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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 782-783
Long neglected neurogenic bladder


Department of Nephrology, Jaslok Hospital and Research Center, Mumbai, India

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Date of Web Publication9-Jul-2011
 

   Abstract 

Urinary diversion is indicated for the management of the neurogenic bladder. However, there is a risk for developing pyocystitis in this type of patients. We present a case of young female who presented with a history of frequent urinary tract infection (UTI) post urinary diversion for neurogenic bladder. Ever since she underwent simple cystectomy, there have been no further episodes of UTI.

How to cite this article:
Binnani P, Gupta R, Kedia N, Pattewar S, Bahadur MM. Long neglected neurogenic bladder. Saudi J Kidney Dis Transpl 2011;22:782-3

How to cite this URL:
Binnani P, Gupta R, Kedia N, Pattewar S, Bahadur MM. Long neglected neurogenic bladder. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Sep 21];22:782-3. Available from: http://www.sjkdt.org/text.asp?2011/22/4/782/82695

   Introduction Top


The ultimate goal of urologic management of patients with neurogenic dysfunction is not only preservation of the upper urinary tract and renal function, but also prevention of urologic and general complications. [1]

The vast majority of patients with neurogenic bladder dysfunction can be managed without resorting to urinary diversion. However, patients who are unwilling or unable to maintain low-pressure urinary storage and voiding and/or continence may benefit from urinary diversion. [2]

We report a case of recurrent urinary tract infection (UTI) resulting in pyocystitis and pyelonephritis due to native bladder in a patient who had undergone urinary diversion for neurogenic bladder and its management.


   Case Report Top


A 35-year-old lady had a road traffic accident in 1987. She fell off a bike and sustained spinal injury. She developed paraplegia and sphincter dysfunction. She underwent a surgical stabilization of T9-T10 vertebrae. She started having urine retention and resultant reflux. Her urinary bladder was bypassed and ureters were implanted in an ileal conduit.

She regained function in legs, became ambulatory and started going to work. Her renal function worsened gradually with serum creatinine levels between 4 and 5 mg/dL.

Her course was complicated with recurrent UTI, and she was treated with regular bladder washes and prophylactic antibiotics.

In February 2006, she presented with a complaint of bleeding per vagina. On admission, she was febrile. She was started on broad-spectrum antibiotics. Her gynecological examination was normal. Her urine culture revealed heavy growth of  Escherichia More Details coli. She was subjected to cystoscopy, which revealed very small contracted fibrotic bladder. Foul smelling fluid was drained as well as lots of debris and clots. There was no growth or lesion seen.

In view of chronic cystitis changes on cystoscopy, the patient was subjected to simple cystectomy. Dense adhesions were found in the perivesical area, causing plastering of small bowel and omentum. Adhesions were released and the bladder was dissected from surrounding tissue. On histopathology, extensive colonic metaplasia with ulceration of urothelium and marked chronic cystitis changes were seen.

The patient has been on regular follow-up with us. Her serum creatinine remained stable between 5 and 6 mg/dL. She did not have any episode of UTI for one year.


   Discussion Top


Preservation of renal function is the main long-term goal of management of neurogenic bladder dysfunction. Supravesical urinary diversion without cystectomy is performed in case of neurogenic bladders and other benign conditions such as radiation cystitis, cyclophosphamide-induced cystitis, interstitial cystitis, intractable incontinence, retroperitoneal fibrosis, urinary tuberculosis (with severely contracted bladder), and trauma. [3]

The main types of urinary diversion include urinary diversion [4] with or without cystectomy. [5],[6]

The issue of whether cystectomy should be performed at the same time as urinary diversion is still controversial. In patients undergoing supravesical urinary diversion for benign disease in whom the bladder remains in situ, the risks of complications related to the defunctionalized bladder, such as urethral bleeding, urethral pain, spasms and infective complications, are more than 50%, and 25% of patients subsequently require cystectomy. [7],[9]

The risk of significant pyocystitis can cause serious future complications. Pyocystitis, also known as vesical empyema, may develop in the defunctionalized bladder, which is retained in situ. The condition is characterized by accumulation of secretions that later become infected because the bladder is not evacuated. [10]

The defunctionalized bladder is also a source of rehospitalization in 25-43% of cases. The rate of pyocystitis was reported to be as high as 67% and required emergency cystectomy in up to 30%. [3],[8],[9],[10] Clinicians may underestimate the role of the remaining bladder in the development of infection; thus, a high index of suspicion is required. This complication is usually treated with drainage of the accumulated pus, as well as intravesical and systemic antibiotics. Resistant or recurrent pyocystitis should be treated by interventions such as suprapubic cystostomy and cystectomy. Complications associated with a neurogenic bladder justify simple cystectomy at the time of urinary diversion.

 
   References Top

1.Rivas D, Karasick S, Chancellor M. Cutaneous ileocystostomy (a bladder chimney) for the treatment of severe neurogenic vesical dysfunction. Paraplegia 1995;33:530-5.  Back to cited text no. 1
    
2.Chartier-Kastler EJ, Morzer P, Denys P, et al. Neurogenic bladder management and cutaneous non-continent ileal conduit. Spinal Cord 2002;40:443-8.  Back to cited text no. 2
    
3.Neulander EZ, Rivera I, Eisenbrown N, et al. Simple Cystectomy in patients requiring urinary diversion. J Urol 2000;164:1169-72.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Falagas ME, Vergidis PI. Urinary tract infections in patients with urinary diversion. Am J Kidney Dis 2005;46:1030-7.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Madersbacher S, Schmidt J, Eberle JM, et al. Long-term Outcome of ileal conduit diversion. J Urol 2003;169:985-90.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Hautmann RE, de Petriconi R, Gottfried HW, et al. The ileal Neobladder: Complications and functional results in 363 patients after 11 years of follow-up. J Urol 1999;161:422-7.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Singh G, Wilkinson JM, Thomas DG. Supravesical diversion for Incontinence: A longterm follow-up. Br J Urol 1997;79:348-53.  Back to cited text no. 7
[PUBMED]    
8.Eigner EB, Freiha FS. The fate of the remaining bladder following Supravesical diversion. J Urol 1990;144:31-3.  Back to cited text no. 8
[PUBMED]    
9.Granados EA, Salvador J, Vicente J, et al. Follow-up of the Remaining bladder after supravesical urinary diversion. Eur Urol 1996;29: 308-11.  Back to cited text no. 9
[PUBMED]    
10.Matthew E. Falagas, MD, Paschalis I. Vergidis et al. Urinary tract infections in patients with urinary diversion. Am J Kidney Dis 2005;46:6.  Back to cited text no. 10
    

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Correspondence Address:
Pooja Binnani
Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai
India
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PMID: 21743229

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    Abstract
   Introduction
   Case Report
   Discussion
    References
 

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