Noncontinent Urinary Diversions Ileal Conduit

Ileal conduit urinary diversion is commonly employed and has few short-term complications. Initial isolated reports and clinical series describing laparoscopic ileal conduit urinary diversion took advantage of the fact that radical cystectomy specimens are often removed through laparotomy incisions, and therefore used open-assisted or mini-laparotomy techniques.

Kozminski and Partamian performed the first laparoscopic-assisted ileal conduit diversion in 1992. Their procedure did not include a cystectomy. A total of five port sites were used, one of which served as the stoma site. Both ureters were mobilized and transected laparoscopically, whereas isolation of the ileal segment, restoration of small bowel continuity, and bilateral ureteroileal anastomoses were all performed extracor-poreally by elevating a small loop of ileum through a port site. The stoma was fashioned last. Operative time was 6 hours and 20 minutes.

Sanchez de Badajoz et al. reported the first laparoscopic combined radical cystectomy and laparoscopic-assisted ileal conduit in 1995 in a 64-year-old woman with high-grade muscle invasive transitional cell carcinoma. Again, an open-assisted approach was used to create the ileal conduit; however, two trocar sites were used to externalize the bowel segment instead of one. The ileal loop was first extracted through an extended right-sided flank incision, where the ileal segment was isolated, bowel continuity was restored, and the ipsilateral ureteroileal anastomosis performed. The contents were then placed back into the peritoneal cavity and brought out a left-sided extended trocar incision for the second ureteroenteric anastomosis. The authors note that their technique requires less mobilized ureteral length, and maintains the ileal segment in a transverse lie. In 1994, the same group reported a case in which no cystectomy was performed for a patient with a solitary left kidney who had previously undergone a partial cystectomy and adjuvant radiotherapy. The single ureteroileal anastomosis was performed through a widened left-sided port site, which also served as the eventual stoma site. Operative time was four hours. Puppo and colleagues reported mini laparo-tomy at a single stoma site in another four patients following laparoscopically assisted transvaginal radical cystectomy in 1995. In 2002, Peterson and colleagues reported the first case of laparoscopic hand-assisted radical cystectomy with ileal conduit.

They employed four laparoscopic ports and one infraumbilical hand port. Following radical cystectomy, pneumoperitoneum was released and the hand port ring was left in place for skin retraction. The ileal loop was delivered though this incision, and a Wallace ureteroileal anastomosis was subsequently performed. In this particular case, a separate stoma site was created due to an impractical location of their existing right-sided 12-mm port site. Operative time was seven hours, blood loss was 750 mL.

Hemal et al. published their series of 10 patients who underwent laparoscopic radical cystectomy and ileal conduit reconstructed through an infraumbilical incision through which the specimen had been retrieved. A right-sided 12-mm port site was used for the stoma site. Mean operative time was 6.5 hours. They concluded that the extracorporeal reconstruction of the ileal conduit was advantageous in two respects: (1) decreased operative time, and (2) decreased cost, particularly in obviating the need for stapling devices to restore ileal continuity.

Currently, laparoscopic radical cystectomy, bilateral pelvic lymphadenectomy, and ileal conduit can be performed using a mini-lap technique with operative times comparable to open surgery.

Sorcini and Tuerk reported a case in which the operative time was less than five hours. The first two reports of complete intracorporeal techniques for ileal conduit diversion were in 2000 by Potter et al. (without cystectomy) as well as Gill et al. (following radical cystoprostatectomy).

Potter and colleagues performed laparoscopic ileal conduit without cystectomy as a treatment for neurogenic bladder in a 28-year-old man. Five port sites were used, and total operative time was 4.5 hours. With the ileal segment pulled out through the eventual stoma site, a Babcock clamp was negotiated down and through ileotomies, the ureters were pulled into the conduit, and a modified Bernstein anastomosis was performed. The patient had anastomotic edema in the short term, but long-term patency at five years.

Gill et al. reported the first two cases of completely intracorporeal laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion.

Gill et al. reported the first two cases of completely intracorporeal laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion.

This clinical report was elegantly substantiated first in a porcine model, where the technique was refined in 10 pigs. Preservation of renal function was preserved in surviving animals, and although six animals developed stomal stenosis at the skin, unique healing characteristics of porcine skin were postulated to account for this observation. In their subsequent clinical report in two men, operative times were 11.5 and 10 hours, and blood loss was 1200 and 1000 mL, respectively. A six-port transperitoneal approach was used. The most salient feature of Gill's technique involved initial creation of the stoma, which effectively anchors the external end of the ileal segment, greatly facilitating freehand intracorporeal suturing of the ureteroileal anastomosis. In addition, laparoscopic optical magnification afforded precise mucosa-to-mucosa approximation. Although operative times were lengthy, this important study demonstrated that this complex ablative and reconstructive urologic procedure was feasible laparoscopically. As expected, further experience shortened operative times, and unpublished data mentioned in an accompanying editorial comment suggested that subsequent cases were performed in less than eight hours, and as short as 6.5 hours in one patient.

This was performed in three patients, two with radiation cystitis and one with transitional cell carcinoma. Still early in the learning curve, the mean operative time was 11.5 hours. Mean blood loss was 250 mL. Similar to the technique described by Gill et al., the stoma was created first, and Bricker-type ureteroileal anastomoses were created using the DaVinci robot.

Two different colored 4-0 Vicryl holding sutures are placed at the distal ends of the ureters.

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