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Urinary diversion

Urinary diversion is a surgical procedure that creates an alternative pathway for urine to exit the body when the normal flow is obstructed or the bladder must be bypassed or removed due to disease or dysfunction.^[1]^[2] It is most commonly performed following cystectomy, the surgical removal of the bladder, to prevent urine accumulation that could lead to infections, kidney damage, or life-threatening complications.^[1]^[3] The primary indications for urinary diversion include muscle-invasive bladder cancer, which accounts for the majority of cases requiring radical cystectomy, as well as neurogenic bladder dysfunction, severe trauma, or chronic conditions causing intractable pain or infections.^[3]^[2] In such scenarios, the procedure reroutes urine from the kidneys via the ureters, often using segments of the intestine to form a conduit or reservoir, thereby preserving renal function and quality of life.^[1]^[3] While it can be temporary for reversible blockages, it is typically permanent after bladder removal, with patient selection influenced by factors such as age, overall health, and ability to manage post-operative care.^[1]^[2] Urinary diversions are broadly classified into incontinent and continent types, each designed to suit different patient needs and lifestyles. Incontinent diversions, such as the ileal conduit, direct urine continuously through a stoma on the abdomen into an external ostomy bag, representing the most common and straightforward option.^[2]^[3] Continent diversions, including cutaneous reservoirs like the Indiana pouch or orthotopic neobladders, allow for internal urine storage and controlled emptying via catheterization or natural voiding, offering greater independence but requiring more patient involvement.^[2]^[3] These procedures can be performed via open surgery or minimally invasive techniques, such as robotic-assisted methods, to minimize recovery time.^[3] Post-operative outcomes vary, with most patients recovering within 1-2 months and resuming normal activities, though complications like infections, strictures, or metabolic imbalances occur in up to 66% of cases within 90 days.^[3]^[2] Long-term management involves stoma care, pouch monitoring, and regular follow-up to address issues such as hernias or stone formation, emphasizing the importance of multidisciplinary support for optimal results.^[1]^[3] Advances in surgical techniques continue to improve continence rates and reduce morbidity, particularly for neobladder reconstructions that restore near-normal urinary function in suitable candidates.^[3]

Overview

Definition and Purpose

Urinary diversion is a surgical procedure that reroutes the flow of urine from the kidneys and ureters to an alternative pathway outside the body, bypassing the bladder and urethra when the bladder is non-functional, removed, or otherwise compromised.^[1]^[4] This intervention is commonly performed in cases such as bladder cancer, where the bladder's removal (cystectomy) necessitates a new route for urine elimination to maintain bodily homeostasis.^[5] The primary purposes of urinary diversion include preserving renal function by preventing urine backflow and stasis that could lead to kidney damage, reducing the risk of recurrent urinary tract infections through improved drainage, and enabling continence or manageable incontinence to support patient autonomy.^[6]^[7] Additionally, it aims to enhance quality of life after procedures like cystectomy by providing a reliable method for urine storage and elimination that aligns with daily activities.^[8]^[9] Urinary diversions can be classified as temporary or permanent based on the underlying condition and treatment goals. Temporary diversions reroute urine for days, weeks, or months to allow healing or resolution of reversible issues, after which normal bladder function may be restored.^[1] In contrast, permanent diversions are constructed for lifelong use when the bladder cannot be salvaged, ensuring long-term renal protection and urinary management.^[10] Anatomically, urinary diversions typically involve isolating segments of the bowel, such as the ileum, colon, or less commonly the jejunum, to create conduits or reservoirs that connect the ureters to a stoma on the abdominal wall or other exit points.^[3] These bowel segments are repurposed due to their tubular structure and vascular supply, which facilitate urine transport while minimizing disruption to gastrointestinal function.^[11]

Historical Background

The history of urinary diversion traces back to the mid-19th century, when surgeons sought solutions for congenital anomalies and malignancies that rendered the bladder nonfunctional. In 1852, German surgeon Johann Simon performed the first documented ureterosigmoidostomy, implanting the ureters into the sigmoid colon to divert urine in a patient with bladder exstrophy, marking the initial use of intestinal segments for urinary reconstruction.^[12] This procedure, though innovative, carried high risks of ascending infections, electrolyte imbalances, and renal deterioration in an era without antibiotics, limiting its long-term success.^[13] By the mid-20th century, advancements in surgical techniques and postoperative care led to more reliable methods. In 1950, American surgeon Eugene M. Bricker introduced the ileal conduit, utilizing a segment of ileum to create an external urinary stoma, which offered a safer alternative to ureterosigmoidostomy by minimizing direct intestinal-urinary mixing and reducing infection and metabolic complication rates.^[14] This incontinent diversion became the gold standard for over three decades, particularly following radical cystectomy for bladder cancer, with Bricker's series of 307 cases reporting a surgical mortality of 12.4%, largely attributable to underlying disease rather than the procedure itself.^[13] The 1970s and 1980s brought a paradigm shift toward continent diversions, prioritizing patient autonomy and quality of life. In 1975, Swedish surgeon Nils M. Kock pioneered the Kock pouch, a detubularized ileal reservoir with an efferent nipple valve for continent catheterizable access, representing the first widely adopted continent urinary diversion using bowel segments.^[15] Concurrently, orthotopic neobladder reconstruction evolved, with early modern techniques like the Camey II procedure in the late 1970s and the Studer pouch in 1989 enabling near-normal voiding through urethral anastomosis, further refined by figures such as W. Scott McDougal in subsequent optimizations.^[16]^[17] Entering the late 20th and early 21st centuries, the field emphasized minimally invasive approaches and long-term outcomes. Post-2000, robotic-assisted laparoscopic techniques for urinary diversion gained traction, with the first completely intracorporeal robotic radical cystectomy and neobladder reported in 2003, offering reduced blood loss, shorter hospital stays, and improved recovery compared to open surgery.^[18] This evolution aligned with a growing focus on quality-of-life enhancements, including continent options to preserve renal function and psychological well-being; systematic reviews as recent as 2025 underscore the sustained impact of these innovations through analyses of long-term complication rates and patient-reported outcomes.^[19]

Indications and Patient Selection

Primary Indications

The primary indication for urinary diversion is muscle-invasive bladder cancer, where radical cystectomy is the standard treatment, necessitating reconstruction of the urinary tract to manage urine flow post-bladder removal.^[3]^[1] This accounts for approximately 90% of cases, reflecting the prevalence of advanced urothelial carcinoma requiring such intervention.^[20] Other indications include neurogenic bladder dysfunction, such as from spinal cord injury, which impairs bladder emptying and increases infection risk, leading to diversion as a salvage option after failed conservative management.^[16] Congenital anomalies like bladder exstrophy, severe pelvic trauma, intractable infections such as radiation cystitis, and benign urethral or bladder strictures also warrant urinary diversion when they result in irreversible bladder failure or life-threatening complications.^[21]^[22] In palliative settings, urinary diversion plays a key role for patients with advanced pelvic malignancies, such as cervical or rectal cancer, to alleviate symptoms like intractable hematuria or obstruction without curative intent.^[3] Approximately 10% of urinary diversions are performed for benign conditions overall.^[20] Patient selection often considers factors like adequate renal function to minimize postoperative risks.^[23]

Contraindications and Patient Factors

Urinary diversion procedures, while essential for managing conditions such as muscle-invasive bladder cancer, carry absolute contraindications that preclude their use in certain patients to avoid excessive risks. These include uncontrolled metastatic disease leading to limited life expectancy, severe renal impairment with creatinine clearance below 35 mL/min, significant hepatic dysfunction, and debilitating neurological or psychiatric conditions that impair postoperative management.^[24]^[3] Additionally, inability to manage a stoma or perform self-catheterization, often due to profound cognitive impairment or lack of social support, represents an absolute barrier, as these diversions require ongoing patient involvement.^[24]^[3] Relative contraindications encompass factors that elevate complication risks but do not universally exclude surgery, necessitating individualized assessment. Advanced age over 80 years increases perioperative morbidity and challenges recovery, particularly for continent diversions.^[24] Obesity with a body mass index greater than 35 kg/m² complicates surgical access and healing, serving as a relative deterrent to complex reconstructions like orthotopic neobladders.^[25] Prior pelvic radiation heightens the incidence of anastomotic leaks, infections, and incontinence, often favoring simpler incontinent options over continent ones.^[3] Impaired manual dexterity or motivational deficits further contraindicate continent diversions requiring intermittent catheterization, as up to 50% of patients may need this for adequate emptying.^[3] Patient selection prioritizes renal function evaluation through serum creatinine, estimated glomerular filtration rate, and imaging to ensure adequate baseline status, with a minimum creatinine clearance of 35-40 mL/min typically required for continent procedures to mitigate metabolic acidosis risks.^[3] Younger, motivated patients with good dexterity and social support are preferred for continent diversions like neobladders, which preserve quality of life through natural voiding, whereas elderly or frail individuals with dexterity issues benefit from incontinent ileal conduits due to lower maintenance demands.^[24]^[3] In high-risk cases involving comorbidities or obesity, robotic-assisted approaches have gained favor by 2025, demonstrating reduced perioperative morbidity and equivalent oncologic outcomes compared to open surgery in select cohorts.^[26]

Types of Urinary Diversion

Incontinent Diversions

Incontinent urinary diversions involve the creation of a pathway for urine to exit the body through an abdominal stoma into an external collection appliance, without any mechanism for voluntary control over urination.^[10] These procedures are designed for passive drainage, relying on gravity and the appliance to manage urine output continuously.^[21] The primary subtype is the ileal conduit, also known as the Bricker procedure, which utilizes a segment of the ileum to form the conduit.^[10] In this technique, a 15-20 cm isolated segment of ileum is mobilized, the ureters are anastomosed to its proximal end using methods such as the Bricker or Wallace technique, and the distal end is brought through the abdominal wall to form a stoma.^[10] Urine then flows from the kidneys through the conduit and collects in an external urostomy bag attached to the stoma.^[21] A colonic conduit serves as an alternative, employing a segment of colon instead of ileum, though it is less commonly performed due to similar functional outcomes but potentially higher risks of electrolyte imbalances.^[10] These diversions offer advantages including shorter operative times, typically 4-6 hours, compared to more complex continent options.^[27] Initial postoperative complication rates are relatively lower, ranging from 20-30%, attributed to the procedure's technical simplicity and avoidance of additional anastomoses or reservoirs.^[28] Ileal conduits account for approximately 75-85% of all urinary diversions performed, particularly favored for elderly patients or those with high surgical risk due to comorbidities, impaired renal function, or limited dexterity for self-management.^[21]^[29]

Continent Diversions

Continent urinary diversions involve the creation of an internal reservoir using segments of the bowel to store urine, paired with a continence mechanism that enables patient-controlled emptying, thereby avoiding the need for a permanent external urinary appliance.^[30] These procedures aim to restore more natural voiding patterns, either through the urethra or via self-catheterization through a stoma, enhancing patient autonomy and body image compared to incontinent options.^[31] The primary subtypes include orthotopic neobladders and continent cutaneous reservoirs. Orthotopic neobladders, such as the Studer pouch constructed from ileum, connect directly to the urethra, allowing patients to void spontaneously in a near-physiological manner without visible external devices.^[32] In contrast, continent cutaneous diversions, exemplified by the Indiana pouch formed from ileum and cecum, feature a catheterizable stoma on the abdominal wall for periodic emptying.^[33] Both types typically utilize bowel segments like ileum or cecum to form the reservoir.^[6] Advantages of continent diversions include preservation of body image and higher patient satisfaction, with daytime continence rates ranging from 70% to 90% in suitable candidates.^[34] However, they require intermittent self-catheterization, typically 4 to 6 times per day, particularly for cutaneous pouches and in cases of incomplete emptying with neobladders, which can pose challenges for patients with dexterity issues or motivation barriers.^[35] Continent diversions are performed in approximately 15% of patients undergoing cystectomy in the United States, though up to 30-50% may be suitable based on factors like age, renal function, manual dexterity, and motivation; orthotopic neobladders comprise the majority of these continent cases. Recent trends show a decline in their utilization, from about 17% in 2004-2006 to 12% in 2010-2013.^[36]^[37] As of 2024, advancements in pouch designs, such as the intracorporeal Vesuvian orthotopic neobladder, have shown promise in improving reservoir capacity and valve mechanisms, potentially reducing catheterization frequency to 3 to 4 times daily in select patients while maintaining continence.^[38]

Surgical Techniques

Ureteroenteric Anastomosis

Ureteroenteric anastomosis refers to the surgical connection between the ureters and an isolated segment of the intestine, enabling the diversion of urine from the kidneys into a bowel-based reservoir or conduit following procedures such as radical cystectomy.^[39] This step is essential in most forms of urinary diversion to ensure unobstructed urine flow while minimizing complications like obstruction or infection.^[40] The primary techniques for ureteroenteric anastomosis are classified as refluxing or non-refluxing, with refluxing methods generally preferred due to their simplicity and lower risk of stricture formation. In the refluxing Bricker technique, each ureter is spatulated and anastomosed independently in an end-to-side fashion to the serosa of the intestinal segment using interrupted absorbable sutures, allowing urine to reflux into the upper urinary tract.^[41] The Wallace technique, another refluxing approach, involves conjoining the ureters (either side-to-side in Wallace I or head-to-tail in Wallace II) before attaching the common ureteral wall to the bowel end, often with serosal backing to support the anastomosis.^[41] These methods are favored for their technical ease and reported stricture rates of approximately 2-6%, as demonstrated in comparative studies of ileal conduit diversions.^[41]^[39] Non-refluxing techniques, such as the Le Duc or Nesbit methods, aim to prevent urine backflow by tunneling the distal ureter through the intestinal submucosa before anastomosis, theoretically reducing the risk of pyelonephritis.^[40] However, these approaches are associated with higher rates of anastomotic obstruction, with stricture incidences reported up to 13-15% in long-term follow-up of continent diversions like ileal neobladders.^[40] Surgeon preference often dictates the choice, as meta-analyses show no definitive superiority in renal outcomes between refluxing variants, though non-refluxing methods are less commonly used due to increased complication risks.^[41] Key surgical considerations include meticulous preservation of the ureteral blood supply to prevent ischemia, achieved by minimizing dissection of the periureteral adventitia and avoiding electrocautery near the ureteral wall.^[42] Anastomoses are typically performed with 4-0 or 5-0 absorbable sutures in an interrupted manner to ensure a tension-free, watertight closure, with the ureteral mucosa everted for optimal alignment.^[39] Robotic-assisted approaches enhance precision through magnified visualization, potentially reducing technical errors in intracorporeal diversions.^[43] Specific risks associated with ureteroenteric anastomosis include anastomotic leakage, occurring in 2-5% of cases primarily due to inadequate vascularization or technical issues, and stricture formation from ischemia or inflammation, with overall rates ranging from 2-10% depending on the technique.^[39] These complications can lead to hydronephrosis or renal deterioration if not addressed promptly.^[40] Ureteroenteric anastomosis is employed in approximately 90% of urinary diversions involving bowel segments, such as ileal conduits and orthotopic neobladders, but is typically avoided in ureterosigmoidostomy variants where direct ureteral implantation into the sigmoid colon is performed.^[39]

Reservoir Construction and Stoma Creation

The selection of bowel segments for reservoir construction in urinary diversion is critical to minimize metabolic complications and optimize functional outcomes. The ileum is the most commonly used segment due to its favorable handling properties and lower risk of electrolyte disturbances compared to other intestinal portions. Typically, 10 to 15 cm of terminal ileum, located approximately 10 to 15 cm proximal to the ileocecal valve, is isolated for incontinent conduits, while 40 to 60 cm may be required for continent reservoirs or orthotopic neobladders to achieve adequate capacity.^[11] The colon, particularly the right or sigmoid segments, is preferred for longer conduits or specific pouch configurations like the Mainz II, as it provides greater length and better continence properties in select cases.^[44] Jejunum is generally avoided because of its association with severe metabolic issues, including hyponatremia, hyperkalemia, and acidosis, stemming from its high absorptive capacity.^[44] For incontinent diversions like the ileal conduit, construction involves simple tubularization of the isolated bowel segment, where the proximal end is anastomosed to the ureters and the distal end prepared for stoma formation, preserving the natural peristalsis for urine drainage. In contrast, continent reservoirs require detubularization—incising the bowel along the antimesenteric border—to eliminate peristalsis and reduce intraluminal pressure, followed by reconfiguration into spherical or low-pressure shapes. Common techniques include U- or S-shaped folding for orthotopic neobladders, utilizing segments of ileum to create a compliant reservoir with a capacity of approximately 400 to 500 mL, enabling volitional voiding while minimizing reflux.^[45]^[46] Stoma creation differs markedly between incontinent and continent diversions. In incontinent types, such as the ileal conduit, the distal bowel end is everted and sutured to the skin in a protruding, rosebud-like fashion to facilitate appliance adhesion and prevent stenosis, often achieving a height of 2 to 3 cm for optimal protrusion.^[47] For continent diversions, a valve mechanism is essential for voluntary control; this may involve an intussuscepted nipple valve (as in the Kock pouch) or a flap valve (as in the Indiana pouch), where the efferent limb is embedded or tapered to create resistance against leakage, allowing intermittent catheterization.^[48] Operative nuances emphasize meticulous preservation of the mesentery and vascular arcades during bowel isolation to ensure adequate perfusion and prevent ischemia, with careful mobilization to avoid tension. Both open and robotic approaches are employed, though robotic-assisted techniques demonstrate reduced estimated blood loss—often 20% to 50% lower than open surgery—due to enhanced precision and minimized manipulation, without significantly prolonging overall operative time.^[49] The reservoir construction phase typically requires 1 to 2.5 hours, depending on complexity, excluding cystectomy and anastomosis times.^[50]

Complications

Early Complications

Early complications following urinary diversion surgery, defined as those occurring within 30 to 90 days postoperatively, affect 20% to 60% of patients overall, with rates reaching up to 76% in continent diversions due to the complexity of reservoir construction.^[21]^[51] These events contribute significantly to short-term morbidity and prolonged hospital stays, emphasizing the need for vigilant perioperative monitoring and preventive strategies such as enhanced recovery after surgery (ERAS) protocols.^[51] Common early complications include wound infections, occurring in 10% to 15% of cases, often managed with targeted antibiotics and wound care to prevent dehiscence.^[52] Postoperative ileus or bowel obstruction affects approximately 20% of patients, typically resolving with conservative measures like nasogastric decompression and electrolyte correction, though severe cases may require reoperation.^[51] Urinary leaks or fistulas, seen in 5% to 10% of procedures, arise from anastomotic issues such as ureteroenteric junctions and are addressed through percutaneous drainage or surgical revision if persistent.^[51] Acute kidney injury, frequently resulting from obstruction or hypoperfusion, complicates 11% to 38% of cases and necessitates prompt imaging and ureteral stenting to mitigate renal damage.^[53] Pulmonary issues, including atelectasis and pneumonia, occur in about 17% of patients, often linked to prolonged ventilation and immobility, and are prevented through early mobilization and incentive spirometry.^[54] In neobladder diversions, reservoir rupture due to overdistension represents a rare but serious early complication, with an incidence of 1% to 2%, requiring immediate surgical intervention to avoid peritonitis.^[55] Risk factors for these early events include prior pelvic radiation, which impairs tissue healing, and preoperative malnutrition, associated with hypoalbuminemia and increased infection rates.^[56]^[57] Studies on robotic-assisted approaches indicate reduced early morbidity, including lower rates of ileus and infections, attributed to minimized tissue trauma and enhanced precision.^[58] Overall management prioritizes multidisciplinary care, with antibiotics for infections, drainage for collections, and selective reoperation for leaks or obstructions to optimize recovery.^[59]

Late Complications

Late complications of urinary diversion, defined as those occurring months to years after surgery, affect 30% to 70% of patients over five years, with higher rates observed in continent diversions compared to incontinent types due to increased complexity and bowel involvement.^[21]^[19] Ureteroenteric strictures represent a common late issue, with incidences ranging from 10% to 14% in ileal conduits and similar rates in orthotopic neobladders, often leading to hydronephrosis and renal impairment if untreated.^[21] Robotic-assisted techniques have been associated with lower stricture rates compared to open surgery.^[60] Urinary stones occur in approximately 10% to 15% of cases, more frequently in continent diversions (up to 20% in orthotopic neobladders), driven by stasis, infection, and metabolic alterations.^[21]^[19] Parastomal hernias, particularly in incontinent diversions such as ileal conduits, develop in 10% to 30% of patients, often requiring surgical repair if symptomatic, and can be mitigated with prophylactic mesh placement.^[61]^[62] Metabolic disturbances are prevalent, with hyperchloremic metabolic acidosis affecting about 25% of patients using ileal or colonic segments, resulting from intestinal reabsorption of chloride and ammonium in exchange for bicarbonate loss.^[21] This condition, exacerbated by renal impairment or prolonged urine-bowel contact, is managed with oral sodium bicarbonate supplementation (1-2 g three times daily) to restore acid-base balance.^[63] Vitamin B12 deficiency arises in up to 17% of cases involving ileal segments, due to malabsorption in the terminal ileum, and may manifest years later as megaloblastic anemia or neuropathy, necessitating annual serum monitoring and supplementation.^[64]^[65] Bowel-related late effects include mucus production from incorporated intestinal segments, which can cause catheter obstruction or infections in continent reservoirs, and chronic diarrhea in 11% to 23% of patients following ileal or ileocecal resection, often linked to bile salt malabsorption.^[66]^[21] Secondary malignancies, particularly adenocarcinomas, occur in 1% to 5% of ureterosigmoidostomy cases, with a reported rate of 2.58%, attributed to chronic inflammation and fecal-urine contact; 2025 reviews emphasize enhanced surveillance for upper tract urothelial tumors in all diversions.^[67]^[68] Ongoing monitoring is essential, involving annual renal imaging (e.g., ultrasound or CT) to detect strictures or stones, regular electrolyte and acid-base assessments, and vitamin level checks to mitigate progression of these complications.^[21]^[69]^[70]

Postoperative Care and Outcomes

Immediate Postoperative Management

Following radical cystectomy with urinary diversion, patients typically require a hospital stay of 5 to 10 days, depending on the type of diversion and individual recovery factors, though high-risk patients may need initial intensive care unit monitoring for hemodynamic stability.^[71]^[72] Close monitoring in the immediate postoperative period focuses on vital signs, urine output (maintained above 30 mL per hour to ensure adequate renal perfusion), and drain outputs, where creatinine levels in drain fluid are compared to serum to detect potential urine leaks.^[3]^[73] Electrolyte imbalances, such as hyperchloremic metabolic acidosis, are also routinely assessed due to the bowel segment's impact on acid-base balance.^[69] This vigilance helps identify early complications like infections or anastomotic issues promptly.^[6] Key interventions include nasogastric tube placement to manage postoperative ileus, early ambulation starting on postoperative day 1 to promote bowel function and prevent thrombosis, and multimodal pain control with opioids minimized in favor of non-opioid analgesics.^[74]^[3] Oral intake advances to clear liquids on postoperative day 1 or 2 as tolerated, supporting gastrointestinal recovery.^[75] For incontinent diversions like ileal conduits, stoma appliance fitting occurs on postoperative day 1, with patient education on bag changes and skin care initiated immediately to ensure proper adhesion and prevent irritation.^[73] In continent diversions, such as pouches, training in clean intermittent self-catheterization begins once output is stable, typically within the first week, to foster independence.^[76] Nutritional support may involve total parenteral nutrition if enteral feeding is delayed due to ileus, though evidence suggests it does not confer significant benefits and may increase infection risk in routine cases.^[77] Dietary counseling starts early, advising avoidance of high-oxalate foods like spinach and nuts to reduce the risk of urinary stone formation in the diversion.^[78]^[79] Contemporary protocols incorporating enhanced recovery after surgery (ERAS) elements, such as standardized multimodal analgesia and early feeding, have been shown to reduce hospital length of stay by approximately 6-8 days compared to traditional care.^[80]^[81]

Long-term Follow-up and Quality of Life

Long-term follow-up for patients with urinary diversion typically involves clinic visits at intervals of 3, 6, and 12 months postoperatively, transitioning to annual assessments thereafter to monitor oncological status, renal function, and diversion-specific issues.^[82] Imaging such as CT urography is recommended every 6 months for the first 3 years, then annually up to 5 years, while renal function tests, including serum creatinine and electrolytes, are performed regularly to detect deterioration early.^[83] For orthotopic neobladder patients, periodic cystoscopy may be incorporated to evaluate reservoir integrity and rule out upper tract involvement, alongside annual vitamin B12 level checks due to potential malabsorption from ileal segment use.^[64] Ongoing interventions address metabolic derangements and structural complications to preserve function. Metabolic acidosis, common in ileal diversions, is managed with oral sodium bicarbonate supplementation at 1 to 2 g three times daily to restore acid-base balance and mitigate symptoms like fatigue.^[69] Vitamin B12 deficiency, affecting up to 50% of patients long-term,^[84] requires supplementation (oral high-dose or parenteral) if levels fall below normal, with monitoring every 3 to 6 months initially per AUA guidelines.^[64] Urolithiasis, occurring in 10-20% of cases, is often treated endoscopically via percutaneous or transstomal approaches for efficient stone fragmentation and removal, minimizing morbidity.^[85] Quality of life assessments reveal nuanced differences between diversion types, with continent options like neobladders generally associated with improved body image and urinary function domains, though overall SF-36 scores show no significant difference (pooled p=0.31) compared to incontinent ileal conduits.^[86] Patients with continent diversions report higher satisfaction in social and emotional subscales, but challenges persist, including body image concerns and sexual dysfunction, with recovery rates exceeding 60% even in prostate-sparing techniques.^[87] As of 2025, studies report high patient satisfaction with neobladder reconstruction, bolstered by robotic-assisted approaches achieving daytime continence rates up to 90%.^[88] Nighttime continence lags at 50-80%, influencing sleep and overall well-being.^[83] Psychosocial support plays a vital role in adaptation, with organizations like the United Ostomy Associations of America (UOAA) and Bladder Cancer Advocacy Network (BCAN) offering dedicated support groups and counseling to address emotional burdens such as adjustment to stoma care or altered intimacy.^[89] These resources help mitigate isolation, with professional oncology social workers providing tailored guidance on family communication and coping strategies, ultimately enhancing long-term adherence to follow-up and intervention protocols.^[90]

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Continent diversions include orthotopic neobladders, in which a bladder constructed of intestine connects to the urethra, allowing more natural volitional ...
[32]
Ileal conduit or orthotopic neobladder: selection and contemporary ...
Severe renal insufficiency is a contraindication to orthotopic neobladder, due to an inability to handle the increased resorption of metabolic waste products in ...
[33]
[PDF] The Basics of Neobladder and Indiana Pouch Dr. Alexander Kutikov:
A neobladder urinary diversion, again, uses a larger segment of small bowel. It basically creates a reservoir where the patients can urinate through their ...
[34]
Advances in Urinary Diversion: From Cutaneous Ureterostomy to ...
The Studer neobladder was first published in 1989 and has become a common approach for orthotopic neobladder reconstruction [94]. In 2011, an intracorporeal ...
[35]
Functional Outcomes of Orthotopic Neobladder in Women
Aug 28, 2024 · Overall daytime continence rates for female bladder cancer patients that have undergone cystectomy with ONB range from 64 to 90% [38, 52].Missing: suitability percentage
[36]
Indiana Pouch: Causes, Symptoms, Complications & Surgery
An Indiana pouch holds your pee after a provider removes your bladder. You must drain the Indiana pouch multiple times a day with a catheter.Missing: Studer | Show results with:Studer
[37]
Assessing trends in urinary diversion after radical cystectomy for ...
Aug 7, 2025 · Results: Overall, 23,224 (85.5%) and 3,946 (14.5%) patients underwent incontinent and continent diversion, respectively. Continent diversion ...
[38]
Advances in Urinary Diversion: From Cutaneous Ureterostomy to ...
Apr 1, 2024 · The new intracorporeal Vesuvian Orthotopic Neobladder technique is a feasible and good alternative to traditional robotic intracorporeal ...<|separator|>
[39]
A catheterizable serous-lined urinary outlet associated with the ileal ...
Feb 28, 2024 · Purpose: This study aims to evaluate the long-term outcome of the serous-lined extramural continent catheterizable outlet procedure ...
[40]
Comparative analysis of Bricker versus Wallace ureteroenteric ... - NIH
Dec 23, 2021 · Ureteroenteric anastomosis after cystectomy is usually performed using the Bricker or Wallace technique. Deterioration of renal function is the ...<|control11|><|separator|>
[41]
Ureteroenteric anastomosis in continent urinary diversion - PubMed
For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it ...
[42]
A meta-analysis of ureteroenteric stricture rates after ileal conduit ...
The two most common types of ureteroenteric anastomosis during the procedure are the refluxing Bricker and Wallace techniques. The Bricker technique, initially ...
[43]
A modified ureteroileal anastomosis can reduce the incidence of ...
Oct 9, 2025 · Before anastomosis, visual assessment of ureteral blood supply is required—the surface of the ureteral mucosa should be reddish in appearance.
[44]
Robotic Repair of Ureteroenteric Stricture Following Radical ... - NIH
Conclusion: Robotic reimplantation of ureteroenteric strictures following radical cystectomy is safe and feasible in experienced centers with high success rates ...
[45]
Selection of Bowel for Urinary Diversion and Choice of ... - NIH
Jan 10, 2017 · These reservoirs are constructed from a segment of detubularized bowel segment and anastomosed to the native urethra. As this technique ...
[46]
Current Indications and Techniques for the Use of Bowel Segments ...
Jun 12, 2019 · Continent anal reservoirs have been the first kind of continent urinary diversion. The history of continent anal diversion started in July 1851 ...Missing: selection | Show results with:selection
[47]
Urinary Diversion: Ileal Conduit to Neobladder | Journal of Urology
Improved quality of life after orthotopic bladder substitution compared with alternative forms of diversion fails to be achieved when voiding dysfunction arises ...Urinary Diversion: Ileal... · Intestinal Tissue As A... · Reflux Prevention In...<|control11|><|separator|>
[48]
Improved technique for creation of ileal conduit stoma - PubMed
We describe our method of stoma formation that creates a circumferentially symmetrical protruding stoma free of tension that has been used successfully even in ...
[49]
Continent Urinary Diversion - PMC - NIH
The absolute and relative contraindications[3] for continent urinary diversion are summarized in Table 1.
[50]
Robot-assisted radical cystectomy: Where we are in 2023
Feb 28, 2023 · With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of ...
[51]
A simplified technique for continent urinary diversion: an all-stapled ...
A simple continent colonic reservoir was constructed in its entirety with the aid of surgical stapling techniques in 17 men and 10 women.Missing: bowel | Show results with:bowel
[52]
Urinary diversions for radical cystectomy: a review of complications ...
Jun 6, 2021 · Ileal conduit ureteroileal anastomosis leak occurs in 2%-5.5% of the patients in the short term. Urethral anastomotic leaks in orthotopic ...Missing: percentage | Show results with:percentage<|control11|><|separator|>
[53]
Assessment of complications following urinary diversion for benign ...
The most common early complication was wound infection (12%); delayed was urinary tract infection (39%). Multivariable logistic regression modeling found no ...Missing: incidence | Show results with:incidence
[54]
Incidence and Perioperative Risk Factors for Early Acute Kidney ...
Results: Early postoperative AKI occurred in 100/912 patients (11%). An increased risk was seen in patients with surgery lasting>400minutes, male and obese ...
[55]
Respiratory Complications after Cystectomy with Urinary Diversion
Mar 10, 2024 · Within 30 days following surgery, 41 patients (17%) experienced postoperative respiratory complications, including pneumonia, respiratory ...
[56]
Role of CT in Postoperative Evaluation of Patients Undergoing ...
Urinary Leakage and Rupture Urinary leakage from anastomosis is an uncommon early complication and previous studies reported incidence of up to 1.1% [5]. On CT ...<|separator|>
[57]
Stoma-related complications and emergencies
May 9, 2022 · Risk factors for postoperative complications include age, co-morbidities, female sex, obesity, and previous radiation to the abdominal or pelvic ...Main Text · Ileostomy And Colostomy · Urostomy
[58]
Early Complications and Mortality following Radical Cystectomy
Sep 28, 2018 · Hypoalbuminemia and class III obesity were associated with early mortality. This study highlights the fact that malnutrition may coexist in ...Missing: radiation | Show results with:radiation
[59]
Contemporary morbidity and mortality of open versus robotic ...
RARC was associated with reduced risk of multiple 30-day complications, including mortality, as well as organ system and cystectomy-specific outcomes.
[60]
Management of Early and Late Complications of Ileocolonic ...
Successful conservative therapy constitutes establishment of drainage, adequate nutrition, avoidance of sepsis, close observation, and patience. This article ...
[61]
Comparative analysis of ureteroileal anastomotic stricture rates
Oct 23, 2025 · Comparative outcomes of Bricker versus Wallace ureteroenteric anastomosis: a systematic review. ... Keywords: bladder cancer, urinary diversion, ...
[62]
Metabolic complications of urinary intestinal diversion - PMC - NIH
Patients undergoing a urinary diversion often report diarrhea. This symptom has a significant impact on the patient's QOL.[7] Following the loss of intestinal ...
[63]
Functional Follow-Up After Cystectomy and Urinary Diversion - LWW
Nov 20, 2023 · After urinary diversion using distal ileum, vitamin B12 deficiency can be observed in 17%. Because of malabsorption, which depletes the body's ...
[64]
Metabolic Abnormalities Following Urinary Diversion
Nov 1, 2012 · Vitamin B12 is exclusively absorbed in the distal ileum, and serum levels may not deplete for 5 years. In patients with normal vitamin B12 ...
[65]
Metabolic and functional consequences of urinary reconstruction ...
Jan 7, 2003 · Intestinal segments continue to produce mucus after incorporation into the urinary tract. This mucus can be troublesome when it interferes with ...Growth And Development · Urolithiasis · Bowel Function
[66]
Tumor risk after urinary diversion | Nature Reviews Urology
Aug 10, 2011 · Of the continent urinary diversions, secondary tumor risk was greatest following ureterosigmoidostomy (2.58%) and cystoplasty (1.58%).Missing: incidence | Show results with:incidence
[67]
Secondary Tumors After Urinary Diversion - PubMed
It has been known that urinary diversions juxtaposing the urinary and intestinal tracts lead to increased incidence of secondary malignancies.
[68]
Metabolic Changes after Urinary Diversion - PMC - NIH
From the patient's perspective, diarrhea is the most bothersome complaint after urinary diversion. This might be accompanied by malabsorption syndromes, such as ...
[69]
Long-Term Complications of Conduit Urinary Diversion
Serum electrolytes were monitored during each visit and upper tracts were imaged every 3 to 6 months initially and then on an annual basis. Urine cultures ...
[70]
Radical Cystectomy – Bladder Removal Surgery
Many parts of the body are affected during the surgery and need time to heal. On average, your hospital stay will be 5 to 10 days.
[71]
What to Expect Before and After Surgery - Johns Hopkins Medicine
We aim to have patients stay in the hospital for four to five days, but they often require additional time before it's safe to discharge. Hydration, pain, bowel ...
[72]
[PDF] Nursing Care for Patients After Urostomy Surgery
Normal urinary output is defined as 800 to 1200 mL per day.17 For optimal monitoring, the ostomy pouch is usually connected to a bedside drainage bag during ...
[73]
Integrated enhanced recovery after surgery protocol in radical ... - NIH
Oct 6, 2024 · Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion. Int Braz J Urol. 2011;37 ...
[74]
Postoperative Care Pathways - ScienceDirect.com
Post-operative care pathways tend to include early ambulation, early introduction of oral liquids and diet, and some authors have sent patients home taking ...
[75]
How To Care for Your Continent Cutaneous Diversion
Jul 18, 2025 · Empty your pouch every 6 hours. Do not wait more than 6 hours to empty it. Tips for following a catheterization schedule. Never go more than the ...
[76]
Immediate total parenteral nutrition after radical cystectomy and ...
Conclusion: Immediate administration of TPN following radical cystectomy and urinary diversion does not provide a significant postoperative benefit and may ...Missing: management | Show results with:management
[77]
[PDF] Nutrition in Stoma Patients: A Practical View of Dietary Therapy
Postoperatively, it is important to provide a high-energy, high-protein ... peanuts are high in oxalate; nuts, and nut butters, berries, concord grapes ...<|separator|>
[78]
Nutritional Management of Kidney Stones (Nephrolithiasis) - PMC
Dietary oxalate may be important in stone development; spinach, beets and rhubarb in particular, contain large amounts of oxalate and they may increase urinary ...
[79]
Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs ...
Mar 3, 2024 · In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.
[80]
Integrated enhanced recovery after surgery protocol in radical ...
Oct 6, 2024 · Enhanced recovery after surgery (ERAS) is a patient-centerd, evidence-based approach to improve postoperative outcomes.
[81]
Bladder Cancer: Surgery - University of Rochester Medical Center
You'll need regular follow-up visits with your urologist after surgery. At first, these visits may be every 3 to 6 months. Over time, they'll be less often.
[82]
EAU Guidelines on MIBC - FOLLOWUP - Uroweb
After trimodality treatment with curative intent, follow-up for the detection of relapse is recommended every 3–4 months initially; then after 2-3 years, every ...
[83]
EAU Guidelines on Urolithiasis - BLADDER STONES - Uroweb
Stones may be removed by open or endoscopic surgery in patients with bladder augmentation or diversion [790].6. Bladder Stones · 6.4. Disease Management · 6.4. 3. Bladder Stone...
[84]
A systematic review and meta-analysis of quality of life outcomes ...
Pooled post-operative FACT and SF-36 scores showed no difference in overall QOL between continent and incontinent diversion (p = 0.31).
[85]
MP41-05 ASSESSING THE INCIDENCE, TIMING, AND RISK ...
Apr 1, 2020 · The use of ileum for urinary diversion following cystectomy is standard in modern practice, but the impact on B12 absorption remains unclear.Missing: supplementation guidelines
[86]
UOAA is Here for Bladder Cancer Survivors
UOAA has supported and welcomed members living with a urostomy (ileal conduit) or urinary diversion as a result of bladder cancer and related conditions.
[87]
Find Support - Bladder Cancer Advocacy Network
By calling 833-ASK-4-BCA (833-275-4222), callers will be connected with professional oncology social workers with specific expertise on issues affecting bladder ...