Short-term Change in Renal Function in Patients Undergoing Continent vs Noncontinent Urinary Diversions

Abstract

Introduction: Despite good supporting evidence, the dogma still exists that patients with renal insufficiency are not good candidates for continent diversions. In this paper, we attempt to evaluate this relationship and investigate the short-term effects of continent and noncontinent diversions on patients with both normal renal function and preexisting renal insufficiency. Methods: From Sept 2004 to June 2009, 212 adult patients underwent radical cystectomy and intestinal urinary diversion by a single surgeon (SD). Forty-four were excluded secondary to inadequate follow-up (41) or other factors leading to renal compromise (3). Continent diversions were performed either with a Studer orthotopic ileal neobladder (ONB) or a catheterizable stoma with right colon pouch. Evaluation of renal function included pre-and postoperative serum creatinine, bicarbonate, and estimated glomerular filtration rate (eGFR) using the National Kidney Foundation (MDRD) equation. A multivariable linear regression model was used to assess the influence of different urinary diversions on the change in renal function. results: Median follow-up for the 168 patients was 18.7 months (3 to 60 months). Forty-four patients underwent ileal conduit and 124 underwent continent diversion (109 ONBs; 15 continent cutaneous diversions). The mean preoperative eGFR between the conduit and continent groups was 63.8 and 73.3, respectively (P < 0.001). The mean decrease in eGFR between the 2 groups was -4.1 and -10.3, respectively (P = 0.41). In patients with preexisting renal insufficiency, the mean change in eGFR was 1.7 and -0.49, respectively (P = 0.49). conclusions: The mean change in eGFR, creatinine, and bicarbonate levels following urinary diversion with either conduit or continent diversions were not statistically different in patients with normal or preexisting renal insufficiency at short-term follow-up. This data suggests that mild preexisting renal insufficiency may not be a contraindication to continent diversion.

Long‐term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder

“…Jin et al [7] followed a group of 161 patients (50 IC, 111 ONB) for a median of 10 years. In 204 [4]. Despite the short follow-up period of 18 months, we showed that there was no significant difference in decline in GFR between patients receiving IC vs continent diversion (P = 0.49).…”

“…In this group, 36% of patients with IC and 21% of patients with ONB showed a decline in GFR of >10 mL/min/1.73 m 2 at 10 years after surgery, with 38% of patients with IC and 22% of patients with ONB developing CKD Stage III–V [7]. Our group has previously attempted to address the difference in GFR decline among different types of diversion in a relatively small cohort of 168 patients (44 IC, 109 ONB, 15 CCUD) with preexisting renal insufficiency (GFR 40–59 mL/min/1.73 m 2 ) [4]. Despite the short follow‐up period of 18 months, we showed that there was no significant difference in decline in GFR between patients receiving IC vs continent diversion ( P = 0.49).…”

“…Unfortunately there is a steady decline in the proportion of patients undergoing orthotopic diversion [3]. Contraindications for continent urinary diversion include pelvic disease (clinical stage T4bNx or TxN3), preexisting urinary incontinence, history of pelvic radiation, positive urethral margin in frozen section, urethral stricture, and hepatic or neurological disease [4]. In addition, one often cited concern is baseline renal function.…”

“…Chronic kidney disease (CKD) Stage ≥III (GFR between 45-60 /1.73 m 2 ), is generally considered at least a relative contraindication to continent diversions, with the understanding that adequate renal function is required to attenuate the possible metabolic effects of continent diversions due to increased solute absorption and urine dwell time [4]. However, the exact renal reserve required to blunt such side-effects is unclear [1,[5][6][7][8][9].…”

“…Another concern is the possibility of worsening CKD due to ageing or progression of disease, which can be exacerbated by metabolic abnormalities [7]. Overall, the literature suggests that there is no significant difference in the risk of renal function decline following incontinent vs continent urinary diversion [4,8,9]. However, there is a paucity of data comparing the decline in renal function between patients with different baseline GFR values who chose to receive an ONB.…”