Procedure Notes-Urinary Diversions - Campbell's 80

Front 1

What is the blood supply to the stomach?

Back 1

The stomach is a vascular organ that receives its blood supply primarily from the celiac axis (Fig. 80-1). There are three branches of the celiac axis that give rise to the majority of the arterial supply of the stomach.
The left gastric (coronary) artery arises directly from the celiac axis and supplies the lesser curvature.
The hepatic artery, after arising from the celiac axis, gives off the right gastric artery, which also supplies the lesser curve of the stomach, and the gastroduodenal artery, which supplies the antrum and duodenum before giving off the right gastroepiploic artery.
The splenic artery originates from the celiac axis and gives off the vasa brevia (short gastric), which supply the fundus and cardia, and the left gastroepiploic artery.

The right gastroepiploic artery anastomoses with the left gastroepiploic artery, and both supply the greater curve of the stomach. By use of the gastroepiploic vessels, a pedicle of stomach may be mobilized to the pelvis.

Front 2

What is a billroth I and a billroth II procedure?

Back 2

Front 3

What are the advantages of using the stomach in a diversion?

Back 3

The advantage of stomach over other intestinal segments for urinary intestinal diversion is that it is less permeable to urinary solutes, it has a net excretion of chloride and protons rather than a net absorption of them, and it produces less mucus. Urodynamically, it behaves like other intestinal segments. When it is used in urinary reconstruction, electrolyte imbalance rarely ensues in patients with normal renal function, although a hypochloremic metabolic alkalosis has been described.

Front 4

What is the extent of small bowel fed by each straight vessel?

Back 4

About 15 cm, however typically only 8 cm of bowel should be left to a single straight vessel operatively.

Front 5

Why is the jejunum not typically used for urinary diversion? If it must be employed, what portion should be
used?

Back 5

Severe electrolyte imbalances that result (hyperkalemic, hyponatremic metabolic acidosis)

As distal a segment as possible

Front 6

What portions of bowel are most often used for urinary reconstruction?

Back 6

Ileum and colon

Front 7

What nutritional problems are associated with use of ileum?

Back 7

Pernicious anemia due to lack of B12 reabsorption, diarrhea due to lack of bile salt reabsorption, fat
malabsorption

Front 8

What are some advantages to using colon vs. ileum for reconstruction?

Back 8

In patients who have received pelvic radiation, portions of the right, transverse, and descending colon can be used confidently without fear of contamination

Fewer nutritional deficits with colonic use

Lower incidence of post-op bowel obstruction with colon (4% vs 10%)

Front 9

What is the rationale for performing preoperative bowel preps prior to use of intestinal segments? How do
mechanical vs. antibiotic preps differ in accomplishing this goal?

Back 9

Reduction in the chance of bacterial contamination during surgery which has been shown to be a major
cause of morbidity and mortality in patients undergoing these surgeries

Mechanical preps seek to decrease the number of bacteria by decreasing the amount of feces; antibiotic preps seek to decrease the bacterial concentration of the feces itself

Front 10

Does the literature support the use of mechanical preps? What do the authors suggest?

Back 10

No, studies have shown no difference in post-op complication rate with mechanical preps. The majority of these studies were done in elective colorectal surgery, which theoretically would have a higher bacterial colonization than small bowel surgery, but in meta-analysis as well as multiple studies dating back to the '90s show no increased complication rate or decreased bowel anastamotic leak rate with mechanical bowel preps versus no prep.

The colorectal surgeons at UNC also agree with this and don't do mechanical bowel prep prior to their surgeries.

The authors recommend a limited prep done as an outpatient with a clear liquid diet and sodium
phosphate (Fleet Phosphosoda). Contraindications to the phosphosoda include renal insufficiency, hyperphosphatemia, and hypocalcemia.

Front 11

Does the literature support antibiotic bowel preps? What are the disadvantages?

Back 11

Yes, most studies suggest that antibiotic preps reduce postop complications
♦ Higher incidence of post op diarrhea and pseudomembranous enterocolitis; monilial overgrowth
resulting in stomatitis, thrush, and diarrhea; and, with prolonged use, malabsorption of protein,
carbohydrate, and fat.

Front 12

What are some common antibiotic regimens used?

Back 12

kanamycin monotherapy, neomycin and erythromycin base, and neomycin and metronidazole

Front 13

What are the surgical principles important for reducing morbidity and mortality from intestinal surgery?

Back 13

Adequate exposure
♦ Maintain proper blood supply to the severed end of the bowel
♦ Prevention of local spillage
♦ Accurate apposition of serosa to serosa of the two segments of bowel
♦ Not to tie the sutures so tight that the tissue is strangulated
♦ Realignment of the mesentery of the two segments of bowel to be joined

Front 14

Sutured or stapled anastomoses: are there differences in complication rates? When, in general, is it better to
do sutured anastomoses

Back 14

No difference in complication when performed correctly
♦ Sutured anastomosis with absorbable sutures should be used for intestinal segments exposed to urine

Front 15

What are the advantages of stapled anastomoses?

Back 15

Provides for a better blood supply to the healing margin
♦ There is reduced tissue manipulation
♦ There is minimal edema with uniformity of suture placement
♦ A wider lumen is constructed
♦ There is greater ease and less time involved in performing the anastomosis
♦ The length of postoperative paralytic ileus is reduced

Front 16

Is NG decompression postoperatively recommended?

Back 16

Though controversial, the authors do recommend it in all but the most fit patients as it does decrease
incidence of abdominal distention, nausea, and vomiting

Front 17

What are the known complications of intestinal anastomoses?

Back 17

Fistulas: usually occur in first several weeks post-op
♦ Infections: wound infections (5%), abscesses, and dehiscences may complicate immediate postop period
♦ Bowel obstruction: 10% incidence with ileal diversion, 5% with colon
♦ Hemorrhage: rare
♦ Intestinal stenosis: two time frames, immediately post-op or long term
♦ Pseudo-obstruction of colon (Ogilvie’s): usually presents in first 3 days, requires emergent cecostomy

Front 18

What are some complications of the isolated intestinal segment?

Back 18

Stricture: usually a late complication occurring in conduits, thought to be due to lymphoid depletion of
the segment exposed to urine leading to persistent infection
♦ Elongation: results in massive enlargement and may be due to obstruction or failure to catheterize
continent diversions

Front 19

What are the two types of abdominal stomas?

Back 19

Flush: used for continent diversions
♦ Protruding: used with appliances; two types: rosebud (nipple) and loop

Front 20

Where should stomas be placed?

Back 20

Through the belly of the rectus muscle and be located at the peak of the infraumbilical fat roll

Front 21

What are the early complications of abdominal stomas?

Back 21

Bowel necrosis, bleeding, dermatitis, parastomal hernia, prolapse, obstruction, stomal retraction, and
stomal stenosis; at some point virtually every patient has one of these complications

Front 22

Is stenosis more common with colon or ileal conduits?

Back 22

Ileal (20-24% vs. 10-20%)

Front 23

What can cause massive bleeding from a conduit?

Back 23

Intestinal varices

Front 24

What are the causes of upper tract deterioration after diversion? What is the reported rate?

Back 24

Lack of ureteral motility, infection, stones, or less commonly due to obstruction at the ureteral-intestinal
anastomosis
♦ Wide reported rate of 10-60%

Front 25

. Is pressure transmitted from the conduit to the renal pelvis in a non-refluxing anastomosis?

Back 25

No. Peristaltic ureteral contractions dampen pressure transmission.

Front 26

Does an anti-refluxing anastomosis decrease bacterial transmission to the upper tracts?

Back 26

No

Front 27

What are the basic principles of a ureteral-intestinal anastomosis?

What suture do we use?

Back 27

Only as much ureter as is needed should be mobilized
♦ Mobilization should not strip the ureter of it’s periadventitial blood supply
♦ Use fine absorbable sutures in a watertight fashion with mucosal apposition
♦ If possible, retroperitonealize the anastomosis

We use Vicryl here and at CMC many of the attendings use Monocryl instead, which I think might be a better idea.

Front 28

What causes ureterointestinal strictures?

Back 28

Ischemia, urine leak, radiation or infection are the most common causes. The incidence of leak can be
reduced to nearly zero if soft Silastic stents are used.

Front 29

What are the types of ureterocolonic anastomoses?

Back 29

Leadbetter and Clarke- nonrefluxing anastomosis with a submucosal tunnel
♦ Goodwin- transcolonic nonrefluxing anastomosis with a submucosal tunnel
♦ Strickler- nonrefluxing anastomosis with a submucosal tunnel. High stricture rate (14%)
♦ Pagano- nonrefluxing anastomosis with a submucosal tunnel
♦ Cordonnier and Nesbit- no tunnel. Same as a Bricker in small bowel

Front 30

What are the types of ureter-small bowel anastomosis?

Back 30

Bricker- refluxing end-to-side ureter-small bowel anastomosis; stricture 4-22%, avg 6%
♦ Wallace- ureters are spatulated and laid beside each other; lowest complication rate of all anastomoses
♦ Tunneled small bowel anastomosis- nonrefluxing with a submucosal tunnel
♦ Split-nipple- ureter is spatulated and tunneled back on itself to create a nipple valve
♦ Le Duc- nonrefluxing anastomosis created by laying the ureter onto the interior of the bowel wall
♦ Hammock- nonrefluxing anastomosis with conjoined ureters

Front 31

What are the 3 types of intestinal anti-reflux valves?

Back 31

Intussuscepted ileocecal valve
♦ Intussuscepted ileal valve
♦ Nipple valve

Front 32

Which anastomosis has the lowest incidence of stricture formation? What about anti-reflux anastomoses?

Back 32

Wallace
♦ Anti-reflux anastomoses have a higher rate of stricture than refluxing anastomoses

Front 33

When do fistulas typically present?

Back 33

Within the first 7-10 days; markedly reduced by the use of stents

Front 34

What is the most common location of a ureterointestinal stricture? What is the most successful way of repairing a stricture? What is the success rate at 3 years?

Back 34

Left ureter usually as it crosses over the aorta beneath the IMA
Reexploration with removal of the stenotic segment and reanastomosis; 75% success at 3 years vs. only
15% for balloon dilation

Front 35

What percentage of patients with ileal conduits eventually die of renal failure?

Back 35

6%

Front 36

What should a patient’s GFR be to tolerate a continent urinary diversion?

Back 36

40 mL/min. In general, patients with normal urine protein content who have a serum Cr below 2.0
mg/dL do well with intestine interposed in the urinary tract.
♦ Limited segments of bowel should be used in patients who have an inability to acidify the urine to less
than 5.8, an inability to concentrate greater than 600 mOsm/kg, or a GFR less than 35 mL/min

The AUA board review course says the eGFR should be greater than 50ml/min.

Front 37

When should ileum not be used?

Back 37

Short bowel syndrome, IBD, or extensive radiation to the small bowel

Front 38

What is the electrolyte abnormality in ileal conduits (and colon conduits)? What are the symptoms? What
is the mechanism? How is it treated?

Back 38

Hyperchoremic metabolic acidosis; occurs in approximately 70% of cases
♦ Fatigability, anorexia, weight loss, polydipsia, and lethargy
♦ Ammonium substitutes for sodium in the Na-H antiport, thus ammonium chloride is reabsorbed across
the lumen in exchange for carbonic acid
Alkalizing agents such as sodium bicarbonate, sodium citrate (bicitra), potassium citrate (urocit-K)

Front 39

What is the main electrolyte abnormality with jejunal conduits?

Back 39

Hyperkalemic, hyponatremic metabolic acidosis. Treat with NaCl and NaHCO3. The more proximal the
segment of jejunum, the more severe the problem

J - just plain bad choice
E - erosive - acidosis
J - juiceless - dehydration
U - unelevated
N - NaCl - so sodium and chloride are low
U - upchuck, they often present with emesis
M - muscle weakness.

Front 40

When is a transverse colon conduit a particularly good option?

Back 40

When there has been extensive pelvic radiation

Front 41

What is the metabolic abnormality with a stomach conduit? How is it treated?

Back 41

Hypochloremic metabolic alkalosis. Can be treated with an H2 blocker

Front 42

Which gastrocystoplasty patients are most at risk for the development of severe metabolic alkalosis?

Back 42

Those with high resting levels of serum gastrin who overdistend their pouches and are dehydrated

Front 43

What drugs are more likely to cause problems in someone with urinary diversion? When is this especially
important?

Back 43

Drugs more likely to be a problem are those that are absorbed by the GI tract and excreted unchanged by
the kidney, thus the excreted drug is re-exposed to the intestinal segment which reabsorbs it leading to toxic serum levels. Phenytoin, methotrexate.
Patients with diversions receiving chemotherapy have increased toxicity, and those with continent
diversions should have the pouch drained during therapy

Front 44

Chronic acidosis can lead to what condition commonly referred to as renal rickets?

Back 44

Osteomalacia

Front 45

What is the most common stone type in a patient with urinary diversion?

Back 45

Magnesium Ammonium Phosphate

Front 46

What is the risk of cancer in someone with a ureterosigmoidostomy?

Back 46

Between 6-29% with a mean of 11%

Front 47

Which configuration of bowel has the most volume for the least surface area?

Back 47

Sphere

Front 48

Why do we detubularize the bowel before neobladder or augmentation cystoplasty?

Back 48

To interrupt the coordinated motor activity of the bowel and decrease intraluminal pressure and increase
volume

Front 49

Which part of the small bowel has the largest diameter and which has the smallest diameter?

Back 49

*The small bowel diameter gets progressively smaller as it moves from the duodenum to the ileum with the duodenum being the widest diameter and the ileum the smallest.

Front 50

How can a surgeon distinguish between the ileum and the jejunum?

Back 50

The ileum, being more distal in location, has a smaller diameter. It has multiple arterial arcades, and the vessels in the arcades are smaller than those in the jejunum. The ileal mesentery is also thicker than the jejunal mesentery. In contrast, the jejunal diameter is larger, the arterial arcades are usually single, and the vessels composing them are larger in diameter.

Front 51

When you are looking at the mesentery of the small bowel and you see the arcades how do they supply blood to the bowel itself?

Back 51

The arcades anastomose one with another and give off straight vessels, which enter the bowel and form an anastomotic network within the bowel wall.

Front 52

How much bowel wall can you skinny mesentery off of when preparing a conduit and have it survive?

Back 52

It has been shown experimentally that up to 15 cm of small bowel can survive lateral to a straight vessel. Thus, theoretically, the mesentery could be cleaned from the small bowel for a length of 15 cm without necrosis of the end. In general, however, it is unwise to assume that more than 8 cm of small bowel will survive away from a straight vessel.

Front 53

What two portions of small bowel may lie within the pelvis and be exposed to pelvic radiation?

Back 53

two portions of the small bowel that may lie within the confines of the pelvis and as such may be exposed to pelvic irradiation and pelvic disease: the last 2 inches of the terminal ileum, which is often fixed in the pelvis by ligamentous attachments;and 5 feet of small bowel beginning approximately 6 feet from the ligament of Treitz, the mesentery of which is the longest of the entire small bowel, and as such, this portion of the small bowel can descend into the pelvis. In a postirradiated patient, one should try to avoid use of these two segments of the small intestine in any reconstructive procedure.

Front 54

What is the blood supply to the colon?

Back 54

colon receives its blood supply from the superior mesenteric artery, the inferior mesenteric artery, and the internal iliac arteries ( Fig. 80-2 ). The major arteries supplying the colon and rectum include the ileocolic, right colic, middle colic, left colic, sigmoid, superior hemorrhoidal, middle hemorrhoidal, and inferior hemorrhoidal arteries.

The middle colic artery arises from the first portion of the superior mesenteric artery and generally ascends the transverse mesocolon to the right of midline. The right colic artery usually arises just below the middle colic artery from the superior mesenteric artery and courses to the right colon. It may arise, however, from the ileocolic or directly from the middle colic artery. If it arises from the ileocolic artery, mobilization of the distal ascending colon is facilitated so that this portion of the colon can easily be brought into the deep pelvis

Front 55

What is the arc of drummond?

Back 55

major arteries supplying the colon and rectum include the ileocolic, right colic, middle colic, left colic, sigmoid, superior hemorrhoidal, middle hemorrhoidal, and inferior hemorrhoidal arteries. These arteries anastomose one with the other to form the arc of Drummond and allow considerable leeway in mobilizing the colon.

Front 56

What is the terminal portion of the SMA?

Back 56

The ileocolic artery is the terminal portion of the superior mesenteric artery and supplies the last 6 inches of ileum and ascending colon.

Front 57

What are three weak points when talking about the vascular supply to the colon and things that you should be concerned about when considering re-anastomosis sites?

Back 57

Three weak points involving the vascular supply to the colon have been described. Sudeck's critical point, which is located between the junction of the sigmoid and superior hemorrhoidal arteries, was thought to be a particularly tenuous anastomotic area such that if the colon were transected in this region, the anastomosis would heal with difficulty because the blood supply might be compromised. So to try and remember the epynom would be the S so sigmoidal branches, superior hemmorhoidal branches and the epynom starts with an S, and if the anastamosis broke down it would Suck. so ...

Similarly, the midpoints between the middle colic and right colic arteries and between the middle colic and left colic arteries also have somewhat tenuous anastomotic communications. Although anastomoses in these areas generally heal well, provided the principles of proper technique are adhered to, it is usually wise to select an area for the anastomosis to one side of these points.

Front 58

How would you mobilize the ascending, transverse, and descending colon segments?

Back 58

The ascending colon is mobilized first by transecting the cecal and distal ileal fibrous attachments to the lateral abdominal wall and retroperitoneum described previously and then by detaching it from the lateral abdominal wall along the avascular line of Toldt. This is a bloodless plane, provided the colonic mesentery is not violated. The transverse colon is mobilized by detaching the gastrocolic omentum along the avascular plane of its attachment to the colon; the hepatocolic ligament, which may have some small vessels coursing through it; and the phrenocolic ligament. The descending colon is mobilized much like the right colon by incising the avascular line of Toldt lateral to the colon. When these attachments are taken down, considerable mobility of the colon is achieved. Further mobility is gained by isolating a pedicle of intestine, which should be based on one of the major arterial vessels described earlier.

Front 59

What are the complications associated with using stomach for urinary diversion?

Back 59

Early complications of the use of portions of the stomach for reconstruction include gastric retention due to atony of the stomach or edema of the anastomosis; hemorrhage, most commonly originating from the anastomotic site; hiccups secondary to gastric distention; pancreatitis as a consequence of intraoperative injury; and duodenal leakage. Delayed complications include dumping syndrome, steatorrhea, small stomach syndrome, increased intestinal transit time, bilious vomiting, afferent loop syndrome, hypoproteinemia, and megaloblastic or iron deficiency anemia. Postoperative bowel obstruction occurs with an incidence of 10% (2 of 21 patients) ( Leong, 1978 ). Gastroduodenal and gastroureteral leaks have also been reported, occasionally resulting in a fatal outcome.

Complications specific to the use of stomach include the hematuria-dysuria syndrome and severe metabolic alkalosis associated with respiratory distress in some patients

Front 60

What complications might you see in patients where the ileo-cecal valve is used for the urinary diversion?

Back 60

Should the ileocecal valve be used, diarrhea, excessive bacterial colonization of the ileum with malabsorption, and fluid and bicarbonate loss may occur.

Front 61

Is there a high bacterial content in most of the GI tract, where is it the lowest?

Back 61

The bacterial population in the stomach is relatively low. The upper small intestine is an environment of relatively low bacterial counts because of the combined effects of gastric acid and peristalsis. Bacterial counts in aspirates from the normal upper small intestine generally are less than 1000/mL. --Fordtran's GI & Liver disease textbook.

Front 62

What are the two different aspects of bowel preperation, in other words what is the difference between a mechanical prep and an antibiotic perp?

Back 62

There are two aspects to bowel preparation, mechanical and antibiotic. Both methods attempt to reduce the complication rate from intestinal surgery. The mechanical preparation reduces the amount of feces, whereas the antibiotic preparation reduces the bacterial count. The bacterial flora in the bowel consists of aerobic organisms, the most common of which are Escherichia coli and Streptococcus faecalis, and anaerobic organisms, the most common of which are Bacteroides species and Clostridium species. The bacterial concentration ranges from 10 to 105 organisms per gram of fecal content in the jejunum, 105 to 107 in the distal ileum, 106 to 108 in the ascending colon, and 1010 to 1012 in the descending colon.

Front 63

What is meant by whole gut irrigation?

Back 63

In an attempt to reduce the time required for intestinal preparation and to obviate low-calorie intakes, whole-gut irrigation has been used. Originally, whole-gut irrigation was performed by placement of a nasogastric tube into the stomach and infusion of 9 to 12 liters of lactated Ringer's solution or normal saline during a several-hour period. These fluids were subsequently replaced with 10% mannitolView drug information, which was equally successful in ridding the bowel of its fecal content; however, the mannitolView drug information served as a bacterial nutrient and thereby facilitated microbial growth (Hares and Alexander-Williams, 1982). These solutions have largely been replaced by a polyethylene glycol-electrolyte solution. go-lytely.

The advantages of the whole-gut irrigation are that it gives the patient dietary freedom, there is a short preparation time, and it eliminates the enema. Its disadvantages are that it may result in the patient's exhaustion, it is rather rigorous, and it does result on occasion in fluid overload.

Front 64

What are contra-indications for whole gut irrigation in bowel preperation for surgery?

Back 64

Whole-gut irrigation is contraindicated in patients with an unstable cardiovascular system, patients with cirrhosis, patients with severe renal disease, patients with congestive heart failure, or those with an obstructed bowel.

Front 65

Back 65

Front 66

Back 66

This is a good example of the text from Campbell's chapter 80 where it discusses the early complications of cystectomy and diversion including early fistula formation which is what it appears this patient has. the treatment recomendation in sasp was to place perc tube and then to place a stent across the fistula to hopefully get it to heal and then to revise it if necessary.

Front 67

What are the benefits and risks with the use of colon for urinary diversions?

Back 67

Removal of segments of colon from the enteric tract results in fewer nutritional problems than does removal of segments of ileum, provided the ileocecal valve is not violated. Should the ileocecal valve be used, diarrhea, excessive bacterial colonization of the ileum with malabsorption, and fluid and bicarbonate loss may occur. The incidence of postoperative bowel obstruction with colon is 4%, less than that occurring with ileum. Both ileal and colon segments result in the same type of electrolyte imbalance with similar frequencies. An antireflux ureterointestinal anastomosis by the submucosal tunnel technique is easier to perform with use of colon. In general, ileum and colon are comparable and have few differences, which does not argue strongly for the selection of one over the other except under special circumstances.

Front 68

Do bowel preps decrease infection rates or anastamotic leak rates?

Back 68

have recently begun to question the widely held belief that bowel preparation is mandatory. In a meta-analysis of randomized clinical trials of anastomotic leakage during colon and rectal surgery, researchers found that there was no support for the conclusion that bowel preparation reduces anastomotic leak rates and other complications ( Guenaga et al, 2003 ). In further work, this group found suggestions in their analysis that mechanical bowel preparation may actually increase the rate of anastomotic leakage and wound complications ( Guenaga et al, 2005 ).

Preoperative Mechanical bowel prep caused an imbalance in the bowel microflora, suggesting that it offers no advantages in terms of enterobacterial microflora for patients undergoing colonic cancer resection. This was a randomized clinical trial in patients undergoing elective colon surgery, in the British Journal of Surgery 2010.

Front 69

What are the different bacterial colony counts

Back 69

The bacterial concentration ranges from 10 to 105 organisms per gram of fecal content in the jejunum, 105 to 107 in the distal ileum, 106 to 108 in the ascending colon, and 1010 to 1012 in the descending colon.

Front 70

Back 70

Front 71

What is a Kock pouch?

Back 71

This website below has a great explanation of what this pouch is with great images.

http://www.atlasofpelvicsurgery.com/10MalignantDisease/20KockPouchContinentUrostomy/cha10sec20.html

Front 72

How do you construct a T pouch ileal neobladder?

Back 72

*The best explanation was a surgical atlas article from BJU that is saved on the desktop.

Front 73

How do you mature an appendiceal stoma to the skin?

Back 73

This doesn't need to be everted. The one I did with Gaston he said the more sutures you place the better.

Front 74

What are the two largest categories of continent non-orthotopic urinary diversions?

Back 74

Continent, nonorthotopic urinary diversion can be divided into two major categories.

First, the variations of ureterosigmoidostomy such as ileocecal sigmoidostomy, rectal bladder, and sigmoid hemi-Kock operation with proximal colonic
intussusception are discussed. These techniques allow for
excretion of urine by means of evacuation.

Second, there is the large category of continent diversions requiring clean intermittent catheterization for emptying urine at intervals from
the constructed pouch.

Front 75

In a patient that has a urinary diversion that is a ureterosigmoidostomy how do you manage them for risk of colorectal Ca after surgery?

Back 75

Because of the definite concern for the occurrence of rectal
cancer some 5 to 50 years (average 21 years) after ureterosigmoidostomy
(Ambrose, 1983), it is suggested that patients
with long-term ureterosigmoidostomy be subjected to annual
colonic investigation by means of colonoscopy (Filmer and
Spencer, 1990). Barium enemas are relatively contraindicated,
because reflux of this material into the kidneys (if the antireflux
procedure fails) can result in dire consequences
(Williams, 1984).

Front 76

How do you make a rectosigmoid bladder?

Back 76

Front 77

What does the word MAINZ in MAINZ I and MAINZ II mean?

Back 77

*Mainz means mixed augmentation of ileum and zecum which is what the MAINZ I pouch is.

The MAINZ II pouch is different and I am not quite sure why it is called a MAINZ pouch at all but it is a type of low pressure rectal resorvoir, called the sigma rectum pouch, that is fairly straightforward to create. So MAINZ I is with ileaum and cecum but not MAINZ II.

Front 78

Describe the surgical steps in a MAINZ pouch procedure?

Back 78

Front 79

What is LaPlace's Law?

Back 79

That the pressure within something is directly proportinal to the wall tension and inversely proportional to the radius.

Front 80

What is hematuria dysuria syndrome?

Back 80

In the authors' experience and that of Nguyen and colleagues, the symptoms of the hematuria-dysuria syndrome do respond well to H2 blockers and hydrogen ion pump blockers. Bladder irrigation with baking soda may also be effective. It has been demonstrated that urine pH may decrease remarkably after meals following gastrocystoplasty (Bogaert et al, 1995). The signs and symptoms of the hematuria-dysuria syndrome are most likely secondary to acid irritation. Recent work has suggested that Helicobacter pylori may play a role in this complication as it may in acid complications in the native stomach (Celayir et al, 1999). Such problems can occur but are less frequent after antral cystoplasty where there is a smaller load of parietal cells (Ngan et al, 1993).

Acid in the urine may also cause external irritation. Leong first noted glanular excoriation after gastrocystoplasty in a patient with voiding symptoms (Ngan et al, 1993). Similar meatal irritation has been noted in other patients after gastrocystoplasty; most have had significant dysuria. Nguyen and associates (1993) noted skin excoriation in 8 of 57 patients after gastrocystoplasty; all 8 patients had some element of urinary incontinence. It is imperative to achieve reliable urinary continence in patients undergoing gastrocystoplasty because urine leakage may result in the exposure of the skin to gastric secretions and in gastric secretions that are poorly diluted and buffered.