19. Urinary Diversions in Adults - Construction and Complications

In this class, we're going to continue our discussion of urinary diversions and adults. Right now, our focus is going to be on surgical construction and potential complications. So we'll talk about the various options for surgical construction of a urinary diversion. And we'll talk about early and long-term complications. We'll differentiate between those that are fairly common and those that are possible but pretty unlikely. So talking about options for construction for many years, the diversion of choice was ureterostomy. It's just what it sounds like. They literally disconnected the ureters from the bladder and attached one or both ureters to the skin surface. Now they could do either a ureterostomy or a trans ureterostomy. So if they do a ureterostomy, they bring each ureter out and attach it to the skin. So you've got a single ureteral opening at the skin surface and that's what you see on top. Trans ureteral ureterostomy means that they took one ureter and nastimosed it to the other ureter and then brought that ureter out as a stoma. So that's what you see in the middle of the screen. You can see that they've swung the left ureter over attached it to the right ureter and then brought the right ureter out as the stoma. Now why would they do ureterostomy? Well it was the obvious diversion. If you have to take out the bladder, it's like okay well I've got these ureters. They're draining urine. I better do something with them. I'll connect them to the skin. We'll attach a pouch. That's how we'll manage. And it is a very simple surgical procedure. But that is the so advantage. And look at all the disadvantages. There's a reason that ureterostomy is very rarely done today. And the first is ureters are very narrow in diameter. 0.2 centimeters. That's nothing. So they're incredibly prone to stenosis. When you disconnect the ureter from the bladder wall, you bring it out to the abdominal surface so it down. You're going to get scar tissue. And that is going to narrow the lumen further. So it starts out 0.2. But it's going to become smaller than that. And as a result, they're very prone to stenosis. Now surgeons have done a number of things to try to prevent stenosis. They'll cut little darts in the wall of the ureter and suture it down to try to enlarge the ureteral opening. That's called spatulation of the ureter. Doesn't make that much difference. Stenosis is still an issue. Here's another major problem. The location of the stoma is dictated by where the ureter ends. What's the length of the ureter? How far can you bring it in terms of reaching the abdominal wall, reaching a suitable pouching surface? So I've had patients with a ureterostomy stoma on the flank where they literally had to stand in front of a mirror and try to get a pouch on. Because that's where the surgeon could bring it out. So usually you end up with a less than optimal stoma site. The fact that you have a very small skin level stoma creates pouching issues. And then one of the biggest problems is any bacteria on the surface of the skin have a straight shot to the renal pelvis. They can migrate right into the ureter and up to the renal pelvis so UTIs are common. For a period of time they did ureterosigmoid ostomies, which might sound like a good idea, but you're going to quickly see why this is really not a great choice. They're very rarely done today. There are still people who had them done a number of years ago. So here's what they did. They removed the bladder, obviously disconnected the ureters, and then connected the ureters to the sydmoid colon. So now the rectum serves as a reservoir for both urine and stool. And I can see you all shaking your heads like who thought that was a good idea? You don't want to mix urine and stool. You're going to get bacteria up the ureters. There's going to be all kinds of problems. So why did they do this? Well they did it because they thought, well, look, this would be advantageous. The person would not have to wear a pouch. There wouldn't be a stoma. They could just control both urine and stool elimination with their anal sphincter. But here are all the negatives. And this is why this is in general a diversion of the past. First of all, as you all guessed, very high risk for urinary tract infection. Either because of reflux or when they tried to tunnel the ureters because of retention. So if they tried tunneling the ureters through the bowel wall to create resistance to reflux and hopefully to create protection. But the thing is if you don't create enough of an angle then they still get reflux and bacterial migration to the renal pelvis. If you create too much of an angle, they get resistance to urine flow and hydrogen afrosis. So huge issues with urinary tract infection. Also urine is flowing into the rectum and it's sitting there until you go to avoid the urine in the stool. And that gives you prolonged contact with the mucosa of the rectum. So metabolic abnormalities were a huge issue. Patients got reabsorption of urine metabolites. So they got that hyperchloramic metabolic acidosis with hypochlamia. A lot of them ended up on chronic medical management for that. Bullet point number three. High risk for incontinence because you always have liquid stool. I had a patient early young in my career as an ostomy nurse who had this done. He was furious with everyone on the team. He's like, why did you do that? Why did you make it sound like a good choice? It was awful. I was running to the bathroom all the time. I couldn't go anywhere. I couldn't do anything. I want you to undo this and give me back that other thing where I wear a bag on the outside. So yes, high risk for incontinence. And here was really the final insult. What they found was that there was increased risk of adenocarcinoma at the anestimotic site beginning about 15 to 20 years post-construction. So I don't think you'll see patients undergoing Ureero sigmoid ostomy, but you might encounter patients who had it done in the past. That's why we wanted to know what this is. By far, the most common approach to urinary diversion today is a Ureero intestinal conduit, most often, an Ilioconduit. So how do they do this? This actually was a great breakthrough in urinary diversions. So first of all, they isolate a 10 to 12-centimeter segment of bowel and its mesenteri. So 10 to 12 centimeters has about 5 inches, 4 to 5 inches. So you see that on the illustration on top. You see they have resected a segment of bowel with the mesenteri intact. And then you see the bowel itself is reconnected so there will be no change in bowel function. Then they're going to take that little segment of bowel. They're going to close the proximal end with staples or sutures. They're going to connect the uritors and they're going to bring the distal end out to the abdominal wall as a stoma. So those illustrations show you the progression and construction of a Ureero intestinal conduit. Now look at the illustration on bottom. This is what you end up with. So now urine is produced by the kidneys, flows through the uritors into that little segment of bowel. Remember the proximal end is sewn shut, stapled shut. So urine flows through that little segment of bowel out the stoma and into the pouch. Now, one thing I emphasize to patients when I'm doing pre-op teaching, I want them to understand how this little section of bowel, this conduit, how it differs from their bladder. And the first thing I point out to them, your bladder serves as a reservoir. So it fills with urine and then empties. Fills with urine and then empties. This little section of bowel acts as a pipeline, a conduit. urine flows in and out, in and out, in and out. Your inflow is almost constant and a pouch will be needed at all times. Now there are major advantages to a uretero intestinal conduit as compared to a ureterostomy. First of all, instead of having a 0.2 centimeter diameter stoma, now your stoma is between one and a half inches in diameter. That means you're going to be low risk for stenosis. So you're not going to need to undergo frequent surgical revisions. So now we've taken stenosis off the board as a common complication. Almost always you're able to cite the stoma on a flat surface because now you have a length of bowel interposed between the ureters and the skin. That segment of bowel in its mesenteria is usually pretty mobile. So now we've taken stenosis off the table as a common complication. We've taken pouching problems off the table as a common issue. And we also have reduced risk of UTI. Now can they get a urinary tract infection with a uretero intestinal conduit, yes. But the fact that we've interposed a length of bowel between the ureters and the skin does give you a level of protection. Still very important for the patient to drink adequate. Fluids to keep everything flushed. But the bacteria have further to go. To cause paloma fridus in the patient with conduit as opposed to the patient with a ureterostomy. There are some disadvantages or one disadvantage of the uretero intestinal conduit as compared to a ureterostomy. And that is simply, it's a longer and more difficult procedure. But you can see the advantages far outweigh the disadvantages. Now you think uretero intestinal conduit, okay, that's a great idea. Which segment of bowel would be best? So just so you know, surgeons have used almost every section of bowel to create a uretero intestinal conduit. So now we have data to answer the question which segment would be best. Scientists have tried using the jagenum but here's the big problem with the jagenum. You have extremely absorptive mucosa which increases the risk of metabolic abnormalities. And as a result, the jagenum is very rarely used. Surgeons have used the colon and this might be the best option if you have a patient who has inflammatory bowel disease and you don't want to use the small bowel or if you have bowel that's been damaged by radiation, typically at small bowel that's damaged by radiation, the colon is usually spared. The disadvantages of a colon conduit, it is a more difficult surgery because of blood flow patterns and it's also a larger stoma that may be more difficult to pouch. So colon conduits are not routinely done. They're usually reserved for situations when the small bowel cannot be used. The ilium is currently the gold standard for uretero intestinal diversion and incontinent diversion. Now, when they're making the ilio conduit, they typically spare the distal 12 to 15 centimeters of terminal ilium because that is the site where most B12 absorption occurs, where most bile salt reabsorption occurs. So typically they're looking at the bowel, they're like, "Okay, we want to spare the last 15 centimeters of terminal ilium, we'll come just proximal to that." Well isolate that segment, close the proximal land, connect the ureters, bring the distal land to the abdominal wall. Advantages of the ilio conduit is a much simpler surgical procedure if you compare it to a colon conduit and you have a smaller stoma that's easier to manage. Advantages as compared to a jagenal conduit, many fewer metabolic issues. Now, I'm going to mention a procedure that you may never see done. I hope if you do see it done, it's very uncommon, but this has resurfaced in the literature. It is being done occasionally in medical centers, surgical centers across the country. So I want you to know what it is and the procedure is a wet colostomy. So what are they doing here? So they are going to divide the colon between the sigmoid and the rectum. They're going to create a heart-man's pouch. So essentially the rectal segment is just going to sit in the pelvis and it is not going to play a role. It is just sitting there. And the only reason they do a heart-man's pouch is to avoid all the surgical trauma associated with removal of the rectum. So they divide the bowel, they close the distal segment and it sits there. Then look at the illustration on the bottom. So you can see that they have divided the sigmoid colon into proximal sigmoid and distal sigmoid. The distal portion is used to create a sigmoid conduit. Now you can see that on the illustration, you see that the distal sigmoid, they have closed the proximal end, they have brought the distal end to the abdominal wall and they have connected the uritors. And then the proximal portion of the sigmoid is brought to the abdominal wall as a colostomy. So the stomas are side by side. They've got your colostomy stoma on top and your sigmoid conduit stoma on bottom. They're going to be incorporated into one pouch and both urine and stool are going to drain into that pouch. And I'm sure you're wondering why would you do that? And about the only time that we're seeing this done is if you have a patient who's end of life, they're undergoing surgery due to obstruction of both bowel and bladder. And the only advantage is that they only have to manage one pouching system. But you're probably sitting there saying, yeah, but there's lots of disadvantages. So they're going to have urine and stool going into the same pouch. Is that going to increase the risk of infection, yes? And isn't that going to be difficult to manage because you're going to have liquid and solid? Yes. So typically they have to manage with a high output pouch or with a fecal pouch. I'm not recommending this. I'm not saying this is a great idea. I'm saying you may see this and I want you to know what it is. Nobody wants you to know what it is. So that's what it is. Hopefully you'll never see it. Okay. I wanted to differentiate between an end stoma and a loop in stoma that's sometimes known as a turnable loop. So end stoma is the standard approach. You have a section of bowel. You bring the bowel through the abdominal wall. You turn it back on itself and you have one lumen, single and stoma, okay, that's standard. But in some situations they will do a turnable loop, also known as a loop in stoma. It can be advantageous if you have a patient with a very obese abdomen because it can reduce tension on the stoma, it can reduce the risk of retraction and it can also reduce the risk of ischemic changes which can occur when you're trying to feed the end of the bowel through a very thick abdominal wall and you have to trim away the meds and terry. So loop in stoma's turnable loops can be advantageous in people with an obese abdomen. So what are they going to do? So they're going to take the piece of bowel, they're going to close by. both ends with staples or sutures, ideally sutures, then they're going to bring that entire loop through an opening in the abdominal wall. They're gonna open the anterior wall of that loop and turn it back on itself and sew it down. So you have one stoma, you're gonna be pouching one stoma, but you can see from the illustration on bottom that you have access to both ends of that little loop. They're obviously going to connect the urutors to the proximal end so that you're in exits the stoma into the pouch. The distal end just ends in a blind pouch. And again, why would you do this? Just to improve stoma formation in a patient with an obese abdomen. You manage it essentially the same. One stoma, one pouch, but surgical construction is a little bit different. And if you ever have to catheterize that stoma to get a urine specimen, you want to be sure that you're catheterizing the proximal end. So the last thing we're gonna talk about is complications of you redraw intestinal conduits. This is a complex surgical procedure in that you're dealing with both the urinary tract and the GI tract. Overall, complication rate, you can see is very high. 25 to 45%. That's high complication rate. So we're gonna talk about common complications and we're gonna talk about complications that are much less likely. Pallondilius is one of the most common complications. It is so common that I routinely tell my patients who are scheduled for a uretero intestinal conduit that length of hospital stay will probably be determined by the rate at which their bowel and bowel function returns to normal. So I tell them, you know, to do this, we have to remove a section of bowel. Then we have to reconnect the bowel itself. When we mess with the bowel, it goes to sleep. So we know that intestinal manipulation during surgery causes an ilias. We know that anesthesia further contributes to the ilias and opioids postop add yet another insult. So at what point would we expect that ilias to resolve? At what point do we expect parasitic activity to return? It can be anywhere from two days to six or seven days. Now it's the small bowel. So normally if we give the patient liquids by mouth or if we encourage them to chew gum so that they get that sham feeding, typically that helps to resolve the ilias at an earlier point. Normally that promotes parasitosis. Eating, drinking, gum chewing can all promote parasitosis and resolution of the ilias. Once the patient starts passing gas, once they start passing stool, we can gradually advance their diet. Things that help in addition to gum chewing, early-ambulation, limited use of opioids. But some individuals, despite all of these things, have very slow return of bowel function. And here's what we frequently see. So we do see that they're starting to pass gas. They might be having bowel movements, especially with use of suppositories or enemas. But then when we go to advance their diet, they might have gastric intolerance. They might have bloating, they might have nausea, they might have vomiting. Because in many individuals, the stomach is the last section of the gut to go back to work. It's the holdout. So we have to progress very slowly based on their tolerance. So I have patients who are eating day two and doing well. They're up walking around, they're passing gas, they're having bowel movements, they're tolerating their diet. They have no issues, and they go home day five. I have other patients who day six, they're walking, they're limiting their opioids, they're chewing gum, they're doing everything they know to do. But every time they try to eat, they get sick. So there's obviously things we don't yet fully understand about Ilius and Resolution of Ilius. But I want you to know prolonged Ilius is a pretty common complication. And it causes prolonged hospitalization, delay discharge, and a lot of patient frustration. But I've never yet had a patient who's Ilius did not eventually resolve so that they could go home. What about small bowel obstruction due to adhesions? Fortunately, that's much less common. When we have a patient with a prolonged Ilius, one of the things we always do is we get a flat plate X-ray, we get a CT to determine. Is this a mechanical obstruction from adhesions or is it just slow motility? If they have a small bowel obstruction and mechanical obstruction due to adhesions, then we put down an NGTube to decompress the proximal bowel. We maintain them on IV fluids, we monitor. Most of the time, what happens is that trapped loop of bowel is able to slip free of the adhesive band, bowel function resumes, and they're able to go home. Surgery is indicated only if they fail to respond to medical management. Unfortunately, is very uncommon. So prolonged Ilius, very common, small bowel obstruction, much less common. What about an asthmotic breakdown? Yes, that can occur. Fortunately, again, this is uncommon. Now, an asthmotic breakdown can occur either at the level of the intestinal anastomosis where we put the bowel back together or it can occur at the point where the uritors are connected to the conduit. If you have a bowel leak, if you get breakdown of the intestinal anastomosis in a bowel leak, you're gonna have signs of paratonitis, increasing pain, tenderness, distention, rising white count, we're gonna be doing a CT, we're gonna be able to see the leak, see the fluid collection, see if there's abscess formation. Typically then they go to interventional radiology where a drain is placed to manage the fluid accumulation to drain the abscess. If it's a very small bowel leak, many times it will see alone its own. If it's significant, we take them back to surgery, but again, this is uncommon. What about a urine leak? Break down the anastomosis between the uritors and the conduit. Again, uncommon. There are things we do to prevent this. So, intraoperatively they play stints that go all the way from the renal pelvis through the uritor out the ilial conduit, out the stoma. And those stints support the uretero ilial anastomosis. They maintain patency, they help prevent distinction and anastomotic brain temp. Also, at the time of surgery, they're gonna place a drain adjacent to those anastomoses. We're gonna be monitoring the volume of drainage through that drain. If it's increasing, if we're seeing increasing drainage through that surgical drain, increasing output through the drain, decreasing output through the conduit, time to do a CT to verify our rule out leakage. If we have concerns about what's coming through that surgical drain, is it urine? It shouldn't be urine. It should be essentially a plasma derivative, just the fluid that leaks out from damaged cells. That occurs normally post-operatively. But if we're seeing increasing output through this surgical drain, we can run creatinine levels to see if this looks more like urine and less like plasma. If there is a leak, if it's significant or if it fails to close on its own, they have to go back to surgery. Fortunately, that is uncommon. What about urinary tract infection? Yes, this is a relatively common complication, something that we're always talking to patients about. So think about the risk factor. Most of your ureteroil and nastimosis are freely refluxing that creates the risk for ascending bacteria. They have tried creating an anti refluxing and nastimosis but it's more difficult surgically, it's more likely to stenose and to cause back pressure on the kidneys so most of the time they do freely refluxing the nastimosis and we know that that patient is at risk for ascending bacteria. How do we prevent infection? The best protection is high volume fluid intake. As long as you're drinking enough, you're constantly making urine as flushing through the ureter through the conduit and out. So it's constantly flushing out any bacteria. If you go for long periods without fluid intake and I tell my patients you're creating a dry creek bed and it's very easy in that situation for bacteria to migrate through the conduit of the ureters and to the kidneys. So they should be drinking throughout the day, making urine throughout the day, flushing throughout the day. We do not routinely check the urine of somebody with a conduit for bacteria because you know what? We're going to find bacteria. Asymptomatic chronic bacteria is common but if they're asymptomatic we do not need to treat. If we do treat them when they're asymptomatic we're just going to create resistant strains of bacteria. So asymptomatic chronic bacteria, urea, not treated. No need to routinely do cultures of conduit urine. If they're symptomatic, yes. When they're symptomatic, we get a culture and we treat based on the culture. So then the patient's going to say, well, how would I know I had an infection? What symptom should I report? Just feeling terrible. That is the most common symptom. I feel awful, I just feel so drug-out, I feel like I can't walk across the room. Flank pain. Because remember, the bladder has been removed or bypassed. Any infection is going to involve the kidneys. So you're talking pile of nephritis. So significant malaise, flank pain, nausea, nausea's very common sign of pile of nephritis. They might notice increased urine odor. They might notice cloudy urine but probably the most common signs and symptoms are malaise, feeling bad in general, flank pain, and possibly nausea. A much less common complication, metabolic abnormalities due to reabsorption of urine metabolites. We've already talked about that. If you have a patient with a nilial conduit, with a colon conduit, what we tend to see if we see anything is hypochaluramic, hypochalamic metabolic acidosis. Because they tend to reabsorb sodium and chloride, dump potassium and bicarb. In contrast, if you have a patient with a jajunal conduit, they end up with hyponutremia, hyperkalemia, and metabolic acidosis. Because in the jajunum, the absorption pathways favor potassium. So potassium's reabsorbed sodium and bicarb is excreted. But again, these are very uncommon because conduits are now constructed to be short and straight. So there's minimal contact between urine and the mucosa minimal time for electrolyte reabsorption. It's been years since I've seen a patient with metabolic abnormalities. What about renal calculi? Yes, renal calculi can occur in a patient with a urethrointestinal conduit. Here are the reasons. I want to start with the bottom one. Potassium oxalate stones, which are one of the most common types they can occur in anyone. They're the most common type. They're not unique to individuals with conduits, but neither does a conduit provide protection. So anyone can develop calcium oxalate stones whether or not they have a conduit. And then look at the other two things. When they do the conduit, if they leave an exposed staple line, it can serve as anitis for stone formation. It's a great place for minerals to attach. Well, surgeons are very aware of this. So they typically suture over the staple line, close over the staple line so that that doesn't happen. If you have a patient who has chronic UTIs, then they're at increased risk of magnesium phosphate stones because of the chronic bacterial colonization. Again, what's your best protection, constant fluid intake. So our message to all of our patients is, can you develop stones, yes? Are you more likely than the average person to develop stones? Not so long as you maintain high level fluid intake, that's your best protection. The signs and symptoms of renal calculi are the same in patients with a conduit as in a patient without blood in the urine, acute excruciating flake pain, nausea and vomiting. We don't miss these, excuse me, prevention, we've talked about this, we've said the same thing, fluid intake, constant fluid intake, prompt treatment of any UTI that's symptomatic, analysis of any stones that occur so we know how to manipulate the pH. It doesn't matter whether you have a conduit or not, we're going to give medication for pain and nausea, you're going to undergo lithotripsy or surgical excision unless you pass it spontaneously. Now vitamin B12 deficiency is extremely unlikely. We're not going to test you on this, I don't even think they'll ask you this on the certification exam. Remember the distal 100 centimeters of ilium is the only site for reabsorption of bousalts and for absorption of B12 intrinsic factor complex. If you remove a significant portion of the terminal ilium, yes you do place that patient at risk for B12 deficiency, it typically doesn't show up until many years later because it develops very gradually. If you have a patient who is at risk, then you do want to monitor B12 levels probably once a year, who's at risk? Any patient who has significant resections, so how much did you remove? If you only removed 10 to 15 centimeters, it's very unlikely they're going to develop a deficiency. If you removed 20 to 30, okay now your risk is starting to go up, typically that's not done. There are other risk factors that contribute, so B12 deficiency, the risk of that increases with age because we have diminished absorption of B12 over time. People with diabetes are higher risk. People who use proton pump inhibitors are higher risk, smokers are higher risk and people with chronic opioid use, so some clinicians say you know what, I just monitor them once a year when they come in for their checkup, I just do a B12 level so we don't miss it. So are people with conduits higher risk, maybe slightly higher risk, depending on how much of the terminal helium was resected? Probably most of the risk goes back to these other factors, but you could look at it from this perspective as well, it's not going to hurt anyone to take sublingual B12, most of our patients are over the age of 50, many of them are diabetic, many of them use proton pump inhibitors, a lot of them are smokers, so it wouldn't be a bad idea to just recommend B12 replacement on an ongoing basis. What about chronic renal insufficiency, renal failure? Again, not typically a complication, but if you have a patient with chronic infections that are poorly managed over time, they're going to damage the kidneys and they're going to progress to renal failure. So if you had a patient who developed a stretch. causing back pressure on the kidneys and hydro nephrosis. Yes, they could end up in renal failure. So anyone with an conduit should be followed at routine intervals every year just to make sure all their labs look normal and that if anything abnormal is seen, we can do imaging studies. You read oral strictures uncommon. It is a potential complication due to the narrow lumen of the ureter, most common in people who undergo ureterostomy, much less common in people who undergo uretero intestinal conduits. But again, patients should be followed once a year. They should have routine lab work to check for any evidence of developing renal failure. They should have imaging if there are any concerns. So can they get stricter at the level of the uretero intestinal and asthmosis? They can. The stance that are placed at the time of surgery go a long way toward preventing that. So it's not anything we see commonly. If they do develop stricter, they can usually either be dilated or they might have to have surgical revision. So uretero strictures possible not common. So to summarize the main surgical options for urinary diversion, ureterostomy was the standard of care in the past. Today, the standard of care is a uretero intestinal conduit, typically an ilio conduit. Conplications, the most common early complication is ilius, which can delay discharge, obstruction is possible and asthmotic leaks are possible. Long term urinary tract infections are by far the most common. Patients can develop calculi, metabolic derangements are very uncommon. Be 12 deficiency can develop, but is more likely to be due to other factors. Strictures, renal failure, uncommon, stomal and peristomal complications will be addressed in later classes. That's it. Thank you very much.