69415685 urinary diversion

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Urinary diversion is any one of severalsurgical proceduresto rerouteurineflow from its

normal pathway. It may be necessary for diseased or defectiveureters,bladderorurethra, either

temporarily or permanently. Some diversions result in astoma.

An ileal conduit urinary diversion is a surgical technique usually referred to as the Bricker ilealconduit after its inventor, Eugene M. Bricker. It was developed during the 1940s and is still one

of the most used techniques for the diversion of urine after a patient has had their bladder

removed, due to its low complication rate and high patient satisfaction level. It is usually used in

conjunction with radicalcystectomyin order to control invasive bladder cancer.

To create an ileal conduit, theuretersare surgically resected from the bladder and a

ureteroenteric anastomosisis made in order to drain the urine into a detached section ofileum(a

part of thesmall intestine). The end of the ileum is then brought out through an opening (a

stoma) in theabdominal wall. The urine is collected through a bag that attaches on the outside of

the body over the stoma. The bag must be periodically emptied of urine, and must be replaced

every one or two days. Any period longer than this poses the risk of infection.

Another and very effective use of an ileal conduit is for systemic isolation of a kidney transplant,

often due to bladder nephropathy that may pose an unacceptable risk of reflux and thus infection

or obstruction, into the transplanted organ. The urostomy is fashioned as previously described

and connectedureteroenteric anastomosisto the transplant ureter. Urinary tract infections are

unfortunately very common because stomas are natural colonisers of bacteria; in transplant

patients, antibiotic treatment, often over a long term and more frequent appliance changes are

effective but not curative countermeasures.

The bag adheres to the skin using a disk made of flexible, adherent materials. Unfortunately,

there can be problems with leaking and rashes (excoriation), and heavy physical exertion willexacerbate deterioration of the appliance. Sometimes the leakage occurs unexpectedly, and

"ostomates" (as they are known) usually carry a spare appliance to deal with unexpected

emergencies.

An Indiana pouch is asurgically-createdurinarydiversion used to create a way for the body to

store and eliminateurinefor patients who have had theirurinary bladdersremoved as a result of

bladder cancer,pelvic exenteration,bladder exstrophyor who are not continent due to a

congenital,neurogenic bladder. This particular urinary diversion results in a continent reservoir

that the patient must catheterize to empty urine. This concept and technique was developed by

Drs. Mike Mitchell, Randall Rowland, and Richard Bihrle at Indiana University.[1]

With this type of surgery, a reservoir, or pouch, is created out of approximately two feet of the

ascending colonand a portion of theileum(a part of thesmall intestine). Theuretersare

surgically removed from the bladder and repositioned to drain into this new pouch. The end of

the segment of small intestine is brought out through a small opening in theabdominal wall

called astoma. Since a segment including the large and small intestines is utilized, also included

in this new system is the ileal-cecal valve. This is a one-way valve located between the small and

large intestines. This valve normally prevents the passage of bacteria and digested matter from
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re-entering the small intestine. Originally, it was thought that removing the ileal-cecal valve from

the digestive tract would likely result in diarrhea, but this has not shown to be the case. After a

period of several weeks, the body adjusts to the absence of this valve (from the digestive tract)

by absorbing more liquids and nutrients. Importantly, this valve, in its new capacity, will now

effectively prevent the escape of urine from the stoma.

Patients can usually expect a hospital stay of between seven and ten days for this surgery. The

abdominal incision for this surgery may be up to eight inches in length and is typically closed

with staples on the outside and several layers of dissolvable stitches on the inside. After surgery,

patients will have a three drainage tubes place while tissues heal: one through the newly-created

stoma, one through another temporary opening in the abdominal wall into the pouch, and an SP

tube (to drain non-specific post-surgical abdominal fluid). In the hospital, the SP tube and

external staples will be removed, after several days. The remaining two tubes will each be

connected to collection bags worn on each leg and the patient is usually sent home like this.

After sufficient healing, and another doctor's visit, the tube will be removed from the stoma. The

patient will now begin to catheterize the pouch every two hours. Since one other tube will still be

in place, patients can still sleep through the night, since a larger collection bag is attached to thattube at night time. After approximately one month, patients will return to the hospital for a

special x-ray. Dye will be instilled into the pouch to verify that there is no leakage of urine. If

there is no leakage, this last tube will be removed. Emptying time now may be increased to 3

hours, however, now the patient will need to wake up during the night (every 3 hours) to empty

the pouch. Over time, emptying time can increased up to 46 hours. The pouch will continue to

expand and will reach its final size at approximately six months. The pouch will then hold up to

1,200 cubic centimeters (cc). Each day, the pouch will need to be irrigated with 60 cc of sterile

water. This removes mucus, salts, and bacteria. If consumption of liquids is reduced in the

evening, patients should be able to sleep through the night after approximately six months.

In contrast to other urinary diversion techniques, such as theIleal conduit urinary diversion, the

Indiana pouch has the advantage of not using an external pouch adhered to the abdomen to store

urine. This can result in a better body image and broader clothing options. Also, there will not be

the worry of an external appliance coming loose and leaking. Additionally, the cost of urostomy

appliances can be significant, and is usually not covered in full by most health insurance plans.

Nor will there be the need to monitor how many appliances are left or ordering more and waiting

for them to be shipped.

Indiana pouch surgery can be done in very young patients, as long as they understand how to

catheterize the pouch and can empty the pouch on a schedule. Indiana pouch surgery also has

been successful in patients of advanced ages, also as long as they are able to empty and irrigate

the pouch on a schedule. Some patients, after having had an ileal conduit, requiring an external

appliance, have opted to have the Indiana pouch, as elective surgery. Such a surgery is usually

recommended, if possible, since it has been documented that the Indiana pouch may reduce the

possibility of kidney damage because the ureters are repositioned lower in the abdomen. This

positioning reduces the possible back-flow of urine to the kidneys. After having an Indiana

pouch surgery, patients may choose to wear a medical alert medallion indicating they have an

Indiana pouch.
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There are three main types of urinary diversions which are described below:

Ileal Conduit Urinary Diversion

The ileal conduit is the oldest and simplest form of urinary diversion. This is composed of a short

part of ileum (small intestine) into which the ureters drain freely. The end of this ileal segment is

brought out to the skin, usually in the right side of the stomach. This is called a stoma. The stomais covered by a bag, which catches the urine as it drains from the ileal conduit.

Advantages:

Shorter surgery time Shorter recovery time No need for intermitten catheterization Least risk of complications

Disadvantages:

External bag with possible leakage and odor. Urine back-up (reflux) to kidneys, leading to possible infections, stones and kidney

damage over time.

Indiana Pouch Reservoir

City of Hope is one of the leaders in Indiana pouch urinary diversions and have been performing

this type of continent urinary diversions for many years. In this form of urinary diversion, a

reservoir (pouch) is constructed out of the right colon (large intestine) and a small segment of

ileum (small intestine).

A short piece of small intestine is brought out to the skin as a small stoma. A one way valvemechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the

skin.

A bag is not required and the patient simply wears a bandage over the stoma. At specific times

during the day, usually every four to six hours, the patient passes a small thin catheter (tube)

through the stoma, into the pouch, and empties the urine.

Advantages:

Urine is kept inside the body until it is ready to be emptied

No bag necessary No odor Minimal risk of leaking Small stoma which can be covered by a bandage.

Disadvantages:

Longer surgery time


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Need for intermittent catheterization (passing a small plastic tube into the pouch everyfour to six hours to empty it)

Slightly higher risk for complications requiring reoperationNeobladder to Urethra Diversion

In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to theurethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch)

is made to mimic the normal storage function of the urinary bladder.

The patient is able to pass urine through the urethra, although there is a period of incontinence

(leakage of urine) that all patients go through following this surgery.

It may take some patients 12 to 18 months to regain control of their urination. A small but not

insignificant percentage of patients will have persistent incontinence.

Rarely, a patient may not be able to empty this reservoir (pouch) well and will require

intermittent catheterization (placement of a small tube into the urethra) in order to empty thereservoir (pouch). Some patients will be required to do this several times a day for a prolonged

time period and in some cases permanently.

In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at

the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the

urethra to empty the reservoir (pouch) if necessary.

Advantages:

The patient is able to empty the reservoir (pouch) of urine in a manner similar to thenormal voiding pattern

No stoma is required No catheters required

Disadvantages:

Slightly longer surgery time Potential for temporary or permanent incontinence in a small percentage of patients. Some patients may have to perform intermittent catheterization (place plastic tube via the

urethra into pouch every six hours to drain urine) for a prolonged time period and,

possibly, forever.

69415685 urinary diversion

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