THE NATURAL HISTORY OF THE UPPER RENAL TRACTS IN ADULTS FOLLOWING URETERO- ILEAL DIVERSION (BRICKER PROCEDURE)*

Transcription

1 DECEMBER, 1975 THE NATURAL HISTORY OF THE UPPER RENAL TRACTS IN ADULTS FOLLOWING URETERO- ILEAL DIVERSION (BRICKER PROCEDURE)* By PHILIP STANLEY, M.R.C.P., F.R.C.R.,f J. DUNCAN CRAVEN, M.R.C.P., F.R.C.R., DONALD G. SKINNER, M.D., and JEROME P. RICHIE, M.D4 ABSTRACT: LOS ANGELES, CALIFORNIA The natural history of the upper tracts (170 renal units) of 87 patients undergoing total cystectomy and ileal loop diversion has been followed roentgenologically for up to seven years. The complications inherent in the procedure are illustrated and the appearances of new upper tract tumors demonstrated. Of 126 renal units which were normal preoperatively, 87 remained normal. The most common complication was obstruction of the anastomosis, seen in 29 units. The need for regular contrast material examination of the surgically modified upper tracts is emphasized. TAL cystectomy with insertion of the ureters into an isolated loop of ileum is a well-established surgical procedure, one use of which is in the treatment of certain stages of bladder cancer. Because of the type of urinary diversion and the nature of the underlying disease process, these patients require frequent postoperative contrast material examinations of the surgically modified urinary tract. It is the purpose of this communication to report our experiences, paying particular attention to the natural history of the kidneys subjected to the invariable reflux from the ileal loop, and also to document the complications inherent in the procedure with emphasis on their roentgenological features. MATERIAL AND METHOD Eighty-seven patients who have undergone urinary diversion using an isolated loop of ileum form the basis of this report. All had transitional cell carcinoma of the bladder. The degree of hydronephrosis demonstrated by intravenous urography in the individual collecting system (or renal unit) was graded according to the criteria shown in Table #{149}3 17 Two patients had congenital absence of one kidney, and one nonfunctioning kidney was removed at the time of the original surgery, as was one kidney of a fourth patient with a concomitant renal pelvis transitional cell carcinoma. Thus, 170 postoperative renal units were available for assessment and comparison with their preoperative appearance. In addition to assigning a degree of hydronephrosis to the individual collecting systems, the renal length and substance thickness were also measured, and the roentgenological features of complications were recorded. Some of the patients had ileal loopograms, and the presence or absence of reflux was noted. In those patients in whom progressive postoperative obstruction was TABLE CRITERION FOR GRADING Individual Collecting System Grade Normal 0 Minimal or questionable hydronephrosis I Definite hydronephrosis 2 Massive hydronephrosis 3 Nonvisualization 4 I * Presented at the Seventy-fourth Annual Meeting of the American Roentgen Ray Society, Montreal, Quebec, Canada, September 25-28, From the Departments of Radiological Sciences and Surgery-Urology, The Center for the Health Sciences4 and the Children s Hospital of Los Angeles,t Los Angeles, California. 804

2 VOL. 125, No. 4 Uretero-Ileal Diversion (Bricker Procedure) 805 TABLE II COMPARISON OF PREOPERATIVE AND POSTOPERATIVE APPEARANCES Preoperative - Urogram Normal Normal Abnormal but Improved Postoperative Deterio.. rationt Mild hydronephrosis Moderate hydronephrosis 9 3 3* I 2 Severe hydronephrosis i6 I 9* 3* Urogram * *. 36* * New Tumor Formation 3 Unchanged Postobstruction Atrophy I 2 Nonvisualization Chronic pyelonephritis Total-I7o II 41 4 * Indicates calculus formation. t See text. suspected, antegrade pyelograms were performed. Two of the four patients who developed new upper tract tumors had selective renal arteriograms. RESULTS Table II compares the preoperative and postoperative urographic appearances of the individual renal units and demonstrates the following noteworthy features. Of the I 26 preoperative normal renal units, 87 remained normal. These patients have been followed for periods varying from six months to seven years to determine if any roentgenographic change could be observed in the upper tracts which are subjected to the almost inevitable reflux from the ileal loop In not one was there a generalized or localized loss of renal substance nor was there an alteration in the calyceal architecture. In 13 patients who had loopograms with normal postoperative upper tracts, there was failure to reflux in only one system. In the presence of a normal urogram this reaction indicates that a fortuitous flap-like valve may be present at the uretero-ileal anastomosis. 3 It was also noted that in the three units which showed roentgenographic evidence of chronic pyelonephritis preoperatively, there was no change following radical bladder surgery. Thirty-six of the 126 normal preoperative units exhibited increasing hydronephrosis postoperatively as did five of the preoperative hydronephrotic units. The causes of deterioration in these 41 units are shown in Table III. The most common cause of deterioration was obstruction at or very close to the uretero-ileal anastomosis, TABLE CAUSE OF DETERIORATION IN 41 PATIENTS Obstruction at uretero-ileal anastomosis 29 Obstruction by calculus 2 Disseminated tumor 8 Cause undetermined 2 III 4

3 8o6 Stanley, Craven, Skinner and Richie DECEMBER, FIG. i. Urogram performed one month after surgery showing some dilatation of the left collecting system. demonstrated by postoperative hydronephrosis with dilatation of the ureter down to the ileal insertion. The obstruction was more common on the left side (19 vs. ten), and this left-sided preponderance was almost certainly related to the increased technical difficulty associated with the anastomosis on the left, where the ureter must course around the base of the sigmoid mesentery.2 It was in this type of patient that roentgenology was most helpful, with loopograms and antegrade pyelograms confirming the findings on intravenous urography (Fig. 1-4). Antegrade pyelography has the added advantage of providing a specimen 73J.73 I is of urine for culture and cytology, two factors of importance in the subsequent surgical management. Of the 29 units with obstruction at the uretero-ileal anastomosis, the sequential intravenous urograms of 18 units showed complete recovery over a period of three to twelve months. This figure also included one patient who had a postoperative nonfunctioning upper tract. An additional operation was required in seven units. In five, the cause of the obstruction was shown to be fibrosis and not recurrent tumor, and two other units showed leakage at the site of the anastomosis. As sequential intravenous urograms showed nonprogressive hydronephrosis in two units with uretero-ileal anastomosis obstruction, further surgery has not been performed, and the fate of two other units is unknown. In eight units with progressive hydronephrosis appearing after surgery in patients with disseminated malignant disease, pelvic recurrences were found at autopsy. It should be noted, however, that this paper is FIG. 2. Two months later there is further deteriora- FIG. 3. A loopogram performed at the same time as tion with massive dilatation of the left side and Figure 2 demonstrates reflux up the right side poor opacification. only.

4 VOL. 125, No. 4 Uretero-Ileal Diversion (Bricker Procedure) FIG. 4. An antegrade pyelogram confirms the presence of narrowing at the lower end of the left ureter. A fibrous stricture at the anastomosis site was found at surgery. a survey of the roentgenological findings, and as such will give a falsely low incidence of recurrent tumor because some patients with a clinically obvious recurrence at the site of the original surgery may not have additional contrast material examinations of the urinary tract. None of the units had stones prior to surgery. In two normal preoperative units that showed increasing hydronephrosis following surgery there was ureteric obstruction due to calculus formation. Calculi -- CLINICAL TI TABLE i Fic.. An intravenous urogram performed one month following surgery shows minimal dilatation of the upper tracts but no evidence of tumor. developed in five other systems which were hydronephrotic prior to surgery. These calculi appeared between one to four years following the Bricker procedure. All the calculi were radiopaque. Of the 39 preoperative hydronephrotic units 28 improved following radical surgery. In this group of patients it is important, when assessing functioning in a previously nonfunctioning system, to avoid being misled by contrast medium which has been excreted by the other system and which refluxes from the ileal loop. 7 When the seven systems that were nonfunctioning preoperatively were examined following surgery all showed visualization on the early roentgenograms before contrast medium had entered the ileal loop. Incidentally noted were five units which were either nonfunctioning or showed massive dilatation before operation and following the procedure exhibited the classical features of postobstructi ye atrophy. IV DETAILS I Age at Time of Initials Total Cystectomy Site of New Tumor J.D. I.C. Z.I. R.P ! Right renal pelvis Right upper calyx Right renal pelvis and upper ureter Left lower ureter, multiple tumors Right ureter, multiple tumors Interval Total Following Cystectomy * 2 years 3 years 1.5 years 4.5 years 2 years

5 8o8 Stanley, Craven, Skinner and Richie DECEMBER, 1975 cc. MPR73J FIG. 6. An intravenous urogram three years later shows obliteration of the major calyx of the upper pole of the right kidney with irregularity of the upper pelvis. The upper tracts of four patients developed new tumors between 18 to 36 months after total cystectomy. There was no roentgenological evidence of tumor elsewhere at the time of surgery, although all had evidence of carcinoma in situ within the distal ureter removed at the time of original surgery. The clinical details are - :. 55#{149}t shown in Table Iv. The new tumor manifested itself in two patients by progressive narrowing of a major calyx (Fig. 5-7) and in a third by two irregularly surfaced radiolucent filling defects in the right pelvis and upper right ureter which could be misinterpreted as calculi. However, renal arteriography provided conclusive evidence that there was a new tumor (Fig. 8-10). This patient had a right nephroureterectomy, and three years later developed multiple ureteric tumors (Fig. II) on the left similar to the multiple ureteric tumors found in the fourth patient (Fig. 12). DISCUSSION Following Bricker s original description of the uretero-ileal conduit in 1950, several large series in adults have established its adequacy, and the complications are well documented #{176} The most common postoperative complication was obstruction at the uretero-ileal an astomosis. Intravenous urograms, usually performed within a month of surgery, showed deterioration in 29 systems due to anastomotic narrowing. In this situation the surgeon is interested in the patency of the uretero-ileal anastomosis, and failure to reflux from the ileal loop with a hydronephrotic collecting system indicates obstruction at the anastomosis Further information was obtained in some cases by FIG. 7. A selective right renal angiogram demonstrates pruning of some of the interlobar arteries to the upper pole with irregularity and beading FIG. 8. Intravenous urogram before total cystectomy due to tumor encasement. Surgery confirmed the shows minimal dilatation of the upper tracts but presence of a new tumor in the upper pole. no evidence of new tumor formation.

6 VOL. 125, No. 4 Uretero-Ileal Diversion (Bricker Procedure) 809 antegrade pyelography which, in addition to confirming the site of the obstruction, supplied a sample of urine from the closed system. In the majority of cases the obstruction was due to edema which resolved over a period of three to six months, similar findings having been reported by other workers In eight units progressive hydronephrosis appeared later in the postoperative period, and at autopsy extensive pelvic recurrence was found. That the later appearance of hydronephrosis is very suggestive of recurrence at the site of original surgery has been recorded previously.3 In this series calculi appeared one to four years following surgery. A higher incidence of calculous disease may become apparent upon longer follow-up, calculi having been reported five to 15 years following the Bricker procedure. 4 Of the seven units which showed calculus formation following surgery, in only two were the systems not dilated. Dretler5 covered the subject of stone formation very extensively, and the precipitating factors included a large vol- FIG. 10. A right selective arteriogram demonstrates neovascularity within the pelvic tumor. Surgery confirmed the presence of transitional cell carcinomata in the pelvis and ureter. Fic.. Urogram at the time of angiography 8 months following surgery demonstrates filling defects with irregular surfaces within the right renal pelvis and in the ureter at the level of L-4. ume or an obstructed system. Speculation on the source of upper tract tumors occurring after total cystectomy has moved away from the tumor implantation theory toward the hypothesis of a generalized instability of the urothelium perhaps caused by a biochemical carcinogen. 9 Further evidence for this latter hypothesis is provided by the four patients in our series. The long time interval of i8 to 36 months between total cystectomy and the appearance of new upper tract tumors makes the implantation theory less acceptable. Instability of the urothehum was seen in all four patients in whom there were changes of carcinoma in situ at the level of the ureteric orifice distant from the primary tumor at the time of original surgery. These four patients are from a larger series recently reported2 in which it

7 0 8o Stanley, Craven, Skinner and Richie DECEMBER, 1975 Fic. i I. A loopogram performed four and one-half years following total cystectomy shows multiple filling defects in the left lower ureter presumably due to new transitional cell carcinomas. was noted that one-third of the patients with histological changes of carcinoma in situ developed another transitional cell tumor within the remaining pelvis and ureter within i8 months to three years following total cystectomy. These cases are important, for not only do they add to our knowledge of urothehial neoplastic disease but make regular followup -contrast material examination of the remainder of the urinary tract mandatory, particularly if at the time of cystectomy premalignant changes are found elsewhere. In addition, the unwary could misinterpret roentgenological features due to new tumor as those of calculous disease or inflammation and thus delay further surgery. In this series no deterioration was observed in the kidney which was normal preoperatively for as long as seven years, although the majority were followed for only one to three years. These kidneys are subjected to invariable reflux from the ileal conduit which contains pathogenic bacteria in a high proportion of patients.4 The question of whether the reflux of infected urine can be followed by pyelonephritic scarring of the growing kidney excites controversy and is incompletely solved.20 In adults the evidence is also inconclusive. Nonspecific roentgenological deterioration has been reported in some adults with ureteric reflux following bladder irradiation,24 and roentgenological pyelonephritis has been recorded in three patients following surgery in whom there was reflux of infected urine.8 However, in this series there was no deterioration, and in addition a group of adults with ileal ureters where there is inevitable reflux of infected urine showed no loss of renal substance or alteration in the calyceal architecture.9 None of the patients in our series had an episode of acute pyelone- F,c. I 2. A loopogram demonstrates bilateral reflux. There are many nodular filling defects in the right ureter due to multiple transitional cell carcinomata.

8 VOL. 125, No. Uretero-Ileal Diversion (Bricker Procedure) 811 phritis clinically, although even in this situation roentgenological signs are seen infrequently in the follow-up pyelogram. J. Duncan Craven, M.D. Department of Radiology The Center for the Health Sciences University of California, Los Angeles Los Angeles, California REFERENCES I. BRICKER, E. M. Bladdersubstitution after pelvic evisceration. Surg. Clin. North America, i 950, 30, BURNHAM, J. P., and FARRER, J. Group cxperience with ureteroilial cutaneous anastomosis for urinary diversion. 7. Urol., I970, 83, BUTCHER, H. R., SUGG, W. L., MCAFEE, C. A., and BRICKER, E. M. Ileal conduit method of ureteral urinary diversion. Ann. Surg., 1962, 156, CAMPBELL, J. E., OLIVER, J. A., and MCKAY, D. E. Dynamics of ileal conduits. Radiology, 1965, 85, g. DRETLER, S. P. Pathogenesis of urinary tract calculi occurring after ileal conduit diversion. 7. Urol., 1973, 109, ELLIS, L. R., UDALL, D. A., and HODGES, C. R. Further clinical experiences with intestinal segment for urinary diversion. 7. Urol., 1971, 105, ENOLE, R. M. Complications of bilateral uretero-ileal cutaneous urinary diversion: review of 208 cases. 7. Urol., 1969, JO!, FRITJOFSSON, A., and SUNDIN, T. Studies of renal function in vesico-ureteric reflux. Brit. 7. Urol., 1966,38, FRITZSCHE, P. GOODWIN, W. E., SKINNER, D. G., CRAVEN, J. D., and CAHILL, P. Long-term radiographic changes of kidney following ileal ureter operation. To be published. TO. HARBACH, L. B., HALL, R. L., COCKETT, A. T. K., KAUFMAN, J. J., MARTIN, D. C., MIMS, M. M., and GOODWIN, W. E. Ile4.kop. utaneous urinary diversion: critical, review. 7.. Vro., 1971, 105, II. HODSON, C. J., and CRAVEN, J. D. Radiology of obstructive atrophy of kidney. Clin. Radiol., 1966, 17, JAFFE, B. M., BRICKER, E. M., and BUTCHER, H. R. Surgical complications of ileal segment urinary diversion. Ann. Surg., 1968, 167, JUDE, J. R., LUSTED, L. B., and SMITH, R. R. Radiographic valuation of urinary tract following diversion to ijeal bladder. Cancer, 1959, 12, 1134-I KOEHLER, P. R., BOWLES, W. T., and MCALIS- TER, W. H. Roentgenographic evaluation of late results of ileal-loop urinary diversion in infants and children. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1967, 100, IS. LITTLE, P. J., MCPHERSON, D. R., and DE WARDNER, H. E. Appearance of intravenous pyelogram during and after acute pyelo_ nephritis. Lancet, 1965, I, i6. PARKHURST, E. C. Experiences with more than 500 ileal conduit diversions in a I 2-year period. 7. Urol., 1968, 99, RETIK, A. B., PERLMUTTER, A. D., and GRoss, R. E. Cutaneous ureteroileostomy in children. New England 7. Med., 1967, 277, i8. SCHMIDT, J. D., HAWTREY, C. E., FLOCKS, R. H., and CULP, D. A. Complications, results, and problems of ileal conduit diversions. 7. Urol., 1973, 109, SHERWOOD, T. Upper urinary tract tumors following on bladder carcinoma. Brit. 7. Radiol., 1971, 41, SHERWOOD, T. Ureteric reflux: chronic pyelonephritis vs. reflux nephropathy. Brit. 7. Radiol., 1973, 46, SKINNER, D. G., RICHIE, J. P., COOPER, P. M., WAISMAN, J., and KAUFMAN, J. J. Clinical significance of carcinoma in situ of bladder and its association with overt carcinoma. 7. Urol., 1974, 112, 68-7,. 22. SMITH, E. D. Follow-up studies on io ileal conduits in children. 7. Pediat. Surg., 1972, 7, STAMEY, T. A., and Scorr, W. W. Uretero-ileal anastomosis. Surg., Gynec. & Obst., 1957, 104, WILLIAMS, G., WALLACE, D. M., BLOOM, M. J. G., and STEVENSON, J. J. Vesico-ureteric reflux following irradiation of urinary bladder. Proc. Roy. Soc. Med., 1971, 64,

9 This article has been cited by: 1. F.L. Flanagan, H.M. Fenlon, É. Breatnach Ileal loop conduit volvulus: A rare but reversible cause of bilateral ureteric obstruction. Clinical Radiology 50:3, [CrossRef] 2. Wiking Månsson, Göran Ahlgren, Thomas White Glomerular Filtration Rate up to 10 Years After Urinary Diversion of Different Types. Scandinavian Journal of Urology and Nephrology 23:3, [CrossRef] 3. W. Månsson, S. Colleen, L. Forsberg, I. Larsson, T. Sundin, T. White Renal Function after Urinary Diversion. Scandinavian Journal of Urology and Nephrology 18:4, [CrossRef] 4. W. Månsson, S. Colleen, L. Stigsson Four Methods of Uretero-Intestinal Anastomosis in Urinary Conduit Diversion. Scandinavian Journal of Urology and Nephrology 13:2, [CrossRef]