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Ileal Conduits in Children
Vol. 103, Apr. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
ILEAL CONDUITS TN CHILDREN R. MAXIE McCOY
AND
ROBERT K. RHAMY
From the Division of Urology, Vanderbilt University Hospital. Nashville, Tennessee
Since the first report of ileal conduits in children in 19541 several large series have demonstrated the advantages of this form of diversion in adults and children. 2 - 6 While most reports consist primarily of patients with renal deterioration preoperatively, persistent infection with further deterioration has been reported postoperatively. Because of increased experience and improved appliances, ileal conduit urinary diversion became an accepted procedure in children for social reasons. Early diversion in children was believed to afford not only social acceptance but to prevent renal deterioration from infection and/or obstruction. Our study is a comparison between children with normal upper urinary tracts radiographically in whom diversion was done purely for social reasons and those in whom diversion was done after signs of renal deterioration had appeared. CLINICAL EXPERIENCE
Ileal conduit urinary diversion for neurogenic vesical dysfunction has been accomplished in 39 children less than 15 years old at Vanderbilt University Hospital between 1961 and July 1968. Of the 24 girls and 15 boys operated on, 37 are available for followup evaluation. There were no operative deaths in this group. One patient died 2 months postoperatively of meningitis and one Accepted for publication April 21, 1969. 1 Bill, A. H., Jr., Dillard, D. H., Eggers, H. E. and Jenson, 0., Jr.: Urinary and fecal incontinence due to congenital abnormalities in children: management by implantation of the ureters into an isolated ileostomy. Surg., Gynec. & Obst., 98:
575, 1954.
2 Rickham, P. P.: Permanent urinary diversion in childhood. Ann. Roy. Coll. Surg., 36: 84, 1964. 3 Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversions. Ann. Surg., 167: 367, 1968. 4 Retik, A. B., Perlmutter, A. D. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. J. Med., 227: 217, 1967. 5 Logan, C. W., Scott, R., Jr. and Laskowski, T. Z.: Ilea! loop diversion: evaluation of late results in pediatric urology. J. Urol., 94: 544, 1965. 6 Cook, R. C., Lister, J. and Zachary, R. B.: Operative management of the neurogenic bladder in children: diversion through intestinal conduits. Surgery, 63: 825, 1968.
491
was lost to followup when she moved from the state, 3 months after diversion. Although many basic pathological processes underlie vesical dysfunction (table 1) we classified patients in 1 of 2 groups according to indications for diversion-1) renal deterioration and 2) social acceptance-to obtain a more meaningful basis for evaluation. A patient was considered to have renal deterioration when there was persistent urinary tract infection with evidence of change on excretory urograms (IVPs). All patients with normal preoperative IVPs were considered candidates for social diversion regardless of the urinary bacteriological status. Patients in whom diversion was done for renal deterioration were primarily in the younger and older age groups, while patients who underwent the procedure for social reasons were usually between ages 4 and 10 years old (fig. 1). Complications directly related to the formation of the ileal conduit were noted in 10 of the 37 cases. The relationship among complications, age of patients and the year the ileal conduit was performed was noted (figs. 1 and 2 and table 2). There were 7 complications necessitating an operation among 23 conduits done for social reasons (30 per cent). With 1 exception complications directly related to formation of the ileal conduit were exhibited within 13 months after diversion (fig. 3). Uretero-ileal stenosis occurred in 3 patients all of whom had been operated upon within a 4-month period in 1962 using a 2-layer uretero-ileal anastomosis. While 1 patient had prolonged ileus in the immediate postdiversion period which yielded to non-operative management, 2 patients required exploratory laparotomy for intestinal obstruction. One patient with acute pyelonephritis in the immediate postoperative period suffered an incisional hernia which required repair. Six years after diversion 1 child had a pyovesicle which necessitated cystectomy to resolve the infection which was not considered a direct result of conduit formation. Of the patients in whom diversion was done
492
MCCOY AND RHAMY
for renal deterioration there were 7 complications necessitating an operation among 14 patients (50 per cent); 4 complications were directly related to formation of the ileal conduit. Two patients had stomal stenosis, 2 had intestinal obstructions, 1 had recurrent calculi, 1 had a pyovesicle, and 1 had a urethral diverticulum. Both patients with stomal stenosis had persistently infected urine while no patient with non-infected urine postoperatively had stenosis. Results of the preoperative and postoperative IVPs were compared (table 3). Of the 46 normal renal units in patients undergoing diversion for social reasons 40 remained normal postoperatively while 6 units deteriorated (15 per cent). In patients in whom diversion was done for renal deterioration there were 9 normal units, 11 with mild hydronephrosis, 7 with moderate hydronephrosis and 1 unit which failed to visualize in the preoperative evaluation. On postoperative evaluation 4 units (14 per cent) had deteriorated further while 14 (50 per cent) improved and 10 (36 per cent) remained unchanged. Preoperative infection was found in 13 of 23 patients who underwent diversion for social reasons while all 14 patients with renal deterioraTABLE
1. Basic pathological lesions Social
Renal
18 0 2 0
14
Myelodysplasia Epispadias Traumatic paraplegia Transverse myelitis Congenital absence of sacrum Bladder exstrophy* Congenital stricture
1 0 0 0 0
• Post•ureterosigmoidostomy with rectal incontinence.
tion had infected urine. The postoperative urine was collected on each visit from the ileal conduit by use of a catheter and submitted for routine serial cultures and sensitivity testing. No urinary infection was considered present when the urine culture on 2 consecutive occasions contained less than 1,000 organisms per ml. in the absence of systemic antimicrobials. The relationship of the disappearance of infection to the length of time postoperatively was noted (fig. 4). Only 1 patient who underwent diversion for social reasons has had persistent urinary infection for more than 6 months (4.3 per cent incidence of chronic urinary infection). This patient had urinary tract infection preoperatively that never resolved in spite of intensive antimicrobials and IVPs have shown postoperative deterioration of the upper tracts. Although this patient has had a positive urine culture she has not had episodes of clinical pyelonephritis. One patient who underwent diversion for social reasons had acute pyelonephritis immediately after operation but has had a persistently negative culture since 2 months after diversion and has received no further antimicrobials. Acute pyelonephritis developed in 1 patient in this group 2 years post-diversion although urine cultures were negative preoperatively and throughout the postoperative period. This patient had a normal upper urinary tract at the time the infection manifested itself. The infection yielded to specific antimicrobials and urine cultures are again negative without the need for therapy. Of the 14 patients who underwent diversion for renal deterioration 4 have had infection which has persisted for 1 year after the ileal conduit in spite of continuous antimicrobials. Two of these pa-
RELATIONSHIP OF AGE AT TIME OF ILEAL CONDUIT COMPARED TO COMPLICATIONS DIRECTLY RELATED TO FORMATION OF LOOP
7
6 5 4
NUMBER OF PATIENTS
3 2
PATIENTS DIVERTED
•
RENAL DETERIORATION
f'.2
SOCIAL DIVERSION
493
ILEAL CONDUITS IN CHILDREN
RELATIONSHIP BETWEEN YEAR ILEAL CONDUIT CONSTRUCTED AND COMPLICATIONS DIRECTLY RELATED TO SURGICAL FORMATION OF CONDUIT
TIME FROM FORMATION OF ILEAL CONDUIT TO SURGICAL COMPLICATION DIRECTLY RELATED TO FORMATION OF CONDUIT
~ RENAL DETERIORATION
rzJ
o
SOCIAL LOOPS
L o'
USETEROSTENOS!LEAL IS
PATIENTS DIVERTED
o
IJ\JCISIONAL
i-lERNIA STOMAL STENOS IS
~
INTESTINAL 08STRUCTION
i~UMBER
~
0
~~-~~~
0
OF 0
SOCIAL DIVERSION
'"' RENAL DETERIORATION
3
6
9
12
15
18
21
24
48
36
60
;i ME !N MONTHS
ATIENTS
FIG,
0
N
~1
"' ""'
U)
"'"'
"-
0)
"' "''!' '!'"' m "''!' '!' "''!' '!' '!'
01 I
2
3
3
"'
3. Renal evaluation by IVP
T,\BLE
~I~ I
Post-Op. PreOp
UnIm- Deterichanged proYed orated
4 5
COMPLICATIONS
TABLE
40
Normal-social reasons') for di,-ersion
FIG- 2
2. Complications-.rnrgical and medical Social
Renal
23
H
Renal deteriorationt ~onnal Mild hydronephrosis l\Iod. hydronephrosis ::,.;J" on-visualization
11
* Social loops-23 patients v,:ith 46 renal units. No, patients Early Requiring operation: Intestinal obstruction Not requiring operation: Acute pyelonephritis .Prolonged ileus Late Requiring operation: Incisional. hernia U retero-ileal steno sis Intestinal obstruction Pyovesicle Stomal stenosis Urethral diverticulum Calculi Not requiring operation: Pyovesicle Pyelonephritis Stomal excoriation
t Renal deterioration loops--14 patients vi·ith 28 renal nnit.s.
0 Tl ME FROM
I LEAL CONDUIT
o--c SOCIAL LOOPS - - - RENAL DETERIORATION
14
0 0
12 \ NUMBER IQ OF
\
\
\
PATIENTS S
2
0
6 4
0
2
i 2
0
0
\,
'
--------*
'-o,
' ' '0---0-----0 6
12
24
36
TIME IN MONTHS
* tients have sterile urine cultures while they are taking antibiotics but the cultures are positive when the antimicrobials are discontinued. Therefore these patients must be considered infected. The other 2 patients have had symptoms of pyelonephritis and both have had further deterioration of the upper urinary tract. One patient has had recurrent calculi and is the only one in the series in whom calculi developed after diversion. In none of the 10 patients with negative urine cultures has the culture reverted to positive once it
CONSTRUCTION
TO STERILE URINE
0 0
2 of these 4 have sterile urines whiie on antimicrobials
FIG, 4
was sterile and none of the patients bas had symptoms of pyelc,nephritis. Mild hyperchloremic acidosis occurred in 1 patient but no therapy for symptomatic acido,is has been required. Renal function, as determined by blood urea nitrogen and serum c:reatinine levels, remained the same or improved in all patients-
494
MCCOY AND RHAMY DISCUSSION
Indications for permanent ileal conduit diversion and the age of children at the time of diversion have been widely discussed. We agree with Creevy7 and others2• 4 that children with marked renal impairment or ureteral dilatation and tortuosity are best managed by some form of ureterocutaneous anastomosis. Children with neurogenic vesical dysfunction should undergo diversion into ileal conduits at the earliest signs of renal deterioration. The fact that no operative deaths occurred in our series is most likely a reflection of the preoperative renal status of our patients. Most operative deaths reported on have been in patients who were azotemic preoperatively.2. 4 , 6 Because of social problems Rickham favored diversion into the isolated ileal loop for children with vesical dysfunction and no evidence of renal deterioration. He believed that this procedure should be done when the child is 2 years old. 2 Swenson 8 thought that many of these children could be continent with training at 10 to 12 years of age. 8 Recently Eckstein demonstrated that children with myelomeningoceles who are going to become continent do so by 3 years of age. 9 Regardless of the macroscopic appearance of the lesion 33 per cent of these children do become continent. Presently it is our policy to establish an ilea! conduit for purely social acceptance reasons in children when they are 4 to 5 years old and at least 6 months before the educable child is to begin school. External penile urinals have been tried in several boys but problems with their body habitus and excoriation indicated the need for subsequent diversion. Stomal stenosis is a frequent complication in many reported series but we have had to revise only 2 stomas in our 37 patients. 2 • 4 • 5 Parents are instructed to dilate the mature stoma once weekly and all patients are examined on return visits for evidence of stenosis or residual urine in the loop. Since children must be followed frequently for evidence of stenosis it is our policy to see them every 2 to 3 months for the first 2 years after diversion and at least every 6 months thereafter. 7 Creevy, C. D.: Renal complications after ilea! div8rrsion of the urine in non-neoplastic disorders. J. Drol., 83: 394, 1960. 8 Swenson, 0., Fisher, J. H. and Gendron, J.: Treatment of cord bladder incontinence in children. Ann. Surg., 144: 421, 1956. 9 Eckstein, H. B.: Urinary control in children with myelomeningocele. Brit. J. Urol. 40: 191
1968.
'
'
The fact that in 3 patients who underwent diversion for social reasons uretero-ileal stenosis developed, demonstrates again the care and precision required in anastomosing normal-sized ureters to bowel. Barzilay and Goodwin recently described a technique of uretero-ileal anastomosis in normal-sized ureters to prevent stenosis and leakage. 10 However, by using a 1-layer mucosa-tomucosa anastomosis this complication has not occurred again in the last 28 cases. Intestinal obstruction occurred in 10.8 per cent of these patients and occurred in approximately the same ratio of patients diverted for social reasons as those diverted for renal deterioration. These results parallel those of Jaffe and associates who found intestinal obstruction in 11.8 per cent of patients operated on for benign disease.3 While infections in the isolated bladder are usually controlled by a short period of 1 per cent neomycin 11 irrigation, subsequent cystectomy has been required in 2 patients (5.4 per cent) to control a pyovesicle. Retik and associates found that 15 per cent of patients operated upon before pyelographic abnormalities had renal deterioration postoperatively and our results parallel those exactly. 4 This is a more acceptable rate of postoperative pyelographic deterioration than the 42 per cent reported by Susset and associates. 12 A low incidence of pyelonephritis following ileal conduit has been established. 2 • 4 , 5, 13 However, long-term chemotherapy has been maintained in many series. 2• 4 • 6 • 14 In Bricker's original description of the operation he thought that peristalsis in the segment would favor rapid emptying and thus avoid stasis and that the growth of bacteria in the urine would be minimal because of the rapid emptying. 15 That only 1 of the 23 children who underwent diversion for 10 Barzilay, B. I. and Goodwin W. E.: Clinical application of an experimental study of ureteroileal anastomosis. J. Urol., 99: 35, 1968. 11 Neomycin Sulfate U.S.P. 12 Susset,. J. G., Taguchi, Y., DeDomenico, I. and MacKm_non, K. J.: Hydronephrosis and hydroureter 1n 1leal conduit urinary diversion. Canad. J. Surg., 9: 141, 1966. 13 ~mith, E. D.: Ilea-cutaneous urethrostomy • 111 children. I. Indications and results. Aust. New Zeal. J. Surg., 33: 169, 1964. 14 Straffon, R. A., Turnbull, R. B., Jr. and Mercer, R. _D.: The_ileal conduit in the management of children with neurogenic lesions of the bladder. J. Urol., 89: 198, 1963. 15 Bricker, E_. M._: Symposium on clinical surgery, bladder substitut10n after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950.
ILEAL CONDUITS IN CHILDREN
social reasons has bacteriuria substantiates the fact that infection is a minimal problem in patients with normal functioning ilea! conduits, All attempts should be made to sterilize the urine in patients following formation of an ilea! conduit and abacteriuria can be obtained in most (86 per cent) without continuous antimicrobial rn,,rc,rm SUJ\IlVL\RY
Ilea! conduit urinary diversion in children with neurogenic vesical dysfunction is an accepted procedure. Our report is a comparison of post-
495
operative complications in 23 children in whom diversion was done before radiographic evidence of renal deterioration and in 14 children in whom diversion wa~ done after renal deterioration. Of patients in whom diversion was done for social reasons 96 per cent are abacteriuric, 85 per cent have normal and the complication rate has been low with meticulous surgical technique and careful followup. We believe ilea! conduit urinary diversion is preferable before renal deterioration develops because it offers both social acceptance and 11ormal renal function without infection in a high per cent of patients.
THE JOURNAL OF UROLOGY
Copyright © 1970 by The Williams & Wilkins Co.
ILEAL CONDUITS TN CHILDREN R. MAXIE McCOY
AND
ROBERT K. RHAMY
From the Division of Urology, Vanderbilt University Hospital. Nashville, Tennessee
Since the first report of ileal conduits in children in 19541 several large series have demonstrated the advantages of this form of diversion in adults and children. 2 - 6 While most reports consist primarily of patients with renal deterioration preoperatively, persistent infection with further deterioration has been reported postoperatively. Because of increased experience and improved appliances, ileal conduit urinary diversion became an accepted procedure in children for social reasons. Early diversion in children was believed to afford not only social acceptance but to prevent renal deterioration from infection and/or obstruction. Our study is a comparison between children with normal upper urinary tracts radiographically in whom diversion was done purely for social reasons and those in whom diversion was done after signs of renal deterioration had appeared. CLINICAL EXPERIENCE
Ileal conduit urinary diversion for neurogenic vesical dysfunction has been accomplished in 39 children less than 15 years old at Vanderbilt University Hospital between 1961 and July 1968. Of the 24 girls and 15 boys operated on, 37 are available for followup evaluation. There were no operative deaths in this group. One patient died 2 months postoperatively of meningitis and one Accepted for publication April 21, 1969. 1 Bill, A. H., Jr., Dillard, D. H., Eggers, H. E. and Jenson, 0., Jr.: Urinary and fecal incontinence due to congenital abnormalities in children: management by implantation of the ureters into an isolated ileostomy. Surg., Gynec. & Obst., 98:
575, 1954.
2 Rickham, P. P.: Permanent urinary diversion in childhood. Ann. Roy. Coll. Surg., 36: 84, 1964. 3 Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ilea! segment urinary diversions. Ann. Surg., 167: 367, 1968. 4 Retik, A. B., Perlmutter, A. D. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. J. Med., 227: 217, 1967. 5 Logan, C. W., Scott, R., Jr. and Laskowski, T. Z.: Ilea! loop diversion: evaluation of late results in pediatric urology. J. Urol., 94: 544, 1965. 6 Cook, R. C., Lister, J. and Zachary, R. B.: Operative management of the neurogenic bladder in children: diversion through intestinal conduits. Surgery, 63: 825, 1968.
491
was lost to followup when she moved from the state, 3 months after diversion. Although many basic pathological processes underlie vesical dysfunction (table 1) we classified patients in 1 of 2 groups according to indications for diversion-1) renal deterioration and 2) social acceptance-to obtain a more meaningful basis for evaluation. A patient was considered to have renal deterioration when there was persistent urinary tract infection with evidence of change on excretory urograms (IVPs). All patients with normal preoperative IVPs were considered candidates for social diversion regardless of the urinary bacteriological status. Patients in whom diversion was done for renal deterioration were primarily in the younger and older age groups, while patients who underwent the procedure for social reasons were usually between ages 4 and 10 years old (fig. 1). Complications directly related to the formation of the ileal conduit were noted in 10 of the 37 cases. The relationship among complications, age of patients and the year the ileal conduit was performed was noted (figs. 1 and 2 and table 2). There were 7 complications necessitating an operation among 23 conduits done for social reasons (30 per cent). With 1 exception complications directly related to formation of the ileal conduit were exhibited within 13 months after diversion (fig. 3). Uretero-ileal stenosis occurred in 3 patients all of whom had been operated upon within a 4-month period in 1962 using a 2-layer uretero-ileal anastomosis. While 1 patient had prolonged ileus in the immediate postdiversion period which yielded to non-operative management, 2 patients required exploratory laparotomy for intestinal obstruction. One patient with acute pyelonephritis in the immediate postoperative period suffered an incisional hernia which required repair. Six years after diversion 1 child had a pyovesicle which necessitated cystectomy to resolve the infection which was not considered a direct result of conduit formation. Of the patients in whom diversion was done
492
MCCOY AND RHAMY
for renal deterioration there were 7 complications necessitating an operation among 14 patients (50 per cent); 4 complications were directly related to formation of the ileal conduit. Two patients had stomal stenosis, 2 had intestinal obstructions, 1 had recurrent calculi, 1 had a pyovesicle, and 1 had a urethral diverticulum. Both patients with stomal stenosis had persistently infected urine while no patient with non-infected urine postoperatively had stenosis. Results of the preoperative and postoperative IVPs were compared (table 3). Of the 46 normal renal units in patients undergoing diversion for social reasons 40 remained normal postoperatively while 6 units deteriorated (15 per cent). In patients in whom diversion was done for renal deterioration there were 9 normal units, 11 with mild hydronephrosis, 7 with moderate hydronephrosis and 1 unit which failed to visualize in the preoperative evaluation. On postoperative evaluation 4 units (14 per cent) had deteriorated further while 14 (50 per cent) improved and 10 (36 per cent) remained unchanged. Preoperative infection was found in 13 of 23 patients who underwent diversion for social reasons while all 14 patients with renal deterioraTABLE
1. Basic pathological lesions Social
Renal
18 0 2 0
14
Myelodysplasia Epispadias Traumatic paraplegia Transverse myelitis Congenital absence of sacrum Bladder exstrophy* Congenital stricture
1 0 0 0 0
• Post•ureterosigmoidostomy with rectal incontinence.
tion had infected urine. The postoperative urine was collected on each visit from the ileal conduit by use of a catheter and submitted for routine serial cultures and sensitivity testing. No urinary infection was considered present when the urine culture on 2 consecutive occasions contained less than 1,000 organisms per ml. in the absence of systemic antimicrobials. The relationship of the disappearance of infection to the length of time postoperatively was noted (fig. 4). Only 1 patient who underwent diversion for social reasons has had persistent urinary infection for more than 6 months (4.3 per cent incidence of chronic urinary infection). This patient had urinary tract infection preoperatively that never resolved in spite of intensive antimicrobials and IVPs have shown postoperative deterioration of the upper tracts. Although this patient has had a positive urine culture she has not had episodes of clinical pyelonephritis. One patient who underwent diversion for social reasons had acute pyelonephritis immediately after operation but has had a persistently negative culture since 2 months after diversion and has received no further antimicrobials. Acute pyelonephritis developed in 1 patient in this group 2 years post-diversion although urine cultures were negative preoperatively and throughout the postoperative period. This patient had a normal upper urinary tract at the time the infection manifested itself. The infection yielded to specific antimicrobials and urine cultures are again negative without the need for therapy. Of the 14 patients who underwent diversion for renal deterioration 4 have had infection which has persisted for 1 year after the ileal conduit in spite of continuous antimicrobials. Two of these pa-
RELATIONSHIP OF AGE AT TIME OF ILEAL CONDUIT COMPARED TO COMPLICATIONS DIRECTLY RELATED TO FORMATION OF LOOP
7
6 5 4
NUMBER OF PATIENTS
3 2
PATIENTS DIVERTED
•
RENAL DETERIORATION
f'.2
SOCIAL DIVERSION
493
ILEAL CONDUITS IN CHILDREN
RELATIONSHIP BETWEEN YEAR ILEAL CONDUIT CONSTRUCTED AND COMPLICATIONS DIRECTLY RELATED TO SURGICAL FORMATION OF CONDUIT
TIME FROM FORMATION OF ILEAL CONDUIT TO SURGICAL COMPLICATION DIRECTLY RELATED TO FORMATION OF CONDUIT
~ RENAL DETERIORATION
rzJ
o
SOCIAL LOOPS
L o'
USETEROSTENOS!LEAL IS
PATIENTS DIVERTED
o
IJ\JCISIONAL
i-lERNIA STOMAL STENOS IS
~
INTESTINAL 08STRUCTION
i~UMBER
~
0
~~-~~~
0
OF 0
SOCIAL DIVERSION
'"' RENAL DETERIORATION
3
6
9
12
15
18
21
24
48
36
60
;i ME !N MONTHS
ATIENTS
FIG,
0
N
~1
"' ""'
U)
"'"'
"-
0)
"' "''!' '!'"' m "''!' '!' "''!' '!' '!'
01 I
2
3
3
"'
3. Renal evaluation by IVP
T,\BLE
~I~ I
Post-Op. PreOp
UnIm- Deterichanged proYed orated
4 5
COMPLICATIONS
TABLE
40
Normal-social reasons') for di,-ersion
FIG- 2
2. Complications-.rnrgical and medical Social
Renal
23
H
Renal deteriorationt ~onnal Mild hydronephrosis l\Iod. hydronephrosis ::,.;J" on-visualization
11
* Social loops-23 patients v,:ith 46 renal units. No, patients Early Requiring operation: Intestinal obstruction Not requiring operation: Acute pyelonephritis .Prolonged ileus Late Requiring operation: Incisional. hernia U retero-ileal steno sis Intestinal obstruction Pyovesicle Stomal stenosis Urethral diverticulum Calculi Not requiring operation: Pyovesicle Pyelonephritis Stomal excoriation
t Renal deterioration loops--14 patients vi·ith 28 renal nnit.s.
0 Tl ME FROM
I LEAL CONDUIT
o--c SOCIAL LOOPS - - - RENAL DETERIORATION
14
0 0
12 \ NUMBER IQ OF
\
\
\
PATIENTS S
2
0
6 4
0
2
i 2
0
0
\,
'
--------*
'-o,
' ' '0---0-----0 6
12
24
36
TIME IN MONTHS
* tients have sterile urine cultures while they are taking antibiotics but the cultures are positive when the antimicrobials are discontinued. Therefore these patients must be considered infected. The other 2 patients have had symptoms of pyelonephritis and both have had further deterioration of the upper urinary tract. One patient has had recurrent calculi and is the only one in the series in whom calculi developed after diversion. In none of the 10 patients with negative urine cultures has the culture reverted to positive once it
CONSTRUCTION
TO STERILE URINE
0 0
2 of these 4 have sterile urines whiie on antimicrobials
FIG, 4
was sterile and none of the patients bas had symptoms of pyelc,nephritis. Mild hyperchloremic acidosis occurred in 1 patient but no therapy for symptomatic acido,is has been required. Renal function, as determined by blood urea nitrogen and serum c:reatinine levels, remained the same or improved in all patients-
494
MCCOY AND RHAMY DISCUSSION
Indications for permanent ileal conduit diversion and the age of children at the time of diversion have been widely discussed. We agree with Creevy7 and others2• 4 that children with marked renal impairment or ureteral dilatation and tortuosity are best managed by some form of ureterocutaneous anastomosis. Children with neurogenic vesical dysfunction should undergo diversion into ileal conduits at the earliest signs of renal deterioration. The fact that no operative deaths occurred in our series is most likely a reflection of the preoperative renal status of our patients. Most operative deaths reported on have been in patients who were azotemic preoperatively.2. 4 , 6 Because of social problems Rickham favored diversion into the isolated ileal loop for children with vesical dysfunction and no evidence of renal deterioration. He believed that this procedure should be done when the child is 2 years old. 2 Swenson 8 thought that many of these children could be continent with training at 10 to 12 years of age. 8 Recently Eckstein demonstrated that children with myelomeningoceles who are going to become continent do so by 3 years of age. 9 Regardless of the macroscopic appearance of the lesion 33 per cent of these children do become continent. Presently it is our policy to establish an ilea! conduit for purely social acceptance reasons in children when they are 4 to 5 years old and at least 6 months before the educable child is to begin school. External penile urinals have been tried in several boys but problems with their body habitus and excoriation indicated the need for subsequent diversion. Stomal stenosis is a frequent complication in many reported series but we have had to revise only 2 stomas in our 37 patients. 2 • 4 • 5 Parents are instructed to dilate the mature stoma once weekly and all patients are examined on return visits for evidence of stenosis or residual urine in the loop. Since children must be followed frequently for evidence of stenosis it is our policy to see them every 2 to 3 months for the first 2 years after diversion and at least every 6 months thereafter. 7 Creevy, C. D.: Renal complications after ilea! div8rrsion of the urine in non-neoplastic disorders. J. Drol., 83: 394, 1960. 8 Swenson, 0., Fisher, J. H. and Gendron, J.: Treatment of cord bladder incontinence in children. Ann. Surg., 144: 421, 1956. 9 Eckstein, H. B.: Urinary control in children with myelomeningocele. Brit. J. Urol. 40: 191
1968.
'
'
The fact that in 3 patients who underwent diversion for social reasons uretero-ileal stenosis developed, demonstrates again the care and precision required in anastomosing normal-sized ureters to bowel. Barzilay and Goodwin recently described a technique of uretero-ileal anastomosis in normal-sized ureters to prevent stenosis and leakage. 10 However, by using a 1-layer mucosa-tomucosa anastomosis this complication has not occurred again in the last 28 cases. Intestinal obstruction occurred in 10.8 per cent of these patients and occurred in approximately the same ratio of patients diverted for social reasons as those diverted for renal deterioration. These results parallel those of Jaffe and associates who found intestinal obstruction in 11.8 per cent of patients operated on for benign disease.3 While infections in the isolated bladder are usually controlled by a short period of 1 per cent neomycin 11 irrigation, subsequent cystectomy has been required in 2 patients (5.4 per cent) to control a pyovesicle. Retik and associates found that 15 per cent of patients operated upon before pyelographic abnormalities had renal deterioration postoperatively and our results parallel those exactly. 4 This is a more acceptable rate of postoperative pyelographic deterioration than the 42 per cent reported by Susset and associates. 12 A low incidence of pyelonephritis following ileal conduit has been established. 2 • 4 , 5, 13 However, long-term chemotherapy has been maintained in many series. 2• 4 • 6 • 14 In Bricker's original description of the operation he thought that peristalsis in the segment would favor rapid emptying and thus avoid stasis and that the growth of bacteria in the urine would be minimal because of the rapid emptying. 15 That only 1 of the 23 children who underwent diversion for 10 Barzilay, B. I. and Goodwin W. E.: Clinical application of an experimental study of ureteroileal anastomosis. J. Urol., 99: 35, 1968. 11 Neomycin Sulfate U.S.P. 12 Susset,. J. G., Taguchi, Y., DeDomenico, I. and MacKm_non, K. J.: Hydronephrosis and hydroureter 1n 1leal conduit urinary diversion. Canad. J. Surg., 9: 141, 1966. 13 ~mith, E. D.: Ilea-cutaneous urethrostomy • 111 children. I. Indications and results. Aust. New Zeal. J. Surg., 33: 169, 1964. 14 Straffon, R. A., Turnbull, R. B., Jr. and Mercer, R. _D.: The_ileal conduit in the management of children with neurogenic lesions of the bladder. J. Urol., 89: 198, 1963. 15 Bricker, E_. M._: Symposium on clinical surgery, bladder substitut10n after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950.
ILEAL CONDUITS IN CHILDREN
social reasons has bacteriuria substantiates the fact that infection is a minimal problem in patients with normal functioning ilea! conduits, All attempts should be made to sterilize the urine in patients following formation of an ilea! conduit and abacteriuria can be obtained in most (86 per cent) without continuous antimicrobial rn,,rc,rm SUJ\IlVL\RY
Ilea! conduit urinary diversion in children with neurogenic vesical dysfunction is an accepted procedure. Our report is a comparison of post-
495
operative complications in 23 children in whom diversion was done before radiographic evidence of renal deterioration and in 14 children in whom diversion wa~ done after renal deterioration. Of patients in whom diversion was done for social reasons 96 per cent are abacteriuric, 85 per cent have normal and the complication rate has been low with meticulous surgical technique and careful followup. We believe ilea! conduit urinary diversion is preferable before renal deterioration develops because it offers both social acceptance and 11ormal renal function without infection in a high per cent of patients.