A urinary diversion is a surgical procedure that creates a new pathway for urine to exit the body, bypassing the bladder or the original urinary tract structure. This operation becomes necessary when the bladder is unable to store or expel urine safely, or when the bladder itself must be removed. The procedure ensures that urine, which is produced continuously by the kidneys, can still be eliminated from the body without backing up and causing potential damage to the kidneys. By rerouting the flow of urine, a diversion preserves kidney function and allows an individual to maintain health and quality of life.
Reasons for Urinary Diversion
The need for a urinary diversion arises from various medical conditions that compromise the function or integrity of the bladder and lower urinary tract. The most frequent reason for this surgery is the treatment of bladder cancer, which often requires the complete removal of the bladder, known as a radical cystectomy.
Chronic inflammation of the bladder can also necessitate a diversion, such as in severe cases of interstitial cystitis, chronic urinary retention, or damage from prior radiation therapy. Neurological conditions that cause severe bladder dysfunction, including multiple sclerosis, spina bifida, or spinal cord injuries, are further indications for the procedure, alongside severe trauma or congenital defects that affect the normal flow of urine.
Types of Urinary Diversion Procedures
Urinary diversion procedures are broadly categorized into two main groups based on how the urine is managed: incontinent and continent diversions. The choice between these categories depends on a patient’s overall health, anatomy, and lifestyle preferences.
Incontinent Diversions
The most common type of incontinent diversion is the Ileal Conduit, sometimes referred to as a urostomy. This procedure involves taking a short segment of the small intestine (ileum) and using it as a conduit for the urine.
The ureters, which carry urine from the kidneys, are surgically attached to one end of this intestinal segment. The other end of the conduit is brought out through an opening created in the abdominal wall, called a stoma, typically located on the lower right side of the abdomen. Urine flows out of the stoma and is collected in an external pouching system worn over the opening.
Continent Diversions
Continent diversions are designed to create an internal reservoir for urine storage, offering the patient more control over emptying. These diversions are divided into two types: Continent Cutaneous Diversion and Orthotopic Neobladder.
Continent Cutaneous Diversion
A Continent Cutaneous Diversion, like the Indiana Pouch, constructs an internal pouch from a section of the bowel. The ureters drain urine into this reservoir, which is equipped with a specialized valve mechanism that prevents spontaneous leakage. The patient empties the pouch several times a day by inserting a catheter through a small, flush stoma on the abdomen, eliminating the need for an external collection bag.
Orthotopic Neobladder
The Orthotopic Neobladder is the most anatomically similar procedure to a native bladder, as it is connected directly to the urethra. Surgeons create this new bladder substitute from a segment of the small intestine and place it in the pelvic space. The patient learns to empty the neobladder by relaxing the pelvic floor muscles and using abdominal pressure, a technique known as Valsalva voiding. This option allows for urination through the natural channel, though some patients may need to intermittently catheterize through the urethra if they cannot fully empty the pouch.
Adapting to Life with a Urinary Diversion
Adjusting to life after a urinary diversion involves learning new routines for managing the altered anatomy and maintaining overall health. For those with an incontinent diversion, management involves regular cleaning of the skin around the stoma and changing the external pouching system to ensure a secure seal and prevent irritation.
Patients with a continent diversion must learn the technique of intermittent self-catheterization, which is performed multiple times daily to drain the internal pouch. Specialized nurses provide hands-on training for all aspects of post-operative care, including managing the equipment and troubleshooting potential issues.
Most people can return to their usual activities, including work, exercise, and travel, within one to two months after the surgery. Maintaining proper hydration is important for all patients, and a return to a normal diet is expected, though some may find avoiding odor-causing foods beneficial. Emotional and psychological support, through counseling or joining a support group, is also important as patients navigate changes in body image and intimacy.
Long-term follow-up care is necessary to monitor for potential complications related to the diversion, such as infections, stone formation, or narrowing of the passageway. This monitoring ensures the kidneys remain healthy and addresses any concerns regarding the function of the diversion.