What are the methods for urinary diversion, such as ileal conduit or continent urinary reservoir?

Urinary Diversion Methods: Ileal Conduit and Continent Urinary Reservoir

Urinary diversion methods include ileal conduit (non-continent) and continent reservoirs (such as ureterosigmoidostomy and neobladder), with each option having specific indications, advantages, and long-term monitoring requirements based on patient factors and quality of life considerations.

Types of Urinary Diversions

Non-Continent Diversions

• Ileal Conduit: The most common urinary diversion method where a segment of ileum is isolated to create a conduit between ureters and the abdominal wall, requiring an external collection appliance 1
• Colonic Conduit: Used as a salvage procedure after unsuccessful ileal conduit or other diversions, with lower rates of reflux and stomal stenosis compared to ileal conduits 2

Continent Diversions

• Ureterosigmoidostomy: Ureters are implanted directly into the sigmoid colon, allowing for continence but requiring regular monitoring due to high cancer risk 1
• Continent Ileal Reservoir: Creates an intra-abdominal receptacle for urine storage with nipple valves to maintain continence and prevent reflux; emptied via self-catheterization 3, 4
• Neobladder: Orthotopic reconstruction using detubularized bowel segments to create a bladder substitute in the original bladder position 5
• Florida Pouch: Uses extended, detubularized right colonic segment as reservoir with distal ileum as catheterizable efferent system 6

Clinical Considerations for Selection

Patient Education and Preparation

• Patients must be thoroughly educated about their urinary diversion options before surgery 1
• Meeting with an enterostomal therapist is essential for patients considering an ileal conduit to mark optimal stoma site 1
• Even patients choosing continent diversions should be marked for potential stoma in case intraoperative findings necessitate an ileal conduit 1
• Manual dexterity assessment is crucial for patients considering continent catheterizable diversions to ensure ability to self-catheterize 1

Monitoring and Long-Term Care

For Ureterosigmoidostomy

• Annual flexible sigmoidoscopy is mandatory beginning 10 years after surgery due to significantly increased cancer risk (24% at 20 years follow-up) 1
• Neoplasia risk at ureterocolonic anastomosis is estimated at 1,726 times that of normal population 1
• Even patients who later convert to different diversion methods require continued surveillance unless the anastomosis was completely removed 1

For Other Diversions

• Continent ileal reservoirs require regular self-catheterization (3-6 times daily) 4
• Neobladders may have complications including nocturnal leakage, urinary retention requiring clean intermittent catheterization, rupture, and mucous tamponade 5
• Florida pouch can accommodate large urine volumes (550-1,200cc) with catheterization every 4-6 hours 6

Complications and Management

Immediate Post-Operative Care

• Appropriate perioperative antibiotics are essential, with second or third-generation cephalosporins recommended 1
• Deep vein thrombosis prophylaxis is critical due to high risk in this population 1

Long-Term Complications

• Ureterosigmoidostomy carries significant risk of adenoma/adenocarcinoma development (earliest reported at 10 years post-surgery) 1
• Neobladders and continent reservoirs may have complications with nipple valves requiring surgical correction 4
• Ureteral reimplantation techniques vary in success rates, with direct mucosa-to-mucosa anastomosis showing 90.1% success 6
• For patients with persistent incontinence after prostatectomy, urinary diversion may be considered when other options fail 7

Clinical Pearls and Pitfalls

• Polypoid lesions at ureterosigmoidostomy anastomoses should not be removed with endoscopic snare due to risk of urinary leakage 1
• The neoplastic process in ureterosigmoidostomy begins early and continues even if diversion is changed but anastomosis remains 1
• Orthotopic neobladder reconstruction has similar or lower complication rates than ileal conduits, contrary to popular belief that conduits are simpler and safer 5
• Reflux prevention is less critical in neobladders than in other diversions, and non-refluxing techniques have twice the risk of obstruction compared to direct anastomosis 5