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 form ulate a plan for early recognition and effective management of early a nd late complications seen in patients who have undergone construction of the ileocolonic continent urinary reservoir. Method. Charts of pat ients who underwent continent urinary diversion at the Division of Gyn ecologic Oncology, University of Miami School of Medicine, from 1988 t o 1996 were reviewed. We analyzed our data in terms of early and late (beyond 6 weeks) complications resulting directly from the operation o r from this form of urinary diversion. Results. Urinary diversion via the continent ileocolonic reservoir has been performed at our institut ion since February 1988. Sixty-six women have undergone construction o f the Miami pouch over the past 81 years. Sixty-three of 66 patients n eeded a reservoir as a part of total pelvic exenteration for persisten t or recurrent gynecologic malignancy. Three patients underwent reserv oir 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/obstr uction [10], anastomotic leak [4], reservoir-cutaneous fistula [4], di fficulty in catheterization [5], pyelonephritis [10], sepsis [6], DIC [2], and ARDS [1]. Nonsurgical management strategies used for reservoi r-related complications in these cases included percutaneous nephrosto my, peripheral hyperalimentation, intravenous antibiotics, and ultraso und-guided catheter placement. Eighty-four percent (16/19) of function al complications of the reservoir resolved with conservative managemen t, whereas 3/19 patients needed surgical revision. One or more late co mplications (beyond 6 weeks) occurred in 25 patients (37%). Late compl ications seen included ureteral stricture/obstructions [6], incontinen ce [8], difficulty in catheterization [7], and urinary stones [4]. Non surgical management strategies used included percutaneous nephrostomy, balloon dilation, scheduled catheterization, ultrasound-guided cathet er placement, and endoscopic/percutaneous lithotripsy. Four of 25 pati ents needed reoperation, whereas in 84% (21/25) of patients problems r esolved with initial conservative management. Conclusion. Successful c onservative therapy constitutes establishment of drainage, adequate nu trition, avoidance of sepsis, close observation, and patience. This ar ticle reviews the complications of the continent ileocolonic form of u rinary diversion and formulates a treatment outline emphasizing an ini tial conservative approach that offers optimal management of early and late complications seen in this patient group. (C) 1998 Academic Pres s.