Continent Urinary Diversion
You do not need to have a bladder in order to live but it is critical to maintain an uninterrupted flow of urine from the body. Fortunately, this flow can be accomplished with a continent urinary diversion procedure. This procedure is not suitable for everyone, so read on to learn more so you can discuss this option with your urologist.
What happens under normal conditions?
The urinary tract is similar to a plumbing system, with special pipes that allow water and salts to flow through them. The urinary tract includes the kidneys, two ureters, the bladder and the urethra.
The kidneys act as a filtration system for the blood, cleansing it of poisonous materials and retaining valuable glucose, salts and minerals. Urine, the waste product of the filtration, is produced in the kidney and trickles down through two 10- to 12-inch long tubes called the ureters, which connect the kidneys to the bladder. The ureters are about one-fourth inch in diameter and their muscular walls contract to make waves of movement to force the urine into the bladder. The bladder is expandable and stores the urine until it can be conveniently disposed of. It also is a one-way flap valve that allows unimpeded urinary flow into the bladder but prevents urine from flowing backward (vesicoureteral reflux) into the kidneys. The tube through which the urine flows out of the body is called the urethra.
What is continent urinary diversion?
Urinary diversion is a term used when the bladder is removed or the normal structures are being bypassed and an opening is made in the urinary system to divert urine. The flow of urine is diverted through an opening in the abdominal wall. Individuals who might require urinary diversion would be those whose bladders were non-functional or needed to be removed due to cancer or injury.
Continent urinary diversion describes all forms of urinary diversion that enable the patient to urinate at his or her own discretion without the use of any form of appliance or collecting device. This form of urinary diversion can be broadly divided into two categories: cutaneous and orthotopic.
Cutaneous continent urinary diversion refers to use of the gastrointestinal tract to create a new bladder, which is attached to the skin inside the body. This form of urinary diversion does not require the use of a collection appliance, however the patient is required to place a catheter or small plastic tube into their new bladder four to five times per day to empty the reservoir.
Orthotopic continent urinary diversion, commonly referred to as neobladder, most closely resembles the normal urinary anatomy. The intestinal tract is used to fashion a new bladder, which is then attached to the urethra in the pelvis. Patients then urinate spontaneously via the urethra and may be required to catheterize to ensure complete bladder emptying. This form of continent urinary diversion has been used in both men and women requiring cystectomy.
Who probably isn't a good candidate for continent urinary diversion?
Patients with borderline kidney or liver function are usually not ideal candidates for continent urinary diversion due to problems with re-absorption of waste products from the urine via the intestine. Patients with cancer involving the urethra can rarely undergo neobladder reconstruction because of the high risk of developing recurrent cancer in the area where the neobladder connects with the urethra. In addition, continent urinary diversion is unadvisable for patients lacking the physical inability to catheterize due to neurologic or orthopedic conditions.
The management and care of continent urinary diversion require a close working relationship between the patient and the urinary diversion health-care team, and follow-up is key as it can lower the risk for postoperative complications.
Certain patients may not be able to comprehend the regimens that must be followed after continent urinary diversion or they may lack the motor skills to perform self-care. Patients with severe multiple sclerosis, quadriplegics and the very frail or mentally impaired will require the care of members of the family or a visiting nurse and are therefore considered poor candidates for continent diversion. There is no absolute age restriction for consideration of continent urinary diversion, however patients over the age of 70 generally have a more difficult time adjusting to the care of the newly formed bladder.
How is continent diversion performed?
All patients undergoing anticipated continent urinary diversion should be prepared for the possibility that a traditional ileal conduit might be performed. Therefore, prior to the operation, the site for an external stoma should be selected in conjunction with an enterostomal therapist.
Kidney and liver function must also be reviewed carefully in the patient selected for continent diversion.
The removal of the bladder (cystectomy) will always be preceded by complete bowel preparation. Healthy patients undergoing radical cystectomy can be admitted to the hospital on the day of surgery. A "Go-Lytely" one-gallon bowel preparation is administered, following a liquid dinner on the night prior to surgery. Oral antibiotics are also given to help sterilize the intestinal tract and reduce the chance of infection. All forms of urinary diversion require the placement of drainage tubes in the new bladder and the kidneys, and these will be present when the patient wakes from surgery. Certain drainage tubes will remain in place for two to three weeks postoperatively. Before removal of the drainage tubes, X-ray studies may be performed to ensure that the new bladder has healed and has no leakage. Postoperatively, patients are taught to wash out the urethral catheter at home every four to six hours. In the early postoperative period, the new bladder may hold only a small volume of urine and patients are required to empty frequently.
What can be expected after a continent urinary diversion?
Because urinary diversion procedures are so complex, patients should be aware that surgical complications could occur.
Patients undergoing continent diversion should also be aware of the functional complications and results of this form of urinary tract reconstruction. Nocturnal enuresis is common to all neobladder procedures.
All patients, male and female, should be aware of the possible need for clean intermittent catheterization (CIC). Rarely, a male patient will be unable to urinate by pelvic floor relaxation and Valsalva maneuver. In women, the incidence of urinary retention requiring clean intermittent catheterization may be as high as 50 percent. In both men and women, there have been reports of greatly distended bladders occurring with the passage of time after continent urinary diversion. To avoid the silent development of this complication, patients are advised to self-catheterize at least monthly in order to measure post-urination residual volume.
All patients with catheterized bladders will have bacteria in the urine. Bacteria in the urine that does not cause symptoms does not warrant antibiotics. The construction of an effective anti-reflux mechanism in all of these bladders may prevent clinical episodes of severe kidney infection (pyelonephritis). Obviously, if clinical kidney infections do occur, antibiotics should be given. Another condition which is pain caused by inflammation in the small intestine is known as pouchitis. Although rare, pouchitis, may result in temporary failure of the control mechanism because of the hypercontractility of the bowel segment used for construction of the urinary diversion. Appropriate antibiotics will usually result in resolution of these symptoms.
Urinary retention is infrequent but represents a true emergency and the patient must seek immediate attention so that catheterization and drainage by experienced personnel can be achieved promptly. After the immediate problem has been resolved by emptying the new bladder, a catheter is usually left in place for a few days and the patient is observed for ability to successfully catheterize on a number of occasions.
The opposite problem (hypercontinence) has been reported following neobladder diversion more commonly in females than males (30 percent vs. 5 percent). This problem is managed with intermittent catheterization.
Intraperitoneal rupture of catheterizable bladders has been reported. In general, these episodes are more common in the neurologic patient where sensation of bladder fullness may be less distinct. In general, these patients require immediate bladder decompression and radiologic bladder studies. For patients with large defects, surgical exploration and bladder repair are required.
Some metabolic complications that can result from use of the intestinal tract in urinary diversion are: urinary tract infection, urinary stone formation, vitamin B12 deficiency, changes in bowel habits and changes in pH balance.
Daytime urinary control rates of greater than 90 percent should be expected following both cutaneous and neobladder diversion. Slightly lower rates of nocturnal continence can be expected following neobladder diversion particularly in the first six to nine months following surgery. This problem can usually be managed by external collecting devices in the male (condom catheter) or fluid restriction before bed.
Frequently asked questions:
Will I be on a special diet?
Yes, probably. Follow your doctor's orders regarding nutrition at each stage of your adjustment.
Do I need to be concerned about urinary tract infections?
Yes. You should contact your doctor if you experience any symptoms like flank or abdominal pain, foul smelling or cloudy urine or fever. Drinking six to eight ounces of fluid (especially water) is recommended to reduce your chances of getting a urinary tract infection.
Reviewed January 2011
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