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Intro: Welcome to UAB Med Cast, a continuing education podcast for medical professionals, providing knowledge that's moving medicine forward. Here's Melanie Cole.

Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me in this panel today is Dr. Chas Peyton, he's a urologic oncologist and an assistant professor; and Dr. Jeffrey Nix, he's a urologic oncologist and associate professor. They're both at UAB Medicine and they're here to highlight urinary diversion procedures for us today.

Doctors, thank you so much for joining us. And Dr. Peyton, I'd like to start with you. Why do we need to perform urinary diversions? What are the indications? Tell us a little bit about this and the clinical indications for these types of procedures.

Dr Chas Peyton: Sure, Melanie. Thanks so much for having us back on the podcast. We enjoy doing this when we can. But today, we're going to talk about urinary diversions. And I guess, the first question is why we need to do this. So, there's variety of indications. And the world that Jeff and I live in most of the time, Dr. Nix and I, it's usually for a cancer reason, meaning an organ is being removed such that the person can't urinate normally anymore, so the urine has to be diverted somewhere else.

There's a variety of other indications as well for non-malignant indications. Someone, for instance, who's a spina bifida patient and doesn't walk, doesn't use their legs and, as they age, managing the urine becomes an issue. And for that person, there's another indication to divert their urine to their abdomen or to another way to allow them to pass urine in a much more easy fashion rather than through the urethra.

So, that's the general gist of what a urine diversion is. The most simplest type of urinary diversion is just a tube, a nephrostomy tube into the kidney or a suprapubic tube into the bladder. But I think what we want to get at with this podcast is talking about more of the complex diversions that we do surgically that we see in the hospital quite a bit that can sometimes create a lot of confusions for both patients and providers that aren't used to dealing with them.

Dr Jeffrey Nix: Yeah, and I think what I would add is kind of just simplify exactly what Chad is saying. I think the person that's listening should think, if for whatever reason we can't use the bladder anymore, right? The bladder functions in two ways. It stores urines so that we can pee when it's convenient for us to do so. And then, it functions to help us get rid of that urine. So, it's a storage container, but it also is a muscle and that it has to be able to squeeze and get rid of all that waste. And so, if for a myriad of different reasons, you no longer have the use of that, and Dr. Peyton mentioned, we had to remove that organ because it had cancer or that organ becomes poorly functioning, let's say radiation exposure for certain types of cancer can be an example of that. Or you have limitations in movement, like a spinal cord injury where you're bound to a wheelchair and the bladder becomes dysfunctional for those reasons.

So, for any of a myriad of reasons, the bladder becomes an organ that is no longer functioning to the benefit of the patient, then we have to come up with alternative solutions. And that's, I think, where these urinary diversions can become so helpful for patients.

Melanie Cole (Host): Well, thank you for that. Then, Dr. Nix, tell us about some of those types of urinary diversions. Go from the most simple, as Dr. Peyton mentioned, to the most complex that other providers might be referring their patients for.

Dr Jeffrey Nix: Right. Let's say providers are going to see patients come in with tubes all the time, right? So, catheters. So, these are what we would consider to be temporary diversions. And you might not even think of them in that context, but they are diversions. So, a catheter, a Foley catheter that goes into the penis, or a suprapubic tube that goes directly through the skin into the bladder or nephrostomy tubes, which are smaller diameter tubes, which go directly into the kidneys. So for each of those very simple mechanisms, we're temporarily diverting the urinary stream at some part of the plumbing, so to speak, to get the urine removed from the patient in a safe manner. Now, again, I would consider those temporary.

And then, we go up to what are surgical types of diversions. And the easiest one we make is something that's just a conduit. Providers are going to see patients who wear ostomy bags all the time from colon cancer surgeries. And so, those are stool-containing ostomy appliances, but we can do the exact same thing with the urinary stream as well. So, a conduit, very simple and it just carries the urine from inside the body to an outside appliance that the patient then manages. That obviously is not continent. And so, the patient, it's just a passive drip system. And so, then we can go up to much more complicated diversions that all have some form of continence. And when we as urologists think about them, we think about them, and Dr. Peyton may want to elaborate on this, we think about them as orthotopic and non-orthotopic diversions that can be continent.

Dr Chas Peyton: Sure. Just like Dr. Nix says, we go from least complex to most complex. And after an ileal conduit like we talked about, which is just simply a segment of ileum repurposed to draining urine as opposed to stool. It's just removed from the stool tract and hooked up to the ureters on one side and the other side to the skin.

The next level complexity would be whether or not you want orthotopic, non-orthotopic, which means you want the new reservoir to hold the urine to urinate like a normal bladder. Meaning, do you want to pee through your urethra? So, the next one we'll talk about is what's called a neobladder. So, an orthotopic neobladder where we are taking a longer segment of usually ileum, and repurposing that ileum to serve as a urinary reservoir in the pelvis. It's a lot more complicated. We're using about probably anywhere from 40 to 60 centimeters of ileum as opposed to maybe 10 to 20 for a conduit. It's a lot of complex reconstructive effort. And that is ultimately sewn. The ureters are plugged into one side and the other side is sewn to the urethra. So, that would be what we call a continent orthotopic urinary diversion, because that patient will eventually learn how to use their external sphincter and urinate similarly to how they had their native bladder, but use more of a Valsalva technique by pushing and whatnot to allow the urine to drain.

And the third type of diversion we always talk about would be a continent cutaneous diversion, where again it's a pouch made out of repurposed, in this case, it's usually colon, right colon. And then, a stoma brought to the skin such that the patient has a pouch on the inside that they catheterize through their abdomen. So, we're taking the urethra out of the equation with that. And they're not leaking to a urinary bag on the abdomen, but instead they have a continent catheterizable stoma at the abdomen. This is probably the most complex urinary diversion, I'd argue, that we do and it's not as frequent. But for certain indications, we can do it. And basically, you're using part of the right colon and the terminal ileum, opening that up, and repurposing that as a pouch on the inside and the terminal ileum limb of that pouch is then brought to the skin such that it's a tiny continent stoma that doesn't leak urine. So, people don't have to wear a bag, which just they have to every three to five hours go and catheterize that pouch to get the urine out.

So, that's the basics. Now, there's a lot of variety on the surgical techniques with each one of those, and I don't think we need to get into that, but that's another discussion in and of itself. But those are the three main types that we're going to talk about.

Melanie Cole (Host): Thank you for that comprehensive answer. So, then Dr. Nix, based on what Dr. Peyton was just saying, how do you select those patients for the most appropriate type of urinary diversion? How do you decide which type of procedure to use and how does the choice of type of diversion require careful clinical and quality of life assessments with the patient and shared decision-making?

Dr Jeffrey Nix: Yeah. I mean, you said it all. Of course, the context for us, and this is often a multi-interview process. So, if I'm bringing a patient in for counseling on this topic, as you can imagine, we could talk about this for hours and hours. And so, our main job is one of education. We're going to go over the basics with the patient. And then, we're going to usually do a second or even a third counsel session because it is so important that we get this right and that we select something that is appropriate medically as well as in terms of their quality of lives. And some of that requires a knowledge of the kinds of activities they do, their expectations. And it's always patient-specific.

So, let me use a situational vignette to sort of describe that. If you're wheelchair-bound because you were in an auto accident as an example, and getting from your wheelchair to-- let's say you're a female patient and you have less upper body strength, and getting you back and forth from your wheelchair to a bedside commode or to the commode at night is difficult, and it's not just because of maybe transitioning out of a the chair is hard for you, but let's say you've got limitations because of the home you live in, and so that's a great patient. And you're younger. Let's say you're mid-30s and you don't want an appliance or an outside conduit reservoir like a bag. And so, as a patient, that would be a perfect patient for a catheterizable diversion, like the last one that Dr. Peyton mentioned, the Indiana pouch, because they will be able to have continence. So, they won't have urine constantly dripping into a bag and, because they're wheelchair-bound, we can put that opening that they catheterize somewhere around their belly button level or mid-abdomen level, and so they won't have to get in and out of their wheelchair to be able to manage that diversion. So, that's a perfect patient for that kind of diversion.

What would be a really bad patient for that kind of diversion? Let's say you're an older patient and you have really poor vision. And because of diabetes or other situations, you don't have great sensation and maybe you have limited dexterity. So, that would be a really bad diversion for that patient because they're going to struggle to be able to catheterize themselves. They're going to struggle to be able to have the sensation they need and the awareness they need to be able to capitalize consistently. And so, all those things would weigh in. And that's just a couple of examples. So as you mentioned, this is shared decision-making. This is going over all of these different variables to make sure we make the right choice.

Melanie Cole (Host): Dr. Peyton, as urologic surgeons who perform these urinary diversions, and you're speaking to other healthcare providers, what should they take note of or be aware of when they're thinking about the physiological and metabolic changes that can occur from some of these surgeries? I'd like you to speak about complications that can be associated with urinary diversion. And specific to each type, what should they be keeping in mind that could be associated with this?

Dr Chas Peyton: It's really an important thing that we encounter from time to time. I'll keep on the same kind of pathway that we've been discussing from simplest to most complicated.

So, anytime somebody has a urinary diversion where we're repurposing bowel, there's going to be contact of the urine with the intestines. So that does pose occasional problems for these patients, particularly metabolic problems. Specifically, I can kind of tell you, since there'll be providers listening to this, they'll know what I'm saying, depending on segment of bowel that you use will dictate some metabolic abnormalities some of these patients will have, also how long the urine is in contact with those places of intestine, meaning that a ileal conduit urinary diversion, the most simple type, the urine is in contact with it not that long because the urine is constantly leaking into a bag. Whereas opposed to someone with an ileal neobladder or a colon neobladder or a colon continent cutaneous diversion like we talked about, the Indiana pouch, the urine's going to be in contact with that quite a bit longer. So, the risk for metabolic problems is a little bit higher in those patients.

But just to talk to you specifically if you're using colon or ileum, people get low potassium levels, high chloride levels, and they get a metabolic acidosis or they can get it. Sometimes in these patients, if they have it long enough, we replace them. We give them bicarb, just to kind of replace some of the acidosis that they get. If you see a patient that has a stomach urinary diversion, that's a historic urinary diversion, we hardly ever see that anymore. But there are patients out there that occasionally have had elements of stomach used for their diversion. Those people get low potassium levels, high chloride levels, and they get a metabolic alkalosis. And then, if you see patients that have used jejunum as part of their diversion, again that's uncommon this day and age, but historically we saw them. Those patients get high potassium levels, low chloride levels, low sodium levels, and they get a metabolic acidosis. So, those are just some of the temporary metabolic concerns. But some of the other concerns or problems that you see is how to manage these.

So, something I see frequently is I've had other providers ask me if these diversions are reversible. And for the most part, the answer to that is usually no. When we do these diversions, they're permanent. They're expected to be permanent. And rare situations can we change them. So, that's one thing to know.

And then, the next thing that I see frequently is that people that have an Indiana pouch or a continent catheterizable urinary diversion. I've seen providers or other folks ask us why this is not leaking or if the patient's sick and they're not able to tell us, the thing they need to know is that you have to drain the urine from them, they have to pass a catheter. So if the patient's obtunded, they can't tell you. You need to know that that stoma is usually at the belly button or in the right lower quadrant. You can just pass a regular 16 French Foley catheter or 14 French Foley catheter and then you can blow up the balloon like usual. That's how you drain them.

And then, patients with a neobladder, you're going to catheterize them just like you would catheterize a native bladder. And in men, it's actually a lot easier to catheterize a neobladder because most of the time when we're doing this specifically for cancer reasons, the prostate's removed, so it's a lot easier to catheterize them.

In terms of other complications, one of the main things we see is stenosis or scarring at the junction of the ureters and the diversion and then sometimes where the diversion comes to the skin. That's the most common thing we see, and we have to operate on those sometimes. Urinary diversions, I tell patients all the time, the higher the complexity level, the more likely they are to require a secondary intervention years down the road. So, someone who gets the ileal conduit, oftentimes we're never having to operate on this again. But occasionally people that have a Indiana pouch or a continent cutaneous urinary diversion, or occasionally a neobladder, sometimes we'll have to do a procedure 10 years from after when their initial one is to just kind of revise things or make it so it works a little bit better. Those are broad strokes of some of the issues we see.

Dr Jeffrey Nix: Just to add a little bit to that. So, Dr. Peyton mentioned some of the long-term consequences of these diversions and then some of the direct consequences of the different types, bowel segments we might use. There are some nutritional derangements. So if we use the ileum, which tends to be the best segment of bowel to use in terms of the disturbances from an electrolyte basis, but long-term you can get some B12 deficiencies because that's the most common portion of the bowel to absorb B12. And so, usually, it's two to three years down the road. So, we'll start checking annual B12 levels. I think this is something that's really relevant for primary care providers to focus on is if there's a lot of fatigue in these patients down the road, it could be a simple B12 abnormality, it's very difficult to correct from an oral supplement. Usually, they require shots to bypass the absorption issue. But it also could be, as Dr. Peyton mentioned, a bicarb issue as well, and supplementing maybe a requirement there too. So, getting regular chemical series, chem panels on these patients is helpful in making sure you're able to be proactive about any electrolyte abnormalilty.

I think the other thing I would add is whenever we use the colon or a longer segment of small bowel, one of the things you see at least in the short-term, and hopefully not long-term, can be diarrhea as a consequence of shortening the bowel in those patients. It typically is short lived or is something that can be controlled from a medical standpoint, like using something as easy as loperamide. And this isn't common after removing a short segment, like for a conduit, but if we have to do a more complex segment, especially if we remove the ileocecal valve, they could have diarrhea or even patients sometimes will describe it as bowel urgency, and so that's something for physicians to look out for.

Melanie Cole (Host): Wow. This is so interesting, doctors. Thank you. And I want to give you each a chance for a final thought. Dr. Nix, both of you have shown us truly how experience of the surgeon matters so much for these types of procedures. Can you speak a little bit about your outcomes and how generally is the quality of life of the patient.

Dr Jeffrey Nix: So, we have both done hundreds and thousands of these diversions. And as an example, the complex ones, and Dr. Peyton hit on it, the more complicated things we do, the more things that can go wrong. And so, having the reservoir size-- as an example, let's say we make you this beautiful pouch on the inside, but we make it way too small. Well, it's not going to be functional. If we make it way too big, then you're going to have so many different electrolyte abnormalities because these things continue to resorb. And so, where we put the pouch and how we set up your ability to catheterize can make a huge difference. And this is why this is a team approach. We have a well-trained staff of stoma nurses that will have the patient sit down, have the patient stand up, look at where creases in their skin are, so that if we are going to have them catheterized, that thing has to be perfect in order to be accessible to the patient.

And so, I think to your point, it has to be great craftsmanship on the front end. But the other thing you have to be cognizant of as surgeons is that things will go wrong. And so, we're constantly looking at these patients. Even when we think their risk of cancer recurrence has gone, we still need to follow them to make sure that there's no derangement with their diversions long-term. And so, as Dr. Peyton so astutely mentioned, some of these complications don't come until five or seven or 10 years down the road. They develop a little bit of scar tissue at one of those connections. And if we don't evaluate that proactively, you might end up with renal failure or renal dysfunction. So, I think experience is a huge part of doing these complicated diversions, and I do think that's why physicians see a regionalization of some of these procedures. But to Dr. Peyton's point, when patients go back home to get their followup or their standard care, it's great for providers to at least have some insight into these complex diversions.

Dr Chas Peyton: Yeah. Just to piggyback on that, Dr. Nix is exactly right. This is an ever-changing field. I think when people started doing complex urinary diversion in the '80s, a lot of urologists were very excited about it. And there was a tremendous series about doing all sorts of wild diversions out there. But since then, we've really narrowed things down and learned from years of experience what works, what doesn't work. But one thing that's certain is if you're going to have a complex diversion, you want it done by a surgeon and by a team that's used to doing them. And I think we have some of that experience here at UAB.

By far the easiest is always to do a ileal conduit urinary diversion, and most everyone is trained on how to do that. Far fewer people are trained on how to do more complicated diversions for specific indications like we've been discussing. So, it's really a decision between the patient and the provider. And there's all sorts of nuance here, but we're kind of just scraping the surface here. But it's something that is an option and we talk about it with all our patients that need urinary diversion and share that decision together. And as a provider taking care of one of these patients after the fact, it's important to kind of realize some of these things we've discussed today and have it in the back of your mind when you're seeing these folks.

Melanie Cole (Host): You've both said it so perfectly and made such great points. And I love the use of craftmanship, as Dr. Nix said, and considerations of body types and patient quality of life. So important for that shared decision-making and those kinds of discussions. Dr. Peyton, as we wrap up, anything on the modern surgical field that's changed, any game changers that you'd like to mention for other providers and when you feel it's important that they refer to the incredible expertise at UAB Medicine?

Dr Chas Peyton: Melanie, you just reminded me something. I think that it is important to understand what the options are with every patient and why some would work and why others wouldn't. In terms of modern surgical changes of how the landscape's changed, I kind of described how we've adjusted some of our urinary diversion to those three main types. There used to be a plethora of other ones. But one thing we can do, and Dr. Nix can comment on this now, is we actually have a more minimally invasive approach that's right for some patients to do some of these complex urinary diversions. Not everyone, but some patients, we were able to do that through minimally invasive approach these days, and Jeff can comment on that. It's not right for everyone, but some of these patients can benefit from that as far as new techniques that are out there.

Dr Jeffrey Nix: To Dr. Peyton's point, we want to try to get patients to recover as quickly as possible. Now, the primary part of that is doing the procedure well. And if that requires an open surgery versus a minimally invasive surgery, fine. But some of the advancements we've made is going even from multi-incision robotic or laparoscopic surgeries to single-incision procedures. And so, if you have a patient who has a complex procedure that needs to recover quickly because they then require adjuvant therapy as an example, then we can do that minimally invasive and limit their time off therapy, as an example for cancer patients. Or for newer immunotherapeutics, sometimes we don't even have to bridge them off therapy at all. I use Keytruda as an example simply because we use it a lot in urology now, that infusion is once every three weeks often, and we can just time it and do the procedure without having to take patients off for some of these more advanced cancer procedures we do.

So, in terms of the other advances we've made is we're getting more aggressive with bladder. So if we can preserve the organ, we're going to try to do so. I think some of that is determined also by the age of the patient. And I don't just mean we're going to be more aggressive preserving the bladder and younger patients. Again, I love using patient examples because I think it drives it home to our providers. If you're going to send me or us an 82, 83-year-old patient that has a bladder cancer that may be aggressive, they don't have the social support as an example, or they don't have the physical support or the emotional support to handle a complex procedure or complex chemotherapy. Is there a way we could palliate that patient by doing a minimally invasive approach to try to get them the best option as we can? So, as we're thinking about these diversions, again we're also thinking about longevity and what kind of expectations we can create with those patients, and that is, you mentioned it before, a shared decision-making process.

Melanie Cole (Host): Well, you are both just incredibly expert at this discussion and really fascinating for other providers. I know they will find it as interesting as I did, and I thank you so very much for coming on and really sharing all these nuances of these procedures with us. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website uabmedicine.org/physician.

That concludes this episode of UAB MedCast. For more updates on the latest medical advancements, breakthroughs, and research, be sure to follow us on your social channels. I'm Melanie Cole.