WALLACE METHOD OF URETEROILEAL ANASTOMOSIS C . A . LINKE, M .D. H . A. RASHID, M .D . R. S . DAVIS, M.D. C . W. FRIDD, B.S . From the Division of Urology, Department of Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, New York
ABSTRACT - The Wallace technique for ureteroileal anastomosis was used in 28 consecutive patients requiring urinary diversion . Details of the surgical technique are reported . The method is found to be appropriate for children and adults, for primary ureteroileal anastomosis, or for revision of previous ureteroileal anastomosis done by other techniques, and for patients with one or two ureters . Its
continued use appears to be
indicated .
Ureterocutaneous urinary diversion using a conduit of ileum has proved to be practical, well tolerated, and suited to the management of many urologic problems . In the technique described by Bricker in 1950' the proximal end of the segment of ileum is closed and each ureter is joined to the segment in an end to side manner. In 1966 Wallace' described a modification of the ureteroileal anastomosis in which both ureters are joined together and then "capped" to the proximal end of the segment of ileum . The technique described by Wallace has been used in 28 consecutive patients requiring urinary diversion . Experience in the management of this group of patients is the subject of this report . Material and Methods The patients treated were seen from January, to October, 1974 . The age range was three years to eighty-two years . The conditions treated included neurogenic bladder (14 cases), carcinoma of the bladder (11.), bladder exstrophy (1), carcinoma of the ovary (1), and urinary incontinence and ureteral obstruction following severe pelvic trauma (1) . The method was used for revision of ureteroileal anastomosis done by the Bricker technique in 1 patient . Three patients in the group had only a single ureter . 1970,
UHOLOGY / JULY 1975 / VOLUME VI,
NUMBER 1
Surgical
technique
The ureters were isolated through a transverse incision of posterior peritoneum beginning just below the cecum and were sectioned at or just proximal to the ureterovesical junction . Fatty areolar tissue and vessels around each ureter were carefully preserved in the segments to he used for anastomosis . Lateral attachments to the left ureter were divided up to and above the level of origin of the inferior mesenteric artery from the aorta . To stabilize the ureters during anastomosis, they were clamped side by side in their distal redundant portions. A transverse incision was made into each ureteral lumen ; this was lengthened longitudinally to an approximately even level (Fig . 1A) . The medial edges of the cut ureters were sutured together with continuous 4-0 chromic catgut beginning at the distal end (Fig . IB) . As the suturing of the medial edge approached the upper end of the incision in the ureters, any discrepancy in length of incision was corrected by further appropriate incision (Fig . 1B) . The medial edge suture was brought out through the right ureter at the apex of the incision in this ureter so that it was then outside of the ureteral lumen . The upper corners of incisions in the ureters were joined by a second
43
LISTING ETERAL INCISION LENGTH
ING MEDIAL EDGES
NDANT MUCOSA EXCISED R
APICAL
SUTURE (2) INSERTED
ILEUM
SUTURED TO URETERS
FicuiiE 1 . Surgical technique for Wallace method of ureteroileal anastomosis . (A) Transverse incision through posterior peritoneum, followed by transverse and longitudinal incisions in each mobilized ureter ; (B) medial edges ofureters sutured (suture no . 1), and proximal end of ureteral incisions lengthened if necessary ; (C) apical (suture no . 2) used to approximate upper corners of ureteral incisions ; (D) redundant ileal mucosa excised ; (E) ileum sutured to conjoined ureters .
44
UROLOGY / JULY 1975 / VOLUME V1, NUMBER 1
F
ANASTOMOSIS CONTINUED
ANASTOMOSIS COMPLETED
PERITONEUM SUTURED TO ILEUM FIGURE 1 . Wallace method ofureteroileal anastomosis (continued) . (F) Ureteroileal anastomosis continued from outside of left ureteral wall; (G) anastomosis completed, after excision of redundant portions of ureters ; and (H) ureteroileal anastomosis placed retroperitoneally in closure of posterior peritoneum .
UROLOGY / JULY 1975 / VOLUME VI . NUMBER 1
45
suture which was tied with the knot outside of the lumen (Fig . 1C). The loose end of the first ureteral suture was tied to this second suture knot . In this way the suture was secured without having the knot in the small opening of either ureteral lumen. A cuff of the redundant mucosa which protruded from the proximal end of the isolated segment of ileum was excised to facilitate careful suturing of ileum to ureteral wall (Fig . 1D) . A third (continuous) suture (4-0 chromic) was then used to suture full thickness of ileum to the conjoined ureters beginning on the right lateral ureteral edge near the distal end of the incision into the ureteral lumen (Fig . iE) . Suturing of ileum to ureter was continued under direct vision from
TABLE I .
within the lumen until the suturing had been accomplished well beyond the lumen of the left ureter. At this point it became easier to suture ureter to ileum from the outside so the third suture was then passed outside on the left lateral ureteral wall (Fig . 1F) and continued around to complete the anastomosis (Fig . 1G) . When suturing of ileum to ureters came near to the lower ends of the ureteral incisions, the redundant portions of ureters were excised . Following ureteral transection, ureteral arterial vessels often required individual ligature . A few superficial interrupted 5-0 chromic catgut sutures were often used to reinforce the ureteroileal anastomosis, but no effort was made to make a complete twolayer closure . In those patients having a single
Wallace technique of ureteroileostomies - preand postoperative status of ureters*
Ureter Case Number 1 2 3 4 5 6} 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Right Diagnosis
Pre
Post
3 80 19 45 20 29 10 67 22 30 82 63 80 8 20 71 40 67 51 23 24 71 56 5 11 63 27 64
NB CB NB NB NB NB NB CB NB NB C B CB CB EB NB CB NB CB CO NB NB CB CB NB PT CB NB CB
++++ 0 ++ 0
++ 0 + 0 0 + 0 -
NB = neurogenic bladder CB = carcinoma of bladder EB = exstrophy of bladder PT = pelvic trauma CO = carcinoma of ovary (Revision of ureteroileal anastomosis
*Key:
46
Left
Age
+++ +++ 0 0
Absent + 0 + 0 0 0
+
0 0 + +
++ + + 0
Post
++++ ++ 0 0 + 0 0 0 + 0 ++++ + 0 ++ 0 + 0 + 0 0 0
+ 0
0 0
0 0 0 0 0 +
++ + 0 0 0 0 ++++
0 0 0 0 0 0 ++
0 0 0
0 0
Absent + + 0 0 0 ++ 0 0 0
Pre
Absent 0 0
+ = degree of ureteral dilatation 0 = normal ureter - = no postoperative intravenous pyelogram done by Bricker technique .
UROLOGY / JULY 1975 / VOLUME VI, NUMBER 1
ureter, only the third suture described was needed . The entire ureteroileal anastomosis was placed retroperitoneally by including the wall of the isolated segment of ileum in the closure of posterior peritoneum (Fig . 1H) . Infant feeding tubes (no . 5 or 8) were left in each ureter and brought through the ilea] stoma for four to five days postoperatively. Results Pre- and postoperative intravenous pyelograms were reviewed, and each ureter was evaluated regarding evidence of dilatation . Values assigned to each ureter are tabulated in Table I . Follow-up intravenous pyelograms were obtained in 24 patients, and all ureters that were normal preoperatively remained normal postoperatively, except in 1 patient (Case 7) . In this patient there was postoperative dilatation of the left ureter of moderate degree, above the level where it was brought medially to join the right side . In ureters in which preoperative dilatation was noted, the ureters remained the same or were improved postoperatively. There was no indication of leakage of urine noted in any patient . Stenosis of the stoma of the ileum at the level of the skin occurred in 1 child (Case 1) . This responded to dilatation of the stoma. In 1 quadriplegic patient (Case 5) a left ureteral stone developed three years following urinary diversion and required ureterolithotomy . Postradiation bowel obstruction in 1 patient required reoperation and surgical correction (Case 23) . Four patients (Cases 8, 11, 12, and 13) died of recurrent carcinoma of the bladder .
ureteral lumen throughout the anastomosis is possible ; (4) separate closure of the proximal end of the conduit is avoided ; (5) a shorter ileal segment may be used ; and (6) the entire anastomosis may be peritonealized under direct vision . In 1970 Wallace' reported a change in his technique in which the right and left ureters were both directed toward the midline, placed head to tail suturing the medial edge of the right ureter to the lateral edge of the left ureter to form a U-shaped cap rather than the V-shaped arrangement originally described . This revision of the technique was said to be used because of difficulties encountered with angulation of the left ureter as it came toward the midline . In 1 patient (Case 7) in our study there was evidence of dilatation of the left ureter above the level where it crosses medially to join the right ureter . In our other patients, it appeared that mobilization of the left ureter to the level of the inferior mesenteric artery and often above this level allowed satisfactory positioning of the left ureter to avoid this complication . Anterior retraction of inferior mesenteric vessel branches allows complete vision of the left ureter throughout this portion of its retroperitoneal course . Where angulation appeared to exist, it could usually be corrected by diversion of fatty areolar attachments lateral to the ureter . 601 Elmwood Avenue New York 14642 (DR . LINKE)
Rochester,
References Bladder substitution after pelvic evisceration, Surg. Clin . North Am . 30 : 1511 (1950) . 2 . WATTACE,D .N1 . : IJretericdiversionusingacondnit:a simplified technique, Br . J . Urol . 38 : 522 (1966) . 3 . ALBERT, D . J ., and PERSKY, L . : Conjoined end-to-end ureterointestinal anastomosis, J . Urol . 105 : 201 (1971) . 4 . WIEDERHORN, A. R ., and ROBERTS, M . : Ureteroileal anastomosis, Urology 3 : 168 (1974) . 5 . ESHO, J . O ., VITKO, R . J ., IRELAND, G . W ., and CASS, A. S . : Comparison of Bricker and Wallace methods of uretcroileal anastomosis in urinary diversions, J . Urol . 111 : 600 (1974) . 6 . WALLACE, D . M . : Uretero-ileostomy, Br . J . Urol . 42 : 529 (1970) . 1 . BRICKER, E . M . :
Comment Favorable experience using the Wallace technique has been reported by Albert and Perskey,a Wiederhorn and Roberts, 4 and Esho et al.' As noted by previous authors the technique offers the following advantages : (1) a single, large anastomosis of ureters to ileum is developed ; (2) ureteroileal anastomosis may be performed higher on the ureter than with the conventional Bricker anastomosis ; (3) direct visualization of the
UROLOGY /
JULY 1975
/ VOLUME VI, NUMBER I
47
ABSTRACT - The Wallace technique for ureteroileal anastomosis was used in 28 consecutive patients requiring urinary diversion . Details of the surgical technique are reported . The method is found to be appropriate for children and adults, for primary ureteroileal anastomosis, or for revision of previous ureteroileal anastomosis done by other techniques, and for patients with one or two ureters . Its
continued use appears to be
indicated .
Ureterocutaneous urinary diversion using a conduit of ileum has proved to be practical, well tolerated, and suited to the management of many urologic problems . In the technique described by Bricker in 1950' the proximal end of the segment of ileum is closed and each ureter is joined to the segment in an end to side manner. In 1966 Wallace' described a modification of the ureteroileal anastomosis in which both ureters are joined together and then "capped" to the proximal end of the segment of ileum . The technique described by Wallace has been used in 28 consecutive patients requiring urinary diversion . Experience in the management of this group of patients is the subject of this report . Material and Methods The patients treated were seen from January, to October, 1974 . The age range was three years to eighty-two years . The conditions treated included neurogenic bladder (14 cases), carcinoma of the bladder (11.), bladder exstrophy (1), carcinoma of the ovary (1), and urinary incontinence and ureteral obstruction following severe pelvic trauma (1) . The method was used for revision of ureteroileal anastomosis done by the Bricker technique in 1 patient . Three patients in the group had only a single ureter . 1970,
UHOLOGY / JULY 1975 / VOLUME VI,
NUMBER 1
Surgical
technique
The ureters were isolated through a transverse incision of posterior peritoneum beginning just below the cecum and were sectioned at or just proximal to the ureterovesical junction . Fatty areolar tissue and vessels around each ureter were carefully preserved in the segments to he used for anastomosis . Lateral attachments to the left ureter were divided up to and above the level of origin of the inferior mesenteric artery from the aorta . To stabilize the ureters during anastomosis, they were clamped side by side in their distal redundant portions. A transverse incision was made into each ureteral lumen ; this was lengthened longitudinally to an approximately even level (Fig . 1A) . The medial edges of the cut ureters were sutured together with continuous 4-0 chromic catgut beginning at the distal end (Fig . IB) . As the suturing of the medial edge approached the upper end of the incision in the ureters, any discrepancy in length of incision was corrected by further appropriate incision (Fig . 1B) . The medial edge suture was brought out through the right ureter at the apex of the incision in this ureter so that it was then outside of the ureteral lumen . The upper corners of incisions in the ureters were joined by a second
43
LISTING ETERAL INCISION LENGTH
ING MEDIAL EDGES
NDANT MUCOSA EXCISED R
APICAL
SUTURE (2) INSERTED
ILEUM
SUTURED TO URETERS
FicuiiE 1 . Surgical technique for Wallace method of ureteroileal anastomosis . (A) Transverse incision through posterior peritoneum, followed by transverse and longitudinal incisions in each mobilized ureter ; (B) medial edges ofureters sutured (suture no . 1), and proximal end of ureteral incisions lengthened if necessary ; (C) apical (suture no . 2) used to approximate upper corners of ureteral incisions ; (D) redundant ileal mucosa excised ; (E) ileum sutured to conjoined ureters .
44
UROLOGY / JULY 1975 / VOLUME V1, NUMBER 1
F
ANASTOMOSIS CONTINUED
ANASTOMOSIS COMPLETED
PERITONEUM SUTURED TO ILEUM FIGURE 1 . Wallace method ofureteroileal anastomosis (continued) . (F) Ureteroileal anastomosis continued from outside of left ureteral wall; (G) anastomosis completed, after excision of redundant portions of ureters ; and (H) ureteroileal anastomosis placed retroperitoneally in closure of posterior peritoneum .
UROLOGY / JULY 1975 / VOLUME VI . NUMBER 1
45
suture which was tied with the knot outside of the lumen (Fig . 1C). The loose end of the first ureteral suture was tied to this second suture knot . In this way the suture was secured without having the knot in the small opening of either ureteral lumen. A cuff of the redundant mucosa which protruded from the proximal end of the isolated segment of ileum was excised to facilitate careful suturing of ileum to ureteral wall (Fig . 1D) . A third (continuous) suture (4-0 chromic) was then used to suture full thickness of ileum to the conjoined ureters beginning on the right lateral ureteral edge near the distal end of the incision into the ureteral lumen (Fig . iE) . Suturing of ileum to ureter was continued under direct vision from
TABLE I .
within the lumen until the suturing had been accomplished well beyond the lumen of the left ureter. At this point it became easier to suture ureter to ileum from the outside so the third suture was then passed outside on the left lateral ureteral wall (Fig . 1F) and continued around to complete the anastomosis (Fig . 1G) . When suturing of ileum to ureters came near to the lower ends of the ureteral incisions, the redundant portions of ureters were excised . Following ureteral transection, ureteral arterial vessels often required individual ligature . A few superficial interrupted 5-0 chromic catgut sutures were often used to reinforce the ureteroileal anastomosis, but no effort was made to make a complete twolayer closure . In those patients having a single
Wallace technique of ureteroileostomies - preand postoperative status of ureters*
Ureter Case Number 1 2 3 4 5 6} 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Right Diagnosis
Pre
Post
3 80 19 45 20 29 10 67 22 30 82 63 80 8 20 71 40 67 51 23 24 71 56 5 11 63 27 64
NB CB NB NB NB NB NB CB NB NB C B CB CB EB NB CB NB CB CO NB NB CB CB NB PT CB NB CB
++++ 0 ++ 0
++ 0 + 0 0 + 0 -
NB = neurogenic bladder CB = carcinoma of bladder EB = exstrophy of bladder PT = pelvic trauma CO = carcinoma of ovary (Revision of ureteroileal anastomosis
*Key:
46
Left
Age
+++ +++ 0 0
Absent + 0 + 0 0 0
+
0 0 + +
++ + + 0
Post
++++ ++ 0 0 + 0 0 0 + 0 ++++ + 0 ++ 0 + 0 + 0 0 0
+ 0
0 0
0 0 0 0 0 +
++ + 0 0 0 0 ++++
0 0 0 0 0 0 ++
0 0 0
0 0
Absent + + 0 0 0 ++ 0 0 0
Pre
Absent 0 0
+ = degree of ureteral dilatation 0 = normal ureter - = no postoperative intravenous pyelogram done by Bricker technique .
UROLOGY / JULY 1975 / VOLUME VI, NUMBER 1
ureter, only the third suture described was needed . The entire ureteroileal anastomosis was placed retroperitoneally by including the wall of the isolated segment of ileum in the closure of posterior peritoneum (Fig . 1H) . Infant feeding tubes (no . 5 or 8) were left in each ureter and brought through the ilea] stoma for four to five days postoperatively. Results Pre- and postoperative intravenous pyelograms were reviewed, and each ureter was evaluated regarding evidence of dilatation . Values assigned to each ureter are tabulated in Table I . Follow-up intravenous pyelograms were obtained in 24 patients, and all ureters that were normal preoperatively remained normal postoperatively, except in 1 patient (Case 7) . In this patient there was postoperative dilatation of the left ureter of moderate degree, above the level where it was brought medially to join the right side . In ureters in which preoperative dilatation was noted, the ureters remained the same or were improved postoperatively. There was no indication of leakage of urine noted in any patient . Stenosis of the stoma of the ileum at the level of the skin occurred in 1 child (Case 1) . This responded to dilatation of the stoma. In 1 quadriplegic patient (Case 5) a left ureteral stone developed three years following urinary diversion and required ureterolithotomy . Postradiation bowel obstruction in 1 patient required reoperation and surgical correction (Case 23) . Four patients (Cases 8, 11, 12, and 13) died of recurrent carcinoma of the bladder .
ureteral lumen throughout the anastomosis is possible ; (4) separate closure of the proximal end of the conduit is avoided ; (5) a shorter ileal segment may be used ; and (6) the entire anastomosis may be peritonealized under direct vision . In 1970 Wallace' reported a change in his technique in which the right and left ureters were both directed toward the midline, placed head to tail suturing the medial edge of the right ureter to the lateral edge of the left ureter to form a U-shaped cap rather than the V-shaped arrangement originally described . This revision of the technique was said to be used because of difficulties encountered with angulation of the left ureter as it came toward the midline . In 1 patient (Case 7) in our study there was evidence of dilatation of the left ureter above the level where it crosses medially to join the right ureter . In our other patients, it appeared that mobilization of the left ureter to the level of the inferior mesenteric artery and often above this level allowed satisfactory positioning of the left ureter to avoid this complication . Anterior retraction of inferior mesenteric vessel branches allows complete vision of the left ureter throughout this portion of its retroperitoneal course . Where angulation appeared to exist, it could usually be corrected by diversion of fatty areolar attachments lateral to the ureter . 601 Elmwood Avenue New York 14642 (DR . LINKE)
Rochester,
References Bladder substitution after pelvic evisceration, Surg. Clin . North Am . 30 : 1511 (1950) . 2 . WATTACE,D .N1 . : IJretericdiversionusingacondnit:a simplified technique, Br . J . Urol . 38 : 522 (1966) . 3 . ALBERT, D . J ., and PERSKY, L . : Conjoined end-to-end ureterointestinal anastomosis, J . Urol . 105 : 201 (1971) . 4 . WIEDERHORN, A. R ., and ROBERTS, M . : Ureteroileal anastomosis, Urology 3 : 168 (1974) . 5 . ESHO, J . O ., VITKO, R . J ., IRELAND, G . W ., and CASS, A. S . : Comparison of Bricker and Wallace methods of uretcroileal anastomosis in urinary diversions, J . Urol . 111 : 600 (1974) . 6 . WALLACE, D . M . : Uretero-ileostomy, Br . J . Urol . 42 : 529 (1970) . 1 . BRICKER, E . M . :
Comment Favorable experience using the Wallace technique has been reported by Albert and Perskey,a Wiederhorn and Roberts, 4 and Esho et al.' As noted by previous authors the technique offers the following advantages : (1) a single, large anastomosis of ureters to ileum is developed ; (2) ureteroileal anastomosis may be performed higher on the ureter than with the conventional Bricker anastomosis ; (3) direct visualization of the
UROLOGY /
JULY 1975
/ VOLUME VI, NUMBER I
47
