Long-Term Results of Ileum Interposition for Ureteral Obstruction

Transcription

1 European Urology European Urology 42 (2002) 181±187 Long-Term Results of Ileum Interposition for Ureteral Obstruction Frank J.H. Verduyckt, John P.F.A. Heesakkers *, Frans M.J. Debruyne Department of Urology, University Medical Center St. Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands Accepted 7 June 2002 Abstract Objective: To present the long-term results of ileum interposition in the ureter for uni- or bilateral ureteral obstruction. Patients and Methods: Between 1981 and 2000, a total of 22 patients received an ileal segment interposition as a substitution for the ureter, of whom 18 were available for analysis. The mean age was 54 years (range 29±73). Patients were followed for a mean period of 65 months (range 2±196). Assessment included clinical examination, serum creatinine levels, renal ultrasonography, intravenous pyelography and isotopic renography. In eight patients, the ileal-ureteral substitution was the rst reconstructive procedure. The other patients underwent up to four previous reconstructions of different types. Fourteen patients were treated for unilateral ureteral obstruction, four of whom had a functional or anatomical solitary kidney, the other four patients had bilateral obstruction. Results: In 16 patients renal function improved after ileal-ureteral substitution. One patient underwent a nephrectomy because of a decreased renal function due to an obstruction at the level of the uretero-ileal anastomosis. One patient had a nephrectomy because of recurrent macroscopic hematuria caused by multiple arterio-venous malformations. Overall, 15 patients (83%) had a good functioning kidney after a mean period of 65 months. In three patients an early reintervention was necessary because of bleeding, small bowel obstruction and urinary leakage from a pyelo-ileal anastomosis. Six patients required a reintervention in the long-term: two had a nephrectomy, three had a re-anastomosis between the renal pelvis and the proximal ileal segment, while the sixth patient underwent a PNL for a kidney stone. Recurrent urinary tract infections were seen in six patients, of whom three had to undergo a reintervention. Metabolic acidosis was detected in two patients and was treated withsodium bicarbonate substitution. Conclusion: Ileal-ureteral substitution is a valuable procedure withgood long-term results and an acceptable rate of secondary interventions in patients for whom other alternatives are not feasible. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Ureter; Ileum; Ureteral substitution; Ileum interposition; Outcome 1. Introduction Patients present witha variety of ureteral diseases for which a reconstructive procedure is necessary because of reasons like brosis, stenosis or even tumour. Sometimes a substantial part of the ureter has to be removed. To overcome the defect, techniques like psoas-hitch, Boari ap, transuretero-ureterostomy or auto transplantation exist, as well as appendix substitution and * Corresponding author. Tel ; Fax: address: j.heesakkers@uro.azn.nl (J.P.F.A. Heesakkers). recon gured colon-interposition [1]. Sometimes a ureteral substitution using a segment of ileum may be required to prevent further renal damage. In 1906, Schoemaker performed the procedure for the rst time in Holland as he stated during a meeting of Dutchsurgeons in 1911 [2]. He used a part of the small bowel as a substitute for the ureter in an 18-yearold girl suffering from tuberculosis. Gradually this technique was used more often and as urologists gained more experience withbladder substitution using small bowel, ureteral ileal substitution became an established procedure in ureteral reconstructive surgery [3] /02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S (02)00266-X

2 182 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181±187 During the last decades endo-urological techniques have been developed to treat ureteral obstruction, including endo-dilatation, stenting and ureteroscopic lasering. Since tuberculosis, being the primary indication for ileal-ureteral substitution, is almost eradicated in industrialised regions, ileal-ureteral substitution nowadays is infrequently performed. Moreover, the development of minimal invasive techniques makes ileal-ureteral substitution more or less the last rescue treatment before nephrectomy. To appreciate the indications and results of ileal-ureteral substitution in modern times, we present the experience with ileal-ureteral substitution in our centre over the last two decades. 2. Patients and methods Twenty-two patients were treated withan ileum interposition in the ureter between 1981 and Substantial follow-up data were available in 18 patients, 10 males and 8 females, witha mean age of 54 years (range 29±73). In these 18 patients, 22 renal units were treated withan ileal substitution. The indications were idiopathic retroperitoneal brosis (n ˆ 5, 28%), iatrogenic ureteral lesions (n ˆ 5, 28%), retroperitoneal brosis after radiotherapy (n ˆ 4, 22%), brosis after failed pyeloplasty (n ˆ 3, 17%) and one ureterectomy for urothelial carcinoma in a patient witha solitary kidney (6%) (Table 1). Of the patients with an iatrogenic ureteral lesion, two had complications after a ureterorenoscopic procedure for urolithiasis and one after a Dormia extraction. Another patient suffered a ureteral lesion during a Wertheim±Meigs operation, while the fth patient had a bilateral ureteral lesion during a laparoscopic lymph node dissection for prostatic carcinoma. In eight of the patients, the ileal-ureteral substitution was done as the rst reconstructive operation. Up to four previous reconstructive procedures were attempted before the interposition of ileum in the other 10 patients. Time interval between rst diagnosis of ureteral obstruction and the moment of ileum interposition varied between 3 and 54 months (mean 16 months). Fourteen patients were treated unilaterally, four of them had an anatomical or functional solitary kidney. In one patient, a unilateral ileum interposition was combined withan ileal augmentation cystoplasty and a contralateral ureter-reimplantation. Four patients received a bilateral ileal-ureteral substitution, in three of these patients the ileal segment was placed in a U-shaped position, while in the fourth patient both ureters were anastomosed at the top of a vertically placed ileal segment. To bridge the diseased length of Table 1 Indications for ileo-ureteral substitution Indications Primary retroperitoneal brosis 5 Iatrogenic ureteral trauma 5 Post-radiotherapy brosis 4 Recurrent UPJ stenosis 3 Recurrent ureteral tumour 1 Total 18 Number of patients (n) ureter, an ileal segment of equal length, ending 20 cm proximal of Bauhin's valve, was interposed between renal pelvis or proximal ureter and bladder in an isoperistaltic direction. The proximal ureter was anastomosed end-to-side with the ileal segment (Nesbit technique), while the pyelo-ileal anastomoses were made end-to-end. None of the ileal segments were tapered. The distal ileo-vesical anastomosis was performed end-to-side on the back of the bladder after excision of a circular part of bladder wall, in seven of these patients an anti-re ux nipple valve was created. The ileal ureters were placed in an intraperitoneal fashion. In the three patients with a U-shaped reconstruction, a side-toside anastomosis between the ileal segment and the bladder was made. A nasogastric tube was used as a ureteral stent to bridge the anastomosis temporarily after operation, while the bladder was drained witha Foley catheter. Fluoroscopic control for leakage or obstruction was done before removing the ureteral stent. Postoperative follow-up was carried out every 3 months during the rst year, twice a year during the second year and annually afterwards. Routine check-up comprised a chemical pro le, including serum creatinine and bicarbonate levels, urine cultures and a renal ultrasonography. An excretory urography, a cystography or an isotopic renography were obtained on indication. The mean period of follow-up was 65 months (range 2±196). 3. Results No mortality occurred in our group of patients during a 30-day post-operative period. Renal function improved after ileum interposition in 20 of 22 renal units (90%), while two patients experienced a decreased renal function. In one patient, there was an afunctional kidney due to an obstruction at the level of the uretero-ileal anastomosis and a nephrectomy was performed. The other patient had a decreased but stable renal function after a re-anastomosis between the renal pelvis and the ileal ureter, without further complaints. In one patient, recurrent hematuria of renal origin occurred in an otherwise good functioning kidney, which could not be treated conservatively and ultimately, a nephrectomy was performed. Pathological investigation revealed multiple small arterio-venous malformations in the kidney. Overall, after a mean period of 65 months, 19 renal units (86%) were functioning witha stable or improved renal function as was shown by a normal serum creatinine and ultrasound (mono-kidney) or a normal serum creatinine, isotopic renography and IVU (other patients). Post-operative complications demanded surgical reintervention in three patients (17%): once because of bleeding, once because of prolonged ileus due to adhesions, caused by previous abdominal surgery, and in a third patient because of urinary leakage through the proximal anastomosis. Direct post-operative complications that could be treated conservatively included: wound infection (n ˆ 2), pneumonia (n ˆ 1), cardiac decompensation (n ˆ 1), temporary femoral nerve

3 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181± palsy (n ˆ 1) and one cerebrovascular accident which recovered to normal function. Six patients (33%) required seven surgical reinterventions in the long term. Two of them had a nephrectomy as mentioned earlier, another patient developed a stenosis of the proximal uretero-ileal anastomosis and twice a re-anastomosis was performed. The fourth patient, witha mono-kidney, developed brosis at the level of the pyelo-ileal anastomosis after a percutaneous procedure for suspected recurrence of transitional cell carcinoma (TCC) and a re-anastomosis between the renal pelvis and the ileal segment was performed (Fig. 1). The fth patient had to be treated for a stone in the renal pelvis with a percutaneous litholapaxy, because this stone could not pass the uretero-ileal anastomosis that was made end-to-side. The sixth Fig. 1. IVU of the female patient with a mono-kidney. She developed brosis at the level of the pyelo-ileal anastomosis after the percutaneous procedure for suspected recurrence of transitional cell carcinoma. This is the result of a successful re-anastomosis of the pyelo-ileal junction.

4 184 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181±187 Table 2 Post-operative complications Complication Number of patients (n) Therapy Short-term complications (<30 days post-operative) Leakage uretero-ileal anastomosis 2 Ureteral splint for 10 days, uretero-ileal re-anastomosis Wound infection 2 Conservative treatment Pneumonia 1 Medical therapy CVA 1 Spontaneous recuperation Prolonged ileus/intestinal adhesion 1 Re-laparotomy Bleeding 1 Re-laparotomy Cardiac decompensation 1 Medical treatment Femoral nerve palsy 1 Spontaneous recuperation Long-term complications (>30 days post-operative) Metabolic acidosis 2 Sodium bicarbonate substitution Recurrent UTI 6 See Table 3 Recurrent hematuria/av malformation in the kidney 1 Nefrectomy Fibrosis uretero-ileal anastomosis 4 Uretero-ileal re-anastomosis (n ˆ 3), nefrectomy (deteriorating renal function) (n ˆ 1) Renal stone 1 PNL patient developed a stenosis at the right side of the U-shaped bilateral ileum interposition and a re-anastomosis had to be performed. All of these reinterventions were carried out without any problem (Table 2). Overall, six patients (33%) experienced recurrent urinary tract infections. One patient was treated uneventfully withantibiotic maintenance therapy. The second patient who developed a UTI had an ileal augmentation cystoplasty combined witha unilateral ileum interposition and developed stenosis at the contralateral uretero-vesical junction, which had to be reimplanted. Because of urinary stasis and re ux into the interposed ileal segment, this patient was treated withprophylactic antibiotics and a clean intermittent catheterization regime. The third patient suffered from recurrent upper UTI associated withstenosis at the pyelo-ileal anastomosis, for which he underwent a reanastomosis. The fourth patient suffered from residual urine due to a hypotonic detrusor function and was treated withclean intermittent catheterization (CIC) and antibiotic maintenance therapy. The fth patient also had a UTI because of bladder out ow obstruction. He underwent TURP, but the residual urine persisted. Therefore, he was also put on CIC and antibiotic maintenance therapy. He also had a urolithiasis of the upper urinary tract for which he underwent PNL. The last patient who developed a UTI had several UTI after percutaneous procedures for suspected TCC, and received prophylactic antibiotic therapy after a reintervention for stenosis at the pyelo-ileal junction. Overall, re ux was found in four out of six patients (66%) who presented with urinary tract infections. The results are listed in Table 3. Stenosis was found in four patients (four renal units). Diagnosis was made during follow-up with the help of technical investigations, which are carried out to detect this complication. In patients with a functional or anatomical mono-kidney serum creatinine and routine renal ultrasound gave adequate information. In the other patients, further technical investigation with renal isotope-scanning (MAG3) and intravenous pyelogram (IVU) was carried out to have more information about the function of the renal unit treated with ileal substitution. In one patient, the kidney had become afunctional, which was detected because of loin pain after a car accident. A MAG3-scan and an IVU con rmed this diagnosis, whereafter a nephrectomy was performed. Three other patients experienced an obstruction at the level of the uretero-ileal anastomosis. Diagnosis was made witha MAG3-scan and IVU in one patient, using a Whitaker-test and an antegrade pyelography in another, and during a percutaneous pyeloscopy in the third patient with suspected recurrent TCC of the renal pelvis. In these three patients, a re-anastomosis was performed and the kidney-function could be preserved successfully. These results are also listed in Table 3. Hyperchloremic acidosis was diagnosed in two of our patients (11%), withserum bicarbonate levels less than 20 mmol/l and serum chloride levels exceeding 107 mmol/l. In bothpatients, acidosis could be treated withoral sodium bicarbonate. One patient had a preoperative serum creatinine of 150 mmol/l, the other patient also had an augmentation cystoplasty, urinary stasis and urinary tract infections. Urolithiasis occurred in two of the patients. One lithiasis occurred at the contralateral side of the ileum interposition and was successfully evacuated during a ureterorenoscopy. The second patient was treated with a PNL for a stone in the renal pelvis, which could not pass the Nesbit-type uretero-ileal anastomosis at that

5 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181± Table 3 Overview of characteristics of consecutive operations, occurrence of UTI, outcome of renal function and additional treatments Patient no. Specialities or additional procedures Anti-re ux nipple Re ux UTI Cause of UTI Renal function Kind of intervention 1 Bilaterally Unknown Creatinine normal, IVU normal Antibiotics, Sodium bicarbonate 2 Mono-kidney Creatinine normal 3 Augmentation cystoplasty MAG3 normal Reimplantation because of stenosis at contralateral uretero-vesical junction, CIC, antibiotics 4 MAG3 normal 5 Chronic pyelonephritis Obstruction uretero-ileal MAG3: deteriorated renal function Re-anastomosis of uretero-ileal junction 6 MAG3 normal Nephrectomy due to AV malformations 7 Bladder Creatinine normal, IVU normal CIC, antibiotics hypocontractility 8 Pyelo-ileal obstruction Nephrectomy 9 Mono-kidney Creatinine normal, normal ultrasound of kidney 10 MAG3 normal 11 Bilaterally Outlet obstruction MAG3 normal PNL, TURP, CIC, antibiotics 12 Mono-kidney, TCC? Pyelonephritis Obstruction after percutaneous pyeloscopy Re-anastomosis pyelo-ileal 13 MAG3 normal 14 MAG3 normal 15 Bilaterally Obstruction pyelo-ileal on Re-anastomosis IVU and Whitaker-test 16 MAG3 normal 17 Bilaterally Creatinine and ultrasound of kidney normal 18 Mono-kidney Creatinine and ultrasound of kidney normal side in a patient witha bilateral, U-shaped, ileal substitution. Overall, in eight of our patients vesicoileal re ux was diagnosed (10 renal units). Three of these patients had had an anti-re uxing nipple valve technique at the ileo-vesical junction. None of these developed any problems. In 5 of 11 patients, without an anti-re uxing mechanism, re ux occurred. In three of these patients, recurrent urinary tract infections had to be treated. Re ux occurred in 43% of the patients with an antire uxing nipple and in 45% of those without this mechanism (Table 4). Table 4 Correlation between anti-re ux nipple and re ux (number of renal units in parenthesis) Re ux (n) No re ux (n) Total (n) Withanti-re ux nipple 3 (3) 4 (5) 7 (8) Without anti-re ux nipple 5 (7) 6 (7) 11 (14) Total 8 (10) 10 (12) 18 (22) 4. Discussion Ureteral obstruction of various origins may cause the need for a reconstructive procedure to prevent damage to the affected kidney. Many surgical solutions are described to cope withthis problem [1], including ileal-ureteral substitution. This operation was rst described by Schoemaker in 1906, for ureteral obstruction in a patient suffering from tuberculosis. Initially this operation had a high mortality and a high morbidity rate. With urologists gaining experience in complex reconstructive surgery, the procedure became more popular [4±7]. It was done mostly in dif cult cases where other possibilities such as primary ureteral re-anastomosis, Boari ap or psoashitch with ureteral reimplantation, appendix interposition, recon gured colon-interposition, transureteroureterostomy or renal auto transplantation was not feasible. Although, previously, tuberculosis was the most frequent cause for this operation, we now see a shift towards ureteral obstruction caused by secondary

6 186 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181±187 retroperitoneal brosis after various types of treatment, including radiotherapy and surgery for malignant tumours. Idiopathic retroperitoneal brosis also remains an important indication. A last reason is iatrogenic ureteral obstruction, resulting from endourological procedures to resolve obstruction in a diseased ureter. As withthe indications for this kind of surgery, also the surgical techniques improved [8]. Still several technical issues remain unclear with regard to their effects on long-term ef cacy of this operation. One of these issues is vesico-ureteral re ux of urine withsubsequent renal damage. Tanagho, in 1975, postulated that in a patient with an ileal ureter and re ux, the renal pelvis is constantly exposed to intermittent high vesical pressures that causes ilealureteral dilatation and functional obstruction with subsequent renal damage. Therefore, he did not recommend an ileal-ureteral substitution [9]. Other authors [10±12], however, found no deterioration in renal function when an anti-re ux mechanism was incorporated in the vesico-ileal anastomosis. Waldner et al. [13] found no difference in renal function between patient groups treated withor without an anti-re ux valve. In our own series, 8 of 18 patients were diagnosed withre ux (Table 2). Three of them had an antire uxing nipple which showed to be insuf cient, but without consequences regarding renal function. From the ve other patients without a nipple, three experienced recurrent UTI. All of them could be managed withconservative measures without further damage to the kidney. The other two patients without a nipple had re ux but never experienced any problem from it. Six patients without an anti-re uxing mechanism never had any clinical or radiological evidence of re ux. Regarding these ndings one can still question the importance of an anti-re uxing mechanism with respect to the preservation of renal function. This has also been described by other authors [3,11,13,14]. It is hypothesised that ileal peristalsis causes protection against urinary re ux and transmission of intravesical pressure into the renal pelvis to prevent re ux-nephropathy as long as the ileal segment used is long enough. Buskens [2] also recognised the importance of ileal segment length and he proposed to use ileal lengths of at least 20 cm. Accordingly, he indicates that an anti-re ux mechanism is not always necessary when an ileal segment of suf cient lengthcan be incorporated in the reconstruction. Stenosis, found in four patients, was responsible for an important part of the long-term reinterventions which had to be performed. One renal unit was lost due to stenosis in a patient who already had a pyelolithotomy years before the ileum interposition. Another patient suffered form stenosis due to recurrent TCC in the renal pelvis and several percutaneous procedures withlaser coagulation, accompanied witha pyelonephritis episode. The other two patients probably had a stenosis due to the implantation technique. Overall, stenosis at the uretero-ileal junction was responsible for a deteriorated renal function after ileum interposition. In their series of 89 patients, Boxer et al. [3] described a difference in outcome between patient groups depending on the pre-operative serum creatinine level. It is generally understood that in a patient witha decreased pre-operative renal function, the ileal segment interposition into the urinary system can disrupt the metabolic equilibrium and cause hyperchloremic acidosis. Other factors in the development of metabolic acidosis in these patients are urinary retention, contact time between urine and intestinal mucosa and the amount of mucosal surface involved in the substitution. Buskens postulated that signi cant hyperchloremic acidosis could be avoided when no urinary retention occurred and the patient had a normal preoperative renal function. We had two patients (11%) withsigni cant metabolic acidosis that could be treated uneventful withsodium bicarbonate substitution. One patient had urinary retention due to voiding dysfunction after an ileal augmentation cystoplasty, while the other patient had a borderline renal function with a creatinine level of 150 mmol/l, and thus a reduced renal functional reserve. These ndings indicate that careful patient control withattention to renal function, treatment of urinary stasis and out ow obstruction and substitution therapy, when necessary, can prevent metabolic acidosis. Although careful patient selection and adequate surgical techniques are key features in patient outcome in the long-term, there may still arise problems after a considerable period of time, as seen in our series. Therefore, careful follow-up is demanded in these patients and they should be followed during the rest of their lives and treated for conditions which may interfere with the function of their ileal-ureteral substitution. Iatrogenic ureteral lesions were, together with idiopathic retroperitoneal brosis, the most frequent indications for ileal-ureteral substitution. Three of the ve iatrogenic lesions (60%) were caused by endo-urological procedures. Since the frequency of minimal invasive procedures increase, it may also be expected that the number of complications of these techniques will increase. This may also enhance the need for ilealureteral substitution in many cases.

7 F.J.H. Verduyckt et al. / European Urology 42 (2002) 181± Conclusion Ileal-ureteral substitution still remains a valuable procedure withgood long-term results and an acceptable reintervention rate in patients withunilateral or bilateral ureteral obstruction for whom other alternatives are not feasible. Because of the eradication of tuberculosis also some of the indications to perform this procedure disappeared, but withthe increasing number of endo-urological procedures, radiotherapy and extensive surgery for malignant tumours other indications for ileal-ureteral substitution are to be expected. References [1] Benson MC, Ring KS, Olsson CA. Ureteral reconstruction and bypass: experience with ileal interposition, the Boari ap, psoas-hitch and renal auto-transplantation. J Urol 1990;143:20±3. [2] Buskens FMG. Over het vervangen van de ureter door dunne darm, Thesis. K.U. Nijmegen, [3] Boxer RJ, Fritzsche P, Skinner DG, Kaufman JJ, Belt E, Smith RB, Goodwin WE. Replacement of the ureter by small intestine: Clinical application and results of the ileal ureter in 89 patients. J Urol 1979;121:728±31. [4] Perkash I, Siddigi AM, Chakravarti RN, Pathak MS, Kashyap KU. Segmental replacement of the ureter by a narrowed ileal loop. Br J Urol 1970;42:545±50. [5] Le Duc A, Camey M, Teillac P. An original anti-re ux uretero-ileal implantation technique: long-term follow-up. J Urol 1987;137:1156± 8. [6] Mattos RM, SmithJJ. Ileal ureter. Urol Clin NorthAm 1997;24:813± 25. [7] Shokeir AA. Interposition of ileum in the ureter: A clinical study withlong-term follow-up. Br J Urol 1997;79:324±7. [8] Shokeir AA, Gaballah MA, Ashamallah AA, Ghoneim MA. Optimization of replacement of the ureter by ileum. J Urol 1991;146:306±10. [9] Tanagho E. A case against incorporation of bowel segment into the closed urinary system. J Urol 1975;133:796±9. [10] Bejany DE, Lockhart JL, Politano VA. Ileal segment for ureteral substitution or for improvement of ureteral function. J Urol 1991;146:302±5. [11] Goodwin WE, Winter CC, Turner RD. Replacement of ureter by small intestine: Clinical application and results of the ``ileal ureter''. J Urol 1959;81:406±18. [12] Shokeir AA, Mahran MR, Shamaa MA. Interposition of ileum in the ureter. Scand J Urol Nephrol 1993;27:421±4. [13] Waldner M, Hertle L, RothS. Ileal-ureteral substitution in reconstructive urological surgery: Is an anti-re ux procedure necessary? J Urol 1999;162:323±6. [14] Fritzsche P, Skinner D, Craven J, Cahill P, Goodwin W. Long-term radiographic changes of the kidney following the ileal ureter operation. J Urol 1975;114:843±7.