Editing Orthotopic Urinary Diversion (section)

=== Late post-operative complications ===
* '''<span style="color:#ff0000">Occur at similar rate in all types of urinary diversions:</span>'''
** '''<span style="color:#ff0000">Bowel obstruction, thrombotic events, and cardiovascular complications</span>'''
** '''<span style="color:#ff0000">Ventral hernias are quite common</span> and may be in part related to the need for increased abdominal pressure to empty the neobladder'''
* '''<span style="color:#ff0000">Major long-term problems with continent cutaneous diversion relate to malfunction of the efferent continence mechanism, and open surgical revision is often required</span>'''
*'''<span style="color:#ff0000">Late complications directly related to diversion include:</span>'''
** '''<span style="color:#ff0000">UTI</span>'''
** '''<span style="color:#ff0000">Ureteroileal or afferent limb obstruction</span>'''
** '''<span style="color:#ff0000">Urethral stricture</span>'''
** '''<span style="color:#ff0000">Upper tract and pouch stones</span>'''
** '''<span style="color:#ff0000">Pouch-vaginal fistula</span>'''
** '''<span style="color:#ff0000">Pouch perforation</span>'''
** '''<span style="color:#ff0000">Incontinence</span>'''
** '''<span style="color:#ff0000">Urinary retention</span>'''
** '''Other than incontinence and urinary retention, these complications tend to be less common in orthotopic diversion than in continent cutaneous diversion, and many if not most can be managed by endoscopic procedures and rarely require open surgical revision'''
* '''UTI'''
** Although symptomatic urinary infections do occur, asymptomatic colonization of the neobladder with bacteria is also very common, although less common than in continent cutaneous diversion unless the patient is on intermittent self-catheterization.
** '''Asymptomatic bacteriuria should not be treated''' and is likely to simply encourage development of resistant organisms. If local symptoms suggest an infection, it should be confirmed whenever possible by a culture in this patient population.
** '''A patient who develops a febrile infection after the initial few months should be evaluated for possible upper tract obstruction and incomplete emptying.'''
* '''Ureteroileal or afferent limb obstruction'''
** '''The rate of ureteroileal stricture is identical to that in ileal conduit diversion, and is influenced by the type of anastomosis. The direct end-to-side Leadbetter or the combined Wallace anastomoses with interrupted fine absorbable sutures have been shown to have the lowest risk of stricture''' (≈3-6%)
** Obstruction from an antireflux valve has been seen. These may be clinically silent until the patient develops bilateral hydronephrosis or even renal failure
* '''Urethral stricture'''
** Actual stricture of the neobladder-urethral anastomosis is rare
* '''Upper urinary tract and pouch stones'''
** '''Pouch stones were very commonly seen in the Kock neobladder because of the use of surgical staples to maintain the intussuscepted nipple valve but have been''' '''rare in the Studer and Hautmann neobladders''', which are made entirely with absorbable suture
* '''Pouch-vaginal fistula'''
** '''A unique complication of orthotopic neobladder in women''' that can be quite difficult to repair.
** Reported incidence is 5-10%, and the risk is increased if a portion of the anterior vaginal wall is excised along with the cystectomy specimen and in irradiated patients.
** Prevention methods include:
**# Leaving the vagina intact whenever it is safe from an oncologic standpoint
**# Careful watertight closure of the vaginal cuff when it is opened
**# Placement of an omental flap between the vagina and neobladder, secured to the perivaginal tissue on either side of the urethral anastomosis.
** '''Fistula should be ruled out in any woman with persistent significant incontinence after the first few months of recovery.'''
*** This is most easily done with a careful pelvic examination and with methylene blue instilled into the neobladder if necessary.
* '''Pouch perforation'''
** '''Potentially life-threatening complication'''
** Rare in continent diversion in general, especially in orthotopic diversion because outlet resistance is usually low.
*** '''Risk may be increased in patients who have had previous radiation therapy'''.
** '''Typically presents with acute abdominal pain and distention, often with signs of sepsis'''
** '''CT cystogram is usually diagnostic'''
** '''In general, these patients should be managed with exploration and repair,''' although conservative management with percutaneous drains has been described
* '''Incontinence'''
** '''Generally less continent at night than in the daytime'''[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310095/]
**'''Daytime continence'''
*** '''Gradually improves over the first 6-12 months'''
*** '''Ultimately achieved in 80-90% of both male and female patients'''
**** '''Preserving the uterus may be associated with improved daytime continence'''
** '''Nighttime continence'''
*** '''Improves more slowly and may continue to improve beyond 12 months'''
*** '''One of the most bothersome sequelae of neobladders, persisting in 20-50% of patients'''
*** Results in part from the absence of neurologic feedback and sphincter detrusor reflex, as well as decreased sphincter tone at night
** Factors influencing continence rates include:
*** Age; older patients take longer to regain continence than younger patients
*** Intestinal segment used
*** Possibly the application of a nerve-sparing technique
** '''The evaluation and management of urinary incontinence after orthotopic diversion should be delayed until the neobladder has had time to expand. This may take 6-12 months after surgery'''
** '''Physical therapy with biofeedback focused on the pelvic floor muscles may help some patients attain initial continence.'''
** '''Urodynamic investigation may be indicated to ensure adequate capacity, without pressure waves, especially if colon is used for the neobladder.'''
*** '''If reduction in maximal urethral closure or low Valsalva leak pressure is demonstrated, anti-incontinence procedures''' (such as transurethral injection of bulking agents, AUS, artificial urinary sphincter or urethral sling) '''can be considered.'''
**** '''In patients undergoing slings, use of infrapubic bone anchors or a prepubic approach may provide the safest surgical options to avoid injury to the pouch or bowel'''
* '''<span style="color:#ff0000">Urinary retention</span>'''
** '''<span style="color:#ff0000">Occurs in 4-10% of males[https://pubmed.ncbi.nlm.nih.gov/23159582/] and 20-60% of females[https://pubmed.ncbi.nlm.nih.gov/28843339/]</span>'''
***'''Risk of retention increases with time'''
** '''Diagnosis and Evaluation'''
***'''Patients with incomplete emptying may have acute retention but more often have urinary infections or the new onset of overflow incontinence on presentation'''. They may also be discovered on routine follow-up with a palpable suprapubic mass, or distended reservoir or new-onset hydronephrosis on imaging.
*** '''Rectal or vaginal examination and cystoscopy should be performed in patients who develop retention, to rule out a urethral anastomotic stricture or tumor recurrence'''
** '''Management'''
*** '''Intermittent self-catheterization preferred'''
*** '''Pharmacologic intervention for patients with urinary retention does not appear to be an effective measure to improve this voiding dysfunction.'''
*** Biofeedback training in pelvic floor relaxation may be helpful.
*** Many of these patients have a flap of mucosa causing the obstruction that may be incised endoscopically with good effect
*** '''Hernias should be identified and surgically repaired'''
**** '''A significant number of patients with orthotopic reservoirs will develop abdominal wall or incisional hernias postoperatively.'''
**** '''These fascial defects will reduce the efficiency in completely evacuating the neobladder by reducing the ability to effectively increase intra-abdominal pressure.'''
*** '''In women it appears that posterior prolapse of the pouch may contribute to late retention, and posterior support by means of omental flaps and sacrocolpopexy has been advocated'''