Complications of Urinary Diversion

transcript

Complications of Urinary Complications of Urinary DiversionDiversion

ByPeter Tran, D.O.

Garden City HospitalResident Talk12/17/2008

OverviewOverviewClassification of urinary

diversionsFactors influencing complicationsComplications according to bowel

segmentsMetabolic/physiologic

complicationsSurgical complications: early and

Clasification of DiversionsClasification of DiversionsOrthotopicHeterotopic

◦Continent cutaneous◦Non-continent cutaneous◦Diversion to GIT

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.

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.

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.

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.

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.

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.

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

Factors Influencing Factors Influencing ComplicationsComplications

Patient factorsBowel factors

Patient FactorsPatient FactorsPerformance status/co-morbiditiesPt/caregiver compliance with CICMobilityPrevious XRTRenal functionLiver functionBody habitusBMI

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

Gastric ComplicationsGastric ComplicationsHypochloremic, hypokalemic

metabolic alkalosisHyper-gastrinemiaHematuria-dysuria syndrome

Jejunum ComplicationsJejunum ComplicationsMost severe metabolic

complicationsHyponatremiaHyperkalemic, hypochloremic

metabolic acidosisSevere dehydration

Ileal ComplicationsIleal ComplicationsHyperchloremic, hypokalemic

metabolic acidosisVit B12 deficiency

Colonic ComplicationsColonic ComplicationsHyperchloremic, hypokalemic

metabolic acidosis

Metabolic/Physiologic Metabolic/Physiologic ComplicationsComplicationsRenal deteriorationElectrolyte disturbanceHypertensionAltered sensoriumAbnormal drug metabolismOsteomalaciaAbnormal growth/developmentVit deficiencyAnemiaChronic diarrheaHyper-gastrinemia

Electrolyte DisturbanceElectrolyte Disturbance Colon/Ileum

◦ Hyperchloremic, hypokalemic metabolic acidosis Stomach

◦ Hypochloremic, hypokalemic metabolic alkalosis Jejunum

◦ Hyperchloremic, hyperkalemic, hyponatremic metabolic acidosis

Hyperammonemia Hypomagnesemia Hypocalcemia

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

Hyperchloremic, Hyperchloremic, hypokalemic metabolic hypokalemic metabolic

acidosisacidosisSymptoms

◦Easy fatigability◦Anorexia/weight loss◦Polydipsia◦Lethargy◦Exacerbation of diarrhea in GI

diversions

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

acidosis: Treatmentacidosis: Treatment Alkalinizing agent◦ NaHCO3

◦ K-Citrate◦ Na-Citrate

Blockers of Cl transport◦ Chlorpromazine◦ Nicotinic acid

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

Gastric ComplicationsGastric ComplicationsSymptoms

◦Lethargy◦Weakness◦Respiratory insufficiency◦Seizures◦Ventricular arrhythmia

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

Gastric Complications: TxGastric Complications: TxAcute severe metabolic alkalosis

◦Empty bladder◦NaCl volume replacement◦H2 blocker◦PPI◦Arginine HCl◦Surgical removal of gastric segment

Gastric Complications: TxGastric Complications: TxMild/prophylaxis

◦Oral Na/K supplementation◦H2 blockers

Hypokalemia - IncidenceHypokalemia - IncidenceColonic diversions

◦30% reduction in total body KIleal diversions

◦0-15% reduction

Hypokalemia: MOAHypokalemia: MOAColonic/Ileal diversions

◦Ileum may passively reabsorb some K blunting the loss

◦Chronic metabolic acidosis◦Renal K wasting

HypokalemiaHypokalemiaSymptoms

◦Typically no symptoms◦At most severe

Muscle weakness Paralysis

Hypokalemia: TxHypokalemia: TxCorrect the acidosis

◦Beware of acutely worsening K as in moves backto intracellular stores

◦Oral K supplementation

Altered Sensorium: MOAAltered Sensorium: MOAHypomagnesemiaDrug reabsorptionAmmonia encephalopathy

Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia

Renal lossChronic diarrheaDecreased absorption

Altered Sensorium: Altered Sensorium: HypomagnesemiaHypomagnesemia

Symptoms◦Cardiac arrhythmias◦Tremor◦Tetany◦Seizures

Treament◦Mg replacement

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

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

Ammoniogenic Ammoniogenic Encephalopathy: SymptomsEncephalopathy: Symptoms

ApathyRestlessnessSleep disturbanceImpaired intellectual abililitesAsterixis and lethargyStuporComa

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

Abnormal Drug Abnormal Drug MetabolismMetabolism

Drugs absorbs in GITDrugs excreted unchanged in

urineReabsorbed in intestinal segment

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

OsteomalaciaOsteomalaciaPotential long-term complicationAffects children and adultsBone demineralizationMineralized component of bone is

replace with osteoid

OsteomalaciaOsteomalacia Risk Factors

◦ Bowel segment used Ureterosig most commonly Colon or ileal cystoplasties Colon or ileal conduits/neobladders

◦ Renal failure Chronic untreated metabolic acidosis

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

OsteomalaciaOsteomalaciaSymptoms

◦Diffuse skeletal pain◦Bone tenderness◦Fractures◦Gait disturbance◦Proximal muscle weakness

OsteomalaciaOsteomalaciaPrevention

◦Particularly important in postmenopausal women and children

◦Tx underlying metabolic acidosisVit CVit DActivated Vit D metabolite

◦1-alpha-hydroxycholecalciferol◦Ca supplementation

Vitamin DeficiencyVitamin DeficiencyADEK – fat soluble lost in

malabsorption of fatVit B12 – absorbed in distal ileum

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

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

Vitamin B12 Deficiency: Vitamin B12 Deficiency: LabsLabsMCV > 120Often neutropenia and

thrombocytopeniaHypersegmented neutrophilsLow serum B12 levels

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

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

Surgical ComplicationsSurgical ComplicationsEarly

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

Surgical ComplicationsSurgical ComplicationsLate

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

Stomal ComplicationsStomal ComplicationsEarly

◦Bleeding◦Necrosis

Late◦Dermatitis◦Retraction◦Prolapse◦Parastomal hernia◦Stenosis

Stomal BleedingStomal BleedingEarly

◦Conservative Tx◦Most will stop with pressure/time

Late◦Liver disease due to dilated veins◦Correct coagulopathy◦Ligation◦Porto-systemic shunting

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

Stomal StenosisStomal StenosisIncidence

◦3-25% of ileal conduits◦10-20% of colon conduits◦Catherizable stoma – 50%

Brooke > Turnbull loop

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

Stomal StenosisStomal StenosisSymptoms

◦Suspect in Metabolic disturbance Infection/pyelo/sepsis Stones Renal decline

Stomal StenosisStomal Stenosis Work-up

◦ Conduit residual urine◦ Loopogram

Elongation Reflux with upper tract dilation Segment stenosis

Tx◦ Requires surgical repair

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

Ureteroenteric StrictureUreteroenteric StrictureSymptom

◦Stones◦Back pain◦Infection/sepsis

DDx◦Ureteral stone◦TCC recurrence

Ureteroenteric StrictureUreteroenteric StrictureImagingUSLoopogramCT/IVPRenogramAntegrade Nephrostogram

◦Most useful◦Diagnostic/therapeutic◦Tract for antegrade procedure

Ureteroenteric StrictureUreteroenteric Stricture Tx

◦ Endoscopic Antegrade vs retrograde Balloon dilation Cold knife Laser incision

◦ Open

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

Ureteroenteric StrictureUreteroenteric StrictureFactors associated with failure of

endoscopic repair◦Length > 1cm◦Stricture presenting < 6 months

since surgery◦Left sided stricture

Ureteroenteric Ureteroenteric AnastomosisAnastomosis

Ureteroenteric StrictureUreteroenteric StrictureProcedure Stricture

Leadbetter-Clarke 14%

Strickler 14%

Pagano 7%

Small Bowel

Bricker 7%

Wallace 3%

Nipple 8%

Le Duc 18%

Complications of Urinary Diversion

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