A reconstructive operation is necessary following the surgical removal of the bladder (radical cystectomy) to establish a way to store urine and empty it. There are three possible types of reconstruction: an ileal conduit, a continent cutaneous pouch and an orthotopic bladder (neobladder). All procedures involve part of the intestine being surgically transformed into part of a system that allows urine to be stored and to exit the body in the typical way or through a stoma, an opening that is created surgically through the skin (see Figure 1).
An ileal conduit is the most common type of reconstructive surgery performed on patients who have had a radical cystectomy. This surgery involves using a piece of the ileum, the end section of the small intestine, to create a pouch to hold the urine and from which it can be expelled. At the time of surgery, the following steps to construct an ileal conduit or ileostomy are also taken. The surgeon isolates a piece of intestine (ileum) while making sure blood vessels are still supplying the intestine. The surgeon stitches the ends of the ileum from which the isolated pieces has been removed, restoring the integrity of the bowel.
The surgeon then attaches the ureters (tubes through which urine normally flows from the kidney to the bladder) to the end of the surgically isolated intestine. Then the other end of the piece of ileum is attached to your skin through an incision in your abdominal wall. This results in the creation of an opening of the piece of ileum through your abdominal wall, called a stoma. The stoma empties urine into a bag taped or glued to your abdominal wall.
This option allows urine to flow continuously through the new conduit to the outside, where it is collected in a small bag called an ostomy bag. This bag is attached to the stoma and is emptied periodically. The pouch lies flat against the body, and can be covered with clothes. This surgery is classified as an incontinent diversion because you no longer control the flow of urine from the body.
Continent cutaneous pouch
Another option is a continent cutaneous pouch. This diversion involves an internal storage container for urine, which is made from a section of intestine attached to the ureters. This container, also referred to as an Indiana pouch, is folded and then connected to a stoma on one end with the ureters on the other. The pouch is drained by inserting a small, string-like tube known as a catheter through the stoma. It is crucial that the skin surrounding the stoma is washed and dried prior to and following each catheterization.
This type of diversion allows for some control over dispelling urine. In the weeks following the procedure, the pouch will need to be drained every two to three hours.
Orthotopic bladder (neobladder)
The third option for reconstructive surgery is an orthotopic bladder, also known as a neobladder. This is created using a small portion of your intestine (usually the ileum) that acts as an internal reservoir for storing urine. One end is attached to the ureters, while the other is attached to the urethra, the part of your body through which urine exits. A collection bag is not needed, and urine is able to leave your body in the regular way.
During the healing process, urine will be drained through a catheter or stents (small mesh tubes), which are placed into the neobladder through a small incision in the abdomen. Though you initially will not have control over when urine flows, over time, you may be able to have some control. The catheter also serves to remove mucus, an important step of maintaining hygiene throughout the reconstructive process.
Living With a Stoma
A stoma is a word used for any opening in the body. Any hollow organ can be surgically made into a stoma. When undergoing a urostomy or treatment for bladder cancer, a stoma will be made in your abdomen and connected to your urinary system. A barrier ring can be used to fill in any gaps. A pouch will be attached to your stoma, which serves to collect urine.
Though having a stoma may take some getting used to, remember that most people are able to resume their daily lifestyles, as well as wear the same clothes. Talk with your ostomy nurse about your concerns and ask for any advice that may help you adjust. These additional suggestions may help:
- Wash your hands with soap and water before and after caring for your stoma and pouch.
- Keep the area around your stoma clean by using water and patting dry.
- Changing the pouch regularly helps avoid leaks and skin irritation. Getting used to changing your pouch is incredibly helpful and an important part of keeping yourself comfortable.
- Shaving the area around the pouch will help the pouch stick better to skin.
- Pouches include filters that help prevent odors. Using fragrance drops or sprays to further mask the odor may boost your confidence.