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Long Tunnel Ureterosigmoidostomy
'I'i-rn OF URDLCGY Copyright © 1973 b~i The c;li/illiarr:s
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lVIarc'.1
Fri;1ted in [T,S.A.
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LONG TUNNEL URETEROSIGMOIDOSTOMY IAN M. THOMPSON From the Section of Urolo{{y, University of Missouri School of Medicine, Columbia, Missouri
Although the techniques of intestinal conduit and cutaneous ureterostomy are widely used for supravesical urinary diversion at the present time, ureterosigmoidostomy continues to have its proponents owing to its provision for continence of urine. Since ascending infection from the intact bowel to the kidney has been the major shortcoming of ureterosigmoid diversion it would appear that if colo-ureteral reflux could be obviated the procedure might be used more generally. The variations of ureterosigmoidostomy that have been devised in an attempt to resolve this problem have been impressive in their number and ingenuity but have been generally unsuccessful. Our first experimental modification of this form of diversion involved the interposition of an acid-secreting Heidenhain's gastric pouch between the ureter and the colon to determine if such an acid environment would protect the kidney from the bacterial flora of the bowel (fig. 1). Although the technical aspects of the procedure and the urographic results were bacteria were found in renal pelvic urine and renal tissue. Postulating that the normally high intracolonic pressures had overcome whatever protection the pouch might theoretically have had to offer we then considered the possibility of trying to prevent reflux mechanically in ureterosigmoid diversion on the basis of the same general principles that had been used in antireflux types of ureterovesical reimplantations. The main factor in the prevention of vesicoureteral reflux has appeared to be the submucosal, intravesical position of 2 or :3 cm. of terminal ureter which reputedly produces a flap valve. Since intracolonic pressures are not only much more variable and generally markedly higher than those in the resting or contracting bladder, it seemed reasonable to assume that in moid anastomosis a greater length of submucosal intraluminal ureter would be needed to secure a competent valve. To reinforce the muscle backing of the ureter in its intracolonic course we used a an isolated around the ureter for above the ureterocolic anastomosis (fig. 2). The lateral colon margins created by the isolation of the strip were brought together over this muscle tube. 1 In the postoperative evaluation for more than a year in these dogs there was no evidence of reflux, no infection in the renal pelvic urine or Accepted for publication June 6, 1972. 1 Thompson, I. M. and Smith, .J. A.: Double colon sleeve ureterosigmoidostomy. J. Urol., 105: 205, 1971. 371
renal tissue and the renal architecture and function were preserved. The procedure was performed in 1 patient who required palliative diversion for cancer. In this case it was apparent that producing a double colon sleeve in the right colon was awkward and that the bilateral procedure was cumbersome and time-consuming. In view of the apparent obviation of reflux and ascending infection engendered by a long, musclebacked course of the ureter within the lumen of the colon and in an attempt to simplify the procedure we then studied the possibility that a simple submucosal tunnel of a substantially greater length than that provided by the Leadbetter ureterosigmoidostomy technique might be similarly effective. METHODS AND MATERIALS
Three groups of dogs were subjected to ureterosigmoidostomy with different lengths of submucosal tunnels: group 1-9 animals with tunnels of 8 to 10 cm. in length, group 2-5 dogs with tunnels between 4 and 8 cm. and group 3-6 dogs with tunnels between 2 and :3 cm. long. All animals had preliminary excretory urograms (IVPs) and serum electrolyte and blood urea nitrogen (BUN) studies which were normal and cultures of bladder urine which were sterile. Subsequent to pentobarbital anesthesia and a midline abdominal incision, the sigmoid tunnels were prepared by incising and retracting the colonic muscle until troughs as nearly submucosal as possible were prepared to permit invagination of the ureters under the lateral colon walls without compression. No difficultv was encountered in securing 2 portions of de;cending colon, 10 cm. long, for bilateral ureterocolic anastomosis. Occasional nicks made in the colonic mucosa were closed and did not interfere with the The mucosa-to-muof the cosa ureterointestinal anastomoses were made just above the lower ends of the colon troughs so that a wide margin of colon muscle could be over the anastomotic site to antibiotics were administered to peall animals m the immediate riod. IVPs and hypaque enemas were obtained on all dogs '.'l and 6 months postoperatively. Serum electrolytes and blood chemistry studies were done periodically until sacrifice. RESULTS
Two dogs in group 1 died of intestinal obstruc-
372
THOMPSON
FIG. 1
FIG. 2
tion or dehiscence of the ureterointestinal anastomosis. One dog in group 3 died of peritonitis. The remainder of the animals survived and were clinically stable. IVPs at 3 and 6 months in all animals revealed satisfactory function and reasonably normal renal architecture (fig. 3). Hypaque enemas demonstrated no colo-ureteral reflux. In the early postoperative period transient elevations of the BUN occurred in 5 animals in group 1, 3 dogs in group 2 and 3 dogs in group 3. Relatively mild hyperchloremic acidosis was observed in the early postoperative course in 4 animals in group 1, 3 in group 2 and 3 in group 3. In all animals the electrolyte aberrations returned to preoperative or near preoperative levels in the 3 to 6-month postoperative period. The animals were sacrificed between 6 and 9 months postoperatively and renal pelvic urine and portions of renal parenchyma were taken for culture under sterile precautions. The urine and renal tissue cultures in all group 1 animals were sterile. One animal in group 2 had growth of 1 by 10 3 Escherichia coli from renal pelvic urine and renal tissue. The tunnel appeared to be approximately 4 cm. in length in this animal. Four of the 5 animals in group 3 had greater than 1 by 10 5 coliform organisms in pelvic urine and coliforms were isolated from the renal tissue of all 5 dogs. Examination of the kidneys and ureters of each animal revealed little if any gross pathological changes (fig. 4). Histologic study of the kidneys in groups 1 and 2 revealed no evidence of inflammation in the sections examined. In group 3 animals
FIG. 3
LONG TUNNEL URETEROSIGMOIDOSTOMY
small scattered areas of inflammatory cell infiltrates were seen in the kidney and more commonly edema and submucosal round cell infiltration in the caliceal regions. The ureters were generally well preserved within the tunnel and above it in animals in all groups (fig. 5). CLINICAL RESULTS
Eight patients have undergone long tunnel ureterosigmoidostomy. Tunnels of at least 6 cm. in length were fashioned for each ureter in a manner similar to that used in the experimental studies. During 1 to 3-year periods of postoperative observation, the IVPs in these patients appear quite normal (fig. 6). Other than mild hyperchloremia, which has required no therapy, there have been
373
no untoward reactions. There have been no episodes of sepsis and the patients have been completely asymptomatic. DISCUSSION
Our experimental studies in ureteroenterostomy are reminiscent of those carried out 20 years ago by Weyrauch, 2 Woodruff 3 and others. They affirmed the superiority of the Nesbit and Cordonnier techniques of anastomosis in preventing the obstruction encountered in the Coffey procedure and indicated that the addition of a tunnel prevented leakage and minimized reflux and ascending infection. Woodruff and Leadbetter demonstrated a mechanical impedance to colo-ureteral reflux with a 2 to 3 cm. tunnel but Weyrauch's bacteriologic studies clearly showed that infection supervened in at least 60 per cent of these kidneys. The clinical burgeoning of conduit diversions in the past 2 decades would imply that the problem of renal functional deterioration owing to infection in ureterosigmoidostomy has not been resolved by the short tunnel. The significant feature of our colon sleeve and current studies is the complete lack of infection in any of the animals in which the longer (6 to 10 cm.) tunnels were used. It would appear that the
FIG. 4. Kidneys grossly normal in appearance. Tunnel lengths are apparent.
FIG. 6. Two-year postoperative IVP in patient with exstrophy.
FIG. 5. A, ureter within sigmoid tunnel. B, ureter above tunnel.
'Weyrauch, H. M. and.Young, B. W.: Evaluation of common methods of uretero-intestinal anastomosis: an experimental study. J. Urol., 67: 880, 1952. 'Woodruff, L. M., Cooper, J. F. and Leadbetter, W. F.: Uretero-enterostomy: experimental studies. J. Urol., 67: 873, 1952.
374
THOMPSON
critical juncture in regard to the prevention of ascending infection is at a tunnel length of more than 4 cm. For this reason tunnels of 6 cm. were used in our patients and although sampling of renal urine is not feasible they have had no clinical infections. Certainly, a more than modest number of patients have tolerated ureteroenterostomy relatively well in the past, as have a number of exper-
imental animals, and the results of this study must be reviewed in this light. Long-term evaluation of this technique in a larger number of patients is necessary to definitively assess the protection afforded by a long tunnel but since conversion to a colon conduit is relatively simple if infection or other complications ensue, this form of ureterosigmoidostomy appears to warrant further trial.
Ye\.
lVIarc'.1
Fri;1ted in [T,S.A.
ilbr,s
LONG TUNNEL URETEROSIGMOIDOSTOMY IAN M. THOMPSON From the Section of Urolo{{y, University of Missouri School of Medicine, Columbia, Missouri
Although the techniques of intestinal conduit and cutaneous ureterostomy are widely used for supravesical urinary diversion at the present time, ureterosigmoidostomy continues to have its proponents owing to its provision for continence of urine. Since ascending infection from the intact bowel to the kidney has been the major shortcoming of ureterosigmoid diversion it would appear that if colo-ureteral reflux could be obviated the procedure might be used more generally. The variations of ureterosigmoidostomy that have been devised in an attempt to resolve this problem have been impressive in their number and ingenuity but have been generally unsuccessful. Our first experimental modification of this form of diversion involved the interposition of an acid-secreting Heidenhain's gastric pouch between the ureter and the colon to determine if such an acid environment would protect the kidney from the bacterial flora of the bowel (fig. 1). Although the technical aspects of the procedure and the urographic results were bacteria were found in renal pelvic urine and renal tissue. Postulating that the normally high intracolonic pressures had overcome whatever protection the pouch might theoretically have had to offer we then considered the possibility of trying to prevent reflux mechanically in ureterosigmoid diversion on the basis of the same general principles that had been used in antireflux types of ureterovesical reimplantations. The main factor in the prevention of vesicoureteral reflux has appeared to be the submucosal, intravesical position of 2 or :3 cm. of terminal ureter which reputedly produces a flap valve. Since intracolonic pressures are not only much more variable and generally markedly higher than those in the resting or contracting bladder, it seemed reasonable to assume that in moid anastomosis a greater length of submucosal intraluminal ureter would be needed to secure a competent valve. To reinforce the muscle backing of the ureter in its intracolonic course we used a an isolated around the ureter for above the ureterocolic anastomosis (fig. 2). The lateral colon margins created by the isolation of the strip were brought together over this muscle tube. 1 In the postoperative evaluation for more than a year in these dogs there was no evidence of reflux, no infection in the renal pelvic urine or Accepted for publication June 6, 1972. 1 Thompson, I. M. and Smith, .J. A.: Double colon sleeve ureterosigmoidostomy. J. Urol., 105: 205, 1971. 371
renal tissue and the renal architecture and function were preserved. The procedure was performed in 1 patient who required palliative diversion for cancer. In this case it was apparent that producing a double colon sleeve in the right colon was awkward and that the bilateral procedure was cumbersome and time-consuming. In view of the apparent obviation of reflux and ascending infection engendered by a long, musclebacked course of the ureter within the lumen of the colon and in an attempt to simplify the procedure we then studied the possibility that a simple submucosal tunnel of a substantially greater length than that provided by the Leadbetter ureterosigmoidostomy technique might be similarly effective. METHODS AND MATERIALS
Three groups of dogs were subjected to ureterosigmoidostomy with different lengths of submucosal tunnels: group 1-9 animals with tunnels of 8 to 10 cm. in length, group 2-5 dogs with tunnels between 4 and 8 cm. and group 3-6 dogs with tunnels between 2 and :3 cm. long. All animals had preliminary excretory urograms (IVPs) and serum electrolyte and blood urea nitrogen (BUN) studies which were normal and cultures of bladder urine which were sterile. Subsequent to pentobarbital anesthesia and a midline abdominal incision, the sigmoid tunnels were prepared by incising and retracting the colonic muscle until troughs as nearly submucosal as possible were prepared to permit invagination of the ureters under the lateral colon walls without compression. No difficultv was encountered in securing 2 portions of de;cending colon, 10 cm. long, for bilateral ureterocolic anastomosis. Occasional nicks made in the colonic mucosa were closed and did not interfere with the The mucosa-to-muof the cosa ureterointestinal anastomoses were made just above the lower ends of the colon troughs so that a wide margin of colon muscle could be over the anastomotic site to antibiotics were administered to peall animals m the immediate riod. IVPs and hypaque enemas were obtained on all dogs '.'l and 6 months postoperatively. Serum electrolytes and blood chemistry studies were done periodically until sacrifice. RESULTS
Two dogs in group 1 died of intestinal obstruc-
372
THOMPSON
FIG. 1
FIG. 2
tion or dehiscence of the ureterointestinal anastomosis. One dog in group 3 died of peritonitis. The remainder of the animals survived and were clinically stable. IVPs at 3 and 6 months in all animals revealed satisfactory function and reasonably normal renal architecture (fig. 3). Hypaque enemas demonstrated no colo-ureteral reflux. In the early postoperative period transient elevations of the BUN occurred in 5 animals in group 1, 3 dogs in group 2 and 3 dogs in group 3. Relatively mild hyperchloremic acidosis was observed in the early postoperative course in 4 animals in group 1, 3 in group 2 and 3 in group 3. In all animals the electrolyte aberrations returned to preoperative or near preoperative levels in the 3 to 6-month postoperative period. The animals were sacrificed between 6 and 9 months postoperatively and renal pelvic urine and portions of renal parenchyma were taken for culture under sterile precautions. The urine and renal tissue cultures in all group 1 animals were sterile. One animal in group 2 had growth of 1 by 10 3 Escherichia coli from renal pelvic urine and renal tissue. The tunnel appeared to be approximately 4 cm. in length in this animal. Four of the 5 animals in group 3 had greater than 1 by 10 5 coliform organisms in pelvic urine and coliforms were isolated from the renal tissue of all 5 dogs. Examination of the kidneys and ureters of each animal revealed little if any gross pathological changes (fig. 4). Histologic study of the kidneys in groups 1 and 2 revealed no evidence of inflammation in the sections examined. In group 3 animals
FIG. 3
LONG TUNNEL URETEROSIGMOIDOSTOMY
small scattered areas of inflammatory cell infiltrates were seen in the kidney and more commonly edema and submucosal round cell infiltration in the caliceal regions. The ureters were generally well preserved within the tunnel and above it in animals in all groups (fig. 5). CLINICAL RESULTS
Eight patients have undergone long tunnel ureterosigmoidostomy. Tunnels of at least 6 cm. in length were fashioned for each ureter in a manner similar to that used in the experimental studies. During 1 to 3-year periods of postoperative observation, the IVPs in these patients appear quite normal (fig. 6). Other than mild hyperchloremia, which has required no therapy, there have been
373
no untoward reactions. There have been no episodes of sepsis and the patients have been completely asymptomatic. DISCUSSION
Our experimental studies in ureteroenterostomy are reminiscent of those carried out 20 years ago by Weyrauch, 2 Woodruff 3 and others. They affirmed the superiority of the Nesbit and Cordonnier techniques of anastomosis in preventing the obstruction encountered in the Coffey procedure and indicated that the addition of a tunnel prevented leakage and minimized reflux and ascending infection. Woodruff and Leadbetter demonstrated a mechanical impedance to colo-ureteral reflux with a 2 to 3 cm. tunnel but Weyrauch's bacteriologic studies clearly showed that infection supervened in at least 60 per cent of these kidneys. The clinical burgeoning of conduit diversions in the past 2 decades would imply that the problem of renal functional deterioration owing to infection in ureterosigmoidostomy has not been resolved by the short tunnel. The significant feature of our colon sleeve and current studies is the complete lack of infection in any of the animals in which the longer (6 to 10 cm.) tunnels were used. It would appear that the
FIG. 4. Kidneys grossly normal in appearance. Tunnel lengths are apparent.
FIG. 6. Two-year postoperative IVP in patient with exstrophy.
FIG. 5. A, ureter within sigmoid tunnel. B, ureter above tunnel.
'Weyrauch, H. M. and.Young, B. W.: Evaluation of common methods of uretero-intestinal anastomosis: an experimental study. J. Urol., 67: 880, 1952. 'Woodruff, L. M., Cooper, J. F. and Leadbetter, W. F.: Uretero-enterostomy: experimental studies. J. Urol., 67: 873, 1952.
374
THOMPSON
critical juncture in regard to the prevention of ascending infection is at a tunnel length of more than 4 cm. For this reason tunnels of 6 cm. were used in our patients and although sampling of renal urine is not feasible they have had no clinical infections. Certainly, a more than modest number of patients have tolerated ureteroenterostomy relatively well in the past, as have a number of exper-
imental animals, and the results of this study must be reviewed in this light. Long-term evaluation of this technique in a larger number of patients is necessary to definitively assess the protection afforded by a long tunnel but since conversion to a colon conduit is relatively simple if infection or other complications ensue, this form of ureterosigmoidostomy appears to warrant further trial.