Ureterosigmoidostomy Long-term results

URETEROSIGMOIDOSTOMY” Long-Term JOHN OTTO

B. WEAR,

Results Jr., M.D.

P. BARQUIN,

M.D.

From the Section of Urology, Department University of Wisconsin Medical School, Madison, Wisconsin

of Surgery,

ABSTRACT-Ureterosigmoidostomy was performed on 103 patients between 1928 and 1963 at the University of Wisconsin Medical Center. The indication for urinary diversion was a benign condition in 46 patients and a malignant disease in 57 patients. The surgical (hospital) mortality rate was 10 per centfor the entire series and 3 per cent for procedures performed since 1943. In patients with exstrophy of the bladder, the ten-year survival rate was 82 per cent and the twenty-year survival rate was 61 per cent. The complications of abnormal findings on postoperative pyelogram and of recurrent acute pyelonephritis have been markedly reduced by exclusive use of the Leadbetter combined technique of ureterosigmoidostomy.

Between 1928 and 1963, ureterosigmoidostomy was performed on 103 patients at the University of Wisconsin Medical Center (Table I). There were 46 patients with benign conditions treated with this method of urinary diversion, and on 57 occasions patients with malignant disease were subjected to ureterocolonic anastomosis. Most of these procedures were bilateral, but in 24 patients only unilateral ureterosigmoidostomy was performed (including eight patients who had some other form of urinary diversion on the opposite side and 16 patients who had no diversion on the contralateral side) (Table II). In nephrectomy had some instances, a previous been performed (four out of five patients with tuberculosis of the urinary tract), and occasionally one kidney was found to be nonfunctioning and diversion was not felt to be worthwhile. Not infrequently, bilateral ureterosigmoidostomy was planned as a two-stage procedure only to find at a later date there was significant hydronephrosis or hydroureter on the nonsurgical side necessitating nephrostomy or cutaneous ureterostomy as a second-stage procedure (two to eight weeks after unilateral ureterosigmoidostomy). This was *Editor’s Note: Dr. Wear’s work was completed in 1967 but has never been published in full or in part. We believe his large series of patients with long-term survival following primary ureterosigmoidostomy is particularly relevant today in view of the increasing disillusionment with long-term results of the ileal conduit procedure.

192

more often the case in patients with malignant disease. None of the patients with exstrophy of the bladder had any type of urinary diversion other than ureterosigmoidostomy. Prior to 1951, various techniques of ureterosigmoidostomy were employed. These included the Coffey I, the Mayo modification of the Coffey I, the Coffey II, 1-Sthe Nesbit,4 and the Cordonniers TABLE

Indications for ureterosigmoidostomy on 103 patients (1928 to 1963)

I.

Condition

Number

Benign Exstrophy of bladder Tuberculosis of bladder Interstitial cystitis Post-transurethral resection incontinence Vesicovaginal fistula Bite by hyena

32 5 3 2 3 1

TOTAL

46

Malignant Transitional-cell carcinoma of bladder Adenocarcinoma of bladder Squamous-cell carcinoma bladder Carcinoma of cervix Carcinoma of vulva Carcinoma of ovary TOTAL

UROLOGY

of Patients

48 1

of 1 4 2 1 57

/ MARCH1973

/ VOLUMEI,NUMBER3

procedures. In 1951, the combined procedure, direct mucosa-to-mucosa anastomosis in addition to a submucosal tunnel, as described by Leadbetter was adopted. Thereafter this technique was used exclusively.” Table III illustrates the dichotomy in surgical technique as applied to operative indications. Less than half of the surgical procedures employed the Leadbetter procedure and were performed since 1950. Mortality

and Survival

and 1943. The four deaths in the group with malignant disease occurred in 1931, 1935, 1955, and 1958. Thus seven of the ten deaths were prior to 1936-over 35 years ago. The causes of death* in these ten patients are as follows: 3 3 2 2 1 1 1

Renal failure Acute pyelonephritis Extensive metastatic carcinoma Peritonitis Evisceration Pneumonia Sepsis Shock and convulsions

Rates

Ten patients died within one month after ureterosigmoidostomy. Thus, the overall surgical (hospital) mortality rate was slightly less than 10 per cent in this series. The six deaths in the group with benign diseases occurred in 1928, 1931, 1931, 1934, 1935,

Mortality are shown

statistics in Table

1

derived from the literature IV. Although the general

* More than one cause of death given for some patients.

TABLE II. Type of urinary diversion

Procedure Bilateral ureterosigmoidostomy Unilateral ureterosigmoidostomy and nephrostomy or cutaneous ureterostomy contralateral side Unilateral ureteroSigmoidostomy and no diversion on contralateral side

Benign Conditions

Malignant Disease

38

41

79

2

6

8

6

10

16

46

57

103

on

TOTALS TABLE III. Technique

Conditions

20

12

32

10 26 2

4 24 5

14 50 7

58

45

103

(hospital)

mortality

Authors

Year Reported

Hinman and Weyrauch’ Higgins8 Harvard and ThompsonY Cordonnier and Lage”’ Jacobs and Sterling” Hellstrom” Leadbetter and Clarke’” Hoffman and Spence14 Wear and Barquin

1936 1947 1951 1951 1952 1952 1955 1965 1967

AVERAGES

* Ureterosigmoidostomy

L~ROLOCY

/ MARCH

with or without cystectomy.

1973 / VOLUME

(103 patients) Combined Technique (1951 to 1963)

TOTALS Surgical

of ureterosigmoidostomy

Noncombined Technique (1928 to 1950)

Exstrophy of bladder Benign conditions other than exstrophy Carcinoma of bladder Other malignant disease

TABLE IV.

All Patients

I,NUhlBER3

rate for ureterosigmoidostomy Benign Conditions Number Per Cent 101/490 4141 18/144 013 571492 0137 o/4 O/32 6146 t 186/1,289

20 10 12.5 0 12 0 0 0 13 14

All Procedures

(all techniques) Malignant Number 1031203

. .

Disease* Per Cent SO

. ...

o/5;. 296/1,181 431169 8161

0 25 25 13

4157’ 45411,722

7 26.4

t No surgical (hospital) deaths since 1943. # Overall total 640/3,011 = 21.3 per cent.

193

TABLE V. Surgical and delayed deaths after ureterosigmoidostomy (three- to thirty-eight-year

follow-up)

Benign Condition Number Per Cent

Deaths Cases Surgical

46 6

13

Remaining patients Delayed (known and presumed)

40 4

10

Remaining patients TOTALS

36 10

finding has been a surgical mortality rate twice as high in patients with malignant disease as in patients with benign conditions, this has not been our experience. The delayed mortality rate, known and presumed, however, is quite the opposite. Table V reveals a delayed mortality rate of 75 per cent for patients with malignant disease and only 10 per cent for those with benign conditions. Long-term survival rates in patients with malignant disease do not reflect the mortality rate associated with ureterosigmoidostomy alone. This is particularly true in our series since the philosophy at the University of Wisconsin Medical Center was toward conservative treatment of carcinoma of the bladder. Thus urinary diversion, with or without cystectomy, was most often employed as palliative rather than curative treatment. This explains why the average survival of patients with malignant disease was only six months, and the five-year survival rate was only 4 of 50 or 8 per cent in this group. The longest survivor treated for malignant disease was fifteen years post-cystectomy and bilateral ureterosigmoidostomy for Grade III to IV transitional-cell carcinoma of the bladder. Our long-term survival rates in patients with exstrophy of the bladder treated by ureterosigmoidostomy show a ten-year survival rate of 82 per cent, and a twenty-year survival rate of 61

57

Mayog9’“*

(Per Cent)

- 4 53 40 -

13 44

22

7

75 77

per cent (Table VI). For comparison, the figures show the expected survival of untreated patients with exstrophy of the bladder previously reported by Harvard and Thompson9 as well as the often-quoted figures of Mayo.15 The average known survival rate to date is eleven years per patient in our entire group. Survival statistics for all 32 patients with exstrophy of the bladder are given in Table VII. There were only two delayed (nonsurgical) deaths, and these occurred sixteen and twenty-eight years after the ureterosigmoidostomy had been performed. The ages of these patients were nineteen and thirtyeight years, respectively. Both deaths were secondary to renal causes. Stevens16 collected a number of reports of longterm survivors after ureterosigmoidostomy. These and other cases reported in subsequent articles plus three of our patients make up a total of 19 known members of the “Quarter Century Club” patients who are known to have lived for at least twenty-five years after ureterosigmoidostomy (Table VIII). Complications Hyperchloremic acidosis has long been recognized as one of the common complications of ureterosigmoidostomy.1E-23 The occurrence of this electrolyte abnormality in our series is pre-

TABLE VI. Survival rates for patients with erstrophy Years

Malignant Disease Number Per Cent

Harvard and Thompsor$‘t Number Per Cent

of the bladder

Wear and Barquint Number Per Cent

5 10

5b’

85198 63185

87 74

23127 18122

85 82

15 20

33’

42169 25148

61 52

11/15 8113

73 61

* Expected survival of untreated patients. t Treated

194

with ureterosigmoidostomy.

UROLOGY / MARCH1973 / VOLUMEI, NUMBER3

TABLE VII.

Survival

Case Number

rate of patients

with erstrophy

Year of Surgery

of bladder,

postureterosigmoidostomy

68

1928

Age at Surgery 2

Date Last Seen

48 67 70 74 75 50 82 84 89 72 73 38 46 91

1931 1931 1933 1933 1933 1936 1936 1939 1940 1942 1942 1943 1943 1943

39 2 5 3 10 3 3 6 7 1 1 10 2 16

* * 1940 1966 1961 t 1952 t 1965 1940 1941 1966 1966 1966 1953 *

... ...

94 102 97 66 58 14 3 17 20 4 18 10 31 24 36 26 30

1944 1944 1947 1949 1950 1951 1953 1953 1953 1954 1954 1955 1957 1959 1959 1961 1963

1 1 20 10 1 1 3 36 2 23 38 4 3 4 44 4 5

1965 1965 1950 1951 1965 1966 1965 1965 1966 1966 1965 1965 1966 1966 1966 1966 1966

‘2.1’ 21 3 2 15 15 12 12 13 12 11 10 9 7 7 5 3

Known Survival

*

7 33 28 16 29 1 1 24 24 23 10

* Postoperative death. t Died. TABLE

VIII.

Quarter Century Year of Surgery

Author or Surgeon

Mayat

Harvard and Thompsor? Wear and Barquin Harvard and Thompson9 Stiles* Bangerter” Stevens”’ Hoffman and Spence14 Wear and Barquin Wear and Barquin Allen* Lower17 Allison* Peters* Starr* Falk*

UROLOGY

by Stevens.

/

MARCH 1873

Age at Surgery

1896 1917 1921 1920 1912 1933 1916

Fowler* Mayot Hoffman and Spence’”

“Reported

Club (twenty-five-year-postureterosigmoidostomy)

6

.. .. 7 3 3

. 19’1; 1934 1936 1933

Known Survival (years)

Follow-up (year) 1940 1959 1963 1959 1947 1966 1946

..

‘16

... 3 10

1946 1963 1965 1961

... i&3 1906

/

Nesbit

. .. .

i943 1932

. i937

i&2 tReported by

7

- _~

43.5 42.5 42 39 35 33 30 30 30 29 29 29 28 (died) 28 27 26 26 25 25

(via Culp).

VOLUME I, NUMBER 3

195

TABLE

Complications Disease Group Hyperchloremic Benign Malignant

IX.

Noncombined Technique 1928 to 1950

and

All Procedures

13/29

(45)

16/34

22144 18137

TOTALS

40/81

(47)

12129 17134 29163

(32)

30173 (41) 30/70 (43) 601143 (42)

22127

*Serum chloride of greater than 110 mEq./L. employed. t Parentheses = per cent.

Change

8129 12/33 (49)

20162

17121 516

TOTALS

X.

6115 10119

(41) t (50) (46)

(units)

Clinical acute pyelonephritis Benign Malignant

Preoperative Postoperative

Combined Technique 1951 to 1963

6114 7115

TOTALS

Surgical Period

postureterosigmoidostomy

acidosis*

Abnormal pyelogram Benign Malignant

TABLE

Corn&cations

in pyelogram

8/14 417 (81)

12/21

(57)

and serum carbon dioxide of less than 20 mEq./L.

(units) after ureterosigmoidostomy

27130 16/32

*Net change: 40 per cent worse (noncombined

(90) (50)

3130 16/32

technique),

(10) (50)

and 17 per cent worse (combined

(71) (69)

34/48

(71)

or alkalinizing

for exstrophy

Noncombined Technique” 1928- 1950 Intravenous Pyelogram Normal Abnormal

25135 9/13

medication

of bladder

Combined Technique* 1951-1963 Intravenous Pyelogram Normal Abnormal 21123 17/23

(91) (74)

technique)

2/23 6123

(9) (26)

than preoperative

period.

sented in Table IX. The overall incidence of 46 per cent was not significantly different in the benign and malignant disease groups, and it was not influenced by the technique of ureterosigmoidostomy employed. An abnormal condition was noted on pyelograms subsequent to ureterosigmoidostomy in 42 per cent of the units (one kidney and ureter) studied by intravenous pyelography. There was a considerable difference in the incidence of this complication depending on the technique of ureterosigmoidostomy (Table IX). When the Leadbetter type of combined anastomosis was used, the postoperative pyelogram showed abnormal findings (to some degree, at some time) in 32 per cent. When some other type of operative technique was employed, an abnormal condition was noted on pyelogram in 49 per cent of the cases. Once again there was no significant difference between the patients in the benign and malignant disease groups. In patients with exstrophy of the bladder, we were able to compare the preoperative with the postoperative pyelograms over a prolonged period of time. A significant difference in the

196

magnitude of pyelographic evidence of deterioration of the upper urinary tracts, depending on the technique of ureterosigmoidostomy, was noted (Table X). The pyelograms showed there was deterioration (from normal to abnormal) in 40 per cent of patients subsequent to a noncombined technique of ureterosigmoidostomy. There was only a 17 per cent deterioration noted in the pyelograms of those patients subjected to the Leadbetter surgical procedure. It might be added that a 10 to 20 per cent incidence of a worse result appearing on postoperative pyelograms is not unusual in patients after an “ileal loop” (cutaneous ureteroileostomy). Clinical evidence of acute pyelonephritis was more than a rare occurrence in 71 per cent of our patients after ureterosigmoidostomy, without prophylactic antimicrobial therapy. A much lower incidence of acute pyelonephritis is evident in those patients where a combined technique of ureterocolonic anastomosis was employed, 57 per cent compared with 81 per cent in patients who had a noncombined type of operative procedure (Table IX). The difficulty of comparing the incidence of

postoperative complications obtained from various reports in the literature is illustrated in Table XI. It i.s obvious that there is a wide variation in opinion as to what constitutes significant hyperchloremic acidosis, what pyelographic changes can be present and still rate the patient’s condition as “excellent” or “normal,” and what frequency or magnitude of clinical symptoms and signs represents significant acute pyelonephritis. Indeed, it is amazing that the three reports in Table XII have such comparable data referable to the incidence of these complications after ureterosigmoidostomy using the Leadbetter technique. In view of the debate on the existence and significance of total body potassium depletion, we studied the serum potassium and the red blood cell potassium levels in nine patients. The results show a low potassium level in red blood cells in one patient (75.4 mEq. per liter) and a high value in another patient (120 mEq. per liter). The serum potassium values were within normal limits in all nine patients.

tract between the lumen of the ureter and the lumen of the bowel created by passing sutures through these structures in a thirteen-year-old boy with exstrophy of the bladder. Smith,“8 another Englishman, is credited with the first direct implantation of the ureters into the bowel in man. This consisted of a mucosa-to-mucosa anastomosis performed in 1878 and was subsequently described in detail by Chaput.“” Coffey’-” was among the first to describe a tunnel method of ureterosigmoidostomy, and his techniques were widely used in the early part of this century. StevensI states that Fowler performed a ureterosigmoidostomy on a patient with exstrophy of the bladder in 1896 by using a tunnel and flap-valve technique. The patient is the longest known survivor of ureterosigmoidostomy (Table VIII). An excellent review of variations in surgical technique was published by Hinman and Weyrauch in 1936.7 They noted that more than 60 different methods of ureterosigmoidostomy had been described by more than 50 surgeons. Their summary of the surgical results in 740 patients who had ureterosigmoidostomy revealed a mortality rate of 20 per cent in those with benign conditions and 50 per cent in patients with malignant disease (Table IV). These mortality rates and the high incidence of complications led them

Comment The first surgical ureterocolonic anastomosis in a human being was established over one hundred years ago by Simon. 27 This consisted of a fistulous TABLE XI.

Complications

postureterosigmoidostomy

Author

Year

Hinman and Weyrauch’ Schnittman’” Graves and Buddington’” Ferris and OdellY Harvard and Thompson9 Cordonnier and Lage’” Jacobs and Stirling” Leadbetter and Clarke’” Ridlon’” Hoffman and Spence”’ Wear and Barquin

1936 1948 1950 1950 1951 1951 1952 1955 1963 1965 1967

RANGE

TABLE XII.

Year

Leadbetter and ClarkeI RidlonZG Wear and Barquin

1955 1963 1967

AVERA.GE

~JHOLO~:l’

Hyl,erchloremic Acidosis Number Per Cent

111/141’

.

14/21 ” ’ 811201 6120 40167 7/30 29163 (23-79)

in benign

and malignunt

Abnormal Pyelogram Number Per Cent

134/216. 35174

..

Complications

Author

(all techniques

disease)

Clinical Acute Pyelonel)hritis Number Per Cent 1201395 81108

62 47

30 7

79 67 40 30 60 23 46

50/91

441111’ . 26/60 lo/28 601143 (36-62)

postureterosigmoidostomy

Hyl,erchloremic Acidosis Number Per Cent

”

48169 21148

”

55

70 44

40 43 36 42

3134 17167 6130 34148

.

9 25 20 71

(7-71)

by combined

technique

Abnormal Pyelogram Number Per Cent

Clinical Acute Pyelonephritis Number Per Cent

6120 22140 16134

30 55 47

24167 18138 20162

36 47 32

3134 9/40 12/21

9 23 57

44194

47

621167

37

25195

26

/ LIAHCH 1973 / \‘OLUME I, NUMBEH 3

197

to state, “A study of the literature on ureterointestinal implications . . . leaves one with a feeling of disappointment at the lack of improvement with the advent of newer methods and greater experience.” This general attitude of pessimism toward ureterosigmoidostomy was responsible in large part for the swing toward cutaneous ureteroileostomy after it was described by Bricker3’a31 in the 1950s and subsequently popularized by Cordonnier”” and others.33 Almost simultaneously, Leadbetter6 described his combined technique of ureterosigmoidostomy which became the procedure of choice among urologists who were still performing ureterocolonic urinary diversion. Advantages The advantages of ureterosigmoidostomy as a means of supravesical urinary diversion have been recognized for many years but have become obscured by the enthusiasm for the “ileal loop” procedure. Among the advantages of ureterocolonic anastomosis are the following: 1. Voluntary sphincter control of urination. 2. No abnormal external orifice. 3. No stoma1 complications (prolapse, retraction, or stenosis). 4. No indwelling tubes or catheters. 5. No external collecting device or urine bag. 6. Shorter operating time than required in cutaneous ureteroileostomy. 7. Technically easier operative procedure than cutaneous ureteroileostomy. 8. Can be performed via intraperitoneal or retroperitoneal approach. 9. Can be done in stages, one side at a time. 10. Requires two rather than five suture lines on the bowel and/or ureter. 11. Better acceptance by the patient and his relatives. Complications In view of such an imposing list of advantages, why did so many urologists abandon this procedure in favor of cutaneous ureteroileostomy? The answer, of course, lies in the complications encountered after ureterosigmoidostomy. Let us consider each of these complications separately. Reflux of gas and fecal matter to the kidney. Reflux of gas to the kidney has rarely been reported except after the Nesbit! or Cordonnier5 direct mucosa-to-mucosa anastomosis. With the combined technique of ureterosigmoidostomy, it is difficult to demonstrate reflux with various radiopaque media even utilizing a strong “Val-

198

salva” maneuver. It is obvious that reflux is much more likely to occur with a dilated ureter. Thus we do not consider ureterosigmoidostomy if one or both ureters are significantly dilated. Recurrent acute pyelonephritis. Recurrent episodes of acute pyelonephritis have been reported to occur in less than 25 per cent of cases in recent articles especially when the combined technique of anastomosis is employed (Table XI).13*14*26Presumably, the use of long-term antimicrobial therapy would reduce this figure even further. Chronic pyelonephritis, impaired renal function, hydronephrosis and/or hydroureter, and stricture at anastomotic site. Abnormal findings on pyelograms were found in patients with complications such as impaired renal function, hydronephrosis and/or hydroureter, and stricture at anastomotic site. Worse results were noted in postoperative pyelograms in 17 per cent of patients who had combined-technique ureterosigmoidostomy (Table X). This compares favorably with results reported after cutaneous ureteroileostomy. Uremia or azotemia. Uremia, in many instances, does occur after ureterosigmoidostomy, but it is known to be due to partial reabsorption of urea from the rectosigmoid, it is more likely to be present if there was considerable preoperative impairment of renal function, and uremia per se is of doubtful clinical significance under these circumstances.1g-21 Ureterocolocutaneous fistula. there was one ureterocolocutaneous did not close spontaneously.

In

this series fistula which

Hyperchloremic acidosis. Hyperchloremic acidosis is not influenced by the technique of ureterosigmoidostomy. It is known to be due to the selective reabsorption of chloride from the urine in the colon and is less likely to occur if the preoperative renal function is norma1.20~22*36It can usually be treated effectively by more frequent bowel evacuation, by alkalinizing medication, or (in severe cases) drainage by rectal tube. Potassium depletion. Potassium depletion is considered by Stamey37 to be an inevitable consequence of ureterosigmoidostomy and that it invariably causes progressive renal insufficiency. Others question whether potassium depletion is the cause or the result of impaired renal function.3s-43 Some authors have been unable to demonstrate a potassium deficit, but this has been shown by Ansell, Geist, and Creevy.44 In any event, the condition responds quite readily to potassium supplements and (if necessary) to drainage of urine via a rectal tube.

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VOLUME

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Fecal and urinary incontinence. Fecal and urinary incontinence are seen rarely in young children and almost never in adults. The surgeon must be sure of the existence of a normal external anal sphincter prior to performing ureterosigmoidostomy. It is advisable to check the bulbocavernosis reflex as well as the muscle tone of the anal sphincter to exclude significant neurogenic dysfunction of sacral cord segments 2, 3, and 4 or their motor nerves. Hemorrhagic proctitis. Hemorrhagic proctitis is seen rarely unless radiation therapy has been administered to the pelvic area before or after ureterosigmoidostomy is performed. If radiation therapy is contemplated, another form of urinary diversion should be chosen. It is unfortunate that Leadbetter’s description of the combined-technique ureterosigmoidostomy appeared in the literature at about the same time that Bricker described the technique of cutaneous ureteroileostomy. Many physicians, weary of the complications of ureterosigmoidostomy, abandoned the procedure in favor of cutaneous ureteroileostomy without giving a fair trial to the combined technique of ureterocolonic anastomosis. It will be most interesting to see the results of long-term follow-up studies on cutaneous ureteroileostomy compared with the combined technique of ureterosigmoidostomy. It might be added that Ridlon26 found little difference between the closed combined technique described by Leadbetter and the open transcolonic combined technique of ureterosigmoidostomy described by Goodwin et a1.34 With modern principles of pre- and postoperative care, with excellent general and regional anesthesia, and with antimicrobial drugs and blood transfusions readily available, the surgical mortality rate from this procedure should be less than 5 per cent. Since 1943, we have performed ureterosigmoidostomy on 72 patients including those with benign and malignant disease. Only two patients died within one month after the surgical procedure, yielding a surgical mortality rate of 2.8 per cent. In Table IV you will note that the surgical mortality rate was 0 per cent in several reported series. The long-term survival rate following ureterosigmoidostomy in patients with benign disease is much better than we have been led to believe. This fact was stressed by Stevens in 1941,16 and specific long-term survival rates were first published by Harvard and Thompson in 1951.” When Nesbip5 presented the Ramon Guiteras Lecture titled, “Another Hopeful Look at Uretero-

UROLOGY

/ MARCH 1973 / VOLUME I, NUMBER 3

sigmoid Anastomosis,” before the American Urological Association meeting in Chicago, Illinois, in May, 1960, he stated: These and similar cases with long survival and good health demonstrate that man can indeed adapt to the cloaca1 status in some instances, and would appear to refute the contention that renal deterioration is an inevitable consequence of ureterocolic anastomosis . . , . Many patients can accommodate themselves satisfactorily to cutaneous urinary drainage if survival depends upon this arrangement, but other people will find the cloaca1 status to be a much more acceptable compromise for reasons of aesthetic or social well being, even at the expense of an increased risk of morbidity. We would like to add that we are not sure that the long-term morbidity and mortality rate of ureterosigmoidostomy with the combined technique is any greater than that associated with other methods of supravesical urinary diversion. Perhaps the choice of ureterosigmoidostomy is not such a sacrifice after all. 1300 Madison.

University Wisconsin

Avenue 53706

References 1. COFFEY, R. C.: Transplantation of the ureters into the large intestine, Surg. Cynec. Obst. 47: 593 (1928). 2. IDEM: Bilateral submucous transplantation of ureters into large intestine by tube technic: Clinical report of 25 cases, J.A.M.A. 93: 1529 (1929). of the ureters into the large in3. IDEM: Transplantation testine. Submucous implantation method. Personal studies and experiences, Brit. J. Urol. 3: 353 (1931). 4. NESBIT, R. M.: Ureterosigmoid anastomosis by direct elliptical connection: A preliminary report, J, Urol. 61: 728 (1949). Ureterosigmoid anastomosis, ibid. 5. CORDONNIER, J. J.: 63: 276 (1950). 6. LEADBETTER, W. F.: Consideration of problems iocident to performance of uretero-enterostomy: Report of a technique, ibid. 65: 818 (1951). 7. HINMAN, F., and WEYRAUCH, H. M.: Transplantation of the ureters into the rectosigmoid: A critical study of the different principles of surgery which have been used in uretero-intestinal implantation, Tr. Am. A. Genitourin. Surg. 29: 15 (1936). Transplantation of the ureters into the 8. HIGGINS, C. C.: rectosigmoid for exstrophy of the bladder: Review of 41 cases, J. Urol. 57: 693 (1947). Congenital 9. HARVARD, M., and THOMPSON, G. J.: exstrophy of the urinary bladder: Late results of treatment by the Coffey-Mayo method of uretero-intestinal anastomosis, ibid. 65: 223 (1951). 10. CORDONNIER, J. J., and LAGE, W. J.: An evaluation of ureterosigmoid anastomosis by mucosa-to-mucosa method after two and one-half years’ experience, ibid. 66: 565 (1951). 11. JACOBS, A., and STIRLING, W. B.: The late results of ureterocolic anastomosis, Brit. J. Ural. 24: 259 (1952).

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12. HELLSTROM, J.: Discussion of paper by Jacobs and Stirling at annual meeting of Brit. Assoc. of Urol. Surgeons, London, June 27, 1952, ibid. 24: 305 (1952). 13. LEADBETTER, W. F., and CLARKE, B. G.: Five years experience with uretero-enterostomy by the “combined technique,” J. Urol. 73: 67 (1955). 14. HOFFMAN, W. W., and SPENCE, H. M.: Management of exstrophy of the bladder, South. Med. J. 58: 436 (1965). 15. HIGGINS, C. C.: Transplantation of the ureters into the rectosigmoid in infants, Tr. Am. A. Genitourin. Surg. 36: 267 (1943). 16. STEVENS, A. R.: Longevity following uretero-intestinal anastomosis, J. Urol. 46: 57 (1941). 17. LOWER, W. E.: Late results following transplantation of ureters into the rectosigmoid, Tr. Am. A. Genitourin. Surg. 36: 279 (1943). 18. BOYD, J. D.: Chronic acidosis secondary to ureteral transplantation, Am. J. Dis. Child. 42: 366 (1931). 19. FERRIS, D. O., and ODEL, H. M.: Electrolyte pattern of the blood after bilateral ureterosigmoidostomy, J.A.M.A. 142: 634 (1950). 20. BOYCE, W. H.: The absorption of certain constituents of urine from the large bowel of the experimental animal (dog), J. Urol. 65: 241 (1951). 21. ODEL, H. M., FERRIS, D. O., and PRIESTLEY, J. T.: Further observations on the electrolyte pattern of the blood ibid. 65: 1013 (1951). ’ afterbilateral ureterosigmoidostomy, 22. LAPIDES, J,: Mechanism of electrolyte imbalance following ureterosigmoid transplantation, Surg. Gynec. Obst. 93: 691 (1951). 23. DOROSHOW, H. S.: Electrolyte imbalance following bilateral ureterosigmoidostomy, J. Urol. 65: 831 (1951). 24. SCHNITTMAN, M.: Results of the ureterointestinal anastomosis, New York State J. Med. 48: 882 (1948). 25. GRAVES, R. C., BUDDINGTON, W. T., and THOMPSON, R. S.: Ureterointestinal anastomosis, J. Ural. 63: 261(1950). (1950). 26. RIDLON, H. C.: Ureterosigmoidostomy: A comparison of two techniques, ibid. 89: 167 (1963). 27. SIMON, J.: Ectopia vesicae; operation for directing the orifices of the ureters into the rectum; temporary success, autopsy, Lancet 2: 568 (1852). 28. SMITH, T.: An account of an unsuccessful attempt to treat extroversion of the bladder by a new operation, St. Barth. Hosp. Rep. 15: 29 (1879).

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29. CHAPUT, H.: De I’abouchement des ureters dans I’intestin, Arch. Gen. de med. 173: 5 (1894). 30. BRICKER, E. M.: Bladder substitution after pelvic evisceration, Surg. Clin. North Am. 30: 1511 (1950). 31. BRICKER, E. M.: Functional results of small intestinal segments as bladder substitutes following pelvic evisceration, Surgery 32: 372 (1952). 32. CORDONNIER, J. J.: Urinary diversion utilizing an isolated segment of ileum, J. Urol. 74: 789 (1955). 33. CORDONNIER, J. J., and NICOLAI, C. H.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion, ibid. 83: 834 (1960). 34. GOODWIN, W. E., HARRIS, A. P., KAUFMAN, J. J., and BEAL, J. M.: Open transcolonic ureterointestinal anastomosis: A new approach, Surg. Gynec. Obst. 97: 295 (1953). 35. NESBIT, B. M.: Another hopeful look at ureterosigmoid anastomosis, J, Ural. 84: 691 (1960). 36. CREEVY, C. D., and REISER, M. P.: Observations upon the absorption of urinary constituents after ureterosigmoidostomy: Importance of renal damage, Surg. Gynec. Obst. 95: 589 (1952). 37. STAMEY, T. A.: The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy, Surg. Gynec. Obst. 103: 736 (1956). 38. FOSTER, F. P., DREW, D. W., and WISS, E. J.: Hyperchloremic acidosis and potassium deficiency following total cystectomy and bilateral ureterosigmoidostomy, Lahey Clin. Bull. 6: 231 (1950). 39. DIEFENBACH, W. C., FISK, S. C., and GILSON, S. B.: Hypotassemia following bilateral ureterosigmoidostomy, New England J. Med. 244: 326 (1951). 40. MATERN, D. I.: Hypokalemia accompanying hyperibid. 250: chloremic acidosis after ureterosigmoidostomy, 941 (1954). 41. SKANSE, B., and WIDER, T.: Potassium deficiency syndrome following bilateral ureterosigmoidostomy, J. Urol. 73: 62 (1955). 42. LOUGHLIN, J. F.: Quadriplegia, hypotassemia, and hyperchloremic acidosis after bilateral ureterosigmoidostomy, New England J. Med. 254: 329 (1956). 43. STRAFFON, R. A., and COPPRIDGE, A. J,: Respiratory paralysis and severe potassium depletion after ureterosigmoidostomy, J.A.M.A. 171: 139 (1959). 44. ANSELL, J. S., GEIST, R. W., and CREEVY, C. D.: Estimation of total body potassium in patients with ureterosigmoidostomies, Surg. Cynec. Obst. 112: 322 (1961).

UROLOGY

/ MARCH 1973 / VOLUME I, NUMBER3