Twenty-year experience with jejunal conduits

Genitourinary Cancer: Updates on Treatments and Their Impact on the Kidney

Genitourinary cancers are diverse in their presentation, prevalence, and mortality risk. Although there have been significant advancements in medical (eg, immune checkpoint inhibitors and tyrosine kinase inhibitors) and surgical treatments of genitourinary cancers, patients are still at risk for chronic kidney disease, hypertension, and electrolyte derangements in the short and long term. In addition, pre-existing kidney disease may increase the risk of developing some genitourinary cancers. This review focuses on the kidney-related effects of treatments for renal cell carcinoma and bladder and prostate cancers.

Jejunocystoplasty and Bilateral Ureteral Reimplantation in a Dog Following Total Cystectomy

A 6 yr old Boston terrier presented with acute onset of vomiting and anuria 4 days following a caesarian section and ovariohysterectomy for treatment of dystocia. A total cystectomy with ligation of both ureters was diagnosed via exploratory laparotomy surgery. A jejunocystoplasty was performed in addition to a bilateral reimplantation of the ureters into the reconstructed bladder and proximal urethra. Postoperative complications included a retained ureteral stent, persistent pyelectasia, persistent hydroureters, recurrent urinary tract infections, and intermittent urinary incontinence. Four years postoperation, the dog is doing clinically well with intermittent urinary incontinence and periodic urinary tract infections. Jejunocystoplasty with bilateral ureteral reimplantation should be considered as a treatment option for dogs following total cystectomy that occurred because of a surgical error. Owners should be informed of potential complications prior to surgery.

Parastomal hernias after radical cystectomy and ileal conduit diversion

Parastomal hernia, defined as an "incisional hernia related to an abdominal wall stoma", is a frequent complication after conduit urinary diversion that can negatively impact quality of life and present a clinically significant problem for many patients. Parastomal hernia (PH) rates may be as high as 65% and while many patients are asymptomatic, in some series up to 30% of patients require surgical intervention due to pain, leakage, ostomy appliance problems, urinary obstruction, and rarely bowel obstruction or strangulation. Local tissue repair, stoma relocation, and mesh repairs have been performed to correct PH, however, long-term results have been disappointing with recurrence rates of 30%–76% reported after these techniques. Due to high recurrence rates and the potential morbidity of PH repair, efforts have been made to prevent PH development at the time of the initial surgery. Randomized trials of circumstomal prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have shown significant reductions in PH rates with acceptably low complication profiles. We have placed prophylactic mesh at the time of ileal conduit creation in patients at high risk for PH development and found it to be safe and effective in reducing the PH rates over the short-term. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors associated with its development, and the use of prophylactic mesh placement for patients undergoing ileal conduit urinary diversion with the intent of reducing PH rates.

Rationale and Early Experience with Prophylactic Placement of Mesh to Prevent Parastomal Hernia Formation after Ileal Conduit Urinary Diversion and Cystectomy for Bladder Cancer

Parastomal hernias (PH) represent a clinically significant problem for many patients after radical cystectomy and ileal conduit diversion. The prevalence may be as high as 60% and in some series, up to 30% of patients require surgical intervention due to the complications of pain, poor fit of an ostomy appliance, leakage, urinary obstruction, and bowel obstruction or strangulation. Due to the potential morbidity associated with PH repair, there have been efforts to prevent PH development at the time of the index surgery. Four randomized trials of prophylactic mesh placement at the time of colostomy and ileostomy stoma formation have demonstrated significant reductions in PH rates with acceptably low complication rates. In this review, we describe the clinical and radiographic definitions of PH, the clinical impact and risk factors behind its development, and the rationale behind prophylactic mesh placement for patients undergoing ileal conduit urinary diversion. Additionally, we report our experience with prophylactic mesh placed at radical cystectomy at our institution.

We can rebuild it: reconstructive solutions for structural urologic diseases

Bladder augmentation and urinary diversion have become standard of care as surgical treatments for structural and functional disorders affecting the bladder, both in children and adults. With improved medical care, long-term survival of these patients is expected. Common medical problems that can occur such as metabolic side effects including acid-base imbalances and nutritional issues need to be anticipated and addressed. In addition, surgical problems caused by impaired urinary drainage, namely stones and urinary tract infections, and mechanical factors related to catheterizable channels and continence also may compound postoperative management. The risk of malignancy after bladder augmentation and substitution, and appropriate surveillance for this, remains to be clearly defined.

Metabolic consequences after urinary diversion

Metabolic disturbances are well-known, but sometimes neglected immediate consequences or late sequelae following urinary diversion (UD) using bowel segments. Whereas subclinical disturbances appear to be quite common, clinically relevant metabolic complications, however, are rare. Exclusion of bowel segments for UD results in loss of absorptive surface for its physiological function. Previous studies demonstrated that at least some of the absorptive and secreting properties of the bowel are preserved when exposed to urine. For each bowel segment typical consequences and complications have been reported. The use of ileal and/or colonic segments may result in hyperchloremic metabolic acidosis, which can be prevented if prophylactic treatment with alkali supplementation is started early. The resection of ileal segments may be responsible for malabsorption of vitamin B12 and bile acids with subsequent neurological and hematological late sequelae as well as potential worsening of the patient's bowel habits. Hence, careful patient and procedure selection, meticulous long-term follow-up, and prophylactic treatment of subclinical acidosis is of paramount importance in the prevention of true metabolic complications.

Metabolic complications of urinary intestinal diversion

Patients with a urinary bladder malignancy or severe anatomical/functional bladder abnormalities may be candidates for urinary diversion at the time of cystectomy. Most urinary diversions are constructed from intestinal segments. Urological surgeons who perform urinary diversion surgery should be aware of the physiological and metabolic changes that can occur when intestinal segments are in direct contact with urine. The complications associated with urinary diversion are both acute and chronic. The most important factor associated with the development of metabolic complications following urinary diversion is the length of time that the urine is in contact with the bowel and the type of bowel segment used for urinary diversion. In this review, we describe the metabolic complications associated with urinary diversion, their characteristic clinical presentation, follow-up, and specific treatment.

[Metabolic long-term complications after urinary diversion]

Metabolic long-term complications and consequences after urinary diversion are somewhat neglected. Subclinical metabolic disturbances are quite common; however, complications are rare. The absorptive surface of the bowel segment is lost for the physiological function of the gastrointestinal tract. Some studies demonstrated that at least some of the absorbent and secreting properties of the bowel are preserved if exposed to urine. For each bowel segment typical complications are reported. Using ileal and/or colon segments, hyperchloremic metabolic acidosis may occur. Studies demonstrated that metabolic effects are not as severe as suspected and could be prevented if a prophylactic treatment is started early.The resection of ileal segments is responsible for malabsorption of vitamin B(12) and bile acid; when using colonic segments, electrolyte disturbances are more common. Careful patient selection, meticulous follow-up and prophylactic treatment are crucial to prevent metabolic complications.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: non-surgical considerations

Segments from almost all parts of the bowel have been used for urinary diversion. As a result, the available absorptive surface area of the bowel is reduced, and the incorporation of bowel segments into the urinary tract may have metabolic consequences. This is an area somewhat neglected in the literature. Metabolic complications are rare, but sub-clinical metabolic disturbances are quite common. Several studies have demonstrated that some of the absorbent and secreting properties of the bowel tissue are preserved after incorporation into the urinary tract. Hyperchloraemic metabolic acidosis can occur if ileal and/or colon segments are used, as well as malabsorption of vitamin B(12) and bile acid after the use of ileal segments. These metabolic effects are not as severe as may be suspected and can be prevented by prophylactic substitution. Secondary malignancies can develop as a long-term consequence of bladder augmentation. Using colonic segments, tumours are most likely to occur at the ureteral implantation site. To prevent metabolic complications, careful patient selection and meticulous and lifelong follow up, as well as prophylactic treatment, are mandatory. Endoscopy for early detection has been recommended, starting 10 years postoperatively for patients who underwent surgery for a benign condition.

A review of metabolic consequences and long-term complications of enterocystoplasty in children

This review summarizes the important metabolic consequences and long-term complications associated with enterocystoplasty, with a particular emphasis on the pediatric patient with genitourinary abnormalities. A directed Medline literature review for metabolic and long-term complications following enterocystoplasty was performed. Information gained through published literature and from our database was reviewed and summarized to provide the reader with a thorough review of the subject. Bowel is not a perfect tissue for substitution or augmentation, and its use to treat functionally and structurally compromised bladders is associated with several metabolic consequences and long-term complications. Metabolic acidosis is the most common metabolic abnormality seen. The rates and severity of these complications vary, though they may have a profound impact on a patient's quality of life after enterocystoplasty. The metabolic consequences and long-term complications associated with enterocystoplasty are important clinical features of this intervention, and careful consideration should be given to them before pursuing enterocystoplasty.

Parastomal hernias

The incidence of parastomal hernias is probably 30% to 50%. Suture repair of a parastomal hernia or relocation of the stoma results in a high recurrence rate, whereas with mesh repair recurrence rates are lower. Several mesh repair techniques are used in open and laparoscopic surgery, but randomized trials comparing various techniques and with long-term follow-up are needed for better evidence.

Chapitre A - Lithiase et vessie neurogène

Stones of the upper and lower urinary tract are frequently observed in spinal cord injury patients. In this article, the authors reviewed the literature to identify the most reliable tools for diagnosis and follow-up. A review of recently published series demonstrated an excess risk of kidney and bladder stones in this population. The authors discuss the possible measures of prevention and identification of high-risk groups likely to benefit from more intensive follow-up.

Urinary Diversion

A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review reports of urinary diversion. The world literature on urinary diversion was identified through a Medline search. Evidence-based recommendations for urinary diversion were prepared with reference to a 4-point scale. Many level 3 and 4 citations, but very few level 2 and no level 1, were noted. This outcome supported the clinical practice pattern. Findings of >300 reviewed citations are summarized. Published reports on urinary diversion rely heavily on expert opinion and single-institution retrospective case series: (1) The frequency distribution of urinary diversions performed by the authors of this report in >7000 patients with cystectomy reflects the current status of urinary diversion after cystectomy for bladder cancer: neobladder, 47%; conduit, 33%; anal diversion, 10%; continent cutaneous diversion, 8%; incontinent cutaneous diversion, 2%; and others, 0.1%. (2) No randomized controlled studies have investigated quality of life (QOL) after radical cystectomy. Such studies are desirable but are probably difficult to conduct. Published evidence does not support an advantage of one type of reconstruction over the others with regard to QOL. An important proposed reason for this is that patients are subjected preoperatively to method-to-patient matching, and thus are prepared for disadvantages associated with different methods. (3) Simple end-to-side, freely refluxing ureterointestinal anastomosis to an afferent limb of a low-pressure orthotopic reconstruction, in combination with regular voiding and close follow-up, is the procedure that results in the lowest overall complication rate. The potential benefit of "conventional" antireflux procedures in combination with orthotopic reconstruction seems outweighed by the higher complication and reoperation rates. The need to prevent reflux in a continent cutaneous reservoir is not significantly debated, and this should be done. (4) Most reconstructive surgeons have abandoned the continent Kock ileal reservoir largely because of the significant complication rate associated with the intussuscepted nipple valve.

Parastomal hernia: an exploration of the risk factors and the implications

Risk may be defined as 'the chance that something may happen to cause loss or an adverse effect' (Concise Oxford Medical Dictionary, 2003). Patients undergoing stoma formation are at risk of developing a wide range of complications following surgery. A parastomal hernia is an adverse effect that can contribute to postoperative morbidity. The risk of developing a parastomal hernia is dependent upon a number of variables, and stoma care nurses need to be aware of these to plan the appropriate care for patients undergoing stoma formation. This article discusses the issues surrounding the development of parastomal hernias and also looks at ways in which the risk factors associated with the development of a parastomal hernia may be minimized.

METABOLIC CONSEQUENCES AND LONG-TERM COMPLICATIONS OF ENTEROCYSTOPLASTY IN CHILDREN: A REVIEW

PURPOSE

We summarize important metabolic consequences and long-term complications associated with enterocystoplasty with particular emphasis on the pediatric patient with genitourinary abnormalities.

MATERIALS AND METHODS

A directed MEDLINE literature review for metabolic and long-term complications following enterocystoplasty was performed. Information gained through the published literature and from our database was reviewed and summarized to provide the reader with a thorough review of the subject.

RESULTS

Bowel is not a perfect tissue for substitution or augmentation and its use to treat functionally and structurally compromised bladders is associated with several metabolic consequences and long-term complications. Metabolic acidosis is the most common metabolic abnormality seen. The rates and severity of these complications vary, although they may have a profound impact on patient quality of life after enterocystoplasty.

CONCLUSIONS

The metabolic consequences and long-term complications associated with enterocystoplasty are important clinical features of this intervention. Careful consideration should be given to them prior to pursuing enterocystoplasty.