Chapter 189: Supravesical Urinary Diversion
repair are disappointing though recent
techniques of open transabdominal repair
using mesh to buttress the fascial defect
have yielded better results. Successful
reso-lution frequently requires
contralateral re-location of the stoma.
CONCLUSIONS
Urinary diversion is a technically challenging
operation associated with high risk of long-
term complications. The variety of ap-
proaches perhaps speaks to the less than ideal
outcomes of each. Meticulous attention to
detail and careful long-term monitoring are
essential for ensuring good outcomes.
EDITOR’S COMMENT
This chapter is well written, where the authors
basically outline three different types of su-
pravesical urinary diversion, some of which in-volve
portions of the bladder, but many involve
increasingly complicated reconstructions, some of
which are continent and some of which have to be
catheterized. The patient undergoing su-pravesical
urinary diversion is of really signifi-cant
consideration, because some people can do self-
catheterization and some cannot. One of the aspects
which is of interest to me is the many different types
of S-pouches that are available, which basically
mirror the types of pouches that surgeons and bowel
surgeons do in ulcerative colitis and in carcinoma of
the lower rectum and other such conditions. I myself
have done 400 ileal pouch-anal anastomoses, all as
pouches, while working with Dr. Lester Martin, the
legend-ary chief of pediatric surgery at the
Cincinnati Children’s Hospital, who actually was the
one who determined that Sir Alan Parks’s S-pouch
re-quired catheterization because the exit spout was
too long. He and I did these procedures in both
adults and children together in two teams, and we
always had, when I made the pouch, which we both
worked on together, the exit spout, as I called it, was
always less than 1 cm, so there was no ob-struction
to stool-emptying neorectum. I have also done a
number of bowel or colonic surgeries on j-pouches
in lower anterior or coleanal types of situations. I
have also had the opportunity to repair and put right
a number of Kock pouches, in which the collar
slipped. Since all of these dif-ferent pouches are
now being done by urologists, many of whom are
from the same department, it is remarkable for me to
contemplate the fact that there has been very little
communication between what we call the general
surgery or the colon- and rectal-surgery
pouchotomists and the urologic community. For
example, for those who are actively doing Kock
pouche surgery, I could suggest them ideas about
how to prevent slipping of the collar, since I have
never done a primary Kock pouch surgery, but I
have done a number of repairs when the collar has
slipped. I cannot be-lieve that there would not be the
same problems in the urological Kock pouch as we
observed in the colon and rectal surgery and general
surgery on Kock pouches. Having said that, it does
appear
2011
SUGGESTED READINGS
Benson MC, Olsson CA. Cutaneous continent uri-nary
diversion. In: Walsh PC, Retik AB, Vaughan Jr ED,
et al., eds. Compbell’s urology, 8th ed. Phil-
adelphia, PA: Saunders; 2002;3789–834.
Bricker EM. Substitution for the urinary bladder
by the use of isolated ileal segments. Surg
Clin North Am 1956;103:1117–30.
Casale AJ. A long continent ileovesicostomy
us-ing a single piece of bowel. J Urol
1999;162: 1743–5.
Lawrentschuk N, Colombo R, Hakenberg OW, et
al. Prevention and management of complica-
tions following radical cystectomy for bladder
cancer. Eur Urol 2010;57:983–1001.
McDougal WS. Use of intestinal segments in uri-nary
diversion. In: Walsh PC, Retik AB, Vaughan
as if there are many different criteria as per what
kind of pouch goes where. Some patients are so
incapacitated that all they can have is a large exit
of urine from some area of their abdomen, which
is wide enough that it bulges into a bag and is
then collected. Some patients, on the other hand,
can catheterize a continent pouch. I am sure that
an interchange of ideas would be useful, because
probably the urological-pouch community can
enrich the knowledge of the general-surgical
pouch community.
Once one contemplates a pouch, it appears
that this is irreversible, since with some rare
ex-ceptions, when one does a supravesical
diversion, the bladder must be removed, for,
as we can ob-serve, and as the author says,
one must prevent pyocystis.
Of all the bypasses and new arrangements that
are mentioned in this chapter, I do not agree with the
concept of bladder/vaginal fistula to drain the
bladder, because it is rather cruel for any thought of
sexual function. One of the things I learned from the
legendary Dr. Wayland Leadbetter and Dr. Hardy
Hendren as the chief resident on pediatric surgery
was the process of tunneling of the ureters. Both the
surgeons had one characteristic which probably
many others and I absorbed. Dr. Leadbetter in
particular did not cared how many residents he
called out of the laboratory to hold retractors; he
would not take a knife or a scissors to any tissue if
he could not see clearly. He was technically very
good, had a vast practice, and a wonderful
relationship with his patients. Dr. Hendren was
technical wizard, in visualizing surgery, and his
suggestions to ensure the right operation were really
spectacular.
Elsewhere in the chapter, the author discusses
about not taking the terminal ileum but going
upstream a little bit, about 15 or 20 cm, so that B 12 is
absorbed. From my own experience with short-
bowel syndrome and people who have had mas-sive
bowel resections, and who were initially on TPN
and then gradually were able to be weaned off and
take it orally, I can tell you that B 12 absorp-tion and
a Schilling test is not absolute with re-spect to the
distal ileum. I did Schilling tests for a number of
patients, and found that patients who had undergone
a complete ileal resection were normal after the first
Schilling test, but just for my own interest, I never
wrote this up, and B12 seemed to be absorbed by
other sites, which took over when the ileum was
totally lost.
Jr ED, et al., eds. Compbell’s urology, 8th ed.
Phil-adelphia, PA: Saunders; 2002;3745–88.
Monti PR, Lara RC, Dutra MA, et al. New techniques
for construction of efferent conduits based on the
Mitrofanoff principle. Urology 1997;49:112–15.
Shaaban AA, Abdel-Latif M, Mosbah A, et al. A
randomized study comparing an antireflux
system with a direct ureteric anastomosis in
patients with orthotopic ileal neobladders.
BJU Int 2006;97:1057–62.
Stein JP, Skinner DG. Orthotopic urinary diver-
sion. In: Walsh PC, Retik AB, Vaughan Jr
ED, et al., eds. Compbell’s urology, 8th ed.
Philadel-phia, PA: Saunders; 2002;3835–67.
Studer UE, Varol C, Danuser H. Orthotopic ileal
neobladder. BJU Int 2004;93(1):183–93.
Wallace DM. Ureteric diversion using a conduit: a
simplified technique. BJU Int 1966;38:522–7.
Finally, let me say that I thought that the Kock
pouch in general surgery and colo-rectal surgery was
pretty dead after the number of revisions. I
participated in a symposium (1986) on pouches in
ulcerative colitis, in which Professor Kock also
participated. He attested the fact that there were
some patients with a Kock pouch which he had had
to do six revisions on. The S-pouch, on the other
hand, especially first when Dr. Martin and I did it
and later Dr. Michael Nusbaum and I did, I do not
recall of ever having revised a pouch. There were
some “spouts,” as I called them, that were slightly
stenotic, and since we did them with in-terrupted
sutures rather than stapler, there were few indeed
that I had to dilate. It would be nice if we, the
urological “pouchotomists,” as we used to call
ourselves, had united in this regard.
One of the most miserable diseases that I came
across, when I was a resident on the urology service,
is interstitial cystitis or bladder pain syn-drome.
Rössberger et al. (Urology 2007; 70:638–42)
reviewed 47 patients with these syndromes and
ended with the admonishment that we needed to
define whether these were classic Hunner-type
diseases, or whether the 13 patients with nonul-cer
disease of the 47 they reviewed [were?]. There was a
mélange of the types of reconstructive sur-gery
undergone in the 25-year period, from 1978 to 2003.
They included noncontinent ureteroen-
terocutaneostomy in 12 patients, supratrigonal
cystectomy and ileocystoplasty in 23 patients,
continent Kock-pouch urinary diversion in 10
patients, and a few other surgeries of one patient
each. Of the 34 patients with a classic Hunner-type
disease, the initial procedure in 28 patients resulted
in complete symptom resolution. In 4 of the
remaining 6 patients, a supplementary diver-sion
procedure, cystectomy, or transurethral ulcer
resection in the trigonal remnant yielded reason-able
Nongastrointestinal Transabdominal Surgery
outcomes. However, the important concept of this
chapter is that, in those 13 patients with nonulcer
disease, only 3 experienced symptom resolution and
2 of these required a supravesical diversion
procedure. The crux of this chapter is that one needs
to be very certain as to the diag-nosis, and, if one is
certain of the diagnosis, the patients will have
maximum relief.
In this chapter, Professor Konety and Dr.
Elliott have emphasized that, once the patient
undertakes a supravesical urinary diversion, he/
she must undergo cystectomy to restrict the de-
velopment of pyocystis when the urinary flow is
(continued)