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Continent cutaneous urinary diversion (CCUD) requires the use of intestinal segment to construct a urinary reservoir as well as a catheterizable continence mechanism. It constitutes an ideal solution for patients who are not candidates for orthotopic neobladder and do not want to have incontinent diversions. In this chapter, we explain the selection and preparation process for patients undergoing radical cystectomy with CCUD. We also describe the most commonly used surgical techniques for CCUD and focus mostly on Indiana pouch creation, which is the most common CCUD performed at our institution.

Recent advances in transperineal and endovaginal ultrasound have enabled better understanding of static and dynamic sling function. There is compelling evidence in favor of the primacy of location in the continence mechanism of slings. However, sling location is only one component underlying dynamic sling function: best outcomes following sling surgery are found to be associated with concordance of urethral movement with the sling and midurethral location at maximal Valsalva followed by deformability of the sling on dynamic assessment. The three parameters often work together to compensate for the failure of an individual parameter to ensure successful outcome. Voiding dysfunction or de novo urgency is more common if the tape is placed too tightly. Patients who undergo transobturator sling surgery and cystocele repair through the same incision are more likely to have the sling located more proximally when compared with patients who undergo sling surgery alone. Lastly determination of the location of a failed sling is an essential step in deciding the future course of treatment.

ProACT is an extra urethral bulking system made of a silicone balloon connected with a dual lumen tubing (12–14 cm) to a titanium scrotal port that allows the postoperative adjustment (Fig. 6.1). It was introduced in the European market in 2000 as the first non-circumferential compressive device. The continence mechanism is guaranteed by a bilateral compression of the urethra, augmenting maximum urethral closure pressure (MUCP). In a study by Reuvers et al. this mechanism was demonstrated in a cohort of 23 successfully implanted patients in which a significant increase in MUCP from 58 cmH2O to 79 cmH2O was observed [1].

The continent cystostomy technique was first described by Mitrofanoff in 1980 and originally applied to children with neurological disorders [1]. It consists in fashioning a catheterizable channel with a flap-valve continence mechanism, in order to be both continent to promote storage and accessible to allow emptying. This method allows an alternative procedure for patients with urethral disease (congenital or acquired after surgery: exstrophy-epispadias complex) or for those with neurological disabilities who are unable or unwilling to access the urethral meatus. Indications for the procedure are varied: it may be used as isolated procedure for clean intermittent catheterization (CIC) or associated with bladder augmentation and another bladder surgery.

Continent cutaneous urinary diversion (CCUD) utilizes an intestinal segment to create a low-pressure urinary reservoir and a catheterizable continence mechanism. It provides a urinary tract reconstruction option for patients who are not candidates for continent orthotopic urinary diversion and in patients with whom an ileal conduit is not desirable. The ideal candidate for a CCUD is the same patient who would be considered for orthotopic neobladder but may not have a usable urethra. In this chapter, we describe the surgical technique used for the most commonly used CCUDs.

Neurophysiologic function of the continence mechanism in the male has been largely focused on voiding difficulties and directed to explore the obstruction instead of incontinence. Over the past 20 years, much has been elucidated about the pathophysiology of male SUI. As improved diagnostic modalities have provided new insight into the function and dysfunction of the urethral continence mechanism, theories have evolved from being purely anatomic to being both functional and anatomic.