British Journal of Urology (1976), 48, 19-26
0
Experience with the Ileal Ureter HESSEIN A. AMIN Urology Unit, Sabah Hospital, Kuwait
The ileum was first used in urology by Von Mickulicz in 1898 as a means of enlarging the capacity of a contracted bladder. Not until 1950 was attention given to it again, first as an external urinary diversion, then as a replacement of the bladder after cystectomy and only more recently as replacement for ureteric defects. Houtapel and Grundemann (1960) reported 7 cases which unfortunately were complicated by dilatation. Goodwin and Cockett (1961) succeeded in facilitating the passage of stones in recurrent renal lithiasis by connecting the kidney directly to the bladder with a long loop of ileum. Weinberg (1970) reported his experience in 4 cases of bilharzial ureters treated in Rhodesia by partial ureterectomy and ileal loop replacement. Cordonnier and Bowles (1970) reported 4 cases of successful replacement of ureteric defects by ileum. Uhlii! (1 973) reported I case of haemangioma of the lower third of the ureter which was resected and successfully replaced by an ileal loop. We present our experience in a series of 18 cases. This started in 1972 when 10 patients were operated upon in rapid succession. They were 10 chronic cases with fistulae, gross hydronephrosis, recurrent infection and sometimes uraemia which had, for long, haunted our wards. The results obtained were a great relief both to patients and to the wards. Table I shows the aetiology and Table I1 shows whether unilateral or bilateral operation was performed. The clinical presentation is shown in Table 111. Methods Preoperative gut preparation is essential; oral neomycin is given for 3 days and the gastro-intestinal tract should be empty on the morning of the operation. Cysto-urethroscopy should have been done and any bladder outlet obstruction such as prostatic disease or stricture should have been excluded or treated long before the operation is scheduled. Only if it is a vesical neck contracture can it be dealt with as a part of the operation. Our routine exposure is a transverse suprapubic Pfannenstiel incision. It offers an excellent exposure of the whole pelvis and the lower halves of ureters, it is extendible lateral to the recti on either side up to the kidney and is rarely followed by incisional hernia. Scars of previous midline exposures are, in our view, a still stronger indication for a transverse exposure, as incisional hernia would otherwise almost certainly follow. The first step, after a brief intraperitoneal examination, is appendicectomy. The loop is then prepared. Its length depends on the extent of the lesion but 6 inches is a good average. There should be at least one full vascular arch in it with a broad base. Intestinal continuity is restored, the mesenteric gap being always closed transversely and not longitudinally. This keeps the “umbilical cord” of the loop widely based and less liable to torsion. The preparation of the loop should precede the preparation of the ureters, which allows time to detect any possible diminished vascular supply. The ureters are exposed transperitoneally and it is essential to reach a healthy segment for the anastomosis. If upward intubation shows a higher stricture or if higher ureteric tortuosityper se is considered obstructive (Fig. 1) on either side, then the abdominal incision is extended lateral to the rectus on the affected side and the upper lesion is dealt with accordingly. The distal ureter is either ignored, ligated, or resected. The bladder is then opened, inspected and prepared for the anastomosis. Any vesical neck contracture present is punched out at this stage with our special bladder neck punch (Amin, 1974). Our usual plans of anastomosis are shown in Figure 2. Thus it will be iso-peristaltic on the left side, and antiperistaltic on the right side. The left ureter must be passed behind the sigmoid to its right side, so that the anastomosis is not allowed to cross over the colon. If the loop is anastomosed to the lower pole of the kidney it should pass behind and not in front of the descending colon. This was carried out in 1 case in this series (Fig. 3 ) . in whom the left ureter was totally destroyed following repeated ureterolithotomies. The whole loop length was utilised to bridge the gap between the left kidney and bladder. The right ureter had only a single stricture at its lower end and this was dilated and splinted. 19
20
BRITISH JOURNAL OF UROLOGY
Table 1
Table I1
Aetiology
Distribution of Sides No. of cases
Original pathology .~
~~~
.
~~~
~
Bilharzial fibrosis of lower third of the ureter Multiple strictures and operations (nonbilharzial) Tuberculosis Irradiation fibrosis ~~
~
~~
9
7 2
-7
~
~~
Bilateral anastomosis Loop connected to one ureter (other side healthy, 2. cases; other side splinted, 1 case; other side removed, 2 cases)
1.1
Total
18
18
Table I11
Table IV
Clinical Presentation
Postoperative Complications No. of cases
~
~
_
_
Persistent renal fistula (following nephrostomy) Persistent ureteric fistula (following ureterolithotomy or ureterostomy) Palpable painful renal mass Total
S
~
Total
Presentation
No. of cases
Side of operation -
~
~
. _ ~
7 6 5
Complication _
~
_
~~
.
No.
7"
~
Postoperative mortality Mechanical intestinal obstruction Suprapubic urinary fistula (for 6 and 8 weeks only) Minor wound infections
0 1
on,,
2. 4
ll", 2.2.":
55""
18
A button of bladder tissue should be resected for the ileovesical anastomosis. Theoretically no splint is needed either for the uretero-ileal or for the ileovesical suture-lines. Usually, however, a long Gibbon catheter has been used as a temporary splint on each side. The catheters emerge from the bladder through a separate stab or through the cystotomy incision and are retained for only a few days. Peritoneal toilet is essential before closure. This consists of abolishing any possible narrow spaces into which gut herniation or strangulation can take place. Sometimes it may be possible to fix the sides of the loop mesentery to the retroperitoneum completely. The flaps of the posterior peritoneal incisions (through which the ureters were exposed) can usually be made to cover the anastomosis itself and obliterate any gaps in the corners. In some cases it is difficult to obliterate a gap and then it is preferable to leave it widc open rather than to narrow i t ineffectively.
Results The immediate convalescence was smooth in most of the cases. Postoperative complications were relatively few and are shown in Table 1V.Longer-term results are shown in Table V. The brighter postoperative clinical picture shown by Table V is usually not equally reflected in the postoperative radiological findings and in spite of the better drainage the dilated, poorly functioning kidneys are not usually much improved. Mucus is always present mixed with urine in varying degrees. Repeated serum electrolyte estimations, both in hospital and after discharge, have not shown any important derangement attributable to absorption by the ileal loop. Patients are encouraged to increase the fluid intake,
EXPERIENCE WITH T H E ILEAL URETER
21
Fig. 1 . Such tortuosity per se is obstructive, in addition to the distal obstruction.
b
a
Fig, 2. Usual plans of anastomosis; (a) Right, ureter anastomosis; (b) Left ureter anastomosis; (c) Bilateral anastomosis.
arid to micturate at intervals of not more than 2 to 3 hours, even at night. Hiprex (methenamine hippurate) is prescribed as a urinary antiseptic for some weeks or months following the operation, according to the degree of preoperative urinary infection. The longest follow-up in this series is 3 years (approximately 50 % of the cases) and we believe their lives have been made much nearer to normal than before.
Discussion
The use of ileum for the replacement of ureters gives the best alternative at the present time. Boari-Ockerblad vesical flaps can replace only limited defects of the lower segment and that only on one side. Sometimes the flap may even be difficult to fashion in a thickened contracted bladder such as tuberculous or bilharzial. A Boari flap is best applied in unilateral gynaecological injury, with or without ureterovaginal fistula (Amin, 1975).
22
BRITISH JOURNAL O F UROLOGY
Table V Clinical Results Presentation Renal fistula Ureteric fistula Renal m x s
No. 7 6 5
Clinical result Healed Healed Size diminished, pain less Size stationary, recurrent infection, multiple preexisting stones _ _ _ _ _ ~
~
Total
18
No.
Total
-
7 6 3
2
~~~
18
Fig. 3. W . N. age 30, operated 19th August 1972. Stricture lower end right ureter and destroyed left ureter with left nephrostomy fistula. Right ureter was splinted, left ureter was replaced by loop with T-tube at ileorenal anastomosis. Bilateral retrograde X-ray at the time of renioval of the right splint; an air bubble noticed in right lower ureler. Patient IS now leading B normal active life.
Mucus in the urine has caused very little upset to our patients. I t greatly diminishes a few month$ after operation. Roblejo and Malament (1973) have published a case in which a part of an ileal loop used for ileocystoplasty was resected 12 years later and was subjected to pathological examination. There was marked atrophy of the mucosa and a diminished number of mucoid cells, which shows a change of both the absorptive and mucus secreting characters of the loop lining when it is transferred from the gastro-intestinal into the urinary tract. The risk of the surgical tailoring of the loop and reconstruction of the gastro-intestinal tract should be no more than the risks of simple gut resection for any other reason. The main hazard is possible mechanical bowel obstruction by internal herniation behind the mesentery of thc isolated loop, or behind the ureteric anastomosis. Kuss c f al. (1970) in a review of 185 cases o f
EXPERIENCE WITH THE ILEAL URETER
23
Fig. 4. (a) Retrograde pyelograms of the completed bilateral operation at the time of removal of the tubes; (b) Cystogram a few days later. (Arrows indicate limits of ileal loop.)
Fig. 5. Possible alternatives to avoid anti-peristaltic anastomosis to right ureter; (a) Twisting of loop; (b) Transureteroureterostomy combined with a short left ureter replacement; (c) Longer loop getting the two ureters at mid-lumbar region, where they are nearest to each other.
sigmoid or ileal loops used for bladder replacement found that mechanical gut obstruction by internal herniation formed the main postoperative complication ( 1 1.5 %). They warn against nonsurgical management of obstruction under the assumption that it may be due to ileus and a low serum potassium; on the contrary they strongly advise early exploration even if the obstruction occurs only a few days following the primary operation. Peritoneal toilet and gap closure is very carefully considered before closure of the peritoneal incision. We had one complication in this respect; the patient was safely relieved by early interference on the 4th postoperative day. Routine appendicectomy is advised because of possible future hazards to the vascular supply of the isolated loop should appendicitis take place and require operation in another hospital.
24
BRITISH JOURNAL OF UROL.OGY
Fig. 6. Bilateral gross ureteric tortuosity caused merely by bladder outlet, obstruction without any ureteric Ftric!ure: (a) IVP; (b) Cystogram after T U R .
The patient should know that the appendix has been removed and he should be given a report and diagram of his new anatomy. Urinary obstruction distal to the loop should be carefully excluded and treated. The 2-layered muscle coat of the loop is much weaker than the 3-layered detrusor and is much more liable to dilate in the presence of distal obstruction. That was the explanation given by Cordonnier a n d Bowles (1970) for the delayed dilatation of the ileal segment reported in 7 cases by Houtapel and Griindemann (1960). For the same reason we also advise resection of a button of vesical wall at the site of the ileovesical anastomosis, which otherwise may in time become narrowed. This hnppened in 2 of our earlier cases; both were treated by limited widening of the osteum with cystoscopic scissors. Reflux has been noticeably absent in left-sided anastomosis but was present in varying degrees on the right side (Fig. 4), probably due to the direction of the loop peristalsis. Shown in Figure 5 are possible alternatives that can secure iso-peristaltic anastomosis. Twisting the loop (Fig. 5a) may positively jeopardise its blood supply (Weinberg, 1970). Transureterostomy (Fig. 5b) o r long midline loop (Fig. 5c) both require exposure of the ureters high up in the lumbar region. This may be difficult through the transverse Pfannenstiel incision and may require extending the incision. Oblique or tunnel-like uretero-ileal anastomosis (with a view to preventing reflux) may end in stenosis. We prefer the risk of reflux to the risk of stenosis. Kuss et a / . (1970), in their excellent review of bladder replacement, have shown that reflux when present after, intestinocystoplasty caused no harm provided there was no distal outlet obstruction. Reflux per se, in the presence of vesical outlet obstruction, can cause much dilatation and tcrtuosity of the ureters, which could be missed for lower ureteric obstructions. Figure 6 shows
25
EXPERIENCE WITH THE ILEAL URETER
Fig. 7. Acceptable end result of bilharzial ureters, no tortuosity.
Fig. 8. Early tortuosity caused by stricture; it shows ureteric decornpensation and is an indication for interference.
an extreme example of this clinical entity. Transurethral resection of the prostate was all the treatment required. The lack of much radiological improvement in the IVP is attributed to the long standing structural changes of the kidneys. The earlier these patients are operated upon the healthier are their kidneys. We pass as acceptable many bilharzial-strictured ureters which show mild dilatation, with minimal symptoms, infection or stone formation, as in Figure 7. We accept it to be a reasonable end-result if the patient has migrated from re-infestation areas, has received two ambilhar courses and the 1VP remains stationary for 1 year. The appearance of ureteric tortuosity, on the other hand, is a sign of ureteric decompensation. The degree of obstruction in such cases will be progressively deleterious to renal tissue even in the absence of pain, infection or stones; hence the necessity of interference whatever the cause of obstruction. If the lower ureters cannot be repaired then they are better replaced by ileal loop. In Figure 8 we illustrate the optimum time for interference: early tortuosity of the ureter and a well-functioning kidney.
Summary
The isolated ileal loop often provides a satisfactory solution to the problem of extensive ureteric defects. Our experience in 18 cases of diseased ureters partially or totally replaced by isolated ileal loops is presented. The indications for the operation and important operative and preoperative details are discussed. The operation presents a definite method for renal conservation in many cases in which nephrectomy would otherwise have been unavoidable.
26
BRITISH JOURNAL OF UROLOGY
References AMIN, H. A. (1974). Open resection of the contracted bladder neck. Journal of tlir Kuwaii Medical A.ssociufioir, 8, 19-25. ~(1975). Uretero-vaginal fistula. Journal of the Kuwait Medical Association, 9, 65-71. COKDONNIER. J. J . and BOWLES,W. T. (1970). Replacement of ureteral defects by ileal segmcnts. I n UrolokJy,
ed. M. F. Campbell, and J. H. Harrison, 3rd ed. Philadelphia: Saunders. pp. 2296-2299. GO:WWIN,W. E. and COCKETT, A. T. K. (1961). Surgical treatment of multiple, recurrent, branched, renal (stagliorn) calculi by pyelo-nephro-ileo-vesicalanastomosis. fourrial of Urolugy, 85, 214-222. HOUTAPEL, H. C. E. M. and GRUNDEMANN, A. M. (1960). Observations on ileoplasty. Brifi.sh fourrial q/’Ulolo,y.r, 32, 255-266. Ki;ss, R.. BIKTER, M., CAMEY,M . , CHATELAIN, C. and LASSAU,J. P. (1970). Indications and early and late result\ of intestinocystoplasty : a review of 185 cases. fourrial of Urology, 103, 53-63. K O I ~ L ~ J LP.J ,G . and MALAMENT, M. (1973). Late results of an ileocystoplasty; a 12-year follow-up. J O I I ~ I I o/ NI Urology, 109, 38-42. U t i L I ’ R , K. (1973). Hemangioma of the ureter. fourrial of Urology, 110, 647-649. WALLACE, D. M. (1972). Uretero-vaginal fistula. Rrifish fourrial of Urology, 44, 617422. WI-INBERG, R. W. (1970). Extensive schistosomiasis of the ureter: the use of the ileal loop in its management. Briii.h Jorir~inlof Urology, 42, 136-139.
The Author Hesein A. Amin, MCh, FACS, Head of Urology Unit.
0
Experience with the Ileal Ureter HESSEIN A. AMIN Urology Unit, Sabah Hospital, Kuwait
The ileum was first used in urology by Von Mickulicz in 1898 as a means of enlarging the capacity of a contracted bladder. Not until 1950 was attention given to it again, first as an external urinary diversion, then as a replacement of the bladder after cystectomy and only more recently as replacement for ureteric defects. Houtapel and Grundemann (1960) reported 7 cases which unfortunately were complicated by dilatation. Goodwin and Cockett (1961) succeeded in facilitating the passage of stones in recurrent renal lithiasis by connecting the kidney directly to the bladder with a long loop of ileum. Weinberg (1970) reported his experience in 4 cases of bilharzial ureters treated in Rhodesia by partial ureterectomy and ileal loop replacement. Cordonnier and Bowles (1970) reported 4 cases of successful replacement of ureteric defects by ileum. Uhlii! (1 973) reported I case of haemangioma of the lower third of the ureter which was resected and successfully replaced by an ileal loop. We present our experience in a series of 18 cases. This started in 1972 when 10 patients were operated upon in rapid succession. They were 10 chronic cases with fistulae, gross hydronephrosis, recurrent infection and sometimes uraemia which had, for long, haunted our wards. The results obtained were a great relief both to patients and to the wards. Table I shows the aetiology and Table I1 shows whether unilateral or bilateral operation was performed. The clinical presentation is shown in Table 111. Methods Preoperative gut preparation is essential; oral neomycin is given for 3 days and the gastro-intestinal tract should be empty on the morning of the operation. Cysto-urethroscopy should have been done and any bladder outlet obstruction such as prostatic disease or stricture should have been excluded or treated long before the operation is scheduled. Only if it is a vesical neck contracture can it be dealt with as a part of the operation. Our routine exposure is a transverse suprapubic Pfannenstiel incision. It offers an excellent exposure of the whole pelvis and the lower halves of ureters, it is extendible lateral to the recti on either side up to the kidney and is rarely followed by incisional hernia. Scars of previous midline exposures are, in our view, a still stronger indication for a transverse exposure, as incisional hernia would otherwise almost certainly follow. The first step, after a brief intraperitoneal examination, is appendicectomy. The loop is then prepared. Its length depends on the extent of the lesion but 6 inches is a good average. There should be at least one full vascular arch in it with a broad base. Intestinal continuity is restored, the mesenteric gap being always closed transversely and not longitudinally. This keeps the “umbilical cord” of the loop widely based and less liable to torsion. The preparation of the loop should precede the preparation of the ureters, which allows time to detect any possible diminished vascular supply. The ureters are exposed transperitoneally and it is essential to reach a healthy segment for the anastomosis. If upward intubation shows a higher stricture or if higher ureteric tortuosityper se is considered obstructive (Fig. 1) on either side, then the abdominal incision is extended lateral to the rectus on the affected side and the upper lesion is dealt with accordingly. The distal ureter is either ignored, ligated, or resected. The bladder is then opened, inspected and prepared for the anastomosis. Any vesical neck contracture present is punched out at this stage with our special bladder neck punch (Amin, 1974). Our usual plans of anastomosis are shown in Figure 2. Thus it will be iso-peristaltic on the left side, and antiperistaltic on the right side. The left ureter must be passed behind the sigmoid to its right side, so that the anastomosis is not allowed to cross over the colon. If the loop is anastomosed to the lower pole of the kidney it should pass behind and not in front of the descending colon. This was carried out in 1 case in this series (Fig. 3 ) . in whom the left ureter was totally destroyed following repeated ureterolithotomies. The whole loop length was utilised to bridge the gap between the left kidney and bladder. The right ureter had only a single stricture at its lower end and this was dilated and splinted. 19
20
BRITISH JOURNAL OF UROLOGY
Table 1
Table I1
Aetiology
Distribution of Sides No. of cases
Original pathology .~
~~~
.
~~~
~
Bilharzial fibrosis of lower third of the ureter Multiple strictures and operations (nonbilharzial) Tuberculosis Irradiation fibrosis ~~
~
~~
9
7 2
-7
~
~~
Bilateral anastomosis Loop connected to one ureter (other side healthy, 2. cases; other side splinted, 1 case; other side removed, 2 cases)
1.1
Total
18
18
Table I11
Table IV
Clinical Presentation
Postoperative Complications No. of cases
~
~
_
_
Persistent renal fistula (following nephrostomy) Persistent ureteric fistula (following ureterolithotomy or ureterostomy) Palpable painful renal mass Total
S
~
Total
Presentation
No. of cases
Side of operation -
~
~
. _ ~
7 6 5
Complication _
~
_
~~
.
No.
7"
~
Postoperative mortality Mechanical intestinal obstruction Suprapubic urinary fistula (for 6 and 8 weeks only) Minor wound infections
0 1
on,,
2. 4
ll", 2.2.":
55""
18
A button of bladder tissue should be resected for the ileovesical anastomosis. Theoretically no splint is needed either for the uretero-ileal or for the ileovesical suture-lines. Usually, however, a long Gibbon catheter has been used as a temporary splint on each side. The catheters emerge from the bladder through a separate stab or through the cystotomy incision and are retained for only a few days. Peritoneal toilet is essential before closure. This consists of abolishing any possible narrow spaces into which gut herniation or strangulation can take place. Sometimes it may be possible to fix the sides of the loop mesentery to the retroperitoneum completely. The flaps of the posterior peritoneal incisions (through which the ureters were exposed) can usually be made to cover the anastomosis itself and obliterate any gaps in the corners. In some cases it is difficult to obliterate a gap and then it is preferable to leave it widc open rather than to narrow i t ineffectively.
Results The immediate convalescence was smooth in most of the cases. Postoperative complications were relatively few and are shown in Table 1V.Longer-term results are shown in Table V. The brighter postoperative clinical picture shown by Table V is usually not equally reflected in the postoperative radiological findings and in spite of the better drainage the dilated, poorly functioning kidneys are not usually much improved. Mucus is always present mixed with urine in varying degrees. Repeated serum electrolyte estimations, both in hospital and after discharge, have not shown any important derangement attributable to absorption by the ileal loop. Patients are encouraged to increase the fluid intake,
EXPERIENCE WITH T H E ILEAL URETER
21
Fig. 1 . Such tortuosity per se is obstructive, in addition to the distal obstruction.
b
a
Fig, 2. Usual plans of anastomosis; (a) Right, ureter anastomosis; (b) Left ureter anastomosis; (c) Bilateral anastomosis.
arid to micturate at intervals of not more than 2 to 3 hours, even at night. Hiprex (methenamine hippurate) is prescribed as a urinary antiseptic for some weeks or months following the operation, according to the degree of preoperative urinary infection. The longest follow-up in this series is 3 years (approximately 50 % of the cases) and we believe their lives have been made much nearer to normal than before.
Discussion
The use of ileum for the replacement of ureters gives the best alternative at the present time. Boari-Ockerblad vesical flaps can replace only limited defects of the lower segment and that only on one side. Sometimes the flap may even be difficult to fashion in a thickened contracted bladder such as tuberculous or bilharzial. A Boari flap is best applied in unilateral gynaecological injury, with or without ureterovaginal fistula (Amin, 1975).
22
BRITISH JOURNAL O F UROLOGY
Table V Clinical Results Presentation Renal fistula Ureteric fistula Renal m x s
No. 7 6 5
Clinical result Healed Healed Size diminished, pain less Size stationary, recurrent infection, multiple preexisting stones _ _ _ _ _ ~
~
Total
18
No.
Total
-
7 6 3
2
~~~
18
Fig. 3. W . N. age 30, operated 19th August 1972. Stricture lower end right ureter and destroyed left ureter with left nephrostomy fistula. Right ureter was splinted, left ureter was replaced by loop with T-tube at ileorenal anastomosis. Bilateral retrograde X-ray at the time of renioval of the right splint; an air bubble noticed in right lower ureler. Patient IS now leading B normal active life.
Mucus in the urine has caused very little upset to our patients. I t greatly diminishes a few month$ after operation. Roblejo and Malament (1973) have published a case in which a part of an ileal loop used for ileocystoplasty was resected 12 years later and was subjected to pathological examination. There was marked atrophy of the mucosa and a diminished number of mucoid cells, which shows a change of both the absorptive and mucus secreting characters of the loop lining when it is transferred from the gastro-intestinal into the urinary tract. The risk of the surgical tailoring of the loop and reconstruction of the gastro-intestinal tract should be no more than the risks of simple gut resection for any other reason. The main hazard is possible mechanical bowel obstruction by internal herniation behind the mesentery of thc isolated loop, or behind the ureteric anastomosis. Kuss c f al. (1970) in a review of 185 cases o f
EXPERIENCE WITH THE ILEAL URETER
23
Fig. 4. (a) Retrograde pyelograms of the completed bilateral operation at the time of removal of the tubes; (b) Cystogram a few days later. (Arrows indicate limits of ileal loop.)
Fig. 5. Possible alternatives to avoid anti-peristaltic anastomosis to right ureter; (a) Twisting of loop; (b) Transureteroureterostomy combined with a short left ureter replacement; (c) Longer loop getting the two ureters at mid-lumbar region, where they are nearest to each other.
sigmoid or ileal loops used for bladder replacement found that mechanical gut obstruction by internal herniation formed the main postoperative complication ( 1 1.5 %). They warn against nonsurgical management of obstruction under the assumption that it may be due to ileus and a low serum potassium; on the contrary they strongly advise early exploration even if the obstruction occurs only a few days following the primary operation. Peritoneal toilet and gap closure is very carefully considered before closure of the peritoneal incision. We had one complication in this respect; the patient was safely relieved by early interference on the 4th postoperative day. Routine appendicectomy is advised because of possible future hazards to the vascular supply of the isolated loop should appendicitis take place and require operation in another hospital.
24
BRITISH JOURNAL OF UROL.OGY
Fig. 6. Bilateral gross ureteric tortuosity caused merely by bladder outlet, obstruction without any ureteric Ftric!ure: (a) IVP; (b) Cystogram after T U R .
The patient should know that the appendix has been removed and he should be given a report and diagram of his new anatomy. Urinary obstruction distal to the loop should be carefully excluded and treated. The 2-layered muscle coat of the loop is much weaker than the 3-layered detrusor and is much more liable to dilate in the presence of distal obstruction. That was the explanation given by Cordonnier a n d Bowles (1970) for the delayed dilatation of the ileal segment reported in 7 cases by Houtapel and Griindemann (1960). For the same reason we also advise resection of a button of vesical wall at the site of the ileovesical anastomosis, which otherwise may in time become narrowed. This hnppened in 2 of our earlier cases; both were treated by limited widening of the osteum with cystoscopic scissors. Reflux has been noticeably absent in left-sided anastomosis but was present in varying degrees on the right side (Fig. 4), probably due to the direction of the loop peristalsis. Shown in Figure 5 are possible alternatives that can secure iso-peristaltic anastomosis. Twisting the loop (Fig. 5a) may positively jeopardise its blood supply (Weinberg, 1970). Transureterostomy (Fig. 5b) o r long midline loop (Fig. 5c) both require exposure of the ureters high up in the lumbar region. This may be difficult through the transverse Pfannenstiel incision and may require extending the incision. Oblique or tunnel-like uretero-ileal anastomosis (with a view to preventing reflux) may end in stenosis. We prefer the risk of reflux to the risk of stenosis. Kuss et a / . (1970), in their excellent review of bladder replacement, have shown that reflux when present after, intestinocystoplasty caused no harm provided there was no distal outlet obstruction. Reflux per se, in the presence of vesical outlet obstruction, can cause much dilatation and tcrtuosity of the ureters, which could be missed for lower ureteric obstructions. Figure 6 shows
25
EXPERIENCE WITH THE ILEAL URETER
Fig. 7. Acceptable end result of bilharzial ureters, no tortuosity.
Fig. 8. Early tortuosity caused by stricture; it shows ureteric decornpensation and is an indication for interference.
an extreme example of this clinical entity. Transurethral resection of the prostate was all the treatment required. The lack of much radiological improvement in the IVP is attributed to the long standing structural changes of the kidneys. The earlier these patients are operated upon the healthier are their kidneys. We pass as acceptable many bilharzial-strictured ureters which show mild dilatation, with minimal symptoms, infection or stone formation, as in Figure 7. We accept it to be a reasonable end-result if the patient has migrated from re-infestation areas, has received two ambilhar courses and the 1VP remains stationary for 1 year. The appearance of ureteric tortuosity, on the other hand, is a sign of ureteric decompensation. The degree of obstruction in such cases will be progressively deleterious to renal tissue even in the absence of pain, infection or stones; hence the necessity of interference whatever the cause of obstruction. If the lower ureters cannot be repaired then they are better replaced by ileal loop. In Figure 8 we illustrate the optimum time for interference: early tortuosity of the ureter and a well-functioning kidney.
Summary
The isolated ileal loop often provides a satisfactory solution to the problem of extensive ureteric defects. Our experience in 18 cases of diseased ureters partially or totally replaced by isolated ileal loops is presented. The indications for the operation and important operative and preoperative details are discussed. The operation presents a definite method for renal conservation in many cases in which nephrectomy would otherwise have been unavoidable.
26
BRITISH JOURNAL OF UROLOGY
References AMIN, H. A. (1974). Open resection of the contracted bladder neck. Journal of tlir Kuwaii Medical A.ssociufioir, 8, 19-25. ~(1975). Uretero-vaginal fistula. Journal of the Kuwait Medical Association, 9, 65-71. COKDONNIER. J. J . and BOWLES,W. T. (1970). Replacement of ureteral defects by ileal segmcnts. I n UrolokJy,
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The Author Hesein A. Amin, MCh, FACS, Head of Urology Unit.
