Complications of Urinary Diversion

1
Complications of Urinary Diversion

• By
• Peter Tran, D.O.
• Garden City Hospital
• Resident Talk
• 12/17/2008

2
Overview

• Classification of urinary diversions
• Factors influencing complications
• Complications according to bowel segments
• Metabolic/physiologic complications
• Surgical complications early and late

3
Clasification of Diversions

• Orthotopic
• Heterotopic
• Continent cutaneous
• Non-continent cutaneous
• Diversion to GIT

4
Examples of Orthotopic Neobladders
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.
5
Examples of Orthotopic Neobladders
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.
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Examples of Orthotopic Neobladders
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.
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Examples of Orthotopic Neobladders
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.
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Examples of Orthotopic Neobladders
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.
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Examples of Orthotopic Neobladders
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.
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Examples of Heterotopic Cutaneous 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

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Factors Influencing Complications

• Patient factors
• Bowel factors

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Patient Factors

• Performance status/co-morbidities
• Pt/caregiver compliance with CIC
• Mobility
• Previous XRT
• Renal function
• Liver function
• Body habitus
• BMI

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Bowel Factors/Technical Factors

• Type of intestinal segment used
• Length of intestinal segment
• Continent vs. incontinent
• Method/extend of detubularization
• Capacity
• Compliance
• Refluxing/non-refluxing uretero-enteric
  anastomosis
• Type of diversion chosen

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Gastric Complications

• Hypochloremic, hypokalemic metabolic alkalosis
• Hyper-gastrinemia
• Hematuria-dysuria syndrome

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Jejunum Complications

• Most severe metabolic complications
• Hyponatremia
• Hyperkalemic, hypochloremic metabolic acidosis
• Severe dehydration

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Ileal Complications

• Hyperchloremic, hypokalemic metabolic acidosis
• Vit B12 deficiency

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Colonic Complications

• Hyperchloremic, hypokalemic metabolic acidosis

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Metabolic/Physiologic Complications

• Renal deterioration
• Electrolyte disturbance
• Hypertension
• Altered sensorium
• Abnormal drug metabolism
• Osteomalacia
• Abnormal growth/development
• Vit deficiency
• Anemia
• Chronic diarrhea
• Hyper-gastrinemia

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Electrolyte Disturbance

• Colon/Ileum
• Hyperchloremic, hypokalemic metabolic acidosis
• Stomach
• Hypochloremic, hypokalemic metabolic alkalosis
• Jejunum
• Hyperchloremic, hyperkalemic, hyponatremic
  metabolic acidosis
• Hyperammonemia
• Hypomagnesemia
• Hypocalcemia

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Colon and Ileum

• Hyperchloremic, 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

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Hyperchloremic, hypokalemic metabolic acidosis

• Symptoms
• Easy fatigability
• Anorexia/weight loss
• Polydipsia
• Lethargy
• Exacerbation of diarrhea in GI diversions

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Hyperchloremic, hypokalemic metabolic acidosis
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

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Hyperchloremic, hypokalemic metabolic acidosis
Treatment

• Alkalinizing agent
• NaHCO3
• K-Citrate
• Na-Citrate
• Blockers of Cl transport
• Chlorpromazine
• Nicotinic acid

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Gastric 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

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Gastric Complications

• Symptoms
• Lethargy
• Weakness
• Respiratory insufficiency
• Seizures
• Ventricular arrhythmia

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Gastric Complications MOA

• H, K, and Cl- loss in gastric segment
• Net addition of HCO3
• Serum gastrin levels correlate with systemic HCO3
  concentration

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Gastric Complications Tx

• Acute severe metabolic alkalosis
• Empty bladder
• NaCl volume replacement
• H2 blocker
• PPI
• Arginine HCl
• Surgical removal of gastric segment

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Gastric Complications Tx

• Mild/prophylaxis
• Oral Na/K supplementation
• H2 blockers

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Hypokalemia - Incidence

• Colonic diversions
• 30 reduction in total body K
• Ileal diversions
• 0-15 reduction

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Hypokalemia MOA

• Colonic/Ileal diversions
• Ileum may passively reabsorb some K blunting the
  loss
• Chronic metabolic acidosis
• Renal K wasting

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Hypokalemia

• Symptoms
• Typically no symptoms
• At most severe
• Muscle weakness
• Paralysis

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Hypokalemia Tx

• Correct the acidosis
• Beware of acutely worsening K as in moves backto
  intracellular stores
• Oral K supplementation

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Altered Sensorium MOA

• Hypomagnesemia
• Drug reabsorption
• Ammonia encephalopathy

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Altered Sensorium Hypomagnesemia

• Renal loss
• Chronic diarrhea
• Decreased absorption

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Altered Sensorium Hypomagnesemia

• Symptoms
• Cardiac arrhythmias
• Tremor
• Tetany
• Seizures
• Treament
• Mg replacement

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Ammoniogenic Encephalopathy

• Ammonium secreted by the kidney
• Ammonia is produced by urease splitting bacteria
• Reabsorbed and transferred to liver by portal
  circulation
• Nomally liver copes and coverts ammonia to urea

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Ammoniogenic Encephalopathy

• Risk Factors
• Typically in pre-existing or acquired liver
  disease
• UreterosigmoidostomygtColon 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

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Ammoniogenic Encephalopathy Symptoms

• Apathy
• Restlessness
• Sleep disturbance
• Impaired intellectual abililites
• Asterixis and lethargy
• Stupor
• Coma

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Ammoniogenic Encephalopathy 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

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Abnormal Drug Metabolism

• Drugs absorbs in GIT
• Drugs excreted unchanged in urine
• Reabsorbed in intestinal segment

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Abnormal Drug Metabolism

• 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

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Osteomalacia

• Potential long-term complication
• Affects children and adults
• Bone demineralization
• Mineralized component of bone is replace with
  osteoid

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Osteomalacia

• Risk Factors
• Bowel segment used
• Ureterosig most commonly
• Colon or ileal cystoplasties
• Colon or ileal conduits/neobladders
• Renal failure
• Chronic untreated metabolic acidosis

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Osteomalacia 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

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Osteomalacia

• Symptoms
• Diffuse skeletal pain
• Bone tenderness
• Fractures
• Gait disturbance
• Proximal muscle weakness

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Osteomalacia

• Prevention
• Particularly important in postmenopausal women
  and children
• Tx underlying metabolic acidosis
• Vit C
• Vit D
• Activated Vit D metabolite
• 1-alpha-hydroxycholecalciferol
• Ca supplementation

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Vitamin Deficiency

• ADEK fat soluble lost in malabsorption of fat
• Vit B12 absorbed in distal ileum

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Vitamin B12 Deficiency Etiology

• Not synthesized by mammals only dietary source
• B12 released from food by enzymes in stomach
• Bound to IF in duodenum
• Absorbed in terminal ileum
• Stored mainly in liver
• Total body stores of 2-5mg, loss of 0.1 daily
• Takes 2-4 years for defeciency to take effect
• 3-20 incidence after terminal ileum resection

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Vitamin B12 Deficiency Symptoms

• Neurologic
• Peripheral neuropathy
• Degenerative changes/demyelination in spinal cord
• Voiding dysfunction
• Optic neuropathy
• Hematologic
• Megaloblastic anemia
• Inflammation of tongue/mouth
• Psychiatric disturbances

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Vitamin B12 Deficiency Labs

• MCV gt 120
• Often neutropenia and thrombocytopenia
• Hypersegmented neutrophils
• Low serum B12 levels

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Vitamin B12 Deficiency Bowel Segment

• Continent diversion increased risk
• Larger bowel segment used
• TI/IC junction resection
• Resection of gt 50cm appears to be a major risk
  factor

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Vitamin B12 Deficiency Tx

• Prevention
• Replace with 100ug cobalamin IM monthly starting
  1 year after surgery if gt 50cm ileum resected
• Treatment
• Neurologic symptoms may precede other
• Treat if the least bit concered
• Treat if lab values are abnormal but asymptomatic

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Surgical Complications

• Early
• Wound infection
• Intra-abdominal abscess
• Pyelonephritis
• Hemorrhage
• Urine leak/fistula
• Bowel leak/fistula
• Ileus
• Bowel obstruction
• Stomal bleeding/necrosis

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Surgical Complications

• Late
• Wound hernia or dehiscence
• Bowel obstruction
• Ureteral stricture
• UTI/pyelo
• Urinary stones
• Renal deterioration
• Stomal stenosis/parastomal hernia
• Hematuria dysuria syndrome

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Stomal Complications

• Early
• Bleeding
• Necrosis
• Late
• Dermatitis
• Retraction
• Prolapse
• Parastomal hernia
• Stenosis

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Stomal Bleeding

• Early
• Conservative Tx
• Most will stop with pressure/time
• Late
• Liver disease due to dilated veins
• Correct coagulopathy
• Ligation
• Porto-systemic shunting

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Parastomal Hernia

• Incidence
• 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

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Stomal Stenosis

• Incidence
• 3-25 of ileal conduits
• 10-20 of colon conduits
• Catherizable stoma 50
• Brooke gt Turnbull loop

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Stomal Stenosis

• Risk Factors
• Catherizable gt end gt loop
• Technical
• Protruding better and flushed for non-continent
• Insufficient fascial opening
• Muscle spasm
• Ischemia
• Infection
• Poor stomal hygiene
• Poor fitting appliance

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Stomal Stenosis

• Symptoms
• Suspect in
• Metabolic disturbance
• Infection/pyelo/sepsis
• Stones
• Renal decline

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Stomal Stenosis

• Work-up
• Conduit residual urine
• Loopogram
• Elongation
• Reflux with upper tract dilation
• Segment stenosis
• Tx
• Requires surgical repair

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Ureteroenteric 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

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Ureteroenteric Stricture

• Symptom
• Stones
• Back pain
• Infection/sepsis
• DDx
• Ureteral stone
• TCC recurrence

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Ureteroenteric Stricture

• Imaging
• US
• Loopogram
• CT/IVP
• Renogram
• Antegrade Nephrostogram
• Most useful
• Diagnostic/therapeutic
• Tract for antegrade procedure

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Ureteroenteric Stricture

• Tx
• Endoscopic
• Antegrade vs retrograde
• Balloon dilation
• Cold knife
• Laser incision
• Open

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Ureteroenteric Stricture

• Advantages 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

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Ureteroenteric Stricture

• Factors associated with failure of endoscopic
  repair
• Length gt 1cm
• Stricture presenting lt 6 months since surgery
• Left sided stricture

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Ureteroenteric Anastomosis
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Ureteroenteric Stricture
Procedure Stricture
Colon
Leadbetter-Clarke 14
Strickler 14
Pagano 7
Small Bowel
Bricker 7
Wallace 3
Nipple 8
Le Duc 18