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Diversion of the Urinary Stream1
DIVERSION OF THE URINARY STREAM1 GEORGE GILBERT SMITH Boston, Massachusetts
The indications for diversion of the urine are numerous. Ahead of all others is that distressing condition, exstrophy of the bladder, for which the greatest number of operations for diversion has been done. Other conditions involving loss of urinary control, such as incurable vesico-vaginal fistula, have called for ureteral transplantation. Another group of patients who have begged for relief has been composed of cases with extreme vesical irritability; cases of submucous fibrosis and tuberculosis are found in this group. All of the above-mentioned cases come but seldom to the urologist; they are relatively few in number. Another type of case-the patient with cancer of the bladder-is in a different category; him we see frequently; his problem is the outstanding problem of urology today. Although many cases of bladder carcinoma are amenable to less radical methods of treatment, there is gradually developing among urologists the conviction that for a considerable proportion of such cases, total cystectomy is the only logical solution. The difficulty lies not so much in the removal of the bladder as in the diversion of the urine. The series of 50 cases forming the basis of this report were chiefly cases of malignant disease of the bladder. I hope that you will bear this fact in mind when appraising the results. Of the 50 cases, 38 had bladder cancer, 4 prostatic cancer, 3 vesico vaginal fistula, 3 fibrosis of the bladder, 1 exstrophy, 1 diverticulitis (thought to be cancer). The methods of diverting the urine are three-nephrostomy, transplantation of the ureters to the skin and transplantation to the bowel. In only 1 case of this series was nephrostomy done, and that was preliminary to ureteroenterostomy, as suggested by Hinman. Nephrostomy, while a satisfactory method of draining the kidney in cases of hydronephrosis and pyonephrosis, is not always free from complications. Unless the ureter is ligated at the pelvic outlet, some urine is likely to pass down the ureter. At times, the sinus tract may lose its continuity so that replacement of the tube in the renal pelvis is difficult. Minor 1 Presented before the annual meeting of the American Urological Association, Atlantic City, N. J., May 22-24, 1934. 179
180
GEORGE GILBERT SMITH
calices may become blocked because the tube obstructs the infundibulum; stone formation may occur. Bilateral nephrostomy requires 2 major operations, even though both are done at one time, and the location of the fistulae in the loin interferes with the patient's care of his drainage apparatus. That permanent nephrostomy is not the best solution to the problem of urinary diversion is indicated by the fact that it is seldom employed for this purpose. Papin (10), however, found 9 cases in which nephrostomy had been done. There was but 1 death. Ureterostomy- transplantation of the ureters to the skin-is said to have been first suggested by Gigon (5) in 1856; LeDentu is credited with being the first surgeon to do this operation. It is not suitable for cases of exstrophy, in which ureterosigmoidostomy has given such satisfactory results, nor for most cases of vesico-vaginal fistula. In cancer of the bladder, however, it has certain advantages over other methods of urinary diversion. Two indications exist: (a) in inoperable cancer, purely as a palliative procedure; (b) when total cystectomy is possible. In cancer of the bladder, one or both ureters are likely to be dilated, with an accompanying pyelonephritis. By bringing the ureters to the skin and draining the renal pelves with catheters, faulty drainage can be relieved and the pelves can be irrigated until infection is reduced to a minimum. If total cystectomy is planned, the removal of the bladder and the transplantation of the ureters to the skin may be done at the same operation without imposing too great a burden on the patient. This procedure has been advocated by Edwin Beer (2), who reported 7 cases without an operative death, and by Henry Wade (14). In his series of 181 collected cases of cystectomy, Papin (10) found 57 in which ureterostomy had been done. The mortality was 32 per cent, in contrast with a mortality of 59 per cent in 81 cases in which ureteroenterostomy was the method selected. There is no question in my own mind that ureterostomy in most cases of cancer of the bladder is a more feasible operation than ureteroenterostomy. The technique of ureterostomy which I have followed has varied somewhat in its minor details. There were 22 cases; in 3 cases a musclesplitting (gridiron) incision was made mesial to the anterior superior spine. The peritoneum was stripped inwards, the ureter identified, freed as low as possible below the pelvic brim, and the cephalad segment fastened at the lower angle of the incision. A rubber drain was placed above the ureter to drain the retroperitoneal space, and a catheter, varying in size according to the degree of dilatation of the ureter, was inserted
DIVERSION OF URINARY STREAM
181
to the renal pelvis. The free end of the ureter was sutured to the edge of the skin incision. In 1 case the same operation was done through incisions at the outer edge of the rectus. In 18 cases the ureters were freed through a median suprapubic incision (extraperitoneal) and were brought to the skin through stab wounds made 1 inch mesial to and 1 inch below the anterior superior spine. This approach was used in all cases of total cystectomy, of which there were ·11. In 10 days to 2 weeks after operation the catheters may be changed, larger ones being inserted if desired. Eventually the ureteral wall thickens and thr lumen becomes more dilated, so that 16 French catheters with open tips may be used as the permanent drains. These are held in place by a flange made of sponge rubber or by the disk manufactured by Eynard. Strips of adhesive or some form of belt may be used to hold the catheters in place; the patient irrigates the tubes once a day and if at all adept he can even remove, clean and replace the catheters. The catheters are attached to a Y tube which is connected with a hot water bottle by the type of stopper which is perforated by a short tube. The entire system is air-tight and leakage about the catheters does not occur unless they become obstructed or out of place. The patient who was drained in this way for the greatest length of time was a woman with a vesico-vaginal fistula; I had planned to do a ureteroenterostomy, but found this impossible because the bowels were matted together by adhesions. This patient died of cancer of the biliary tract 6 years later; autopsy showed the kidneys to be in excellent condition, neither dilated nor appreciably infected. Ureterostomy, however, has not been without fatalities and complications. Of the 22 cases in this series, 10 died within 6 weeks after operation. Three of these had prostatic cancer; all died just 6 weeks after operation. Autopsy in 1 of them showed bilateral pyelonephritis. All were in poor condition; operation was done as an alternative to suprapubic cystotomy. Three others died after simple bilateral ureterostomy, 1 in 4 days, 1 in 13 days, 1 in 4 weeks. Autopsy in one of these showed chronic pyelonephritis and abscesses of spleen and kidneys; in another, facial erysipelas, acute tubular nephritis, pyelonephritis. In 4 cases, cystectomy was done at the same time as the ureterostomy. One died ·immediately of shock; 1 in 4 days of suppurative nephritis, (autopsy); 1 in 11 days of right pyonephrosis and perinephritic abscess; 1 in 6 days of delirium tremens. Autopsy in this case showed the kidneys and ureters to be in good condition (table 1).
182
GEORGE GILBERT SMITH
Eleven cystectomies were done. Of these 7 survived operation. One died 5 months later of recurrence in the pelvis; another 10 weeks after operation of a cerebral accident, either metastasis or thrombosis. Five are living and apparently well, 2 months, 2 months, 10 months, 1 year and 17 months after operation. The value of this operation in cases of bladder cancer which are too advanced for cystectomy is doubtful. Life is probably prolonged, but to what purpose? Bladder distress is by no means done away with, for the sloughing, infected bladder still strives to express the foul purulent fluid which accumulates. The patient grows weaker day by day; TABLE
1.-Ureterostomy, 22 cases LIVED
DIED
U reterostomy alone .... . . ........ .. . .. . ... . . . . . . ... . ... . . Ureterostomy plus cystectomy . . ........... . ..... . .... . ... .
5
6
7
4
Cancer of prostate .. ... . . . . . . ........ . .. . . .. ... .. . ... ... . Cancer of bladder . . ... . . . . . .. .. . . . ...... . .. . ... . . . . ..... . Vesico-vaginal fistula ....... . .... . .. . ... . . ... ... . .. ... . . . .
3 18 1
TABLE
2.-Ureteral slough NUMBER OF CASES
Died too soon for this to occur . . . . . ...... . ... . .... . .. . .... . ..... . . . . No slough ................ . . . . .. . . . ... . . .. . . . . .. . . . . . . . . ... . . . ... . One ureter sloughed . ............... . .. ... . ... . . . . . ..... ... . ... . .. . Both ureters sloughed ... .. . .. . . . ....... . . . .. .. . . .. .. . ...... . . .... .
3
13 4 2
nausea is constant. The 4 patients in this group lived- if it can be called such-an average of 14 weeks after operation. For the surgeon, the chief source of anxiety after ureterostomy is the question of viability of the ureter. The ureter may slough for a varying distance, but if a perforation takes place beneath the abdominal wall, retroperitoneal abscess is likely to form. If the abscess does not develop, the continuity of the urinary channel may become lost; the catheter, once removed, cannot be replaced. In these 22 cases, 3 died before sloughing might occur. In the remaining 19, 37 ureters were transplanted (table 2). Eight ureters in 6 patients sloughed to a degree that required another operation to explore the retroperitoneal space, pick up the ureter and carry it to another point on the surface of the body. This operation is not a severe one; no patient died as a result. Experience
DIVERSION OF URINARY STREAM
183
has shown that the best method is to make a muscle-splitting inos10n above the crest of the ilium, roll back the peritoneum, identify the ureter well above the area of inflammatory exudate, free it as far down as it is viable and swing it outwards to a location above the iliac crest. The ureter will be found to be thicker .than normal and better able to withstand transplantation. Hypertrophied, dilated ureters are much less likely to slough than are the delicate, normal ureters. I am hoping to get some light upon this point; Beer apparently had no such mishap in the 7 cases reported by him although other operators mention this complication (Schunk (12)). It is possible that better results might be obtained if the ureters were not intubed during the first week. The advantages of ureteral transplantation to the bowel are obvious. Two questions remain to be settled, however. (a) Can this operation be done with as little risk to the patient as ureterostomy? (b) Is the renal drainage sufficiently adequate to prevent the development of hydronephrosis, pyelonephritis and renal calculus? As to the ability of the rectum to adapt itself to this new function, there is no question. Occasional cases have been reported in which rectal tenesmus or incontinence has occurred, but these instances have been so few as to be negligible. The mortality of this operation has varied tremendously with different operators and with varying types of patients. The best results have been attained in exstrophy; in this condition the patient is usually operated upon in childhood, when the power to resist infection and the ability of the organs to readjust themselves to new conditions are high. There is no need for haste, as there is when cancer exists, so the ureters may be transplanted one at a time. That transplantation of one ureter at a time is the safest method there is little doubt. Walters (15) reports from the Mayo Clinic 76 cases done in this way with but three operative deaths; Cabot (3) reports 14 with no operative deaths. On the other hand, Coffey (4) himself, implantating both ureters at once, had 2 deaths in cases of exstrophy, 1 from intestinal obstruction and 1 from ureteral slough and pyonephrosis. More than 25 surgeons have reported successful cases of ureteroenterostomy, done mostly for exstrophy but in a few instances for vesico-vaginal fistula and tuberculosis. There is no question that in exstrophy, transplantation into the bowel is a relatively safe procedure, certainly so far as immediate results are concerned. Ureteroenterostomy for cancer of the bladder, however, is a different
184
GEORGE GILBERT SMITH
matter. Here the element of time is all-important; one seldom feels justified in advising 3 major operations within a period of a few weeks. The procedure which is generally followed consists in transplanting both ureters at 1 operation, and removing the bladder at a second operation. Coffey (4) reported 15 cases of bladder tumor in which he did ureteral transplantation; 10 of these had ureteroenterostomy done, with 2 deaths; 3 had secondary cystectomy, with no deaths; 2 had simultaneous transplantation and cystectomy and both died. The total mortality, 4 deaths in 15 cases, is considerably below that reported by other operators. Papin (10), in a paper on total cystectomy, summarizes the results in 181 collected cases. In 81, preliminary ureteroenterostomy had been performed with a mortality of 59.2 per cent. Papin says " The results remain bad because the patients are always in a worse state than one supposes. Renal lesions are always more advanced." Little need be said about the technique of this operation, nor about its history. The latter has been well covered by Steinke (13), Charles Mayo (8) and Kirwin (7) . The older methods of Maydl, Bergenhem and Peters have been discarded by the vast majority of operators in favor of Coffey's oblique implantation, either with or without tubes. If both ureters are transplanted at once, it is undoubtedly safer to intube the ureters; when one side is done at a time, there is some question whether tubes should be used or not. Cabot has advised the use of a short tube, just long enough to preserve a channel through the portion of the ureter which lies within the intestinal wall. Mayo has employed a strand of catgut to serve this purpose. The Coffey technique No. 3, in which the formation of a stoma is delayed for 24 to 48 hours, has been used, so far as I am aware, by only one operator. Higgins (6) incorporated this feature in his ingenious technique, in which he does a lateral anastomosis between the ureter and the bowel, allowing the ureter to drain into the bladder until the second operation, when the ureter is ligated just below its anastomosis with the bowel. He reports 7 cases operated upon by this method with no deaths- a most excellent result. It would appear to me, however, that a lateral anastomosis of this sort would be much more liable to cicatricial contraction later on; I hope that we may have a report 2 years from now on the condition of these 7 patients. In my own series of 28 ureteroenterostomies, 52 ureters were transplanted. In 24 of these cases, the operation was done for cancer of the bladder; 10 of them had cystectomies. In 2, the operation was because
185
DIVERSION OF URINARY STREAM
of vesico-vaginal fistula; in 1, exstrophy; in 1, intractable submucous fibrosis. Table 3 gives the results. Thirty-three per cent of intubecl patients livecl; 70 per cent of non-intubecl patients lived; lived 13; died 15-a mortality of 53 per cent. Looking at this from another angle, we see that 52 ureters were transplanted. Five patients died too soon for one to determine whether the implantation was successful, thereby removing 10 ureteral implantations from the picture. Of the 42 remaining, there were: I
WITH TUBES
I Successful transplants . Unsuccessful transplants.
17 7
I
I
WITHOUT TUBES
--1
12
I
6
In other words, of the intubed ureters, 71 per cent functioned; 29 per cent did not. TABLE
3 DIED
Ll\'ED
I ---------~---~
One ureter at a time Both ureters at once Both ureters and cystectomy.
b l
ntu ec
-~·-
Ij
"ot
-----
2
s
3
2
6
?\~ot intulwd
In tubed
intuLed
I
I
3
2 0
()
I
7 2
7
I
12
I
3
----------------
Of the non-intubed ureters, 67 per cent functioned; 33 per cent did not. Too much weight should not be attached to these figures; I still believe that when both ureters are transplanted at once, tubes should be used. The figures do prove that intubation is not essential to successful transplantation; indeed, it may be a factor against it. When tubes are employed, I believe they should lie in the kidney pelvis. An excellent tube for this purpose is the soft rubber ureteral catheter size 8 French, manufactured by Eynard. The method which I have used for the past 4 or 5 years to draw the tube down the bowel is as follows: A No. 12 French ureteral bougie is passed into the rectum; the operator can guide it past the kinks in the bowel until the tip is opposite the site of anastomosis. A tiny nick is then made through the mucosa of the bowel over the tip of the bougie, the tip is extruded, the
186
GEORGE GILBERT SMITH
open end of the ureteral tube threaded over it and the bougie then withdrawn.2 Aside from this point, I have no technical modifications to offer. I believe that careful pre-operative cleansing of the bowel is important; if this is done, it is unnecessary to irrigate the bowel at the time of operation, and intestinal clamps will not be needed unless one is doing the second ureter. In that case, urine from the other side may be present in the bowel, although this can be largely obviated by leaving in a rectal tube. I have always employed rubber wick drainage, al-
FIG. l. Microphotograph of cross-section of intestinal wall, with transplanted right ureter, taken from a case dying 3 weeks after ureteroenterostomy. The right kidney and ureter \Yere in good condition.
though I endeavor to place the wick as far from the anastomosis as possible. The total operative mortality in these 28 cases was 15 (53 per cent). In 13, the chief cause of death was determined either by operation or by autopsy. Two cases, both of which had cystectomy and ureteroenterostomy at one time, died of shock. Three cases developed intestinal obstruction, a loop of small bowel having adhered to the line of suture in 2, and in 1 having become caught beneath the ureter. (In 2
This technique has also been suggested by Chute.
187
DIVERSION OF URINARY STREAM
this case both ureters were implanted side by side.) One case died of endocarditis, with multiple infarcts. One case showed thrombosis of the iliac vein and vena cava. Three cases had pelvic abscesses and local peritonitis. In 7 cases renal sepsis was the apparent cause of death (1 of these also had intestinal obstruction, relieved by enterostomy) (table 4). In all but 1 of the cases of renal sepsis, there was trouble at the lower end of the ureter, evidenced by urinary leakage. A recent autopsy on a man dying 3 weeks after combined cystectomy and ureteroenterostomy illustrated the pathology of this condition. The right anastomosis, kidney and ureter were healthy (fig. 1). The left ureter (in which a short tube had been placed because of preexisting dilatation and infection) was still implanted in the bowel, but it was sloughing and had perforated. An abscess had formed which in spite of drainage, had extended across the pelvic peritoneum to the region of TABLE
4.-Causes of death and complications in u.reteroenterostomy, 15 cases NU1t BER OJ? CA.SF:::;
- - - - - - - - - - - - - ---------··---- --------
Shock (cystectomy at same time). Intestinal obstruction (all of small bowel) .. Endocarditis and multiple infarcts .. Local abscess and peritonitis .... Renal sepsis (slough of ureter or non-union in 6) --
--
2 3
. . .I
3
. . .i
7
---------~----------------
the cecum. The left kidney was severely infected. It is disheartening to have some of these cases, in which operation appears to have been technically satisfactory, develop complications which are almost certain to result fatally. Secondary nephrostomy, bihteral in 1 case, was done 3 times in this series; 1 of these cases lived, but 2 died. I have not done any secondary ureterostomies, as advised by Coffey. The later results of ureteroenterostomy have not been thoroughly reported in the literature. Walters (15) reports a series of 59 patients, 10 of whom had been operated upon less than 1 year before. Fifty per cent of these 59 cases showed no evidence of renal infection. In 21 per cent, slight evidence of mild renal infection had occurred at long intervals. A few scattering reports of cases operated upon years before are to be found. Allison (1) reports a case of exstrophy in whom some type of Maydl's operation had been done 26 years before A left calculous pyonephrosis had developed; the right kidney was hypertrophied. Middleton (9) reports a case of exstrophy 20 years after he had transplanted
188
GEORGE GILBERT SMITH
the ureters by Coffey's method (but without catheters). An intravenous pyelogram showed normal ureters and pelves. Robinson and Foulds (11) report later developments in 1 of Peters' original 5 cases. The boy was operated upon in 1905; in 1925 he developed a right pyonephrosis, but after nephrectomy he regained his health. Of the cases in my series that survived operation, the following facts are known: Ureteroenterostomy for cancer of the bladder without cystectomy-6 cases-all died within 9 months. Ureteroenterostomy for cancer of the bladder with cystectomy-5 cases: 1. Halligan. Died 14 months after operation. Cause unknown. Barium enema showed reflux of barium to left renal pelvis (fig. 2).
FIG. 2 FIG. 2. Barium enema. X-ray barium in the left ureter and renal FIG. 3. Intravenous pyelogram FIG. 4. Intravenous pyelogram ureter was transplanted).
FIG.4 FIG.3 taken 25 days after tramplantation of ureters, showing pelvis. (Patno) before operation. (Patno) March 20, 1934 (about 3 months after second
2. Hamer. Died 8 months after operation of recurrence in spine. X-rays showed a left renal calculus. General health had been excellent until recurrence developed. 3. Briggs. (Unilateral transplantation, the other kidney having been removed for primary cancer of the ureter.) Died 14 months after operation of local recurrence. Enjoyed excellent health for at least 1 year. 4. Tobak. (Cystectomy and ureteral transplantation at 1 operation.) Died 2½ years after operation, apparently of pulmonary metastasis. He worked as a peddler in the interim. 5. Patno. (Ureters transplanted one at a time. Cystectomy on January 24, 1934.) Alive and apparently well. Non-protein nitrogen normal April 20, 1934. No symptoms. Urine shows
DIVERSION OF URINARY STREAM
189
practically no pus. Intravenous pyelograms (figs. 3 and 4) show an increasing hydronephrosis. Another case (No. 18), the only one of exstrophy in this series, was 25 years of age when he had bilateral transplantation of the ureters in April, 1929. Cystectomy was done a few months later, and 1 year ago his suprapubic hernia was repaired. He has married and his health has been much better since operation. His intravenous pyelograms done on April 10, 1930 and August 18, 1933 showed moderate dilatation of the right ureter and pelvis, but this had hardly increased in 3 years. He had developed a small calculus in the left kidney. His non-protein nitrogen is normal (figs. 5 and 6). A recent case (No. 13), in whom the right ureter was transplanted on January 15, 1934 because of submucous
FIG.5 FIG. 7 FIG.6 FIG. 5. Intravenous pyelogram (Treworgy) April 10, 1930, approximately 1 year after ureteral transplantation. FIG. 6. Intravenous pyelogram (Treworgy) September 18, 1933, 4½ years after transplantation. Plain films, though not very satisfactory, suggest the presence of calcium deposits in one calyx on each side. One ureter shows considerable dilatation, the other is normal. FrG. 7. Intravenous pyelogram of case 13, made 4 months after right ureteroenterostomy. Slight dilatation of the pelvis and concentration of the chemical point to some obstruction.
cystitis, has had no symptoms referable to the kidney. Her pyelogram done 4 months after the transplantation showed a slight dilatation of the pelvis on the transplanted side. A portion of dilated ureter may be seen just at the pelvic brim (fig. 7). SUMMARY
A discussion of the indications for diversion of the urinary stream and of the 3 principal methods of accomplishing this purpose-i.e., nephrostomy, ureterostomy and ureteroenterostomy-is the subject of this paper. A series of 50 cases, 22 ureterostomies and 28 ureteroenterostomies, is reported. The technique, the mortality, the causes of death and the end results are considered.
190
GEORGE GILBERT SMITH TABLE
NUM-1 BER
NAME
5-Ureteroenterostomies, 28 cases INDICATION
Group I.
REMARKS
One ureter transplantated at a time
Champlain
F.
56
Lymphosarcoma of bladder
Macbeth
M.
61
Carcinoma bladder
of
Patno
F.
58
Carcinoma bladder
of
Maxwell
M.
43
Carcinoma bladder
of
Cooper
M.
48
Carcinoma of bladder, extensive
Roach
M.
61
Carcinoma bladder
of
Seely
M.
49
Carcinoma bladder
of
W. Hamer
M.
47
Carcinoma bladder
of
9
Briggs
M.
67
Primary carci noma right ureter and bladder
10
Wallis
F.
39
Cancer of cervix; vesico-vaginal fistula
11
Rawding
F.
62
Carcinoma bladder
4
of
6/27 /22 Right ureter into ascending colon. No tube. 7/8/22 Left ureter into descending colon. No tube. 7/29/22 Total cystectomy. 8/20/22 Bilateral nephrostomy. Right kidney edematous; left perinephritic abscess. Died 8/21/22 10/22/20 Right ureter into cecum. No tube. 10 /29 /20 Left ureter into sigmoid. No tube. Both ureters dilated. Died at home 3/16/21 10/17 /33 Right ureter into sigmoid. No tube. 11/11/33 Left ureter into sigmoid. No tube. 1/24/34 Cystectomy. Alive and well 5/10/34 6/23/31 Bilateral nephrostomy. 7/23/31 Total cystectomy. 9/20/31 Left ureter into sigmoid. Intubed. Urine leaked from incision and continued to drain from nephrostomy sinus. 6/27 /32 Exploration of ureteral implantation. Ureter found to have sloughed or pulled out of bowel. Nephrostomy done, ureter ligated. 6/28/32 Patient had a sudden massive hemorrhage from left kidney and died 12/17 /21 Left ureter, dilated 0.5 cm., into sigmoid. No tube. 1/4/22 Right ureter, dilated 2 cm., into sigmoid. No tube. Had persistent urinary fistulae from both incisions. Discharged from hospital 2/15 /22 and died 3 days later 5/10/22 Right ureter into cecum. No tube. 5/31/22 Left ureter, dilated 1 cm., into sigmoid. No tube. Brief leakage of urine from right side. Discharged from hospital. Died 2 /9 /23 7/11/23 Right ureter, dilated, into cecum. No tube. 8/1/23 Left ureter into sigmoid. No tube. Died 8/4/23. Autopsy: Right kidney and ureter in good condition. Anastomosis well healed. Left anastomosis poorly healed. Left perirenal infection and left pyelonephritis 1/4/22 Right ureter into cecum. No tube. 1/17 /22 Left ureter into sigmoid. No tube. Both ureters normal. 2/7 /22 Total cystectomy. Patient made excellen t recovery and was well enough to play cricket. 7/19 /22 X-rays showed metastasis to spine and a stone in the left kidney. Died October, 1922 2/4/25 Right nephro-ureterectomy. 9/26/25 Left ureter, normal, into sigmoid. Intubed. 10/14/25 Cystectomy. Enjoyed excellent health for eight months then developed recurrence in pelvis. Died 11/6/26 8/18/31 Right ureter, normal, into sigmoid. No tube. 9/24/31 Left ureter, 0.5 cm. in diameter, into sigmoid. Intubed. Drained pus in urine from left incision. Died of pyelonephritis 10 /25 /31 4/10/31 Right ureter, 0.5 cm., into sigmoid. Intuhed. 5/21/31 Left ureter, normal, into sigmoid. Intubed. Good recovery. 6/15/31 Vesico-vaginal septum laid open and radium in platinum needles inserted into bladder cancer. Died at home 10/22/31
191
DIVERSION OF URINARY STREAM TABLE
NUM-1 BER
NAME
INDICATION
Group I. 12
Smith
5-Continued
F.
REMARKS
One ureter transplantated at a time-Concluded 60
Carcinoma
of
bladder
13
Mason
F.
58
14
Robertson
M.
50
Submucous fibrosis
Edwards
M.
47
Carcinom'a
of
Carcinoma
of
bladder
16
17
Doering
McKay
F.
M.
I \
56
Carcinoma
of
bladder
64
Carcinoma
elf
bladder
18
Treworgy
M.
25
Exstrophy bladder
19
Halligan
M.
43
Carcinoma
of
Halloran
M.
49
Carcinoma
of
bladder 21
Colby
M.
50
Carcinoma
bladder
5/27 /20 Both ureters, dilated, in sigmoid. No tubes. Developed intestinal obstruction. Laparotomy 6/1/20 Loop of small bowel adhered to anastomosis. Died 6/6/20 6/7 /20 Both ureters into rectum extraperitoneally. Right normal. Left dilated. Both intubed. Suprapubic urinary fistula on second day. 7/17 /20 Exploratory incision : Left side well healed. Right ureter re-implanted into cecum. 8/20/20 Right nephrostomy. Died 5/19/21 11/15/26 Both ureters into sigmoid. Intubed. Intestinal obstruction. Laparotomy 11/30/26 Loop of small bowel caught under one ureter. Enterostomy. Died 12/2/30 10/19/28 Both ureters into sigmoid. Right dilated 1 Intubed. Died 10/30/28. cm., left normal. Autopsy : Anastomosis well healed. Bacterio-endocarditis; septic infarcts, kidney, spleen, adrenal; early broncho-pneumonia 4/12/29 Both ureters, normal, into sigmoid. Intubed. Discharged 17 days after operation. Five years later in excellent health. Right pelvis and ureter moderately dilated. Left normal. Early renal calculi t 5 /2 /29 Both ureters, normal, into sigmoid. Intubed. Barium enema three weeks after operation showed
bladder
20
Died 12/6/30. Autopsy: Anastomosis well healed. Abscess in pelvis. Both kidneys showed noninfected hydronephrosis 1/15/34 Right ureter, normal, into sigmoid. No tube. Uneventful recovery. Intravenous pyelogram 2 months later shows slight dilatation of pelvis. 5/1/34 Left ureter, normal, into sigmoid. Ten days after operation patient was in excellent condition•
Both ureters transplanted at one time bladder
1-S
Left
ureter was occluded at the uretero-vesical junction.
of bladder
Group II.
11/15/30 Right ureter, dilated, in sigmoid.
of
reflux into left kidney. 6/21 /29 Total cystectomy and prostatectomy. Discharged 7/21/29. Died 7/21/30. Cause unknown 11/18/32 Both ureters, dilated, into sigmoid. Intubed. Some urinary leakage from incision. Died suddenly 12/11/32. No autopsy 9/23/25 Both ureters into sigmoid. Right normal; left I cm. in diameter. Intubed. Suprapubic tistula draining urine and feces.
Some urine by rec-
tum. 10/1/25 Extrusion of bowel into wound . Wound resutured . 10/31/25 Right nephrostomy for pyelonephntis. Died 11/9/25. No autopsy • Patient well Dec. 1934. had nephrectomy for calculous pyonephrosis. Recovery.
t Patient has
192
GEORGE GILBERT SMITH TABLE
NBER UM-1
NAME
INDICATION
Group II. 22
5-Conclztded
Clark
F.
REMARKS
Both ureters transplanted at one time-Conclztded 51
Carcinoma
of
bladder
23
Cook
F.
73
Carcinoma of cervix; vesicovaginal fistula
24
Parrow
M.
48
Carcinoma bladder
Group III.
of
12/ 11 / 29 Both ureters, normal, into sigmoid. Intubed. Four days after operation, nurse had pulled out both tubes. Patient died 12/ 16/ 29. Autopsy: Right anastomosis well healed . Left ureter torn off in the intramural portion of stump, pulled out of anastomosis easily. Intestinal wall not very well healed. Mucous membrane of bowel had sloughed over an area of 2 x 1 cm. Small abscess, 1 ccm. of pus between bowel and ovary 11 / 6/ 28 Both ureters into sigmoid . Intubed. Right dila ted I cm. Left normal. Dead 11 /14/ 28. Autopsy: Left hydronephrosis. Biiateral acute ureteritis; thrombosis right iliac vein and vena cava inferior. Cancer of cervix with invasion of bladder and rectum. Both anastomoses well healed 7/ 10/ 33 Both ureters, normal, into sigmoid. Intubed . Intestinal obstruction. 7/ 17 / 33 Laparotomy: Loop of small bowel adhered to anastomosis. Enterostomy. Died 7/ 30/ 33. Autopsy: Both kidneys show multiple abscesses; Left kidney shows a healing infarct. Both pelves contain pus. Bilateral pyoureteritis. Lower end of left ureter completely sloughed away from bowel surrounded by localized abscesses, right ureteroenterostomy well healed and lumen free
Both ureters transplanted at one time plus cystectomy
25
Tobek
M.
so
Carcinoma bladder
of
26
H. Hamer
M.
68
Carcinoma bladder
of
27
Chase
M.
58
Carcinoma bladder
of
28
Norris
M.
73
Carcinoma bladder
of
7/ 26/ 26 Total cystectomy. Both ureters implanted into rectum below peritoneal fold. Right normal Left moderately dilated. Intubed. Suprapubi fistula leaked feces and urine for a time then healed In good health for t wo years and able to work as a peddler. Died 2/28/ 29 with signs of metastasis in lungs 5/ 2/ 27 Total cystectomy. Both ureters into rectum extraperitoneally. Intubed. Died within 48 hour of shock 3/ 30/ 34 Total cystectomy. Both ureters into sig moid. Right normal, no tube. Left dilated ½cm short tube. Died 4/ 21/ 34. Autopsy: Right kid ney and ureter in good condition. Left kidney septic. Left ureter still implanted in bowel bu sloughing above the site of anastomosis. Ther e was a perforation with urinary leakage and an ab scess extending across the peritoneal cavity t 0 cecum 5/ 6/ 18 Total cystectomy. Both ureters into sigmoid No tubes. Died in three hours of shock
DIVERSION OF URINARY STREAM
193
CONCLUSIONS
1. Diversion of the urinary stream is indicated in exstrophy of the bladder, in intractable submucous cystitis, in certain cases of vesicovaginal fistula, in a few cases of vesical tuberculosis, and in selected cases of bladder cancer. 2. Nephrostomy is not the most favored method of urinary diversion. 3. Ureterostomy is particularly suitable in conjunction with total cystectomy. The chief complication is sloughing of the ureter. The mortality is less than with ureteroenterostomy. 4. Ureteroenterostomy is especially suitable in cases of exstrophy and vesico-vaginal fistula. It is less suitable in cancer of the bladder, largely because of the lowered resistance of the patient and the likelihood of ureteral dilatation and preexisting urinary infection. 5. The late results of ureteroenterostomy are still subjudice. This phase of the subject has not been thoroughly studied, but a number of cases have been reported in which renal calculi and pyelonephritis have developed.
I wish to express my thanks to Dr. E. Ross Mintz for his help in the preparation of this paper. 6 Commonwealth Ave., Boston, Mass. REFERENCES (1) ALLISON, P.R.: Result of transplantation of ureters more than a quarter of a century after operation. Brit. Jour. Surg., 1933, xx, 529. (2) BEER, E.: Total cystectomy and partial prostatectomy for infiltrating carcinoma of the neck of the bladder. Ann. Surg., 1929, xc, 864. (3) CABOT, H.: The treatment of exstrophy of the bladder by ureteral transplantation. New England Jour. Med., 1931, ccv, 706. (4) COFFEY, R. C.: Transplantation of the ureters into the large intestine, submucous implantation method. Brit. Jour. Urol., 1931, iii, 353. (5) HAzANOFF, J. 0., AND TZHWETADZE, J. J.: Sur !'implantation des ureteres a la peau dans !'ablation total de la vessie. Jour. d'urol., 1933, xxxv, 473. (6) HIGGINS, C. C.: Aseptic uretero-intestinal anastomosis. Surg., Gynecol. and Obstet., 1933, lvii, 359. (7) KIRWIN, T. J.: A study of ureteral implantation. Amer. Jour. Surg., 1930, viii, 1. (8) MAYO, C. H.: Exstrophy of the bladder. Contributions to Medical and Biological Research. Dedicated to Sir William Osler. Hoeber, New York, 1919, ii, 1095. (9) MIDDLETON, G. W.: Submucous ureteral implantation into the bowel. Twenty year report on the first human case. Jour. Amer. Med. Assoc., 1931, xcvii, 1536. (10) PAPIN, E.: La derivation haute des urines. Jour. d'urol., 1925, xx, 388. (11) ROBINSON, T. A., AND Fouws, G. S.: The late results after an operation for exstrophy of the bladder. Brit. Jour. Surg., 1926-27, xiv, 529. (12) SCHUNK, A. S.: Valeur de l'ureterostomie cutanee chez les nephrectomies pour tuberculose. Jour. d'urol., 1_933, xxxv, 203.
194
DISCUSSION
(13) STEINKE, C. R.: Transplantation of ureters into rectum or bladder; suggestion for improvement in technique. Univ. Penn. Med. Bull., 1909- 1910, xxii, 110. (14) WADE, H.: The treatment of malignant tumors of the urinary bladder. Surg., Gynecol. and Obstet., 1931, Iii, 312. (15) WALTERS, W.: Transplantation of ureters to recto-sigmoid and cystectomy for exstrophy of bladder. Amer. Jour. Surg., 1922, xv, 15.
DISCUSSION DR. A. R. STEVENS (New York City): As has been pointed out in the paper by Dr. Smith, there are available three types of operation for diverting the urinary stream from the lower urinary tract. While nephrostomy may be demanded in certain cases, the choice is usually to be made between anastomosis of the ureter to the skin in the groin and anastomosis to the intestinal tract. To estimate their relative merits, one must compare the immediate risks of the operations, the time required for the same, the prognosis as to length of life, and the prospects of future comfort. In the long run, the intestinal operations probably carry greater immediate risk. The outlook for length of life following the two operations seems equally good, although available statistics do not warrant dogmatic statements. On the other hand, the physical and mental relief afforded by ureteralintestinal anastomosis is to my mind clearly superior to that associated with nephrostomy or ureteral transplantation to the skin; the avoidance of tubes, requiring constant care, and of urinous odors are the outstanding practical advantages. The important question is whether the slightly increased risk of the intraperitoneal intestinal procedure is warranted, in order to afford the patient the ultimate greater satisfaction. I believe it is, and hence have favored this type of operation. However, with our present lack of knowledge concerning the life expectancy following diversion of the urinary stream, I have been cautious in choosing patients for such procedures, and have transplanted the ureters to the bowel in only 8 cases. There were 2 deaths in hospitals-both cases of advanced bladder carcinoma. In 1, after bilateral transplantation of the ureters, I undertook to place one supporting suture through the walls of the ureter and bowel and entered the lumen of the ureter; the patient died 12 days after operation with peritonitis, the result of my faulty technique. In another similar case, but having diabetes as well as carcinoma, only one ureter was transplanted. This functioned well within 12 hours and until death, there was no temperature above 101.5° and no evidence of infection of the wound, the kidney or ~he peritoneum. A depressive psychosis developed
The indications for diversion of the urine are numerous. Ahead of all others is that distressing condition, exstrophy of the bladder, for which the greatest number of operations for diversion has been done. Other conditions involving loss of urinary control, such as incurable vesico-vaginal fistula, have called for ureteral transplantation. Another group of patients who have begged for relief has been composed of cases with extreme vesical irritability; cases of submucous fibrosis and tuberculosis are found in this group. All of the above-mentioned cases come but seldom to the urologist; they are relatively few in number. Another type of case-the patient with cancer of the bladder-is in a different category; him we see frequently; his problem is the outstanding problem of urology today. Although many cases of bladder carcinoma are amenable to less radical methods of treatment, there is gradually developing among urologists the conviction that for a considerable proportion of such cases, total cystectomy is the only logical solution. The difficulty lies not so much in the removal of the bladder as in the diversion of the urine. The series of 50 cases forming the basis of this report were chiefly cases of malignant disease of the bladder. I hope that you will bear this fact in mind when appraising the results. Of the 50 cases, 38 had bladder cancer, 4 prostatic cancer, 3 vesico vaginal fistula, 3 fibrosis of the bladder, 1 exstrophy, 1 diverticulitis (thought to be cancer). The methods of diverting the urine are three-nephrostomy, transplantation of the ureters to the skin and transplantation to the bowel. In only 1 case of this series was nephrostomy done, and that was preliminary to ureteroenterostomy, as suggested by Hinman. Nephrostomy, while a satisfactory method of draining the kidney in cases of hydronephrosis and pyonephrosis, is not always free from complications. Unless the ureter is ligated at the pelvic outlet, some urine is likely to pass down the ureter. At times, the sinus tract may lose its continuity so that replacement of the tube in the renal pelvis is difficult. Minor 1 Presented before the annual meeting of the American Urological Association, Atlantic City, N. J., May 22-24, 1934. 179
180
GEORGE GILBERT SMITH
calices may become blocked because the tube obstructs the infundibulum; stone formation may occur. Bilateral nephrostomy requires 2 major operations, even though both are done at one time, and the location of the fistulae in the loin interferes with the patient's care of his drainage apparatus. That permanent nephrostomy is not the best solution to the problem of urinary diversion is indicated by the fact that it is seldom employed for this purpose. Papin (10), however, found 9 cases in which nephrostomy had been done. There was but 1 death. Ureterostomy- transplantation of the ureters to the skin-is said to have been first suggested by Gigon (5) in 1856; LeDentu is credited with being the first surgeon to do this operation. It is not suitable for cases of exstrophy, in which ureterosigmoidostomy has given such satisfactory results, nor for most cases of vesico-vaginal fistula. In cancer of the bladder, however, it has certain advantages over other methods of urinary diversion. Two indications exist: (a) in inoperable cancer, purely as a palliative procedure; (b) when total cystectomy is possible. In cancer of the bladder, one or both ureters are likely to be dilated, with an accompanying pyelonephritis. By bringing the ureters to the skin and draining the renal pelves with catheters, faulty drainage can be relieved and the pelves can be irrigated until infection is reduced to a minimum. If total cystectomy is planned, the removal of the bladder and the transplantation of the ureters to the skin may be done at the same operation without imposing too great a burden on the patient. This procedure has been advocated by Edwin Beer (2), who reported 7 cases without an operative death, and by Henry Wade (14). In his series of 181 collected cases of cystectomy, Papin (10) found 57 in which ureterostomy had been done. The mortality was 32 per cent, in contrast with a mortality of 59 per cent in 81 cases in which ureteroenterostomy was the method selected. There is no question in my own mind that ureterostomy in most cases of cancer of the bladder is a more feasible operation than ureteroenterostomy. The technique of ureterostomy which I have followed has varied somewhat in its minor details. There were 22 cases; in 3 cases a musclesplitting (gridiron) incision was made mesial to the anterior superior spine. The peritoneum was stripped inwards, the ureter identified, freed as low as possible below the pelvic brim, and the cephalad segment fastened at the lower angle of the incision. A rubber drain was placed above the ureter to drain the retroperitoneal space, and a catheter, varying in size according to the degree of dilatation of the ureter, was inserted
DIVERSION OF URINARY STREAM
181
to the renal pelvis. The free end of the ureter was sutured to the edge of the skin incision. In 1 case the same operation was done through incisions at the outer edge of the rectus. In 18 cases the ureters were freed through a median suprapubic incision (extraperitoneal) and were brought to the skin through stab wounds made 1 inch mesial to and 1 inch below the anterior superior spine. This approach was used in all cases of total cystectomy, of which there were ·11. In 10 days to 2 weeks after operation the catheters may be changed, larger ones being inserted if desired. Eventually the ureteral wall thickens and thr lumen becomes more dilated, so that 16 French catheters with open tips may be used as the permanent drains. These are held in place by a flange made of sponge rubber or by the disk manufactured by Eynard. Strips of adhesive or some form of belt may be used to hold the catheters in place; the patient irrigates the tubes once a day and if at all adept he can even remove, clean and replace the catheters. The catheters are attached to a Y tube which is connected with a hot water bottle by the type of stopper which is perforated by a short tube. The entire system is air-tight and leakage about the catheters does not occur unless they become obstructed or out of place. The patient who was drained in this way for the greatest length of time was a woman with a vesico-vaginal fistula; I had planned to do a ureteroenterostomy, but found this impossible because the bowels were matted together by adhesions. This patient died of cancer of the biliary tract 6 years later; autopsy showed the kidneys to be in excellent condition, neither dilated nor appreciably infected. Ureterostomy, however, has not been without fatalities and complications. Of the 22 cases in this series, 10 died within 6 weeks after operation. Three of these had prostatic cancer; all died just 6 weeks after operation. Autopsy in 1 of them showed bilateral pyelonephritis. All were in poor condition; operation was done as an alternative to suprapubic cystotomy. Three others died after simple bilateral ureterostomy, 1 in 4 days, 1 in 13 days, 1 in 4 weeks. Autopsy in one of these showed chronic pyelonephritis and abscesses of spleen and kidneys; in another, facial erysipelas, acute tubular nephritis, pyelonephritis. In 4 cases, cystectomy was done at the same time as the ureterostomy. One died ·immediately of shock; 1 in 4 days of suppurative nephritis, (autopsy); 1 in 11 days of right pyonephrosis and perinephritic abscess; 1 in 6 days of delirium tremens. Autopsy in this case showed the kidneys and ureters to be in good condition (table 1).
182
GEORGE GILBERT SMITH
Eleven cystectomies were done. Of these 7 survived operation. One died 5 months later of recurrence in the pelvis; another 10 weeks after operation of a cerebral accident, either metastasis or thrombosis. Five are living and apparently well, 2 months, 2 months, 10 months, 1 year and 17 months after operation. The value of this operation in cases of bladder cancer which are too advanced for cystectomy is doubtful. Life is probably prolonged, but to what purpose? Bladder distress is by no means done away with, for the sloughing, infected bladder still strives to express the foul purulent fluid which accumulates. The patient grows weaker day by day; TABLE
1.-Ureterostomy, 22 cases LIVED
DIED
U reterostomy alone .... . . ........ .. . .. . ... . . . . . . ... . ... . . Ureterostomy plus cystectomy . . ........... . ..... . .... . ... .
5
6
7
4
Cancer of prostate .. ... . . . . . . ........ . .. . . .. ... .. . ... ... . Cancer of bladder . . ... . . . . . .. .. . . . ...... . .. . ... . . . . ..... . Vesico-vaginal fistula ....... . .... . .. . ... . . ... ... . .. ... . . . .
3 18 1
TABLE
2.-Ureteral slough NUMBER OF CASES
Died too soon for this to occur . . . . . ...... . ... . .... . .. . .... . ..... . . . . No slough ................ . . . . .. . . . ... . . .. . . . . .. . . . . . . . . ... . . . ... . One ureter sloughed . ............... . .. ... . ... . . . . . ..... ... . ... . .. . Both ureters sloughed ... .. . .. . . . ....... . . . .. .. . . .. .. . ...... . . .... .
3
13 4 2
nausea is constant. The 4 patients in this group lived- if it can be called such-an average of 14 weeks after operation. For the surgeon, the chief source of anxiety after ureterostomy is the question of viability of the ureter. The ureter may slough for a varying distance, but if a perforation takes place beneath the abdominal wall, retroperitoneal abscess is likely to form. If the abscess does not develop, the continuity of the urinary channel may become lost; the catheter, once removed, cannot be replaced. In these 22 cases, 3 died before sloughing might occur. In the remaining 19, 37 ureters were transplanted (table 2). Eight ureters in 6 patients sloughed to a degree that required another operation to explore the retroperitoneal space, pick up the ureter and carry it to another point on the surface of the body. This operation is not a severe one; no patient died as a result. Experience
DIVERSION OF URINARY STREAM
183
has shown that the best method is to make a muscle-splitting inos10n above the crest of the ilium, roll back the peritoneum, identify the ureter well above the area of inflammatory exudate, free it as far down as it is viable and swing it outwards to a location above the iliac crest. The ureter will be found to be thicker .than normal and better able to withstand transplantation. Hypertrophied, dilated ureters are much less likely to slough than are the delicate, normal ureters. I am hoping to get some light upon this point; Beer apparently had no such mishap in the 7 cases reported by him although other operators mention this complication (Schunk (12)). It is possible that better results might be obtained if the ureters were not intubed during the first week. The advantages of ureteral transplantation to the bowel are obvious. Two questions remain to be settled, however. (a) Can this operation be done with as little risk to the patient as ureterostomy? (b) Is the renal drainage sufficiently adequate to prevent the development of hydronephrosis, pyelonephritis and renal calculus? As to the ability of the rectum to adapt itself to this new function, there is no question. Occasional cases have been reported in which rectal tenesmus or incontinence has occurred, but these instances have been so few as to be negligible. The mortality of this operation has varied tremendously with different operators and with varying types of patients. The best results have been attained in exstrophy; in this condition the patient is usually operated upon in childhood, when the power to resist infection and the ability of the organs to readjust themselves to new conditions are high. There is no need for haste, as there is when cancer exists, so the ureters may be transplanted one at a time. That transplantation of one ureter at a time is the safest method there is little doubt. Walters (15) reports from the Mayo Clinic 76 cases done in this way with but three operative deaths; Cabot (3) reports 14 with no operative deaths. On the other hand, Coffey (4) himself, implantating both ureters at once, had 2 deaths in cases of exstrophy, 1 from intestinal obstruction and 1 from ureteral slough and pyonephrosis. More than 25 surgeons have reported successful cases of ureteroenterostomy, done mostly for exstrophy but in a few instances for vesico-vaginal fistula and tuberculosis. There is no question that in exstrophy, transplantation into the bowel is a relatively safe procedure, certainly so far as immediate results are concerned. Ureteroenterostomy for cancer of the bladder, however, is a different
184
GEORGE GILBERT SMITH
matter. Here the element of time is all-important; one seldom feels justified in advising 3 major operations within a period of a few weeks. The procedure which is generally followed consists in transplanting both ureters at 1 operation, and removing the bladder at a second operation. Coffey (4) reported 15 cases of bladder tumor in which he did ureteral transplantation; 10 of these had ureteroenterostomy done, with 2 deaths; 3 had secondary cystectomy, with no deaths; 2 had simultaneous transplantation and cystectomy and both died. The total mortality, 4 deaths in 15 cases, is considerably below that reported by other operators. Papin (10), in a paper on total cystectomy, summarizes the results in 181 collected cases. In 81, preliminary ureteroenterostomy had been performed with a mortality of 59.2 per cent. Papin says " The results remain bad because the patients are always in a worse state than one supposes. Renal lesions are always more advanced." Little need be said about the technique of this operation, nor about its history. The latter has been well covered by Steinke (13), Charles Mayo (8) and Kirwin (7) . The older methods of Maydl, Bergenhem and Peters have been discarded by the vast majority of operators in favor of Coffey's oblique implantation, either with or without tubes. If both ureters are transplanted at once, it is undoubtedly safer to intube the ureters; when one side is done at a time, there is some question whether tubes should be used or not. Cabot has advised the use of a short tube, just long enough to preserve a channel through the portion of the ureter which lies within the intestinal wall. Mayo has employed a strand of catgut to serve this purpose. The Coffey technique No. 3, in which the formation of a stoma is delayed for 24 to 48 hours, has been used, so far as I am aware, by only one operator. Higgins (6) incorporated this feature in his ingenious technique, in which he does a lateral anastomosis between the ureter and the bowel, allowing the ureter to drain into the bladder until the second operation, when the ureter is ligated just below its anastomosis with the bowel. He reports 7 cases operated upon by this method with no deaths- a most excellent result. It would appear to me, however, that a lateral anastomosis of this sort would be much more liable to cicatricial contraction later on; I hope that we may have a report 2 years from now on the condition of these 7 patients. In my own series of 28 ureteroenterostomies, 52 ureters were transplanted. In 24 of these cases, the operation was done for cancer of the bladder; 10 of them had cystectomies. In 2, the operation was because
185
DIVERSION OF URINARY STREAM
of vesico-vaginal fistula; in 1, exstrophy; in 1, intractable submucous fibrosis. Table 3 gives the results. Thirty-three per cent of intubecl patients livecl; 70 per cent of non-intubecl patients lived; lived 13; died 15-a mortality of 53 per cent. Looking at this from another angle, we see that 52 ureters were transplanted. Five patients died too soon for one to determine whether the implantation was successful, thereby removing 10 ureteral implantations from the picture. Of the 42 remaining, there were: I
WITH TUBES
I Successful transplants . Unsuccessful transplants.
17 7
I
I
WITHOUT TUBES
--1
12
I
6
In other words, of the intubed ureters, 71 per cent functioned; 29 per cent did not. TABLE
3 DIED
Ll\'ED
I ---------~---~
One ureter at a time Both ureters at once Both ureters and cystectomy.
b l
ntu ec
-~·-
Ij
"ot
-----
2
s
3
2
6
?\~ot intulwd
In tubed
intuLed
I
I
3
2 0
()
I
7 2
7
I
12
I
3
----------------
Of the non-intubed ureters, 67 per cent functioned; 33 per cent did not. Too much weight should not be attached to these figures; I still believe that when both ureters are transplanted at once, tubes should be used. The figures do prove that intubation is not essential to successful transplantation; indeed, it may be a factor against it. When tubes are employed, I believe they should lie in the kidney pelvis. An excellent tube for this purpose is the soft rubber ureteral catheter size 8 French, manufactured by Eynard. The method which I have used for the past 4 or 5 years to draw the tube down the bowel is as follows: A No. 12 French ureteral bougie is passed into the rectum; the operator can guide it past the kinks in the bowel until the tip is opposite the site of anastomosis. A tiny nick is then made through the mucosa of the bowel over the tip of the bougie, the tip is extruded, the
186
GEORGE GILBERT SMITH
open end of the ureteral tube threaded over it and the bougie then withdrawn.2 Aside from this point, I have no technical modifications to offer. I believe that careful pre-operative cleansing of the bowel is important; if this is done, it is unnecessary to irrigate the bowel at the time of operation, and intestinal clamps will not be needed unless one is doing the second ureter. In that case, urine from the other side may be present in the bowel, although this can be largely obviated by leaving in a rectal tube. I have always employed rubber wick drainage, al-
FIG. l. Microphotograph of cross-section of intestinal wall, with transplanted right ureter, taken from a case dying 3 weeks after ureteroenterostomy. The right kidney and ureter \Yere in good condition.
though I endeavor to place the wick as far from the anastomosis as possible. The total operative mortality in these 28 cases was 15 (53 per cent). In 13, the chief cause of death was determined either by operation or by autopsy. Two cases, both of which had cystectomy and ureteroenterostomy at one time, died of shock. Three cases developed intestinal obstruction, a loop of small bowel having adhered to the line of suture in 2, and in 1 having become caught beneath the ureter. (In 2
This technique has also been suggested by Chute.
187
DIVERSION OF URINARY STREAM
this case both ureters were implanted side by side.) One case died of endocarditis, with multiple infarcts. One case showed thrombosis of the iliac vein and vena cava. Three cases had pelvic abscesses and local peritonitis. In 7 cases renal sepsis was the apparent cause of death (1 of these also had intestinal obstruction, relieved by enterostomy) (table 4). In all but 1 of the cases of renal sepsis, there was trouble at the lower end of the ureter, evidenced by urinary leakage. A recent autopsy on a man dying 3 weeks after combined cystectomy and ureteroenterostomy illustrated the pathology of this condition. The right anastomosis, kidney and ureter were healthy (fig. 1). The left ureter (in which a short tube had been placed because of preexisting dilatation and infection) was still implanted in the bowel, but it was sloughing and had perforated. An abscess had formed which in spite of drainage, had extended across the pelvic peritoneum to the region of TABLE
4.-Causes of death and complications in u.reteroenterostomy, 15 cases NU1t BER OJ? CA.SF:::;
- - - - - - - - - - - - - ---------··---- --------
Shock (cystectomy at same time). Intestinal obstruction (all of small bowel) .. Endocarditis and multiple infarcts .. Local abscess and peritonitis .... Renal sepsis (slough of ureter or non-union in 6) --
--
2 3
. . .I
3
. . .i
7
---------~----------------
the cecum. The left kidney was severely infected. It is disheartening to have some of these cases, in which operation appears to have been technically satisfactory, develop complications which are almost certain to result fatally. Secondary nephrostomy, bihteral in 1 case, was done 3 times in this series; 1 of these cases lived, but 2 died. I have not done any secondary ureterostomies, as advised by Coffey. The later results of ureteroenterostomy have not been thoroughly reported in the literature. Walters (15) reports a series of 59 patients, 10 of whom had been operated upon less than 1 year before. Fifty per cent of these 59 cases showed no evidence of renal infection. In 21 per cent, slight evidence of mild renal infection had occurred at long intervals. A few scattering reports of cases operated upon years before are to be found. Allison (1) reports a case of exstrophy in whom some type of Maydl's operation had been done 26 years before A left calculous pyonephrosis had developed; the right kidney was hypertrophied. Middleton (9) reports a case of exstrophy 20 years after he had transplanted
188
GEORGE GILBERT SMITH
the ureters by Coffey's method (but without catheters). An intravenous pyelogram showed normal ureters and pelves. Robinson and Foulds (11) report later developments in 1 of Peters' original 5 cases. The boy was operated upon in 1905; in 1925 he developed a right pyonephrosis, but after nephrectomy he regained his health. Of the cases in my series that survived operation, the following facts are known: Ureteroenterostomy for cancer of the bladder without cystectomy-6 cases-all died within 9 months. Ureteroenterostomy for cancer of the bladder with cystectomy-5 cases: 1. Halligan. Died 14 months after operation. Cause unknown. Barium enema showed reflux of barium to left renal pelvis (fig. 2).
FIG. 2 FIG. 2. Barium enema. X-ray barium in the left ureter and renal FIG. 3. Intravenous pyelogram FIG. 4. Intravenous pyelogram ureter was transplanted).
FIG.4 FIG.3 taken 25 days after tramplantation of ureters, showing pelvis. (Patno) before operation. (Patno) March 20, 1934 (about 3 months after second
2. Hamer. Died 8 months after operation of recurrence in spine. X-rays showed a left renal calculus. General health had been excellent until recurrence developed. 3. Briggs. (Unilateral transplantation, the other kidney having been removed for primary cancer of the ureter.) Died 14 months after operation of local recurrence. Enjoyed excellent health for at least 1 year. 4. Tobak. (Cystectomy and ureteral transplantation at 1 operation.) Died 2½ years after operation, apparently of pulmonary metastasis. He worked as a peddler in the interim. 5. Patno. (Ureters transplanted one at a time. Cystectomy on January 24, 1934.) Alive and apparently well. Non-protein nitrogen normal April 20, 1934. No symptoms. Urine shows
DIVERSION OF URINARY STREAM
189
practically no pus. Intravenous pyelograms (figs. 3 and 4) show an increasing hydronephrosis. Another case (No. 18), the only one of exstrophy in this series, was 25 years of age when he had bilateral transplantation of the ureters in April, 1929. Cystectomy was done a few months later, and 1 year ago his suprapubic hernia was repaired. He has married and his health has been much better since operation. His intravenous pyelograms done on April 10, 1930 and August 18, 1933 showed moderate dilatation of the right ureter and pelvis, but this had hardly increased in 3 years. He had developed a small calculus in the left kidney. His non-protein nitrogen is normal (figs. 5 and 6). A recent case (No. 13), in whom the right ureter was transplanted on January 15, 1934 because of submucous
FIG.5 FIG. 7 FIG.6 FIG. 5. Intravenous pyelogram (Treworgy) April 10, 1930, approximately 1 year after ureteral transplantation. FIG. 6. Intravenous pyelogram (Treworgy) September 18, 1933, 4½ years after transplantation. Plain films, though not very satisfactory, suggest the presence of calcium deposits in one calyx on each side. One ureter shows considerable dilatation, the other is normal. FrG. 7. Intravenous pyelogram of case 13, made 4 months after right ureteroenterostomy. Slight dilatation of the pelvis and concentration of the chemical point to some obstruction.
cystitis, has had no symptoms referable to the kidney. Her pyelogram done 4 months after the transplantation showed a slight dilatation of the pelvis on the transplanted side. A portion of dilated ureter may be seen just at the pelvic brim (fig. 7). SUMMARY
A discussion of the indications for diversion of the urinary stream and of the 3 principal methods of accomplishing this purpose-i.e., nephrostomy, ureterostomy and ureteroenterostomy-is the subject of this paper. A series of 50 cases, 22 ureterostomies and 28 ureteroenterostomies, is reported. The technique, the mortality, the causes of death and the end results are considered.
190
GEORGE GILBERT SMITH TABLE
NUM-1 BER
NAME
5-Ureteroenterostomies, 28 cases INDICATION
Group I.
REMARKS
One ureter transplantated at a time
Champlain
F.
56
Lymphosarcoma of bladder
Macbeth
M.
61
Carcinoma bladder
of
Patno
F.
58
Carcinoma bladder
of
Maxwell
M.
43
Carcinoma bladder
of
Cooper
M.
48
Carcinoma of bladder, extensive
Roach
M.
61
Carcinoma bladder
of
Seely
M.
49
Carcinoma bladder
of
W. Hamer
M.
47
Carcinoma bladder
of
9
Briggs
M.
67
Primary carci noma right ureter and bladder
10
Wallis
F.
39
Cancer of cervix; vesico-vaginal fistula
11
Rawding
F.
62
Carcinoma bladder
4
of
6/27 /22 Right ureter into ascending colon. No tube. 7/8/22 Left ureter into descending colon. No tube. 7/29/22 Total cystectomy. 8/20/22 Bilateral nephrostomy. Right kidney edematous; left perinephritic abscess. Died 8/21/22 10/22/20 Right ureter into cecum. No tube. 10 /29 /20 Left ureter into sigmoid. No tube. Both ureters dilated. Died at home 3/16/21 10/17 /33 Right ureter into sigmoid. No tube. 11/11/33 Left ureter into sigmoid. No tube. 1/24/34 Cystectomy. Alive and well 5/10/34 6/23/31 Bilateral nephrostomy. 7/23/31 Total cystectomy. 9/20/31 Left ureter into sigmoid. Intubed. Urine leaked from incision and continued to drain from nephrostomy sinus. 6/27 /32 Exploration of ureteral implantation. Ureter found to have sloughed or pulled out of bowel. Nephrostomy done, ureter ligated. 6/28/32 Patient had a sudden massive hemorrhage from left kidney and died 12/17 /21 Left ureter, dilated 0.5 cm., into sigmoid. No tube. 1/4/22 Right ureter, dilated 2 cm., into sigmoid. No tube. Had persistent urinary fistulae from both incisions. Discharged from hospital 2/15 /22 and died 3 days later 5/10/22 Right ureter into cecum. No tube. 5/31/22 Left ureter, dilated 1 cm., into sigmoid. No tube. Brief leakage of urine from right side. Discharged from hospital. Died 2 /9 /23 7/11/23 Right ureter, dilated, into cecum. No tube. 8/1/23 Left ureter into sigmoid. No tube. Died 8/4/23. Autopsy: Right kidney and ureter in good condition. Anastomosis well healed. Left anastomosis poorly healed. Left perirenal infection and left pyelonephritis 1/4/22 Right ureter into cecum. No tube. 1/17 /22 Left ureter into sigmoid. No tube. Both ureters normal. 2/7 /22 Total cystectomy. Patient made excellen t recovery and was well enough to play cricket. 7/19 /22 X-rays showed metastasis to spine and a stone in the left kidney. Died October, 1922 2/4/25 Right nephro-ureterectomy. 9/26/25 Left ureter, normal, into sigmoid. Intubed. 10/14/25 Cystectomy. Enjoyed excellent health for eight months then developed recurrence in pelvis. Died 11/6/26 8/18/31 Right ureter, normal, into sigmoid. No tube. 9/24/31 Left ureter, 0.5 cm. in diameter, into sigmoid. Intubed. Drained pus in urine from left incision. Died of pyelonephritis 10 /25 /31 4/10/31 Right ureter, 0.5 cm., into sigmoid. Intuhed. 5/21/31 Left ureter, normal, into sigmoid. Intubed. Good recovery. 6/15/31 Vesico-vaginal septum laid open and radium in platinum needles inserted into bladder cancer. Died at home 10/22/31
191
DIVERSION OF URINARY STREAM TABLE
NUM-1 BER
NAME
INDICATION
Group I. 12
Smith
5-Continued
F.
REMARKS
One ureter transplantated at a time-Concluded 60
Carcinoma
of
bladder
13
Mason
F.
58
14
Robertson
M.
50
Submucous fibrosis
Edwards
M.
47
Carcinom'a
of
Carcinoma
of
bladder
16
17
Doering
McKay
F.
M.
I \
56
Carcinoma
of
bladder
64
Carcinoma
elf
bladder
18
Treworgy
M.
25
Exstrophy bladder
19
Halligan
M.
43
Carcinoma
of
Halloran
M.
49
Carcinoma
of
bladder 21
Colby
M.
50
Carcinoma
bladder
5/27 /20 Both ureters, dilated, in sigmoid. No tubes. Developed intestinal obstruction. Laparotomy 6/1/20 Loop of small bowel adhered to anastomosis. Died 6/6/20 6/7 /20 Both ureters into rectum extraperitoneally. Right normal. Left dilated. Both intubed. Suprapubic urinary fistula on second day. 7/17 /20 Exploratory incision : Left side well healed. Right ureter re-implanted into cecum. 8/20/20 Right nephrostomy. Died 5/19/21 11/15/26 Both ureters into sigmoid. Intubed. Intestinal obstruction. Laparotomy 11/30/26 Loop of small bowel caught under one ureter. Enterostomy. Died 12/2/30 10/19/28 Both ureters into sigmoid. Right dilated 1 Intubed. Died 10/30/28. cm., left normal. Autopsy : Anastomosis well healed. Bacterio-endocarditis; septic infarcts, kidney, spleen, adrenal; early broncho-pneumonia 4/12/29 Both ureters, normal, into sigmoid. Intubed. Discharged 17 days after operation. Five years later in excellent health. Right pelvis and ureter moderately dilated. Left normal. Early renal calculi t 5 /2 /29 Both ureters, normal, into sigmoid. Intubed. Barium enema three weeks after operation showed
bladder
20
Died 12/6/30. Autopsy: Anastomosis well healed. Abscess in pelvis. Both kidneys showed noninfected hydronephrosis 1/15/34 Right ureter, normal, into sigmoid. No tube. Uneventful recovery. Intravenous pyelogram 2 months later shows slight dilatation of pelvis. 5/1/34 Left ureter, normal, into sigmoid. Ten days after operation patient was in excellent condition•
Both ureters transplanted at one time bladder
1-S
Left
ureter was occluded at the uretero-vesical junction.
of bladder
Group II.
11/15/30 Right ureter, dilated, in sigmoid.
of
reflux into left kidney. 6/21 /29 Total cystectomy and prostatectomy. Discharged 7/21/29. Died 7/21/30. Cause unknown 11/18/32 Both ureters, dilated, into sigmoid. Intubed. Some urinary leakage from incision. Died suddenly 12/11/32. No autopsy 9/23/25 Both ureters into sigmoid. Right normal; left I cm. in diameter. Intubed. Suprapubic tistula draining urine and feces.
Some urine by rec-
tum. 10/1/25 Extrusion of bowel into wound . Wound resutured . 10/31/25 Right nephrostomy for pyelonephntis. Died 11/9/25. No autopsy • Patient well Dec. 1934. had nephrectomy for calculous pyonephrosis. Recovery.
t Patient has
192
GEORGE GILBERT SMITH TABLE
NBER UM-1
NAME
INDICATION
Group II. 22
5-Conclztded
Clark
F.
REMARKS
Both ureters transplanted at one time-Conclztded 51
Carcinoma
of
bladder
23
Cook
F.
73
Carcinoma of cervix; vesicovaginal fistula
24
Parrow
M.
48
Carcinoma bladder
Group III.
of
12/ 11 / 29 Both ureters, normal, into sigmoid. Intubed. Four days after operation, nurse had pulled out both tubes. Patient died 12/ 16/ 29. Autopsy: Right anastomosis well healed . Left ureter torn off in the intramural portion of stump, pulled out of anastomosis easily. Intestinal wall not very well healed. Mucous membrane of bowel had sloughed over an area of 2 x 1 cm. Small abscess, 1 ccm. of pus between bowel and ovary 11 / 6/ 28 Both ureters into sigmoid . Intubed. Right dila ted I cm. Left normal. Dead 11 /14/ 28. Autopsy: Left hydronephrosis. Biiateral acute ureteritis; thrombosis right iliac vein and vena cava inferior. Cancer of cervix with invasion of bladder and rectum. Both anastomoses well healed 7/ 10/ 33 Both ureters, normal, into sigmoid. Intubed . Intestinal obstruction. 7/ 17 / 33 Laparotomy: Loop of small bowel adhered to anastomosis. Enterostomy. Died 7/ 30/ 33. Autopsy: Both kidneys show multiple abscesses; Left kidney shows a healing infarct. Both pelves contain pus. Bilateral pyoureteritis. Lower end of left ureter completely sloughed away from bowel surrounded by localized abscesses, right ureteroenterostomy well healed and lumen free
Both ureters transplanted at one time plus cystectomy
25
Tobek
M.
so
Carcinoma bladder
of
26
H. Hamer
M.
68
Carcinoma bladder
of
27
Chase
M.
58
Carcinoma bladder
of
28
Norris
M.
73
Carcinoma bladder
of
7/ 26/ 26 Total cystectomy. Both ureters implanted into rectum below peritoneal fold. Right normal Left moderately dilated. Intubed. Suprapubi fistula leaked feces and urine for a time then healed In good health for t wo years and able to work as a peddler. Died 2/28/ 29 with signs of metastasis in lungs 5/ 2/ 27 Total cystectomy. Both ureters into rectum extraperitoneally. Intubed. Died within 48 hour of shock 3/ 30/ 34 Total cystectomy. Both ureters into sig moid. Right normal, no tube. Left dilated ½cm short tube. Died 4/ 21/ 34. Autopsy: Right kid ney and ureter in good condition. Left kidney septic. Left ureter still implanted in bowel bu sloughing above the site of anastomosis. Ther e was a perforation with urinary leakage and an ab scess extending across the peritoneal cavity t 0 cecum 5/ 6/ 18 Total cystectomy. Both ureters into sigmoid No tubes. Died in three hours of shock
DIVERSION OF URINARY STREAM
193
CONCLUSIONS
1. Diversion of the urinary stream is indicated in exstrophy of the bladder, in intractable submucous cystitis, in certain cases of vesicovaginal fistula, in a few cases of vesical tuberculosis, and in selected cases of bladder cancer. 2. Nephrostomy is not the most favored method of urinary diversion. 3. Ureterostomy is particularly suitable in conjunction with total cystectomy. The chief complication is sloughing of the ureter. The mortality is less than with ureteroenterostomy. 4. Ureteroenterostomy is especially suitable in cases of exstrophy and vesico-vaginal fistula. It is less suitable in cancer of the bladder, largely because of the lowered resistance of the patient and the likelihood of ureteral dilatation and preexisting urinary infection. 5. The late results of ureteroenterostomy are still subjudice. This phase of the subject has not been thoroughly studied, but a number of cases have been reported in which renal calculi and pyelonephritis have developed.
I wish to express my thanks to Dr. E. Ross Mintz for his help in the preparation of this paper. 6 Commonwealth Ave., Boston, Mass. REFERENCES (1) ALLISON, P.R.: Result of transplantation of ureters more than a quarter of a century after operation. Brit. Jour. Surg., 1933, xx, 529. (2) BEER, E.: Total cystectomy and partial prostatectomy for infiltrating carcinoma of the neck of the bladder. Ann. Surg., 1929, xc, 864. (3) CABOT, H.: The treatment of exstrophy of the bladder by ureteral transplantation. New England Jour. Med., 1931, ccv, 706. (4) COFFEY, R. C.: Transplantation of the ureters into the large intestine, submucous implantation method. Brit. Jour. Urol., 1931, iii, 353. (5) HAzANOFF, J. 0., AND TZHWETADZE, J. J.: Sur !'implantation des ureteres a la peau dans !'ablation total de la vessie. Jour. d'urol., 1933, xxxv, 473. (6) HIGGINS, C. C.: Aseptic uretero-intestinal anastomosis. Surg., Gynecol. and Obstet., 1933, lvii, 359. (7) KIRWIN, T. J.: A study of ureteral implantation. Amer. Jour. Surg., 1930, viii, 1. (8) MAYO, C. H.: Exstrophy of the bladder. Contributions to Medical and Biological Research. Dedicated to Sir William Osler. Hoeber, New York, 1919, ii, 1095. (9) MIDDLETON, G. W.: Submucous ureteral implantation into the bowel. Twenty year report on the first human case. Jour. Amer. Med. Assoc., 1931, xcvii, 1536. (10) PAPIN, E.: La derivation haute des urines. Jour. d'urol., 1925, xx, 388. (11) ROBINSON, T. A., AND Fouws, G. S.: The late results after an operation for exstrophy of the bladder. Brit. Jour. Surg., 1926-27, xiv, 529. (12) SCHUNK, A. S.: Valeur de l'ureterostomie cutanee chez les nephrectomies pour tuberculose. Jour. d'urol., 1_933, xxxv, 203.
194
DISCUSSION
(13) STEINKE, C. R.: Transplantation of ureters into rectum or bladder; suggestion for improvement in technique. Univ. Penn. Med. Bull., 1909- 1910, xxii, 110. (14) WADE, H.: The treatment of malignant tumors of the urinary bladder. Surg., Gynecol. and Obstet., 1931, Iii, 312. (15) WALTERS, W.: Transplantation of ureters to recto-sigmoid and cystectomy for exstrophy of bladder. Amer. Jour. Surg., 1922, xv, 15.
DISCUSSION DR. A. R. STEVENS (New York City): As has been pointed out in the paper by Dr. Smith, there are available three types of operation for diverting the urinary stream from the lower urinary tract. While nephrostomy may be demanded in certain cases, the choice is usually to be made between anastomosis of the ureter to the skin in the groin and anastomosis to the intestinal tract. To estimate their relative merits, one must compare the immediate risks of the operations, the time required for the same, the prognosis as to length of life, and the prospects of future comfort. In the long run, the intestinal operations probably carry greater immediate risk. The outlook for length of life following the two operations seems equally good, although available statistics do not warrant dogmatic statements. On the other hand, the physical and mental relief afforded by ureteralintestinal anastomosis is to my mind clearly superior to that associated with nephrostomy or ureteral transplantation to the skin; the avoidance of tubes, requiring constant care, and of urinous odors are the outstanding practical advantages. The important question is whether the slightly increased risk of the intraperitoneal intestinal procedure is warranted, in order to afford the patient the ultimate greater satisfaction. I believe it is, and hence have favored this type of operation. However, with our present lack of knowledge concerning the life expectancy following diversion of the urinary stream, I have been cautious in choosing patients for such procedures, and have transplanted the ureters to the bowel in only 8 cases. There were 2 deaths in hospitals-both cases of advanced bladder carcinoma. In 1, after bilateral transplantation of the ureters, I undertook to place one supporting suture through the walls of the ureter and bowel and entered the lumen of the ureter; the patient died 12 days after operation with peritonitis, the result of my faulty technique. In another similar case, but having diabetes as well as carcinoma, only one ureter was transplanted. This functioned well within 12 hours and until death, there was no temperature above 101.5° and no evidence of infection of the wound, the kidney or ~he peritoneum. A depressive psychosis developed