Mark Nallaratnam, MD

• Clinical Cardiovascular Fellow, Department
• of Cardiovascular Medicine
• Boston University Medical Center
• Boston, Massachusetts

Note that the distal mesenteric division is made between the ileocolic and terminal branches of the superior mesenteric artery anxiety symptoms reddit generic 100mg desyrel free shipping, which extends into the avascular plane of the mesentery anxiety symptoms visual disturbances 100 mg desyrel with amex. Two 22-cm lengths make the reservoir and a proximal 10- to 12-cm length for the afferent limb anxiety 24 hour hotline desyrel 100mg with visa. Proximal to this anxiety symptoms related to menopause generic desyrel 100 mg free shipping, a 5-cm segment of small bowel is discarded to allow mobility to the pouch and small bowel anastomosis and avoid deep incision into the mesentery at that location anxiety symptoms peeing purchase cheap desyrel line, which could compromise vascular supply to the pouch anxiety ocd purchase desyrel 100 mg otc. The reservoir is then folding it in half in the opposite direction to which it was opened. The dotted line depicts the incision line on the 44-cm segment to detubularize the portion for the reservoir. The incision is, diverted laterally near the two ends to form the flap for the afferent limb tunnel. Mesenteric windows are opened between the vascular arcades adjacent to the serosa of the afferent limb, and a piece of small Penrose drain is placed through each mesenteric window. The serosa of the two limbs of the reservoir is brought together through the windows with interrupted 3-0 silk sutures to fix the backing of the tunneled afferent limb. Multiple sutures are placed through each window to secure the fixation while maintaining good blood supply to the afferent limb. A fingerbreadth opening can be left in the most dependent end of the suture line for the urethral anastomosis, or, alternatively, a separate buttonhole opening can be made in the reservoir. A small button of colon is removed from the most dependent portion of the reservoir, and the urethroenteric anastomosis is performed. The pouch is constructed from about 42 cm of distal ileum, approximately 20 cm proximal to the ileocecal valve. The optimal point of the selected bowel loop for the urethral anastomosis is identified about 12 to 14 cm proximally to the distal ileal end, after ensuring it reaches the urethral stump without tension. The proximal half of the loop will configure the left base, and the dome of the ileal segments is utilized to tailor the neobladder. Ureteroileal anastomoses are performed according to Le Duc/Camey technique with 4-0 Monocryl interrupted sutures and stented. Initial attempts to perform the diversion completely intracorporeally were fraught with difficulty, and the procedure was performed with extracorporeal construction after removal of the bladder through a small midline incision (Haber et al. The Studer ileal neobladder has been the most popular because of ease of mobilization of the segment and simpler bowel anastomosis with a low abdominal incision. In the case of orthotopic neobladders, some authors reestablish the pneumoperitoneum and redock the robot to complete the urethral anastomosis. Postoperative recovery in most series has only been modestly improved compared with open series, with longer operative times but decreased blood loss. Other unselected large series have shown that postoperative complications were equivalent or even increased compared with open series (Parekh et al. A randomized single-institution trial confirmed longer operative time and less blood loss, but no difference in other complications or short-term outcomes (Bochner et al. A multi-institutional prospective randomized noninferiority trial accrued 302 evaluable patients and found longer surgery time, lower blood loss and transfusion rates, and 1 day shorter average length of stay (6 vs. They also found no difference in major early complications or quality of life between the two arms (Parekh et al. Sigmoid Pouch Patients who are candidates for radical cystectomy often have a redundant sigmoid colon, which is readily available for use. The only concern is the potential compromise of the vasculature of the distal colon segment because of interruption of branches of the internal iliac artery during the cystectomy. It is important, therefore, to maintain as much of the vascular supply to both ends of the bowel anastomosis as possible. Some patients will complain of frequent stools or rectal urgency for a period after sigmoid colectomy. The medial taenia of the U is incised down to an area just short of the urethral anastomosis. The incised medial limbs of the U are then brought together with an absorbable suture. A buttonhole is made in the caudal portion of the colon that is later anastomosed to the urethra. This remains a technically difficult procedure, even in the hands of surgeons with extensive robotic experience. The prospect of prolonged operation times and steep learning curves for similar length of stay and higher costs necessitate that these procedures be performed in centers of excellence with highly specialized robotic skills to facilitate superior outcomes. There is a lack of studies with comparable functional, quality-of-life and long-term outcomes of intracorporeal diversion techniques. Robotic cystectomy and urinary diversion are covered extensively in other chapters. These complications could have detrimental effects on health and quality of life, and they may even be life-threatening. Long-term follow-up of patients with urinary diversion is of utmost importance as many diversion-related complications occur years after surgery (Amini and Djaladat, 2017; Ali-El-Dein et al. Early complications include bleeding, thrombotic events, infection, and cardiovascular and pulmonary complications, which are not directly related to the urinary diversion and do not appear to be different in patients undergoing different types of diversion. Gastrointestinal complications, particularly ileus, are also common after cystectomy and are at least partially related to the need for a bowel anastomosis, which is common to all types of diversion (Bazargani et al. Similarly, urine leak and ureteral complications are possible with any type of diversion. A number of authors have shown that the overall rate of complications, hospital stay, and reoperation rates are not increased by use of continent diversion compared with ileal conduit diversion (Benson et al. Urine leaks may be more common in continent diversion than in conduits because of the long suture lines, but with good catheter drainage and properly managed stents and drains, these usually resolve with observation alone as long as a urinoma does not form. If a patient has an undrained leak, an attempt at percutaneous drainage and/or bilateral nephrostomy tube placement is preferable to open surgical repair. The latter is extremely difficult during the first few weeks after the initial surgery and is likely to be complicated by enterotomies and a risk for fistula formation. In our experience, less than 5% of patients require some sort of percutaneous drain or nephrostomy tube placement during the early postoperative period to manage these problems. Both early and late complications may also be influenced by other factors such as prior radiation therapy, diabetes, and other comorbidities. Late complications are also influenced by tumor recurrence and the use of adjuvant or salvage systemic chemotherapy or radiation, and these causes may be difficult to separate out from causes related to the surgery. Late complications not directly related to the diversion include bowel obstruction, ventral hernia, thrombotic events, and cardiovascular problems common to patients in this age group. The ileum is formed into a spiral shape (as shown), and the back wall is sutured with running absorbable sutures. The poor fascial strength associated with advanced age and smoking undoubtedly contributes to this risk as well. The primary late complications of orthotopic diversion that are directly related to the diversion itself include incontinence, urinary retention, urinary tract infection, ureteroileal or afferent limb obstruction, urethral stricture, upper tract and pouch stones, vaginal fistula, and pouch rupture. Most of these can be managed by endoscopic procedures and rarely require open surgical revision (Amini and Djaladat, 2017; Hautmann et al. Although symptomatic urinary infections do occur, asymptomatic colonization of the neobladder with bacteria is also very common, particularly if the patient is on intermittent self-catheterization (Suriano et al. Incidence of urinary tract infection is comparable between conduit and continent diversions (Al Hussein et al. Symptomatic urinary tract infections are uncommon after the initial 90-day postoperative period. Bowel mucosa in contrast with urothelium is not capable of inhibiting bacterial proliferation. Treatment of asymptomatic bacteriuria is likely to simply encourage development of resistant organisms and is often unnecessary. However, patients with symptomatic infection and those with positive cultures for Proteus or Pseudomonas require treatment because these infections may result in renal function deterioration (McDougal, 1986). A patient who develops a febrile urinary infection or pyelonephritis after the initial few months should be evaluated for possible upper tract obstruction, stones, or incomplete emptying. Daily suppressive antibiotics with nitrofurantoin, sulfa, or methenamine may be helpful in the patient with recurrent symptomatic urinary infections in whom an anatomic cause has been ruled out. The risk may be increased in patients who have had previous radiation therapy or are in chronic retention. Patients with a perforation typically have acute abdominal pain and distention, often with signs of sepsis. If the patient is stable, conservative management with catheter drainage with or without percutaneous drains can be considered (Hautmann et al. The rate of ureteroileal stricture is identical to that in ileal conduit diversion and is influenced by the type of anastomosis. The direct end-to-side Leadbetter or the combined Wallace anastomoses with interrupted fine absorbable sutures have been shown to have the lowest risk for stricture, approximately 3% to 6% (Hautmann et al. Obstruction from an antireflux valve has been seen in both hemi-Kock pouches and in the extraserosal tunneled afferent limb of the T pouch (Stein et al. In a randomized clinical trial comparing refluxing and nonrefluxing ureteroenteric anastomosis, Shaaban et al. Stricture usually occurs within a few months of surgery but can occur even after 10 years. Therefore, lifelong observation for ureteral stricture is imperative in patients with urinary diversion. Previous history of abdominal/pelvic irradiation has been postulated to increase the risk for ureteroenteric anastomosis; however, in a recent large series from the University of Southern California, multivariate logistic regression analysis did not show any correlation between ureteroenteric anastomosis stricture and history of perioperative radiation therapy. Surgical technique is the most important determining factor, and ureteroileal anastomosis should be performed using meticulous surgical techniques. Strictures may be clinically silent until the patient develops bilateral hydronephrosis or even renal failure. The obstructing antireflux segment may be managed by endoscopic incision of the valve mechanism. It can be technically challenging to find the afferent limb in some cases, and special techniques may be necessary to catheterize and incise it (Dunn et al. Although in selected cases endourologic techniques may be effective, overall success rate is much lower compared with open surgical repair, and the retreatment rate exceeds 50% (Schondorf et al. Pouch stones were very commonly seen in the Kock neobladder because of the use of surgical staples to maintain the intussuscepted nipple valve, with the incidence increasing steadily with time (Stein et al. Stones have been rare in the Studer and Hautmann neobladders, which are made entirely with absorbable suture (Studer et al. In one such series of 50 patients, stones were found in 6% of patients with only a 20-month median follow-up (Barbalat et al. It is predictable that the incidence of such stones will increase with more follow-up, and although they can be managed endoscopically this carries significant cost in both money and inconvenience for patients and may lead to further complications (Suriano et al. Pouch-vaginal fistula is a unique complication of orthotopic neobladder in women that can be quite difficult to repair. The reported incidence in larger series is 5% to 10%, and the risk is increased if a portion of the anterior vaginal wall is excised along with the cystectomy specimen and in irradiated patients (Ali-El-Dein et al. Prevention methods include vaginal-sparing techniques whenever it is safe from an oncologic standpoint, careful watertight closure of the vaginal cuff when it is opened, and placement of an omental flap between the vagina and neobladder, secured to the perivaginal tissue on either side of the urethral anastomosis (Stein and Skinner, 2006). In the early postoperative period, any concern about vaginal urinary leakage should be evaluated with a lateral cystogram before removal of the catheter. Fistula should also be ruled out in any woman with persistent significant incontinence after the first few months of recovery. This is most easily done with a careful pelvic examination and with methylene blue instilled into the neobladder if necessary. Beyond the initial few weeks, a pouch-vaginal fistula is unlikely to heal spontaneously or with catheter drainage or percutaneous nephrostomy tubes alone. Repair may be attempted transvaginally, although reported success varies (Ali-El-Dein and Ashamallah, 2013; Ali-El-Dein et al. Repair may ultimately require transabdominal exploration or even conversion to a cutaneous form of diversion. Orthotopic Urinary Diversion 3251 Continence the prevalence and severity of urinary incontinence may be influenced by a number of variables including age and gender of the patients, prior treatments (such as radiation or prostate surgery), surgical techniques, and surgeon experience. Although there is general consensus that the ideal tool for studying functional outcomes is a validated patientcompleted questionnaire, all the tools available today have significant drawbacks. It captures urinary leakage but not details such as the severity of incontinence or pad use (Gilbert et al. Only a few reports have used questionnaires such as these to evaluate neobladder patients (Ahmadi et al. In summary, one should use caution in attempting to compare continence results from different series of patients with orthotopic diversion. Common observations from series of patients undergoing orthotopic diversion include a gradual period of improvement in daytime continence over the first 6 to 12 months with a slower improvement in nighttime continence, even into the second year. In a pooled analysis of 2238 patients with various forms of orthotopic neobladder, daytime incontinence was reported in an average of only 13% of patients. Risk factors for daytime incontinence included advanced age of the patient (older than 65 years), use of colonic segments, and in some series lack of nerve-sparing techniques (Furrer et al. Other series have identified hysterectomy in women and diabetes as a risk factor for poorer continence results (Ahmadi et al. The response rate was 68%, and 139 of 179 responders used pads at least sometimes, one-half of whom used them both in the day and at night. Forty-seven percent used pads in the day, with one-third of those using a small pad or minipad, and almost one-half found that the pad was usually dry or only slightly wet. We recently reported our continence outcomes in a prospective study of 188 male patients using a previously validated pictorial pad usage questionnaire. Daytime continence (defined as no pad use or pads "almost dry") peaked at 92% at 12 to 18 months postoperatively, and nighttime continence peaked at 51% at 18 to 36 months. Only 10% of the patients reported clean intermittent catheterization at any time point in the postoperative period (Clifford et al.

Radical prostatectomy is the only form of treatment for localized prostate cancer that has been shown in a randomized controlled trial to reduce progression to metastases and death from the disease (Bill-Axelson et al anxiety symptoms scale order 100mg desyrel amex. Furthermore anxiety symptoms one side of body order desyrel 100 mg fast delivery, on the basis of improved understanding of the periprostatic anatomy anxiety 4 months postpartum buy desyrel 100 mg with mastercard, today less bleeding and improved rates of postoperative continence and potency are seen (Nielsen et al anxiety 0 technique purchase desyrel 100 mg on-line. The three goals of surgery anxiety network 100mg desyrel mastercard, in order of importance anxiety meditation purchase cheapest desyrel, are cancer control, preservation of urinary control, and preservation of sexual function. Great skill and experience in the selection of surgical candidates and operative technique are necessary to achieve all three. These capsular vessels provide the macroscopic landmark to aid in the identification of the microscopic branches of the pelvic plexus that innervate the corpora cavernosa. The major arterial supply to the corpora cavernosa is derived from the internal pudendal artery. However, pudendal arteries can arise from the obturator, inferior vesical, and superior vesical arteries. Because these aberrant branches travel along the lower part of the bladder and anterolateral surface of the prostate, they are divided during radical prostatectomy. This may compromise arterial supply to the penis, especially in older patients with borderline penile blood flow (Breza et al. Pelvic Plexus the autonomic innervation of the pelvic organs and external genitalia arises from the pelvic plexus, which is formed by parasympathetic, visceral, efferent, preganglionic fibers that arise from the sacral center (S2 to S4), and sympathetic fibers via the hypogastric nerve from the thoracolumbar center (Lepor et al. The pelvic plexus in men is located retroperitoneally beside the rectum 5 to 11 cm from the anal verge and forms a fenestrated rectangular plate that is in the sagittal plane with its midpoint at the level of the tip of the seminal vesicle. The branches of the inferior vesical artery and vein that supply the bladder and prostate perforate the pelvic plexus. For this reason, ligation of the so-called lateral pedicle in its midportion not only interrupts the vessels but also transects the nerve supply to the prostate, urethra, and corpora cavernosa. In addition, branches that contain somatic motor axons travel through the pelvic plexus to supply the levator ani, coccygeus, and striated urethral musculature. The nerves innervating the prostate travel outside the capsule of the prostate and Denonvilliers fascia until they perforate the capsule where they enter the prostate. Although these nerves are microscopic, their anatomic location can be estimated intraoperatively by use of the capsular vessels as a landmark. At the apex of the prostate, the branches of the nerves to the cavernous bodies and striated sphincter also have a spraylike distribution both anteriorly and posteriorly with wide variation (Costello et al. After piercing the urogenital diaphragm, the nerve branches pass behind the dorsal penile artery and dorsal penile nerve before entering the corpora cavernosa (Walsh and Donker, 1982). It is necessary to have a complete understanding of these veins to avoid excessive bleeding and to ensure a bloodless field in exposing the membranous urethra and the apex of the prostate. The superficial branch, which travels between the puboprostatic ligaments, is the centrally located vein overlying the bladder neck and prostate. This vein is easily visualized early in retropubic operations and has communicating branches over the bladder itself and into the endopelvic fascia. The common trunk and lateral venous plexuses are covered and concealed by the prostatic and endopelvic fascia. The lateral venous plexuses traverse posterolaterally and communicate freely with the pudendal, obturator, and vesical plexuses. Near the puboprostatic ligaments, small branches from the lateral plexus often penetrate the pelvic sidewall musculature and communicate with the internal pudendal vein. The lateral plexus interconnects with other venous systems to form the inferior vesical vein, which empties into the internal iliac vein. With the complex of veins and plexuses anastomosing freely, any laceration of these friable structures can lead to considerable blood loss. The urethral vessels enter the prostate at the posterolateral vesicoprostatic junction and supply the vesical neck and periurethral portion of the gland. The capsular branches run along the pelvic sidewall in the lateral pelvic fascia posterolateral to the prostate, providing branches that course ventrally and dorsally to supply the outer portion of the prostate. The capsular vessels terminate as a small cluster of vessels that supply the pelvic floor. Location of the superficial and deep branches of the dorsal vein as they travel over the anterior and anterolateral surfaces of the prostate. The pelvic plexus provides visceral branches that innervate the bladder, ureter, seminal vesicles, prostate, rectum, membranous urethra, and corpora cavernosa. The branches that innervate the corpora cavernosa enter in a spraylike distribution 20 to 30 mm distal to the junction of the prostate and bladder, where they continue distally posterolateral to the prostate. The striated urethral sphincter with its surrounding fascia is a vertically oriented tubular sheath that surrounds the membranous urethra. One group, the urethral vessels, enters the prostate at the posterolateral vesicoprostatic junction to supply the bladder neck and periurethral portions of the gland. The second group, the capsular branches, runs along the pelvic sidewall in the lateral pelvic fascia posterolateral to the prostate, providing branches that course ventrally and dorsally to supply the outer portion of the prostate. Note at the apex that small branches of the nerves travel anteriorly away from the vessels. In utero, this sphincter extends without interruption from the bladder to the perineal membrane. In the adult, the fibers at the apex of the prostate are horseshoe shaped and form a tubular, striated sphincter surrounding the membranous urethra. Rather, the external striated sphincter is more tubular and has broad attachments over the fascia of the prostate near the apex. This has important implications in the apical dissection and reconstruction of the urethra for preservation of urinary control postoperatively (Walsh et al. The striated sphincter contains fatigue-resistant, slow-twitch fibers that are responsible for passive urinary control. Active continence is achieved by voluntary contraction of the levator ani musculature, which surrounds the apex of the prostate and membranous urethra. Some fibers of the levator ani (levator urethrae, pubourethralis) surround the proximal urethra and the apex of the prostate and insert into the perineal body in the midline posteriorly (Myers, 1991, 1994). The pudendal nerve provides the major nerve supply to the striated sphincter and levator ani. When patients are instructed to perform sphincter exercises postoperatively, they are actually contracting the levator ani musculature. However, because the striated urethral sphincter has similar innervation, patients are exercising this important muscle as well. Somatic motor nerves traveling through the pelvic plexus provide additional innervation to the pelvic floor musculature (Costello et al. Pelvic Fascia the prostate is covered with three distinct and separate fascial layers: Denonvilliers fascia, the prostatic fascia (also called the capsule of the prostate), and the levator fascia. This fascial layer extends cranially to cover the posterior surface of the seminal vesicles and lies snugly against the posterior prostatic capsule. This fascia is most prominent and dense near the base of the prostate and the seminal vesicles and thins dramatically as it extends caudally to its termination at the striated urethral sphincter. On microscopic Striated Urethral Sphincter the external sphincter, at the level of the membranous urethra, is often depicted as a "sandwich" of muscles in the horizontal plane. Note that at this level, the striated sphincter circumferentially surrounds the urethra. In performing a proper nerve-sparing operation, the prostatic fascia must remain on the prostate. For this reason, one must excise this fascia completely to obtain an adequate surgical margin. In addition to Denonvilliers fascia, the prostate is also invested with the prostatic fascia and levator fascia. Anteriorly and anterolaterally, the prostatic fascia is in direct continuity with the parenchyma of the prostate. The major tributaries of the dorsal vein of the penis and Santorini plexus travel within the anterior prostatic fascia. Posterolaterally, the levator fascia separates from the prostate to travel immediately adjacent to the pelvic musculature surrounding the rectum. In an effort to avoid injury to the dorsal vein of the penis and Santorini plexus during radical perineal prostatectomy, the lateral and anterior pelvic fasciae are reflected off the prostate. This accounts for the reduced blood loss associated with radical perineal prostatectomy. For this reason, the dorsal vein complex must be ligated and the lateral pelvic fascia must be divided (Walsh et al. A lateral view illustrating that the prostate receives its blood supply and autonomic innervation between the layers of the levator fascia and prostatic fascia. The preoperative assessment must identify candidates who are at increased risk for these mortality events to intervene to attenuate these risks. The preoperative assessment should also identify factors that may add to the technical challenge of the surgical procedure, including Chapter 155 prior abdominal or pelvic surgery and irradiation, prior transurethral surgery, extensive prostate biopsies, history of significant inflammatory bowel disease, prior use of mesh during inguinal or incisional hernia repair, and the size of the prostate. Approximately 15% of men undergoing radical prostatectomy will have a coexisting inguinal hernia detected if an appropriate inguinal examination is performed (Lepor and Robbins, 2007). Therefore examination of the inguinal canal with the Valsalva maneuver should be performed, enabling pre-peritoneal hernia repairs at the time of the radical prostatectomy. Surgery is deferred for 6 to 8 weeks after needle biopsy of the prostate and 12 weeks after transurethral resection of the prostate. This delay enables inflammatory adhesions or hematomas to resolve so that the anatomic relationships between the prostate and the surrounding structures return to a nearly normal state before surgery. Donation of autologous blood is not performed at our institutions because transfusion rates are less than 1%. High hematocrit at hospital discharge can improve the pace of recovery (Sultan et al. The recommended prophylactic regimens for open or laparoscopic surgery involving entry into the urinary tract are a first- or secondgeneration cephalosporin or an aminoglycoside in combination with metronidazole or clindamycin (Wolf et al. The preoperative management of anticoagulants and antiplatelet agents used for the treatment of specific medical conditions, such as prosthetic valves, atrial fibrillation, and coronary artery stent implants, should be performed in conjunction with the internist or cardiologist. With nearly 1 million coronary interventions occurring every year and the majority including an implant of a drug-eluting stent, managing prescribed antiplatelet therapy can create a dilemma in balancing the risks for stent stenosis and perioperative bleeding. In the majority of cases, stent thrombosis is a catastrophic event resulting in life-threatening complications (Cutlip et al. The optimal preoperative regimen is often best developed through communication between the surgical/anesthesia team and treating physician (Grines et al. Patients are prescribed a clear liquid diet on the day before surgery, are requested to drink one-half bottle of magnesium citrate in the evening, and have an enema on the morning of surgery. Open Radical Prostatectomy 3551 systolic blood pressure of no more than 100 mm Hg and to limit the replacement of crystalloid to 1500 mL until the prostate is removed (Davies et al. The table can be flexed in obese men to increase the distance between the umbilicus and pubis. The use of a 16-Fr catheter facilitates placement of sutures in the mucosa of the urethra. An extraperitoneal, lower abdominal incision is made extending from the pubis toward the umbilicus. The anterior fascia is incised down to the pubis, the rectus muscles are separated in the midline, and the transversalis fascia is opened sharply to expose the space of Retzius. Laterally, the peritoneum is mobilized off the external iliac vessels to the bifurcation of the common iliac artery. Care is taken to preserve the soft tissue covering the external iliac artery that contains the lymphatics draining the lower extremity. Interruption of these lymphatics may lead to lower extremity edema and lymphocele formation. Exposure for the lymph node dissection is facilitated by placement of a narrow, malleable blade attached to the Balfour retractor beneath the mobilized vas deferens to displace the peritoneum superiorly and a deep Deaver retractor to retract the bladder medially. The dissection proceeds beneath the external iliac vein out to the pelvic sidewall and then inferiorly to the femoral canal, where the lymphatic channels are ligated at a convenient point. The dissection then proceeds cranially along the pelvic sidewall to the bifurcation of the common iliac artery, where the lymph nodes in the angle between the external iliac and hypogastric arteries are removed. Next, the obturator lymph nodes are removed with care to avoid injury to the obturator nerve.

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