Urinary Diversion & Urostomy

After a radical cystectomy, urine still has to go somewhere — and the type of diversion the surgeon creates determines everything you assess, teach, and troubleshoot at the bedside.

A urinary diversion reroutes urine when the bladder is removed or nonfunctional, most commonly after radical cystectomy for bladder cancer. The ileal conduit (Bricker's procedure) is the most tested type: a segment of ileum is used as a passive conduit — urine drains continuously into an external pouching system because there is no voluntary control. Stents protrude from the stoma postoperatively and are expected for 7–14 days to maintain ureteral patency. The stoma should be beefy red and moist, like buccal mucosa. A dusky or cyanotic stoma signals compromised blood supply and requires immediate provider notification. Normal output is at least 30 mL/hour. Mucus in the pouch is expected because the conduit is made from bowel tissue — this is not infection. A continent diversion (Indiana pouch, neobladder) uses a surgically created internal reservoir. The patient with an Indiana pouch self-catheterizes the stoma on a schedule; a neobladder connects to the urethra, allowing near-normal voiding but requiring timed voiding and pelvic floor training. Skin care around the stoma is critical: the appliance should fit within 1/8 inch of the stoma base to prevent urine contact with peristomal skin, which causes chemical irritant dermatitis.

Key Distinctions

Don't confuse an ileal conduit (continuous drainage, external pouch, no catheterization) with a continent diversion (internal reservoir, intermittent self-catheterization or voiding). Students mistake mucus threads in the pouch for a sign of infection — mucus is normal because bowel mucosa produces it. A pale or cyanotic stoma is abnormal; slight postoperative edema with a red, moist appearance is expected and normal.

Clinical Pearl

Red and wet is what you want — if the stoma turns dusky or dry, blood supply is failing. Call the provider before it becomes necrotic.