Hypothesis / aims of study
This original abstract explores urinary deviations, which are present in every urology clinic. Most of the deviations are constructed in older patients who suffer from a urinary malignancies. Another substantial group of urinary deviations are realized in patients who suffer from functional voiding or storage disorders. For urinary deviations for functional disorders it is often stated that the functioning is more cumbersome and the deviations are prone to more complications and re interventions as compared to deviations made for patients with malignancies (1). These data are mostly derived from series with a limited follow-up duration. However most patients with deviations made for benign reasons, have to live with the constructions for many years and little is known about long term use and difficulties.
Therefore we investigated the disease origin, type of deviation, complications and functional quality of urinary deviations in patients with a urinary deviation that was made at least 25 years earlier.
Study design, materials and methods
We performed a retrospective study of those patients that were regularly seen for control in our clinic and who gave consent to be analyzed. The study received ethical approval of our Committee on Research Involving Human Subjects, registration number 2018-4971. Informed written consent was obtained from the patients. Our data set consists of 43 patients, 17 men and 26 women. Data are presented based on descriptive statistics, including means ± SEM and range. Statistical differences are analyzed by one-sample t-tests. P<0.05 is considered to be statistically significant.
The disease origins for the population for obtaining a urinary deviation were: bladder exstrophy (n=15), urinary incontinence (n=9), malignancies (n=8), spina bifida (n=5), urinary tract infection (n=3), kidney failure (n=1), hydronefrose (n=1) and trauma (n=1). The types of deviation were: ileal conduit (n=19), ureterosigmoidostomy (n=11), Indiana Pouch (n=5), ureterocutaneostomy (n=2), bladder augmentation (n=2) neobladder (n=1) and others (3). Mean age of patients at the time of deviation was 22 years (range of 0-57 yrs). Mean age of the patients at the time of analyses was 63 years (range of 30-92 yrs).
The mean follow per deviation was 498 months or 40,2 yrs (range of 242-804 months). The time until first revision is shown in figure 1.The total number of re interventions was 166 (shown in table 1). The number of re interventions per person differed from 0 until 14 times, with a mean of 3.9±0.5. The most common reasons for re interventions were: urinary tract stones (44), parastomal hernia (19), stenosis of the deviation at skin level (19), incontinence (18), obstruction at the ureteral anastomosis (14) and infection (12). The total number of hospitalizations was 128 times, which implies 2.9 times per patient on average. Most common admissions was for urinal tract infections (UTI): 120 times. Other reasons were: acute renal failure, metabolic acidosis, pain and skin irritation. 95% Of the study population had chronic UTI’s.18 patients had kidney failure, 50% had acute and the other 50% chronic. The mean difference in creatinine level between creatinine at start and the last known level, is a rise of + 26 mmol/l ± 8.24 with a range of 95 – 273 mmol/l (p=0.003), over a period of mean 18 years. One patient died of recurrent pyelonephritis with the wish from the patient of stopping treatment, at the age of 81 years after 32 years of living with a deviation.
Interpretation of results
In our series we observed kidney function deterioration but it seems to be mild in many cases. UTI’s is a frequent finding and if the underlying cause cannot be solved often hospital admission with IV antibiotics is necessary for some patients. The complications of the ileal conduit are mostly parastomal hernia’s (21%), urinary tract stones (14%), incontinence (14%), stenosis (13%) and obstructions (12%). Most observed complication with an Indiana pouch is stones (69%), this also holds true for an ureterosigmoidostomy (40%). Incontinence as underlying cause leads to most re interventions. For bladder exstrophy the most fit deviation in our series is the ureterosigmoidostomy.
Concerning the time until first revision the ureterosigmoidostomy gives the best result (32.3 ± 6.7 yrs). Followed by bladder augmentation and the ileal conduit, with respectively 21.6 ± 0.7 and 11.3 ± 2.9 years. Because of multiple division of the data in various categories, the study populations per category become smaller resulting in less strong evidence and firm conclusions can therefore not be made.
In conclusion, this series with a mean duration of urinary deviation of 40 years shows that it is possible to live and cope with a urinary deviation for a very long time. Because of the underlying cause and the period in which the deviation was constructed and some deviation were standard and popularized, some deviations like ureterosigmoidostomy are present in our series, that are not done that often anymore. However ileal conduits are still most chosen option and can be used with proper functioning and acceptable complication rates. There is variability in amount and in type of revisions within the group of the same type of deviation. But also between different types of deviations and underlying causes. Apart from UTI’s urinary stones are the most common problem, followed by parastomal hernia’s, incontinence and stenosis. In average the deviation will last for 13.6 ± 2.5 yrs before any revision is done.