Approach to urinary diversion in the surgical patient.

Major surgical procedures may remove part or all of the bladder and make an incontinent or continent urinary diversion appropriate. Preoperative consideration must be given to 1) the stoma and its position, 2) the catheterizable channel, 3) the urinary continence mechanism, and 4) the substitute bladder reservoir. Complete bowel preparation and broad-spectrum antibiotics are desirable. The patient's motivation for taking care of a continent urinary diversion is important, since lifelong catheterization and mucous irrigation may be necessary. The status of the native bladder outlet and urinary sphincter is important in cases in which an orthotopic continent urinary diversion is considered. Preoperative evaluation by a stoma therapist is invaluable. Adequate urinary drainage is important in the immediate postoperative period. Patients with urinary diversions must be followed lifelong to rule out asymptomatic deterioration of their upper urinary tracts and to check for potential metabolic and nutritional problems.