A Common Diversion
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.
conduit provides a surgical option to patients with altered
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.
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
- 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
- Examining skin with each
pouch change for lesions, unusual coloring, or other skin
irritations like rashes or skin breakdown around the
- 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
It’s not just
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.
- Carry stoma supplies in hand
- Pre-cut the wafer if traveling
by air (scissors are not allowed in hand
- Pack extra supplies (twice
what is usually required).
- Fasten seat belt above or
below the stoma
- Store supplies in a cool place
(heat can melt adhesive).
- Carry product order numbers to
- Wear a medic alert bracelet
that indicates altered urinary anatomy.
Note: For self-study CE on bladder cancer, go
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 email@example.com.
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.
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.