Temporary Urinary Diversion:
This is what occurs when urine needs to be temporarily diverted because of
urinary obstruction and/or infection. This is usually performed by inserting a
Ureteral stent or by performing a percutaneous nephrostomy which are
described below:
URETERAL STENTS
What is a Ureteral Stent?
A stent is a narrow, hollow plastic tube that runs between the kidney and
bladder, inside of the conduit that normally carries urine between those
organs called the ureter. The stent functions to hold the ureter open and
allow drainage of urine and allows the kidney to function properly.
Why are they used?
There are a variety of reasons why a stent has been placed. For patients
undergoing stone surgery .the stent allows passage of residual fragments
without blocking the ureter. Patients who have had ureteroscopy (a look up
the ureter) have a stent placed to allow the ureter to remain open while the
normal postoperative swelling of the ureter resolves. Patients who have had
any form of surgery on the ureter have a stent placed to allow healing of the
ureter in the proper open fashion.
The stent is held in place by its design, which incorporates "pig tail"
spiraling where it is located in the kidney and bladder. Occasionally, a blue
suture is attached to the end of the stent and comes out of the body through
the urethra ( the urine tube leading from the bladder outside the body. If you
have such a blue string present, under no circumstances pull on it, as it will
cause the stent to become dislodged. Be especially careful when bathing, not
to catch the string on the terry cloth towel.
Bottom of Form
Pow erPoint Slide for Teaching
Plastic Ureteral Stents: One end coils in the kidney the other in the bladder
Drawing of stent in kidney and bladder:
Percutaneous Nephrostomy (Upper Urinary Tract Diversion):
Urine is diverted by placing a tube through the skin of the patient’s flank
into the kidney. This is usually performed under local anesthesia and with
sonographic or radiographic guidance.
Cartoon depicting tube in kidney diverting urine from the bladder:
Skin appearance of percutaneous nephrostomy:
What is permanent urinary diversion?
When the urinary bladder is removed (due to cancer, other medical
condition, or because the organ no longer works), another method must be
constructed for urine to exit the body. Urinary reconstruction and diversion
is a surgical method to create a new way for urine to exit the body.
There are three main types of permanent urinary diversion surgeries:
Ileal Conduit Urinary Diversion
Indiana Pouch Reservoir
Neobladder to Urethra Diversion
For all of these procedures, a portion of the small and/or large intestine is
disconnected from the gastrointestinal (fecal) stream and used for
reconstruction.
ILEAL CONDUIT: This reconstruction includes removing an approximately
8 inch segment of small intestine, which will remain on its vascular stalk to
insure a continuous blood supply. The gap in the remaining small intestines
is reconnected, and one of the open ends of the removed 8 inch segment is
closed. The ureter(s) will be connected to the free segment of intestine or
"conduit" at the side of the closed end. Finally, the open end of the segment
is connected to the skin as an opening, or stoma, at the lower aspect of the
abdomen. Urine will continuously drain from the stoma, so it is necessary to
wear an appliance to collect it. The appliance sac will need to be emptied
manually approximately 3-4 times per day. At nighttime, individuals can
connect their appliance sac to a larger collection bag, obviating the need to
empty their urine during sleep. The urinary conduit is the simplest of the 3
reconstructions, and has the lowest rate of complications.
typical
abdominal
appearance
of the stoma
Ileal loop and stoma
CATHETERIZABLE STOMA: A modification of the urinary conduit, the
catheterizable stoma enables an individual to excrete urine from their stoma
without the need for an external appliance. The stoma is modified into a oneway valve so that urine cannot leak out. Usually , a larger segment of large
intestine is removed, and fashioned into a reservoir or "pouch" for holding
approximately pint of urine. By inserting a rubber catheter into the stoma,
urine is easily drained from the reservoir. This reconstruction requires
individuals to have a level of dexterity and self-motivation to perform the
catheterization several times each day. Unlike the urinary conduit,
individuals cannot connect their stoma to a larger drainage sac at night, but
rather must awaken at least once to empty their reservoir.
NEOBLADDER: The most technically complex reconstruction results in no
external device but rather connects the intestinal reservoir to the urethra (the
tube that exits urine naturally from the body). The neobladder is
cosmetically attractive. This operation is far more complex for several
reasons. First, the connection of the reservoir to the urethra is technically
more difficult since it is deep within the pelvis. The complexity of this
connection may lead to complications such as scarring leading to urinary
retention; or internal leakage leading to urine collections that can become
infected. Additionally, because the removal of the bladder includes part of
the urinary sphincter responsible for continence, it is possible that there will
be significant urinary leakage or frank incontinence. Also because the
intestinal reservoir does not have the same innervation and musculature as
does the bladder, the ability of the reservoir to contract and therefore excrete
the urine is fairly limited. Because of this potential scenario, individuals
must be motivated in and capable of performing self-catheterization through
their native(original) urethra. Nevertheless, in most cases careful training
and rehabilitation teach individuals to exert internal abdominal pressures in
order to excrete urine. It should be noted that the extent of local bladder
cancer may impact on the safety and efficacy of this reconstruction from a
cancer-control standpoint.
Here is the internal view
of a neobladder. Intestine
has been made into a
pouch and the ureters are
connected to the top
while the pouch itself is
connected to the urethra