Overview
Definition:
Ileal conduit creation is a surgical procedure that creates a diversion for urine from the ureters to a stoma on the abdominal wall, typically using a segment of the ileum
It is a common form of incontinent urinary diversion, most frequently performed after cystectomy for bladder cancer or in cases of bladder exstrophy, severe interstitial cystitis, or trauma
The stoma allows urine to exit the body into an external collection appliance.
Epidemiology:
Urinary diversion procedures are performed in thousands of patients annually worldwide
Ileal conduits remain a popular choice due to their established track record and relative technical simplicity compared to continent diversions
Incidence varies by geographic region and cancer prevalence
The majority of patients undergoing cystectomy for bladder cancer will require a urinary diversion.
Clinical Significance:
Successful ileal conduit creation and meticulous stoma management are crucial for patient quality of life, preventing complications such as infection, skin breakdown, and electrolyte imbalances
For surgeons, understanding stoma site selection, operative technique, and postoperative care is paramount to optimizing outcomes and minimizing morbidity
This procedure represents a significant functional and psychological adjustment for patients.
Indications And Contraindications
Indications:
Radical cystectomy for bladder cancer
Severe bladder dysfunction unresponsive to conservative management
Bladder exstrophy
Traumatic injury to the bladder or urethra
Radiation-induced bladder damage
Certain congenital anomalies of the urinary tract.
Contraindications:
Uncontrolled inflammatory bowel disease affecting the ileum
Significant renal insufficiency or severe comorbidities precluding major surgery
Patient refusal or inability to manage a stoma
Previous extensive abdominal surgery with adhesions compromising intestinal mobility
Morbid obesity making stoma care difficult.
Stoma Site Selection
Importance:
Optimal stoma site selection is critical for patient independence, appliance adherence, and prevention of skin complications
A well-sited stoma facilitates self-care and improves body image.
Criteria:
Visible and accessible to the patient
Located on a flat abdominal surface, away from bony prominences (ribs, iliac crest) and the umbilicus
Sufficient distance from scars, skin folds, and beltlines
Avoidance of areas prone to pressure from clothing or obesity
Palpation of the underlying rectus muscle for good vascularity and structural support
Patient involvement in site marking (e.g., in standing, sitting, and lying positions) is highly recommended.
Marking Technique:
Use a reliable marking pen
Mark multiple potential sites after considering all criteria
Have the patient review the marked sites in different positions
Educate the patient on the importance of the marked site and how to check it.
Surgical Technique And Stoma Construction
Intestinal Segment Selection:
A segment of the ileum, typically 15-20 cm, is isolated 15-20 cm proximal to the ileocecal valve
Care must be taken to preserve adequate blood supply via the mesentery
The remaining bowel is re-anastomosed to restore intestinal continuity (e.g., end-to-end or side-to-side anastomosis).
Ureteroileal Anastomosis:
The ureters are spatulated and anastomosed to the isolated ileal segment
Various techniques exist, including direct implantation or using a common stenting method
Ureteral stents may be placed to facilitate drainage and prevent early anastomotic strictures.
Stoma Formation:
The efferent limb of the ileal segment is brought out through a carefully fashioned opening in the abdominal wall (the stoma site)
The bowel is everted and secured to the skin using sutures to create a mature, flush or slightly protuberant stoma
A wide opening is avoided to prevent parastomal hernia
The stoma should ideally be 2-3 cm in diameter and protrude 1-2 cm above the skin level.
Closure And Diversion:
The bowel ends are closed or anastomosed to restore bowel continuity
The stoma is then created as described above
Meticulous hemostasis is crucial.
Postoperative Care And Stoma Management
Immediate Postoperative Care:
Monitoring vital signs, fluid balance, and electrolyte levels
Early ambulation to prevent deep vein thrombosis and improve bowel function
Nasogastric tube may be used for decompression if ileus is suspected
Pain management is essential
The urinary collection appliance (stoma bag) is applied after the surgical dressing is removed.
Stoma Care Education:
Patient and caregiver education on stoma care is critical
This includes how to empty and change the appliance, skin cleansing around the stoma, recognizing signs of infection or leakage, and managing output
A stoma nurse specialist plays a vital role in this education.
Appliance Selection And Adherence:
Choosing an appropriate ostomy appliance (one-piece or two-piece system) with a suitable wafer or barrier is essential for skin integrity and leak prevention
Regular monitoring of the skin barrier and appliance changes (typically every 3-7 days) are recommended
Proper fit is crucial to avoid peristomal skin irritation.
Dietary And Fluid Considerations:
Patients should maintain adequate hydration to promote urine flow and prevent stomal blockage
Dietary modifications may be necessary to prevent constipation or diarrhea, which can affect appliance adherence and stoma output
Monitoring for electrolyte imbalances, especially hyponatremia and hyperchloremic metabolic acidosis, is important.
Key Points
Exam Focus:
Stoma site selection criteria are frequently tested
Common early and late stoma complications and their management are high-yield
Understanding the indications for ileal conduit and its role in urinary diversion is crucial
The principles of ostomy care and prevention of peristomal skin breakdown are important.
Clinical Pearls:
Always involve the patient in stoma site selection and mark it in multiple positions
Use a properly fitting appliance to protect the peristomal skin
Educate the patient comprehensively and provide resources for ongoing support (stoma nurse, support groups)
Monitor for electrolyte imbalances, particularly hyperchloremic metabolic acidosis.
Common Mistakes:
Selecting a suboptimal stoma site that leads to appliance leaks or patient difficulty in self-care
Inadequate eversion or fixation of the stoma, leading to retraction or stenosis
Insufficient patient education, resulting in poor stoma management and complications
Failure to recognize and manage peristomal skin issues promptly
Overlooking the risk of parastomal hernia formation.