@UrologyQuiz Quiz8 Answer: Ileal Conduit (aka urostomy) demonstrating the stomal portion

Advantages of ileal conduit

Simple, technically easier than an orthotopic diversion (continent diversion or neobladder) Reliable Fewer complications No bladder retraining No nocturnal incontinence Less postoperative resources, well understood by health professionals So ideal patients for ileal conduit (or other diversion) are those that cannot have neobladder being: 1. Chronic renal failure with serum creatinine exceeding 2 mg/dl without acute hydronephrosis. In doubtful cases percutaneous drainage is indicated preoperatively in an attempt to normalise renal function. 2. Severe hepatic failure. 3. Compromised intestinal function especially caused by radiation or inflammatory bowel disease. 4. The presence of histologically proven cancer at the prostatic apex (male) or bladder neck (female) 5. Lack of patient motivation and/or intellect to follow a strict postoperative voiding regime, to accept possible incontinence (mainly nocturnal) in the early post-operative phase and sometimes in the long-term. 6. Pelvic floor disorders such as detrusor sphincter dis-synergia or neurourological diseases.

Complications of an ileal conduit (normal bled, infection, DVT, PE etc. not discussed)
Complications occur in at least 30% of patients
Early Bowel related (ileus) Intestinal anastomosis related (leak) Ureteral-ileal anastomosis leakage Enteric stula Bowel obstruction Prolonged ileus Conduit necrosis Late Stoma related (parastomal hernia, stenosis) Abdominal wall related (hernia) Conduit stenosis Uretero-enteric anastomosis Stricture Hydronephrosis Kidney failure Metabolic changes

Full discussion: Prevention and management of complications following radical cystectomy for bladder cancer. Lawrentschuk N, Colombo R, Hakenberg OW, Lerner SP, Mnsson W, Sagalowsky A, Wirth MP. Eur Urol. 2010 Jun;57(6):983-1001 http://www.ncbi.nlm.nih.gov/pubmed/20478600

Alternatives to ileal conduit are: Incontinent urinary diversion 1. (Transuretero-) Ureterocutaneostomy 2. Ileal and colonic conduits

Continent urinary diversion A. Continent catheterizable reservoir B. Orthotopic neobladder C. Ureterosigmoidostomy

Teaching Points: 1) The advantages of a conduit relate to simplicity, reliability and familiarity 2) However , ALL diversions have complications and people involved need to understand them 3) In many centres a fit person who does not have contraindications a neobladder is the preferred option over an ileal conduit in many instances but this is by no means a settled argument based on quality of life

References: http://www.uroweb.org/fileadmin/ESU/Poland/Stenzl%20-%20Key%20paper.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532542/; http://www.ncbi.nlm.nih.gov/m/pubmed/327103/

By @lawrentschuk Editor-in-Chief @UrologyQuiz Assoc. Professor Nathan Lawrentschuk, University of Melbourne AUSTRALIA