Ureteric
Sigmoidostomy- The Preferred Urinary Diversion
Gupta
J.1, Naidu A.2, Bansal A.K. 3 and Gupta K.M.
4
Dept. of Surgery1,
Radiodiagnosis2, Community Medicine3, Medicine4 Govt.
Medical College, Jagdalpur ( Bastar ) – 494001 INDIA.
ABSTRACT:
Background information: Urinary diversion is always a reluctant
compromise, since there is not a satisfactory substitute for normally
functioning urinary system.The need for adequate method of urinary diversion
has long been recognized. Research
Question: wheather uretero sigmoidostomy is the proffered method for
urinary diversion? Material Method:
Five adult, healthy dogs of both sexes were studied for the maximum period of
1½ months, in experimental laboratory of, Pt. J.N.M. Medical college, Raipur. Statistical analysis: were applied as
and when required. Observations: The
operations lasted for three hour and twenty five minutes on an average. The
mortality rate was 60 % however 20 % of the dogs died of the effect of
anaesthetic drug.40% died of chemical peritonitis because of the leakage of
urinethrough anastmotic site. Conclusion:
Most time consuming procedure of urinary diversion.40 % incidence of urinary leak further devalues this procedure in
regards to the practical applicability. Though avoidance of external stoma
offers a distinct advantage in comparison to other procedures.
KEYWORDS: Anastomosis, Reflux, Leak.
INTRODUCTION:
Urinary diversion is the surgical procedure designed to
drain the urine to exterior through a passage other than the normal one. The
criterion for successful urinary diversion are: (i) It must provide good
drainage to upper urinary tract.(ii) It must have continence with voluntary
control of urine and faeces without resort to catheterization or appliances.
(iii) must eliminate residual urine.(iv) must have complete separation of
urinary and faecal stream (v) should have functional urinary resvoir without
reabsorptive problems (vi)Postoperatively
the dogs were observed for the maximum period of 1½ month, should not have
unnatural or artificial orifices. (vii) must provide condition which readily
permit total cystectomy at a later stage.(viii) should provide accessibility of
the new resvoir for visuaisation by endoscopic means if necessary. (ix) The
procedure must be socially and psychologically acceptable to the patient and
community. Choice of operation demands very careful, critical appraisal of the
for diversion, material available and above all, age of patient and the
psychological to a proposed new way of life. By taking in to account the above
facts and as very few such studies are available and in 1957 a study group of
World Health Organization has expressed the view that in order to get a
comprehensive picture of disease more and more studies have to be carried out,
Garg Narendra K.4. This prompted the authors to undertake this
study.
MATERIAL
AND METHOD:
The present study under taken on five adult, healthy
dogs weighing between 1ten and 16 Kg of weight. The study was carried out in
experimental lab. of Surgery Dept. of Medical college, Raipur.
Before operation
all preoperative procedure i.e. dos were put under observation for seven days
to rule out the possibility of Rabies, dogs were kept on milk diet for three
days, nil orally for 24 hours, premedication mixing with milk or by inj. as the
case may be etc. were carried out.
Abdomen was opened by midline incision and ureters were
isolated. The end of ureter was spatulated upward and on anchoring suture was
passed through the anterior flap of ureter. A straight needle was threaded on
each of the loose ends of the anchoring suture. Site for anastmosis was
selected on the sigmoid colon on one of the taenia coli .As the chosen site of
anastomosis the colon was made taught. A slight oblique, longitudinal incision
about 5 cm. in length was made through the serosa and partially through the
muscularis. By blunt dissection the muscles were separated and a stab wound
corresponding to the size of ureter was made through the mucosa at the distal
end of the incision. Each needle was passed in to the lumen of intestine
through the stab incision and brought through the intestinal wall about 18 mm. distal
to the opening in the mucosa. Ureter was intubated by a polythene catheter, the
other end of which was brought out through rectum in to anus through rectal
tube the ureter was pulled in to the lumen and the traction suture was tied.
The intestinal incision was closed by chromic catgut sutures over ureter not
compressing it. The sigmoid colon was anchored to parietal peritoneum. The
rectal tube was fixed by skin stitches. Abdomen was closed in layers after
complete haemostasis.
Post Operative Care: Dogs were kept on i./ v.
fluids for month during which each dog
was observed clinically for evidence for 48 to 72 hours. Antibiotoc, Anti
inflammatory analgesics for seven days in therapeutic doses was administered
Ureteric catheter and rectal tube was removed on 8 and 10 days respectively.
Stitches were removed on 8 day. The dressing was done as usual. Follow Up:
investigation was done as shown in (Table - III). Post martum was done on died
dogs and other dogs were sacrificed and findings were noted. The dogs were
studied for the maximum period of one and half month.
RESULTS:
On analysis of collected data it was observed that
blood urea level was ranging between 12 to 21 mgs. percent. The value of serum
sodium, serum potassium and urinary chloride was ranging between 130 to 137 mEq
/ L, 3.5 to 4.2 mEq /L and 6 to 12 gm. /L respectively. Urine culture
examination was negative for pathogenic organism in 60 %of dogs and in
remaining 40 % revealed E. coli group of organism (Table –I ).
It is evident from Table – II that post operative
values of blood urea, serum sodium and serum potassium were within normal limit
in all the dogs. Urinary chloride was not estimated because problems in
collection of urine .Table –III revealed that only postoperatively in first
week only four urine samples were examined and all were showing E. coli.
Table IV shows that 60 % (20 % could not come out of
the effect of anaesthesia and 40 % died of chemical peritonitis because of the
leakage of urine through the ureterosigmoid anastomosis. Table further reveal
that on post martum of the sacrificed dogs there was satisfactory healing of
the anastomosis in 20 % of and in the remaining 20 % dogs there was slight
enlargement of left kidney.
DISCUSSION:
In 1851 Sir John Simon10 attempted to
perform a Ureterosigmoidostomy utilizing a type of seton to create a fistula
between a bladder extrophy and rectum. Probably the first workable and
effective ureterosigmoidostomy was described by Tuffier, 1892. The absence of
external urine collecting appliance and embressing smell of urine is tempting but
the very high incidence pf pyelonephritis, hyperchloramic acidosis associated
with high morbidity and mortality and high incidence of development of
carcinoma colon are not favourable. The experimental uterosigmoisostomy was
done in dogs by Coffey2. Coffy – I technique of submucosal valve
principle which is still popular in this era. Ferguson (1931), Jewtt (1942) and
Flock (1948) performed by using intact
ureter principle .
Table – I: Preoperative blood Urea, Serum Sodium, Serum
Potassium, Urinary Chloride and Urinary Culture.
|
Dog No. |
Blood Urea
(mgs%) |
Serum mEg/L |
Urianry
Chloride (gms./L) |
Urine Culture |
|
|
Sodium |
Potassium |
||||
|
1 |
20 |
131 |
4.1 |
12 |
E. coli. |
|
2 |
18 |
135 |
4.2 |
10 |
Sterile |
|
3 |
15 |
137 |
3.9 |
12 |
Sterile |
|
4 |
12 |
130 |
3.7 |
8 |
Sterile |
|
5 |
21 |
133 |
3.5 |
6 |
E. coli. |
Table – II: Postoperative Value of Blood Urea, Serum
Sodium, Serum Potassium, Urinary Chloride
|
Postoperative |
Blood Urea
(gms.%) |
Serum
Sodium(mEq/L) |
Serum
Potassium(mEq/L) |
Urinary
Chloride(mEq/L) |
||||||||||||||||
|
Dog No. |
1 |
2 |
3 |
4 |
5 |
1 |
2 |
3 |
4 |
5 |
1 |
2 |
3 |
4 |
5 |
1 |
2 |
3 |
4 |
5 |
|
1st Week |
- |
- |
- |
- |
- |
- |
- |
- |
18 |
23 |
- |
- |
- |
130 |
130 |
- |
- |
- |
3.5 |
3.5 |
|
2nd Week |
- |
- |
- |
- |
- |
- |
- |
- |
20 |
26 |
- |
- |
- |
130 |
137 |
- |
- |
- |
3.5 |
3.2 |
|
3rd Week |
- |
- |
- |
- |
- |
- |
- |
- |
18 |
26 |
- |
- |
- |
132 |
137 |
- |
- |
- |
3.7 |
3.5 |
|
4th Week |
- |
- |
- |
- |
- |
- |
- |
- |
16 |
26 |
- |
- |
- |
135 |
125 |
- |
- |
- |
3.3 |
3.5 |
|
5th Week |
- |
- |
- |
- |
- |
- |
- |
- |
18 |
24 |
- |
- |
- |
135 |
132 |
- |
- |
- |
3.3 |
3.3 |
|
6th Week |
- |
- |
- |
- |
- |
- |
- |
- |
18 |
24 |
- |
- |
- |
130 |
133 |
- |
- |
- |
3.2 |
3.3 |
Table – III: Post Operative Urine Culture
|
Dog No. |
Post Operative
Urine Culture (Weeks) |
|||||
|
Fist |
Second |
Third |
Fourth |
Fifth |
Sixth |
|
|
1 |
- |
- |
- |
- |
- |
- |
|
2 |
- |
- |
- |
- |
- |
- |
|
3 |
- |
- |
- |
- |
- |
- |
|
4 |
E. coli. |
- |
- |
- |
- |
E. coli. |
|
5 |
E. coli. |
- |
- |
- |
- |
E. coli. |
Table -I V: Length of Survival, Postmortum Findings and
Cause of Death
|
Dog No. |
Length of
Survival |
Postmortum
Findings |
Cause of Death |
|
1 |
4 DAYS. |
Peritoneal cavity
was full of foul smelling fluid. The intestines were friable left ureter was
lying free in peritoneal cavity |
Chemical
Peritonitis. |
|
2 |
6 DAYS. |
Ulcer around
cuteneous stoma present. Peritoneal cavity was full of pus and faecal matter.
Intestinal anastomosis was opend. At mesenteric boreder. |
Chemical
Peritonitis. |
|
3 |
2 HOURS |
Ulcer around
cuteneous stoma was present. Adhesions were present between peritoneum
kidneys and ureter and intestines. Kidneys and urete were normal in size and
shape. |
Anaesthesis |
|
4 |
45 DAYS. |
Ulcer around cuteneous
stoma was present. Adhesions were present between peritoneum kidneys and
ureter and intestines. Kidneys and urete were normal in size and shape. |
Sacrificed |
|
5 |
45 DAYS. |
Ulcer around
cuteneous stoma was present. Adhesions were present between peritoneum
kidneys and ureter and intestines. Kidneys and ureters were normal in size
and shape. |
Sacrificed |
Nesbit8 used end to side anastomosis of
ureteric mucosa with intestinal mucosa where as Cordonnier3 used
direct end to side anastomosis of ureter with intestinal wall. The main
complication associated with the ureterosigmoidostomy is pyelonephritis because
of reflux of the colonic contents in to upper urinary tract. This reflux is
mainly due to high intra colonic pressure. Lovagrove at al7 in his
study on dogs concluded that reduction in intracolonic pressure after sigmoid
myotomy is only temporary. To prevent the reflux leadbetter6,
Wayrauch and Young (1951)introduced long tunneling plus direct anastomosis of
ureteral mucosa to intestinal mucosa ,the most popular procedure of this era.
Mathisan (1953) introduced anti refluxing nipple method, Goodwin et al. used
trans colonic technique of uretero intestinal mucosal anastomosis. Peter et.
al.9 introduced a new technique of staged ureterocolostomy in three
adults .Follow up studies had shown stable renal function and electrolyte
balance as well as faecal and urinary incontinence. Bakker et. al. (1949)
studied the amount of reflux and infection of upper urinary tract in dogs by
using various common methods of ureterointestinal anastomosis.
The hydronephrosis reported by various authors in dogs
are as follows- (i) Leadbetter6 37% (ii) Harbach et. al.4
50% .In present series 40 % dogs lived full length of period of observation. On
autopsy in 20%of dogs evidence of mild nephrosis only on lt.side seen this less
percentage of hydronephrosis may be because of short time of follow up.ans
small sample. Further in present study 60% mortality recorded. These deaths
were probably due to faulty technique of anastomosis and could have been
prevented. Serial weekly blood urea, serumelectrolyte not revealed any evidence
of electrolyte imbalance (hyper chloramic acidosis) which was in accordance of
the
findings of Harbach et. al.4 Short term
follow up of the animals has not provided sufficient lapse of time for electro
imbalance to come up to a detected level.
CONCLUSION:
The authors reached to the conclusion that, most time
consuming procedure of urinary diversion.40
% incidence of urinary leak further devalues this procedure in regards to
the practical applicability, though avoidance of external stoma offers a
distinct advantage in comparison to other procedures.
ACKNOWLEDGEMENT:
The authors express their cordial thanks to Mr. Anand
Singh Kanwar, Lab-Technician, Dept. of Community Medicine, Govt. Medical
College, Jagdalpur (C.G.) for his neat and excellent typing.
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Received on 26.04.2011
Accepted on 20.06.2011
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Research J. Pharmacology and
Pharmacodynamics. 3(5): Sept –Oct. 2011, 285-288