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Surgical management of urolithiasis in patients after urinary diversion.

ABSTRACT: OBJECTIVE: To present our experience in surgical management of urolithiasis in patients after urinary diversion. PATIENTS AND METHODS: Twenty patients with urolithiasis after urinary diversion received intervention. Percutaneous nephrolithotomy, percutaneous based antegrade ureteroscopy with semi-rigid or flexible ureteroscope, transurethral reservoir lithotripsy, percutaneous pouch lithotripsy and open operation were performed in 8, 3, 2, 6, and 1 patients, respectively. The operative finding and complications were retrospectively collected and analyzed. RESULTS: The mean stone size was 4.5 ± 3.1 (range 1.5-11.2) cm. The mean operation time was 82.0 ± 11.5 (range 55-120) min. Eighteen patients were rendered stone free with a clearance of 90%. Complications occurred in 3 patients (15%). Two patients (10%) had postoperative fever greater than 38.5 °C, and one patient (5%) suffered urine extravasations from percutaneous tract. CONCLUSIONS: The percutaneous based procedures, including percutaneous nephrolithotomy, antegrade ureteroscopy with semi-rigid ureteroscope or flexible ureteroscope from percutaneous tract, and percutaneous pouch lithotripsy, provides a direct and safe access to the target stones in patients after urinary diversion, and with high stone free rate and minor complications. The surgical management of urolithiasis in patients after urinary diversion requires comprehensive evaluation and individualized consideration depending upon the urinary diversion type, stone location, stone burden, available resource and surgeon experience.

SUBMITTER: Zhong W

PROVIDER: S-EPMC4216071 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Project description:PurposeSurveillance following urinary diversion should be tailored to capture complications downstream from the initial reconstruction. Most analyses of the morbidity associated with urinary diversion are restricted to the index admission or the immediate postoperative period. We characterize the long-term medical and surgical complications and burden of health care use after urinary diversion.Materials and methodsUsing the 5% Medicare sample from 1998 to 2005 we identified individuals who underwent cutaneous and orthotopic continent urinary diversion, ileal conduit or other types of diversion including enterocystoplasty from physician claims for the index admission. We restricted our sample to subjects with claims 1 year before surgery and at least 2 years after the diversion. We included benign and malignant primary diagnoses, and evaluated the incidence of medical and surgical complications 2 and 5 years after surgery. We stratified complications by diversion type and compared long-term complications after urinary diversion surgery.ResultsOf the 1,565 subjects identified 80% underwent ileal conduit urinary diversion, 7% underwent cutaneous or orthotopic continent diversion and 13% underwent other types of reconstruction. Urinary stone formation, wound complications and fistula complications were more common following continent diversion 5 years after surgery, while ureteral obstruction and renal failure/impairment were more common after ileal conduit diversion. Overall we estimated that more than 16% of patients experienced renal failure or impairment after urinary diversion.ConclusionsComplications are common after urinary diversion and continue to occur through 5 years postoperatively. Urolithiasis and delayed wound complications appear to occur more commonly after continent diversion than after other urinary diversions. A large proportion of patients experience renal deterioration after diversion. These results highlight the need to survey patients for the diversion related complications of cystectomy as rigorously as we monitor for cancer recurrence.

Project description:BackgroundParastomal hernia after ileal conduit urinary diversion is an underestimated and undertreated clinical entity, which heavily impairs patients' quality of life due to symptoms of pain, leakage, application or skin problems. As for all gastrointestinal stomata the best surgical repair technique has yet to be determined. Thereby, surgery for ileal conduit parastomal hernias poses some specific perioperative challenges. This review aims to give an overview of current evidence on the surgical treatment of parastomal hernia after cystectomy and ileal conduit urinary diversion, and on the use of prophylactic mesh at index surgery in its prevention.MethodsA systematic review was performed according to PRISMA-guidelines. The electronic databases Embase, PubMed, Cochrane Library, and Web of Science were searched. Studies were included if they presented postoperative outcomes of patients undergoing surgical treatment of parastomal hernia at the ileal conduit site, irrespective of the technique used. A search was performed to identify additional studies on prophylactic mesh in the prevention of ileal conduit parastomal hernia, that were not identified by the initial search.ResultsEight retrospective case-series were included for analysis, reporting different surgical techniques. If reported, highest complication rate was 45%. Recurrence rates varied highly, ranging from 0 to 80%. Notably, lower recurrence rates were reported in studies with shorter follow-up. Overall, available data suggest significant morbidity after the surgical treatment of ileal conduit parastomal hernias. Data from five conference abstracts on the matter were retrieved, and systematically reported. Regarding prophylactic mesh in the prevention of ileal conduit parastomal hernia, 5 communications were identified. All of them used keyhole mesh in a retromuscular position, and reported on favorable results in the mesh group without an increase in mesh-related complications.ConclusionData on the surgical treatment of ileal conduit parastomal hernias and the use of prophylactic mesh in its prevention is scarce. Given the specific perioperative challenges and the paucity of reported results, more high-quality evidence is needed to determine the optimal treatment of this specific surgical problem. Initial results on the use of prophylactic mesh in the prevention of ileal conduit parastomal hernias seem promising.

Project description:One in three women will experience a clinically significant urinary tract infection (UTI) by age twenty-four and almost half will have at least one in their lifetime. Recurrent UTIs (rUTIs) are defined as having greater than two infections in a 6-month period, or three infections over twelve months, with complete resolution for at least two weeks. These may be due to relapse from incomplete treatment (persistence) or re-infection (new source). It may be difficult to distinguish between the two, where the same organism is cultured. There are several risk factors for rUTIs including an impairment of the body's immune system and virulence factors. Reversible or treatable causes are sought and excluded in the patient's initial review. Patient's with rUTI are often complex and difficult to manage. The long-term management options in women are multimodal and should focus on prevention of relapse and recurrence. Behavioural factors include adequate hydration, care with sexual hygiene, reducing one's body mass index (BMI) and post-void residual (PVR) volume. There are several non-antimicrobial options for rUTIs which have become a multi-billion-dollar business. Unfortunately, there are numerous studies which fail to show any major benefit or having conflicting data. Vaccines are currently being explored as a prevention strategy, delivered through injection, intra-nasal sprays, or vaginal suppositories, which are made from combinations of heat killed uro-pathogenic strains. There are no widely available vaccines at present due to limited clinical success. It is well established that appropriate antibiotic therapy results in higher rates of symptom relief and bacterial eradication in women with uncomplicated cystitis. There are several options for antimicrobial use which have been shown to be highly effective in reducing the risk of rUTI in women. The pain and discomfort of the UTI must be balanced with the cost and risk of developing resistance when using antimicrobials. Continuous prophylaxis, pre- and post-coital voiding, and self-starting are the three commonly accepted options for prophylaxis. The choice between these will depend upon patient preference, cultures and previous pattern of infection. Intra-vesical instillation of hyaluronic acid and chondroitin sulphate have been used for glycosaminoglycan (GAG) layer replenishment for many indications, including interstitial cystitis, overactive bladder syndrome, radiation cystitis and prevention of rUTI. At present, intra-vesical therapies are reserved for only those with the most unresponsive rUTIs. The principles of treating rUTI are to break the cycle and to treat any reversible causes. With our ever-expanding research knowledge, there are now many useful products that may be used for the successful treatment of rUTI. A management plan including a combination of a non-antimicrobial and selective antimicrobial regime for a minimum of six months should be considered. It is a prudent clinician that clearly defines this management plan, with reassurance of a finite period of therapy.

Project description:BACKGROUND:The presence of urinary fistula after ileal conduit urinary diversion is a challenging complication, and this study investigated the role of the intra-conduit negative pressure system (NPS) in the presence of urinary fistula following ileal conduit (IC) urinary diversion as a conservative treatment. METHODS:Using the intra-conduit NPS, a minor drainage tube was placed within a silicon tube to suck urine from the conduit with consistent negative pressure. Patients with urinary fistula following IC from August 2012 to July 2017 were recorded, and the clinical characteristics and outcome were retrospectively analyzed. RESULTS:The intra-conduit NPS was used as a primarily conservative treatment for 13 patients who suffered from urinary fistula and presented with a large amount of abdominal/pelvic drainage without other significant morbidities. The median age was 60?years old (42-74?years), and 7patients were male. The median duration between the IC operation and the presence of urinary fistula was 15?days (2-28?days), and elevated creatinine levels were detected in the abdominal/pelvic drainage with a median level of 2114??mol/L (636-388??mol/L). A significant decrease in abdominal/pelvic drainage was identified in 12 patients. The median time that the NPS was used was 9?days (7-11?days). The other patient did not show any improvements after 2?days of observation and then underwent open surgery. With ureteral stenting, 2 abdominal drainage tubes and the intra-conduit NPS were placed during operation, no urine leakage was observed in the abdominal/pelvic field, and the patient was cured in 9?days. With a median follow-up of 22?months, no fistula recurrence or hydronephrosis was detected. CONCLUSION:The intra-conduit negative pressure system is a feasible and promising way to cure urinary fistula following ileal conduit urinary diversion. Because this procedure is a mini-invasive and simple approach, it might represent an alternative in selected patients.

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Surgical management of urolithiasis in patients after urinary diversion.

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