Usefull Application of Cutaneous Uretero-Ileostomy

Gupta J.¹, Naidu, A.², Kar P.K.³, Bansal A.K. ⁴ and Gupta K.M. ⁵

Dept. of Surgery¹, Radio Diagnosis², Dean³, Community Medicine⁴, Medicine⁵, Govt. Medical College, Jagdalpur (BASTAR) – 494001.

ABSTRACT:

Research question: Cutaneous uretero-ileostomy is useful as an urinary diversion? Material and Method: Experiment was carried out on five adult healthy dogs weighing ten to sixteen Kgs. of weight in the department of Surgery, Pt. JNM Medical College, Raipur. Statistical Analysis: Proportion etc. were applied as and when required. Observations: Cutaneous ureterostomy the operative procedure on an average lasted for 3 hours 6 minutes, 80 percent dogs developed cutaneous ulcers all around the ileostomy stoma. 40 percent dogs died in the period of observation. On autopsy one dog died of intestinal anastomotic leak while one dog died of urteroileal leak. In rest of the 3 dogs the diversion was found to be working efficiently. Conclusion: Cutaneous uretero-ileostomy is the most suitable and physiologically exceptable method of diversion, However cutaneous ulcers around stoma and intestinal anastomotic leak has considerably masked the merits of this method. It carries the least incidence of urinary leakage, stomal stenosis and ascending urinary tract infection.

KEYWORDS: Urinary leak, Diversion, Social stigma.

INTRODUCTION:

Since 1956’s Bricker’s (1) ileal conduit has been the most widely used method of supra-vesical diversion. As it is only a conduit and is incontinent thus require a bag to be worn to collect the constant flow of urine. However, it has also serious long term problems such as pyelonephritis, hydronephrosis and calculus formation.

Since its first description by Shoemaker (2) and than by Seiffert in (3) and its establishment by Bricker in 1950 as a method of urinary diversion following radical pelvic operations, ureteroileostomy has become a preferred method of urinary diversion. Although it is a widely accepted with frequent early and late complication. The main problem with this form of diversion is that the patient has to wear an external appliance lifelong causing inconvenience and social stigma.

In recent past there have been many series of ileal conduit diversion reporting a wide variation in complication rates and results. This variation is because of the many factors: (i) The length of period of follow-up, (ii) The condition for which diversion was done, (iii) Technical facilities available, the availability of experienced surgeon, (iv) Intelligence of the patient, (v) Proper follow-up at frequent intervals and (vi) Finally the preoperative status of urinary tract. In patients with preoperative dialated upper tracts the complications are higher.

Keeping in mind the above facts and as very few reports of 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 to assess the impact of bilateral cutaneous ureteroiliostomy as an urinary diversion.

MATERIAL AND METHODS:

The present study consisted of an experimental work on 5 adult healthy dogs of both sexes ranging in weight from 10 to 16Kgs. Each dog were study for the maximum period of 1½ month. Preoperative blood urea, serum sodium, serum potassium, urinary chloride and urine culture were carried out for organism. The study was conducted in Pt. J.N.M.Medical College ,Raipur, in the Deptt. of Surgery.

Preoperative preparation and pre medications were done as per requirements. A circular area in right iliac fossa, about 2 cm. in diameter was excised through all layers of abdomen. Then the abdomen was opened by midline incision and ureters were isolated.

A loop of ileum not longer than 10-15 cm., with one to two complete arcades of blood vessels in its mesentery and 10-20 cms. proximal to the ileo-caecal volve, was selected with its base attached having intact blood supply. Two intestinal clamps were applied on either sides of the selected loop and the loop was isolated by cutting between two clamps on both sides. Proper haemostasis obtained continuity of the bowel was restored by end to end anastomosis of cut ends in 4 layers by 3/0 silk, keeping the isolated segment of ileum below. The proximal end of the isolated loop was closed in two layers.

The site for ureteroileal anstomosis was selected for the left ureter, 5 cms. distal to the proximal end of loop and for right ureter 10 cms. distal to proximal end of loop, on antinesenteric border. Both ureters were spatulated. The intestinal serosa was incised by stab knife at final site of uretero-intestinal anastomosis. A circular piece of musculeris and mucosa removed corresponding to the size of ureter which is tobe implanted. Stay sutures applied to ureter and a ilial loop. The ureters were anastomosed to ileum with a single layer of several interrupted 4/0 chromic catgut sutures, after intubation of ureter with 6 /F infant feeding tube, one end of which was brought out through open end of isolated ileal loop. The loop was tacked to the posterior wall of abdominal cavity. The open end of ileal loop with infant feeding tube was brought out through abdominal stoma. The intestine was anastomosed with the skin forming averted nipple type stoma. Abdomen was closed in layers after complete haemostasis.Post operative care and follow up were carried out as per guide lines.

OBSERVATION:

As shown in (table - I) blood urea level was ranging between 10 - 22 mgs. /Percent. The value of serum sodium, serum potassium and urinary chloride ranged between 128 to 135 mEq./L, 3.5 to 4.2 mEq/L, and 6 -12 mg./L respectively. Urine culture examination was negative for pathogenic organism in 80 percent of dogs. Culture report of rest of 20 percent dogs revealed E. coli group of organism.

As shown in table – II, it is evident that all dogs developed urinary tract infection. The infection set in very first postoperative weel. Only one dog remained sterile from pathogens in the first week which later on hower got infection. E. coli was the most prevalent organism. It was present in all urine samples. All the survival dogs though were initially infected with E. cluisubsequently developed mixed infection, protuse joined E.cli, as an infecting organism.. Table –III revealed that blood urea, serum sodium, serum potassium, and urinary chloride level were within normal limits in all the dogs through post operatively period. Table –IV shows that 60 % dogs survived for the full lengthof the period of observation i.e. 1 ½ months, whereas 40 % of the dogs died in early postoperative period i.e. within 3 to 6 days.80 % dogs developed ulcer all around cutaneous stoma. 20% out of 40% dogs died ,intestinal anastomosis was the cause of death ,as evidenced on post martum examination.Inthe other 20% dogs died from chemical peritonitis .There was complete ureteoileal anastomosis disruption of the left ureter.60% survived dogs, no abnormality of upper urinary tract or uteroileal anastomosis found on gross examination.

DISCUSSIONS:

The early complications associated with this form of diversion includes wound infection and dehiscence intestinal obstruction, stenosis of stoma, uraemia, ureteroileal anastomotic leak and disruption. Faecal fistula, acute pyelonephritis, septicaemia. The late complications includes pylonephritis, hydronephrosis,calculaus formation, uraemia and acidosis, intestinal obstruction and prolapse of stoma etc.

In most of the series stenosis of stoma is a common complication, which may be because of postoperative scar. A poorly fitting bag mat lead to hyperkeratosis with scarring due to underlying inflammation. Cordonnor (2) stated that stomal stenosis is more common in paediatric age group because of greater sensitivity of the skin and small size of the ileum. An ill fitting appliance, alkalinity of urine, neglect and poor hygiene of patient increase the incidence somal stenosis. In a properly filled appliance the diameter of appliance should not exceed that of the conduit stoma bt more than 1/8^th of an inch. Otherwise leakage of alkaline urine causes encrustation of the skin while the acid urine cause skin burn.

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	10	130	3.7	11	Sterile
2	18	134	3.3	9	Sterile
3	16	135	3.5	7	E. coli.
4	20	128	3.3	12	Sterile
5	22	130	3.5	10	Sterile

Table – II: Post Operative Urine Culture

Dog No.	Post Operative Urine Culture (Weeks)
	Fist	Second	Third	Fourth	Fifth	Sixth
1	E. coli.	-	-	-	-	-
2	E. coli.	-	-	-	-	-
3	E. coli.	E. coli. + Proteus	E. coli.	E. coli.	E. coli.	E. coli. + Proteus
4	Sterile	E. coli. + Proteus	E. coli.	E. coli.	E. coli.	E. coli. + Proteus
5	E. coli.	E. coli.	E. coli. + Proteus	E. coli. + Proteus	E. coli.	E. coli.

Table – III: 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	-	24	18	20	22	-	134	137	128	135	-	3.4	3.5	3.7	3.5	-	8	8	10	9
2nd Week	-	-	20	22	26	-	-	135	128	130	-	-	3.5	3.7	3.5	-	-	8	9	11
3rd Week	-	-	22	20	26	-	-	135	133	130	-	-	3.5	3.5	3.5	-	-	7	12	13
4th Week	-	-	22	20	24	-	-	137	135	137	-	-	3.7	3.7	3.5	-	-	6	12	12
5th Week	-	-	24	18	24	-	-	138	137	130	-	-	3.6	3.5	3.5	-	-	6	12	12
6th Week	-	-	22	20	24	-	-	132	133	130	-	-	3.7	3.5	3.5	-	-	9	12	11

Table – IV: Survival Period, Postmortum Findings and Cause of Death

Dog No.	Length of Survival	Postmortum Findings	Cause of Death
1	3 DAYS.	Peritoneal cavity was full of foul smelling fluid. The intestines were friable left urete 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.	Faecal Peritonitis.
3	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
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

Berman et. al. (1979) studied the skin around stomal area in 76 patients with ileal conduit diversion and found superficial erosive dermatitis in 27 cases. In 10 cases the area was showing hyperplastic, papillomatous skin lesion of chronic nature.

The stenosis of stoma can be prevented by (i) Proper site selection prior to operation and removing a whole circular button of tissue including all laters of anterior abdominal wall (skin to peritoneum), (ii) Daily finger dilation postoperatively, (iii) Keeping the urine acidified by avoiding fruit juices, prescribing ascorbic acid and use of acetic acid into the appliance prior to bed time. The use of 5 gms. Of aspirin in the appliance effectively made the urine acidic, reduces foul odour, reduces plagues, bleeding and encrustation, (iv) Proper hygiene of appliance is important.

To increases the diameter of ileum for stoma formation V-Z plasty is helpful. The stomal stenosis can be corrected by excising a rim of skin and refashioning of the distal end of conduit to remove scar (Derrick et. al. 1972), Price et. al. (1973) advise preconditioning of the peristomal skin 3 to 6 days prior to operation. A appliance face plate of appropriate size is cementad to the patients intect skin and patient is asked to remove and reapply it once every 3 days. So the patient and family gets adopted to the appliance.

In the present study the peristomal skin excoriation occurred in 100 percent cases but stomal stenosis did not occur in any case probably because of proper excision of all layers of anterior abdominal wall.Cordonier et.al. (2) Reported that stomal stenosis is more common in paediatric age group because of greater sensitivity o skin and small size of ileum.An ill fitting appliance, alkanity of urine, neglect and poor hygiene of patient increase the incidence of stomal stenosis.

20 percent dogs of present series died of uretero-intestinal leak. This is one of the common complication reported by various aurthors as follows: -

Burnham and Ferror, (3) 15.0%

Jaffe et. al., (4) 2.8 %

Kafetsiouslie and Swinney,(5) 6.9.0%

Harbach et. al.,(6) 5.7 %

Demeterious et. al., (18) 16.0%

The ureteroileal leak was suspected by the reduced amount of urine/24 hours and gradually setting peritonitis. The 20% incidences are similar to results reported by Burnham and Ferror, 1960 and Osmetrius et al, 1979.

20 percent dogs of this series developed intestinal anastomotic leakage at mesenteric border, leading to faecal peritonitis and death. It is probably because of faulty technique. 60 percent dogs of present series survived the full period of observation. There were no abnormal findings seen on postmartum. Blood urea, serum electrolytes and urinary chlorides were within normal limit in all living dogs.

All the preoperative sterile urine became infected postoperatively and was showing E. coli and proteus organism. Our observations are similar to Spence B. et al (19) who reported 94 percent positive culture from ileal conduits in dogs and concluded that a dilated upper urinary tract has much higher positive bacterial culture than a nondialated tract.

CONCLUSION:

The operative procedure on an average lasted for three hours and six minutes. 80% of dogs developed cutaneous ulcer all around the ileostoma stoma. 40% dogs died in the period of observation. On autopsy one dog died of intestinal anastomotic keak while one dog died of ureteroileal leak. In rest of three dogs the diversion was found to be working efficiently.

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 11.02.2011

Modified on 12.03.2011

Accepted on 15.04.2011

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Research J. Science and Tech. 3(3): May-June. 2011: 169-172