ILEAL CONDUIT SURGERY

Recent research has shown there is little difference in infection rates or in renal deterioration between the conduit surgical techniques and the continent techniques. The patients preference becomes important as to which type of surgery and resulting procedures for urinationthey want. Of course, some patients, unable to conduct catheterization due to debilitating diseases like multiple sclerosis or neurological injuries, should be encouraged to have the reservoir or continent procedures. Materials for fashioning continent channels have included sections of the appendix, stomach, ileum and cecum of the intestines, and for the reservoir, sigmoid and ureter tissues, usually with an anti-refluxing mechanism to maximize continence. A segment of the ileum is often preferred, unless the tissue has received radiation. In this case, other tissue must be used. Ileum is preferred because the ileal tissue of the intestines accommodates larger urine volume at lower pressure.

Many urinary diversion procedures are performed in conjunction with surgery for recurrent cancer or complications of pelvic radiation. Fistula development and repeated repair as well as ureteral obstruction also are reasons to have the surgery. If the surgery is considered because of cancer, the physician and the patient need to discuss how appropriate the surgery is for cure or for relieving pain. Highly relevant are the patients age, medical

condition, and ability to comprehend both the procedure and the patients role in the changed state that will result with the surgery. In general, ileal conduit surgery is easier, faster, and has fewer complications than continent reservoir surgery.

In addition to these considerations, great emphasis must be put on preparing the patient psychologically, and physicians must make themselves available for counseling and questions before proceeding with patient evaluation for the procedures. The renal system must be assessed using pylography, which is the visualization of the renal pelvis of the kidneys to determine the health of each renal system. Patients with renal disease or abnormalities are not good candidates for urinary diversion.

Bowel preparation and prophylactic antibiotics are necessary to avoid infection with the surgery. Bowel preparation includes injecting a clear-liquid diet preoperatively for two days, followed by using a cleansing enema or enemas until the bowel runs clear. The importance of these preparations must be explained to the patient: leaking from the bowel during surgery can be life threatening.

For ileal conduits, the placement of the stoma must be decided. This is accomplished after the physician evaluates the patients abdomen in both a sitting and standing position, to avoid placing the stoma in a fatty fold of the abdomen. The input from a stomal therapist is important for this preparation with the patient.

Aftercare
Ureteral stents are generally removed one week after surgery. A urine culture is taken from each stent.Radiologic contrast studies are carried out to ensure against ureteral anastomotic leakage or obstruction. On the seventh postoperative day, a contrast study is performed to ensure pouch integrity. Thereafter, ureteral stents may be removed, again with radiologic control.

When it has been determined that the ureteral anastomoses and pouch are intact, the suction drain is removed. The patient is shown how to support the operative site when sleeping and with breathing and coughing. Fluids and electrolytes are infused intravenously until the patient can take liquids by mouth. The patient is usually able to get up in eight to 24 hours and leave the hospital in about a week.

Patients are taught how to care for the ostomy, and family members are educated as well. Appropriate supplies and a schedule of how to change the pouch are discussed, along with skin care techniques for the area sur-a home visit after discharge to help the patient return to normal daily activities.

Risks
This surgery includes the major risks of thrombosis and heart difficulties that can result from abdominal surgery. Many difficulties can occur after urinary diversion surgery, including urinary leakage, problems with a stoma, changes in fluid balance, and infections over time. However, urinary diversion is usually tolerated well by most patients, and reports indicate that patient satisfaction is very high. Common complications are stricture caused by inflammation or scar tissue from surgery, disease, or injury. The incidence of urine leakage for all types of ureterointestinal anastomoses is 3 - 5% and occurs within the first 10 days after surgery. According to some researchers, this incidence of leakage can be reduced to near zero if stents are used during surgery.

Normal results
Complete healing is expected without complications, with the patient returning to normal activities once they have recovered from surgery.

Morbidity and mortality rates
Possible complications associated with ileal conduit surgery include bowel obstruction, blood clots, urinary tract infection, pneumonia, skin breakdown around the stoma, stenosis of the stoma, and damage to the upper urinary tract by reflux. Pyelonephritis, or bacterial infection of a kidney, occurs both in the early postoperative period and over the long term. Approximately 12% of patients diverted with ileal conduits and 13% in those diverted with anti-refluxing colon conduits have this complication. Pyelonephritis is associated with significant mortality.

Alternatives
An alternative to ileal conduit surgery is continent surgery in which a neo-bladder is fashioned from bowel segments, allowing the patient to evacuate the urine and avoid having an external appliance. The procedures of continent diversion are more complicated, require more hospitalization, and have higher complication rates than conduit surgery. Many patients, unable to manage a stoma, are good candidates for continent diversion.