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Bladder and Ureter

Insertion of Suprapubic Catheter

Retropubic Urethropexy:
and Burch Operations


and Ureteroneocystostomy
With Bladder Flap

End-to-Side Anastomosis

Intestinal Loop
Urinary Diversion



Clam Gastrocystoplasty

Intestinal Loop Urinary Diversion

There are several ways in which the urinary system can be diverted: nephrostomy, cutaneous ureterostomy, ureterosigmoidostomy, intestinal loop urinary diversion, and continent urostomy. Intestinal loop is a good procedure for diverting the urine in elderly patients or in patients without sufficient bowel to perform one of the continent urostomies. This procedure began as an ileal loop urinary diversion. The colon loop urinary diversion eliminates the need for a bowel resection in the terminal ileum. This is particularly important when the patient has had total pelvic irradiation. Hyperchloremic acidosis associated with implantation of the ureters into the intact sigmoid colon does not occur with colon loop urinary diversion because the average length of the colon loop, 8-10 cm, is too short for significant absorption of urine from the colonic mucosa.

The purpose of the intestinal loop urinary diversion is to divert the urine following removal of the bladder at the time of anterior or total exenteration or if the bladder and lower ureters have lost their neurologic function and a continent urostomy is contraindicated.

Physiologic Changes. The most significant physiologic change of an intestinal loop urinary diversion is the rapid runoff of urine from the isolated intestinal loop.

Because of this, the incidence of urinary tract infection is less than that encountered when the ureter is implanted into a functional segment of the rectosigmoid colon.

A negative change in intestinal loop diversion is the problem of contaminated reflux from the loop of the renal pelvis. This produces loss of upper renal units in 65% of patients.

Points of Caution. The ureters should be transected as low in the pelvis as possible. Excess ureter can be trimmed away if necessary. Silastic catheters should always be inserted up the ureter and through the intestinal loop to splint the anastomosis for 10-12 days. This alone has significantly reduced the incidence of ureteral stricture and separation from the intestinal anastomotic site.

Another point of caution concerns the design of the loop. In general, it should be selected from bowel that has had the least irradiation. The length should be long enough to reach the abdominal wall, usually 8-12 cm. Care should be taken to close mesenteric defects in the reanastomosed intestine and those between the loop and the abdominal side wall to prevent internal hernia.


The patient is placed in the supine position, and the abdomen is opened through a lower midline incision. Occasionally, extension of the incision around the umbilicus is required. The pelvis is thoroughly explored, and both ureters are identified and traced as deep in the pelvis as is technically possible.

The loop of bowel to be used, colon or ileum, is selected. Figure 2 shows the terminal ileum and the colon. The appropriate length of bowel is measured, selected, and marked. The mesentery of the bowel is carefully illuminated with bright light to delineate the vascular arcades. This confirms that the loop is adequately nourished by a generous blood supply from the vascular branches of the arcade. The mesentery of the loop is opened for approximately 4-5 cm, and the small vessels are clamped and tied. The loop can be transected in the classic way between Kocher clamps. Today, however, the automatic surgical stapler with TA-55 premium absorbable staples for the proximal end of the loop is often used. If wire or permanent suture is used in the proximal end of the loop, stone formation may occur.

As shown here, a GIA (gastrointestinal anastomosis) stapling and division device can be applied to the distal portion of the loop. A standard TA-55 wire staple can be applied to the proximal portion of the bowel, but a TA-55 premium absorbable staple is preferable for the proximal portion of the loop. If staples are not available, the proximal loop can be closed with synthetic absorbable suture.

After all of these staples are fired, the loop can be transected between the TA-55 wire staples and the TA-55 absorbable staples. A standard bowel anastomosis can be made between the proximal and distal ileum or proximal and distal colon as outlined in the technique in Figure 7-10.

The ureter is identified deep in the pelvis and mobilized, presevering the delicate ureteral sheath that surrounds the ureter from the renal pelvis to the bladder. After transecting the ureter, the distal stump is tied with 0 synthetic absorbable suture. The proximal ureter is catheterized with a Silastic "J" ureteral anastomosis catheter that contains either a suture sleeve or a suture rib.

If the ileal segment of bowel has been selected, the mesentery of the rectosigmoid colon must be opened to allow the left ureter to be transported through the mesentery to bring it into position for anastomosis to the ileum. If the sigmoid colon has been selected for the loop, this is not necessary, since the mesentery will already be open.

The intestinal segment has been cross-clamped with the GIA stapler, so that both proximal and distal ends of the segment are stapled closed. A small opening must be made in the distal segment of the loop to admit a narrow arterial forceps that is advanced down the segment of bowel to within 3 cm of the distal end. At that point, the arterial forceps is slightly elevated, and an incision is made over the tip of the arterial forceps until the intestine is entered. A small button of bowel wall measuring 1 x 1 cm in diameter may be removed. The forceps is advanced through this opening and grasps the Silastic catheter that is in the ureter. A 4-0 synthetic absorbable suture on two small needles has been previously placed through the Silastic suture sleeve or suture rib on the Silastic catheter.

If an ileal segment of bowel is to be used as seen in b, a defect has to be created in the mesentery of the sigmoid colon to allow the left ureter to be brought through that defect and into position for an anastomosis to the ileum. In b, the right ureter is seen in the approximate position for anastomosis.

This sagittal section of the intestinal segment illustrates the technique of suturing the Silastic catheter sleeve with a fine 4-0 synthetic absorbable suture to the wall of the intestine to hold the Silastic catheter in place and prevent peristalsis of the ureter from pushing the catheter into the loop and thus out of the ureter. This step is unnecessary if the stent has a "J" or "pigtail" configuration that prevents expulsion. The Silastic catheter should stay in the ureter, stenting the anastomosis, for at least 10-12 days. The sutures for the ureteral intestinal anastomosis are placed full thickness through the bowel wall and the ureter so that, when tied, a mucosa-to-mucosa anastomosis is performed.

The ureter is anastomosed to the intestinal wall with interrupted 4-0 synthetic absorbable sutures. Generally, 4-5 sutures are needed to complete the anastomosis. In addition, some periureteral peritoneum is anchored across the anastomosis to take tension off the suture line. The opposite ureter is sutured to the intestine in a similar manner.

The intestinal segments are lifted superior to the constructed loop, allowing an end-to-end functional anastomosis to be completed between the segments of bowel. If a segment of rectosigmoid colon is used, the intestinal loop is moved medially to allow an end-to-end colocolostomy.

Figure 7 shows the anastomosis being performed on the descending colon, but the technique of the stapler anastomosis is the same for both large and small bowel.

Both blades of the GIA stapler are passed into the colon along the antimesenteric border. The stapler is activated, and a V-shaped ostium is created along the antimesenteric border for a  distance of approximately 5 cm with a double row of staples on each side and an incision down the middle.

The edges of the remaining defect are picked up with Babcock clamps and brought through the activated TA-55 stapler. Any excess bowel is trimmed away with curved Mayo scissors.

The functional end-to-end anastomosis is completed. The mesentery is sutured with interrupted 3-0 synthetic absorbable sutures.

The distal portion of the intestinal urinary loop, with the ureters anastomosed in place, is pulled through the abdominal wall defect, which should be at least 2 fingersbreadth or 4 cm in diameter. The excess Silastic catheter is trimmed away.

The stoma is sutured to the skin of the abdominal wall with a rosebud stitch, as shown in the operation for end sigmoid colostomy (see Colon), which raises the stoma approximately 1 cm above the level of the skin and allows urine to drip off the stroma into its bag without contact with the skin. The mesentery of the intestinal segment must be carefully closed to the lateral pelvic wall to prevent internal hernia.

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