Ileal conduit surgery





Definition

There are many surgical techniques for urinary diversion surgery. They fall into two categories: continent diversion and conduit diversion. In continent diversion, also known as continent catheterizable stomal reservoir, a separate rectal reservoir for urine is created, which allows evacuation from the body. In conduit diversion, or orthotopic urethral anastomotic procedure, an intestinal stoma or conduit for release of urine is created in the abdominal wall so that a catheter or ostomy can be attached for the release of urine. An ileal conduit is a small urine reservoir that is surgically created from a small segment of bowel. Both techniques are forms of reconstructive surgery to replace the bladder or bypass obstructions or disease in the bladder so that urine can pass out of the body. Both procedures have been used for years and should be considered for all appropriate patients. Ileal conduit surgery, the easiest of the reconstructive surgeries, is the gold standard by which other surgical techniques, both continent and conduit, have been compared as the techniques have advanced over the decades.


Purpose

The bladder creates a reservoir for the liquid wastes created by the kidneys as a result of the ability of these organs to filter and retain glucose, salts, and minerals that the body needs. When the bladder must be removed; or becomes diseased, injured, obstructed, or develops leak points; the release of urinary wastes from the kidneys becomes impaired, endangering the kidneys with an overburden of poisons. Reasons for disabling the urinary bladder are: cancer of the bladder; neurogenic sources of bladder dysfunction; bladder sphincter detrusor overactivity that causes continual urge incontinence; chronic inflammatory diseases of the bladder; tuberculosis; and schistosomiasis, which is an infestation of the bladder by parasites, mostly occurring Africa and Asia. Radical cystectomy , removal of the bladder, is the predominant treatment for cancer of the bladder, with radiation and chemotherapy as other alternatives. In both cases, urinary diversion is often necessitated, either due to the whole or partial removal of the bladder or to damage done by radiation to the bladder.


Demographics

Urinary diversion has a long history and, over the last two decades, has developed new techniques for urinary tract reconstruction to preserve renal function and to increase the quality of life. A number of difficulties had to be solved for such progress to take place. Clean intermittent catherization by the patient became possible in the 1980s, and many patients with loss of bladder function were able to continue to have urine release through the use of catheters. However, it soon became clear that catherization left a residue that cumulatively, and over time, increased the risk of infection, which subsequently decreased kidney function through reflux, or backup, of urine into the kidneys. A new way had to be found. With the advent of surgical anatomosis (the grafting of vascularizing tissue for the repair and expansion of organ function) as well as with the ability to include a flap-type of valve to prevent backup, bladder reconstructive surgery that allowed for protection of the kidneys became possible.


Description

Ileal conduit surgery consists of open abdominal surgery that proceeds in the following three stages:

  • Isolating the ileum, which is the last section of small bowel. The segment used is about 5.9–7.8 in (15–20 cm) in length.
  • The segment is then anastomosized, or grafted, to the ureters with absorbable sutures.
  • A stoma, or opening in skin, is created on the right side of the abdomen.
  • The other end of the bowel segment is attached to the stoma, which drains into a ostomy bag.

Stents are used to bypass the surgical site and divert urine externally, ensuring that the anastomotic site has adequate healing time. Continent surgeries are more extensive than the ileal conduit surgery and are not described here. Both types of surgery require an extensive hospitalization with careful monitoring of the patient for infections, removal of stents placed in the bowel during surgery, and removal of catheters.


Diagnosis/Preparation

Ileal conduit surgery is recommended depending on what conditions are being treated; whether the urinary diversion is immediately necessary; for the relief of pain or discomfort; or for relatively healthy individuals or individuals with terminal illness. Three major decisions that must be made by the physician and patient include:

  • The type of surgery to restore bladder function: either by sending urine through the ureters to a new repository fashioned in the rectum, or by creating a conduit for the removal of the urine out through the stomach wall and into a permanent storage pouch, or ostomy outside the body.
  • The type of material out of which to fashion the reservoir or conduit.
  • Where to place the stoma outlet for patient use.

Recent research has shown there is little difference in infection rates or in renal deterioration between the conduit surgical techniques and the continent techniques. The patient's preference becomes important as to which type of surgery and resulting procedures for urination they want. Of course, some patients, unable to conduct catheterization due to debilitating diseases like multiple sclerosis or neurological injuries, should be encouraged to have the reservoir or continent procedures.

Materials for fashioning continent channels have included sections of the appendix, stomach, ileum and cecum of the intestines, and for the reservoir, sigmoid and ureter tissues, usually with an anti-refluxing mechanism to maximize continence. A segment of the ileum is often preferred, unless the tissue has received radiation. In this case, other tissue must be used. Ileum is preferred because the ileal tissue of the intestines accommodates larger urine volume at lower pressure.

Many urinary diversion procedures are performed in conjunction with surgery for recurrent cancer or complications of pelvic radiation. Fistula development and repeated repair as well as ureteral obstruction also are reasons to have the surgery. If the surgery is considered because of cancer, the physician and the patient need to discuss how appropriate the surgery is for cure or for relieving pain. Highly relevant are the patient's age, medical condition, and ability to comprehend both the procedure and the patient's role in the changed state that will result with the surgery. In general, ileal conduit surgery is easier, faster, and has fewer complications than continent reservoir surgery.

In addition to these considerations, great emphasis must be put on preparing the patient psychologically, and physicians must make themselves available for counseling and questions before proceeding with patient evaluation for the procedures. The renal system must be assessed using pylography, which is the visualization of the renal pelvis of the kidneys to determine the health of each renal system. Patients with renal disease or abnormalities are not good candidates for urinary diversion. Bowel preparation and prophylactic antibiotics are necessary to avoid infection with the surgery. Bowel preparation includes injecting a clear-liquid diet preoperatively for two days, followed by using a cleansing enema or enemas until the bowel runs clear. The importance of these preparations must be explained to the patient: leaking from the bowel during surgery can be life threatening. For ileal conduits, the placement of the stoma must be decided. This is accomplished after the physician evaluates the patient's abdomen in both a sitting and standing position, to avoid placing the stoma in a fatty fold of the abdomen. The input from a stomal therapist is important for this preparation with the patient.


Aftercare

Ureteral stents are generally removed one week after surgery. A urine culture is taken from each stent.

In a cystectomy with ileal conduit, an incision is made in the patient's lower abdomen (A). The ureters are disconnected from the bladder, which is then removed (B). They are then attached to a section of ileum (small intestine) that has been removed and refashioned for that purpose (C). A stoma, or hole in the abdominal wall, is created at the site to allow drainage of the urine (D). (Illustration by GGS Inc.)
In a cystectomy with ileal conduit, an incision is made in the patient's lower abdomen (A). The ureters are disconnected from the bladder, which is then removed (B). They are then attached to a section of ileum (small intestine) that has been removed and refashioned for that purpose (C). A stoma, or hole in the abdominal wall, is created at the site to allow drainage of the urine (D). (
Illustration by GGS Inc.
)
Radiologic contrast studies are carried out to ensure against ureteral anastomotic leakage or obstruction. On the seventh postoperative day, a contrast study is performed to ensure pouch integrity. Thereafter, ureteral stents may be removed, again with radiologic control. When it has been determined that the ureteral anastomoses and pouch are intact, the suction drain is removed. The patient is shown how to support the operative site when sleeping and with breathing and coughing. Fluids and electrolytes are infused intravenously until the patient can take liquids by mouth. The patient is usually able to get up in eight to 24 hours and leave the hospital in about a week.

Patients are taught how to care for the ostomy, and family members are educated as well. Appropriate supplies and a schedule of how to change the pouch are discussed, along with skin care techniques for the area surrounding the stoma. Often, a stomal therapist will make a home visit after discharge to help the patient return to normal daily activities.


Risks

This surgery includes the major risks of thrombosis and heart difficulties that can result from abdominal surgery. Many difficulties can occur after urinary diversion surgery, including urinary leakage, problems with a stoma, changes in fluid balance, and infections over time. However, urinary diversion is usually tolerated well by most patients, and reports indicate that patient satisfaction is very high. Common complications are stricture caused by inflammation or scar tissue from surgery, disease, or injury. The incidence of urine leakage for all types of ureterointestinal anastomoses is 3–5% and occurs within the first 10 days after surgery. According to some researchers, this incidence of leakage can be reduced to near zero if stents are used during surgery.


Normal results

Complete healing is expected without complications, with the patient returning to normal activities once they have recovered from surgery.


Morbidity and mortality rates

Possible complications associated with ileal conduit surgery include bowel obstruction, blood clots, urinary tract infection, pneumonia, skin breakdown around the stoma, stenosis of the stoma, and damage to the upper urinary tract by reflux. Pyelonephritis, or bacterial infection of a kidney, occurs both in the early postoperative period and over the long term. Approximately 12% of patients diverted with ileal conduits and 13% in those diverted with anti-refluxing colon conduits have this complication. Pyelonephritis is associated with significant mortality.

Alternatives

An alternative to ileal conduit surgery is continent surgery in which a neo-bladder is fashioned from bowel segments, allowing the patient to evacuate the urine and avoid having an external appliance. The procedures of continent diversion are more complicated, require more hospitalization, and have higher complication rates than conduit surgery. Many patients, unable to manage a stoma, are good candidates for continent diversion.


Resources

BOOKS

Walsh, P., et al. Campbell's Urology, 8th Edition. St. Louis: Elsevier, 2000.


PERIODICALS

Estape, R., L. E. Mendez, R. Angioli, and M. Penalver. "Gynecologic Oncology: Urinary Diversion in Gynecological Oncology." Surgical Clinics of North America 81, no. 4 (August 2002).


ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. http://www.niddk.nih.gov .

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org. .


OTHER

"Urinary Diversion." American Urological Association. http://www.urologyhealth.org. .


Nancy McKenzie, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


Surgery is performed by a urological surgeon who specializes in urinary diversion. It is performed in a general hospital.

QUESTIONS TO ASK THE DOCTOR


  • How soon after the surgery will I be taught how to use an ostomy?
  • Will the ostomy be obvious to others?
  • Is continent surgery, or surgery with an internal neo-bladder, a better alternative?
  • How do conduit and continent surgery compare in terms of recuperation, complications, and quality-of-life issues?


User Contributions:

Michelle Clements
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Mar 1, 2006 @ 1:01 am
This is the best article that I have been able to find on the Ileal Conduit. I am facing the decision of whether to have the surgery or not. I have only found articles that tell about the surgery but none with pictures diagramming well, the exact procedure and how it is anatomically done. I really needed an article this well done, in order to understand what the operation would entail and about the different issues around it. I am grateful for the person who put this together. My life is very seriously impacted right now by severe Hunner's Ulcers...so much so, that I am constant severe pain that is just excruciating. Yesterday my doctor discussed this procedure (I am a patient going to UC Davis Medical Center in Sacramento). My Urologist has scheduled me for the procedure in April...but I was trying to find an article I could read that would really answer alot of my questions about it. Thank you for providing the illustrations and details to help me research it and help me make this very important decision.
catherine bennett
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May 16, 2006 @ 12:12 pm
My mother is going through a hard time with her bladder now,for the past 6 years.She has alot of leakage and spasems.She wears the cathered now but alot of infections weekly.Would this be a good thing for her. She's had aleast 6 operations and even botox injections!!Nothing is working.I hate seeing her like this,she's only 61 years old.ASAP
Lorraine
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Jun 1, 2007 @ 6:18 pm
I am a nursing student and I had a case study about Ileal Conduit which I had to research on and discuss in class. I never found an article that provided information as good as this one while I was researching for my study. I wish I was able to find this site before I have presented my case. This article is very comprehensive. I had a few questions about this surgical precedure left unnswered after my study. But this article answered all those questions for me. Thank you!
ellen Joyce
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Jan 21, 2008 @ 9:21 pm
My sister has had an ileal conduit for over 15 years.
She has been ill with a UTI and a urologist is recommending scoping the conduit because loops can develop that can allow pools of pus to form. He said that the conduit should be irrigated about twice a year.
We had not known about this at the time of the procedure to make the conduit which has functioned very well.
Dr Ellen Joyce
vimal goyle
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Jan 23, 2008 @ 2:14 pm
This is very informative article. It is a must read for patients and the family members to read before the surgery is performed.
David Kidd
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Feb 6, 2008 @ 5:17 pm
I am about to undergo this surgery in australia and it has been of great assistance to read about it so comprohensivly
William Lynn
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Feb 16, 2008 @ 9:09 am
I found this article very helpfull as I am about to go through the ileal conduit diversiion surgery myself, I knew nothing about the procedure until I found your website. I keep it on my desktop now always for future refernce,
extrophite
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Jun 26, 2008 @ 2:14 pm
I have had an ileal conduit since 1961. Although I've had occasional UTIs, I've never had to have it irrigated. 99% of the people I know ("bladderites") have no idea I have it. I'm sure it would be an adjustment if you're used to using a bladder, but it's not a significant impediment to normal life, and in some ways it has advantages. (You can never get arrested for public indecency for urinating in public! Think about it...)
rakesh
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Sep 20, 2008 @ 5:05 am
i am suffering from intestinal odour comming through anus from the 1 year the endoscope and colonoscope and blood all type and liver function test also over later in endoscope a clean based depressed leison in the right antrum will be seen and in colonoscope at ileum region infection is there they consider pacty ileitis diagnosis and blood tests all are normal tell me sujession about controll this odour the odour comming easily 30 to 35 times in a day tell me sujesstion
Hadjer
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Mar 28, 2009 @ 11:11 am
i was wondering would a person who has cancer of the ballder undergo this surgery andif so what tupe of bladder cancer would this person have to have to ubdergo this sergery?? also would blood transfusion be needed after the surgery?
Robbin
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Jul 17, 2009 @ 5:17 pm
Do your patients have problems with raw vegetables and do the get lots of different infections and become dehydrated? If so what do you suggest to do about them?
Noreen
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Aug 3, 2009 @ 1:13 pm
I am a retired REgistered nursing Assistant,but with 3 years of RN training-I have not been in nursing for 25 years now,but I have a friend who will be having this surgery in September and I find this is an excellent article and explains everything so well.I am sure this is the right choice for her.Thanks
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Apr 27, 2010 @ 2:14 pm
I have been suffering with a sensory bladder which means the slightist bit of urine in the bladder i have to pee i have been like this for two and a half years now ,i am in constent pain and discomert i have had my bladder streched and had cystate treatment to no avail i resently had surgery and had botox injections and had a pubic cafeter fitted with a leg bag 6 weeks later i cant wee properly i have spasams whih are painful and infetions so now i am facing surgery to have my bladder removed as it has holes aswell the information i have read was useful but i wish they had supplied photos of the surgery and how you look after.
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Jun 24, 2010 @ 1:13 pm
I had this procedure done in January, and although not common in a man my age (44), it was nessesary due to me having cancer in my bladder. It has been a minor inconvience and I was in the hospital 6 days and back to work in 6 weeks. I would highly reccomend this procedure over the alternative.
Smedley
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Dec 7, 2010 @ 3:15 pm
I had this surgery in March 2010. reason for the surgery was bladder cancer. In speaking with the urologist and my oncologist they suggested the surgery. All I can say is that the procedure and recovery were about 1 week in the hospital and out of work for 6 weeks. today I lead a normal and cancer FREE life style. You are still able to perform daily duties as you have in the past, exercise, running, cycling are no problem and you NEVER have the sensation to urinate!!! I recommend the surgery for anyone.
Marie
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Dec 19, 2010 @ 2:14 pm
I have suffered from interstitial cystitis for 7 years. I had numerous instillations and stretchings and diets and this that and the other, - all useless in the long term. For a whle I had an indwelling urethral cathether which irritated my already sensitive bladder. Now I have a supra pubic one which causes me awful spasms of pain. I'm getting a reputation for odd behaviour now. While I'm chatting to someone I suddenly shout "Oh GOD!!" when the spasm strikes. I meet the urologist tomorrow to discuss ileal conduit diversion I hope. Would welcome comments from those who had it done. Marie
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Feb 18, 2011 @ 6:18 pm
My father has cancer of the bladder & the dr is recommending an Ileal Conduit, however my father is 78 & very hesitant. Is there a site that I can get information on what the "bag" outside the body looks like & what maintenance goes with such a device. He has concerns of people being able to see that he has this device & is concerned that it will smell. How often do you have to go in to get it "irrigated"?
Any information would be helpful..thank you!
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Mar 14, 2011 @ 7:19 pm
My father is 71 with reoccuring bladder cancer (it has not invaded the muscle wall). He weighs 314 pounds. One Dr. suggested the removal of the bladder with an ileal conduit because of the increased reoccurance of the cancer and the effects of chemo on a man my Fathers age and weight.
Another dr. suggests another resectioning of the baldder followed by chemo & radiation, he feels my fathers weight would strangle the part of the bowel that would have to come through the abdominal wall. Just with the info I have provided what are your thoughts. We actually have an appt. for a consulation with a dr. at hopkins but not until after the next resectioning is to be done and before chemo & radiation is to be started. As you can tell he is sort of leaning towards to dr. who suggested the resectioning again and chemo & radiation. How much of a factors is a persons weight when considering a ileal conduit? Thank you for any feed back you can offer.
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Oct 28, 2011 @ 4:16 pm
I had a problem with the stoma (urostomy) becoming too small and the opening became smaller than a pin, I had asmall operation to make the hole larger, but now see a hard, bone like, material in the opening...what is it?
Craig
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Dec 6, 2011 @ 12:12 pm
I have little manual dexterity, and so I am hesitant about any procedure that involves use of a catheter. Is there any procedure that does not? If not, how hard is it to use the catheter? thank you.
Martin Gilmore
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Jan 7, 2012 @ 2:02 am
I am about to make my choice of which proceedure to accept, and this article is understandable and concise, aiding my decision. My diagnosis is high grade superficial bladder cancer, necessitating the removal of the bladder and prostate, at the age of 63 years in 2012. I thank the author(s) for this contribution to medical information for the layman.
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Jan 30, 2012 @ 10:22 pm
I have had nothing but problems since I had my ileal conduit. It leaks all the time! I was told I would not get infections. I have had MORE infections since I've had it. I was told it was revesable. Now they tell me it is not. I still have my bladder but it is just disconected.

Has anyone heard of it been reversed?

Any info would be great!

Thanks.
john pickup
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Feb 6, 2012 @ 6:06 am
i had urinery diversion on jan 3rd everything is gong to plan but one problem i am having is spasms about 7 or 8 times aday it his a strong pain that lasts about 30 secs my gp has prescribed lyrinel anyone know will the spasms go away
Caroline Knight
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Mar 7, 2012 @ 5:05 am
Am 48 and have had both an ileal conduit and colostomy since December 2008. Both have had to be revised due to various complications e.g tumas, fistulas and bowel stenosa. I do get frequent infections usually 1every few months which can leave you very ill. The secret is to get these need treated immediately as can lead to very serious side effects. With regards to the spasms metioned by john these do eventually subside but can be quite worrying. As an individual with two stomas all i can add is its better than what i had to deal with before and have improved my qulity of life. Oh yes make sure your GP nurses and specialist keep on top of things - mine are excellant and make all the difference.

Hope this helps

Caroline Knight
Sandy
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Jun 11, 2012 @ 2:14 pm
My husband had agressive, level 3 bladder cancer which led to removal of the bladder at the Moffitt Cancer Center and an ileal conduit July 2011. He has had nothing but problems with consistent UTIs every three weeks. He has been in the hospital for more than three months (different stays) in the last 11 months. Each hospital stay makes him weaker and he loses more muscle mass. My once big 6'4" man is very frail, walking with a cane and can hardly get up out of a chair. He's had to have metal stents put in both ureters and they still are not helping. He has an appointment with a Hopkins doc this week to try to fix the problem. It's been a rough year! Good luck to anyone who must have this procedure.
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Nov 15, 2012 @ 12:00 am
Question:
Sir, my father had undergo through systectomy with ileal conduilt. but there comes pus in urine in very larg quantity.it comes when my father laughs or talk with forcfully. please tell me its a normal thing or its too dangerous.
if its abnormal, what medication should he use to recover himself.
i will be very thankful to your guidence.
denise davies parsons
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May 20, 2013 @ 8:08 am
i had an ileal conduit 11 yrs ago which has worked very well but i have had several parastoma hernias the last one was in march 2011unfortunatley this has never healed and it has tracked back to my conduit so it has been leaking urine for over 2yrs ive been told it will never heal and it is a big problem keeping dry as its too close to my conduit to fit a drainage bag so i have alot of dressings as i can feel the urine running out of the sinus ive had nephrecomy tubes fitted which i have to go into hospitalevery 6 week to have them changed ive also had stents in my coduit to help diver the urine away from the sinus ive been to see a consultant at a different hospital who has said i neen to close down my conduit my sinus and another hernia and do another conduit on my left side im petrified about going through this big op been ive no choice any advise please
naveen saxena
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Jun 20, 2013 @ 7:07 am
Four years back My urinary bladder was removed and an illeal conduit was made for urine purpose, now I am wearing a urobag, in bangalore where I am livimg the temp is 27degree celcius, I am suffering with exessive urination, I have to drain my bag after every 10 to 15 minutes which is causing weakness. Is there any way to increase thisperiod I hve to travel a 5 hour journey , I wish to travel without using a large urine collecting bag . Your an early reply is requesed.
Susan Bashaw Cummins
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Sep 24, 2013 @ 9:21 pm
What year was the first Illeo loop surgery done in the United States? When was the last Illeo loop surgery done in the United States? Thank you.
Jane
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Nov 8, 2013 @ 1:13 pm
I am a stoma nurse, and feel that the more bowel is used - the better. The majority of ileal conduit clients have stomas that are either flat or totally receded. They are very difficult to pouch because of the constant flow of urine that eats away at the flange because the urine cannot drain properly into the bag. It would be WONDERFUL to see stomas that actually protrude and allow the urine to flow easily into the pouch without pooling around the opening and eroding the flange causing melt-down and leakage. This is a permanent thing and people have to live the rest of their lives with it - it would be great if it was more easily managed to give better quality of life to these people!
Really, if another 2-3 inches of small bowel is taken to make a decent stoma - how will that impact on the client??? If anything, I believe it would be a good thing and take a great burden off of the clients affected. Thank you. Jane.
Kat
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Jan 4, 2014 @ 7:07 am
To Jane, my mother has a flat stoma and was even pulling so inverted if I can all it that. Her tummy is large and loose, when she sits the goes inside skin folds. At first her bag was barely lasting beyond one day, big problem. Finally our stoma nurse suggested a using convex barrier ring together with a convex flange and it works really well. Her skin is good and it doesn't leak. Her bag lasts one week, we change it usually after 5-7 days. We attach the barrier ring to the flange which makes a deeper convexity, then we place it (the flange/barrier ring) onto her stoma like you would the flange.

The bag is a two piece system. Also the bag she uses does not have clips, instead the bag adheres to the flange with a peel off adhesive, so it is softer more flexible than a clip, I believe.

Hope this helps as it was a huge solution to how we were doing the bag before. (We had to try to customize by cutting small pieces in pie shape pieces or using paste to fill in the gaps.) It was difficult and felt like each bag change was a procedure. It was also discouraging for my mother. Now so much easier & less stressful!
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Feb 26, 2014 @ 9:09 am
Brenda,

I am 78 and had the ileal surgery 2 months ago. Was in hospital 4 days, came home and was shoveling snow in about 2 weeks. While this is something to put up with,its not a big life changer.You can see pictures of the pouches at a number of sites. I get my supplies from Byram, you can see pictures of many different pouches at thir web site. I am using Convatec pouches, very thin and light. When full or almost full there is a slight bulge in the stomach area. Not too visible now because I am layered up with clothing in the cold weather we have been having. For patients with bladder cancer this is the most popular way to go. I still have my bladder but it was destroyed in a surgical accident 3 years ago.
Glenn
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Feb 27, 2014 @ 9:09 am
Brenda,

When I replied to your post I ignored the fact that your father has bladder cancer. The ileal conduit is the most popular procedure for that, but removing the bladder means a longer more involved surgical procedure with longer hospitalization than simply the ileal conduit. Your father's choice is to go for the surgery or wait and see how long he can live with the bladder cancer. Tough choice.
Michelle Mulligan
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May 20, 2014 @ 10:10 am
I had this surgery and bladder removal in feb14 I had a horrid time with infections after surgery, now I have major pains like spasm to the right of my stoma they get so bad I have to take morphine for it to subside, I'm also having bowel issues and finding it difficult to go regularly despite medication, can anyone shed any light on what the pain is? I cannot handle more pain or hospital stays, any advice welcome
Si Lane
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Jun 25, 2014 @ 10:10 am
Very helpful and informative!I have had and IC for almost 2 years and, still, I picked up useful information.

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