Management of Early and Late Complications of Ileocolonic Continent Urinary Reservoir (Miami Pouch)

Purpose.The object of this study is to review our experience and formulate a plan for early recognition and effective management of early and late complications seen in patients who have undergone construction of the ileocolonic continent urinary reservoir.Method.Charts of patients who underwent continent urinary diversion at the Division of Gynecologic Oncology, University of Miami School of Medicine, from 1988 to 1996 were reviewed. We analyzed our data in terms of early and late (beyond 6 weeks) complications resulting directly from the operation or from this form of urinary diversion.Results.Urinary diversion via the continent ileocolonic reservoir has been performed at our institution since February 1988. Sixty-six women have undergone construction of the Miami pouch over the past 81 years. Sixty-three of 66 patients needed a reservoir as a part of total pelvic exenteration for persistent or recurrent gynecologic malignancy. Three patients underwent reservoir construction for repair of vesicovaginal fistula. Sixty-two of 66 patients (95%) have a history of prior pelvic radiation. A total of 35 patients (53%) suffered early complications resulting in an operative mortality rate of 9% (6 of 66 patients). Early complications related to the construction of the reservoir included ureteral stricture/obstruction [10], anastomotic leak [4], reservoir-cutaneous fistula [4], difficulty in catheterization [5], pyelonephritis [10], sepsis [6], DIC [2], and ARDS [1]. Nonsurgical management strategies used for reservoir-related complications in these cases included percutaneous nephrostomy, peripheral hyperalimentation, intravenous antibiotics, and ultrasound-guided catheter placement. Eighty-four percent (16/19) of functional complications of the reservoir resolved with conservative management, whereas 3/19 patients needed surgical revision. One or more late complications (beyond 6 weeks) occurred in 25 patients (37%). Late complications seen included ureteral stricture/obstructions [6], incontinence [8], difficulty in catheterization [7], and urinary stones [4]. Nonsurgical management strategies used included percutaneous nephrostomy, balloon dilation, scheduled catheterization, ultrasound-guided catheter placement, and endoscopic/percutaneous lithotripsy. Four of 25 patients needed reoperation, whereas in 84% (21/25) of patients problems resolved with initial conservative management.Conclusion.Successful conservative therapy constitutes establishment of drainage, adequate nutrition, avoidance of sepsis, close observation, and patience. This article reviews the complications of the continent ileocolonic form of urinary diversion and formulates a treatment outline emphasizing an initial conservative approach that offers optimal management of early and late complications seen in this patient group.