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Female Urology

General Urology

Genitourinary Reconstruction

Men’s Sexual Health

Microsurgery (Infertility)

Minimally Invasive Therapies

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Kdiney Stones

Urinary Diversion

Urinary Incontinence

Urologic Oncology

Uropathology

Urinary Diversion:

This is what occurs when urine needs to be temporarily diverted because of urinary obstruction and/or infection. This is usually performed by inserting a Ureteral stent or by performing a percutaneous nephrostomy which are described below:

URETERAL STENTS

What is a Ureteral Stent?

A stent is a narrow, hollow plastic tube that runs between the kidney and bladder, inside of the conduit that normally carries urine between those organs called the ureter. The stent functions to hold the ureter open and allow drainage of urine and allows the kidney to function properly.

Why are they used?

There are a variety of reasons why a stent has been placed. For patients undergoing stone surgery .the stent allows passage of residual fragments without blocking the ureter. Patients who have had ureteroscopy (a look up the ureter) have a stent placed to allow the ureter to remain open while the normal postoperative swelling of the ureter resolves. Patients who have had any form of surgery on the ureter have a stent placed to allow healing of the ureter in the proper open fashion.

The stent is held in place by its design, which incorporates "pig tail" spiraling where it is located in the kidney and bladder. Occasionally, a blue suture is attached to the end of the stent and comes out of the body through the urethra ( the urine tube leading from the bladder outside the body. If you have such a blue string present, under no circumstances pull on it, as it will cause the stent to become dislodged. Be especially careful when bathing, not to catch the string on the terry cloth towel.

 Plastic Ureteral Stents: One end coils in the kidney the other in the bladder

 

Drawing of stent in kidney and bladder:

Percutaneous Nephrostomy (Upper Urinary Tract Diversion):

Urine is diverted by placing a tube through the skin of the patient’s flank into the kidney. This is usually performed under local anesthesia and with sonographic or radiographic guidance.

Skin appearance
of percutaneous
nephrostomy:

What is permanent urinary diversion?

When the urinary bladder is removed (due to cancer, other medical condition, or because the organ no longer works), another method must be constructed for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way for urine to exit the body.

For all of these procedures, a portion of the small and/or large intestine is disconnected from the gastrointestinal (fecal) stream and used for reconstruction.

ILEAL CONDUIT: This reconstruction includes removing an approximately 8 inch segment of small intestine, which will remain on its vascular stalk to insure a continuous blood supply. The gap in the remaining small intestines is reconnected, and one of the open ends of the removed 8 inch segment is closed. The ureter(s) will be connected to the free segment of intestine or "conduit" at the side of the closed end. Finally, the open end of the segment is connected to the skin as an opening, or stoma, at the lower aspect of the abdomen. Urine will continuously drain from the stoma, so it is necessary to wear an appliance to collect it. The appliance sac will need to be emptied manually approximately 3-4 times per day. At nighttime, individuals can connect their appliance sac to a larger collection bag, obviating the need to empty their urine during sleep. The urinary conduit is the simplest of the 3 reconstructions, and has the lowest rate of complications.

typical abdominal appearance of the stoma Bladder Cancer

Ileal loop and stoma

CATHETERIZABLE STOMA: A modification of the urinary conduit, the catheterizable stoma enables an individual to excrete urine from their stoma without the need for an external appliance. The stoma is modified into a one-way valve so that urine cannot leak out. Usually , a larger segment of large intestine is removed, and fashioned into a reservoir or "pouch" for holding approximately pint of urine. By inserting a rubber catheter into the stoma, urine is easily drained from the reservoir. This reconstruction requires individuals to have a level of dexterity and self-motivation to perform the catheterization several times each day. Unlike the urinary conduit, individuals cannot connect their stoma to a larger drainage sac at night, but rather must awaken at least once to empty their reservoir.

NEOBLADDER: The most technically complex reconstruction results in no external device but rather connects the intestinal reservoir to the urethra (the tube that exits urine naturally from the body). The neobladder is cosmetically attractive. This operation is far more complex for several reasons. First, the connection of the reservoir to the urethra is technically more difficult since it is deep within the pelvis. The complexity of this connection may lead to complications such as scarring leading to urinary retention; or internal leakage leading to urine collections that can become infected. Additionally, because the removal of the bladder includes part of the urinary sphincter responsible for continence, it is possible that there will be significant urinary leakage or frank incontinence. Also because the intestinal reservoir does not have the same innervation and musculature as does the bladder, the ability of the reservoir to contract and therefore excrete the urine is fairly limited. Because of this potential scenario, individuals must be motivated in and capable of performing self-catheterization through their native(original) urethra. Nevertheless, in most cases careful training and rehabilitation teach individuals to exert internal abdominal pressures in order to excrete urine. It should be noted that the extent of local bladder cancer may impact on the safety and efficacy of this reconstruction from a cancer-control standpoint.

Here is the internal view of a neobladder. Intestine has been made into a pouch and the ureters are connected to the top while the pouch itself is connected to the urethra

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