Continent right colon reservoir using a cutaneous appendicostomy

SURGICAL TECHNIQUES IN UROLOGY

CONTINENT RIGHT COLON RESERVOIR USING A CUTANEOUS APPENDICOSTOMY JOHN P. STEIN, SIAMAK DANESHMAND, MATTHEW DUNN, MAURICE GARCIA, GARY LIESKOVSKY, AND DONALD G. SKINNER

ABSTRACT Introduction. Although orthotopic reconstruction has become the preferred form of lower urinary tract reconstruction after cystectomy there remains a select group of patients who are not appropriate for an orthotopic neobladder substitute. A continent cutaneous reservoir provides an alternative means to store urine and protect the upper urinary tract without the need for a urostomy appliance. We report our surgical technique of a continent cutaneous right colon reservoir using a catheterizable submucosally embedded appendicostomy. Technical Considerations. The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy incorporates the ascending and proximal transverse colon, which are detubularized and folded to form the reservoir component of the urinary diversion. The terminal ileum acts as the afferent limb, with the intact native ileocecal valve providing the antireflux mechanism. The continence catheterizable mechanism incorporates the submucosally tunneled appendix with preservation of the mesentery in a flap-valve technique. Conclusions. The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present, with good functional results and excellent continence. UROLOGY 63: 577–581, 2004. © 2004 Elsevier Inc.

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rthotopic reconstruction has become the preferred form of lower urinary tract reconstruction at most institutions. However, a select group of patients remains who are not appropriate for an orthotopic neobladder substitute.1 Patients with tumor involvement of the proximal urethra (distal surgical margin) and those patients without an intact, functional rhabdosphincter should be considered for a cutaneous form of diversion.1 The ideal continent cutaneous reservoir avoids the need for a urostomy appliance, should protect the upper urinary tract, and should allow relatively easy emptying using intermittent catheterization, with effective day and night continence.2 A plethora of various continent cutaneous reservoirs have been described in published reports.2 From the Department of Urology, Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles, California Reprint requests: John P. Stein, M.D., Department of Urology, Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, MS No. 74, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089 Submitted: July 16, 2003, accepted (with revisions): October 31, 2003 © 2004 ELSEVIER INC. ALL RIGHTS RESERVED

The continent cutaneous ileocecal reservoir using the submucosally embedded appendix has been described by several innovative surgeons, with excellent clinical outcomes.3–7 We present our surgical technique and experience with a continent right and proximal transverse colon urinary reservoir using a bilateral ureteroileal coloappendicostomy. SURGICAL TECHNIQUE The bowel segments (terminal ileum, cecum, and ascending and proximal transverse colon) and mesentery are first freed to provide mobility to the entire reservoir. The cecum and ascending colon are mobilized off Gerota’s fascia, and the transverse colon is freed from the hepatic flexure. A 30 to 40-cm segment of the ascending right and transverse colon is isolated along with a terminal portion of ileum (Fig. 1). The small bowel mesenteric attachments are best mobilized off the retroperitoneum up to the level of the duodenum. The proximal mesenteric division is made along the avascular plane of Treves between the ileocolonic artery and terminal branches of the ileum. The distal mes0090-4295/04/$30.00 doi:10.1016/j.urology.2003.10.072 577

FIGURE 1. Bowel segments of continent right colon reservoir are identified. A 30 to 40-cm segment of the ascending right and of the proximal transverse colon are isolated along with a terminal portion of ileum. Note, distal mesenteric division is made just proximal to middle colic artery. Care is taken to maintain the right colic artery, which provides the blood supply to the reservoir portion of the pouch. The proximal mesenteric incision should be along the avascular plane of Treves. The bowel is divided at the terminal ileum and transverse colon with bowel continuity restored by an ilealtransverse colonic anastomosis.

enteric division is made just proximal to the middle colic artery. Attention is then directed toward the appendix to determine its appropriateness as an efferent catheterizable continence mechanism. A suitable appendix generally requires 5 to 6 cm of length and should accommodate at least a 12F catheter. The intact appendix and corresponding mesoappendix are carefully cleaned and mobilized to ensure preservation of the blood supply. The distal tip of the appendix is incised and the appendix softly cannulated and dilated with red Robinson catheters to a 12F or 14F size. If the appendix is short, or unable to accommodate a 12F catheter, an alternative efferent catheterizable limb should be considered. We prefer creating an efferent ileal continent Tmechanism (variation of the double-T pouch).8 Next, three to four mesenteric windows are opened in the appendiceal mesentery adjacent to the serosa of the appendix (Fig. 2). Preservation of these arches maintains a well-vascularized appendix. After this, a 4 to 5-cm longitudinal incision is made into the seromuscular portion of the anterior tenia coli at the base of the appendix extending onto the cecum. This tenia incision allows the colonic mucosa to bulge and provides a submucosal trough for the appendix to be embedded. The appendix is then laid into the incised seromuscular trough on top of the bulging colonic mucosa (submucosally). The seromuscular edges are approximated with a series of 3-0 silk sutures through the opened mesenteric windows (Fig. 3). This process is repeated through each mesenteric window until at least 3.5 to 4 cm of the appendix is 578

FIGURE 2. After the appendix is mobilized, three to four mesenteric windows are opened in the appendiceal mesentery adjacent to the serosa of the appendix. Next, a 4 to 5-cm longitudinal incision is made into the seromuscular portion of the tenia at the base of the appendix extending onto the cecum. Note, the bulging colonic mucosa and the seromuscular trough of the tenia for the appendix to be embedded (arrow). This dissection is facilitated by infiltrating with 1:100,000 epinephrine into the seromuscular layers.

FIGURE 3. Appendix is anchored into the seromuscular trough. The seromuscular edges are approximated with 3-0 silk sutures through the opened mesenteric windows. Specifically, a silk suture is placed into the seromuscular flap on one side. This suture is brought through the opened mesenteric window and placed at a corresponding seromuscular site in the opposite tenia flap. The suture is then brought back through the same window and tied down. This process is repeated through each mesenteric window until at least 3.5 to 4 cm of the appendix is permanently secured into the trough. Note, the appendix is cannulated with a 12F catheter.

permanently secured into the submucosal trough. We prefer placement of two or three silk sutures for each mesenteric window. The placement of Penrose drains (0.25 in.) in each window of the mesoappendix will facilitate passage of the silk sutures back and forth through the mesentery. Next, the previously designated 30 to 40-cm colonic segment is placed in an inverted U orientation (Fig. 4). The colon is detubularized and inUROLOGY 63 (3), 2004

FIGURE 4. Designated 30 to 40-cm colonic segment is placed in an inverted U orientation, and colon is incised with electrocautery along the tenia for the entire length until the cecum is reached (dotted line). Note, once the cecum is reached, the incision is directed slightly laterally to avoid injury to the previously tunneled appendix. Care should also be taken to avoid injury to the ileocecal valve during this incision.

FIGURE 5. Incised colonic mucosa is then re-approximated and oversewn in two layers with a running suture. The reservoir is then closed by folding it in half (caudally) in the direction opposite to which it was opened (arrow).

cised with electrocautery along the tenia for the entire length until the cecum is reached. Once the cecum is reached, the incision is directed slightly laterally to avoid injury to the previously tunneled appendix. After the incised colonic mucosa is reapproximated with two layers of a running 3-0 polyglycolic acid suture (Fig. 5), the reservoir is closed by folding it (caudally) in the direction opposite to which it was opened. The colonic mucosa is sutured in two layers with a running suture to close the reservoir (Fig. 6). Next, a standard bilateral end-to-side (stented) ureteroileal anastomosis is performed to the terminal segment of distal ileum (Fig. 7). Finally, the stoma site is identified. Two horizontal mattress sutures are passed through the anterior rectus fascia on either side of the stoma site and placed into the cecum just lateral to the embedded appendix. The appendix is passed through the abdominal wall, and the sutures are securely fashioned to fix the reservoir to the anterior abdominal wall or umbilicus. UROLOGY 63 (3), 2004

FIGURE 6. Colon is folded over and the colonic mucosa is then sutured in two layers with a running suture to close the reservoir.

FIGURE 7. Completed reservoir. A standard bilateral end-to-side stented ureteroileal anastomosis is performed to the terminal segment of ileum. Note, we prefer to place a 24F hematuria catheter into the reservoir as an irrigating catheter, which is brought out through the skin lateral to the designated stoma site. The ureteral stents may be attached to this irrigating catheter, which facilitates removal postoperatively.

COMMENT Two basic reconstruction challenges common to all forms of continent cutaneous urinary diversion include the creation of an antireflux mechanism and an effective long-term continence mechanism that catheterizes easily. We believe the continent cutaneous right colon reservoir using a bilateral ureteroileal coloappendicostomy is an ideal continent diversion when the appendix is present and suitable. This reservoir incorporates a detubularized and folded right and proximal transverse colon, the ileocecal valve as the antireflux mechanism, and the appendix (with preservation of mesentery) as a catheterizable continence mechanism using a flap-valve technique. Excellent results have been reported with the ileocecal reservoir using the submucosally embedded appendix.3–7 Our preliminary experience with this reservoir has been good. A total of 27 patients have undergone this continent right colon reservoir without 579

intraoperative complications. No early pouch-related complications have occurred. One perioperative death occurred secondary to myocardial infarction. Five patients died within the first 4 months of surgery (all related to the primary disease). These 6 patients were not evaluated. The mean follow-up of the 21 evaluated patients was 33 months (range 6 to 81). Of the 21 patients, 6 (28%) developed a late complication of stomal stenosis; all were successfully repaired with open surgical revision. One patient (5%) developed right ureteral hydronephrosis secondary to a benign ureteral-enteral stricture that was successfully treated endoscopically with ureteral dilation. Of the 21 evaluated patients, all (100%) reported complete continence day and night, with ease of catheterization and a mean frequency of catheterization of 5.4 hours (range 4 to 7). The use of the ileocecal valve to prevent urinary reflux and protect the upper urinary tracts in patients undergoing continent urinary diversion has been previously described.3–7,9 The ileocecal valve acts as a natural, in situ antireflux mechanism and allows for a technically simple ureteroileal anastomosis—similar to that performed in an ileal conduit. We favor this end-to-side ureterointestinal anastomosis, because it may have a lower risk of obstruction compared with tunneled reimplants, which, even in experienced hands, may approximate 10%.10 The appendix should be of sufficient caliber (12F) and length (5 to 6 cm) to serve as an effective continence mechanism. A tunnel length of 3.5 to 4 cm provides an effective flap-valve continence mechanism. The preservation of the vascular arcades maintains the blood supply and should reduce the problems of ischemia or stenosis of the appendiceal stoma. To maintain the vascular supply to the appendix, mesenteric windows adjacent to the serosa of the appendix are opened that will allow for a submucosally embedded limb with preservation of the blood supply. If the appendix is not patent or otherwise inappropriate as a catheterizable limb, an alternative efferent continence mechanism must be used. The early clinical results in this series regarding continence, ease of catheterization, and pouch capacity have been good. Stomal stenosis remains the primary late complication. This technique is an excellent choice for a cutaneous urinary diversion when a viable appendix is present. REFERENCES 1. Stein JP, and Skinner DG: Orthotopic urinary diversion, in Walsh PC, Retick AB, Vaughan ED, et al (Eds): Campbell’s Urology, 8th ed. WB Saunders, Philadelphia, 2002, vol 4, pp 3835–3867. 580

2. Benson MC, and Olsson CA: Cutaneous continent urinary diversion, in Walsh PC, Retick AB, Vaughan ED, et al (Eds): Campbell’s Urology, 8th ed. WB Saunders, Philadelphia, 2002, vol 4, pp 3787–3834. 3. Riedmiller H, Burger R, Muller S, et al: Continent appendix stoma: a modification of the Mainz pouch technique. J Urol 143: 1115–1117, 1990. 4. Gerharz EW, Kohl UN, Melekos MD, et al: Ten years’ experience with the submucosally embedded in situ appendix in continent cutaneous diversion. Eur Urol 40: 625–631, 2001. 5. Roth S, Weining C, and Hertle L: Simplified ureterointestinal implantation in continent cutaneous urinary diversion using ileovalvular segment as afferent loop and appendix as a continent outlet. J Urol 155: 1200 –1205, 1996. 6. Zinman LN, Libertino JA, and Bihrle W III: Urinary diversion: techniques for reconstruction and management of complications. Semin Colon Rectal Surg 2: 115–123, 1991. 7. Libertino JA: Ileocecal reservoirs and neobladders. Atlas Urol Clin North Am 9: 45–56, 2001. 8. Stein JP, and Skinner DG: T-mechanism applied to urinary diversion: the orthotopic T-pouch ileal neobladder and cutaneous double-T-pouch ileal reservoir. Tech Urol 7: 209 – 222, 2001. 9. Alcini E, Racioppi M, D’Addessi A, et al: Refluxes in orthotopic neobladders: can the ileocecal sphincter be considered an adequate antireflux mechanism? Urology 44: 38 –45, 1994. 10. Schwaibold H, Friedrich MG, Fernandez S, et al: Improvement of ureteroileal anastomosis in continent urinary diversion with modified Le Duc procedure. J Urol 160: 718 – 720, 1998.

EDITORIAL COMMENT The surgical technique suggested by the authors is a mosaic of procedures previously used by various investigators. The choice of the ileocecal region and use of the ileocecal valve for reflux prevention were proposed by Gilchrist et al.1 as early as 1950. Detubularization and folding of the right colon to provide a low pressure and a compliant reservoir were used by Lockhart.2 Following the Mitrofanoff principle,3 the appendix was commonly used as a continent outlet with or without embedding in the cecal wall.4,5 Nevertheless, it seems that the appendix outlet has an inherent tendency for gradual stenosis. The necessity for reoperation could be as high as 28%.6 The introduction of the concept of using a tapered segment of ileum embedded in a serous-lined tunnel to provide a continent outlet was initially proposed by Abol-Enein and Ghoneim.7 The results of a large clinical experience were reported in 1999.8 The authors failed to cite these two publications. The use of this technique provides several distinct advantages: continence is provided by a passive mechanism derived from the tubular resistance of the tapered ileum and a dynamic mechanism resulting from its embedding in the wall of the reservoir. The mucous lining of the continent outlet tolerates the trauma of, and provides a natural lubricant for, intermittent catheterization. The envelopment within a serous-lined tunnel prevents any tendency for fistula formation. REFERENCES 1. Gilchrist RK, Merricks JW, Hamlin HH, et al: Construction of a substitute for bladder and urethra. Surg Gynecol Obstet 90: 752, 1950. 2. Lockhart JL: An alternative method for continent supravesical diversion. Soc Pediatr Urol News I 3: 18, 1987. UROLOGY 63 (3), 2004