Urinary Diversion Surgery

Definition

A urinary diversion involves removal of the urinary bladder and adjacent tissues and organs, and re-routing of the urinary stream. This may involve creation of an artificial opening in the abdomen called an ostomy.

Purpose

A urinary diversion is created as a means to treat cancer of the bladder, when conservative measures have been unsuccessful, or when there is recurrence of the disease invading the muscle wall. Congenital deformities or traumatic injury may also necessitate formation of a urinary diversion.

Description

Under general anesthesia, an incision is made in the abdomen. The ureters (tubes that carry urine away from the kidneys) are cut and tied. The bladder and surrounding tissues are cut free and removed. The ureters are then attached to a portion of the intestine. The most common types of urinary diversion are:

• Ileal conduit. Ureters are attached to a portion of the small intestine, the ileum, one end of which is brought through the abdominal wall as a conduit for the urine, creating a stoma
• Ureterosigmoidostomy. The ureters are attached to a portion of the large intestine, the sigmoid, which allows the urine to flow through the large intestine and out through the rectum
• Cutaneous ureterostomy. Bringing the detached ureters through the abdominal wall and attaching it to an opening in the skin

Following creation of an artificial opening to drain the urine, ureteral stents (tubes that go through the stoma and up into the ureters) are often inserted and left in place to allow urine to drain freely from the kidneys, without risk of blockage from swelling due to surgery. The muscles are replaced and sewn together. A transparent pouch is applied to the abdomen to collect urine, and attached to a bedside drainage bag. The incision is closed with sutures or clips ("staples"), which are usually removed about a week after surgery.

An alternative to a conventional urinary diversion is the continent urinary diversion. In this surgical procedure, a "false bladder" is constructed within the abdomen, using several lengths of small or large intestine. The ureters are sewn to this new reservoir for urine and nipple valves which are created at two sites; the abdominal wall for continence; and where the ureters are implanted, to prevent reflux of urine back to the kidneys. The patient is then taught to catheterize the reservoir to drain urine at regular intervals during the day. Although a continent diversion is not suitable for every patient who requires urinary diversion, it is an option to be considered.

Preparation

As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly. Blood and urine studies, along with various x rays and an electrocardiogram (EKG), may be ordered as the doctor deems necessary. If creation of an ostomy is planned, the patient should visit an enterostomal therapist, who will mark an appropriate place on the abdomen for a stoma and offer preoperative education on ostomy management.

Eating or drinking is prohibited after midnight the night before the surgery. Oral anti-infectives, such as neomycin, erythromycin, or kanamycin sulfate, may be ordered to decrease bacteria in the intestine and help prevent postoperative infection. A nasogastric tube is inserted the day of surgery, or during surgery, to remove gastric secretions and prevent nausea and vomiting.

Aftercare

Postoperative care for the patient with a urinary diversion, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respirations, and temperature. Breathing tends to be shallow because of the effect of anesthesia, and the patient is reluctant to breathe deeply and experience pain that is caused by the abdominal incision. The patient is shown how to support the operative site during deep breathing and coughing, and is given pain medication as necessary. Fluid intake and output are measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube will remain in place, attached to low intermittent suction, until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids. The patient is usually able to move about in 8-24 hours after surgery, and is discharged from the hospital in 5-10 days.

If an ostomy has been placed, the patient and close family members will be educated on how to care for it. Determination of appropriate pouching supplies and a schedule of how often to change the pouch should be established. Regular assessment and meticulous care of the skin surrounding the stoma is important to maintain an adequate surface on which to apply the pouch. The pouch should be connected to a bedside drainage bag at night to prevent large volumes of urine from collecting in the pouch. Otherwise, the weight of the pouch could cause disruption of the pouch seal and leakage of urine onto the surrounding skin. Often, an enterostomal therapist will visit the patient at home after discharge to help the new ostomy patient make the transition back to normal daily activities.

Risks

Potential complications of urinary diversion surgery include:

• excessive bleeding
• surgical wound infection
• thrombophlebitis (inflammation and blood clot to veins in the legs)
• pneumonia
• pulmonary embolism (blood clot or air bubble in the lungs' blood supply)

Normal results

Complete healing is expected without complications. The amount of time required for recovery from the surgery may vary depending of the patient's overall health status prior to surgery. The patient with a urinary diversion, without other medical complications, should be able to resume all daily activities once recovered from the surgery.

Abnormal results

The doctor should be made aware of any of the following problems after surgery:

• Increased pain, swelling, redness, drainage, or bleeding in the surgical area
• Headache, muscle aches, dizziness, or fever
• Increased abdominal pain or swelling, constipation, nausea, or vomiting

Stomal complications to be monitored include:

• Stomal tissue death (necrosis). This occurs because of inadequate blood supply, this is usually visible 12 to 24 hours after surgery and may require additional surgery
• Stoma flush or below the abdomen surface (retraction). Caused by insufficient stomal length, this may be managed by use of special pouching supplies. Elective revision of the stoma is also an option
• Narrowing at the opening of the stoma (stenosis). Often associated with infection around the stoma or scarring, mild stenosis can be removed under local anesthesia. Severe stenosis may require surgery for stomal revision
• Parastomal hernia. The bowel causes a bulge in the abdominal wall next to the stoma. This is usually due to placement of the stoma where the abdominal wall is weak, or an overly large opening in the abdominal wall. Use of an ostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location

Resources

ORGANIZATIONS

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. 〈http://www.uoa.org〉.

KEY TERMS

Ischemia— A compromise in blood supply to body tissues that causes tissue damage or death.

Ostomy— A surgically-created opening in the abdomen for elimination of waste products (urine or stool).

Urostomy

Definition

Urostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall through which urine leaves the body.

Purpose

Doctors perform urostomy when a patient has bladder cancer , spinal cord injury, specific types of birth defects, or when the bladder is not functioning properly and must be removed.

Precautions

In an individual who is obese or who has folds in the skin or scars in the abdominal wall, an internal collection sac (reservoir) the patient can empty (catheterize) works better than a passage that lets urine flow out of the body into a collection bag (pouch) worn next to the skin under the clothes.

Description

Urostomy is a form of urinary diversion. Surgeons perform this reconstructive procedure when disease, infection, injury, or congenital abnormality makes it necessary to remove a patient's bladder and create a new channel (conduit) for urine to leave the body.

Surgeons perform urostomy by separating a short piece of the large or small intestine from the rest of the intestine. They attach the separated intestine to the two thick tubes (ureters) that carry urine from the kidneys to the bladder and connect the ureters to the stoma.

Continent and incontinent diversions

An incontinent ostomy drains continuously into a small pouch fitted over the stoma and worn under the patient's clothes. The patient wears a collection pouch at all times and empties it several times a day.

To perform a continent urinary diversion, the surgeon uses a piece of the patient's intestine to create an internal reservoir to store urine. The patient does not wear an ostomy pouch but empties the reservoir four to six times a day by inserting a drainage tube (catheter) into the stoma.

Types of urostomy

The most common types of urostomy are the ileal conduit, which uses a piece of the small intestine (ileum) and the colonic conduit, which uses a piece of the large intestine (colon). Orthotopic neobladder is a new type of continent diversion that channels urine into the tube that drains urine from the bladder (urethra) and enables the patient to urinate almost normally.

Temporary urostomy does not involve severing the ureters and is most often performed in children.

Doctors consider the likelihood of disease recurring in the pelvis or urethra as well as the patient's gender to determine which type of urostomy is most appropriate. Neobladders are not appropriate for female patients whose cancer involves the bladder neck or male patients with problems affecting the right colon or small bowel.

If bladder cancer has metastasized or cannot be surgically removed, the surgeon may perform a urostomy without removing the patient's bladder.

Preparation

Before undergoing a urostomy, the patient learns where on the abdomen the stoma will be created, what type of collection device (if any) will be worn, and what changes in appearance the operation may cause.

Nurses encourage the patient preparing to undergo an incontinent urostomy to become familiar with the collection device that will be worn after the operation. They may arrange to have someone who has already had the operation (ostomate) reassure the patient preparing for either an incontinent or continent procedure and answer questions about life after the surgery.

Preoperative restrictions

The patient may be told not to eat certain foods before surgery and must fast for eight hours and have a cleansing enema before the operation.

Fluid and antibiotics may be given to a patient who is frail.

Aftercare

A patient who has undergone an incontinent diversion wears a collection device that is odor-free, not visible under clothing, disposable or reusable, and available at drug stores or medical supply houses or through the mail.

To prevent urine leakage, infection, skin irritation, and odor, the patient should re-measure the stoma and make any necessary adjustments in the size of the flat sponge-like patch that covers and protects it. This should be done during the first few months after the operation (when shrinkage occurs) or whenever gaining or losing weight. Measuring devices and instructions are included in every box of collection pouches.

Some doctors recommend taking Vitamin C to prevent infection-and odor-causing bacteria from accumulating in the urine. Other recommendations include drinking eight to 10 glasses of water a day to reduce the likelihood of kidney infection.

Risks

Because tumors sometimes develop in neobladders, a patient who undergoes this procedure must have a cystoscopy within five years.

Normal results

A patient who has had a urostomy can:

• Shower or bathe with or without the collection pouch.
• Usually wear the clothes worn before the operation.
• Return to work shortly after leaving the hospital, although a doctor's permission is required before doing heavy lifting.
• Enjoy intimate relationships.
• Participate in athletic activities, but should avoid strenuous contact sports like football or wrestling.

Dietary restrictions are rare.

A woman who has undergone a urostomy should talk with her doctor before becoming pregnant.

Abnormal results

Almost half (40%) of patients who undergo continent diversions and 24.1% of those who undergo ileal or colonic conduits require subsequent surgery to repair leaks or obstructions and correct other surgery-related problems.

A patient who has had a urostomy may also experience:

• kidney damage, infection, or failure
• swelling, shrinkage (stenois), or displacement (pro-lapse) of the stoma
• infections of the stoma or urinary tract
• fever
• hernia
• diarrhea
• urinary problems
• chills
• pain in the leg or abdomen
• blood or pus in the urine

Resources

BOOKS

Kupfer, Barbara, et al. Yes We Can! Advice on Traveling with an Ostomy and Tips for Everyday Living. Worcester, MA:Chandler House Press, 2000.

ORGANIZATIONS

United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826.<http://www.uoa.org>.

OTHER

"Bladder Cancer: Types of Treatment." ACS Cancer Resource Center 11 July 2000. 18 July 2001 <http://www3.cancer.org/cancerinfo>.

Cherath, Lata. "Bladder Cancer." 1999. <http://www.findarticles.com/cf_1/g2601/0002/2601000204/print.html>.20 May 2001. 6 July 2001.

Guttman, Cheryl. "Diversion Procedures Require Similar Rein-tervention." June 1999. 18 July 2001 <http://www.findarticles.com/cf_1/m0VPB/6_27/54852652/print.jhtml>.

"Urostomy fact sheet." United Ostomy Association. 15 April 2001. 18 July 2001 <http://www.uoa.org/factsheets/urostomyfs.html>.

Maureen Haggerty

KEY TERMS

Bladder neck

—The narrowest part of the bladder.

Cystoscopy

—Diagnostic procedure that allows the doctor to view the entire bladder wall.

Kidney failure

—Inability of the kidneys to excrete waste and maintain a proper chemical balance. Also called renal failure.

QUESTIONS TO ASK THE DOCTOR

• What type of urostomy will I have?
• Will I have to wear a pouch after the operation?
• Will I be able to take care of myself after the operation?
• Will other people be able to tell that I have had a urostomy?

urinary diversion (dy-ver-shŏn) n. any of various techniques for the collection and diversion of urine away from its usual excretory channels, after the bladder has been removed (see cystectomy) or bypassed. These techniques include ureterosigmoidostomy and the construction of an ileal conduit. See also continent diversion.

ileal conduit (il-i-ăl) n. a segment of small intestine (ileum) used to convey urine from the ureters to the exterior into an appliance (see also urinary diversion). The ureters are implanted into an isolated segment of bowel, one end of which is brought through the abdominal wall to the skin surface.