TRANSURETEROURETEROSTOMY
FOR
URINARY DIVERSION IN CHILDREN STEPHEN
R. SHAPIRO,
MARK S. PECKLER, J. H. JOHNSTON,
M.D.
M.D. F.R.C.S.
From the Department of Urology, Alder Hey Children’s Hospital, Liverpool, England
with cutaneous ureterostomy has been used effectively as a ABSTRACT - Transureteroureterostomy method of external urinary diversion in ten children. Of the 20 renal units involved, 15 showed pyelographic improvement and 5 stabilized after diversion. The method requires that at least one ureter is sufficiently dilated to provide a stoma of adequate caliber. It avoids the disadvantages or complications associated with most other forms of external diversion.
External urinary diversion remains a necessary procedure in the management of many children with neuropathic bladder. It is often also needed in cases of bladder exstrophy when the upper tracts are dilated so that ureterosigmoidostomy is contraindicated. The most popular method has been the ileal conduit, but this technique carries the inevitable risks associated with a bowel anastomosis, and long-term follow-up has shown that late complications are frequent. Stoma1 stenosis, elongation and kinking of the conduit, ureteroileal strictures, urinary calculi, and progressive upper tract and renal deterioration of uncertain pathogenesis have been common experience.‘-3 Recent reports have suggested that the sigmoid conduit, employing an antireflux ureteric implantation, may be more successful in avoiding upper urinary tract changes, but this method also necessitates bowel surgery.4 Bilateral terminal ureterostomies carry the advantage that the alimentary tract remains intact, but both ureters must be dilated to avoid stoma1 strictures. In addition, it can be difficult or even impossible to place the stoma sufficiently close together to allow drainage into a single collecting appliance. With transureteroureterostomy and cutaneous ureterostomy a single stoma is provided and only one ureter need be dilated. This report records our experience with 10 children treated by this method in the last five years.
UROLOGY
/ JULY 1976
/ VOLUME
VIII,
NUMBER
1
FICUF&1. Technique of transureteroureterostomy. It is of critical importance to avoid in&ring distal blood supply of recipient ureter when performing vertical ureterotomy and during suturing of ureters.
Technique The peritoneal cavity is opened through a midline or paramedian incision. Each ureter is exposed by incising the overlying posterior peritoneum and divided close to the bladder. The
35
FIGURE 2. Intravenous pyelograms of girl with neuropathic bladder due to spina bij& cystica (A) four months afier bilateral ureteric reimplantation and Y-V-plasty of bladder neck showing persistent bilateral hydroureteronephrosis; and(B) six months after diversion by transureteroureterostomy showing marked bilateral improvement.
more dilated ureter forms the terminal stoma. The opposite ureter is passed across the midline, behind the posterior peritoneum, and in front of the great vessels to join it. A stoma is fashioned, usually about halfway between the umbilicus and the anterior superior iliac spine, by excising a disk of skin and making cruciate incisions in the muscular and aponeurotic layers. The terminal ureter is drawn through to the exterior, extraperitoneally, and its extremity is sutured to the skin edges, using interrupted chromic catgut sutures. A vertical incision of appropriate length is made in the :* recipient ureter at about the level of the pelvic brim, carefully avoiding the vessels on its surface. The obliquely cut extremity of the opposite ureter is anastomosed to the recipient, using fine interrupted chromic catgut sutures. Again, care is needed during the suturing to avoid injury to the longitudinally running vessels on the recipient ureter since this could jeopardize its distal blood supply (Fig. 1). A single-layer anastomosis suffices. During the anastomosis fine polyethylene catheters are passed through the ureteric stoma and up each ureter to the renal pelves. A drain is left in the retroperitoneum to the site of the anastomosis and brought out through a lower abdominal stab incision. The incisions in the posterior peritoneum are sutured and the abdomen closed.
36
An adhesive collecting bag is applied over the stoma and the emerging catheters. The drain is removed after one week, and the catheters are removed on the tenth postoperative day. Material and Results Transureteroureterostomy with cutaneous ureterostomy was carried out in 10 children between the ages of two and sixteen years. Follow-up has ranged from three months to five years. In 7 cases the operation was performed because of upper tract deterioration consequent on neuropathic bladder dysfunction, with failure of conservative methods to provide adequate bladder and ureteric emptying. In 1 boy cloaca1 exstrophy had been repaired in the neonatal period with the formation of a perineal colostomy; the development of bilateral ureteric dilatation necessitated urinary diversion at the age of five years. Another boy with exstrophy of the bladder underwent closure of the bladder shortly after birth. Ureteroileosigmoidostomy was performed five years later because of upper tract deterioration. At the age of sixteen years further deterioration led to performance of a left to right transureteroureterostomy with a right cutaneous ureterostomy. The final patient was a boy with spina bifida who had previously undergone ileal
UROLOGY
/ JULY 1976 / VOLUME
VIII,
NUMBER
1
FIGURE 3. lntravenous pyelograms of girl with neuropathic bladder after removal of spinal cord lipoma (A) at age twenty-one months showing bilateral hydroureteronephrosis despite transurethral resection of bladder neck and urethral dilatation; and (B) three months after transureteroureterostomy diversion showing delicate calyces and decreased ureteral dilatation.
conduit diversion for urinary incontinence. Upper tract dilatation had developed as a result of severe widening and elongation of the conduit. At the age of fifteen years the conduit was excised and transureteroureterostomy with cutaneous ureterostomy performed. There were no significant early postoperative complications and no urinary leaks from the ureteral anastomoses. Stoma1 stenosis did not occur in any patient. Routine catheterization of the stoma at outpatient attendances revealed minimal volumes of residual urine in all cases with the exception of one, a nine-year-old girl with bladder neuropathy. In this child postoperative urography suggested some hold up in the terminal ureter within the abdominal wall. She had gained 20 pounds in weight following the diversion, and it was considered that the urinary stasis was due to stretching of the ureter in its course through the subcutaneous fat. Catherization of the stoma and emptying of the urinary tract were carried out nightly by the child’s mother and this, combined with weight reduction, led to obvious pyelographic improvement. The results of urography after transureteroureterostomy with cutaneous ureterostomy in 10 children were as follows: of 20 renal units 15 (75 per cent) showed improvement and 5 (25 per cent) were unchanged. Illustrative examples are given in Figures 2 to 4.
UROLOGY
/ JULY1976
/ VOLUMEVIII,
NUMBER]
Comment External diversion by transureteroureterostomy was first described by Obrant5 who employed the technique in 2 adult patients. Eckstein and Kapila’ and Belman and King’ described the procedure in children but did not elaborate on the results obtained. Weiss, Beland, and Lattimer,’ from their experience of 5 cases, concluded that the method was a simple, safe, and satisfactory form of urinary diversion in children with dilated ureters. Similar results were reported recently by Beland and Labergeg in a larger series of children. Transureteroureterostomy with cutaneous ureterostomy has the great advantage over intestinal conduits in that it is a much lesser operative procedure and the possible complications of bowel surgery are avoided. Also, metabolic disturbances resulting from intestinal absorption of urinary constituents cannot occur. The operation requires that at least one ureter be dilated but in our experience only moderate dilatation suffices to avoid stoma1 stenosis. Indeed, the procedure may well be contraindicated in the presence of massively dilated and inert ureters because of poor urinary drainage. In such cases high urinary diversion by means of a pyelocolonicl’ or a pyeloileal” anastomosis may be preferable. Ureteroureteral reflux must inevitably occur, but there is no evidence from our cases or from
37
FIGURE 4. Intravenous pyelograms of boy with neuropathic bladder due to sacral agenesis (A) at age eight years demonstrating right hydroureteronephrosis and mild dilatation of left ureter; (B) six months after transureteroureterostomy showing bilateral improvement,
others reported that this causes any ill effects under these circumstances. We have experienced no problems with fitting collecting appliances even though we have deliberately avoided trying to create a projecting stoma. We have found that eversion of the ureter to form a nipple is prone to interrupt the blood supply to the ureteral extremity and leads to stricturing. Our experience with this series has shown that transureteroureterostomy with a single stoma is very effective in promoting upper tract drainage bilaterally, and we believe that, in the correctly selected case, it is the optimal form of external urinary diversion at present available in children with at least one dilated ureter. Department of Urology University of California, Davis Sacramento Medical Center Sacramento, California 95817 (DR. SHAPIRO) References 1. SCOTT, J. E. : Urinary diversion in children, Arch Dis. Child. 48: 199 (1973).
38
2. SMITH, E. D.: Follow-up study on 150 ileal conduits in children, J. Pediatr. Surg. 7: 1 (1972). 3. SHAPIRO, S. R., LEBOWITZ, R., and COLODNY, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later, J. Ural. 114: 289 (1975). 4. SKINNER, D. G.: The isolated sigmoid segment: its value in temporary urinary diversion and reconstruction, ibid. 113: 614 (1975). 5. OBRANT, K. A.: Cutaneous ureterostomy with skin 6. 7.
8.
9. 10. 11.
tube and plastic cup appliance together with transuretero-ureteral anastomosis, Br. J. Urol. 29: 135 (1957). ECKSTEIN, H. B., and KAPILA, L.: Cutaneous ureterostomy, ibid. 42: 306 (1970). BELMAN,A. B., and KING, L. Il. : Urinary diversion in children, in Johnston, J. H., and Goodwin, W. E., Eds.: Reviews in Paediatric Urology, Amsterdam, Excerpta Medica, 1974, p. 173 WEISS, R. M., BELAND, G. A., and LATTIMER, J. K.: Transureteroureterostomy and cutaneous ureterostomy as a form of urinary diversion in children, J. Urol. 96: 155 (1966). BELAND, G., and LABERGE, I.: Cutaneous transureteroureterostomy in children, ibid. 114: 588 (1975). JOHNSTON,J.H.: Pyelo-colonic diversion in children, Br. J. Urol. 46: 169 (1974). KING, L. R., and SCOT, W. W.: Ileal urinary diversion: success of pyeloileocutaneous anastomosis in correction of hydroureteronephrosis persisting after uretero-ileocutaneous anastomosis, J.A.M.A. 181: 831 (1962).
UROLOGY
/
JULY 1976
/
VOLUME VIII, NUMBER 1
FOR
URINARY DIVERSION IN CHILDREN STEPHEN
R. SHAPIRO,
MARK S. PECKLER, J. H. JOHNSTON,
M.D.
M.D. F.R.C.S.
From the Department of Urology, Alder Hey Children’s Hospital, Liverpool, England
with cutaneous ureterostomy has been used effectively as a ABSTRACT - Transureteroureterostomy method of external urinary diversion in ten children. Of the 20 renal units involved, 15 showed pyelographic improvement and 5 stabilized after diversion. The method requires that at least one ureter is sufficiently dilated to provide a stoma of adequate caliber. It avoids the disadvantages or complications associated with most other forms of external diversion.
External urinary diversion remains a necessary procedure in the management of many children with neuropathic bladder. It is often also needed in cases of bladder exstrophy when the upper tracts are dilated so that ureterosigmoidostomy is contraindicated. The most popular method has been the ileal conduit, but this technique carries the inevitable risks associated with a bowel anastomosis, and long-term follow-up has shown that late complications are frequent. Stoma1 stenosis, elongation and kinking of the conduit, ureteroileal strictures, urinary calculi, and progressive upper tract and renal deterioration of uncertain pathogenesis have been common experience.‘-3 Recent reports have suggested that the sigmoid conduit, employing an antireflux ureteric implantation, may be more successful in avoiding upper urinary tract changes, but this method also necessitates bowel surgery.4 Bilateral terminal ureterostomies carry the advantage that the alimentary tract remains intact, but both ureters must be dilated to avoid stoma1 strictures. In addition, it can be difficult or even impossible to place the stoma sufficiently close together to allow drainage into a single collecting appliance. With transureteroureterostomy and cutaneous ureterostomy a single stoma is provided and only one ureter need be dilated. This report records our experience with 10 children treated by this method in the last five years.
UROLOGY
/ JULY 1976
/ VOLUME
VIII,
NUMBER
1
FICUF&1. Technique of transureteroureterostomy. It is of critical importance to avoid in&ring distal blood supply of recipient ureter when performing vertical ureterotomy and during suturing of ureters.
Technique The peritoneal cavity is opened through a midline or paramedian incision. Each ureter is exposed by incising the overlying posterior peritoneum and divided close to the bladder. The
35
FIGURE 2. Intravenous pyelograms of girl with neuropathic bladder due to spina bij& cystica (A) four months afier bilateral ureteric reimplantation and Y-V-plasty of bladder neck showing persistent bilateral hydroureteronephrosis; and(B) six months after diversion by transureteroureterostomy showing marked bilateral improvement.
more dilated ureter forms the terminal stoma. The opposite ureter is passed across the midline, behind the posterior peritoneum, and in front of the great vessels to join it. A stoma is fashioned, usually about halfway between the umbilicus and the anterior superior iliac spine, by excising a disk of skin and making cruciate incisions in the muscular and aponeurotic layers. The terminal ureter is drawn through to the exterior, extraperitoneally, and its extremity is sutured to the skin edges, using interrupted chromic catgut sutures. A vertical incision of appropriate length is made in the :* recipient ureter at about the level of the pelvic brim, carefully avoiding the vessels on its surface. The obliquely cut extremity of the opposite ureter is anastomosed to the recipient, using fine interrupted chromic catgut sutures. Again, care is needed during the suturing to avoid injury to the longitudinally running vessels on the recipient ureter since this could jeopardize its distal blood supply (Fig. 1). A single-layer anastomosis suffices. During the anastomosis fine polyethylene catheters are passed through the ureteric stoma and up each ureter to the renal pelves. A drain is left in the retroperitoneum to the site of the anastomosis and brought out through a lower abdominal stab incision. The incisions in the posterior peritoneum are sutured and the abdomen closed.
36
An adhesive collecting bag is applied over the stoma and the emerging catheters. The drain is removed after one week, and the catheters are removed on the tenth postoperative day. Material and Results Transureteroureterostomy with cutaneous ureterostomy was carried out in 10 children between the ages of two and sixteen years. Follow-up has ranged from three months to five years. In 7 cases the operation was performed because of upper tract deterioration consequent on neuropathic bladder dysfunction, with failure of conservative methods to provide adequate bladder and ureteric emptying. In 1 boy cloaca1 exstrophy had been repaired in the neonatal period with the formation of a perineal colostomy; the development of bilateral ureteric dilatation necessitated urinary diversion at the age of five years. Another boy with exstrophy of the bladder underwent closure of the bladder shortly after birth. Ureteroileosigmoidostomy was performed five years later because of upper tract deterioration. At the age of sixteen years further deterioration led to performance of a left to right transureteroureterostomy with a right cutaneous ureterostomy. The final patient was a boy with spina bifida who had previously undergone ileal
UROLOGY
/ JULY 1976 / VOLUME
VIII,
NUMBER
1
FIGURE 3. lntravenous pyelograms of girl with neuropathic bladder after removal of spinal cord lipoma (A) at age twenty-one months showing bilateral hydroureteronephrosis despite transurethral resection of bladder neck and urethral dilatation; and (B) three months after transureteroureterostomy diversion showing delicate calyces and decreased ureteral dilatation.
conduit diversion for urinary incontinence. Upper tract dilatation had developed as a result of severe widening and elongation of the conduit. At the age of fifteen years the conduit was excised and transureteroureterostomy with cutaneous ureterostomy performed. There were no significant early postoperative complications and no urinary leaks from the ureteral anastomoses. Stoma1 stenosis did not occur in any patient. Routine catheterization of the stoma at outpatient attendances revealed minimal volumes of residual urine in all cases with the exception of one, a nine-year-old girl with bladder neuropathy. In this child postoperative urography suggested some hold up in the terminal ureter within the abdominal wall. She had gained 20 pounds in weight following the diversion, and it was considered that the urinary stasis was due to stretching of the ureter in its course through the subcutaneous fat. Catherization of the stoma and emptying of the urinary tract were carried out nightly by the child’s mother and this, combined with weight reduction, led to obvious pyelographic improvement. The results of urography after transureteroureterostomy with cutaneous ureterostomy in 10 children were as follows: of 20 renal units 15 (75 per cent) showed improvement and 5 (25 per cent) were unchanged. Illustrative examples are given in Figures 2 to 4.
UROLOGY
/ JULY1976
/ VOLUMEVIII,
NUMBER]
Comment External diversion by transureteroureterostomy was first described by Obrant5 who employed the technique in 2 adult patients. Eckstein and Kapila’ and Belman and King’ described the procedure in children but did not elaborate on the results obtained. Weiss, Beland, and Lattimer,’ from their experience of 5 cases, concluded that the method was a simple, safe, and satisfactory form of urinary diversion in children with dilated ureters. Similar results were reported recently by Beland and Labergeg in a larger series of children. Transureteroureterostomy with cutaneous ureterostomy has the great advantage over intestinal conduits in that it is a much lesser operative procedure and the possible complications of bowel surgery are avoided. Also, metabolic disturbances resulting from intestinal absorption of urinary constituents cannot occur. The operation requires that at least one ureter be dilated but in our experience only moderate dilatation suffices to avoid stoma1 stenosis. Indeed, the procedure may well be contraindicated in the presence of massively dilated and inert ureters because of poor urinary drainage. In such cases high urinary diversion by means of a pyelocolonicl’ or a pyeloileal” anastomosis may be preferable. Ureteroureteral reflux must inevitably occur, but there is no evidence from our cases or from
37
FIGURE 4. Intravenous pyelograms of boy with neuropathic bladder due to sacral agenesis (A) at age eight years demonstrating right hydroureteronephrosis and mild dilatation of left ureter; (B) six months after transureteroureterostomy showing bilateral improvement,
others reported that this causes any ill effects under these circumstances. We have experienced no problems with fitting collecting appliances even though we have deliberately avoided trying to create a projecting stoma. We have found that eversion of the ureter to form a nipple is prone to interrupt the blood supply to the ureteral extremity and leads to stricturing. Our experience with this series has shown that transureteroureterostomy with a single stoma is very effective in promoting upper tract drainage bilaterally, and we believe that, in the correctly selected case, it is the optimal form of external urinary diversion at present available in children with at least one dilated ureter. Department of Urology University of California, Davis Sacramento Medical Center Sacramento, California 95817 (DR. SHAPIRO) References 1. SCOTT, J. E. : Urinary diversion in children, Arch Dis. Child. 48: 199 (1973).
38
2. SMITH, E. D.: Follow-up study on 150 ileal conduits in children, J. Pediatr. Surg. 7: 1 (1972). 3. SHAPIRO, S. R., LEBOWITZ, R., and COLODNY, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later, J. Ural. 114: 289 (1975). 4. SKINNER, D. G.: The isolated sigmoid segment: its value in temporary urinary diversion and reconstruction, ibid. 113: 614 (1975). 5. OBRANT, K. A.: Cutaneous ureterostomy with skin 6. 7.
8.
9. 10. 11.
tube and plastic cup appliance together with transuretero-ureteral anastomosis, Br. J. Urol. 29: 135 (1957). ECKSTEIN, H. B., and KAPILA, L.: Cutaneous ureterostomy, ibid. 42: 306 (1970). BELMAN,A. B., and KING, L. Il. : Urinary diversion in children, in Johnston, J. H., and Goodwin, W. E., Eds.: Reviews in Paediatric Urology, Amsterdam, Excerpta Medica, 1974, p. 173 WEISS, R. M., BELAND, G. A., and LATTIMER, J. K.: Transureteroureterostomy and cutaneous ureterostomy as a form of urinary diversion in children, J. Urol. 96: 155 (1966). BELAND, G., and LABERGE, I.: Cutaneous transureteroureterostomy in children, ibid. 114: 588 (1975). JOHNSTON,J.H.: Pyelo-colonic diversion in children, Br. J. Urol. 46: 169 (1974). KING, L. R., and SCOT, W. W.: Ileal urinary diversion: success of pyeloileocutaneous anastomosis in correction of hydroureteronephrosis persisting after uretero-ileocutaneous anastomosis, J.A.M.A. 181: 831 (1962).
UROLOGY
/
JULY 1976
/
VOLUME VIII, NUMBER 1
