- Email: [email protected]
Restoring and Maintaining Urinary Function
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Seminars in Oncology Nursing, Vol 28, No 3 (August), 2012: pp 163-169
RESTORING AND MAINTAINING URINARY FUNCTION JOANNE LESTER OBJECTIVES: To describe surgical urinary diversion methods, nursing management, and survivorship issues in urologic cancer survivors. DATA SOURCES: PubMed, Scopus, Cochran Reviews, Core 25 online texts. CONCLUSION: Options exist for patients that require urinary diversion, although long-term symptoms may persist.
IMPLICATIONS FOR NURSING PRACTICE: Nurses must be knowledgeable about obstructive uropathy and understand the surgical options for urinary diversion following a cystectomy; pre- and post-operative needs exist for the cancer patient, family, and caregiver. Following completion of active treatment, a survivorship care plan summarizes active treatment and complications, plans long-term health outcomes and surveillance, and communicates with the primary care provider.
KEY WORDS: Urinary diversion, obstructive uropathy, ileal conduit, orthotopic diversion
P
ATIENTS undergoing surgical interventions to correct obstructive uropathy have many challenges that include specific procedure decisions, short- and long-term side effects, self-image issues, alterations in sexuality, and disease-related concerns. Joanne Lester, PhD, CRNP, ANP-BC, AOCNÒ: Research Scientist, Comprehensive Cancer Center, James Cancer Hospital & Solove Research Institute, Clinical Assistant Professor, College of Nursing, The Ohio State University, Columbus, OH. Address correspondence to Joanne Lester, PhD, CRNP, ANP-BC, AOCNÒ, Research Scientist, Comprehensive Cancer Center, James Cancer Hospital & Solove Research Institute, Clinical Assistant Professor, College of Nursing, The Ohio State University, 1142 Holton Road, Grove City, OH 43123. e-mail: joanne. [email protected] Ó 2012 Elsevier Inc. All rights reserved. 0749-2081/2803-$36.00/0. doi:10.1016/j.soncn.2012.05.005
Nursing professionals caring for these patients must be effective educators, knowledgeable caregivers, and empathetic listeners, with an understanding of the pathophysiology of obstructive uropathy and function of urinary diversions. Multiple options are available for patients today, although the same disruptive thought remains: ‘‘I will never urinate the ‘normal’ way again’’.
OBSTRUCTIVE UROPATHY Etiology Urinary function may be altered by intrinsic or extrinsic mechanical and functional defects, including primary or secondary effects of malignancies. In children, congenital malformations with narrowing of structures are the most frequent source of obstruction; in adults, acquired mechanical or functional defects make up the majority of obstructions.1,2 Alterations in urinary function may result in acute or chronic obstructive
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uropathy and can lead to permanent damage in the urinary tract (eg, hydronephrosis, renal failure) if urinary function is not promptly restored.1,2 Mechanical obstructions can occur at any level of the urinary tract, precipitated by tumors, calculi, infection, injury, inflammation, and urethral stricture.1,2 Urinary tract obstruction may occur in patients with solid tumors, such as prostate or gynecologic malignancies, or as a secondary effect of cervical spine, solid tumor, or lymphoma metastases.2,3 Ureteral obstruction can result from fibrosis secondary to pelvic surgery, chemotherapy, or radiation therapy,4 or from an encroaching tumor mass. Bladder outlet obstruction may be secondary to cervical or bladder tumors, or scarring from chemotherapeutic agents or radiation therapy. Urethral obstructions can be caused by scar tissue or tumor, and may lead to abnormal enlargement of the bladder and surrounding structures with significant alteration in urinary output.1,3 Functional impairments of urinary flow result from ureter and bladder disorders, such as neurogenic bladder, adynamic ureter(s), and vesicoureteral reflux.2
PRESENTATION AND DIAGNOSIS Signs and Symptoms Symptoms of obstructive uropathy commonly include flank pain with or without radiation to lower pelvis, changes in urinary function, arthralgia, skin rash, pallor, persistent urinary
tract infections, edema, proteinuria, or hematuria.1-3 Complete anuria or partial anuria that alternates with polyuria are possible; when accompanied by a rise or a prolonged increase in serum creatinine, obstructive uropathy is suspect.2,3 Identification of the source of obstruction and the presence of hydronephrosis is essential and may be accomplished with a renal ultrasound.1 If not definitive, an intravenous pyelogram or computed tomography scan should be ordered (Table 1). The pyelogram is effective in the diagnosis of kidney obstruction, whereas the computed tomography scan may reveal the point of obstruction and presence/absence of an encroaching structure or malignant mass.3,5 Prolonged obstructive uropathy can result in signs such as azotemia, acquired tubular acidosis, hyperkalemia, and renal salt wasting.2 A urinalysis may be helpful to identify abnormal elements in the urine that lead to the diagnosis and etiology of obstructive uropathy.6 A 24-hour urine collection may be ordered simultaneously with serum creatinine levels to measure the degree of proteinuria and urinary albumin, and ultimately, the degree of renal failure.6 Related serum studies include a complete blood count to evaluate for anemia secondary to renal insufficiency, creatinine, and blood urea nitrogen to follow renal function, glucose to rule out diabetes mellitus, potassium to identify elevation, albumin to evaluate severity of proteinuria, and protein electrophoresis if multiple myeloma is suspect.6 Arterial blood pressure should also be monitored to rule out acute or
TABLE 1. Obstructive Uropathy: Signs, Symptoms, and Diagnostic Tests Symptom
Sign
Flank pain
Pain with light palpation at site or posterior over kidney(s) Pain radiates to lower pelvis Generalized abdominal, flank, posterior pain Changes in urinary function
Anuria, partial anuria, polyuria
Skin rash, itching Pallor Urinary tract infection Edema
[creatinine Yhemoglobin [bacteria, white blood cells Abnormal concentration of urine, bilateral lower extremity edema, elevated blood pressure
Hematuria Proteinuria
Visual or microscopic blood in urine Increased urine protein, decreased serum albumin
Diagnostic Tests Physical exam, renal ultrasound, urinalysis Physical exam (rectal and gynecologic exams), renal ultrasound, urinalysis Urinalysis, serum creatinine and blood urea nitrogen; urinary catheter Serum creatinine and blood urea nitrogen Complete blood count Urinalysis, complete blood count Blood pressure, serum potassium, renal ultrasound, intravenous pyelogram, computed tomography scan Urinalysis, visual exam Urinalysis; serum creatinine, blood urea nitrogen, albumin, potassium, glucose, 24-hour urine
Data from Seifter and Breener,1 Calabrese,2 Gucalp and Dutcher,3 O’Rourke,5 McDougal,6 and Mansson et al.8
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uncontrolled hypertension.1-3,7 Physical examination should include rectal exam, genital structures, and abdomen. Insertion of a bladder catheter may be considered to evaluate the presence or absence of urine in bladder (Table 1).2
URINARY DIVERSION PROCEDURES Urinary diversion procedure(s) may be necessary to establish a method of urine evacuation in cases of advanced uropathic obstruction or surgical removal of urologic structures. Flexible or rigid stents can be placed in the ureters to relieve focal intrinsic or extrinsic encroachment, although they do not provide a permanent solution in the case of tumor invasion or encroachment.5 Percutaneous nephrostomy can be used as a temporary solution, or as a palliative intervention for obstructive renal failure that is not amenable to more advanced surgical interventions.7 Bladder cancer that presents with invasion into or through the bladder muscle requires a radical cystectomy with a continent or incontinent urinary diversion.5,8,9 In men, the surgical procedure involves a cystoprostatectomy; in women, both a cystectomy and hysterectomy are performed.8 Several surgical options exist that provide for urine collection from the ureters, e.g., urinary diversions (incontinent and continent), bladder reconstruction, or replacement.10 Incontinent Cutaneous Diversion Incontinent cutaneous diversions are surgical conduits that use a segment of bowel (typically ileum or colon, and less frequently jejunum).5,7-9 If the pelvis has been irradiated or is involved with tumor, a segment of the right colon or jejunum may be selected. During the surgical procedure the ureters are implanted into the proximal end of this segment of bowel. The distal end of the bowel is brought to the surface and sutured to the skin of the anterior abdominal wall, with creation of an ostomy on the surface.8 Urine is routed to a urinary collection appliance, or ostomy bag. The advantages of an ileal or colonic conduit are their relative simplicity and the minimal perioperative complication rate (13%).4,9 Continent Cutaneous Diversion Continent cutaneous diversion offers the advantage of a hidden pouch inside the body.4,7,11 The abdominal diversion, or continent cutaneous diversion,10 uses a continence valve and a segment of
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bowel to create an intra-abdominal reservoir for urine storage.4,8 The ureters are implanted into the proximal bowel segment, and the distal bowel is brought to the surface and sutured to the skin to create an ostomy as described above.8 The patient self-catheterizes the ostomy every 4 to 6 hours to remove accumulated urine.4,8 The valve prevents reflux of urine and enables the patient to control urinary elimination without the use of an ostomy bag. Continent diversions involve a longer and more challenging surgery9,12 and hold higher complication and reoperation rates.9,13 Alternatively, a low-pressure rectal reservoir can be constructed with anastomosis of the ureters to the rectum; the anal sphincter maintains continence.10 Bladder Reconstruction Bladder reconstruction techniques are based on the addition of a bower segment onto a coronal- or sagittal-resected bladder.10 In the case of bladder cancer, the entire bladder is removed to provide optimal treatment for the underlying malignancy. Therefore, for purposes of this article, these options will not be explained further. Neobladder, Orthotopic Reconstruction In the case of the orthotopic neobladder, the bowel is carried down to the urethra, and the urethral sphincter is used as the reflux valve.4,7-9 The patient eliminates urine through the urethra with the Valsalva movement, eg, induced stress on the urethral sphincter to eliminate accumulated urine; the patient may occasionally need to self-catheterize. This surgical method provides rehabilitation to normal voiding through the urethra4,8 and may be the most comfortable option. Similar to the abdominal diversion, the need for an ostomy bag is eliminated. Aspects for consideration include the type of gastrointestinal tract available, anatomic location of a possible stoma, preservation of the urethra for an orthotopic diversion, upper urinary tract protection, preservation of sexual activity, and gender differences.12,13 Meticulous dissection and preservation of urinary structures and autonomic nerves may preserve continence with intact voiding function.11 The most worrisome question in orthotopic diversion is whether the remaining urethral tissue harbors any cancer cells that will later metastasize to the area.13 A surgical option to the orthotopic diversion is the uretocutaneostomy, a procedure that joins the two ureters with an end-to-side anastomosis.13
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The right ureter is then fixed to the fascia and skin; single J stents are inserted into the ureters, which allow drainage of the urine in an ostomy pouch. This option may have fewer complications13 than the orthotopic diversion, and is more desirable than the ileal conduit because neither bowel segment nor stoma is required.13 Summary A Cochran review of urinary surgical diversion techniques noted that evidence from clinical trials is limited with few common pre-identified comparisons.10 Of the four reviewed trials that met baseline inclusion criteria, the authors note that no evidence existed to suggest that bladder replacement with orthotopic or continent diversions were superior to conduit diversion following cystectomy for bladder cancer.10 A more recent publication discussed observed long-term complications in patients more than 90 days post orthotopic neobladder surgery in a tertiary institution. Using the Kaplan-Meier method for timedependent events, surgical-related complications in 923 patients from a 25-year period were evaluated (Table 2).14 Complications were documented in 40.8% of patients (n ¼ 377).14 A recent Medline database review (1996 to 2008) yielded 14 publications that met inclusion criteria for external stoma and peristomal complications following radical cystectomy and ileal conduit diversion. Commonly reported complications were stoma or abdominal wall-related changes and peristomal skin changes.15
NURSING CONSIDERATIONS Preoperative Evaluation As described above, there are multiple options for urinary diversion in the event that the bladder must be removed, either for primary bladder cancer or infiltrative metastatic tumor. In the event of a surgical urinary diversion, preplanning can make a significant difference in the patient’s satisfaction and acceptance of the device.8,16 During preoperative patient/family/ caregiver counseling, primary discussion goals about surgical urinary diversion should include: 1) the safest method for cancer control; 2) fewest short- and long-term complication rates; 3) anticipated lifestyle adjustment; and 4) projected quality of life.7 The patient and surgeon should have an honest discussion about the pros and
cons of each type of surgical diversion before decisions are made. Unless otherwise contraindicated, all cystectomy patients are candidates for a neobladder.7 Referral to a tertiary facility with trained surgeons should be recommended, if necessary. Before surgery, the patient and significant other or caregiver should meet with professionals specially trained in the care of cystectomy with urinary diversion. Advanced practice nurses and enterostomal therapists can augment the surgeon’s discussion and provide the patient/ family/caretaker with invaluable resources. If warranted, optimal placement of a stoma site can be discussed because pre-planning is essential for postoperative management, care of the device, perceived self-image, and quality of life.8,16 A preoperative bowel preparation with age- and disease-appropriate laxatives is necessary to prepare the gut for surgery. The importance of a complete bowel evacuation should be reinforced to the patient and caregiver.5 Postoperative Care Postoperative care and nursing management should include assessment for complications related to the primary surgery as well as the urinary diversion. Complications such as an anastomotic leak can be responsible for the development of peritonitis, and should be suspected if symptoms occur, such as a sudden drop in urinary output, malodorous urine, abdominal distention or tenderness, or elevated temperature with leukocytosis.17 Decreased urinary output can signal obstruction of the urinary diversion; therefore, urinary output should be monitored hourly postoperatively and reported if less than 30cc/ hour.8,13 Anastomotic failure can result in peritonitis, compromised blood supply, or impaired healing with necrotic tissue.8 Patient/Caregiver Teaching Patient/caregiver education includes the importance of increased oral intake, as well as the early signs and symptoms of infection. Postoperative visits from the enterostomal nurse will provide for the proper fit of collection devices and skin barriers, stoma appearance and care, body change/image, and emotional needs.8 The patient/caregiver must be able to demonstrate care of their urinary diversion and appliances. Patients with continent reservoirs must demonstrate self-catheterization before discharge from
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TABLE 2. Long-Term Complications of Urinary Diversion Complication Ureteroileal stenosis
Incisional hernia
Rate (%)
Etiology
11.05
Stricture; tumor compression or infiltration (5.4%)
Hydronephrosis Surgery (n ¼ 22) Hemodialysis (n ¼ 4) Death (n ¼ 1)
Dehiscence; excessive postoperative coughing (<90 days) Excessive intra-abdominal pressure for urination (>90 days)
Surgical repair <90 days (n ¼ 11)
Multiple factors Recurrent tumor or carcinogenesis (n ¼ 10) Failed neobladder (c2 23.609; P ¼ .0002); ureteroileal strictures with hydronephrosis Local tumor recurrence Neovesicourethral anastomotic stricture Urethral stricture Multiple, including salt imbalances, hypovolemia, acidosis, short bowel syndrome, vitamin B12 deficiency Poor emptying, idiopathic Tissue damage secondary to preoperative radiation therapy, bicycle injury, traumatic catheterization Tumor invasion; chronic alcohol abuse Failure to empty, failure to store
Surgery (n ¼ 16) Death following surgery (n ¼ 1)
4.4
Small bowel obstruction/ileus
3.4
Febrile urinary tract infections
5
Subneovesical obstruction
1.1 1.2
Metabolic complications
0.9 33
Renal stones Neobladder rupture
0.02 0.02
Neobladder resection/ undiversion Urinary retention
0.05 More common in women than men
Outcome
Surgical repair >90 days (n ¼ 18) Normal neobladder emptying (3%) Failure to empty (11%) (c2 17.087; P ¼ .0004)
1 to 4 febrile infections/year (n ¼ 4)
Chemotherapy, surgery (n ¼ 10) Endoscopic surgery (n ¼ 11) Endoscopic surgery (n ¼ 8) Hospitalizations (n ¼ 11) Corrected with daily sodium bicarbonate (n ¼ 304) Vitamin B12 substitution (n ¼ 2) Stones removed transurethrally (n ¼ 3) Immediate laparotomy Peritonitis
Surgical revision Self-catheterization; external protection
Data from O’Rourke, 5 Nabi et al,14 and Thulin et al. 17
the hospital. The primary nurse should assess the ability of the patient/caregiver to care for their device, as well as cope with the physical changes from surgery. Referral to a support group may be helpful, or to a mental health specialist if psychological needs are unmet. Long-Term Survivorship Care Following completion of active treatment (eg, surgery, chemotherapy, radiation therapy), a survivorship care plan should be provided to the patient and their primary care provider to document specific treatment received and possible
related complications.18 Potential long-term effects of the cancer treatment and surgical intervention should be discussed with instructions about what symptoms to report, to whom, and when.18 Healthy lifestyle interventions should be recommended to maximize the patient’s outcomes and reduce the risk of complications with documented compliance by the care team. Ongoing assessment, discussion, interventions, and evaluations must occur to maximize the survivor’s potential, satisfaction, adaptability, and overall quality of life.18 A Cochran review10 quantified few studies that incorporated all components of a surgical
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review, although important concepts related to long-term survivorship care were identified. Excerpts of these studies related to quality of life are described below to illustrate the numerous issues that surround the care of cancer survivors with a urinary diversion. Bladder cancer survivors who underwent a radical cystectomy with an orthotopic bladder substitution (N ¼ 101) were compared with a matched nonsurgical control healthy group in regard to global quality-of-life outcomes (mean follow-up, 37 months) using a self-reported questionnaire developed by the researchers.19 Quality of life was preserved at a higher degree in the orthotopic diversion group, with similar scores on anxiety, fatigue, and depression scales (P < .05).19 Distress as reported by the cancer survivors was related to compromises in sexual function, urinary issues, and bowel dysfunction.19 The subjective morbidity of ileal neobladder to the urethra (n ¼ 69) versus ileal conduit urinary diversion (n ¼ 33) was compared in bladder cancer survivors.20 Participants completed self-report questionnaires (Qualify of Life Questionnaire, Cancer-30 [QLQ C-30] and physician-derived questionnaire) related to quality of life and urinary-specific items.20 Participants that underwent an ileal neobladder surgery reported a shorter time of physical rehabilitation compared with the ileal conduit participants. Reduced selfconfidence related to familial, social, and physical aspects was noted in the ileal conduit patients as compared with the ileal neobladder group (48.5% vs. 16.4%); 48.5% of ileal conduit patients reported urine leakage as compared with only 1.5% of ileal neobladder respondents.20 In a study of 35 men and 4 women, aged 66.95 (8.18 years) with bladder cancer who underwent a radical cystectomy and urinary diversion 17 months prior, 25 had an orthotopic neobladder and 14 had an uretero-uretocutaneostomy procedure.13 Patients completed four questionnaires to measure health-related quality of life: 1) Functional Assessment of Cancer Therapy, General (FACT-G), 2) the FACT Vanderbilt Cancer Index (FACT-VCI), 3) the Short Form (SF-36), as well as 4) the Beck Depression Inventory (BDI) to determine the potential effect of depression on quality of life.13 Analyses of both patient group responses revealed non-significant comparisons (0.051> P < .949), indicating that the presence or absence of a stoma and/or urostomy bag did not negatively affect health-related quality of life
measures.13 Of note, this sample did not include a healthy control group. Bladder cancer survivors with an ileal conduit diversion (n ¼ 58) or modified S-pouch neobladder (n ¼ 50), and healthy subjects (n ¼ 54) completed self-report questionnaires related to quality of life (QLQ C-30) and urinary/sexual function/bother.16 There were no significant differences in quality of life between the three groups. Impaired urinary function was observed in the ileal conduit participants (P < .005).16 Sexual function was compromised in male cancer survivors (P < .003) with reports of erectile dysfunction; equivalent levels of sexual dysfunction were noted between the three female groups (P ¼ .3).16 Female bladder cancer survivors (N ¼ 29) who underwent cystectomy with orthotopic ileal neobladder construction were observed for at least 14 months (mean, 27.5 months) postoperatively. The bladder capacity at 6 months was 450 mL (350 to 700 mL); 14% of women had nocturnal incontinence and 10% required urethral catheterization for postvoid residual.21 Overall, women were satisfied with their choice of surgery.21 A study of 452 Swedish bladder cancer survivors (aged 30-80 years) that underwent a cystectomy with urinary diversion completed a self-report questionnaire validated by the researchers to assess defecation and bowel function following surgery. Overall, 30% of survivors reported difficulty with the stool emptying process, stating problems with bowel movements, sensory rectal function, awareness of need for defecation, rectal and anal function, and straining ability.22 Other common symptoms were faecal urgency (46%), faecal leakage and soiling (15%), uncontrolled flatulence (30%), and abdominal pain (16%).22 Participants (41%) reported moderate ‘bother’ (47% in the non-continent urostomy group and 40% in the continent reservoir group, and 36% in the orthotopic neobladder group, respectively).22
CONCLUSION The treatment of primary bladder cancer or metastatic disease can include a cystectomy with an incontinent or continent cutaneous urinary diversion, or a reconstructed orthotopic neobladder to provide an alternate reservoir for urine. Surgical advances using minimally invasive approaches with hand- or robot-assisted laparoscopic equipment may minimize complications
RESTORING AND MAINTAINING URINARY FUNCTION
related to a large abdominal incision and extended hospitalization.5 These complex surgical procedures require a skilled surgeon with a specially trained team to maximize the patient’s outcomes. Nurses need to assume a primary role in the care of patients with complex urologic surgeries with ongoing support to the patient, family, and caregiver. Reinforcement of patient education and continuing evaluation of interventions can minimize complications and maximize patient outcomes. Empowerment for the patient with independent control of symptoms and
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appliance care are integral to improved quality of life. Multiple short- and long-term survivorship issues have been described above, including sexuality challenges, bladder and bowel dysfunction, self-confidence issues, electrolyte imbalances, and urinary and bowel incontinence. Additional psychosocial needs related to the cancer diagnosis may also exist. Recommendations to provide the patient and primary care provider with a summary of interventions and a personalized cancer survivorship care plan can maximize healthy outcomes and management of cancer-related symptoms.18
REFERENCES 1. Seifter JL, Breener BM. In: Kasper DL, Braunwald E, Fauci A, et al., eds. Harrison’s principles of internal medicine. Ed 16. New York, NY: McGraw-Hill; 2005: pp. 1722-1724. 2. Calabrese DA. Oliguri/Anuria/Azotemia. In: CampSorrel D, Hawkins RA, eds. Clinical manual for the oncology advanced practice nurse. Ed 2. Pittsburgh, PA: Oncology Nursing Society; 2006: pp. 601-604. 3. Gucalp R, Dutcher J. In: Kasper DL, Braunwald E, Fauci A, et al., eds. Harrison’s principles of internal medicine. Ed 16. New York, NY: McGraw-Hill; 2005: pp. 575-576. 4. Calabrese DA. Urinary incontinence. In: Camp-Sorrel D, Hawkins RA, eds. Clinical manual for the oncology advanced practice nurse. Ed 2. Pittsburgh, PA: Oncology Nursing Society; 2006: pp. 615-621. 5. O’Rourke M. In: Langhorne ME, Fulton JS, Otto SE, eds. Oncology nursing. Ed 5. St. Louis, MO: Mosby Elsevier; 2007: pp. 165-184. 6. McDougal WS, Shipley WU, Kaufman DS, et al. In: Devita VT Jr, Hellman S, Rosenberg SA, eds. Cancer: principles and practice. Ed 9. Philadelphia, PA: Lippincott-Raven; 2011: pp. 1197-1199. 7. Vakalopoulos I, Dimitriadis G, Anastasiadis A, et al. Does intubated ureter-ureterocutaneostomy provide better healthrelated quality of life than orthotopic neobladder in patients after radical cystectomy for invasive bladder cancer? Int Urol Nephrol 2011;43:743-748. 8. Mansson W, Davidsson T, Konyves J, et al. Continent urinary tract reconstruction – The Lund experience. BJU Int 2005;95:371-373. 9. Stenzl A, Hammouda S, Markus K. Radical cystectomy with orthotopic neobladder for invasive bladder cancer: a critical analysis of long term oncological, functional and quality of life results. Int Bra J Urol 2010;36:537-547. 10. Henningsohn L, Steven K, Kallestrup EB, et al. Distressful symptoms and well-being after radical cystectomy and orthotopic bladder substitution compared with a matched control population. J Urol 2002;18:338-344. 11. Frich PS, Kvestad CA, Angelsen A. Outcome and quality of life in patients operated on with radical cystectomy and three
different urinary diversion techniques. Scand J Urol Neph 2009;43:37-41. 12. Protogerou V, Moschou M, Antoniou N, et al. Modified S-pouch neobladder vs. ileal conduit and a matched control population: a quality-of-life survey. BJU Int 2004;94:350-354. 13. Hobisch A, Tosun K, Kinzl J, et al. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol 2000;18:338-344. 14. Cody JD, Nabi G, Dublin N, et al. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev 2012;2:CD003306. doi:10.1012/14651858. CD003306.pub2 15. Hautmann RE, de Petriconi RC, Volkmer BG. 25 years of experience with 1,000 neobladders: long-term complications. J Urol 2011;185:2207-2212. 16. Nesrallah LJ, Almeida FG, Dall’oglio MF, et al. Experience with the orthotopic ileal neobladder in women: a mid-term follow-up. BJU Int 2005;95:1045-1047. 17. Thulin H, Kreicbergs U, Onelov E, et al. Defecation disturbances after cystectomy for urinary bladder cancer. BJU Int 2010;108:196-202. 18. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. J Urol 2007;69:17-49. 19. Szymanski KM, St-Cyr D, Alam T, et al. External stoma and peristomal complications following radical cystectomy and ileal conduit diversion: a systematic review. Ostomy Wound Manage 2010;56:28-35. 20. Lester J. Cancer survivorship care plans. In: Lester J, Schmidt P, eds. Cancer rehabilitation and survivorship: transdisciplinary approaches to personalized care. Pittsburgh, PA: Oncology Nursing Society; 2011. 21. Singh I, Strandhoy JW, Assimos DG. Pathology of urinary tract obstruction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, Novick AC, eds. Campbell-Walsh urology. Ed 10. New York: Elsevier-Saunders; 2011: pp. 1087-1121. 22. Hautmann RE, Hautmann SH, Hautmann O. Complications associated with urinary diversion. Nat Rev Urol 2011;8:667-777.
Seminars in Oncology Nursing, Vol 28, No 3 (August), 2012: pp 163-169
RESTORING AND MAINTAINING URINARY FUNCTION JOANNE LESTER OBJECTIVES: To describe surgical urinary diversion methods, nursing management, and survivorship issues in urologic cancer survivors. DATA SOURCES: PubMed, Scopus, Cochran Reviews, Core 25 online texts. CONCLUSION: Options exist for patients that require urinary diversion, although long-term symptoms may persist.
IMPLICATIONS FOR NURSING PRACTICE: Nurses must be knowledgeable about obstructive uropathy and understand the surgical options for urinary diversion following a cystectomy; pre- and post-operative needs exist for the cancer patient, family, and caregiver. Following completion of active treatment, a survivorship care plan summarizes active treatment and complications, plans long-term health outcomes and surveillance, and communicates with the primary care provider.
KEY WORDS: Urinary diversion, obstructive uropathy, ileal conduit, orthotopic diversion
P
ATIENTS undergoing surgical interventions to correct obstructive uropathy have many challenges that include specific procedure decisions, short- and long-term side effects, self-image issues, alterations in sexuality, and disease-related concerns. Joanne Lester, PhD, CRNP, ANP-BC, AOCNÒ: Research Scientist, Comprehensive Cancer Center, James Cancer Hospital & Solove Research Institute, Clinical Assistant Professor, College of Nursing, The Ohio State University, Columbus, OH. Address correspondence to Joanne Lester, PhD, CRNP, ANP-BC, AOCNÒ, Research Scientist, Comprehensive Cancer Center, James Cancer Hospital & Solove Research Institute, Clinical Assistant Professor, College of Nursing, The Ohio State University, 1142 Holton Road, Grove City, OH 43123. e-mail: joanne. [email protected] Ó 2012 Elsevier Inc. All rights reserved. 0749-2081/2803-$36.00/0. doi:10.1016/j.soncn.2012.05.005
Nursing professionals caring for these patients must be effective educators, knowledgeable caregivers, and empathetic listeners, with an understanding of the pathophysiology of obstructive uropathy and function of urinary diversions. Multiple options are available for patients today, although the same disruptive thought remains: ‘‘I will never urinate the ‘normal’ way again’’.
OBSTRUCTIVE UROPATHY Etiology Urinary function may be altered by intrinsic or extrinsic mechanical and functional defects, including primary or secondary effects of malignancies. In children, congenital malformations with narrowing of structures are the most frequent source of obstruction; in adults, acquired mechanical or functional defects make up the majority of obstructions.1,2 Alterations in urinary function may result in acute or chronic obstructive
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uropathy and can lead to permanent damage in the urinary tract (eg, hydronephrosis, renal failure) if urinary function is not promptly restored.1,2 Mechanical obstructions can occur at any level of the urinary tract, precipitated by tumors, calculi, infection, injury, inflammation, and urethral stricture.1,2 Urinary tract obstruction may occur in patients with solid tumors, such as prostate or gynecologic malignancies, or as a secondary effect of cervical spine, solid tumor, or lymphoma metastases.2,3 Ureteral obstruction can result from fibrosis secondary to pelvic surgery, chemotherapy, or radiation therapy,4 or from an encroaching tumor mass. Bladder outlet obstruction may be secondary to cervical or bladder tumors, or scarring from chemotherapeutic agents or radiation therapy. Urethral obstructions can be caused by scar tissue or tumor, and may lead to abnormal enlargement of the bladder and surrounding structures with significant alteration in urinary output.1,3 Functional impairments of urinary flow result from ureter and bladder disorders, such as neurogenic bladder, adynamic ureter(s), and vesicoureteral reflux.2
PRESENTATION AND DIAGNOSIS Signs and Symptoms Symptoms of obstructive uropathy commonly include flank pain with or without radiation to lower pelvis, changes in urinary function, arthralgia, skin rash, pallor, persistent urinary
tract infections, edema, proteinuria, or hematuria.1-3 Complete anuria or partial anuria that alternates with polyuria are possible; when accompanied by a rise or a prolonged increase in serum creatinine, obstructive uropathy is suspect.2,3 Identification of the source of obstruction and the presence of hydronephrosis is essential and may be accomplished with a renal ultrasound.1 If not definitive, an intravenous pyelogram or computed tomography scan should be ordered (Table 1). The pyelogram is effective in the diagnosis of kidney obstruction, whereas the computed tomography scan may reveal the point of obstruction and presence/absence of an encroaching structure or malignant mass.3,5 Prolonged obstructive uropathy can result in signs such as azotemia, acquired tubular acidosis, hyperkalemia, and renal salt wasting.2 A urinalysis may be helpful to identify abnormal elements in the urine that lead to the diagnosis and etiology of obstructive uropathy.6 A 24-hour urine collection may be ordered simultaneously with serum creatinine levels to measure the degree of proteinuria and urinary albumin, and ultimately, the degree of renal failure.6 Related serum studies include a complete blood count to evaluate for anemia secondary to renal insufficiency, creatinine, and blood urea nitrogen to follow renal function, glucose to rule out diabetes mellitus, potassium to identify elevation, albumin to evaluate severity of proteinuria, and protein electrophoresis if multiple myeloma is suspect.6 Arterial blood pressure should also be monitored to rule out acute or
TABLE 1. Obstructive Uropathy: Signs, Symptoms, and Diagnostic Tests Symptom
Sign
Flank pain
Pain with light palpation at site or posterior over kidney(s) Pain radiates to lower pelvis Generalized abdominal, flank, posterior pain Changes in urinary function
Anuria, partial anuria, polyuria
Skin rash, itching Pallor Urinary tract infection Edema
[creatinine Yhemoglobin [bacteria, white blood cells Abnormal concentration of urine, bilateral lower extremity edema, elevated blood pressure
Hematuria Proteinuria
Visual or microscopic blood in urine Increased urine protein, decreased serum albumin
Diagnostic Tests Physical exam, renal ultrasound, urinalysis Physical exam (rectal and gynecologic exams), renal ultrasound, urinalysis Urinalysis, serum creatinine and blood urea nitrogen; urinary catheter Serum creatinine and blood urea nitrogen Complete blood count Urinalysis, complete blood count Blood pressure, serum potassium, renal ultrasound, intravenous pyelogram, computed tomography scan Urinalysis, visual exam Urinalysis; serum creatinine, blood urea nitrogen, albumin, potassium, glucose, 24-hour urine
Data from Seifter and Breener,1 Calabrese,2 Gucalp and Dutcher,3 O’Rourke,5 McDougal,6 and Mansson et al.8
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uncontrolled hypertension.1-3,7 Physical examination should include rectal exam, genital structures, and abdomen. Insertion of a bladder catheter may be considered to evaluate the presence or absence of urine in bladder (Table 1).2
URINARY DIVERSION PROCEDURES Urinary diversion procedure(s) may be necessary to establish a method of urine evacuation in cases of advanced uropathic obstruction or surgical removal of urologic structures. Flexible or rigid stents can be placed in the ureters to relieve focal intrinsic or extrinsic encroachment, although they do not provide a permanent solution in the case of tumor invasion or encroachment.5 Percutaneous nephrostomy can be used as a temporary solution, or as a palliative intervention for obstructive renal failure that is not amenable to more advanced surgical interventions.7 Bladder cancer that presents with invasion into or through the bladder muscle requires a radical cystectomy with a continent or incontinent urinary diversion.5,8,9 In men, the surgical procedure involves a cystoprostatectomy; in women, both a cystectomy and hysterectomy are performed.8 Several surgical options exist that provide for urine collection from the ureters, e.g., urinary diversions (incontinent and continent), bladder reconstruction, or replacement.10 Incontinent Cutaneous Diversion Incontinent cutaneous diversions are surgical conduits that use a segment of bowel (typically ileum or colon, and less frequently jejunum).5,7-9 If the pelvis has been irradiated or is involved with tumor, a segment of the right colon or jejunum may be selected. During the surgical procedure the ureters are implanted into the proximal end of this segment of bowel. The distal end of the bowel is brought to the surface and sutured to the skin of the anterior abdominal wall, with creation of an ostomy on the surface.8 Urine is routed to a urinary collection appliance, or ostomy bag. The advantages of an ileal or colonic conduit are their relative simplicity and the minimal perioperative complication rate (13%).4,9 Continent Cutaneous Diversion Continent cutaneous diversion offers the advantage of a hidden pouch inside the body.4,7,11 The abdominal diversion, or continent cutaneous diversion,10 uses a continence valve and a segment of
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bowel to create an intra-abdominal reservoir for urine storage.4,8 The ureters are implanted into the proximal bowel segment, and the distal bowel is brought to the surface and sutured to the skin to create an ostomy as described above.8 The patient self-catheterizes the ostomy every 4 to 6 hours to remove accumulated urine.4,8 The valve prevents reflux of urine and enables the patient to control urinary elimination without the use of an ostomy bag. Continent diversions involve a longer and more challenging surgery9,12 and hold higher complication and reoperation rates.9,13 Alternatively, a low-pressure rectal reservoir can be constructed with anastomosis of the ureters to the rectum; the anal sphincter maintains continence.10 Bladder Reconstruction Bladder reconstruction techniques are based on the addition of a bower segment onto a coronal- or sagittal-resected bladder.10 In the case of bladder cancer, the entire bladder is removed to provide optimal treatment for the underlying malignancy. Therefore, for purposes of this article, these options will not be explained further. Neobladder, Orthotopic Reconstruction In the case of the orthotopic neobladder, the bowel is carried down to the urethra, and the urethral sphincter is used as the reflux valve.4,7-9 The patient eliminates urine through the urethra with the Valsalva movement, eg, induced stress on the urethral sphincter to eliminate accumulated urine; the patient may occasionally need to self-catheterize. This surgical method provides rehabilitation to normal voiding through the urethra4,8 and may be the most comfortable option. Similar to the abdominal diversion, the need for an ostomy bag is eliminated. Aspects for consideration include the type of gastrointestinal tract available, anatomic location of a possible stoma, preservation of the urethra for an orthotopic diversion, upper urinary tract protection, preservation of sexual activity, and gender differences.12,13 Meticulous dissection and preservation of urinary structures and autonomic nerves may preserve continence with intact voiding function.11 The most worrisome question in orthotopic diversion is whether the remaining urethral tissue harbors any cancer cells that will later metastasize to the area.13 A surgical option to the orthotopic diversion is the uretocutaneostomy, a procedure that joins the two ureters with an end-to-side anastomosis.13
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The right ureter is then fixed to the fascia and skin; single J stents are inserted into the ureters, which allow drainage of the urine in an ostomy pouch. This option may have fewer complications13 than the orthotopic diversion, and is more desirable than the ileal conduit because neither bowel segment nor stoma is required.13 Summary A Cochran review of urinary surgical diversion techniques noted that evidence from clinical trials is limited with few common pre-identified comparisons.10 Of the four reviewed trials that met baseline inclusion criteria, the authors note that no evidence existed to suggest that bladder replacement with orthotopic or continent diversions were superior to conduit diversion following cystectomy for bladder cancer.10 A more recent publication discussed observed long-term complications in patients more than 90 days post orthotopic neobladder surgery in a tertiary institution. Using the Kaplan-Meier method for timedependent events, surgical-related complications in 923 patients from a 25-year period were evaluated (Table 2).14 Complications were documented in 40.8% of patients (n ¼ 377).14 A recent Medline database review (1996 to 2008) yielded 14 publications that met inclusion criteria for external stoma and peristomal complications following radical cystectomy and ileal conduit diversion. Commonly reported complications were stoma or abdominal wall-related changes and peristomal skin changes.15
NURSING CONSIDERATIONS Preoperative Evaluation As described above, there are multiple options for urinary diversion in the event that the bladder must be removed, either for primary bladder cancer or infiltrative metastatic tumor. In the event of a surgical urinary diversion, preplanning can make a significant difference in the patient’s satisfaction and acceptance of the device.8,16 During preoperative patient/family/ caregiver counseling, primary discussion goals about surgical urinary diversion should include: 1) the safest method for cancer control; 2) fewest short- and long-term complication rates; 3) anticipated lifestyle adjustment; and 4) projected quality of life.7 The patient and surgeon should have an honest discussion about the pros and
cons of each type of surgical diversion before decisions are made. Unless otherwise contraindicated, all cystectomy patients are candidates for a neobladder.7 Referral to a tertiary facility with trained surgeons should be recommended, if necessary. Before surgery, the patient and significant other or caregiver should meet with professionals specially trained in the care of cystectomy with urinary diversion. Advanced practice nurses and enterostomal therapists can augment the surgeon’s discussion and provide the patient/ family/caretaker with invaluable resources. If warranted, optimal placement of a stoma site can be discussed because pre-planning is essential for postoperative management, care of the device, perceived self-image, and quality of life.8,16 A preoperative bowel preparation with age- and disease-appropriate laxatives is necessary to prepare the gut for surgery. The importance of a complete bowel evacuation should be reinforced to the patient and caregiver.5 Postoperative Care Postoperative care and nursing management should include assessment for complications related to the primary surgery as well as the urinary diversion. Complications such as an anastomotic leak can be responsible for the development of peritonitis, and should be suspected if symptoms occur, such as a sudden drop in urinary output, malodorous urine, abdominal distention or tenderness, or elevated temperature with leukocytosis.17 Decreased urinary output can signal obstruction of the urinary diversion; therefore, urinary output should be monitored hourly postoperatively and reported if less than 30cc/ hour.8,13 Anastomotic failure can result in peritonitis, compromised blood supply, or impaired healing with necrotic tissue.8 Patient/Caregiver Teaching Patient/caregiver education includes the importance of increased oral intake, as well as the early signs and symptoms of infection. Postoperative visits from the enterostomal nurse will provide for the proper fit of collection devices and skin barriers, stoma appearance and care, body change/image, and emotional needs.8 The patient/caregiver must be able to demonstrate care of their urinary diversion and appliances. Patients with continent reservoirs must demonstrate self-catheterization before discharge from
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TABLE 2. Long-Term Complications of Urinary Diversion Complication Ureteroileal stenosis
Incisional hernia
Rate (%)
Etiology
11.05
Stricture; tumor compression or infiltration (5.4%)
Hydronephrosis Surgery (n ¼ 22) Hemodialysis (n ¼ 4) Death (n ¼ 1)
Dehiscence; excessive postoperative coughing (<90 days) Excessive intra-abdominal pressure for urination (>90 days)
Surgical repair <90 days (n ¼ 11)
Multiple factors Recurrent tumor or carcinogenesis (n ¼ 10) Failed neobladder (c2 23.609; P ¼ .0002); ureteroileal strictures with hydronephrosis Local tumor recurrence Neovesicourethral anastomotic stricture Urethral stricture Multiple, including salt imbalances, hypovolemia, acidosis, short bowel syndrome, vitamin B12 deficiency Poor emptying, idiopathic Tissue damage secondary to preoperative radiation therapy, bicycle injury, traumatic catheterization Tumor invasion; chronic alcohol abuse Failure to empty, failure to store
Surgery (n ¼ 16) Death following surgery (n ¼ 1)
4.4
Small bowel obstruction/ileus
3.4
Febrile urinary tract infections
5
Subneovesical obstruction
1.1 1.2
Metabolic complications
0.9 33
Renal stones Neobladder rupture
0.02 0.02
Neobladder resection/ undiversion Urinary retention
0.05 More common in women than men
Outcome
Surgical repair >90 days (n ¼ 18) Normal neobladder emptying (3%) Failure to empty (11%) (c2 17.087; P ¼ .0004)
1 to 4 febrile infections/year (n ¼ 4)
Chemotherapy, surgery (n ¼ 10) Endoscopic surgery (n ¼ 11) Endoscopic surgery (n ¼ 8) Hospitalizations (n ¼ 11) Corrected with daily sodium bicarbonate (n ¼ 304) Vitamin B12 substitution (n ¼ 2) Stones removed transurethrally (n ¼ 3) Immediate laparotomy Peritonitis
Surgical revision Self-catheterization; external protection
Data from O’Rourke, 5 Nabi et al,14 and Thulin et al. 17
the hospital. The primary nurse should assess the ability of the patient/caregiver to care for their device, as well as cope with the physical changes from surgery. Referral to a support group may be helpful, or to a mental health specialist if psychological needs are unmet. Long-Term Survivorship Care Following completion of active treatment (eg, surgery, chemotherapy, radiation therapy), a survivorship care plan should be provided to the patient and their primary care provider to document specific treatment received and possible
related complications.18 Potential long-term effects of the cancer treatment and surgical intervention should be discussed with instructions about what symptoms to report, to whom, and when.18 Healthy lifestyle interventions should be recommended to maximize the patient’s outcomes and reduce the risk of complications with documented compliance by the care team. Ongoing assessment, discussion, interventions, and evaluations must occur to maximize the survivor’s potential, satisfaction, adaptability, and overall quality of life.18 A Cochran review10 quantified few studies that incorporated all components of a surgical
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review, although important concepts related to long-term survivorship care were identified. Excerpts of these studies related to quality of life are described below to illustrate the numerous issues that surround the care of cancer survivors with a urinary diversion. Bladder cancer survivors who underwent a radical cystectomy with an orthotopic bladder substitution (N ¼ 101) were compared with a matched nonsurgical control healthy group in regard to global quality-of-life outcomes (mean follow-up, 37 months) using a self-reported questionnaire developed by the researchers.19 Quality of life was preserved at a higher degree in the orthotopic diversion group, with similar scores on anxiety, fatigue, and depression scales (P < .05).19 Distress as reported by the cancer survivors was related to compromises in sexual function, urinary issues, and bowel dysfunction.19 The subjective morbidity of ileal neobladder to the urethra (n ¼ 69) versus ileal conduit urinary diversion (n ¼ 33) was compared in bladder cancer survivors.20 Participants completed self-report questionnaires (Qualify of Life Questionnaire, Cancer-30 [QLQ C-30] and physician-derived questionnaire) related to quality of life and urinary-specific items.20 Participants that underwent an ileal neobladder surgery reported a shorter time of physical rehabilitation compared with the ileal conduit participants. Reduced selfconfidence related to familial, social, and physical aspects was noted in the ileal conduit patients as compared with the ileal neobladder group (48.5% vs. 16.4%); 48.5% of ileal conduit patients reported urine leakage as compared with only 1.5% of ileal neobladder respondents.20 In a study of 35 men and 4 women, aged 66.95 (8.18 years) with bladder cancer who underwent a radical cystectomy and urinary diversion 17 months prior, 25 had an orthotopic neobladder and 14 had an uretero-uretocutaneostomy procedure.13 Patients completed four questionnaires to measure health-related quality of life: 1) Functional Assessment of Cancer Therapy, General (FACT-G), 2) the FACT Vanderbilt Cancer Index (FACT-VCI), 3) the Short Form (SF-36), as well as 4) the Beck Depression Inventory (BDI) to determine the potential effect of depression on quality of life.13 Analyses of both patient group responses revealed non-significant comparisons (0.051> P < .949), indicating that the presence or absence of a stoma and/or urostomy bag did not negatively affect health-related quality of life
measures.13 Of note, this sample did not include a healthy control group. Bladder cancer survivors with an ileal conduit diversion (n ¼ 58) or modified S-pouch neobladder (n ¼ 50), and healthy subjects (n ¼ 54) completed self-report questionnaires related to quality of life (QLQ C-30) and urinary/sexual function/bother.16 There were no significant differences in quality of life between the three groups. Impaired urinary function was observed in the ileal conduit participants (P < .005).16 Sexual function was compromised in male cancer survivors (P < .003) with reports of erectile dysfunction; equivalent levels of sexual dysfunction were noted between the three female groups (P ¼ .3).16 Female bladder cancer survivors (N ¼ 29) who underwent cystectomy with orthotopic ileal neobladder construction were observed for at least 14 months (mean, 27.5 months) postoperatively. The bladder capacity at 6 months was 450 mL (350 to 700 mL); 14% of women had nocturnal incontinence and 10% required urethral catheterization for postvoid residual.21 Overall, women were satisfied with their choice of surgery.21 A study of 452 Swedish bladder cancer survivors (aged 30-80 years) that underwent a cystectomy with urinary diversion completed a self-report questionnaire validated by the researchers to assess defecation and bowel function following surgery. Overall, 30% of survivors reported difficulty with the stool emptying process, stating problems with bowel movements, sensory rectal function, awareness of need for defecation, rectal and anal function, and straining ability.22 Other common symptoms were faecal urgency (46%), faecal leakage and soiling (15%), uncontrolled flatulence (30%), and abdominal pain (16%).22 Participants (41%) reported moderate ‘bother’ (47% in the non-continent urostomy group and 40% in the continent reservoir group, and 36% in the orthotopic neobladder group, respectively).22
CONCLUSION The treatment of primary bladder cancer or metastatic disease can include a cystectomy with an incontinent or continent cutaneous urinary diversion, or a reconstructed orthotopic neobladder to provide an alternate reservoir for urine. Surgical advances using minimally invasive approaches with hand- or robot-assisted laparoscopic equipment may minimize complications
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related to a large abdominal incision and extended hospitalization.5 These complex surgical procedures require a skilled surgeon with a specially trained team to maximize the patient’s outcomes. Nurses need to assume a primary role in the care of patients with complex urologic surgeries with ongoing support to the patient, family, and caregiver. Reinforcement of patient education and continuing evaluation of interventions can minimize complications and maximize patient outcomes. Empowerment for the patient with independent control of symptoms and
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appliance care are integral to improved quality of life. Multiple short- and long-term survivorship issues have been described above, including sexuality challenges, bladder and bowel dysfunction, self-confidence issues, electrolyte imbalances, and urinary and bowel incontinence. Additional psychosocial needs related to the cancer diagnosis may also exist. Recommendations to provide the patient and primary care provider with a summary of interventions and a personalized cancer survivorship care plan can maximize healthy outcomes and management of cancer-related symptoms.18
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different urinary diversion techniques. Scand J Urol Neph 2009;43:37-41. 12. Protogerou V, Moschou M, Antoniou N, et al. Modified S-pouch neobladder vs. ileal conduit and a matched control population: a quality-of-life survey. BJU Int 2004;94:350-354. 13. Hobisch A, Tosun K, Kinzl J, et al. Quality of life after cystectomy and orthotopic neobladder versus ileal conduit urinary diversion. World J Urol 2000;18:338-344. 14. Cody JD, Nabi G, Dublin N, et al. Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractable incontinence or following cystectomy. Cochrane Database Syst Rev 2012;2:CD003306. doi:10.1012/14651858. CD003306.pub2 15. Hautmann RE, de Petriconi RC, Volkmer BG. 25 years of experience with 1,000 neobladders: long-term complications. J Urol 2011;185:2207-2212. 16. Nesrallah LJ, Almeida FG, Dall’oglio MF, et al. Experience with the orthotopic ileal neobladder in women: a mid-term follow-up. BJU Int 2005;95:1045-1047. 17. Thulin H, Kreicbergs U, Onelov E, et al. Defecation disturbances after cystectomy for urinary bladder cancer. BJU Int 2010;108:196-202. 18. Hautmann RE, Abol-Enein H, Hafez K, et al. Urinary diversion. J Urol 2007;69:17-49. 19. Szymanski KM, St-Cyr D, Alam T, et al. External stoma and peristomal complications following radical cystectomy and ileal conduit diversion: a systematic review. Ostomy Wound Manage 2010;56:28-35. 20. Lester J. Cancer survivorship care plans. In: Lester J, Schmidt P, eds. Cancer rehabilitation and survivorship: transdisciplinary approaches to personalized care. Pittsburgh, PA: Oncology Nursing Society; 2011. 21. Singh I, Strandhoy JW, Assimos DG. Pathology of urinary tract obstruction. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, Novick AC, eds. Campbell-Walsh urology. Ed 10. New York: Elsevier-Saunders; 2011: pp. 1087-1121. 22. Hautmann RE, Hautmann SH, Hautmann O. Complications associated with urinary diversion. Nat Rev Urol 2011;8:667-777.