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Percutaneous intrapelvic pressure registration in patients with ureterointestinal urinary diversion
PERCUTANEOUS INTRAPELVIC PRESSURE REGISTRATION
IN PATIENTS WITH
URETEROINTESTINAL
URINARY DIVERSION
TADASHI HAYASHI, M.D.
YOJI TAKI, M.D.
KYOKO IKAI, M.D.
MASARU HIURA, M.D.
TADAO KIRIYAMA,
M.D.
From the Department of Urology, Wakayama Red Cross Hospital, Wakayama, Japan
ABSTRACT-batrapelvic pressure registration using percutaneous needle renal pelvic puncture in 4 patients with intestinal loop diversion was done to determine whether or not there is loop-ureteral reflux under physiologic condition in loop diversion without any urinary tract obstruction. There was no pressure elevation related to reflux on pressure recording. We concluded that loop-ureteral reflux in intestinal loop diversion does not occur without obstruction.
Renal deterioration without urinary obstruction is a problem in patients with free-refluxing ureterointestinal urinary diversion, especially in children. Pyelonephritis or reflux or both are cited as the major contributor to such renal deterioration. This article reports intrapelvic pressure registration in 4 patients to confirm the necessity of antirefluxing procedure in adults. Material and Methods This study was done two to three months after diversion on 4 patients (2 with ileal and 2 with colonic conduits) who had no urinary tract obstruction (Table I). All ureterointestinal TABLE Pt.
FH YS AI KO
176
Age, Sex 66, 77, 55, 56,
F M F F
I.
anastomoses were of the free-refluxing, end-toend type, as described by Wallace.’ Intrapelvic pressure registration was done as follows. Under local anesthesia, with the patient lying in a prone position on the roentgen table, a 22G spinal needle was inserted toward the lower calyx percutaneously under fluoroscopic guidance. For pressure registration, a cystometric recorder was used. The range of estimation was O-SO mm Hg. Resting pressure was calculated from the level of the renal pelvis with a hydrostatic manometer. Pressure recording was done under ordinary hydration and under furosemide loading (10 mg) for fifteen minutes each. Patient profile
Diseases Treated Bladder cancer Bladder cancer Cervix cancer Cervix cancer
Treatment
Diversion
Total cystectomy Total cystectomy Pelvic exenteration Pelvic exenteration
Ileal conduit Ileal conduit Colonic conduit Colonic conduit
UROLOGY
/ SEPTEMBER
1986
I
VOLUME
XXVIII,
NUMBER 3
FIGURE 1. Intrapelvic pressure registration in patient FH after furosemide loading shows respiratory wave (-1) and peristaltic wave (I).
Results The intrapelvic pressure varied with respiration. The amplitude of the pressure variation with respiration was l-3 mm Hg. Table II shows the intrapelvic pressure registration data. No remarkable change was found on the intrapelvic pressure pattern in either the ileal or the colonic conduit. No pressure elevation that implied the conduit-ureteral reflux was found (Fig. 1). Although transient gross hematuria developed in 1 of 4 patients, no other complication was experienced. Comment There is general agreement concerning conduit urinary diversion in children that colonic conduit with antireflux procedure is desirable because of the low incidence of stomal obstruction and future undiversion. But some criticism has been raised on the use of the antireflux procedure in adults. The antireflux procedure is accompanied by the operative complexities and high incidence of stenosis of ureterointestinal anastomosis.
TABLE II.
Richie, Skinner, and Waisman2 reported the necessity of the antireflux procedure. When the ileal loop was performed on 1 kidney and nonrefluxing colonic conduit on the other in dogs, there was a marked difference in incidence of pyelonephritis on the two sides. Pyelonephritis was seen in only 7 per cent of the renal units diverted by nonrefluxing colonic conduit but was present in 83 per cent of those diverted by ileal loop with reflux. Middleton and Hendren3 found renal deterioration in 13 per cent of the renal units diverted by refluxing ileal conduit in children without any urinary tract obstruction. Morales and Golimbu* also found renal deterioration in 13 per cent of the renal units after colonic conduit diversion without any antireflux procedure. These reports cited pyelonephritis and/or reflux as the major contributors. On the other hand, Shapiro, Lebowitz, and Colodny5 reported deteriorated renal units without any obstruction in 3 of 144 units. It is difficult to find a conduit-ureteral reflux in loop diversion under physiologic conditions. The reflux demonstrated on standard loopography occurs under highly abnormal conditions.4,6 Woodside and associates’ developed an
Results of intrapelvic pressure registration
Before Furosemide Loading -Peristaltic Wave---Amplitude Frequency (per min.) (mm Hg) (mm Hg) Resting Pressure
Pt.
8 15 8 5
FH YS AI KO
UROLOGY
/
SEPTEMBER
1986
l-3 l-2
5 6-7
(-) (-)
(-) (-)
/
VOLUME XXVIII,
After Furosemide Loading -Peristaltic Wave--Frequency Amplitude (per min.) (mm Hg) (mm Hg)
Baseline Elevation (5)
(5)
NUMBER 3
2-3 2-3
5
‘2-j
177
isotope loopography, which is done under a near physiologic condition. However, catheter insertion and injection of small amounts of isotope into the conduit may alter the physiologic condition. We examined the intrapelvic pressure to determine whether or not under physiologic condition there is reflux that damages the renal function. According to Rattner, Fink, and Murphy8 the intrapelvic pressure measured by ureteral catheterization to renal pelvis in 17 women without hydronephrosis was 11-18 mm Hg. Michaelsong reported a mean- pressure of 6.5 mm Hg in 10 normal pelves measured by percutaneous intrapelvic pressure registration. Ong, Ferguson, and StephenslO studied the effect of hydrostatic pressure on kidney function through intrapelvic pressure registration during vesicoureteral reflux in dogs. They reported the intrapelvic pressure- during micturition reached from 30 mm Hg to 60 mm Hg tending to stay about 5 mm Hg below the bladder pressure. Our results were similar to those of Michaelson. No pressure pattern implying a conduit-ureteral reflux which was showed in the study of Ong and associates was found both in normal and diuretic conditions. There was no difference of intrapelvic pressure pattern in patients with ileal or colonic conduit. It thus appeared that reflux did not occur in a diverted patient without urinary tract obstruction although the number of observations made was small and there was some question about the examination position of patients. Magnus I1 showed that a peristaltic wave in the ureter could prevent the reflux in a
178
UROLOGY
free-refluxing ileal conduit. This may explain the lack of pressure elevation caused by a reflux in our study. In adults, we believe that conduit diversion without the use of an antireflux procedure is preferable because of the low incidence of anastomosis stenosis and no indication for future undiversion, Wakayama, Japan 640 (DR.
HAYASHI)
References 1. Wallace DM: Uretero-ileostomy, Br J Urol 42: 529 (1970). 2. Richie JP, Skinner DC, and Waisman J: The effect of reflux on the development of pyelonephritis in urinary diversion: an experimental studv. I Sure Res 16: 256 (1974). 3. Middleton-‘AR Jr, and Hendren WH: Ileal conduits in children at the Massachusetts General Hospital from 1955 to 1970, J Urol 115: 591 (1976). 4. Morales P, and Golimhu M: Colonic urinary diversion: 10 years of experience, J Urol 113: 302 (1975). 5. Shapiro SR, Lebowitz R, and Colodny AH: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology, ibid 114: 289 (1975). 6. Smith ED: Follow-up studies on 150 ileal conduits in children, J Pediat Surg 7: 1 (1972). 7. Woodside JR, Borden TA, Damron JR, and Kiker JD: Isotope loopography, a new test: comparison with standard loopography and its relationship to renal function in patients with ilea conduit urinarv diversion. I Urol 119: 31 (1978). 8. Rattner WH, Fink S; and Murphy JJ:‘Pr&ure studies in the human ureter and renal pelvis, ibid 78: 359 (1957). 9. Michaelson G: Percutaneous puncture of the renal pelvis, intrapelvic pressure and the concentrating capacity of the kidney in hydronephrosis, Acta Med Stand (Suppl. 559): p 1 (1974). 10. Ong TH, Ferguson RS, and Stephens FD: The pattern of intrapelvic pressures during vesicoureteral reflux in the dog with normal caliber ureters, Invest Urol 11: 347 (1974). 11. Magnus RV: Pressure studies and dynamics of ileal conduits in children, J Urol 118: 406 (1977).
/
SEPTEMBER
1986
/ VOLUME
XXVIII,
NUMBER
3
IN PATIENTS WITH
URETEROINTESTINAL
URINARY DIVERSION
TADASHI HAYASHI, M.D.
YOJI TAKI, M.D.
KYOKO IKAI, M.D.
MASARU HIURA, M.D.
TADAO KIRIYAMA,
M.D.
From the Department of Urology, Wakayama Red Cross Hospital, Wakayama, Japan
ABSTRACT-batrapelvic pressure registration using percutaneous needle renal pelvic puncture in 4 patients with intestinal loop diversion was done to determine whether or not there is loop-ureteral reflux under physiologic condition in loop diversion without any urinary tract obstruction. There was no pressure elevation related to reflux on pressure recording. We concluded that loop-ureteral reflux in intestinal loop diversion does not occur without obstruction.
Renal deterioration without urinary obstruction is a problem in patients with free-refluxing ureterointestinal urinary diversion, especially in children. Pyelonephritis or reflux or both are cited as the major contributor to such renal deterioration. This article reports intrapelvic pressure registration in 4 patients to confirm the necessity of antirefluxing procedure in adults. Material and Methods This study was done two to three months after diversion on 4 patients (2 with ileal and 2 with colonic conduits) who had no urinary tract obstruction (Table I). All ureterointestinal TABLE Pt.
FH YS AI KO
176
Age, Sex 66, 77, 55, 56,
F M F F
I.
anastomoses were of the free-refluxing, end-toend type, as described by Wallace.’ Intrapelvic pressure registration was done as follows. Under local anesthesia, with the patient lying in a prone position on the roentgen table, a 22G spinal needle was inserted toward the lower calyx percutaneously under fluoroscopic guidance. For pressure registration, a cystometric recorder was used. The range of estimation was O-SO mm Hg. Resting pressure was calculated from the level of the renal pelvis with a hydrostatic manometer. Pressure recording was done under ordinary hydration and under furosemide loading (10 mg) for fifteen minutes each. Patient profile
Diseases Treated Bladder cancer Bladder cancer Cervix cancer Cervix cancer
Treatment
Diversion
Total cystectomy Total cystectomy Pelvic exenteration Pelvic exenteration
Ileal conduit Ileal conduit Colonic conduit Colonic conduit
UROLOGY
/ SEPTEMBER
1986
I
VOLUME
XXVIII,
NUMBER 3
FIGURE 1. Intrapelvic pressure registration in patient FH after furosemide loading shows respiratory wave (-1) and peristaltic wave (I).
Results The intrapelvic pressure varied with respiration. The amplitude of the pressure variation with respiration was l-3 mm Hg. Table II shows the intrapelvic pressure registration data. No remarkable change was found on the intrapelvic pressure pattern in either the ileal or the colonic conduit. No pressure elevation that implied the conduit-ureteral reflux was found (Fig. 1). Although transient gross hematuria developed in 1 of 4 patients, no other complication was experienced. Comment There is general agreement concerning conduit urinary diversion in children that colonic conduit with antireflux procedure is desirable because of the low incidence of stomal obstruction and future undiversion. But some criticism has been raised on the use of the antireflux procedure in adults. The antireflux procedure is accompanied by the operative complexities and high incidence of stenosis of ureterointestinal anastomosis.
TABLE II.
Richie, Skinner, and Waisman2 reported the necessity of the antireflux procedure. When the ileal loop was performed on 1 kidney and nonrefluxing colonic conduit on the other in dogs, there was a marked difference in incidence of pyelonephritis on the two sides. Pyelonephritis was seen in only 7 per cent of the renal units diverted by nonrefluxing colonic conduit but was present in 83 per cent of those diverted by ileal loop with reflux. Middleton and Hendren3 found renal deterioration in 13 per cent of the renal units diverted by refluxing ileal conduit in children without any urinary tract obstruction. Morales and Golimbu* also found renal deterioration in 13 per cent of the renal units after colonic conduit diversion without any antireflux procedure. These reports cited pyelonephritis and/or reflux as the major contributors. On the other hand, Shapiro, Lebowitz, and Colodny5 reported deteriorated renal units without any obstruction in 3 of 144 units. It is difficult to find a conduit-ureteral reflux in loop diversion under physiologic conditions. The reflux demonstrated on standard loopography occurs under highly abnormal conditions.4,6 Woodside and associates’ developed an
Results of intrapelvic pressure registration
Before Furosemide Loading -Peristaltic Wave---Amplitude Frequency (per min.) (mm Hg) (mm Hg) Resting Pressure
Pt.
8 15 8 5
FH YS AI KO
UROLOGY
/
SEPTEMBER
1986
l-3 l-2
5 6-7
(-) (-)
(-) (-)
/
VOLUME XXVIII,
After Furosemide Loading -Peristaltic Wave--Frequency Amplitude (per min.) (mm Hg) (mm Hg)
Baseline Elevation (5)
(5)
NUMBER 3
2-3 2-3
5
‘2-j
177
isotope loopography, which is done under a near physiologic condition. However, catheter insertion and injection of small amounts of isotope into the conduit may alter the physiologic condition. We examined the intrapelvic pressure to determine whether or not under physiologic condition there is reflux that damages the renal function. According to Rattner, Fink, and Murphy8 the intrapelvic pressure measured by ureteral catheterization to renal pelvis in 17 women without hydronephrosis was 11-18 mm Hg. Michaelsong reported a mean- pressure of 6.5 mm Hg in 10 normal pelves measured by percutaneous intrapelvic pressure registration. Ong, Ferguson, and StephenslO studied the effect of hydrostatic pressure on kidney function through intrapelvic pressure registration during vesicoureteral reflux in dogs. They reported the intrapelvic pressure- during micturition reached from 30 mm Hg to 60 mm Hg tending to stay about 5 mm Hg below the bladder pressure. Our results were similar to those of Michaelson. No pressure pattern implying a conduit-ureteral reflux which was showed in the study of Ong and associates was found both in normal and diuretic conditions. There was no difference of intrapelvic pressure pattern in patients with ileal or colonic conduit. It thus appeared that reflux did not occur in a diverted patient without urinary tract obstruction although the number of observations made was small and there was some question about the examination position of patients. Magnus I1 showed that a peristaltic wave in the ureter could prevent the reflux in a
178
UROLOGY
free-refluxing ileal conduit. This may explain the lack of pressure elevation caused by a reflux in our study. In adults, we believe that conduit diversion without the use of an antireflux procedure is preferable because of the low incidence of anastomosis stenosis and no indication for future undiversion, Wakayama, Japan 640 (DR.
HAYASHI)
References 1. Wallace DM: Uretero-ileostomy, Br J Urol 42: 529 (1970). 2. Richie JP, Skinner DC, and Waisman J: The effect of reflux on the development of pyelonephritis in urinary diversion: an experimental studv. I Sure Res 16: 256 (1974). 3. Middleton-‘AR Jr, and Hendren WH: Ileal conduits in children at the Massachusetts General Hospital from 1955 to 1970, J Urol 115: 591 (1976). 4. Morales P, and Golimhu M: Colonic urinary diversion: 10 years of experience, J Urol 113: 302 (1975). 5. Shapiro SR, Lebowitz R, and Colodny AH: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology, ibid 114: 289 (1975). 6. Smith ED: Follow-up studies on 150 ileal conduits in children, J Pediat Surg 7: 1 (1972). 7. Woodside JR, Borden TA, Damron JR, and Kiker JD: Isotope loopography, a new test: comparison with standard loopography and its relationship to renal function in patients with ilea conduit urinarv diversion. I Urol 119: 31 (1978). 8. Rattner WH, Fink S; and Murphy JJ:‘Pr&ure studies in the human ureter and renal pelvis, ibid 78: 359 (1957). 9. Michaelson G: Percutaneous puncture of the renal pelvis, intrapelvic pressure and the concentrating capacity of the kidney in hydronephrosis, Acta Med Stand (Suppl. 559): p 1 (1974). 10. Ong TH, Ferguson RS, and Stephens FD: The pattern of intrapelvic pressures during vesicoureteral reflux in the dog with normal caliber ureters, Invest Urol 11: 347 (1974). 11. Magnus RV: Pressure studies and dynamics of ileal conduits in children, J Urol 118: 406 (1977).
/
SEPTEMBER
1986
/ VOLUME
XXVIII,
NUMBER
3