Urinary tract reconstruction following ileal conduit diversion

Treatment of upper urinary lithiasis in patients who have undergone urinary diversion

Patients undergoing urinary diversion are at high risk for developing stone disease due to the metabolic and structural features intrinsic to the creation of a urinary reservoir. The utilization of shockwave lithotripsy as well as antegrade and retrograde endoscopic techniques in appropriately selected patients affords a relatively safe and effective means of stone removal. This review focuses on the etiology of stone formation in patients with urinary diversion and examines the most relevant and current reports on expulsive techniques and their associated outcomes for patients within this population who develop upper urinary tract calculi.

Replacement of ureter by ileum

PURPOSE OF REVIEW

The challenge of bridging long defects of ureter has been reviewed with particular emphasis on the utilization of ileum.

RECENT FINDINGS

The application of the Yang-Monti principle can provide an ileal tube of adequate length and suitable cross-sectional diameter. An antireflux ileovesical anastomosis is also feasible.

SUMMARY

Although long-term results are still lacking, an ileal tube constructed on the basis of the Yang-Monti principle seems ideal for ureteric substitution.

Ileal ureteric replacement in complex reconstruction of the urinary tract

OBJECTIVE

To report 10 years' experience with ileal ureteric replacement as a last resort in complex reconstruction of the urinary tract.

PATIENTS AND METHODS

From March 1991 to February 2002 ileal segments were used for partial or total substitution of the ureter in 43 patients (mean age 45.6 years) with structural or functional ureteric loss secondary to irradiation, surgical complications or various other pathological conditions. Ileum was either implanted into the native urinary bladder (in 14) or an intestinal reservoir (in 29). In the latter group the technique was used at the time of primary urinary diversion in eight, in a secondary approach for treating early or late complications in nine and in undiversion or conversion procedures in 12. The ileal ureter was implanted into the urinary reservoir using a serous-lined extramural tunnel or distal intussusception for reflux prevention (in 31). All patients were followed prospectively according to a standardized protocol.

RESULTS

There were no perioperative deaths; the mean (range) follow-up was 40.8 (1.5-109.5) months. In 41 patients with dilatation of the upper urinary tract before surgery there was a significant improvement radiographically in 34, no change in five and deterioration in two. The serum creatinine level decreased or remained stable in all. Reflux occurred in the 12 cases without and in three with an antireflux mechanism. Shortening of an elongated kinking ileal ureter became necessary because of recurrent severe metabolic acidosis and mucus obstruction in two; in one case mucus obstruction was treated endoscopically. There was pyelonephritis only in three patients with refluxing implantation into an intestinal reservoir.

CONCLUSION

Ileal ureteric replacement is a safe and reliable last resort even in difficult cases. Whenever feasible, antirefluxing implantation into intestinal urinary reservoirs is recommended.

Management of complete ureteral replacement. Experiences and review of the literature

The common treatment for patients with extensive damage to the ureter is complete ureteral replacement, combining Boari flap-psoas bladder hitch and downward mobilization of the involved kidney, with complete ideal replacement of the ureter, renal autotransplantation, of elective nephrectomy. Three case reports serve to describe two options of reconstructive treatment for complete ureteral replacement. The operative techniques, their limits, their postoperative results, and the treatment alternatives are discussed with due regard to recent literature. In the case of ileal replacement we have used a very short ileal segment to reduce the absorption surface of the ileal mucosa. Reflux prevention of the ileal segment was performed by creating an invaginated distal ileum nipple which was additionally fixed at the Boari flap by a third stapler row (auto suture TASS) to prevent potential nipple-gliding.

Volvulus of the ileal conduit: a late complication

We report 2 cases of ileal conduit volvulus presenting as a late complication. The importance of early diagnosis and surgical intervention is discussed.

Optimization of replacement of the ureter by ileum

Fifty patients for whom an ileal replacement of the ureter was indicated were prospectively randomized among 2 treatment groups according to the surgical technique used. In group 1 the standard operation was performed. In group 2 a tailored and valved (modified) ileal ureter was used. Patients were followed every 3 to 6 months for 12 to 28 months. Kidney functions were evaluated by 99m technetium diethylenetriaminepentaacetic acid scans and by determination of the 24-hour creatinine clearance. Urine cultures were obtained, and urine viscosity and flow rates were measured. A urographic study, including ascending cystography, was done every 6 months. Results indicated that the modified operation is functionally superior to the standard procedure. It provides efficient unidirectional flow of urine from the kidney to the bladder with less mucus secretion. This was ultimately reflected as better renal function when it was quantitated by renography and/or chemical clearance.

Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients

A total of 12 spinal cord injury adults underwent augmentation enterocystoplasty for treatment of a high pressure neurogenic bladder. These patients suffered from urinary incontinence, recurrent urinary tract infection, upper tract deterioration and severe autonomic dysreflexia. A sigmoid colon segment fashioned into a cup-patch was used in 11 patients and detubularized cecum was used in 1. The artificial urinary sphincter was implanted in 3 patients at augmentation enterocystoplasty and in 1 after enterocystoplasty. After a mean followup of 15 months all patients were continent on clean intermittent self-catheterization, the upper tract had remained stable or had improved and the symptoms of autonomic dysreflexia had disappeared. A third of the patients are on maintenance antibiotic therapy to control bacteriuria.

Continent urinary diversion in gynecologic oncology

Pelvic exenteration is a salvage procedure used primarily for recurrent gynecologic carcinoma. Up to the present time, an ileal or colon conduit has been used for urinary diversion and the patient remains incontinent of urine. This is a preliminary report of nine patients with gynecologic carcinoma in whom a continent urinary diversion procedure was performed. A segment of distal ileum, the ascending colon, and part of the transverse colon are used to create the colonic reservoir. The segment of colon is opened along the tenia and folded onto itself. The walls of the ascending and transverse colon are anastomosed to detubularize this segment of bowel and eliminate the transient high pressure of the colon. Surgical staples are used for the anastomosis. The segment of ileum is tapered and three purse-string sutures (2-O silk) are placed at the level of the ileocecal valve to achieve continence. The short segment of ileum is then exteriorized as a stoma through which the patient catheterizes. Antirefluxing, non-tunneled ureterocolonic anastomoses are performed. The anterior wall of the reservoir is closed with absorbable staples. Postoperative urodynamic studies have shown maximum capacity of 750 ml and the area of continence to be at the ileocecal valve where the purse-string sutures are placed. All patients are continent and postoperative radiographs were negative for reflux. Follow-up was 6 to 12 months. The colonic reservoir is a capacious low-pressure system and warrants further clinical trials in patients with gynecologic cancer.

Pediatric applications of augmentation cystoplasty: the Johns Hopkins experience

Since 1976, 23 children with bladder or cloacal exstrophy, meningomyelocele, sacral agenesis, the prune belly syndrome and noncompliant bladders associated with urethral valves or prior diversion underwent augmentation cystoplasty. Of these procedures 7 were combined with some type of urinary undiversion. Bowel segments used for augmentation included ileum alone in 10 patients, ileocecal segments in 4, a sigmoid patch in 8 and a hindgut patch in 1. An artificial urinary sphincter was placed at the time of bladder augmentation in 3 patients. There were no urinary fistulas or cases of urinary rediversion. Two patients required oral alkalizing agents as a result of persistent systemic acidosis. One patient required reoperation twice for ureteral obstruction, 1 had removal of the sphincter device secondary to erosion, 1 required reinforcement of the ileocecal valve owing to persistent reflux and 1 required reoperation for small bowel obstruction. Other complications included a superficial wound infection and 5 urinary tract infections, all of which were managed easily. Three patients were voiding and continent, 18 were dry with intermittent self-catheterization, 1 had giggle incontinence and 1 remained incontinent after sphincter removal. Augmentation cystoplasty appears to offer a reliable alternative to urinary diversion in the reconstructive management of children with small capacity bladders.

The complications of urinary tract reconstruction

We reviewed 56 patients who underwent urinary tract reconstruction between 1977 and 1984. There were 27 total complications in this group, which ranged from straightforward undiversion to total bladder replacement. Complications were divided into preoperative planning errors and errors of surgical technique. The patients at greatest risk seemed to be those with compromised renal function who previously had undergone diversion for severe obstructive uropathic conditions and those in whom bowel segment was an integral part of the reconstruction. Patients with adequate renal function in whom urothelium alone was used in the reconstruction experienced the fewest complications.

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.

Intestinocystoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction

Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.

Undiversion using ileocecocystoplasty in a case of retroperitoneal hemorrhage after cardiac catheterization

We performed urinary undiversion using ileocecocystoplasty in a patient who sustained bladder and ureteral necrosis secondary to transfemoral cardiac catheterization.

Ileal replacement of the bilharzial ureter: is it worthwhile?

Our 14-year experience with the use of isolated ileal segments for replacement of the bilharzial ureter is analyzed retrospectively. Of 52 patients subjected to this procedure followup data were available for 38, in whom 52 ureters were repaired. The results generally were unsatisfactory: the morbidity and mortality rates were high and the percentage of functional improvement was low. The risk was higher for patients with low creatinine clearance. Therefore, we recommend that this operation be avoided when possible. If the operation is unavoidable, tapering of the ileal segment with antireflux ileovesical anastomosis may improve the outcome. Further clinical study must be done.

Bladder augmentation in the pediatric neuropathic bladder

Augmentation enterocystoplasty was used as an aid to reconstruction of the urinary tract and undiversion in 14 children with neurogenic bladder dysfunction. The long-term results have been excellent in children in whom an effective program of clean intermittent catheterization has been possible. The elements and the importance of the preoperative evaluation are discussed.

Urinary undiversion in adults

At our medical center 7 adult patients with various types of urinary diversion have undergone total reconstruction during a 3-year period. Followup has ranged from 12 to 36 months. Initial pathological conditions included 3 patients with obstruction, 3 with myelodysplasia and associated incontinence, and 1 with massive vesicoureteral reflux. Thorough radiologic, endoscopic and urodynamic evaluation, as well as physiologic testing after vesical hydrodistension, allows careful preoperative selection of reconstruction candidates. Followup studies, including excretory urography and voiding cystourethrography at 3 and 12 months, as well as monthly urine cultures during the first year, have shown that 5 of the 7 patients (71 per cent) are free of vesicoureteral reflux. Two patients have persistent reflux after reconstruction and sterile urine cultures on antibiotic suppression. Renal function has been maintained in 5 of the 7 reconstructed patients (71 per cent) and social continence has been achieved in all 7, including 3 who have achieved social continence by means of clean intermittent catheterization.

The role of bladder augmentation in undiversion

Twenty-nine pediatric patients underwent bladder augmentation as part of their urinary undiversion. Indications included spina bifida deformity, contracted small bladder, and extrophy. Cecal and sigmoid segments were used. Prior diversion included ureterointestinal conduits, vesicostomies, ureterostomies, and suprapubic catheter drainage. In most cases the renal function was normal. Intermittent catheterization is used in almost every cases. Several illustrative cases are shown.

Urinary tract diversion and undiversion in the pediatric age group

Undiversion is an interesting phenomenon but may in part be self-limiting. As the experience with techniques in reconstruction increases, the need for diversion may give way to that of earlier correction of the original pathology, Thus, reversal of diversion by offering a wealth of experience in reconstruction may well lead to its own demise. Nevertheless, even with newer reconstructive techniques, there is, to date, a definite place for diversion of the urinary tract in the pediatric age group and there are now many pediatric patients still to be considered candidates for undiversion

Radiology of urinary undiversion

Many patients with urinary diversions are now considered candidates for "undiversion". Radiographic evaluation prior to undiversion of the urinary tract includes cystography to determine bladder capacity and sensation, urinary continence, and the presence of reflux. Urography, loopography, and/or ureterography (antegrade and/or retrograde) are necessary to completely visualize the remaining urinary structures. Surgical techniques involved in the reconstruction are briefly discussed to facilitate an understanding of the often unusual radiographic appearance of the undiverted urinary tract. Stentograms and cystography are recommended for early postoperative evaluation to exclude urinary leakage or significant obstruction. Percutaneous ureteral perfusion studies are often useful in the long-term follow-up of these patients.

Simplified nonrefluxing ileovesical anastomosis. Experimental study and clinical application

A simplified ileovesical anastomosis is herein described. It prevents vesicoileal reflux and allows for unimpeded efflux of urine into the bladder. The technique involves implanting 3 inches of distal ileum into a denuded muscular bed in the bladder. Vesical mucosa grows over the ileum creating an effective valvular mechanism. Experimental work done on the canine bladder and the use of this technique in 2 patients is described.

Urinary undiversion in myelomeningocele patients with an ileal conduit diversion

Neurogenic bladder in myelomeningocele has been managed until recently by routine ileal conduit urinary diversion. Long-term complications are not uncommon after an ileal conduit and 23 of our patients required major surgical revision during the last 2 years. In 5 patients with an ileal conduit urinary undiversion was performed after excision of the conduit and direct ureteral anastomoses. Over-all progress of these patients has been satisfactory. We conclude that when major surgery is required to correct ileal conduit complications in myelomeningocele, urinary undiversion should be considered in selected cases.

Ileal conduit undiversion: experience with tunneled vesical implantation of tapered conduit

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Urinary tract undiversion in a patient with an areflexic neurogenic bladder: management with intermittent catheterization

Neurogenic bladder disease generally is though to be a contraindication to urinary undiversion. We describe a teenage boy who received an ileal conduit for an areflexic neurogenic bladder. He had a poor emotional reaction to the diversion and requested reconstruction. After extensive studies undiversion was done. The neurogenic bladder has been managed with intermittent catheterization. Thus far, the result has been quite satisfactory.

Experiences with urinary undiversion in children with neurogenic bladder

Six children have undergone reconstruction of the urinary tract 14 months to 14 years after supravesical diversion for neurogenic bladder dysfunction. Five are continent: 4 by intermittent catheterization and 1 by voiding to completion. One child is just beyond infancy and wets but is not yet on a systematic program. One boy was considered a technical failure despite incontinence because of progressive hydronephrosis from a non-compliant bladder but he subsequently had an augmentation cystoplasty. Urinary undiversion into a neurogenic bladder is an acceptable option as an alternative to ileal conduit revision or for reasons of patient preference, provided bladder storage capacity is adequate at acceptably low resting pressures, without incontinence.

Tapered ileum as ureter substitute in severe renal damage: antireflux technique for bladder implantation

Three cases are reported in which ileum has been used to replace irreparably damaged ureters despite preexisting moderate to severe pyelocaliectasis. Two cases have had satisfactory results while one had increasing pyelocaliectasis and azotemia requiring subsequent cutaneous diversion. The rationale for using ileum to replace ureter is presented with a discussion of objectives to be achieved surgically to assure the success of the procedure.

Ileal substitute of ureter with reflux-plasty by terminal intussusception of bowel: animal experiments and clinical experience

The conflicting results reported after substitution of the ureter by isolated bowel segments suggest that the procedure is still hazardous. This induced us to check experimentally the performance of the ileal ureter with antireflux-plasty before using it clinically. The antireflux mechanism is constructed by intussuscepting the terminal 8 cm. of an isolated ileal segment into each other thus forming a nipple. After vesicoileostomy the nipple protrudes into the urinary bladder. In the pig vesicoileorenal reflux was prevented, and anterograde urinary flow from the kidney through the ileal ureter into the bladder was unobstructed. Finally, the case of a patient is recorded who was submitted to the same procedure successfully.

Ileal conduits in children at the Massachusetts General Hospital from 1955 to 1970

The 45 ileal conduits performed on children at the Massachusetts General Hospital from 1955 to 1963 are reviewed and compared to the 45 ileal conduits performed from 1964 to 1970. Late complications involving the conduits occurred in 60 per cent of the early group and in 51 per cent of the late group. Of the renal units judged normal pyelographically preoperatively in the early group 77 per cent went on to at least some deterioration, while 62 per cent of the late group judged normal later deteriorated. Combining all renal units, 34 per cent remained unchanged, 26 per cent improved and 41 per cent showed some degree of deterioration after ileal conduit urinary diversion. The late complication and renal deterioration rates seem to increase progressively with time. There was no apparent urinary obstruction in 13 per cent of the renal units that deteriorated. Theoretical and experimental considerations indicate the reflux of infected urine as the etiology of the renal deterioration. Because of the late complications and the unacceptably high rate of renal deterioration we no longer perform ileal conduits in children. Instead every effort is made to reconstruct the urinary tract or if urinary diversion is necessary, a colon conduit with non-refluxing ureterocolonic anastomoses is performed.

Reflux into the unused ureter

Reflux occurs into unused ureters in patients with urinary diversion and renal tranplantation, and into the ipsilateral ureter in patients with renal agenesis or dysplasia. Efflux may prevent reflux in patients with normal ureterovesical anatomy. If urine begins to flow down the ureter again the reflux may cease. Thus, in patients undergoing urinary tract reconstruction, undiversion should be done before an antireflux operation is performed. Reimplantation can be done after undiversion on a normal capacity bladder if the reflux persists.

Fate of 90 children with ileal conduit urinary diversion a decade later: analysis of complications, pyelography, renal function and bacteriology

A study of the long-term results of ileal conduit urinary diversion for non-malignant disease in 90 children has shown that there were 75 survivors after 10 to 16 years. Stomal stenosis and ureteroileal or other intrinsic obstructions requiring ileal loop revisions occurred frequently and as late as 13 years postoperatively. Of 144 renal units 76 per cent improved or remained stable and 69.3 per cent of normal kidneys remained normal after more than a decade of urinary diversion. In order to obtain these results close lifetime followup and aggressive loop revisions have been required. Urine cultures were consistently negative in 70.5 per cent of all patients. Good results were obtained in terms of preservation of renal function in all categories. Creatinine clearance remained in the normal range after 10 years if the excretory urogram remained normal. Ileal conduit urinary diversion remains a major surgical undertaking but it also remains the standard of urinary diversion against which all other methods must be judged. The results in terms of renal preservation are impressive but so too are the significant number of long-term complications. Any other method of diversion (such as the sigmoid conduit) that can improve upon these results will be welcomed. All children with ileal conduit urinary diversion for reasons other than a neurogenic bladder must be considered candidates for urinary reconstruction.

Complications of megaureter repair in children

In the last 14 years 160 megaureters were repaired in 110 patients. Complications encountered are described as well as suggestions which can help prevent and correct them.

Complications of megaureter repair in children

In the last 14 years 160 megaureters were repaired in 110 patients. Complications encountered are described as well as suggestions which can help prevent and correct them.

Urinary tract refunctionalization after prior diversion in children

Thirty-two children who had undergone previous urinary diversion were operated upon to refunctionalize the bladder. In 24 the diversion had been considered permanent, and in eight, temporary. Success in these procedures suggests that many young patients deserve a second look for possible "undiversion."