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Urinary diversion

A urinary diversion is surgery to make a new pouch (reservoir) to collect urine and a new path for urine to leave the body. Normally, urine is produced by the kidneys and flows to the bladder through 2 long tubes called ureters. The urine is collected in the bladder and passes out of the body through a tube called the urethra.

Diagram of the Location of the Bladder

Why a urinary diversion is done

This surgery is done whenever the bladder doesn’t work normally or it has to be removed. This may happen because of the cancer or damage caused by cancer treatment. A urinary diversion may also be needed with other bladder conditions such as nerve problems, a defective bladder at birth or a severe injury.

The diversion may be temporary until the urine can flow through the normal path again. Or it may be permanent.

In the treatment of cancer, a urinary diversion is done:

  • after the bladder is removed during a radical cystectomy
  • after the bladder is removed to treat other cancers that have spread to the bladder – cancer of the colon, uterus, ovary, cervix or vagina may spread to the bladder
  • because of damage to the bladder due to radiation treatment
  • as palliative care in advanced cancer to bypass a blockage of urine

How a urinary diversion is done

There are different types of urinary diversions. A urostomy is a urinary diversion that opens in the abdominal (belly) wall. An orthotopic neobladder is a type of diversion where the pouch is connected back to the urethra for the urine to pass out of the body in the normal way.

Urinary diversions can be either incontinent (the person can’t control urination) or continent (the person can control urination). In rare cases, a urinary diversion may be done without removing the bladder. This is done to relieve blocked urine flow if the cancer has spread or cannot be removed by surgery.

Incontinent diversion

With incontinent diversions, the ureters are connected directly or indirectly to an opening in the abdominal wall using a part of the bowel or small or large intestine (urostomy).

With an incontinent diversion, urine is collected in a small bag worn on the outside of the body. This type of diversion is used more often for people who are older or in poor health.

Urinary conduit

The main type of incontinent diversion is a urinary conduit. A urinary conduit uses a part of the bowel or small or large intestine as a tube that the urine passes through (a conduit).

The most common urinary conduit is an ileal conduit, or ileal loop, procedure. A part of the ileum (the last part of the small intestine) is used as the conduit. The ureters are attached to the conduit. The conduit is attached to an opening (called a stoma) in the abdominal wall (urostomy). Urine drains from the kidneys, through the ureters, into the conduit and then through the stoma. The urine is collected in a small bag attached to the stoma and worn on the outside of the body.

Diagram of Ileal Conduit

Cutaneous ureterostomy

The ureters open directly in the front of the abdominal wall. This surgery is used more commonly in children and rarely in adults.

Continent diversion

With a continent diversion, you can control urination through a pouch that stores the urine. If the pouch is connected to an opening in the skin of the abdominal wall, it is called a continent cutaneous diversion. If it is attached to the urethra, it is called a continent urinary diversion.

There are 3 main types of continent diversions – continent catheterizable diversion, orthotopic neobladder diversion and ureterosigmoidostomy.

Continent catheterizable diversion (Indiana pouch)

The Indiana pouch is an example of a diversion that opens in the abdominal wall (urostomy). It’s a type of continent diversion.

With an Indiana pouch, the surgeon creates a pouch inside the body using the right colon and part of the small intestine. The pouch is connected to an opening in the abdominal wall in a way that the urine does not drip or leak out of this opening. A collection device or bag to collect the urine outside the body is not needed.

You will need to drain the pouch with a tube, or catheter, 4–6 times throughout the day.

Diagram of the Indiana Pouch

Orthotopic neobladder

With an orthotopic neobladder, the surgeon creates a pouch called a neobladder (or new bladder) inside the body using part of the small intestine. In rare cases, part of the large intestine is used. The ureters are attached to the pouch and the pouch is connected to the urethra.

If you have this type of diversion you can urinate normally. You can empty the pouch by relaxing muscles in the pelvic floor and increasing pressure in the abdomen. You don’t need a bag on the outside of your body, and you don’t have to empty the pouch with a tube.

This surgery cannot be done if the cancer is too close to the urethra where the neobladder will be connected. And because it is a more difficult surgery with a higher risk for complications, it is not usually done in older people or those with other serious medical problems.

Diagram of Orthotopic Neobladder

Ureterosigmoidostomy

This surgery is sometimes used if someone does not want to have a stoma or if it is not possible to create a urinary diversion through the urethra. In this surgery, the ureters are connected to the sigmoid colon (the last part of the large intestine). The urine leaves the body with the stool through the anus.

Side effects

Paralytic ileus

Paralytic ileus is decreased bowel activity that can be caused by surgery or general anesthesia. It is a common side effect of abdominal surgery. The exact reason why this happens is not clear. After the surgery, the intestines can fill with fluid, and swallowed air cannot move through the intestine. A person may feel bloated and have nausea and vomiting. This is a temporary side effect that usually gets better 3–7 days after the surgery.

Bowel obstruction

Bowel obstruction is when the small intestine or colon (part of the large intestine) is partly or completely blocked. The blockage prevents food, fluids and gas from passing through the intestines normally. The small intestine is the long, tube-shaped organ in the abdomen that receives partially digested food from the stomach and passes digested food to the large intestine. The colon absorbs water and nutrients from almost completely digested food from the small intestine and passes waste (stool, or feces) to the rectum.

Reservoir (pouch) rupture and bacterial peritonitis

The reservoir, or pouch (also called a neobladder), may break open. Urine will leak out and may cause infection of the peritoneum lining the abdomen. This is called bacterial peritonitis. It is treated with antibiotics and sometimes surgery.

Urinary retention and urinoma

Sometimes urine is blocked because part of the passage from the pouch to the opening in the abdomen or through the urethra is narrow or there is scar tissue along the passage. Urine may also be blocked because of stones (calculi) or other causes. The urine fills up the pouch (called urinary retention, or urinoma). This is treated by draining the urine through the skin and finding out what is blocking its path. Once the cause is found, surgery may be needed to remove the blockage.

Kidney infection (pyelonephritis)

Kidney infection may develop if the flow of urine is slow or blocked or if it backs up (called reflux). This is usually treated with surgery to improve the flow of urine and antibiotics to control infection.

Stones (calculi)

Stones are mineral deposits. They can sometimes develop in the kidneys or the reconstructed urinary pouch after bladder cancer surgery. Drinking lots of fluids is important. Some people may need to have surgery to remove stones that do not pass out of the body on their own.

Narrowing of the stoma

Narrowing of the stoma (called stomal stenosis) is a late side effect that may develop after ileal conduit reconstructive surgery. It is fairly common after Indiana pouch or similar surgery. It is treated by widening (dilating) the stoma.

Parastomal hernia

A parastomal hernia is a bulging around the stoma. It can develop as a late side effect of ileal conduit or Indiana pouch reconstructive surgery. Some people may need surgery to repair a hernia.

Metabolic disorders

Metabolic disorders, such as an electrolyte imbalance, can develop after reconstructive surgery. The healthcare team will monitor levels of electrolytes, such as potassium and sodium, in the blood. Supplements may be given to bring electrolyte levels back to normal. Also, vitamin B12 levels may go down between 3 and 5 years after surgery. Vitamin B12 supplements and injections are used to return this level to normal.

Special considerations for children

Preparing children before surgery can lower their anxiety, increase their cooperation and help them develop coping skills. Preparation includes explaining to children what will happen during the surgery, including what they will see, feel and hear.

The preparation for a urinary diversion depends on the age and experience of the child. Find out more about how to prepare a child for tests and procedures.

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