- Email: [email protected]
Late Stricture of Intestinal Ureter
0022-5347/83/1293-0590$02.00/0 Vol.129, March
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
LATE STRICTURE OF INTESTINAL URETER W. HARDY HENDREN* AND GORDON A McLORIEt From the Division of Pediatric Surgery, Massachusetts General Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT
Late stricture is a well known complication of ileal loops. We herein report on late stricture in 5 patients in whom bowel was used as a substitute ureter in closed, nondiverted urinary tracts. This late complication mandates the need to provide continuing followup indefinitely in patients in whom bowel segments are incorporated in the urinary tracts. Late stricture is a well recognized complication of ileal loop urinary diversion. 1- 3 The pathological condition is predominately mucosal and submucosal fibrosis, and edema with segmental narrowing causing obstruction. This is not to be confused with ischemia of a bowel segment, which can lead to diffuse fibrosis of the entire segment. Tapper and Folkman noted lymphocyte depletion in intestinal segments exposed to urine and postulated that this may be an etiologic factor in the development of strictures of bowel segments for ileal loop urinary diversion.4• 5 We herein describe late stricture formation in small bowel segments used as intestinal ureters in the closed urinary tract. These patients require the same diligent long-term followup that has proved essential in patients with cutaneous urinary diversion using small bowel conduits. CASE REPORTS
Case 1. A 22-month-old child was referred in April 1967 with a prior ileal loop diversion that was obstructed by the vascular pedicle of the bowel. The original problem had been urethral valves with massive reflux and severe hydronephrosis. The ileal loop was removed and a new loop was performed. The cutaneous stoma was revised for stenosis 1 year later and the patient subsequently did well. In June 1973 undiversion was performed when the patient was 8 years old, the ileal loop being tapered and implanted into the long defunctioned bladder (fig. 1). Left pyeloileal revision was performed 1 month later. Both of these reconstructive procedures would be performed in a single operation today. Convalescence was uneventful and the general health was satisfactory. Excretory urography (IVP) showed satisfactory drainage of the upper tracts with less hydronephrosis than had been present with diversion (fig. 2, A). An interval IVP 2½ years later was believed to be stable, although in retrospect there was an area of narrowing in the bowel just below the level of the right renal pelvis (fig. 2, B). The patient remained well clinically. In February 1978 hematuria occurred after a fall from a tree. A repeat IVP showed an alarming degree of hydronephrosis (fig. 2, C). Antegrade pyelography showed obstruction in the tapered bowel segment below the junction with the right renal pelvis (fig. 3, A). This study also was suggestive of a second point of narrowing in the bowel segment overlying the spine just below the junction with the left renal pelvis. At endoscopy the panendoscope could be passed into the bladder and up the tunneled and tapered bowel segment. The stenotic segment was a thin mucosa! diaphragm, which was explored. A discrete point of narrowing on the external surface of the tapered bowel Accepted for publication July 28, 1982. * Requests for reprints: Department of Surgery, Children's Hospital, 300 Longwood Ave., Boston, Massachusetts 02115. tCurrent address: Department of Urology, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada.
conduit was excised, with reanastomosis of the bowel with chromic catgut. Microscopic sections of the specimen showed urothelial metaplasia and chronic inflammation. The mucosa was replaced by regenerating urothelial epithelium. No ileal epithelium was noted. At endoscopy 8 months later the tapered bowel segment showed no residual narrowing at the point of repair. It was elected to repair also the more proximal narrowing just below the left renal pelvis by resection and reanastomosis of the bowel to the lower pole of the kidney instead of the renal pelvis. Microscopic examination showed narrowing of the lumen with asymmetrical hypertrophy of the muscularis and muscularis mucosa, fibrosis and edema of the submucosa, and focal acute and chronic inflammation. The ileal segment was lined primarily by urothelium. The patient has remained well. An antegrade pyelogram in November 1980 showed satisfactory drainage (fig. 3, B). Presently, the patient is 17 years old with height in the 90th percentile and weight at the 75th percentile. Blood urea nitrogen (BUN) is 15 mg. per cent, creatinine 1.3 mg. per cent and creatinine clearance 136 1. absolute or 73.5 1./M.2 body surface area daily. Comment: This patient, like many boys with urethral valves 15 to 20 years ago, was treated with an ileal loop, which in retrospect was ill-advised. A better approach would have been destruction of the valves and, in this severe case, tailoring and reimplantation of the ureters with massive reflux. Of 119 undiversions to date 54 were in patients whose original pathological condition was urethral valves. The patient has surprisingly good renal function (about 75 per cent of normal) despite once having had massive hydronephrosis. He has done well in the 9 years since undiversion. The late appearance of 2 strictures in the bowel ureter indicates the need to follow these patients indefinitely. In those patients with poor renal function in whom contrast medium will not outline clearly the entire urinary tract antegrade perfusion of contrast medium through a percutaneous 22 gauge spinal needle offers the best method of radiographic evaluation, with the further advantage of allowing measurement of perfusion pressures. The normal differential pressure between the upper tract and bladder is between 5 and 10 cm. water. Case 2. This newborn was referred in June 1963 with bilateral massive hydronephrosis caused by a ureterocele involving a duplicated collecting system on the left side. The ureterocele obstructed bladder outflow and was removed. The megaureter and. the upper pole of the left kidney were removed 1 month later. The patient did poorly with recurrent severe infection. A high pyeloileal conduit was performed when the patient was 4 months old, leaving the right lower ureter in hopes that the upper tract would improve and allow subsequent reconstruction. The patient thrived although there were recurrent mild infections during ileal loop diversion. The stoma was revised twice for stenosis. In July 1969 undiversion was performed when the patient
584
685 PRE-OP
Small !hin-walled bladder
POST-OP
9
" -<---Valves
FIG. 1. Case l. Preoperative and postoperative anatomy. Undive.rsion was staged, tapering and implanting conduit in I procedure and revising upper end in second operation. Today this would be done in single procedure.
Fm. 2. Case 1. A, IVP in May 1974, 1 year afte:r undiversion shows satisfactory drainage of upper tracts with only moderate dilatation. B, IVP in 1976, 2½ years after undiversion, shows slight increase in dilatation of tracts and some narrowing of small bowel segment below pelvis s1s,mit1c1m<:e of which was not appreciated at that time. IVP in February 1978 after episode of trauma hematuria shows massive of upper tracts,
-·--···••vu
was 6 years old 4), A nn-«u,,--.,,-,-,,t,, ephJ:"ost,)g:;:·,nnshowed passage of contrast tapered ileal into the (fig. 5, Subsequent IVPs each year bowel. ureter 5, B). Convalescence was uneventful until an episode of tract infection with flank in 1978, 9 years undiversion. An IVP shm;ved increased hydronephrosi.s and antegrade pyelography revealed marked stenosis in the upper of the small bowel segment (fig, 5, C). In contrast to case 1, there was no external evidence of narrowing of the bowel segment at open operation. The bowel segment was opened and a thin obstructing diaphragm was found, which seemed to be formed of mucosa only. This diaphragm was resected, leaving the seromuscular layer of bowel intact and the mucosa edges were repaired with interrupted chromic sutures. Microscopically, this proved to be gastrointestinal mucosa with marked chronic inflammation and edema. A biopsy of the bowel segment lining above the point of obstruction showed urothelium replacing gastrointestinal mucosa. An IVP 4 months later showed satisfactory drainage of the upper tract with less hydronephrosis. The patient presently
health. Renal function studies at the for correction of the obstn,cted diashowed BUN 14 mg, per cent and creatinine clearance 73 1Comrnent: The ileal diversion was done in this almost 2 decades ago because the child was not on antibiotic treatment, We would not choose that treatment today. Of 119 undiversions performed to date 3 were in patients who we had diverted, This case and case 3 are 2 of the 3 undiversion cases originally diverted by us. Case 3. A 2-week-old newborn was referred in August 1963 with severe hydronephrosis from urethral valves and hyaline membrane disease. Suprapubic cystostomy had been performed previously. His condition did not improve with antibiotics and drainage. End ureterostomies were done l month later but the patient continued to do poorly. High ileal loop diversion was performed at age 2 months in the belief at that time that this would give ideal drainage of the upper tracts. Considering the desperate condition as an infant, the patient thrived reasonably well. When he was 6 years old BUN was 38 mg. per cent, creatinine 1.7 mg. per cent and creatinine clearance 34 1./M. 2
586
HENDREN AND MCLORIE
Fm. 3. Case 1. A, antegrade perfusion study in March 1978 shows marked narrowing of bowel segment below right renal pelvis (large arrow) and lesser degree of narrowing of bowel overlying spine (small arrow). Both stenoses subsequently were removed. B, bilateral antegrade perfusion study in November 1980 shows free passage of contrast medium without narrowing of bowel segment.
BEFORE
previous borderline gradient of 11 cm. water when the diaphragm was present. Comment: This patient was our first in whom ileal loop undiversion was done by tapering and implanting the loop. He has thrived remarkably well through the years considering the severe degree of upper tract damage when first presented. He is now 19 years old, and in the 15th percentile for height and 25th percentile for weight. When undiversion was done in 1969 at age 6 years BUN was 47 mg. per cent and creatinine was 1.3 mg. per cent. After 13 years, during which time adult body mass was attained, BUN has reached 54 mg. per cent and creatinine 4.0 mg. per cent. Renal transplantation probably will be necessary for this patient some day. However, this may well be forestalled for many years if he remains free of infection. It is not clear whether the valve-like obstruction in the bowel segment in this case was truly acquired like those in cases 1 and 2 or whether it was a flap valve of mucosa created from tapering the bowel segment. In any event it was possible to open the valve from below as an endoscopic cutting procedure in contrast to open exploration as was done in cases 1 and 2. Case 4. This 20-year-old man was referred with urinary infection and hydronephrosis in April 1975. When he was 2
AFTER
Fm. 4. Case 2. Preoperative and postoperative anatomy
body surface area. Undiversion was performed in November 1969. The lower part of the ureteral loop was tapered and implanted into the bladder with a tunneling technique. Two years later the upper part of the loop was tapered to reduce the absorptive surface of intestinal mucosa and, possibly, improve emptying of the system. The patient did remarkably well except for several urinary infections. Cystography showed some reflux up the tapered bowel segment, which was revised (fig. 6). The previously tapered bowel was dissected free from the bladder, further narrowing its caliber, and implanted with a longer tunnel and higher psoas hitch, which stopped the reflux. Comparison of antegrade perfusion studies before and after this procedure showed improvement in the lower end of the conduit but suggested partial obstruction of the bowel just below the right renal pelvis on both examinations (fig. 7). No obvious narrowing had been noted at the time of operation. During endoscopy of the bowel segment from below it was possible to visualize a flap valve of mucosa narrowing the lumen, which was incised with a Bugbee electrode. It then was possible to view the inside of the right kidney from below the point at which the flap valve had been located. Subsequent antegrade pressure perfusion study showed a slightly lower gradient (6 cm. water) from the upper tracts to the bladder compared to a
Fm. 5. Case 2. A, nephrostogram 2 weeks after undiversion reveals free passage of contrast material to bladder. Note irregularity of bowel segment, recently tapered, near its upper end (arrow). At this point obstruction was manifest 9 years later. B, IVP 1 year after undiversion shows no evidence of narrowing in tapered bowel segment. C, antegrade pyelogram study in August 1978, 9 years after undiversion demonstrates high grade obstruction in upper third of small bowel segment (arrow). Comparing parts A to C it is likely that when bowel was tapered mucosal fold was created that was not obstructive initially but became obstructive several years later. D, IVP 4 months after resection of obstructive diaphragm shows improvement of hydronephrosis.
BEFORE AFTER
( 10 yrs. after Undiversion; --,_!,,.....,,.,\ .,.~~.-i f (:.,,'\
z',/:: "'~:---
I
' ,/
To be
Much higher____,., psoas hitch
Prior psoas h1tcti
~ __/I
Angulot1on at hiatus when bladder full, causing partial obstruction
Intact mucosol br,dge
Closure old hiatus 4 cm tunnel - loo short, causing refluK
Narrowed orifice drain upper tract
Fm. 6. Case 3. Anatomy 10 years after undiversion shows revision performed to stop reflux, which resulted from too short of tunnel
Fm. 7. Case 3. aucq;,au" perfusion study before revision of bowel segment shows dilatation of lower bowel segment and also suggests of right renal pelvis although this was not evident at repeat exploration. B, antegrade perfusion study narrowing of bowel after revision of lower end of segment shows uv.uu.ua•vcu lower segment, higher psoas hitch and abrupt change m caliber of bowel (a.rrow) at which level diaphragm of mucosa could be seen endoscopically from inside bowel. This flap valve was incised endoscopically with cutting electrode.
years old an obstructive left megaureter had been removed elsewhere and replaced with a tapered small bowel segment created in 2 stages by a technique then in use. 6 Temporary nephrostomy drainage showed good renal function, well worth salvaging the kidney despite the presence of a normal right kidney. A nephrostogram showed an obstruction in the upper third of the tapered bowel segment, which proved at operation to be a fibrous stricture of the bowel (fig. 8). Revision of the bowel segment was performed, with resection of the upper end to straighten it and remove the stricture as well as implantation of the lower end with a tunnel to stop reflux (fig. 9). Subsequent radiographic studies showed free passage of contrast material through the revised segment. A cystogram showed no reflux after tunneling implantation of the lower bowel segment. Comment: This patient presented 20 years after a tapered
bowel segment was constructed elsewhere. Since he had been without clinical difficulties for many years it is likely that this represents a late onset of stricture and not narrowing that had been present for many years. Case 5. A 37-year-old surgeon was referred with recurrent left pyelonephritis and flank pain. The patient had been operated upon in India for bilateral ureteropelvic junction obstruction 15 years earlier. Right pyeloplasty was performed. Because there were stones the left ureter was discarded and replaced with a segment of bowel (nontapered and without tunneling into the bladder). The patient did well until just before referral in September 1980. Antegrade pyelography disclosed high grade obstruction at the upper end of the bowel segment (fig. 10, A). At operation there was severe stenosis of the bowel segment 1 inch below its anastomosis to the renal pelvis. This stenosis was
588
HENDREN AND MCLORIE
not apparent by viewing the outside of the bowel segment but it was seen by transecting the anastomosis of the bowel to the renal pelvis, looking down into the bowel itself. The lumen funneled down to the pinpoint opening <1 mm. in diameter. The upper bowel segment was resected, including the stenotic area, and reanastomosed to the renal pelvis by mobilization of the kidney and sliding it downward to avoid tension on the anastomosis. Microscopic examination of the specimen showed marked muscular hyperplasia and collagenization of the muscularis mucosa in the stenotic area (fig. 11). A postoperative nephrostogram showed free flow of contrast material through the revised upper bowel segment. Comment: The late stricture in this patient is especially interesting because there is no chance that it might have been iatrogenic, which could be questioned in the previous 4 cases in which a tapering procedure had been done. The patient elected
FIG. 8. Case 4. A, preoperative antegrade pyelogram shows narrowing in upper third of tapered bowel segment (arrow), which proved to be fibrous stricture. B, postoperative study shows free flow of contrast material to bladder. No reflux on cystogram after implantation oflower bowel segment by tunneled technique.
not to have revision of the lower end of the bowel segment to stop the reflux seen on cystography, since this had not caused significant problems in the preceding 15 years. DISCUSSION
The use of small bowel to replace the ureter is a well established operation. Goodwin7 and Boxer8 and their associates have reported its value and excellent long-term results in managing patients with recurrent stones. It has proved satisfactory to use the bowel in its full diameter without tapering or tunneling the lower end into the bladder in those patients. However, in young patients without stone disease it has been our preference to taper and tunnel the bowel segment into the bladder in a manner that will prevent reflux. Often in the pediatric age group the bladders are quite abnormal, such as those with urethral valves, ureteroceles or multiple previous operations. In some of these cases it is not possible to taper and tunnel a bowel segment because the bladder is too small and fibrotic to attain a reasonable tunnel. Ileocecal augmentation of the bladder has been used in such cases, creating a nonrefluxing nipple of intussuscepted terminal ileum that must be
FIG. 10. Case 5. A, preoperative bilateral antegrade roentgenogram shows severe stricture (arrow) below anastomosis of bowel ureter to renal pelvis. B, postoperative nephrostogram shows free flow after resection of stricture.
AFTER
but reasonable amount of cortex Bowel shortened
+
\ Kidney moved downward and pexed Reim plant ( 5 cm tunnel )
Normal
.....__ Prominent posterior bladder neck
FIG. 9. Case 4. Anatomy before and after reVISion of long-standing tapered bowel segment
589
FIG. 11. Case 5. Photomicrograph of stricture shows marked "muscle hyperplasia and collagenization of muscularis mucosa at stenotic site
reinforced with sutures and. staples to prevent undoing of the nipple. Similarly, in 2 recent cases in which augmentation was not needed a small bowel ureter was joined to the bladder with a 4 cm. nipple, reinforced with staples together with a psoas hitch to immobilize the bladder wall hiatus. To date, we have reconstructed 43 cases in which small bowel was used for ureteral replacement in closed urinary tracts (that is not diverted to the surface). 9 Our 3 cases and 2 done elsewhere serve to emphasize that all cases with bowel in the urinary tract will require repeated and never ending radiographic assessment to rule out insidious onset of late bowel stricture. REFERENCES 1. Hardy, B. E., Lebowitz, R. L., Baez, A. and Colodny, A. H.:
Strictures of the ileal loop. J. Urol., 117: 358, 1977. 2. Mitchell, M. E., Yoder, I. C., Pfister, R. C., Daly, J. and Althausen, A.: Ileal loop stenosis: a late complication of urinary diversion. J. Urol., 118: 957, 1977. 3. Shapiro, S. R., Lebowitz, R. and Colodny, A.H.: Fate of90 children with ileal conduit urinary diversion a decade later: of complications, pye!ography, renal function and J. U.roL, 114: 289, 1975. " Tapper, D. and Folkman, M. J.: The ilea! loop: a novel ap·p:rc,acn to study oflymuhoid depletion mediated by urine. Surg. 129, 1976. 5. Tapper, D. and Folkman, J.: Lymphoid ae101eno,n mechanism and clinical implications. J. 6. Swenson, 0., Fisher, J. H. and Cendron, J.: Ln•e,;,Huu1eu;;, investigation as to the cause and report on the results of newer forms of treatment. Surgery, 40: 223, 1956. 7. Goodwin, W. E., Winter, C. C. and Turner, R. D,: Replacement of the ureter by small intestine: clinical application and results of the "ileal ureter". J. Urol., 81: 406, 1959. 8. Boxer, R. J., Fritzsche, P., Skinner, D. G., Kaufman, J. J., Belt, E., Smith, R. B. and Goodwin, W. E.: Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J. Urol., 121: 728, 1979. 9. Hendren, W. H.: Tapered bowel segment for ureteral replacement. Urol. Clin. N. Amer,, 5: 607, 1978.
EDITORIAL COMMENT This is an important paper and a real contribution to urologists who have had long-range experience with the use of intestinal segments in urological surgery. Doctor Hendren and I are diametrically opposed on the subject of tailoring or narrowing the ileum when it is used as a ureter. The important message of this paper is in the last sentence,
"Our 3 cases and 2 done elsewhere serve to emphasize that all cases with bowel in the urinary tract will require repeated and never ending radiographic assessment to rule out insidious onset of late bowel stricture1) I believe that rnost of these strictures were iatrogenic and that it is meddlesome to try to taper the ileum. The authors address this point in commenting on case 5 when they state, "The late stricture in this patient is especially interesting because there is no chance that it might have been iatrogenic, which could be questioned in the previous 4 cases in which a tapering procedure had been done". In case 4 there is a long-range followup on the technique proposed by Swenson and associates in 1956 (reference 6 in article). They first suggested tapering the ileum to replace megaloureter. When we were first aware of that idea we tried it in the animal laboratory and decided that it was unnecessary and did not contribute to improved results. Our experience with more than 100 replacements of the ureter with sm1Jll intestine (reference 7 in article) leads us to believe that an antireflux procedure is not necessary (even though we know from study that reflux does occur). The system is low pressure and reflux does not seem to matter. I believe that most strictures that occur late a:rn related to ischemia of the segn1ent of ileum. We have seen cases similar to that demonstrated in figure 10, A. I had aiways thought that this was related to some defect in the anastomosis of the prnxhnal piece of ileum to the renal pelvis or to the kidney. The authors have performed a real service in presenting th.is longterm followup and pointing out the necessity for careful long-range surveillance. Recently, we described some of ou:r own lor1g-iran,ge experiences, The illustrations show what I believe to be true. most part, the segment of ileum that is acting as a ureter :remains empty because of its peristalsis until the bladder becomes overdistended. Therefore, I believe that tapering is not necessary and may be meddlesome, as in cases 1 to 4. <
Willard E. Goodwin Department of Surgery University of California School of Medicine Los Angeles, California
REPLY BY AUTHORS We do not agree that tapering is meddlesome or that reflux is always innocuous. Reflux in a young patient is a potential threat from the standpoint of infection and is best prevented when possible. Reflux can be prevented by tapering and tunneling the small bowel when it is joined to the bladder. We have seen several patients with small bowel ureters in whom reflux was associated with infection, which cleared when the reflux was corrected by creating an effective tunnel.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
LATE STRICTURE OF INTESTINAL URETER W. HARDY HENDREN* AND GORDON A McLORIEt From the Division of Pediatric Surgery, Massachusetts General Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT
Late stricture is a well known complication of ileal loops. We herein report on late stricture in 5 patients in whom bowel was used as a substitute ureter in closed, nondiverted urinary tracts. This late complication mandates the need to provide continuing followup indefinitely in patients in whom bowel segments are incorporated in the urinary tracts. Late stricture is a well recognized complication of ileal loop urinary diversion. 1- 3 The pathological condition is predominately mucosal and submucosal fibrosis, and edema with segmental narrowing causing obstruction. This is not to be confused with ischemia of a bowel segment, which can lead to diffuse fibrosis of the entire segment. Tapper and Folkman noted lymphocyte depletion in intestinal segments exposed to urine and postulated that this may be an etiologic factor in the development of strictures of bowel segments for ileal loop urinary diversion.4• 5 We herein describe late stricture formation in small bowel segments used as intestinal ureters in the closed urinary tract. These patients require the same diligent long-term followup that has proved essential in patients with cutaneous urinary diversion using small bowel conduits. CASE REPORTS
Case 1. A 22-month-old child was referred in April 1967 with a prior ileal loop diversion that was obstructed by the vascular pedicle of the bowel. The original problem had been urethral valves with massive reflux and severe hydronephrosis. The ileal loop was removed and a new loop was performed. The cutaneous stoma was revised for stenosis 1 year later and the patient subsequently did well. In June 1973 undiversion was performed when the patient was 8 years old, the ileal loop being tapered and implanted into the long defunctioned bladder (fig. 1). Left pyeloileal revision was performed 1 month later. Both of these reconstructive procedures would be performed in a single operation today. Convalescence was uneventful and the general health was satisfactory. Excretory urography (IVP) showed satisfactory drainage of the upper tracts with less hydronephrosis than had been present with diversion (fig. 2, A). An interval IVP 2½ years later was believed to be stable, although in retrospect there was an area of narrowing in the bowel just below the level of the right renal pelvis (fig. 2, B). The patient remained well clinically. In February 1978 hematuria occurred after a fall from a tree. A repeat IVP showed an alarming degree of hydronephrosis (fig. 2, C). Antegrade pyelography showed obstruction in the tapered bowel segment below the junction with the right renal pelvis (fig. 3, A). This study also was suggestive of a second point of narrowing in the bowel segment overlying the spine just below the junction with the left renal pelvis. At endoscopy the panendoscope could be passed into the bladder and up the tunneled and tapered bowel segment. The stenotic segment was a thin mucosa! diaphragm, which was explored. A discrete point of narrowing on the external surface of the tapered bowel Accepted for publication July 28, 1982. * Requests for reprints: Department of Surgery, Children's Hospital, 300 Longwood Ave., Boston, Massachusetts 02115. tCurrent address: Department of Urology, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, Canada.
conduit was excised, with reanastomosis of the bowel with chromic catgut. Microscopic sections of the specimen showed urothelial metaplasia and chronic inflammation. The mucosa was replaced by regenerating urothelial epithelium. No ileal epithelium was noted. At endoscopy 8 months later the tapered bowel segment showed no residual narrowing at the point of repair. It was elected to repair also the more proximal narrowing just below the left renal pelvis by resection and reanastomosis of the bowel to the lower pole of the kidney instead of the renal pelvis. Microscopic examination showed narrowing of the lumen with asymmetrical hypertrophy of the muscularis and muscularis mucosa, fibrosis and edema of the submucosa, and focal acute and chronic inflammation. The ileal segment was lined primarily by urothelium. The patient has remained well. An antegrade pyelogram in November 1980 showed satisfactory drainage (fig. 3, B). Presently, the patient is 17 years old with height in the 90th percentile and weight at the 75th percentile. Blood urea nitrogen (BUN) is 15 mg. per cent, creatinine 1.3 mg. per cent and creatinine clearance 136 1. absolute or 73.5 1./M.2 body surface area daily. Comment: This patient, like many boys with urethral valves 15 to 20 years ago, was treated with an ileal loop, which in retrospect was ill-advised. A better approach would have been destruction of the valves and, in this severe case, tailoring and reimplantation of the ureters with massive reflux. Of 119 undiversions to date 54 were in patients whose original pathological condition was urethral valves. The patient has surprisingly good renal function (about 75 per cent of normal) despite once having had massive hydronephrosis. He has done well in the 9 years since undiversion. The late appearance of 2 strictures in the bowel ureter indicates the need to follow these patients indefinitely. In those patients with poor renal function in whom contrast medium will not outline clearly the entire urinary tract antegrade perfusion of contrast medium through a percutaneous 22 gauge spinal needle offers the best method of radiographic evaluation, with the further advantage of allowing measurement of perfusion pressures. The normal differential pressure between the upper tract and bladder is between 5 and 10 cm. water. Case 2. This newborn was referred in June 1963 with bilateral massive hydronephrosis caused by a ureterocele involving a duplicated collecting system on the left side. The ureterocele obstructed bladder outflow and was removed. The megaureter and. the upper pole of the left kidney were removed 1 month later. The patient did poorly with recurrent severe infection. A high pyeloileal conduit was performed when the patient was 4 months old, leaving the right lower ureter in hopes that the upper tract would improve and allow subsequent reconstruction. The patient thrived although there were recurrent mild infections during ileal loop diversion. The stoma was revised twice for stenosis. In July 1969 undiversion was performed when the patient
584
685 PRE-OP
Small !hin-walled bladder
POST-OP
9
" -<---Valves
FIG. 1. Case l. Preoperative and postoperative anatomy. Undive.rsion was staged, tapering and implanting conduit in I procedure and revising upper end in second operation. Today this would be done in single procedure.
Fm. 2. Case 1. A, IVP in May 1974, 1 year afte:r undiversion shows satisfactory drainage of upper tracts with only moderate dilatation. B, IVP in 1976, 2½ years after undiversion, shows slight increase in dilatation of tracts and some narrowing of small bowel segment below pelvis s1s,mit1c1m<:e of which was not appreciated at that time. IVP in February 1978 after episode of trauma hematuria shows massive of upper tracts,
-·--···••vu
was 6 years old 4), A nn-«u,,--.,,-,-,,t,, ephJ:"ost,)g:;:·,nnshowed passage of contrast tapered ileal into the (fig. 5, Subsequent IVPs each year bowel. ureter 5, B). Convalescence was uneventful until an episode of tract infection with flank in 1978, 9 years undiversion. An IVP shm;ved increased hydronephrosi.s and antegrade pyelography revealed marked stenosis in the upper of the small bowel segment (fig, 5, C). In contrast to case 1, there was no external evidence of narrowing of the bowel segment at open operation. The bowel segment was opened and a thin obstructing diaphragm was found, which seemed to be formed of mucosa only. This diaphragm was resected, leaving the seromuscular layer of bowel intact and the mucosa edges were repaired with interrupted chromic sutures. Microscopically, this proved to be gastrointestinal mucosa with marked chronic inflammation and edema. A biopsy of the bowel segment lining above the point of obstruction showed urothelium replacing gastrointestinal mucosa. An IVP 4 months later showed satisfactory drainage of the upper tract with less hydronephrosis. The patient presently
health. Renal function studies at the for correction of the obstn,cted diashowed BUN 14 mg, per cent and creatinine clearance 73 1Comrnent: The ileal diversion was done in this almost 2 decades ago because the child was not on antibiotic treatment, We would not choose that treatment today. Of 119 undiversions performed to date 3 were in patients who we had diverted, This case and case 3 are 2 of the 3 undiversion cases originally diverted by us. Case 3. A 2-week-old newborn was referred in August 1963 with severe hydronephrosis from urethral valves and hyaline membrane disease. Suprapubic cystostomy had been performed previously. His condition did not improve with antibiotics and drainage. End ureterostomies were done l month later but the patient continued to do poorly. High ileal loop diversion was performed at age 2 months in the belief at that time that this would give ideal drainage of the upper tracts. Considering the desperate condition as an infant, the patient thrived reasonably well. When he was 6 years old BUN was 38 mg. per cent, creatinine 1.7 mg. per cent and creatinine clearance 34 1./M. 2
586
HENDREN AND MCLORIE
Fm. 3. Case 1. A, antegrade perfusion study in March 1978 shows marked narrowing of bowel segment below right renal pelvis (large arrow) and lesser degree of narrowing of bowel overlying spine (small arrow). Both stenoses subsequently were removed. B, bilateral antegrade perfusion study in November 1980 shows free passage of contrast medium without narrowing of bowel segment.
BEFORE
previous borderline gradient of 11 cm. water when the diaphragm was present. Comment: This patient was our first in whom ileal loop undiversion was done by tapering and implanting the loop. He has thrived remarkably well through the years considering the severe degree of upper tract damage when first presented. He is now 19 years old, and in the 15th percentile for height and 25th percentile for weight. When undiversion was done in 1969 at age 6 years BUN was 47 mg. per cent and creatinine was 1.3 mg. per cent. After 13 years, during which time adult body mass was attained, BUN has reached 54 mg. per cent and creatinine 4.0 mg. per cent. Renal transplantation probably will be necessary for this patient some day. However, this may well be forestalled for many years if he remains free of infection. It is not clear whether the valve-like obstruction in the bowel segment in this case was truly acquired like those in cases 1 and 2 or whether it was a flap valve of mucosa created from tapering the bowel segment. In any event it was possible to open the valve from below as an endoscopic cutting procedure in contrast to open exploration as was done in cases 1 and 2. Case 4. This 20-year-old man was referred with urinary infection and hydronephrosis in April 1975. When he was 2
AFTER
Fm. 4. Case 2. Preoperative and postoperative anatomy
body surface area. Undiversion was performed in November 1969. The lower part of the ureteral loop was tapered and implanted into the bladder with a tunneling technique. Two years later the upper part of the loop was tapered to reduce the absorptive surface of intestinal mucosa and, possibly, improve emptying of the system. The patient did remarkably well except for several urinary infections. Cystography showed some reflux up the tapered bowel segment, which was revised (fig. 6). The previously tapered bowel was dissected free from the bladder, further narrowing its caliber, and implanted with a longer tunnel and higher psoas hitch, which stopped the reflux. Comparison of antegrade perfusion studies before and after this procedure showed improvement in the lower end of the conduit but suggested partial obstruction of the bowel just below the right renal pelvis on both examinations (fig. 7). No obvious narrowing had been noted at the time of operation. During endoscopy of the bowel segment from below it was possible to visualize a flap valve of mucosa narrowing the lumen, which was incised with a Bugbee electrode. It then was possible to view the inside of the right kidney from below the point at which the flap valve had been located. Subsequent antegrade pressure perfusion study showed a slightly lower gradient (6 cm. water) from the upper tracts to the bladder compared to a
Fm. 5. Case 2. A, nephrostogram 2 weeks after undiversion reveals free passage of contrast material to bladder. Note irregularity of bowel segment, recently tapered, near its upper end (arrow). At this point obstruction was manifest 9 years later. B, IVP 1 year after undiversion shows no evidence of narrowing in tapered bowel segment. C, antegrade pyelogram study in August 1978, 9 years after undiversion demonstrates high grade obstruction in upper third of small bowel segment (arrow). Comparing parts A to C it is likely that when bowel was tapered mucosal fold was created that was not obstructive initially but became obstructive several years later. D, IVP 4 months after resection of obstructive diaphragm shows improvement of hydronephrosis.
BEFORE AFTER
( 10 yrs. after Undiversion; --,_!,,.....,,.,\ .,.~~.-i f (:.,,'\
z',/:: "'~:---
I
' ,/
To be
Much higher____,., psoas hitch
Prior psoas h1tcti
~ __/I
Angulot1on at hiatus when bladder full, causing partial obstruction
Intact mucosol br,dge
Closure old hiatus 4 cm tunnel - loo short, causing refluK
Narrowed orifice drain upper tract
Fm. 6. Case 3. Anatomy 10 years after undiversion shows revision performed to stop reflux, which resulted from too short of tunnel
Fm. 7. Case 3. aucq;,au" perfusion study before revision of bowel segment shows dilatation of lower bowel segment and also suggests of right renal pelvis although this was not evident at repeat exploration. B, antegrade perfusion study narrowing of bowel after revision of lower end of segment shows uv.uu.ua•vcu lower segment, higher psoas hitch and abrupt change m caliber of bowel (a.rrow) at which level diaphragm of mucosa could be seen endoscopically from inside bowel. This flap valve was incised endoscopically with cutting electrode.
years old an obstructive left megaureter had been removed elsewhere and replaced with a tapered small bowel segment created in 2 stages by a technique then in use. 6 Temporary nephrostomy drainage showed good renal function, well worth salvaging the kidney despite the presence of a normal right kidney. A nephrostogram showed an obstruction in the upper third of the tapered bowel segment, which proved at operation to be a fibrous stricture of the bowel (fig. 8). Revision of the bowel segment was performed, with resection of the upper end to straighten it and remove the stricture as well as implantation of the lower end with a tunnel to stop reflux (fig. 9). Subsequent radiographic studies showed free passage of contrast material through the revised segment. A cystogram showed no reflux after tunneling implantation of the lower bowel segment. Comment: This patient presented 20 years after a tapered
bowel segment was constructed elsewhere. Since he had been without clinical difficulties for many years it is likely that this represents a late onset of stricture and not narrowing that had been present for many years. Case 5. A 37-year-old surgeon was referred with recurrent left pyelonephritis and flank pain. The patient had been operated upon in India for bilateral ureteropelvic junction obstruction 15 years earlier. Right pyeloplasty was performed. Because there were stones the left ureter was discarded and replaced with a segment of bowel (nontapered and without tunneling into the bladder). The patient did well until just before referral in September 1980. Antegrade pyelography disclosed high grade obstruction at the upper end of the bowel segment (fig. 10, A). At operation there was severe stenosis of the bowel segment 1 inch below its anastomosis to the renal pelvis. This stenosis was
588
HENDREN AND MCLORIE
not apparent by viewing the outside of the bowel segment but it was seen by transecting the anastomosis of the bowel to the renal pelvis, looking down into the bowel itself. The lumen funneled down to the pinpoint opening <1 mm. in diameter. The upper bowel segment was resected, including the stenotic area, and reanastomosed to the renal pelvis by mobilization of the kidney and sliding it downward to avoid tension on the anastomosis. Microscopic examination of the specimen showed marked muscular hyperplasia and collagenization of the muscularis mucosa in the stenotic area (fig. 11). A postoperative nephrostogram showed free flow of contrast material through the revised upper bowel segment. Comment: The late stricture in this patient is especially interesting because there is no chance that it might have been iatrogenic, which could be questioned in the previous 4 cases in which a tapering procedure had been done. The patient elected
FIG. 8. Case 4. A, preoperative antegrade pyelogram shows narrowing in upper third of tapered bowel segment (arrow), which proved to be fibrous stricture. B, postoperative study shows free flow of contrast material to bladder. No reflux on cystogram after implantation oflower bowel segment by tunneled technique.
not to have revision of the lower end of the bowel segment to stop the reflux seen on cystography, since this had not caused significant problems in the preceding 15 years. DISCUSSION
The use of small bowel to replace the ureter is a well established operation. Goodwin7 and Boxer8 and their associates have reported its value and excellent long-term results in managing patients with recurrent stones. It has proved satisfactory to use the bowel in its full diameter without tapering or tunneling the lower end into the bladder in those patients. However, in young patients without stone disease it has been our preference to taper and tunnel the bowel segment into the bladder in a manner that will prevent reflux. Often in the pediatric age group the bladders are quite abnormal, such as those with urethral valves, ureteroceles or multiple previous operations. In some of these cases it is not possible to taper and tunnel a bowel segment because the bladder is too small and fibrotic to attain a reasonable tunnel. Ileocecal augmentation of the bladder has been used in such cases, creating a nonrefluxing nipple of intussuscepted terminal ileum that must be
FIG. 10. Case 5. A, preoperative bilateral antegrade roentgenogram shows severe stricture (arrow) below anastomosis of bowel ureter to renal pelvis. B, postoperative nephrostogram shows free flow after resection of stricture.
AFTER
but reasonable amount of cortex Bowel shortened
+
\ Kidney moved downward and pexed Reim plant ( 5 cm tunnel )
Normal
.....__ Prominent posterior bladder neck
FIG. 9. Case 4. Anatomy before and after reVISion of long-standing tapered bowel segment
589
FIG. 11. Case 5. Photomicrograph of stricture shows marked "muscle hyperplasia and collagenization of muscularis mucosa at stenotic site
reinforced with sutures and. staples to prevent undoing of the nipple. Similarly, in 2 recent cases in which augmentation was not needed a small bowel ureter was joined to the bladder with a 4 cm. nipple, reinforced with staples together with a psoas hitch to immobilize the bladder wall hiatus. To date, we have reconstructed 43 cases in which small bowel was used for ureteral replacement in closed urinary tracts (that is not diverted to the surface). 9 Our 3 cases and 2 done elsewhere serve to emphasize that all cases with bowel in the urinary tract will require repeated and never ending radiographic assessment to rule out insidious onset of late bowel stricture. REFERENCES 1. Hardy, B. E., Lebowitz, R. L., Baez, A. and Colodny, A. H.:
Strictures of the ileal loop. J. Urol., 117: 358, 1977. 2. Mitchell, M. E., Yoder, I. C., Pfister, R. C., Daly, J. and Althausen, A.: Ileal loop stenosis: a late complication of urinary diversion. J. Urol., 118: 957, 1977. 3. Shapiro, S. R., Lebowitz, R. and Colodny, A.H.: Fate of90 children with ileal conduit urinary diversion a decade later: of complications, pye!ography, renal function and J. U.roL, 114: 289, 1975. " Tapper, D. and Folkman, M. J.: The ilea! loop: a novel ap·p:rc,acn to study oflymuhoid depletion mediated by urine. Surg. 129, 1976. 5. Tapper, D. and Folkman, J.: Lymphoid ae101eno,n mechanism and clinical implications. J. 6. Swenson, 0., Fisher, J. H. and Cendron, J.: Ln•e,;,Huu1eu;;, investigation as to the cause and report on the results of newer forms of treatment. Surgery, 40: 223, 1956. 7. Goodwin, W. E., Winter, C. C. and Turner, R. D,: Replacement of the ureter by small intestine: clinical application and results of the "ileal ureter". J. Urol., 81: 406, 1959. 8. Boxer, R. J., Fritzsche, P., Skinner, D. G., Kaufman, J. J., Belt, E., Smith, R. B. and Goodwin, W. E.: Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients. J. Urol., 121: 728, 1979. 9. Hendren, W. H.: Tapered bowel segment for ureteral replacement. Urol. Clin. N. Amer,, 5: 607, 1978.
EDITORIAL COMMENT This is an important paper and a real contribution to urologists who have had long-range experience with the use of intestinal segments in urological surgery. Doctor Hendren and I are diametrically opposed on the subject of tailoring or narrowing the ileum when it is used as a ureter. The important message of this paper is in the last sentence,
"Our 3 cases and 2 done elsewhere serve to emphasize that all cases with bowel in the urinary tract will require repeated and never ending radiographic assessment to rule out insidious onset of late bowel stricture1) I believe that rnost of these strictures were iatrogenic and that it is meddlesome to try to taper the ileum. The authors address this point in commenting on case 5 when they state, "The late stricture in this patient is especially interesting because there is no chance that it might have been iatrogenic, which could be questioned in the previous 4 cases in which a tapering procedure had been done". In case 4 there is a long-range followup on the technique proposed by Swenson and associates in 1956 (reference 6 in article). They first suggested tapering the ileum to replace megaloureter. When we were first aware of that idea we tried it in the animal laboratory and decided that it was unnecessary and did not contribute to improved results. Our experience with more than 100 replacements of the ureter with sm1Jll intestine (reference 7 in article) leads us to believe that an antireflux procedure is not necessary (even though we know from study that reflux does occur). The system is low pressure and reflux does not seem to matter. I believe that most strictures that occur late a:rn related to ischemia of the segn1ent of ileum. We have seen cases similar to that demonstrated in figure 10, A. I had aiways thought that this was related to some defect in the anastomosis of the prnxhnal piece of ileum to the renal pelvis or to the kidney. The authors have performed a real service in presenting th.is longterm followup and pointing out the necessity for careful long-range surveillance. Recently, we described some of ou:r own lor1g-iran,ge experiences, The illustrations show what I believe to be true. most part, the segment of ileum that is acting as a ureter :remains empty because of its peristalsis until the bladder becomes overdistended. Therefore, I believe that tapering is not necessary and may be meddlesome, as in cases 1 to 4. <
Willard E. Goodwin Department of Surgery University of California School of Medicine Los Angeles, California
REPLY BY AUTHORS We do not agree that tapering is meddlesome or that reflux is always innocuous. Reflux in a young patient is a potential threat from the standpoint of infection and is best prevented when possible. Reflux can be prevented by tapering and tunneling the small bowel when it is joined to the bladder. We have seen several patients with small bowel ureters in whom reflux was associated with infection, which cleared when the reflux was corrected by creating an effective tunnel.