Blackwell Science, LtdOxford, UKBJUBJU International1464-410XBJU InternationalJune 2004 939 Point of tech LAPAROSCOPIC URETERO-ENTERIC ANASTOMOSES A. SIMONATO et al.
Intracorporeal uretero-enteric anastomoses during laparoscopic continent urinary diversion A. SIMONATO, A. GREGORI, A. LISSIANI, A. BOZZOLA, S. GALLI and F. GABOARDI Division of Urology, Department of Surgery, ‘Luigi Sacco’ Hospital, Milan, Italy Accepted for publication 6 January 2004
INDICATIONS Laparoscopic cystectomy with different urinary diversions has been described and shown to provide many advantages during and after surgery when compared with open surgery [1–8]. Uretero-enteric anastomosis is an important step during continent urinary diversion and fundamental for a successful surgical and functional result. There is still considerable controversy as to whether a nonrefluxing or refluxing anastomosis is desirable [9]. Intracorporeal uretero-enteric anastomosis is a demanding procedure also for experienced laparoscopic surgeons. The ureter may be laparoscopically anastomosed to the bowel so that it produces a refluxing or nonrefluxing anastomosis. We describe our techniques for simple, refluxing and nonrefluxing intracorporeal laparoscopic uretero-enteric anastomoses.
METHODS Between July 2001 and July 2002, eight men (mean age 67.5 years, range 63–72) with bladder cancer who were candidates for radical surgery had a laparoscopic cystoprostatectomy with continent urinary diversion (six orthotopic ileal neobladders and two sigmoid ureterostomies) [10]. The ureters were isolated up to the iliac vessels, preserving the ureteric branches of the common iliac artery. After frozen-section evaluation of the ureteric margins we
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constructed eight laparoscopic direct refluxing uretero-enteric anastomoses and eight laparoscopic antirefluxing anastomoses with a split-cuff ureteric nipple if the ureter was large (Table 1). TECHNIQUE For the split-cuff ureteric nipple antirefluxing uretero-enteric anastomosis we laparoscopically extended the everting suture described by Atta [11]. The ureter is passed through a small enterotomy, then forceps are used to hold one edge of the ureteric wall. A 20-cm long 3/0 suture is passed through the ureter ª2 cm proximal to the stoma, transfixing the ureteric lumen (Fig. 1a). The suture is tied ª5 cm away from the ureteric wall and the ends cut 5 cm long (Fig. 1b). A forceps is used to pull the suture with delicate and continuous traction (Fig. 1c) and the ureteric wall easily everted (Fig. 1d). Four to five basal fixation sutures are then passed between the ureteric and intestinal edges (Fig. 1e). An interrupted suture is placed through the adventitia of the ureter and the serosa of the bowel (Fig. 1f). An Amplatz 8 F sheath is passed lateral to a trocar, and a guidewire and a stent inserted into the ureter up to the kidney (Fig. 2). Finally, the loop of the everting suture is cut and easily removed by pulling the free end. For direct refluxing uretero-enteric anastomosis the ureter is passed through a small enterotomy, then forceps used to hold 1351
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TABLE 1 The patients’ characteristics and results of surgery
Characteristic/result Age, years Urinary diversion pTNM Grading Anastomosis: R, refluxing; A, antirefluxing right left Follow-up, months Status of anastomosis, grade (G) of hydronephrosis Right Cystography Urography Left Cystography Urography
Patient 1 63 SU T2bN0 G2
2 68 SU T1N0+Cis G3
3 68 OIN T1N0+Cis G3
4 70 OIN T2bN0 G2–3
5 68 OIN T2bN0 G2–3
6 66 OIN T2bN0 G2–3
7 72 OIN T2aN0+Cis G3
8 65 OIN T2bN0 G2–3
A A 22
A A 19
A A 19
R R 15
A R 13
R A 13
R R 11
R R 9
Normal G3, AS
Normal Normal
Normal Normal
VUR, G2 Normal
Normal G2
VUR, G1 G1
Normal Normal
Normal Normal
Normal G3, AS
Normal Normal
Normal Normal
VUR, G2 Normal
Normal G2
Normal Normal
Normal Normal
Normal Normal
SU, sigmoid ureterostomy; OIN, orthotopic ileal neobladder; AS, anastomotic stricture.
one edge of the ureteric wall. A 15-cm long 3/0 suture is passed through the ureter (Fig. 3a). The assistant holds the suture and the ureter is spatulated (Fig. 3b), and sutured to the mucosa with four to five interrupted 3/0 sutures (Fig. 3c). An interrupted suture is placed through the adventitia of the ureter and the serosa of the bowel. Finally, an Amplatz 8 F sheath is passed lateral to a trocar and a guidewire and stent inserted into the ureter up to the kidney (as described in Fig. 2). The patients were assessed by cystography, urography, creatinine, blood urea nitrogen, electrolytes, blood gas analyses, urine analysis and urine culture, after 3, 6, 12, and 18 months. The histopathology results are shown in Table 1; all surgical margins were tumour-free. The uretero-enteric anastomoses were successfully completed in one step in all cases in 30–45 min, with no intraoperative complications. All the anastomoses were confirmed to be watertight. The ureteric stents were removed after 7–8 days, after follow-up radiography. The mean (range) hospital stay was 8.1 (7–9) days for ileal orthotopic neobladder and 8 (7–9) days for sigmoid ureterostomy. The mean follow up was 15.1 (9–22) months. Biochemical tests showed no metabolic alterations, renal failure or infection in six patients. Table 1 1352
summarizes the patients’ characteristics and the results. Cystography showed bilateral grade 2 and unilateral grade 1 reflux in two patients with an orthotopic ileal neobladder, where a direct uretero-ileal anastomosis was used, confirmed by urography. Urography showed grade 3 bilateral hydronephrosis and anastomotic strictures in a patient after sigmoid ureterostomy with split-cuff ureteric nipples. The two patients with bilateral hydronephrosis had metabolic acidosis controlled by oral sodium bicarbonate.
ADVANTAGES AND DISADVANTAGES Uretero-enteric anastomoses in continent urinary diversions should preserve the upper urinary tract and renal function. One of the limits of laparoscopy is the highly limited tactile feedback available to the surgeon. Manipulations of the ureter should be minimised to avoid the risk of oedema and ischaemia, which increase the risk of stenosis or anastomotic dehiscence. The ureter should be mobilized carefully, preserving the adventitia and the ureteric vessels. During laparoscopic radical cystectomy we try to preserve the ureteric blood supply by limited isolation up to the iliac vessels, preserving the adventitia and sparing the ureteric branches of the common iliac artery.
A suture transfixing the ureteric lumen, as described here, can enable the correct tension and visualization of the ureteric margin during the laparoscopic approach. Moreover, avoiding the use of forceps the suture reduces any manipulation of the ureter. Finally, the guidewire and stent are easily passed into the lumen of the ureter with the 8 F Amplatz sheath passed lateral to a trocar (in the same port site). If this manoeuvre is difficult it is possible to choose a more favourable angle for stent insertion by passing the 8 F Amplatz through the abdominal wall with a percutaneous approach. In this way all the trocars can be used with no need for another port site. The everting suture proposed by Atta [11] is a simple, smooth, atraumatic technique for split-cuff ureteric nipple construction. Moreover, with this method the time needed for the antirefluxing anastomosis with a split-cuff ureteric nipple is not substantially longer than a direct nonrefluxing anastomosis. Maintaining the ureter under tension the enterotomy is well visualized and an interrupted suture may be easily placed through the adventitia of the ureter and the serosa of the bowel to fix the ureter to the external wall of the reservoir and to create a tension-free anastomosis.
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FIG. 1. The split-cuff ureteric nipple anastomosis: a, A 3/0 transfixing suture is passed through the ureter ª 2 cm proximal to the distal end; b, the suture is tied ª 5 cm from the ureteric wall; c, A forceps is inserted inside the ureteric lumen to take and pull the suture; d, While the forceps pulls the ureter, two other forceps gently evert the ureteric wall; e, Four to five sutures are passed between the ureteric and intestinal edges to complete the anastomosis; f, an interrupted suture is placed to fix the adventitia of the ureter to the serosa of the bowel.
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f
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FIG. 2. Ureteric stenting: an Amplatz sheath is inserted in the abdomen, passing lateral to a trocar site to permit the positioning of a ureteric stent over a guidewire.
FIG. 3. Direct refluxing anastomosis; a, A 3/0 suture is passed through the distal end of the ureter; b, the assistant holds the suture to facilitate spatulating the ureter; c, the ureter is directly sutured to the mucosa with four to five interrupted 3/0 sutures.
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The rationale for using laparoscopy is that it should be associated with less morbidity and a shorter hospital stay without compromising the surgical results. The present results are no better than those from contemporary open surgery, but these initial results are encouraging for applying the concept of minimally invasive surgery in a technically demanding procedure. Thus laparoscopic radical cystectomy with urinary diversion appears to be a challenging but feasible procedure, and although uretero-enteric anastomosis is important the present techniques for refluxing and nonrefluxing anastomoses are feasible and fulfil the aim of reducing ureteric trauma during laparoscopy. Future developments and better functional results of laparoscopic techniques for treating bladder neoplasms are desirable and will depend on the oncological outcome.
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CONFLICT OF INTEREST None declared. REFERENCES 6 1
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Laparoscopically assisted transvaginal radical cystectomy. Eur Urol 1995; 27: 80–4 Sanchez de Badajoz E, Gallego Perales JL, Reche Rosado A, Gutierrez de la Cruz JM, Jimenez Garrido A. Laparoscopic cystectomy and ileal conduit: case report. J Endourol 1995; 9: 59–62 Denewer A, Kotb S, Hussein O, El-Maadawy M. Laparoscopic assisted cystectomy and lymphadenectomy for bladder cancer: initial experience. World J Surg 1999; 23: 608–11 Gill IS, Fergany A, Klein EA et al. Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases. Urology 2000; 56: 26–9 Turk I, Deger S, Winkelmann B, Schonberger B, Loening SA. Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J Urol 2001; 165: 1863–6 Gill IS, Kaouk JH, Meraney AM et al. Laparoscopic radical cystectomy and continent orthotopic ileal neobladder
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performed completely intracorporeally: the initial experience. J Urol 2002; 168: 13–8 7 Abdel-Hakim AM, Bassiouny F, Abdel Azim MS et al. Laparoscopic radical cystectomy with orthotopic neobladder. J Endourol 2002; 16: 377–81 8 Gaboardi F, Simonato A, Galli S, Lissiani A, Gregori A, Bozzola A. Minimally invasive laparoscopic neobladder. J Urol 2002; 168: 1080–3 9 McDougal WS. Use of intestinal segments and urinary diversion. In Walsh PC, Retik AB, Vaughan ED, Wein AJ eds. Campbell’s Urology, 7th edn. Philadelphia: WB Saunders Co, 1998: 3121–61 10 Simonato A, Gregori A, Lissiani A, Bozzola A, Galli S, Gaboardi F. Laparoscopic radical cystoprostatectomy: a technique illustrated step by step. Eur Urol 2003; 44: 133–9 11 Atta MA. The everting suture: a new technical aid for ureteral nipple construction. J Urol 1996; 155: 1372–3 Correspondence: A. Simonato, Division of Urology, Department of Surgery, ‘Luigi Sacco’ Hospital, Milan, Italy. e-mail:
[email protected]
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