A urinary diversion involves removal of the urinary bladder and adjacent tissues and organs, and re-routing of the urinary stream. This may involve creation of an artificial opening in the abdomen called an ostomy.
Purpose
A urinary diversion is created as a means to treat cancer of the bladder, when conservative measures have been unsuccessful, or when there is recurrence of the disease invading the muscle wall. Congenital deformities or traumatic injury may also necessitate formation of a urinary diversion.
Description
Under general anesthesia, an incision is made in the abdomen. The ureters (tubes that carry urine away from the kidneys) are cut and tied. The bladder and surrounding tissues are cut free and removed. The ureters are then attached to a portion of the intestine. The most common types of urinary diversion are:
Ileal conduit. Ureters are attached to a portion of the small intestine, the ileum, one end of which is brought through the abdominal wall as a conduit for the urine, creating a stoma.
Ureterosigmoidostomy. The ureters are attached to a portion of the large intestine, the sigmoid, which allows the urine to flow through the large intestine and out through the rectum.
Cutaneous ureterostomy. Bringing the detached ureters through the abdominal wall and attaching it to an opening in the skin.
Following creation of an artificial opening to drain the urine, ureteral stents (tubes that go through the stoma and up into the ureters) are often inserted and left in place to allow urine to drain freely from the kidneys, without risk of blockage from swelling due to surgery. The muscles are replaced and sewn together. A transparent pouch is applied to the abdomen to collect urine, and attached to a bedside drainage bag. The incision is closed with sutures or clips ("staples"), which are usually removed about 1 week after surgery.
An alternative to a conventional urinary diversion is the continent urinary diversion. In this surgical procedure, a "false bladder" is constructed within the abdomen, using several lengths of small or large intestine. The ureters are sewn to this new reservoir for urine and nipple valves are created at two sites; the abdominal wall for continence; and where the ureters are implanted, to prevent reflux of urine back to the kidneys. The patient is then taught to catheterize the reservoir to drain urine at regular intervals during the day. Although a continent diversion is not suitable for every patient who requires urinary diversion, it is an option to be considered.
Preparation
As with any surgical procedure, the patient will be required to sign a consent form after the procedure is explained thoroughly. Blood and urine studies, along with various x rays and an electrocardiogram (EKG), may be ordered as the doctor deems necessary. If creation of an ostomy is planned, the patient should visit an enterostomal therapist, who will mark an appropriate place on the abdomen for a stoma and offer preoperative education on ostomy management.
Eating or drinking is prohibited after midnight the night before the surgery. Oral anti-infectives, such as neomycin, erythromycin, or kanamycin sulfate, may be ordered to decrease bacteria in the intestine and help prevent postoperative infection. A nasogastric tube is inserted the day of surgery, or during surgery, to remove gastric secretions and prevent nausea and vomiting.
Aftercare
Postoperative care for the patient with a urinary diversion, as with those who have had any major surgery, involves monitoring of blood pressure, pulse, respirations, and temperature. Breathing tends to be shallow because of the effect of anesthesia, and the patient is reluctant to breathe deeply and experience pain that is caused by the abdominal incision. The patient is shown how to support the operative site during deep breathing and coughing, and is given pain medication as necessary. Fluid intake and output are measured, and the operative site is observed for color and amount of wound drainage. The nasogastric tube will remain in place, attached to low intermittent suction, until bowel activity resumes. Fluids and electrolytes are infused intravenously until the patient's diet can gradually be resumed, beginning with liquids. The patient is usually able to move about in 8–24 hours after surgery, and is discharged from the hospital in 5–10 days.
If an ostomy has been placed, the patient and close family members will be educated on how to care for it. Determination of appropriate pouching supplies and a schedule of how often to change the pouch should be established. Regular assessment and meticulous care of the skin surrounding the stoma is important to maintain an adequate surface on which to apply the pouch. The pouch should be connected to a bedside drainage bag at night to prevent large volumes of urine from collecting in the pouch. Otherwise, the weight of the pouch could cause disruption of the pouch seal and leakage of urine onto the surrounding skin. Often, an enterostomal therapist will visit the patient at home after discharge to help the new ostomy patient make the transition back to normal daily activities.
Risks
Potential complications of urinary diversion surgery include:
pulmonary embolism (blood clot or air bubble in the lungs' blood supply)
Normal results
Complete healing is expected without complications. The amount of time required for recovery from the surgery may vary depending of the patient's overall health status prior to surgery. The patient with a urinary diversion, without other medical complications, should be able to resume all daily activities once recovered from the surgery.
Abnormal results
The doctor should be made aware of any of the following problems after surgery:
Increased pain, swelling, redness, drainage, or bleeding in the surgical area
Increased abdominal pain or swelling, constipation, nausea, or vomiting.
Stomal complications to be monitored include:
Stomal tissue death (necrosis). This occurs because of inadequate blood supply, this is usually visible 12 to 24 hours after surgery. It may require additional surgery.
Stoma flush or below the abdomen surface (retraction). Caused by insufficient stomal length, this may be managed by use of special pouching supplies. Elective revision of the stoma is also an option.
Narrowing at the opening of the stoma (stenosis). Often associated with infection around the stoma or scarring, mild stenosis can be removed under local anesthesia. Severe stenosis may require surgery for stomal revision.
Parastomal hernia. The bowel causes a bulge in the abdominal wall next to the stoma. This is usually due to placement of the stoma where the abdominal wall is weak, or an overly large opening in the abdominal wall. Use of an ostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location.
BOOKS
Doughty, Dorothy. Urinary and Fecal Incontinence. St. Louis: Mosby-Year Book, Inc., 1991.
Hampton, Beverly, and Ruth Bryant. Ostomies and Continent Diversions. St. Louis: Mosby-Year Book, Inc., 1992.
Monahan, Frances. Medical-Surgical Nursing. Philadelphia: W. B. Saunders Co., 1998.
Suddarth, Doris. The Lippincott Manual of Nursing. Philadelphia: J. B. Lippincott, 1991.
ORGANIZATIONS
United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <http://www.uoa.org>.
Wound Ostomy and Continence Nurses Society. 1550 South Coast Highway, Suite #201
