George Grey Turner, 1877-195 I club, with a special nurse to train the patients to look after their sticky bags. Throughout the I950s and I96os my old Leadbetter patients still attended for regular review and they were remarkably well and socially acceptable. So in the mid- i96os I decided to give each patient a choice between the three methods of diversion-namely, ureterocolic anastomosis, an isolated loop with a bag, or a rectal bladder with a dry colostomy. Although I warned them of the possible complications and of the need to take bicarbonate and potassium for the rest of their lives, all chose the ureterocolic anastornosis. In conclusion, I think you would like me to stand up and be counted. For the past I 2 years I have done ureterocolic anastomoses for all patients with reasonable anal sphincters, regardless of age or life expectancy. I have always warned them that a conversion might


be necessary if renal problems developed, but (as I have said) I have not had to do one for many years and none has died from renal failure. I think we often forget the physical discomfort that some of our procedures cause, and many patients with carcinoma value the quality oif life as much as its quantity. We can help them to live better, even if we can't help them to, live longer, and those with ureterocolic anastomoses are relatively fit, comfortable, and socially acceptable. Geoff Chisholm will describe the philosophy and opinions of the younger urologists toiday, and obviously today's fashions affect today's patients. I don't wish to appear cynical, but I have always thought that a patient should find out what was wrong with him, decide how he would like to be treated, and then choose his surgeon. Unfortunately he usually has to choose his surgeon first!

TODAY G D Chisholm chM FRCS House Surgeon at Hammersmith, 1958; Consultant Urologist, I967; Professor of Surgery at Edinburgh, I977

It is a great pleasure for me to join in honouring Professor Grey Turner today and to acknowledge my link with him through Professor Ralph Shackman. In starting my review of ureteric transplantation today, I went back to read the papers on urinary diversion presented at a BAUS meeting in I967'"' 1. However, these did not seem to reveal the current thinking on this topic at that time and that is why Mr Hanley's comments are so important. It is now evident that a number of surgeons who had continued to practise ureterocolic anastomoses, but kept quiet about them, had been achieving excellent results. I propose to consider various aspects of urinary diversion, to describe what is happening in different parts of the world, and to discuss the various underlying philosophies. My own experience is mainly in adults, but I have discussed the problems in children (and many of Grey Turner's patients were children) with colleagues, especially at Great Ormond Street Hospital for Sick Children. The three prime indications for urinary

diversion in both children and adults have not changed for many years. They are: (i) to protect the upper urinary tracts from damage due to lower tract disease; (2) to make a hopelessly incontinent patient dry; and (3) to, divert urine after a lower urinary tract malignancy has been removed. Children with ectopia vesicae have been subjected to varying procedures with varying degrees of success. The policy at Great Ormond Street is to close the bladder and bladder neck at about 6 months and to review the situation a year later. If this has failed to provide continence or if it is followed by dilatation of the upper urinary tracts, then diversion is carried out at about 2 years of age. The usual procedure is a Bricker ileal conduit. If there is any objection to this, and the child can be followed up carefully, a ureterocolic anastomosis may be performed, but this is the less usual procedure. Some surgeons prefer a colon conduit as a primary procedure; others reserve colon or ileal conduits for children with problems in


George Grey Turner, I877-I95I

the upper urinary tract. Techniques using rectal bladders across the anal sphincter have been disappointing. Spina bifida is possibly the most common problem requiring diversion in children in the United Kingdom. Practices vary, but there is now a strong tendency to ensure (by excretion urography) that there are good renal tracts before undertaking surgery. Conservative methods for managing the bladder almost always fail to achieve social dryness, and diversion is done at about 2 years while the upper tracts are normal. The main emphasis in the last decade has been on the state of the urinary tract at the time of diagnosis; if the kidneys have been destroyed there is much less enthusiasm for conservative surgical procedures than there was formerly because the results are so poor. Maybe if renal transplantation was accepted more readily in children we would see a swing back, but this is not the case in this country today. The problems of urinary diversion in children are often underrated, but they are very real. Operations must be done before the children go to school so that they are used to being left alone to cope. Care of the stoma requires devoted attention by many people, including a stoma therapist. More and more late complications of urinary diversion intoi ileal segments are being reported in children'8, and psychological problems cannot be dismissed

lightly. Let us review briefly what has happened in urinary diversion for adults over the years. First there was the era of the ureterosigmoid anastomosis, which, as we have heard, aliot died in I95I. Then this was largely replaced by 'the ileal conduit. The swing to this procedure might have been much less hasty if the Leadbetter type of anastomosis had been introduced earlier'9. Nevertheless, the ileal conduit was the mainstay of most adult urological practice in the I95oS and I960S, but doubts have been creeping in and various series of complications continue to be published. Again in children complications, have developed in so'me 40 % of patients after about io years, and many of these are in children who started with normal upper urinary tracts. In adults, even though the indications for diversion are often for malignant disease, there can be a

variety of both early and late complications20. Some of the metabolic aspects of urinary diversion have already been discussed, but there are two other potential hazards related to the use of ileum. Vitarmin B,2 absorption is decreased with ileal diversion, but since the total body stores are sufficient to last for several years the deficiency may not become apparent for some time2'. Hyperoxaluria and calcium oxalate stones may develop in the urinary tract after ileal resection22. The degree of oxaluria is proportional to the length of ileum resected so that the risk could be significant if a large length of ileum was resected, as for a continent ileostoKmy. The basic surgical procedure has not changed greatly, but Wallace7 23 has recommended several variants to make the operation easier and to reduce the complications. Some have welcomed these techniques, wrhile others have found disadvantages. The main drawback, which is now receiving more attention, is the free reflux into the kidneys (demonstrated by a loopogram), which may be associated with progressive destruction of the upper urinary tracts. A very valuable recent diagnostic tool, the antegrade pyelogram, is obtained by the passage of a long needle through the skin of the back into the calyces or renal pelvis. This radiological technique can be of great help in distinguishing stones, tumour, or stenosis, especially in those patients whose renal function deteriorates and in whom there appears to be an obstruction. Mr Hanley has referred to the colonic conduit with a Leadbetter stomra, and in the BAUS symposium of I967 Mogg24 reported favourably on his experience of it. Other groups, particularly in North America and Germany, have also reported good results. Altwein and Hohenfeliner2", of Mainz, have had a large experience of this technique, particularly in adults, but they have used it more often as a salvage procedure in those in whom a ureterocolic anastomosis, or even an ileal conduit, has gone wrong. Their results in over 50 patients are very encouraging and suggest that the Leadbetter procedure with a colonic conduit may indeed be almost the ideal form of diversion. Finally I want to discuss briefly the latest developments-namely, the creation of a con-

George Grey Turner, 1877-I95I tinent coniduit with the formation of an ileal reservoir or bladder which the patient catheterises for himself instead of having to wear a bag. Thils is similar in principle to the continent ileostomy developed by Nils Kock26, of Gothenburg, for patients undergoing total proctocolectomy. This interesting approach to the ileal conduit has been studied in various parts of the world, notably by Michael Ashken in Norwich27, by Leisinger in Zurich, and by Tscholl in Berne. Several techniques have been devised and they are still being evolved. They all involve the creation of a sizeable ileal reservoir and depend on the principle of the flutter valve whereby the intra-abdominal pressure compresses the valve to the exterior and prevents urine passing until the valve is catheterised. The results are certainly encouraging, but the proponents of these operations would advise further development and follow-up before their widespread use is encouraged. Perhaps I can summarise the history of ureteric transplantation in this way. First the ureterosigmoid era came (largely due to Grey Turner's work) and nearly went, but it is now well back in the practice of many centres. The ileal conduit was a significant advance, but its problems have been, and continue to be, greater than its innovators anticipated. The colonic conduit is more than just a passing phase and we should perhaps be concentrating on it more. Finally, it may be that in i o years' time we will recognise the continent conduit as an important method for the management of these patients.

References Stiles, H (i9 ii) Surgery, Gynecology and Obstetrics I3, I 27. 2 Turner, G G (I929) British Journal of Surgery, I

17, I I 4.

3 Turner, G G, and Saint, J H (1936) British Journal of Surgery, 23, 580.


4 Turner, G G (1939) Macewan Memorial Lecture. Glasgow, Jackson. 5 Turner, G G (1948) Newcastle Medical Journal, 23, 87. 6 Turner, G G (I943) British Medical Journal, 2, 535. 7 Nesbit, R (I948) University Hospital Bulletin of Michigan, 14, 45. 8 Cordonnier, J J (I950) Journal of Urology, 63, 276. 9 Leadbetter, W F (I95I) Journal of Urology, 65, 8I8. Io Wells, C A (I953) Annals of the Royal College of Surgeons of England, I3, 7I. ii Jacobs, A, and Stirling, W B (1952) British Journal of Urology, 24, 259. 1 2 Rubin, S W (1951) Journal of Urology, 65, 588. I3 Glaser, S (1952) British Journal of Urology, 24, 2I6.

14 Pyrah, L N (1954) Annals of the Royal College of Surgeons of England, 14, 1911. I5 Hanley, H G (1956) British Journal of Urology, 28, 402. I6 Jacobs, A (I967) British Journal of Urology, 39, 670.

17 Wallace, D M (I967) British Journal of Urology, 39, 68 i. i8 Richie, J P (i974) Journal of Urology, III, 687. I9 Leadbetter, W F, and Clarke, B G (I955) Journal of Urology, 73, 67. 20 Kafetsioulis, A, and Swinney, J (I968) British Journal of Urology, 40, I. 2I Rogers, A C N, and Steyn, J H (I97'4) British Journal of Urology, 46, 625. 22 Chadwick, V S, Modha, K, and Dowling, R H (1973) New England Journal of Medicine, 289, 172.

23 Wallace, D M (1970) British Journal of Urology, 42, 529. 24 Mogg, R A (1967) British Journal of Urology, 39, 687. 25 Altwein, J E, and Hohenfellner, R (I975) Surgery, Gynecology and Obstetrics, 140, 33. 26 Kock, N G (I973) in Progress in Surgery, vol. I2, ed. M Allgower, S E Bergentz, and R Y Calne, p. i8o. Basel, Karger. 27 Ashken, M H (I974) British Journal of Urology,

46, 631.

Ureteric transplantation. Today.

George Grey Turner, 1877-195 I club, with a special nurse to train the patients to look after their sticky bags. Throughout the I950s and I96os my old...
486KB Sizes 0 Downloads 0 Views