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ADULT UROLOGY

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LONG-TERM EFFECTS OF ILEAL CONDUIT URINARYDIVERSION ON UPPER URINARY TRACT IN

BLADDER CANCER

WON JAE YANG, KANG SU CHO, KOON HO RHA, HYE YOUNG LEE, BYUNG HA CHUNG,SUNG JOON HONG, SEUNG CHOUL YANG, AND YOUNG DEUK CHOI

ABSTRACTbjectives. To evaluate the functional and morphologic changes of the upper urinary tract after radical

ystectomy and ileal conduit urinary diversion for bladder cancer.ethods. Radical cystectomy and ileal conduit urinary diversion were performed in a total of 249 patientsith bladder cancer at our hospital from 1980 to 1999. Of the 249 patients, 67 were excluded becausef the presence of preoperative lesions in the upper urinary tract or elevated serum creatinine (greater than.4 mg/dL). Of the remaining 182 patients, 82 were also excluded because of incomplete follow-up or death

ess than 5 years after surgery.esults. Of the 249 patients, a total of 100 (40.2%) who had no preoperative lesions in upper urinary tractnd normal renal function and survived 5 years or longer were included in this analysis. The median follow-uperiod was 91 months (range 60 to 193). The serum creatinine was greater than the normal range in 10atients (10.0%), and radiologic changes in the upper urinary tract were observed in 14 patients (14.0%).hey had diabetes mellitus nephropathy (4.0%) or specific comorbidities that could contribute to theeterioration of the upper urinary tract, such as ureteroileal anastomotic stricture (4.0%), chronic pyelo-ephritis (4.0%), urinary stones (1.0%), and upper urinary tract tumor (1.0%).onclusions. The results of our study have shown that the functional and morphologic changes in the upperrinary tract after radical cystectomy and ileal conduit urinary diversion occur in patients with specificomorbidities that could contribute to those changes. Different from previous reports, none of the upperrinary tract changes developed without an obvious cause. UROLOGY 68: 324–327, 2006. © 2006 Elseviernc.

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leal conduit urinary diversion (ICUD), popular-ized by Bricker,1 has been applied to the patients

or half a century as the most standardized form ofrinary diversion. Its simple surgical techniquend the expectation of less complications are theostulated reasons for the popular use.2 However,pper urinary tract damages after ICUD, whichave been consistently found in other long-term

part of this article was presented as a poster at the Americanrological Association Annual Meeting, San Antonio, Texas, 2005.From the Department of Urology, Inje University College ofedicine, Seoul, Korea; and Department of Urology, Urological

cience Institute, Yonsei University College of Medicine, Seoul,oreaReprint requests: Young Deuk Choi, M.D., Ph.D., Department

f Urology, Yonsei University College of Medicine, 134 Shinchon-ong, Seodaemungu, Seoul 120-752, Korea. E-mail: youngd74@umc.yonsei.ac.kr

Submitted: April 27, 2005, accepted (with revisions): February

(, 2006

© 2006 ELSEVIER INC.24 ALL RIGHTS RESERVED

tudies, have been known as one of the most con-erning issues. The mechanisms causing these al-erations are unknown, but the most frequentlyuoted are reflux and chronic infection.3–5

In this study, we evaluated the functional and mor-hologic changes in the upper urinary tract after rad-cal cystectomy and ICUD for bladder cancer.

MATERIAL AND METHODS

ATIENT SELECTIONRadical cystectomy and ICUD were performed in 249 pa-

ients with bladder cancer at our hospital from 1980 to 1999.f the 249 patients, 67 (26.9%) were excluded from this studyecause of the presence of preoperative lesions in the upperrinary tract, including unilateral/bilateral high-grade hydro-ephrosis in 48 patients (19.3%), concurrent tumor in 11atients (4.4%), solitary/atrophied kidney in 8 patients3.2%), or elevated serum creatinine (greater than 1.4 mg/dL)n 25 patients (10.0%). Of the remaining 182 patients, 82

31.7%) were also excluded because of a follow-up period of

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ess than 5 years, including follow-up loss in 24 patients9.6%) and patient death in 58 patients (23.3%).

URGICAL TECHNIQUEAll radical cystectomy and ICUDs were performed concom-

tantly, and the basic technique was identical regardless of theperator. An ileal segment 15 to 20 cm proximal to the ileo-ecal valve was isolated. The ureters were anastomosed by thericker or Nesbit technique in an end-to-side fashion. All ure-ers were stented for 1 to 2 weeks. The ileal segment wasnastomosed to the abdominal wall in a nipple-to-stomaormation.2

OLLOW-UP AND ANALYSISPatients were followed up every 3 months for 1 year after sur-

ery unless the cancer recurred or specific complications oc-urred. Thereafter, they were followed up every 6 months for 5ears and annually after 5 years. At every visit, patients under-ent complete blood count, routine chemistry, urinalysis, chest-ray, and ultrasonography. Abdominopelvic computed tomog-aphy and whole body bone scan were performed depending onhe pathologic stage. During follow-up, all conduit-related com-lications detected within 3 months after surgery were recorded,nd the serum creatinine and radiologic findings of the upperrinary tract before and after surgery were compared. The change

n the serum creatinine value was analyzed by paired t-test, and P0.05 was considered significant.

RESULTS

Of the 249 patients, 100 (40.2%) who had noesions in the upper urinary tract and normalenal function before surgery and who had sur-ived 5 years or longer were included in thistudy. The number of patients surviving morehan 10 years was 15 and more than 15 years was

IGURE 1. Major complications by follow-up duratiotricture; RI � renal insufficiency. Number of patients wespectively.

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ROLOGY 68 (2), 2006

The median patient age at surgery was 57 yearsrange 27 to 82), and the male/female ratio was.6:1. The median follow-up period was 91 monthsrange 60 to 193).

OTAL CONDUIT-RELATED COMPLICATIONS

A total of 47 major complications requiring admis-ion or surgery occurred in 36 patients (36.0%). Py-lonephritis, renal insufficiency, and urinary stoneseveloped mainly late in the follow-up period (Fig. 1).

HANGE IN SERUM CREATININE

The mean serum creatinine value at 5 years after

N � pyelonephritis; UIS � ureteroileal anastomotic5, 8, and 10 years of follow-up was 100, 39, and 15,

IGURE 2. Change in mean serum creatinine level byollow-up duration in patients who survived longer than

years.

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urgery was 1.18 mg/dL, which was significantly

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reater than the preoperative value (1.02 mg/dL;�0.01). The mean serum creatinine value persis-

ently increased until 8 years after surgery and thentarted to decrease (Fig. 2). However, the serumreatinine of 90 patients (90.0%) remained withinhe normal range and that of 10 patients (10.0%)ncreased to greater than the normal range. Of these0 patients, 4 (4.0%) progressed to chronic renalailure that eventually required hemodialysis. How-ver, they all had combined diabetes mellitus ne-hropathy. The remaining 6 patients had specificonduit-related complications that could have con-ributed to the deterioration of renal function, includ-ng ureteroileal anastomotic stricture, chronic pyelo-ephritis, or urinary stones.

ADIOLOGIC CHANGES IN UPPER URINARY TRACT

New lesions developed in the upper urinary tractf 14 patients (14.0%) compared with the preop-rative findings. High-grade hydronephrosis wasetected in 6 patients, and renal atrophy was de-ected in 8 patients. Of the 14 patients, 4 had renaltrophy associated with diabetes mellitus nephrop-thy as previously mentioned, 9 patients had con-uit-related complications, and 1 patient had a newlyeveloped urothelial tumor in the upper urinary tractTable I). All patients whose serum creatinine levelncreased to greater than the normal range had radio-ogic changes in the upper urinary tract.

COMMENT

Even though ICUD is a noncontinent diversion,t has been favored for half a century, because it haseen postulated that the associated complicationate would be low.2 However, the longer the fol-ow-up, the greater the number of conduit-relatedomplications occurred, particularly the func-ional and morphologic changes in the kidney.3–5

his gave rise to the question of whether this tech-ique was simple and safe.3 Neal6 analyzed the resultsf 111 cases followed up for 5 years. They reportedhat the serum creatinine value showed a statisticallyignificant increase during follow-up, and morpho-ogic changes in the upper urinary tract could be ob-erved in 47.0% of cases. In particular, in that report,

TABLE I. Radiologic chaPatients

Hydronephrosis (grade III, IV) 6 (6.0)

Renal atrophy 8 (8.0)

KEY: UIS � ureteroileal anastomotic stricture; DM � diabetes

ilateral dilation of the upper urinary tract without t

26

definite cause was noted in 18.9%.6 Other studiesave also reported a 20% to 30% incidence in theeterioration of the upper urinary tract.3,5,7,8

The hypothesis proposed for these deteriorationsithout an obvious cause is chronic inflammation

aused by reflux of bacteriuria.3 Because the ilealonduit is not an antirefluxing procedure, the riskf reflux always exists.5,9 However, other studiesave reported that the formation of the antireflux-

ng mechanism is not associated with the develop-ent of pyelonephritis, and, in most cases, the in-

idence of pyelonephritis has been reported to be% to 15%.10,11 In our study, pyelonephritis oc-urred in 12 patients (12.0%).Our results showed a persistent increase in the

erum creatinine value for 8 years after surgery.fter 8 years, it started to decrease, which mightave been associated with the decreasing numberf surviving patients. Of the 100 patients, the se-um creatinine value increased to greater than theormal range in 10 patients (10.0%). In one study,adiologic changes in the upper urinary tract wereeported in 28.1% during follow-up; however, thectual increase in the serum creatinine value toreater than the normal range was reported in only.3%.5 Although other studies have not clearly de-cribed the proportion of patients with a creatinineevel greater than normal among patients showingadiologic damage in the upper urinary tract, func-ional renal damage was observed in approximately% of patients.3,7 In our study, the development ofew lesions in the upper urinary tract were observed

n 14 patients (14.0%). Unlike in previous reports,one of the deteriorations in the upper urinary tracteveloped without an obvious cause.7,8

Our report is far more optimistic with regard toenal function than other published series. In othertudies,3,5–8 the investigators included the patientsho had preoperative lesions in the upper urinary

ract or an elevated serum creatinine. However, ourtudy excluded such patients. We thought that ifhose patients were included and the patient groupecame heterogenous, then we would not be ableo evaluate the ileal conduit for exactly how it in-uences renal function and radiologic changes in

s in upper urinary tractCause Patients (%)

UIS 4 (4.0)Urinary stones 1 (1.0)Urothelial tumor 1 (1.0)DM nephropathy 4 (4.0)Chronic pyelonephritis 4 (4.0)

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UROLOGY 68 (2), 2006

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According to recently reported studies on therthotopic neobladder, the long-term complica-ion rate is 10% to 30%, similar to, or less than, theate for ICUD.12–14 In particular, in the orthotopiceobladder, because the incidence of lower urinaryract infection is low, its effect on the upper urinaryract observed in ICUD is anticipated to be low.14,15

CONCLUSIONS

Our results have shown that the functional andorphologic changes after ICUD occur in patientsaving specific comorbidities such as diabetes melli-us nephropathy, ureteroileal anastomotic stricture,hronic pyelonephritis, urinary stones, or recurrentrothelial tumor in the upper urinary tract. Different

rom previous reports, none of the upper urinaryract changes developed without an obvious cause.

REFERENCES1. Bricker EM: Bladder substitution after pelvic eviscera-

ion. Surg Clin North Am 30: 1511–1521, 1950.2. Williams O, Vereb MJ, and Libertino JA: Noncontinent

rinary diversion. Urol Clin North Am 24: 735–744, 1997.3. Pernet FPPM, and Jonas U: Ileal conduit urinary diver-

ion: early and late results of 132 cases in a 25-year period.orld J Urol 3: 140–145, 1985.

4. Frazier HA, Robertson JE, and Paulson DF: Complica-ions of radical cystectomy and urinary diversion: a retrospective

eview of 675 cases in 2 decades. J Urol 148: 1401–1405, 1992. r

ROLOGY 68 (2), 2006

5. Madersbacher S, Schmidt J, Eberle JM, et al: Long-termutcome of ileal conduit diversion. J Urol 69: 985–990, 2003.

6. Neal DE: Complications of ileal conduit diversion indults with cancer followed up for at least five years. BMJ 290:695–1697, 1985.

7. Svare J, Walter S, Kristensen JK, et al: Ileal conduitrinary diversion—early and late complications. Eur Urol 11:3–86, 1985.

8. Heath AL, and Eckstein HB: Ileal conduit urinary diver-ion in children: a long term follow-up. J Urol (Paris) 90:1–96, 1984.

9. Schmidt JD, Hawtrey CE, Flocks RH, et al: Complica-ions, results and problems of ileal conduit diversions. J Urol09: 210–216, 1973.10. Bernstein IT, Bennicke K, Rordam P, et al: Bricker’s ileal

onduit diversion with a simple non-refluxing ureteroilealnastomosis. Scand J Urol Nephrol 25: 29–33, 1991.

11. Hampel N, Bondner DR, and Persky L: Ileal and jejunalonduit urinary diversion. Urol Clin North Am 13: 207–224,986.12. Hautmann RE, Petriconi RD, Gottfried H, et al: Ileal

eobladder: complications and functional results. J Urol 161:22–428, 1999.13. Elmajian DA, Stein JP, Esrig D, et al: The Kock ileal

eobladder: updated experience in 295 male patients. J Urol56: 920–925, 1996.14. Abol-enein H, and Ghoneim MA: Functional results of

rthotopic ileal neobladder with serous-lined extramural ure-eral reimplantation: experience with 450 patients. J Urol 165:427–1432, 2001.15. Nabi G, Yong SM, Ong E, et al: Is orthotopic bladder

eplacement the new gold standard? Evidence from a systemic

eview. J Urol 174: 21–28, 2005.

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