0022-5347/78/1192-0282$02. 00/0 The Journal of Urology Copyright © 1978 by The Williams & Wilkins Co.
Vol. 119, February Printed in U.SA.
VOLVULUS OF AN !LEAL CONDUIT WITH RETROPERITONEAL URINOMA IN A CHILD: FIRST REPORTED CASE DAVID L. HAROLD
AND
EVAN J. KASS
From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
Heal loop urinary diversion requires long-term followup. A case of an ileal conduit volvulus with a retroperitoneal urinoma 14 years after the initial procedure is reported. A brief discussion oflong and short-term complications ofileal loops is presented. sage of a large bolus of urine. Multiple evaluations at another hospital failed to elicit an etiology. The patient was seen by us during an acute episode. Physical examination revealed a temperature of98.6F, generalized abdominal tenderness and hypoactive bowel sounds. No masses were palpable. The stoma was pink, everted in nipple fashion and easily admitted the fifth finger. The conduit was catheterized for 10 cc of residual urine that subsequently showed no growth on culture. Laboratory values included white blood count 4,100, hematocrit 32.5 volumes per cent,
Tizzoni and Foggi described cutaneous ureteroileostomy in dogs in 1888. Seiffert tried cutaneous ureterojejunostomy in a patient in 1932. 1 In 1950 Bricker reintroduced and popularized ileal conduits. 2 Bill and associates, 3 and Nash4 applied the procedure to children. Soon many series were published extolling the virtues of ileal conduits. It was not until long-term data became available that the excessive number of complications associated with ileal conduits was noted. Herein we report a case of an ileal conduit volvulus with a retroperitoneal urinoma, a long-term complication not described previously.
Fm. 1. A, IVP at 45 minutes shows tortuous ileal loop and mild hydronephrosis. B, loopogram demonstrates loop elongation and free ileal ureteral reflux bilaterally. Distal and proximal loop segments are connected by thin ribbon of contrast medium. Beak sign indicated by arrow. CASE REPORT
K. J. M., UMMC 0039943, a 14-year-old black girl, was born with exstrophy of the bladder. Cystectomy and creation of a cutaneous ureteroileostomy were done when she was 5 months old. No postoperative complications were noted, and the upper tracts and renal function remained normal. Two months before we saw her the patient began having episodes of sharp, cramping, abdominal pain associated with nausea, vomiting and anuria. There was no fever, chills or flank pain noted. These episodes would resolve spontaneously after pasAccepted for publication October 7, 1977. Read at annual meeting of North Central Section, American Urological Association, San Diego, California, November 6-12, 1977.
hemoglobin 11 gm. per cent, serum creatinine 1.1 mg. per cent, blood urea nitrogen 14 mg. per cent and serum electrolytes in mEq./1.: sodium 141, potassium 3.8, chloride 108 and carbon dioxide 24. Serum amylase was within normal limits. An excretory urogram (IVP) showed mild hydroureteronephrosis. Thirty and 45-minute films also revealed collection of contrast medium in a tortuous tubular structure (fig. 1, A). A loopogram demonstrated an elongated ileal loop distally with a narrow ribbon of contrast medium flowing into the proximal loop, which was dilated (fig. 1, B). Fluoroscopy during the IVP showed free flow through the ureteroileal anastomosis but a beak sign diagnostic of a volvulus was noted in the ileal segment (fig. 1, B, arrow). At operation a large cystic mass was noted arising in the
282
VOLVULUS OF XLEAL CONDUIT WITH RETROPERITONEAL URINOMA IN CHILD
283
retroperitoneal space. The intraperitoneal ileum distal to the volvulus appeared normal. A new conduit was fashioned from a short segment of normal ileum, and the excess conduit and old ureterointestinal anastomosis were resected. Postoperatively, an IVP showed resolution of the hydroure-· teronephrosis (fig. 3) and the symptoms were relieved. DISCUSSION
Early complications of Heal conduits in children include intestinal obstruction, ureteroileal anastomotic leak, pyelonephritis, wound infection and dehiscence, and so forth, and occur in up to 27 per cent of the patients. Many of these lems are technical and seem to decrease with refinement of surgical technique. Late complications include stomal problems, pyelonephritis, ureteroileal stenosis, pyocystitis, calculi, elongation of conduit, intestinal obstruction and so forth. These late ----·~-.----tions seem to increase as a function of time and one can expect more complications the longer that children with ileal conduits are folloWl:ld. Pyelographic deterioration also seems to increase as a function of time and has been reported to occur in up to 77 per cent of children with previously normal upper tracts. 5- 12 Our patient with an ileal conduit volvulus is unique. The symptoms of intermittent obstruction of the conduit are col-icky abdominal pain and anuria. Spontaneous remission of the volvulus is heralded by the passage of a large bolus of urine and relief of pain. A volvulus is made possible by the presence of a large mobile segment of bowel that can rotate around a fixed point. The retroperitoneal urinoma accumulated from a perforation through a necrotic segment. A short segment of ileum that is fixed along its entire length is not prone to this problem. Since complications of ileal conduits i.n children increase as a function of time one may expect to see more of these cases. Children with urinary diversions must be followed regularly throughout the rest of their lives. REFERENCES
shows resolution of hydro-
the small bowel cephalad a retroperitoneal urinoma from no,c·fr•""h conduit. The 1,100 cc of aspirated content of 127 mg. per cent and cent, consistent with urine. It yielded no bacteria. on and aerobic culture attempts. The Heal conduit was markedly redundant. The proximal 4 cm_. were fixed re1tro,pent.on,ea.Hy An intraperitoneal length of 20 cm. was noted to be mobile in a rotary had occurred at the junction between the and ret:roperitoneal conduit because of the mobility of the redundant ileum. The ureterointestinal anastomosis was patent. The ret:roperitoneal ileum '-''-',A''-"'" to the was dilated markedly with area.s necrosis with a perforation into the
1. Seiffert, L.: Die "Darm-Siphoblase". Arch. f. Klin. Chir., rn;1,: 569, 1935. 2. Bricker, E. M.: Bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Bill, A.H., Jr., Dillard, D. H., Eggers, H. E. and Jensen, 0., Jr.: Urinary and fecal incontinence due to congenital abnor·malities in children; management by implantation of ureters into isolated ileostomy. Surg., Gynec. & Obst., 98: 575, J.954. 4. Nash, D. F. E.: Heal loop bladder in congenital spinal palsy, Brit. J. Urnl., 28: 387, 1956. 5. Delgado, G. E. and Muecke, E. C.: Evaluation of 80 cases of ileal conduits in children: indication, complication and results. J. UroL, 109: 311, 1973. 6. Logan, C. W., Scott, R., Jr. and Laskowski, T. Z.: Ilea! diversion: evaluation of late results in pediatric urology. UroL, 94: 544, 1965. 7. Smith, E. D.: Follow-up studies on 150 ileal conduits in children, J. Pediat. Surg., 7: 10, 1972. 8. Schwarz, G. R. and Jeffs, R. D.: Ileal conduit urinary diversion in children: computer analysis of followup from 2 to 16 years. J. Urol., 114: 285, 1975. 9. Shapiro, S. R., Lebowitz, R and Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology. J. Urol., 114: 289, 1975. 10. Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ileal segment urinary diversion. Ann. Surg., 167: 367, 1968. 11. Engel, R. M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 12. Middleton, A. W. and Hendren, W. H.: Heal conduits in children at the Massachusetts General Hospital from 1955 to 1970. ,J. Urol., 115: 591, 1976.
Vol. 119, February Printed in U.SA.
VOLVULUS OF AN !LEAL CONDUIT WITH RETROPERITONEAL URINOMA IN A CHILD: FIRST REPORTED CASE DAVID L. HAROLD
AND
EVAN J. KASS
From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
Heal loop urinary diversion requires long-term followup. A case of an ileal conduit volvulus with a retroperitoneal urinoma 14 years after the initial procedure is reported. A brief discussion oflong and short-term complications ofileal loops is presented. sage of a large bolus of urine. Multiple evaluations at another hospital failed to elicit an etiology. The patient was seen by us during an acute episode. Physical examination revealed a temperature of98.6F, generalized abdominal tenderness and hypoactive bowel sounds. No masses were palpable. The stoma was pink, everted in nipple fashion and easily admitted the fifth finger. The conduit was catheterized for 10 cc of residual urine that subsequently showed no growth on culture. Laboratory values included white blood count 4,100, hematocrit 32.5 volumes per cent,
Tizzoni and Foggi described cutaneous ureteroileostomy in dogs in 1888. Seiffert tried cutaneous ureterojejunostomy in a patient in 1932. 1 In 1950 Bricker reintroduced and popularized ileal conduits. 2 Bill and associates, 3 and Nash4 applied the procedure to children. Soon many series were published extolling the virtues of ileal conduits. It was not until long-term data became available that the excessive number of complications associated with ileal conduits was noted. Herein we report a case of an ileal conduit volvulus with a retroperitoneal urinoma, a long-term complication not described previously.
Fm. 1. A, IVP at 45 minutes shows tortuous ileal loop and mild hydronephrosis. B, loopogram demonstrates loop elongation and free ileal ureteral reflux bilaterally. Distal and proximal loop segments are connected by thin ribbon of contrast medium. Beak sign indicated by arrow. CASE REPORT
K. J. M., UMMC 0039943, a 14-year-old black girl, was born with exstrophy of the bladder. Cystectomy and creation of a cutaneous ureteroileostomy were done when she was 5 months old. No postoperative complications were noted, and the upper tracts and renal function remained normal. Two months before we saw her the patient began having episodes of sharp, cramping, abdominal pain associated with nausea, vomiting and anuria. There was no fever, chills or flank pain noted. These episodes would resolve spontaneously after pasAccepted for publication October 7, 1977. Read at annual meeting of North Central Section, American Urological Association, San Diego, California, November 6-12, 1977.
hemoglobin 11 gm. per cent, serum creatinine 1.1 mg. per cent, blood urea nitrogen 14 mg. per cent and serum electrolytes in mEq./1.: sodium 141, potassium 3.8, chloride 108 and carbon dioxide 24. Serum amylase was within normal limits. An excretory urogram (IVP) showed mild hydroureteronephrosis. Thirty and 45-minute films also revealed collection of contrast medium in a tortuous tubular structure (fig. 1, A). A loopogram demonstrated an elongated ileal loop distally with a narrow ribbon of contrast medium flowing into the proximal loop, which was dilated (fig. 1, B). Fluoroscopy during the IVP showed free flow through the ureteroileal anastomosis but a beak sign diagnostic of a volvulus was noted in the ileal segment (fig. 1, B, arrow). At operation a large cystic mass was noted arising in the
282
VOLVULUS OF XLEAL CONDUIT WITH RETROPERITONEAL URINOMA IN CHILD
283
retroperitoneal space. The intraperitoneal ileum distal to the volvulus appeared normal. A new conduit was fashioned from a short segment of normal ileum, and the excess conduit and old ureterointestinal anastomosis were resected. Postoperatively, an IVP showed resolution of the hydroure-· teronephrosis (fig. 3) and the symptoms were relieved. DISCUSSION
Early complications of Heal conduits in children include intestinal obstruction, ureteroileal anastomotic leak, pyelonephritis, wound infection and dehiscence, and so forth, and occur in up to 27 per cent of the patients. Many of these lems are technical and seem to decrease with refinement of surgical technique. Late complications include stomal problems, pyelonephritis, ureteroileal stenosis, pyocystitis, calculi, elongation of conduit, intestinal obstruction and so forth. These late ----·~-.----tions seem to increase as a function of time and one can expect more complications the longer that children with ileal conduits are folloWl:ld. Pyelographic deterioration also seems to increase as a function of time and has been reported to occur in up to 77 per cent of children with previously normal upper tracts. 5- 12 Our patient with an ileal conduit volvulus is unique. The symptoms of intermittent obstruction of the conduit are col-icky abdominal pain and anuria. Spontaneous remission of the volvulus is heralded by the passage of a large bolus of urine and relief of pain. A volvulus is made possible by the presence of a large mobile segment of bowel that can rotate around a fixed point. The retroperitoneal urinoma accumulated from a perforation through a necrotic segment. A short segment of ileum that is fixed along its entire length is not prone to this problem. Since complications of ileal conduits i.n children increase as a function of time one may expect to see more of these cases. Children with urinary diversions must be followed regularly throughout the rest of their lives. REFERENCES
shows resolution of hydro-
the small bowel cephalad a retroperitoneal urinoma from no,c·fr•""h conduit. The 1,100 cc of aspirated content of 127 mg. per cent and cent, consistent with urine. It yielded no bacteria. on and aerobic culture attempts. The Heal conduit was markedly redundant. The proximal 4 cm_. were fixed re1tro,pent.on,ea.Hy An intraperitoneal length of 20 cm. was noted to be mobile in a rotary had occurred at the junction between the and ret:roperitoneal conduit because of the mobility of the redundant ileum. The ureterointestinal anastomosis was patent. The ret:roperitoneal ileum '-''-',A''-"'" to the was dilated markedly with area.s necrosis with a perforation into the
1. Seiffert, L.: Die "Darm-Siphoblase". Arch. f. Klin. Chir., rn;1,: 569, 1935. 2. Bricker, E. M.: Bladder substitution after pelvic evisceration. Surg. Clin. N. Amer., 30: 1511, 1950. 3. Bill, A.H., Jr., Dillard, D. H., Eggers, H. E. and Jensen, 0., Jr.: Urinary and fecal incontinence due to congenital abnor·malities in children; management by implantation of ureters into isolated ileostomy. Surg., Gynec. & Obst., 98: 575, J.954. 4. Nash, D. F. E.: Heal loop bladder in congenital spinal palsy, Brit. J. Urnl., 28: 387, 1956. 5. Delgado, G. E. and Muecke, E. C.: Evaluation of 80 cases of ileal conduits in children: indication, complication and results. J. UroL, 109: 311, 1973. 6. Logan, C. W., Scott, R., Jr. and Laskowski, T. Z.: Ilea! diversion: evaluation of late results in pediatric urology. UroL, 94: 544, 1965. 7. Smith, E. D.: Follow-up studies on 150 ileal conduits in children, J. Pediat. Surg., 7: 10, 1972. 8. Schwarz, G. R. and Jeffs, R. D.: Ileal conduit urinary diversion in children: computer analysis of followup from 2 to 16 years. J. Urol., 114: 285, 1975. 9. Shapiro, S. R., Lebowitz, R and Colodny, A. H.: Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology. J. Urol., 114: 289, 1975. 10. Jaffe, B. M., Bricker, E. M. and Butcher, H. R., Jr.: Surgical complications of ileal segment urinary diversion. Ann. Surg., 167: 367, 1968. 11. Engel, R. M.: Complications of bilateral uretero-ileo cutaneous urinary diversion: a review of 208 cases. J. Urol., 101: 508, 1969. 12. Middleton, A. W. and Hendren, W. H.: Heal conduits in children at the Massachusetts General Hospital from 1955 to 1970. ,J. Urol., 115: 591, 1976.
