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New Technique of Antireflux Ureteroileal Anastomosis and its Clinical Experiences
0022-534 7/78/1196-0735.$02. 00/0 Vol. 119, June Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
NEW TECHNIQUE OF ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES HIROAKI ITATANI
AND
TAKAO SONODA
From the Department of Urology, Osaka University Hospital, Osaka, Japan
ABSTRACT
Free ileoureteral reflux in patients with an ileal conduit has been indicated as the etiology of late renal complications. A new technique for ureteroileal anastomosis was devised in an attempt to prevent reflux without causing obstruction. This anastomosis has been done on 20 ureters from 11 patients with pelvic malignancies. Satisfactory results have been obtained in patients with normal as well as dilated ureters, with no serious operative complications, no episodes of pyelonephritis and no renal deterioration. The ureteroileal junction created with this technique has been demonstrated radiographically and histologically. Since Bricker popularized the use of an isolated ileal segment as a bladder substitute 1 the ileal conduit has become the most widely accepted mode of supravesical urinary diversion. Today, most techniques of this satisfactory procedure create free ileoureteral reflux, which has been viewed with less concern than vesicoureteral or coloureteral reflux since the ileal conduit has been relied upon as a low pressure or no pressure reservoir system.
this goal. s-s Among them the subserosal tunneling technique has been reported to provide better results than the others,9 although this technique has been used only in patients with normal ureters. We have used a new type of antireflux ureteroileal anastomosis on 11 patients with normal and dilated ureters. Our technique has prevented reflux successfully without causing obstruction in not only the normal but also the dilated ureters.
Fm. 1. Stages of antireflux ureteroileal anastomosis OPERATIVE PROCEDURE However, in recent years serious long-term problems, such as pyelonephritis, calculous formation and renal deterioration After a suitable ileal loop is created in the usual manner without apparent urinary obstruction, have been reported. 2-4 the proximal end of the loop is fixed to the retroperitoneum. Clinical and experimental studies indicate that reflux of Two anchoring stitches are placed between the serosa of the infected urine to the kidney is the etiology of these late ileum and the adventitia of the ureter so that the distal ureter complications. Therefore, a ureteroileal anastomosis that pre- can be fixed longitudinally to the ileal loop. An incision vents reflux without causing obstruction would contribute approximately 2.5 cm. long is made on the ileal serosa with a greatly to the reduction of long-term renal complications. sharp pointed scalpel and the serosa in dissected from the Several antireflux techniques have been proposed to achieve underlying muscularis with a small curved clamp. Bleeding points from the muscularis should be ligated carefully. The Accepted for publication April 15, 1977. 735
736
ITATANI AND SONODA
MATERIALS AND METHODS dissecte,d serosa of the ileum and the adventitia of the ureter are sewn together with 5 or 6, 4-zero interrupted chromic Patient information is summarized in table 1. There were catgut sutures on each side of the ureter at the 3 and 9 o'clock 20 ureters from 11 patients implanted into the ileal conduits positions (fig. 1, A). Care must be taken to stitch only the with this technique. Patient 5 underwent total cystectomy and adventitia, not the muscularis, of the ureter. After the distal nephroureterectomy for invasive carcinoma of the left perivesureteral fixation is completed a sharp incision is made through ical ureter. In our first case, patient 1, the right ureter was the serosa, muscularis and mucosa of the ileal loop 0.5 cm. implanted in the ordinary fashion for comparison. Preoperafrom the fixed ureteral end. Then an adequate portion for tive excretory urograms (IVPs) and operative findings indidirect anastomosis to the ileal loop is cut obliquely from the cated that 8 of the 20 ureters were dilated: 1 slightly, 3 distal end of the ureter (fig. 1, B). When the ureteral diameter moderately and 4 severely. The remaining 12 ureters were is small the cut end of the ureter is spatulated a little or normal. spread out to obtain an adequate size for the anastomosis. The presence or absence of ileoureteral reflux was demonThe ureteroileal anastomosis is done in a single layer with strated by a retrograde conduitogram with a No. 20 balloon interrupted sutures and additional covering sutures are placed catheter and gravity filling at approximately 30 to 100 cm. between the serosa of the ileum and the adventitia of the water pressure, depending on the patient. In each case good ureter with 4-zero chromic catgut. This modified technique of filling of the loops was confirmed by television observation. Cordonnier is simpler than a mucosa-to-mucosa technique. To Preoperative and postoperative renal function was assessed by prevent obstruction of the anastomosis it is important that IVP and serum creatinine values. A patient was considered to less stitches are used in the ileal serosa and the ureter, and have urinary tract infection when urine cultures directly from that many stitches are used in the ileal mucosa. the conduits were positive. Followup has ranged from 4 to 16 During the procedure it is not necessary to use a splint. months, with an average of 9.4 months. Serosal fixation of the right distal ureter and the ureteroileal anastomosis are done in the same way as those on the left side RESULTS (fig. 1, C). After these procedures are completed the resulting Table 2 indicates results noted on postoperative IVPs and ureteroileal junctions are retroperitonealized completely (fig. retrograde conduitograms in all 11 cases. IVPs revealed excel1,D). TABLE
Pt. Age-Sex No. 1-28-M
1
Disease
Preoperative IVP
2-61-F
Giant seminomas of bilat. abdominal testes Advanced cervical Ca of uterus
3-42-M
Invasive bladder Ca
4-37-M
Sigmoid Ca
5-61-M
Lt. perivesical ureteral Ca with blad-
Normal It. side, slight dilatation rt. side Normal lt. side, severe obstruction rt. side Moderate dilatation It. side, normal rt. side Moderate dilatation It. side, normal rt. side Non-function lt. side, normal rt. side
der invasion
6-62-M 7-48-M 8-49-M 9-66-M 10-53-M 11*-68-M
Invasive bladder Ca Rectal Ca Invasive bladder Ca Invasive bladder Ca Bilat. hydronephrosis from previous total cystectomy and ilea! conduit for invasive bladder Ca Invasive bladder Ca
Normal Normal Normal Normal Severe dilatation and hydronephrosis bilat. Non-function lt. side, moderate dilatation rt. side
Associated Operations Pelvic exenteration
Total cystectomy Pelvic exenteration Total cystectomy, lt. nephroureterectomy Total cystectomy Pelvic exenteration Total cystectomy Total cystectomy
Radical cystectomy
* Died of hepatic dysfunction 4 months postoperatively. TABLE 2
Pt. No.
7
Followup (mos.)
Postop. IVP
Reflux
Pressure (cm. water)
1
16
Excellent
2
13
3 4
12 12
Excellent lt. side, marked improvement rt. side Excellent Excellent
5
11
Excellent
100 50 30 100
6 7 8
11
7 7
Excellent Excellent Excellent
100 80 80
9
5
Excellent
10
5
11
4
Improvement It. side, unchanged rt. side Bilat. improvement
Lt. Rt.+
Lt.+, Rt. Lt.+, Rt. -
Lt.+, Rt. -
50
Slight dilatation It. side temporarily
Neg.
100
Persisted moderate dilatation ofpelviocaliceal system rt. side Returning to normal It. side Persisted reflux It. side for short ureteral fixation Two silver clips placed for radiographic observation for ureteroileal junction Ureters normal preop. and postop. Ureters normal preop. and postop. Bilat. mild obstructions but ultimately returning to normal after 5mos. Reflux slightly It. side at 80 cm. water pressure but no reflux at 50 cm. water pressure Reflux on remnant ureters
Neg.
80 50 80
Lt. Rt.+
Urine Cultures
Radiographic Results
50
Revisualization It. side, minimal and intermittent reflux rt. side
Neg. Pseudomonas 105/ml. ->neg. Neg. Neg. Neg. Neg. Klebsiella 105/ml. ->neg. Neg. Pseudomonas 105 /ml.
ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES
lent results in 15 cases, improvement in 4 and unchanged in 1 regardless of the presence or absence of reflux. None of the ureters deteriorated subsequently although temporary ureteral obstruction was observed in 3 ureters from patients 1 and 8. Reflux was demonstrated in 3 of 20 ureters in which this technique was used (patients 4, 9 and 11). However, reflux in patient 9 occurred only at pressures of 80 cm. water. The left ureter of patient 4 was implanted with short ureteral fixation, approximately 1 cm., since the lower half of the ureter had been removed for ureteral invasion of sigmoid carcinoma. Reflux in patient 11 was minimal but this patient died of
737
hepatic dysfunction 4 months postoperatively. Autopsy specimens of the ureteroileal junctions were obtained for histological examinations. None of the 4 ureters with severe dilatation (right ureters from patients 2 and 10, and left ureters from patients 10 and 11) had reflux (fig. 2). In patient 10 reflux into the bilateral remnant ureters was demonstrated with no reflux into the reimplanted ureters (fig. 3). A conduitogram in patient 1, 16 months postoperatively, revealed reflux in the right ureter, which had been implanted in the ordinary fashion, but none in the left ureter, which had been implanted with the new antireflux technique.
Fm. 2. A, preoperative IVP from patient 2 reveals normal left side and severe obstruction on right side owing to invasive cervical carcinoma. Patient received radiation therapy after ileal conduit. B, IVP 1 year postoperatively reveals marked improvement on right side. C, conduitogram reveals no ileoureteral reflux at 100 cm. water pressure.
Fm. 3. A, preoperative IVP from patient 10 reveals bilateral marked hydronephrosis owing to ureteroileal obstruc~ion. B, IVP ~ month after bilateral reanastomoses ofureteroilealjunctions reveals improvement on left side and not much change on right side. C, condm~ogram 1 month postoperatively demonstrates reflux into bilateral remnant ureters and absence of reflux on ureters newly anastomosed usmg our antireflux technique.
ITATANI AND SONODA
738
Serum creatinine values had been slightly elevated preoperatively in patients 10 and 11, and were unchanged postoperatively in patient 10 but returned to normal in patient 11. All other patients had normal serum creatinine values preoperatively and postoperatively. None of the 11 patients had pyelonephritis postoperatively, although temporary positive urine cultures were obtained in patients 4, 9 and 11. DISCUSSION
Several antireflux techniques for ureteroileal anastomosis have been described. Starr and associates have reported on the subserosal tunneling and ureteroileal envelopment technique in animals and the subserosal tunneling technique in 6 patients. 5 • 9 The nippling technique has been used in animal experiments by Schellhammer and Texter, and clinically by
Mount and associates. 7 A submucosal tunneling technique also has been reported. Of these procedures the subserosal tunneling technique has provided good results, while results with the other techniques have been discouraging. However, the clinical application of the subserosal tunneling technique will be restricted when the ureters are dilated preoperatively. On the other hand, our new antireflux technique can be used not only for normal but also for dilated ureters and provides satisfactory results, as demonstrated in patients 2, 3, 10 and 11. The ureteroileal junction, which prevents reflux with an adequate length, is indicated radiographically by 2 silver clips in patient 5 (fig. 4). Histological studies of the ureteroileal junction obtained from autopsy specimens from patient 11 showed that the fixed ureteral segment had adequate length and intact musculature and had been covered completely by
Fm. 4. A, IVP 3 month postoperatively reveals essentially normal right side and post-nephroureterectomized status on left side. Note 2 silver clips indicating fixed ureteral segment at ureteroilealjunction. B, conduitogram confirms absence of reflux at 100 cm. water pressure. Two silver clips also indicate ureteroileal junction.
Fm. 5. Sagittal sections of ureteroileal junction from autopsy specimens of patient 11 show intact ureteral musculature. Ureter follows submuscular course of ileum and is covered completely by ileal serosal coat. A. ureteral orifice. B, ureteral musculature. C, ileal musculature. D, ureteral lumen. E, ureteral adventita. F, ileal serosa. G, chromic catgut. Elastica van Gieson, reduced from x 3.25.
ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES
an ileal serosal coat (fig. 5). Therefore, this new technique and the subserosal tunneling technique involve the same principle to prevent reflux. In addition, this new technique seems to be more reasonable to prevent reflux compared to the subserosal tunneling technique, since the fixed ureteral segment and the ileal loop are isoperistaltic. This technique also will be useful for ureteroileocystoneostomy to prevent ileoureteral reflux, since reflux can be prevented at pressures more than 50 cm. In fact, we have had 1 successful case. Although satisfactory results have been obtained with this technique the clinical value must be studied in a larger group of patients and evaluated for a longer interval.
3. 4. 5. 6. 7.
REFERENCES
8. 1. Bricker, E. M.: Bladder substitution after pelvic evisceration.
Surg. Clin. N. Amer., 30: 1511, 1950. 2. Middleton, A. W., Jr. and Hendren, W. H.: Ileal conduit in
9.
739
children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976. Dretler, S. P.: The pathogenesis of urinary tract calculi occurring after ileal conduit diversion: I. Clinical study. II. Conduit study. III. Prevention. J. Urol., 109: 204, 1973. Schmidt, J. D., Hawtrey, C. E., Flocks, R.H. and Culp, D. A.: Complications, results and problems of ileal conduit diversions. J. Urol., 109: 210, 1973. Starr, A., Rose, D. H., Cooper, J. F. and Snyder, R. M.: Antireflux ureteroileal anastomosis: two experimental techniques. Invest. Urol., 12: 165, 1974. Schellhammer, P. F. and Texter, J. H.: An experimental ureteroileal anastomosis to prevent reflux. Invest. Urol., 11: 319, 1974. Mount, B. M., Susset, J. G., Campbell, J. and MacKinnon, K. J.: Ureteral implantation into ileal conduits. J. Urol., 100: 605, 1968. Scott, F. B. and Baum, N.: Ureteroileal anastomosis: new antirefluxing technique. Urology, 6: 215, 1975. Starr, A., Rose, D. H. and Cooper, J. F.: Antireflux ureteroileal anastomosis in humans. J. Urol., 113: 170, 1975.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
NEW TECHNIQUE OF ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES HIROAKI ITATANI
AND
TAKAO SONODA
From the Department of Urology, Osaka University Hospital, Osaka, Japan
ABSTRACT
Free ileoureteral reflux in patients with an ileal conduit has been indicated as the etiology of late renal complications. A new technique for ureteroileal anastomosis was devised in an attempt to prevent reflux without causing obstruction. This anastomosis has been done on 20 ureters from 11 patients with pelvic malignancies. Satisfactory results have been obtained in patients with normal as well as dilated ureters, with no serious operative complications, no episodes of pyelonephritis and no renal deterioration. The ureteroileal junction created with this technique has been demonstrated radiographically and histologically. Since Bricker popularized the use of an isolated ileal segment as a bladder substitute 1 the ileal conduit has become the most widely accepted mode of supravesical urinary diversion. Today, most techniques of this satisfactory procedure create free ileoureteral reflux, which has been viewed with less concern than vesicoureteral or coloureteral reflux since the ileal conduit has been relied upon as a low pressure or no pressure reservoir system.
this goal. s-s Among them the subserosal tunneling technique has been reported to provide better results than the others,9 although this technique has been used only in patients with normal ureters. We have used a new type of antireflux ureteroileal anastomosis on 11 patients with normal and dilated ureters. Our technique has prevented reflux successfully without causing obstruction in not only the normal but also the dilated ureters.
Fm. 1. Stages of antireflux ureteroileal anastomosis OPERATIVE PROCEDURE However, in recent years serious long-term problems, such as pyelonephritis, calculous formation and renal deterioration After a suitable ileal loop is created in the usual manner without apparent urinary obstruction, have been reported. 2-4 the proximal end of the loop is fixed to the retroperitoneum. Clinical and experimental studies indicate that reflux of Two anchoring stitches are placed between the serosa of the infected urine to the kidney is the etiology of these late ileum and the adventitia of the ureter so that the distal ureter complications. Therefore, a ureteroileal anastomosis that pre- can be fixed longitudinally to the ileal loop. An incision vents reflux without causing obstruction would contribute approximately 2.5 cm. long is made on the ileal serosa with a greatly to the reduction of long-term renal complications. sharp pointed scalpel and the serosa in dissected from the Several antireflux techniques have been proposed to achieve underlying muscularis with a small curved clamp. Bleeding points from the muscularis should be ligated carefully. The Accepted for publication April 15, 1977. 735
736
ITATANI AND SONODA
MATERIALS AND METHODS dissecte,d serosa of the ileum and the adventitia of the ureter are sewn together with 5 or 6, 4-zero interrupted chromic Patient information is summarized in table 1. There were catgut sutures on each side of the ureter at the 3 and 9 o'clock 20 ureters from 11 patients implanted into the ileal conduits positions (fig. 1, A). Care must be taken to stitch only the with this technique. Patient 5 underwent total cystectomy and adventitia, not the muscularis, of the ureter. After the distal nephroureterectomy for invasive carcinoma of the left perivesureteral fixation is completed a sharp incision is made through ical ureter. In our first case, patient 1, the right ureter was the serosa, muscularis and mucosa of the ileal loop 0.5 cm. implanted in the ordinary fashion for comparison. Preoperafrom the fixed ureteral end. Then an adequate portion for tive excretory urograms (IVPs) and operative findings indidirect anastomosis to the ileal loop is cut obliquely from the cated that 8 of the 20 ureters were dilated: 1 slightly, 3 distal end of the ureter (fig. 1, B). When the ureteral diameter moderately and 4 severely. The remaining 12 ureters were is small the cut end of the ureter is spatulated a little or normal. spread out to obtain an adequate size for the anastomosis. The presence or absence of ileoureteral reflux was demonThe ureteroileal anastomosis is done in a single layer with strated by a retrograde conduitogram with a No. 20 balloon interrupted sutures and additional covering sutures are placed catheter and gravity filling at approximately 30 to 100 cm. between the serosa of the ileum and the adventitia of the water pressure, depending on the patient. In each case good ureter with 4-zero chromic catgut. This modified technique of filling of the loops was confirmed by television observation. Cordonnier is simpler than a mucosa-to-mucosa technique. To Preoperative and postoperative renal function was assessed by prevent obstruction of the anastomosis it is important that IVP and serum creatinine values. A patient was considered to less stitches are used in the ileal serosa and the ureter, and have urinary tract infection when urine cultures directly from that many stitches are used in the ileal mucosa. the conduits were positive. Followup has ranged from 4 to 16 During the procedure it is not necessary to use a splint. months, with an average of 9.4 months. Serosal fixation of the right distal ureter and the ureteroileal anastomosis are done in the same way as those on the left side RESULTS (fig. 1, C). After these procedures are completed the resulting Table 2 indicates results noted on postoperative IVPs and ureteroileal junctions are retroperitonealized completely (fig. retrograde conduitograms in all 11 cases. IVPs revealed excel1,D). TABLE
Pt. Age-Sex No. 1-28-M
1
Disease
Preoperative IVP
2-61-F
Giant seminomas of bilat. abdominal testes Advanced cervical Ca of uterus
3-42-M
Invasive bladder Ca
4-37-M
Sigmoid Ca
5-61-M
Lt. perivesical ureteral Ca with blad-
Normal It. side, slight dilatation rt. side Normal lt. side, severe obstruction rt. side Moderate dilatation It. side, normal rt. side Moderate dilatation It. side, normal rt. side Non-function lt. side, normal rt. side
der invasion
6-62-M 7-48-M 8-49-M 9-66-M 10-53-M 11*-68-M
Invasive bladder Ca Rectal Ca Invasive bladder Ca Invasive bladder Ca Bilat. hydronephrosis from previous total cystectomy and ilea! conduit for invasive bladder Ca Invasive bladder Ca
Normal Normal Normal Normal Severe dilatation and hydronephrosis bilat. Non-function lt. side, moderate dilatation rt. side
Associated Operations Pelvic exenteration
Total cystectomy Pelvic exenteration Total cystectomy, lt. nephroureterectomy Total cystectomy Pelvic exenteration Total cystectomy Total cystectomy
Radical cystectomy
* Died of hepatic dysfunction 4 months postoperatively. TABLE 2
Pt. No.
7
Followup (mos.)
Postop. IVP
Reflux
Pressure (cm. water)
1
16
Excellent
2
13
3 4
12 12
Excellent lt. side, marked improvement rt. side Excellent Excellent
5
11
Excellent
100 50 30 100
6 7 8
11
7 7
Excellent Excellent Excellent
100 80 80
9
5
Excellent
10
5
11
4
Improvement It. side, unchanged rt. side Bilat. improvement
Lt. Rt.+
Lt.+, Rt. Lt.+, Rt. -
Lt.+, Rt. -
50
Slight dilatation It. side temporarily
Neg.
100
Persisted moderate dilatation ofpelviocaliceal system rt. side Returning to normal It. side Persisted reflux It. side for short ureteral fixation Two silver clips placed for radiographic observation for ureteroileal junction Ureters normal preop. and postop. Ureters normal preop. and postop. Bilat. mild obstructions but ultimately returning to normal after 5mos. Reflux slightly It. side at 80 cm. water pressure but no reflux at 50 cm. water pressure Reflux on remnant ureters
Neg.
80 50 80
Lt. Rt.+
Urine Cultures
Radiographic Results
50
Revisualization It. side, minimal and intermittent reflux rt. side
Neg. Pseudomonas 105/ml. ->neg. Neg. Neg. Neg. Neg. Klebsiella 105/ml. ->neg. Neg. Pseudomonas 105 /ml.
ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES
lent results in 15 cases, improvement in 4 and unchanged in 1 regardless of the presence or absence of reflux. None of the ureters deteriorated subsequently although temporary ureteral obstruction was observed in 3 ureters from patients 1 and 8. Reflux was demonstrated in 3 of 20 ureters in which this technique was used (patients 4, 9 and 11). However, reflux in patient 9 occurred only at pressures of 80 cm. water. The left ureter of patient 4 was implanted with short ureteral fixation, approximately 1 cm., since the lower half of the ureter had been removed for ureteral invasion of sigmoid carcinoma. Reflux in patient 11 was minimal but this patient died of
737
hepatic dysfunction 4 months postoperatively. Autopsy specimens of the ureteroileal junctions were obtained for histological examinations. None of the 4 ureters with severe dilatation (right ureters from patients 2 and 10, and left ureters from patients 10 and 11) had reflux (fig. 2). In patient 10 reflux into the bilateral remnant ureters was demonstrated with no reflux into the reimplanted ureters (fig. 3). A conduitogram in patient 1, 16 months postoperatively, revealed reflux in the right ureter, which had been implanted in the ordinary fashion, but none in the left ureter, which had been implanted with the new antireflux technique.
Fm. 2. A, preoperative IVP from patient 2 reveals normal left side and severe obstruction on right side owing to invasive cervical carcinoma. Patient received radiation therapy after ileal conduit. B, IVP 1 year postoperatively reveals marked improvement on right side. C, conduitogram reveals no ileoureteral reflux at 100 cm. water pressure.
Fm. 3. A, preoperative IVP from patient 10 reveals bilateral marked hydronephrosis owing to ureteroileal obstruc~ion. B, IVP ~ month after bilateral reanastomoses ofureteroilealjunctions reveals improvement on left side and not much change on right side. C, condm~ogram 1 month postoperatively demonstrates reflux into bilateral remnant ureters and absence of reflux on ureters newly anastomosed usmg our antireflux technique.
ITATANI AND SONODA
738
Serum creatinine values had been slightly elevated preoperatively in patients 10 and 11, and were unchanged postoperatively in patient 10 but returned to normal in patient 11. All other patients had normal serum creatinine values preoperatively and postoperatively. None of the 11 patients had pyelonephritis postoperatively, although temporary positive urine cultures were obtained in patients 4, 9 and 11. DISCUSSION
Several antireflux techniques for ureteroileal anastomosis have been described. Starr and associates have reported on the subserosal tunneling and ureteroileal envelopment technique in animals and the subserosal tunneling technique in 6 patients. 5 • 9 The nippling technique has been used in animal experiments by Schellhammer and Texter, and clinically by
Mount and associates. 7 A submucosal tunneling technique also has been reported. Of these procedures the subserosal tunneling technique has provided good results, while results with the other techniques have been discouraging. However, the clinical application of the subserosal tunneling technique will be restricted when the ureters are dilated preoperatively. On the other hand, our new antireflux technique can be used not only for normal but also for dilated ureters and provides satisfactory results, as demonstrated in patients 2, 3, 10 and 11. The ureteroileal junction, which prevents reflux with an adequate length, is indicated radiographically by 2 silver clips in patient 5 (fig. 4). Histological studies of the ureteroileal junction obtained from autopsy specimens from patient 11 showed that the fixed ureteral segment had adequate length and intact musculature and had been covered completely by
Fm. 4. A, IVP 3 month postoperatively reveals essentially normal right side and post-nephroureterectomized status on left side. Note 2 silver clips indicating fixed ureteral segment at ureteroilealjunction. B, conduitogram confirms absence of reflux at 100 cm. water pressure. Two silver clips also indicate ureteroileal junction.
Fm. 5. Sagittal sections of ureteroileal junction from autopsy specimens of patient 11 show intact ureteral musculature. Ureter follows submuscular course of ileum and is covered completely by ileal serosal coat. A. ureteral orifice. B, ureteral musculature. C, ileal musculature. D, ureteral lumen. E, ureteral adventita. F, ileal serosa. G, chromic catgut. Elastica van Gieson, reduced from x 3.25.
ANTIREFLUX URETEROILEAL ANASTOMOSIS AND ITS CLINICAL EXPERIENCES
an ileal serosal coat (fig. 5). Therefore, this new technique and the subserosal tunneling technique involve the same principle to prevent reflux. In addition, this new technique seems to be more reasonable to prevent reflux compared to the subserosal tunneling technique, since the fixed ureteral segment and the ileal loop are isoperistaltic. This technique also will be useful for ureteroileocystoneostomy to prevent ileoureteral reflux, since reflux can be prevented at pressures more than 50 cm. In fact, we have had 1 successful case. Although satisfactory results have been obtained with this technique the clinical value must be studied in a larger group of patients and evaluated for a longer interval.
3. 4. 5. 6. 7.
REFERENCES
8. 1. Bricker, E. M.: Bladder substitution after pelvic evisceration.
Surg. Clin. N. Amer., 30: 1511, 1950. 2. Middleton, A. W., Jr. and Hendren, W. H.: Ileal conduit in
9.
739
children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976. Dretler, S. P.: The pathogenesis of urinary tract calculi occurring after ileal conduit diversion: I. Clinical study. II. Conduit study. III. Prevention. J. Urol., 109: 204, 1973. Schmidt, J. D., Hawtrey, C. E., Flocks, R.H. and Culp, D. A.: Complications, results and problems of ileal conduit diversions. J. Urol., 109: 210, 1973. Starr, A., Rose, D. H., Cooper, J. F. and Snyder, R. M.: Antireflux ureteroileal anastomosis: two experimental techniques. Invest. Urol., 12: 165, 1974. Schellhammer, P. F. and Texter, J. H.: An experimental ureteroileal anastomosis to prevent reflux. Invest. Urol., 11: 319, 1974. Mount, B. M., Susset, J. G., Campbell, J. and MacKinnon, K. J.: Ureteral implantation into ileal conduits. J. Urol., 100: 605, 1968. Scott, F. B. and Baum, N.: Ureteroileal anastomosis: new antirefluxing technique. Urology, 6: 215, 1975. Starr, A., Rose, D. H. and Cooper, J. F.: Antireflux ureteroileal anastomosis in humans. J. Urol., 113: 170, 1975.