Overview of Ileal Conduit
Urinary diversion is a medical procedure that redirects the flow of urine to exit the body in a different way. It can be a temporary or permanent solution, often used after surgery to treat bladder or pelvic cancer. However, it can also be done for other urinary tract issues that involve abnormal functions or structures. Urinary diversion can be grouped into three types: percutaneous, continent, or incontinent. This article will focus on the incontinent type, which includes two kinds: ureterostomy (where the ureter is made into a stoma), and intestinal or ileal conduit (using a small piece of intestine to create a passage for urine).
Ureterostomy is usually the last choice, used mainly in complex, life-saving procedures. The most common incontinent urinary diversion is the ileal conduit, a method where urine is guided to leave the body through the small intestine into a bag or pouch. While there are options for continent urinary diversion techniques (where the urine stays within the body and is emptied at will), the ileal conduit method remains the preferred choice in Europe, and is the gold standard, or most recommended approach, worldwide.
The ileal conduit technique was initially devised by French surgeons during the Second World War. Despite this, it became widely adopted only in 1950 when a workable adhesive bag for ileostomy (creating a stoma, or artificial opening, for waste) was designed. As cancer treatments and surgical methods have improved over time, the selection process for picking the right patients for an ileal conduit, as well as the way the surgery itself is performed, have become more sophisticated and effective.
Anatomy and Physiology of Ileal Conduit
The bladder is like a storage tank for urine, holding it until you’re ready to go to the bathroom. It’s located in your pelvis and is made mostly of muscle that can stretch to hold a lot of urine and then shrink again after you urinate.
Urine is made in the kidneys, which filter out waste and water from your blood. This fluid then travels down through tubes called ureters into the bladder. When it’s time to urinate, the bladder squeezes the urine out through another tube, the urethra.
Sometimes, for medical reasons, doctors need to create a new path for urine to leave the body. This is called an ileal conduit. They disconnect the ureters from the bladder, and instead attach them to a piece of the small intestine that has been shaped into a new pouch, or reservoir.
The ureters start up near the kidneys and run down alongside your back muscles, cross over your hip joints, and then enter your bladder from the back. They go into the bladder at an angle so that when the bladder squeezes to force out urine, it closes off the ureters. This prevents urine from going back up into the kidneys.
Ureters get their blood from different arteries depending on their position in the body. For example, the part of the ureters in the abdomen gets blood from the kidney, testicular or ovarian arteries, and branches of the large artery (the aorta) that runs through your abdomen. The portion of the ureters in the pelvis is supplied by arteries that also supply the bladder.
The ileum, which is the last part of the small bowel, connects to the large bowel. It has four layers, which start from the inside lining (the mucosa) and extend outward through the submucosa, smooth muscle, and outermost layer (the serosa). The ileum’s main job is to absorb certain nutrients and also makes some enzymes and hormones. But when it’s used to make an ileal conduit, it can absorb ammonia and chloride from the urine. This can sometimes upset the body’s acid-base balance.
Why do People Need Ileal Conduit
An ileal conduit, a type of urinary diversion, is a procedure where a part of the small intestine is used to replace the bladder. It is typically done when removing the bladder is vital to improving a patient’s health or prolonging their life. For instance, this procedure might be necessary if the patient has conditions like neurogenic bladder, which is a problem with the nerves that control the bladder, or severe bladder damage due to radiation therapy.
This procedure is often performed when the bladder hosts serious illnesses such as bladder cancer that has spread into the bladder’s muscle (stages T2-T4a), or non-muscle invasive bladder cancer that hasn’t responded to lesser treatments like BCG therapy (a type of immunotherapy for bladder cancer) or hasn’t improved after a TURBT procedure (a surgery to remove abnormal tissue from the bladder).
Moreover, an ileal conduit might be needed for patients whose bladder symptoms have a significant negative effect on their quality of life. This includes conditions like chronic pelvic pain or severe, unmanageable urinary incontinence (which means they can’t control their urine flow) in women.
When a Person Should Avoid Ileal Conduit
Your kidney health plays a big role in figuring out the best method for urinary diversion, a surgery that reroutes urine when the usual pathway is blocked or removed. The ileal conduit, a common type of urinary diversion, is a good choice for older people or those with poor kidney health. This is because the part of the bowel used is quite short, which minimizes contact time with urine.
Extended contact between the conduit and urine can lead to metabolic disturbances, particularly a condition called metabolic acidosis. This happens because chemicals like ammonia, hydrogen, and chloride get absorbed from the bowel into the body. Over time, metabolic acidosis can cause your kidney function to decline, regardless of the type of urinary diversion surgery you’ve had.
On average, kidney function naturally reduces as we age. But in people with ileal conduits, the rate of kidney health decline is even higher due to increased risks of urinary infections, blockage caused by narrowing of the ureter or presence of stones, and persistent backward flow of urine. For people with chronic kidney disease (a condition often identified by serum creatinine levels above 1.7 to 2.2 mg/dL), a continent diversion usually isn’t recommended. They would generally be offered a urinary conduit instead.
Some people might not be able to have certain types of urinary diversion due to factors such as urethral injury, past inflammatory bowel disease, and pelvic radiation. If a patient may require radiation therapy or further surgery that could harm an orthotopic diversion, a urinary conduit is a better option. Patients with severe liver disease are generally not recommended for continent diversion.
There are also certain factors that can make ileal conduit surgery more challenging. These include impaired cognition, making it difficult to learn how to manage a stoma (the artificial opening created during surgery) or to wake up regularly to empty the pouch. Manual skill deficits can also make it hard to care for an ileal conduit.
Equipment used for Ileal Conduit
To take care of the stoma (an artificial opening created on your body for waste removal), certain tools are required. These tools can be grouped into two categories: those needed during the operation (intraoperatively) and those needed for continued care after the operation (postoperatively). The details of equipment used during surgery are mentioned in the surgery technique part of your medical information.
For the long-term care of a stoma, you will need stoma bags, which collect waste, and an anti-adhesive spray, which prevents the bag from sticking to the skin. Sometimes, additional materials like stoma paste, stoma rings, and barrier cream might be necessary. This is particularly true if you have an ileal conduit (a tube created from a small part of the intestine to carry urine from the kidneys out of your body). The urine can irritate the skin, so these items help protect the stoma and surrounding area.
Who is needed to perform Ileal Conduit?
For your surgery to be carried out safely, it’s important to have a full team in the operating room. This includes a team of surgeons, anesthetic team (who put you to sleep), operating department practitioners (ODPs), a scrub team (the people who help the surgeons during the operation), and recovery nurses who look after you after the surgery. Due to the complexity of the operation, you might need special intensive care (known as ITU care), so their involvement from the beginning is crucial. Some patients with other health issues (co-morbidities) may need to visit a special clinic before surgery to make sure they are prepared and healthy for the operation.
Another important part of the preparation for surgery is meeting with stoma nurses. They’re professional nurses who will provide you with information to get ready mentally and emotionally for a significant change of having a stoma. They’re there to support you after the operation, specifically patients with a loop of the small intestine used for urinary diversion, which is called an ileal conduit. In fact, they are often the first contact for those living with an ileal conduit. Their role is to help you understand and adjust to life after the surgery.
Preparing for Ileal Conduit
Getting ready for surgery is very important for the results after the operation. When someone is preparing for an ileal conduit procedure, there are several steps involved. This process begins with an initial meeting where the doctor explains the diagnosis and details about the operation. This meeting also includes explaining what it means to have an ileal conduit, or a tube made from a piece of the small intestine to allow urine to pass from the kidneys to the outside of the body.
The patient may also need to meet with other medical team members to ensure their heart health is in good shape. This could include special tests and exercise programs. It’s also important for the patient to understand both the practical and emotional aspects of living with a stoma. A stoma is a small opening on the outside of the abdomen that’s made during the operation.
Choosing the right place for the stoma is a delicate process. The patient will often try wearing a stoma bag filled with water in different positions and clothing styles to make sure it is comfortable and practical. The surgeon needs to make sure the stoma isn’t positioned on a scar or skin crease, or under the belt line. Guidance and support from the stoma nurses are crucial from the very beginning, so the patient knows what to anticipate after the operation. Their knowledge can help patients recover more quickly after their surgery.
How is Ileal Conduit performed
An ileal conduit is a type of surgical procedure, and it can be done in a few different ways: through open surgery or through minimally invasive methods such as laparoscopic (using a tiny camera and tools) or robotic surgery. Here are the basic steps.
In the first phase, the surgeon selects a part of the small intestine (specifically, a 15 cm piece of the ileum that’s located 15 cm from a section called the ileocecal junction). This piece is inspected to ensure it’s healthy and doesn’t show signs of diseases like inflammatory bowel disease. The surgeon also makes sure this piece can easily reach the future stoma site – where the tip of the diverted intestine comes out on your belly – without any tension before they separate it from the rest of the intestine. They’re careful to not affect the blood supply while doing so. After separation, this small piece is then reconnected to the rest of the ileum using surgical staples or stitches.
Next, the surgeon carefully moves the ureters, which are the tubes that transport urine from your kidneys to your bladder. The surgeon does this carefully to avoid injury. The left ureter is moved to the right side of the belly through an opening created behind the colon. During this step, the surgeon ensures they don’t disturb the blood supply to the colon and that the ureter isn’t under any tension.
The third phase involves connecting the ureters to the isolated piece of the intestine, a process known as ureteroenteric anastomosis. There are different ways to do this, but the most important part is that the connection should be secure, without compromising blood supply, and with no kinks or twists in the tubes.
Finally, the surgeon forms the stoma, which is the opening on the belly where urine will exit the body. This is done by creating an incision, or cut, in the skin and then guiding the end of the intestine through this incision. The surgeon makes sure that the intestine doesn’t twist while doing this. The stoma is then finished and shaped to ensure the skin around it doesn’t get irritated.
This kind of surgery takes a lot of precision and care. The surgeons want to make sure they do everything they can to prioritize your health and comfort during the process.
Possible Complications of Ileal Conduit
Urinary conduits, a kind of urinary diversion surgery, are generally easier to perform than other kinds. This is because they involve a less complicated surgical procedure and take less time. This type of surgery doesn’t need to be connected to the urethra and needs a smaller section of bowel to create the conduit. Compared to creating a neobladder (an artificial bladder), an ileal conduit needs minimal changes.
Complications from this surgery can happen either soon after the surgery (within 90 days) or much later. The early complications involve issues with the bowel, such as a blockage, leakage at the surgical connection, or a condition called ileus which involves the bowel not working properly. This can happen in up to 20% of operations and can often cause a longer hospital stay. Another concern is urine leaking from the surgical connection, accounting for roughly 7% of early problems.
Problems that occur much later include issues with the new stoma (an opening on the surface of the abdomen which the conduit connects to). Examples are hernias, shrinkage or narrowing of the stoma, and bleeding. Some people can also have frequent urinary tract infections (UTIs) and up to 6% might end up with kidney failure. These patients are also at a higher risk of developing kidney stones, which can be detected with ultrasound imaging. It’s also not uncommon to face significant metabolic issues post-surgery and these patients need regular check-ups to monitor their electrolyte (body’s salt) levels, and to ensure they’re not too acidic. It’s good to note that learning to live with a stoma can be mentally challenging and it’s important that patients get the proper counselling beforehand.
What Else Should I Know About Ileal Conduit?
When a segment of the lower part of the small intestine is removed to create a urinary pathway (ileal conduit), this could cause a lack of vitamin B12. The lower part of your small intestine plays a crucial role in absorbing certain nutrients like, B12 and Magnesium.
Our bodies usually have a large supply of vitamin B12, so this deficiency might not show up until a few years after surgery. This shortage can increase your risk of developing types of anemia (low red blood cells) and some nerve-related issues in the spine. To prevent this, make sure to regularly check your Vitamin B12 levels during doctor’s appointments every 6-12 months.
Surgeons are advised to remove as little as possible of this part of the intestine to reduce the risk of deficiency. This is particularly important for patients with diseases, like Crohn’s disease, that affect the intestines.
Another potential complication after this procedure is a kind of metabolic disorder, mainly seen in around 15% of patients, especially those who have kidney problems. This can lead to a condition called osteoporosis, which makes your bones weak and more likely to break. Hence, patients should also regularly get a blood test for up to 15 years after the operation to detect metabolic abnormalities.
