Vol. I 15, ,January Printed in U.S.A.
THE ,JOVRNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
URETEROILEOURETHROSTOMY: 16-YEAR FOLLOWUP JOHN M. BARRY,* THOMAS M. PITRE
AND
CLARENCE V. HODGES
From the Urolof{y Section, Veterans Administration Hospital and the Division of Urolo{?y, University of Oregon Health Sciences Center, Portland, Oref{on
ABSTRACT
Ureteroileourethrostomy has been abandoned at our institution for """' '"'" of the bladder because: 1) it the cancer and 2) upper tract deterioration forced conversion to ureteroileocutaneous diversion in 2 of metabolic acidosis can be satis""'""'u1u citrate administratio11. The upper uri·
ureteroileal anastomoses. substitute after cystectomy. It permits through the urethra with daytime urinary continence. In 1951 Couvelaire first rP1nrnrtPrl the use of this procedure as a bladder substitute after cystectomy for carcinoma. 1 The ureters were anastomosed to a loop of ileum, which was joined to the prostatic urethra. The upper end of the ileum was brought to the skin as a temporary ileostomy and was closed subsequently. Since then at least 3 modifications have been described.,_, A recent favorable report Winter' prompted us to review our own cases of ureteroileourethrostomy in an attempt to answer the question: is ureteroileourethrostomy an acceptable bladder substitute after cystectomy. SURGICAL TECHN!QVE
The surgical technique used in our 3 patients was a minor modification of the techniques used Mellinger and and Gandin. 3 After cystectomy. seminal vesiculectomy and subtotal prostatectomy a 25 cm. segment of terminal ileum with its mesentery was isolated. The end of the segment was closed and the ureters were anastomosed separately to the isolated ilea! segment. The isolated segment was then placed in a gentle C position in the pelvis and an ileourethrostomy was accomplished with interrupted 2-zero chromic catgut sutures over a 22F 5 cc balloon catheter. When possible the ilea! segment was retroperitonealized (fig. 1). The newly formed ilea! bladder was drained through separate stab incisions in the lower abdomen. CASE REPORTS
Case 1. E. M., UOMS 24-98-91, a 45-year-old white man, presented in 1957 with gross hematuria and suprapubic pain. The staging examination revealed normal upper urinary tracts but grade III, stage B transitional cell carcinoma of the bladder. On October 3, 1958 the patient underwent total cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy. The immediate postoperative course was complicated by frequent mucus plugging of the right pyelonephritis and increasing residual urine to 100 cc. Because of the residual urine a transurethral resection of residual apical -~,,~•~+.- tissue was done on November 11. A cystometrogram showed periodic 10 to 20 cm. contractions, of Accepted for publication June l::l, 1975. Read at annual meeting of 1f/estern Section. American Urological Association, April 13-17, 1975. ;~ Sectior, Ve-u::ran.s Adl-:-:inistratiol-1 2S
ileum. The able to void to urea nitrogen (BUN) and excretory urogram when the patient was discharged from the time he had good control and an external device for nocturnal incontinence. A year later the ilea! reservoir ~u,Jac,s, had increased to 800 cc and the residual urine to 125 cc, and the patient was experiencing pain with ilea! distension more than 400 cc. An enterogram demonstrated reflux on the right side but none on the left. The BUN and serum creatinine were normal. Two years postoperatively the residual urine had increased to 225 cc and the patient had to void every 2 hours because of flank pain. He was unable to tolerate more than 525 cc in the bladder because of pain. However, the upper urinary tracts remained normal on an IVP and the BUJ\; and serum creatinine were normal. The patient did not have hyperchloremic metabolic acidosis. After 7 years the residual urine had increased to 1,600 cc (fig. 2) and an IVP showed bilateral The serum creatinine was still normal. Periods of urethral catheter drainage failed to reduce the residual urine significantly and, because of the progressive upper urinary tract changes, conversion to a ureteroileocutaneous form of diversion was done, with excision of 80 per cent of the redundant ilea! bladder. The procedure was done in February 1969 and a followup from the referring physician in March 1975 revealed that the patient has had no problems with the ilea! conduit and was free of cancer. Case 2. F. E., UOMS 25-91-80, a 44-year-old white man, had grade III, stage B transitional cell carcinoma of the bladder diagnosed in 1958. An IVP. renal function tests, liver function tests and metastatic bone survey were normal. On September 9 the patient underwent cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy. The postoperative course was complicated by recurrent ileus, recurrent urinary retention caused by mucus obstruction, right pyelonephritis and hyperchloremic metabolic acidosis. A transurethral resection of obstructing tissue was performed and perforation of the ileal reservoir required exploration and closure at that time. Invasive transitional cell carcinoma was discovered on histologic examination of the prostatectomy specimen, and the underwent urethrectomy, prostatectomy, excision of the distal of the ilea! bladder and conversion to a ureteroileocutaneous form of di.version on November 21. Transitional cell carcinoma was found in the bulbous urethra The suffered 3 5:10re urinar:v tra-:t in:'ecbons before he died in February 1960 of the bladds:;_·
30
BARRY, PITRE AND HODGES
:,.:
FIG. 2. Case 1. Enterogram shows original 25 cm. ilea! segment had markedly dilated and elongated during 7 years.
Complications of ureteroileourethrostomy FIG. 1. Ureteroileourethrostomy technique. Ureters were individually anastomosed to antimesenteric side of isolated ilea! segment. Isoperistaltic ilea! segment was then sutured to residual prostate.
Case 3. P. S., VAH 540 01 62 48, a 59-year-old white man, underwent cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy in 1958 because of grade IV, stage B transitional cell carcinoma of the bladder. The upper urinary tracts were normal prior to the operations. The postoperative course was complicated by recurrent obstruction of the urethral catheter by mucus. When the patient was discharged from the hospital he had good daytime urinary control except for occasional stress incontinence. At night he relied upon an external collection device. The stream was weak but the patient emptied the bladder completely with mild Crede maneuver. In January 1959 he underwent exploratory laparotomy, lysis of adhesions and retroperitonealization of the ilea! bladder because of bowel obstruction. An IVP at the time showed minimal blunting of the calices and elevation of the BUN to 32. He was taking potassium citrate to avoid hypokalemic metabolic acidosis. In the subsequent years he has had recurrent urinary tract infections characterized by frequency and urgency without flank pain or fever. He presently is on chronic suppression with trimethoprim-sulfamethoxazole. In April 1974 he had residual urine of 200 cc (fig. 3, A) and was begun on a program of clean, intermittent self-catheterization. An IVP showed moderate dilatation of the upper urinary tracts (fig. 3, B), the serum creatinine was 1.8 and the serum electrolytes were normal. The patient remains continent during the day but requires an external device at night. He is free of tumor 16 years after the cancer operation. DISCUSSION
A review of the 22 cases reported in the literature, Couvelaire's first case and our own 3 cases revealed that a constella-
Case 1 Followup (yrs.) Nocturnal enuresis Mucus plugging Prostatic obstruction Acidosis Stones Infection Upper tract deterioration Bowel obstruction Conversion to ileocutaneous diversion
18
+ + + 0 0
Case 2 l
'-'1.
16
0
+
+ + +
+
0
+
+
+
0 0 2mos.
0 12 yrs.
Case 3
0 0
+ + + 0
tion of complications occurred after ureteroileourethrostomy (see table). Most patients have had daytime urinary continence with mild stress incontinence and nocturnal enuresis requiring an external collection device. Obstruction with mucus has been a problem, especially in the immediate postoperative period. Mucus production decreases when the isolated ileum is in constant contact with urine and light microscopic examinations of the ilea! bladder mucosa have demonstrated thinning of the mucosal layers with autolysis and separation of the tubular glands.• Two of our cases required transurethral resections of obstructing prostatic tissue and the third required clean, intermittent self-catheterization. Hyperchloremic metabolic acidosis occurs occasionally, especially when the conduit becomes obstructed. This problem can be controlled by reduction of residual urine with clean, intermittent self-catheterization, by converting the ureteroileourethrostomy to a ureteroileocutaneous urinary diversion and by giving the patient potassium citrate. Stones in the ilea! bladder form because of infection, retained mucus and residual urine. Reflux of the infected mucous plugs can result in renal calculi or pyelonephritis. Deterioration of the upper tracts occurred in both of our patients who retained their ureteroileourethrostomies for 10 years or more.
31
URETEROILEOURETHROSTOMY: 16-YEAR FOLLOWUP
FIG. 3. Case 3. A, enterogram 16 years after ureteroileourethrostomy reveals residual urine (200 cc) and bilateral reflux. B, excretory nephrotomogram reveals bilateral hydronephrosis and cortical scarring 16 years after ureteroileourethrostomy.
Nearly all of the cases followed for more than 5 years have had upper urinary tract deterioration demonstrated either by pyelograms or renal function studies. 5 · 7 An antiretlux ureteroileal anastomosis will reduce the reflux of infected, mucus-containing urine into the upper urinary tract, thereby reducing the incidence of upper urinary tract infection, hydronephrosis and calculus formation. Postoperative bowel obstruction occurred in 1 of our :3 cases and in 15 per cent of the cases reported by Kuss and associates. 7 Retroperitonealization of the ilea! bladder may reduce the incidence of this complication in the future. The potential complications of ureteroileourethrostomy must be seriously weighed against the major advantage, daytime urinary continence. With improved stomal technique and improved urinary appliances. ureteroileocutaneous diversion has become the accepted method of managing the functionally or anatomically absent bladder. The technique we used in 1958 cannot be recommended
because the residual prostate may contain mvas1ve bladder carcinoma. REFERENCES
l. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie totale ches l'homme. ,J. d'UroL 57: 408, 1951. 2. Mellinger, G. T. and Klatte, P. B.: Uretero-ileo-urethral anastomosis. ,J. Urol., 82: 459, 1959. :l. Gandin, M. M.: Uretero-ileo-urethral anastomosis: case report ..J. Urol., 83: 279, 1960. 4. Pyrah, L. N.: The use of the ileum in urology. Brit. J. Urol., 28: 36:3, 1956. 5. Winter, C. C.: Complete ileocystoplasty (uretero-ileo-urethrostomy): long-term followup. J. Urol., 11 l: 19, 1974. 6. Roblejo, P. G. and Malament, M.: Late results of an ileocystoplasty: a 12-year followup. J. Urol., 109: 38, 197:3. 7. Kiiss, R., Bitker, M., Camey, M., Chatelain, C. and Lassau, J. P.: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. ,J. Urol., !03: 53, 1970.
THE ,JOVRNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
URETEROILEOURETHROSTOMY: 16-YEAR FOLLOWUP JOHN M. BARRY,* THOMAS M. PITRE
AND
CLARENCE V. HODGES
From the Urolof{y Section, Veterans Administration Hospital and the Division of Urolo{?y, University of Oregon Health Sciences Center, Portland, Oref{on
ABSTRACT
Ureteroileourethrostomy has been abandoned at our institution for """' '"'" of the bladder because: 1) it the cancer and 2) upper tract deterioration forced conversion to ureteroileocutaneous diversion in 2 of metabolic acidosis can be satis""'""'u1u citrate administratio11. The upper uri·
ureteroileal anastomoses. substitute after cystectomy. It permits through the urethra with daytime urinary continence. In 1951 Couvelaire first rP1nrnrtPrl the use of this procedure as a bladder substitute after cystectomy for carcinoma. 1 The ureters were anastomosed to a loop of ileum, which was joined to the prostatic urethra. The upper end of the ileum was brought to the skin as a temporary ileostomy and was closed subsequently. Since then at least 3 modifications have been described.,_, A recent favorable report Winter' prompted us to review our own cases of ureteroileourethrostomy in an attempt to answer the question: is ureteroileourethrostomy an acceptable bladder substitute after cystectomy. SURGICAL TECHN!QVE
The surgical technique used in our 3 patients was a minor modification of the techniques used Mellinger and and Gandin. 3 After cystectomy. seminal vesiculectomy and subtotal prostatectomy a 25 cm. segment of terminal ileum with its mesentery was isolated. The end of the segment was closed and the ureters were anastomosed separately to the isolated ilea! segment. The isolated segment was then placed in a gentle C position in the pelvis and an ileourethrostomy was accomplished with interrupted 2-zero chromic catgut sutures over a 22F 5 cc balloon catheter. When possible the ilea! segment was retroperitonealized (fig. 1). The newly formed ilea! bladder was drained through separate stab incisions in the lower abdomen. CASE REPORTS
Case 1. E. M., UOMS 24-98-91, a 45-year-old white man, presented in 1957 with gross hematuria and suprapubic pain. The staging examination revealed normal upper urinary tracts but grade III, stage B transitional cell carcinoma of the bladder. On October 3, 1958 the patient underwent total cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy. The immediate postoperative course was complicated by frequent mucus plugging of the right pyelonephritis and increasing residual urine to 100 cc. Because of the residual urine a transurethral resection of residual apical -~,,~•~+.- tissue was done on November 11. A cystometrogram showed periodic 10 to 20 cm. contractions, of Accepted for publication June l::l, 1975. Read at annual meeting of 1f/estern Section. American Urological Association, April 13-17, 1975. ;~ Sectior, Ve-u::ran.s Adl-:-:inistratiol-1 2S
ileum. The able to void to urea nitrogen (BUN) and excretory urogram when the patient was discharged from the time he had good control and an external device for nocturnal incontinence. A year later the ilea! reservoir ~u,Jac,s, had increased to 800 cc and the residual urine to 125 cc, and the patient was experiencing pain with ilea! distension more than 400 cc. An enterogram demonstrated reflux on the right side but none on the left. The BUN and serum creatinine were normal. Two years postoperatively the residual urine had increased to 225 cc and the patient had to void every 2 hours because of flank pain. He was unable to tolerate more than 525 cc in the bladder because of pain. However, the upper urinary tracts remained normal on an IVP and the BUJ\; and serum creatinine were normal. The patient did not have hyperchloremic metabolic acidosis. After 7 years the residual urine had increased to 1,600 cc (fig. 2) and an IVP showed bilateral The serum creatinine was still normal. Periods of urethral catheter drainage failed to reduce the residual urine significantly and, because of the progressive upper urinary tract changes, conversion to a ureteroileocutaneous form of diversion was done, with excision of 80 per cent of the redundant ilea! bladder. The procedure was done in February 1969 and a followup from the referring physician in March 1975 revealed that the patient has had no problems with the ilea! conduit and was free of cancer. Case 2. F. E., UOMS 25-91-80, a 44-year-old white man, had grade III, stage B transitional cell carcinoma of the bladder diagnosed in 1958. An IVP. renal function tests, liver function tests and metastatic bone survey were normal. On September 9 the patient underwent cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy. The postoperative course was complicated by recurrent ileus, recurrent urinary retention caused by mucus obstruction, right pyelonephritis and hyperchloremic metabolic acidosis. A transurethral resection of obstructing tissue was performed and perforation of the ileal reservoir required exploration and closure at that time. Invasive transitional cell carcinoma was discovered on histologic examination of the prostatectomy specimen, and the underwent urethrectomy, prostatectomy, excision of the distal of the ilea! bladder and conversion to a ureteroileocutaneous form of di.version on November 21. Transitional cell carcinoma was found in the bulbous urethra The suffered 3 5:10re urinar:v tra-:t in:'ecbons before he died in February 1960 of the bladds:;_·
30
BARRY, PITRE AND HODGES
:,.:
FIG. 2. Case 1. Enterogram shows original 25 cm. ilea! segment had markedly dilated and elongated during 7 years.
Complications of ureteroileourethrostomy FIG. 1. Ureteroileourethrostomy technique. Ureters were individually anastomosed to antimesenteric side of isolated ilea! segment. Isoperistaltic ilea! segment was then sutured to residual prostate.
Case 3. P. S., VAH 540 01 62 48, a 59-year-old white man, underwent cystectomy, seminal vesiculectomy, subtotal prostatectomy and ureteroileourethrostomy in 1958 because of grade IV, stage B transitional cell carcinoma of the bladder. The upper urinary tracts were normal prior to the operations. The postoperative course was complicated by recurrent obstruction of the urethral catheter by mucus. When the patient was discharged from the hospital he had good daytime urinary control except for occasional stress incontinence. At night he relied upon an external collection device. The stream was weak but the patient emptied the bladder completely with mild Crede maneuver. In January 1959 he underwent exploratory laparotomy, lysis of adhesions and retroperitonealization of the ilea! bladder because of bowel obstruction. An IVP at the time showed minimal blunting of the calices and elevation of the BUN to 32. He was taking potassium citrate to avoid hypokalemic metabolic acidosis. In the subsequent years he has had recurrent urinary tract infections characterized by frequency and urgency without flank pain or fever. He presently is on chronic suppression with trimethoprim-sulfamethoxazole. In April 1974 he had residual urine of 200 cc (fig. 3, A) and was begun on a program of clean, intermittent self-catheterization. An IVP showed moderate dilatation of the upper urinary tracts (fig. 3, B), the serum creatinine was 1.8 and the serum electrolytes were normal. The patient remains continent during the day but requires an external device at night. He is free of tumor 16 years after the cancer operation. DISCUSSION
A review of the 22 cases reported in the literature, Couvelaire's first case and our own 3 cases revealed that a constella-
Case 1 Followup (yrs.) Nocturnal enuresis Mucus plugging Prostatic obstruction Acidosis Stones Infection Upper tract deterioration Bowel obstruction Conversion to ileocutaneous diversion
18
+ + + 0 0
Case 2 l
'-'1.
16
0
+
+ + +
+
0
+
+
+
0 0 2mos.
0 12 yrs.
Case 3
0 0
+ + + 0
tion of complications occurred after ureteroileourethrostomy (see table). Most patients have had daytime urinary continence with mild stress incontinence and nocturnal enuresis requiring an external collection device. Obstruction with mucus has been a problem, especially in the immediate postoperative period. Mucus production decreases when the isolated ileum is in constant contact with urine and light microscopic examinations of the ilea! bladder mucosa have demonstrated thinning of the mucosal layers with autolysis and separation of the tubular glands.• Two of our cases required transurethral resections of obstructing prostatic tissue and the third required clean, intermittent self-catheterization. Hyperchloremic metabolic acidosis occurs occasionally, especially when the conduit becomes obstructed. This problem can be controlled by reduction of residual urine with clean, intermittent self-catheterization, by converting the ureteroileourethrostomy to a ureteroileocutaneous urinary diversion and by giving the patient potassium citrate. Stones in the ilea! bladder form because of infection, retained mucus and residual urine. Reflux of the infected mucous plugs can result in renal calculi or pyelonephritis. Deterioration of the upper tracts occurred in both of our patients who retained their ureteroileourethrostomies for 10 years or more.
31
URETEROILEOURETHROSTOMY: 16-YEAR FOLLOWUP
FIG. 3. Case 3. A, enterogram 16 years after ureteroileourethrostomy reveals residual urine (200 cc) and bilateral reflux. B, excretory nephrotomogram reveals bilateral hydronephrosis and cortical scarring 16 years after ureteroileourethrostomy.
Nearly all of the cases followed for more than 5 years have had upper urinary tract deterioration demonstrated either by pyelograms or renal function studies. 5 · 7 An antiretlux ureteroileal anastomosis will reduce the reflux of infected, mucus-containing urine into the upper urinary tract, thereby reducing the incidence of upper urinary tract infection, hydronephrosis and calculus formation. Postoperative bowel obstruction occurred in 1 of our :3 cases and in 15 per cent of the cases reported by Kuss and associates. 7 Retroperitonealization of the ilea! bladder may reduce the incidence of this complication in the future. The potential complications of ureteroileourethrostomy must be seriously weighed against the major advantage, daytime urinary continence. With improved stomal technique and improved urinary appliances. ureteroileocutaneous diversion has become the accepted method of managing the functionally or anatomically absent bladder. The technique we used in 1958 cannot be recommended
because the residual prostate may contain mvas1ve bladder carcinoma. REFERENCES
l. Couvelaire, R.: Le reservoir ilea! de substitution apres la cystectomie totale ches l'homme. ,J. d'UroL 57: 408, 1951. 2. Mellinger, G. T. and Klatte, P. B.: Uretero-ileo-urethral anastomosis. ,J. Urol., 82: 459, 1959. :l. Gandin, M. M.: Uretero-ileo-urethral anastomosis: case report ..J. Urol., 83: 279, 1960. 4. Pyrah, L. N.: The use of the ileum in urology. Brit. J. Urol., 28: 36:3, 1956. 5. Winter, C. C.: Complete ileocystoplasty (uretero-ileo-urethrostomy): long-term followup. J. Urol., 11 l: 19, 1974. 6. Roblejo, P. G. and Malament, M.: Late results of an ileocystoplasty: a 12-year followup. J. Urol., 109: 38, 197:3. 7. Kiiss, R., Bitker, M., Camey, M., Chatelain, C. and Lassau, J. P.: Indications and early and late results of intestino-cystoplasty: a review of 185 cases. ,J. Urol., !03: 53, 1970.
