ILEAL CONDUIT SURGERY URINARY DIVERSION
Category: General Surgery
Abstract : There are many surgical techniques for urinary diversion surgery. They fall into
two categories: continent diversion and conduit diversion. In continent
diversion, also known as continent catheterizable stomal reservoir, a separate
rectal reservoir for urine is created, which allows evacuation from the body. In
conduit diversion, or orthotopic urethral anastomotic procedure, an intestinal
There are many surgical techniques for urinary diversion surgery. They fall into
two categories: continent diversion and conduit diversion. In continent
diversion, also known as continent catheterizable stomal reservoir, a separate
rectal reservoir for urine is created, which allows evacuation from the body.
In
conduit diversion, or orthotopic urethral anastomotic procedure, an intestinal
stoma or conduit for release of urine is created in the abdominal wall so that a
catheter or ostomy can be attached for the release of urine.
An ileal
conduit is a small urine reservoir that is surgically created from a small
segment of bowel. Both techniques are forms of reconstructive surgery to replace
the bladder or bypass obstructions or disease in the bladder so that urine can
pass out of the body. Both procedures have been used for years and should be
considered for all appropriate patients. Ileal conduit surgery, the easiest of
the reconstructive surgeries, is the gold standard by which other surgical
techniques, both continent and conduit, have been compared as the techniques
have advanced over the decades.
Purpose
The bladder creates a reservoir for the liquid wastes created by
the kidneys as a result of the ability of these organs to filter and retain
glucose, salts, and minerals that the body needs. When the bladder must be
removed; or becomes diseased, injured, obstructed, or develops leak points; the
release of urinary wastes from the kidneys becomes impaired, endangering the
kidneys with an overburden of poisons.
Reasons for disabling the urinary
bladder are: cancer of the bladder; neurogenic sources of bladder dysfunction;
bladder sphincter detrusor overactivity that causes continual urge incontinence;
chronic inflammatory diseases of the bladder; tuberculosis; and schistosomiasis,
which is an infestation of the bladder by parasites, mostly occurring Africa and
Asia. Radical cystectomy, removal of the bladder, is the predominant treatment
for cancer of the bladder, with radiation and chemotherapy as other
alternatives. In both cases, urinary diversion is often necessitated, either due
to the whole or partial removal of the bladder or to damage done by radiation to
the bladder.
Demographics
Urinary diversion has a long history and, over the last two
decades, has developed new techniques for urinary tract reconstruction to
preserve renal function and to increase the quality of life. A number of
difficulties had to be solved for such progress to take place. Clean
intermittent catherization by the patient became possible in the 1980s, and many
patients with loss of bladder function were able to continue to have urine
release through the use of catheters.
However, it soon became clear that
catherization left a residue that cumulatively, and over time, increased the
risk of infection, which subsequently decreased kidney function through reflux,
or backup, of urine into the kidneys. A new way had to be found. With the advent
of surgical anatomosis (the grafting of vascularizing tissue for the repair and
expansion of organ function) as well as with the ability to include a flap-type
of valve to prevent backup, bladder reconstructive surgery that allowed for
protection of the kidneys became possible.
Description
Ileal conduit surgery consists of open abdominal surgery that
proceeds in the following three stages:
• Isolating the ileum, which is the
last section of small bowel. The segment used is about 5.9 - 7.8 in (15 - 20 cm) in
length.
• The segment is then anastomosized, or grafted, to the ureters with
absorbable sutures.
• A stoma, or opening in skin, is created on the right
side of the abdomen.
• The other end of the bowel segment is attached to the
stoma, which drains into a ostomy bag.
Stents are used to bypass the surgical site and divert urine externally,
ensuring that the anastomotic site has adequate healing time. Continent
surgeries are more extensive than the ileal conduit surgery and are not
described here. Both types of surgery require an extensive hospitalization with
careful monitoring of the patient for infections, removal of stents placed in
the bowel during surgery, and removal of
catheters.
Diagnosis/Preparation
Ileal conduit surgery is recommended
depending on what conditions are being treated; whether the urinary diversion is
immediately necessary; for the relief of pain or discomfort; or for relatively
healthy individuals or individuals with terminal illness. Three major decisions
that must be made by the physician and patient include:
• The type of surgery
to restore bladder function: either by sending urine through the ureters to a
new repository fashioned in the rectum, or by creating a conduit for the removal
of the urine out through the stomach wall and into a permanent storage pouch, or
ostomy outside the body.
• The type of material out of which to fashion the
reservoir or conduit.
• Where to place the stoma outlet for patient use.
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