A study of ileal substitution for the creation of a continent urinary bladder

A study of ileal substitution for the creation of a continent urinary bladder

A Study of Ileal Substitution for the Creation of a Continent Urinary Bladder CHARLES L. REYNOLDS, JR., M.D., Dallas, Texas In igrz Heitz-Boyer and H...

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A Study of Ileal Substitution for the Creation of a Continent Urinary Bladder CHARLES

L. REYNOLDS, JR., M.D., Dallas, Texas In igrz Heitz-Boyer and Hovelacque [2] created a rectal bladder with a permanent diversionary colostomy, with the anus serving as a vesical sphincter. This has the advantages in that a coIostomy is more easily controlled than a urine-draining ileostomy and there are lessened chances of infection as compared with simple ureterosigmoidostomy, but urinary continence is obtained at the price of a colostomy. In rg5o Bricker [I] reported his excellent and now widely accepted urine-diverting, isolatedsegment ileostomy, the technic of which is we11 known. It provides continuous diversion of urine, thus avoiding selective reabsorption of electrolytes. It drains freely and rellux problems are minimal. A distinct advantage lies in the fact that the loop may be placed high above the peIvis where recurrence of carcinoma of the bladder is less likely to interfere with its function. Mucous plugging is no problem. However, the Bricker procedure has the disadvantages of a continuously draining ileostomy with the necessity for some device for collection of urine, and ascending urinary infections appear to be rather frequent. The substitute bIadder introduced by Shoemaker and Grotzinger [5] attempts to solve the probIem of mucous plugging by turning an isolated segment of ileum inside out so that the urine is in contact with serosa. The authors report good functional results but a high mortality rate and a high incidence of ureteral stricture. In 1956 Pyrah [3] reported three clinical cases of total cystectomy and substitution in which ileum was anastomosed to the urethra. Two were one-stage procedures; the third was done in two stages by a coheague and has not been folIowed up. Pyrah isolated approximateIy 21 inches of distal ileum and anastomosed the urethra to the antemesenteric surface. The

From tbe Veterans Administration Hospital and tbe University of Texas Soutbwestern Medical School, Dallas, Texas.

T

HE purpose of this study is to determine the

feasibility of creating a continent and closed substitute bladder using a segment of ileum, and to observe its behavior, as well as any chemical disturbance which might be produced. A review of the many attempts to divert urine after removal of the urinary bladder indicates that the problem has never been completely solved. To be entirely satisfactory, diversion must be cosmetically and functionally acceptable to the patient, with assurance that he will remain in chemical balance and not be subject to ureteral reflux or recurrent infections. Until this can be obtained, surgeons will be reluctant to urge patients to accept total cystectomy and other radical procedures when they are indicated. HISTORICALREVIEW Tizzoni and Foggi [6], in 1888, made a substitute bladder in two dogs by a two-stage procedure, first placing an isolated segment of small bowel between the urethra and skin surface, and implanting the ureters therein. The cutaneous opening was closed at a later date. These dogs were continent and voided once an hour some two months later. Although no chemical studies were made, they were apparentIy in good heahh. Sixty years later Rubin [4] successfulIy fashioned a substitute bladder from sigmoid in dogs. This was a one-stage procedure, implanting ureters and anastomosing one end of the sigmoid loop into the urethra, leaving the prostate. These dogs regained continence in one week, but there is Iate evidence that this type of substitute bIadder diIates. American Journalof

Surgery,

Volume 99.January,

1960

50

IIeaI Substitution

for Continent

Urinary

BIadder

FIG. I. A, segment of iIeum to be isoIated. B, ureterat and urethraI anastomosis. C, cutaneous opening of iIeum closed extraperitonealIy.

bIadder. The terminal 4 or 5 inches of both ureters are isoIated, taking care not to injure their paraIIe1 bIood suppIy. The ureters are then divided at their entrance into the bladder. SmaII polyethylene tubes are placed temporarily in the ureters in order to divert urine during removal of the bladder. The bIadder is removed, severing it at the IeveI of the prostatic urethra in male animaIs but Ieaving the gIand intact; in femaIes, the urethra is transected just below the neck of the bIadder. An isoIated segment of iIeum is obtained by transecting bowe1 and its mesentery to obtain a 12 inch Ioop, and then restoring continuity by end-to-end anastomosis. (Fig. I, A.) After cIosure, this segment of bowe1 is irrigated with norma saIine soIution folIowed by the instiIIation of 20 cc. of I per cent neomycin. Both ends are then closed using a fine continuous catgut suture for the mucosa and reinforcing this by inverting mattress sutures of cotton. Because of disappointing experiences with various types of tunneling operations, we have come to regard the technic of impIantation of

ureters were implanted bIuntIy into the very dista1 and proximal ends of the Ioop. One of Pyrah’s patients died. The other is reported to be happy, and is continent in the daytime but not while asIeep. He has no chemica1 imbaIances. EXPERIMENTAL

STUDY

Our experimenta operations on twenty dogs have incIuded both singIe- and dual-stage operations, and a variety of methods of uretera impIantations. Operative Preparations. The animaIs were prepared for operation by administering Neothaladine@ tabIets, 2 gm. four times daiIy for three days, and 2 ounces of milk of magnesia forty-eight hours prior to surgery. For twentyfour hours prior to operation they had free access to water but no food. The animaIs were anesthetized with 2.5 per cent sodium PentothaI@’ as a continuous intravenous drip. Technic of tbe One-Stage Procedure. A median incision is made from the umbiIicus to the symphysis pubis. In male animaIs the vas deferens is ligated to faciIitate exposure of the

51

ReynoIds

FIG.

2.

Postmortem

retrograde

technic is foIIowed for the right uretera anastomosis. (Fig. I, B.) The poIyethyIene tubes protruding from the centra1 incision are threaded through the urethra and brought out the external meatus. They are removed after twenty-four hours. The urethra is anastomosed to the bower with a two-Iayer technic. Just prior to completion of the anastomosis, a FoIey catheter is pIaced down the urethra into the isoIated segment and inflated with 2 cc. of water. Postoperative Care. After operation the dogs are wrapped in warm bIankets and pIaced in recovery cages in a temperature-controIIed room. They receive 200 to 1,000 cc. of 5 per cent gIucose in Ringer’s Iactate during surgery, and usualIy 1,000 cc. of 5 per cent gIucose in distiIIed water during the first twenty-four hours after operation. These dogs are given 300,000 units of procaine penicillin and 0.3 gm. of streptomycin. They are aIIowed to drink miIk or water as desired after the first day, and resume their regular diet on the. fourth day. The poIyethyIene tubes are removed from the ureters after twenty-four hours and the urethra1 catheter after one week. Technic of the Two-Stage Procedure. The two-stage procedure is essentiaIIy the same with these exceptions: (I) Instead of cIosing the dista1 end of the iIea1 segment, it is brought out as an iIeostomy. (2) The poIyethyIene tubes are brought out through the iIeostomy instead of through the urethra and removed at the end of the procedure. (3) No uretera catheter is used to spIint the anastomosis with the iIea1 segment. The second stage of the two-stage procedure consists of closure of the ileostomy extraperitoneaIIy, thus compIeting the construction of the new bIadder three to six weeks after the first stage. (Fig. I, C.) Results: One-Stage Procedure. Five animaIs had various tunneIing anastomoses and died of uremia foIIowing hydronephrosis due to stricture at the ureterosegment anastomosis. One received an overdose of sodium PentothaI during surgery; in another a prostatic abscess deveIoped which perforated into the peritoneal cavity causing peritonitis and death; the Iast fataIity was due to an intussusception of the proxima1 portion of the isoIated Ioop, leading to perforation, peritonitis and death. Of the three dogs surviving the one-stage procedure, a11 had direct uretera anastomosis as described in the surgica1 procedure.

pyeIograms.

the ureters as an exceedingIy important part of the operation. Two 3 mm. stab wounds are made through the fuII thickness of the iIeum and I cm. from the antemesenteric border. These incisions are pIaced 4 to 6 cm. on either side of the mid-point of the isoIated segment. A 1.5 cm. incision is made in the Iong axis of the iIeum on its antemesenteric border. This opening in the exact center of the loop wiI1 be used for the anastomosis of the urethra. (Fig. I, B.) The poIyethyIene tube previousIy placed in the Ieft ureter is brought up to the ilea Ioop, and threaded through the left-hand stab wound and out through the larger antemesenteric incision. Four sutures of fine catgut on an Atraumatic@ needIe are pIaced at equa1 distances around the circumference of the ureter, being passed from without inward through the ureter and then from within outward through the bowe1. The poIyethyIene tubing serves as a spIint, and care is taken to incIude not more than 2 mm. of tissue as the needIe passes through ureter and bowe1. These sutures are tied on the outside. AnguIation of the ureter is then encouraged by anchoring it to the serosa of the bowe1 in a pIane perpendicuIar to the axis of the Iatter. This is accompIished by placing superficia1 sutures of No. 6-o siIk on an Atraumatic needIe aIong both sides of the ureter for a distance of 2 to 3 cm. A similar 52

IIeaI Substitution

for Continent TABLE

PRE-

Urinary

Bladder

I

AND POSTOPERATIVE

CHEMISTRIES*

Time

Preoperatively I wk. 2 wk. f mo. 2 mo. 3 mo.

3 3 3 3 3

I53 150 148 150 150

2

I49

4.4 4.4 4.7 4.3 4.3 4.4

17 46 35 29 27 31

23

113

21

III

2.2

III

4.3 5.3 5.3 6.7

20

103

24 23 24

II0 III

6.1

I.7

I09

5.2 6 5.2 6.2

1.6 2.8 2.1 I.9

6.4 3.5 5.4 5.3 5.3 5.0

1.6 I.1 I.5 I.3 I.4 I.2

6.9

I.7 I.7 I.3

.9

Dogs Surviving Two-Stage Procedure Preoperativety I wk. 2 wk. I mo. Ileostomy closed: I wk. 2 wk. I mo. 2 mo. 3 mo. 7 mo. * Deviation

5 5 5 5

146 148 I55 146

4.8 4.9 5.0 4.9

21

20

37 38 37

I9

5 5 5 5

I44 150 148 ‘49 151 150

4.9 4.8 4.8 4.9 5.1 4.8

30 30 27 29 31 26

2

I

III

21

110

22

I09

23 23 24 25 24

113

22

III

108 log 109 109

from the above averages are very IittIe, if any, in individual animals.

resuIting in death on the ninety-eighth postoperative day; (2) overdose of sodium pentothal at surgery; (3) trauma foIIowing a dog fight on the eighty-fifth postoperative day; and (4) a prostatic abscess with perforation, peritonitis and death on the seventy-seventh postoperative day. Functional Results: Two-Stage Procedure. Prior to closure of the iIeostomy, progressive stenosis of the ileostomy and simuItaneous graduaIIy increasing continent voiding per urethra were noted. A marked diminution in the output of mucus occurred from the third to the sixth week after completion of the first stage of the operation, whereupon the iIeostomy was cIosed. FolIowing cIosure very Iittle subsequent mucus was formed. Immediate continent voiding every one to two hours was noted. ResiduaI urine was not present. Combined Results: Eigbt Dogs, One- and TwoStage Procedures. Cystometrograms on three animaIs revealed bIadder capacities from IOOto 120 cc. with forcefu1 kick-off at these voIumes. (Fig. 3.) ImmediateIy foIIowing uretera anastomosis there was sometimes an initia1 rise in

Functional Results: One-Stage Procedure. By one week folIowing the operation, voiding occurred every hour. No residua1 urine was obtained. No reffux couId be demonstrated. Postmortem retrograde pyeIograms foIIowing sacrifice reveaIed IittIe to no diIation. (Fig. 2.) Excretory urograms were of IittIe vaIue because of the rapid emptying of dye into the bIadder before concentration in the upper urinary tract was possible. However, of the three surviving dogs, exceIIent cystograms folIowing excretory urograms were obtained in Iess than five minutes. Chemistries remained within normal limits. (TabIe I.) The discharge of mucus was enormous. Repeated irrigations to prevent obstruction were required. Gross pathological examination folIowing sacrifice reveaIed an abufidance of mucus in the substitute bladder but no demonstrabIe diIation of the upper tract and iIea1 segment. Results: Two-Stage Procedure. Among the nine animaIs undergoing the two-stage procedure, four deaths occurred, the causes of which were (I) acute pyeIonephritis foIIowing repeated diIations of a stenosing externa1 urethrotomy, 53

ReynoIds 60 t

CYSTOMETROGRAM

50

: ij L . E 0

KICKOFF

40

/J

1

V 0

9

I I

I

I

1

20

40

60

80

VOLUME

(CC)

FIG. 3. Cystometrogram

100

120

of a surviving dog.

blood urea nitrogen which eventually stabilized within normaI Iimits. Cystograms reveaIed evidence of reffux on one side onIy in two dogs. (Fig. 4.) Immediate postmortem retrograde pyeIograms reveaIed IittIe if any diIation of the upper urinary tract. (Fig. 2.) There was no variation in the blood chemistry at the time of cIosure of the ileostomies. The onIy changes observed were those foIlowing uretera anastomosis. (Table I.) PATHOLOGY

(TABLE

FIG. 4. Cystogram

showing reffux up one ureter.

found to have moderate infiItration of the interstitia1 spaces with mononucIear ceIIs; another, slight necrosis of the papiIIae; and the Iast, fibrinoid necrosis of an occasiona gIomeruIus. The remaining kidneys were normaI. AI1 substitute bladders appeared to be undergoing a pathoIogica1 change in a uniform manner. (Fig. 5.) Pseudomembranous-like necrosis

11)

Gross Examination, One-Stage Procedure. There was no evidence of diIation of the iIeum or the upper urinary tract. However, an abundance of mucus was noted within the Iumen of the segment. Gross Examination, Two-Stage Procedure. There was no evidence of diIation of either the segment or upper urinary tract, and IittIe to no debris couId be found in the substitute bladder. The mucosa appeared thin and pale grey to pink in coIor. Microscopic Patbology. AI1 ureters in both one- and two-stage procedures were norma and there was no stenosis. A tota of six kidneys studied from survivors of the one-stage procedure reveaIed that two had moderate infiItration of the interstitia1 spaces with mononucIear ceIIs; one had poIynucIear ceI1 intittration and another had congestion of vascuIar components. Eight kidneys from survivors of the twostage procedure were studied, and two were

FIG. 5. Section of artificia1 bladder showing intact basement membrane and pseudomembranous necrosis of the mucosa.

54

IIeaI Substitution

for Continent TABLE

PATHOLOGICAL

CHANGES

OCCURRING

IN THE

Ureter

1 Left Ureter )

Right Kidney

Bladder

II

URETERS,

OF SURVIVING Dog No. 1 Right

Urinary KIDNEY

AND

SUBSTITUTE

BLADDER

ANIMALS

)

Left Kidney

1

New BIadder

Histological Studies: One-Stage Operation NormaI

Normal

Occasiona infikration of Occasiona infiltration of mononuclear and polymononucIear and polynuclear cells into internucIear ceIIs into interstitial spaces stitial spaces; sIight diIation of tubules

Normal

Normal

Normal

NormaI

Normal

Norma1

SIight congestion of vascuIar components; no inflammation Norma1

SuperficiaI necrosis of mucosa; numerical decrease in number of gfarids; basement membrane intact; no inflammation Same changes as above

Same changes as above, onIy much Iess severe

Histological Studies: Two-Stage Operation I

Normal

Normal

Norma1 Norma1 Normal

Norma1 Normal Norma1

2

3 :

Moderate infiltration of Moderate infiItration of mononuclear cells in mononucIear ceIIs in interstitial spaces; interstitia1 spaces; very sIight necrosis of sIight fibrinoid necrosis some papiIIi of occasional glomeruli Not sacrificed, to be used in Iong term study Norma1 Normal Normal Norma1 Normal Norma1

with actual numerical diminution of gIands was apparent. The basement membranes remained intact, and no submucosa1 inffammatory changes were demonstrabIe. The muscuIar Iayers were normal. TWO-STAGE

PROCEDURE

COMMENTS

AND

Necrosis of mucosa; decrease in number of glands; intact basement membrane; no infIammation Same as (I) Same as (I) and (3) Same as (I), (3) and (4)

CONCLUSIONS

Realizing that these studies are short term ones and as yet incompIete, one of the eight surviving dogs and four animaIs freshly prepared by the two-stage procedure are being subjected to studies of Iong term surviva1, the rest&s of which wil1 be released at a Iater date. It is our belief that one of the most important technica aspects of this operation is the type of uretera anastomosis empIoyed. It is a direct end-to-side method with the ureter wrapped around and attached to the bowel waI1 aIong its undersurface for some distance. This creates a sphincteric action in that as the segment expands with urine the ureter flattens, causing temporary occIusion so that reffux does not easily occur, and with contraction the Iong attachment of the ureter to the bowe1 surface tends to bend the ureter and again to prevent reff ux. Another important aspect of the study is the apparent diminution of mucous secretion after urine has bathed the mucous membrane of the bowel for a period of time. The decreased

IN MAN

On the basis of the preceding studies we feIt justified in operating upon a thirty-eight year oId white man who for ten years had progressive IeukopIakia of the bIadder with scattered isIands of cystitis gIanduIaris and a bladder capacity of approximately 30 to 40 cc. At the time of writing it is nine months after the twostage operation. Mucous secretion is no problem. His bIood chemistry is normaI. PyeIograms show minima1 to no diIation, and cystograms show some refIux up the right but not the left ureter. His bIadder capacity is 4 ounces and no residua1 urine is present. There is perfect continence during the day but bed-wetting occurs once nightIy. The detaiIs and Iong term study of this case wiI1 be reported at a Iater date. 55

ReynoIds artificia1 bIadder from a loop of iIeum, and the technic is described. Pre- and postoperative chemica1 studies, physioIogica1 studies of the new bladder and studies of the pathoIogica1 changes are described and compared. The twostage procedure appears more feasibIe because of the mucus factor. The optima1 time for cIosure of the ileostomy in the two-stage procedure appears to be when mucous secretion has diminished, chemistries are stabiIized and dilation of the upper tract is minimaI. AI1 tunneling anastomoses of the ureter produced stricture with subsequent hydronephrosis, uremia and death. A brief description of a man subjected to the two-stage procedure, aIong with the earIy resuIts, is submitted. Late foIIow-up studies on five dogs prepared by the two-stage procedure are being made and wiI1 be presented at a Iater date.

mucus might be expIained on the basis of superficial pseudomembranous necrosis and actua1 decrease in secreting tissue, as noted in the histoIogica1 study. An explanation for the necrosis cannot be offered except that the usua1 secretions bathing iIea1 mucosa are aIkaIine, and a shift of pH may be a factor. As pointed out, there is no essentia1 difference in the chemistries after completion of the first and second stages of the two-stage procedure, nor is there a difference in these chemistries and those obtained after the one-stage operation. The onIy changes which occur are those after the ureteral anastomosis, whether it be a one- or two-stage procedure. This is taken as evidence that there is IittIe or no differentia1 reabsorption between chIorides and sodium from the iIea1 segment. It further impIies that changes which do occur are secondary to uretera impIants into the segment. The fact that these animaIs have voIuntary contro1 has caused us to postuIate that sensory fibers in the urethra are stimuIated as the intraIumina1 pressure of the segment rises. ImpuIses are then carried to the brain on sensory pathways where motor centers are stimuIated, causing impuIses to be carried down motor pathways to the externa1 sphincter. This motor stimuIus causes the sphincter to open, aIIowing the segment to empty by virtue of the fact that it is a smooth muscIe, hoIIow viscus which when stretched wiI1 normaIIy contract. The pathoIogica1 changes in the segment are interesting to specuIate upon. ApparentIy the necrosis and decrease in the number of gIands is of cIinica1 benefit, in that there is a corresponding decrease in mucous secretion. The basement membrane remains intact in a mucous membrane whose environment has been compIeteIy changed. This Ieads one to wonder if after a Iong period of time the norma iIea1 mucosa might not disappear and be repIaced by transitiona epithelium extending upward from the urethra and downward from the ureters on aIready viabIe intact basement membrane.

Sincere gratitude is exAcknowledgment: tended to Dr. John PauI North, Chief, Surgical Service, V. A. Hospital, DaIIas, Texas, for his critica reviews and advice; to Drs. RaIph Smith and Percy Duff, Urology Service, V. A. HospitaI, DaIIas, Texas, for their encouragement and heIpfu1 suggestions; to Drs. Ben Wilson and Jerry Stirman for their critical anaIyses of the subject; to Dr. Dode Hanke, Mr. I. Noguera, Dr. Thomas Capers and Miss Jeanne PaImer, and to the U. S. PubIic HeaIth Service grant, without which this experimenta study wouId have been impossibIe. REFERENCES I. BRICKER, E.

2.

3. 4.

5.

SUMMARY

Twenty one- and

dogs were operated two-stage procedures

6.

upon utilizing to create an

56

M. Bladder substitution after peIvic evisceration. S. Clin. Nortb America, 30: r5111521, 1950. HEITZ-BOYER, M. and HOVELACQUE, A. Creation dune nouvehe vessie et dun nouvel uretre. J. d’urol., I: 237-258, 1912. PYRAH, L. N. The use of iIeum in uroIogy. Bit. J. Sol., 28: 363-370, 1956. RUBIN, S. W. The formation of an artihcia1 urinary bIadder with perfect continence; an experimental study. Am. J. Ural., 60: 874901, 1948. SHOEMAKER, W. and GROTZINGER, P. TotaI bIadder substitution using reversed seromuscuIar grafts. S. Forum, 6: 61g-6a3, 1955. TIZZONI and FOGGI, A. Die WeiderhersteIIung der Harnblase; Experimentehe Untersuchengen. Centralbl. f. Cbir., 15: 921-924, 1888.