Urinary diversion: information & urinary diversion specialists

If the urine cannot be drained via the body's own bladder, an artificial remedy must be found. A distinction is made between a continent and an incontinent form of urinary diversion. With continent urinary diversion, the urine is stored inside the body in an artificial replacement bladder (Mainz pouch). It is then emptied via the urethra or an artificial bladder outlet. With incontinent urinary diversion, on the other hand, the urine is passed through a piece of bowel (conduit) through the abdominal wall to the surface of the body. It is collected outside the body in a plastic bag.

Here you will find further information and selected urinary diversion specialists and centers.

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Urinary diversion - Further information

When must a urinary diversion be performed?

A urinary diversion may be necessary due to

  • a malignant neoplasm of the bladder(bladder cancer),
  • the absence of a urinary bladder from birth or
  • severe impairment of the function of the bladder or the sphincter muscle.

may be necessary. If the urinary bladder is to be removed or eliminated, the urine must be drained.

What types of urinary diversion are there?

Continent urinary diversion

In the "continent" form of urinary diversion, the urine is stored inside the body.

A reservoir (also known as a pouch) is surgically created from a piece of bowel to act asa"replacement bladder". The model for this is the natural bladder. The pouch can hold a urine volume of around 500 ml. It must be emptied at certain intervals.

There are two ways to empty the bladder:

  • via the urethra, i.e. the natural way (orthotopic bladder replacement), or
  • via a continent stoma located in the navel (continent cutaneous urinary diversion).

Two variants can be distinguished for continent urinary diversion:

  • Mainz pouch I: orthotopic bladder replacement and continent cutaneous urinary diversion
  • Mainz pouch II: continent anal urinary diversion

In the Mainz pouch II method, the surgeons move the ureters into the rectum. The urine can then be excreted together with the stool.

Incontinent urinary diversion

In the "incontinent" form of urinary diversion, the urine is collected outside the body.

The urine is passed through the abdominal wall to the surface of the body via a short piece of bowel (conduit). There it is collected in a plastic bag glued to the skin. The skin opening of the conduit is called a stoma.

What is the preparation before urinary diversion surgery?

A number of examinations are necessary before urinary diversion surgery, such as

The latter is particularly necessary for continent forms of urinary diversion. Contrast imaging of the intestinal conditions is also important.

If urine and stool are drained together, the surgeon requires a urodynamic assessment of the rectum (rectodynamics).

  • of the rectum (rectodynamics) and
  • the anal sphincter (anal pressure profile).

The bowel is removed from its natural course but is filled with stool. This represents a potential source of inflammation. For this reason, the bowel must be cleansed before the urinary diversion operation. To do this, the patient must drink around 2 to 4 liters of irrigation fluid within a short period of time the day before.

Before creating an incontinent stoma, the surgeon determines favorable outlets on the patient's abdomen. He marks these directly on the skin.

As a precaution, he also does this for patients who are to receive a continent bowel reservoir. During the operation, the team must be prepared for the event that the planned procedure is not possible. In this case, they must switch to an incontinent stoma during the operation. A marker has already been placed in advance for this purpose.

The anesthetist places a catheter into a central blood vessel via a jugular vein immediately before the operation . This allows the patient to be supplied with fluids and nutrients for the days following the operation.

Incontinent urinary diversion: the ileum conduit and the colon conduit

First, a longitudinal abdominal incision is made in the midline (so-called median laparotomy).

The surgeons then remove

  • the bladder,
  • the surrounding lymph nodes and
  • In men, the prostate and seminal vesicles are also removed, as well as the urethra if necessary.

They then remove an approximately 15 cm long piece of small intestine (ileum) or large intestine (colon) from the bowel. The continuity of the intestine is restored.

One end of the removed bowel segment (the so-called conduit) is surgically connected to both ureters. The other end is passed to the outside at the marked point.

The ureters are each splinted with a splint (thin plastic catheter) for 10 to 12 days. A catheter is also inserted into the conduit.

Continent urinary diversion: the Mainz pouch I and II

Continent urinary diversion with Mainz pouch I (reservoir)

This urinary diversion operation is also performed via a median laparotomy. However, a longer section of small intestine and colon is now isolated: Approximately 20 to 24 cm of small bowel and 10 to 12 cm of colon.

Kontinente Harnableitung1
Median laparotomy (l.) and intestinal segment used (r.) (From: Surgery Illustrated - Surgical Atlas: Mainz pouch continent cutaneous diversion; J. W. Thüroff, H. Riedmiller, M. Fisch, R. Stein, C. Hampel R. Hohenfellner, BJU 2010)

As with the conduit, the remaining intestine is reconnected.

The separated tube-like piece of intestine is now cut open lengthwise. The surgeons then suture it so that a "plate" is formed. They fold the edges of this intestinal plate and sew them together to form a spherical reservoir (pouch). Both ureters are then implanted back into the pouch.

Kontinente Harnableitung2
Implanting the ureters into the pouch (From: Surgery Illustrated - Surgical Atlas: Mainz pouch continent cutaneous diversion; J. W. Thüroff, H. Riedmiller, M. Fisch, R. Stein, C. Hampel R. Hohenfellner, BJU 2010)

Continent urinary diversion using Mainz pouch I with umbilical stoma (continent cutaneous diversion)

The intestinal reservoir can be connected to the abdominal skin in the form of a continent stoma. The umbilicus is preferred for this. The surgeon inserts another piece of bowel segment as a catheterizable continence mechanism.

Kontinente Harnableitung3
Use of the appendix as a stoma (From: Surgery Illustrated - Surgical Atlas: Mainz pouch continent cutaneous diversion; J. W. Thüroff, H. Riedmiller, M. Fisch, R. Stein, C. Hampel R. Hohenfellner, BJU 2010)

If the appendix is still present and usable, it is preferably used for this purpose. Alternatively, the surgeon can also use another piece of small intestine about 8 cm long.

Kontinente Harnableitung4
Use of a piece of small intestine as a stoma (From: Surgery Illustrated - Surgical Atlas: Mainz pouch continent cutaneous diversion; J. W. Thüroff, H. Riedmiller, M. Fisch, R. Stein, C. Hampel R. Hohenfellner, BJU 2010)

This bowel segment is inserted into the pouch and the skin in such a way that spontaneous leakage of urine(incontinence) is not possible. A catheter must then be inserted through the continent stoma (the navel) to empty the pouch.

Kontinente Harnableitung5
Insertion of a catheter through the continent stoma (From: Surgery Illustrated - Surgical Atlas: Mainz pouch continent cutaneous diversion; J. W. Thüroff, H. Riedmiller, M. Fisch, R. Stein, C. Hampel R. Hohenfellner, BJU 2010)

Drains, splints and a gastrostomy or jejunostomy are also inserted during this urinary diversion operation.

Continent urinary diversion with orthotopic Mainz pouch I (replacement bladder with connection to the urethra)

If the bowel reservoir is to be connected to the urethra(replacement bladder), the pouch is now sutured directly to the remaining urethra.

Kontinente Harnableitung6
Disconnected bowel segment (l.) and completed pouch (r.) (From: Surgery Illustrated - Surgical Atlas: Simplified orthotopic ileocaecal pouch (Mainz pouch) for bladder substitution; J. W. Thüroff, L. Franzaring, R. Gillitzer, M. Wöhr, S. Melchior, BJU 2005)

The pelvic floor muscles and the urethral sphincter muscles later prevent spontaneous emptying of the pouch. You therefore become continent again. The replacement bladder is emptied naturally through the urethra using the abdominal press.

Drains and splints are also inserted during this urinary diversion operation as described above.

Continent urinary diversion with Mainz pouch II (connection of the ureters to the rectum)

In this urinary diversion operation, the ureters are connected to the rectum. Stool and urine are then excreted together via the rectum.

kontinente-Harnableitung7.jpg
Connection of the ureters to the rectum (From: Surgery Illustrated - Surgical Atlas: Sigma-rectum pouch (Mainz pouch II); M. Fisch, R. Hohenfellner BJU 2007)

The anal sphincter muscle then ensures continence. This solution is only recommended if the sphincter function is good and no restriction is to be expected. The doctor can test this on you before the operation.

Follow-up treatment after urinary diversion surgery

The urinary diversion operation may be followed by a 1 to 3-day stay in the intensive care unit. The patient is then transferred to the urological recovery ward. Here, the patient's condition can be monitored more closely than on the normal ward.

The first few days after the urinary diversion operation are spent recovering. All drains and splints are then gradually removed over the course of around 10 days. During this time, check-ups are carried out, e.g.

  • blood samples and
  • a new x-ray of the urinary tract.

Follow-up treatment for urinary diversion with ileum conduit and colon conduit

After urinary diversion surgery with collection bags, the patient is familiarized with the urine collection bags. They learn how to attach and empty them themselves.

There are no special dietary requirements for the patient in the future. They should simply ensure that they drink enough fluids. This is usually at least 2 liters a day.

Follow-up care should initially be carried out after three and six months. The procedure can lead to an expansion of the renal hollow system. The examination should therefore include an ultrasound examination of the kidneys . However, follow-up care is essentially based on the underlying disease.

There are no special requirements for the rest of your life in terms of work and leisure. All usual activities can be resumed. However, excessive strain on the abdominal muscles should be avoided in the first three months. This includes

  • Lifting heavy objects,
  • rowing and the like.

Follow-up treatment for Mainz pouch I with umbilical stoma

Initially, for about three weeks after discharge

  • a permanent catheter through the umbilical stoma and
  • an abdominal wall catheter

in the pouch. They serve to support the healing process. During this time, urine is drained into a bag that the patient can wear on their thigh under their clothing.

During the initial period, the bowel still produces a lot of mucus, which can block the catheter. It is therefore necessary to flush the pouch at certain intervals during this time. Stoma therapists will teach the patient how to do this and will be available to answer any questions. After this period , the pouch will be checked as an inpatient.

The patient will also learn how to insert a catheter through the stoma into the pouch in order to empty it. Initially, catheterization must be performed every 3 to 4 hours, even at night. It must also be flushed at fixed intervals. Later, flushing is no longer necessary and the intervals between catheterizations can be extended.

There are only a few special requirements with regard to nutrition. Patients should ensure that they drink enough fluids, usually 2 to 3 liters a day.

The bowel movements are initially softer than usual due to the intestinal parts that have been removed. This may make dietary measures necessary, such as

  • eating more bananas or
  • the administration of medication (e.g. Quantalan).

Necessary follow-up examinations

Regular follow-up examinations should be carried out to detect complications at an early stage. In the first year this is necessary every three months, thereafter every six months is sufficient.

This aftercare includes regular blood tests. This allows metabolic problems affecting the acid-base balance to be detected and treated in good time. A so-called blood gas analysis is carried out for this purpose. Acidification of the blood (base excess below -2.5 mmol/l) is balanced with medication. The following are available

  • Acetolyt®
  • Uralyt®
  • Nephrotrans®

These examinations are necessary in the first postoperative year for the majority of patients. An ultrasound examination of the kidneys is also necessary. This allows any dilation of the renal hollow system to be detected.

In rare cases, it may be necessary to re-implant the ureters into the pouch. Stones may also occur in the pouch, which must be removed under anesthesia. Sometimes there is a narrowing of the stoma in the skin area. A dilation is then necessary. This is performed under anesthesia with a small incision. Aftercare naturally also depends on the underlying disease.

There are only a few restrictions in terms of work and leisure time. As with other urinary diversions, almost all activities can be resumed. However, as with the ileum conduit, avoid excessive strain on the abdominal muscles for the first three months.

The elimination of the intestinal segments can lead to a long-term vitamin B12 deficiency. Blood tests are therefore necessary from the fifth postoperative year onwards. This allows a vitamin deficiency to be detected and compensated for by injections.

Follow-up treatment for orthotopic Mainz pouch I

For 2 to 3 weeks

  • a permanent catheter in the urethra and
  • an abdominal wall catheter

to drain the pouch. As with the continent pouch with a skin stoma, urine is drained into a bag during this time.

The initial course is the same as for a continent pouch with a skin stoma: the patient must flush the pouch at certain intervals. The pouch is then checked as an inpatient and the catheter is removed.

After urinating, the urine remaining in the pouch can be emptied and measured via the remaining abdominal wall catheter. If there is 50 to 70 ml of residual urine, the abdominal wall catheter is also removed.

Initially, it is best for the patient to urinate in a sitting position. He may have to push with his stomach to empty the bladder completely. Occasionally, patients may leak some urine at night or have to empty the pouch with a catheter through the urethra.

Initially, emptying must be carried out every 3 to 4 hours, even at night. Later, the intervals between voiding can be extended.

In terms of nutrition, aftercare, work and leisure, the course of the procedure is the same as for continent Mainz pouch I with a skin stoma (see above).

Follow-up treatment for Mainz pouch II (connection to the rectum)

Immediately after discharge, the patient feels the urge to defecate when the pouch empties into the rectum at certain intervals. It should then be emptied as with normal bowel movements.

During follow-up care, blood gas analyses (see section "Follow-up treatment for Mainz pouch I with umbilical stoma") are required to detect and treat hyperacidity of the blood and ultrasound examinations of the kidneys to rule out dilation of the renal pelvic cavity system.

With this form of urinary diversion, there is a risk of pyelonephritis with fever. Renal pelvic inflammation must be treated as an inpatient.

After the fifth postoperative year, regular endoscopies of the rectum and the pouch are required. This allows changes or tumors to be detected in good time. The further course is essentially the same as the previous one.

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