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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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Continent Urinary Diversion Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • anatomy: The physical structure of an internal structure of an organism or any of its parts.

  • antibiotic: Drug that kills bacteria or prevents them from multiplying.

  • bacteria: Single-celled microorganisms that can exist independently (free-living) or dependently upon another organism for life (parasite). They can cause infection and are usually treated with antibiotics.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bowel: Another word for intestines or colon.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • catheterization: Insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.

  • catheterize: To insert a catheter, which is a thin, flexible tube, into a patient or a specific part of the body to drain liquid.

  • catheterized: Inserted a catheter, which is a thin, flexible tube, into a patient or a specific part of the body to drain liquid.

  • CIC: Also known as clean intermittent catheterization. Periodic insertion of a clean catheter into the urethra after washing your hands to drain the urine from the bladder.

  • clean intermittent catheterization: Also known as CIC. Periodic insertion of a clean catheter into the urethra after washing your hands to drain the urine from the bladder.

  • condom catheter: A device or cone-shaped condom catheter that is placed over the penis to allow for urine drainage in men who have urinary incontinence. These devices are attached to the shaft of the penis by some form of adhesive and are connected to urine collecting bags by a tube.

  • continence: The ability to control the timing of urination or a bowel movement.

  • contract: To shrink or become smaller.

  • cutaneous: Relating to the skin.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystectomy: Surgical removal of the bladder.

  • decompression: A surgical procedure to reduce pressure in an organ, part of the body or the pressure of tissues on a nerve.

  • distended: Swollen.

  • enterostomal: A surgically-created permanent opening into the intestine through the abdominal wall.

  • enuresis: Urinary incontinence not caused by a physical disorder. Involuntary discharge of urine during sleep at night. Bedwetting beyond the age when bladder control should have been established.

  • enuresis: Urinary incontinence not caused by a physical disorder.

  • flank: The area on the side of the body between the rib and hip.

  • gas: Material that results from: swallowed air, air produced from certain foods or that is created when bacteria in the colon break down waste material. Gas that is released from the rectum is called flatulence.

  • gastrointestinal: Also referred to as GI. The stomach and the intestines.

  • gastrointestinal tract: The gastrointestinal tract starts from the mouth and proceeds to the esophagus, stomach, duodenum, small intestine, large intestine, rectum and anus.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • glucose: A simple sugar produced in animals by the conversion of carbohydrates, proteins and fats.

  • hypercontinence: Excessive ability to prevent involuntary urination and bowel movements.

  • hypercontractility: Excessive tightening/narrowing.

  • ileal conduit: Made by using a small segment of the small intestine and creating an artificial opening on the surface of the skin for urine to pass outside the body into a collecting pouch attached to the skin.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • inflammation: Swelling, redness, heat and/or pain produced in the area of the body as a result of irritation, injury or infection.

  • intermittent catheterization: Periodic insertion of a narrow tube through the urethra or through the front of the abdominal wall into the bladder to allow urine drainage.

  • intestine: The part of the digestive system between the stomach and the anus that digests and absorbs food and water.

  • ions: Electrically charged atoms.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • kidney infection: Also called pyelonephritis. Urinary tract infection involving the kidney. Typical symptoms include abdominal or back pain, fever, malaise and nausea or vomiting.

  • kidneys: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • liver: A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.

  • multiple sclerosis: A serious progressive disease of the central nervous system.

  • neobladder: A new bladder.

  • nephritis: Inflammation of the kidneys.

  • neurologic: Pertaining to the nervous system.

  • nocturnal continence: The ability to prevent involuntary urination and bowel movements at night.

  • orthopedic: Relating to or marked by disorders of the bones, joints, ligaments or muscles.

  • orthotopic: In the normal or usual position.

  • pelvic: Relating to, involving or located in or near the pelvis.

  • pelvis: The bowl-shaped bone that supports the spine and holds up the digestive, urinary and reproductive organs. The legs connect to the body at the pelvis.

  • postoperative: Occurring after a surgical operation.

  • pouchitis: Inflammation of the pouch created as treatment of a patient with ulcerative colitis.

  • pyelonephritis: Also referred to as kidney infection usually caused by a germ that has traveled up through the urethra, bladder and ureters from outside the body. Typical symptoms include abdominal or back pain, fever, malaise and nausea or vomiting.

  • quadriplegics: Individuals who are unable to move their entire body below the neck.

  • radical: Complete removal.

  • radiologic: X-ray.

  • reflux: Backward flow of urine. Also referred to as vesicoureteral reflux (VUR). An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.

  • reflux: Backward flow.

  • retention: In ability to empty urine from the bladder, which can be caused by atonic bladder or obstruction of the urethra.

  • stage: Classification of the progress of a disease.

  • stoma: An opening.

  • stone: Small hard mass of mineral material formed in an organ.

  • uresis: Urinate.

  • ureter: One of two tubes that carry urine from the kidneys to the bladder.

  • ureteral: Pertaining to the ureter. Also referred to as ureteric.

  • ureters: Pair of tubes that carry urine from each kidney to the bladder.

  • ureters: Tubes that carry urine from the kidneys to the bladder.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urge: Strong desire to urinate.

  • urinary: Relating to urine.

  • urinary diversion: 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.

  • urinary retention: Failure to empty the bladder totally.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • vesicoureteral reflux: Also referred to as VUR. An abnormal condition in which urine backs up from the bladder into the ureters and occasionally into the kidneys, raising the risk of infection.

  • void: To urinate, empty the bladder.

Continent Urinary Diversion Anatomical Drawings

click images for a larger view
 

 

 

 

 

 

 

 

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