RENAL TRANSPLANTATION AND PLACEMENT OF ILEAL STOMA
V. L. ROBARDS, JR., M.D. E. N. LUBIN, M.D. T. R. MEDLOCK,
M.D.
From the Hillcrest Medical Center, Tulsa, Oklahoma
The literature has been reuiewed to present the technigues used by others when renal transplantation is done in conjunction with ileal segment urinay diversion. A successful technique for the conuenient placement of the ileal stoma away from the transplanted kidney in the left lower abdominal quadrant while plating the donor kidney in the right iliac fossa is described and recommended, using a fourteen-year-old patient as an illustratiue case.
ABSTRACT -
For years it was generally accepted that candidates for renal transplantation should have a normal lower urinary tract. In 1966 Kelly, Merkel, and Markland’ reported their experience with ileal urinary diversion in conjunction with renal homotransplantation in 6 patients with severely damaged or unacceptable lower urinary tracts. The technique they described was that of plating the isolated ileal segment in the usual location with the stoma in the right lower abdominal quadrant. The transplanted kidney was then placed “upside down” on the lefi side anastomosing the renal artery to the left common iliac artery and the renal vein to the left common iliac vein. The kidney was then allowed to assume a transverse position, and the superiorly located ureter was anastomosed to the blind end of the ileal segment. In 1972 Markland et al2 reported an additional 14 patients who had transplantations using the same technique. In 1970 Tunner et al3 suggested placement of the ileal stoma on the opposite side of the transplanted kidney. Marchioro and Tremann in 19744 gresented a modified technique for ureteroileostomy in 5 renal transplant patients. In their preferred technique the renal artery is anastomosed either to the terminal aorta or to the proximal right iliac artery. The renal vein is anastomosed to either the distal vena cava or the right iliac vein,
UROLOGY / JUNE1975 / VOLUMEV, NUMBERG
whichever is easier. In this way, the kidney lies essentially in the old renal fossa and is superior to the inferior-lying ileal conduit, thus providing dependent drainage of urine from the transplanted kidney to the ileal segment. The present report wil1 describe a method which provides dependent drainage of urine by the convenient placement of the ileal stoma in the left lower abdominal quadrant while plating the donor kidney in the right iliac fossa. Technique If possible, the ileal conduit is constructed four to six weeks prior to the transplantation to allow the intestinal anastomosis and closure to heal before the institution of immunosuppressive drugs. Through a midline incision appendectomy and isolation of an appropriate length (as short as possible) segment of terminal ileum are carried out. The isolated segment of intestine is placed inferior to the ileum, and the ileoileal anastomosis is completed by a standard method. The proximal end of the isolated ileum is closed and then tacked to the retroperitoneum just to the right of the midline at the leve1 of the sacral promontory with a single suture of black silk which is cut long for future identification. The ileal stoma is then fashioned in the left lower quadrant thus giving
787
FIGURE 1. (A) Postoperatiue retrograde pyelogram demonstrating straight and dependent course of urinary drainage. (B) Postoperatiue excretoy urogram illustrating normal renal excretion and unimpaired urinary drainage system.
the ileal loop a transverse direction. If indicated, bilateral nephrectomy and splenectomy can be carried out through the same incision. The renal transplantation is subsequently performed through the same incision. The blind end of the ileum is easily identified and freed from the posterior peritoneum. An incision is then made in the right posterior peritoneum, developing the right iliac fossa retroperitoneally and exposing the inferior vena cava, iliac vessels, and hypogastric artery. The donor renal artery is anastomosed to the recipient hypogastric artery and the donor renal vein to the inferior vena cava or common iliac vein. A window is cut in the posterior peritoneum at the leve1 of the blind end of the ileal loop. The end of the ileal loop is then drawn through the window and the upper ureter or renal pelvis is spatulated and anastomosed end to side to the ileal segment. The kidney then conveniently lies in the iliac fossa, and the ureteroileal anastomosis is dependent to or inferior to the renal pelvis. The peritoneal window is closed around the segment of ileum distal to the anastomosis, and the incision in the posterior peritoneum is closed thus completely extraperitonealizing the transplanted kidney and ureteroor pelvointestinal anastomosis. Case Report The subject of this report is a fourteen-yearold girl who was born in juiy, I957, wïth bilateral
788
complete duplication of the upper urinary tracts; al1 four ureteral orifices being ectopically located in the vagina or on the perineum. In May, 1960, she underwent an exploratory procedure which revealed cystic changes of the lower portion of both kidneys. The ureters draining the lower poles were ligated; a segment of ileum was isolated, and a right pyeloileal anastomosis and a left ureteroileal anastomosis were performed. The terminal end of the isolated segment was joined to the bladder. Thereafter the patient suffered from recurrent attacks of pyelonephritis. Catheter drainage was not successful in decreasing the incidence of infections and functional deterioration, therefore, in October, 1964, the ileum was brought out to the skin. In early 1972 the patient’s renal function deteriorated to the point that it was necessary to institute hemodialysis. Bilateral nephrectomies and resection of the ileal loop were carried out in September, 1972. An ileocystoplasty was planned prior to an anticipated renal transplantation inasmuch as the patient’s bladder capacity was only 45 cc. with maximal distention under anesthesia. However, the patient was transferred to our care, and we preferred to establish a new ileal segment and planned on plating the transplanted ureter into it. In November, 1973, a segment of ileum was isolated and prepared as described. Splenectomy was also performed, On December 13, 1973, renal transplantation was undertaken. The left kidney was removed from the patient’s HLA
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
identical brother and placed in the right iliac fossa. The ureteroileal anastomosis was splinted with a no. 10 polyethylene feeding tube for one week. The film done prior to removal of the catheter demonstrates the straight and dependent course of urinary drainage from the kidney and ileum (Fig. 1A). The patient has done extremely wel1 since transplantation. She has grown, developed, excelled in school, and enjoyed the usual extracurricular activities of a fourteen-year-old girl, which has included working this past summer as a volunteer in the hospital. A postoperative excretory urogram illustrates the normal renal function and unimpaired urinary drainage system (Fig. 1B). Comment Patients with serious abnormalities of the lower urinary tract need not be excluded as candidates for renal transplantation. If the lower urinary tract cannot be satisfactorily reconstructed, renal transplantation in conjunction with ileal segment urinary diversion is a useful surgical endeavor. While several techniques have been described, the one we used is preferred by USand highly recommended. It permits the use of a short segment of intestine located in a position away from and not superimposed over the transplanted kidney. The transplanted kidney can be placed in the usual position or slightly higher in the right iliac fossa utilizing the hypogastric artery instead of the external iliac artery or aorta avoiding possible attendant complications
UROLOGY / JUNE 1975 /
VOLUME V, NUMBER 6
in using these-vessels. The urinary drainage is in a relatively dependent direction. The use of the ureteral splint was an individual preferente in this case and is possibly not always indicated. Although it appears to be preferred to perform the operative procedures in two stages as described herein, Kelly, Merkel, and Markland’ have shown that the entire procedure can be done successfully in one operation. It is apparent that the procedure could be used in a wide variety of lower urinary tract abnormalities. Since the renal pelvis can be anastomosed directly to the blind end of the ileal loop, the technique might on occasion be useful in selected instances of early or late irreparable ureteral damage after transplantation. 2021
South Gewis Avenue Tulsa, Oklahoma 74104 (DR. ROBARDS)
References KELLY, W. D., MERKEL, F. K., and MARKLAND,C.: Ileal urinary diversion in conjunction with renal homotransplantation, Lancet 1: 222 (1966). into MARKLAND, C., et al. : Renal transplantation ileac urinary conduits, Transplant. Proc. 4: 629 (1972). TUNNER, W. S., WHITSELL, J. C., JR., RUBIN, A., and MARSHALL, V. F.: Renal transplantation in children with damaged and repaired or replaced lower urinary tracts. Presented at the Fourth AnnuaJ Meeting of the Association for Academie Surgery, Denver, Colorado, November 19, 1970. MARCHIORO,T. L., and TREMANN, J. A.: Ureteroileostomy in renal transplant patients, a modified technique, Urology 3: 171 (1974).
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V. L. ROBARDS, JR., M.D. E. N. LUBIN, M.D. T. R. MEDLOCK,
M.D.
From the Hillcrest Medical Center, Tulsa, Oklahoma
The literature has been reuiewed to present the technigues used by others when renal transplantation is done in conjunction with ileal segment urinay diversion. A successful technique for the conuenient placement of the ileal stoma away from the transplanted kidney in the left lower abdominal quadrant while plating the donor kidney in the right iliac fossa is described and recommended, using a fourteen-year-old patient as an illustratiue case.
ABSTRACT -
For years it was generally accepted that candidates for renal transplantation should have a normal lower urinary tract. In 1966 Kelly, Merkel, and Markland’ reported their experience with ileal urinary diversion in conjunction with renal homotransplantation in 6 patients with severely damaged or unacceptable lower urinary tracts. The technique they described was that of plating the isolated ileal segment in the usual location with the stoma in the right lower abdominal quadrant. The transplanted kidney was then placed “upside down” on the lefi side anastomosing the renal artery to the left common iliac artery and the renal vein to the left common iliac vein. The kidney was then allowed to assume a transverse position, and the superiorly located ureter was anastomosed to the blind end of the ileal segment. In 1972 Markland et al2 reported an additional 14 patients who had transplantations using the same technique. In 1970 Tunner et al3 suggested placement of the ileal stoma on the opposite side of the transplanted kidney. Marchioro and Tremann in 19744 gresented a modified technique for ureteroileostomy in 5 renal transplant patients. In their preferred technique the renal artery is anastomosed either to the terminal aorta or to the proximal right iliac artery. The renal vein is anastomosed to either the distal vena cava or the right iliac vein,
UROLOGY / JUNE1975 / VOLUMEV, NUMBERG
whichever is easier. In this way, the kidney lies essentially in the old renal fossa and is superior to the inferior-lying ileal conduit, thus providing dependent drainage of urine from the transplanted kidney to the ileal segment. The present report wil1 describe a method which provides dependent drainage of urine by the convenient placement of the ileal stoma in the left lower abdominal quadrant while plating the donor kidney in the right iliac fossa. Technique If possible, the ileal conduit is constructed four to six weeks prior to the transplantation to allow the intestinal anastomosis and closure to heal before the institution of immunosuppressive drugs. Through a midline incision appendectomy and isolation of an appropriate length (as short as possible) segment of terminal ileum are carried out. The isolated segment of intestine is placed inferior to the ileum, and the ileoileal anastomosis is completed by a standard method. The proximal end of the isolated ileum is closed and then tacked to the retroperitoneum just to the right of the midline at the leve1 of the sacral promontory with a single suture of black silk which is cut long for future identification. The ileal stoma is then fashioned in the left lower quadrant thus giving
787
FIGURE 1. (A) Postoperatiue retrograde pyelogram demonstrating straight and dependent course of urinary drainage. (B) Postoperatiue excretoy urogram illustrating normal renal excretion and unimpaired urinary drainage system.
the ileal loop a transverse direction. If indicated, bilateral nephrectomy and splenectomy can be carried out through the same incision. The renal transplantation is subsequently performed through the same incision. The blind end of the ileum is easily identified and freed from the posterior peritoneum. An incision is then made in the right posterior peritoneum, developing the right iliac fossa retroperitoneally and exposing the inferior vena cava, iliac vessels, and hypogastric artery. The donor renal artery is anastomosed to the recipient hypogastric artery and the donor renal vein to the inferior vena cava or common iliac vein. A window is cut in the posterior peritoneum at the leve1 of the blind end of the ileal loop. The end of the ileal loop is then drawn through the window and the upper ureter or renal pelvis is spatulated and anastomosed end to side to the ileal segment. The kidney then conveniently lies in the iliac fossa, and the ureteroileal anastomosis is dependent to or inferior to the renal pelvis. The peritoneal window is closed around the segment of ileum distal to the anastomosis, and the incision in the posterior peritoneum is closed thus completely extraperitonealizing the transplanted kidney and ureteroor pelvointestinal anastomosis. Case Report The subject of this report is a fourteen-yearold girl who was born in juiy, I957, wïth bilateral
788
complete duplication of the upper urinary tracts; al1 four ureteral orifices being ectopically located in the vagina or on the perineum. In May, 1960, she underwent an exploratory procedure which revealed cystic changes of the lower portion of both kidneys. The ureters draining the lower poles were ligated; a segment of ileum was isolated, and a right pyeloileal anastomosis and a left ureteroileal anastomosis were performed. The terminal end of the isolated segment was joined to the bladder. Thereafter the patient suffered from recurrent attacks of pyelonephritis. Catheter drainage was not successful in decreasing the incidence of infections and functional deterioration, therefore, in October, 1964, the ileum was brought out to the skin. In early 1972 the patient’s renal function deteriorated to the point that it was necessary to institute hemodialysis. Bilateral nephrectomies and resection of the ileal loop were carried out in September, 1972. An ileocystoplasty was planned prior to an anticipated renal transplantation inasmuch as the patient’s bladder capacity was only 45 cc. with maximal distention under anesthesia. However, the patient was transferred to our care, and we preferred to establish a new ileal segment and planned on plating the transplanted ureter into it. In November, 1973, a segment of ileum was isolated and prepared as described. Splenectomy was also performed, On December 13, 1973, renal transplantation was undertaken. The left kidney was removed from the patient’s HLA
UROLOGY
/ JUNE1975 / VOLUMEV,
NUMBERG
identical brother and placed in the right iliac fossa. The ureteroileal anastomosis was splinted with a no. 10 polyethylene feeding tube for one week. The film done prior to removal of the catheter demonstrates the straight and dependent course of urinary drainage from the kidney and ileum (Fig. 1A). The patient has done extremely wel1 since transplantation. She has grown, developed, excelled in school, and enjoyed the usual extracurricular activities of a fourteen-year-old girl, which has included working this past summer as a volunteer in the hospital. A postoperative excretory urogram illustrates the normal renal function and unimpaired urinary drainage system (Fig. 1B). Comment Patients with serious abnormalities of the lower urinary tract need not be excluded as candidates for renal transplantation. If the lower urinary tract cannot be satisfactorily reconstructed, renal transplantation in conjunction with ileal segment urinary diversion is a useful surgical endeavor. While several techniques have been described, the one we used is preferred by USand highly recommended. It permits the use of a short segment of intestine located in a position away from and not superimposed over the transplanted kidney. The transplanted kidney can be placed in the usual position or slightly higher in the right iliac fossa utilizing the hypogastric artery instead of the external iliac artery or aorta avoiding possible attendant complications
UROLOGY / JUNE 1975 /
VOLUME V, NUMBER 6
in using these-vessels. The urinary drainage is in a relatively dependent direction. The use of the ureteral splint was an individual preferente in this case and is possibly not always indicated. Although it appears to be preferred to perform the operative procedures in two stages as described herein, Kelly, Merkel, and Markland’ have shown that the entire procedure can be done successfully in one operation. It is apparent that the procedure could be used in a wide variety of lower urinary tract abnormalities. Since the renal pelvis can be anastomosed directly to the blind end of the ileal loop, the technique might on occasion be useful in selected instances of early or late irreparable ureteral damage after transplantation. 2021
South Gewis Avenue Tulsa, Oklahoma 74104 (DR. ROBARDS)
References KELLY, W. D., MERKEL, F. K., and MARKLAND,C.: Ileal urinary diversion in conjunction with renal homotransplantation, Lancet 1: 222 (1966). into MARKLAND, C., et al. : Renal transplantation ileac urinary conduits, Transplant. Proc. 4: 629 (1972). TUNNER, W. S., WHITSELL, J. C., JR., RUBIN, A., and MARSHALL, V. F.: Renal transplantation in children with damaged and repaired or replaced lower urinary tracts. Presented at the Fourth AnnuaJ Meeting of the Association for Academie Surgery, Denver, Colorado, November 19, 1970. MARCHIORO,T. L., and TREMANN, J. A.: Ureteroileostomy in renal transplant patients, a modified technique, Urology 3: 171 (1974).
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