Ureterosigmoidostomy

Ureterosigmoidostomy is a surgical procedure that is done to create an alternate pathway for removing urine in individuals who have undergone bladder removal surgery.

Organs including the kidneys, bladder, ureters, and urethra make up the urinary tract. Kidneys filter blood and produce urine, which then passes into the urinary bladder via two tiny tubes called ureters. The bladder stores urine until you are ready to excrete it. Urethra is a single tube that carries urine from the bladder to outside the body.

During ureterosigmoidostomy, the ureters are disconnected from the bladder and attached to the last section of the large intestine (sigmoid colon). The procedure is usually done in individuals with bladder cancer who have undergone a radical cystectomy (whole bladder removal). In such people this surgery allows the urine and stool to be eliminated from the same opening, i.e., through the anus.

This surgery is recommended in individuals with:

• Bladder cancer who have undergone radical cystectomy
• Traumatic lower urinary tract lesions
• Bladder exstrophy (birth defect in which the skin does not form over the urinary bladder, leaving it exposed)
• Large vesicovaginal fistulas (fistula connecting the urinary bladder and vagina)
• Bladder fibrosis
• Injury to the bladder caused by radiation therapy or other treatments for cancer

This procedure can be done in individuals who have a well functioning sigmoid colon, anal sphincter, ureters, and kidneys.

The surgery should not be performed in individuals with:

• Co-existing bowel condition
• Inflammation of the inner lining of the rectum due to radiation
• Ureter dilated more than 1 cm
• Diverticulitis

Ureterosigmoidostomy is performed with caution in individuals with a smoking habit; lung, heart, or kidney diseases; and in pregnant women.

You will need to visit the hospital for a preoperative assessment prior to the surgery. During the assessment, you will have to undergo various tests, including a blood test, pregnancy test, and urine test. Additionally, the following preparations will be needed for the surgery:

• Inform your healthcare provider if you are pregnant or have any allergies.
• Tell your doctor about all the medicines that you take, including herbs and over-the-counter medications.
• You will be asked to discontinue blood-thinning medicines like ibuprofen, aspirin, warfarin, or clopidogrel.
• If you smoke, quitting it before the surgery can expedite your recovery.
• The doctor will share with you a list of medicines that you are permitted to take on the day of the surgery.
• You should shower and remove nail polish, make-up, and body piercings before arriving at the hospital on the day of the procedure.
• Arrange for a friend, family member, or responsible adult to drive you home after discharge from the hospital.
• Inform the surgeon if you experience fever, cold, or flu on the days leading to the surgery. In such a case, your surgery will be postponed.
• Avoid drinking or eating anything from midnight the night prior to the surgery.
• You will be given special instructions to keep your bowel empty on the day of the operation. This process should begin one to two days prior to the procedure. You will be prescribed laxatives (medicine to soften stool and increase bowel movements) or enema to empty your bowel. In addition, you will be put on a liquid diet along with other dietary restrictions.
• You will be asked to sign an approval or consent form to grant your permission for the surgery.

Once you reach the hospital, the hospital staff will provide you with a hospital gown. They will start an intravenous (IV) line in your arm or hand to provide you with essential fluids and medicines during the surgery. The procedure is performed under general anaesthesia to put you into a deep sleep during the operation. Medications to prevent clotting of the blood will also be given to you. The surgery usually involves the following steps:

• The surgeon will make a cut on the lower part of your abdomen, which may extend from your navel to your hip bone.
• Once access to the large intestine is gained, the surgeon will make a cut on your sigmoid colon, fold it into a U shape, and stitch the edges to create a pouch-like structure that will hold urine and stool.
• Next, the surgeon will make an incision in a layer of the wall of your colon, which is then made into a longitudinal tunnel with the other opening inside the colon.
• The surgeon will insert one of your ureters into your colon through this tunnel and stitch it in place.
• He/she may insert a thin, hollow tube into your ureter to widen the passage for easy flow of urine.
• The procedure will be repeated with the second ureter.
• Finally, the surgeon will close all the incisions with stitches, glue or staples.
• Afterwards, he/she will place a tube in your rectum (a portion from the end of the sigmoid colon to the anus) to remove stool and urine until the wound heals.

The procedure will take three to four hours to complete. You will need a hospital stay of about one to three nights and can expect the following:

• You will be encouraged to get up from your bed and walk. This will help promote recovery
• A nurse will give you medicines for pain relief.
• You will be taught some breathing and coughing methods. Follow these methods to clear your lungs and prevent pneumonia.
• You will be started on a liquid diet and gradually allowed to resume your regular diet.
• The surgeon will remove the tubes inserted in your ureters and rectum before you are discharged from the hospital.

The surgeon will give you the following instructions to take care of yourself after the surgery:

• Take all the recommended medicines on time.
• Keep the operated site dry and clean. The surgeon will give you instructions on how to change your dressing. Usually, you will be allowed to remove the bandage after 48 hours or if it gets dirty or wet. You will be asked to clean the wound with soap and water.
• Do not sit in a hot tub, bathtub, pool or perform any other activities that will soak your wound in water until your cuts have healed completely.
• While sneezing or coughing, you should keep a pillow tightly held against the wound to avoid any tear in stitches and to decrease abdominal discomfort.
• Take short walks every day and gradually increase your distance and pace over the next few days.
• Avoid lifting heavy objects or indulging in strenuous activities until your surgeon allows you to.
• Drink a lot of water to avoid dehydration and urine odour.
• You should resume driving only after consulting with the surgeon as some of your medicines may make you feel sleepy or drowsy.

This surgery is usually not performed now due to associated risks. However, unlike other techniques, ureterosigmoidostomy does not require external openings and appliances to collect urine. Moreover, this procedure is relatively easy and improves the quality of life.

When to see the doctor?

Contact the surgeon at the earliest if you experience any of the following symptoms:

• Fever with body temperature over 100.4^°F (38^°C)
• Pain or swelling in legs
• Blood in stool
• Blood in urine
• Pain in the lower back
• Increased swelling or redness around the operated area
• Worsened pain
• Foul-smelling discharge from the incision
• Persistent nausea or vomiting

The potential risks and complications associated with the surgery include:

• Infection
• Bleeding
• Formation of blood clots
• Build-up of urine inside kidneys
• Increased risk of colon cancer
• Difficulty passing urine and/or stool
• Leakage of urine from the incisions in the intestine
• Stones in the ureters or kidneys
• Damage to organs of the urinary tract
• Abnormal levels of minerals in the blood
• Risks of anaesthesia such as confusion, lung infection, or heart attack

A schedule for follow-up appointments will be provided to you before you are discharged from the hospital. During the follow-up, your surgeon may remove your stitches, monitor your progress after the surgery, and discuss the possibilities of additional treatments that may be required.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.