Urostomy and Continent Urinary Diversion

A urinary diversion is a surgical procedure performed to provide an alternate pathway to release urine from the body when there is functional or anatomical abnormalities to the lower urinary tract.

Why Urostomy and Continent Urinary Diversion Is Done

A urinary diversion is performed, for example, if the bladder has been removed to treat bladder cancer, or if the bladder is not functioning properly due to nerve damage.

Types

The surgical procedure can be accomplished either by making direct contact with the urinary tract to the skin to allow drainage or more commonly by using a portion of the gastrointestinal tract (ex. bowel) to create either a tubular conduit to allow drainage of urine or to form it into a bladder-like reservoir to store urine. An advantage for the latter procedure is that it allows freedom from an external appliance like a Foley bag. Thus, it may provide psychological and functional benefit to the patient.

A urinary diversion may mean a urostomy, which requires a pouch to be worn outside the body, or a continent diversion, which involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract. Nearly every segment of the gastrointestinal tract has been used to form a urinary diversion.

Anatomic drawing of male torso with ileal conduit urostomy and inner organs visible. The small and large intestines are shown in outline. The kidneys, ureters, and ileal conduit are displayed in more detail. The ureters descend from the kidneys to the ileal conduit, which has been formed from a piece of the intestine. One end of the conduit extends beyond the skin surface to form a stoma.Source: NIDDK, NIH

Preparation

Patients considered for urinary diversion should undergo careful preoperative counseling including a detailed discussion of the objectives and potential complications of each method.

A careful history should be taken including previous abdominal and pelvic surgeries, irradiation, or systemic diseases. A history of intestinal resection, renal failure, diverticulitis, or ulcerative colitis would be important in selecting the method of urinary diversion to be used.

Laboratory testing and imaging is standard prior to any procedure. Specific imaging for urinary diversion would include intravenous urography or abdominal ultrasound to image the kidneys. The gastrointestinal tract would be examined by either a CT scan or a colonoscopy with patients who have a history of radiation therapy.

One or two days prior to surgery, the patient will undergo bowel cleansing to prepare the bowel for surgery.

How Urostomy and Continent Urinary Diversion Is Done

Urostomy

A surgeon creates a urostomy by redirecting urine to an opening created in the abdomen. The opening is called a stoma. Two main types of urostomy are available.

• Ileal conduit. To create an ileal conduit, the surgeon takes a short segment of the small intestine and reconnects the remaining intestine so that it functions normally. One end of the removed short segment of intestine is placed at the skin surface to create the stoma. The ureters, which normally carry urine from the kidneys to the bladder, are then attached to the other end of the segment of intestine. The urine travels through the newly formed ileal conduit and the stoma into an external collecting pouch. The pouch has an outlet for releasing urine into a toilet without removing it from the stoma.[Image:stoma300B.jpg|thumb|300px|Close-up drawing of a stoma, an opening in the abdomen used for releasing urine from the body. Source: NIDDK, NIH]]
• Ureterostomy. Very rarely, the surgeon connects the ureters directly to the abdominal wall to create a stoma. Like the ileal conduit, a ureterostomy requires a collecting pouch placed over the stoma because there are no muscles around the stoma to control the flow of urine.
  

  

  Anatomic drawing of male torso with ureterostomy and inner organs visible. The small and large intestines are shown in outline. The kidneys and ureters are displayed in more detail. The ureters descend from the kidneys to the skin surface, where they form two stomas. Source: NIDDK, NIH

Continent Diversion

Another method of storing and eliminating urine is the continent diversion. In this method, the surgeon creates a pouch, or reservoir, inside the body from a section of stomach or small or large intestine. The ureters carry urine to the pouch, where it is stored.

• Continent cutaneous reservoir. This form of continent diversion does include a stoma. This method requires the patient to empty the reservoir, the internal pouch, regularly through the stoma using a catheter or thin plastic tube.
  
  If the urethra is preserved during the operation, the patient may be able to have a urinary diversion that does not require a stoma or catheter.
  
  
  

  

  Anatomic drawing of female torso with internal pouch for continent urinary diversion. The large intestine is shown in outline. The kidneys, ureters, and internal pouch are displayed in more detail. The ureters descend from the kidneys to the internal pouch, which has been formed from a piece of the stomach or intestine. A tube from the pouch extends beyond the skin surface to form a stoma. Source: NIDDK, NIH

  
  
  
  
  
• Neobladder. With a neobladder, a patient may be able to urinate through the urethra as with the original bladder. Occasionally, patients may need to empty their neobladder by catheterizing through urethra. The surgeon creates an internal pouch that stores urine as the bladder did. It is connected to the urethra so that urine will be excreted through the urethral, although patients will need to valsalva to expel the urine.
  
  
  

  

  Anatomic drawing of male torso with bladder substitute and other inner organs visible. The large intestine is shown in outline. The kidneys, ureters, bladder substitute, and urethra are displayed in more detail. The ureters descend from the kidneys to the bladder substitute, which is attached to the patient's urethra. Source: NIDDK, NIH

  
  With a neobladder, the patient can urinate through the urethra.

Recovery

After surgery, a wound, ostomy, and continence (WOC) nurse can work with patients to help them learn how to take care of their urinary diversion.

Changing Pouches
The pouching system may consist of two pieces—a barrier that sticks to the skin and a pouch that attaches to the barrier. In some systems, the barrier and pouch are a single unit.

Drawing of a two-piece urostomy pouch system. On the left is a square-shaped barrier that attaches to the skin. The barrier has a hole in the center for the stoma. On the right is a pouch that attaches to the barrier over the stoma so that it catches urine as it is released.Source: NIDDK, NIH

A two-piece pouch system. The square barrier sticks to the skin. The pouch attaches to the barrier.

Using a Catheter
With a continent reservoir, patients will learn how to insert a catheter through the stoma or their urethra to drain the reservoir. They may do this either by standing in front of the toilet or by sitting on the toilet and then emptying the catheter between their legs. In the first few weeks, they will need to use the catheter every couple of hours. Soon, they will be able to go 4 to 6 hours between catheterizations. It is important to wash ones hands with soap and water each time before using a catheter.

Cleaning
The skin area around the pouch needs to be cleaned with a wet towelette or washcloth as the pouch is being changed. Skin needs to dry completely before a new pouch is applied. Protective skin wipes or ostomy powder designed to protect the skin around a stoma may help if the skin around the stoma becomes irritated

With a continent diversion, patients will need to irrigate, or flush out, the reservoir using sterile water or normal saline and a syringe. Since the reservoir may be made from a part of the intestine, it may produce mucus that normally lines the digestive tract. Irrigating or flushing the reservoir clears this mucus from the reservoir.

Recognizing Infection
Urostomies and continent urinary diversions can get infected. Symptoms of infection include

• dark urine or urine containing excess mucus
• strong-smelling urine
• pain in the back
• poor appetite
• nausea
• vomiting

Drinking eight full glasses of water every day can help prevent infection by flushing out bacteria.

Diet
One will be able to eat a normal diet after urinary diversion. Some foods, such as asparagus and seafood, may cause urine to have a stronger odor.

Clothing
Wearing a urostomy pouch does not require special clothing. Modern pouches are designed to lie flat against the body so they can't be noticed. The pouch can be tucked inside underwear or between underwear and outer clothing. Women may wear a pouch under a girdle as long as it is made of stretchy material. Men may wear the pouch inside an athletic supporter.

Activities
Strenuous physical activity should be limited during the first 2 to 3 weeks after surgery. Such activities include driving and heavy lifting, which may interfere with stoma heal. Once healed, most patients can return to the activities they enjoyed before their surgery. The only exceptions may be contact sports like football or karate.

Relationships
Patients can still maintain a satisfying sexual relationship with their partner in many situations. A doctor or WOC nurse will tell patients when they may safely resume sexual activity after surgery. Nurses and doctors can give more information about ways to protect the stoma during sex.

Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has many research programs aimed at finding and improving treatments for urinary disorders. Researchers supported by the NIDDK are working to understand the growth of bladder tissue in order to find artificial methods of generating that kind of tissue. In an experimental setting, a patient whose bladder must be removed may be given a replacement bladder made from bioengineered tissues instead of from a segment of the patient's bowel. The bioengineered tissue would function much more like a natural bladder.

Other Resources

American Urological Association, Inc.
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1–800–RING–AUA (746–4282) or 410–689–3700
Email: aua@auanet.org
Internet: www.urologyhealth.org

Wound, Ostomy & Continence Nurses Society
4700 W. Lake Avenue
Glenview, IL 60025–1485
Phone: 1–888–224–9626
Email: info@wocn.org
Internet: www.wocn.org

National Kidney and Urologic Diseases Information Clearinghouse
3 Information Way
Bethesda, MD 20892–3580
Phone: 1–800–891–5390
Fax: 703–738–4929
Email: [/about/contact.htm nkudic@info.niddk.nih.gov]
Internet: www.kidney.niddk.nih.gov/