Urinary Reconstruction & Diversion

What is a urinary diversion?

Urinary diversion refers to procedures that create a new place for pee (urine) to go when you no longer have a fully functioning bladder. There are a few ways surgeons perform urinary diversion, but the goal is to find a new way for pee to leave your body.

Urinary tract anatomy

The urinary tract typically consists of two kidneys, two ureters, a bladder and a urethra:

• Kidneys filter your blood, maintain fluid balance, and remove water and waste to make your pee.
• Pee travels from your kidney to your bladder through tubes called ureters.
• Your bladder holds your pee until it’s time to use the bathroom. It moves through your urethra and then out of your body.

Your brain and your bladder are communicating all day long through nerves that go through your spinal cord. When it’s time to pee, your brain tells your bladder to squeeze and the muscles below your bladder to relax.

Why would someone need a urinary diversion?

There are many reasons a person may need a urinary diversion. It’s usually because your bladder was removed (cystectomy) or your bladder doesn’t work anymore. This could be due to:

• Bladder cancer.
• Damage from radiation therapy for cancer.
• Chronic bladder infections.
• Severe trauma to your urinary tract.
• Congenital disorders like spina bifida.
• Neurological disorders like multiple sclerosis (MS).
• Severe incontinence (urinary leakage) or bladder pain.

What are the types of urinary diversion procedures?

Urinary diversion can either be incontinent or continent. Both methods involve using a piece of your intestines to divert urine.

• Incontinent: An incontinent urinary diversion involves creating an opening in your abdomen for pee to come out of. Surgeons do this by connecting your ureters to a piece of your intestine that they bring out through your belly (ostomy or stoma). Pee collects into a bag called an ostomy bag, which you empty. This is sometimes called an incontinent diversion or urostomy.
• Continent: A continent urinary diversion involves making a pouch inside your body from your intestines. This might be in the form of a “neobladder” that connects to your urethra, or with an Indiana pouch that collects urine inside your body that you drain by passing a catheter into a stoma at your belly button.

Within each type of urinary diversion are several different methods your surgeon can use. The type of urinary diversion you have depends on factors such as your age, medical conditions and health history.

Incontinent urinary diversion

The main type of incontinent urinary diversion is an ileal conduit. You don’t control urination with this type of urinary diversion — it automatically goes into a bag.

Ileal conduit

An Ileal conduit urinary diversion is the most common incontinent urinary diversion method. In an ileal conduit diversion, your ureters are attached to a part of your intestines that’s separate from the rest of your bowels, which is then brought up through your belly wall as a stoma. This automatically directs your pee through the stoma and into an external collection bag that you must empty every few hours.

The advantages of the ileal conduit urinary diversion surgery are:

• It’s a more straightforward procedure compared to other methods.
• There’s no need for self-catheterization (using a tube to drain your own pee).

The disadvantages of the ileal conduit urinary diversion are:

• People may feel self-conscious about having a bag that collects their pee.
• There’s a chance the bag can leak pee and cause an odor.

Continent urinary diversion

A continent urinary diversion gives you more control over urination. It involves either a surgeon creating an internal pouch or making a new (neobladder) bladder to hold your pee.

Indiana pouch reservoir (continent cutaneous reservoir)

An Indiana pouch is made from portions of your intestines. A surgeon cuts your ureters and sews them into this pouch. A short piece of small intestine connected to this pouch is then narrowed to form a channel and brought out through a stoma, often at the belly button. The stoma is smaller than an ileal conduit stoma and doesn’t drain spontaneously. It stores your pee until you drain it via a catheter you place in your stoma. There are different types of pouches a surgeon may create, but an Indiana pouch is the most common.

Unlike the incontinent diversion, no external bag is necessary. Instead, a one-way valve is surgically created to keep your pee inside the pouch. Several times a day (usually every four hours), you insert a small, thin catheter into the stoma and into the pouch to drain your pee. You’ll also have to flush the pouch regularly to clear any mucus that might build up inside.

Most insurance policies will allow you to have enough catheters so that you can use a new one each time. If your policy doesn’t, or if you run out, catheters can be washed with soap and water and reused.

The advantages of the continent cutaneous reservoir method are:

• Your pee is kept inside your body. You don’t need to wear a bag under your clothes.
• Because there’s no bag, the risk of leaking pee is smaller and there’s no potential for odors.
• You can cover your stoma with an adhesive bandage.

The disadvantages of the continent cutaneous reservoir method are:

• The surgery takes longer compared to incontinent urinary diversion.
• There’s the need for catheterization (placing a small tube into the stoma to empty the pouch), every four hours around the clock.
• Channel complications are common. The channel can leak or develop scar tissue, and a buildup of mucus in the pouch can cause stones and recurrent infections. If you can’t pass a catheter to drain the pouch, it can burst (this is an emergency).

Neobladder or bladder substitute

This procedure most closely resembles the usual function of your bladder and involves creating a replacement or new bladder. A portion of your small intestine is made into a new bladder, which your surgeons connect to your urethra. Pee passes from your kidneys to your ureters and into the pouch (new bladder), and through your urethra, just like it would with a typical bladder. To empty the neobladder, you need to contract (tighten) your abdominal muscles.

To be a candidate for this surgery, there must be a low risk of cancer recurrence (return) in your urethra, and you can’t have any scar tissue or blockage of your urethra Additionally, some people can’t empty the neobladder by contracting their abdominals. In these cases, they must pass a catheter into the urethra to empty the pouch up to six times a day.

The advantages of the neobladder diversion are:

• The process of urination most closely matches normal urination.
• There’s no stoma to care for.

The disadvantages of the neobladder diversion are:

• Surgery time is usually longer.
• Urinary incontinence (leaking pee) is normal after surgery and might last up to six months. About 20% of people with this type of diversion have incontinence during the night. Up to 10% of people have incontinence during the day and must wear pads to catch leaking pee.
• Some people may never be able to fully empty their new bladders and will still need to perform catheterization (either temporarily or permanently).

Is urostomy the same as urinary diversion?

A urostomy is a type of incontinent urinary diversion. A urostomy is when a surgeon makes an opening in your abdominal wall so that pee can pass through. The pee goes into a bag you wear under your clothes (ostomy bag).

What are the risks of urinary diversion?

Different types of urinary diversion procedures carry their own unique risks. Some problems that can occur in all types include:

• Difficulty with the stoma like trouble inserting a tube into it or skin growing over it.
• Leaking poop or blocked bowels.
• Injury to nearby organs.
• Rupture of the neobladder or pouch.
• Scar tissue where the ureters are sewn into the diversion.

What is the benefit of urinary diversion?

Pee needs to leave your body. If it doesn’t, it can back up into your kidneys and cause permanent damage like kidney disease or kidney failure. Having urinary diversion surgery may be the only way to stop pee from backing up into your kidneys and doing harm.

What is recovery like after a urinary diversion?

After urinary reconstruction and diversion, it takes one to two months to feel well again and to regain your strength. The goal is to get you back to your lifestyle as soon as possible. It may take you several weeks to get used to your new way of urinating. Ask your healthcare provider any questions you have about caring for your stoma and ostomy bag or draining your pouch with a catheter. They’ll make sure you have all the instructions you need to take care of yourself when you leave the hospital.

People with urinary diversions are usually able to return to the lives, work and hobbies they enjoy:

• 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 healthcare provider.
• Activities: You should be able to go back to exercising or participating in sports as soon as you recover. Your healthcare provider will let you know when you can resume your normal activity level after surgery and if you should avoid contact sports or swimming. Ask your surgeon about any temporary restrictions on lifting objects.
• Eating plan: Your surgeon may recommend soft foods that are easy to digest for a month after surgery. If you have food-related questions, ask your provider.
• Travel: There are no travel restrictions. But, you should travel with any supplies you need or have emergency supplies (like extra ostomy bags, for example) available.

Urinary diversion surgery can affect you emotionally as well as physically. You may feel anxious about resuming sexual intimacy or feel scared that your relationship with your partner may change after surgery. It’s important to talk with your provider about your concerns to see if medication, sex therapy or other support groups can help you.

When should I see my healthcare provider?

Contact your healthcare provider if you notice signs of a urinary tract infection such as:

• Fever.
• Chills.
• Nausea or vomiting.
• Back or abdominal pain.
• Peeing more often or painful urination.
• Cloudy pee or pee that has a strong smell.

Additionally, contact your provider if you have problems caring for your ostomy bag or stoma. Things to look for include skin irritation like swelling or redness or leaking pus or pee.

A note from Cleveland Clinic

As with any life change, an adjustment period is normal after a major surgery like urinary diversion. It’s not unusual to feel discouraged or worried about how your life has changed or what you need to do differently after surgery. The good news is most people go back to their usual activities within two months of surgery. Because a major change was made to how you pee, there’s going to be a learning curve. Be patient with yourself. If your urinary diversion procedure makes you feel self-conscious, talk to your healthcare provider about support groups or other resources available to help you cope.