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Continent Urostomy with Hydraulic Ileal Valve in 136 Patients: 13 Years of Experience
0022-534 7 /89/1421-0046$02.00/0 Vol. 142, July
THE JOURNAL OF UROLOGY
Copyright© 1989 by Williams & Wilkins
Printed in U.S.A.
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE IN 136 PATIENTS: 13 YEARS OF EXPERIENCE A. BENCHEKROUN, N. ESSAKALLI, M. FAIK, M. MARZOUK, M. HACHIMI AND T. ABAKKA From the Urology Clinic, C.H. U. Avicenne, Rabat, Morocco
ABSTRACT
The hydraulic ileal valve, which we developed in 1975, ensures continence by adapting to 5 different urinary reservoirs. The valve is made by isolating a 14 cm. long intestinal loop with the mesentery. The isolated ileal segment then is folded inward on itself throughout its entire length. We performed 136 continent urostomies with this hydraulic valve. An ileocecal reservoir was used in 122 patients, ileum in 8, sigmoid in 1, rectum in 1 and bladder (continent cystostomy) in 4. Indications for continent urostomy were bladder tumor in 55 patients, complex vesicovaginal fistulas in 5, neurogenic bladder in 13, vesical exstrophy in 12 and miscellaneous reasons in 5. Of the patients 103 (75 per cent) were continent immediately. Continence was obtained after repair of the valve in 24 patients (17.6 per cent). Therefore, 127 patients over-all were continent. Mean followup of our patients was 38 months (range 3 to 154 months). Continence remained excellent with self-catheterization performed easily in 88.3 per cent of the patients. Over-all, all of our continent urostomies were well tolerated biologically and radiologically. (J. Ural., 142: 46-51, 1989) During the last 4 years there have been many reports on continent urinary diversion, especially in regard to the Kock reservoir. 1 - 4 In an effort to solve the problems of incontinent diversions in our country (cost of complex appliances and difficulties of social reintegration of patients), we developed a hydraulic ileal valve that ensures continence with various types of urinary reservoirs (ileocecal, ileum, sigmoid, rectum or bladder after closure of the bladder neck; sectioned cut at the vesicourethral junction). Continence is defined as no loss of urine between emptyings of the reservoir by self-catheterization.
surfaces of the inverted ileal segment are lined with mucosa. The openings are meant to allow the mucus secreted by the inverted mucosa to flow into the cecal reservoir, and also for urine to pass into the invaginated ileal segment later when the reservoir is full to provide compression along the full length of the valve. The urine in the ileal valve thus formed increases resistance to the leakage of urine through the conduit. The ureters are implanted into the end of the ileum that is attached to the cecum. The left ureter is transposed to the right side by bringing it under the sigmoid mesentery. The hydraulic valve then is rotated for anastomosis to the open end of the cecum superiorly (fig. 3, a). The cecum is closed partially with interrupted 2-zero silk sutures on the mesenteric side until the remaining opening is similar in diameter to that of the base of the invaginated ileum. Then, 2-zero polyglycolic acid is used to suture the side of the invaginated ileal segment that has been closed to the cecum, using a running suture placed through the seromuscular layers. On the posterior aspect only the outer layer of the invaginated ileal segment is sutured with interrupted full thickness stitches to the posterior aspect of the cecum, thus, preserving the intra-ileal spaces described previously and the ability of the ileal valve to communicate with the cecal reservoir. The cecum is irrigated to reveal any leaks, which then are oversewn. 5 - 8 Drains are used. Ureteral stents as well as a balloon catheter then are exteriorized by bringing them through the inverted ileal conduit and skin stoma. The stoma generally is placed approximately equidistant from the umbilicus and iliac crest. We remove a plug of tissue on the abdominal wall, as for an ileal conduit stoma, widening the orifice to exteriorize the catheter and ureteral stents as described previously. The serosa of the inverted ileum only then is fixed to the abdominal skin with silk sutures (fig. 3, b). Intraperitoneal incisions into the mesentery are closed to prevent internal hernia. The ureteral stents are removed 8 days postoperatively and the cecal catheter is removed after 3 weeks or after it has become plugged with mucus, in which case it is changed earlier. The patient then usually begins self-catheterization every 4 hours. Re-epithelialization of the exposed ileal serosa of the stoma, which becomes covered with granulation tissue, occurs approximately 1 month later (fig. 4). Urine collection reservoir. The ileal valve can be adapted to
MATERIAL AND TECHNIQUE
The ileocecal bladder with hydraulic valve. Careful intestinal preparation is done with a low residue diet and administration of antibacterials 2 days preoperatively. The abdomen is opened through a midline incision from above the umbilicus. The terminal ileum is transected 22 cm. above the ileocecal valve and the right colon is transected 15 cm. from the base of the cecum. After the appendix is removed bowel continuity is restored by an end-to-end ileocolic anastomosis with 2-zero silk sutures in a 1-layer closure. Closure is performed by placing the sutures further apart on the colon side than the ileal side but linear closure of a portion of the diameter of the colon also may be needed. The isolated ileocecal segment is irrigated first with saline and then with an antibiotic solution. The hydraulic valve. The terminal ileum attached to the isolated segment is divided 8 cm. above the ileocecal valve, leaving the shorter segment attached to the cecum and freeing a 14 cm. length of ileum on a separate vascular axis (fig. 1, a). The isolated ileal segment then is folded inward on itself throughout its entire length (fig. 1, b). One end (A) is attached to the other end (B). The ventral side of the inverted loop (of segments A and B) will be approximated in watertight fashion by running 3-zero polyglycolic acid sutures, taking bites of the adventitia and muscle on each side to buttress the mucosal closure. The closure is continued with a single mattress suture through all thicknesses of both layers in the posterior midline (fig. 2, a). As a result, 2 distinct openings are left between the layers of the inverted ileum posteriorly (fig. 2, b). The internal Accepted for publication September 14, 1988. 46
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
47
FIG. 1. a, isolated ileocecal segment for urine collection reservoir and 14 cm. ilea! loop for hydraulic valve. Ends A and B are attached to each other. b, 14 cm. ilea! loop is isolated.
b~
FIG. 2. a, ilea! invaginated loop. b, 2 spaces on either side of posterior median point
FIG. 3. a, fixation of valve above cecum opening is done by running sutures taking 2 levels of invaginated ileum on anterior level. Posteriorly, inner portion of ileum is left free and external level only is sutured, so that there are 2 openings for communication between cecum and interior of valve. b, ilea! value is exteriorized.
48
BENCHEKROUN AND ASSOCIATES
FIG. 5. Kock pouch with ileal valve invaginated intraluminally
FIG. 4. Skin stoma and self-catheterization
all types of reservoirs, according to the indications and patients involved. Heal Valve and Sigmoid: The sigmoid loop is isolated and the distal section site is sutured. Ureters are implanted via the Leadbetter antireflux technique. Finally, the ileal valve is placed at the proximal colonic section site and exteriorized at the left iliac fossa. Heal Valve and Rectum: This type of diversion is designed only for bypass of a rectal bladder. After the rectum is sectioned at the anus the section site is sutured. The ileal valve then is attached to the margins of a proximal rectotomy. The cutaneous stoma can be made at the left iliac fossa at the median. Heal Valve and Bladder (Continent Cystostomy): This technique consists of preserving the vesical reservoir, excluding the bladder neck and apposing the ileal valve on the bladder dome. The cutaneous stoma can be either median or pararectal. Ureteral implantation. When we conserve the bladder as a reservoir we keep the natural implantation of the ureter, otherwise we must perform a ureteroileal implantation. There are 3 possible techniques for a continent ileocecal bladder and continent ileal pouch: 1) ureteroileal implantation with eversion of a few millimeters of ureter in a flap, 2) ureteroileal implantation using the Leduc-Camey method and 3) an original antireflux ureteral implant. For continent sigmoidostomy and continent rectostomy the ureter will be implanted via a Leadbetter antireflux technique. Variant technique. Ileal Valve and Ileal Pouch: There are 2 processes for ileal pouches: 1) the Kock pouch9 • 10 and 2) the Hautman pouch. The ileal valve is made by sacrificing the efferent loop and it is exteriorized at the right iliac fossa. Continent Ileostomy: This variant technique is used in cases of continent ileostomy. The ureters are implanted in an ileal loop afferent to the urine reservoir using the Camey-Leduc method. The efferent loop measures 16 cm. and is used to make the valve. A transverse ileotomy is performed 14 cm. from the distal end of this loop. The loop then is folded inward on itself throughout its entire length. Then, the invaginated end is anchored to the distal labium of the transverse ileotomy by a
half circumferential continuous suture (fig. 5), which creates a half circumferential posterior space that allows urine to circulate between the double thickness of the ileal valve and the urine collection reservoir. Material. From 1975 to 1987 we used this ileal valve continence system in 70 male and 66 female patients 5 to 76 years old (average age 39 years). Indications. Initially, we only envisioned the use of ileal valves for patients with benign disorders, such as irreparable vesicovaginal fistulas. Given the dependability of this continence system, we progressively extended our indications to bladder tumor diversions. Consequently, 40.4 per cent of our patients had bladder tumor, 37.5 per cent had complex vesicovaginal fistulas, 9.5 per cent had a neurogenic bladder, 8.8 per cent had vesical exstrophy and 3.7 per cent had miscellaneous disorders, including cancer of the prostate, extensive stenosis of the urethra, malignant lithiasis of the bladder and vesicourethrorectal fistulas (table 1). Of our 136 patients 31 (22.8 per cent) had a urinary diversion that was tolerated poorly, including internal diversion in 16 (14 ureteroneosigmoidostomies and 2 rectal bladders) and external diversion in 15 (7 Bricker procedures, 3 cutaneous ureterostomies, 3 cystostomies, 1 nephrostomy and 1 wet colostomy). Preoperative examination. Renal function as reflected by blood urea nitrogen (BUN, normal 0.30 gm./1.) and creatinine (normal 10 mg./1.) levels was acceptable, with maximum rates of 0.8 gm./1. and 20 mg./1. (average 0.38 gm./1. and 12 mg./1.), respectively. The routine preoperative excretory urogram (IVP) was studied (264 renal units in 136 patients). Only 131 kidneys (49.6 per cent) appeared to be normal. Moreover, we noted 62 cases of "atonia" (the state between normal, and dilated ureter and pelvis) of the excretory cavities (23.4 per cent), 52 cases of hydronephrosis (17.6 per cent), 12 pyelonephritic kidneys (4.5 per cent), 5 destroyed kidneys and 2 lithiasic kidneys (0.7 per cent). Other surgery associated with continent urinary diversion. During the same operation an additional procedure was necessary in several patients, including 63 cystectomies (46.2 per cent of the cases, including 42 extending to the prostate and 8 to the uterus), 13 nephroureterectomies, 2 colostomies and 1 cholecystectomy. RESULTS
Postoperative recovery. No complications arose during postoperative recovery in 102 patients (75 per cent) with effective urinary continence. The complications arising in 34 patients can be classified into 2 categories, 1 related to valve failure and 1 that is more serious since it endangers the life of the patient. Two patients were placed into both categories of complications, Valve failure was observed in 24 patients (17 .6 per cent) and required intervention to correct continence. The problem con-
49
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
cerned necrosis of the valve in 2 patients, external devagination of the valve in 8 and valve fistulas in 14. The other serious complications (12 patients, 8.8 per cent) involved irreversible septic shock in 5 patients, fatal urodigestive fistulas in 3, digestive fistulas in 3 (including 1 fatal) and neovesicourethral fistulas (ilea! pouch) that disappeared spontaneously in 1, for a total of 9 deaths (6.5 per cent). Consequently, we obtained continence in 127 patients (93.3 per cent). Results were considered to be perfect in 125 patients and improved (few episodes of urinary leakage) in 2 when the reservoir was full and the capacity was more than 300 cc (table 2).
Technique of self-catheterization. After the skin around the valve is cleansed, the patient introduces a lubricated 20 Ch. Mercier, coude round-tip catheter with 2 side holes. When the reservoir is empty the patient removes the catheter and there is no need of any protection. The catheter is cleansed with soap and water, and stored in a bottle containing antiseptic solution. We recommend 2 tablets of trimethoprim per day for 1 week each month to the patients who can afford it. Followup. Although regular medical followup is recommended for all patients, some only returned for consultation 2 or 3 years later (9 years in 1 woman). Nevertheless, we followed 103 patients, including 63 for more than 2 years (range 3 to 154 months, average 38 months). In 91 patients (88.3 per cent) continence remained with regular, simple self-catheterization (fig. 5). Twelve patients (11.6 per cent) had urinary incontinence, which was total in 4 due to external devagination of the ilea! valveo In the remaining 8 patients devagination was internal (the valve is devaginated under the skin, and the exterior aspect appears to be normal but there is leakage of urine). Like the 24 patients with valve failure soon after the operation these 12 patients had to undergo an additional procedure before achieving continence. Moreover, 2 patients had metabolic problems. There was 1 case of acute pyelonephritis with acidosis and renal insufficiency. Effective treatment (permanent catheter, antibiotics and restoration of hydroelectrolytic equilibration) corrected this condition. There were no major modifications in BUN (0.2 to 1 gm./1., average 0.4) and creatinine (5 to 20 mg./1., average 10) levels. Blood chlorides generally remained normal, except in 2 cases when hyperchloremia (106 and 107 mEq./1., normal 25) was observed (1 with an ilea! pouch and 1 with an ileocecal bladder). Finally, the alkaline reserve showed a slight tendency toward acidosis in some patients (3 with an ileal pouch and 2 with an ileocecal bladder), with an average of 24 mEq./1. (14 to 25 mEq./1.) corrected by the absorption of 5 gm. sodium bicarbonate daily. A radiograph of the unprepared abdomen and an IVP revealed that 16 patients had a stone in the reservoir. The upper urinary tract was studied after continent urostomy in 193 renal units in 103 patientso We observed 94 normal units (4807 per cent), 69 with excretory cavity "atonia" (35. 7 per cent) and with hydronephrosis, including 21 (12.4 per cent) with lithiasis, 5 (2.5 per cent) with pyelonephritis and 1 destroyed kidney (005 per cent)o It is interesting to draw a parallel between the radiographs of the upper urinary tract taken preoperatively (264 units in 136 patients) and postoperatively (193 units in 103 patients, fig. 6). The normal renal unit figures remained similar. However, there was a clear regression in hydroneTABLE
Bladder tumor Vesicovaginal fistula Neurogenic bladder Exstrophy Miscellaneous Totals
phrosis (-7.2 per cent) to the detriment of "atonia" of the excretory cavities (+ 12.3 per cent, fig. 7, a). A complement to the radiology study was provided by the loopogram (retrograde opacification of the pouch), which enabled us to determine the urine reservoir capacity, judge the quality of the ureter implant and evaluate the integrity of the ileal valve. Thus, in 85 patients followed (75 with an ileocecal bladder, 6 with an ileal pouch, 1 with a sigmoidostomy, 1 with a rectostomy and 3 with a continent bladder) the vesical capacity was more than 300 cc. In certain undisciplined patients who only performed self-catheterization 1 or 2 times a day this capacity reached almost 1 1. (ileocecal bladder, fig. 7, b ). Ureteral neobladder reflux was observed in 6 patients (ileocecal bladder), totaling 9 renal units. Ureters in these patients were highly dilated preoperatively and a ureteroileal implant was performed as a flap (ureteral eversion). To overcome this problem we developed a new ureteral implant technique. Original ureteral implant technique. A 2 to 3 cm. longitudinal incision was made at the end of the 2 ureters. The 2 ureters then were joined by suturing 1 margin of a ureterotomy to the margin of the second ureter. These 2 joined ureters then were anastomosed in latero (ureter) and terminal (ileum) at the ilea! section site. Eight cm. from the ilea! ureter anastomosis a transverse ileotomy was done. A 4 cm. ilea! invagination was created by pushing the ureteroileal anastomosis intraluminally into the ileum. Thus, the ureteroileal anastomosis zone was opposite the transverse ileotomy from the inside. It was attached to the proximal labium of the transverse ileotomy by a 3-quarter circumferential 3-zero polyglycolic acid continuous suture. Finally, the ileotomy was sutured with the distal labium of this ileotomy on 1 side and the proximal labium complex of the ileotomy ureteroileal anastomosis on the other side.
50
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40
:: r 10
G
-.rr__. . .
,
L._ Sl'B)'LlR.UAL
liltUWQl'il, PTI:UIN!!l'II,
o
UPPER TRACT
FIGO 6. Preoperative (111, 264 kidneys) and postoperative (~. 193 kidneys) IVP findings. Subnormal urinary tract is state between normal, and dilated ureter and pelvis. Bar graphs indicate percentage of kidneys. HYDRONEPH., hydronephrosis. PYELONEPH., pye!onephritiso DESTRU., destroyed kidney.
TABLE
Immediate continence Continence after intervention Totals
2. Continence results Excellent
Improved
Totals
102 23
1
!
103 24
125
2
127
1. Indication for continent urinary diversion
Ileocecal Bladder
Ileum
47 47 12
8
Sigmoid
Rectum
Bladder
2 1
11 5
122
'"""'=-,_,_J ounu
8
T
T
4
Total No.(%) 55 51 13 12 5 136
(40.4) (37.5) (9.5) (8.8)
(3.7)
50
BENCHEKROUN AND ASSOCIATES
FIG. 7. a, IVP 12 years postoperatively. b, loopogram shows no reflux at 600 cc and ilea! valve appears as "crab claw"
With this ureteral implant technique we constructed a hydraulic valve antireflux system while retaining a large ureteroileal anastomosis. This antireflux ureteral implantation technique was performed effectively in the last 8 patients. Opacification of the continent urostomy enabled us to observe the integrity of the ileal valve. The classical aspect is referred to as the "crab claw". In 8 cases opacification also revealed internal devagination of the valve. Urodynamic study. The profile of the valve ensuring continence is a function of the fullness or emptying of the reservoir. When the bladder is full the maximum closing pressure in some cases is approximately 80 cm. water. This is because urine accumulates during filling between the 2 ileal thicknesses of the valve and, consequently, it compresses the invaginated ileal segment. In regard to the continent ileocecal bladder, which accounts for most of our cases, pressure studies determined that pressure is never high in the cecum. While pressure peaks of 30 cm. water are noted in the cecum during the first postoperative months, these peaks tend to disappear with time (fig. 8, closing pressure of the valve with empty and full reservoir, and cystometry). Additional surgery. Some patients required an additional operation. The ileal valve can fail sooner (24 patients) or later (12). A valve fistula (14 patients) may arise within 2 weeks postoperatively and is caused by skin attachment points that catch more than the ileal serous membrane. Necrosis of the valve in 2 patients was caused by thrombosis of the nutrient vascular axis. There were 2 types of devagination of the valve (24 patients): 1) external-with an ileal segment exteriorized by its mucous face or 2) internal-the ileal valve unfolds internally for a reason that is hard to explain.
There are 3 possible methods to correct these hydraulic valve failures: 1) suturing a valve fistula, which was successful in only 2 patients, 2) reinvagination of the same ileal loop, which was possible in 1811 - 13 and 3) reforming the valve by taking a new 14 cm. ileal segment, which was done in 18. A remark must be made concerning reinvagination of the same ileal valve. After an ileal cutaneous incision circumscribing the urostomy orifice was made, the devaginated ileal loop was dissected without damage up to its implantation on the substitute bladder (cecum, ileum or sigmoid). Then, a transverse incision was made (cecotomy, ileotomy or sigmoidotomy). The devaginated ileal loop was reinvaginated over 6 cm., making the ileum-mesentery intraluminal. The invaginated ileal margin then was joined to the upper edge of the transverse enterotomy by a 3-zero polyglycolic acid continuous suture over half of its circumference. The complex was sutured to the lower edge of the enterotomy by a second continuous suture. The ileal valve thus constituted was attached to the skin by 3 serocutaneous sutures. In addition to these cases, we performed 15 cecolithotomies, 1 pyelolithotomy, 6 ureterolyses and 2 nephrectomies. DISCUSSION
Our technique creates a serous membrane stoma to the skin. The ilea! loop is invaginated so as to leave a space for mucus and urine to circulate between the double thickness of the ileal valve and the urine collection reservoir. The passage of urine between the double ileal wall compresses the internal segment, thereby obstructing the central space where the mesentery is located. The continent urostomy can be emptied by catheterization of this obstructed space. This movement of urine between the hydraulic ileal valve and the urine reservoir clearly
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
51
us to obtain continence and create a reservoir well adapted to its new function, as proved on biological and pressure studies. The pressure adaptation of the cecal reservoir to its new function enabled us to override the idea of performing cecal incisions to break down intracecal pressure. This spontaneous adaptation of the cecal reservoir may be explained by the fact that a valve was apposed on the cecum, thereby eliminating cecal peristaltis. Moreover, in our study biological and radiological followup showed that continent urostomy was tolerated well by the upper urinary tract.
REFERENCES 1. Gilchrist, R. K., Merricks, J. W., Hamlin, M. H. and Rieger, I. T.:
2.
3.
4. 5. 6.
7. 8. 9. FIG. 8. a, closing pressure of valve with empty reservoir. b, with full reservoir ( 300 cc). c, cystometry.
is confirmed by radiographic (loopogram) and profilometric studies. In this manner we achieved continence in 127 of 136 patients. The ileocecal bladder was the most widely used in our study. The original intent of our technique was to oppose the ileal valve on the cecal section site (ileocecal bladder), which enabled
10.
11. 12. 13.
Construction of substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Changes in renal parenchyma and the upper urinary tracts following urinary diversion via a continent ileum reservoir: an experimental study in dogs. Scand. J. Ural. Nephrol., suppl. 49, pp. 11-22, 1978. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir. Clinical experience. Scand. J. Ural. Nephrol., suppl. 49, p. 23, 1978. Sullivan, H., Gilchrist, R. K. and Merricks, J. W.: Ileocecal substitute bladder: long-term followup. J. Ural., 109: 43, 1973. Benchekroun, A.: Continent caecal bladder. Brit. J. Ural., 54: 505, 1982. Benchekroun, A.: The ileocecal continent bladder. In: Bladder Reconstruction and Continent Urinary Diversion. Edited by L. R. King, A. R. Stone and G. D. Webster. Chicago: Year Book Medical Publishers, Inc., pp. 224-237, 1987. Mansson, W.: The continent caecal reservoir for urine. Scand. J. Ural. Nephrol., suppl., 85: 1, 1984. Benchekroun, A.: L'urostomie continente utilisant le caecum. J. d'Urol., 91: 704, 1985. Kock, N. G., Myrvold, H. E., Nilson, L. 0. and Ahren, C.: Construction of a stable nipple valve for the continent ileostomy. Ann. Chir. Gynaec., 69: 132, 1980. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ilea! reservoir for urinary diversion. J. Ural., 132: 1101, 1984. Ashken, M. H.: An appliance-free ileocaecal urinary diversion: preliminary communication. Brit. J. Ural., 46: 631, 1974. Askhen, M. H.: Continent ileocaecal urinary reservoir. J. Roy. Soc. Med., 71: 357, 1978. Ashken, M. H.: The continent urostomy. Letter to the Editor. Brit. Med. J., 2: 830, 1978.
THE JOURNAL OF UROLOGY
Copyright© 1989 by Williams & Wilkins
Printed in U.S.A.
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE IN 136 PATIENTS: 13 YEARS OF EXPERIENCE A. BENCHEKROUN, N. ESSAKALLI, M. FAIK, M. MARZOUK, M. HACHIMI AND T. ABAKKA From the Urology Clinic, C.H. U. Avicenne, Rabat, Morocco
ABSTRACT
The hydraulic ileal valve, which we developed in 1975, ensures continence by adapting to 5 different urinary reservoirs. The valve is made by isolating a 14 cm. long intestinal loop with the mesentery. The isolated ileal segment then is folded inward on itself throughout its entire length. We performed 136 continent urostomies with this hydraulic valve. An ileocecal reservoir was used in 122 patients, ileum in 8, sigmoid in 1, rectum in 1 and bladder (continent cystostomy) in 4. Indications for continent urostomy were bladder tumor in 55 patients, complex vesicovaginal fistulas in 5, neurogenic bladder in 13, vesical exstrophy in 12 and miscellaneous reasons in 5. Of the patients 103 (75 per cent) were continent immediately. Continence was obtained after repair of the valve in 24 patients (17.6 per cent). Therefore, 127 patients over-all were continent. Mean followup of our patients was 38 months (range 3 to 154 months). Continence remained excellent with self-catheterization performed easily in 88.3 per cent of the patients. Over-all, all of our continent urostomies were well tolerated biologically and radiologically. (J. Ural., 142: 46-51, 1989) During the last 4 years there have been many reports on continent urinary diversion, especially in regard to the Kock reservoir. 1 - 4 In an effort to solve the problems of incontinent diversions in our country (cost of complex appliances and difficulties of social reintegration of patients), we developed a hydraulic ileal valve that ensures continence with various types of urinary reservoirs (ileocecal, ileum, sigmoid, rectum or bladder after closure of the bladder neck; sectioned cut at the vesicourethral junction). Continence is defined as no loss of urine between emptyings of the reservoir by self-catheterization.
surfaces of the inverted ileal segment are lined with mucosa. The openings are meant to allow the mucus secreted by the inverted mucosa to flow into the cecal reservoir, and also for urine to pass into the invaginated ileal segment later when the reservoir is full to provide compression along the full length of the valve. The urine in the ileal valve thus formed increases resistance to the leakage of urine through the conduit. The ureters are implanted into the end of the ileum that is attached to the cecum. The left ureter is transposed to the right side by bringing it under the sigmoid mesentery. The hydraulic valve then is rotated for anastomosis to the open end of the cecum superiorly (fig. 3, a). The cecum is closed partially with interrupted 2-zero silk sutures on the mesenteric side until the remaining opening is similar in diameter to that of the base of the invaginated ileum. Then, 2-zero polyglycolic acid is used to suture the side of the invaginated ileal segment that has been closed to the cecum, using a running suture placed through the seromuscular layers. On the posterior aspect only the outer layer of the invaginated ileal segment is sutured with interrupted full thickness stitches to the posterior aspect of the cecum, thus, preserving the intra-ileal spaces described previously and the ability of the ileal valve to communicate with the cecal reservoir. The cecum is irrigated to reveal any leaks, which then are oversewn. 5 - 8 Drains are used. Ureteral stents as well as a balloon catheter then are exteriorized by bringing them through the inverted ileal conduit and skin stoma. The stoma generally is placed approximately equidistant from the umbilicus and iliac crest. We remove a plug of tissue on the abdominal wall, as for an ileal conduit stoma, widening the orifice to exteriorize the catheter and ureteral stents as described previously. The serosa of the inverted ileum only then is fixed to the abdominal skin with silk sutures (fig. 3, b). Intraperitoneal incisions into the mesentery are closed to prevent internal hernia. The ureteral stents are removed 8 days postoperatively and the cecal catheter is removed after 3 weeks or after it has become plugged with mucus, in which case it is changed earlier. The patient then usually begins self-catheterization every 4 hours. Re-epithelialization of the exposed ileal serosa of the stoma, which becomes covered with granulation tissue, occurs approximately 1 month later (fig. 4). Urine collection reservoir. The ileal valve can be adapted to
MATERIAL AND TECHNIQUE
The ileocecal bladder with hydraulic valve. Careful intestinal preparation is done with a low residue diet and administration of antibacterials 2 days preoperatively. The abdomen is opened through a midline incision from above the umbilicus. The terminal ileum is transected 22 cm. above the ileocecal valve and the right colon is transected 15 cm. from the base of the cecum. After the appendix is removed bowel continuity is restored by an end-to-end ileocolic anastomosis with 2-zero silk sutures in a 1-layer closure. Closure is performed by placing the sutures further apart on the colon side than the ileal side but linear closure of a portion of the diameter of the colon also may be needed. The isolated ileocecal segment is irrigated first with saline and then with an antibiotic solution. The hydraulic valve. The terminal ileum attached to the isolated segment is divided 8 cm. above the ileocecal valve, leaving the shorter segment attached to the cecum and freeing a 14 cm. length of ileum on a separate vascular axis (fig. 1, a). The isolated ileal segment then is folded inward on itself throughout its entire length (fig. 1, b). One end (A) is attached to the other end (B). The ventral side of the inverted loop (of segments A and B) will be approximated in watertight fashion by running 3-zero polyglycolic acid sutures, taking bites of the adventitia and muscle on each side to buttress the mucosal closure. The closure is continued with a single mattress suture through all thicknesses of both layers in the posterior midline (fig. 2, a). As a result, 2 distinct openings are left between the layers of the inverted ileum posteriorly (fig. 2, b). The internal Accepted for publication September 14, 1988. 46
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
47
FIG. 1. a, isolated ileocecal segment for urine collection reservoir and 14 cm. ilea! loop for hydraulic valve. Ends A and B are attached to each other. b, 14 cm. ilea! loop is isolated.
b~
FIG. 2. a, ilea! invaginated loop. b, 2 spaces on either side of posterior median point
FIG. 3. a, fixation of valve above cecum opening is done by running sutures taking 2 levels of invaginated ileum on anterior level. Posteriorly, inner portion of ileum is left free and external level only is sutured, so that there are 2 openings for communication between cecum and interior of valve. b, ilea! value is exteriorized.
48
BENCHEKROUN AND ASSOCIATES
FIG. 5. Kock pouch with ileal valve invaginated intraluminally
FIG. 4. Skin stoma and self-catheterization
all types of reservoirs, according to the indications and patients involved. Heal Valve and Sigmoid: The sigmoid loop is isolated and the distal section site is sutured. Ureters are implanted via the Leadbetter antireflux technique. Finally, the ileal valve is placed at the proximal colonic section site and exteriorized at the left iliac fossa. Heal Valve and Rectum: This type of diversion is designed only for bypass of a rectal bladder. After the rectum is sectioned at the anus the section site is sutured. The ileal valve then is attached to the margins of a proximal rectotomy. The cutaneous stoma can be made at the left iliac fossa at the median. Heal Valve and Bladder (Continent Cystostomy): This technique consists of preserving the vesical reservoir, excluding the bladder neck and apposing the ileal valve on the bladder dome. The cutaneous stoma can be either median or pararectal. Ureteral implantation. When we conserve the bladder as a reservoir we keep the natural implantation of the ureter, otherwise we must perform a ureteroileal implantation. There are 3 possible techniques for a continent ileocecal bladder and continent ileal pouch: 1) ureteroileal implantation with eversion of a few millimeters of ureter in a flap, 2) ureteroileal implantation using the Leduc-Camey method and 3) an original antireflux ureteral implant. For continent sigmoidostomy and continent rectostomy the ureter will be implanted via a Leadbetter antireflux technique. Variant technique. Ileal Valve and Ileal Pouch: There are 2 processes for ileal pouches: 1) the Kock pouch9 • 10 and 2) the Hautman pouch. The ileal valve is made by sacrificing the efferent loop and it is exteriorized at the right iliac fossa. Continent Ileostomy: This variant technique is used in cases of continent ileostomy. The ureters are implanted in an ileal loop afferent to the urine reservoir using the Camey-Leduc method. The efferent loop measures 16 cm. and is used to make the valve. A transverse ileotomy is performed 14 cm. from the distal end of this loop. The loop then is folded inward on itself throughout its entire length. Then, the invaginated end is anchored to the distal labium of the transverse ileotomy by a
half circumferential continuous suture (fig. 5), which creates a half circumferential posterior space that allows urine to circulate between the double thickness of the ileal valve and the urine collection reservoir. Material. From 1975 to 1987 we used this ileal valve continence system in 70 male and 66 female patients 5 to 76 years old (average age 39 years). Indications. Initially, we only envisioned the use of ileal valves for patients with benign disorders, such as irreparable vesicovaginal fistulas. Given the dependability of this continence system, we progressively extended our indications to bladder tumor diversions. Consequently, 40.4 per cent of our patients had bladder tumor, 37.5 per cent had complex vesicovaginal fistulas, 9.5 per cent had a neurogenic bladder, 8.8 per cent had vesical exstrophy and 3.7 per cent had miscellaneous disorders, including cancer of the prostate, extensive stenosis of the urethra, malignant lithiasis of the bladder and vesicourethrorectal fistulas (table 1). Of our 136 patients 31 (22.8 per cent) had a urinary diversion that was tolerated poorly, including internal diversion in 16 (14 ureteroneosigmoidostomies and 2 rectal bladders) and external diversion in 15 (7 Bricker procedures, 3 cutaneous ureterostomies, 3 cystostomies, 1 nephrostomy and 1 wet colostomy). Preoperative examination. Renal function as reflected by blood urea nitrogen (BUN, normal 0.30 gm./1.) and creatinine (normal 10 mg./1.) levels was acceptable, with maximum rates of 0.8 gm./1. and 20 mg./1. (average 0.38 gm./1. and 12 mg./1.), respectively. The routine preoperative excretory urogram (IVP) was studied (264 renal units in 136 patients). Only 131 kidneys (49.6 per cent) appeared to be normal. Moreover, we noted 62 cases of "atonia" (the state between normal, and dilated ureter and pelvis) of the excretory cavities (23.4 per cent), 52 cases of hydronephrosis (17.6 per cent), 12 pyelonephritic kidneys (4.5 per cent), 5 destroyed kidneys and 2 lithiasic kidneys (0.7 per cent). Other surgery associated with continent urinary diversion. During the same operation an additional procedure was necessary in several patients, including 63 cystectomies (46.2 per cent of the cases, including 42 extending to the prostate and 8 to the uterus), 13 nephroureterectomies, 2 colostomies and 1 cholecystectomy. RESULTS
Postoperative recovery. No complications arose during postoperative recovery in 102 patients (75 per cent) with effective urinary continence. The complications arising in 34 patients can be classified into 2 categories, 1 related to valve failure and 1 that is more serious since it endangers the life of the patient. Two patients were placed into both categories of complications, Valve failure was observed in 24 patients (17 .6 per cent) and required intervention to correct continence. The problem con-
49
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
cerned necrosis of the valve in 2 patients, external devagination of the valve in 8 and valve fistulas in 14. The other serious complications (12 patients, 8.8 per cent) involved irreversible septic shock in 5 patients, fatal urodigestive fistulas in 3, digestive fistulas in 3 (including 1 fatal) and neovesicourethral fistulas (ilea! pouch) that disappeared spontaneously in 1, for a total of 9 deaths (6.5 per cent). Consequently, we obtained continence in 127 patients (93.3 per cent). Results were considered to be perfect in 125 patients and improved (few episodes of urinary leakage) in 2 when the reservoir was full and the capacity was more than 300 cc (table 2).
Technique of self-catheterization. After the skin around the valve is cleansed, the patient introduces a lubricated 20 Ch. Mercier, coude round-tip catheter with 2 side holes. When the reservoir is empty the patient removes the catheter and there is no need of any protection. The catheter is cleansed with soap and water, and stored in a bottle containing antiseptic solution. We recommend 2 tablets of trimethoprim per day for 1 week each month to the patients who can afford it. Followup. Although regular medical followup is recommended for all patients, some only returned for consultation 2 or 3 years later (9 years in 1 woman). Nevertheless, we followed 103 patients, including 63 for more than 2 years (range 3 to 154 months, average 38 months). In 91 patients (88.3 per cent) continence remained with regular, simple self-catheterization (fig. 5). Twelve patients (11.6 per cent) had urinary incontinence, which was total in 4 due to external devagination of the ilea! valveo In the remaining 8 patients devagination was internal (the valve is devaginated under the skin, and the exterior aspect appears to be normal but there is leakage of urine). Like the 24 patients with valve failure soon after the operation these 12 patients had to undergo an additional procedure before achieving continence. Moreover, 2 patients had metabolic problems. There was 1 case of acute pyelonephritis with acidosis and renal insufficiency. Effective treatment (permanent catheter, antibiotics and restoration of hydroelectrolytic equilibration) corrected this condition. There were no major modifications in BUN (0.2 to 1 gm./1., average 0.4) and creatinine (5 to 20 mg./1., average 10) levels. Blood chlorides generally remained normal, except in 2 cases when hyperchloremia (106 and 107 mEq./1., normal 25) was observed (1 with an ilea! pouch and 1 with an ileocecal bladder). Finally, the alkaline reserve showed a slight tendency toward acidosis in some patients (3 with an ileal pouch and 2 with an ileocecal bladder), with an average of 24 mEq./1. (14 to 25 mEq./1.) corrected by the absorption of 5 gm. sodium bicarbonate daily. A radiograph of the unprepared abdomen and an IVP revealed that 16 patients had a stone in the reservoir. The upper urinary tract was studied after continent urostomy in 193 renal units in 103 patientso We observed 94 normal units (4807 per cent), 69 with excretory cavity "atonia" (35. 7 per cent) and with hydronephrosis, including 21 (12.4 per cent) with lithiasis, 5 (2.5 per cent) with pyelonephritis and 1 destroyed kidney (005 per cent)o It is interesting to draw a parallel between the radiographs of the upper urinary tract taken preoperatively (264 units in 136 patients) and postoperatively (193 units in 103 patients, fig. 6). The normal renal unit figures remained similar. However, there was a clear regression in hydroneTABLE
Bladder tumor Vesicovaginal fistula Neurogenic bladder Exstrophy Miscellaneous Totals
phrosis (-7.2 per cent) to the detriment of "atonia" of the excretory cavities (+ 12.3 per cent, fig. 7, a). A complement to the radiology study was provided by the loopogram (retrograde opacification of the pouch), which enabled us to determine the urine reservoir capacity, judge the quality of the ureter implant and evaluate the integrity of the ileal valve. Thus, in 85 patients followed (75 with an ileocecal bladder, 6 with an ileal pouch, 1 with a sigmoidostomy, 1 with a rectostomy and 3 with a continent bladder) the vesical capacity was more than 300 cc. In certain undisciplined patients who only performed self-catheterization 1 or 2 times a day this capacity reached almost 1 1. (ileocecal bladder, fig. 7, b ). Ureteral neobladder reflux was observed in 6 patients (ileocecal bladder), totaling 9 renal units. Ureters in these patients were highly dilated preoperatively and a ureteroileal implant was performed as a flap (ureteral eversion). To overcome this problem we developed a new ureteral implant technique. Original ureteral implant technique. A 2 to 3 cm. longitudinal incision was made at the end of the 2 ureters. The 2 ureters then were joined by suturing 1 margin of a ureterotomy to the margin of the second ureter. These 2 joined ureters then were anastomosed in latero (ureter) and terminal (ileum) at the ilea! section site. Eight cm. from the ilea! ureter anastomosis a transverse ileotomy was done. A 4 cm. ilea! invagination was created by pushing the ureteroileal anastomosis intraluminally into the ileum. Thus, the ureteroileal anastomosis zone was opposite the transverse ileotomy from the inside. It was attached to the proximal labium of the transverse ileotomy by a 3-quarter circumferential 3-zero polyglycolic acid continuous suture. Finally, the ileotomy was sutured with the distal labium of this ileotomy on 1 side and the proximal labium complex of the ileotomy ureteroileal anastomosis on the other side.
50
········································
40
:: r 10
G
-.rr__. . .
,
L._ Sl'B)'LlR.UAL
liltUWQl'il, PTI:UIN!!l'II,
o
UPPER TRACT
FIGO 6. Preoperative (111, 264 kidneys) and postoperative (~. 193 kidneys) IVP findings. Subnormal urinary tract is state between normal, and dilated ureter and pelvis. Bar graphs indicate percentage of kidneys. HYDRONEPH., hydronephrosis. PYELONEPH., pye!onephritiso DESTRU., destroyed kidney.
TABLE
Immediate continence Continence after intervention Totals
2. Continence results Excellent
Improved
Totals
102 23
1
!
103 24
125
2
127
1. Indication for continent urinary diversion
Ileocecal Bladder
Ileum
47 47 12
8
Sigmoid
Rectum
Bladder
2 1
11 5
122
'"""'=-,_,_J ounu
8
T
T
4
Total No.(%) 55 51 13 12 5 136
(40.4) (37.5) (9.5) (8.8)
(3.7)
50
BENCHEKROUN AND ASSOCIATES
FIG. 7. a, IVP 12 years postoperatively. b, loopogram shows no reflux at 600 cc and ilea! valve appears as "crab claw"
With this ureteral implant technique we constructed a hydraulic valve antireflux system while retaining a large ureteroileal anastomosis. This antireflux ureteral implantation technique was performed effectively in the last 8 patients. Opacification of the continent urostomy enabled us to observe the integrity of the ileal valve. The classical aspect is referred to as the "crab claw". In 8 cases opacification also revealed internal devagination of the valve. Urodynamic study. The profile of the valve ensuring continence is a function of the fullness or emptying of the reservoir. When the bladder is full the maximum closing pressure in some cases is approximately 80 cm. water. This is because urine accumulates during filling between the 2 ileal thicknesses of the valve and, consequently, it compresses the invaginated ileal segment. In regard to the continent ileocecal bladder, which accounts for most of our cases, pressure studies determined that pressure is never high in the cecum. While pressure peaks of 30 cm. water are noted in the cecum during the first postoperative months, these peaks tend to disappear with time (fig. 8, closing pressure of the valve with empty and full reservoir, and cystometry). Additional surgery. Some patients required an additional operation. The ileal valve can fail sooner (24 patients) or later (12). A valve fistula (14 patients) may arise within 2 weeks postoperatively and is caused by skin attachment points that catch more than the ileal serous membrane. Necrosis of the valve in 2 patients was caused by thrombosis of the nutrient vascular axis. There were 2 types of devagination of the valve (24 patients): 1) external-with an ileal segment exteriorized by its mucous face or 2) internal-the ileal valve unfolds internally for a reason that is hard to explain.
There are 3 possible methods to correct these hydraulic valve failures: 1) suturing a valve fistula, which was successful in only 2 patients, 2) reinvagination of the same ileal loop, which was possible in 1811 - 13 and 3) reforming the valve by taking a new 14 cm. ileal segment, which was done in 18. A remark must be made concerning reinvagination of the same ileal valve. After an ileal cutaneous incision circumscribing the urostomy orifice was made, the devaginated ileal loop was dissected without damage up to its implantation on the substitute bladder (cecum, ileum or sigmoid). Then, a transverse incision was made (cecotomy, ileotomy or sigmoidotomy). The devaginated ileal loop was reinvaginated over 6 cm., making the ileum-mesentery intraluminal. The invaginated ileal margin then was joined to the upper edge of the transverse enterotomy by a 3-zero polyglycolic acid continuous suture over half of its circumference. The complex was sutured to the lower edge of the enterotomy by a second continuous suture. The ileal valve thus constituted was attached to the skin by 3 serocutaneous sutures. In addition to these cases, we performed 15 cecolithotomies, 1 pyelolithotomy, 6 ureterolyses and 2 nephrectomies. DISCUSSION
Our technique creates a serous membrane stoma to the skin. The ilea! loop is invaginated so as to leave a space for mucus and urine to circulate between the double thickness of the ileal valve and the urine collection reservoir. The passage of urine between the double ileal wall compresses the internal segment, thereby obstructing the central space where the mesentery is located. The continent urostomy can be emptied by catheterization of this obstructed space. This movement of urine between the hydraulic ileal valve and the urine reservoir clearly
CONTINENT UROSTOMY WITH HYDRAULIC ILEAL VALVE
51
us to obtain continence and create a reservoir well adapted to its new function, as proved on biological and pressure studies. The pressure adaptation of the cecal reservoir to its new function enabled us to override the idea of performing cecal incisions to break down intracecal pressure. This spontaneous adaptation of the cecal reservoir may be explained by the fact that a valve was apposed on the cecum, thereby eliminating cecal peristaltis. Moreover, in our study biological and radiological followup showed that continent urostomy was tolerated well by the upper urinary tract.
REFERENCES 1. Gilchrist, R. K., Merricks, J. W., Hamlin, M. H. and Rieger, I. T.:
2.
3.
4. 5. 6.
7. 8. 9. FIG. 8. a, closing pressure of valve with empty reservoir. b, with full reservoir ( 300 cc). c, cystometry.
is confirmed by radiographic (loopogram) and profilometric studies. In this manner we achieved continence in 127 of 136 patients. The ileocecal bladder was the most widely used in our study. The original intent of our technique was to oppose the ileal valve on the cecal section site (ileocecal bladder), which enabled
10.
11. 12. 13.
Construction of substitute bladder and urethra. Surg., Gynec. & Obst., 90: 752, 1950. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Changes in renal parenchyma and the upper urinary tracts following urinary diversion via a continent ileum reservoir: an experimental study in dogs. Scand. J. Ural. Nephrol., suppl. 49, pp. 11-22, 1978. Kock, N. G., Nilson, A. R., Norlen, L., Sundin, T. and Trasti, H.: Urinary diversion via a continent ileum reservoir. Clinical experience. Scand. J. Ural. Nephrol., suppl. 49, p. 23, 1978. Sullivan, H., Gilchrist, R. K. and Merricks, J. W.: Ileocecal substitute bladder: long-term followup. J. Ural., 109: 43, 1973. Benchekroun, A.: Continent caecal bladder. Brit. J. Ural., 54: 505, 1982. Benchekroun, A.: The ileocecal continent bladder. In: Bladder Reconstruction and Continent Urinary Diversion. Edited by L. R. King, A. R. Stone and G. D. Webster. Chicago: Year Book Medical Publishers, Inc., pp. 224-237, 1987. Mansson, W.: The continent caecal reservoir for urine. Scand. J. Ural. Nephrol., suppl., 85: 1, 1984. Benchekroun, A.: L'urostomie continente utilisant le caecum. J. d'Urol., 91: 704, 1985. Kock, N. G., Myrvold, H. E., Nilson, L. 0. and Ahren, C.: Construction of a stable nipple valve for the continent ileostomy. Ann. Chir. Gynaec., 69: 132, 1980. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Clinical experience with the Kock continent ilea! reservoir for urinary diversion. J. Ural., 132: 1101, 1984. Ashken, M. H.: An appliance-free ileocaecal urinary diversion: preliminary communication. Brit. J. Ural., 46: 631, 1974. Askhen, M. H.: Continent ileocaecal urinary reservoir. J. Roy. Soc. Med., 71: 357, 1978. Ashken, M. H.: The continent urostomy. Letter to the Editor. Brit. Med. J., 2: 830, 1978.