Ureterosigmoidostomy
Relies on the external anal sphincter for continence.
Technique:
- Bowel prep, supine with slight break, rectal tube
- Mobilise ureters if not done as part of cystectomy
- Incise anterior sigmoid between stay sutures through anterior taenia coli to expose posterior wall
- 4 stay sutures over distance of 4 cm in posterior wall of sigmoid
- Incise mucosa proximally between stays and create submucosal tunnel towards distal stays
- Open posterior muscularis proximally and bring ureter through into sigmoid lumen and through tunnel
- Spatulate ureter and anastomose with interrupted PDS over a Bander stent
- Repeat on other side
- Bring stents out through anus through rectal tube side holes then replace rectal tube
- Close anterior sigmoid enterotomy with 2 layers
Mainz II pouch
Essentially a ureterosigmoidostomy but with the creation of rectosigmoid pouch, which aims to reduce incontinence and pressure to avoid pyelonephritis and upper tract deterioration.
- Ensure bowel reaches without tension to sacral promontory and keep 2 stay sutures on promontory
- 20 cm incision in anterior taenia coli along rectosigmoid
- Close posterior wall of pouch in two layers with PDS
- Ureteric tunnelled separate anastomoses through submucosal tunnel as above from proximal to distal, over stents
Complications of ureterosigmoidostomy:
- Infections
- Leaks
- Incontinence (consider testing external anal sphincter competence preoperatively)
- Ureterosigmoid strictures
- Metabolic
- Hypokalaemic, hyperchloraemic metabolic acidosis
- Cancer
- 2 – 3 % risk of cancer, usually after 10 – 15 years
- Need surveillance colonoscopies from year 5
Colonic conduit
Transverse colon:
- For the avoidance of bowel irradiated by pelvic radiation
- Also useful if needing to replace ureter with bowel
- Very mobile
- Need to free off omental attachments
- Typically right upper quadrant stoma
Sigmoid colon:
- Useful in pelvic exenteration – avoids need for intestinal anastomosis
- Consider avoiding sigmoid if radiated pelvis, or if rectum is left in situ with significant compromise of internal iliacs to avoid rectal sloughing and ischaemia
- Easily placed on left side if needed
Contraindications to colon conduits:
- Inflammatory bowel disease / colitis
- Severe chronic diarrhoea
Cutaneous vesicostomy
Paediatric vesicostomy – used in high pressure bladders e.g. PUV – opening bladder directly through abdominal wall – can be managed just with nappies or with appliances as patients get older
- Pfannenstiel and divide urachus with small cuff of bladder
- Suture detrusor to fascia 1 cm below cystotomy edge, ensuring posterior bladder wall is taut for reduce risk of prolapse
- Risks of stenosis, prolapse
Ileal vesicostomy – transverse cystotomy with incorporation of spatulated ileal segment on a pedicle which is then matured as a stoma a la ileal conduit.
- Particularly well suited to patients with neuropathic bladder or spinal cord injury, unable to self catheterise and with significant DSD
- Women or patient with detrusor overactivity may have some urethral incontinence still, requiring closure of bladder neck (up to 20 %).
- Stomal stenosis can occur
- Stones in bladder still can occur
- Reversible if appropriate
Bladder neck closure:
- Requires simultaneous urinary diversion procedure – catheterisable channel or vesicostomy
- Bladder must be aggressively mobilised away from urethra
- Anterior cystotomy and ensure closure is away from UOs
- Closure of bladder in multiple layers incorporating closure of cystotomy and urethra
- Interposition of omentum or similar to prevent fistula formation and leakage
- Patient must be reliable and compliant with catheterisation
Cutaneous ureterostomies
- Most common issue is stricture, usually at skin level
- Use V-Y plasty or skin flaps to try reduce
- May require recurrent dilations, long term stents, or revisions
- An option for frail patients requiring diversion to reduce operative time and avoid bowel anastomosis and resection
- Ureterostomies may be combined to one stoma or separate stomas
Gastric pouches
Avoids metabolic acidosis and is an option for those who cannot have bowel resected.
May require TUU and then use of either ileum or ureter as catheterisable channel.
Not often used as sole diversion – may be used in augments more commonly.