Selected patients with lower urinary tract cancers or severe functional or anatomic abnormalities of the bladder may require urinary diversion. Although this can be accomplished by establishing direct contact between the urinary tract and the skin surface, it is most often performed by incorporating various intestinal segments into the urinary tract. Virtually every segment of the gastrointestinal tract has been used to create urinary reservoirs or conduits. No single technique is ideal for all patients and clinical situations. The decision is based on a patient’s underlying disease and optimal method of treatment as well as on renal function, individual anatomy, and personal preference. An ideal method of urinary diversion would most closely approximate the normal bladder; it would be nonrefluxing, low-pressure, continent, and nonabsorptive.
Individual methods of urinary diversion can be categorized in various ways, such as by (1) the segment of intestine used and (2) whether the method provides complete continence or simply acts as a conduit carrying urine from the renal pelvis or ureter to the skin, where the urine is collected in an appliance attached to the skin surface. Continent forms of urinary diversion can be categorized further according to whether they are attached to the urethra (ie, as a bladder substitute) or are placed in the abdomen and rely on another mechanism for continence (continent urinary reservoir).
PREOPERATIVE COUNSELING AND PREPARATION
All candidates for urinary diversion and bladder substitution should undergo careful preoperative counseling and preparation, including a detailed discussion of the goals and potential complications of each method. Any potential impact of a procedure on sexual function, body image, and lifestyle should be discussed. Overall satisfaction of most patients undergoing urinary diversion appears to be high (Allareddy et al, 2006; Dutta et al, 2002; Fujisawa et al, 2000; Hara et al, 2002). However, because they allow freedom from an external appliance, continent forms of urinary diversion, especially bladder substitution, may be of great psychological and functional benefit to well-selected patients (Bjerre et al, 1995; Okada et al, 1997). More recent data suggest that the differences in quality of life between continent and noncontinent diversion may not be as significant as previously predicted (Gilbert et al, 2007).
A careful history taken from the patient should note any previous abdominal or pelvic surgery, irradiation, or systemic disease. A history of intestinal resection or irradiation, renal insufficiency, diverticulitis, regional enteritis, or ulcerative colitis would be especially important to consider when selecting a method of urinary diversion or bladder substitution. A complete blood count and measurement of serum electrolytes, urea nitrogen, and creatinine should be performed. The upper urinary tract should be imaged with ultrasound or computed tomography to determine whether hydronephrosis, renal parenchymal scarring, or calculous disease exists. Contrast imaging of the small or large bowel or colonoscopy should be considered preoperatively for patients with a history of significant intestinal irradiation, occult bleeding, or other gastrointestinal diseases. ...