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Urinary Diversions

Acute Care Emergency Service University of Maryland

Uzoma Anele

on 5 October 2012

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Transcript of Urinary Diversions

Indications Primary indications for diversion include:
Preservation of renal function
Prevention of recurrent infection
Elimination of need for permanent indwelling catheters
Other indications:
Bladder cancer requiring cystectomy
Neurogenic bladder conditions that threaten renal function
Severe radiation injury to the bladder
Intractable incontinence in females
Chronic pelvic pain syndromes
Dysfunctional bladders that result in persistent bleeding
Obstructed ureters Urinary Diversions Uzoma Anele, MS-IV September 28, 2012 To introduce the history and purpose of urinary diversion To understand the indications for diversion types To be aware of the complications of various methods To introduce the various types of urinary diversions Objectives Objectives 1800 2000 1900 1852 The first reported urinary diversion into a segment of bowel by Simon 1950 Bricker refines and popularizes the ileal conduit form of urinary diversion Orthotopic reconstruction replaces the ileal conduit as the standard form of reconstruction in many centers worldwide 1982 The first continent diversion previously described by Gilchrist and colleagues but reintroduced by Kock Urinary Diversion Types Cutaneous Ureterstomy Cutaneous conduits Catherizable Orthotopic
Bladder Replacement Uretero-sigmoidostomy Incontinent Continent goals of urinary diversion after cystectomy have evolved from simple diversion and protection of the upper tracts to functional and anatomic restoration as close as possible to the natural preoperative state (hautmann, et al) initially described as a means of diversion in children
later used in adults with ureteral obstruction, generally from malignancy
stomal stenosis rate of 50% in endocutaneous ureterostomy has limited its application. most common form of cutaneous diversion
15- to 20-cm-long distal ileal segment is isolated, and ureters are implanted in the proximal end Incidence of both sepsis and renal failure is greater in patients with uretero-sigmoidostomy than in those with conduits http://www.prostatechicago.com/bladder-cancer/treatment-options/surgery/ileal-conduit.php http://www.kmle.co.kr/search.php?Search=cutaneous+ureterostomy&Page=5 https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcQEKaDMEiovGcqOysJLDvheCdwX9Mz6PwxX_KUd07kvUD8LYMss http://www.kumed.com/health-library/content?contenttypeId=3&contentId=41095 http://kidney.niddk.nih.gov/kudiseases/pubs/urostomy/ Relies on the external urethral sphincter for continence
Most patients are continent and able to void to completion without the need for intermittent catheterization. Continent Diversions Uretero-sigmoidostomy Orthotopic Bladder Replacement Catherizable Incontinent Diversions Cutaneous Ureterstomy Cutaneous Conduits No longer particularly indicated due to complications main purpose is to diminish operative invasiveness

first choice for patients who can undergo cystectomy but not urinary diversion with the use of a bowel segment Ileal - the most common form of diversion used in conjunction with cystectomy and simplest type of conduit

Jejunal - acquired a bad reputation because of several reports in the 1970s on "jejunal conduit syndrome"

Colonic - most often used when high-dose irradiation has been given previously (transverse) Patient must have adequate external sphincter mechanism and non-obstructed urethra
Reservoir must be sufficiently compliant
Reservoir must have adequate volume to allow for reasonable voiding intervals Ideal in patients for whom orthotopic bladder replacement is contra-indicated Urolithiasis Risk of Cancer Infection Mucous Production Diarrhea Metabolic Abnormalities References

1. Rink M., Kluth L., Eichelberg E., Fisch M., Dahlem R. "Continent
Catheterizable Pouches for Urinary Diversion." European Urology
Supplements. 2010 9, p754-762

2. Hautmann R., et al. "Urinary Diversion." Journal of Urology. 2007. 69, p17-49

3. Dahl, D., McDougal W., "Use of Intestinal Segments in Urinary Diversion"
Campbell's Chapter 85

4. E., Skinner D., Stein J. "Orthotopic Urinary Diversion" Campbell's Chapter 87

5. Costa J. "Urinary Diversions and Neobladders
Treatment & Management" http://emedicine.medscape.com/article/451882-treatment#a1128
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