Neobladder Continent Urinary Diversion

Normal Urinary Tract

 

The normal urinary tract consists of two kidneys, two ureters, the bladder, and the urethra.  The kidneys are toward your back at about the waist level.  They make urine, filter the blood, and remove waste from the body.  Urine from each kidney is carried to the bladder by tubes called ureters.  The bladder is an organ made of muscle that stores urine.  The urethra is the channel that carries urine from the bladder to the outside of the body.

 

 

What is a neobladder?

 

A neobladder replaces the bladder by using part of the large bowel.  A new bladder is made from  a piece of the large bowel and attached to the neck of the urethra.  It will store your urine and allow you to urinate through the urethra much like you did before your surgery.

 

How does a neobladder differ from the IndianaPouch and an Ileal Loop?  

 

An  IndianaPouch is a pouch made from part of your bowel to store urine.  The end of the pouch is brought out through an opening made on your abdomen.  This opening is called a stoma.  Using a catheter, you will drain urine out of the pouch at certain times.

 

An Ileal Loop uses  a part of bowel to create a loop to carry urine to the outside.  The ureters are attached so that urine is carried to and emptied through the passageway.  The other end is brought out through the abdomen.  Urine comes into the passageway and out of the stoma so you need to wear a bag all the time to collect the urine. 

 

How is the neobladder made? 

 

The first step is to remove the bladder.  In men, the prostate is almost always removed along with the bladder, while the uterus is often removed in women.  The neobladder is made from part of the bowel and joined to the neck of urethra.  A sample (biopsy) of the neck of the bladder and the urethra is taken to check for cancer.  If cancer is present, the neobladder will not be possible.  Instead, you may need to have an Indiana pouch or an ileal loop.  Sometimes, other factors (scar tissue, anatomic reasons) prevent the making of the neobladder.

How does the neobladder work?

 

The neobladder functions like your own bladder.  Urine drains into the neobladder, then empties through the urethra when you strain or contract your abdominal muscles.  This increases the pressure within the neobladder causing it to empty.  Over time, the neobladder stretches and you will be able to hold more urine.  It may take you weeks to months to be able to store urine without leakage.  To stay dry, you may need to wake up to urinate at night.  

 

Work-up Exam

 

At your work-up visit, a nurse practitioner will perform a complete health history and physical exam.  You will have urine and blood tests, a chest X-Ray and an EKG.  You will also visit the anesthesia screening clinic.

 

A nurse will explain how to get ready for your surgery.  A nurse will also mark your abdomen.  This is done in case your doctor decides during surgery that a pouch or loop is needed instead of a neobladder.

 

Please eat before you come for your work-up visit since it may take 4 to 6 hours. 

 

Getting Ready for Surgery

 

Two Days before Surgery

 

To prepare for surgery, you are asked to follow a clear liquid diet and clean your bowels.  You will only be drinking clear liquids.  Please follow these directions carefully.

 

Clear liquid diet includes:

 

• Water
• Tea
• Broth
• Juice without pulp (apple, cranberry, white grape)
• Popsicles®
• Jello®, plain only
• Carbonated beverages or clear sodas
• Hard candy
• No dairy products of any kind
• Weak coffee without milk or cream, you may have sugar or sugar substitute
• No alcoholic beverages allowed

 

Day before Surgery

 

 

• Continue with clear liquids only.

 

• At 11:30 am
  • Take one metoclopramide (Reglan®) tablet by mouth.

 

• At 12:00noon
  • Start drinking 4 liters of GoLYTELY®.  Drink 8 ounces every 10 minutes until gone (stools will be clear).  GoLYTELY®is easier to drink when it is kept chilled.  You may add 2 packets of Crystal Light®for flavor.

 

• One hour after finishing the GoLYTELY®
  • Take second metoclopramide (Reglan®) tablet. 
  • Take first dose of antibiotics – Erythromycin 1 gm and Neomycin 1 gm.

 

• Two hours after finishing the GoLYTELY®
  • Take another dose of antibiotics– Erythromycin 1 gm and Neomycin 1 gm.

 

• At 10:00 pm
  • Take another dose of antibiotics– Erythromycin 1 gm and Neomycin 1 gm.

 

• During the evening drink 1 liter of a sports-type drink (i.e. Gatorade®).

 

Do not eat or drink anything after midnight.

 

After Surgery

 

Plan to be in the hospital for 7 to 10 days. 

 

We will help you to start walking the day after your surgery.  Getting up and walking early are the best ways to speed your recovery.  Walking helps to prevent problems such as a bowel obstruction, pneumonia, or blood clots. Expect to walk in the hall 3-4 times a day.  Pain medicine may make it easier for you to move around. 

 

Incision, Drains, and Tubes

 

Incision:  You will have an incision down the middle of your abdomen.  This makes it easier for the doctor to remove your bladder.  Staples are used to hold the incision together.  They will be taken out in 7-10 days.  You may have a small amount of drainage from your incision.  It will be cleaned and the dressing changed daily and as needed.

 

Drains and Tubes

 

• You will have an intravenous line (IV) to give you fluids.

 

• You may have oxygen on.

 

• NG (Nasogastric) Tube: You will have a tube in your nose going to your stomach to help prevent nausea and vomiting until your bowel starts to work again (about 3-5 days).  You will not eat or drink by mouth while the tube is in place.

 

• You may have TED hose and leg wraps (Venodynes) on your legs to prevent blood clots in your legs.  

 

• A Foley catheter will be placed in the space where your bladder was. This is a tube placed through your urethra to protect the healing of the suture lines that join the urethra and the neobladder.  It is taken out about 3-4 weeks after surgery.  It takes this much time for the neobladder to heal.

 

• You will have two soft, long rubber drainage tubes called Jackson-Pratt (J-P) drains.  They are brought out through the skin, one on each side of your abdomen.  JP drains are used to drain old blood and fluid from around your neobladder.  This helps to prevent infection.  Nurses will measure the drainage.  Your doctor will remove the drains after the drainage has stopped, most often within 2-3 days.

 

• You will have a suprapubic catheter.  This is a tube placed through your abdominal wall into the new bladder to keep it drained.  It is removed in about 2-3 weeks.

 

• You will have two small hollow tubes called stents (one for each kidney) to drain the urine from the kidneys while your neobladder is healing.  The stents allow the urine to flow freely. The ends are brought to the outside through the same opening as the suprapubic catheter.  They are connected to a drainage bag at the side of your bed.  You will go home with the stents in place.  They will be taken out when you come for your first clinic visit.

 

 

 

 

 

 

 

 

Going Home

 

While in the hospital, nurses will teach you how to care for your tubes.  You will learn how to flush the catheters every 4 hours and as needed to help prevent blockage.  Because the neobladder is made out of bowel, it secretes mucus.  This can plug the catheter.

 

After your catheter is removed, you will be taught how to pass urine by straining the abdominal muscles.  You will be asked to follow a schedule for the first 6 weeks.  You will need to urinate at set times.  This will help to slowly expand the neobladder to hold greater volumes of urine and promote dryness.

 

The time it takes you to control the neobladder can vary.  Most often, nighttime leaking is the last to recover.  You may be taught to do pelvic exercises.  These will help you to stay dry.  You may need to perform 15-20 sets of pelvic exercises once or twice a day as you are able.

 

You may need to use adult diapers or other devices.  If needed, you will be taught how to catheterize yourself since abdominal straining may not be enough to empty urine from the neobladder.  

 

Home Care

 

Diet and Fluid Intake

 

Eat a regular diet as you are able.  Some foods, such as spicy foods, asparagus, fish, eggs, medicines, and vitamins, can change the smell of your urine.  You should drink at least 2-3 quarts of fluids per day.  A high urine output will help to keep the neobladder flushed and reduce your risk of infection.  High fluid intake also reduces the risk of stones.

 

Activities

 

• You may shower or take sponge baths.  Do not take tub baths.
• No straining or lifting over 10 pounds for 4-6 weeks.
• You may drive after 4 weeks.
• Avoid contact sports for 4 to 6 weeks, or until your doctor tells you it is safe.
• Swimming is okay after 6 weeks.
• You may resume sexual activity when you are ready. 
• Plan on being off work for 6-8 weeks.

 

Tube and Drain Care

 

You will go home with a Foley and a suprapubic catheter.  You will need to flush them with normal saline or sterile water once a day and as needed.  A nurse will show you how to do this.  You will also have the stents in place, but you do not have to do anything to care for them.  They are removed in about 10 days.

 

Mucus Management

 

Flush your neobladder every morning and evening, and as needed.  This will break up and flush out mucus that can block the tube.  One of the first signs of blockage (obstruction) is a decrease in urine output.

Supplies Needed

 

• Normal saline solution or sterile water
• Bulb or piston syringe

 

Procedure/Steps

 

• Gather your supplies.
• Wash and dry your hands.
• Draw up 30-50mL of saline or sterile water into the syringe.
• Using the syringe, gently flush the solution through the catheter into the neobladder.  Do not force it.
• Gently withdraw or pull back any solution and mucus through the syringe, or allow it to drain by gravity into a toilet.
• Flush gently until the urine is free and clear of mucus.

 

Voiding Routine

 

Weeks 1-3:     Every 2 hours during the day

Every 3 hours at night 

 

Weeks 3-6:     Every 3 hours during the day

Every 4 hours at night

 

After week 6: Every 4 hours during the day

At night, void as needed

 

The goal is to void every 4 hours.  Do not worry if you are not able to wait for 4 hours.  If your urine output is greater than 500 ml each time, you will need to void more often.  If your bladder feels full and you are not able to empty your bladder, you will have to catheterize yourself.  You must not wait longer than 6 hours before you empty your bladder.

 

When to Call the Doctor

 

• Fever over 100.5° F when taken by mouth for two readings taken 4 hours apart
• Shaking chills or sweating
• Decreased or no urine output
• Pink, red, cloudy and/or foul-smelling urine
• Redness, warmth, swelling or pus-like drainage at incision line
• Loss of appetite
• Nausea and vomiting
• Diarrhea that lasts more than a few days
• Abdomen, back, or flank pain
• Leg swelling or calf tenderness  

 

MED ALERT Band

 

You should always wear a medical alert bracelet or necklace on you at all times.  This will alert healthcare providers that you have a neobladder.  It should read:

 

Neobladder - Continent Urinary Diversion

May catheterize 4-6 times a day with a # 16 catheter

 

Ask your doctor or nurse for a form, or order the Medic Alert band from

 

Medical Alert Foundation

2323 Colorado Ave.

Turlock, CA 95382

 

1-800-432-5378

www.medicalert.org

 

Follow-Up

 

You will be followed by your doctor and a nurse practitioner.  Your follow-up visits should be at 1 week, 2 weeks, 3 weeks, 3 months, 6 months, and yearly.  You may need to have more tests after your surgery to include, urine, blood, ultrasound, CAT scan, chest X-ray, or a pouchogram (a special X-ray of the new bladder)  Your first visit will be made for you before you leave the hospital.  Please call your doctor with any questions or concerns.

 

Phone Numbers

 

Urology Clinic Nursing Staff: (608) 263-4757  Monday-Friday 8:00 AM-4:30 PM 

 

After hours, nights, weekends, and holidays, this will give you the paging operator.  Ask for the urology doctor on call.  Leave your name and phone number with the area code.  The doctor will call you back.

 

If you live out of the area, please call 1-800-323-8942.

 

Your Urology Doctor is:___________________________________________

 

 

MalecotTube Care

 

Cleaning

 

• Clean around the tube every day with mild soap (Cetaphil^®, Basis^®, Dove^®, Ivory^®, Aveeno^®, Neutrogena^®) and water.
• A dressing is not needed unless there is drainage around the tube.

 

Irrigating and Flushing

 

It is normal for your bowel to secrete mucus.  Mucus in the urine is normal with a Neobladder since the pouch was made with part of the bowel.  Flush at least 2-3 times each day to prevent plugging with mucus.

 

• Supplies
  • Irrigation set (bottle, basin, and syringe)
  • Saline.  Write the date you open the bottle on it.  An open saline bottle can be used for only 3 days.

 

• Steps

1. Wash your hands with soap and warm water for at least 15 seconds.  Rinse.  Dry with a clean towel.
2. Stand by the sink or sit by the toilet.
3. Fill the irrigation bottle with 150-200 ml of saline.
4. Draw up 50 ml of saline into the syringe.
5. Gently flush saline into the malecot tube.  Gently withdraw fluid or allow it to drain freely.  Repeat 3- 4 times until the urine is mostly clear of mucus.  Do not flush more than 4 times.  This could overfill your pouch.
6. Connect the malecot tube to the leg or night bag.
7. Wash all items in warm soapy water.  Rinse well.  Air-dry on a clean towel.

 

Leg Bag

 

Your malecot tube will drain into a leg bag during the day.  At night, change to a larger urine bag. 

 

How to Change Urine Bags

 

1. Wash your hands with warm water and soap for at least 15 seconds.  Rinse.  Dry thoroughly with a clean towel.
2. Wipe the end of malecot tube and leg bag connector with an alcohol wipe.
3. Attach a new bag.
4. Secure the leg bag to your thigh using leg strap.
5. Empty the leg bag as needed.
6. Rinse the bag with cold water and allow to air dry.  Once a week, rinse with 1 part white vinegar to 3 parts water.  Drain.  Allow to air dry.

Night Bag

 

At bedtime, change from your leg bag to the larger, night bag.  Do not wear your leg bag while sleeping.  It does not allow for proper drainage while sleeping.

 

How to Change to a Night Bag

 

1. Wash your hands with warm water and soap for at least 15 second.  Rinse and dry.
2. Wipe the end of the malecot tube and night drainage tubing with alcohol wipe.
3. Insert the end of night drainage tubing into the malecot tube.
4. Secure the tubing to your leg.  Use tape or Velcro strap.  This prevents pulling during sleep.
5. Put the bag near the foot of the bed at a level lower than your hips.
6. Always clean the night bag with a mix of equal parts white vinegar and water after use and allow to air dry.

 

The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.

Last Updated: 07/31/2009

Copyright © 07/31/2009 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. UWH #5787

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