Urinary diversion is a surgical procedure that creates a new pathway for urine to leave the body when the normal system of storage and expulsion is compromised. This intervention is necessary when the bladder is removed, non-functional, or severely diseased. The goal is to prevent urine from backing up into the kidneys, which can cause severe damage, infection, or life-threatening kidney failure if left untreated. This procedure is generally performed to improve the quality of life or is a necessary step in the treatment of serious medical conditions.
Understanding the Purpose of Urinary Diversion
The body’s urinary tract is a drainage system designed to filter waste and fluid from the blood, transport it from the kidneys via the ureters, store it in the bladder, and finally expel it through the urethra. When this system fails, rerouting the urine becomes necessary. The diversion acts as a bypass, ensuring continuous and safe drainage to protect the upper urinary tract.
A blocked or damaged lower urinary tract, particularly a bladder that cannot safely hold or empty urine, can cause backflow, leading to hydronephrosis and permanent kidney injury. Redirecting the flow removes this pressure. By providing an alternative route, the procedure maintains the long-term health of the kidneys and prevents complications like chronic infections or stone formation.
Common Medical Conditions Requiring Diversion
The most frequent indication for permanent urinary diversion is bladder cancer, which often requires a radical cystectomy (complete removal of the bladder). Once the natural reservoir is removed to treat the malignancy, a new system for urine collection and exit is necessary.
Other medical issues can also necessitate this surgery, including:
- Severe congenital defects like spina bifida, which cause nerve damage that prevents the bladder from functioning correctly.
- Chronic inflammatory conditions, such as severe interstitial cystitis or radiation damage, that compromise the bladder wall.
- Severe trauma to the pelvis or lower abdomen, causing irreparable damage to the ureters or bladder.
Surgical Methods for Redirecting Urine Flow
Urinary diversion procedures are broadly categorized into incontinent and continent types, with the choice depending on the patient’s overall health, anatomy, and lifestyle factors. Both methods typically involve using a segment of the patient’s intestine to create the new pathway or reservoir.
Incontinent Diversions
Incontinent diversions involve the continuous drainage of urine and require an external collection appliance. The most common example is the ileal conduit (urostomy), which utilizes a segment of the small intestine (ileum) to create a passageway. The ureters are connected to this segment, and the other end is brought through the abdominal wall, forming a stoma. Urine flows continuously from this stoma into a waterproof bag worn on the abdomen, which must be emptied several times daily.
Continent Diversions
Continent diversions are designed to store urine internally, offering the patient control over when they void, usually without the need for an external bag.
One technique is the creation of a continent cutaneous reservoir, such as the Indiana Pouch. A section of the bowel is refashioned into an internal storage pouch, accessed via a small stoma on the abdomen. The patient empties the pouch by inserting a catheter a few times per day.
A second type is the orthotopic neobladder, considered the closest alternative to natural anatomy. Surgeons construct a new bladder from a segment of the intestine and connect it directly to the urethra. This allows the patient to void through the urethra, often using abdominal pressure, though self-catheterization may be needed to fully empty the neobladder.
Managing Life with a Urinary Diversion
Adjusting to life after a urinary diversion involves learning new routines for hygiene and management, which are tailored to the specific type of procedure performed.
Management Based on Diversion Type
For those with an incontinent diversion, meticulous stoma care is necessary to prevent skin irritation and infection. This includes regularly changing the external pouching system and cleaning the skin around the stoma, often with guidance from a specialized ostomy nurse.
Individuals with a continent pouch must learn the sterile technique for self-catheterization to drain the internal reservoir every four to six hours. Those with a neobladder need to retrain their body to recognize the sensation of fullness and to use their abdominal muscles to empty the new reservoir.
Long-Term Care
Proper hydration is important for all patients to maintain kidney function and keep the urine dilute. Maintaining adequate fluid intake is important to prevent urinary tract infections and stone formation. Regular, long-term follow-up appointments are necessary to monitor kidney function, check the health of the reservoir or conduit, and address any potential complications.