Management of New or Worsening Urinary Infections in Continent Urostomies/Ileocystoplasty

Hadley Wood, MD, and Kenneth Angermeier, MD

Recurrent, escalating urinary infections are by far the most common complaint in patients with continent diversions by any means. They can lead to a number of easily treatable conditions, such as bladder stones or diverticula. They may also lead to a negative evaluation in which the only possible explanation is a capacious, multilobulated reservoir that no longer drains to completion. The former is easily diagnosed and treated, but the latter often requires extensive surgery and recovery, with an uncertain outcome with respect to infection.

The first step in arriving at a diagnosis is to ensure an absence of foreign objects (stones, clips, stents) that may be harboring bacteria, which is easily accomplished with non-contrast CT and/or cystoscopy.

The second step is more complex and involves understanding the reservoir, including its shape and how it drains, involvement of the ureters in the past (as with a cutaneous ureterostomy) and the condition of the ureterointestinal or uretero-ureteral anastomoses. The only way to understand the reservoir is to scrutinize prior operative reports and to use fluoroscopy and cysto/ureteroscopy judiciously. An obstructed upper tract can often lead to silent renal deterioration. Renal function may play an important role in helping to elucidate the area of urinary stasis (as with an obstructed uretero-enteric anastomosis). It may also play a key role in developing a treatment plan.

Bladder Stones

The incidence of bladder/reservoir stones after enterocystoplasty or continent supravesical diversion is 12 percent to 30 percent over a median follow-up of 13 years. For large stone burden, particularly in patients with channels that can be catheterized, open surgery is preferable (Figure 1). Typically, the reservoir is directly under the fascia, often in the location of the prior cecostomy tube. Access in this location directly into the pouch is usually fairly straightforward. A “temporary vesicostomy,” which is made by suturing the pouch to the fascia, will affix the pouch open and allow stone retrieval with Randall stone graspers or an empty sponge stick, which serves to facilitate stone removal without fracture. After the stones have been removed, the vesicostomy can be closed with a braided absorbable suture, and fascia can be closed in the usual fashion. We typically leave a 20F-22F Foley catheter or Malecot tube for secondary drainage for one to three weeks.

For smaller stones, endoscopic approaches through either a 1- to 2-cm incision or a tract dilated over Amplatz dilators can be used (Figure 2). Although some prefer to use a trocar to enter the pouch, we prefer to make an incision through the fascia, confirm that the pouch has been identified with aspiration via spinal needle and place an Amplatz sheath under direct visualization. Cutting the sheath in half (or in thirds) prior to introducing it allows better mobility of the cystoscope within a capacious pouch. This approach is optimal for stones that can be removed either without fracturing via a Nitinol or Segura basket or with limited fracturing. At the conclusion of the case, the defect is closed over an 18F-20F Foley catheter with a purse-string Chromic suture and delivered through the abdominal defect as a percutaneous drain.

Understanding the Reservoir

After a foreign object has been excluded, the next step involves defining the patient’s anatomy. Operative reports and historical information may include critical information, such as a patient having had cutaneous ureterostomies for a period of time, which can point to a potential source of obstruction in the proximal or mid-ureters. Defining other patients’ anatomy may require starting from scratch. It is our preference to use a combination of imaging (typically fluoroscopy) and cysto-ureteroscopy to help clarify the situation.

A cystogram can help determine whether diverticula are poorly drained or a capacious pouch does not reliably drain to completion via a 14F catheter (Figure 3). To prove poor drainage, we often ask the patient to self-catheterize in his typical position, and shoot an image after he is finished. The cystogram also provides information about the uretero-enteric anastomoses (Figure 4).

When the upper tracts are a source of concern, a combination of antegrade or retrograde pyelography and/or ureteroscopy can be used to help sort out areas of potential obstruction. For these cases, the patient is typically placed on a tilt table (for antegrade studies, Figure 5) or sat upright in the operating room for cross-table images (for retrograde studies). For upper tract obstruction, nuclear renal scanning can provide very poor — and often misleading — information. Catheters must be in place for all patients with congenital or acquired vesicoureteral reflux or with refluxing ureteroenteric anastomoses who are undergoing renal scanning. Moreover, for patients with moderate to severe renal insufficiency, renal scanning can be very inaccurate.

Serum creatinine alone often poorly characterizes global renal function in patients who are wheelchair-bound, and the most accurate way to determine renal function in this group of patients is still under investigation (Figure 6).

Once the source of urinary stasis has been identified in the patient presenting with complex urinary reconstruction, a decision can be made about surgery. Endoscopic procedures may be used to help provide critical diagnostic information, even if this treatment is unlikely to provide a lasting outcome. Ultimately, however, most cases of idiopathic recurrent urinary tract infections require extensive lysis of adhesions and a prolonged hospital stay. The key to success is ensuring that all less invasive causes have been excluded and that the clinical picture and diagnostic evidence align with the surgical plan.

Dr. Wood (woodh@ccf.org) is a Staff Physician in the Glickman Urological and Kidney Institute’s Center for Genitourinary Reconstruction.

Dr. Angermeier (angermk@ccf.org) is a Staff Physician in the Glickman Urological and Kidney Institute’s Center for Genitourinary Reconstruction.

Figure 1. A 27-year-old male with exstrophy, post-Indiana pouch, who presented with a massively enlarged reservoir filled with large stones, and recurrent urinary tract infection stones. The patient underwent open cystolithalopaxy and pouch reduction/reconfiguration.

Figure 2. A 21-year-old male with bladder exstrophy post-multiple percutaneous and open cystolithalopaxies from his enterocystoplasty presented with recurrent urinary tract infection and increased urgency. Kidney, ureters and bladder x-ray demonstrated four 0.7-1.2 cm stones, which were removed cystoscopically through a 30F Amplatz sheath.

Figure 3. a. CT cystogram from a 21-year-old patient who presented with worsening renal function and recurrent urosepsis, depicting an enormous pouch that occupied more than half of this young man’s abdominal cavity. b. Intraoperative image of the pouch dissected out at the time of pouch-reduction surgery.

Figure 4. A 56-year-old woman with myelomeningocele who previously had a Koch urostomy and who presented with multidrug-resistant urinary tract infections and multiple antibiotic allergies despite meticulous hygiene and catheterization schedule. She had a laparoscopic partial nephrectomy in 2007 that was complicated by prolonged intra-abdominal urine leak, then an open completion nephrectomy in 2008. The remnant ureter was left in place. Cystogram demonstrated a reasonably round reservoir that emptied to completion, and cystoscopy demonstrated no foreign objects (calcified staples are common in this type of reconstruction). Upright, cross-table cystogram, however, revealed reflux up the remnant ureter, with poor drainage of the remnant after emptying pouch (a. pouch full; b. pouch nearly empty with remnant ureter filling). She subsequently underwent extensive laparotomy to address this remnant ureter.

Figure 5. A 23-year-old woman with myelomeningocele and a thick-walled, severely neurogenic bladder presented with a complaint of severe right flank pain and a renal scan that demonstrated a T1/2 of 28 minutes. She also has Crohn’s disease and a prior ileocecal resection. A CT scan demonstrated mild hydroureter above the pelvic brim, suggesting that the etiology of obstruction could be postsurgical. A percutaneous nephrostomy tube relieved her pain, and antegrade pyelography on a tilt table clearly pointed to the ureterovesical junction, not the mid-ureter, as being the area of obstruction (a. and b.).

Figure 6. A 55-year-old patient with posterior urethral valves who underwent cutaneous ureterostomies in infancy. At age 34 he underwent ileal conduit urinary diversion that twice required revision. He presented with a baseline creatinine of 1.3 mg/dL and parastomal hernia leading to recurrent urinary tract infection (loopogram c.-d.). After an extensive lysis of adhesions and conversion to an Indiana pouch, the patient experienced anuric renal failure with need for temporary hemodialysis. His renal function subsequently recovered to his baseline, but the fragility of his kidneys as well as the appearance on CT (a.-b.) was suggestive that his renal function is much poorer than estimated by his serum creatinine.