LATE SPONTANEOUS
BHUSHAN DAVID
M. MAZOR,
WILLIAM SAMUEL
L. KHASHU,
H. SEERY,
RUPTURE OF ILEAL CONDUIT
M.D.
M.D. M.D.
H. ROTHFELD,
M.D.
From the Division of Urology, Long Island JewishHillside Medical Center, Queens Hospital Center Affiliation, Jamaica, and the State University of New York at Stonybrook, New York
ABSTRACT - A case of late spontaneous rupture of an ileal conduit, obstructed by ajbrous band, is presented. Resection of the proximal segment of the conduit bearing the perforation resulted in complete recovery.
Ileal conduit urinary diversion, initially described by Seiffert in 1935l in the German literature, was popularized in this country by Bricker2 fifteen years later. Ileal conduit diversion is generally regarded as the best form of supravesical urinary diversion for a myriad of benign and malignant conditions of the lower urinary tract.2’3 This method has the advantage of separating urine from the fecal stream, less than lo-per cent indidence of pyelonephritis and calculus disease,4 prompt emptying because of the absence of a sphincter, and low incidence of electrolyte and acid base imbalance. The over-all mortality rate of this procedure varies from 3.7 per cent5 to 12 per cent,6 the figure being 3 per cent in benign disease. Among the early complications wound infection, dehiscence, and anastomotic leaks predominate. Many late complications have been reported. Intestinal obstruction from adhesions, volvulus, and internal herniation heads the list.4 Complications attributed to the conduit itself include redundancy, reversed peristalsis with poor emptying,’ stoma1 stenosis, and infarction of the conduit. To our knowledge, this is the first reported case of late spontaneous rupture of an ileal conduit. Case Report A sixty-three-year-old black female, who had had an ileal conduit done elsewhere in 1968 for a
616
decompensated neurogenic bladder followed by a right nephroureterectomy five years later, was admitted because of sudden onset of acute lower abdominal pain, absence of urinary drainage from the conduit, and nausea and vomiting for five hours prior to admission. The patient was markedly toxic with a temperature of 101” F., tachycardia, normal blood pressure, and a normal looking ileal stoma in the right lower quadrant. Exquisite tenderness, rebound tenderness, and guarding were present over the entire abdomen. The bowel sounds were sluggish. Digital examination of the ileal stoma did not On insertion of a Foley reveal any stenosis. catheter deep into the conduit, 150 cc. of bloody urine were obtained. A complete blood cell count and SMA 6 revealed normal hemoglobin, leukocytosis with a shift to the left, a blood urea nitrogen of 25 mg. Serum per 100 ml., and normal electrolytes. creatinine was 0.9 mg. per 100 ml. Intravenous urogram showed absence of the right kidney, grade 1 pyelocaliectasis on the left side, and a redundant ileal conduit with extravasation of contrast medium into the peritoneal cavity (Fig. 1A). Ileostogram displayed a markedly redundant and dilated conduit with reflux into the left collecting system and extravasation into the peritoneal cavity (Fig. 1B). Laporatomy revealed about 1,000 cc. of urinous fluid in the peritoneal cavity, numerous
UROLOGY
/ NOVEMBER
1975 / VOLUME
VI, NUMBER
5
-I
..-
FIGURE1. (A) Intravenous urogram shows absence of right kidney, left pyelocaliectasis, patent ureteroileal anastomosis, and extravasation of contrast material from ileal conduit. (B) lleostogram shows redundant and dilated ileal conduit, rejlux into left collecting system, and extravasation of contrast material from conduit.
.
adhesions, and a redundant ileal conduit measuranastomosis was ining 16 inches. Ureteroileal tact. A fibrous band constricting the middle of the conduit distal to the ureteroileal anastomosis was resected. Further exploration demonstrated a perforation in the closed end of the conduit. The proximal 6 inches of the conduit was resected leaving the original ureterointestinal anastomosis intact. The postoperative course was characterized by persistent sepsis which responded to intravenous cephalothin and gentamicin sulfate. The resected specimen revealed acute inflammatory changes with a 2.7-cm. perforation in the proximal end. Follow-up intravenous urogram and ileostogram were normal.
of the proximal end of the conduit. The site of the perforation is indicative of the foregoing mechanism. Resection of the constricting band and the perforation bearing redundant portion of the ileal conduit resulted in complete recovery. 264-16 74th Avenue Glen Oaks, New York 11004 (DR. KHASHU) References 1. 2. 3.
Comment A case of late spontaneous rupture of an ileal conduit is presented. A search of the literature failed to reveal any other report of a similar complication. The presence of acute peritonitis and lack of urine output prompted the evaluation of the conduit. A redundant ileal conduit, obstructed by a fibrous band distal to the ureteroileal anastomosis, resulted in a “closed loop” phenomenon with marked distention and rupture
UROLOGY
/ NOVEMBER 1975
/
VOLUME VI, NUMBER 5
4.
5.
6. 7.
SEIFFERT, L.: Die “Darm-Siphonblase,” Arch. f. klin. Chir. 183: 569 (1935). BRICKER, E. M. : Bladder substitution after pelvic evisceration, Surg. Clin. North Am. 30: 1511 (1950). BRICKER, E. ?vl., BUTCHER, H., and MCAFEE, C. A.: Late results of bladder substitution with isolated ileal segments, Surg. Gynecol. Obstet. 99: 469 (1954). JAFFE, B. M., BRICKER, E. M., and BUTCHER, H. R.: Surgical complications of ileal segment urinary diversion, Ann. Surg. 167: 367 (1968). CORDONNIER, J. J., and NICOLAI, C. M.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion, J. Urol. 83: 834 (1960). HARBACH, L. B., et al. : Ileal loop cutaneous urinary diversion: a critical review, ibid. 105: 511 (1971). BORMEL, P., and GALLEHER, E. P., JR.: Reversed peristalsis and other complications of ureteroileostomies, ibid. 88: 203 (1962).
617
BHUSHAN DAVID
M. MAZOR,
WILLIAM SAMUEL
L. KHASHU,
H. SEERY,
RUPTURE OF ILEAL CONDUIT
M.D.
M.D. M.D.
H. ROTHFELD,
M.D.
From the Division of Urology, Long Island JewishHillside Medical Center, Queens Hospital Center Affiliation, Jamaica, and the State University of New York at Stonybrook, New York
ABSTRACT - A case of late spontaneous rupture of an ileal conduit, obstructed by ajbrous band, is presented. Resection of the proximal segment of the conduit bearing the perforation resulted in complete recovery.
Ileal conduit urinary diversion, initially described by Seiffert in 1935l in the German literature, was popularized in this country by Bricker2 fifteen years later. Ileal conduit diversion is generally regarded as the best form of supravesical urinary diversion for a myriad of benign and malignant conditions of the lower urinary tract.2’3 This method has the advantage of separating urine from the fecal stream, less than lo-per cent indidence of pyelonephritis and calculus disease,4 prompt emptying because of the absence of a sphincter, and low incidence of electrolyte and acid base imbalance. The over-all mortality rate of this procedure varies from 3.7 per cent5 to 12 per cent,6 the figure being 3 per cent in benign disease. Among the early complications wound infection, dehiscence, and anastomotic leaks predominate. Many late complications have been reported. Intestinal obstruction from adhesions, volvulus, and internal herniation heads the list.4 Complications attributed to the conduit itself include redundancy, reversed peristalsis with poor emptying,’ stoma1 stenosis, and infarction of the conduit. To our knowledge, this is the first reported case of late spontaneous rupture of an ileal conduit. Case Report A sixty-three-year-old black female, who had had an ileal conduit done elsewhere in 1968 for a
616
decompensated neurogenic bladder followed by a right nephroureterectomy five years later, was admitted because of sudden onset of acute lower abdominal pain, absence of urinary drainage from the conduit, and nausea and vomiting for five hours prior to admission. The patient was markedly toxic with a temperature of 101” F., tachycardia, normal blood pressure, and a normal looking ileal stoma in the right lower quadrant. Exquisite tenderness, rebound tenderness, and guarding were present over the entire abdomen. The bowel sounds were sluggish. Digital examination of the ileal stoma did not On insertion of a Foley reveal any stenosis. catheter deep into the conduit, 150 cc. of bloody urine were obtained. A complete blood cell count and SMA 6 revealed normal hemoglobin, leukocytosis with a shift to the left, a blood urea nitrogen of 25 mg. Serum per 100 ml., and normal electrolytes. creatinine was 0.9 mg. per 100 ml. Intravenous urogram showed absence of the right kidney, grade 1 pyelocaliectasis on the left side, and a redundant ileal conduit with extravasation of contrast medium into the peritoneal cavity (Fig. 1A). Ileostogram displayed a markedly redundant and dilated conduit with reflux into the left collecting system and extravasation into the peritoneal cavity (Fig. 1B). Laporatomy revealed about 1,000 cc. of urinous fluid in the peritoneal cavity, numerous
UROLOGY
/ NOVEMBER
1975 / VOLUME
VI, NUMBER
5
-I
..-
FIGURE1. (A) Intravenous urogram shows absence of right kidney, left pyelocaliectasis, patent ureteroileal anastomosis, and extravasation of contrast material from ileal conduit. (B) lleostogram shows redundant and dilated ileal conduit, rejlux into left collecting system, and extravasation of contrast material from conduit.
.
adhesions, and a redundant ileal conduit measuranastomosis was ining 16 inches. Ureteroileal tact. A fibrous band constricting the middle of the conduit distal to the ureteroileal anastomosis was resected. Further exploration demonstrated a perforation in the closed end of the conduit. The proximal 6 inches of the conduit was resected leaving the original ureterointestinal anastomosis intact. The postoperative course was characterized by persistent sepsis which responded to intravenous cephalothin and gentamicin sulfate. The resected specimen revealed acute inflammatory changes with a 2.7-cm. perforation in the proximal end. Follow-up intravenous urogram and ileostogram were normal.
of the proximal end of the conduit. The site of the perforation is indicative of the foregoing mechanism. Resection of the constricting band and the perforation bearing redundant portion of the ileal conduit resulted in complete recovery. 264-16 74th Avenue Glen Oaks, New York 11004 (DR. KHASHU) References 1. 2. 3.
Comment A case of late spontaneous rupture of an ileal conduit is presented. A search of the literature failed to reveal any other report of a similar complication. The presence of acute peritonitis and lack of urine output prompted the evaluation of the conduit. A redundant ileal conduit, obstructed by a fibrous band distal to the ureteroileal anastomosis, resulted in a “closed loop” phenomenon with marked distention and rupture
UROLOGY
/ NOVEMBER 1975
/
VOLUME VI, NUMBER 5
4.
5.
6. 7.
SEIFFERT, L.: Die “Darm-Siphonblase,” Arch. f. klin. Chir. 183: 569 (1935). BRICKER, E. M. : Bladder substitution after pelvic evisceration, Surg. Clin. North Am. 30: 1511 (1950). BRICKER, E. ?vl., BUTCHER, H., and MCAFEE, C. A.: Late results of bladder substitution with isolated ileal segments, Surg. Gynecol. Obstet. 99: 469 (1954). JAFFE, B. M., BRICKER, E. M., and BUTCHER, H. R.: Surgical complications of ileal segment urinary diversion, Ann. Surg. 167: 367 (1968). CORDONNIER, J. J., and NICOLAI, C. M.: An evaluation of the use of an isolated segment of ileum as a means of urinary diversion, J. Urol. 83: 834 (1960). HARBACH, L. B., et al. : Ileal loop cutaneous urinary diversion: a critical review, ibid. 105: 511 (1971). BORMEL, P., and GALLEHER, E. P., JR.: Reversed peristalsis and other complications of ureteroileostomies, ibid. 88: 203 (1962).
617
