ISSN: 2320-5407 Int. J. Adv. Res.

11(09), 952-956

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/17607

DOI URL: http://dx.doi.org/10.21474/IJAR01/17607

RESEARCH ARTICLE
COMPLICATIONS OF ENTEROCYSTOPLASTY“CASE SERIES”

Jihad Lakssir1, Hicham El Bote2, Omar Bellouki1, Abdelmounim Boughaleb1, Ahmed Ibrahimi1, Hachem El-
Sayegh1 and Yassine Nouini1
1. Department of Urology A, Ibn Sina Hospital University of Rabat, Morocco.
2. Faculty of Medicine and Pharmacy of Beni Mellal, Morocco.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Radical cystectomy is the reference treatment for infiltrating bladder
Received: 28 July 2023 tumors or those that escape local treatment. A urinary diversion is then
Final Accepted: 31 August 2023 necessary, enterocystoplasty has become, when possible, the preferred
Published: September 2023 choice of urologists because of its advantage of respecting the body
schema of the patients and offering them a natural micturition. We
Key words:-
Bladder Cancer, Urinary Diversion, present a series of 50 patients who underwent enterocystoplasty as a
Enterocystoplasty, Surgical Morbidity urinary diversion over a period of 20 years, performed by the
Department of Urology A at Ibn Sina hospital university, while
specifying early and late complications related to this procedure as well
as it functional results.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Bladder cancer ranks 9th among cancers worldwide and ranks the 2nd urogenital cancer in men after prostate cancer
[1]. Bladder tumors benefit from several treatment modalities, from the least to the most invasive.

We are interested in an invasive treatment preserving the body pattern with its complications, represented by the
continental internal bypass which is enterocystoplasty where the objective of this work is to appreciate its benefit
and to study its early and late complications.

Methodology:-
Retrospective study, spread over a period of 20 years, in the department of urology A of the Ibn SinaUniversity
Hospital.

From February 15th, 2000, to February 15th, 2020.

During this period, 50 patients underwent radical cystectomy with replacement enterocystoplasty for a bladder
tumor. And all patients who had undergone a urinary diversion other than enterocystoplasty or who had incomplete
records were excluded.

In our study, per and postoperative elements, early (<30 days) and late (> 30 days) postoperative complications were
analyzed, with a total follow-up of 60 months.

Corresponding Author:- Jihad Lakssir

Address:- Department of Urology A, Ibn Sina Hospital University of Rabat, Morocco.
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Results:-
The distribution of patients was 44 men and 6 women, with an average age of 53 years with extremes of 33 to 63
years.

For intraoperative elements, the average duration of the intervention is 360 min with extremes of 260 min to 500
min; this time includes the realization of the cystectomy with the preparation of the neo-bladder, the intraoperative
bleeding is estimated at 1300 cc on average, of which 31 patients required a transfusion of 2CG on average; this
blood loss was mainly at the expense of the cystectomy.

After total cystectomy, four types of neo-bladders were used: CAMEY II (20 cases), HAUTMANN pocket (15
cases), KOCK pocket (8 cases) and STUDER pocket (7 cases)[Table 1].

In our series, the early postoperative follow-up of patients was characterized by an average hospital stay of 24 days
(D) with extremes ranging from 17 to 60 days, with resumption of transit on D3 on average (D2-D7) and a delay
means of resumption of food at D4. As for the use of drainage, the abdominal drains were removed on average on
the 6th postoperative day (D4-D10), the ureteral catheters on average on the 11th day (D9-D14) while the urethral
catheter was removed on the 14th day on average (D11-D20).

During postoperative patient monitoring, no death occurred among our 50 patients immediately. On the other hand,
16 early complications were noted in 9 patients (18%) appeared within 30 days of the postoperative period [Table
2].

Among these early postoperative complications, we note that related to the neo bladder, of which 7 patients had
presented a complication related to their urinary diversion (14%) where leaks from the bag were reported in 6
patients and one patient who presented with urinal peritonitis. following a leakage of the uretero-ileal anastomosis
requiring a surgical revision.

Regarding the long-term follow-up of patients, 10 patients (20%) presented 10 late postoperative complications
[Table 3]. 8 patients with a complication related to their urinary diversion where 4 patients presented a stenosis of
the urethro-neo-vesical anastomosis treated endoscopically, and 5 patients required a second intervention including
one patient for a neo-bladder stone after 5 years, one for the appearance of a neo-vesico-vaginal fistula at 2 months
and the last two months hydronephrosis on stenosis of the uretero-neo-vesical anastomosis.

Functional follow-up with assessment of the quality of life was assessed by daytime and night-time continence and
the need for self-catheterization for chronic urine retention where 32 patients (64%) out of 49 (one patient had a
conversion to an incontinent bag) were continents including 25 (50%) patients with nocturnal continence and 2
patients (2%) requiring self-catheterization for chronic retention of urine.

Among the 44 male patients in our series, nerve preservation was performed in 26 patients taking into consideration
the carcinological results. Thus, 15 patients kept a a satisfying erection, which represents 57.7%, and 6 patients
required the application of local treatment.

Discussion:-
Several surgical teams are starting to prefer replacement enterocystoplasty as a method of urinary diversion with an
operating time of 285 min reported in the SOULIE series [2] for HAUTMANN type derivations or 382 min reported
by the Japanese team from OBARA [3] as well as blood loss, reported in the literature [4], estimated between 400
and 2000 cc mainly related to cystectomy that can be minimized by the use of automatic staples [5] or by controlled
hypotension in intraoperative [6].

The intraoperative mortality has clearly decreased to less than 1% due to the improvement in surgical techniques and
the progress of anesthesia [4] as reported in our series where no death during the operation. For early postoperative
mortality is most often medical, infectious or secondary to comorbidity. It is now accepted that the ASA score of
patients is a predictor of morbidity and mortality [7].

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The known delicate radical cystectomy in the 1980s has become a standardized routine intervention which
nevertheless is not without complications, estimated between 25-57% [8] which are represented mainly by parietal
infections at 10%, intestinal obstruction at 10%, postoperative hemorrhages and thromboembolic complications at
5% and rectal wounds at 4% [4].

Despite progress in patient management, reflex ileus is a common cause of prolonged hospitalization, affecting the
patient's recovery time [9], the cause of which is multifactorial, its occurrence can be minimized by early removal of
the nasogastric tube, early resumption of feeding and early ambulation [4].

With a rate varying between 3% and 48% depending on the series [Table 4], represents the percentage of late
complications related to enterocystoplasty

These late complications rarely require surgical revision with a rate estimated between 9% and 19% [10, 11],
whether for uretero-neo-vesical reimplantation or continent cystostomy.

Late complications of neo-bladder can be broadly divided into 3 groups:

1. Mechanical complications represented by uretero-neo-vesical stenosis, the risk of which is twice as high when
an anti-reflux system is used regardless of the method and type of intestinal segment used [12] and stenosis
urethro-neo-vesical which can compromise the evacuation of the graft with an occurrence rate of 1-2% [13, 14]
whose occurrence is related in the event of anastomosis performed under tension in a patient with a short
mesentery.
2. Metabolic complications linked either to malabsorption by digestive resection of the ileum or by reabsorption of
electrolytes in the urine. These complications can be prevented by preserving the last ileal loop and eliminating
the retention of mucus [2].
3. Infectious complications dominated by pyelonephritis on obstacle whose etiological treatment allows healing or
bacterial colonization of the graft with a rate of 40% [4] which must be treated even in an asymptomatic patient
according to Studer [15] and which may favor calculus formation [16].

The enterocystoplasty type urinary diversion requires good monitoring and functional evaluation, watching for
nocturnal leaks, which are often more present than leaks during the day, hence the need for good postoperative
rehabilitation. Soulie and Hautmann estimate that the rate of daytime and night-time continence decreases over the
1st postoperative year. And the chronic urine retention occurring especially in women, of a mechanical nature, due
to an excessive angulation of the urethra in relation to the neo-bladder during abdominal thrust [17], prevented by
the location of the neo-orifice urethral at the most inclined point of the neobadder and closest to the posterior
insertion of the mesentery which is fixed.

Conclusion:-
Enterocystoplasty is the urinary diversion of choice when the patient's condition allows it, hence a good selection
upstream.

Thus, for good postoperative results, a good operative technique, a strict anesthetic monitoring with mainly a
rigorous postoperative follow-up and an early perineal reeducation without forgetting the good choice of patients.

type of intervention number of patients

CAMEY II 20 cases
HAUTMANN 15 cases
KOCK 8 cases
STUDER 7 cases
Table 1:- Type of intervention.

Early complications Number of patient (%)

Urinary leakage from the pouch 6 (12%)
Leakage of the uretero-ileal anastomosis 1 (2%)
Urine peritonitis 1 (2%)
Abdominal wall infection 4 (8%)

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Sepsis 1 (2%)
Occlusion 1 (2%)
Ileus 2 (4%)
TOTAL 16 complications
Table 2:- Types of early complications and number of patients affected.

Late complications Number of patients (%)

Urethro-neo-vesicalstenosis 4 (8%)
Uretero-neo-vesicalstenosis 2 (4%)
Neo-vesico-vaginal fistula 1 (2%)
Neo-bladderlithiasis 2 (4%)
Eventration 1 (2%)
TOTAL 10 complications
Table 3:- Types of late complications and number of affected patients.

Series Number of patients Middle age(year) Morbidity rate (%)

Obara 31 64 3,2
Hautmann 363 63 32
Soulie 55 58 25,4
Our serie 50 53 20
Table 4:- Rate of late complications according to series.

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