Endoscopy of ureterointestinal conduits and retrograde pyelography David B. Falkenstein, Chaim B. Reich, Mircea N. Golimbu, Roger S. Warner, Pablo A. Morales, David S. Zimmon,

MD MD MD MD MD MD

New York, New York

The ureterointestinal conduits of 15 patients were examined using gastrointestinal fiberoptic instruments and techniques. Retrograde pyelography by direct cannulation of ureterointestinal anastomoses was successful in 5 of 7 attempts. Endoscopic instrumentation of upper urinary passages may ultimately be useful in managing postoperative complications in patients with urinary diversion into intestinal loops. The establishmentof a ureterointestinal conduit is a preferred surgical technique for permanent supravesical urinary diversion after radical pelvic surgery for neoplasia and a suitable method for treating non-malignant disease such as neurogenic bladder, congenital urinary anomalies, or intractable lower urinary tract infections.1-3 Complications of urinary diversion by ureterointestinal anastomosis include recurrence of neoplasia in the residual urinary tract, formation of urinary calculi, and stricture at anastomotic sites. 4 - 6 The evaluation of these complications by urologic surgeons may be hampered by inadequate opacification of the urinary tract using standard radiographic techniques and the inability to visualize intestinal conduits and catheterize ureterointestinal anastomoses using urologic endoscopic instruments. This report describes our experience in examining intestinal conduits in 15 patients using fiberoptic gastrointestinal endoscopes. MATERIALS AND METHODS Patients were examined in the supine position on a fluoroscopy table equipped for spotfilm-

ing. After removal of the ostomy appliance, the abdomen surrounding the stoma was pressed to expel retained urine from the intestinal loop. A review of the patient's operative report and available radiographs aided in predicting type, length, and configuration of intestinal loop to be encountered as well as the approximate position of ureteral orifices within the loop. Examination of the intestinal stoma with a lubricated, gloved finger provided an estimation of stomal diameter, allowed gentle dilation of stenotic stomas and indicated the initial direction of the intestinal loop. An endoscope, selected principally for stomal diameter, was thoroughly re-c1eaned using antiseptic solutions. We have not employed gas sterilization for this procedure. After insertion of the tip of the endoscope into the intestinal stoma, an assistant can stabilize the shaft of the advancing endoscope at the stoma to prevent undue stretching during endoscopic manipulation. The assistant may also compress the stoma around the endoscope during air insufflation if

From the Gastroenterology Section, Medical Service and Urology Service, Manhattan Veterans Administration Hospital, and the New York University School of Medicine, New York, New York. Reprint requests: David B. Falkenstein, MD, Manhattan Veterans Administration Hospital, 408 First Avenue, New York, New York 10010. 24

GASTROINTESTINAL ENDOSCOPY

excessive air leak causes inadequate bowel distention. Glucagon, 0.5 mg intravenously, is effective in inhibiting peristalsis in a hyperactive intestinal loop. Urine is suctioned intermittently from the visual field (Figure I a). Ureterointestinal anastomoses appear as 1 mm to 2 mm flat outpouchings from the intestinal wall (Figure I b) or as nippled structures protruding into intestinal lumen (Figure Ic). They can be in close proximity or widely spaced. Ureteral orifices may be identified when urine bubbles from anastomotic sites as gentle suction is appl ied to an air-d istended intestinalloop. For retrograde pyelography, a teflon catheter prefilled with diatrizoate 50% is inserted through the biopsy channel of the endoscope and directed into the ureteral orifice (Figure Id). If available, an elevating lever at the tip of the endoscope (Olympus jF-B, jF-B2, jF-K) is helpful for directing the cannulating catheter. We may try several makes and models of gastrointetinal endoscopes in the same patient to achieve retrograde pyelography. When cannulation is achieved, contrast is injected under careful fluoroscopic control and spot films are taken for radiographic interpretation. RESULTS We examined the intestinal conduits of 15 patients in whom supravesical diversion of urine was created for various urologic indications. Eleven patients had ureteroileal cOjlduits, 2 had ureterocolonic conduits, and 2 had pyelocolonic conduits. The entire length of intestinal loop was visualized in all but 1 patient who had an excessively redundant ileal loop. Both ureterointestinal anastomoses were identified in 12 of 13 cases. In 1 case with pyelocolonic anasc tomosis (pelvis of a hydronephrotic kidney to a colonic segment), an Olympus GIF-P endoscope (outer diameter, 7 mm) was easily passed into the renal pelvis to permit visualization and photography of functioning renal calyces and papillae (Figures le/,g). Retrograde pyelography by cannulation of ureteral orifices was achieved in 5 of 7 attempts and provided excellent radiographic opacification of both the upper urinary tract (Figure 2a) and area of ureterointestinal anastomosis

appreciation of abnormalities that might be encountered is essential for the endoscopist examining intestinal conduits and performing retrograde pyelography. Urinary tract calcu Ii are reported after uri nary diversion into intestinal loops in 4% to 30% of patients. Although the conduit is fashioned to be short and straight, stomal obstruction, conduit lengthening and dilatation, and conduit fibrosis may occur. These factors impede the flow of urine and allow increased chloride-bicarbonate exchange resulting in systemic hyperchloremic acidosis, increased calcium release from bone, and hypercalciuria. When the urine becomes

(Figure 2b).

Patients experienced no pain during endoscopy but most complained of a sensation of costovertebral angle pressure during air insufflation of intestinal loops or retrograde pyelography. This sensation was brief and self-limited. No patient required systemic sedation. We found the intestinal mucosa of conduits to be more fragile than expected when compared to that encountered at routine colonoscopy or duodenoscopy. With minor endoscopic manipulations, mucosal abrasions with petechial bleeding were produced in several patients. This may be related to mucosal villous atrophy reported in intestinal urinary conduits.' These patients were told to expect mild hematuria for 8 hours after the examination. After endoscopy, oral antibiotics were prescribed for 3 days unless the patient was already taking urinary bacteriostatic agents. No patient experienced fever or chi lis after endoscopic exam ination.

DISCUSSION Since Bricker" popularized the use of intestinal conduits for supravesical urinary diversion in 1950 several reviews of collected experiences with this procedure and its modifications have defined trends in postoperative complications. 2 ,',s Although no major postoperative lesions were found in the initial series of patients described here, an VOLUME 22, NO.1, 1975

Figure 1 a, Endoscopic view of ileal conduit. b, Ureterointestinal anastomosis. c, Ureterointestinal anastomosis, nippled-type. d, Catheter in anastomotic orifice. e, Pye/oco/onic anastomosis. f, Two openings of the major calyces visualized from the renal pelvis. g, Close-up of renal papilla. 25

Figure 2 a, Retrograde pyelography. Arrowheads indicate tip of cannulating catheter within renal pelvis. b, Opacification of ureterointestinal anastomosis. Arrowheads indicate catheter tip. alkaline due to the presence of urea-splitting organisms, an environment highly favorable to calculus formation is created." Furthermore, any foreign body (e.g., suture) retained within the intestinal conduit and in contact with the urinary stream may serve as a nidus for stone formation." Obstruction at the ureterointestinal anastomosis because of calculi, inflammatory fibrosis, preoperative radiotherapy, faulty operative technique, or recurrent tumor is a frequent cause of acute or progressive postoperative hydronephrosis and deterioration of renal function.' To identify these complications, frequent radiographic examination of the residual urinary tract has been advocated for the patient with an intestinal conduil.'o The lower portions of the ureters and their course into the intestinal conduit may be poorly demonstrated by standard excretory urography (IVP), particularly when renal function is poor or hydronephrosis is present. Improved radiographic visual ization of the ureteroenteric anastomosis may be achieved by placing the patient in the prone position during IVP." When this maneuver fails to achieve adequate opacification, a retrograde ileogram ("Ioopogram") may be performed. 12 For this procedure, a balloon catheter is used to occlude the conduit stoma, and a water-soluble radiopaque contrast medium is instilled into the intestinal loop using sterile barium enema equipment. Retrograde opacification of the urinary tract by this method requires the presence of intestinal ureteral reflux. As surgeons aspire to construct antireflux anastomoses,13 direct catheterization by endoscopy may be required to demonstrate postoperative disorders at the ureterointestinal junction. Endoscopy and instrumentation of intestinal conduits for diagnosis and therapy have been the subject of recent reports. Redman et al. 14 have described the use of a rigid panendoscope in a patient with an ileal conduit to gain access to the upper urinary passages. In that case, passage of a Dormia stone basket into the ureter was successful in extracting a calculus. In Europe, Leisinger and Deyhle'S have recently demonstrated that the combined efforts of the urologist and 26

gastrointestinal endoscopist allows fiberoptic endoscopy and retrograde pyelography to be performed with safety and ease in patients with conduits. Our experience indicates that fiberoptic endoscopy of ureterointestinal conduits allows inspection and mucosal biopsy. Ureterointestinal anastomoses can be identified and cannulated. Retrograde pyelography allows opacification of remnant urinary passages. Utilizing gastrointestinal endoscopic instruments and techniques, instrumentation of upper urinary passages in patients with ureterointestinal conduits ultimately may be useful in managing obstructing calculi or recurrent neoplasia.

.~ REFERENCES 1. HARBACH LB, HALL RL, COCKETT ATK, KAUFMAN j], MARTIN DC, MIMS MM, GOODWIN WE: Ileal loop cutaneous urinary diversion: a critical review.} Uro/l05:511, 1971 2. ELLIs LR, UDALL DA, HODGES CV: Further clinical experience with intestinal segments for urinary diversion.! Urol 105:354, 1971 3. MALEK RS, BURKE EC, DEWEERD jH: Ileal conduit urinary diversion in children.! Urol 105:892, 1971 4. WYATT jK: Ileal conduit diversion for benign disease: a critical review and long-term follow-up. Can} Surg 17:270, 1974 5. SCHMIDT jD, HAWTREYCE, FLOCKS RH, CULP DA: Complications, results and problems of ileal conduit diversions.! Urol 109:210, 1973 6. DRETLER SP: Urinary tract calculi and ileal conduit diversion. Am ) Surg 123:480, 1972 7. DESCHNER EE, GOLDSTEIN M], MELAMED MR, SHERLOCK P: A histological and kinetic study of an ileal conduit. Gastroenterology 64:920, 1973 8. BRICKER EM: Bladder substitution after pelvic evisceration. Surg Clin North Am 30:1511, 1950 9. ASSADNIAA, LEECN, PETREjH, LYONS RC: Two cases of stone formation in ileal conduits after using staple gun for closure of proximal end of isolated loop.! Urol 108:553, 1972 10. KOEHLER PR, BOWLES WT: Radiologic evaluation of the upper urinary tract following ileal loop urinary diversion. Radiology 86:227, 1966 11. SOLOVAY j: Advantages of the prone position for the excretory urogram in ileal conduit urinary diversion.) Urol 111 :530, 1974 12. JUDE jR, LUSTED LB, SMITH RR: Radiographic evaluation of the urinary tract following urinary diversion to an ileal bladder. Cancer 12:1134, 1959 13. STARR A, ROSE DH, COOPER IF, SNYDER RN: Antireflux ureteroileal anastomoses; two experiementaltechniques. Invest Uro/12:165, 1974 14. REDMAN IF, MEACHAM KR, ROUNTREE GA, BISSADA NK: Endoscopy ileal conduit with ureteral instrumentation. Urology 3:565, 1974 15. LEISINGER Hj, DEYHLE P: Eine neue Methode zur Endoskopie und retrograden Pyelographie beim Ileam conduit. Urologe A 13:267, 1974

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Endoscopy of ureterointestinal conduits and retrograde pyelography.

Endoscopy of ureterointestinal conduits and retrograde pyelography David B. Falkenstein, Chaim B. Reich, Mircea N. Golimbu, Roger S. Warner, Pablo A...
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