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Bladder Replacement
Urine is produced by filtering blood through the kidneys. Urine accumulates in the renal collecting system
(called the renal calyces and pelvis). The urine then flows down the ureters into the bladder. The bladder
stores the urine under low pressure. When there is enough urine in the bladder, a signal is sent to the brain
which triggers bladder emptying. 

When the bladder is removed (either for cancer or other reasons), urine must be diverted outside the body.
This can be accomplished a number of different ways.

Many attempts have been made to make an artificial bladder out of synthetic (man-made) products. No
such development has been successful to date. The use of human bowel segments (both large and small
intestine) have been used with success. Use of bowel segments can be divided into continent and non-
continent urinary diversions. 

A non-continent urinary diversion typically consists of a piece of bowel which acts as a conduit taking
urine from the ureters through bowel to the skin in a continuous flow pattern. This requires an appliance
(stoma bag) on the skin to collect the urine. 

A continent urinary diversion attempts to mimic the action of the normal bladder by storing urine for a
period of time at low pressure. Drainage of urine is performed by either normal voiding through the urethra
or catheterization of either the urethra or a reservoir of bowel. This type of diversion does not require a skin
appliance (bag). 

Patient Selection
Ileal Conduit

 Patient choice
 Elderly
 Renal insufficiency (kidney disease)
 Patient Non-compliance (unreliable patient)
 Multiple other medical problems
 Extensive tumor volume or specific tumor location

Continent Urinary Diversion

 Patient choice
 Relatively young
 Adequate renal function (kidneys function well)
 Compliant patient (reliable patient)
 Acceptable medical risk
 Relatively low tumor volume, no involvement of urethra

Non-Continent Urinary Diversions

Ileal Conduit
The bowel is divided into small bowel and large bowel. The ileum is the second half of the small bowel prior
to the transition to large bowel. A segment of ileum approximately 15 cm. (7 inches) is separated from the
small bowel. This is isolated and brought to the skin. Typically the bowel is everted at the junction with the
skin in an attempt to minimize contact of the urine with skin. The ureters are connected to this isolated
piece of bowel. Urine then flows from the kidney to the ureter, through the ileal segment and into a
collection device on the skin. This collection device, referred to as an "appliance", is emptied periodically
during the day. The appliance is typically changed every 3 to 5 days.

The ileal conduit is the simplest of the forms of urinary diversion. This can be performed even when the
bladder is left in place. Benefits include a lower complication rate, ease of use, and shorter operative time to
complete. Postoperative care is less complicated in comparison to other forms of urinary diversion 
Percutaneous Neprostomy
Percutaneous nephrostomy drainage consists of the use of tube(s) to drain the kidneys. These tubes can be
either temporary or permanent. These tubes are made of a soft plastic material which needs to be changed
monthly. Benefits include decreased operative risk as these can be placed in radiology and do not require a
general anesthetic for placement. Downsides of the procedure include patient discomfort, frequency of tube
change required, and increased risk of infection. This is not a typical type of diversion used when the
bladder is removed. Typically, this may be used temporarily before bladder removal is performed or if a
patient is unable to undergo a more complicated procedure. 

Continent Urinary Diversion

The normal function of the urinary bladder is to store urine at low pressure and empty urine when required.
A continent urinary diversion attempts to mimic this function through the use of bowel. Surgeons use a
portion of the patient's own bowel to reconstruct a new bladder. In order to do this, certain principles must
be adhered to. The bowel has muscle within the wall which aids in the propulsion of stool through the
gastrointestinal tract. This muscle tone must be reduced or eliminated in order to make an effective urinary
reservoir. This is accomplished by a process known as detubularization. In this way, we divide the bowel and
sew it back together to form a spherical rather than tubular reservoir. In so doing, the pressure generated
by the reservoir is decreased and the volume is increased. This principle is known as Laplace's law and is the
basis for continent urinary diversion. 
Continent neobladders are grouped into orthotopic and non-orthotopicreplacements. Orthotopic
neobladders are placed in the pelvis (where the bladder was prior to removal) and are connected to the
urethra (as a normal bladder would be). Non-orthotopic neobladders are located in the abdomen, are not
connected to the urethra, and require catheterization to drain. 

Orthotopic Neobladder
Orthotopic neobladder is a urinary diversion which typically utilizes small bowel to construct a new bladder
for the patient. This is usually performed in males but can be performed in selected females as well. This
type of urinary diversion uses 40 to 60 cm. of small bowel (ileum) to form the urinary diversion pouch. The
ileum is separated from the remaining portion of the bowel and isolated. The ileum is then divided to
increase storage volume and decrease the pressure generated within the pouch. Next, the ureters are
attached to the pouch with temporary stents in place to aid in the healing process. The lowest portion of the
pouch is then connected to the urethra to complete the restoration of the urinary tract. Typically, a series of
tubes, all temporary, are used to drain the diversion. This consists of ureteral drainage stents (from the
kidney to the pouch), a Foley catheter (from the pouch out of the body through the urethra), and a
suprapubic tube (from the pouch out of the body through the skin). 

Below are representations of the various steps in the procedure. 

After the operation, patients typically can expect to stay in the hospital for 5 - 7 days. When they are
discharged, they will typically have a urethral Foley in place as well as a suprapubic tube, both of which
drain the new bladder. It is important to facilitate adequate drainage as the bowel used in the urinary
diversion will continue to secrete mucous. You will be taught how to irrigate these catheters at regular
intervals to remove mucous from the new bladder. After several weeks, the urethral Foley is removed. The
suprapubic tube is typically kept in place a little longer to assure adequate bladder emptying and function.
Once this is confirmed, the patient will have all catheters removed. 

Non-orthotopic Neobladders
Non-orthotopic neobladders are typically performed when an othotopic neobladder is anatomically difficult to
perform, functional quality of an orthotopic neobladder would not be optimal, or it is contraindicated from a
cancer standpoint. While this type of diversion does not require an appliance (bag), it does require
catheterization. 

There is a variety of non-orthotopic neobladders performed. One of the most common is called the Indiana
Pouch. This utilizes the natural tissue valve between the small and large intestine as the source of
continence. 

Approximately 15 cm. of small bowel along with the right colon (large bowel) are isolated from the
gastrointestinal tract. The right colon is detubularized (see above) to increase volume and reduce pressure.
The right colon is then fashioned into a sphere and the ureters are attached to this pouch along with
temporary drainage stents. The small bowel portion of the pouch is left as a tube and is narrowed in size to
accommodate a small catheter. This small bowel is brought to the skin (called the efferent limb) as a small
stoma which is flush with the skin. The connection point of the small and large bowel contains the ilealcecal
valve. This is a naturally occurring tissue valve which keeps urine from leaking from the spherical reservoir
into the tubular efferent limb with goes to the skin. In comparison, the ileal conduit stoma is the size of a
half-dollar as apposed to the neobladder stoma which is the size of a nickel. Additionally, the ileal conduit
stoma is raised whereas the neobladder stoma is flush with the skin 
After the operation, patients typically stay in the hospital 5 - 7 days. When they go home, they will have a
catheter which enters the new bladder through the skin. A second smaller catheter may be present which
catheterizes the efferent limb. Eventually, the patient is taught to catheterize the pouch themselves several
times a day. Once the patient has learned how to catheterize the pouch, all drainage catheters are removed.
Patients are taught to irrigate the pouch as the bowel in the pouch will continue to secret mucous which
must be eliminated. 

Postoperative Care
Foley catheter
After surgery while your pouch is healing, a tube called a Foley catheter drains the urine from your pouch to
a leg bag or bedside bag. A second catheter (called a suprapubic tube) may come out temporarily through
the skin also. Typically, patients use a leg bag during the day and a bedside bag at night. You may shower
with the catheters - simply clean them daily with soap and water. Make sure to bring a Depends
Undergarment or similar pad to your visit when your catheter is to be removed. 

Irrigating the Foley

Your pouch will continue to produce mucous after the operation. It is critical to irrigate this mucous from the
pouch as it may lead to obstruction and infection if it collects to a large degree. While you are in the
hospital, you will be taught to irrigate the Foley. To irrigate, you will need an irrigation kit, normal saline, a
urinary drainage bag.

 Wash your hands before and after irrigation

 Draw up 60 cc normal saline in syringe
 Disconnect the Foley tube from the drainage bag
 If two catheters are present, occlude the Foley catheter which is not being irrigated
 Insert and flush the syringe of normal saline into the tube to be irrigated
 Withdraw fluid from the tube and flush down the toilet
 Repeat irrigation as above until clear
 Reconnect the drainage bag
 If multiple tubes present, alternate tubes when irrigating
 Change your position if you have trouble irrigating

Normal Saline for Irrigation

 You may obtain a prescription from your doctor to buy saline at the drugstore
  You may make normal saline yourself
o Boil 1 quart water for 10 minutes
o Add 2 teaspoons table salt
o Allow to cool, place in clean bottles
o Refrigerate until use

Diet

 Fluids are very important. Drink frequently, water is always the best
 Eat several small meals rather than fewer large meals
 Many patients loose weight after this surgery. Ask you doctor about supplements such as Boost,
Ensure, etc
 Take a multivitamin with iron daily after surgery
 Keep bowel movements soft with stool softener of choice

Activity

 Avoid lifting over 10 pounds for 6 weeks after surgery

 Walk every day. Short frequent walks are better that 1 long walk
 It is normal to be fatigued after surgery
 Patients recover at different rates. It is normal to have days in which you just don't feel as good
follow by some stellar days. Remember, "two steps forward, one step back" is NORMAL

Results
Results will vary based on patient age, medical condition, extent of tumor, and patient motivation and
compliance. Generally, most patients with orthotopic neobladders (pouch connected to the urethra) are
initially incontinent in both the day and night. It takes 3 - 6 months for the new pouch to attain its final
capacity. During this time, it will require more frequent voiding or catheterizing, depending on the type of
diversion performed. Some physicians prefer patients to perform Kegel exercises which may help in
obtaining urinary control. 

Non-orthotopic neobladders (catheterizable stoma brought out to the skin) also take 3 - 6 months to
expand. Frequent catheterizations will be required until the pouch expands to its mature volume. 

Up to 92% of men undergoing an orthotopic neobladder are eventually continent of urine during the day and
up to 80% are dry at night. Generally, the need to catheterize is 5% or less. 

For women undergoing an orthotopic neobladder (very select population), the likelihood of continence is
somewhat less than men due to anatomical considerations. Furthermore, women are at increased risk to
need to catherize. 

Conclusion
Urinary diversion is necessary after removal of the bladder and for certain conditions when the bladder may
remain but is no longer functional. Non-continent and continent urinary diversions offer patients and their
physicians a number of different options. With education and discussion, the proper selection of urinary
diversion can lead to an optimal quality of life for the patient.

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Normal urinary anatomy (top) and after bladder removal via ileal conduit surgery (bottom).
Permission to use these copyrighted illustrations has been granted by the owner, hollister
incorporated.

Ileal conduit provides a surgical option to patients with altered urinary anatomy.

Roberta, a hairdresser for more than 30 years, has recently been diagnosed with
bladder cancer. So has Mike, a machinist, and Jimmy, a housepainter. Though their
jobs are completely different, the three have one thing in common — their
occupations exposed them to chemicals containing carcinogens, increasing their risk
of getting the disease.

Roberta, Mike, and Jimmy were all told by their physicians that their bladders would
have to be removed, but they were also told about a surgical procedure that would
allow them to continue to live relatively normal lifestyles. Upon hearing the
advantages of ileal conduit surgery, they each asked their physician to immediately
schedule an appointment for the procedure.

Bladder cancer affects 38,000 men and 15,000 women each year, primarily those
older than 40 years of age. Ileal conduit is the most commonly performed surgical
procedure for muscle invasive bladder cancer. Created when the bladder is
removed, the ileal conduit diverts urine from the body to a stoma located usually in
the right lower quadrant of the abdomen, just below the waistline. Urine continually
flows through the stoma and empties into an external pouch.

Stoma placement

Stomal siting is an important part of the preoperative preparation. The patient’s

abdomen must be assessed in the supine, sitting, and bending positions to evaluate
any hidden creases not normally seen that could affect the stoma. The ideal stoma
placement is below the umbilicus, within the rectus muscle, away from scars,
creases, bony prominences, the umbilicus, and the belt line. It should be on the
summit of the infraumbilical bulge. This bulge is seen on the abdomen inferior to the
umbilicus. It must also be visible to the patient. A poorly placed stoma could result in
a malformed ostomy, a pouching problem, skin irritation, and increase the potential
for leakage.

Ileal conduit construction uses a piece of small bowel to create the stoma, which
protrudes through the abdomen. Although normal urinary bladder mucosa forms an
effective barrier against reabsorption of fluid or salts from the urine, conduits
constructed from the bowel both secrete and reabsorb a variety of ions and fluids.
The most common disturbance in patients with ileal conduits is hyperchloremic
metabolic acidosis with hypokalemia; this condition is caused by reabsorption of
sodium and chloride with corresponding loss of bicarbonate and potassium. 1

Once created, the ileal conduit is freely refluxing, which means that urine can travel
in either direction through the anastomosis. When the pressure within the conduit
exceeds the pressure in the renal pelvis and the ureters, the outward urinary flow
becomes obstructed and reflux into the kidney can occur. If untreated, this can
develop into hydro-nephrosis and nephritis.2

Blood creatine levels provide information on how well the kidneys are functioning.
Elevated blood levels of creatine indicate kidney damage. Kidney damage can occur
over time and affected patients will require systemic alkalization to prevent or
alleviate bone demineralization caused by metabolic acidosis. In fact, renal
deterioration occurs in about 18% of ileal conduit patients. 3 It’s important for nurses
to understand the metabolic complications that are associated with this procedure.

Postoperative ostomy care

During the first postoperative day, the stoma should undergo a baseline assessment,
with the nurse carefully noting its shape, size, and color. With each subsequent
inspection, any signs of ischemia, necrosis, retraction, stenosis, or herniation should
be noted and promptly reported to the physician. Ureteral stents are placed for
protection at the anastomoses of the ureters and bowel section. A Foley catheter is
placed to drain the anastomoses and pelvis areas. These tubes should be identified
and monitored for secure placement. Urinary output is measured from each.
Asymptomatic bacteriuria is not uncommon. These assessments provide an
excellent opportunity to start patient teaching.

At the outset, it’s important that the patient understand that —

 The stoma is a portion of intestine and that it is red and moist, similar to the
tissue inside the mouth.
 The stoma is usually swollen after surgery and that the swelling will
gradually shrink in size during the next four to eight weeks.
 The stoma will change in size throughout the patient’s lifetime with weight
gains and losses.
 Slight bleeding from the stoma is normal because of the stoma’s high
concentration of blood vessels.
 A stoma does not have nerve endings and therefore does not transmit pain.

The skin surrounding the stoma, the peristomal skin, needs special attention to
prevent complications. If the skin is exposed to urine, the patient can experience
some distressing and painful symptoms. Basic care for the peristomal skin includes
—

 Bathing or showering as normal, with or without the pouch on, with a

residue-free soap.
 Examining skin with each pouch change for lesions, unusual coloring, or
other skin irritations like rashes or skin breakdown around the stoma.
 Checking for wartlike nodules with white-gray-brown discoloration. These
lesions are pseudoverrucous lesions, caused by extension exposure of urine
to the peristomal skin.1

Because most peristomal skin complications are caused by leakage from around the
skin barrier or pouch, or from irritation caused by an improperly fitting pouching
system, care must be taken during basic ostomy care —

 Avoid aggressively pulling the adhesive backing away from the skin during
pouch changes. When pulling off the wafer with the dominant hand, use the
other hand to press on the skin that is being exposed. This will prevent
accidental tearing of the peristomal skin.
 Carefully clean and dry the skin around the stoma with warm water and
paper towels with every appliance change. The appliance change schedule
depends upon the patient. It can range from two to six days.
 Cut the barrier wafer to the correct size. The opening of the wafer should
hug the stoma, limiting the amount of the peristomal skin that will be
exposed to urine.
 Correctly apply the pouch, making sure there is no opening in the seal. If an
opening occurs, the patient will experience leakage.

In the morning, before eating or drinking, is the best time for a pouch change.

Lessons for a lifetime

An ileal conduit is a permanent procedure. Issues relating to everyday life and

coping strategies are of paramount interest to patients and should be part of the
teaching process. Patients do not need to buy a new wardrobe to accommodate the
urostomy pouch. Urostomy pouches are inconspicuous under most kinds of clothing
because they are designed to lie flat against the body. Pouches can be tucked inside
underwear or worn outside, if desired. Patients should be instructed to avoid
pressure across the stoma from tight-waisted pants, belts, and seat belts.

Most people can return to work as soon as they have recovered from surgery,
usually within four to six weeks. Patients with jobs that require heavy lifting might
need to adjust how they perform their work functions or discuss alternative duties.
Patients may resume all prior activities with the exception of heavy lifting and contact
sports like boxing, football, or wrestling. They are also free to travel. (See sidebar.)

It’s not just physical

It is not uncommon for patients to develop body image and self-esteem issues.
Because of the pouch, they may see themselves as less sexually attractive to their
partners, which may affect their sexual activity.4 Some patients may also experience
sexual dysfunction. Males may have damage to the nerves governing ejaculation
and erection as a result of the surgery, and females may experience dysparenia, or
painful intercourse.

Communication and trust are the core of the healing process and it is important for
the patient to share his or her concerns with his or her partner. Be sure patients
know that —

 Sexual relations will not harm the stoma.

 The stoma should never be used as a penetration point of sexual
intercourse.
 They can wear a smaller pouch during sexual activity and the pouch can be
covered with specially designed underwear, lingerie, or pouch covers.
 The pouch should be emptied before sexual activity.

The wound ostomy consultant (WOC) can be a valuable resource to nurses caring
for patients who have had this procedure. Together, the staff nurse and the WOC
can help patients adapt to their new body change, while providing crucial guidance
and education during the postoperative period.

Taking a trip?

 Carry stoma supplies in hand luggage

 Pre-cut the wafer if traveling by air (scissors
are not allowed in hand luggage).
 Pack extra supplies (twice what is usually
required).
 Fasten seat belt above or below the stoma
 Store supplies in a cool place (heat can melt
 adhesive).
 Carry product order numbers to order refills.
 Wear a medic alert bracelet that indicates
altered urinary anatomy.

Editor's Note: For self-study CE on bladder cancer, go

tohttp://www2.nursingspectrum.com/CE/Self-Study_modules/syllabus.html?ID=220.

Linda Demarest, RN, BSN, CWOCN, is an enterostomal therapist at Hackensack University

Medical Center — Home Care Division, East Rutherford, N.J. To comment on this article, e-
mail jspillane@nursingspectrum.com.

References

1. Hampton, BG Bryant RA. Ostomies and Continent Diversions: Nursing Management.St.

Louis: Mosby; 1992: 110, 257, 356.

2. Doughty DB, Lightner DJ. Genitourinary surgical procedures. In: BG Hampton & R
A. Bryant. Ostomies and Continent Diversions: Nursing Management. St. Louis: Mosby;
1992:255.

3. Shannon T. Radical cystectomy and ileal diversion. Available

at:http://www.hollywoodurology.com/radcyst.html. Accessed March 22, 2004.

4. Sprunk E, Alteneder RR. The impact of an ostomy on sexuality. Clin J Oncol Nurs.

200; 4:2.

Features Home    

 
 There are many surgical techniques for urinary diversion surgery.
They fall into two categories: continent diversion and conduit
diversion. In continent diversion, also known as continent
catheterizable stomal reservoir, a separate rectal reservoir for urine is
created, which allows evacuation from the body. In conduit diversion,
or orthotopic urethral anastomotic procedure, an intestinal stoma or
conduit for release of urine is created in the abdominal wall so that a
catheter or ostomy can be attached for the release of urine. An ileal
conduit is a small urine reservoir that is surgically created from a small
segment of bowel. Both techniques are forms of reconstructive surgery
to replace the bladder or bypass obstructions or disease in the bladder
so that urine can pass out of the body. Both procedures have been used
for years and should be considered for all appropriate patients. Ileal
conduit surgery, the easiest of the reconstructive surgeries, is the gold
standard by which other surgical techniques, both continent and
conduit, have been compared as the techniques have advanced over
the decades.

Purpose

The bladder creates a reservoir for the liquid wastes created by the
kidneys as a result of the ability of these organs to filter and retain
glucose, salts, and minerals that the body needs. When the bladder
must be removed; or becomes diseased, injured, obstructed, or
develops leak points; the release of urinary wastes from the kidneys
becomes impaired, endangering the kidneys with an overburden of
poisons. Reasons for disabling the urinary bladder are: cancer of the
bladder; neurogenic sources of bladder dysfunction; bladder sphincter
detrusor overactivity that causes continual urge incontinence; chronic
inflammatory diseases of the bladder; tuberculosis; and
schistosomiasis, which is an infestation of the bladder by parasites,
mostly occurring Africa and Asia. Radical cystectomy , removal of the
bladder, is the predominant treatment for cancer of the bladder, with
radiation and chemotherapy as other alternatives. In both cases,
urinary diversion is often necessitated, either due to the whole or
partial removal of the bladder or to damage done by radiation to the
bladder.

Demographics

Urinary diversion has a long history and, over the last two decades, has
developed new techniques for urinary tract reconstruction to preserve
renal function and to increase the quality of life. A number of
difficulties had to be solved for such progress to take place. Clean
intermittent catherization by the patient became possible in the 1980s,
and many patients with loss of bladder function were able to continue
to have urine release through the use of catheters. However, it soon
became clear that catherization left a residue that cumulatively, and
over time, increased the risk of infection, which subsequently
decreased kidney function through reflux, or backup, of urine into the
kidneys. A new way had to be found. With the advent of surgical
anatomosis (the grafting of vascularizing tissue for the repair and
expansion of organ function) as well as with the ability to include a
flap-type of valve to prevent backup, bladder reconstructive surgery
that allowed for protection of the kidneys became possible.

Description

Ileal conduit surgery consists of open abdominal surgery that proceeds

in the following three stages:

 Isolating the ileum, which is the last section of small bowel. The
segment used is about 5.9–7.8 in (15–20 cm) in length.
 The segment is then anastomosized, or grafted, to the ureters
with absorbable sutures.
  A stoma, or opening in skin, is created on the right side of the
abdomen.
 The other end of the bowel segment is attached to the stoma,
which drains into a ostomy bag.

Stents are used to bypass the surgical site and divert urine externally,
ensuring that the anastomotic site has adequate healing time.
Continent surgeries are more extensive than the ileal conduit surgery
and are not described here. Both types of surgery require an extensive
hospitalization with careful monitoring of the patient for infections,
removal of stents placed in the bowel during surgery, and removal of
catheters.

Diagnosis/Preparation

Ileal conduit surgery is recommended depending on what conditions

are being treated; whether the urinary diversion is immediately
necessary; for the relief of pain or discomfort; or for relatively healthy
individuals or individuals with terminal illness. Three major decisions
that must be made by the physician and patient include:

 The type of surgery to restore bladder function: either by

sending urine through the ureters to a new repository fashioned
in the rectum, or by creating a conduit for the removal of the
urine out through the stomach wall and into a permanent
storage pouch, or ostomy outside the body.
 The type of material out of which to fashion the reservoir or
conduit.
 Where to place the stoma outlet for patient use.

Recent research has shown there is little difference in infection rates or

in renal deterioration between the conduit surgical techniques and the
continent techniques. The patient's preference becomes important as
to which type of surgery and resulting procedures for urination they
want. Of course, some patients, unable to conduct catheterization due
to debilitating diseases like multiple sclerosis or neurological injuries,
should be encouraged to have the reservoir or continent procedures.

Materials for fashioning continent channels have included sections of

the appendix, stomach, ileum and cecum of the intestines, and for the
reservoir, sigmoid and ureter tissues, usually with an anti-refluxing
mechanism to maximize continence. A segment of the ileum is often
preferred, unless the tissue has received radiation. In this case, other
tissue must be used. Ileum is preferred because the ileal tissue of the
intestines accommodates larger urine volume at lower pressure.

Many urinary diversion procedures are performed in conjunction with

surgery for recurrent cancer or complications of pelvic radiation.
Fistula development and repeated repair as well as ureteral
obstruction also are reasons to have the surgery. If the surgery is
considered because of cancer, the physician and the patient need to
discuss how appropriate the surgery is for cure or for relieving pain.
Highly relevant are the patient's age, medical condition, and ability to
comprehend both the procedure and the patient's role in the changed
state that will result with the surgery. In general, ileal conduit surgery
is easier, faster, and has fewer complications than continent reservoir
surgery.

In addition to these considerations, great emphasis must be put on

preparing the patient psychologically, and physicians must make
themselves available for counseling and questions before proceeding
with patient evaluation for the procedures. The renal system must be
assessed using pylography, which is the visualization of the renal pelvis
of the kidneys to determine the health of each renal system. Patients
with renal disease or abnormalities are not good candidates for urinary
diversion. Bowel preparation and prophylactic antibiotics are
necessary to avoid infection with the surgery. Bowel preparation
includes injecting a clear-liquid diet preoperatively for two days,
followed by using a cleansing enema or enemas until the bowel runs
clear. The importance of these preparations must be explained to the
patient: leaking from the bowel during surgery can be life threatening.
For ileal conduits, the placement of the stoma must be decided. This is
accomplished after the physician evaluates the patient's abdomen in
both a sitting and standing position, to avoid placing the stoma in a
fatty fold of the abdomen. The input from a stomal therapist is
important for this preparation with the patient.

Aftercare

Ureteral stents are generally removed one week after surgery. A urine
culture is taken from each stent.
In a cystectomy with ileal conduit, an incision is made in the
patient's lower abdomen (A). The ureters are disconnected
from the bladder, which is then removed (B). They are then
attached to a section of ileum (small intestine) that has been
removed and refashioned for that purpose (C). A stoma, or
hole in the abdominal wall, is created at the site to allow
drainage of the urine (D). (
Illustration by GGS Inc.
)
Radiologic contrast studies are carried out to ensure against ureteral
anastomotic leakage or obstruction. On the seventh postoperative day,
a contrast study is performed to ensure pouch integrity. Thereafter,
ureteral stents may be removed, again with radiologic control. When it
has been determined that the ureteral anastomoses and pouch are
intact, the suction drain is removed. The patient is shown how to
support the operative site when sleeping and with breathing and
coughing. Fluids and electrolytes are infused intravenously until the
patient can take liquids by mouth. The patient is usually able to get up
in eight to 24 hours and leave the hospital in about a week.

Patients are taught how to care for the ostomy, and family members
are educated as well. Appropriate supplies and a schedule of how to
change the pouch are discussed, along with skin care techniques for
the area surrounding the stoma. Often, a stomal therapist will make a
home visit after discharge to help the patient return to normal daily
activities.

Risks

This surgery includes the major risks of thrombosis and heart

difficulties that can result from abdominal surgery. Many difficulties
can occur after urinary diversion surgery, including urinary leakage,
problems with a stoma, changes in fluid balance, and infections over
time. However, urinary diversion is usually tolerated well by most
patients, and reports indicate that patient satisfaction is very high.
Common complications are stricture caused by inflammation or scar
tissue from surgery, disease, or injury. The incidence of urine leakage
for all types of ureterointestinal anastomoses is 3–5% and occurs
within the first 10 days after surgery. According to some researchers,
this incidence of leakage can be reduced to near zero if stents are used
during surgery.

Normal results

Complete healing is expected without complications, with the patient

returning to normal activities once they have recovered from surgery.

Morbidity and mortality rates

Possible complications associated with ileal conduit surgery include

bowel obstruction, blood clots, urinary tract infection, pneumonia,
skin breakdown around the stoma, stenosis of the stoma, and damage
to the upper urinary tract by reflux. Pyelonephritis, or bacterial
infection of a kidney, occurs both in the early postoperative period and
over the long term. Approximately 12% of patients diverted with ileal
conduits and 13% in those diverted with anti-refluxing colon conduits
have this complication. Pyelonephritis is associated with significant
mortality.

Alternatives

An alternative to ileal conduit surgery is continent surgery in which a

neo-bladder is fashioned from bowel segments, allowing the patient to
evacuate the urine and avoid having an external appliance. The
procedures of continent diversion are more complicated, require more
hospitalization, and have higher complication rates than conduit
surgery. Many patients, unable to manage a stoma, are good
candidates for continent diversion.

Resources

BOOKS

Walsh, P., et al. Campbell's Urology, 8th Edition. St. Louis: Elsevier,

2000.
PERIODICALS

Estape, R., L. E. Mendez, R. Angioli, and M. Penalver. "Gynecologic

Oncology: Urinary Diversion in Gynecological Oncology." Surgical
Clinics of North America 81, no. 4 (August 2002).

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information

Way, Bethesda, MD 20892-3570. http://www.niddk.nih.gov .

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite

200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org. .

OTHER

"Urinary Diversion." American Urological

Association. http://www.urologyhealth.org. .

Nancy McKenzie, PhD

WHO PERFORMS THE PROCEDURE AND

WHERE IS IT PERFORMED?

Surgery is performed by a urological surgeon who specializes in

urinary diversion. It is performed in a general hospital.
QUESTIONS TO ASK THE DOCTOR

 How soon after the surgery will I be taught how to use an

ostomy?
 Will the ostomy be obvious to others?
 Is continent surgery, or surgery with an internal neo-bladder, a
better alternative?
 How do conduit and continent surgery compare in terms of
recuperation, complications, and quality-of-life issues?

Read more: Ileal Conduit Surgery - procedure, blood, removal, pain,

complications, time, infection, heart, types, risk, cancer, Definition,
Purpose, Demographics, Description, Diagnosis/Preparation,
Aftercare http://www.surgeryencyclopedia.com/Fi-La/Ileal-Conduit-
Surgery.html#ixzz1GqlnlTJy

http://www.rcsed.ac.uk/journal/vol44_6/4460030.htm