Ureteroneocystostomy by Means of a Modified Triangular Flap Method

Vol. 114, November

ThE JOURNAL OF UROLOGY

Copyright © 1975 by The Williams & Wilkins Co.

Printed in U.S.A.

URETERONEOCYSTOSTOMY BY MEANS OF A MODIFIED TRIANGULAR FLAP METHOD HIROKAZU TAGUCHI, KIYOSHI SAITO

AND

TETSUO YAMADA

From the Department of Urology, Sagamihara National Hospital, Japan

ABSTRACT

A modified triangular flap method of ureteroneocystostomy is described. This method was used in 19 cases (21 ureters) requiring ureteroneocystostomy owing to various diseases. The patients have been followed postoperatively for 1 to 9 years. Our method is more simple than the original method described by Girgis and provides good results. Postoperative complications could be reduced or prevented by gentle manipulation of the ureter and bladder wall and by careful placement of the intravesical ureter into the incised ditch of the bladder floor, loosely anastomosed with interrupted sutures 5 mm. apart. Dilated hydrometers without peristalsis and/or severe degenerative changes of the bladder wall involving the muscle layer are poor indications for the application of this method.

/;·

Many techniques for ureterovesical anastomosis have been reported, specifically to prevent vesicoureteral reflux and infection, and to preserve urinary function. Each method has certain advantages and disadvantages but the success of the operation depends upon the prevention of stricture at the ureterovesical anastomosis and vesicoureteral reflux. When manipulations deep down in the pelvis are required, wide adequate exposure and simple techniques are important for the satisfactory completion and successful outcome of the operation. With these objectives in mind we have simplified the method described by Girgis and associates and have used this modified technique on 19 patients (21 ureters) with good results. 1 • 2 Indications for the method have been considered. MATERIALS

The series consists of urological patients hospitalized between 1965 and 1973. Ureteroneocystostomy was performed in 7 of 19 cases for correction of vesicoureteral reflux and/or stricture at the end of the ureter, and in the remaining 12 cases ureteroneocystostomy was combined with other J operative procedures for the treatment of various diseases. The patients have been observed at periodic intervals for 1 to 9 years postoperatively (see table). TECHNIQUE

The anesthetic method and the type of skin ' ~ incision depend on the operation being performed. . The bladder was exposed anteriorly through the •1 incision. The peritoneal fold over the bladder was Accepted for publication February 28, 1975.

stripped upward and the posterior wall of the bladder was bluntly separated toward the base. The ureter was exposed adequately and held with a 3F Nelaton catheter and the ureter was separated from the surrounding tissues so that it could be passed into the bladder without undue tension. The ureter was ligated and severed close to its junction with the bladder. The bladder was then opened in the anterior midline and the ureteral orifices were identified. A long, slim clamp was forced through the entire wall of the bladder approximately 3 cm. superior and slightly lateral to the former ureteral orifice and passed behind the bladder until it could grasp the traction suture of the ureter. The clamp was then withdrawn into the bladder. The new opening was made large enough to allow easy passage of the small finger to avoid the occurrence of postoperative stricture. The severed ureter was thus pulled into the bladder. A marker suture was placed through the tip of the ureter to later identify the anterior wall of the ureter during anastomosis. The ureter was spatulated by incising longitudinally the posterior wall for about 2 cm. The incised ureter would then show an inverted V shape. To create a raw ditch on the bladder wall into which the incised ureter could be inserted an inverted V-shaped incision was now made through the bladder membrane and superficial musculature to correspond to that of the ureter. Thus, the apex of this inverted Vshaped incision started at the new ureteral orifice and the limbs of the inverted V-shaped incision in the bladder were at least 3 cm. long. A 3-zero chromic interrupted suture was used to join the apex of the inverted V-shaped incised ureter to the apex of the inverted V shape of the bladder. Then each margin of the incised intravesi705

706

TAGUCHI, SAITO AND YAMADA

Results after the simplified method by Taguchi in 21 ureters (19 cases) Sex-Age

M-71

I I

Side of Reimplantation

Followup

9 yrs. 3 mos.

M-54 F-29

Rt. Rt. Rt.

6 yrs. 11 mos.

M- 3

Lt./rt.

5 yrs. 9 mos.

M-18

Lt.

4 yrs. 10 mos.

M-33

Lt.

4 yrs. 6 mos.

F-28

Lt./rt.

4 yrs. 1 mo.

F-25

Lt.

4 yrs.

F-25

Lt.

3 yrs. 1 mo.

F-49

Lt.

2 yrs. 11 mos.

F-35

Rt.

2 yrs. 9 mos.

F-34

Lt.

2 yrs. 6 mos.

F-30

Lt.

2 yrs. 5 mos.

M-23

Lt.

1 yr. 7 mos.

F-23 F-26

Rt. Rt.

1 yr. 6 mos. 1 yr. 6 mos.

F-52

Rt.

1 yr. 5 mos.

M-19

Lt.

1 yr. 3 mos.

F- 6

Lt.

1 yr,

9 yrs. 2 mos.

Reason for Operation

Partial cystectomy for bladder tumor Partial cystectomy for bladder tumor Stricture rt. ureter end with lt. renal tuberculosis Chronic pyelonephritis with bilat. ureteral reflux Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with lt. staghorn calculi Bilat. ureter with rt. hydronephrosis and lt. contracted kidney Lt. ureteral reflux with vesicosigmoidal fistula Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with contracted bladder for urinary tuberculosis Stricture rt. ureter end for urinary tuberculosis Lt. ureteral reflux with interstitial cystitis Chronic pyelonephritis with lt. ureteral reflux Stricture lt. ureter end with stricture lt. ureteropelvic junction Stricture rt. ureter end Rt. ureteral reflux with contracted bladder and lt. non-functional kidney Stricture rt. ureter end and rt. ureteral reflux, staghorn calculi in rt. solitary kidney, contracted bladder, vesicovaginal fistula Stricture lt. ureter end and lt. ureteral reflux Stricture lt. ureter end with lt. hydroureteronephrosis

Grade of Dilatation in Pyelogram

Voiding Cystogram

Preop. *

Postop. *

Preop.

Postop.

N A

N N NA

None None None

None None None

C

B

Bilat. reflux Lt. reflux None

None

A

NA NA NA

C

B

AB

N

C

BC

C

B A A

None None None

B

Bilat. reflux Lt. reflux Lt. reflux None

Lt. reflux None

NA

N

None

None

D

AB

C

NA

Lt. reflux None

A

A

Lt. reflux Lt. reflux None

NA DE

NA DE

B

A

None Rt. reflux Lt. reflux

None Rt. reflux Lt. reflux

B

A

C

C

Lt. reflux None

Lt. reflux None

None

None

* A-apex of minor calices is minimally round but persists hallowed out and shows pyramidal depression. B-apex of minor calices shows clubbing and the isthmus and pelvis are moderately dilated. C-major calices, isthmus and pelvis are greatly dilated but retain their proper functions. D-major calices and pelvis show remarkable dilatation and finally to large round calices. E-pelvis and calices cannot be differentiated and appear as a huge dilatated sac. NA-intermediate between N (normal) and A. AB-intermediate between A and B.

cal ureter was sutured with stitches about 5 mm. apart into each limb of the inverted V-shaped incision on the bladder wall with 3-zero chromic interrupted sutures. The opposing raw surfaces were approximated carefully with a small pincer. The sutures included the full thickness of the ureteral wall and half of the muscular layer of the bladder (figs. 1, A and 2). Two or 3 sutures of3-zero chromic catgut were then placed on the outside of the bladder where the ureter passed. Splinting catheters were ordinarily not required for the reimplanted ureter. The bladder was then closed with 1-zero catgut interrupted sutures in 2 layers. The bladder was drained by a transurethral 15F Nelaton cathet0,. with :rn
RESULTS

The patients were examined postoperatively in detail, undergoing excretory urography (IVP), retrograde cystography and tests for renal function and urinary infection. 3 • 4 The table shows the preoperative and postoperative findings on the IVP and retrograde cystogram in our 19 cases (21 ureters). The grading of the dilatation in the pyelogram was according to Huzino, and Toyoda and associates. 5 • 6 The grade of dilatation in all our cases was improved or not changed after the operation. Reflux was prevented postoperatively in all nonrefluxing ureters. In 11 ureters with reflux preoperatively, reflux was corrected in 7 ureters while 4 ureters continued to reflux. There were no remarkable effects on renal function and urinalysis. DISCUSSION

Many techniques exist for ureteroneocystostomy to prevent and correct vesicoureteral reflux but

URETERONEOCYSTOSTOMY BY MODIFIED TRIANGULAR FLAP METHOD

707

000 chromic

A Ureter

Ureter

Incised ditch of the bladder wall

. ~ f o r m e r ureteral orifice

orifice

Ureter

B

.jt

Incised ditch of the bladder wall

/:_

S.~ T • • · · " ~ Fo,m« "'""'" orifice FIG. 1. A, interrupted sutures in modified method. B, interrupted horizontal mattress sutures in original method

most could be categorized into 2 main groups: 1) direct end-to-side anastomosis with nipple or cuff and 2) elongation of intravesical ureter or submucosal tunnel technique. These techniques all have certain merits as well as disadvantages but most are difficult to apply to dilated ureters. In 1965 Girgis and Veenema reported the triangular flap method of ureteroneocystostomy, which provided a wide ureteral orifice and a valve-like flap made of the elongated intravesical ureter.' Generally, trauma inflicted to the bladder wall during the operation easily induces transient edema of the bladder mucosa and, therefore, complicated procedures in the bladder mucosa would be unsuitable. A simple method that ent sures as satisfactory anastomosis as that obtained with a complicated technique would be ideal. The use of interrupted horizontal mattress sutures to anastomose the reimplanted ureter and the bladder wall in Girgis' triangular flap ureteroneocystos-

tomy was often found difficult or impossible to perform because of edema or tearing of the bladder mucosa (fig. 1, B). Therefore, simple interrupted sutures were used to anastomose the intravesical ureter and the bladder floor (fig. 1, A). With the use of the simplest method of suture we were able to obtain the same results as with the original method. Complications that may arise after ureteroneocystostomy include reflux, ureterovesical obstruction and, rarely, disruption of the anastomosed wound. To prevent ureterovesical stricture it is important to use the sound part of the ureter for reimplantation and to avoid fine sutures that may impede blood flow. Of course, establishment of good drainage is essential to prevent infection of the anastomosis. To prevent vesicoureteral reflux the connecting parts of the ureter and bladder must be handled carefully to keep local damage to a minimum. Careful treatment will result in less

708

TAGUCHI, SAITO AND YAMADA

FIG. 2

in 20 adult female dogs. Relapse of vesicoureteral reflux occurred in 4 patients, all of whom had megaloureters and loss of peristaltic movement owing to organic changes and/or bladder wall damage extending down to and involving the deep portion, that is the so-called interstitial cystitis. However, with the exclusion of such cases our method seems to be applicable and suitable in all other cases requiring ureteroneocystostomy. REFERENCES

FIG. 3. Cystoscopic photograph

reduction of mobility and flexibility owing to fibrous degeneration of the reimplanted intravesical ureter. Precise insertion into and approximation of the incised surface of the ureter to the incised ditch of the bladder wall are important. Disruption of the anastomosed wound may occur occasionally because of added tension on the intravesical ureter. Therefore, it is essent.ial to mobilize the ureter sufficiently so that no undue tPn.sion i,- nertPC] and to pav attention to the supplying vessels of the mobilized ureter. Postoperatively, an IVP has been made at least once a year and retrograde cystography is done when necessary. Our technique produced as satisfactory and excellent results as those obtained with Girgis' original method and as demonstrated in preliminary experimental studies with this method

1. Girgis, A. S. and Veenema, R. J.: Triangular flap ureterovesicoplasty: a new technique for the correction of ureter al reflux; a preliminary report. J. Urol., 94: 233, 1965. 2. Girgis, A. S., Veenema, R. J. and Lattimer, J. K.: Triangular flap ureterovesical anastomosis: a new technique for correction or prevention of ureteral reflux. J. Urol., 95: 19, 1966. 3. Taguchi, H., Saito, K. and Ishii, N.: Long-term followup of ureteroneocystostomy by means of the modified triangular flap method. Jap. J. Urol., 64: 348, 1973. 4. Taguchi, H., Saito, K. and Yamada, T.: Clinical and experimental study on ureteroneocystostomy by means of the modified triangular flap method. Jap. J. 0101., Q;;: 2.UG, J.S7~.

5. Huzino, H.: Contributions to study of hydronephrosis: I. Statistical studies on hydronephrosis. Nagoya City Med. J., 8: 225, 1958. 6. Toyoda, Y., Yoshida, H., Tsuchiya, F.: Postoperative course of the 2nd ureterocysto anastomosis without provisions for prevention of vesico-ureteral reflux. Operation, 25: 963, 1971.