Mucus production after transposition of intestinal segments into the urinary tract

Characteristics of Urinary Tract Infections and the Use of Cranberry Products in Patients With Urinary Diversions: A Narrative Review

PURPOSE

The aim of this narrative literature review was to summarize evidence regarding bacteriuria and urinary tract infections (UTIs) in patients living with a urinary diversion and the use of cranberry products for the prevention of these infections.

METHODS

We searched for articles in the English language and available in full text to address the role of cranberry products in the management of UTIs in those with urinary diversions. We searched the electronic databases of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials between January 2003 and December 2023. Thirty-two elements were read in full and 9 elements that evaluated UTIs and/or the role of cranberries in preventing UTIs are included in this narrative review.

RESULTS

Research indicates no significant difference in UTI rates, microbiology, or antibiotic sensitivity and resistance patterns between the different types of urinary diversions (orthoptic diversions, ileal conduit diversions, and continent cutaneous diversions). Similar to persons with an intact urinary tract, Escherichia coli (a prevalent coliform bacteria) was the most prevalent pathogen resulting in symptomatic UTIs. In addition, we found that E. coli strains persisted in urinary diversions involving reconstructed intestinal segments for prolonged periods of time despite antibiotic treatment. We found sparse evidence suggesting that cranberry products are effective for the prevention of UTIs after ileal conduit urinary diversion.

CONCLUSIONS

There are inconsistencies in the definition of bacteriuria in the literature making it difficult to compare findings among the studies. Clinical guidance discussing the optimal method for obtaining a urine specimen from a urinary diversion and its management is limited. Research studies on the use of cranberry products to treat UTIs in persons living with a urinary diversion are urgently needed.

Long-term complications arising from bowel interposition in the urinary tract

After radical cystectomy or pathologies affecting the ureter(s), bowel segments can be employed to restore the natural urine flow or to create an external urinary diversion. Nevertheless, the interposition of bowel segments in the urinary tract is not devoid of complications. In fact, bowel's microstructure differs from the urothelium; specifically its mucosa is aimed at reabsorption, rather than storage. The aim of this paper is to revise the pathophysiology of complications related to bowel's mucosal properties. Those are: metabolic imbalance, malabsorption of vitamins, cholelitiasis, nephrolitiasis and infections. Their entity varies according to the segment used and to its length, which reflects the surface in contact with urine. Mostly, they occur on the long-term, but metabolic imbalances might occur soon after surgery as well.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Efficacy of Long-Acting Octreotide on Reducing Mucus Production in Patients With Ileal Neobladder

PURPOSE

To evaluate the efficacy of long-acting-release octreotide (trade name Sandostatin) on decreasing mucus secretion, thus reducing catheter obstruction after radical cystectomy and orthotopic reconstruction.

PATIENTS AND METHODS

In this double-blind, placebo-controlled study, we treated 73 cases of radical cystectomy between the years 2008 and 2014; 65 were deemed eligible for the study. Cases were randomly divided into 2 groups. Group A (n = 32) received 2 doses of 20 mg intramuscular long-acting-release octreotide 4 weeks before and on the day of surgery, while group B (n = 33) received placebo. Catheter irrigation was only performed when there was an obstruction due to a mucus plug. The need for catheter irrigation and the volume of mucus produced by the neobladder were evaluated and compared between the 2 groups.

RESULTS

The average number of neobladder irrigations required to treat mucus plugs was 2.3 ± 1.5 in group A and 9.5 ± 4.3 in group B (P < .001) before hospital discharge. This number changed to 2.5 ± 1.5 versus 11.4 ± 2.7 in groups A and B, respectively (P < .001), after discharge from the hospital. The 24-hour mucus production at the end of the first week was 5.4 ± 2.7 mL versus 21.5 ± 5.6 mL in groups A and B, respectively (P < .001). At the end of the third week, this amount changed to 5.5 ± 2.3 mL versus 21.8 ± 5.6 mL in groups A and B, respectively (P < .001).

CONCLUSION

Two injections of long-acting-release octreotide can dramatically reduce mucus production and hence catheter obstruction due to mucus plugs after radical cystectomy and orthotopic reconstruction.

Postoperative outcomes after continent versus incontinent urinary diversion at the time of pelvic exenteration for gynecologic malignancies

OBJECTIVE

To compare outcomes of patients undergoing continent or incontinent urinary diversion after pelvic exenteration for gynecologic malignancies.

METHODS

Data on patients who underwent pelvic exenteration for gynecologic malignancies at The University of Texas MD Anderson Cancer Center between January 1993 and December 2010 were collected. A multivariate logistic regression model was used and statistical significance was P<0.05.

RESULTS

A total of 133 patients were included in this study. The mean age at exenteration was 47.6 (range, 30-73) years in the continent urinary diversion group and 57.2 (range, 27-86) years in the incontinent urinary diversion group (P<0.0001). Forty-six patients (34.6%) had continent urinary diversion, and 87 patients (65.4%) had incontinent urinary diversion. The rates of postoperative complications in patients with continent and incontinent urinary diversion, respectively, were as follows: pyelonephritis, 32.6% versus 37.9% (P=0.58); urinary stone formation, 34.8% versus 2.3% (P<0.001); renal insufficiency, 4.4% versus 14.9% (P=0.09); urostomy stricture, 13.0% versus 1.2% (P=0.007); ureteral (anastomotic) leak, 4.4% versus 6.9% (P=0.71); ureteral (anastomotic) stricture, 13.0% versus 23% (P=0.25); fistula formation, 21.7% versus 19.5% (P=0.82); and reoperation because of complications of urinary diversion, 6.5% versus 2.3% (P=0.34). Among patients with continent urinary diversion, the incidence of incontinence was 28.3%, and 15.2% had difficulty with self-catheterization.

CONCLUSION

There were no differences in postoperative complications between patients with continent and incontinent conduits except that stone formation was more common in patients with continent conduits.

Tissue engineering for the oncologic urinary bladder

Urinary diversion after radical cystectomy in patients with bladder cancer normally takes the form of an ileal conduit or neobladder. However, such diversions are associated with a number of complications including increased risk of infection. A plausible alternative is the construction of a neobladder (or bladder tissue) in vitro using autologous cells harvested from the patient. Biomaterials can be used as a scaffold for naturally occurring regenerative stem cells to latch onto to regrow the bladder smooth muscle and epithelium. Such engineered tissues show great promise in urologic tissue regeneration, but are faced with a number of challenges. For example, the differentiation mesenchymal stem cells from various sources can be difficult and the smooth muscle cells formed do not precisely mimic the natural cells.

The role of mucoregulatory agents after continence-preserving urinary diversion surgery

PURPOSE

The postsurgical use of N-acetylcysteine, octreotide, and other agents to reduce mucus accumulation after urinary diversion procedures is described.

SUMMARY

Patients undergoing continence-sparing bladder resection are at risk for infection and stone formation due to mucus accumulation. In addition to N-acetylcysteine, agents studied for mucoregulatory control in such patients include aspirin, urea, ranitidine, and octreotide. N-acetylcysteine has high mucolytic activity in vitro, and positive outcomes with instillations of 20% N-acetylcysteine solution have been reported in some patients. Significant mucus reductions were reported in small numbers of patients treated with oral ranitidine 300 mg daily or instillations of 30 mL of urea 40% solution, while the benefits of aspirin are more questionable. To date, there has been only one randomized controlled trial comparing various agents for mucus reduction after reconstructive bladder surgery; the results indicated no significant benefits with the use of N-acetylcysteine, aspirin, or ranitidine. In one small study (n = 40), the use of subcutaneous octreotide immediately before and for 15 days after surgery was reported to yield significant reductions in mucus production, the need for bladder irrigation to clear blockages, and the mean duration of hospital stays.

CONCLUSION

Various agents evaluated for mucus control after urinary diversion procedures (oral ranitidine or aspirin, N-acetylcysteine or urea instillations, and subcutaneous octreotide), while reportedly effective for some patients, remain of questionable benefit. More research is needed to define the optimal role of these agents for this indication.

Treatment of upper urinary lithiasis in patients who have undergone urinary diversion

Patients undergoing urinary diversion are at high risk for developing stone disease due to the metabolic and structural features intrinsic to the creation of a urinary reservoir. The utilization of shockwave lithotripsy as well as antegrade and retrograde endoscopic techniques in appropriately selected patients affords a relatively safe and effective means of stone removal. This review focuses on the etiology of stone formation in patients with urinary diversion and examines the most relevant and current reports on expulsive techniques and their associated outcomes for patients within this population who develop upper urinary tract calculi.

Irrigation of continent catheterizable ileal pouches: tap water can replace sterile solutions because it is safe, easy, and economical

BACKGROUND

Continent catheterizable ileal pouches require regular irrigations to reduce the risk of bacteriuria and urinary tract infections (UTIs).

OBJECTIVE

Our aim was to compare the UTI rate, patient friendliness, and costs of standard sterile irrigation versus irrigation with tap water.

DESIGN, SETTING, AND PARTICIPANTS

Twenty-three patients participated in a prospective randomized two-arm crossover single-center trial. Aseptic intermittent self-catheterization (ISC) combined with sterile sodium chloride (NaCl) 0.9% irrigation was compared with clean ISC and irrigation with tap water (H(2)O) during two study periods of 90 d each.

INTERVENTION

Patients underwent daily pouch irrigations with NaCl 0.9% solution or tap water.

MEASUREMENTS

Urine nitrite dipstick tests were evaluated daily; urine culture (UC) and patient friendliness were evaluated monthly. Costs were documented.

RESULTS AND LIMITATIONS

A total of 3916 study days with nitrite testing and irrigation were analyzed, 1876 (48%) in the NaCl arm and 2040 (52%) in the H(2)O arm. In the NaCl arm, 418 study days (22%) with nitrite-positive dipsticks were recorded, 219 d (11%) in the H(2)O arm, significantly fewer (p=0.01). Of the 149 UCs, 96 (64%) were positive, 48 in each arm, revealing a total of 16 different germs. All patients preferred the H(2)O method. Monthly costs were up to 20 times lower in the H(2)O arm.

CONCLUSIONS

Pouch irrigation with sterile NaCl 0.9% solution and tap water had comparable rates of positive UC. Irrigation with tap water significantly lowered the incidence of nitrite-positive study days and was substantially less costly and more patient friendly than NaCl irrigation. We therefore recommend the use of tap water (or bottled water) instead of sterile NaCl 0.9% solution for daily irrigation of continent catheterizable ileal pouches.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12610000618055, http://www.ANZCTR.org.au/ACTRN12610000618055.aspx.

Gritty sensation on catheter: a new clinical sign for self-diagnosis of stone formation in the continent urinary pouch

With more experience and better management, the incidence of complications like stone formation after continent urinary diversion is uncommon today. We report a case of large stone bulk in a patient who underwent this surgery 10 years back and who suggested the formation of stones in the pouch herself by sounding them. Proper counseling, regular pouch irrigation and follow-up are essential in any kind of diversion.

[Urinary diversions: which one one is right for which patient?]

Standardized operating techniques and surgeons' experiences have contributed to the development of complex urinary diversion systems over the last two decades. Patients' desires and comorbidity risks, such as kidney or bowel dysfunction, as well as their mental and manual abilities need to be taken into account. Careful preoperative decision making is essential if patients are to accept the chosen urinary diversion system and improve their quality of life. Ileal and ileocecal orthotopic neobladders have proven to be effective and comfortable for long-time use, thus stimulating decisions for orthotopic bladder substitution despite the risk of incontinence episodes, especially during the night. Catheterization of continent reservoirs connected to the umbilicus (e.g., ileocecal reservoirs, Mainz pouch I) are widely accepted as an alternative diversion procedure if the urethra and/or sphincter region have to be removed. The patient's desire to avoid a wet stoma and achieve a cosmetically "unchanged" body image is met by these urinary diversion techniques. The surgeon's experience and the patient's mental and general health status must be considered in order to meet the increased complexity of these specific urinary diversions. Nevertheless, elderly patients often tend to prefer an ileal conduit as the easiest solution for urinary diversion. Therefore, even in experienced urological departments, the percentage of patients with orthotopic or self-catheterizable bladder substitution ranges between 30% and 66%, while the ileal conduit is selected in up to 64% of cases after cystectomy. The future of laparoscopic cystectomy has just begun and will affect future techniques of urinary diversion.

Effect of urinary tract infection on reservoir function in patients with ileal bladder substitute

PURPOSE

We determined the functional consequences of urinary tract infection in patients with an ileal bladder substitute in terms of urinary continence, post-void residual and urinary retention.

MATERIALS AND METHODS

A total of 48 patients with culture documented urinary tract infection (single organism, 10(5) or greater cfu) were retrospectively evaluated before, during and after the infection for changes in continence, post-void residual and urinary retention as well as for resolution of symptomatology after appropriate antibiotic therapy.

RESULTS

Of the 48 patients 40 had a single infection while the remaining 8 had multiple urinary tract infection episodes. During daytime 27 of the 44 patients with previously good daytime continence experienced deterioration in their baseline voiding status while infected. Of the 40 patients who were previously continent at night 20 had incontinence while infected. There were 15 patients with documented post-void residual and urinary retention developed in 4 during the urinary tract infection. All patients returned to baseline continence status and reservoir function after appropriate antibiotic treatment based on objective and subjective assessments.

CONCLUSIONS

Urinary tract infection may cause urinary incontinence in patients with ileal bladder substitutes. Therefore, when there are complaints of de novo urinary incontinence, a finding of post-void residual or an acute presentation of urinary retention, a urinary tract infection should be excluded. When the urinary tract infection is appropriately treated urinary continence and reservoir function return to their baseline status.

Glycosylation of the two O-glycosylated domains of human MUC2 mucin in patients transposed with artificial urinary bladders constructed from proximal colonic tissue

Transposition of intestinal segments is frequently used for bladder reconstruction. Following transposition, bowel segments continue to produce mucus and a correlation between excessive mucus production and complications such as urinary tract infection or catheter blockage has been observed for a long time. However, no information is currently available on the change of mucin expression and glycosylation under these abnormal conditions. In this study, the variable number tandem repeat region and the irregular repeat domain of human MUC2 were isolated as two glycopeptide populations after reduction and trypsin digestion followed by gel chromatography from urine of patients transposed with urinary bladders. After alkaline borohydride treatment, the oligosaccharides released from the whole MUC2 mucin and the two glycosylated domains were investigated by nanoESI Q-TOF MS/MS (electrospray ionization quadrupole time-of-flight tandem mass spectrometry). More than 60 different glycans were identified, mainly based on sialylated core 3 structures. Some core 1, 2 and 4 oligosaccharides were also found. Most of the structures were acidic with NeuAc residues mainly alpha2-6 linked to the N-acetylgalactosaminitol and sulphate residues exclusively 3-linked to galactose. No expression of blood group A and B or Sda/Cad determinants was observed. Similar patterns of glycosylation were found in the tandem repeat region and the irregular repeat domain and the level of expression of the major oligosaccharides were in the same order of magnitude. The most interesting feature of this study was that sialyl-Tn antigen, which is considered as a tumour antigen, was the oligosaccharide most highly expressed. This result suggests that mucins from intestinal transposed segments are abnormally glycosylated.

Urinary Tract Infections in Patients With Urinary Diversion

Several surgical techniques have been used to provide urinary diversion after radical cystectomy. The noncontinent type of urinary diversion (using an intestinal conduit) and the continent urinary diversion (ureterosigmoidostomy or construction of an intestinal pouch that serves as a deposit of urine) were used commonly in the past, leading to a cumulative considerable number of patients encountered in clinical practice. The orthotopic urinary diversion (neobladder) has been used widely during the last years. The incidence and characteristics of urinary tract infection in patients with different types of urinary diversion are reviewed. Clinicians should be aware that urinary tract infection is a frequent cause of fever in patients with urinary diversion because it occurs in a significant proportion. In addition, symptoms from the lower urinary tract may not be prominent in this population.