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Urinary Diversion Through an Isolated Rectal Segment
TTIE JOURNAL OF "GEOLOGY
Vol. 85. No. 4 April 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
URINARY DIVERSION THROUGH AN ISOLATED RECTAL SEGMENT JOHN W. DORSEY
ROGER W. BARNES
AND
From the Department of Siirgery (Urology), U.C.L.A. School of Medicine, ancl the Department of Surgery (Urology), School of Medicine, College of ivleclical Evangelists, Los Angeles, Cal.
Urinary diversion through the rectum was first done more than a hundred years ago. 1 Numerous methods and techniques have been described since then. 2 - 5 An exhaustive survey of the literature was made by Hinman and Weyrauch in 1936. 6 More recently Lowsley and Johnson have reported the technique and results of diversion through an isolated rectal segment and pcrineal intrasphincteric colostomy1 - 9 Two years ago one of us (R. ,V. B.) 10 was coauthor of a report of 6 cases, four of which were in children with congenital malformations of the lower urinary tract. The technique of the procedure was also described. These cases are included in this present report. Upper urinary tract dilatation, uremia and hyperchloremic acidosis have been the chief disadvantages of ureterosigmoidostomy. 2 , 5 , 8 , 11 - 14 These late complications are Read at annual meeting of Western Section of American Urological Association, Inc., Vancouver, B. C., Canada, June 20-23, 1960. 1 Simon, J.: Ectopia vesicae (absence of anterior walls of bladder and pubic abdominal parietes); operation for directing orifices of ureters into rectum; temporary success; subsequent death; autopsy. Lancet, 2: 568, 1852. 2 Campbell, E. W.: Reconstruction of bladder with seromuscular graft. J. Urol., 78: 236, 1957. 3 Creevy, C. D.: Some observations upon absorption after ureterosigmoidostomy. J. Urol., 70: 196, 1953. 4 Kinman, L. JVI., Sauer, D., Houston, V. T. and Melick, W. F.: Substitution of excluded rectosigmoid colon for urinary bladder. AMA Arch. Surg., 66: 531, 1953. 5 Rubin, S. W.: Formation of artificial urinary bladder with perfect continence: Experimental study. J. Urol., 60: 874, 1948. 6 Hinman, F. and Weyrauch, H. M., Jr.: Critical study of different principles of surgery which have been used in uretero-intestinal implantation. Trans. Am. Assn. Genito-Urin. Surg., 29: 15, 1936. 7 Johnson, T. H.: Further experiences with new operation for urinary diversion. J. Urol., 76: 380, 1956. 8 Lowsley, 0. S. and Johnson, T. H.: New operation for diversion of urine with voluntary control of feces and urine. J. Internat. Coll. Surg., 23: 16, 1955. 9 Lowsley, 0. S. and Johnson, T. H.: New operation for creation of artificial bladder with voluntary control of urine and feces. J. Urol., 73: 83, 1955. 10 Barnes, R. W., Hill, M. R., Sr., Hill, JVI. R., Jr. and Hill, .J. T.: Urinary diversion through an
largely eliminated by isolating the lower bowel segment which acts as a urinary reservoir. This report is based on a combined series of 25 cases, cared for by the authors, working independently of each other. The ideal method of urinary diversion should incorporate the following objectives: 1) sphincteric control of both urine and feces, 2) freedom from recurrent pyelonephritis, and electrolyte imbalance; 3) social and psychological acceptability, 4) efficient, uncomplicated surgical technique. Urinary diversion through an isolated rectal segment with concurrent perineal intrasphincteric pull-through colostomy is the only method that separates urine and feces and, in most cases, provides voluntary continence of both. The fecal and urine exits are both close to their normal location and therefore are more socially acceptable than abdominal drainage. Diversion of the urine through the isolated rectal segment combined with permanent abdominal colostomy also separates urine and feces and provides voluntary control of the urine, and partial voluntary control of the semi-solid feces. Since the pioneer efforts of Coffey, numerous attempts to create a valve at the site of the ureterosigmoicl anastomosis have been attempted, but to elate none have been consistently successful in preventing recurrent pyelonephritis when subjected to general usage. A review of the literature indicates that a large percentage of the cases subjected to ureterosigmoiclostomy isolated rectal bladder with intraphincteric (anal) colostomy. Dis. Colon & Rectum, 1: 485, 1958. 11 Boyce, vV. H.: Absorption of certain constituents of urine from large bowel of experimental animal (dog) . .J. U rol., 65: 241, 1951. 12 Eiseman, B. and Bricker, E. M.: Electrolyte absorption following bilateral uretero-enterostorn.y into isolated intestinal segment. Ann. Surg., 136: 761, 1952. 13 Godfrey, G.: Substitute bladder: Report of 5, cases. Austral. & New Zealand J. Surg., 23: 161, 1954. 14 Mitchell, A. D. and Valk, W. L.: Hyperchloremic acidosis of ureterosigmoidostomies. J. Urol., 69: 82, 1953. 569
570
JOHN W. DORSEY AND ROGER W. BARNES
Frn.1 .4, excretory urogram of patient upon whom ureterosigmoidostomy was done 4 years previously. B, excrntory urogram of same patient taken 2 weeks following isolation of rectal segment into which ureterR had been implanted. have been plagued by recurrent pyelonephritis and electrolyte imbalance. On the premise that feces and increased gas pressure within the bowel and an intact colon contribute to ureteral dilatation, infection and electrolyte imbalance, the authors elected to divert the urine through an isolated rectal segment. An illustrative case is that of a 45-year-old white woman with an infiltrating papillary carcinoma involving the vesical neck. In September 1952 urethrocystectomy, partial vaginectomy, regional lymph node dissection, and bilateral ureterosigmoidostomy utilizing the Nesbit mucosa-to-mucosa technique were performed. During the following 4 years the patient experienced numerous bouts of recurrent pyelonephritis with febrile episodes, and also electrolyte imbalance. Progressive hydronephrosis developed as evidenced by the excretory urogram in April 1956 (fig. 1, A). In May 1956, surgery for making a permanent abdominal colostomy was performed, and inspection of the ureterosigmoid anastomosis was made. There was no evidence of constriction of either ureteral ostium, each accommodated a size 14F catheter easily, hence no revision was necessary. The 2 week postoperative excretory urogram (fig. 1, B) revealed
complete return to normal of the upper urinary tract. Since the isolation of the rectal segment, this patient has enjoyed complete freedom from urinary tract infection and electrolyte imbalance. She is socially active and is an enthusiastic supporter of this method of urinary diversion. From the results of this case and of other cases in our series, it is assumed that increased gas pressure and presence of feces within the bowel are major factors contributing to ureterectasis and pyelectasis and subsequent recurrent pyelonephritis, and that the intact colon absorbs urine and contributes to electrolyte imbalance. If the changes in the upper urinary tract had been solely the result of scarring and fibrosis, the return to normal of the upper urinary tract would not have been so prompt and dramatic. Our series of 25 cases utilizing diversion of the urine to the isolated rectal .segment has been characterized by complete freedom from electrolyte imbalance, urinary tract infection and dilatation irrespective of the type of permanent colostomy used. SOCIAL ACCEPTABILITY
Diversion of the urine by means of cutaneous ureterostomy, or an isolated loop of ileum, demands the use of a receptacle cemented to the
URINARY DIVERSION THROUGH ISOLATED RECTAL SEGMENT
l
I I
skin with a water-tight seal to collect the fluid medium. Any break in the integrity of this system is apt to create an embarrassing situation. Diversion to the isolated rectal segment provides voluntary continence of the urine. The use of an abdominal colostomy provides a partial voluntary control of the solid or semisolid feces. A cotton pad is used over the colostomy opening to muffle the sound of escaping gas and prevent any soiling from seepage. We advise against the use of a colostomy bag. Many of our chronically constipated female patients have been restored to a relatively normal bowel habit by this method. The female patient experiences no psychologic trauma with this method of urinary diversion; she has always assumed the squatting position when voiding. The male admittedly must make a psychological adjustment, but we feel that the freedom from dependence on a mechanical contrivance for the collection of urine counteracts the undesirability of having to sit when he voids. Nine cases constitute the series wherein an intrasphincteric perineal colostomy was used. Five were children, four with exstrophy of the bladder, and one with a congenital hypoplastic bladder and ectopic ureteral orifices. Four adults were in the seventh and eighth decades, three having vesical carcinoma, and one a fibrotic, contracted bladder from vesical tuberculosis. The longest followup in this series is 4 years. Wound dehiscence occurred in 2 cases, in one instance complicated by a faulty ureteral anastomosis and urinary leakage. In 2 cases a fibrous constriction of the perineal colostomy stoma developed and required subsequent transverse colostomy. Two of the older patients experienced occasional fecal soiling and leakage of urine if they went longer than two to three hours without emptying the rectal bladder. No deaths occurred in this series. Sixteen cases seen in private practice comprise the series utilizing an abdominal colostomy. They range in age from the fourth to the seventh decades. Thirteen had carcinoma of the bladder. Of the other patients, one had a neurogenic cord bladder; one had conversion of a previous ureterosigmoidostomy to an isolated rectal segment; and one had a fibrotic contracted bladder and multiple suprapubic sinus tracts secondary to previous segmental resections of the bladder. The longest followup in this series is 9 years. All of the patients with benign lesions are living
571
and well. Of the thirteen with malignancy two have been lost to followup. Four are living and apparently free of their disease at 3, 5, 6 and 8 years. The remainder have succumbed from metastases. One patient, early in the series, who had cardiac decompensation, leakage at the ureteral anastomotic site, wound dehiscence, subsequently expired. In 2 cases an apparently nonfunctioning kidney resumed its function as evidenced by the postoperative excretory urogram. All patients have enjoyed urinary continence, freedom from electrolyte imbalance and upper urinary tract infection. The management of the colostomy has presented no real problem. SURGICAL TECHNIQUE
Diversion of the urine through an isolated rectal segment, and concurrent abdominal colostomy and cystectomy, are done with two surgical teams working simultaneously to expedite the procedure. With the patient in the low lithotomy position one team performs a colostomy and closes the proximal end of the rectal segment, while the second team frees the prostate, seminal vesicles and vesical neck (or in the female, the urethra, roof of the vagina, and vesical neck). Closure of the perineum usually coincides with completion of the colostomy. The hypogastric arteries are ligated, followed by extirpation of the bladder and regional lymph node resection. The proximal end of the rectal segment is sutured to the parietal peritoneum above the promontory of the sacrum to prevent prolapse of the segment and to eliminate tension at the site of the ureterosigmoid anastomosis. Bilateral ureterosigmoidostomy is accomplished by the transcolonic mucosato-mucosa technique described by Dr. Willard Goodwin. The technique utilizing the intrasphincteric pull-through perinea! colostomy is also facilitated by two surgical teams working simultaneously. The transcolonic, mucosa-to-mucosa technique for ureterosigmoidostomy is modified slightly by using a shorter segment of rectum to act as a rectal bladder. The surgeon working from below separates the anal sphincter from the anterior rectal wall, while his colleague working from above separates the tissues in front of the rectum, until the tunnel is completed. The loose end of the previously mobilized sigmoid is drawn through
572
DISCUSSION
am honored to be afforded the privilege of being associated with you at this meeting and of participating in the scientific program. I should first like to direct your attention to the subject of urinary diversion in general. With the advent of anti-infective therapy, blood bank and improvements in surgical technique extensive pelvic surgery has become feasible. Many of these procedures require sacrifice of the urinary bladder and diversion of the urinary stream. Several methods have been devised for this purpose. These include cutaneous ureterostomy, ureteral anastomosis to the intact colon, the ileal conduit or Bricker operation, colocystoplasty as advocated in this country by Bourque of Montreal, and urinary diversion through an isolated rectal segment, the subject of this discussion. Cutaneous ureterostomy has been discarded by most surgeons because of its impracticability. Ureterosigmoidostomy has enjoyed the greatest popularity having survived for a period of more than forty years. Urinary continence and minimal interference with the alimentary tract eA'})lain its favored position. However, biochemical disturbances often result in hyperchloremic acidosis, potassium depletion and calcium depletion. High pressures within the normal colon are transmitted to the kidney resulting in ascending infection. For these reasons many surgeons have advocated abandonment of this procedure, but its record of survival must not be overlooked. Physiological adjustment does occur and many people live in relative comfort for a long period of time. An adaptive change occurs within the kidney as a result of increased excretory work imposed upon it. Evidence for the concept of renal response is given by the striking structural changes seen at postmortem examination of kidneys that have been subjected to an increased excretory load. Even the colonic mucosa may undergo an adaptive change whereby absorption of chlorides is diminished. The operation of ureterosigmoidostomy should therefore not be discarded with levity and without consideration of the problem involved. Three methods are now chiefly on trial: 1) The isolated ileal segment: The effects of backpressure and ascending infection are minimized. Biochemical changes are controlled. On the debit side there is a lack of urinary continence.
2) Colocystoplasty: Protagonists of this method claim complete urinary and fecal continence without the disadvantages incurred by ureteral transplantation into the intact colon. More time and more cases are required to substantiate these claims. 3) Urinary diversion through an isolated rectal segment: A continent urinary reservoir is thus separated from the fecal stream. A voiding pressure lower than that of the intact rectosigmoid, minimizing ascending infection and electrolyte imbalance, is possible. On the debit side, an unaffected system has been interfered with. One must not obtain the impression that in this procedure biochemical changes do not occur. Experiences of others have indicated that there is some reabsorption of urea through the rectosigmoid. Serum potassium remains at a low normal level for many months after surgery but there is no evidence of large potassium loss. Slight hyperchloremic acidosis has been recorded. However, it is agreed that electrolyte disturbances are minor and readily preventable. The experience of the authors noted in the case report has been duplicated by others. The transformation noted in the 2 urograms is amazing. One would have expected that permanent changes should have developed in the upper urinary tract after 4 years of recurrent pyelonephritis and electrolyte imbalance. The attempt to obtain both urinary and fecal continence by intrasphincteric perineal colostomy poses technical difficulties that render this procedure suited only to a group of selected cases. Untoward complications have occurred and there is always the danger of injury to the anal sphincter jeopardizing both urinary and fecal control. In conclusion, I would like to say that the experience of the authors and many others who have contributed to the literature would indicate that urinary diversion through the isolated rectal segment has a good deal of merit. Its great appeal is urinary continence with minimal electrolyte imbalance. Its disadvantage is that an unaffected system has been disturbed. A note of caution should be added: that the enthusiasm of its protagonists should be tempered by the lesson of history, that no method is established until it has withstood the test of time and experience.
Vol. 85. No. 4 April 1961 Copyright © 1961 by The Williams & Wilkins Co. Printed in U.S.A.
URINARY DIVERSION THROUGH AN ISOLATED RECTAL SEGMENT JOHN W. DORSEY
ROGER W. BARNES
AND
From the Department of Siirgery (Urology), U.C.L.A. School of Medicine, ancl the Department of Surgery (Urology), School of Medicine, College of ivleclical Evangelists, Los Angeles, Cal.
Urinary diversion through the rectum was first done more than a hundred years ago. 1 Numerous methods and techniques have been described since then. 2 - 5 An exhaustive survey of the literature was made by Hinman and Weyrauch in 1936. 6 More recently Lowsley and Johnson have reported the technique and results of diversion through an isolated rectal segment and pcrineal intrasphincteric colostomy1 - 9 Two years ago one of us (R. ,V. B.) 10 was coauthor of a report of 6 cases, four of which were in children with congenital malformations of the lower urinary tract. The technique of the procedure was also described. These cases are included in this present report. Upper urinary tract dilatation, uremia and hyperchloremic acidosis have been the chief disadvantages of ureterosigmoidostomy. 2 , 5 , 8 , 11 - 14 These late complications are Read at annual meeting of Western Section of American Urological Association, Inc., Vancouver, B. C., Canada, June 20-23, 1960. 1 Simon, J.: Ectopia vesicae (absence of anterior walls of bladder and pubic abdominal parietes); operation for directing orifices of ureters into rectum; temporary success; subsequent death; autopsy. Lancet, 2: 568, 1852. 2 Campbell, E. W.: Reconstruction of bladder with seromuscular graft. J. Urol., 78: 236, 1957. 3 Creevy, C. D.: Some observations upon absorption after ureterosigmoidostomy. J. Urol., 70: 196, 1953. 4 Kinman, L. JVI., Sauer, D., Houston, V. T. and Melick, W. F.: Substitution of excluded rectosigmoid colon for urinary bladder. AMA Arch. Surg., 66: 531, 1953. 5 Rubin, S. W.: Formation of artificial urinary bladder with perfect continence: Experimental study. J. Urol., 60: 874, 1948. 6 Hinman, F. and Weyrauch, H. M., Jr.: Critical study of different principles of surgery which have been used in uretero-intestinal implantation. Trans. Am. Assn. Genito-Urin. Surg., 29: 15, 1936. 7 Johnson, T. H.: Further experiences with new operation for urinary diversion. J. Urol., 76: 380, 1956. 8 Lowsley, 0. S. and Johnson, T. H.: New operation for diversion of urine with voluntary control of feces and urine. J. Internat. Coll. Surg., 23: 16, 1955. 9 Lowsley, 0. S. and Johnson, T. H.: New operation for creation of artificial bladder with voluntary control of urine and feces. J. Urol., 73: 83, 1955. 10 Barnes, R. W., Hill, M. R., Sr., Hill, JVI. R., Jr. and Hill, .J. T.: Urinary diversion through an
largely eliminated by isolating the lower bowel segment which acts as a urinary reservoir. This report is based on a combined series of 25 cases, cared for by the authors, working independently of each other. The ideal method of urinary diversion should incorporate the following objectives: 1) sphincteric control of both urine and feces, 2) freedom from recurrent pyelonephritis, and electrolyte imbalance; 3) social and psychological acceptability, 4) efficient, uncomplicated surgical technique. Urinary diversion through an isolated rectal segment with concurrent perineal intrasphincteric pull-through colostomy is the only method that separates urine and feces and, in most cases, provides voluntary continence of both. The fecal and urine exits are both close to their normal location and therefore are more socially acceptable than abdominal drainage. Diversion of the urine through the isolated rectal segment combined with permanent abdominal colostomy also separates urine and feces and provides voluntary control of the urine, and partial voluntary control of the semi-solid feces. Since the pioneer efforts of Coffey, numerous attempts to create a valve at the site of the ureterosigmoicl anastomosis have been attempted, but to elate none have been consistently successful in preventing recurrent pyelonephritis when subjected to general usage. A review of the literature indicates that a large percentage of the cases subjected to ureterosigmoiclostomy isolated rectal bladder with intraphincteric (anal) colostomy. Dis. Colon & Rectum, 1: 485, 1958. 11 Boyce, vV. H.: Absorption of certain constituents of urine from large bowel of experimental animal (dog) . .J. U rol., 65: 241, 1951. 12 Eiseman, B. and Bricker, E. M.: Electrolyte absorption following bilateral uretero-enterostorn.y into isolated intestinal segment. Ann. Surg., 136: 761, 1952. 13 Godfrey, G.: Substitute bladder: Report of 5, cases. Austral. & New Zealand J. Surg., 23: 161, 1954. 14 Mitchell, A. D. and Valk, W. L.: Hyperchloremic acidosis of ureterosigmoidostomies. J. Urol., 69: 82, 1953. 569
570
JOHN W. DORSEY AND ROGER W. BARNES
Frn.1 .4, excretory urogram of patient upon whom ureterosigmoidostomy was done 4 years previously. B, excrntory urogram of same patient taken 2 weeks following isolation of rectal segment into which ureterR had been implanted. have been plagued by recurrent pyelonephritis and electrolyte imbalance. On the premise that feces and increased gas pressure within the bowel and an intact colon contribute to ureteral dilatation, infection and electrolyte imbalance, the authors elected to divert the urine through an isolated rectal segment. An illustrative case is that of a 45-year-old white woman with an infiltrating papillary carcinoma involving the vesical neck. In September 1952 urethrocystectomy, partial vaginectomy, regional lymph node dissection, and bilateral ureterosigmoidostomy utilizing the Nesbit mucosa-to-mucosa technique were performed. During the following 4 years the patient experienced numerous bouts of recurrent pyelonephritis with febrile episodes, and also electrolyte imbalance. Progressive hydronephrosis developed as evidenced by the excretory urogram in April 1956 (fig. 1, A). In May 1956, surgery for making a permanent abdominal colostomy was performed, and inspection of the ureterosigmoid anastomosis was made. There was no evidence of constriction of either ureteral ostium, each accommodated a size 14F catheter easily, hence no revision was necessary. The 2 week postoperative excretory urogram (fig. 1, B) revealed
complete return to normal of the upper urinary tract. Since the isolation of the rectal segment, this patient has enjoyed complete freedom from urinary tract infection and electrolyte imbalance. She is socially active and is an enthusiastic supporter of this method of urinary diversion. From the results of this case and of other cases in our series, it is assumed that increased gas pressure and presence of feces within the bowel are major factors contributing to ureterectasis and pyelectasis and subsequent recurrent pyelonephritis, and that the intact colon absorbs urine and contributes to electrolyte imbalance. If the changes in the upper urinary tract had been solely the result of scarring and fibrosis, the return to normal of the upper urinary tract would not have been so prompt and dramatic. Our series of 25 cases utilizing diversion of the urine to the isolated rectal .segment has been characterized by complete freedom from electrolyte imbalance, urinary tract infection and dilatation irrespective of the type of permanent colostomy used. SOCIAL ACCEPTABILITY
Diversion of the urine by means of cutaneous ureterostomy, or an isolated loop of ileum, demands the use of a receptacle cemented to the
URINARY DIVERSION THROUGH ISOLATED RECTAL SEGMENT
l
I I
skin with a water-tight seal to collect the fluid medium. Any break in the integrity of this system is apt to create an embarrassing situation. Diversion to the isolated rectal segment provides voluntary continence of the urine. The use of an abdominal colostomy provides a partial voluntary control of the solid or semisolid feces. A cotton pad is used over the colostomy opening to muffle the sound of escaping gas and prevent any soiling from seepage. We advise against the use of a colostomy bag. Many of our chronically constipated female patients have been restored to a relatively normal bowel habit by this method. The female patient experiences no psychologic trauma with this method of urinary diversion; she has always assumed the squatting position when voiding. The male admittedly must make a psychological adjustment, but we feel that the freedom from dependence on a mechanical contrivance for the collection of urine counteracts the undesirability of having to sit when he voids. Nine cases constitute the series wherein an intrasphincteric perineal colostomy was used. Five were children, four with exstrophy of the bladder, and one with a congenital hypoplastic bladder and ectopic ureteral orifices. Four adults were in the seventh and eighth decades, three having vesical carcinoma, and one a fibrotic, contracted bladder from vesical tuberculosis. The longest followup in this series is 4 years. Wound dehiscence occurred in 2 cases, in one instance complicated by a faulty ureteral anastomosis and urinary leakage. In 2 cases a fibrous constriction of the perineal colostomy stoma developed and required subsequent transverse colostomy. Two of the older patients experienced occasional fecal soiling and leakage of urine if they went longer than two to three hours without emptying the rectal bladder. No deaths occurred in this series. Sixteen cases seen in private practice comprise the series utilizing an abdominal colostomy. They range in age from the fourth to the seventh decades. Thirteen had carcinoma of the bladder. Of the other patients, one had a neurogenic cord bladder; one had conversion of a previous ureterosigmoidostomy to an isolated rectal segment; and one had a fibrotic contracted bladder and multiple suprapubic sinus tracts secondary to previous segmental resections of the bladder. The longest followup in this series is 9 years. All of the patients with benign lesions are living
571
and well. Of the thirteen with malignancy two have been lost to followup. Four are living and apparently free of their disease at 3, 5, 6 and 8 years. The remainder have succumbed from metastases. One patient, early in the series, who had cardiac decompensation, leakage at the ureteral anastomotic site, wound dehiscence, subsequently expired. In 2 cases an apparently nonfunctioning kidney resumed its function as evidenced by the postoperative excretory urogram. All patients have enjoyed urinary continence, freedom from electrolyte imbalance and upper urinary tract infection. The management of the colostomy has presented no real problem. SURGICAL TECHNIQUE
Diversion of the urine through an isolated rectal segment, and concurrent abdominal colostomy and cystectomy, are done with two surgical teams working simultaneously to expedite the procedure. With the patient in the low lithotomy position one team performs a colostomy and closes the proximal end of the rectal segment, while the second team frees the prostate, seminal vesicles and vesical neck (or in the female, the urethra, roof of the vagina, and vesical neck). Closure of the perineum usually coincides with completion of the colostomy. The hypogastric arteries are ligated, followed by extirpation of the bladder and regional lymph node resection. The proximal end of the rectal segment is sutured to the parietal peritoneum above the promontory of the sacrum to prevent prolapse of the segment and to eliminate tension at the site of the ureterosigmoid anastomosis. Bilateral ureterosigmoidostomy is accomplished by the transcolonic mucosato-mucosa technique described by Dr. Willard Goodwin. The technique utilizing the intrasphincteric pull-through perinea! colostomy is also facilitated by two surgical teams working simultaneously. The transcolonic, mucosa-to-mucosa technique for ureterosigmoidostomy is modified slightly by using a shorter segment of rectum to act as a rectal bladder. The surgeon working from below separates the anal sphincter from the anterior rectal wall, while his colleague working from above separates the tissues in front of the rectum, until the tunnel is completed. The loose end of the previously mobilized sigmoid is drawn through
572
DISCUSSION
am honored to be afforded the privilege of being associated with you at this meeting and of participating in the scientific program. I should first like to direct your attention to the subject of urinary diversion in general. With the advent of anti-infective therapy, blood bank and improvements in surgical technique extensive pelvic surgery has become feasible. Many of these procedures require sacrifice of the urinary bladder and diversion of the urinary stream. Several methods have been devised for this purpose. These include cutaneous ureterostomy, ureteral anastomosis to the intact colon, the ileal conduit or Bricker operation, colocystoplasty as advocated in this country by Bourque of Montreal, and urinary diversion through an isolated rectal segment, the subject of this discussion. Cutaneous ureterostomy has been discarded by most surgeons because of its impracticability. Ureterosigmoidostomy has enjoyed the greatest popularity having survived for a period of more than forty years. Urinary continence and minimal interference with the alimentary tract eA'})lain its favored position. However, biochemical disturbances often result in hyperchloremic acidosis, potassium depletion and calcium depletion. High pressures within the normal colon are transmitted to the kidney resulting in ascending infection. For these reasons many surgeons have advocated abandonment of this procedure, but its record of survival must not be overlooked. Physiological adjustment does occur and many people live in relative comfort for a long period of time. An adaptive change occurs within the kidney as a result of increased excretory work imposed upon it. Evidence for the concept of renal response is given by the striking structural changes seen at postmortem examination of kidneys that have been subjected to an increased excretory load. Even the colonic mucosa may undergo an adaptive change whereby absorption of chlorides is diminished. The operation of ureterosigmoidostomy should therefore not be discarded with levity and without consideration of the problem involved. Three methods are now chiefly on trial: 1) The isolated ileal segment: The effects of backpressure and ascending infection are minimized. Biochemical changes are controlled. On the debit side there is a lack of urinary continence.
2) Colocystoplasty: Protagonists of this method claim complete urinary and fecal continence without the disadvantages incurred by ureteral transplantation into the intact colon. More time and more cases are required to substantiate these claims. 3) Urinary diversion through an isolated rectal segment: A continent urinary reservoir is thus separated from the fecal stream. A voiding pressure lower than that of the intact rectosigmoid, minimizing ascending infection and electrolyte imbalance, is possible. On the debit side, an unaffected system has been interfered with. One must not obtain the impression that in this procedure biochemical changes do not occur. Experiences of others have indicated that there is some reabsorption of urea through the rectosigmoid. Serum potassium remains at a low normal level for many months after surgery but there is no evidence of large potassium loss. Slight hyperchloremic acidosis has been recorded. However, it is agreed that electrolyte disturbances are minor and readily preventable. The experience of the authors noted in the case report has been duplicated by others. The transformation noted in the 2 urograms is amazing. One would have expected that permanent changes should have developed in the upper urinary tract after 4 years of recurrent pyelonephritis and electrolyte imbalance. The attempt to obtain both urinary and fecal continence by intrasphincteric perineal colostomy poses technical difficulties that render this procedure suited only to a group of selected cases. Untoward complications have occurred and there is always the danger of injury to the anal sphincter jeopardizing both urinary and fecal control. In conclusion, I would like to say that the experience of the authors and many others who have contributed to the literature would indicate that urinary diversion through the isolated rectal segment has a good deal of merit. Its great appeal is urinary continence with minimal electrolyte imbalance. Its disadvantage is that an unaffected system has been disturbed. A note of caution should be added: that the enthusiasm of its protagonists should be tempered by the lesson of history, that no method is established until it has withstood the test of time and experience.