Urinary Diversion Surgery

Urinary diversion surgery is a significant medical procedure that involves rerouting the normal flow of urine due to disease, injury, or dysfunction of the urinary system. This guide explores the reasons for urinary diversion, the different surgical techniques, pre- and post-operative considerations, potential risks, and the impact on daily life.

Introduction to Urinary Diversion Surgery

Urinary diversion is a surgical method used when the bladder is removed or cannot function properly, necessitating an alternative route for urine to exit the body. Common reasons for this surgery include bladder cancer, neurogenic bladder (bladder dysfunction due to nerve damage), severe urinary incontinence, traumatic injury, birth defects, and chronic inflammation or infection of the bladder.

This operation is often life-changing, requiring adaptation by the patient. Understanding the procedure, why it’s performed, and what to expect can help prepare patients and their families.

Indications for Urinary Diversion

• Bladder Cancer: The most common reason for urinary diversion, especially after radical cystectomy (removal of the bladder).
• Neurogenic Bladder: Conditions such as spinal cord injury, multiple sclerosis, or spina bifida may impair the nerves controlling the bladder.
• Congenital Abnormalities: Birth defects like bladder exstrophy or cloacal anomalies may require diversion early in life.
• Trauma: Severe pelvic injuries can destroy the bladder or urethra.
• Refractory Incontinence: When other treatments have failed to control severe incontinence.
• Chronic Inflammation/Infection: Interstitial cystitis or severe radiation cystitis may make the bladder unusable.

Types of Urinary Diversion

There are several forms of urinary diversion, which are categorized mainly as non-continent (incontinent) or continent. The choice depends on patient factors, underlying conditions, and the surgeon’s expertise.

Incontinent Urinary Diversion

This is the simplest and most common form, where urine drains continuously into an external appliance. Types include:

Ileal Conduit:

• The surgeon removes a short segment of the small intestine (ileum), attaches the ureters to one end, and brings the other end out through a small opening (stoma) in the abdominal wall. Urine drains into a urostomy bag worn on the outside of the body.

Colon Conduit:

• Similar to the ileal conduit but uses a segment of the colon.

Advantages: Requires less self-management and no catheterization.

Disadvantages: Reliance on external bags and possible stoma-related complications.

Continent Urinary Diversion

These methods create a reservoir for urine, either inside or outside the body, enabling the patient more control over voiding.

• Continent Cutaneous Reservoir (Indiana Pouch, Kock Pouch):
• A reservoir is made from a section of the intestine. The ureters are attached to this pouch, which is then connected to the skin via a stoma. The patient inserts a catheter periodically to drain urine.
• Orthotopic Neobladder:
• A new bladder is fashioned from a segment of intestine and connected to the urethra. The patient can void urine in a near-normal way, though sometimes with the need to self-catheterize.

Advantages: Improved body image, less reliance on external equipment.

Disadvantages: Requires self-catheterization, possible retention, and more complex surgery.

Surgical Procedure

The steps vary depending on the type, but generally include:

• Removal of the bladder (if indicated, as in cancer cases).
• Isolation of a segment of intestine to construct the conduit or reservoir.
• Attachment of the ureters to the chosen segment.
• Creation of the stoma (for non-orthotopic versions) or connection to the urethra (for neobladder).
• Closure and recovery.

Modern techniques may use open, laparoscopic, or robotic-assisted approaches, with varying recovery times and risks.

Pre-operative Considerations

Patients undergo thorough evaluation including:

• Imaging (CT, MRI, ultrasound) to assess the urinary tract and surrounding organs.
• Blood and urine tests.
• Assessment of kidney function.
• Pre-surgical counseling, ideally with a stoma therapist or wound/ostomy care nurse.
• Discussion of lifestyle changes, self-care requirements, and possible complications.

Post-operative Care and Recovery

Recovery varies but often requires a hospital stay of 5–10 days, depending on the complexity of the surgery and the patient’s general health. Key aspects of recovery include:

• Pain management and prevention of infection.
• Monitoring kidney function and fluid balance.
• Education on stoma care or catheterization as needed.
• Gradual reintroduction of food and mobility.
• Emotional and psychological support, as the adjustment can be significant.

Potential Complications

Like any major surgery, urinary diversion carries risks, both short- and long-term:

• Infection (urinary tract, surgical site).
• Bleeding.
• Stoma or wound complications (hernia, prolapse, retraction, skin irritation).
• Urinary leakage, kidney damage, or electrolyte imbalances.
• Bowel obstruction (from the use of intestine).
• Stone formation in the urinary tract or diversion pouch.
• Psychological adjustment difficulties.

Living with a Urinary Diversion

Adapting to life after urinary diversion can be challenging, but with education and support, most patients resume many normal activities:

• Body Image: Some may struggle initially with changes to their body, especially with a stoma or appliance.
• Daily Management: Learning proper care for the stoma, skin, and equipment is critical. Many hospitals offer training by specialized nurses.
• Diet and Hydration: Staying hydrated and following recommended dietary adjustments helps prevent complications such as stones or infection.
• Physical Activity: Most non-contact sports and activities are possible after recovery; swimming, walking, and cycling are encouraged.
• Sexuality and Relationships: Open communication with partners and counseling can help address concerns related to sexual function or intimacy.

Quality of Life and Support Resources

Most individuals with a urinary diversion regain a high quality of life. Support groups, counseling, and peer networks can be invaluable for patients and their families. Specialized stoma and continence nurses provide ongoing education and reassurance.

Recent Advances and Future Directions

Surgical methods for urinary diversion are continually evolving. Minimally invasive and robotic techniques are being refined to reduce recovery time and complication rates. Advances in stoma appliance technology improve comfort, discretion, and skin protection. Research into tissue engineering may one day allow for the creation of bioengineered urinary tracts.

Nursing Care of Patients with Urinary Diversion Surgery

Nursing care for individuals who have undergone urinary diversion requires a thorough understanding of various diversion techniques, meticulous attention to physical and psychosocial needs, and expert skill in postoperative management to ensure optimal patient outcomes.

Preoperative Nursing Care

Preoperative care focuses on patient preparation, both physically and psychologically:

• Patient Education: Nurses should explain the procedure, its purpose, and expected outcomes. Ensure the patient understands how the urinary diversion will change their bodily function, and introduce them to the devices they will use postoperatively.
• Psychosocial Support: Address anxieties and fears regarding body image changes, sexual health, and daily living. Involving family members in discussions may provide essential support.
• Physical Preparation: Ensure bowel preparation is completed according to protocol. Assess for infection, malnutrition, and manage co-morbidities that could affect healing.
• Consent and Documentation: Confirm that consent forms are signed, and all documentation is complete.

Immediate Postoperative Nursing Care

The immediate postoperative phase demands vigilant monitoring and care to prevent complications:

• Vital Signs and Fluid Balance: Closely monitor for hypovolemia, hemorrhage, or infection. Record intake and output meticulously, as large fluid shifts may occur.
• Pain Management: Assess pain regularly and administer analgesics as prescribed. Employ non-pharmacological measures to complement pain control.
• Stoma Assessment and Care: For ileal conduit or ureterostomy, inspect the stoma every 2-4 hours. Look for color (should be moist and pink/red), size, swelling, bleeding, and peri-stomal skin integrity. Report pale, dusky, or black stomas immediately as this may indicate ischemia.
• Appliance Management: Ensure the urostomy bag is properly fitted, emptied when one-third full, and changed as needed. Prevent leaks to protect skin and maintain hygiene.
• Monitoring Catheterization: For continent diversions, educate on intermittent self-catheterization. Monitor for signs of infection, obstruction, and leakage.
• Preventing Complications: Watch for signs of infection, bowel obstruction, deep vein thrombosis, and metabolic imbalances. Administer prophylactic antibiotics if ordered, and encourage early ambulation.

Ongoing Nursing Management

Long-term care focuses on rehabilitation, education, and adaptation:

Stoma and Skin Care

• Teach patients and families proper stoma hygiene: gentle cleaning with warm water, attentive drying, and regular inspection.
• Use skin barriers and correctly sized appliances to reduce risk of irritation, breakdown, and infection.
• Monitor for changes such as swelling, prolapse, or retraction, and educate on when to seek medical attention.

Infection Prevention

• Emphasize hand hygiene and appliance cleanliness.
• Ensure routine urine cultures, especially for continent diversions, as these patients are at increased risk for urinary tract infections.
• Educate on symptoms of infection: fever, foul-smelling urine, abdominal pain, and cloudy urine.

Education and Self-Care Training

• Provide step-by-step demonstrations of appliance changes, stoma cleaning, and catheterization techniques.
• Encourage independence while offering ongoing support and reassurance.
• Supply written instructions and refer to ostomy nurse specialists and support groups.

Dietary Management

• Encourage a balanced diet to promote healing and prevent constipation, which can affect stoma function.
• Monitor for vitamin B12 deficiency, especially in patients with ileal conduits, as the ileum is involved in B12 absorption.
• Advise adequate fluid intake to maintain hydration and dilute urine, reducing risk of infection and stone formation.

Psychosocial Adaptation

• Address body image concerns, sexual health questions, and feelings of loss or anxiety.
• Encourage open communication, involvement in support networks, and consideration of professional counseling if needed.
• Support return to normal activities, including work, exercise, and social engagements.

Monitoring for Late Complications

• Be vigilant for signs of obstruction, renal impairment, metabolic disturbances, and pouch dysfunction.
• Refer to specialists for ongoing assessment of renal function, metabolic panels, and cancer surveillance if required.

Discharge Planning and Home Care

Effective discharge planning is essential for patient safety and satisfaction:

• Assessment of Home Environment: Ensure access to stoma supplies, clean water, and a safe space for appliance changes.
• Coordination of Follow-Up Care: Schedule regular appointments with urologists, ostomy nurses, and primary care providers.
• Community Resources: Refer to home health agencies, ostomy support groups, and counseling services as needed.
• Emergency Plan: Teach patients when and how to seek emergency care, especially for obstruction, severe infection, or stoma complications.

REFERENCES

1. American Cancer Society. Types of Urostomies and Pouching Systems. https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/urostomy/types.html. Last reviewed 10/2019.
2. Almassi N, et al. (2020). Ileal conduit or orthotopic neobladder: Selection and contemporary patterns of use.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261790/
3. American Urological Association. What is Urinary Diversion?https://www.urologyhealth.org/urology-a-z/u/urinary-diversion 
4. El-Taji OM, Khattak AQ, Hussain SA. Bladder reconstruction: The past, present and future. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487078. Oncol Lett. 2015;10(1):3-10.
5. Clements MB, et al. (2022). Health-related quality of life for patients undergoing radical cystectomy: Results of a large prospective cohort.
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891075/
6. National Institute of Diabetes and Digestive and Kidney Diseases (U.S.). Urinary Diversion. https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-diversion. Last reviewed 6/2020.
7. Check DK, et al. (2020). Decision regret related to urinary diversion choice among patients treated with cystectomy.
   https://pubmed.ncbi.nlm.nih.gov/31441673/

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.