mCancerPartner sat down recently with Cheryl Lee, M.D., a surgeon and associate professor of urology, to discuss the ileal conduit, one of several urinary diversion options after the bladder has been removed. Dr. Lee’s research focuses on improving quality of life and surgical outcomes for bladder cancer patients. She is also active with the Bladder Cancer Advocacy Network, where she co-chairs the Survivorship Committee and serves on its Bladder Cancer Research Network .
mCancerPartner: What is an ileal conduit, and how does it differ from the neobladder and colon, or Indiana pouch?
Dr. Lee: Bladder cancer management sometimes involves bladder removal or cystectomy. When we do this, we need to reconstruct or revise the urinary system so urine can exit the body. There are several ways to do it. Historically, the ileal conduit has been the most common way. When we make an ileal conduit, we isolate 15-20 centimeters (about 6-8 inches) of small intestine from the bowel system. We attach the ureters to this small tube of intestine, and then bring the tube (or conduit) out through the belly (abdominal) wall. (The ureters are thin tubes that normally transport urine from the kidneys to the bladder.)
The ileal conduit diversion allows urine to drain from the kidneys, down the ureters, through the conduit tube, out of the body into a bag that sits on the skin. The bag is held in place by a piece of soft material (wafer) that attaches to the skin with a sticky substance. The bag connects to the wafer with a locking system, similar to Tupperware. When it locks, there is a water tight connection, allowing urine to drain into the bag without spilling on the skin and causing irritation, or dermatitis. The bag is under one’s clothing, and prevents the embarrassment of leaking. It isn’t hard to learn how to apply the wafer and bag. Other caregivers can help the patient, if needed. In fact, many couples share the duties of wafer placement. But, it is important for patients to also learn to do it by themselves.
Another diversion is called the Indiana pouch, or the right colon pouch. Instead of using the small intestine, it is made from the right colon, which we remove from the intestinal stream to become an internal pouch for storing urine. We also take 10-15 centimeters (about 4-6 inches) of the small intestine to form a limb that will connect the pouch to the outer abdominal wall. The patient passes a catheter through the opening in the abdomen to manually drain the pouch.
Another type of urinary diversion is the neobladder, or “new” bladder. It isn’t the same as the one you were born with, but it does permit a natural pattern of voiding. We use a section of the small intestine to create a pouch or bladder with enough capacity to hold urine. It is placed where the old bladder used to be, with all the same connections to receive urine from the kidneys and pass it out of the body through the urethra. This type of diversion uses 3-4 times the small intestine used for the ileal conduit.
In all of these diversions, there is an increased risk of infection over one’s native bladder. The more complicated the diversion, the higher the risk of infection.
mCancerPartner: Why is the ileal conduit an attractive option?
Dr. Lee: It’s the least complicated of the diversions and has the least chance for serious side effects. Other advantages:
- Of all the diversions, it requires the shortest amount of time in surgery, so if being under anesthesia is problematic, the ileal conduit is optimal.
- It is the simplest one for a surgeon to do, and that may be important for patients who are not having the surgery at a large hospital, or if their surgeon does not perform a large number of cystectomies each year.
- If someone is very elderly and has a significant number of medical problems, in particular kidney trouble, the ileal conduit is less likely to worsen other preexisting problems.
- All urinary diversions have side effects, including risk for infection, changes in body salts or vitamin deficiencies. However, these problems happen less commonly for the ileal conduit.
- Another advantage is that the ileal conduit only uses a small amount of the intestine. For someone who has had previous bowel (intestinal) surgery, radiation and other types of treatment in their abdomen this is important. In these situations, it can be difficult to find a nice healthy segment of bowel large enough to create an Indiana pouch or neobladder, so the fact that we only need a small amount of intestine for the ileal conduit is an advantage for these patients.
mCancerPartner: Who is the ideal candidate for an ileal conduit?
Dr. Lee: Since the ileal conduit is the simplest urinary diversion, anyone is a candidate. Historically, the vast majority of patients received this diversion type. Today, 40% – 60% of the patients at major centers with robust bladder programs are getting ileal conduits. In the community, that number is likely much higher. So who opts for ileal conduits? People who:
- do not want to assume some of the maintenance of the other diversions that might involve catheterization, retraining of voiding patterns, nighttime leakage, and possible use of pads to manage leakage
- want the simplest procedure they can have so they can move on with other aspects of their lives
- are under the care of others so that someone else is managing most of their adult living skills
- have substantial medical problems, particularly kidney or liver trouble, since there is a higher chance of worsening these conditions by using larger pieces of intestine/colon. It’s healthier for them to opt for the ileal conduit.
The bottom line: when making a decision, patients should have an open discussion with their doctors, talk to their families and to their peers, including at least one person who has already had an ileal conduit. There are two excellent on-line communities, the Bladder Cancer Support Network (BCAN) and INSPIRE for peer discussions. In fact there are thousands of people engaged in discussion around bladder cancer management through these on-line communities.
mCancerPartner: Perception, including misperception, can have a lot to do with someone’s opinion about urinary diversions. What to you tell your patients about this?
Dr. Lee: A perceived disadvantage of any of these urinary diversions is that they reduce people’s ability to be active and to have sex, exercise, swim, bike ride, and so on. Some think you can’t do these things, but it isn’t true. People with a urinary diversion can have meaningful healthy lives and continue to pursue their hobbies. Since any diversion can impact one’s self esteem, ego, femininity or masculinity, patients should talk to their doctors about their ability to get back to social and intimate activities. They should also consider joining a support group that is focused on bladder cancer, if possible. Many patients learn quite a bit from their peers in these groups.
At the U- M Multidisciplinary Urologic Oncology Clinic our patients are cared for by nationally recognized experts – urologists, medical oncologists, radiation oncologists and pathologists – as well as nurse practitioners and physician assistants who specialize in the treatment of bladder cancer. Each member of our team is committed to the best possible treatment for our patients.
The University of Michigan Comprehensive Cancer Center’s 1,000 doctors, nurses, care givers and researchers are united by one thought: to deliver the highest quality, compassionate care while working to conquer cancer through innovation and collaboration. The center is among the top-ranked national cancer programs, and #1 in Michigan for cancer patient care. Seventeen multidisciplinary clinics offer one-stop access to teams of specialists for personalized treatment plans, part of the ideal patient care experience. Patients also benefit through access to promising new cancer therapies.