Mo Belal Consultant Urological Surgeon University Hospitals Birmingham

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Presentation transcript:

Mo Belal Consultant Urological Surgeon University Hospitals Birmingham Ketamine Bladder Mo Belal Consultant Urological Surgeon University Hospitals Birmingham

Physiological impact of ketamine on the bladder Surgical Options Pre-assessment implications Post-operative management

Ketamine Ketamine hydrochloride is an N-methyl-D-aspartic acid receptor antagonist Used as an anesthetic agent in human and veterinary procedures Use in severe depression, nasal and IV early trial promising

Ketamine Hallucinogenic properties Taken orally, inhaled or injected into muscle. Cheap and easy to obtain it is often mixed with ecstasy. It has several street names, such as “Cat Valium”, “Jet K”, “Kit Kat”, and “Special K Super K High and “k-hole” (outer body experience) it can give. In 2006, the Misuse of Drugs Act made ketamine a class C substance (Cottrell and Gillatt, 2008)

Volpe, M. A. , Shah, S. , Cooper, K. , & Kaplan, S. A Volpe, M. A., Shah, S., Cooper, K., & Kaplan, S. A. 2003, "Illicit ketamine abuse (special K) causing eosinophilic cystitis", J.Urol., vol. 169, no. 4 (supplement 1), p. 9

Presenting Symptoms Increased day time frequency Urgency Urge urinary incontinence Increased bladder sensation Pelvic, bladder and or urethral pain Haematuria

Investigations Rigid Cystoscopy and biopsy Video Urodynamics CT Abdomen/Pelvis

Cystoscopic findings BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f1

Histology Ketamine‐associated cystitis shows a variable degree of inflammation (A,B). The infiltrates comprised predominantly lymphocytes and a variable number of eosinophils (C). Ultrastructural examination shows querciphylloid muscle cells (D). IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f2

Video Urodynamic findings Cystometric plot showing severely decreased bladder compliance with detrusor overactivity and leakage when only 22 mL of 0.9% normal saline was instilled to the bladder. IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f4

Video urodynamic findings Cystometric bladder capacities in 47 patients who had a video‐urodynamic study, showing that most of them had capacities of <150 mL. IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f3

Video urodynamics VCMG finding of the same patient in Fig. 1A: the cystometric bladder capacity was 30 mL only, with detrusor overactivity and leakage (A), and bilateral VUR during detrusor overactivity (B). IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f5

Not just the bladder Upper and lower tract issues

Anterograde stenting and upper tract destruction Bilateral antegrade pyelogram of a patient who had used ketamine for 10 years and presenting with acute renal failure 3 months after augmentation enterocystoplasty. He required bilateral PCNs. Nephrostograms subsequently showed bilateral ureteric strictures involving the (A) right upper ureter and (B) left upper ureter. IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON PERMISSIONS@WILEY.COM OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER. BJU International Volume 102, Issue 11, pages 1616-1622, 1 AUG 2008 DOI: 10.1111/j.1464-410X.2008.07920.x http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2008.07920.x/full#f6

Pre operative considerations Absolute requirement for a patient to stop ketamine use Unreliable attendees at both outpatient and investigation appointments Multi disciplinary team working Chronic pain team Drug support Analgesic strategy buprenorphine patches with cocodamol and amytriptiline. . This may sound straightforward, but in a context where patients feel their only way of controlling the pain is with ketamine, it has proven to be difficult. It is not universally true, but many of

Treatment options Lifestyle Management Oral medication Stop ketamine, bladder retraining Oral medication Analgesics, anticholinergics, beta 3 agonists, amitrip Intravesical agents Hyacyst, cystistat, heparin/lidacaine Minimal invasive therapies SPC, hydrodistension, Intradetrusor botox injections

Operative Treatment strategies Clam ileocystoplasty Cystectomy and Substitution cystoplasty Ileal interposition for ureters Ileal condiut

Comparison Type Reservoir Continent method Conduit Ileal conduit N/A Ileum Clam cystoplasty Ileum/bladder Rhabdosphincter Urethra Continent Diversion Caecum/ileum Ileocaecal valve Ureterosigmoidostomy Sigmoid Anal sphincter Anorectal

What can you use Reservoir Continent mechanism Conduit Bladder Rhabdosphincter urethral Urethra Stomach Mitrofanoff Appendix Ileum Kock Caecum Ileocaecal Ileum (tubed) Colon Anal Sphincter Ureter Rectum Artificial Sphincter Skin tube

Mitrofanoff

Monti

Augmentation cystoplasty

Augmentation Cystoplasty Use ileum Preoperative counselling bowel disturbance metabolic acidosis mucus production UTI and urinary retention Small risk of malignancy Provide life-long follow-up

Summary Ketamine is a veterinary anaesthetic that has hallucinogenic properties and impairs memory Bladder symptoms associated with ketamine abuse are consistent with those of interstitial cystitis, ulcerative cystitis and lower urinary tract symptoms Ketamine abusers are often aware of these side effects but reluctant to seek help Prompt recognition of the syndrome and referral to urologists could prevent further damage to the bladder and make treatment more effective A multi-disciplinary approach is needed to manage patients with urinary tract pathology associated with ketamine use