As part of Plenary Session 1 (Bladder Cancer in the Young Patient: Unique Aspects) at the 2019 European Association of Urology (EAU) annual meeting, Dr. Emmanuel Jean Chartier-Kastler from Sorbonne University, Pierre and Marie Curie University in Paris France, discussed the unique challenges of taking care of pregnant women with urinary diversions. He began his talk by noting that there are several important considerations that a urologist must consider when caring for a pregnant patient with a urinary diversion. These include the type of urinary diversion that the patient underwent, the concept of bacterial colonization and increased risk of urinary tract infections, cosmetic considerations, and options for delivery of the child.
He acknowledged that patients with urinary diversions are at risks of pregnancy-related complications including urinary tract infection, low birth weight, premature delivery (up to 25%) and autonomic dysreflexia in those patients with higher spinal cord injuries. He believes that these patients need to be counseled about the potential risks and challenges of pregnancy ideally prior to conception. A multidisciplinary approach to care including a urologist and obstetrician is crucial to identify risk factors and manage complications.
Up to 64% of patients with urinary diversion experienced urinary tract infections during pregnancy, which can increase the risk of pre-term labor. He believes that it is important to ensure that patients are adequately emptying their urinary reservoir and that checking post-void residual volumes frequently throughout the pregnancy is crucial. Those patients who self-catheterize their reservoir need to understand that its capacity will decrease over time as the fetus develops, and more frequent catheterization regimens will be needed to avoid incontinence and to ensure complete emptying. Some patients may develop difficulty catharizing because of changes in the angulation of their catheterizable channel. He strongly believes that patients should not have a chronic indwelling catheter placed during pregnancy because it can increase the risk of urinary tract infections and subsequent complications.
Chartier-Kastler also stressed that it is important to acknowledge that many of these individuals are on medical treatment for their neurogenic bladder or underlying medical conditions. Anticholinergic use appears to be safe during pregnancy, but botulinum toxin should not be used during pregnancy, and should ideally be held for at least 6 months prior to conception because fetal safety is unknown.
He moved on to discuss the importance that the care team understands the difference between bacterial colonization of the reservoir versus a true urinary tract infection. Some centers are using cycled antibiotic regimens to decrease the risk of urinary tract infection. He believes judicious use of antibiotics and early treatment at the development of symptoms is important.
He next discussed the challenges of delivery in this patient cohort. The caesarian rate is reasonably high, from 7-89%. Historically this was done to help prevent theoretical complications of disruption of the reservoir or sphincteric function, and to potentially decrease the risk of pelvic organ prolapse. More recent data, however, has suggested that vaginal delivery can be safely performed in women with prior urologic surgery and urinary diversion. He noted the importance that the urologist be closely involved and notified when a patient does go into labor, as they should be present in the operating room at the time of delivery if a caesarian were to be necessary. This is because the urologist better understands the altered anatomy after urinary diversion and can work in conjunction with the obstetrician to help avoid injuries to the reservoir and its blood supply.
He concluded that fertility can persist after urologic oncological surgery and that it does place patients at higher risk for pregnancy-related complications. He believes that deliveries should be done at tertiary centers and that ideally vaginal delivery should be prioritized if safe from an obstetric standpoint.
Presenterd by: Emmanuel Jean Chartier-Kastler, MD Sorbonne University, Pierre and Marie Curie University in Paris France
Written by: Brian Kadow, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.