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APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR
0022-5347/99/1626-2052/0 THE JOURNAL OF UROLOGY® Copyright © 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 162, 2052–2053, December 1999 Printed in U.S.A.
Urologists at Work APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR JOHN P. STEIN, MAURIZIO BUSCARINI, ROGER E. DE FILIPPO
AND
DONALD G. SKINNER
From the Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California. KEY WORDS: proctocolectomy, restorative; urinary diversion; bladder exstrophy
We recently reported our initial clinical experience with a novel form of urinary diversion, that is the T pouch.1 The T pouch incorporates a unique antireflux mechanism and eliminates the complications associated with an intussuscepted nipple valve. We describe the application of this concept with conversion of a ureterosigmoidostomy into a new ileo-anal reservoir with an antireflux mechanism. Others have reported followup of as long as 40 years.2 To our knowledge 61 years is the longest interval to be reported between construction of a ureterosigmoidostomy and its revision. CASE HISTORY
P. K., a 64-year-old woman with a history of bladder exstrophy, underwent cystectomy and ureterosigmoidostomy at age 3 years. At 18 years she underwent right nephrectomy for intractable pyelonephritis, and was well until she was 55 years old and had recurrent episodes of pyelonephritis, which necessitated suppressive antibiotic therapy. Multiple drug allergies developed, and she was ultimately hospitalized for urosepsis. Renal ultrasound demonstrated moderate to severe left hydroureteronephrosis. A furosemide nuclear scan was consistent with obstruction. Creatinine was 1.6 mg./dl. (normal 0.3 to 0.9) and blood chemistry study revealed severe hyperchloremic metabolic acidosis. Colonoscopy showed no evidence of malignancy. The patient was satisfied with the voiding pattern and declined any form of external urinary Accepted for publication July 2, 1999.
diversion. Conversion of the ureterosigmoidostomy to an ileoanal reservoir incorporating the T pouch antireflux mechanism to the sigmoid colon was performed. At the time of surgery a 24F Medina tube was placed into the anus and, after copious irrigation with a diluted povidone-iodine solution, sutured in place. The Medina tube served as a tactile cue for proper placement of the proctostomy. The colon was mobilized and the previous ureterocolostomy was excised at its junction and sent for frozen section to rule out neoplastic degeneration. A 15 cm. proctostomy was then made at the tip of the Medina tube 10 cm. proximal to the transition zone between the rectum and anus. A portion of sigmoid colon was isolated 4 to 6 cm. proximal to the proctostomy and intussuscepted to prevent urine reflux into the proximal colon. A T pouch was then constructed using techniques previously described.1 A 20 cm. segment of distal ileum was placed in an inverted V configuration with each limb of the V measuring 10 cm. A more proximal 10 cm. segment of ileum was isolated as the afferent limb. Adhering to the principles outlined for the T pouch, the antireflux mechanism was created by anchoring the distal 3 to 4 cm. of afferent limb into a serosal lined trough. This trough was constructed by maintaining the windows of Deaver to the afferent limb, which allowed for permanent fixation to the serosa of the ileal pouch. The ileal trough was then closed by over sewing the adjacent ileal flaps that are created when the bowel is detubularized (part A of figure). The ileum was left open to be laid onto the rectum as a pouch
A, mucosa is over sewn in 2 layers from apex of V toward ostium of afferent ileal segment. B, completion of T pouch. Ileal flap mucosal edges are brought over distal portion of afferent ileal segment. Staple line is excluded from contact with urine. C, T pouch is laid over 15 cm. proctostomy and attached to it with 2-layer anastomosis. 2052
2053
T POUCH AS ILEO-ANAL RESERVOIR
(part B of figure). The left ureteroileal anastomosis was stented with an 8F pediatric feeding tube and tied to an 18F Malecot catheter, which was brought out through the sigmoid portion of the reservoir and fashioned to the skin. The edges of the pouch were then sutured to the rectum in a standard 2-layer fashion (part C of figure). An excretory urogram, radiography of the pouch and biochemical studies were done 3 months postoperatively. Creatinine was 1.4 mg./dl. with complete resolution of the metabolic acidosis. Antibiotics were discontinued, and daytime and nighttime continence was achieved. Excretory urography showed significant improvement in the preoperative hydronephrosis. DISCUSSION
The procedure of choice for ureterosigmoidostomy failure has not been established to date. Some advocate the use of ureteral reimplantation with preservation of the original diversion, while others discourage this type of urinary diversion and suggest that these patients are susceptible to further complications.3 Due to the increased incidence of these complications we converted the ureterosigmoidostomy to an ileo-anal reservoir. The T pouch combines a novel ileal antireflux mechanism to protect the upper urinary tract. The low pressure, high volume reservoir minimizes frequency and nocturnal fecaluria. Our efforts to improve the antireflux mechanism can be easily transferred to this type of diversion with a lower incidence of complications. A unique advantage
of this technique concerns ureteral diameter. Frequently, ureters become grossly dilated and hypertrophied in an attempt to overcome the high intracolic pressures. Such ureters may be difficult to reimplant with the standard Camey-Le Duc technique. Therefore, our antireflux mechanism with end-to-side ureteral reimplant is an appealing option. CONCLUSIONS
The excellent results obtained in our case confirm the versatility of the techniques available with the T pouch orthotopic diversion. The ability to create an antireflux mechanism without complications of the afferent nipple of the Kock pouch, and the relative ease of ureteral anastomosis without any ureteral tailoring or manipulation make this option viable for undiversion in cases of failed ureterosigmoidostomy. REFERENCES
1. Stein, J. P., Lieskowsky, G., Ginsberg, D. A. Bochner, B. H. and Skinner, D. G.: The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique. J. Urol., 159: 1836, 1998. 2. Masrobian, H. J., Kelalis, P. P. and Kramer, S. A.: Long-term followup of 103 patients with bladder exstrophy. J Urol., 138: 719, 1988. 3. Koo, H. P., Avolio, L. and Duckett, J. W.: Long-term results of ureterosigmoidostomy in children with bladder exstrophy. J. Urol., 156: 2037,1996.
Vol. 162, 2052–2053, December 1999 Printed in U.S.A.
Urologists at Work APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR JOHN P. STEIN, MAURIZIO BUSCARINI, ROGER E. DE FILIPPO
AND
DONALD G. SKINNER
From the Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California. KEY WORDS: proctocolectomy, restorative; urinary diversion; bladder exstrophy
We recently reported our initial clinical experience with a novel form of urinary diversion, that is the T pouch.1 The T pouch incorporates a unique antireflux mechanism and eliminates the complications associated with an intussuscepted nipple valve. We describe the application of this concept with conversion of a ureterosigmoidostomy into a new ileo-anal reservoir with an antireflux mechanism. Others have reported followup of as long as 40 years.2 To our knowledge 61 years is the longest interval to be reported between construction of a ureterosigmoidostomy and its revision. CASE HISTORY
P. K., a 64-year-old woman with a history of bladder exstrophy, underwent cystectomy and ureterosigmoidostomy at age 3 years. At 18 years she underwent right nephrectomy for intractable pyelonephritis, and was well until she was 55 years old and had recurrent episodes of pyelonephritis, which necessitated suppressive antibiotic therapy. Multiple drug allergies developed, and she was ultimately hospitalized for urosepsis. Renal ultrasound demonstrated moderate to severe left hydroureteronephrosis. A furosemide nuclear scan was consistent with obstruction. Creatinine was 1.6 mg./dl. (normal 0.3 to 0.9) and blood chemistry study revealed severe hyperchloremic metabolic acidosis. Colonoscopy showed no evidence of malignancy. The patient was satisfied with the voiding pattern and declined any form of external urinary Accepted for publication July 2, 1999.
diversion. Conversion of the ureterosigmoidostomy to an ileoanal reservoir incorporating the T pouch antireflux mechanism to the sigmoid colon was performed. At the time of surgery a 24F Medina tube was placed into the anus and, after copious irrigation with a diluted povidone-iodine solution, sutured in place. The Medina tube served as a tactile cue for proper placement of the proctostomy. The colon was mobilized and the previous ureterocolostomy was excised at its junction and sent for frozen section to rule out neoplastic degeneration. A 15 cm. proctostomy was then made at the tip of the Medina tube 10 cm. proximal to the transition zone between the rectum and anus. A portion of sigmoid colon was isolated 4 to 6 cm. proximal to the proctostomy and intussuscepted to prevent urine reflux into the proximal colon. A T pouch was then constructed using techniques previously described.1 A 20 cm. segment of distal ileum was placed in an inverted V configuration with each limb of the V measuring 10 cm. A more proximal 10 cm. segment of ileum was isolated as the afferent limb. Adhering to the principles outlined for the T pouch, the antireflux mechanism was created by anchoring the distal 3 to 4 cm. of afferent limb into a serosal lined trough. This trough was constructed by maintaining the windows of Deaver to the afferent limb, which allowed for permanent fixation to the serosa of the ileal pouch. The ileal trough was then closed by over sewing the adjacent ileal flaps that are created when the bowel is detubularized (part A of figure). The ileum was left open to be laid onto the rectum as a pouch
A, mucosa is over sewn in 2 layers from apex of V toward ostium of afferent ileal segment. B, completion of T pouch. Ileal flap mucosal edges are brought over distal portion of afferent ileal segment. Staple line is excluded from contact with urine. C, T pouch is laid over 15 cm. proctostomy and attached to it with 2-layer anastomosis. 2052
2053
T POUCH AS ILEO-ANAL RESERVOIR
(part B of figure). The left ureteroileal anastomosis was stented with an 8F pediatric feeding tube and tied to an 18F Malecot catheter, which was brought out through the sigmoid portion of the reservoir and fashioned to the skin. The edges of the pouch were then sutured to the rectum in a standard 2-layer fashion (part C of figure). An excretory urogram, radiography of the pouch and biochemical studies were done 3 months postoperatively. Creatinine was 1.4 mg./dl. with complete resolution of the metabolic acidosis. Antibiotics were discontinued, and daytime and nighttime continence was achieved. Excretory urography showed significant improvement in the preoperative hydronephrosis. DISCUSSION
The procedure of choice for ureterosigmoidostomy failure has not been established to date. Some advocate the use of ureteral reimplantation with preservation of the original diversion, while others discourage this type of urinary diversion and suggest that these patients are susceptible to further complications.3 Due to the increased incidence of these complications we converted the ureterosigmoidostomy to an ileo-anal reservoir. The T pouch combines a novel ileal antireflux mechanism to protect the upper urinary tract. The low pressure, high volume reservoir minimizes frequency and nocturnal fecaluria. Our efforts to improve the antireflux mechanism can be easily transferred to this type of diversion with a lower incidence of complications. A unique advantage
of this technique concerns ureteral diameter. Frequently, ureters become grossly dilated and hypertrophied in an attempt to overcome the high intracolic pressures. Such ureters may be difficult to reimplant with the standard Camey-Le Duc technique. Therefore, our antireflux mechanism with end-to-side ureteral reimplant is an appealing option. CONCLUSIONS
The excellent results obtained in our case confirm the versatility of the techniques available with the T pouch orthotopic diversion. The ability to create an antireflux mechanism without complications of the afferent nipple of the Kock pouch, and the relative ease of ureteral anastomosis without any ureteral tailoring or manipulation make this option viable for undiversion in cases of failed ureterosigmoidostomy. REFERENCES
1. Stein, J. P., Lieskowsky, G., Ginsberg, D. A. Bochner, B. H. and Skinner, D. G.: The T pouch: an orthotopic ileal neobladder incorporating a serosal lined ileal antireflux technique. J. Urol., 159: 1836, 1998. 2. Masrobian, H. J., Kelalis, P. P. and Kramer, S. A.: Long-term followup of 103 patients with bladder exstrophy. J Urol., 138: 719, 1988. 3. Koo, H. P., Avolio, L. and Duckett, J. W.: Long-term results of ureterosigmoidostomy in children with bladder exstrophy. J. Urol., 156: 2037,1996.