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Cutaneous Transureterostomy in Children
Vol. 114, October
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1975 by The Williams & Wilkins Co.
CUTANEOUS TRANSURETEROSTOMY IN CHILDREN GILLES BELAND
IVAN LABERGE
AND
From the Section of Urology, Department of Surgery, University of Montreal, Montreal, Canada
ABSTRACT
Cutaneous transureterostomy was done on 18 patients with chronically dilated upper tracts. The operation is simple with minimal immediate complications. Long-term results are good despite the frequent persistence of chronic urinary infection and dilatation of the ureters, which are attributable to their persistent damage. We believe that cutaneous transureterostomy represents a good type of urinary diversion for these children. Although some controversy persists about cutaneous ureterostomy it has become generally accepted as a good type of diversion when performed on thickened and dilated ureters. 1-3 Transureteroureterostomy also has been recognized as a safe procedure. 4-7 The association of these 2 operations as a form of urinary diversion was first reported in 1957 by Obrant. 8 It was used primarily as a diversion on terminal patients when an operation shorter than a ureteroileal conduit with avoidance of bowel problems was sought. 5 • 6 • "· 10 Weiss and associates were the first to report it as a form of permanent urinary diversion in children in 1966, with 5 successful cases and followup evaluation of 19 months to 7 years. 11 Since that time 43 cases have been reported with uniformly good results.•, 12 • 14 MATERIAL AND METHODS
Cutaneous transureterostomy was done on 18 children at Ste-Justine Hospital during the last 8 years. The ages of the children ranged from 1 to 13½ years, with an average of 7.9 years. All patients had 2 ureters of at least 1 cm. and usually more in diameter, secondary to a chronic disease of the lower urinary tract. The abnormalities of the upper tracts were secondary to neurogenic bladders in 13 patients, vesicoureteral reflux in 3 and functional closures of exstrophies in 2. All patients had constantly infected urine and 14 had had multiple episodes of acute renal infection. Renal function was normal in 11 patients, slightly abnormal (serum creatinine up to 2 mg. per cent) in 4 and definitely abnormal in 3. The cutaneous ureterostomy was done indifferently on 1 side or the other except when 1 ureter appeared larger and thicker than the other or when the stoma seemed better located on a particular side. The selection of the stomal site is considered important to facilitate the use of the collecting device. Its best location is determined preopera-
tively with each patient in the supine, upright and sitting positions, In all cases the cutaneous ureter ostomy consisted of a simple direct anastomosis of the spatulated end of the ureter with the skin. The ureters never traversed the peritoneal cavity freely, The only other common principles observed were the lack of tension on the ureter, the maximal protection of its blood supply and an opening of 2 fingerbreadths through the whole thickness of the abdominal wall, The transureteroureterostomy was done without tension and with careful displacement of the ureter in order to prevent any injury to its vascular supply. An end-to-side anastomosis was done with or without spatulation and with or without excision of a wedge in the receiving ureter. Chromic catgut was used in all cases, ranging in size from 3 to 5-zero, with continuous sutures in 12 cases an<' interrupted sutures in 6. A watertight closure was desired, A ureteral stent was left temporarily in 1 ureter or the other in 8 cases. It is our present policy to leave a large infant feeding tube (SF) through the thickness of the abdominal wall for the first few days postoperatively. A Penrose drain was left close to the ureteroureteral anastomosis and brought out through a stab wound in the flank or through the inferior portion of the abdominal incision when a cystectomy was done. Cystectomy was performed at the same time in 5 cases. RESULTS
Convalescence was uneventful in all patients except 1 who had some pulmonary atelectasis. No significant ileus was noted and no urinary leakage was seen in any case. All wounds healed primarily without problem, Followup of 16 children ranged from 1 to 8 years, with an average period of 4.7 years. The remaining 2 patients are doing well but it is too early to include them in the followup study. Of the 16 children renal function remained stable in 10, improved in 5 and deteriorated in L This last patient, who is the only failure of the series, died of severe hypertension with chronic
Accepted for publication March 7, 1975. Read at annual meeting of Canadian Urological Association, Ottawa, Canada, June 29-July 2, 1974, 588
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z A, preoperative excretory urogram (IVP) shows poor renal function and marked bilateral dilatation. B, IVP 2 months after left cutaneous transureterostomy shows improved function and markedly decreased dilatation. C, retrograde ureterogram shows minimal dilatation 6 years after diversion and 3 months before death.
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BELAND AND LABERGE
renal failure and chronic urinary infection 6 years after diversion. The urinary tract drained well with no residual urine and with moderate dilatation and a stomal calibration of 18F (see figure). The appearance of the upper tracts on followup pyelograms was always similar on both sides. Improvement in dilatation depended upon the intrinsic lesion of the ureters rather than on any persistent obstruction. Dilatation remained unchanged in 7 patients, decreased slightly in 3 and decreased markedly in 6. After diversion 5 patients continue to have infected urine, 5 have never had infected urine and 6 have variable cultures. Only 1 episode of acute pyelonephritis was seen 4 years after diversion. With the bladder left in place 1 patient had 1 episode of cystitis which responded well to irrigations with antibiotics and 1 patient had multiple episodes of purulent cystitis for which a cystectomy was done. This cystectomy was the only operation that was done in all the urinary tracts after diversion had been performed. Some decrease in the size of the stoma was seen in all patients up to 6 months postoperatively. However, after a period of time the size of the stoma always remained stable, except in 1 patient who has a stenosis at the skin level that is responding well to dilatation. A catheter was passed in the ureters of all patients and no residual urine under tension was seen. No ureter is intubated and urinary collecting devices were well tolerated by all patients. DISCUSSION
Although some authors have recommended different types of skin anastomosis to prevent the formation of a stenosis 3 • 6 • 9 • 12 this does not seem necessary. Transureteroureterostomy has never been a problem in our cases. The type of suture and the size of suture material do not seem to matter provided a watertight anastomosis is done without tension. The use of a splint postoperatively is also irrelevant. Our alternatives in these children would have been bilateral cutaneous ureterostomies with a single stoma or ilea! conduits. Other types of diversion such as bilateral nephrostomies or bilateral cutaneous ureterostom1es with 2 stomas are not even contemplated as a permanent condition. We have used bilateral cutaneous ureterostomies with a single stoma in only 1 case with a satisfactory result. 12 • 13 The operation probably has the advantage of permitting an easier bilateral catheterization if the need should arise 13 but this has never been necessar_y: in _the present series. On the other hand there is the disadvantage of a larger pool of urine in which a urinary tract infection is
probably more difficult to treat. The replacement of a ureteral mobilization to the skin by a transureteroureterostomy is more appealing. Cutaneous ureteroileostomy represents a longer and much more complex operation. It involves the use of bowel with its numerous related complications. The long-term results obtained with this type of diversion as reviewed by Richie in dilated renal units are not as good as generally believed 15 and definitely not as good as those obtained in our short series with cutaneous transureterostomy. Persistent urinary tract infection remains a problem. However, this infection is usually not clinical and is comparable in incidence to that seen in cutaneous ureteroileostomy. 16
REFERENCES
1. De Vries, J. K.: Permanent diversion of urinary stream. J. Ural., 73: 217, 1955. 2. Humphreys, G. A.: Permanent cutaneous ureterostomy; a review of 17 4 cases. Cancer, 9: 572, 1956. 3. Lapides, J.: Butterfly cutaneous ureterostomy. J. Ural., 88: 735, 1962. 4. Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy: a neglected procedure. J. Ural., 109: 817, 1973. 5. Smith, R. B., Harbach, L. B., Kaufman, J. J. and Goodwin, W. E.: Crossed ureteroureterostomy: variation of uses. J. Ural., 106: 204, 1971. 6. Malament, M.: The ureteral conduit: cutaneous transnretero-ureterostomy.J. Ural., 101: 162, 1969. 7. Smith, I.: Trans-uretero-ureterostomy. Brit. J. Ural., 41: 14, 1969. 8. Obrant, K. 0.: Cutaneous ureterostomy with skin tube and plastic cup appliance together with transuretero-ureteral anastomosis. Brit. J. Ural., 29: 135, 1957. 9. Brown, R., Barnes, R., Wensell, G. and Asghar, M.: Ureteroureterostomy and cutaneous ureterostomy. J. Ural., 106: 658, 1971. 10. Young, J. D., Jr. and Aledia, F. T.: Further observations on flank ureterostomy and cutaneous transureteroureterostomy. J. Ural., 95: 327, 1966. 11. Weiss, R. M., Beland, G. A. and Lattimer, J. K.: Transuretero-ureterostomy and cutaneous ureterostomy as a form of urinary diversion in children. J. Ural., 96: 155, 1966. 12. Straffon, R. A., Kyle, K. and Corvalan, J.: Techniques of cutaneous ureterostomy and results in 51 patients. J. Ural., 103: 138, 1970. 13. Kendall, A. R. and Karafin, L.: Urinary diversion in children. J. Ural., 109: 717, 1973. 14. Halpern, G. N., King, L. R. and Belman, A. B.: Transureteroureterostomy in children. J. Ural., 109: 504, 1973. 15. Richie, J. P.: Intestinal loop urinary diversion in children. J. Ural., 111: 687, 1974. 16. Stewart, W., Cass, A. S. and Matsen, J. M.: Variation in bacteriuria with intestinal loop urinary diversions. J. Ural., 111: 117, 1974.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1975 by The Williams & Wilkins Co.
CUTANEOUS TRANSURETEROSTOMY IN CHILDREN GILLES BELAND
IVAN LABERGE
AND
From the Section of Urology, Department of Surgery, University of Montreal, Montreal, Canada
ABSTRACT
Cutaneous transureterostomy was done on 18 patients with chronically dilated upper tracts. The operation is simple with minimal immediate complications. Long-term results are good despite the frequent persistence of chronic urinary infection and dilatation of the ureters, which are attributable to their persistent damage. We believe that cutaneous transureterostomy represents a good type of urinary diversion for these children. Although some controversy persists about cutaneous ureterostomy it has become generally accepted as a good type of diversion when performed on thickened and dilated ureters. 1-3 Transureteroureterostomy also has been recognized as a safe procedure. 4-7 The association of these 2 operations as a form of urinary diversion was first reported in 1957 by Obrant. 8 It was used primarily as a diversion on terminal patients when an operation shorter than a ureteroileal conduit with avoidance of bowel problems was sought. 5 • 6 • "· 10 Weiss and associates were the first to report it as a form of permanent urinary diversion in children in 1966, with 5 successful cases and followup evaluation of 19 months to 7 years. 11 Since that time 43 cases have been reported with uniformly good results.•, 12 • 14 MATERIAL AND METHODS
Cutaneous transureterostomy was done on 18 children at Ste-Justine Hospital during the last 8 years. The ages of the children ranged from 1 to 13½ years, with an average of 7.9 years. All patients had 2 ureters of at least 1 cm. and usually more in diameter, secondary to a chronic disease of the lower urinary tract. The abnormalities of the upper tracts were secondary to neurogenic bladders in 13 patients, vesicoureteral reflux in 3 and functional closures of exstrophies in 2. All patients had constantly infected urine and 14 had had multiple episodes of acute renal infection. Renal function was normal in 11 patients, slightly abnormal (serum creatinine up to 2 mg. per cent) in 4 and definitely abnormal in 3. The cutaneous ureterostomy was done indifferently on 1 side or the other except when 1 ureter appeared larger and thicker than the other or when the stoma seemed better located on a particular side. The selection of the stomal site is considered important to facilitate the use of the collecting device. Its best location is determined preopera-
tively with each patient in the supine, upright and sitting positions, In all cases the cutaneous ureter ostomy consisted of a simple direct anastomosis of the spatulated end of the ureter with the skin. The ureters never traversed the peritoneal cavity freely, The only other common principles observed were the lack of tension on the ureter, the maximal protection of its blood supply and an opening of 2 fingerbreadths through the whole thickness of the abdominal wall, The transureteroureterostomy was done without tension and with careful displacement of the ureter in order to prevent any injury to its vascular supply. An end-to-side anastomosis was done with or without spatulation and with or without excision of a wedge in the receiving ureter. Chromic catgut was used in all cases, ranging in size from 3 to 5-zero, with continuous sutures in 12 cases an<' interrupted sutures in 6. A watertight closure was desired, A ureteral stent was left temporarily in 1 ureter or the other in 8 cases. It is our present policy to leave a large infant feeding tube (SF) through the thickness of the abdominal wall for the first few days postoperatively. A Penrose drain was left close to the ureteroureteral anastomosis and brought out through a stab wound in the flank or through the inferior portion of the abdominal incision when a cystectomy was done. Cystectomy was performed at the same time in 5 cases. RESULTS
Convalescence was uneventful in all patients except 1 who had some pulmonary atelectasis. No significant ileus was noted and no urinary leakage was seen in any case. All wounds healed primarily without problem, Followup of 16 children ranged from 1 to 8 years, with an average period of 4.7 years. The remaining 2 patients are doing well but it is too early to include them in the followup study. Of the 16 children renal function remained stable in 10, improved in 5 and deteriorated in L This last patient, who is the only failure of the series, died of severe hypertension with chronic
Accepted for publication March 7, 1975. Read at annual meeting of Canadian Urological Association, Ottawa, Canada, June 29-July 2, 1974, 588
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z A, preoperative excretory urogram (IVP) shows poor renal function and marked bilateral dilatation. B, IVP 2 months after left cutaneous transureterostomy shows improved function and markedly decreased dilatation. C, retrograde ureterogram shows minimal dilatation 6 years after diversion and 3 months before death.
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590
BELAND AND LABERGE
renal failure and chronic urinary infection 6 years after diversion. The urinary tract drained well with no residual urine and with moderate dilatation and a stomal calibration of 18F (see figure). The appearance of the upper tracts on followup pyelograms was always similar on both sides. Improvement in dilatation depended upon the intrinsic lesion of the ureters rather than on any persistent obstruction. Dilatation remained unchanged in 7 patients, decreased slightly in 3 and decreased markedly in 6. After diversion 5 patients continue to have infected urine, 5 have never had infected urine and 6 have variable cultures. Only 1 episode of acute pyelonephritis was seen 4 years after diversion. With the bladder left in place 1 patient had 1 episode of cystitis which responded well to irrigations with antibiotics and 1 patient had multiple episodes of purulent cystitis for which a cystectomy was done. This cystectomy was the only operation that was done in all the urinary tracts after diversion had been performed. Some decrease in the size of the stoma was seen in all patients up to 6 months postoperatively. However, after a period of time the size of the stoma always remained stable, except in 1 patient who has a stenosis at the skin level that is responding well to dilatation. A catheter was passed in the ureters of all patients and no residual urine under tension was seen. No ureter is intubated and urinary collecting devices were well tolerated by all patients. DISCUSSION
Although some authors have recommended different types of skin anastomosis to prevent the formation of a stenosis 3 • 6 • 9 • 12 this does not seem necessary. Transureteroureterostomy has never been a problem in our cases. The type of suture and the size of suture material do not seem to matter provided a watertight anastomosis is done without tension. The use of a splint postoperatively is also irrelevant. Our alternatives in these children would have been bilateral cutaneous ureterostomies with a single stoma or ilea! conduits. Other types of diversion such as bilateral nephrostomies or bilateral cutaneous ureterostom1es with 2 stomas are not even contemplated as a permanent condition. We have used bilateral cutaneous ureterostomies with a single stoma in only 1 case with a satisfactory result. 12 • 13 The operation probably has the advantage of permitting an easier bilateral catheterization if the need should arise 13 but this has never been necessar_y: in _the present series. On the other hand there is the disadvantage of a larger pool of urine in which a urinary tract infection is
probably more difficult to treat. The replacement of a ureteral mobilization to the skin by a transureteroureterostomy is more appealing. Cutaneous ureteroileostomy represents a longer and much more complex operation. It involves the use of bowel with its numerous related complications. The long-term results obtained with this type of diversion as reviewed by Richie in dilated renal units are not as good as generally believed 15 and definitely not as good as those obtained in our short series with cutaneous transureterostomy. Persistent urinary tract infection remains a problem. However, this infection is usually not clinical and is comparable in incidence to that seen in cutaneous ureteroileostomy. 16
REFERENCES
1. De Vries, J. K.: Permanent diversion of urinary stream. J. Ural., 73: 217, 1955. 2. Humphreys, G. A.: Permanent cutaneous ureterostomy; a review of 17 4 cases. Cancer, 9: 572, 1956. 3. Lapides, J.: Butterfly cutaneous ureterostomy. J. Ural., 88: 735, 1962. 4. Udall, D. A., Hodges, C. V., Pearse, H. M. and Burns, A. B.: Transureteroureterostomy: a neglected procedure. J. Ural., 109: 817, 1973. 5. Smith, R. B., Harbach, L. B., Kaufman, J. J. and Goodwin, W. E.: Crossed ureteroureterostomy: variation of uses. J. Ural., 106: 204, 1971. 6. Malament, M.: The ureteral conduit: cutaneous transnretero-ureterostomy.J. Ural., 101: 162, 1969. 7. Smith, I.: Trans-uretero-ureterostomy. Brit. J. Ural., 41: 14, 1969. 8. Obrant, K. 0.: Cutaneous ureterostomy with skin tube and plastic cup appliance together with transuretero-ureteral anastomosis. Brit. J. Ural., 29: 135, 1957. 9. Brown, R., Barnes, R., Wensell, G. and Asghar, M.: Ureteroureterostomy and cutaneous ureterostomy. J. Ural., 106: 658, 1971. 10. Young, J. D., Jr. and Aledia, F. T.: Further observations on flank ureterostomy and cutaneous transureteroureterostomy. J. Ural., 95: 327, 1966. 11. Weiss, R. M., Beland, G. A. and Lattimer, J. K.: Transuretero-ureterostomy and cutaneous ureterostomy as a form of urinary diversion in children. J. Ural., 96: 155, 1966. 12. Straffon, R. A., Kyle, K. and Corvalan, J.: Techniques of cutaneous ureterostomy and results in 51 patients. J. Ural., 103: 138, 1970. 13. Kendall, A. R. and Karafin, L.: Urinary diversion in children. J. Ural., 109: 717, 1973. 14. Halpern, G. N., King, L. R. and Belman, A. B.: Transureteroureterostomy in children. J. Ural., 109: 504, 1973. 15. Richie, J. P.: Intestinal loop urinary diversion in children. J. Ural., 111: 687, 1974. 16. Stewart, W., Cass, A. S. and Matsen, J. M.: Variation in bacteriuria with intestinal loop urinary diversions. J. Ural., 111: 117, 1974.