Ileal neobledder without ureteroileal stents- preventing of

postoperative urinary tract infection.

P. Kowal, T. Szydełko, J. Dembowski, J. Sokołowski, T. Niezgoda, R. Zdrojowy, A. Kolodziej, J. Kasprzak, M. Wróbel, W. Apoznański, K.

Dudek, S.P. Wożniak, B. Malkiewicz, J. Lorenz

 Chair and Clinic of Urology, Wrocław Medical University

 

Purpose.We examined the frequency of

urinary tract infections in patients after cystectomy and orthotopic

neobladder, in whom ureteroileal stents were not placed in

comparison to the group of patients where ureteral stents

were used as a routine.

Radical cystectomy and continent urinary reconstruction with orthotopic placement of neobladder is considered a major operative

procedere with potential for significant complications, the most of which develop in

the early postoperative period. Stein estimates the risk of early complications as 27%. The

one of the most frequent minor failures is the acute renal inflammatory process, which may

be detected in 1,3 to 12,3% of patients.

Ureteroileal stents and the necessity of postoperative systematic rinse of

the pouch are the factors that contribute to the upper urinary tract infections due to biofilm formation

on ureteric stents. It was first described by Reid who found that

90% of indwelling silicone JJ stents were colonized by adherent bacteria.

We suppose that the risk of symptomatic urinary tract infection in patients after

cystectomy and orthotopic bladder substitution without ureteroileal stents is smaller.

MATERIAL. Since 1992 to 2002, 351 patients underwent

lower urinary tract reconstruction after cystectomy. The data are obtained on 152

patients with orthotopic bladder substitution with an afferent tubular isoperistaltic segment. On the basis of whether the ureteroileal stents were used or not, patients were divided into two groups : group A (without the drainage)

or group B (with the drainage). Group A comperised 59 patients, group B 93.

Both groups were analyzed according to:

-postoperative symptomatic urinary tract infections,- perioperative major complications, -duration of pelvic drainage, -hospitalizatin length,

-late ureteroileal strictures.

Cystecomy with the bilateral pelvical lymphatic nodes

removal was performed in both groups of patients. In group A

ileal S-shaped pouch was constructed in all patients; in group B: S-67, U-7, W-19.

Ureteroileal anastomosis was performed by Nesbit method in each patient from group A. Anastomosis in group B was performed by the following methods: -Nesbit in 11 patients,-Wallace I in 41, -Wallace II in 9,-LeDuc in 31 patients. A running monofilament 5,0 (maxon) suture was used for ureteroileal anastomosis in both groups.

In group B all ureteroileostomies were splinted with 7 to 8Ch. tubes which were led through the anterior wall of the pouch. The

pouch was drained by an 22Ch. urethral Foley catheter and cystostomy tube (Nelaton 12Ch.). Postoperatively the pouch was rinsed every 6 hours for 3 days and then every 12 hours. The stents were removed either 14 or 15 days after

the operation, Foley catheter after 21 days and suprapubic fistula was removed after 22

days.

In group A ureteroileal stents, Foley catheter and suprapubic tube were not used. The pouch was drained by 22Ch. Couvelair catheter with additional side holes making urine and mucus drainage easier. Special attention was paid to an-

hour diuresis. The urine volume was checked every 2 hours in patients from

group A in the postoperative period. Couvelaire catheter was removed after 21

days.

In both groups sucking drainage of peritoneal cavity with the use of Redon drains was applied and

a similar pattern of antybiotic therapy (cefalosporyna +

metronidazol) during 7 days after the operation was administered.

Results. In group A symptomatic renal

inflammatory process appeared in 5 (8%) patients and in group B in

36 (39%). Infection of urinary tract depended fundamentally on

the way of the treatment (the presence or absence of

ureteroileal stents) p<0.01.

Results.Stenosis of uretero-intestinal

anastomosis was detected in 1 (2%) patient from group A and in

2 (2%) patients from group B. There was no significant

difference between the groups.

Results. The average time of the operation

in group A was 6 hours (4.5-9hrs) and in group B - 7.5hrs (5-11.5hrs). The operation length for patients from group A was

essentially shorter than the operation time in group B (about

1.5 hour).

Resultes.-The time of sustaining peritoneal cavity drainage was on average in group A 7 (3-40) days and in group B 10 (2-30) days. -The average time of postoperative hospitalization in group A was 12 days (7-40) and in group B 26 days (18-65).

Resultes.Serious postoperative complications appeared in 4 patients from group A and in 4 from group B. In group A:-1 mortal case on the 6th day due to pulmonary embolism, -1 eventeration,-2 fecal fistula.

In group B:-1 mortal case on the 14th day due to respiratory failure,-2 eventeration,-1 fecal fistula.

In the light of the presented data the question arises whether it is necessary to install urinary drains that are to make the

urinary flow easy. The authors have not found in the

urological literature the data describing a the pattern of operational technique and postoperative care we used in group A.

 Conclusion.Drains left in the urinary tract which are

to allow or to ease the urinary flow constitute a potential risk for the patients. They cause infections of the urinary tract

as they facilitate bacterial colonization on their own surface. The presence of biofilms on urinary drains was first

observed and described by Reid who noticed bacteria colonies on the 90% of

the surface of silicon JJ drains.

Conclusion.The authors claim that the precise and

non-traumatic ureteroileal anastomosis, an easy flow of urine and mucus from

the pouch, which is possible with Couvelair catheter with additional side holes, and systematic (every 2 hours) control of diuresis, make it possible to

eliminate the interior drainage of ureteroileal anastomosis.

Conclusion.

The improved operational technique of forming the substitutive intestinal bladder presented by the authors, brings clear benefits: -lesser risk of renal inflammatory process,-fine postoperative rehabilitation (smaller number of troublesome drains for the patient),-shorter time of the operation,-shorter hospitalization and as a consequence lower costs of the treatment.