The Role of Mucoregulatory Agents After Continence-preserving Urinary Diversion Surgery

Wendy M. Covert; Shannon N. Westin; Pamela T. Soliman; Ginger D. Langley

Disclosures

Am J Health Syst Pharm. 2012;69(6):483-486. 

In This Article

Abstract and Introduction

Abstract

Purpose. The postsurgical use of N-acetylcysteine, octreotide, and other agents to reduce mucus accumulation after urinary diversion procedures is described.
Summary. Patients undergoing continence-sparing bladder resection are at risk for infection and stone formation due to mucus accumulation. In addition to N-acetylcysteine, agents studied for mucoregulatory control in such patients include aspirin, urea, ranitidine, and octreotide. N-acetylcysteine has high mucolytic activity in vitro, and positive outcomes with instillations of 20% N-acetylcysteine solution have been reported in some patients. Significant mucus reductions were reported in small numbers of patients treated with oral ranitidine 300 mg daily or instillations of 30 mL of urea 40% solution, while the benefits of aspirin are more questionable. To date, there has been only one randomized controlled trial comparing various agents for mucus reduction after reconstructive bladder surgery; the results indicated no significant benefits with the use of N-acetylcysteine, aspirin, or ranitidine. In one small study (n = 40), the use of subcutaneous octreotide immediately before and for 15 days after surgery was reported to yield significant reductions in mucus production, the need for bladder irrigation to clear blockages, and the mean duration of hospital stays.
Conclusion. Various agents evaluated for mucus control after urinary diversion procedures (oral ranitidine or aspirin, N-acetylcysteine or urea instillations, and subcutaneous octreotide), while reportedly effective for some patients, remain of questionable benefit. More research is needed to define the optimal role of these agents for this indication.

Introduction

The surgical construction of a urinary diversion may be performed as part of a pelvic exenteration or cystectomy procedure.[1–4] The traditional method of performing this procedure (i.e., the reconnection of the ureter to a transposed portion of the bowel to create a new urinary pouch) leads to incontinence as a result of the constant drainage of the pouch through a stoma into a urostomy appliance (thus, the procedure is known as incontinent urinary diversion).[5–7] In an attempt to preserve quality of life, some patients have undergone an alternative, continence-preserving procedure (i.e., a continent urinary diversion) that allows for urine drainage via intermittent self-catheterization through a small stoma on the abdominal wall.[8]

Regardless of the type of urinary diversion created, the bowel mucosa retain mucus-secreting properties, producing as much as 35 g of mucus per day.[9] The resultant increase in urine viscosity due to retained mucus may lead to complications such as urine-pouch obstruction, infection, and stone formation.[10,11] Patients with an incontinent diversion are less likely than those with a continent diversion to develop these complications, as the constant draining of urine through the stoma is protective against mucus accumulation.[5,6] Patients with continent urinary diversions are at increased risk for mucus-related complications associated with intermittent self-catheterization.[8]

As the use of continent urinary diversion has increased, so has clinician interest in determining the best agent to reduce mucus accumulation. The comparative effectiveness of various mucoregulatory agents used for this purpose is the focus of this article.

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