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Ostomy 2.2 > Lessons 18-21: Urinary Diversion In Adults > Flashcards

Lessons 18-21: Urinary Diversion In Adults Flashcards

1
Q

Bladder Cancer - Risk Factors

A
  • Male > female
  • Smoking
  • Exposure to industrial carcinogens
    — Dye, rubber, petroleum, textiles
  • Long-term in-dwelling catheter
  • Bilharzia parasite
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2
Q

Bladder Cancer - Clinical Presentation

A
  • Hematuria (macro or microscopic)
  • Irritative voiding symptoms
    — Like UTI but no infection
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3
Q

Bladder Cancer - Pathology

A

Lesions begins at mucosal layer and infiltrate bladder wall in stepwise fashion

Mucosa → submucosa → muscularis → perivesical fat → lymph nodes → distant organs

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4
Q

Bladder Cancer - Diagnostics

A
  • CT scan with contrast
  • Urine cytology
  • Cystoscopy with biopsy
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5
Q

Bladder Cancer Classifications

A

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

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6
Q

Bladder Cancer - Male Surgical Approach

A

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

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7
Q

Bladder Cancer - Female Surgical Approach

A

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
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8
Q

Pelvic Cancer - Anterior Exenteration

A
  • 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

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9
Q

Pelvic Cancer - Posterior Exenteration

A
  • 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

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10
Q

Pelvic Cancer - Total Pelvic Exenteration

A
  • 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

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11
Q

Benign Indications - Neurogenic Bladder

A

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

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12
Q

Benign Indications - Radiation Cystitis

A
  • 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

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13
Q

Benign Indications - Interstitial Cystitis

A

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

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14
Q

Benign Indications - Severe Pelvic Trauma

A

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

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15
Q

Benign Indications - Fistulas

A
  • Colovesical or vesicovaginal
  • Diversion can promote healing or prevent infection
  • Bladder left in place
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16
Q

Ureterostomy

A

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

17
Q

Ureterosigmoidostomy

A

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

18
Q

Ileal Conduit

A

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

19
Q

End stoma vs loop end stoma

A

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

20
Q

Complications - Prolonged Ileus

A
  • NG tube used early post-op
  • Sham feeding with chewing gum to promote peristalsis
  • Gradual diet advancement
  • Limited opioid use
  • Early ambulation
21
Q

Complications - Small Bowel Obstruction

A
  • NG for decompression
  • IV fluid hydration
  • Back to OR if no response to medical management
22
Q

Complications - Bowel Leak

A
  • CT to identify leak/fluid collection/abscess formation
  • CT-guided placement of drain to manage intra-abdominal fluid
  • Surgical correction of anastomotic dehiscence
23
Q

Complications - Urine Leak

A
  • 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
24
Q

Complications - UTI

A
  • 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

25
Q

Complications - Metabolic Abnormalities

A

Uncommon d/t minimal contract between urine and bowel mucosa

Ileal and colonic conduit
- Hyperchloremia
- Hypokalemia
- Metabolic acidosis

Jejunum conduit
- Hyponatremia
- Hyperkalemia
- Metabolic acidosis

26
Q

Complications - Renal Calculi

A

Proximal ileal staple line can be site of stone formation

S/S
- Hematuria
- Flank pain
- N/V

Prevention
- Constant high volume fluid intake
- Prompt treatment of UTI
- Calcium/oxalate stones = keep urine acidic
- Urine acid stones = keep urine alkaline

Management
- Medicate for N/V and pain
- Lithotripsy +/- surgical resection

27
Q

Complications - B12 Deficiency

A

Terminal ileum only site for B12 + bile salt absorption

Risk factors
- Age
- DM2
- Opioid use
- Use of PPIs
- Smoking

Routine monitoring and initiate replacement PRN

28
Q

Complications - Chronic Renal Insufficiency

A
  • Can occur with chronic and poorly managed UTI
  • Can also be caused by ureteral strictures
  • Can obstruct and damage upper tract
29
Q

Complications - Ureteral Strictures

A
  • Potential complication d/t narrow lumen diameter
  • Scarring at uretero-ileal anastomosis

Prevention
- Stents for patency
- Removed 2-3 weeks post-op
- Strictures can be dilated with endoscopy
- Rarely surgically corrected

30
Q

Preoperative Counselling

A
  • Need to remove/bypass bladder d/t cancer or dysfunction
  • Creation of new path for urine elimination
  • Describe urostomy procedure
    —Segment of bowel removed to create pathway
    — Ureters connected to bowel segment
    — One end closed, other to surface
    — No storage of urine
  • Sexual counseling critical
31
Q

Postoperative Assessment

A
  • Stoma viability
  • Colour and clarity of urine
  • Hematuria normal, but urine should still be transparent
  • Mucous normal d/t uretero-intestinal anastomosis
  • Output should be from stents and stoma only
  • If surgical drain present, should be serosang
    — If increased drain volume and decreased stoma output
    — ?uretero-ileal leak
32
Q

Ureteral Stents

A
  • Supports anastomosis until edema resolves
  • Helps prevent strictures
  • Stents externalized for removal
  • Irrigation possible but not usual
    — If ordered, sterile technique and 3-5 mls only
33
Q

Conduit Stent

A
  • Red rubber catheter sutured to skin
  • Maintains urine flow until stomal edema subside
  • Usually removed 3-5 days postop
34
Q

Ileal Conduit - Pouching System

A
  • When ⅓-½ full
  • Urinary pouch with anti-reflux valve preferred
    — Directs urine away from skin
  • 1-piece vs 2-piece
    — Consider patient preference and ability to attach pouch to flange
    — 2 piece preferred when stents in place
    — Convex pouch for stoma in valley or skin-level stoma
35
Q

Ileal Conduit - Pouch Change

A
  • Usually 1-2 times/week
  • Best time either early in am or 2 hours post-intake
  • Hand hygiene critical
  • Standard approach to removal and change
36
Q

Ileal Conduit - Overnight Management

A
  • Large volumes produced overnight
  • 500 - 1000 mls
  • Can get up during the night to empty
  • Can use night drainage system
  • Connect pouch to jug via adaptor
  • Ensure urine in pouch prior to connecting
  • Clean bag/jug with 1:3 vinegar:water
37
Q

Ileal Conduit - Diet + Fluids

A

No restriction
- High volume fluid intake critical
- 30 mls/kg/day

Odor control
- Avoid smelly foods (ie. asparagus or fish)
- Keep urine dilute and acidic

38
Q

UTI

A

Significant concern d/t loss of anti reflux protection
Risk increases if urine is concentrated and/or alkaline

S/S
- Malaise
- Flank plain
- N/V
- Fever
- Cloudy Rubin
- Malodorous urine

Diagnosed with C+S
- Only if patient is symptomatic
- Either catheterized with sterile technique or drip collect

Treat only if colony counts >100,000

39
Q

Renal Calculi

A

Increased risk if
- Hx of calculi
- Metabolic or renal disease
- Concentrated urine
- Inadequate fluid intake
- Immobility/paralysis d/t demineralization of bones
- Recurrent UTIs

Treatment
- adequate fluid intake
- prompt treatment of UTI
- hydration
- Rx for pain + nausea

Ostomy 2.2 (15 decks)

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