How is incontinent urinary diversion created during a radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Bricker popularized the ileal conduit in the 1950s. The conduit drains to a cutaneous stoma and requires the use of an external appliance. Ureteral anastomoses are freely refluxing. Approximately 12-15 cm of ileum is mobilized, and the proximal end is closed with a staple line or sutures. The left ureter is tunneled through the sigmoid mesocolon and both ureters are spatulated and sutured to the ileal segment with interrupted absorbable sutures (eg, 4-0 Vicryl). Temporary stenting of the ureterointestinal anastomoses is traditionally performed, although some groups no longer routinely practice this. The Wallace technique is a variation, with a distal ureteroureteral anastomosis prior to the ileal anastomosis. This provides a wider lumen anastomosis; however, in the rare occurrence of an anastomotic tumor recurrence, it places both kidneys at risk of obstruction.

A circular 2.5-cm diameter incision is made on the skin in a premarked position and carried down through Scarpa fascia. A cruciate incision large enough for 2 fingers is made in the anterior and posterior rectus sheath. The stoma is "rosebudded" with eversion of the end segment of ileum.

Absorbable sutures are placed from the stomal skin edge to the serosa of the conduit, approximately 3 cm proximal to its distal end, and are continued as a full-thickness bite through the distal end of the conduit. Then, tailor the posterior rectus fascial sheath to an appropriate fit to prevent intestinal herniation.

A colonic conduit can be used if the ileum has been irradiated. Every segment of colon has been used, with the most popular being the transverse colon because it is outside the field of any previous pelvic radiation.


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