Urinary Diversion Surgery

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After performing a cystectomy, creating a urinary diversion from an intestinal segment is necessary. The various types of urinary diversions can be separated into the following continent and incontinent diversions:

Conduit (incontinent diversion): Conduits can be constructed from either ileum or colon. The ileal conduit is the most common incontinent diversion performed (see Image 1) and has been used for more than 40 years with excellent reliability and minimal morbidity. A small segment of ileum (at least 15 cm proximal to the ileocecal valve) is taken out of gastrointestinal continuity, but maintained on its mesentery, with care to preserve its blood supply. The gastrointestinal tract is restored with a small-bowel anastomosis. Anastomosis of the ureters to an end or side of this intestinal segment is performed and the other end is brought out as a stoma to the abdominal wall. Urine continuously collects in an external collection device worn over the stoma.

Indiana pouch (continent diversion): This is a continent urinary reservoir created from a detubularized right colon and an efferent limb of terminal ileum (see Image 2). The terminal ileum is plicated and brought to the abdominal wall. The ileocecal valve acts as a continence mechanism. The Indiana pouch is emptied with a clean intermittent catheterization 4-6 times per day.

Neobladder (continent diversion): Various segments of intestine including ileum, ileum and colon, and sigmoid colon (see Image 3) can be used to construct a reservoir. The ureters are implanted to the reservoir, and the reservoir is anastomosed to the urethra. This operation has been performed successfully in men for more than 20 years and, more recently, in women. The orthotopic neobladder most closely restores the natural storage and voiding function of the native bladder. Patients have volitional control of urination and void by Valsalva. Contraindications to performing continent urinary diversions include multiple comorbid health problems, chronic renal insufficiency, hepatic dysfunction, and advanced disease stage.

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