Surgical Complications of Ileal Segment Urinary Diversion

BERNARD M. JAFFE, M.D., EucENE M. BRICKER, M.D., HARvEY R. BUrcmR, JR., M.D.

From the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri

Tiis sTUDy was undertaken to evaluate with hydronephrosis before diversion are the complications among 543 patients un- much improved.' Hyperchloremic acidosis dergoing uretero-ileal urinary diversions developing after uretero- ileal diversion for for reasons other than pelvic exenteration. any indication is rare, occurring only when The high incidence of intestinal obstruc- the segment is made excessively long or tion in this group of patients prompted this when pre-existing renal damage is severe. study. Continual drainage of urine through the The uretero-ileal conduit, first employed abdominal wall, while important for pres- in association with pelvic exenteration, is ervation of renal function, is a disadvan- currently our choice as the best method tage despite good permanent rubber ileos- available for urinary diversion, although tomy appliances. However, rehabilitation, it has definite disadvantages, as have all starting in the hospital, is usually nearly other technics that have been used. The complete. Most patients resume normal ac- indications for uretero-ileal urinary diver- tive lives. sion have increased since 1950; it is being Construction of an ileal segment is an done today for benign as well as for malig- exacting procedure. The operation is asso- nant diseases involving the lower urinary ciated with significant morbidity and mor- tract. The distinct physiologic advantages tality, particularly when considered with of this technic are: 1) isolation of the other intra-abdominal procedures. urine from the fecal stream and 2) prompt peristaltic emptying of the intestinal seg- Material ment because of the absence of a sphincter. Five hundred forty-three persons had Although the incidence of positive bac- urinary diversions by the ileal conduit terial cultures of the urine is high, the fre- method performed in the Washington Uni- quency of pyelonephritis and calculous dis- versity Medical Center between January, ease is only approximately 10 per cent. De- 1953 and July, 1966. None of these indi- spite the fact that one-half of the patients viduals had total pelvic exenteration. The with normal kidneys preoperatively have patients were operated upon by both resi- some hydronephrosis in the early post- dents and staff surgeons of the Urologic operative period, more than 90 per cent of and General Surgical services. Although these have normal renal collecting systems two-thirds of the patients were men (Table as determined by pyelography 6 months 1), women slightly outnumbered men be- later. In addition, a majority of patients fore the sixth decade. Above the age of 50, men outnumbered women because of Submitted for publication August 10, 1967. the frequency of carcinoma of the bladder, 367 BRICKER AND BUTCHER Annals of Surgery 368 JAFFE, March 1968 TABLE 1. Age and Sex Distribution urethral stricture, 38 ileal conduits were constructed for complications of radiation M F Total therapy alone. 0-15 30 32 62 The indications for operation in children 16-29 10 5 15 are in 30-39 4 12 16 listed Table 3. The operations were 40-49 35 34 69 done for congenital abnormalities in 85 per 50-59 70 44 114 cent. One child, however, had cystectomy 60-69 147 32 179 70-79 63 14 77 and segment for sarcoma botryoides of the >80 6 5 11 bladder. He died of the sarcoma 41/2 years later. Total 365 178 543 Operations

a disease occurring three times more often Cystectomy with uretero-ileal diversion in men than in women. Forty-seven pa- accounted for 47 per cent of the total pro- tients were Negroes. cedures. Ileal conduit construction alone accounted for another 40 per cent, if one Indications includes procedures to convert ureterioileo- cystostomies and ureterosigmoidostomies to The most frequent indication for uretero- uretero-ileal segments and the operations ileal urinary diversion was carcinoma of to construct ureteroileocystostomies. Al- the bladder (Table 2). Slightly more than though total pelvic exenterations were de- one-half of the patients having curative liberately excluded, nineteen anterior ex- cystectomy had had no previous endo- enterations are included in the series be- scopic therapy other than biopsy. Ileal cause these operations do not include segments were constructed for palliation colonic resection nor do they require so in 68 patients, or 21 per cent of those oper- extensive a pelvic dissection. erated upon for bladder carcinoma. Relief of dysuria, frequency, and hematuria Complications often followed. Palliative urinary diver- sions among women with carcinomas of the Two-thirds of the patients had unevent- cervix are indicated only when an associ- ful postoperative courses. The remaining ated urinary fistula exists. Three hundred 175 had 35 renal and 52 medical compli- eighty-three of the 543 patients (70 per cations and 118 complications directly re- cent) operated upon had cancer. Of these, lated to surgical technic (Table 5). Nine- 274 were associated with curative re- teen per cent of patients who developed sections, one hundred nine with palliative complications died in the immediate post- procedures. operative period. Of the fistulae which necessitated uri- Transient postoperative elevations of nary diversion, three were complications of blood urea nitrogen occurred infrequently. previous operations, one resulted from Twenty patients, who were not uremic pre- trauma, and ten were secondary to radia- operatively, developed significant azotemia. tion. Eighteen patients had ileal segments The diagnosis of pyelonephritis in 15 pa- constructed for lower ureteral obstruction tients was based upon the clinical findings associated with pelvic fibrosis. All these of chills, flank pain and response to anti- patients had prior radiation for pelvic car- biotic therapy, not on bacilluria alone, cinoma; but, at the time of diversion, no which was frequent in asymptomatic pa- tumor was present. Thus, including the tients. nine cases of radiation cystitis and one of Sixty-five of the 118 technical complica- Volume 167 SURGICAL COMPLICATIONS OF ILEAL SEGMENT URINARY DIVERSION Number 3 369 tions were related to infection. Forty-one TABLE 2. Indications for Ileal Segment patients had superficial wound infections Intes- (7.6 per cent). Although 14 had uretero- Number tinal ileal anastomotic leaks proved either by Per- Number Obstruc- injection of the ileal segment with radio- formed Died tion opaque material or by pyelography, only Tumor Of five required operative intervention. Bladder carcinoma 321 25 36 these, three simply had revision of one or Cervical carcinoma* 31 3 3 both uretero-ileal anastomoses, one had anastomotic revision and diverting neph- Carcinoma of the 8 0 0 rectum rostomies, and one had only nephrostomy. patients survived. There Carcinoma of the 8 0 0 Four of these five prostate were no complications related to the ileo- Carcinoma of the 6 3 3 ileal anastomoses or to closure of the proxi- vagina segment. Only one patient mal end of the Carcinoma of the 4 0 0 had gangrene of the ileal segment requir- urethra ing construction of a new conduit. Miscellaneous tumors 5 0 0 Intestinal obstruction was a serious prob- lem following ileal segment diversion and No tumor will be discussed in detail in a later section. Neurogenic bladder 45 Ureterovesical 29 1 8 Mortality obstruction Exstrophy of the 18 5 Thirty-six of the 543 patients died post- bladder operatively (6.6 per cent). The mortality Bladder neck obstruc- 17 rates for men (6.8 per cent) and women tion (6.2 per cent) were comparable. There Fistula 14 2 2 were no deaths among patients younger Urethral stricture 10 1 than 40 years. Old age and elevated blood Radiation cystitis 9 1 urea nitrogen levels were associated with increased mortality (Table 6). Spastic bladder 8 1 2 Hunner's ulcer 5 Mortality statistics were not significantly influenced by the use of pre- or postopera- Failure of prior 5 diversion tive antibiotics, or performance of a con- comitant appendectomy in 355 patients or * Excluding pelvic exenteration. a gastrostomy in 74. Preparation of the bowel with neomycin and sulfasuxidine per cent). Although usually involving only was associated with a statistically signifi- construction of an ileal conduit, palliative cant lowering of the death rate than oc- operations were associated with higher curred after no preparation of the bowel mortality rate (10.1 per cent), than cura- or the use of sulfasuxidine or neomycin tive procedures for cancer (7.2 per cent), alone. The choice of method for preparing in which there was considerable pelvic dis- the bowel was dependent upon the opinion section (Table 2). Among operations for of the surgeon eLnd, therefore, was not ran- benign as well as malignant diseases, how- domly distributed. ever, the performance of a cystectomy or Operations for cancer carried a signifi- another intra-abdominal procedure along cantly higher mortality rate (8.1 per cent) with the uretero-ileal urinary diversion than operations for benign diseases (3.1 doubled the mortality rate. JAFFE, BRICKER AND BUTCHER Annals of Surgery 370 March 1968 TABLE 3. Indications in Children mainder necessitated subsequent hospital admissions. Five of the seven instances of Indication Boys Girls Total partial obstruction required laparotomy Neurogenic bladder 5 20 25 while two were treated by nasogastric suc- Meningomyelocele 3 16 tion for several days. Injury 0 2 TBC of spine 1 0 The age and sex distribution of ob- Diabetes 0 1 structed patients paralleled that of the en- Cerebral palsy 0 1 Meningitis 1 0 tire series (Table 8). The incidence was Exstrophy 10 5 15 not increased by previous abdominal or Bladder neck obstruction 11 2 13 pelvic operations, prior radiation, peritoni- Ureterovesical obstruction 2 3 5 Failure of diversion 1 1 2 tis, or intestinal obstruction, or the per- Necrotising cystitis 0 1 1 formance of either appendectomy or gas- Sarcoma botryoides 1 0 1 trostomy. Closing the mesenteric defect Total 30 32 62 created by construction of the ileal conduit usually placed the uretero-ileal anasto- moses in a retroperitoneal position, thus One hundred twenty patients with be- preventing this form of internal hernia as nign urinary tract diseases had ileal seg- a cause of intestinal obstruction. Neverthe- ments constructed without other ancillary less, the incidence of intestinal obstruction procedures. Only two died. Both had had was approximately 11 per cent whether the irradiation for pelvic carcinoma. anastomoses were retroperitoneal or not. Including intraperitoneal abscesses, peri- An attempt was made to correlate intesti- tonitis and anastomotic leaks, infection was nal obstruction with failure of closure of the most common cause of death (Table 7). the right gutter. No correlation could be Seven patients died of complications re- drawn because the operative notes fre- lated to the urinary system, one of pyelo- nephritis with gram negative septicemia, TABLE 4. Type of Operations Performed and six of renal failure not related to in- Number Performed Intes- tinal fection. Malig- Number Obstruc- Of the six patients who died of uremia, Benign nant Died tion Cystectomy and 28 228 18 31 four had preoperative blood urea nitrogen segment levels below 30 mg. %; only one had a com- Ileal segment alone 81 92 9 20 pletely normal intravenous pyelogram. The Ureteroileocystostomy 25 1 1 indication for diversion in all of these pa- Segment and 2 20 2 1 hysterectomy tients was carcinoma of the bladder. Four Anterior exenteration 2 17 2 of the six had cystectomy in addition to the Conversion of uretero- 12 2 3 ileal segment. Three patients died of ure- sigmoidostoniy Bowel resection and 0 8 2 mia alone. The other three had associated segment surgical complications (peritonitis, anasto- Cystectomy, segment 1 5 2 1 motic leak, and dehiscence) and died ulti- and colostomy Segment and 1 5 1 mately of renal failure. colostomy Segment and kidney 2 3 1 operation Intestinal Obstruction Conversion of uretero- 4 0 ileocystostomy Sixty-one patients had 71 episodes of in- Cystostomy and 2 0 1 1 testinal obstruction, an incidence of 11.2 segment Bowel resection, 0 2 1 per cent. Thirty instances occurred during cystectomy, and segment the early postoperative period and the re- Volume 167 SURGICAL COMPLICATIONS OF ILEAL SEGMENT URINARY DIVERSION 371 Number 337 quently did not describe whether the ce- TABLE 5 cum was laid over the segment or not. Complications Directly Medical complications Although less than one-third of the op- Related to Surgical erations were done for benign diseases, the Technique incidence of intestinal obstruction was ap- Superficial wound 41 Pneumonia 18 proximately the same (11.8 per cent) as in infection Dehiscence 14 Thrombophlebitis 9 the group operated upon for cancer (10.7 Anastomotic leak 14 Pulmonary embolism 4 per cent) (Table 2). This is due primarily Fistula 6 CVA 4 to the high incidence of obstruction follow- Intraperitoneal 5 Myocardial infarction 3 ob- abscess ing procedures done for uretero-vesical Peritonitis 5 Pleural effusion 2 struction (8/29 cases) and for exstrophy of Hemorrhage 3 Atria] fibrillation 2 the bladder (5/18 cases). Palliative divert- Ventral hernia 2 Parotitis 2 Prolonged ileus 1 Hepatitis 2 ing procedures imposed a lesser risk of ob- Gangrene of the 1 Hypotension 1 struction (8.3 per cent) than did curative segment 22 1 (12.0 per cent). Intestinal ob- Atelectasis operations struction The original operations which were com- Intestinal ob- 4 Fever of unknown 1 plicated by intestinal obstruction are listed struction with etiology inci- peritonitis in Table 4. It is interesting that the Pulmonary edema 1 dence of obstruction was about 11 per cent Total 118 Femoral artery 1 whether only an ileal diversion was per- Renal complications embolus 1 was car- Azotemia 20 Acute brain svndrome formed or an additional procedure Pyelonephritis 15 ried out as well. Total 52 The causes of intestinal obstruction are Total 35 detailed in Table 9. Adhesions accounted for nearly half the cases, although meta- TABLE 6. Mortality According to Age static carcinoma was a very important late Mortality cause obstruction. Of six cases of volvu- of Age Proportion Rate lus, four were of the small bowel and two were of the left colon. Incarceration oc- 40-49 1/69 1.4% in a paraileostomy stomal hernia 50-59 6/114 5.3% curred 60-69 19/179 10.6% and an inguinal hernia. The small bowel > 70 10/88 11.4% was obstructed in 52 instances and the colon in 11. Included are four cases in Mortality According to Bun which the intestinal segment itself was ob- Mortality structed by extra-mural causes, not by in- Bun Proportion Rate trinsic defects. intestinal <30 25/433 5.8c% Although infrequent causes of 30-49 6/58 10.3%o obstruction, internal hernias accounted for 50-99 4/24 16.7% 7 of the 71 episodes of obstruction follow- > 100 1/3 33.3(,o diversion. These cases are ing uretero-ileal Mortality According to Bowel Prep summarized in Table 10. The right colon or the ileal segment was implicated in all Mortality Rate cases in which the site was specified. Two Bowel Prep Proportion of these patients died. None 2/14 14.3^lo Treatment of the obstructions was op- Mechanical and sulfa 21/250 8.3%o erative in 61 instances (Table 11). The Mechanical and neomycin 6/38 15.4% and 3.0% was Mechanical, sulfa, 7/232 most common method of treatment aureomvcin bowel resection. Decompressive enterosto- AND BUTCHER Annals of Surgery 372 JAFFE, BRICKER March 1968 TABLE 7. Causes of Death mortality rate. The severity of the intesti- nal lesion (Table 13) was responsible for Uremia 6 Carcinomatosis 5 this prohibitive mortality. Peritonitis 5 Pulmonary embolism 3 Subsequent Operations Fecal fistula 3 Pneumonia 2 One hundred forty-three patients (26 per Myocardial infarction 2 Anastomotic leak 2 cent of the series) had 192 subsequent Intra-abdominal abscess 2 operations related to the ileal segment Unknown 2 (Table 14). Pyelonephritis with septicemia 1 Pulmonary edema 1 Prolapse and stenosis of the ileal stoma Evisceration 1 was frequent, particularly in children. The Hemorrhage 1 largest group of subsequent operations was revision of the ileal stoma. mies were done in 11 patients treated by One of the common causes of postopera- lysis of the adhesions or reduction of an tive hydronephrosis is stricture at the ure- internal hernia. tero-ileal anastomosis. Careful mucosa-to- mucosa apposition, prevention of ureteral Mortality and Complications Incident to devascularization and ureteral kinking in Postoperative Intestinal Obstruction the sigmoid mesocolon can reduce the The overall mortality rate in 61 ob- incidence of this complication. If stric- structed patients was 21 per cent (Table ture develops, operative repair is done 12). Three of 30 patients who developed extra-peritoneally and three technics have obstruction immediately after operation been described by Bowles.' He suggested died. However, of 41 whose obstruction either reanastomosis, side-to-side uretero- necessitated a subsequent hospitalization ileal anastomosis above the structure, or ten died. This is partly due to the high longitudinal incision through the anasto- proportion of cases with metastatic carci- mosis which is closed transversely. noma in the late group. The mortality rate In a small percentage of patients, renal for obstruction of the small bowel and the function either did not improve or even colon were the same. Only one patient degenerated. These failures included com- treated without operation died, a man in binations of infection, hydronephrosis, and whom proctoscopy was performed to re- calculus disease. Nephrectomy was per- duce a colonic volvulus. Bowel resection, formed twelve times subsequent to uretero- however, was associated with 33 per cent ileal diversion. Furthermore, there were eleven late operations performed to remove TABLE 8. Age and Sex Distribution of stones and an additional fifteen procedures Obstructed Patients to achieve better urinary drainage. Hence, seven per cent of patients who had ileal <15 6 15-29 2 conduits constructed did not maintain good 30-39 0 urinary function and required further up- 40-49 7 tract 50-59 17 per urinary operations. 60-69 23 70-79 4 Discussion >80 2 Uretero-ileal urinary diversion has been Males 43 used successfully as an adjunct to the treat- Females 18 ment of carcinoma of the bladder and the Volume 167 SURGICAL ILEAL DIVERSION Number 3 COMPLICATIONS OF SEGMENT URINARY 373 TABLE 9. Causes of Intestinal Obstruiction Early Subsequent Postoperative Hospital- Mortality Period ization Total Died Rate Adhesions 17 17 34 5 14.670 Metastatic tumor 0 12 12 4 33% Internal hernia 4* 3 7 1 14.2% Volvulus 4* 2 6 1 16.7% Compression by extrinsic 0 3 3 0 0 radiation changes External hernia 1 1 2 1 50% Vascular 1 1 2 1 50%0 Not determined 4 2 6 0 0 * One patient had both a small bowel volvulus and an internal hernia. cervix. In children, ileal conduits have been mor or pelvic fibrosis secondary to irradia- used primarily in the management of neu- tion. rogenic bladders and exstrophy. With the Burns3 followed 295 patients who had exception of the frequent need for ileal radiation therapy for carcinoma of the stoma revision, children tolerate this method cervix. Of the patients who developed hy- of diversion well. dronephrosis after treatment, 27.3 per cent In 1963, Sugg et al.7 reported 105 pa- survived 5 years, whereas 79 per cent of tients requiring operations for irradiational those intravenous pyelograms were un- injury to the enteric and urinary tracts. In- changed survived for that length of time. cluded in this group were four patients In that series, 10/11 patients with increas- who had ileal conduits constructed for uri- ing dilatation of the collecting system had nary tract complications. In their recent recurrent tumor. Hence, whether or not a review, Kiselow and his associates 4 re- biopsy diagnosis of recurrent tumor can be ported 13 patients who had pelvic exen- made, the likelihood is great that the late terations for irradiation complications. The development of hydronephrosis is second- series currently reported includes 38 ileal ary to recurrent cancer. Therefore, at the conduits constructed for complications of time of operation, if biopsies of the ureters, pelvic radiation therapy. The parametrial pelvic lymph nodes, or soft tissue show injection of radioactive gold198 had been only radiation changes, uretero-ileal uri- used to treat 18 of the 38 patients. nary diversion should be carried out if the If a patient who has been previously radiational injury is not so severe as to treated with radiation for pelvic carcinoma warrant pelvic exenteration. develops a urinary tract fistula, severe blad- Among 383 ileal segment operations done der pain or bleeding, or hydronephrosis, it for cancer, the operative mortality rate was is imperative to ascertain if recurrent or eight per cent and the rate of intestinal ob- persistent carcinoma is present. It is not struction was 11 per cent. This is compared difficult to detect recurrent tumor by trans- with Kiselow's4 review of pelvic exentera- urethral bladder biopsies and biopsies of tions in which the operative mortality rate the fistulous tract. If the biopsies reveal was 10 per cent and 17 per cent of the pa- only radiation changes, these patients tients developed intestinal obstruction. The benefit from urinary diversion. It is consid- two groups differed in that the patients who erably more difficult to determine whether had pelvic exenterations were considerably ureteral obstruction is due to recurrent tu- younger, were operated on by a smaller BRICKER AND BUTCHER Annals of Surgery 374 JAFFE, March 1968 TABLE 10. Internal Hernia Location Time Operation Result 1. Right gutter Early Bowel resection Good 2. Paraduodenal-right colon Early Reduction and decompression Good 3. Right gutter Early Reduction and decompression Azotemia but recovered 4. Right gutter Early Reduction Good 5. Right gutter and small Late Reduction-later Pelvic abscess bowel volvulus Bowel resection for plastic Plastic peritonitis-died peritonitis 6. Right gutter and external Late Reduction and inguinal Good indirect inguinal hernia herniorrhaphy 7. Site unspecified Late Bowel resection Uremia and dehiscence -died

TABLE 11. Operations for Intestinal Obstruction Early Subsequent Postoperative Hospital- Mortality Period ization Total Died Rate Bowel resection 6 17 23 6 26.1% Adhesiolysis 13 9 22 3 13.6% Suction 4 4 8 0 Enterostomy 0 5 5 1 20.0% Reduction internal 3 1 4 0 hernia Ureteroileal reanasto- 2 1 3 1 33.3%c/o mosis Revision of segment 1 2 3 1 33.3(% Proctoscopy 1 1 2 1 50% Bypass 0 1 1 0 group of surgeons, and had colon resec- tion died as a result of this complication. tions as well as extensive pelvic dissections Adhesions and recurrent tumor were the in heavily irradiated tissues. It is apparent, most frequent causes of obstruction. How- however, that construction of a uretero- ever, of considerable interest are seven in- ileal segment contributes significantly to ternal hernias. Internal hernias are infre- the morbidity and mortality of pelvic ex- quent causes of intestinal obstruction (0.6 enteration. per cent of 1252 cases reported by Smith 6), Postoperative intestinal obstruction is as- but because the small bowel insinuates sociated with a mortality rate of from 5 to through a small aperture, strangulation 35 per cent.2 5, 8 The distinction between commonly occurs early. Of 20 instances of simple and strangulating obstruction is not intestinal obstruction following 249 ab- always clear and yet it must be drawn be- domino-perineal resections reported by Ul- fore a patient can be treated safely by in- felder,8 two were caused by herniation of testinal intubation and suction. Following the small bowel down the left gutter be- cystectomy or pelvic exenteration, it often hind the colostomy. This situation is com- takes several days before peristalsis returns. parable to the problem of the right gutter During this period, it is difficult to differ- in ileal segment construction. Following entiate adynamic ileus from mechanical in- ileal segment construction, in each case in testinal obstruction. In our series, 13 of 61 which a site of hernia was described, the patients who developed intestinal obstruc- right colon or ileal loop were involved. In Volume 167 SURGICAL COMPLICATIONS OF ILEAL SEGMENT URINARY DIVERSION Number 3 375 TABLE 12. Complications and Mortality from TABLE 14. Subsequent Operations Intestinal Obstruction Revisions of ileal stoma Num- Once 30 Num- ber Twice 13 ber Died Three times 1 Superficial wound infection 10 Revision of ureteroileal anastomosis 20 Pneumonia 4 2 Upper urinary tract surgery Peritonitis 3 3 Nephrostomy 12 Uremia 3 1 Ureterostomy 3 Fistula 3 1 Pyelonephritis 2 Pyelolithotomy 6 Evisceration 2 Ureterolithotomy 5 Intraperitoneal abscess 2 1 Anastomotic breakdown 2 2 Nephrectomy 12 Atelectasis 1 1 Congestive heart failure 1 1 Other Myocardial infarction 1 1 Cystectomy 11 Parotitis 1 Fistula resection 6 Hemorrhage 1 Colostomy 10 Ileus (>6 days) 1 Colostomy closure 8 Revision of segment 3 Para-ileostomy hernia repair 4 TABLE 13. Pathology of Resected Bowel Incision and drainage of abscess 9 Exploratory laparotomy 8 Number Urethrectomy 5 Number Died Urethrostomy 1 Miscellaneous 10 Acute inflammation 9 2 Metastatic carcinoma 7 4 Necrosis 5 2 sults in improved urinary function. Hence, Normal 2 0 it is imperative to follow these patients Radiation change 1 0 closely and at regular intervals with intra- venous pyelograms. Failure of the segment two patients with internal hernia, small to empty properly is usually due to re- bowel resections were performed resulting dundancy of the ileal conduit or stricture in one death. Another patient developed at the ileal stoma. This can be evaluated plastic peritonitis following internal hernia best by radiographic visualization of the reduction; the patient died following bowel ileal segment. Appropriate surgical inter- resection. This serious problem may in part vention to relieve mechanical problems will be prevented by mobilizing the cecum and not only often improve renal function, but bringing it to the left of the ileal conduit. will also prevent further renal damage. Although uretero-ileal urinary diversion Summary has solved many problems, it has created some as well. One-third of the patients have Five hundred forty-three patients had early postoperative complications which uretero-ileal urinary diversion from 1953 to are most commonly related to infection. July, 1966. Sixty per cent of the operations Late complications are frequently disturb- were done for carcinoma of the bladder, ances in renal function. Although clinical but there were 38 ileal conduits con- pyelonephritis and ureteral calculi cause structed for the complications of radiation considerable pain, patients may have di- therapy. Cystectomy and ileal segment con- minished renal function and yet be asymp- struction and uretero-ileal diversion alone tomatic. Furthermore, many of the late accounted for the vast majority of the op- problems, particularly hydronephrosis, are erations. One hundred seventy-five patients amenable to surgical correction which re- had 205 complications, including 20 in- 376 JAFFE, BRICKER AND BUTCHER AnnalofSurgery stances of postoperative azotemia. The .mcKnowieugment overall operative mortality was 6.6 per We appreciate the cooperation of Dr. Justin J. cent. Operations for benign disease in- Cordonnier and the Division of Urology. curred a mortality of 3.1 per cent while 8.1 per cent of the patients operated on for References cancer died. Sixty-one patients had 71 epi- 1. Bowles, W. T., Cordonnier, J. J. and Parsons, sodes of intestinal obstruction, an incidence R. P.: Treatment of the Late Ureteroileal of 11.2 per cent. The incidence for obstruc- Stenosis Following Ileal Segment Diversion. J. Urol., 92:627, 1964. tion was the same for benign and malig- 2. Boynton, P. S. and Bonsnes, R. W.: Intestinal nant diseases as well as for ileal diversion Obstruction Following Pelvic Surgery for Be- nign Disease. Amer. J. Obs. & Gyn., 73:149, alone and diversion plus auxillary proce- 1957. dures. The causes of obstruction were 3. Burns, B. C., Everett, H. S. and Brack, C. B.: Value of Urologic Study in the Management mainly adhesions and recurrent tumor, but of Carcinoma of the Cervix. Amer. J. Obs. & there were 7 instances of internal hernia. Gyn., 80:997, 1960. 4. Kiselow, M., Butcher, H. R., Jr. and Bricker, Twenty-one per cent of the patients who E. M.: The Results of the Radical Surgical developed intestinal obstruction died. Treatment of Advanced Pelvic Cancer: A 15- One Year Study. Ann. Surg., 166:428, 1967. hundred forty-three patients had 5. Miller, E. M. and Winfield, J. M.: Acute In- 192 subsequent operations, 20 per cent of testinal Obstruction Secondary to Post-Opera- which were on the upper urinary system. tive Adhesions. Arch. Surg., 78:952, 1959. 6. Smith, G. A., Perry, J. F. and Yonehiro, E. G.: The importance of adequate mobilization Mechanical Intestinal Obstructions: A Study of the cecum and placing it anterior to the of 1252 Cases. Surg. Gynec. Obstet., 100:651, 1955. ileal conduit to close the right gutter was 7. Sugg, W. L., Lawler, W. H., Ackerman, L. V. discussed. It was emphasized that many and Butcher, H. R., Jr.: Operative Therapy for Severe Irradiation Injury in the Enteric late complications are amenable to surgical and Urinary Tracts. Ann. Surg., 157:62, 1963. correction and, hence, patients need to be 8. Ulfelder, H. and Quimby, W. C.: Small Bowel followed with and ileo- Obstruction Following Combined Abdomino- closely pyelograms perineal Resection of the Rectum. Surg., 30: grams if necessary. 174, 1951.