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Substitution for the Urinary Bladder by the Use of Isolated Ileal Segments
TI
Substitution for the Urinary Bladder by the Use of Isolated Ileal Segments EUGENE M. BRICKER, M.D., F.A.C.S. *
THE operation of pelvic exenteration has led to the need for a method of substitution for the urinary bladder in the absence of a functioning rectum. Various other methods of solving this problem were tried prior to 1950. 1 • 4 These early attempts were directed at providing an intraabdominal urinary reservoir under some type of voluntary control. The results of these procedures were unsatisfactory in that complete continence was not provided and the operations were too complex to be associated with pelvic exenteration without prolonging the operation unduly, or without resorting to multiple stages. The use of the "wet colostomy" and bilateral skin ureterostomies was not practiced. In April 1950, four patients were subjected to bilateral ureteral transplantation to an isolated small bowel segment fashioned in such a manner as to convey the urine to an external stoma in the right lower quadrant to drain into a glued-on bag. The results of these early trials were so gratifying that the method has been used exclusively since this time for all patients undergoing exenteration of the pelvic viscera (118 operationst) and for a smaller group of patients for whom bladder substitution was done for other reasons (32 operationst). The results of this experience have been reported at various times. 1 • 2. 3, 5 Since the turn of the century the intestinal tract has been used in practically every conceivable way in attempting to substitute for the urinary bladder.9, 13 However, this appears to be the first time that an isolated segment of small intestine was deliberately used as a simple From the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri. * Associate Professor of Clinical Surgery, Washington University School of Medicine; Assistant Surgeon, Barnes and affiliated hospitals; Attending Surgeon, St. Louis City Hospital; Conwltant Surgeon, The Ellis Fischel State Cancer Hospital. t Including operations done by or under the supervision of Dr. Harvey Butcher ~nd Dr. C. Alan McAfee.
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conduit for the urine to an extra-abdominal reservoir. It is of interest that concomitantly with this experience, Mersheimer, Kolarsick and Kammandel were studying the same operation in dogsY' 12 PRELIMINARY CONSIDERATIONS
Operative Mortality
It is difficult to assess the mortality risk of ileal segment bladder substitution since it is most frequently associated with the operation of pelvic exenteration. In a report of the procedure in 1954" in which St. Louis cases were combined with those done by colleagues at the Ellis Fischel State Cancer Hospital in Columbia, Missouri, it appeared that 5 of 15 operative deaths in a group of 106 patients were attributable to the bladder substitution procedure. A recent survey of the St. Louis material 6 indicates that 5 of 16 operative deaths in 118 patients having pelvic exenteration resulted from complications of the bladder substitute. Taking all cases of ileal segment bladder substitution since April 1950 (150 operations), there have been five "bladder" deaths. In the first three years of this experience, there were three "bladder" deaths in 64 operations. In the last three years, there have been two "bladder" deaths in 86 operations. In 32 operations not involving pelvic exenteration, there have been no "bladder" deaths. The reader may make his own interpretation of these figures, but it would appear that the operative risk of ileal segment bladder substitution at the present time is about 3 per cent when all operations are considered. It is slightly more in those patients having pelvic exenteration (two "bladder" deaths in 61 operations in the past three years), and somewhat less in those patients having lesser procedures. COnlplications
Space does not permit a detailed consideration of complications of the procedure. For this, the reader is referred to previous publications. l • 2. 3. 5 The five operative fatalities mentioned above resulted from technical faults with one exception (pyelonephritis). The nonfatal early complications have been of minor consequence. There have been two fatal late complications: (1) bilateral hydronephrosis with death following operative revision, and (2) one death from pyelonephritis. These two late deaths have occurred in a group of approximately 100 patients surviving the operation from six months to six years. It is to be expected that there will be more deaths from late complications as time passes. Pyelonephritis has been no problem clinically except in two or three patients who have grown organisms refractory to antibiotic therapy. The 1954 study" indicated that 12 of 65 patients (20 per cent) had had more than one attack of chills and fever with flank pain. Cachexia from terminal carcinoma was thought to have been a contributing factor in
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part of this group. The recent study of patients subjected to pelvic exenteration revealed 11 of 102 survivors of the operation to be subject to repeated bouts of pyelonephritis. In most instances these episodes have been easily controlled by appropriate antibiotic therapy. At the present writing it appears that the true incidence of clinically evident postoperative pyelonephritis lies between 10 and 20 per cent. The results of this method of bladder substitution as judged by intravenous pyelography have been most gratifying. Eighty-six per cent of all ureters transplanted were normal or showed minimal hydronephrosis six months or more after operation." Sixty-six per cent of all ureters of Grade II to IV hydronephrosis were normal or Grade I six months after operation. The development and progression of hydronephrosis in the late postoperative period has been extremely rare. Hyperchloremia and acidosis have thus far not been recognized as complicating this method of bladder substitution. Basic Principles of the Operation
The features of ileal segment substitution for the urinary bladder that are of importance in producing the results above outlined appear to be the following: 1. The mechanical and technical simplicity of the procedure makes it practical to combine with a major resection without staging. Operating time for isolating the segment, rejoining the bowel, and anastomosing the ureters averages 75 minutes. 2. Isolation of the segment from the fecal stream decreases the chance of ascending infection. 3. The wide open external stoma with the absence of a sphincter mechanism is thought to decrease the chance of back pressure and reflux up the ureters. 4. It has been found that the segments evacuate promptly through peristaltic action and are always in a relatively empty state. 10 As a result, there is no stagnant reservoir of urine within which bacteria can multiply. 5. The method of uretero-intestinal anastomosis by the "mucosa-tomucosa" technique,7 which is aimed at primary healing with a minimum of scar tissue formation, is thought to result in a low incidence of obstruction and consequently in a low incidence of hydronephrosis and pyelonephritis. 6. Although absorption is known to take place through the mucosa of the segments 8 they are so short that the amount of absorption of urinary constituents is of no clinical significance. External Appliance
The operation is based on the fact that it is possible for a patient to wear a water-tight bag glued to the skin as a receptacle for the urine.
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Fig. 416. The ileostomy site should be marked on the skin prior to laparotomy. If the colon and rectum are not to be sacrificed the ureter is located through an incision in the lateral peritoneal reflexion of the sigmoid mesocolon. It is most important that adequate adventitial tissue be left attached to the ureter in order to assure blood supply.
Several such bags are now available and they are all easily managed by the patient. The Rutzen bag is the one most frequently used by the patients represented in this study. It has been found that these appliances are very satisfactory as external urinary reservoirs and cause the patients a minimum of inconvenience. Preoperative Preparation
The intestinal tract is bacteriologically and mechanically prepared for the operation by antibiotics, catharsis, enemas and diet. Sulfasuxidine is given in the usual dose forJour or five days and neomycin for two days
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Fig. 417. The left ureter is passed through the mesentery of the sigmoid colon, posterior to the superior hemorrhoidal vessels. This opening must be adequate and placed in such a manner as to prevent angulation of the ureter. The right ureter is dissected similarly through an appropriately placed peritoneal incision.
before operation. Early in the afternoon of the day before operation, castor oil is given and the patient is limited to a liquid diet for that evening. Late in the evening, a saline enema is administered and this is repeated in the morning an hour or so before the patient is taken to the operating room. With this routine, the bowel is clean and deflated. The other facets of preparation are the same as for any major abdominal operation. If intestinal obstruction is present the entire preparation and plan of attack may have to be altered. TECHNIQUE
Level of Sectioning the Ureters. It is possible to so fashion the ileal segment that the ureters can be anastomosed to it even though they are sectioned quite high above the pelvic brim. However, the optimum level seems to be 2 or 3 cm. below the iliac artery. This level leaves ample ureter for an easy anastomosis and makes unnecessary a deeper dissection into the tumor area. If the operation is one not requiring sacrifice of the rectum and sigmoid colon, the left ureter is dissected through an incision in the lateral peritoneal reflection and transferred medially through the mesosigmoid beneath the superior hemorrhoidal artery (Figs. 416 and 417). This medial transfer of the left ureter must be made
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Fig. 418. The anatomical relationship.:; exiiltin6 after exenteration of the pelvic viscera are illustrated above. Four or 5 cm. of ureter may be mobilized safely if adequate adventitia is included. The appendix is always removed.
through an adequate opening without angulation. In mobilizing the ureter, it is most important that an adequate amount of adventitial tissue be included in order that vascularity be retained. Proximal mobilization should be carried no higher than necessary, 4 to 5 cm. usually being adequate. This amount of mobilization appears perfectly safe if the adventitial blood supply is left intact. It is quite easy to "telescope" the ureter out of its adventitial sheath during manipulation. Such an occurrence must be guarded against since it will jeopardize the vascularity of the ureter. When the bladder substitution is being done in conjunction with pelvic exenteration, the anatomical relationships are as illustrated in Figure 418 with the problem of medial direction of the left ureter being greatly simplified. Appendectomy. The appendix is always removed in order to simplify the evaluation of any subsequent abdominal symptoms. I solation of Intestinal Segment. In most instances, a segment of terminal ileum 6 to 7 inches in length is isolated (Fig. 419, A). The exact level of this segment may be varied to suit the individual circumstances, but usually a segment ending 4 or 5 inches from the cecum has been advantageous. Occasionally a higher segment has been used because of thickness of the abdominal wall, a short mesentery, or for some other reason. There are no measurements that will make this procedure exact.
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Fig. 419. A segment of terminal ileum 6 or 7 inches in length is isolated (A). The end-to-end anastomosis of ileum is made anterior to the segment with 2 layers of fine silk sutures (B). Closure of the mesenteric rent must be done very carefully, with the sutures placed only through peritoneum in order not to jeopardize the blood supply of the anastomosis or the isolated segment (C).
It must depend on the intuition, skill and mechanical ingenuity of the surgeon. The mesenteric incisions must be no longer than necessary and the vascular pedicle caimot be jeopardized. The proximal end of the isolated segment is closed with two inverting rows of 3-0 or 4-0 chromic catgut. End-to-End Anastomosis. As illustrated (Fig. 419, B), the continuity of the bowel is re-established by open end-to-end anatomosis. The exact technique of this anastomosis is inconsequential provided (1) the vascularity of the two ends is not impaired, (2) fine interrupted nonabsorbable suture material is used for both layers, and (3) as little of the bowel wall as possible is inverted in placing the sutures. Running catgut for anastomoses of small bowel tends to produce constriction that can be avoided by the use of interrupted sutures.
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Fig. 420. The approximation of the left ureter to the end of the isolated segment produces a potential "tunnel" which is obliterated by sutures as indicated above. This is done in order to prevent herniation of the small intestine through this potential space. The protected position of the right ureter posterior to the mesentery of the terminal ileum does not present the same problem.
The mesenteric rent may be closed as the next step (Fig. 419, C) or it may be done later. It is of vital importance that the sutures be placed superficially in the peritoneum and that the blood supply of the isolated segment and of the anastomosis not be impaired. It may be preferable to close the rent after the distal end of the segment has been delivered through the abdominal wall if it is feared that distortion and tension may jeopardize the closure. Closure of "Tunnel" Formed by Medial Direction of the Left Ureter. As the left ureter is approximated to the proximal end of the isolated segment, a "tunnel" or window is formed by the ureter, the segment, and the inferior surface of the mesentery of the small intestine (Fig. 420). This space is present whether or not the sigmoid colon has been removed and it must be closed to prevent herniation of the small intestine. The sutures may be placed to fit the individual situation so long as the defect is closed completely and the blood supply of the bowel and segment is not impaired. It is unnecessary to close the window formed by anasto-
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Fig. 421. The left ureter is anastomosed to the ileal segment first, the anastomosis being quite near the blind end of the segment. The first sutures are placed through the adventitia of the ureter and the serosa of the intestine. Excess ureter is then trimmed off.
mosis of the right ureter since it is smaller and lies in a protected position beneath the mesentery, making herniation very unlikely to occur. Uretero-Intestinal Anastomosis. Figure 421 illustrates the approximation of the left ureter to the end of the isolated segment. The right ureter is visible and will in turn be anastomosed quite close to the left (Fig. 422). First, three fine silk sutures are placed through the adventitia of the ureter and the serosa of the bowel, care being taken not to pass the suture into the lumen of the ureter. It is during this manipulation that the ureter must be prevented from telescoping out of its adventitia. Excess ureter is trimmed off with sharp scissors with no attempt'being made to bevel the cut end. Next, an opening is made through the~bowel wall the exact size of the ureter (Fig. 422). If done carefully with short strokes of a pointed knife, the mucosa will pout into the opening. Too large an opening greatly complicates the anastomosis and increases the chance of obstruction being inadvertently produced. The internal row of
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Fig. 422. Fine catgut is used for the "mucosa-to-mucosa" sutures which in actuality include full thickness of ureteral wall, and serosa and mucosa of ileum (A). The anastomosis is facilitated if the opening into the ileum is made no larger than the ureter. The anterior row of catgut sutures can be placed more accurately if the knots are tied outside the lumen (B, C). The second row is completed with fine silk, taking very small bites and inverting a minimum of the ureter (C). The ureteral anastomoses are placed only a centimeter or two apart and are both quite near the blind end of the segment (D).
sutures are now placed by a "mucosa-to-mucosa" technique which in actuality includes full-thickness of ureter and serosa and mucosa of bowel. These sutures must be placed with the greatest care and exactitude. The suture material is 4-0 or 5-0 chromic catgut with an atraumatic needle. A ureter of normal size will require six to eight such sutures as illustrated. It makes little difference whether the knots are placed inside or outside the lumen. The sutures of the anterior row are placed with the knots on the outside since they can be placed more easily and
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Fig. 423. In order to establish anatomical relationships it is sometimes advisable to deliver the external stoma of the ileum earlier in the course of the procedure than here indicated. A button of skin is removed, making the stoma approximately 1 inch in diameter. A standard size ileostomy bag is kept in stock for application to the stoma at the time of operation or soon thereafter.
accurately in this manner. After the internal row of catgut sutures has been completed, the anterior layer of fine silk sutures is inserted between adventitia and serosa. Care is taken to turn in as little ureter as possible and not to penetrate the ureteral lumen. The right ureter is anastomosed immediately adjacent to the left. Both ureters are anastomosed near the blind end of the segment so that kinking of the segment will not occur and the possibility of impaired emptying of the proximal end is prevented. External Stoma. A circular piece of skin 1 inch in diameter is excised from the right lower quadrant at a site previously selected for the application of a Rutzen bag (Figs. 416 and 423). While skin, fascia and peritoneum are held taut, the opening is extended directly through the abdominal wall. It is important that the opening be adequate (a snug two fingers usually) and that there be no constriction of the opening when the
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B
Fig. 424. If the cecum lies in normal position in the iliac fossa the terminal ileum is not embarrassed by the position of the isolated segment (A). However, if the cecum lies quite low in the pelvis, angulation of the terminal ileum in the region of the end-to-end anastomosis may result (B). It is sometimes advisable to incise the lateral peritoneal reflexion between the cecum and lateral abdominal wall and to transfer the cecum medial to the isolated segment as indicated in C, thus preventing distortion and angulation of the terminal ileum.
layers of the abdomen are closed. The distal end of the isolated ileal segment is then withdrawn gently through this opening, care being taken not to disrupt any of the various suture lines. As an alternate technique, it is sometimes advisable to deliver the external stoma earlier in the operation if there is any uncertainty regarding the final relationship between the segment and the ureters and the mesenteric suture lines. The external stoma is opened and sutured to the skin as illustrated (Fig. 423). Interrupted 3-0 chromic catgut has been found satisfactory for this purpose, the suture incorporating skin edge, serosa and bowel edge in such a manner as to form a slight eversion of the mucosa. The ileal stoma must ride easily at skin level without tension. It is the aim to obtain immediate primary healing without sloughing or infection. Relationship of Cecum to Segme:nt. The normal relationship between the cecum and ileal segment as it extends to the anterior abdominal wall
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is illustrated in Figure 424, A. However, if the cecum hangs unusually low in the pelvis, it has been found that the terminal ileum may be acutely angulated over the ileal segment (Fig. 424, B). When this situation exists, it has been found advantageous to incise the right lateral peritoneal reflection and to transfer the cecum medial to the segment (Fig. 424, C). No attempt is made to close the right lumbar gutter by suturing the ileal segment to the lateral abdominal peritoneum. POSTOPERATIVE CARE
Patients are given the usual postoperative care for major abdominal surgery. This includes continuous gastric suction by Levin tube, antibiotics, and the necessary fluid and electrolyte supportive therapy. A Rutzen bag is applied to the ileal stoma in the operating room or on the following morning. Urine excretion on the dressing or in the bag should be apparent in the first 12 hours. If the appearance of urine is delayed, the external stoma should be checked to ascertain its adequacy. Catheter drainage of the segments is unsatisfactory because of plugging with mucus. Early postoperative care of the skin around the stoma must be meticulous to prevent excoriation. The nasogastric tube is left in place somewhat longer than usual (four to five days) to prevent any degree of distention until it is certain that the gastrointestinal tract is decompressing per anum or per colostomy. Patients are taught as rapidly as possible to care for the ileostomy stoma and skin and to change the bag. Pyelograms are repeated two weeks after operation. The patients are followed closely after discharge until they are competent and confident in the management of the stoma and bag. Pyelograms and blood chemistries are repeated at six-month intervals for the next year or until it is evident that the functional status of the kidneys and ureters has stabilized, following which studies are made when specifically indicated. REFERENCES 1. Bricker, E. M.: Bladder Substitution after Pelvic Evisceration. S. CLIN. NORTH AMERICA 30: 1511-1521, 1950. 2. Idem: Bladder Subst.itution with Isolated Small Intestinal Segments; Progress Report. Am. Surgeon 18: 654-664, 1952. 3. Idem: Functional Results of Small Intestinal Segments as Bladder Substitutes Following Pelvic Evisceration; Progress Report. Surgery 32: 372-383, 1952. 4. Bricker, E. M. and Eiseman, B.: Bladder Reconstruction from Cecum and Ascending Colon Following Resection of Pelvic Viscera. Ann. Surg. 132: 7784,1950. 5. Bricker, E. M., Butcher, H. R. Jr. and McAfee, C. A.: Late Results of Bladder Substitution with Isolated Ileal Segments. Surg., Gynec. & Obst. 99: 469482,1954. 6. Idem: Results of Pelvic Exenteration. In press. 7. Cordonnier, J. J.: Ureterosigmoid Anastomosis. Surg., Gynec. & Obst. 88: 441446,1949. 8. Eiseman, E. and Bricker, E. M.: Electrolyte Absorption Following Bilateral Uretero-Enterostomy into an Isolated Intestinal Segment. Ann. Surg. 136:761-769,1952.
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9. Hinman, F. and Weyrauch, H. M.: Critical Study of Different Principles of Surgery Which Have Been Used in Uretero-Intestinal Implantation. Tr. Am. A. Genito-urin. Surg. 29: 15-156, 1946. 10. Klinge, F. and Bricker, E. M.: Evacuation of Urine by Ileal Segments in Man. Ann. Surg. 137: 36-40, 1953. 11. Mersheimer, W. L., Kolarsick, A. J. and Kammandel, H.: Method for Construction of Artificial Urinary Bladder by Implantation of Ureters into Completely or PartiaIly Excluded Segments of SmaIl Intestine. BuIl. New York M. CoIl. 13: 71-77, 1950. 12. Mersheimer, W. L., Kolarsick, A. J. and Kammandel, H.: Implantation of Ureters into Completely Isolated Loops of SmaIl Intestine. Proc. Soc. Exper. BioI. & Med. 76: 170-171, 1951. 13. Verhoogen, J. and de Graeuve"A.: La' Cystectomie Totale. Folia Urol. 3: 629, 1909. 100 North Euclid St. Louis 8, Missouri
Substitution for the Urinary Bladder by the Use of Isolated Ileal Segments EUGENE M. BRICKER, M.D., F.A.C.S. *
THE operation of pelvic exenteration has led to the need for a method of substitution for the urinary bladder in the absence of a functioning rectum. Various other methods of solving this problem were tried prior to 1950. 1 • 4 These early attempts were directed at providing an intraabdominal urinary reservoir under some type of voluntary control. The results of these procedures were unsatisfactory in that complete continence was not provided and the operations were too complex to be associated with pelvic exenteration without prolonging the operation unduly, or without resorting to multiple stages. The use of the "wet colostomy" and bilateral skin ureterostomies was not practiced. In April 1950, four patients were subjected to bilateral ureteral transplantation to an isolated small bowel segment fashioned in such a manner as to convey the urine to an external stoma in the right lower quadrant to drain into a glued-on bag. The results of these early trials were so gratifying that the method has been used exclusively since this time for all patients undergoing exenteration of the pelvic viscera (118 operationst) and for a smaller group of patients for whom bladder substitution was done for other reasons (32 operationst). The results of this experience have been reported at various times. 1 • 2. 3, 5 Since the turn of the century the intestinal tract has been used in practically every conceivable way in attempting to substitute for the urinary bladder.9, 13 However, this appears to be the first time that an isolated segment of small intestine was deliberately used as a simple From the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri. * Associate Professor of Clinical Surgery, Washington University School of Medicine; Assistant Surgeon, Barnes and affiliated hospitals; Attending Surgeon, St. Louis City Hospital; Conwltant Surgeon, The Ellis Fischel State Cancer Hospital. t Including operations done by or under the supervision of Dr. Harvey Butcher ~nd Dr. C. Alan McAfee.
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conduit for the urine to an extra-abdominal reservoir. It is of interest that concomitantly with this experience, Mersheimer, Kolarsick and Kammandel were studying the same operation in dogsY' 12 PRELIMINARY CONSIDERATIONS
Operative Mortality
It is difficult to assess the mortality risk of ileal segment bladder substitution since it is most frequently associated with the operation of pelvic exenteration. In a report of the procedure in 1954" in which St. Louis cases were combined with those done by colleagues at the Ellis Fischel State Cancer Hospital in Columbia, Missouri, it appeared that 5 of 15 operative deaths in a group of 106 patients were attributable to the bladder substitution procedure. A recent survey of the St. Louis material 6 indicates that 5 of 16 operative deaths in 118 patients having pelvic exenteration resulted from complications of the bladder substitute. Taking all cases of ileal segment bladder substitution since April 1950 (150 operations), there have been five "bladder" deaths. In the first three years of this experience, there were three "bladder" deaths in 64 operations. In the last three years, there have been two "bladder" deaths in 86 operations. In 32 operations not involving pelvic exenteration, there have been no "bladder" deaths. The reader may make his own interpretation of these figures, but it would appear that the operative risk of ileal segment bladder substitution at the present time is about 3 per cent when all operations are considered. It is slightly more in those patients having pelvic exenteration (two "bladder" deaths in 61 operations in the past three years), and somewhat less in those patients having lesser procedures. COnlplications
Space does not permit a detailed consideration of complications of the procedure. For this, the reader is referred to previous publications. l • 2. 3. 5 The five operative fatalities mentioned above resulted from technical faults with one exception (pyelonephritis). The nonfatal early complications have been of minor consequence. There have been two fatal late complications: (1) bilateral hydronephrosis with death following operative revision, and (2) one death from pyelonephritis. These two late deaths have occurred in a group of approximately 100 patients surviving the operation from six months to six years. It is to be expected that there will be more deaths from late complications as time passes. Pyelonephritis has been no problem clinically except in two or three patients who have grown organisms refractory to antibiotic therapy. The 1954 study" indicated that 12 of 65 patients (20 per cent) had had more than one attack of chills and fever with flank pain. Cachexia from terminal carcinoma was thought to have been a contributing factor in
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part of this group. The recent study of patients subjected to pelvic exenteration revealed 11 of 102 survivors of the operation to be subject to repeated bouts of pyelonephritis. In most instances these episodes have been easily controlled by appropriate antibiotic therapy. At the present writing it appears that the true incidence of clinically evident postoperative pyelonephritis lies between 10 and 20 per cent. The results of this method of bladder substitution as judged by intravenous pyelography have been most gratifying. Eighty-six per cent of all ureters transplanted were normal or showed minimal hydronephrosis six months or more after operation." Sixty-six per cent of all ureters of Grade II to IV hydronephrosis were normal or Grade I six months after operation. The development and progression of hydronephrosis in the late postoperative period has been extremely rare. Hyperchloremia and acidosis have thus far not been recognized as complicating this method of bladder substitution. Basic Principles of the Operation
The features of ileal segment substitution for the urinary bladder that are of importance in producing the results above outlined appear to be the following: 1. The mechanical and technical simplicity of the procedure makes it practical to combine with a major resection without staging. Operating time for isolating the segment, rejoining the bowel, and anastomosing the ureters averages 75 minutes. 2. Isolation of the segment from the fecal stream decreases the chance of ascending infection. 3. The wide open external stoma with the absence of a sphincter mechanism is thought to decrease the chance of back pressure and reflux up the ureters. 4. It has been found that the segments evacuate promptly through peristaltic action and are always in a relatively empty state. 10 As a result, there is no stagnant reservoir of urine within which bacteria can multiply. 5. The method of uretero-intestinal anastomosis by the "mucosa-tomucosa" technique,7 which is aimed at primary healing with a minimum of scar tissue formation, is thought to result in a low incidence of obstruction and consequently in a low incidence of hydronephrosis and pyelonephritis. 6. Although absorption is known to take place through the mucosa of the segments 8 they are so short that the amount of absorption of urinary constituents is of no clinical significance. External Appliance
The operation is based on the fact that it is possible for a patient to wear a water-tight bag glued to the skin as a receptacle for the urine.
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Fig. 416. The ileostomy site should be marked on the skin prior to laparotomy. If the colon and rectum are not to be sacrificed the ureter is located through an incision in the lateral peritoneal reflexion of the sigmoid mesocolon. It is most important that adequate adventitial tissue be left attached to the ureter in order to assure blood supply.
Several such bags are now available and they are all easily managed by the patient. The Rutzen bag is the one most frequently used by the patients represented in this study. It has been found that these appliances are very satisfactory as external urinary reservoirs and cause the patients a minimum of inconvenience. Preoperative Preparation
The intestinal tract is bacteriologically and mechanically prepared for the operation by antibiotics, catharsis, enemas and diet. Sulfasuxidine is given in the usual dose forJour or five days and neomycin for two days
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Fig. 417. The left ureter is passed through the mesentery of the sigmoid colon, posterior to the superior hemorrhoidal vessels. This opening must be adequate and placed in such a manner as to prevent angulation of the ureter. The right ureter is dissected similarly through an appropriately placed peritoneal incision.
before operation. Early in the afternoon of the day before operation, castor oil is given and the patient is limited to a liquid diet for that evening. Late in the evening, a saline enema is administered and this is repeated in the morning an hour or so before the patient is taken to the operating room. With this routine, the bowel is clean and deflated. The other facets of preparation are the same as for any major abdominal operation. If intestinal obstruction is present the entire preparation and plan of attack may have to be altered. TECHNIQUE
Level of Sectioning the Ureters. It is possible to so fashion the ileal segment that the ureters can be anastomosed to it even though they are sectioned quite high above the pelvic brim. However, the optimum level seems to be 2 or 3 cm. below the iliac artery. This level leaves ample ureter for an easy anastomosis and makes unnecessary a deeper dissection into the tumor area. If the operation is one not requiring sacrifice of the rectum and sigmoid colon, the left ureter is dissected through an incision in the lateral peritoneal reflection and transferred medially through the mesosigmoid beneath the superior hemorrhoidal artery (Figs. 416 and 417). This medial transfer of the left ureter must be made
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Fig. 418. The anatomical relationship.:; exiiltin6 after exenteration of the pelvic viscera are illustrated above. Four or 5 cm. of ureter may be mobilized safely if adequate adventitia is included. The appendix is always removed.
through an adequate opening without angulation. In mobilizing the ureter, it is most important that an adequate amount of adventitial tissue be included in order that vascularity be retained. Proximal mobilization should be carried no higher than necessary, 4 to 5 cm. usually being adequate. This amount of mobilization appears perfectly safe if the adventitial blood supply is left intact. It is quite easy to "telescope" the ureter out of its adventitial sheath during manipulation. Such an occurrence must be guarded against since it will jeopardize the vascularity of the ureter. When the bladder substitution is being done in conjunction with pelvic exenteration, the anatomical relationships are as illustrated in Figure 418 with the problem of medial direction of the left ureter being greatly simplified. Appendectomy. The appendix is always removed in order to simplify the evaluation of any subsequent abdominal symptoms. I solation of Intestinal Segment. In most instances, a segment of terminal ileum 6 to 7 inches in length is isolated (Fig. 419, A). The exact level of this segment may be varied to suit the individual circumstances, but usually a segment ending 4 or 5 inches from the cecum has been advantageous. Occasionally a higher segment has been used because of thickness of the abdominal wall, a short mesentery, or for some other reason. There are no measurements that will make this procedure exact.
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Fig. 419. A segment of terminal ileum 6 or 7 inches in length is isolated (A). The end-to-end anastomosis of ileum is made anterior to the segment with 2 layers of fine silk sutures (B). Closure of the mesenteric rent must be done very carefully, with the sutures placed only through peritoneum in order not to jeopardize the blood supply of the anastomosis or the isolated segment (C).
It must depend on the intuition, skill and mechanical ingenuity of the surgeon. The mesenteric incisions must be no longer than necessary and the vascular pedicle caimot be jeopardized. The proximal end of the isolated segment is closed with two inverting rows of 3-0 or 4-0 chromic catgut. End-to-End Anastomosis. As illustrated (Fig. 419, B), the continuity of the bowel is re-established by open end-to-end anatomosis. The exact technique of this anastomosis is inconsequential provided (1) the vascularity of the two ends is not impaired, (2) fine interrupted nonabsorbable suture material is used for both layers, and (3) as little of the bowel wall as possible is inverted in placing the sutures. Running catgut for anastomoses of small bowel tends to produce constriction that can be avoided by the use of interrupted sutures.
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Fig. 420. The approximation of the left ureter to the end of the isolated segment produces a potential "tunnel" which is obliterated by sutures as indicated above. This is done in order to prevent herniation of the small intestine through this potential space. The protected position of the right ureter posterior to the mesentery of the terminal ileum does not present the same problem.
The mesenteric rent may be closed as the next step (Fig. 419, C) or it may be done later. It is of vital importance that the sutures be placed superficially in the peritoneum and that the blood supply of the isolated segment and of the anastomosis not be impaired. It may be preferable to close the rent after the distal end of the segment has been delivered through the abdominal wall if it is feared that distortion and tension may jeopardize the closure. Closure of "Tunnel" Formed by Medial Direction of the Left Ureter. As the left ureter is approximated to the proximal end of the isolated segment, a "tunnel" or window is formed by the ureter, the segment, and the inferior surface of the mesentery of the small intestine (Fig. 420). This space is present whether or not the sigmoid colon has been removed and it must be closed to prevent herniation of the small intestine. The sutures may be placed to fit the individual situation so long as the defect is closed completely and the blood supply of the bowel and segment is not impaired. It is unnecessary to close the window formed by anasto-
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Fig. 421. The left ureter is anastomosed to the ileal segment first, the anastomosis being quite near the blind end of the segment. The first sutures are placed through the adventitia of the ureter and the serosa of the intestine. Excess ureter is then trimmed off.
mosis of the right ureter since it is smaller and lies in a protected position beneath the mesentery, making herniation very unlikely to occur. Uretero-Intestinal Anastomosis. Figure 421 illustrates the approximation of the left ureter to the end of the isolated segment. The right ureter is visible and will in turn be anastomosed quite close to the left (Fig. 422). First, three fine silk sutures are placed through the adventitia of the ureter and the serosa of the bowel, care being taken not to pass the suture into the lumen of the ureter. It is during this manipulation that the ureter must be prevented from telescoping out of its adventitia. Excess ureter is trimmed off with sharp scissors with no attempt'being made to bevel the cut end. Next, an opening is made through the~bowel wall the exact size of the ureter (Fig. 422). If done carefully with short strokes of a pointed knife, the mucosa will pout into the opening. Too large an opening greatly complicates the anastomosis and increases the chance of obstruction being inadvertently produced. The internal row of
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Fig. 422. Fine catgut is used for the "mucosa-to-mucosa" sutures which in actuality include full thickness of ureteral wall, and serosa and mucosa of ileum (A). The anastomosis is facilitated if the opening into the ileum is made no larger than the ureter. The anterior row of catgut sutures can be placed more accurately if the knots are tied outside the lumen (B, C). The second row is completed with fine silk, taking very small bites and inverting a minimum of the ureter (C). The ureteral anastomoses are placed only a centimeter or two apart and are both quite near the blind end of the segment (D).
sutures are now placed by a "mucosa-to-mucosa" technique which in actuality includes full-thickness of ureter and serosa and mucosa of bowel. These sutures must be placed with the greatest care and exactitude. The suture material is 4-0 or 5-0 chromic catgut with an atraumatic needle. A ureter of normal size will require six to eight such sutures as illustrated. It makes little difference whether the knots are placed inside or outside the lumen. The sutures of the anterior row are placed with the knots on the outside since they can be placed more easily and
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Fig. 423. In order to establish anatomical relationships it is sometimes advisable to deliver the external stoma of the ileum earlier in the course of the procedure than here indicated. A button of skin is removed, making the stoma approximately 1 inch in diameter. A standard size ileostomy bag is kept in stock for application to the stoma at the time of operation or soon thereafter.
accurately in this manner. After the internal row of catgut sutures has been completed, the anterior layer of fine silk sutures is inserted between adventitia and serosa. Care is taken to turn in as little ureter as possible and not to penetrate the ureteral lumen. The right ureter is anastomosed immediately adjacent to the left. Both ureters are anastomosed near the blind end of the segment so that kinking of the segment will not occur and the possibility of impaired emptying of the proximal end is prevented. External Stoma. A circular piece of skin 1 inch in diameter is excised from the right lower quadrant at a site previously selected for the application of a Rutzen bag (Figs. 416 and 423). While skin, fascia and peritoneum are held taut, the opening is extended directly through the abdominal wall. It is important that the opening be adequate (a snug two fingers usually) and that there be no constriction of the opening when the
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B
Fig. 424. If the cecum lies in normal position in the iliac fossa the terminal ileum is not embarrassed by the position of the isolated segment (A). However, if the cecum lies quite low in the pelvis, angulation of the terminal ileum in the region of the end-to-end anastomosis may result (B). It is sometimes advisable to incise the lateral peritoneal reflexion between the cecum and lateral abdominal wall and to transfer the cecum medial to the isolated segment as indicated in C, thus preventing distortion and angulation of the terminal ileum.
layers of the abdomen are closed. The distal end of the isolated ileal segment is then withdrawn gently through this opening, care being taken not to disrupt any of the various suture lines. As an alternate technique, it is sometimes advisable to deliver the external stoma earlier in the operation if there is any uncertainty regarding the final relationship between the segment and the ureters and the mesenteric suture lines. The external stoma is opened and sutured to the skin as illustrated (Fig. 423). Interrupted 3-0 chromic catgut has been found satisfactory for this purpose, the suture incorporating skin edge, serosa and bowel edge in such a manner as to form a slight eversion of the mucosa. The ileal stoma must ride easily at skin level without tension. It is the aim to obtain immediate primary healing without sloughing or infection. Relationship of Cecum to Segme:nt. The normal relationship between the cecum and ileal segment as it extends to the anterior abdominal wall
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is illustrated in Figure 424, A. However, if the cecum hangs unusually low in the pelvis, it has been found that the terminal ileum may be acutely angulated over the ileal segment (Fig. 424, B). When this situation exists, it has been found advantageous to incise the right lateral peritoneal reflection and to transfer the cecum medial to the segment (Fig. 424, C). No attempt is made to close the right lumbar gutter by suturing the ileal segment to the lateral abdominal peritoneum. POSTOPERATIVE CARE
Patients are given the usual postoperative care for major abdominal surgery. This includes continuous gastric suction by Levin tube, antibiotics, and the necessary fluid and electrolyte supportive therapy. A Rutzen bag is applied to the ileal stoma in the operating room or on the following morning. Urine excretion on the dressing or in the bag should be apparent in the first 12 hours. If the appearance of urine is delayed, the external stoma should be checked to ascertain its adequacy. Catheter drainage of the segments is unsatisfactory because of plugging with mucus. Early postoperative care of the skin around the stoma must be meticulous to prevent excoriation. The nasogastric tube is left in place somewhat longer than usual (four to five days) to prevent any degree of distention until it is certain that the gastrointestinal tract is decompressing per anum or per colostomy. Patients are taught as rapidly as possible to care for the ileostomy stoma and skin and to change the bag. Pyelograms are repeated two weeks after operation. The patients are followed closely after discharge until they are competent and confident in the management of the stoma and bag. Pyelograms and blood chemistries are repeated at six-month intervals for the next year or until it is evident that the functional status of the kidneys and ureters has stabilized, following which studies are made when specifically indicated. REFERENCES 1. Bricker, E. M.: Bladder Substitution after Pelvic Evisceration. S. CLIN. NORTH AMERICA 30: 1511-1521, 1950. 2. Idem: Bladder Subst.itution with Isolated Small Intestinal Segments; Progress Report. Am. Surgeon 18: 654-664, 1952. 3. Idem: Functional Results of Small Intestinal Segments as Bladder Substitutes Following Pelvic Evisceration; Progress Report. Surgery 32: 372-383, 1952. 4. Bricker, E. M. and Eiseman, B.: Bladder Reconstruction from Cecum and Ascending Colon Following Resection of Pelvic Viscera. Ann. Surg. 132: 7784,1950. 5. Bricker, E. M., Butcher, H. R. Jr. and McAfee, C. A.: Late Results of Bladder Substitution with Isolated Ileal Segments. Surg., Gynec. & Obst. 99: 469482,1954. 6. Idem: Results of Pelvic Exenteration. In press. 7. Cordonnier, J. J.: Ureterosigmoid Anastomosis. Surg., Gynec. & Obst. 88: 441446,1949. 8. Eiseman, E. and Bricker, E. M.: Electrolyte Absorption Following Bilateral Uretero-Enterostomy into an Isolated Intestinal Segment. Ann. Surg. 136:761-769,1952.
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9. Hinman, F. and Weyrauch, H. M.: Critical Study of Different Principles of Surgery Which Have Been Used in Uretero-Intestinal Implantation. Tr. Am. A. Genito-urin. Surg. 29: 15-156, 1946. 10. Klinge, F. and Bricker, E. M.: Evacuation of Urine by Ileal Segments in Man. Ann. Surg. 137: 36-40, 1953. 11. Mersheimer, W. L., Kolarsick, A. J. and Kammandel, H.: Method for Construction of Artificial Urinary Bladder by Implantation of Ureters into Completely or PartiaIly Excluded Segments of SmaIl Intestine. BuIl. New York M. CoIl. 13: 71-77, 1950. 12. Mersheimer, W. L., Kolarsick, A. J. and Kammandel, H.: Implantation of Ureters into Completely Isolated Loops of SmaIl Intestine. Proc. Soc. Exper. BioI. & Med. 76: 170-171, 1951. 13. Verhoogen, J. and de Graeuve"A.: La' Cystectomie Totale. Folia Urol. 3: 629, 1909. 100 North Euclid St. Louis 8, Missouri