< BACK Bladder Replacement Urine is produced by filtering blood through the kidneys. Urine accumulates in the renal collecting system (called the renal calyces and pelvis). The urine then flows down the ureters into the bladder. The bladder stores the urine under low pressure. When there is enough urine in the bladder, a signal is sent to the brain which triggers bladder emptying. When the bladder is removed (either for cancer or other reasons), urine must be diverted outside the body. This can be accomplished a number of different ways. Many attempts have been made to make an artificial bladder out of synthetic (man-made) products. No such development has been successful to date. The use of human bowel segments (both large and small intestine) have been used with success. Use of bowel segments can be divided into continent and non-continent urinary diversions. A non-continent urinary diversion typically consists of a piece of bowel which acts as a conduit taking urine from the ureters through bowel to the skin in a continuous flow pattern. This requires an appliance (stoma bag) on the skin to collect the urine. A continent urinary diversion attempts to mimic the action of the normal bladder by storing urine for a period of time at low pressure. Drainage of urine is performed by either normal voiding through the urethra or catheterization of either the urethra or a reservoir of bowel. This type of diversion does not require a skin appliance (bag). Patient Selection Ileal Conduit Patient choice Elderly Renal insufficiency (kidney disease) Patient Non-compliance (unreliable patient) Multiple other medical problems Extensive tumor volume or specific tumor location Continent Urinary Diversion Patient choice Relatively young Adequate renal function (kidneys function well) Compliant patient (reliable patient) Acceptable medical risk Relatively low tumor volume, no involvement of urethra Non-Continent Urinary Diversions Ileal Conduit The bowel is divided into small bowel and large bowel. The ileum is the second half of the small bowel prior to the transition to large bowel. A segment of ileum approximately 15 cm. (7 inches) is separated from the small bowel. This is isolated and brought to the skin. Typically the bowel is everted at the junction with the skin in an attempt to minimize contact of the urine with skin. The ureters are connected to this isolated piece of bowel. Urine then flows from the kidney to the ureter, through the ileal segment and into a collection device on the skin. This collection device, referred to as an "appliance", is emptied periodically during the day. The appliance is typically changed every 3 to 5 days. The ileal conduit is the simplest of the forms of urinary diversion. This can be performed even when the bladder is left in place. Benefits include a lower complication rate, ease of use, and shorter operative time to complete. Postoperative care is less complicated in comparison to other forms of urinary diversion Percutaneous Neprostomy Percutaneous nephrostomy drainage consists of the use of tube(s) to drain the kidneys. These tubes can be either temporary or permanent. These tubes are made of a soft plastic material which needs to be changed monthly. Benefits include decreased operative risk as these can be placed in radiology and do not require a general anesthetic for placement. Downsides of the procedure include patient discomfort, frequency of tube change required, and increased risk of infection. This is not a typical type of diversion used when the bladder is removed. Typically, this may be used temporarily before bladder removal is performed or if a patient is unable to undergo a more complicated procedure. Continent Urinary Diversion The normal function of the urinary bladder is to store urine at low pressure and empty urine when required. A continent urinary diversion attempts to mimic this function through the use of bowel. Surgeons use a portion of the patient's own bowel to reconstruct a new bladder. In order to do this, certain principles must be adhered to. The bowel has muscle within the wall which aids in the propulsion of stool through the gastrointestinal tract. This muscle tone must be reduced or eliminated in order to make an effective urinary reservoir. This is accomplished by a process known as detubularization. In this way, we divide the bowel and sew it back together to form a spherical rather than tubular reservoir. In so doing, the pressure generated by the reservoir is decreased and the volume is increased. This principle is known as Laplace's law and is the basis for continent urinary diversion. Continent neobladders are grouped into orthotopic and non-orthotopic replacements. Orthotopic neobladders are placed in the pelvis (where the bladder was prior to removal) and are connected to the urethra (as a normal bladder would be). Non-orthotopic neobladders are located in the abdomen, are not connected to the urethra, and require catheterization to drain. Orthotopic Neobladder Orthotopic neobladder is a urinary diversion which typically utilizes small bowel to construct a new bladder for the patient. This is usually performed in males but can be performed in selected females as well. This type of urinary diversion uses 40 to 60 cm. of small bowel (ileum) to form the urinary diversion pouch. The ileum is separated from the remaining portion of the bowel and isolated. The ileum is then divided to increase storage volume and decrease the pressure generated within the pouch. Next, the ureters are attached to the pouch with temporary stents in place to aid in the healing process. The lowest portion of the pouch is then connected to the urethra to complete the restoration of the urinary tract. Typically, a series of tubes, all temporary, are used to drain the diversion. This consists of ureteral drainage stents (from the kidney to the pouch), a Foley catheter (from the pouch out of the body through the urethra), and a suprapubic tube (from the pouch out of the body through the skin). Below are representations of the various steps in the procedure. After the operation, patients typically can expect to stay in the hospital for 5 - 7 days. When they are discharged, they will typically have a urethral Foley in place as well as a suprapubic tube, both of which drain the new bladder. It is important to facilitate adequate drainage as the bowel used in the urinary diversion will continue to secrete mucous. You will be taught how to irrigate these catheters at regular intervals to remove mucous from the new bladder. After several weeks, the urethral Foley is removed. The suprapubic tube is typically kept in place a little longer to assure adequate bladder emptying and function. Once this is confirmed, the patient will have all catheters removed. Non-orthotopic Neobladders Non-orthotopic neobladders are typically performed when an othotopic neobladder is anatomically difficult to perform, functional quality of an orthotopic neobladder would not be optimal, or it is contraindicated from a cancer standpoint. While this type of diversion does not require an appliance (bag), it does require catheterization. There is a variety of non-orthotopic neobladders performed. One of the most common is called the Indiana Pouch. This utilizes the natural tissue valve between the small and large intestine as the source of continence. Approximately 15 cm. of small bowel along with the right colon (large bowel) are isolated from the gastrointestinal tract. The right colon is detubularized (see above) to increase volume and reduce pressure. The right colon is then fashioned into a sphere and the ureters are attached to this pouch along with temporary drainage stents. The small bowel portion of the pouch is left as a tube and is narrowed in size to accommodate a small catheter. This small bowel is brought to the skin (called the efferent limb) as a small stoma which is flush with the skin. The connection point of the small and large bowel contains the ilealcecal valve. This is a naturally occurring tissue valve which keeps urine from leaking from the spherical reservoir into the tubular efferent limb with goes to the skin. In comparison, the ileal conduit stoma is the size of a half-dollar as apposed to the neobladder stoma which is the size of a nickel. Additionally, the ileal conduit stoma is raised whereas the neobladder stoma is flush with the skin After the operation, patients typically stay in the hospital 5 - 7 days. When they go home, they will have a catheter which enters the new bladder through the skin. A second smaller catheter may be present which catheterizes the efferent limb. Eventually, the patient is taught to catheterize the pouch themselves several times a day. Once the patient has learned how to catheterize the pouch, all drainage catheters are removed. Patients are taught to irrigate the pouch as the bowel in the pouch will continue to secret mucous which must be eliminated. Postoperative Care Foley catheter After surgery while your pouch is healing, a tube called a Foley catheter drains the urine from your pouch to a leg bag or bedside bag. A second catheter (called a suprapubic tube) may come out temporarily through the skin also. Typically, patients use a leg bag during the day and a bedside bag at night. You may shower with the catheters - simply clean them daily with soap and water. Make sure to bring a Depends Undergarment or similar pad to your visit when your catheter is to be removed. Irrigating the Foley Your pouch will continue to produce mucous after the operation. It is critical to irrigate this mucous from the pouch as it may lead to obstruction and infection if it collects to a large degree. While you are in the hospital, you will be taught to irrigate the Foley. To irrigate, you will need an irrigation kit, normal saline, a urinary drainage bag. Wash your hands before and after irrigation Draw up 60 cc normal saline in syringe Disconnect the Foley tube from the drainage bag If two catheters are present, occlude the Foley catheter which is not being irrigated Insert and flush the syringe of normal saline into the tube to be irrigated Withdraw fluid from the tube and flush down the toilet Repeat irrigation as above until clear Reconnect the drainage bag If multiple tubes present, alternate tubes when irrigating Change your position if you have trouble irrigating Normal Saline for Irrigation You may obtain a prescription from your doctor to buy saline at the drugstore You may make normal saline yourself Boil 1 quart water for 10 minutes Add 2 teaspoons table salt Allow to cool, place in clean bottles Refrigerate until use Diet Fluids are very important. Drink frequently, water is always the best Eat several small meals rather than fewer large meals Many patients loose weight after this surgery. Ask you doctor about supplements such as Boost, Ensure, etc Take a multivitamin with iron daily after surgery Keep bowel movements soft with stool softener of choice Activity Avoid lifting over 10 pounds for 6 weeks after surgery Walk every day. Short frequent walks are better that 1 long walk It is normal to be fatigued after surgery Patients recover at different rates. It is normal to have days in which you just don't feel as good follow by some stellar days. Remember, "two steps forward, one step back" is NORMAL Results Results will vary based on patient age, medical condition, extent of tumor, and patient motivation and compliance. Generally, most patients with orthotopic neobladders (pouch connected to the urethra) are initially incontinent in both the day and night. It takes 3 - 6 months for the new pouch to attain its final capacity. During this time, it will require more frequent voiding or catheterizing, depending on the type of diversion performed. Some physicians prefer patients to perform Kegel exercises which may help in obtaining urinary control. Non-orthotopic neobladders (catheterizable stoma brought out to the skin) also take 3 - 6 months to expand. Frequent catheterizations will be required until the pouch expands to its mature volume. Up to 92% of men undergoing an orthotopic neobladder are eventually continent of urine during the day and up to 80% are dry at night. Generally, the need to catheterize is 5% or less. For women undergoing an orthotopic neobladder (very select population), the likelihood of continence is somewhat less than men due to anatomical considerations. Furthermore, women are at increased risk to need to catherize. Conclusion Urinary diversion is necessary after removal of the bladder and for certain conditions when the bladder may remain but is no longer functional. Non-continent and continent urinary diversions offer patients and their physicians a number of different options. With education and discussion, the proper selection of urinary diversion can lead to an optimal quality of life for the patient. < BACK Click Here to contact your doctor's office regarding questions about patient care. To Contact The Business Office By Email (For Billing Questions Only) CLICK HERE The Urology Group 4700 Smith Road Cincinnati, Ohio 45212 Click Here For A Complete Listing Of Our Locations Copyright © 2010 - The Urology Group - All rights reserved