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Vesicopyelostomy: A Method for Urinary Drainage of the Transplanted Kidney
Vol. 109, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1973 by The Williams & Wilkins Co.
VESICOPYELOSTOMY: A METHOD FOR URINARY DRAINAGE OF THE TRANSPLANTED KIDNEY KARL R. HERWIG
AND
JOHN W. KONNAK
From the Department of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor, Michigan
In renal transplantation cases anastomotic failure with urinary leakage or obstruction requires immediate correction for patient and graft survival. Satisfactory methods for reconstruction include 1) simple drainage for leaks, 2) ureteroneocystostomy, 3) ureteroureterostomy and 4) ureteropyelostomy with either recipient ureter. 1 Nephrostomy drainage may be used in conjunction with these methods or if necessary as definitive urinary diversion. However, nephrostomy drainage requires a collecting device and inevitably leads to chronic infection and insidious decline of renal function. 2 As an alternative method of reconstruction we propose direct anastomosis of the renal pelvis to the bladder (vesicopyelostomy).
patient is instructed to void often without straining so that high pressures are not generated in the system. RESULTS
We have performed vesicopyelostomy upon 2 patients. These patients faced loss of their renal transplants or permanent nephrostomy drainage
PROCEDURE
The bladder and renal pelvis are in close approximation in the transplant patient (fig. 1). Because of perivesical and peripelvic fibrosis usually present from urinary extravasation, simple approximation of longitudinal incisions is not enough to prevent possible contracture. To prevent contracture a U-shape incision is made in the renal pelvis forming a flap. The stoma formed should easily accommodate an index finger. The edge of this flap and remainder of the renal pelvis are then sutured to a longitudinal incision in the bladder with absorbable suture. The bladder incision is in the area nearest the renal pelvis so that no tension occurs on the suture line. A broadbased bladder flap may be used for additional length. Care is taken to approximate the mucosa of the pelvis to the mucosa of the bladder in an attempt to reduce scarring of the stoma. Decompression of the kidney by nephrostomy tube and stenting of the anastomosis with a small caliber tube complete the procedure. Penrose drains are placed in the perirenal and perivesical space. The nephrostomy tube is removed after 2 weeks and the stent is removed 4 to 6 weeks later. The Accepted for publication November 22, 1972. Read at annual meeting of North Central Section, American Urological Association, Chicago, Illinois, September 27-30, 1972. 1 Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 2 Olsson, C. A., Mannick, J. A., Schmitt, G. W., Idelson, B. A., Williams, L. F., Jr., Lemann, J., Jr., Harrington, J. T. and Nabseth, D. C.: Nephrostomy in renal transplantation. Amer. J. Surg., 121: 467, 1971.
Fm. 1. Line drawing of vesicopyelostomy shows formation of pelvic flap and direct anastomosis of renal pelvis to bladder.
because of failure of primary and secondary attempts to reconstruct the urinary tract. The first patient, an 18-year-old identical twin, had failure of the original ureteroneocystostomy, a subsequent ureteroureterostomy and a ureteropyelostomy. She tolerated nephrostomy drainage poorly and had many episodes of sepsis. Serum creatinine rose from 1.2 to 2.0 mg. per cent. Exploration was undertaken in expectation of performing a ureteropyelostomy using the contralateral ureter but this ureter was too short to reach the renal pelvis comfortably and a vesicopyelostomy was performed (fig. 2, A). When the nephrostomy tube was removed the patient 955
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voided normally. She was instructed to void without straining hourly during the day and every 2 hours at night. When the stent was removed the serum creatinine had fallen to 1.6 mg. per cent and the urine became sterile. Fourteen months
postoperatively the urine was still sterile and the serum creatinine was 1.3 mg. per cent. The patient leads a normal active life (fig. 2, B). The second patient, a 42-year-old man, received a related donor renal transplant that functioned
Fm. 2. Case 1. A, excretory urogram (IVP) before vesicopyelostomy demonstrates moderate hydronephrosis. B, voiding film of IVP series 1 year after vesicopyelostomy. Anastomosis is patent but hydronephrosis persists.
Fm. 3. Case 2. A, cystogram shows reflux of contrast into renal pelvis. Anastomosis is patent. B, voiding cystourethrogram demonstrates emptying of renal pelvis and bladder.
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VESICOPYELOSTOMY
well. Total necrosis of the ureter necessitated nephrostomy drainage, which he did not tolerate. Serum creatinine rose from 1.4 to 2 mg. per cent and the patient had several septic episodes. Vesicopyelostomy was done. The patient is now voiding frequently with low pressure, the serum creatinine has fallen to 1.4 mg. per cent and the urine is sterile (fig. 3). A fistula at the site of the nephrostomy tube is slowly healing. COMMENT
To avoid some of the urologic complications of renal transplantation, the blood supply to the renal pelvis and ureter should be carefully preserved at the time of donor nephrectomy. 3 -• If leakage or obstruction occurs, disaster can result and nephrectomy may become necessary. In both of our patients nephrectomy was considered beca use of the intolerance to nephrostomy drainage. Vesicopyelostomy was chosen because of the ease of performance and because it should allow normal renal function and voiding despite reflux of urine into the renal pelvis. We believe, as do others, that reflux of sterile urine into the renal pelvis in the absence of bladder outlet obstruction probably has no deleterious effects upon renal function. 6 • 7 Recent experimental evidence sup3 Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. • Weil, R., III, Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M .. _and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. 5 Anderson, E. E., Glenn, J. F., Siegler, H.F., Enson, R. D. and Stickel, D. L.: Urologic morbidity in renal transplantation. Southern Med. J., 64: 1513, 1971. "Lalli, A. F. and Lapides, J.: Long-term followup of ureteroneocystostomy without anti-reflux technique. J. Urol., 100: 441, 1968. 7 Uehling, D. T.: Effect of vesicoureteral reflux on concentrating ability. J. Urol., 106: 947, 1971.
ports this clinical observation. 8 • 9 Preoperatively both patients voided with normal bladder pressures of less than 35 cm. water and had no evidence of outlet obstruction. Presently urine refluxes freely into the renal pelvis but neither patient shows changes of renal function as measured by serum creatinine. Both patients void frequently with low pressure and low volume. The urine of these patients became sterile after removal of the nephrostomy tube and stent. In the first patient it has remained sterile for more than a year. The urine of the second patient is uninfected despite the healing nephrostomy tract. This fact supports the concept that reflux of urine is not a cause of urinary tract infection and that a frequent voiding program in the face of reflux can maintain a sterile urine. 10 The long-term results of this procedure are unknown but at present it appears to be adequate to maintain normal renal function and voiding. Vesicopyelostomy may be a valuable research tool for studying the effect of urinary reflux and pressure upon the kidney and could help clarify some of the controversy surrounding vesicoureteral reflux. SUMMARY
Vesicopyelostomy, or direct anastomosis of the renal pelvis to the bladder, is a possible alternative to permanent nephrostomy drainage or removal of a transplanted kidney for urologic complications. Good renal function should be preserved if the patient can void normally with low pressure. • King, L. R. and Sellards, H. G.: The effect of vesicoureteral reflux on renal growth and development in puppies. Invest. Urol., 9: 95, 1971. 9 Lenaghan, D., Cass, A. S., Cussen, L. J. and Stephens, F. D.: Long-term effect of vesicoureteral reflux on the upper urinary tract of dogs: I. Without urinary infection. J. Urol., 107: 755, 1972. 10 Lapides, J., Costello, R. T., Jr., Zierdt, D. K. and Stone, T. E.: Primary cause and treatment of recurrent urinary infection in women: preliminary report. J. Urol., 100: 552, 1968.
THE JOURNAL OF UROLOGY
Copyright© 1973 by The Williams & Wilkins Co.
VESICOPYELOSTOMY: A METHOD FOR URINARY DRAINAGE OF THE TRANSPLANTED KIDNEY KARL R. HERWIG
AND
JOHN W. KONNAK
From the Department of Surgery, Section of Urology, University of Michigan Medical Center, Ann Arbor, Michigan
In renal transplantation cases anastomotic failure with urinary leakage or obstruction requires immediate correction for patient and graft survival. Satisfactory methods for reconstruction include 1) simple drainage for leaks, 2) ureteroneocystostomy, 3) ureteroureterostomy and 4) ureteropyelostomy with either recipient ureter. 1 Nephrostomy drainage may be used in conjunction with these methods or if necessary as definitive urinary diversion. However, nephrostomy drainage requires a collecting device and inevitably leads to chronic infection and insidious decline of renal function. 2 As an alternative method of reconstruction we propose direct anastomosis of the renal pelvis to the bladder (vesicopyelostomy).
patient is instructed to void often without straining so that high pressures are not generated in the system. RESULTS
We have performed vesicopyelostomy upon 2 patients. These patients faced loss of their renal transplants or permanent nephrostomy drainage
PROCEDURE
The bladder and renal pelvis are in close approximation in the transplant patient (fig. 1). Because of perivesical and peripelvic fibrosis usually present from urinary extravasation, simple approximation of longitudinal incisions is not enough to prevent possible contracture. To prevent contracture a U-shape incision is made in the renal pelvis forming a flap. The stoma formed should easily accommodate an index finger. The edge of this flap and remainder of the renal pelvis are then sutured to a longitudinal incision in the bladder with absorbable suture. The bladder incision is in the area nearest the renal pelvis so that no tension occurs on the suture line. A broadbased bladder flap may be used for additional length. Care is taken to approximate the mucosa of the pelvis to the mucosa of the bladder in an attempt to reduce scarring of the stoma. Decompression of the kidney by nephrostomy tube and stenting of the anastomosis with a small caliber tube complete the procedure. Penrose drains are placed in the perirenal and perivesical space. The nephrostomy tube is removed after 2 weeks and the stent is removed 4 to 6 weeks later. The Accepted for publication November 22, 1972. Read at annual meeting of North Central Section, American Urological Association, Chicago, Illinois, September 27-30, 1972. 1 Starzl, T. E., Groth, C. G., Putnam, C. W., Penn, I., Halgrimson, C. G., Flatmark, A., Gecelter, L., Brettschneider, L. and Stonington, 0. G.: Urological complications in 216 human recipients of renal transplants. Ann. Surg., 172: 1, 1970. 2 Olsson, C. A., Mannick, J. A., Schmitt, G. W., Idelson, B. A., Williams, L. F., Jr., Lemann, J., Jr., Harrington, J. T. and Nabseth, D. C.: Nephrostomy in renal transplantation. Amer. J. Surg., 121: 467, 1971.
Fm. 1. Line drawing of vesicopyelostomy shows formation of pelvic flap and direct anastomosis of renal pelvis to bladder.
because of failure of primary and secondary attempts to reconstruct the urinary tract. The first patient, an 18-year-old identical twin, had failure of the original ureteroneocystostomy, a subsequent ureteroureterostomy and a ureteropyelostomy. She tolerated nephrostomy drainage poorly and had many episodes of sepsis. Serum creatinine rose from 1.2 to 2.0 mg. per cent. Exploration was undertaken in expectation of performing a ureteropyelostomy using the contralateral ureter but this ureter was too short to reach the renal pelvis comfortably and a vesicopyelostomy was performed (fig. 2, A). When the nephrostomy tube was removed the patient 955
956
HERWIG AND KONNAK
voided normally. She was instructed to void without straining hourly during the day and every 2 hours at night. When the stent was removed the serum creatinine had fallen to 1.6 mg. per cent and the urine became sterile. Fourteen months
postoperatively the urine was still sterile and the serum creatinine was 1.3 mg. per cent. The patient leads a normal active life (fig. 2, B). The second patient, a 42-year-old man, received a related donor renal transplant that functioned
Fm. 2. Case 1. A, excretory urogram (IVP) before vesicopyelostomy demonstrates moderate hydronephrosis. B, voiding film of IVP series 1 year after vesicopyelostomy. Anastomosis is patent but hydronephrosis persists.
Fm. 3. Case 2. A, cystogram shows reflux of contrast into renal pelvis. Anastomosis is patent. B, voiding cystourethrogram demonstrates emptying of renal pelvis and bladder.
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VESICOPYELOSTOMY
well. Total necrosis of the ureter necessitated nephrostomy drainage, which he did not tolerate. Serum creatinine rose from 1.4 to 2 mg. per cent and the patient had several septic episodes. Vesicopyelostomy was done. The patient is now voiding frequently with low pressure, the serum creatinine has fallen to 1.4 mg. per cent and the urine is sterile (fig. 3). A fistula at the site of the nephrostomy tube is slowly healing. COMMENT
To avoid some of the urologic complications of renal transplantation, the blood supply to the renal pelvis and ureter should be carefully preserved at the time of donor nephrectomy. 3 -• If leakage or obstruction occurs, disaster can result and nephrectomy may become necessary. In both of our patients nephrectomy was considered beca use of the intolerance to nephrostomy drainage. Vesicopyelostomy was chosen because of the ease of performance and because it should allow normal renal function and voiding despite reflux of urine into the renal pelvis. We believe, as do others, that reflux of sterile urine into the renal pelvis in the absence of bladder outlet obstruction probably has no deleterious effects upon renal function. 6 • 7 Recent experimental evidence sup3 Belzer, F. 0., Kountz, S. L., Najarian, J. S., Tanagho, E. A. and Hinman, F., Jr.: Prevention of urological complications after renal allotransplantation. Arch. Surg., 101: 449, 1970. • Weil, R., III, Simmons, R. L., Tallent, M. B., Lillehei, R. C., Kjellstrand, C. M .. _and Najarian, J. S.: Prevention of urological complications after kidney transplantation. Ann. Surg., 174: 154, 1971. 5 Anderson, E. E., Glenn, J. F., Siegler, H.F., Enson, R. D. and Stickel, D. L.: Urologic morbidity in renal transplantation. Southern Med. J., 64: 1513, 1971. "Lalli, A. F. and Lapides, J.: Long-term followup of ureteroneocystostomy without anti-reflux technique. J. Urol., 100: 441, 1968. 7 Uehling, D. T.: Effect of vesicoureteral reflux on concentrating ability. J. Urol., 106: 947, 1971.
ports this clinical observation. 8 • 9 Preoperatively both patients voided with normal bladder pressures of less than 35 cm. water and had no evidence of outlet obstruction. Presently urine refluxes freely into the renal pelvis but neither patient shows changes of renal function as measured by serum creatinine. Both patients void frequently with low pressure and low volume. The urine of these patients became sterile after removal of the nephrostomy tube and stent. In the first patient it has remained sterile for more than a year. The urine of the second patient is uninfected despite the healing nephrostomy tract. This fact supports the concept that reflux of urine is not a cause of urinary tract infection and that a frequent voiding program in the face of reflux can maintain a sterile urine. 10 The long-term results of this procedure are unknown but at present it appears to be adequate to maintain normal renal function and voiding. Vesicopyelostomy may be a valuable research tool for studying the effect of urinary reflux and pressure upon the kidney and could help clarify some of the controversy surrounding vesicoureteral reflux. SUMMARY
Vesicopyelostomy, or direct anastomosis of the renal pelvis to the bladder, is a possible alternative to permanent nephrostomy drainage or removal of a transplanted kidney for urologic complications. Good renal function should be preserved if the patient can void normally with low pressure. • King, L. R. and Sellards, H. G.: The effect of vesicoureteral reflux on renal growth and development in puppies. Invest. Urol., 9: 95, 1971. 9 Lenaghan, D., Cass, A. S., Cussen, L. J. and Stephens, F. D.: Long-term effect of vesicoureteral reflux on the upper urinary tract of dogs: I. Without urinary infection. J. Urol., 107: 755, 1972. 10 Lapides, J., Costello, R. T., Jr., Zierdt, D. K. and Stone, T. E.: Primary cause and treatment of recurrent urinary infection in women: preliminary report. J. Urol., 100: 552, 1968.