Replacement of the ureter by small intestine: clinical application and results of the ileal ureter

Urinary tract reconstruction in children

The successful introduction of clean intermittent catheterization and increased awareness of urinary tract physiology and urodynamics have been the basis for recent major advances in urinary tract reconstructive surgery. Surgical techniques are now available to manage anatomical and functional deficiencies of any isolated or combined components of the urinary tract. The high incidence of unsatisfactory long-term results with ileal conduit diversion has led to increased popularity in urinary tract undiversion and greater utilization of reconstructive principles. As with any new surgical field of endeavour, new operative techniques are appearing at a rapid rate. In particular, there has been a recent proliferation of surgical procedures that provide a continent, low pressure, catheterizable reservoir for urine storage. Most children with major urinary tract deficiencies can now be offered socially and cosmetically unobtrusive surgical solutions without jeopardizing renal function.

Pediatric urinary diversion and undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.

Management of the short ureter in urinary tract reconstruction

Among our 56 patients who have undergone urinary tract reconstruction with intact bladders 45 have required some compensation for lost ureteral length. Of these patients 33 had only distal ureteral loss and underwent reconstruction with a combination of a psoas hitch, transureteroureterostomy and primary reimplantation. Four patients with more extensive ureteral loss underwent a Boari flap procedure, and of the 8 patients with major ureteral loss 6 had small bowel interposition and 2 have had renal autotransplantation to compensate for lost ureteral length. All patients are well with stable renal function at 1 to 7-year followup.

Repair of upper ureteric obstruction with Boari flap and psoas hitch

A case of iatrogenic traumatic obstruction to both upper and lower ureters resulting in severe hydronephrosis is reported. Continuity and good functional result was achieved with a Boari flap and psoas hitch to the renal pelvis.

Nonrefluxing ureteroileal cystoplasty for bladder augmentation or replacement of ureters: long-term results of own technique

The technique of a nonrefluxing end-to-end ureteroileal anastomosis is described. The conjoined ends of both ureters are formed into a 4 to 5 cm. long ureteral tube that is placed loosely into the bowel lumen. Increased intraluminal pressure during micturition closes the valve by compressing the ureter wall from outside, thus, preventing reflux. An end-to-end enteroureteral anastomosis has been used in 32 ileal or colon conduits and in 6 patients with ureteroileal cystoplasty. The followup (range 1 to 15 years) of these 6 patients who underwent bladder augmentation or ureteral replacement is presented. Based on this experience, this type of anastomosis appears to be fast and safe, without urine leakage, stenosis or reflux. The nonrefluxing safety valve mechanism makes this anastomosis applicable for bladder augmentation, with no ill-effects and good long-term function.

An intussuscepted ileal ureter bladder nipple

We report a case of an intussuscepted bladder nipple following construction of an ileal ureter. The ileal ureter has become a valuable option in reconstructing the urinary system. This complication bears consideration during construction of an ileal ureter and stresses the need for close observation of these patients.

Ureteral replacement with ileum in transverse colon conduit

A case of replacement of a damaged ureter with ileum, in a previously constructed transverse colon conduits, is reported. This is an attractive surgical alternative that deserves a place as a reconstructive procedure in the management of ureteral complications following urinary diversion.

Extreme hypernatraemia in association with renal failure following caecocystoplasty

A case of extreme hypernatraemia (serum sodium 212 mmol/l) occurring in association with renal failure following a caecocystoplasty procedure is reported. The causative factors in extreme hypernatraemia are reviewed and an unusual reabsorptive mechanism via the transposed intestinal segment is proposed to explain the degree of hypernatraemia present in this case.

Pan-caliceal ileoneocystostomy: indications, modifications and further evaluation

During the last 4 years we treated 11 patients with obstructed kidneys and intrapelvic strictures, which were owing to tuberculosis in 9 and renal stone surgery in 2. Pan-caliceal ileoneocystostomy was performed in all 11 cases. The entire caliceal system was anastomosed to an ileal ureter and, thus, relieved the obstruction. The result of this operation was most gratifying. Although 1 patient died of anastomotic leakage and sepsis the morbidity was low.

Ileal segment replacement of ureter. I. Effects on kidney of refluxing vs nonrefluxing ileovesical anastomosis

Unilateral partial ureteral obstruction was induced in 32 dogs followed by total ileal replacement of the obstructed ureter. The morphologic and functional effects on the kidney using a freely refluxing versus a nonrefluxing ileovesical anastomosis were compared, as well as the effect of total tapering of the reimplanted ileal segment. The tapered ileovesical anastomosis proved more reliable for prevention of reflux than the nontapered technique. Reflux prevention does not appear necessary for maintaining renal morphology and function when bladder function is normal and the observation period short. Total tapering of the ileal segment did not prove to be advantageous in protecting against hyperchloremic acidosis in this short-term canine study.

Ileal segment replacement of ureter. II. Dynamic characteristics of refluxing, nonrefluxing, and totally tapered ileal ureter

The pressure characteristics and cinefluoroscopic appearances of a refluxing, nonrefluxing, and totally tapered ileal " neoureter " were compared in 22 dogs with normal bladder function. The totally tapered ileal segment with a reflux preventing ileovesicostomy simulates normal ureteral peristalsis most closely on cinefluoroscopic evaluation. Pressure gradients across the ileovesical junction though were similar in refluxing and nonrefluxing ileovesicostomies , as well as in totally tapered ureters.

Osteomalacia due to ileal replacement of ureters: report of 2 cases

We report 2 cases of ileal replacement of the ureters: 1 bilateral and 1 unilateral with a single kidney. Hyperchloremic acidosis developed in both patients and osteomalacia was proved by iliac bone biopsy. Patient 1 had symptomatic bone disease and control of acidosis with sodium bicarbonate was difficult because of associated hypertension. The level of alkaline phosphatase varied inversely with the level of serum bicarbonate. Pharmacological doses of 1-alpha hydroxycholecalciferol were ineffective and osteomalacia persisted in a second biopsy. Patient 2, who was asymptomatic, suffered acidosis and increased serum alkaline phosphatase levels immediately postoperatively and osteomalacia was confirmed histologically at 6 months.

The treatment of urinary tuberculosis

During the last 7 years we treated 92 patients with tuberculosis of the urinary tract. Patients with tuberculous infection were divided into 3 groups according to treatment: group 1--no surgical treatment (18 patients), group 2--ablative surgery (45 patients) and group 3--reconstructive surgery (29 patients). Antituberculous drugs, consisting of rifampin, pyrazinamide, isoniazid and ethambutol, were given according to the severity and extent of the infection process. The results of medical and surgical treatment were most gratifying. Surgical morbidity was low and there was no immediate mortality.

Autologous renal transplantation and pyelocystostomy after unsuccessful pyeloplasty

A total of 4 patients with persistent outflow obstruction after pyeloplasty for hydronephrosis was reoperated with renal autotransplantation and pyelocystostomy. All 4 patients had undergone an unsuccessful Anderson-Hynes pyeloplasty and 2 also had had a second operation. All patients had relief of pain, normalization of urine outflow and improved renal function during an observation of 27 to 37 months. Occasional asymptomatic bacteriuria occurred in 2 patients. Thus, renal autotransplantation and pyelocystostomy may be considered a useful and safe method to eliminate persistent outflow obstruction after unsuccessful pyeloplasty.

Autologous renal transplantation with direct pyelocystostomy in the treatment of recurrent renal calculi

Six male patients with severe recurrent urinary calculus disease underwent renal autotransplantation with direct pyelocystostomy to allow spontaneous passage of stones. The only serious complication was an early renal vascular thrombosis with graft loss in one patient who had been operated on three times before with ipsilateral partial resections for nephrolithiasis. The other five patients did well (observation time 4-34 months). Their renal function has remained unchanged. Autotransplantation with direct pyelocystostomy should be considered in patients with multiple recurrent stones of the upper urinary tract, especially when some degree of obstruction has developed or when other predisposing anomalies prevail.

Late stricture of intestinal ureter

Late stricture is a well known complication of ileal loops. We herein report on late stricture in 5 patients in whom bowel was used as a substitute ureter in closed, nondiverted urinary tracts. This late complication mandates the need to provide continuing followup indefinitely in patients in whom bowel segments are incorporated in the urinary tracts.

Further experience with the ileocecal segment in urinary reconstruction

In selected patients it is possible and desirable to reconstruct a normal or near normal method of urinary drainage after temporary ileal loop urinary diversion or after cystectomy for nonurothelial pelvic malignancy. Satisfactory results have been achieved in 20 of 23 patients, with followup as long as 10 years. Seven patients have undergone reconstruction after temporary ileal conduit urinary diversion for benign conditions. One patient underwent urinary reconstruction following prolonged ileal conduit urinary diversion for radiation-induced injury to the bladder as part of treatment for cervical carcinoma. In 11 patients the ileocecal segment was used as part of a planned urinary reconstructive procedure after cystectomy for nonurothelial pelvic malignancy or when correcting a benign lower urinary tract pathologic condition that resulted in a cutaneous fistula. The ileocecal segment is a surgical unit that allows replacement or augmentation of the bladder, with the ileum substituting for as much ureteral length as necessary. However, the ileocecal valve is not effective in the long-term prevention of reflux and use of a recently described ileal intussusception technique seems preferable.

Endoscopic removal of staghorn calculi in patient with high urinary diversion

The treatment of recurrent renal calculi in patients after ureteroileal urinary diversion is difficult, especially when urinary stones are formed in the presence of urinary tract infection. In many cases, these patients already have undergone multiple renal operations and more surgery could pose difficult technical problems. We report on a patient with a high urinary diversion in whom bilateral staghorn renal calculi developed, and then were endoscopically removed. The conversion of ureteroileocutaneous diversion to a high pyeloileocutaneous diversion is recommended in selected cases as alternate treatment for patients with recurrent stone formation.

The use of antirefluxing intestinal segments in pediatric urinary reconstruction

Because of inadequate ureteral length or disease preventing direct ureterovesical anastomoses, antirefluxing intestinal segments were used in eight children during reconstruction of their urinary tracts. Previous urinary diversions by either ileal conduit or cutaneous ureterostomy had been done in six of the eight. In five of the children, bladder augmentation was also required because of nondistensible fibrotic bladders secondary to disuse or prior obstruction. The intestinal segments used were ileal (4), ileocecal (4), and sigmoid (1). The ileal segments were tapered along the antimesenteric border and reimplanted into the bladder with long submucosal tunnels to prevent reflux. Reflux was prevented in the ileocecal segments by plication of the normal ileocecal valve. Reflux has not developed postoperatively in any of these patients. In one patient in whom an ileal segment was used. In one patient in whom an ileal segment was used, partial obstruction occurred at the new bladder hiatus. The serum creatinine rose from 2.8 mg/dl to 3.5 mg/dl necessitating a secondary repair. Renal function and serum electrolytes have improved or remained stable in all other patients. For children who have undergone multiple previous procedures resulting in inadequate ureteral length and/or abnormal bladders, these techniques offer excellent alternatives to permanent urinary diversion.

Pan-caliceal ileoneocystostomy--a new operation for intrapelvic tuberculotic strictures of the renal pelvis

Intrarenal scarring with stricture formation is common in late cases of renal tuberculosis and has caused more loss of renal function than direct involvement by tuberculosis. The classical treatment of this condition is heminephrectomy for early cases and total nephrectomy for late cases. However, these destructive procedures are far from satisfactory. We describe a new operation, pan-caliceal ileoneocystostomy, that aims at draining the entire caliceal system into an ileal ureter, which thereby relieves the obstruction. Good results were obtained in 2 cases. This procedure also is applicable to cases of intrarenal scarring with stricture formation owing to other causes.

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

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.

Reoperative ureteral reimplantation: management of the difficult case

Reoperative ureteral reimplantation can be difficult if the bladder and ureters are abnormal or the patient has undergone multiple operations. In some cases both ureters can be mobilized and reimplanted again with satisfactory result. That is impossible in others. A useful alternative is long tunnel reimplantation of the better ureter, with psoas hitch, and transureteroureterostomy of the other ureter. If neither ureter is suitable a tapered bowel segment can be used, but this must be done in a manner that prevents reflux. In those patients for whom none of the above choices are possible, cecal augmentation of the bladder offers yet another option, intussuscepting the ileocecal valve to prevent reflux. With these various approaches in the reconstructive armamentarium, urinary diversion should be avoidable in nearly all cases who present after previous failure of ureteral reimplantation.

Renal autotransplantation for recurrent renal colic

Renal autotransplantation as an alternative to ileal interposition has been done successfully in patients with repetitive episodes of renal colic. Urinary tract continuity has been re-established by anastomosis of a Boari tube directly to the renal pelvis. This has resulted in easy egress of recurrent calculi without pain. Furthermore, the musculature of the Boari tube seems to be adequate for prevention of vesicorenal reflux. The procedure has been devoid of electrolyte and mucous urinary retention problems associated with ileal interpositionand it is advocated as an alternative in the management of such patients when medical therapy fails.

Vesicovaginal and ureterovaginal fistulas: a summary of 25 years of experience

The difficult problem of a vesicovaginal fistula originally was cured surgically by Sims in 1849. During the last 25 years at UCLA and affiliated hospitals 68 patients have been treated by urologic surgeons for fistulas between the vagina and the urinary tract: 21 ureterovaginal and 47 vesicovaginal and urethrovaginal fistulas. The ureterovaginal fistulas often were complex and patients presented the most challenging diagnostic problem. However, they usually were repaired successfully by simple ureteroneocystostomy. Vesicovaginal and urethrovaginal fistulas were repaired transvaginally in 24 cases, with 70 per cent success at the first attempt and 92 per cent success with 2 attempts. Transabdominal or combined approaches were less successful. Only 58 per cent of the cases were closed at first attempt. The transvaginal approach required less operating time, and resulted in less blood loss and shorter hospital stays than the transabdominal approach and will be described in detail.

Total replacement of the ureter with a segment of ileum. A follow-up study

Total replacement of the ureter with a segment of ileum was performed on seven patients. Five of them were followed up for a mean of 20 months. The results of the operation were good. Serum electrolyte imbalance occurred postoperatively in one case.

Techniques of urinary undiversion surgery in children

During the past eight years, reestablishment of previously diverted urinary tracts has become more frequent. During the past three years, 11 patients have been evaluated and 7 subsequently operated on to reestablish continuity of the urinary tract. Four patients were eliminated from surgical consideration because of the extent of renal disease. The surgical procedures involve the use of ileum as well as the transureteroureterostomy with the psoas hitch procedure to reestablish urinary continuity. Examination of the over-all results illustrates urinary undiversion surgery in children is worthwhile. The initial results with neuropathic bladder disease has been a little discouraging, and more data will be required before a conclusion can be reached.

Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.

Ureteral replacement using a new variation of the tailored ileal segment

Long-term complications of ureteral replacement by the small intestine are discussed. A new concept of tailoring the intestinal graft has proved successful in experimental animals. The first clinical application of this technique involves a 22-year-old women whose left kidney and right ureter were destroyed by tuberculosis. Excellent results were noted at the 3-year followup.

Flap ureteroplasty for segmental structure of middle third of ureter

A technique is described for repair of segmental stricture of the middle third of the ureter utilizing spiral or vertical flap from the proximal dilated ureter. In all cases a 10 F polyethylene ureteric stent with a ureterotomy exit 5 cm. distal to the repair site was used. Twenty-eight ureters in 27 patients were repaired by this technique, with good results in all except 3 cases which showed postoperative residual dilatation three months after surgery.

Some alternatives to urinary diversion in children

Many children with severe urologic problems have been treated by urinary diversions, often after unsuccessful operations to correct the original pathology. Urinary diversion should be avoided when possible, since often it is accompanied by chronic infection and quality of life is less good than it could be. Most diversions can be prevented by use of other alternatives including 1) reimplanting 1 ureter and transureteroureterostomy of the other, 2) psoas hitch, 3) wide mobilization and downward displacement of the kidney and ureter, 4) use of bowel as ureter, 5) cecal cystoplasty and 6) early repair of complex pathology. Autotransplantation is probably seldom indicated in childhood.

Replacement of the damaged or neoplastic ureter by ileum

Ileum was used as a ureteral replacement in 12 patients, 7 of whom had solitary kidneys. The conditions that necessitated an operation included renal pelvic and ureteral complications of calculi, a variety of traumatic ureteral injuries, retroperitoneal fibrosis and ureteral neoplasms. Renal function has been well preserved and electrolyte imbalance has been minimal.

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.

Total replacement of ureter with a segment of ileum

Replacement of ureter with a segment of ileum was successfully performed in two patients. One had ureteral cancer and the other recurrent calculi due to cystinuria. The first patient had only one kidney. In the second both ureters were replaced with ileum. Formation of a papilla at the distal end of the ileal segment in the bladder may reduce the risk of vesico-ileal reflux.

The ileal ureter in recurrent urolithiasis

An ileal segment was interposed between the renal collecting system and bladder in 4 cases. The surgical technique is outlined, with emphasis on the pyelo-infundibulocalico-ileal anastomosis and other technical aspects. The ileal ureter is recommended in selected cases of recurrent renal calculi and nephrocalcinosis with associated nephrolithiasis.

Long-term radiographic changes of the kidney following the ileal ureter operation

A long-term retrospective evaluation was done on the preoperative and postoperative radiographic studies from patients who had undergone the ileal ureter operation. The comparative studies demonstrated decreased or stable pelviocaliceal dilatation, no measurable parenchymal loss, frequent high pressure vesico-ileac reflux and decreased number of renal calculi. Radiographically there was no evidence of renal morphological deterioration.