Originally performed by placement of NG tube  into the stomach and infusion of 9-12 L of RL or NS 
    • - Replaced by Polyethylene Glycol (PEG) electrolyte solution - 1 to 1.5 litres per hour or 3 hours 
    • - Advantages - dietary freedom, short preparation time and it eliminates as an enema 
    • - Disadvantages - may result in exhaustion, is rigorous and it does result on occasion in fluid overload 
    • - Contraindications of whole gut irrigation - unstable cardiovascular system, cirrhosis, severe renal diseases or bowel obstruction (liver, heart, kidney, GI issues ) 

    • Oral Cathartic  
    • - Magnesium Citrate - 148 ml 
    • - Sodium phosphate  - 45 ml, phosphate nephropathy is a serious complication of NaP
    • [@ corelate with Nacitrate, K-Citrate and Mg-citrate] 
  3. Antibiotic bowel preparation?
    • Kanamycin 
    • Neomycin + Erythromycin 
    • Neomycin + Metronidazole
  4. Enhanced Recovery After Surgery (ERAS) Society Guidelines for Radical Cystectomy
    1. Preoperative counseling and education - Patients should receive routine dedicated preoperative counseling and education.

    2. Preoperative medical optimization - Preoperative optimization of medical conditions should be recommended. Preoperative nutritional support should be considered, especially for malnourished patients. Correction of anemia and comorbidities; nutritional support; smoking cessation and reduction of alcohol intake 4 weeks before surgery; encouraging physical exercise

    3. Oral mechanical bowel preparation - Preoperative bowel preparation can be safely omitted.

    4. Preoperative carbohydrates loading - Preoperative oral carbohydrate loading should be administered to all nondiabetic patients.

    5. Preoperative fasting Intake of clear fluids until 2 h before induction of general anesthesia is recommended. Solids are allowed until 6 h before anesthesia.

    6. Preanasthesia medication Avoidance of long- acting sedatives.

    7. Thrombosis prophylaxis Patients should wear well-fitting compression stockings and receive pharmacologic prophylaxis with LMWH.   In addition to the administration of prophylaxis prior to incision,  extended prophylaxis for 4 weeks should be carried out in patients at risk. Allow a 12-h interval between injections and epidural manipulation. Cystectomy patients are considered at risk; prolonged prophylaxis should therefore be administered

    8. Epidural analgesia Thoracic epidural analgesia is superior to systemic opioids in relieving pain. It should be continued for 72 h.

    9. Minimally invasive approach - At most feasible; in trial setting Long-term oncologic results awaited

    10. Resection site drainage - Perianastomotic and/or pelvic drain can be safely omitted. Because of urine leak, drainage might be required in cystectomy patients.

    11. Antimicrobial prophylaxis and skin preparation - Patient should receive single-dose antimicrobial prophylaxis 1 h before skin incision. Skin preparation with  chlorhexidinealcohol prevents/decreases surgical site infection.

    12. Standard anesthetic protocol - To attenuate the surgical stress response, intraoperative maintenance of adequate hemodynamic control, central and peripheral oxygenation, muscle relaxation, depth of anesthesia, and appropriate analgesia is recommended.

    13. Perioperative fluid management - Fluid balance should be optimized by targeting cardiac output using the esophageal Doppler system or other systems for this purpose and avoiding overhydration. Judicious use of vasopressors is recommended with arterial hypotension. High-risk patients need close and individualized goal directed fluid management. There are several ways to achieve this and all must be used together with sound clinical judgment.

    14. Preventing intraoperative hypothermia - Normal body temperature should be maintained preoperatively and postoperatively. Especially relevant for cystectomy patients because operative duration is prolonged.

    15. Nasogastric intubation Postoperative nasogastric intubation should not be used routinely. Early removal is recommended. In several studies there was no significant difference in major intestinal complications between those who had postoperative nasogastric tubes and those who did not; however, those who did not have gastric decompression showed a much greater incidence of abdominal distention, nausea, and vomiting.

    16. Urinary drainage Transurethral catheter can be removed on postoperative day 1 after pelvic surgery in patients with a low risk for urinary retention. Ureteral stents and transurethral neobladder catheter should be used. The optimal duration of ureteral stenting (at least until POD 5) and transurethral catheterization is unknown.

    17. Prevention of postoperative ileus - A multimodal approach to optimize gut function should involve gum chewing and oral magnesium.

    18. Prevention of PONV - Multimodal PONV prophylaxis should be adopted in all patients with two risk factors. Multimodal prophylaxis Very low/low (high in high-risk patients)

    19. Postoperative analgesia - Multimodal postoperative analgesia should include thoracic epidural analgesia.

    20. Early mobilization Early mobilization should be encouraged. 2 h out of bed POD 0 6 h out of bed POD 1

    21. Early oral diet Early oral nutrition should be started 4 h after surgery -   Early enteral feeding, neostigmine, and alvimopan have all demonstrated efficacy in improving return of bowel function following abdominal surgery.

    22. Audit All patients should be audited for protocol compliance and outcomes. Routine audit of outcomes, cost-effectiveness, compliance, and changes in protocol.

    These protocols have resulted in shorter hospital stay by 30%, a reduction in complications by 50%, decrease in readmission rates, and thus reducing healthcare costs
  5. Discuss the basic principles, indications, and use of intestinal segments in the urinary tract. (TU 69,10)
    • - Principles of intestinal anastomosis 
    • - Principles of Ureterointestinal anastomosis 
    • - Principles of orthotopic neobladder 
    • - Principles of cutaneous continent pouch
  6. Difference between jejunum and ileum?
    Image Upload 1

    Image Upload 2
  7. Principles of intestinal anastomosis?
    • Obtaining adequate exposure - mesentery should be cleared from the bowel segments to be anastomosed for a distance of about 0.5cm 
    • Maintaining good blood supply
    • Minimizing spillage of bowel contents
    • Apposing serosa to serosa
    • Avoiding strangulation of the bowel
    • Aligning the mesentery of the two segments

    The ileum should be isolated approximately 20 cm proximal to the ileocecal valve to spare the terminal ileum and avoid risk for bile salt and vitamin B12 malabsorption.
  8. Postoperative care after radical cystectomy?
    • Begin clear liquid when the paralytic ileus resolves and bowel activity resumes. 
    • If clear liquids are tolerated, the diet may be advanced. This sequence of events generally takes 1 to 4 days.
    • If the nutritional condition of the patient is impaired preoperatively, a postoperative complication delays oral feeding, or the paralytic ileus is still present on the fifth postoperative day, the patient should receive intravenous nutrition that supplies the total calorie requirement (hyperalimentation). It is preferable to begin the hyperalimentation the day after surgery if any of these complications are anticipated. Once started, it is discontinued only when oral intake is sufficient to satisfy the body’s calorie requirements. Postoperative TPN was found to increase infectious complications in nutritionally non-compromised patients in one study. 

    Use of NG tube - controversial. Because of limitations in the available studies, it is still recommended to use nasogastric in all patients. Remove NGT early.

    Ureter stent removal in one week after surgery. If no increase in the drain volume, remove the abdominal drain.
  9. Complications of intestinal anastomosis
    • Fistulas
    • Sepsis and other infectious complications 
    • Bowel obstruction -  The incidence of postoperative bowel obstruction is 4% to 10% - highest in lieum, less in Colon, stomach, and sigmoid
    • Haemorrhage 
    • Intestinal stenosis 
    • Pseudo-obstruction

    Note -   The 90-day mortality rate for radical cystectomy is approximately 3%
  10. What are the different types of urinary diversion. Describe the pros and cons of each type. How do you decide to perform a particular type of urinary diversion after cystectomy? (TU 68-10)
    • Ileal conduit 
    • Continent cutaneous diversion 
    • Orthotopic neobladder
  11. Types of intestinal stomas
    • Flush stoma
    • - when CIC is planned 

    • Protruding stoma
    • - preferable when a collection device is worn
    • - lesser incidence of stomal stenosis
    • - better appliance fit with fewer peristomal skin problems
    • - E.g - Nipple stoma, loop end ileostomy 
    • - Nipple stoma - bring out 5-6 cm, make nipple of about 2-3 cm 
    • - Loop end ileostomy - for obese patients

    Most complications of stomas are the result of technical errors  in their construction
  12. Technical issues with stoma formation?
    • Site of the stoma should be selected preoperatively by marking the stomal site with the patient in the sitting position and in the supine position
    • Care is taken to place it over the rectus muscle at least 5 cm away from the planned incision line
    • The point chosen should be well away from skin creases, scars, the umbilicus, belt lines, and bone prominences
    • A site in which radiotherapy has previously injured the area should be avoided
    • All stomas should be placed through the belly of the rectus muscle and be located at the peak of the infraumbilical fat roll
    • If the stoma is placed lateral to the rectus sheath, a parastomal hernia is likely to occur
    • The bowel should traverse the abdominal wall perpendicular to the peritoneal lining (i.e., it should come straight out)
    • One should avoid trimming fat or epiploic appendages from around the margin of the stoma, and the appliances should be applied in the operating room
  13. Complications of stoma?
    Early complications - bowel necrosis, bleeding, dermatitis, parastomal hernia, prolapse, obstruction, stomal retraction, and stomal stenosis

    • Parastomal skin lesions
    • - Irritative - hypopigmentation, hyperpigmentation, and skin atrophy
    • - Erythematous erosive lesions - macular lesions, scaling of the skin, and loss of the epidermis
    • - Pseudoverrucous - wartlike lesions

    • Stomal stenosis
    • - 20% to 24% of patients with ileal conduits
    • - 10% to 20% of patients with colon conduits
    • - Stomal stenosis is less for loop stomas than for end stomas

    • Parastomal hernias
    • - occur rarely (1% to 4%) with end stomas
    • - more likely to occur with loop stomas, with reported incidences ranging from 4% to 20%
    • - Incidence of stenosis of catheterizable stomas is high, reaching more than 50% in children
  14. Principles of ureterointestinal anastomosis?
    • Only as much ureter as needed should be mobilized so that there is no redundancy or tension on the anastomosis.
    • Mobilization should not strip the ureter of its periadventitial tissue because it is in this tissue that the ureter’s blood supply courses. 

    • The ureter should be cleaned of its adventitial tissue only for 2 to 3 mm at its most distal portion where the ureter–intestinal mucosa anastomosis is to be performed.
    • The ureterointestinal anastomosis must be performed with fine  absorbable sutures, which are placed so that a watertight mucosa-to-mucosa apposition is constructed.
    • The bowel should be brought to the ureter and not vice versa (i.e., the ureter should not be extensively mobilized so that it can be brought into the wound to the bowel lying on the anterior abdominal wall).
    • At the completion of the anastomosis, the bowel should be fixed to the abdominal cavity, preferably adjacent to the site of the ureterointestinal anastomosis. If possible, the anastomosis should be retroperitonealized or a pedicle flap of peritoneum should be placed over the anastomosis.

    • • Ureteral reimplantation into native bladder is preferable when necessary; the initial bladder incision may facilitate such a procedure.
    • • An antireflux mechanism can be created with any bowel segment but is most challenging with ileum
  15. Refluxing vs non-refluxing ureterointestinal anastomosis?
    • When bowel is substituted for the ureter, it does not appear that it makes any difference whether there is reflux at the bladder. The voiding pressure is blunted by the distensible bowel segment. 
    • Successful construction of an antirefluxing anastomosis does not prevent bacterial colonization of the renal pelvis. 

    • Disadvantages of refluxing anastomosis 
    • - more incidence of pyelonephritic scarring and renal deterioration

    • Advantages of refluxing 
    • - upper tracts may be observed by periodic introduction of contrast material into the conduit.
    • - less stricture formation
  16. Types of Uretero-intestinal anastomosis?
    • Ureterocolonic (usually non refluxing)
    • - Leadbetter-Clarke
    • - Strickler
    • - Pagano [@ Imagine Lead stick with onion in tip]
    • - Transcolonic technique of Goodwin

    • Small Intestine anastomosis (people don't like non refluxing in small intestine) 
    • - Bricker (refluxing)
    • - Wallace (refluxing)
    • - Le Duc (non refluxing)
    • - Nipple (non refluxing) [@ Brick ko wall ma duck ko nipple]

    Bricker vs Wallace - Metaanalysis show no difference between two methods, selection based on own preference
  17. Bricker Anastomosis and Wallace anastomosis?
    Bricker anastomosis - refluxing end-to-side ureter–small bowel anastomosis. 

    Wallace - end to end 

    • The Wallace anastomosis has the lowest complication rate of any of the ureterointestinal anastomotic techniques.
    • The Wallace technique is not recommended for patients who have extensive carcinoma in situ or who have a high likelihood of recurrent tumor in the ureter. A recurrence of tumor at the anastomotic line in one ureter would block both ureters, causing uremia from bilateral obstruction.
  18. Modified Bricker?
    • Left ureter is anastomosed in end to end fashion - has long anastomosis line
    • Right in end to side fashion 

    • Bricker was the procedure suggested by a chief resident - who was initially scolded for his idea 
    • Image Upload 3
  19. Complications of ureterointestinal anastomosis?
    Urinary fistula - occurs within 7-10 POD, incidence 3-9%, the incidence is reduced by the use of soft silastic stents 

    Stricture - most common in left side (where ureter crosses the aorta beneath the IMA). Management - Open repair vs balloon dilatation. Open repair has higher success rate but is more morbid and difficult procedure. Strictures occurring in less than 1 year from the original procedure, strictures 1.5 cm or longer, and left-sided strictures have less favorable outcomes with endourologic methods. 

    Pyelonephritis - incidence is 10-20% patients
  20. Stricture after ureteroinstestinal anastomosis?
    • Strictures are caused by
    • - ischemia
    • - urine leak
    • - radiation, or
    • - infection

    Ureteral intestinal anastomotic strictures. Antirefluxing anastomoses have a 10%–20% stricture rate; refluxing anastomoses have a 3%– 10% stricture rate. The Wallace ureteral intestinal anastomosis has the lowest stricture rate.

    • Incidence of urine leak for all types of ureterointestinal anastomoses - 3% to 5%. 
    • This incidence of leak can be reduced nearly to zero if soft Silastic (silicon) stents are used
  21. Ileal conduit
    It is not advisable to use ileum for a conduit in patients with a short bowel syndrome, in patients with inflammatory small bowel disease, and in those whose ileum has received extensive irradiation, often as a consequence of prior radiation therapy for a pelvic malignant neoplasm. 

    A segment 10 to 15 cm in length is selected 10 to 15 cm from the ileocecal valve. 

    Indeed, the ileum may be anastomosed directly to the renal pelvis on both sides if necessary. 

    Conduit segment should be distal to the bowel segments 

    The base of the conduit is fixed to the retroperitoneum in the right lower quadrant by suturing the posterior peritoneum to the conduit, thus effectively retroperitonealizing the ureterointestinal anastomosis. 

    One should be cautious in identifying duplex ureters. A failure to identify a second ureter on one side results in intraperitoneal urine leak and can cause excessive morbidity
  22. Jejunal Conduit?
    Jejunal conduit is the most dangerous bowel to incorporate with. The jejunum is usually not used for reconstruction of the urinary system because it may result in severe electrolyte imbalance. The patient may land in the ER with metabolic complications known as Jejunal conduit syndrome. Jejunum as a urinary conduit produces a syndrome of hypochloremic acidosis, hyponatremia, and hyperkalemia in patients with poor renal function.  This syndrome is secondary to the loss of sodium chloride into the urine passing through the conduit and absorption of potassium and urea from it

    • Advantages of jejunum mesentery. 
    • - Jejunum has the largest diameter of the small bowel and the longest mesentery. 
    • - thinner mesentery with a less fat
    • - long single arcade of bigger blood vessels

    • Jejunum conduit is indicated only when there is extensive irradiation that involved the ileum, absence of large bowel or with IBD.
    • When jejunum is taken for conduit, use as terminal jejunum as possible. More proximal the segment used, the more likely the syndrome to develop.
  23. Colon conduit?
    Three types 

    • Transverse colon 
    • - if one wants to be sure that the conduit segment has not been irradiated, the excellent segment for intestinal pyelostomy 
    • - a stoma is usually in the right upper quadrant 

    • Sigmoid - Contraindicated with
    • - disease of this segment
    • - when the hypogastric arteries have been ligated and the rectum has been left in situ
    • - extensive pelvic irradiation 

    • Ileocecal
    • - Advantage - provide a long segment of ileum when long segments of ureter need replacement and providing colon for the stoma. It is also used in situations in which free reflux of urine from the conduit to the upper tracts is thought to be undesirable.
    • - Contraindications - presence of inflammatory large bowel disease and severe chronic diarrhea.
  24. What is ileal vesicostomy?

    Performed by spatulating an ileal segment and performing a generous transverse cystotomy 

    Spatulated ileum is sutured to the bladder wall with absorbable suture, and the distal segment is brought to the abdominal wall by fashioning a rosebud stoma
  25. Describe the pathophysiological changes related to urinary reconstruction with bowel. (TU 69,10)

    Complications with urinary intestinal diversion
    Metabolic complications 

    Altered sensorium - as a result of magnesium deficiency, drug intoxication or abnormalities in ammonia metabolism. The treatment of ammoniagenc coma is drainage of the urinary intestinal diversion, neomycin 

    Abnormal drug absorption - excreted drug is re-exposed to the intestinal segment, which then reabsorbs it, and toxic serum level develop. eg - phenytoin

    Osteomalacia - Causes are acidosis (MC), vitamin D resistance and calcium loss by kidney; with persistent acidosis, the excess protons are buffered by the bone with release of bone calcium

    Growth and development - urinary intestinal diversion has a detrimental effect on growth and development. Long term diversions are susceptible to fractures. 

    Infections - deterioration of upper tract is most likely when the culture becomes dominant with urea splitting organism (proteus, Pseudomonas) because of risk of stone formation. So, these organism need to be treated. 

    Stones - Magnesium ammonium phosphate stones

    Renal deterioration after a conduit diversion with normal kidneys occurs in 20% of renal units.   The most common cause of death in patients who have had a ureterosigmoidostomy for more than 15 years is acquired renal disease (renal failure).   Because urea and creatinine are reabsorbed by both the ileum and the colon, serum concentrations of urea and creatinine do not necessarily accurately reflect renal function.

    Intestinal motility, short bowel and nutritional problems - loss of significant portion of ileum leads to malabsorption of bile salts, vitamin B12 deficiency, 

    Cancer - Cancer occurring in urinary intestinal diversion is most likely to occur in ureterosigmoidostomies. 500 fold increased risk, (ref?) delay of 10-20 years (latency period of as shout as 5 years have been reported), tumors are usually adenocarcinoma, malignancy develop from urothelial component. If the urothelium is left in contact with the intestinal mucosa, however, even though the diversion is defunctionalized and the area is not bathed in urine, adenocarcinoma may still develop. This suggests that when ureterointestinal anastomoses are defunctionalized, they should be excised rather than merely ligated and left in situ. When ureters are directed into the fecal stream, routine colonoscopy should be performed. For an isolated anastomotic recurrence, distal ureterectomy and reimplantation may be appropriate. If nephroureterectomy is necessary, some patients may require removal of their continent diversion because of resulting renal insufficiency.

    Role of Prophylactic use of sodium bicarbonate in neobladder QQQ  in Vellore, routinely use sodium bicarbonate prophylactically and continue for 4-5 years, later can stop as blunting of mucosa

    [@  RISAo MUGI DM - Renal, Infection, Stone, Alteroed Sensorium, Osteoporosis, Metabolic, Uremic encephalopathy,  Growth, Intestinal motility, Drugs, Malignancy] 
  26. Metabolic complications in using intestinal segments?
    Stomach - alkalosis, hypochloremia, hypokalemia - manifest as lethargy, respiratory insufficiency, seizures, and ventricular arrhythmia. Treatment - H2-blocker, omeprazole. Arginine hydrochloride infusion can be used to treat life-threatening complications caused by stomach conduit. 

    Jejunum - Hyponatremia, hypocholoremia, acidosis, hyperkalemia. Manifest as lethargy, vomiting, dehydration, muscle weakness. 

    Ileum, Colon - acidosis, hyperkalemia, Hyperchloremic

    Removal of the distal ileum - vitamin B12 deficiency and megaloblastic anemia

    Least metabolic abnormality is the colon, then is the ileum

    Hypokalemia is more common in patients with  ureterosigmoidostomies than in patients who have other types of urinary intestinal diversion

    The ability to establish a hyperchloremic metabolic acidosis appears to be retained by most segments of ileum and colon over time. 

    • [@ Alkalosis is only in the stomach, all other acidoses,
    • HCL secreted by the stomach is absorbed in the colon.
    • Jejunum excretes salt (NaCl)
    • The bowel is bowel - it will absorb, and it will secrete
    • When there is acidosis, there is hyperkalemia, when there is alkalosis, there is hypokalemia, al- K- Loss-is, al- Ca- Loss-is, hypokalemia and hypocalcemia in alkalosis]
  27. Advantages and disadvantages of the stomach?
    Advantage - less permeable, acidifies urine, net excretion of chlorine and protons, less mucus, address metabolic acidosis of renal failure 

    Disadvantages - severe uncontrolled metabolic alkalosis, gastric retention, hiccups secondary to gastric distension, afferent loop syndrome, hematuria-dysuria syndrome, cutaneous breakdown because of low pH of urine

    Hematuria-dysuria syndrome - Acidic urine could irritate the native bladder and any exposed skin and was particularly bothersome in patients with intact sensation.

    Note - When a wedge of fundus is used, it should not include a significant portion of the antrum and should never extend to the pylorus or all the way to the lesser curve of the stomach
  28. Postassium level in acidosis?
    Alkalaosis - K loss , hypokalemia, shift of potassium inside body cells 

    Acidosis - shift of potassium outside cells, Potassium store is depletd even if potassium level is normal, so replace potassium with sodium bicarbonate while correcting acidosis. 
  29. Role of gastrin and aldosterone when the stomach is used for diversion?
    Gastrin - a stretch of the stomach, release of gastrin - more acid secretion, acid loss, alkalosis. 

    Aldosterone - dehydration, more aldosterone secretion, more acid loss, more alkalosis 

    This vicious cycle continues
  30. Ideal continent diversion?
    • Continent 
    • Compliant 
    • Compliance 
    • Capacious
  31. Measures to reduce mucus production?
    • NAC 
    • Bladder wash regularly 
    • Sodium bicarbonate
  32. Overnight drainage in the continent diversion?
    Either wake up at night and drain, or keep overnight drainage tube to prevent metabolic complications

    It also prevents bacterial transloation - distended bowel, ischemia, increased chance of bacterial translocation
  33. Laplace law?
    Image Upload 4

    P α Tension/Radius [@ PTR - पिटर को ल्याप] 

    This is more important in children who have to live longer, than in case of carcinoma urinary bladder. Tension  should be kept low.

    It can be demonstrated in experimental animals that after the bowel wall has been split on its antimesenteric border and reconfigured, acutely there is a marked interruption of coordinated activity fronts, which over a period of 3 months return to their normal coordinated state.

    Reconfiguring bowel usually increases the volume, but its effect on motor activity and wall tension over the long term is unclear at this time.
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Three14 139 Use of intestinal segments in urinary diversion
metabolic complications