A Common Diversion

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Normal urinary anatomy (top) and after bladder removal via ileal conduit surgery (bottom). Permission to use these copyrighted illustrations has been granted by the owner, hollister incorporated.

Ileal conduit provides a surgical option to patients with altered urinary anatomy.

Roberta, a hairdresser for more than 30 years, has recently been diagnosed with bladder cancer. So has Mike, a machinist, and Jimmy, a housepainter. Though their jobs are completely different, the three have one thing in common — their occupations exposed them to chemicals containing carcinogens, increasing their risk of getting the disease.

Roberta, Mike, and Jimmy were all told by their physicians that their bladders would have to be removed, but they were also told about a surgical procedure that would allow them to continue to live relatively normal lifestyles. Upon hearing the advantages of ileal conduit surgery, they each asked their physician to immediately schedule an appointment for the procedure.

Bladder cancer affects 38,000 men and 15,000 women each year, primarily those older than 40 years of age. Ileal conduit is the most commonly performed surgical procedure for muscle invasive bladder cancer. Created when the bladder is removed, the ileal conduit diverts urine from the body to a stoma located usually in the right lower quadrant of the abdomen, just below the waistline. Urine continually flows through the stoma and empties into an external pouch.

Stoma placement

Stomal siting is an important part of the preoperative preparation. The patient’s abdomen must be assessed in the supine, sitting, and bending positions to evaluate any hidden creases not normally seen that could affect the stoma. The ideal stoma placement is below the umbilicus, within the rectus muscle, away from scars, creases, bony prominences, the umbilicus, and the belt line. It should be on the summit of the infraumbilical bulge. This bulge is seen on the abdomen inferior to the umbilicus. It must also be visible to the patient. A poorly placed stoma could result in a malformed ostomy, a pouching problem, skin irritation, and increase the potential for leakage.

Ileal conduit construction uses a piece of small bowel to create the stoma, which protrudes through the abdomen. Although normal urinary bladder mucosa forms an effective barrier against reabsorption of fluid or salts from the urine, conduits constructed from the bowel both secrete and reabsorb a variety of ions and fluids. The most common disturbance in patients with ileal conduits is hyperchloremic metabolic acidosis with hypokalemia; this condition is caused by reabsorption of sodium and chloride with corresponding loss of bicarbonate and potassium.¹

Once created, the ileal conduit is freely refluxing, which means that urine can travel in either direction through the anastomosis. When the pressure within the conduit exceeds the pressure in the renal pelvis and the ureters, the outward urinary flow becomes obstructed and reflux into the kidney can occur. If untreated, this can develop into hydro-nephrosis and nephritis.²

Blood creatine levels provide information on how well the kidneys are functioning. Elevated blood levels of creatine indicate kidney damage. Kidney damage can occur over time and affected patients will require systemic alkalization to prevent or alleviate bone demineralization caused by metabolic acidosis. In fact, renal deterioration occurs in about 18% of ileal conduit patients.³ It’s important for nurses to understand the metabolic complications that are associated with this procedure.

Postoperative ostomy care

During the first postoperative day, the stoma should undergo a baseline assessment, with the nurse carefully noting its shape, size, and color. With each subsequent inspection, any signs of ischemia, necrosis, retraction, stenosis, or herniation should be noted and promptly reported to the physician. Ureteral stents are placed for protection at the anastomoses of the ureters and bowel section. A Foley catheter is placed to drain the anastomoses and pelvis areas. These tubes should be identified and monitored for secure placement. Urinary output is measured from each. Asymptomatic bacteriuria is not uncommon. These assessments provide an excellent opportunity to start patient teaching.

At the outset, it’s important that the patient understand that —

• The stoma is a portion of intestine and that it is red and moist, similar to the tissue inside the mouth.
• The stoma is usually swollen after surgery and that the swelling will gradually shrink in size during the next four to eight weeks.
• The stoma will change in size throughout the patient’s lifetime with weight gains and losses.
• Slight bleeding from the stoma is normal because of the stoma’s high concentration of blood vessels.
• A stoma does not have nerve endings and therefore does not transmit pain.

The skin surrounding the stoma, the peristomal skin, needs special attention to prevent complications. If the skin is exposed to urine, the patient can experience some distressing and painful symptoms. Basic care for the peristomal skin includes —

• Bathing or showering as normal, with or without the pouch on, with a residue-free soap.
• Examining skin with each pouch change for lesions, unusual coloring, or other skin irritations like rashes or skin breakdown around the stoma.
• Checking for wartlike nodules with white-gray-brown discoloration. These lesions are pseudoverrucous lesions, caused by extension exposure of urine to the peristomal skin.¹

Because most peristomal skin complications are caused by leakage from around the skin barrier or pouch, or from irritation caused by an improperly fitting pouching system, care must be taken during basic ostomy care —

• Avoid aggressively pulling the adhesive backing away from the skin during pouch changes. When pulling off the wafer with the dominant hand, use the other hand to press on the skin that is being exposed. This will prevent accidental tearing of the peristomal skin.
• Carefully clean and dry the skin around the stoma with warm water and paper towels with every appliance change. The appliance change schedule depends upon the patient. It can range from two to six days.
• Cut the barrier wafer to the correct size. The opening of the wafer should hug the stoma, limiting the amount of the peristomal skin that will be exposed to urine.
• Correctly apply the pouch, making sure there is no opening in the seal. If an opening occurs, the patient will experience leakage.

In the morning, before eating or drinking, is the best time for a pouch change.

Lessons for a lifetime

An ileal conduit is a permanent procedure. Issues relating to everyday life and coping strategies are of paramount interest to patients and should be part of the teaching process. Patients do not need to buy a new wardrobe to accommodate the urostomy pouch. Urostomy pouches are inconspicuous under most kinds of clothing because they are designed to lie flat against the body. Pouches can be tucked inside underwear or worn outside, if desired. Patients should be instructed to avoid pressure across the stoma from tight-waisted pants, belts, and seat belts.

Most people can return to work as soon as they have recovered from surgery, usually within four to six weeks. Patients with jobs that require heavy lifting might need to adjust how they perform their work functions or discuss alternative duties. Patients may resume all prior activities with the exception of heavy lifting and contact sports like boxing, football, or wrestling. They are also free to travel. (See sidebar.)

It’s not just physical

It is not uncommon for patients to develop body image and self-esteem issues. Because of the pouch, they may see themselves as less sexually attractive to their partners, which may affect their sexual activity.⁴ Some patients may also experience sexual dysfunction. Males may have damage to the nerves governing ejaculation and erection as a result of the surgery, and females may experience dysparenia, or painful intercourse.

Communication and trust are the core of the healing process and it is important for the patient to share his or her concerns with his or her partner. Be sure patients know that —

• Sexual relations will not harm the stoma.
• The stoma should never be used as a penetration point of sexual intercourse.
• They can wear a smaller pouch during sexual activity and the pouch can be covered with specially designed underwear, lingerie, or pouch covers.
• The pouch should be emptied before sexual activity.

The wound ostomy consultant (WOC) can be a valuable resource to nurses caring for patients who have had this procedure. Together, the staff nurse and the WOC can help patients adapt to their new body change, while providing crucial guidance and education during the postoperative period.

Editor's Note: For self-study CE on bladder cancer, go to http://www2.nursingspectrum.com/CE/Self-Study_modules/syllabus.html?ID=220.

Linda Demarest, RN, BSN, CWOCN, is an enterostomal therapist at Hackensack University Medical Center — Home Care Division, East Rutherford, N.J. To comment on this article, e-mail jspillane@nursingspectrum.com.

References

1. Hampton, BG Bryant RA. Ostomies and Continent Diversions: Nursing Management. St. Louis: Mosby; 1992: 110, 257, 356.

2. Doughty DB, Lightner DJ. Genitourinary surgical procedures. In: BG Hampton & R A. Bryant. Ostomies and Continent Diversions: Nursing Management. St. Louis: Mosby; 1992:255.

3. Shannon T. Radical cystectomy and ileal diversion. Available at: http://www.hollywoodurology.com/radcyst.html. Accessed March 22, 2004.

4. Sprunk E, Alteneder RR. The impact of an ostomy on sexuality. Clin J Oncol Nurs. 200; 4:2.

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