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Urinary Diversion in Children by the Sigmoid Conduit: Its Advantages and Limitations
Pediatric Urology URINARY DIVERSION IN CHILDREN BY THE SIGMOID CONDUIT: ITS ADVANTAGES AND LIMITATIONS PANAYOTIS P. KELALIS
From the Departments of Urology and Pediatrics, Mayo Clinic and J\,!ayo Foundation, Rochester, Minnesota
The ideal bladder substitute providing urinary control but without adverse effects to the kidneys remains elusive. In children with a normal bowel and an efficient anal sphincter, the use of the uninterrupted colon for urinary diversion is a practical proposition and should be the first choice-a statement that is supported by Spence's superb results of ureterosigmoidostomy in children.' Unfortunately, in most instances permanent supravesical diversion in children is undertaken to alleviate complications of neurogenic bladder and associated anorectal dysfunction is
It is universally agreed that for children with dilated ureters that show reasonably active peristalsis, cutaneous ureterostomy is preferable. When the ureters are normal or minimally dilated it is necessary to interpose a piece of intestinal tract to act as a conduit. To this end the ileum has long been used and, indeed, many authors have reported that this is a satisfactory method of permanent supravesical urinary diversion. 2 - 1 However, as experience with the procedure accumulates and as long-term results become available it is becoming clear that, at least in
FIG. 1. Restoration of continuity of bowel and closure of defect in mesocolon so that isolated segment lies transversely in left paracolic gutter.
the rule in these patients, at preservation of the Such urinary diversion should be performed before demonstrable changes in the upper tract become evident. Upper tract deterioration prior to urinary diversion predisposes to stone formation. Accepted for publication May 17, 1974. Read at annual meeting of North Central Section, American Urological Association, Acapulco, Mexico, November 11-18, 1973. 1 Spence, H. M.: Ureterosigmoidostomy for exstrophy of the bladder: results in a personal series of thirty-one cases. Brit. J. Urol., 38: 36, 1966. 666
the ileal conduit has certain inherent risks and disadvantage_s. s- 12 These may be precluded the use of the sigmoid colon. 13 , 14 'Ray, P. and De Domenico, I.: Intestinal conduit urinary diversion in children. Brit. J. Urol., 44: 345, 1972. 3 Livaditis, A.: Cutaneous uretero-ileostomy in children. Acta Paediat. Scand., 54: 131, 1965. ' G. E. and Muecke, E. C.: Evaluation of 80 cases conduits in children: indication, complication and results. J. Urol., Ui9: 1973. 'Retik, A. B., Pedmutter, A. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. ,J. Med., 277: 1967. 'Strnffon, B., Jr. and D.: The ilea! in children. Clin. Quart., 30: 89, 1963.
URINARY DIVERSION IN CHILDREN BY SIGMOID CONDUIT
FIG.
2. Details of tueterosigxnoid anastormosis . A to C, incision, anastomosis and insertion. of stent. _D to
of seromuscular tunnel.
The results of di version with the conduit in 12 chiidren are herein 8 J.: Ilea! conduit in children. Uro!. InL,
S.: Comchiidren. m children. Arch. in
u"""l-''·a~,a of
followed
for
5
years or more are included in this
!PREOPERATIVE PREPARATION
of J.
mechanical bowel A rectal. washouts and a low residue anti.biotic was used. Saline
668
KELALIS
given 2 and 3 days preoperatively and a mixture of saline, hydrogen peroxide and glycerol in equal parts was substituted the day before the operation and given until the returns were clear. During this period the site of the stoma is selected and the collecting device is applied on a trial basis. This is an important test in patients with meningomyelocele and deformity of the spine. OPERATIVE TECHNIQUE
A midline or right paramedian incision is made. Complete mobilization of the sigmoid colon is achieved by severing the lateral adhesion. Children with myelodysplasia usually have a redundant colon which, together with the absence of mesenteric fat, makes isolation of an adequate length of bowel and subsequent reanastomosis easy. A segment of sigmoid supplied by the inferior mesenteric artery is chosen. Careful selection of the loop of bowel will facilitate isoperistaltic placement, a most important consideration. The length of the loop varies from 10 to 15 cm., depending on the age of the patient and the thickness of the abdominal wall. Continuity of the bowel is restored and the defect in the mesocolon is closed so that the isolated segment lies almost transversely in the left paracolic gutter (fig. 1). The proximal end of the conduit is then closed with 2 rows of continuous inverting sutures of fine chromic catgut. Next, the ureters are isolated and severed as close to the bladder wall as possible. The right ureter is transposed retroperitoneally beneath the
arch of the inferior mesenteric artery and, as with the left ureter, any excessive length is discarded. A 1 cm. linear incision is made through all layers of the bowel. Ureterosigmoid anastomosis is carried out between the full thickness of the ureter and mucosa of the bowel. Spatulation of the ureter may be necessary. On each side, 4 or at most 5 chromic 5-zero interrupted sutures are used and the anastomosis is carried over a teflon catheter of appropriate size (usually 8F). Because teflon is non-reactive the catheter must be transfixed in place with a chromic suture through its lumen and tied to the outside of the ureteral wall. Each catheter is brought out via the stoma to drain temporarily into the urinary collecting device (fig. 2, A to C). The anastomosis is buried by inverting seromuscular sutures of 4-zero chromic catgut which are continued proximally for 2 to 3 cm. so as to create a seromuscular tunnel (sleeve) 2 to 3 cm. in length, through which the ureter traverses, thus creating an antireflux type of anastomosis (fig. 2, D to F). The stoma is constructed next. An inverted V incision is made at the pre-arranged site and subcutaneous fat is removed. Sections of all remaining layers of the abdominal wall are excised in a circular manner and the conduit is brought through the defect to the surface. The external oblique aponeurosis is attached to the seromuscular layer of the conduit with several interrupted chromic catgut sutures.Next, the conduit is spatulated at the inferior border and the skin flap is interposed in the incised defect. In order to keep the skin inverted the edge of the skin flap must be anchored to the aponeurosis (fig. 3). The stoma is
FIG. 3. Steps in creation of stoma
URKNARY D.IVERSKON IN CHILDREN BY SIGMOID CONDUIT
Fm. 4. Extraperitonealization of conduit
completed suturing the edges of the conduit to the skin plain catgut. After the abdominal has been re-entered. the leaves of the open retroperitoneum of the left paracolic gutter are used so that the conduit can be totally ex(fig. 4). A cystectomy is not routinely. POSTOPERATIVE COURSE AND COMPLICATIONS
The first ureteral stent is removed 8 days postopand the other is removed 48 hours later. hospital stay has been 14 days. immediate no~t
In 1 patient obstruction at the ureterocolic anastomosis leading to hydronephrosis necessi-
tated revision 4 months later. In retrospect, patient could have been served best cutaneous ureterostomy because of the dilated ureter. Six years later, the same protruding stoma without of the that will necessitate revision sometime future. In another child there was a mild hyperkeratosis around the stoma. Electrolyte homeostasis and renal function remained normal, plasma chloride centrations that remained within the normaI rnnrre in all patients. The rate, as height and weight, has also remained within mal limits. There has been no evidence of stenosis of stoma. Calibration of the stoma has been routinely at 3-month intervals during the first and 6-month intervals thereafter. All 24 renal and ureteral units have remained normal without any evidence of dilatation of the collecting system (fig. 5). Sigmoidograms" are available for all patients and have shown no in 14 units (fig. 6), immediate reflux of total in 4 (in 3 of which there had been no the antireflux technique at the anastomosis) reflux at pressures exceeding 40 cm. water in 6 (fig. 7). Interestingly, 3 of the 4 renal units associ15 Nogrady, M. B., Petitclerc, R and Moir, J. D.: roentgenologic evaluation of supravesical permanent urinary diversion in childhood (ilea! and colonic conduit). J. Canad. Ass. Radio!., 20: 75, J.969.
670
KELALIS
FIG.
5. A, postoperative IVP. Band C, preoperative and postoperative IVP in same patient
FIG. 6. Sigmoidogram without reflux
ated with low pressure reflux have shown minimal retardation of renal growth. Conduit intraluminal pressures have been measured by small spherical latex balloons (5 mm. in diameter) tied over the open end of the polyethylene tube (0.5 mm. inside diameter), which was connected to strain gauge pressure transducers (Statham, model P-23De). The balloon, tube and gauge were water-filled and the fluid column conducted intra-balloon pressures to the transducers. Alterations in the output circuit of the strain gauges were recorded photokymographically. Recordings were obtained for at least 1 hour, with the patients in the supine position and pressures were recorded before, during and after a meal. A typical pattern is noted in figure 8, A. Figure 8, B records the response of the large bowel to nearly complete occlusion of the stoma. DISCUSSION
In this series sigmoid conduit urinary diversion has proved most satisfactory. Admittedly the number of patients is small and, in fairness to the
proponents of the ilea! conduit, it should be stated that for the 2 forms of urinary diversion, accurate and comprehensive comparative statistics that directly compete are lacking. The operation is easy to perform, disturbance of the abdominal contents is minimal and convalescence is surprisingly smooth. Because the conduit is compartmentalized and extraperitonealized the risk of bowel complication is decidedly small. Technically, a short segment of bowel suffices and, as a result of this and probably different reabsorptive qualities of the mucosa of the large bowel, electrolyte disturbances are virtually absent. With cutaneous ureteroileostomy reports on disturbance of homeostasis are at best conflicting and in some series significant. 12 Stomal problems, one of the most troublesome complications of ilea! conduit diversions in children, have been surprisingly few (fig. 9) .1°- 12 Such problems are thought to result from differential growth of the scar tissue around the stoma, necessitating repeated revisions during periods of growth. Because of the large lumen of the colon, a certain degree of contraction at the skin level can occur without significant stenosis and, therefore (despite a single report to the contrary), 16 with minimal elevation of intraluminal pressures. Such is not the case in cutaneous ureteroileostomy, in which noticeable increases in intraluminal pressure can occur even with minimal degrees of stenosis. Interposition of a skin flap appears to break the continuity of the scar tissue at the skin level and in this respect, it may be beneficial in preventin~ stenosis. Although the early results of ureteroileostomy have been encouraging, there is increasing evidence that this form of urinary diversion causes a significant number of unsatisfactory results when "Dybner, R., Jeter, K. and Lattimer, J. K.: Comparison of intraluminal pressures in ilea! and colonic conduits in children. J. Ural., I08: 477, 1972.
DIVERSION !N Cl-HLDREN
SIGiVIOW CONDUIT
A. early.
Sigmoidograms
1
M u 8. A.,
intra.h;JIJ.ina.l pressure
B, conduit intralux:ni.n.al pressure p2.ttern
672
KELALIS
used in children. Critical analysis of results reported in various large series uncovers a significant number of patients (10 to 15 per cent) in whom the condition of the upper urinary tract was normal before operation but deteriorated postoperatively, even in the absence of any evidence of stenosis either at the level of the skin or at the ureteroileal anastomosis. 4 • 9• 12 • 17 The incidence of such deterioration appears to increase with time. This has been variously attributed to ill-fitting appliances or to occlusion of the lumen by the pressure of underpants, skirts or trousers. However, it is more likely to be related to the prolonged hydrodynamic effect of reflux, which is universal in the ileal conduit. In contrast, in the sigmoid conduit an antireflux type of anastomosis between the ureter and the bowel is possible, which protects the kidneys from the ravages of reflux and also prevents access of the infected material of the lumen of the bowel to the kidneys. I believe that this is the singular most important advantage of the procedure. 17 Smith, E. D.: Follow-up studies on 150 ilea! conduits in children. J. Pediat. Surg., 7: 1, 1972.
Acidification of urine with vitamin C appears to have a beneficial effect on the skin around the stoma. SUMMARY
Permanent supravesical urinary diversion with the sigmoid conduit was performed in 12 children. A minimum followup of 5 years showed that the results of this form of urinary diversion are highly satisfactory. Disturbances in homeostasis are virtually absent and stomal difficulties are minimal. The most important advantage of this technique is facilitation of an effective antireflux mechanism provided by ureterocolic anastomosis. Thus, in children, there are many advantages of the sigmoid conduit as compared to the ileal conduit. Probably its only limitation is the anorectal dysfunction so frequently present in those children in whom the procedure is necessary, which makes thorough preoperative preparation of the bowel difficult at times. Dr. Floyd Csir performed the intraluminal pressure studies.
From the Departments of Urology and Pediatrics, Mayo Clinic and J\,!ayo Foundation, Rochester, Minnesota
The ideal bladder substitute providing urinary control but without adverse effects to the kidneys remains elusive. In children with a normal bowel and an efficient anal sphincter, the use of the uninterrupted colon for urinary diversion is a practical proposition and should be the first choice-a statement that is supported by Spence's superb results of ureterosigmoidostomy in children.' Unfortunately, in most instances permanent supravesical diversion in children is undertaken to alleviate complications of neurogenic bladder and associated anorectal dysfunction is
It is universally agreed that for children with dilated ureters that show reasonably active peristalsis, cutaneous ureterostomy is preferable. When the ureters are normal or minimally dilated it is necessary to interpose a piece of intestinal tract to act as a conduit. To this end the ileum has long been used and, indeed, many authors have reported that this is a satisfactory method of permanent supravesical urinary diversion. 2 - 1 However, as experience with the procedure accumulates and as long-term results become available it is becoming clear that, at least in
FIG. 1. Restoration of continuity of bowel and closure of defect in mesocolon so that isolated segment lies transversely in left paracolic gutter.
the rule in these patients, at preservation of the Such urinary diversion should be performed before demonstrable changes in the upper tract become evident. Upper tract deterioration prior to urinary diversion predisposes to stone formation. Accepted for publication May 17, 1974. Read at annual meeting of North Central Section, American Urological Association, Acapulco, Mexico, November 11-18, 1973. 1 Spence, H. M.: Ureterosigmoidostomy for exstrophy of the bladder: results in a personal series of thirty-one cases. Brit. J. Urol., 38: 36, 1966. 666
the ileal conduit has certain inherent risks and disadvantage_s. s- 12 These may be precluded the use of the sigmoid colon. 13 , 14 'Ray, P. and De Domenico, I.: Intestinal conduit urinary diversion in children. Brit. J. Urol., 44: 345, 1972. 3 Livaditis, A.: Cutaneous uretero-ileostomy in children. Acta Paediat. Scand., 54: 131, 1965. ' G. E. and Muecke, E. C.: Evaluation of 80 cases conduits in children: indication, complication and results. J. Urol., Ui9: 1973. 'Retik, A. B., Pedmutter, A. and Gross, R. E.: Cutaneous ureteroileostomy in children. New Engl. ,J. Med., 277: 1967. 'Strnffon, B., Jr. and D.: The ilea! in children. Clin. Quart., 30: 89, 1963.
URINARY DIVERSION IN CHILDREN BY SIGMOID CONDUIT
FIG.
2. Details of tueterosigxnoid anastormosis . A to C, incision, anastomosis and insertion. of stent. _D to
of seromuscular tunnel.
The results of di version with the conduit in 12 chiidren are herein 8 J.: Ilea! conduit in children. Uro!. InL,
S.: Comchiidren. m children. Arch. in
u"""l-''·a~,a of
followed
for
5
years or more are included in this
!PREOPERATIVE PREPARATION
of J.
mechanical bowel A rectal. washouts and a low residue anti.biotic was used. Saline
668
KELALIS
given 2 and 3 days preoperatively and a mixture of saline, hydrogen peroxide and glycerol in equal parts was substituted the day before the operation and given until the returns were clear. During this period the site of the stoma is selected and the collecting device is applied on a trial basis. This is an important test in patients with meningomyelocele and deformity of the spine. OPERATIVE TECHNIQUE
A midline or right paramedian incision is made. Complete mobilization of the sigmoid colon is achieved by severing the lateral adhesion. Children with myelodysplasia usually have a redundant colon which, together with the absence of mesenteric fat, makes isolation of an adequate length of bowel and subsequent reanastomosis easy. A segment of sigmoid supplied by the inferior mesenteric artery is chosen. Careful selection of the loop of bowel will facilitate isoperistaltic placement, a most important consideration. The length of the loop varies from 10 to 15 cm., depending on the age of the patient and the thickness of the abdominal wall. Continuity of the bowel is restored and the defect in the mesocolon is closed so that the isolated segment lies almost transversely in the left paracolic gutter (fig. 1). The proximal end of the conduit is then closed with 2 rows of continuous inverting sutures of fine chromic catgut. Next, the ureters are isolated and severed as close to the bladder wall as possible. The right ureter is transposed retroperitoneally beneath the
arch of the inferior mesenteric artery and, as with the left ureter, any excessive length is discarded. A 1 cm. linear incision is made through all layers of the bowel. Ureterosigmoid anastomosis is carried out between the full thickness of the ureter and mucosa of the bowel. Spatulation of the ureter may be necessary. On each side, 4 or at most 5 chromic 5-zero interrupted sutures are used and the anastomosis is carried over a teflon catheter of appropriate size (usually 8F). Because teflon is non-reactive the catheter must be transfixed in place with a chromic suture through its lumen and tied to the outside of the ureteral wall. Each catheter is brought out via the stoma to drain temporarily into the urinary collecting device (fig. 2, A to C). The anastomosis is buried by inverting seromuscular sutures of 4-zero chromic catgut which are continued proximally for 2 to 3 cm. so as to create a seromuscular tunnel (sleeve) 2 to 3 cm. in length, through which the ureter traverses, thus creating an antireflux type of anastomosis (fig. 2, D to F). The stoma is constructed next. An inverted V incision is made at the pre-arranged site and subcutaneous fat is removed. Sections of all remaining layers of the abdominal wall are excised in a circular manner and the conduit is brought through the defect to the surface. The external oblique aponeurosis is attached to the seromuscular layer of the conduit with several interrupted chromic catgut sutures.Next, the conduit is spatulated at the inferior border and the skin flap is interposed in the incised defect. In order to keep the skin inverted the edge of the skin flap must be anchored to the aponeurosis (fig. 3). The stoma is
FIG. 3. Steps in creation of stoma
URKNARY D.IVERSKON IN CHILDREN BY SIGMOID CONDUIT
Fm. 4. Extraperitonealization of conduit
completed suturing the edges of the conduit to the skin plain catgut. After the abdominal has been re-entered. the leaves of the open retroperitoneum of the left paracolic gutter are used so that the conduit can be totally ex(fig. 4). A cystectomy is not routinely. POSTOPERATIVE COURSE AND COMPLICATIONS
The first ureteral stent is removed 8 days postopand the other is removed 48 hours later. hospital stay has been 14 days. immediate no~t
In 1 patient obstruction at the ureterocolic anastomosis leading to hydronephrosis necessi-
tated revision 4 months later. In retrospect, patient could have been served best cutaneous ureterostomy because of the dilated ureter. Six years later, the same protruding stoma without of the that will necessitate revision sometime future. In another child there was a mild hyperkeratosis around the stoma. Electrolyte homeostasis and renal function remained normal, plasma chloride centrations that remained within the normaI rnnrre in all patients. The rate, as height and weight, has also remained within mal limits. There has been no evidence of stenosis of stoma. Calibration of the stoma has been routinely at 3-month intervals during the first and 6-month intervals thereafter. All 24 renal and ureteral units have remained normal without any evidence of dilatation of the collecting system (fig. 5). Sigmoidograms" are available for all patients and have shown no in 14 units (fig. 6), immediate reflux of total in 4 (in 3 of which there had been no the antireflux technique at the anastomosis) reflux at pressures exceeding 40 cm. water in 6 (fig. 7). Interestingly, 3 of the 4 renal units associ15 Nogrady, M. B., Petitclerc, R and Moir, J. D.: roentgenologic evaluation of supravesical permanent urinary diversion in childhood (ilea! and colonic conduit). J. Canad. Ass. Radio!., 20: 75, J.969.
670
KELALIS
FIG.
5. A, postoperative IVP. Band C, preoperative and postoperative IVP in same patient
FIG. 6. Sigmoidogram without reflux
ated with low pressure reflux have shown minimal retardation of renal growth. Conduit intraluminal pressures have been measured by small spherical latex balloons (5 mm. in diameter) tied over the open end of the polyethylene tube (0.5 mm. inside diameter), which was connected to strain gauge pressure transducers (Statham, model P-23De). The balloon, tube and gauge were water-filled and the fluid column conducted intra-balloon pressures to the transducers. Alterations in the output circuit of the strain gauges were recorded photokymographically. Recordings were obtained for at least 1 hour, with the patients in the supine position and pressures were recorded before, during and after a meal. A typical pattern is noted in figure 8, A. Figure 8, B records the response of the large bowel to nearly complete occlusion of the stoma. DISCUSSION
In this series sigmoid conduit urinary diversion has proved most satisfactory. Admittedly the number of patients is small and, in fairness to the
proponents of the ilea! conduit, it should be stated that for the 2 forms of urinary diversion, accurate and comprehensive comparative statistics that directly compete are lacking. The operation is easy to perform, disturbance of the abdominal contents is minimal and convalescence is surprisingly smooth. Because the conduit is compartmentalized and extraperitonealized the risk of bowel complication is decidedly small. Technically, a short segment of bowel suffices and, as a result of this and probably different reabsorptive qualities of the mucosa of the large bowel, electrolyte disturbances are virtually absent. With cutaneous ureteroileostomy reports on disturbance of homeostasis are at best conflicting and in some series significant. 12 Stomal problems, one of the most troublesome complications of ilea! conduit diversions in children, have been surprisingly few (fig. 9) .1°- 12 Such problems are thought to result from differential growth of the scar tissue around the stoma, necessitating repeated revisions during periods of growth. Because of the large lumen of the colon, a certain degree of contraction at the skin level can occur without significant stenosis and, therefore (despite a single report to the contrary), 16 with minimal elevation of intraluminal pressures. Such is not the case in cutaneous ureteroileostomy, in which noticeable increases in intraluminal pressure can occur even with minimal degrees of stenosis. Interposition of a skin flap appears to break the continuity of the scar tissue at the skin level and in this respect, it may be beneficial in preventin~ stenosis. Although the early results of ureteroileostomy have been encouraging, there is increasing evidence that this form of urinary diversion causes a significant number of unsatisfactory results when "Dybner, R., Jeter, K. and Lattimer, J. K.: Comparison of intraluminal pressures in ilea! and colonic conduits in children. J. Ural., I08: 477, 1972.
DIVERSION !N Cl-HLDREN
SIGiVIOW CONDUIT
A. early.
Sigmoidograms
1
M u 8. A.,
intra.h;JIJ.ina.l pressure
B, conduit intralux:ni.n.al pressure p2.ttern
672
KELALIS
used in children. Critical analysis of results reported in various large series uncovers a significant number of patients (10 to 15 per cent) in whom the condition of the upper urinary tract was normal before operation but deteriorated postoperatively, even in the absence of any evidence of stenosis either at the level of the skin or at the ureteroileal anastomosis. 4 • 9• 12 • 17 The incidence of such deterioration appears to increase with time. This has been variously attributed to ill-fitting appliances or to occlusion of the lumen by the pressure of underpants, skirts or trousers. However, it is more likely to be related to the prolonged hydrodynamic effect of reflux, which is universal in the ileal conduit. In contrast, in the sigmoid conduit an antireflux type of anastomosis between the ureter and the bowel is possible, which protects the kidneys from the ravages of reflux and also prevents access of the infected material of the lumen of the bowel to the kidneys. I believe that this is the singular most important advantage of the procedure. 17 Smith, E. D.: Follow-up studies on 150 ilea! conduits in children. J. Pediat. Surg., 7: 1, 1972.
Acidification of urine with vitamin C appears to have a beneficial effect on the skin around the stoma. SUMMARY
Permanent supravesical urinary diversion with the sigmoid conduit was performed in 12 children. A minimum followup of 5 years showed that the results of this form of urinary diversion are highly satisfactory. Disturbances in homeostasis are virtually absent and stomal difficulties are minimal. The most important advantage of this technique is facilitation of an effective antireflux mechanism provided by ureterocolic anastomosis. Thus, in children, there are many advantages of the sigmoid conduit as compared to the ileal conduit. Probably its only limitation is the anorectal dysfunction so frequently present in those children in whom the procedure is necessary, which makes thorough preoperative preparation of the bowel difficult at times. Dr. Floyd Csir performed the intraluminal pressure studies.