Radiologic evaluation of the upper urinary tract following ileal loop urinary diversion.

Abstract

Fifteen years have elapsed since Eugene Bricker first popularized the use of an isolated segment of terminal ileum as a urinary conduit in patients requiring urinary diversion (3). Since that time, nearly 400 urologic patients have undergone urinary diversion by means of the ileal conduit at Barnes Hospital in St. Louis, Mo. The postoperative course in this type of urinary diversion is generally more satisfactory than that following any other form of bladder substitution. Although much has been written in the surgical and urologic journals about the operation itself and the expected postoperative results, little has been published in the radiologic literature (7, 8). For this reason, we are presenting our experience with the procedure, together with illustrative cases to show the usual technics utilized in evaluating the surgical result postoperatively and the more common complications which may follow the operation. Indications Urinary diversion becomes necessary whenever the bladder must be removed in the attempted surgical cure of carcinoma or when the ureters become obstructed by intrinsic or extra-ureteral disease where local surgical repair of the obstructive process is not feasible. Other common indications are advanced bladder neck obstruction in children, congenital vesical exstrophy, and neurogenic bladder secondary to meningomyelocele. Table I shows the number of patients in each category. Description of Procedure A detailed description of the operation appears in Bricker's original communication. Briefly, the ureters are isolated and divided where they cross the brim of the bony pelvis. A suitable segment of terminal ileum is selected. The length of the segment depends on the thickness of the abdominal wall and should be only long enough to bridge the gap between the left ureter and the abdominal skin. Excessive length of the segment will result in poor drainage and stasis and may also contribute to the development of hyperchloremic acidosis. The proximal end of the isolated segment is closed, and the distal end is brought out through a stomal opening prepared in the right lower quadrant of the abdomen. It is extremely important that the surgeon bring the distal end of the segment to the skin, as an inadvertent transposition of the segment will result in retrograde peristalsis, poor drainage of urine, and the ultimate failure of the operation. The closed end of the ileum is then fixed to the posterior peritoneum, and the ureters are anastomosed to the ileum. The urine is subsequently collected in a bag cemented to the abdominal skin. Despite the fact that the operation calls for at least five separate anastomoses and closures, with careful surgical technic, early postoperative complications have been few (1, 2, 6).