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Urinary diversion and reconstruction following cystectomy

INTRODUCTION

Removal of the bladder (cystectomy) necessitates reconstruction of the lower urinary tract. Bladder cancer is the most common reason for cystectomy. However, the same principles apply to patients who undergo pelvic exenteration for other malignancies [1,2] or who require cystectomy for non-malignant conditions, such as birth defects, trauma, or neurologic disorders [3]. (See "Radical cystectomy and bladder-sparing treatments for urothelial (transitional cell) bladder cancer".)

Ureterosigmoidostomy was the first widely used surgical technique for urinary diversion, providing an effective diversion that relied upon the anal sphincter for continence. However, deterioration of renal function over time, metabolic complications, and the increased risk for the development of secondary malignancies limited its usefulness. Subsequent surgical advances in reconstructive techniques have led to major improvements in both functional outcomes and quality of life.

Here we will discuss the available reconstructive options after cystectomy, the criteria for selection of the most appropriate procedure, and the outcomes and complications associated with the different urinary diversions. The indications for and complications of cystectomy in patients with bladder cancer are discussed in detail elsewhere. (See "Radical cystectomy and bladder-sparing treatments for urothelial (transitional cell) bladder cancer".)

GENERAL PRINCIPLES

As a general principle, any segment of bowel can be used to form a urinary diversion. However, there are metabolic consequences associated with the utilization of each segment based upon the absorptive function of bowel (table 1) [4-20]. In addition, the length and location of bowel segment used can affect the patient's postoperative bowel function.

Ureterosigmoidostomy was the first widely used surgical approach for urinary diversion after cystectomy. With this technique, the ureters were implanted into the sigmoid colon and the anal sphincters were relied upon to provide continence. Approximately 50 years of experience with this approach defined a series of complications that guided subsequent surgical progress:

                          

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Literature review current through: Oct 2014. | This topic last updated: Jun 26, 2012.
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