to high rates of incontinence and renal func-
tion loss. Current approaches share the con-
cept of detubularized and reconfigured il-
eum, with continence achieved by the
preserved external urinary sphincter. Ure-ters
are typically reimplanted in a refluxing
manner. Some leave a suprapubic catheter
and a urethral catheter, others just a urethral
catheter. Some externalize “single J” ureteral
catheters through the skin and put them to an
external pouch until removal. Others tie
“double J” stents to the urethral catheter, al-
lowing them to be removed with the urethral
catheter at 3 weeks after a cystogram shows
an intact neobladder. In our experience, in-
cluding the larger suprapubic catheter al-lows
for better irrigation of mucus than the single
16F urethral catheter. However, when no
suprapubic catheter was left in place we
obtained good results by using a 24F hema-
turia catheter as the urethral catheter. Simi-
larly, while the “double J” stents may at first
appear to minimize morbidity we have expe-
rienced increased pyelonephritis in the post-
operative period due to the prolonged stent-
ing and reflux that occurs with irrigation.
Thus we prefer to externalize the stents and
remove them within a week.
Voiding is achieved by Valsalva and si-
multaneous voluntary sphincter relaxation.
Daytime continence is better than night-time
continence due to relaxation of the voluntary
sphincter during sleep. Both types of
incontinence improve over time, with only a
minority continuing to experi-ence these
issues at 1-year postsurgery. Ini-tial problems
with urinary retention, espe-cially in women,
have been improved by fixing the pouch to
the anterior abdominal wall to avoid kinking
of the urethra.
Studer Neobladder
The Studer pouch is the simplest to perform
of the orthotopic pouches. It is essentially a
“J” pouch with the upper limb of the “J”
serving as the afferent limb for ureteral re-
implantation. A 60-cm segment of ileum is
isolated 15 to 25 cm from the ileocecal valve
(Fig. 13). The distal 40 cm is detubularized
and the posterior plate reconstructed in a “U”
fashion using running absorbable su-ture
(typically 3-0), then the upper and lower
halves are closed to each other in a clam-
shell fashion, forming a sphere. The upper 20
cm is left intact, allowing this segment to
reach the mid ureters. The ureters are sewn to
the conduit in the fashion of Bricker. This
afferent limb may offer several advantages.
First, the peristaltic waves help minimize
reflux. Second, it allows the surgeon to re-
sect the ureters above the iliac vessels. As the
internal iliac blood supply to the ureters is
interrupted during cystectomy the distal
Chapter 189: Supravesical Urinary Diversion 2009
Fig. 13. Studer neobladder. A: A U-shaped pouch is created from 40 cm of ileum while sparing
the ter-minal 15 cm. Another proximal 15-cm segment of ileum acts as the “chimney” into
which the ureters are reimplanted. B: The bottom of the pouch is closed up, but not before the
most dependent portion is brought down and anastomosed to the urethra.
ureters are relatively devascularized, relying Mainz Neobladder
on blood flow from the upper and mid ure- The Mainz neobladder is created in a fash-
ter. By anastomosing the mid ureter to the ion similar to the Mainz heterotopic pouch,
afferent limb, the “chimney” of the Studer using 10 to 15 cm of cecum and right colon
neobladder minimizes distal ischemia and and two 10- to 15-cm segments of ileum
may thus minimize ureterointestinal anas- (Fig. 15). The 20- to 25-cm segment of ileum
tomotic strictures. The most dependent used for the catheterizable channel of the
portion of the pouch is opened and the mu- Mainz heterotopic pouch is, of course, not
cosa everted for anastomosis to the urethral used. The posterior plate is constructed in an
stump with 2-0 or 3-0 absorbable sutures. “S” fashion using the three limbs. The
Initial pouch volumes are lower than with urethral anastomosis is performed and then
other pouches—about 150 mL—but this in- the anterior wall is closed.
creases over time to about 500 mL.
POSTOPERATIVE
Hautmann Neobladder
MANAGEMENT
The Hautmann neobladder is an ileal reser-
voir that uses 60 to 80 cm of ileum with the Cystectomy and urinary diversion is a highly
back plate fashioned in a “W” (Fig. 14), thus complex operation and operative times may
achieving higher initial volumes compared exceed 8 hours. Blood loss is minimized with
with the Studer pouch. Classically, the ure- current techniques but can still reach 1,000
ters were brought through the posterior wall mL. Patients with bladder cancer or radia-
of the neobladder and the anastomo-sis was tion cystitis are frequently elderly and may
done from the inside. Alternatively, a Studer possess multiple comorbidities. For all these
Nongastrointestinal Transabdominal Surgery
modification can be performed by creating a reasons, careful postoperative care is essen-
chimney into which the ureters are tial to a successful outcome. Care pathways
anastomosed. This technique also dif-fers have led to earlier discharge and helped
from the Studer approach in that the segment minimize complications.
to be used for the urethral anasto-mosis is If a bowel anastomosis is performed,
chosen before opening the bowel. The line many opt to leave a nasogastric tube. We
one follows when opening the bowel should prefer to omit the nasogastric tube based on a
be deviated away from the antimesenteric meta-analysis of a randomized trial that
line toward the anterior mesentery in the area showed no change in return to bowel func-
of the planned ure-thral anastomosis. This tion but an increase in pulmonary compli-
creates a posteri-orly based “U,” flap which cations with a nasogastric tube. Some groups
makes the anas-tomosis easier to perform. add metoclopramide to help with bowel
activity; evidence of efficacy in the