Lessons 18-21: Urinary Diversion In Adults Flashcards
Bladder Cancer - Risk Factors
- Male > female
- Smoking
- Exposure to industrial carcinogens
— Dye, rubber, petroleum, textiles - Long-term in-dwelling catheter
- Bilharzia parasite
Bladder Cancer - Clinical Presentation
- Hematuria (macro or microscopic)
- Irritative voiding symptoms
— Like UTI but no infection
Bladder Cancer - Pathology
Lesions begins at mucosal layer and infiltrate bladder wall in stepwise fashion
Mucosa → submucosa → muscularis → perivesical fat → lymph nodes → distant organs
Bladder Cancer - Diagnostics
- CT scan with contrast
- Urine cytology
- Cystoscopy with biopsy
Bladder Cancer Classifications
Low-grade, superficial tumors
- Confined to mucosa and submucosa
- Conservative management
- Intravesical chemo
- Cystoscopic resection
High-grade, recurrent, or muscle invasive
- Preop adjuvant chemo
- Surgical removal of bladder
Bladder Cancer - Male Surgical Approach
Male: radical cystoprostatectomy
- Prostate is continuous with bladder neck and proximal urethra
- Removal of prostate causes loss of ejaculatory function
- Can still orgasm, but its dry
- Nerve-sparing procedure usually done
Goal to preserve erectile function
Bladder Cancer - Female Surgical Approach
Female: radical cystectomy with hysterectomy, bilateral salpingooophectomy, and anterior vaginectomy
- Reproductive organs in close proximity to bladder and urethra
- Can preclude intercourse
- Removal of urethral meatus reduces blood flow to clitoris
Pelvic Cancer - Anterior Exenteration
- Cancer extending to bladder
- Removal of tumor, bladder, and urinary diversion
For females
- Removal of uterus, tubes, ovaries, and partial/total removal of vagina
- Vaginal reconstruction done during vaginectomy
Pelvic Cancer - Posterior Exenteration
- Cancer extending to rectum
- Removal of tumor and rectum with either
— Lower anterior resection with possible temp ostomy
— Abdominal perineal resection with permanent colostomy
Male: possible radical prostatectomy
Female: Removal of uterus, tubes, ovaries, and partial/total removal of vagina
Pelvic Cancer - Total Pelvic Exenteration
- Invasive cervical cancer, pelvic sarcoma, etc
- Removal of tumor, surrounding tissues, and lymph nodes
- Removal of rectum with possible fecal diversion
Male: cystoprostatectomy
Female: radical cystectomy with hysterectomy, bilateral salpingooophectomy, and anterior vaginectomy
Benign Indications - Neurogenic Bladder
Caused by neurological disorders
- Spinal cord injury
- Spina bifida
- MS
Results in intractable incontinence and/or retention
- Clean intermittent catheterization good management choice
- Only if good visual field or easy access
- If not, urinary diversion with intact bladder
Benign Indications - Radiation Cystitis
- Radiation to pelvis causing irreversible damage to bladder with sphincter
S/S
- Incontinence
- Bleeding frequency
- Pain with bladder filling
- Can be treated with HBOT
- Can also divert and bypass bladder
Benign Indications - Interstitial Cystitis
S/S
- Frequency
- Urgency
- Nocturnal
- Pain with bladder filling
Diagnostics
- Cystoscopy
- Humer’s ulcers
- Petechial hemorrhages
Management
- Medical
— Avoiding dietary irritants
- Rx
— NSAIDS
— Pentosan sulfate
— Intravesical dimethylsulfoxide
— Intravesical heparin
— Antihistamines
— Tricyclic antidepressants
- Surgical
— Diversion only for refractory cases
— May help with pain
— Bladder left intact
Benign Indications - Severe Pelvic Trauma
Urethral trauma causing scarring/strictures with chronic retention
- Suprapubic catheter vs urinary diversion
- SPC required routine changes
- SPC has increased risk for UTI, leakage and obstruction
Benign Indications - Fistulas
- Colovesical or vesicovaginal
- Diversion can promote healing or prevent infection
- Bladder left in place
Ureterostomy
Ureters disconnected from bladder and attached to skin
- Ureterostomy or transureteroureterostomy
Pros
- Simple procedure
Cons
- Stoma prone to stenosis
- Stoma location dictated by ureteral length and mobility
— May not be on flat surface
— Skin level stomas difficult to pouch
— Skin bacteria can migrate to renal pelvis
Ureterosigmoidostomy
Ureters implanted into sigmoid colon
- Rectum serves as reservoir for both urine and stool
Pros
- No external stoma or pouch
Cons
- High risk for UTI
- High risk for metabolic abnormalities
- High risk for incontinence
- Increase risk for adenocarcinoma at anastomotic site
Ileal Conduit
10-12 cm of bowel and mesentery isolated for conduit
- Bowel is resected
- Proximal end closed, distal end to surface as stoma
- Ureters are connected to segment
- Urine flows through ureters → conduit → stoma → pouch
- No reservoir function
Pros
- Large stoma with reduced risk for stenosis
- Can side stoma on flat pouching surface
- Reduced risk for UTI
Cons
- Difficult surgical procedure
End stoma vs loop end stoma
End stoma = standard approach
- Bowel inverted to form end stoma
Loop end stoma
- Best option for obese patient
- Loop of segment isolated and brought to surface
- Anterior wall of loop opened and surgically matured
- Ureters connected to proximal end of loop
— Distal end terminated in blind pouch
Complications - Prolonged Ileus
- NG tube used early post-op
- Sham feeding with chewing gum to promote peristalsis
- Gradual diet advancement
- Limited opioid use
- Early ambulation
Complications - Small Bowel Obstruction
- NG for decompression
- IV fluid hydration
- Back to OR if no response to medical management
Complications - Bowel Leak
- CT to identify leak/fluid collection/abscess formation
- CT-guided placement of drain to manage intra-abdominal fluid
- Surgical correction of anastomotic dehiscence
Complications - Urine Leak
- Placement of surgical drain intraoperatively adjacent to ureterostomy-ileal anastomosis
- Monitoring drain output to identify urine leak
- CT verification of leak
- Surgical correction if leak does not close spontaneously
Complications - UTI
- Ureterostomy-ileal anastomosis is freely refluxing
- No sphincter
- Risk for ascending bacteriuria
Best protecting is high volume fluid intake
Asymptomatic = no treatment
Symptomatic = culture and treat
S/S
- Malaise
- Fever
- Flank pain
- Nausea
- Malodorous urine
- Cloudy urine
