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.