Background
Historically, as early as 1852, Simon reported the first continent urinary diversion by creating a fistula between the ureters and the rectum in a patient with bladder exstrophy. The technique was popularized in the first half of the 20th century as Coffey procedure. Until 1936, more than 60 modifications of ureterosigmoidostomy had been published. Important modifications of antirefluxive ureter implantation to prevent reflux and pyelonephritis were reported in 1951 by Leadbetter and in 1953 by Goodwin et al. The concept of urinary diversion without a stoma and external appliance or need for catheterization of a continent stoma but voluntary control of urination remains intriguing even with the advent of continent cutaneous urinary diversion after Bricker’s ileum conduit. In 1991, Fisch and Hohenfellner introduced the pouch concept for ureterosigmoidostomy (Mainz pouch II) in which a low-pressure pouch reduces upper tract complications and improves continence. This was updated, and 10-year results were reported in 2004. In this chapter, we describe the Goodwin technique of ureterosigmoidostomy and the Mainz pouch II technique.
Patient Selection
Prerequisite of a successful continent anal diversion is a competent anal sphincter to control continence and allow spontaneous evacuation. This excludes most patients with neurogenic deficits of pelvic floor innervation (e.g., secondary to myelomeningocele or spinal cord trauma) when they have compromised control of the anal sphincter. Moreover, patients with other forms of a reduced anal sphincter control (e.g., secondary to surgical trauma such as hemorrhoids or anal fistulae) may not be good candidates for this procedure. In any case, competence of the anal sphincter and confidence of the patient to accommodate liquids in the rectum must be tested preoperatively. This is easily accomplished by instilling 200 to 350 mL warm saline into the rectum and observing the patient’s response during normal activities. If the patient is comfortable with this situation and able to hold the saline for 3 or more hours, he or she may be a good candidate for the procedure. Anal profilometry is another option of preoperative anal sphincter assessment, which is, however, only required in equivocal cases. In anal profilometry, the resting closure pressure should be greater than 60 cm H 2 O and the closing pressure under stress greater than 100 cm H 2 O. Contraindications are a reduced renal function (glomerular filtration rate <50%, serum creatinine >1.5 mg/dL), grade III or higher hydroureteronephrosis or a history of recurrent pyelonephritis, benign or malignant rectosigmoid pathology such as ulcerative colitis, diverticulitis, polyposis, previous or present adenocarcinoma, previous or planned adjuvant radiotherapy of the pelvis, and lack of anal sphincter control.
Preoperative Preparation
Preoperatively, coexistent large bowel pathology must be excluded by colonoscopy, computed tomography colonography, or conventional colonography with double contrast. Twenty-four hours before surgery, patients are placed on a clear liquid diet. The afternoon before surgery, mechanical bowel cleansing is mandatory for this type of surgery. Preferably, this is achieved in an antegrade fashion by administration of 3 L of a hyperosmotic solution (e.g., polyethylene glycol) either by drinking or through a nasogastric tube. Retrograde bowel cleansing by administration of one or several enemas may be performed in addition or as an alternative. On the operation table, before draping the patient, a rectal tube must be placed, in which later on the ureteral stents can be inserted for their intraoperative extraction through the anus. The patient is placed in a flat supine position with slight anti-Trendelenburg tilting of the table. Before skin incision, broad-spectrum antibiosis are administered consisting of either a broad-spectrum penicillin (e.g., piperacillin–tazobactam) or a fourth-generation cephalosporin plus metronidazole and an aminoglycoside.
Surgical Technique
Ureterosigmoidostomy (Goodwin Technique)
The patient is placed on the operating table in a supine position with slight elevation of the pelvis. A rectal tube is placed before draping, and administration of the antibiosis is initiated before skin incision. A lower median laparotomy is performed. If the indication for urinary diversion was not radical cystectomy, in which at the time of urinary diversion the ureters are already mobilized and transected, the posterior peritoneum is incised above the common iliac artery; the left ureter is identified, mobilized, and transected; the distal end is ligated; and a stay suture is placed into the proximal end ( Fig. 57.1 ). The same peritoneal incision, ureter mobilization, and transection are performed on the right side.
Both ureters are advanced underneath the peritoneum close to the mesentery of the sigmoid colon, and the peritoneal incisions are closed. The anterior tenia of the sigmoid colon is proximal to the transition into the rectum incised between stay sutures over a length of about 5 cm ( Fig. 57.2 ). If necessary, the rectosigmoid is mechanically cleansed by several wet swabs with gentamycin.
At the posterior wall of the open sigmoid colon, four stay sutures are placed over a length of about 4 cm for preparation of a submucosal tunnel. Proximally, the mucosa is incised between the stay sutures.
With a fine curved clamp, a submucosal tunnel is prepared from the proximal mucosal incision over a distance of 3 to 4 cm toward the distal stay sutures, where the mucosa is incised for the neo-orifice of the ureter ( Fig. 57.3 ). Previous submucosal injection of a small amount (1–2 mL) of saline eases separation of mucosa from muscularis.
The muscular layer of the posterior wall of the sigmoid colon is incised crosswise to allow an unobstructed pull-through of the ureter.
The ureter is freed from excessive connective tissue outside its genuine longitudinal vascular supply. A curved clamp is inserted through the incision of the posterior wall of the sigmoid colon, and the ureter is beneath the peritoneum pulled through into the lumen of the sigmoid colon ( Fig. 57.4 ).
With a fine curved clamp, the ureter is pulled into the submucosal tunnel.
- 1.
The ureter is spatulated ventrally over 2 to 3 mm.
- 2.
The ureter is anchored at the most distal aspect of its neo-orifice with two absorbable monofilament sutures (e.g., 5-0 glyconate) through muscularis and mucosa of the bowel. The neo-orifice of the spatulated ureter is completed by several uretero-mucosal absorbable monofilament sutures (e.g., 6-0 glyconate). A 6-Fr ureteric stent is inserted and secured to the intestinal mucosa by a rapidly absorbable monofilament suture (e.g., 4-0 polyglytone).
- 3.
The mucosal incision at the proximal end of the tunnel is closed with a few stitches of absorbable monofilament suture (e.g., 5-0 glyconate).
On the right side, preparation of the submucosal tunnel and pull-through of the ureter is performed in the same way as on the left side ( Fig. 57.5 ).
Both ureteric stents are inserted into the side holes of the rectal tube, which is being pulled back to bring out the stents transanally ( Fig. 57.6 ). However, the rectal tube is reinserted and secured to the perianal skin by a stitch at the end of the procedure to serve as a rectal drainage of urine, which may pass alongside the stents.
The anterior incision of the sigmoid colon is closed in two layers: the mucosa is closed with a running absorbable monofilament suture (e.g., 5-0 glyconate), and the seromuscularis is closed with either interrupted or running absorbable monofilament sutures (e.g., 4-0 polydioxanone [PDS]) ( Fig. 57.7 ).
Mainz Pouch II (Sigma Rectum Pouch)
The Mainz pouch II, as described by Fisch and Hohenfellner in 1991, is a modification of ureterosigmoidostomy with pouch formation. Briefly, the rectosigmoid colon is detubularized and reconfigured into a spherical shape to reduce complications of pyelonephritis and anal incontinence. Detubularization of these bowel segments interrupts circular bowel contractions and decreases storage pressures and spherical reconstruction increases capacity, so that both urinary continence and upper tract protection are improved.
Two stay sutures are placed into the rectosigmoid at a position, where it reaches tension free to the promontory, to which the pouch will be sutured later ( Fig. 57.8, A ). The bowel segments are opened along the anterior tenia ( dashed line in Fig. 57.8, B ) over a distance of about 20 cm. The rectosigmoid is mechanically cleansed by several wet swabs with gentamycin. If the sigmoid colon is short and the intended side-to-side anastomosis appears impossible without tension, the descending colon must be mobilized up to the left colonic flexure with division of the phrenocolic ligament.
