ILEAL URETER

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USE OF BOWEL IN UROLOGIC SURGERY

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ILEAL URETER RogQio M. Mattos, MD, and John J. Smith 111, MD

The search for an optimal method for reconstruction or replacement of the diseased ureter is a classic example of the way urologists seek solutions to complex genitourinary problems. Numerous types of grafts have failed, including those using blood vessels, fallopian tubes, peritoneal tubes, and metal and plastic. Ureteral replacement with ileal bowel segments has become part of’the urologic surgeon’s armamentarium more than 35 years after Goodwin et allo first popularized the procedure. Fenger7 is credited with the first written proposal for reconstructing the ureter with small bowel. In 1900, the operation was successfully performed on three dogs by d’Urso and de Fabii.6 In 1906, ShoemakeP carried out the first repair in a human by replacing the ureter of an 18-year-old woman who was presumed to have genitourinary tuberculosis. MelnikofF5published a classic treatise in 1912 on the history of the procedure but, by 1950, only three case reports were found in the literature. In 1959, the summary by Goodwin et allopopularized the procedure. In general, the indications for intestinal replacement of the ureter remain the same today: Recurrent calculi Extensive ureteral injury Retroperitoneal fibrosis Ureteral stricture Fistula Tuberculosis Ureteral carcinoma in solitary kidney Undiversion

Congenital obstruction Schistosomiasis This is because ileal ureter reconstruction should usually be considered when all other more conservative procedures, such as ureteroneocystostomy, ureterocalicostomy, Boari flap, transureteroureterostomy, and in some cases autotransplantation, are not applicable. Contraindications to ileal ureter replacement include an inadequate length of usable bowel or inflammatory bowel disease: Ileal disease (inflammatory bowel disease) Incontinence Bladder neck obstruction Neurogenic bladder Metastatic disease Renal failure Hepatic dysfunction Patients with hepatic dysfunction are at risk for the development of hepatic encephalopathy secondary to absorption of nitrogenous waste into the enteric circulation. This risk is particularly noteworthy in a patient with portacaval shunt.I4 Furthermore, to avoid high-pressure reflux and subsequent renal deterioration, any difficulty with emptying the bladder should be evaluated and ruled out before operation. Pre-existing azotemia has been a relative contraindication, particularly when the serum level of creatinine is greater than 2 mg/dL. Infrequently, however, we are faced with a patient with a level of creatinine greater than 2 mg/dL who wishes to risk metabolic complications to avoid a less palatable alternative.

From the Department of Urology, Lahey Hitchcock Medical Center, Burlington, Massachusetts UROLOGIC CLINICS OF NORTH AMERICA

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VOLUME 24 NUMBER 4 * NOVEMBER 1997

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We recommend using a much smaller area of bowel as a segment or interposition graft. The safe use of small segments with caution to replace damaged ureters has been reported by Casale et a15 and Lytton and Schiff13 in humans and Waters et alZ4in dogs. Experience at the Lahey Hitchcock Medical Center now totals 61 ureteral replacements. In this group were 17 solitary kidneys and 11 segmental replacements, 3 of which are true interposition grafts. PREOPERATIVE PREPARATION Standard preoperative treatment includes bowel preparation with polyethylene glycol electrolyte solution (GoLYTELY, Braintree Laboratories, Braintree, MA), oral administration of antibiotics, and parenteral use of antibiotics at the time of operation and continued 24 hours after operation. Miniheparinization or pneumatic compression boots are used perioperatively. It is usually prudent to use retrograde ureteral catheterization, percutaneous antegrade nephrostomy, or both to aid in identification of the ureter because in many patients previous reconstructive procedures have failed or extensive periureteral reaction has occurred. Preoperative percutaneous nephrostomy may also be an important consideration in restoring optimal renal function before ileal replacement of the ureter. SURGICAL TECHNIQUE The patient is placed in the supine position with the arms extended at the sides. A Foley catheter is introduced into the bladder to monitor urinary output. The skin of the lower chest, flank, and abdomen is prepared so that access to a nephrostomy site is available. Although the patient can be placed in a modified flank position and the incision extended onto the abdomen, we prefer to use a midline incision from the xiphoid process to the symphysis pubis. The abdominal cavity is entered and carefully inspected, and all adhesions are lysed. The ileum is briefly checked to observe if there are any limitations that are imposed by its mesentery. The technique for replacement of the ureter on either side is similar. The cecum and ascending colon are mobilized medially on the right. The descending and sigmoid colon are mobilized on the left, and a window is cre-

Figure 1. Mobile,segment of ileum selected to be longer than anatomically required. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

ated in the mesentery of the descending colon to permit the ileal segment to reach the bladder with ease. The following comments concentrate on right ureteral replacement. The right colon is mobilized by entering the retroperitoneal space through an incision in the lateral peritoneal gutter along the white line of Toldt. Mobilization in this fashion permits inspection of the entire course of the ureter as well as an accurate measure of the diseased segment. A 25- to 35-cm length of ileum is selected (Fig. 1).The length should be somewhat re-

Figure 2. Technique for isolating the segment of ileum. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

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Figure 3. Irrigation of isolated bowel to wash out mucus and fecal material, (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

dundant. Any excess can be excised in the bladder at the time of this anastomosis. Continuity of the ileum is restored with a standard two-layer bowel anastomosis anterior to the isolated ileal segment (Fig. 2) or using stapling devices in a side-to-side anastomosis. When staples are used, it is important to remove any staples that can have contact with urine because the chance that calculi will develop in the future is much greater. Any mesenteric openings are closed to avoid internal herniation. The isolated bowel is irrigated to

Figure 4. Maintenance of isoperistaltic orientation of ileum segment (arrows). (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

remove any remaining mucus (Fig. 3), and the segment is marked to maintain its isoperistaltic direction (Fig. 4). The segment is placed in an isoperistaltic direction in its retroperitoneal position (Fig. 5).

Figure 5. Segment of ileum isolated for interposition.

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The diseased ureter is resected or ligated according to the clinical situation. The mesentery should be inspected to be sure no vascular compromise is imminent before the proximal anastomosis is performed (Fig. 6). The site of the proximal anastomosis is determined by the existing anatomy and clinical indications. In a patient with multiple recurrent calculi, for example, the proximal ileum may be sutured to the renal pelvis and lower calix to facilitate passage of the calculus through a wide anastomosis. In the rare situation where both ureters are to be replaced, a longer segment of ileum is isolated. It may pass from the left renal pelvis to the right renal pelvis and descend to the bladder in a Y formation (Fig. 7). Usually, the ureter and renal pelvis can be spatulated at a 45-degree angle (Fig. 8).. The length of the opening in the pelvis and ureter should be identical (Fig. 9). The anastomosis is carried out with interrupted sutures of 2-0 Vicryl (Figs. 10-12). Before completion of the anastomosis, a nephrostomy tube and a smooth round Jackson-Pratt drain (Baxter Healthcare Corp, Deerfield, IL) acting as a ureteral stent are placed in the kidney. If the patient already has a previous nephrostomy

Figure 6. Care must be exercised to prevent injury to the vasculature of the isolated ileal segment by rotation. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

Figure 7. Replacement of both ureters by one long segment of ileum. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

tube in place, there is no need to stent the ureter, and a control ureterogram can be obtained without problem. The drain traverses the anastomosis both proximally and distally and is brought out though the anterior wall of the bladder. This permits a large tube for drainage and stenting that is less likely to migrate or clog with mucus than a smaller conventional single or double-J stent (Medical Engineering, Surgitek, Racine, WI). The bladder is opened anteriorly in the midline (Fig. 13). It is important to remove an adequate full-thickness segment of the bladder posteriorly. The ileum can be grasped and passed into the bladder (Figs. 14 and 15). Any redundant distal ileum can be excised at this time. A seromuscular anastomosis of the ileum to the posterior wall of the bladder is carried out with interrupted sutures of 2-0 Vicryl. The second anastomosis between the mucosa of the ileal ureter and the gnucosa of the bladder is carried out with Gterrupted sutures of 4-0 Dexon (Figs. 16 and 17). The Jackson-Pratt drain is brought through the anterior wall of the bladder and secured

ILEAL URETER

Figure 8. Opening of the renal pelvis in a 45" angle.

Figure 9. Identical sizes of the ileal segment and renal pelvis prepared for anastomosis.

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Figure 10. Anastomosis of renal pelvis and ileum. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

Figure 11. Anastomosis of the ileum to the renal pelvis with interrupted sutures of 2-0 Vicryl. Anterior side of the suture line.

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Figure 12. Completion of the anastomosis on both sides without any visible leakage.

with sutures of 4-0 chromic catgut. It is important also to place several seromuscular sutures between the ileum and the serosa of the to Secure the anastom'sis further. To complete the procedure, the anterior wall of the bladder is closed in lavers, and the right colon can be reperitonealized (Fig. 18). Two representative radiographic examples are shown in Figures 19 and 20. SEGMENTAL REPLACEMENT An alternative technique for shorter diseased segments is segmental replacement of the ureter. The technique has been used with

Figure 14. A clamp is passed from within the bladder outward through posterior window. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

success by a number of groups. The preoperative preparation and surgical principles are the same as previously described, however, a much smaller segment of bowel is mobilized and used. Oftenra window can be made in the colonic mesentery rather than to elect complete mobilization of the colon.

Figure 13. Opening of the bladder in the midline.

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Figure 15. A Babcock clamp'brings the distal ileal segment into the bladder.

The proximal anastomosis can be made to the renal pelvis or to a segment of proximal spatulated ureter. The distal anastomosis, usually tapered over a red rubber catheter, is made to the spatulated ureter or into the bladder (Fig. 21). Hendren and McLorie12 have described a technique of reducing the

ileal lumen by excising a full-thickness strip from the antimesenteric border and implanting it diagonally across the posterior wall of the bladder. When the segmental replacement or the vesical implantation is performed in this fashion, the potential for late stricture formation, as seen in one of our patients, exists. Although our experience with segmental replacement is limited to 11 patients, including 3 who had interposition grafts, we have had excellent results. Segmental replacement in an obstructed kidney is shown in Figure 22. RESULTS

Figure 16. Anastomosis of ileum to posterior wall of bladder. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

Ileum as a replacement in cases of ureteral loss is reported in the literature by many different groups. Some prefer to interpose a segment of ileum only in the area obstructed or in the presence of a severe stricture. Shokeir et .alZ1reported on the use of an ileal loop interposed to replace a long defect of the upper ureter with preservation of the lower ureteral continuity in three patients, with satisfactory urinary drainage and improvement in renal function postoperatively. Gomez-Avraham et a1,9 demonstrated similar results in four patients with severe ureteral strictures after application of an ileal patch graft in the area of the ureteral stenosis without metabolic abnormalities. Twenty-nine patients of Bejany et a12 un-

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Figure 17. Anastomosis of the ileal segment to the bladder, with a nipple protruding to the inner side.

denvent an ileal segment interposition between the upper and the lower urinary tract for partial or total ureteral substitution. Some of these patients had already had previous attempted reconstruction that had failed. In another group of patients, an antirefluxing

Figure 18. Completed ileal ureter substitute with reperitonealization of the right colon and closure of anterior wall of bladder. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

ureteral anastomosis was performed that resulted in a success rate of 50%. An ileal segment is used to maintain urinary drainage from the kidneys to the bladder and to reconstruct iatrogenic ureteral injuries, as reported by Selzman and Spirnak.17 In their 165 cases of iatrogenic ureteral injury, various forms of management were implemented. Among the ones that required definitive surgical reconstruction, three patients had an ileal interposition. Some less common entities can also be suitable for ileal ureteral replacement, as reported by Tsuji et al.23Localized pelviureteral amyloidosis was managed by surgical reconstruction of an ileal ureter. One of our recent patients with a low-grade ureteral tumor in a horseshoe kidney underwent total ureterectomy on the affected side and an ileal interposition from the kidney to the bladder (see Fig. 22) (Mattos RM, Smith JJ 111, Libertino JA, Unpublished data, 1997). Another rare situation using an ileal ureter was described in a patient with bilharziasis of the urinary tract affecting the ureter, which was replaced by ileum.' One instance of carcinoma of the bladder occurring after construction of an ileal ureter has been described by Shokeir.19 Squamous cell carcinoma of the ileovesical junction developed 12 years after total replacement of the ureter with ileum. The author believed that urine infected with fecal bacterial flora and a healing uroenteric suture line could have been the responsible factors and recommended yearly evaluation of urine cytology. Urogenital tuberculosis is associated with strictures of the urinary system, including the

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Figure 19. A, Nephrostogram of 37-year-old woman with a solitary kidney who underwent right ureteral tapering and reimplantation. Diffuse ureteral stenosis and necrosis developed after operation. 6,Intravenous pyelogram 10 years after replacement of ureter with a tapered segment of ileum.

Figure 20. A, Preoperative film of a 19-year-old man with diffuse left upper ureteral injury, obstruction, and extravasation after two left pyeloplasties. B, Intravenous pyelogram 4 years after left ileal ureter procedure.

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Figure 21. A, Diseased segment of ureter. B, Interposition graft with a small segment of bowel. (Copyright of Lahey Hitchcock Medical Center, Burlington, MA.)

Figure 22. Intravenous pyelogram of an ileal ureter in a horseshoe kidney.

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ureters. Carl and Stark4 reported a case of active tuberculosis with a nonfunctioning kidney and nearly total loss of bladder capacity. Treatment consisted of ileal bladder augmentation and ileal ureter replacement, with complete return of normal function. Many pathologic conditions following kidney transplantation may result in partial or complete loss of the ureter, as in fistulas or ureteral necrosis. In a case report by Fontana et al; a patient with extensive fibrosis of'the transplanted ureter without available native ureter was treated with an isolated segment of ileum as a substitute for the ureter. Two questions that always present when dealing with the ileal ureter are (1) whether the antireflux anastomosis is necessary and (2) whether it prevents further damage to the upper urinary tract.3,lo, 11, 22 A study of 50 patients from the experience of Shokeir and Ghoneim20deals with this topic. Of the two prospectively randomized groups, one was treated with a standard ileal ureter procedure and the other with a modified valved ileal ureter. Among the 23 patients in the latter group, 22% still experience postoperative reflux. The study concluded that prevention of reflux is an important issue and preserves renal function. At the Lahey Hitchcock Medical Center, the ileovesical anastomosis is performed as a Paquin nipple procedure, and we have not encountered significant loss of renal function or considerable reflux because it is a good antireflux mechanism for these patients. When both ureters are damaged and need to be replaced, a more complicated operation is required. Rothauge et all6 reported their experience in reconstruction of the urinary tract with ileum, partially on both sides with a transposed ileal loop and total replacement of one or even both ureters. LAHEY HITCHCOCK MEDICAL CENTER EXPERIENCE

Our experience with ureteral replacement spans over three decades. To date, 61 ureteral replacements have been performed, and 57 patients have had follow-up studies of more than 1 year. This experience includes 11 patients with segmental replacements, three of whom, as previously mentioned, had small interposition grafts. Success was defined as the absence of operative deaths, complications, troublesome recurrent calculi, the need for subsequent diversion, progressive azotemia, or evidence of

deterioration as seen on pyelography. When these criteria were applied, 54 of these patients (88.5%) had a successful result. Complications are listed in Table 1. In two patients with solitary kidneys, worsening azotemia necessitated cutaneous diversion of the ileal segment. One patient required conversion to a freely refluxing distal anastomosis after an ileovesical stricture developed, and one patient died of a postoperative myocardial infarction. Of 57 patients, 21 had bacteriuria at some point in their follow-up period; however, this finding was never clinically important. Two patients had pancreatitis and one patient had diarrhea requiring treatment with cholestyramine. Tanagho" argued against the inclusion of intestinal segments in a closed urinary system because of the possibility of electrolyte abnormalities, disabling infection, obstruction, and exposure to intermittently high pressures that potentially lead to decompensation of the upper urinary tract. We have not experienced any of these concerns in our group of patients. Furthermore, the advantage of an interposition graft should limit the potential for electrolyte disturbances, formation of mucus plugs, acidosis, and diarrhea because a smaller surface area is used. Moreover, when the ureterovesical junction is left intact, reflux and its attendant potential for progressive deterioration of the upper urinary tract is avoided. In the patient with compromised renal function, the ileum can be used with caution as an interposition graft. In conclusion, ileal ureteral substitution can be used safely for renal salvage. Careful selection of patients and attention to surgical deTable 1. COMPLICATIONS ASSOCIATED WITH ILEAL URETER LAHEY HITCHCOCK MEDICAL CENTER EXPERIENCE (58 PATIENTS)

Complication Major ' Renal deterioration Death lleovesical stricture Recurrent calculi Urinary extravasation Pyelonephritis Minor Bacteriuria Pancreatitis Metabolic acidosis Diarrhea Transient hepatic encephalopathy Osteomalacia

Number 3 1 1 0 0 0

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ILEAL URETER

tail ensure a favorable success rate in an often difficult situation.

References 1. Bazeed MA, El-Rakhawy M, Ashamallah A, et al: Ileal replacement of the bilharzial ureter: Is it worthwhile? J Urol 130:245-248, 1983 2. Bejany DE, Lockhart JL, Politano VA Ileal segment for ureteral substitution or for improvement of ureteral function. J Urol 146:302-305, 1991 3. Boxer RJ, Fritzsche P, Skinner DG, et al: Replacement of the ureter by small intestine: Clinical application and results of the ileal ureter in 89 patients. J Urol 121:728-731, 1979 4. Carl P, Stark L Ileal bladder augmentation combined with ileal ureter replacement in advanced urogenital tuberculosis. J Urol 151:1345-1347, 1994 5. Casale AJ, Colodny AH, Bauer SB, Retik AB: The use of bowel interposed between proximal and distal ureter in urinary tract reconstruction. J Urol 134737740, 1985 6. d’Urso and de Fabii, cited by Moore EV, Weber R, Woodward ER, et al: Isolated ileal loops for ureteral repair. Surg Gynecol Obstet 102:87-99, 1956 7. Fenger C: Surgery of the ureter. Ann Surg 20:257, 1894 8. Fontana I, Arcuri V, Verrina E, et a1 Tapered bowel segment for ureteral replacement in renal transplantation. Transplant Proc 26117-118, 1994 9. Gomez-Avraham I, Nguyen T, Drach G W Ileal patch ureteroplasty for repair of ureteral strictures: Clinical application and results in 4 patients. J Urol 152:20002004, 1994 10. Goodwin WE, Winter CC, Turner R D Replacement of the ureter by small intestine: Clinical application

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and results of the ”ileal ureter.” J Urol 81:40&418, 1959 11. Hendren WH. Tapered bowel segment for ureteral replacement. Urol Clin North Am 5:607416, 1978 12. Hendren WH, McLorie GA: Late stricture of intestinal ureter. J Urol 129:584-590, 1983 13. Lytton 8, Schiff M: Interposition of an ileal segment for repair of ureteral injuries. J Urol125:739-741,1981 14. McDermott WV Jr: Diversion of urine to the intestines as a factor in ammoniagenic coma. N Engl J Med 25646M62, 1957 15. Melnikoff AE: Sur le replacement de l’uretere par une anse isolee de l’intestin [email protected] Clin Urol 1:601, 1912 16. Rothauze CF. Tarrar K.Weidner W. 25 vears of exuerience k the’ ;econstruction of the efierent uriniry tract with ileum. Urol Int 46:31&323, 1991 17. Selzman AA, Spirnak IP: Iatrogenic ureteral iniuries: A 20-year expirience in treatXg 165 injuries. J Urol 155:87&881, 1996 18. Shoemaker, cited by Moore EV, Weber R, Woodward ER, et al: Isolated ileal loops for ureteral repair. Surg Gynecol Obstet 102:87-97, 1956 19. Shokeir AA: Bladder cancer following ileal ureter: Case report. Scand J Urol Nephrol29:112-115, 1995 20. Shokeir AA, Ghoneim MA: Further experience with the modified ileal ureter. J Urol 15445-48, 1995 21. Shokeir AA, Mahran MR, Shamaa MA: Interposition of ileum in the ureter. Scand J Urol Nephrol 27421424, 1993 22. Tanagho EA: A case against incorporation of bowel segments into the closed urinary system. J Urol 113:796-802, 1975 23. Tsuji Y, Michinaga S, Ariyoshi A: Ileal ureter: Another option for the treatment of localized amyloidosis of the upper urinary tract. J Urol 151:9991000,1994 24. Waters WB, Herbster G, Jablokow VR, Reda DJ: Ureteral replacement using ileum in compromised renal function. J Urol 14L432-436, 1989

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Address reprint requests to John J. Smith 111, MD Department of Urology Lahey Hitchcock Medical Center 41 Mall Road Burlington, MA 01805