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Outcomes and Morbidity for Multiple Sclerosis Patients Undergoing Urinary Diversion/Reconstruction
Jessica DeLong, MD1, John Stoffel, MD1, Hocine Tighiouart, MS2.
1The Lahey Clinic, Burlington, MA, USA, 2Tufts University Medical Center, Boston, MA, USA.

BACKGROUND: Our objective was to report outcomes for multiple sclerosis (MS) patients undergoing urinary diversion/reconstruction and to identify risk factors for increased postoperative morbidity.
METHODS: Data from MS neurogenic bladder patients treated with urinary diversion or reconstruction were retrospectively reviewed. Outcomes were evaluated by assessing postoperative urinary continence status, incidence of urinary tract infections (UTI), and hydronephrosis. Continence was defined as no leakage per urethra within the previous week prior to clinic visit. A UTI was defined as any symptomatic cystitis requiring antibiotic treatment. Complications, defined as any adverse event outside of routine operative or postoperative care, were assigned a Clavien grade 1 - 4, and complications grade 3 or higher were classified as high grade (HG) surgical morbidity. Risk factors for HG complications were evaluated through Cox proportional hazards regression.
RESULTS: Twenty-six patients (22 women) underwent a total of 15 ileovesicostomy, 5 enterocystoplasty, 4 ileal loop, and 2 continent catheterizable stoma procedures for treatment of a refractory neurogenic bladder. Mean patient age was 57 and patients had been symptomatic with MS for a mean of 24 years prior to surgery. Four patients (15%) had quadriplegia neurologic impairment and 14 (54%) had pre-operative indwelling urinary catheters. Mean length of follow up after surgery was 9 months. After surgery, 63% of patients reported urethral continence at last follow up, compared to only 23% reporting urethral continence at pre-operative baseline (p = 0.01). Additionally, 42% of patients experienced a symptomatic UTI after surgery, compared to 77% reporting symptomatic UTI at pre-operative baseline (p=0.03). No patients developed upper tract deterioration on postoperative radiologic evaluations. Eighteen complications occurred, 11 of which were HG. A pre-operative indwelling catheter was significantly associated with a HG complication occurrence (OR = 5.89, 95% CI [1.26-27.49], p=0.014). Increased blood loss during surgery was associated with HG complications (OR 1.09 for each additional 100cc, CI [1.02-1.17], p = 0.014). Diabetes was also associated with an increased risk for HG complications, (HR 5.60, 95% CI [1.55-20.27], p=0.009). For every 3 kg/m2, BMI was significantly associated with HG complications (HR 1.24, 95% CI [1.01-1.51], p=0.04). Lastly, there was a trend toward increased HG complications for Charlson Co-Morbidity Index (HR per 1 point increase 1.57, 95% CI [0.98-2.50], p=0.061).
CONCLUSIONS: Urinary diversion/reconstruction improved urinary continence, reduced the incidence of urinary tract infections, and offered significant upper tract protection for multiple sclerosis patients who had failed conservative therapy. Patients with an indwelling urinary catheter prior to surgery were at increased risk for post operative high grade complications.


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