Metabolic complications of urinary intestinal diversion

Urinary bladder transplantation in humans - current status and future perspectives

Urinary bladder vascularized allograft transplantation in humans is currently extensively being investigated worldwide, owing to the theoretical potential of this approach as a therapeutic option for individuals with end-stage, non-oncological bladder conditions or congenital bladder pathologies. To date, a successful attempt at urinary bladder autotransplantation was carried out in a heart-beating brain-dead research human donor. The robot-assisted surgical technique was shown to be optimal for performing this procedure, achieving a good performance in terms of both bladder allograft collection as well as vascular, ureterovesical and vesicourethral anastomoses. The urinary bladder vascularized allograft would be an alternative to traditional urinary diversion methods that rely on the use of intestinal segments, potentially avoiding adverse effects associated with these approaches. However, different from ileal urinary diversion, bladder transplantation would require lifelong immune suppression. Clinical trials are in progress to assess the vascularized bladder allograft transplantation technique, as well as the safety of this procedure in oncological and non-oncological indications.

Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review

Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.

Causes and management of urinary system problems in children on long-term home invasive mechanical ventilation

Many ventilator-dependent children have comorbid conditions including urinary tract disorders. We aimed to present a focused review of the literature describing the causes and management of urinary system problems in children with long-term home mechanical ventilation. We performed a literature search in PubMed/MEDLINE, Scopus, and Web of Science with keywords "children," "home mechanical ventilation," "urinary system," "urinary tract," "neurogenic bladder," "clean intermittent catheterization," "urinary tract infection," "urolithiasis," and "acute kidney injury." We included original articles, reviews, guidelines, and case reports published in English. Ventilator-dependent children may have neurogenic bladder/bowel dysfunction which renders them prone to urinary tract infection, high bladder pressure, vesicoureteral reflux, hydronephrosis, and renal dysfunction. These children require bladder catheterization, medications affecting parasympathetic/sympathetic nervous systems, or surgical procedures to prevent urinary infections, and to maintain continence and renal functions. However, bladder catheterization or surgical procedures like augmentation cystoplasty may also be complicated with urinary infections, urolithiasis, or urethral strictures. Urolithiasis frequency is also increased due to immobilization-related hypercalciuria, hypocitraturia caused by antiepileptic drugs, urinary stasis, and urinary infections. On the other hand, mechanical ventilation can impair renal function by reduction of cardiac output, redistribution of intrarenal blood flow and stimulation of sympathetic and hormonal pathways. Children requiring long-term invasive home mechanical ventilation may have other comorbid conditions, including urinary system diseases, which become manifest as these patients are being kept alive due to the advances in ventilation strategies. These children must be carefully observed for urological complications and managed accordingly to prevent kidney injury.

Long-term Renal Preservation and Complication Profile With Ileal Ureter Creation

OBJECTIVE

To examine long-term ileal ureter replacement results at over 32 years at our institution. Long segment or proximal ureteral strictures pose a challenging reconstructive problem. Ureteroureterostomy, psoas hitch, Boari flap, buccal ureteroplasty, and autotransplantation are common reconstructive techniques. We show that ileal ureter remains a lasting option.

METHODS

We performed a retrospective review of patients undergoing open ileal ureter creation from 1989-2021. Patient demographics, operative history, and complications were examined. All patients were followed for changes in renal function. Demographic data were analyzed and Cox proportional hazard models were performed.

RESULTS

One hundred and fifty-eight patients were identified with median follow-up time of 40 months. Eighty-one percent had a unilateral ileal ureter creation. Fifty percent were female, median age was 53.3. Twenty-seven percent of patients had radiation-induced strictures. Preoperatively, 56.3% of patients were chronic kidney disease stage 1-2 and 43.7% were stage 3-5. Post-operatively, 54% were stage 1-2 and 46% were stage 3-5. Cox proportional hazard models demonstrated no significant correlation between worsening renal function and stricture cause, bilateral repair, complications, or sex (biologically male or female). Seventy-seven percent had no 30-day complications. Clavien complications included grade 1 (18), grade 2 (4), grade 3 (9), and grade 4 (5). Long-term complications included worsening renal function (3%), incisional hernia (8.2%), and small bowel obstruction (6.9%). Five (3.1%) patients ultimately required dialysis and 5 (3.1%) patients developed metabolic acidosis.

CONCLUSION

Ileal ureteral reconstruction is often a last resort for patients with complex ureteral injuries. Clinicians can be reassured by our long-term data that ileal ureteral creation is a safe treatment with good preservation of renal function and low risk of hemodialysis and metabolic acidosis.

Advances in Urinary Diversion: From Cutaneous Ureterostomy to Orthotopic Neobladder Reconstruction-A Comprehensive Review

Bladder cancer ranks as the 10th most prevalent cancer globally with an increasing incidence. Radical cystectomy combined with urinary diversion represents the standard treatment for muscle-invasive bladder cancer, offering a range of techniques tailored to patient factors. Overall, urinary diversions are divided into non-continent and continent. Among the first category, cutaneous ureterostomy and ileal conduit represent the most common procedures while in the second category, it could be possible to describe another subclassification which includes ureterosigmoidostomy, continent diversions requiring catheterization and orthotopic voiding pouches and neobladders. In this comprehensive review, urinary diversions are described in their technical aspects, providing a summary of almost all alternatives to urinary diversion post-radical cystectomy.

Management of neurogenic bladder in patients with spinal cord injuries/disorders and end stage renal disease: a case series

INTRODUCTION

Patients with spinal cord injuries/disorders (SCI/D) often suffer from bladder dysfunction, commonly referred to as neurogenic bladder or neurogenic lower urinary tract dysfunction (NLUTD). Standard urologic evaluation and management help to minimize complications such as vesicoureteral reflux, urinary tract infection, and nephrolithiasis. However, we have further encountered patients with more complex issues, such as chronic kidney disease (CKD), end-stage renal disease (ESRD), bilateral nephrectomies, and urinary diversion/augmentation surgeries. Of particular interest, there is a lack of standardized guidance for bladder management in SCI/D patients with ESRD. These patients are at high risk for urological complications and would benefit from codified bladder management strategies.

CASE PRESENTATION

In this article, we present eleven unique cases of NLUTD with associated ESRD and discuss recommendations utilizing simple and commonly available clinical interventions.

DISCUSSION

The inherently small population size of SCI/D patients with NLUTD and ESRD makes detailing a large sample size case series difficult. Future studies must aim to include a larger sample size as able, however, to better determine standardized protocols for chronic bladder management in SCI/D patients with NLUTD and ESRD. Experiences from this small case series are offered for consideration.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

[Update on ureteral reconstruction 2024]

Ureteral strictures can occur along the entire course of the ureter and have many different causes. Factors involved in the development include, among other things, congenital anomalies, iatrogenic injuries during endoscopic as well as open or minimally invasive visceral surgical, gynecological, and urological procedures as well as prior radiation therapy. Planning treatment for ureteral strictures requires a detailed assessment of stricture and patient characteristics. Given the various options for ureteral reconstruction, various methods must be considered for each patient. Short-segment proximal strictures and strictures at the pyeloureteral junction are typically surgically managed with Anderson-Hynes pyeloplasty. End-to-end anastomosis can be performed for short-segment proximal and middle ureteral strictures. Distal strictures are treated with ureteroneocystostomy and are often combined with a Boari and/or Psoas Hitch flap. Particularly, the treatment of long-segment strictures in the proximal and middle ureter remain a surgical challenge. The use of bowel interposition is an established treatment option for this, offering good functional results but also potential associated complications. Robot-assisted surgery is increasingly becoming a minimally invasive treatment alternative to reduce hospital stays and optimize postoperative recovery. However, open surgical ureteral reconstruction remains an established procedure, especially after multiple previous abdominal operations.

A Modification of the Newborn Operation for Cloacal Exstrophy: Leaving the Cecal Plate Untouched

The conventional approach to managing a newborn with cloacal exstrophy typically includes separating the cecal plate from between the two hemibladders, tubularizing it to be included in the fecal stream, creating an end colostomy, and bringing the two bladder halves together. This study introduces an alternative approach wherein the cecal plate is retained in its original position and designated for future use as an autoaugment of the bladder. Four cases of cloacal exstrophy cases managed between November 2019 and February 2024 are described, with surgical approach and postoperative outcomes reported. Two patients who underwent traditional reconstruction experienced bacterial overgrowth attributed to stasis in the cecal plate, which manifested in increased ostomy output and feeding intolerance. Treatment in these two cases was to remove the cecum from the fecal stream and use it instead for a bladder augment. Learning from these cases, the third and fourth newborn's approach involved retaining the cecum in situ for autoaugmentation of the bladder and performing an ileal to hindgut anastomosis. No postoperative acidosis occurred in these patients. The alternative approach to the newborn management of cloacal exstrophy whereby the cecal plate is left in situ can decrease stasis and postoperative bacterial overgrowth. It allows for an autoaugmentation of the bladder and is technically easier than the traditional rescue of the cecal plate from within the two hemibladders.

Ileal conduit to small intestine fistula following extensive abdominopelvic resection and radiation for metastatic colon cancer

A woman in her mid-60s presented with decreased output from urostomy, which was an opening from the neobladder (ileal conduit). Presentation was preceded by a 6-month history of alternating faecaluria and increased colostomy output. Laboratory studies were notable for normal anion gap metabolic acidosis. Creatinine level of the colostomy output was 17.7 mg/dL, a finding indicative of the presence of urine in the sample. CT enterography and X-ray loopogram confirmed neobladder to small intestine fistula.Neobladder creation is commonly performed in patients with bladder cancer requiring resection. Fistulas between the neobladder and intestine are observed in fewer than 2.7% of cases. The patient's history of extensive abdominopelvic resection, colostomy creation and radiation likely contributed to fistula development. We highlight the need for a high index of suspicion for a fistula in a patient with a neobladder experiencing recurrent urinary tract infections or a high colostomy output concurrently with low neobladder output.

Bladder Replacement Therapy

The bladder, as a vital organ of the urinary system, facilitates urine storage and micturition. The bladder can store urine under low pressure, sense volume changes, and coordinate with the urethral sphincter to ensure autonomous and efficient urination and bladder emptying. However, irreversible bladder damage may result from various conditions, such as nerve injuries, aging, or metabolic syndrome, compromising its normal physiological functions and necessitating various interventions for anatomical and functional bladder replacements. This review aimed to summarize advances on anatomical and functional bladder replacements.

Regeneration of Functional Bladder Using Cell-seeded Amnion and P(LA/CL) Scaffolds

BACKGROUND

Long-term bladder regeneration hasn't been successful instead of augmentation with gastrointestinal segments, as is commonly performed for bladder reconstruction. To evaluate whether or not cell-seeded bioabsorbable materials regenerate half-resected bladder in a rabbit model.

EXPERIMENT

Female Japanese white rabbits were divided two groups: cell-seeded material (CSM) group and Control (n=6 each). Control rabbits underwent resection of half the bladder. CSM rabbits were sutured with cell-seeded amniotic membrane and P(LA/CL) material after bladder resection. After 6, 12, and 18 months, rabbits underwent X-ray and cystometry, and bladder tissues after 18 months were subjected to functional and histological analyses.

RESULTS

X-ray confirmed the peristaltic movements of the reconstructed bladders in the CSM group. On cystometry, the mean maximum bladder volume, maximum bladder pressure, and 25 mL bladder volume compliance in the CSM group were significantly greater than in the control group at 6, 12, and 18 months. In addition, organ bath studies showed good contraction under electrical stimulation with increasing stimulation frequency in the CSM group, while, the control group showed weak contraction on both tests in the central marginal zone. Furthermore, the rates of neo-vascularization, urothelial and smooth muscle formation and neurofilamentation in the CSM group were significantly greater than in the control group.

CONCLUSIONS

Oral mucosal cell-seeded amniotic membrane and stomach smooth muscle cell- seeded P(LA/CL) scaffold with omentum after abdominal implantation regenerated functional bladder with satisfactory epithelium and smooth muscle without scarring more than one year.

Male urethral stricture disease. Why management guidelines are challenging in low-income countries

Urethral stricture disease is one of the commonest urological pathologies in adult men in low or low-middle income countries, providing a significant work burden for the small number of specialist surgeons who are able to provide appropriate treatment. The underlying causes of anterior urethral stricture relate to urethral fibrosis from sexually transmitted infection, with posterior urethral disruption secondary to pelvic trauma being an equally common cause of stricture disease in many countries in sub-Saharan Africa. Anterior urethral strictures are often long, and multifocal, and bulbo-prostatic disruptions are usually due to relatively low-velocity pelvic trauma. The management options available in resource poor settings are often severely limited by the individual's ability to pay for care, the availability of a specialist surgeon and, importantly, a shortage of functioning endoscopic equipment for less-invasive treatments. Consequently, reconstructive surgery is often regarded by the patient, and surgeon, as the most cost-effective and, therefore, primary means of treating a urethral stricture once urethral dilatation has failed. Regional anaesthetic techniques have limited the adoption of free graft augmentation as an alternative to pedicled flaps of locally available skin for reconstruction, whilst an inability to provide tension-free bulbo-prostatic anastomoses has negatively impacted the outcome from the treatment of pelvic fracture disruption injuries in much of sub-Saharan Africa. Urolink has, however, found that local surgeons can be taught sustainable skills required for successful complex urethroplasty when supported by longitudinal mentorship in the management of difficult clinical issues. Evidence-based practice is known to improve the standard of care in specific conditions in high-income countries, including the management of male urethral stricture disease. However, guidelines developed in high-income countries aren't necessarily appropriate for stricture management in less well-resourced healthcare environments, but could be adapted to help improve the delivery of stricture care for men in low- or low-middle income countries.

Biomaterials assisted reconstructive urology: The pursuit of an implantable bioengineered neo-urinary bladder

Urinary bladder is a dynamic organ performing complex physiological activities. Together with ureters and urethra, it forms the lower urinary tract that facilitates urine collection, low-pressure storage, and volitional voiding. However, pathological disorders are often liable to cause irreversible damage and compromise the normal functionality of the bladder, necessitating surgical intervention for a reconstructive procedure. Non-urinary autologous grafts, primarily derived from gastrointestinal tract, have long been the gold standard in clinics to augment or to replace the diseased bladder tissue. Unfortunately, such treatment strategy is commonly associated with several clinical complications. In absence of an optimal autologous therapy, a biomaterial based bioengineered platform is an attractive prospect revolutionizing the modern urology. Predictably, extensive investigative research has been carried out in pursuit of better urological biomaterials, that overcome the limitations of conventional gastrointestinal graft. Against the above backdrop, this review aims to provide a comprehensive and one-stop update on different biomaterial-based strategies that have been proposed and explored over the past 60 years to restore the dynamic function of the otherwise dysfunctional bladder tissue. Broadly, two unique perspectives of bladder tissue engineering and total alloplastic bladder replacement are critically discussed in terms of their status and progress. While the former is pivoted on scaffold mediated regenerative medicine; in contrast, the latter is directed towards the development of a biostable bladder prosthesis. Together, these routes share a common aspiration of designing and creating a functional equivalent of the bladder wall, albeit, using fundamentally different aspects of biocompatibility and clinical needs. Therefore, an attempt has been made to systematically analyze and summarize the evolution of various classes as well as generations of polymeric biomaterials in urology. Considerable emphasis has been laid on explaining the bioengineering methodologies, pre-clinical and clinical outcomes. Some of the unaddressed challenges, including vascularization, innervation, hollow 3D prototype fabrication and urinary encrustation, have been highlighted that currently delay the successful commercial translation. More importantly, the rapidly evolving and expanding concepts of bioelectronic medicine are discussed to inspire future research efforts towards the further advancement of the field. At the closure, crucial insights are provided to forge the biomaterial assisted reconstruction as a long-term therapeutic strategy in urological practice for patients' care.

Hyperchloremic Metabolic Acidosis with Hyperglycemic Hyperosmolar Syndrome after Robot-Assisted Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion: A Case Report

Hyperchloremic metabolic acidosis can be a problem in urinary diversion using the ileum. A 73-year-old Japanese male was hospitalized in emergency due to anorexia and malaise 3 weeks after being discharged from the hospital after getting robot-assisted radical cystoprostatectomy and intracorporeal ileal conduit urinary diversion. The blood analysis revealed metabolic acidosis, elevated chloride ions, and marked hyperglycemia: he was diagnosed with hyperchloremic metabolic acidosis and hyperglycemic hyperosmolar syndrome. We started administering insulin and large amounts of fluid replacement; besides, we inserted a large-diameter open tip catheter into the ileal conduit in hopes of inhibiting urine reabsorption in the intestinal mucosa. His general condition gradually improved, and he was discharged 10 days after his hospitalization.

Optimizing Nutritional Status in Patients Undergoing Radical Cystectomy: A Systematic Scoping Review

BACKGROUND

Nutrition is a modifiable risk factor for patients undergoing multimodal oncologic interventions and plays a major supportive role in the setting of bladder cancer. For patients undergoing radical cystectomy (RC), malnutrition is associated with increased postoperative complications and mortality.

OBJECTIVES

The purpose of this scoping review is to characterize the role of nutritional interventions for patients undergoing RC for bladder cancer.

METHODS

A multi-database systematic scoping review based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) guidelines was performed. Search terms were developed a priori to identify clinical trials that focused on nutritional interventions for patients with bladder cancer undergoing RC. Eligible articles were original research articles or abstracts from clinical trials evaluating nutritional interventions in adult patients undergoing RC. Articles were excluded if they did not focus on a nutritional intervention, if patients did not carry a diagnosis of bladder cancer, or if RC was not performed. Articles were reviewed independently by the authors, and inclusion/exclusion were based on consensus agreement.

RESULTS

A total of 83 articles were identified, of which 17 were included in the final analysis. A total of 49 articles were excluded during abstract screening. An additional 17 articles were excluded based on the review of full-text articles. Results of the scoping review suggest that data on the use of nutritional screening, assessment, and intervention for patients undergoing RC are scarce. Although parenteral nutrition (PN) appears to be associated with greater complications after RC, early introduction of food postoperatively or feeding enterally offers benefit and immunonutrition supplements with a focus on a high protein diet has the potential to better optimize surgical outcomes.

CONCLUSIONS

Although the prevalence and consequences of malnutrition among patients undergoing RC are well-established, there are limited data evaluating the use of nutritional screening, assessment, and interventions for this population. The pursuit of future clinical trials in this space is critical.

Anorexia and Starvation Related Duodenal Villous Atrophy in an Adult Patient

Coeliac disease is the most well-known cause of villous atrophy in duodenal biopsies. Other well recognised causes of villous atrophy include infection with Giardiaduodenalis and HIV, peptic duodenitis, drug-induced enteropathy, common variable immunodeficiency, Crohn’s disease, Whipple’s disease, small intestinal bacterial overgrowth, eosinophilic gastroenteritis, tropical or collagenous sprue and autoimmune enteropathy. While mucosal adaptation due to malnutrition, leading to villous atrophy, has been reported in paediatric populations in Africa and South America, in hibernating animals and animal models of experimental starvation, there is very little literature on adult human subjects. We report a case of a 76-year-old gentleman, presenting with chronic metabolic acidosis and anorexia who was found to have villous atrophy on duodenal biopsy, in the absence of any evidence of coeliac disease or other non-coeliac enteropathy. The nutritional state improved with correction of the underlying metabolic abnormality, and serial endoscopic assessment showed improvement in the villous atrophy. We discuss the relationship between malnutrition and villous atrophy, and suggest a potential workup for non-coeliac villous atrophy.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines

BACKGROUND

Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. So, clear and comprehensive clinical guidelines based on evidence-based data and best practice are needed. This article aims to elaborate guidelines for practice management of urinary stomas in adults.

METHODS

Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care" and "stoma reversal". The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.

RESULTS

After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.

CONCLUSIONS

These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

Urinary diversions: a primer of the surgical techniques and imaging findings

OBJECTIVE

The article attempts to describe the indications, classification, and surgical anatomy of the commonly performed urinary diversion procedures, followed by the imaging protocol and radiological appearances of the normal postoperative anatomy and complications related to these procedures.

CONTENTS

Diversion procedures are used to reroute urine after cystectomy and in patients with refractory neurogenic or outlet obstruction of the urinary bladder. Broadly, these can be classified as continent and incontinent diversions. Patients with urinary diversions frequently undergo radiological investigations for the detection of complications. Commonly, a loopogram or pouchogram is performed few weeks after the surgery to look for leak, whereas CT or MRI is used for long-term follow-up. Postoperative complications can be early (within 30 days of the surgery) or delayed and include leaks, collections, strictures, calculi, parastomal hernia, small bowel obstruction, and oncologic recurrence.

CONCLUSION

A variety of urinary diversion procedures are commonly performed and interpretation of the postsurgical anatomy can be overwhelming for the general radiologist. This article provides a basic understanding of the normal anatomy as well as a thorough discussion on the imaging protocol and radiological appearances of the potential complications associated with these procedures.

Urogenital tuberculosis - epidemiology, pathogenesis and clinical features

Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6-9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12-24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.

Urostomy Care: A Guide for Home Care Clinicians

This article focuses on the care and management of patients living with a urostomy. Improved surgical techniques and shortened hospital stays result in more patients receiving home care in the immediate postoperative period after surgical creation of a urostomy. It is important that home care clinicians have the knowledge and skills to manage the care of patients with a urostomy from hospital discharge to self-care. This article reviews the anatomy and physiology of the urinary tract, the formation of a stoma, and indications for the creation of a urostomy. Stent management, peristomal skin care, stomal complications as well as pouching options and accessories are discussed. Knowledge of care of patients with a urostomy can reduce the risk of complications and hospital readmissions, and assist patients to adjust to life with a urostomy.

A rare case of hyperammonaemic encephalopathy

A 75-year-old female patient presented to the accident and emergency department following a collapse. She was treated for a saddle pulmonary embolism and underlying urinary tract infection. However, 48 hours later she was found to have reduced consciousness with no apparent cause (Glasgow Coma Scale of 8 out of 15). Subsequent blood results revealed a highammonia level. After reflection into her medical history, it was found that she had bladder exstrophy, which was managed with urinary diversion surgery as an infant, and her presentation was a rare complication of this operation.

Understanding the role of mesenchymal stem cells in urinary bladder regeneration-a preclinical study on a porcine model

BACKGROUND

The tissue engineering of urinary bladder advances rapidly reflecting clinical need for a new kind of therapeutic solution for patients requiring urinary bladder replacement. Majority of the bladder augmentation studies have been performed in small rodent or rabbit models. Insufficient number of studies examining regenerative capacity of tissue-engineered graft in urinary bladder augmentation in a large animal model does not allow for successful translation of this technology to the clinical setting. The aim of this study was to evaluate the role of adipose-derived stem cells (ADSCs) in regeneration of clinically significant urinary bladder wall defect in a large animal model.

METHODS

ADSCs isolated from a superficial abdominal Camper's fascia were labeled with PKH-26 tracking dye and subsequently seeded into bladder acellular matrix (BAM) grafts. Pigs underwent hemicystectomy followed by augmentation cystoplasty with BAM only (n = 10) or BAM seeded with autologous ADSCs (n = 10). Reconstructed bladders were subjected to macroscopic, histological, immunofluoresence, molecular, and radiological evaluations at 3 months post-augmentation.

RESULTS

Sixteen animals (n = 8 for each group) survived the 3-month follow-up without serious complications. Tissue-engineered bladder function was normal without any signs of post-voiding urine residual in bladders and in the upper urinary tracts. ADSCs enhanced regeneration of tissue-engineered urinary bladder but the process was incomplete in the central graft region. Only a small percentage of implanted ADSCs survived and differentiated into smooth muscle and endothelial cells.

CONCLUSIONS

The data demonstrate that ADSCs support regeneration of large defects of the urinary bladder wall but the process is incomplete in the central graft region. Stem cells enhance urinary bladder regeneration indirectly through paracrine effect.

Follow-up Management of Cystectomy Patients

Bladder cancer is the sixth leading cancer in the United States. Radical cystectomy is a lifesaving procedure for bladder cancer with or without muscle invasion. Radical cystectomy is performed on 39% of these patients, and 35% will have a life-threatening recurrence. Distant metastases are the most common; local, upper tract, and urethral recurrence can also occur. Surveillance after cystectomy is critical to diagnosing recurrence early. Functional complications after urinary diversion include bowel dysfunction, vitamin B12 deficiency, acidosis, electrolyte abnormalities, osteopenia, nephrolithiasis, urinary tract infections, renal functional decline, and urinary obstruction, which can be reversed when diagnosed early.

ENERGY HOMEOSTASIS OF THE ARTIFICIAL BLADDER IN EXPERIMENTAL CONDITIONS

Patients with malignant neoplasms of the bladder or severe anatomical and functional bladder abnormalities are the candidates for cystectomy and orthotopic urine diversion. The distal portion of the ileum is the most frequent anatomical organ, which is used for the formation of the urinary conduit. The formation of a urinary reservoir from the ileum that is unable to perform new functions, and mainly programmed to isolate enzymes, digest food and absorb nutrients, salts and minerals changes the energy exchange in the ileum wall under the influence of urine. The aim of the research is the examination of energy metabolism changes in the ileum wall during the formation of artificial bladder in experimental conditions conducted on mini-pigs. Experimental studies were performed on 21 female mini-pigs with an average age of 6 to 14 months. The duration of the experiment was 12 months. An imbalance of the ATP-ADP-AMP system was observed in the transplant tissue of the graft in different postoperative periods. Changes in the level of ATP are characteristics of the development of tissue ischemia. Results. The values of the adenosine nucleotides sum (the energy potential indicative of the respiration rate of mitochondria) and the phosphorylation index were lower at different times of observation in the transplant tissue. The energy charge value was lower to a lesser extent relative to the control. Conclusion. The revealed changes in the level of adenosine nucleotides confirm the severity of the disturbances of the energy homeostasis in the transplant tissue at all stages of the observation.

Concise Review: Tissue Engineering of Urinary Bladder; We Still Have a Long Way to Go?

Regenerative medicine is a new branch of medicine based on tissue engineering technology. This rapidly developing field of science offers revolutionary treatment strategy aimed at urinary bladder regeneration. Despite many promising announcements of experimental urinary bladder reconstruction, there has been a lack in commercialization of therapies based on current investigations. This is due to numerous obstacles that are slowly being identified and precisely overcome. The goal of this review is to present the current status of research on urinary bladder regeneration and highlight further challenges that need to be gradually addressed. We put an emphasis on expectations of urologists that are awaiting tissue engineering based solutions in clinical practice. This review also presents a detailed characteristic of obstacles on the road to successful urinary bladder regeneration from urological clinician perspective. A defined interdisciplinary approach might help to accelerate planning transitional research tissue engineering focused on urinary tracts. Stem Cells Translational Medicine 2017;6:2033-2043.

OSTEOMALACIA AS A RESULT OF URINARY DIVERSION

A 54 years old man, who had undergone a cystectomy and urinary diversion surgery 31 years previously, complained of progressive generalized bone pain, muscle weakness and walking abnormality for six months. Laboratory investigations revealed elevated alkaline phosphatase, high serum chloride level and metabolic acidosis. Osteomalacia was suspected due to clinical and laboratory findings. Osteomalacia due to hyperchloremic metabolic acidosis is a complication of urinary diversion. Regular monitoring of pH, chloride, bicarbonate, and calcium-phosphorus metabolism is therefore essential for early diagnosis and treatment.

Metabolic and Electrolyte Abnormalities Related to Use of Bowel in Urologic Reconstruction

Many urologic reconstructive techniques involve the use of autologous bowel for urinary diversion and bladder augmentation. The resection of bowel and its reimplantation into the urinary system often comes with a variety of metabolic and electrolyte derangements, depending on the type of bowel used and the quantity of urine it is exposed to in its final anatomic position. Clinicians should be aware of these potential complications due to the serious consequences that may result from uncorrected electrolyte disturbances. This article reviews the common electrolyte complications related to both bowel resection and the interposition of bowel within the urinary tract.

Ileal Neobladder: An Important Cause of Non-Anion Gap Metabolic Acidosis

BACKGROUND

The differential diagnosis for a non-anion gap metabolic acidosis is probably less well known than the differential diagnosis for an anion gap metabolic acidosis. One etiology of a non-anion gap acidosis is the consequence of ileal neobladder urinary diversion for the treatment of bladder cancer.

CASE REPORT

We present a case of a patient with an ileal neobladder with a severe non-anion gap metabolic acidosis caused by a urinary tract infection and ureteroenterostomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Part of the ileal neobladder surgery includes ureteroenterostomy and predisposes patients to several clinically significant metabolic derangements, including a non-anion gap metabolic acidosis. These patients have an increased chronic acid load, bicarbonate deficit, and hypokalemia, which should be appreciated when resuscitating these patients.

Robot-assisted ureteral reconstruction using a tubularized peritoneal flap: a novel technique in a chronic porcine model

OBJECTIVE

To evaluate the feasibility and functional outcomes in porcine models of a novel robotic surgical technique for the treatment of complex ureteral injuries and strictures.

MATERIALS AND METHODS

Six pigs underwent robotic ureteral reconstruction using a long tabularized peritoneal flap and followed for 6-9 weeks after the surgery. Ureteral flap vascularity, intra-renal pressure, patency of the conduct, endoscopic aspect of the flap, renal function and histopathology were evaluated.

RESULTS

All animals successfully underwent ureteral reconstruction using a tubularized peritoneal flap. Median operative time was 223 min (162-360). Flap tubularization suture took 31 min (19-47), and proximal anastomosis took 20 min (15-38). Bladder mobilization with psoas hitch and distal anastomosis took 9 min (7-12) and 23 min (13-46), respectively. On follow-up, significant shrinkage of the ureteral flap in both length and width was observed. Antegrade pyelograms confirmed dilation and tortuosity of the proximal ureter, dilation of the renal pelvis, and major and minor calyxes without any definitive strictures. Microscopically, focal urothelial lining was seen in the neoureter. Creatinine level was significantly higher at the end of the follow-up period (p = 0.003).

CONCLUSIONS

Robot-assisted ureteral reconstruction using a tubularized peritoneum flap is technically feasible and reproducible. The flap sustained abundant vascular supply after different intervals of follow-up and the peritoneal mesenchymal cells differentiated into urothelium and myofibroblasts. Further studies are needed to address the issue of functional obstruction to improve long-term renal function outcomes.

Bacterial Cellulose-Based Biomimetic Nanofibrous Scaffold with Muscle Cells for Hollow Organ Tissue Engineering

In this study, we built a bilayer nanofibrous material by utilizing the gelatinization properties of potato starch (PS) to interrupt bacterial cellulose (BC) assembly during static culture to create more free spaces within the fibrous network. Then, muscle cells were cultured on the loose surface of the BC/PS scaffolds to build biomaterials for hollow organ reconstruction. Our results showed that the BC/PS scaffolds exhibited similar mechanical characters to those in the traditional BC scaffolds. And the pore sizes and porosities of BC/PS scaffolds could be controlled by adjusting the starch content. The average nanofiber diameters of unmodified BC and BC/PS composites is approximately to that of the urethral acellular matrix. Those scaffolds permit the muscle cells infiltration into the loose layer and the BC/PS membranes with muscle cells could enhance wound healing in vivo and vitro. Our study suggested that the use of bilayer BC/PS nanofibrous scaffolds may lead to improved vessel formation. BC/PS nanofibrous scaffolds with muscle cells enhanced the repair in dog urethral defect models, resulting in patent urethra. Improved organized muscle bundles and epithelial layer were observed in animals treated with BC/PS scaffold seeded by muscle cells compared with those treated with pure BC/PS scaffold. This study suggests that this biomaterial could be suitable for tissue engineered urinary tract reconstruction and this type of composite scaffold could be used for numerous other types of hollow organ tissue engineering grafts, including vascular, bladder, ureter, esophagus, and intestine.