Follow-Up after Urinary DiversionFichtner J.
Department of Urology, Mainz University Medical School, Mainz, Germany
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With modern forms of urinary diversion being widely employed during recent years, the awareness of possible complications and appropriate follow-up strategies gains rising importance and current follow-up strategies are reviewed herewith. Follow-up investigations after urinary diversion have to address possible surgical complications, metabolic changes as well as the risk of secondary malignancies in the incorporated bowel segments. The most important and possible deleterious surgical complication is upper tract dilation and obstruction following ureteroenteric anastomotic stenosis and occurs in 2–30% depending on the surgical technique and evaluated series. The most appropriate follow-up study to detect upper tract dilation is ultrasonography while the associated obstructional component can best be estimated by functional renographic studies (MAG3 renal scan). The significance of reflux associated with urinary diversion remains controversial although experimental studies and clinical observations suggest a risk of renal functional deterioration associated with reflux which is certainly true in ureterosigmoidostomy following pyelonephritic changes. Possible metabolic changes include hyperchloremic metabolic acidosis and problems related to malabsorption due to bowel resection and incorporation of bowel segments into the urinary tract. The incidence of hyperchloremic acidosis is related to the form of urinary diversion, being higher in continent forms than in incontinent diversions, while hyperchloremic metabolic acidosis is most frequently encountered in ureterosigmoidostomy. While acute complications of metabolic acidosis may encompass hyperventilation as well as severe changes of serum electrolytes and acid base balance leading to cardiac arrhythmias necessitating immediate hospital treatment with intravenous alkalinizing, chronic acidosis may lead to osteopenia through hypocalcemia and stimulation of osteoclastic activity. Metabolic acidosis can be best detected by regular blood gas analysis. To prevent these complications prophylactic administration of alkalinizing agents (e.g. potassium citrate) should be readily performed. Malabsorption of bile acid strongly correlates with the length of ileum resected and can induce both chologenic diarrhea and malabsorption of liposoluble vitamins (A, D, E, K). Vitamin B12 is exclusively absorbed in the distal ileum, serum levels therefore may be reduced following resection of distal ileum. This will not occur during the first 3–5 years following diversion because B12 deposits usually will last for this period. Later, however, serum levels of vitamin B12 should be checked annually while others favor routine substitution of this vitamin. The incidence of cancer occurring at the ureterointestinal anastomosis seems to be highest in patients with ureterosigmoidostomy varying between 2 and 29% with polypoid benign lesions being more frequent. The most common type of tumor is adenocarcinoma which has also been reported in colonic and ileal conduits as well as augmentation cystoplasty using either colon or ileum. Since the time interval between surgery and cancer occurrence is longer than 10 years, the newer forms of continent diversion theoretically also inherit the risk of tumor formation, which, however, has yet to be established because these diversions are only in wide use since 10 years. Currently, annual endoscopic controls are recommended in those patients with diversions where feces and urine are in contact with urothelium starting 5 years after surgery. Although formal guidelines for follow-up after urinary diversion have not yet been established by the working group on oncology of the German urological association, this paper suggests a follow-up strategy addressing surgical complications, metabolic changes and the risk of secondary malignancies.
© 1999 S. Karger AG, Basel
Shapiro SR, Leibowitz R, Colodny AH: Fate of 90 children with ileal conduit urinary diversion a decade later. Analysis of pyelography, complications and renal function. J Urol 1975;114:289A.
- Thüroff JW, Alken P, Riedmiller H, Engelmann U, Jacobi GH, Hohenfellner R: The Mainz pouch for bladder augmentation and continent diversion. J Urol 1986;136:17.
- LeDuc A, Camey M: An original antirefluxive uretero-ileal implantation technique: Long-term follow-up. J Urol 1987;137:1156.
- Studer UE, Danuser H, Merz MW, Springer J, Zingg EJ: Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol 1995;154:49.
Ritchie J, Skinner DG, Waisman J: The effect of reflux on the development of pyelonephritis in urinary diversion: An experimental study. J Surg Res 1964;16:256.
- Koch MO, McDougal WS: The pathophysiology of hyperchloremic metabolic acidosis after urinary diversion through intestinal segments. Surgery 1985;98:561.
Lemann JJ, Litzow JR, Lennon EJ: Studies of the mechanism by which chronic metabolic acidosis augments urinary calcium excretion in man. J Clin Invest 1967;46:1318.
Stein R, Fisch M, Andreas J, Hohenfellner R: Knochenmineralgehalt und Ganzkörperkaliumbestimmung bis zu 30 Jahre nach Harnableitung. Urologe [A] 1997;37:S116.
- Bertoni JM, Abraham FA, Falls HF, Itabashi HH: Small bowel resection with vitamin E deficiency and progressive spinocerebellar syndrome. Neurology 1984;34:1046.
- Matsui U, Topoll B, Miller K, Hautmann R: Metabolic long-term follow-up of the ileum neobladder. Eur Urol 1993;24:197.
- Stein R, Lotz J, Fisch M, Beetz R, Prellwitz W, Hohenfellner R: Vitamin metabolism in patients with a Mainz pouch I. Long-term follow-up. J Urol 1997;157:44.
- Steiner MS, Morton RA: Nutritional and gastrointestinal complications of the use of bowel segments in the urinary tract. Urol Clin N Am 1991;18:743.
Thompson WG, Wrathell E: The relation between ileal resection and vitamin B12 absorption. Can J Surg 1977:20:461.
- Kinn AC, Lantz BV: Vitamin B12 deficiency after irradiation for bladder carcinoma. J Urol 1984;131:888.
- Racioppi M, Mingtrone G, D’Adessi A, Fanasca A, Benedetti G, Capristo E, Alcini A, Alcini E: Xylose absorption and metabolic status in urinary intestinal orthotopic reservoir: Ileocecal compared with ileal neobladder. J Urol 1998;160:1655.
Kälble T: Ätiologie, Inzidenz und Prophylaxe von Tumoren in verschiedenen Formen der Harnableitung. Akt Urol 1996;27:166.
Harzmann R: Harnableitungskarzinom – Fiktion oder Realität? Akt Urol 1989;20:179.
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