ORTHOTOPIC URINARY

DIVERSION
(ONB)
• HISTORY
• BASIC PRINCIPLES
• PATIENT SELECTION
• TECHNIQUES OF ONB
• RESULTS
• COMPLICATIONS
• FOLLOW UP
 HISTORY

• Ureterosigmoidostomy oldest form of UD (Simon;1852)

• Bricker (1950) popularized the ileal conduit form of UD

• Gilchrist (1950) described continent cutaneous diversion

• Lemoine (1913) performed first Orthotopic UD

• Camey and Le Duc (1979) credited for pioneering experience in

ONB using ileum
BASIC PRINCIPLES
 PATIENT SELECTION

• Oncologic factors

• Patient related factors

 Oncologic Factors

• Risk of urethral recurrence

• Locally advanced tumor stage

 Patient Related factors

• Age
• General health
• Social circumstances
• Renal functions
• Body habitus
• Manual dexterity
• Urethral & external sphincter status
• Prior Radiation
• Prior surgery
 TECHNIQUES OF ONB

• Choice of bowel segment

• Surgical techniques
 BOWEL SEGMENT

• Ileum

• Colon

• Stomach

• jejunum
 SURGICAL TECHNIQUES

• Ileal reservoirs

• Ileocolic pouches

• colon reservoirs
 ILEAL RESERVOIRS

• Camey reservoir (1979)

• camey II reservoir (1990)
• Hautmann W-neobladder (1988)
• “hemi-Kock” neobladder (1991)
• Studer pouch (1989)
• serous lined,extramural ileal neobladder (Abol-Enein-
Ghoneim) (1993)
• T pouch (1998)
 CAMEY RESERVOIR (1979)

• Used intact segment of ileum (40 cm)

• non refluxing ureterointestinal anastomosis (Le Duc-Camey)

• High pressure reservoir

• pros- orthotopic diversion

• cons- poor capacity/compliance/continence

 CAMEY II RESERVOIR (1990)

• used 65 cm of ileum

• detubularization and folding of ileum

• transverse U orientation

• pros- better capacity/compliance/continence

• cons- bladder configuration not spherical

 HAUTMANN W NEOBLADDER (1988)

• 70 cm of distal ileum

• W configuration

• non-refluxing/refluxing ureteric anastomosis

• pros-larger initial capacity/earlier continence

• cons- urinary retention/electrolyte reabsorption

 “HEMI-KOCK” NEOBLADDER (1991)

• modification of original continent cutaneous reservoir

• no efferent valve required

• 61 cm of terminal ileum

• pros-excellent continence/low ureteroileal stricture

• cons-technically difficult/valve related complications

 GHONEIM ILEAL NEOBLADDER (1993)

• serous line extramural tunnel for anti-reflux mechanism

• 40 cm of ileum in W configuration

• pros-no staples/sound healing/short ileal segment/versatile

• cons-long ureteral length/risk ureteral stricture/not for dilated

ureters
 STUDER POUCH (1989)

• 15 cm of afferent ileal segment

• 44 cm as reservoir

• pros- simple to construct/no staples/better for short ureter

 ILEOCOLIC POUCH

• Orthotopic Mainz pouch (Mainz III)

• Le Bag pouch
 Orthotopic Mainz pouch (Mainz III)

• mixed augmented ileum and zecum

• 10-15 cm of caecum along with 20-30 cm of distal ileum

• W configuration

• multiple previous small bowel surgeries

 Le Bag pouch

• 20 cm of ascending colon with 20 cm of distal ileum

• ureters anastomosed in colon

• proximal ileum to urethra

 Sigmoid pouch (Reddy)

• with redundant sigmoid colon

• 35 cm of segment
 RESULTS

• day time continence

• night time continence

• hypercontinence (retention)
 Day time continence

• developes gradually over 6-12 months

• ultimately achieve 80%-90% of day time continence

• risk factors- age >65 yrs/colonic segments

 Night time continence

• persistent nocturnal incontinence in 20%-50% patients

• slower improvement (>12 months)

• absent sphincter-detrusor reflex/ decreased sphincter tone at

night
 Hypercontinence

• failure to empty or urinary retention

• reported in 4%-10% (men) and 20% - 60% (women)of patients

• often associated with UTI

• risk factors- large reservoir (>60 cm ileum)/nerve sparing

surgery
• rule out stricture/tumor recurrence/ventral hernia/ posterior
prolapse of pouch

• intermittent self catheterization

 COMPLICATIONS

• Early complications

• Late complications
• Early complications-

1. bleeding
2. urine leak
3. thrombotic events
4. infections
5. cardiovascular
6. pulmonary
7. ileus
• Late complications-
1. Voiding problems
2. UTI
3. Metabolic complications
4. Bowel obstructions
5. Ureteroileal/ afferent limb obstruction
6. Urethral stricture
7. Urolithiasis
8. Vaginal fistula
9. Pouch rupture
 FOLLOW UP

• Divided into 3 time zones-

1) early term follow up- first 4 months

2) intermediate term follow up- 4 months to 3 yrs

3) long term follow up- beyond 3 yrs