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Infections in Uro-oncology Patients

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  1. Infections inUro-oncology Patients Dr Bill WONG Queen Elizabeth Hospital Hong Kong

  2. Queen Elizabeth Hospital

  3. Bladder & Prostate CancerIncidence in Hong Kong Hong Kong Cancer Registry

  4. Bladder CancerCritical Limits Determining Surgery

  5. Bladder CancerIncidence of Lymph Node Metastases

  6. Bladder CancerRadical Cystectomy • N = 1,026 • Postop mortality = 4 % • Overall 5-yr survival rate = 48 % • Significant factors on survival: • Tumour stage • Tumour grade • LN status Histology – squamous, TCC, or adenocarcinoma Ghoneim, et al J Urol 158:393, 1997 *

  7. Post Cystectomy Urinary Diversion • Cutaneous ureterostomy • Uretero-sigmoidostomy / Rectal bladder • Ileal conduit / Colonic conduit

  8. Post Cystectomy Urinary DiversionIleal Conduit (Bricker 1950) Surg Clin N Am 30:1511, 1950

  9. Urostomy

  10. Ileal Conduit: Long-term CxParastomal Hernia

  11. Ileal Conduit Cx: HydronephrosisUrostomy Clinic, Q E H

  12. Ileal Conduit: Long-term CxUpper Tract Complications • Obstructive • Ischaemia  ureteral stricture • Retroperitoneal fibrosis • Non-obstructive / Reflux • Bacterial colonization of intestinal segment • Ureteral reflux • Chronic pyelonephritis

  13. Pressure Waves in Ileal Conduits

  14. A5764206 LoKC M / 6719-6-87 Ileal conduit7-4-97 Ur = 19.0; Cr = 195 11-10-96 IVU

  15. Post Cystectomy Urinary Diversion • Cutaneous ureterostomy • Uretero-sigmoidostomy / Rectal bladder • Ileal conduit / Colonic conduit • Substitution cystoplasty / Orthotopic neobladder • Continent cutaneous diversion

  16. Pelvic Cancer Surgery • Ca bladder • Radical total cysto-prostatectomy Radical total cystectomy • Radical total cysto-prostato-urethrectomy Radical total cysto-urethrectomy • Ca cervix - Post radiation recurrence • Salvage pelvic exenteration

  17. Post Cystectomy Continent DiversionQueen Elizabeth Hospital Jan 1991 - Dec 2005 • Orthotopic neobladder 75 • Ca bladder 74 • Leiomyosarcoma of bladder 1 • Continent cutaneous diversion 30 • Ca bladder 17 2 had post-RT salvage cystectomy • Ca cervix (post radiation) 6 • Ca urethra 7

  18. Post Cystectomy Continent DiversionQueen Elizabeth Hospital Jan 1991 - Dec 2005 • Orthotopic neobladder 75 • 1991 Tubular colonic 2 • 1992 - 1997 Le Bag ileocolonic 19 • 1998 - 2005 T pouch ileal 54 • Continent cutaneous diversion 30 • Kock pouch 2 • Le Bag ileocolonic pouch + Mitrofanoff 7 • Mansson colonic pouch + Mitrofanoff 12 • Native bladder 9

  19. The Ideal Neobladder • Urine storage & voiding • Adequate capacity, low pressure • Elasticity for voiding / emptying • Protection of upper tract • Absence of reflux • Absence of infected urine

  20. The Ideal Neobladder • Urine storage & voiding • Adequate capacity, low pressure • Elasticity for voiding / emptying • Protection of upper tract • Absence of reflux • Absence of infected urine

  21. The Ideal NeobladderAbsence of Reflux

  22. Direct (Non-tunneled)Uretero-enteric Reimplantation • Florida colonic pouch (n = 190) Helal, et al J Urol 150:835,1993

  23. Antireflux Ureteral Implantation • Afferent isoperistaltic ileal segment (Studer) • Submucosal tunnel (Goodwin, Leadbetter) Mucosal sulcus (Le Duc) • Split-cuff ureteric nipple (Turner-Warwick) • Afferent ileal nipple valve (Kock) • Serosal-lined extramural tunnel (Abol-Enein)

  24. Ileal Low Pressure Bladder SubstituteStuder, et al (1989) BJU 63:43-52, 1989

  25. Antireflux Nipple or Afferent Tubular SegmentStuder, et al (1991) • Prospectively randomised Antireflux nippleTubular segment n = 20 n = 20 • Median follow-up 36 months 30 months • Pyelonephtritis 4 2 • With afferent ileal tubular segments, contrast medium could be forced upwards into renal pelvis when bladder substitutes were overfilled. Peristalsis in isoperistaltic segment gradually returned contrast medium back to reservoir. Eur Urol 20:315, 1991

  26. Submucosal Tunnel (Leadbetter, Goodwin) Mucosal Sulcus (Le Duc) • Cumbersome technique • Angulation and kinking

  27. Ileal Nipple Valve • High complexity • Nipple ischaemia • Nipple stenosis • Stone formation • Valve prolapse *

  28. Refluxing vs Anti-reflux AnastomosisAn Experimental Study Kristjansson, et al BJU 78:840,1996

  29. The Ideal Technique • Effective • Low complication rate • Easy and reproducible

  30. Ileal Neobladder with Serosal Lined Extramural Ileal Tunnel • T pouch DG Skinner (1998) • Serous lined extramural tunnel Abol-Enein (1994)

  31. B7796701 WongK M / 73  T pouch ileal neobladder 10-12-98 (post-op 3 weeks) Cystogram

  32. Orthotopic T Pouch Ileal NeobladderStein, Skinner, et al J Urol 172:584,2004 • 209 patients • Median follow-up = 33 (range 0 – 69) months • Reflux (15 / 158) 10 % • Renal function worsened (7 / 181) 4 % • 5 had normal upper tract

  33. Orthotopic Ileal T Pouch Reflux n = 31 / 46 • Reflux (demonstrable by VUDS) in 11 / 31 (35 %) • Filling pressure at first reflux mean = 18 cmH2O (range 10 - 39) • Filling volume at first reflux mean = 366 ml (range 250 - 530)

  34. Orthotopic Ileal T Pouch Late Complications N = 46 • Diarrhoea 1 • Lower urinary tract infection 4 • Pyelonephritis - • Metabolic acidosis 2 • Deterioration in renal function -

  35. The Ideal NeobladderAbsence of Infected Urine

  36. Vesico-Ureteric Reflux Cystitis + VUR  Pyelonephritis  Renal scar / Reflux nephropathy

  37. CICClean Intermittent CatheterisationCISCClean Intermittent Self Catheterisation The insertion of a catheter into the bladder four times or more daily to provide regular and complete bladder evacuation, helps to prevent urinary tract infection and deleterious effects of high intravesical pressure damaging the upper urinary tract. Lapides 1972

  38. Urostomy n = 19 5 (26.3 %) required assistance to - prepare stomahesives - empty urostomy bags Orthotopic Neobladder n = 20 18/20 (90 %) resumed urethral voiding 6/18 (33.3 %) urethral voiders needed supplementary CISC Only 2 (10 %) totally relied on regular CISC Only 1 (5 %) required assistance for CIC QoL after Total CystectomyVoiding Routines

  39. Reduce Infected Urine • Clean intermittent self catheterisation • Regular bladder washout

  40. The Ideal Neobladder • Urine storage & voiding • Adequate capacity, low pressure • Elasticity for voiding / emptying • Protection of upper tract • Absence of reflux • Absence of infected urine

  41. The Ideal NeobladderAdequate Capacity

  42. Orthotopic Bladder SubstitutionTubular Colonic Neobladder

  43. Colding-Jorgensen et al BJU 72:586,1993 Studer et al World J Urol 10:11,1992

  44. Orthotopic Bladder SubstitutionLe Bag Ileocolonic Neobladder