Review Article
Bladder augmentation and urinary diversion in patients with neurogenic bladder: Non-surgical considerations

https://doi.org/10.1016/j.jpurol.2011.03.015Get rights and content

Abstract

Segments from almost all parts of the bowel have been used for urinary diversion. As a result, the available absorptive surface area of the bowel is reduced, and the incorporation of bowel segments into the urinary tract may have metabolic consequences. This is an area somewhat neglected in the literature.

Metabolic complications are rare, but sub-clinical metabolic disturbances are quite common. Several studies have demonstrated that some of the absorbent and secreting properties of the bowel tissue are preserved after incorporation into the urinary tract. Hyperchloraemic metabolic acidosis can occur if ileal and/or colon segments are used, as well as malabsorption of vitamin B12 and bile acid after the use of ileal segments. These metabolic effects are not as severe as may be suspected and can be prevented by prophylactic substitution. Secondary malignancies can develop as a long-term consequence of bladder augmentation. Using colonic segments, tumours are most likely to occur at the ureteral implantation site.

To prevent metabolic complications, careful patient selection and meticulous and lifelong follow up, as well as prophylactic treatment, are mandatory. Endoscopy for early detection has been recommended, starting 10 years postoperatively for patients who underwent surgery for a benign condition.

Section snippets

Metabolic complications

When bowel segments are used for urinary diversion, the available absorptive surface area of the bowel is reduced, which affects the absorption of nutrients from the small and large bowel [1], [2], [3], [4], [5]. Some authors have demonstrated that at least some of the absorbent and secreting properties of bowel are preserved if exposed to urine [3], [5]. For each bowel segment typical complications are reported, especially in association with the use of longer intestinal segments in continent

Electrolytes

Electrolyte imbalance is one of the most common metabolic complications. The majority of electrolytes traverse the intestinal segments via the intestinal cells, with some movement occurring between cells [7].

If gastric segments are used, hypochloraemic hypokalaemic metabolic alkalosis may occur. This can be life threatening [8]. The concentration of gastrin seems to be important in this syndrome, as metabolic alkalosis becomes more severe with higher gastrin levels [9].

If jejunum is used for

Bone density

Chronic acidosis may play a major role in a decrease in bone mineral density after bladder augmentation or urinary diversion. This could lead to rickets in children and osteomalacia and osteoporosis in adults. Chronic acidosis is buffered by carbonate from the bone in exchange for hydrogen ions with subsequent release of calcium into the circulation, which is then cleared by the kidneys [25], [26], [27]. Sulfate directly inhibits renal tubule calcium reabsorption [7], [28]. Increased intestinal

Growth retardation

In 1992, Wagstaff et al. found delayed linear growth in 12 of 60 children after urinary diversion [47]. At the same time, Mundy and Nurse reported similar findings in 3 of 6 patients with colocystoplasty [48]. Gros et al. found decreased linear growth in patients with bladder exstrophy who had undergone intestinal augmentation, compared to those without augmentation [49]. In a long-term study involving 93 patients with meningomyelocele (colonic conduit n = 2, ileal conduit n = 28, conservative

Vitamin B12

Vitamin B12 (cobalamin) plays an important role in DNA synthesis and neurological functions. It cannot be synthesized by mammalians and must be ingested from food. In the stomach, the acidic environment facilitates the uncoupling of vitamin B12 from food. The intrinsic factor, secreted by the parietal cells in the stomach, binds to vitamin B12 in the duodenum. The vitamin B12 –intrinsic factor complex aids in the absorption of vitamin B12 in the ileum [56]. The cubilin receptor plays a

Bowel dysfunction

A pool of bile acids of 2–4 g circulates 5–10 times per day (enterohepatic circulation) [97]. The active reabsorption of conjugated bile acids from the intestine involves a Na+-coupled co-transport system limited to the ileum [98]. Most of the conjugated bile acids are absorbed in the ileum [99]. Enterohepatic circulation also includes some passive absorption of deconjugated bile acids from the jejunum and ileum. When conjugated bile acids reach the colon, deconjugation, 7α-dehydroxylation and

Secondary malignancies

The first case of a malignant tumour after ureterosigmoidostomy was reported in 1929 [132]. Since then, more than 200 cases have been reported [133]. In their review article, Austen and Kälble concluded that ‘all urinary diversions using bowel with or without separation of urine and faeces carry a significantly higher tumour risk for intestinal tumour development compared to the general population’ [133]. In one large series with a mean follow up of 27 years [10], [11], [12], [13], [14], [15],

Conclusion

Metabolic disturbances are quite common when using intestinal segments for urinary tract replacement. However, with careful patient selection, prophylactic substitution therapy (acidosis, vitamin B12), early intervention (bowel tumours), and life-long surveillance, problems are manageable and can be minimized in most cases. Twenty years ago, Mike Mitchell stated that ‘Perhaps, once bowel is used, a patient should never be considered normal’ [143]. This applies in particular to patients with

Funding

None.

Conflict of interest

None.

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