A urostomy or urinary diversion is a surgical opening that enables urine to bypass the bladder and urethra. The word urostomy derives from the Greek words ouran (urine) and stoma (opening). Specialists perform it as a result of bladder cancer, chronic inflammation or neurological bladder dysfunction, and malfunctions or defects in kidneys, ureter, and urethra.
During the procedure, a surgeon removes the ureters from the bladder. Urine flow remains through the ureters and evacuates into a urostomy bag that affixes to the abdomen. Thy may remove or leave the bladder, and the creation of the type of stoma will vary according to the procedure.
“A urostomy is the least common of the three main types of stoma. […] A urostomy is formed to pass urine from the body via the abdomen. A small segment of bowel is used as a passage (conduit), often the ileum, giving the name ileal conduit. The bowel is isolated and one end is oversewn and the ureters are attached. Generally immediately after surgery, there are stents in situ to prevent the anastomosis between the ureter and bowel from stenosing. Ileal conduits are an improvement on the ureterostomy, where the ureters were brought to the surface of the skin often resulting in problems such as stenosis of the ureters. A urostomy is nearly always a permanent end stoma. The appropriate appliance to use is a drainable bag with a tap or bung. As part of the bowel is used to form the urostomy the urine will also contain small amounts of mucus. The appliance is usually emptied four to six times daily, as the appliances have a maximum capacity of about 400ml. This is about the same frequency as a bladder requires emptying. The appliance is generally replaced on alternate days but may be more or less frequent. The volume passed will vary depending on the volumes consumed, but can be about 1.5 liters daily. A urostomy is usually situated in the right iliac fossa and is similar in appearance to an ileostomy. The urostomy is warm, red and moist with a 2.5cm spout and is about 30mm diameter.”1
Before the surgery, the ostomy surgeon should discuss and mark the stoma’s placement. This is a very important step. The ostomy patient must be able to see it and have easy access. In most cases, an ileal conduit goes below the waist and to the right of the belly button. A colon conduit goes exactly opposite to the left of the belly button.
Types of Urostomy
The names of the three main urostomy procedures are associated with the body part that makes the stoma.
- Ileal conduit. It is the resection of a minor portion of the ileum (small intestine) and its corresponding blood supply. Surgeons attach one end of the resected ileum to the abdominal wall to create a stoma while sewing the other and connecting it to the two ureters. This action disables the passage between ureters and bladder. The urine now flows directly from the kidneys to the stoma through the ileal conduit, and finally into a urostomy bag. The surgeon reconnects the remaining part of the small intestine to restore the digestive function.
- Colon conduit. It is similar to the ileal conduit, except that the conduit here composed of a colon segment. Accordingly, this stoma is bigger than when using the small intestine, thus the urostomy bag will have a slightly larger diameter. Aside from this, the mechanics are the same as in the ileal conduit.
- Ureterostomy. In this procedure, the surgeon connects each ureter to the abdominal wall, creating one or two stomas. The former is called a transureteroureterostomy and occurs when the ureters are linked internally and one ureter makes the stoma, requiring only one ostomy bag to collect urine. The latter is called a bilateral ureterostomy and occurs when each ureter comes out the abdomen surface, thus creating two stomas and requiring two ostomy bags. The bladder no longer functions, but the surgeon avoids using the large or small intestine, though they seldom perform this procedure.
“Cutaneous ureterostomy is the simplest form of incontinent urinary diversion with an attached urine storage appliance. Despite its procedural simplicity, cutaneous ureterostomy has not been the standard method for incontinent urinary diversion because of stromal stenosis. Thus, several attempts have been made to prevent stenosis. Several surgical factors give rise to stromal stenosis: dissection of the ureter to preserve lymph vessels, avoiding excess tension on the ureter, and the formation of the flap or fistulae between the dissected ureter and the skin. In order to overcome these problems, surgeons should continue to deliberate on the anatomical and histological considerations and preoperative design. Without such consideration, high-quality results may not be reproducible. Taking the above problems into consideration, it may be possible to successfully accomplish cutaneous ureterostomy.”2
The Continuous Urine Flow
Once the urostomy starts working, urine flows continuously.
“Because urine flows continuously from an incontinent urinary diversion, placement of the pouch is more challenging than with the fecal diversion. In the immediate postoperative period, urinary stents extend out from the stoma. […] The surgeon places these stents into the ureters to keep them from becoming stenosed or closed at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon. The stoma is normally red and moist. It is made from a portion of the intestinal tract, usually the ileum. The stoma should protrude above the skin. An ileal conduit is usually located in the right lower quadrant. While the patient is in bed, the pouch may be connected to a bedside drainage bag to decrease the need for frequent emptying. When the patient goes home, the bedside drainage bag may be used at night to avoid having to get up to empty the pouch. Each type of urostomy pouch comes with a connector for the bedside drainage bag. Incorrect pouch placement, large volumes of urine in the pouch or a urinary pouch without an antireflux valve promotes reflux and the risk of infection. You can reduce the risk of reflux by attaching the urinary pouch to straight drainage when high urinary output is expected. A patient must understand the importance of draining the pouch when it is 1/3 to ½ full and using a clean technique during stomal and skincare.”3
The urostomy bag has to be emptied a few times daily, and it is recommended that at night it be attached to a night drainage system.
Night Drainage System for Urostomies
“A night drainage system is a large collection bag that is similar to a catheter drainage bag. The urostomy pouch is attached by a drainage tube to the larger collection bag to ensure that the smaller urostomy pouch is never full and that the patient does not have to wake up in the middle of the night to empty. In addition, keeping the urine away from the stoma prevents the formation of urinary crystals. When alkaline urine bathes the stoma or peristomal skin in an ill-fitting pouching system, crystals will appear as white gritty deposits form. To acidify the urine, vitamin C may be recommended, and the peristomal skin can be treated with vinegar soaks at each appliance change. Another method of treating the crystals is the application of an acidic washer around the stoma on the peristomal skin under the regular faceplate.”4
Difficulties with night drainage equipment
“Most patients with urinary stomas pass a greater volume of urine overnight than can be contained in their urostomy bag. Some patients choose to wake and empty their bags during the night but the majority connect their stoma bag to the night drainage equipment. Some patients use leg bags, particularly if they change their position frequently while sleeping. A history of urostomy bags lifting or leaking at night even though someone is using a night drainage system almost always indicates that urine is not flowing adequately from the stoma bag into the secondary bag. Patients should be taught to pay particular attention to two points in the system when setting it up, and if the drainage does not readily occur.
(1) The connection between urostomy bag and night drainage bag tubing
Boxes of urostomy bags usually contain connector taps or tubing for use with night drainage and leg bags. Connectors may need to be kept and cleansed then the bags are discarded so patients always have sufficient connecting equipment. Where manufacturers do not supply secondary drainage equipment with their stoma bags it is essential to check that the connector is of a size that is fully compatible with both stoma and night drainage equipment.
Patients must ensure there is no twisting of their stoma bag, for example from tension in the way the equipment is set up, as that can prevent urine flowing from one to the other. A small amount of urine can be left in the urostomy bag so that following connection to the night drainage system, patients can observe whether it empties freely into the secondary bag before they go to sleep.
(2) The connection between the night drainage tubing and secondary drainage bag
Kinks in the section where the tubing joins the secondary drainage bag opening prevent urine flowing into the bag. The resultant collection of urine in tubing and stoma bag is the commonest cause of leakage from urostomy equipment at night. Correct use of a night drainage hanger should enable this connecting are to be kept straight, so urine flows into the secondary drainage bag, leaving the urostomy bag reasonably empty.
Demonstration of how, exactly, patients set up their night equipment may reveal they are hanging the secondary equipment too high for their bed height (so urine has to go uphill in the tubing before entering the night drainage bag). They may be lying the night drainage bag on the floor in order to let urine drain down into it, but in so doing kinking the tubing to a bag section, or allowing it to twist, creating a blockage. Patients who do not wish to use a hanger may use two safety pins to pin the drainage bag to the bottom bed sheet using the hanger holes. A third safety pin can then be pinned across the tubing just above its connection with the bag to prevent kinking at the joint.
Curtailment of fluids during the evening so that less urine is passed overnight should be discouraged. Fluid intake spread over patients’ waking hours should be sufficient to produce an output of 1000-1800 ml urine in 24 hours in order to reduce the risk of urinary infection or stone formation.”5
Although the user should change the ostomy bag according to personal preference, ideally it should not exceed 3 days.
“The urinary system is a simple network with complex functions. It plays a role in fluid balance, electrolyte balance, acid-base balance, and excretion of waste. To maintain healthy kidney function, drink sufficient fluids to keep the urine diluted. If urine color is darker than usual, it is an indication of concentrated urine which requires an increase in fluid intake. Certain foods and drugs can discolor the urine or produce a strong odor. Urine pH is defined as the fluid’s degree of acidity or alkalinity. When the food we eat is burned in the body, it yields a mineral residue called ‘ash.’ This ash can be either acidic or basic (alkaline) depending on whether the food that is ‘burned’ contains mostly acidic or basic ions. Most fruits and vegetables actually give an alkalinized ash and tend to alkaline the urine. Meats and cereals will usually produce acidic ash.”6
“Surgery for urinary diversion has been performed for more than a century. Some techniques, such as ureterosigmoidostomy, have been abandoned because of serious complication rates. During the last decade, continent orthotopic diversion is considered the procedure of choice because it closely resembles physiological urine evacuation and is associated with improved quality of life compared with other techniques. However, regarding complications, including UTIs, there is a lack of evidence concerning the best way to replace lower urinary tract integrity after cystectomy. Thus, additional research is required to determine the incidence of infectious and other complications in patients with different types of urinary diversion and the preferable treatment that should be instituted.”7
Different sources may provide support to ostomates. An ostomy nurse can help with various aspects of ostomy care, such as skin healing, ostomy bags, complications and changes in the stoma over time. Other people find support groups helpful, either personally or online. Ostomy patients should find a place or a health care provider that offers reliable information, as various situations may occur even years after the surgery, so if anything occurs, they know where to find assistance. Seek a professional if you have problems with your urostomy.
(1) Burch, J. (Ed.). (2008). Stoma care. John Wiley & Sons. Available online at https://books.google.co.ve/books?id=oYg1t5a-RdoC&pg=PA6&dq=urostomy&hl=es-419&sa=X&ved=0ahUKEwiWkLXsh7ziAhUHjlkKHR9VAK0Q6AEIQzAE#v=onepage&q=urostomy&f=false
(2) Wada, Y., Kikuchi, K., Imamura, T., Suenaga, T., Matsumoto, K., & Kodama, K. (2008). Modified technique for improving tubeless cutaneous ureterostomy by Ariyoshi method. International journal of urology, 15(2), 144-150. Available online at https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1442-2042.2007.01948.x
(3) Perry, A. G., Potter, P. A., & Ostendorf, W. (2015). Nursing Interventions & Clinical Skills-E-Book. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=6TocBgAAQBAJ&pg=PA531&dq=urostomy+procedure&hl=es-419&sa=X&ved=0ahUKEwj52eq6iLziAhXDs1kKHdbrB24Q6AEISjAE#v=onepage&q=urostomy&f=false
(4) Colwell, J. C., Goldberg, M. T., & Carmel, J. E. (2012). Fecal & Urinary Diversions-E-Book: Management Principles. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=u7x6AII_zdMC&pg=PA409&lpg=PA409&dq=urostomy+appliances+and+accessories+PDF&source=bl&ots=9m97qx45gL&sig=ACfU3U10fe9f-1Oni1DK69RV6C4Ejbungg&hl=es-419&sa=X&ved=2ahUKEwiHjtGNsbriAhUlxVkKHYt5D_I4MhDoATAAegQICRAB#v=onepage&q=urostomy&f=false
(5) Breckman, B. (Ed.). (2005). Stoma care and rehabilitation. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?id=F7NE_iXpEvgC&pg=PA295&dq=urostomy&hl=es-419&sa=X&ved=0ahUKEwjigeuaiLziAhWs1lkKHcJYBmMQ6AEIMTAB#v=onepage&q=urostomy&f=false
(6) Akbulut, G. (2011). Nutrition in stoma patients: a practical view of dietary therapy. International Journal of Hematology and Oncology, 28(4), 061-066. Available online at http://www.uhod.org/pdf/PDF_452.pdf
(7) Falagas, M. E., & Vergidis, P. I. (2005). Urinary tract infections in patients with urinary diversion. American journal of kidney diseases, 46(6), 1030-1037. Available online at https://www.ajkd.org/article/S0272-6386(05)01352-1/pdf