British Journal of Urology (1975), 41, 269-275
Urinary Diversion: the Physiological Rationale for Non-refluxing Colonic Conduits JEROME P. RICHIE and DONALD G. SKINNER
Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles, California
The desirability and necessity of providing patients undergoing urinary diversion with a suitable and practical means of eliminating urine has long taxed the imagination of urologists, especially since the advent of major ablative cancer surgery. Transplantation of the ureters into the intact sigmoid with incorporation of a valve-like mechanism was first performed by Mayo and Coffey in 1912 and described by Coffey (1928). A wide varietyof ureteralanastomosesinto theintact sigmoid was subsequently described, and the popularity of ureterosigmoidostomy increased substantially over the next 40 years. However, not until Ferris and Ode1 (1950) reported on the problems of electrolyte imbalance in these patients was a critical re-evaluation of the problem of urinary diversion undertaken. Since Bricker (1950) popularised the use of an isolated segment of ileum, the ileal loop has largely replaced ureterosigmoidostomy as a bladder substitute. As long-term follow-up data have become available, however, delayed complications resulting from this form of diversion have become increasingly apparent. Mogg (1965) redirected attention to the use of a segment of sigmoid colon as an isolated conduit rather than in continuity with the faecal stream. Whereas Mogg’s group made little effort to create an antirefluxing uretero-intestinal anastomosis, Leadbetter and Clarke (1 955) have clearly shown that this is possible, and the long-term advantage of this alone may prevent the late serious complications of pyelonephritis and calculus formation seen with ileal loops. Recent studies have compared ileal and colonic conduits in man ;however, individual differences in position, acid-base and electrolyte balance, intra-abdominal pressure, and state of hydration make adequate comparison difficult. In order to minimise the number of variables, this study was formulated to compare both small and large bowel conduits in the same experimental animal by creating an ileal conduit from the right kidney and a non-reff uxing colonic conduit from the left kidney (Fig. 1). In addition, this study made possible further evaluation in the dog of the basic physiology of sigmoid loops with tunneled ureters vis-h-vis the traditional ileal loop form of diversion. Materials and Method 16 adult mongrel dogs with normal preoperative creatinine levels and sterile urine cultures were used. After intravenous administration of pentobarbital and a midline incision, 10-cm segments of colon, distal ileum, or both, were isolated, and entero-enterostomy was performed with a two-layer silk anastomosis. The proximal ends of the conduits were closed with inverting two-layer chromic (Parker-Kerr) suture, followed by an interrupted silk layer. All uretero-colonic anastomoses were of the tunneled (3-cm) mucosa-to-mucosa type, as described by Leadbetter and Clarke (1955). All uretero-ileal anastomoses were direct one-layer interrupted mucosa-to-mucosa type without stents. All the conduits were made isoperistaltic. Stomas 2-3 cm in diameter were created for all loops. Antibiotics were administered routinely for 3 days postoperatively. In 5 of these dogs, only 1 kidney was implanted in a loop (3 colonic and 2 ileal); the other kidney remained in continuity with the bladder and thus served as a control. Intravenous pyelograms were obtained at 1 and 3 months postoperatively. Conduitograms were obtained at 6 weeks postoperatively with a 16F Foley catheter and gravity filling (35 cm HzO). Pressure tracings were taken with 4113-c 269
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BRITISH JOURNAL OF UROLOGY
Fig. 1. Schematic drawing of experimental preparation. Right kidney is connected to ileal conduit and left kidney to
tunnelled colonic conduit in the dog.
the Sanborn Polygraph (Model 7702B) connected to Statham strain gauges (0-75 cm Hg). Simultaneous tracings were done in unoccluded loops with 8F plastic feeding catheters and in occluded loops with 16F Foley catheters. After acute occlusion, pressures were recorded simultaneously as saline was introduced into the loops in proportion to the capacity. Functional emptying of the conduits was evaluated by the introduction of Technetium-99mdiethyltriaminopentaceticacid (99"Tc-DTPA) until capacity was reached; serial collections of urinary efflux were collected every 15 minutes and emptying curves charted. Serum creatinine levels were measured at 1 and 3 months postoperatively, and blood and urine specimens were analysed for pH and bicarbonate. All dogs were sacrificed at 3 months postoperatively. Urine cultures were collected at necropsy from conduits, bladder (by needle aspiration), or both, and from both renal pelves. Histologic sections of both kidneys and 'ureters were taken.
Results 15 of the 16 dogs were available for a 3-month follow-up study. One dog among the control group died of wound infection and sepsis. Three instances of stomal stenosis, all occurring in ileal conduits, required surgical revision at 1 month. There were no urine leaks, no intestinal obstructions, and no ureterointestinal obstructions. Radiological Studies Intravenous pyelograms performed at 3 months were normal in all dogs (Fig. 2); 3 with stomal stenosis at 1 month had 2 + dilatation of the right renal pelvis which returned to normal after revision. Conduitograms using equal gravity filling showed free reflux in 11 of the 12 ileal loops and absence of reflux in all 14 colonic loops (Fig. 3).
Chemistry Studies All serum creatinine levels were normal at 3 months postoperatively, and there were no instances ofelevated serum chloride or lowered bicarbonate. Urinary pH collected from both loops or from one loop and bladder showed no significant differences (6*0-6.4), and bicarbonate excretion in all loops was zero.
URINARY DIVERSION
Fig. 2. Dog No. 10 with right ileal and left colonic loops. Normal IVP 3 months after diversion. Fig. 3. Dog No. 7. Conduitogram demonstrates free reflux in ileal conduit (right) and absence of reflux in colonic conduit (left).
Conduit Dynamics Emptying curves showed essentially no difference between colonic and ileal conduits (Fig. 4). Resting pressures were uniformly low in both conduits, averaging 3-4 mm Hg. Peristaltic waves occurred more frequently in ileal conduits, and pressure spikes were higher. After acute occlusion, pressures were elevated more rapidly in the ileum with higher pressure spikes (Fig. 5). Histology Histologic evidence of pyelonephritis was present in 83 % of kidneys connected to ileal conduits, as compared to 7 % of those connected to colonic conduits (P
Urinary Diversion: the Physiological Rationale for Non-refluxing Colonic Conduits JEROME P. RICHIE and DONALD G. SKINNER
Department of Surgery, Division of Urology, UCLA School of Medicine, Los Angeles, California
The desirability and necessity of providing patients undergoing urinary diversion with a suitable and practical means of eliminating urine has long taxed the imagination of urologists, especially since the advent of major ablative cancer surgery. Transplantation of the ureters into the intact sigmoid with incorporation of a valve-like mechanism was first performed by Mayo and Coffey in 1912 and described by Coffey (1928). A wide varietyof ureteralanastomosesinto theintact sigmoid was subsequently described, and the popularity of ureterosigmoidostomy increased substantially over the next 40 years. However, not until Ferris and Ode1 (1950) reported on the problems of electrolyte imbalance in these patients was a critical re-evaluation of the problem of urinary diversion undertaken. Since Bricker (1950) popularised the use of an isolated segment of ileum, the ileal loop has largely replaced ureterosigmoidostomy as a bladder substitute. As long-term follow-up data have become available, however, delayed complications resulting from this form of diversion have become increasingly apparent. Mogg (1965) redirected attention to the use of a segment of sigmoid colon as an isolated conduit rather than in continuity with the faecal stream. Whereas Mogg’s group made little effort to create an antirefluxing uretero-intestinal anastomosis, Leadbetter and Clarke (1 955) have clearly shown that this is possible, and the long-term advantage of this alone may prevent the late serious complications of pyelonephritis and calculus formation seen with ileal loops. Recent studies have compared ileal and colonic conduits in man ;however, individual differences in position, acid-base and electrolyte balance, intra-abdominal pressure, and state of hydration make adequate comparison difficult. In order to minimise the number of variables, this study was formulated to compare both small and large bowel conduits in the same experimental animal by creating an ileal conduit from the right kidney and a non-reff uxing colonic conduit from the left kidney (Fig. 1). In addition, this study made possible further evaluation in the dog of the basic physiology of sigmoid loops with tunneled ureters vis-h-vis the traditional ileal loop form of diversion. Materials and Method 16 adult mongrel dogs with normal preoperative creatinine levels and sterile urine cultures were used. After intravenous administration of pentobarbital and a midline incision, 10-cm segments of colon, distal ileum, or both, were isolated, and entero-enterostomy was performed with a two-layer silk anastomosis. The proximal ends of the conduits were closed with inverting two-layer chromic (Parker-Kerr) suture, followed by an interrupted silk layer. All uretero-colonic anastomoses were of the tunneled (3-cm) mucosa-to-mucosa type, as described by Leadbetter and Clarke (1955). All uretero-ileal anastomoses were direct one-layer interrupted mucosa-to-mucosa type without stents. All the conduits were made isoperistaltic. Stomas 2-3 cm in diameter were created for all loops. Antibiotics were administered routinely for 3 days postoperatively. In 5 of these dogs, only 1 kidney was implanted in a loop (3 colonic and 2 ileal); the other kidney remained in continuity with the bladder and thus served as a control. Intravenous pyelograms were obtained at 1 and 3 months postoperatively. Conduitograms were obtained at 6 weeks postoperatively with a 16F Foley catheter and gravity filling (35 cm HzO). Pressure tracings were taken with 4113-c 269
270
BRITISH JOURNAL OF UROLOGY
Fig. 1. Schematic drawing of experimental preparation. Right kidney is connected to ileal conduit and left kidney to
tunnelled colonic conduit in the dog.
the Sanborn Polygraph (Model 7702B) connected to Statham strain gauges (0-75 cm Hg). Simultaneous tracings were done in unoccluded loops with 8F plastic feeding catheters and in occluded loops with 16F Foley catheters. After acute occlusion, pressures were recorded simultaneously as saline was introduced into the loops in proportion to the capacity. Functional emptying of the conduits was evaluated by the introduction of Technetium-99mdiethyltriaminopentaceticacid (99"Tc-DTPA) until capacity was reached; serial collections of urinary efflux were collected every 15 minutes and emptying curves charted. Serum creatinine levels were measured at 1 and 3 months postoperatively, and blood and urine specimens were analysed for pH and bicarbonate. All dogs were sacrificed at 3 months postoperatively. Urine cultures were collected at necropsy from conduits, bladder (by needle aspiration), or both, and from both renal pelves. Histologic sections of both kidneys and 'ureters were taken.
Results 15 of the 16 dogs were available for a 3-month follow-up study. One dog among the control group died of wound infection and sepsis. Three instances of stomal stenosis, all occurring in ileal conduits, required surgical revision at 1 month. There were no urine leaks, no intestinal obstructions, and no ureterointestinal obstructions. Radiological Studies Intravenous pyelograms performed at 3 months were normal in all dogs (Fig. 2); 3 with stomal stenosis at 1 month had 2 + dilatation of the right renal pelvis which returned to normal after revision. Conduitograms using equal gravity filling showed free reflux in 11 of the 12 ileal loops and absence of reflux in all 14 colonic loops (Fig. 3).
Chemistry Studies All serum creatinine levels were normal at 3 months postoperatively, and there were no instances ofelevated serum chloride or lowered bicarbonate. Urinary pH collected from both loops or from one loop and bladder showed no significant differences (6*0-6.4), and bicarbonate excretion in all loops was zero.
URINARY DIVERSION
Fig. 2. Dog No. 10 with right ileal and left colonic loops. Normal IVP 3 months after diversion. Fig. 3. Dog No. 7. Conduitogram demonstrates free reflux in ileal conduit (right) and absence of reflux in colonic conduit (left).
Conduit Dynamics Emptying curves showed essentially no difference between colonic and ileal conduits (Fig. 4). Resting pressures were uniformly low in both conduits, averaging 3-4 mm Hg. Peristaltic waves occurred more frequently in ileal conduits, and pressure spikes were higher. After acute occlusion, pressures were elevated more rapidly in the ileum with higher pressure spikes (Fig. 5). Histology Histologic evidence of pyelonephritis was present in 83 % of kidneys connected to ileal conduits, as compared to 7 % of those connected to colonic conduits (P
