Diane Leach
Wednesday 21st September - Leeds
Outline of presentation Treatment options Types of urinary diversion Radical cystectomy and ileal conduit Patient counselling Care of the stoma Types of appliances Discharge and follow up
Treatment options: BCG Neo adjuvant chemotherapy Radiotherapy Surgery
Types of urinary diversion: Radical cystectomy and ileal conduit Radical cystectomy and orthotopic neo-bladder formation Pelvic exenteration Cutaneous ureterostomy Nephrostomy Radical cystectomy and mitrofanoff formation
Examples of urinary diversions
Cutaneous ureterostomy Ureters are excised from the bladder and brought through the abdominal wall to form stoma. Advantages: Not considered major surgery Disadvantages: External collecting device must be worn. Possibility of stricture or stenosis of small stoma.
Nephrostomy Catheter is inserted into the pelvis of the kidney. May be done on one or both kidneys and may be temporary or permanent. Most frequently done in advanced disease as a palliative measure. Advantage: No need for major surgery Disadvantage: High risk of renal infection. Predisposition to calculus formation from catheter. May have to be changed every month. Catheter should not be clamped, should remain open.
Cystectomy and orthotopic neobladder formation
Radical cystectomy and ileal conduit
Counselling Clinics We allow a 60 minute slot Patients receive a pre-operative pack containing: 1. Booklet about urostomys 2. A pre-operative practice pack 3. Patient DVD How to care for your urostomy 4. Information regarding the urostomy association. 5. Enhanced Recovery booklet for Admission
Patient counselling Studies show that the vast majority of patients want to have as much information as possible regarding their disease. ( Cox et al, 2006, Rutten et al, 2005, and Jenkins et al, 2001).
Factors that may influence patient consultations: Age Gender Ethnicity Education Level Complexity of information required Sometimes we assume what the patient wants to know and it is not always what the patient needs ( Snyder et al, 2007)
Remember A well informed patients adjusts better to the entire post-operative experience and longterm management goals then who have not. Evidence suggests that preoperative information plays a valuable role in reducing postoperative pain and anxiety and in aiding faster recovery. Oshodi (2007)
Care of the urostomy Clean around the stoma with warm water Remove any mucus If stents are in situ check that they are patent and draining.
Care of the urostomy Check the peristomal skin for any redness or excoriation. Apply accessories if required, i.e. barrier wipe for red or excoriated skin Orahesive powder for broken skin Check size of template for flange Apply the cut out flange If a two piece system attach bag to flange
Flange template
Ureteric Stents
Ureteric stents protruding through the urostomy
Equipment for a bag change
Types of appliances Two piece system Advantages: Doctors can check the stoma by unclipping the bag and not disturbing the flange. Flange can stay on for 2-3 days and the bag can be changed as required. (we recommend daily). The position of the bag can be changed for connection to the overnight bag.
Types of appliances One piece system Advantages: Maybe easier for patients to apply especially if they have poor dexterity. It s a flatter bag so may be preferred by people who wear tight clothing. (We recommend changing this daily).
Possible complications post-operatively Small spouted or flush stoma Stoma on tension dips or in a moat Para stomal hernia Mucocutaneous separation Poor position and not where sited Necrotic stoma Oedematous stoma
Types of stoma
Mucocutaneous separation
Parastomal hernia
Poorly sited stomas
Stomal necrosis
Stomal oedema Ileal conduit stoma oedema will begin to subside within 7 days after surgery and continue to decrease in size gradually for the next 6 to 8 weeks.
Problem solving Convex flange or seal Orahesive powder or stomahesive paste.
Discharge and Follow up Patients should be independent with their care on discharge 2 weeks supply of products given to take home In Sheffield we refer to an independent delivery company
Discharge and Follow up Delivery Company will deliver any product ordered, cut flanges to required size and give complimentary items such as toiletry bags, dry wipes and disposal bags. They also provide community stoma care nurse follow up. Patients return to see the consultant in 6week follow up to discuss histology
Thank you for listening Any Questions????