European Urology European Urology 46 (2004) 598–603 Antireflux Uretero-Intestinal AnastomosisFlap-and-Trough TechniqueApplicable to Ileum: Early Clinical Experience Jan Doležela,*, Martin Sutorýa, Pavel Navrátilb a Institution of Traumatology, Brno, Masaryk University School of Medicine, Brno, Czech Republic Section of Kidney Transplantation, Department of Urology, Charles University, Hradec Králové, Czech Republic b Accepted 25 June 2004 Available online 23 July 2004 Abstract Objective: To report our functional results of the ‘‘flap-and-trough’’ (FT) antireflux uretero-intestinal anastomosis (UIA) applied to various forms of urinary diversions. Patients and methods: From April 1998 through March 2003, a total of 49 ureters were implanted in 28 patients into various types of urinary diversions. Forty-six ureters were implanted transluminally (32 separately, 14 conjointly by the double-barrelled method), 3 ureters extraluminally into preformed reservoirs during kidney transplantation. Forty-one ureters were implanted primarily, 8 ureters secondarily due to stricture of former UIA. Results: Median observation time was 26 months. The healing was uneventful in all cases. Late complications were not related to the UIA. Twenty-four patients could be evaluated. The upper urinary tract remained stable, no reflux and no stenosis at the site of UIA were detected. FT anastomoses were clearly seen and easily accessible at endoscopy. Conclusion: In our hands the FT anastomosis has proved to be simple, safe and highly effective in terms of protecting the upper urinary tract against obstruction and reflux. Creation of antireflux UIA need not mean increased risk of obstruction in comparison with direct (reflux) ones. The FT technique could represent another alternative of nonrefluxing implantation of normal as well as dilated ureters into various types of urinary diversion. # 2004 Elsevier B.V. All rights reserved. Keywords: Urinary diversion; Uretero-intestinal anastomosis; Kidney transplantation 1. Introduction The need for construction of antireflux UIA in urinary diversion is controversial [1–8]: It is not exactly known how and when reflux can be harmful to the kidneys, but it is absolutely clear, that untreated obstruction at the site of UIA inevitably leads to renal damage [8]. Questioning the necessity of antireflux UIA is based on the presumption that all antireflux techniques are associated with a higher risk of stenosis in comparison with direct elliptical refluxing UIA [8]. But there are urological surgeons who advocate the use of antireflux UIA in high-pressure urinary diversions [8] or * Corresponding author. Tel. +420 545 538 655; Fax: +420 545 211 082. E-mail address: j.dolezel@unbr.cz, dolezelj@seznam.cz (J. Doležel). simply whenever possible for better kidney protection against reflux of often infected urine [1–3]. For them modern urology offers several safe and highly effective antireflux techniques [9,10]. The FT technique [11] seems to share these attributes as well. 2. Patients and methods Between April 1998 and March 2003 in 28 patients (9 females and 19 males) whose mean age was 56 years (range 24–78) a total of 49 ureters were antirefluxively implanted into various types of intestinal diversions using the original [11] or modified FT technique. The indications for diversion were as follows: bladder cancer (n = 17), shrunken bladder (n = 7), posterior urethral valve (n = 2), exstrophy-epispadias complex (n = 1) and neuropathic bladder (n = 1). Twenty-two patients underwent simultaneous cystectomy. 0302-2838/$ – see front matter # 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2004.06.018 J. Doležel et al. / European Urology 46 (2004) 598–603 Fig. 1. Original technique: (a) The trough in the intestinal mucosa of the reservoir wall. The width of the trough equals the outer diameter of the ureter, the length is four to five times longer. The wide hiatus is created at the base of the trough. (b) The ureter is drawn freely through the hiatus into the lumen of the reservoir. (c) The ureter is spatulated at an avascular plane to the extent of the length of the trough. (d) The spatulated part of the ureter is retracted proximally as a flap covering the intramural part of the ureter. (e) The ureter is anchored at the site of the top of the spatulation to the distal end of the trough by a pair of sutures. The top of the flap is fixed at the site of the hiatus by another pair of anchoring sutures. The burying of the ureter is finished by stitching both sides of the flap to the mucosal sides of the through by continuous sutures. Forty-six ureters were implanted transluminally: 32 separately by the original method (Fig. 1) [11], mostly into low-pressure reservoirs (n = 19). The ileal orthotopic neobladders were constructed from 40 cm long segments of the detubularized preterminal ileum arranged in ‘‘W’’- or ‘‘M’’-shaped configuration. Fourteen ureters were implanted conjointly by the double-barrelled method into ileal (n = 6) or transverse colon (n = 1) conduits (Figs. 2 and 3). Three ureters, in two men and one woman, were implanted extraluminally to preformed low-pressure orthotopic 599 Fig. 2. Double-barrelled technique: (a) The oral end of an intestinal conduit is split antimesenterially to the extent of 3–4 cm. The trough in the intestinal mucosa is created at the mesenterial border, beginning at the end of the conduit; the width of the trough equals the outer diameters of both the ureters and its length is four to five times longer. The ends of both the ureter are spatulated proportionally to the length of the trough. The spatulated ends are sutured together by a continuous suture and (b) retracted proximally as a flap covering the intra-intestinal part of the ureters. (c) The ureters are laid down into the trough, anchored there and the flap sutured to the mucosal sides of the trough like in the original FT technique. (d) The end of the conduit is closed by a longitudinal single layer continuous suture. reservoirs during kidney transplantation (Fig. 4). The specific number of ureteral implantations performed into each type of diversion is shown in Table 1. Forty-one ureters were implanted primarily and 8 ureters secondarily due to stricture at the site of a former UIA. The ureters were stented for 10 days. The original technique [11] was slightly modified: the burying of ureters was completed by suturing both sides of the ureteral flap to the mucosal sides of the trough using continuous suture (i.e. not single ones as originally) between proximal and distal anchoring sutures (Fig. 5). After hospital discharge the patients were closely followed up by laboratory tests, ultrasonography, radionuclide and X-ray imaging, and by endoscopy when needed. A retrograde enterocystography/loopography was taken to examine reflux 3 weeks after the procedure, and again at 6 and 12 months, and thereafter when indicated: The reservoirs/conduits were gravityfilled (80–100 cm and 120 cm water column for reservoirs and conduits respectively) with contrast medium via a catheter 600 J. Doležel et al. / European Urology 46 (2004) 598–603 Fig. 3. The intraoperative appearance of the finished double-barrelled anastomosis at the opened end of the ileal conduit. Ureters are stented. under simultaneous fluoroscopic control with the patient in a supine position. Finally the contrast medium was emptied/voided under fluoroscopic control after moving patient to an upright position. When reflux was present delayed images were obtained to assess the upper tract drainage. Ultrasonography of the upper urinary tract was carried out monthly for the first 6 months and 3-monthly thereafter, IVU and 99mTc-MAG3 radionuclide studies annually. Results were evaluated after minimum follow-up of 12 months. Fig. 4. Extraluminal technique: (a) The wall of the neobladder is opened for 2.5 to 3 cm in the same direction (towards bladder neck) as the axis of intended uretero-intestinal anastomosis. The mucosal trough begins at the distal commissure of the opening. The ureter is spatulated to the proper extent. (b) The ureter, with the retracted spatulated part, is laid into the trough and fixed there in the same manner as in the original method. It is possible to place and tie the anchoring sutures from outside the neobladder. (c) The neobladder wall is closed with care to avoid strangulation of the ureter. Table 1 Number of the FT ureteral implantations into each type of urinary diversion Type of diversion No. of patients No. of ureters/type of UIA Ileal neobladder 13 23/single: 22 translum. 1 extralum. 2/single 4/single 2/extralum. 2/single 14/2 single, 6 double-barrelled 2/double-barrelled Cutaneous ileal reservoir Cutaneous cecoileal reservoir (Indiana) Augmentation ileocystoplasty Ileal anal pouch Ileal conduit 1 2 2 1 8 Transverse colon conduit 1 Total UIA = uretero-intestinal anastomosis. 28 49 ureters Comment Renal transplant pt. Secondary impl. Renal transplant pts. Secondary impl. Secondary impl. 601 J. Doležel et al. / European Urology 46 (2004) 598–603 Fig. 5. The intraoperative appearance of the finished single FT anastomosis: The flap is fixed to the intestinal mucosa by the running sutures between the pairs of proximal and distal anchoring sutures. 3. Results The healing of the anastomoses was uneventful in all cases; no leakage has occurred. Four of 28 patients (7 of 49 reno-ureteral units) were excluded from the study because of short follow-up: A 39-year-old patient with exstrophy-epispadias complex died of extensive myocardial infarction in the first month after surgery. A 43-year old woman, with a cutaneous W-shaped ileal reservoir, developed a volvulus around the mesentery of the reservoir at the third week. The reservoir was removed and the ileal conduit with refluxing UIA was performed during surgical revision. Two patients died of cancer dissemination 3 and 7 months postoperatively. Results of followed-up patients related to the type of diversion and modification of UIA are specified in Table 2. Median follow-up was 26 months (range 13–72). In all but one female patient, the upper urinary tract remained stable: i.e. the progression of upper urinary tract deterioration by obstruction or reflux was not detected by the aforementioned imaging studies and laboratory tests. The woman, with ileal neobladder, developed recurrent (31 years after pyelolithotomy and 3 years after ESWL) bilateral staghorn struvite nephrolithiasis with moderate hydronephrosis three years after the procedure. She successfully passed all stone fragments after ESWL on the right side and is scheduled for PCNL on the left side. One patient with an ileal neobladder died of cancer at 13 month and one is dying of cancer 26 months after cystectomy. All the surviving men with ileal orthotopic reservoirs (n = 7) void spontaneously via the urethra and are continent by day (obviating pads). Three of them are also continent at night, three use pads for safety and one uses a condom urinal at night. One patient passed a 10 mm stone (100% apatite) from the neobladder 2 years after surgery. Of four women with orthotopic reservoirs (followed up for more than 24 months) only one voids spontaneously without residuum, two follow a regime of full self-catheterization, and one voids with about 100 ml residuum catheterizing twice a day [12]. They are fully continent by day and night. In one, the m. rectus fascial sling urethral suspension was performed because of intrinsic sphincter deficiency incontinence. FT anastomoses were clearly seen, remained patent and of stable length at endoscopy or during one open revision for additional ileal patching of the reservoir. Enterocystography/ loopography confirmed reflux in 3 of 49 reno-ureteral units (6%): In one woman the bilateral grade II reflux [13] was detected on the 3-week enterocystogram, but not subsequently. It was the woman who voided with residuum and developed recurrent nephrolithiasis. In one man with the ileal conduit the grade III reflux to the right (preoperatively dilated) ureter was seen on the 3-week loopography, but not two years later. One Table 2 Results related to specific type of performed diversion and modification of anastomosis after median follow up of 26 months (range 13–72) Type of diversion No. of ureters/type of UIA No. of refluxing anastomoses No. of stenotic anastomoses Ileal neobladder 0 0 0 0 0 0 0 0 0 0 Transverse colon conduit 21/single: 20 translum. 1 extralum. 4/single 2/extralum. 13/1 single, 6 double-barrelled 2/double-barrelled 0 0 Total 42 0 0 Cutaneous cecoileal reservoir (Indiana) Augmentation ileocystoplasty Ileal conduit UIA = uretero-intestinal anastomosis. 602 J. Doležel et al. / European Urology 46 (2004) 598–603 Table 3 Complications of currently used uretero-ileal anastomoses/uretero-reservoir junctions Type of UIA/junction Complications (%) Dehiscence Stenosis Reflux Refluxing Nesbit [7,25,26] Wallace [27] 4 6 3–8a 4 + + Nonrefluxing Split-cuff nipple [25,28] Le Duc [29,30] ATIS + ileal neobladder [7] SLET [9,31] T-pouch valve [32] FT [present study] 0 0 ns ns ? 0 3–8 2–29 3 4–5 ? 0 2–17 3–15 0b 3 ? 6c UIA = uretero-intestinal anastomosis; ATIS = afferent tubular isoperistaltic (ileal) segment; SLET = serous-lined extramural tunnel. a Probably depends on presence/absence of chronic infection. b No reflux during physiologic filling of the neobladder and voiding by the pelvic floor relaxation and abdominal straining; reflux during retrograde cystography. c Detected only on the 3-week retrograde cystography not thereafter. woman with the ileal neobladder (on self-catheterization) suffered an episode of acute pyelonephritis 11 months after surgery. Reflux was never detected in this patient. Chronic bacteriuria occurred in all but 7 male patients with ileal neobladders. 4. Discussion The necessity to construct the antireflux UIA in urinary diversion is controversial [1–8]. The main arguments against antireflux implantation are based on hypotheses that antireflux techniques generally have higher inherent potential for stenotization in comparison with direct elliptical techniques and that reflux prevention is less important for protection of renal function than keeping upper urinary tract unobstructed [4,6,8]. Complication rates of currently used UIA/ uretero-reservoir junctions published in literature are summarized in Table 3. Most of strictures at the site of the tunneled antireflux UIA develop within 1 or 2 years postoperatively [14]. There are several animal as well as human studies supporting beneficial effect of the antireflux UIA on kidney preservation [15–18]. Several safe and highly effective methods were developed recently [2,10]. The FT technique [11] might represent another improved antireflux flap valve method, which is highly resistant to obstruction. The potential advantages of this method could be summarized as follows: Perfect and immediate covering of an adventitia of the intramural ureter with physiologically ‘‘urine resistant’’ tissue ensures good prevention of scarring (contrary to the Le Duc technique [19]) [20,21]. Stable length of tunneled ureter secured by two pairs of anchoring sutures ensures good reflux prevention. The ureteral meatus does not comprise complete circumferential suture line. This might reduce development of meatal stenosis. Contrary to the serous-lined extramural tunnel [9], the integrity of the FT tunnel is not dependent on stability of dorsal suture line and thus it cannot open [1]. The FT anastomosis is clearly visible at endoscopy (contrary to Goodwin/Leadbetter methods [22,23]). It is possible to lay the ureter in any direction in relation to a bowel axis: the axis of the ureter could always be oriented to the neobladder neck. This facilitates traversal of the anastomosis by endoscopic instruments. The method allows the implantation of ureters of normal as well as large diameters. The method is simple and easy to learn. The authors intend to perform it laparoscopically. Theoretically, the main potential disadvantage of the FT technique could be longer juxtaposition between transitional and enteric epithelium in comparison with standard methods. Although the relationship between the length of the uro-enteric border and the risk of cancer has not been proved, this fact might increase the incidence of carcinogenesis [24]. For this possibility the method was not applied for diversions in which the UIA is in a direct contact with the fecal stream. Construction of the FT anastomosis has a somewhat higher demand upon ureteral length. 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