CUTANEOUS URINARY DIVERSIONS
The ileal conduit, the oldest of the urinary diversion procedures, is considered the gold standard because of the low number of complications and surgeons’ familiarity with the procedure. In an ileal conduit, the urine is diverted by implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall. This loop of ileum is a simple conduit (passageway) for urine from the ureters to the surface. A loop of the sigmoid colon may also be used. An ileostomy bag is used to collect the urine. The resected (cut) ends of the remaining intestine are anastomosed (connected) to provide an intact bowel.
Stents, usually made of thin, pliable tubing, are placed in the ureters to prevent occlusion secondary to postsurgical edema. The bilateral ureteral stents allow urine to drain from the kidney to the stoma and provide a method for accurate measurement of urine output. They may be left in place 10 to 21 days postopera-tively. Jackson-Pratt tubes or other types of drains are inserted to prevent the accumulation of fluid in the space created by removal of the bladder.
After surgery, a skin barrier and a transparent, disposable uri-nary drainage bag are applied around the conduit and connected to drainage. A custom-cut appliance is used until the edema sub-sides and the stoma shrinks to normal size. The clear bag allows the stoma to be seen and the patency of the stent and the urine output to be monitored. The ileal bag drains urine constantly (not feces). The appliance (bag) usually remains in place as long as it is watertight; it is changed when necessary to prevent leak-age of urine.
Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel ob-struction, ileus, and stomal gangrene. Delayed complications in-clude ureteral obstruction, contraction or narrowing of the stoma (stomal stenosis), renal deterioration due to chronic reflux, pyelo-nephritis, and renal calculi.
In the immediate postoperative period, urine volumes are moni-tored hourly. An output below 30 mL/h may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis. Throughout the patient’s hospitalization, the nurse monitors closely for complications, re-ports signs and symptoms of them promptly, and intervenes quickly to prevent their progression.
A catheter may be inserted through the urinary conduit if pre-scribed to monitor the patient for possible stasis or residual urine from a constricted stoma. Urine may drain through the bilateral ureteral stents as well as around the stents. If the ureteral stents are not draining, the nurse may be instructed to irrigate them with 5 to 10 mL of sterile normal saline solution. It is important to avoid any tension on the stents because this may dislodge them. Hematuria may be noted in the first 48 hours after surgery but usually resolves spontaneously.
Because the patient requires specialized care, a consultation is ini-tiated with an enterostomal therapist or clinical nurse specialist in skin care. The stoma is inspected frequently for color and viabil-ity. A healthy stoma is beefy red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. If cyanosis and a compromised blood supply per-sist, surgical intervention may be necessary. The stoma is not sen-sitive to touch, but the skin around the stoma becomes sensitive if urine or the appliance irritates it. The skin is inspected for (1) signs of irritation and bleeding of the stomal mucosa, (2) encrustation and skin irritation around the stoma (from alkaline urine coming in contact with exposed skin), and (3) wound infections.
Moisture in bed linens or clothing or the odor of urine around the patient should alert the nurse to the possibility of leakage from the appliance, potential infection, or a problem in hygienic management. Because severe alkaline encrustation can accumu-late rapidly around the stoma, the urine pH is kept below 6.5 by administration of ascorbic acid by mouth. Urine pH can be de-termined by testing the urine draining from the stoma, not from the collecting appliance. A properly fitted appliance is essential to prevent exposure of the peristomal skin (skin around the stoma) to urine. If the urine is foul-smelling, the stoma is catheterized, if prescribed, to obtain a urine specimen for culture and sensitivity testing.
Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes many patients to feel anxious. To help relieve this anxiety, the nurse reassures the patient that this is a normal oc-currence after an ileal conduit procedure. The nurse encourages adequate fluid intake to flush the ileal conduit and decrease the accumulation of mucus.
Various urine collection appliances are available, and the nurse is instrumental in selecting an appropriate one. The urinary appli-ance may consist of one or two pieces and may be disposable (usu-ally used once and discarded) or reusable. The choice of appliance is determined by the location of the stoma and by the patient’s normal activity, manual dexterity, visual function, body build, economic resources, and preference.
A reusable appliance has a faceplate that is attached to the skin surface with cement or adhesive. Either reusable pouches or dis-posable pouches may be used with the reusable faceplate. Dis-posable appliances have the advantages of having a surface that is already prepared for application to the skin and of being light-weight and easy to conceal. A skin barrier must be used to pro-tect the skin from excoriation due to exposure to the urine.
Patient education begins in thehospital but continues into the home setting because patients are usually discharged within days of surgery. The nurse teaches the patient how to assess and manage the urinary diversion as well as how to deal with body image changes. An enterostomal therapist is invaluable in consulting with the nurse on various aspects of care and patient education.
The patient and family are taught toapply and change the appliance so that they are comfortable carry-ing out the procedure and can do so proficiently. Ideally, the appliance system is changed before the system leaks and at a time that is convenient for the patient. Many patients find early morn-ing most convenient because the urine output is reduced. A vari-ety of appliances are available; an average collecting appliance lasts 3 to 7 days before leakage occurs.
Regardless of the type of appliance used, a skin barrier is es-sential to protect the skin from irritation and excoriation. To maintain peristomal skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. The patient is instructed to avoid moisturizing soaps when cleaning the area because they in-terfere with the adhesion of the pouch. Because the degree to which the stoma protrudes is not the same in all patients, there are various accessories and custom-made appliances to solve in-dividual problems. Guidelines for applying reusable and dispos-able systems are presented in Chart 45-15.
The patient is instructed to avoid foods thatgive the urine a strong odor (eg, asparagus, cheese, eggs). Today, most appliances contain odor barriers, but a few drops of liquid deodorizer or diluted white vinegar may be introduced through the drain spout into the bottom of the pouch with a syringe or eyedropper to reduce odors. Ascorbic acid by mouth helps acid-ify the urine and suppress urine odor. Patients should be cau-tioned about putting aspirin tablets in the pouch to control odor because they may ulcerate the stoma. Also, the patient is re-minded that odor will develop if the pouch is worn too long and not cared for properly.
The patient is instructed toempty the pouch by means of a drain valve when it is one-third full because the weight of the urine will cause the pouch to separate from the skin if filled more. Some patients prefer wearing a leg bag attached with an adapter to the drainage apparatus. To promote uninterrupted sleep, a collecting bottle and tubing (one unit) are snapped onto an adapter that connects to the ileal appliance. A small amount of urine is left in the bag when the adapter is attached to prevent the bag from collapsing against itself. The tubing may be threaded down the pajama or pants leg to prevent kinking. The collecting bottle and tubing are rinsed daily with cool water and once a week with a 3:1 solution of water and white vinegar.
Usually, the reusable ap-pliance is rinsed in warm water and soaked in a 3 1 solution of water and white vinegar or a commercial deodorizing solution for 30 minutes. It is rinsed with tepid water and air-dried away from direct sunlight. (Hot water and exposure to direct sunlight dry the pouch and increase the incidence of cracking.) After drying, the appliance may be powdered with cornstarch and stored. Two appliances are necessary—one to be worn while the other is air-drying.
Follow-up care is essential to determine howthe patient has adapted to the body image changes and lifestyle changes. Referral for home care is indicated to determine how well the patient and family are coping with the changes necessi-tated by altered urinary drainage. The home care nurse assesses the patient’s physical status and emotional response to urinary di-version. Additionally, the nurse assesses the ability of the patient and family to manage the urinary diversion and appliance, rein-forces previous teaching, and provides additional information (eg, community resources, sources of ostomy supplies, insurance coverage for supplies).
As the postoperative edema subsides, the home care nurse as-sists in determining the appropriate changes needed in the os-tomy appliance. The stoma opening is recalibrated every 3 to 6 weeks for the first few months postoperatively. The correct ap-pliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1⁄8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.
The nurse encourages the patient and family to contact the United Ostomy Association and local ostomy association for vis-its, reassurance, and practical information. In addition, the local division of the American Cancer Society can provide medical equipment and supplies and other resources for the patient who has undergone ostomy surgery for cancer.
The home care nurse also assesses the patient for potential long-term complications, such as ureteral obstruction, stomal stenosis, hernias, or deterioration of renal function, and reinforces previous teaching about these complications.
The nurse also needs to remind the patient who has had surgery for carcinoma to have a yearly physical examination and chest x-ray to assess for metastases. Periodic evaluation of re-maining renal function (creatinine clearance, serum BUN and creatinine levels) is also essential. Long-term monitoring for ane-mia is performed to identify a vitamin B deficiency that may occur when a significant portion of the terminal ileum is re-moved. This may take several years to develop and can be treated with vitamin B injections. Additionally, the patient is reminded of the importance of participating in health promotion activities and recommended health screening.
A cutaneous ureterostomy (see Fig. 45-9), in which the ureters are directed through the abdominal wall and attached to an opening in the skin, is used for selected patients with ureteral obstruction (advanced pelvic cancer); for poor-risk patients, be-cause it requires less extensive surgery than other urinary diversion procedures; and for patients who have had previous abdominal irradiation.
A urinary appliance is fitted immediately after surgery. The management of the patient with a cutaneous ureterostomy is sim-ilar to the care of the patient with an ileal conduit, although the stomas are usually flush with the skin or retracted.
Other cutaneous urinary diversions are used less frequently and are most often used to bypass obstructions.