Ureterosigmoidoscopy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Normal results
Morbidity and mortality rates
Alternatives

Definition

Ureterosigmoidoscopy is a surgical procedure that treats urinary incontinence by joining the ureters to the lower colon, thereby allowing urine to evacuate through the rectum.

Purpose

The surgery is indicated when there is resection (surgical removal), malformation, or injury to the bladder. The bladder disposes of wastes passed to it from the kidneys, which is the organ that does most of the blood filtering and retention of needed glucose, salts, and minerals.

Wastes from the kidneys drip through the ureters to the bladder, and on to the urethra where they are expelled via urination. Waste from the kidneys is slowed or impaired when the bladder is diseased because of ulcerative, inflammatory, or malignant conditions; is malformed; or if it has been removed. In these cases, the kidney is unable to get rid of the wastes, resulting in hydronephrosis (distention of the kidneys). Over time, this leads to kidney deterioration. Saving the kidneys by bladder diversion is as important as restoring urinary continence.

The surgical techniques for urinary and fecal diversion fall into two categories: continent diversion and conduit diversion. In continent diversion, an internal reservoir for urine or feces is created, allowing natural evacuation from the body. In urinary and fecal conduit diversion, a section of existing tissue is altered to serve as a passageway to an external reservoir or ostomy. Both continent and conduit diversions reproduce bladder or colon function that was impaired due to surgery, obstruction, or a neurogenically (nerve dysfunction) created condition. Both the continent and conduit diversion methods have been used for years, with advancements in minimally invasive surgical techniques and biochemical improvements in conduit materials and ostomy appliances.

Catheterization was the original solution for urinary incontinence, especially when major organ failure or removal was involved. But catherization was found to have major residual back flow of urine into the kidneys over the long term. With the advent of surgical anatomosis—the grafting of vascularizing tissue for the repair and expansion of organ function—and with the ability to include flap-type valves to prevent back-up into the kidneys, major continent restoring procedures have become routine in urologic

KEY TERMS

Bladder exstrophy— One of many bladder and urinary congenital abnormalities. Occurs when the wall of the bladder fails to close in embryonic development and remains exposed to the abdominal wall.

Conduit diversion— A surgical procedure that restores urinary and fecal continence by diverting these functions through a constructed conduit leading to an external waste reservoir (ostomy).

Cystectomy— The surgical resection of part or all of the bladder.

Urinary continent diversion— A surgical procedure that restores urinary continence by diverting urinary function around the bladder and into the intestines, thereby allowing for natural evacuation through the rectum or an implanted artificial sphincter.

surgery. Catherization has been replaced as a permanent remedy for persistent incontinence. Continent surgical procedures developed since the 1980s offer the possibility of safely retaining natural evacuation functions in both colonic (intestinal) and urinary systems.

Quality of life issues associated with urinary diversion are increasingly important to patients and, along with medical requirements, put an optimal threshold on the requirements for the surgical procedure. The bladder substitute or created reservoir must offer the following advantages:

• maintain continence
• maintain sterile urine
• empty completely
• protect the kidneys
• prevent absorption of waste products
• maintain quality of life

Ureterosigmoidoscopy is one of the earliest continent diversions for a resected bladder, bladder abnormalities, and dysfunction. It is one of the more difficult surgeries, and has significant complications. Ureterosigmoidoscopy does have a major benefit; it allows the natural expelling of wastes without the construction of a stoma—an artificial conduit—by using the rectum as a urinary reservoir. When evacuation occurs, the urine is passed along with the fecal matter.

Ureterosigmoidoscopy is a single procedure, but there are additional refinements that allow rectal void-g of urine. A procedure known as the Mainz II pouch has undergone many refinements in attempts to lessen the complications that have traditionally accompanied uretersigmoidoscopy. This surgery is indicated for significant and serious conditions of the urinary tract including:

• Cancer or ulceration of the bladder that necessitates a radical cystectomy or removal of the bladder, primarily occurring in adults, particularly those of advanced age.
• Various congential abnormalities of the bladder in infants, especially eversion of part or all of the bladder. Eversion (or exotrophy) is a malformation of the bladder in which the wall adjacent to the abdomen fails to close. In some children, the bladder plate may be too small to fashion a closure.

Demographics

Bladder cancer affects over 50,000 people annually in the United States. The average age at diagnosis is 68 years. It accounts for approximately 10,000 deaths per year. Bladder cancer is the fifth leading cause of cancer deaths among men older than 75 years. Male bladder cancer is three times more prevalent than female bladder cancer.

In the United States, radical cystectomy (total removal of the bladder) is the standard treatment for muscle-invading bladder cancer. The operation usually involves removal of the bladder (with oncology staging) and pelvic lymph node, and prostate and seminal conduits with a form of urinary diversion. Uretersigmoscopy is one option that restores continence.

Pediatric ureterosigmoidoscopy is performed primarily for bladder abnormalities occuring at birth. Classic bladder exstrophy occurs in 3.3 per 100,000 births, with a male to female ratio of 3:1 (6:1 in some studies).

Description

The most basic ureterosigmoidoscopy modification is the Mainz II pouch. There is a 2.4 in (6 cm) cut along antimesenteric border of the colon, both on the proximal and distal sides of the rectum/sigmoid colon junction. The ureters are drawn down into the colon. A special flap technique is applied by folding the colon to stop urine from refluxing back to the kidneys. After the colon is closed, the result is a small rectosigmoid reservoir that holds urine without refluxing it back to the upper urinary tract. Some variations of the Main II pouch include the construction of a valve, as in the Kock pouch, that confines urine to the distal segment of the colon.

Ureterosigmoidoscopy is typically performed in patients with complex medical problems, often those who have had numerous surgeries. Ureterosigmoido scopy as a continent diversion technique relies heavily upon an intact and functional rectal sphincter. The treatment of pediatric urinary incontinence due to bladder eversion or other anatomical anomalies is a technical challenge, and is not always the first choice of surgeons. In Europe, early urinary diversion with ureterosigmoidoscopy is used widely for most exstrophy patients. Its main advantage is the possibility for spontaneous emptying by evacuation of urine and stool.

Diagnosis/Preparation

A number of tests are performed as part of the pre-surgery diagnostic workup for bladder conditions such as cancer, ulcerative or inflammatory disease, or pediatric abnormalities. Tests may include:

• cystoscopy (bladder inspection with a laparoscope)
• CT scan
• liver function
• renal function
• rectal sphincter function evaluation (The rectal sphincter will be a critical ingredient in urination after the surgery, and it is important to determine its ability to function. Adult patients are often asked to have an oatmeal enema and sit upright for a period of time to test sphincter function.)

In adult patients, a discussion of continent diversion is conducted early in the diagnostic process. Patients are asked to consider the possibility of a conduit urinary diversion if the ureterosigmoidoscopy proves impossible to complete. Educational sessions on specific conduit alternatives take place prior to surgery. Topics include options for placement of a stoma, and appliances that may be a part of the daily voiding routine after surgery. Many doctors provide a stomal therapist to consult with the patient.

Aftercare

After surgery, patients may remain in the hospital for a few days to undergo blood, renal, and liver tests, and monitoring for fever or other surgical complications. In pediatric patients, a cast keeps the legs abducted (apart) and slightly elevated for three weeks. Bladder and kidneys are fully drained via multiple catheters during the first few weeks after surgery. Antibiotics are continued after surgery. Permanent

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Uretersigmoidoscopy is usually performed by a urological surgeon with advanced training in urinary continent surgeries, often in consultation with a neonatalist (in newborn patients) or an oncological surgeon. The surgery takes place in a general hospital.

follow-up with the urologist is essential for proper monitoring of kidney function.

Normal results

Good results have been reported, especially in children; however, ureterosigmoidoscopy offers some severe morbid complications. Post-surgical bladder function and continence rates are very high. However, many newly created reservoirs do not function normally; some deteriorate over time, creating a need for more than one diversion surgery. Many patients have difficulty voiding after surgery. Five-year survival rates for bladder surgery patients are 50-80%, depending on the grade, depth of bladder penetration, and nodal status.

Morbidity and mortality rates

The continence success rate with ureterosigmoidoscopy and its variants is higher than 95% for exstrophy; however, long-term malignancy rates are quite high. Adenocarcinoma is the most common of these malignancies, and may be caused by chronic irritation and inflammation of exposed mucosa of the exo-strophic bladder. In one series of studies, adenocarcinoma was reported in more than 10% of patients. However, the malignancy is actually higher in untreated patients whose bladders are left exposed for years before surgery.

Upper urinary tract deterioration is a potential complication, caused by reflux of urine back to the kidneys, resulting in febrile infections.

Alternatives

Other options include construction of a full neo-bladder in certain carefully defined circumstances, and bladder enhancement for congenitally shortened or abnormal bladders. Surgical bladder resection is often followed by continent operations using other

QUESTIONS TO ASK THE DOCTOR

How many times has the surgeon performed this operation?

Is conduit surgery the best route for protecting renal function?

What is the surgeon’s complication rate?

parts of the colon, and by various conduit surgeries that utilize an external ostomy appliance.

Resources

BOOKS

“Continent Urinary Diversion.” In Walsh, P. Campbell’s Urology, 8th ed. Elsevier, 2002.

“Pediatric Urology: Continent Urinary Diversion.” In Walsh, P. Campbell’s Urology, 8th ed. Elsevier, 2002.

PERIODICALS

Stehr, M. “Selected Secondary Reconstructive Procedures for Improvement of Urinary Incontinence in Bladder Exstrophy and Neurogenic Bladder Dysfunction in Childhood.” Wiener Medizinische Wochenschr 150, no.11 (January 1, 2000): 245–8.

Yerkes, B. and H.M. Snyder, H.M. “Exstrophy and Epispadias.” Pediatrics/Urology 3, no.5 (May 6, 2002). www.author.eMedicine.com.

ORGANIZATIONS

American Academy of Pediatrics. 141 Northwest Point Boulevard; Elk Grove Village, IL 60007-1098. (847) 434-4000. Fax: (847) 434-8000. www.aap.org.

National Institutes of Diabetes & Digestive & Kidney Disease. www.niddk.nih.gov/tools/mail.htm.

OTHER

Girgin, C., et. al. “Comparison of Three Types of Continent Urinary Diversions in a Single Center.” Digital Urology Journalwww.duj.com.

Nancy McKenzie, Ph.D.