Urinary diversion is any one of several surgical procedures to reroute urine flow from its normal pathway.

It may be necessary for diseased or defective ureters, bladder or urethra, either temporarily or permanently. Some diversions result in a stoma.

An ileal conduit urinary diversion is a surgical technique usually referred to as the Bricker ileal conduit after its inventor, Eugene M. Bricker. It was developed during the 1940s and is still one of the most used techniques for the diversion of urine after a patient has had their bladder removed, due to its low complication rate and high patient satisfaction level. It is usually used in conjunction with radical cystectomy in order to control invasive bladder cancer. To create an ileal conduit, the ureters are surgically resected from the bladder and a ureteroenteric anastomosis is made in order to drain the urine into a detached section of ileum (a part of the small intestine). The end of the ileum is then brought out through an opening (a stoma) in the abdominal wall. The urine is collected through a bag that attaches on the outside of the body over the stoma. The bag must be periodically emptied of urine, and must be replaced every one or two days. Any period longer than this poses the risk of infection. Another and very effective use of an ileal conduit is for systemic isolation of a kidney transplant, often due to bladder nephropathy that may pose an unacceptable risk of reflux and thus infection or obstruction, into the transplanted organ. The urostomy is fashioned as previously described and connected ureteroenteric anastomosis to the transplant ureter. Urinary tract infections are unfortunately very common because stomas are natural colonisers of bacteria; in transplant patients, antibiotic treatment, often over a long term and more frequent appliance changes are effective but not curative countermeasures. The bag adheres to the skin using a disk made of flexible, adherent materials. Unfortunately, there can be problems with leaking and rashes (excoriation), and heavy physical exertion will exacerbate deterioration of the appliance. Sometimes the leakage occurs unexpectedly, and "ostomates" (as they are known) usually carry a spare appliance to deal with unexpected emergencies. An Indiana pouch is a surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed as a result of bladder cancer, pelvic exenteration, bladder exstrophy or who are not continent due to a congenital, neurogenic bladder. This particular urinary diversion results in a continent reservoir that the patient must catheterize to empty urine. This concept and technique was developed by Drs. Mike Mitchell, Randall Rowland, and Richard Bihrle at Indiana University.[1] With this type of surgery, a reservoir, or pouch, is created out of approximately two feet of the ascending colon and a portion of the ileum (a part of the small intestine). The ureters are surgically removed from the bladder and repositioned to drain into this new pouch. The end of the segment of small intestine is brought out through a small opening in the abdominal wall called a stoma. Since a segment including the large and small intestines is utilized, also included in this new system is the ileal-cecal valve. This is a one-way valve located between the small and large intestines. This valve normally prevents the passage of bacteria and digested matter from

re-entering the small intestine. Originally, it was thought that removing the ileal-cecal valve from the digestive tract would likely result in diarrhea, but this has not shown to be the case. After a period of several weeks, the body adjusts to the absence of this valve (from the digestive tract) by absorbing more liquids and nutrients. Importantly, this valve, in its new capacity, will now effectively prevent the escape of urine from the stoma. Patients can usually expect a hospital stay of between seven and ten days for this surgery. The abdominal incision for this surgery may be up to eight inches in length and is typically closed with staples on the outside and several layers of dissolvable stitches on the inside. After surgery, patients will have a three drainage tubes place while tissues heal: one through the newly-created stoma, one through another temporary opening in the abdominal wall into the pouch, and an SP tube (to drain non-specific post-surgical abdominal fluid). In the hospital, the SP tube and external staples will be removed, after several days. The remaining two tubes will each be connected to collection bags worn on each leg and the patient is usually sent home like this. After sufficient healing, and another doctor's visit, the tube will be removed from the stoma. The patient will now begin to catheterize the pouch every two hours. Since one other tube will still be in place, patients can still sleep through the night, since a larger collection bag is attached to that tube at night time. After approximately one month, patients will return to the hospital for a special x-ray. Dye will be instilled into the pouch to verify that there is no leakage of urine. If there is no leakage, this last tube will be removed. Emptying time now may be increased to 3 hours, however, now the patient will need to wake up during the night (every 3 hours) to empty the pouch. Over time, emptying time can increased up to 46 hours. The pouch will continue to expand and will reach its final size at approximately six months. The pouch will then hold up to 1,200 cubic centimeters (cc). Each day, the pouch will need to be irrigated with 60 cc of sterile water. This removes mucus, salts, and bacteria. If consumption of liquids is reduced in the evening, patients should be able to sleep through the night after approximately six months. In contrast to other urinary diversion techniques, such as the Ileal conduit urinary diversion, the Indiana pouch has the advantage of not using an external pouch adhered to the abdomen to store urine. This can result in a better body image and broader clothing options. Also, there will not be the worry of an external appliance coming loose and leaking. Additionally, the cost of urostomy appliances can be significant, and is usually not covered in full by most health insurance plans. Nor will there be the need to monitor how many appliances are left or ordering more and waiting for them to be shipped. Indiana pouch surgery can be done in very young patients, as long as they understand how to catheterize the pouch and can empty the pouch on a schedule. Indiana pouch surgery also has been successful in patients of advanced ages, also as long as they are able to empty and irrigate the pouch on a schedule. Some patients, after having had an ileal conduit, requiring an external appliance, have opted to have the Indiana pouch, as elective surgery. Such a surgery is usually recommended, if possible, since it has been documented that the Indiana pouch may reduce the possibility of kidney damage because the ureters are repositioned lower in the abdomen. This positioning reduces the possible back-flow of urine to the kidneys. After having an Indiana pouch surgery, patients may choose to wear a medical alert medallion indicating they have an Indiana pouch.

There are three main types of urinary diversions which are described below: Ileal Conduit Urinary Diversion The ileal conduit is the oldest and simplest form of urinary diversion. This is composed of a short part of ileum (small intestine) into which the ureters drain freely. The end of this ileal segment is brought out to the skin, usually in the right side of the stomach. This is called a stoma. The stoma is covered by a bag, which catches the urine as it drains from the ileal conduit. Advantages:

Shorter surgery time Shorter recovery time No need for intermitten catheterization Least risk of complications

Disadvantages:

External bag with possible leakage and odor. Urine back-up (reflux) to kidneys, leading to possible infections, stones and kidney damage over time.

Indiana Pouch Reservoir City of Hope is one of the leaders in Indiana pouch urinary diversions and have been performing this type of continent urinary diversions for many years. In this form of urinary diversion, a reservoir (pouch) is constructed out of the right colon (large intestine) and a small segment of ileum (small intestine). A short piece of small intestine is brought out to the skin as a small stoma. A one way valve mechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the skin. A bag is not required and the patient simply wears a bandage over the stoma. At specific times during the day, usually every four to six hours, the patient passes a small thin catheter (tube) through the stoma, into the pouch, and empties the urine. Advantages:

Urine is kept inside the body until it is ready to be emptied No bag necessary No odor Minimal risk of leaking Small stoma which can be covered by a bandage.

Disadvantages:

Longer surgery time

Need for intermittent catheterization (passing a small plastic tube into the pouch every four to six hours to empty it) Slightly higher risk for complications requiring reoperation

Neobladder to Urethra Diversion In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to the urethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch) is made to mimic the normal storage function of the urinary bladder. The patient is able to pass urine through the urethra, although there is a period of incontinence (leakage of urine) that all patients go through following this surgery. It may take some patients 12 to 18 months to regain control of their urination. A small but not insignificant percentage of patients will have persistent incontinence. Rarely, a patient may not be able to empty this reservoir (pouch) well and will require intermittent catheterization (placement of a small tube into the urethra) in order to empty the reservoir (pouch). Some patients will be required to do this several times a day for a prolonged time period and in some cases permanently. In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the urethra to empty the reservoir (pouch) if necessary. Advantages:

The patient is able to empty the reservoir (pouch) of urine in a manner similar to the normal voiding pattern No stoma is required No catheters required

Disadvantages:

Slightly longer surgery time Potential for temporary or permanent incontinence in a small percentage of patients. Some patients may have to perform intermittent catheterization (place plastic tube via the urethra into pouch every six hours to drain urine) for a prolonged time period and, possibly, forever.