Urinary diversion

1. Urinary diversion

2. Introduction • Diversion of urinary pathway from its natural path • Types: • Temporary • Permanent

3. Indications of permanent urinary diversion • When the bladder has to be removed • When the sphincters of the bladder & the detrusor muscle have been damaged or have lost their normal neurological control • When there is irremovable obstruction in the bladder & distal to that • Ectopic vesicae • Incurable vesico- vagina fistula

4. Temporary urinary diversion • Suprapubic cystostomy • Pyelostomy or nephrostomy or urethrostomy (with indwelling catheters)

5. Illustration of suprapubic tube placed to aid bladder drainage

6. A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney.

7. Permanent urinary diversion • Uretero - sigmoidostomy • Ileal conduit • Colon conduit • Ileocaecaecal segment • Lowsley’s operation

8. Types of urinary diversions Cutaneous urinary diversions • Ileal conduit (ileal loop) • A 12 cm loop of ileum led out through abdominal wall • Stents used • The space at cystectomy site drained by a drainage system • After surgery a skin barrier and a transparent disposable urinary drainage bag • Constantly drains

10. Complications of ileal conduit • Wound infection • Wound dehiscence • Urinary leakage • Ureteral obstruction • Small bowel obstruction • Ileus • Stomal gangrene • Narrowing of the stoma • Pyelonephritis • Renal calculi

11. Cutaneous Ureterostomy…

12. Vesicostomy

13. Nephrostomy…

14. Uretero- sigmoidostomy • Complications: • Reflux of urine • Hyperchloraemic acidosis • Renal infection • Stricture formation

15. Continent Urinary Diversions • Continent Ileal Urinary Reservoir Indiana Pouch • Most common continent urinary diversion • Periodically catheterized Koch Pouch Charleston Pouch Ureterosigmoidostomy • Voiding occurs from rectum

18. Koch Pouch II

19. ureterosigmoidostomy

20. Potential complications • Peritonitis due to disruption of anastomosis • Stomal ischaemia and necrosis due to compromised blood supply to stoma • Stoma retraction and separation of mucocutaneous border due to tension or trauma

22. Bladder reconstruction

23. Recto sigmoid pouch

24. Nursing process : The patient undergoing urinary diversion surgery Preoperative assessment : • Cardiopulmonary assessment • Nutritional assessment • Learning capcity assessment Preoperative nursing diagnosis • Anxiety • Knowledge deficit Preoperative planning and goals • Relief of anxiety • Ensuring adequate nutrition • Explaining surgery and its effects

25. Nursing Management • In the immediate postoperative period urine volumes are monitered hourly • An output below 30 ml/h dehydration or obstruction • Promote urine output – a catheter may be inserted through urinary conduit • Provide stoma and skin care – consult with enterostomal therapist • Skin care specialist consulted • Stoma looked for color – dark purplish –blood supply compromised • Skin inspected for irritation • Bleeding • Wound infections

26. Postoperative nursing interventions • Monitor urinary function • Prevent complications infection, sepsis, respiratory, complications, fluid and electrolyte imbalances, fistula formation. • Ryle’s tube aspiration • Ambulate quickly • Maintain peristomal integrity • Relieve pain • Improve body image • Exploring sexuality issues • Treat peritonitis • Look for stomal ischaemia and necrosis • Look for stomal retraction and separation

27. Neomycin, kanamycin • Immediately after operation – catheter in rectum – to prevent reflux into ureters and infection of the newly formed ureteric opening into the intestines • Monitoring fluid and electrolytes : intestinal mucosa absorb urine water and electrolytes; diarrhoea due to potassium and magnesium; maintain the balance. Pt advised to empty the rectum every 2 hours to ↓ build up of pressure and thereby the absorption of urinary salts • Retrain the rectum – special sphincteric exercises – learn the differentiate between the need to defaecate and the need to urinate

28. Promoting dietary measures – avoid chewing gum, smoking. • Salt intake restricted to prevent hyperchloremic acidosis. Potassium increased to make up for potassium lost in acidosis • Monitoring and managing potential complications : - pyelonephritis due to reflux of bacteria from rectum – long term antibiotics – late complication due to irritation - adenocarcinoma

29. Managing ostomy appliance • Empty the pouch when 1/3 full to prevent weight pulling down • A small amount of urine is left to prevent collapse of the bag against itself • The collecting bottle and tubing is rinsed with cold water daily and once in a week with a 3:1 solution of water and white vinegar • Continuing care – look for metastases

30. Look for leakage of urine from the appliance • Urine pH is kept below 6.5 by administration of ascorbic acid • Appliance to be fitted properly to prevent skin from getting irritated by urine • If the urine is foul smelling C&S done • Ileal conduit – mucosa – mucus produced – urine gets mixed with mucus – patient encouraged to take lot of fluid to wash out the mucus. • Appliances : reusable or disposable • Skin barrier used to protect skin from urine

31. Promoting home and community care • Teach patients self care • Control odour : food that gives odour to urine avoided e.g. Cheese, eggs • Deodorizers or dilute white vinegar introduced into the drainage bag • Ascorbic – acidifies – suppresses odour • Aspirin introduced into bag to deodorize may cause ulceration of the stoma

32. Home and community care • Teaching self care • Continuing care

33. Future aspects • More than 40 variants of continent diversion, no single best technique • Which bowel segment ? • Which continent technique ? • Which anti-reflux technique ? Only long term follow up can answer these questions