Types of Urinary Diversion‏

What is a u. rinary reconstruction and diversion?

The diagnosis of bladder cancer or other serious bladder disease may sometimes necessitate the surgical removal of the bladder.  In this situation, it is necessary to create a new way for the patient’s body to pass urine. This type of surgery is known as urinary diversion surgery.  There are several options available for patients requiring urinary diversion.

At City of Hope, in addition to the standard open surgical approach to removal of the bladder and urinary tract reconstruction, we also perform this operation using a robotic-assisted laparoscopic approach.  A patient’s options for urinary diversion remain the same, regardless of the surgical approach.The Anatomy
The normal urinary tract is made up of two kidneys, which filter the blood and remove extra water and waste through the urine. Urine is eliminated by the kidney’s collecting system (known as the renal pelvis) and travels down through tubes, called ureters, into the urinary bladder. Urine is stored in the urinary bladder until it is full and the person urinates.

When the bladder is removed, the ureters need to be surgically connected to some type of urinary diversion to drain urine.  All forms of urinary diversion use a part of the body's intestinal tract.

This surgery can be performed to have the urine drain into an opening in the abdomen in either a continent or incontinent fashion, or can drain through the urethra (the tube in the penis/vagina) in a continent fashion.  These options should be discussed with your physician

Types

• Ileal conduit urinary diversion (Bricker conduit)
• Indiana pouch
• Neobladder to urethra diversion
• Ureterocutaneostomia

Ileal Conduit Urinary Diversion
The ileal conduit is the oldest and simplest form of urinary diversion. This is composed of a short part of ileum (small intestine) into which the ureters drain freely. The end of this ileal segment is brought out to the skin, usually in the right side of the stomach. This is called a stoma. The stoma is covered by a bag, which catches the urine as it drains from the ileal conduit.

Advantages:

• Shorter surgery time
• Shorter recovery time 
• No need for intermitten catheterization
• Least risk of complications

Disadvantages:

• External bag with possible leakage and odor.
• Urine back-up (reflux) to kidneys, leading to possible infections, stones and kidney damage over time.

Indiana Pouch Reservoir
City of Hope is one of the leaders in Indiana pouch urinary diversions and have been performing this type of continent urinary diversions for many years. In this form of urinary diversion, a reservoir (pouch) is constructed out of the right colon (large intestine) and a small segment of ileum (small intestine).

A short piece of small intestine is brought out to the skin as a small stoma. A one way valve mechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the skin.

A bag is not required and the patient simply wears a bandage over the stoma. At specific times during the day, usually every four to six hours, the patient passes a small thin catheter (tube) through the stoma, into the pouch, and empties the urine.

 Advantages:

• Urine is kept inside the body until it is ready to be emptied
• No bag necessary
• No odor
• Minimal risk of leaking
• Small stoma which can be covered by a bandage.

Disadvantages:

• Longer surgery time
• Need for intermittent catheterization (passing a small plastic tube into the pouch every four to six hours to empty it)
• Slightly higher risk for complications requiring reoperation 

Neobladder to Urethra Diversion
In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to the urethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch) is made to mimic the normal storage function of the urinary bladder.

The patient is able to pass urine through the urethra, although there is a period of incontinence (leakage of urine) that all patients go through following this surgery.

It may take some patients 12 to 18 months to regain control of their urination.  A small but not insignificant percentage of patients will have persistent incontinence. 

Rarely, a patient may not be able to empty this reservoir (pouch) well and will require intermittent catheterization (placement of a small tube into the urethra) in order to empty the reservoir (pouch). Some patients will be required to do this several times a day for a prolonged time period and in some cases permanently.

In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the urethra to empty the reservoir (pouch) if necessary.
Advantages:

• The patient is able to empty the reservoir (pouch) of urine in a manner similar to the normal voiding pattern
• No stoma is required
• No catheters required 

 Disadvantages:

• Slightly longer surgery time
• Potential for temporary or permanent incontinence in a small percentage of patients. 
• Some patients may have to perform intermittent catheterization (place plastic tube via the urethra into pouch every six hours to drain urine) for a prolonged time period and, possibly, forever.

Ureteroenteric anastomosis

A common feature of the three first, and most common, types of urinary diversion is the ureteroenteric anastomosis. This is the joining site of the ureters and the section of intestine used for the diversion.

The ureteroenteric anastomosis can be created in a number of different ways. There is the option of a refluxing or a non-refluxing type, and the two ureters can be joined into the intestinal segment either together or separately. The non-refluxing type has been associated with higher incidence of ureteroenteric anastomosis stricture, and there is doubt whether it has any advantages over the refluxing type. Therefore, many surgeons prefer the refluxing type which is simpler and apparently carries a lesser degree of complications.

Refluxing techniques include the Wallace and Wallace II and the Bricker end-to-side anastomosis. Non-refluxing techniques includes the Le Duc technique.

Complications

Complications include incisional hernia, neobladder-intestinal and neobladder-cutaneous fistulas, ureteroenteric anastomosis stricture, neobladder rupture and mucous formation