What is urinary reconstruction and diversion?

When the urinary bladder is removed (due to cancer, other medical condition, or because the organ no longer works), another method must be devised for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way for you to pass urine.

Urinary diversion options

There are three main types of urinary diversion surgeries

• Ileal Conduit Urinary Diversion
• Indiana Pouch Reservoir
• Neobladder to Urethra Diversion

For all of these procedures, a portion of the small and/or large bowel is disconnected from the fecal stream and used for reconstruction.

Ileal Conduit Urinary Diversion

With this procedure, the ureters drain freely into part of the ileum (the last segment of the small intestine). The end of the ileum into which the ureters drain is then brought out through an opening in the abdominal wall. This opening, called a stoma, is covered with a bag that gathers the urine as it drains from the ileal conduit.

Advantages:

The advantages of the Ileal Conduit Urinary Diversion surgery are:

• It is a relatively simple surgery.
• It requires less surgical time (compared with other surgical methods).
• There is no need for occasional catheterization (use of a tube to drain the urine)

Disadvantages:

The disadvantages of the Ileal Conduit Urinary Diversion are:

• There is a change in body image.
• It uses an external bag to collect urine, which might leak or have odors.
• Urine could back up into the kidneys, causing infections, stone formation in some patients, and organ damage over time.

Indiana Pouch Reservoir

With this type of surgery, a reservoir or pouch is made out of a portion of the large intestine (the ascending colon on the right side of the abdomen) and a portion of the ileum (the last segment of the small intestine). The ureters are repositioned to drain into this pouch. The urine flows freely in a downward direction from the kidneys into the pouch. This positioning prevents urine from backing up into the kidneys, which protects the kidneys from infection. A short piece of small intestine is then brought out through a small opening in the abdominal wall (a stoma). Unlike the Ileal Conduit, no external bag is needed, and the stoma is very small and can be covered with an adhesive bandage. Instead, a one-way valve is surgically created to keep the urine inside the pouch. Several times a day, usually every four to six hours, a small, thin catheter must be passed through the stoma and into the pouch to empty the urine. An adhesive bandage is worn over the stoma at all other times (when not actively emptying the pouch). Catheters are washed with soap and water after each use. The catheters do not have to be sterilized. They can be taken on trips or social events and simply stored in a zip lock bag.

Advantages:

The advantages of the Indiana Pouch Reservoir surgery are:

• Urine is kept inside the body, in the reservoir, until it is ready to be emptied.
• No external bag is necessary.
• There is no odor.
• The risk of urine leaking is minimal.
• The small stoma can be covered with an adhesive bandage.
• The risk of reflux (back up) of urine into the kidneys is lessened, lowering the risk of infection.

Disadvantages:

The disadvantages of the Indiana Pouch are:

• The surgical time is longer compared with the Ileal Conduit.
• There is the need for occasional catheterization (the passing of tubing into the stoma to empty the pouch), every four to six hours.

Neobladder to Urethra Diversion

This procedure most closely mimics the storage function of a urinary bladder. With this procedure, a small part of the small intestine is made into a reservoir or pouch, which is connected to the urethra. The ureters are repositioned to drain into this pouch. As with the Indiana Pouch, this downward flow of urine from the kidneys into the pouch helps prevent urine back up, which helps protect the kidneys from infection. Urine is able to pass from the kidney, to the ureters, to the pouch, and through the urethra in a manner similar to the normal passing of urine. To be a candidate for this surgical procedure, there must be a low risk of cancer recurrence in the urethra, and patients must be able to pass a catheter into the urethra to empty the pouch if necessary.

Advantages:

The advantages of the Neobladder to Urethra Diversion are:

• The process of urination most closely matches normal urination.
• No stoma is needed.
• The kidneys are protected from urine back up and infection.

Disadvantages:

The disadvantages of the Neobladder to Urethra Diversion are:

• Surgery time is slightly longer than the Ileal Conduit Urinary Diversion procedure.
• Urinary incontinence (leakage of urine) is normal after surgery — while regaining control of urination — but might last up to six months. Also, about 20 percent of patients during the night and 5 percent to 10 percent of patients during the day are incontinent, requiring the wearing of a pad.
• Despite the surgery, some patients might not be able to empty their bladder well and will need to perform occasional catheterization (passing tubing through the urethra into the pouch every four to six hours) for a prolonged period of time after surgery and perhaps permanently.

A Look at the Three Surgical Procedures

Ileal Conduit Urinary Diversion: A segment of the intestine directs urine through a stoma into an external collecting bag.

Indiana Pouch Reservoir: A pouch made out of portions of intestines stores urine until it is drained via a catheter inserted through the stoma.

Neobladder to Urethra Diversion: Intestine is made into a reservoir and connected to the urethra

What can I expect in the immediate post-op period?

It takes one to two months on average to feel well again and to regain your strength. Also, it is not unusual to feel a little depressed or discouraged after surgery. Discussing your feeling with friends, family, and even other members of a support group (ask your health care team member about support groups in your area) can help you deal with your emotions. As with any life change, an adjustment period is normal. Don't hesitate to call your doctor or other health care team members for assistance or if you have questions. Their goal for you is to get you back to your lifestyle as soon as possible.

What restrictions will I face regarding work, activities, diet, or travel?

People with urinary diversions are usually able to return to the life, work, and hobbies they previously enjoyed.

• Work — Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.
• Activities — After the post-operative period, exercising and participation in sports and other activities is encouraged. Check with your doctor or health care team member.
• Diet — There are no eating restrictions, but if you have special dietary concerns, check with your doctor or health care team member.
• Travel — There are no travel restrictions. Just a word to the wise — travel fully prepared with necessary supplies, as you might not be able to purchase all supplies at your destination.

Most people can return to their jobs in one or two months on average. If you have concerns about your line of work or other job hazards, be sure to ask your doctor.

Urinary tract anatomy

The urinary tract consists of two kidneys, two ureters, a urinary bladder, and a urethra. The kidneys filter your blood and remove water and waste through the urine. The urine travels from the kidney to the bladder through tubes called ureters. The urine is stored in the urinary bladder, and then moves through the urethra to be passed out of the body when you urinate.

When the bladder is removed, urine needs to exit the body in a new way — through a urinary diversion. In all of the various types of urinary diversions, a part of the intestine is surgically converted to either:

• A passage tube for urine to exit the body
• A reservoir to store urine (like a normal bladder)

Regardless of surgical method, urine and stool remain completely separate from each other. (They are two different systems the urinary and digestive systems, respectively.)