The effects of recreational ketamine cystitis on urinary tract reconstruction - a surgical challenge.

Abstract

To identify the rate of postoperative complications in patients who require surgical reconstruction for ketamine-induced urinary tract dysfunction and to identify any predictors for poor postoperative outcome with subsequent management strategies. A retrospective review of data collected between 2007 and 2017 of all patients with ketamine-induced urinary tract disease was performed. Evaluation included computed tomography urogram, cystoscopy, and biopsy. Indications and outcomes for surgical intervention were assessed. In all, 44 patients were identified of which 68% were male. The mean (range) age at presentation was 31 (23-55) years. All bladder biopsies confirmed an eosinophilic inflammatory infiltrate. A significant proportion of patients (81.8%) were found to have reduced cystoscopic bladder capacity of <300 mL (mean 196, range 25-550 mL). In all, 29 patients were treated conservatively with a view to symptom resolution. Two patients underwent dilatation for urethral strictures. Four patients underwent repeated intra-detrusor onabotulinum toxin injection with minimal subjective symptom relief. Two of these patients proceeded to have major reconstruction. Indications for urinary tract reconstruction included intractable symptoms, high-pressure compliance loss with renal compromise and ureteric obstruction. Patients were advised to abstain from ketamine use for a minimum of 6 months prior to consideration of surgical intervention. A total of 14 patients underwent major reconstruction. Surgical intervention included ileal conduit urinary diversion, augmentation cystoplasty with or without Mitrofanoff channels, ureteric re-implantation, and cystectomy with neobladders. Complications included anastomotic leaks, ureteric strictures, adhesional small bowel obstruction, renal failure, and sepsis. Overall, complications occurred in 10/14 patients. In a tertiary high-volume reconstructive unit, ketamine patients were at high risk of significant perioperative complications. There did not appear to be any other common factor apart from their use of ketamine, and the significant inflammatory change associated with this. We recommend meticulous preoperative evaluation and multidisciplinary consultation for all patients to determine optimal treatment strategies.