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 developed for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way to pass urine.
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 types of urinary diversions, a part of the intestine is surgically converted to either 1) a passage tube for urine to exit the body, or 2) 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.)
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
Ileal conduit urinary diversion: A segment of the intestine directs urine through a stoma into an external collecting bag.
With this procedure, the ureters (the tubes that carry urine from the kidneys to the bladder) 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.
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)
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
Indiana pouch reservoir: A pouch made out of portions of intestines stores urine until it is drained via a catheter inserted through the stoma.
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). The stoma is very small and can be covered with an adhesive bandage.
Unlike the ileal conduit, no external bag is needed. Instead, a one-way valve is surgically created to keep the urine inside the pouch. Several times a day (usually every four hours around the clock), 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).
Most insurance policies will allow you to have enough catheters so that you can use a new one each time. If your policy does not, or if you run out, catheters can be washed with soap and water and reused. The catheters do not have to be sterilized. They can be taken on trips or social events and simply stored in a ziplock bag.
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.
The disadvantages of the Indiana pouch are:
- The surgery takes 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 hours around the clock.
Neobladder to urethra diversion: Intestine is made into a reservoir and connected to the urethra.
This procedure most closely resembles the storage function of a urinary bladder. 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 backup, which helps protect the kidneys from infection. Urine is able to pass from the kidneys, to the ureters, to the pouch, and through the urethra in a manner similar to the normal passing of urine. To empty the pouch, you need to contract (tighten) your abdominal muscle.
To be a candidate for this surgery, there must be a low risk of cancer recurrence (return) in the urethra. Occasionally, patients are not able to empty adequately by contracting their abdominal muscles. In these cases, the patients must pass a catheter into the urethra to empty the pouch, up to six times a day. If this is not something you are willing or able to do, you should probably not consider this type of diversion.
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 backup and infection.
The disadvantages of the neobladder-to-urethra diversion are:
- Surgery time is slightly longer than the ileal conduit urinary diversion procedure.
- While regaining control of urination, urinary incontinence (leakage of urine) is normal after surgery, but might last up to six months. Also, about 20% of patients during the night and 5% to 10% of patients during the day are incontinent (leak urine) and have to wear 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 hours) for a prolonged period of time after surgery, and perhaps permanently.