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Further experience with staged ureterocolocolostomy urinary diversion
FURTHER
EXPERIENCE
WITH
URETEROCOLOCOLOSTOMY PETER T. NIEH, M.D. ALEX F’. ALTHAUSEN,
STAGED URINARY
DIVERSION
M.D.
From the Division of Urology, University of Connecticut School of Medicine, Farmington, Connecticut, and The Urological Service, Massachusetts General Hospital, Boston, Massachusetts
ABSTRACT-Disenchantment with the long-term results with ureterosigmoidostomy and ileal loop urinary diversion led to increased use of the nonrefluring colon conduit. In 1978, we reported our initial experience with 3 adult patients in whom such a diversion was initially performed followed by conversion with an end-to-side colocolostomy achieving a staged nonrefluxing ureterocolocolostomy. We believed that a staged procedure would allow decompression of the upper urinary tract away from thefecal stream, that one could confirm the adequacy of the nonrefluxing tunnels prior to exposure to the fecal stream, and that this might have a lower instance of electrolyte problems and pyelonephritis. Further follow-up on these original 3 patients as well as our experiences with two others, as reported here has somewhat tempered our initial enthusiasm.
In 1978 we published our experience with 3 adult patients in whom the staged ureterocolocolostomy was performed.’ At the time, the problems with long-term complications associated with ureterosigmoidostomy and ileal conduits had led to increasing use of the antirefluxing colon conduit. By allowing the ureterocolic anastomosis to heal away from the fecal stream, and allow existing infection of the upper tracts to subside, we believed this would eliminate some of the major problems associated with primary ureterosigmoidostomy. Our original follow-up ranged between seventeen and twenty-four months, at which time all 3 patients maintained stable renal function, were free of symptomatic upper urinary tract infection, and maintained stable electrolyte balance as well as urinary/fecal continence. We Presented at the Annual the American Urological 25. 1983.
UROLOGY
i
MAY
Meeting of the New England Section of Association, Bermuda, September 21-
1986
/
VOLUME
XXVII,
NUMBER
5
have continued to follow these 3 original patients and have added 2 others to the original series. Technique The specifics of the nonrefluxing colon conduit have been detailed previously.’ We will reemphasize that the colon conduit is studied with a loopogram under gravity to assure the competence of the ureterocolic anastomoses, intravenous urogram (IVP), creatinine clearance, and loop cultures. The colocolostomy is performed when these previous studies are satisfactory, usually six months after the colon conduit. Case Reports Case 1 A twenty-nine-year-old white man had urinary incontinence after a traumatic pelvic injury with urethral disruption. Multiple
,397
FICUHE 1. Case 1. Post-traumatic urinary incontinence. (A) IVP nine months after colocolostomy showing delicate collecting system. (B) IVP six and one-half years after colocolostomy. Despite right renal calculi and infrequent episodes of pain, upper tracts remain normal.
Case 2 A sixty-two-year-old woman with recurrent low-grade transitional cell carcinoma and carcinoma-in-situ of the bladder underwent radical cystectomy and nonrefluxing colon conduit in September, 1975. Her loop studies were normal, and four months later she underwent a colocolostomy. Since that time she has had one episode of left pyelonephritis which defervesced within twenty-four hours with antibiotic treatment. She is otherwise asymptomatic with normal renal scans, BUN 17 mg and creatinine 0.8 mg/lOO ml, chloride 111 mEq/L, and COz 22 mEq/L. She continues to be totally continent.
urethral reconstructions and a urethral lengthening incontinence procedure failed. In January, 1975, a nonrefluxing colon conduit was performed and eight months later, after satisfactory loop function was documented, a colocolostomy was accomplished. He was maintained on trimethoprim/sulfa suppression, having an occasional episode of incontinence at night but being dry during the day (Fig. 1A). He was asymptomatic until March, 1979, when right flank pain and fever developed. An intravenous pyelogram (IVP) demonstrated a calculus in the right kidney. He underwent percutaneous nephrostomy and antegrade pyelogram which showed no obstruction but stones present in the calyces. After a pyelonephrolithotomy, there was no evidence of residual calculi on follow-up IVI? In 1980 he had an episode of left flank pain with low-grade fever but a normal IVI? He was treated with intravenous ampicillin for presumed pyelonephritis, with resolution. In September, 1982, he had an episode of colic on the right side, but the IVP was unremarkable (Fig. 1B). Throughout this time his blood urea nitrogen (BUN) has remained stable at 16 mg/lOO ml; and creatinine 0.8 mg/lOO ml. Serum electrolytes show slight hyperchloremic acidosis with chloride 115 mEq/L and carbon dioxide 22 mEq/L. He remains on a regimen of trimethoprim/sulfa suppression.
Case 3 A thirty-two-year-old white man underwent cystectomy and ureterosigmoidostomy in childhood. Because of recurrent episodes of bilateral pyelonephritis (Fig. 2A), it was converted to a nonrefluxing colon conduit in October, 1975. Six months later his IVP had shown dramatic improvement and he underwent colocolostomy (Fig. 2B). He was maintained on a regimen of nitrofurantoin suppression until 1980. His last IVP (April, 1982) still shows excellent function and drainage (Fig. 2C). Chemistries showed BUN 19 mg and creatinine 1.1 mg/lOO ml, chloride 110 mEq/L, and COz 19 mEq/L. He remains continent and without symptoms of upper urinary tract infection.
398
UROLOGY
/
MAY
1986
/
VOLUME
XXVII,
NUMBER
5
locolostomy
with normal upper urinary
tracts.
Cuse 4 A sixty-year-old white woman with interstitial cystitis requiring cystectomy in 1971 had creation of an ileal conduit. Because of multiple problems with stoma1 stenosis, pelvic abscesses, fistulas, and chronic left flank pain (Fig. 3A), she underwent resection of the ileal conduit and creation of a nonrefluxing colon conduit in December, 1976. At the time her BUN was 21 mg and creatinine 0.8 mg/lOO ml; chloride 95 mEq/L, and COZ 29 mEq/L. Her postoperative course was benign. One year later, her IVP showed excellent function (Fig. 3B), and the loopogram showed no reflux to 55 cm of water. Findings on urine culture, barium enema, and sigmoidoscopy were normal, and she underwent colocolostomy. Within three months she had to be rehospitalized because of severe diarrhea with chloride 116 mEq/L and BUN 29 mgl 100 ml. Barium enema findings were normal, and an IVP showed no obstruction (Fig. 3C). She was treated with sodium bicarbonate and a low fiber diet. While her renal function (BUN 23 mg and creatinine 0.7 mg/lOO ml) and electrolytes (chloride 110 mEq/L, COz 23 mEq/L) remained stable, the persistent frequent loose bowel movements up to twenty per day led to take down of the colocolostomy in June, 1979, eighteen months later. Since then her IVP continues to show normal upper urinary tracts (Fig. 3D), but there is evidence of reflux on the right at 40 cm water pressure.
UROI.OGY
\lAY
1986
:
VOLUME
XXVII.
NUMBER
5
Case 5
A thirty-one-year-old white woman had an ileal conduit for bladder exstrophy. Recurrent episodes of pyelonephritis with bilateral hydronephrosis (Fig. 4A) led to a nonrefluxing colon conduit in February, 1979. At that time her BUN was 25 mg and creatinine 1.9 mg/lOO ml; sodium 135 mEq, potassium 4.2 mEq, chloride 100 mEq, and CO2 25 mEq/L. In March, 1981, she underwent colocolostomy after a loopogram showed no reflux to 35 cm water. She was discharged on a regimen of oral bicarbonate supplement for mild acidosis and maintained on trimethoprim/sulfa suppression. Four months later she was readmitted with dehydration and severe metabolic acidosis with chloride 120 mEq/L and CO, 6 mEq/L. She was treated with vigorous hydration and discharged on higher doses of bicarbonate. Her creatinine was stable at 1.8 mg/lOO ml (Fig. 4B). However, she continued to have bowel movements every two hours and once per night despite taking diphenoxylate (Lomotil). Sigmoidoscopy was normal. Because of the bowel frequency and gradually increasing azotemia with blood urea nitrogen up to 60 mg/lOO ml in August, 1981, she was converted back to a colon conduit. Her intravenous pyelogram showed severe scarring with calicectasis (Fig. 4C). Her renal function has remained stable with BUN 21 mg and creatinine 1.4 mgi 100 ml.
399
3. Case 4. Failed ileal conduit for interstitial cystitis. (A) Prior to colon conduit, showing normal upper urinary tracts. (B) Following colon conduit. (C) IVP four mom !hs after c&co Jostbmy with preservation of delicate calyc eal architecture. (0) IVP two years after co1zversion back to colon conduit because of ch Tonic diarrhea.
FIGURE
Comment In the early and mid-1970s the movement to avoid a permanent urinary stoma and undiversion prompted our interest in a staged ureterosigmoidostomy. Allowing the ureterocolic anastomosis to heal and mature isolated from the fecal stream and subsequently to assess the nonrefluxing competence of the anastomosis were
considered major advantages for this procedure. At the time, we expected a larger number of patients to be candidates for such an appreach, but the tremendous impact of intermittent self-catheterization as well as the introduction of the artificial urinary sphincter has limited the applicability to small numbers of patients.
400
UROLOGY
/
MAY
1986
/
VOLUME
XXVII,
NUMBER
5
4. Case 5. Failed ileal conduit for exstrophy. (A) Bilateral hydroureteronephrosis and cortical irregularity with ileal conduit. (B) Four months after colocolostomy, hydronephrosis is stable. (C) After conversion back to colon conduit because of severe acidosis. significant cortical scarring and calicertasis is readily c%idcnt. FIGLM:
The excellent follow-up experience of our first 3 patients is contrasted by the difficulties in the latter 2 cases (Table I). In reviewing this small series, certain risk factors for failure can be re-emphasized, particularly pyelonephritis and renal dysfunction. Age was not a factor. Prior episodes of pyelonephritis, in patients with unimpaired renal function, did not appear to be predictors for success or failure. Two of our successful patients had no prior infections, yet single episodes of unilateral pyelonephritis developed postoperatively, with a calculus re-
TABLE I.
Case Age 1
29
M
2 3
62 32
F M
3
60
F
5
Urethral trauma with incontinence Carcinoma bladder Failed primary ureterosigmoidostomy Failed ileal loop, interstitial cystitis
F
31
El.:): P!.eloncph. foll0\\~-up
UROLOGY
Diagnosis
Sex
/
Failed ileal loop, exstrophy = p~xbnephritis:
MAY
1886
/
CR
VOLUME
Staged ureterocolocolostomy Preoperative Postoperative--------PyeloPyeloneph. CR neph. Calc. Diar. Acido. + 1.0 +
XXVII,
F-U (MO.)
0.8
92 88 5
0.9 0.9
+ -
-
-
+
0.8 1.1
-
0.8
-
-
+
-
0.7
1.9
(mg/lOO
NUMBER
CR
-
+
= creatinine
quiring surgery developing in 1 case. Conversely, the 1 patient who had bilateral hydronephrosis and pyelonephritis in the past has had no subsequent infections or stones. It is the combination of prior infection and renal impairment that leads to failure. Patients with these risk factors are unable to handle the diarrhea and subsequent acidosis. In our fourth case, the colocolostomy was converted back to a colon conduit because of diarrhea, but the patient had normal renal function and was thus able to prevent the development of acidosis.
ml):
5
-
Calc.
= calculi:
-
+
Diar.
= diarrhea:
+
Acido.
1.4
( + 4Fafter take down) 3 ( + 20 after take down)
= acidosis;
F-U
=
401
The complications of the ureterosigmoidostomy have been well detailed, including ascending infection, obstruction, calculi, electrolyte imbalance,2 5 and neoplasms.6-s While Lapides proposed that the hyperchloremic acidosis resulted from pyelonephritis in patients with normal renal function, Stamey demonstrated that colon reabsorption alone could produce this, even in patients with normal renal function.3.4 When hydronephrosis and/or pyelonephritis result in renal damage, then the colon chloride absorption load readily exceeds the kidney’s excretory capability, resulting in acidosis. In this small series of patients, we have seen the spectrum of difficulties associated with urine in the intact colon. With the staged ureterocolocolostomy, subsequent pyelonephritis is unpredictable, so we would recommend maintaining patients on suppressive antibiotics. Prior pyelonephritis and hydronephrosis are relatively minor risk factors as long as one has normal renal function. As with primary ureterosigmoidostomy, this procedure is contraindicated in the patient whose prior episodes of pyelonephritis have resulted in an elevated serum creatinine. However, careful patient se-
lection will yield stoma-free situation and successful long-term results with minimal diarrhea, infrequent infection, and stable renal function and electrolyte balance, as demonstrated by our first 3 patients.
402
UROLOGY
Division of Urology Room L-l 100 University of Connecticut Health Center 263 Farmington Avenue Farmington, Connecticut 06032 (DR. NIEH) References 1. Nieh PT, Althausen AF, and Dretler SP: Staged ureterocolocolostomy urinary diversion, J Urol 120: 402 (1978). 2. Zincke H, and Segura JW: Ureterosigmoidostomy: critical review of 173 cases, ibid 113: 324 (1975). 3. Lapides J: Mechanism of electrolyte imbalance following ureterosigmoid transplantation, Surg Gynecol Obstet 93: 691 (1951). 4. Stamey TA: The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy, ibid 103: 736 (1956). 5. Wilkinson AW: Biochemical disturbances after transplantation of the ureters, Postgrad Med J 30: 405 (1954). 6. Sorriyaarchchi GS, Johnson RO, and Carbone PP: Neoplasms of the large bowel following ureterosigmoidostom): Arch Surg 112: 1174 (1977). 7. Rivard J-Y, Bedard A, and Dionne L: Colonic neoplasms following ureterosigmoidostomy, J Urol 113: 781 (1975). 8. Shapiro A, et al: Carcinoma of colon after ureterocolic anastomosis. Urology 13: 617 (1979).
i
MAY
1986
i
VOLUME
XXVII,
NUMBER
5
EXPERIENCE
WITH
URETEROCOLOCOLOSTOMY PETER T. NIEH, M.D. ALEX F’. ALTHAUSEN,
STAGED URINARY
DIVERSION
M.D.
From the Division of Urology, University of Connecticut School of Medicine, Farmington, Connecticut, and The Urological Service, Massachusetts General Hospital, Boston, Massachusetts
ABSTRACT-Disenchantment with the long-term results with ureterosigmoidostomy and ileal loop urinary diversion led to increased use of the nonrefluring colon conduit. In 1978, we reported our initial experience with 3 adult patients in whom such a diversion was initially performed followed by conversion with an end-to-side colocolostomy achieving a staged nonrefluxing ureterocolocolostomy. We believed that a staged procedure would allow decompression of the upper urinary tract away from thefecal stream, that one could confirm the adequacy of the nonrefluxing tunnels prior to exposure to the fecal stream, and that this might have a lower instance of electrolyte problems and pyelonephritis. Further follow-up on these original 3 patients as well as our experiences with two others, as reported here has somewhat tempered our initial enthusiasm.
In 1978 we published our experience with 3 adult patients in whom the staged ureterocolocolostomy was performed.’ At the time, the problems with long-term complications associated with ureterosigmoidostomy and ileal conduits had led to increasing use of the antirefluxing colon conduit. By allowing the ureterocolic anastomosis to heal away from the fecal stream, and allow existing infection of the upper tracts to subside, we believed this would eliminate some of the major problems associated with primary ureterosigmoidostomy. Our original follow-up ranged between seventeen and twenty-four months, at which time all 3 patients maintained stable renal function, were free of symptomatic upper urinary tract infection, and maintained stable electrolyte balance as well as urinary/fecal continence. We Presented at the Annual the American Urological 25. 1983.
UROLOGY
i
MAY
Meeting of the New England Section of Association, Bermuda, September 21-
1986
/
VOLUME
XXVII,
NUMBER
5
have continued to follow these 3 original patients and have added 2 others to the original series. Technique The specifics of the nonrefluxing colon conduit have been detailed previously.’ We will reemphasize that the colon conduit is studied with a loopogram under gravity to assure the competence of the ureterocolic anastomoses, intravenous urogram (IVP), creatinine clearance, and loop cultures. The colocolostomy is performed when these previous studies are satisfactory, usually six months after the colon conduit. Case Reports Case 1 A twenty-nine-year-old white man had urinary incontinence after a traumatic pelvic injury with urethral disruption. Multiple
,397
FICUHE 1. Case 1. Post-traumatic urinary incontinence. (A) IVP nine months after colocolostomy showing delicate collecting system. (B) IVP six and one-half years after colocolostomy. Despite right renal calculi and infrequent episodes of pain, upper tracts remain normal.
Case 2 A sixty-two-year-old woman with recurrent low-grade transitional cell carcinoma and carcinoma-in-situ of the bladder underwent radical cystectomy and nonrefluxing colon conduit in September, 1975. Her loop studies were normal, and four months later she underwent a colocolostomy. Since that time she has had one episode of left pyelonephritis which defervesced within twenty-four hours with antibiotic treatment. She is otherwise asymptomatic with normal renal scans, BUN 17 mg and creatinine 0.8 mg/lOO ml, chloride 111 mEq/L, and COz 22 mEq/L. She continues to be totally continent.
urethral reconstructions and a urethral lengthening incontinence procedure failed. In January, 1975, a nonrefluxing colon conduit was performed and eight months later, after satisfactory loop function was documented, a colocolostomy was accomplished. He was maintained on trimethoprim/sulfa suppression, having an occasional episode of incontinence at night but being dry during the day (Fig. 1A). He was asymptomatic until March, 1979, when right flank pain and fever developed. An intravenous pyelogram (IVP) demonstrated a calculus in the right kidney. He underwent percutaneous nephrostomy and antegrade pyelogram which showed no obstruction but stones present in the calyces. After a pyelonephrolithotomy, there was no evidence of residual calculi on follow-up IVI? In 1980 he had an episode of left flank pain with low-grade fever but a normal IVI? He was treated with intravenous ampicillin for presumed pyelonephritis, with resolution. In September, 1982, he had an episode of colic on the right side, but the IVP was unremarkable (Fig. 1B). Throughout this time his blood urea nitrogen (BUN) has remained stable at 16 mg/lOO ml; and creatinine 0.8 mg/lOO ml. Serum electrolytes show slight hyperchloremic acidosis with chloride 115 mEq/L and carbon dioxide 22 mEq/L. He remains on a regimen of trimethoprim/sulfa suppression.
Case 3 A thirty-two-year-old white man underwent cystectomy and ureterosigmoidostomy in childhood. Because of recurrent episodes of bilateral pyelonephritis (Fig. 2A), it was converted to a nonrefluxing colon conduit in October, 1975. Six months later his IVP had shown dramatic improvement and he underwent colocolostomy (Fig. 2B). He was maintained on a regimen of nitrofurantoin suppression until 1980. His last IVP (April, 1982) still shows excellent function and drainage (Fig. 2C). Chemistries showed BUN 19 mg and creatinine 1.1 mg/lOO ml, chloride 110 mEq/L, and COz 19 mEq/L. He remains continent and without symptoms of upper urinary tract infection.
398
UROLOGY
/
MAY
1986
/
VOLUME
XXVII,
NUMBER
5
locolostomy
with normal upper urinary
tracts.
Cuse 4 A sixty-year-old white woman with interstitial cystitis requiring cystectomy in 1971 had creation of an ileal conduit. Because of multiple problems with stoma1 stenosis, pelvic abscesses, fistulas, and chronic left flank pain (Fig. 3A), she underwent resection of the ileal conduit and creation of a nonrefluxing colon conduit in December, 1976. At the time her BUN was 21 mg and creatinine 0.8 mg/lOO ml; chloride 95 mEq/L, and COZ 29 mEq/L. Her postoperative course was benign. One year later, her IVP showed excellent function (Fig. 3B), and the loopogram showed no reflux to 55 cm of water. Findings on urine culture, barium enema, and sigmoidoscopy were normal, and she underwent colocolostomy. Within three months she had to be rehospitalized because of severe diarrhea with chloride 116 mEq/L and BUN 29 mgl 100 ml. Barium enema findings were normal, and an IVP showed no obstruction (Fig. 3C). She was treated with sodium bicarbonate and a low fiber diet. While her renal function (BUN 23 mg and creatinine 0.7 mg/lOO ml) and electrolytes (chloride 110 mEq/L, COz 23 mEq/L) remained stable, the persistent frequent loose bowel movements up to twenty per day led to take down of the colocolostomy in June, 1979, eighteen months later. Since then her IVP continues to show normal upper urinary tracts (Fig. 3D), but there is evidence of reflux on the right at 40 cm water pressure.
UROI.OGY
\lAY
1986
:
VOLUME
XXVII.
NUMBER
5
Case 5
A thirty-one-year-old white woman had an ileal conduit for bladder exstrophy. Recurrent episodes of pyelonephritis with bilateral hydronephrosis (Fig. 4A) led to a nonrefluxing colon conduit in February, 1979. At that time her BUN was 25 mg and creatinine 1.9 mg/lOO ml; sodium 135 mEq, potassium 4.2 mEq, chloride 100 mEq, and CO2 25 mEq/L. In March, 1981, she underwent colocolostomy after a loopogram showed no reflux to 35 cm water. She was discharged on a regimen of oral bicarbonate supplement for mild acidosis and maintained on trimethoprim/sulfa suppression. Four months later she was readmitted with dehydration and severe metabolic acidosis with chloride 120 mEq/L and CO, 6 mEq/L. She was treated with vigorous hydration and discharged on higher doses of bicarbonate. Her creatinine was stable at 1.8 mg/lOO ml (Fig. 4B). However, she continued to have bowel movements every two hours and once per night despite taking diphenoxylate (Lomotil). Sigmoidoscopy was normal. Because of the bowel frequency and gradually increasing azotemia with blood urea nitrogen up to 60 mg/lOO ml in August, 1981, she was converted back to a colon conduit. Her intravenous pyelogram showed severe scarring with calicectasis (Fig. 4C). Her renal function has remained stable with BUN 21 mg and creatinine 1.4 mgi 100 ml.
399
3. Case 4. Failed ileal conduit for interstitial cystitis. (A) Prior to colon conduit, showing normal upper urinary tracts. (B) Following colon conduit. (C) IVP four mom !hs after c&co Jostbmy with preservation of delicate calyc eal architecture. (0) IVP two years after co1zversion back to colon conduit because of ch Tonic diarrhea.
FIGURE
Comment In the early and mid-1970s the movement to avoid a permanent urinary stoma and undiversion prompted our interest in a staged ureterosigmoidostomy. Allowing the ureterocolic anastomosis to heal and mature isolated from the fecal stream and subsequently to assess the nonrefluxing competence of the anastomosis were
considered major advantages for this procedure. At the time, we expected a larger number of patients to be candidates for such an appreach, but the tremendous impact of intermittent self-catheterization as well as the introduction of the artificial urinary sphincter has limited the applicability to small numbers of patients.
400
UROLOGY
/
MAY
1986
/
VOLUME
XXVII,
NUMBER
5
4. Case 5. Failed ileal conduit for exstrophy. (A) Bilateral hydroureteronephrosis and cortical irregularity with ileal conduit. (B) Four months after colocolostomy, hydronephrosis is stable. (C) After conversion back to colon conduit because of severe acidosis. significant cortical scarring and calicertasis is readily c%idcnt. FIGLM:
The excellent follow-up experience of our first 3 patients is contrasted by the difficulties in the latter 2 cases (Table I). In reviewing this small series, certain risk factors for failure can be re-emphasized, particularly pyelonephritis and renal dysfunction. Age was not a factor. Prior episodes of pyelonephritis, in patients with unimpaired renal function, did not appear to be predictors for success or failure. Two of our successful patients had no prior infections, yet single episodes of unilateral pyelonephritis developed postoperatively, with a calculus re-
TABLE I.
Case Age 1
29
M
2 3
62 32
F M
3
60
F
5
Urethral trauma with incontinence Carcinoma bladder Failed primary ureterosigmoidostomy Failed ileal loop, interstitial cystitis
F
31
El.:): P!.eloncph. foll0\\~-up
UROLOGY
Diagnosis
Sex
/
Failed ileal loop, exstrophy = p~xbnephritis:
MAY
1886
/
CR
VOLUME
Staged ureterocolocolostomy Preoperative Postoperative--------PyeloPyeloneph. CR neph. Calc. Diar. Acido. + 1.0 +
XXVII,
F-U (MO.)
0.8
92 88 5
0.9 0.9
+ -
-
-
+
0.8 1.1
-
0.8
-
-
+
-
0.7
1.9
(mg/lOO
NUMBER
CR
-
+
= creatinine
quiring surgery developing in 1 case. Conversely, the 1 patient who had bilateral hydronephrosis and pyelonephritis in the past has had no subsequent infections or stones. It is the combination of prior infection and renal impairment that leads to failure. Patients with these risk factors are unable to handle the diarrhea and subsequent acidosis. In our fourth case, the colocolostomy was converted back to a colon conduit because of diarrhea, but the patient had normal renal function and was thus able to prevent the development of acidosis.
ml):
5
-
Calc.
= calculi:
-
+
Diar.
= diarrhea:
+
Acido.
1.4
( + 4Fafter take down) 3 ( + 20 after take down)
= acidosis;
F-U
=
401
The complications of the ureterosigmoidostomy have been well detailed, including ascending infection, obstruction, calculi, electrolyte imbalance,2 5 and neoplasms.6-s While Lapides proposed that the hyperchloremic acidosis resulted from pyelonephritis in patients with normal renal function, Stamey demonstrated that colon reabsorption alone could produce this, even in patients with normal renal function.3.4 When hydronephrosis and/or pyelonephritis result in renal damage, then the colon chloride absorption load readily exceeds the kidney’s excretory capability, resulting in acidosis. In this small series of patients, we have seen the spectrum of difficulties associated with urine in the intact colon. With the staged ureterocolocolostomy, subsequent pyelonephritis is unpredictable, so we would recommend maintaining patients on suppressive antibiotics. Prior pyelonephritis and hydronephrosis are relatively minor risk factors as long as one has normal renal function. As with primary ureterosigmoidostomy, this procedure is contraindicated in the patient whose prior episodes of pyelonephritis have resulted in an elevated serum creatinine. However, careful patient se-
lection will yield stoma-free situation and successful long-term results with minimal diarrhea, infrequent infection, and stable renal function and electrolyte balance, as demonstrated by our first 3 patients.
402
UROLOGY
Division of Urology Room L-l 100 University of Connecticut Health Center 263 Farmington Avenue Farmington, Connecticut 06032 (DR. NIEH) References 1. Nieh PT, Althausen AF, and Dretler SP: Staged ureterocolocolostomy urinary diversion, J Urol 120: 402 (1978). 2. Zincke H, and Segura JW: Ureterosigmoidostomy: critical review of 173 cases, ibid 113: 324 (1975). 3. Lapides J: Mechanism of electrolyte imbalance following ureterosigmoid transplantation, Surg Gynecol Obstet 93: 691 (1951). 4. Stamey TA: The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy, ibid 103: 736 (1956). 5. Wilkinson AW: Biochemical disturbances after transplantation of the ureters, Postgrad Med J 30: 405 (1954). 6. Sorriyaarchchi GS, Johnson RO, and Carbone PP: Neoplasms of the large bowel following ureterosigmoidostom): Arch Surg 112: 1174 (1977). 7. Rivard J-Y, Bedard A, and Dionne L: Colonic neoplasms following ureterosigmoidostomy, J Urol 113: 781 (1975). 8. Shapiro A, et al: Carcinoma of colon after ureterocolic anastomosis. Urology 13: 617 (1979).
i
MAY
1986
i
VOLUME
XXVII,
NUMBER
5