Continent Urinary Diversion/Neobladder/Ileal Conduit
After the bladder has been removed, the surgeon needs to create a new “bladder” for the urine to pass from the patient’s body. This is called a urinary diversion. There are many options that have been developed for urinary diversion after the radical cystectomy, and some of them are listed below. Preoperatively, all patients who are having a radical cystectomy are required to undergo a full bowel preparation to clear the bowel of any contents in preparation for creation of the urinary diversion. The bowel is then used to build the new “bladder” or urinary conduit.
It can be a very difficult decision to determine which diversion is right for each individual patient. The ileal conduit is by far the simplest solution with the lowest complication rate. This is the diversion that was offered to all patients prior to the development of more complex reconstructive continent diversions. However, many patients, particularly younger patients, want to try to return to as much of a normal existence as possible after such a major surgery is performed. The creation of a complex urinary diversion is a very specialized skill and Dr. Engel is one of the few urologists in the Washington, D.C. area that offer such diversions. Although many continent diversions are possible, Dr. Engel’s approach in men is usually a Neobladder and in women, an Indiana pouch. Continent diversions require work on the patient’s part and it is important for a patient to understand this. There is a higher complication rate and operative times are longer. Thus, the proper patient to offer a continent diversion to is a highly motivated and responsible patient.
The most common urinary diversions utilized today (and those performed by the surgeons in our group) include the following:
- An ileal conduit – this surgical technique uses a segment of the small bowel to serve as a channel for the urine to flow from the ureters out to a new opening on your abdomen, called a stoma. Once the urine passes through the stoma, it collects in a plastic stoma bag attached to the skin. The bag needs to be emptied several times a day. Although a change, most patients get quite used to the presence of wearing a bag and in some cases represents an improvement in quality of life.
- Indiana Pouch – there are many types of reservoirs that have been used over the years by Urologists. We use an Ileocecal reservoir (Indiana Pouch). This technique uses a portion of the large bowel, and a portion of the small bowel. The large bowel serves as the new storage container (bladder). The ureters are attached to the large bowel. The urine is stored for several hours in this bowel segment, and then drained through the small bowel portion, which has a very small opening in the abdominal skin (stoma). Every 4-6 hours the patient has to pass a urinary catheter through the skin stoma, into the small bowel and finally into the large bowel. The urine is drained through the catheter into the toilet. The advantage to this approach is that most patients are dry between catheterizations, and do not need a urinary storage bag (stoma bag) to be worn on the outside of the body. This diversion is most commonly used in women.
- Studer Ileal Neobladder – We use the Studer neobladder, which requires approximately 60 cm of small bowel. The small bowel is reconfigured, the ureters are attached to the upper end of the neobladder, and the end down in the pelvis is attached to the remaining urethra. This allows the patient to pass urine normally through their urethra. Neobladders have been used in women, but there is a very high risk that a woman will no empty their neobladder properly and will have to resort to using a catheter to urinate. Since the Indian Pouch leads to very high patient satisfaction in women and avoids this complication, Dr. Engel avoids neobladders in women. In men, the neobladder eventually will allow for normal urination, including standing up. Lastly, patients with neobladders can have night time incontinence, which can be repaired if necessary.
Preparation for Surgery
In preparation for the surgery, all patients require a formal bowel preparation to include a mechanical cleansing, and antibiotics. The bowel prep is absolutely required and is particularly important in these cases since the bowel will be opened and used to create the urinary diversion. It is not uncommon to receive a transfusion during this case. It is also particularly important that the patient be fully examined and optimized by their internist and/or their cardiologist in preparation for such a large surgery. Also, the patient will have an appointment made for them with a stoma nurse who specializes in education and post-operative help and support for all diversions after surgery.
Risks of Surgery
As with any major operation, there are risks associated with the performance of a radical cystectomy and urinary diversion. The risks of these operations include but are not limited to bleeding, infection, damage to the lung, pleura, liver, spleen, bowel, nerves, major vasculature, and major complications related to prolonged surgery and anesthesia (blood clots, heart attack, pneumonia, stroke and death).
Postoperatively, most patients are taken to the intensive care unit (ICU) for close monitoring. If things go well, transfer to the the main surgical ward occurs in the first couple of days. However, ICU care may be necessary for several days. Patients are typically in the hospital for 7 to 10 days after this particular operation. During this time you will meet with the stoma nurse who will work with you and your spouse, or significant other. She will help educate you on the proper care of your “new” urinary tract.
You may need to use the pain medication for several days, but we encourage you to quickly transition to Tylenol for pain control, and use the narcotic pain medication sparingly. While at home, if you experience a dramatic turn for the worse, such as increasing belly pain, nausea and vomiting, fevers (> 100.5 F) and chills, shortness of breath, chest pain, or unilateral leg swelling, you should return to the GW hospital emergency room (ER) immediately for re-evaluation.
Follow-Up after Surgery
In follow up, the patient is monitored for recurrence of his cancer, through periodic examinations, radiographs, and lab tests. It is also important that various blood tests are checked to monitor the salt and acid/base balance in the body. Finally the patient needs to be aware that Vitamin B12 my become deficient over many years, and this too should be monitored.