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Ureterocolic Diversion of Urine: Management of Some Difficult Problems
co:22 .. 5347 ;83/1294-07::_9$02.oo/o rf'RE Jm:JR!'JA:S 0:;' TJEOLOG':!
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URETEROCOLIC DIVERSIOJ\T OF URINE: DIFFICULT PROBLE1vIS W. HARDY HENDREN* From the Division of Pediatric Surgery, Massachusetts General Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT
During the last 11 years 37 patients were treated with meterocolic diversion of the urine means other than classic ureterosigmoidostomy. By altering the technique of joining the meters to the colon this method of internal urinary diversion is possible even in cases when it would not be feasible by more traditional methods. Ureterosigmoidostomy has been performed for many years and continues to be a useful part of the urological armamentarium. Various methods have been used to join the ureters to the colon, usually by a tunneling technique to provide a valve mechanism that will prevent reflux. Leadbetter and Clarke demonstrated the superiority of not only creating a tunnel but also anatomically anastomosing the ureter to the colon mucosa. 1 Previously, operations had been done using the technique of tunneling the ureter but dunking its end into the colon. 2 Primary healing often failed and in some patients a chronic inflammatory polyp developed subsequently at the site of the dunked ureter. Goodwin and associates described creation of submucosal tunnels for the ureter by opening the colon wall and creating a tunnel on its opposite side, similar to reimplanting a ureter in the bladder. 3 Mathisen described a nipple technique for ureterocolic anastomosis.' The most commonly used technique of ureterosigmoidostomy is implantation of the ureters into the rectosigrn.oid, generally at slightly different levels in the colon (fig. 1). Experience has shown that the success of ureterosigrn.oidostomy depends on several factors. The ureters must be of normal or near normal size. A tunnel must be made long enough to create an effective nomefluxing valve, a principle similar to creating a nonrefluxing ureterovesical reimplantation. If the ureters are dilated it is difficult to achieve a satisfactory tunnel length to prevent coloureteral reflux. If a ureter is scarred and inflamed from infection and/or obstruction its walls will lack and coloureteral reflux can result, which leads to pyelonephritis, stones ultimately, severe renal damage. Ureterosigmoidostomy leads to hho-,,,·,wu "'~'"''"'"" of some solute. Therefore, patients with reduced n:mal func-tion cannot tol.:;rate the added renal work load ,~,,,-v,.,v.,cu Furthermore, pa_tIEm1;s with a uret,en}s1gn101.o.c,st,orr1y sufficient water to be abl.e to re-excrete the resorbed solute load. Even ·Nith normal upper tracts a with a uret,ercis1,!;"n101ctc,stom can become azotemic if of adequate fluid intake, for example patients with gastroenteritis, which causes ~ .... v,...,., and/or diarrhea. When ureterosigmoidostomy is performed successfully, that is the ureters are of good quality, the tunnels are of ample length and there is no reflux and obstruction, the long-term result can be excellent. However, when these anatomic criteria are not present results can be disastrous. Experience with ureterocolic procedures in 82 patients during the last 11 years is described with emphasis on those 37 in Accepted for publication July 23, 1982. Read at annual meeting of American Urological Association, Kansas City, Missouri, May 16-20, 1982. * Requests for reprints: Department of Surgery, The Children's Hospital Medical Center, 300 Longwood Ave., Boston, Massachusetts 02115. 719
Cul de sac peritoneum
FIG. 1. Classic technique of ureterosigmoidostomy
PRIMARY COLON LOOP JOINED LATER TO COLON
diversion v1as ~--,·+~-in 12 patients using a non.refluxing colon conduit -,,, .. ~~-- described previously. Of these 11 had exstrophy believed unsuited for primary reconstruction or in whom primary reconstruction had been attempted elsewhere with failure (3 patients). One patient had sarcoma of the prostate treated by anterior pelvic exenteration (fig. 2). These 12 patients had normal ureters, which posed no problem in obtaining good ureterocolic tunnels. Radiographic examination after temporary colon conduit diversion showed normal drainage of the upper tracts in all patients and absence of low pressure reflux on a loopogram. As might be predicted followup for as long as 10 years after the colon conduit was joined to the rectosigmoid at a second stage has shown continuing normal upper tracts in all of these patients. None has had a clinical episode of pyelo-
720
HENDREN
nephritis or deterioration of the upper tracts. One of these patients has had significant rectal incontinence from lack of neurological control of the perineum secondary to an intraspinal lipoma discovered recently and removed. The following case illustrates the use of a temporary colon conduit later joined to the rectosigmoid. Case 1. A 20-month-old boy was referred with a large pelvic mass that proved to be sarcoma of the prostate. Anterior pelvic exenteration was performed in August 1971. A temporary nonrefluxing colon conduit was used to drain the urinary tract. Lymph nodes were negative despite the large size of the tumor. Postoperative treatment with chemotherapy was used for 2 years but no radiation therapy was given. When the patient was 4 years old and had good rectal control with no evidence of recurrent disease in the pelvis, the colon conduit was joined to the rectosigmoid. The patient presently is 13 years old and well. He has normal daytime rectal continence and has been free of urinary infection. Comment: Primary classic ureterosigmoidostomy was deemed unwise in this child because 1) he was too young to expect reasonably rectal continence of urine and 2) possible recurrence of and treatment for tumor in the pelvis could be complicated by the presence of a ureterosigmoidostomy. The temporary colon conduit allowed continence to be anticipated when the patient was older. Also, one could then be relatively
certain that recurrent tumor would not be a problem and that the ureterocolic anastomosis was satisfactory before the colon conduit was joined to the fecal stream. ILEAL LOOP
CONVERTED TO COLON CONDUIT JOINED TO COLON
AND
LATER
A total of 16 patients had had previous ileal loop urinary diversions that were converted first to nonrefluxing colon conduit diversions, which then were joined to the colon (fig. 3). Of these patients 6 had been treated some years previously by me for bladder exstrophy using an ileal conduit diversion technique (which was abandoned in 1971). The remaining 10 patients with previous ileal conduits were referred for increasing upper tract deterioration. All but 1 patient originally had exstrophy of the bladder. A 55-year-old woman had undergone ileal loop diversion for severe interstitial cystitis. Ultimately this patient requested repeat diversion of the colon conduit to the skin because of rectal urinary frequency after the colon conduit was joined to the colon. Case 2. A 20-month-old girl underwent ileal loop urinary diversion for a rudimentary exstrophic bladder believed unsuited for primary reconstruction in October 1964 (fig. 4). Periodic radiographic control showed dilatation of the right ureter despite 2 operations to correct recurrent stenosis of the stoma.
FrG. 2. Case l. A, IVP 1 year after anterior pelvic exenteration for large sarcoma of prostate shows normal upper tract and colon conduit. B, IVP 5 years after anastomosis of colon conduit to rectosigmoid reveals upper tracts and contrast medium in left colon. COLON LOOP ( No Reflux)
ILEAL LOOP
LOOP LATER JOINED TO COLON
(Reflux)
OR
-
If ureters short, can implant better ureter, and do TUP of other ureter
FIG. 3. Scheme of conversion from ileal loop to nonrefluxing colon loop and later anastomosis to rectosigmoid
721
URETEROCOLIC DIVERSION OF URINE
In June 1971 the ileal loop was resected and a nonrefluxing colon conduit was done. The right ureter was short and the proximal end of the colon conduit was placed in the right gutter to facilitate right ureterosigmoid anastomosis. The left ureter had ample length to bring it across the midline and construct a good tunnel. A loopogram 6 months later showed no reflux. Excretory urography (IVP) revealed improved upper tracts. In August 1972 the conduit was anastomosed to the colon. In the subsequent decade the patient has been well with delicate upper tracts, representing an improvement over their appearance when ileal loop urinary diversion was present. The patient presently is 19 years old and has had no clinical evidence of urinary infection. Comment: There are many young patients who have been treated by ileal loop urinary diversion for exstrophy and are candidates for staged diversion of the urine into the colon. It is not possible to anastomose safely an ileal loop to the colon, since that will allow ascending pyelonephritis. Conversion to an immediate ureterosigmoidostomy in this patient was not believed feasible because the right ureter was dilated and could well have resulted in reflux of colon contents up the ureter. To
wait until the radiographic control showed improved upper tracts and no coloureteral reflux seemed to be the safest course before proceeding with ultimate anastomosis of the conduit to the colon. Case 3. A 14-year-old girl with an ileal loop was referred for increasing hydronephrosis and recurrent urinary infection (figs. 5 and 6). Anterior exenteration had been performed when she was 7 years old for rhabdomyosarcoma of the bladder, followed by chemotherapy and radiation therapy. Treatment had been complicated by spontaneous perforation of the colon. In June 1979 the ileal loop was resected and a colon conduit was created from the splenic flexure to use nonradiated bowel. The better left ureter was used to drain the urinary tract into the isolated colon conduit with a long tunnel. The opposite kidney was drained by transureteropyelostomy. Subsequently, radiographic control showed improvement in the upper tracts and no reflux on a loopogram. In June 1980 the colon conduit was joined to the left colon. The patient continues to do well clinically and the upper tracts remain stable on an IVP. Comment: There doubtless are many patients with urinary diversions following surgery for cancer who could be considered
FIG. 4. Case 2. A, IVP when child was 8 years old with ileal loop shows dilated right ureter. B, loopogram 1 year after conversion to nonrefluxing colon conduit reveals reflux. C, IVP after anastomosis of colon conduit to rectosigmoid shows satisfactory upper tracts. Right ureter can be visualized in its long tunnel (arrowheads). Note anastomosis of colon conduit to rectosigmoid (arrow). BEFORE
AFTER Bilateral
Tronsureleropyelostomy
hydronephrosis
R> L
Cath to
each kidney
To use splenic flexure for (on
conduit
middle colic blood supply)
Condu11 from
u
m,ddleconcbl=ly) )1 /1 · \
..4 /
------... 1Yr later
/ Rectum stro1ghtened (inordertobeoble!o poss endoscope)
!
\=/ FIG. 5. Case 3. Preoperative and postoperative anatomy
/
/
722
HENDREN
for staged ureterocolic diversion of the urine as was possible in this patient. The complication of rectal perforation after radiation therapy illustrates how a primary ureterosigmoidostomy in this case could have proved disastrous had the urine been diverted internally to the colon at that time. This case also
Fm. 6. Case 3. A, preoperative IVP when patient was 14 years old with ileal loop shows dilated upper tracts. Recurrent urinary infection. B, IVP 1 year after conversion to nonrefluxing colon conduit. C, percutaneous antegrade pyelographic study filling urinary tract through needle in right kidney to outline anatomy. Note right-to-left transureteropyelostomy and long tunnel left ureterocolic anastomosis. Loopogram showed no reflux. D, IVP 1 year after implantation of colon conduit into left colon. Patient remains well.
illustrates the use of a segment other than sigmoid colon to have bowel of good quality. Sometimes the blood supply of the bowel will dictate the choice of a segment other than the sigmoid. It was believed that one good ureterosigmoid tunnel with transureteropyelostomy for drainage of the second side was better than attempting to implant 2 foreshortened ureters into the same conduit, with neither tunnel of ideal length to prevent reflux. Case 4. An 8-year-old boy was referred in November 1975 with increasing hydronephrosis (figs. 7 and 8). Primary closure of bladder exstrophy during infancy had failed and an ileal loop had been done. Both ureters were dilated and were tapered at the time of implantation into a colon conduit. Subsequent radiographic followup showed satisfactory drainage on the left side but partial obstruction on the right side. A loopogram showed no reflux on either side. The loop was explored again 1 year after construction of the colon conduit. The right ureter was mobilized again but would not reach the opposite side for transureteroureterostomy free of tension. Therefore, a jejuna! conduit was made to join the right to the left renal pelvis. Revision of the penis repair was performed in February 1978. 5 In July, because the upper tracts were considerably improved and there was no coloureteral reflux, the colon conduit was joined to the rectosigmoid. In July 1979 the patient was rehospitalized for obstruction of the urinary tract by a stone lodged in the left ureter. Temporary drainage of the upper tracts was performed by percutaneous nephrostomy. When the condition improved the stone in the left ureter was removed by passage of an endoscope up the rectum, into the colon conduit and into the ureterosigmoid tunnel. The patient was well clinically 3 years later, with stable upper tracts, no clinical evidence of infection and no further stone formation. Comment: The degree of hydronephrosis and hydroureter in this patient ordinarily would preclude consideration of ureterocolic internal diversion of the urine. Only by performing first an isolated colon conduit and waiting for improvement in the upper tracts before performing the second stage was ureterocolic diversion considered feasible. The occurrence of ureteral obstruction on the right side proved that to be a fortuitous choice, since obstruction could be dealt with without loss of significant renal function, which likely would have occurred had this happened in a conduit joined to the fecal stream. Should this patient have ascending pyelonephritis, recurrent
8 yr old boy. Failed exstrophy closure. I leal loop with hydronephrosis Switched to colon loop but right side was obstructed
Conduit into colon age 11 yrs.
Fm. 7. Case 4. Preoperative and postoperative anatomy
723
URETEROCOLIC DIVERSION OF URINE
stones and so forth, the option remains for separating the fecal and urinary streams by 1) bringing the conduit to the surface or 2) performing a left end colostomy and retaining the rectum as a rectal bladder. Of the 16 patients with ileal loops converted to colon conduits that later were joined to the colon 5 have had at least 1 episode of clinical pyelonephritis as evidenced by fever and flank tenderness. When suspected in patients with ureterosigmoidostomy pyelonephritis should be confirmed by percutaneous needle aspiration of the kidney to obtain a reliable culture for determining antibiotic sensitivities to guide appropriate treatment. Of these 5 patients 3 had a stone secondary to infection. The remaining 2 patients with stones required pyelolithotomy. Those 5 patients with infection and/or stones each had severe upper tract dilatation and renal scarring when first referred with the ileal loops. The better the upper tracts and ureters the less likely that such complications will occur. In 1 case when pyelonephritis occurred selectively on 1 side transureteroureterostomy was performed on the presumption that the pyelonephritis was based on coloureteral reflux. ILEAL LOOP CONVERTED DIRECTLY TO URETEROSIGMOIDOSTOMY
Fm. 8. Case 4. A, IVP when child was 8 years old with ileal loop and severe upper tract dilatation bilaterally. B, antegrade pyelogram via needle percutaneously into each renal pelvis after colon conduit procedure shows satisfactory ureterocolic anastomosis on left side with long tunnel but obstruction of right ureterocolic anastomosis. C, antegrade study after relief of right ureteral obstruction by jejuna! segment to drain right renal pelvis into left renal pelvis. D, IVP 1 year after anastomosis of colon conduit to rectosigmoid.
BEFORE
Two patients with an ileal loop were treated when it appeared reasonable to proceed with direct ureterosigmoidostomy using a variation in technique (fig. 9). Case 5. A 14-year-old boy was referred in July 1975 with an ileal loop complicated by alkaline incrustation of the stoma, and an unsatisfactory result from previous repair of bladder exstrophy and epispadias. Primary functional repair of the bladder had been done elsewhere during infancy and failed, following which ileal loop urinary diversion was performed. Extensive repair of the penis with lengthening was done. 5 For 5 years the patient refused revision of the urinary diversion. In July 1980 the ileal loop was removed and direct ureterosigmoidostomy was performed by the Roux-en-Y method (fig. 9). The patient has been well and free of urinary infection, with good rectal and urinary control, and stable upper tracts (fig. 10). Comment: The lower ureters in this case were thickened and, therefore, were resected. There still was ample length of upper AFTER
Nor mo I kidneys
Only slight dilofofion of ureters
Ileal loop ( 18 yeors ) Failed exstrophy closure ( prior cystectomy )
To funnel
'C----
anastomosis of L. colon to rectosigmoid
'' '0'
Moderate dilotofion of loop
/~ ' ~ OJ
ll Fm. 9. Case 5. Preoperative and postoperative anatomy
Rectal lube
1. ''
HENDREN
724
ureters to obtain long ureterosigmoid tunnels using the method illustrated in this case. This method was believed to be feasible because the upper ureters were relatively normal and the upper tracts were well preserved. There should be rigid selection of cases when proceeding directly from an ileal loop to ureterosigmoidostomy by any technique. REVISION OF URETEROSIGMOIDOSTOMY
Ten patients were referred with malfunctioning ureterosigmoidostomies requiring revision. Simple revision was possible in 3 cases: 1 had an inflammatory pseudopolyp of a ureter joined by the dunking technique 20 years before and 2 had simple anastomotic stenosis. However, in 7 patients a much more extensive 9peration was needed. The following 4 cases will illustrate some solutions used in these cases. Case 6. A 25-year-old man was referred in December 1978 with recurrent episodes of pyelonephritis secondary to ure-
FIG. 10. Case 5. A, preoperative IVP with ileal loop shows good upper tracts but somewhat shortened ureters. B, IVP 1 year after ureterocolic anastomosis by technique shown in figure 9.
terocolic diversion of the urine (figs. 11 and 12). There was gas in the upper tracts. Although classical ureterosigmoidostomies were considered it was believed that longer tunnels could be achieved with less likelihood of angulation of a ureter with the method illustrated in figure 11. Extensive penile lengthening and revision of epispadias were performed 1 year later (the bladder had been removed for pyocystis during childhood). The upper tract remained normal and the patient was clinically well 3½ years after reconstruction. Comment: Bringing the proximal sigmoid colon upward to the level of the aortic bifurcation in this case, or even higher in others, facilitates long ureterosigmoid tunnels with minimal displacement of the ureters. If a patient with this anatomic arrangement should continue to have ascending pyelonephritis from incompetent ureterosigmoid anastomoses, it would be fairly simple to convert this drainage into a cutaneous colon conduit diversion by dividing the colon just above the anasto-
FIG. 12. Case 6. A, preoperative IVP when patient was 25 years old with ureters retouched to show dilatation. There was gas in upper tracts. B, IVP 1 year after ureterocolic revision shown in figure 11.
AFTER
BEFORE
~,- - - - - ,- "r() Good kidneys;
\
\
mild pyelo- ~ nephritic changes ,-______- _ ____ _ \ 1
Ii
;
I;
:
!/
{.~)
( :\, I
I
:
j
8 cm tunnels
I
\/
-,,_
--
\
Ligated stumps --:jj:8 plastic catheter to each kidney
anastomoses gos
in
ureters
FIG. 11. Case 6. Preoperative and postoperative anatomy
URETEROCOLIC DIVERSION OF URINE
725
mosis of the left colon to the rectum and bringing it out as a ureterosigmoidostomies performed when he was 3 years old for exstrophy of the bladder. Colonoscopy performed for rectal cutaneous stoma. Case 7. A 20-year-old man was referred, quite ill, with left bleeding showed polyps. Biopsy showed no evidence of maligpyonephrosis and right recurrent pyelonephritis (fig. 13). Ure- nancy. Exploration was performed, with wide excision of each terocolic diversion of the urine and pull-through of the left ureterosigmoidostomy and frozen sections were benign. Repeat colon had been performed for bladder exstrophy when the long tunnel ureterosigmoidostomy was performed using the patient was a child. The completely destroyed left kidney was Roux-en-Y technique (fig. 17). The patient continued to do well removed. Revision of the right ureterocolic anastomosis was , clinically > 1 year later. done 3 months later. The ureter was short and dilated, precludComment: The polypoid change in the left ureter, responsible ing construction of a long tunnel except by adding a segment of for bleeding in this case, was an example of a ureter dunked colon onto the rectum. The left colon blood supply was not into the colon many years before that had never healed prinormal, owing to a previous pull-through procedure. Therefore, marily. There is a definite increased risk of cancer of the colon cecum was used to extend the rectum upward, creating a nipple in patients with long-standing ureterosigmoidostomy internal to prevent reflux by intussuscepting the terminal ileum. The diversion of the urine. 6 These patients should be warned to patient was well and the upper tract was stable 9 months later. inspect the excreta for passage of blood. Periodic examination Comment: The nipple, buttressed with sutures, appears intact of the colon should be performed to detect early any possible on the postoperative IVP. More recently, as an additional malignant change, which seems to depend on the presence of precaution against loss of such a nipple, the stapler has been urine and feces. 7 Early detection of such a cancer should result used to place 3 or 4 rows of staples longitudinally in the nipple in curability. In my opinion this risk should not preclude to fasten its walls together in a permanent manner. ureterosigmoidostomy when that is the only option available to Case 8. A 14-year-old girl was referred in May 1980 with the a patient who has no bladder. combined problems of incontinence and pyelonephritis (figs. 14 to 16). An extensive reconstruction was performed, lasting 17 URETEROSIGMOIDOSTOMY CONVERTED TO PERMANENT COLON CONDUIT DIVERSION hours. The vagina was opened. The previous pull-through operation was taken down, rejoining continuity of the left colon Four patients were referred with advanced upper tract to the upper rectum. A perineal body was built between the changes secondary to long-standing ureterosigmoidostomy. In anterior rectum and posterior vagina. Ileocecal conduit diver- each patient it was believed inadvisable to retain this method sion of the urine was elected, reasoning that this could be a of urinary drainage. satisfactory permanent cutaneous diversion if needed or it could Case 10. A 22-year-old female nurse was referred with recurbe joined to the colon if rectal continence was achieved. Later, rent pyelonephritis (figs. 18 and 19). Ureterocolic diversion of the patient could retain water instilled into the rectum. There- the urine had been performed for bladder exstrophy during fore, the colon conduit was anastomosed to the rectosigmoid 1 childhood. There had been staghorn calculi bilaterally. Because year later. The patient was well 1 year later, with good rectal the upper tracts were so badly damaged from long-standing continence and stable upper tracts. malfunction of the ureterocolic anastomoses permanent diverComment: The ileocecal segment has proved useful in blad- sion with a nonrefluxing colon conduit was advised as the best der augmentation and cutaneous diversion. This and the pre- means to preserve the scant remaining upper tract function. ceding case illustrate other possible uses for the ileocecal seg- The patient remained well 4 years postoperatively. Comment: A patient with ureterocolic internal diversion of ment. Case 9. A 37-year-old man was referred for investigation of the urine must be watched carefully. Early revision should be
AFTER
QLJ.
/'
L. nephroureterectomy
r ~ =~•.
Nipple to prevent reflux ---: "· ..', { 8 cm of ileum ~;( -~ ··.'.\ intussuscepted after \ .· .. '·~ ;;l: removing mesentery ~~and scarifying bowel wall. Note added buttressing sutures)
Fm. 13. Case 7. Preoperative and postoperative anatomy. Note nipple created in ileal cecal preparation to prevent reflux. Current technique in use to ensure persistence of nipple consists of 3 or 4 rows of staples applied longitudinally to maintain nipple.
726
HENDREN
A BEFORE
\
Pyelonephritic changes ( gas in colyces, pelvis )
Better kidney
Previous exstrophy
)/"'\?\I ~ JL
!) "Rectal bladder"--;--;--~-+i
\( ,)gina covered
,'-fy
\_r
:
u:
I
, :
I ,: I_.'
To be opened by cutback
.
··
,, anastomoses with ref I ux ( L > R )
Transverse / incision to - - - ~ - / expose rectum
,,
U R I N E ~ Anus patulous / and anterior; FECES INCONTINENT
B
C Cutback vaginoplasty
/ I
I i ·.
Mainly vertical closure of skin after repair
.
I,.
i' ,,
\~I
Introital musculature and levators closed anterior to rectum to improve continence
/
/;
- ~ ---- Pu 11 through removed; levators snugged up in back
Fm. 14. Case 8. Patient presented special problem of pyelonephritis from coloureteral reflux as well as incontinence after previous rectal bladder operation with adjacent pull-through of colon. A, preoperative anatomy. B and C, scheme for repair of rectal incontinence.
TJRE':::'EROC'.JLIC DIVERSIO:ts.J OE- URII'~TE
done if there is infection. occur.fed in this case before such a uv~"'"'va v1as :reached. though the patient "'''"'""ni·lu is well the life span ,.ncucv,,a will be shortened with such severe upper tract damage. MISCELLANEOUS URETEROCOUC PROCEDURES
Previous ileal were converted to nonrefluxing colon conduits in 18 patients. Of these patients 8 had myelodysplasia,
B
FIG. 16. Case 8. A, IVP after temporary nonrefluxing ilea! cecal conduit. Note nipple (arrow). B, IVP 1 year after anastomosis of conduit to rectosigmoid as shown in figure 15, C.
AFTER ileum
•
Ureters
spolul_ated and Joined l\t;~
7 had had exstrophy and 3 had rhabdomyosarcoma. In each patient continuing colon conduit drainage was believed to be indicated. A primary nonrefluxing colon conduit diversion was used in 16 additional patients, mostly with myelodysplasia. In some cases refunctionalization of the bladder is contemplated. A previous ileal loop was converted to a colon -~•rn•-•v, which was undiverted later into the bladder in 4 patients. DISCUSSION
lntussusception of ileum to prevent reflux
L colon to rectum anostomosis
Ureters ligoted flush ond divided
Repaired anorectal canal
to avoid
I leocecal segment mobilized, rotated ~, counterclockwise ------------and joined to colon
This series illustrates alternative methods for ureterocolic internal diversion of the urine in cases not suited for classic primary ureterosigmoidostomy. U reterosigmoidostomy should not be performed during infancy before an age at which bowel control is achieved. This procedure can result in several years of malodorous incontinence of stool and feces, which can lead to social ostracism. Conversely, in our experience the majority of older children undergoing ureterosigmoidostomy are continent by day. Some of these patients will leak a small amount at night when even in adulthood, They should be forewarned of this pvom.uuc;cy and instructed to get up in the middle of the night to empty the colon and to wear a protective perinea! pad if necessary. Patients with ureterosigmoidostomy may have electrolyte disturbance, 8 The "-··--.. -., for hypochloremic acidosis should be combated m these patients with liberal intake of fluid, of the rectum and oral sodium bicarbonate s11~rn.tlc:ar,t acidosis. 9 Periodic determination of elecSome .,-,,,-,,cu will lose 0,,;iaw.,aH and require Supplementary P'-''Cao,,,u,u in the diet, patient suffered severe hypokalemia, prompting emergency admission to the Hc,ucow=<• It was believed initially to represent the Guillain-Barre syndrome; the 'Weakness disappeared immediately upon administration of potassium. Endoscopic followup of these patients should be routine to allow early detection of the occasional patient who will suffer malignancy from ureterocolic internal diversion of the urine. REFERENCES
Leadbetter, W. F. and Clarke, B. G.: Five years experience with ureteroenterostomy by the "combined" technique. J. Urol., 73: 67, 1954. 2. Coffey, R. C.: Transplantation of the ureters into the large intestine. Surg., Gynec. & Obst., 47: 593, 1928. 3. Goodwin, W. E., Harris, A. P., Kaufman, J. J. and Beal, J. M.: Open, transcolonic ureterointestinal anastomosis: new approach. Surg., Gynec. & Obst., 97: 295, 1953. 4. Mathisen, W.: A new method for ureterointestinal anastomosis; l,
FIG. 15. Case 8. A and B, technique to create temporary nonrefluxing ileal cecal conduit. Experience with these nipples has shown that some will disappear even with scarification of bowel wall and placement of buttressing sutures. Recently, staples have been used to maintain nipple. C, ultimate rediversion of urine to rectosigmoid after it was evident that rectal continence was restored.
728
HENDREN
AFTER BEFORE
Colon closed ond tocked
Ureterosigmoidostomies for exstrophy 34 years ago. Rectal bleeding. Kidneys normal. 11 Polyps11 seen at colonoscopy.
near aortic bifurcation
Excised eoch
'' '' '\ \'
u-sig. for pathology exam
'\\\ \ /4r,,
Eoch ureter ,._, \ mobilized widely, ~K ..........., • , , with oil ifs ' \ • ~ ~ .___ ,,-
i
~
periureterol
tS:,.
~f;J,
tissue
Q~
'
,;ghl
Long funnel--'~! 1mplonfs [,.,.,.,--,-,4 _ _
' '
',. \ ---1·; \ \ ~
''.
I;
'·'~.
\I
\; .Y-, '\~,
,\,,
; /
[':c/ i
~
<'.\ ·.;···'
~
I
,.,
"Ureterocele" of intramural segment bulging beneoth
L. ureter brought through mesocolon
L colon onastomosed of site of prior R. u-sig.
Inflammatory polyp of
~~
colon mucosa
Soft rectal tube
FIG. 17. Case 9. Preoperative and postoperative anatomy after resection of ureterosigmoidostomies PRE OP. POST OP
Small, scarred kidneys { previous stoghorn calculi J
~
with ureter
#8 catheter to each kidney
Segment to use Reflux up
for conduit
Closure-ureteral opening
ureterorectol anastomoses Pulled through sigmoid
FIG, 18. Case 10. Preoperative and postoperative anatomy. Maintaining ureterosigmoidostomies in this patient was believed unadvisable because upper tracts were badly damaged and renal function was compromised severely.
URETEROCOLIC DIVERSION OF URINE
FIG. 19. Case 10. A, plain film of abdomen shows ureters and upper tracts clearly outlined with air (arrows). B, tomograms from IVP show severely contracted kidneys. Cutaneous diversion with nonrefluxing colon conduit was believed safest option for this patient. preliminary report. Surg., Gynec. & Obst., 96: 255, 1953. 5. Hendren, W. H.: Penile lengthening after previous repair of epispadias. J. Urol., 121: 527, 1979. 6. Mueller, C. W. and Thornbury, J. R.: Adenocarcinoma of the colon complicating ureterosigmoidostomy: a case report and review of the literature. J. Urol., 109: 225, 1973. 7. Crissey, M. M., Steele, G. D. and Gittes, R. F.: Rat model for
carcinogenesis in ureterosigmoidostomy. Science, 207: 1079, 1980. 8. Ferris, D. 0. and Odel, H. M.: Electrolyte pattern of the blood after bilateral ureterosigmoidostomy. J.A.M.A., 142: 634, 1950. 9. Hendren, W. H.: Nonrefluxing colon conduit for temporary or permanent urinary diversion in children. J. Ped. Surg., 10: 381, 1975.
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Printed
Copy-£ight © 1983 by The 'N.illiams & VJilkins Co.
URETEROCOLIC DIVERSIOJ\T OF URINE: DIFFICULT PROBLE1vIS W. HARDY HENDREN* From the Division of Pediatric Surgery, Massachusetts General Hospital and Department of Surgery, Harvard Medical School, Boston, Massachusetts
ABSTRACT
During the last 11 years 37 patients were treated with meterocolic diversion of the urine means other than classic ureterosigmoidostomy. By altering the technique of joining the meters to the colon this method of internal urinary diversion is possible even in cases when it would not be feasible by more traditional methods. Ureterosigmoidostomy has been performed for many years and continues to be a useful part of the urological armamentarium. Various methods have been used to join the ureters to the colon, usually by a tunneling technique to provide a valve mechanism that will prevent reflux. Leadbetter and Clarke demonstrated the superiority of not only creating a tunnel but also anatomically anastomosing the ureter to the colon mucosa. 1 Previously, operations had been done using the technique of tunneling the ureter but dunking its end into the colon. 2 Primary healing often failed and in some patients a chronic inflammatory polyp developed subsequently at the site of the dunked ureter. Goodwin and associates described creation of submucosal tunnels for the ureter by opening the colon wall and creating a tunnel on its opposite side, similar to reimplanting a ureter in the bladder. 3 Mathisen described a nipple technique for ureterocolic anastomosis.' The most commonly used technique of ureterosigmoidostomy is implantation of the ureters into the rectosigrn.oid, generally at slightly different levels in the colon (fig. 1). Experience has shown that the success of ureterosigrn.oidostomy depends on several factors. The ureters must be of normal or near normal size. A tunnel must be made long enough to create an effective nomefluxing valve, a principle similar to creating a nonrefluxing ureterovesical reimplantation. If the ureters are dilated it is difficult to achieve a satisfactory tunnel length to prevent coloureteral reflux. If a ureter is scarred and inflamed from infection and/or obstruction its walls will lack and coloureteral reflux can result, which leads to pyelonephritis, stones ultimately, severe renal damage. Ureterosigmoidostomy leads to hho-,,,·,wu "'~'"''"'"" of some solute. Therefore, patients with reduced n:mal func-tion cannot tol.:;rate the added renal work load ,~,,,-v,.,v.,cu Furthermore, pa_tIEm1;s with a uret,en}s1gn101.o.c,st,orr1y sufficient water to be abl.e to re-excrete the resorbed solute load. Even ·Nith normal upper tracts a with a uret,ercis1,!;"n101ctc,stom can become azotemic if of adequate fluid intake, for example patients with gastroenteritis, which causes ~ .... v,...,., and/or diarrhea. When ureterosigmoidostomy is performed successfully, that is the ureters are of good quality, the tunnels are of ample length and there is no reflux and obstruction, the long-term result can be excellent. However, when these anatomic criteria are not present results can be disastrous. Experience with ureterocolic procedures in 82 patients during the last 11 years is described with emphasis on those 37 in Accepted for publication July 23, 1982. Read at annual meeting of American Urological Association, Kansas City, Missouri, May 16-20, 1982. * Requests for reprints: Department of Surgery, The Children's Hospital Medical Center, 300 Longwood Ave., Boston, Massachusetts 02115. 719
Cul de sac peritoneum
FIG. 1. Classic technique of ureterosigmoidostomy
PRIMARY COLON LOOP JOINED LATER TO COLON
diversion v1as ~--,·+~-in 12 patients using a non.refluxing colon conduit -,,, .. ~~-- described previously. Of these 11 had exstrophy believed unsuited for primary reconstruction or in whom primary reconstruction had been attempted elsewhere with failure (3 patients). One patient had sarcoma of the prostate treated by anterior pelvic exenteration (fig. 2). These 12 patients had normal ureters, which posed no problem in obtaining good ureterocolic tunnels. Radiographic examination after temporary colon conduit diversion showed normal drainage of the upper tracts in all patients and absence of low pressure reflux on a loopogram. As might be predicted followup for as long as 10 years after the colon conduit was joined to the rectosigmoid at a second stage has shown continuing normal upper tracts in all of these patients. None has had a clinical episode of pyelo-
720
HENDREN
nephritis or deterioration of the upper tracts. One of these patients has had significant rectal incontinence from lack of neurological control of the perineum secondary to an intraspinal lipoma discovered recently and removed. The following case illustrates the use of a temporary colon conduit later joined to the rectosigmoid. Case 1. A 20-month-old boy was referred with a large pelvic mass that proved to be sarcoma of the prostate. Anterior pelvic exenteration was performed in August 1971. A temporary nonrefluxing colon conduit was used to drain the urinary tract. Lymph nodes were negative despite the large size of the tumor. Postoperative treatment with chemotherapy was used for 2 years but no radiation therapy was given. When the patient was 4 years old and had good rectal control with no evidence of recurrent disease in the pelvis, the colon conduit was joined to the rectosigmoid. The patient presently is 13 years old and well. He has normal daytime rectal continence and has been free of urinary infection. Comment: Primary classic ureterosigmoidostomy was deemed unwise in this child because 1) he was too young to expect reasonably rectal continence of urine and 2) possible recurrence of and treatment for tumor in the pelvis could be complicated by the presence of a ureterosigmoidostomy. The temporary colon conduit allowed continence to be anticipated when the patient was older. Also, one could then be relatively
certain that recurrent tumor would not be a problem and that the ureterocolic anastomosis was satisfactory before the colon conduit was joined to the fecal stream. ILEAL LOOP
CONVERTED TO COLON CONDUIT JOINED TO COLON
AND
LATER
A total of 16 patients had had previous ileal loop urinary diversions that were converted first to nonrefluxing colon conduit diversions, which then were joined to the colon (fig. 3). Of these patients 6 had been treated some years previously by me for bladder exstrophy using an ileal conduit diversion technique (which was abandoned in 1971). The remaining 10 patients with previous ileal conduits were referred for increasing upper tract deterioration. All but 1 patient originally had exstrophy of the bladder. A 55-year-old woman had undergone ileal loop diversion for severe interstitial cystitis. Ultimately this patient requested repeat diversion of the colon conduit to the skin because of rectal urinary frequency after the colon conduit was joined to the colon. Case 2. A 20-month-old girl underwent ileal loop urinary diversion for a rudimentary exstrophic bladder believed unsuited for primary reconstruction in October 1964 (fig. 4). Periodic radiographic control showed dilatation of the right ureter despite 2 operations to correct recurrent stenosis of the stoma.
FrG. 2. Case l. A, IVP 1 year after anterior pelvic exenteration for large sarcoma of prostate shows normal upper tract and colon conduit. B, IVP 5 years after anastomosis of colon conduit to rectosigmoid reveals upper tracts and contrast medium in left colon. COLON LOOP ( No Reflux)
ILEAL LOOP
LOOP LATER JOINED TO COLON
(Reflux)
OR
-
If ureters short, can implant better ureter, and do TUP of other ureter
FIG. 3. Scheme of conversion from ileal loop to nonrefluxing colon loop and later anastomosis to rectosigmoid
721
URETEROCOLIC DIVERSION OF URINE
In June 1971 the ileal loop was resected and a nonrefluxing colon conduit was done. The right ureter was short and the proximal end of the colon conduit was placed in the right gutter to facilitate right ureterosigmoid anastomosis. The left ureter had ample length to bring it across the midline and construct a good tunnel. A loopogram 6 months later showed no reflux. Excretory urography (IVP) revealed improved upper tracts. In August 1972 the conduit was anastomosed to the colon. In the subsequent decade the patient has been well with delicate upper tracts, representing an improvement over their appearance when ileal loop urinary diversion was present. The patient presently is 19 years old and has had no clinical evidence of urinary infection. Comment: There are many young patients who have been treated by ileal loop urinary diversion for exstrophy and are candidates for staged diversion of the urine into the colon. It is not possible to anastomose safely an ileal loop to the colon, since that will allow ascending pyelonephritis. Conversion to an immediate ureterosigmoidostomy in this patient was not believed feasible because the right ureter was dilated and could well have resulted in reflux of colon contents up the ureter. To
wait until the radiographic control showed improved upper tracts and no coloureteral reflux seemed to be the safest course before proceeding with ultimate anastomosis of the conduit to the colon. Case 3. A 14-year-old girl with an ileal loop was referred for increasing hydronephrosis and recurrent urinary infection (figs. 5 and 6). Anterior exenteration had been performed when she was 7 years old for rhabdomyosarcoma of the bladder, followed by chemotherapy and radiation therapy. Treatment had been complicated by spontaneous perforation of the colon. In June 1979 the ileal loop was resected and a colon conduit was created from the splenic flexure to use nonradiated bowel. The better left ureter was used to drain the urinary tract into the isolated colon conduit with a long tunnel. The opposite kidney was drained by transureteropyelostomy. Subsequently, radiographic control showed improvement in the upper tracts and no reflux on a loopogram. In June 1980 the colon conduit was joined to the left colon. The patient continues to do well clinically and the upper tracts remain stable on an IVP. Comment: There doubtless are many patients with urinary diversions following surgery for cancer who could be considered
FIG. 4. Case 2. A, IVP when child was 8 years old with ileal loop shows dilated right ureter. B, loopogram 1 year after conversion to nonrefluxing colon conduit reveals reflux. C, IVP after anastomosis of colon conduit to rectosigmoid shows satisfactory upper tracts. Right ureter can be visualized in its long tunnel (arrowheads). Note anastomosis of colon conduit to rectosigmoid (arrow). BEFORE
AFTER Bilateral
Tronsureleropyelostomy
hydronephrosis
R> L
Cath to
each kidney
To use splenic flexure for (on
conduit
middle colic blood supply)
Condu11 from
u
m,ddleconcbl=ly) )1 /1 · \
..4 /
------... 1Yr later
/ Rectum stro1ghtened (inordertobeoble!o poss endoscope)
!
\=/ FIG. 5. Case 3. Preoperative and postoperative anatomy
/
/
722
HENDREN
for staged ureterocolic diversion of the urine as was possible in this patient. The complication of rectal perforation after radiation therapy illustrates how a primary ureterosigmoidostomy in this case could have proved disastrous had the urine been diverted internally to the colon at that time. This case also
Fm. 6. Case 3. A, preoperative IVP when patient was 14 years old with ileal loop shows dilated upper tracts. Recurrent urinary infection. B, IVP 1 year after conversion to nonrefluxing colon conduit. C, percutaneous antegrade pyelographic study filling urinary tract through needle in right kidney to outline anatomy. Note right-to-left transureteropyelostomy and long tunnel left ureterocolic anastomosis. Loopogram showed no reflux. D, IVP 1 year after implantation of colon conduit into left colon. Patient remains well.
illustrates the use of a segment other than sigmoid colon to have bowel of good quality. Sometimes the blood supply of the bowel will dictate the choice of a segment other than the sigmoid. It was believed that one good ureterosigmoid tunnel with transureteropyelostomy for drainage of the second side was better than attempting to implant 2 foreshortened ureters into the same conduit, with neither tunnel of ideal length to prevent reflux. Case 4. An 8-year-old boy was referred in November 1975 with increasing hydronephrosis (figs. 7 and 8). Primary closure of bladder exstrophy during infancy had failed and an ileal loop had been done. Both ureters were dilated and were tapered at the time of implantation into a colon conduit. Subsequent radiographic followup showed satisfactory drainage on the left side but partial obstruction on the right side. A loopogram showed no reflux on either side. The loop was explored again 1 year after construction of the colon conduit. The right ureter was mobilized again but would not reach the opposite side for transureteroureterostomy free of tension. Therefore, a jejuna! conduit was made to join the right to the left renal pelvis. Revision of the penis repair was performed in February 1978. 5 In July, because the upper tracts were considerably improved and there was no coloureteral reflux, the colon conduit was joined to the rectosigmoid. In July 1979 the patient was rehospitalized for obstruction of the urinary tract by a stone lodged in the left ureter. Temporary drainage of the upper tracts was performed by percutaneous nephrostomy. When the condition improved the stone in the left ureter was removed by passage of an endoscope up the rectum, into the colon conduit and into the ureterosigmoid tunnel. The patient was well clinically 3 years later, with stable upper tracts, no clinical evidence of infection and no further stone formation. Comment: The degree of hydronephrosis and hydroureter in this patient ordinarily would preclude consideration of ureterocolic internal diversion of the urine. Only by performing first an isolated colon conduit and waiting for improvement in the upper tracts before performing the second stage was ureterocolic diversion considered feasible. The occurrence of ureteral obstruction on the right side proved that to be a fortuitous choice, since obstruction could be dealt with without loss of significant renal function, which likely would have occurred had this happened in a conduit joined to the fecal stream. Should this patient have ascending pyelonephritis, recurrent
8 yr old boy. Failed exstrophy closure. I leal loop with hydronephrosis Switched to colon loop but right side was obstructed
Conduit into colon age 11 yrs.
Fm. 7. Case 4. Preoperative and postoperative anatomy
723
URETEROCOLIC DIVERSION OF URINE
stones and so forth, the option remains for separating the fecal and urinary streams by 1) bringing the conduit to the surface or 2) performing a left end colostomy and retaining the rectum as a rectal bladder. Of the 16 patients with ileal loops converted to colon conduits that later were joined to the colon 5 have had at least 1 episode of clinical pyelonephritis as evidenced by fever and flank tenderness. When suspected in patients with ureterosigmoidostomy pyelonephritis should be confirmed by percutaneous needle aspiration of the kidney to obtain a reliable culture for determining antibiotic sensitivities to guide appropriate treatment. Of these 5 patients 3 had a stone secondary to infection. The remaining 2 patients with stones required pyelolithotomy. Those 5 patients with infection and/or stones each had severe upper tract dilatation and renal scarring when first referred with the ileal loops. The better the upper tracts and ureters the less likely that such complications will occur. In 1 case when pyelonephritis occurred selectively on 1 side transureteroureterostomy was performed on the presumption that the pyelonephritis was based on coloureteral reflux. ILEAL LOOP CONVERTED DIRECTLY TO URETEROSIGMOIDOSTOMY
Fm. 8. Case 4. A, IVP when child was 8 years old with ileal loop and severe upper tract dilatation bilaterally. B, antegrade pyelogram via needle percutaneously into each renal pelvis after colon conduit procedure shows satisfactory ureterocolic anastomosis on left side with long tunnel but obstruction of right ureterocolic anastomosis. C, antegrade study after relief of right ureteral obstruction by jejuna! segment to drain right renal pelvis into left renal pelvis. D, IVP 1 year after anastomosis of colon conduit to rectosigmoid.
BEFORE
Two patients with an ileal loop were treated when it appeared reasonable to proceed with direct ureterosigmoidostomy using a variation in technique (fig. 9). Case 5. A 14-year-old boy was referred in July 1975 with an ileal loop complicated by alkaline incrustation of the stoma, and an unsatisfactory result from previous repair of bladder exstrophy and epispadias. Primary functional repair of the bladder had been done elsewhere during infancy and failed, following which ileal loop urinary diversion was performed. Extensive repair of the penis with lengthening was done. 5 For 5 years the patient refused revision of the urinary diversion. In July 1980 the ileal loop was removed and direct ureterosigmoidostomy was performed by the Roux-en-Y method (fig. 9). The patient has been well and free of urinary infection, with good rectal and urinary control, and stable upper tracts (fig. 10). Comment: The lower ureters in this case were thickened and, therefore, were resected. There still was ample length of upper AFTER
Nor mo I kidneys
Only slight dilofofion of ureters
Ileal loop ( 18 yeors ) Failed exstrophy closure ( prior cystectomy )
To funnel
'C----
anastomosis of L. colon to rectosigmoid
'' '0'
Moderate dilotofion of loop
/~ ' ~ OJ
ll Fm. 9. Case 5. Preoperative and postoperative anatomy
Rectal lube
1. ''
HENDREN
724
ureters to obtain long ureterosigmoid tunnels using the method illustrated in this case. This method was believed to be feasible because the upper ureters were relatively normal and the upper tracts were well preserved. There should be rigid selection of cases when proceeding directly from an ileal loop to ureterosigmoidostomy by any technique. REVISION OF URETEROSIGMOIDOSTOMY
Ten patients were referred with malfunctioning ureterosigmoidostomies requiring revision. Simple revision was possible in 3 cases: 1 had an inflammatory pseudopolyp of a ureter joined by the dunking technique 20 years before and 2 had simple anastomotic stenosis. However, in 7 patients a much more extensive 9peration was needed. The following 4 cases will illustrate some solutions used in these cases. Case 6. A 25-year-old man was referred in December 1978 with recurrent episodes of pyelonephritis secondary to ure-
FIG. 10. Case 5. A, preoperative IVP with ileal loop shows good upper tracts but somewhat shortened ureters. B, IVP 1 year after ureterocolic anastomosis by technique shown in figure 9.
terocolic diversion of the urine (figs. 11 and 12). There was gas in the upper tracts. Although classical ureterosigmoidostomies were considered it was believed that longer tunnels could be achieved with less likelihood of angulation of a ureter with the method illustrated in figure 11. Extensive penile lengthening and revision of epispadias were performed 1 year later (the bladder had been removed for pyocystis during childhood). The upper tract remained normal and the patient was clinically well 3½ years after reconstruction. Comment: Bringing the proximal sigmoid colon upward to the level of the aortic bifurcation in this case, or even higher in others, facilitates long ureterosigmoid tunnels with minimal displacement of the ureters. If a patient with this anatomic arrangement should continue to have ascending pyelonephritis from incompetent ureterosigmoid anastomoses, it would be fairly simple to convert this drainage into a cutaneous colon conduit diversion by dividing the colon just above the anasto-
FIG. 12. Case 6. A, preoperative IVP when patient was 25 years old with ureters retouched to show dilatation. There was gas in upper tracts. B, IVP 1 year after ureterocolic revision shown in figure 11.
AFTER
BEFORE
~,- - - - - ,- "r() Good kidneys;
\
\
mild pyelo- ~ nephritic changes ,-______- _ ____ _ \ 1
Ii
;
I;
:
!/
{.~)
( :\, I
I
:
j
8 cm tunnels
I
\/
-,,_
--
\
Ligated stumps --:jj:8 plastic catheter to each kidney
anastomoses gos
in
ureters
FIG. 11. Case 6. Preoperative and postoperative anatomy
URETEROCOLIC DIVERSION OF URINE
725
mosis of the left colon to the rectum and bringing it out as a ureterosigmoidostomies performed when he was 3 years old for exstrophy of the bladder. Colonoscopy performed for rectal cutaneous stoma. Case 7. A 20-year-old man was referred, quite ill, with left bleeding showed polyps. Biopsy showed no evidence of maligpyonephrosis and right recurrent pyelonephritis (fig. 13). Ure- nancy. Exploration was performed, with wide excision of each terocolic diversion of the urine and pull-through of the left ureterosigmoidostomy and frozen sections were benign. Repeat colon had been performed for bladder exstrophy when the long tunnel ureterosigmoidostomy was performed using the patient was a child. The completely destroyed left kidney was Roux-en-Y technique (fig. 17). The patient continued to do well removed. Revision of the right ureterocolic anastomosis was , clinically > 1 year later. done 3 months later. The ureter was short and dilated, precludComment: The polypoid change in the left ureter, responsible ing construction of a long tunnel except by adding a segment of for bleeding in this case, was an example of a ureter dunked colon onto the rectum. The left colon blood supply was not into the colon many years before that had never healed prinormal, owing to a previous pull-through procedure. Therefore, marily. There is a definite increased risk of cancer of the colon cecum was used to extend the rectum upward, creating a nipple in patients with long-standing ureterosigmoidostomy internal to prevent reflux by intussuscepting the terminal ileum. The diversion of the urine. 6 These patients should be warned to patient was well and the upper tract was stable 9 months later. inspect the excreta for passage of blood. Periodic examination Comment: The nipple, buttressed with sutures, appears intact of the colon should be performed to detect early any possible on the postoperative IVP. More recently, as an additional malignant change, which seems to depend on the presence of precaution against loss of such a nipple, the stapler has been urine and feces. 7 Early detection of such a cancer should result used to place 3 or 4 rows of staples longitudinally in the nipple in curability. In my opinion this risk should not preclude to fasten its walls together in a permanent manner. ureterosigmoidostomy when that is the only option available to Case 8. A 14-year-old girl was referred in May 1980 with the a patient who has no bladder. combined problems of incontinence and pyelonephritis (figs. 14 to 16). An extensive reconstruction was performed, lasting 17 URETEROSIGMOIDOSTOMY CONVERTED TO PERMANENT COLON CONDUIT DIVERSION hours. The vagina was opened. The previous pull-through operation was taken down, rejoining continuity of the left colon Four patients were referred with advanced upper tract to the upper rectum. A perineal body was built between the changes secondary to long-standing ureterosigmoidostomy. In anterior rectum and posterior vagina. Ileocecal conduit diver- each patient it was believed inadvisable to retain this method sion of the urine was elected, reasoning that this could be a of urinary drainage. satisfactory permanent cutaneous diversion if needed or it could Case 10. A 22-year-old female nurse was referred with recurbe joined to the colon if rectal continence was achieved. Later, rent pyelonephritis (figs. 18 and 19). Ureterocolic diversion of the patient could retain water instilled into the rectum. There- the urine had been performed for bladder exstrophy during fore, the colon conduit was anastomosed to the rectosigmoid 1 childhood. There had been staghorn calculi bilaterally. Because year later. The patient was well 1 year later, with good rectal the upper tracts were so badly damaged from long-standing continence and stable upper tracts. malfunction of the ureterocolic anastomoses permanent diverComment: The ileocecal segment has proved useful in blad- sion with a nonrefluxing colon conduit was advised as the best der augmentation and cutaneous diversion. This and the pre- means to preserve the scant remaining upper tract function. ceding case illustrate other possible uses for the ileocecal seg- The patient remained well 4 years postoperatively. Comment: A patient with ureterocolic internal diversion of ment. Case 9. A 37-year-old man was referred for investigation of the urine must be watched carefully. Early revision should be
AFTER
QLJ.
/'
L. nephroureterectomy
r ~ =~•.
Nipple to prevent reflux ---: "· ..', { 8 cm of ileum ~;( -~ ··.'.\ intussuscepted after \ .· .. '·~ ;;l: removing mesentery ~~and scarifying bowel wall. Note added buttressing sutures)
Fm. 13. Case 7. Preoperative and postoperative anatomy. Note nipple created in ileal cecal preparation to prevent reflux. Current technique in use to ensure persistence of nipple consists of 3 or 4 rows of staples applied longitudinally to maintain nipple.
726
HENDREN
A BEFORE
\
Pyelonephritic changes ( gas in colyces, pelvis )
Better kidney
Previous exstrophy
)/"'\?\I ~ JL
!) "Rectal bladder"--;--;--~-+i
\( ,)gina covered
,'-fy
\_r
:
u:
I
, :
I ,: I_.'
To be opened by cutback
.
··
,, anastomoses with ref I ux ( L > R )
Transverse / incision to - - - ~ - / expose rectum
,,
U R I N E ~ Anus patulous / and anterior; FECES INCONTINENT
B
C Cutback vaginoplasty
/ I
I i ·.
Mainly vertical closure of skin after repair
.
I,.
i' ,,
\~I
Introital musculature and levators closed anterior to rectum to improve continence
/
/;
- ~ ---- Pu 11 through removed; levators snugged up in back
Fm. 14. Case 8. Patient presented special problem of pyelonephritis from coloureteral reflux as well as incontinence after previous rectal bladder operation with adjacent pull-through of colon. A, preoperative anatomy. B and C, scheme for repair of rectal incontinence.
TJRE':::'EROC'.JLIC DIVERSIO:ts.J OE- URII'~TE
done if there is infection. occur.fed in this case before such a uv~"'"'va v1as :reached. though the patient "'''"'""ni·lu is well the life span ,.ncucv,,a will be shortened with such severe upper tract damage. MISCELLANEOUS URETEROCOUC PROCEDURES
Previous ileal were converted to nonrefluxing colon conduits in 18 patients. Of these patients 8 had myelodysplasia,
B
FIG. 16. Case 8. A, IVP after temporary nonrefluxing ilea! cecal conduit. Note nipple (arrow). B, IVP 1 year after anastomosis of conduit to rectosigmoid as shown in figure 15, C.
AFTER ileum
•
Ureters
spolul_ated and Joined l\t;~
7 had had exstrophy and 3 had rhabdomyosarcoma. In each patient continuing colon conduit drainage was believed to be indicated. A primary nonrefluxing colon conduit diversion was used in 16 additional patients, mostly with myelodysplasia. In some cases refunctionalization of the bladder is contemplated. A previous ileal loop was converted to a colon -~•rn•-•v, which was undiverted later into the bladder in 4 patients. DISCUSSION
lntussusception of ileum to prevent reflux
L colon to rectum anostomosis
Ureters ligoted flush ond divided
Repaired anorectal canal
to avoid
I leocecal segment mobilized, rotated ~, counterclockwise ------------and joined to colon
This series illustrates alternative methods for ureterocolic internal diversion of the urine in cases not suited for classic primary ureterosigmoidostomy. U reterosigmoidostomy should not be performed during infancy before an age at which bowel control is achieved. This procedure can result in several years of malodorous incontinence of stool and feces, which can lead to social ostracism. Conversely, in our experience the majority of older children undergoing ureterosigmoidostomy are continent by day. Some of these patients will leak a small amount at night when even in adulthood, They should be forewarned of this pvom.uuc;cy and instructed to get up in the middle of the night to empty the colon and to wear a protective perinea! pad if necessary. Patients with ureterosigmoidostomy may have electrolyte disturbance, 8 The "-··--.. -., for hypochloremic acidosis should be combated m these patients with liberal intake of fluid, of the rectum and oral sodium bicarbonate s11~rn.tlc:ar,t acidosis. 9 Periodic determination of elecSome .,-,,,-,,cu will lose 0,,;iaw.,aH and require Supplementary P'-''Cao,,,u,u in the diet, patient suffered severe hypokalemia, prompting emergency admission to the Hc,ucow=<• It was believed initially to represent the Guillain-Barre syndrome; the 'Weakness disappeared immediately upon administration of potassium. Endoscopic followup of these patients should be routine to allow early detection of the occasional patient who will suffer malignancy from ureterocolic internal diversion of the urine. REFERENCES
Leadbetter, W. F. and Clarke, B. G.: Five years experience with ureteroenterostomy by the "combined" technique. J. Urol., 73: 67, 1954. 2. Coffey, R. C.: Transplantation of the ureters into the large intestine. Surg., Gynec. & Obst., 47: 593, 1928. 3. Goodwin, W. E., Harris, A. P., Kaufman, J. J. and Beal, J. M.: Open, transcolonic ureterointestinal anastomosis: new approach. Surg., Gynec. & Obst., 97: 295, 1953. 4. Mathisen, W.: A new method for ureterointestinal anastomosis; l,
FIG. 15. Case 8. A and B, technique to create temporary nonrefluxing ileal cecal conduit. Experience with these nipples has shown that some will disappear even with scarification of bowel wall and placement of buttressing sutures. Recently, staples have been used to maintain nipple. C, ultimate rediversion of urine to rectosigmoid after it was evident that rectal continence was restored.
728
HENDREN
AFTER BEFORE
Colon closed ond tocked
Ureterosigmoidostomies for exstrophy 34 years ago. Rectal bleeding. Kidneys normal. 11 Polyps11 seen at colonoscopy.
near aortic bifurcation
Excised eoch
'' '' '\ \'
u-sig. for pathology exam
'\\\ \ /4r,,
Eoch ureter ,._, \ mobilized widely, ~K ..........., • , , with oil ifs ' \ • ~ ~ .___ ,,-
i
~
periureterol
tS:,.
~f;J,
tissue
Q~
'
,;ghl
Long funnel--'~! 1mplonfs [,.,.,.,--,-,4 _ _
' '
',. \ ---1·; \ \ ~
''.
I;
'·'~.
\I
\; .Y-, '\~,
,\,,
; /
[':c/ i
~
<'.\ ·.;···'
~
I
,.,
"Ureterocele" of intramural segment bulging beneoth
L. ureter brought through mesocolon
L colon onastomosed of site of prior R. u-sig.
Inflammatory polyp of
~~
colon mucosa
Soft rectal tube
FIG. 17. Case 9. Preoperative and postoperative anatomy after resection of ureterosigmoidostomies PRE OP. POST OP
Small, scarred kidneys { previous stoghorn calculi J
~
with ureter
#8 catheter to each kidney
Segment to use Reflux up
for conduit
Closure-ureteral opening
ureterorectol anastomoses Pulled through sigmoid
FIG, 18. Case 10. Preoperative and postoperative anatomy. Maintaining ureterosigmoidostomies in this patient was believed unadvisable because upper tracts were badly damaged and renal function was compromised severely.
URETEROCOLIC DIVERSION OF URINE
FIG. 19. Case 10. A, plain film of abdomen shows ureters and upper tracts clearly outlined with air (arrows). B, tomograms from IVP show severely contracted kidneys. Cutaneous diversion with nonrefluxing colon conduit was believed safest option for this patient. preliminary report. Surg., Gynec. & Obst., 96: 255, 1953. 5. Hendren, W. H.: Penile lengthening after previous repair of epispadias. J. Urol., 121: 527, 1979. 6. Mueller, C. W. and Thornbury, J. R.: Adenocarcinoma of the colon complicating ureterosigmoidostomy: a case report and review of the literature. J. Urol., 109: 225, 1973. 7. Crissey, M. M., Steele, G. D. and Gittes, R. F.: Rat model for
carcinogenesis in ureterosigmoidostomy. Science, 207: 1079, 1980. 8. Ferris, D. 0. and Odel, H. M.: Electrolyte pattern of the blood after bilateral ureterosigmoidostomy. J.A.M.A., 142: 634, 1950. 9. Hendren, W. H.: Nonrefluxing colon conduit for temporary or permanent urinary diversion in children. J. Ped. Surg., 10: 381, 1975.