700 likes | 903 Vues
Infections in Uro-oncology Patients. Dr Bill WONG Queen Elizabeth Hospital Hong Kong. Queen Elizabeth Hospital. Bladder & Prostate Cancer Incidence in Hong Kong. Hong Kong Cancer Registry. Bladder Cancer Critical Limits Determining Surgery. Bladder Cancer Incidence of Lymph Node Metastases.
E N D
Infections inUro-oncology Patients Dr Bill WONG Queen Elizabeth Hospital Hong Kong
Bladder & Prostate CancerIncidence in Hong Kong Hong Kong Cancer Registry
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 *
Post Cystectomy Urinary Diversion • Cutaneous ureterostomy • Uretero-sigmoidostomy / Rectal bladder • Ileal conduit / Colonic conduit
Post Cystectomy Urinary DiversionIleal Conduit (Bricker 1950) Surg Clin N Am 30:1511, 1950
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
A5764206 LoKC M / 6719-6-87 Ileal conduit7-4-97 Ur = 19.0; Cr = 195 11-10-96 IVU
Post Cystectomy Urinary Diversion • Cutaneous ureterostomy • Uretero-sigmoidostomy / Rectal bladder • Ileal conduit / Colonic conduit • Substitution cystoplasty / Orthotopic neobladder • Continent cutaneous diversion
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
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
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
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
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
Direct (Non-tunneled)Uretero-enteric Reimplantation • Florida colonic pouch (n = 190) Helal, et al J Urol 150:835,1993
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)
Ileal Low Pressure Bladder SubstituteStuder, et al (1989) BJU 63:43-52, 1989
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
Submucosal Tunnel (Leadbetter, Goodwin) Mucosal Sulcus (Le Duc) • Cumbersome technique • Angulation and kinking
Ileal Nipple Valve • High complexity • Nipple ischaemia • Nipple stenosis • Stone formation • Valve prolapse *
Refluxing vs Anti-reflux AnastomosisAn Experimental Study Kristjansson, et al BJU 78:840,1996
The Ideal Technique • Effective • Low complication rate • Easy and reproducible
Ileal Neobladder with Serosal Lined Extramural Ileal Tunnel • T pouch DG Skinner (1998) • Serous lined extramural tunnel Abol-Enein (1994)
B7796701 WongK M / 73 T pouch ileal neobladder 10-12-98 (post-op 3 weeks) Cystogram
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
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)
Orthotopic Ileal T Pouch Late Complications N = 46 • Diarrhoea 1 • Lower urinary tract infection 4 • Pyelonephritis - • Metabolic acidosis 2 • Deterioration in renal function -
Vesico-Ureteric Reflux Cystitis + VUR Pyelonephritis Renal scar / Reflux nephropathy
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
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
Reduce Infected Urine • Clean intermittent self catheterisation • Regular bladder washout
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
Colding-Jorgensen et al BJU 72:586,1993 Studer et al World J Urol 10:11,1992
Orthotopic Bladder SubstitutionLe Bag Ileocolonic Neobladder