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Antireflux ureteroileal anastomosis Experimental technique
ANTIREFLUX Experimental
URETEROILEAL Technique
EDUARDO
FARCON,
MALCOLM
SCHWARTZ,
FRANCISCO
ANASTOMOSIS*
M.D.
YUVIENCO,
SALAH AL-ASKARI,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, and New York Veterans Administration Medical Center, New York, New York
ABSTRACT -A technique for ureteroileal anastomosis with an antirejux extraluminal seromuscular ureteral tunnel was evaluated in 9 dogs. Evidence will be presented to show that this approach is effective in preventing rejlux while preserving the integrity of the renal units.
The ileal conduit, first described by Seiffert in 1935l and then popularized by Bricker in 1950,2 has been the most widely used method of supravesical urinary diversion. However it has serious long-term problems such as pyelonephritis, hydronephrosis, and calculus formation. 3~4 Since it is widely believed that ureteral reflux of infected urine is a major causative factor in the morbidity and consequent progressive renal failure,5-i0 several antireflux procedures have with varying degrees of been proposed, success. Ii>12 We report an experimental technique of ureteroileal anastomosis utilizing extraluminal seromuscular ureteral tunnel to prevent reflux. Material
and Methods
Ten adult mongrel dogs weighing 15 to 20 Kg. were used for the experiment. A 10 to 12cm. segment of the distal ileum was used to construct the conduit. The conduit was then connected to the dome of the bladder in an isoperistaltic manner. *Supported by the Medical Research Council of New York Veterans Administration Medical Center.
344
The animals were anesthetized with 20 mg./ Kg. of pentobarbital intravenously. The abdominal cavity was entered through a midline incision. The lower third of the ureter was mobilized and transected above the ureterovesical junction. A suitable segment of ileum was then isolated and intestinal continuity was restored with a two-layer intestinal anastomosis. The proximal end of the ileal loop was then closed in two layers using an inner running 3-O chromic suture and an interrupted 3-O silk inverting suture. The ureters were then implanted into the ileal segment, and the distal end of ileal loop was anastomosed to the dome of the urinary bladder in two layers consisting of an inner layer of 3-O chromic catgut Connell suture and an outer layer of 3-O silk Lambert sutures. In 6 of the dogs, both ureters were anastomosed to the ileal segment using four or five interrupted 4-O chromic catgut sutures taking full thickness of spatulated ureteral and ileal wall. The anastomosis was then buried by two or three inverting seromuscular sutures of 4-O chromic catgut applied proximally for 2 to 3 cm., thus constructing an extraluminal seromuscular tunnel through which the ureter
UROLOGY
/ OCTOBER
1979 / VOLUME
XIV, NUMBER 4
traversed and hopefully creating a nonrefluxing, nonobstructive type of anastomosis (Fig. 1). No ureteral stents were used, and the bladder was not drained. In 3 dogs, only one ureter was implanted in a seromuscular tunnel and the other was left alone. All dogs were treated with antibiotics postoperatively consisting of 100 mg. of tetracycline twice daily for five days. One dog died in the immediate postoperative period and was excluded horn the study. Radiographic studies were done under pentobarbital anesthesia six weeks postoperatively. A 14 F Foley catheter was introduced into the bladder, the balloon inflated with 5 ml. of saline, and sodium diatrizoate (Hypaque 50%) instilled into the bladder and conduit under gravity Wing (30 cm. water) to demonstrate the presence or absence of reflux (Fig. 2A). The bladder was then drained, 30 ml. of Hypaque 50% were administered intravenously, and a urogram was obtained (Fig. 2B). The animals were sacrificed following the radiographic studies. At autopsy the conduit, ureters, and kidneys were removed in one unit, and the patency of each ureteroileal anastomosis was assessed. No microscopic or bacteriologic studies were performed. The external and internal gross appearance of the 3-cm. seromuscular tunnel are demonstrated in Figure 3. Results FIGURE 1. Ureteroileal muscular technique.
UROLOGY
/ OCTOBER
1979
anastomosis
/ VOLUME
using sero-
XIV,
NUMBER
The results were evaluated according to the following criteria: (1) efficacy of the ureteroileal
4
345
Gross specimen external appearance of seromuscular tunnel, and (B) showing internal appearance of 3-cm. seromuscular tunnel. FIGURE
3.
(A) demonstrating
anastomosis with extraluminal seromuscular (2) incidence of tunnel to prevent reflux; stricture of the distal ureter; and (3) promptness of renal excretion and degree of dilatation on intravenous pyelography. Cystoileograms revealed reflux in one of fifteen renal units; fourteen renal units exhibited prompt excretion on intravenous urography; one renal unit exhibited Grade II hydronephrosis (this unit was also a refluxing unit). Another renal unit was nonfunctioning, and at autopsy the ureteral meatus was strictured. All other ureteral meatus were patent to a 5 F ureteral catheter. The one renal unit demonstrating dilatation on excretory urography was probably attributable to reflux and not ureteral obstruction. Comment Leadbetter in 195013 reported success in preventing ureterocolic reflux with a technique utilizing both a direct anastomosis as well as a submucosal tunnel. Mathisen in 195314 also reported a successful nonrefluxing ureterocolic anastomosis using a flap of colonic wall to create a ureterocolic nipple. Mogg in 196915 described still another nonrefluxing colon conduit using a direct anastomosis that created a mucosalcovered internal nipple of ureter within the colonic lumen. Recently, Kelalis16 introduced another technique in which a direct anastomosis between the full thickness of the ureter and the
346
mucosa of the colon was followed by inverting seromuscular sutures, to create a 2 to 3-cm. seromuscular tunnel through which the ureter traversed. It is well known that the use of the colonic conduit for supravesical diversion has certain disadvantages, namely, the higher incidence of complications with large-bowel as opposed to small-bowel surgery,” poor suitability for obese patients and those with diverticulitis,” and longer time to perform the operation. Some urologists create antireflux colonic conduits in the young patients requiring supravesical diversion but resort to ileal conduit diversion in the older patients with pelvic malignancy because of the shorter operating time involved, and survival is dictated by the primary disease rather than deterioration of the upper tracts.lg Therefore, if one were able to create a nonrefluxing ureteroileal conduit, the aforementioned disadvantages could be avoided and one would have a technically simpler smallbowel procedure and the means of preventing ascending pyelonephritis. It was to this end that we devised experimentally a technique of nonrefluxing ureteroileal conduit with extraluminal seromuscular ureteral tunnel. Conclusions We have applied a technique of extraluminal seromuscular ureteral tunnelling to the ureteroileal anastomosis. The results indicate successful
UROLOGY
/ OCTOBER 1979 / VOLUMEXIV, NUMBER4
8. Ellis LR, Udall DA, and Hodges CV: Further clinical experience with intestinal segments for urinary diversion, ibid. 105: 354 (1971). 9. Schmidt JD, Hawtrey CE, Flocks RH, and Culp DA: Complications, results and problems of ileal conduit diversions, ibid. 169: 210 (1973). 10. Delgado GE, and Muecke EC: Evaluation of 89 cases of ileal conduits: indication, complications and results, ibid. 109: 311 (1973). 11. Mount BM, Susset JG, Campbell J, and Mackinnon KJ: Ureteral implantation into ileal conduits, ibid. 100: 605 (1968). 12. Pond HS, and Texter JH Jr: Trigonal-ileal anastomosis: animal studies and preliminary clinical results, ibid. 105: 654 (1971). 13. Leadbetter WF: Consideration of problems incident to performance of uretero-enterostomy: report of a technique, Trans. Am. Assoc. Genitourin. Surg. 42: 39 (1950). 14. Mathisen W: A new method for uretero-intestinal anastomosis, Surg. Gynecol. Obstet. 96: 255 (1953). 15. Mogg RA: The results of urinary diversion using the cofonic conduit, Br. J. Urol. 41: 434 (1969). 16. Kelalis PP: Urinary diversion in children by the sigmoid conduit: its advantages and limitations, J. Ural. 112: 666 (1974). 17. Alpert PF, and Tanagho EA: Experimental and clinical studies of mflux and ascending infection, Invest. Ural. 11: 336 (1974). 18. Williams DI: Urinary diversion by sigmoid conduit, in: Current Controversies in Urologic Management, 1st ed., Philadelphia, W. B. Saunders Company, 1972, p. 294. 19. Morales P: Personal communication, 1977.
nonobstructive antireflux mechanisms at sixweek follow-ups. The technique compared with the use of nonrefluxing colon conduit is technically simpler, less time-consuming, adaptable to obese patients, and not contraindicated by diverticular disease. New York, New York 10016 (DR. FARCON) References 1. Seiffert L: Die “Darm-Siphonblase,” Arch. Klin Chir. 183: 569 (1935). 2. Bricker EM: Bladder substitution after pelvic evisceration, Surg. Clin. North. Am. 30: 1511 (1950). 3. Guinan PD, et al: The bacteriology of deal conduit urine in man, Surg. Gynecol. Obstet. 134: 78 (1972). 4. Minton JP, et al: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection, ibid. 119: 541 (1964). 5. Bricker EM, Butcher HR, and McAfee CA: Reappraisal of ileal segment substitution for the urinary bladder, Surgery 42: 581 (1957). 6. Engel RM: Complications of bilateral ureteroileocutaneous urinary diversion: a review of 200 cases, J. Ural. 101: 508 (1969). 7. Harbach LB, et al: Real loop cutaneous urinary diversion: a critical review, ibid. 105: 511 (1971).
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4
347
URETEROILEAL Technique
EDUARDO
FARCON,
MALCOLM
SCHWARTZ,
FRANCISCO
ANASTOMOSIS*
M.D.
YUVIENCO,
SALAH AL-ASKARI,
M.D. M.D.
M.D.
From the Department of Urology, New York University Medical Center, and New York Veterans Administration Medical Center, New York, New York
ABSTRACT -A technique for ureteroileal anastomosis with an antirejux extraluminal seromuscular ureteral tunnel was evaluated in 9 dogs. Evidence will be presented to show that this approach is effective in preventing rejlux while preserving the integrity of the renal units.
The ileal conduit, first described by Seiffert in 1935l and then popularized by Bricker in 1950,2 has been the most widely used method of supravesical urinary diversion. However it has serious long-term problems such as pyelonephritis, hydronephrosis, and calculus formation. 3~4 Since it is widely believed that ureteral reflux of infected urine is a major causative factor in the morbidity and consequent progressive renal failure,5-i0 several antireflux procedures have with varying degrees of been proposed, success. Ii>12 We report an experimental technique of ureteroileal anastomosis utilizing extraluminal seromuscular ureteral tunnel to prevent reflux. Material
and Methods
Ten adult mongrel dogs weighing 15 to 20 Kg. were used for the experiment. A 10 to 12cm. segment of the distal ileum was used to construct the conduit. The conduit was then connected to the dome of the bladder in an isoperistaltic manner. *Supported by the Medical Research Council of New York Veterans Administration Medical Center.
344
The animals were anesthetized with 20 mg./ Kg. of pentobarbital intravenously. The abdominal cavity was entered through a midline incision. The lower third of the ureter was mobilized and transected above the ureterovesical junction. A suitable segment of ileum was then isolated and intestinal continuity was restored with a two-layer intestinal anastomosis. The proximal end of the ileal loop was then closed in two layers using an inner running 3-O chromic suture and an interrupted 3-O silk inverting suture. The ureters were then implanted into the ileal segment, and the distal end of ileal loop was anastomosed to the dome of the urinary bladder in two layers consisting of an inner layer of 3-O chromic catgut Connell suture and an outer layer of 3-O silk Lambert sutures. In 6 of the dogs, both ureters were anastomosed to the ileal segment using four or five interrupted 4-O chromic catgut sutures taking full thickness of spatulated ureteral and ileal wall. The anastomosis was then buried by two or three inverting seromuscular sutures of 4-O chromic catgut applied proximally for 2 to 3 cm., thus constructing an extraluminal seromuscular tunnel through which the ureter
UROLOGY
/ OCTOBER
1979 / VOLUME
XIV, NUMBER 4
traversed and hopefully creating a nonrefluxing, nonobstructive type of anastomosis (Fig. 1). No ureteral stents were used, and the bladder was not drained. In 3 dogs, only one ureter was implanted in a seromuscular tunnel and the other was left alone. All dogs were treated with antibiotics postoperatively consisting of 100 mg. of tetracycline twice daily for five days. One dog died in the immediate postoperative period and was excluded horn the study. Radiographic studies were done under pentobarbital anesthesia six weeks postoperatively. A 14 F Foley catheter was introduced into the bladder, the balloon inflated with 5 ml. of saline, and sodium diatrizoate (Hypaque 50%) instilled into the bladder and conduit under gravity Wing (30 cm. water) to demonstrate the presence or absence of reflux (Fig. 2A). The bladder was then drained, 30 ml. of Hypaque 50% were administered intravenously, and a urogram was obtained (Fig. 2B). The animals were sacrificed following the radiographic studies. At autopsy the conduit, ureters, and kidneys were removed in one unit, and the patency of each ureteroileal anastomosis was assessed. No microscopic or bacteriologic studies were performed. The external and internal gross appearance of the 3-cm. seromuscular tunnel are demonstrated in Figure 3. Results FIGURE 1. Ureteroileal muscular technique.
UROLOGY
/ OCTOBER
1979
anastomosis
/ VOLUME
using sero-
XIV,
NUMBER
The results were evaluated according to the following criteria: (1) efficacy of the ureteroileal
4
345
Gross specimen external appearance of seromuscular tunnel, and (B) showing internal appearance of 3-cm. seromuscular tunnel. FIGURE
3.
(A) demonstrating
anastomosis with extraluminal seromuscular (2) incidence of tunnel to prevent reflux; stricture of the distal ureter; and (3) promptness of renal excretion and degree of dilatation on intravenous pyelography. Cystoileograms revealed reflux in one of fifteen renal units; fourteen renal units exhibited prompt excretion on intravenous urography; one renal unit exhibited Grade II hydronephrosis (this unit was also a refluxing unit). Another renal unit was nonfunctioning, and at autopsy the ureteral meatus was strictured. All other ureteral meatus were patent to a 5 F ureteral catheter. The one renal unit demonstrating dilatation on excretory urography was probably attributable to reflux and not ureteral obstruction. Comment Leadbetter in 195013 reported success in preventing ureterocolic reflux with a technique utilizing both a direct anastomosis as well as a submucosal tunnel. Mathisen in 195314 also reported a successful nonrefluxing ureterocolic anastomosis using a flap of colonic wall to create a ureterocolic nipple. Mogg in 196915 described still another nonrefluxing colon conduit using a direct anastomosis that created a mucosalcovered internal nipple of ureter within the colonic lumen. Recently, Kelalis16 introduced another technique in which a direct anastomosis between the full thickness of the ureter and the
346
mucosa of the colon was followed by inverting seromuscular sutures, to create a 2 to 3-cm. seromuscular tunnel through which the ureter traversed. It is well known that the use of the colonic conduit for supravesical diversion has certain disadvantages, namely, the higher incidence of complications with large-bowel as opposed to small-bowel surgery,” poor suitability for obese patients and those with diverticulitis,” and longer time to perform the operation. Some urologists create antireflux colonic conduits in the young patients requiring supravesical diversion but resort to ileal conduit diversion in the older patients with pelvic malignancy because of the shorter operating time involved, and survival is dictated by the primary disease rather than deterioration of the upper tracts.lg Therefore, if one were able to create a nonrefluxing ureteroileal conduit, the aforementioned disadvantages could be avoided and one would have a technically simpler smallbowel procedure and the means of preventing ascending pyelonephritis. It was to this end that we devised experimentally a technique of nonrefluxing ureteroileal conduit with extraluminal seromuscular ureteral tunnel. Conclusions We have applied a technique of extraluminal seromuscular ureteral tunnelling to the ureteroileal anastomosis. The results indicate successful
UROLOGY
/ OCTOBER 1979 / VOLUMEXIV, NUMBER4
8. Ellis LR, Udall DA, and Hodges CV: Further clinical experience with intestinal segments for urinary diversion, ibid. 105: 354 (1971). 9. Schmidt JD, Hawtrey CE, Flocks RH, and Culp DA: Complications, results and problems of ileal conduit diversions, ibid. 169: 210 (1973). 10. Delgado GE, and Muecke EC: Evaluation of 89 cases of ileal conduits: indication, complications and results, ibid. 109: 311 (1973). 11. Mount BM, Susset JG, Campbell J, and Mackinnon KJ: Ureteral implantation into ileal conduits, ibid. 100: 605 (1968). 12. Pond HS, and Texter JH Jr: Trigonal-ileal anastomosis: animal studies and preliminary clinical results, ibid. 105: 654 (1971). 13. Leadbetter WF: Consideration of problems incident to performance of uretero-enterostomy: report of a technique, Trans. Am. Assoc. Genitourin. Surg. 42: 39 (1950). 14. Mathisen W: A new method for uretero-intestinal anastomosis, Surg. Gynecol. Obstet. 96: 255 (1953). 15. Mogg RA: The results of urinary diversion using the cofonic conduit, Br. J. Urol. 41: 434 (1969). 16. Kelalis PP: Urinary diversion in children by the sigmoid conduit: its advantages and limitations, J. Ural. 112: 666 (1974). 17. Alpert PF, and Tanagho EA: Experimental and clinical studies of mflux and ascending infection, Invest. Ural. 11: 336 (1974). 18. Williams DI: Urinary diversion by sigmoid conduit, in: Current Controversies in Urologic Management, 1st ed., Philadelphia, W. B. Saunders Company, 1972, p. 294. 19. Morales P: Personal communication, 1977.
nonobstructive antireflux mechanisms at sixweek follow-ups. The technique compared with the use of nonrefluxing colon conduit is technically simpler, less time-consuming, adaptable to obese patients, and not contraindicated by diverticular disease. New York, New York 10016 (DR. FARCON) References 1. Seiffert L: Die “Darm-Siphonblase,” Arch. Klin Chir. 183: 569 (1935). 2. Bricker EM: Bladder substitution after pelvic evisceration, Surg. Clin. North. Am. 30: 1511 (1950). 3. Guinan PD, et al: The bacteriology of deal conduit urine in man, Surg. Gynecol. Obstet. 134: 78 (1972). 4. Minton JP, et al: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection, ibid. 119: 541 (1964). 5. Bricker EM, Butcher HR, and McAfee CA: Reappraisal of ileal segment substitution for the urinary bladder, Surgery 42: 581 (1957). 6. Engel RM: Complications of bilateral ureteroileocutaneous urinary diversion: a review of 200 cases, J. Ural. 101: 508 (1969). 7. Harbach LB, et al: Real loop cutaneous urinary diversion: a critical review, ibid. 105: 511 (1971).
UROLOGY
/
OCTOBER
1979
/
VOLUME
XIV, NUMBER
4
347