APPLICATION OF THE T POUCH AS AN ILEO-ANAL RESERVOIR

Abstract

We recently reported our initial clinical experience with a novel form of urinary diversion, that is the T pouch. 1 The T pouch incorporates a unique antireflux mechanism and eliminates the complications associated with an intussuscepted nipple valve. We describe the application of this concept with conversion of a ureterosigmoidostomy into a new ileo-anal reservoir with an antireflux mechanism. Others have reported followup of as long as 40 years. 2 To our knowledge 61 years is the longest interval to be reported between construction of a ureterosigmoidostomy and its revision. CASE HISTORY P. K., a 64-year-old woman with a history of bladder exstrophy, underwent cystectomy and ureterosigmoidostomy at age 3 years. At 18 years she underwent right nephrectomy for intractable pyelonephritis, and was well until she was 55 years old and had recurrent episodes of pyelonephritis, which necessitated suppressive antibiotic therapy. Multiple drug allergies developed, and she was ultimately hospitalized for urosepsis. Renal ultrasound demonstrated moderate to severe left hydroureteronephrosis. A furosemide nuclear scan was consistent with obstruction. Creatinine was 1.6 mg./dl. (normal 0.3 to 0.9) and blood chemistry study revealed severe hyperchloremic metabolic acidosis. Colonoscopy showed no evidence of malignancy. The patient was satisfied with the voiding pattern and declined any form of external urinary diversion. Conversion of the ureterosigmoidostomy to an ileoanal reservoir incorporating the T pouch antireflux mechanism to the sigmoid colon was performed. At the time of surgery a 24F Medina tube was placed into the anus and, after copious irrigation with a diluted povidone-iodine solution, sutured in place. The Medina tube served as a tactile cue for proper placement of the proctostomy. The colon was mobilized and the previous ureterocolostomy was excised at its junction and sent for frozen section to rule out neoplastic degeneration. A 15 cm. proctostomy was then made at the tip of the Medina tube 10 cm. proximal to the transition zone between the rectum and anus. A portion of sigmoid colon was isolated 4 to 6 cm. proximal to the proctostomy and intussuscepted to prevent urine reflux into the proximal colon. A T pouch was then constructed using techniques previously described. 1 A 20 cm. segment of distal ileum was placed in an inverted V configuration with each limb of the V measuring 10 cm. A more proximal 10 cm. segment of ileum was isolated as the afferent limb. Adhering to the principles outlined for the T pouch, the antireflux mechanism was created by anchoring the distal 3 to 4 cm. of afferent limb into a serosal lined trough. This trough was constructed by maintaining the windows of Deaver to the afferent limb, which allowed for permanent fixation to the serosa of the ileal pouch. The ileal trough was then closed by over sewing the adjacent ileal flaps that are created when the bowel is detubularized (part A of figure). The ileum was left open to be laid onto the rectum as a pouch