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Keywords: cystectomy, ileal conduit, invasive bladder cancer
Radical cystectomy remains one of the most effective methods of control of invasive bladder cancer. The construction of an ileal conduit remains a tried and tested method of urinary diversion. One of the earliest descriptions was by Bricker (1) in 1951 and, despite its wide acceptance, it is increasingly important that this operation is discussed in depth with the patient, to weigh up all the disadvantages.
Patients may have had radiotherapy to their bladder and, where recurrence has taken place, the rather clumsy term of salvage cystectomy has been coined.
In younger patients, who are highly motivated, a discussion of other techniques of diversion should be undertaken.
Also, the presence of a stoma may have difficulties for certain religions and must be discussed with patients.
Indications for radical cystectomy are outlined below.
This is a major procedure and the patient must be assessed for fitness, independent of age.
Staging
An intravenous urogram (IVU) is necessary to exclude more widespread TCC in ureters or renal pelvis.
Various tests need to be carried out to stage the tumour and exclude metastatic disease (Table 1).
Table 1: Tests to stage the tumour and exclude metastatic disease
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Cross Match
A minimum of four units of packed cells are cross matched
Theatre Allocation
An operating time of at least four hours is booked. Two assistants must be free, at least one of whom is experienced.
Consent
Radical cystectomy implies pelvic lymphadenectomy of the iliac and obturator nodes and in addition:
The surgical procedure to be performed must be discussed in full with the patient. It must be stressed that sexual function is usually lost in both sexes.
Admission
The patient is brought into the ward two days prior to surgery and started on a low residue diet. The stoma nurse, or similar counsellor, is booked to discuss the practical aspects of the stoma and show the patient the fitting of the appliance. The patient is shown how to change this and, after discussion, the site for the stoma is chosen below the belt line, paying particular attention to skin folds and avoiding previous scars. This site is marked with an indelible skin pencil.
On the day prior to surgery, the patient is patch tested for iodine. The patient is only permitted clear fluids to drink. Low molecular weight Heparin is given subcutaneously on the day before surgery and until the patient is mobilised and compression (TED) stockings applied.
Picolax sachets are given at 10am and again at 2pm. If there is no result, a Microlax enema can then be given (or a high phosphate enema, if the patient has not opened their bowels for several days). If the patient is frail, urea and electrolytes may be checked on the morning of surgery to identify hypokalaemia. An IV infusion may be requested overnight prior to surgery.
Where high dependency unit facilities are available, epidural analgesia is beneficial and may be mandatory if the patient has pulmonary disease. The pain team discuss analgesics. The physiotherapist instructs the patient on breathing and leg exercises. Where the patient is unfit, it is also prudent to ensure that there is an intensive therapy unit (ITU) bed available.
The operation is performed under a general anaesthetic with muscle relaxation and the patient is placed supine (Figure 1). A small sandbag behind the lumbar spine aids vision within the pelvis.
In view of the occasional high blood loss, many anaesthetists insert a central venous pressure line and, where the patient is unfit, an arterial line. Compression boots are applied in theatre.
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Antibiotics (Augmentin and Metronidazole) are given intravenously soon after anaesthetic induction. The patient is catheterised with a 16 French Foley catheter and the bladder drained. The patient is prepared using an iodine skin preparation, draped exposing the abdomen from xiphisternum to pelvis. The cross marking at the prepared site for the conduit is then transfixed with a silk or Vicryl suture, so that the mark of the site for the conduit does not become obliterated during the operation. In females, the vagina is packed with an iodine soaked swab.
Incision
A standard midline incision is used, skirting the umbilicus. This must avoid the projected stoma site and allow plenty of room for fitting of an appliance.
It is feasible to do a transverse abdominal incision, but the disadvantage with this approach is that it is difficult to free up the greater omentum, if it is stuck in the higher part of the abdomen. For this reason I prefer a midline incision.
Division of the attachments of the rectus abdominis to the pelvic line, as originally described by Richard Turner-Warwick, aids exposure. (2)
Approach
The abdomen is opened. Nowadays, the patient will have previously had an abdominal and a pelvic CT scan, but it is sensible just to check that no large lesion has been missed in the liver (smaller lesions are, paradoxically, usually identified). At this stage, it is also easy to free the greater omentum. Two dry packs are used to retract the abdominal contents and a ring retractor is then placed in position.
The first approach is to open the retroperitoneal space and expose each obturator fossa in turn. Any lymph nodes are excised and sent in separate jars to the pathology laboratory.
The lymph nodes are dissected, taking all tissue medial to the genitofemoral nerve off the iliopsoas muscle and the external iliac vessels, including the fat pad at the inguinal ligament. The lymph node (Cloquet’s node) at the femoral canal, is also removed. The obturator nodes are removed and they lie between the external and internal iliac vessels (Figure 2).
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At this stage, it is useful to expose the ureters and place sloops around each. The bladder can then be mobilised gradually. At this stage it is possible to decide whether the bladder can be removed. If the scans are accurate, it is rare that this decision has to be reversed. Once this decision is made, the ureters can be divided at leisure. I place 2.0 Vicryl sutures around each distal end of the ureter and leave long tails. This is to allow the ureters to dilate, stops urine washing into the peritoneal cavity and the long tails allow easy identification at a later stage.
The vasa deferentes (or the round ligaments in females) are divided bilaterally (to avoid small bowel strangulation). The pedicles of the bladder can be divided, using a mixture of sharp and blunt dissection and automatic clips. The superior and inferior vesical arteries carry most of the blood supply. The pelvic fascia may be opened on either side of the bladder and Santorinis’ venous plexus divided, as one would with a radical prostatectomy. This can allow much easier mobilisation of the bladder and prostate. The parietal peritoneum over the bladder should be removed to allow the small bowel ultimately to fall into the pelvic cavity. Failure to do this can lead to a pyopelvis.
The bladder is removed and any obvious bleeding points diathermied or tied. A dry pack is then placed in the pelvis and attention is then turned to fashioning the ileal conduit. The appendix is identified and, because continent diversion is not being used, there is still a strong argument for removing the appendix, since appendicitis in patients with an ileal conduit can be very difficult to diagnose.
Ileal Conduit
The terminal ileum is then identified (Figure 3) and a portion of ileum is isolated, avoiding the terminal 25cm of terminal ileum, which is where bowel salts are reabsorbed.
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The distance can be measured. The small bowel is trans-illuminated using a satellite lamp at right angles to the bowel (Figure 4).
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The small bowel is divided between non crushing Doyens clamps. At this stage, I find it very helpful to identify the terminal end of the conduit, by marking it with a long Vicryl suture. It is remarkably easy to get these ends reversed during a longer procedure and identification at this stage avoids difficulties later on.
The small bowel is re-anastomosed using controlled release 3.0 Nurolon (Polyamide 6 braided non absorbable, Ethicon) sutures and the window of the mesentery is repaired using interrupted absorbable sutures (2/0 Vicryl). In most cases, the small bowel sits better in an inferior position, below the anastomosis. A Backhaus towel clip can be used to approximate the Doyens clamps while the anastomosis is performed.
The distal ends of the ureters can then be identified using the long tags suture and tunnels are made so that the created gap in the posterior layer of the peritoneum acts as a window, through which the ureters are drawn (Figure 5). The left ureter is drawn through the sigmoid mesocolon. Once again the long tags of Vicryl may be used to assist this.
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The conduit is irrigated with a normal saline solution, ensuring that any remaining debris is removed.
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The ends of the ureters are then
spatulated and the terminal ends of Vicryl sutures can be held together until
the anastomosis is partially fashioned. At this stage, size 6 Fr infant feeding
tubes are passed into each ureter and drawn through the conduit (Figure 6).
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The cap on the infant feeding tube is taken off the left one (shorter tube, shorter number of letters) and I found that a 3.0 Vicryl suture placed through the ureter, but not through its maximum circumference anchors the tube. The suture must of course be absorbable. Alternatively, a No. 8F single J stent may be used and does not need suturing. I use the method described by Wallace, and usually a Wallace 1.(3)
The anastomosis is then completed. At this stage, the integrity of the anastomosis is tested using 50mls of saline, injected gently with a bladder tip syringe into the distal end of the conduit. Any small leaks are sutured.
Fashioning of the stoma
The silk or Vicryl stitch on the skin, at the site of the stoma is lifted. This allows an easy excision of a circular area of skin (Figure 7).
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A tract is then fashioned through the muscle layers (preferably through rectus abdominis to avoid parastomal hernias), into the abdomen and the distal end of the conduit is drawn through the skin. Care must be taken that there is no obstruction at this point (Figure 8).
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It is imperative that there is no tension on this anastomosis. If there is any tension or marked ischaemia, then a new conduit must be fashioned. The ends of the conduit are turned back on themselves, with four sutures 4.0 Dexon (Davis and Geck) at each corner, securing the distal end to the lower proximal area, thus everting the stoma (Figures 9 and 10).
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The anastomosis can then be dropped back into the retroperitoneum, but at this stage, the omentum is drawn down and wrapped around this area, to allow for revascularisation. Any redundant omentum is also placed near the small bowel anastomosis. At this point the attention is then turned to the pelvis again. Any residual bleeders can be dealt with at leisure.
Closure
I close with two 20 French gauge Wallace drains (Robinson drainage system), brought out through separate stab incisions on each iliac fossa and the drains being secured with a suture of 2.0 silk. One drain is led up to the area of the conduit and the other drain is led down into the pelvis. The urethral catheter has of course been divided, when the urethra was divided and unless urethrectomy has been carried out, nothing further need be done at this point.
I close with No. 1 PDS suture with a blunt taper point needle, taking all layers. Skin closure is a matter of choice, but I think there is a strong argument for using skin staples since the operation is already long enough. A stoma bag is applied over the conduit.
The patients vital signs are monitored and, in particular, the urine output is charted. A small degree of haematuria is to be expected. The drains are removed when they stop draining and, where a nasogastric tube has been inserted, the patient may be given 15 - 30ml of fluid hourly after 6 - 8 hours.
Apart from any general complications, occurring with any major surgery, specific complications are associated with the procedure and are listed in Table 2.
Table 2: Complications associated with the procedure
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KEY
POINTS
Patient selection is paramount An ITU bed should be available if needed The conduit must be well vascularised The conduit must not be constricted at the abdominal wall An experienced team of nursing and theatre staff must be available, in addition to an experienced anaesthetist and surgeon |
ACKNOWLEDGEMENTS
The author gratefully acknowledges Miss Linda Smith for her help in typing the manuscript and the assistance of the Department of Medical Illustration, Polworth Building, Grampian University Hospitals NHS Trust.
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