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ILEAL NEOBLADDER CREATION IN A PATIENT WITH RENAL INSUFFICIENCY
0022-5347/00/1631-0236/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 163, 236, January 2000 Printed in U.S.A.
ILEAL NEOBLADDER CREATION IN A PATIENT WITH RENAL INSUFFICIENCY L. ERIC OLSSON, HUBERT S. SWANA
AND
BERNARD LYTTON
From the Section of Urology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut KEY WORDS: bladder, kidney, urinary diversion, ileum
The complications of urinary diversion with intestinal segments are well known. We report 12-month followup of a man with renal insufficiency who underwent construction of an ileal neobladder after total cystoprostatectomy. CASE REPORT
A 34-year-old man presented with shortness of breath and weakness. He had profound anemia and renal failure. Hematocrit was 13% (normal 40 to 52) and creatinine was 6 mg./dl. (normal 0.5 to 1.2). Noncontrast computerized tomography revealed bilateral hydroureteronephrosis and a large bladder mass. Cystoscopy showed abnormal bladder mucosa and bimanual examination revealed a large mobile mass. Pathological examination demonstrated grade II/IV transitional cell carcinoma with lamina propria invasion. After bilateral nephrostomy tube placement creatinine stabilized at 3.7 mg./dl. and creatinine clearance was 23.6 ml. per minute. Radical nerve sparing cystoprostatectomy and bilateral pelvic lymphadenectomy were performed with the creation of an ileal neobladder on February 19, 1998. The neobladder was fashioned from 60 cm. of ileum placed in a W configuration. Ureteroileal anastomoses were performed without antireflux considerations. The bladder contained a huge mass of thickened papilliferous tumor occupying the entire mucosal surface of the bladder. Histological examination revealed a grade II/IV pT1N0M0 lesion. Convalescence was uneventful. At 2-month followup the patient was able to void without any significant residual urine. He is working full time and is sexually active. Renal function has been followed closely by evaluation of serum creatinine and electrolytes (see figure). Protein has been restricted to 40 gm. daily and 9,100 mg. sodium bicarbonate supplementation has been recommended to control metabolic acidosis. At 12-month followup creatinine was 3.2 mg./dl. and metabolic acidosis was well controlled.
Renal function. Left arrow indicates date when 5,200 mg. per day of sodium bicarbonate were added to diet. Right arrow indicates date when additional supplementation of 3,900 mg. per day sodium bicarbonate began. Co2, carbon dioxide.
DISCUSSION
CONCLUSIONS
Metabolic complications after urinary diversion with intestinal segments have been well described. Use of ileal and colonic segments results in a hyperchloremic metabolic acidosis, jejunal segments cause hyponatremic, hyperkalemic acidosis and gastric segments cause hypochloremic alkalosis. Chronic renal insufficiency has long been considered a contraindication to continent urinary reservoirs. Some have argued against the use of ileal1 and gastric2 segments in patients in whom the serum creatinine exceeds 2 mg./dl. With ileal segments impaired renal function may result in the inability to compensate for the increased resorption of cations by the intestinal mucosa. Impaired bicarbonate secretion with a gastric segment places the patient with renal impairment at risk for refractory systemic alkalosis. Interestingly, Chiang et al recently reported on a gastroileal neobladder in a patient with renal insufficiency.3 At 2-year followup no systemic acidosis or alkalosis had occurred and renal function was essentially unchanged.
We managed hyperchloremic metabolic acidosis in our patient with systemic alkalization, and renal function has remained stable. Patients with moderate renal insufficiency may be able to tolerate the increased metabolic stress of an orthotopic ileal neobladder if they are willing to take significant supplements of sodium bicarbonate. Further long-term experience with continent urinary diversion in patients with renal impairment is needed. We believe that continent urinary diversion with intestinal segments can be performed in select patients with renal insufficiency.
Accepted for publication August 13, 1999. 236
REFERENCES
1. Wenderoth, U. K., Bachor, R., Egghart, G. et al: The ileal neobladder: experience and results of more than 100 consecutive cases. J Urol, 143: 492, 1990. 2. McDougal, W. S.: Metabolic complications of urinary intestinal diversion. J Urol, 147: 1199, 1992. 3. Chiang, P. H., Huang, Y-S., Wu, W. J. et al: The gastroileal neobladder for renal insufficiency. J Urol, 158: 1905, 1997.
Vol. 163, 236, January 2000 Printed in U.S.A.
ILEAL NEOBLADDER CREATION IN A PATIENT WITH RENAL INSUFFICIENCY L. ERIC OLSSON, HUBERT S. SWANA
AND
BERNARD LYTTON
From the Section of Urology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut KEY WORDS: bladder, kidney, urinary diversion, ileum
The complications of urinary diversion with intestinal segments are well known. We report 12-month followup of a man with renal insufficiency who underwent construction of an ileal neobladder after total cystoprostatectomy. CASE REPORT
A 34-year-old man presented with shortness of breath and weakness. He had profound anemia and renal failure. Hematocrit was 13% (normal 40 to 52) and creatinine was 6 mg./dl. (normal 0.5 to 1.2). Noncontrast computerized tomography revealed bilateral hydroureteronephrosis and a large bladder mass. Cystoscopy showed abnormal bladder mucosa and bimanual examination revealed a large mobile mass. Pathological examination demonstrated grade II/IV transitional cell carcinoma with lamina propria invasion. After bilateral nephrostomy tube placement creatinine stabilized at 3.7 mg./dl. and creatinine clearance was 23.6 ml. per minute. Radical nerve sparing cystoprostatectomy and bilateral pelvic lymphadenectomy were performed with the creation of an ileal neobladder on February 19, 1998. The neobladder was fashioned from 60 cm. of ileum placed in a W configuration. Ureteroileal anastomoses were performed without antireflux considerations. The bladder contained a huge mass of thickened papilliferous tumor occupying the entire mucosal surface of the bladder. Histological examination revealed a grade II/IV pT1N0M0 lesion. Convalescence was uneventful. At 2-month followup the patient was able to void without any significant residual urine. He is working full time and is sexually active. Renal function has been followed closely by evaluation of serum creatinine and electrolytes (see figure). Protein has been restricted to 40 gm. daily and 9,100 mg. sodium bicarbonate supplementation has been recommended to control metabolic acidosis. At 12-month followup creatinine was 3.2 mg./dl. and metabolic acidosis was well controlled.
Renal function. Left arrow indicates date when 5,200 mg. per day of sodium bicarbonate were added to diet. Right arrow indicates date when additional supplementation of 3,900 mg. per day sodium bicarbonate began. Co2, carbon dioxide.
DISCUSSION
CONCLUSIONS
Metabolic complications after urinary diversion with intestinal segments have been well described. Use of ileal and colonic segments results in a hyperchloremic metabolic acidosis, jejunal segments cause hyponatremic, hyperkalemic acidosis and gastric segments cause hypochloremic alkalosis. Chronic renal insufficiency has long been considered a contraindication to continent urinary reservoirs. Some have argued against the use of ileal1 and gastric2 segments in patients in whom the serum creatinine exceeds 2 mg./dl. With ileal segments impaired renal function may result in the inability to compensate for the increased resorption of cations by the intestinal mucosa. Impaired bicarbonate secretion with a gastric segment places the patient with renal impairment at risk for refractory systemic alkalosis. Interestingly, Chiang et al recently reported on a gastroileal neobladder in a patient with renal insufficiency.3 At 2-year followup no systemic acidosis or alkalosis had occurred and renal function was essentially unchanged.
We managed hyperchloremic metabolic acidosis in our patient with systemic alkalization, and renal function has remained stable. Patients with moderate renal insufficiency may be able to tolerate the increased metabolic stress of an orthotopic ileal neobladder if they are willing to take significant supplements of sodium bicarbonate. Further long-term experience with continent urinary diversion in patients with renal impairment is needed. We believe that continent urinary diversion with intestinal segments can be performed in select patients with renal insufficiency.
Accepted for publication August 13, 1999. 236
REFERENCES
1. Wenderoth, U. K., Bachor, R., Egghart, G. et al: The ileal neobladder: experience and results of more than 100 consecutive cases. J Urol, 143: 492, 1990. 2. McDougal, W. S.: Metabolic complications of urinary intestinal diversion. J Urol, 147: 1199, 1992. 3. Chiang, P. H., Huang, Y-S., Wu, W. J. et al: The gastroileal neobladder for renal insufficiency. J Urol, 158: 1905, 1997.