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A Continent Urostomy
AUGUST 1984, VOL 40, NO 2
A O R N JOURNAL
A Continent Urostornv A CASEHISTORY Sandra S LaFollette, RN
T
he search to improve the quality of life for some patients needing urinary diversion has led to the development of a continent urostomy. The procedure is based on Dr Nils G Kock’s surgically constructed intestinal reservoir for patients with chronic ulcerative colitis, familial polyposis, and certain neoplastic diseases. Just as the continent ileostomy is for selected patients, so is the continent urostomy. Patients who have had the standardureteroilealcutaneous urinary diversion can be converted to this continent urostomy, thus eliminating the need to wear an external appliance to collect their urine and the associatedchronic skin problems. The stoma is flush on the abdomen, and a gauze dressingcan be worn for protection. Patients catheterizethemselveseveryfour to six hours and need only carry a catheter with them.
Sandra S L&oh!eae, RN, BSN, is a private scrub nurse for Donald G Skinner, IUD, at Kenneth Norris Jr Cancer Hospital in Los Angeles. She received her BSN from the University of California, Los Angeles.
Mr S is a 58-year-old airline pilot who had experienced intermittent hematuria during the prior year that had been treated as an infection. During routine physical examination for the airline, he told the physician about his episodes of hematuria. The physician referred him to a urologist who suggested Mr S have an intravenous pyelogram (IVP) and a cystoscopy. The IVP showed a filling defect on the left bladder wall indicative of a bladder tumor. The cystoscopy, performed in the physician’s office, revealed two areas of obvious bladder cancer. Mr S was scheduled for admission to the hospital for cystoscopy and transurethral resection bladder tumor (TURBT). The bladder tumors were poorly differentiated muscle infiltrating transitional cell carcinoma (stage BI [superficial muscle invasion] or Bz [deep muscle invasion]). The urologist advised Mr S to undergo preoperative radiation followed by a radical cystectomy and ileal conduit. Mr S decided to accept preoperative radiation therapy and received 4500 rads to the bladder vicinity over five weeks. Later, Mr S came to see Donald G Skinner, MD, for a second opinion and to discuss his therapy options. Dr Skinner explained the various types of urinary diversions available. 0 A bilateral ureterosigmoidostomy-surgical implantation of a ureter into the sigmoid colon. 0 An ileal conduit-ureters transplanted into resected ileum that is brought through the abdominal wall and creates a stoma. 0 A continent urostomy via a Kock pouch207
AUGUST
AORN JOURNAL
an ileal conduit utilizing two nipple valves, one to maintain continence and one to prevent reflux. Because Mr S was young and highly motivated, in good physical condition, and had an active working life, he was considered a good candidate for a continent urostomy. Mr S was concerned that the airline medical department and the Federal Aviation Administration (FAA) might not allow him to return to work if he had an operation that was not on their approved list. A conversation between Dr Skinner and representatives from the FAA and the airline medical department led to approval for Mr S to return to his job after surgery. If he had not received approval to return to work, Mr S would have opted for the standard ureteroileocutaneous urinary diversion surgery. He was scheduled for a radical cystectomy with bilateral iliac lymph node dissection, creation of continent Kock ileal resevoir with bilateral ureteroileocutaneousurinary diversion, a p pendectomy, and insertion of gastrostomy tube.
Preoperative Care
P
reoperative care for a patient undergoing a continent urostomy procedureis similar to that of a standardureteroileocutaneous urinary diversion patient. Mr S was admitted to the hospital two days before surgery and received a regular diet until after breakfast the day before surgery when he was started on a liquid diet. The day before surgery he was started on a bowel preparation program to clean'se and decompress the bowel. The bowel prep consists of a palatable emulsion of castor oil, along with a total of 7 g of neomycin and 4 g of erythromycin orally at specific intervls throughout the day. No enema is required.2 Reoperative teaching is a team effort. The nurse encouraged Mr S to verbalize his concerns about surgery, and she reinfotced the teaching done by the surgeon, surgical resident, and anesthesiologist. The primary nurse assured him he would be given pain medicationso that he would not experience excessive discomfort postoperatively. He was taught the importanceof using the 208
1984. VOL 40.
NO 2
incentive spirometer and turning, coughing, deep breathing, and early ambulation. The enterostomal therapist visited him and marked the stoma site and answered questions about his stoma. The stoma is usually located just above the pubic hair line in the right lower quadrant, but can be below the bikini line in the young adult. Because fitting of an appliance is unnecessary, there is much flexibility in the location of the stoma. Scars from previous operations, bony protuberances, and skin irregularities no longer discount a preferable site.' On the morning of surgery, Mr S was given 75 mg meperidine hydrochloride (Demerol)and 25 mg hydroxyzine hydrochloride (Vistaril) by his primary nurse, as prescribed by the anesthesiologist. He was brought to the holding area where the circulating nurse did a quick preoperative assessment. She stayed with him and assisted the anesthesiologist in the placement of a catheter in the epidural space. This is used intraoperatively to administer 0.75% bupivacaine hydmchloride (Marcaine) as a muscle relaxing agent and again, postoperatively, to administer morphine to control pain. The catheter was positioned cephalad along his spine and secured with waterproof tape. He was transferred to the operating mom by the circulating nurse and anesthesiologist.
The Procedure
M
r S was placed in the supine position with his iliac crest directly over the break (kidney rest) in the bed so that he was in the correct position for the surgeon when the bed was hyperextended. The circulating nurse supported the area where the epidural catheter was placed to prevent dislodgement of the catheter. The circulating nurse helped the anesthesiologist insert the endotracheal tube, pass the nasogastrictube, start IVs, and connect the ECG monitor. In my hospital, hypotensive anesthesia is usually used, requiring an arterial line for accurate assessment of arterial blood pressure. Hypotensive anesthesia drops the systolic blood pressure to between 90 and 75 mm Hg and the
AUGUST 1984. VOL 40, NO 2
diastolic to approximately 50 mm Hg. This decrease in blood pressure results in less intraoperative bleeding. After the bladder is removed, hypotensive agents are stopped; the patient will be normotensive in a few hours. Different methods for obtaining hypotension include the use of drugs, such as sodium nitroprusside (Nipride) or trimethaphan camsylate (Arfonad), or use of a higher concentration of enflurane or isoflurane gases. The drugs decrease peripheral vascular resistance and lower the blood pressure. The increased concentration of the gases causes cardiac depression, resulting in decreased cardiac output and vasodilation; and thus, the hypotensive state. Instead of administering vasodilators or increasing the concentration of anesthetic gases, our anesthesiologists administer bupivacaine hydrochloride through the epidural catheter, which acts as a semicontrolled sympathectomy, blocking the motor and autonomic nerves to the muscles in the area, decreasing vascular tone, and resulting in a decrease in blood pressure. After Mr S was anesthetized, he was shaved from the nipples to mid-thigh, and a #16 catheter was placed in his bladder. He was then prepped and draped. An open heart sheet with seams of adhesive nylon tape was used for draping, allowing the appropriate exposure of the patient. The surgeon made a midline incision and exposed the peritoneum. A thoroughexploration of the abdominal contents was performed to detect evidence of metastases. Any suspicious nodule on the liver, bowel, mesentery, or other examined organs would be excised and sent to the pathology laboratory for a frozen section. Positive findings might result in changing the planned operation. The surgeon mobilized the sigmoid and elevated its mesentery off the sacral promontory so the left ureter could pass without obstruction for the subsequent left ureteroileal anastomosis. Two hemoclips were placed on each ureter and a portion of each ureter was sent to the pathology laboratory for frozen sections to verify an adequate margin of tumor-free ureter. A self-retaining retractor was placed, and the s m d bowel was packed into the epigastrium
AORN JOURNAL
Fig 1. Approximately 80 cm of ileum is demarcated:17-cm for efferent limb; two 22-cm segments for reservoir, and a 17-cm segment for afferent limb.
with lapamtomy sponges. A meticulous pelvic iliac lymph node dissection was done, and all lymphatic and fibrous tissue from the distal aorta, vena cava, and common iliac vessels was moved into the pelvis. The surgeon then dissected the distal limits including the lymph node of Cloquet, at the femoral canal. The surgeon developed lateral pedicles extending from the bladder to the hypogastric vessels along the side wall of the pelvis. The tissue and vessels in this were clipped and divided caudally to the endopelvic fascia. The peritoneum was then incised laterally and anterior to the rectum to allow the anterior mtal wall to be safely moved away from the fascia1 plane separating the bladder and prostate from me rectum. This delineatedthe posterior pedicleextending from the bladder posteriorly, which next was clippedand dividedcaudally.This left the bladder attached only by the distal urethra. A large clamp was placed across the urethra, the urethra divided distal to clamp, and the entire specimen was removed en bloc. A 0 chromic suture was used to approximatethe levatormusclesin the floor of the pelvis. The surgeonirrigated the pelvis with large amounts of warm, sterile, hyponic water and packed it with a lapamtomy sponge. He then focused on the development of the continent urinary reservoir.
dc 209
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Fig 2 . Creation of pouch begins with taking the 22 cm limbs and folding them together to form a U.The serosal layer of the two limbs is sewn together with a 3-0 absorbable s u m .
Fig. 3. The bowel is opened and the inner (mucosal) layer is approximated with two layers of
The packs were removed from the epigastrium, and a segment of terminal ileum was isolated for creation of the pouch. Approximately 80 cm was demarcated by measwing 17 cm for the efferent limb, two 22-cm segmentsneeded for the reservoir itself, and a 17-cmsegment for the afferentlimb(Fig1). Theefferentlimbiswhatwill laterformthestomaandthecontinentnipplevalve. The reservoir or pouch is where the urine will be stored, and the afferent limb constitutes the antireflux nipple and servesas the sitefortheureteral anastomosis. The surgeon then placed bowel clamps on the isolated segment and divided the ileum. The afferent limb was closed with a running 3-0 c h m i c suture and an interrupted outer layer of 4-0 silk sutures. A bowel anastomosis reestablished continuity to the gastrointestinaltract. The mesentery was closed with a 3-Ochromic suture. The pouch was formed by taking the two 22cm limbs and folding them together to form a U, with the apex of the U pointing caudally (Fig 2). The serosal layer of the two limbs were sewn together with a long continuous 3-0 absorbable suture. The bowel was then opened with an electrosurgical cautery close to the suture line, and
the inner mucosal layer was approximated with two layers of absorbable 3-0 sutures (Fig 3). Next the mesentery was incised, freeing it from the ileum, for approximately7 to 8 cm, proximal to the pouch, along the efferent and afferent limbs. This allowed intussusception of the bowel, thereby creating the nipple valves (Figs 4, 5, and 6).To keep the valves in place, they were stapled using four rows of staples. To further prevent slippage, a 2.5-cm-wide mesh gauze strip that had been soaking in an antibiotic solution was sewn around the afferent limb. A 2.5-cm-wide mesh gauze strip was also placed around the efferent limb to prevent slippage and to anchor the pouch to the fascia when creating the stoma. The pouch takes form by folding the middle portion to the opposite side and closing it with two layers of 3-0 absorbable sutures. The swgeon did the standard ureteroileal anastomosis and placed the ureters in a relaxed position at the afferent limb. To avoid leaks at the afferent nipple, both ureters were stented. The scrub nurse cut multipleeyelets in two At8 feeding tubes, and before the ureteroileal anastomosis was complete, one end of the feeding tube was passed up
212
absorbable 3-0sums.
AORN J O U R N A L
AUGUST 1984, VOL 40. NO 2
9
fimb4 Ileum
/
\ Mucosal
Mesentery Fig 4. The mesentery is incised, freeing it from the ileum, for approximately 7-8 cm, proximal to the pouch, along the efferent and afferent limbs. Mesh gauze is placed around both limbs.
the ureter and the other end down into the pouch. This procedure necessitates endoscopy of the pouch when the patient returns for followup. Using the plunger from a 20 cc syringe as a template, the surgeon excised skin from the stoma site marked by the enterostomal therapist and made a small opening in the subcutaneousfat of the anterior and posterior rectus fascia and rectus muscle. He then placed # 1 nylon sutures in the fascia and passed them through the stoma site where the mesh gauze collar is incorporated in the suture and brought back through the fascia to anchor the efferent limb to the abdominal wall (Figs 7 and 8). The stoma was completed using 3-0 absorbable sutures on a cutting needle and a size 30 French clear tube passed into the pouch. Then the tube was irrigated with normal saline and connected to a gravity drainage bag to maintain pouch decompressionand allow suture lines to heal. A 1-inch wound drain was placed in the pelvis, secured with a suture to the skin, and a stoma bag was applied to measure postoperative drainage. The end of the drain was tacked to the psoas muscle with a 3-0 chromic stitch to keep it from slipping into the urinary pouch. The lapamtomy pad pack in the pelvis was removed, and the area checked for bleeding, and again irrigated with a
Mucosal hyer Fig 5. Intussusception of the bowel is accomplished by using Allis clamps to create the nipple valves.
liter of hypotonic sterile warm water. The surgeon used a #22 Foley catheter with a 5 cc inflated balloon for a gastrostomy tube and closed the fascia with figure-of-eights, using #1 nonabsorbable suhues. The skin was closed using an automatic skin stapler. The incision was covered with gauze dressings, and petroleum jelly gauze was applied over the stoma. All drains and tubes were taped in place, and Mr S was covered with warm blankets and taken to the recovery room, intubated but breathing on his own. The procedure had taken approximatelysix hours, one and one-half hours longer than a standard ileal conduit. The circulating nurse and the anesthesiologist reported to the recovery mom nurse on the patient’s condition.
Postoperative Care
M
r S’s condition was stable upon arrival in the intensive care unit. There, nursing care included strict monitoring of intake and output, vital signs every two hours, administration of pain medication and antibiotics, and reminding Mr S to deep breathe frequently. Because there were no signs of postoperative bleeding, Mr S was transferred to a 213
AUGUST 1984. VOL 40. NO 2
AORN JOURNAL
Mesh gauze to be sewn around mt
1
Mesentery
1 Fig 6. To keep the valves in place. they are stapled, using four rows of staples.
Fig 7. Nylon sutures are placed in the fascia, passed through the stoma site where the mesh gauze collar is incorporated in the suture, and brought back through the fascia to anchor the effemt limb to the abdominal wall.
semi-privatemom the next day after the nasogastric tube was removed. Having that tube removed raised his spirits and reassured him that he was impving. The epidural catheter is also removed before the patient leaves the intensive cart unit. The administration of epidural morphine affoded Mr S a night of pain-free rest. The gastrostomy tube was attached to a gravity drainage bag and patency maintained with every six-hour normal saline irrigations. On the third postoperative day Mr S had bowel sounds indicating peristalsis had nturned.He was able to tolerate the tube clamped three hours out of every four, so on the fourth postopera~veday he was given a diet of liquids, which eventually progressed to soft solids. When he tolerated the gastric tube being clamped all day, it was removed. Mr S faithfully performed the coughing and deep breathing exercises and ambulated in the halls with the nurse's assistance. To maintain strict records of Mr S's intake and output, the nurse charted the output from the clear tube and wound drain separately. In this way if the output from the wound is greater than that from the clear tube, a leak in the pouch may be detected. If a leak is found, no additional medical intervention is requid; the leaks heal with time. At first the clear tube was irrigated by the
nurse. Eventually she taught Mr S how to do this himself by instilling 40 cc to 60 cc of normal saline slowly and allowing it to drain back into a basin. He practiced doing this several times so that the drain was kept free from mucus and clots. If the solution leaks around the tube or through the wound, it may indicate a blockage. As long as the irrigation procedure is done every two hours during the day and every three hours at night, the ileal pouch is kept decompressed and fne of mucus that collects in it. This prevents tension on the suture line of the newlycreated pouch. BecauseMr S would have tocontinuethe irrigation procedures at home, although not as frequently, the nurse taught him to gather all the necessary equipment, place it on the tank of the toilet, sit facing the tank,and irrigate the tube allowing the irrigant to return into the toilet. For the first week after surgery, the tube must be irrigated every two hours during the day and every three hours at night. The second week, every three hours during the day and every four hours at night is sufficient. After that, patients continue to increase the time between irrigations until they find a schedule that works best for them. Most patients, though, can eventually sleepthroughthe night andareableto sleepontheir stomachs. On the eighth postoperative day, Mr S was
Mucosal layer
214
AUGUST 1984. VOL 40, NO 2
3 Afferent
Fig 8. A size 30 French clear tube is passed into the pouch. A 1-inch wound drain is placed in the pelvis.
discharged with the wound drain covered by a stoma bag, and the clear tube attached to a leg bag for gravity drainage.
Follow-up Care
M
r S was readmitted two weeks after discharge for a radiograph and endoscopy of the pouch, for removal of the removal of the tube and ureteral stents, an IW, the wound drain,and instruction on self-catheterization. The IVP showed no reflux, obstruction, or extravasation of the kidney system. The enterostomal therapist taught him to insert a # 18 French caude tip catheter through the continence valve. This normally requires some force to get the catheterpast the valve, and many patients are fearful of hurting themselves or doing damage to the surgery. The enterostomal therapist has prepared a handout for the patients to refer to at home (Patient Home Care of Urinary Kock Pouch Drainage). Still, many patients have an initial period of difficulty. Mr S was taught the procedure in a bed. Catheterizing the pouch at home while standing up or sitting down resulted in an unexpected change in the angle and course the catheter took. Each patient finds the position
AORN JOURNAL
and method that is workable for him. The nurse and enterostomal therapist told Mr S to drain the pouch completely each time to avoid residual stagnant urine and infection. Sometimes the catheter needs to be repositioned in the pouch so that it will be emptied properly. The pouch continues to produce mucus, necessitating use of gauze or a cut-up mini sanitary pad over the stoma. The pad has a plastic backing that acts as added protection against soiling clothes. The amount of mucus decreases over time, and the reservoir reacts more like a bladder. Mr S adjusted to this routine without difficulty. He was advised to wear a bracelet indicating his medical problem in case of emergency, so that the person in attendance would be aware of Mr S’s stoma and its need to be drained every four to six hours. While he was in, the operating Mom nurse was notified that he was there, and she set up the endoscopic equipment for ureteral stent removal. This is done either in the patient’s mom or the unit treatment Mom and gives the operating room nurse an excellent opportunityto follow up on the progress of her patient. A cystoscope is used to view the pouch, and the stents are grabbed with a forceps and removed. Three months after his continent urostomy operation, Mr S was ready to return to his job as a pilot. His cancer has not returned. Dr Skinner and his associates have performed 85 of these procedures. A few revisions have been required due to a redundant efferent nipple valve causing leakage from the pouch. Even so, no patient has expressed a desire to return to use 0 of an external appliance. Notes 1 . Doris MacCleUand, “Kock pouch: A new type of ileostomy,” AORN Journal 32 (August 1980) 191-201. 2. D G Skinner, “Technique of radical cystectomy,” Urologic Clinics of North America 8 (June 1981) 353-366. 3. M M Spencer, W 0 Barnett, “The continent ileal reservoir(Kock pouch): A new approach,”Journal of Enterostomal Therapy 9 (September-October 1982) 8-13.
215
A O R N JOURNAL
A Continent Urostornv A CASEHISTORY Sandra S LaFollette, RN
T
he search to improve the quality of life for some patients needing urinary diversion has led to the development of a continent urostomy. The procedure is based on Dr Nils G Kock’s surgically constructed intestinal reservoir for patients with chronic ulcerative colitis, familial polyposis, and certain neoplastic diseases. Just as the continent ileostomy is for selected patients, so is the continent urostomy. Patients who have had the standardureteroilealcutaneous urinary diversion can be converted to this continent urostomy, thus eliminating the need to wear an external appliance to collect their urine and the associatedchronic skin problems. The stoma is flush on the abdomen, and a gauze dressingcan be worn for protection. Patients catheterizethemselveseveryfour to six hours and need only carry a catheter with them.
Sandra S L&oh!eae, RN, BSN, is a private scrub nurse for Donald G Skinner, IUD, at Kenneth Norris Jr Cancer Hospital in Los Angeles. She received her BSN from the University of California, Los Angeles.
Mr S is a 58-year-old airline pilot who had experienced intermittent hematuria during the prior year that had been treated as an infection. During routine physical examination for the airline, he told the physician about his episodes of hematuria. The physician referred him to a urologist who suggested Mr S have an intravenous pyelogram (IVP) and a cystoscopy. The IVP showed a filling defect on the left bladder wall indicative of a bladder tumor. The cystoscopy, performed in the physician’s office, revealed two areas of obvious bladder cancer. Mr S was scheduled for admission to the hospital for cystoscopy and transurethral resection bladder tumor (TURBT). The bladder tumors were poorly differentiated muscle infiltrating transitional cell carcinoma (stage BI [superficial muscle invasion] or Bz [deep muscle invasion]). The urologist advised Mr S to undergo preoperative radiation followed by a radical cystectomy and ileal conduit. Mr S decided to accept preoperative radiation therapy and received 4500 rads to the bladder vicinity over five weeks. Later, Mr S came to see Donald G Skinner, MD, for a second opinion and to discuss his therapy options. Dr Skinner explained the various types of urinary diversions available. 0 A bilateral ureterosigmoidostomy-surgical implantation of a ureter into the sigmoid colon. 0 An ileal conduit-ureters transplanted into resected ileum that is brought through the abdominal wall and creates a stoma. 0 A continent urostomy via a Kock pouch207
AUGUST
AORN JOURNAL
an ileal conduit utilizing two nipple valves, one to maintain continence and one to prevent reflux. Because Mr S was young and highly motivated, in good physical condition, and had an active working life, he was considered a good candidate for a continent urostomy. Mr S was concerned that the airline medical department and the Federal Aviation Administration (FAA) might not allow him to return to work if he had an operation that was not on their approved list. A conversation between Dr Skinner and representatives from the FAA and the airline medical department led to approval for Mr S to return to his job after surgery. If he had not received approval to return to work, Mr S would have opted for the standard ureteroileocutaneous urinary diversion surgery. He was scheduled for a radical cystectomy with bilateral iliac lymph node dissection, creation of continent Kock ileal resevoir with bilateral ureteroileocutaneousurinary diversion, a p pendectomy, and insertion of gastrostomy tube.
Preoperative Care
P
reoperative care for a patient undergoing a continent urostomy procedureis similar to that of a standardureteroileocutaneous urinary diversion patient. Mr S was admitted to the hospital two days before surgery and received a regular diet until after breakfast the day before surgery when he was started on a liquid diet. The day before surgery he was started on a bowel preparation program to clean'se and decompress the bowel. The bowel prep consists of a palatable emulsion of castor oil, along with a total of 7 g of neomycin and 4 g of erythromycin orally at specific intervls throughout the day. No enema is required.2 Reoperative teaching is a team effort. The nurse encouraged Mr S to verbalize his concerns about surgery, and she reinfotced the teaching done by the surgeon, surgical resident, and anesthesiologist. The primary nurse assured him he would be given pain medicationso that he would not experience excessive discomfort postoperatively. He was taught the importanceof using the 208
1984. VOL 40.
NO 2
incentive spirometer and turning, coughing, deep breathing, and early ambulation. The enterostomal therapist visited him and marked the stoma site and answered questions about his stoma. The stoma is usually located just above the pubic hair line in the right lower quadrant, but can be below the bikini line in the young adult. Because fitting of an appliance is unnecessary, there is much flexibility in the location of the stoma. Scars from previous operations, bony protuberances, and skin irregularities no longer discount a preferable site.' On the morning of surgery, Mr S was given 75 mg meperidine hydrochloride (Demerol)and 25 mg hydroxyzine hydrochloride (Vistaril) by his primary nurse, as prescribed by the anesthesiologist. He was brought to the holding area where the circulating nurse did a quick preoperative assessment. She stayed with him and assisted the anesthesiologist in the placement of a catheter in the epidural space. This is used intraoperatively to administer 0.75% bupivacaine hydmchloride (Marcaine) as a muscle relaxing agent and again, postoperatively, to administer morphine to control pain. The catheter was positioned cephalad along his spine and secured with waterproof tape. He was transferred to the operating mom by the circulating nurse and anesthesiologist.
The Procedure
M
r S was placed in the supine position with his iliac crest directly over the break (kidney rest) in the bed so that he was in the correct position for the surgeon when the bed was hyperextended. The circulating nurse supported the area where the epidural catheter was placed to prevent dislodgement of the catheter. The circulating nurse helped the anesthesiologist insert the endotracheal tube, pass the nasogastrictube, start IVs, and connect the ECG monitor. In my hospital, hypotensive anesthesia is usually used, requiring an arterial line for accurate assessment of arterial blood pressure. Hypotensive anesthesia drops the systolic blood pressure to between 90 and 75 mm Hg and the
AUGUST 1984. VOL 40, NO 2
diastolic to approximately 50 mm Hg. This decrease in blood pressure results in less intraoperative bleeding. After the bladder is removed, hypotensive agents are stopped; the patient will be normotensive in a few hours. Different methods for obtaining hypotension include the use of drugs, such as sodium nitroprusside (Nipride) or trimethaphan camsylate (Arfonad), or use of a higher concentration of enflurane or isoflurane gases. The drugs decrease peripheral vascular resistance and lower the blood pressure. The increased concentration of the gases causes cardiac depression, resulting in decreased cardiac output and vasodilation; and thus, the hypotensive state. Instead of administering vasodilators or increasing the concentration of anesthetic gases, our anesthesiologists administer bupivacaine hydrochloride through the epidural catheter, which acts as a semicontrolled sympathectomy, blocking the motor and autonomic nerves to the muscles in the area, decreasing vascular tone, and resulting in a decrease in blood pressure. After Mr S was anesthetized, he was shaved from the nipples to mid-thigh, and a #16 catheter was placed in his bladder. He was then prepped and draped. An open heart sheet with seams of adhesive nylon tape was used for draping, allowing the appropriate exposure of the patient. The surgeon made a midline incision and exposed the peritoneum. A thoroughexploration of the abdominal contents was performed to detect evidence of metastases. Any suspicious nodule on the liver, bowel, mesentery, or other examined organs would be excised and sent to the pathology laboratory for a frozen section. Positive findings might result in changing the planned operation. The surgeon mobilized the sigmoid and elevated its mesentery off the sacral promontory so the left ureter could pass without obstruction for the subsequent left ureteroileal anastomosis. Two hemoclips were placed on each ureter and a portion of each ureter was sent to the pathology laboratory for frozen sections to verify an adequate margin of tumor-free ureter. A self-retaining retractor was placed, and the s m d bowel was packed into the epigastrium
AORN JOURNAL
Fig 1. Approximately 80 cm of ileum is demarcated:17-cm for efferent limb; two 22-cm segments for reservoir, and a 17-cm segment for afferent limb.
with lapamtomy sponges. A meticulous pelvic iliac lymph node dissection was done, and all lymphatic and fibrous tissue from the distal aorta, vena cava, and common iliac vessels was moved into the pelvis. The surgeon then dissected the distal limits including the lymph node of Cloquet, at the femoral canal. The surgeon developed lateral pedicles extending from the bladder to the hypogastric vessels along the side wall of the pelvis. The tissue and vessels in this were clipped and divided caudally to the endopelvic fascia. The peritoneum was then incised laterally and anterior to the rectum to allow the anterior mtal wall to be safely moved away from the fascia1 plane separating the bladder and prostate from me rectum. This delineatedthe posterior pedicleextending from the bladder posteriorly, which next was clippedand dividedcaudally.This left the bladder attached only by the distal urethra. A large clamp was placed across the urethra, the urethra divided distal to clamp, and the entire specimen was removed en bloc. A 0 chromic suture was used to approximatethe levatormusclesin the floor of the pelvis. The surgeonirrigated the pelvis with large amounts of warm, sterile, hyponic water and packed it with a lapamtomy sponge. He then focused on the development of the continent urinary reservoir.
dc 209
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AORN JOURNAL
NO 2
Fig 2 . Creation of pouch begins with taking the 22 cm limbs and folding them together to form a U.The serosal layer of the two limbs is sewn together with a 3-0 absorbable s u m .
Fig. 3. The bowel is opened and the inner (mucosal) layer is approximated with two layers of
The packs were removed from the epigastrium, and a segment of terminal ileum was isolated for creation of the pouch. Approximately 80 cm was demarcated by measwing 17 cm for the efferent limb, two 22-cm segmentsneeded for the reservoir itself, and a 17-cmsegment for the afferentlimb(Fig1). Theefferentlimbiswhatwill laterformthestomaandthecontinentnipplevalve. The reservoir or pouch is where the urine will be stored, and the afferent limb constitutes the antireflux nipple and servesas the sitefortheureteral anastomosis. The surgeon then placed bowel clamps on the isolated segment and divided the ileum. The afferent limb was closed with a running 3-0 c h m i c suture and an interrupted outer layer of 4-0 silk sutures. A bowel anastomosis reestablished continuity to the gastrointestinaltract. The mesentery was closed with a 3-Ochromic suture. The pouch was formed by taking the two 22cm limbs and folding them together to form a U, with the apex of the U pointing caudally (Fig 2). The serosal layer of the two limbs were sewn together with a long continuous 3-0 absorbable suture. The bowel was then opened with an electrosurgical cautery close to the suture line, and
the inner mucosal layer was approximated with two layers of absorbable 3-0 sutures (Fig 3). Next the mesentery was incised, freeing it from the ileum, for approximately7 to 8 cm, proximal to the pouch, along the efferent and afferent limbs. This allowed intussusception of the bowel, thereby creating the nipple valves (Figs 4, 5, and 6).To keep the valves in place, they were stapled using four rows of staples. To further prevent slippage, a 2.5-cm-wide mesh gauze strip that had been soaking in an antibiotic solution was sewn around the afferent limb. A 2.5-cm-wide mesh gauze strip was also placed around the efferent limb to prevent slippage and to anchor the pouch to the fascia when creating the stoma. The pouch takes form by folding the middle portion to the opposite side and closing it with two layers of 3-0 absorbable sutures. The swgeon did the standard ureteroileal anastomosis and placed the ureters in a relaxed position at the afferent limb. To avoid leaks at the afferent nipple, both ureters were stented. The scrub nurse cut multipleeyelets in two At8 feeding tubes, and before the ureteroileal anastomosis was complete, one end of the feeding tube was passed up
212
absorbable 3-0sums.
AORN J O U R N A L
AUGUST 1984, VOL 40. NO 2
9
fimb4 Ileum
/
\ Mucosal
Mesentery Fig 4. The mesentery is incised, freeing it from the ileum, for approximately 7-8 cm, proximal to the pouch, along the efferent and afferent limbs. Mesh gauze is placed around both limbs.
the ureter and the other end down into the pouch. This procedure necessitates endoscopy of the pouch when the patient returns for followup. Using the plunger from a 20 cc syringe as a template, the surgeon excised skin from the stoma site marked by the enterostomal therapist and made a small opening in the subcutaneousfat of the anterior and posterior rectus fascia and rectus muscle. He then placed # 1 nylon sutures in the fascia and passed them through the stoma site where the mesh gauze collar is incorporated in the suture and brought back through the fascia to anchor the efferent limb to the abdominal wall (Figs 7 and 8). The stoma was completed using 3-0 absorbable sutures on a cutting needle and a size 30 French clear tube passed into the pouch. Then the tube was irrigated with normal saline and connected to a gravity drainage bag to maintain pouch decompressionand allow suture lines to heal. A 1-inch wound drain was placed in the pelvis, secured with a suture to the skin, and a stoma bag was applied to measure postoperative drainage. The end of the drain was tacked to the psoas muscle with a 3-0 chromic stitch to keep it from slipping into the urinary pouch. The lapamtomy pad pack in the pelvis was removed, and the area checked for bleeding, and again irrigated with a
Mucosal hyer Fig 5. Intussusception of the bowel is accomplished by using Allis clamps to create the nipple valves.
liter of hypotonic sterile warm water. The surgeon used a #22 Foley catheter with a 5 cc inflated balloon for a gastrostomy tube and closed the fascia with figure-of-eights, using #1 nonabsorbable suhues. The skin was closed using an automatic skin stapler. The incision was covered with gauze dressings, and petroleum jelly gauze was applied over the stoma. All drains and tubes were taped in place, and Mr S was covered with warm blankets and taken to the recovery room, intubated but breathing on his own. The procedure had taken approximatelysix hours, one and one-half hours longer than a standard ileal conduit. The circulating nurse and the anesthesiologist reported to the recovery mom nurse on the patient’s condition.
Postoperative Care
M
r S’s condition was stable upon arrival in the intensive care unit. There, nursing care included strict monitoring of intake and output, vital signs every two hours, administration of pain medication and antibiotics, and reminding Mr S to deep breathe frequently. Because there were no signs of postoperative bleeding, Mr S was transferred to a 213
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Mesh gauze to be sewn around mt
1
Mesentery
1 Fig 6. To keep the valves in place. they are stapled, using four rows of staples.
Fig 7. Nylon sutures are placed in the fascia, passed through the stoma site where the mesh gauze collar is incorporated in the suture, and brought back through the fascia to anchor the effemt limb to the abdominal wall.
semi-privatemom the next day after the nasogastric tube was removed. Having that tube removed raised his spirits and reassured him that he was impving. The epidural catheter is also removed before the patient leaves the intensive cart unit. The administration of epidural morphine affoded Mr S a night of pain-free rest. The gastrostomy tube was attached to a gravity drainage bag and patency maintained with every six-hour normal saline irrigations. On the third postoperative day Mr S had bowel sounds indicating peristalsis had nturned.He was able to tolerate the tube clamped three hours out of every four, so on the fourth postopera~veday he was given a diet of liquids, which eventually progressed to soft solids. When he tolerated the gastric tube being clamped all day, it was removed. Mr S faithfully performed the coughing and deep breathing exercises and ambulated in the halls with the nurse's assistance. To maintain strict records of Mr S's intake and output, the nurse charted the output from the clear tube and wound drain separately. In this way if the output from the wound is greater than that from the clear tube, a leak in the pouch may be detected. If a leak is found, no additional medical intervention is requid; the leaks heal with time. At first the clear tube was irrigated by the
nurse. Eventually she taught Mr S how to do this himself by instilling 40 cc to 60 cc of normal saline slowly and allowing it to drain back into a basin. He practiced doing this several times so that the drain was kept free from mucus and clots. If the solution leaks around the tube or through the wound, it may indicate a blockage. As long as the irrigation procedure is done every two hours during the day and every three hours at night, the ileal pouch is kept decompressed and fne of mucus that collects in it. This prevents tension on the suture line of the newlycreated pouch. BecauseMr S would have tocontinuethe irrigation procedures at home, although not as frequently, the nurse taught him to gather all the necessary equipment, place it on the tank of the toilet, sit facing the tank,and irrigate the tube allowing the irrigant to return into the toilet. For the first week after surgery, the tube must be irrigated every two hours during the day and every three hours at night. The second week, every three hours during the day and every four hours at night is sufficient. After that, patients continue to increase the time between irrigations until they find a schedule that works best for them. Most patients, though, can eventually sleepthroughthe night andareableto sleepontheir stomachs. On the eighth postoperative day, Mr S was
Mucosal layer
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3 Afferent
Fig 8. A size 30 French clear tube is passed into the pouch. A 1-inch wound drain is placed in the pelvis.
discharged with the wound drain covered by a stoma bag, and the clear tube attached to a leg bag for gravity drainage.
Follow-up Care
M
r S was readmitted two weeks after discharge for a radiograph and endoscopy of the pouch, for removal of the removal of the tube and ureteral stents, an IW, the wound drain,and instruction on self-catheterization. The IVP showed no reflux, obstruction, or extravasation of the kidney system. The enterostomal therapist taught him to insert a # 18 French caude tip catheter through the continence valve. This normally requires some force to get the catheterpast the valve, and many patients are fearful of hurting themselves or doing damage to the surgery. The enterostomal therapist has prepared a handout for the patients to refer to at home (Patient Home Care of Urinary Kock Pouch Drainage). Still, many patients have an initial period of difficulty. Mr S was taught the procedure in a bed. Catheterizing the pouch at home while standing up or sitting down resulted in an unexpected change in the angle and course the catheter took. Each patient finds the position
AORN JOURNAL
and method that is workable for him. The nurse and enterostomal therapist told Mr S to drain the pouch completely each time to avoid residual stagnant urine and infection. Sometimes the catheter needs to be repositioned in the pouch so that it will be emptied properly. The pouch continues to produce mucus, necessitating use of gauze or a cut-up mini sanitary pad over the stoma. The pad has a plastic backing that acts as added protection against soiling clothes. The amount of mucus decreases over time, and the reservoir reacts more like a bladder. Mr S adjusted to this routine without difficulty. He was advised to wear a bracelet indicating his medical problem in case of emergency, so that the person in attendance would be aware of Mr S’s stoma and its need to be drained every four to six hours. While he was in, the operating Mom nurse was notified that he was there, and she set up the endoscopic equipment for ureteral stent removal. This is done either in the patient’s mom or the unit treatment Mom and gives the operating room nurse an excellent opportunityto follow up on the progress of her patient. A cystoscope is used to view the pouch, and the stents are grabbed with a forceps and removed. Three months after his continent urostomy operation, Mr S was ready to return to his job as a pilot. His cancer has not returned. Dr Skinner and his associates have performed 85 of these procedures. A few revisions have been required due to a redundant efferent nipple valve causing leakage from the pouch. Even so, no patient has expressed a desire to return to use 0 of an external appliance. Notes 1 . Doris MacCleUand, “Kock pouch: A new type of ileostomy,” AORN Journal 32 (August 1980) 191-201. 2. D G Skinner, “Technique of radical cystectomy,” Urologic Clinics of North America 8 (June 1981) 353-366. 3. M M Spencer, W 0 Barnett, “The continent ileal reservoir(Kock pouch): A new approach,”Journal of Enterostomal Therapy 9 (September-October 1982) 8-13.
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