Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
CONTINENT CECOILEAL CONDUIT: PRELIMINARY REPORT E. ZINGG
AND
R. TSCHOLL*
From the Department of Urology, I nselspital, University of Bern, Bern, Switzerland
ABSTRACT
A continent cecoileal conduit to improve rehabilitation after external urinary diversion is described. The isolated cecum functions as a reservoir. The continence mechanism is constructed by intussuscepting the terminal ileum into the isolated cecum to form a nipple, preventing leakage of urine. The kidneys are protected from cecoureterorenal reflux by ureterocecostomies with submucous tunnels. We have used this technique on 4 patients, 2 of whom need no external urinary pouch since the urostoma is absolutely continent. One patient became incontinent 3 months postoperatively and is wearing a conventional bag and 1 patient died. There is no reflux into the kidneys. The upper urinary tract, which is dilated s1ightly 4 weeks postoperatively, tends to become normal after a few months. Urinary diversion with a continent urostoma is still one of the main challenges of urologic surgery. Ileal and colon conduits are reliable procedures to guarantee renal outflow and, thus, may save lives. However, the conventional urostoma often makes the life of a sensitive person distressing and proper stoma care can be too difficult for old and disabled people. Optimal rehabilitation would be easier without the appliance and urinary bag. The first technique of external urinary diversion in an attempt to achieve continence was described by Gilchrist and associates in 1950. 1 They used the isolated ileocecal segment. The cecum functioned as a urinary reservoir and the ileum formed the outflow tract and the cutaneous urostoma. Continence was based upon the ileocecal valve and the ileal peristalsis running from the stoma to the cecum. The evacuation by self-catheterization through a long ileum was sometimes tricky. In addition, the retrograde peristalsis apparently could not ensure a reliable closure of the distal outflow tract in every patient. 2 These 2 experiences probably prevented the Gilchrist procedure from becoming generally accepted. Therefore, another principle to maintain continence that would be more reliable than retrograde peristalsis had to be found. Such a principle had, in fact, been devised in 1949 by Perl, who described a continent jejunostomy "permitting the introduction of a feeding tu0e but preventing the escape of the intestinal contents after the tube is removed".:i Perl formed a conical valve, which looked like a nipple, by intussusception of a bowel segment (fig. 1). In 1955 Smith and Hinman used this nipple for an "intussuscepted ileal cystostomy" and found that it not only prevented leakage of intestinal contents from the bowel, as shown by Perl, but also checked the escape of urine from the bladder. 4 The same method of bowel intussusception was adapted by Kock for an "ileostoma without external appliance"." The ileostoma consists of an ileal pouch built according to a procedure reported on by Blandy in 1961. 6 The method avoids an ileus situation and the nipple described by PerI,:J which is the essential element for achieving fecal continence. By adapting the continent ileostomy to the needs of urinary diversion Leisinger and associates created the "continent ileal bladder" in 1976. 7 They added a second nipple between the reservoir and the ureteroileostomy to prevent reflux from the pouch into the kidneys. The surgical construction of the ileal pouch is time-consuming and must be done carefully. Therefore, we tried to simplify the procedure by replacing the ileal Accepted for publication December 3, 1976. *Requests for reprints: Department of Urology, Inselspital, CH3010 Bern, Switzerland.
pouch with a natural reservoir that would not have to be constructed, such as the cecum, and combining it with the nipple, which would ensure continence. An appliance-free ileocecal urinary diversion described by Ashken in 1974 used the cecum as a reservoir. 8 The ureters were implanted into the terminal segment of the ileum, which had been isolated together with the cecum. To build the continent outflow tract another ileal segment had to be isolated, 1 part of which was intussuscepted to form a nipple protruding into the cecum and the other part of which formed
Fm. 1. Perl's continent feeding jejunostomy. Reprinted with permission. 3 724
725
CONTINENT CECOJLEAL CONDUIT
Fm. 2. A, ileocecal segment to be isolated and removed from bowel continuity. B, coagulated area of ileum. C, maintaining nipple in its position. D, nipple after intussusception and rotation of continent cecoileal conduit after completed.
the urostoma. must be connected to the cecum was further We the same h1c•rt.,mP reservoir rn.ade of cecum and a continent be realized more implanting the ureters into the cecum and using terminal ileum to create the nipple-shaped continence valve and the urostorna.
nro0 m,rc,rl
emerge near to where the enteric walls folded each other. 'I'hese sutures are applied on the 3 sides of nipple where there is no mesen-tery. Both ureters are brought to the dorsal wall of the cecal. pouch and along submucous tunnels to their site of tion. The uretero-ascendostomies are intubated with vinyl splints. The are through the the rest of the isolated ileum, which will form the through the abdominal wall and the urostoma. The nal cecotomy is closed in 2 A small round piece of and of the excised from the right lower abdominal leading into the pouch is which requires a rotation about the isolated bowel (figs 2, D and 3). The cecoileal conduit made to adhere to the ventral parietal peritoneum a circle of 2 or 3-zero silk around the base of nipple, La,ou~HLU5 the cecal the inner surface of the abdominal in the area around the urostoma. The fixation of the conduit must be cumi,r,,ce,u while a 20 to 25F rectal tube is inserted into the cecum. Thus, the urostoma on the base of the nipple and its opening on the inside are into a straight line. This is necessary to enable patient to catheterize himself easily. The pouch is fixed to the dorsal ,vµ .. , __ ,,,_ ·where it touches when it from its ventral attachment localized around the stoma. will direct the toward the center of the reservoir. All peritoneal and mesenteric gaps, en1;,e1cwuv between the right abdominal wall and the conduit, are closed The area of the abdominal around drained. ~ucu,uc,,o
OPERATIVE TECHNIQUE
Both ureters are dissected as far distally as vv,ocu,uHo and divided. The terminal 15 to 20 cm. of the ileum and the colon ascendens are mobilized and removed from the the bowel (fig. 2, A). The bowel ·v~i,v,,,~, lS 'l"•"'""'""rl The distal end of isolated colon The distal 12 cm. of the the construction of the contincoagulation of the seromuscular later a.uHc"",''J-' (fig. 2, B). Then the cecum is - - -... , -. . .J on its antimesenteric side. maintain the continence valve in its position 2 sutures (2 or 3-zero silk) are nrPn,c,rprl before the valve is formed. The sutures extend from the cecur.n near the ileal mouth outward to the proximal end of the coagulated ileal segment, where the seromuscularis. re-enter the at which emerged 2, C). Now 6 cm. into the cecal created ileal the cecum. is stabilized by the 2 prepared sutures 2 or 3-zero silk sutures that the the surface to reach its inner lumen and to re-
726
ZINGG AND TSCHOLL POSTOPERATIVE CARE
For 7 days postoperatively the patient receives all necessary fluid and calories by means of a central venous catheter, even if the bowel resumes activity earlier. The liquid supply is sufficient to ensure a diuresis of about 3,000 ml. daily and the
caloric supply amounts to 2,000 to 2,500 calories daily. Amino acids also are administered. The ureteral splints are removed after 2 weeks and the catheter or the rectal tube draining the pouch is withdrawn after 3 weeks. Initially, the pouch is emptied every 2 hours day and night. Within 1 to 2 weeks the intervals determined by the intraabdominal sensation of tension increase to 3 to 5 hours. Soon the patient is taught to evacuate the pouch by self-catheterization. RESULTS
FIG. 3. Situation after operation is completed
Four patients, 2 men and 2 women, were operated upon. The indications for urinary diversion included carcinoma of the bladder (T3Nl with massive bleeding), carcinoma of the urethra, carcinoma of the bladder and neurogenic incontinence secondary to L4 to L5 myelomeningocele. In all 4 patients a continent cecoileal conduit was created according to the procedure described. In 1 patient total cystectomy was done at the same time. Convalescence was complicated in the patient who had had simultaneous cystectomy and urinary diversion. Because of generalized peritonitis an additional operation was necessary. A bowel segment torn into the cystectomy cavity became necrotic, possibly secondary to twisting and strangulation of the mesentery. The damaged gut was resected but the patient died of sepsis and pneumonia. In 1 patient a cecocutaneous fistula occurred 23 days postoperatively. The fistula closed spontaneously after 4 days of continuous drainage. The other 2 patients enjoyed an uneventful convalescence. Continence was maintained in all patients initially. Two have remained continent after 14 and 5 months, respectively, but in 1 woman leakage began after 3 months. Endoscopy showed that the nipple was in place but it seemed to be slightly shrunken. Emptying of the urinary reservoir by self-catheterization usually has been easy but occasionally it was difficult if the pouch had become overdistended and the nipple compressed accordingly. The capacity is limited subjectively by a sensation of fullness and tension. It varies between 450 and 700 ml.
FIG. 4. Case 4. A, retrograde filling of cecal pouch. There is no reflux. B, cecal pouch after self-catheterization. There is no residual urine
CONTINENT CECOILEAL CONDUIT
Fm. IVPs. A, case 1 7 months after continent cecoileal conduit. Upper tracts are normal. B, case 4,, 5 months after continent conduit. Right upper is normal but left one is dilated slightly.
no
a normal upper tract on dilated ureters and calices on the 5,En hnrCl'f(W'V LUU.>WC5'-' are normal in both continent ~-·"~,,~"'"~ acidosis 110.2 millival bicarbonate 17.5 millival per 1.) in l urine from the cecum is infected in 1 richia coli) without clinical vu.u•,,w, but the urine is sterile in the DISCUSSION
conduit can be achieved of the distal 1) if the
of the ileum into the cecum creates the sense that the spontaneous thus, stabilizes Renal function is not w,cuu.ucy is a true reservoir if are nr·rW,e>
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
CONTINENT CECOILEAL CONDUIT: PRELIMINARY REPORT E. ZINGG
AND
R. TSCHOLL*
From the Department of Urology, I nselspital, University of Bern, Bern, Switzerland
ABSTRACT
A continent cecoileal conduit to improve rehabilitation after external urinary diversion is described. The isolated cecum functions as a reservoir. The continence mechanism is constructed by intussuscepting the terminal ileum into the isolated cecum to form a nipple, preventing leakage of urine. The kidneys are protected from cecoureterorenal reflux by ureterocecostomies with submucous tunnels. We have used this technique on 4 patients, 2 of whom need no external urinary pouch since the urostoma is absolutely continent. One patient became incontinent 3 months postoperatively and is wearing a conventional bag and 1 patient died. There is no reflux into the kidneys. The upper urinary tract, which is dilated s1ightly 4 weeks postoperatively, tends to become normal after a few months. Urinary diversion with a continent urostoma is still one of the main challenges of urologic surgery. Ileal and colon conduits are reliable procedures to guarantee renal outflow and, thus, may save lives. However, the conventional urostoma often makes the life of a sensitive person distressing and proper stoma care can be too difficult for old and disabled people. Optimal rehabilitation would be easier without the appliance and urinary bag. The first technique of external urinary diversion in an attempt to achieve continence was described by Gilchrist and associates in 1950. 1 They used the isolated ileocecal segment. The cecum functioned as a urinary reservoir and the ileum formed the outflow tract and the cutaneous urostoma. Continence was based upon the ileocecal valve and the ileal peristalsis running from the stoma to the cecum. The evacuation by self-catheterization through a long ileum was sometimes tricky. In addition, the retrograde peristalsis apparently could not ensure a reliable closure of the distal outflow tract in every patient. 2 These 2 experiences probably prevented the Gilchrist procedure from becoming generally accepted. Therefore, another principle to maintain continence that would be more reliable than retrograde peristalsis had to be found. Such a principle had, in fact, been devised in 1949 by Perl, who described a continent jejunostomy "permitting the introduction of a feeding tu0e but preventing the escape of the intestinal contents after the tube is removed".:i Perl formed a conical valve, which looked like a nipple, by intussusception of a bowel segment (fig. 1). In 1955 Smith and Hinman used this nipple for an "intussuscepted ileal cystostomy" and found that it not only prevented leakage of intestinal contents from the bowel, as shown by Perl, but also checked the escape of urine from the bladder. 4 The same method of bowel intussusception was adapted by Kock for an "ileostoma without external appliance"." The ileostoma consists of an ileal pouch built according to a procedure reported on by Blandy in 1961. 6 The method avoids an ileus situation and the nipple described by PerI,:J which is the essential element for achieving fecal continence. By adapting the continent ileostomy to the needs of urinary diversion Leisinger and associates created the "continent ileal bladder" in 1976. 7 They added a second nipple between the reservoir and the ureteroileostomy to prevent reflux from the pouch into the kidneys. The surgical construction of the ileal pouch is time-consuming and must be done carefully. Therefore, we tried to simplify the procedure by replacing the ileal Accepted for publication December 3, 1976. *Requests for reprints: Department of Urology, Inselspital, CH3010 Bern, Switzerland.
pouch with a natural reservoir that would not have to be constructed, such as the cecum, and combining it with the nipple, which would ensure continence. An appliance-free ileocecal urinary diversion described by Ashken in 1974 used the cecum as a reservoir. 8 The ureters were implanted into the terminal segment of the ileum, which had been isolated together with the cecum. To build the continent outflow tract another ileal segment had to be isolated, 1 part of which was intussuscepted to form a nipple protruding into the cecum and the other part of which formed
Fm. 1. Perl's continent feeding jejunostomy. Reprinted with permission. 3 724
725
CONTINENT CECOJLEAL CONDUIT
Fm. 2. A, ileocecal segment to be isolated and removed from bowel continuity. B, coagulated area of ileum. C, maintaining nipple in its position. D, nipple after intussusception and rotation of continent cecoileal conduit after completed.
the urostoma. must be connected to the cecum was further We the same h1c•rt.,mP reservoir rn.ade of cecum and a continent be realized more implanting the ureters into the cecum and using terminal ileum to create the nipple-shaped continence valve and the urostorna.
nro0 m,rc,rl
emerge near to where the enteric walls folded each other. 'I'hese sutures are applied on the 3 sides of nipple where there is no mesen-tery. Both ureters are brought to the dorsal wall of the cecal. pouch and along submucous tunnels to their site of tion. The uretero-ascendostomies are intubated with vinyl splints. The are through the the rest of the isolated ileum, which will form the through the abdominal wall and the urostoma. The nal cecotomy is closed in 2 A small round piece of and of the excised from the right lower abdominal leading into the pouch is which requires a rotation about the isolated bowel (figs 2, D and 3). The cecoileal conduit made to adhere to the ventral parietal peritoneum a circle of 2 or 3-zero silk around the base of nipple, La,ou~HLU5 the cecal the inner surface of the abdominal in the area around the urostoma. The fixation of the conduit must be cumi,r,,ce,u while a 20 to 25F rectal tube is inserted into the cecum. Thus, the urostoma on the base of the nipple and its opening on the inside are into a straight line. This is necessary to enable patient to catheterize himself easily. The pouch is fixed to the dorsal ,vµ .. , __ ,,,_ ·where it touches when it from its ventral attachment localized around the stoma. will direct the toward the center of the reservoir. All peritoneal and mesenteric gaps, en1;,e1cwuv between the right abdominal wall and the conduit, are closed The area of the abdominal around drained. ~ucu,uc,,o
OPERATIVE TECHNIQUE
Both ureters are dissected as far distally as vv,ocu,uHo and divided. The terminal 15 to 20 cm. of the ileum and the colon ascendens are mobilized and removed from the the bowel (fig. 2, A). The bowel ·v~i,v,,,~, lS 'l"•"'""'""rl The distal end of isolated colon The distal 12 cm. of the the construction of the contincoagulation of the seromuscular later a.uHc"",''J-' (fig. 2, B). Then the cecum is - - -... , -. . .J on its antimesenteric side. maintain the continence valve in its position 2 sutures (2 or 3-zero silk) are nrPn,c,rprl before the valve is formed. The sutures extend from the cecur.n near the ileal mouth outward to the proximal end of the coagulated ileal segment, where the seromuscularis. re-enter the at which emerged 2, C). Now 6 cm. into the cecal created ileal the cecum. is stabilized by the 2 prepared sutures 2 or 3-zero silk sutures that the the surface to reach its inner lumen and to re-
726
ZINGG AND TSCHOLL POSTOPERATIVE CARE
For 7 days postoperatively the patient receives all necessary fluid and calories by means of a central venous catheter, even if the bowel resumes activity earlier. The liquid supply is sufficient to ensure a diuresis of about 3,000 ml. daily and the
caloric supply amounts to 2,000 to 2,500 calories daily. Amino acids also are administered. The ureteral splints are removed after 2 weeks and the catheter or the rectal tube draining the pouch is withdrawn after 3 weeks. Initially, the pouch is emptied every 2 hours day and night. Within 1 to 2 weeks the intervals determined by the intraabdominal sensation of tension increase to 3 to 5 hours. Soon the patient is taught to evacuate the pouch by self-catheterization. RESULTS
FIG. 3. Situation after operation is completed
Four patients, 2 men and 2 women, were operated upon. The indications for urinary diversion included carcinoma of the bladder (T3Nl with massive bleeding), carcinoma of the urethra, carcinoma of the bladder and neurogenic incontinence secondary to L4 to L5 myelomeningocele. In all 4 patients a continent cecoileal conduit was created according to the procedure described. In 1 patient total cystectomy was done at the same time. Convalescence was complicated in the patient who had had simultaneous cystectomy and urinary diversion. Because of generalized peritonitis an additional operation was necessary. A bowel segment torn into the cystectomy cavity became necrotic, possibly secondary to twisting and strangulation of the mesentery. The damaged gut was resected but the patient died of sepsis and pneumonia. In 1 patient a cecocutaneous fistula occurred 23 days postoperatively. The fistula closed spontaneously after 4 days of continuous drainage. The other 2 patients enjoyed an uneventful convalescence. Continence was maintained in all patients initially. Two have remained continent after 14 and 5 months, respectively, but in 1 woman leakage began after 3 months. Endoscopy showed that the nipple was in place but it seemed to be slightly shrunken. Emptying of the urinary reservoir by self-catheterization usually has been easy but occasionally it was difficult if the pouch had become overdistended and the nipple compressed accordingly. The capacity is limited subjectively by a sensation of fullness and tension. It varies between 450 and 700 ml.
FIG. 4. Case 4. A, retrograde filling of cecal pouch. There is no reflux. B, cecal pouch after self-catheterization. There is no residual urine
CONTINENT CECOILEAL CONDUIT
Fm. IVPs. A, case 1 7 months after continent cecoileal conduit. Upper tracts are normal. B, case 4,, 5 months after continent conduit. Right upper is normal but left one is dilated slightly.
no
a normal upper tract on dilated ureters and calices on the 5,En hnrCl'f(W'V LUU.>WC5'-' are normal in both continent ~-·"~,,~"'"~ acidosis 110.2 millival bicarbonate 17.5 millival per 1.) in l urine from the cecum is infected in 1 richia coli) without clinical vu.u•,,w, but the urine is sterile in the DISCUSSION
conduit can be achieved of the distal 1) if the
of the ileum into the cecum creates the sense that the spontaneous thus, stabilizes Renal function is not w,cuu.ucy is a true reservoir if are nr·rW,e>
