This is an important question. Obviously, your body still needs to make urine. It would be ideal to replace your bladder with an artificial or synthetic bladder. Unfortunately, no one has found a man-made material that can be exposed to urine without stones forming on it.
Any nonabsorbable synthetic material in contact with urine will cause stones to form. A single stitch in the bladder will quickly form a stone that in some cases can grow to the size of a football, completely filling the bladder.
Until a synthetic material is found that will not form stones, we are forced to use other parts of the body that are available. The best substitute that we have found is a piece of your own intestine. Surgeons have successfully used portions of stomach, small intestine, and large intestine. In most cases, a segment of small intestine (the ileum) would be the best choice unless you had received prior pelvic radiation.
In these cases, a piece of the large bowel would usually be best as it is less affected by the radiation treatments. As discussed in Question 2, placing tubes into the kidneys (nephrostomy tubes) or attaching the ureters to the abdominal wall (cutaneous ureterostomies) are short-term options but not good long-term solutions.
The ureters can also be attached to the colon (ureterosigmoi-dostomy), allowing the urine to be passed during a bowel movement. This was a common procedure many years ago because it provided the ability for the patient to “hold and evacuate urine.” Urine was voided with each bowel movement. Unfortunately, there is a high risk of colon cancer in patients who have had this type of diversion for many years. For this reason, it is now rarely if ever performed. The mixing of urine and feces in the bowel seems to be the cause of these cancers.
Urine in contact with bowel separate from feces does not seem to have such an increased risk of colon cancer. Current techniques separate urine and feces so that your risk of cancer in the urinary diversion is significantly less than with a ureterosigmoidostomy. Currently, most urologists will offer a patient who is having a cystectomy one of three options. The first and simplest option is called an ileal conduit.
This uses a piece of the ileum to drain the urine to the skin, where it is collected in a bag. The ureters are attached to one end, and the other end is left open onto the abdominal wall. The urine then drains out of the open end and is collected by a urostomy bag. The patient needs only to drain the bag into the toilet every 4 to 6 hours. The bag can be worn under normal clothes, and thus no one needs know that you have a urostomy.
Although it takes a little getting used to, almost all patients adjust to life with an ostomy bag quickly and easily and find that it does not interfere with their nor-mal activities. Your urologist may be able to refer you to other patients who are living with a urostomy to get a firsthand account of how it will be.
The second option is to create what is called a conti-nent urinary diversion. This is similar to the ileal conduit in that it is made out of a piece of bowel, but there is no ostomy bag. Instead, the urine is stored inside a pouch created from a segment of intestine. This is connected to the abdominal wall via a small channel, which is also created from the piece of bowel.
The opening on the skin is then only about the size of a pencil eraser and does not protrude from the skin. Several times a day the patient needs to pass a small catheter through this channel into the pouch to drain the urine. It is a more complicated surgery to create the pouch and requires that you always carry a catheter with you, but it provides a way to avoid having a bag.
If the pouch is not drained regularly, it can become overdistended and may even rupture. The third and most complicated option is called a neobladder. It is an attempt to restore normal urination. Again, it is created with a segment of bowel, although it does require a much longer piece of bowel.
As with the continent urinary diversion, your surgeon fashions into a reservoir that is able to store urine at low pressure. The ureters are connected to it in the same way as with the other two options. However, instead of connecting the pouch to the abdominal wall, it is connected directly to the urethra.
This allows one to urinate per urethra. Although this can be a great solution, it is not appropriate for every patient. The neobladder does not have the muscle that the normal bladder does, and thus it is unable to squeeze out the urine. One must learn to urinate by squeezing the other muscles in the abdomen to increase the pressure inside the neobladder (called Valsalva voiding).
The neobladder also lacks many of the normal bladder’s mechanisms to maintain continence, and some patients will be incontinent after the proce-dure. Night time incontinence is more common than day time incontinence in patients with neobladders.