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Ileal Trigonal Urinary Diversion: 5-Year Followup Evaluation
Vol. 118, July, Part 1 Printed in U.SA.
THE JOURNAL OF UROLOGY Copyright © 1977 by The Williams & Wilkins Co.
ILEAL TRIGONAL URINARY DIVERSION: 5-YEAR FOLLOWUP EVALUATION HARRY S. POND, JOHN H. TEXTER, JR., JAMES I. HARTY
AND
ROGER C. SANDERS
ABSTRACT
We anastomosed the intact, undisturbed vesical trigone to the isolated ileal conduit in 24 patients, most of whom have been followed for 5 years. None of these patients has had any pyelographic evidence of upper tract deterioration. There have been no episodes of pyelonephritis, no hydronephrosis, no renal stones and only 4 of the 46 renal units have demonstrated reflux. These data indicate unsurpassed protection of the upper tracts in those patients with neurogenic bladder dysfunction. Patients with a well constructed conventional ileal loop that allows unimpeded drainage of the upper urinary tracts have a distressingly high number of renal complications. 1 These upper tract problems may well be caused by reflux of conduit urine into the upper collecting system. 2 This concern has led to a number of modifications of the conventional ureteral ileal anastomosis to prevent such reflux. 3 In 1967 we conducted a series of dog experiments to evaluate an anastomosis of the intact undisturbed bladder trigone to an isolated ileal conduit. The purpose of this procedure was to prevent ileal ureteral reflux. Also, it gave the operator a large anastomotic junction between the urinary tract and intestinal conduit, which provided a much larger margin of error than does the meticulous anastomosis necessary for the traditional ureteral ileal loop. The results of our canine experiments were reported in 1970. 4 We were extremely encouraged because these animals had no hydronephrosis, did not have reflux and, perhaps most importantly, had sterile urine when aspirates of urine from the renal pelves were cultured. After these experiments we performed the operation on a number of youngsters with myelodystrophic bladder dysfunction and some adults with neurogenic bladder dysfunction secondary to spinal cord injuries. Our preliminary experience and the animal data were reported in 1971. 5 A number of additional patients have been operated upon subsequently with this technique. Currently, there are 24 patients most of whom have been followed more than 5 years. The clinical results of these patients form the basis of this report.
patient was 6 months old and the oldest one was 48 years old, although the majority ranged from 3 to 10 years old. Twenty-one patients had neurogenic bladders and 3 had exstrophy of the bladder. Of the 21 patients with neurogenic bladder dysfunction 18 had congenital myelomeningoceles, 2 had traumatic cord lesions and 1 had multiple sclerosis. Before the operation none of the patients with neurogenic bladder dysfunction had evidence ofvesicoureteral reflux. At 1 month postoperatively reflux was noted in 5 ureters when conduitograms were performed: 1 patient had bilateral reflux and the other 3 patients had left ureteral reflux. Five years after the operation 4 ureters continued to have reflux: the patient with bilateral reflux, 1 of the patients with left ureteral reflux immediately postoperatively and an additional patient who began to have reflux into the right ureter 3 years postoperatively. Of the 3 patients with exstrophy 2 continue to suffer reflux: 1 bilaterally and the other unilaterally. Two patients had major complications during the immediate postoperative period. Both suffered urine leakage at the ileal trigonal anastomosis, and in 1 case a wound dehiscence developed subsequently. Both patients recovered from secondary operations without evidence of renal damage or subsequent stenosis or scarring at the site of the anastomosis of the ileum to the trigone. However, in both of these patients variations were used of the trigonal-ileal anastomosis described. Our only long-term complications are related to problems with the stoma. Four patients had stenosis and acanthosis and 1 patient had a prolapse of mucosa severe enough to require a surgical repair. In none of these 24 patients has there been any evidence of renal deterioration, hydroureteronephrosis, renal stones, pyelonephritis or failure of renal growth. Even the youngsters with ureteral reflux continue to have normal-appearing upper renal tracts and renal cortex on excretory urograms. Although several patients have had positive urine cultures on specimens obtained from the conduit none has required additional hospitalization for upper urinary tract disease or history suggesting pyelonephritis. Our data are compared to a current large series of patients on whom traditional ileal conduits have been done at the Massachusetts General Hospital (see table). 6
METHODS
The technique for the ileal trigonal anastomosis is simple and has been reported in detail previously. 1• 5 In summary, the excess bladder is removed (fig. 1, A), leaving an unmobilized trigonal patch with its attached ureters and ureteral orifices as well as blood supply and innervation (fig. 1, B). This patch is then anastomosed to an incision in the antimesenteric border of a conventional ileal segment, using a 2-layer anastomosis (fig. 2). The remainder of the operation is performed in the same manner as a conventional ileal conduit. RESULTS
Since September 1969, when the first ileal trigonal urinary diversion was performed, 24 patients have undergone diversion with this technique. Most cases are now 5 years postdiversion. Although 2 patients were lost to followup after 2 years both youngsters are reported to enjoy good health and neither has required additional hospitalization. Our youngest Accepted for publication November 19, 1976. Supported in part by the United States Public Health Service Grant CA-05073 from the National Cancer Institute, National Institutes of Health and by Gricks, Inc., Hollis, New York.
28
DISCUSSION
Neurogenic vesical dysfunction is one of the most troublesome and controversial problems facing the genitourinary surgeon. There is hardly any problem that we face that has generated more therapeutic approaches. At the moment there are efforts to perfect various ways to stimulate the bladder using various electronic devices. 7 Also, there is new enthusiasm for the intermittent clean catheterization technique, 8 which when combined with drug therapy, 9 tends to restore continence and may serve to protect the upper renal tracts.
29
ILEAL TRIGONAL URINARY DIVERSION
Comparison of selected complications observed in 24 patients with trigonal-ileal diversion and 90 patients with ureteroileal diversion Trigonal-Ilea! Anastomosis 24 Pts.
Urine leakage at anastomosis of urinary tract and conduit Postop. deaths Pyelonephritis Stenosis at anastomosis of urinary tract and conduit Calculus formation Pyelographic deterioration of renal units Stomal stenosis
Ilea! Conduit 90 Pts.
No.
(%)
No.
(%)
2
(9)*
2
(2)
0 0 0
(0)
19
(0)
9
(1) (20) (10)
0 0
(0) (0)
63
(9) (41)
5
(22)
38
(42)
(0)
8
* In both of these patients variations of the described techniques were used.
l. A., bladder opened along anterior , isolated unmobilized anastomosis to ilea.I
success of any therapeutic regimen can be measured in terms of success in achieving these goals. We believe that the primary goal must be prevention of progressive deterioration of the upper renal tracts with ultimate renal failure. This is unquestionably the natural history of untreated vesical dysfunction in patients with traumatic cord injuries and myelodystrophic neurogenic bladders. it cannot be disputed that if urinary diversion is resorted to it will not be nearly as successful if done after renal scarring, renal stones and upper tract disease are established. 10 A second goal of almost equal importance is to create a perineum. In our society there can be no meaningful educational or occupational participation if the patient is constantly wet and uriniferous. All of us have been struck with the dramatic improvement in personality and social adjustment when a school-age child is given a manageable stoma rather than a chronically excoriated perineum. A third goal would be the preservation of the lower tract in the hope that new techniques, such as bladder pacemaker devices, may become a functional reality. Unfortuthese devices do not have widespread clinical application at the moment despite a great deal of effort, although it is hoped that there will be progress in the future. Obviously, urinary diversion is a compromise. However, the results that we have reported cannot be surpassed in terms of upper tract preservation. Our stoma problems are the same as the stoma problems of any diverted population but these are more manageable and less socially debilitating than a wet excoriated perineum. Obviously, this diversion with its almost total cystectomy makes a subsequent undiversion impossible. However, the technical ease of this technique and our total success in upper renal tract preservation seem to make this the most attractive and straightforward solution to a difficult problem. Dr. M. J. Vernon Smith and the Medical College of Virginia allowed us to include the 3 patients with exstrophy of the bladder. The majority of patients were followed in the Birth Defects Treatment Center, Johns Hopkins Hospital, and studies were supported by Grant RR-52 from the Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health.
FIG. 2. Technique of trigonal-ilea! anastomosis. Reprinted with permission. 5
Vl!hile all of these approaches have been successful none has the for all with neurovesical be more fo:r the for patients to have a goatrather than a dogn1atic therapeutic regithese goals have to be vve12e1n,u differently and
nnmn,rl<>rl
Mobile Urology Group, P.A., Professional Center, Suite 103, 1720 Center St., Mobile, Alabama 36604. (H.S.P.J REFERENCES
L Engel, R M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 2. Minton, J.P., Kiser, W. S. and Ketcham, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection. Surg., Gynec. & Obst., H!l: 541, 1964.
30
POND AND ASSOCIATES
3. Bergman, B. and Nilson, A. E. V.: Intussusception of the ileal loop: an operative method for preventing urinary backflow in ileal conduits. J. Urol., 112: 735, 1974. 4. Pond, H. S. and Texter, J. H., Jr.: Trigonal-ilea! anastomosis: experimental studies. J. Urol., 103: 746, 1970. 5. Pond, H. S. and Texter, J. H., Jr.: Trigonal-ilea! anastomosis: animal studies and preliminary clinical results. J. Urol., 105: 654, 1971. 6. Middleton, A. W., Jr. and Hendren, W. H.: Ileal conduits in children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976.
7. Boyce, W. H., Lathem, J.E. and Hunt, L. D.: Research related to the development of an artificial electrical stimulator for the paralyzed human bladder: a review. J. Urol., 91: 41, 1964. 8. Guttmann, L. and Frankel, H.: The value of intermittent catheterization in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4: 63, 1966. 9. Krane, R. J. and Olsson, C. A.: Phenoxybenzamine in neurogenic bladder dysfunction. II. Clinical considerations. J. Urol., 110: 653, 1973. 10. McCoy, R. M. and Rhamy, R. K.: Heal conduits in children. J. Urol., 103: 491, 1970.
THE JOURNAL OF UROLOGY Copyright © 1977 by The Williams & Wilkins Co.
ILEAL TRIGONAL URINARY DIVERSION: 5-YEAR FOLLOWUP EVALUATION HARRY S. POND, JOHN H. TEXTER, JR., JAMES I. HARTY
AND
ROGER C. SANDERS
ABSTRACT
We anastomosed the intact, undisturbed vesical trigone to the isolated ileal conduit in 24 patients, most of whom have been followed for 5 years. None of these patients has had any pyelographic evidence of upper tract deterioration. There have been no episodes of pyelonephritis, no hydronephrosis, no renal stones and only 4 of the 46 renal units have demonstrated reflux. These data indicate unsurpassed protection of the upper tracts in those patients with neurogenic bladder dysfunction. Patients with a well constructed conventional ileal loop that allows unimpeded drainage of the upper urinary tracts have a distressingly high number of renal complications. 1 These upper tract problems may well be caused by reflux of conduit urine into the upper collecting system. 2 This concern has led to a number of modifications of the conventional ureteral ileal anastomosis to prevent such reflux. 3 In 1967 we conducted a series of dog experiments to evaluate an anastomosis of the intact undisturbed bladder trigone to an isolated ileal conduit. The purpose of this procedure was to prevent ileal ureteral reflux. Also, it gave the operator a large anastomotic junction between the urinary tract and intestinal conduit, which provided a much larger margin of error than does the meticulous anastomosis necessary for the traditional ureteral ileal loop. The results of our canine experiments were reported in 1970. 4 We were extremely encouraged because these animals had no hydronephrosis, did not have reflux and, perhaps most importantly, had sterile urine when aspirates of urine from the renal pelves were cultured. After these experiments we performed the operation on a number of youngsters with myelodystrophic bladder dysfunction and some adults with neurogenic bladder dysfunction secondary to spinal cord injuries. Our preliminary experience and the animal data were reported in 1971. 5 A number of additional patients have been operated upon subsequently with this technique. Currently, there are 24 patients most of whom have been followed more than 5 years. The clinical results of these patients form the basis of this report.
patient was 6 months old and the oldest one was 48 years old, although the majority ranged from 3 to 10 years old. Twenty-one patients had neurogenic bladders and 3 had exstrophy of the bladder. Of the 21 patients with neurogenic bladder dysfunction 18 had congenital myelomeningoceles, 2 had traumatic cord lesions and 1 had multiple sclerosis. Before the operation none of the patients with neurogenic bladder dysfunction had evidence ofvesicoureteral reflux. At 1 month postoperatively reflux was noted in 5 ureters when conduitograms were performed: 1 patient had bilateral reflux and the other 3 patients had left ureteral reflux. Five years after the operation 4 ureters continued to have reflux: the patient with bilateral reflux, 1 of the patients with left ureteral reflux immediately postoperatively and an additional patient who began to have reflux into the right ureter 3 years postoperatively. Of the 3 patients with exstrophy 2 continue to suffer reflux: 1 bilaterally and the other unilaterally. Two patients had major complications during the immediate postoperative period. Both suffered urine leakage at the ileal trigonal anastomosis, and in 1 case a wound dehiscence developed subsequently. Both patients recovered from secondary operations without evidence of renal damage or subsequent stenosis or scarring at the site of the anastomosis of the ileum to the trigone. However, in both of these patients variations were used of the trigonal-ileal anastomosis described. Our only long-term complications are related to problems with the stoma. Four patients had stenosis and acanthosis and 1 patient had a prolapse of mucosa severe enough to require a surgical repair. In none of these 24 patients has there been any evidence of renal deterioration, hydroureteronephrosis, renal stones, pyelonephritis or failure of renal growth. Even the youngsters with ureteral reflux continue to have normal-appearing upper renal tracts and renal cortex on excretory urograms. Although several patients have had positive urine cultures on specimens obtained from the conduit none has required additional hospitalization for upper urinary tract disease or history suggesting pyelonephritis. Our data are compared to a current large series of patients on whom traditional ileal conduits have been done at the Massachusetts General Hospital (see table). 6
METHODS
The technique for the ileal trigonal anastomosis is simple and has been reported in detail previously. 1• 5 In summary, the excess bladder is removed (fig. 1, A), leaving an unmobilized trigonal patch with its attached ureters and ureteral orifices as well as blood supply and innervation (fig. 1, B). This patch is then anastomosed to an incision in the antimesenteric border of a conventional ileal segment, using a 2-layer anastomosis (fig. 2). The remainder of the operation is performed in the same manner as a conventional ileal conduit. RESULTS
Since September 1969, when the first ileal trigonal urinary diversion was performed, 24 patients have undergone diversion with this technique. Most cases are now 5 years postdiversion. Although 2 patients were lost to followup after 2 years both youngsters are reported to enjoy good health and neither has required additional hospitalization. Our youngest Accepted for publication November 19, 1976. Supported in part by the United States Public Health Service Grant CA-05073 from the National Cancer Institute, National Institutes of Health and by Gricks, Inc., Hollis, New York.
28
DISCUSSION
Neurogenic vesical dysfunction is one of the most troublesome and controversial problems facing the genitourinary surgeon. There is hardly any problem that we face that has generated more therapeutic approaches. At the moment there are efforts to perfect various ways to stimulate the bladder using various electronic devices. 7 Also, there is new enthusiasm for the intermittent clean catheterization technique, 8 which when combined with drug therapy, 9 tends to restore continence and may serve to protect the upper renal tracts.
29
ILEAL TRIGONAL URINARY DIVERSION
Comparison of selected complications observed in 24 patients with trigonal-ileal diversion and 90 patients with ureteroileal diversion Trigonal-Ilea! Anastomosis 24 Pts.
Urine leakage at anastomosis of urinary tract and conduit Postop. deaths Pyelonephritis Stenosis at anastomosis of urinary tract and conduit Calculus formation Pyelographic deterioration of renal units Stomal stenosis
Ilea! Conduit 90 Pts.
No.
(%)
No.
(%)
2
(9)*
2
(2)
0 0 0
(0)
19
(0)
9
(1) (20) (10)
0 0
(0) (0)
63
(9) (41)
5
(22)
38
(42)
(0)
8
* In both of these patients variations of the described techniques were used.
l. A., bladder opened along anterior , isolated unmobilized anastomosis to ilea.I
success of any therapeutic regimen can be measured in terms of success in achieving these goals. We believe that the primary goal must be prevention of progressive deterioration of the upper renal tracts with ultimate renal failure. This is unquestionably the natural history of untreated vesical dysfunction in patients with traumatic cord injuries and myelodystrophic neurogenic bladders. it cannot be disputed that if urinary diversion is resorted to it will not be nearly as successful if done after renal scarring, renal stones and upper tract disease are established. 10 A second goal of almost equal importance is to create a perineum. In our society there can be no meaningful educational or occupational participation if the patient is constantly wet and uriniferous. All of us have been struck with the dramatic improvement in personality and social adjustment when a school-age child is given a manageable stoma rather than a chronically excoriated perineum. A third goal would be the preservation of the lower tract in the hope that new techniques, such as bladder pacemaker devices, may become a functional reality. Unfortuthese devices do not have widespread clinical application at the moment despite a great deal of effort, although it is hoped that there will be progress in the future. Obviously, urinary diversion is a compromise. However, the results that we have reported cannot be surpassed in terms of upper tract preservation. Our stoma problems are the same as the stoma problems of any diverted population but these are more manageable and less socially debilitating than a wet excoriated perineum. Obviously, this diversion with its almost total cystectomy makes a subsequent undiversion impossible. However, the technical ease of this technique and our total success in upper renal tract preservation seem to make this the most attractive and straightforward solution to a difficult problem. Dr. M. J. Vernon Smith and the Medical College of Virginia allowed us to include the 3 patients with exstrophy of the bladder. The majority of patients were followed in the Birth Defects Treatment Center, Johns Hopkins Hospital, and studies were supported by Grant RR-52 from the Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health.
FIG. 2. Technique of trigonal-ilea! anastomosis. Reprinted with permission. 5
Vl!hile all of these approaches have been successful none has the for all with neurovesical be more fo:r the for patients to have a goatrather than a dogn1atic therapeutic regithese goals have to be vve12e1n,u differently and
nnmn,rl<>rl
Mobile Urology Group, P.A., Professional Center, Suite 103, 1720 Center St., Mobile, Alabama 36604. (H.S.P.J REFERENCES
L Engel, R M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 2. Minton, J.P., Kiser, W. S. and Ketcham, A. S.: A study of the functional dynamics of ileal conduit urinary diversion with relationship to urinary infection. Surg., Gynec. & Obst., H!l: 541, 1964.
30
POND AND ASSOCIATES
3. Bergman, B. and Nilson, A. E. V.: Intussusception of the ileal loop: an operative method for preventing urinary backflow in ileal conduits. J. Urol., 112: 735, 1974. 4. Pond, H. S. and Texter, J. H., Jr.: Trigonal-ilea! anastomosis: experimental studies. J. Urol., 103: 746, 1970. 5. Pond, H. S. and Texter, J. H., Jr.: Trigonal-ilea! anastomosis: animal studies and preliminary clinical results. J. Urol., 105: 654, 1971. 6. Middleton, A. W., Jr. and Hendren, W. H.: Ileal conduits in children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976.
7. Boyce, W. H., Lathem, J.E. and Hunt, L. D.: Research related to the development of an artificial electrical stimulator for the paralyzed human bladder: a review. J. Urol., 91: 41, 1964. 8. Guttmann, L. and Frankel, H.: The value of intermittent catheterization in the early management of traumatic paraplegia and tetraplegia. Paraplegia, 4: 63, 1966. 9. Krane, R. J. and Olsson, C. A.: Phenoxybenzamine in neurogenic bladder dysfunction. II. Clinical considerations. J. Urol., 110: 653, 1973. 10. McCoy, R. M. and Rhamy, R. K.: Heal conduits in children. J. Urol., 103: 491, 1970.