Urinary diversion involves redirecting the urinary pathway from the bladder due to conditions like muscle invasive bladder cancer. There are various types including continent, incontinent, internal, and external diversions. The ileal conduit is the most common non-continent diversion and involves using a segment of ileum as a urinary conduit connected to an abdominal stoma. Continent diversions like the Indiana pouch create an internal pouch that allows intermittent self-catheterization. Complications of urinary diversion can include metabolic abnormalities, infections, stone formation, and nutritional deficiencies depending on the bowel segment used.

1. URINARY DIVERSION
Dr. Rojan Adhikari
FCPS II resident
Urology

2. INTRODUCTION
• URINARY DIVERSION
Diversion of urinary pathway from its natural
path
Types:
• Temporary/Permanent
• External /Internal
• Continent / Incontinent
• Definitive/Palliative
• Orthotopic / Heterotopic

3. HISTORY
• First attempted urinary diversion by Simon in
1852
• Ureterosigmoidostomy is the oldest
• Zaayer in 1911 started ileal conduit and it was
gold standard through 1990’s
• 1950 (Bricker): eastablish ileal conduit as first
choice

4. • In 1979, Camey and Le Duc reported their
pioneer othrotopic neobladder
• Kock and associates reintroduced continent
cutaneous diversion in 1982

5. IDEAL URINARY DIVERSION
1. Undisturbed Body Image
2. Natural Micturation
3. Continence
4. Safe Upper Urinary Tract
5. Non Refluxing
6. Low Pressure

6. GOAL OF URINARY DIVERSION
• To provide the best local cancer control.
• To reduce potential range of complications.
• To guarantee the best quality of life for the
patient.

7. PREFERABLE DIVERSION
• Continent reservior connected to urethra
• Ileal segments (lower pressure peaks and ease
of surgical handling)

8. PRINCIPLE OF URINARY DIVERSION
• A reservoir in which to store urine in low
pressure
• A conduit through which the urine is conducted
to the surface
• A continence mechanism

9. BLADDER RESERVOIR
• Able to retent 500-1000ml of fluid
• Maintenance of low pressure after filling
• Elimination of intermittant pressure spikes
• True continence
• Ease of catheterization and emptying
• Prevention of reflux

10. CLASSIFICATION OF DIVERSION
• ORTHOTOPIC:
Orthotopic bladder substitution
• HETEROTOPIC
1. Continent : Cutaneous
2. Non-continent: Ileal conduit / colonic conduit
Cutaneous ureterostomy
3.Diversion to GIT: Uretero-sigmoidostomy/
rectal bladder

11. NON CONTINENT DIVESION
• NON CONTINENT DIVERSION involve a wide
stoma and an external appliance to collect the
urine.
TYPE
1.Ileal Conduit
2.Colonic Conduit
3.Jejunal Conduit

12. CONTINENT URINARY DIVERSION
• Heterotopic Continent Diversion
It’s a catheterizable stoma on the abdominal wall to
empty an intra abdominal neobladder
TYPE
1. Right Colonic Pouches
The Indiana Pouch , The Florida Pouch
The Miami Pouch ,The Penn Pouch
2. Ileal Pouches
The Kock Pouch
The Mainz Pouch

13. CONTINENT URINARY DIVERSION
• Orthotopic Continent Diversion
It creates a pelvic neobladder that is anastomosed
to urethra
TYPE
1.Studder neobladder
2.Hautmann neobladder
3. Mainz neobladder

14. PRINCIPLE OF ANASTOMOSIS
• Adequate exposure
• Ensure good blood supply
• Control spillage
• Accurate apposition of serosa to serosa
• Ensure tight
• Realignment of the mesentery

15. TEMPORARY DIVERSION
• Nephrostomy
• Pyelostomy or ureterostomy
• Suprapubic cystostomy

16. NEPHROSTOMY

17. NEPHROSTOMY

18. URETEROSTOMY

19. SUPRA PUBIC CYSTOSTOMY

20. Indications For Permanent Diversion
• After radical cystectomy in a case of muscle invasive
bladder tumor, along with radical prostatectomy
• Neurogenic bladder dysfunction due to congenital or
acquired disorders in case of neural tube defect and
spinal cord injury.
• Severe idiopathic detrusor overactivity
• Chronic inflammatory conditions like interstitial cystitis,
Tuberculosis, schistosomiasis and post radiation bladder
contraction

21. • As a palliative diversion in case of irremovable
obstruction in the bladder & distal to bladder
• Severe hemorrhagic cystitis
• Ectopic vesicle
• Incurable vesico- vagina fistula

22. SELECTION OF TYPE OF DIVERSION
• Age/ Survival rate
• Co morbidities
• Oncological Extent of disease
• Renal and Hepatic functional status
• Bowel condition
• Patient’s preferences
• Available expertise
• Mental status

23. ILEAL CONDUIT

24. PRE OPERATIVE PREPARATION
• Mechanical bowel preparation
Whole gut irrigation with poly ehylene glycol and
enema
• Pre-op antibiotic: cephalosporin + metronidazole
• Stoma site assessment
• Well informed consent

25. INDICATION
• After a cystectomy
• dysfunctional bladders
 persistent bleeding,
 obstructed ureter,
 poor compliance with upper tract deterioration,
 inadequate storage with total urinary
incontinence

26. CONTRAINDICATION
• Short bowel syndrome
• Inflammatory small bowel disease
• Pelvic irradiation

27. ILEAL CONDUIT
• 10-12cm ileal segment isolated 20cm proximal to
IC valve
• Short straight conduit without kinking
• Continuity of small bowel re-established
• Mesenteric window closed
• Ileum in isoperistaltic fashion

28. • Isolated segment flushed with warm saline till
return of clear fluid
• Left ureter brought beneath the sigmoid
mesocolon (inferior to IMA)
• Ureteroenteric anastomosis

30. ILEAL CONDUIT
• After single J ureteral stent is placed in both ureter
• Distal end of ileal segment fashioned as end
ileostomy in RLQ
• A Rutzen bag/ stoma bag can be applied to the
stoma on the fifth or sixth postoperative day with
complete comfort for the patient

31. ILEAL CONDUIT
• ADVANTAGES
Technically simple surgery
Few complication
No bladder retaining
No nocturnal incontinence
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553

32. ILEAL CONDUIT
• DISADVANTAGES
Risk of stomal complication eg: parastomal
hernia or stenosis
Urinary incontinance
Increased long term expenses of stoma care
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553

33. COLONIC CONDUIT
• Indication
1. Extensive pelvic irradiation
2. When the middle and distal ureter are
absent.
• Containdication
1. Inflammatory large bowel disease
2. Severe chronic diarrhoea

34. INDIANA POUCH
• Rightcolon pouch with tapered ileum as
efferent limb

35. INDIANA POUCH
• A segment of terminal ileum approximately 10
cm in length along with the entire right colon is
isolated.
• An appendectomy is performed, and the
appendiceal fat pad obscuring the inferior margin
of the ileocecal junction is removed by cautery.
• The entire right colon is opened along its
antimesenteric border.

36. INDIANA POUCH
• Interrupted Lembert sutures are taken over a
short distance (3 to 4 cm) in two rows for the
double imbrication of the ileocecal valve.
• Application of opposing Lembert sutures on
each side of the terminal ileum
• Excess ileum can be tapered by stapling
technique.

38. INDIANA POUCH
• ADVANTAGES
Potential for normal or near normal urinary
continence
No nocturnal incontinence
No need for a stoma bag
The small stoma can be easily covered with
bandage that is less effect on physical image vs
ileal conduit
Dwayne Tun Soong Chang Published in Urology annals 2015, DOI:10.4103/0974-7796.148553

39. INDIANA POUCH
• DISADVANTAGES
Technically more difficult procedure
Complication associated with intermittent
catherization
Potential complications from urinary waste
product reabsorption
Risk of stomal complication eg: parastomal hernia
or stenosis

40. Neobladder
• The clinical goal of most neobladders is to
– allow volitional voiding 4 - 6 times per day
– capacity range of 400 to 500 mL of urine at low
pressures (>15 cm H2O)
• Two important criteria
– No compromise of oncological outcomes by
reconstruction at the urethroenteric anastomosis
– Rhabdosphincter mechanism must remain intact
to provide continent

41. Types of Neobladder
• Camey I & II
• Hautman
• Kock
• Mainz
• T-Pouch, Florida, UCLA, S pouch, Le bag
• Studer (most common)

42. STUDER NEOBLADDER
• Designated segments of terminal ileum for
construction of neobladder.
• Note that the distal mesenteric division is made
between the ileocolic and terminal branches of
the superior mesenteric artery, which extends
into the avascular plane of the mesentery.
• In addition, a small window of mesentery and a
5-cm segment of proximal small bowel are
discarded to allow mobility to the pouch and
small bowel anastomosis.

44. Contra-indication of Orthotopic
Neobladder
• Compromised renal function
• Severe hepatic dysfunction
• Compromised intestinal function
• Positive urethral margin

45. • Mental impairment
• Pre-existing incontinence
• Pelvic radiation (increased complications)
• Recurrent urethral stricture disease
• AGE NOT CONTRAINDICTION!!

46. COMPLICATION RELATED WITH
URINARY DIVERSION

47. Metabolic Problems
• Electrolyte Abnormalities
• Abnormal drug metabolism
• Osteomalacia and growth retardation
• Infections
• Formation of renal and reservoir calculi
• Renal deterioration
• Development of urothelial or intestinal cancer

48. Metabolic Problems
• Due to continued solute transport by interposed
segment
• The factors that influence
– Segment of bowel used
– Surface area of the bowel
– The amount of time the urine is exposed
– The concentration of solutes in the urine
– Renal function
– The pH of the fluid

50. • stomach: a hypochloremic hypokalemic metabolic
alkalosis may occur
• jejunum – hyponatremia, hyperkalemia, and
metabolic acidosis occur.
• ileum or colon – hyperchloremic metabolic acidosis
ensues.
• Other electrolyte abnormalities – hypokalemia,
hypomagnesemia, hypocalcemia, hyperammonemia,
and elevated blood urea nitrogen and creatinine.

51. Infection
• An increased incidence of bacteriuria, bacteremia,
and septic episodes occurs in patients with bowel
interposition
• Incidence : 10% to 17% with colon and ileal
conduits
• Patients with continent diversions also have a
significant incidence of bacteriuria and septic
episodes

52. Stones
• Most are infection stone
• Structural or metabolic cause
• Major risk: hyperchloremic metabolic acidosis
• Colon conduits : 3% to 4%
• Ileal conduits : 10% to 12%
• Continent cecal reservoirs : 20%

53. Short bowel and nutritional problem
• Significant loss of ileum
Vit B12 malabsorption : megaloblastic
anemia
Malabsorption of bile salts: diarrhea
Malabsorption of fat: fatty diarrhea

54. References
• Campbell and Walsh Urology 10th edition
•
• Bailey and love 27th edition

55. THANK YOU