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