Complications of orthortopic ileal reservoirs

ABSTRACT

Objectives To evaluate the early and late postoperative complications; upper urinary tract morphology and function and metabolic alterations which may occur after ileal continent orthotopic urinary diversion. Patients and Methods Between July 1999 and January 2001; 42 male patients were subjected to radical cystoprostatectomy for bladder cancer and orthotopic urinary diversion at the urology departments of Cairo University and Suez Canal University Hospitals. All cases were evaluated clinically; bacteriologically; urodynamically and radiologically during the early and late postoperative periods (at 3 - 6 months and 6 - 18 months; respectively). The patients were divided into three groups in Group I (22 cases) a W neobladder was fashioned with the uretero-ileal anastomosis done by creating extramural serosally lined tunnels. In Group II (12 cases) a Camey II pouch was done with ureteroileal anastomosis by direct end-to-end anastomosis in four and by Le Duc technique in eight pouches. In Group III (8 cases) a Kock's pouch was done with the ureters being directly implanted in the afferent loop above the constructed intussusception ileal nipple valve. In all types of reservoirs we used 45 cm of the ileum. Preoperatively all but four ureters were normal. These four ureters were dilated and uretero-ileal anastomosis was done by extramural serosally lined tunnels. Results In the early follow-up period total diurnal continence was achieved in 72; 75and 75of the patients of Groups I; II and III; respectively; versus 91; 83and 88in the late postoperative period. Nocturnal continence was achieved in 64; 67and 63during the early postoperative period compared to 73; 75and 75in the postoperative period for the three groups; respectively. In the early postoperative period complications occurred in 33of the patients including ureteroileal leakage (9.5); a prolonged pouchourethral anastomotic leakage (11.9); wound dehiscence (4.7); deep venous thrombosis (2.3); bronchopneumonia (2.3) and a prolonged ileus (2.3). Late complications occurred in 26.2of the patients including urethral recurrence; pelvic recurrence and urethroileal anastomotic stricture in 4.8; 14.2; 4.8; respectively and urethral stricture at the bulbomembranous junction in 2.4. A higher incidence of renal deterioration was detected in cases where the ureters were implanted directly (60) or in cases where the ureters were implanted by Le Duc technique (30). Deterioration was noted in 12.5of the cases where the ureters were implanted in an intussusception nipple valve and in 4.5of the renal units where the ureters were implanted in an extramural serosally lined tunnel. At 9 months postoperatively metabolic acidosis occurred in one patient with a Camey II neobladder. Conclusion A number of early and late postoperative complications were encountered after orthotopic neobladder. Metabolic complications were found in the form of metabolic acidosis in one patient. The lowest incidence of renal deterioration was reported in cases with extramural serosally lined ureteroileal anastomosis