Unusual presentation of late urological complications after bladder substitution

634

633 LATE

COMPLICATIONS

CLINICALLY

AFTER

RELEVANT?

URINARY

DIVERSION

-

& OBJECTIVES:

Given the relatively high overall rate of

(35.5Y0) of the different

AFTER

OF

BLADDER

LATE

UROLOGICAL

SUBSTITUTION

Urology, Clinical Institute of Urology and Renal Transp., Cluj-Napoca,

Urology, Klinikum Karlsruhe. Karlsruhe, Germany

complications

PRESENTATION

Lucan Mihai, Rotariu Paul, Iacob Gheorghita, Ghervan Liviu, Lucan Valerian

Echtle Dieter, Mueller Elisabeth, Frohneberg Detlef

INTRODUCTION

UNUSUAL

COMPLICATIONS

(N=554)

techniques of urinary diversion, the

INTRODUCTION

& OBJECTIVES:

Romania

Orthotopic bladder substitution (OBS)

brought a new clinical challenge due to unusual presentation of complications. We present our experience with complications in patients with OBS.

question arises as to what the patient can be asked to tolerate. MATERIALS

& METHODS:

In the past IO years (until December 2000), we

performed 554 urinary diversions (mean patient age 65.7 (29.87), more commonly operated on than women, mean follow-up months). 4591554

men 3.8 times

of 63.3 (6-120)

MATERIALS

& METHODS:

Between October 1990 and July 2001,327

OBS

were performed in our institute. Out of them 53 were bladder augmentations. Complications

were noted in I2 patients. The diagnosis was established on

standard and Doppler ultrasound, IVP, retrograde cystogram, and cystoscopy.

patients could be evaluated concerning late complications

(z-3 months): 2071459 (45%) ileal neobladder, 671459 (I 5%) Maim Pouch I and

RESULTS:

1851459 (40%) ileal conduit.

6 patients. Six patients had small perforations. Mean volume of distension was

Spontaneous bladder perforation due to overdistension

was noted in

6.5 litres (range 3 to I I litres). Endoscopy didn’t reveal any urethral obstacle. RESULTS:

The therapy of late complications shows the following distribution:

Four patients with small leakage were treated conservatively by urethral catheter

All patients with ileus (4/4), and nipple slipping (212). half of the abdominal

insertion and 2 patients with bleeding by open surgery. Other 2 patients had

hernias (2/4),

bladder explosion on the background of chronic retention, due to inclavated

and few cases of reflux

(2123) required reoperations.

Stoma

stricture (9/9). anastomosis stricture (13113). and few patients with retlux (4123) underwent minimal invasive endoscopic procedures. Hernias (2/4). mucus (717). acidosis (7/7), retlux (17/23),

and incontinence (32132) could be managed with

maintenance therapy. CONCLUSION:

(range 8-14). Neobladder was not in distension and urine passage was normal. Stones were removed by open surgery. All complications were documented after a mean period of 6.83 years (range 4-9).

Only

open re-intervention.

stones in the urethra. They were treated by open surgery. Gigantic neobladder calculi were encountered in 4 patients. Mean calculi dimension was 10.5 cm

I l/l02

(10.7%)

of late complications had to undergo an

On the other hand, 261102 (25.5%)

patients could be

treated with minimally invasive therapy and 651102 (638%‘) with maintenance

CONCLUSION: produce

The lack of specific symptoms in patients with OBS may

overdistension

and wall

rupture.

Overdistension

by postponing

urination may produce small perforations which can be treated conservatively.

therapy. The high number of relatively minor complications casts the overall rate

Urethral obstruction due to stones produce acute overdistension that may lead to

in a more relative light, which in our opinion also justifies continent urinary

bladder explosion. Giant calculi are not obstructive and need open surgery for

diversion in palliative medicine as well.

extraction.

635 POSTOPERATIVE CONSTITUENTS RESULTS

RESORPTION BY THE ILEAL

Rinnab Ludwig, Gnann Ralf, Juergcn. Hautmann Richard

AND EXCRETION OF URINARY NEOBLADDER - PRELIMINARY

Straub Michael.

Braendle

Edgar. Gschwend

Urology, University of Ulm, Ulm, Germany INTRODUCTION & OBJECTIVES: For the treatment of invasive bladder cancer radical cystectomy and orthotopic bladder replacement has become the standard procedure. Postoperatively. mild metabolic acidosis does often occur and needs pharmacological correction. Although the protone resorption by reservoirs using ileum is well known, its resorptive and excretory capacity for urinary constituents is not well characterised. MATERIALS & METHODS: We investigated 2X patient\ (27 males, I female) with an ileal neobladder, that underwent radical cystectomy because of invasive bladder cancer. Preoperatively all patients had normal retention parameters. Before and after withdrawal of the transurethral catheter at day 21, serum analyses of creatininc and urea were performed. To assess the resorptivje and/or excretory function changes in creatinine and urea values before and after catheter withdrawal were determined: delta-creatininc and delta-urea were expressedin percent change from baseline. RESULTS: There was a significant correlation between the delta-creatinine and delta-urea values (p
636 CRITICAL EVALUATION OF THE PROBLEM OF CHRONIC RETENTION FOLLOWING ORTHOTOPIC BLADDER SUBSTITUTION IN WOMEN Ali-El-Dein Bedeir, Gomha Mohamed, Ghoneim Mohamed Urology, Urology and Nephrology Centre. Mansoura, Egypt INTRODUCTION & OBJECTIVES: To study the possible causes of chronic retention after urethra-sparing radical cystectomy and orthotopic bladder substitution in women. MATERIALS & METHODS: Between January 1995 and January 2001. I34 women (mean age 52+8 years) underwent standard radical cystectomy and orthotopic substitution for muscle-invasive localised bladder cancer. Videoiurodynamics including pelvic floor EMG were carried out. In addition, pelvic Boor MRI and panendoscopy were conducted. Some technical modifications were adopted in the late cases to decrease the rate of chronic retention. RESULTS: There was no operative mortality and postoperative complications were acceptable. 90 patients were evaluable with a mean follow-up of 36 months. 85 were continent at daytime. 75 at night, 2 totally incontinent and I5 women developed chronic retention. Videoiurodynamics showed that the cause of retention was mechamcal due to falling back of the pouch in the wide pelvic cavity causing acute angulation of the posterior poucho- urethral junction, which increased during voiding. In addition. herniation of the pouch wall through the prolapsed vaginal stump were observed. Pelvic floor EMG demonstrated complete silence of the pelvic floor in these cases during voiding. No abnormality of the pelvic floor or the rhabdosphincter was noted on MRI. Panendoscopy showed normal urethra with no urethroileal stricture. Alpha I-adrenergic blocker (doxazosin. 4 mg daily) given to these women was ineffective. therefore excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal ureteral muscles may be the cause of this problem. Following omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at the time of cystectomy, the incidence of chronic retention decreased from 19% (13167) before to 8.7% (2123) in the latter cases. Also, when the prolapsed vaginal wall was temporarily corrected in women with chronic retention the condition improved markedly. CONCLUSION: A strong evidence has been provided that chronic retention after orthotopic substitution is due to anatomical rather than functional or neurogenic reason. Modifications to increase back support of the pouch with ventral suspension near its dome and to support the vaginal stump are recommended to avoid this complication.

European Urology Supplements 1 (2002) No. 1, pp. 161