Urinary Diversion/Reconstruction for cases of catheter intolerant secondary progressive multiple sclerosis with refractory urinary symptoms

Purpose:We assessed surgical outcomes for patients intolerant of catheters with secondary progressive multiple sclerosis undergoing urinary diversion/reconstruction for refractory urinary symptoms.

Materials and methods:Patients with secondary progressive multiple sclerosis treated with ileovesicostomy, enterocystoplasty and ileal loop surgeries were reviewed for demographic, operative and postoperative data. All patients had attempted maximal conservative therapy, including catheterization options. Evaluated outcome measures included incidence of postoperative urinary incontinence, urinary tract infections and Clavien grade 3 or higher complications.

Results:A total of 26 patients (22 female) with secondary progressive multiple sclerosis underwent 15 ileovesicostomy, 7 enterocystoplasty and 4 ileal loop procedures. All patients had significant neurological impairment (mean Expanded Disability Status Scale 7), and the most common indications for surgery were chronic urinary tract infection (77%) and refractory incontinence (77%). Maximum preoperative bladder capacity was 185 cc and mean bladder compliance was 5.7 cc/cm H(2)O. After a mean followup of 16 months 63% of patients were continent (p = 0.01) and 58% had no further urinary tract infections (p = 0.03). The type of diversion/reconstruction was not associated with significantly improved continence or urinary tract infection reduction. No new upper tract changes developed in any patients. There were 11 high grade complications, and patients with a preoperative indwelling catheter (HR 5.89, p = 0.024), diabetes (HR 5.60, p = 0.009) and increasing blood loss during surgery (HR 1.09, p = 0.014) were at greatest risk for significant complications.

Conclusions:Patients with secondary progressive multiple sclerosis treated with urinary diversion/reconstruction who cannot tolerate catheters had improved continence and fewer urinary tract infections. However, patients with secondary progressive multiple sclerosis with preoperative indwelling catheters, diabetes, increased body mass index and increasing operative blood loss were at greatest risk for postoperative morbidity.