Hakala, TR

Shapiro, R

Starzl, TE

Tzakis, A

English

PubMed

D-Scholarship@Pitt

A New Technique of Extravesical Ureteroneocystostomy for Renal Transplantation T.E. Starzl, R. Shapiro, A. Tzakis, and T.R. Hakala I N RENAL transplantation, implantation of the donor ureter has evolved toward greater simplicity and less manipulation of the bladder. The original open techniques1.2 largely have been replaced with variations of an extravesical ureteroneocystostomy, commonly credited to Lich. It is a curious fact that the operation of Lich, Howerton, and Davis) for urinary reflux was designed to avoid reimplantation in nontransplant patients. It consisted of dissection rather than detachment of the distal ureter, which was then buried in a muscular tunnel that provided a valve effect. In all of the so-called Lich ureteroneocystostomies that have been de-scribed since then, the central principle has been the forma-tion of such a tunnel. The details have varied about the exact technique of the ureter-to-bladder mucosal anastomosis and the way the mucosal tunnel has been formed. In this article, we describe a new technique of extravesical ureteroneocystostomy for renal transplantation that is sim-ple. that does not include the formation of a tunnei in the bladder wall, and that can be applied easily for the most abnormal of bladders or when very small pediatric kidneys are transplanted separately or en bloc. We evaluated urinary reflux with this technique in 15 recipients in whom it was performed and compared it with 15 concurrent control cases in whom a conventional extra vesical ureteroneocystostomy was performed by an experienced urologist. MATERIALS AND METHODS Case Material The 30 recipients and their donors had the characteristics summa-rized in Table i. Several recipients had scarred bladders, neuro· pathic bladders, or other abnormalities. The cadavenc kidneys were from adults in is cases and from pediatric donors in the other 15. ln 6 recipients, 5 of them in the experimental series, both pediatric kidneys were used en bloc Surgical Technique The kidneys were revascularized In the usual way. Then, the ureter (or ureters) was brought beneath the spermatic cord (in female recipients. the round ligamenl was divided) to a convenient position on the anterolateral bladder wall (Fig I). An incision through the detrusor muscle of the bladder was made over 2 or 3 em, taking care not to enter the bladder mucosa. A small buttonhole was then made in the distal portion of the bulging bladder mucosa. The donor ureter tip was spatulated by a posterior incision (Fig I). The apex and heel of the splayed ureter tip were then fixed to the bladder (Fig I). A continuous anastomosis between the ureter and the bladder mucosa was made with 6.0 Maxon (Fig I), This completed the ureteroneocystostomy. No effort was made to create a tunnel in the bladder walL The transplanted ureter was allowed to assume whatever natural position it would. By the time wound closure was started, the surrounding tissues, including the transected bladder muscularis, invariably had coapted themselves gently around that portion of the ureter that lay in the cleft of the muscularis incision (Fig I). The use of 2 pediatric kidneys necessi-tated parallel incisions (Fig 2), Three months after the operation, a standard voiding cystourethro· gram was performed in each patient. The bladder was catheterized and filled by gravity with contrast material (Conray) until the patient felt fulL The catheter was then removed, and films were taken before, during, and after voiding. Reflux was graded from a scale of 0 (absent) to 5 by a single senior urologist who did not know either the patient or the technique employed. The 0-5 scale was that defined by the International Reflux Study Committee:' I, contrast in ureter only; II, contrast in ureter and upper collecting system without dilatation; III, mild or moderate dilatation of the ureter and mild or moderate dilatation of the renai pelvis, but no or slight blunting of the fornices; IV, moderate dilatation and/or tortuosity oi the ureter with moderate dilatation of the renai pelvis and calyces and complete obliteration of the sharp angles of the fornices, but maintenance of papillary impressions in the majority of calyces; V, gross dilatation and tortuosity of ureters, renal pelves, and calyces: papillary impressions are not visible in the majority of calyces. The 15 control patients were operated on in the same way, except that a Lich muscularis tunnel was created with an approximating layer of sutures over the distal ureter RESULTS All of the kidneys functioned well, and each of the recipients had adequate renal function 3 months or longer posttransplan-tation. There were no leaks or other complications. The results of the reflux testing are summarized in Table 1. There was no significant difference between the new and conventional techniques in either the frequency or the severity of reflux. Six patients of the 15 in each group had grade II, III, or IV reflux. DISCUSSION Nowhere can the caprices of surgical literature citation be better illustrated than the attribution of the technique of extra vesical ureteroneocystostomy to authors who did not From the Department of Surgery (TES, RS, AT) and Division of Urology (TRH), University Health Center of Pittsburgh, University of Pittsburgh, and the Veterans Administration Medical Center, Pittsburgh, Pennsylvania. Supported by Research Grants from the Veterans Administra tion and Project Grant No. DK 29961 from the National Institutes of Health, Bethesda, Maryland. Address reprint requests to Thomas E. Starzl, MD, PhD, Department of Surgery. 3601 Fifth Avenue, Falk Clinic, Pittsburgh, PA 15213. © 1989 by Appleton & Lange 0041-1345/89/$3.001 +0 3856 Transplantation Proceedings, Vol 21, No 5 (October), 1989: pp 3856·3858 EXTERNAL URETERONEOCYSTOSTOMY 3857 Table 1. Recipient and Donor Characteristics Technique New Conventional Recipient Age 45.7 ± 14.7 43.3 ± 11.9 Sex (M/F) 6r9 6/9 perform this operation.3 1t is probable that Woodruff et al 5 of Edinburgh, Scotland, were the first to use this kind of reconstruction. They described in detail the technique, which became known later as the Lich procedure, and they used this reconstruction for 32 of 33 renal transplantations performed between July 1962 and April 1967. Robson and Calne6 of England learned this method from Woodruff and used it exclusively. In Montreal, a Japanese surgeon, Taguchi, the fourth author of an article by MacKin-non et aV is credited by the other three authors with having used the technique for 6 patients at the Royal Victoria Hospital. The same operation was reported by three different groups in 1972.8. 10 In numerous subsequent reports, the external ureteroneocystostomy and its modifications 1 1·13 have been found to be equal, if not superior, to the open bladder techniques. The principles of the external technique, ie, the performance of a ureterovesical mucosal anastomosis and the creation of a tunnel for the ureter between the bladder mucosa and muscularis, are the same as for the open bladder techniques. I•2 The most common complication has been accidental obstruction as the tunnel is created, either because Spatulaled IfJC7sion Fig 1. Simple technique of edravesical ureteroneocys-tostomy. Donor Age 12.2 ± 12.7 25.8 ± 18.3 En Bloc 5/15 1/15 Reflux/Grade 8/15 1+ =2 2+ = 2 3+ = 3 4+ = 1 6/152+ =2 3+ = 2 4+ = 2 of an actual stricture in the tunnel or because of the creation of awkward entry angles for the ureter. The operation described by us is not based on the Lich principle. It consists of a simple mucosa to mucosa anastomo-sis of the spatulated ureter to the bladder. The only concern that we had was that an operation that did not incorporate the Lich principle might have an unacceptable incidence of harmful reflux. It was to answer this question that the present study was undertaken. The results compared to those after the conventional procedure did not reveal an increased morbidity from reflux. The procedure herein described has been used sporadically for several years, but only for cases in which a conventional Lich operation or an open bladder implantation was too difficult. Thus, the operation was by definition reserved for patients whose bladders presented anatomic problems or whose homografts presented difficulties because of small size or short ureters. It has become evident that a simpler procedure of such versatility could be used as the standard. ACKNOWLEDGMENTS We would like to thank Charles E. Flack, MD, and Frederick N. Schwentker, MD, for their help in performing and interpreting the voiding cystourethrograms. Fig 2. Extravesical ureteroneocystostomy in ad'ult recipient of en bloc pediatric kidneys. 3858 REFERENCES I. Murray JE, Harrison JH: Am J Surg 105:205, 1963 2. Starzl TE: Experience in Renal Transplantation. Philadelphia: W.B. Saunders Co., 1964:99 3. Lich R Jr, Howerton LW, Davis LA: J Uro186:554, 1961 4. Duckett JW, Bellinger MF: Eur Urol 8:74, 1982 5. Woodruff MFA, Nolan B, Robson JS, et al: Lancet 1:6, 1969 6. Robson AJ, Caine RY: Br J Uro143:586, 1971 7. MacKinnon KJ, Oliver JA, Morehouse DD, Taguchi Y: J Urol 99:486, 1968 STARZL, SHAPIRO, TZAKIS ET AL 8. Konnak JW, Herwig KR, Turcotte JG: J Uro1108:380, 1972 9. Lissoos I, Van Blerk PJ, Myburgh lA, et al: S Afr Med J 46: 1335, 1972 10. Fjeldborg 0, Kim CH: Urol Int 27:417,1972 11. Wasnick RJ, Butt KMH, Shirani GLK, et al: Transplanta-tion 126:306, 1981 12. McDonald JC, Rohr MS, Frentz GD: Ann Surg 190:663, 1979 13. Barry 1M, Hatch DA: J Urol134:249, 1985 

A new technique of extravesical ureteroneocystostomy for renal transplantation

Name not available

http://d-scholarship.pitt.edu/4370/1/31735062110253.pdf

A new technique of extravesical ureteroneocystostomy for renal transplantation

Abstract

Similar works

Full text

Available Versions

D-Scholarship@Pitt

Name not available

Name not available