Urinary Diversion

Several minimally invasive surgical techniques have been developed to effectively provide urinary diversion for management of the refractory OAB when bladder and urethral function is compromised to the point that reconstruction or management options described above fail to provide a meaningful improvement in the patient's quality of life and impact on their condition. Although options that preserve the bladder and upper urinary tract with minimally invasive techniques that allow for urinary diversion in cases of evacuation disorders are covered in a later chapter, some consideration must be given to the merits of urinary diver-

Figure 7-3.3. Extracorporeal construction of a right colon reservoir using a reinforced ileocecal valve continence mechanism. (Reprinted with the permission of The Cleveland Clinic Foundation.)

sion with or without cystectomy as the ultimate solution for management of severe cases of refractory OAB conditions. These cases include both bladder hypersensitivity as well as hyperactivity disorders. Furthermore, the choice for cystectomy at the time of urinary diversion must be made on an individual case basis because the long-term risk of developing pyocystitis or bladder malignancy must be weighed against the short-term morbidities associated with this part of the extirpative procedure.

Although the appliance-dependent urinary ileostomy with or without cystectomy is still considered an acceptable practice for urinary diversion, the optimal urinary diversion should replicate bladder function as closely as possible. For this reason, the continent urinary diversions such as the Studer (orthotopic) or Indiana (nonorthotopic) reservoirs have evolved to a point of reliability and simplicity that allows one to consider these options as first-line diversion therapies for the majority of people with severe conditions of refractory OAB. Because they offer a significantly better quality of life, self-image, and sexual function, and have complication rates comparable to those of the standard ileal-conduit, we have been successfully developing laparoscopic approaches for achieving even better results with these forms of continent urinary diversion.

Currently, the Indiana pouch (a right colon reservoir using a reinforced ileocecal valve continence mechanism) offers the best documented outcomes for continence for a continent catheterizable urinary reservoir in a female requiring cystectomy with possible removal or damage to the bladder neck/urethral continence mechanism (Figure 7-3.3). A diversion reservoir such as a Studer pouch (small bowel reservoir without construction of a continence mechanism) can be anastomosed directly to a functional bladder neck/urethral continence mechanism. However, if the continence mechanism is damaged or the reservoir is anastomosed to the remnant urethral or native urethral meatal site, then an artificial sphincter or sling must be placed around the catheterizable bowel segment for continence formation; such techniques are extremely complex and are prone to complications.

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