Incontinent Urinary Diversions
Urinary diversion, defined as rerouting of urine from a normal intact urinary tract, can be classified as either incontinent or continent. Incontinent diversion allows for the free flow of urine outside of the body, which can be collected into an external ostomy appliance.1,2 Incontinent urinary diversions are performed much more often than continent ones, particularly in patients with complex medical or surgical histories and/or those that have a history of previous radiotherapy.3,4
Ureterosigmoidostomy, first performed in 1851 by John Simon, was the first widely used surgical technique for urinary diversion, providing an effective diversion that relied on the anal sphincter for continence. However, its usefulness is limited by deterioration of renal function over time, metabolic complications, and the increased risk for the development of secondary malignancies. Subsequently, substantial progress has been made by incorporating innovative techniques that use isolated bowel segments as either urinary conduits or continent reservoirs and effectively separates the fecal and urinary streams. In the 1950s Bricker used a segment of ileum to which the ureters were anastomosed and a stoma created in the right lower abdomen. The ileal conduit (IC) has subsequently become the gold standard for incontinent urinary diversion.1,2 Cutaneous ureterostomy, which has been used sparingly in adults due to surgeon concern for ureteral obstruction,5 is the simplest method of all permanent urinary diversions. However, there are risks of stomal stenosis requiring intubation and pyelonephritis.6,7
In this chapter, the most commonly used reconstructive options of incontinent urinary diversion will be discussed, as well as indications and clinical applications, anatomic considerations, surgical procedures, postoperative care, and long-term outcomes.
INDICATIONS AND CLINICAL APPLICATIONS
There are a variety of choices for incontinent urinary diversions (IC, colon conduit [CC], and cutaneous ureterostomy). The choice is determined by patient and medical criteria. Important patient criteria are patient preference, age, comorbidities, body mass index (BMI), and the ability and motivation to perform intermittent self-catheterization. Further considerations are the condition of the segment of bowel to be used, kidney function/upper urinary tract status, and the overall medical condition of the patient. The choice of urinary diversion still remains a very personal decision to be made between the patient, family members, and the physician.8
IC urinary diversion remains the gold standard for incontinent urinary reconstruction. Although the introduction of continent urinary diversions has decreased the proportion of these procedures performed, they remain the most common form of urinary diversion.4 It is a procedure that is obligated for patients with a short life expectancy, reduced kidney function, and for those who cannot manage a continent diversion. Due to the relative ease of formation and shorter operative time, an IC is often used in patients with significant medical comorbidities in an attempt to ...