Clinical outcomes of augmentation cystoplasty in patients suffering from ketamine-related bladder contractures

Robotic Augmentation Cystoplasty: Outcome of the Anterior and Posterior Approaches

Introduction: To describe the medium-term outcome of robotic augmentation ileocystoplasty by posterior and anterior approaches in the management of contracted low-capacity bladder from cystitis. Materials and Methods: Data on consecutive cases of robotic augmentation ileocystoplasty between 2011 and 2021 were prospectively collected and reviewed in our center. Retzius-sparing posterior approach was performed by anastomosis of an M-configuration small bowel plate to the posteriorly located U-shaped cystostomy. Conventional anterior augmentation ileocystoplasty was performed by anastomosis of an S-configuration small bowel plate to the anterior cystostomy. The procedure was as per conventional robotic pelvic surgery setting with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Perioperative data and postoperative complications were assessed. Preoperative and postoperative functional outcomes were compared. Results: Six patients underwent posterior augmentation cystoplasty and 20 patients underwent anterior augmentation cystoplasty with a mean follow-up of 51 ± 26 months. Mean operative time was 274 ± 113 minutes and 267 ± 102 minutes, respectively (p = 0.889), and mean hospital stay was 9.0 ± 9.6 days and 8.3 ± 6.1 days, respectively (p = 0.831). Additional procedures include eight ureteral reimplantations and one ileal interposition. Mean functional bladder capacity (FBC) at 2 years of the two approaches were similar, which were 350.2 ± 126.3 mL (posterior approach) and 310.2 ± 151.4 mL (anterior approach) (p = 0.5936). Overall, FBC before the operation and at 24 months was 68.9 ± 48.2 mL and 318.5 ± 144.8 mL (p = <0.0001), respectively. Analgesic requirement was decreased after the operation (preoperative 19 patients, postoperative 4 patients; p < 0.0001). Conclusions: Posterior approach of robotic augmentation ileocystoplasty provided an alternate option to expand the bladder capacity for patients with a small contracted bladder. It could provide a similar symptom relief and functional improvement as the anterior approach. The clinical trial number is CRE-2011.454.

Management of ketamine cystitis: National guidelines from the French Association of Urology (CUROPF/CTMH)

OBJECTIVE

The objective of the CUROPF and CTMH was to establish recommendations about ketamine induced uropathy management.

METHODS

A systematic review of the literature was conducted on Pubmed/Medline by the members of the French committees of female urology and male lower urinary tract symptoms focusing on the epidemiology, pathophysiology, diagnosis and treatment of ketamine induced uropathy, evaluating references and level of evidence.

RESULTS

Recommendations include epidemiology, pathophysiology, diagnosis and treatment of ketamine induced uropathy. It represents a rising healthcare issue, with major augmentation of ketamine consumers and new patients across the world. Several pathophysiology pathways are suspected and need clinical validation. The diagnosis is clinical, with hyperactive bladder symptoms mostly including pollakiuria, but also lower urinary tract symptoms, and histological, requiring bladder biopsies to rule out carcinoma and show specific features and inflammation. Therapeutics are currently limited and non-specific, combining abstinence, hydrodistension, pentosane polysulfate and Botox injections. Complex reconstructive surgeries should be avoided and be considered as a last resort.

CONCLUSION

These guidelines should provide tools to help every physician confronted to ketamine induced uropathy patients, which represents a growing issue. Hopefully, this work will allow the improvement of the screening, management and care of ketamine induced uropathy in the future.

British Association of Urological Surgeons Consensus statements on the management of ketamine uropathy

OBJECTIVES

To provide guidance in the form of consensus statement in the management of ketamine uropathy.

METHODS

A literature review of ketamine uropathy was performed. The consensus method was of a modified nominal group technique and has been use in the previous British Association of Urological Surgeons (BAUS) consensus documents and was led by the Female, Neurological and Urodynamic Urology Section of the BAUS.

RESULTS

A number of consensus statements detailing the assessment and management of urological complications relate to the recreational use of ketamine (ketamine uropathy) in both elective and emergency urology settings.

CONCLUSION

Comprehensive management pathway for ketamine-related urinary tract dysfunction and uropathy has been detailed.

Ketamine uropathy: Clinical experience in a high prevalence center

OBJECTIVES

Ketamine uropathy causes inflammatory changes to the urothelium, manifesting as significant lower urinary tract symptoms, small bladder capacity, and pelvic pain. Upper tract involvement and hydronephrosis can occur. Data from UK centers are limited, and no formal treatment guidelines exist.

PATIENTS AND METHODS

All patients with ketamine uropathy presenting to our unit over an 11-year period were identified through operative and clinic lists, emergency presentations, and a prospectively collected local database. Demographic data, biochemical findings, imaging techniques, and both medical and surgical management were recorded.

RESULTS

A total of 81 patients with ketamine uropathy were identified from 2011 to 2022; however, a large proportion presented from 2018 onwards. The average age at presentation was 26 years (interquartile range [IQR]: 27-34), 72.8% were male, and average follow-up time was 34 months (IQR: 8-46). Therapeutic interventions included anticholinergic medication, cystodistension, and intravesical sodium hyaluronate. Hydronephrosis was present in 20 (24.7%) patients and nephrostomy insertion was required in six. One patient underwent bladder augmentation surgery. Serum gamma-glutamyl transferase and length of follow-up were significantly higher in patients with hydronephrosis. Adherence to follow-up was poor.

CONCLUSIONS

We present a large cohort of patients with ketamine uropathy from a small town in the UK which is unusual. The incidence appears to be rising, in-keeping with increasing recreational ketamine use and should be of concern to urologists. Abstinence is a key aspect of management, and a multi-disciplinary approach works best particularly as many patients are lost to follow-up. The development of formal guidance would be helpful.

Ketamine-induced uropathy: A narrative systemic review of surgical outcomes of reconstructive surgery

Aims

Refractory ketamine-induced uropathy (KU) (RKU) has devastating effects on the lower urinary tract leading to ureteral obstruction and even renal failure. The only effective treatment for RKU is major surgical reconstruction or urinary diversion. Nevertheless, there is a paucity of awareness about this destructive condition; the aim of this study is to conduct a narrative systemic review of all surgical outcomes of RKU.

Methods

This is an English language literature review of surgical outcomes in KU patients who underwent reconstructive lower urinary tract surgery or urinary diversion through 5 August 2022. Two independent researchers assessed the relevance of each paper and disputes were settled by a third party. In-vitro, animal studies, letters to the editor and papers that did not evaluate surgical outcomes were excluded.

Results

Of the 50 763 identified articles, 622 were relevant based on title, 150 based on abstract, but only 23 papers were relevant by content. In all, 875 patients were documented as having KU, of whom 193 (22%) underwent reconstructive surgery. The data were disconcerting, as the apparent rapid progression from the beginning of KU to end-stage bladder was only a 1-year difference of ketamine abuse between those patients who required surgery (4.4 years) and those that did not (3.4 years).

Conclusions

The data suggest that the time interval from the beginning of ketamine-induced uropathy to the end-stage bladder may be measured in months, confounding decision making. There is a dearth of literature about KU, and more research is needed to better understand this pathology.

Current approaches for the treatment of ketamine-induced cystitis

AIMS

Ketamine is a dissociative anesthetic, historically used in a clinical setting for the induction and maintenance of anesthesia. Ketamine usage can produce undesirable psychological manifestations including hallucinations and long-term psychotomimetic effects. As a results of its fast onset and short period of action, ketamine is widely used as a recreational drug. Chronic abuse of ketamine can lead to significant urinary system complications including ketamine-induced cystitis (KIC). Common side effects of chronic ketamine abuse are urinary pain and discomfort and decreased bladder compliance and voiding pressure. Cessation of ketamine use is associated with improvement of symptoms however the exact pathophysiology of KIC remains unknown, complicating the ability of clinicians to treat this condition.

METHOD

A literature search was performed using the National Center for Biotechnology Information (NCBI) Pubmed database up to May 2021.

RESULTS

Animal models of KIC are necessary to further our understanding of KIC pathophysiology and explore potential treatment options. In all cases, cessation of ketamine use is the first line of treatment and is most effective in managing KIC. In addition to cessation, treatment plans must be tailored to the individual, based on the severity of symptoms and disease progression, and include options such as: oral anti-inflammatories, intravesical treatment and in the most severe cases, surgical intervention.

CONCLUSION

KIC is a painful condition that currently lacks standardized treatment methods. Both animal models of KIC and clinical trials to further elucidate the mechanism of KIC pathophysiology must be explored to create targeted treatment plans.

Ketamine Induced Bladder Fibrosis Through MTDH/P38 MAPK/EMT Pathway

Purpose: Ketamine is an anesthetic in clinical, but it has also been used as an abusing drug due to its low price and hallucinogenic effects. It is proved that ketamine abusing would cause multiple system damage including the urinary system, which is called ketamine-induced cystitis (KIC). Bladder fibrosis is late stage in KIC and threaten abusers’ life. This study aimed to investigate the molecular mechanism of ketamine-induced bladder fibrosis.

Methods: Female Sprague Dawley (SD) rats were randomly divided into 3 groups. 2 groups were treated with tail vein injection of ketamine (25 mg/kg/day, 50 mg/kg/day ketamine hydrochloride solution, respectively) for 12 weeks, whereas the control group was treated with normal saline solution. In each group, rat bladders were extracted and samples were examined for pathological and morphological alterations via hematoxylin and eosin (HE) staining, Masson’s trichrome staining and immunohistochemistry (IHC). SV-HUC-1 cells were treated with different concentrations of ketamine solution (0, 0.1, 0.5, 1 mmol/L). Rat bladder and SV-HUC-1 cells were extracted protein and RNA for Western blot and RT-PCR detection. Metadherin (MTDH) siRNAs and overexpression plasmids were used to knock down and overexpress the relative genes. P38 mitogen-activated protein kinase (MAPK) inhibitor was utilized to inhibit the MAPK pathway.

Results: Rats in the ketamine group exhibited fibrosis compared to rats of the control group and fibrosis were also markedly upregulated in SV-HUC-1 cells after treated with ketamine, which were ketamine concentration-dependent. After treating with ketamine in SV-HUC-1 cells, there was an increase expression of MTDH, epithelial-mesenchymal transition (EMT) markers, P38 MAPK. MTDH knockdown would suppresses P38 MAPK/EMT pathway to inhibit fibrosis, however, MTDH overexpression could promote the pathway in SV-HUC-1 cells.

Conclusion: In rats and SV-HUC-1 cells ketamine-treated models, MTDH can regulate EMT through the P38 MAPK pathway to regulate the process of bladder fibrosis.

Comparison of bladder autoaugmentation by transurethral vesicomyotomy and hydrodistention for ketamine cystitis

Background

To illustrate the bladder autoaugmentation by transurethral vesicomyotomy (BATV) and compare the efficacy and safety of BATV to bladder hydrodistention (BH) for managing ketamine cystitis (KC).

Methods

We retrospectively analyzed clinical data for 53 patients with KC who received surgical intervention between 2014 and 2019 at our hospital. Of these, 41 (77.4%) underwent BH and 12 (22.6%) were subjected to BATV, with a minimum of 1-year follow-up. These groups were compared with reference to urodynamic parameters, subjective symptom scores as well as all complications.

Results

Both groups were matched in age, addiction time, preoperative urodynamic parameters, postvoid residual urinary volume (PVR), and symptom scores. All urodynamic parameters including maximum cystometric capacity (MCC), maximum detrusor pressure (P_{det max}), compliance, maximum urinary flow rate (Q_max) and symptom scores had improved significantly in two groups whether at 3 or 12 months. Moreover, the MCC was significantly increased after BATV than BH, at a mean [standard deviation (SD)] of 281.0 (25.7) vs. 213.5 (35.6) mL (P<0.001) at 12-month follow-up. The Q_max and the Pelvic Pain and Urgency/Frequency (PUF) symptom score were still noted better in the BATV group at 3 months after surgery. Additionally, patients in both groups had similarly low rates of complications.

Conclusions

BATV is superior to BH with increased bladder capacity and urodynamic outcomes, although showing equivalent in symptom relief and a similar rate of complications.

Urethroscrotal fistula complicating large spermatocele in a male ketamine abuser: A case report

Ketamine related urinary tract complications were first reported in Hong Kong since 2007. The current case report describes a 37 years old male with long history of ketamine abuse, renal impairment, hypertension and HCV hepatitis, presented to us with insidious onset of painful scrotal swelling post bilateral nephrectomy, prostate and seminal vesicle preserving cystectomy. Radiological imaging and intraoperative finding revealed that it was a large spermatocele with urethroscrotal fistula, which was likely due to urethra stricture. The review of literature showed no guidelines for treatment, a symptoms based and multidisciplinary team approach is recommended.

What urologists need to know about ketamine-induced uropathy: A systematic review

AIMS

Ketamine is a general anesthetic. Dissociative effects and low cost led ketamine becoming an illegal recreational drug in young adults. Ketamine-induced uropathy (KIU) is one of the complications observed in abusers. This study aimed to provide a systematic literature review on KIU clinical presentation, pathophysiology, and treatments.

METHODS

We performed the literature search in PubMed, Web of Science, Scopus, and Embase using the terms ketamine and bladder. English papers on human and animal studies were accepted.

RESULTS

A total of 75 papers were selected. Regular ketamine users complain about severe storage symptoms and pelvic pain. Hydronephrosis may develop in long-term abusers and is correlated to the contracted bladder, ureteral stenosis, or vesicoureteral reflux due to ureteral involvement and/or bladder fibrosis. Cystoscopy shows ulcerative cystitis. Ketamine in urine might exert direct toxicity to the urothelium, disrupting its barrier function and enhancing cell apoptosis. The presence of ketamine/ions in the bladder wall result in neurogenic/IgE-mediated inflammation, stimulation of the inducible nitric oxide synthase-cytokines-cyclooxygenase pathway with persistent inflammation and fibrosis. Abstinence is the first therapeutic step. Anti-inflammatory drugs, analgesics and anticholinergics, intravesical instillation of hyaluronic acid, hydrodistension and intravesical injection of botulin toxin-A were helpful in patients with early-stage KIU. In patients with end-stage disease, the control of intractable symptoms and the increase of bladder capacity were the main recommendations to perform augmentation enterocystoplasty.

CONCLUSIONS

KIU is becoming a worldwide health concern, which should be taken into account in the differential diagnosis of ulcerative cystitis.

Mini review: Ketamine and the urinary tract

The use of ketamine as a recreational drug has become increasingly widespread, particularly amongst teenagers and young men. Its side-effects on the central nervous system and cardiovascular are well established and documented, although it is now clear that ketamine also has significant toxic effects on the genitourinary system. Increasing numbers of patients are presenting to urologists and healthcare professionals with debilitating symptoms attributable to ketamine use, with many clinicians having very little experience of managing patients with this condition. This mini-review aims to provide a contemporary outline of the clinical aspects of ketamine-associated genitourinary toxicity and a summary of management options for treating patients with this often chronic and debilitating condition.

Pregnancy With a Successful Vaginal Delivery Following Augmentation Enterocystoplasty for Ketamine Cystitis: A Case Report

A 28-year-old female with a 1-year history of ketamine abuse developed ketamine-associated urinary symptoms that were refractory to conservative treatment after the complete cessation of ketamine use. Smooth voiding with increased bladder capacity and minimal postvoid residual urine volume were achieved by performing an augmentation enterocystoplasty. An uneventful pregnancy with the vaginal delivery of a healthy baby occurred postoperatively.

Clinical staging of ketamine-associated urinary dysfunction: a strategy for assessment and treatment

PURPOSE

To describe a clinical staging method linked to stepwise treatment indications for ketamine-associated urinary dysfunction (KAUD) based on review of our experience in management of KAUD patients and analysis of their clinical features.

METHODS

The eighty-one KAUD patients hospitalized from January 2008 to June 2014 were studied retrospectively. According to ketamine history, renal and liver function, bladder change and up urinary tract involvement, patients were categorized into a described model of three stages. Discriminant analysis was applied to validate the model. The void volume, micturition interval, nocturnal void frequency and pelvic pain and urgency/frequency (PUF) questionnaire score were, respectively, compared after treatments.

RESULTS

There were, respectively, 24, 47 and 10 patients in three stages. The duration of abuse varied (p = 0.047) correlated with clinical stages (p = 0.015, r = 0.268). The severity of LUTS was not significant. The creatinine, estimated glomerular filtration rate and liver function were worse in higher stages (p < 0.01), and the incidence of ureteral change and hydronephrosis was greater (p < 0.001). Based on the model, cross-validation confirmed 83.1 % cases were classified correctly. Twenty-four patients in stage I were treated with behavioral modification and pharmacotherapy, thirty-five patients in stage II with hydrodistention and six patients in stage III with surgical intervention due to rapid progression after conservative therapy. All patients in three stages demonstrated improvements in void volume, micturition interval, nocturnal void frequency and PUF score (all p < 0.05) after treatment.

CONCLUSION

Clinical staging could serve for assessment of progression, and the staging-based treatment is effective. This model still awaits further validation.

Clinical Outcome of a Prospective Case Series of Patients With Ketamine Cystitis Who Underwent Standardized Treatment Protocol

OBJECTIVE

To assess the outcome of a prospective cohort of patients with ketamine-associated uropathy after standardized treatment.

METHODS

This is a prospective case series of patients with ketamine-related urologic problems. Management for the patients includes a 4-tier approach, namely anti-inflammatory or anti-cholinergic drugs, opioid analgesics or pregabalin, intravesical hyaluronic acid, and finally, surgical intervention including hydrodistension and augmentation cystoplasty. Outcome was assessed with functional bladder capacity, pelvic pain and urgency or frequency (PUF) symptom scale, and the EuroQol visual analog scale.

RESULTS

Between December 2011 and June 2014, 463 patients presented with ketamine-associated uropathy. All were managed by the same standardized protocol. Among these patients, 319 patients came back for follow-up assessment. Overall mean follow-up duration was 10.7 ± 8.5 months. For those patients who received first-line treatment (290 patients), there was a significant improvement in PUF scores, the EuroQol visual analog scale, and functional bladder capacity. Both abstinence from ketamine usage and the amount of ketamine consumed were factors predicting the improvement of PUF scores. For those patients who required second-line oral therapy (62 patients), 42 patients (67.7%) reported improvement in symptoms. Eight patients have completed intravesical therapy. There was a significant improvement in voided volume for the patients after treatment.

CONCLUSION

The study demonstrated the efficacy of managing ketamine-associated uropathy using a 4-tier approach. Both anti-inflammatory drugs and analgesics could effectively alleviate symptoms. Being abstinent from ketamine abuse and the amount of ketamine consumed have bearings on treatment response.

Autotransplantation for the management of ketamine ureteritis

Ketamine-associated cystitis is a well-recognised syndrome; yet upper urinary tract involvement remains poorly understood. We present the case of a 33-year-old man who developed ketamine-associated cystitis and ureteritis. The patient's severe bladder symptoms required subtotal cystectomy and orthotopic reconstruction. However, the associated ureteritis led to bilateral ureteric obstruction and renal failure. Bilateral autotransplantation with pyelovesicostomy was performed. This first case of autotransplantation for ketamine uropathy helps to demonstrate the potentially devastating effects of ketamine on the urinary tract.