Understanding Choices for Urinary Diversion at the time of Bladder Removal Surgery

• Patients who are faced with bladder removal (cystectomy) are presented with a number of challenges, not the least of which is understanding the type of urinary diversion that is best for them.

  There are 3 basic categories of modern urinary diversions:

  (1) incontinent bowel conduit (e.g. ileal conduit)

  (2) continent cutaneous stomal reservoire (e.g. Indiana pouch)

  (3) continent orthotopic urethral diversion (ileal neobladder).

  The ileal conduit is the simplest, most time-tested urinary diversion that requires the least operative time and arguably is associated with the fewest complications. A short piece of ileum is anastamosed (i.e. connected) to the ureters and brought onto the skin. A life-long urostomy appliance (i.e. bag) to collect urine is required. Although time-tested, short-term and long-term issues with ileal conduit diversions are not uncommon, and it is important to discuss these with your surgeon.

  Another type of urinary diversion is an ileal neobladder. The neobladder is constructed from detubularized bowel, which is then sewn into a spherical reservoir for urine storage. The neobladder is anastamosed to the ureters and to the urethra, to mimic functions of the native bladder. The goal is for the patient to void spontaneously by straining of abdominal muscles and relaxation of the pelvic floor. Choice of proceeding with the neobladder vs. ileal conduit must be individualized and balanced against additional issues and risks. It is important to understand these additional risks and balance them against the perceived benefits of not having a stoma.

  A third urinary diversion that is offered by the urologic surgical team at Fox Chase is the Indiana pouch. This diversion consists of a pouch constructed from detubularized right colon. The pouch is catheterized through the native ileocecal valve via a segment of the ileum that is brought onto the skin. Life-long catheterization and irrigation regimen are required with this diversion.

  The decision regarding the type of urinary diversion is not clear-cut and can at times be overwhelming. Patients should have a frank and honest dialogue with their surgeon regarding the risk-benefit trade-offs for this complex choice.