Urinary Reconstruction and Diversion

              When the urinary bladder is removed (due to cancer, other medical condition, or because the organ no longer works), another method must be devised for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way for you to pass urine.

Urinary diversion options

There are three main types of urinary diversion surgeries

• Ileal Conduit Urinary Diversion
• Indiana Pouch Reservoir
• Neobladder to Urethra Diversion

For all of these procedures, a portion of the small and/or large bowel is disconnected from the fecal stream and used for reconstruction.

Ileal Conduit Urinary Diversion

With this procedure, the ureters drain freely into part of the ileum (the last segment of the small intestine). The end of the ileum into which the ureters drain is then brought out through an opening in the abdominal wall. This opening, called a stoma, is covered with a bag that gathers the urine as it drains from the ileal conduit.

Advantages:

The advantages of the Ileal Conduit Urinary Diversion surgery are:

• It is a relatively simple surgery.
• It requires less surgical time (compared with other surgical methods).
• There is no need for occasional catheterization (use of a tube to drain the urine)

Disadvantages:

The disadvantages of the Ileal Conduit Urinary Diversion are:

• There is a change in body image.
• It uses an external bag to collect urine, which might leak or have odors.
• Urine could back up into the kidneys, causing infections, stone formation in some patients, and organ damage over time.

Indiana Pouch Reservoir

With this type of surgery, a reservoir or pouch is made out of a portion of the large intestine (the ascending colon on the right side of the abdomen) and a portion of the ileum (the last segment of the small intestine). The ureters are repositioned to drain into this pouch. The urine flows freely in a downward direction from the kidneys into the pouch. This positioning prevents urine from backing up into the kidneys, which protects the kidneys from infection. A short piece of small intestine is then brought out through a small opening in the abdominal wall (a stoma). Unlike the Ileal Conduit, no external bag is needed, and the stoma is very small and can be covered with an adhesive bandage. Instead, a one-way valve is surgically created to keep the urine inside the pouch. Several times a day, usually every four to six hours, a small, thin catheter must be passed through the stoma and into the pouch to empty the urine. An adhesive bandage is worn over the stoma at all other times (when not actively emptying the pouch). Catheters are washed with soap and water after each use. The catheters do not have to be sterilized. They can be taken on trips or social events and simply stored in a zip lock bag.

Advantages:

The advantages of the Indiana Pouch Reservoir surgery are:

• Urine is kept inside the body, in the reservoir, until it is ready to be emptied.
• No external bag is necessary.
• There is no odor.
• The risk of urine leaking is minimal.
• The small stoma can be covered with an adhesive bandage.
• The risk of reflux (back up) of urine into the kidneys is lessened, lowering the risk of infection.

Disadvantages:

The disadvantages of the Indiana Pouch are:

• The surgical time is longer compared with the Ileal Conduit.
• There is the need for occasional catheterization (the passing of tubing into the stoma to empty the pouch), every four to six hours.

Neobladder to Urethra Diversion

This procedure most closely mimics the storage function of a urinary bladder. With this procedure, a small part of the small intestine is made into a reservoir or pouch, which is connected to the urethra. The ureters are repositioned to drain into this pouch. As with the Indiana Pouch, this downward flow of urine from the kidneys into the pouch helps prevent urine back up, which helps protect the kidneys from infection. Urine is able to pass from the kidney, to the ureters, to the pouch, and through the urethra in a manner similar to the normal passing of urine. To be a candidate for this surgical procedure, there must be a low risk of cancer recurrence in the urethra, and patients must be able to pass a catheter into the urethra to empty the pouch if necessary.

Advantages:

The advantages of the Neobladder to Urethra Diversion are:

• The process of urination most closely matches normal urination.
• No stoma is needed.
• The kidneys are protected from urine back up and infection.

Disadvantages:

The disadvantages of the Neobladder to Urethra Diversion are:

• Surgery time is slightly longer than the Ileal Conduit Urinary Diversion procedure.
• Urinary incontinence (leakage of urine) is normal after surgery — while regaining control of urination — but might last up to six months. Also, about 20 percent of patients during the night and 5 percent to 10 percent of patients during the day are incontinent, requiring the wearing of a pad.
• Despite the surgery, some patients might not be able to empty their bladder well and will need to perform occasional catheterization (passing tubing through the urethra into the pouch every four to six hours) for a prolonged period of time after surgery and perhaps permanently.

A Look at the Three Surgical Procedures

Ileal Conduit Urinary Diversion: A segment of the intestine directs urine through a stoma into an external collecting bag.

Indiana Pouch Reservoir: A pouch made out of portions of intestines stores urine until it is drained via a catheter inserted through the stoma.

Neobladder to Urethra Diversion: Intestine is made into a reservoir and connected to the urethra

Immediate post-op period

It takes one to two months on average to feel well again and to regain your strength. Also, it is not unusual to feel a little depressed or discouraged after surgery. Discussing your feeling with friends, family, and even other members of a support group (ask your health care team member about support groups in your area) can help you deal with your emotions. As with any life change, an adjustment period is normal. Don't hesitate to call your doctor or other health care team members for assistance or if you have questions. Their goal for you is to get you back to your lifestyle as soon as possible.
People with urinary diversions are usually able to return to the life, work, and hobbies they previously enjoyed.

• Work — Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.
• Activities — After the post-operative period, exercising and participation in sports and other activities is encouraged. Check with your doctor or health care team member.
• Diet — There are no eating restrictions, but if you have special dietary concerns, check with your doctor or health care team member.
• Travel — There are no travel restrictions. Just a word to the wise — travel fully prepared with necessary supplies, as you might not be able to purchase all supplies at your destination.

Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.

NURSING CARE PLAN
Incontinent urinary diversions: These ostomies require permanent stoma care and external collecting devices.
Ileal conduit: Ureters are anastomosed to a segment of ileum, resected with the blood supply intact (usually 15–20 cm long). The proximal section is closed, and the distal end brought to skin opening to form a stoma (a passageway, not a storage reservoir).
Colonic conduit: This is a similar procedure using a segment of colon.
Ureterostomy: The ureter(s) is brought directly through the abdominal wall to form its own stoma.
Continent urinary diversions: Continent urinary reservoirs (CURs) have become one of the major options for patients to improve their quality of life regarding stoma care and the ability to sleep and travel.
Kock reservoir or Indiana (ileocecal) pouch: A section of intestine is used to form a pouch inside the patient’s abdomen, creating a reservoir that the patient periodically drains by inserting a catheter through the stoma, thus negating the need for an external collecting device.
 
CARE SETTING
Inpatient acute surgical unit.
 
Surgical intervention
Patient Assessment Database
Data depend on underlying problem, duration, and severity, e.g., malignant bladder tumor, congenital malformations, trauma, chronic infections, or intractable incontinence due to injury/disease of other body systems (e.g., multiple sclerosis). (Refer to appropriate CP.)
 
TEACHING/LEARNING
Discharge plan
DRG projected mean length of inpatient stay: 5.5 days
May require assistance with management of ostomy and acquisition of supplies.
Refer to section at end of plan for postdischarge considerations.
 
DIAGNOSTIC STUDIES
Intravenous pyelogram (IVP): Visualizes size/location of kidneys and ureters and rules out presence of tumors elsewhere in urinary tract.
Cystoscopy with biopsy: Determines tumor location/stage of malignancy. Ultraviolet cystoscopy outlines bladder lesion.
Bone scan: Determines presence of metastatic disease.
Bilateral pedal lymphangiogram: Determines involvement of pelvic nodes, where bladder tumor easily seeds because of close proximity.
CT scan: Defines size of tumor mass, degree of pelvic spread.
Urine cystoscopy: Detects tumor cells in urine (for determining presence and type of tumor).
Endoscopy: Evaluates intestines for use as conduit.
Conduitogram: Assesses length and emptying ability of the conduit and presence of stricture, obstruction, reflux, angulation, calculi, or tumor (may complicate or contraindicate use as a urinary diversion).
 
NURSING PRIORITIES
1. Prevent complications.
2. Assist patient/SO in physical and psychosocial adjustment.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential complications, and resources.
 
DISCHARGE GOALS 1. Complications prevented/minimized.
2. Adjusting to perceived/actual changes.
3. Self-care needs met by self/with assistance as necessary.
4. Procedure/prognosis, therapeutic regimen, potential complications understood and sources of support   identified.
5. Plan in place to meet needs after discharge.