Heal Loop Ureteroileostomy
in Patients with Neurogenic
Bladder Personal Experience with 54 Patients Angelos A. Kambourls, MD, FACS, Detroit, Michigan Robert D. Allaben, MD, FACS, Detroit, Michigan Wllltam S. Carpenter, MD, FACS, Detroit, Michigan Edward J. Shumaker, MD, FACS, Detroit, Michigan
Permanent supravesical urinary diversion is indicated in patients undergoing cystectomy or pelvic exenteration, in patients with neurogenic, congenital, or acquired lower urinary tract dysfunction of irreversible nature, and occasionally for palliation of urinary symptoms due to advanced pelvic malignancy. Although various methods have been employed, the “ileal loop” ureteroileostomy as described by Bricker [I] in 1950 has been widely accepted as the most efficient and least troublesome form of supravesical urinary diversion [2-S]. The general surgeon rarely has the opportunity to employ the ileal loop procedure, unless he is involved in the treatment of large numbers of patients with pelvic malignancy. Most of the candidates for this procedure fall into the domain of the urologists and the gynecologists. In the past six years we have had the unusual opportunity to operate on 63 patients in whom ileal loop ureteroileostomy was part of the definitive operation. Fifty-four of these patients were operated on for neurogenic bladder dysfunction of nonmalignant nature and they constitute the basis for this report. Of the nine excluded patients with ileal loop ureteroileostomy, three had resection for cancer, three resection for palliation, and three revision of conduits. Material and Methods Fifty-four patients with neurogenic bladder dysfunction (due to spinal cord trauma in 26 patients, multiple sclerosis in 18, congenital anomalies in 4, transverse myelitis in 3, and miscellaneous disorders in 3) underwent ileal loop ureteroileostomy from March 1969 to
Fromthe Departments of
Surgery and Urology, tiarper Hospital and mehabilltation Institute. Wayne State University School of Medicine, Detroit, Michigan. Reprint requests should be addressed to Angeles A. Kambouris, MD, 18255 W. McNichols. Detroit. Michigan 48219.
224
July 1975, All operations were performed by us or by senior residents under our direct supervision. Fifty-two operations were performed at Harper Hospital and two at Mt. Carmel Mercy Hospital, both in Detroit. There were thirty-three women and twenty-one men, varying in age from twelve to sixty-five years (median age, thirty-seven years). Forty-two of the patients were Caucasian and twelve were blacks. (Table I.) Indications. Fifty-two of the patients had been under the care of one urologist (EJS) for long periods of time. They had undergone periodic urologic evaluations, including cystoscopy, pyelograms, cystourethrograms, and cystometrograms, and had received appropriate treatment for the underlying urologic dysfunction. Urinary infections had been documented by cultures, and urinary antibacterials had been used accordingly. Several patients had indwelling urethral catheters for months or years; seventeen patients (30 per cent) had bladder stones removed at interval cystoscopies; and nine patients had permanent suprapubic cystostomies. When it was no longer possible to manage the urinary problem safely by the measures just noted, when vesicoureteral reflux became obvious or increased in severity, and when ascending infection became a threat to the integrity of the kidneys, the patients were referred for urinary diversion. Most of the patients with multiple sclerosis had been on corticosteroids for stabilization of their neurologic status. Repeated urinary tract infections, however, were triggering exacerbations of their disease; ileal loop diversion was frequently requested to prevent such exacerbations. In two of the patients, revision of the ileal conduit was performed as a preliminary to renal ~transplantation. Both patients had end-stage renal disease secondary to congenital anomalies. There was frequently more than one indication for supravesical urinary diversion: infection was the most common indication (49 patients), followed by reflux (23), incontinence (22), renal deterioration (20), bladder calculi (17), retention (5), and hematuria (2). Preparation. Once the decision is made that a permanent urinary diversion is necessary, the patient and his
TheAmerkan
Journal of Surgery
MealLoop Ureteroileostomy
family are appropriately informed and gradually prepared psychologically. The urologist and the surgeon present the medical aspects of the procedure and its long-range effects. The enterostomal therapist sees the patient, assesses the ability and comprehension of the patient and his family for satisfactory stoma1 care, and demonstrates types and handling of appliances. Whenever possible, a patient with an ileal loop visits the candidate, demonstrates the appearance of the stoma and the appliance and offers reassuring information. When the patient consents to the procedure, his medical, neurologic, and urologic status is updated. Existing antibacterial program is continued intraoperatively and postoperatively. If corticosteroids are indicated, coverage is begun the night before operation and tapered off in the first five postoperative days. The intestinal tract is prepared mechanically with laxatives, enemas, and dietary adjustment to minimize fecal stasis and postoperative ileus. This is particularly applicable to patients with paraplegia or quadriplegia in whom bowel function has been impaired. Technic. Unless otherwise indicated, the operation is performed through a low midline incision. Appendectomy is routinely performed and the ileocecal region exposed and evaluated. A segment of distal ileum 15 to 20 cm long is isolated with its blood supply intact, and the ileal loop is performed as originally described by Bricker [I]. The distal ends of the severed ureters are transfixed with 00 chromic catgut sutures. The left ureter is brought through the retroperitoneal space posterior to the sigmoid vessels. The space is widely developed to allow graceful curving of the ureter and to avoid kinking. The right ovarian vessels are routinely ligated in females to prevent kinking of the right ureter. An end-toside, two-layer ureteroileostomy is performed close to the proximal end of the loop, which is then placed into the retroperitoneal space at the right paracolic gutter, as described to Harrower, Lome, and Klutz [9]. A wafer of skin, subcutaneous fat, and aponeurosis is then excised at a previously marked point for the ileal stoma. The stoma is placed just below the belt line and midway between the umbilicus and the right anterosuperior iliac spine. The opening is enlarged through the lateral abdominal wall; the loop is brought through, fixed at the fascial level with chromic catgut, and sutured to the skin in a slightly everting manner. The posterior peritoneal leaf is then completely closed, excluding the loop from the peritoneal cavity. The abdominal wound is closed with wire sutures and the skin closed primarily. A disposable collecting bag is applied on the stoma and connected to straight drainage. Postoperative Care. In addition to the routine care given any patient with a complex intra-abdominal operation, special attention is directed to the intestinal and urinary tracts and the ileal stoma. Nasogastric or long tubes are employed to assure postoperative decompression. This is particularly important in patients with spinal cord injury who tend to have prolonged postoperative ileus. Reactivation of urinary infection is treated
Volume 131, February 1978
TABLE I
Sex, Age, and Race Distribution by Disease Category Race
.9X
Disease Category Spinal trauma Multiple sclerosis Congenital anomaly Transverse myelitis Miscellaneous Total
Female
Male
White
Black
9 16 3 3 2 33
17
16 18 4 2 2 42
10 0 0 1 1 12
2 1 0 1 21
Age (yr)
24.5 44.5 19.5 48 50 37
vigorously with antibacterials. The residual neurogenic bladder is irrigated with antiseptic or antibacterial solutions to eradicate infection and reduce mucous secretions. The ileal stoma is frequently inspected to assure satisfactory drainage as well as viability. If signs of congestion are present, low molecular weight dextran is administered, to improve microcirculation and reduce mucosal slough. Unsatisfactory urine output is of grave concern and urinary extravasation must be ruled out by intravenous pyelograms or by loopogram. Patients with major neurologic deficits are prone to respiratory complications and skin breakdown. Vigorous respiratory and skin care have successfully prevented development of such complications in this group of patients. The entorostomal therapist sees the patient during the recovery phase and instructs him in handling the appliances in an independent fashion, and arrangements are made for responsible family members to assist or completely take over the stoma1 care if needed. Eight to ten days after operation a drip infusion intravenous pyelogram is obtained to assess the status and function of the kidneys and ureters and demonstrate the loop. Invariably a mild degree of ureteral dilatation is demonstrated, most likely related to the initial edema at the ureteroileal anastomosis. Such pyelograms are repeated at three month intervals in order to obtain long-term follow-up of the urinary status of these patients. Serum blood urea nitrogen and creatinine levels are also obtained for the same purpose at three month or more frequent intervals if indicated. Complications. Twenty-eight patients (51.8 per cent) had one or more complications in the immediate postoperative period. Fever greater than 1Ol’F for longer than 48 hours was the only complication in eleven patients. Although most of these patients had contaminated urine and history of previous urinary tract infections, in several instances no definite cause of the fever could be found. They were treated, however, with urinary antibacterials with the presumptive diagnosis of urinary tract infection. Twenty-six other complications occurred in seventeen different patients (31.5 per cent), including wound infection (4 patients), cardiopulmonary complication (4), pyelonephritis (3), ileus (3), loop changes (4), ureteral leak (l), and miscellaneous (7). The wound infections were of the subcutaneous space in all four patients. Three of the patients had estab-
225
Kambouris et al
lished urinary tract infection and were on antibiotics before and after operation. Two of them had a suprapubic cystostomy with a stoma adjacent to the abdominal incision. Cardiopulmonary complications of serious nature ocOne had acute pulmonary curred in four patients. edema at the completion of the operation, most likely due to fluid overload. She had preexisting mitral stenosis and was quadriplegic with marked respiratory deficit. She responded to diuretics, digitalis, respiratory support, and fluid restriction. Another patient, a paraplegic, had multiple episodes of cardiorespiratory arrest in the recovery room and eventually required tracheostomy for prolonged respiratory support. He also had pneumonitis and stress gastric bleeding. He responded to appropriate management and completely recovered. A third patient, a fifty-three year old quadriplegic, suffered a pneumothorax during insertion of a central venous catheter for fluid administration and monitoring. He responded well to ciosed chest drainage. His prolonged ileus necessitated long-tube decompression for two weeks but eventually subsided. He also had minor stress bleeding which responded to conservative management. The fourth patient, a quadriplegic, had atelectasis with minimal temperature elevation for three days. Postoperative pyelonephritis with fever, chills, leukocytosis, and flank pain was recorded in three patients. All three had contaminated urine documented by cultures and responded to antibiotic adjustments. Prolonged ileus was the cause of postoperative morbidity in three patients. They ai1 improved on long-tube intestinal decompression. There were no incidents of postoperative intestinal obstruction in this group. Ischemic loop changes were observed in four patients. One required a new loop two months after original diversion, because of fibrosis of the conduit, probably on the basis of arterial ischemia. The second patient had ischemia of the end which resulted in retraction and stenosis. Two stoma1 revisions were performed at intervals to correct this complication. Transient congestion and cyanosis of the loop stoma were observed in one other patient. However, the color returned to normal 48 hours after administration of low molecular weight dextran. In the fourth patient the ileal segment became infarcted during the procedure and a new loop was immediately fashioned. Urinary leak at the ureteroileal anastomosis occurred in one patibnt, documented by intravenous pyelograms. The retroperitoneal urinary collection was drained five days after operation, the fever and ileus subsided, and the patient recovered completely. Both ureters remained unchanged in caliber, as shown by subsequent intravenous pyelograms. There were no postoperative deaths in this series. Comments
Ileal loop ureteroileost,omy ployed in the past twenty-five
226
has been widely emyears, as reflected in
individual [2-4,7,8,10,12,13] and collective [l4] reports. The familiarity with the procedure and its attendant anatomic, biochemical, and bacteriologic changes have had only limited impact on surgical mortality and early and late morbidity after ileal loop urinary diversion. Surgical mortality varies from 2 per cent to less than 10 per cent in patients with non-neoplastic [4,5,7,8,10,12,14] disorders, and from 5 to 23 per cent for patients with carcinoma [l4] in whom cystectomy or other extensive procedures are concurrently performed. The composition of our patients differs considerably from that of others. In most reports [lo12,141, non-neoplastic diseases were primarily of congenital or acquired nature and only a few patients had spinal cord injury with paralysis. In contrast, twenty-six of our patients (49 per cent) had spinal cord injury. Multiple sclerosis is cited only rarely [lOI as the underlying disorder but was present in eighteen of our patients (33 per cent). The propensity of long-term paraplegics or quadriplegics to prolonged ileus and pulmonary and skin complications and the contribution of multiple sclerosis and its treatment with steroids to complications after any operation are well known. Most of the early postoperative deaths in patients with non-neoplastic disease are due to pulmonary complications, peritonitis, and sepsis [2,11,12,18]. Vigorous postoperative respiratory care, judicious use of antibiotics, and meticulous operative technic probably account for the prevention of early mortality in our patients. The 51.8 per cent incidence of complications in our patients agrees with other reports [5,10,13,15]. Excluding the transient fever of unknown significance, seventeen of our patients (31.5 per cent) had serious early postoperative complications. Although several of the complications were of major significance, there were no instances of intestinal obstruction or wound dehiscence, both of which were featured frequently in other reports [2,3,5,8-10,12,13,16]. This is probably due to meticulous reconstitution of the intestinal tract and to placement of the ileal loop in the retroperitoneal space as recommended by Harrower, Lome, and Klutz [9]. The danger of internal herniations or adhesions, a most frequent cause of postoperative obstruction [16], is thus minimized. Initially, long tubes or Baker jejunostomy tubes were employed to assure postoperative intestinal decompression. More recently, we have employed nasogastric suction exclusively and have resorted to long-tube decompression in specific instances only. The absence of wound dehiscence is remark-
the American Journal of Surgery
NealLoop Ureteroileostomy
able, especially since 33 per cent of our patients had long-standing multiple sclerosis and had been receiving corticosteroids at some stage of their disease; and 49 per cent were paralyzed with limited physical ability, prolonged periods of confinement, and a tendency for development of persistent abdominal distention. The routine irrigation of the infected bladder with antiseptic solutions has prevented the development of early pyocystis. However, a number of patients have undergone delayed cystectomy for recurrent or persistent empyema of the urinary bladder. There were no instances of electrolyte disturbances in the immediate postoperative period. This is probably due to the short segment used as a conduit and to the wide stoma, which has prevented urinary stasis and reabsorption of chlorides, both critical factors in the development of hyperchloremic acidosis [17]. The incidence of urinary leaks has been reported as great as 5.7 per cent and the associated mortality 47.8 per cent [18]. The one patient with retroperitoneal urinary leak in our series responded to drainage only and must have had a side fistula at the suture line. Of the miscellaneous complications, diarrhea was encountered in two patients and lasted approximately two months despite symptomatic treatment. Although no definite reference can be found in the reports reviewed, diminished absorption of bile salts after exclusion of an ileal segment may well be the underlying pathophysiologic mechanism. Summary and Conclusions (1) In a six year experience with ileal loops in patients with neurogenic bladder, 49 per cent of the patients were paralyzed, 30 per cent had multiple sclerosis, and 91 per cent had recurrent or persistent urinary tract infection. Reflux, incontinence, retention, and bladder calculi were additional indications for supravesical urinary diversions. (2) All loops were performed in a similar manner, most of them placed retroperitoneally, and a vigorous program of postoperative care was followed. There were no postoperative deaths, and a moderate number of complications occurred in 51.8 per cent of the patients.
Votume 131, February 1976
(3) The participation of the enterostomal therapist in the preparation of the patient and in the immediate and long-term stoma1 care has been invaluable and is strongly recommended.
Acknowledgment: We wish to thank Mrs. Sandy Fishman, Enterostomal Therapist, for her expert help in preparing patients and their families for stoma1 care and her help with appliances and follow-up of stoma1 problems at the Enterostomal Clinic of Harper Hospital. References 1. Bricker EM: Bladder substitution after pelvic exenteration. Surg C/in North Am 30: 1511, 1950. 2. Burnham JP, Farrer J: A group experience with ureteroileocutaneous anastomosis for urinary diversion: results and complications of the isolated ileal conduit (Bricker procedure) in 96 patients. J Ural 83: 622, 1960. 3. Cordonnier JJ, Nicolai CH: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J Ural 63: 834, 1960. 4. Butcher HR Jr, Sugg WL, McAfee AC, Bricker EM: lleal conduit method of ureteral urinary diversion. Ann Surg 156: 682, 1962. 5. Parkhurst EC, Leadbetter WF: A report on 93 ileal loop urinary diversions. J Ural 83: 398, 1960. 6. Hollan JM. Schlrmer HKA, King LR, Gibbons RP, Scott WW: Pyeloileal urinary conduit: an 8-year experience in 37 patients. J Ural 99: 427, 1968. 7. Parkhurst EC: Experience with more than 500 ileal conduit diversions in a 12-year period. J Ural 99: 434. 1968. 8. Schmidt JD. Hawtrey CE, Flocks RH, Culp DA: Complications, results, and problems of ileal conduit diversions. J Ural 109: 210, 1973. 9. Harrower HW, Lome LG, Klutz WS: Retroperitoneal ureteroileal conduit. Surg Gynecol Obstet 130: 4 14, 1970. 10. Cohen SM. Persky L: A ten-year experience with ureteroileostomy. Arch Surg 95: 278, 1967. 11. Creevy CD: Renal complications after ileal diversion of the urine in non-neophstic disorders. J Ural 83: 394, 1960. 12. Ellis LR, Udall DA, Hodges CV: Further clinical experience with intestinal segments for urinary diversion. J Ural 105: 354,197l. 13. Engel RM: Complications of bilateral uretero-ileo-cutaneous urinary diversion: a review of 208 cases. J Ural 101: 508, 1969. 14. Kerr WK, Robson CJ, Russell JLT, Bourque JP: Collective review of urinary tract diversions: Canadian Academy of Urological Surgeons. J Ural 88: 644, 1962. 15. Jose JS: Complications of urinary diversion. Sr J Ural 44: 718, 1972. 16. Manley CB, Silber I, Cordonnier JJ: Intestinal obstruction fOtlowing ileal segment diversion. J Ural 101: 840, 1969. 17. Derrick WA Jr, Hodges CV: lleal conduit stasis: recognition, treatment, and prevention. J Ural 107: 747, 1972. 18. Nichols WK. Krause AH, Donegan WL: Urinary fistulas after ureteral diversion. Am J Surg 124: 311, 1972.
227
in Patients with Neurogenic
Bladder Personal Experience with 54 Patients Angelos A. Kambourls, MD, FACS, Detroit, Michigan Robert D. Allaben, MD, FACS, Detroit, Michigan Wllltam S. Carpenter, MD, FACS, Detroit, Michigan Edward J. Shumaker, MD, FACS, Detroit, Michigan
Permanent supravesical urinary diversion is indicated in patients undergoing cystectomy or pelvic exenteration, in patients with neurogenic, congenital, or acquired lower urinary tract dysfunction of irreversible nature, and occasionally for palliation of urinary symptoms due to advanced pelvic malignancy. Although various methods have been employed, the “ileal loop” ureteroileostomy as described by Bricker [I] in 1950 has been widely accepted as the most efficient and least troublesome form of supravesical urinary diversion [2-S]. The general surgeon rarely has the opportunity to employ the ileal loop procedure, unless he is involved in the treatment of large numbers of patients with pelvic malignancy. Most of the candidates for this procedure fall into the domain of the urologists and the gynecologists. In the past six years we have had the unusual opportunity to operate on 63 patients in whom ileal loop ureteroileostomy was part of the definitive operation. Fifty-four of these patients were operated on for neurogenic bladder dysfunction of nonmalignant nature and they constitute the basis for this report. Of the nine excluded patients with ileal loop ureteroileostomy, three had resection for cancer, three resection for palliation, and three revision of conduits. Material and Methods Fifty-four patients with neurogenic bladder dysfunction (due to spinal cord trauma in 26 patients, multiple sclerosis in 18, congenital anomalies in 4, transverse myelitis in 3, and miscellaneous disorders in 3) underwent ileal loop ureteroileostomy from March 1969 to
Fromthe Departments of
Surgery and Urology, tiarper Hospital and mehabilltation Institute. Wayne State University School of Medicine, Detroit, Michigan. Reprint requests should be addressed to Angeles A. Kambouris, MD, 18255 W. McNichols. Detroit. Michigan 48219.
224
July 1975, All operations were performed by us or by senior residents under our direct supervision. Fifty-two operations were performed at Harper Hospital and two at Mt. Carmel Mercy Hospital, both in Detroit. There were thirty-three women and twenty-one men, varying in age from twelve to sixty-five years (median age, thirty-seven years). Forty-two of the patients were Caucasian and twelve were blacks. (Table I.) Indications. Fifty-two of the patients had been under the care of one urologist (EJS) for long periods of time. They had undergone periodic urologic evaluations, including cystoscopy, pyelograms, cystourethrograms, and cystometrograms, and had received appropriate treatment for the underlying urologic dysfunction. Urinary infections had been documented by cultures, and urinary antibacterials had been used accordingly. Several patients had indwelling urethral catheters for months or years; seventeen patients (30 per cent) had bladder stones removed at interval cystoscopies; and nine patients had permanent suprapubic cystostomies. When it was no longer possible to manage the urinary problem safely by the measures just noted, when vesicoureteral reflux became obvious or increased in severity, and when ascending infection became a threat to the integrity of the kidneys, the patients were referred for urinary diversion. Most of the patients with multiple sclerosis had been on corticosteroids for stabilization of their neurologic status. Repeated urinary tract infections, however, were triggering exacerbations of their disease; ileal loop diversion was frequently requested to prevent such exacerbations. In two of the patients, revision of the ileal conduit was performed as a preliminary to renal ~transplantation. Both patients had end-stage renal disease secondary to congenital anomalies. There was frequently more than one indication for supravesical urinary diversion: infection was the most common indication (49 patients), followed by reflux (23), incontinence (22), renal deterioration (20), bladder calculi (17), retention (5), and hematuria (2). Preparation. Once the decision is made that a permanent urinary diversion is necessary, the patient and his
TheAmerkan
Journal of Surgery
MealLoop Ureteroileostomy
family are appropriately informed and gradually prepared psychologically. The urologist and the surgeon present the medical aspects of the procedure and its long-range effects. The enterostomal therapist sees the patient, assesses the ability and comprehension of the patient and his family for satisfactory stoma1 care, and demonstrates types and handling of appliances. Whenever possible, a patient with an ileal loop visits the candidate, demonstrates the appearance of the stoma and the appliance and offers reassuring information. When the patient consents to the procedure, his medical, neurologic, and urologic status is updated. Existing antibacterial program is continued intraoperatively and postoperatively. If corticosteroids are indicated, coverage is begun the night before operation and tapered off in the first five postoperative days. The intestinal tract is prepared mechanically with laxatives, enemas, and dietary adjustment to minimize fecal stasis and postoperative ileus. This is particularly applicable to patients with paraplegia or quadriplegia in whom bowel function has been impaired. Technic. Unless otherwise indicated, the operation is performed through a low midline incision. Appendectomy is routinely performed and the ileocecal region exposed and evaluated. A segment of distal ileum 15 to 20 cm long is isolated with its blood supply intact, and the ileal loop is performed as originally described by Bricker [I]. The distal ends of the severed ureters are transfixed with 00 chromic catgut sutures. The left ureter is brought through the retroperitoneal space posterior to the sigmoid vessels. The space is widely developed to allow graceful curving of the ureter and to avoid kinking. The right ovarian vessels are routinely ligated in females to prevent kinking of the right ureter. An end-toside, two-layer ureteroileostomy is performed close to the proximal end of the loop, which is then placed into the retroperitoneal space at the right paracolic gutter, as described to Harrower, Lome, and Klutz [9]. A wafer of skin, subcutaneous fat, and aponeurosis is then excised at a previously marked point for the ileal stoma. The stoma is placed just below the belt line and midway between the umbilicus and the right anterosuperior iliac spine. The opening is enlarged through the lateral abdominal wall; the loop is brought through, fixed at the fascial level with chromic catgut, and sutured to the skin in a slightly everting manner. The posterior peritoneal leaf is then completely closed, excluding the loop from the peritoneal cavity. The abdominal wound is closed with wire sutures and the skin closed primarily. A disposable collecting bag is applied on the stoma and connected to straight drainage. Postoperative Care. In addition to the routine care given any patient with a complex intra-abdominal operation, special attention is directed to the intestinal and urinary tracts and the ileal stoma. Nasogastric or long tubes are employed to assure postoperative decompression. This is particularly important in patients with spinal cord injury who tend to have prolonged postoperative ileus. Reactivation of urinary infection is treated
Volume 131, February 1978
TABLE I
Sex, Age, and Race Distribution by Disease Category Race
.9X
Disease Category Spinal trauma Multiple sclerosis Congenital anomaly Transverse myelitis Miscellaneous Total
Female
Male
White
Black
9 16 3 3 2 33
17
16 18 4 2 2 42
10 0 0 1 1 12
2 1 0 1 21
Age (yr)
24.5 44.5 19.5 48 50 37
vigorously with antibacterials. The residual neurogenic bladder is irrigated with antiseptic or antibacterial solutions to eradicate infection and reduce mucous secretions. The ileal stoma is frequently inspected to assure satisfactory drainage as well as viability. If signs of congestion are present, low molecular weight dextran is administered, to improve microcirculation and reduce mucosal slough. Unsatisfactory urine output is of grave concern and urinary extravasation must be ruled out by intravenous pyelograms or by loopogram. Patients with major neurologic deficits are prone to respiratory complications and skin breakdown. Vigorous respiratory and skin care have successfully prevented development of such complications in this group of patients. The entorostomal therapist sees the patient during the recovery phase and instructs him in handling the appliances in an independent fashion, and arrangements are made for responsible family members to assist or completely take over the stoma1 care if needed. Eight to ten days after operation a drip infusion intravenous pyelogram is obtained to assess the status and function of the kidneys and ureters and demonstrate the loop. Invariably a mild degree of ureteral dilatation is demonstrated, most likely related to the initial edema at the ureteroileal anastomosis. Such pyelograms are repeated at three month intervals in order to obtain long-term follow-up of the urinary status of these patients. Serum blood urea nitrogen and creatinine levels are also obtained for the same purpose at three month or more frequent intervals if indicated. Complications. Twenty-eight patients (51.8 per cent) had one or more complications in the immediate postoperative period. Fever greater than 1Ol’F for longer than 48 hours was the only complication in eleven patients. Although most of these patients had contaminated urine and history of previous urinary tract infections, in several instances no definite cause of the fever could be found. They were treated, however, with urinary antibacterials with the presumptive diagnosis of urinary tract infection. Twenty-six other complications occurred in seventeen different patients (31.5 per cent), including wound infection (4 patients), cardiopulmonary complication (4), pyelonephritis (3), ileus (3), loop changes (4), ureteral leak (l), and miscellaneous (7). The wound infections were of the subcutaneous space in all four patients. Three of the patients had estab-
225
Kambouris et al
lished urinary tract infection and were on antibiotics before and after operation. Two of them had a suprapubic cystostomy with a stoma adjacent to the abdominal incision. Cardiopulmonary complications of serious nature ocOne had acute pulmonary curred in four patients. edema at the completion of the operation, most likely due to fluid overload. She had preexisting mitral stenosis and was quadriplegic with marked respiratory deficit. She responded to diuretics, digitalis, respiratory support, and fluid restriction. Another patient, a paraplegic, had multiple episodes of cardiorespiratory arrest in the recovery room and eventually required tracheostomy for prolonged respiratory support. He also had pneumonitis and stress gastric bleeding. He responded to appropriate management and completely recovered. A third patient, a fifty-three year old quadriplegic, suffered a pneumothorax during insertion of a central venous catheter for fluid administration and monitoring. He responded well to ciosed chest drainage. His prolonged ileus necessitated long-tube decompression for two weeks but eventually subsided. He also had minor stress bleeding which responded to conservative management. The fourth patient, a quadriplegic, had atelectasis with minimal temperature elevation for three days. Postoperative pyelonephritis with fever, chills, leukocytosis, and flank pain was recorded in three patients. All three had contaminated urine documented by cultures and responded to antibiotic adjustments. Prolonged ileus was the cause of postoperative morbidity in three patients. They ai1 improved on long-tube intestinal decompression. There were no incidents of postoperative intestinal obstruction in this group. Ischemic loop changes were observed in four patients. One required a new loop two months after original diversion, because of fibrosis of the conduit, probably on the basis of arterial ischemia. The second patient had ischemia of the end which resulted in retraction and stenosis. Two stoma1 revisions were performed at intervals to correct this complication. Transient congestion and cyanosis of the loop stoma were observed in one other patient. However, the color returned to normal 48 hours after administration of low molecular weight dextran. In the fourth patient the ileal segment became infarcted during the procedure and a new loop was immediately fashioned. Urinary leak at the ureteroileal anastomosis occurred in one patibnt, documented by intravenous pyelograms. The retroperitoneal urinary collection was drained five days after operation, the fever and ileus subsided, and the patient recovered completely. Both ureters remained unchanged in caliber, as shown by subsequent intravenous pyelograms. There were no postoperative deaths in this series. Comments
Ileal loop ureteroileost,omy ployed in the past twenty-five
226
has been widely emyears, as reflected in
individual [2-4,7,8,10,12,13] and collective [l4] reports. The familiarity with the procedure and its attendant anatomic, biochemical, and bacteriologic changes have had only limited impact on surgical mortality and early and late morbidity after ileal loop urinary diversion. Surgical mortality varies from 2 per cent to less than 10 per cent in patients with non-neoplastic [4,5,7,8,10,12,14] disorders, and from 5 to 23 per cent for patients with carcinoma [l4] in whom cystectomy or other extensive procedures are concurrently performed. The composition of our patients differs considerably from that of others. In most reports [lo12,141, non-neoplastic diseases were primarily of congenital or acquired nature and only a few patients had spinal cord injury with paralysis. In contrast, twenty-six of our patients (49 per cent) had spinal cord injury. Multiple sclerosis is cited only rarely [lOI as the underlying disorder but was present in eighteen of our patients (33 per cent). The propensity of long-term paraplegics or quadriplegics to prolonged ileus and pulmonary and skin complications and the contribution of multiple sclerosis and its treatment with steroids to complications after any operation are well known. Most of the early postoperative deaths in patients with non-neoplastic disease are due to pulmonary complications, peritonitis, and sepsis [2,11,12,18]. Vigorous postoperative respiratory care, judicious use of antibiotics, and meticulous operative technic probably account for the prevention of early mortality in our patients. The 51.8 per cent incidence of complications in our patients agrees with other reports [5,10,13,15]. Excluding the transient fever of unknown significance, seventeen of our patients (31.5 per cent) had serious early postoperative complications. Although several of the complications were of major significance, there were no instances of intestinal obstruction or wound dehiscence, both of which were featured frequently in other reports [2,3,5,8-10,12,13,16]. This is probably due to meticulous reconstitution of the intestinal tract and to placement of the ileal loop in the retroperitoneal space as recommended by Harrower, Lome, and Klutz [9]. The danger of internal herniations or adhesions, a most frequent cause of postoperative obstruction [16], is thus minimized. Initially, long tubes or Baker jejunostomy tubes were employed to assure postoperative intestinal decompression. More recently, we have employed nasogastric suction exclusively and have resorted to long-tube decompression in specific instances only. The absence of wound dehiscence is remark-
the American Journal of Surgery
NealLoop Ureteroileostomy
able, especially since 33 per cent of our patients had long-standing multiple sclerosis and had been receiving corticosteroids at some stage of their disease; and 49 per cent were paralyzed with limited physical ability, prolonged periods of confinement, and a tendency for development of persistent abdominal distention. The routine irrigation of the infected bladder with antiseptic solutions has prevented the development of early pyocystis. However, a number of patients have undergone delayed cystectomy for recurrent or persistent empyema of the urinary bladder. There were no instances of electrolyte disturbances in the immediate postoperative period. This is probably due to the short segment used as a conduit and to the wide stoma, which has prevented urinary stasis and reabsorption of chlorides, both critical factors in the development of hyperchloremic acidosis [17]. The incidence of urinary leaks has been reported as great as 5.7 per cent and the associated mortality 47.8 per cent [18]. The one patient with retroperitoneal urinary leak in our series responded to drainage only and must have had a side fistula at the suture line. Of the miscellaneous complications, diarrhea was encountered in two patients and lasted approximately two months despite symptomatic treatment. Although no definite reference can be found in the reports reviewed, diminished absorption of bile salts after exclusion of an ileal segment may well be the underlying pathophysiologic mechanism. Summary and Conclusions (1) In a six year experience with ileal loops in patients with neurogenic bladder, 49 per cent of the patients were paralyzed, 30 per cent had multiple sclerosis, and 91 per cent had recurrent or persistent urinary tract infection. Reflux, incontinence, retention, and bladder calculi were additional indications for supravesical urinary diversions. (2) All loops were performed in a similar manner, most of them placed retroperitoneally, and a vigorous program of postoperative care was followed. There were no postoperative deaths, and a moderate number of complications occurred in 51.8 per cent of the patients.
Votume 131, February 1976
(3) The participation of the enterostomal therapist in the preparation of the patient and in the immediate and long-term stoma1 care has been invaluable and is strongly recommended.
Acknowledgment: We wish to thank Mrs. Sandy Fishman, Enterostomal Therapist, for her expert help in preparing patients and their families for stoma1 care and her help with appliances and follow-up of stoma1 problems at the Enterostomal Clinic of Harper Hospital. References 1. Bricker EM: Bladder substitution after pelvic exenteration. Surg C/in North Am 30: 1511, 1950. 2. Burnham JP, Farrer J: A group experience with ureteroileocutaneous anastomosis for urinary diversion: results and complications of the isolated ileal conduit (Bricker procedure) in 96 patients. J Ural 83: 622, 1960. 3. Cordonnier JJ, Nicolai CH: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J Ural 63: 834, 1960. 4. Butcher HR Jr, Sugg WL, McAfee AC, Bricker EM: lleal conduit method of ureteral urinary diversion. Ann Surg 156: 682, 1962. 5. Parkhurst EC, Leadbetter WF: A report on 93 ileal loop urinary diversions. J Ural 83: 398, 1960. 6. Hollan JM. Schlrmer HKA, King LR, Gibbons RP, Scott WW: Pyeloileal urinary conduit: an 8-year experience in 37 patients. J Ural 99: 427, 1968. 7. Parkhurst EC: Experience with more than 500 ileal conduit diversions in a 12-year period. J Ural 99: 434. 1968. 8. Schmidt JD. Hawtrey CE, Flocks RH, Culp DA: Complications, results, and problems of ileal conduit diversions. J Ural 109: 210, 1973. 9. Harrower HW, Lome LG, Klutz WS: Retroperitoneal ureteroileal conduit. Surg Gynecol Obstet 130: 4 14, 1970. 10. Cohen SM. Persky L: A ten-year experience with ureteroileostomy. Arch Surg 95: 278, 1967. 11. Creevy CD: Renal complications after ileal diversion of the urine in non-neophstic disorders. J Ural 83: 394, 1960. 12. Ellis LR, Udall DA, Hodges CV: Further clinical experience with intestinal segments for urinary diversion. J Ural 105: 354,197l. 13. Engel RM: Complications of bilateral uretero-ileo-cutaneous urinary diversion: a review of 208 cases. J Ural 101: 508, 1969. 14. Kerr WK, Robson CJ, Russell JLT, Bourque JP: Collective review of urinary tract diversions: Canadian Academy of Urological Surgeons. J Ural 88: 644, 1962. 15. Jose JS: Complications of urinary diversion. Sr J Ural 44: 718, 1972. 16. Manley CB, Silber I, Cordonnier JJ: Intestinal obstruction fOtlowing ileal segment diversion. J Ural 101: 840, 1969. 17. Derrick WA Jr, Hodges CV: lleal conduit stasis: recognition, treatment, and prevention. J Ural 107: 747, 1972. 18. Nichols WK. Krause AH, Donegan WL: Urinary fistulas after ureteral diversion. Am J Surg 124: 311, 1972.
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