URETEROURETEROSTOMY UNILATERAL Alternate MICHAEL NICHOLAS LEONARD
AND
NEPHROSTOMY”
Rapid Method of Diversion WECHSLER, ROMAS, RUDIN,
From the Department Columbia-Presbyterian
M.D. M.D.
M.D. of Urology, Columbia University, Medical Center, New York, New York
ABSTRACT - Ureteroureterostomy with u Silastic nephrostomy has been utilized in 3 patients as a temporary diversion. It is a short procedure which is performed transabdominally and is well tolerated. It may be indicated in selected patients who will not be able to handle an appliance and cannot tolerate major surgery. This is not a panacea for urinary diuersion, but in selected cases it may be applicable.
Crossed ureteroureterostomy is not a new technique. It was repopularized by Anderson et al. in 19601 and since then has gained wide acceptance. Arnold and Garrett in 1969’ reported good results with the use of ureteroureterostomy combined with unilateral nephrostomy as a rapid method for palliative diversion. Over the last few years we have had occasion to be confronted with patients who were in need of a diversion but for one reason or another would not wear or tolerate an appliance. It is in this select group of patients that we have performed transureteroureterostomy with unilateral nephrostomy, as a palliative diversion.
dissection. We believe it is important to place the nephrostomy tube as far anterior as possible, usually along the anterior axillary line, to avoid the discomfort the patient experiences if the tubes are positioned too far posteriorly.
Technique A midline transabdominal approach is utilized and extended well above the umbilicus to facilitate access to the kidney selected for nephrostomy. The kidney with the greater degree of hydronephrosis is usually selected for insertion of the nephrostomy tube. If the patient is obese, a sandbag under the flank on the side where the nephrostomy is to be performed may aid in the
*Supported in part by the Mollie and Harry Grekmburg Gift for Research.
FIGURE 1. Drawing shows completed ureteral anastomosis in relation to surrounding anatomic structures.
UROLOGY
/ APRIL 1976 / VOLUME
VII,
NUMBER 4
was thought that urinary diversion with subsequent radio- and chemotherapy would be the optimal therapy. However, the patient was unable to manage an external urinary appliance, therefore a unilateral ureteroureterostomy with a solitary nephrostomy was performed. Postoperatively she did well and renal function improved, with a decrease in blood urea nitrogen to 22 mg. and creatinine to 1.5 mg per 100 ml. Case 2
FIGURE
2.
Postoperative
j&n
showing improved
radiologic function.
An incision is made in the posterior peritoneum and both ureters are isolated and incised in their midportions. Care is taken to preserve the ureteral mesentery on each side. A large retroperitoneal tunnel is made anterior to the aorta and preferably above the inferior mesenteric artery. The ureters are anastomosed end to end with interrupted 4-O chromic catgut. A drain is placed to the area and brought out through a stab wound. A 24 Silastic nephrostomy tube is placed in the kidney with the better pelvis. Care must be taken in placing the nephrostomy tube. The ureter has been cut distally and if the blood supply to the pelvis is compromised during placement of the nephrostomy, we could be left with a devitalized segment of ureter. We have not used ureteral splints, and the drains are left in place for seven to ten days. The operating time is short, and the Silastic nephrostomy tubes have been left in place for periods of four to six months with no incrustations noted (Fig. 1). Case Reports
Case 1 A seventy-year-old female was first seen in February, 1974, when a diagnosis of squamous cell cancer of the bladder was made. Intravenous pyelogram showed marked bilateral hydroRenal function was comureteronephrosis. promised, with a blood urea nitrogen of 90 mg. and creatinine of5 mg. per 100 ml. After complete evaluation and supportive medical treatment, it
UROLOGY
/ APRIL1976 / VOLUME
VII.NUMBER-I
An eighty-six-year-old white male had had 6,500 rads for invasive cancer of the bladder. Later a recurrent tumor developed with severe radiation cystitis. The patient had massive bleeding requiring multiple transfusions. He was treated conservatively but failed to respond to medical management. He underwent a left nephrostomy and transureteroureterostomy. His hypogastric arteries were ligated in situ. Postoperatively he did well and required no further transfusions. However, he eventually died of the bladder cancer. Case 3 A fifty-six-year-old white female fifteen years previously had had a pelvic exenteration with ileal conduit and colostomy for carcinoma of the cervix. She had recently been explored because of bowel obstruction and had had a urinary stoma revised twice. At no time was recurrent tumor ever documented. She was admitted to the hospital in extreme acidosis and found to have a urinary fistula to her colostomy. After initial diverting nephrostomies she was finally stabilized and definitive surgery was performed. At exploration the proximal end of the conduit and ureters were found to be involved with a large fistulous mass. After excising this we were left with two short ureters and a small piece of conduit still anastomosed to the skin. She had an end to end transureteroureterostomy and the proximal end of her ileal conduit was anastomosed to the side of the right ureter. One year postoperatively she is well. Comment Urinary diversion with the use of ureteroureterostomy combined with a nephrostomy tube is a relatively simple operative procedure and does not require prolonged anesthesia. Another major advantage is that (in a previously radiated lower abdomen in a poor-risk patient) no intestinal anastomosis is required. If bleeding
367
from a cancerous bladder is a problem, the hypogastric arteries can be ligated at the same time, as described in Case 2. When ureteroureterostomy was first described, one of the theoretical problems was the necessity for antiperistaltic flow of urine, namely down one ureter and up the other. However, subsequent tine studies have shown that the collecting system empties itself and that while there may be both antegrade and retrograde peristalsis, it causes no problem. Our postoperative studies have shown that there is usually an improvement radiographitally, in the degree of dilation of the upper tracts (Fig. 2). In this postoperative intravenous pyelogram the patient had massive bilateral hydroureteronephrosis with a blood urea nitrogen of 100 mg. per 100 ml. His blood urea nitrogen is now in the upper 20s and his renal function has remained stable. We have noted no patient whose renal function has deteriorated further. The introduction of improved catheter materials, such
368
as Silastic, often allows one to leave the nephrostomy tube in place for four to six months before replacing it. For example, the Silastic threewinged Malecot catheter used in Case 1 remained in place four months before it was changed. Ureteroureterostomy with unilateral nephrostomy is proposed as an alternative method for urinary diversion. Patients who are elderly, or for medical or social reasons could not tolerate an external appliance, may respond well to this operation. In those selected patients, we believe it is a simple, effective method for urinary diversion. 620 West 168th Street New York, New York 10032 (DR. WECHSLER) References 1. ANDERSON,H. U., HODGES,C. U., BEHNAM,A. M., and OCKER, J. M., JR.: Transureteroureterostomy: experimental and clinical experiences, J. Urol. 83: 593 (1960). 2. ARNOLD, T. L., and GARRETT, N.: Ureteroureterostomy and unilateral nephrostomy, ibid. 102: 316 (1969).
UROLOGY I APRIL 1976 / VOLUME VII, NUMBER 4
AND
NEPHROSTOMY”
Rapid Method of Diversion WECHSLER, ROMAS, RUDIN,
From the Department Columbia-Presbyterian
M.D. M.D.
M.D. of Urology, Columbia University, Medical Center, New York, New York
ABSTRACT - Ureteroureterostomy with u Silastic nephrostomy has been utilized in 3 patients as a temporary diversion. It is a short procedure which is performed transabdominally and is well tolerated. It may be indicated in selected patients who will not be able to handle an appliance and cannot tolerate major surgery. This is not a panacea for urinary diuersion, but in selected cases it may be applicable.
Crossed ureteroureterostomy is not a new technique. It was repopularized by Anderson et al. in 19601 and since then has gained wide acceptance. Arnold and Garrett in 1969’ reported good results with the use of ureteroureterostomy combined with unilateral nephrostomy as a rapid method for palliative diversion. Over the last few years we have had occasion to be confronted with patients who were in need of a diversion but for one reason or another would not wear or tolerate an appliance. It is in this select group of patients that we have performed transureteroureterostomy with unilateral nephrostomy, as a palliative diversion.
dissection. We believe it is important to place the nephrostomy tube as far anterior as possible, usually along the anterior axillary line, to avoid the discomfort the patient experiences if the tubes are positioned too far posteriorly.
Technique A midline transabdominal approach is utilized and extended well above the umbilicus to facilitate access to the kidney selected for nephrostomy. The kidney with the greater degree of hydronephrosis is usually selected for insertion of the nephrostomy tube. If the patient is obese, a sandbag under the flank on the side where the nephrostomy is to be performed may aid in the
*Supported in part by the Mollie and Harry Grekmburg Gift for Research.
FIGURE 1. Drawing shows completed ureteral anastomosis in relation to surrounding anatomic structures.
UROLOGY
/ APRIL 1976 / VOLUME
VII,
NUMBER 4
was thought that urinary diversion with subsequent radio- and chemotherapy would be the optimal therapy. However, the patient was unable to manage an external urinary appliance, therefore a unilateral ureteroureterostomy with a solitary nephrostomy was performed. Postoperatively she did well and renal function improved, with a decrease in blood urea nitrogen to 22 mg. and creatinine to 1.5 mg per 100 ml. Case 2
FIGURE
2.
Postoperative
j&n
showing improved
radiologic function.
An incision is made in the posterior peritoneum and both ureters are isolated and incised in their midportions. Care is taken to preserve the ureteral mesentery on each side. A large retroperitoneal tunnel is made anterior to the aorta and preferably above the inferior mesenteric artery. The ureters are anastomosed end to end with interrupted 4-O chromic catgut. A drain is placed to the area and brought out through a stab wound. A 24 Silastic nephrostomy tube is placed in the kidney with the better pelvis. Care must be taken in placing the nephrostomy tube. The ureter has been cut distally and if the blood supply to the pelvis is compromised during placement of the nephrostomy, we could be left with a devitalized segment of ureter. We have not used ureteral splints, and the drains are left in place for seven to ten days. The operating time is short, and the Silastic nephrostomy tubes have been left in place for periods of four to six months with no incrustations noted (Fig. 1). Case Reports
Case 1 A seventy-year-old female was first seen in February, 1974, when a diagnosis of squamous cell cancer of the bladder was made. Intravenous pyelogram showed marked bilateral hydroRenal function was comureteronephrosis. promised, with a blood urea nitrogen of 90 mg. and creatinine of5 mg. per 100 ml. After complete evaluation and supportive medical treatment, it
UROLOGY
/ APRIL1976 / VOLUME
VII.NUMBER-I
An eighty-six-year-old white male had had 6,500 rads for invasive cancer of the bladder. Later a recurrent tumor developed with severe radiation cystitis. The patient had massive bleeding requiring multiple transfusions. He was treated conservatively but failed to respond to medical management. He underwent a left nephrostomy and transureteroureterostomy. His hypogastric arteries were ligated in situ. Postoperatively he did well and required no further transfusions. However, he eventually died of the bladder cancer. Case 3 A fifty-six-year-old white female fifteen years previously had had a pelvic exenteration with ileal conduit and colostomy for carcinoma of the cervix. She had recently been explored because of bowel obstruction and had had a urinary stoma revised twice. At no time was recurrent tumor ever documented. She was admitted to the hospital in extreme acidosis and found to have a urinary fistula to her colostomy. After initial diverting nephrostomies she was finally stabilized and definitive surgery was performed. At exploration the proximal end of the conduit and ureters were found to be involved with a large fistulous mass. After excising this we were left with two short ureters and a small piece of conduit still anastomosed to the skin. She had an end to end transureteroureterostomy and the proximal end of her ileal conduit was anastomosed to the side of the right ureter. One year postoperatively she is well. Comment Urinary diversion with the use of ureteroureterostomy combined with a nephrostomy tube is a relatively simple operative procedure and does not require prolonged anesthesia. Another major advantage is that (in a previously radiated lower abdomen in a poor-risk patient) no intestinal anastomosis is required. If bleeding
367
from a cancerous bladder is a problem, the hypogastric arteries can be ligated at the same time, as described in Case 2. When ureteroureterostomy was first described, one of the theoretical problems was the necessity for antiperistaltic flow of urine, namely down one ureter and up the other. However, subsequent tine studies have shown that the collecting system empties itself and that while there may be both antegrade and retrograde peristalsis, it causes no problem. Our postoperative studies have shown that there is usually an improvement radiographitally, in the degree of dilation of the upper tracts (Fig. 2). In this postoperative intravenous pyelogram the patient had massive bilateral hydroureteronephrosis with a blood urea nitrogen of 100 mg. per 100 ml. His blood urea nitrogen is now in the upper 20s and his renal function has remained stable. We have noted no patient whose renal function has deteriorated further. The introduction of improved catheter materials, such
368
as Silastic, often allows one to leave the nephrostomy tube in place for four to six months before replacing it. For example, the Silastic threewinged Malecot catheter used in Case 1 remained in place four months before it was changed. Ureteroureterostomy with unilateral nephrostomy is proposed as an alternative method for urinary diversion. Patients who are elderly, or for medical or social reasons could not tolerate an external appliance, may respond well to this operation. In those selected patients, we believe it is a simple, effective method for urinary diversion. 620 West 168th Street New York, New York 10032 (DR. WECHSLER) References 1. ANDERSON,H. U., HODGES,C. U., BEHNAM,A. M., and OCKER, J. M., JR.: Transureteroureterostomy: experimental and clinical experiences, J. Urol. 83: 593 (1960). 2. ARNOLD, T. L., and GARRETT, N.: Ureteroureterostomy and unilateral nephrostomy, ibid. 102: 316 (1969).
UROLOGY I APRIL 1976 / VOLUME VII, NUMBER 4
