Continent urinary diversion (internal pouch)

A continent urinary diversion is a way to pass urine after you have surgery to remove your bladder (cystectomy). Your surgeon makes a new internal pouch from a section of your bowel. The pouch stores your urine. Your surgeon makes a new opening called a stoma on your tummy (abdomen). They connect it to the pouch so the urine can exit through the stoma.

This operation is also called an internal pouch. Or a Mitrofanoff.

It is a more difficult operation than a urostomy and it is less common. A specialist surgeon has to do the surgery. Because the operation is more complicated, about 20 in 100 people (20%) need further surgery to correct problems afterwards.

Why you might have this surgery?

Your surgeon might ask you to choose which type of urinary diversion you want to have. They might recommend one type of diversion over another because of where your cancer is or your general health.

Your surgeon might suggest a continent urinary diversion if:

• you are unable to, or don't want to have, a bladder reconstruction (neobladder)
• you want to avoid wearing a urostomy bag to collect urine
• your risk of the cancer coming back is low
• your bowels are working well and aren't affected by any other problems, such as Crohn's disease or previous bowel surgery
• you haven’t had, and won’t be having radiotherapy to your pelvis
• your kidneys and liver are working well
• you are willing and able to learn how to pass a thin tube (catheter) into your stoma - this is called self catheterisation

Your surgeon and specialist nurse will support you before and after your operation. They will tell you about the different options available and what type is best for you. They will also show you how to look after and manage the type of urinary diversion you have.

What happens

You have a continent urinary diversion during the operation to remove your bladder (cystectomy). You have this operation while you’re asleep, so you will have a general anaesthetic . The operation takes between 2 and 6 hours.

There are 3 parts to the continent urinary diversion operation. These involve making:

• a pouch to collect your urine
• a channel to connect your pouch to the opening on the wall of your abdomen
• the opening on the wall of your abdomen (stoma)

The surgeon takes a section of your bowel. They join the cut ends of the bowel back together. They use the piece of bowel to make a pouch inside your body. This is called an internal urine pouch. The surgeon then sews the tubes that carry urine from your kidneys (the ureters ) to the pouch. Your urine runs down the ureters, into the pouch.

Then the surgeon makes a channel to connect the pouch to your tummy wall. They may do this using your bowel or appendix . Or, depending on your situation, they might use a piece of your ureter, urethra , or fallopian tube .

They cut a small opening on the surface of your tummy (abdomen). This is called a stoma. They put a part of your bowel into this hole. They use the part where the large and small bowel join. There is a natural valve in this part of the bowel. This keeps the stoma closed so urine does not leak out of the stoma.

The surgeon makes the stoma at, or just under your tummy button (navel) so that it doesn’t show under clothes. You’ll meet the specialist nurse before the operation to talk through best place for your stoma. Once it’s decided they’ll mark the spot on your tummy to guide your surgeon.

You will learn how to empty urine from the pouch by passing a tube (catheter) through the stoma. This is called self catheterisation. 

After surgery

When you wake up from surgery, you’ll have a lot of tubes attached to your body. You have tubes (catheters) to drain urine and allow your new pouch to heal. These stay in place for around 6 weeks. You might have 1 or 2 catheters going into the new pouch through:

• your tummy (abdominal) wall 
• your new stoma 

You might also have wound drains, a drip and ureteric stents. These are thin tubes that drain the urine from your ureters. They stay in place for up to 2 weeks.

You are usually in hospital for about 1 to 2 weeks after this surgery. You will go home with the catheters, and the nurse will show you how to care for these.

After a period of time you come back into hospital. The doctor or nurse removes your catheters. The nurse will then teach you how to empty your stoma yourself.

Your stoma

At first, the stoma looks swollen and red. It does not hurt because it has no nerve supply. Your stoma eventually becomes less obvious than it does if you’d had a urostomy. It shrinks as it heals and becomes far less noticeable.

Emptying your pouch

You put a catheter into the stoma to drain off the urine. You need to do this at least 4 to 6 times a day. Never go longer than 4 to 6 hours between catheterisations. You must be as clean and careful as possible when you do this so that you don't get an infection.

If the pouch gets too full it might leak and you may not be able to push the catheter in.

Problems after surgery

There is a risk of problems or complications after any type of operation. We have a separate page about general problems you might have after surgery to remove your bladder and having a urinary diversion.

You might have one or more of the following problems after a continent urinary diversion.

Difficulty with self catheterisation

You might have difficulty passing the catheter through your stoma to drain urine. This might be because of a tightening in the opening or in the tube to the pouch.

Tell your doctor or nurse if you are having any difficulties passing the catheter. They might suggest you leave the catheter in place for a short time as this can sometimes help. Your team will support you and try and find out what is causing the problem. You might need a small operation to help with this problem.

Stones in your urine pouch

The surgeon uses a piece of your bowel to make the urine pouch. The bowel tissue continues to make mucus. Mucus can build up inside the pouch and which can develop into bladder stones. You might need surgery to remove the stones.

To prevent bladder stones, you might need to wash out your bladder regularly. This can stop the build up of mucus. Your nurse will show you how to do this. 

High levels of chloride in your blood

Your bowel is designed to reabsorb nutrients from food. The urine pouch is made from your bowel and this bowel tissue continues to absorb some of the chemicals in your urine. You can get high levels of a chemical called chloride. Long term high chloride levels may cause problems such as fluid retention, high blood pressure and bone problems.

You will have blood tests to check this when you go to your follow up appointments. If your levels are high, your doctor might give you bicarbonate tablets to help with this. 

Leaking urine 

There might be a problem with the valve that closes the stoma. If the valve isn't working, urine can leak (incontinence). This problem isn't very common. You might need an operation to correct it.

There is a risk that the pouch might tear and leak urine inside you if the pouch becomes over full. So, it is important that you empty your pouch regularly and do not let it become over full.  

Going home

You are usually in hospital for 7 – 14 days after the operation. Your nurse will tell you how to get the equipment you need when you are at home. 

Your nurse is likely to set up an ordering system for you to get the bags. This can be from:

• your local pharmacy prescription service
• a medical devices delivery service
• a prescription card your nurse gives you with details of all the equipment you need -you take the card to your GP to get the bags and supplies

When you collect this from your pharmacy you will then need to show your medical exemption card so you don't have to pay for your stoma equipment.

Your stoma nurse might visit you at home. Or you may have a district nurse visit instead. You will have phone numbers to contact for advice when you are sent home. They are there to help you. So do ask for their help with any questions or difficulties you have.