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Study on Use of Isolated Segment of Ileum in Urological Plastic Operation
\, o!. ~-l·t December
J Ol'!{l'<,\L CF U ROLOC''t CopJilight © 1975 'T'he \Viliia1-1s 8,., 'i/iE:ins
Printed
U.8.A.
STUDY ON USE OF ISOLATED SEGMENT OF ILEUNl: IN UROLOGICAL PLASTIC OPERATION SEIZO HORIUCHI
AND
YOSHINOBU HOSHINO
From the Department of Urology, Tokyo Teishin Hospital and Fuchu Metropolitan Hospital, Tokyo, Japan
ABSTRACT
Studies were done on 33 cases of plastic reconstruction of the urinary tract with an isolated ilea! segment. We found that electrolytes and other components in the urine can be absorbed or excreted by the isolated ilea! mucosa. Although electrolyte balance was preserved in most cases the tendency for hyperchloremic acidosis and high blood urea nitrogen was observed in some patients with poor renal function. The degree and the incidence of these changes were influenced by the length of ileal segment used and the volume of urine excreted. These 2 factors were related to infection, which gave deleterious effects on renal function. Among the tests used for prognosis the excretory urogram was found to be the most simple and provided the best information. In 1899 Rutkowski 1 and Mikulicz 2 used the ileum to magnify the capacity of a diseased human bladder. In 1911 Schoemaker substituted an isolated ilea! segment for a ureter. 3 The use of the isolated ilea! segment for the diseased urinary tract has become popular because of the progress in and antibiotics. Our report is based on the study of 33 cases in which isolated ilea! segments were used for urological plastic operations. PATIENTS AND METHODS
Patients. The 33 patients underwent plastic reconstruction of the urinary tract with isolated ilea! segments between 1958 and 1968. In 30 cases the original disease was urinary tract tuberculosis, while l patient had a ureteral 1 had interstitial cystitis and 1 had a bladder after irradiation for cancer of the cervix. The 18 female and 15 male patients ranged in age from 12 to 62 years. Except for those in renal failure, the patients were on a normal diet without any restrictechniques have been (fig. 1). In 7 cases a tostomy was done--4 right and :3 left ureters 1 and 2), In 1 case a right and left \.,CillVUH<;V-lHOVO,LVlH This and left
roileo-ileocystostomy was done in 2 cases (fig. 1, 5 and 6), a pyeloileo-ileocystostomy in 1 case (fig. 1, 7) and a modified ileocystoplasty in 4 cases (fig. 1, 8 and 9). In 5 cases Scheele's method of the ileocystoplasty with ilea! loop was done-4 cases without ureteroneostomy and l case with ureteroneostomy (fig. 1, 10 and 11), while in 13 cases Goodwin's modified method for ileocystoplasty by cap-patch or cup-patch was done- 7 cases without ureteroneostomy and 6 cases with ureteroneostomy (fi!s5. 1, 12 to 15). Renal function. Renal function was estimated by blood urea nitrogen (BUN), serum creatinine, excretory urography (IVP), radioisotope renogram and renoscintigram. In addition tests for creatinine clearance, para-aminohippuric acid clearance, phenolsulfonphthalein excretion and concentration were also tried, although these tests were not reliable in our patients except those with an ileocystoplasty only. Peristalsis of the ilea! segment used for the ureter and the passage of dye were observed by television cine-
calcium, contents
case a modified ureteroileo-neocystostomy ,.vas done (fig. 1, 4). The upper part of the isolated ilea! segment was substituted for the ureter as a closed and the lower part of the segment was used as an open flap to increase bladder capacity. UreteAccepted for publication April 25, 1975.
848
m urine. in the urine were also studied and those in the urine obtained from other urological patients with normal renal function and also from those with nephrostomy who had normal serum electrolytes. Changes of electrolytes in urine in ileal segment. To study the absorption of electrolytes in the urine while passing through the ileal segment substituted for the ureter we examined 3 patients with ileoureteroplasty and temporary nephrostomy.
ISOLATED SEGMENT OF ILEUM IN UROLOGICAL PLASTIC OPERATION
The samples of urine collected from nephrostomy were compared to those collected from the bladder after clamping the nephrostomy tube . Besides these examinations we tried to see the excretion of electrolytes from the ilea! segment. We put distilled water into the ilea! bladder and observed the change of electrolytes before connecting the ureter to it on the second-stage operation. Histological examination. In some cases the tissues of the ilea! segments were taken at another operation several years after the initial one. Histological examination was done on these materials. Bacteriological study. Bacteriological examinations of the urine were performed in 17 cases.
849
l'. ·.-. .;
. :.q.i'.·.
.
~
-
RESULTS
Clinical findings. Scheele's and Goodwin's methods for the contracted bladder provided satisfactory results in obtaining normal bladder capacity and normal urinary frequency. However, Goodwin's method was superior to Scheele's in regard to residual urine. In cases in which the isolated ilea! segment was used for ureters, residual urine was observed more in long ileal segments. Nevertheless, renal function improved in most cases. Operative death occurred in only 1 case with a post-radiation contracted bladder. Another patient died by accident (stabbed) within 1 year after the plastic operation. Two patients died of chronic renal insufficiency 3 years and 9 years 10 months postoperatively, respectively. The main complications were the strictures at the site of anastomosis. Stricture with granulomatous change of the end of the ureter at the point of ureteroileo-neostomy was observed in 2 cases by the Kerr-Colby method of anastomosis. No stricture was seen in the cases done by Nesbit's method of anastomosis. Stricture at the site of ileocystostomy was observed in 3 cases-1 case by Scheele's method and 2 by Goodwin's method. Marked dilatation of the ileal segment was noticed in these cases. However, there were no strictures at the site of ileocystostomy after the technique of anastomosis was modified by extensively resecting the contracted bladder wall and making the part of the anastomosis as wide as possible. In cases in which bladder neck contraction was found a corrective procedure was necessary. None of our patients suffered intestinal problems postoperatively. Renal functions. BUN and serum creatinine were within normal range in approximately twothirds of the patients. Patients with poor renal function preoperatively had a tendency to have high BUN and creatinine values postoperatively. In some cases the elevated values of BUN and creatinine were transitory postoperatively. Patients who underwent pyeloileo-ileocystostomy and pyeloileo-neocystostomy and calicoileoileostomy had a BUN of 20 to about 40 mg. per dl. and these BUN values increased with the onset of urinary infection. We noticed that urinary infection occurred more commonly in patients with long
FIG. 1.
Various types of plastic operations
ilea! segments and that renal infection was inevitable in patients with the ilea! segments anastomosed to the pelvis or calices. The predisposition to infection seems to be correlated with poor renal function and the high value of BUN. Although the estimation of renal function by IVP is disputable the procedure is easily carried out clinically and can provide an outline of renal function. Five patients had normal IVPs preoperatively. These patients did not show any remarkable change on the postoperative IVP, except for 1 who had a slight delay in excretion of radiopaque dye. Of the 21 patients who had a slight degree of hydronephrosis on the preoperative IVP 5 had close to normal IVPs, 10 showed some improvement, 3 had no change and another 3 showed deterioration postoperatively. Deterioration in the last 3 cases was caused by stricture at the site of ureteroileo anastomosis, which was confirmed and corrected at another operation. The radioisotope renogram with 1311 hippuran was used also to estimate renal function. Patients with normal IVPs who had undergone ileocystoplasty and/or lower part ureteroplasty with ilea! segment had normal renograms. Those cases in which more than half of the ureter was replaced with an ilea] segment retained radioactive material in the pelvis for a while and then excreted abruptly with peristalsis of the ilea! segment. This phenomenon could be observed also by television cinematography.
HORIUCHI AND HOSHINO
Renoscintigraphy was done with 213Hg neohydrine. Although kidneys with strictures of the major calices showed cold areas in the obstructed portions the procedure was not an effective indicator of renal function. Serum electrolytes. Most patients with normal renal function had serum electrolytes within normal range. However, patients with poor renal function showed a tendency for hyperchloremic acidosis and 5 patients required medication such as sodium bicarbonate to correct postoperative acidosis. No case of hypokalemia was seen. Electrolytes in urine. Sodium excretion was within normal range in all cases examined. However, potassium excretion of patients proved to be less than that of controls. As expected urinary electrolyte concentration of patients with poor renal function was much lower. It seems to be necessary for these patients to have a high urinary output to maintain normal electrolyte balance. Changes of urinary electrolytes in ileal segments. Urine collected from ileal bladders was compared to that from nephrostomy (fig. 2). The concentration of electrolytes such as sodium, potassium and chloride was found to be less in the ileal urine than the nephrostomy urine. The ileal urine contained urea nitrogen also in lower concentration. These disparities in the concentration between the ileal urine and the nephrostomy urine were more apparent in cases with long ileal segments. The electrolytes were excreted into the contents of the ilea! bladder until reaching the electrolyte concentrations of serum (fig. 3). Histological findings. Tissues of the isolated ilea! segments obtained after a second operation could not have shown the expected change of the ileum
substituted for the urinary tract because of some complication which made the second operation necessary. However, they suggested certain changes of the ilea! mucosa substituted for urinary tract (fig. 4). Most glandular structures were " preserved, although partial metaplasia with marked cellular infiltration was observed in a case with stone formation and in other cases with high grade stricture at the point of anastomosis. Infections. Of 17 cases examined bacteriologically 3 were asymptomatic and had negative cultures. The remaining 14 patients suffered infection ,.,, with slight or no manifestations. Causative bacteria were Escherichia coli in 8 cases, Klebsiella in 4, Proteus vulgarus in 1 and Staphylococcus aureus in 1. The patients with only ileocystoplasty showed less positive bacteriological findings than those with ileal segments substituted for ureter. DISCUSSION
One of the main problems encountered in plastic operations with an isolated ileal segment is the absorption through the ilea! mucosa of the components of urine. There are few reports on the histological changes in the isolated ilea! segments used for the urinary tract. Experimentally, Gaza noted a change in the ileal mucosa in isolated segments from dogs,• while Sebening and Meltzer could not detect any change. 5 In patients, Goodwin and associates found no apparent change in the ileal mucosa,• while Filimon and Tarabuta did observe progressive atrophy of the ilea! mucosa without metaplasia. 7 Although we have noted partial metaplasia and cellular infiltration in some cases, these changes might be caused by the effects of obstruction, stone formation and/or infection. In
Fm. 2. Concentration of electrolytes and urea nitrogen in serum and in urine collected from ilea! bladder and from nephrostomy.
ISOLATED SEGMENT OF ILEUM IN UROLOGICAL PLASTIC OPERATION
851
FIG. 3. Changes in electrolytes and urea nitrogen concentration. Distilled water was put into ilea! bladder and changes in concentrations of electrolytes and urea nitrogen were observed.
most cases with an uneventful course the ilea! mucosa showed a slight histological change and appeared to retain its function as ileum. Many investigators have reported on the absorption of electrolytes and water by the isolated ilea! segments.•· 1 • Castro and Ram studied patients in whom isolated ilea! segments were used for urinary tract operations and observed hyperchloremic acidosis in cases of renal failure only. 1 ' We also noted ', a high value of serum chloride in our few patients with poor renal function. However, except for these few cases the serum chloride was within normal range in our series. Many investigators have found that the serum potassium concentration is affected by a urinary tract operation with intestinal segments. Pyrah reported that the serum potassium concentration rarely increased unless the patient had poor renal function. 16 In an experiment with potassium Williams and associates observed that the serum potassium values were low in many patients with ureterosigmoidostomy, while in those with ureteroileocystostomy they found rather high values. 17 In our studies serum potassium concentration remained normal except in patients with renal failure. Although potassium seems to be absorbed by the ilea! segments, patients with good renal function rarely have hyperkalemia. Our experiments revealed that electrolytes were excreted through the isolated ilea! mucosa and that their concentration in the contents of the ilea! segment approached the ratio in the serum in approximately 3 hours. This result suggests that electrolytes and other materials in the urine are absorbed or excreted by the ilea! segment and approach the density in the serum if the urine remains in the ilea! segment for a long time. Elevated BUN was observed in patients with an
isolated ilea! segment more than 40 cm. long. Takai and associates noted no such effect in patients with ilea! segments 30 cm. or less in length. 18 Castro and Ram reported that the BUN increased in cases in which long segments of ileum were used for urinary tract operations, even if the patient had normal renal function. The absorption of creatinine from the ilea! segment was not detected by Rosenberg. 1 • Castro and Ram also reported that serum creatinine values remained within normal range even if the value of BUN was elevated. Consequently, they suggested that serum creatinine would be better than BUN as an indicator of renal function. However, these values often seem to remain normal in certain cases even when renal function is considerably damaged. Conventional renal function tests, such as those for phenolsulfonphthalein excretion, concentration and clearance, are difficult to evaluate because of the absorption and excretion by the ilea! segments. However, in cases with short ilea! segments the phenolsulfonphthalein and clearance tests may be used as renal function tests under proper diuresis, as reported by Kuss and associates, 20 Because of this difficulty in applying the ordinary renal function tests to patients who undergo urinary tract operations with intestinal segments, the IVP is often used as an indicator of renal function. Some investigators believe that the radioisotope renogram is a useful test of renal function. With this test some status of renal function can be shown occasionally even when the IVP fails to offer valuable information. In our experience those patients with an apparently intact pyelogram can have a good prognosis, and even patients with a long ilea! segment and some urine stasis can have uneventful courses when the IVPs show some
852
HORIUCHI AND HOSHINO
FIG. 4. A, histological changes in isolated ileal segment used for bladder (10 years). B, histological changes in isolated ilea! segment used for ureter (9 years 10 months). Reduced from x 150. improvement. The IVP is easily performed in the clinic and it may display other changes in the urinary tract such as stricture. Therefore, the IVP seems to be one of the best routine tests for patients with plastic operations involving an ileal segment.
5.
6.
Drs. K. R. Varma and D. Lynm provided valuable advice for the preparation of this paper. REFERENCES
7.
1. Rutkowski, M.: Zur Methods der Harnblasenplastik.
Centrabl. Chir., 16: 473, 1899. 2. Mikulicz, J.: Zur Operation der angeborenen Blasenspalte. Centralb. Chir., 22: 641, 1899. 3. Schoemaker, J.: Discussie op voordracht van J. M. van Dam over intra-abdominale plastieken. Ned. T. Geneesk., p. 386, 1911. 4. Gaza, W., von: Experimentelle Untersuchungen iiber
8.
9.
Vergrosserung der Harnblase durch angeschaltete Darmabschnitte. Z. Urol. Chir., 13: 129, 1923. Sebening, W. and Meltzer, H.: Experimentelle Grundlagen fur die Verwendung von Diinndarm zur Blasenvergrosserung. Arch. Klin. Chir., 178: 591, 1934. 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. Filimon, C. and Tarabuta, G. C.: Les modification de la muqueuse intestinale dans l'enterocytoplastie. J. Urol. Nephrol., 76: 687, 1970. Code, C. F., Bass, P., McClary, G. B., Jr., Newnum, R. L. and Orvis, A. L.: Absorption of water, sodium, and potassium in small intestine of dogs. Amer. J. Physiol., 199: 281, 1960. Maged, A.: Evaluation of different techniques of ileocystoplasty: an analysis of complications in 32 cases. J. Urol., 99: 276, 1968.
ISOLATED SEGMENT OF ILEUM IN UROLOGICAL PLASTIC OPERATION
10. Tweiss, E. E. and Kolff, W. J.: Treatment of uremia by perfusion of an isolated intestinal loop. J.A.M.A., 146: 1019, 1951. 11. Pyrah, L. N., Care, A. D., Reed, G. W. and Parsons, F. M.: The migration of sodium, chloride and potassium ions across the mucous membrane of the ileum. Brit. J. Surg., 42: 357, 1955. 12. Tasker, J. H.: Ileo-cystoplasty: a new technique; an experimental study with report of a case. Brit. J. Urol., 25: 349, 1953. 13. Rangel, D. M., Yakeishi, Y., Stevens, G. H. and Fonkalsrud, E.W.: Absorption of urinary contents from isolated segments of jejunum and ileum. Surg., Gynec. & Obst., 129: 1189, 1969. 14. Madsen, P. 0.: The etiology ofhyperchloremic acidosis following urointestinal anastomosis: an experimental study. J. Urol., 92: 448, 1964. 15. Castro, J.E. and Ram, M. D.: Electrolyte imbalance following ilea! urinary diversion. Brit. J. Urol., 42:
853
29, 1970. 16. Pyrah, L. N .: The use of the ileum in urology. Brit. J. Urol., 28: 363, 1956. 17. Williams, R. E., Davenport, T. J., Burkinshaw, L. and Hughes, D.: Changes in whole body potassium associated with uretero-intestinal anastomoses. Brit. J. Urol., 39: 676, 1967. 18. Takai, S., Koyama, T., Kawahara, A. and Yamashita, S.: On pelvo-ileo-cystoplasty. Shujutsu, 13: 281, 1959. 19. Rosenberg, M. L.: The physiology of hyperchloremic acidosis following ureterosigmoidostomy: a study of urinary reabsorption with radioactive isotopes. J. Urol., 70: 569, 1953. 20. Kiiss, R., Bitker, M., Camey, M., Chatelain, C. and Lassau, J.P.: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. J. Urol., 103: 53, 1970.
J Ol'!{l'<,\L CF U ROLOC''t CopJilight © 1975 'T'he \Viliia1-1s 8,., 'i/iE:ins
Printed
U.8.A.
STUDY ON USE OF ISOLATED SEGMENT OF ILEUNl: IN UROLOGICAL PLASTIC OPERATION SEIZO HORIUCHI
AND
YOSHINOBU HOSHINO
From the Department of Urology, Tokyo Teishin Hospital and Fuchu Metropolitan Hospital, Tokyo, Japan
ABSTRACT
Studies were done on 33 cases of plastic reconstruction of the urinary tract with an isolated ilea! segment. We found that electrolytes and other components in the urine can be absorbed or excreted by the isolated ilea! mucosa. Although electrolyte balance was preserved in most cases the tendency for hyperchloremic acidosis and high blood urea nitrogen was observed in some patients with poor renal function. The degree and the incidence of these changes were influenced by the length of ileal segment used and the volume of urine excreted. These 2 factors were related to infection, which gave deleterious effects on renal function. Among the tests used for prognosis the excretory urogram was found to be the most simple and provided the best information. In 1899 Rutkowski 1 and Mikulicz 2 used the ileum to magnify the capacity of a diseased human bladder. In 1911 Schoemaker substituted an isolated ilea! segment for a ureter. 3 The use of the isolated ilea! segment for the diseased urinary tract has become popular because of the progress in and antibiotics. Our report is based on the study of 33 cases in which isolated ilea! segments were used for urological plastic operations. PATIENTS AND METHODS
Patients. The 33 patients underwent plastic reconstruction of the urinary tract with isolated ilea! segments between 1958 and 1968. In 30 cases the original disease was urinary tract tuberculosis, while l patient had a ureteral 1 had interstitial cystitis and 1 had a bladder after irradiation for cancer of the cervix. The 18 female and 15 male patients ranged in age from 12 to 62 years. Except for those in renal failure, the patients were on a normal diet without any restrictechniques have been (fig. 1). In 7 cases a tostomy was done--4 right and :3 left ureters 1 and 2), In 1 case a right and left \.,CillVUH<;V-lHOVO,LVlH This and left
roileo-ileocystostomy was done in 2 cases (fig. 1, 5 and 6), a pyeloileo-ileocystostomy in 1 case (fig. 1, 7) and a modified ileocystoplasty in 4 cases (fig. 1, 8 and 9). In 5 cases Scheele's method of the ileocystoplasty with ilea! loop was done-4 cases without ureteroneostomy and l case with ureteroneostomy (fig. 1, 10 and 11), while in 13 cases Goodwin's modified method for ileocystoplasty by cap-patch or cup-patch was done- 7 cases without ureteroneostomy and 6 cases with ureteroneostomy (fi!s5. 1, 12 to 15). Renal function. Renal function was estimated by blood urea nitrogen (BUN), serum creatinine, excretory urography (IVP), radioisotope renogram and renoscintigram. In addition tests for creatinine clearance, para-aminohippuric acid clearance, phenolsulfonphthalein excretion and concentration were also tried, although these tests were not reliable in our patients except those with an ileocystoplasty only. Peristalsis of the ilea! segment used for the ureter and the passage of dye were observed by television cine-
calcium, contents
case a modified ureteroileo-neocystostomy ,.vas done (fig. 1, 4). The upper part of the isolated ilea! segment was substituted for the ureter as a closed and the lower part of the segment was used as an open flap to increase bladder capacity. UreteAccepted for publication April 25, 1975.
848
m urine. in the urine were also studied and those in the urine obtained from other urological patients with normal renal function and also from those with nephrostomy who had normal serum electrolytes. Changes of electrolytes in urine in ileal segment. To study the absorption of electrolytes in the urine while passing through the ileal segment substituted for the ureter we examined 3 patients with ileoureteroplasty and temporary nephrostomy.
ISOLATED SEGMENT OF ILEUM IN UROLOGICAL PLASTIC OPERATION
The samples of urine collected from nephrostomy were compared to those collected from the bladder after clamping the nephrostomy tube . Besides these examinations we tried to see the excretion of electrolytes from the ilea! segment. We put distilled water into the ilea! bladder and observed the change of electrolytes before connecting the ureter to it on the second-stage operation. Histological examination. In some cases the tissues of the ilea! segments were taken at another operation several years after the initial one. Histological examination was done on these materials. Bacteriological study. Bacteriological examinations of the urine were performed in 17 cases.
849
l'. ·.-. .;
. :.q.i'.·.
.
~
-
RESULTS
Clinical findings. Scheele's and Goodwin's methods for the contracted bladder provided satisfactory results in obtaining normal bladder capacity and normal urinary frequency. However, Goodwin's method was superior to Scheele's in regard to residual urine. In cases in which the isolated ilea! segment was used for ureters, residual urine was observed more in long ileal segments. Nevertheless, renal function improved in most cases. Operative death occurred in only 1 case with a post-radiation contracted bladder. Another patient died by accident (stabbed) within 1 year after the plastic operation. Two patients died of chronic renal insufficiency 3 years and 9 years 10 months postoperatively, respectively. The main complications were the strictures at the site of anastomosis. Stricture with granulomatous change of the end of the ureter at the point of ureteroileo-neostomy was observed in 2 cases by the Kerr-Colby method of anastomosis. No stricture was seen in the cases done by Nesbit's method of anastomosis. Stricture at the site of ileocystostomy was observed in 3 cases-1 case by Scheele's method and 2 by Goodwin's method. Marked dilatation of the ileal segment was noticed in these cases. However, there were no strictures at the site of ileocystostomy after the technique of anastomosis was modified by extensively resecting the contracted bladder wall and making the part of the anastomosis as wide as possible. In cases in which bladder neck contraction was found a corrective procedure was necessary. None of our patients suffered intestinal problems postoperatively. Renal functions. BUN and serum creatinine were within normal range in approximately twothirds of the patients. Patients with poor renal function preoperatively had a tendency to have high BUN and creatinine values postoperatively. In some cases the elevated values of BUN and creatinine were transitory postoperatively. Patients who underwent pyeloileo-ileocystostomy and pyeloileo-neocystostomy and calicoileoileostomy had a BUN of 20 to about 40 mg. per dl. and these BUN values increased with the onset of urinary infection. We noticed that urinary infection occurred more commonly in patients with long
FIG. 1.
Various types of plastic operations
ilea! segments and that renal infection was inevitable in patients with the ilea! segments anastomosed to the pelvis or calices. The predisposition to infection seems to be correlated with poor renal function and the high value of BUN. Although the estimation of renal function by IVP is disputable the procedure is easily carried out clinically and can provide an outline of renal function. Five patients had normal IVPs preoperatively. These patients did not show any remarkable change on the postoperative IVP, except for 1 who had a slight delay in excretion of radiopaque dye. Of the 21 patients who had a slight degree of hydronephrosis on the preoperative IVP 5 had close to normal IVPs, 10 showed some improvement, 3 had no change and another 3 showed deterioration postoperatively. Deterioration in the last 3 cases was caused by stricture at the site of ureteroileo anastomosis, which was confirmed and corrected at another operation. The radioisotope renogram with 1311 hippuran was used also to estimate renal function. Patients with normal IVPs who had undergone ileocystoplasty and/or lower part ureteroplasty with ilea! segment had normal renograms. Those cases in which more than half of the ureter was replaced with an ilea] segment retained radioactive material in the pelvis for a while and then excreted abruptly with peristalsis of the ilea! segment. This phenomenon could be observed also by television cinematography.
HORIUCHI AND HOSHINO
Renoscintigraphy was done with 213Hg neohydrine. Although kidneys with strictures of the major calices showed cold areas in the obstructed portions the procedure was not an effective indicator of renal function. Serum electrolytes. Most patients with normal renal function had serum electrolytes within normal range. However, patients with poor renal function showed a tendency for hyperchloremic acidosis and 5 patients required medication such as sodium bicarbonate to correct postoperative acidosis. No case of hypokalemia was seen. Electrolytes in urine. Sodium excretion was within normal range in all cases examined. However, potassium excretion of patients proved to be less than that of controls. As expected urinary electrolyte concentration of patients with poor renal function was much lower. It seems to be necessary for these patients to have a high urinary output to maintain normal electrolyte balance. Changes of urinary electrolytes in ileal segments. Urine collected from ileal bladders was compared to that from nephrostomy (fig. 2). The concentration of electrolytes such as sodium, potassium and chloride was found to be less in the ileal urine than the nephrostomy urine. The ileal urine contained urea nitrogen also in lower concentration. These disparities in the concentration between the ileal urine and the nephrostomy urine were more apparent in cases with long ileal segments. The electrolytes were excreted into the contents of the ilea! bladder until reaching the electrolyte concentrations of serum (fig. 3). Histological findings. Tissues of the isolated ilea! segments obtained after a second operation could not have shown the expected change of the ileum
substituted for the urinary tract because of some complication which made the second operation necessary. However, they suggested certain changes of the ilea! mucosa substituted for urinary tract (fig. 4). Most glandular structures were " preserved, although partial metaplasia with marked cellular infiltration was observed in a case with stone formation and in other cases with high grade stricture at the point of anastomosis. Infections. Of 17 cases examined bacteriologically 3 were asymptomatic and had negative cultures. The remaining 14 patients suffered infection ,.,, with slight or no manifestations. Causative bacteria were Escherichia coli in 8 cases, Klebsiella in 4, Proteus vulgarus in 1 and Staphylococcus aureus in 1. The patients with only ileocystoplasty showed less positive bacteriological findings than those with ileal segments substituted for ureter. DISCUSSION
One of the main problems encountered in plastic operations with an isolated ileal segment is the absorption through the ilea! mucosa of the components of urine. There are few reports on the histological changes in the isolated ilea! segments used for the urinary tract. Experimentally, Gaza noted a change in the ileal mucosa in isolated segments from dogs,• while Sebening and Meltzer could not detect any change. 5 In patients, Goodwin and associates found no apparent change in the ileal mucosa,• while Filimon and Tarabuta did observe progressive atrophy of the ilea! mucosa without metaplasia. 7 Although we have noted partial metaplasia and cellular infiltration in some cases, these changes might be caused by the effects of obstruction, stone formation and/or infection. In
Fm. 2. Concentration of electrolytes and urea nitrogen in serum and in urine collected from ilea! bladder and from nephrostomy.
ISOLATED SEGMENT OF ILEUM IN UROLOGICAL PLASTIC OPERATION
851
FIG. 3. Changes in electrolytes and urea nitrogen concentration. Distilled water was put into ilea! bladder and changes in concentrations of electrolytes and urea nitrogen were observed.
most cases with an uneventful course the ilea! mucosa showed a slight histological change and appeared to retain its function as ileum. Many investigators have reported on the absorption of electrolytes and water by the isolated ilea! segments.•· 1 • Castro and Ram studied patients in whom isolated ilea! segments were used for urinary tract operations and observed hyperchloremic acidosis in cases of renal failure only. 1 ' We also noted ', a high value of serum chloride in our few patients with poor renal function. However, except for these few cases the serum chloride was within normal range in our series. Many investigators have found that the serum potassium concentration is affected by a urinary tract operation with intestinal segments. Pyrah reported that the serum potassium concentration rarely increased unless the patient had poor renal function. 16 In an experiment with potassium Williams and associates observed that the serum potassium values were low in many patients with ureterosigmoidostomy, while in those with ureteroileocystostomy they found rather high values. 17 In our studies serum potassium concentration remained normal except in patients with renal failure. Although potassium seems to be absorbed by the ilea! segments, patients with good renal function rarely have hyperkalemia. Our experiments revealed that electrolytes were excreted through the isolated ilea! mucosa and that their concentration in the contents of the ilea! segment approached the ratio in the serum in approximately 3 hours. This result suggests that electrolytes and other materials in the urine are absorbed or excreted by the ilea! segment and approach the density in the serum if the urine remains in the ilea! segment for a long time. Elevated BUN was observed in patients with an
isolated ilea! segment more than 40 cm. long. Takai and associates noted no such effect in patients with ilea! segments 30 cm. or less in length. 18 Castro and Ram reported that the BUN increased in cases in which long segments of ileum were used for urinary tract operations, even if the patient had normal renal function. The absorption of creatinine from the ilea! segment was not detected by Rosenberg. 1 • Castro and Ram also reported that serum creatinine values remained within normal range even if the value of BUN was elevated. Consequently, they suggested that serum creatinine would be better than BUN as an indicator of renal function. However, these values often seem to remain normal in certain cases even when renal function is considerably damaged. Conventional renal function tests, such as those for phenolsulfonphthalein excretion, concentration and clearance, are difficult to evaluate because of the absorption and excretion by the ilea! segments. However, in cases with short ilea! segments the phenolsulfonphthalein and clearance tests may be used as renal function tests under proper diuresis, as reported by Kuss and associates, 20 Because of this difficulty in applying the ordinary renal function tests to patients who undergo urinary tract operations with intestinal segments, the IVP is often used as an indicator of renal function. Some investigators believe that the radioisotope renogram is a useful test of renal function. With this test some status of renal function can be shown occasionally even when the IVP fails to offer valuable information. In our experience those patients with an apparently intact pyelogram can have a good prognosis, and even patients with a long ilea! segment and some urine stasis can have uneventful courses when the IVPs show some
852
HORIUCHI AND HOSHINO
FIG. 4. A, histological changes in isolated ileal segment used for bladder (10 years). B, histological changes in isolated ilea! segment used for ureter (9 years 10 months). Reduced from x 150. improvement. The IVP is easily performed in the clinic and it may display other changes in the urinary tract such as stricture. Therefore, the IVP seems to be one of the best routine tests for patients with plastic operations involving an ileal segment.
5.
6.
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