What is the recommended approach for patients requiring urinary diversion?

Multidisciplinary Approach to Urinary Diversion

For patients requiring urinary diversion, a multidisciplinary team approach is strongly recommended with the decision tailored to the individual patient's clinical condition, anatomical considerations, and specific needs. 1

Patient Selection and Evaluation

When considering urinary diversion, the following factors must be assessed:

• Clinical indications:

  • Radical cystectomy for bladder cancer
  • Fournier's gangrene with urethral involvement
  • Intractable bladder neck contracture
  • Multiple artificial urinary sphincter failures
  • Severe detrusor instability unresponsive to other treatments

• Patient-specific factors:

  • Comorbidities and performance status
  • Cognitive function and manual dexterity
  • Social support system
  • Patient preferences after thorough counseling

Types of Urinary Diversion

1. Incontinent Diversions

• Ileal conduit: Most common incontinent diversion, requiring external appliance
• Ureterocutaneostomy: Simpler procedure for high-risk patients
• Suprapubic cystostomy: Temporary option in emergency settings

2. Continent Diversions

• Orthotopic neobladder: Preferred by most patients (60%) due to better quality of life and preservation of body image 2
• Continent cutaneous diversion: Requires intermittent catheterization
• Continent anal diversion (MAINZ Pouch II): Alternative when urethral diversion not possible

Specific Clinical Scenarios

For Radical Cystectomy Patients

• Hospital volume matters: Centers performing >20 radical cystectomies annually have lower mortality and complication rates 1
• Contraindications to orthotopic bladder substitution: Invasive tumor in the urethra or at urethral dissection level 1

For Fournier's Gangrene

• Indications for suprapubic diversion: Extensive penile/perineal debridement, urethral involvement, periurethral abscesses 1
• Standard approach: Urinary catheterization is usually sufficient for most patients 1
• Suprapubic cystostomy: Reserved for patients with urethral disruption or stricture 1

For Incontinence After Prostate Treatment

• Urinary diversion: Consider only after failure of artificial urinary sphincter due to multiple device failures, intractable bladder neck contracture, or severe detrusor instability 1
• Options: Ileal conduit or continent catheterizable pouch in the "hostile" bladder scenario 1

Perioperative Considerations

• Preoperative preparation:

  • Complete bowel preparation for intestinal diversions
  • Broad-spectrum antibiotics
  • Evaluation by stoma therapist when applicable 3

• Postoperative care:

  • Implementation of "fast track"/ERAS protocols reduces complications and improves recovery 1
  • Venous thromboembolism prophylaxis for at least 4 weeks 1

Long-term Follow-up

• Regular monitoring of renal function and upper tract imaging
• Assessment for metabolic abnormalities when intestinal segments are used
• Evaluation for urinary tract infections and stone formation
• For continent diversions, monitoring of continence status and reservoir function

Common Pitfalls and Considerations

• Avoid premature conversion from percutaneous nephrostomy to internal drainage in cases of infection or patient instability 4
• Recognize that no "perfect" solution exists for bladder substitution; all methods carry some risk to long-term renal function 5
• Consider patient's ability to manage the diversion long-term, including catheterization if needed 3
• Monitor for deterioration of upper urinary tract which may be asymptomatic 3

Conclusion

The decision regarding urinary diversion should be made by a multidisciplinary team including urologists, general surgeons, and other specialists as needed. The approach must be tailored to the individual patient's clinical condition, anatomical considerations, and specific needs, with the ultimate goal of optimizing morbidity, mortality, and quality of life outcomes.