Facts
after Transuretero-Ureterostomy
Gupta J.1*, Gupta
K.M. 2, Bansal A.K. 3, Thakur, J. 4
1Deptt. of Surgery, 2Medicine, 3Community
Medicine, 4Radio-Diagnosis Govt. Medical College, Jagdalpur (BASTAR) – 494001.
ABSTRACT:
Back ground: Urinary diversion is made necessary for
variety of conditions when it is no longer desirable to use the bladder as
receptacle of urine. Objectives: To
know the facts about Transuretero - ureterostomy?
Material and Method: The study was carried out in Dept. of
Surgery, Pt. Jawahar Lal
Nehru Memorial Medical College, Raipur on five dogs of
both sexes. All the dogs were healthy and carried weight ranging from 10 Kg. to
16 Kg.
Results and Inferences: Transsuretero-Ureterostomy,
the procedure though technically a bit hazardous takes on an average 1 hour 45 mts. for its completion. 60 percent of the dogs of this
group died during the period of observation. On autopsy anastomotic
leak and urinary infection were the cause of death.
KEY WORDS: Transureteroureterostomy, Urinary diversion.
INTRODUCTION:
Temporary procedure are too often employed when the available
evidence point out to the need for permanent urinary diversion.
Until the early 1950’s ureterosigmoidostomy
was the preferred method of urinary diversion. Absence of external appliance
for collection of urine is tempting, as Goodwin has stated that if he
personally were confronted with the necessity of urinary diversion, he would
elect ureterosigmoidostomy in preference to other
forms. But the long term results like high incidence of hyperchloraemic
acidosis, pyelonephritis, hydronephrosis,
and increased incidence of CA sigmoid colon are not acceptable. Patents always
have some leakage of a malodorus mixture of faces and
urine, especially at night or when passing gas. Their unusually high frequency
of elimination weds them to a bathroom for rest of life. Hence an alternative
method inform of Transuretero-ureterostomy may be
used. In keeping view the above facts and as per recommendation of the authors
have undertaken this study to assess up to what extent Transuretero-ureterostomy
is useful in urinary diversion.
Urinary diversions are the surgical procedure designed to drain
the urine to exterior through a passage other than the normal one. These
techniques are of great help in persons who are having some obstructive
abnormally congemital or acquired, in their urinary
tract.
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.(1). This prompted the authors to undertake this study to assess the impact
of bilateral cutaneous ureterostomy
as an urinary diversion.
Table – I: Preoperative blood
Urea, Serum Sodium, Serum Potassium, Urinary Chloride and Urinary Culture.
|
Dog No. and Group |
Blood Urea (mgs%) |
Serum mEg/L |
Urianry Chloride
(gms./L) |
Urine Culture |
|
|
Sodium |
Potassium |
||||
|
Group (II) |
|
|
|
|
|
|
1 |
10 |
128 |
3.5 |
10 |
Sterile |
|
2 |
12 |
137 |
3.8 |
9 |
Sterile |
|
3 |
10 |
130 |
3.7 |
8 |
Sterile |
|
4 |
10 |
135 |
4 |
10 |
Sterile |
|
5 |
12 |
134 |
4 |
12 |
Sterile |
Table – II:
Postoperative Value of Blood Urea, Serum Sodium, Serum Potassium, Urinary
Chloride in Dogs
|
Postoperative |
Blood
Urea (gms.%) |
|
Serum
Sodium (mEq/L) |
|
Serum
Potassium (mEq/L) |
||||||||||||
|
Dog No. |
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1 |
2 |
3 |
4 |
5 |
|
1st Week |
- |
- |
12 |
10 |
14 |
|
- |
- |
132 |
135 |
128 |
|
- |
- |
3.7 |
4.2 |
4.1 |
|
2nd Week |
- |
- |
16 |
14 |
16 |
|
- |
- |
132 |
134 |
128 |
|
- |
- |
3.7 |
4.2 |
4.1 |
|
3rd Week |
- |
- |
18 |
20 |
16 |
|
- |
- |
133 |
137 |
130 |
|
- |
- |
3.7 |
4 |
4.3 |
|
4th Week |
- |
- |
- |
20 |
19 |
|
- |
- |
- |
128 |
132 |
|
- |
- |
- |
4 |
4.3 |
|
5th Week |
- |
- |
- |
22 |
20 |
|
- |
- |
- |
128 |
135 |
|
- |
- |
- |
4 |
4.2 |
|
6th Week |
- |
- |
- |
18 |
17 |
|
- |
- |
- |
133 |
135 |
|
- |
- |
- |
4 |
4.2 |
MATERIAL AND METHODS:
Five adult, healthy dogs weighing 10 to 16 Kg. range
were included in the study. All the dogs were kept under supervision for seven days to rule out the possibilities
of Rabbies. After proper aseptic precaution and pre
operative procedure and pre medication, the abdomen was cleaned with Savlon and spirit. The operation site was wrapped with
sterilized towels. The abdomen was opened by midline incision intestines were
packed into upper abdomen. A small incision was made medial to left ureter and
ureter was freed by blunt dissection taking care not to injure the adventitia.
Ureter was clamped and cut 2 cm. above the bladder, and distal and lighted. A
stay suture was passed into proximal cut end an incision was made in posterior
peritoneum medial to right ureter and posterior peritoneum was elevated from
the underlying aorta and venacava by blunt dissection
dissection with the help of blunt curved forceps. The
left ureter was brought near the right ureter across midline retroperitoneally with the help of stay sutures at a point
where it could be anastomosed end to side with right
ureter without tension. The distal end of left ureter was spatulated
for a distance of 1.5 cm. and sutured by 4/0 chromic catgut to a linear
incision in right ureter given at anterior medial surface. A corrugated soft
rubber drain was passed through a stab wound in the flank and left in place
till the drainage ceased. Posterior peritoneum was closed. No splint was used.
Abdomen was closed in layers after complete haemostasis.
Dogs were kept on IV fluids only for 48 to 72 hours. Inj. Ampicillin 500 mgs. 8 hourly given for 7 days. Tab. Analgin
1 TDS and Tab. Reducin 1 TDS were given for 7 days.
The dressing was covered with plaster of paris to
prevent biting of wound and dressing by dog itself. Ureteric
catheter (infant feeding tube) and rectal tube were removed on 8th
and 10th day respectively. Stiches was removed on 8th day.
Follow Up: -
Blood urea, serum sodium, serum potassium, urinary chlorides were
estimated on alternate day for 1st week, twice a week for rest of
the 1˝ months. Urinary cultures were examined for pathogens every week for 6
weeks.
Blood urea was estimated by King’s method and urinary chloride by Fantus test, serum sodium and potassium were estimated by
Flame photometery.
Intravenous pyelogram
not done because of shortage of radiological gacilities
for animala.
Postmartum was carried out if the dog died in post
operative period. Other dogs were sacrificed and findings were noted.
Table – III-
Post Operative Urine Culture in Dogs
|
Dog No. |
Post
Operative Urine Culture (Weeks) |
|||||
|
First |
Second |
Third |
Fourth |
Fifth |
Sixth |
|
|
1 |
- |
- |
- |
- |
- |
- |
|
2 |
- |
- |
- |
- |
- |
- |
|
3 |
- |
- |
- |
- |
- |
- |
|
4 |
- |
- |
- |
- |
- |
Sterile |
|
5 |
- |
- |
- |
- |
- |
E. coli. |
OBSERVATION:
Each dog was studied for the maximum period of 1˝ months. Preoperative blood urea, serum sodium, serum potassium, urinary
chloride and urine cultures for organism done in each dog to standardize the
normal values.
Table – IV; The Survival Time Postmortum Findings and Cause of Death In Dogs.
|
Dog No. |
Length of
Survival |
Postmortum Findings |
Cause of
Death |
|
1 |
3rd DAYS. |
Adhesions were
present between peritoneum and ureters. Urine was
present in peritoneal cavity. Anastomotic,
disruption was present. |
Chemical
Peritonitis. |
|
2 |
6th DAYS. |
Adhesions were
present between peritoneum, kidneys and ureters.
Peritoneal cavity was full of pus ureteroureteric anastomosis was open. |
Chemical
Peritonitis. |
|
3 |
25th DAYS. |
Mild adhesions
were present between peritoneum, kidney and uretes
was present at anastomotic site. Kidneys were
enlarged to a moderate degree. They were showing irregularities. On bisecting
the kidney the pelvis contained purulent urine. On microscopic examination
urine contained plenty of pus cells. |
Pyonephrosis. |
|
4 |
45th DAYS. |
Adhesion between
peritoneum, kidneys and ureters were present
kidneys and ureters were normal. Anastomotic site was healed and showing mild stenosis. |
Sacrificed |
|
5 |
45th DAYS. |
Adhesion between
peritoneum, kidneys and ureters were present
kidneys and ureters were normal. Anastomotic site was healed and showing mild stenosis. |
Sacrificed |
As shown in (table - I) blood urea level was ranging between 10 to 12 mgs. /Percent. The value of serum sodium,
serum potassium and urinary chloride ranged between 128 to 137 mEq/L, 3.5 to 4.0 mEq/L, and 8 to
12 gm/L, respectively. Urine culture examination was negative for pathogenic
organism in 100 percent of dogs. Culture report of rest of 25 percent dogs
revealed E.coli group of organism.
As shown in table - III post operatively only 2 urine culture were examined, in dog No. 4 and 5. At the time of
sacrificed, out of which one sample (50 percent) was sterile, while in one
sample (50 percent) E. coli was grown.
As it is evident from table – IV. 40 percent dogs of this group survived the
period of observation i.e. 1˝ month and were subsequently sacrificed while 3
(60 percent) died. Out of these 2 dogs (40 percent) had anastomotic
leakage resulting in to sepage of urine in peritoneal
cavity causing chemical peritonitis. While one dog (20
percent) showed gross features of pyonephrosis.
Pyonephrosis was because of superadded infection on
stagnant urine resulting from stenosis at the anastomotic site.
Remaining 40 percent dogs of this group which survived the full
period of observation on post martum revealed mild stenosis at the anastomotic site.
There was however no evidence of hydroureter or hydronephrosis.
DISCUSSION:
Transureteroureterostomy though not a very old idea in the field of
diversion offers palliation by opening a channel of outflow to unilaterally
obstructed supravesical urinary out flow.
Willium Brannan (1972) emphasized that this
procedure not only offers a outlet but maintains
almost normal excretory physiology, by anastomosing
the obstructed ureter to the healthy ureter an d may prevent needless
sacrificed of the renal tissue. The procedure however demands strict adherence
to certain principle like: avoidance of angulation,
tension, construction and undue stripping of ureteral
adventitia.
Weiss, Beland and Lattimer
(1966) found 40 percent stomal complication and development
of matrix calculi in 20 percent of his cases.
Pedro, G. Parmo et.
al (1976) reported chronic unspecific sepsis and uretero-dyelectasis in
most of his patients.
Hodges and Anderson et.al. (1960) lost 90 percent of their
experimental animals and on autopsy 80 percent dogs had anastomotic
leak while 10 percent dog had bilateral pyelonephitis
with cortical abscesses. On clinical study he observed temporary ureteral dyskinesia leading to
transient hydronephrosis in all cases which disappear
spontaneously.
In our series we have lost 60 percent of the transuretero-ureterostomy
cases. In 40 percent cases there was leakage of anastomosis.
In one case (20 [percent) there was pyonephrosis.
Stenosis however was noticed in 60 percent cases.
In 40 percent cases it was mild without producing any alteration in the morbid
anatomy at the time of sacrifice of animal. In 20 percent cases, the stenosis was severe enough to hamper the urinary flow. This
on subsequent superadded infection must have led to pyonephrosis.
Healing of Anastomosis depends mainly
upon adequate blood supply at the anastomotic site.
Careless excessive dissection of adventitia to mobilize the donor ureter
seriously threatens its vascularity which is vital
for sound leak proof anastomosis. Incidence of anastomotic leak in our series is 40 percent.
40 percent of the e40 percent of the experimental animals survived
the full period of observation, with evidence of adequate gross disturbance in
the anatomy.
Ivan L. Sandox et.
al (1979) defined the essential points in the
technique of transuretero-ureterostomy. He postulated
6 points to achieve successful anastomosis:
(1) The ideal site for anastomosis
is 2 to 4 cm. above the pelvic brim.
(2) 1.5 cms. long, anastomosis in the line of
ureter over its antero medial aspect.
(3) Good blood supply of a donor ureter with a
broad gradual curve on its way to the anastomotic
site.
(4) Least dissection of the anastomotic
bed.
(5) Adequate retroperitoneal drainage. and
(6) Use of splint in cases of narrow recipient
ureter.
Transuretero-ureterostomy it is technically hazardous procedure with
greater risk of damage to vital structures like aorta and inferior vena cava,
The incidence of anastomotic leak, is also high (40
percent). However the incidence of stomal stenosis and the resultant ascending urinary tract
infection is less.
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Received on 25.08.2009
Modified on 24.11.2009
Accepted
on 12.12.2011
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Research J. Science and Tech.
4(6): November –December, 2012: 274-277