© Springer-Verlag London 2017
Abhay Rané, Burak Turna, Riccardo Autorino and Jens J. Rassweiler (eds.)Practical Tips in Urology10.1007/978-1-4471-4348-2_2525. Lifetime Advice to Patients After Urinary Diversion
(1)
Department of Urology and Pediatric Urology, University of Hospital Ulm, Ulm, Germany
(2)
Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heilbronn, Germany
Abstract
The use of bowel segments for urinary diversion is the reason of physiological changes, and therefore it has a lifelong impact on the patients metabolism and quality of life. Until now almost all bowel segments from stomach to the rectum have been used for urinary diversion techniques. The use of every different bowel segment causes its own pathopysiological changes in the patient. In the lifelong treatment of the patient it is inevitable to know about and monitor the changes caused by the urinary diversion to avoid serious health damage to the patient. In this chapter we focus on the nowadays mainly used urinary diversions and their spectrum of possible changes in the patients to give a lifetime advice to the patient after urinary diversion.
Keywords
ComplicationsUrinary diversionPreventionQuality of lifeIntroduction
There are numerous indications for a urinary diversion in a patient. The most frequent is the urinary diversion following radical cystectomy in the management of muscle-invasive bladder cancer, according to the EAU-guidelines.
The use of bowel segments for urinary diversion is the reason of physiological changes, and therefore it has a lifelong impact on the patients metabolism and quality of life. Until now almost all bowel segments from stomach to the rectum have been used for urinary diversion techniques. The use of every different bowel segment causes its own pathopysiological changes in the patient. In the lifelong treatment of the patient it is inevitable to know about and monitor the changes caused by the urinary diversion to avoid serious health damage to the patient. In this chapter we focus on the nowadays mainly used urinary diversions and their spectrum of possible changes in the patients to give a lifetime advice to the patient after urinary diversion.
Complications resulting from an urological surgical technique using a bowel segment have mainly three mechanisms:
Technical: continence, renal reflux, infections, etc.
Oncological: cancerogenesis in a bowel segment e.g. MAINZ Pouch II
Metabolical: these are result of exclusion of a specific bowel segment or continuous contact of the bowel segment with urine
The type of diversion influences the clinical appearance of specific metabolic changes but there is a high variability to compensate the changes and in the velocity of the onset of the symptoms so the clinical diagnosis can be sometimes difficult.
To classify the different pathophysiological changes that happen to the patient after having radical cystectomy including the formation of a urinary diversion we first have to focus on the basic physiological aspects of bowel function.
Physiological Aspects of Bowel Function
The basic bowel function is the active reabsorption of water and electrolytes. Within the diversion this function is unwanted.
Because of the histological structure of the bowel wall the intestinal resorption of water and electrolytes is more important in the duodenum and jejunum than in the colon.
Energy sources for the reabsorption are the Na+/K+ Pump (basal) and the Na+/H+ pump (apical), and they are located in the cell membrane.
Reabsorption of Cl− happens by exchange with HCO3− in the ileal mucosa. Na + is reabsorbed by exchange of H+. The amount of reabsorbed Cl− exceeds the amount of reabsorbed Na+. As a result, the amount of secreted HCO3− exceeds the amount of secreted H+. This leads to a hyperchloremic metabolic acidosis. Additional reabsorption of NH+ is amplifying this process.
In general:
Diversions using ileum segments have slight benefits compared to colon segments related to urine storage pressure and reabsorption of urine components.
A usually mild form of metabolic acidosis can be seen when using the ileum (70 %).
The utilization of jejunum for urinary diversion led to frequent development of severe metabolic acidosis (25–40 %). As a result the use of jejunum in urological surgery was clinically abandoned.
Severe acidosis can be observed if the bowel segments were not discontinued e.g. ureterosigmoidostomy or Mainz pouch II.
Factors that make metabolic disorders more likely to appear:
Length of the bowel segment
Duration of urine contact with the bowel segment
The longer the specific bowel segment used, the larger the resorption surface gets and the more likely metabolic disorders will occur:
Ileal conduit – 15 cm terminal ileum segment
Ileum neobladder (e.g. Hautmann) – 60 cm ileum segment
Ileal Pouch (Kock) – 80 cm ileum segment
If the contact duration of urine with the bowel segment is very shortly like in an ileal conduit of 15 cm length there are almost no clinical metabolic disorders observed. If the situation changes due to stenosis of the urostomy or a too long bowel segment used the patient develops the typical metabolic acidotic disorders.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
