What is urinary reconstruction and diversion?

When your urinary bladder is removed (due to cancer, other medical conditions or because the organ no longer works), you need another way to pass urine through your body (pee). Urinary reconstruction and diversion are types of surgery done to help you do this.

Urinary tract anatomy

The urinary tract normally 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.)

What are the 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.

Advantages and disadvantages

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’s a change in body image.
  • It uses an external bag to collect urine, which might leak or have odors.
Indiana pouch reservoir

Indiana pouch reservoir: A pouch is 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 doesn’t, or if you run out, catheters can be washed with soap and water and reused. The catheters don’t have to be sterilized. They can be taken on trips or social events and simply stored in a plastic bag.

Advantages and disadvantages

The advantages of the Indiana pouch reservoir surgery are:

  • Urine is kept inside the body, in the reservoir, until it’s 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 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

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.

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, people aren’t able to empty adequately by contracting their abdominal muscles. In these cases, they must pass a catheter into the urethra to empty the pouch, up to six times a day. If this isn’t something you’re willing or able to do, you probably shouldn’t consider this type of diversion.

Advantages and disadvantages

The advantages of the neobladder-to-urethra diversion are:

  • The process of urination most closely matches normal urination.
  • No stoma is needed.

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.

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