Urinary Diversion

The anatomy of the human urinary tracts includes two kidneys, two ureters, one urinary bladder and a urethra. Kidneys perform the function of making urine by filtering the blood, which then passes to the bladder through hollow tubes, known as ureters. When the bladder gets filled completely, the reflex of micturition (urination) helps in emptying the bladder with the help of the urethra.

If there is an organic disease process anywhere along the urinary system, the normal physiology is altered. In all such cases, your surgeon will have to create an alternative pathway to expel the toxic nitrogenous products in the urine to minimize the risk of complications. For example, after major surgical procedures like bladder removal (for the management of a malignant lesion or other indications), surgeons usually create a pathway for the urinary excretion from the body by a process known as urinary reconstruction and diversion.

What are some types of Urinary Diversion?

Most common urinary diversion surgeries are as follows:

1. Ileal conduit urinary diversion: It is the diversion of urine to the ileum.

Procedure: In this procedure, the ureters drain urine directly into the terminal ileum, which is then brought to the exterior via a stoma in the abdominal wall.

Merits:

• It is a simple procedure.
• Easy and quick to perform with excellent outcomes.
• No catheter is needed to be placed to drain the urine out.

Demerits:

• The procedure is not cosmetically appealing for the patient.
• The external bag with urine may leak and produce awful odor.
• Any obstruction in the pathway or poor management of the stoma can lead to urine backing up in the kidneys, causing infections and stones.

2. Indiana Pouch Reservoir: it is the diversion of urine to the large intestine and portions of ileum.

Procedure: In this procedure, a pouch is made from the colon (mainly ascending part or from part of ileum). That pouch serves as the reservoir of urine. The ureters flow directly into the pouch, from where it is then removed by a small stoma made on the abdominal wall. A catheter is used every 4-6 hours to empty the pouch. Catheter is passed from the stoma into the pouch, for emptying purpose. The catheter does not need to be sterilized, but should be washed thoroughly after every use. Stoma is covered by a bandage.

Merits:

• Urine is inside the body and hence no external stoma bag required.
• No leakage of urine occurs and hence no offensive odor.
• Urine backing up in kidney is lowered and infections are rare.
• Stoma is small and covered by bandage.

Demerits:

• Long surgery required and is expensive.
• Catheter is required every 4-6 hours to empty the pouch.

Neobladder to Urethra Diversion: The storage function of bladder is preserved in this surgery.

Procedure: In this procedure, a small pouch is made from the small intestine (just like Indiana pouch reservoir). The pouch is connected directly to the ureters on the proximal end and to the urethra on the distal end. Hence the urine flows from kidney to ureters, from the ureters to the pouch, and from the pouch to the exterior via urethra as in a normal person expelling urine. A catheter must be passed if the urine flow stops at any time, or to empty the pouch if necessary.

Merits:

• The procedure preserves the normal anatomy and physiology of the body.
• No stoma formation is required.
• The chances of kidney infection due to urine back-up is very little (especially when compared to the above procedures).

Demerits:

• Longer surgery required.
• Incontinence of urine is a major disadvantage because of restoration of urinary control. Some patients may develop incontinence during night, and therefore require diapers or pads. The condition might last up for six months after surgery.
• Passage of catheter in some patients, who do not develop or regain urination control gets necessary. Even in some patients, permanent use is mandatory to empty the bladder.

Immediate Post- Operation Period:

• Depression and risk of mental health issues increases significantly due to chronic nature of illness and disability.
• The patient should join support groups to learn better coping mechanisms.
• Discussion with friend and family usually helps in boosting the confidence.
• Never hesitate to ask your doctor if you have any query.

What to Expect after Urinary Diversion?

• Work: Routine day-to-day activities can be resumed in about one to two months after the surgery.
• Activities: Exercise and sports are highly appreciated after the surgery for the rehabilitation purpose.
• Diet: No dietary restrictions are advised after the procedure.
• Travel: You can travel anywhere in the world, but make sure that you carry your supplies, such as catheters, stoma bags and pads.

References:

1. Sofos, S. S., Walsh, C. J., Parr, N. J., & Hancock, K. (2015). Radical cystectomy and pelvic lymphadenectomy with ileal conduit urinary diversion and abdominal wall reconstruction: an interesting case of multidisciplinary management. International medical case reports journal, 8, 29.

2. Shimko, M. S., Tollefson, M. K., Umbreit, E. C., Farmer, S. A., Blute, M. L., & Frank, I. (2011). Long-term complications of conduit urinary diversion. The Journal of urology, 185(2), 562-567.

3. Wuethrich, P. Y., Burkhard, F. C., Stueber, F., & Studer, U. E. (2014). Blood loss is reduced in patients undergoing open radical cystectomy and urinary diversion with a low pelvic venous pressure: a secondary analysis of a randomized clinical trial: 6AP4‐2. European Journal of Anaesthesiology (EJA), 31, 99.