NON-CONTINENT CUTANEOUS URINARY DIVERSION IN NEUROUROLOGY

In document Neurologic Urinary and Faecal Incontinence (Page 66-69)

Table 10 Main series concerning gastro-intestinal bladder augmentation in neurological patients with bladder dysfunction (Max BC:Maximal Bladder capacity

7. NON-CONTINENT CUTANEOUS URINARY DIVERSION IN NEUROUROLOGY

• Keywords for Pubmed search

neurogenic bladder; spinal cord injury; spina bifida; myéloméningocèle; multiple sclerosis; urinary diversion; ileovesicostomy; Bricker; ureterostomy; vesicostomy; ileal conduit

a) Introduction

Non-continent cutaneous diversion refers to all methods used to divert urine, and where incontinence remains or where a system of extra-physiological continence is created, i.e. urine flow is continuous and requires a means of collecting urine attached to the skin.

In the context of neurogenic bladder, these diversions make it possible to obtain low bladder pressure and to preserve the upper urinary tract.

This type of surgery is a last resort for the many complications related to neurogenic bladder (and congenital anomalies of the lower urinary tract), in patients for whom other therapies have failed to help. Four techniques are described for non-continent urinary diversions for patients with neurological vesico- sphincter disorders. In order of frequency these are: ileal conduit urinary diversion, ileovesicostomy, cystostomy and cutaneous ureterostomy.

b) Ileal conduit urinary diversion

Ileal conduit urinary diversion is the type of diversion most frequently performed on neurological patients with bladder dysfunction. It differs only slightly from the cystectomy performed for bladder cancer [1]. Pre- operative location of the intended stoma site is crucial

and must be adapted to the patient’s main position (wheelchair or bed); the stoma site must be easy to access for management. The ileal segment must be as short as possible to prevent stasis [2](LOE3). There is a variant to this technique whereby a segment of jejunal loop is removed and a stoma made on the left hemi-abdomen. This technique can be proposed after irradiation of the pelvis minor, if the ileum has been impaired and a short loop must be used (about 10 cm) to avoid metabolic disorder (jejunal conduit syndrome: hyperkaliemia, hyponatremia, hypochloremia, acidosis) [3](LOE3).

In neurological patients, ileal conduit urinary diversion by laparoscopy and by robot-assisted laparoscopy have been described [4-7](LOE4). Patients seem to benefit from the procedure, though this remains to be confirmed in the medium and long-term [8] (LOE 2).

1. RESULTS IN NEUROLOGICAL PATIENTS WITH BLADDER

DYSFUNCTION

Some series of neurological patients were evaluated to determine the onset of early and late complications [8-14](LOE2-3). Early series of children can be evaluated to determine the morphology of the upper urinary tract and renal function after urinary diversion over a long period (up to 20 years) [15-20](LOE3).

2. EARLY COMPLICATIONS

Mortality is estimated between 0 and 3.4% (LOE2-3) [8-14].

The commonest early complication is intestinal occlusion (4 to 12.6%), usually reversible after prolonged intestinal drainage [8-14](LOE2-3). The risk of gastrointestinal fistula should also be taken into account (0 to 3.3%). As for enterocystoplasty, the current trend is to try to reduce nasogastric tube drainage time to a few hours [21](LOE3).

The most frequent medical complications encountered (3 to 8%) are febrile urinary infections and thrombo- embolism (2 to 3%)[8-14](LOE2-3).

Other major complications include: urinary fistula in 0.3 to 3.4% of patients which may be prevented by placing a ureteral catheter for about ten days [8- 14](LOE3). This complication could be a risk factor for later uretero-ileal anastomosis (LOE4).

3. LATE COMPLICATIONS

a. Gastrointestinal risk

The risk of long-term intestinal occlusion is difficult to evaluate. It ranges between 5 and 7% (LOE3) [9-14]. Even when a short intestinal segment is used, some patients can experiment transient constipation or diarrhoea, which could adversely affect their quality of life[22](LOE2).

b. Complications affecting the bladder left in situ • Indication for cystostomy presumes a

multidisciplinary evaluation involving the urologist and a neurologist or a reeducation doctor, as well as stomatherapy nurses or occupational therapists for estimating patient catheterization capabilities (A) • Use of the appendix to carry out continent

cystostomy is the standard method today, but few long term data are available in adults (C)

• If the patient has undergone an appendicectomy the use of a segment of the small intestine can be proposed, with slightly poorer short term results ( C) • Long term follow up of the patients having

had a continent cystostomy is needed to have a better idea of the long term results of the various procedures ( C).

For the particular indication of neurological patients with bladder dysfunction, several authors have proposed not carrying out cystectomy so as to avoid potentially morbid surgery. At present, this is debatable for several reasons:

• First, there is a risk of pyocyst formation in the unused bladder (21-50%) [9, 10, 14, 23] (LOE3). Even where conservative treatments have been attempted (combining vesicular irrigation with antibiotherapy)[24] (LOE3), secondary cystectomy is then necessary in 50 to 100% of cases [10, 15, 17]. For women, a surgical alternative is vaginovesicostomy, which appears to be effective [11, 17](LOE4).

• Furthermore, the unused bladder is frequently infected and may become an “irritative thorn”, especially in patients with spinal injury or multiple sclerosis (LOE 4) [10, 25].

• A final argument in favour of cystectomy is that the risk of bladder neoplasia is higher in neurogenic patients, the principal risk factors being long-term indwelling catheterization (more than 8 years), bladder calculi and smoking [26-28](LOE3). Moreover, screening by cystoscopy-biopsy is not effective [29, 30] (LOE3).

• Finally, improvement of the cystectomy technique (noticeably laparoscopic cystectomy) has considerably reduced related morbidity [8] [31](LOE2-3). Supratrigonal cystectomy can be performed in men, preserving the prostate and preventing any genital and sexual sequellae. c. Upper urinary tract complications

Stenosis of the uretero-ileal anastomosis may occur in the medium and long term. This is very damaging to the upper urinary tract and requires regular monitoring of the morphology. In contemporary series of neurological patients with bladder dysfunction, it occurs in 2 to 7.8% of cases within 10 years [9-14] (LOE3). For cases followed for more than 10 years, the finding of 16.5 to 50% stenosis is essentially that of early paediatric series [15-20](LOE3). Impairment of the upper urinary tract and renal function seems to be correlated mainly with stenosis of the uretero-ileal anastomosis, but also with a long ileal graft and stomal stenosis leading to poor voiding and pyelonephritis [16](LOE4). In the event of poor functioning of the uretero-ileal anastomosis, some authors suggest endoscopic dilation before further surgical repair of the anastomosis (LOE3)[13, 32-34]. Surgery however remains the reference treatment [32](LOE3). The risk of upper urinary tract lithiasis (3 to 31%) is always present in these patients (even without stenosis of the uretero-ileal anastomosis) [9, 10, 13, 14](LOE3). Patient monitoring should include regular screening of the upper urinary tract to detect any lithiasis and to implement timely treatment (LOE 4).

Chronic bacteriuria is frequent but should not be treated if asymptomatic. Both patients and attending physicians must be informed so as to avoid the administration of unnecessary antibiotics. However, the risk of febrile infection persists over the long term and is logically favoured by uretero-ileal stenosis (12 to 34%) [9, 10, 13, 14].

d. Stoma complications

These are relatively frequent (18.6 to 30%) and varied [10, 13, 14]. The risk of peristomal eventration is the most frequently reported (between 7.7 and 10%). Stomal stenosis may also occur. Stoma complications appear to occur more often in obese patients (LOE3) [35].

Finally, it should be noted that some patient could ask for undiversion. These mainly concern adults who underwent surgery as children and who later wished to recover a continent system, or who have had complications with their non-continent urinary diversion [36-40](LOE3-4).

c) Ileovesicostomy [41-50]

This technique was first described by Cordonnier in 1957 for treatment of three children suffering from myelomeningocele [48](LOE4). Its theoretical advantages are relative simplicity, the absence of dissection and suture of the ureter, thus preventing ureteral complications and the potential of “restitutio

ad integrum” of the bladder (only one case described) [47](LOE4).

The surgery consists in removing a 10 cm ileal segment from about 15 to 20 cm above the ileocecal valve. One side of the segmnt is anastomosed to the dome of the bladder and the other to the skin halfway between the ileac spine and the umbilicus. A partial cystectomy is performed to reduce reservoir volume and possible urine stagnation. Surgical variants have been described with simple partial detubularization of the ileum before vesico-ileal suture [50], or the creation of a modified Boari flap on the bladder associated with partial detubularization of the ileum [42, 45-47, 49](LOE3). These improve drainage by reducing the ileal segment. Laparoscopic ileovesi- costomy seems to be feasible [41, 44] (LOE4). One of the problems with this type of surgery, particularly in women, is the need for further surgery to prevent residual urinary leakage. All authors agree that this significantly prolongs surgery time. This further surgery may consist in closing the bladder neck or placing a suburethral tape [47, 49, 51, 52] (LOE3). Some authors propose performing this surgery later, where necessary [50](LOE3).

1. EARLY COMPLICATIONS

Early complications are related to the underlying condition of these patients, which is often poor. No case

of post-operative mortality has been reported in the published series [42, 43, 45-47, 49, 50, 52](LOE3). In some cases of poor drainage through the stoma, the drainage was prolonged to six weeks (instead of the usual three). Other early complications were related to poor results of the surgery performed to render patients continent (Table 12). Patients with this type of problem are the most likely to resort to cystectomy with ileal diversion (3 to 6%) [47, 51](LOE3).

2. LATE COMPLICATIONS

These are summarized in Table 10. No reported series to date has more than five years of follow-up. The most frequent problems appear to be poor voiding related to stenosis of the stoma or the ileovesical anastomosis. Only one report specifically mentions problems related to stoma equipment that occur in about 28% of patients [51](LOE3). The incidence of renal or vesicular lithiasis appears to be low, and several authors report that affected patients had history of lithiasis.

Renal function appears to be preserved with this procedure at least with a mean follow-up of five years (LOE 3) [16, 42, 43, 45-47, 49-51, 53]. No case of impaired renal function, or even post-operative uretero- hydronephrosis was reported.

Finally, it should be underline that two patients in the series with the longest follow-up who developed a bladder tumor [45](LOE4).

d) Vesicostomy

Vesicostomy was described by Blocksom in 1957 [54] and detailed more recently by Lapides [55, 56]. The technique consists in constructing a bladder tube anastomosed to the skin by making a transverse suprapubic incision to reach the space of Retzius. The stoma is located half way between the umbilicus and the incision.

The principal benefits of vesicostomy are its simplicity

and reversibility, particularly in children [57-63], making it possible to envisage temporary surgery to treat an acute urological problem. In pediatric series, an improvement in the symptoms of infection was reported, with 6 to 20% of patients suffering bladder calculi and 6 to 18% stomal stenosis. Hydronephroses improved or stabilized in most cases. The rate of end- stage renal failure varied between 6 and 18% for mean follow-ups of 6-7 years.

Nowadays, it is rare to conserve a vesicostomy long term. The results of Lapides are therefore all the more interesting: after two years of follow-up, no urinary infection, 16% poor drainage and 12% calculi [56] (LOE3). Renal function was preserved. At 10 years of age, however, 9.6% of deaths due to end-stage renal failure, mainly due to calculi and repeated infection of the upper urinary tract, were reported [56] [64](LOE3). At 20 years, the rate of chronic renal failure is around 16.6%[54-65](LOE3).

e) Cutaneous ureterostomy

During this procedure, the ureters are placed in direct contact with the skin without using the gastrointestinal tract. There is no gastrointestinal resection/ anastomosis which is a marked source of morbidity and mortality. Surgery via the retroperitoneal route is quick and simple.

The main inconveniences are: cutaneous stenosis if the stoma is left without catheter, upper urinary tract infections and calcification around catheters if stoma is equipped. Moreover, it is frequently necessary to construct a double stoma.

It is used in adults, usually in the context of palliative urinary diversion for those with obstructive pelvic cancer (bladder, uterus, rectum), and rarely in neurological patients [66-71].

Surgery is simple: in the absence of cystectomy, two short lateral incisions are made in the iliac fossa, at approximately 3-4 cm from the anterosuperior iliac Table 12. Results for contemporary series of ileovesicostomy

LOE n Mean follow-up (months) Re operation following primary surgery (%) Stomal problems (%) Kidney lithiasis Bladder lithiasis Continent (%) Post-op hydrone- phrosis (%) Symptomatic urinary infection (%) Tan, 2007 [51] 3 50 26,3 54 38 2 6 72 0 10 Gauthier, 2003 [43] 4 7 37,4 NP 1/7 1/7 0/7 NP 0/7 1/7 Atan, 1999 [42] 3 15 23,2 NP 16 33 20 67 0 20 Gudziak, 1999 3 13 23 23 8 8 0 92 0 8 Leng, 1999 3 38 52 NP 13 10 5 NP 3 3 Mutchnik, 1997 4 6 12 1/6 1/6 0 0 6/6 0/6 0 Rivas, 1995 3 11 24 NP NP NP NP 100 0 0 Schwartz, 1994 3 23 45 NP 21 0 0 NP 0 NP

spine. Direct retroperitoneal access is made and the two ureters located on the internal border of the psoas muscle or above the iliac vessels.

It is important that the peri-ureteral region be spared and the ureter sectioned as low as possible. The ureter is then catheterized and raised to the skin. The stoma is formed by attaching the ureter to the skin, or by spatulating the sutured ureter on a V-shaped cutaneous incision (separate sutures with fine resorbable thread).

Variants are described so as to obtain only one stoma: Y-transuretero-ureterostomy, implantation of both ureters in a single stoma, implantation of a single ureter (ureter ligated to the least functional kidney, or even nephrectomy). The use of cutaneous plasties may remove the need for ureteral catheterization [72]. Cutaneous ureterostomy was first performed in the 1960s, to treat children with spina bifida and severe upper urinary tract impairment [68, 71]. The technique was also developed to treat malformative uropathies (extrophy of the bladder and the posterior urethral valves) [66, 68-70].

Long-term results with a mean follow-up of 8 years are given hereafter: rates of stenosis between 8.7 to 11%, infections from 6.6 to 10% and calculi from 10 to 15.5%) [67, 70](LOE3).

Renal function was preserved for short follow-up times, but fatal end-stage renal failure occurred in up to 26.6% of children during long-term follow-up [69](LOE3).

This technique is almost never used for neurological patients with bladder dysfunction anymore because conservative treatments (intermittent catheterization, urological endoscopy) have improved and the number of children suffering from spina bifida or presenting with complex malformation of the lower urinary tract has gradually lowered. Moreover, new urinary diversion techniques have been developed.

RECOMMENDATIONS

• Summary from the previous edition [1]

There have been limited numbers of references giving data on prevalence of faecal incontinence (FI) following neurological diseases. Searching from Pubmed from 1964 to 2004, 36 papers were included and the prevalence and incidence of FI varied due to different definitions, severity and also causes/diseases. The incidence of FI among spinal cord injury (SCI) patients after discharge from rehabilitation was reported between 11% and 75%; the prevalence of constipation and/or FI among multiple sclerosis (MS) ranged from 20% to 73%; and 30% to 50% of Parkinson’s disease (PD) patients reported bowel incontinent.

Regarding stroke patients, during acute admission 32% to 79% of the patients reported FI; the prevalence dropped to 25% to 28% at discharge and 12% to 19% at 6 months. New-onset FI in stroke survivors was transient. Modified risk factors for FI at 3 month after stroke onset were anticholinergic drug use and difficulty with toilet access. It was recommended that bowel dysfunction should be evaluated jointly with bladder dysfunction.

• Search strategy

To add new information to the previous edition, we searched from Pubmed from 2004 to 2008 with search words neurogenic bowel, faecal incontinence, prevalence, incidence, epidemiology, stroke, SCI, MS, PD. Relevant papers from Pubmed, non-Pubmed,

I. EPIDEMIOLOGY

D. NEUROLOGICAL FAECAL

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