A continent cutaneous reservoir is a urinary diversion that creates an internal pouch to store urine when the bladder is removed or no longer functions. The reservoir’s purpose is to hold urine inside the body, eliminating the need for an external bag. This approach provides continence, giving an individual control over when and how they empty their urine.
The reservoir is constructed inside the abdomen and connects to the skin through a small opening called a stoma. Urine is drained by the patient at regular intervals using a thin, flexible tube known as a catheter. This method differs from an ileal conduit, which involves a stoma that continuously drains urine into an external pouch.
The Surgical Creation of the Reservoir
The construction of a continent cutaneous reservoir is a surgical procedure that repurposes a segment of the patient’s intestine. Surgeons isolate a section of the small or large bowel, most commonly using the right colon and ileum for an Indiana pouch. This piece of bowel is then reshaped and sutured to form a new, watertight pouch designed to hold around 600 milliliters of urine.
Once the pouch is created, the surgeon modifies the urinary tract. The ureters, the tubes that transport urine from the kidneys, are detached from the bladder. They are then reattached to the new intestinal reservoir, allowing urine to flow from the kidneys directly into the pouch for storage.
A key part of this surgery is creating a continent valve mechanism to prevent urine from leaking involuntarily. Surgeons often utilize the natural ileocecal valve, the junction between the small and large intestines, reinforcing it to remain closed. A channel is then formed from a narrowed piece of the small intestine that connects the internal pouch to the abdominal wall.
The final step is creating the stoma, a small opening on the skin’s surface that serves as the access point for emptying the reservoir. Unlike stomas for incontinent diversions, this one does not continuously leak urine.
Managing and Living with the Reservoir
Daily life with a continent cutaneous reservoir centers on a consistent management routine. The primary task is emptying the pouch via self-catheterization. This involves inserting a sterile, flexible tube through the stoma into the reservoir to drain the urine. The process is painless and becomes a routine part of daily life.
A regular schedule for emptying the reservoir is necessary to prevent overfilling and maintain the pouch’s health. Initially, the pouch may need to be drained every couple of hours. As the reservoir stretches and its capacity increases, the schedule extends to every four to six hours, including once during the night. Adhering to this schedule is important for preventing complications.
Because the reservoir is made from intestinal tissue, it naturally produces mucus. This mucus must be cleared out regularly through irrigation to prevent blockages or the formation of stones. Irrigation involves flushing the pouch with a sterile saline or water solution using a syringe to keep the reservoir clean.
Caring for the stoma is straightforward. The area around the opening should be kept clean and dry with mild soap and water. Since the stoma does not leak, it is discreet and can be covered with a small adhesive bandage or gauze.
Suitability and Candidacy for the Procedure
Determining suitability for a continent cutaneous reservoir involves evaluating medical necessity and patient-specific factors. The procedure is often for individuals requiring bladder removal (cystectomy) due to bladder cancer. Other reasons include severe urinary incontinence, bladder damage from radiation, or congenital defects. People with neurological conditions like spina bifida or spinal cord injuries may also be candidates.
Patient attributes are a significant part of the selection process. A person must have the manual dexterity and vision to handle catheter insertion multiple times a day. Strong motivation and the cognitive ability to follow the emptying and irrigation schedule are also required for long-term success.
Certain pre-existing health conditions can make a patient ineligible. Good kidney and liver function are prerequisites. Individuals with inflammatory bowel diseases, such as Crohn’s disease, are not candidates because their intestinal tissue is compromised. A history of extensive radiation to the abdomen may also disqualify a patient, as it can affect the bowel tissue needed to create the pouch.
Potential Complications and Long-Term Considerations
This procedure is associated with potential complications that require ongoing monitoring. One common issue is stomal stenosis, a narrowing of the stoma opening. This can make inserting the catheter difficult and may require a surgical procedure to correct. Another problem is leakage from the stoma, which can occur if the continent valve mechanism weakens.
The formation of stones within the pouch is another long-term consideration. These stones can develop when urinary crystals mix with the mucus produced by the intestinal lining. Regular irrigation helps minimize this risk, but stones can still form and may require medical intervention. The presence of bacteria in the pouch also leads to a higher risk of urinary tract infections (UTIs).
Because a segment of the intestine holds urine, there can be metabolic consequences. The intestinal tissue may reabsorb waste products like chloride and ammonia from the urine, leading to electrolyte imbalances like metabolic acidosis. In some cases, repurposing a significant portion of the ileum can affect the body’s ability to absorb vitamin B12, requiring supplementation.