Urinary Reconstruction Options
- After radical cystectomy, or the removal of the bladder, there are several different techniques that can be used to restore urinary function.
- The three main options include urostomy (ileal conduit), where urine drains continuously into an external pouch, neobladder, where an artificial bladder is created from parts of the intestine, and the continent cutaneous pouch, which is an internal reservoir that empties into a catheter.
- Your surgeon will recommend the most appropriate option based on several factors, including your overall health, age, previous surgeries, kidney function, radiation history, and your ability to manage certain care routines after surgery.
- Your personal preferences should be part of the treatment decision as well.
“The bladder is a storage organ and you have to figure out how you’re going to store the urine and how you’re going to get the urine out of the body,” Dr. Piyush Agarwal, a urologic oncologist at the University of Chicago, tells SurvivorNet.
Read MoreWhy Urinary Diversion Is Needed
The bladder plays a crucial role in the urinary system. It acts as a storage organ for urine produced by the kidneys. Normally, urine travels from the kidneys through tubes called ureters into the bladder, where it is stored until it is expelled through the urethra. But when the bladder is removed because of cancer, the body needs a new way to collect and eliminate urine. Urinary diversion surgery aims to create a new pathway for urine to exit the body safely.Although every patient’s situation is unique, there are generally three major urinary diversion options after a radical cystectomy:
- Urostomy (ileal conduit)
- Neobladder
- Continent cutaneous pouch
Each approach works differently and comes with its own advantages and challenges.
Your surgeon will recommend the most appropriate option based on several factors, including your overall health, age, previous surgeries, kidney function, whether you have had previous radiation, and your ability to manage certain care routines after surgery.
Urostomy (Ileal Conduit)
The urostomy, also known as an ileal conduit, is the most common type of urinary diversion performed after bladder removal.
This procedure involves creating a small opening in the abdomen called a stoma, which allows urine to leave the body continuously. During the surgery, the surgeon removes a small segment of the small intestine and uses it as a passageway for urine.
“We make an opening in the abdomen and create what’s called a urostomy or an ostomy,” Dr. Agarwal explains. “Essentially we take a piece of intestine and use it as a conduit to carry the urine from the ureters out of the body through an opening in the skin called the stoma.”
In other words, the ureters (which normally connect to the bladder) are instead attached to a small piece of intestine. That intestinal segment directs urine to the stoma. From there, urine drains into a small external pouch worn on the abdomen.
The pouch attached to the stoma collects urine throughout the day. It is designed to be discreet and worn under clothing. Patients empty the bag periodically using a valve at the bottom. Most people empty the pouch several times per day.
At night, some patients connect their pouch to a larger drainage bag to allow uninterrupted sleep.
Modern ostomy appliances are designed to:
- Prevent leaks
- Protect the skin around the stoma
- Reduce odor
- Stay discreet under clothing
Adjusting to life with a stoma can take time. For many patients, the first few weeks after surgery involve learning how to care for the stoma and change the pouching system.
A specialized nurse, often called a stomal therapy nurse or ostomy nurse, typically provides guidance and training.
Early after surgery, the stoma may appear swollen and may produce mucus. This is normal because the intestinal segment used in the diversion continues to produce mucus naturally.
Over time, most patients adapt to the routine of caring for the pouch and regain confidence in their daily activities.
People with a urostomy can typically return to many of their normal activities, including work, exercise, travel, and even swimming.
The adjustment period can be emotional as well. Concerns about body image, intimacy, and relationships are common, but many patients find that with time and support, they are able to return to a normal life.
Neobladder
Another option is the neobladder, which attempts to recreate a bladder using a segment of the small intestine. Instead of directing urine to an external pouch, surgeons construct a new internal reservoir that is connected to the urethra. This means patients can still urinate through the urethra in a way that resembles natural urination.
“In patients who are really motivated, we can build an artificial bladder out of their intestine using small intestine, and that’s called a neobladder,” Dr. Agarwal explains. “It’s a little bit of a euphemism … nothing is as good as the bladder you were born with. But if that bladder has cancer and it has to be removed, a neobladder is something that can store your urine.”
During this surgery:
- A section of small intestine is reshaped into a pouch
- The ureters are connected to this new reservoir
- The pouch is connected to the urethra
- Urine then flows from the kidneys into the neobladder and is released through the urethra
Although this approach avoids a stoma and external pouch, it requires learning a new way to urinate.
Unlike a normal bladder, the neobladder does not have the same nerve signals that tell you when it is full. Patients must learn to empty the neobladder at regular intervals.
In the early months after surgery, people may need to urinate every 2 to 3 hours. Over time, the reservoir stretches and can hold more urine. Eventually, many patients can go 4 to 6 hours between emptying.
“With time, you can get really good urinary control,” Dr. Agarwal says.
Still, some challenges may remain. For example, some patients may experience urine leakage at night, especially during the first year after surgery. Neobladders can also produce mucus because they are made from intestinal tissue. This mucus may appear as threads in the urine.
Continent Cutaneous Pouch
A third option is the continent cutaneous pouch, sometimes called a continent urinary diversion.
“In patients who are not candidates for a neobladder but do not want the urostomy, we can build what’s called a continent cutaneous pouch,” Dr. Agarwal explains.
In this surgery, a surgeon creates an internal reservoir using a piece of intestine. This pouch stores urine inside the body. Unlike the ileal conduit, urine does not drain continuously. Instead, patients empty the pouch using a catheter inserted into a small stoma on the abdomen several times per day.
“There is a channel that goes to the skin and they can use a catheter to drain that pouch when it fills up with urine,” Dr. Agarwal explains.
One common type of continent pouch is known as the Indiana pouch, named after the institution where it was first developed.
People with a continent pouch typically insert a catheter four to five times per day to empty the reservoir. Because the pouch remains inside the body, this option does not require wearing an external bag. However, it requires comfort with self-catheterization, which not every patient prefers.
Choosing The Right Urinary Diversion
There is no single “best” urinary diversion. The right choice depends on each patient’s medical condition and lifestyle preferences.
Factors that may influence the decision include:
- Kidney function
- Age and overall health
- Prior abdominal surgeries
- Whether radiation therapy has been used
- Manual dexterity and mobility
- Patient preference
Some patients prefer the simplicity of a urostomy. Others value the body image advantages of a neobladder or continent pouch.
Surgeons typically discuss these options before surgery to help patients choose the approach that aligns best with their goals and health status.
Life After Urinary Diversion
Although urinary diversion represents a major life change, many patients return to their normal activities after recovery.
Support from healthcare professionals plays an important role during this transition. Nurses, surgeons, and physical therapists often help patients learn how to manage their urinary diversion and adapt to new routines.
Patients may also benefit from speaking with others who have undergone similar surgeries.
Beyond the physical recovery, emotional adjustment is an important part of the journey. Some patients experience anxiety or concerns about body image, especially if they have a stoma or urinary pouch. These feelings are normal.
Over time, most patients gain confidence managing their new urinary system and resume fulfilling lives. For patients facing bladder cancer surgery, understanding these options and discussing them with an experienced surgical team can make the road ahead feel more manageable.
And while urinary diversion requires adjustment, many patients discover that life after bladder surgery can still be active, meaningful, and full.
Questions To Ask Your Doctor
- Which urinary diversion option do you recommend for me and why?
- What potential side effects should I be aware of as I adjust?
- Are there resources I can use to help me adjust?
- How will I be monitored after surgery?
Learn more about SurvivorNet's rigorous medical review process.
