Use of Intestinal Segments in Urinary Diversion By Dr.Turky Al-Mouhissen R3 at KKNGH.
Complications of Urinary Diversion
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Transcript of Complications of Urinary Diversion
Complications of Urinary Complications of Urinary DiversionDiversion
ByPeter Tran, D.O.
Garden City HospitalResident Talk12/17/2008
OverviewOverviewClassification of urinary
diversionsFactors influencing complicationsComplications according to bowel
segmentsMetabolic/physiologic
complicationsSurgical complications: early and
late
Clasification of DiversionsClasification of DiversionsOrthotopicHeterotopic
◦Continent cutaneous◦Non-continent cutaneous◦Diversion to GIT
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-2 Construction of the modified Camey II. A, The ileal loop is folded three times (Z shaped) and incised on the antimesenteric border. B, The reservoir is closed with a running suture to approximate the incised ileum. C, The urethroenteric anastomosis is performed.
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-3 Construction of the Hautmann ileal neobladder. A, A 70-cm portion of terminal ileum is selected. Note that the isolated segment of ileum is incised on the antimesenteric border. B, The ileum is arranged into an M or W configuration with the four limbs sutured to one another. C, After a buttonhole of ileum is removed on an antimesenteric portion of the ileum, the urethroenteric anastomosis is performed. The ureteral implants (Le
Duc) are performed and stented, and the reservoir is then closed in a side-to-side manner.
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-4 Construction of the ileal neobladder (Studer pouch) with an
isoperistaltic afferent ileal limb. A, A 60- to 65-cm distal ileal segment is
isolated (approximately 25 cm proximal to the ileocecal valve) and folded into a U configuration. Note
that the distal 40 cm of ileum constitutes the U shape and is opened on the antimesenteric
border; the more proximal 20 to 25 cm of ileum remains intact (afferent limb). B, The posterior plate of the reservoir is formed by joining the medial borders of the limbs with a
continuous running suture. The ureteroileal anastomoses are
performed in a standard end-to-side technique to the proximal portion
(afferent limb) of the ileum. Ureteral stents are used and brought out anteriorly through separate stab
wounds. C, The reservoir is folded and oversewn (anterior wall). D,
Before complete closure, a buttonhole opening is made in the most dependent (caudal) portion of the reservoir. E, The urethroenteric
anastomosis is performed. F, A cystostomy tube is placed, and the
reservoir is closed completely.
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-5 Construction of the Kock ileal reservoir. A, A total of 61 cm of
terminal ileum is isolated. Two 22-cm segments are placed in a U
configuration and opened adjacent to the mesentery. Note that the more
proximal 17-cm segment of ileum will be used to make the afferent
intussuscepted nipple valve. B, The posterior wall of the reservoir is then
formed by joining the medial portions of the U with a continuous running suture. C, A 5- to 7-cm antireflux valve is made by intussusception of the afferent limb with the use of Allis forceps clamps. D, The afferent limb is fixed with two rows
of staples placed within the leaves of the valve. E, The valve is fixed to the back wall from outside the reservoir. F, After
completion of the afferent limb, the reservoir is completed by folding the ileum on itself and closing it (anterior wall). Note that the most dependent portion of the reservoir becomes the
neourethra. The ureteroileal anastomosis is performed first, and the
urethroenteric anastomosis is completed in a tension-free, mucosa-to-mucosa
fashion.
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-8 Construction of the Mainz ileocolonic orthotopic reservoir. A, An isolated 10 to 15 cm of cecum in continuity with 20 to 30 cm of ileum is
isolated. B, The entire bowel segment is opened along the antimesenteric border. Note that an appendectomy is performed. C, The posterior plate of the reservoir is constructed by joining the opposing three limbs together
with a continuous running suture. D, An antireflux implantation of the ureters through a sub-mucosal tunnel is performed and stented. E, A
buttonhole incision in the dependent portion of the cecum is made that provides for the urethroenteric anastomosis. Note that the ureterocolonic
anastomoses are performed before closure of the reservoir. F, The reservoir is closed side to side with a cystostomy tube and the stents exiting.
Examples of Orthotopic Examples of Orthotopic NeobladdersNeobladders
Figure 82-9 Construction of Le Bag (ileocolonic) orthotopic reservoir. A, A total of 20 cm of ascending cecum and colon, with a corresponding length of adjacent terminal ileum, is isolated. The bowel is opened along the entire antimesenteric border, and the two incised segments are then sewn to one another. This forms the posterior plate of the reservoir. B, This reservoir is folded and rotated
180 degrees into the pelvis with the most proximal portion of the ileum (2 cm non-detubularized) anastomosed to the urethra. C, Modification is performed with complete detubularization of the bowel segment, which is then anastomosed to the urethra.
Examples of Heterotopic Examples of Heterotopic Cutaneous DiversionCutaneous Diversion
Continent/catherizable Pouch◦ Indiana Pouch
Segment of ascending colon with terminal ileum and IC valve as continence mechanism.
◦ Penn Pouch Same as Indiana pouch except appendix used based on
Mitrofanoff principle in which continence mechanism is the appendix.
◦ Gastric Pouch Segment of stomach and ileum recreated in to a
reservoir Non-Continent
◦ Most popular - ileal loop Excretion of urine by means of evacuation
◦ Ureterosigmoidostomy◦ Rectal bladder◦ Sigmoid hemi-Kock
Factors Influencing Factors Influencing ComplicationsComplications
Patient factorsBowel factors
Patient FactorsPatient FactorsPerformance status/co-morbiditiesPt/caregiver compliance with CICMobilityPrevious XRTRenal functionLiver functionBody habitusBMI
Bowel Factors/Technical Bowel Factors/Technical FactorsFactors
Type of intestinal segment usedLength of intestinal segmentContinent vs. incontinentMethod/extend of detubularizationCapacityComplianceRefluxing/non-refluxing uretero-
enteric anastomosisType of diversion chosen
Gastric ComplicationsGastric ComplicationsHypochloremic, hypokalemic
metabolic alkalosisHyper-gastrinemiaHematuria-dysuria syndrome
Jejunum ComplicationsJejunum ComplicationsMost severe metabolic
complicationsHyponatremiaHyperkalemic, hypochloremic
metabolic acidosisSevere dehydration
Ileal ComplicationsIleal ComplicationsHyperchloremic, hypokalemic
metabolic acidosisVit B12 deficiency
Colonic ComplicationsColonic ComplicationsHyperchloremic, hypokalemic
metabolic acidosis
Metabolic/Physiologic Metabolic/Physiologic ComplicationsComplicationsRenal deteriorationElectrolyte disturbanceHypertensionAltered sensoriumAbnormal drug metabolismOsteomalaciaAbnormal growth/developmentVit deficiencyAnemiaChronic diarrheaHyper-gastrinemia
Electrolyte DisturbanceElectrolyte Disturbance Colon/Ileum
◦ Hyperchloremic, hypokalemic metabolic acidosis Stomach
◦ Hypochloremic, hypokalemic metabolic alkalosis Jejunum
◦ Hyperchloremic, hyperkalemic, hyponatremic metabolic acidosis
Hyperammonemia Hypomagnesemia Hypocalcemia
Colon and IleumColon and IleumHyperchloremic, hypokalemic
metabolic acidosis◦15% of ileal conduits
10% severe enough to require Tx
◦20% of colon conduits 15% require Tx
◦50% ileal or colonic pouches 40% require Tx
◦80% of ureterosigmoidostomy
Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic
acidosisacidosisSymptoms
◦Easy fatigability◦Anorexia/weight loss◦Polydipsia◦Lethargy◦Exacerbation of diarrhea in GI
diversions
Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic
acidosis: MOAacidosis: MOA Net absorption of ammonium + chloride Increased secretion of HCO3
Impaired distal tubular secretion of hydrogen
Physiologic Response◦ Increased acid secretion by kidneys
◦ Bone demineralization to buffer acidosis
Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic
acidosis: Treatmentacidosis: Treatment Alkalinizing agent◦ NaHCO3
◦ K-Citrate◦ Na-Citrate
Blockers of Cl transport◦ Chlorpromazine◦ Nicotinic acid
Gastric ComplicationsGastric Complications Hypochloremic, hypokalemic metabolic alkalosis
◦ Rare unless comcomitant renal failure◦ Severe dehydration, often triggered by vomiting or GI
illness◦ High serum gastrin levels
Overdistension of gastric segment triggers gastrin release
Gastric ComplicationsGastric ComplicationsSymptoms
◦Lethargy◦Weakness◦Respiratory insufficiency◦Seizures◦Ventricular arrhythmia
Gastric Complications: Gastric Complications: MOAMOA
H+, K+, and Cl- loss in gastric segment
Net addition of HCO3
Serum gastrin levels correlate with systemic HCO3 concentration
Gastric Complications: TxGastric Complications: TxAcute severe metabolic alkalosis
◦Empty bladder◦NaCl volume replacement◦H2 blocker◦PPI◦Arginine HCl◦Surgical removal of gastric segment
Gastric Complications: TxGastric Complications: TxMild/prophylaxis
◦Oral Na/K supplementation◦H2 blockers
Hypokalemia - IncidenceHypokalemia - IncidenceColonic diversions
◦30% reduction in total body KIleal diversions
◦0-15% reduction
Hypokalemia: MOAHypokalemia: MOAColonic/Ileal diversions
◦Ileum may passively reabsorb some K blunting the loss
◦Chronic metabolic acidosis◦Renal K wasting
HypokalemiaHypokalemiaSymptoms
◦Typically no symptoms◦At most severe
Muscle weakness Paralysis
Hypokalemia: TxHypokalemia: TxCorrect the acidosis
◦Beware of acutely worsening K as in moves backto intracellular stores
◦Oral K supplementation
Altered Sensorium: MOAAltered Sensorium: MOAHypomagnesemiaDrug reabsorptionAmmonia encephalopathy
Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia
Renal lossChronic diarrheaDecreased absorption
Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia
Symptoms◦Cardiac arrhythmias◦Tremor◦Tetany◦Seizures
Treament◦Mg replacement
Ammoniogenic Ammoniogenic EncephalopathyEncephalopathyAmmonium secreted by the
kidneyAmmonia is produced by urease
splitting bacteriaReabsorbed and transferred to
liver by portal circulationNomally liver copes and coverts
ammonia to urea
Ammoniogenic Ammoniogenic EncephalopathyEncephalopathy
Risk Factors◦ Typically in pre-existing or acquired liver disease◦ Ureterosigmoidostomy>Colon or ileal conduits◦ Triggers in setting of liver disease
Constipation Increased protein load GI bleed UTI with ammonia producer Co-existing CNS depressant use Renal failure
◦ Normal liver◦ Bacterial endotoxin – liver dysfunction with normal LFT
Ammoniogenic Ammoniogenic Encephalopathy: SymptomsEncephalopathy: Symptoms
ApathyRestlessnessSleep disturbanceImpaired intellectual abililitesAsterixis and lethargyStuporComa
Ammoniogenic Ammoniogenic Encephalopathy: TxEncephalopathy: Tx
Decrease nitrogen load/remove precipitants◦ Drain urine diversion◦ Limit dietary protein intake◦ Treat any systemic or UTI◦ Lactulose
Lowers gut pH so more NH4 than NH3
Promotes non-urease producing bacteria Decreases transit time of fecal matter Complexes the ammonia
◦ Neomycin/tetracycline Eliminate ammonia producing bacteria from the GIT
◦ Arginine glutamate Complexes ammonia
Abnormal Drug Abnormal Drug MetabolismMetabolism
Drugs absorbs in GITDrugs excreted unchanged in
urineReabsorbed in intestinal segment
Abnormal Drug Abnormal Drug MetabolismMetabolism
List of drugs◦ Dilantin◦ Methotrexate/chemo◦ Theophylline◦ Abx (beta-lactams, nitrofurantoin, aminoglycosides)
ChemoTx◦ Ensure pt well hydrated◦ Drain diversion with catheter◦ Consider leukovorin administration with methotrexate
OsteomalaciaOsteomalaciaPotential long-term complicationAffects children and adultsBone demineralizationMineralized component of bone is
replace with osteoid
OsteomalaciaOsteomalacia Risk Factors
◦ Bowel segment used Ureterosig most commonly Colon or ileal cystoplasties Colon or ileal conduits/neobladders
◦ Renal failure Chronic untreated metabolic acidosis
Osteomalacia: MOAOsteomalacia: MOA Bone buffering of chronic metabolic acidosis Vit D resistance – less Ca absorption by GIT Vit D deficiency – acidosis limits vit D production Sulphate in urine inhibits Ca and Mg re-absorption Resitance to PTH
◦ = Ca loss
OsteomalaciaOsteomalaciaSymptoms
◦Diffuse skeletal pain◦Bone tenderness◦Fractures◦Gait disturbance◦Proximal muscle weakness
OsteomalaciaOsteomalaciaPrevention
◦Particularly important in postmenopausal women and children
◦Tx underlying metabolic acidosisVit CVit DActivated Vit D metabolite
◦1-alpha-hydroxycholecalciferol◦Ca supplementation
Vitamin DeficiencyVitamin DeficiencyADEK – fat soluble lost in
malabsorption of fatVit B12 – absorbed in distal ileum
Vitamin B12 Deficiency: Vitamin B12 Deficiency: EtiologyEtiology
Not synthesized by mammals – only dietary source
B12 released from food by enzymes in stomach
Bound to IF in duodenumAbsorbed in terminal ileumStored mainly in liverTotal body stores of 2-5mg, loss of 0.1% dailyTakes 2-4 years for defeciency to take effect3-20% incidence after terminal ileum
resection
Vitamin B12 Deficiency: Vitamin B12 Deficiency: SymptomsSymptoms
Neurologic◦ Peripheral neuropathy◦ Degenerative changes/demyelination in
spinal cord◦ Voiding dysfunction◦ Optic neuropathy
Hematologic◦ Megaloblastic anemia
Inflammation of tongue/mouthPsychiatric disturbances
Vitamin B12 Deficiency: Vitamin B12 Deficiency: LabsLabsMCV > 120Often neutropenia and
thrombocytopeniaHypersegmented neutrophilsLow serum B12 levels
Vitamin B12 Deficiency: Vitamin B12 Deficiency: Bowel SegmentBowel Segment
Continent diversion increased risk◦Larger bowel segment used◦TI/IC junction resection◦Resection of > 50cm appears to be a
major risk factor
Vitamin B12 Deficiency: Vitamin B12 Deficiency: TxTx
Prevention◦Replace with 100ug cobalamin IM
monthly starting 1 year after surgery if > 50cm ileum resected
Treatment◦Neurologic symptoms may precede
other◦Treat if the least bit concered◦Treat if lab values are abnormal but
asymptomatic
Surgical ComplicationsSurgical ComplicationsEarly
◦Wound infection◦Intra-abdominal abscess◦Pyelonephritis◦Hemorrhage◦Urine leak/fistula◦Bowel leak/fistula◦Ileus◦Bowel obstruction◦Stomal bleeding/necrosis
Surgical ComplicationsSurgical ComplicationsLate
◦Wound hernia or dehiscence◦Bowel obstruction◦Ureteral stricture◦UTI/pyelo◦Urinary stones◦Renal deterioration◦Stomal stenosis/parastomal hernia◦Hematuria dysuria syndrome
Stomal ComplicationsStomal ComplicationsEarly
◦Bleeding◦Necrosis
Late◦Dermatitis◦Retraction◦Prolapse◦Parastomal hernia◦Stenosis
Stomal BleedingStomal BleedingEarly
◦Conservative Tx◦Most will stop with pressure/time
Late◦Liver disease due to dilated veins◦Correct coagulopathy◦Ligation◦Porto-systemic shunting
Parastomal HerniaParastomal HerniaIncidence
◦10% ileal conduit◦20% colon conduit
Risk Factors◦Wound infection◦Steriod use◦Malnutrition◦Obesity◦Chronic cough/COPD◦Advanced age◦Stomal not brought out through rectus
muscle
Stomal StenosisStomal StenosisIncidence
◦3-25% of ileal conduits◦10-20% of colon conduits◦Catherizable stoma – 50%
Brooke > Turnbull loop
Stomal StenosisStomal StenosisRisk Factors
◦Catherizable > end > loop◦Technical
Protruding better and flushed for non-continent
Insufficient fascial opening◦Muscle spasm◦Ischemia◦Infection◦Poor stomal hygiene◦Poor fitting appliance
Stomal StenosisStomal StenosisSymptoms
◦Suspect in Metabolic disturbance Infection/pyelo/sepsis Stones Renal decline
Stomal StenosisStomal Stenosis Work-up
◦ Conduit residual urine◦ Loopogram
Elongation Reflux with upper tract dilation Segment stenosis
Tx◦ Requires surgical repair
Ureteroenteric StrictureUreteroenteric Stricture Risk Factors
◦ Technical Tension Stripping ureteric blood supply Insufficient window through colon mesentery No mucosal to mucosal apposition
◦ Infection◦ Stone passage◦ Radiation◦ IBD◦ Previous urine leak
Ureteroenteric StrictureUreteroenteric StrictureSymptom
◦Stones◦Back pain◦Infection/sepsis
DDx◦Ureteral stone◦TCC recurrence
Ureteroenteric StrictureUreteroenteric StrictureImagingUSLoopogramCT/IVPRenogramAntegrade Nephrostogram
◦Most useful◦Diagnostic/therapeutic◦Tract for antegrade procedure
Ureteroenteric StrictureUreteroenteric Stricture Tx
◦ Endoscopic Antegrade vs retrograde Balloon dilation Cold knife Laser incision
◦ Open
Ureteroenteric StrictureUreteroenteric StrictureAdvantages of Endoscopic
◦Reasonable 1st line Tx◦Less morbidity◦Less OR time◦Less blood loss◦Shorter hospital stay◦Pt. with metastatic disease
Disadvantages◦High failure rate◦May complicate open repair
Ureteroenteric StrictureUreteroenteric StrictureFactors associated with failure of
endoscopic repair◦Length > 1cm◦Stricture presenting < 6 months
since surgery◦Left sided stricture
Ureteroenteric Ureteroenteric AnastomosisAnastomosis
Ureteroenteric StrictureUreteroenteric StrictureProcedure Stricture
Colon
Leadbetter-Clarke 14%
Strickler 14%
Pagano 7%
Small Bowel
Bricker 7%
Wallace 3%
Nipple 8%
Le Duc 18%