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Ureteroneocystostomy Simplex: A Simple and Effective Approach to Vesicoureteral Reflux
Vol. 98, Aug"
THE JOURNAL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
Printed in
.S,.l1,
URETERONEOCYSTOSTO.MY SIMPLEX: A SilvIPLE AND EFFECTIVE APPROACH TO VESICOURETERAL REFLUX JOSEPH H. POYNTER,* RALPH. II. MONGER, JR.
AND
S. BRITT OWENS
From the Section of Urology, United States Naval Hospital, M~emphis, Tennessee
History credits Gustav Simon with the performance of the first successful reimplantation of a ureter into a bladder in 1856.1 However, it was well into the twentieth century before ureteroneocystostomy gained wide acceptance. In the early 1930's, :rviarion and Legueu, speaking at a meeting of the French urological Society, went so far as to say that reimplantation of a ureter into a bladder was an operation without any value. 2 As late as 1940, Hyman and Leiter, while advocating the procedure, pointed out that considerable controversy still existed in regard to the efficacy of reimplantation. 3 The results of the early cases are not well documented but with the advent of excretory urography in 1929, successes could be proven and the procedure gained favor. 4 Originally, reimplantation was done for injuries encountered during pelvic operations and for ureterovaginal fistulas. Later the urologist applied the technique in segmental bladder resection for cancer, and more recently, vesicoureteral reflux has been corrected by reimplantation. Surgical ingenuity has provided an abundance of techniques for reimplanting the ureter into the bladder but, in general, most can be categorized into 2 groups: 1) direct end-to-side anastomosis and 2) valvular or submucosal tunnel technique. In recent years, awarene8S of the sequelae of vesicoureteral reflux has led to the general acceptance of the valvular or submucosal tunnel technique as the procedure of choice for ureteroneocystostomy. In 1952, Hutch reported his experience with vesicouretcroplasty in paraplegics Accepted for publication September 27, 1966. * Present address: Boulder Medical Center, 2750 Broadway, Boulder, Colorado. The opinions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. 1 Bissel, D.: Amer. J. Obst., 47: 145, 1903. 2 Beer, E.: Amer. J. Surg., 20: 8, 1933. 3 Hyman, A. and Leiter, H. E.: S. Clin. North Amer., 20: 341, 1940. 4 Emmett, J. L.: Clinical Urography. An Atlas and Textbook of Roentgenographic Diagnosis. Philadelphia: W. B. Saunders Co., 2nd edition, 1964.
with reflux. 5 Later in 1958, Politano and Leadbetter presented their technique for correction of reflux. 6 Then in 1959, Paquin reported a technique for correction of vesicoureteral reflux which was also applicable for reimplantation following trauma or segmental resection. 7 'With the introduction of these 3 techniques, valvular ureternneocystostomy made rapid gains and in 1962 Paquin compiled 346 cases comparing the application and results of these 3 methods. 8 He found an over-all success rate of 75 per cent with a 10 per cent failure rate due to reflux, a 9 per cent failure rate due to ureterovesical obstruction and a 5 per cent failure due to unknown causes. The vast majority of commonly used antlreflux procedures, with the notable exception of those used by Paquin, strive to maintain the entire continuity of the ureter, including the intra,vesical portion. It seems reasonable to make an effort not to sever a normal structure if at all possible; however, on the other hand, we are not dealing with a normal structure in a refluxing; ureter. Knowing that the intravesical portion of the ureter is diseased, why then would it not be just as reasonable to eliminate as much of the diseased segment as possible and reimplant more normal ureter? vVe tried several commonly used anti-reflux procedures and were not entirely satisfied with any one particular technique. Certainly, satisfactory results were obtained with the more commonly used techniques, but we felt that there must be a technically more simple, as well as more effective approach, vVe claim no originality whatsoever for the basic technique used as it has been used in one form or another for years. However, we do feel that after some refinements it has been the most successful anti-reflux procedure that we have employed. Because of its technical simplicity and the favorable results that we have had, ·we have elected to UBe the term ureteronPm'ysto~5 Hutch, J. A.: J. Urol., 68: 457, 1952. 6 Politano, V. A. and Leadbetter, W. F.: J. Urol., 79: 932-941, 1958. 7 Paquin, A. J., Jr.: J, Urol., 82: 573-58:·L l\J5\L 8 Paqnin, A. ,J., Jr.: J. Urol., 87: 818, 1962. 195
196
POYNTER, MONGER AND OWENS
FIG. 1
tomy simplex as descriptive of the operative procedure. Certainly any one who is adept and has good results with one procedure will continue that technique. On the other hand, one who deals with anti-reflux procedures infrequently or who is looking for a technically simple and effective method should find the ureteroneocystostomy simplex approach to the problem most applicable. It should be further pointed out that although most of the cases reported in this paper are those done specifically for correction of vesicoureteral reflux, this method may be used in any situation in which reimplantation of the ureter is required. TECHNIQUE
We use the standard Pfannenstiel incision with reflection of the anterior rectus fascia both superiorly and inferiorly. The rectus muscles are bluntly separated and a small Balfour retractor is used to maintain adequate exposure. Prior to opening the bladder, which previously has been distended with normal saline via a Foley catheter, the anterior and deep lateral vesical regions are mobilized. The bladder is opened in the anterior midline or further laterally if a Y-V plasty of the bladder neck is proposed. The orifice of the ureter is identified and a No. SF red Robinson catheter is passed up the ureter about 10 cm. By palpation of the retrovesical area, the ureter is identified and grasped with a Babcock clamp. It is then relatively easy to free the ureter down to the bladder and superiorly to the region of the iliac vessels.
FIG. 2
Following removal of the red Robinson catheter, the ureter is clamped close to the bladder, severed and the distal portion suture ligated with an O chromic catgut suture. A marking suture of 4-0 silk through the tip of the ureter is attached to a hemostat and laid aside. At this point 3 tenting sutures of 4-0 chrnmic catgut are placed through the bladder mucosaone on each side of the proposed new orifice and the third marking the end of the submucosal tunnel (fig. 1, A). The tunnel length should be approximately 5 times the diameter of the ureter involved but care should be exercised not to greatly exceed this length. The new orifice is usually superior and slightly medial to the original one. The 2 sutures on each side of the new orifice are held by an assistant and a small mucosal incision is made. With all 3 tenting sutures held, a hemostat is used to make a quick and accurate tunnel. These mucosal elevating
197
URETERONEOCYSTOSTOMY SIMPLEX
sutures greatly facilitate the procedure, eliminate guessing as to length and angulation and "buttonholes" in the mucosa are avoided. The hemostat is pushed through the bladder wall at the end of the tunnel and spread approximately 3 times the diameter of the ureter (fig. 1, B). The silk marking suture attached to the ureter is grasped with the protruding hemostat and the ureter is brought down through the new submucosal tunnel. The ureter is spatulated by means of an incision approxin1ately 1 cm. in length. A nipple is formed using three to four 4-0 chromic catgut sutures (fig. 1, C). We generally use a polyethylene ureteral splint and have found a No. 8 infant feeding tube to be most satisfactory. It is brought out through a stab wound in the anterior bladder wall. A 4-0 chromic catgut suture is placed through the mucosa medial to the new orifice and tied to the splint (fig. 2). This will maintain the splint in position and its removal after 7 days has caused no problem. Prior to closure of the bladder a suture of 4-0 chromic catgut is placed through the posterior bladder wall and the advcntitia of the ureter at its new entrance. This is to help provide stabilization of the newly implanted ureter. RESULTS
At the U. S. Naval Hospital in Tennessee, 14 ureters in 11 patients were reimplanted during an 18-month period. All except 1 case involved female patients. Because of the transient status of the military population, complete followup on all patieRts was not possible. However, in most cases postoperative excretory urograms and cystograms were obtained. Eight of the 10 female patients were children who had had recurrent urinary tract infections over a long period of time. They had been treated conservatively with chemotherapy and/or urethral dilatations. Reflux was demonstrated on cystograms in each case and some had upper urinary tract cbanges. As a result, all the aforementioned cases ·were higbly selective and refractory to other methods of treatment. Of the 2
women involved, one was reimplanted becausco of carcinoma (wedge resection) involving the ureteral orifice and tbe other as a result of massive reflux and pyelonephritis in a The 1 male patient was a IO-year-old boy who had a large bladder diverticulum the ureteral orifice. Three of the 11 patients have not been evaluated as to their postoperative status, since two are too recent to comment and one moved shortly after the procedure. Two occurred in this series. One child required revision of the nipples of a duplicated left ureter and no,v has a normal excretory urogram and cystogram. Another child had severe stenosis of the ureter from the orifice proximally for 3 to 4 cm. and her revision is too recent to evaluate. Tbcrefore of 14 ureters reimplanted, 11 are classified as excellent results in that they all had normal excretory urograms and fluid postoperatively and remained free of infection. One patient was lost to followup and two were too early to completely evaluate. The presented is not offered as one to eliminate all complications and acbieve 100 per cent excellent results but to afford the operator a more satisfactory procedure. These results are certainly comparable to any other series, admittedly small. Certainly an occasional case will need revision but the technique nevertheless needs no alteration, SUMMARY
A technique of ureteroneocystostomy has been presented. This method basically is not new but refinements have been added to greatly aid the operator. By use of the tenting sutures the submucosal tunnel is easily and accurately eliminating some of the usual hazards, In addi tion other aids in technique were including the use of a suture to secure the ure teral splint. A small series of cases was discussed and evaluated. It is hoped that this will be beneficial to those who both frequently and infrequently use ureteral reimplantation.
THE JOURNAL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
Printed in
.S,.l1,
URETERONEOCYSTOSTO.MY SIMPLEX: A SilvIPLE AND EFFECTIVE APPROACH TO VESICOURETERAL REFLUX JOSEPH H. POYNTER,* RALPH. II. MONGER, JR.
AND
S. BRITT OWENS
From the Section of Urology, United States Naval Hospital, M~emphis, Tennessee
History credits Gustav Simon with the performance of the first successful reimplantation of a ureter into a bladder in 1856.1 However, it was well into the twentieth century before ureteroneocystostomy gained wide acceptance. In the early 1930's, :rviarion and Legueu, speaking at a meeting of the French urological Society, went so far as to say that reimplantation of a ureter into a bladder was an operation without any value. 2 As late as 1940, Hyman and Leiter, while advocating the procedure, pointed out that considerable controversy still existed in regard to the efficacy of reimplantation. 3 The results of the early cases are not well documented but with the advent of excretory urography in 1929, successes could be proven and the procedure gained favor. 4 Originally, reimplantation was done for injuries encountered during pelvic operations and for ureterovaginal fistulas. Later the urologist applied the technique in segmental bladder resection for cancer, and more recently, vesicoureteral reflux has been corrected by reimplantation. Surgical ingenuity has provided an abundance of techniques for reimplanting the ureter into the bladder but, in general, most can be categorized into 2 groups: 1) direct end-to-side anastomosis and 2) valvular or submucosal tunnel technique. In recent years, awarene8S of the sequelae of vesicoureteral reflux has led to the general acceptance of the valvular or submucosal tunnel technique as the procedure of choice for ureteroneocystostomy. In 1952, Hutch reported his experience with vesicouretcroplasty in paraplegics Accepted for publication September 27, 1966. * Present address: Boulder Medical Center, 2750 Broadway, Boulder, Colorado. The opinions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Navy Department or the Naval Service at large. 1 Bissel, D.: Amer. J. Obst., 47: 145, 1903. 2 Beer, E.: Amer. J. Surg., 20: 8, 1933. 3 Hyman, A. and Leiter, H. E.: S. Clin. North Amer., 20: 341, 1940. 4 Emmett, J. L.: Clinical Urography. An Atlas and Textbook of Roentgenographic Diagnosis. Philadelphia: W. B. Saunders Co., 2nd edition, 1964.
with reflux. 5 Later in 1958, Politano and Leadbetter presented their technique for correction of reflux. 6 Then in 1959, Paquin reported a technique for correction of vesicoureteral reflux which was also applicable for reimplantation following trauma or segmental resection. 7 'With the introduction of these 3 techniques, valvular ureternneocystostomy made rapid gains and in 1962 Paquin compiled 346 cases comparing the application and results of these 3 methods. 8 He found an over-all success rate of 75 per cent with a 10 per cent failure rate due to reflux, a 9 per cent failure rate due to ureterovesical obstruction and a 5 per cent failure due to unknown causes. The vast majority of commonly used antlreflux procedures, with the notable exception of those used by Paquin, strive to maintain the entire continuity of the ureter, including the intra,vesical portion. It seems reasonable to make an effort not to sever a normal structure if at all possible; however, on the other hand, we are not dealing with a normal structure in a refluxing; ureter. Knowing that the intravesical portion of the ureter is diseased, why then would it not be just as reasonable to eliminate as much of the diseased segment as possible and reimplant more normal ureter? vVe tried several commonly used anti-reflux procedures and were not entirely satisfied with any one particular technique. Certainly, satisfactory results were obtained with the more commonly used techniques, but we felt that there must be a technically more simple, as well as more effective approach, vVe claim no originality whatsoever for the basic technique used as it has been used in one form or another for years. However, we do feel that after some refinements it has been the most successful anti-reflux procedure that we have employed. Because of its technical simplicity and the favorable results that we have had, ·we have elected to UBe the term ureteronPm'ysto~5 Hutch, J. A.: J. Urol., 68: 457, 1952. 6 Politano, V. A. and Leadbetter, W. F.: J. Urol., 79: 932-941, 1958. 7 Paquin, A. J., Jr.: J, Urol., 82: 573-58:·L l\J5\L 8 Paqnin, A. ,J., Jr.: J. Urol., 87: 818, 1962. 195
196
POYNTER, MONGER AND OWENS
FIG. 1
tomy simplex as descriptive of the operative procedure. Certainly any one who is adept and has good results with one procedure will continue that technique. On the other hand, one who deals with anti-reflux procedures infrequently or who is looking for a technically simple and effective method should find the ureteroneocystostomy simplex approach to the problem most applicable. It should be further pointed out that although most of the cases reported in this paper are those done specifically for correction of vesicoureteral reflux, this method may be used in any situation in which reimplantation of the ureter is required. TECHNIQUE
We use the standard Pfannenstiel incision with reflection of the anterior rectus fascia both superiorly and inferiorly. The rectus muscles are bluntly separated and a small Balfour retractor is used to maintain adequate exposure. Prior to opening the bladder, which previously has been distended with normal saline via a Foley catheter, the anterior and deep lateral vesical regions are mobilized. The bladder is opened in the anterior midline or further laterally if a Y-V plasty of the bladder neck is proposed. The orifice of the ureter is identified and a No. SF red Robinson catheter is passed up the ureter about 10 cm. By palpation of the retrovesical area, the ureter is identified and grasped with a Babcock clamp. It is then relatively easy to free the ureter down to the bladder and superiorly to the region of the iliac vessels.
FIG. 2
Following removal of the red Robinson catheter, the ureter is clamped close to the bladder, severed and the distal portion suture ligated with an O chromic catgut suture. A marking suture of 4-0 silk through the tip of the ureter is attached to a hemostat and laid aside. At this point 3 tenting sutures of 4-0 chrnmic catgut are placed through the bladder mucosaone on each side of the proposed new orifice and the third marking the end of the submucosal tunnel (fig. 1, A). The tunnel length should be approximately 5 times the diameter of the ureter involved but care should be exercised not to greatly exceed this length. The new orifice is usually superior and slightly medial to the original one. The 2 sutures on each side of the new orifice are held by an assistant and a small mucosal incision is made. With all 3 tenting sutures held, a hemostat is used to make a quick and accurate tunnel. These mucosal elevating
197
URETERONEOCYSTOSTOMY SIMPLEX
sutures greatly facilitate the procedure, eliminate guessing as to length and angulation and "buttonholes" in the mucosa are avoided. The hemostat is pushed through the bladder wall at the end of the tunnel and spread approximately 3 times the diameter of the ureter (fig. 1, B). The silk marking suture attached to the ureter is grasped with the protruding hemostat and the ureter is brought down through the new submucosal tunnel. The ureter is spatulated by means of an incision approxin1ately 1 cm. in length. A nipple is formed using three to four 4-0 chromic catgut sutures (fig. 1, C). We generally use a polyethylene ureteral splint and have found a No. 8 infant feeding tube to be most satisfactory. It is brought out through a stab wound in the anterior bladder wall. A 4-0 chromic catgut suture is placed through the mucosa medial to the new orifice and tied to the splint (fig. 2). This will maintain the splint in position and its removal after 7 days has caused no problem. Prior to closure of the bladder a suture of 4-0 chromic catgut is placed through the posterior bladder wall and the advcntitia of the ureter at its new entrance. This is to help provide stabilization of the newly implanted ureter. RESULTS
At the U. S. Naval Hospital in Tennessee, 14 ureters in 11 patients were reimplanted during an 18-month period. All except 1 case involved female patients. Because of the transient status of the military population, complete followup on all patieRts was not possible. However, in most cases postoperative excretory urograms and cystograms were obtained. Eight of the 10 female patients were children who had had recurrent urinary tract infections over a long period of time. They had been treated conservatively with chemotherapy and/or urethral dilatations. Reflux was demonstrated on cystograms in each case and some had upper urinary tract cbanges. As a result, all the aforementioned cases ·were higbly selective and refractory to other methods of treatment. Of the 2
women involved, one was reimplanted becausco of carcinoma (wedge resection) involving the ureteral orifice and tbe other as a result of massive reflux and pyelonephritis in a The 1 male patient was a IO-year-old boy who had a large bladder diverticulum the ureteral orifice. Three of the 11 patients have not been evaluated as to their postoperative status, since two are too recent to comment and one moved shortly after the procedure. Two occurred in this series. One child required revision of the nipples of a duplicated left ureter and no,v has a normal excretory urogram and cystogram. Another child had severe stenosis of the ureter from the orifice proximally for 3 to 4 cm. and her revision is too recent to evaluate. Tbcrefore of 14 ureters reimplanted, 11 are classified as excellent results in that they all had normal excretory urograms and fluid postoperatively and remained free of infection. One patient was lost to followup and two were too early to completely evaluate. The presented is not offered as one to eliminate all complications and acbieve 100 per cent excellent results but to afford the operator a more satisfactory procedure. These results are certainly comparable to any other series, admittedly small. Certainly an occasional case will need revision but the technique nevertheless needs no alteration, SUMMARY
A technique of ureteroneocystostomy has been presented. This method basically is not new but refinements have been added to greatly aid the operator. By use of the tenting sutures the submucosal tunnel is easily and accurately eliminating some of the usual hazards, In addi tion other aids in technique were including the use of a suture to secure the ure teral splint. A small series of cases was discussed and evaluated. It is hoped that this will be beneficial to those who both frequently and infrequently use ureteral reimplantation.