Urinary Reconstruction and Diversion is a surgical process that creates a new path for urine to leave the body when the bladder has been removed or is not functioning properly.
What is a urinary diversion?
A Urinary Reconstruction is a procedure that creates a new place for urine to drain when the bladder stops working properly. Surgeons perform urinary diversion in a variety of ways, but the goal is to find a new route for urine to leave the body.
Anatomy of the Urinary Tract
The urinary tract generally consists of two kidneys, two ureters, the bladder, and the urethra:
- The kidneys filter the blood, maintain fluid balance, and remove water and waste to form urine.
- Urine flows from the kidneys to the bladder through tubes called ureters.
- The bladder holds urine until it’s time to urinate. It passes through the urethra and is then drained from the body.
- The brain and bladder communicate constantly through nerves that run along the spinal cord. When it’s time to urinate, the brain sends signals to the bladder to contract and to the underlying muscles to relax.
Why is a urinary diversion needed?
There are many reasons why a person might need a urinary diversion. Typically, it is due to bladder removal (cystectomy) or bladder dysfunction. This can be due to:
- Bladder cancer.
- Bladder damage caused by radiation therapy for cancer.
- Chronic bladder infections.
- Severe trauma to the urinary tract.
- Congenital conditions such as spina bifida.
- Neurological conditions such as multiple sclerosis (MS).
- Severe urinary incontinence (urinary leakage) or bladder pain.
Procedure Details
What are the different types of urinary diversions?
Urinary diversions can be for incontinence or chronic (continental). Both methods involve using a section of the bowel to drain urine.
Incontinence: Continental urinary diversion involves creating an opening in the abdomen for urine to drain. Surgeons do this by connecting the ureters to a section of bowel that drains through the abdomen (stoma). Urine is collected in a bag called a stoma, which is emptied. This is sometimes called an incontinence diversion or urostomy.
Continental: Continental urinary diversion involves creating a pouch within the body from the bowel. This can be a neobladder, which connects to the urethra, or an Indiana pouch, which collects urine within the body and drains it by inserting a catheter into the stoma in the navel.
Within each type of urinary diversion, there are several different techniques the surgeon may use. The type of urinary diversion you choose will rest on on factors such as your age, medical conditions, and medical history.
Urinary Diversion for Urinary Incontinence
The main type of urinary diversion for urinary incontinence is an ileal conduit. With this type of urinary diversion, you do not control urination; urine flows automatically into a urine bag.
Ileal Conduit
Ileal conduit urinary diversion is the most mutual method for urinary incontinence. With an ileal conduit urinary diversion, the ureters are connected to a separate section of the intestine and drained through the abdominal wall like a stoma. This automatically directs urine through the stoma into an external collection bag, which must be emptied every few hours.
Advantages of ileal conduit urinary diversion:
- It is a simpler procedure than other methods.
- It does not require self-catheterization (using a tube to drain urine).
- Disadvantages of ileal conduit urinary diversion:
- People may feel uncomfortable due to the presence of a urine collection bag.
- There is a possibility that urine may leak from the bag and cause a bad odor.
Continental Urinary Diversion
Urinary Reconstruction and Diversion can be for incontinence or chronic. Both methods involve using a section of the bowel to drain urine.
Indiana Pouch (Continental Cutaneous Pouch)
- The Indiana pouch is made from pieces of intestine. The surgeon cuts the ureters and sutures them to the pouch. The short section of small intestine connected to the pouch narrows to form a channel and drains through a stoma, usually in the belly button.
- The stoma is smaller than an ileal conduit stoma and does not drain on its own. It stores urine until it is emptied through a catheter placed in the stoma. The surgeon can create different types of pouches, but the Indiana pouch is the most common.
- Several times a day (usually every four hours), a small, thin catheter is inserted into the stoma and a drainage bag is inserted. You will also need to rinse the bag regularly to remove any mucus that may accumulate inside.
Advantages of the skin pouch method:
- Urine stays inside your body. You don’t need to wear a drainage bag under your clothing.
- By not using a drainage bag, there is less risk of leaks and no chance of odor.
- You can cover the stoma with a bandage.
Disadvantages of the skin pouch method:
The surgery takes longer than urinary diversion for incontinence. Catheterization (insertion of a small tube into the stoma to empty the reservoir) is required every four hours, 24 hours a day. Complications with the reservoir are common. The reservoir can leak or develop scar tissue, and mucus buildup in the reservoir can lead to stones and recurrent infections. If a catheter cannot be passed to empty the reservoir, it could burst (this is an emergency).
Neobladder or Bladder Substitute
This procedure closely mimics normal bladder function and involves the creation of a new bladder. A section of the small intestine is transformed into a new bladder, which surgeons connect to the urethra. Urine flows from the kidneys into the ureters, then into the pouch (new bladder), and finally through the urethra, just like a normal bladder. Emptying the neobladder requires contracting the abdominal muscles.
A candidate for this surgery may be someone with a low risk of cancer recurrence in the urethra and who does not have scar tissue or urethral obstruction. Additionally, some people are unable to empty the neobladder by contracting their abdominal muscles. In these cases, a catheter is inserted into the urethra to empty the pouch up to six times a day.
Advantages of Neobladder Diversion:
- Urination is as normal as possible.
- No stoma care is required.
- Disadvantages of a neocystodermal urinary diversion:
- The surgery usually takes longer.
Urinary incontinence (urinary leakage) is normal after surgery and can last up to six months. About 20% of people with this type of urinary diversion experience nighttime urinary incontinence. Up to 10% experience daytime urinary incontinence and must use pads to collect lost urine.
Some people may not completely empty their new bladders and still require catheterization (temporary or permanent).
Is a urostomy the same as a Urinary Reconstruction?
A urostomy is a type of urinary diversion for incontinence. A urostomy involves making an opening in the abdominal wall to drain urine. Urine is collected in a bag worn under clothing (an ostomy bag).
Risks/Benefits
What are the risks of Urinary Reconstruction?
Different types of urinary diversion procedures each have their own risks.
Some problems that can occur with all types include:
- Complications with the stoma, such as tube placement or skin growth over it.
- Fecal incontinence or bowel obstruction.
- Injury to nearby organs.
- Rupture of the neobladder or bladder.
- Appearance of scar tissue where the ureters are sewn to the urinary diversion system.
What are the benefits of urinary diversion?
Urine must be removed from the body. Otherwise, it can back up into the kidneys and cause permanent damage, such as kidney disease or kidney failure. Urinary diversion surgery may be the only way to prevent urine from support up into the kidneys and causing damage.
Recovery and Prognosis
What is recovery like after urinary diversion?
After bladder reconstruction and urinary diversion, it takes one to two months to feel well and regain your strength. The goal is to get back to your normal routine as soon as possible. It may take a few weeks to get used to the new way of urinating. Talk to your doctor about caring for your stoma and drainage bag, or emptying your catheter. They will give you any necessary instructions for self-care after you leave the hospital.
People with urinary diversion can generally return to their usual routine, work, and hobbies:
- Work: Most people can return to their regular job after one to two months, on average. If you are concerned about your job or other occupational risks, talk to your doctor.
- Physical Activity: You should be able to return to sports or exercise immediately after your recovery. Your doctor will tell you when you can resume your normal activity level after surgery and whether you should avoid contact sports or swimming. Talk to your surgeon about temporary lifting restrictions. Diet Plan: Your surgeon may recommend soft, easy-to-digest foods for one month after surgery. If you have any questions about your diet, consult your doctor.
- Travel: There are no travel restrictions. However, you should bring necessary supplies or have emergency supplies (such as extra colostomy bags) on hand. Urinary diversion surgery can affect you both emotionally and physically. You may feel nervous about resuming sexual activity or fear that your relationship may change after surgery. It is important to discuss your concerns with your doctor to see if medication, sex therapy, or other support groups may be helpful.
Summary
As with any life change, a period of adjustment is normal after a major surgery such as urinary diversion. It’s common to feel sad or anxious about how your life has reformed or what you need to do differently after surgery. The good news is that most people return to their normal routine within two months of surgery. Since your urinary flow has changed significantly, there will be a learning curve. Be patient. If you feel uncomfortable with the urinary diversion procedure, talk to your doctor about support groups or other resources to help you cope.