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The Nature of Peristalsis in Ureters Anastomosed to the Skin
Vol. 94, Nov. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
THE NATURE OF PERISTALSIS IN URETERS ANASTOMOSED TO THE SKIN PAUL K. MALONEY, JR. From the Squier Urological Clinic, Columbia-Presbyterian Medical Center, New York, New York
The success of urinary diversion operations depends upon many variables. Since the advent of cineradiographic studies, it has become apparent that one of the most important of these factors is ureteral peristalsis. These studies have suggested that urinary transport is dependent upon adequate peristalsis and that the degree to which peristalsis is maintained, with all other
study of peristalsis was undertaken in patients with cutaneous ureterostomies. These patients are particularly adaptable for study because of the ease of ureteral catheterization and the variety of clinical states they present. It is a common urologic experience that some of these patients manage very well without intubation and that in some, strictures develop and continu-
Fm. 1. Pressure tracing of 4-year-old boy demonstrates effect of urine flow on peristalsis. With adequate hydration, relatively normal tracing is produced corresponding with satisfactory clinical course of patient. Saw-tooth waves are respiratory waves and 2 spikes on upper tracing (A) are artifacts produced by abdominal straining by patient. things being equal, would appear to determine the future course of renal function. In order to further evaluate this concept, a Accepted for publication January 6, 1965. This work was supported in part by a grant from the United States Public Health Service (AM 05225). Read at prize essay contest, New York Section, American Urological Association, Inc., New York, New York, April 17-18, 1964.
ous intubation or reoperation is necessary. However, there are some patients with no apparent obstruction in whom significant residual urine accumulates and necessitates intubation for preservation of renal function. Comparisons of peristaltic patterns in these 3 groups might aid in understanding this variable clinical response. Since strain gauge measurement of ureteral peristalsis is a relatively new method for urolog-
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PERISTALSIS IN URETERS ANASTOMOSED TO SKIN
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B
FIG. 2. A, bilateral cutaneous ureterostomies in patient who requires intubation on right for adequate function. Rise in resting pressure and low systolic peaks in fibrotic segment can be clearly seen. Peristalsis on left is normal. B, reappearance of peristalsis is seen distal to stricture on right. Impressive peristalsis on left to 60 mm. Hg. with normal resting pressure correlates with normal left collecting system on excretory urogram.
ical investigation, normal values are still being established. We were anxious to learn the usual pattern of peristalsis in cutaneous ureterostomies, and in what way, if any, did it differ from that of the intact ureter. MATERIALS AND METHODS
The patients examined were from the urological services of the Babies Hospital, the Presbyterian
Hospital and the Francis Delafield Hospital. Five patients had unilateral cutaneous ureterostomy, and 2 patients had bilateral cutaneous ureterostomy. No. 5F ureteral or No 5 polyvinyl catheters were used to record pressures. After a catheter was passed to the renal pelvis and an adequate urine drip was obtained, it was connected to a No. 267-B Sanborn transducer by means of a saline-
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FIG. 3. Pressure tracings in 55-year-old patient with bilateral cutaneous ureterostomies and minimally dilated ureters on excretory urogram.
FrG. 4. Normal peristalsis in well-functioning cutaneous ureterostomy
filled adapter tube and the transducer was connected to a multichannel direct writing carrier amplifier. Measurements were recorded from the renal pelvis and at multiple points along the length of the ureteral segment. Values were recorded in millimeters of mercury. Hydration of all patients was maintained by liberal intake of water during the morning preceding the test. RESULTS
Four of the 7 patients (5 ureters) had smoothly functioning cutaneous ureterostomies and a stable clinical course. Their excretory urograms showed minimal to moderate dilation and did not change on followup examinations. These patients had a ureteral resting pressure of less than 10 mm. mercury and contraction waves varying from 10 to 60 mm. mercury (figs. 1-4). Peristalsis was regular and forceful.
Three patients (3 ureters) experienced varying degrees of failure with cutaneous ureterostomy, but cicatricial obstruction could not be demonstrated. Case 2 (N. N.) while clinically stable, maintained a moderately severe dilation of the collecting system. Peristalsis was poor and ineffectual, rising only 2 mm. mercury above the base line, with a resting pressure continuously above 10 mm. mercury (fig. 5). Cases 3 and 7 (N. F. and H. A.) required continuous intubation for maintenance of renal function. Their strain gauge measurements showed complete absence of peristalsis (fig. 6). Case 4 (J. J) has a satisfactory left cutaneous ureterostomy, but requires constant intubation of the right side. A retrograde ureteral pyelogram demonstrated a strictured segment 3 inches above the stoma on the right. Peristalsis was forceful above and below the stricture, but was absent in
PFRISTALSIS IN URETERS ANASTOMOSED TO SKIN
.539
Fm. 5. Poor peristaltic waves, 2 mm. Hg. greater than resting pressure in dilated ureter. Little improvement has been noted in state of upper tracts since surgery 6 years previously.
Fm. 6. A, lack of peristalsis is seen in tracing of 9-year-old girl with cutaneous ureterostomy and failing renal function on excretory urogram. Saw-toothed waves are respiratory waves. B, complete lack of peristalsis in moderately dilated ureter, with decreasing renal function on excretory urogram. the strictured segment (fig. 2). This is the only patient with definite ureteral obstruction. Peristalsis would not pass through thefibrotic segment, although the lumen of this area would accept a No. SF red rubber catheter. DISCUSSION
In clinically asymptomatic patients with normal urograms, studies have shown ureteral resting pressures of generally less than 10 mm. mercury and ureteral contraction pressures varying
from 10 to 50 mm. mercury. 1 - 4 Our 4 patients with good surgical results and stable upper tracts 1 Kiil, F.: The Function of the Ureter and Renal Pelvis. Philadelphia: W. B. Saunders Co., 1957. 2 Weinberg, S. R. and Maletta, T. J.: Measurement of peristalsis of the ureter and its relation to drugs. J.A.M.A., 175: 15, 1961. 3 Lenaghan, D.: Bifid ureters in children; an anatomical, physiological and clinical study. J. Urol., 87: 808, 1962. 4 Davis, D. M., Zimskind, P. D. and Paquet, J. P.: Studies on urodynamics; a new light on ureteral function. J. Urol., 90: 150, 1963.
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had values within these ranges. In these patients, peristaltic pressure tracings did not seem to differ at all from those of normal subjects with an unoperated ureter and their patterns would appear to be a satisfactory norm against which the following cases can be compared. Patients with normal ureteral peristalsis are suitable candidates for preservation of the ureter where urinary diversion is required. However, with no obstruction patients who required continuous intubation consistently had an atonic ureter. Regardless of their atonicity, the ureters were only moderately dilated and x-rays showed an open tract from pelvis to orifice. Therefore, peristalsis is a sine qua non for satisfactory ureteral drainage. Perhaps atonic ureter may be better treated by providing an ileal ureter which has been performed m 1 patient with a good result. There appears to be an intermediary state between these 2 extremes as demonstrated by patient 2 (N. N.). Peristalsis is poor, but is just sufficient to maintain a stable clinical course and the result is not as good as had been hoped. Patient 4 (J. J.) demonstrated that an indwelling catheter could preserve peristalsis when ureteral obstruction is present and that the obstruction is not necessarily at the stoma but may be a fibrotic segment proximal to it. Although this
ureter was dilated to No. 12F with comparative ease, an indwelling catheter was always required for adequate function of the respective kidney. High cutaneous ureterostomy probably would have been better. 5 This simple test of ureteral function by strain gauges is an additional means of determining whether a ureter can be salvaged when diversion must be performed. It also enables the surgeon to determine just how long a segment has maintained function and is suitable for use. SUMMARY
Measurements of ureteral peristalsis were taken by means of strain gauge techniques in patients with cutaneous ureterostomies. Those with smoothly functioning cutaneous ureterostomies were found to have normal ureteral systolic and diastolic peristaltic pressures. Patients who required intubation of a cutaneous ureterostomy for satisfactory function and in whom cicatrization had not been demonstrated had either absent or ineffectual peristalsis. It is suggested that high cutaneous ureterostomy or an ileal ureter might be better in such cases. 5 Lloyd, F. A., Cottrell, T. L. 0., Simpson, K., Cross, R.R. and Calams, J.: High ureterocutaneous anastomosis. J. Urol., 88: 33, 1962.
THE JOURNAL OF UROLOGY
Copyright © 1965 by The Williams & Wilkins Co.
THE NATURE OF PERISTALSIS IN URETERS ANASTOMOSED TO THE SKIN PAUL K. MALONEY, JR. From the Squier Urological Clinic, Columbia-Presbyterian Medical Center, New York, New York
The success of urinary diversion operations depends upon many variables. Since the advent of cineradiographic studies, it has become apparent that one of the most important of these factors is ureteral peristalsis. These studies have suggested that urinary transport is dependent upon adequate peristalsis and that the degree to which peristalsis is maintained, with all other
study of peristalsis was undertaken in patients with cutaneous ureterostomies. These patients are particularly adaptable for study because of the ease of ureteral catheterization and the variety of clinical states they present. It is a common urologic experience that some of these patients manage very well without intubation and that in some, strictures develop and continu-
Fm. 1. Pressure tracing of 4-year-old boy demonstrates effect of urine flow on peristalsis. With adequate hydration, relatively normal tracing is produced corresponding with satisfactory clinical course of patient. Saw-tooth waves are respiratory waves and 2 spikes on upper tracing (A) are artifacts produced by abdominal straining by patient. things being equal, would appear to determine the future course of renal function. In order to further evaluate this concept, a Accepted for publication January 6, 1965. This work was supported in part by a grant from the United States Public Health Service (AM 05225). Read at prize essay contest, New York Section, American Urological Association, Inc., New York, New York, April 17-18, 1964.
ous intubation or reoperation is necessary. However, there are some patients with no apparent obstruction in whom significant residual urine accumulates and necessitates intubation for preservation of renal function. Comparisons of peristaltic patterns in these 3 groups might aid in understanding this variable clinical response. Since strain gauge measurement of ureteral peristalsis is a relatively new method for urolog-
536
PERISTALSIS IN URETERS ANASTOMOSED TO SKIN
537
B
FIG. 2. A, bilateral cutaneous ureterostomies in patient who requires intubation on right for adequate function. Rise in resting pressure and low systolic peaks in fibrotic segment can be clearly seen. Peristalsis on left is normal. B, reappearance of peristalsis is seen distal to stricture on right. Impressive peristalsis on left to 60 mm. Hg. with normal resting pressure correlates with normal left collecting system on excretory urogram.
ical investigation, normal values are still being established. We were anxious to learn the usual pattern of peristalsis in cutaneous ureterostomies, and in what way, if any, did it differ from that of the intact ureter. MATERIALS AND METHODS
The patients examined were from the urological services of the Babies Hospital, the Presbyterian
Hospital and the Francis Delafield Hospital. Five patients had unilateral cutaneous ureterostomy, and 2 patients had bilateral cutaneous ureterostomy. No. 5F ureteral or No 5 polyvinyl catheters were used to record pressures. After a catheter was passed to the renal pelvis and an adequate urine drip was obtained, it was connected to a No. 267-B Sanborn transducer by means of a saline-
538
MALONEY
FIG. 3. Pressure tracings in 55-year-old patient with bilateral cutaneous ureterostomies and minimally dilated ureters on excretory urogram.
FrG. 4. Normal peristalsis in well-functioning cutaneous ureterostomy
filled adapter tube and the transducer was connected to a multichannel direct writing carrier amplifier. Measurements were recorded from the renal pelvis and at multiple points along the length of the ureteral segment. Values were recorded in millimeters of mercury. Hydration of all patients was maintained by liberal intake of water during the morning preceding the test. RESULTS
Four of the 7 patients (5 ureters) had smoothly functioning cutaneous ureterostomies and a stable clinical course. Their excretory urograms showed minimal to moderate dilation and did not change on followup examinations. These patients had a ureteral resting pressure of less than 10 mm. mercury and contraction waves varying from 10 to 60 mm. mercury (figs. 1-4). Peristalsis was regular and forceful.
Three patients (3 ureters) experienced varying degrees of failure with cutaneous ureterostomy, but cicatricial obstruction could not be demonstrated. Case 2 (N. N.) while clinically stable, maintained a moderately severe dilation of the collecting system. Peristalsis was poor and ineffectual, rising only 2 mm. mercury above the base line, with a resting pressure continuously above 10 mm. mercury (fig. 5). Cases 3 and 7 (N. F. and H. A.) required continuous intubation for maintenance of renal function. Their strain gauge measurements showed complete absence of peristalsis (fig. 6). Case 4 (J. J) has a satisfactory left cutaneous ureterostomy, but requires constant intubation of the right side. A retrograde ureteral pyelogram demonstrated a strictured segment 3 inches above the stoma on the right. Peristalsis was forceful above and below the stricture, but was absent in
PFRISTALSIS IN URETERS ANASTOMOSED TO SKIN
.539
Fm. 5. Poor peristaltic waves, 2 mm. Hg. greater than resting pressure in dilated ureter. Little improvement has been noted in state of upper tracts since surgery 6 years previously.
Fm. 6. A, lack of peristalsis is seen in tracing of 9-year-old girl with cutaneous ureterostomy and failing renal function on excretory urogram. Saw-toothed waves are respiratory waves. B, complete lack of peristalsis in moderately dilated ureter, with decreasing renal function on excretory urogram. the strictured segment (fig. 2). This is the only patient with definite ureteral obstruction. Peristalsis would not pass through thefibrotic segment, although the lumen of this area would accept a No. SF red rubber catheter. DISCUSSION
In clinically asymptomatic patients with normal urograms, studies have shown ureteral resting pressures of generally less than 10 mm. mercury and ureteral contraction pressures varying
from 10 to 50 mm. mercury. 1 - 4 Our 4 patients with good surgical results and stable upper tracts 1 Kiil, F.: The Function of the Ureter and Renal Pelvis. Philadelphia: W. B. Saunders Co., 1957. 2 Weinberg, S. R. and Maletta, T. J.: Measurement of peristalsis of the ureter and its relation to drugs. J.A.M.A., 175: 15, 1961. 3 Lenaghan, D.: Bifid ureters in children; an anatomical, physiological and clinical study. J. Urol., 87: 808, 1962. 4 Davis, D. M., Zimskind, P. D. and Paquet, J. P.: Studies on urodynamics; a new light on ureteral function. J. Urol., 90: 150, 1963.
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had values within these ranges. In these patients, peristaltic pressure tracings did not seem to differ at all from those of normal subjects with an unoperated ureter and their patterns would appear to be a satisfactory norm against which the following cases can be compared. Patients with normal ureteral peristalsis are suitable candidates for preservation of the ureter where urinary diversion is required. However, with no obstruction patients who required continuous intubation consistently had an atonic ureter. Regardless of their atonicity, the ureters were only moderately dilated and x-rays showed an open tract from pelvis to orifice. Therefore, peristalsis is a sine qua non for satisfactory ureteral drainage. Perhaps atonic ureter may be better treated by providing an ileal ureter which has been performed m 1 patient with a good result. There appears to be an intermediary state between these 2 extremes as demonstrated by patient 2 (N. N.). Peristalsis is poor, but is just sufficient to maintain a stable clinical course and the result is not as good as had been hoped. Patient 4 (J. J.) demonstrated that an indwelling catheter could preserve peristalsis when ureteral obstruction is present and that the obstruction is not necessarily at the stoma but may be a fibrotic segment proximal to it. Although this
ureter was dilated to No. 12F with comparative ease, an indwelling catheter was always required for adequate function of the respective kidney. High cutaneous ureterostomy probably would have been better. 5 This simple test of ureteral function by strain gauges is an additional means of determining whether a ureter can be salvaged when diversion must be performed. It also enables the surgeon to determine just how long a segment has maintained function and is suitable for use. SUMMARY
Measurements of ureteral peristalsis were taken by means of strain gauge techniques in patients with cutaneous ureterostomies. Those with smoothly functioning cutaneous ureterostomies were found to have normal ureteral systolic and diastolic peristaltic pressures. Patients who required intubation of a cutaneous ureterostomy for satisfactory function and in whom cicatrization had not been demonstrated had either absent or ineffectual peristalsis. It is suggested that high cutaneous ureterostomy or an ileal ureter might be better in such cases. 5 Lloyd, F. A., Cottrell, T. L. 0., Simpson, K., Cross, R.R. and Calams, J.: High ureterocutaneous anastomosis. J. Urol., 88: 33, 1962.