Ileal loop (ileal conduit) and orthotopic ileal neobladder operations are common procedures following bladder removal. While they are effective for urinary diversion, they can lead to long-term complications. In this article i will give information about long term complications of ileal loop and orthotopic neobladder.

Long term complications of ileal loop operations

Ileal loop operations, also known as ileal conduit urinary diversion, are commonly performed for patients who have had their urinary bladder removed (cystectomy), often due to bladder cancer. While this procedure can be life-saving and effective in managing urinary tract function, it can also lead to several long-term complications. Some of the most common long-term complications include:

Stomal Complications:

• Stenosis: Narrowing of the stoma, which can obstruct the flow of urine.
  • Parastomal Hernia: Hernia around the stoma site.
  • Stomal Prolapse: Protrusion of the bowel through the stoma.

Infectious Complications:

• Urinary Tract Infections (UTIs): Due to the presence of the ileal conduit.
  • Pyelonephritis: Infection of the kidneys, which can occur if bacteria ascend from the stoma to the kidneys.

Metabolic Complications:

• Electrolyte Imbalances: Particularly hyperchloremic metabolic acidosis due to the absorption of chloride from the urine in the ileal segment.
  • Vitamin B12 Deficiency: If a significant portion of the ileum is used, it can affect the absorption of vitamin B12.

Renal Complications:

• Hydronephrosis: Swelling of a kidney due to a build-up of urine, which can occur if there is an obstruction in the ileal conduit.
  • Deterioration of Renal Function: Over time, chronic infections or obstructions can impair kidney function.

Gastrointestinal Complications:

• Bowel Obstruction: Adhesions or other changes in the abdomen can lead to bowel obstruction.
  • Ileus: Temporary paralysis of the bowel can occur after surgery or due to other complications.

Skin Complications:

• Skin Irritation: Around the stoma site due to urine leakage or the adhesive from ostomy appliances.
  • Infection: The skin around the stoma can become infected.

Psychosocial Issues:

• Body Image Concerns: Patients may have difficulty adjusting to the presence of a stoma.
  • Depression and Anxiety: Due to changes in body function and lifestyle.

Functional Complications:

• Leakage: From the stoma, which can cause hygiene issues and skin problems.
  • Difficulty in Appliance Management: Managing the stoma appliance can be challenging for some patients.

Long term complications of neobladder operations

Orthotopic ileal neobladder operations involve constructing a new bladder (neobladder) from a segment of the ileum, which is then connected to the urethra, allowing the patient to void urine in a manner similar to natural urination. While this procedure can significantly improve quality of life compared to other forms of urinary diversion, it also comes with potential long-term complications. Some of these complications include:

Urinary Incontinence:

• Daytime Incontinence: Difficulty controlling urine during the day.
  • Nocturnal Enuresis: Nighttime incontinence, which is more common and can persist long-term.

Urinary Retention:

• Incomplete Emptying: Some patients may have difficulty completely emptying the neobladder, leading to urinary retention and the need for intermittent self-catheterization.

Metabolic Complications:

• Metabolic Acidosis: Absorption of urinary constituents by the ileal segment can lead to metabolic acidosis, characterized by an imbalance in the body’s acid-base status.

Infectious Complications:

• Urinary Tract Infections (UTIs): Increased risk due to residual urine and the presence of mucus in the neobladder.
  • Pyelonephritis: Infection of the kidneys, particularly if the infection ascends from the neobladder.

Renal Complications:

• Hydronephrosis: Swelling of the kidneys due to urine build-up from obstructions or improper function of the neobladder.
  • Renal Function Deterioration: Long-term infections and obstructions can impair kidney function.

Neobladder Dysfunction:

• Neobladder Stones: Formation of stones within the neobladder, which can cause pain, infection, and obstruction.
  • Mucus Production: The ileal segment continues to produce mucus, which can lead to blockages and infections if not properly managed.

Gastrointestinal Complications:

• Bowel Obstruction: Adhesions or other changes can lead to bowel obstruction.
  • Vitamin B12 Deficiency: If a significant portion of the ileum is used, it can affect the absorption of vitamin B12.

Sexual Dysfunction:

• Erectile Dysfunction: In males, due to nerve damage during surgery.
  • Dyspareunia: Painful intercourse in females, which can be due to changes in pelvic anatomy and nerve function.

Psychosocial Issues:

• Body Image Concerns: Patients may have difficulty adjusting to the changes in their urinary function and the presence of the neobladder.
  • Depression and Anxiety: Due to changes in body function and lifestyle.

Functional Issues:

• Difficulty with Voiding: Learning to void the neobladder properly can be challenging, and some patients may require training or interventions to develop effective voiding techniques.

Metabolic complications of ileal loop (ileal conduit)

Metabolic Acidosis:

• Hyperchloremic Metabolic Acidosis: The ileal segment absorbs chloride from the urine, which can lead to a systemic increase in chloride levels and a corresponding decrease in bicarbonate levels, resulting in metabolic acidosis. This condition is more pronounced in patients with impaired renal function.

Electrolyte Imbalances:

• Hypokalemia: The increased flow of urine through the ileal segment can lead to the loss of potassium, causing hypokalemia.
  • Hyponatremia: There can be sodium loss in the urine, leading to low sodium levels in the blood.
  • Hypercalcemia: Rarely, prolonged acid-base disturbances can affect calcium metabolism.

Vitamin and Mineral Deficiencies:

• Vitamin B12 Deficiency: If a significant portion of the terminal ileum is used, absorption of vitamin B12 can be impaired, leading to deficiency over time.
  • Magnesium and Calcium Imbalance: Malabsorption issues can lead to imbalances in magnesium and calcium.

Metabolic complications of neobladder operation

Metabolic Acidosis:

• Hyperchloremic Metabolic Acidosis: Similar to ileal conduit, the ileal neobladder can absorb chloride from the urine, leading to an acid-base imbalance characterized by hyperchloremic metabolic acidosis.

Electrolyte Imbalances:

• Hypokalemia: Potassium loss through the neobladder can lead to hypokalemia.
  • Hyponatremia: Sodium can also be lost in the urine, leading to hyponatremia.
  • Hypercalcemia: Although rare, chronic metabolic acidosis can affect calcium balance, potentially leading to hypercalcemia.

Vitamin and Mineral Deficiencies:

• Vitamin B12 Deficiency: Use of a significant portion of the terminal ileum for the neobladder can lead to impaired absorption of vitamin B12, resulting in deficiency.
  • Magnesium and Calcium Imbalance: Chronic malabsorption issues due to the use of the ileal segment can lead to imbalances in magnesium and calcium.

Summary

Ileal loop and orthotopic ileal neobladder operations can lead to long-term complications such as metabolic imbalances, infections, renal problems, and sexual dysfunction. Understanding these potential issues is crucial for effective management and maintaining quality of life post-surgery.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE