Editorial: Reconstruction and Diversion
2
@322-5347/95/1535- 1439$03.00/0 THE JOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROL~CICAL ASSOCIATION, INC. Vol. 153,1439-1440, May 1995 Printed in U.S.A. EDITORIAL: RECONSTRUCTION AND DIVERSION The article by Bissada et a1 (page 1429) in this issue of the Journal advocating the viability of ureterosigmoidostomy in this age of continent diversion and bladder substitution makes a strong statement for its acceptance. In their view ureterosigmoidoscopy is believed to be a suitable alternative for patients who are not candidates for the other procedures. The most attractive feature of ureterosigmoidoscopy is the lack of need for an external appliance. However, the ease and rapidity of construction of ureterosigmoidoscopy are counter- acted to date by the use of new stapling techniques in conti- nent diversion, which allow for rapid intestinal interruption and reanastomosis with minimal morbidity. Moreover, uret- erosigmoidoscopy has not been easily accepted in our practice due to a variety of difficulties. The main drawback in the series presented by Bissada et a1 is the high incidence of renal unit deterioration (23%). This untoward effect is of grave concern in patients with reasonable life expectancy. It is likely secondary to uretero- intestinal obstruction or reflux. Among their patients 8% already have progression to renal failure. Although it is not clearly delineated in the article, obstruction is probably the main cause of the pyelonephritis and renal deterioration, Among 35 deceased patients who had undergone ureterosig- moidoscopy for bladder exstrophy, acquired renal disease (sepsis or renal failure) was the most prominent single lead- ing cause of death (22%, reference 15 in article). In the same report, among 52 patients who had survived the operation 18 (34.6%) had undergone secondary urinary diversion. The in- cidence of ureteral obstruction in segments of ileum and colon fashioned for continent urinary diversion has been much lower (3 to 6%).1,2 Reflw, moreover, has not been demonstrated to be a primary cause of pyelonephritis in these newer storage systems,3 which is probably related to the large volume ca- pacity and low pressure associated with these reservoirs. Reflux of infected urine from a high pressure tubular system is a common phenomenon and, if present, may be a probable cause of upper tract damage. Patients who present with renal failure in this clinical setting have an associated higher in- cidence of electrolyte disturbance and acidosis.3 Another concern in the reported series of ureterosigmoid- oscopy is the increased frequency of bowel movements at night. Although all patients are continent during the day, the average defecation frequency has not been discussed. Still, 31 patients (50%) empty the rectum 2 or more times at night, which represents a major inconvenience, particularly if occa- sional episodes of fecal soiling also occur. In addition, these patients are almost unanimously condemned to ingest potas- sium and alkali for life, which might pose a hazardous occur- rence in elderly individuals with cardiac disease. If these possible side effects and changes in quality of life from the procedure are clearly understood, as well as the need for lifelong followup made clear, ureterosigmoidoscopy becomes a surgical alternative in patients who are not candidates for bladder substitution or continent diversion. Rogers and Scardino (page 1432) report on the use of a modified Studer procedure for orthotopic bladder replace- ment in male patients. The overall results with this tech- nique are excellent and, if analyzed together with the out- come reported by Studer (reference 17 in article), we are confronted with one of the best alternatives for ileal bladder substitution. The authors report a low incidence of ure- throileal anastomotic obstruction (lo%), and this has been easily treated by urethrotomy and intermittent catheteriza- tion. This experience is similar to that reported with other ileal neobladders (references 6 and 18 in article). The patients investigated urodynamically have demon- strated an adequate voiding pattern with only 2 of 11 having relatively large residual volumes. We must assume that these patients require intermittent catheterization for vesi- cal emptying. The incidence of bacteriuria is similar to that of other neobladders and less than that for procedures with an abdominal wall stoma requiring routine reservoir catheter- ization.2 A disturbing complication with orthotopic bladders has been urinary incontinence. Two patients in this group (10%) have total incontinence, with 1 ultimately requiring an arti- ficial urinary sphincter. Although daytime continence was present in 90% of the patients 9 (45%) have nocturnal incon- tinence. Furthermore, among the totally continent patients 5 (45%) require an alarm for awakening to prevent episodes of leakage. The alternative then is frequent nocturnal voiding. When the overall data are evaluated, 14 patients (70%) are incontinent of urine or require frequent nocturnal voidings. The necessity for nocturnal voiding might not be well re- ceived by all patients, since for some a draining stoma into an appliance or catheterization of a large reservoir at bedtime would be a more attractive feature. A second problem with intestinal reservoirs is obstruction at the ureterointestinal anastomosis. Although the authors report stable upper tracts on followup excretory urography, 2 patients experienced pyelonephritis and hydronephrosis. The incidence of ureteral obstruction in colonic reservoirs may be close to 6%, including cases of silent auto-nephrectomy.2 Other series have found up to a 10% rate of ureteral obstruc- tion on long-term followup with colonic reservoirs.4 As far as the demonstration of reflux, we wholeheartedly agree with the authors (as previously discussed by Studer) that this abnormality probably will not be associated with renal damage. The capacious, low pressure systems buffer pressure increases, and probably protect the kidneys from infection and pyelonephritis. Furthermore, post-voiding x- rays of these large reservoirs show adequate emptying of the upper tracts with no contrast medium remaining in the renal pelves. In other reservoirs into which the ureters are directly reimplanted reflux has been demonstrated to be nondelete- rious to the kidneys when simultaneous obstruction does not exist.2 The operative advantage of the method of Rogers and Scardino, and Studer over the catheterizable systems in- cludes the lesser incidence of bacteriuria and pyelonephritis. An advantage of this procedure over other orthotopic bladder techniques is the proximal limb length, which allows for a tension-free anastomosis particularly when short ureters exist. Whether this proximal limb will become dilated and act as a bladder diverticulum in the future requires long-term followup. Leaving 15 cm. of distal ileum has created a 20% incidence of vitamin B12 deficiency in these patients and 2 had predis- posing factors for this abnormality. The same extensive bowel resection explains the high incidence of diarrhea when the ileocecal valve has remained functional. Perhaps these patients will also present with a higher incidence of renal lithiasis and cholelithiasis compared with other ileal storage systems in which less ileum is resected. The bowel malfundion is probably due to a deficit in bile salt absorption. As mentioned by the authors, these abnormalities could have been prevented if a longer distal ileal segment would have been saved (as recommended by Studer). Hyperchloremia and acidosis occur in reservoirs constructed with ileum and colon. However, few adults have required treatment due to this abnormal it^.^ Understanding the higher risk of nocturnal incontinence andor frequent voidings, the simplicity of this technique 1439
Transcript of Editorial: Reconstruction and Diversion
@322-5347/95/1535- 1439$03.00/0 THE JOURNAL OF UROLOGY Copyright 0 1995 by AMERICAN UROL~CICAL ASSOCIATION, INC.
Vol. 153, 1439-1440, May 1995 Printed in U.S.A.
EDITORIAL: RECONSTRUCTION AND DIVERSION The article by Bissada et a1 (page 1429) in this issue of the
Journal advocating the viability of ureterosigmoidostomy in this age of continent diversion and bladder substitution makes a strong statement for its acceptance. In their view ureterosigmoidoscopy is believed to be a suitable alternative for patients who are not candidates for the other procedures. The most attractive feature of ureterosigmoidoscopy is the lack of need for an external appliance. However, the ease and rapidity of construction of ureterosigmoidoscopy are counter- acted to date by the use of new stapling techniques in conti- nent diversion, which allow for rapid intestinal interruption and reanastomosis with minimal morbidity. Moreover, uret- erosigmoidoscopy has not been easily accepted in our practice due to a variety of difficulties.
The main drawback in the series presented by Bissada et a1 is the high incidence of renal unit deterioration (23%). This untoward effect is of grave concern in patients with reasonable life expectancy. It is likely secondary to uretero- intestinal obstruction or reflux. Among their patients 8% already have progression to renal failure. Although it is not clearly delineated in the article, obstruction is probably the main cause of the pyelonephritis and renal deterioration, Among 35 deceased patients who had undergone ureterosig- moidoscopy for bladder exstrophy, acquired renal disease (sepsis or renal failure) was the most prominent single lead- ing cause of death (22%, reference 15 in article). In the same report, among 52 patients who had survived the operation 18 (34.6%) had undergone secondary urinary diversion. The in- cidence of ureteral obstruction in segments of ileum and colon fashioned for continent urinary diversion has been much lower (3 to 6%).1,2 Reflw, moreover, has not been demonstrated to be a primary cause of pyelonephritis in these newer storage systems,3 which is probably related to the large volume ca- pacity and low pressure associated with these reservoirs. Reflux of infected urine from a high pressure tubular system is a common phenomenon and, if present, may be a probable cause of upper tract damage. Patients who present with renal failure in this clinical setting have an associated higher in- cidence of electrolyte disturbance and acidosis.3
Another concern in the reported series of ureterosigmoid- oscopy is the increased frequency of bowel movements a t night. Although all patients are continent during the day, the average defecation frequency has not been discussed. Still, 31 patients (50%) empty the rectum 2 or more times at night, which represents a major inconvenience, particularly if occa- sional episodes of fecal soiling also occur. In addition, these patients are almost unanimously condemned to ingest potas- sium and alkali for life, which might pose a hazardous occur- rence in elderly individuals with cardiac disease. If these possible side effects and changes in quality of life from the procedure are clearly understood, as well as the need for lifelong followup made clear, ureterosigmoidoscopy becomes a surgical alternative in patients who are not candidates for bladder substitution or continent diversion.
Rogers and Scardino (page 1432) report on the use of a modified Studer procedure for orthotopic bladder replace- ment in male patients. The overall results with this tech- nique are excellent and, if analyzed together with the out- come reported by Studer (reference 17 in article), we are confronted with one of the best alternatives for ileal bladder substitution. The authors report a low incidence of ure- throileal anastomotic obstruction (lo%), and this has been easily treated by urethrotomy and intermittent catheteriza- tion. This experience is similar to that reported with other ileal neobladders (references 6 and 18 in article).
The patients investigated urodynamically have demon- strated an adequate voiding pattern with only 2 of 11 having relatively large residual volumes. We must assume that these patients require intermittent catheterization for vesi- cal emptying. The incidence of bacteriuria is similar to that of other neobladders and less than that for procedures with an abdominal wall stoma requiring routine reservoir catheter- ization.2
A disturbing complication with orthotopic bladders has been urinary incontinence. Two patients in this group (10%) have total incontinence, with 1 ultimately requiring an arti- ficial urinary sphincter. Although daytime continence was present in 90% of the patients 9 (45%) have nocturnal incon- tinence. Furthermore, among the totally continent patients 5 (45%) require an alarm for awakening to prevent episodes of leakage. The alternative then is frequent nocturnal voiding. When the overall data are evaluated, 14 patients (70%) are incontinent of urine or require frequent nocturnal voidings. The necessity for nocturnal voiding might not be well re- ceived by all patients, since for some a draining stoma into an appliance or catheterization of a large reservoir at bedtime would be a more attractive feature.
A second problem with intestinal reservoirs is obstruction a t the ureterointestinal anastomosis. Although the authors report stable upper tracts on followup excretory urography, 2 patients experienced pyelonephritis and hydronephrosis. The incidence of ureteral obstruction in colonic reservoirs may be close to 6%, including cases of silent auto-nephrectomy.2 Other series have found up to a 10% rate of ureteral obstruc- tion on long-term followup with colonic reservoirs.4
As far as the demonstration of reflux, we wholeheartedly agree with the authors (as previously discussed by Studer) that this abnormality probably will not be associated with renal damage. The capacious, low pressure systems buffer pressure increases, and probably protect the kidneys from infection and pyelonephritis. Furthermore, post-voiding x- rays of these large reservoirs show adequate emptying of the upper tracts with no contrast medium remaining in the renal pelves. In other reservoirs into which the ureters are directly reimplanted reflux has been demonstrated to be nondelete- rious to the kidneys when simultaneous obstruction does not exist.2 The operative advantage of the method of Rogers and Scardino, and Studer over the catheterizable systems in- cludes the lesser incidence of bacteriuria and pyelonephritis. An advantage of this procedure over other orthotopic bladder techniques is the proximal limb length, which allows for a tension-free anastomosis particularly when short ureters exist. Whether this proximal limb will become dilated and act as a bladder diverticulum in the future requires long-term followup.
Leaving 15 cm. of distal ileum has created a 20% incidence of vitamin B12 deficiency in these patients and 2 had predis- posing factors for this abnormality. The same extensive bowel resection explains the high incidence of diarrhea when the ileocecal valve has remained functional. Perhaps these patients will also present with a higher incidence of renal lithiasis and cholelithiasis compared with other ileal storage systems in which less ileum is resected. The bowel malfundion is probably due to a deficit in bile salt absorption. As mentioned by the authors, these abnormalities could have been prevented if a longer distal ileal segment would have been saved (as recommended by Studer). Hyperchloremia and acidosis occur in reservoirs constructed with ileum and colon. However, few adults have required treatment due to this abnormal it^.^ Understanding the higher risk of nocturnal incontinence andor frequent voidings, the simplicity of this technique
1439
1440 RECONSTRUCTION AND DIVERSION
associated with the paucity of untoward results makes it an excellent alternative for vesical substitution.
Jorge G. Lockhart Department of Surgery Division of Urology University of South Florida College of Medicine Tampa, Florida
REFERENCES
1. Skinner, D. G., Lieskovsky, G. and Boyd, S.: Continent urinary
2. Helal, M., Pow-Sang, J., Sanford, E., Figueroa, T. E. and diversion. J. Urol., 141: 1323, 1989.
Lockhart, J. L.: Direct (nontunneled) ureterocolonic reimplan- tation in association with continent reservoirs. J. Urol., 150: 835, 1993.
3. McDougal, W. S.: Metabolic complications of urinary intestinal diversion. J. Urol., 147: 1199, 1992.
4. Mansson, W.: The continent cecal urinary reservoir. In: Blad- der Reconstruction and Continent Urinary Diversion. Ed- ited by L. R. King, A. R. Stone and G. D. Webster. Chicago: Year Book Medical Publishers, Inc., chapt. 15, pp. 209-223, 1986.
5. Lockhart, J. L., Davies, R., Persky, L., Figueroa, T. E. and Ramirez, G.: Acid-base changes following urinary tract recon- struction for continent diversion and orthotopic bladder re- placement. J. Urol., 152: 338, 1994.
