Urinary Reconstruction and Diversion

Overview

Urinary diversion consists of surgical procedures designed to redirect urine flow when the bladder is unable to function effectively. Surgeons employ various techniques to establish an alternative route for urine to exit the body, with the main goal of facilitating efficient urine removal.

Anatomy of the Urinary Tract

Normally, the urinary tract is made up of the bladder, urethra, two ureters, and two kidneys:

• Your kidneys cleanse your blood, regulate fluid levels, and eliminate excess water and waste, producing urine.
• Urine moves from the kidneys to the bladder through tubes known as ureters.
• The bladder stores urine until you’re ready to urinate. It then passes through the urethra and exits the body.
• Nerves connected to your spinal cord allow constant communication between your brain and bladder. When it’s time to urinate, the brain signals the bladder to contract and the muscles beneath it to relax.

Reasons for undergoing the procedure

There are several reasons why someone might require a urinary diversion. It is often necessary when the bladder has been removed (cystectomy) or no longer functions properly. This can happen due to:

• Persistent bladder infections.
• Cancer of the bladder
• Significant injury to the urinary tract.
• Congenital conditions such as spina bifida.
• Damage caused by radiation treatment for cancer.
• Severe urinary incontinence or chronic bladder pain.
• Neurological conditions like Multiple Sclerosis (MS).

Types of urinary diversion procedures

There are two types of urinary diversion: incontinent and continent. Urine is diverted utilizing a portion of your intestines in both techniques.

• Incontinent: An incontinent urinary diversion entails making a hole in your abdomen through which urine can escape. To accomplish this, surgeons join your ureters to an ostomy or stoma, a portion of your intestine that is brought out through your abdomen. Urine accumulates in an ostomy bag, which you empty. This is sometimes referred to as a urostomy or incontinent diversion.
• Continent: A continent urinary diversion entails creating a bag from your intestines within your body. This might be in the form of a “neobladder” that links to your urethra, or with an Indiana pouch that collects urine within your body that you empty by putting a catheter into a stoma near your belly button.

There exist multiple techniques that your surgeon may employ under each category of urine diversion. Your age, medical history, and other criteria will determine the kind of urine diversion you have.

Incontinent urinary diversion

An ileal conduit is the most common type of urinary diversion for patients who are incontinent. In this procedure, urine is mechanically channeled into a bag, resulting in a lack of control over its flow.

Ileal conduit

The ileal conduit is the most commonly used urinary diversion technique for incontinent individuals. In this procedure, the ureters are connected to a segment of the intestine that has been detached from the rest of the digestive system. This segment is then brought through the abdominal wall to form a stoma. As a result, urine is automatically directed through the stoma into an external collection bag, which must be emptied every few hours.

The following are some benefits of ileal conduit urinary diversion surgery:

• Compared to other procedures, it’s a simpler process.
• Self-catheterization—using a tube to drain one’s own urine—is not required.

The following are the drawbacks of the ileal conduit urine diversion:

• Individuals can be embarrassed to be seen carrying a bag that holds their faeces.
• There’s a possibility the bag will leak and smell.

Continent urinary diversion

You can manage your urinating better with a continent urinary diversion. To store your urine, a surgeon can either create an internal pouch or create a new bladder (called a neobladder).

Indiana pouch reservoir (continent cutaneous reservoir)

An Indiana pouch is constructed using sections of the intestines. In this procedure, the surgeon disconnects the ureters and connects them to the pouch. A small segment of the small intestine is then narrowed to create a channel that is brought out through a stoma, usually located near the belly button. Unlike the ileal conduit stoma, this stoma is smaller and does not drain urine automatically; instead, it serves as a storage pouch that holds urine until it is drained using a catheter inserted into the stoma.

While various types of pouches can be created, the Indiana pouch is the most common. Unlike incontinent diversions, this method eliminates the need for an external bag by surgically creating a one-way valve that keeps urine contained within the pouch. You will need to insert a thin catheter into the stoma several times a day (approximately every four hours) to drain the urine. Regular flushing of the pouch is also necessary to prevent mucus buildup.

Most insurance plans provide an adequate supply of single-use catheters, but if necessary, catheters can be cleaned with soap and water for reuse.

The benefits of the continent cutaneous reservoir approach include:

• Your body retains the urine you excrete. You don’t need to wear a bag under your clothes. 
• Because there’s no bag, the chance of spilling pee is reduced and there’s no potential for odors.
• You can use an adhesive bandage to cover your stoma.

The continent cutaneous reservoir approach has the following drawbacks:

• This surgery takes more time than an incontinent urinary diversion.
• Catheterization is required every four hours to empty the pouch by inserting a small tube into the stoma.
• Complications with the channel are common, including leakage, scar tissue formation, and mucus buildup in the pouch, which can lead to stones and recurrent infections. In emergencies, if the catheter can’t be inserted to drain the pouch, it could rupture.

Neobladder or bladder substitute

This procedure closely mimics the natural function of the bladder by creating a replacement or new bladder. A section of your small intestine is transformed into a neobladder, which is then connected to your urethra. Urine flows from your kidneys through the ureters into this new bladder and then out through the urethra, similar to a normal bladder. To empty the neobladder, you need to tighten your abdominal muscles.

To qualify for this surgery, there should be a low risk of cancer returning in the urethra, and there must be no scar tissue or blockages in that area. Additionally, some individuals may find it difficult to empty the neobladder using abdominal contractions; in such cases, they need to use a catheter to drain the pouch up to six times daily.

The benefits of neobladder diversion include:

• Urination most closely resembles regular urination
• There is no stoma to maintain.

The following are the drawbacks of the Neobladder Diversion:

• Recovery from surgery typically takes longer.
• Urinary incontinence, or leaking urine, is common following surgery and may last for up to six months. Approximately 20% of individuals undergoing this kind of diversion experience overnight incontinence. Up to 10% of people experience daytime incontinence and need to use pads to catch leaking urine. 
• Some people may never be able to completely empty their replacement bladders, necessitating catheterization (either permanently or temporarily).

Risks

Urinary diversion techniques come with certain dangers associated with them. Among the issues that can arise in any kind are:

• Problems with the stoma, such as difficulty putting a tube in or skin developing over it.
• Blocked bowels or leaking excrement.
• Damage to adjacent organs.
• The neobladder or pouch rupturing.
• Scar tissue at the point of ureteric diversion stitching.

Outcome

Recovery after urinary reconstruction and diversion typically takes one to two months as you rebuild your strength. The goal is to return to your regular lifestyle as quickly as possible, though it may take a few weeks to adapt to your new urination habits. If you have any questions about using a catheter to empty your pouch or caring for your ostomy bag or stoma, be sure to ask your doctor. Before you leave the hospital, they will provide you with all the necessary instructions for self-care.

Urinary diversion patients can typically resume their normal lifestyles, jobs, and hobbies:

• Employment: The majority of people may typically return to their occupations in one to two months. Make sure to ask your doctor about any concerns you may have regarding your line of work or other employment dangers.
• Activities: As soon as you heal, you ought to be able to resume your workouts and sporting endeavors. When you can return to your regular activity level following surgery and if you should avoid contact sports or swimming will be communicated to you by your doctor. Inquire with your surgeon about any short-term limitations on object lifting.
• Dietary plan: For a month following surgery, your surgeon could suggest soft, easily digested foods. Ask your doctor any questions you may have about eating.

Urinary diversion surgery can lead to both physical and psychological effects. After the procedure, you may worry that your relationship with your partner will change or feel anxious about resuming sexual activity. It’s important to discuss these concerns with your doctor, as they can help determine whether medication, sex therapy, or support groups might be beneficial for you.