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Plastic Repair of Ureterosigmoidostomies
THE JOURNAL OF UROLOGY
Vol. 72, No. 3, September 1954 Printed in U.S.A.
PLASTIC REPAIR OF URETEROSIGMOIDOSTOMIES HOMER W. HUMISTON
A 45 year old man was initially seen in March 1950, for gross hematuria which had occurred 1 year and 1 week previously. Cystoscopic inspection revealed several square centimeters of the bladder involved with low grade papillary carcinoma. Attempts to deal with the growth transurethrally failed. A transvesical fulguration was done, which was supplemented with additional transurethral fulguration. Six months of these efforts had failed to control the tumor. On September 6, 1950, bilateral ureterosigmoidostomies and a total cystectomy were performed in one stage. The transplants were done by the Coffey 1 technic. Preoperatively, the patient had had no symptoms except hematuria, his blood chemistry was normal, and excretory urography revealed a normal upper tract bilaterally. For the next 11 months he felt under par, although he worked fairly consistently as a salesman. He would have a degree or more of fever approximately two days out of three. He had several episodes of chills and high fever for which he was hospitalized, a rectal tube placed, and intensive antibiotic therapy prescribed. J=Ie consistently described an increasing thirst which he could not satisfy, and failure to regain his strength and endurance. Two months after cystectomy his blood urea nitrogen was 28.9 mg. per cent; 2 months later it was 22.0 mg. per cent; and 4 months later it was 33.6 mg. per cent. On August 17, 1951, eleven months after cystectomy, the low midline incision was reopened after bowel preparation with aureomycin. No recurrence of the bladder tumor could be demonstrated. A colotomy was done on each side, and the transplants were explored and dealt with through the lumen of the bowel. On the left, no stoma could be found. The dilated ureter was visualized through the bowel mucosa, and was incised for 1 cm. longitudinally. Interrupted sutures of 5-0 chromic were used to bring mucosa to mucosa. There remained a stoma estimated to be 30F. This colotomy was then closed. On the right it was found that the intraluminal stump of the ureter had failed to slough, and was a fibrotic strictured stub about one centimeter long. The ureter above this stub was dilated. The stub was amputated and the ureter was incised about 1 cm. longitudinally, as had been done on the left, and mucosa-to-mucosa sutures were placed. The colotomy was then closed. The postoperative course was entirely uneventful. After a few days the blood urea nitrogen was 12.0 mg. per cent. Since this operation 20 months ago, the patient has felt as well as he did a few years ago, has no abnormal thirst, and has regained his strength and endurance. On April 14, 1953, his blood urea nitrogen was 26.4 mg. per cent, creatinine 1.5 mg. per cent, CO 2 combining power was 36 volumes per cent, and the blood chlorides 714 mg. per cent. The line drawings traced from the excretory urograms are shown in figures 1 and 2. The hydronephrosis following the anastomoses was more severe on the Read at annual meeting, Western Section of American Urological Association, San Francisco, April 27-30, 1953. 358
359
URETEROSIGMOIDOSTOMY
Lf.-N-.S-3 FIG. 1
;;,,.-J..o-Sf
/o-7-SJ...
4-
t'f- S-3
FIG. 2
left, and the improvement following the plastic repair was substantially better on the right. DISCUSSION
Stricture of the terminal ureter occurs not infrequently following ureterosigmoidostomies regardless of the technique used in making the anastomosis. It is believed that the incidence of stricture is less when the bowel mucosa is sutured directly to the terminal ureter, but this complication is not thereby eliminated. The plastic procedure which was used in this instance is applicable only if the ureterosigmoidostomy has been performed by one of the tunneling techniques.
360
HOMER W. HUMISTON
The marked clinical improvement and the less striking but definite improvement in the pyelograms following the plastic procedures are very encouraging. It is my belief that a mucosa-to-mucosa anastomosis with a submucus tunnel is the technique of choice for ureterosigmoidostomy. The feasability of reconstruction of the anastomosis through a colotomy incision when a stricture develops is offered as an argument in favor of the use of the tunnel. This same procedure has been reported by D. St. Clair L. Henderson (1952).
1512 Medical Arts Bldg., Tacoma, Wash.
REFERENCE HENDERSON,
D. ST
CLAIR
L.: J. Urol., 67: 479, 1952.
Vol. 72, No. 3, September 1954 Printed in U.S.A.
PLASTIC REPAIR OF URETEROSIGMOIDOSTOMIES HOMER W. HUMISTON
A 45 year old man was initially seen in March 1950, for gross hematuria which had occurred 1 year and 1 week previously. Cystoscopic inspection revealed several square centimeters of the bladder involved with low grade papillary carcinoma. Attempts to deal with the growth transurethrally failed. A transvesical fulguration was done, which was supplemented with additional transurethral fulguration. Six months of these efforts had failed to control the tumor. On September 6, 1950, bilateral ureterosigmoidostomies and a total cystectomy were performed in one stage. The transplants were done by the Coffey 1 technic. Preoperatively, the patient had had no symptoms except hematuria, his blood chemistry was normal, and excretory urography revealed a normal upper tract bilaterally. For the next 11 months he felt under par, although he worked fairly consistently as a salesman. He would have a degree or more of fever approximately two days out of three. He had several episodes of chills and high fever for which he was hospitalized, a rectal tube placed, and intensive antibiotic therapy prescribed. J=Ie consistently described an increasing thirst which he could not satisfy, and failure to regain his strength and endurance. Two months after cystectomy his blood urea nitrogen was 28.9 mg. per cent; 2 months later it was 22.0 mg. per cent; and 4 months later it was 33.6 mg. per cent. On August 17, 1951, eleven months after cystectomy, the low midline incision was reopened after bowel preparation with aureomycin. No recurrence of the bladder tumor could be demonstrated. A colotomy was done on each side, and the transplants were explored and dealt with through the lumen of the bowel. On the left, no stoma could be found. The dilated ureter was visualized through the bowel mucosa, and was incised for 1 cm. longitudinally. Interrupted sutures of 5-0 chromic were used to bring mucosa to mucosa. There remained a stoma estimated to be 30F. This colotomy was then closed. On the right it was found that the intraluminal stump of the ureter had failed to slough, and was a fibrotic strictured stub about one centimeter long. The ureter above this stub was dilated. The stub was amputated and the ureter was incised about 1 cm. longitudinally, as had been done on the left, and mucosa-to-mucosa sutures were placed. The colotomy was then closed. The postoperative course was entirely uneventful. After a few days the blood urea nitrogen was 12.0 mg. per cent. Since this operation 20 months ago, the patient has felt as well as he did a few years ago, has no abnormal thirst, and has regained his strength and endurance. On April 14, 1953, his blood urea nitrogen was 26.4 mg. per cent, creatinine 1.5 mg. per cent, CO 2 combining power was 36 volumes per cent, and the blood chlorides 714 mg. per cent. The line drawings traced from the excretory urograms are shown in figures 1 and 2. The hydronephrosis following the anastomoses was more severe on the Read at annual meeting, Western Section of American Urological Association, San Francisco, April 27-30, 1953. 358
359
URETEROSIGMOIDOSTOMY
Lf.-N-.S-3 FIG. 1
;;,,.-J..o-Sf
/o-7-SJ...
4-
t'f- S-3
FIG. 2
left, and the improvement following the plastic repair was substantially better on the right. DISCUSSION
Stricture of the terminal ureter occurs not infrequently following ureterosigmoidostomies regardless of the technique used in making the anastomosis. It is believed that the incidence of stricture is less when the bowel mucosa is sutured directly to the terminal ureter, but this complication is not thereby eliminated. The plastic procedure which was used in this instance is applicable only if the ureterosigmoidostomy has been performed by one of the tunneling techniques.
360
HOMER W. HUMISTON
The marked clinical improvement and the less striking but definite improvement in the pyelograms following the plastic procedures are very encouraging. It is my belief that a mucosa-to-mucosa anastomosis with a submucus tunnel is the technique of choice for ureterosigmoidostomy. The feasability of reconstruction of the anastomosis through a colotomy incision when a stricture develops is offered as an argument in favor of the use of the tunnel. This same procedure has been reported by D. St. Clair L. Henderson (1952).
1512 Medical Arts Bldg., Tacoma, Wash.
REFERENCE HENDERSON,
D. ST
CLAIR
L.: J. Urol., 67: 479, 1952.