1. Urinary Diversion in Urological Cancer
J.Edson Pontes

2. Radical Cystectomy: Historical Perspective
Radical Cystectomy in the 40s/50s was considered a major surgical procedure, done only in a few centers.
The procedure was often done in 2 stages.
The mortality associated with it was about 30%

3. Radical Cystectomy: Historical Perspective
Advances in Antibiotic Therapy.
Improvement in Nutrition.
Improvement in Pre and post operative care.
Resulted in decreased mortality to about 1-2% in modern series.

4. Urinary Diversion
Most of the present techniques of continent urinary diversion, can be found in experimental procedures at the end of the 19th century.
Ureterosigmoidostomy was used widely before the 50s.
Metabolic problems, ascending urinary infections and sepsis drove the need for alternatives.
The Gilcrest procedure and the ileal loop (Bricker) were developed therefore.

5. Continent Urinary Diversion
Couvelaire in 1950, published the first case of a continent urinary diversion.
Camey, made this procedure popular in France in the 60s/70s, and Lillien presented it to the AUA in the 80s.
The concept of detubularization and low pressure reservoir consolidated this procedure.

6. Continent Urinary Diversion
Does not affect the Outcome of the disease.
The only Goal is improvement in Quality of life!

7. QUALITY OF LIFE IN NONCONTINENT UROSTOMIES
FEAR OF STOMAL LEAKAGE
ODOR
LACK OF SEXUAL ATTRACTIVENESS
AND PERFORMANCE

8. PATIENT SELECTION CRITERIA
Clinically organ confined disease
Serum creatinine < 2.5mg/dl
High self motivation
Adequate manual dexterity
No significant comorbidity
Low risk for urethral recurrence

9. CONTINENT URINARY RESERVOIR - GOALS
GOOD CAPACITY AT LOW PRESSURE
EMPTIES EASILY WITH NO OR LITTLE RESIDUAL
PRESERVATION OF UPPER URINARY TRACT
GOOD URINARY CONTROL
LOW COMPLICATION RATE

11. CONTINENT CONTANEOUS URINARY DIVERSION
CREATION OF CONTINENT NIPPLE VALVE
KOCH POUCH
MAINZ POUCH
ILEOCOLONIC RESERVOIRS WITH PLICATED ILEAL SEGMENT
MITROFANOFF PRINCIPLE

13. PHYSIOLOGICAL PRINCIPLES FOR CONTINENT RESERVOIR OUTLET RESISTANCE ON “INDIANA” POUCHES MAY BE DUE:
REDUCED DIAMETER OF TERMINAL ILEUM, PHASIC AND TONIC CONTRACTIONS OF THE ILEUM, PASSIVE RESISTANCE AND ACTIVE CONTRACTION IN THE ILEOCECAL VALVE.
P. CARROLL ET AL., J. UROL 1989

16. CONTINENT URINARY DIVERSION TO THE URETHRA
ILEAL
ILEO-CECAL
LARGE BOWEL
STOMACH

17. Commonly used Continent Reservoirs
Camey 2
W Pouch(Studder)
Le Bag
Mainz Pouch
Padova Neo bladder

20. Conclusions 1
Continent urinary diversion are now common place in bladder replacement.
Continent reservoirs are now used in 60-70% of all patients in our Center.
Despite the complexities of the procedure there only minimal increase complications
Selection of patients and procedures are key to success.

21. Conclusion 2
Remember that no Neo Bladder can replace a Normal Bladder!