Urine Leak

It is very common to have some degree of urine leak from one of the suture lines in the pouch during the first few days after the surgical procedure. This is not a true complication as long as the urine comes out the drain. The leakage may persist for days to weeks but nearly always heals with time as long as good catheter drainage is maintained. More frequent irrigation of the pouch catheter may hasten resolution of the leak. Sometimes the drain is too close to the pouch and is acting as a wick, and a few centimeters withdrawal of the drain can resolve this problem.

An undrained leak is potentially serious and may present with abdominal distention, ileus, decreased urine output, fever, or rising blood urea nitrogen. In this situation, the following measures should be taken:

• 1.
  

  A gravity cystogram under fluoroscopic guidance to confirm proper position of the catheter. This study can also identify the site of extravasation.

  
  
• 2.
  

  Computed tomography (CT) scan to evaluate for a large fluid collection in the abdomen or pelvis. If a collection is identified, an additional drain should be placed percutaneously under image guidance. The site of leakage may also be identified if the CT scan is done with intravenous (IV) contrast in the excretion phase.

Diversion of urine with unilateral or bilateral nephrostomy tubes may be required if the leak is severe and persistent, appears to be arising from one or both ureters, or if urine is draining from the wound or has fistulized to another site (e.g., bowel anastomosis or vaginal cuff). This diversion of urine away from the pouch facilitates healing at the site of leakage. The nephrostomy tubes may be left in place for several weeks if necessary. Antegrade studies can confirm resolution of the leak before the tubes are removed. This measure nearly always resolves even the most difficult leak, so it is crucial that the surgeon performing continent diversion have skilled interventional radiologists available to assist in these situations.

A basic principle of management of urinary leaks in the early postoperative period is to avoid attempting open surgical repair. Open exploration and primary repair are extremely difficult in this early period as a result of intense inflammatory reaction. These procedures are rarely successful in achieving a watertight repair. The only situation requiring reoperation is a large, undrained leak that is not amenable to percutaneous drainage. Any repair of a persistent leak should be delayed if possible to 8 to 12 weeks after the initial surgical procedure, once inflammation has had an opportunity to decrease.

Necrosis of the Efferent Limb of the Pouch

Necrosis of the efferent limb of the pouch should be an extremely rare event if care is taken in mobilizing the bowel and constructing the catheterizable efferent limb. The most distal portion of the efferent limb or appendix has the most tenuous blood supply, so slight duskiness at the mucocutaneous border is not uncommon shortly after the surgical procedure. However, if there is concern that the limb looks necrotic, a flexible cystoscopy can be performed. No intervention is necessary if healthy mucosa is encountered in the efferent limb. Reoperation with construction of a new efferent limb is required in patients with total necrosis of the limb.

Problems Related to Catheterization

Mucus production is universal in continent diversions made from small or large bowel. All cutaneous pouches should be regularly irrigated to clear the mucus. Mucus plugging of catheters can usually be managed by aggressive irrigation. Gross hematuria with clots rarely complicates a continent diversion during the initial healing phase. Continuous irrigation and correction of any coagulopathy are helpful, and rarely an endoscopic evaluation to identify and cauterize a bleeding vessel might be necessary. If a catheter is dislodged or must otherwise be replaced in the early postoperative period, a fluoroscopic cystogram should be performed to confirm proper position of the new catheter.

Urinary Infection

Febrile urinary tract infections are relatively common in patients in the early postoperative period, especially while catheters are still in place. In a review of 27 perioperative mortalities in cystectomy patients over a 30-year period, eight cases were caused by overwhelming sepsis. Many of these patients had urine or bowel leak, and all had reoperations during their hospital course. Fungal infections and resistant bacterial infections have become more common in hospitalized patients and can cause significant morbidity and death, especially if not recognized early. Long-term antibiotics have not generally been used because of induction of highly resistant organisms, but we will reintroduce antibiotics at the first sign of fever. We often also add antifungal medications to the treatment of hospitalized patients who become febrile or have leukocytosis after the first week in the hospital in the absence of other obvious sites of infection, even before the urine culture grows yeast. One must suspect resistant organisms in acutely ill postoperative patients and treat them accordingly.

Bowel Fistula to the Pouch and Other Bowel Complications

A fistula to the pouch is heralded by the presence of fecal material in the urinary drainage bag or drain, possibly associated with fever or pain. It is generally caused by a leak from the bowel anastomosis or a missed bowel injury. The recommended initial management in the early postoperative setting is bowel rest with parenteral nutrition. CT scan is advisable to ensure that an undrained abscess is not contributing to the problem. Again, early surgical exploration is difficult in the setting of inflammatory postoperative reaction and should be avoided in favor of delayed repeat exploration and repair if the fistula does not resolve within 4 to 6 weeks of bowel rest. An asymptomatic fistula is occasionally identified on routine postoperative imaging. In the absence of symptomatic infections or diarrhea these can be managed conservatively.

Other early bowel complications include prolonged ileus, partial or total small bowel obstruction, gastrointestinal bleeding (usually resulting from stomach or duodenal ulcers), Clostridium difficile enterocolitis, and pelvic abscess caused by a bowel leak. The problems are common to all types of urinary diversion and to most other major abdominal surgical procedures involving bowel resection. The incidence of prolonged postoperative ileus has been markedly reduced in recent years by adoption of ERAS (enhanced recovery after surgery) techniques, including avoidance of bowel preparation, careful fluid management, minimized narcotics, and the addition of alvimopan, a µ-opioid antagonist. Management is nonoperative whenever feasible, with endoscopic and percutaneous techniques used as needed. Taken together, these types of gastrointestinal complications account for approximately 30% of all early complications in patients undergoing cystectomy and diversion.

General Medical Complications and Complications Unrelated to the Diversion

Many early postoperative complications result from cystectomy itself rather than from the specific type of diversion performed. These complications include hemorrhage, thrombotic events, and medical complications such as cardiac or pulmonary problems. Patients undergoing cystectomy and diversion have an average age of almost 70 years, and an increasing proportion of our patients receiving treatment are older than 80 years of age. Previous smoking behavior often contributes to significant cardiac and pulmonary comorbidities in these patients. Other problems that increase complications include diabetes, poor nutrition, obesity, limitations to mobility, and renal insufficiency. General medical problems account for over half of the early complications observed following cystectomy. It is important to optimize the patient’s other medical conditions preoperatively whenever possible.

Infections

Colonization of the urine with bacteria is always present in patients with a continent cutaneous reservoir on intermittent catheterization. Conversely, late serious infections such as pyelonephritis and sepsis are relatively rare in the absence of upper tract obstruction or stones. Therefore, it is very important not to subject patients to unnecessary antibiotics for asymptomatic bacterial colonization. Patients and their primary care physicians need to be instructed in this principle.

Patients with cutaneous diversion who have symptomatic infections should be evaluated for completeness of emptying, hydronephrosis, and the presence of stones in the pouch or in the kidney. Occasionally patients with no anatomic abnormality may develop recurrent symptomatic infections that cause pain over the pouch or fevers, often preceded by very foul-smelling urine. This presentation appears to be much more common in patients with a history of interstitial cystitis than in patients with malignant disease. Daily pouch irrigation with saline solution (or even a very dilute bleach solution) should be recommended. Chronic low-dose antibiotic suppression may be helpful. A useful approach for patients who suffer recurrent symptomatic infections is to have them take a very short course of antibiotics (e.g., 2–3 days of a sulfonamide or fluoroquinolone) at the first sign of symptoms, no more than once or twice per month. Longer-term antibiotic use risks colonization with highly resistant organisms.

Incontinence

Incontinence in a continent cutaneous diversion affects on average 15% of patients and can occur at any time. Occasionally what is interpreted as urine leakage is actually mucus drainage from the efferent limb (which is unavoidable) or failure to pinch the catheter on withdrawal, thus leaving a small amount of urine in the efferent limb. Persistent leakage, however, is due to a failure of the continence mechanism. Endoscopic injection of bulking agents has been described, but resulted in complete resolution of leakage in a minority of patients. Although some patients may opt for more frequent catheterization, a pad, or an external collection device as management of smaller leaks, most patients with significant leakage ultimately require open surgical repair. The diagnostic approach prior to surgical correction depends on the type of urinary diversion that had been constructed, but generally includes endoscopy of the pouch and a cystogram with drainage views. Urodynamic studies should be considered in pouches constructed from colon, which is more likely to have high-pressure waves and be amenable to pouch augmentation with a patch of ileum.

The following are some considerations for each type of diversion:

• 1.
  

  Kock pouch to skin . These procedures are now rarely performed in the United States, but some older patients still have a cutaneous Kock pouch and may require treatment. Incontinence results from incompetence of the intussuscepted nipple valve possibly caused by extussusception of the valve, stones on the nipple valve, or a fistula through the midpoint of the valve (e.g., by traumatic catheterization). Flexible endoscopy allows retroflexion of the scope and identification of the problem at the efferent valve. Detubularized ileal reservoirs generally have reliable low-pressure systems, so urodynamic evaluation is not necessary. Occasionally an extussuscepted nipple valve can be restapled to the back wall of the pouch, or a stone can be removed and the nipple repaired. However, it is often preferable to replace the efferent continence mechanism completely with a new limb (e.g., using a T-limb or the Mitrofanoff principle).

  
  
• 2.
  

  Indiana pouch and its variations. Incontinence in this type of right colon pouch is generally the result of incompetence of the reinforced ileocecal valve. It may also be caused by a high-pressure reservoir, especially if the colon was not adequately detubularized; thus urodynamic studies should be performed prior to a planned repair. Repair may be accomplished by mobilizing the pouch and reinforcing the ileocecal valve with additional Lembert silk sutures around the base, with the addition of an ileal patch onto the pouch if high-pressure contractions were seen on urodynamic study. Alternatively, a new efferent limb can be constructed. Temporary improvement may occasionally be achieved with endoscopic subcutaneous injection of collagen around the base of the efferent limb near the ileocecal valve.

  
  
• 3.
  

  Appendix or tapered tunneled ileal segment. Incontinence in these systems is unusual, but it may result from loss of the reinforced tunnel at the base of the appendix or erosion of the appendix from an indwelling catheter. Again, flexible endoscopy and urodynamic studies to identify high-pressure contractions are helpful in defining the problem. Repair may be achieved by constructing a new tunnel at the base of the appendix (using the Mitrofanoff principle) or by making a new efferent limb with a tapered ileal segment. Injection of collagen in the submucosa at the base of the appendix has also occasionally been helpful.

  
  
• 4.
  

  Extraserosal tunnel (T-limb). Incontinence is usually caused by loss of the extraserosal tunnel, as occurs when the permanent silk backing sutures pull through the serosa, most likely due to trauma from daily catheterization. It may be difficult to recognize this situation convincingly on a cystoscopic examination or cystogram because the problem is on the outside of the reservoir. Urodynamic studies should be performed preoperatively if the pouch was made from colon to identify high-pressure contractions. To repair the continence mechanism, either the tunnel can be reinforced with a new set of backing sutures or an entirely new efferent limb can be constructed.

Pouch Stones

Stones can develop in any continent diversion, with an incidence that varies between 5% and 10% and increases over time. The incidence is highest in pouches constructed using surgical staples (such as the Kock pouch), but it is also seen in pouches without any foreign body and is related to mucus production, chronic bacterial colonization, and incomplete emptying. As a result, all patients with a continent diversion should be followed with at least yearly plain radiographs, CT scan, or cystogram for surveillance of stones while still small and amenable to endoscopic management.

There is a higher incidence of stones in continent cutaneous diversions than in neobladders, probably because of a higher rate of bacterial colonization and elevated post-void residual of urine leading to stasis. The incidence appears to increase with longer follow-up, and patients with a history of one pouch stone have a high recurrence rate and should be followed more diligently. These patients should also be encouraged to irrigate their catheters more regularly and may benefit from potassium citrate supplementation to reduce future stone formation.

Stones in a pouch should be suspected in a patient with hematuria, pain, difficulty with catheterization, urinary incontinence, or recurrent symptomatic urinary tract infections. The stones are almost always radiopaque and can be identified on cystogram or CT scan without contrast. It is crucial for the urologist to review these films personally, as many radiologists are unfamiliar with the anatomy of this type of reconstruction and may easily miss the presence of stones in the pouch on plain films ( Fig. 46.2 ). It is more straightforward to identify small pouch stones on CT scan, though these may be missed as well ( Fig. 46.3 ). MRI is not sufficiently sensitive for detecting stones in the reservoir.

Small stones are faintly visible overlying the surgical staples on the efferent intussuscepted Kock ileal nipple valve (arrow). These stones can be missed by an inexperienced radiologist.

CT scan without contrast in the reservoir depicting a 1-cm stone (arrow) in the pouch.

If left untreated, these stones inevitably increase in size and tend to harden in consistency as more stone deposits in layers. Therefore pouch stones should not be observed but rather treated by complete removal at the time of initial diagnosis. The goal of treatment is to remove all fragments without damaging the pouch or its continence mechanism. Fortunately, most pouch stones can be removed endoscopically by using techniques similar to those for removal of large bladder or kidney stones. The availability of versatile endoscopes, both rigid and flexible, and of efficient energy sources such as electrohydraulic, ultrasonic, and pneumatic lithotriptors and holmium lase has allowed efficient fragmentation and removal of stones even through small stomas. Extracorporeal shock wave lithotripsy is not recommended for pouch stones because of the need to remove all fragments to prevent recurrence.

Small stones can be easily retrieved with a flexible cystoscope inserted through the stoma. Such scopes are approximately the same caliber as the catheters used to empty the pouch. Basket removal or lithotripsy followed by basket removal can be performed safely without significant concern for damaging the continence mechanism. However, because these scopes are smaller than their rigid counterparts, the smaller working channel makes them less efficient for treating larger stones.

For large stones, a rigid scope such as an offset rigid nephroscope or cystoscope provides a large enough channel to break up and remove the stone fragments efficiently. This technique is preferable to flexible endoscopy, and a rigid scope can generally be inserted safely through a stoma under direct vision. Aggressive manipulation of a rigid scope within the efferent limb should be avoided. An Amplatz type access sheath can be used to protect the continence mechanism from damage from repetitive insertion of instruments during the course of the procedure. This device does dilate the efferent limb and stoma, but provides safe access into the pouch without damaging either the mucosa of the efferent limb or the continence mechanism. Use of continuous flow irrigation facilitated by this device decreases the pressures within the pouch, allows for efficient irrigation of stone fragments, and improves visibility during the procedure. The development of permanent incontinence after endoscopy through a stoma is extremely rare. Some patients may find it difficult to catheterize immediately after endoscopic manipulation because of the presence of edema, a complication more likely with rigid than flexible endoscopy. It may be helpful to leave a catheter in the efferent limb for 24 hours after the procedure to allow the edema to subside.

Rigid endoscopy of the stoma should be avoided in certain situations. Appendiceal stomas tend to be too narrow for most rigid scopes and the angle entering the pouch limits manipulation. Small stones in such pouches can be removed with a flexible cystoscope. Larger stones or stones in a difficult location within the pouch are better managed percutaneously. This procedure can be safely accomplished as long as one is careful to identify a spot where the pouch is up against the abdominal wall without the intervening bowel. When a percutaneous catheter had been used perioperatively, use of this old scar is generally safe. If any doubt exists, ultrasound or CT scan should be used to identify a safe passage for percutaneous access. Once access is obtained, the tract can be dilated either by balloon dilation or sequential manual dilators. An Amplatz sheath along the percutaneous tract allows access to the pouch and facilitates irrigation and removal of stone fragments. All stone fragments must be extracted or irrigated out of the pouch at the end of the procedure because they may not pass through the catheter and subsequently stick to bowel mucosa and become a nidus for additional stone formation.

Patients who are not followed up with at least annual radiographs may present with very large stones ( Fig. 46.4 ). When stones are more than 3–4 cm in diameter, endoscopic management is difficult and inefficient. In these rare situations, the stones are best managed with a simple open cystotomy lateral and superior to the stoma.

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