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Complications of Urinary Complications of Urinary DiversionDiversion

Jennifer L. Dodson, M.D.Jennifer L. Dodson, M.D.Department of UrologyDepartment of Urology

Johns Hopkins UniversityJohns Hopkins University

Types of DiversionTypes of Diversion

Conduit DiversionsConduit DiversionsIleal conduitIleal conduitColon conduitColon conduit

Continent DiversionsContinent DiversionsContinent catheterizable reservoirContinent catheterizable reservoirContinent rectal pouchContinent rectal pouch

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Overview of ComplicationsOverview of Complications

MechanicalMechanicalStoma problemsStoma problemsBowel obstructionBowel obstructionUreteral obstructionUreteral obstructionReservoir perforationReservoir perforation

MetabolicMetabolicAltered absorptionAltered absorptionAltered bone metabolism Altered bone metabolism Growth delayGrowth delayStonesStonesCancerCancer

Conduit DiversionsConduit DiversionsIleal Conduit: Ileal Conduit:

Technically simplestTechnically simplestSegment of choiceSegment of choice

Colon Conduit:Colon Conduit:Transverse or sigmoidTransverse or sigmoidUsed when ileum not appropriate (eg: concomitant colon resectioUsed when ileum not appropriate (eg: concomitant colon resection, n, abdominal radiation, short bowel syndrome, IBD)abdominal radiation, short bowel syndrome, IBD)

Early complications (< 30 days): 20Early complications (< 30 days): 20--56%56%Late complications : 28Late complications : 28--81%81%Risks: Risks:

abdominal radiationabdominal radiationabdominal surgeryabdominal surgerypoor nutritionpoor nutritionchronic steroidschronic steroids

Farnham & Cookson, World J Urol, 2004Farnham & Cookson, World J Urol, 2004

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Complications of Ileal ConduitComplications of Ileal Conduit

Campbell’s Urology, 8th Edition, 2002

Conduit: Bowel Complications Conduit: Bowel Complications

Paralytic ileus 18Paralytic ileus 18--20%20%Conservative management vs NGTConservative management vs NGTConsider TPNConsider TPN

Bowel obstruction 5Bowel obstruction 5--10%10%Causes: Adhesions, internal herniaCauses: Adhesions, internal herniaEvaluation: CT scan, Upper GI seriesEvaluation: CT scan, Upper GI series

Anastomotic leak 1Anastomotic leak 1--5 %5 %Risk factors: bowel ischemia, radiation, Risk factors: bowel ischemia, radiation, steroids, IBD, technical errorsteroids, IBD, technical error

Prevention:Prevention:PrePre--operative bowel prepoperative bowel prepAttention to technical detail Attention to technical detail

Blood supply, tensionBlood supply, tension--free anastomosis, free anastomosis, realignment of mesenteryrealignment of mesenteryFarnham & Cookson, World J Urol, 2004Farnham & Cookson, World J Urol, 2004

Stapled small-bowelAnastomosis (Campbell’sUrology, 8th Ed, 2004)

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Conduit ComplicationsConduit Complications

Conduit necrosis:Conduit necrosis:Acute ischemia to bowel segmentAcute ischemia to bowel segmentUrgent reUrgent re--explorationexploration

Conduit ischemia:Conduit ischemia:Stomal stenosis or strictureStomal stenosis or stricture

Conduit elongation:Conduit elongation:Distal obstruction at fascia or stomaDistal obstruction at fascia or stoma

Prevention:Prevention:Attention to blood supply of segmentAttention to blood supply of segmentPeriodic imaging postPeriodic imaging post--operativelyoperatively

Stoma ComplicationsStoma ComplicationsMost common longMost common long--term term complication 25complication 25--60%60%Most common cause for reMost common cause for re--operationoperationStomal Stenosis 10Stomal Stenosis 10--25%25%

Cause: ischemia, fascial Cause: ischemia, fascial constriction, retraction, local constriction, retraction, local skin changes, poorly fitting skin changes, poorly fitting applianceappliance

Stomal ProlapseStomal ProlapseParastomal Hernia 5Parastomal Hernia 5--25%25%

Cause: gap between conduit Cause: gap between conduit and fasciaand fascia

“Rosebud” Stoma (Campbell’s Urology, 8th Ed., 2004)

Parastomal Hernia (Farnham & Cookson, World J Urol, 2004

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Ureterointestinal AnastomosisUreterointestinal Anastomosis

Urinary leak 2%Urinary leak 2%Prevention: stents, drains, surgical Prevention: stents, drains, surgical techniquetechnique

UreteroUretero--enteric stricture 4enteric stricture 4--7%7%Potential renal damagePotential renal damageCause: urinary leakage with fibrosis, Cause: urinary leakage with fibrosis, anastomotic tension, ischemia of ureter, anastomotic tension, ischemia of ureter, infectioninfectionEvaluation: IVP, CT scan, loopogram (if Evaluation: IVP, CT scan, loopogram (if refluxing anastomosis)refluxing anastomosis)Treatment: endoscopic balloon dilation or Treatment: endoscopic balloon dilation or incision vs open reconstruction incision vs open reconstruction

Campbell’s Urology, 8th Ed, 2004

Antegrade nephrostogram

Continent Diversion: Reservoir Continent Diversion: Reservoir ComplicationsComplications

Pouch stones 10%Pouch stones 10%Mostly struvite stonesMostly struvite stonesCause: chronic bacteriuria, Cause: chronic bacteriuria, urinary stasis, mucous, metabolic urinary stasis, mucous, metabolic abnormalities, staplesabnormalities, staplesPrevention: treatment of Prevention: treatment of symptomatic infection, irrigationsymptomatic infection, irrigationTreatment: percutaneous vs open Treatment: percutaneous vs open extraction extraction

Spontaneous perforation of Spontaneous perforation of reservoir: rare but potentially reservoir: rare but potentially fatalfatal

CT cystogram, clinical suspicionCT cystogram, clinical suspicionLow threshold for explorationLow threshold for exploration

CT scan of stone burden in Indiana Pouch(Farnham & Cookson, WorlD J Urol, 2004)

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IncontinenceIncontinenceLeakage : 1Leakage : 1--8%8%Uninhibited pouch Uninhibited pouch contractionscontractions

Tx: anticholinergicsTx: anticholinergicsPoorly compliant reservoirPoorly compliant reservoir

Tx: augmentationTx: augmentationIncontinent mechanism Incontinent mechanism

Tx: revisionTx: revisionUrodynamic testingUrodynamic testing

Types of continence mechanisms:Nipple valves, tunneled Mitrofanoff Channels (Campbell’s Urology, 8th Ed, 2004)

Stomal ComplicationsStomal Complications

Difficulty catheterizing 3Difficulty catheterizing 3--18%18%Cause: stomal stenosis or tortuosity of channelCause: stomal stenosis or tortuosity of channelHighest incidence in tunneled appendixHighest incidence in tunneled appendixPrevention: in the OR, by stabilizing the channel, Prevention: in the OR, by stabilizing the channel, avoiding kinking, tension, or ischemiaavoiding kinking, tension, or ischemiaTreatment: dilation vs stomal revision with VTreatment: dilation vs stomal revision with V--flapflap

Appendiceal Continent Catheterizable Stoma(Campbell’s Urology, 8th Ed, 2002)

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Ureterointestinal AnastomosisUreterointestinal Anastomosis

Etiology and rates of Etiology and rates of leakage and stricture leakage and stricture similar to conduit diversionsimilar to conduit diversionContinent diversions Continent diversions usually use nonusually use non--refluxing refluxing anastomosisanastomosis

Decreased risk of upper tract Decreased risk of upper tract deterioration, deterioration, May increase to risk of May increase to risk of stenosis/stricturestenosis/stricture Ureterointestinal anastomosis in Ureterosigmoidostomy

(Campbell’s Urology, 8th Ed, 2002)

Metabolic: Removed BowelMetabolic: Removed Bowel

Resection of terminal ileum: 3.3Resection of terminal ileum: 3.3--20%20%B12 malabsorption/deficiencyB12 malabsorption/deficiencyMegaloblastic anemia, neurologic manifestationsMegaloblastic anemia, neurologic manifestations

Resection of >60Resection of >60--100 cm ileum: 100 cm ileum: Bile Acid MalabsorptionBile Acid Malabsorptionlipid malabsorption, hypertriglyceridemialipid malabsorption, hypertriglyceridemiaSteatorrheic diarrheaSteatorrheic diarrheaImpaired absorption of fatImpaired absorption of fat--soluble vitamins: A, D, E, Ksoluble vitamins: A, D, E, KIncreased risk of gallstone formationIncreased risk of gallstone formationMills & Studer, J Urol, 1999; DeMarco & Koch, AUA Update SeriesMills & Studer, J Urol, 1999; DeMarco & Koch, AUA Update Series, 2003, 2003

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MalabsorptionMalabsorption

Metabolic: Removed BowelMetabolic: Removed Bowel

Resection of ileocecal valve: Resection of ileocecal valve: Decreased transit timeDecreased transit timeIncreased wet weight of stoolIncreased wet weight of stooldiarrheadiarrhea

Resection of colon segment:Resection of colon segment:Right colon important for storage of stoolRight colon important for storage of stool

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Metabolic AcidosisMetabolic Acidosis

Hyperchloremic acidosis Hyperchloremic acidosis Ileal conduit: 10Ileal conduit: 10--15%15%Continent diversion: 50%Continent diversion: 50%Ureterosigmoidostomy: Ureterosigmoidostomy: 80%80%Treatment: Treatment:

oral sodium bicarbonateoral sodium bicarbonatesodium citratesodium citratepotassium citratepotassium citrate

Mills & Studer, J Urol, 1999. Mills & Studer, J Urol, 1999.

Metabolic: Interposed BowelMetabolic: Interposed Bowel

Bone demineralizationBone demineralizationAcidosisAcidosis

carbonate and phosphate released from bone to carbonate and phosphate released from bone to buffer hydrogen ionsbuffer hydrogen ionsAcidosis inhibits production of 1, 25Acidosis inhibits production of 1, 25--dihydroxycholecalciferoldihydroxycholecalciferolAcidosis activates osteoclast activityAcidosis activates osteoclast activityIncreased excretion of calcium in urine Increased excretion of calcium in urine

RicketsRicketsOsteomalaciaOsteomalacia

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Stone DiseaseStone Disease

Upper tract stones: Upper tract stones: Metabolic etiologyMetabolic etiologyChronic dehydration, concentrated urineChronic dehydration, concentrated urineIf large ileal resection, risk of enteric hyperoxaluria with calIf large ileal resection, risk of enteric hyperoxaluria with calcium cium oxalate stone formationoxalate stone formationHypocitraturiaHypocitraturiaHypercalciuria due to metabolic acidosis Hypercalciuria due to metabolic acidosis

Cancer riskCancer risk

Ureterosigmoidostomy:Ureterosigmoidostomy:> 200 cases of secondary malignancy reported> 200 cases of secondary malignancy reportedAge 25Age 25--30 yo: 47730 yo: 477--fold increased riskfold increased riskAge 55Age 55--60 yo: 860 yo: 8--fold increased risk over general populationfold increased risk over general populationHistology: adenoma, adenocarcinomaHistology: adenoma, adenocarcinomaFollowFollow--up starting between 3up starting between 3--5 years post5 years post--op with yearly op with yearly endoscopy, ultrasoundendoscopy, ultrasound

Austen & Kalble, J Urol, 2004

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Cancer riskCancer risk

Conduit and continent diversions:Conduit and continent diversions:Variable histologyVariable histology

Austen & Kalble, J Urol, 2004

Compliance & Access to Care Compliance & Access to Care

Conduit diversions:Conduit diversions:AppliancesAppliancesStomal nurse supportStomal nurse supportFollowFollow--upup

Continent diversions:Continent diversions:Rectal pouch:Rectal pouch:

FollowFollow--upupCatheterizable reservoir:Catheterizable reservoir:

CathetersCathetersLubricationLubricationIrrigation and frequent catheterizationIrrigation and frequent catheterizationFollowFollow--upup

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Potential Research QuestionsPotential Research Questions

Which is better in this context: Which is better in this context: Conduit, Conduit, rectal reservoir, or rectal reservoir, or catheterizable reservoir?catheterizable reservoir?

Major issues:Major issues:Complications: short and longComplications: short and long--termtermCosts: FollowCosts: Follow--up and consumablesup and consumablesCultural acceptance of different diversionsCultural acceptance of different diversions

References:References:

Austen, M., Kalble, T.: Secondary malignancies in different forAusten, M., Kalble, T.: Secondary malignancies in different forms of ms of urinary diversion using isolated gut. J Urol., 172: 831, 2004.urinary diversion using isolated gut. J Urol., 172: 831, 2004.DeMarco, R.T., and Koch, M.O.: Metabolic complications of DeMarco, R.T., and Koch, M.O.: Metabolic complications of continent urinary diversion. AUA Update Series, 15, XXII, 2003.continent urinary diversion. AUA Update Series, 15, XXII, 2003.Farnham, S.B. and Cookson, M.S.: Surgical complications of Farnham, S.B. and Cookson, M.S.: Surgical complications of urinary diversion. World J Urol, 22: 157, 2004urinary diversion. World J Urol, 22: 157, 2004Mills, R.D., and Studer, U.E.: Metabolic consequences of continMills, R.D., and Studer, U.E.: Metabolic consequences of continent ent urinary diversion. J Urol., 161: 1057, 1999.urinary diversion. J Urol., 161: 1057, 1999.Nagi, G., Dublin, N., McClinton, S., NNagi, G., Dublin, N., McClinton, S., N’’Dow, J.M.O., Neal, D.E., Dow, J.M.O., Neal, D.E., Pickard, R., Yong, S.M.: Urinary diversion and bladder Pickard, R., Yong, S.M.: Urinary diversion and bladder reconstruction/replacement using intestinal segments for intractreconstruction/replacement using intestinal segments for intractable able incontinence or following cystectomy. The Cochrane Collaboratioincontinence or following cystectomy. The Cochrane Collaboration, n, Issue 3, 2005.Issue 3, 2005.