This overview was to discuss the types of urinary diversion in women who have had a pelvic exenteration type procedure where the urinary bladder was removed. Over the last seventy years plus now, with the introduction of pelvic exenteration in the early ‘40s with Alexander Brunschwig in New York at Memorial Hospital, there has been a shift and an evolution of this type of reconstruction. His initial type of diversion was a wet colostomy where the ureters were placed into the sigmoid colon going out into the stoma and mixing urine and stool into one bag. This was the initial operation, it was quick, it was easy but had lots of complications.

In the ‘50s Eugene Bricker modified and improved the ilial conduit where it also separates the urine from the stool by taking the ureters into a segment of small bowel, bringing them out to the skin. This remains a very valid and very solid type of urinary diversion. It’s quick, it has low complications and it’s very popular in GYN oncology and is very popular in the United Kingdom.

Late ‘80s to 1990s there was a big surge in enthusiasm about creating continent urinary diversion where the patient would not have to wear a bag. It’s a more complex reconstruction, usually using the right colon, a piece of small bowel, sometimes the appendix as a stoma, placing the ureters into a reservoir that contains anywhere from 300-600cc of urine. The patient would self-catheterise several times a day to empty the urine. These reconstructions in GYN oncology really fall into two broad categories – one of them using the terminal ilium as the segment for continence where you would catheterise by narrowing the lumen and by using the iliocecal valve as a mechanism for continence. The other option would use an appendix, to create the appendix as the track where the catheter would go. They take more to build, they’re usually more complex, they may carry a higher risk of complications – stenosis, leak and reoperations – but they do provide 24 hour continence where the patient would not need a bag. Usually the patients are younger, more motivated, are able to self-catheterise, have healthy upper urinary tract system where there’s less concern about chronic renal disease. It’s definitely an option but usually in an elderly or more sick patient where you’re trying to do a quicker diversion you would go to the route of the ilial conduit.

Lastly we went full circle, going back to the wet colostomy. Beginning in 1989 there was a description by a urologist named Carter of a double-barrelled wet colostomy where it basically creates a loop colostomy from the left colon, inserts the ureters into the quiet or distal limb, so you’re really not totally mixing stool and urine. The advantages of that, you have one stoma, there’s no division of any bowel or colon so there’s less bowel division, less bowel anastomosis, and it’s a quick way to divert the urine and the stool. So it’s taken some interest in the GYN oncology field; we’ve done some cases, Ohio State University has done cases and published on that so it’s an interesting approach for people to consider in selected patients.

The final and fifth way to divert is by creating an orthotopic bladder which is not usually suitable for most of our patients because of the heavily irradiated vagina and urethra. So it’s hard to find a patient who would be suitable for creation of a Madrid-type pouch or a Budapest-type pouch where you bring the colon or intestine to the remaining urethra.

So, in summary, the ilial conduit remains a very solid way, quick way, low complication rate. Continent diversion with an Indiana/Miami type pouch or an appendix-based pouch is also a reasonable strategy. This double-barrelled wet colostomy is also interesting to consider in some cases.