الفهرس 
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Abstract
Summary and conclusion
The history of continent cutaneous diversion dates back to 1908 when
Verhoogen and Makkas used the excluded ileocecal segment as a reservoir and the
appendix as an outlet valve.
Indications of continent cutaneous urinary diversion are Pelvic malignancies
as Invasive bladder cancer and gynecologic malignancies, Non Malignant
Indications include neurogenic bladder, Bladder extrophy-Epispadias complex,
Complicated recurrent cases of urethral stricture and Conversion to continent
cutaneous diversion.
Renal and hepatic insufficiency are absolute contraindications. Relative
contraindications are age aove 70 years old, multiple sclerosis, quadriplegic
individuals, frail, mentally impaired patients and impaired intestinal function.
Many types of reservoirs are described and classified according to the bowel
segment used in; ileocolonic reservoirs depending on the ileo-caecal valve as a
continent mechanism (Glichrist pouch, Mainz pouch I, Indiana pouch, Florida
pouch, Miami Pouch and Penn Pouch), Ileal Reservoir (Kock pouch, Hemi Kock
procedure and double T-pouch), Gastric reservoirs and Colonic reservoirs (Mainzpouch
III).
There are four Principles of construction of continent outlet: Anti-peristaltic
ileal segment , Passive tubular resistance mechanism, Pressure equilibrium
principle, The flap valve principle.
Many Types of continent outlet are described: Ileal Nipple Valve, Serous
lined Extramural Valve, Plicated Terminal Ileum (Indiana Type Outlet), Appendix
outlet and Mitrofanoff principle Wich considerd one of the most important
techniques in CCD many authers discribed altrnatives to the appendix as (the
ureter, fallopian tubes, gastric tube, tapered ileum, continent vesicostomy and
large bowel tube), Hydraulic Ileal Valve (Benchekroun technique) which is n
longer practiced due to high falure rate, Monti technique with its modifications as
full monti, spiral monti.
Selection of the stomal site is the most important factor for success. There are
two favorite sites for stomal location which are at the umbilicus and in the lower
quadrant of the abdomen through the rectus bulge and below the bikini line.
Stomal application to the skin have several modalities: Flush stoma, Nipple
stoma, Y-V Plasty stoma and VQZ plasty stoma; the later is the most cosmotic and
have the lowest risk of stenosis.
Continence is the challenging goal of CCD. Serous lined extramural tunnel
reported the highst continence success rate of all the above mentioned types of
continence (up to 100% continence) followed by Mitroffanof appendix stoma
(93%) then ileal nipple valve(87%).
The existing literature does not support the assumption that continent
reconstruction provides higher QOL than ileal conduit diversion. So ilal conduit is
still the gold standard technique for urinary diversion.
The preservation of renal function is both the ultimate goal and an essential
prerequisite of successful intestinal urinary diversion. No or minimal impairment
of the kidney function had been reported with continent urinary diversion.
The growing number of techniques described for achieving continence in
urinary reconstruction indicates that a universally applicable procedure with low
complication rates has not yet evolved.
Complications related to the upper tract are Ureterointestinal stenosis or
stricture which is the most serious complications inherent to urinary diversion, the
overall incidence of anastomotic stricture after urinary diversion is 3% to 9 % and
Pouchoureteral reflux.
Complications related to the pouch are rupture of the pouch (rare), urinary
tract infection 56-71%, excessive mucous secretion and Stone formation.
Complications related to the stoma are parastomal hernia (0-5%),stomal
stenosis and difficult catheterization ( 4 years follow up reports 1-2% incidence
with appendix , 3–6% plicated tubes and 9 % with intussuscepted valves)
incontinence (5.8% with intussuscepted ileal nipple valves, 3% with a tunneled
appendix, and 0.6% with stapled plicated ileocecal valves), urine retention wich
represents a true emergency, stomal Prolapse; a one of the most common
complications, parastomal pyoderma gngrenosum and parastomal varices in
hepatic patients.
Complications of the intestinal anastomosis are fistulas(fecal and urinary
with mortality rate 2%), sepsis and other infectious complications (The overall
septicemia rate after radical cystectomy is currently 3.6% with a 17% mortality
rate), bowel obstruction( 5% with colonic reservoirs, 10% with gastric and ileal
reseroirs), hemorrhage ( a rare complication), intestinal stenosis and pseudoobstruction
(Ogilvie’s syndrome).
Metabolic complications including; complications following exclusion of
intestinal segment(diarrhea, lipid malabsorption and vitamin B12 deficiency),
complications due to urine storage in intestinal reservoirs (hyperchloremic
metabolic acidosis, hypokalemia, hypocalcaemia, hypomagnesaemia and
ammoniagenic encephalopathy), bone disease (osteomalacia), altered sensorium
(due to magnesium deficiency, drug intoxication, or ammoniagenic
encephalopathy), abnormal drug absorption and carcinogenesis