Bricker / Ileal Conduit: The Surgical Procedure Step by Step

What is the Bricker technique

The Bricker ureteroenterodermostomy (known internationally as ileal conduit ) is the most common method of urinary diversion after radical cystectomy — accounting for over 60% of urinary diversion procedures worldwide ^[1] . The technique was first described in 1950 by Eugene Bricker in Surgical Clinics of North America ^[2] and remains the gold standard 75 years later — because it is technically simple, safe, and suitable for a wide range of patients.

In this article we explain the entire process: from preoperative preparation to discharge and return to daily life.

Stage 1: Preoperative preparation (2-4 weeks before)

According to the EAU Guidelines 2024 for muscle-invasive bladder cancer ^[1] , proper preparation includes:

1. Oncological staging: CT/MRI of the upper abdomen and pelvis, bone scan, lymph node evaluation.
2. Renal function: eGFR, creatinine, electrolytes — eGFR > 45 mL/min for safe ileal conduit.
3. Cardiological and anesthesiological assessment: ECG, echo, respiratory function.
4. Stoma siting: By a qualified stoma nurse — critical step. Correct positioning affects the adherence of the pouch for the patient’s entire life.
5. Bowel prep: Bowel cleansing with osmotic medication 1 day before, according to the ERAS protocol.
6. Nutrition and hygiene: Protein supplementation 7-14 days before, smoking cessation (ideally 4 weeks) ^[3] .
7. Selection of stoma materials: Discussion with supplier — here we recommend B Braun Flexima Uro Silk for flat stomas, Active O' convex for retracted/flush.

Stage 2: Surgery (4-7 hours)

Radical cystectomy with ileal conduit creation is performed under general anesthesia and lasts 4-7 ​​hours depending on the technique (open, laparoscopic, or robotic). In modern high-volume clinics, the robotic approach (RARC — robot-assisted radical cystectomy) is increasingly used, although ileal conduit construction is often performed extracorporeally ^[3] .

The 6 basic steps of the procedure

Step	What is done	Duration
1	Access and exploration: mid-lower abdominal incision or robotic trocar. Liver inspection, lymph nodes, assessment of local tumor extent.	~30 minutes
2	Pelvic lymphadenectomy: removal of pelvic lymph nodes (obturator, internal iliac, external iliac) for staging.	60-90 minutes
3	Radical cystectomy: removal of the bladder (in men together with the prostate and seminal vesicles, in women with the uterus and anterior vaginal wall in some cases).	90-120 minutes
4	Intestinal loop isolation: selection of a 15-20 cm segment of the terminal ileum, ~15 cm from the ileocolic valve. Preservation of vascularity (mesenteric pedicle).	30 minutes
5	Ureteroileal anastomosis (Bricker or Wallace): union of the two ureters at the posterior end of the ileal loop. Either separately (Bricker), or united in a plate (Wallace).	45-60 minutes
6	Stoma: the anterior end of the loop is brought out through the abdominal wall at a preoperatively marked position, forming an evertable nipple stoma 1-2 cm high.	30 minutes

Ureteral stents are placed into the anastomoses and removed through the stoma — they are left in place for 10–14 days to allow the suture to heal without pressure.

Stage 3: Hospitalization (5-10 days)

According to current ERAS protocols and large cohort data, the average length of hospital stay is 7-9 days — but depends on the patient's course ^[3] .

• Days 1-2: ICU or post-anesthesia care unit — mobilization, breathing exercises, IV fluids, analgesia.
• Days 3-5: Gradual resumption of feeding (clear fluids → full). Stoma nurse begins bag change training.
• Days 6-9: Full mobilization, independent bag change, discharge.
• Days 10-14: Ureteral stents removed in the office.

The Memorial Sloan Kettering study of 1,142 patients ^[4] showed that approximately 64% of patients experience some postoperative complication in the first 90 days—although serious complications (Clavien Grade III+) are relatively rare (~13%). Modern ERAS techniques further reduce the rates.

Stage 4: Home Recovery (Weeks 2-12)

Full recovery takes 3 months . In the first 6 weeks:

• The stoma changes shape — it starts out swollen and gradually shrinks. Different sizes of flanges will be needed.
• No heavy lifting (over 5 kg) for 6 weeks — risk of parastomal hernia.
• No swimming or hot baths for 4 weeks (although showers are allowed after the 1st week).
• Bag change: every 3-5 days with Flexima — see detailed article on urostomy bag change .

The systematic review by Cookingham et al. (2022) in World Journal of Urology ^[5] shows that quality of life (HRQoL) in patients with ileal conduit is comparable to that of patients with neocystic kidney after the first 6-12 months of adaptation. Many patients return to work and activities.

Selection of materials after surgery

In the first 4-6 weeks, the right choice of bag makes the difference for:

• Protection of peristomal skin (the skin is sensitive in the first weeks)
• Prevention of urinary tract infections (anti-reflux valve)
• Psychological adaptation (discreet appearance under clothes)

At Traumacare, as exclusive representatives of B Braun Avitum in Greece , we recommend:

Stage	Flexima Recommendation
Weeks 1-4 (bulging stoma)	Flexima Uro Silk Flat larger size, with midi beige cover
Weeks 4-12 (reducing stoma)	Re-sizing — possible change to Convex if retraction is present
After 3rd month (stable stoma)	Permanent system: Flexima Uro Silk (flat) or Active O' convex accordingly

Full EOPYY coverage: According to the Government Gazette B' 5395/09-10-2025 ^[6] , EOPYY covers 270€/month urostomy materials with 0% patient participation. Traumacare handles the entire process (e-EOPYY, pickup, next-day delivery).

Complications to be aware of

According to BAUS (British Association of Urological Surgeons) data ^[7] :

• Early (first 30 days): ileus 10-15%, surgical wound infection ~10%, renal dysfunction ~5%, deep vein thrombosis 2-3%.
• Late (after 3 months): parastomal hernia 15-30% (increasing with age), stoma stenosis 5-10%, kidney stones 5-10%, hydronephrosis 5%.
• Rare: incidental calcification, metabolic acidosis from intestinal absorption.

Regular follow-up with a urologist every 3-6 months for the first two years, and annually thereafter, is critical for early detection of complications ^[1] .

Book a pre-operative consultation

Related articles

• What is ureterostomy — cutaneous vs ileal conduit
• When is a ureterostomy done — indications
• Comparison: Nephrostomy vs Ureterostomy vs Neocyst
• How do I change a urostomy bag — steps

📚 Bibliography / Scientific sources

1. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer . European Association of Urology, 2024. uroweb.org/guidelines
2. Bricker EM. Bladder substitution after pelvic evisceration . Surgical Clinics of North America , 1950;30(5):1511-1521. PMID: 14782163. pubmed.ncbi.nlm.nih.gov
3. AUA/ASCO/SUO Guideline on Muscle-Invasive Bladder Cancer . American Urological Association, 2017 (amended 2024). auanet.org
4. Shabsigh A et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology . European Urology , 2009;55(1):164-176. pubmed.ncbi.nlm.nih.gov
5. Cookingham LM et al. Health-related quality of life in patients with ileal conduit urinary diversion: a systematic review . World Journal of Urology , 2022. pubmed.ncbi.nlm.nih.gov
6. ΦΕΚ Β' 5395/09-10-2025 — Definition of stoma materials with EOPYY coverage . National Printing House. eopyy.gov.gr
7. BAUS — Information about Urinary Diversion (Ileal Conduit) . British Association of Urological Surgeons. baus.org.uk
8. ​​ UOAA — United Ostomy Associations of America: Urostomy Guide . ostomy.org/urostomy
9. Stein JP et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients . Journal of Clinical Oncology , 2001;19(3):666-675. pubmed.ncbi.nlm.nih.gov