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Urinary diversion following cystectomy remains one of the great challenges of radical pelvic surgery because an equivalent replacement for the native bladder has yet to be developed. The bladder is ideally a low-pressure, highly compliant reservoir for the storage of urine with its own intrinsic continence mechanism, sensation, and coordinated, volitional emptying by muscular contraction. In addition, the bladder is generally impermeable, stores sterile urine, and possesses antirefluxing ureters to protect the kidneys and upper tracts from sustained increases in bladder pressure. Recapitulating many of the intrinsic properties of the native bladder and understanding the impact of the choice of bowel segments are paramount to successfully reconstructing the urinary tract. Urinary diversions are broadly divided into 2 main categories: continent and incontinent diversions. In this chapter, we will review the principles, surgical technique, perioperative management, and long-term issues associated with continent cutaneous reservoirs. The other major type of continent diversion, orthotopic urinary diversion is described in Chapter 13.
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A continent catheterizable diversion was first described by Gilchrest et al1 in 1950, but it was not until more than 30 years later when continent cutaneous diversions were routinely performed. Although many different techniques have been described, all are based upon 2 underlying principles: a detubularized, spherical bowel reservoir for storage and a continent, catheterizable stoma for emptying. A variety of continent stomas have been described. The terminal ileum can be tailored and used as a catheterizable limb to take advantage of the nonrefluxing ileocecal valve. The appendix or a tailored segment of bowel can be submucosally tunneled to form a stoma utilizing the principles described by Mitrofanoff.2 With the Kock or Mainz pouch, a nipple or flap valve is constructed to provide a new continence mechanism. Continent cutaneous reservoirs are an outstanding option for patients in whom an orthotopic urinary diversion is contraindicated.
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The Indiana Pouch, a continent cutaneous diversion based upon the terminal ileum and right colon, was first described in 1985 and uses the nonrefluxing ileocecal valve as the continence mechanism. The right hemicolon is detubularized, folded, and is used to fashion a spherical reservoir. The tapered terminal ileum is matured into a stoma either in the right lower quadrant or umbilicus for catheterization of the pouch. Long-term data from multiple institutions have shown this to be a safe and reliable form of urinary diversion, with continence rates that range from 94% to 98%,3 reoperation rates of 15%, and long-term complications, such as pouch calculi, stomal hernia, stomal stenosis, bowel obstruction, and renal insufficiency, in 17%.4 Bochner et al5 described a modification to the ileocecal reservoir whereby the ureters are anastomosed into the terminal ileum as a ureteral substitution segment and a flap valve is developed with the in situ appendix as the catheterizable stoma. This technique is especially useful in patients who have undergone preoperative radiation therapy where excessive manipulation of the ureters can result in devascularization ...