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Urinary Diversion in Children
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y;_;ili,;:i1,ii
URINARY DIVERSION IN CHILDREN A. RICHARD KENDALL
AND
LESTER KARAFIN
From the Department of Urologv, St. Christopher's Hospital for Children, Temple University School of Medicine and the Medical College of Pennsylvania, Philadelphia, Pennsylvania
While the basic operations for urinary diversion are similar in children and in adults, the indications for urinary diversion in children are significantly different (table 1). In the child more than in the adult, one tends to choose an operation that might be reversible and permit reconstitution of the urinary tract at a later date. Thus, there is a tendency to use suprapubic cystostomy, or loop ureterostomy as a temporary procedure in the patient with obstructive disease in the hope that vesical function and satisfactory renal drainage will return. Between 1963 and 1971, 121 urinary diversion operations were perforn1ed in 85 children at this hospital (tables 2 and 3).
ating a vesicocutaneous fistula resulting in vesical urinary diversion without the complications attributed to an indwelling catheter. 1 Since that time hundreds of these or similar operations have been performed in adults and children, especially in those with neurovesical dysfunction. Recently, Lapides and associates reported on a 10-year survey of 52 patients who had undergone vesicostomy and concluded that "the number of patients doing well with cutaneous vesicostomy would approach 100 per cent if patients with pre-existing severe renal disease and those who failed to return for regular followup studies were deleted from the series". 2 There are potential complications of vesicostomy. 1) Bladder flap slough may be caused by excess tension or faulty technique interfering with the blood supply. 2) Stomal stenosis is usually caused excision of an inadequate segment of rectus fascia or slough of the bladder flap. 3) Residual urine may be due to stomal stenosis. Normally, there is some residual urine vesicostomy but since there is no increase in intraveiscal pressure, ureteral reflux, even if present preoperatively, is usually not a clinical problem. 4) Infected uritte-almost all patients have bacteriuria but clinical and pyelonephritis are less frequent than with suprapubic cystostomy. 5) Calculus formation-small calculi often form on the hairs of the skin but can be removed manually through the stoma without any In 5 per cent of patients who were calculus-free prior to renal calculi develop. 6) Urethral incontinence may be prevented by closure of the vesical neck at the time of operation. This is imperative in all female subjects. Stomal stenosis may result in urethral incontinence in male to vesical 7) Roentgenographic evio.ence of renal deterioration ""'"v,.1u,,_1 to infection or calculus disease shouid m pa8) Paraof the bladder the stoma usuaily is caused the technical error of excising too a segment of anterior rectus fascia. 9) Skin reactions and collection device failures may be noted. Most of these potential complications are preventable with a carefui technique. We
VESlCAL DIVERSION
Suprapubic cystostomy. During the past :2 decades the indications for temporary and permanent cystostomy drainage have diminished. The maior goals of any are to adequate drainage and protection to the upper urinary tract, maintain continence and eliminate residual urine without introduction of a foreign body into the urinary tract. Although cystostomy is clinically successful in many cases, it does fall far short of these goals. The catheter produces vesical calculi and ascending renal infection while vesical spasm may result in incontinence per urethram. Too often cystostomy drainage is unsatisfactory in the achievement of its drainage of the upper urinary tract. If cystostomy is ~ v+,w,~ in the presence of decompensated ureters, one cannot expect to have adequate renal drainage. However, it is not infrequent to find increasing ureteral dilatation and poor secondary to a more or less functional obstruction ovving to the contracted, empty bladder. The indications for cystostomy drainage are at the time of ,H,v,fj,cw urethral or vesical trauma, in cases of mild ureterai dilatation to urethral valves prior to definitive resection and in some cases of neurogenic bladder or u'11,gi1u,,eu vesical prior to consideration of permanent supravesical diversion. Cutaneous and ere0
1 Lapides, J., Ajemian, E. P. and Lichtward.t, ,J. R.: Cutaneous vesicostomy. ,J. Urol., 84: 609, 1960. 2 Lapid.es, ,J., Koyanagi, T. and Diokno, A.: Cutaneous vesicostomy: 10-year survey. ,J. Urol., 105: 76, 1971.
Accepted for publication August 4, 1972. Read at annual meeting of American Urological Association, Washington, D.C., May 21-25, 1972. 717
KENDALL AND KARAFIN
718 TABLE
1. Indications for urinary diversion in children
N eurogenic bladder disease Exstrophy or epispadias Renal damage secondary to infravesical (urethral valves) or vesical (ureterocele) obstruction Renal damage secondary to advanced ureteral reflux Incorrectable incontinence Incorrectable traumatic lesions of the lower urinary tract TABLE
2. Indications for operation in 85 patients No.Pts.
Neurogenic bladder disease Exstrophy or epispadias with incontinence Renal damage secondary to infravesical obstruction Renal damage secondary to advanced ureteral reflux Renal damage secondary to ureterocele Sarcoma of the prostate
51 4
21 5 3
1 85
TABLE
3 No. Operations
Suprapubic cystostomy Cutaneous vesicostomy Cutaneous ureteroileostomy (ilea! loop) Transureteroureterostomy Unilateral cutaneous ureterostomy Bilateral cutaneous ureterostomy single stoma Bilateral cutaneous loop ureterostomy Nephrostomy
25 13 42 8 7 13 11 2
121
have found vesicostomy to be a technically easy operation that provides excellent protection of the upper urinary tracts. 3 When properly performed, it has few serious complications. However, owing to the localization of the stoma in the midline of the lower abdomen, we have not been successful in maintaining a collection device in ambulatory children. Thus, cutaneous vesicostomy has lost some of its appeal and we have found it necessary t5J convert approximately 75 per cent of these children to cutaneous ureteroileostomy. 4 SUPRAVESICAL DIVERSION
For more than 80 years urologists have searched in vain for the ideal bladder substitute, that is an internal bladder controlled by a sphincter without adverse side effects. The decision to perform supravesical diversion is most important in the life of the child. Diversion should not be performed too early if a more conservative, temporizing approach might suffice but, more impor"Karafin, L. and Kendall, A. R.: Vesicostomy in the management of neurogenic bladder disease secondary to meningomyelocele in children. J. Ural., 96: 723, 1966. 'Brady, T. W., Mebust, W. K., Valk, W. L., Foret, J. D. and Sloss, T. B.: The cutaneous vesicostomy reappraised. J. Ural., 105: 81, 1971.
tantly, it should not be delayed until irreparable renal damage has occurred. Ureterosigmoidostomy. We believe that there are few indications for the implantation of ureters into the intact intestinal tract of children. As previously noted, most diversionary procedures are performed because of neurogenic bladder disease and with ureterosigmoidostomy there would be constant urinary soiling of the perineum. Even in children with exstrophy of the bladder, we believe that classical ureterosigmoidostomy should be avoided inasmuch as this form of diversion continues to be fraught with life-endangering complications incompatible with a normal life expectancy. The complications of pyelonephritis with hyperchloremic acidosis and potassium deficiency undoubtedly are caused by the relatively high intraluminal pressure, the high absorptive capacity and the mixing of urine and stool. Cutaneous ureterostomy. Theoretically, cutaneous ureterostomy is ideal since dependent drainage of the urinary tract is achieved without need of intubation. The primary difficulty encountered throughout the years has been stomal stricture formation. It is now realized that cutaneous ureterostomy should be limited to dilated, thickened ureters since these appear to have a richer vascular network and they maintain their viability and resist stomal slough and stricture formation when anastomosed to the skin. No one has succeeded clinically in converting normal into thickened dilated ureters although this has been performed experimentally by obstruction or surgical diathermy. Furthermore, it must be remembered that gravity plays a limited role in the drainage of the kidneys. Thus, cutaneous ureterostomy is not ideal in the presence of markedly atonic aperistaltic ureters because postoperative drainage will be poor. Unilateral cutaneous ureterostomy. We have performed 7 such procedures in children with hydronephrosis in a solitary kidney. As in all forms of diversion, the stomal site should be selected and marked preoperatively and should be located in the right or left lower quadrant. The ureter is approached extraperitoneally and is mobilized and straightened. The stoma is fashioned with a U-shaped skin flap with its base cephalad. The size of the flap is dependent upon the degree of ureteral dilatation. It is imperative to excise an adequate portion of fascia from the anterior abdominal wall to prevent obstruction. The stomal anastomosis is carried out by suturing the apex of the U-flap to the apex of the spatulated ureter and interposing the remainder of the skin flap into the spatulated portion of the ureter (fig. 1).
Bilateral cutaneous ureterostomy with a single stoma. We have had great success with this operation as a result of care in fashioning the stoma. Thirteen such procedures have been car-
URINARY DIVERSION IN CHILDREN
719
C
FIG. 2. Bilateral butterfly cutaneous ureterostomy. Reprinted from Lap ides.' FIG. 1. Unilateral cutaneous ureterostomy. Reprinted from Straffon and associates. 7
ried out using the butterfly technique proposed by Lapides. 5 If a single stoma is impossible, another form of urinary diversion is warranted because 2 separate collection devices are not acceptable. Several investigators have advised an extraperitoneal approach through a low transverse incision, drawing the ureters in front of the peritoneal envelope to a common midline subu~bilical stoma. 6 The difficulty with this approach 1s 3-fold: 1) the location in the midline below the umbilicus is a poor site for a collection device, 2) it is often difficult to remain extraperitoneally near the midline although no difficulty has been encountered due to the distal few centimeters of the ureters transversing the peritoneal cavity and 3) a somewhat greater length of dilated ureter is necessary. Our usual technique involves a transperitoneal approach, bringing the left ureter under the sigmoid to lie in proximity with the right ureter. Both ureters can be brought out through the peritoneal cavity to construct a peritoneal envelope around the ureters as described by Straffon and associates in order to prevent complications of small bowel obstruction. 7 Likewise, both ureters can be drawn extraperitoneally to the stomal site. The fashioning of the stoma is performed as described by Lapides (fi?~· 2 ~nd 3) or according to the Z-plasty mod1f1cat10n of Straffon. 'Lapides, J.: Butterfly cutaneous ureterostomy. J. Urol., 88: 735, 1962. . . "Thompson, I. M. and Ross, G., Jr.: Experiences with a new technique for supravesical urinary diversion. J. Urol., 90: 691, 1963. 7 Straffon, R. A., Kyle, K. and Corvalan, J.: !echniques of cutaneous ureterostomy and results m 51 patients. J. Urol., 103: 138, 1970.
Cutaneous transureteroureterostomy. The technique is quite similar to that for bilateral cutaneous ureterostomy except that an end-to-side anastomosis of the ureters is carried out and a single ureter is brought out transperitoneally or extraperitoneally to the stomal site. The advantage of this technique is that a shorter segment of left ureter is used, thus encouraging better drainage. This is useful when a segment of one ureter is too short for cutaneous ureterostomy. A potential difficulty is that percutaneous intubation of the contralateral ureter is impossible should obstruction occur. Furthermore, it is possible that drainage may be impaired secondary to the Y type of anastomosis. We have performed 8 such operations but we prefer bilateral cutaneous ureterostomy when it is feasible. Cutaneous loop ureterostomy. This procedure has received widespread attention as a form of temporary urinary diversion, especially in children with massive hydronephrosis secondary to urethral valves. Dissatisfaction with the inability of suprapubic cystostomy to provide adequate drainage for atonic, dilated ureters has encouraged this far superior operation. We have performed 22 of these procedures in 11 infants without significant morbidity. In all cases the operative results were encouraging (fig. 4). In 3 of these children the urinary tract has been reconstituted without difficulty. Loop cutaneous ureterostomy is not acceptable as a means of permanent diversion because of the poor location of the stoma and the need for bilateral collection devices which are always to be avoided. If one is convinced that reconstitution of the urinary tract will be impossible, permanent diversion should be done instead of loop ureterostomy. Complications of cutaneous ureterostomy. This technique should be considered the operation of
720
KENDALL AND KARAFIN
Fm. 3. Bilateral butterfly cutaneous ureterostomy. Reprinted from Lapides 5
choice in children with dilated thickened ureters that maintain peristalsis. In properly selected patients, the complication rate has been negligible. There has been no case of stomal slough or stenosis in the 28 operations performed here. There has been no early or late bowel obstruction in the 5 children in whom the ureters were drawn directly through the peritoneal cavity without construction of a protective peritoneal sleeve. However, we prefer an extraperitoneal ureteral course or construction of a peritoneal envelope around the ureters. The major complication encountered was owing to the choice of operation and not to the operation itself. In 3 cases there has been no demonstrable improvement in the architecture of the upper urinary tracts, despite improvement in renal function. This is thought to be caused by atonicity of the long-standing obstructed ureters with subsequent poor drainage. The operation of choice in these cases might have been cutaneous pyeloileostomy. Figure 5 demonstrates significant improvement despite markedly dilated, tortuous collecting systems. Cutaneous ureterostomy (ileal loop). Since being popularized by Bricker, this operation has become the most widely used mode of supravesical diversion although it falls far short of being a perfect bladder substitute. 8 The ileal segment acts as a conduit, has little electrolyte imbalance and provides a suitable location for the stoma. We use Bricker's technique with few modifications. Most recently, the ureteroileal anastomosis has been modified by spatulating the ureters and performing a ureteroureteral anastomosis with the common ureteral bud then being anastomosed to the proximal end of the ilea! segment. The obvious 'Bricker, E. M.: Substitution for the urinary bladder by the use of isolated ilea! segments. Surg. Clin. N. Amer., 36: 1117, 1956.
advantages of this modification are the reduction in operative time and the need for fewer anastomoses, as well as the ability to provide a shorter ilea! segment. The major disadvantage, which has not yet been a clinical problem, is that "one places all his eggs in one basket" and urinary extravasation or ureteral obstruction may affect both collecting systems. We have performed 42 such operations, mainly in children with some form of neurogenic bladder. The postoperative complications are listed in table 4. MANAGEMENT OF THE URINARY STOMA
To often, following permanent urinary diversion the child is miserable owing to stomal complications. A physical and mental adjustment must be made. Location of the stoma. It has been established that the right or left lower quadrant is the ideal location and assures satisfactory adherence of the appliance. The exact site is usually just below the center of a line drawn from the umbilicus to the anterior, superior iliac spine. With this area in mind, the child is observed in the reclining, standing and sitting positions. Braces, skin folds or scars that may interfere with the wearing of an appliance · are noted. Wheelchair patients have a tendency to gain weight and since patients must see the stoma in order to apply the appliance the stoma must be fashioned somewhat higher in these obese patients. Preoperative fitting of the site with a clear stomal seal or with the planned appliance will prevent selection of an unfavorable area. Once the site is agreed upon it is marked with 0.1 cc methylene blue injected intradermally. The midline subumbilical area is usually not successful and is to be avoided whenever possible. Types of stoma. A protruding bud or nipple,
CHILD RE_'."~
a half mch the patient to apply the device -.vith ease and does not allow urine to undermine the adhesive seal. This type of stoma is easily obtained with ureteroileostomy but unfortunately a flat type of stoma occurs with cutaneous ureterostomy or vesicostomy. Postoperative care. A temporary, inexpensive disposable appliance should be applied in the operating room. At the first sign of leakage or at least every second day this must be changed to protect the surrounding skin from the irritating effects of urine. If no device is applied, constant
72~
attention to the skin to the stoma is mandatory. About 8 postoperatively the is measured for the permanent appliance. The openings on standard appliances are usually round but these can be tailored to the individual stoma and there must be no more than 1/,6 to Ys inch of skin exposed around the stoma. The stoma will shrink and recalibration should be scheduled at 3 weeks, 6 weeks. 3 months and so on for at least a year in order to maintain a close-fitting appliance. It is not necessary to order new appliances since the stoma shrinks and closed-cell foam pads with the appropriate sized openings may be cemented
FIG. 4. A, bilateral hydroureteronephrosis. B, decreased hydronephrosis following cutaneous loop ureterostomy
FIG. 5. A, marked hydronephrosis prior to diversion. B, significant improvement following bilateral butterfly cutaneous ureterostomy.
722 TABLE
KENDALL AND KARAFIN
4. Complications in 42 ilea! loop diversion operations No.Pts. (%)
Early Prolonged ileus Small bowel obstruction Wound infection Urinary extravasation Wound dehiscence Stomal slough
Late Pyelonephritis Increased hydronephrosis* Stomal stenosis Renal calculi Intestinal obstruction Parastomal hernia Ureteral obstruction Electrolyte imbalance
6 (14) 2 (5) 2 (5) 2 (5) 0
(0)
1
(2)
6 (16) 8 (10) 5 (12) 1 (3) 3
2 2 3
(7) (5) (5) (7)
incrustations around the stoma may be minimized by dilute vinegar soaks and irrigation of the pouch by a similar solution. Jeter and Bloom have found a significant decrease in stomal problems following routine acidification of the urine.• After many years of frustration and numerous complications it has become evident that the physician does not have the time, patience or even the knowledge necessary for satisfactory stomal care. If possible the services of a stomal therapist should be secured. The success of urinary diversion depends on the ability of the child and his parents to manage the stoma. The parents and the patients should be knowledgeable concerning the device. However, the psychological adjustment may be difficult and require a great deal of understanding, patience and time.
* 8 of 84 renal units. SUMMARY
to the appliance face plate to adjust to the shrinking stoma. Accessories for the permanent appliance include a night drainage tube and receptacle, since the capacity of the appliance pouch is inadequate to collect the overnight urinary output in a well hydrated child. Complications related to the stoma. Skin irritation around the stoma may be caused by an improperly fitted device with resultant bathing of the surrounding skin. Removal of the appliance and application of dry heat have been found to be beneficial. Bleeding from the stoma as well as
Herein we review experience with 121 operations for urinary diversion in children. Some form of cutaneous ureterostomy is advocated in the presence of dilated ureters that maintain peristalsis. Ureterosigmoidostomy is considered to be inapplicable to children. In the presence of ureters of normal caliber, cutaneous ureteroileostomy is the procedure of choice. The enthusiasm for cutaneous vesicostomy has waned owing to problems encountered in stomal care. 9 Jeter, K. and Bloom, S.: Management of stomal complications following ilea! or colonic conduit operations in children. J. Urol., 106: 425, 1971.
y;_;ili,;:i1,ii
URINARY DIVERSION IN CHILDREN A. RICHARD KENDALL
AND
LESTER KARAFIN
From the Department of Urologv, St. Christopher's Hospital for Children, Temple University School of Medicine and the Medical College of Pennsylvania, Philadelphia, Pennsylvania
While the basic operations for urinary diversion are similar in children and in adults, the indications for urinary diversion in children are significantly different (table 1). In the child more than in the adult, one tends to choose an operation that might be reversible and permit reconstitution of the urinary tract at a later date. Thus, there is a tendency to use suprapubic cystostomy, or loop ureterostomy as a temporary procedure in the patient with obstructive disease in the hope that vesical function and satisfactory renal drainage will return. Between 1963 and 1971, 121 urinary diversion operations were perforn1ed in 85 children at this hospital (tables 2 and 3).
ating a vesicocutaneous fistula resulting in vesical urinary diversion without the complications attributed to an indwelling catheter. 1 Since that time hundreds of these or similar operations have been performed in adults and children, especially in those with neurovesical dysfunction. Recently, Lapides and associates reported on a 10-year survey of 52 patients who had undergone vesicostomy and concluded that "the number of patients doing well with cutaneous vesicostomy would approach 100 per cent if patients with pre-existing severe renal disease and those who failed to return for regular followup studies were deleted from the series". 2 There are potential complications of vesicostomy. 1) Bladder flap slough may be caused by excess tension or faulty technique interfering with the blood supply. 2) Stomal stenosis is usually caused excision of an inadequate segment of rectus fascia or slough of the bladder flap. 3) Residual urine may be due to stomal stenosis. Normally, there is some residual urine vesicostomy but since there is no increase in intraveiscal pressure, ureteral reflux, even if present preoperatively, is usually not a clinical problem. 4) Infected uritte-almost all patients have bacteriuria but clinical and pyelonephritis are less frequent than with suprapubic cystostomy. 5) Calculus formation-small calculi often form on the hairs of the skin but can be removed manually through the stoma without any In 5 per cent of patients who were calculus-free prior to renal calculi develop. 6) Urethral incontinence may be prevented by closure of the vesical neck at the time of operation. This is imperative in all female subjects. Stomal stenosis may result in urethral incontinence in male to vesical 7) Roentgenographic evio.ence of renal deterioration ""'"v,.1u,,_1 to infection or calculus disease shouid m pa8) Paraof the bladder the stoma usuaily is caused the technical error of excising too a segment of anterior rectus fascia. 9) Skin reactions and collection device failures may be noted. Most of these potential complications are preventable with a carefui technique. We
VESlCAL DIVERSION
Suprapubic cystostomy. During the past :2 decades the indications for temporary and permanent cystostomy drainage have diminished. The maior goals of any are to adequate drainage and protection to the upper urinary tract, maintain continence and eliminate residual urine without introduction of a foreign body into the urinary tract. Although cystostomy is clinically successful in many cases, it does fall far short of these goals. The catheter produces vesical calculi and ascending renal infection while vesical spasm may result in incontinence per urethram. Too often cystostomy drainage is unsatisfactory in the achievement of its drainage of the upper urinary tract. If cystostomy is ~ v+,w,~ in the presence of decompensated ureters, one cannot expect to have adequate renal drainage. However, it is not infrequent to find increasing ureteral dilatation and poor secondary to a more or less functional obstruction ovving to the contracted, empty bladder. The indications for cystostomy drainage are at the time of ,H,v,fj,cw urethral or vesical trauma, in cases of mild ureterai dilatation to urethral valves prior to definitive resection and in some cases of neurogenic bladder or u'11,gi1u,,eu vesical prior to consideration of permanent supravesical diversion. Cutaneous and ere0
1 Lapides, J., Ajemian, E. P. and Lichtward.t, ,J. R.: Cutaneous vesicostomy. ,J. Urol., 84: 609, 1960. 2 Lapid.es, ,J., Koyanagi, T. and Diokno, A.: Cutaneous vesicostomy: 10-year survey. ,J. Urol., 105: 76, 1971.
Accepted for publication August 4, 1972. Read at annual meeting of American Urological Association, Washington, D.C., May 21-25, 1972. 717
KENDALL AND KARAFIN
718 TABLE
1. Indications for urinary diversion in children
N eurogenic bladder disease Exstrophy or epispadias Renal damage secondary to infravesical (urethral valves) or vesical (ureterocele) obstruction Renal damage secondary to advanced ureteral reflux Incorrectable incontinence Incorrectable traumatic lesions of the lower urinary tract TABLE
2. Indications for operation in 85 patients No.Pts.
Neurogenic bladder disease Exstrophy or epispadias with incontinence Renal damage secondary to infravesical obstruction Renal damage secondary to advanced ureteral reflux Renal damage secondary to ureterocele Sarcoma of the prostate
51 4
21 5 3
1 85
TABLE
3 No. Operations
Suprapubic cystostomy Cutaneous vesicostomy Cutaneous ureteroileostomy (ilea! loop) Transureteroureterostomy Unilateral cutaneous ureterostomy Bilateral cutaneous ureterostomy single stoma Bilateral cutaneous loop ureterostomy Nephrostomy
25 13 42 8 7 13 11 2
121
have found vesicostomy to be a technically easy operation that provides excellent protection of the upper urinary tracts. 3 When properly performed, it has few serious complications. However, owing to the localization of the stoma in the midline of the lower abdomen, we have not been successful in maintaining a collection device in ambulatory children. Thus, cutaneous vesicostomy has lost some of its appeal and we have found it necessary t5J convert approximately 75 per cent of these children to cutaneous ureteroileostomy. 4 SUPRAVESICAL DIVERSION
For more than 80 years urologists have searched in vain for the ideal bladder substitute, that is an internal bladder controlled by a sphincter without adverse side effects. The decision to perform supravesical diversion is most important in the life of the child. Diversion should not be performed too early if a more conservative, temporizing approach might suffice but, more impor"Karafin, L. and Kendall, A. R.: Vesicostomy in the management of neurogenic bladder disease secondary to meningomyelocele in children. J. Ural., 96: 723, 1966. 'Brady, T. W., Mebust, W. K., Valk, W. L., Foret, J. D. and Sloss, T. B.: The cutaneous vesicostomy reappraised. J. Ural., 105: 81, 1971.
tantly, it should not be delayed until irreparable renal damage has occurred. Ureterosigmoidostomy. We believe that there are few indications for the implantation of ureters into the intact intestinal tract of children. As previously noted, most diversionary procedures are performed because of neurogenic bladder disease and with ureterosigmoidostomy there would be constant urinary soiling of the perineum. Even in children with exstrophy of the bladder, we believe that classical ureterosigmoidostomy should be avoided inasmuch as this form of diversion continues to be fraught with life-endangering complications incompatible with a normal life expectancy. The complications of pyelonephritis with hyperchloremic acidosis and potassium deficiency undoubtedly are caused by the relatively high intraluminal pressure, the high absorptive capacity and the mixing of urine and stool. Cutaneous ureterostomy. Theoretically, cutaneous ureterostomy is ideal since dependent drainage of the urinary tract is achieved without need of intubation. The primary difficulty encountered throughout the years has been stomal stricture formation. It is now realized that cutaneous ureterostomy should be limited to dilated, thickened ureters since these appear to have a richer vascular network and they maintain their viability and resist stomal slough and stricture formation when anastomosed to the skin. No one has succeeded clinically in converting normal into thickened dilated ureters although this has been performed experimentally by obstruction or surgical diathermy. Furthermore, it must be remembered that gravity plays a limited role in the drainage of the kidneys. Thus, cutaneous ureterostomy is not ideal in the presence of markedly atonic aperistaltic ureters because postoperative drainage will be poor. Unilateral cutaneous ureterostomy. We have performed 7 such procedures in children with hydronephrosis in a solitary kidney. As in all forms of diversion, the stomal site should be selected and marked preoperatively and should be located in the right or left lower quadrant. The ureter is approached extraperitoneally and is mobilized and straightened. The stoma is fashioned with a U-shaped skin flap with its base cephalad. The size of the flap is dependent upon the degree of ureteral dilatation. It is imperative to excise an adequate portion of fascia from the anterior abdominal wall to prevent obstruction. The stomal anastomosis is carried out by suturing the apex of the U-flap to the apex of the spatulated ureter and interposing the remainder of the skin flap into the spatulated portion of the ureter (fig. 1).
Bilateral cutaneous ureterostomy with a single stoma. We have had great success with this operation as a result of care in fashioning the stoma. Thirteen such procedures have been car-
URINARY DIVERSION IN CHILDREN
719
C
FIG. 2. Bilateral butterfly cutaneous ureterostomy. Reprinted from Lap ides.' FIG. 1. Unilateral cutaneous ureterostomy. Reprinted from Straffon and associates. 7
ried out using the butterfly technique proposed by Lapides. 5 If a single stoma is impossible, another form of urinary diversion is warranted because 2 separate collection devices are not acceptable. Several investigators have advised an extraperitoneal approach through a low transverse incision, drawing the ureters in front of the peritoneal envelope to a common midline subu~bilical stoma. 6 The difficulty with this approach 1s 3-fold: 1) the location in the midline below the umbilicus is a poor site for a collection device, 2) it is often difficult to remain extraperitoneally near the midline although no difficulty has been encountered due to the distal few centimeters of the ureters transversing the peritoneal cavity and 3) a somewhat greater length of dilated ureter is necessary. Our usual technique involves a transperitoneal approach, bringing the left ureter under the sigmoid to lie in proximity with the right ureter. Both ureters can be brought out through the peritoneal cavity to construct a peritoneal envelope around the ureters as described by Straffon and associates in order to prevent complications of small bowel obstruction. 7 Likewise, both ureters can be drawn extraperitoneally to the stomal site. The fashioning of the stoma is performed as described by Lapides (fi?~· 2 ~nd 3) or according to the Z-plasty mod1f1cat10n of Straffon. 'Lapides, J.: Butterfly cutaneous ureterostomy. J. Urol., 88: 735, 1962. . . "Thompson, I. M. and Ross, G., Jr.: Experiences with a new technique for supravesical urinary diversion. J. Urol., 90: 691, 1963. 7 Straffon, R. A., Kyle, K. and Corvalan, J.: !echniques of cutaneous ureterostomy and results m 51 patients. J. Urol., 103: 138, 1970.
Cutaneous transureteroureterostomy. The technique is quite similar to that for bilateral cutaneous ureterostomy except that an end-to-side anastomosis of the ureters is carried out and a single ureter is brought out transperitoneally or extraperitoneally to the stomal site. The advantage of this technique is that a shorter segment of left ureter is used, thus encouraging better drainage. This is useful when a segment of one ureter is too short for cutaneous ureterostomy. A potential difficulty is that percutaneous intubation of the contralateral ureter is impossible should obstruction occur. Furthermore, it is possible that drainage may be impaired secondary to the Y type of anastomosis. We have performed 8 such operations but we prefer bilateral cutaneous ureterostomy when it is feasible. Cutaneous loop ureterostomy. This procedure has received widespread attention as a form of temporary urinary diversion, especially in children with massive hydronephrosis secondary to urethral valves. Dissatisfaction with the inability of suprapubic cystostomy to provide adequate drainage for atonic, dilated ureters has encouraged this far superior operation. We have performed 22 of these procedures in 11 infants without significant morbidity. In all cases the operative results were encouraging (fig. 4). In 3 of these children the urinary tract has been reconstituted without difficulty. Loop cutaneous ureterostomy is not acceptable as a means of permanent diversion because of the poor location of the stoma and the need for bilateral collection devices which are always to be avoided. If one is convinced that reconstitution of the urinary tract will be impossible, permanent diversion should be done instead of loop ureterostomy. Complications of cutaneous ureterostomy. This technique should be considered the operation of
720
KENDALL AND KARAFIN
Fm. 3. Bilateral butterfly cutaneous ureterostomy. Reprinted from Lapides 5
choice in children with dilated thickened ureters that maintain peristalsis. In properly selected patients, the complication rate has been negligible. There has been no case of stomal slough or stenosis in the 28 operations performed here. There has been no early or late bowel obstruction in the 5 children in whom the ureters were drawn directly through the peritoneal cavity without construction of a protective peritoneal sleeve. However, we prefer an extraperitoneal ureteral course or construction of a peritoneal envelope around the ureters. The major complication encountered was owing to the choice of operation and not to the operation itself. In 3 cases there has been no demonstrable improvement in the architecture of the upper urinary tracts, despite improvement in renal function. This is thought to be caused by atonicity of the long-standing obstructed ureters with subsequent poor drainage. The operation of choice in these cases might have been cutaneous pyeloileostomy. Figure 5 demonstrates significant improvement despite markedly dilated, tortuous collecting systems. Cutaneous ureterostomy (ileal loop). Since being popularized by Bricker, this operation has become the most widely used mode of supravesical diversion although it falls far short of being a perfect bladder substitute. 8 The ileal segment acts as a conduit, has little electrolyte imbalance and provides a suitable location for the stoma. We use Bricker's technique with few modifications. Most recently, the ureteroileal anastomosis has been modified by spatulating the ureters and performing a ureteroureteral anastomosis with the common ureteral bud then being anastomosed to the proximal end of the ilea! segment. The obvious 'Bricker, E. M.: Substitution for the urinary bladder by the use of isolated ilea! segments. Surg. Clin. N. Amer., 36: 1117, 1956.
advantages of this modification are the reduction in operative time and the need for fewer anastomoses, as well as the ability to provide a shorter ilea! segment. The major disadvantage, which has not yet been a clinical problem, is that "one places all his eggs in one basket" and urinary extravasation or ureteral obstruction may affect both collecting systems. We have performed 42 such operations, mainly in children with some form of neurogenic bladder. The postoperative complications are listed in table 4. MANAGEMENT OF THE URINARY STOMA
To often, following permanent urinary diversion the child is miserable owing to stomal complications. A physical and mental adjustment must be made. Location of the stoma. It has been established that the right or left lower quadrant is the ideal location and assures satisfactory adherence of the appliance. The exact site is usually just below the center of a line drawn from the umbilicus to the anterior, superior iliac spine. With this area in mind, the child is observed in the reclining, standing and sitting positions. Braces, skin folds or scars that may interfere with the wearing of an appliance · are noted. Wheelchair patients have a tendency to gain weight and since patients must see the stoma in order to apply the appliance the stoma must be fashioned somewhat higher in these obese patients. Preoperative fitting of the site with a clear stomal seal or with the planned appliance will prevent selection of an unfavorable area. Once the site is agreed upon it is marked with 0.1 cc methylene blue injected intradermally. The midline subumbilical area is usually not successful and is to be avoided whenever possible. Types of stoma. A protruding bud or nipple,
CHILD RE_'."~
a half mch the patient to apply the device -.vith ease and does not allow urine to undermine the adhesive seal. This type of stoma is easily obtained with ureteroileostomy but unfortunately a flat type of stoma occurs with cutaneous ureterostomy or vesicostomy. Postoperative care. A temporary, inexpensive disposable appliance should be applied in the operating room. At the first sign of leakage or at least every second day this must be changed to protect the surrounding skin from the irritating effects of urine. If no device is applied, constant
72~
attention to the skin to the stoma is mandatory. About 8 postoperatively the is measured for the permanent appliance. The openings on standard appliances are usually round but these can be tailored to the individual stoma and there must be no more than 1/,6 to Ys inch of skin exposed around the stoma. The stoma will shrink and recalibration should be scheduled at 3 weeks, 6 weeks. 3 months and so on for at least a year in order to maintain a close-fitting appliance. It is not necessary to order new appliances since the stoma shrinks and closed-cell foam pads with the appropriate sized openings may be cemented
FIG. 4. A, bilateral hydroureteronephrosis. B, decreased hydronephrosis following cutaneous loop ureterostomy
FIG. 5. A, marked hydronephrosis prior to diversion. B, significant improvement following bilateral butterfly cutaneous ureterostomy.
722 TABLE
KENDALL AND KARAFIN
4. Complications in 42 ilea! loop diversion operations No.Pts. (%)
Early Prolonged ileus Small bowel obstruction Wound infection Urinary extravasation Wound dehiscence Stomal slough
Late Pyelonephritis Increased hydronephrosis* Stomal stenosis Renal calculi Intestinal obstruction Parastomal hernia Ureteral obstruction Electrolyte imbalance
6 (14) 2 (5) 2 (5) 2 (5) 0
(0)
1
(2)
6 (16) 8 (10) 5 (12) 1 (3) 3
2 2 3
(7) (5) (5) (7)
incrustations around the stoma may be minimized by dilute vinegar soaks and irrigation of the pouch by a similar solution. Jeter and Bloom have found a significant decrease in stomal problems following routine acidification of the urine.• After many years of frustration and numerous complications it has become evident that the physician does not have the time, patience or even the knowledge necessary for satisfactory stomal care. If possible the services of a stomal therapist should be secured. The success of urinary diversion depends on the ability of the child and his parents to manage the stoma. The parents and the patients should be knowledgeable concerning the device. However, the psychological adjustment may be difficult and require a great deal of understanding, patience and time.
* 8 of 84 renal units. SUMMARY
to the appliance face plate to adjust to the shrinking stoma. Accessories for the permanent appliance include a night drainage tube and receptacle, since the capacity of the appliance pouch is inadequate to collect the overnight urinary output in a well hydrated child. Complications related to the stoma. Skin irritation around the stoma may be caused by an improperly fitted device with resultant bathing of the surrounding skin. Removal of the appliance and application of dry heat have been found to be beneficial. Bleeding from the stoma as well as
Herein we review experience with 121 operations for urinary diversion in children. Some form of cutaneous ureterostomy is advocated in the presence of dilated ureters that maintain peristalsis. Ureterosigmoidostomy is considered to be inapplicable to children. In the presence of ureters of normal caliber, cutaneous ureteroileostomy is the procedure of choice. The enthusiasm for cutaneous vesicostomy has waned owing to problems encountered in stomal care. 9 Jeter, K. and Bloom, S.: Management of stomal complications following ilea! or colonic conduit operations in children. J. Urol., 106: 425, 1971.