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Ureteroureterostomy and Cutaneous Ureterostomy
Vol. 106, November Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY ROBERT BROWN, ROGER BARNES,* GUNNAR WENSELL
AND
MOHAMED ASGHAR
From the Urology Section, School of Medicine, Loma Linda University, and the Department of Urology, White Memorial Medical Center, Los Angeles, California Transureteroureterostomy or ipsilateral ureteroureterostomy may be indicated for diseases or abnormalities of the lower ureter. Cutaneous ureterostomy, with or without transureteroureterostomy, is a method of urinary diversion which may be indicated in some cases. Laboratory evaluation and clinical experience with these procedures are reported herein. REVIEW OF LITERATURE
Transureteroureterostomy was first described by Boari in 1894.1 He and other authors reported that when this procedure is done on dogs there is a high mortality due to leakage of urine through the anastomosis. 2 • 3 However, many patients have undergone transureteroureterostomy with excellent resultii. 4- 9 Accepted for publication December 1970. Read at annual meeting of Western Section, American Urological Association, Phoenix, Arizona, April 12-17, 1970. * Requests for reprints: 1700 Brooklyn AYenue, Los Angeles, California 90033. 1 Boari, A. and Casati, E.: Contributo sperimentale alla plastica delle uretere. Att. delle Aecad. delle sc. mod. e nat. di Ferrara, 68: 149, 1894. 2 Tan, P. Y., Taira, A., Arcilla, C., McCann, W. J. and Madden, J. L.: Cross end-to-side ureteroureterostomy between normal ureters and between the unilateral obstructed and normal ureter. An experimental study. Surg. Forum, 13: 504, 1962. 3 Boyarsky, S., Labay, P. and Lenaghan, D.: Transureteroureterostomy, bifid ureters and ureteral dyskinesia. J. Urol., 99: 156, 1968. 4 Higgins, C. C.: Transuretero-ureteral anastomosis: report of a clinical case. J. Urol., 34: 349, 1935. 6 Anderson, H. V., Hodges, C. V., Behnam, A. M. and Ocker, J. M., Jr.: Transuretero-ureterostomy (contralateral uretero-ureterostomy): experimental and clinical experiences. J. Urol., 83: 593, 1960. 6 Hodges, C. V., Moore, R. J., Lehman, T. H. and Behnam, A. M.: Clinical experiences with transuretero-ureterostomy. J. Urol., 90: 552, 1963. 7 Jacobs, D., Politano, V. A. and Harper, J.M.: Experiences with transureteroureterostomy. J. Urol., 97: 1013, 1967. 8 Smith, I.: Trans-uretero-ureterostomy. Brit. J. Urol., 41: 14, 1969. 9 Weems, W. L.: Combined use of bladder flap and transureteroureterostomy: report of a case. J. Urol., 103: 50, 1970.
Cutaneous ureterostomy experiments have shown that in dogs there is nearly always sloughing of the distal end of the normal ureter when excised at the bladder and dissected upward far enough to implant into the skin. However, when the blood supply of the lower end of the ureter is cut off and the ureteral lumen is obstructed, resulting in ureteral dilatation, the ureter remains viable when cutaneous ureterostomy is done. 10- 13 There are numerous reports of cutaneous ureterostomy done on patients using varying techniques with fair results. 14- 26 Different methods of pre10 Mingledorff, W. E., Rinker, J. R. and Owen, G.: Experimental study of the blood supply of the distal ureter with reference to cutaneous ureterostomy. J. Urol., 92: 424, 1964. 11 DeWeerd, J. H. and Henry, J. D.: Z-plastic ureteroureterostomy. J. Urol., 93: 690, 1965. 12 Blanchard, T. W., Rinker, J. R. and McLendon, R. L.: Cutaneous ureterostomy following blockage of the ureteral vasculature: an experimental study. J. Urol., 96: 39, 1966. 13 Rinker, J. R. and Blanchard, T. W.: Improvement of the circulation of the ureter prior to cutaneous ureterostomy: a clinical study. J. Urol., 96: 44, 1966. 14 De Vries, J. K.: Permanent diversion of urinary stream. J. Urol., 73: 217, 1955. 15 Humphreys, G. A.: Permanent cutaneous ureterostomy; a review of 174 cases. Cancer, 9: 572, 1956. 16 Obrant, K. 0.: Cutaneous ureterostomy with skin tube and plastic cup appliance together with transuretero-ureteral anastomosis. Brit. J. Urol., 29: 135, 1957. 17 Swenson, 0. and Smyth, B. T.: Aperistaltic megaloureter: treatment by bilateral cutaneous ureterostomy using a new technique, preliminary communication. J. Urol., 82: 62, 1959. 18 Chute, R. and Sallade, R. L.: Bilateral sideby-side cutaneous ureterostomy in the midline for urinary diversion. J. Urol., 85: 280, 1961. 19 Lapides, J.: Butterfly cutaneous ureterostomy. J. Urol., 88: 735, 1962. 20 Lloyd, F. A., Cottrell, T. L. C., Cross, R.R. and Calams, J.: High cutaneous ureterostomy. J. Urol., 88: 740, 1962. 21 Young, J. D., Jr. and Powder, J. R.: Flank cutaneous ureterostomy and ureteroureteral cutaneous neostomy. New York J. Med., 62: 2200, 1962. 22 Thompson, I. M. and Ross, G.: Single stoma skin flap interposition cutaneous ureterostomy. Surg., Gynec. & Obst., 115: 363, 1962. 23 Higgins, R. B.: Bilateral transperitoneal umbilical ureterostomy. J. Urol., 92: 289, 1964. 24 Young, J. D. and Aledia, F. T.: Further
658
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
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Fm. 1. Cutaneous transureteroureterostomy. Left ureter is tunneled retroperitoneally and its spatulated end is anastomosed to side of right ureter. Right cutaneous nreterostomy. Skin flap at stoma. venting stenosis of the stoma are used. It was necessary to revise the stoma in a number of cases and to resort to permanent intubation in others. The results of ipsilateral ureterouretemstomy have been good almost without exception when done on patients with duplicated ureters. 21 - 31 Cass and associates have shown that continuous suture is preferable to interrupted suture in ureteral observations on flank ureterostomy and cutaneous transureteroureterostomy. J. Urol., 95: 327, 1966. 25 Malament, M.: The ureteral conduit: cutaneous transuretero-ureterostomy. J. Urol., 101: 162, 1969. 26 Straffon, R. A., Kyle, K. and Corvalan, J.: Techniques of cutaneous ureterostomy and results in 51 patients. J. Urol., 103: 138, 1970. 27 Rothfeld, S. H.: Uretero-ureterostomy: a means of conservation of renal tissue. J. Urol., 84: 60, 1960. 28 Swenson, 0. and Ratner, I. A.: Pyeloureterostomy for treatment of symptomatic ureteral duplications in children. J. Ural., 88: 184, 1962. 29 Buchtel, H. A.: Uretero-ureterostomy. J. Urol., 93: 153, 1965. 30 Diaz-Ball, F. L., Fink, A., Moore, C. A. and Gangai, M. P.: Pyeloureterostomy and ureteroureterostomy: alternative procedures to partial nephrectomy for duplication of the ureter with only one pathological segment. J. Urol., 102: 621, 1969. 31 Gutierrez, J., Chang, C-Y. and Nesbit, R. M.: Ipsilateral uretero-ureterostomy for vesicoureteral reflux in duplicated ureter. J. Urol., 101: 36, 1969.
anastomosis. 32 Fine suture abo is coarser suture. 33
to a
LABORATORY EVALUATIO~
Cutaneous transureteroureterostomy was done on 10 dogs. Both ureter~ were excised at the bladder and 1 was tunneled under the peritoneum and its spatulated end was anastomosed to a longitudinal incision in the other ureter (fig. 1). The lower third of this ureter was then displaced laterally and upwardly through the retroperitoneal space to the site of the cutaneous ureterostomy in the lateral abdominal wall. A circular area of muscle and fascia was excised from the abdominal wall and a wedge-shaped skin flap long enough to reach through the abdominal wall into the end of the ureter was used to prevent stenosis of the ureterocutaneous stoma. The distal end of the ureter was sutured to the skin edges except where the skin flap formed approximately half of the stoma. Continuous sutu.re8 of 5-zero catgut were used. 32 Cass, A. S., Schmaelzle, J. F. and Hinman, F., Jr.: Ureteral anastomosis in the dog comparing continuous sutures with interrupted sutures. Invest. Urol., 6: 94, 1968. 33 Bower, J. 0., Burns, J.C. and Mengle, H. A.: Superiority of very fine catgut in gastrointestinal surgery. Amer. J. Surg., 47: 20, 1940.
660
BROWN AND ASSOCIATES
FIG. 2. Dog sacrificed 4 months after cutaneous transureteroureterostomy. Note mild pyelonephritis but no stenosis of ureteroureterostomy nor of cutaneous ureterostomy. A, kidneys and ureters. B, ureteroureteral and cutaneous anastomosis.
FIG. 3. Cutaneous stoma
The procedure was done in 2 dogs with normal ureters. Urine leaked into the abdominal wall and the dogs died 5 days postoperatively. We then attempted to produce dilated ureters and promote collateral circulation from above 3 weeks prior to the cutaneous transureterostomy. We first electrocoagulated the lower 1 cm. of 6 ureters through a cystotomy opening. Because of sloughing and leakage of urine 2 dogs died. No ureteral dilatation resulted from the electrocoagulation. We then ligated the ureterovesical
junction over a No. 5 ureteral catheter passed into the ureter through a cystotomy opening. The 1 dog in which ligation was done with 4-zero steel surgical wire died of complete occlusion of the ureters. In 5 dogs ligation was done with 2-zero silk. The ureters dilated in all cases and good results were obtained with the cutaneous transureteroureterostomy (figs. 2 and 3). In 1 dog 5-zero interrupted suture was used for anastomosis of the ureter. This dog died of leakage of urine through the anastomosis. Conclusions. Best results with cutaneous transureteroureterostomy are obtained when the ureters are dilated and collateral circulation from above is established. The best method to produce these conditions is to ligate the ureter at the ureterovesical junction over a No. 5 catheter with 2-zero silk. Continuous fine suture is preferable to interrupted suture for the anastomosis. CLINICAL EXPERIENCE
Cutaneous ureterostomy. Cutaneous ureterostomy was done on 16 patients with lower ureteral obstruction. Both ureters were transplanted to the skin in 12 patients, while in 4 patients with only 1 kidney the transplant was unilateral. All but 3 ureters were kept intubated. The cause of obstruction was carcinoma of the bladder, urethra or cervix in 12 patients, bilateral hydrone-
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
Frn. 4. Patient lived 19½ years after intubated cutaneous ureterostomy. Renal calculi 11 years after urinary diversion. phrosis in a pelvic fused kidney in 1, irreducible hydronephrosis in a single kidney in 1, stenosis of the ureteral orifice following uretero-ileal diversion in 1 and bilateral renal tuberculosis in 1. The patient with renal tuberculosis lived for 19 years after the cutaneous ureterostomy. A skin flap was used in the last 3 cases and stomal stenosis did not develop. All patients with intubated ureters had chronic infection with acute exacerbations at intervals and renal calculi developed in 2 cases (fig. 4). Cutaneous transureteroureterostomy. This operation was done to divert the urine in 6 patients who underwent total cystectomy for carcinoma of the bladder at the same time. The technique used was described previously (see fig. 1). There was no operative mortality. Group 1: Good results were obtained in 2 patients who had bilateral dilated ureters and elevated blood urea nitrogen. Preoperative radiation therapy was not given to either of these patients. There were no immediate postoperative complications. Moderate stenosis of the cutaneous stoma developed in 1 case and revision was advised 4 months later but was refused. This patient died 2 years 2 months later, shortly after he had frac-
661
tured a hip. The other patient died of metastatic disease 3 years 5 months after the diversionary procedure. The stoma in this patient functioned well until death. Group 2: Poor results were obtained in 3 patients with normal ureters and in 1 patient with a dilated left ureter who underwent left-to-right anastomosis. Radiation therapy had been given preoperatively in all 4 cases. Immediate complications included sloughing of the terminal ureter, bacteremia and shock, wound dehiscence and extravasation at the site of ureteroureterostomy. Late complications included stomal stricture requiring numerous dilations, incisional hernia, ileocutaneous fistulas and colocutaneous fistulas. It was necessary to revise the stoma in 2 cases: in 1 case uretero-ileal conduit was established 3 months after the cutaneous ureterostomy and in the other case the stoma was reconstructed. These 4 patients are doing well 16, 19, 20 and 24 months postoperatively (fig. 5). Discussion: The better results in group 1 can be attributed to bilateral ureteral dilatation and the lack of preoperative radiation therapy. The results in group 2 with the high incidence of complications make this form of diversion unacceptable when ureters are of normal size. Some compli-
Frn. 5 _ IVP 16 months after cutaneous transureteroureterostomy.
662
BROWN AND ASSOCIATES
Fm. 6. Bilateral ureteral stenosis after transurethral prostatic resection. A, before ureteroureterostomy. B, 2 months after transureteroureterostomy and ureteroneocystostomy.
Fm. 7. Ten years following bilateral ureteroureterostomy. There was reflux to lower segment on each side preoperatively. A, cystogram. B, IVP.
cations in this group were due to preoperative radiation. Transureteroureterostom y. Transureteroureterostomy ,was done in 2 cases. One patient had bilateral ureteral obstruction owing to carcinoma of
the cervix. The lower end of the right ureter was reconstructed with a bladder flap tube and left-toright transureteroureterostomy was done. The ureters remained open for 1 year but extension of the cervical malignancy then closed the lower re-
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
constructed end of the right ureter. Right nephrostomy was done but the patient died of the malignancy 6 months later. The other patient underwent transurethal prostatic resection elsewhere. Bilateral ureterovesical stenosis caused azotemia 4 months later. Bilateral ureteroneocystostomy was unsuccessful, Therefore, right-toleft transureteroureterostomy and left ureteroneocystostomy were done. Two months later an excretory urogram (IVP) showed a normal renal pelvis on each side (fig. 6). Discussion: Transureteroureterostomy is usually successful even though a corrective surgical procedure is done on the lower end of the ureter entering the bladder. I psilateral ureteroureterostomy. This procedure is indicated when there is complete duplication of the collecting system and reflux up 1 ureter only.2 7- 31 In our series, 2 girls less than 1 year old had bilateral complete duplication and reflux into the lower renal pelvis on each side. Ureteroureterostomy was done on both sides at the same time. An incision is made through the posterior peritoneum lateral to the colon which is deflected medially, and the 2 ureters are identified at about mid point between the kidney and the bladder at which place they are easily accessible. The dilated refluxing ureter is divided, the distal segment is excised close to the bladder and the spatulated end of the proximal segment is anastomosed to a
663
longitudinal incision in the normal ureter. A continuous suture 32 of fine catgut, 33 preferably 6-zero chromic, is used to suture each side of the spatulated end of the ureter to the corresponding side of the longitudinal incision in the normal ureter, Discussion: lJ rinary tract infection which had recurred previous to the procedure cleared and has not recurred. The patients are well 10 years and 2 years postoperatively (fig. '7). SUMMARY A"ID CO:\'CLUSIOKS
vVe have found that transureteroureterostomy and ipsilateral ureteroureterostomy are safe procedures. When performed meticulously with fine continuous absorbable suture, there is no stenosis of the anastomosis nor injury to the normal ureter or renal pelvis. Cutaneous urcterostomy usually is successful when the ureters are dilated and when a skin is used to form part of the stoma. Sloughing of the distal ureter and stenosis of the stoma are frequent complications when the ureters are not dilated. Intubated cutaneous ureterostomy is a simple method of urinary diversion and may be indicated for palliation in patients whose prognosis is poor. The results of cutaneous transureterostomy on 10 dogs are given, and our clinical experience with 26 patients having ureteroureterostomy cutaneous ureterostomy is reported.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY ROBERT BROWN, ROGER BARNES,* GUNNAR WENSELL
AND
MOHAMED ASGHAR
From the Urology Section, School of Medicine, Loma Linda University, and the Department of Urology, White Memorial Medical Center, Los Angeles, California Transureteroureterostomy or ipsilateral ureteroureterostomy may be indicated for diseases or abnormalities of the lower ureter. Cutaneous ureterostomy, with or without transureteroureterostomy, is a method of urinary diversion which may be indicated in some cases. Laboratory evaluation and clinical experience with these procedures are reported herein. REVIEW OF LITERATURE
Transureteroureterostomy was first described by Boari in 1894.1 He and other authors reported that when this procedure is done on dogs there is a high mortality due to leakage of urine through the anastomosis. 2 • 3 However, many patients have undergone transureteroureterostomy with excellent resultii. 4- 9 Accepted for publication December 1970. Read at annual meeting of Western Section, American Urological Association, Phoenix, Arizona, April 12-17, 1970. * Requests for reprints: 1700 Brooklyn AYenue, Los Angeles, California 90033. 1 Boari, A. and Casati, E.: Contributo sperimentale alla plastica delle uretere. Att. delle Aecad. delle sc. mod. e nat. di Ferrara, 68: 149, 1894. 2 Tan, P. Y., Taira, A., Arcilla, C., McCann, W. J. and Madden, J. L.: Cross end-to-side ureteroureterostomy between normal ureters and between the unilateral obstructed and normal ureter. An experimental study. Surg. Forum, 13: 504, 1962. 3 Boyarsky, S., Labay, P. and Lenaghan, D.: Transureteroureterostomy, bifid ureters and ureteral dyskinesia. J. Urol., 99: 156, 1968. 4 Higgins, C. C.: Transuretero-ureteral anastomosis: report of a clinical case. J. Urol., 34: 349, 1935. 6 Anderson, H. V., Hodges, C. V., Behnam, A. M. and Ocker, J. M., Jr.: Transuretero-ureterostomy (contralateral uretero-ureterostomy): experimental and clinical experiences. J. Urol., 83: 593, 1960. 6 Hodges, C. V., Moore, R. J., Lehman, T. H. and Behnam, A. M.: Clinical experiences with transuretero-ureterostomy. J. Urol., 90: 552, 1963. 7 Jacobs, D., Politano, V. A. and Harper, J.M.: Experiences with transureteroureterostomy. J. Urol., 97: 1013, 1967. 8 Smith, I.: Trans-uretero-ureterostomy. Brit. J. Urol., 41: 14, 1969. 9 Weems, W. L.: Combined use of bladder flap and transureteroureterostomy: report of a case. J. Urol., 103: 50, 1970.
Cutaneous ureterostomy experiments have shown that in dogs there is nearly always sloughing of the distal end of the normal ureter when excised at the bladder and dissected upward far enough to implant into the skin. However, when the blood supply of the lower end of the ureter is cut off and the ureteral lumen is obstructed, resulting in ureteral dilatation, the ureter remains viable when cutaneous ureterostomy is done. 10- 13 There are numerous reports of cutaneous ureterostomy done on patients using varying techniques with fair results. 14- 26 Different methods of pre10 Mingledorff, W. E., Rinker, J. R. and Owen, G.: Experimental study of the blood supply of the distal ureter with reference to cutaneous ureterostomy. J. Urol., 92: 424, 1964. 11 DeWeerd, J. H. and Henry, J. D.: Z-plastic ureteroureterostomy. J. Urol., 93: 690, 1965. 12 Blanchard, T. W., Rinker, J. R. and McLendon, R. L.: Cutaneous ureterostomy following blockage of the ureteral vasculature: an experimental study. J. Urol., 96: 39, 1966. 13 Rinker, J. R. and Blanchard, T. W.: Improvement of the circulation of the ureter prior to cutaneous ureterostomy: a clinical study. J. Urol., 96: 44, 1966. 14 De Vries, J. K.: Permanent diversion of urinary stream. J. Urol., 73: 217, 1955. 15 Humphreys, G. A.: Permanent cutaneous ureterostomy; a review of 174 cases. Cancer, 9: 572, 1956. 16 Obrant, K. 0.: Cutaneous ureterostomy with skin tube and plastic cup appliance together with transuretero-ureteral anastomosis. Brit. J. Urol., 29: 135, 1957. 17 Swenson, 0. and Smyth, B. T.: Aperistaltic megaloureter: treatment by bilateral cutaneous ureterostomy using a new technique, preliminary communication. J. Urol., 82: 62, 1959. 18 Chute, R. and Sallade, R. L.: Bilateral sideby-side cutaneous ureterostomy in the midline for urinary diversion. J. Urol., 85: 280, 1961. 19 Lapides, J.: Butterfly cutaneous ureterostomy. J. Urol., 88: 735, 1962. 20 Lloyd, F. A., Cottrell, T. L. C., Cross, R.R. and Calams, J.: High cutaneous ureterostomy. J. Urol., 88: 740, 1962. 21 Young, J. D., Jr. and Powder, J. R.: Flank cutaneous ureterostomy and ureteroureteral cutaneous neostomy. New York J. Med., 62: 2200, 1962. 22 Thompson, I. M. and Ross, G.: Single stoma skin flap interposition cutaneous ureterostomy. Surg., Gynec. & Obst., 115: 363, 1962. 23 Higgins, R. B.: Bilateral transperitoneal umbilical ureterostomy. J. Urol., 92: 289, 1964. 24 Young, J. D. and Aledia, F. T.: Further
658
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
r'
;JJ2
II
RI.
659
m
II Urelers
~
l"I Pedicle
3
Excess lrimmed
Ill
RI
Li.
Fm. 1. Cutaneous transureteroureterostomy. Left ureter is tunneled retroperitoneally and its spatulated end is anastomosed to side of right ureter. Right cutaneous nreterostomy. Skin flap at stoma. venting stenosis of the stoma are used. It was necessary to revise the stoma in a number of cases and to resort to permanent intubation in others. The results of ipsilateral ureterouretemstomy have been good almost without exception when done on patients with duplicated ureters. 21 - 31 Cass and associates have shown that continuous suture is preferable to interrupted suture in ureteral observations on flank ureterostomy and cutaneous transureteroureterostomy. J. Urol., 95: 327, 1966. 25 Malament, M.: The ureteral conduit: cutaneous transuretero-ureterostomy. J. Urol., 101: 162, 1969. 26 Straffon, R. A., Kyle, K. and Corvalan, J.: Techniques of cutaneous ureterostomy and results in 51 patients. J. Urol., 103: 138, 1970. 27 Rothfeld, S. H.: Uretero-ureterostomy: a means of conservation of renal tissue. J. Urol., 84: 60, 1960. 28 Swenson, 0. and Ratner, I. A.: Pyeloureterostomy for treatment of symptomatic ureteral duplications in children. J. Ural., 88: 184, 1962. 29 Buchtel, H. A.: Uretero-ureterostomy. J. Urol., 93: 153, 1965. 30 Diaz-Ball, F. L., Fink, A., Moore, C. A. and Gangai, M. P.: Pyeloureterostomy and ureteroureterostomy: alternative procedures to partial nephrectomy for duplication of the ureter with only one pathological segment. J. Urol., 102: 621, 1969. 31 Gutierrez, J., Chang, C-Y. and Nesbit, R. M.: Ipsilateral uretero-ureterostomy for vesicoureteral reflux in duplicated ureter. J. Urol., 101: 36, 1969.
anastomosis. 32 Fine suture abo is coarser suture. 33
to a
LABORATORY EVALUATIO~
Cutaneous transureteroureterostomy was done on 10 dogs. Both ureter~ were excised at the bladder and 1 was tunneled under the peritoneum and its spatulated end was anastomosed to a longitudinal incision in the other ureter (fig. 1). The lower third of this ureter was then displaced laterally and upwardly through the retroperitoneal space to the site of the cutaneous ureterostomy in the lateral abdominal wall. A circular area of muscle and fascia was excised from the abdominal wall and a wedge-shaped skin flap long enough to reach through the abdominal wall into the end of the ureter was used to prevent stenosis of the ureterocutaneous stoma. The distal end of the ureter was sutured to the skin edges except where the skin flap formed approximately half of the stoma. Continuous sutu.re8 of 5-zero catgut were used. 32 Cass, A. S., Schmaelzle, J. F. and Hinman, F., Jr.: Ureteral anastomosis in the dog comparing continuous sutures with interrupted sutures. Invest. Urol., 6: 94, 1968. 33 Bower, J. 0., Burns, J.C. and Mengle, H. A.: Superiority of very fine catgut in gastrointestinal surgery. Amer. J. Surg., 47: 20, 1940.
660
BROWN AND ASSOCIATES
FIG. 2. Dog sacrificed 4 months after cutaneous transureteroureterostomy. Note mild pyelonephritis but no stenosis of ureteroureterostomy nor of cutaneous ureterostomy. A, kidneys and ureters. B, ureteroureteral and cutaneous anastomosis.
FIG. 3. Cutaneous stoma
The procedure was done in 2 dogs with normal ureters. Urine leaked into the abdominal wall and the dogs died 5 days postoperatively. We then attempted to produce dilated ureters and promote collateral circulation from above 3 weeks prior to the cutaneous transureterostomy. We first electrocoagulated the lower 1 cm. of 6 ureters through a cystotomy opening. Because of sloughing and leakage of urine 2 dogs died. No ureteral dilatation resulted from the electrocoagulation. We then ligated the ureterovesical
junction over a No. 5 ureteral catheter passed into the ureter through a cystotomy opening. The 1 dog in which ligation was done with 4-zero steel surgical wire died of complete occlusion of the ureters. In 5 dogs ligation was done with 2-zero silk. The ureters dilated in all cases and good results were obtained with the cutaneous transureteroureterostomy (figs. 2 and 3). In 1 dog 5-zero interrupted suture was used for anastomosis of the ureter. This dog died of leakage of urine through the anastomosis. Conclusions. Best results with cutaneous transureteroureterostomy are obtained when the ureters are dilated and collateral circulation from above is established. The best method to produce these conditions is to ligate the ureter at the ureterovesical junction over a No. 5 catheter with 2-zero silk. Continuous fine suture is preferable to interrupted suture for the anastomosis. CLINICAL EXPERIENCE
Cutaneous ureterostomy. Cutaneous ureterostomy was done on 16 patients with lower ureteral obstruction. Both ureters were transplanted to the skin in 12 patients, while in 4 patients with only 1 kidney the transplant was unilateral. All but 3 ureters were kept intubated. The cause of obstruction was carcinoma of the bladder, urethra or cervix in 12 patients, bilateral hydrone-
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
Frn. 4. Patient lived 19½ years after intubated cutaneous ureterostomy. Renal calculi 11 years after urinary diversion. phrosis in a pelvic fused kidney in 1, irreducible hydronephrosis in a single kidney in 1, stenosis of the ureteral orifice following uretero-ileal diversion in 1 and bilateral renal tuberculosis in 1. The patient with renal tuberculosis lived for 19 years after the cutaneous ureterostomy. A skin flap was used in the last 3 cases and stomal stenosis did not develop. All patients with intubated ureters had chronic infection with acute exacerbations at intervals and renal calculi developed in 2 cases (fig. 4). Cutaneous transureteroureterostomy. This operation was done to divert the urine in 6 patients who underwent total cystectomy for carcinoma of the bladder at the same time. The technique used was described previously (see fig. 1). There was no operative mortality. Group 1: Good results were obtained in 2 patients who had bilateral dilated ureters and elevated blood urea nitrogen. Preoperative radiation therapy was not given to either of these patients. There were no immediate postoperative complications. Moderate stenosis of the cutaneous stoma developed in 1 case and revision was advised 4 months later but was refused. This patient died 2 years 2 months later, shortly after he had frac-
661
tured a hip. The other patient died of metastatic disease 3 years 5 months after the diversionary procedure. The stoma in this patient functioned well until death. Group 2: Poor results were obtained in 3 patients with normal ureters and in 1 patient with a dilated left ureter who underwent left-to-right anastomosis. Radiation therapy had been given preoperatively in all 4 cases. Immediate complications included sloughing of the terminal ureter, bacteremia and shock, wound dehiscence and extravasation at the site of ureteroureterostomy. Late complications included stomal stricture requiring numerous dilations, incisional hernia, ileocutaneous fistulas and colocutaneous fistulas. It was necessary to revise the stoma in 2 cases: in 1 case uretero-ileal conduit was established 3 months after the cutaneous ureterostomy and in the other case the stoma was reconstructed. These 4 patients are doing well 16, 19, 20 and 24 months postoperatively (fig. 5). Discussion: The better results in group 1 can be attributed to bilateral ureteral dilatation and the lack of preoperative radiation therapy. The results in group 2 with the high incidence of complications make this form of diversion unacceptable when ureters are of normal size. Some compli-
Frn. 5 _ IVP 16 months after cutaneous transureteroureterostomy.
662
BROWN AND ASSOCIATES
Fm. 6. Bilateral ureteral stenosis after transurethral prostatic resection. A, before ureteroureterostomy. B, 2 months after transureteroureterostomy and ureteroneocystostomy.
Fm. 7. Ten years following bilateral ureteroureterostomy. There was reflux to lower segment on each side preoperatively. A, cystogram. B, IVP.
cations in this group were due to preoperative radiation. Transureteroureterostom y. Transureteroureterostomy ,was done in 2 cases. One patient had bilateral ureteral obstruction owing to carcinoma of
the cervix. The lower end of the right ureter was reconstructed with a bladder flap tube and left-toright transureteroureterostomy was done. The ureters remained open for 1 year but extension of the cervical malignancy then closed the lower re-
URETEROURETEROSTOMY AND CUTANEOUS URETEROSTOMY
constructed end of the right ureter. Right nephrostomy was done but the patient died of the malignancy 6 months later. The other patient underwent transurethal prostatic resection elsewhere. Bilateral ureterovesical stenosis caused azotemia 4 months later. Bilateral ureteroneocystostomy was unsuccessful, Therefore, right-toleft transureteroureterostomy and left ureteroneocystostomy were done. Two months later an excretory urogram (IVP) showed a normal renal pelvis on each side (fig. 6). Discussion: Transureteroureterostomy is usually successful even though a corrective surgical procedure is done on the lower end of the ureter entering the bladder. I psilateral ureteroureterostomy. This procedure is indicated when there is complete duplication of the collecting system and reflux up 1 ureter only.2 7- 31 In our series, 2 girls less than 1 year old had bilateral complete duplication and reflux into the lower renal pelvis on each side. Ureteroureterostomy was done on both sides at the same time. An incision is made through the posterior peritoneum lateral to the colon which is deflected medially, and the 2 ureters are identified at about mid point between the kidney and the bladder at which place they are easily accessible. The dilated refluxing ureter is divided, the distal segment is excised close to the bladder and the spatulated end of the proximal segment is anastomosed to a
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longitudinal incision in the normal ureter. A continuous suture 32 of fine catgut, 33 preferably 6-zero chromic, is used to suture each side of the spatulated end of the ureter to the corresponding side of the longitudinal incision in the normal ureter, Discussion: lJ rinary tract infection which had recurred previous to the procedure cleared and has not recurred. The patients are well 10 years and 2 years postoperatively (fig. '7). SUMMARY A"ID CO:\'CLUSIOKS
vVe have found that transureteroureterostomy and ipsilateral ureteroureterostomy are safe procedures. When performed meticulously with fine continuous absorbable suture, there is no stenosis of the anastomosis nor injury to the normal ureter or renal pelvis. Cutaneous urcterostomy usually is successful when the ureters are dilated and when a skin is used to form part of the stoma. Sloughing of the distal ureter and stenosis of the stoma are frequent complications when the ureters are not dilated. Intubated cutaneous ureterostomy is a simple method of urinary diversion and may be indicated for palliation in patients whose prognosis is poor. The results of cutaneous transureterostomy on 10 dogs are given, and our clinical experience with 26 patients having ureteroureterostomy cutaneous ureterostomy is reported.