Continent diversion

Urinary bladder is a muscular sack which receives , stores the urine and release urine through the distal ( lower) urinary tract. Bladder cancer is a cancer which begins in the lining of the walls of the urinary bladder. Radical Cystectomy is surgery (operation) performed to remove enlarged (overgrown) urinary bladder and surrounding tissues. In the event , an opening ( whole) is created in the urinary tract and through this opening, usually made in the abdominal wall, urine flows out. This is called urinary diversion.

Safety:

Since urinary diversion operations are inherently complex, patients should be informed that some surgical complications may occur during and after the surgery. However, due precautions are observed at the super-specialty centers to minimize – tissue and organ damage, blood loss, postoperative pain and inconvenience experienced by the patients.

Length of Surgery:

3- 4 hours, may be longer in some isolated cases and situations

Diagnosis:

As Continent urinary diversion is therapeutic procedure, no prior or special investigations are requested or advised. Usually, Continent urinary diversion are preceded by Radical Cystectomy as surgical intervention for urinary bladder cancer, dysfunctional bladder or trauma to urinary tract.

Treatment:

Continent urinary diversion is the procedure performed to enable the patient to pass urine at his or her own convenience without any external collection equipment or container. There are two distinct categories of continent urinary diversion : 1. Orthotopic ( Neobladder), and 2. Cutaneous.

In Orthotopic continent urinary diversion, also referred to as Neobladder, the surgeon (urologist) tries to restore the normal urinary anatomy. While in , Cutaneous continent urinary diversion the patient needs to use plastic tube or clinical catheter frequently to empty the newly prepared bladder.

Preparation:

Certain medications to be specifically avoided pre surgery:

  • Aspirin.
  • Ibuprofen Motrin.
  • Voltaren, Plavix, Lovenox, Vioxx, Celebrex.
  • Arthritis medications: avoided since before a week of the surgery otherwise it can cause bleeding during the surgery.
  • In case of severe lung/ heart conditions, it is advisable to exercise extra caution before and during the procedure
  • Before surgery, the site for an external opening ( stoma) should be identified
  • liver function and Kidney function are to be monitored meticulously
  • liquid dinner on the night before surgery
  • Complete bowel preparation by administering “Go-Lytely” one-gallon bowel preparation.
  • Oral antibiotics are also given to help sterilize the intestinal tract and reduce the chance of infection.

Procedure:

In Orthotopic continent urinary diversion ( Neobladder) , part of small intestine is used to craft a pouch that will function as a new bladder. This new bag/pouch is then surgically sutured ( approximated)with the urethra ( urine tube) in the pelvic cavity. Following this ,Patients can urinate as spontaneously through the urethra. Many patients still require urethral catheter bladder emptying.

Cutaneous ( skin) continent urinary diversion – in this procedure also, new bladder is prepared from part of small intestine and is placed just under the skin (inside the body). Patient doesn’t have to wear any external collection equipment or container. however, every patient is trained to use plastic tube or clinical catheter frequently to empty the newly prepared bladder.

Risks:

  • Bleeding.
  • Fever.
  • Constipation.
  • Infection.
  • Urinary leakage
  • Ileus
  • Delayed complications include (after 6 weeks):
  • Recurrent UTI
  • Parastomal hernia
  • Stomal infarction – ischaemic
  • Stomal retraction
  • Stomal stricture
  • Bilateral hydronephrosis
  • Renal stone

Follow- up:

  • 24 hour surveillance.
  • Emergency Follow up:
  • Chest pain/ breathing difficulty.
  • Vomiting/ nausea
  • Worsening pain .
  • Large amounts of blood clots in the urine.
  • Difficult/ painful voiding and fully emptying the bladder.
  • After Continent urinary diversion , patient is hospitalized stay for up to one week.
  • Postoperatively , drainage tubes are placed for two to three weeks. Before drainage tubes are removed, radiography( X-ray) is done to ensure that the new pouch ( bladder) has satisfactorily healed and there are no leakage.
  • Following discharge, patients are trained to keep the urethral catheter clean by washing at home every four to six hours.
  • During initial postoperative period, the new bladder can hold only a small quantity of urine, hence patients need to empty more frequently.

All above, treatments are finalized taking into consideration the overall health, severity, age and other ailments of the patient. Only a well experienced urologist should perform the above treatment.