The Ileocolic Segment in Urologic Surgery

THE ILEOCOLIC SEGMENT IN UROLOGIC SURGERY

J. M. GIL-VERNET, JR. From the Deparlment of Urology, School of Medicine, University of Barcelona, Spain

When, in 1957, we wrote on ileocystoplasty sufficiency and infected urine, urinary diversion versus colocystoplasty' we started a controversy must be provided, for instance by means of a about which of the two intestinal segments nephrostomy tube, 20 or 30 days before colo- would be the more appropriate for enterocys- cystoplasty is done. This will permit eradication toplasty. The sigmoid colon seems to be the more of infection, put the pyelocalyceal system at rest, advantageous for total or partial bladder sub- improve the renal function, and permit, through stitution. This fact has been proven by clinical the nephrostomy tube, radiographic studies of results. the excretory system. The drainage tube is left in The ileum, because of its urine-conveying place at least 12 to 15 days (enterocystoplasty) properties, apparently is more suitable for which will permit, at the same time, dry healing ureteral substitution. of the vesicoHc anastomosis and its defunctionalization as well. We have used the sigmoid colon in 158 cases of vesicoplasty and the ileum in 33 cases of However, two-stage operations are not justi- ureterojjlasty. fied for total bladder substitution because cu- A logical eagerness to improve om- results in- taneous ureterostomies or transileal ones jeopard- duced us to use the ileocolic segment. In 1956, ize the surgical future of the patient. If both together with Arandes Adan,^' ^ we reported a ureters are obstructed by tumor, which is the case of contracted bladder, ureteritis and a soli- cause of hyperazotemia, upper urinaiy tract tary kidney. This was the first time that the dilatation, and anemia, etc., the neoplasm is ileocolic segment was utilized to enlarge a small beyond the limits of operability. bladder and also provided a substitute for the The fii'st stage of the operation (total or sub- ureter. Since then we have amended and extended total cystectomy) is extraperitoneal. One must the indications for this operation in many vesical avoid entering the peritoneal cavity during the and ureteral lesions. bladder detachment maneuver. This permits When techniques 1 and 2 for construction of a working under strict aseptic conditions, away functioning ai-tificial bladder were described,^ from all the intraperitoneal structm-es, and pre- we stated that ui'eteral reflux almost always fol- vents leakage of urine and blood into the perito- lowed the procedure. However this type of reflux neal cavity, which is one of the causes of intestinal tends to disappear with time, and usually does adhesions. not result in upper urinary tract infection. In- In cases of enterocystoplasty for small tuber- stead, the reflux causes dilatation of the pyelo- culous bladder, a complete resection of the path- calyceal system from which secondary infection ologic detrusor is a must. may develop or calculi may form, although the Re-establishment of intestinal continuity in one latter possibility has not been observed. layer is far superior to the usual 2 layers, thus In previously irradiated patients plastic sur- avoiding postoperative complications. gery cannot be contemplated until at least 3 A good confrontation of both the vesical and months have elapsed.® Even so, complications are the intestinal mucosa is necessary but difficult to frequent and dreadful. accomplish in the depth of the pelvic excavation, In patients with small tuberculous bladders, particularly with the posterior sutm-e layers, so solitary kidney, large hydronephrosis, renal in- that the excess of mucosa from the intestinal segment and bladder openings must be excised Accepted for publication December 2, 1964. 1 J. d'urol., 63: 466, 1957. about 2 or 3 cm. in order to avoid eversión, which 2 J. d'lirol., 62: 491, 1956. constitutes one of the causes of urinary fistula. 3 J. d'urol., 62: 674, 1956. «J. Urol., 83: 39, 1960. Especial attention must be given the rough 6 Gil-"\"ernet, J. M.: Official Report at the VI surfaces (where intestinal obstruction is likely Spanisli Surgical Congress. Cir. Gin. Urol., 17: 4, 1963. to develop). After the ileocolic segment has been isolated, a large .surface is exposed where adhe- anatomo-physiologic angles may imply insuffi- sions are likely to form. The covering of large ciency of Bauhin's valve. The ileal .segment inter- })eritoneal losses must not be attempted; instead, posed iDetween the ureter and the cecum must be thc>\' must be covered by the aid of a large surface under no undue tension. from the small intestinal loojjs, which will be Defunctionalization of the colon bj' cecostomy sutured and fastened to the edges of the peritoneal or cutaneous appendicostomy is a must in casas Oldening (method of guided production of inte.sti- of extremely oljese i)atients and those in poor nal adhesions). general condition. Wlien the ileocolic segment is used, this must Of primary importance is drainage of the cavi- remain in such a position that neither the sharp tary and extracavitary .spaces. ileocecal angle or flexm-e, nor the blunt ileocolic Some of these operations require from 5 to 6 one is disturbed. The disa]:)pearance of both these liours for completion.

FIG. 1. A, exclusion of ileocolic segment and debridement of its mesentery. Ji, in some cases exclusion of ascending colon and part of transverse may be necessary. Entire segment being irrigated by ileocolic artery.

FIG, 2. Different mounts of ileocolic segment TECHNIQUE ply. Usually, the right mid-colic artery is clamjjed Once the peritoneal cavity has been opened and and ligated from below its anastomosis with the the structure of the i-ight colon verified, one inferior and superior or right cohc artery. The proceeds with right i:)arietocolic detachment, paracolic arcade is ligated at the level of the usually up to the he]Datic flexure. hepatic flexuie and divided by previous suturing Surgical interruption of the ileum u.sually of the colon with Petz's ai)]>aratus or l^y any of takes place 20 to 30 cm. from the ileocecal valve, the u.sual means. which permits observation of the \'asicular sujo- Transverse division of the mesocolon is done

FIG. 3. Total substitution of bladder by ileocolic segment, a, Ejid-to-eiid with prostatic apex. 6 and b', Side-to-end.

FIG. 4. Observation 1. A, urinary tuberculosis. Solitary kidney. Retrograde cystography. Contracted bladder and ureteral reflu.x. Micturition every 10 minutes. Ii, excretory »irogram after ureteroileocolo- cystoplasty. Micturition every hours. ILEOCOLIC SEGMENT IN UKOLOGIC SURGERY 421 from below the artei-ial arcade, and close to the the other half, intraperitoneal. Slight rotation ileocolic vascular pedicle, the only arteiy which of this ileocecocolic segment does not interfere will sujjply the whole segment. in any way with its blood sujjply. Ana.stomo.sis A rectal tube is inserted through the ileal end. with the small bladder can be either ond-to-side An antibiotic solution (200 cc) h instilled for or side-to-side. cecocolic u-rigation. The solution will be left in In a functioning artificial bladder, the anasto- place until intestinal continuity is re-establi.shed mosis with the urethra takes place in a side-to-end by ileotransversostomy. manner, the haustra from the cecum being useful A counter-clockwise rotation of the intestinal for that ]-)urpose. This type of anastomo.sis is loop is done in order to place it in isoperistaltism, preferable to end-to-end due to the different passing it through a peritoneal ojiening over caliber of both anastomotic oj^enings. Douglas' ])ouch in such a wa}- that half of the Both ureters are reimiilanted into the ileum, isolated intestinal segment is extraj^eritoneal and the anastomosis being done in accordance with

FIG. 5. Observation 2. A, retrograde cystography. Contracted tuberculous bladder. B, definitive cutaneous ureterostomy on solitar}' kidney for renal insufficiency and contracted tuberculous bladder. Retrograde ureteropyelography. C, retrograde ll^eteropyelog^aph3^ Pyelonephritis, retraction of renal pelvis and ureteritis originated by catheter. D, excretory urogram 4 years after total substitution of ureter and partial bladder by ileocolic segment. E, micturition cystourethrography. Bauhin valve is competent. No ureteral reflux. F, post-micturition. Residue unappreciable. FIG. 6. Observatiou 3. A, urinary tuberculosis. Solitary kidney. Cutaneous ureterostomy with renal calculi and pyelonephritis. Cj'stography; contracted bladder. B, retrograde ureteropyelography tliroiigh cutaneous stoma. C, result after total substitution of ureter and bladder by ileocolic segment iNÍicturition every 5 hours. usual methods. If both are dilated they are i-e- culosis of the bladder and ureter with a solitary implanted by the aid of metallic rings, thereby kidney) the ileal segment with its mesocolon will avoiding stenosis. cover the rough .surface bed resulting from i.sola- The light ureter is reiniplanted at a distance tion of the ascending colon. The anastomosis not less than 10 cm. from the ileocecal valve and between the proximal end of the ileum and tlie the left one, 2 cm. from the closed ileal end, renal pelvis can be done through a regular kidney ui-eteral catheters being always utilized at this incision at the same time, or in a .«second .stage. stage. The right m-eteroileal anastomosis must be In the latter case the ileum is left in the renal done in such a way as to avoid undue kinking of fo.ssa fixing it in place with a few sutures of black the ileal loop which would result in poor drainage silk long enough to be easily identified. of the distal segment. In one of our cases kinking In a substitution of the left ureter, the proximal was the cause of a severe jjaralytic ileus, which end of the ileum must be passed through the necessitated another o]3eration. descending mesocolon for anastomosis with the Both the ileal segment and the ureteral anas- renal pelvis. tomosis are intraperitoneal. Anastomosis between the colon and the blad- "RTien a side-to-end anastomosis between the der as well as with the urethra is done according colon and the ui-ethra has been made, an 18F to the aforementioned techniques. T tube is left in place to drain the newly formed In vesicoureteral substitutions, the technical bladder. modalities and potentialitis of the ileocolic seg- In the end-to-side anastomosis between the ment are multiple. See figures 1 to 9. colon and the remainder of the bladder, a drain- The indications for this method are numerous. age system will be established by a 22F urethral The procedure is used not only for partial or total catheter, preferably the Malecot 4-wing t}'])e. bladder enlargement but for total or partial .sul)- Intestinal continuity is re-established by a stitution of both ureters and their valve-like side-to-side ileotransversostomy in 2 la>'ers and mechanism as well. close to the colonic stump to avoid the blind loop In such cases, the measurements of the ileocolic .syndrome. segment will vary according to the clinical inrli- In tota,l substitution of the right ureter a.«; well cations. as in partial .-substitution of the bladder (tuber- The ileal portion will have an increased length ILEOCOLIC SEGMENT IN UROLGGIC SURGERY 423

FIG. 7. Observation 4. A , preoperative excretorj' urogram. Infiltrating tumor of bladder with notable ureteral repercussion on both sides. B, retrograde cystography by pressure, after total prostato-cystectomy and ileocolic segment substitution. The Bauhiii valve has been forced but there is no ureteral reflux. Capacity, GOO cc. Micturition every 5 hours.

in proportion to the extension of the ureters. The The ureters of j^atients who have had urinary colic .segment will be limited to the cul de sac of diversion provided by cutaneous ureterostomy the cecum in order to preserve the function of usually have some irreversible lesions due to the Bauhin's valve, in this in.stancc the intestinal prcscncc of catheters and associated infection. continuity being re-e.stablished by ascending Even reimplanting the ureter.s into an isolated ileocol ostomy. intestinal segment will not establish normal The ileocecal loop is placed in isoperistaltism phj'siolog}'. The ureters are rigid tubes witli no and in an S-shaped fashion. The proximal end of possibility for contraction or relaxation. In these the ileum will be anastomosed to the renal pelvis cases, generally i)atients with a solitary kidney or to the upjjer ureter through the descending and a small bladder, use of the ileocolic segment mesocolon. The left ureter is reimplanted in the jjermits total or jjartial substitution of ureters. mid-|)ortion between the ileum and cecum to the The ileocolonic segment can be u.sed as a cor- bladder dome in 2 layers. The bladder incision is rective o])eration in patients who have undergone made transversely. Thus the anatomic oiDening ileocystoplasty or colocystoplasty and still have will look like a fissure which will be closed during ])ollakiuria due to a poor volumetric capacity the act of micturition from the detrasor contrac- from their old isolated intestinal segment or from tion. Therefore reflux of urine to the cecum will vesicoureteral reflux. be avoided. By this means the atonic megalo- The ileocolic segment can also be iLsed in a ureters are rejjlaced by a ])eristaltic segment case of small bladder and stenosing ureteritis, together with an efficient valve-like mechanism. usually with a solitary kidney and severe renal insufficiency |)lus infected hydronephrosis. The DISCUSSION oi)eration must be done in three stages to restore

Use of the ileocolic segment is indicated in a urinary passage and improve the bladder ca.ses of retractile cystitis, .small bladder with capacity: 1) nephrostomy or pyelostomy, 2) vesicocolic anastomosis and 3) pyelo- or ure- reflux, small bladder and .steno.sing ureteritis, teroileal anastomosis. bladder tumors, and also for the conditions about to be de.scribed. When the case is one of bilateral megaloureter, FIG. 8. Observation 5. A, retrograde ureteropyelographj'. Bilateral megaureter. Pronounced hydronephrosis especially on right side. B, retrograde cystography. Mega-bladder with no ureteral reflux. Micturition normal, no residue. C, excretory urogram after interposition of ileocecal segment. Notable improvement of renal function and excretory tracts on both sides. D, postoperative retrograde cystography. Cecal reservoir is filled. Banhin valve is opposed to ureteral reflux. No vesical residue. and l\ydronei)hrosis and h>'droureter have de- without I'eflux, the teehnique.s for bladder re- veloped, partial or total substitution of the.se implantation change the stenosis to reflux, wliich damaged ureters i.s a must. is just as inconvenient. According to Cihert, in ca-ses of megaloureters Twenty-.six |)atients have been o])erat«d on for FIG. 9. Observation G. A, contracted bladder by Hunner ulcer. Intense pain on micturition; pollakiuria every 10 minutes. B, cystography aher 4 years of colocystoplasty. Micturition every 2 hours with no disturbance. Notable ureteral reflux. C, micturition cj'stography after double transplant operation. Bivalve implantation on right ureter, left with ring. No reflux on left. Micturition every 4 hours. D, excretory urogram after double segment operation. Recuperation of renal function and regression of excretory tracts. several reasons. Nine of these had a soHtary kid- IJj-elonephritis. The good capacity of the ascend- ney and marked renal in.snfficiency. In 6 cases the ing colon has made possible voiding intervals operation was done in 2 stages. •from 4 to 5 hour.s, .satisfactory bladder emptying One patient who had carcinoma of the bladder and a normal forceful ui'inarj' stream. died following operation of peritonitis of unknown Protection afforded by the ileocecal valve has cause. prevented or at least dimini.shed to a large extent One patient had dysuria and a fil^rotic contrac- reflux to the kidne}'. In no case wa.s there an)- ture of the vesical neck. One had severe paralytic tyi)ical symjjtom from such reflux. ileus due to retention of urine in the ileal segment Long-term results obtained by using the ileo- that was initiated l^y kinking at the level of the right ureteroileal anastomosis. Recovery followed colic segment prove that it is far better tlian a second oj^eration. ileocystoplasty and colocystoplasty, providing Functional results have been excellent, ])ar- the advantages of both and none of the di.sad- ticularly in those cases with a permanent cu- vantages. taneous ureterostomy. The patients have been The ileocolic segment is a surgical unit, ana- able to resume a normal life without the annoj'- tomical and functional, the ideal substitute for ance from collecting appliances and the threat of both the m-eter and the bladder.