Page 223 - Urological Health

With orthotopic urinary diversion, you learn to void by
straining (bearing down) to increase pressure on the low
pressure bladder. Normally this tightens the valve which you
need to relax. Most patients have good control during the
day, but during the night, they may lose urine as the muscle
of the bowel still contracts resulting in pressure of urine
against the valve which may be compromised after bladder
and prostate removal. Some doctors keep a portion of the
prostate in the patient (as opposed to total removal) to
improve urine control and to avoid loss of erectile function.
This decision is balanced with the risk of leaving prostate
and bladder cancer which can be difficult to manage.

With the heterotopic neobladder, you need insert a soft
plastic/rubber tube yourself through the one-way stoma
three to four times a day (sometimes more) to empty the
Figure 6. The catheterizable Indiana pouch bladder (this is called self-catheterization). You need good
(heterotopic). A detubularized large bowel hand coordination. As long as the neobladder is completely
(cecum) and small bowel (ileum) with emptied, there is little risk of infection. You may also have
catheterizable stoma and drains coming out
to skin at umbilicus (belly button). to rinse the neobladder to make sure it is clear of mucus.
UNDER REVIEW
This is required more frequently at first.
If you have an orthotopic neobladder, you may also need to self-catheterize to rinse your bladder
in case you can’t completely empty it and to make sure it is clear of mucus. Continent urinary diversion
requires a longer length of bowel (up to 90 cm). Neobladders result in greater reabsorbtion of waste
products and salts requiring the kidneys to work harder. As such, good renal (kidney) function is
required and it is important that it is assessed prior to planning surgery. Most centres require a
creatinine clearance (a measure of renal function) of greater than 60 mL/minute before
recommending continent diversion. Neobladders are at higher risk for requiring additional surgery for
ureteric and stomal strictures (scar tissue that narrows or blocks these tubes).The incidence of this can
be 20–30%.

You are not a candidate for continent diversion if:

• You are an elderly patient with other medical problems
• You have a spinal cord injury, such that you can’t look after the neobladder
• You live in a remote area, far away from a specialized neobladder care

• You have renal disease that is likely to progress (proteinuria [protein in the urine]
and low creatinine clearance)

• You have a bowel disease (Crohn’s disease, ulcerative colitis, prior bowel resections)
• You have had high-dose radiotherapy to the abdomen and pelvis

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