@@ Line 4: / Line 4: @@
 === Stomach ===
+[[File:2560px-Regions of stomach.svg.png|alt=Regions of stomach.|thumb|450x450px|Regions of stomach. Source: [[commons:File:Regions_of_stomach.svg|Wikipedia]]]]
 * Vascular organ
 * '''Arterial blood supply'''
@@ Line 14: / Line 14: @@
 **# '''The splenic artery'''
 **#* '''Gives off the vasa brevia (short gastrics),''' which supply the fundus and cardia, '''and the left gastroepiploic artery'''.
-* '''When a wedge of fundus is used, it should not include a significant portion of the antrum and should never extend to the pylorus or all the way to the lesser curve of the stomach.'''
+* '''When a wedge of fundus is used, it should not include a significant portion of the antrum and should never extend to the pylorus or all the way to the lesser curve of the stomach.'''[[File:2560px-Stomach blood supply.svg.png|thumb|600x600px|Blood supply of stomach. Source: [[commons:File:Stomach_blood_supply.svg|Wikipedia]]]]
-* INSERT FIGURE
 * '''The right gastroepiploic artery meets with the left gastroepiploic artery; both supply collateral flow to the greater curve of the stomach.''' '''By use of the gastroepiploic vessels, a pedicle of stomach may be mobilized as far as the pelvis'''
-* INSERT FIGURE
 === Small bowel ===
@@ Line 40: / Line 38: @@
 *# '''Last 2 inches of the terminal ileum'''
 *# '''5 feet of small bowel beginning ≈6 feet from the ligament of Treitz''' (also known as the suspensory ligament of the duodenum), a thin muscle connecting the junction between the duodenum, jejunum, and duodenojejunal flexure to connective tissue surrounding the superior mesenteric artery and celiac artery
-* INSERT FIGURE
+[[File:Gray 1913 1285.png|alt=Ligament of Treitz|none|thumb|600x600px|Ligament of Treitz. Source: [[commons:File:Gray_1913_1285.png|Wikipedia]]]]
 === Colon ===
@@ Line 70: / Line 68: @@
 ** INSERT FIGURE
-== Bowel preparation ==
+== Bowel Preparation ==
+=== Normal bowel bacterial flora ===
+*Consists of:
+** Aerobic organisms
+*** Most common: Escherichia coli and Enterococcus faecalis
+** Anaerobic organisms
+*** Most common: Bacteroides and Clostridium
+* Bacterial concentration ranges from
+**10-10e5 organisms per gram of fecal content in the jejunum
+**10e5-10e7 in the distal ileum
+**10e6-10e8 in the ascending colon
+**10e10-10e12 in the descending colon
+=== Rationale for Bowel Preparation ===
+*Solid feces may place strain on the anastomosis in the early phase of healing and result in ischemia with subsequent perforation
+*In experimental animals, an anastomosis with vascular compromise at the anastomotic line, which would normally result in perforation, heals if the bowel has been properly prepared with antibiotics
+*Infectious complications after radical cystectomy that are a direct result of fecal contamination include
+**Peritonitis
+**Intra-abdominal abscesses
+**Wound dehiscence
+**Anastomotic dehiscence
+**Systemic sepsis
+=== Classification (2) ===
+*'''Mechanical vs. antibiotic'''
+==== Mechanical (whole-gut irrigation) ====
+* '''<span style="color:#ff0000">Reduces the amount of feces/total number of bacteria but not their concentration'''
+* '''Can be done with polyethylene glycol (PEG)–electrolyte solution'''
+===== Efficacy =====
+*'''<span style="color:#ff00ff">2011 Cochrane review: Mechanical bowel preparation for elective colorectal surgery'''
+** '''18 trials with 5,805 participants were analyzed'''
+** '''No difference in anastomotic leakage or wound infection rates; important to note that many of these studies involved peri-operative intravenous antibiotics and likely crucial in keeping the complication rate low'''
+** '''[https://pubmed.ncbi.nlm.nih.gov/21901677/ Güenaga, Katia F., Delcio Matos, and Peer Wille‐Jørgensen."Mechanical bowel preparation for elective colorectal surgery." Cochrane Database of Systematic Reviews 9 (2011)]'''
+* '''No studies have adequately assessed the safety of omitting mechanical bowel preparation in urologic reconstructive surgery'''
+===== Contraindications (5): =====
+# '''Obstructed bowel'''
+# '''Unstable cardiovascular system'''
+# '''Congestive heart failure'''
+# '''Cirrhosis'''
+# '''Severe CKD'''
+===== Adverse Events =====
+*'''Hypokalemia'''
+**'''Vigorous bowel cleansing, even with Go-Lytely or other electrolyte solutions, will often result in low potassium.'''
+*** '''Characteristic signs include muscular weakness with poor respiratory effort causing decreased ventilation in the presence of a normal chest x-ray.'''
+*'''Diarrhea'''
+==== Antibiotic ====
+* '''<span style="color:#ff0000">Reduces the bacterial concentration'''
+* '''<span style="color:#ff0000">PERIoperative IV antibiotics appear to be the most important means of preventing infectious complications of intestinal surgery.'''
+**'''Systemic antibiotics must be given before the operative event if they are to be effective.'''
+***A randomized trial in elective colorectal surgery found that PREoperative antibiotics did not reduce the risk of clinical infections[https://www.ncbi.nlm.nih.gov/pubmed/17443852 §]
+** '''If perioperative antibiotics are given, they should be effective against anaerobes because it is complications from these organisms against which perioperative antibiotics appear to be particularly effective.'''
-* '''The bacterial flora in the bowel consists of:'''
+===== Adverse Events =====
-** '''Aerobic organisms'''
+*'''Diarrhea'''
-*** '''Most common: Escherichia coli and Enterococcus faecalis'''
+*'''Pseudomembranous enterocolitis'''
-** '''Anaerobic organisms'''
+** '''Treatment involves the administration of vancomycin or metronidazole and discontinuance of other antibiotics that the patient is receiving'''
-*** '''Most common: Bacteroides and Clostridium'''
-* '''The bacterial concentration ranges from 10-10e5 organisms per gram of fecal content in the jejunum, 10e5-10e7 in the distal ileum, 10e6-10e8 in the ascending colon, and 10e10-10e12 in the descending colon'''
-* Infectious complications after radical cystectomy that are a direct result of fecal contamination include peritonitis, intra-abdominal abscesses, wound dehiscence, anastomotic dehiscence, and systemic sepsis
-* '''Two types of bowel preparation: mechanical vs. antibiotic'''
-** '''Mechanical'''
-*** '''Reduces the amount of feces/total number of bacteria but not their concentration'''
-**** '''Solid feces may place strain on the anastomosis in the early phase of healing and result in ischemia with subsequent perforation'''
-*** '''Whole-gut irrigation can be done with polyethylene glycol (PEG)–electrolyte solution'''
-*** '''Vigorous bowel cleansing, even with Go-Lytely or other electrolyte solutions, will often result in low potassium.'''
-**** '''The characteristic signs include muscular weakness with poor respiratory effort causing decreased ventilation in the presence of a normal chest x-ray.[SASP 2014]'''
-*** '''Contraindications to whole-gut irrigation (5):'''
-***# '''Obstructed bowel'''
-***# '''Unstable cardiovascular system'''
-***# '''CHF'''
-***# '''Cirrhosis'''
-***# '''Severe CKD'''
-*** '''2011 Cochrane review: Mechanical bowel preparation for elective colorectal surgery'''
-**** '''18 trials with 5,805 participants were analyzed'''
-**** '''No difference in anastamotic leakage or wound infection rates; important to note that many of these studies involved peri-operative intravenous antibiotics and likely crucial in keeping the complication rate low'''
-**** '''Güenaga, Katia F., Delcio Matos, and Peer Wille‐Jørgensen."Mechanical bowel preparation for elective colorectal surgery." Cochrane Database of Systematic Reviews 9 (2011).'''
-*** '''No studies have adequately assessed the safety of omitting mechanical bowel preparation in urologic reconstructive surgery'''
-** '''Antibiotic'''
-*** '''Reduces the bacterial concentration'''
-*** '''In experimental animals, an anastomosis with vascular compromise at the anastomotic line, which would normally result in perforation, heals if the bowel has been properly prepared with antibiotics'''
-*** '''A randomized trial in elective colorectal surgery found that PREoperative antibiotics did not reduce the risk of clinical infections§'''
-*** '''PERIoperative IV antibiotics appear to be the most important means of preventing infectious complications of intestinal surgery. Systemic antibiotics must be given before the operative event if they are to be effective.'''
-*** '''If perioperative antibiotics are given, they should be effective against anaerobes because it is complications from these organisms against which perioperative antibiotics appear to be particularly effective.'''
-* '''Bowel preparations may result in diarrhea and pseudomembranous enterocolitis. Treatment involves the administration of vancomycin or metronidazole and discontinuance of other antibiotics that the patient is receiving.'''
+== Indications for Urinary Diversion after Cystectomy ==
+# Diseased bladder
+# Dysfunctional bladders that result in persistent bleeding
+# Obstructed ureters
+# Poor compliance with upper tract deterioration
+# Inadequate storage with total urinary incontinence
+# Before transplantation in a patient who has a bladder that cannot adequately receive the transplant ureter
 == Selecting the segment of intestine ==
-* The indications for a conduit are the need for urinary diversion after a cystectomy due to:
+* '''Intestinal segments used most often for urinary tract reconstruction (2):'''
-** Diseased bladder
+*#'''Ileum'''
-** Dysfunctional bladders that result in persistent bleeding
+*#'''Colon'''
-** Obstructed ureters
+*#* '''Jejunum is usually not used for reconstruction of the urinary system because it may result in severe electrolyte imbalance'''
-** Poor compliance with upper tract deterioration
+*#** Although the same electrolyte abnormalities are possible with either ileum or colon, nutritional problems (Vitamin B12 deficiency and bile acid salt absorption) are less with colon when compared to ileum as long as the ileocecal valve is left intact
-** Inadequate storage with total urinary incontinence
-** Before transplantation in a patient who has a bladder that cannot adequately receive the transplant ureter
+=== Ileal Conduit ===
-* '''The ileum and colon are used most often for urinary tract reconstruction'''
+* Simplest type of conduit diversion to perform; fewest intraoperative and immediate postoperative complications
-** '''The jejunum is usually not used for reconstruction of the urinary system because it may result in severe electrolyte imbalance'''
-** '''Although the same electrolyte abnormalities are possible with either ileum or colon, nutritional problems (Vitamin B12 deficiency and bile acid salt absorption) are less with colon when compared to ileum as long as the ileocecal valve is left intact'''
+==== Contraindications (3): ====
-* '''Ileal conduit'''
+# '''Short bowel syndrome'''
-** Simplest type of conduit diversion to perform; fewest intraoperative and immediate postoperative complications
+# '''Inflammatory small bowel disease'''
-** '''Contraindications to use ileum for diversion(3):'''
+# '''History of extensive pelvic irradiation''' where the ileum may have been affected
-**# '''Short bowel syndrome'''
-**# '''Inflammatory small bowel disease'''
+==== Summary of steps ====
-**# '''History of extensive pelvic irradiation''' where the ileum may have been affected
+* '''A segment 10-15 cm in length is selected 10-15 cm from the ileocecal valve'''. The cecum and ileal appendage (i.e., that portion of the distal ileum fixed to the retroperitoneum) are mobilized. The ileal mesentery is transilluminated, and a major arcade to the segment selected identified. With a mosquito clamp, the mesentery immediately beneath the bowel is penetrated, and the bowel is encircled with a vessel loop. An area at the base of the mesentery that is to one side of the feeding vessel is selected, and a second vessel loop is placed through the mesentery. At this juncture, the peritoneum overlying both sides of the mesentery is incised from bowel vessel loop to the base of mesentery vessel loop. With mosquito clamps, the tissue is clamped, severed, and tied with 4-0 silk. A portion of mesentery 2 cm in length is cleaned away from the bowel beneath the mesenteric incision. This procedure is repeated at the other end of the selected segment. The base of the mesentery should be as wide as possible and the mesenteric windows not excessive (in general about 5 cm in length) to prevent ischemia of the segment. Allen clamps are placed across the bowel in an angled fashion such that the antimesenteric portion is shorter than the mesenteric portion. (Some prefer to transect the bowel with an anastomotic stapler.) Thus a triangular piece of bowel is removed and discarded.
-** '''Summary of steps'''
+* The isolated ileal segment is placed caudad, and an ileoileostomy is performed as described earlier. The mesenteric window of the ileoileostomy is closed with interrupted 3-0 silk sutures. The isolated segment is then flushed with copious amounts of saline until the irrigant is clear, at which point the ureters are brought out the retroperitoneum in the right lower quadrant. To accomplish this, the left ureter must be brought over the great vessels and posterior to the sigmoid mesentery to the rent in the posterior peritoneum. This may be done by mobilizing the cecum cephalad to identify the right ureter. The left ureter may be identified by incising the line of Toldt of the left descending colon (Fig. 97-35). This dissection allows anastomosis of the ileal segment as proximally as needed to the ureter. Indeed, the ileum may be anastomosed directly to the renal pelvis on both sides if necessary (see Fig. 97-35C). After a cystectomy, the ureters are identified caudad to the iliac vessels and may be conveniently traced cephalad similar to the previous description. The ureteroileal anastomoses are performed as described previously. These anastomoses are stented
-*** '''A segment 10-15 cm in length is selected 10-15 cm from the ileocecal valve'''. The cecum and ileal appendage (i.e., that portion of the distal ileum fixed to the retroperitoneum) are mobilized. The ileal mesentery is transilluminated, and a major arcade to the segment selected identified. With a mosquito clamp, the mesentery immediately beneath the bowel is penetrated, and the bowel is encircled with a vessel loop. An area at the base of the mesentery that is to one side of the feeding vessel is selected, and a second vessel loop is placed through the mesentery. At this juncture, the peritoneum overlying both sides of the mesentery is incised from bowel vessel loop to the base of mesentery vessel loop. With mosquito clamps, the tissue is clamped, severed, and tied with 4-0 silk. A portion of mesentery 2 cm in length is cleaned away from the bowel beneath the mesenteric incision. This procedure is repeated at the other end of the selected segment. The base of the mesentery should be as wide as possible and the mesenteric windows not excessive (in general about 5 cm in length) to prevent ischemia of the segment. Allen clamps are placed across the bowel in an angled fashion such that the antimesenteric portion is shorter than the mesenteric portion. (Some prefer to transect the bowel with an anastomotic stapler.) Thus a triangular piece of bowel is removed and discarded.
+* The base of the conduit is fixed to the retroperitoneum in the right lower quadrant by suturing the posterior peritoneum to the conduit, thus effectively retroperitonealizing the ureterointestinal anastomosis.
-*** The isolated ileal segment is placed caudad, and an ileoileostomy is performed as described earlier. The mesenteric window of the ileoileostomy is closed with interrupted 3-0 silk sutures. The isolated segment is then flushed with copious amounts of saline until the irrigant is clear, at which point the ureters are brought out the retroperitoneum in the right lower quadrant. To accomplish this, the left ureter must be brought over the great vessels and posterior to the sigmoid mesentery to the rent in the posterior peritoneum. This may be done by mobilizing the cecum cephalad to identify the right ureter. The left ureter may be identified by incising the line of Toldt of the left descending colon (Fig. 97-35). This dissection allows anastomosis of the ileal segment as proximally as needed to the ureter. Indeed, the ileum may be anastomosed directly to the renal pelvis on both sides if necessary (see Fig. 97-35C). After a cystectomy, the ureters are identified caudad to the iliac vessels and may be conveniently traced cephalad similar to the previous description. The ureteroileal anastomoses are performed as described previously. These anastomoses are stented
-*** The base of the conduit is fixed to the retroperitoneum in the right lower quadrant by suturing the posterior peritoneum to the conduit, thus effectively retroperitonealizing the ureterointestinal anastomosis.
+=== Colon Conduit ===
-* '''Colon conduit'''
+* '''Commonly used colon conduits: transverse, sigmoid, and ileocecal'''
-** '''Commonly used colon conduits: transverse, sigmoid, and ileocecal'''
-*** '''Transverse colon'''
+==== Transverse colon ====
-**** '''Used in patients with prior extensive pelvic irradiation or when an intestinal pyelostomy needs to be performed.'''
+* '''Used in patients with prior extensive pelvic irradiation or when an intestinal pyelostomy needs to be performed.'''
-*** '''Sigmoid conduit'''
-**** '''Good choice in patients undergoing a pelvic exenteration who will have a colostomy since no bowel anastomosis needs to be made.'''
+==== Sigmoid conduit ====
-**** '''Contraindications:'''
+* '''Good choice in patients undergoing a pelvic exenteration who will have a colostomy since no bowel anastomosis needs to be made.'''
-***** '''When the internal iliac artery has been ligated and the rectum has been left in situ'''
+* '''Contraindications:'''
-***** '''Extensive pelvic irradiation'''
+** '''When the internal iliac artery has been ligated and the rectum has been left in situ'''
-*** '''Ileocecal conduit'''
+** '''Extensive pelvic irradiation'''
-**** '''Advantages:'''
-***** '''Provides a long segment of ileum when long segments of ureter need replacement'''
+==== Ileocecal conduit ====
-***** '''Provides colon for the stoma'''
+* '''Advantages:'''
-** '''Contraindications to the use of transverse, sigmoid, and ileocecal conduits:'''
+** '''Provides a long segment of ileum when long segments of ureter need replacement'''
-**# '''Presence of inflammatory large bowel disease'''
+** '''Provides colon for the stoma'''
-**# '''Disease of segement being considered'''
-**# '''Severe chronic diarrhea'''
+==== Contraindications (3): ====
-* '''Jejunal conduit'''
+# '''Presence of inflammatory large bowel disease'''
-** '''Advantages'''
+# '''Disease of segement being considered'''
-*** '''Avoids irradiated bowel and ureter'''
+# '''Severe chronic diarrhea'''
-** '''Disadvantage:'''
-*** '''May result in severe electrolyte imbalance'''
+=== Jejunal Conduit ===
-**** '''Rarely used except when neither colon or ileum can be used'''
+* '''Advantages'''
-* '''Stomach conduit'''
+** '''Avoids irradiated bowel and ureter'''
-** '''Rarely indicated; may be considered when the use of other intestinal segments in a patient with a decreased amount of intestine would result in serious nutritional problems'''
+* '''Disadvantage:'''
-** '''Advantages (5):'''
+** '''May result in severe electrolyte imbalance'''
-**# '''Electrolyte imbalances rarely occur in patients with normal renal function, although a hypochloremic, hypokalemic, metabolic alkalosis has been described'''
+*** '''Rarely used except when neither colon or ileum can be used'''
-**#* '''Less permeable to urinary solutes'''
-**#* '''Has a net excretion of chloride and hydrogen ions rather than a net absorption of them, effectively reversing the acidosis of renal insufficiency; may be preferred option in patients with pre-existing metabolic acidosis or renal dysfunction'''
+=== Stomach Conduit ===
-**# '''Not associated with malabsorption; may be preferred option in patients with short bowel syndrome'''
+* '''Rarely indicated; may be considered when the use of other intestinal segments in a patient with a decreased amount of intestine would result in serious nutritional problems'''
-**# '''Not usually in field of radiation, may be preferred option in patients with previous pelvic radiation'''
+* '''Advantages (5):'''
-**# '''Produces less mucus'''
+*# '''Electrolyte imbalances rarely occur in patients with normal renal function, although a hypochloremic, hypokalemic, metabolic alkalosis has been described'''
-**# '''Acidic pH reduces bacterial colonization'''
+*#* '''Less permeable to urinary solutes'''
-** '''Complications specific to stomach conduit'''
+*#* '''Has a net excretion of chloride and hydrogen ions rather than a net absorption of them, effectively reversing the acidosis of renal insufficiency; may be preferred option in patients with pre-existing metabolic acidosis or renal dysfunction'''
-*** '''Early:'''
+*# '''Not associated with malabsorption; may be preferred option in patients with short bowel syndrome'''
-**** '''Gastric retention'''
+*# '''Not usually in field of radiation, may be preferred option in patients with previous pelvic radiation'''
-***** '''Caused by atony of the stomach or edema of the anastomosis'''
+*# '''Produces less mucus'''
-**** '''Hemorrhage'''
+*# '''Acidic pH reduces bacterial colonization'''
-***** '''Most commonly originating from the anastomotic site'''
+* '''Complications specific to stomach conduit'''
-**** '''Hiccups'''
+** '''Early:'''
-***** '''Secondary to gastric distention'''
+*** '''Gastric retention'''
-**** '''Pancreatitis'''
+**** '''Caused by atony of the stomach or edema of the anastomosis'''
-***** '''As a consequence of intraoperative injury.'''
+*** '''Hemorrhage'''
-**** '''Gastroduodenal and gastroureteral leaks'''
+**** '''Most commonly originating from the anastomotic site'''
-***** '''Have been reported, occasionally resulting in a fatal outcome'''
+*** '''Hiccups'''
-*** '''Late:'''
+**** '''Secondary to gastric distention'''
-**** '''Dumping syndrome'''
+*** '''Pancreatitis'''
-**** '''Steatorrhea'''
+**** '''As a consequence of intraoperative injury.'''
-**** '''Small stomach syndrome'''
+*** '''Gastroduodenal and gastroureteral leaks'''
-**** '''Increased intestinal transit time'''
+**** '''Have been reported, occasionally resulting in a fatal outcome'''
-**** '''Bilious vomiting'''
+** '''Late:'''
-**** '''Afferent loop syndrome'''
+*** '''Dumping syndrome'''
-**** '''Hypoproteinemia'''
+*** '''Steatorrhea'''
-**** '''Hematuria-dysuria syndrome (from the excreted acid)'''
+*** '''Small stomach syndrome'''
-**** '''Severe metabolic alkalosis associated with respiratory distress'''
+*** '''Increased intestinal transit time'''
-***** '''The syndrome of severe metabolic alkalosis in patients who have had a gastrocystoplasty is most likely to occur in patients who have elevated gastrin levels'''
+*** '''Bilious vomiting'''
-**** '''Megaloblastic or iron deficiency anemia'''
+*** '''Afferent loop syndrome'''
-**** '''Severe ulcerative complications'''
+*** '''Hypoproteinemia'''
-***** '''Rare'''
+*** '''Hematuria-dysuria syndrome (from the excreted acid)'''
-***** '''Long-term histamine (H2) or proton-pump inhibition should be considered for these patients.'''
+*** '''Severe metabolic alkalosis associated with respiratory distress'''
-* '''Ileal vesicostomy'''
+**** '''The syndrome of severe metabolic alkalosis in patients who have had a gastrocystoplasty is most likely to occur in patients who have elevated gastrin levels'''
-** '''An ileal vesicostomy uses spatulated ileum and a generous transverse cystotomy to decompress the bladder and to allow an appliance to be used on the abdomen. This procedure is particularly well suited to spinal cord injury patients or those with significant neurologic disease. The concept is that patients with a neurogenic bladder have an easier job of caring for themselves with an abdominal stoma. Patients who are particularly good candidates are those with significant detrusor–external sphincter dyssynergia.'''
+*** '''Megaloblastic or iron deficiency anemia'''
+*** '''Severe ulcerative complications'''
+**** '''Rare'''
+**** '''Long-term histamine (H2) or proton-pump inhibition should be considered for these patients.'''
-== Intestinal anastomoses ==
+=== Ileal vesicostomy ===
+* Uses spatulated ileum and a generous transverse cystotomy to decompress the bladder and to allow an appliance to be used on the abdomen.
+*Particularly well suited to spinal cord injury patients or those with significant neurologic disease.
+**Patients who are particularly good candidates are those with significant detrusor–external sphincter dyssynergia.
+*Concept is that patients with a neurogenic bladder have an easier job of caring for themselves with an abdominal stoma.
+== Intestinal Anastomoses ==
 * '''Principles of intestinal anastomoses (6):'''
@@ Line 234: / Line 277: @@
 ***# '''Drains placed on an intra-abdominal anastomosis'''
 ***# '''Anastomosis performed in irradiated bowel'''
-***** '''Prior radiation significantly increases the likelihood of serious complications after radical cystectomy'''
+***#* '''Prior radiation significantly increases the likelihood of serious complications after radical cystectomy'''
 *** '''Complications of bowel anastamosis:'''
 ***# '''Leakage of fecal contents'''
@@ Line 261: / Line 304: @@
 ***** Enlargement and elongation of the intestine may also result in a volvulus of the segment
-== Abdominal stoma ==
+== Abdominal Stoma ==
 * '''Two types of stomas may be made on the anterior abdominal wall:''' '''flush with the skin and those that protrude.'''
@@ Line 294: / Line 337: @@
 **# '''Obstruction'''
-== Ureterointestinal anastomoses ==
+== Ureterointestinal Anastomoses ==
 * '''The ureter may be anastomosed to the small bowel or colon or in a refluxing or non-refluxing anastomosis. There is controversy as to whether there is a benefit for either approach'''
-* '''Methods of ureterocolonic anastomoses''' [Further details in Campbell’s]
+* '''Methods of ureterocolonic anastomoses'''
 *# Leadbetter-Clarke technique
 *# Strickler technique
@@ Line 371: / Line 414: @@
 == Complications of urinary intestinal diversion ==
-* '''3 categories: metabolic, neuromechanical, and technical-surgical'''
+* See [https://www.youtube.com/watch?v=udIoQKwmcfQ&pp=ygUNdXJvbG9neSBib2FyZA%3D%3D Video Review] (Dr. John Phillips)
+*'''3 categories: metabolic, neuromechanical, and technical-surgical'''
 ** '''Metabolic complications result from altered solute reabsorption by the intestine of the urine that it contains'''
 ** '''Neuromechanical aspects involve the configuration of the gut, which affects storage volume and contraction of the intestine that may lead to difficulties in storage.'''
 ** '''Technical-surgical complications involve aspects of the procedure that result in surgical morbidity'''
-* '''Metabolic complications include (9): LSD ORGASMIC'''
-** '''Lytes'''
+=== Metabolic ===
-*** '''Factors that influence the amount of solute and type of absorption are:'''
+*'''<span style="color:#0000ff">LSD ORGASMIC (9):</span>'''
-***# '''Segment of bowel used'''
-***# '''Surface area of the bowel'''
+==== <span style="color:#0000ff">L</span><span style="color:#ff0000">ytes ====
-***# '''Amount of time the urine is exposed to the bowel'''
+* '''Factors that influence the amount of solute and type of absorption are:'''
-***# '''Concentration of solutes in the urine'''
+*# '''Segment of bowel used'''
-***# '''Renal function'''
+*# '''Surface area of the bowel'''
-***# '''pH of the fluid'''
+*# '''Amount of time the urine is exposed to the bowel'''
+*# '''Concentration of solutes in the urine'''
+*# '''Renal function'''
+*# '''pH of the fluid'''
 INSERT TABLE
-*** '''Stomach conduit'''
+*'''Stomach conduit'''
-**** '''Electrolyte imbalances rarely occur in patients with normal renal function. However, hypochloremic, hypokalemic metabolic alkalosis''' '''can occur in patients with concomitant renal failure.'''
+** '''Electrolyte imbalances rarely occur in patients with normal renal function. However, hypochloremic, hypokalemic metabolic alkalosis''' '''can occur in patients with concomitant renal failure.'''
-***** Symptoms of this include lethargy, respiratory insufficiency, seizures, and ventricular arrhythmias may occur.
+*** Symptoms of this include lethargy, respiratory insufficiency, seizures, and ventricular arrhythmias may occur.
-***** '''Patients are usually successfully treated with an H2 blocker to reduce proton secretion by the gastric segment and rehydration.'''
+*** '''Patients are usually successfully treated with an H2 blocker to reduce proton secretion by the gastric segment and rehydration.'''
-*** '''Jejunal conduit'''
+* '''Jejunal conduit'''
-**** '''Hypochloremic, hyperkalemic, hyponatremic metabolic acidosis can occur.'''
+** '''Hypochloremic, hyperkalemic, hyponatremic metabolic acidosis can occur.'''
-***** Symptoms of this include lethargy, nausea, vomiting, dehydration, muscle weakness, and elevated temperature.
+*** Symptoms of this include lethargy, nausea, vomiting, dehydration, muscle weakness, and elevated temperature.
-***** '''May be exacerbated by administration of hyperalimentation solutions'''.
+*** '''May be exacerbated by administration of hyperalimentation solutions'''.
-***** The severity of the syndrome depends on the location of the segment of jejunum that is used. The more proximal the segment, the more likely the syndrome is to develop.
+*** The severity of the syndrome depends on the location of the segment of jejunum that is used. The more proximal the segment, the more likely the syndrome is to develop.
-***** '''Treatment is rehydration with sodium chloride and correction of the acidosis with sodium bicarbonate'''.
+*** '''Treatment is rehydration with sodium chloride and correction of the acidosis with sodium bicarbonate'''.
-****** Provided that renal function is normal, the hyperkalemia is corrected by renal secretion.
+**** Provided that renal function is normal, the hyperkalemia is corrected by renal secretion.
-****** '''A thiazide diuretic may be helpful to correct the hyperkalemia''' '''(recall side effects of thiazides: 3 hypers and 3 hypos: hyperglycemia, hyperlipidemia, and hyperuricemia with hypokalemia, hypocitraturia, and hypomagnesuria with metabolic alkalosis).'''
+**** '''A thiazide diuretic may be helpful to correct the hyperkalemia''' '''(recall side effects of thiazides: 3 hypers and 3 hypos: hyperglycemia, hyperlipidemia, and hyperuricemia with hypokalemia, hypocitraturia, and hypomagnesuria with metabolic alkalosis).'''
-****** After restoration of normal electrolyte balance, long-term therapy involves oral supplements with sodium chloride and a thiazide diuretic, if needed.
+**** After restoration of normal electrolyte balance, long-term therapy involves oral supplements with sodium chloride and a thiazide diuretic, if needed.
-*** '''Ileum or colon conduit'''
+* '''Ileum or colon conduit'''
-**** '''Hyperchloremic metabolic acidosis can occur.'''
+** '''Hyperchloremic metabolic acidosis can occur.'''
-***** Symptoms of this include lethargy, easy fatigability, anorexia, weight loss, and polydipsia.
+*** Symptoms of this include lethargy, easy fatigability, anorexia, weight loss, and polydipsia.
-***** '''The mechanism of hyperchloremic metabolic acidosis is a result of the ionized transport of ammonium'''
+*** '''The mechanism of hyperchloremic metabolic acidosis is a result of the ionized transport of ammonium'''
-**** '''Treatment involves alkalizing agents or blockers of chloride transport.'''
+** '''Treatment involves alkalizing agents or blockers of chloride transport.'''
-***** '''≈16% of patients with ileal conduits will develop metabolic acidosis requiring treatment.'''
+*** '''≈16% of patients with ileal conduits will develop metabolic acidosis requiring treatment.'''
-***** '''Alkalinization with oral sodium bicarbonate is effective in restoring normal acid-base balance.'''
+*** '''Alkalinization with oral sodium bicarbonate is effective in restoring normal acid-base balance.'''
-***** '''Potassium citrate, sodium citrate, and citric acid solution (Polycitra) may be used instead if excessive sodium administration is a problem because of cardiac or renal disease and if potassium supplementation is desirable or at least not harmful.'''
+*** '''Potassium citrate, sodium citrate, and citric acid solution (Polycitra) may be used instead if excessive sodium administration is a problem because of cardiac or renal disease and if potassium supplementation is desirable or at least not harmful.'''
-*** '''Hypokalemia and total-body depletion of potassium may occur''' in patients with urinary intestinal diversion [though hyperkalemia with jejunal conduit].
+* '''Hypokalemia and total-body depletion of potassium may occur''' in patients with urinary intestinal diversion [though hyperkalemia with jejunal conduit].
-**** '''More common in patients with ureterosigmoidostomies'''
+** '''More common in patients with ureterosigmoidostomies'''
-**** '''In treating these patients, if the hypokalemia is associated with severe hyperchloremic metabolic acidosis, treatment must involve both replacement of potassium and correction of the acidosis with bicarbonate'''
+** '''In treating these patients, if the hypokalemia is associated with severe hyperchloremic metabolic acidosis, treatment must involve both replacement of potassium and correction of the acidosis with bicarbonate'''
-** '''Altered Sensorium'''
-*** '''May occur as a consequence of magnesium deficiency, drug intoxication, or abnormalities in ammonia metabolism'''
+==== <span style="color:#ff0000">Altered </span><span style="color:#0000ff">S</span><span style="color:#ff0000">ensorium ====
-*** '''Ammoniagenic coma in patients with urinary intestinal diversion is most commonly associated with decreased liver function.'''
+* '''May occur as a consequence of magnesium deficiency, drug intoxication, or abnormalities in ammonia metabolism'''
-**** '''Ammonium excreted by the kidneys is reabsorbed by the intestinal segment,''' and then returned to the liver via the portal circulation. The liver metabolizes ammonium to urea via the ornithine cycle.
+* '''Ammoniagenic coma in patients with urinary intestinal diversion is most commonly associated with decreased liver function.'''
-**** '''The liver usually adapts to the excess ammonia and rapidly metabolizes it; hepatic dysfunctionmay therefore result in ammoniagenic coma.'''
+** '''Ammonium excreted by the kidneys is reabsorbed by the intestinal segment,''' and then returned to the liver via the portal circulation. The liver metabolizes ammonium to urea via the ornithine cycle.
-***** Ammoniagenic coma can occur in patients with normal hepatic function.
+** '''The liver usually adapts to the excess ammonia and rapidly metabolizes it; hepatic dysfunctionmay therefore result in ammoniagenic coma.'''
-****** Systemic bacteremia, with endotoxin production, inhibits hepatic function and may precipitate this clinical entity. Urinary tract infections with urea-splitting organisms may also overload the ability of the liver to clear the ammonia.
+*** Ammoniagenic coma can occur in patients with normal hepatic function.
-****** If this syndrome occurs in a patient suspected of having near normal hepatic function, systemic bacteremia or urinary obstruction should be suspected.
+**** Systemic bacteremia, with endotoxin production, inhibits hepatic function and may precipitate this clinical entity. Urinary tract infections with urea-splitting organisms may also overload the ability of the liver to clear the ammonia.
-**** '''Prompt urinary drainage''' with treatment of the offending urinary pathogens along with systemic antibiotics '''and the administration of oral neomycin or lactulose to reduce absorption of ammonia in the gastrointestinal tract are the key components to patient management.'''
+**** If this syndrome occurs in a patient suspected of having near normal hepatic function, systemic bacteremia or urinary obstruction should be suspected.
-** '''Abnormal Drug metabolism'''
+** '''Prompt urinary drainage''' with treatment of the offending urinary pathogens along with systemic antibiotics '''and the administration of oral neomycin or lactulose to reduce absorption of ammonia in the gastrointestinal tract are the key components to patient management.'''
-*** '''Drug intoxication can occur in patients with urinary intestinal diversion. Drugs more likely to be problematic are those absorbed by the gastrointestinal tract and excreted unchanged by the kidney.''' Thus, the excreted drug is re-exposed to the intestinal segment, which then reabsorbs it, and toxic serum levels develop. '''This has been reported with phenytoin, methotrexate, lithium and theophylline.'''
-*** Patients receiving chemotherapy who have intestine interposed in the urinary tract have increased toxic effects of chemotherapeutic agents. '''Although chemotherapy is usually well tolerated by patients with conduits, toxicity has been documented in a patient with an ileal conduit.'''
+==== <span style="color:#ff0000">Abnormal </span><span style="color:#0000ff">D</span><span style="color:#ff0000">rug metabolism ====
-**** In patients with continent diversions who are receiving chemotherapy, consideration should be given to draining the pouch while the toxic drugs are being administered.
+* '''Drug intoxication can occur in patients with urinary intestinal diversion. Drugs more likely to be problematic are those absorbed by the gastrointestinal tract and excreted unchanged by the kidney.''' Thus, the excreted drug is re-exposed to the intestinal segment, which then reabsorbs it, and toxic serum levels develop. '''This has been reported with phenytoin, methotrexate, lithium and theophylline.'''
-** '''Osteomalacia'''
+* Patients receiving chemotherapy who have intestine interposed in the urinary tract have increased toxic effects of chemotherapeutic agents. '''Although chemotherapy is usually well tolerated by patients with conduits, toxicity has been documented in a patient with an ileal conduit.'''
-*** Osteomalacia or renal rickets occurs when mineralized bone is reduced and the osteoid component becomes excessive.
+** In patients with continent diversions who are receiving chemotherapy, consideration should be given to draining the pouch while the toxic drugs are being administered.
-*** Osteomalacia in urinary intestinal diversion may be caused by:
-**** Persistent acidosis
+==== <span style="color:#0000ff">O</span><span style="color:#ff0000">steomalacia ====
-**** Vitamin D resistance
+* Osteomalacia or renal rickets occurs when mineralized bone is reduced and the osteoid component becomes excessive.
-**** Excessive calcium loss by the kidney
+* Osteomalacia in urinary intestinal diversion may be caused by:
-*** Treatment involves correction of the acidosis and dietary supplementation of calcium
+** Persistent acidosis
-*** '''Patients who develop osteomalacia report lethargy, joint pain, especially in the weight-bearing joints, and proximal myopathy'''
+** Vitamin D resistance
-** '''Renal function deterioration'''
+** Excessive calcium loss by the kidney
-*** '''≈20% of patients experience significant and progressive renal function deterioration independent of the type of urinary diversion'''
+* Treatment involves correction of the acidosis and dietary supplementation of calcium
-**** '''Incidence for both sepsis and renal failure are greater in patients with ureterosigmoidostomy than in those with conduits'''
+* '''Patients who develop osteomalacia report lethargy, joint pain, especially in the weight-bearing joints, and proximal myopathy'''
-***** '''Most common cause of death in patients with ureterosigmoidostomy for > 15 years is acquired renal disease'''
-*** '''Renal function necessary for urinary intestinal diversion'''
+==== <span style="color:#0000ff">R</span><span style="color:#ff0000">enal function deterioration ====
-**** The amount of renal function required to effectively blunt the reabsorption of urinary solutes by the intestinal segment and to prevent serious metabolic side effects '''depends on the type of urinary intestinal diversion constructed (i.e., the amount of bowel to be used and the length of time the urine is exposed to the intestinal mucosa).'''
+* '''≈20% of patients experience significant and progressive renal function deterioration independent of the type of urinary diversion'''
-***** '''A greater degree of renal function is necessary for continent diversions than for short conduit diversions.'''
+** '''Incidence for both sepsis and renal failure are greater in patients with ureterosigmoidostomy than in those with conduits'''
-**** '''eGFR cut-off for continent diversion''' varies by source:
+*** '''Most common cause of death in patients with ureterosigmoidostomy for > 15 years is acquired renal disease'''
-***** Chapter 97: > 40ml/min
+* '''Renal function necessary for urinary intestinal diversion'''
-***** Chapter 99: >35 – 40 mL/min
+** The amount of renal function required to effectively blunt the reabsorption of urinary solutes by the intestinal segment and to prevent serious metabolic side effects '''depends on the type of urinary intestinal diversion constructed (i.e., the amount of bowel to be used and the length of time the urine is exposed to the intestinal mucosa).'''
-***** '''2019 AUA MIBC Guidelines: > 45 mL/min'''
+*** '''A greater degree of renal function is necessary for continent diversions than for short conduit diversions.'''
-****** '''A patient with serum creatinine > 2 mg/dL (177 µmol/L) may be considered for a continent diversion if:'''
+** '''eGFR cut-off for continent diversion''' varies by source:
-******# '''Able to achieve a urine ≤ pH of 5.8 after an ammonium chloride load'''
+*** Chapter 97: > 40ml/min
-******# '''Able to achieve urine osmolality ≥ 600 mOsm/kg in response to water deprivation'''
+*** Chapter 99: >35 – 40 mL/min
-******# '''GFR > 35 mL/min'''
+*** '''2019 AUA MIBC Guidelines: > 45 mL/min'''
-******# '''Minimal protein in the urine'''
+**** '''A patient with serum creatinine > 2 mg/dL (177 µmol/L) may be considered for a continent diversion if:'''
-*** '''Because urea and creatinine are reabsorbed by both the ileum and the colon, serum concentrations of urea and creatinine do not necessarily accurately reflect renal function'''
+****# '''Able to achieve a urine ≤ pH of 5.8 after an ammonium chloride load'''
-**** '''Fractional excretion of sodium most accurately measures renal function in a patient with a urinary diversion.'''
+****# '''Able to achieve urine osmolality ≥ 600 mOsm/kg in response to water deprivation'''
-** '''Growth retardation'''
+****# '''GFR > 35 mL/min'''
-*** Conduits have detrimental effect on linear growth and development. Patients are more susceptible to fractures and to complications after orthopedic procedures.
+****# '''Minimal protein in the urine'''
-** '''Acidosis/alkalosis'''
+* '''Because urea and creatinine are reabsorbed by both the ileum and the colon, serum concentrations of urea and creatinine do not necessarily accurately reflect renal function'''
-*** '''The ability to establish a hyperchloremic metabolic acidosis appears to be retained by most segments of ileum and colon over time.'''
+** '''Fractional excretion of sodium most accurately measures renal function in a patient with a urinary diversion.'''
-** '''Stones'''
-*** '''Risk factors for stone formation with urinary diversion'''
+==== <span style="color:#0000ff">G</span><span style="color:#ff0000">rowth retardation ====
-***# Persistent infection, associated with the development of '''magnesium ammonium phosphate stones.'''
+* Conduits have detrimental effect on linear growth and development. Patients are more susceptible to fractures and to complications after orthopedic procedures.
-***# Foreign body such as a staple or nonabsorbable suture, on which concretions form
-***# Alterations in bowel mucosa may also serve as a nidus for stone formation
+==== <span style="color:#0000ff">A</span><span style="color:#ff0000">cidosis/</span><span style="color:#0000ff">A</span><span style="color:#ff0000">lkalosis ====
-***# Alterations in intestinal mucus, particularly in the presence of infection or obstruction, may serve as a nidus or, more important, may interfere with emptying and thereby exacerbate infection and stone formation
+* '''The ability to establish a hyperchloremic metabolic acidosis appears to be retained by most segments of ileum and colon over time.'''
-** '''Malabsorption'''
-*** '''In patients with a significant loss of ileum, there can be malabsorption of'''
+==== <span style="color:#0000ff">S</span><span style="color:#ff0000">tones ====
-***# '''Vitamin B12 resulting in anemia and neurologic abnormalities'''
+* '''Risk factors for stone formation with urinary diversion'''
-***#* '''Since the liver stores enough vitamin B12 to supply the body’s requirement for 3-5 years without oral intake''', pathologic problems would not be expected to manifest themselves for many years
+*# Persistent infection, associated with the development of '''magnesium ammonium phosphate stones.'''
-***# '''Bile salts resulting in''' mucosal irritation and '''diarrhea''' because the ileum is the major site of bile salt reabsorption.
+*# Foreign body such as a staple or nonabsorbable suture, on which concretions form
-***#* '''There are 3 mechanisms of diarrhea in a patient with ileal conduit:'''
+*# Alterations in bowel mucosa may also serve as a nidus for stone formation
-***#*# '''Malabsorption of bile salts''' since the ileum is the major site of bile salt reabsorption
+*# Alterations in intestinal mucus, particularly in the presence of infection or obstruction, may serve as a nidus or, more important, may interfere with emptying and thereby exacerbate infection and stone formation
-***#*# '''Malabsorption of fat''' from loss of “ileal break" and small intestinal bacterial overgrowth from loss of ileocecal valve
-***#*## The ileal break is a mechanism whereby gut motility is reduced when lipids come in contact with the ileal mucosa so that increased absorption can occur. With the loss of ileum, the lipid does not result in decreased motility and is presented unmetabolized to the colon, which may cause '''fatty diarrhea.'''
+==== <span style="color:#0000ff">M</span><span style="color:#ff0000">alabsorption ====
-***#*# '''Loss of ileocecal valve'''
+* '''In patients with a significant loss of ileum, there can be malabsorption of'''
-***#*#* '''May result in reflux of large concentrations of bacteria into the ileum,''' resulting in small intestinal bacterial overgrowth which may cause nutritional abnormalities that involve '''interference with fatty acid reabsorption and bile salt interaction.'''
+*# '''Vitamin B12 resulting in anemia and neurologic abnormalities'''
-***#** '''With the lack of absorption of fats and bile salts, these are presented to the colon and result in diarrhea.'''
+*#* '''Since the liver stores enough vitamin B12 to supply the body’s requirement for 3-5 years without oral intake''', pathologic problems would not be expected to manifest themselves for many years
-*** '''Loss of a significant portion of jejunum may result in malabsorption of fat, calcium, and folic acid'''
+*# '''Bile salts resulting in''' mucosal irritation and '''diarrhea''' because the ileum is the major site of bile salt reabsorption.
-*** '''Loss of the colon may result in diarrhea because of lack of fluid and electrolyte absorption, loss of bicarbonate'''
+*#* '''There are 3 mechanisms of diarrhea in a patient with ileal conduit:'''
-** '''Infections'''
+*#*# '''Malabsorption of bile salts''' since the ileum is the major site of bile salt reabsorption
-*** An increased incidence of bacteriuria, bacteremia, and septic episodes occurs in patients with bowel interposition.
+*#*# '''Malabsorption of fat''' from loss of “ileal break" and small intestinal bacterial overgrowth from loss of ileocecal valve
-*** '''≈75% of ileal conduit urine specimens are infected.''' Many of these patients, however, show no untoward effects and seem to do well with chronic bacteriuria.
+*#*## The ileal break is a mechanism whereby gut motility is reduced when lipids come in contact with the ileal mucosa so that increased absorption can occur. With the loss of ileum, the lipid does not result in decreased motility and is presented unmetabolized to the colon, which may cause '''fatty diarrhea.'''
-**** Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas. '''Thus patients with relatively pure cultures of Proteus or Pseudomonas should be treated, whereas those with mixed cultures may, in general, be observed, provided they are not symptomatic.'''
+*#*# '''Loss of ileocecal valve'''
-*** '''Pouchitis'''
+*#*#* '''May result in reflux of large concentrations of bacteria into the ileum,''' resulting in small intestinal bacterial overgrowth which may cause nutritional abnormalities that involve '''interference with fatty acid reabsorption and bile salt interaction.'''
-**** '''Not uncommon, especially in the early postoperative period when mucous accumulation can be high.'''
+*#** '''With the lack of absorption of fats and bile salts, these are presented to the colon and result in diarrhea.'''
-**** '''A simple program of mechanical irrigation can decrease the incidence of infections, though asymptomatic colonization may not decrease'''
+* '''Loss of a significant portion of jejunum may result in malabsorption of fat, calcium, and folic acid'''
-*** '''Pyocystis'''
+* '''Loss of the colon may result in diarrhea because of lack of fluid and electrolyte absorption, loss of bicarbonate'''
-**** '''Ooccurs in ≈20% of patients who undergo supravesical diversion.'''
-**** '''Patients typically have a malodorous discharge and may develop sepsis.'''
+==== <span style="color:#0000ff">I</span><span style="color:#ff0000">nfections ====
-**** '''If conservative measures, such as routine bladder irrigations fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in women. This is an especially good alternative for an elderly or high risk patient. Cystectomy is an effective treatment for pyocystis and would likely be required if the patient was a male'''
+* An increased incidence of bacteriuria, bacteremia, and septic episodes occurs in patients with bowel interposition.
-** '''Cancer'''
+* '''≈75% of ileal conduit urine specimens are infected.''' Many of these patients, however, show no untoward effects and seem to do well with chronic bacteriuria.
-*** '''Bladder cancer after augmentation presents:'''
+** Deterioration of the upper tracts is more likely when the culture becomes dominant for Proteus or Pseudomonas. '''Thus patients with relatively pure cultures of Proteus or Pseudomonas should be treated, whereas those with mixed cultures may, in general, be observed, provided they are not symptomatic.'''
-**** '''At a younger age''' than is typical for bladder malignancies
+* '''Pouchitis'''
-**** '''With atypical symptoms''' such as vague abdominal pain, urosepsis or increased frequency of urinary tract infection (UTI), difficult catheterization, and renal failure.
+** '''Not uncommon, especially in the early postoperative period when mucous accumulation can be high.'''
-**** '''With atypical signs''' such as new hydronephrosis and bladder wall thickening.
+** '''A simple program of mechanical irrigation can decrease the incidence of infections, though asymptomatic colonization may not decrease'''
-**** '''Advanced disease'''
+* '''Pyocystis'''
-**** '''Usually with a minimum 10-year lag time between augmentation and presentation of bladder malignancy.'''
+** '''Ooccurs in ≈20% of patients who undergo supravesical diversion.'''
-**** '''Most of the tumors are adenocarcinomas,''' but can also be adenomatous polyps, sarcomas, and urothelial carcinoma
+** '''Patients typically have a malodorous discharge and may develop sepsis.'''
-*** The incidence of cancer development in patients with ureterosigmoidostomy varies between 6-29%, mean 11%. '''Because its incidence is significant in patients with ureterosigmoidostomies, they should have routine colonoscopies on a scheduled periodic basis.''' Case reports of tumors developing in patients with ileal conduits, colon conduits, bladder augmentations, rectal bladder, neobladders, and ileal ureters have been described. '''When ureterointestinal anastomoses are defunctionalized, there remains a risk of adenocarcinoma in the defunctionalized diversion. Therefore, they should be excised rather than merely ligated and left in situ'''
+** '''If conservative measures, such as routine bladder irrigations fail, vaginal vesicostomy (creation of a large vesico-vaginal fistula), is an effective method of preventing pyocystis in women. This is an especially good alternative for an elderly or high risk patient. Cystectomy is an effective treatment for pyocystis and would likely be required if the patient was a male'''
-* '''False-positive pregnancy test'''
-** '''Male and female patients with urinary diverison can have false positive urinary pregnancy tests,''' possibly due to the mucous produced§
+==== <span style="color:#0000ff">C</span><span style="color:#ff0000">ancer ====
-* Ruptured augmented bladder
+* '''Bladder cancer after augmentation presents:'''
-** Up to 50% of cystogram studies in cases of a ruptured augmented bladder may be negative for the injury; therefore, a negative cystogram does not rule out a bladder rupture.
+** '''At a younger age''' than is typical for bladder malignancies
-** Confirmation of suspected perforation of an augmented bladder is best achieved by performing a CT cystogram with a minimum of 300 ml of contrast placed in the bladder with a CT phase taken with the bladder distended and emptied.
+** '''With atypical symptoms''' such as vague abdominal pain, urosepsis or increased frequency of urinary tract infection (UTI), difficult catheterization, and renal failure.
+** '''With atypical signs''' such as new hydronephrosis and bladder wall thickening.
+** '''Advanced disease'''
+** '''Usually with a minimum 10-year lag time between augmentation and presentation of bladder malignancy.'''
+** '''Most of the tumors are adenocarcinomas,''' but can also be adenomatous polyps, sarcomas, and urothelial carcinoma
+* The incidence of cancer development in patients with ureterosigmoidostomy varies between 6-29%, mean 11%. '''Because its incidence is significant in patients with ureterosigmoidostomies, they should have routine colonoscopies on a scheduled periodic basis.''' Case reports of tumors developing in patients with ileal conduits, colon conduits, bladder augmentations, rectal bladder, neobladders, and ileal ureters have been described. '''When ureterointestinal anastomoses are defunctionalized, there remains a risk of adenocarcinoma in the defunctionalized diversion. Therefore, they should be excised rather than merely ligated and left in situ'''
+==== False-positive pregnancy test ====
+* '''Male and female patients with urinary diverison can have false positive urinary pregnancy tests,''' possibly due to the mucous produced§
+==== Ruptured augmented bladder ====
+* Up to 50% of cystogram studies in cases of a ruptured augmented bladder may be negative for the injury; therefore, a negative cystogram does not rule out a bladder rupture.
+* Confirmation of suspected perforation of an augmented bladder is best achieved by performing a CT cystogram with a minimum of 300 ml of contrast placed in the bladder with a CT phase taken with the bladder distended and emptied.
 == Neuromechanical Aspects of Intestinal Segments ==
 * '''2 aspects of neuromechanical properties are important to urinary intestinal diversion: volume-pressure relationships and motor activity:'''
-** '''Volume-pressure considerations'''
-*** '''By splitting most segments, the volume increases by ≈50%.''' The goal in reconfiguring the bowel is to achieve a spheric storage vessel. This configuration has the most volume for the least surface area.
+=== Volume-pressure considerations ===
-*** '''Over time, the volume capacity of segments increases'''. This occurs only if they are frequently filled. Their volume decreases with time if they are nonfunctional
+* '''By splitting most segments, the volume increases by ≈50%.''' The goal in reconfiguring the bowel is to achieve a spheric storage vessel. This configuration has the most volume for the least surface area.
-** '''Motor activity'''
+* '''Over time, the volume capacity of segments increases'''. This occurs only if they are frequently filled. Their volume decreases with time if they are nonfunctional
-*** It has been suggested that splitting the bowel on its antimesenteric border discoordinates motor activity and thereby causes a lesser intraluminal pressure. However, the literature is contradictory with respect to the effect of detubularization on segments of ileum and colon used to construct storage vessels for continent diversions.
-*** Thus, '''reconfiguring bowel usually increases the volume, but its long-term effect on motor activity and wall tension is unclear at this time'''. Some patients with orthotopic bladders after a number of years of spontaneous voiding require intermittent catheterization. In these patients the bowel segment has become flaccid, and the ability of the patient to generate intraluminal pressure by a Valsalva maneuver is limited.
+=== Motor activity ===
+* It has been suggested that splitting the bowel on its antimesenteric border discoordinates motor activity and thereby causes a lesser intraluminal pressure. However, the literature is contradictory with respect to the effect of detubularization on segments of ileum and colon used to construct storage vessels for continent diversions.
+* Thus, '''reconfiguring bowel usually increases the volume, but its long-term effect on motor activity and wall tension is unclear at this time'''. Some patients with orthotopic bladders after a number of years of spontaneous voiding require intermittent catheterization. In these patients the bowel segment has become flaccid, and the ability of the patient to generate intraluminal pressure by a Valsalva maneuver is limited.
 == Questions ==

Intestinal Segments and Urinary Diversion: Difference between revisions