Reconstructive Urologic Surgery Research Articles

Transuretero-ureterostomy: a review of 253 cases.

To review our experience of transuretero-ureterostomy (TUU), which can be a dangerous procedure if a problem arises with the anastomosis, because both upper urinary tracts are put at risk to deal with a problem that initially affected only one side. TUU was performed in 253 patients following undiversion, trauma or strictures of the distal ureter, with a Mitrofanoff-type of continent urinary diversion, or otherwise during reconstructive urological surgery, mainly in association with cystectomy and substitution cystoplasty. The patients were followed and complications or problems reviewed. Five patients had problems with the distal ureter below the TUU and one had problems as a result of stone disease in the transposed ureter some distance proximal to the TUU, but there were no long-term complications as a direct result of the TUU. Providing the anastomosis is stented until there is radiological evidence of healing of the TUU, then TUU is a safe and reliable procedure.

Penetration of ampicillin and sulbactam into human epididymis and testis.

Urologic refertilization microsurgery such as vaso-vasostomy or vaso-epididymostomy benefits from perioperative antibiotic prophylaxis. The ability of ampicillin and sulbactam to penetrate sufficiently into mixed epididymis or testis tissue was investigated in nine patients (bodyweights ranged from 58 kg to 92 kg, mean 77.3 kg) undergoing orchiectomy for testicular cancer or advanced prostatic cancer. Each patient received a single infusion of 3 g ampicillin/sulbactam (ratio 2:1) preoperatively for antibiotic prophylaxis. The concentrations of both components were determined in serum and in epididymis/testis tissue samples taken 30 min to 65 min after infusion. Ampicillin was determined by bioassay and sulbactam was determined by gas chromatography/ mass spectrometry. Mean tissue concentrations of ampicillin were 38.5 +/- 15.9 mg/kg. Mean tissue concentrations of sulbactam at the same time were 19.8 +/- 5.2 mg/kg. Comparison of the tissue/serum ratios for both agents showed no significant difference. These values indicate that both compounds achieve high concentrations in the scrotal organs. The concentrations exceed the MIC (minimal inhibitory concentration) values of important bacterial pathogens such as Staphylococcus aureus involved in postoperative wound infections. The combination of ampicillin and sulbactam may be effective for perioperative prophylaxis in reconstructive scrotal urologic surgery.

Laser tissue soldering in urinary tract reconstruction: First human experience

Objectives Laser tissue soldering (LTS) in the urinary tract provides an immediate leak-free seal and may avoid complications seen with conventional repair (such as fistula and stricture). We have begun a Phase I clinical trial investigating the use of LTS in performing urologic reconstructive surgery. Methods Ten patients (aged 3 months to 38 years) underwent urologic reconstruction using LTS with a protein solder composed of human albumin (42%) and indocyanine green dye. In each case standard microsuture repair preceded laser-soldered suture line reinforcement. Anastomotic closure time and immediate leak pressure were measured. Postoperatively, all patients were evaluated for evidence of complications, including stricture, fistula formation, or impaired healing. Results Using LTS as an adjunct to suturing added an average of 7.9 ± 3.0 minutes (28%) to the overall mean anastomotic time of 28.3 ± 9.4 minutes. Intraoperative leak pressure measurements for laser-soldered anastomoses (≥94.2 ± 24.2 mm Hg) were significantly higher ( P < 0.001) than primarily sutured anastomoses (20 ± 2.9 mm Hg). Two instances of suture disruption (20%) occurred during laser activation, neither of which were repaired with sutures. Average follow-up for all patients was 7.1 ± 2.2 months. There were no intraoperative or postoperative complications, including the 2 patients with suture disruption. Conclusions These initial clinical results indicate that LTS is safe, easy to perform, and, contrary to conventional suturing, provides an immediate leak-free closure. Follow-up in these and other patients, as well as those undergoing sutureless and stent-free procedures, will determine whether our method of LTS benefits patients undergoing urologic reconstruction.

Does the Use of the Ileocecal Region in Reconstructive Urology Cause Persistent Diarrhea?

The ileocecal region (ICR) is used extensively in reconstructive urological surgery. To evaluate whether resection of the ICR may cause protracted diarrhea, 50 patients undergoing ileocecal resection were studied. Fifty patients undergoing left colectomy for cancer were used as controls. No significant change in bowel habits was noted in the control group. Among patients undergoing ICR resection 42% had transient loosening of stools 2 weeks after surgery which improved within 3 months. Twelve months after surgery only 6 patients with solid stools preoperatively had loose stools, and none suffered diarrhea. In conclusion, in the patients studied after resection of the ICR diarrhea gradually resolved. More work is necessary to study other potential metabolic consequences of such resection.

Use of biodegradable mesh as a transport for a cultured uroepithelial graft an improved method using collagen gel

Objectives. To create an improved delivery vehicle for cultured uroepithelialcells using biodegradable mesh and collagen gel. Methods. Twenty uroepithelial grafts were prepared by seeding cultured urothelial cellsonto previously prepared collagen gel-polyglactin mesh. As a control, cells were seeded onto 20 plain polyglactin mesh (without gel) squares in the same fashion. Results. The presence of urothelial cells was confirmed in all cultures by immunohistochemistrytesting with anticytokeratin antibody. After 5 to 7 days, a confluent monolayer of cells covered 90% to 100% of the surface of all 20 collagen gel-mesh grafts. A confluent monolayer of cells did not form on any control graft (plain mesh). After 3 weeks, the cells had formed a sporadic, multiple cell layer confluence over 10% to 50% of the control graft surface; however, the mesh became friable and fell apart. Conclusions. By combining collagen gel with a biodegradable mesh scaffold, we createda surgically implantable cultured uroepithelial graft. The production of the collagen gel-mesh vehicle is simple and inexpensive. With this technique, the use of cultured urothelium for reconstructive urologic surgery can be investigated in greater detail.

Laparoscopic suturing in urology: A model for vesicourethral anastomosis

SummaryLaparoscopic urological reconstructive surgery represents an arduous task for intracorporeal suturing. This article describes the development of skills, instruments, suturing materials and models to aid in the successful sutured laparoscopic reconstruction of the vesicourethral anastomosis.

CONTINENT URINARY DIVERSION USING AN ILEAL SERVOMECHANISM SPHINCTER

A continent, catheterizable, physiologically responsive urinary sphincter servomechanism can be created from a short segment of ileum for use in a continent urinary diversion. Because it is easily constructed and provides dynamic continence control, this new sphincter appears to have applications in reconstructive urologic surgery.

Effectiveness of a Handsewn Nipple Valve for Reflux Prevention in Bladder Reconstruction

The intussuscepted nipple has proved to be a versatile mechanism to provide continence or prevent reflux in urological reconstructive surgery. Early in its use detussusception of the nipple was recognized as a common complication, which was usually prevented by using several rows of staples to stabilize the nipple. The use of staples has reduced the rate of reoperation for eversion or obstruction but it has led to a higher stone formation rate, ranging from 10 to 18% in recent series.Since 1983 we have used a handsewn intussuscepted ileal nipple stabilized without staples as our antireflux mechanism in bladder augmentations and continent diversions. This technique has been performed in 30 patients with an average followup of greater than 3 years. A small bladder stone developed in only 1 (3%) of the patients, who was completely dependent on intermittent catheterization, while 4 (13%) required reoperation due to eversion of the nipple. This incidence compares well with nipple reoperation rates in recent series, which range from 7 to 28%. We conclude that absorbable sutures are as effective as staples in stabilizing the antireflux nipple, and that they result in a lower incidence of subsequent stone formation.

Urinary tract calculi that form on surgical staples: a characteristic radiologic appearance.

An autostapler is frequently used when bowel is interposed in the urinary tract during reconstructive urologic surgery in children. Usually the metallic staples are buried beneath the intestinal mucosa. However, if a portion of a staple is unintentionally left exposed or becomes exposed through migration and is then bathed by urine, it can become the nidus for formation of a calculus. The radiologic studies of 30 patients having surgery of this type in our hospital from 1980 to 1990 were reviewed prospectively, and stones were found to have developed on staples in eight patients. None of the patients had metabolic abnormalities. The stones were easily visible on plain radiographs because they were calcified. They formed in the lumen of the bladder or the bowel segment on the exposed portion of the staple. Thus, the staple was eccentric in the calculus and not central, as is usually the case with a stone forming on a foreign body. This experience suggests that stones forming on surgical staples during reconstructive urologic surgery have a characteristic radiologic appearance that may aid in their identification.

Pharmacokinetics of intravenous cefetamet and oral cefetamet pivoxil in children

The pharmacokinetics of cefetamet were determined after intravenous (i.v.) administration of cefetamet and oral administration of cefetamet pivoxil syrup to patients between the ages of 3 and 12 years. The patients were hospitalized for reconstructive urological surgery; to prevent infection, prophylactic i.v. cefetamet was administered on the day of surgery and oral cefetamet pivoxil was administered 2 days later. After i.v. administration, the mean (+/- standard deviation) half-life of cefetamet was 1.97 +/- 0.60 h (n = 18), which was different from the 2.46 +/- 0.33 h reported for nine adults (22 to 68 years old) in a previous study. The average values for the mean residence times were 2.35 +/- 0.94 and 2.83 +/- 0.34 h and the average values for the fraction of the dose eliminated unchanged in the urine were 79.9% +/- 8.99% and 80% +/- 11% in children and adults, respectively. Plots of mean systemic clearance and steady-state volume of distribution versus body weight for the children and comparative adults were linear on log-log coordinates, and the slopes of the plots were 0.661 and 0.880, respectively. These slope values suggested that mean systemic clearance values per unit of body surface area were similar in children and adults and that maintenance doses for children should be the adult maintenance dose multiplied by the child's surface area divided by 1.73 m2. The mean (+/- standard deviation) oral bioavailabilities of cefetamet pivoxil were 49.3% +/- 15.7% in 3- to 7-year-old children who received a 500-mg dose and 37.9% +/- 10.0% in 8- to 12-year-old children who received a 1,000-mg dose. These values were not different from that observed in the adult group after two 500-mg tablets. Likewise, the peak concentration of cefetamet in plasma and its time of occurrence in children were in line with the values which have been observed for adults.

The Development of Urology as a Scientific and Clinical Discipline

I T IS A STAGGERING task to attempt to describe development of urology in this space. So many things have happened since end of second World War that this could simply be a list with references to try to help anyone interested in a special topic to find an appropriate source. The best reference to urological history is History of Urology by Leonard J.T. Murphy.' ·' Urology is one of oldest and also one of newest surgical specialties. The Hippocratic Oath interdicts for stone, and suggests it should be left for experts. Fortunately, in these days, cutting for stone is not as common as it used to be. The astonishing development of extracorporeal sound wave lithotripsy changed treatment of urinary calculi immensely. This is probably greatest technical advance in our field . 3 Another classical surgical procedure is still a topic for discussion. Circumcision, which at onc time was widely condemned, is now given respectability as a way to decrease urinary tract infection in boys. The greatest stimulus to urology, as a specialty, occurred with invention of cystoscope. 4 Many years of work led to present superb visualization of urinary tract. One of greatest discoveries was intravenous pyelography by Swick, an American, in early 1930s. , .• Dilatation of prostatic urethra with balloons for benign prostatic hypertrophy (BPH) is under study and currently used.' It is thought to be successful in appropriate cases, but probably not long lasting. In Europe, until after World War II, general surgeons performed most urological surgery. In United States, it became a recognized specialty much earlier and was taught as such. The oldest uTological association in world, American Association of Genito-Urinary Surgeons, was initiated in 1886. Ramon Guiteras founded American Urological Association in 1902, and in 1912 Association declared urology to be a specialty. The International Society of Urology originated in Paris in 1907. The Journal of Urology was introduced in 1917 by Hugh Hampton Young, affectionately known as the father of American urology. 8 The European Association of Urology celebrated its IXth Congress in June 1990. The American Society of University Urologists was organized in 1967. William H. Boyce was first President. Properly, to understand writer's perspective, one should know that when he was in medical school, sulpha drugs, penicillin, and other early antibiotics were first introduced. All other advances mentioned in this report did not exist at that time. Probably introduction of sulpha drugs and antibiotics was single greatest advancement. The concept and development of exiracorporeal lithotripsy is, in my opinion, second greatest contribution. [t is surely greatest technical advancement in urological surgery. 3 Another great surgical advancement eagerly accepted by urology is development of kidney transplantation. This has led to a proliferation of many other types of transplantation, and surely Starzl covers this completely in his report, which is included in this issue. 9 Another tremendous rediscovery in surgical urology has been modern use of intestine as part of urinary tract.1.10 Formerly, Coffey's operation, ureterosigmoidostomy for continent urinary diversion , was only general use of intestine. In past 40 years, intestine has been used in almost every conceivable way. 10 It is used to divert urine to skin, as in Eugene Bricker's operation (uretero-ilio-cutaneous anastomosis). Small intestine is used as a substitute for damaged ureters , and in a number of complicated operations for surgical procedures, to replace and enlarge urinary bladder. ''''' One of greatest achievements in reconstructive urological surgery is reconstruction of urinary space. From 1969 to 1990 these imaginative procedures, after previous diversions, have been reported by W. Hardy Hendren of Boston Children's Hospital. He is a leader in this field. He

Book Reviews

Book reviewed in this article: Percutaneous Renal Surgery. Second edition. By S. R. Payne and D. R. Webb. Uremic Toxins. (Advances in Experimental Medicine and Biology). Volume 23. Edited by S. Ringoir, R. Vanholder and S. G. Massry. Progress in Infertility. Third edition. Edited by S. J. Behrman, R. W. Kistner and G. W. Patton, Jr. Nephrology. (Mainstream Medicine Series). By A. M. Davison. Pediatric and Adult Reconstructive Urologic Surgery. Second edition. Edited by J. A. Libertino. Current Therapy in Genitourinary Surgery. Edited by M. I. Resnick and E. Kursh. New Techniques in Urology. Edited by R. W. DeVere White and J. M. Palmer. Urogenital Infections. New Developments in Laboratory Diagnosis and Treatment. (Advances in Experimental Medicine and Biology). Volume 24. Edited by A. Bondi, D. D. Stieritz, J. M. Campos and Linda Ann Miller.

Perforation of the Augmented Bladder in Patientsundergoing Clean Intermittent Catheterization

During urological reconstructive surgery small or large bowel is used to increase bladder capacity or to create a urinary reservoir. In most patients clean intermittent catheterization is necessary for urinary drainage. We report on 4 patients with a sigmoid cystoplasty who perform clean intermittent catheterization and who have experienced a serious long-term complication, urinary reservoir perforation, which was fatal in 1. Two were adolescent girls with myelodysplasia and 2 were prepubertal boys with bladder exstrophy. One patient experienced 2 separate reservoir perforations. Rupture occurred 15 to 48 months (mean 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in 2 of 4 patients, and ultrasound. In 2 patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop reservoir perforation should be considered in the differential diagnosis. (J. Urol, part 2, 140:1159-1162, 1988)

Book Reviews

Book reviewed in this article: UPPER‐LIMB DEFICIENCIES IN CHILDREN: PROSTHETIC, ORTHOTIC, AND SURGICAL MANAGEMENT By Douglas W. Lamb, FRCS and Hamish T. Law, BSc, PhD. COMPUTER TOMOGRAPHIC IMAGING AND ANATOMIC CORRELATION OF THE HUMAN BRAIN By C. Plets, A. L. Baert, G. L. Nijs and G. Wilms. CLINICAL ENDOCRINOLOGY OF CALCIUM METABOLISM Edited by T. John Martin DSc, MD, FRACP and Lawrence G. Raw MD. SURGICAL TREATMENT OF METASTATIC CARCINOMA Edited by S. A. Rosenbrg. PEDIATRIC AND ADULT RECONSTRUCTIVE UROLOGIC SURGERY Edited by John A. Libertino. COST‐EFFECTIVE SURGICAL MANAGEMENT By BEN EISEMAN AND LEROY STAHLGREN.

Ureterocalicostomy

Reconstructive urologic surgery in the upper tract in general is a successful and rewarding procedure. In some settings, however, either complications ensue, or unusual renal anatomy precludes normal procedures. Ureterocalicostomy is an excellent procedure to have available when usual procedures may not be used. In the properly selected patient and with observance of technical details, excellent results may be seen in either primary reconstructive efforts or secondary operations for renal salvage.

Use of ureter of nonfunctioning renal unit in pediatric urinary reconstruction

If following posterior urethral valve fulguration a unilateral nonfunctioning or poorly functioning kidney remains, nephroureterectomy is the customary method of management. The distal ureter of such renal units can serve as a means of salvage for complications resulting from surgery on the ureter serving the remaining solitary functioning renal unit. We present 2 cases of posterior urethral valves where planned preservation of the distal ureter of a nonfunctioning kidney allowed salvage of such complications. We advocate preserving the ureter of a nonfunctioning renal unit if possible until the fate of the solitary functioning kidney and ureter is clear. This approach can be applied to other aspects of pediatric urologic reconstructive surgery.

Treatment of Ureteral Strictures after Therapy for Carcinoma of the Uterus

The long term result after the operative treatment of 29 ureteral strictures by various methods in 19 patients treated radically for a malignant tumor of the uterus was evaluated an average of 50 months after the urologic reconstructive surgery. Four patients died of repeat carcinoma and one patient died of a pulmonary embolism before the follow-up examination. In the other patients, a clinical examination, isotopic nephrography, intravenous pyelography, midstream culture and sediment as well as serum creatinine assay demonstrated that transureteroureterostomy resulted in a good, or satisfactory, outcome in patients with a unilateral stricture. A similar outcome was obtained by ileal replacement of the ureter, provided renal function had not been impaired preoperatively. The results obtained with the bladder flap operation, ureterolysis and cutaneous ureterostomy were poor. The significance of early detection and active therapy for strictures is emphasized. Nonradiated tissue should be used for the reconstructive procedure.

Urinary tract infection in pediatric renal transplantation

Urinary tract infection is a frequent complication following renal transplantation and represents a potential focus for systemic infection in the immunosuppressed transplant recipient. The incidence, etiologic factors, temporal pattern, bacteriology, and prognostic significance of urinary tract infection were determined by analysis of 85 renal allografts in 69 patients. Significant bacteriuria occurred after 49 of 85 transplants (58 per cent). The incidence of infection was not related to success or source of the allograft, but was related to patient gender. Urinary tract infections developed in 68 per cent of females, while only 43 per cent of males became infected (p < 0.05). Escherichia coli caused most first infections (30 per cent), while Pseudomonas aeruginosa and E. coli were equally responsible for recurrent infections (25 per cent each). Children with previous reconstructive urologic surgery had similar allograf success (63 per cent) and infection rates (53 per cent) as our other children (61 per cent and 58 per cent, respectively). No apparent correlation was noted between episodes of infection and graft rejection. Thorough preoperative assessment and preparation and prompt, specific treatment minimize the adverse influences of urinary tract infection.

Experience with omentoplasty.

A 6-year experience with omentoplasty is presented. During this period pedicled omentum was used in 145 procedures of reconstructive urologic surgery. On the basis of this experience the authors conclude that omentoplasty is an essential part in urological reconstructive surgery.

Replacement of the Ureter by Small Intestine: Clinical Application and Results of the “ileal Ureter”

Replacement of the Ureter by Small Intestine: Clinical Application and Results of the “ileal Ureter”