Urinary Diversions

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Urinary Diversions
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• Urinary diversion
• to divert urine from the bladder to a new exit
  site
• Usually through a surgically created opening
  (stoma) in the skin

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Indications

• Tumour necessitating removal of entire bladder
• Pelvic malignancy
• Birth defects
• Strictures
• Trauma to ureters and urethra
• Neurogenic bladder
• Chronic infection causing severe uretral and
  renal damage
• Intractable interstitial cystitis and
• Incontinence

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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

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Complications of ileal conduit

• Wound infection
• Wound dehiscence
• Urinary leakage
• Ureteral obstruction
• Hyperchloremic acidosis
• Small bowel obstruction
• Ileus
• Stomal gangrene
• Ureteral obstruction
• Narrowing of the stoma
• Renal deterioration due to chronic reflux
• Pyelonephritis
• Renal calculi

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• Cutaneous Ureterostomy
• Stoma flush with the skin or retraction
• Other cutaneous urinary diversions suprapubic
  cystostomy, nephrostomy

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Cutaneous Ureterostomy
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Vesicostomygo to the next
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Nephrostomy
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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

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Koch Pouch II
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ureterosigmoidostomy
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• 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

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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

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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
• Vleeding
• Encrustation
• Wound infections

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• Postoperative nursing interventions
• Monitor urinary function
• Prevent complications
• infection, sepsis, respiratory, complications,
  fluid and electrolyte imbalances, fistula
  formation.
• Ryles 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

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• 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

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• 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

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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 31
  solution of water and white vinegar
• Continuing care look for metastases

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• 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 CS 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

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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 drainag bag
• Ascorbic acidifies suppresses odour
• Aspirin introduced into bag to deodorize may
  cause ulceration of the stoma

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

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