Introduction
Radical cystectomy is considered an ideal treatment for bladder cancer which allows urinary diversion and replaces the lower urinary tract. Nowadays, it is created in an extracorporeal or minimally invasive, totally intracorporeal way. It is believed that an ideal urinary holder would be, storing approximately 500 milliliters of urine, a low-pressure system with complete continence, complete voluntary control of voiding, and minimal absorption of urinary waste products. Basically, there is a variety of urinary divisions which can be classified into non-continent and continent diversions. Both have certain characteristics and complications and their treatment.
What Are the General Complications of Urinary Diversion?
The following are the general long-term complication of urinary diversion -
Early Postoperative Complications:
Most of the surgeries come along with some or other complications. It is reported that these complications are seen in the first 90 days of post-operations. Complications can be seen in both open or robot-assisted radical cystectomy.
The following are the early postoperative complications -
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Gastrointestinal complications like ileus or small bowel obstruction.
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Infectious complications are the most common.
1. Ileus:
Postoperative ileus can be defined in many ways, but it can be the inability to tolerate solid food by postoperative day 5, the need to insert a nasogastric tube through the nose, or being asked to stop oral intake due to abdominal distension or nausea.
2. Urinary Tract Infection:
Urinary tract infections (UTIs) are a common complication causing readmission in many cystectomized patients. Early postoperative urinary tract infection rates vary from 5.7 percent to 44 percent, but a lack of standardization is evident. Detecting urinary tract infections in a patient with a urinary diversion requires a high level of suspicion because of its vague presentation, ranging from abdominal discomfort and changes in urine smell to septic shock. Most often, UTIs occur before stent removal, and their higher frequency in the early vs. late postoperative period also suggests an important role of these foreign bodies in UTI pathogenesis. Antibiotic treatment should be directed to cultured microorganisms as soon as possible.
3. Urinary Leakage:
Ileal conduit ureteroileal anastomosis leak occurs in 2 percent to 5.5 percent of patients in the short term. Urethral anastomotic leaks in orthotopic neobladders are more frequent, reaching a rate of 25 percent in the first 90 days.
Late Postoperative Complications:
Studies in urinary diversion complications usually focus on early complications due to the high early mortality of underlying cancer, with cancer-specific survival rates of 66 % at five years. Long-term complications are more frequently related to the urinary diversion itself than the extirpative radical cystectomy.
The following are the late postoperative complication -
1. Renal Failure:
Renal failure is one of the complications seen in urinary diversion. On average, 19 percent of patients may suffer from renal failure due to ureteroenteric stenosis causing hydronephrosis, chronic infection, and reflux of infected urine.
2. Metabolic Abnormalities:
In urinary division, there are some long-term metabolic complications associated.
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Metabolic complications are corrected with intestinal shortening.
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The bowel segment resected, and the absorptive properties of the conduit or neobladder intestinal mucosa.
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Acid-base disorders, vitamin deficiencies, and electrolyte disturbances are consistently reported. The most frequent pH disturbance is hyperchloremic metabolic acidosis due to chloride absorption and bicarbonate excretion, mainly if a colonic segment is used.
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Vitamin B12 deficiency is also expected, as this vitamin is absorbed in the terminal ileum, a segment frequently respected to use both in conduits and neobladders.
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Hypovitaminosis is mainly asymptomatic but can evolve into megaloblastic anemia, neuropathy, glossitis, and other diseases after the body’s stores are depleted, which usually lasts three to five years.
3. Urinary Tract Infection:
Urinary tract infection is a major complication seen in urinary diversion.
The risk factors for UTIs can involve -
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Incomplete emptying of the urinary pouch (as residual urine is an infectious focus), intermittent catheterization or stenosis of the stoma, or ureterointestinal anastomosis.
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Bacteriuria is common in these patients, but UTIs and urosepsis are not, so there is no need for prolonged suppressive antibiotic therapy.
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However, UTI is less frequent than in the early postoperative.
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UTI can be treated with the indication of antibiotics.
4. Urolithiasis:
Urolithiasis is used to describe calculi or stones that form the urinary tract. Different factors like bowel epithelium, incomplete emptying of reservoirs with urinary stasis, foreign materials like staples, and chronic bacterial colonization or UTIs contribute to stone formation, which is not uncommon in these patients. These stones can be infectious and mixed, with metabolic stones being less frequent, particularly if only reservoir stones are considered.
5. Ureteroenteric Stricture:
It is believed that the cutaneous ureterostomy diversion involves ureter-enteric anastomosis. There are multiple methods for anastomosing the ureters to the bowel, either refluxing or non-refluxing.
Ureteroenteric stricture is a well-known complication, with its serious consequences being the disturbing glomerular filtration rate with reduced working efficacy of the kidneys. The rates of stenosis described in the literature range from 1.3 percent to 10 percent, occurring predominantly in the first two years after surgery.
Ureteroenteric stricture can have malignant causes, but most are benign. The pathophysiology of the benign stricture formation is not fully understood, but it is likely secondary to ischemia or urine leakage leading to periureteral fibrosis. Preserving the ureteral blood supply, with careful handling and minimization of electrocautery around the ureters, and the creation of tension-free anastomosis may reduce the stenosis risk.
Conclusion
Urinary diversion is doubtlessly the most difficult surgical procedure in urology. Complication rates are high in the early and late stages after the procedure, with various complications already reported in various case studies. It is very important to make a standardized complication reporting so different series can be comparable. Careful patient selection, thorough long-term follow-up, and standardization of complication reporting are compulsory conditions to achieve successful outcomes.
