Ureterovesical Anastomosis: A Comparison of Two Principles

THE JOURNAL OF UROLOGY

Vol. 87, No. 6 June 1962 Copyright© 1962 by The Williams & Wilkins Co. Printed in U.S.A.

URETEROVESICAL ANASTOMOSIS: A COJVIPARISON OF TViTO PRINCIPLES ALBERT J. PAQUIN, JR. From the Department of Urology, University of Virginia, School of Medicine, Charlottesville, Va.

Ureterovesical anastomoses have been performed by various techniques for almost three quarters of a century. When Bovee 1 reviewed the literature on the subject in 1900 he found that 65 surgeons had done 80 such operations of which 86 per cent were successful. Some 30 years later, however, Marion2 and Legueu 3 stated that ureterovesical anastomosis was a worthless operation and that in France only 1 case had not been followed by ipsilateral renal destruction. Such divergence of opinion was occasioned by an absence of critical postoperative evaluation. Modern techniques of evaluation were unavailable both to Bovee and to the French authors, though the statement of the latter better described the operation's status as it was then and for some years thereafter. More precise assessments of the results of anastomoses were not forthcoming until the introduction of the excretory urogram. This important parameter provided a basis for establishing a reliable standard of criteria for evaluation of results and techniques. From this time on an assessment of the results of a given technique for ureteroneocystostomy is properly based upon a significant number of cases, followed for at least 6 months but preferably longer, in which the preoperative and postoperative cystograms and excretory urograms are available for comparison. It is helpful as well to know in each instance both the indication for reimplantation and the degree of dilatation and tortuosity of the ureter. The presence of additional urinary tract disorders should further be noted, particularly those which predispose towards subsequent or continuing urinary infection and those, such as cancer, neurogenic disorders, or distal obstruction, which are prejudicial to the anastomosis itself. All this information is Accepted for publication November 7, 1961. Bovee, J. W.: A critical survey of ureteral implantation. A. Surg., 32: 165, 1900. 2 Marion, G. and Legueu, F.: In Societe frangaise d'urologie: Seance du lundi 15 juin 1925. J .d' urol., 20: 58, 1925. 3 Legueu, F.: In Soci6t6 frangaise d'urologie: Seance du lundi 18 mai 1931. J.d'urol., 31: 615, 1931. 818 1

of course not available to a retrospective study, but the more of it that is obtained, the more precise can be the evaluation of anastomotic techniques, the more accurate can comparisons be made between them, and the more easily can their weaknesses be exposed. The purpose of this paper is to review within the limits of available data those publications on ureteroneocystostomy which are significant in the light of these critical requirements in order to compare principles of ureterovesical anastomosis and assess their relative merits. The results obtained by the various techniques of ureteroneocystostomy described in the literature fall historically into two groups, which shall be referred to as the "end-to-side-or-back" and "valvular" techniques. In the first group the principle has been to attach the ureter to the bladder without making any effort to simulate the normal course of the ureter through the submucosa; such simulation, indeed, said some authors, was impossible. Procedures based upon this principle have included perforating the bladder at various points, directing the ureter through the perforation by divers ingenious means, and stitching the ureter either inside or outside the bladder or both. Techniques have varied chiefly in the means by which this attachment was effected and in the management of the distal encl of the ureter _4- 13 Several of these varia4 Orr, L. J\11.: The consequences of the surgical relief of ureterovesical obstruction. J. Urol.. 63: 1043, 1950. . 5 Vest, S. A.: Personal communication. 6 Councill, W. A.H., Jr.: Surgical treatment of vesicorenal reflux. South. Med. J., 49: 1104, 1956. 7 Grey, D. H., Flynn, P. and Goodwin, W. E.: Experimental methods of ureteroneocystostomy: Experiences with the ureteral intussusception to produce a nipple or valve. J. Urol., 77: 154, 1957. 8 Hill, J. E., Dodson, A. I., Jr. and Hooper, J. W., Jr.: Experimental ureteroneocystostomy using nipple anastmnosis technique. J. 1Jrol., 74: 596, 1955. 9 Burns, J. E.: Extraperitoneal reimplantation of the ureter into the bladder. J. Urol., 19: 541, 1928. 10 Lowsley, 0. S. and Kirwin, T. J.: Clinical Urology, 1st ed. Baltimore: Williams & Wilkins Company, 1940. vol. 2. 11 Valk, W. L. and Donald, E. W.: Ureteroneocystostomy. J. Urol., 81: 403, 1959.

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URE'TEROVESICAL ANASTOMOSIS

"END-TO-SIDE -OR-BACK" TECHNIQUES FOR URETERONEOCYSTOSTOMY Vest Council Grey,Flynn SGoodwin Hill,Dodson a Hooper

-

I. Simple "end-to-side"

2."Cuffs"

3. "Fish mouth"

Grey,Flynrr S.Goodwin

FIG. 1. Schematic presentation of some reported techniques for ureterovesical anastomoses employing "end-to-side-or-back" principle. tions are schematically represented in figure 1. All these techniques can be described as deriving from the end-to-side-or-back principle of anastomosis. Combined experience has led various authors adhering to this principle to suggest that the operation be performed extraperitoneally, that the ureteral blood supply be preserved, that the ureter be straightened, that it be implanted as low in the bladder as possible, that the bladder be put at rest by supra pubic drainage, and that only rubber drains be employed. Testing by current criteria the three significant series of anastomoses since 1933 which were based upon the end-to-side-or-back principle can elicit some idea of its value. In 1933 Beer14 reported 41 cases in which ureteroneocystostomies were performed, some in connection with ureteral injury or obstruction but the majority in conjunction with excision of vesical cancers. Few of the patients had preoperative pyelograms and cystograms. Only six had postoperative cystograms, none of which disclosed ureteral reflux. Of the 14 postoperative 12 Patton, J. F.: Ureterovaginal fistula: A new method of reimplantation of the ureter into the bladder. J. Urol., 42: 1021, 1939. 13 Young, H. H. and Davis, D. M.: Young's Practice of Urology. Philadelphia and London: W. B. Saunders Co., 1926, vol. 2. 14 Beer, E.: Value of ureteral re-implantation in bladder. Am. J. Surg., 20: 8, 1933.

pyelograms, one showed no evidence of excretion of the contrast agent and five were normal, while eight, one of which was said to have shown improvement when compared with the preoperative pyelogram, demonstrated some degree of hydronephrosis. The six postoperative cystograms supplemented four of these hydronephrotic and two of the normal pyelograms. By current criteria then, only 6 patients underwent sufficient radiographic studies to test properly the results of anastomosis and only two of these six had no reflux and normal pyelograms. Although more of the 41 operations in this series may have succeeded in fact, 2 successes alone were therefore proved. There were four immediate postoperative deaths, 3 deaths following urinary sepsis, and 2 deaths following subsequent nephrectomy. Two additional patients had nephrectomies following sepsis and two had pain in the flank on the operative side. More instructive perhaps is a series, reported by Henderson,1 5 of 73 cases, in 67 of which ureteroneocystostomy was performed in conjunction with partial cystectomy for carcinoma. Unfortunately, however, preoperative and postoperative radiographic studies of this series were correlated neither with one another nor with 15 Henderson, D. St. C. L.: Reimplantation of the ureter. Brit. J. Urol., 25: 3, 1953.

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ALBERT J. PAQliI:'<, JH.

TABLE

1. Comparison of res11.lts obtained from techniques for nreteroncocystostoiny utilizing 2 different

principles as summarized from selected reports in the literatw·e Results Technique

Number of Anastomoses Reflux

End-to-side Valvular

138 346

75% 10.7%

Proven obstruction

:s/o obstruction

Unknown 9%

48% 91%

postoperative studies of infection. Of 31 postoperative cy;;tograms, 15 showed evidence of stricture and six showed evidence of infection; reflux was disclosed in all but three, but for these three there was no specific report of the status of the upper urinary tract. Forty-two patients had postoperative excretory urograms, 29 demonstrating good function, five moderately good function, five poor function, and three no function; hydronephrosis was reported in 3 patients, chronic pyelonephritis in 10, and early changes of chronic pyelonephritis in nine. The pyclogram was reported normal in 19. A third report, by Valk and Donald, 11 dealt with 24 patients divided equally into two groups according to the t"·o anastomotic techniques employed. Both techniques were variants of endto-side ureteroneocystostomy. Cystography of the patients in one group revealed reflux in all 14. Cystography of 6 patients in the second group disclosed reflux in one. Five patients in this second group had normal pyelograms. In these 3 reports there was a total of 138 anastomoses (table 1). Of 55 postoperative cystograms, 14 (25.4 per cent) den10nstrntecl no reflux, but at least four of the ptttients with no reflux had some degree of hydronephrosis. Of 60 postoperatiYe excretory urograms, only 29 (48 per cent) ,vere reported as normal but there is no indication of how man)· of the 52 per cent demonstrating hydronephrosis or failing function showed improvement when compared with preoperative pyelograms. These data suggest that while end-to-side anastomosis will not be followed b)' obstruction in 48 per cent of instances where it is employed, it \1ill be followed by reflux in 75 per cent. Although no statement can be made about associated infection in the postoperative period, the association of infection with reflux is so frequent that orn! would surmise that a correspondingly high percentage of these patients had chronic or recurring infection. Of this point Henderson's series 15 is most illustra-

i

I Failmes cause unspectfied

I I

Successes

I

Unknown Less than 25% 75c;,'c, 5% I I

tive, for he reported that 19 (46 per cent) of 41 patients tested showed radiographic evidence of pyelonephritis and that many of these patients wei:e among those follmrnd for the longest time. A similar assessment can be made of a series of ureteroneocystostomies designed to reconstruct a competent ureterm·esical valve. Graves and Davicloff16 in 1925 ancl Vermooten, Spies and Neuswanger 17 in 1934 used a submucosal tunnel to reimplant ureters in dogs. 1Vhile the former authors reported success in both of 2 animals, the latter authors found that fo·e of 10 ureteroneocystostomies resulted in stricture at the site of anastomosis. Stevens and :'viarshall 18 in 1943 employed this principle in 10 patients. Postoperatively, four of these patients had cystograms, tv,o of which showed reflux, and nine had excretory urograms, two of "·hich disclosed hydronepbrosis; there was 1 death. In 1952 Hutch 19 presented his technique for Yulvular reconstruction and in 1958 20 summurizecl the results obtained b,1· .'52 urologists. Of 252 operations he reported 185 were successful and 67 were failures. Reflux accounted for 29 of these failures, obstruction for 21 and 17 were not explained. Politano and Leadbetter 21 described their technique in the same year, with the results of 21 ureterom:ocystostomies in 14 patients; 20 of the 16 Graves, R. C. and Davidoff, L. M.: Studies on bladder and ureters with especial reference to regurgitation of vesical contents: Regurgitation as observed in cats and dogs. J. Urol., 14: 1, 1925. 17 Vermooten, V., Spies, J. W. and :i'\euswanger, C.: Transplant,ition of the lower encl of the dog's ureter: An experimental study . .J. Urol., 32: 261, 1934. 18 Stevens, A. R. and Marshall, V. F.: Reimplantation of the ureter into bladder: report of a method applied to ten patients. Surg., Gynec. & Obst., 77: 585, 1943. 19 Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. Urol., 68: 457, 1952. 20 Hutch, J. A.: The Ureterovesical Junction. Berkeley: University of California, 1958. 21 Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 19,58.

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URETEROVESICAL ANASTOMOSIS

0BUQUE VALVULARH TECHNIQUES FOR URETERONEOCYSTOSTOMY 11

Stevens

a Marshall

Politano

Hess

Dodson

a Leadbetter

Hutch

Paquin

F1G. 2. Rchenrntic presentation of some reported techniques for urcterovesic:1! anastomoses employing principle of valvular obliquity.

21 were suc:ccssful, the singk failure owing to obstruction. ln 1959 the present ::nithor22 reported his ex1ierience with 63 anastomoses, 71 per cent of \Yhich 1n·rc successful Of the failures, eight were due to reflux, three to obstruction, and six to sloughing of the ureter. Some of these techniques are schematically represented rn figure 2.1s-1\J, n-24 In these series then tht'n' 1wrc) 84ti anastomosr's based upon the principle of YrtlYular reconstruction. All but six of thc-.~e anastomo~es \YCTe folluwecl with posto1wrntin· cystoµ;rams and all bnt one were follmved ,vith postoperative pyelog;rams. According to l
thens,, of the principle• of ndndar r<'C(mstnwtim1 \\'ith or without a submncosal tunnel ubtui11ccl a. far higher pc"rcentage of good resnlt, than tlie use of the end-to-side-or-back prillciplc. lateral reflux follcmrd 7.5 per cent of tJ-,e l'ild--to side anastonwsc:s, for (-:xamplt•, hut 1i-:1,- demonstrated in onl,1' 10.7 JH:r ('l:nt of th1: ntlndar anastomoses; and ,dthough pustu11eratin" obstruction mnnot be assessed 1,·ith <'Cp1al :t(·nm1cy, pyelograms in the end-to-side-or-back ,eri(:s showed absence of obstruction in onl,1per cent 1 \\'hile in the valvular series only 9 JK'l' c,·nt. wc·n: sho\\'n to Im n: failed from obstrm:tiun . .J uclging from these comparisons, a kchniqm' of anastomosis invoh·ing an oblique passage t,l tlw ureter into the bladder to form a vc,h (,' therefore seems preferable to a simple c rnl-tu-~ide-orback technique. Although more d,,m:1ndinµ;, such a technique is not formidabJ, ,md the greater attention and care n:quired tc, form the vain' are fully justified by its for snrwricJr re.sults. 0

DTSCUSSIO='!

Since results olitainecl will vary 1Yitl1 t!t{' underlying disease process im,o!Yecl, the· resLtlts of anastomosis done for a gin:n tmcler],1-ing di,;cmlcr, whether it be cancer, congenital anon1:,l,1-, 1wuro-genic bladder, or trauma, should lw summarized

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ALBERT J. PAQUIN, JR.

separately. There has been a tendency, however, to summarize results without an adequate descriptive classification of the disorders which prompted the anastomoses and a comparison of the two principles of ureteroneocystostomy can therefore be made only in the most general terms. In contrast with the valvular series, where anastomosis was employed principally for the correction of congenital anomalies and of reflux from ncurogenic bladders, the bulk of ureteroneocystostomies done by the end-to-side-or-back technique were performed in connection with vesical cancer or ureteral trauma. To the extent then to which lack of information prohibits taking these underlying disorders into account, the comparison of principles made here contains an inherent inaccuracy which may be prejudicial to a just asse8sment of either principle or of both. At this time, nevertheless, it is the best comparison possible. Of equal or greater importance to the accuracy of a comparison between techniques is a consideration of the status of the bladder, ureter and kidney at the time of operation. That distinctions of such status should be made in postoperative evaluation of a ureterovesical anastomosis has been suggested by the present author before. The results obtained, for example, from transplanting a single straight ureter of good length but less than 1 cm. in diameter into a large

untrabeculated bladder, for whatever reasons, will undoubtedly be far superior to results obtained from transplanting a large, tortuous ureter into a small, heavily trabeculated bladder. Just evaluation will be largely inhibited by failure to take these differing conditions into account. It would hardly seem, however, that reflux should follow so large a portion as 75 per cent of the end-to-side-or-back anastomoses and so small a portion as 10.7 per cent of the valvular anastomoses unless, with inherent weaknesses in both techniques, the weaknesses were greater in the end-to-side-or-back technique. Little information was supplied relative to either technique which would allow a comparison of the preoperative status of the upper urinary tract with its postoperative status and therefore a similar assessment of comparative postoperative obstruction is less revealing. In terms of available data, however, the great disparity between the two techniques nevertheless openly stands, a disparity of successful results so great as to suggest, first, that major responsibility for failures of ureteroneocystostomy belongs considerably less to underlying disorders or operative conditions than to a basic weakness of anastomotic principle and, secondly, that of the two such principles here evaluated, the valvular principle of uretcroneocystostomy is much the superior.