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An Original Antireflux Ureteroileal Implantation Technique: Long-Term Followup
0022-534 7/87 /1376-1156$02.00/0 Vol. 137, June
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1987 by The Williams & Wilkins Co.
AN ORIGINAL ANTIREFLUX URETEROILEAL IMPLANTATION TECHNIQUE: LONG-TERM FOLLOWUP A. LE DUC, M. CAMEY AND P. TEILLAC From the Departments of Urology, Saint-Louis Hospital and Foch Hospital, Paris, France
ABSTRACT
An original ureteroileal reimplantation technique in which the ureter is placed in a sulcus created in the ileal mucosa was performed on 51 patients (97 ureters). Followup ranged from 3 to 8 years. As determined by excretory urography, retrograde ileography and urine bacteriology studies the method was effective in 85 per cent of the patients, with a low rate of stenosis (1.5 per cent). The use of this technique, initially limited to patients with the U-shaped continent ileal bladder, has been broadened to include those who undergo various reconstructive or urinary diversion procedures that require ureteroileal reimplantation. The ileum can be used for bladder reconstruction1 or urinary diversion. Attention in this field recently has been focused on the U-shaped continent ileal bladder2 or continent ileal diversion. 3 Such procedures must include an effective ureteroileal reimplantation without reflux. Commonly used ureteroileal reimplantation procedures usually fail to prevent reflux or are associated with a high rate of stenosis when the ureter is reimplanted through a primary submucosal tunnel. To protect the upper urinary tract (primarily in the continent ileal bladder procedure) we developed a new antireflux ureteroileal reimplantation technique based on the observation that a ureter placed in a sulcus created in the ileal mucosa will be covered progressively by growth of the surrounding mucosa. After healing the ureter then is situated in a loose, natural submucosal tunnel. MATERIALS AND METHODS
We reviewed 51 patients who underwent radical cystectomy for bladder cancer between December 1977 and October 1982. There were 45 men and 6 women between 22 and 71 years old (mean age 58 years). Followup ranged from 3 to 8 years. Of the patients 27 men (53 ureters) underwent replacement ileocystoplasty, 23 patients (42 ureters) underwent ureteroileal conduit diversion and 1 (2 ureters) underwent ureterocolonic conduit ili~ersion. Over-all, 97 ureters were reimplanted via the antireflux procedure. The majority of the patients were evaluated preoperatively and postoperatively by total renal function studies, urine bacteriology and excretory urography (IVP), as well as postoperatively by retrograde opacification of the conduit or neo-bladder via loopograms or cystograms before and after voiding. Volumes of contrast medium used were 150 cc for loopograms and 300 cc for cystograms. The pressure was not recorded. The first 3 patients who underwent implantation also were examined by radiocinematography. Studies were performed at least 3 years postoperatively (early 1985). At this time earlier surgical patients underwent the second or third retrograde study. The technique of antireflux ureteroileal reimplantation has been described previously. 4 Exposure of the ileal mucosa is achieved by a 5 cm. incision on the antimesenteric border of the loop or by rolling back the end of the loop to form a 5 cm. cuff. A mucosa! sulcus is made close to the mesenteric border beginning 2 cm. from the end of the ileal segment to provide sufficient tissue to allow for closure of the ileum (fig. 1, A). The Accepted for publication September 15, 1986.
incision should be 3 cm. long through the entire thickness of the mucosa as far as the submucosa. The mucosa! edges of the sulcus are separated gradually, with careful, fine electrocoagulation, bipolar if possible, applied to the bleeding points. The ureter is introduced into the ileal lumen through a sufficiently large orifice created just at the proximal end of the sulcus. The vascular supply of the ureter is placed at the base of the sulcus between the mucosa! edges. The ureter is fixed by interrupted absorbable 4-zero sutures, approximating the edges of the mucosa along the sulcus to the ureteral adventitia. The beveled cut end of the ureter is anchored at the distal end of the sulcus by 3 interrupted 3-zero sutures that incorporate all of the ureteral wall and ileal muscularis mucosa (fig. 1, B). The ureter is not covered completely by ileal mucosa (fig. 1, C). The ureter is anchored outside of the seromuscular layer of the ileum as it enters the reservoir by 3 interrupted 3-zero absorbable sutures. A 7F stent is inserted into the ureter and fixed to the ileal mucosa close to the ureteral end with 4-zero absorbable sutures. The ileum is closed with continuous 3-zero absorbable sutures (fig. 1, D). The margins of the ileal incision can be excised if necessary to obtain a more secure closure. Further operative steps depend on the procedure to be performed. For the U-shaped ileal bladder (Camey) procedure the ureters are reimplanted into each extremity of the loop. The ureteral stents are brought out through the urethra or the ileal ana. anterior abdominal walls.In the fatter case the stents must be fixed to the peritoneum as they exit from the ileum and penetrate the abdominal wall. The right limb of the loop is drained by a multiperforated 20F catheter. For ureteroileal conduit diversion the ureters lie in 2 separate parallel grooves situated on each side of the mesenteric border of the ileum. Ureteral stents are brought out through the stoma and the ileal segment is drained by a 20F multiperforated catheter. In both techniques the ureteral stents and ileal catheter are removed 12 and 15 days postoperatively, respectively. RESULTS
One patient who underwent ureteroileal conduit diversion suffered a fistula at the ureteroileal anastomosis owing to defective drainage of the repair. At operation a drainage device was placed into the loop and the urinary collection was evacuated. Revision of the reimplanatation was not required. Patency was evaluated by an IVP on an outpatient basis in 71 ureters after a minimum followup of 3 years: 57 (80.3 per cent) were unchanged, 6 (8.4 per cent) became smaller and 8 (16.32 per cent) were more dilated with persistent reflux (dem-
1156
ANTIREFLUX URETERGILEAL IJ\1PLANTATION
1157
A
C
FIG. 1. A, exposure of ileal mucosa and formation of mucosa! sulcus close to mesenteric border. B, approximation of ureter into sulcus and fixation to mucosa! edges. C, transverse cross-section of loop shows ureter in sulcus between mucosa! edges. D, closure of ilea! loop with continuous sutures after insertion of ureteral stent.
onstrated by retrograde contrast medium studies). No stenosis was observed in any case (fig. 2). 5 Of 64 ureters studied by retrograde opacification only 12 (19 per cent) had reflux: 6 in patients with a neo-bladder and 6 in those with cutaneous diversion (fig. 3). Urinary tract infection, evaluated by urine bacteriology screening, occurred in 90 per cent of the patients who underwent cutaneous diversion. Of the patients who underwent replacement enterocystoplasty 70 per cent had sterile urine. No episode of pyelonephritis was associated with either type of diversion. Evaluation of total renal function revealed 2 cases of acute tubular necrosis in the early postoperative period owing to septic shock and causing transient renal functional deterioration (the last creatinine level was 150 µmoL/1.). In the longterm total renal function remained unchanged in all patients, including all 4 with preoperative renal failure and without deterioration. DISCUSSION
The essential requirement for a ureteroileal reimplantation is that it must not be stenotic. 5 •6 This requirement is achieved by the majority of ureteroileal reimplantation techniques without an antireflux procedure, since only 9 to 23 per cent of all anastomoses subsequently become stenotic. 6
Antireflux reimplantation via the mucosal sulcus technique seems to be remarkably free of obstructive complications. 7 A recent report on 220 reimplantations has confirmed a low rate of stenosis (1.5 per cent), which may be related to the prevention of local hematoma formation. 8 Furthermore, prompt revascularization from the edges of the mucosal sulcus may have of ischemic stricture, The antireflux a role in the procedure was effective in 85 per cent of 151 ureteroileal reimplantations evaluated retrograde ileography. 8 Endoscopically, the effectiveness this procedure has been proved the growth of the ileal mucosa over the ureter, thus, forming a natural submucosal tunnel. Failure to prevent reflux might be owing to the shortness of the submucosal tunnel. The ideal length appears to be 3 cm. Care must be taken to prevent shortening of the implanted portion of the ureter by strong fixation at the point at which it penetrates into the ileum and at the distal end of the sulcus. Urinary :fistulas do not occur after this type of antireflux reimplantation provided the ileal reservoir is drained correctly and the implanted ureter is catheterized. No case of renal parenchymal infection was observed, which reflects the effectiveness of the antireflux system. 6 Furthermore, owing to the low incidence of positive urine bacteriological tests after enterocystoplasty (25 per cent) chemotherapy may be given postoperatively without the risk of infection,
1158
LE DUC, CAMEY AND TEILLAC
The mucosal sulcus technique for ureteroileal antireflux reimplantation is easy to perform and ensures effective protection of the upper urinary tract. The method is recommended for use with various reconstructive procedures. 9 REFERENCES
1. Couvelaire, R.: Le reservoir ileal de substitution apres la cystecto-
FIG. 2. IVP after ileocystoplasty shows excellent ureteral patency
mie totale chez l'homme. J. d'Urol., 57: 408, 1951. 2. Camey, M. and Le Due, A.: L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13: 114, 1979. 3. Kock, N. G., Nilsson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 4. Le Due, A. and Camey, M.: Un procede d'implantation ureteroileale antireflux dans l'entero-cystoplastie. J. Urol. Nephrol., 85: 449, 1979. 5. Teillac, P.: These. L'implantation uretero-ileale anti-reflux dans les derivations urinaires trans-ileales et les vessies de substitutions. Fae. Med. Paris, 1983. 6. Bricker, E. M.: Current status of urinary diversion. Cancer, 45: 2986, 1980. 7. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Urol., 132: 886, 1984. 8. Le Due, A., Camey, M. and Teillac, P.: Antireflux ureter implantation in an ileal loop. Poster session 3 at annual meeting of American Urological Association, New York, New York, May 18-22, 1986. 9. Lockhart, J. L. and Bejany, D.: The antireflux ureteroileal reimplantation in children and adults. J. Urol., 135: 576, 1986.
FIG. 3. A, retrograde opacification of neo-bladder shows absence of vesicoureteral reflux postoperatively. B, retrograde opacification of ureteroileal conduit shows absence of reflux postoperatively.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1987 by The Williams & Wilkins Co.
AN ORIGINAL ANTIREFLUX URETEROILEAL IMPLANTATION TECHNIQUE: LONG-TERM FOLLOWUP A. LE DUC, M. CAMEY AND P. TEILLAC From the Departments of Urology, Saint-Louis Hospital and Foch Hospital, Paris, France
ABSTRACT
An original ureteroileal reimplantation technique in which the ureter is placed in a sulcus created in the ileal mucosa was performed on 51 patients (97 ureters). Followup ranged from 3 to 8 years. As determined by excretory urography, retrograde ileography and urine bacteriology studies the method was effective in 85 per cent of the patients, with a low rate of stenosis (1.5 per cent). The use of this technique, initially limited to patients with the U-shaped continent ileal bladder, has been broadened to include those who undergo various reconstructive or urinary diversion procedures that require ureteroileal reimplantation. The ileum can be used for bladder reconstruction1 or urinary diversion. Attention in this field recently has been focused on the U-shaped continent ileal bladder2 or continent ileal diversion. 3 Such procedures must include an effective ureteroileal reimplantation without reflux. Commonly used ureteroileal reimplantation procedures usually fail to prevent reflux or are associated with a high rate of stenosis when the ureter is reimplanted through a primary submucosal tunnel. To protect the upper urinary tract (primarily in the continent ileal bladder procedure) we developed a new antireflux ureteroileal reimplantation technique based on the observation that a ureter placed in a sulcus created in the ileal mucosa will be covered progressively by growth of the surrounding mucosa. After healing the ureter then is situated in a loose, natural submucosal tunnel. MATERIALS AND METHODS
We reviewed 51 patients who underwent radical cystectomy for bladder cancer between December 1977 and October 1982. There were 45 men and 6 women between 22 and 71 years old (mean age 58 years). Followup ranged from 3 to 8 years. Of the patients 27 men (53 ureters) underwent replacement ileocystoplasty, 23 patients (42 ureters) underwent ureteroileal conduit diversion and 1 (2 ureters) underwent ureterocolonic conduit ili~ersion. Over-all, 97 ureters were reimplanted via the antireflux procedure. The majority of the patients were evaluated preoperatively and postoperatively by total renal function studies, urine bacteriology and excretory urography (IVP), as well as postoperatively by retrograde opacification of the conduit or neo-bladder via loopograms or cystograms before and after voiding. Volumes of contrast medium used were 150 cc for loopograms and 300 cc for cystograms. The pressure was not recorded. The first 3 patients who underwent implantation also were examined by radiocinematography. Studies were performed at least 3 years postoperatively (early 1985). At this time earlier surgical patients underwent the second or third retrograde study. The technique of antireflux ureteroileal reimplantation has been described previously. 4 Exposure of the ileal mucosa is achieved by a 5 cm. incision on the antimesenteric border of the loop or by rolling back the end of the loop to form a 5 cm. cuff. A mucosa! sulcus is made close to the mesenteric border beginning 2 cm. from the end of the ileal segment to provide sufficient tissue to allow for closure of the ileum (fig. 1, A). The Accepted for publication September 15, 1986.
incision should be 3 cm. long through the entire thickness of the mucosa as far as the submucosa. The mucosa! edges of the sulcus are separated gradually, with careful, fine electrocoagulation, bipolar if possible, applied to the bleeding points. The ureter is introduced into the ileal lumen through a sufficiently large orifice created just at the proximal end of the sulcus. The vascular supply of the ureter is placed at the base of the sulcus between the mucosa! edges. The ureter is fixed by interrupted absorbable 4-zero sutures, approximating the edges of the mucosa along the sulcus to the ureteral adventitia. The beveled cut end of the ureter is anchored at the distal end of the sulcus by 3 interrupted 3-zero sutures that incorporate all of the ureteral wall and ileal muscularis mucosa (fig. 1, B). The ureter is not covered completely by ileal mucosa (fig. 1, C). The ureter is anchored outside of the seromuscular layer of the ileum as it enters the reservoir by 3 interrupted 3-zero absorbable sutures. A 7F stent is inserted into the ureter and fixed to the ileal mucosa close to the ureteral end with 4-zero absorbable sutures. The ileum is closed with continuous 3-zero absorbable sutures (fig. 1, D). The margins of the ileal incision can be excised if necessary to obtain a more secure closure. Further operative steps depend on the procedure to be performed. For the U-shaped ileal bladder (Camey) procedure the ureters are reimplanted into each extremity of the loop. The ureteral stents are brought out through the urethra or the ileal ana. anterior abdominal walls.In the fatter case the stents must be fixed to the peritoneum as they exit from the ileum and penetrate the abdominal wall. The right limb of the loop is drained by a multiperforated 20F catheter. For ureteroileal conduit diversion the ureters lie in 2 separate parallel grooves situated on each side of the mesenteric border of the ileum. Ureteral stents are brought out through the stoma and the ileal segment is drained by a 20F multiperforated catheter. In both techniques the ureteral stents and ileal catheter are removed 12 and 15 days postoperatively, respectively. RESULTS
One patient who underwent ureteroileal conduit diversion suffered a fistula at the ureteroileal anastomosis owing to defective drainage of the repair. At operation a drainage device was placed into the loop and the urinary collection was evacuated. Revision of the reimplanatation was not required. Patency was evaluated by an IVP on an outpatient basis in 71 ureters after a minimum followup of 3 years: 57 (80.3 per cent) were unchanged, 6 (8.4 per cent) became smaller and 8 (16.32 per cent) were more dilated with persistent reflux (dem-
1156
ANTIREFLUX URETERGILEAL IJ\1PLANTATION
1157
A
C
FIG. 1. A, exposure of ileal mucosa and formation of mucosa! sulcus close to mesenteric border. B, approximation of ureter into sulcus and fixation to mucosa! edges. C, transverse cross-section of loop shows ureter in sulcus between mucosa! edges. D, closure of ilea! loop with continuous sutures after insertion of ureteral stent.
onstrated by retrograde contrast medium studies). No stenosis was observed in any case (fig. 2). 5 Of 64 ureters studied by retrograde opacification only 12 (19 per cent) had reflux: 6 in patients with a neo-bladder and 6 in those with cutaneous diversion (fig. 3). Urinary tract infection, evaluated by urine bacteriology screening, occurred in 90 per cent of the patients who underwent cutaneous diversion. Of the patients who underwent replacement enterocystoplasty 70 per cent had sterile urine. No episode of pyelonephritis was associated with either type of diversion. Evaluation of total renal function revealed 2 cases of acute tubular necrosis in the early postoperative period owing to septic shock and causing transient renal functional deterioration (the last creatinine level was 150 µmoL/1.). In the longterm total renal function remained unchanged in all patients, including all 4 with preoperative renal failure and without deterioration. DISCUSSION
The essential requirement for a ureteroileal reimplantation is that it must not be stenotic. 5 •6 This requirement is achieved by the majority of ureteroileal reimplantation techniques without an antireflux procedure, since only 9 to 23 per cent of all anastomoses subsequently become stenotic. 6
Antireflux reimplantation via the mucosal sulcus technique seems to be remarkably free of obstructive complications. 7 A recent report on 220 reimplantations has confirmed a low rate of stenosis (1.5 per cent), which may be related to the prevention of local hematoma formation. 8 Furthermore, prompt revascularization from the edges of the mucosal sulcus may have of ischemic stricture, The antireflux a role in the procedure was effective in 85 per cent of 151 ureteroileal reimplantations evaluated retrograde ileography. 8 Endoscopically, the effectiveness this procedure has been proved the growth of the ileal mucosa over the ureter, thus, forming a natural submucosal tunnel. Failure to prevent reflux might be owing to the shortness of the submucosal tunnel. The ideal length appears to be 3 cm. Care must be taken to prevent shortening of the implanted portion of the ureter by strong fixation at the point at which it penetrates into the ileum and at the distal end of the sulcus. Urinary :fistulas do not occur after this type of antireflux reimplantation provided the ileal reservoir is drained correctly and the implanted ureter is catheterized. No case of renal parenchymal infection was observed, which reflects the effectiveness of the antireflux system. 6 Furthermore, owing to the low incidence of positive urine bacteriological tests after enterocystoplasty (25 per cent) chemotherapy may be given postoperatively without the risk of infection,
1158
LE DUC, CAMEY AND TEILLAC
The mucosal sulcus technique for ureteroileal antireflux reimplantation is easy to perform and ensures effective protection of the upper urinary tract. The method is recommended for use with various reconstructive procedures. 9 REFERENCES
1. Couvelaire, R.: Le reservoir ileal de substitution apres la cystecto-
FIG. 2. IVP after ileocystoplasty shows excellent ureteral patency
mie totale chez l'homme. J. d'Urol., 57: 408, 1951. 2. Camey, M. and Le Due, A.: L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la vessie. Ann. Urol., 13: 114, 1979. 3. Kock, N. G., Nilsson, A. E., Nilsson, L. 0., Norlen, L. J. and Philipson, B. M.: Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J. Urol., 128: 469, 1982. 4. Le Due, A. and Camey, M.: Un procede d'implantation ureteroileale antireflux dans l'entero-cystoplastie. J. Urol. Nephrol., 85: 449, 1979. 5. Teillac, P.: These. L'implantation uretero-ileale anti-reflux dans les derivations urinaires trans-ileales et les vessies de substitutions. Fae. Med. Paris, 1983. 6. Bricker, E. M.: Current status of urinary diversion. Cancer, 45: 2986, 1980. 7. Lilien, 0. M. and Camey, M.: 25-Year experience with replacement of the human bladder (Camey procedure). J. Urol., 132: 886, 1984. 8. Le Due, A., Camey, M. and Teillac, P.: Antireflux ureter implantation in an ileal loop. Poster session 3 at annual meeting of American Urological Association, New York, New York, May 18-22, 1986. 9. Lockhart, J. L. and Bejany, D.: The antireflux ureteroileal reimplantation in children and adults. J. Urol., 135: 576, 1986.
FIG. 3. A, retrograde opacification of neo-bladder shows absence of vesicoureteral reflux postoperatively. B, retrograde opacification of ureteroileal conduit shows absence of reflux postoperatively.