**2. Selection criteria for urinary diversion**

The ultimate aim in reconstruction of the lower urinary tract in patients with adequate storage function is to attain continence. Adequate emptying can be achieved with consideration of manual dexterity, cognitive capability and patient choice. The options to create a continent or incontinent urinary system can range from long-term catheterisation, intermittent cathterisation or diversion – incontinent, or continence cutaneous.

Continent Urinary Diversions in Non Oncologic Situations: Alternatives and Complications 281

Patient must present manual dexterity to firmly hold a catheter and accurately introduce it into the channel lumen. Previous abdominal surgeries and obesity may anticipate surgical

Continence must be pursued when feasible. In this sense, self catheterisation need to be adjusted in order to empty the bladder before it reaches its maximum capacity in an attempt to significantly reduce incontinence episodes in between intervals. Bladder capacity may be optimized with the rationale use of anticholinergic agents which may control unhibited detrusor contractions, maintain storage volumes and prevent the development of poor

An improvement in Quality of Life (QoL) is a consequence of the above mentioned measures. Increase in patients' self-esteem and the perception of self control and physical

In a recent work, Lee et al. [9] reviewed QoL assessed using validated tools comparing continent x incontinent urinary diversions in cystectomized patients. Orthotopic diversions did not provide overwhelming or major QoL benefit over an incontinent cutaneous diversion at one year follow up after surgical treatment. Although cancer treated patients are not the exact same as neurogenic bladder ones, results could be extrapolated in regards

It is of utmost importance for patients to be adequately informed on the details involving

A review by Moore et al. [10] showed no convincing data favoring any specific catheterization technique (clean vs sterile), catheter type (coated vs uncoated), method (single vs multiple use) or person (self vs other). Different catheter types, materials and sizes can be tested depending on patient preference. Accessories may ease the procedure execution including catheter mirror, knee spreader with mirror, catheter holder. Regardless of using these, catheterization education and support is fundamental [11]. The nurse or physician should assess patient knowledge about the urinary tract; an overview of the perineum and urinary tract through pictures, figures and videos may be very helpful. Nurse should also assess the patient's ability to learn intermittent self-catheterization, awareness of problems related to it, motivation to continue long-term catheterization and the

As mentioned previously, urinary diversion (continent versus incontinent) must be based upon: patient's wishes; patient's manual dexterity to perform self catheterization;

Whenever possible, patient's wishes regarding an incontinent conduit or an abdominal catheterizable stoma should be considered. This may result in better acceptance of the

While a catheterizable conduit will demand a caregiver's attention every 4 to 6 hours to keep it down to the maximum storage capacity, an incontinent one may yield several hours

availability of a care provider; surgical feasibility; quality of life and life expectancy.

difficulty to prepare and externalize the intestinal channel.

compliance [7,8].

independence all contribute as well.

**2.2 Patient education and training** 

**3. Selecting the urinary diversion** 

to urinary habit satisfaction and adaptation.

intermittent self catheterization in order to avoid complications.

understanding of how to avoid possible complications [11].

urinary diversion and therefore improve quality of life.

Ultimately there is no hard and fast answer for every situation, rather an individualised decision must be made.

#### **2.1 Pre operative evaluation**

Physical examination should determine patient's cognitive capacity to perform self catheterisation. The body habitus may strongly influence the sitting position of the urinary stoma. Attention must be given on how the urine collecting bag plate will adhere to the patient's skin, whether it is going to adequately cope with the external abdominal wall when patient is sitting or standing, etc. It is a useful tip to delineate and mark the exact site where the stoma should be before patient is taken to the operating room.

Comorbidities that may impair patient's ability to properly heal such as uncontrolled diabetes or immunodeficient states must be set even beforehand.

The description by McGuire and cols. [6] that storage leak point pressures above 40 cmH2O would jeopardize the integrity of the upper urinary tract set a reference value for urodynamic monitoring and treatment orientation. Urodynamics is also helpful in identifying or confirming detrusor overactivity and determining maximum capacity and compliance.

Upper urinary tract preservation is the corner stone of dysfunctional voiding patient management. Upper tract evaluation can be simply performed through an abdominal ultrassonography which is a non invasive procedure that provides valuable information on kidneys morphological features such as shape and size, which may preclude congenital pathologies, anatomical variances, parenchymal scars, and others [1]; and serum labs (urea, creatinine). Creatinine clearance is also recommended to assess global renal function. Evidence of renal atrophy or changes in shape that might suggest impairment of renal function, including previous history of recurrent urinary tract infection (UTI) must be confirmed with static renal scintigraphy (DMSA). This will provide precise information on the patient's baseline renal function status at the beginning of treatment and allow for future monitoring and assurance of renal preservation through comparative analysis. Renal function deterioration is an important landmark to decide upon indicating a reconstructive procedure in this specific population. As such, it seems obvious that prevention of UTIs is critical. An adequate global renal function will reduce the chance for acid/base imbalances secondary to intestinal absorption. However, regular monitoring is needed.

Whenever ureteral dilation is identified, assessment with DTPA or MAG-3 scintigraphy is recommended to rule out ureteral obstruction which may occur as a consequence of bladder wall thickening as well as urethrocistography which will identify possible associated secondary vesicoureteral reflux. In these cases ureteral reimplantation may be needed. This evaluation will not only assure ureteral patency but also determine renal split function.

Urodynamic evaluation is mandatory when bladder dysfunction is suspected. When considering a catheterizable channel, one must be certain about the bladder normal capacity and compliance. Otherwise an augmentation procedure may be necessary in association. Also, continence evaluation may indicate the need for an anti incontinence procedure such as bladder neck closure. This is recommended when urinary leak pressures are detected below 30 cm H2O. Videourodynamics combine conventional urodynamics with contrast imaging providing both functional and morphological information at once [4,15].

Patient must present manual dexterity to firmly hold a catheter and accurately introduce it into the channel lumen. Previous abdominal surgeries and obesity may anticipate surgical difficulty to prepare and externalize the intestinal channel.

Continence must be pursued when feasible. In this sense, self catheterisation need to be adjusted in order to empty the bladder before it reaches its maximum capacity in an attempt to significantly reduce incontinence episodes in between intervals. Bladder capacity may be optimized with the rationale use of anticholinergic agents which may control unhibited detrusor contractions, maintain storage volumes and prevent the development of poor compliance [7,8].

An improvement in Quality of Life (QoL) is a consequence of the above mentioned measures. Increase in patients' self-esteem and the perception of self control and physical independence all contribute as well.

In a recent work, Lee et al. [9] reviewed QoL assessed using validated tools comparing continent x incontinent urinary diversions in cystectomized patients. Orthotopic diversions did not provide overwhelming or major QoL benefit over an incontinent cutaneous diversion at one year follow up after surgical treatment. Although cancer treated patients are not the exact same as neurogenic bladder ones, results could be extrapolated in regards to urinary habit satisfaction and adaptation.
