Use of Intestinal Segments in Urinary Diversion

Question 1

When a portion of stomach is to be used for augmentation, it should:
a. always be based on the right gastroepiploic artery.
b. include only the antrum.
c. never extend to the pylorus.
d. include a significant portion of the lesser curve.
e. be mobilized with the omentum.

Answer 1

c. Never extend to the pylorus. When a wedge of fundus is used, it should not include a significant portion of the antrum and should never extend to the pylorus or all the way to the lesser curve of the stomach.

Question 2

The ileum differs from the jejunum in that:
a. it has a larger diameter.
b. the mesentery is thinner.
c. it has multiple arcades.
d. the vessels in the mesentery are larger.
e. the mesentery is longer.

Answer 2

c. It has multiple arcades.The ileum, more distal in location, has a smaller diameter. It has multiple arterial arcades, and the vessels in the arcades are smaller than those in the jejunum.

Question 3

When stomach is used for urinary diversion, the electrolyte abnormality that may occur is most commonly what type of metabolic alkalosis?
a. Hyperchloremic
b. Hypochloremic
c. Hyperkalemic
d. Hypernatremic
e. Hypocalcemic

Answer 3

b. Hypochloremic. Complications specific to the use of stomach include the hematuria-dysuria syndrome and uncontrollable metabolic alkalosis in some patients. When stomach is used, a hypochloremic, hypokalemic metabolic alkalosis may ensue.

Question 4

Postoperative bowel obstruction is most common when which of the following segments is used for diversion?
a. Right colon
b. Stomach
c. Sigmoid
d. Ileum
e. Transverse colon

Answer 4

4. d. Ileum. The incidence of postoperative bowel obstruction is 4% to 10%. Colon, stomach, and sigmoid obstruction result in a 4% incidence, less than that occurring with ileum.

Question 5

Mechanical bowel preparation results in a reduction in:
a. bacterial counts per gram of enteric contents.
b. bacterial count in the jejunum.
c. total number of bacteria in the bowel.
d. bacterial counts in the stomach.
e. bacterial counts in the ileum.

Answer 5

c. Total number of bacteria in the bowel. The mechanical preparation reduces the amount of feces, whereas the antibiotic preparation reduces the bacterial count. A mechanical bowel preparation reduces the total number of bacteria but not their concentration.

Question 6

Systemic antibiotics in elective surgery should be given:
a. before the patient is anesthetized.
b. before the skin incision is made.
c. intraoperatively before closure commences.
d. at any time in the perioperative period.
e. postoperatively for 3 to 5 days.

Answer 6

a. Before the patient is anesthetized.Systemic antibiotics must be given before the operative event if they are to be effective.

Question 7

The most common cause of a lethal bowel complication is:
a. use of previously irradiated bowel.
b. lack of mechanical bowel prep.
c. lack of antibiotic bowel prep.
d. placement of a drain adjacent to the anastomosis.
e. failure to give preoperative antibiotics.

Answer 7

a. Use of previously irradiated bowel. In one study of urinary intestinal diversion, 75% of the lethal complications that occurred in the postoperative period were related to the bowel. Eighty percent of these patients had received radiation before the intestinal surgery.

Question 8

When stapled anastomoses are compared with sutured anastomoses, there is/are:
a. fewer leaks.
b. less compatibility with urine.
c. reduced overall operative time.
d. lesser incidence of bowel obstruction.
e. earlier return of bowel function.

Answer 8

b. Less compatibility with urine. In general, anastomoses using reabsorbable sutures or reabsorbable staples are preferable for intestinal segments that are exposed to urine.

Question 9

The use of a nasogastric tube in the postoperative period:
a. hastens the return of intestinal motility.
b. reduces the incidence of bowel leak.
c. reduces postoperative vomiting.
d. increases the risk of aspiration.
e. reduces the incidence of anastomotic leak.

Answer 9

c. Reduces postoperative vomiting. In several studies there was no significant difference in major intestinal complications between those who had postoperative nasogastric tubes and those who did not; however, those who did not have gastric decompression showed a much greater incidence of abdominal distention, nausea, and vomiting.

Question 10

The abdominal stoma for a conduit should be:
a. flush with the skin.
b. placed through the belly of the rectus muscle.
c. made as a loop to reduce parastomal hernia.
d. made with the colon for the lowest complication rate.
e. placed in the right lower quadrant.

Answer 10

b. Placed through the belly of the rectus muscle.All stomas should be placed through the belly of the rectus muscle and be located at the peak of the infraumbilical fat roll.

Question 11

The loop end ileostomy is best used in:
a. the obese patient.
b. the thin patient.
c. when a stoma is revised.
d. in female patients.
e. in spinal cord injury patients.

Answer 11

a. The obese patient. The loop end ileostomy is usually easier to perform than the ileal end stoma in the patient who is obese.

Question 12

Ureteral strictures occurring after an ileal conduit not associated with the ureteral intestinal anastomosis most frequently occur:
a. at the ureteropelvic junction.
b. in the right ureter several centimeters proximal to the ureteral intestinal anastomosis.
c. on the left side where the ureter crosses the aorta.
d. in the mid-ureter.
e. in either ureter within several centimeters proximal to the anastomosis.

Answer 12

c. On the left side where the ureter crosses the aorta. Of importance is that ureteral strictures also occur away from the ureterointestinal anastomosis. This stricture is most common in the left ureter and is usually found as the ureter crosses over the aorta beneath the inferior mesenteric artery.

Question 13

Renal deterioration after a conduit diversion with normal kidneys occurs in what percent of renal units?
a. 20%
b. 40%
c. 50%
d. 70%
e. 80%

Answer 13

a. 20%. Patients who are studied during the long term show a significant degree of renal deterioration. Indeed, 20% of renal units have shown significant anatomic deterioration.

Question 14

The most common cause of death in patients with ureterosigmoidostomies during the long term is:
a. cancer.
b. renal failure.
c. acid–base abnormalities.
d. the primary disease.
e. ammonium intoxication.

Answer 14

b. Renal failure. The most common cause of death in patients who have had a ureterosigmoidostomy for more than 15 years is acquired renal disease (i.e., sepsis or renal failure).

Question 15

The minimal glomerular filtration rate (GFR) in mL/min necessary for a continent diversion is:
a. 70.
b. 60.
c. 35.
d. 25.
e. 20.

Answer 15

b. 60.If the patient is able to achieve a urine pH of 5.8 or less, can establish a urine osmolality of 600 mOsm/kg or greater in response to water deprivation, has a GFR that exceeds 60 mL/min, and has minimal protein in the urine, he or she may be considered for a retentive diversion.

Question 16

The urinary diversion with the fewest intraoperative and immediate postoperative complications is:
a. ileal conduit.
b. colon conduit.
c. Koch pouch.
d. Indiana pouch.
e. neobladder.

Answer 16

a. Ileal conduit. It is the simplest type of conduit diversion to perform and is associated with the fewest intraoperative and immediate postoperative complications.

Question 17

The jejunal conduit syndrome is manifested by:
a. hyperchloremic metabolic acidosis.
b. hypochloremic metabolic alkalosis.
c. hyperkalemic, hyponatremic metabolic acidosis.
d. hypokalemic, hyponatremic metabolic alkalosis.
e. hyperkalemic metabolic alkalosis.

Answer 17

17. c. Hyperkalemic, hyponatremic metabolic acidosis. The early and long-term complications are similar to those listed for ileal conduit except that the electrolyte abnormality that occurs is hyperkalemic, hyponatremic metabolic acidosis instead of the hyperchloremic metabolic acidosis of ileal diversion.

Question 18

The primary advantage of a transverse colon conduit is:
a. its ease of construction.
b. the ability to perform a non-refluxing anastomosis.
c. less likely to be injured by radiation.
d. reduced electrolyte problems.
e. equidistant from each kidney, allowing for short ureteral length on both sides.

Answer 18

c. Less likely to be injured by radiation. The transverse colon is used when one wants to be sure that the segment of conduit used has not been irradiated in individuals who have received extensive pelvic irradiation.

Question 19

Total body potassium depletion is most common in:
a. ureterosigmoidostomy.
b. ileal conduit.
c. colon conduit.
d. sigmoid conduit.
e. gastrocystoplasty.

Answer 19

a. Ureterosigmoidostomy. Hypokalemia and total body depletion of potassium may occur in patients with urinary intestinal diversion. This is more common in patients with ureterosigmoidostomies than it is in patients who have other types of urinary intestinal diversion.

Question 20

In urinary intestinal diversion, serum creatinine may not be an accurate reflection of renal function because of:
a. interfering substances.
b. tubule secretion.
c. tubule reabsorption.
d. bowel reabsorption.
e. decreased renal elimination.

Answer 20

d. Bowel reabsorption.Because urea and creatinine are reabsorbed by both the ileum and the colon, serum concentrations of urea and creatinine do not necessarily accurately reflect renal function.

Question 21

Patients with urinary diversions who have a hyperchloremic metabolic acidosis with time:
a. retain the ability to maintain the acidosis.
b. lose the ability for electrolyte transport in the intestinal segments.
c. compensate for the metabolic acidosis, thus eliminating risk.
d. intermittently absorb ammonia when infection is present.
e. tend to retain potassium.

Answer 21

a. Retain the ability to maintain the acidosis. The ability to establish a hyperchloremic metabolic acidosis appears to be retained by most segments of ileum and colon over time.

Question 22

Bone density abnormalities:
a. are unlikely to occur with ileum.
b. are most likely to occur with colon.
c. are more common in patients with persistent hyperchloremic metabolic acidosis.
d. are common in patients with total body potassium depletion.
e. are unlikely to occur in patients with conduits.

Answer 22

c. Are more common in patients with persistent hyperchloremic metabolic acidosis.Osteomalacia in urinary intestinal diversion may be due to persistent acidosis, vitamin D resistance, and excessive calcium loss by the kidney. It appears that the degree to which each of these contributes to the syndrome may vary from patient to patient.

Question 23

Urinary intestinal diversion in children:
a. increases the need for vitamin D.
b. increases the need for calcium.
c. limits linear growth.
d. decreases epiphyseal growth.
e. results in premature epiphyseal closure.

Answer 23

c. Limits linear growth. There is considerable evidence to suggest that urinary intestinal diversion has a detrimental effect on growth and development.

Question 24

Cancer occurring in urinary intestinal diversion is most likely to occur in:
a. augmentations.
b. colon conduits.
c. ileal conduits.
d. ureterosigmoidostomies.
e. sigmoid conduits.

Answer 24

d. Ureterosigmoidostomies. The highest incidence of cancer occurs when the transitional epithelium is juxtaposed to the colonic epithelium and both are bathed by feces.

Question 25

Reconfiguring the bowel during the long term results in:
a. decreased motor activity.
b. increased volume.
c. decreased metabolic complications.
d. decreased absorption of solutes.
e. increased absorption of solutes.

Answer 25

b. Increased volume. Reconfiguring bowel usually increases the volume, but its effect on motor activity and wall tension over the long term is unclear at this time.

Question 26

The syndrome of severe metabolic alkalosis in patients who have had a gastrocystoplasty is most likely to occur in patients who have:
a. decreased aldosterone levels.
b. jejunum interposed in the urinary tract.
c. total body potassium depletion.
d. elevated gastrin levels.
e. decreased renin levels.

Answer 26

d. Elevated gastrin levels.The syndrome of severe metabolic alkalosis is most likely to occur in patients with high resting gastrin levels who are dehydrated and fail to empty their pouch in a timely manner.

Question 27

There is direct evidence from cystectomy patients that the following can be safely omitted from an enhanced recovery after surgery (ERAS) protocol:
a. preoperative fasting
b. thrombosis prophylaxis
c. mechanical bowel prep
d. pelvic drain
e. preoperative intravenous antibiotics

Answer 27

c. Mechanical bowel prep. There is direct evidence for omission of a mechanical bowel can be safely omitted from cystectomy and urinary diversion patients on an ERAS pathway. Thrombosis prophylaxis (b.) and perioperative antibiotics (e.) should never be omitted. There is evidence that preoperative fasting (a.) and a pelvic drain (d.) may be safely omitted in colorectal surgery patients, but this has not be studied in depth in cystectomy population.

Question 28

Arginine hydrochloride infusion can be used to treat life-threatening complications caused by the following type of conduit:
a. stomach
b. jejunum
c. ileum
d. colon
e. all of the above

Answer 28

a. Stomach. Only urinary diversion consisting of stomach result in metabolic alkalosis. Arginine hydrochloride infusion plays no role in the management of acidosis caused by other bowel segments.

Question 29

Perioperative care. The use of a preoperative mechanical bowel prep, oral antibiotic bowel prep, and postoperative nasogastric tube decompression in patients undergoing bowel surgery is?

Administering intravenous antibiotics 1 h before the surgical incision is not controversial and is supported by many studies. Patients undergoing elective intestinal surgery in the studies that show no advantage to a mechanical and/or antibiotic bowel prep received preoperative intravenous antibiotics. It should be appreciated that the majority of these studies involve isolated anastomoses—not large segments of bowel that are opened, as is the case in urologic procedures.

Answer 29

Controversial and can be safely omitted in appropriately selected patients.

Question 30

Ureteral intestinal anastomotic strictures. Antirefluxing anastomoses have a ? stricture rate; refluxing anastomoses have a ? stricture rate. The ? has the lowest stricture rate.

Answer 30

10%–20%;
3%–10%;
Wallace ureteral intestinal anastomosis

Question 31

Renal function and urinary diversion. Serum creatinine and blood urea nitrogen do not accurately reflect renal function in patients with intestine in the urinary tract because these substances, when excreted by the kidney, are reabsorbed by the bowel. This is more likely to be a problem in ?.

A glomerular filtration rate (GFR) of at least ? and an ability to ? are necessary prerequisites for a continent diversion.

Answer 31

continent diversions;
60 mL/min;
acidify the urine

Question 32

Table 139.1
Syndromes of Electrolyte Disturbances in Patients in Whom the Bowel is Interposed in the Urinary Tract

Answer 32

Question 33

Significant perioperative infectious complications occur in up to ? undergoing cystectomy and urinary diversion.

Answer 33

10% of patients

Question 34

The most common cause of mortality in urologic procedures when the gut is used relates to ?

Answer 34

complications involving the bowel.

Question 35

Complications specific to the use of stomach include the ? and ? in some patients.

Answer 35

hematuria-dysuria syndrome; uncontrollable metabolic alkalosis

Question 36

The incidence of postoperative bowel obstruction is ?. Colon, stomach, and sigmoid obstruction result in a ? incidence, less than that occurring with ileum.

Answer 36

4%–10%; 4%

Question 37

The mechanical preparation reduces ?, whereas the antibiotic preparation reduces the ?

Answer 37

the amount of feces and therefore total bacteria; bacterial count and therefore the concentration of bacteria.

Question 38

If the patient is able to achieve a urine pH of ?, can establish a ?, has a GFR that exceeds ?, and has ?, he or she may be considered for a retentive diversion.

Answer 38

5.8 or less; urine osmolality of 600 mOsm/kg or greater in response to water deprivation; 60 mL/min; minimal protein in the urine

Question 39

Osteomalacia in urinary intestinal diversion may be due to ?, ?, and ?.

Answer 39

persistent acidosis; vitamin D resistance; excessive calcium loss by the kidney

Question 40

In patients with gastric tissue in the urinary tract (usually gastrocystoplasty), the syndrome of ? is most likely to occur in those with high resting gastrin levels who are dehydrated and fail to empty their pouch in a timely manner.

Answer 40

severe metabolic alkalosis