Chapter 189: Supravesical Urinary Diversion
189 Supravesical Urinary Diversion
Badrinath Konety and Sean P. Elliott
INTRODUCTION
Supravesical diversion involves the external
diversion of the urine stream without use of
the bladder. While percutaneous nephros-
tomy offers a short-term alternative to op-
erative diversion, problems with frequent
tube changes, infection, and external appli-
ances make surgical diversion the preferred
method in those needing long-term su-
pravesical diversion. This chapter focuses on
surgical supravesical diversion. Except in the
case of cutaneous pyelostomy or ureteros-
tomy, supravesical diversion employs intes-
tinal segments to bridge the gap between the
ureters and the skin. Types of supravesical
diversion may generally be categorized as
continent and noncontinent. Noncontinent
diversions involve a wide stoma and an ex-
ternal appliance to collect the urine (uros-
tomy bag). Heterotopic continent diversions
utilize a catheterizable stoma on the ab-
dominal wall to empty an intra-abdominal
neobladder whereas orthotopic continent
diversions create a pelvic neobladder that is
anastomosed to the urethra.
INDICATIONS
The most common indication for supravesi-
cal diversion is following radical cystectomy
for cancer of the bladder. Other indications
include refractory ureteral or urethral ob-
struction and urinary fistula: these are of-ten
less amenable to repair when the etiol-ogy is
radiation damage. Radiation cystitis,
interstitial cystitis, or hemorrhagic cystitis
not responsive to less invasive means of
management are managed with supravesi-cal
diversion. Additionally, supravesical di-
version may be considered in the manage-
ment of neurogenic bladder when bladder
augmentation cystoplasty is not an option.
PREOPERATIVE PLANNING
Patients should be appropriately selected
to ensure they are medically fit for major
surgery. Coexistent bowel pathology
includ-ing inflammatory bowel disease
or previous resection should factor into
selection of the appropriate intestinal
segment for diver-sion.
Patient considerations specific to the
choice of the type of urinary diversion in-
clude visual, cognitive, neuromotor, and
renal function as well as the level of avail-
2001
able social support. As continent neoblad-
ders can be associated with electrolyte
disturbances they are to be avoided in pa-
tients with cognitive or renal impairment.
When considering a neobladder, one must
take into account the patient’s neuromo-tor
status and dexterity along with the
availability of other caregivers to assist
with care of the diversion. Patients can
suffer from urinary retention or incom-
plete emptying after an orthotopic neo-
bladder and hence the ability to catheter-
ize the neobladder is important in them as
well as in those considering a heterotopic
neobladder with an abdominal stoma.
When the ability to catheterize or electro-
lyte disturbances are a concern, the pre-
ferred diversion is one with a nonconti-
nent stoma.
If a urinary diversion is being contem-
plated in a patient with ureteral stricture, it is
important to delineate the length and lo-
cation of the stricture before surgery. As an
indwelling stent may mask the true extent of
disease, a preoperative nephrostomy and
ureteral stent removal is recommended. An
antegrade ureterogram several weeks later or
in the operating room at the time of re-
construction will best identify the level for
ureteral transection. A stent-free period also
allows ureteral inflammation associ-ated with
the stent to resolve before recon-struction.
Because such inflammation can make
intraoperative identification of the ureters
more difficult due to periureteral scarring and
induration of the plane inside Gerota’s fascia,
antegrade ureteral catheters may be placed
down to the site of obstruc-tion on the day of
diversion.
It is always advisable to remove the
blad-der when performing supravesical
diver-sion, even in the absence of bladder
malig-nancy. Diversion of the urine stream
away from an intact bladder too frequently
re-sults in pyocystis, a condition of
retained mucous and desquamated bladder
epithe-lial cells complicated by infection.
Pyocys-tis is managed by bladder drainage
and/or cystectomy. One alternative in
women is to create an iatrogenic fistula
into the vagina, which allows for bladder
drainage without the need for an
indwelling or intermittent catheterization.
When anastomosing the ureters to the
intestinal segment one may elect a tunneled
or a refluxing reimplant. Longitudinal stud-
ies have shown the risk of renal dysfunction
from obstruction in a tunneled reimplant may
outweigh the risk of renal dysfunction from
reflux in a nontunneled, refluxing re-implant.
Most opt for a refluxing reimplant in the
modern era. Refluxing reimplants may be
done in the fashion of Bricker or Wallace.
The Bricker reimplant is the tech-nique of
separately anastomosing the two ureters to
the bowel in an end-to-side man-ner. The
Wallace reimplant is the technique of a side-
to-side anastomosis of the two ureters to each
other followed by an end-to-end anastomosis
of the “double-barrel” ure-ters to the back
end of a loop of intestine. The Wallace
anastomosis makes it easier to
endoscopically access the ureters postop-
eratively if there is a need for upper tract
evaluation or stone removal. The principal
concern about the Wallace anastomosis is
that obstruction of the terminal portion of one
ureter, due to stenosis, a stone, or re-current
tumor, may obstruct both ureters, resulting in
critical renal impairment. If a ureteric or
renal pelvic tumor should de-velop in one
renal moiety, it would be harder to separately
dissect out the corresponding ureter at the
time of a nephroureterectomy. Tunneling
techniques are covered below in the relevant
sections.
SURGICAL TECHNIQUE
Noncontinent Diversions
Cutaneous Ureterostomy
Cutaneous loop ureterostomy or pyelos-
tomy can be performed as a temporary di-
version to manage the infant with severe
hydroureteronephrosis in anticipation of
future reimplant. Due to the high rate of
stomal stenosis, few employ cutaneous end
ureterostomy as a permanent diversion for
adults in the modern era. The degree of Nongastrointestinal Transabdominal Surgery
mobilization of the ureters that is required
in order to bring them to skin results in
devascularization and stenosis in approxi-
mately 60%. The small caliber ureter may
also be predisposed to stomal stenosis.
However, in the patient with multiple co-
morbidities and very dilated ureters, there
may still be a role for permanent cutane-
ous ureterostomy. In order to avoid two
stomas it is customary to perform a “dou-
ble-barrel” ureterostomy. Stomal stenosis
may be minimized by eversion of the ure-
ters into a rosebud and by incorporating a
V-shaped skin flap into each ureterostomy.