Vol. 114, November
ThE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
URETERONEOCYSTOSTOMY BY MEANS OF A MODIFIED TRIANGULAR FLAP METHOD HIROKAZU TAGUCHI, KIYOSHI SAITO
AND
TETSUO YAMADA
From the Department of Urology, Sagamihara National Hospital, Japan
ABSTRACT
A modified triangular flap method of ureteroneocystostomy is described. This method was used in 19 cases (21 ureters) requiring ureteroneocystostomy owing to various diseases. The patients have been followed postoperatively for 1 to 9 years. Our method is more simple than the original method described by Girgis and provides good results. Postoperative complications could be reduced or prevented by gentle manipulation of the ureter and bladder wall and by careful placement of the intravesical ureter into the incised ditch of the bladder floor, loosely anastomosed with interrupted sutures 5 mm. apart. Dilated hydrometers without peristalsis and/or severe degenerative changes of the bladder wall involving the muscle layer are poor indications for the application of this method.
/;·
Many techniques for ureterovesical anastomosis have been reported, specifically to prevent vesicoureteral reflux and infection, and to preserve urinary function. Each method has certain advantages and disadvantages but the success of the operation depends upon the prevention of stricture at the ureterovesical anastomosis and vesicoureteral reflux. When manipulations deep down in the pelvis are required, wide adequate exposure and simple techniques are important for the satisfactory completion and successful outcome of the operation. With these objectives in mind we have simplified the method described by Girgis and associates and have used this modified technique on 19 patients (21 ureters) with good results. 1 • 2 Indications for the method have been considered. MATERIALS
The series consists of urological patients hospitalized between 1965 and 1973. Ureteroneocystostomy was performed in 7 of 19 cases for correction of vesicoureteral reflux and/or stricture at the end of the ureter, and in the remaining 12 cases ureteroneocystostomy was combined with other J operative procedures for the treatment of various diseases. The patients have been observed at periodic intervals for 1 to 9 years postoperatively (see table). TECHNIQUE
The anesthetic method and the type of skin ' ~ incision depend on the operation being performed. . The bladder was exposed anteriorly through the •1 incision. The peritoneal fold over the bladder was Accepted for publication February 28, 1975.
stripped upward and the posterior wall of the bladder was bluntly separated toward the base. The ureter was exposed adequately and held with a 3F Nelaton catheter and the ureter was separated from the surrounding tissues so that it could be passed into the bladder without undue tension. The ureter was ligated and severed close to its junction with the bladder. The bladder was then opened in the anterior midline and the ureteral orifices were identified. A long, slim clamp was forced through the entire wall of the bladder approximately 3 cm. superior and slightly lateral to the former ureteral orifice and passed behind the bladder until it could grasp the traction suture of the ureter. The clamp was then withdrawn into the bladder. The new opening was made large enough to allow easy passage of the small finger to avoid the occurrence of postoperative stricture. The severed ureter was thus pulled into the bladder. A marker suture was placed through the tip of the ureter to later identify the anterior wall of the ureter during anastomosis. The ureter was spatulated by incising longitudinally the posterior wall for about 2 cm. The incised ureter would then show an inverted V shape. To create a raw ditch on the bladder wall into which the incised ureter could be inserted an inverted V-shaped incision was now made through the bladder membrane and superficial musculature to correspond to that of the ureter. Thus, the apex of this inverted Vshaped incision started at the new ureteral orifice and the limbs of the inverted V-shaped incision in the bladder were at least 3 cm. long. A 3-zero chromic interrupted suture was used to join the apex of the inverted V-shaped incised ureter to the apex of the inverted V shape of the bladder. Then each margin of the incised intravesi705
706
TAGUCHI, SAITO AND YAMADA
Results after the simplified method by Taguchi in 21 ureters (19 cases) Sex-Age
M-71
I I
Side of Reimplantation
Followup
9 yrs. 3 mos.
M-54 F-29
Rt. Rt. Rt.
6 yrs. 11 mos.
M- 3
Lt./rt.
5 yrs. 9 mos.
M-18
Lt.
4 yrs. 10 mos.
M-33
Lt.
4 yrs. 6 mos.
F-28
Lt./rt.
4 yrs. 1 mo.
F-25
Lt.
4 yrs.
F-25
Lt.
3 yrs. 1 mo.
F-49
Lt.
2 yrs. 11 mos.
F-35
Rt.
2 yrs. 9 mos.
F-34
Lt.
2 yrs. 6 mos.
F-30
Lt.
2 yrs. 5 mos.
M-23
Lt.
1 yr. 7 mos.
F-23 F-26
Rt. Rt.
1 yr. 6 mos. 1 yr. 6 mos.
F-52
Rt.
1 yr. 5 mos.
M-19
Lt.
1 yr. 3 mos.
F- 6
Lt.
1 yr,
9 yrs. 2 mos.
Reason for Operation
Partial cystectomy for bladder tumor Partial cystectomy for bladder tumor Stricture rt. ureter end with lt. renal tuberculosis Chronic pyelonephritis with bilat. ureteral reflux Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with lt. staghorn calculi Bilat. ureter with rt. hydronephrosis and lt. contracted kidney Lt. ureteral reflux with vesicosigmoidal fistula Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with contracted bladder for urinary tuberculosis Stricture rt. ureter end for urinary tuberculosis Lt. ureteral reflux with interstitial cystitis Chronic pyelonephritis with lt. ureteral reflux Stricture lt. ureter end with stricture lt. ureteropelvic junction Stricture rt. ureter end Rt. ureteral reflux with contracted bladder and lt. non-functional kidney Stricture rt. ureter end and rt. ureteral reflux, staghorn calculi in rt. solitary kidney, contracted bladder, vesicovaginal fistula Stricture lt. ureter end and lt. ureteral reflux Stricture lt. ureter end with lt. hydroureteronephrosis
Grade of Dilatation in Pyelogram
Voiding Cystogram
Preop. *
Postop. *
Preop.
Postop.
N A
N N NA
None None None
None None None
C
B
Bilat. reflux Lt. reflux None
None
A
NA NA NA
C
B
AB
N
C
BC
C
B A A
None None None
B
Bilat. reflux Lt. reflux Lt. reflux None
Lt. reflux None
NA
N
None
None
D
AB
C
NA
Lt. reflux None
A
A
Lt. reflux Lt. reflux None
NA DE
NA DE
B
A
None Rt. reflux Lt. reflux
None Rt. reflux Lt. reflux
B
A
C
C
Lt. reflux None
Lt. reflux None
None
None
* A-apex of minor calices is minimally round but persists hallowed out and shows pyramidal depression. B-apex of minor calices shows clubbing and the isthmus and pelvis are moderately dilated. C-major calices, isthmus and pelvis are greatly dilated but retain their proper functions. D-major calices and pelvis show remarkable dilatation and finally to large round calices. E-pelvis and calices cannot be differentiated and appear as a huge dilatated sac. NA-intermediate between N (normal) and A. AB-intermediate between A and B.
cal ureter was sutured with stitches about 5 mm. apart into each limb of the inverted V-shaped incision on the bladder wall with 3-zero chromic interrupted sutures. The opposing raw surfaces were approximated carefully with a small pincer. The sutures included the full thickness of the ureteral wall and half of the muscular layer of the bladder (figs. 1, A and 2). Two or 3 sutures of3-zero chromic catgut were then placed on the outside of the bladder where the ureter passed. Splinting catheters were ordinarily not required for the reimplanted ureter. The bladder was then closed with 1-zero catgut interrupted sutures in 2 layers. The bladder was drained by a transurethral 15F Nelaton cathet0,. with :rn
ThE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
Printed in U.S.A.
URETERONEOCYSTOSTOMY BY MEANS OF A MODIFIED TRIANGULAR FLAP METHOD HIROKAZU TAGUCHI, KIYOSHI SAITO
AND
TETSUO YAMADA
From the Department of Urology, Sagamihara National Hospital, Japan
ABSTRACT
A modified triangular flap method of ureteroneocystostomy is described. This method was used in 19 cases (21 ureters) requiring ureteroneocystostomy owing to various diseases. The patients have been followed postoperatively for 1 to 9 years. Our method is more simple than the original method described by Girgis and provides good results. Postoperative complications could be reduced or prevented by gentle manipulation of the ureter and bladder wall and by careful placement of the intravesical ureter into the incised ditch of the bladder floor, loosely anastomosed with interrupted sutures 5 mm. apart. Dilated hydrometers without peristalsis and/or severe degenerative changes of the bladder wall involving the muscle layer are poor indications for the application of this method.
/;·
Many techniques for ureterovesical anastomosis have been reported, specifically to prevent vesicoureteral reflux and infection, and to preserve urinary function. Each method has certain advantages and disadvantages but the success of the operation depends upon the prevention of stricture at the ureterovesical anastomosis and vesicoureteral reflux. When manipulations deep down in the pelvis are required, wide adequate exposure and simple techniques are important for the satisfactory completion and successful outcome of the operation. With these objectives in mind we have simplified the method described by Girgis and associates and have used this modified technique on 19 patients (21 ureters) with good results. 1 • 2 Indications for the method have been considered. MATERIALS
The series consists of urological patients hospitalized between 1965 and 1973. Ureteroneocystostomy was performed in 7 of 19 cases for correction of vesicoureteral reflux and/or stricture at the end of the ureter, and in the remaining 12 cases ureteroneocystostomy was combined with other J operative procedures for the treatment of various diseases. The patients have been observed at periodic intervals for 1 to 9 years postoperatively (see table). TECHNIQUE
The anesthetic method and the type of skin ' ~ incision depend on the operation being performed. . The bladder was exposed anteriorly through the •1 incision. The peritoneal fold over the bladder was Accepted for publication February 28, 1975.
stripped upward and the posterior wall of the bladder was bluntly separated toward the base. The ureter was exposed adequately and held with a 3F Nelaton catheter and the ureter was separated from the surrounding tissues so that it could be passed into the bladder without undue tension. The ureter was ligated and severed close to its junction with the bladder. The bladder was then opened in the anterior midline and the ureteral orifices were identified. A long, slim clamp was forced through the entire wall of the bladder approximately 3 cm. superior and slightly lateral to the former ureteral orifice and passed behind the bladder until it could grasp the traction suture of the ureter. The clamp was then withdrawn into the bladder. The new opening was made large enough to allow easy passage of the small finger to avoid the occurrence of postoperative stricture. The severed ureter was thus pulled into the bladder. A marker suture was placed through the tip of the ureter to later identify the anterior wall of the ureter during anastomosis. The ureter was spatulated by incising longitudinally the posterior wall for about 2 cm. The incised ureter would then show an inverted V shape. To create a raw ditch on the bladder wall into which the incised ureter could be inserted an inverted V-shaped incision was now made through the bladder membrane and superficial musculature to correspond to that of the ureter. Thus, the apex of this inverted Vshaped incision started at the new ureteral orifice and the limbs of the inverted V-shaped incision in the bladder were at least 3 cm. long. A 3-zero chromic interrupted suture was used to join the apex of the inverted V-shaped incised ureter to the apex of the inverted V shape of the bladder. Then each margin of the incised intravesi705
706
TAGUCHI, SAITO AND YAMADA
Results after the simplified method by Taguchi in 21 ureters (19 cases) Sex-Age
M-71
I I
Side of Reimplantation
Followup
9 yrs. 3 mos.
M-54 F-29
Rt. Rt. Rt.
6 yrs. 11 mos.
M- 3
Lt./rt.
5 yrs. 9 mos.
M-18
Lt.
4 yrs. 10 mos.
M-33
Lt.
4 yrs. 6 mos.
F-28
Lt./rt.
4 yrs. 1 mo.
F-25
Lt.
4 yrs.
F-25
Lt.
3 yrs. 1 mo.
F-49
Lt.
2 yrs. 11 mos.
F-35
Rt.
2 yrs. 9 mos.
F-34
Lt.
2 yrs. 6 mos.
F-30
Lt.
2 yrs. 5 mos.
M-23
Lt.
1 yr. 7 mos.
F-23 F-26
Rt. Rt.
1 yr. 6 mos. 1 yr. 6 mos.
F-52
Rt.
1 yr. 5 mos.
M-19
Lt.
1 yr. 3 mos.
F- 6
Lt.
1 yr,
9 yrs. 2 mos.
Reason for Operation
Partial cystectomy for bladder tumor Partial cystectomy for bladder tumor Stricture rt. ureter end with lt. renal tuberculosis Chronic pyelonephritis with bilat. ureteral reflux Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with lt. staghorn calculi Bilat. ureter with rt. hydronephrosis and lt. contracted kidney Lt. ureteral reflux with vesicosigmoidal fistula Lt. ureteral reflux with contracted bladder for urinary tuberculosis Stricture lt. ureter end with contracted bladder for urinary tuberculosis Stricture rt. ureter end for urinary tuberculosis Lt. ureteral reflux with interstitial cystitis Chronic pyelonephritis with lt. ureteral reflux Stricture lt. ureter end with stricture lt. ureteropelvic junction Stricture rt. ureter end Rt. ureteral reflux with contracted bladder and lt. non-functional kidney Stricture rt. ureter end and rt. ureteral reflux, staghorn calculi in rt. solitary kidney, contracted bladder, vesicovaginal fistula Stricture lt. ureter end and lt. ureteral reflux Stricture lt. ureter end with lt. hydroureteronephrosis
Grade of Dilatation in Pyelogram
Voiding Cystogram
Preop. *
Postop. *
Preop.
Postop.
N A
N N NA
None None None
None None None
C
B
Bilat. reflux Lt. reflux None
None
A
NA NA NA
C
B
AB
N
C
BC
C
B A A
None None None
B
Bilat. reflux Lt. reflux Lt. reflux None
Lt. reflux None
NA
N
None
None
D
AB
C
NA
Lt. reflux None
A
A
Lt. reflux Lt. reflux None
NA DE
NA DE
B
A
None Rt. reflux Lt. reflux
None Rt. reflux Lt. reflux
B
A
C
C
Lt. reflux None
Lt. reflux None
None
None
* A-apex of minor calices is minimally round but persists hallowed out and shows pyramidal depression. B-apex of minor calices shows clubbing and the isthmus and pelvis are moderately dilated. C-major calices, isthmus and pelvis are greatly dilated but retain their proper functions. D-major calices and pelvis show remarkable dilatation and finally to large round calices. E-pelvis and calices cannot be differentiated and appear as a huge dilatated sac. NA-intermediate between N (normal) and A. AB-intermediate between A and B.
cal ureter was sutured with stitches about 5 mm. apart into each limb of the inverted V-shaped incision on the bladder wall with 3-zero chromic interrupted sutures. The opposing raw surfaces were approximated carefully with a small pincer. The sutures included the full thickness of the ureteral wall and half of the muscular layer of the bladder (figs. 1, A and 2). Two or 3 sutures of3-zero chromic catgut were then placed on the outside of the bladder where the ureter passed. Splinting catheters were ordinarily not required for the reimplanted ureter. The bladder was then closed with 1-zero catgut interrupted sutures in 2 layers. The bladder was drained by a transurethral 15F Nelaton cathet0,. with :rn
