Urinary Diversion - Types, Procedure, Post-Operative Instructions, and Complications

Introduction:

Urinary diversion or reconstruction is a surgery done to facilitate urine flow from a different path. It is usually indicated when the urinary bladder is damaged and unable to store the urine, or it has been removed during surgery (cystectomy). If the surgery is not carried out, the urine remains in the body and allows the bacteria to multiply. As a result, it can lead to urinary tract infections and other complications. However, the patients need not worry about life after surgery. They can work and continue their activities one to two months after the surgery.

What Is Urinary Diversion?

Urinary diversion is a surgical procedure done after removing the bladder to allow the urine to flow through a different path. It is important to know about the organs of the urinary system and their functions to understand the flow of urine in normal conditions. The urinary system comprises the following organs:

The work of the urinary bladder is to store the urine until it is expelled from the body. If the patient is suffering from conditions that affect the bladder function, or has been removed due to cancer, urinary diversion needs to be done. The part of the intestine is reconstructed surgically to allow the urine to leave the body.

Why Does a Patient Need a Urinary Diversion?

The reasons for which the patient needs to undergo a urinary diversion are listed below:

1. Bladder Cancer: It begins in the cells lining the bladder walls. If cancer is diagnosed later, a surgery known as cystectomy is done to remove the bladder. However, the urine will not generally flow in the absence of a bladder, so urinary diversion needs to be done to allow the urine to flow through another path.

2. Spinal Injury: The spinal cord consists of nerves that control the functions of the bladder and connects it to the brain. In the case of spinal cord injury, this communication is disrupted, resulting in a condition called neurogenic bladder. In this condition, bladder control is lost, resulting in urine leakage.

3. Interstitial Cystitis: It is a condition in which the inflammation of the bladder occurs due to bacterial infection. If the condition is present for a prolonged period, the bladder wall becomes stiff, making it impossible to hold the urine. So, a new pathway needs to be created for the urine to flow freely.

4. Urinary Retention: Enlargement of the prostate gland in males and uterus in females, the presence of kidney stones, and tumors are some of the conditions that block the urine flow resulting in urinary retention. If the urine remains within the body for a long time, it can cause a urinary tract infection. So urinary diversion builds a new pathway for the urine to flow and prevent infection.

5. Radiation Therapy: The radiations cause damage to the bladder lining resulting in a condition called radiation cystitis. The long-term effects of radiation include pain while passing urine, blood in the urine, and damage to the nerves and blood vessels present around the bladder. As a result, the bladder gets damaged permanently, making it necessary for the patient to undergo urinary diversion surgery.

6. Severe Urinary Incontinence: Urinary incontinence is when urine leaks out while coughing, lifting heavy objects, and sneezing. Treatment options are available for the condition, but a urinary diversion is the only choice left in severe cases.

What Are the Different Options for Urinary Diversion?

There are different types of urinary diversion surgeries available. The surgery aims to reconstruct a part of the intestine to serve as a pouch to hold the urine or allow the urine to flow. The different types of urinary diversion surgeries are listed below:

• Continent urinary diversion.

• Urostomy (incontinent urinary diversion).

• Cystostomy.

• Nephrostomy.

• Bladder catheterization.

How Is the Continent Urinary Diversion Surgery Carried Out?

Continent urinary diversion is a procedure in which urine is collected and stored in a pouch created from the intestine. Then, it is drained through the catheter or the urethra. This procedure enables the patient to control when the urine leaves the body. The two main types of continent urinary diversion are listed below:

1) Continent Cutaneous Reservoir (Indiana Pouch Reservoir): In this procedure, a pouch or a bag is created using a part of the large intestine (ascending colon) and small intestine (ileum is used). The pouch is placed in the abdomen. The ureters are connected to this pouch to receive urine from the ureters. Next, a portion of the small intestine is attached to this pouch by making an opening in the wall of the abdomen known as a stoma. It consists of a valve that prevents the backflow of urine. Finally, a tube known as a catheter is inserted into the stoma to drain the urine.

Advantages of Indiana Pouch Reservoir:

• The urine is collected in a pouch or a bag present in the body until it flows outside.

• The patient is not required to carry an external pouch or a bag to collect the urine.

• An adhesive bandage can cover the stoma, and the urine does not leak out from the body.

Disadvantages of Indiana Pouch Reservoir: The procedure is time-consuming, and the urine needs to be drained through the catheter every four hours.

2) Neobladder: The procedure aims to create a substitute for the urinary bladder (neobladder). The doctor converts a portion of the small intestine into a pouch and connects it to the urethra. The ureters are linked to this pouch. As a result, the urine flows from the kidneys to the ureters, is stored in the bag, and is drained outside through the urethra. The patient needs to tighten the muscles of the abdomen to urinate.

Advantages of Neobladder: The process of passing urine is similar to normal urination, and the abdominal wall opening (stoma) is not required.

Disadvantages of Neobladder: The disadvantages of the procedure are listed below:

1. The surgery gets completed in a long time compared to others.

2. The patient needs to wear a disposable pad for six months or more as the urine might leak during the day or at night.

3. The patient might need to urinate through the catheter permanently for a long time.

What Happens in the Other Procedures of Urinary Diversion?

The other procedures of urinary diversion are described below:

1. Urostomy: It is a surgical procedure to divert urine if the bladder cannot function or has been removed. A hole or an opening is made in the abdomen to help the patient urinate without a bladder. The urine gets collected in a pouch outside the body. The different types of urostomy are listed below:

   • Ileal Conduit: A part of the small intestine known as the ileum is removed to create a urine pathway. The ureters are connected to the part of the intestine, which is further attached to the abdominal wall opening (stoma). Hence, the urine flows through the ureters to the intestine and is drained out through the stoma.

   • Cutaneous Urostomy: The ureters are directly attached to the abdominal wall opening (stoma).

2. Cystostomy: In this procedure, a tube is inserted into the urinary bladder through the abdominal area. The urine moves out through the tube and gets collected in a bag outside the body.

3. Nephrostomy: The doctor makes an incision in the back (at the location of the kidneys) to insert a wire through the needle. Next, the needle is removed, and the wire is left in place. Next, a tube (nephrostomy tube) is inserted along the wire and tied to the area. Next, a bag is attached to the tube, and the urine drains through the tube into the bag.

4. Bladder Catheterization: A small tube known as a catheter is inserted into the urinary bladder. The urine drains through the bladder and gets collected in a bag attached. The two types of catheters used commonly are foley and supra-pubic catheters. A Foley catheter is inserted into the urethra to reach the bladder. A supra-pubic catheter is inserted into the bladder through the skin below the stomach.

What Instructions Are to Be Followed After the Surgery?

The patient needs to wait for one to two months to allow the site to heal. Then, the patient can resume normal activities only after consultation with the doctor. The instructions to be followed by the patients are listed below:

• In the case of a urostomy, a pouch is attached to the body to collect urine. This pouch needs to be emptied as soon as it is one-third to half full to avoid urinary tract infection.

• The urostomy pouch should be changed once or twice a week as the doctor recommends.

• The abdominal opening (stoma) skin should be cleaned, rinsed with warm water, and dried properly.

• In the case of continent cutaneous reservoir surgery, the urine gets collected in the pouch present created in the body. The catheter should be inserted every two hours to drain the urine after the surgery.

• The pouch should be cleaned regularly with sterile water to prevent bacterial accumulation.

• In the case of neobladder surgery, the patient must urinate every two to three hours during the day and night to keep the bladder empty.

• The urine leakage occurs six to twelve months after the surgery, so the patient needs to wear disposable pads that absorb the urine.

• There is no particular diet plan to be followed, and the patient can continue his job one to two months after the surgery.

What Are the Complications of Urinary Diversion Surgeries?

The most common complication of urinary diversion surgeries includes urinary tract infection. This is because the bacteria can quickly enter the urinary system through the pouch attached to the body externally. The symptoms of urinary tract infection include the following:

1. The infection is usually accompanied by fever in infants and young children.

2. The patient experiences pain in the lower back and abdominal region.

3. The urine flow is restricted, so the patient can pass only a few drops of urine each time.

4. Urinary incontinence or leakage of urine can occur in some children.

5. The urine appears cloudy and smells bad.

Conclusion:

Urinary diversion surgery is a boon for patients suffering from bladder problems. It creates a new path to allow the urine to flow through the body. After the surgery, the patient cannot work or carry out other activities for one to two months. However, the patient need not feel depressed because healing after a major surgery takes time. The patient must remember to drain the urostomy pouch to avoid bacterial infection when it becomes one-third to half full. If the patient follows all the instructions after the surgery, complications rarely occur.