TRANSVERSE
COLON
SUPRAVESICAL JOSEPH HERBERT
FOR
URINARY TRACT DIVERSION
D. SCHMIDT,
M.D.
J, BUCHSBAUM,
ELIAS C. JACOBO,
CONDUIT
M.D.
M.D.
From the Departments of Urology and Obstetrics-Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
ABSTRACT - Twenty-two patients with extensive pelvic irradiation underwent supravesical urinary diversion using a transverse colon conduit. Primary diseases were most often carcinoma of the cervix and urinary bladder. Indications for diversion included original treatment planning, radiation cystitis, vesicovaginal fistula, and ureteral obstruction. Operative mortality was low (4 per cent), and most complications were managed by further surgery. Normal upper urinary tracts usually remained normal afier diversion; relief of existing hydroureteronephrosis was seen in a majority of patients. Stoma1 problems have been minimal, and renal function has remained normal or stable. The method affords the use of nonirradiated transverse colon as well as the ureter high above the field of pelvic irradiation and is the preferred diversion in such patients.
Many reviews of patients receiving supravesical urinary diversion using intestinal segments have emphasized the increased morbidity and mortality associated with prior extensive pelvic radiotherapy.ls2 Even in the absence of malignancy, patients undergoing standard ileal conduit diversion after pelvic irradiation are at increased risk for urinary and bowel fistula or obstruction as well as poor wound healing. Efforts to reduce this risk have included nephrostomy or ureterostomy which carry their own long-term problems. Ureteral-intestinal diversions using the nonirradiated proximal ureter as well as nonirradiated bowel segments have been developed. The transverse colon is such a segment that it is less apt to be in the field of pelvic irradiation; its use in supravesical urinary diversion has been recognized only recentlya This report deals with 22 patients so Read in part at the Annual Meeting of the Western Section, American Urological Association, Inc., Coronado, California, February 22, 1976.
542
treated at the University of Iowa Hospitals and Clinics. Material and Methods Since 1970, 25 patients have had a supravesical urinary diversion using the transverse colon conduit. Twenty-two of these patients (17 females and 5 males) have been followed up for at least three months and are described herein. Follow-up ranges from four to sixty-eight months with an average of eighteen months per patient. At the time of surgery patients ranged TABLE
I.
Indications fur transverse colon conduit (22 patients) Number
Indication Radiation cystitis Part of original treatment plan Vesicovaginal fistula - no cancer Vesicovaginal fistula and cancer Ureteral obstruction
UROLOGY /
DECEMBER 1976 /
VOLUME VIII,NUMBER
6
in age from forty-two to seventy-seven years with an average age of fifty-seven years. Primary disease requiring radiation therapy included carcinoma of the urinary bladder (11 patients), uterine cervix (ll), and endometrium (1). One patient had both cervical and bladder carcinoma. Radiation dosages in this group ranged from 4,000 to 10,000 rads with an average of 6,300 rads midtumor dose. Indications for diversion are listed in Table I. Additional procedures performed concomitantly with the diversion are listed in Table II. The technique of the procedure is similar to that outlined earliera In this series one patient with a solitary hydronephrotic kidney had a pyelocolic anastomosis constructed (Fig. 1); another patient had a right to left transureteroureterostomy constructed proximal to a left ureterocolic anastomosis. Ureteral stents and antireflux ureterocolic anastomosis techniques were not used.
TABLE
II.
Procedures performed with transverse colon conduit (22 patients)
Procedure
Number
Cystectomy or cystoprostatectomy Pelvic exenteration, sigmoid colostomy Anterior exenteration Nephrectomy
7 2 1 1
Results Sixteen patients are living, and all but 2 are clinically free of cancer. Six patients have died, all but one with residual cancer. Surgical mortality was 4 per cent; the only fatality was a sixty-year-old woman with persistent endometrial cancer who died in the immediate postoperative period from fulminating hepatitis. The other deaths occurred three to fourteen months after diversion. Seven patients had normal excretory urograms preoperatively. Six remain normal, while in one hydroureteronephrosis has developed (Fig. 2). Of 15 patients with unilateral or bilateral hydroureteronephrosis prior to diversion,
FIGURE 1. Excretory urogram three months after right pyelocolic anastomosis and left nephrectomy in fifty-four-year-old female with cervical cancer. Right hydronephrosis markedly improved compared with prediversion study.
FIGURE 2. Conduitogram (4 and excretory urogram 03) five years after transvc erse colon conduit and velvic exeflteration in forty-four-yearold female with cervical carcinoma. Upper urinary tracts remain normal in spite of rejux.
UROLOGY
/ DECEMBER1976
/ VOLUMEVIII,
NUMBER6
543
FIGURE 3. Preoperative ercretory urograms (A) demonstrating bilateral hydroureteronephrosis in seventy-fiveyear-old male with persistent bladder cancer, and (B) six months after transverse colon conduit diversion showing normal upper tracts.
FIGURE 4. Excretory urograms (A) preoperative demonstrating right hydroureteronephrosis in forty-year-old female with cervical cancer, and (B) eighteen months after diversion showing normal upper tracts.
10 have improved upper tracts (9 to normal, Figs. 3 and 4), 1 has a stable excretory urogram and 1 patient has continued to deteriorate with progressive ureteral obstruction. Three TABLE III. Complications of transverse colon conduit (22 patients) Complications Ureterocolic leak, wound dehiscence Fatal hepatitis* Cerebrovascular accident Ureterorectal fistula* Ureterocolic stricture, stoma1 prolapse* Osteitis pubis, osteomyelitis* Peristomal hernia* Small-bowel fistula* Wound infection None *Required surgical intervention.
544
Number 1 1 1 1 1 1 1 1 2 12
patients have not cretory urogram.
yet
been
restudied
by ex-
In no patient has hyperchloremic acidosis or other deterioration of kidney function developed. Preoperative renal function as measured by blood urea nitrogen and serum creatinine has remained stable in all patients. Residual urine determinations have been generally less than 5 ml. Complications related to the performance of the transverse colon conduit are listed in Table III. Problems can be attributed to the prior irradiation therapy, persistent malignancy, and associated procedures performed as well as to technical failure of the diversion itself. Ten patients suffered a total of twelve complications considered significant, In no patient has stoma1 stenosis or any prolonged difficulty with the appliance developed.
UROLOGY
/ DECEMBER1976
/ VOLUMEVIII, NUMBER6
FIGURE 6. Conduitograms one year after diversion for cervical cancer in forty-twoyear-old female. (A) Overdistention produces apparent hydronephrosis; (B) drainage film demonstrates no obstruc_ -am was tion. Ex ‘cre tort4 Ul also norI Inn1
Although no attempt was made to construct an antireflux ureterocolic anastomosis, retrograde contrast studies of the colon segment have occasionally shown no reflux, yet an excretory urogram demonstrated no evidence of obstruction (Fig. 5). Since the colon segment is generally shorter and of greater width than an ileal conduit segment, greater care must be exercised in performing this diagnostic study (Fig. 6). Comment Use of the transverse colon in supravesical urinary diversion is still not widely publicized or accepted. At the time of our initial report of 8 patients so managed,3 only the experience in gynecologic oncology by Nelson4 had been
t’ROLO(:Y
/
DECE\lRER
1976
/
documented prior. Also in 1975, Morales and Golimbu5 reported their experience with 46 patients receiving a colon conduit. The transverse colon was used in 39 patients and the sigmoid in 7. Twenty-six patients of the entire group were diverted because of problems related to malignancy, but no mention was made of the number treated because of extensive pelvic irradiation. Their technique differs from ours in their increasing use of a two-layer ureterocolic anastomosis constructed in an antireflux manner. Morales and Golimbu5 emphasized the advantage of a colon conduit which can be made either isoperistaltic or antiperistaltic since the segment empties by mass contraction rather than by peristalsis. Altwein and Hohenfellner” reported their total experience of 42 colonic conduits with a
\‘OLCXIE \‘III, NUMBER 6
345
mortality rate of only 2 per cent. Of the 8 patients described in detail, only 4 had had irradiation therapy; the sigmoid rather than the transverse colon was the segment utilized in all instances. The transverse colon offers the following advantages for use as a conduit in supravesical urinary diversion: (I) This segment of bowel is less likely to be damaged by extensive pelvic irradiation; even the redundant ptotic transverse colon seen in so many patients is mobile enough to receive less radiation than fixed pelvic structures. (2) A high ureteral or renal pelvic anastomosis can be achieved, thus also using a segment of norm-radiated urinary tract. (3) Colon segments are less frequently complicated by stoma1 stenosis and the related sequelae. (4) Th e effects of absorption of urine across the colon wall on renal function are minimized because of the mass contraction emptying of the segment and the resultant small residual volumes. (5) Other surgical procedures can be performed at the time of the (6) Although proof of its urinary diversion. superiority is still lacking, an antireflux ureterocolic anastomosis can be constructed optionally because of the thick-walled colonic segment. Our generally good results with the use of the transverse colon conduit for supravesical urinary diversion in patients with extensive pelvic irradiation makes us believe that the procedure should become more widespread and is probably a logical alternative for other (non-
546
irradiated) patients requiring diversion. Similarly, rather than only “falling back” on the transverse colon or other nonirradiated bowel segments for salvage of problem patients, we now believe that the procedure can be carried out as part of the primary treatment program in patients previously irradiated or in those who will later be treated by radiation and pelvic surgery. Division of Urology University Hospital San Diego, California 92103 (DR. SCHMIDT) ACKNOWLEDGMENT. her assistance.
To Mrs.
Barbara
Ziegler
for
References 1. JOHNSON, D. E., JACKSON, L., and GUINN, G. A.: Ileal conduit diversion for carcinoma of the bladder, South. Med. J. 63: 1115 (1970). 2. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H., and CULP, D. A.: Complications, results and problems of ileal conduit diversions, J. Ural. 109: 210 (1973). 3. SCHMIDT, J. D., HA~TREY, C. E., and BUCHSRAUM, H. J.: Transverse colon conduit: a preferred method of urinary diversion for radiation-treated pelvic malignancies, ibid. 113: 308 (1975). 4. NELSON, J. H.: Atlas of Radical Pelvic Surgery, New York, Appleton-Century-Crofts, 1969, pp. 181-191. 5. MORALES, P., and GOLIMBU, M.: Colonic urinary diversion: 10 years of experience, J. Urol. 113: 302 (1975). 6. ALTWEIN, J. E., and HOHENFELLNER, R.: Use of the colon as a conduit for urinary diversion, Surg. Gynecol. Obstet. 140: 33 (1975).
UROLOGY
/
DECEMBER
1976 /
VOLUME VIII, NUMBER 6
COLON
SUPRAVESICAL JOSEPH HERBERT
FOR
URINARY TRACT DIVERSION
D. SCHMIDT,
M.D.
J, BUCHSBAUM,
ELIAS C. JACOBO,
CONDUIT
M.D.
M.D.
From the Departments of Urology and Obstetrics-Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
ABSTRACT - Twenty-two patients with extensive pelvic irradiation underwent supravesical urinary diversion using a transverse colon conduit. Primary diseases were most often carcinoma of the cervix and urinary bladder. Indications for diversion included original treatment planning, radiation cystitis, vesicovaginal fistula, and ureteral obstruction. Operative mortality was low (4 per cent), and most complications were managed by further surgery. Normal upper urinary tracts usually remained normal afier diversion; relief of existing hydroureteronephrosis was seen in a majority of patients. Stoma1 problems have been minimal, and renal function has remained normal or stable. The method affords the use of nonirradiated transverse colon as well as the ureter high above the field of pelvic irradiation and is the preferred diversion in such patients.
Many reviews of patients receiving supravesical urinary diversion using intestinal segments have emphasized the increased morbidity and mortality associated with prior extensive pelvic radiotherapy.ls2 Even in the absence of malignancy, patients undergoing standard ileal conduit diversion after pelvic irradiation are at increased risk for urinary and bowel fistula or obstruction as well as poor wound healing. Efforts to reduce this risk have included nephrostomy or ureterostomy which carry their own long-term problems. Ureteral-intestinal diversions using the nonirradiated proximal ureter as well as nonirradiated bowel segments have been developed. The transverse colon is such a segment that it is less apt to be in the field of pelvic irradiation; its use in supravesical urinary diversion has been recognized only recentlya This report deals with 22 patients so Read in part at the Annual Meeting of the Western Section, American Urological Association, Inc., Coronado, California, February 22, 1976.
542
treated at the University of Iowa Hospitals and Clinics. Material and Methods Since 1970, 25 patients have had a supravesical urinary diversion using the transverse colon conduit. Twenty-two of these patients (17 females and 5 males) have been followed up for at least three months and are described herein. Follow-up ranges from four to sixty-eight months with an average of eighteen months per patient. At the time of surgery patients ranged TABLE
I.
Indications fur transverse colon conduit (22 patients) Number
Indication Radiation cystitis Part of original treatment plan Vesicovaginal fistula - no cancer Vesicovaginal fistula and cancer Ureteral obstruction
UROLOGY /
DECEMBER 1976 /
VOLUME VIII,NUMBER
6
in age from forty-two to seventy-seven years with an average age of fifty-seven years. Primary disease requiring radiation therapy included carcinoma of the urinary bladder (11 patients), uterine cervix (ll), and endometrium (1). One patient had both cervical and bladder carcinoma. Radiation dosages in this group ranged from 4,000 to 10,000 rads with an average of 6,300 rads midtumor dose. Indications for diversion are listed in Table I. Additional procedures performed concomitantly with the diversion are listed in Table II. The technique of the procedure is similar to that outlined earliera In this series one patient with a solitary hydronephrotic kidney had a pyelocolic anastomosis constructed (Fig. 1); another patient had a right to left transureteroureterostomy constructed proximal to a left ureterocolic anastomosis. Ureteral stents and antireflux ureterocolic anastomosis techniques were not used.
TABLE
II.
Procedures performed with transverse colon conduit (22 patients)
Procedure
Number
Cystectomy or cystoprostatectomy Pelvic exenteration, sigmoid colostomy Anterior exenteration Nephrectomy
7 2 1 1
Results Sixteen patients are living, and all but 2 are clinically free of cancer. Six patients have died, all but one with residual cancer. Surgical mortality was 4 per cent; the only fatality was a sixty-year-old woman with persistent endometrial cancer who died in the immediate postoperative period from fulminating hepatitis. The other deaths occurred three to fourteen months after diversion. Seven patients had normal excretory urograms preoperatively. Six remain normal, while in one hydroureteronephrosis has developed (Fig. 2). Of 15 patients with unilateral or bilateral hydroureteronephrosis prior to diversion,
FIGURE 1. Excretory urogram three months after right pyelocolic anastomosis and left nephrectomy in fifty-four-year-old female with cervical cancer. Right hydronephrosis markedly improved compared with prediversion study.
FIGURE 2. Conduitogram (4 and excretory urogram 03) five years after transvc erse colon conduit and velvic exeflteration in forty-four-yearold female with cervical carcinoma. Upper urinary tracts remain normal in spite of rejux.
UROLOGY
/ DECEMBER1976
/ VOLUMEVIII,
NUMBER6
543
FIGURE 3. Preoperative ercretory urograms (A) demonstrating bilateral hydroureteronephrosis in seventy-fiveyear-old male with persistent bladder cancer, and (B) six months after transverse colon conduit diversion showing normal upper tracts.
FIGURE 4. Excretory urograms (A) preoperative demonstrating right hydroureteronephrosis in forty-year-old female with cervical cancer, and (B) eighteen months after diversion showing normal upper tracts.
10 have improved upper tracts (9 to normal, Figs. 3 and 4), 1 has a stable excretory urogram and 1 patient has continued to deteriorate with progressive ureteral obstruction. Three TABLE III. Complications of transverse colon conduit (22 patients) Complications Ureterocolic leak, wound dehiscence Fatal hepatitis* Cerebrovascular accident Ureterorectal fistula* Ureterocolic stricture, stoma1 prolapse* Osteitis pubis, osteomyelitis* Peristomal hernia* Small-bowel fistula* Wound infection None *Required surgical intervention.
544
Number 1 1 1 1 1 1 1 1 2 12
patients have not cretory urogram.
yet
been
restudied
by ex-
In no patient has hyperchloremic acidosis or other deterioration of kidney function developed. Preoperative renal function as measured by blood urea nitrogen and serum creatinine has remained stable in all patients. Residual urine determinations have been generally less than 5 ml. Complications related to the performance of the transverse colon conduit are listed in Table III. Problems can be attributed to the prior irradiation therapy, persistent malignancy, and associated procedures performed as well as to technical failure of the diversion itself. Ten patients suffered a total of twelve complications considered significant, In no patient has stoma1 stenosis or any prolonged difficulty with the appliance developed.
UROLOGY
/ DECEMBER1976
/ VOLUMEVIII, NUMBER6
FIGURE 6. Conduitograms one year after diversion for cervical cancer in forty-twoyear-old female. (A) Overdistention produces apparent hydronephrosis; (B) drainage film demonstrates no obstruc_ -am was tion. Ex ‘cre tort4 Ul also norI Inn1
Although no attempt was made to construct an antireflux ureterocolic anastomosis, retrograde contrast studies of the colon segment have occasionally shown no reflux, yet an excretory urogram demonstrated no evidence of obstruction (Fig. 5). Since the colon segment is generally shorter and of greater width than an ileal conduit segment, greater care must be exercised in performing this diagnostic study (Fig. 6). Comment Use of the transverse colon in supravesical urinary diversion is still not widely publicized or accepted. At the time of our initial report of 8 patients so managed,3 only the experience in gynecologic oncology by Nelson4 had been
t’ROLO(:Y
/
DECE\lRER
1976
/
documented prior. Also in 1975, Morales and Golimbu5 reported their experience with 46 patients receiving a colon conduit. The transverse colon was used in 39 patients and the sigmoid in 7. Twenty-six patients of the entire group were diverted because of problems related to malignancy, but no mention was made of the number treated because of extensive pelvic irradiation. Their technique differs from ours in their increasing use of a two-layer ureterocolic anastomosis constructed in an antireflux manner. Morales and Golimbu5 emphasized the advantage of a colon conduit which can be made either isoperistaltic or antiperistaltic since the segment empties by mass contraction rather than by peristalsis. Altwein and Hohenfellner” reported their total experience of 42 colonic conduits with a
\‘OLCXIE \‘III, NUMBER 6
345
mortality rate of only 2 per cent. Of the 8 patients described in detail, only 4 had had irradiation therapy; the sigmoid rather than the transverse colon was the segment utilized in all instances. The transverse colon offers the following advantages for use as a conduit in supravesical urinary diversion: (I) This segment of bowel is less likely to be damaged by extensive pelvic irradiation; even the redundant ptotic transverse colon seen in so many patients is mobile enough to receive less radiation than fixed pelvic structures. (2) A high ureteral or renal pelvic anastomosis can be achieved, thus also using a segment of norm-radiated urinary tract. (3) Colon segments are less frequently complicated by stoma1 stenosis and the related sequelae. (4) Th e effects of absorption of urine across the colon wall on renal function are minimized because of the mass contraction emptying of the segment and the resultant small residual volumes. (5) Other surgical procedures can be performed at the time of the (6) Although proof of its urinary diversion. superiority is still lacking, an antireflux ureterocolic anastomosis can be constructed optionally because of the thick-walled colonic segment. Our generally good results with the use of the transverse colon conduit for supravesical urinary diversion in patients with extensive pelvic irradiation makes us believe that the procedure should become more widespread and is probably a logical alternative for other (non-
546
irradiated) patients requiring diversion. Similarly, rather than only “falling back” on the transverse colon or other nonirradiated bowel segments for salvage of problem patients, we now believe that the procedure can be carried out as part of the primary treatment program in patients previously irradiated or in those who will later be treated by radiation and pelvic surgery. Division of Urology University Hospital San Diego, California 92103 (DR. SCHMIDT) ACKNOWLEDGMENT. her assistance.
To Mrs.
Barbara
Ziegler
for
References 1. JOHNSON, D. E., JACKSON, L., and GUINN, G. A.: Ileal conduit diversion for carcinoma of the bladder, South. Med. J. 63: 1115 (1970). 2. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H., and CULP, D. A.: Complications, results and problems of ileal conduit diversions, J. Ural. 109: 210 (1973). 3. SCHMIDT, J. D., HA~TREY, C. E., and BUCHSRAUM, H. J.: Transverse colon conduit: a preferred method of urinary diversion for radiation-treated pelvic malignancies, ibid. 113: 308 (1975). 4. NELSON, J. H.: Atlas of Radical Pelvic Surgery, New York, Appleton-Century-Crofts, 1969, pp. 181-191. 5. MORALES, P., and GOLIMBU, M.: Colonic urinary diversion: 10 years of experience, J. Urol. 113: 302 (1975). 6. ALTWEIN, J. E., and HOHENFELLNER, R.: Use of the colon as a conduit for urinary diversion, Surg. Gynecol. Obstet. 140: 33 (1975).
UROLOGY
/
DECEMBER
1976 /
VOLUME VIII, NUMBER 6
