Vol. 113, April
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
VESICOURETEROPLASTY IN THE PARAPLEGIC: LONG-TERM FOLLOWUP IN PATIENTS
77
RICHARD W. REECE AND ROBERT H. HACKLER
From the Section of Urology, Surgical Service, McGuire Veterans Administration Hospital, Richmond, Virginia
Irreversible vesicoureteral reflux will develop in 13 to 15 per cent of the spinal cord injury patients after 10 years of paraplegic life. 1 • 2 The association of permanent reflux with upper tract dilatation, pyelonephritis and ultimately renal failure was noted in a study from this hospital in the late 1940s. 3 More than 60 per cent of the paraplegic patients who died of renal failure had reflux. 4 Although a greatly debated topic in the 1950s, the deleterious effects of infected refluxing urine are now well established. Because of the insidious effect of irreversible reflux in the paraplegic, Hutch in collaboration with Bunts designed the first true antireflux procedure in the early 1950s (Hutch I). 1,
5
METHOD AND MATERIALS
In the last 23 years 90 spinal cord injury patients from more than 2,000 evaluated have undergone vesicoureteroplasties for reflux at our hospital. Our study included 77 patients who had had a urological evaluation in the last 2 years or had died and the charts were complete. INDICATIONS
The individual must have permanent (irreversible) reflux. We accept as diagnostic 3 consecutive positive cystograms during a 3-month period despite good bladder hygiene and appropriate antibiotic therapy. The bladder must have enough capacity to act as a reservoir (at least 150 cc). The patient must have a good reflex (balanced) bladder, that is he must be able to consistently empty the bladder with minimal residual urine (100 to 150 cc). The upper urinary tract should be essentially normal. TECHNIQUE
We have continued to use the Hutch I vesicoureteroplasty except for the fact that the mucosa is left open. Most modifications of the Hutch I Accepted for publication July 5, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. 1 Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. Urol., 68: 457, 1952. 2 Bunts, R. C.: Vesicoureteral reflux in paraplegic patients. J. Urol., 79: 747, 1958. 3 Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: hydronephrosis due to vesico-ureteral reflux. J. Urol., 61: 870, 1949. • Hackler, R. H.: Spinal cord injuries. Urologic care. Urology, 2: 13, 1973. 6 Hutch, J. A.: A 20-year experience with surgery for ureteral reflux. MCV/Q, 9: 207, 1973.
procedure have been done strictly intravesically and usually for non-neurogenic disease.•. 7 Good results are reported especially if the ureter is normal or only minimally dilated. •- 10 However, in the paraplegic patient we continue to do most of our dissection extravesically and then complete the dissection intravesically. With a ureteral catheter in place the mucosa superior and lateral to the meatus is incised (part 1 of figure). The entire distal ureter is then mobilized extravesically except for its attachment to the trigone (part 2 of figure). The opening in the detrusor should be long enough to allow 2 ½ to 3 cm. of extravesical ureter to be brought into the bladder (part 3 of figure). Detrusor muscle is sutured under this using about 3, 3-zero chromic atraumatic catgut interrupted sutures. The mucosa is left open (part 4 of figure). The new floor is then reinforced extravesically (part 5 of figure). To prevent postoperative obstruction the detrusor muscle must be sutured loosely in the area of the new ureteral hiatus. Tunneling procedures have been generally unsuccessful in our hands and this could be related to the difficulty in dissecting the mucosa from the detrusor in a chronically infected bladder (commonly seen in the paraplegic). RESULTS
Vesicoureteroplasties were performed on 77 patients. The over-all success rate per ureter was 73 per cent. Unilateral vesicoureteroplasty was performed in 29 patients and 24 procedures were successful (83 per cent), with an average followup of 8.7 years. Bilateral procedures were done in 46 patients, with an average followup of 9.4 years. Of these patients 24 no longer have reflux, 17 had residual reflux unilaterally and 5 have reflux bilaterally. In terms of ureters, 92 were operated upon and 65 were successful. Failure is not always immediate but may be found several years later. 'Jewett, H. J.: Symposium on pediatric urology: upper urinary tract obstructions in infants and children; diagnosis and treatment. Pediat. Clin. N. Amer., 2: 737, 1955. 7 Ambrose, S. S. and Nicolson, W. P.: Vesicoureteral reflux secondary to anomalies of the ureterovesical junction: management and results. J. Urol., 87: 695, 1962. 'Palk en, M.: Surgical correction of vesicoureteral reflux in children: results with the use of a single standard technique. J. Urol., 104: 765, 1970. 9 Hutch, J. A., Smith, D.R. and Osborne, R.: Review of a series of ureterovesicoplasties. J. Urol., 100: 285, 1968. '°Williams, D. I. and Eckstein, H.B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965.
474
47!5
VESICOURETEROPLASTY IN PARAPLEGICS
ureter and uremia secondary to high residual urine. The kidneys deteriorated because of der decompensation although the vesicoureteroplasty was successful. COMPLICATIONS
Significant early complications included 2 operative deaths from sepsis. Obstruction oped in a few cases performed Hutch and Bunts in the early 1950s. Bunts believes that the obstruction was caused by tight suturing beneath the travesical ureter at its new hiatus angulation. 11 Since the Hutch I operation has been modified there has been no obstruction. During the 23-year period 23 patients have If one combines the 8 renal deaths with the 6 deaths of unknown etiology, one finds that 12 these 14 patients were on catheters. Of the 2 tients on external drainage, 1 died of renal failure secondary to amyloidosis 17 years n~o,,,~,,~n and the other death was of unknown reasons" DISCUSSION
The figures given are for the most recent cystogram. Repeat vesicoureteroplasty failed in 5 of 6 patients. More than 90 per cent of the renal units with successful vesicoureteroplasty of the ureter remained stable, that is zero to minimal dilatation. There were 27 patients who continued to have reflux postoperatively and 80 per cent demonstrated continued deterioration of the upper tracts despite catheter drainage. There are 36 patients on external urinary appliance drainage (or they were at the time of death). In 9 patients in which 1 side failed after bilateral vesicoureteroplasty, a transureteroureterostomy eliminated the reflux and thereby maintained the catheter-free status. Thirty-three patients are currently maintained by a Foley catheter (or they were at the time of death). Seventeen had successful operations and had been on external drainage for a prolonged period only to have the bladder decompensate. Decompensation was often associated with formation and care of decubitus ulcers. Upper tract status was maintained in these catheter patients with successful vesicoureteroplasty. Three patients have undergone ilea! conduits. These patients were interesting since all had undergone successful bilateral vesicoureteroplasty and were without a catheter for more than 15 years. were lost to followup from 3 to 5 years and returned with massive hydronephrosis, hydro-
Long-term followup has demonstrated that tients requiring indwelling catheters because reflux, poor voiding potential or lower tract complications have more damage to the upper tracts and significantly lower survival rates than those without catheters. 12 The paraplegic on catheter drainage because of reflux has the worse prognosis. 13 If the reflux could be corrected then the patient with a good reflex bladder would be free of the catheter. Vesicoureteroplasty is not recommended when the catheter must be maintained, which is often owing to a thick walled (contracted) and bladder. The initial success rate may be but increasing spasticity can lead to failure. A sacral nerve interruption procedure may voiding potential to the point at which the patient could be rendered free of the catheter if the reflux was also corrected. 14 IleaI conduit diversion reserved for those patients in whom the more conservative approaches have failed to protect the upper urinary tracts. 4 Antireflux procedures in the paraplegic have been tried elsewhere with less than results. 15 • 16 This study demonstrates a success rate Bunts, R. C.: Personal communication. Donnelly, J., Hackler, R. H. and Bunts, R. Present urologic status of the World War II paraplegic: 25-year fo!lowup. Comparison with status of the 20-year Korean War paraplegic and 5-year Vietnam paraplegic, J. Urol., 108: 558, 1972. 13 Hackler, R.H., Dalton, J. J., Jr. and Changing concepts in the preservation of renal in the paraplegic. J. Urol., 94: 107, 1965. 14 Misak, S. J., Bunts, R. C., Ulmer, J. L. and W. M.: Nerve interruption procedures in the management of paraplegic patients. J. Urol., 88: 1962. 15 Ross, J. C.: Surgical treatment of hydronephrosis iri paraplegia. Paraplegia, 1: 137, 1963. "Tarabulcy, E., Morales, P. and Sullivan, J. Fo:o 11 12
476
REECE AND HACKLER
of 83 per cent in the unilateral cases and 70 per cent (per ureter) in the bilateral cases. The most important fact was that only 5 patients had failure of both sides. Transureteroureterostomy has been successful in rendering the patient with unilateral failure free of the catheter. 17 Repeat vesicoureteroplasties have met with little success. Although 90 per cent of thr renal units with successful reimplantation of the ureters remained stable, the necessity of careful close followup cannot be overstated. Hydronephrosis developed in Vesico-ureter reflux in paraplegia: results of various forms of management. Paraplegia, 10: 44, 1972. 17 Malkin, R. B., Schellhammer, P. F. and Hackler, R. H.: Experience with transureteroureterostomy in the paraplegic patient with irreversible vesicoureteral reflux. J. Urol., 112: 181, 1974.
the 3 long-term patients because of high residual unne. SUMMARY
The results of vesicoureteroplasty in 77 spinal cord injury patients during a 23-year period are reviewed. The carefully selected patient must have a good reflex (balanced) neurogenic bladder, that is it would be catheter-free except for the permanent vesicoureteral reflux. Of those patients successfully operated upon 78 per cent are free of the catheter with unchanged upper urinary tracts. Therefore, we believe that vesicoureteroplasty is definitely indicated in the properly selected spinal cord injury patient.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1975 by The Williams & Wilkins Co.
VESICOURETEROPLASTY IN THE PARAPLEGIC: LONG-TERM FOLLOWUP IN PATIENTS
77
RICHARD W. REECE AND ROBERT H. HACKLER
From the Section of Urology, Surgical Service, McGuire Veterans Administration Hospital, Richmond, Virginia
Irreversible vesicoureteral reflux will develop in 13 to 15 per cent of the spinal cord injury patients after 10 years of paraplegic life. 1 • 2 The association of permanent reflux with upper tract dilatation, pyelonephritis and ultimately renal failure was noted in a study from this hospital in the late 1940s. 3 More than 60 per cent of the paraplegic patients who died of renal failure had reflux. 4 Although a greatly debated topic in the 1950s, the deleterious effects of infected refluxing urine are now well established. Because of the insidious effect of irreversible reflux in the paraplegic, Hutch in collaboration with Bunts designed the first true antireflux procedure in the early 1950s (Hutch I). 1,
5
METHOD AND MATERIALS
In the last 23 years 90 spinal cord injury patients from more than 2,000 evaluated have undergone vesicoureteroplasties for reflux at our hospital. Our study included 77 patients who had had a urological evaluation in the last 2 years or had died and the charts were complete. INDICATIONS
The individual must have permanent (irreversible) reflux. We accept as diagnostic 3 consecutive positive cystograms during a 3-month period despite good bladder hygiene and appropriate antibiotic therapy. The bladder must have enough capacity to act as a reservoir (at least 150 cc). The patient must have a good reflex (balanced) bladder, that is he must be able to consistently empty the bladder with minimal residual urine (100 to 150 cc). The upper urinary tract should be essentially normal. TECHNIQUE
We have continued to use the Hutch I vesicoureteroplasty except for the fact that the mucosa is left open. Most modifications of the Hutch I Accepted for publication July 5, 1974. Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. 1 Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. Urol., 68: 457, 1952. 2 Bunts, R. C.: Vesicoureteral reflux in paraplegic patients. J. Urol., 79: 747, 1958. 3 Talbot, H. S. and Bunts, R. C.: Late renal changes in paraplegia: hydronephrosis due to vesico-ureteral reflux. J. Urol., 61: 870, 1949. • Hackler, R. H.: Spinal cord injuries. Urologic care. Urology, 2: 13, 1973. 6 Hutch, J. A.: A 20-year experience with surgery for ureteral reflux. MCV/Q, 9: 207, 1973.
procedure have been done strictly intravesically and usually for non-neurogenic disease.•. 7 Good results are reported especially if the ureter is normal or only minimally dilated. •- 10 However, in the paraplegic patient we continue to do most of our dissection extravesically and then complete the dissection intravesically. With a ureteral catheter in place the mucosa superior and lateral to the meatus is incised (part 1 of figure). The entire distal ureter is then mobilized extravesically except for its attachment to the trigone (part 2 of figure). The opening in the detrusor should be long enough to allow 2 ½ to 3 cm. of extravesical ureter to be brought into the bladder (part 3 of figure). Detrusor muscle is sutured under this using about 3, 3-zero chromic atraumatic catgut interrupted sutures. The mucosa is left open (part 4 of figure). The new floor is then reinforced extravesically (part 5 of figure). To prevent postoperative obstruction the detrusor muscle must be sutured loosely in the area of the new ureteral hiatus. Tunneling procedures have been generally unsuccessful in our hands and this could be related to the difficulty in dissecting the mucosa from the detrusor in a chronically infected bladder (commonly seen in the paraplegic). RESULTS
Vesicoureteroplasties were performed on 77 patients. The over-all success rate per ureter was 73 per cent. Unilateral vesicoureteroplasty was performed in 29 patients and 24 procedures were successful (83 per cent), with an average followup of 8.7 years. Bilateral procedures were done in 46 patients, with an average followup of 9.4 years. Of these patients 24 no longer have reflux, 17 had residual reflux unilaterally and 5 have reflux bilaterally. In terms of ureters, 92 were operated upon and 65 were successful. Failure is not always immediate but may be found several years later. 'Jewett, H. J.: Symposium on pediatric urology: upper urinary tract obstructions in infants and children; diagnosis and treatment. Pediat. Clin. N. Amer., 2: 737, 1955. 7 Ambrose, S. S. and Nicolson, W. P.: Vesicoureteral reflux secondary to anomalies of the ureterovesical junction: management and results. J. Urol., 87: 695, 1962. 'Palk en, M.: Surgical correction of vesicoureteral reflux in children: results with the use of a single standard technique. J. Urol., 104: 765, 1970. 9 Hutch, J. A., Smith, D.R. and Osborne, R.: Review of a series of ureterovesicoplasties. J. Urol., 100: 285, 1968. '°Williams, D. I. and Eckstein, H.B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965.
474
47!5
VESICOURETEROPLASTY IN PARAPLEGICS
ureter and uremia secondary to high residual urine. The kidneys deteriorated because of der decompensation although the vesicoureteroplasty was successful. COMPLICATIONS
Significant early complications included 2 operative deaths from sepsis. Obstruction oped in a few cases performed Hutch and Bunts in the early 1950s. Bunts believes that the obstruction was caused by tight suturing beneath the travesical ureter at its new hiatus angulation. 11 Since the Hutch I operation has been modified there has been no obstruction. During the 23-year period 23 patients have If one combines the 8 renal deaths with the 6 deaths of unknown etiology, one finds that 12 these 14 patients were on catheters. Of the 2 tients on external drainage, 1 died of renal failure secondary to amyloidosis 17 years n~o,,,~,,~n and the other death was of unknown reasons" DISCUSSION
The figures given are for the most recent cystogram. Repeat vesicoureteroplasty failed in 5 of 6 patients. More than 90 per cent of the renal units with successful vesicoureteroplasty of the ureter remained stable, that is zero to minimal dilatation. There were 27 patients who continued to have reflux postoperatively and 80 per cent demonstrated continued deterioration of the upper tracts despite catheter drainage. There are 36 patients on external urinary appliance drainage (or they were at the time of death). In 9 patients in which 1 side failed after bilateral vesicoureteroplasty, a transureteroureterostomy eliminated the reflux and thereby maintained the catheter-free status. Thirty-three patients are currently maintained by a Foley catheter (or they were at the time of death). Seventeen had successful operations and had been on external drainage for a prolonged period only to have the bladder decompensate. Decompensation was often associated with formation and care of decubitus ulcers. Upper tract status was maintained in these catheter patients with successful vesicoureteroplasty. Three patients have undergone ilea! conduits. These patients were interesting since all had undergone successful bilateral vesicoureteroplasty and were without a catheter for more than 15 years. were lost to followup from 3 to 5 years and returned with massive hydronephrosis, hydro-
Long-term followup has demonstrated that tients requiring indwelling catheters because reflux, poor voiding potential or lower tract complications have more damage to the upper tracts and significantly lower survival rates than those without catheters. 12 The paraplegic on catheter drainage because of reflux has the worse prognosis. 13 If the reflux could be corrected then the patient with a good reflex bladder would be free of the catheter. Vesicoureteroplasty is not recommended when the catheter must be maintained, which is often owing to a thick walled (contracted) and bladder. The initial success rate may be but increasing spasticity can lead to failure. A sacral nerve interruption procedure may voiding potential to the point at which the patient could be rendered free of the catheter if the reflux was also corrected. 14 IleaI conduit diversion reserved for those patients in whom the more conservative approaches have failed to protect the upper urinary tracts. 4 Antireflux procedures in the paraplegic have been tried elsewhere with less than results. 15 • 16 This study demonstrates a success rate Bunts, R. C.: Personal communication. Donnelly, J., Hackler, R. H. and Bunts, R. Present urologic status of the World War II paraplegic: 25-year fo!lowup. Comparison with status of the 20-year Korean War paraplegic and 5-year Vietnam paraplegic, J. Urol., 108: 558, 1972. 13 Hackler, R.H., Dalton, J. J., Jr. and Changing concepts in the preservation of renal in the paraplegic. J. Urol., 94: 107, 1965. 14 Misak, S. J., Bunts, R. C., Ulmer, J. L. and W. M.: Nerve interruption procedures in the management of paraplegic patients. J. Urol., 88: 1962. 15 Ross, J. C.: Surgical treatment of hydronephrosis iri paraplegia. Paraplegia, 1: 137, 1963. "Tarabulcy, E., Morales, P. and Sullivan, J. Fo:o 11 12
476
REECE AND HACKLER
of 83 per cent in the unilateral cases and 70 per cent (per ureter) in the bilateral cases. The most important fact was that only 5 patients had failure of both sides. Transureteroureterostomy has been successful in rendering the patient with unilateral failure free of the catheter. 17 Repeat vesicoureteroplasties have met with little success. Although 90 per cent of thr renal units with successful reimplantation of the ureters remained stable, the necessity of careful close followup cannot be overstated. Hydronephrosis developed in Vesico-ureter reflux in paraplegia: results of various forms of management. Paraplegia, 10: 44, 1972. 17 Malkin, R. B., Schellhammer, P. F. and Hackler, R. H.: Experience with transureteroureterostomy in the paraplegic patient with irreversible vesicoureteral reflux. J. Urol., 112: 181, 1974.
the 3 long-term patients because of high residual unne. SUMMARY
The results of vesicoureteroplasty in 77 spinal cord injury patients during a 23-year period are reviewed. The carefully selected patient must have a good reflex (balanced) neurogenic bladder, that is it would be catheter-free except for the permanent vesicoureteral reflux. Of those patients successfully operated upon 78 per cent are free of the catheter with unchanged upper urinary tracts. Therefore, we believe that vesicoureteroplasty is definitely indicated in the properly selected spinal cord injury patient.
