18. Urinary Diversions in Adults - Indications

In this class, we're going to begin our discussion of urinary diversions and adults. Our specific focus will be on why would an adult require a urinary diversion? What are the specific indications? The list of malignancies resulting in a urinary diversion will also discuss benign conditions that might require a urinary diversion. By far, the most common reason for urinary diversion in adults is malignancy involving the bladder, the urethra, or adjacent pelvic organs. So it is so far the predominant condition that when I see a patient with a urinary diversion I assume that they have bladder urethral or pelvic cancer until I know differently. So you will see the terms urethelial cancer and you will see the terms transitional cell cancer. The urethelium just means the tissue lining the bladder, the urethra, and the collecting ducts of the urinary system. Transitional cell carcinoma is a very specific cell type of cancer. Transitional cell epithelium does line the bladder and the urethra. So it's the most common type, but occasionally we do have patients with other types such as squamous cell. The vast majority of patients undergoing urinary diversion, or male, the male to a female ratio is typically three to one. And that is probably because the major risk factors affect men much more commonly than they affect women. So smoking for many years men were the predominant smokers and so it was less common to see a heavy female smoker who might end up with bladder cancer. Of course, women are trying to catch up and as a result, the numbers of women with bladder cancer have increased as well. The second risk factor is exposure to industrial carcinogens, which again is disproportionately likely to affect men. So dyes, rubber products, petroleum products, textiles. It turns out that all of those service carcinogens that affect the urinary system. Long term indwelling catheters, but when we talk about long term indwelling catheters, we're talking about years. We're not talking about somebody who requires a folic catheter for weeks or months. We're talking truly long term because long term catheter use causes chronic inflammation at the level of the bladder. And finally, there's a parasitic infection, the bill horsey a parasite, that primarily affects people in the Middle East and can actually penetrate the body through the skin of the feet so it can burrow in. And then it takes up residence primarily in the bladder and causes intense chronic inflammation that can translate over time into malignancy. Now in the US, by far, the most common reasons are smoking and industrial carcinogens. What are the early signs of bladder cancer, well the most common sign is hematuria. Most people when they go in for an annual physical exam, one component of that exam is a urinalysis. And if that urinalysis reveals any level of hematuria, even if it's microscopic, further workup is required because it's never normal to have blood in your urine. When I talk to patients and I'm like, "Well, what was the first thing you noticed?" The vast majority of them tell me, "Well, I saw blood in my urine. I knew that wasn't right, so I immediately went to my doctor. He sent me to the urologist. They did that cystoscopy thing and then that's when they found it." But there is another clinical presentation. Some people do not see blood in their urine, but they experience irritative symptoms. They experience frequency, urgency, dysuria, which sounds like a urinary tract infection. Most of them think they have a urinary tract infection. They go in for treatment and what they find is there are no bacteria in the urine, but there is microscopic hematuria. So patients may go in because they see blood. They may go in because they think they have a bladder infection. Now the progression of bladder cancer is very predictable. So it's going to start at the lining of the bladder, the urethelium. Then it's going to progress to the submucosal, also known as the laminopropria. Then it's going to go to the muscle and then it's going to extend through the bladder wall to the peri-vescal fat and left nose, and eventually to distant organs. So if you look at the illustration on top, you see that stepwise progression and when they're determining management for an individual patient, one of the critical factors is, well, how extensive is this tumor? Is it limited to the lining of the bladder, is it just sitting there? Has it extended into the submucosal layer or the laminopropria, or is it muscle invasive? Once the tumor is muscle invasive, surgery is almost always required. Diagnosis, very straightforward. They're going to do a CT scan with contrast. They're going to look at the kidneys, the urethers, and the bladder for any evidence of malignancy. They're going to take a urine specimen and they're going to look specifically for cancer cells so they can do urine cytology. And the definitive diagnosis is to do endoscopy. So put in a cystoscope, look at the lining of the bladder, biopsy, any abnormal areas or clear cut lesions. Now, we've already said that treatment is dictated by the depth to which the tumor penetrates. So patients who have low grade, meaning that their malignant potential is limited, and they have superficial tumors that are confined to the mucosa, to the urethelium, or the submucosa of the laminopropria, we can manage those patients conservatively. What these patients usually get is intravascular chemotherapy, most commonly BCG, which triggers an inflammatory immune response that hopefully will eliminate the malignancy. They will do cystoscopic resection, so they will remove any cancers seen at the level of the bladder lining. So they put the cystoscope in, they're like, "Okay, there's a lesion there." So excise it, send it to the lab, and then we'll do chemo. So cystoscopy and cystoscopic resection is both diagnostic and therapeutic. They're going to bring them back typically every three months. The range is every one to six months, the most common interval is every three months. So they talk about TURBT, trans-u-rethral resection of the bladder tumor. We did a cystoscopy, we resected any abnormal lesion, now we've provided intravascular chemotherapy, we're going to have you come back in three months, and we're going to repeat the whole process. Do we see anything? If so, we're going to excise, send to pathology. When is surgery indicated? Anytime you have a high grade malignancy, so on pathology, they always look at the tumor to determine, are we seeing rapid turnover of malignant cells, rapid growth of malignant cells, that is considered to be a high grade malignancy, that tumor is going to grow quickly, you're going to become high risk for metastatic disease at an early point. So if you have a high grade tumor, if you keep developing bladder tumors, you've received intravascular chemo, but pretty much every time you come back, they have to excise another lesion, or if the tumor invades the muscle. So highly malignant with early potential for metastatic spread, persistently recurrent [BLANK_AUDIO] vessel invasive. And treatment typically involves pre-optimotherapy to reduce fastillarity of the tumor and potential for spread to shrink the size of the tumor and increase resectability. And then they'll remove the bladder and create urinary diversion. So now let's talk about differences in surgical procedure for men and women because you think about the bladder and the urethra. It's right there in the pelvis adjacent to reproductive organs. So most of the time among patients undergoing removal of the bladder, cystectomy, and urinary diversion for a malignancy, there's some potential for sexual dysfunction. So let's go through that. So for a male, look at this slide carefully. Look at the illustration and you can see the prostate gland is wrapped right around the proximal urethra right at the base of the bladder. There is no way to separate out the prosthetic tissue from the base of the bladder in the proximal urethra. So curative resection for bladder cancer in a male is radical cystoprostetectomy. They're going to remove the bladder, they're going to remove the prostate gland and they're going to remove regional lymph nodes. So just talked about why they remove the prostate. You'll frequently need to explain that to a patient. Why are they taking my prostate? I don't have cancer in my prostate. I just had my PSA. It was okay. This is why. Let me show you this diagram. Well, what does that mean for the patient? If they have a prostatectomy, they remember most of these men are older. They're typically at least in their 60s and more of them are in their 70s or 80s. So the first thing I have to explain to them or reinforce if their surgeon already did the initial explanation is removal of the prostate causes loss of ejaculatory function because where does seminal fluid come from? The prostate gland. So if we take out the prostate, there's no way you're going to ejaculate. There's no fluid flowing into the urethra. Now, can you still have an orgasm? Yes, because you'll still have muscle contractions that create the pleasurable sensations, but there won't be any fluid. It will be a dry orgasm. So as I tell my patients all the time, this means you can't make any more babies. You know, we're gonna turn it into just a recreational process. And since they're usually in their 70s or 80s or at least their 60s, the vast majority are telling me that's just fine. I'm not into making babies at this point, but they need to understand that. They need to understand that they're going to lose ejaculatory function. I have had younger men who are undergoing cystoproesthetectomy. I want to talk to them about maybe banking their sperm if they do want to have children later on. What about erectile function because the nerves that control erection pass right through the prosthetic capsule on their way to the erectile tissue. So the vast majority of patients undergoing cystoproesthetectomy undergo a nerve-sparing procedure. And what does that mean? Well, I want you to think of my arm as the nerve pathway. And I want you to think of my sleeve as the prosthetic tissue. So what they're going to do is they're going to scrape away all the prosthetic tissue. They're going to preserve the nerve pathway, but all the prostate is going to be removed. Now in the process of scraping off all the prosthetic tissue, this nerve is going to sustain some trauma. There's going to be some bruising. There's going to be some swelling. So I may lose erectile function short term until this nerve recovers, but almost all men recover erectile function within a few months. So they need to know all of that if they're undergoing a nerve-sparing cystoproesthetectomy. What about in the female? Well, again, look at the proximity of the bladder and the urethra to the uterus to the vagina. So typically if a woman is undergoing cystectomy for bladder cancer, they're going to remove the bladder and the urethra. They're also going to remove the uterus, the tubes, the ovaries. And because the posterior urethral wall is continuous with the anterior vaginal wall, they're typically going to do an anterior vaginectomy. And that can definitely affect sexual function in the female, so it can either preclude intercourse or cause difficulty with intercourse. If you're taking care of women who are undergoing radical cystectomy, very helpful to talk to the surgeon. Find out exactly what he or she is doing surgically and what it means for your patient so that you can answer their questions. Also, typically when they remove the bladder and the female, they remove the entire urethra. The urethra is short in women and continuous with the bladder. So typically they remove the entire urethra. And when they do that, that can affect pathways of blood flow to the clitoris. So you can get reduced blood flow to the clitoris, which affects sexual arousal. Now in addition to bladder cancer, urethral cancer, you may have patients who undergo removal of the bladder and urinary diversion because of different types of pelvic cancer, pelvic sarcomas, and men and women, cervical cancer, and women. There's actually three radical procedures that might be done in anterior excineration, a posterior excineration, or a total pelvic excineration. You need to know all of those terms. So an anterior excineration means that the malignancy involves the anterior pelvis as going to involve the bladder. So there's going to be removal of the tumor itself, removal of the bladder, and a urinary diversion. And women, you're going to have removal of all of the reproductive organs. They will do a partial or a total vaginectomy, and typically they'll do vaginal reconstruction at the time of the original surgery. A posterior excineration is done when the tumor involves the posterior compartment of the pelvis. So now you've got involvement of the rectum, and possibly the anal canal. So now you're going to remove the tumor, you're going to remove the rectum or the portion of the rectum that has the malignant involvement. They'll either do a low anterior resection where they take out the section of rectum with malignant involvement, and connect the colon to the anal canal, in which case the patient might require a temporary fecal diversion, or they'll do an abdominal perineal resection where they remove the entire rectum and the anal canal, and the patient has a permanent ostomy. If you're doing a posterior excineration in a male patient, they're going to typically do a radical prostatectomy. Remember that the anterior rectum is right next to the prostate gland. How do we do prostate exams through the rectum? That's how close they are. So if you have a rectal cancer, and it's extensive at all, you're probably going to have to remove the prostate gland. The female posterior excineration is going to involve removal of all of the reproductive organs as well as that portion of the rectum, as well as part or all of the vagina, and probably they'll undergo reconstruction. Now a total pelvic excineration is also known, excuse me, also known as a pelvic sweep. So essentially they're going to remove all the pelvic organs, whether it's male or female. And this is going to be done for a large invasive pelvic sarcoma. That's what we typically see in men and women. It may be done for either a pelvic sarcoma or an invasive cervical cancer. And here you've got a tumor that has spread to involve the anterior pelvis and the public. to your pelvis. So I'm going to take out the tumor, the surrounding tissue, local lymph nodes. They're going to remove the bladder. They're going to do a urinary diversion and men. It would be cystoprostatectomy. And women, it would be cystoyurythrectomy. They're going to remove the involve portion of the rectum. Most of the time it's a total removal of the rectum with a colostomy. And women, partial or total vaginectomy, and hopefully reconstruction. Reconstruction is beneficial for multiple reasons. First of all, you think about the body image issues and someone who's undergone such radical surgery. So they're already dealing with a new ostomy, maybe two new ostomies. Loss of continents is they've known it. And then in a woman who's required vaginectomy, she's lost the potential for intercourse and for the sexual relationship she had before surgery. So if they do vaginal reconstruction, that supports psychosexual rehabilitation because now she can have intercourse. But it also prevents a lot of post op complications because when you take out all the pelvic organs, then what tends to happen is loops of bowel drop down into the pelvis. They adhere to the pelvic floor. Now you can get bowel obstruction, you can get fistula formation. So reconstructing the vagina not only promotes psychosexual rehabilitation, but also significantly reduces the risk of serious complications. Okay, so by far the most common reason for urinary diversion in adults is some kind of pelvic malignancy. Either bladder or urethral cancer or some other malignancy that involves adjacent organs and requires removal of the bladder. But there are some benign conditions that may necessitate urinary diversion as well. And the first is neurogenic bladder. So you break that down neurogenic bladder. Well that suggests that you have no control over bladder function and that's exactly what it means. Neurogenic bladder, there's damage to the nerve pathways that provide you with bladder control. So it's typically someone with multiple sclerosis or a spinal cord injury or a spinal bifida. So you have a lesion somewhere along the nerve pathways that take messages from the bladder to the brain and from the brain to the bladder. And as a result these individuals have no ability to control voidet. So they have intractable incontinence or intractable retention. Now some of these patients can manage very well with clean intermittent catheterization. That's a particularly good option for men because it's much easier for them to access the urethra. And a male who has good visual acuity, good hand coordination, clear intermittent catheterization is usually a very reasonable effective management option for neurogenic bladder. But think about women who are probably wheelchair bound. Think how difficult it's going to be for them to access the urethra and to do clean intermittent catheterization. So for them, urinary diversion might make management ever so much easier. So if you're doing a urinary diversion because of neurogenic bladder, the bladder is usually left in place. There's nothing really wrong with the bladder. You've just lost voluntary control. So typically they don't put them through a cystectomy. They just disconnect the ureters, create the urinary diversion, lead the bladder in place. Another benign indication for urinary diversion is severe refractory inflammation. And there's a couple of different processes that can cause severe refractory inflammation. One is radiation system status. Think about people who require radiation to the pelvis. This is commonly a person who had rectal cancer and they had the rectum removed and then they underwent radiation to the pelvis to eradicate any stray cancer cells. But unfortunately, radiation to the pelvis can also affect the bladder because that's where it lives. And radiation can cause irreversible damage to the bladder in this fincter. Some people have incontinence. More individuals complain of intermittent bleeding, severe frequency because radiation to the bladder can cause fibrosis of the bladder wall, scoring of the bladder wall. And so instead of having a nice stretchy high volume bladder, now you have this very small scar down stiff bladder that can hold very little. So I've talked to people who could hold only 90 milliliters, three ounces. They were running to the bathroom all the time and having persistent incontinence at night. And also many times experiencing pain with bladder filling because the bladder's so stiff. So sometimes they'll initially treat cystitis caused by radiation with hyperbaric oxygen therapy. We know that some of the changes in the bladder wall are due to changes in the blood vessels and diminished blood flow and diminished oxygenation. So they frequently will do a round of hyperbaric oxygen therapy to see where can we use oxygen to try to reverse some of these symptoms? And if you get good response, great. But for most people, either they get limited response or very short term response. And so then we're right back to how are we going to manage these symptoms? And diversion bypasses the inflamed bladder and eliminates all these symptoms. So now they're not having pain. They're not having urgency. They're not having frequency. They're not having incontinence. And again, typically they leave the bladder in place. The other type of inflammatory process is interstitial cystitis. A lot of you have heard of this. It's also known as painful bladder syndrome. It is a chronic inflammatory process of unknown etiology. We're not sure what causes this. Sometimes in talking to patients who are familiar with inflammatory bowel disease, I'll tell them this is kind of like the bladder version of inflammatory bowel disease, where you can have flare ups, where you have a lot of urgency and frequency and notchuria and pain. And then maybe it'll settle down. But then it comes back. For some people, flare ups are relatively and frequent and they're like, I can manage this. And for other people, the symptoms are almost constant. And they're like, I need relief. I've got to do something. So the first thing is an accurate diagnosis. Are we dealing with interstitial cystitis? So they'll do a cystoscopy. The classic finding zone cystoscopy are little particular hemorrhages and hunter's ulcers. Now you can have all of the symptoms of interstitial cystitis and not yet have developed those particular hemorrhages or those hunter's ulcers. So for some patients, a cystoscopy is just very frustrating because they come back with no definitive answers and they still have all the symptoms. But if cystoscopy does demonstrate hunter's ulcers or particular hemorrhages, it can be so relieving to the patient because they're like, it's not in my mind. I knew I was having all these symptoms. And you can imagine the frustration. So you go into your doctor with frequency urgency, getting up at night, pain, and they're like, oh, you have a bladder infection. Let's get a specimen and we'll get you on antibiotics. But the specimen doesn't show infection. So a lot of times they'll say, well, you know what? Going to take a round of antibiotics. I know it didn't show up, but I think that's what it is. So you take the antibiotics, but you're no better. So then it's like, well, what's causing this? And if they do a cystoscopy and they don't see anything, then that's incredibly frustrating. You start thinking, is this in my head? Is it all in my head? No, it's not in my head. It's in my bladder. So for people who undergo cystoscopy and they're like, okay, we solve this this and this and this. That means you're dealing with intercessions. cystitis. This is what that means and this is what we can do about it. It can actually be a relief to have a diagnosis. They will start with medical management. The vast majority of patients do respond well to medical management. So the first thing they'll do is they'll have the patient keep a record of things they eat and drink and the severity of their symptoms because for most patients there are dietary irritants that trigger flare-ups. Citrus based tomato based foods and fluids are almost across the board. Intense irritants, they cause a marked increase in urgency and frequency and pain. So most patients routinely avoid citrus, routinely avoiding things that's tomato based and then you think how many foods that eliminates. Chocolate is an irritant for many people. Caffeine, I would die if I had interstitial cystitis because if you said no more caffeine for you I'm like oh my god. So dietary modifications can help a lot of people but it's also a major lifestyle change. Has major impact. Medications are beneficial for some people. Insights because they're anti-inflammatory. Pintasan sulfate has been beneficial for many patients. Pintasan works by reinforcing the gag layer, the glycosamino glycans layer, to provide protection to the cells of the bladder wall. Some people benefit from intravascular administration of dimethyl sulfoxide and/or heparin. Some people benefit from antihistamine therapy because histamine is a major inflammatory stimulant and so shutting down histamine production can reduce symptomatology and some people. Tricyclicanida presents primarily to reduce pain and promote sleep. So we start out with medical management. If that makes symptoms manageable for the patient we don't even look at surgery. Surgery is considered only for a reach fractory cases and it doesn't always eliminate the pain. For some people those pain pathways have been activated. They continue to have pain and so then they have to wonder what if I get by having surgery. So we want to be very clear with them that surgery may or may not eradicate your symptoms. And then the final reasons that you might see urinary diversion. These are very uncommon reasons severe pelvic trauma. What if I sustained urethral trauma? Maybe because of some kind of medical accident that caused major pelvic trauma. Anything that caused scarring or stricter of the urethra. If I have scarring and stricter at the level of the urethra I'm going to have chronic retention. I'm not going to be able to manage with intermittent catheterization because I can't pass a catheter. We can't put in a folly. The only alternative would be a super pubic catheter and super pubic catheters are not as easy as they sound because they require routine changes. They're associated with increased risk of infection, increased risk of leakage, increased risk of obstruction. So some patients might start out with a super pubic catheter and then say talk to me about that urinary diversion. I think I'm ready to have a urinary diversion. And then finally fissulas that involve the bladder. It could be between the colon and the bladder. It could be between the bladder and the vagina. How are you going to get that fissula to close? Well you won't get it to close as long as urine is flowing through that fissula tract and keeping it open. So diversion is frequently required to promote healing and to prevent managed infection. Like if it's colon vesicle, communication between the colon and the bladder, that's not a good thing because now you have colonic bacteria in the bladder. You have chronic infection. The only way you're going to get away from that is to divert the urinary street and stop that communication. And again the bladder is typically left in place. So to summarize indications for urinary diversion in adults, bladder cancer is by far the most common reason. The next most common reason is some other pelvic malignancy, a pelvic sarcoma, extensive cervical cancer. Be non-conditions. I count for a very small percentage of urinary diversions and include neurogenic bladder with intractable incontinence, radiation cystitis or interstitial cystitis, urethral trauma and stricter or fissulas involving the bladder. And then in later classes we'll talk about how urinary diversions are constructed and how they're managed. Thank you. [BLANK_AUDIO]