Temporary urinary diversion by ileal conduit

Comparison of Adjustment or Adaptation to the Formation of a Temporary Versus a Permanent Ostomy: A Systematic Review

PURPOSE

The aim of this systematic review was to review evidence on adjustment or adaptation to an ostomy in persons with a temporary versus permanent ostomy.

METHOD

Systematic review.

SEARCH STRATEGY

We comprehensively searched the following bibliographic databases: MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO, CINAHL, Joanna Briggs, Scopus, and EThOS and ProQuest dissertations from inception to July 21, 2021. We located 570 studies. Data were extracted into Covidence, and the risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs tool.

FINDINGS

Thirty-one studies met inclusion criteria and were included; only 2 assessed adjustment using a validated adjustment tool (Ostomy Adjustment Inventory, OAI-23). One found better adjustment in those with a permanent ostomy at 6 months; the second did not formally test for statistically significant differences between groups. Other included studies assessed aspects of adjustment such as health-related quality of life and psychological symptoms. Findings differed between studies; the majority of studies were deemed at a high risk of bias.

CONCLUSIONS

The quality of evidence among studies evaluating adjustment to an ostomy in permanent versus temporary stomas was poor; the majority did not measure adjustment using a validated adjustment instrument. Therefore, differences in the ways those with a temporary ostomy or permanent ostomy adjust or adapt remain largely unknown.

IMPLICATIONS

Further high-quality studies are needed that compare adjustment to a temporary or permanent ostomy using a validated instrument. An understanding of differences in adjustment in those with a temporary and permanent ostomy is important for planning how health care services can be better tailored to meet the needs of ostomy patients beyond the initial postoperative period of recovery.

Further experience with the ileocecal segment in urinary reconstruction

In selected patients it is possible and desirable to reconstruct a normal or near normal method of urinary drainage after temporary ileal loop urinary diversion or after cystectomy for nonurothelial pelvic malignancy. Satisfactory results have been achieved in 20 of 23 patients, with followup as long as 10 years. Seven patients have undergone reconstruction after temporary ileal conduit urinary diversion for benign conditions. One patient underwent urinary reconstruction following prolonged ileal conduit urinary diversion for radiation-induced injury to the bladder as part of treatment for cervical carcinoma. In 11 patients the ileocecal segment was used as part of a planned urinary reconstructive procedure after cystectomy for nonurothelial pelvic malignancy or when correcting a benign lower urinary tract pathologic condition that resulted in a cutaneous fistula. The ileocecal segment is a surgical unit that allows replacement or augmentation of the bladder, with the ileum substituting for as much ureteral length as necessary. However, the ileocecal valve is not effective in the long-term prevention of reflux and use of a recently described ileal intussusception technique seems preferable.

Radiology of urinary undiversion

Many patients with urinary diversions are now considered candidates for "undiversion". Radiographic evaluation prior to undiversion of the urinary tract includes cystography to determine bladder capacity and sensation, urinary continence, and the presence of reflux. Urography, loopography, and/or ureterography (antegrade and/or retrograde) are necessary to completely visualize the remaining urinary structures. Surgical techniques involved in the reconstruction are briefly discussed to facilitate an understanding of the often unusual radiographic appearance of the undiverted urinary tract. Stentograms and cystography are recommended for early postoperative evaluation to exclude urinary leakage or significant obstruction. Percutaneous ureteral perfusion studies are often useful in the long-term follow-up of these patients.

Experiences with urinary undiversion in children with neurogenic bladder

Six children have undergone reconstruction of the urinary tract 14 months to 14 years after supravesical diversion for neurogenic bladder dysfunction. Five are continent: 4 by intermittent catheterization and 1 by voiding to completion. One child is just beyond infancy and wets but is not yet on a systematic program. One boy was considered a technical failure despite incontinence because of progressive hydronephrosis from a non-compliant bladder but he subsequently had an augmentation cystoplasty. Urinary undiversion into a neurogenic bladder is an acceptable option as an alternative to ileal conduit revision or for reasons of patient preference, provided bladder storage capacity is adequate at acceptably low resting pressures, without incontinence.

The flush versus the protruding urinary stoma

All too often arbitrary or theoretical considerations are the determinants of the external stomal dimensions at the time of ureterointestinal diversion. To the patient this facet of the operation becomes one of immediate, lasting and paramount importance. A comparative analysis of the experiences of 125 stoma patients suggests that there are distinct advantages to the protruding nipple insofar as the patient is concerned. Management and clinical problems of the flush and the protruding urinary stoma are discussed.

The isolated sigmoid segment: its value in temporary urinary diversion and reconstruction

Two patients with severe bladder disease have undergone temporary urinary diversion with a sigmoid conduit as part of planned reconstruction of the lower urinary tract. Their lower urinary tracts have been reconstituted successfully by means of sigmoid cystoplasties. Experimental data further support use of the sigmoid conduit vis-a-vis use of the traditional ileal conduit for long-term diversion and reconstruction. A main advantage of the sigmoid segment is the ability to create an antirefluxing ureterointestinal anastomosis. We have demonstrated that ureteral reflux from ileal conduits produces histologic evidence of pyelonephritis. Colonic conduits, by preventing reflux, reduce the frequency of pyelonephritis and function in an equivalent manner to ileal segments when used either for cutaneous diversion or ureteral substitution in reconstruction.

Ileocecal conduit for temporary and permanent urinary diversion

The ileocecal intestinal segment has been used as a diverting conduit with a satisfactory colonic stoma in 6 patients with potentially reversible bladder disorders. Followup has been from 1 to 5 years. The ileocecal valve has been modified successfully by a fundoplication procedure similar to the Nissen esophagogastric junction operation to prevent ileocecal and ureteral reflux. IVP and renal function studies revealed resolution of pre-existing hydronephrosis and preservation of previously normal upper urinary tracts. One patient has undergone reversal of the diversion by cecocystoplasty and simultaneous bladder augmentation, and has been followed for 5 years with sterile urine and normal IVPs. The anatomic and functional advantages of a conduit with an antireflux mechanism that is applicable to the hydronephrotic collecting system are discussed.