UTI and UrinaryTract Reconstruction

Transcription

1 EAU Update Series 2 (2004) UTI and UrinaryTract Reconstruction Werner W. Hochreiter *, Sebastian Z Brun Department of Urology, University of Bern, Anna-Seiler-Haus, Inselspital, CH-3010 Bern, Switzerland Abstract Reconstruction of the lower urinary tract is necessary after a variety of urological interventions. Radical cystectomy is the mainstay of treatment for muscle-invasive bladder cancer. But also neurogenic bladder dysfunction or other non-malignant diseases may require cystectomy with the need for restoration of the urinary tract. Indications for reconstruction using intestinal segments have expanded greatly. However, bowel was not meant to serve as a conduit or a storage device for urine and its incorporation into the urinary tract may result in numerous complications. Urinary diversions include incontinent stomas, continent urinary reservoirs, and orthotopic bladder substitutes. One of the major goals of urinary diversions is to prevent infectious complications and to preserve the upper urinary tract. Renal function may potentially be at risk from several factors including urinary infection, urinary tract obstruction, ureteric reflux, stone formation, and recurrent tumour formation in case of malignancy. Infections manifest themselves as bacteriuria or as acute or chronic pyelonephritis. The vast majority of conduits and most continent diversions will develop chronic bacteriuria at some stage. In contrast to orthotopic bladder substitutes which remain sterile, particularly if they are free of residual urine. The significance and consequences of bacteriuria and urinary tract infections will be discussed in this section taking into account the most common forms of incontinent, continent and orthotopic urinary diversions. # 2004 Elsevier B.V. All rights reserved. Keywords: Urinary tract infection; Urinary diversions; Upper urinary tract; Reflux 1. Introduction * Corresponding author. Tel. þ ; Fax: þ address: werner.hochreiter@insel.ch (W.W. Hochreiter). Urinary diversion is nearly 150 years old [1], but high rates of surgical, infectious and metabolic complications precluded a widespread use. Evolution in surgical techniques and better understanding of the many consequences of incorporation of gastrointestinal segments into the urinary tract allowed a renaissance of urinary diversions in the 1950s, which progressed rapidly in the last decade. Cystectomy is generally indicated for patients with muscle-invasive bladder tumours or with nonmalignant disease of the lower urinary tract. Following cystectomy, urine can either be diverted into an incontinent stoma, into a continent urinary reservoir catheterised by the patient or controlled by the anal sphincter, or into an orthotopic bladder substitute so that the patient voids urethrally. There are several factors, i.e. physical properties of the reservoir, renal function, intestinal malabsorbtion, fluid and electrolyte alterations, long-term metabolic sequelae and infections of the urinary tract that can influence the outcome of urinary diversions. 2. Incontinent urinary diversion Incontinent urinary diversion is diversion to the skin with incorporation of either ileum or colon into the urinary tract. The ileal conduit, first described in 1935 by Seiffert and advanced by Bricker [2], rapidly became very popular and remained the standard urinary diversion for many years. However, there was no anti-reflux mechanism and one of the major complications was the high rate of upper urinary tract infections [3]. Subsequently, colonic conduits have been developed mainly in an attempt to avoid the complications of the ileal conduit by using a non-refluxing uretero-intestinal anastomosis. Being open systems with free communication to the skin, microbial colonization is inevitable and /$ see front matter # 2004 Elsevier B.V. All rights reserved. doi: /j.euus

2 102 W.W. Hochreiter, S. Z Brun / EAU Update Series 2 (2004) Fig. 1. Overall complications of ileal conduit. conduits have a high incidence of bacteriuria. It has been reported that up to 80% of patients with a cutaneous diversion of the urine through conduits results in bacteriuria with uropathogenic organisms [4 6] and up to 20% of these patients may experience at least one septic event [7]. Thus, infections have a significant impact on the overall complications in conduits (Fig. 1). 3. Continent urinary diversion A continent urinary diversion is an intra-abdominal urinary reservoir, catheterisable, or with an outlet controlled by the anal sphincter. Ureterosigmoidostomy is one of the oldest forms of continent urinary diversion. In the colon urine mixes with stool and is inevitably contaminated with faecal flora. Although there are undoubtedly patients who have an excellent result with this procedure, the operation has become unpopular because of the high incidence of late complications [8], which include pyelonephritis and upper tract deterioration, presumed to be due to reflux of inevitably infected urine. Also, the incidence of sepsis in these patients is greater than in those with conduits [9]. In view of the complications of ureterosigmoidostomy and the psychosocial disadvantages of conduits, the development of continent catheterisable reservoirs, using ileal, ileocecal or colonic segments, has been stimulated. One of the best studied continent diversions is the ileal Kock pouch [10,11]. In a prospective 5 to 11 year follow-up study, Akerlund [12] reported that bacterial contamination was found in most samples of urine and none of the patients had constantly negative urine cultures from the reservoir but 18% of the patients had constantly positive cultures. Fig. 2. Overall complications of Kock pouch. Furthermore, patients with any kind of continent diversion have a 5 to 20% incidence of septic episodes within 1 year of the reconstruction [13]. The reasons for the increased incidence of bacteriuria and UTI in continent diversions are still controversial. It has been hypothesized that the intestine is incapable of inhibiting bacterial proliferation, in contrast to the urothelium. Thus, intestine that normally lives in symbiosis with bacteria may make the urine less bacteriostatic, promote bacterial growth and thereby may serve as a source of infection [14]. In contrast, Mansson [15] showed that the chemical differences of reservoir urine did not promote bacterial growth when compared to urine from intact bladders. Therefore, it is much more likely that the increased incidence of bacteriuria and UTI is due to other factors, such as bacterial contamination of the reservoir at catheterization, incomplete emptying with urinary stasis and defecting function of the reservoir outlet. The infection rate in terms of overall complications in continent pouches is similar to those found for conduits (Fig. 2). 4. Orthotopic bladder substitution Unlike conduits and continent reservoirs orthotopic bladder substitutes usually have sterile urine [16,17].As these pouches are emptied by relaxation of the pelvic floor and, if necessary, abdominal straining, careful postoperative training to empty the neobladder is required. In a series with 200 patients Studer [18] reported an incidence of positive urinary cultures in up to 12% of the patients at the follow-up visits during 8 postoperative years. However, the urinary tract infections were usually associated with irregular or improper voiding habits combined with residual urine. After

3 W.W. Hochreiter, S. Z Brun / EAU Update Series 2 (2004) Fig. 3. Overall complications of ileal bladder substitutes. antibiotic treatment and elimination of causes of residual urine, reinstruction of the patients on how to void without retaining residual urine usually sufficed. Thus, it seems that orthotopic bladder reconstruction is better than continent diversion in preventing UTI because orthotopic bladder substitutes usually empty spontaneously, more efficiently and hence reduce the degree of urinary stasis [19] (Fig. 3). 5. The issue of reflux in urinary diversions One of the major goals of urinary diversions is the preservation of an intact upper urinary tract. There seems to be a consensus about the fact that progressive renal deterioration results from repeated reflux of infected urine into the upper urinary tract [4,9,20,21], although it can occur either with reflux of sterile urine over long periods or in the presence of obstruction and consequently raised pressure in the reservoir. The combination of reflux, infection and obstruction can result in fulminant renal damage and sepsis. There is considerable controversy as to whether a nonrefluxing or refluxing uretero-intestinal anastomosis is desirable in urinary tract reconstruction. Despite the use of antireflux techniques, the Mayo Clinic reported that 20% of 173 patients with ureterosigmoidostomy had had pyelonephritis during the follow-up period of 5 15 years [22] and other authors found even higher incidences up to 70% in these patients [8,23]. Patients with a refluxing ileal or colon conduit are subject to a 15 22% incidence of acute pyelonephritis during the course of the diversion [14,24] and this is often related to urographic deterioration of the upper tract [4,25]. Bergman investigated on patients with ileal conduit urinary diversions measuring the intraluminal conduit pressure. In the absence of obstruction, low pressure reflux (12 cmh 2 O) was observed in about 50% of the cases [26]. However, conduits are not always low pressure systems, often due to obstruction at the level of the fascia immediately superficial to the external oblique muscle [27]. These circumstances combined with the usually infected urine means that high pressure reflux may occur. This reflux or alternatively ureteroileal obstruction may contribute to the development of pyelonephritis with gradual deterioration in renal function. In patients with continent caecal reservoirs, Mansson [28] found symptomatic pyelonephritis only in combination with outflow obstruction. Skinner [29] reported that of 250 patients with a continent ileal reservoir, pyelonephritis was observed in 6, 4 of whom had malfunction of the anti-reflux nipple valve. In orthotopic bladder substitutes Studer [30] reports that there is no reflux under physiologic conditions in a correctly functioning neobladder. Videourodynamic studies of ileal orthotopic bladder substitutes have demonstrated reflux from the bladder substitute through the afferent tubular ileal segment only when the reservoir is overfilled by an indwelling catheter. However, under physiological, low pressure conditions the afferent tubular segment serves as a dynamic antireflux system. During the filling phase absence of coordinated contractions of the bladder substitute guarantees a low pressure reservoir. The fact that patients empty the bladder substitute by relaxation of the external sphincter and ultimately via the Valsalva maneuver ensures a low pressure also during the voiding phase. This Valsalva maneuver does not provoke reflux because pressure increases simultaneously in the bladder, abdomen and renal pelvis [31,32] (Fig. 4). In two large series, Elmajian and Hautmann [33,34] found an incidence of reflux in 2 3% of their patients with either an afferent nipple valve or a Le Duc ileoureterostomy as anti-reflux mechanism. The occurence of pyelonephritis as a late complication is about 7% in these series. It seems clear now that either reflux of infected urine or outlet obstruction increases the incidence of pyelonephritis. Ureterosigmoidostomy and both ileal and colonic conduits characteristically have high pressure, tubular peristaltic segments and are all associated with a high rate of bacterial colonization, thus having the ability to cause reflux nephropathy. Although continent urinary reservoirs usually contain bacteria, it seems to be less harmfull for the upper tract provided that the system is strictly at low pressure and that the anti-reflux mechanism prevents ascending infection. However, if an anti-reflux technique is used, it should have minimal morbidity in order to avoid obstructive complications

4 104 W.W. Hochreiter, S. Z Brun / EAU Update Series 2 (2004) continent diversion where body movement in the presence of an absolutly continent outlet mechanism (nipple or Mitroffanoff) may allow intermittent high pressure peaks with potential reflux of infected urine into the kidney. Orthotopic bladder substitutes, in contrast, usually have sterile urine, empty without an isolated pressure rise and have no or minimal reflux [30,33 35], hence the need for reflux prevention is not justified. 6. To treat or not to treat? Fig. 4. (A) Ileal bladder substitute filled to functional capacity. Simultaneous pressure recordings obtained in an ileal bladder substitute, the renal pelvis (through a nephrostomy tube), and the rectum of a patient with an afferent tubular segment. When the reservoir was filled to the patient s maximal functional capacity (maximal voiding volume), the basal pressure varied between 10 and 20 cmh 2 O(lower curve). The intermittent pressure peaks (tipically seen in low-capacity bladder substitutes during the early postoperative period) were not transmitted and not recorded in the renal pelvis (middle curve). (B) Ileal bladder substitute filled beyond functional capacity. When the reservoir was overfilled through the indwelling catheter, the basal pressure in the reservoir was raised to 40 cmh 2 O(lower curve). The basal pressure recorded in the renal pelvis was slightly elevated but significantly lower than that measured in the overfilled bladder substitute (10 versus 40 cmh 2 O). The unnaturally high pressure peaks that were provoked in the reservoir (80 cmh 2 O) were immediately transmitted and recorded in the renal pelvis. However, such situations do not occur under normal conditions. which inevitably would rise the risk for upper urinary tract infections. In urinary diversions with chronic bacteriuria and the possibility of high-pressure peaks, either some form of anti-reflux measure or surgery to reduce pressure is appropriate. This applies to patients with ureterosigmoidostomy, conduit patients and to patients with a Bacteriuria is universal in incontinent stomas and continent reservoirs [19]. Many of these patients, however, show no untoward effects and seem to do quite well with chronic bacteriuria. Certainly, bacteriuria should be treated if symptoms of urinary tract infection result. Deterioration of the upper tract is more likely when the culture becomes dominant for urea-splitting organisms like Proteus and Pseudomonas that may predispose to stone formation. Thus, treatment of patients with relatively pure cultures of Proteus and Pseudomonas is recommended even in the absence of symptoms, whereas those with mixed cultures may generally be observed, provided that they neither are symptomatic nor had previous infections or stones [9]. The development of recurrent UTI in patients with incontinent stomas and continent reservoirs should raise the question of adequacy of the reservoir and rule out the possibility of underlying functional or anatomical causes. Orthotopic bladder substitutes usually have sterile urine and it is unknown if treatment of asymptomatic bacteriuria in a well functioning neobladder is required. However, bacteriuria and UTI are often associated with outflow obstruction (scar, mucosal flap, tumor), irregular (too long) voiding intervals or lousy voiding habits. Once excluded or eliminated factors that might have caused bacterial colonization, it is the authors opinion that treatment should be recommended in order to restore a sterile system and to prevent potential infectious complications. References [1] Simon J. Ectopia vesicae (absence of the anterior walls of the bladder and pubic abdominal parietes): operation for directing the orifices of the ureters into the rectum. Temporary success: subsequent death: autopsy. Lancet 1852;ii: [2] Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30: [3] Pitts Jr WR, Muecke EC. A 20-year experience with ileal conduits: the fate of the kidneys. J Urol 1979;122: [4] Middleton Jr AW, Hendren WH. Ileal conduits in children at the Massachusetts General Hospital from 1955 to J Urol 1976;115: [5] Elder DD, Moisey CU, Rees RW. A long-term follow-up of the colonic conduit operation in children. Br J Urol 1979;51: [6] Nickel JC, Olson M, Lam K, Moody M, Costerton JW. Bacterial colonization of intestinal urinary conduit diversion: a morphologic and bacteriologic experimental study. Can J Surg 1987;30:273 7.

5 W.W. Hochreiter, S. Z Brun / EAU Update Series 2 (2004) [7] Schwarz GR, Jeffs RD. Ileal conduit urinary diversion in children: computer analysis of followup from 2 to 16 years. J Urol 1975;114: [8] Wear Jr JB, Barquin OP. Ureterosigmoidostomy. Long-term results. Urology 1973;1: [9] McDougal WS. Metabolic complications of urinary intestinal diversion. J Urol 1992;147: [10] Kock NG, Nilson AE, Nilsson LO, Norlen LJ, Philipson BM. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol 1982;128: [11] Skinner DG, Lieskovsky G, Boyd S. Continent urinary diversion. J Urol 1989;141: [12] Akerlund S, Delin K, Kock NG, Lycke G, Philipson BM, Volkmann R. Renal function and upper urinary tract configuration following urinary diversion to a continent ileal reservoir (Kock pouch): a prospective 5 to 11-year followup after reservoir construction. J Urol 1989;142: [13] McDougal WS. 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Eur Urol 1991;20: [32] Studer UE, Danuser H, Thalmann GN, Springer JP, Turner WH. Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: long-term results of a prospective randomized trial. J Urol 1996;156: [33] Elmajian DA, Stein JP, Esrig D, Freeman JA, Skinner EC, Boyd SD, et al. The Kock ileal neobladder: updated experience in 295 male patients. J Urol 1996;156: [34] Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 1999;161:422 7, discussion [35] Studer UE, Turner WH. Is reflux prevention important in urinary diversion? In: Webster GD, Goldwasser B, editors. Urinary diversion: scientific foundations and clinical practice. Oxford, UK, Isis Medical Media. 1995, pp CME questions Please visit to answer these CME questions on-line. The CME credits will then be attributed automatically. 1. The incidence of pyelonephritis in patients with conduits is A. 5 8%; B %; C %; D. unknown. 2. Patients with an ileal bladder substitute usually have A. chronic bacteriuria; B. a high incidence of obstructive pyelonephritis; C. sterile urine; D. frequent UTIs. 3. Protection of the upper urinary tract seems to be best in A. ureterosigmoidostomy; B. ileal or colonic conduits; C. ileal bladder substitutes; D. all of the above. 4. Ileal conduits A. are always low pressure systems; B. contain sterile urine; C. have few long-term complications; D. may develop low-pressure reflux.