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MEDICAL, TECHNICAL AND FUNCTIONAL ASPECT OF VARIOUS URINARY DIVERSIONS: Edited by John P.F.A. Heesakkers and Fred Witjes

The functioning and the complication rate of extreme long existing urinary diversions

Van Ginkel, Charlotte J.a; Cobussen-Boekhorst, Hannya; Martens, Franka; Feitz, Wout F.J.a,b; Heesakkers, John P.F.A.a,c

Author Information
doi: 10.1097/MOU.0000000000000928

Abstract

INTRODUCTION

Urinary diversions are constructed for various reasons; malignancies, functional disorders and/or congenital anomalies. Only few studies are available on the long-term wellbeing of patients and the functioning in every aspect of their urinary diversion [1,2]. Even though this is important knowledge for patient counselling and follow-up. It is often stated that urinary diversions constructed for functional disorders, compared to malignancies, are functioning more cumbersome and are prone to more complications. 

Box 1
Box 1:
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Most literature about diversions for functional disorders mainly focused on early on-set complications. Zillioux et al. mentioned that 25% of the patients had at least 1 complication, mostly urinary tract infection (UTI) (39%), during the 2 years follow-up [3]. A Cochrane review looked at urinary diversions and bladder reconstruction using intestinal segments for intractable incontinence after cystectomy [3]. The study with the maximum mean follow-up was 132 months [1]. Kidney function was followed up to 16 years. Although this is much longer than most studies, it is still a relatively short period of time in a human's life. Another study looked at continent colonic urinary reservoir with a mean follow-up of 133 months (38 males, 36 females). The most common problem was ureteral obstruction in patients who previously underwent irradiation (29%) [2]. Hautmann et al investigated the complications rate in 1.000 neobladders, with a mean follow-up of 20 years. In total, 22/1000 cases were for benign reasons. Hydronephrosis, incisional hernia, ileus or small bowel obstruction and feverish UTIs were observed in 16.9%, 6.4%, 3.6% and 5.7% of patients [4]. Another study looked at complications arising in plus 10 years of follow-up in 183 patients with orthotopic low pressure bladder substitute, showing pyelonephritis as the most frequent cause. This analysis was in 194 patients for malignant tumours and 6 for benign conditions [5].

The objective of this retrospective study was to investigate the functional quality and the complications of urinary diversions in patients with at least 25 years follow-up.

METHODS

A retrospective study was performed in patients with a urinary diversion constructed at least 25 years earlier who still had regular control in our clinic in 2018–2019. Most of them are seen yearly for systematic control of the urinary diversion. They also had given written consent to evaluate their medical files. The endpoints looked at surgical re-interventions, hospital admission, UTI (urine culture proven) and kidney function. The glomerular filtration rate (GFR) was calculated with the MDRD formula. The study received ethical approval of our Institute; registration number 2018-4971.

Statistical analysis

For the descriptive statistics median with range is chosen, because the relatively small number of patients.

RESULTS

Overall group

The study included 43 patients, 17 men and 26 women. The age at time of constructing the diversion was 18 years (0–57). The median follow-up was 40 years (25–67). Demographic descriptives are shown in Table 1. The disease origins were bladder exstrophy (n = 15), urine incontinence (n = 9), urinary malignancy (n = 8), spina bifida (n = 5), recurring UTI (n = 3), kidney failure (n = 1), hydronephrosis (n = 1) and trauma (n = 1). Type of diversions was ileal conduit (n = 19), ureterosigmoidostomy (n = 11), Indiana Pouch (n = 5), ureterocutaneostomy (n = 2), bladder augmentation (n = 2), neobladder (n = 1) and three other diversions taken together as one group (n = 3): Blockson's vesicostomy, Mathisen's re-implantation and Koch pouch.

Table 1 - Demographic analysis of (A) the total study population and divided into disease origin and (B) diversion type
Population number 43
Gender Men ( n = 17) Woman (n = 26)
(A) Disease origin In Total (n = 43) Bladder Exstrophy (n = 15) Incontinence (n = 9) Malignancy (n = 8) Other (n = 11)
Age at time of analysis, years 66 (30–92) 57 (39–84) 75 (30–92) 75 (47–86) 59 (42–87)
Age at time of diversion, years 20 (0–57) 2 (0–51) 45 (1–52) 47 (1–57) 19 (0–47)
First creatinine, μmol/La 85 (39–254) 86 (39–143) 84 (69–103) 85 (46–165) 79 (49–254)
Last creatinine, μmol/Lb 100 (42–378) 102 (80–226) 11 (56–156) 78 (58–249) 94 (42–378)
(B) Diversion type Ileal conduit (n = 25) Ureterosigmoidostomy (n = 11) Other (n = 13)
Age at time of analysis, yrs 75 (39–92) 66 (30–79) 56 (39–87)
Age at time of diversion, yrs 36 (1–55) 2 (0–18) 23 (0–57)
First creatinine, μmol/La 86 (39–254) 83 (62–165) 78 (39–112)
Last creatinine, μmol/Lb 91 (42–226) 108 (65–249) 100 (42–378)
Data presented as median with range.
aFirst documented creatinine level, often not at time of constructing the diversion.
bLast documented creatinine level, in a mean time difference of ∼20 years.

In six cases the original urinary reconstructions were converted into an ileal conduit because of complications. The original urinary diversions were ureterosigmoidostomy (n = 2), ureterocutaneostomy (n = 1), bladder augmentation (n = 1), Blockson's vesicostomy (n = 1) and Koch pouch (n = 1).

The median time to the first surgical re-intervention was 6 years. (Figure 1). Six patients had no re-interventions. The most common reasons for surgery were urolithiasis (27%), ureteroileal anastomosis stenosis (20%), parastomal hernia (11%), leakage at skin level (11%) and infections (10%) (Table 2). In 4% the reason for surgical re-intervention could not be found. If surgery was needed in case of infection, this was mainly through nephrectomies. Of the total 128 hospital admissions, 120 were for antibiotic treatment or for treating obstructions because of UTI. Two patients were responsible for 45% of the admissions. Other reasons for admission were acute renal failure, metabolic acidosis, pain and skin irritation. In total, 95% of the study population had UTIs. There was a mild deterioration of kidney function based on increase of creatinine level. The last GFR was in 45% above 60, another 45% had a GFR between 30 and 60 and only 12% had a GFR < 30. Twelve patients (28%) were under regular control by the nephrologists. Two patients underwent kidney transplantation. One patient died at age 81, of recurrent pyelonephritis after 32 years of living with a urinary diversion, with the patient's wish to abstain from treatment.

FIGURE 1
FIGURE 1:
The time to first surgical re-intervention (TTI1). The figure shows the time to first surgical re-intervention per patient in categories of type of diversion in months. The mean follow-up is 164.273 (range 0–686 months). The mean total time to first surgical re-intervention is 6814 months in a total duration of 21.401 months. The mean time between surgical re-interventions is 129.0 months (range of 0.9–686), implying a total mean of 4644 months. The ileal conduit (N = 19) has a mean TTI1 of 136 months (0–474). The ureterosigmoidostomy (N = 10), Indiana Pouch (N = 5) and ureterocutaneostomy (N = 2), respectively: 387.1 months (24–686), 17.8 months (3–51) and 95.9 months (44–148). Finally, the bladder augmentation (N = 2) and others (N = 3), have a TTI1 of respectively 259.7 (252–268) and 24 ± 6.9 months (11–34).
Table 2 - Analysis of number and reasons of surgical re-intervention. Per disease origin and type of diversion
Disease origin Reason for surgical re-intervention
Bladder exstrophy (n = 15) Diversion type Stones Incontinence Infection Pain Parastomal Hernia Stenosis Tumour Metabolic Functional Prolapse Leakage Fistula Cyste Incisional Hernia Kidney Failure Missing Total Mean ± SEM
Ileal conduit (n = 8) 14 2 1 14 1 1 3 2 1 39
Ureterosigmoidostomy (n = 8) 2 1 1 3 1 1 9
Ureterocutaneostomy (n = 1) 1 1 2
Total 15 3 3 1 x 14 2 3 1 2 3 x x 2 x 1 50 3.3 ± 0.8
Incontinence (n = 9)
Ileal conduit (n = 8) 1 4 1 16 9 12 3 2 4 52
Bladder augmentation (n = 1) 1 1
Ureterosigmoidostomy (n = 1) x
Total 1 1 4 1 16 9 x x x x 12 3 2 x x 4 53 5.8 ± 1.6
Malignancy (n = 8)
Ileal conduit (n = 3) 2 3 1 6
Ureterosigmoidostomy (n = 1) 5 1 1 7
Indiana Pouch (n = 4) 10 1 1 1 1 14
Total 15 x x x 2 3 1 x 1 x 1 1 x 1 1 1 27 3.5 ± 1.0
Other (n = 11)
Ileal conduit (n = 6) 11 2 1 7 1 3 1 4 30
Indiana Pouch (n = 1) 1 1 1 3
Ureterocutaneostomy (n = 1) 1 1
Bladder augmentation (n = 1) 1 1
Neobladder (n = 1) x
Ureterosigmoidostomy (n = 1) x
Other (n = 1) 1 1
Total 13 1 3 x 1 8 x 1 3 x 2 x x x 4 x 36 3.6 ± 0.9
Total (sum of all) 44 5 10 2 19 34 3 4 5 2 18 4 2 3 5 6 166 3.9 ± 0.5
Total, % 27 3 6 1 11 20 2 2 3 1 11 2 1 2 3 4 101

Results according to disease origin

Table 3 summarizes the results separately for the three most frequent disease origin and for the type of diversion.

Table 3 - Summary of the results for (A) the total study population and per disease origin and for (B) Diversion type
(A) Disease origin In Total (n = 43) Bladder exstrophy (n = 15) Incontinence (n = 9) Malignancy (n = 8) Other (n = 11)
FU, yr. 40 (25–67) 49 (33–65) 36 (25–45) 30 (25–67) 37 (25–63)
Number of surg. reinterv.a 4 (0–14) 3.0 (0–12) 7.0 (0–14) 6 (0–7) 3 (0–10)
Number of surg. reinterv./10yrb 1.0 (0–3.5) 0.6 (0–2.4) 1.9 (0–3.5) 2 (0–2) 0.8 (0–2.4)
Time to first surg. reinterv., yr. 6 (0–57) 27 (1–57) 1.0 (0–21) 3 (0–27) 12 (0–22)
Hospitalization for UTI 1.0 (0–28) 1.0 (0–8) 1.0 (0–23) 0.0 (0–28) 2 (0–6)
Reasons for surg. reinterv. Urinary tract stones (27%)Stenosisc (20%)Parastomal hernia (11%)Leakage (11%)Infection (6%) Urinary tract stones (30%)Stenosisc (28%) Parastomal hernia (30%)Leakage (22%)Stenosisc 28%) Urinary tract stones (55%)Stenosisc (11%)Parastomal hernia (7%) Urinary tract stones (36%)Stenosisc (22%)
(B) Diversion type Ileal conduit (n = 25) Ureterosigmoidostomy (n = 11) Other (n = 13)
FU, yrs 36 (25–54) 63 (29–67) 33 (25–54)
Number of surg. reinterv.a 4 (0–14) 2.0 (0–7) 5.0 (1–8)
Number of surg. reinterv./10yrb 1.1 (0–4.2) 0.3 (0–1.3) 2.6 (0.3–2.4)
Time to first surg. reinterv., yrs 6 (0–40) 30 (2–57) 3.0 (0–22)
Hospitalization for UTI 2.0 (0–28) 1.0 (0–4) 1.0 (0–23)
Reasons for surg. reinterv. Stenosisc (28%)Urinary tract stones (21%)Parastomal hernia (15%)Leakage (13%) Urinary tract stones (31%)Metabolic imbalance (19%)Anal incontinence (13%) Urinary tract stones (52%)
Data presented as median with range.
aSurg. reinterv. = surgical re-intervention
bPer 10 years of FU. per 10 years of follow-up (mean).
cStenosis of the ureteroileal anastomosis.

Bladder exstrophy

Fifteen patients had a diversion because of bladder exstrophy (ureterosigmoidostomy (n = 8), ileal conduit (n = 4), ureterocutaneostomy (n = 1), Blockson's vesicostomy (n = 1) and Mathisen's re-implantation (n = 1). There was 1 surgical re-intervention per person per 16 years (in 49yr FU). Two patients didn’t have any surgical re-interventions. In 2% the reason for surgical re-intervention was unclear.

Incontinence

In nine patients, all women, refractory incontinence that failed all other treatments was the reason to construct a diversion (ileal conduit (n = 7), ureterosigmoidostomy (n = 1) and bladder augmentation (n = 1)). In the median follow-up of 36 years, there was 1 surgical re-intervention per person per 5 years. Two patients did not have any surgical re-interventions.

Malignancy

Eight oncological patients had a diversion (ileal conduit (n = 3), ureterosigmoidostomy (n = 1) and Indiana pouch (n = 4)). Six patients had bladder cancer, subtypes: urothelial cell carcinoma (n = 4), squamous cell carcinoma (n = 1) and adenocarcinoma (n = 1). Two patients were diagnosed in their first year of birth with a sarcoma of the prostate. The median age of surgery was 48 years (1–57). In the median follow-up of 30 years, there was 1 surgical re-intervention per 5 years. Two patients didn’t have any surgical re-interventions.

Results according to type of diversion

Ileal conduit

The number of patients who initially had an ileal conduit was 19; 8 men and 11 women. Six patients had their initial construction converted into an ileal conduit. The analysis below includes all these 25 patients.

Disease origins were urine incontinence (n = 8), bladder exstrophy (n = 8), spina bifida (n = 4), malignancy (n = 3), kidney failure (n = 1) and recurrent UTI (n = 1). In the median follow-up of 36 years, there was 1 surgical re-intervention per person per 9 years. Two patients did not have any surgical re-interventions

Ureterosigmoidostomy

The 11 patients had their ureterosigmoidostomy for different reasons, bladder exstrophy (n = 8), malignancy (n = 1), incontinence (n = 1) and trauma (n = 1). In the median follow-up of 63 years, there was 1 surgical re-intervention per person per 32 years. Three patients did not have any surgical re-interventions. One patient had her ureterosigmoidostomy converted into an ileal conduit after 30 years because of an adenocarcinoma of the colon. Other reasons for converting the ureterosigmoidostomy were metabolic imbalance (n = 1), kidney function deterioration (n = 1), infection (n = 1) and anal incontinence (n = 1).

Results functional versus oncological

We compared functional origins, bladder exstrophy and incontinence, with oncological origins; the median age at time of constructing the diversion was respectively 6 and 47 years.

One re-intervention per 9 years was found in the functional group, with as most common reasons: urinary tract stones (16%), parastomal hernia (16%) and leakage (14%). This was 1 re-intervention per 5 years in the oncological group, in 63% of the cases because of urinary tract stones. In Table 4 these results are summarized.

Table 4 - Summary of results divided into functional- and oncological origin
Functional (n = 24) Oncological (n = 8)
FU, yr. 44 (25–65) 30 (25–67)
Age at time of analysis, yr. 67 (30–92) 75 (47–86)
Age at time of diversion, yr. 6 (0–52) 47 (1–57)
First documented creatinine, μmol/L 85 (39–143) 74 (46–165)
Last documented creatinine, μmol/L 103 (56–226) 88 (58–249)b
Hospitalization for UTI 1.0 (0–23) 0.0 (0–28)
Time to first surgical re-interv., yr. 6 (0–57) 3 (1–57)
Number of surgical re-interv. (mean) 5.0 (0–14) 6.0 (0–7)
Number of surg. re-interv/10y FUc 1.1 (0–3.2) 2.0 (0–2)
Reasons for surgical re-interv. Urinary tract stones (16%)Parastomal hernia (16%)Leakage (14%) Urinary tract stones (63%)
Data presented as median with range.aIn a mean difference of 20 years (range 9–45).
bIn a mean difference of 18 years (range 8–44).
cNumber of surgical re-interventions per 10 years of follow-up.

DISCUSSION

Extreme long follow-up

It is technically possible to make a lower urinary tract reconstruction with drainage to the skin, interposition of segment of ileum or sigmoid or to construct a bladder enlargement. However, constructing a perfect long lasting diversion is still very difficult. Many complications have been described, such as metabolic issues, skin and adhesive problems, UTIs, kidney failure, incontinence and urinary tract stones [2,6,7,8].

In this series the median age of patients at time of constructing the diversion was 20 years (0–57), because the series includes patients with congenital anomalies. In total, 31/43 patient had their urinary diversion because of benign reasons (functional and/or congenital anomalies). The fate of these patients is life-long follow-up. Only few data are currently available on the long-term wellbeing of these patients and the functioning in every aspect of their urinary diversion [1,2].

Surgical re-interventions: ileal conduit versus ureterosigmoidostomy

The separate analysis of ileal conduit and the ureterosigmoidostomy gives respectively 1 surgical re-intervention per 9 years and 1 per 32 years of follow-up, in favour for the ureterosigmoidostomy. The ureterosigmoidostomy is also superior in time to the first surgical re-intervention, respectively 30 years compared to 6 years. This is an interesting finding since other surgical solutions for bladder exstrophy now prevail although the results of the ureterosigmoidostomy are very acceptable. This was already noticed by Goodwin in 1977 and repeated by Corcos in 2018 [9,10]. Also, this construction can be converted to an ileal conduit later on, if complications become too cumbersome. With a reported incidence of 2–15% in the literature, the most feared complication of an ureterosigmoidostomy is the increased risk of colorectal malignancy [11,12], with a mean time of malignancy development of 26 years [13]. In our series, 1 patient out of 11 (9%) had the ureterosigmoidostomy converted into an ileal conduit after 30 years because of an adenocarcinoma of the colon. Other reasons for conversion were metabolic imbalance (n = 1), kidney function deterioration (n = 1), infection (n = 1) and anal incontinence (n = 1). In 45% of the converted cases the ureterosigmoidostomy was converted into ileal conduits (80%), after a mean time of 41 years (35–52). The relatively high number of conversions can be explained because it was the wish of the patient although medically not necessary. Whereas in some cases the fate of patients, for example with an ileal conduit, will be living with recurring complications the rest of their lives.

Urinary tract infections

95% of the study populations had recurrent UTI, meaning at least multiple treatments for UTI (> 3 times). The UTI was diagnosed by positive urine culture. This number is comparable with other published series [14]. Most patients were treated with oral antibiotics on outpatient base. Reasons for hospital admission were intravenous antibiotic treatment or solving obstructions. In some cases, nephrectomy was the final solution for recurring UTIs. Even though almost all patients had to deal with UTI, the number of admissions was acceptable low (median 1.0).

Renal function

An important parameter in the functioning of a urinary diversion is renal function. In our series the overall kidney function does not deteriorate much. The first documented creatinine level of 85 μmol/L (39–254) (often not at time of constructing the diversion) increased to 100 μmol/L (42–378) at last known level. The last documented GFR was in 45% above 90, another 45% had a GFR between 30 and 60 and only 12% had a GFR < 30. This implies that with proper follow-up kidney function can be preserved in majority of the cases in the long run. However, the reliability of GFR in this patient population is limited, because of possible overestimation of creatinine levels. Furthermore, the reason for the increase of creatinine level is not simply the functioning of the urinary diversion. Age-dependent increase of creatinine can also translate through these results. Gondo et al. also showed that renal function deterioration was not a very frequent finding in their series although the follow-up was only 3 months [15]. This is also in line with the findings from Mansson [1]. They observed a mean GFR drop of approximately 25% in the follow-up of 123 months in a group of 56 patients (with 18 ileal diversions, 20 colon diversions and 18 continent reservoir).

Functional versus oncology

Recent literature states that urinary diversions for functional aetiologies are associated with a significant rate of complications [3]. It is stated often that they are more prone to complications and re-interventions compared to oncological reasons. If we exhibit this statement in our series, 24 patients had a urinary diversion because of benign/function reasons (bladder exstrophy and incontinence) and 8 patients because of a malignancy. We found that urinary diversions for functional disorders do not have more surgical reinterventions compared to the oncological group, 1 per 9 years compared to 1 per 5 years. However, we have to take into account that the low percentage of surgical re-interventions for functional reasons could be found because of the very good functional result of the ureterosigmoidostomy, covering 1/3 of the patients. This might mask the higher percentage of surgical re-interventions for other reconstructions for benign reasons. For the malignancy group almost two-third of the cases for re-intervention was because of urinary tract stones. For the functional group, stones went parallel with parastomal hernia with 16%, followed by leakage of the diversion at skin level (14%). Compared to stone treatment [16] the repair of a parastomal hernia is challenging [17] and often leads to recurrences. This implies that if this complication could be avoided, it increases quality of life for the patients [18]. So, although the number of surgical re-interventions was lower, the complications arising in the functional group were more cumbersome. The time to the first surgical re-intervention favours the functional group as compared to the oncological group (6 versus 3 years).

There were less hospital admissions in the oncological group. The renal function is preserved in both groups. Important to note is that patients receiving a urinary diversion because of an oncological reason, were younger (median age 47) than normally expected in oncologic practice. This can be explained because two patients had a congenital malignancy. Moreover, the poor survival rate of invasive bladder cancer translates in the median age, those patients did not survive the minimal follow-up period of 25 years.

Limitations of the study

The data are collected retrospectively. It is a small inhomogeneous study, giving les strong evidence and firm conclusions can therefore not be made. Having a minimum follow-up of 25 years may result in selection bias. The index patient who receives a urinary diversion is a patient with muscle invasive bladder cancer. Those patients most of the time do not have a mean survival of 25 years because of their underlying oncological disease and the age at which the disease occurs. Because of the above it is slightly tricky to interpret the findings of our study but it does give an interesting glimpse in the long term problems.

CONCLUSION

This study with an extreme long follow-up of 40 years shows in this series that it is possible to live and cope with a urinary diversion with only 1 surgical re-intervention in 10 years. Because of the period of when the urinary diversion was constructed and the underlying cause, some diversions like ureterosigmoidostomy are present in our series, even though they are not done that often anymore. However, ileal conduits are still the most chosen option and they can be constructed with proper functioning and acceptable complication rates. Whereas renal function deterioration was mild, UTIs were a very common problem. Diversions constructed for functional origins did not have more complications but did have more cumbersome and difficult to treat complications as compared to the oncological group.

Acknowledgements

None

Financial support and sponsorship

None

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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Keywords:

retrospective; studies; urinary bladder diseases; urinary diversion; urologic neoplasm; urologic surgical procedures

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