Lesson 34: Continent Urostomy

Question 1

Continent Urostomy - Definitions

Answer 1

creation of internal pouch connected to abdominal wall with one-way catheterizable channel
- Ureters connected to pouch
- Managed by intermittent catheterization
- Internal pouch created from detubularized loops of bowel
- Ureters connected to reservoir
- Continent provided via one-way valve between reservoir and abdomen
- Managed via catheterization at routine intervals

Question 2

Continent Urostomy - Pros + Cons

Answer 2

Pros
- No external pouch
- No pouching problems

Cons
- Need for routine catheterization
- Potential for difficult intubations
- Failure of continence mechanism

Question 3

Indications/Criteria

Answer 3

Patient who requires urinary diversion d/t urothelial cancer or neurogenic bladder

Patient need sufficient cognition + hand-eye coordination to manage multiple catheterizations per day

No bowel disease

Question 4

Contraindications

Answer 4

• Insufficient healthy bowel to construct reservoir
• Hepatic or renal dysfunction
  — Need creatinine > 1.7
  — Can cause metabolic abnormalities
  — D/t constant exposure of urine to bowel mucosa
• Cognitive issues that limit ability to perform catheterizations

Question 5

Indiana or Miami Reservoir

Answer 5

• Reservoir constructed from detubularized cecum + ascending colon
• Reservoir is acontractile
• Ureters connected to reservoir
• Continence mechanism
  — Ileocecal valve + tapering of ileum
  — Creates narrow, supportive sleeve around catheterizable stoma
• Skin level stoma created from ileum
• Anastomosis is freely refluxing

Question 6

Koch Urostomy

Answer 6

• Reservoir constructed from 60 cm of ileum

Continence mechanism
- Intussusception of segmented bowel between abdo stoma and reservoir
- Ureters connected to ileal chimney at proximal end of pouch
- Bowel intussusception between ureters + pouch for anti-reflux protection

Question 7

Mitrofanoff

Answer 7

• Usually for neurogenic bladder management
• Appendicovesicostomy
• Bladder is the reservoir
  — Bladder is augmented to eliminate contractility
• Appendix is the catheterizable channel
  — Proximal end is tunneled into bladder
  — Distal end is brought to skin
  — If no appendix available, can use narrowed segments of bowel

Question 8

Preoperative Management

Answer 8

• Assure understanding of surgical options
• Assure understanding of lifelong need for pouch intubations
• Assure cognitive + psychomotor ability to perform intubation
• Stoma site marking

Question 9

Early Postoperative Management

Answer 9

Goals
- Keep pouch decompressed until suture/staple line healed
- Avoided repeated intubations until continence mechanism healed
- Protect ureterointestinal anastomosis

Strategies
- Large bore catheter placed into pouch at time of OR
— Left in place for 2-3 weeks
— Usually 24Fr Malecot
- Urethral stents are placed + externalizer
- 16Fr catheter placed through channel and into pouch
- Irrigations PRN for patency

Question 10

Late Postoperative Period

Answer 10

Goals
- Teach patient self care
- Gradually increase size of reservoir

Strategies
- Reservoir catheter removed once healing complete
- Frequency of intubation Q2H during days
- Must intubate on schedule + PRN

Question 11

Stoma Management

Answer 11

• Keep stoma covered with stoma cap or gauze with tape
• Protect periwound skin from moisture damage
• Treat minor skin irritation with crusting

Question 12

Invitation + Catheter Care

Answer 12

• Have 1-2 catheters on hand always
• Wash catheters with warm soapy water
• Carry in plastic bags
• Replace monthly + PRN if rough edges develop
• Routine follow-up for pouchoscopy

Question 13

Complications

Answer 13

• UTIs
• Metabolic Complications
• Pouchitis
• Stenosis
• Difficult Intubation