Renal function after urinary diversion. A study of continent caecal reservoir, ileal conduit and colonic conduit

Total and separate renal function, renal parenchymal thickness and dilatation of the upper urinary tract were studied in 40 patients preoperatively and 24 to 67 months after urinary diversion, using 51Cr-EDTA clearance test, scintillation camera renography and urography. In ten patients a continent caecal reservoir was used for diversion. In the other patients, an ileal or a colonic conduit (15 patients with each method) was used, one ureter being implanted with an anti-reflux method and the other with direct technique. Renal function following urinary diversion showed little or no deterioration in most patients. The functional outcome was not related to the method of diversion or, in the conduit groups, to the mode of ureteral implantation. Serum creatinine tests and urography were not adequate for determining loss of renal function. Radionuclide studies proved to be valuable for assessing renal function after urinary diversion.     

The continent ileal reservoir (kock pouch) for urinary diversion

Summary Urinary diversion via a continent ileal reservoir was performed in 31 patients. The diversion was a primary procedure in 11 patients, while in 18 it was performed to convert an existing urinary diversion to a continent diversion. In two patients, malfunctioning cecocystoplasties were converted to continent ileum reservoirs. There were no operative mortalities and few early complications. Late complications causing malfunction of the nipple valves required revisional surgery in 15 patients. Postoperative follow-up presently is between 6 months and 10 years. Two patients have died: one in an accident and one of metastatic bladder carcinoma. The remaining 29 patients are continent and without reflux to the upper urinary tract. The reservoir is emptied by catheterization 4–5 times daily, not at night. The volume capacity of the reservoir is around 700 ml. One-third of our patients had constantly negative quantitative urine cultures, whereas two-thirds either had intermittent or constant bacteriuria. Dilatation of the upper urinary tract, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are very satisfied with this type of urinary diversion.Urinary diversion is performed in non-malignant as well as malignant bladder diseases; the majority because of bladder carcinoma. However, long-term studies of conventional urinary diversion procedures have shown that there is a high incidence of late complications with progressive deterioration of renal function [11, 13]. As a result, indications for urinary diversion have been critically reconsidered and alternatives have been sought. Bladder replacement is one method which has been suggested. In non-malignant disease, intermittent catheterization and/or uropharmacological manipulation may be auspicious alternatives. The trend against diversion has also led to reconstruction of the urinary tract in cases previously regarded as suitable only for diversion. In this era of critical reappraisal of conventional urinary diversion procedures a new method for continent urinary diversion was elaborated and introduced for clinical use in 1982 [8]. The low-pressure ileal reservoir originally devised for urinary bladder augmentation or replacement [4] and later used for rendering the ileostomy continent in patients after proctocolectomy [7] has, since 1975, been used in our institution for continent supra-vesical urinary diversion. In this paper the operative method is described and our results and experience obtained during a 10-year period are reported.Supported by grants from the Medical Research Council (Project No 577)     

Selection of the type of urinary diversion in conjunction with radical cystectomy

Several different methods of urinary diversion currently are available for use in conjunction with radical cystectomy. The method of urinary diversion performed at the time of radical cystectomy was reviewed for patients undergoing surgery from April 1984 through March 1986. A total of 91 urinary diversions was performed. Of the patients 74 per cent had a diversion with an external appliance (including 68 per cent with an ileal conduit), 14 per cent had a continent urinary reservoir (Kock pouch) and 11 per cent had an internal reservoir anastomosed to the urethra and, thus, avoided any stoma. There are inherent disadvantages to each form of urinary diversion and patient selection will be important to identify the most appropriate method of diversion for an individual.     

Simplified urinary diversion in patients with preexisting or imminent colostomy.

The indications for urinary and fecal diversion often mirror each other and at times overlap. Between 1980 and 1990 we encountered 14 patients with preexisting or newly diagnosed rectosigmoid disease who required diverting colostomy and urinary diversion. We describe a simple method for managing urinary diversion in these patients, which avoids a bowel anastomosis. The preexisting or newly created colostomy is used as the urinary stoma for a colon conduit, while a proximal colostomy is created for fecal diversion. This technique has proved to be beneficial and should be considered for high risk patients who require urinary and fecal diversion, and for whom an abbreviated operation would be desired.     

Ileal conduit in era of systemic chemotherapy

The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.     

Transverse colon conduit for supravesical urinary tract diversion

Twenty-two patients with extensive pelvic irradiation underwent supravesical urinary diversion using a transverse colon conduit. Primary diseases were most often carcinoma of the cervix and urinary bladder. Indications for diversion included original treatment planning, radiation cystitis, vesicovaginal fistula, and ureteral obstruction. Operative mortality was low (4 per cent), and most complications were managed by further surgery. Normal upper urinary tracts usually remained normal after diversion; relief of existing hydroureteronephrosis was seen in a majority of patients. Stomal problems have been minimal, and renal function has remained normal or stable. The method affords the use of nonirradiated transverse colon as well as the ureter high above the field of pelvic irradiation and is the preferred diversion in such patients.     

Ileal and jejunal conduit urinary diversion

The indications for urinary diversion have changed in recent years, and it is most often required in association with radical surgery for pelvic malignancies. Many patient with lower urinary tract dysfunction can be managed satisfactorily without diversion by use of intermittent catheterization, administration of specific pharmacologic agents, and, when necessary, implantation of artificial sphincters. For patients who require urinary diversion, the ureteroileal conduit remains the standard by which other methods should be judged. If satisfactory results are to be obtained, it is clear that meticulous attention to indications, operative technique, and careful follow-up are essential. As many of these patients have other disabilities, the management of the urinary tract must be integrated with other aspects of patient care. The introduction of the colonic conduit and recently the continent types of urinary diversion represent a search for the ideal method that has yet to be achieved.     

Cutaneous ureterostomy as palliative diversion in adults with malignancy

Over a twenty-one-year period (1963-1984) 46 patients underwent a permanent urinary diversion using cutaneous ureterostomy. Thirty-seven of these patients had this method of diversion employed as palliation for pelvic malignancies. In 70 per cent of the patients diversion was done secondary to ureteral obstruction and in the other patients because of either severe lower urinary tract symptoms or a failed alternate form of diversion. Forty-nine per cent of the patients experienced a postoperative complication. The late postoperative complications were either related to the choice of diversion or presumed progression of the patient's disease. Palliative diversion is now best initially attempted with percutaneous nephrostomy or indwelling ureteral stents if bladder function allows. Cutaneous ureterostomy no longer is indicated as a primary form of palliative diversion, however, it may be used as an alternative to open nephrostomy tube placement or intestinal conduit should other more conservative forms of management fail. The presence of at least one dilated ureter is a prerequisite to the success of this form of diversion.     

Analysis of continent versus standard urinary diversion.

The seemingly high complication and re-operation rates associated with continent urinary diversion have led some to criticize its morbidity and question its role in reconstructive urological surgery. We therefore reviewed our experience with all patients undergoing either continent or standard urinary diversion performed by 3 urological surgeons during a specified 3-year period. In 73 consecutive patients (22 continent urinary diversion, 51 standard urinary diversion), no significant difference was demonstrated with respect to the number of post-operative in-hospital days, complication rate, re-operation rate and operative mortality rate between the 2 groups. While those undergoing continent diversion were on average younger and healthier than their counterparts receiving standard diversion, stratification of patients in each group according to age and a pre-operative "fitness" score showed no significant difference in operative mortality or major morbidity between comparable patients in each group. The mean post-operative length of hospital stay was, however, 3 days shorter for the youngest and fittest patients receiving standard versus continent urinary diversion.     

Terminal loop cutaneous ureterostomy in renal transplantation.

Patients presenting for renal transplantation with urinary diversion abnormalities pose serious problems. The use of a terminal loop cutaneous ureterostomy (TLCU) in patients whose outcome was satisfactory was first described in 1977. Primary urinary drainage was achieved in 3 recipients of cadaver renal allografts by creating a TLCU. This method of drainage has been satisfactory in these patients with follow-up between four and thirty months. We suggest that this simple technique should be considered more frequently for selected patients who require supravesical urinary diversion.     

Afferent intussuscepted antireflux nipple valve complications in the Kock pouch for continent urinary diversion Early results with a modified technique

OBJECTIVES: To analyse the risk of afferent nipple valve stenosis and its consequences and management in patients with a Kock pouch for continent urinary diversion and to study the early results after using an alternative antireflux technique. MATERIAL AND METHODS: Sixty patients consecutively operated on with a conventional Kock reservoir for continent cutaneous urinary diversion between 1988 and 2001 were analysed with regard to the occurrence of afferent nipple valve stenosis and its clinical characteristics. Sixteen patients operated on for continent urinary diversion during the period 2002-04 had the antireflux valve constructed according to the serous-lined extramural ileal valve technique. RESULTS: Eight patients with a conventional Kock pouch developed true afferent nipple valve stenosis and the risk approached 30% after 15 years. Dilatation and stenting were usually successful. CONCLUSIONS: The high risk of afferent nipple valve stenosis when using the intussuscepted nipple valve in the construction of a Kock reservoir for continent cutaneous urinary diversion calls for an alternative method for anastomosing the ureters to the reservoir. Our early results with the combined Kock/T-pouch are promising.     

Pregnancy and urinary diversion

In most children or premenopausal women who need urinary diversion, the underlying disease is benign. After the problems associated with urinary incontinence have been resolved, and patients have reached puberty, sexuality and fertility become more significant. In women with urinary diversion, numerous influencing factors exist, including, but not limited to, the underlying disease and form of urinary diversion. The authors' center has a large expertise in urinary diversion, although the number of cases with pregnancies is limited. This article uses this prior experience and data from a literature review to provide guidance for urologists, obstetricians, general practitioners, and patients to aid decision making in pregnancies after urinary diversion.     

Komplikationen und deren Management nach Harnableitung

Background

Bladder cancer is a common disease. It is predicted that 11,900 men and 4,500 women in Germany will be diagnosed with invasive bladder cancer in 2014. The cystectomy, which is standard treatment in muscle-invasive bladder cancer, requires urinary diversion.

Purpose

The goal of this article is to present the complications associated with urinary diversions and their management.

Methods

Based on a selective literature search in PubMed and our own clinical experience, the options for urinary diversion and their management are discussed.

Results

In patients treated with curative intent, orthotopic bladder replacement is preferred. In patients with palliative intent, incontinent cutaneous urinary diversion is commonly used. The present work shows the variety of early and late complications, peri-/postoperative mortality, and the management of these patients.

Conclusion

After cystectomy, various methods for urinary diversion are available, which can be used in curative and/or palliative intent. Crucial to the success and the long-term satisfaction of the patients is selection of the right urinary diversion method.     

Extracorporeal shock wave lithotripsy of urolithiasis in patients with urinary diversion

We evaluate the efficacy of ESWL in the management of calculi in patients with urinary diversion. We treated 5 patients who suffered from urinary lithiasis after urinary diversion post cistectomy. We managed the patients with extracorporeal shock wave lithotripsy in monotherapy with a Siemens Lithostar Modularis device. Mean stone size (long axis) was 1.95 cm (range 1 to 3.5 cm). The mean shockwave number per session was 2.6 per patient. Stone free result was 100%. We conclude that ESWL technique can provide acceptable results in patients with urinary diversion and can be used as first choice treatment in these type of patients due to its minimal morbidity and excellent results, equivalent to those achieved in patients without urinary diversion.     

Long-term results of ileocecal continent urinary diversion in patients treated with and without previous pelvic irradiation

PURPOSE: Patients who receive pelvic irradiation may require urinary diversion to manage complications resulting from progressive malignancy or radiotherapy. The choice of urinary diversion is an important issue and remains controversial. We characterized the long-term outcome of urinary diversion with a continent ileocecal reservoir in patients who received pelvic irradiation versus those who underwent urinary diversion without previous irradiation. MATERIALS AND METHODS: Continent urinary diversion with an ileocecal reservoir (Mainz pouch 1) was performed in 36 irradiated patients in a 9-year period. Morbidity, mortality, the reoperative rate and parameters associated with the surgical procedure were determined at a median followup of 57 months. Results were compared with those in 385 nonirradiated patients who received the same type of continent diversion after cystectomy for bladder cancer. RESULTS: Irradiated patients had a significantly higher rate of serious complications after ileocecal urinary diversion than nonirradiated controls. Continence mechanism failure occurred in 25% of patients in the irradiated group and 5.7% in nonirradiated patients, stomal complications were noted in 38.8% and 10.6%, and ureteral complications developed in 22.2% and 6.5%, respectively. CONCLUSIONS: In patients who have received pelvic radiotherapy, ileocecal Mainz pouch 1 continent urinary diversion is associated with a high rate of serious complications and should be avoided.     

Urologic and plastic surgical collaboration for continent diversion when urine leakage is complicated by pressure ulcers or obesity

BACKGROUND: Patients with neurogenic bladder dysfunction and urine leakage combined with pressure ulceration, fistulae, and/or obesity present a major surgical challenge. Given the urgent need to control urine leakage, suprapubic cystostomy or incontinent urinary diversion such as ileal conduit often are chosen for definitive intervention, despite the fact that continent urinary diversion generally is the preferred method of management for the motivated patient. DESIGN: Case series. METHOD: This article presents 4 patients in whom urine leakage was complicated by pressure ulcers, urethral erosion, and/or morbid obesity. Due to the complicated nature of their problems, these patients were managed in a collaborative fashion by the departments of urology, plastic surgery, and physiatry. Each of these patients underwent a combined surgical intervention that addressed issues of skin ulceration or morbid obesity and allowed for continent urinary diversion. RESULTS: After intervention, all 4 patients were independent in bladder management and were completely continent. CONCLUSION: This series demonstrates how collaboration between the urologist and plastic surgeon in evaluation and treatment planning allows for the formulation of surgical options that include continent urinary diversion.     

Complications of the Heitz-Boyer urinary diversion: case report of late development of malignancy

We report on 3 patients with bladder exstrophy followed for more than 15 years after having undergone Heitz-Boyer urinary diversion. One patient had adenocarcinoma at the ureterocolonic anastomoses 16 years after diversion. To our knowledge this is the first reported case of a malignancy developing after a Heitz-Boyer procedure. The other 2 patients had significant problems with urinary incontinence and recurrent urinary tract infections. Initial success with this form of urinary diversion can be followed by significant long-term complications.     

Transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus

The transverse retubularized ileovesicostomy is useful as a continent urinary diversion when the appendix is unusable or unavailable for an appendicovesicostomy continent urinary diversion. Eight patients (mean age 29 years) with difficulty catheterizing their native urethras underwent creation of a transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus. Diagnoses included myelomeningocele (3), multiple sclerosis (1), and spinal cord injury (4). Concomitant procedures included ileocystoplasty, antegrade continence enema procedure, and pubovaginal sling. All patients were able to catheterize their ileovesicostomy conduit and stoma easily with a 14F catheter. Six patients were completely dry, and two patients needed to catheterize every 3 to 4 hours to prevent urinary leakage. Mean follow-up was 3 years. Experience with the transverse retubularized ileovesicostomy continent urinary diversion to the umbilicus has been favorable. When the Mitrofanoff appendicovesicostomy continent urinary diversion is not an option, the transverse retubularized ileovesicostomy has several advantages as a second choice.     

膀胱腺癌的诊断和治疗(附29例报告)

目的提高膀胱腺癌的诊断与治疗水平。方法29例中原发性膀胱腺癌18例，其中行全膀胱切除、尿流改道11例，膀胱部分切除7例；脐尿管腺癌9例，6例行扩大膀胱部分切除术，3例行全膀胱切除、尿流改道；印戒细胞癌2例，行全膀胱切除、尿流改道术。结果4例患者失访，25例患者随访时间为5个月一10年。生存1年者17例（64％），生存2年15例（60％），生存5年5例（20％），生存时间超过5年者均为早期患者。结论早期诊断、鉴别原发性膀胱腺癌与脐尿管腺癌、选择合适的手术方式是膀胱腺癌治疗的关键。     

Endoscopic removal of staghorn calculi in patient with high urinary diversion

The treatment of recurrent renal calculi in patients after ureteroileal urinary diversion is difficult, especially when urinary stones are formed in the presence of urinary tract infection. In many cases, these patients already have undergone multiple renal operations and more surgery could pose difficult technical problems. We report on a patient with a high urinary diversion in whom bilateral staghorn renal calculi developed, and then were endoscopicady removed. The conversion of ureteroileoeutaneous diversion to a high pyeloileocutaneous diversion is recommended in selected cases as alternate treatment for patients with recurrent stone formation.