Complications Of Urinary Diversion Research Articles

#6212 SEVERE HYPERCHLOREMIC METABOLIC ACIDOSIS WITH SGLT-2 INHIBITORS IN PATIENTS WITH URINARY DIVERSION

Abstract Background and Aims Urinary diversion after cystectomy using autologous intestinal segments has been the gold standard treatment of benign and malignant diseases of urinary tract. The most frequent metabolic abnormalities is hyperchloremic metabolic acidosis, due to ammonium absorption alongside chloride gain and bicarbonate excretion in the bowel conduit. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a class of antihyperglycemic agents that recently revolutionized the paradigm of chronic kidney disease. It exerts its effect by preventing the reabsorption of filtered glucose from the tubular lumen, acting on the SGLT2 proteins in the renal proximal convoluted tubules, and thus promoting a greater urinary glucose excretion. The authors described 2 patients with bowel conduit and mild hyperchloremic metabolic acidosis, presented with severe metabolic acidosis short after starting SGLT2 inhibitors. Method Consultation of medical records. Results Case 1: 62-year-old male with an orthotopic neobladder since 2005, type 2 diabetes and nonspecific interstitial pneumonia. In 2018 arterial blood gas (ABG) was: pH 7.45, pO2 81, pCO2 28, HCO3- 19.3, Cl 107, AG 7.7 (normal albumin), K+ 3.25. In February 2022 he was sent to the emergency department (ER) from a Pneumology appointment, after an ABG showed an aggravated hyperchloremic metabolic acidosis: pH 7.25, pCO2 27.5, HCO3- 12, Cl 122, Na+ 143, K+ 3.74, AG 9, lactate 0.69, glucose 261, ketone bodies negative); blood workup added acute kidney injury (AKI), urea 81, creatinine 1.6. The patient medical history revealed: administration of 5 cycles of cyclophosphamide (7 months before) and the introduction of empagliflozin 10mg id, 10 months prior to this event, as an addition to Metformin 1000mg id. A progressive metabolic normalization was observed after the SGLT2 inhibitor was withdrawn and intravenous hydration. Case 2: A 63-year-old male with an ileal conduit since 2018 and type 2 diabetes. He had chronic renal disease since 2021 with serum creatinine 1.5-2. He presented with a 3-day history of lethargy and anorexia. He had started dapagliflozina 10mg id 10 months prior to this event. At admission the patient had normal vital signs, glasgow coma scale 15 and no major signs at observation. ABG showed severe hyperchloremic metabolic acidemia (pH 6.98, pCO2 20.5, pO2 124.4, HCO3- 4.7, Na 129, Cl 120, AG 4.3, K+ 3.54, glucose 200, lactate 0.5) alongside AKI, urea 209 and creatinine 2.8 and spot urine without ketone bodies. He was admitted for a short period to the intensive care unit, for intravenous sodium bicarbonate and hydration, on top of SGLT2 inhibitor suspension, with progressive clinical and metabolic resolution. Conclusion Chronic hyperchloremic metabolic acidosis is a frequent and known complication of urinary diversion, due to the reabsorption of solutes by the intestinal mucosa because of the presence of urine (ammonium and chloride absorption and bicarbonate excretion) and diarrhea and volume depletion due to reduced sodium absorption in the gout. Euglycemic Ketoacidosis is a well-known complication of SGLT2 Inhibitor therapy and was not this case as both patients had normal anion gap. Hyperchloremic acidosis as been rarely described but not so severe as we presented. Although both patients had AKI, was not severe. We hypothesize that SGLT2 inhibitors, could exacerbate the chronic hyperchloremic metabolic acidosis by increasing urinary sodium and glucose excretion, that could exacerbate volume depletion, diarrhea and hyperglycemia (and subsequent volume depletion). This are the first 2 cases reported of severe hyperchloremic metabolic acidosis in patients with orthotopic neobladder and SGLT2 inhibitors treatment. The physiopathology of this presentation needs to be studied.

Follow-up in superficial and metastatic bladder cancer

Concerning follow-up in bladder cancer, it must be distinguished between superficial, muscle-invasive, and metastatic tumors. In superficial bladder cancer, urethrocystoscopy is still standard for follow-up. Frequency depends on the risk classification. Even muscle-invasive carcinomas, which underwent aR0resection, will metastasize in about 30% of cases. These tumors as well as primarily metastasized cancer cannot be cured. Therefore, in these cases, one should not speak about follow-up but therapeutic control. Nonetheless, even in these cases the S3guideline recommends regular follow-up examinations because new therapeutic options can clearly improve patient survival. Possible complications of urinary diversions need consideration during follow-up.

MP58-16 RADICAL CYSTECTOMY WITH JUNIOR RESIDENTS: LONGER DAYS, EQUIVALENT OUTCOMES

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety IV (MP58)1 Sep 2021MP58-16 RADICAL CYSTECTOMY WITH JUNIOR RESIDENTS: LONGER DAYS, EQUIVALENT OUTCOMES Joshua Linscott, Randie White, Stephen Ryan, Moritz Hansen, Jesse Sammon, and Matthew Hayn Joshua LinscottJoshua Linscott More articles by this author , Randie WhiteRandie White More articles by this author , Stephen RyanStephen Ryan More articles by this author , Moritz HansenMoritz Hansen More articles by this author , Jesse SammonJesse Sammon More articles by this author , and Matthew HaynMatthew Hayn More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002088.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is known to be a highly morbid, complex, and technically challenging operation. At academic centers, the assistant is traditionally a chief or senior resident. Our institution has one urology resident per year and annually performs a total of 40-50 open or robotic radical cystectomies. This leads to junior residents (PGY2, PGY3) frequently participating as the primary assistant. Here we explore the impact of resident experience level on operative, hospital, and post-operative outcomes in RC. METHODS: A single institution, prospectively maintained database identified 159 consecutive patients who underwent open or robotic RC from 2015-2019. Resident involvement was recorded in 154 cases. Operative time, estimated blood loss (EBL), intraoperative transfusion, length of stay (LOS), in hospital complication, complications in 90d, readmission at 90d, and urinary diversion complications (eg uretero-ileal stricture) were compared between junior (PGY2 & PGY3) and senior (PGY4 & PGY5) residents. Patient demographics including age, sex, BMI, neoadjuvant chemotherapy, and ASA score were examined. Statistical analysis was performed with SPSS. RESULTS: Over a 5-year period, junior residents assisted in 53 of 154 cases (34%) where a resident was involved. The number of cases done by PGY2, PGY3, PGY4, & PGY5 residents was 6, 47, 44, and 57, respectively. The percentage of open versus robotic cases was similar. There were no differences in examined patient demographics between groups. Cases with junior residents took 29.1 min (CI 3.4-54.8, p=0.027) longer than when a senior resident was present. No other significant differences between the two groups were seen when comparing EBL, intraoperative transfusion, surgical margin status, LOS, in hospital complication, 90d complication, 90d readmission, or urinary diversion complication (Table 1). CONCLUSIONS: RC remains a challenging urologic operation demanding technical excellence. Our data suggests participation by junior residents increases the length of operation by ∼10% (29.1 min) but does not negatively impact patient outcomes. We propose this is explained by increased time required for teaching and oversight from the attending surgeon, which allows junior residents to participate in a complex surgery without increasing the risk to the patient. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e994-e994 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Linscott More articles by this author Randie White More articles by this author Stephen Ryan More articles by this author Moritz Hansen More articles by this author Jesse Sammon More articles by this author Matthew Hayn More articles by this author Expand All Advertisement Loading ...

Urinary diversions for radical cystectomy: a review of complications and their management

Radical cystectomy involves a urinary diversion, the most used being the ileal conduit and the orthotopic neobladder. This review focuses on the complications associated with these procedures, dividing them into general and diversion related complications, as well as their management. We conducted a search on PubMed and Scopus to identify eligible articles on complications of urinary diversions. Randomized controlled trials and systematic reviews with meta-analysis were preferred when available. Early complications occur in the first 90 days after surgery. The most common is post-operative ileus, followed by urinary tract infections and urinary leakage. Most complications occur in the late post-operative setting, being related to the type of urinary diversion. Some of these complications are renal failure, metabolic abnormalities, infections, urolithiasis, and ureteroenteric strictures, each with particular management options. Specific ileal conduit complications are conduit deformities and parastomal hernias. Neobladder patients can have continence problems, like incontinence or urinary retention, but also fistulas and dehiscence. Standardization of complications’ definitions and time-dependent reporting are crucial to better understand and manage these complications. Complication rates are similar between open and robot-assisted procedures and between intracorporeal and extracorporeal diversion. Radical cystectomy with urinary diversion is the most difficult surgical procedure in urology with high early and late complication rates. There is an urgent need of standardizing complication reporting to better compare different procedures.

Pelvic exenteration for primary and recurrent malignancies in urology department

Objective The objectives of present study is to investigate the safety and efficacy of pelvic exenteration (PE) for the treatment of pelvic malignancies in urology department. Methods From April 2010 to December 2014, 20 patients with primary or recurrent pelvic malignancy accepted anterior pelvic exenteration (APE) or total pelvic exenteration(TPE) surgery, including 7 males and 13 females, ranged from 35 to 87 years old with an average of 65 years old. Ten case accepted APE and 10 for TPE. The ilium conduit was done in 5 cases for APE and 6 cases for TPE as urinary diversion, cutaneous ureterostomy was done in 5 cases for APE and 4 cases for TPE as urinary diversion. There were 6 cases primary tumor in APE group and 3 primary tumors in TPE. All of the patients had 13 cases of the urinary tract tumor group, and none of the urinary tract tumor group in 7 cases. There were 4 cases received preoperative chemotherapy in the urinary tract tumor group. No case received preoperative radiotherapy. 3 cases received preoperative chemotherapy in none of the urinary tract tumor group, 3 cased received preoperative radiotherapy. After induction of general anesthesia using a laryngeal mask for airway management. All patients took the abdominal incision, then dissected lymph nodes on both sides of the iliac vessels, freed bilateral ureters to the end of the swollen bladder, separated the peritoneal space.The bilateral vas deferens was cutted and ligated, then isolated and ligated the seminal vesicles between the posterior wall of the bladder and the anterior wall of the rectum.Lateral ligaments of bladder was cuted, then cuted ligament of prostate and puboprostatic ligament, sutured and cut deep vein of penis. Urethra of apex prostate was freed and cuted. Female patients needed to free the uterus and the posterior wall, cut the cardinal ligament and round ligament of uterus, isolate the posterior wall of the uterus to the posterior vaginal wall. Rectal resection adopted Miles operation.And sigmoid colostomy was performed on the left side of the abdominal wall. The perioperative characters, pathological results and patients′ survival data were collected and analyzed. Results The average operation time for APE was 3.8 hours and 5.2 hours for TPE (P=0.173). Median length of hospital stay was 17.9 (7-47) days. The median blood loss was 300ml (80-2 500 ml) for APE and 400ml (50-6 000 ml) for TPE (P=0.909). The median follow-up time was 12.5 months (1-41months). The estimated 2-year survival rate for APE was 55.6% and 45.0% for TPE (P=0.642). Urinary system tumors group and non urinary system tumors group were analyzed and compared, The median survival time was 28 months and 13 months (P=0.538) in the two groups.The incidence of gastrointestinal complications of urinary system tumors and non-urinary system tumors was 7.7% and 28.6%, incision complications was 7.7% and 28.6%. Complications of urinary diversion only occurred in the non urologic tumor group, the incidence was 14.3%. The incidence of transfusion in two groups was 46.2% and 28.6%. Conclusions Pelvic exenteration (APE and TPE) could be a safe and reliable choice for local advanced primary and recurrent pelvic malignancy. Even for the recurrent malignancies, the survival results of the patients were satisfactory. Key words: Pelvic malignancy; Anterior pelvic exenteration; Total pelvic exenteration

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

BackgroundThe ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.MethodsFrom March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.ResultsWith a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.ConclusionsThe SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Complicaciones metabólicas y óseas de las derivaciones urinarias

Hyperchloremic metabolic acidosis is a complication of urinary diversion using ileum or colon. Its prevalence ranges from 25% and 46% depending on the procedure used and renal function of the patient. It is a consequence of intestinal fluid and electrolyte exchange between intestinal mucosa and urine. The main mechanism is absorption of ammonium and chloride from urine. Long-term chronic metabolic acidosis in these patients may lead to impaired bone metabolism and osteomalacia. Regular monitoring of pH, chlorine, bicarbonate, and calcium-phosphorus metabolism is therefore essential for early diagnosis and treatment.

Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort

Standardized methods of reporting complications after radical cystectomy (RC) and urinary diversions (UD) are necessary to evaluate the morbidity associated with this operation to evaluate the modified Clavien classification system (CCS) in grading perioperative complications of RC and UD in a real life cohort of patients with bladder cancer. A consecutive series of patients treated with RC and UD from April 2011 to March 2012 at 19 centers in Italy was evaluated. Complications were recorded according to the modified CCS. Results were presented as complication rates per grade. Univariate and binary logistic regression analysis were used for statistical analysis. 467 patients were enrolled. Median age was 70 years (range 35-89). UD consisted in orthotopic neobladder in 112 patients, ileal conduit in 217 patients and cutaneous ureterostomy in 138 patients. 415 complications were observed in 302 patients and were classified as Clavien type I (109 patients) or II (220 patients); Clavien type IIIa (45 patients), IIIb (22 patients); IV (11 patients) and V (8 patients). Patients with cutaneous ureterostomy presented a lower rate (8%) of CCS type ≥IIIa (p = 0.03). A longer operative time was an independent risk factor of CCS ≥III (OR: 1.005; CI: 1.002-1.007 per minute; p = 0.0001). In our study, RC is associated with a significant morbidity (65%) and a reduced mortality (1.7%) when compared to previous experiences. The modified CCS represents an easily applicable tool to classify the complications of RC and UD in a more objective and detailed way.

P016 Complications of urinary diversion after radical cystoprostatectomy

P016 Complications of urinary diversion after radical cystoprostatectomy

Multiple Stones in Atypical Heterotopic Reservoir in a Patient with Renal Transplant: Endourologic Resolution

Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity. Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence. We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones. preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted. No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported. In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Ileal Conduit and Continent Ileocecal Pouch for Patients Undergoing Pelvic Exenteration: Comparison of Complications and Quality of Life

Objectives:Creating a continent urinary pouch has become an alternative to the ileal conduit for patients undergoing exenteration for advanced gynecologic malignancies. The objective of this study was to compare clinical outcomes for the 2 methods.Methods:In this retrospective study, we compared intraoperative and postoperative complications and quality-of-life scores for the modified ileocecal pouch and the ileal conduit in anterior or total pelvic exenteration.Results:In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes compared to an IC (IC, 453 minutes vs IP, 550 minutes;P= 0.009). Overall complication rates were similar, but patients with an IP had significantly more complications of urinary diversion (48%) than patients with an IC (31%;P= 0.03). Follow-up showed urinary loss and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal complications (n = 2) and treatment of bladderstones were necessary more frequently (n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire was similar in both groups.Conclusion:A continent IP is an alternative to the IC in cases of pelvic exenteration. Early complications are more frequent with an IP than with an IC. The mode of urinary diversion has little influence on the quality of life in patients with advanced genital cancer.

Ethical aspects of urinary diversion for women with irreparable obstetric fistulas in developing countries: response to comments by Morgan and Husain

Dear Editor, We thank Drs. Morgan and Husain for their interest in our paper [1] and we are pleased to offer a few comments in reply. Drs Morgan and Husain [2] seem to hold the mistaken impression that we are opposed to urinary diversion in all cases in which women are incontinent due to an obstetric fistula. This is certainly not true, as any fair reading of our paper will disclose. If, after a careful consideration of the issues involved, Miriam had decided that she wanted to undergo a diversion operation, it would have been arranged for her. The process of ethical deliberation is sometimes described as “determining what ought to be done, all things considered.” We hope that Drs. Morgan and Husain are insightful and honest enough as surgeons to recognize that not every operation goes as planned, that complications can arise unexpectedly, and that major operations performed under marginal conditions—especially by surgeons who have limited experience with the procedures they are undertaking—may not end well. We say this without casting any aspersions on their own surgical talents, assuming they understand that urinary diversions in Africa have been performed by surgeons other than themselves and that not all of those operations have been successful. Some patients have died from these procedures. Our article presents a series of questions that we believe ought to be answered before one proceeds with urinary diversion in a patient with an obstetric fistula: (1) Is the fistula reparable using another operative technique – and if so, what is the likelihood of success given the risk–benefit ratio in each case? (2) Are there contraindications to a urinary diversion? (3) Can the proposed operation be carried out safely under local circumstances with the resources available? (4) Can the patient receive appropriate post-operative care, both acutely and – in view of the known complications of urinary diversion – over the long term? (5) Does the patient understand the operation and its potential consequences, in terms of both her immediate surgical risk and the long-term consequences that may ensue? We are pretty sure that there is a broad surgical consensus that holds it would be unacceptable to carry out a urinary diversion in the USA unless these questions could be answered satisfactorily. We do not understand why Drs. Morgan and Husain seem uncomfortable with these questions: to us they seem like routine matters of basic surgical ethics. African women with obstetric fistulas are overwhelmingly poor, largely uneducated, culturally stigmatized, and politically powerless in the societies in which they live. They are a classic example of a “vulnerable patient population” at risk of being abused or exploited by others as a result of their marginalized status. We remain adamant Int Urogynecol J (2009) 20:613–614 DOI 10.1007/s00192-008-0799-0

Aspects métaboliques de l'usage de l'intestin en urologie

Urinary diversion, pouches and orthotopic bladder replacement have been made possible by the use of bowel segments in urologic surgery. The most important complications at short and long-term are metabolic disorders due to the permanent contact of urine with the bowel segment or the exclusion of this segment from bowel continuity. Metabolic acid-base problems occur immediately after the derivation beginning and depend on the renal capacity to compensating. The metabolic disorder due to the exclusion of a bowel segment appears generally years later, after complete depletion of physiologic reserves (vitamin B12). Perfect knowledge of early and late metabolic complications of urinary diversion allows a more accurate indication, a more adequate selection of the derivation type, an improved patient followup, and better long-term results. Metabolic complications constitute the best selection criteria for urinary diversion; subsequently, only a few techniques are likely to persist in the future.

Bowel Preparation Versus No Preparation Before Ileal Urinary Diversion

To compare the outcome and complications of urinary diversion using ileum, with and without bowel preparation. Recent studies have questioned the necessity of bowel preparation, especially for urinary diversion when ileum is used. In this clinical trial, 30 candidates for urinary diversion underwent a 3-day standard bowel preparation (group 1), and 32 were admitted 24 hours before surgery and received only a soft diet, with no oral intake, 8 hours before surgery (group 2). They were followed up for at least 6 months and were evaluated for outcome and surgical complications. All surgical operations were performed successfully using ileum. Postoperative complications were documented in 2 and 4 patients in groups 1 and 2, respectively (relative risk 0.69, 95% confidence interval 0.37 to 1.31, P = 0.41). Anastomotic leak, enterocutaneous fistula, and wound infection and dehiscence occurred in 1 patient in group 1, leading to reoperation. One case of ileus was also seen in group 1. In group 2, wound infection and dehiscence occurred 2 in patients and ileus in 2 others. This study failed to demonstrate any advantage of bowel preparation for urinary diversion when we use the ileal segment. Furthermore, a meticulous use of ileum can be done without the need for a colon segment in bladder substitution procedures.

MP-07.03: Randomized clinical trial of bowel preparation versus no preparation before ileal urinary diversion

Recent studies have questioned bowel preparation, especially for urinary diversion when ileum is used. Our aim was to compare the outcome and complications of urinary diversion with ileum, with and without bowel preparation.

Surgical Complications of Urinary Diversion

Surgical Complications of Urinary Diversion

Complications of urinary diversion after pelvic exenteration for gynecological malignancy.

A series of 21 patients who underwent pelvic exenteration for local advanced or recurrent gynecological malignancies and urinary diversions was retrospectively reviewed. The major disease process was carcinoma of the cervix. Early complications included sepsis with wound infection and dehiscence in 4 patients, intestinal insuffency in 2 patients, 4 urinary fistulas and 3 ureteral obstructions. Six patients had a late urinary complication of stenosis of the ureterointestinal anastomosis; stones in the urinary reservoir and pyelonephritis were also noted. Factors responsible for these complications are identified and discussed with a view to reducing the morbidity related to urinary diversion in such patients.

Metabolic Complications of Urinary Diversions: An Overview

Patients with urinary diversions present unique challenges to internists who have an important role in their long-term management. Advances in surgical techniques over the past 30 years have given rise to a number of urinary diversion procedures that use various intestinal segments. In its normal function, the intestine absorbs water and solutes. When placed in contact with the urinary stream, the intestine can create numerous metabolic abnormalities. These include bone disease, hepatobiliary disease, infection, malignancy, neurologic complications, nutritional deficiencies, and a number of electrolyte and acid-base disorders. An overview of these metabolic abnormalities and their causes is provided, as well as recommendations for screening and management of patients.

Routine stentograms are not necessary before stent removal following radical cystectomy.

Although ureteral stents have significantly reduced perioperative complications of urinary diversion, there is no universal agreement regarding their postoperative management. As part of an effort to eliminate unnecessary studies and hospital costs for radical cystectomy, we recently reviewed our experience with postoperative radiological stent studies to determine their clinical use and cost. A retrospective examination of medical records and radiographic studies was performed for 96 patients undergoing cystectomy and urinary reconstruction between 1989 and 1996. All patients were stented at the time of surgery. Of the patients 51 underwent bilateral retrograde "stentograms" performed under fluoroscopic guidance before stent removal to evaluate for obstruction or urine leak as dictated by the preference of the primary surgeon in each case. A total of 41 evaluable patients did not undergo stentograms. In this study 102 stent injections were performed on 51 patients before stent removal. No patients were found to have ureteral obstruction at the ureterointestinal anastomosis, while 1 (0.98%) had a clinically silent anastomotic leak that healed with conservative measures. Complications directly attributable to the stent studies, including episodes of urosepsis, were noted in 9 patients (17.6%). Nine additional leaks were diagnosed in this cohort by other means. Half of all leaks were evident clinically and 60% of this group required further invasive procedures. All clinically silent leaks healed with conservative measures. Of 41 evaluable patients who did not undergo stentograms leak following stent removal developed in only 2 and both healed with conservative measures. The additional cost of detecting a single anastomotic leak with routine stentograms is estimated to be $58,000. Routine evaluation of the ureterointestinal anastomosis with stentograms before stent removal is unnecessary, costly and may in fact increase patient morbidity.

Urinary Diversion

After a total cystectomy, urine can be diverted by means of a cutaneous ureterostomy, an intestinal conduit diversion, or a continent diversion. Intestinal conduit diversions use segments of the stomach, jejunum, and, most commonly, the ileum or colon and a refluxing or nonrefluxing anastomosis. Continent diversions include ortho topic voiding pouches and continent catheterization pouches. Complications of urinary diversion may be technical, metabolic, nutritional, or carcinogenic. Surgical techniques for bladder reconstruction continue to improve, as does understanding of the physiologic effects of such surgery.