Vacuum-assisted closure therapy in ureteroileal anastomotic leakage after surgical therapy of bladder cancer
© Denzinger et al; licensee BioMed Central Ltd. 2007
Received: 31 January 2007
Accepted: 12 April 2007
Published: 12 April 2007
Vacuum-assisted closure (VAC) is an acknowledged method of treating wound healing disorders, but has been viewed as a contraindication in therapy of intraabdominal fistulas.
We present the case of an 83-year old patient with ureteroileal anastomotic insufficiency following cystectomy and urinary diversion by Bricker ileal conduit due to urothelial bladder cancer. After developing an open abdomen on the 16th postoperative day a leakage of the ureteroileal anastomosis appeared that cannot be managed by surgical means. To stopp the continued leakage we tried a modified VAC therapy with a silicon covered polyurethane foam under a suction of 125 mmHg. After 32 days with regularly changes of the VAC foam under general anesthesia the fistula resolved without further problems of ureteroileal leakage.
We present the first report of VAC therapy successfully performed in urinary tract leakage after surgical treatment of bladder cancer. VAC therapy of such disorders requires greater care than of superficial application to avoid mechanical alterations of internal organs but opens new opportunities in cases without surgical alternatives.
In 1995 Morykwas and Argenta introduced vacuum-assisted closure (VAC) into the management of complex wound healing disorders . Negative pressure is established in the wound area by applying suction through a fitted polyurethane foam secured by adhesive tape dressing. The negative pressure drains wound exudate continuously and reduces edema and bacterial load. Furthermore, granulation tissue formation and angioneogenesis are stimulated. These factors accelerate wound healing. The classical indications for VAC therapy are decubitus ulcers, leg ulcers, posttraumatic and postoperative wounds, mesh grafts, sternal wound infections and open abdomen. In the current literature the feasibility of VAC in intraabdominal fistulas is debated as mechanical alterations can cause intestinal damage . The presence of malignant tissue is generally viewed as a contraindication for VAC, as it stimulates cell growth . There are only three reports of VAC in urology [2–4]. No treatment of intraabdominal urinary leakage, a rare but severe event in urinary diversion , has been reported to date. We present the initial report of a successful treatment of an ureteroileal anastomotic insufficiency after cystectomy and Bricker ileal conduit urinary diversion due to bladder cancer by VAC therapy.
Vacuum-assisted closure (VAC) is a recognized tool in the management of complex wound healing disorders expanding the spectrum of surgical strategies. While enteral leakage has been viewed as a contraindication for VAC, previous singular reports of successful treatment of intestinal anastomotic insufficiency [6–10] disprove this notion. While no application in urinary leakage has been reported to date, even in complex insufficiencies involving mucus and urine, intraabdominal granulation can be obtained. Suction by the fitted polyurethane foam lead to an absorption of the leaking urine and intestinal mucus that can disturb wound healing in the anastomotic area like in our case. In addition granulation tissue formation and angioneogenesis that means no problem after complete tumor resection are stimulated further accelerating wound healing. Whereas the application of VAC in superficial i.e. cutaneous wound defects is a largely standardized procedure and broadly applied, intraabdominal use requires great care as intestinal abrasion causing novel leakage may occur due to mechanical alterations. But Bricker ileal conduit today being the most uncomplicated urinary diversion system in treatment after radical cystectomy and no chance to close the urinary leakage by surgical means we had to try VAC therapy. Accurate inspection of the surrounding area, especially of adjacent organs such as the intestines, is necessary. Provided careful surveillance, even complex intraabdominal enteral leakages involving the urinary tract can be closed by local administration of VAC in a transperitoneal approach. Remaining abdominal wounds will heal in the absence of urine leakage impairing wound healing.
We present the first report of vacuum-assisted closure therapy successfully performed in urinary tract leakage after surgical treatment of bladder cancer. Appreciated in superficial wound healing disorders VAC even may be considered in the face of lacking surgical alternatives for the closure of complex anastomotic insufficiencies.
The authors thank Cornelia Mohaupt and Ingrid Gebhard for excellent assistance. Written consent was obtained from the patient for publication of the study.
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