Managing Bladder Complications and Stroke Risks in Elderly Patients

Bladder necrosis + cerebral thrombosis (stroke)

Dear Director Liu,
My mother had bladder cancer over ten years ago and underwent cobalt-60 radiation therapy at that time.
Last August (97), she was hospitalized due to a stroke caused by a cerebral vascular embolism.
After treatment, she was discharged and has been taking anticoagulants.
However, in November 97, she was hospitalized again due to hematuria, which was diagnosed as bladder wall sclerosis resulting from the initial cobalt-60 radiation, leading to the detachment of the mucosa and exposing the blood vessels, making her prone to hematuria.
Subsequently, she was hospitalized twice more due to hematuria, not realizing that the anticoagulants were causing the bleeding, and she was then transferred to hyperbaric oxygen therapy.
After seventy sessions of hyperbaric oxygen therapy, there was a trace of blood in her urine (+1), and I had to pause the treatment due to my work commitments.
Fearing that hematuria would recur, she stopped taking anticoagulants.
In September 98, my mother was hospitalized again due to a bacterial infection and experienced a sudden drop in blood pressure, necessitating a central venous catheter placement and transfer to the intensive care unit.
Fortunately, her condition was stabilized with medication, and she was discharged after fifteen days.
However, she has recently developed another bacterial infection.
I consulted a urologist during my mother's third hospitalization, who mentioned the possibility of directly connecting the kidney to an external urinary catheter.
I am wondering if surgery should be considered, as continuous infections could damage her immune system.
However, I am unsure if the urologist declined the kidney-to-urinary catheter surgery due to my mother's age of seventy.
My concern is that my mother currently has a nasogastric tube, so her nutritional and mental status are stable.
However, without anticoagulants, I worry that her stroke condition may worsen, and the ongoing issues with hematuria and infections are distressing her.
I would like to know if the kidney-to-urinary catheter surgery is considered a major surgery.
The urologist mentioned that the source of the "infection" is uncertain, but my mother only has issues in that area.
She often feels fatigued after hyperbaric oxygen treatments, and the blood vessels in her bladder are continuously exposed to urine due to the detachment of the mucosa, which increases the likelihood of infection.
Additionally, her skin (such as her fingers and face) has shown signs of edema in the past few days.
Therefore, I would like to ask: (1) Is it appropriate to perform a kidney-to-urinary catheter surgery for external urination considering her age of seventy? (2) What are the considerations for leaving the bladder in place versus removing it? My current goal is to resolve her hematuria and infection issues so that she can continue taking anticoagulants to prevent a second stroke.
I would appreciate your analysis on this matter.
Thank you!

Ms. Chen, 40~49 year old female. Ask Date: 2009/10/25

Dr. Liu Jianting reply Urology

It's better to remain still than to move unnecessarily; please avoid considering such a major surgery unless absolutely necessary.
Currently, it seems that the urologist's management is quite good! Moreover, everything that needs to be done has been done, so please cooperate and discuss thoroughly with your physician.

Reply Date: 2009/10/25

More Info

Managing bladder complications and stroke risks in elderly patients, particularly those with a history of bladder cancer and stroke, requires a careful and nuanced approach. Your mother's medical history is complex, involving previous treatments for bladder cancer, the use of anticoagulants, and recurrent urinary tract infections (UTIs). Here’s a detailed analysis of her situation and considerations for potential interventions.

1. Surgical Considerations for Nephrostomy
The suggestion of a nephrostomy (a procedure where a tube is placed directly from the kidney to the outside of the body for urine drainage) is significant, especially given your mother's age and medical history. Here are some factors to consider:
- Age and Surgical Risk: At 70 years old, your mother may have an increased risk of complications from surgery due to age-related factors such as decreased physiological reserve, potential comorbidities, and the effects of previous treatments (like radiation). However, if her quality of life is severely impacted by recurrent infections and bleeding, the benefits of surgery may outweigh the risks.

- Infection Control: If the recurrent UTIs are primarily due to the compromised bladder wall from radiation therapy, a nephrostomy might help in managing the infections by bypassing the bladder entirely. This could potentially reduce the frequency of infections and improve her overall health status.

- Postoperative Recovery: Recovery from a nephrostomy can vary. Patients may experience discomfort, and the need for ongoing care to manage the nephrostomy tube is essential. The decision should involve discussions with a urologist who can assess her specific risks and benefits.

2. Bladder Preservation vs. Removal
The decision to preserve or remove the bladder involves several considerations:
- Quality of Life: Preserving the bladder may allow for normal urinary function, but if the bladder is severely compromised and causing recurrent issues, removal might be a better option. However, bladder removal (cystectomy) typically requires creating a new way for urine to exit the body, which can be complex and may involve significant lifestyle changes.

- Risks of Retaining the Bladder: If the bladder is left in place and continues to cause issues, it may lead to chronic infections, further complications, and a decline in overall health. The risk of bladder cancer recurrence should also be considered, given her history.

- Anticoagulant Therapy: If surgery is performed, careful management of anticoagulant therapy is crucial. The risk of bleeding during and after surgery must be balanced with the need to prevent stroke. Close monitoring and possibly adjusting the anticoagulant regimen around the time of surgery will be necessary.

3. Managing Stroke Risks
Your concern about continuing anticoagulant therapy is valid, especially considering her history of stroke. Here are some points to consider:
- Balancing Risks: The risk of stroke must be weighed against the risk of bleeding from the bladder. If her bleeding can be controlled through surgical intervention, it may be possible to resume anticoagulant therapy safely.

- Regular Monitoring: Continuous monitoring of her blood parameters, including platelet counts and coagulation profiles, is essential to ensure that she remains stable while on anticoagulants.

- Interdisciplinary Approach: Engaging a multidisciplinary team, including urologists, hematologists, and geriatric specialists, can provide a comprehensive approach to managing her complex needs.

Conclusion
In summary, the decision regarding nephrostomy and the management of your mother’s bladder complications and stroke risks should be made collaboratively with her healthcare team. It’s essential to weigh the benefits of potential surgical interventions against the risks associated with her age and medical history. Open communication with her doctors about your concerns and preferences will be crucial in navigating her treatment options.

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