ILEAL CONDUIT: ACUTE OBSTRUCTION OF THE URETERO-ILEAL ANASTOMOSIS1

By E. PROCA, M.D. Panduri Hospital, Bucharest

THERE has been a great deal of discussion on problems related to the ileal conduit, and many modifications of the surgical technique have been devised in order to improve the results of this method of urinary diversion.

In the present paper we do not intend to discuss the advantages or disadvantages of ileo- cutaneous ureterostomy, which has proved to be possibly the most satisfactory means of urinary diversion (Parkhurst, 1968) and the most widely used, especially because it can prevent further renal deterioration which is rarely the case with other methods of diversion (Fonkalsrud and Smith, 1965). We should like to focus our attention upon a particular complication we have had, namely acute obstruction of the uretero-ileal anastomosis, a condition which requires prompt diagnosis and careful management.

Whilst chronic slowly developing strictures of the uretero-ileal anastomosis are not un- common (Thompson, 1964; Bowles et al., 1964), acute obstruction has rarely been reported. Kafetsioulis and Swinney (1968) mentioned one case in a series of 64 patients with ileal conduits but gave no details, and Fonkalsrud and Smith (1965) noted a similar case in a series of 16 patients.

The present paper refers to a group of 14 consecutive patients who underwent urinary diversion by means of an ileal conduit between September 1964 and March 1969.

Clinical Features.-In all cases a standard technique was used. An isolated ileal loop was prepared in conventional fashion. The ureters were localised,

divided and intubated with 12F. whistle-tip plastic catheters for about 12 cm., each being held in position by a catgut suture. A soft intestinal clamp introduced through the ileal conduit seized the intubated ureters and pulled them into the intestinal lumen for approximately 3 cm. (Fig. 1). The proximal end of the conduit was then closed by two or three inverting silk stitches. The ureters were firmly fixed near the mesenteric border of the conduit by a stay suture carefully passed through the ureteric muscular coat (Fig. 2). Finally the proximal end of the conduit with the uretero-ileal anastomosis was retro-peritonealised with interrupted sutures (Fig. 3) and the cutaneous ileostomy was completed in the desired location. The catheters were withdrawn on the sixth post-operative day.

The early post-operative course was uneventful in all but six patients (Table), two of whom developed fever and oliguria when the catheters were withdrawn. These were managed con- servatively and recovered without incident.

In three of the patients withdrawal of the catheter was followed by complete urinary obstruction at the uretero-ileal junction, high fever, rigors, BUN elevation and clinical symptoms of septic shock. The kidneys became swollen and painful.

One patient was hEmodialysed and had an early revision of the anastomosis, but he died from sepsis.

The other two patients who had a nephrostomy performed as a life-saving procedure subsequently recovered, and had a delayed successful revision of the uretero-ileal anastomosis.

All of them had dilated ureters above the intestinal implantation. The revision consisted 1 Read at the Twenty-fifth Annual Meeting of the British Association of Urological Surgeons in London,

June 1969. 744

ILEAL C O N D U I T : A C U T E O B S T R U C T I O N OF URETERO-ILEAL ANASTOMOSIS 745

Fig. 1.-A soft intestinal clamp seizes the intubated ureter (or ureters) and pulls i t (them) into the intestinal con- duit for about 3 cm. Note the fine catgut suture fixing the divided ureter

t o tube.

Fig. 2.-Closure of the proximal end of the ileal conduit. Inset: closer view to show the free end of the intubated ureter drawn into the ileal

Fig. 3.-Burying retro-peritoneally the uretero-ileal anastomosis. Inset: the ureteric catheter (or catheters) and the tube draining the ileal conduit emerge

through the ileal stoma.

conduit.

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Rec

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case

748 BRITISH JOURNAL OF U R O L O G Y

of resection of the intra-intestinal ureteric stump and performance of a new end-to-side uretero- ileal anastomosis.

Pathological Findings.-Gross microscopic examinations of the specimens were highly

The resected intra-intestinal free ureteric segment presented as a fibrotic nipple, with significant.

FIG. 4

Resected segment of the intra-intestinal ureter evincing a nipple-like shape. It is hard in consistency, fibrotic, and has a narrowed lumen, with difficulty passed through by a probe.

FIG. 5

Section through the ureteric nipple. Strongly thickened wall, with excessive proliferation of the conymctival tissue dissociating the

muscular fibres. Van Gieson stain; magnifying glass.

thickened wall, hard on cutting. A probe could just be passed through the nipple lumen (Fig. 4), but it was obviously narrowed and too rigid for free urinary passage.

The closed end of the conduit was also fibrotic in consistency and dense adhesions were present round the uretero-ileal anastomosis.

Microscopically, the ureteric nipple showed excessive proliferation of the connective tissue

I L E A L C O N D U I T : A C U T E O B S T R U C T I O N OF U R E T E R O - I L E A L A N A S T O M O S I S 749

between the muscular fibres (Fig. 5 ) , and here and there were nidi of inflammatory infiltration in the muscular coat.

Comment.-Such a high incidence of complications was unacceptable. In order to learn more about the mechanism of obstruction, we performed the same technique of urinary diversion on dogs.

Experimental Findings.-Ten mongrel dogs were operated on under intravenous anresthesia with Pentothal Sodium 30 mg. per kg./body weight and mechanical respiration.

FIG. 6 FIG. 7 Fig. 6.-Dog ileography. No reflux of the dye into the ureter. Large filling defect in the proximal end of the

ileal conduit due to the ureteric nipple.

Fig. 7.--Ileal conduit in dog. Note dilatation of the ureter and abscesses on the upper pole of the kidney.

All the animals had a single right kidney, the left kidney having been previously removed

Pre-operatively they had normal blood biochemistry and were free of urinary infection. We followed the same surgical steps and post-operative management as in humans, with

the exception that the intubation was omitted; dogs do not tolerate the ureteric catheter coming out through the ileal cutaneous stoma for more than a few days, usually pulling it out on the second post-operative day.

Results.-One dog died on the fifth day with intestinal obstruction and another dog died on the seventh day with acute pyelonephritis. The remaining eight dogs were killed at different intervals varying from 5 to 20 days. No intra- or retro-peritoneal urinary leakage was recorded and ileal " loopograms " showed no reflux of the dye from the conduit up into the ureters. On " loopography " the ureteric nipple could be seen as a large filling defect in the proximal end of the conduit (Fig. 6) .

In all cases post-mortem examination showed dilatation of the ureter above the intestinal implantations, hydronephrosis and various degrees of pyelonephritis. Two dogs had micro-

for allo-transplantation.

750 BRITISH J O U R N A L OF U R O L O G Y

abscesses in the renal parenchyma (Fig. 7). The intraconduit ureteric nipple displayed the same macroscopic changes as in humans (Fig. 8).

Two dogs had a clear-cut necrosis of the intra-intestinal free segment of the ureter (Fig. 9). Microscopic examination revealed the same thickening of the ureteric nipple and excessive

proliferation of the conjunctival tissue, in the muscular layer.

FIG. 8

Fig. 8.-Ileal conduit in dog. Isch- zmic area of the ureteric nipple and

ureteral dilatation.

Fig. 9.-Ileal conduit in dog. Ne- crosis of the intra-intestinal segment

of the ureter. FIG. 9

DISCUSSION

Undoubtedly this method of anastomosing a ureter to an ileal conduit-the so-called

1. I t is quick and easy to perform, because there are no sutures between ureter and conduit. 2. I t is watertight and has no risk of urinary leakage. 3. I t prevents urinary reflux from the conduit up the ureter because of the nipple shape

into which the intraconduit free segment of the ureter develops.

However, as our modest experimental and clinical experience has emphasised, the above advantages are exceeded by the great disadvantage of the possibility of impairment of the urine flow through the uretero-ileal anastomosis, due to fibrotic changes in the newly formed ureteric nipple.

Why these sclerotic changes occur more frequently in this kind of anastomosis in comparison with others we do not know, but this may be a consequence of the ischzmic lesions provoked by the impaired blood flow into the ureteric tissues below the implantation, combined with the deleterious effect of the catheter on the ureter. In any case, the result is often an alarming picture of anuria, acute pyelonephritis and uraemia.

" elephant trunk " anastomosis-has many advantages :

I L E A L CONDUIT: ACUTE OBSTRUCTION OF URETERO-ILEAL ANASTOMOSIS 751

This acute complication is a challenging one, because it requires early diagnosis and treat- ment.

For diagnosis one can rely mainly on clinical symptoms: absence of urine in the ileal conduit, lumbar pain, fever and sometimes palpable renal enlargement.

The ileal " loopogram " is of no help in diagnosis, since absence of reflux up into the ureters is a common feature of this kind of anastomosis even when it is not obstructed; one can resort to an immediate IVP which may show ureteric hold-up of the dye and an empty conduit or to an isotope renogram with its suggestive retention slope; but in our opinion these investigations are both unnecessary and time-consuming.

The clinical condition of the patient may deteriorate rapidly due to the combination of urzmia and sepsis and, consequently, the prompt relief of obstruction becomes compulsory and pressing. Hzmodialysis can lower the raised BUN and improve the clinical state, as it did in one of our patients, but has little application in most of these cases; renal back-pressure and urinary infection will continue their devastating action on the renal parenchyma, worsening the prognosis.

The only reasonable procedure is an emergency nephrostomy which is usually followed by diuresis and clinical improvement.

Subsequent " nephrostograms " will indicate the need for revision of the uretero-ileal anastomosis if the obstruction persists or will reveal resolution in the case of temporary urinary obstruct ion.

Our belief is that the " elephant-trunk " uretero-ileal anastomosis must be discarded from the urological armamentarium. This opinion is based not only on the occurrence of acute urinary obstruction. The follow-up of the other patients showed only one patient living after five years with good renal function and normal IVP. All the others have the same upper urinary tract dilatation as prior to surgery or demonstrate progression of dilatation.

CONCLUSIONS

1. The direct intubated uretero-ileal (" elephant-trunk ") anastomosis induces the risk of

2. Such an accident is life-threatening and requires prompt diagnosis. 3. Nephrostomy is a life-saving procedure, to be performed immediately the diagnosis of

4. If revision of the anastomosis becomes necessary, it should be postponed until the patient

5. The " elephant-trunk " technique of uretero-ileal anastomosis should be abandoned.

acute ureteric obstruction.

ureteric obstruction has been established.

recovers from ursemia and infection.

REFERENCES

BOWLES, T. W., CORDONNIER, J. J., andPARsoNs, P. R. (1964). Treatment of late uretero-ileal stenosis following ileal segment urinary diversion. J. Urol., 92, 627-634.

FONKALSRUD, W. E., and SMITH, P. J. (1965). Permanent urinary diversion in infancy and childhood. J. Urol., 94, 132-140.

KAFETSIOULIS, A., and SWINNEY, J. (1968). Urinary diversion by ileal conduit. Br. J. Urol., 40, 1-1 1 . PARKHURST, C. E. (1968). Experience with more than 500 ileal conduit diversions in a twelve-year

THOMPSON, T. H. (1964). Surgical correction of uretero-iIeal stricture: a new technique. J. Urol.,

WALLACE, D. M. (1966). Ureteric diversion using a conduit: a simplified technique. Br. J. Urol.,

WILLIAMS, D. INNES (1965). Chirurgia, Bukarest, 14, 289-297.

period. J. Urol., 99, 434-435.

91, 515-519.

38, 522-527.