complications of urinary diversion
DESCRIPTION
Complications of Urinary Diversion. By Peter Tran, D.O. Garden City Hospital Resident Talk 12/17/2008. Overview. Classification of urinary diversions Factors influencing complications Complications according to bowel segments Metabolic/physiologic complications - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/1.jpg)
Complications of Urinary Complications of Urinary DiversionDiversion
ByPeter Tran, D.O.
Garden City HospitalResident Talk12/17/2008
![Page 2: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/2.jpg)
OverviewOverviewClassification of urinary
diversionsFactors influencing complicationsComplications according to bowel
segmentsMetabolic/physiologic
complicationsSurgical complications: early and
late
![Page 3: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/3.jpg)
Clasification of DiversionsClasification of DiversionsOrthotopicHeterotopic
◦Continent cutaneous◦Non-continent cutaneous◦Diversion to GIT
![Page 4: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/4.jpg)
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.
![Page 5: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/5.jpg)
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.
![Page 6: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/6.jpg)
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.
![Page 7: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/7.jpg)
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.
![Page 8: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/8.jpg)
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.
![Page 9: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/9.jpg)
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.
![Page 10: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/10.jpg)
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
![Page 11: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/11.jpg)
Factors Influencing Factors Influencing ComplicationsComplications
Patient factorsBowel factors
![Page 12: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/12.jpg)
Patient FactorsPatient FactorsPerformance status/co-morbiditiesPt/caregiver compliance with CICMobilityPrevious XRTRenal functionLiver functionBody habitusBMI
![Page 13: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/13.jpg)
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
![Page 14: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/14.jpg)
Gastric ComplicationsGastric ComplicationsHypochloremic, hypokalemic
metabolic alkalosisHyper-gastrinemiaHematuria-dysuria syndrome
![Page 15: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/15.jpg)
Jejunum ComplicationsJejunum ComplicationsMost severe metabolic
complicationsHyponatremiaHyperkalemic, hypochloremic
metabolic acidosisSevere dehydration
![Page 16: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/16.jpg)
Ileal ComplicationsIleal ComplicationsHyperchloremic, hypokalemic
metabolic acidosisVit B12 deficiency
![Page 17: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/17.jpg)
Colonic ComplicationsColonic ComplicationsHyperchloremic, hypokalemic
metabolic acidosis
![Page 18: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/18.jpg)
Metabolic/Physiologic Metabolic/Physiologic ComplicationsComplicationsRenal deteriorationElectrolyte disturbanceHypertensionAltered sensoriumAbnormal drug metabolismOsteomalaciaAbnormal growth/developmentVit deficiencyAnemiaChronic diarrheaHyper-gastrinemia
![Page 19: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/19.jpg)
Electrolyte DisturbanceElectrolyte Disturbance Colon/Ileum
◦ Hyperchloremic, hypokalemic metabolic acidosis Stomach
◦ Hypochloremic, hypokalemic metabolic alkalosis Jejunum
◦ Hyperchloremic, hyperkalemic, hyponatremic metabolic acidosis
Hyperammonemia Hypomagnesemia Hypocalcemia
![Page 20: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/20.jpg)
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
![Page 21: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/21.jpg)
Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic
acidosisacidosisSymptoms
◦Easy fatigability◦Anorexia/weight loss◦Polydipsia◦Lethargy◦Exacerbation of diarrhea in GI
diversions
![Page 22: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/22.jpg)
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
![Page 23: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/23.jpg)
Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic
acidosis: Treatmentacidosis: Treatment Alkalinizing agent◦ NaHCO3
◦ K-Citrate◦ Na-Citrate
Blockers of Cl transport◦ Chlorpromazine◦ Nicotinic acid
![Page 24: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/24.jpg)
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
![Page 25: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/25.jpg)
Gastric ComplicationsGastric ComplicationsSymptoms
◦Lethargy◦Weakness◦Respiratory insufficiency◦Seizures◦Ventricular arrhythmia
![Page 26: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/26.jpg)
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
![Page 27: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/27.jpg)
Gastric Complications: TxGastric Complications: TxAcute severe metabolic alkalosis
◦Empty bladder◦NaCl volume replacement◦H2 blocker◦PPI◦Arginine HCl◦Surgical removal of gastric segment
![Page 28: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/28.jpg)
Gastric Complications: TxGastric Complications: TxMild/prophylaxis
◦Oral Na/K supplementation◦H2 blockers
![Page 29: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/29.jpg)
Hypokalemia - IncidenceHypokalemia - IncidenceColonic diversions
◦30% reduction in total body KIleal diversions
◦0-15% reduction
![Page 30: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/30.jpg)
Hypokalemia: MOAHypokalemia: MOAColonic/Ileal diversions
◦Ileum may passively reabsorb some K blunting the loss
◦Chronic metabolic acidosis◦Renal K wasting
![Page 31: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/31.jpg)
HypokalemiaHypokalemiaSymptoms
◦Typically no symptoms◦At most severe
Muscle weakness Paralysis
![Page 32: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/32.jpg)
Hypokalemia: TxHypokalemia: TxCorrect the acidosis
◦Beware of acutely worsening K as in moves backto intracellular stores
◦Oral K supplementation
![Page 33: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/33.jpg)
![Page 34: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/34.jpg)
Altered Sensorium: MOAAltered Sensorium: MOAHypomagnesemiaDrug reabsorptionAmmonia encephalopathy
![Page 35: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/35.jpg)
Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia
Renal lossChronic diarrheaDecreased absorption
![Page 36: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/36.jpg)
Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia
Symptoms◦Cardiac arrhythmias◦Tremor◦Tetany◦Seizures
Treament◦Mg replacement
![Page 37: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/37.jpg)
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
![Page 38: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/38.jpg)
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
![Page 39: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/39.jpg)
Ammoniogenic Ammoniogenic Encephalopathy: SymptomsEncephalopathy: Symptoms
ApathyRestlessnessSleep disturbanceImpaired intellectual abililitesAsterixis and lethargyStuporComa
![Page 40: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/40.jpg)
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
![Page 41: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/41.jpg)
Abnormal Drug Abnormal Drug MetabolismMetabolism
Drugs absorbs in GITDrugs excreted unchanged in
urineReabsorbed in intestinal segment
![Page 42: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/42.jpg)
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
![Page 43: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/43.jpg)
OsteomalaciaOsteomalaciaPotential long-term complicationAffects children and adultsBone demineralizationMineralized component of bone is
replace with osteoid
![Page 44: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/44.jpg)
OsteomalaciaOsteomalacia Risk Factors
◦ Bowel segment used Ureterosig most commonly Colon or ileal cystoplasties Colon or ileal conduits/neobladders
◦ Renal failure Chronic untreated metabolic acidosis
![Page 45: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/45.jpg)
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
![Page 46: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/46.jpg)
OsteomalaciaOsteomalaciaSymptoms
◦Diffuse skeletal pain◦Bone tenderness◦Fractures◦Gait disturbance◦Proximal muscle weakness
![Page 47: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/47.jpg)
OsteomalaciaOsteomalaciaPrevention
◦Particularly important in postmenopausal women and children
◦Tx underlying metabolic acidosisVit CVit DActivated Vit D metabolite
◦1-alpha-hydroxycholecalciferol◦Ca supplementation
![Page 48: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/48.jpg)
Vitamin DeficiencyVitamin DeficiencyADEK – fat soluble lost in
malabsorption of fatVit B12 – absorbed in distal ileum
![Page 49: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/49.jpg)
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
![Page 50: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/50.jpg)
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
![Page 51: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/51.jpg)
Vitamin B12 Deficiency: Vitamin B12 Deficiency: LabsLabsMCV > 120Often neutropenia and
thrombocytopeniaHypersegmented neutrophilsLow serum B12 levels
![Page 52: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/52.jpg)
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
![Page 53: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/53.jpg)
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
![Page 54: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/54.jpg)
Surgical ComplicationsSurgical ComplicationsEarly
◦Wound infection◦Intra-abdominal abscess◦Pyelonephritis◦Hemorrhage◦Urine leak/fistula◦Bowel leak/fistula◦Ileus◦Bowel obstruction◦Stomal bleeding/necrosis
![Page 55: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/55.jpg)
Surgical ComplicationsSurgical ComplicationsLate
◦Wound hernia or dehiscence◦Bowel obstruction◦Ureteral stricture◦UTI/pyelo◦Urinary stones◦Renal deterioration◦Stomal stenosis/parastomal hernia◦Hematuria dysuria syndrome
![Page 56: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/56.jpg)
Stomal ComplicationsStomal ComplicationsEarly
◦Bleeding◦Necrosis
Late◦Dermatitis◦Retraction◦Prolapse◦Parastomal hernia◦Stenosis
![Page 57: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/57.jpg)
Stomal BleedingStomal BleedingEarly
◦Conservative Tx◦Most will stop with pressure/time
Late◦Liver disease due to dilated veins◦Correct coagulopathy◦Ligation◦Porto-systemic shunting
![Page 58: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/58.jpg)
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
![Page 59: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/59.jpg)
Stomal StenosisStomal StenosisIncidence
◦3-25% of ileal conduits◦10-20% of colon conduits◦Catherizable stoma – 50%
Brooke > Turnbull loop
![Page 60: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/60.jpg)
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
![Page 61: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/61.jpg)
Stomal StenosisStomal StenosisSymptoms
◦Suspect in Metabolic disturbance Infection/pyelo/sepsis Stones Renal decline
![Page 62: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/62.jpg)
Stomal StenosisStomal Stenosis Work-up
◦ Conduit residual urine◦ Loopogram
Elongation Reflux with upper tract dilation Segment stenosis
Tx◦ Requires surgical repair
![Page 63: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/63.jpg)
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
![Page 64: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/64.jpg)
Ureteroenteric StrictureUreteroenteric StrictureSymptom
◦Stones◦Back pain◦Infection/sepsis
DDx◦Ureteral stone◦TCC recurrence
![Page 65: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/65.jpg)
Ureteroenteric StrictureUreteroenteric StrictureImagingUSLoopogramCT/IVPRenogramAntegrade Nephrostogram
◦Most useful◦Diagnostic/therapeutic◦Tract for antegrade procedure
![Page 66: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/66.jpg)
Ureteroenteric StrictureUreteroenteric Stricture Tx
◦ Endoscopic Antegrade vs retrograde Balloon dilation Cold knife Laser incision
◦ Open
![Page 67: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/67.jpg)
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
![Page 68: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/68.jpg)
Ureteroenteric StrictureUreteroenteric StrictureFactors associated with failure of
endoscopic repair◦Length > 1cm◦Stricture presenting < 6 months
since surgery◦Left sided stricture
![Page 69: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/69.jpg)
Ureteroenteric Ureteroenteric AnastomosisAnastomosis
![Page 70: Complications of Urinary Diversion](https://reader035.vdocument.in/reader035/viewer/2022062309/5681501b550346895dbe019e/html5/thumbnails/70.jpg)
Ureteroenteric StrictureUreteroenteric StrictureProcedure Stricture
Colon
Leadbetter-Clarke 14%
Strickler 14%
Pagano 7%
Small Bowel
Bricker 7%
Wallace 3%
Nipple 8%
Le Duc 18%