Advances in Pediatric Urinary Diversion.

Pediatric urinary diversion is performed for a unique set of indications with many options to consider. Although surgical intervention has decreased in necessity overall due to advances in expectant management, it remains an important tool. There are many options and various factors to consider in choosing the right type of diversion for an individual and these patients require lifelong follow-up with a pediatric urologist and eventually an adult urologist. This article provides a detailed review of the most relevant techniques used by pediatric urologists for urinary diversion.

Comparative impact of continent and incontinent urinary diversion on long-term renal function after radical cystectomy in patients with preoperative chronic kidney disease 2 and chronic kidney disease 3a.

OBJECTIVES: To evaluate the differences in estimated glomerular filtration rate decline by urinary diversion type (incontinent diversion vs continent diversion) and preoperative estimated glomerular filtration rate among patients undergoing radical cystectomy and urinary diversion. METHODS: We evaluated 1383 patients treated with radical cystectomy between 1980-2006 who had a preoperative estimated glomerular filtration rate of 45-89 mL/min/1.73 m(2). Estimated glomerular filtration rate was estimated using Chronic Kidney Disease Epidemiology Collaboration equations, and patients were stratified by preoperative estimated glomerular filtration rate into chronic kidney disease 2 (estimated glomerular filtration rate 60-89 mL/min/1.73 m(2)) and chronic kidney disease 3a (estimated glomerular filtration rate 45-59 mL/min/1.73 m(2)). Multiple definitions of estimated glomerular filtration rate decline were evaluated: (i) 10-point decline in estimated glomerular filtration rate; (ii) 20% decline in estimated glomerular filtration rate; and (iii) 10% decline in estimated glomerular filtration rate. Time to estimated glomerular filtration rate decline was compared using the Kaplan-Meier method stratified by diversion type. Cox regression models were used to evaluate the association of diversion type with estimated glomerular filtration rate decline risk. RESULTS: In total, 74% (1021/1383) of patients underwent incontinent diversion and 26% (362/1383) underwent continent diversion. Preoperative chronic kidney disease 2 and chronic kidney disease 3a were noted among 59% and 41% of patients who underwent incontinent diversion, versus 74% and 26% with continent diversion. Median follow up after RC was 11.2 years. The rate of estimated glomerular filtration rate decline in patients with incontinent diversion versus continent diversion was similar when stratified by preoperative chronic kidney disease 2 and preoperative chronic kidney disease 3a, regardless of estimated glomerular filtration rate decline definition. On multivariable analysis, continent diversion was not associated with estimated glomerular filtration rate decline for patients with preoperative chronic kidney disease 3a. CONCLUSIONS: The risk of estimated glomerular filtration rate decline over 10 years was not significantly different after incontinent diversion versus continent diversion among patients with preoperative chronic kidney disease 2 or chronic kidney disease 3a. Continent diversion does not appear to confer an independently increased risk of estimated glomerular filtration rate decline in patients with preoperative chronic kidney disease 3a.

Risk of end stage kidney disease after radical cystectomy according to urinary diversion type.

PURPOSE: The risk of renal insufficiency has historically been viewed as a long-term consequence of urinary diversion after radical cystectomy. However, there are little data on the long-term rate of end stage kidney disease after urinary diversion and few studies have compared end stage kidney disease rates by diversion type. In a large, population based cohort we evaluated the risk of end stage kidney disease in patients who received an ileal conduit vs continent urinary diversion after cystectomy for bladder cancer. MATERIALS AND METHODS: Using the SEER-Medicare 1992 to 2010 data set we identified 4,015 patients treated with radical cystectomy for bladder cancer, excluding those with preexisting renal disease or clinically significant preoperative hydronephrosis. The outcome of interest was end stage kidney disease stratified by diversion type. We used a Cox proportional hazard model for multivariate analysis controlling for demographic, tumor and comorbidity characteristics. RESULTS: End stage kidney disease developed in 7.2% of patients, including 84% with an ileal conduit and 16% with continent urinary diversion. Median followup was 34 months (IQR 12-73). On multivariate analysis no increased risk of end stage kidney disease was associated with continent diversion (HR 1.06, 95% CI 0.78-1.44, p = 0.71). Overall the estimated risk at 5, 10 and 15 years was 8.3% (95% CI 7.1-9.5), 16.9% (95% 14.6-19.2) and 24.4% (95% CI 20.3-28.5), respectively. CONCLUSIONS: No significant difference in the rate of end stage kidney disease was identified when comparing ileal conduits to continent urinary diversion. A significant risk of end stage kidney disease in the long term was identified in patients with post-cystectomy survival beyond 5 years.

[Representation of cystectomy and urinary diversion in the G-DRG system 2010: an example for the complexity of the reimbursement system]. / Kodierung der Zystektomie im DRG-System 2010 : Ein Beispiel für die Komplexität des Abrechnungssystems.

Cystectomy and urinary diversion is an excellent example for the growing complexity of the G-DRG (German diagnosis-related groups) system. Based on different diagnoses (malignant tumor of the urinary tract, benign disease of the urinary tract, malignant tumor of the female genital tract, or malignant tumor of the male genital tract), identical cases may lead to very different codes, resulting in even more differences in reimbursement.

Percutaneous incision of stenotic uroenteric anastomoses with a cutting balloon catheter: long-term results.

PURPOSE: To describe the technique and results of incision of strictures in anastomotic urinary diversions with a commercially available cutting balloon catheter. MATERIALS AND METHODS: Thirty-seven stenoses were treated in 32 patients. Most (28 [88%]) of the patients had undergone surgery for bladder cancer 17.7 months +/- 17.4 (SD) (range, 3-72 months) before incision. Thirteen patients had undergone ileal conduit diversion, and nineteen had undergone enterocystoplasty. All stenoses were shorter than 3 cm. The presence of adjacent ileal loops and/or iliac vessels was assessed with computed tomography before incision. The cutting wire was oriented anteriorly or anterolaterally, and the balloon was inflated with diluted contrast material during the incision. A Kaplan-Meier survival curve was constructed to illustrate the success rates over time. RESULTS: No major complications occurred. Twelve (32%) stenoses recurred in nine patients 15 months +/- 10 (range, 6-36 months) after stent removal; the failure rate was 53% (eight of 15 stenoses) for ileal conduits and 18% (four of 22 stenoses) for enterocystoplasties. Late failure (>12 months) was observed in four patients. The patency of the other 25 stenoses (23 patients) was checked 25 months +/- 11 after stent removal (range, 5-43 months). The actuarial patency rate was 77% at 1 year, 68% at 2 years, and 62% at 3 years. CONCLUSION: Cutting balloon incision is a safe and simple alternative to surgery, particularly when the urinary diversion is enterocystoplasty.

The type of urinary diversion after radical cystectomy significantly impacts on the patient's quality of life.

BACKGROUND: In this study, we used a previously well-validated survey to assess the impact of different forms of urinary diversion on overall quality of life in patients with bladder cancer. METHODS: A total of 92 patients, having three different forms of urinary diversion after radical cystectomy, completed by mail the SF-36, a validated quality-of-life survey. All patients had local/regional disease at the time of cystectomy and are currently without evidence of disease. Completed surveys were then analyzed into physical (PCS) and mental (MCS) component quality-of-life scores per published protocols. Results were then compared with published age-based norms. RESULTS: A total of 38 men who had cystectomy and ileal neobladder had a mean PCS (+/- SD) of 48.4 (7.8) and a mean MCS of 51.0 (7.4); 16 men and women who had cystectomy and Indiana Pouch had a mean PCS of 48.4 (8.9) and a mean MCS of 55.7 (3.8). None of these results is statistically different from published age- and sex-based population norms. Thirty-eight men who had cystectomy and ileal conduit had a mean PCS of 41.4 (8.5) and a mean MCS of 48.2 (10.7). The PCS is not statistically different from the population-based norm; however, the MCS is significantly decreased from the published norm (P = .01). CONCLUSIONS: Patients with ileal conduits have significantly decreased mental health quality of life whereas patients with continent urinary diversions do not. Therefore, when not medically contraindicated, patients should be offered a continent diversion as the diversion of choice after cystectomy.

Approach to urinary diversion in the surgical patient.

Major surgical procedures may remove part or all of the bladder and make an incontinent or continent urinary diversion appropriate. Preoperative consideration must be given to 1) the stoma and its position, 2) the catheterizable channel, 3) the urinary continence mechanism, and 4) the substitute bladder reservoir. Complete bowel preparation and broad-spectrum antibiotics are desirable. The patient's motivation for taking care of a continent urinary diversion is important, since lifelong catheterization and mucous irrigation may be necessary. The status of the native bladder outlet and urinary sphincter is important in cases in which an orthotopic continent urinary diversion is considered. Preoperative evaluation by a stoma therapist is invaluable. Adequate urinary drainage is important in the immediate postoperative period. Patients with urinary diversions must be followed lifelong to rule out asymptomatic deterioration of their upper urinary tracts and to check for potential metabolic and nutritional problems.

Practical stoma care.

Patricia Black looks at the reasons behind and management of different types of stoma as well as outlining some of the possible problems associated with stomas. She emphasises the importance of caring for a stoma patient's psychological as well as physical wellbeing.

Reservorio urinario continente: técnica de Indiana / Urinary reservoir with the Indiana's technique

El tratamiento de muchas enfermedades de la cavidad pelviana provoca la pérdida de la continencia fecal, urinaria y a veces ambas. Se presenta la experiencia obtenida en 7 enfermos a los que se les efectuó un reservorio urinario con colon derecho con la técnica de Indiana. La enfermedad que motivó su indicación fue: cáncer ginecológico recidivado, 57,1 por ciento; cistitis actínica, 28,6 por ciento; y fístula vesico rectovaginal actínica, 14,3 por ciento. Se complicaron en el postoperatorio inmediato 2 enfermos con absceso de herida y fístula temporaria del reservorio. El período de vaciado de la bolsa osciló entre 5 y 9 horas, permitiendo un tiempo de sueño satisfactorio. El volumen promedio obtenido fue de 700cc con una continencia efectiva en todos los pacientes. Fallecieron en el postoperatorio alejado, 2 enfermos por progresión de la enfermedad y 2 por causas no inherentes a su tratamiento. No se comprobaron alteraciones ni dilataciones del árbol urinario

Postoperative management of patients undergoing radical cystectomy and urinary diversion.

The management of patients undergoing radical cystectomy and urinary diversion requires an understanding of the various tubes and drains used in reconstructing the urinary tract. The three major types of urinary diversions are presented with particular attention to the nursing skills required for successful postoperative care.

Reservorio urinario continente / Urinary continent reservoirs

El método más efectivo en el tratamiento de los tumores de vejiga infiltrantes es la cistectomía radical que incluye la derivación urinaria, que clásicamente ha sido el conducto ileal. Sin embargo, a partir de los años 80, ha habido un elevado interés por parte de los urólogos en las derivaciones urinarias continentes, ya que con ello se elimina los recolectores externos y por consiguiente una aceptación mayor por parte del paciente. Se hace en este artículo una revisión y clasificación de los reservorios urinarios continentes así como de las características y resultados de las operaciones que más se usan en la actualidad. Y para finalizar se hace notar que apesar del gran avance que se ha hecho con estas operaciones, todavía no se ha llegado al método de derivación ideal