0022-5347 /78/1202-0402$02. 00/0 Vol. 120, October Printed in U.S.A .
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION PETER T. NIER, ALEX F. ALTHAUSEN*
AND
STEPHEN P. DRETLER
From the Urological Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
ABSTRACT
Disappointing long-term experience with the ureterosigmoidostomy and ileal loop diversion has prompted our use of a staged ureterocolocolostomy in 3 adults with a good prognosis. Creation of a non-refluxing colon conduit was followed by conduit take-down and end-to-side colocolostomy 4 to 8 months later, when satisfactory loop function was documented (that is absence of reflux, obstruction and infection). Followup has shown stable renal function and electrolyte balance, as well as urinary/fecal continence. The staged ureterocolocolostomy, as opposed to the primary ureterosigmoidostomy, allows the partially obstructed urinary tract to decompress isolated from the fecal stream, may be used with established pyelonephritis, permits confirmation of the non-refluxing nature of the ureterocolic anastomosis prior to colocolostomy and may have a lower incidence of electrolyte imbalance. The staged I>!_~ ure . is contraindicated in patients with a poor prognosis, previously irradiatea. rectosigmoid, fecalrnoonfinence-r poor anal sphmcter tone, mflammatory large bowel disease, inadequate ureteral length and strong family histo of colon cancer.
-
Until the early 1950s ureterosigmoidostomy was the preferred method of urinary diversion. However, the high incidence of hyperchloremic acidosis, pyelonephritis and hydronephrosis prompted multiple revisions of the ureterocolic anastomosis. The combined technique, introduced by Leadbetter and Clarke in 1955, 1 brought together Nesbit's mucosa-tomucosa anastomosis with Coffey's ureteral tunnel to prevent reflux. However, the favorable early experience with ileal conduits had influenced most institutions to abandon ureterocolic diversions.2 Long-term followup with ileal conduits revealed an alarming deterioration rate in previously normal upper tracts.3- 13 In the mid 1960s Mogg and Syme redirected efforts to the isolated sigmoid colon conduit with little attention to an antirefluxing anastomosis. 14 The addition of the combined technique to colon conduits has produced a promising result. 15 However, the stigma of the external stoma remains. We present 3 adults who underwent antirefluxing colon conduit urinary diversion with subsequent colon conduit takedown and end-to-side anastomosis to the rectosigmoid, thereby accomplishing a staged ureterocolocolostomy. TECHNIQUE
Colon conduit (fig. 1, A) . After a normal preoperative barium enema all patients undergo a 3-day large bowel preparation, as well as neomycin rectal irrigations in the operating room. Through a midline or right paramedian incision the ureters are isolated, transected and intubated. A suitable 12 to 15 cm. segment of colon is mobilized and resected. Extra length is often desirable since there may be significant foreshortening owing to spasm and the stoma is discarded when the colocolostomy is performed. The conduit is fashioned isoperistaltically, with at least 3 to 4 cm. tunnels and mucosa-to-mucosa ureterocolic anastomoses. 1 • 16 Colored non-absorbable suture material to close the tenia will facilitate identification of the ureterocolic anastomosis at the time of subsequent colocolostomy. The ureters are stented if there had been prior obstruction or if ureteral tapering had been performed. A left lower quadrant stoma is Accepted for publication October 21, 1977. Read at annual meeting of American Urological Association, Chicago, Illinois, April 24- 28, 1977. * Requests for reprints: One Hawthorne Place, Boston, Massachusetts 02114. 402
preferable since it allows for the construction of a shorter loop. An important anatomical landmark when radical cystectomy has been performed before the colon conduit is the superior rectal artery. The middle and inferior rectal arteries, as terminal branches of the anterior division of the hypogastric artery, are sacrificed during radical cystectomy (fig. 2). Thus, utmost care is required in selecting the distal margin of the sigmoid segment to preserve vascularity of the rectum. 17 Also, careless dissection may injure the pelvic nerves and impair anal sphincter tone . Colocolostomy (fig. 1, B) . Before the colocolostomy the conduit is evaluated with the following studies: loopogram under gravity to assure the absence of reflux to 40 cm. water pressure, excretory urogram (IVP), creatinine clearance, serum electrolytes and loop cultures. We find that preoperative fecal continence and reasonable anal sphincter tone are satisfactory predictors of post-colocolostomy continence. If doubt exists the retention of an oatmeal enema, which simulates the stool and urine mixture, is informative. The bowel preparation is similar to that used for the colon conduit. The conduit is dissected from the anterior abdominal wall and the distal 3 to 5 cm. are excised, if necessary, carefully identifying the distal limits of the ureteral tunnels. After the rectosigmoid is cleared a routine end-to-side 2-layer anastomosis is performed. The rectal tube is used for 1 week. Routine preoperative and postoperative antibiotics are administered, followed by antibiotic urinary suppression for at least 1 year. CASE REPORTS
Case 1. L. D., MGH 138-06-74, a 23-year-old white man, was struck by a truck when he was 12 years old, suffering severe pelvic fractures with urethral disruption (fig. 3 and table). Initial management consisted of Foley traction and suprapubic drainage, resulting in a dense membranous urethral stricture and urinary incontinence. Multiple urethral reconstructions and a urethral lengthening incontinence procedure failed. In January 1975 a colon conduit urinary diversion with nonrefluxing submucosal tunnels was done. An IVP showed right upper pole papillary necrosis. Postoperatively, the patient had sterile urine, normal serum electrolytes and a creatinine clearance of 140 1. per day. Eight months later, after a loopogram confirmed the absence of reflux to 50 cm. water
__ .... - - ... - - .
-----?__ . .-
- - - - ---·
•. . : - - ~
--~
-
-·
--.,.-- - - -~ ---c-a:c~----:----~:=== ------=-=~-----::-i--~--
..
403
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION
®
®
FIG. 1. Staged u reterocolocolostomy. A, colon conduit with non-refluxing submucosal tunnels. B , colocolostomy after satisfactory conduit function confirmed.
pressure, the colon loop was taken down and a colocolostomy was done. The patient had nocturnal incontinence for only the first week after removal of the rectal tube and, currently, is asymptomatic, with normal renal function and chemistry studies, as well as a stable IVP 2 years post-colocolostomy. Case 2 . E. P., MGH 183-30-55, a 56-year-old white woman with a history of recurrent low grade transitional cell carcinoma of the bladder, suffered carcinoma in situ despite multiple transurethral resections and monthly thio-tepa instillations (fig. 4 and table). In September 1975 radical cystectomy and an antirefluxing colon conduit were done. The IVPs remained unremarkable throughout the course. Four months later the urine was sterile, there was negligible loop residual and no reflux was detected to 40 cm. water pressure. The patient underwent an uncomplicated colocolostomy and remains totally continent with normal IVP and only slightly decreased carbon dioxide content. Case 3 . A. T., MGH 202-79-42, a 25-year-old white man, was 13 years post-cystectomy and ureterosigmoidostomies for pyocystis (fig. 5 and table). During this time there were multiple episodes of bilateral pyelonephritis despite various antibiotics. An IVP demonstrated left hydroureter and hydronephrosis, and right papillary necrosis. In October 1975 the ureterosigmoidostomies were excised and an ascending transverse colon conduit was constructed because dense adhesions around the splenic flexure, descending colon and rectosigmoid prevented adequate mobilization of a satisfactory segment of colon. Six months later, in April 1976, the IVP had improved markedly, the urine was sterile and no reflux was seen to 42 cm. water pressure. Therefore, a colocolostomy was undertaken with a
L. Colic A.
tJ
Ir t1' jj I,
Hypogastric A.
Sup. and Inf. ----fi'l....t.1 Vesica l As. Obturator A. Middle Rectal A. Jnr. Pudenda! A.
),
FIG . 2. Anatomy of pelvic vessels
Clinical data-staged ureterocolocolostomy
Case - Age - Sex
1- 23 - M
2 - 56-F 3-26-M
Diagnosis
Post-traumatic urinary Incontinence Bladder carcinoma in situ Post-cystectomy with ureterosigmoidostomies a nd pyelonephritis
Interval Between Conduit and Colocolostomy (mos.) 8
4
6
Post-Colocolostomy
Pre-Colocolostomy
IVP
Loopowam (cm. 20)
Culture
Papillary necrosis of rt . u~per pole calix Norma
No. reflux (50) No reflux (40) No reflux (42)
Sterile
Decrease hydronephrosis from precolon loop
-1
Chemis- F 11 t St d- 0 owup ry iet (mos.)
IVP
Chemistry Studies
Contnent
Normal
24
Stable
Normal
Yes
Sterile
Normal
20
Normal
Sterile
Normal
17
Normal
C0,21 Cl 105 Normal
Yes
Yes
404
NIEH, ALTHAUSEN AND DRETLER
FIG. 3. Case 1, 23-year-old man with post-traumatic urethral stricture and urinary incontinence. A, IVP in January 1975, before colon conduit, reveals right upper pole papillary necrosis. B, IVP in September 1975, 8 months after colon conduit. C, IVP in June 1976, 9 months after colocolostomy.
FIG. 4. Case 2, 56-year-old woman with bladder carcinoma in situ, requiring radical cystectomy and colon loop. A, IVP in January 1975, before diversion. B, IVP in January 1976, 4 months after colon conduit. C, IVP in April 1977, 15 months after colocolostomy.
benign course. Since then there have been no recurrent episodes of pyelonephritis on chronic antibiotic suppression. Serum electrolytes are normal, as is the IVP. DISCUSSION
While satisfactory for diversion in patients with poor prognosis the ileal loop has several shortcomings for the patient with a relatively normal life expectancy. Long-term experience has revealed progressive upper tract deterioration in previously normal renal units. 3-13 The early adult experiences showed approximately 20 per cent deteriorated on pyelograms. 4--0, s, 11 However, with longer followup in children, progressive upper tract damage ranged upwards to 56 to 68 per cent. 3, 12 The high incidence of stomal stenosis is particularly
dangerous in the freely refluxing system, as are pyelonephritis and ureteroileal stenosis. The colon conduit offers several advantages, including thicker musculature to create a non-refluxing tunnel, 16 fewer stomal problems, 15· 16 less marked pressure spike response to acute occlusion, 15 infrequent pyelographic deterioration16· 18· 19 or histologic evidence of pyelonephritis15 and insignificant electrolyte imbalance. 20 The staged ureterocolocolostomy has been used successfully in children with bladder exstrophy16 and we believe that this procedure should be considered in adults with a good prognosis requiring diversion. In contrast to primary ureterosigmoidostomy the ~taged 11roi;edure is_s.Jiperio~ forseveral re asons: 1) it is applicable in ~ ients with hydroureter/hydronephrosis,
- - - -- - - --""":--:,,,-----=-- - - ~
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION
allowing decompression isolated from t may be used w1 es a lished pyelone hritis :ermits accurateassessmen ofliac enal cultures and creatinine clearances; ·asweir as conhrmationofthe non-refluxing nature of t e ure eroco 1c anastomosis before exposure to the fecal stream and- "4")--we-precl.tcrtli:at electrolyte disor ers will l:ie dimhtistred m tre9.!!_ency and severity. - obstructive changes and pyelonephritis have been the classic contraindications to primary ureterosigmoidostomy, since the high incidence of both developing in previously normal upper tracts after this procedure has been well documented. 1, 21- 23 However, by isolating the ureterocolic anastomosis from the fecal stream during healing the incidence of pyelonephritis and hydronephrosis decreases dramatically. 15 Subsequent take-down of the colon conduit with colocolostomy has not produced clinical pyelonephritis or upper tract deterioration in the 11 children in Hendren's series 16 and we have not seen either problem in our patients. Ureteral tapering may be
405
performed with the colon conduit. The opportunity to study all aspects of the conduit and the ureterocolic anastomosis (that is renal function, absence of reflux, obstruction and infection) is a significant advantage over primary ureterosigmoidostomy. Should renal function be less than expected, the infection be difficult to irradicate or obstructive changes be slow to resolve the colocolostomy may be deferred until all parameters are optimal. All 3 patients had non-refluxing loopograms, stable or improved IVP, sterile urine and stable renal function before colocolostomy. Finally, the question arises as to whether a staged procedure will be spared the high incidence of hyperchloremic, hypokalemic acidosis observed in primary ureterosigmoidostomy. We have seen no deterioration in renal function and 1 patient had an asymptomatic decrease in serum bicarbonate without hyperchloremia. The important features in the development of the hyperchloremic acidosis are obstruction, pyelonephritis, pre-exist-
.I
I
FIG. 5. Case 3, 25-year-old man with ureterosigmoidostomies and bilateral recurrent pyelonephritis. A, IVP in October 1975, showing left hydronephrosis and right papillary necrosis. B, IVP in April 1976, 6 months after colon condult, demonstrating marked improvement on left. C, IVP in April 1977, 1 year after colocolostomy.
OBSTRUCTION PYELONEPHRITIS
'
MEDULLARY OESTRUCTION
'
BACK PRESSURE W1TH NEPHRON LOSS
l
MEOULLARY HYPOTON ICITY WITH RED ISTRIBUT ION TO SUPERFIC I AL CORTICAL NEPHRONS
I
j FREE WATER BACK - DIFFUSION VIA COLLECTING DUCT
f GFR / RESIOUAL
\
NEPHRON (SUK I I
OR
j WATER EXTRACT ION
j GFR / NEPHRON WITH MORE DECREASED
FROM HENLE'S DESCENDING LOOP
f
FRACT IONAL REABSORPTION OF NA AND WATER (BRICKER)
I
t "SALINE DIURESIS"
FILTRATE FRACTION DELIVERED TO DISTAL TUBULE
I
!
CHLORIDE REABSORPTION (COLON MUCOSA)
NA - K EXCHANGE
I URINARY
l
/
NA, K, OSMOLAR I TY
FIG. 6. Pathophysiology of electrolyte imbalance in ureterosigmoidostomy ~.
--- j
406
NIER, ALTHAUSEN AND DRETLER
ing renal disease (that is corticomedullary loss) and chloride reabsorption (fig. 6). 16 • 24- 28 It is the cumulative effect of these factors that determines predisposition to electrolyte imbalance. More extensive experience is required but we expect that by minimizing obstruction and pyelonephritis the staged procedure will be less susceptible to hyperchloremic acidosis. Careful monitoring of patients with pre-existing renal disease is essential. Avoidance of a high acid-ash diet to decrease chloride intake 27 and frequent rectal evacuation should be used also. Contraindications to ureterocolocolostomy include those patients with a previously irradiated rectosigmoid, fecal incontinence or poor anal sphincter tone, and inflammatory large bowel disease (for example ulcerative colitis and diverticulitis). Those patients with inadequate ureteral length may require a transverse colon conduit but if there is still insufficient ureter to create a non-refluxing tunnel the colocolostomy is subject to the same risks as the primary ureterosigmoidostomy. A relative contraindication is a strong family history of colon cancer. Primary carcinoma at the ureterocolic anastomosis has been reported in ureterosigmoidostomy an average of 7 years postoperatively for malignant disease and 22 years for those diverted for benign disorders. 29 However, these were all likely to have been Coffey anastomoses with a projecting ureteral stump where constant mechanical trauma might predispose to carcinogenic changes. We believe that the staged ureterocolocolostomy with the non-refluxing ureterocolic anastomosis will decrease the complications associated with the ileal loop and ureterosigmoidostomy and should be considered in the management of the adult with a good prognosis who requires urinary diversion. REFERENCES
1. Leadbetter, W. F. and Clarke, B. G.: Five years' experience with uretero-enterostomy by the "combined" technique. J. Urol., 73: 67, 1955. 2. Bricker, E. M.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Middleton, A. W., Jr. and Hendren, W. H.: Heal conduits in children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976. 4. Burnham, J.P. and Farrer, J.: A group experience with ureteroileal-cutaneous anastomosis for urinary diversion: results and complications of the isolated ileal conduit (Bricker procedure) in 96 patients. J. Urol., 83: 622, 1960. 5. Butcher, H. R., Sugg, W. L., McAfee, C. A. and Bricker, E. M.: Ileal conduit method of ureteral urinary diversion. Ann. Surg., 156: 682, 1962. 6. Cordonnier, J. J. and Nicolai, C.H.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J. Urol., 83: 834, 1960. 7. Delgado, G. E. and Muecke, E. C.: Evaluation of80 cases ofileal conduits in children: indication, complication and results. J. Urol., 109: 311, 1973.
8. Murphy, J. J. and Schoenberg, H. W.: Survey of long-term results of total urinary diversion. Brit. J. Urol., 39: 700, 1967. 9. Rabinowitz, R. and Price, S. E., Jr.: Heal conduit urinary diversion in children. J. Urol., 114: 444, 1975. 10. Ray, P. and DeDomenico, I.: Intestinal conduit urinary diversion in children. Brit. J. Urol., 44: 345, 1972. 11. Schmidt, J. D., Hawtrey, C. E., Flocks, R. H. and Culp, D. A.: Complications, results and problems of ileal conduit diversions. J. Urol., 109: 210, 1973. 12. Schwarz, G. R. and Jeffs, R. D.: Heal conduit urinary diversion in children: computer analysis of followup from 2 to 16 years. J. Urol., 114: 285, 1975. 13. Shapiro, S. R., Lebowitz, R. and Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade lateranalysis of complications, pyelography, renal function and bacteriology. J. Urol., 114: 289, 1975. 14. Mogg, R. A. and Syme, R. R.: The results of urinary diversion using the colonic conduit. Brit. J. Urol., 41: 434, 1969. 15. Richie, J. P. and Skinner, D. G.: Urinary diversion: the physiological rationale for non-refluxing colonic conduits. Brit. J. Urol., 47: 269, 1975. 16. Hendren, W. H.: Exstrophy of the bladder-alternative method of management. J. Urol., 115: 195, 1976. 17. Fegiz, G., Tonelli, F., Rossi, P., DiPaola, M., Passariello, R., DeMasi, E. and Simonetti, G.: Preservation of the superior hemorrhoidal artery in resection of the colon and rectum. Surg., Gynec. & Obst., 143: 919, 1976. 18. Kelalis, P. P.: Urinary diversion in children by the sigmoid conduit: its advantages and limitations. J. Urol., 112: 666, 1974. 19. Morales, P. and Golimbu, M.: Colonic urinary diversion: 10 years of experience. J. Urol., 113: 302, 1975. 20. Genster, H. G.: Changes in the composition of the urine in sigmoid loop bladders. A comparison with ileal loops. Scand. J. Urol. Nephrol., 5: 41, 1971. 21. Spence, H. M., Hoffman, W.W. and Pate, V. A.: Exstrophy of the bladder. I. Long-term results in a series of 37 cases treated by ureterosigmoidostomy. J. Urol., 114: 133, 1975. 22. Weyrauch, J. M.: Landmarks in the development of ureterointestinal anastomosis. Ann. Roy. Coll. Surg., 18: 343, 1956. 23. Zincke, H. and Segura, J. W.: Ureterosigmoidostomy: critical review of 173 cases. J. Urol., 113: 324, 1975. 24. Ferris, D. 0. and Odel, H. M.: Electrolyte pattern of blood after bilateral ureterosigmoidostomy. J.A.M.A., 142: 634, 1950. 25. Bricker, N. S. and Klahr, S.: Obstructive· nephropathy. In: Diseases of the Kidney, 2nd ed. Edited by M. B. Strauss and L. G. Welt. Boston: Little, Brown & Co., pp: 997-1038, 1971. 26. Michaelson, G.: Percutaneous puncture of renal pelvis, intrapelvic pressure and the concentrating capacity of the kidney in hydronephrosis. Acta Med. Scand. (suppl.), 559: 1, 1974. 27. Stamey, T. A.: The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy. Surg., Gynec. & Obst., 103: 736, 1956. 28. Suki, W., Eknoyan, G., Rector, F. C. and Seldin, D. W.: Patterns of nephron perfusion in acute and chronic hydronephrosis. J. Clin. Invest., 45: 122, 1966. 29. Rivard, J.-Y., Bedard, A. and Dionne, L.: Colonic neoplasms following ureterosigmoidostomy. J. Urol., 113: 781, 1975.
THE JOURNAL OF UROLOGY
Copyright © 1978 by The Williams & Wilkins Co.
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION PETER T. NIER, ALEX F. ALTHAUSEN*
AND
STEPHEN P. DRETLER
From the Urological Service, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
ABSTRACT
Disappointing long-term experience with the ureterosigmoidostomy and ileal loop diversion has prompted our use of a staged ureterocolocolostomy in 3 adults with a good prognosis. Creation of a non-refluxing colon conduit was followed by conduit take-down and end-to-side colocolostomy 4 to 8 months later, when satisfactory loop function was documented (that is absence of reflux, obstruction and infection). Followup has shown stable renal function and electrolyte balance, as well as urinary/fecal continence. The staged ureterocolocolostomy, as opposed to the primary ureterosigmoidostomy, allows the partially obstructed urinary tract to decompress isolated from the fecal stream, may be used with established pyelonephritis, permits confirmation of the non-refluxing nature of the ureterocolic anastomosis prior to colocolostomy and may have a lower incidence of electrolyte imbalance. The staged I>!_~ ure . is contraindicated in patients with a poor prognosis, previously irradiatea. rectosigmoid, fecalrnoonfinence-r poor anal sphmcter tone, mflammatory large bowel disease, inadequate ureteral length and strong family histo of colon cancer.
-
Until the early 1950s ureterosigmoidostomy was the preferred method of urinary diversion. However, the high incidence of hyperchloremic acidosis, pyelonephritis and hydronephrosis prompted multiple revisions of the ureterocolic anastomosis. The combined technique, introduced by Leadbetter and Clarke in 1955, 1 brought together Nesbit's mucosa-tomucosa anastomosis with Coffey's ureteral tunnel to prevent reflux. However, the favorable early experience with ileal conduits had influenced most institutions to abandon ureterocolic diversions.2 Long-term followup with ileal conduits revealed an alarming deterioration rate in previously normal upper tracts.3- 13 In the mid 1960s Mogg and Syme redirected efforts to the isolated sigmoid colon conduit with little attention to an antirefluxing anastomosis. 14 The addition of the combined technique to colon conduits has produced a promising result. 15 However, the stigma of the external stoma remains. We present 3 adults who underwent antirefluxing colon conduit urinary diversion with subsequent colon conduit takedown and end-to-side anastomosis to the rectosigmoid, thereby accomplishing a staged ureterocolocolostomy. TECHNIQUE
Colon conduit (fig. 1, A) . After a normal preoperative barium enema all patients undergo a 3-day large bowel preparation, as well as neomycin rectal irrigations in the operating room. Through a midline or right paramedian incision the ureters are isolated, transected and intubated. A suitable 12 to 15 cm. segment of colon is mobilized and resected. Extra length is often desirable since there may be significant foreshortening owing to spasm and the stoma is discarded when the colocolostomy is performed. The conduit is fashioned isoperistaltically, with at least 3 to 4 cm. tunnels and mucosa-to-mucosa ureterocolic anastomoses. 1 • 16 Colored non-absorbable suture material to close the tenia will facilitate identification of the ureterocolic anastomosis at the time of subsequent colocolostomy. The ureters are stented if there had been prior obstruction or if ureteral tapering had been performed. A left lower quadrant stoma is Accepted for publication October 21, 1977. Read at annual meeting of American Urological Association, Chicago, Illinois, April 24- 28, 1977. * Requests for reprints: One Hawthorne Place, Boston, Massachusetts 02114. 402
preferable since it allows for the construction of a shorter loop. An important anatomical landmark when radical cystectomy has been performed before the colon conduit is the superior rectal artery. The middle and inferior rectal arteries, as terminal branches of the anterior division of the hypogastric artery, are sacrificed during radical cystectomy (fig. 2). Thus, utmost care is required in selecting the distal margin of the sigmoid segment to preserve vascularity of the rectum. 17 Also, careless dissection may injure the pelvic nerves and impair anal sphincter tone . Colocolostomy (fig. 1, B) . Before the colocolostomy the conduit is evaluated with the following studies: loopogram under gravity to assure the absence of reflux to 40 cm. water pressure, excretory urogram (IVP), creatinine clearance, serum electrolytes and loop cultures. We find that preoperative fecal continence and reasonable anal sphincter tone are satisfactory predictors of post-colocolostomy continence. If doubt exists the retention of an oatmeal enema, which simulates the stool and urine mixture, is informative. The bowel preparation is similar to that used for the colon conduit. The conduit is dissected from the anterior abdominal wall and the distal 3 to 5 cm. are excised, if necessary, carefully identifying the distal limits of the ureteral tunnels. After the rectosigmoid is cleared a routine end-to-side 2-layer anastomosis is performed. The rectal tube is used for 1 week. Routine preoperative and postoperative antibiotics are administered, followed by antibiotic urinary suppression for at least 1 year. CASE REPORTS
Case 1. L. D., MGH 138-06-74, a 23-year-old white man, was struck by a truck when he was 12 years old, suffering severe pelvic fractures with urethral disruption (fig. 3 and table). Initial management consisted of Foley traction and suprapubic drainage, resulting in a dense membranous urethral stricture and urinary incontinence. Multiple urethral reconstructions and a urethral lengthening incontinence procedure failed. In January 1975 a colon conduit urinary diversion with nonrefluxing submucosal tunnels was done. An IVP showed right upper pole papillary necrosis. Postoperatively, the patient had sterile urine, normal serum electrolytes and a creatinine clearance of 140 1. per day. Eight months later, after a loopogram confirmed the absence of reflux to 50 cm. water
__ .... - - ... - - .
-----?__ . .-
- - - - ---·
•. . : - - ~
--~
-
-·
--.,.-- - - -~ ---c-a:c~----:----~:=== ------=-=~-----::-i--~--
..
403
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION
®
®
FIG. 1. Staged u reterocolocolostomy. A, colon conduit with non-refluxing submucosal tunnels. B , colocolostomy after satisfactory conduit function confirmed.
pressure, the colon loop was taken down and a colocolostomy was done. The patient had nocturnal incontinence for only the first week after removal of the rectal tube and, currently, is asymptomatic, with normal renal function and chemistry studies, as well as a stable IVP 2 years post-colocolostomy. Case 2 . E. P., MGH 183-30-55, a 56-year-old white woman with a history of recurrent low grade transitional cell carcinoma of the bladder, suffered carcinoma in situ despite multiple transurethral resections and monthly thio-tepa instillations (fig. 4 and table). In September 1975 radical cystectomy and an antirefluxing colon conduit were done. The IVPs remained unremarkable throughout the course. Four months later the urine was sterile, there was negligible loop residual and no reflux was detected to 40 cm. water pressure. The patient underwent an uncomplicated colocolostomy and remains totally continent with normal IVP and only slightly decreased carbon dioxide content. Case 3 . A. T., MGH 202-79-42, a 25-year-old white man, was 13 years post-cystectomy and ureterosigmoidostomies for pyocystis (fig. 5 and table). During this time there were multiple episodes of bilateral pyelonephritis despite various antibiotics. An IVP demonstrated left hydroureter and hydronephrosis, and right papillary necrosis. In October 1975 the ureterosigmoidostomies were excised and an ascending transverse colon conduit was constructed because dense adhesions around the splenic flexure, descending colon and rectosigmoid prevented adequate mobilization of a satisfactory segment of colon. Six months later, in April 1976, the IVP had improved markedly, the urine was sterile and no reflux was seen to 42 cm. water pressure. Therefore, a colocolostomy was undertaken with a
L. Colic A.
tJ
Ir t1' jj I,
Hypogastric A.
Sup. and Inf. ----fi'l....t.1 Vesica l As. Obturator A. Middle Rectal A. Jnr. Pudenda! A.
),
FIG . 2. Anatomy of pelvic vessels
Clinical data-staged ureterocolocolostomy
Case - Age - Sex
1- 23 - M
2 - 56-F 3-26-M
Diagnosis
Post-traumatic urinary Incontinence Bladder carcinoma in situ Post-cystectomy with ureterosigmoidostomies a nd pyelonephritis
Interval Between Conduit and Colocolostomy (mos.) 8
4
6
Post-Colocolostomy
Pre-Colocolostomy
IVP
Loopowam (cm. 20)
Culture
Papillary necrosis of rt . u~per pole calix Norma
No. reflux (50) No reflux (40) No reflux (42)
Sterile
Decrease hydronephrosis from precolon loop
-1
Chemis- F 11 t St d- 0 owup ry iet (mos.)
IVP
Chemistry Studies
Contnent
Normal
24
Stable
Normal
Yes
Sterile
Normal
20
Normal
Sterile
Normal
17
Normal
C0,21 Cl 105 Normal
Yes
Yes
404
NIEH, ALTHAUSEN AND DRETLER
FIG. 3. Case 1, 23-year-old man with post-traumatic urethral stricture and urinary incontinence. A, IVP in January 1975, before colon conduit, reveals right upper pole papillary necrosis. B, IVP in September 1975, 8 months after colon conduit. C, IVP in June 1976, 9 months after colocolostomy.
FIG. 4. Case 2, 56-year-old woman with bladder carcinoma in situ, requiring radical cystectomy and colon loop. A, IVP in January 1975, before diversion. B, IVP in January 1976, 4 months after colon conduit. C, IVP in April 1977, 15 months after colocolostomy.
benign course. Since then there have been no recurrent episodes of pyelonephritis on chronic antibiotic suppression. Serum electrolytes are normal, as is the IVP. DISCUSSION
While satisfactory for diversion in patients with poor prognosis the ileal loop has several shortcomings for the patient with a relatively normal life expectancy. Long-term experience has revealed progressive upper tract deterioration in previously normal renal units. 3-13 The early adult experiences showed approximately 20 per cent deteriorated on pyelograms. 4--0, s, 11 However, with longer followup in children, progressive upper tract damage ranged upwards to 56 to 68 per cent. 3, 12 The high incidence of stomal stenosis is particularly
dangerous in the freely refluxing system, as are pyelonephritis and ureteroileal stenosis. The colon conduit offers several advantages, including thicker musculature to create a non-refluxing tunnel, 16 fewer stomal problems, 15· 16 less marked pressure spike response to acute occlusion, 15 infrequent pyelographic deterioration16· 18· 19 or histologic evidence of pyelonephritis15 and insignificant electrolyte imbalance. 20 The staged ureterocolocolostomy has been used successfully in children with bladder exstrophy16 and we believe that this procedure should be considered in adults with a good prognosis requiring diversion. In contrast to primary ureterosigmoidostomy the ~taged 11roi;edure is_s.Jiperio~ forseveral re asons: 1) it is applicable in ~ ients with hydroureter/hydronephrosis,
- - - -- - - --""":--:,,,-----=-- - - ~
STAGED URETEROCOLOCOLOSTOMY URINARY DIVERSION
allowing decompression isolated from t may be used w1 es a lished pyelone hritis :ermits accurateassessmen ofliac enal cultures and creatinine clearances; ·asweir as conhrmationofthe non-refluxing nature of t e ure eroco 1c anastomosis before exposure to the fecal stream and- "4")--we-precl.tcrtli:at electrolyte disor ers will l:ie dimhtistred m tre9.!!_ency and severity. - obstructive changes and pyelonephritis have been the classic contraindications to primary ureterosigmoidostomy, since the high incidence of both developing in previously normal upper tracts after this procedure has been well documented. 1, 21- 23 However, by isolating the ureterocolic anastomosis from the fecal stream during healing the incidence of pyelonephritis and hydronephrosis decreases dramatically. 15 Subsequent take-down of the colon conduit with colocolostomy has not produced clinical pyelonephritis or upper tract deterioration in the 11 children in Hendren's series 16 and we have not seen either problem in our patients. Ureteral tapering may be
405
performed with the colon conduit. The opportunity to study all aspects of the conduit and the ureterocolic anastomosis (that is renal function, absence of reflux, obstruction and infection) is a significant advantage over primary ureterosigmoidostomy. Should renal function be less than expected, the infection be difficult to irradicate or obstructive changes be slow to resolve the colocolostomy may be deferred until all parameters are optimal. All 3 patients had non-refluxing loopograms, stable or improved IVP, sterile urine and stable renal function before colocolostomy. Finally, the question arises as to whether a staged procedure will be spared the high incidence of hyperchloremic, hypokalemic acidosis observed in primary ureterosigmoidostomy. We have seen no deterioration in renal function and 1 patient had an asymptomatic decrease in serum bicarbonate without hyperchloremia. The important features in the development of the hyperchloremic acidosis are obstruction, pyelonephritis, pre-exist-
.I
I
FIG. 5. Case 3, 25-year-old man with ureterosigmoidostomies and bilateral recurrent pyelonephritis. A, IVP in October 1975, showing left hydronephrosis and right papillary necrosis. B, IVP in April 1976, 6 months after colon condult, demonstrating marked improvement on left. C, IVP in April 1977, 1 year after colocolostomy.
OBSTRUCTION PYELONEPHRITIS
'
MEDULLARY OESTRUCTION
'
BACK PRESSURE W1TH NEPHRON LOSS
l
MEOULLARY HYPOTON ICITY WITH RED ISTRIBUT ION TO SUPERFIC I AL CORTICAL NEPHRONS
I
j FREE WATER BACK - DIFFUSION VIA COLLECTING DUCT
f GFR / RESIOUAL
\
NEPHRON (SUK I I
OR
j WATER EXTRACT ION
j GFR / NEPHRON WITH MORE DECREASED
FROM HENLE'S DESCENDING LOOP
f
FRACT IONAL REABSORPTION OF NA AND WATER (BRICKER)
I
t "SALINE DIURESIS"
FILTRATE FRACTION DELIVERED TO DISTAL TUBULE
I
!
CHLORIDE REABSORPTION (COLON MUCOSA)
NA - K EXCHANGE
I URINARY
l
/
NA, K, OSMOLAR I TY
FIG. 6. Pathophysiology of electrolyte imbalance in ureterosigmoidostomy ~.
--- j
406
NIER, ALTHAUSEN AND DRETLER
ing renal disease (that is corticomedullary loss) and chloride reabsorption (fig. 6). 16 • 24- 28 It is the cumulative effect of these factors that determines predisposition to electrolyte imbalance. More extensive experience is required but we expect that by minimizing obstruction and pyelonephritis the staged procedure will be less susceptible to hyperchloremic acidosis. Careful monitoring of patients with pre-existing renal disease is essential. Avoidance of a high acid-ash diet to decrease chloride intake 27 and frequent rectal evacuation should be used also. Contraindications to ureterocolocolostomy include those patients with a previously irradiated rectosigmoid, fecal incontinence or poor anal sphincter tone, and inflammatory large bowel disease (for example ulcerative colitis and diverticulitis). Those patients with inadequate ureteral length may require a transverse colon conduit but if there is still insufficient ureter to create a non-refluxing tunnel the colocolostomy is subject to the same risks as the primary ureterosigmoidostomy. A relative contraindication is a strong family history of colon cancer. Primary carcinoma at the ureterocolic anastomosis has been reported in ureterosigmoidostomy an average of 7 years postoperatively for malignant disease and 22 years for those diverted for benign disorders. 29 However, these were all likely to have been Coffey anastomoses with a projecting ureteral stump where constant mechanical trauma might predispose to carcinogenic changes. We believe that the staged ureterocolocolostomy with the non-refluxing ureterocolic anastomosis will decrease the complications associated with the ileal loop and ureterosigmoidostomy and should be considered in the management of the adult with a good prognosis who requires urinary diversion. REFERENCES
1. Leadbetter, W. F. and Clarke, B. G.: Five years' experience with uretero-enterostomy by the "combined" technique. J. Urol., 73: 67, 1955. 2. Bricker, E. M.: Symposium on clinical surgery; bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Middleton, A. W., Jr. and Hendren, W. H.: Heal conduits in children at the Massachusetts General Hospital from 1955 to 1970. J. Urol., 115: 591, 1976. 4. Burnham, J.P. and Farrer, J.: A group experience with ureteroileal-cutaneous anastomosis for urinary diversion: results and complications of the isolated ileal conduit (Bricker procedure) in 96 patients. J. Urol., 83: 622, 1960. 5. Butcher, H. R., Sugg, W. L., McAfee, C. A. and Bricker, E. M.: Ileal conduit method of ureteral urinary diversion. Ann. Surg., 156: 682, 1962. 6. Cordonnier, J. J. and Nicolai, C.H.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion. J. Urol., 83: 834, 1960. 7. Delgado, G. E. and Muecke, E. C.: Evaluation of80 cases ofileal conduits in children: indication, complication and results. J. Urol., 109: 311, 1973.
8. Murphy, J. J. and Schoenberg, H. W.: Survey of long-term results of total urinary diversion. Brit. J. Urol., 39: 700, 1967. 9. Rabinowitz, R. and Price, S. E., Jr.: Heal conduit urinary diversion in children. J. Urol., 114: 444, 1975. 10. Ray, P. and DeDomenico, I.: Intestinal conduit urinary diversion in children. Brit. J. Urol., 44: 345, 1972. 11. Schmidt, J. D., Hawtrey, C. E., Flocks, R. H. and Culp, D. A.: Complications, results and problems of ileal conduit diversions. J. Urol., 109: 210, 1973. 12. Schwarz, G. R. and Jeffs, R. D.: Heal conduit urinary diversion in children: computer analysis of followup from 2 to 16 years. J. Urol., 114: 285, 1975. 13. Shapiro, S. R., Lebowitz, R. and Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade lateranalysis of complications, pyelography, renal function and bacteriology. J. Urol., 114: 289, 1975. 14. Mogg, R. A. and Syme, R. R.: The results of urinary diversion using the colonic conduit. Brit. J. Urol., 41: 434, 1969. 15. Richie, J. P. and Skinner, D. G.: Urinary diversion: the physiological rationale for non-refluxing colonic conduits. Brit. J. Urol., 47: 269, 1975. 16. Hendren, W. H.: Exstrophy of the bladder-alternative method of management. J. Urol., 115: 195, 1976. 17. Fegiz, G., Tonelli, F., Rossi, P., DiPaola, M., Passariello, R., DeMasi, E. and Simonetti, G.: Preservation of the superior hemorrhoidal artery in resection of the colon and rectum. Surg., Gynec. & Obst., 143: 919, 1976. 18. Kelalis, P. P.: Urinary diversion in children by the sigmoid conduit: its advantages and limitations. J. Urol., 112: 666, 1974. 19. Morales, P. and Golimbu, M.: Colonic urinary diversion: 10 years of experience. J. Urol., 113: 302, 1975. 20. Genster, H. G.: Changes in the composition of the urine in sigmoid loop bladders. A comparison with ileal loops. Scand. J. Urol. Nephrol., 5: 41, 1971. 21. Spence, H. M., Hoffman, W.W. and Pate, V. A.: Exstrophy of the bladder. I. Long-term results in a series of 37 cases treated by ureterosigmoidostomy. J. Urol., 114: 133, 1975. 22. Weyrauch, J. M.: Landmarks in the development of ureterointestinal anastomosis. Ann. Roy. Coll. Surg., 18: 343, 1956. 23. Zincke, H. and Segura, J. W.: Ureterosigmoidostomy: critical review of 173 cases. J. Urol., 113: 324, 1975. 24. Ferris, D. 0. and Odel, H. M.: Electrolyte pattern of blood after bilateral ureterosigmoidostomy. J.A.M.A., 142: 634, 1950. 25. Bricker, N. S. and Klahr, S.: Obstructive· nephropathy. In: Diseases of the Kidney, 2nd ed. Edited by M. B. Strauss and L. G. Welt. Boston: Little, Brown & Co., pp: 997-1038, 1971. 26. Michaelson, G.: Percutaneous puncture of renal pelvis, intrapelvic pressure and the concentrating capacity of the kidney in hydronephrosis. Acta Med. Scand. (suppl.), 559: 1, 1974. 27. Stamey, T. A.: The pathogenesis and implications of the electrolyte imbalance in ureterosigmoidostomy. Surg., Gynec. & Obst., 103: 736, 1956. 28. Suki, W., Eknoyan, G., Rector, F. C. and Seldin, D. W.: Patterns of nephron perfusion in acute and chronic hydronephrosis. J. Clin. Invest., 45: 122, 1966. 29. Rivard, J.-Y., Bedard, A. and Dionne, L.: Colonic neoplasms following ureterosigmoidostomy. J. Urol., 113: 781, 1975.
