A technique for ureterosigmoidostomy by direct interposition of an ileal loop with a valve

Indications

There may be problems with ureterosigmoidostomy in patients whose ureters have a thick wall, are short or very dilated and there may be difficulties if there is hydroureteronephrosis in continent patients after ureterosigmoidostomy, or in those with a rectal bladder with a terminal colostomy. A procedure was thus developed using direct interposition of an ileal loop with a valve. The procedure was carried out in two patients with normal renal function, one who had undergone three repairs for ectopic bladder which resulted in bilateral hydroureteronephrosis, incontinent penopubic epispadias and a contracted bladder containing a stone, and one patient with T3b bladder cancer with bilateral hydroureteronephrosis.

Methods

Fig. 1. The isolated 15 cm ileal segment, with mesentery excluded in its middle third.

A 15 cm long ileal segment 30-50 cm oral to the caecum is isolated, the continuity of bowel restored by end-to-end anastomosis and the mesentery excluded from the middle third of the isolated ileal segment (Fig. 1). An intussuscepted ileal valve is constructed using the distal 10 cm of the ileal segment by passing a Babcock clamp through the distal opened ileal lumen, grasping wall and pulling it out to form a 5 cm long nipple valve; this is stabilized using three longitudinal parallel 0 Nylon suture lines and 3/0 Nylon interrupted security sutures at the base of valve. The ureters are anastomosed end-to-side in the proximal 5 cm of the ileal segment using 4/0 polyglyconate sutures around 6 F ureteric stents. The proximal supravalvular ileal end is closed in two layers by 3/0 continuous then interrupted polyglyconate sutures (Fig. 2). A 3 cm rectal incision is made, followed by an end-to-side ileorectal anastomosis so that the distal half of the valve projects inside the rectal lumen, and two rectal 18 F tubes, one reaching above valve and the other below, are inserted (Fig. 3).

Fig. 2. The distal 10 cm of ileum is intussuscepted and stabilized with three rows of Nylon 0 sutures. The stented end-to-side ureteroileal anastomosis is shown.

Fig. 3. The ileal valve is anastomosed end-to-side into rectosigmoid, so that the distal half of the valve projects inside the rectal lumen; note the two rectal tubes in place.

Comparison with other methods

The augmented and valved rectum ^[1] (AVR) with two separate ileal and colonic valves is applicable in cases with relatively short, very dilated and thick ureters; a temporary colostomy is required for 6-8 weeks after which a second operation for its closure is needed. In the present procedure, no colonic valve or ileal patch is used and thus a temporary colostomy is not needed.

A double-folded rectosigmoid with serous-lined extramural tunnel ureterocolic reimplantation ^[2] is applicable for moderately dilated ureters if they are long enough, but if the ureters are short or very dilated and thick, that method is unsuitable. However, the present technique entails no rectosigmoid reconfiguration and is suitable for thick-walled, short or very dilated ureters.

Ureteroileocaecosigmoidostomy ^[3] and ileocaecoureterosigmoidostomy ^[4] use caecum, but the present technique uses no caecum and the ileum adjacent to the caecum is saved. Obstruction complicating ureterosigmoidostomy can be avoided by the ileal interposition technique ^[5], where after ileal intussusception the nipple at the 12 o’clock position is incised then sutured with the overlying bowel wall and distal ileum is anastomosed to the colon via a wide anastomosis. The present technique entails no wide anastomosis and the nipple is not incised or sutured to overlying bowel wall; it also avoids ileal patching. The interposition of an antireflux ileal valve to a rectal bladder ^[6] also entails an ileal patch; neither ileal patch nor rectal isolation are required in the present method.

Advantages and disadvantages

The technique is relatively simple and similar to Bricker’s ileal loop conduit, the only addition being the intussusception of the distal part of the ileal loop and then, instead of ileocutaneous anastomosis, the intussuscepted ileal valve is anastomosed end-to-side in the sigmoid. Although it can be used in patients with short, very dilated or thick ureters, if the ureters are normal, then the submucous tunnel would be the procedure of choice.

The colorectal valve and temporary colostomy of the AVR were not constructed in the present procedure, but they are needed if the serum creatinine is elevated, to decrease the possibility of absorption through the entire colon and any resultant acidosis. The ileocaecal segment was not used, thus avoiding malabsorption, diarrhoea and vitamin B2 deficiency.

In ureterosigmoidostomy techniques without colorectal valves, urine could reflux to the colon ^[7]. Consequently, the ileal patch was not used, to simplify the procedure, but it is needed in cases with an isolated rectal bladder and terminal colostomy complicated by urinary incontinence, because there is high intraluminal rectal pressure and hydroureteronephrosis. Thus, the present procedure should be restricted to cases with hydroureteronephrosis complicating a rectal bladder if it is not associated with urinary incontinence and where proctometry is acceptable.

With the present method, the ureters are not anastomosed to colon but ileum, and the uretero-enteric anastomotic site is not in contact with the faeco-urinary admixture; this might protect against the development of carcinoma at the implantation site ^[8]. Nevertheless, these patients should undergo yearly proctoscopy.

Difficulties and complications

Two patients taking oral alkali for 12 and 8 months showed no overt or clinical acidosis and both had normal serum creatinine levels. Early IVU showed a greater ureteric back-pressure than before surgery, caused by valve oedema, but later IVU showed the return of preoperative morphology. In the first patient with ectopic bladder, the tube-drain emitted copious urine on the second day, because the patient became mobile while the rectal tube was fixed high and above the level of the valve, which was not fenestrated in the middle. Another rectal tube was placed lower, beside the first, and drainage ceased the next day.

Authors

• H. Arif, MD, Lecturer.
• S. Shaaban, MD, Associate Professor.
• H. Rashwan, MD, Professor and Head.
• Correspondence: Dr H. Arif Abdullah, Urology Unit, Department of Surgery, College of Medicine, Suez Canal University, Ismaelia, Egypt.

References

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3. ^ Rink RC, Retik AB. Ureteroileocecalsigmoidostomy and avoidance of carcinoma of the colon. In King LR et al. eds, Bladder Reconstruction and Continent Urinary Diversion. Chicago: Year Book Medical Publishers, 1987: 172-8
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