Part 1 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder

Author(s): 
Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN



Familial adenomatous polyposis is an inherited disorder in which the affected person's large intestine contains multiple polyps. The polyps have a virtually 100% chance of malignant degeneration. Familial polyposis occurs across the world at an incidence of 1:10,000 to 1:20,000 in the population.6,7 Conversely, CUC occurs mostly in the Scandinavian countries, Great Britain, and North America at a rate of 1 to 15 cases per 100,000 population or 1 in 160 people.8,9 Because of the substantially lower occurrence of FAP, not as many persons undergo IAR surgery for the disorder.

Ileoanal reservoir surgery is used in persons suffering from only one form of inflammatory bowel disease - CUC, a condition that affects the inner lining of the large intestine. The bleeding, pain, mucus, and other symptoms can be treated definitively if the diseased tissue is surgically removed - that is, by total colectomy. Chronic ulcerative colitis is also associated with a higher incidence of colon cancer development. About 5% of persons with ulcerative colitis develop colon cancer.10 The risk of malignant degeneration over time is eradicated when the entire large intestine is removed. Because CUC sufferers are often younger persons, the IAR offers eradication of a horrible disease state along with preservation of their native anal sphincters.

Ileoanal reservoir surgery is not performed in people with Crohn's disease because the disease potentially affects the entire gastro-intestinal tract, including the ileum. Some research suggests that complications (eg, anal complications) are associated with people who were later diagnosed with Crohn's disease.11 When people have indeterminate colitis (IC), it is not certain whether their disease is CUC or Crohn's.12 The challenge for future care is to develop better diagnostic tests to truly rule out Crohn's disease. Therefore, in a person with IC, the choice of pouch surgery as an option is left to the colorectal surgeon and the patient.3

Bladder cancer is the fourth most common cancer in men, the eighth most common cancer in women, and the sixth most common cause of cancer deaths in the US.13 The American Cancer Society estimates that in 2004, approximately 60,240 new cases of bladder cancer (44,640 men and 15,600 women) will be diagnosed in the US.13 Bladder cancer affects twice as many men as women. The incidence of bladder cancer rises dramatically with age among men and women in all populations. Rates among people 70 years old and older are about 15 to 20 times higher than those age 30 to 54 years.14 The disease is most often linked with cigarette smoking,15 which is known to increase a person's risk of bladder cancer by at least threefold. The length of time of smoking appears to be the most important predictor of that risk.16

Occupational exposures also contribute to bladder cancer, particularly a group of chemicals known as arylamines; therefore, occupations with exposure to arylamines, (dye workers, rubber workers, leather workers, truck drivers, painters, and aluminum workers) are at higher risk. Other risk factors include exposure to certain drugs like arsenic and cyclophosphamide, frequent urinary tract infections, and infections from the parasite, schistosomiasis.17

The most common histologic type of bladder tumor is the "transitional" cell or "urothelial" cell form. Eighty percent of bladder tumors are "superficial"; they do not invade the bladder wall. As long as it is superficial, the tumor can be controlled by periodic surveillance, instillation of intravesical chemotherapy, and/or transuretheral resection of the bladder tumor (TURBT).

References: 

1. Colwell JC, Goldberg M, Carmel, J. The state of the standard diversion. Journal of WOCN. 2001;28(1):6-17.
2. Colwell JC, Gray M. What functional outcomes and complications should be taught to the patient with ulcerative colitis or familial adenomatous polyposis who undergoes ileal pouch anal anastomosis? Journal of WOCN. 2000;28(4):184-189.
3. Hocevar BJ, Remzi F. The ileal pouch anal anastamosis: past, present, and future. Journal of WOCN. 2001;28(1):32-36.
4. Young M. Caring for patients with coloanal reservoirs for rectal cancer. MEDSURG Nursing. 2000;9(4):193-197.
5. Choi JS, Wexner S. Secondary reconstruction of an ileal reservoir in patients with failed straight ileoanal pull-through: report of two cases. Techniques in Coloproctology. 2002;6:183-186.
6. FAP - Familial adenomatous polyposis. Resources for Genetic Counselors 2003. Available at: www.genesoc.com. Accessed February 25, 2004.
7. Familial Adenomatous Polyposis Sydrome. Generations - Hereditary Gastrointestinal Cancer Registry 2003. Available at: www.generations.HK.com. Accessed February 25, 2004.
8. DIY Medical Knowledge. Ulcerative Colitis. Available at: www.diy-medical-knowledge.com Accessed February 24, 2004.
9. Johns Hopkins Digestive Disease Library - Colon + Rectum: Ulcerative Colitis 2004. Available at: www.hopkins-gi.org. Accessed February 24, 2004.
10. Ulcerative colitis. National Digestive Diseases Information Clearinghouse 2004. Available at: www.digestive.niddk.nih.gov. Accessed February 25, 2004.
11. Rossi HL, Brand M, Saclarides TJ. Anal complications after restorative proctocolectomy (J-Pouch). American Surgeon. 2002;68:628-630.
12. Metcalf C. Crohn's disease: an overview. Nursing Standard. 2002;16(31):45-52.
13. American Cancer Society. What are the key statistics for bladder cancer: 2004? Available at: www.cancer.org. Accessed February 25, 2004.
14. Urinary bladder: U.S. racial/ethnic cancer patterns. National Cancer Institute. Available at: www.cancer.gov. Accessed February 25, 2004.
15. Bladder Cancer 2003. Cancersource.com. Available at: www.cancersource.com. Accessed February 25, 2004.
16. Pashos CL, Botteman MF, Laskin BL, Redaelli A. Bladder cancer: epidemiology, diagnosis, and management. Cancer Practice. 2002;10(6):311-322.
17. Bladder Cancer Statistics and Risk Factors 2003. www.bladder-cancer-symptoms.com. Accessed February 25, 2004.
18. Krupski T, Theodorescu D. Orthotopic neobladder following cystectomy: indications, management, and outcomes. Journal of WOCN. 2001;28:37-46.
19. Beitz J. The lived experience of having an ileoanal reservoir. Journal of WOCN. 1999;26:185-200.
20. Sercombe J. Surgical therapy for inflammatory bowel disease. Nursing Times. 2001;97(10):34-36.
21. Thirlby RC, Land JC, Fenster F, Lonborg R. Effect of surgery on health-related quality of life in patients with inflammatory bowel disease. Archives of Surgery. 1998;133:826-832.
22. Hull TL. Ileoanal procedures: acute and long-term management issues. Journal of WOCN. 1999;26(4):201-206.
23. Follett SB. From uninformed patient to CWOCN: my life with ulcerative colitis and the ileoanal reservoir. Journal of WOCN. 2003;30(1):4-6.
24. Pace DE, Seshadri PA, Chiasson MD, Poulin EC, Schlachta CM, Mamazza J. Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis. Surgical Laparoscopy, Endoscopy + Percutaneous Techniques. 2002;12(5):337-341.
25. Gullberg K, Liljeqvist L. Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. International Journal of Colorectal Disease. 2001;16(4):221-227.
26. Choi H, Saigusa N, Choi J, Shin E, Weiss E, Nogueras J, Wexner S. How consistent is the anal transitional zone in the double stapled ileoanal reservoir? International Journal of Colorectal Disease. 2003;18:116-120.
27. Laureti S, Ugolini F, D'Errico A, Rago S, Poggioli, G. Adenocarcinoma below ileoanal anastamosis for ulcerative colitis: report of a case and review of the literature. Diseases of the Colon + Rectum. 2002;45(3):418-421.
28. Vieth M, Grunewald M, Niemeyer C, Stolte M. Adenocarcinoma in an ileal pouch after prior proctocolectomy for carcinoma in a patient with ulcerative pancolitis. Virchow's Archives. 1998;433(3):281-284.
29. Tulchinsky H, Cohen C, Nicholls R. Salvage surgery after restorative proctocolectomy. British Journal of Surgery. 2003;90(8):909-921.
30. MacLean AR, O'Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed ileal pouch - anal anastomosis. Diseases of Colon + Rectum. 2002;45(7):880-886.
31. Weiss EG, Wexner S. Surgical therapy for ulcerative colitis. Gastroenterology Clinics of North America. 1995;24(3):559-575.
32. Wei JT, Park J, Vallorosi C, Wood D, Montie JE. Gender differences in urinary function after orthotopic neobladder surgery. Contemporary Urology. 2001;7:50-64.
33. Kane A. Criteria for successful neobladder surgery: patient selection and surgical construction. Urologic Nursing. 2000;20(3):182-188.
34. Polt CA. The ins and outs of continent urinary diversions. Nursing Spectrum. 2003;12(22 PA):22-24.
35. Stein JP, Skinner DG. T-mechanism applied to urinary diversion: the orthotopic T-Pouch ileal neobladder and cutaneous double T-pouch ileal reservoir. Techniques in Urology. 2001;7(3):209-222.
36. McGuire S, Girmaldi G, Grotas J, Russo P. The type of urinary diversion after radical cystectomy significantly impacts on the patient's quality of life. Annals of Surgical Oncology. 2000;7(1):4-8.
37. Kulkarni J N, Pramesh CS, Rathi S, Pantvaidya GH. Long-term results of orthotpic neobladder reconstruction after radical cystectomy. BJU International. 2003;91(6):485-488.
38. Kucyk M, Machtens S, Bokemeyer C, et al. Surgical bladder preserving strategies in the treatment of muscle-invasive bladder cancer. World Journal of Urology. 2002;20:183-184.



Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.