Ureterosigmoidostomy and Mainz Pouch II

MICHAEL RINK

MARGIT FISCH

The first ureterocolonic anastomosis using the anus as continence mechanism was described over 160 years ago by John Simon of St. Thomas’ Hospital for a child with ectopia vesicae (1). Since its first description, more than 60 modifications of ureterosigmoidostomy have been published (2). This technique was the method of choice for urinary diversion until the late 1950s, when electrolyte deterioration and secondary malignancies arising at the ureteral implantation site were observed (3,4). However, secondary malignancies, although to a lesser extent, were later also reported in other forms of urinary diversion (5). Critics of ureterosigmoidostomy tend to quote publications dealing with complications in patients treated prior to the 1950s (6). The development of new absorbable suture material, modern ureteric stents, antibiotics, and alkalinizing drugs served in solving many of the traditional shortcomings of ureterosigmoidostomy and have revitalized the interest in this technique.

A distinct drawback of ureterosigmoidostomy was frequency and urgency especially reported at night (3,7,8). Urodynamic investigations found that bowel contractions increased the pressure in the reservoir provoking incontinence (8,9). By interrupting the circular contractions (antimesenteric opening of the bowel and “reconfiguration”), low-pressure reservoirs can be constructed, thus improving continence rates and protecting the upper urinary tract by reducing the rates of reflux-related pyelonephritis (10). The era of low-pressure anal reservoirs began.

Kock et al. (9) were the first who applied these principles to ureterosigmoidostomy. Reports on similar techniques either augmenting the sigma with ileal (11) or ileocecal (12) segments followed. The sigma-rectum pouch (10,13) represents an equally effective but simpler operative procedure for creating a rectal low-pressure reservoir. The idea was initially described by Kocher in 1903 (14). R. Coffey (15) revolutionized the ureterointestinal anastomosis by inventing the physiologic submucosal tunnel, which also became the standard technique for ureteral implantation in classical ureterosigmoidostomy. However, in dilated or ureters with thick walls, this technique is associated with increased complication rates. Thus, for patients with these conditions, the ureteral implantation technique into an ileal neobladder published by Abol-Enein and Ghoneim (16,17) represents an alternative. This technique is also applicable for the sigma-rectum pouch (18). In the past decades, further modification of the original technique were described (19,20,21) underscoring the perpetual interest in this procedure. Nowadays, the techniques of lowpressure anal reservoirs have completely replaced classical ureterosigmoidostomy (2).

INDICATIONS

Indications for Surgery

The sigma-rectum pouch is suitable for primary urinary diversion, revision of ureterosigmoidostomy, and conversion of incontinent diversion. A major goal in patient counseling about urinary diversion is to determine the method, that is, the safest for the underlying disease (e.g., cancer control), has the fewest complications during short- and the long-term follow-up, and provides the easiest adjustment for patients’ lifestyle, thereby supporting the best quality of life (QOL) (22). Hence, it is important to notice that adults, particularly elderly patients, often have problems adopting to a reservoir holding the urine with the anal sphincter, as they habitually used the urinary sphincter.

Nevertheless, the procedure is indicated in patients with actual or functional loss of the urinary bladder. The main indications were urinary diversion in patients with bladder exstrophy or after radical cystectomy for bladder cancer. The technique shows particularly good results in children that adjust well to anal reservoirs. Paramount to the success of anal sphincter-controlled urinary diversion is a competent anal sphincter mechanism. This is essential for the sigma-rectum pouch as well as for ureterosigmoidostomy.

Contraindications for Surgery

An absolute contraindication for rectosigmoid reservoirs is an incompetent anal sphincter. Inability of the patient to retain at least 400 mL in the upright position for 1 hour is a contraindication (22,23). Patients with neurogenic bladder dysfunction also have to be evaluated with caution because of the possible association of anal sphincter dysfunction (22). Another absolute contraindication is a preceding irradiation of the pelvis. In addition, rectosigmoid reservoirs are contraindicated in patients with diverticulosis of the sigmoid colon or polyposis.

Compromised renal function or chronic renal failure with serum creatinine levels above 1.5 to 2 mg/dL also represents a contraindication. In addition, severe hepatic dysfunction is a contraindication to continent diversion in general. Patients with compromised intestinal function, particularly inflammatory bowel disease, may benefit from an incontinent urinary diversion (22).

DIAGNOSIS

Preoperative Examinations

When a patient is considered for ureterosigmoidostomy or the sigma-rectum pouch, the anal sphincter function should be examined by a tap water enema (perianal instillation of 200 to 300 mL saline, which the patients should keep at least for 3 hours) as well as a rectodynamic investigation (exclusion of incontinence during measurement; anal sphincter profile: resting closure pressure >60 cm H₂O, closure pressure under stress >100 cm H20). Bowel diseases such as polyposis or diverticulosis have to be excluded. To that end, bowel imaging with water-soluble contrast media should be performed preoperatively. In case of conspicuous findings, coloscopy is recommended for further diagnostics.

Patient Preparation

Nowadays, bowel preparation before urinary diversion is debatable particularly in ileal diversions. For elective colorectal surgery, mechanical bowel preparation has been practiced as a clinical routine for many decades. However, contemporary randomized clinical trials and meta-analyses found no strong evidence supporting the use of mechanical bowel preparation for elective colorectal surgery (24). Yet, the authors of this chapter recommend some type of bowel preparation prior to elective colonic surgery to reduce the stool burden. This may facilitate surgery and potentially avoid postoperative complications.

Broad-spectrum antibiotics such as cephalosporins combined with metronidazole are administered perioperatively. Alternatively, piperacillin sodium combined with an aminoglycoside can be given at the beginning of surgery. A gastric tube (occasional alternative: gastrostomy) and a rectal tube are placed. For parenteral nutrition, a central venous catheter is placed.

ALTERNATIVE THERAPY

Alternatives to the sigmoid-rectal pouch are any other forms of urinary diversion, including bladder substitution, continent cutaneous urinary diversion, and conduit diversion.

SURGICAL TECHNIQUE

Classical Ureterosigmoidostomy

After a median laparotomy, the peritoneum is incised lateral to the descending colon and the left ureter is identified. A peritoneal incision is made on the contralateral side lateral to the ascending colon and the right ureter identified. Both ureters are dissected, respecting the longitudinal vessels running inside the Waldeyer sheet. The dissection is extended caudally to the ureterovesical junction. The ureters are cut as distal as possible, and stay sutures are placed at the 6 o’clock position. The ureteral stumps are ligated.

The colon is slightly elevated at the rectosigmoid junction by four stay sutures. After opening of the sigmoid colon over a length of 4 cm by an incision of the anterior teniae, four mucosal stay sutures are placed in the mucosa of the posterior aspect of the sigmoid (Fig. 83.1). The bowel mucosa is incised between the proximal stay sutures, and a buttonhole type of excision of posterior bowel wall is performed. A straight or slightly curved clamp is advanced through the opening, and a tunnel is created by blunt dissection below the visceral peritoneum of the mesosigmoid (Fig. 83.2). The ureter is pulled into the lumen of the intestine. After creation of a submucosal tunnel of about 3 cm in length, the ureter is threaded through this tunnel, avoiding torsion of the ureter (Fig. 83.3). The anterior wall of the ureter is spatulated for a length of 1 cm (Fig. 83.4A). For the ureterointestinal anastomosis, an anchor suture is placed at the 6 o’clock position grasping intestinal mucosa and musculature (5-0 polyglactin), and the anastomosis is completed by several ureteromucosal single stitches (6-0 polyglactin). A 6Fr silastic stent is inserted into the ureter and fixed to the mucosa by a polyglactin rapide
4-0 suture (Fig. 83.4B). The contralateral ureter is implanted about 3 cm lateral and either proximal or distal to the first anastomosis using the same technique (Fig. 83.5). The ureteral stents are inserted into the rectal tube and pulled out through the anus. Thereafter, the rectal tube is reinserted.

FIGURE 83.1 Open transcolonic ureterosigmoidostomy: Both ureters have been cut at its entrance into the bladder and mobilized. The site of the planned ureteral implantations in the posterior sigmoid wall are outlined by stay sutures.

FIGURE 83.2 After incision of the mucosa and excision of a buttonhole type of excision of the posterior bowel wall site, the ureter is brought through the intestinal wall; a subperitoneal tunnel is modelled bluntly from this point to the left incision in the peritoneum. The curved clamp is advanced precisely below the peritoneum.

FIGURE 83.3 The ureter has been pulled into the bowel and through a submucous tunnel reaching from the proximal to the distal stay suture.

The anterior sigmoid colon is closed in one layer using interrupted sutures of 4-0 polyglactin or in two layers using running sutures (5-0 polyglactin for the mucosa and 4-0 polyglactin for the seromuscularis). The peritoneal incisions are closed. At the end of the operation, separate fixations of the rectal tube and ureteral stents to the skin of the anus are performed (nonabsorbable material).

FIGURE 83.4 Spatulation of the anterior wall of the ureter (A) and ureteromucosal anastomosis between ureter and intestinal wall. The ureter is stented (B).

Sigmoid-Rectal Pouch (Mainz Pouch II)

Access is gained by a median laparotomy as for ureterosigmoidostomy. The rectosigmoid junction is identified and two stay sutures are placed. The peritoneum is incised lateral to the descending colon and the left ureter is identified. Another perineal incision is made lateral to the ascending colon and the right ureter is identified. Both ureters are dissected down to the ureterovesical junction, respecting the longitudinal vessels running inside the Waldeyer sheet. The ureters are cut as distal as possible, stay sutures are placed at the 6 o’clock position, and the ureteral stumps are ligated.

For creation of the pouch, the intestine is opened at the anterior tenia starting from the rectosigmoid junction over a total length of 20 to 24 cm distal and proximal of this point (Fig. 83.6). By placing two stay sutures in the middle of the incision at the right side of the opened rectosigmoid, the intestine is positioned in a shape of an inverted U. The posterior wall of the pouch is closed by side-to-side anastomosis of the medial margins of the U using two-layer running sutures of 4-0 polyglactin for the seromuscular layer and 5-0 polyglactin for the mucosa (Fig. 83.7).

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