Renal function in the setting of urinary diversion

Long-term renal function in patients undergoing surgical reconstruction for tubercular cicatrized bladder

PURPOSE

We evaluated the long-term renal function in patients after surgical reconstruction for tuberculous contracted bladder (TBC) and determined factors associated with decreased renal function (RF) during follow up.

MATERIALS AND METHODS

We reviewed the records of 61 patients who underwent augmentation cystoplasty (AC) or orthotopic neobladder (ONB) for TBC between June 1994 and August 2019 in our institute. The estimated glomerular filtration rate (eGFR) was calculated preoperatively at initial presentation, before augmentation and at various intervals during follow up. Renal function decrease was defined as a defined as new-onset stage-3A Chronic kidney disease(CKD) or upstaging of pre-operative CKD stage 3A in follow-up. Multivariable analysis was done to evaluate the association of clinicopathological features and postoperative complications with decreased renal function.

RESULTS

We analyzed 39 patients who had a minimum follow-up of 1-year post reconstruction. At a median follow-up of 52 months (IQR 31-103 months), 16/39 patients developed RF decrease. In univariate analyses, initial eGFR, and associated ureteric stricture in contralateral renal unit were significantly associated with new-onset renal insufficiency (p < 0.001 each). On multivariable analysis, only initial presenting eGFR (p < 0.001) was an independent predictor of new-onset renal insufficiency. ROC cut-off levels for eGFR at presentation predicting the primary end point of RF decrease was 45 ml/min.

CONCLUSIONS

Decreased renal function is noted in most patients during long term follow-up after surgical reconstruction for TBC. After controlling for preoperative and postoperative risk factors, patients with initial presenting GFR < 45 ml/min are at greater risk of a decline in renal function following reconstruction.

Evaluation of Upper Urinary Tract Integrity After Radical Cystectomy and Orthotopic Diversion with Ileal and Sigmoid Neobladder

The study aims to evaluate the effects of orthotopic urinary diversion using ileal and sigmoid segments after radical cystectomy on upper urinary tract function and morphology. A retrospective study included 60 patients divided into 2 equal groups (W-ileal pouch group and sigmoid pouch group). We assessed renal function and morphology post-operative after 6 months and after 1 year by serum creatinine, ultrasound, IVP, pouchogram, and renal scan study. After 6 months post-operatively, in the W-ileal group, there were 16 renal units (26.6%) deteriorated in morphology and 11 renal units (18.4%) deteriorated in function. After 1 year, further deterioration in morphology was noted in 17 renal units (28.3%) and in function in 16 renal units (26.7%). In the sigmoid group, after 6 months post-operatively, there were 14 renal units (23.3%) deteriorated in morphology and 14 renal units (23.4%) deteriorated in function. After 1 year, further deterioration in morphology was noted in 47 renal units (24.4%) and in function in 18 renal units (30%). Incorporating the bowel into the urinary tract is potentially dangerous to the upper urinary tract's integrity, and the leading cause of renal impairment is uretero-pouch obstruction.

Factors Predicting Renal Function Outcome after Augmentation Cystoplasty

We determined the cause of renal deterioration after augmentation cystoplasty (AC). Twenty-nine adult patients with refractory bladder dysfunction and who underwent ileocystoplasty from 2004 to 2015 were studied. Patients with a decline in glomerular filtration rate (GFR) after augmentation were reviewed. The primary outcome was to determine the factors that might lead to deterioration of estimated GFR. Median follow-up was 7.0 ± 2.6 years. Significant bladder capacity, end filling pressure, and bladder compliance were achieved from median 114 ± 53.6 to 342.1 ± 68.3 ml (p = .0001), 68.5 ± 19.9 to 28.2 ± 6.9 cm H₂O (p = .0001), and 3.0 ± 2.1 to 12.8 ± 3.9 (p = .0001), respectively. Renal function remained stable and improved in 22 (76%) patients from median eGFR 135 ± 81.98 to 142.82 ± 94.4 ml/min/1.73 m² (p = .160). Significant deterioration was found in 7 (24%) patients from median eGFR 68.25 ± 42 to 36.57 ± 35.33 (p = .001). The causes of renal deterioration were noncompliance to self-catheterization (2 patients), posterior urethral valve/dysplastic kidneys (2 patients), and reflux/infection (2 patients). On multivariate analysis, recurrent pyelonephritis (OR 3.87, p = 0.0155) and noncompliance (OR 30.78, p = 0.0156) were significant. We concluded that AC is not the cause of progression to end-stage renal disease in patients with renal insufficiency.

Patients with an Orthotopic Low Pressure Bladder Substitute Enjoy Long-Term Good Function

PURPOSE

Orthotopic bladder substitution has been performed on a regular basis for more than 30 years and yet data on long-term functional outcomes are still lacking.

MATERIALS AND METHODS

We evaluated 181 men and 19 women who underwent radical cystectomy and urinary diversion with ileal orthotopic bladder substitution from 1985 to 2004 and who had 10 years or more of followup.

RESULTS

Median age at radical cystectomy was 63 years (IQR 57-69). Median followup was 167 months (IQR 137-206). Daytime and nighttime continence rates peaked 24 months postoperatively and decreased slightly thereafter during almost 2 decades. At 10, 15 and 20 years daytime continence rates were 92%, 90% and 79%, and nighttime continence rates were 70%, 65% and 55%, respectively. During the day and at night fewer than 3% and 10% of patients, respectively, had urine loss 100 ml or greater at any time 10 years or longer after surgery. At 10 and 20 years 11 of 200 patients (6%) and 1 of 29 (3%), respectively, had to perform clean intermittent self-catheterization. After an initial postoperative decrease in the estimated glomerular filtration rate the subsequent decrease was less than 1 ml/minute/1.73 m(2) per year. A total of 81 complications were observed in 42 of the 200 patients (21%) 10 years or longer after radical cystectomy with pyelonephritis as the most frequent cause.

CONCLUSIONS

Patients who survive up to 20 years after radical cystectomy and diversion with an ileal orthotopic bladder substitution may enjoy satisfactory urinary continence and retain the ability to void spontaneously while experiencing no more than a physiological decrease in renal function.

Renal function evaluation in patients undergoing orthotopic bladder substitution: a systematic review of literature

Renal function (RFn) after orthotopic bladder substitution (OBS) is a critical point to be assessed. We performed a systematic review of MEDLINE for full length peer reviewed English articles from the year 2000 till January 2013. We included only original articles and excluded reviews, editorials and replies and abstracts presented in conferences. The outcome is formulated in research questions; what is the status of RFn after OBS? Which is better, the direct free-refluxing or anti-refluxing ureteroileal anastomosis (UIA) techniques? Studies reporting RFn as secondary outcome were also reported. A total of 129 publications were reviewed for full text and only 41 were included in this review. All studies were of low level of evidence and grade of recommendations. Only 3 randomized controlled trials were included and were of poor quality. Renal function after OBS was poorly described in the literature with no universal definition about RFn deterioration or outcome with no consensus on the best evaluation method. Urinary obstruction, chemotherapy and pyelonephritis appeared significant factors but with insufficient evidence. There is a universal trend to use the free refluxing technique for UIA to avoid complications of anti-refluxing techniques. However, the anti-reflux technique proved acceptable outcome in experienced hands. There is marked heterogeneity and underestimation of RFn evaluation among reported outcomes after OBS with most publications reporting the incidence of UIA and pyelonephritis with paucity reporting absolute figures about RFn measurements. In conclusion, urinary tract obstruction remains the main factor of RFn deterioration after OBS. Methods evaluating RFn, definitions of RFn outcome and factors predicting it are poorly studied in the literature and the current evidence is relatively weak to draw solid conclusions. Further well-designed studies and consensus about method of assessment and definitions of RFn are warranted.

Urinary diversion: long-term functional aspects

Functional aspects and quality of life (QOL) of patients with a urinary diversion (UD) represent important issues in Urology. Any form of UD has its specific problems. In experienced hands and with regular long-term follow-up, serious complications can be avoided and excellent long-term results can be achieved. Thus, the selection of an appropriate UD is critical to patient's long-term satisfaction. Patients must be fully counseled in all types of UD and should have ready access to all options. There are 3 kinds of factors to be considered in the selection of UD: patient, physician, and general factors. In the pre-operative counseling, it is mandatory to explain all factors that over time may contribute to affect the patient's urinary tract function and QOL, mainly linked to long-term complications of UD. One of the most important requirements for any bladder substitution is that it should not jeopardize the renal function. There are many urological and non-urological potential reasons for deterioration in renal function following UD. Continence results after neobladder (NB) are difficult to compare between series published in the literature because of a lack of consensus of definitions, varied follow-up periods, and different mechanisms of data collection. In up to 22% of patients with NB, significant residual urine volumes were observed. The overall patients' QOL reported in most articles was good, irrespective of the type of UD. QOL of patients with a well functioning NB seems to be significantly better than other forms of diversion. Well-designed randomized prospective trials are warranted to render definitive conclusions.

Effect of ureterointestinal anastomosis on renal function and morbidity in intestinal urinary diversion

OBJECTIVE

The authors previously successfully applied the "flap-and-trough" (FT) method of antireflux ureterointestinal anastomosis (UIA) in a pilot set of 81 patients. This randomized prospective trial tested the effectiveness of this method in protecting the upper urinary tract from obstruction, reflux and infections.

MATERIAL AND METHODS

Forty-nine patients indicated for cystectomy and intestinal urinary diversion were randomly split into two groups, A and B. The FT antireflux UIA was applied in group A (n = 20), and refluxing direct elliptical UIA in group B (n = 29). Both groups were divided into two subcategories according to the type of diversion used: Ar (n = 10) and Br (n = 16) with low-pressure reservoirs and Ac (n = 10) and Bc (n = 13) with conduits. The follow-up evaluation compared the groups regarding perioperative complications, antireflux efficiency of FT, occurrence of obstruction and urinary infection, kidney morphology and glomerular filtration rate.

RESULTS

During the follow-up period (median 31 months), the obstruction occurred only in group Br (insignificant difference compared to Ar). A significant decrease in glomerular filtration rate and shortening of the left kidney occurred in group Br during the period and in comparison with Ar. There were no other considerable divergences in other studied parameters.

CONCLUSIONS

The antireflux FT anastomosis represents a low risk for stenosis. The reduced occurrence of obstructive complications in comparison with direct UIA was statistically insignificant. Its construction did not increase the frequency of complications; on the contrary, it guarantees a better protection of renal morphology and function.

Key considerations of intermittent catheterisation

Intermittent catheterisation provides a safe and effective alternative to indwelling catheterisation for patients who require bladder drainage. It can be undertaken by health professionals in a variety of clinical settings for a range of clinical indications, and increasingly by patients themselves who use it as a long-term bladder management technique. The relative simplicity of the technique comes with the potential for health professionals to underestimate the skills required when considering a regimen of intermittent catheterisation and, perhaps more importantly, to underestimate the impact it may have on individual patients. The aim of this article is to consider intermittent catheterisation, its indications as a bladder management technique, and the potential psychological impact it may have on the patient, as well as how this may influence concordance.

Clinical experience in a modified Roux-Y-shaped sigmoid neobladder: assessment of complications and voiding patterns in 43 patients

OBJECTIVE

To evaluate the complications and urinary voiding patterns in patients with a new Roux-Y-shaped continent neobladder, using a modified sigmoid pouch.

PATIENTS AND METHODS

Between June 2003 and July 2008, 43 patients (26 men and 17 women, mean age 69.5 years) underwent a modified Roux-Y-shaped sigmoid continent neobladder reconstruction after radical cystectomy. The surgical procedures involved the construction of a Roux-Y-shaped sigmoid pouch, making an antifeces-refluxing valve into the sigmoid urine reservoir and ureterosigmoidostomy using the Leadbetter method. This pouch method has not been described before. The patients' clinical, biochemical, radiological and urodynamic variables were assessed.

RESULTS

During the mean (range) follow-up of 24 (6-65) months, there were no deaths related to the procedure. In 16% of the patients, early complications occurred, whereas 12% had late complications. There were no cases with local recurrence and metastasis. Routine electrolyte evaluation revealed a slight metabolic acidosis in six patients (14%). Hypovitaminosis B(12) did not occur in any patients. All patients were continent in the daytime and night-time continence was poor in eight patients (19%). The mean (sd, range) neobladder capacity and residual urine volume was 330 (110, 120-410) mL and 48 (26, 25-80) mL, respectively. Moreover, the maximum urinary flow rate was 9.2-25.3 mL/s.

CONCLUSION

The modified Roux-Y-shaped sigmoid neobladder replacement provides a new simple surgical procedure with low complication rates. The procedure offers comparatively satisfactory daytime continence with low postvoid residual urine volumes and voiding patterns. This technique is a valid alternative to continent urinary diversion.

Does reflux in orthotopic diversion matter? A randomized prospective comparison of the Studer and T-pouch ileal neobladders

PURPOSE

Orthotopic neobladder reconstruction has become a standard form of urinary diversion in many centers for patients undergoing radical cystectomy for bladder cancer. There is still controversy about the best technique for construction of the neobladder, and especially whether it is necessary to include an antireflux mechanism.

METHODS

We designed a prospective randomized clinical trial comparing two forms of ileal neobladder: the Studer pouch and the T-pouch. The latter includes an extraserosal tunneled afferent limb which prevents reflux from the pouch to the kidneys. The primary endpoint of the study is renal function and anatomy at 3 years following surgery, with secondary endpoints including early and late postoperative complications, renal infections and need for secondary procedures.

RESULTS

To date we have randomized 462 patients over approximately 6 years, with a planned full enrollment of 550 patients. Ten percent of patients have been withdrawn because they did not undergo the planned orthotopic diversion due to a positive urethral margin on frozen section. We expect approximately 70% of patients to be alive and available for follow-up at 3 years, which will give us ample power to detect clinically meaningful differences in the outcome of these two diversions.

CONCLUSION

This trial has been feasible and randomization has been acceptable to most patients. Long-term follow-up of the patients on this trial should be able to definitively answer the question of the importance of an antireflux mechanism in the orthotopic neobladders construction.

Persistent Urine Leak after Cryoablation of a Renal Tumor in a Patient with an Ileal Conduit

Thermal ablation is expanding as a technique to treat small renal masses. Damage to the collecting system is uncommon with either radiofrequency ablation or cryoablation. Early evidence suggests that cryoablation is less damaging to the urinary tract, and investigators have advocated the use of aggressive treatment in central tumors in contact with the renal hilum. The authors report a nonhealing urinary fistula after successful cryoablation of an exophytic upper pole renal mass in a patient with an ileal conduit. The presence of an ileal conduit may present an increased risk of urinary fistula after thermal ablation.

Clinical outcome of orthotopic neobladder replacement in patients with a solitary functioning kidney

OBJECTIVE

To evaluate the outcome of orthotopic neobladder creation in patients with a solitary functioning renal unit at the time of surgery.

METHODS

This study included a total of 18 patients (15 men and three women) with a solitary functioning kidney who underwent radical cystectomy for invasive bladder cancer followed by orthotopic neobladder replacement. Of these, an ileal, ileocolic or sigmoid colon neobladder was constructed in 11, three or four patients, respectively. Clinical data from these patients were retrospectively reviewed to clarify the significance of neobladder creation in patients with a solitary functioning kidney.

RESULTS

During the observation period of this series (mean, 44.2 months; range, 15-95 months), there were nine early complications in six patients (wound infection, ileus, urine leakage and pulmonary embolism in four, three, one and one, respectively) and 10 late complications in nine patients (severe metabolic acidosis, vesicourethral anastomotic stricture, ureterointestinal anastomotic stricture and neobladder calculi in six, two, one and one, respectively). Severe metabolic acidosis occurred in six (five ileal neobladders and one ileocolic neobladder); however, there were no significant differences in preoperative renal function and serum electrolytes as well as postoperative voiding function between patients with and without severe metabolic acidosis. These six patients required administration of sodium bicarbonate, and their metabolic status was normalized thereafter. Furthermore, there were no significant differences in renal function and serum electrolytes between these two groups throughout the observation period, and none of the patients demonstrated renal deterioration.

CONCLUSIONS

These findings suggest, despite the analysis including a small number of patients with a short follow-up period, orthotopic neobladder replacement could provide comparatively satisfactory results in patients with a solitary functioning kidney; hence, a solitary kidney should not be regarded as a contraindicated factor for neobladder creation after radical cystectomy.

The natural history of postoperative renal function in patients undergoing ileal conduit diversion for cancer measured using serial isotopic glomerular filtration rate and 99m technetium-mercaptoacetyltriglycine renography

PURPOSE

There is little consensus regarding long-term followup of renal function in patients who undergo urinary diversion. We established the usefulness of combined serial isotopic glomerular filtration rate measurement and diuresis renography in the early identification of patients at risk for deterioration of renal function following ileal conduit diversion.

MATERIALS AND METHODS

A total of 340 patients with ileal conduit diversion who were followed between 1990 and 2000 were identified. We analyzed data on 178 patients who had more than 4 years of followup. Renal function was assessed by serial estimation of serum creatinine, isotopic glomerular filtration rate and diuresis renographic measurements.

RESULTS

Of the patients 52 (29%) demonstrated a worsening glomerular filtration rate. Mean followup +/- SEM was 8.2 +/- 0.4 years (range 4 to 30) and 67% of patients had more than 6 years of followup. In this group we found that hypertension, recurrent urinary sepsis and an initial post-diversion glomerular filtration rate of less than 50 ml per minute per 1.73 m were prevalent risk factors. Hypertension was an independent predictor of a decreased glomerular filtration rate in this group. Of 52 patients with a deteriorating glomerular filtration rate 19 had type II or IIIb curves on followup renography, of whom 13 underwent revision surgery. Renal function subsequently stabilized or improved in this group.

CONCLUSIONS

Of patients with an ileal conduit 29% have renal function deterioration in the long term. No surgical cause for glomerular filtration rate deterioration was found in 18%. Important predisposing factors in nonobstructed cases were hypertension, recurrent urinary sepsis and a glomerular filtration rate of less than 50 ml per minute per 1.73 m. Hypertension was an independent predictor of a decreased glomerular filtration rate in the group with worsening glomerular filtration rates. In 11% of patients deterioration was due to upper tract obstruction. This was identifiable using renography and the glomerular filtration rate. A type IIIb curve was an early indicator of obstruction.

Changes in the upper urinary tract after radical cystectomy and urinary diversion: a comparison of antirefluxing and refluxing orthotopic bladder substitutes and the ileal conduit

PURPOSE

We evaluated and compared the effects of different types of urinary diversion on functional and radiographic changes in the upper urinary tract.

MATERIALS AND METHODS

We analyzed data on 275 patients who underwent radical cystectomy and urinary diversion for bladder cancer and were observed at least 12 months. Of the patients 197 received an orthotopic bladder substitute, including antirefluxing ureteral anastomoses in 111 (group 1) and refluxing ureteral anastomoses in 86 (group 2). Ileal conduits were created in 78 patients (group 3). Serial serum Cr, radiographic changes in the upper urinary tract after diversion and the number of episodes of APN were compared by diversion method. Mean followup was 52 months (range 12 to 174 months) with no difference among the groups.

RESULTS

Compared with group 3 patients in groups 1 and 2 demonstrated a significantly higher incidence of moderate to severe hydronephrosis (p = 0.001) but the incidence was similar between groups 1 and 2 (6.3%, 8.3% and 1.4% of the renal units in groups 1 to 3, respectively). Stabilized postoperative Cr did not differ among the groups. CRF, defined as Cr 3.0 mg/dl or greater, occurred in 2.7% of the patients in group 1 and in 3.5% of those in group 2 but in none in group 3. APN was noted in 3.3%, 4.4% and 0.4% of patients in groups 1 to 3, respectively (p = 0.012).

CONCLUSIONS

An ileal conduit with a lower rate of diversion related hydronephrosis, CRF and morbidity associated with APN was superior to orthotopic bladder substitutes. Between the refluxing and antirefluxing types of orthotopic bladder substitutes no significant difference in functional or radiographic changes was noted.