Speaker 1In this class we're going to talk about continent urinary diversion, specifically the Indiana-Miami pouch, the Koch pouch, and the Mitrofanov procedure. We're going to talk about what's meant by continent urinary diversion. We'll discuss the indications, contraindications, and criteria for construction of a continent urostomy. We'll talk about pre-op education for the patient who's undergoing this procedure, and then post-op management and education. And one thing that I'll just go on and tell you right now is that we are seeing fewer continent urinary diversion procedures being done. We're seeing more patients and more patients who have selected the orthotopic neobladder. But again, there are a number of patients out there who have had this done in the past, and there are still selected patients who are good candidates for a continent urinary diversion. So you may very well be taking care of these patients in the future, even if they're not done in large numbers. So here's the basic concept with a pre-op. The surgeon will create an internal reservoir that is a contractile. That reservoir will be constructed from different segments of bowel most of the time. Occasionally the bladder itself will serve as the reservoir, but most commonly the reservoir is constructed from loops of bowel. The reservoir will be connected to the abdominal wall. There is an internal reservoir that is called the stoma. And between the stoma and the reservoir, you will have a one-way catheterizable channel. So that one-way catheterizable channel creates access to the reservoir, but also provides for continence. So when a patient has a continent urinary diversion, they will manage by intermittent catheterization of the internal reservoir. So they'll be able to go to the catheterization of the internal reservoir, but they will not require a pouch because the urine will come out only when they pass the catheter in. So again, we've said the internal pouch is typically created from detubularized loops of bowel. We will talk about one exception to that rule. The ureters, as you can see here, are connected to the reservoir, but most of the anastomoses between the ureters and the reservoir are freely refluxing anastomoses. It's very difficult to construct non-refluxing anastomoses. So most of the time, they're freely refluxing. That means it's critical to reinforce to the patient the importance of adequate fluid intake on a daily basis so that they're constantly flushing the system, flushing bacteria out. As we've said, continence is provided by a one-way valve, either surgically created or naturally occurring. You have that one-way valve between the catheterizable channel and the reservoir, and that one-way valve provides continence. And the patient manages by passing a catheter at routine intervals to drain the reservoir. What are the benefits? Well, because it is an internal reservoir with a one-way valve, the patient does not have to wear a pouch. So they don't get into issues with peristomal skin complications, with leakage episodes. That's the major benefit. There are potential issues with a continent urinary diversion. First of all, the patient has to be comfortable with routine catheterization because they're going to need to catheterize this reservoir multiple times a day. Just like we void multiple times a day, they will catheterize multiple times a day. Now the catheterization procedure is clean and straightforward, but still they have to be comfortable with that concept. There's always the potential for difficult intubation, so most of the time it's easy to pass the catheter through that catheterizable channel, through that one-way valve. But sometimes that one-way channel slips a little bit and you have deviations in the one-way catheterizable channel and it can become difficult to intubate. So they have to be aware that that's a possibility. Also the continence mechanism might fail over time and they might develop leakage and have to wear a pouch or undergo surgical revision. As we said at this time, continent urostomies are less commonly done. Most individuals who elect a continent procedure choose orthotopic neobladder. So let's review indications and criteria for a continent urinary diversion. We're talking about a group of patients who require urinary diversion either due to urothelial cancer or to neurogenic bladder. The patient has to have sufficient cognitive function, sufficient eye-hand coordination and dexterity to remember to catheterize, to remember how to catheterize, and to actually perform the procedure. They have to have a healthy bowel because we're going to use bowel to construct the reservoir and the vast majority of the majority of cases. So if we are doing a diversion that requires construction of a reservoir from loops of bowel, they need healthy bowel. Not a good choice for patients with Crohn's disease. And this should be the patient's choice. So they should have the information about what's involved with the anilineal conduit, what does management of anilineal conduit look like, what are the potential issues with management of anilineal conduit. And then they need the same information about the continent urostomy and about an orthotopic neobladder if that is an option for them. So they need informed consent. There are definitely contraindications. If they have a lot of bowel disease, not a good choice. If they have either hepatic or renal dysfunction, and renal dysfunction for these patients is defined as a creatinine of 1.7 or higher. And why is that an issue? And look at those two bullet points. Remember that if you expose urine to intestinal mucosa, there's always the potential that you'll get reabsorption of some electrolytes and secretion of other electrolytes. And that can create metabolic abnormalities. We've talked in the past about hypochloremic metabolic acidosis with hypokalemia. That's one metabolic derangement that can occur. There are others that may also occur. What is our primary defense against metabolic derangements? What helps to maintain acid-base balance, fluid electrolyte balance? Normal kidney function and normal liver function. So normally those two organ systems help protect us and help to keep us within normal limits. So if we know that this patient's borderline in terms of liver function, borderline in terms of renal function, we do not want to place this patient in a position where they're at constant risk for metabolic abnormalities that require optimal renal function optimal hepatic function. So that's considered a contraindication. That patient would be better off with an ileal conduit. Let everything shoot straight through with minimal potential for electrolyte reabsorption and abnormalities. And as we've already said, the patient has to have the cognitive ability and the physical ability to perform intermittent catheterization. We're going to review the specific procedures that are currently used to construct a continent urostomy. For patients with urothelial malignancy who require cystectomy, the most common approach is the Indiana or Miami Reservoir. And you can see from the illustrations on this slide that with the Indiana or Miami Reservoir, the Reservoir itself is constructed from regularize cecum and ascending colon. So you can see at the top left, where the distal portion of the ileum, the cecum, and the ascending colon, along with its mesentery, has been resected. And then the bowel will be reconnected, so the ileum will be connected to the transverse colon, so that there is minimal or no change in bowel function. And then the surgeon is going to open the cecum and the ascending colon to interrupt peristaltic pathways. And they're going to reconfigure that section of bowel to form an acontractile reservoir. So that's what you see being done mid-screen and then on the top right. The ureters will then be connected to the reservoir. We've already said that the anastomosis between the ureters and the reservoir typically are freely refluxing. So the best protection against UTI, constant adequate fluid intake. Now let's talk about the continence mechanism. So look at the bottom right. Remember you have that ileocecal valve between the small bowel and the cecum. So it truly is a one-way valve. That allows contents to pass from the small bowel into the large bowel but prevents reflux of contents from the large bowel into the small bowel. And when you look at that illustration on the bottom right you can see that the ileocecal valve is actually a muscular one-way valve. So that can be used for the continence mechanism. And then what the surgeon typically does is he tapers the ileum right around the ileocecal valve so that you end up with a narrow supportive sleeve for that one-way continence mechanism. And then a skin-level stoma is created from the ileum itself. So when you go back to the top left on your screen, the reservoir is constructed from the cecum and the ascending colon, which is reconfigured to create an acontractile reservoir. Then the continence mechanism is the tapered ileum and the ileocecal valve. And the stoma is constructed from the ileum. Now there is another procedure known as the cocurostomy, but it requires resection of a lot of ileum, more than 60 centimeters of ileum. So almost all of these patients end up with B12 deficiencies. Also, if you look at the very bottom line, it's a very complex procedure, very high risk for complications, and extremely rarely done. It's been years since I've seen a patient with a cocurostomy. So I'm very quickly going to go through how a cocurostomy is done. We really do not want you to focus on this. Most likely you will never see a patient with a cocurostomy, even during its heyday. Not many patients had this done. So as you can see, the reservoir itself is constructed from detubularized loops of ileum, so you end up with an acontractile reservoir. The continence mechanism is formed by intussuscepting a section of bowel between the abdominal stoma and the reservoir. So you see that on the right side of the illustration. Then the ureters are connected to a little ileal chimney, and you create anti-reflux protection by intussuscepting the bowel between that chimney, between the ureters and the reservoir. So you can see this is a very complex procedure. It takes a lot longer to do this surgery than it takes to do the Miami or the Indiana. So very rarely done. Don't focus on this. You will probably see patients who have a Mitrofanoff procedure done. This is also known as an appendicovesicostomy. It's primarily done in the pediatric population for children with neurogenic bladder. So here the issue is not bladder cancer, and we don't have to remove the bladder. Here the problem is because of spinal cord injury, because of spina bifida, the bladder is not innervated, and the child lacks bladder control. But there's nothing wrong with the bladder itself. So the bladder can serve as a reservoir. If the bladder is small and fibrotic, we can also remove the bladder. We can also augment the bladder by creating an incision along the dome of the bladder that opens the bladder up. We can take a small piece of intestine, open that up, and attach it to the bladder. And by separating the muscle fibers, we've created an acontractile reservoir. So the reservoir is the bladder, which is frequently augmented to eliminate contractility. Obviously, you could not do this if there was bladder pathology, if there was bladder cancer. So no, this is restricted in use almost exclusively to the pediatric population with neurogenic bladder. So the bladder becomes the reservoir. You open it and augment it if necessary, and then the appendix typically becomes the catheterizable channel. They disconnect the appendix from the bowel, maintain its mesenteric attachment. They attach the proximal end to the bladder. They bring the distal end out at the abdominal wall frequently at the level of the umbilicus. If the child has already undergone appendectomy, so there is no appendix, then they can take a small section of bowel, they taper that section of bowel way down to create a very narrow catheterizable channel, and they do exactly the same thing. And then you see in the illustration on bottom where the child is standing, they have passed the catheter through the stoma that's at the level of the umbilicus, and they're draining the reservoir into the toilet. Okay, so now we're going to focus on management. We're going to talk about preoperative teaching. We're going to talk about postoperative management. So, as always, when we're doing preoperative teaching, we want to assure informed consent. So we want the patient to understand what we're talking about, what is a Miami pouch, what is an Indiana reservoir, a continent urostomy. These are all medical surgical terms. We have to make them understandable to our patient. And how does this differ from that ileal conduit? So you're going to use illustrations. You're going to show them with an ileal conduit. You take a small section of bowel. It serves as a pipeline. There's no storage at all. The ureters are connected. Urine flows from the kidneys, through the ureters, through the conduit, and out. And urine flow is almost constant, so you always have to wear a pouch, and the big issue with an ileal conduit is maintaining a secure pouch seal. Leakage can occur. It's not common, but it can occur. So you have to be aware of that. Now with the continent urostomy, what we're going to do is create an internal reservoir. And the ureters are connected to that internal reservoir, which does have storage capacity. The reservoir, in turn, is a container. It's connected to the abdominal wall. So you have an opening on the abdominal wall. You have an internal reservoir. Between the stoma on the abdominal wall and the reservoir, you have a one-way catheterizable channel. And the way you manage this, you pass a catheter every two to three hours during the day, and you may have to get up at night and do it once. And that's how you manage. Now if neobladder is also an option for this patient, you have to take time to explain the neobladder advantages and disadvantages of that procedure as well. In talking to a patient about a continent urostomy, the single most critical thing for them to understand is that the reservoir is internal. It's connected to the abdominal wall and to the stoma. It does not drain on its own. There's a one-way mechanism. between the stoma and the reservoir, they will have to pass a catheter multiple times a day for the rest of their lives. So we spend a lot of time on that, making sure they understand that. I remember very early on when we started doing these and I was talking to a patient post-operatively and he was like, now how much longer am I going to have to do this catheterization thing? When is it going to be healed and I can stop this? Like, wow, that was a huge disconnect in his understanding of the procedure. So absolutely essential we make this very clear to the patient and ask them, are you okay with that? Are you comfortable with the idea of passing a catheter every time you need to urinate for the rest of your life? Because that's how this is managed. Okay. Make sure they have the cognitive and psychomotor skills to actually do the procedure. And we do want to mark their stoma site preoperatively. It needs to be in their visual field if at all possible and ideally on a flat surface just in case the continence mechanism fails and we need to pouch. Early post-operatively, our whole goal is get the reservoir healed, get the continence mechanism healed, and then we're going to do the procedure. Okay. So we have the continence mechanism, that one-way channel healed. So we've just made this reservoir. The surgeons just created this. You have all these suture lines, staple lines. We do not want the reservoir to distend, to stretch, to fill until healing is complete. And we have this newly formed continence mechanism. So yes, the ileocecal valve is native. It's always been there. But it's not going to heal. It's going to heal. It's going to heal. It's going to heal. It's going to heal. It's going to heal. It's going to heal. It's going to heal. We're not worried about that. But what about that tapered ileal segment that is acting as a snug sleeve around the continence mechanism? We want to support that during healing. So we want to keep the pouch decompressed until the suture and staple lines heal. We want to avoid repeated intubations until we've had healing of that ileal sleeve around our ileocecal valve. And we want to always, with any urinary diversion, protect our uretero-intestinal anastomosis until edema has subsided, until healing is complete. We want to prevent stenosis. So you know how we solve these problems? We solve them with tubes. We put tubes at any anastomotic line to prevent stenosis, to prevent blockage. And we put a catheter into the reservoir to keep it decompressed until healing is complete. So you'll have a large bore catheter placed into the reservoir at the time of the surgery and brought through the abdominal wall through a stab wound. Typically, it's about a 24 French malicot catheter that's placed into the reservoir, brought out through the abdominal wall, usually in the suprapubic area. You will have ureteral stents that run all the way from the renal pelvis, through the ureters, through the reservoir, through the catheterizable channel, and out the stoma. And typically, those are managed with a pouch, because we're going to have a lot of urine flowing through the ureters, through the stents, or around the stents. So the stents exit through the stoma, and they are pouched. And then typically, you'll have a 16 French catheter that's placed through the ileal segment where they tapered the ileum to create a snug sleeve. So then they place a 16 French catheter through that tapered ileal sleeve to provide support during the healing phase. And that is also pouched. So almost always, we have a pouch. The stoma is pouched because we have two stents, two ureteral stents, and a conduit stent exiting the stoma. So the stoma is pouched temporarily. And we also have a reservoir catheter that is connected to a bedside drainage bag. That's typical. Now, surgeons sometimes have slightly different protocols. So if you're doing this in your agency, you want to sit down with the surgeons, talk about their protocols, talk about how they manage stents. Do they externalize them? Do they leave them internalized? How do they manage the reservoir catheter? Does it come out through a stab wound? Pretty much the answer is always yes. So you just want to know their individual protocols. Late post-operatively. Now we have initial healing. The reservoir is healed. We can look at removing the reservoir catheter and teaching in and out catheterization. We have healing at the anastomosis between the ureters and the reservoir. So we can look at removing our stents. The edema has subsided and healing has occurred along that tapered ileal sleeve. So we can remove the stoma stent. So reservoir catheter will be removed once the healing's complete. We'll teach the patient in and out catheterization. You know what that's going to involve? Lubrication of the catheter, insertion through the one-way channel through the ileocecal valve into the reservoir. We teach patients to feel their way with the lubricated catheter, to use a rolling motion, steady, gentle pressure, deep breathing. We tell, we teach them do not force. You do not want to cause trauma to the continence mechanism, either the ileal sleeve or the ileocecal valve. Typically, we start them catheterizing every two hours during the day, every three to four hours at night. And then we gradually reduce catheterization frequency as the capacity of the reservoir expands. Long-term patients. Patients always want to know, what's it going to be like long-term? Long-term, you're probably going to need to catheterize about every four hours. Most of the time, the reservoir capacity increases to about 500 milliliters. So that's the same as a good-sized bladder. So most people will need to catheterize about every four hours during the day, possibly once at night. We have to teach them, pay attention to a sensation of fullness. It's not going to feel the same as when your bladder was full. This is a different reservoir, but pretty quickly, you're going to recognize this sensation of fullness. Don't ignore it. When it's full, you need to go catheterize. And the good thing is that catheterization is straightforward. If you were someplace where you couldn't get to a bathroom so long as you have your catheter, ideally a little bit of lubricant, you can literally catheterize wherever you are. What about stoma management? So we want to keep the stoma covered. It's going to secrete mucus. So we want to absorb the mucus. We want to keep the peristomal skin protected. We want to protect the clothing. And we also want to protect the stoma against friction. So most people keep the stoma covered all the time, either with a little piece of gallbladder with a mini pad they strip to their underwear, with a commercial product that is designed specifically for continent diversions. There's a company that makes patches for continent diversions. The name of the company is Austin. If they ever develop any peristomal irritation, they need to know how to do crusting. If they ever get a yeast rash, they'll need to do crusting with myconazole. Now let's talk complication prevention. So any time that we remove the bladder, we eliminate anti-reflux protection. We place this patient in a more vulnerable position in terms of urinary tract infection. Organisms that get into the stoma can migrate through the catheterizable channel into the reservoir and up the ureters into the kidneys. So they are at risk for pyelonephritis. Best protection, adequate fluid intake on a consistent basis. So they should be drinking fluid throughout the day. The goal is a minimum of two liters for most adults. Also, they want to use careful, clean technique for catheterization. It's not necessary to use sterile, the stoma is not sterile. And we've made this reservoir of bowel. So we do careful clean technique. Wash your hands. Wash your catheter. Lubricate the catheter. Pass the catheter in. Drain the urine out. Remove the catheter. Then wash your catheter and store it. We do want the patient to recognize early signs of a urinary tract infection. They have flank pain. They have some degree of nausea and vomiting. They don't feel well. Not feeling well is typically the earliest sign. They might run fever. They might notice that their urine is cloudy and has more of an odor than normal. But probably the most common early sign of urinary tract infection is just feeling bad. I don't feel good. And I think my urine does look kind of cloudy, but mainly I don't feel good. And I have some dull pain in my sight. Early signs of pyelonephritis. I don't feel good. And I think my urine does look kind of cloudy. We also want to prevent metabolic complications. So remember, we've created an internal reservoir. So now we have prolonged contact between urine and intestinal mucosa. So this patient can develop electrolyte abnormalities. They can develop metabolic acidosis. We did take out a section of aniline so they are at potential risk of B12 deficiency. So again, we want them to drain the pouch at routine intervals. We want them to maintain adequate fluid intake. We want them to adhere to routine follow-up so that we can do lab studies and we can make sure that everything remains within normal limits. If they have a reservoir construction, we want them to be able to do a lot of lab studies. We can make sure that everything remains within normal limits. reservoir constructed from bowels like the Indiana reservoir, the Miami pouch. They are at some degree of risk for pouchitis, which of course is inflammation of the mucosal lining of the pouch, probably due to bacterial overgrowth. Now we see this much less commonly in our continent urostomy patients as compared to our continent ileostomy patients or our patients with an ileal pouch anal anastomosis. So it's a potential complication. It's not commonly seen. If they should develop a pouchitis, what would their symptoms be? How would they present? They would have this constant feeling that they have a lot of urine in the reservoir, that they need to drain the reservoir. They probably will not feel good. They might have blood in their urine. They might have nausea and vomiting. And again, any abnormal symptoms should prompt physician notifications so that we can do a workup. We can see what's going on. Do they have a UTI? Do they have pouchitis? Treatment of pouchitis is with antibiotics to restore normal flora within the reservoir. Possibly with probiotics to promote normal flora. But again, with a continent urostomy, we have isolated this section of bowel from the rest of the bowel. So probiotics will have little effect. It might be beneficial for some. It might be recommended by the surgeon. But you just have to realize that this bowel is not in continuity with the rest of the bowel. Some surgeons will have the patient flush the reservoir to eliminate retained mucus to see if that helps get flora back to normal. Again, pouchitis is not a common complication. So you may never see that. You could develop stoma stenosis and difficulty passing the catheter into the catheterizable channel. It would be obvious if you had that problem. You would send the patient to the surgeon and they would have to revise the stoma. And a rare but very serious complication is rupture of the reservoir. And that occurs only if the patient allows the reservoir to significantly over-distent. So this is easy to prevent. Catheterize on schedule. Catheterize when you feel full. Difficult intubation is probably the most common complication other than urinary tract infection. Now things that can cause difficult intubation, if they allow the reservoir to overfill, then all of the urine in the reservoir puts additional pressure against the ileocecal valve, against that narrowed ileal sleeve. And it makes it very difficult to get the catheter through there. Most patients learn the first time. I've had many patients tell me, "I let it overfill once. I won't do that again. I thought I would never get that catheter in." So you tell them up front, "Do not allow your reservoir allow your reservoir to overfill. It will make it very difficult to get the catheter in." If your abdominal muscles are very tense, so one thing we tell people to do if they're having trouble passing their catheter in is deep breathing to help relax abdominal muscles. And if they have anything that causes some swelling of the catheterizable channel, that ileal channel. So you want to make sure that they have enough pressure to pass the catheter through. And then you want to make sure that they have enough pressure to pass the catheter through. So you're getting your labs monitored. They're watching the health of the reservoir. So in summary, you won't see nearly as many continent urostomies, but when you do, if you see the term Miami Pouch, Indiana Reservoir, Mitrofanoff Procedure, or Appendicobesicostomy, you know that you have an acontractile reservoir constructed either from loops of bowel or from an augmented bladder. The ureters are connected to the reservoir, and then you have a catheterizable channel. If it's a Miami Pouch in Indiana Reservoir, then your catheterizable channel, you have a stoma created out of it. You have a tight ileal sleeve that ends at the ileocecal valve. So your continence mechanism and your one-way catheterizable channel is the ileal sleeve and the ileocecal valve. If you have a Mitrofanoff and Appendicobesicostomy, typically it's the appendix that creates that one-way catheterizable channel into the bladder or a small tapered sac. So you have a large segment of bowel. Early post-op, it's all about allowing the reservoir, either the constructed reservoir, the augmented bladder to heal. So you have a reservoir catheter as well as ureteral stents. And then long-term, it's all about teaching the patient the catheterization procedure, the critical importance of catheterizing on schedule and any time they feel full, the critical importance of catheterization on schedule, and any time they feel full. The critical importance of medical alert, the need to assure adequate ongoing fluid intake to prevent infection, and the basics of stoma management. And I think that's it for this class. Thank you.
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