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Conjoined End-To-End Uretero-Intestinal Anastomosis
Vol. 105, Feb. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
CONJOINED END-TO-END URETERO-INTESTINAL ANASTOMOSIS DAVID J. ALBERT
AND
Classical end-to-side ureteroileostomy has been attended by 2 major problems-leakage and stricture at the anastomotic site. Particularly when normal-sized ureters are encountered, a nonobstructed, water-tight suture line is often difficult to obtain. In an attempt to obviate these complications we used a modification of the technique described by Wallace in 1966.1 The method involve::; spatulation and conjoining of the ureters prior to anastomosis with the ileal segment.2 METHOD
Once a suitable ileal segment has been fashioned, a 4 to 6 cm. incision is made in the posterior parietal peritoneum directly over the right ureter. After division and careful isolation of the ureter through this incision, the left ureter is identified lateral to the sigmoid colon. The left ureter is divided as close to the bladder as possible. It is then drawn beneath the sigmoid mesentery and brought out through the same incision through which the right ureter was isolated. Palpation insures absence of angulation or compression. Each ureter is trimmed, allowing approximately 5 cm. of distal ureter to be exposed above the retroperitoneum. The ureters are then spatulated by incising the anterior border a distance equal to the diameter of the entire open end of the proposed ilea! segment (fig. 1, A). The conjoining is begun at the apex of each ureteral incision using atraumatic suture of 4-zero chromic catgut with the knots tied outside the lumen. Interrupted sutures are continued along the posterior edges to complete the conjoiniug suture line (fig. 1, B). The proximal end of the ilea! segment is opened and the contents are aspirated. The conjoined ureters are anastomosed to the open end of the conduit with interrupted sutures of 3-zero chromic catgut Accepted for publication March 13, 1970. Read at ammal meeting of North Central Section, American Urological Association, Milwaukee, Wisconsin, September 24-27, 1969. 1 Wallace, D. M.: Ureteric diversion using a conduit: a simplified techniqne. Brit. J. Urol., 38: 522, 1966. 2 Wendel, R. G., Henning, D. C. and Evans, A. T.: End-to-end ureteroileal anastomosis for iliac conduits: preliminary report. J. Urol., 102: 42, 1969.
LESTER PERSKY
through full thickness of ureter and ileum. It has been our practice to place both apical sutures before tying them down to insure accurate approximation of this critical area without corn.-promising the lumen (fig. 1, G). The anastomosis proceeds by first approximating the posterior walls and is completed with the suturing of the anterior edges (fig. 1, . Ureteral patency can be assessed just prior to closure by inserting a blunt probe into each ureter. When suturing along the distal portion of the spatulated ureters, knots may be tied where convenient either within or outside the lumen. Only the proximal end of the conduit requires retroperitonealization and this is easily accomplished with a running suture of 2-zero chromic. This suture joins the edges of the posterior toneal incision to the seromuscular wall of the conduit (fig. 2). Wallace stated that no attempt should be made to close the large opening between the right border of the conduit mesentery and the anterior abdominal wall.1 DISCUSSION
We have used this method of ileal conduit construction almost exclusively for the past 20 months in adults and children with both normal and dilated ureters. Fifty patients ha,ve undergone this modification of ileal loop diversion and form the basis of our report. The indications for operation are listed in the table. vVe believe there are several distinct advantages of this method compared to separate end-to-side anastomosis· 1) a single large anastomosis of ureters to ileum, 2) direct visualization of the ureteral lumina throughout the closure, 3) avoidance of separate closure of the proximal end of the conduit, 4) a shorter ileal segment may be used since it exits from the right side of the posterior peritoneum rather than from the base of the sigmoid mesen-tery and 5) the entire anastomosis may be and easily retroperitonealized under direct vision. We have had some complications with this procedure. Case 1. A 14-year-old girl, grotesquely deformed by rotoscoliosis and flexion contractures, had anuria 5 days postoperatively. An ileosto201
202
ALBERT AND PERSKY
A
Frn. 1. A, anterior border of each ureter is incised, distance equal to entire diameter of proximal end of proposed conduit. B, posterior edges are conjoined with interrupted sutures of 4-zero chromic with knots tied outside lumen. C, anastomosis is begun with suture of 3-zero chromic placed through each apex of ureteral incisions and full thickness of ileum. D, anastomosis begins on posterior edges of conjoined ureters and ileal segment and is completed with suturing anterior row.
gram revealed no reflux and no extravasation (fig. 3). At operation there appeared to be a twisting of the conduit just distal to the anastomotic line. The anastomosis was taken down and appeared to be intact and patent. The conduit was re-fashioned. Convalescence was uneventful. Case 2. A 55-year-old white man underwent cystectomy for invasive bladder carcinoma. An excretory urogram (IVP) 3 months postoperatively was normal but at 9 months mild bilateral hydronephrosis and hydroureter had developed (fig. 4). Subsequently the hydronephrosis and hydroureter resolved without treatment. Case 3. A 51-year-old man required diversion following total cystectomy for invasive carcinoma. Three months postoperatively left hydronephrosis and hydroureter were noted to persist (fig. 5). While unfortunate, this complication
indicates that one ureter may be compromised without necessarily damaging the other. Case 4. A 65-year-old, obese, white man had a total cystectorny for invasive carcinoma. One day postoperatively a urinary leak was revealed. At exploration a disruption of the anastomosis was repaired. Although the patient had a rather stormy convalescence, he ultimately recovered and has done well. IVP 3 months postoperatively shows no evidence of obstruction. Case 5. A 75-year-old Negro required supravesical diversion prior to irradiation for invasive bladder carcinoma. On the evening of operation, the patient became septic and the ilea! stoma appeared cyanotic. By the following morning, gross urinary extravasation was demonstrated by ileostogram. Exploration revealed total necrosis of the conduit secondary to vascular compromise.
URETERO-INTESTINAL ANASTOMOSIS
Fra. 2. Proximal end of conduit is retroperitonealized with running 2-zero chromic suture between seromuscular wall of ileum and posterior parietal peritoneum.
203
FIG. 3. Ileostogram 5 days postoperatively reveals no reflux or extravasation. Multiple skeletal deformities are seen.
Indications for supravesical diversion Indication Cystectomy for carcinoma
Myelodysplasia Traumatic paraplegia Multiple sclerosis Multiple urethrocutaneous fistulas
No. Cases 21 12
9 2
2
Vesicovaginal fistula-carcinoma of vagina Radiation cystitis with hemorrhage Exenteration for carcinoma of cervix 50
Emergency diversion was accomplished by cutaneous ureterostomy. The patient is presently receiving irradiation. Case 6. An obese 36-year-old white man underwent total cystectomy for invasive bladder carcinoma. Eight days postoperatively he experienced through-and-through dehiscence of the wound which required secondary closure. No difficulty with the urinary diversion was encountered. Case 7. A 48-year-old, alcoholic, white man underwent emergency supravesical diversion and colostomy for a rectovesical fistula secondary to
FIG. 4. IVP 9 months postoperatively shows mild bilateral hydronephrosis.
perforating bladder carcinoma. Fourteen postoperatively he was explored for persistent ileus. A small bowel obstruction was demon-
204
ALBERT AND PERSKY
strated secondary to a bowel loop incarcerated alongside the conduit. Five days later the patient vomited and, following aspiration, he died. The conduit had functioned well and at exploration was intact. This case represents our only experience of small bowel obstruction with this procedure and the only operative death. Our complication rate of 14 per cent compares favorably to the experience of others using the classical anastomosis and no new complications that could be attributed solely to the modification of ureteral implantation have been encountered. SUMMARY
A modification of uretero-intestinal anastomosis by conjoining the spatulated ureter with suturing to the opened proximal end of the ilea! segment has been described. The procedure has been performed successfully in 50 children and adults with both normal caliber and dilated ureters. There have been few complications and only one operative death. Advantages of this procedure are discussed. FIG. 5. Marked left hydronephrosis and hydroureter 3 months following end-to-end anastomosis.
University Hospual, 2065 Adelbert Road, Cleveland, Ohio 44106
THE JOURNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
CONJOINED END-TO-END URETERO-INTESTINAL ANASTOMOSIS DAVID J. ALBERT
AND
Classical end-to-side ureteroileostomy has been attended by 2 major problems-leakage and stricture at the anastomotic site. Particularly when normal-sized ureters are encountered, a nonobstructed, water-tight suture line is often difficult to obtain. In an attempt to obviate these complications we used a modification of the technique described by Wallace in 1966.1 The method involve::; spatulation and conjoining of the ureters prior to anastomosis with the ileal segment.2 METHOD
Once a suitable ileal segment has been fashioned, a 4 to 6 cm. incision is made in the posterior parietal peritoneum directly over the right ureter. After division and careful isolation of the ureter through this incision, the left ureter is identified lateral to the sigmoid colon. The left ureter is divided as close to the bladder as possible. It is then drawn beneath the sigmoid mesentery and brought out through the same incision through which the right ureter was isolated. Palpation insures absence of angulation or compression. Each ureter is trimmed, allowing approximately 5 cm. of distal ureter to be exposed above the retroperitoneum. The ureters are then spatulated by incising the anterior border a distance equal to the diameter of the entire open end of the proposed ilea! segment (fig. 1, A). The conjoining is begun at the apex of each ureteral incision using atraumatic suture of 4-zero chromic catgut with the knots tied outside the lumen. Interrupted sutures are continued along the posterior edges to complete the conjoiniug suture line (fig. 1, B). The proximal end of the ilea! segment is opened and the contents are aspirated. The conjoined ureters are anastomosed to the open end of the conduit with interrupted sutures of 3-zero chromic catgut Accepted for publication March 13, 1970. Read at ammal meeting of North Central Section, American Urological Association, Milwaukee, Wisconsin, September 24-27, 1969. 1 Wallace, D. M.: Ureteric diversion using a conduit: a simplified techniqne. Brit. J. Urol., 38: 522, 1966. 2 Wendel, R. G., Henning, D. C. and Evans, A. T.: End-to-end ureteroileal anastomosis for iliac conduits: preliminary report. J. Urol., 102: 42, 1969.
LESTER PERSKY
through full thickness of ureter and ileum. It has been our practice to place both apical sutures before tying them down to insure accurate approximation of this critical area without corn.-promising the lumen (fig. 1, G). The anastomosis proceeds by first approximating the posterior walls and is completed with the suturing of the anterior edges (fig. 1, . Ureteral patency can be assessed just prior to closure by inserting a blunt probe into each ureter. When suturing along the distal portion of the spatulated ureters, knots may be tied where convenient either within or outside the lumen. Only the proximal end of the conduit requires retroperitonealization and this is easily accomplished with a running suture of 2-zero chromic. This suture joins the edges of the posterior toneal incision to the seromuscular wall of the conduit (fig. 2). Wallace stated that no attempt should be made to close the large opening between the right border of the conduit mesentery and the anterior abdominal wall.1 DISCUSSION
We have used this method of ileal conduit construction almost exclusively for the past 20 months in adults and children with both normal and dilated ureters. Fifty patients ha,ve undergone this modification of ileal loop diversion and form the basis of our report. The indications for operation are listed in the table. vVe believe there are several distinct advantages of this method compared to separate end-to-side anastomosis· 1) a single large anastomosis of ureters to ileum, 2) direct visualization of the ureteral lumina throughout the closure, 3) avoidance of separate closure of the proximal end of the conduit, 4) a shorter ileal segment may be used since it exits from the right side of the posterior peritoneum rather than from the base of the sigmoid mesen-tery and 5) the entire anastomosis may be and easily retroperitonealized under direct vision. We have had some complications with this procedure. Case 1. A 14-year-old girl, grotesquely deformed by rotoscoliosis and flexion contractures, had anuria 5 days postoperatively. An ileosto201
202
ALBERT AND PERSKY
A
Frn. 1. A, anterior border of each ureter is incised, distance equal to entire diameter of proximal end of proposed conduit. B, posterior edges are conjoined with interrupted sutures of 4-zero chromic with knots tied outside lumen. C, anastomosis is begun with suture of 3-zero chromic placed through each apex of ureteral incisions and full thickness of ileum. D, anastomosis begins on posterior edges of conjoined ureters and ileal segment and is completed with suturing anterior row.
gram revealed no reflux and no extravasation (fig. 3). At operation there appeared to be a twisting of the conduit just distal to the anastomotic line. The anastomosis was taken down and appeared to be intact and patent. The conduit was re-fashioned. Convalescence was uneventful. Case 2. A 55-year-old white man underwent cystectomy for invasive bladder carcinoma. An excretory urogram (IVP) 3 months postoperatively was normal but at 9 months mild bilateral hydronephrosis and hydroureter had developed (fig. 4). Subsequently the hydronephrosis and hydroureter resolved without treatment. Case 3. A 51-year-old man required diversion following total cystectomy for invasive carcinoma. Three months postoperatively left hydronephrosis and hydroureter were noted to persist (fig. 5). While unfortunate, this complication
indicates that one ureter may be compromised without necessarily damaging the other. Case 4. A 65-year-old, obese, white man had a total cystectorny for invasive carcinoma. One day postoperatively a urinary leak was revealed. At exploration a disruption of the anastomosis was repaired. Although the patient had a rather stormy convalescence, he ultimately recovered and has done well. IVP 3 months postoperatively shows no evidence of obstruction. Case 5. A 75-year-old Negro required supravesical diversion prior to irradiation for invasive bladder carcinoma. On the evening of operation, the patient became septic and the ilea! stoma appeared cyanotic. By the following morning, gross urinary extravasation was demonstrated by ileostogram. Exploration revealed total necrosis of the conduit secondary to vascular compromise.
URETERO-INTESTINAL ANASTOMOSIS
Fra. 2. Proximal end of conduit is retroperitonealized with running 2-zero chromic suture between seromuscular wall of ileum and posterior parietal peritoneum.
203
FIG. 3. Ileostogram 5 days postoperatively reveals no reflux or extravasation. Multiple skeletal deformities are seen.
Indications for supravesical diversion Indication Cystectomy for carcinoma
Myelodysplasia Traumatic paraplegia Multiple sclerosis Multiple urethrocutaneous fistulas
No. Cases 21 12
9 2
2
Vesicovaginal fistula-carcinoma of vagina Radiation cystitis with hemorrhage Exenteration for carcinoma of cervix 50
Emergency diversion was accomplished by cutaneous ureterostomy. The patient is presently receiving irradiation. Case 6. An obese 36-year-old white man underwent total cystectomy for invasive bladder carcinoma. Eight days postoperatively he experienced through-and-through dehiscence of the wound which required secondary closure. No difficulty with the urinary diversion was encountered. Case 7. A 48-year-old, alcoholic, white man underwent emergency supravesical diversion and colostomy for a rectovesical fistula secondary to
FIG. 4. IVP 9 months postoperatively shows mild bilateral hydronephrosis.
perforating bladder carcinoma. Fourteen postoperatively he was explored for persistent ileus. A small bowel obstruction was demon-
204
ALBERT AND PERSKY
strated secondary to a bowel loop incarcerated alongside the conduit. Five days later the patient vomited and, following aspiration, he died. The conduit had functioned well and at exploration was intact. This case represents our only experience of small bowel obstruction with this procedure and the only operative death. Our complication rate of 14 per cent compares favorably to the experience of others using the classical anastomosis and no new complications that could be attributed solely to the modification of ureteral implantation have been encountered. SUMMARY
A modification of uretero-intestinal anastomosis by conjoining the spatulated ureter with suturing to the opened proximal end of the ilea! segment has been described. The procedure has been performed successfully in 50 children and adults with both normal caliber and dilated ureters. There have been few complications and only one operative death. Advantages of this procedure are discussed. FIG. 5. Marked left hydronephrosis and hydroureter 3 months following end-to-end anastomosis.
University Hospual, 2065 Adelbert Road, Cleveland, Ohio 44106