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Technique for Preventing Urinary Fistulas Following Pelvic exenteration and Ureteroileostomy
Vol. llO, September Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
TECHNIQUE FOR PREVENTING URINARY FISTULAS FOLLOWING PELVIC EXENTERATION AND URETEROILEOSTOMY HARRY W. SCHOENBERG
AND
JOHN J. MIKUTA
From the Department of Surgery, Division of Urology and the Department of Obstetrics and Gynecology, School of Medicine and the Hospital, University of Pennsylvania and the Harrison Department of Surgical Research, Philadelphia, Pennsylvania
A major postoperative complication of pelvic are involved in this adherence. The fistulas usually exenteration for pelvic cancer is the development occur at the site of one of the anastomoses. Of 32 patients who had either anterior or total of urinary fistulas. Ureteral anastomosis to an isolated bowel segment of either ileum or sigmoid pelvic exenteration in 1966, 7 had urinary pelvic colon is the usual way in which the urinary tract is fistulas. 2 One of these patients had had an anterior reconstructed after this operation.' A number of exenteration and 6 had had total pelvic exenterafactors make the development of urinary fistula a tions. This high incidence of urinary fistulas common problem in these patients. Ordinarily the caused us to modify the technique of ureteroileosbowel segment and ureters have been extensively tomy. Ordinarily in the performance of ureteroileosradiated, resulting in poor vascular supply and
poor healing. The lack of available pelvic peritoneum for covering the pelvic floor allows the abdominal contents, particularly the bowel segment into which the ureters have been implanted, to fall into the pelvis. Here the bowel segment is against bone, fascia, muscle or a gauze pack which may or may not have been covered with cellophane. Re-operation upon patients in whom urinary fistulas have developed reveals that the bowel segment is densely adherent to the raw pelvic surface and that the ureterointestinal anastomoses Accepted for publication February 16, 1973. Read at annual meeting of South Central Section, American Urological Association, Guadalajara, Puerto Vallarta, Mexico, October 7-13, 1972. 1 Murphy, J. J. and Schoenberg, S.: The technique of ureteroileostomy. Surgery, 59: 903, 1966.
tomy or ureterosigmoidostomy the bowel segment is placed posterior to the small bowel to facilitate bringing the ureters to it without tension. As a result, when the abdominal contents are allowed to fall into the pelvis after exenteration, the most posterior segment will be the newly formed urinary conduit. Therefore, it will be the organ most likely to become adherent to the raw pelvic surface. In a patient who has had extensive radiation therapy, a segment of bowel is chosen which appears reasonably normal. One must be careful not to strip the adventitia from the ureters or these structures will be devascularized. 2 Mikuta, J. J., Murphy, J. J. and Schoenberg, H. W.: Pelvic exenteration for cervical cancer. Obst. Gynec., 29: 858, 1967.
294
URINAR'f FISTULi-.. S AFTER PELVIC
The of diversion is altered as follows. Instead of allowing the urinary conduit to lie posteriorly, it is placed anterior to the small bowel. This variation requires that the ureters be passed through openings in the mesentery of the small bowel to bring them into apposition with the isolated bowel segment (see figure). After completion of anastomoses the bowel segment is fixed by several tacking sutures of fine chromic catgut to the anterior surface of the mesentery of the small bowel or to available adjacent loops of small bowel. This procedure prevents descent of the conduit
~JRETEROILEOSTOrvJ.Y
into the pelvis and the ureterointestinal anastomoses in contact with smooth serosal surfaces. This procedure has been carried out in 11 patients and in no instance has the ureterointestinal anastomosis broken down. Postoperative excretory urograms have demonstrated no evidence of ureteral obstruction and there have been no bowel complications. The use of this modification should decrease the incidence of urinary-pelvic fistulas when urinary diversion is done in patients in whom reperitonealization of the pelvis is impossible.
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
TECHNIQUE FOR PREVENTING URINARY FISTULAS FOLLOWING PELVIC EXENTERATION AND URETEROILEOSTOMY HARRY W. SCHOENBERG
AND
JOHN J. MIKUTA
From the Department of Surgery, Division of Urology and the Department of Obstetrics and Gynecology, School of Medicine and the Hospital, University of Pennsylvania and the Harrison Department of Surgical Research, Philadelphia, Pennsylvania
A major postoperative complication of pelvic are involved in this adherence. The fistulas usually exenteration for pelvic cancer is the development occur at the site of one of the anastomoses. Of 32 patients who had either anterior or total of urinary fistulas. Ureteral anastomosis to an isolated bowel segment of either ileum or sigmoid pelvic exenteration in 1966, 7 had urinary pelvic colon is the usual way in which the urinary tract is fistulas. 2 One of these patients had had an anterior reconstructed after this operation.' A number of exenteration and 6 had had total pelvic exenterafactors make the development of urinary fistula a tions. This high incidence of urinary fistulas common problem in these patients. Ordinarily the caused us to modify the technique of ureteroileosbowel segment and ureters have been extensively tomy. Ordinarily in the performance of ureteroileosradiated, resulting in poor vascular supply and
poor healing. The lack of available pelvic peritoneum for covering the pelvic floor allows the abdominal contents, particularly the bowel segment into which the ureters have been implanted, to fall into the pelvis. Here the bowel segment is against bone, fascia, muscle or a gauze pack which may or may not have been covered with cellophane. Re-operation upon patients in whom urinary fistulas have developed reveals that the bowel segment is densely adherent to the raw pelvic surface and that the ureterointestinal anastomoses Accepted for publication February 16, 1973. Read at annual meeting of South Central Section, American Urological Association, Guadalajara, Puerto Vallarta, Mexico, October 7-13, 1972. 1 Murphy, J. J. and Schoenberg, S.: The technique of ureteroileostomy. Surgery, 59: 903, 1966.
tomy or ureterosigmoidostomy the bowel segment is placed posterior to the small bowel to facilitate bringing the ureters to it without tension. As a result, when the abdominal contents are allowed to fall into the pelvis after exenteration, the most posterior segment will be the newly formed urinary conduit. Therefore, it will be the organ most likely to become adherent to the raw pelvic surface. In a patient who has had extensive radiation therapy, a segment of bowel is chosen which appears reasonably normal. One must be careful not to strip the adventitia from the ureters or these structures will be devascularized. 2 Mikuta, J. J., Murphy, J. J. and Schoenberg, H. W.: Pelvic exenteration for cervical cancer. Obst. Gynec., 29: 858, 1967.
294
URINAR'f FISTULi-.. S AFTER PELVIC
The of diversion is altered as follows. Instead of allowing the urinary conduit to lie posteriorly, it is placed anterior to the small bowel. This variation requires that the ureters be passed through openings in the mesentery of the small bowel to bring them into apposition with the isolated bowel segment (see figure). After completion of anastomoses the bowel segment is fixed by several tacking sutures of fine chromic catgut to the anterior surface of the mesentery of the small bowel or to available adjacent loops of small bowel. This procedure prevents descent of the conduit
~JRETEROILEOSTOrvJ.Y
into the pelvis and the ureterointestinal anastomoses in contact with smooth serosal surfaces. This procedure has been carried out in 11 patients and in no instance has the ureterointestinal anastomosis broken down. Postoperative excretory urograms have demonstrated no evidence of ureteral obstruction and there have been no bowel complications. The use of this modification should decrease the incidence of urinary-pelvic fistulas when urinary diversion is done in patients in whom reperitonealization of the pelvis is impossible.