Metabolic Abnormalities

In Urinary Diversion
Using Intestine
MEKBEB CHERE M.D –UROLOGY RESIDENT
Outline

 Metabolic complications
 Electrolyte Physiology In Intestinal Segments
 Patho-Physiology of Diversion
 Stomach
 Jejunum
 Ilium
 Colon
 Early Post Op follow-up
 Treatment
Metabolic Complications
 Electrolyte abnormality
 Altered sensorium
 Abnormal Drug metabolism
 Osteomalecia
 Growth Retardation
 Renal and reservoir calculi
 Malignancies
 Malabsorbtion, Trace element deficiencies
Bowel Factors
 Tight Junction
 Type and Length of Bowel  Stomach > Colon > Ilium > Jejunum
 Duration of Urine stasis in Bowel  Osmotic Gradiant– Water vs Urine
Reservoir
 Concentration of urinary solutes
 Urine PH , Osmolality
 Change of Bowel Property with time –
Villous atrophy - Ilium
Pathophysiology Of Stomach Substitute

 Metabolic Alkalosis , Hypochloremia

, Hypokalemia , Aciduria

 Rx -Hypertonic Saline + Potassium

Supplementation, Acid Suppression
Jejunum
 Rarely Used due to significant metabolic complications.
 Hyponatremia, Hyperkalemia, Azotemia and acidosis
 Increased secretion of Na and Cl
 Increased Reabsorption of potassium and hydrogen ions
 Solute driven fluid shift – rapid equilibrium – dehydration – Renin – Aldosterone – Cycle
 Hyperkalemia – Aldosterone
 Aldosterone – K+ excretion – K + reabsorbed from jejunal Bladder
 Mechanism of Acidosis : Ilium Vs Colon

 Principal mechanism for Acidosis

 Ammonium chloride reabsorption
Metabolic Consequences of Colon /Illial
substitutes
 Acidosis  Ilial
 Hypokalemia  Conduit – 10%
 Hypomagnesemia  Continent reservoir – 50%
 60cm vs 40cm length
 Hyperammonemia
 Balance with risk of incontinence
 Colon
 Stool – 40mmol/l Na, 15 Cl-
 Higher risk for Hyperchloremic Acidosis
 Water reabsorption – increment in weight , Blood Pressure
 Infection urea splitting - Hyperammonemia
 Volume of “Urine” during day and night time
equalizes if prolonged voiding intervals during the
night.
Early Postoperative period
 Shift from IV to PO
 Dilute Urine – low Na
 Na and Cl in to Bowel, K+ and H+
 Aldosterone release – Na reabsorption , K+ &
H+ excretion
 Low Na in reservoir - Increased K+ and H+
reabsorption.
Follow-up

 General Condition
 V/S, Drainage and Catheter
 RFT, Serum Electrolytes, Venous Blood
gas analysis
Rx of Acidosis and Hypokalemia
 Hypokalemia – serum + Total body
 Na-HCO3 , Potassium citrate Orally
 Ilium > Colon
 Alternatively
 K+ citrate - Colon
 CPZ or Nicotinic acid
 Correct both acidosis and Hypokalemia
 inhibition of cyclic adenosine
simultaniously
monophosphate thereby impeding
chloride transport.
 Significant side effects
 Used to decrease dose of alkalinising agent
Problems with Endogenous Creatinine Clearance

 urine outputs in patients with intestinal diversions do not accurately reflect the true
rate of urine out put from the kidney, the true state of hydration or renal
concentrating ability

 RFT assessment using conventional methods is not accurate

References

 Campbel Walsh Urology 12th edition

 Keys to Successful Orthotopic Bladder Substitution - Studer