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N35 Pathophysiological and clinical problems after urinary diversion

      Introduction and Objectives

      During the period bowels had been used for urinary diversion (UD), many clinical and pathophysiological problems are seen.

      Material and Methods

      We want to focus on the most important problems, using the latest clinical data and own experience.

      Results

      Before Bricker in 1950 described his conduit, ureterosigmoidostomy were the only UD used commonly. Malignancies are reported in large series and is about 3.5–19% [

      BJS, 1991,1216–8.

      ]. In Denmark the few patients still alive is recommended to sigmoidoscopy when symptoms occur; in symptomless pt – bloodtest every year and sigmoidoscopy every 3rd year [

      Eur.Urol.1986,360–1.

      ].
      Metabolic acidosis has been reported in 100% of pt after ureterosigmoidostomy, bladder substitutions or continent reservoir [

      J Urol.1999,1057–66.

      ]. Metabolic acidosis can be life-threatening, as we will show in our case later and prophylaxis with peroral bicarbonate is simple and cheap treatment.
      The mucus production can be trouble as bad acute ureteric obstruction, can be important in reservoirs stones formation. Asymptomatic bakteriuria in pt with reservoirs, rectal reservoirs and ileal conduits not require antibiotics, but symptomatic upper urinary tract infection shows problem with reflux or obstruction.
      Urolithiasis formation is common in reservoirs due to artificial materials (e.g. staples), infections, abnormal composition of urine, mucus production, urinary stasis, noncompliance with irrigation and catheterization regimens [

      J Urol.1997,1709–13.

      ]. Osther et al. [

      Scan J Urol.Neph.2000,257–61.

      ] investigated urine in pt with ileal-urethral Kock reservoirs, they have lower urinary excretion of citrate and higher ph, calcium oxalate, calcium phosphate, brushite and magnesium ammonium phosphate than in normal men.
      Pts with UD after removing of terminal ileum and ileocaecal valve can have problems as: malabsorption of bile acids and fat,secretory-osmotic diarrhea, acceleration of bowel transit, hypovitaminosis, formation of gallstones and urinary tract stones.
      Case: The 58 years old female with Coffey-bladder because of urethral atresia, was operated at 5 years old. She was hospitalized several times in the last 7 years in very bad condition due to metabolic acidosis and low bicarbonate (8 mmol/l). Pt is in prophylaxis treatment now, feels good, when she remember medication.

      Conclusions

      Conclusions: The problems can be minimized by pts better selection, life-long surveillance and early operation.

      References

      1. BJS, 1991,1216–8.

      2. Eur.Urol.1986,360–1.

      3. J Urol.1999,1057–66.

      4. J Urol.1997,1709–13.

      5. Scan J Urol.Neph.2000,257–61.