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.