Glenn's urologic surgery [5 ed.] 9780781740821, 0781740827

Table of contents :
Glenn's Urologic Surgery CONTENTS
Preface
Chapter 1 Cushing's Disease and Syndrome
Chapter 2 Adrenal Adenoma and Carcinoma
Chapter 3 Primary Aldosteronism
Chapter 4 Pheochromocytoma
Chapter 5 Simple Nephrectomy
Chapter 6 Partial Nephrectomy
Chapter 7 Radical Nephrectomy
Chapter 8 Intracaval Tumors
Chapter 9 Transplant Nephrectomy
Chapter 10 Renovascular Disease
Chapter 11 Anatrophic Nephrolithotomy
Chapter 12 Renal and Retroperitoneal Abscesses
Chapter 13 Renal Trauma
Chapter 14 Renal Allotransplantation
Chapter 15 Ureteral Complications Following Renal Transplantation
Chapter 16 Renal Autotransplantation
Chapter 17 Nephroureterectomy
Chapter 18 Pyelolithotomy
Chapter 19 Ureterolithotomy
Chapter 20 Ureteral Reconstruction
Chapter 21 Ureteral Stricture
Chapter 22 Simple and Partial Cystectomy
Chapter 23 Radical Cystectomy in Men
Chapter 24 Radical Cystectomy in Women
Chapter 25 Bladder Diverticulectomy
Chapter 26 Bladder Augmentation
Chapter 27 Vesicovaginal Fistula
Chapter 28 Vesicoenteric Fistula
Chapter 29 Vesical Trauma and Hemorrhage
Chapter 30 Interstitial Cystitis
Chapter 31 Open Prostatectomy
Chapter 32 Pelvic Lymphadenectomy
Chapter 33 Radical Retropubic Prostatectomy
Chapter 34 Radical Perineal Prostatectomy
Chapter 35 Brachytherapy for Localized Prostate Cancer
Chapter 36 Prostatic Ultrasound and Needle Biopsy
Chapter 37 Stamey and Gittes Bladder Neck Suspension
Chapter 38 Abdominal Approaches to Surgery for Female Incontinence
Chapter 39 Anterior Vaginal Wall Sling
Chapter 40 Pubovaginal Fascial Slings
Chapter 41 Injections for Incontinence in Women and Men
Chapter 42 Pelvic Floor Relaxation
Chapter 43 Rectus Muscle Sling Procedure for Severe Stress Urinary Incontinence
Chapter 44 Cystocele
Chapter 45 Transvaginal Enterocele Repair
Chapter 46 Vaginal Hysterectomy
Chapter 47 Vaginal Repair of Vesicovaginal Fistula
Chapter 48 Female Urethral Diverticula
Chapter 49 Closure of Bladder Neck in the Male and Female
Chapter 50 Reconstruction of the Severely Damaged Female Urethra
Chapter 51 Urethral Stricture and Disruption
Chapter 52 Surgery for Urethral Trauma
Chapter 53 Artificial Genitourinary Sphincter Implantation
Chapter 54 Urethral Cancer in Women
Chapter 55 Carcinoma of the Male Urethra
Chapter 56 Seminal Vesicle and Ejaculatory Duct Surgery
Chapter 57 Vasectomy
Chapter 58 Vasoepididymostomy
Chapter 59 Vasovasostomy
Chapter 60 Varicocele
Chapter 61 Simple Orchiectomy
Chapter 62 Inguinal Orchiectomy
Chapter 63 Retroperitoneal Lymphadenectomy
Chapter 64 Torsion of the Testicle
Chapter 65 Scrotal Trauma and Reconstruction
Chapter 66 Penectomy for Invasive Squamous Cell Carcinoma of the Penis
Chapter 67 Inguinal Lymphadenectomy for Penile Carcinoma
Chapter 68 Peyronie's Disease
Chapter 69 Priapism
Chapter 70 Penile Prosthesis
Chapter 71 Penile Venous Surgery
Chapter 72 Penile Arterial Reconstruction (Penile Revascularization)
Chapter 73 Penile Trauma
Chapter 74 Penile Replantation
Chapter 75 Hydrocele and Spermatocele
Chapter 76 Ureterosigmoidostomy and the Mainz Pouch II
Chapter 77 Conduit Urinary Diversion
Chapter 78 Kock Pouch Continent Urinary Diversion
Chapter 79 Right Colon Reservoir
Chapter 80 Mitrofanoff Continent Urinary Diversion
Chapter 81 Orthotopic Urinary Diversion Using an Ileal Low-Pressure Reservoir with an Afferent Tubular Segment
Chapter 82 Orthotopic Urinary Diversion Using a Colonic Segment
Chapter 83 Orthotopic Bladder Replacement in Women
Chapter 84 Neuroblastoma
Chapter 85 Wilms' Tumor
Chapter 86 Renal Fusion and Ectopia
Chapter 87 Transureteroureterostomy
Chapter 88 Pyeloplasty
Chapter 89 Megaureter
Chapter 90 Triad Syndrome
Chapter 91 Supravesical Urinary Diversions
Chapter 92 Surgery for Childhood Rhabdomyosarcoma
Chapter 93 Vesicoureteral Reflux
Chapter 94 Ureterocele
Chapter 95 Urachal Anomalies and Related Umbilical Disorders
Chapter 96 Vesical Neck Reconstruction
Chapter 97 Considerations in Pediatric Endoscopy
Chapter 98 Pediatric Urethral Diverticulum
Chapter 99 Posterior Urethral Valves
Chapter 100 Megalourethra
Chapter 101 Hypospadias
Chapter 102 Exstrophy and Epispadias
Chapter 103 Congenital Anomalies of the Scrotum
Chapter 104 Cryptorchidism and Pediatric Hydrocele/Hernia
Chapter 105 Imperforate Anus and Cloacal Malformations
Chapter 106 Ambiguous Genitalia
Chapter 107 Pediatric Vesical Diversion
Chapter 108 Urinary Undiversion
Chapter 109 Circumcision
Chapter 110 Cystoscopic Stone Basket Extraction
Chapter 111 Cystoscopic Treatment of Bladder Tumors
Chapter 112 Transurethral Resection, Incision, and Ablation of the Prostate
Chapter 113 Endoscopic Laser Surgery
Chapter 114 Ureteroscopy
Chapter 115 Percutaneous Lithotomy
Chapter 116 Endopyelotomy for Ureteral Pelvic Junction Obstruction
Chapter 117 Endoscopic Ablation of Upper Urinary Tract Tumors
Chapter 118 Internal Urethrotomy
Chapter 119 Transurethral Cystolitholapaxy
Chapter 120 Extracorporeal Shock Wave Lithotripsy
Chapter 121 Ureteral Stents and Endoscopic Treatment of Ureteral Obstruction
Chapter 122 Basic Laparoscopy: Transperitoneal and Extraperitoneal Approaches
Chapter 123 Laparoscopic Pelvic Lymph Node Dissection: Transperitoneal and Extraperitoneal Techniques
Chapter 124 Laparoscopic Varix Ligation
Chapter 125 Transperitoneal Laparoscopic Nephrectomy and Nephroureterectomy
Chapter 126 Retroperitoneoscopic Nephrectomy and Nephroureterectomy
Chapter 127 Laparoscopic Retroperitoneal Renal Procedures
Chapter 128 Laparoscopic Pyeloplasty
Chapter 129 Laparoscopic Bladder Neck Suspension
Chapter 130 Laparoscopic Management of Lymphoceles
Chapter 131 Laparoscopic Management of the Impalpable Undescended Testicle
Chapter 132 Laparoscopic Adrenalectomy
Chapter 133 Renal Cysts
Chapter 134 Robotics, Telepresence, and Virtual Reality in Urologic Surgery
Chapter 135 Cryosurgical Ablation of the Prostate
Chapter 136 Transurethral Microwave Thermotherapy
Chapter 137 Interstitial Laser Therapy of Benign Prostatic Hyperplasia
Color Plate

Citation preview

Glenn's Urologic Surgery 5th edition (September 15, 1998): By by Sam D. Graham (Editor), James F. Glenn (Editor) By Lippincott Williams & Wilkins Publishers

By OkDoKeY

Glenn's Urologic Surgery CONTENTS Editors Contributors Preface Acknowledgments

Section I: Adrenal Thomas E. Keane Chapter 1 Cushing’s Disease and Syndrome David P. O’Brien III Chapter 2 Adrenal Adenoma and Carcinoma Muta M. Issa and Thomas E. Keane Chapter 3 Primary Aldosteronism James F. Glenn Chapter 4 Pheochromocytoma Thomas E. Keane, Pablo J. Santamaria, and Muta M. Issa

Section II: Kidney Jerome P. Richie Chapter 5 Simple Nephrectomy W. Holt Sanders and Cragin Anderson Chapter 6 Partial Nephrectomy Andrew C. Novick Chapter 7 Radical Nephrectomy Michael S. Cookson Chapter 8 Intracaval Tumors Thomas J. Polascik and Fray F. Marshall Chapter 9 Transplant Nephrectomy J. Thomas Rosenthal Chapter 10 Renovascular Disease John A. Libertino Chapter 11 Anatrophic Nephrolithotomy Michael L. Paik and Martin I. Resnick Chapter 12 Renal and Retroperitoneal Abscesses J. Quentin Clemens and Anthony J. Schaeffer Chapter 13 Renal Trauma Allen F. Morey and Jack W. McAninch Chapter 14 Renal Allotransplantation Bruce A. Lucas Chapter 15 Ureteral Complications Following Renal Transplantation Rodney J. Taylor Chapter 16 Renal Autotransplantation Philip Ayvazian and Mani Menon

Section III: Ureter and Pelvis Charles B. Brendler Chapter 17 Nephroureterectomy Gary D. Steinberg Chapter 18 Pyelolithotomy John M. Fitzpatrick Chapter 19 Ureterolithotomy Michael Marberger Chapter 20 Ureteral Reconstruction Bernd J. Schmitz-Dräger and Rolf Ackermann Chapter 21 Ureteral Stricture Glenn S. Gerber

Section IV: Bladder James E. Montie Chapter 22 Simple and Partial Cystectomy Paul LaFontaine and John A. Petros Chapter 23 Radical Cystectomy in Men Mohamed A. Ghonheim Chapter 24 Radical Cystectomy in Women James E. Montie Chapter 25 Bladder Diverticulectomy J. M. Gil-Vernet Chapter 26 Bladder Augmentation R. Duane Cespedes and Edward J. McGuire Chapter 27 Vesicovaginal Fistula

Hubert G. W. Frohmüller Chapter 28 Vesicoenteric Fistula Luis Gonzalez-Serva Chapter 29 Vesical Trauma and Hemorrhage Badrinath R. Konety, Michael P. Federle, and Robert R. Bahnson Chapter 30 Interstitial Cystitis Gary J. Faerber

Section V: Prostate Joseph A. Smith, Jr. Chapter 31 Open Prostatectomy Ray E. Stutzman Chapter 32 Pelvic Lymphadenectomy Ralph W. deVere White and Andrew Huang Chapter 33 Radical Retropubic Prostatectomy Joseph A. Smith, Jr. Chapter 34 Radical Perineal Prostatectomy Sam D. Graham, Jr. Chapter 35 Brachytherapy for Localized Prostate Cancer Haakon Ragde Chapter 36 Prostatic Ultrasound and Needle Biopsy Johan Braeckman and Louis J. Denis

Section VI: Urethra Shlomo Raz Chapter 37 Stamey and Gittes Bladder Neck Suspension David A. Ginsberg, Eric S. Rovner, and Shlomo Raz Chapter 38 Abdominal Approaches to Surgery for Female Incontinence E. P. Arnold and Peter Gilling Chapter 39 Anterior Vaginal Wall Sling Lynn Stothers Chapter 40 Pubovaginal Fascial Slings R. Duane Cespedes and Edward J. McGuire Chapter 41 Injections for Incontinence in Women and Men Rodney A. Appell and Randy A. Fralick Chapter 42 Pelvic Floor Relaxation David A. Ginsberg, and Eric S. Rovner, and Shlomo Raz Chapter 43 Rectus Muscle Sling Procedure for Severe Stress Urinary Incontinence Niall T. M. Galloway Chapter 44 Cystocele Eric S. Rovner,David A. Ginsberg, and Shlomo Raz Chapter 45 Transvaginal Enterocele Repair Victor W. Nitti Chapter 46 Vaginal Hysterectomy Eric S. Rovner, David A. Ginsberg, and Shlomo Raz Chapter 47 Vaginal Repair of Vesicovaginal Fistula David A. Ginsberg, Eric S. Rovner, and Shlomo Raz Chapter 48 Female Urethral Diverticula Kumaresan Ganabathi and Gary E. Leach Chapter 49 Closure of Bladder Neck in the Male and Female Scott E. Litwiller and Philippe E. Zimmern Chapter 50 Reconstruction of the Severely Damaged Female Urethra Jerry G. Blaivas Chapter 51 Urethral Stricture and Disruption E. James Wright and George D. Webster Chapter 52 Surgery for Urethral Trauma David M. Nudell, Allen F. Morey, and Jack W. McAninch Chapter 53 Artificial Genitourinary Sphincter Implantation James A. Dugan and David M. Barrett Chapter 54 Urethral Cancer in Women John Naitoh, William J. Aronson, and Jean B. DeKernion Chapter 55 Carcinoma of the Male Urethra William J. Aronson, John Naitoh, and Jean B. deKernion

Section VII: Vas Deferens and Seminal Vesicle Jon L. Pryor Chapter 56 Seminal Vesicle and Ejaculatory Duct Surgery Paul J. Turek Chapter 57 Vasectomy Jon L. Pryor and Douglas A. Schow Chapter 58 Vasoepididymostomy Anthony J. Thomas, Jr. Chapter 59 Vasovasostomy William Forbes Hendry Chapter 60 Varicocele Alain Jardin

Section VIII: Testes David A. Swanson

Chapter 61 Simple Orchiectomy Sherri M. Donat Chapter 62 Inguinal Orchiectomy David A. Swanson Chapter 63 Retroperitoneal Lymphadenectomy Michael A. S. Jewett Chapter 64 Torsion of the Testicle Giovanni Grechi and Vincenzo Li Marzi Chapter 65 Scrotal Trauma and Reconstruction Gerald H. Jordan

Section IX: Penis and Scrotum Tom F. Lue Chapter 66 Penectomy for Invasive Squamous Cell Carcinoma of the Penis James L. Mohler and John A. Freeman Chapter 67 Inguinal Lymphadenectomy for Penile Carcinoma John A. Freeman and James L. Mohler Chapter 68 Peyronie’s Disease Kenneth S. Nitahara and Tom F. Lue Chapter 69 Priapism Kenneth S. Nitahara and Tom F. Lue Chapter 70 Penile Prosthesis John J. Mulcahy Chapter 71 Penile Venous Surgery Mark R. Licht and Ronald W. Lewis Chapter 72 Penile Arterial Reconstruction (Penile Revascularization) John Mulhall and Irwin Goldstein Chapter 73 Penile Trauma David M. Nudell, Allen F. Morey, and Jack W. McAninch Chapter 74 Penile Replantation Farhad Parivar, Allen F. Morey, and Jack W. McAninch Chapter 75 Hydrocele and Spermatocele Theodros Yohannes and James I. Harty

Section X: Urinary Diversion George D. Webster Chapter 76 Ureterosigmoidostomy and the Mainz Pouch II Margit Fisch and Rudolf Hohenfellner Chapter 77 Conduit Urinary Diversion Lesley K. Carr and George D. Webster Chapter 78 Kock Pouch Continent Urinary Diversion John A. Freeman Chapter 79 Right Colon Reservoir Jorge L. Lockhart Chapter 80 Mitrofanoff Continent Urinary Diversion Hubertus Riedmiller and Elmar Werner Gerharz Chapter 81 Orthotopic Urinary Diversion Using an Ileal Low-Pressure Reservoir with an Afferent Tubular Segment Hansjörg Danuser and Urs E. Studer Chapter 82 Orthotopic Urinary Diversion Using a Colonic Segment Daniela Schultz-Lampel and Joachim W. Thüroff Chapter 83 Orthotopic Bladder Replacement in Women John P. Stein and Donald G. Skinner

Section XI: Pediatric Urology Edmond T. Gonzales, Jr., and Stephen A. Kramer Chapter 84 Neuroblastoma Yves L. Homsy and Paul F. Austin Chapter 85 Wilms’ Tumor O. Lenayne Westney and Michael L. Ritchey Chapter 86 Renal Fusion and Ectopia Ross M. Decter Chapter 87 Transureteroureterostomy Anthony J. Casale Chapter 88 Pyeloplasty Eugene Minevich and Jeffrey Wacksman Chapter 89 Megaureter Edmond T. Gonzales, Jr. Chapter 90 Triad Syndrome David B. Joseph Chapter 91 Supravesical Urinary Diversions Byron Joyner and Antoine Khoury Chapter 92 Surgery for Childhood Rhabdomyosarcoma Bruce Broecker Chapter 93 Vesicoureteral Reflux Anthony Atala and R. Dixon Walker Chapter 94 Ureterocele Sami Arap and Amilcar Martins Giron

Chapter 95 Urachal Anomalies and Related Umbilical Disorders H. Norman Noe Chapter 96 Vesical Neck Reconstruction Stuart B. Bauer Chapter 97 Considerations in Pediatric Endoscopy Scott A. Berkman and Edwin A. Smith Chapter 98 Pediatric Urethral Diverticulum Hrair-George O. Mesrobian Chapter 99 Posterior Urethral Valves Alan B. Retik Chapter 100 Megalourethra Mark P. Cain Chapter 101 Hypospadias Warren Snodgrass Chapter 102 Exstrophy and Epispadias Stephen A. Kramer Chapter 103 Congenital Anomalies of the Scrotum David R. Roth Chapter 104 Cryptorchidism and Pediatric Hydrocele/Hernia Stanley J. Kogan and Bhagwant Gill Chapter 105 Imperforate Anus and Cloacal Malformations W. Hardy Hendren III Chapter 106 Ambiguous Genitalia Richard I. Silver and John P. Gearhart Chapter 107 Pediatric Vesical Diversion Steven J. Skoog Chapter 108 Urinary Undiversion Andrew L. Freedman and Ricardo Gonzalez Chapter 109 Circumcision Jay B. Levy and Stephen A. Kramer

Section XII: Endoscopy Culley C. Carson III Chapter 110 Cystoscopic Stone Basket Extraction Stevan B. Streem Chapter 111 Cystoscopic Treatment of Bladder Tumors Keith A. Harmon and Michael J. Droller Chapter 112 Transurethral Resection, Incision, and Ablation of the Prostate Richard P. Santarosa, Alexis E. Te, and Steven A. Kaplan Chapter 113 Endoscopic Laser Surgery Ken Koshiba and Toyoaki Uchida Chapter 114 Ureteroscopy Anuar Ibrahim Mitre, Jose Luis Chambo, and Sami Arap Chapter 115 Percutaneous Lithotomy Joseph W. Segura Chapter 116 Endopyelotomy for Ureteral Pelvic Junction Obstruction Culley C. Carson III Chapter 117 Endoscopic Ablation of Upper Urinary Tract Tumors Mantu Gupta and Arthur D. Smith Chapter 118 Internal Urethrotomy Joseph M. Khoury Chapter 119 Transurethral Cystolitholapaxy Marshall L. Stoller and Donald L. Gentle Chapter 120 Extracorporeal Shock Wave Lithotripsy James E. Lingeman and John W. Dushinski Chapter 121 Ureteral Stents and Endoscopic Treatment of Ureteral Obstruction Gerhard J. Fuchs, Kamil Noordin, and Anup Patel

Section XIII: Laparoscopy Leonard G. Gomella Chapter 122 Basic Laparoscopy: Transperitoneal and Extraperitoneal Approaches Leonard G. Gomella and David M. Albala Chapter 123 Laparoscopic Pelvic Lymph Node Dissection: Transperitoneal and Extraperitoneal Techniques Blake D. Hamilton and Howard N. Winfield Chapter 124 Laparoscopic Varix Ligation James F. Donovan and Eduardo Sanchez de Badajoz Chapter 125 Transperitoneal Laparoscopic Nephrectomy and Nephroureterectomy Inderbir S. Gill and Sakti Das Chapter 126 Retroperitoneoscopic Nephrectomy and Nephroureterectomy Inderbir S. Gill and Sakti Das Chapter 127 Laparoscopic Retroperitoneal Renal Procedures John B. Adams II Chapter 128 Laparoscopic Pyeloplasty Robert G. Moore and Jeffrey A. Cadeddu Chapter 129 Laparoscopic Bladder Neck Suspension J. Stuart Wolf, Jr. and Elspeth M. McDougall Chapter 130 Laparoscopic Management of Lymphoceles

Blake D. Hamilton and Howard N. Winfield Chapter 131 Laparoscopic Management of the Impalpable Undescended Testicle Gerald H. Jordan Chapter 132 Laparoscopic Adrenalectomy H. Tazaki Chapter 133 Renal Cysts Michael P. O’Leary

Section XIV: Frontiers R. Ernest Sosa Chapter 134 Robotics, Telepresence, and Virtual Reality in Urologic Surgery Roland N. Chen and Louis R. Kavoussi Chapter 135 Cryosurgical Ablation of the Prostate Harry S. Clarke Chapter 136 Transurethral Microwave Thermotherapy Aaron P. Perlmutter Chapter 137 Interstitial Laser Therapy of Benign Prostatic Hyperplasia Rolf Muschter Color Plate

Editors Editor-in-Chief Sam D. Graham, Jr., M.D. Louis McDonald Orr Professor of Urology Emory University School of Medicine The Emory Clinic 1365 Clifton Road NE Atlanta, Georgia 30322 Consultant Editor James F. Glenn, M.D. Professor of Surgery (Urology) University of Kentucky College of Medicine P.O. Box 1390 Lexington, Kentucky 40536 Associate Editors Charles B. Brendler M.D. Professor and Chief Section of Urology, MC6038 University of Chicago Pritzker School of Medicine University of Chicago Medical Center 5841 South Maryland Avenue Chicago, Illinois 60637 Section: Ureter and Pelvis Culley C. Carson III, M.D. Professor and Chief Division of Urology University of North Carolina School of Medicine Division of Urology 427 Burnett-Womack CB7235 Chapel Hill, North Carolina 27599 Section: Endoscopy Leonard G. Gomella, M.D. The Bernard W. Godwin, Jr. Associate Professor of Prostate Cancer Department of Urology Thomas Jefferson University School of Medicine 1025 Walnut Street, Suite 1102 Philadelphia, Pennsylvania 19107 Section: Laparoscopy Edward T. Gonzales, Jr., M.D. Chief of Pediatric Urology Department of Urology Baylor College of Medicine Scott Feigin Center, Suite 270 6621 Fannin Street Houston, Texas 77030-2399 Section: Pediatric Urology Thomas E. Keane, M.D. Associate Professor of Urology Division of Urology Emory University 1365 Clifton Road NE Atlanta, Georgia 30322 Section: Adrenal Stephen A. Kramer, M.D. Head, Section of Pediatric Urology Urology Professor in Honor of Dr. Utz Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 Section: Pediatric Urology Tom F. Lue, M.D. Professor of Urology Department of Urology, U-575 University of California San Francisco, Box 0738 San Francisco, California 94143-0738 Section: Penis and Scrotum James E. Montie, M.D. Interim Head Section of Urology George F. and Nancy P. Valassis Professor of Urologic Oncology University of Michigan Medical Center 1500 East Medical Center Drive Ann Arbor, Michigan 48109-0330 Section: Bladder Jon L. Pryor, M.D. Associate Professor and Director Center for Men’s Health and Infertility Departments of Urologic Surgery, Cell Biology and Neuroanatomy, and Obstetrics and Gynecology

University of Minnesota P.O. Box 394 UMHC 420 Delaware Street SE Minneapolis, Minnesota 55455 Section: Vas Deferens and Seminal Vesicle Shlomo Raz, M.D. Professor of Surgery Department of Urology U.C.L.A. School of Medicine Box 951738 Los Angeles, California 90024 Section: Urethra Jerome P. Richie, M.D. Elliot C. Cutler Professor of Surgery Chair, Department of Urology Brigham and Women’s Hospital Harvard Medical School 45 Francis Street, ASB II-3 Boston, Massachusetts 02115 Section: Kidney Joseph A. Smith, Jr., M.D. Professor and Chairman Department of Urologic Surgery Vanderbilt University Medical Center A-1302 Medical Center North Nashville, Tennessee 37232-2765 Section: Prostate R. Ernest Sosa, M.D. Associate Professor of Surgery/Urology New York Hospital—Cornell Medical Center 525 East 68th Street, Box 94 New York, New York, 10021 Section: Frontiers David A. Swanson, M.D., F.A.C.S. Professor and Chairman (Ad Interim) Department of Urology The University of Texas M.D. Anderson Cancer Center 1515 Holcombe Boulevard, Box 110 Houston, Texas 77030 Section: Testes George D. Webster, M.B., F.R.C.S. Professor of Urology Surgery Department of Surgery Division of Urology Duke University Medical Center Box 3146 Durham, North Carolina 27710 Section: Urinary Diversion

Contributors Rolf Ackermann, M.D. Professor of Urology and Medicine Department of Urology Heinrich-Heine-University Moorenstrasse 5 D-40225 Düsseldorf, Germany Chapter 20 John B. Adams II, M.D. Assistant Professor of Surgery Head of Endourology and Laparoscopy Department of Surgery Section of Urology Medical College of Georgia 1120 15th Street Augusta, Georgia 30912-4050 Chapter 127 David M. Albala, M.D. Associate Professor of Urology Department of Urology Loyola University Medical Center 21065 First Avenue Maywood, Illinois 60153, and Attending Urologist Hines Veteran’s Hospital Hines, Illinois Chapter 122 Cragin Anderson, M.D. Atlanta Urological Institute 217 Upper Riverdale Road Riverdale, Georgia 30274 Chapter 5 Rodney A. Appell, M.D. Head Section of Voiding Dysfunction and Female Urology Department of Urology The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195 Chapter 41 Sami Arap, M.D. Professor and Chairman Division of Urology Hospital das Clínicas University of Sao Paulo School of Medicine Caixa Postal 11-273-9 CEP 05422-970 Sao Paulo, SP, Brazil Chapters 94 and 114 E. P. Arnold, M.B., Ch.B. (NZ), Ph.D. (U.K.), F.R.C.S. (U.K.), F.R.A.C.S. Associate Professor of Urology Department of Urology Christchurch Hospital Riccarton Avenue Christchurch, New Zealand Chapter 38 William J. Aronson, M.D. Assistant Clinical Professor Department of Urology U.C.L.A. School of Medicine Box 951738 Los Angeles, California 90095-1738 Chapters 54 and 55 Anthony Atala, M.D. Assistant Professor of Surgery Department of Surgery Harvard Medical School, and Assistant in Urology Department of Urology Children’s Hospital 300 Longwood Avenue Boston, Massachusetts 02115 Chapter 93 Paul F. Austin, M.D. Fellow in Pediatric Urology Indiana University School of Medicine James Whitcomb Riley Hospital for Children Indiana University Medical Center 702 Barnhill Drive, Suite 1739 Indianapolis, Indiana 46202 Chapter 84 Philip Ayvazian, M.D. Department of Urology University of Massachusetts

55 Lake Avenue North Worcester, Massachusetts 01655 Chapter 16 Robert R. Bahnson, M.D. Louis Levy Professor and Director Division of Urology Ohio State University Medical Center 456 West 10th Avenue Columbus, Ohio 43210-1228 Chapter 29 David M. Barrett, M.D. Anson L. Clark Professor of Urology Department of Urology Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 Chapter 53 Stuart B. Bauer, M.D. Associate Professor of Urology Department of Urology Harvard Medical School, and Department of Urology The Children’s Hospital 300 Longwood Avenue Boston, Massachusetts 02115 Chapter 96 Scott A. Berkman, M.D. Department of Surgery Emory University School of Medicine Egleston Children’s Hospital Atlanta, Georgia 30322 Chapter 97 Jerry G. Blaivas, M.D. Department of Urology New York Hospital-Cornell Medical Center 400 East 56th Street New York, New York 10022 Chapter 50 Johan Braeckman, M.D. Assistant Head Department of Urology Vrije Universiteit Brussels Laarbeeklaan 101 1090 Brussels, Belgium Chapter 36 Bruce Broecker, M.D. Department of Surgery Medical College of Virginia Virginia Commonwealth University Richmond, Virginia 23298 Chapter 92 Jeffrey A. Cadeddu, M.D. Resident Department of Urology Johns Hopkins Hospital 600 North Wolfe St. Baltimore, Maryland 21287 Chapter 128 Mark P. Cain, M.D. Department of Pediatric Urology Indiana University School of Medicine Indianapolis, Indiana 46202 Chapter 100 Lesley K. Carr Department of Surgery Division of Urology University of Toronto Wellesley Hospital Toronto M4Y 1J3 Ontario, Canada Chapter 77 Culley C. Carson III, M.D. Professor and Chief Division of Urology University of North Carolina School of Medicine 427 Burnett-Womack CB7235 Chapel Hill, North Carolina 27599 Chapter 116 Anthony J. Casale, M.D. Associate Professor

Department of Urology Indiana University School of Medicine, and Pediatric Urology Division James Whitcomb Riley Hospital for Children 702 Barnhill Drive, Room 1739 Indianapolis, Indiana 46202 Chapter 87 R. Duane Cespedes, M.D. Department of Urology/MKCU Wilford Hall Medical Center 2200 Bergquist Drive, Suite I Lackland AFB, Texas 78236 Chapters 26 and 40 Jose Luis Chambo, M.D. Assistant Attendent Division of Urology Hospital das Clínicas University of Sao Paulo School of Medicine Caixa Postal 11-273-9 CEP 05422-970 Sao Paulo, SP, Brazil Chapter 114 Roland N. Chen, M.D. Department of Urology The Cleveland Clinic Florida 3000 West Cypress Creek Road Fort Lauderdale, Florida 33309 Chapter 134 Harry S. Clarke, M.D. Division of Urology Emory University School of Medicine Atlanta, Georgia 30322 Chapter 135 J. Quentin Clemens M.D. Department of Urology Northwestern University Medical School 303 East Chicago Avenue, T299 Chicago, Illinois 60611-3008 Chapter 12 Michael S. Cookson, M.D. Division of Urology Department of Surgery University of Kentucky 800 Rose Street, MS 273 Lexington, Kentucky 40536 Chapter 7 Hansjorg Danuser, M.D. Department of Urology University of Berne 3010 Berne, Switzerland Chapter 81 Sakti Das, M.B.B.S., F.R.C.S. Chief Department of Urology Kaiser Permanente Medical Center Associate Professor of Urology University of California, Davis School of Medicine Walnut Creek, California 94596 Chapters 125 and 126 Ross M. Decter, M.D. Associate Professor Department of Surgery Section of Urology Pennsylvania State Geisinger Health System 500 University Drive Hershey, Pennsylvania 17033 Chapter 86 Jean B. deKernion, M.D. Department of Urology U.C.L.A. School of Medicine Room 66-133 CHS, 10833 LeConte Avenue Los Angeles, California 90095-1738 Chapters 54 and 55 Louis J. Denis, M.D. Professor and Director Department of Urology Oncology Centre Antwerp Lindendreef 1 2020 Antwerp, Belgium Chapter 36 Ralph W. deVere White, M.D. Professor and Chair

Department of Urology University of California, Davis School of Medicine 4301 X Street Suite 2210 Sacramento, California 95817 Chapter 32 Sherri M. Donat, M.D. Assistant Attending Surgeon Department of Surgery Division of Urology Memorial Sloan-Kettering Cancer Center 1275 York Avenue, Room M-606 New York, New York 10021 Chapter 61 James F. Donovan, Jr., M.D. Professor of Urology University of Oklahoma Health Science C 920 Stanton L. Young Boulevard, WP3150 Oklahoma City, Oklahoma 73190 Chapter 124 Michael J. Droller, M.D. Professor and Chair Department of Urology The Mount Sinai Medical Center One Gustave L. Levy Place, Box 1272 New York, New York 10029 Chapter 111 James A. Dugan, M.D. Department of Urology Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 Chapter 53 John W. Dushinski, M.D. Assistant Clinical Professor Department of Surgery University of Calgary, and Rockyview Professional Center 1011 Glenmore Trail, SW Calgary, Alberta T2V 4R6, Canada Chapter 120 Gary J. Faerber, M.D. Assistant Professor of Surgery Department of Urology University of Michigan 1500 East Medical Center Drive Ann Arbor, Michigan 48109-0330 Chapter 30 Michael P. Federle, M.D. Professor of Radiology Department of Radiology University of Pittsburgh Medical Center Presbyterian University Hospital Pittsburgh, Pennsylvania 15213 Chapter 29 Margit Fisch, M.D. Associate Professor of Urology Department of Urology Johannes Gutenberg University Medical School Langenbeckstrasse 1 55131 Mainz, Germany Chapter 76 John M. Fitzpatrick, M.Ch., F.R.C.S.I. Professor of Surgery Department of Surgery/Urology Mater Hospital and University College Dublin 47 Eccles Street Dublin 7, Ireland Chapter 18 Randy A. Fralick, M.D. Fellow Section of Voiding Dysfunction and Female Urology Department of Urology The Cleveland Clinic Foundation Cleveland, Ohio 44195, and Holy Family Memorial Medical Center 1020 Maritime Drive Manitowoc, Wisconsin 54220 Chapter 41 Andrew L. Freedman, M.D.

Pan-Pacific Pediatric Urologic Institute Los Angeles, California 90095 Chapter 108 John A. Freeman, M.D. Assistant Professor of Urology Division of Urology University of North Carolina School of Medicine 428 Burnett Womack Building CB 7235 Chapel Hill, North Carolina 27599-7235 Chapters 66, 67, and 78 Hubert G. W. Frohmüller, M.D., M.S., F.A.C.S. Emeritus Professor of Urology Department of Urology University of Würzburg School of Medicine Josef Schneidederstrasse 2 Würzburg D-97080, Germany Chapter 27 Gerhard J. Fuchs, M.D. Professor of Urology Section Chief Endourology, Laparascopic Surgery, and Stone Disease Director, Stone Treatment Center Box 951738, Room BU-183 U.C.L.A. Medical Center Los Angeles, California 90095-1738 Chapter 121 Niall T. M. Galloway, M.B., F.R.C.S., F.R.S.C.(E) Associate Professor of Surgery/Urology Department of Surgery Section of Urology Emory University School of Medicine The Emory Clinic 1364 Clifton Road, NE Atlanta, Georgia 30322 Chapter 43 Kumaresan Ganabathi, M.B., B.S., M.S. (Gen Surg), Dip. Urol. (London), F.R.C.S. (E) Brookville, Punxsutawney, and Clarion Hospitals 240 Allegheny Boulevard Suite C Brookville, Pennsylvania 15825 Chapter 48 John P. Gearhart, M.D. Professor and Director of Pediatric Urology Department of Pediatric Urology Johns Hopkins University School of Medicine The James Buchanan Brady Urological Institute Marburg, 149 600 North Wolfe Street Baltimore, Maryland 21287-2101 Chapter 106 Donald L. Gentle, M.D. Department of Urology University of California San Francisco Urology Clinic 400 Parnassus Avenue Room A605 San Francisco, California 94143 Chapter 119 Glenn S. Gerber, M.D. Associate Professor Department of Surgery The University of Chicago Hospitals 5841 South Maryland Avenue, MC 6038 Chicago, Illinois 60637 Chapter 21 Elmar Werner Gerharz, M.D. Department of Urology Julius Maximilians-University Medical School 97080 Wurzburg, Germany, and The Institute of Urology and Nephrology University College London Medical School London W1P 7PN, United Kingdom Chapter 80 Mohamed A. Ghoneim, M.D. Professor of Urology Director, Urology and Nephrology Center Mansoura, Egypt Chapter 23 J. M. Gil-Vernet, M.D. Catedra de Urologia Facultad de Medicina

C. Casanova 143 Urologia 08036 Barcelona, Spain Chapter 25 Bhagwant Gill, M.D. Eastchester Professional Center 1695 Eastchester Road Suite 501 Bronx, New York 10461-2330 Chapter 104 Inderbir S. Gill, M.D., MCh Head Section of Laparoscopic and Minimally Invasive Surgery Department of Urology/A100 The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195 Chapters 125 and 126 Peter J. Gilling Consultant Urologist Promed House P.O. Box 56 Tauranga, New Zealand Chapter 38 David A. Ginsberg, M.D. Assistant Professor of Urology Department of Urology University of Southern California/Norris Cancer Center 1441 Eastlake Avenue, Suite 7414 Los Angeles, California 90033 Chapters 37, 42, 44, 46, and 47 Amilcar Martins Giron, M.D. Associate Professor Division of Urology Hospital das Clínicas University of Sao Paulo School of Medicine Caixa Postal 11-273-9 CEP 05422-970 Sao Paulo, SP, Brazil Chapter 94 James F. Glenn, M.D. Professor of Surgery Department of Surgery Division of Urology University of Kentucky Medical Center 800 Rose Street Lexington, Kentucky 40536 Chapter 3 Irwin Goldstein, M.D. Boston Medical Center Boston, Massachusetts 02118 Chapter 72 Leonard G. Gomella, M.D. The Bernard W. Godwin, Jr. Associate Professor of Prostate Cancer Department of Urology Thomas Jefferson University School of Medicine 1025 Walnut Street, Suite 1102 Philadelphia, Pennsylvania 19107 Chapter 122 Edmond T. Gonzales, Jr., M.D. Chief of Pediatric Urology Department of Urology Baylor College of Medicine Scott Feigin Center, Suite 270 6621 Fannin Street Houston, Texas 77030-2399 Chapter 89 Ricardo Gonzalez, M.D. Professor and Chief Department of Pediatric Urology Children’s Hospital of Michigan Wayne State University School of Medicine 3901 Beaubien Boulevard Detroit, Michigan 48201 Chapter 108 Luis Gonzalez-Serva, M.D. Jet International M-211 P.O. Box 0200-11 Miami, Florida 33102 Chapter 28 Sam D. Graham, Jr., M.D. Louis McDonald Orr Professor of Urology

Department of Urology Emory University School of Medicine The Emory Clinic 1365 Clifton Road NE Atlanta, Georgia 30322 Chapter 34 Giovanni Grechi, M.D. Professor of Urology Department of Urology Clinica Urologica II Università degli Studi di Firenze Viale Pieraccini, 18 50139 Firenze, Italy Chapter 64 (Deceased) Mantu Gupta, M.D. Department of Urology Columbia-Presbyterian Medical Center New York, New York 10032 Chapter 117 Blake D. Hamilton, M.D. Division of Urology University of Utah Salt Lake City, Utah 84132 Chapters 123 and 130 Keith A. Harmon, M.D. Department of Urology The Mount Sinai Medical Center One Gustave L. Levy Place, Box 1272 New York, New York 10029 Chapter 111 James I. Harty Division of Urology University of Louisville School of Medicine Louisville, Kentucky 40292 Chapter 75 W. Hardy Hendren III, M.D. Department of Surgery Children’s Hospital 300 Longwood Avenue Boston, Massachusetts 02115 Chapter 105 William Forbes Hendry, M.D. Consultant Urologist St. Bartholomew’s Hospital and Royal Marsden Hospital 149 Harley Street London W1N 2DE, United Kingdom Chapter 59 Rudolf Hohenfellner, M.D. Department of Urology Johannes Gutenberg University Medical School Lagenbeckstrasse 1 55131 Mainz, Germany Chapter 76 Yves L. Homsy, M.D., F.R.C.S.C., F.A.A.P. Director Department of Pediatric Urology University of South Florida College of Medicine 2727 West Dr. Martin Luther King Boulevard Tampa, Florida 33607 Chapter 84 Andrew Huang, M.D. Chief Resident Department of Urology University of California, Davis School of Medicine 4301 X Street Suite 2210 Sacramento, California 95817 Chapter 32 Muta M. Issa, M.D., F.A.C.S. Assistant Professor of Urology Department of Surgery Division of Urology Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center 1365 Clifton Road NE Atlanta, Georgia 30322 Chapters 2 and 4 Alain Jardin, M.D. Professor and Chairman

Hopital de Bicêtre Université Paris Sud 78 Rue General Leclerc 94275 Kremlin Bicêtre, France Chapter 60 Michael A. S. Jewett, M.D. Division of Urology University of Toronto 200 Elizabeth Street, EN14-205 Toronto, Ontario M5G 2C4, Canada Chapter 63 Gerald H. Jordan, M.D. Professor of Urology Department of Urology Eastern Virginia Medical School 400 West Brambleton Avenue Suite 100 Norfolk, Virginia 23510 Chapters 65 and 131 David B. Joseph, M.D. Chief of Pediatric Urology Division of Urology Children’s Hospital of Alabama, and Professor Department of Surgery The University of Alabama 1600 7th Avenue, South Birmingham, Alabama 35233 Chapter 90 Byron Joyner, M.D. Division of Urology The Hospital for Sick Children 555 University Avenue Toronto, Ontario M5G 1X8, Canada Chapter 91 Steven A. Kaplan, M.D. Professor and Vice-Chairman Department of Urology Columbia Presbyterian Medical Center 161 Fort Washington Avenue New York, New York 10032 Chapter 112 Louis R. Kavoussi, M.D. Associate Professor of Urology Department of Urology The James Buchanan Brady Urological Institute Chief of Urology Department of Urology Johns Hopkins Bayview Medical Center 4940 Eastern Avenue Baltimore, Maryland 21224 Chapter 134 Thomas E. Keane, M.B., F.R.C.S.I., F.A.C.S. Associate Professor of Urology Section of Urology Emory University School of Medicine 1365 Clifton Road NE Atlanta, Georgia 30322 Chapters 2 and 4 Antoine E. Khoury, M.D. Associate Professor University of Toronto Department of Surgery/Division of Urology The Hospital for Sick Children 555 University Avenue Toronto, Ontario M5G 1X8, Canada Chapter 91 Joseph M. Khoury, M.D. Associate Professor of Urology Medical Director, Urodynamics and Reconstructive Urology Division of Urology University of North Carolina CB 7235 Burnett-Womack Building, Room 428 Chapel Hill, North Carolina 27599 Chapter 118 Stanley J. Kogan, M.D. 311 North Street Suite 310 White Plains, New York 10605 Chapter 104 Badrinath R. Konety, M.D. Chief Resident

Department of Urology University of Pittsburgh 3471 Fifth Avenue, Suite 700 Pittsburgh, Pensylvania 15213 Chapter 29 Ken Koshiba, M.D. Professor and Chairman Department of Urology Kitasato University School of Medicine Kitasato, Sagamihara Kangawa, 228 Japan, and Director Kitasato University Medical Center Kitamoto, Saitama, 364 Japan Chapter 113 Stephen A. Kramer, M.D. Head Section of Pediatric Urology Urology Professor in Honor of Dr. Utz Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 Chapters 102 and 109 Paul LaFontaine, M.D. Section of Urology The Emory Clinic 1365 Clifton Road NE Atlanta, Georgia 30322 Chapter 22 Gary E. Leach, M.D. Director Tower Urology Institute for Continence Cedar Sinai Medical Center, and Department of Urology University of Southern California 8631 West 3rd Street, Suite 915E Los Angeles, California 90048 Chapter 48 Jay B. Levy, M.D. Assistant Clinical Professor Division of Urology University of North Carolina School of Medicine, and Presbyterian Hospital Carolinas Medical Center, and 1718 East Fourth Street Suite 805 Charolotte, North Carolina 28204 Chapter 109 Ronald W. Lewis, M.D. Chairman Section of Urology Medical College of Georgia Room BA-8412 1120 15th Street Augusta, Georgia 30912 Chapter 71 John A. Libertino, M.D. Assistant Clinical Professor of Surgery Department of Surgery, Harvard University Medical School Boston, Massachusetts 02115, and Clinical Professor of Urology Tufts University School of Medicine Lahey Clinic Medical Center 41 Mall Road Burlington, Massachusetts 01805 Chapter 10 Mark R. Licht, M.D. Head Section of Sexual Dysfunction and Prosthetic Surgery Department of Urology The Cleveland Clinic Florida 3000 West Cypress Creek Road Fort Lauderdale, Florida 33309 Chapter 71 Vincenzo Li Marzi, M.D. Department of Urology Clinica Urologica II Università degli Studi di Firenze Viale Pieraccini, 18 50139 Firenze, Italy Chapter 64 James E. Lingeman, M.D. Director of Research Methodist Hospital of Indiana Institute for Kidney Stone Diseases, and Associate Clinical Instructor Department of Urology Indiana University School of Medicine 1801 North Senate Boulevard

Suite 655 Indianapolis, Indiana 46202 Chapter 120 Scott E. Litwiller, M.D. Assistant Professor Department of Urology University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, Texas 75235-9110 Chapter 49 Jorge L. Lockhart, M.D. Director Division of Urology Harborside Medical Center Suite 730 4 Columbia Drive Tampa, Florida 33606 Chapter 79 Bruce A. Lucas, M.D. Professor of Surgery Director Kidney Transplant Program Transplant Section, Department of Surgery University of Kentucky Medical Center 800 Rose Street Lexington, Kentucky 40536 Chapter 14 Tom F. Lue, M.D. Professor of Urology Department of Urology, U-575 University of California Box 0738 San Francisco, California 94143-0738 Chapter 68 and 69 Michael Marberger, M.D. Professor and Chairman Department of Urology University of Vienna Wahringer Gurtel 18-20 Vienna A-1090, Austria Chapter 19 Fray F. Marshall, M.D. Professor of Urology and Oncology Department of Urology The Johns Hopkins Medical Institutions 600 North Wolfe Street Baltimore, Maryland 21287-2101 Chapter 8 Jack W. McAninch M.S., M.D. Professor of Urological Surgery Department of Urology University of California, and San Francisco General Hospital 1001 Potrero Avenue, Room 3A20 San Francisco, California 94110 Chapter 13, 52, 73, and 74 Elspeth M. McDougall, M.D. Associate Professor of Urologic Surgery Washington University Medical School 10130 Wohl Clinic 4960 Children’s Place St. Louis, Missouri 63110 Chapter 129 Edward J. McGuire, M.D. Division of Urology University of Texas 6431 Fannin, Suite 6018 Houston, Texas 77030 Chapters 26 and 40 Mani Menon, M.D. Chairman Department of Urology Henry Ford Hospital 2799 West Grand Boulevard Detroit, Michigan 48202 Chapter 16 Hrair-George O. Mesrobian, M.D. Chief Division of Pediatric Urology Medical College of Wisconsin Medical Director, Section of Urology Children’s Hospital of Wisconsin

Suite 3035 8701 Watertown Plank Road Milwaukee, Wisconsin 53226 Chapter 98 Eugene Minevich, M.D. Instructor of Clinical Surgery Department of Surgery University of Cincinnati College of Medicine Division of Pediatric Urology Children’s Hospital Medical Center 3333 Burnet Avenue Cincinnati, Ohio 45229 Chapter 88 Anuar Ibrahim Mitre, M.D. Associate Professor Division of Urology Hospital das Clínicas University of Sao Paulo School of Medicine Caixa Postal 11-273-9 CEP 05422-970 Sao Paulo, SP, Brazil Chapter 114 James L. Mohler, M.D. Associate Professor of Surgery Adjunct Associate Professor of Pathology Division of Urology University of North Carolina School of Medicine CB 7235 Chapel Hill, North Carolina 27599-7235 Chapters 66 and 67 James E. Montie, M.D. George F. and Nancy P. Valassis Professor of Urologic Oncology Interim Head Section of Urology University of Michigan Medical Center 1500 East Medical Center Drive Ann Arbor, Michigan 48109-0330 Chapter 24 Robert G. Moore, M.D. Associate Professor of Surgery St. Louis University, and Department of Surgery Division of Urology St. Louis University Hospital 3635 Vista Avenue at Grand Boulevard P.O. Box 15250 St. Louis, Missouri 63110-0250 Chapter 128 Allen F. Morey, M.D., F.A.C.S. Clinical Assistant Professor of Surgery (Urology) Department of Surgery (Urology Service) Uniformed Services University of the Health Sciences, and Attending Urologist Brooke Army Medical Center Fort Sam Houston, Texas 78258 Chapters 13, 52, 73, and 74 John J. Mulcahy, M.D., Ph.D. Professor of Urology Department of Urology Indiana University Medical Center 1001 West 10th Street Indianapolis, Indiana 46202 Chapter 70 John Mulhall Department of Urology Loyola University Medical Center Maywood, Illinois 60153 Chapter 72 Rolf Muschter, M.D., PhD Associate Professor Department of Urology Grosshadern Hospital of Ludwig-Maximilians University of Munich Marchioninistrasse 15 D-81377 Munich, Germany Chapter 137 John Naitoh, M.D. Clinical Instructor Department of Urology U.C.L.A. School of Medicine Los Angeles, California 90095-1738 Chapters 54 and 55 Kenneth S. Nitahara, M.D.

Department of Urology University of California Box 0738 San Francisco, California 94143-0738 Chapters 68 and 69 Victor W. Nitti, M.D. Assistant Professor Director of Neurology and Female Urology Department of Urology New York University Medical Center 540 First Avenue New York, New York 10016 Chapter 45 H. Norman Noe Department of Urology LeBonheur Children’s Medical Center Memphis, Tennessee 38120 Chapter 95 Kamil Noordin, M.D. Universiti Kebangsaan Malaysia 43600 UKM, Bangi Selangor Darul Ehsan, Malaysia Chapter 121 Andrew C. Novick, M.D. Chairman Department of Urology The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195 Chapter 6 David M. Nudell, M.D. Department of Urology University of California 533 Parnassus Avenue, U-575 San Francisco, California 94110 Chapters 52 and 73 David P. O’Brien III, M.D. Professor of Surgery (Urology) Section of Urology Emory University School of Medicine The Emory Clinic 1365 Clifton Road NE Atlanta, Georgia 30322 Chapter 1 Michael P. O’Leary, M.D. Department of Surgery Division of Urology Harvard University Medical School, and Division of Urology Brigham and Women’s Hospital 45 Francis Street ASB 11-3 Boston, Massashusetts 02115 Chapter 133 Michael L. Paik, M.D. Resident Department of Urology University Hospitals of Cleveland/Case Western Reserve University School of Medicine 11100 Euclid Avenue Cleveland, Ohio 44106 Chapter 11 Farhad Parivar, M.D., F.R.C.S.(Ed) Chief Resident Department of Urology University of Calfornia, San Francisco San Francisco, California 94143, and Kaiser Permanente Medical Center 27400 Hesperian Boulevard Hayward, California 94545 Chapter 74 Anup Patel, M.D., M.S., F.R.C.S. Clinical Instructor in Urology University of California, Los Angeles Los Angeles, California 90095, and 58 Whiteadder Way Clippers Quay London E14 9UR, United Kingdom Chapter 121 Aaron P. Perlmutter, M.D., Ph.D. Director Brady Prostate Center Department of Urology The New York Hospital-Cornell Medical Center

525 East 68th Street New York, New York 10021 Chapter 136 John A. Petros, M.D. Assistant Professor and Director of Urologic Research Department of Surgery Division of Urology Emory University School of Medicine 1365 Clifton Road, NE Atlanta, Georgia 30322 Chapter 22 Thomas J. Polascik, M.D. Instructor in Urology The James Buchanan Brady Urological Institute The Johns Hopkins Medical Institutions 600 North Wolfe Street Baltimore, Maryland 21287 Chapter 8 Jon L. Pryor, M.D., M.S. Associate Professor Departments of Urologic Surgery, Cell Biology and Neuroanatomy, and Obstetrics and Gynecology University of Minnesota P.O. Box 394 UMHC 420 Delaware Street SE Minneapolis, Minnesota 55455, and Director Center for Men’s Health and Infertility Reproductive Health Associates 360 Sherman Street, Suite 160 St. Paul, Minnesota 55102 Chapter 57 Haakon Ragde, M.D. Director Department of Prostate Brachytherapy Urological Services Pacific Northwest Cancer Foundation Northwest Hospital 1560 North 115th Street Seattle, Washington 98133 Chapter 35 Shlomo Raz, M.D. Professor of Surgery Department of Urology U.C.L.A. School of Medicine Box 951738 Los Angeles, California 90024 Chapters 37, 42, 44, 46, and 47 Martin I. Resnick, M.D. Lester Persky Professor and Chairman Department of Urology University Hospitals of Cleveland Case Western Reserve University School of Medicine 11100 Euclid Avenue Cleveland, Ohio 44106 Chapter 11 Alan B. Retik, M.D. Department of Urology Children’s Hospital 300 Longwood Avenue Mailstop HU-216 Boston, Massachusetts 02115 Chapter 99 Hubertus Riedmiller, M.D. Professor of Urology Department of Urology Julius Maximilians-University Medical School Josef Schneider Strasse 2 97080 Wurzburg, Germany Chapter 80 Michael L. Ritchey, M.D. Division of Surgery and Pediatrics University of Texas Medical School 6431 Fannin, Suite 5.258 Houston, Texas 77030 Chapter 85 J. Thomas Rosenthal, M.D. Professor of Urology Department of Urology U.C.L.A. School of Medicine 10833 LeConte Avenue Los Angeles, California 90095-1731 Chapter 9

David R. Roth, M.D. Associate Professor Scott Department of Urology Baylor College of Medicine, and Department of Pediatric Urology Texas Children’s Hospital MC 3-3430 6221 Fannin Street Houston, Texas 77030-2399 Chapter 103 Eric S. Rovner, M.D. Assistant Professor of Urology Division of Urology Department of Surgery Hospital of the University of Pennsylvania 1 Rhoads 3400 Spruce Street Philadelphia, Pennsylvania 19104 Chapters 37, 42, 44, 46, and 47 Eduardo Sanchez de Badajoz, M.D. Profesor Titular de Urologia Universidad de Malaga Strachan 4 29015 Malaga, Spain Chapter 124 W. Holt Sanders, M.D. Assistant Professor Department of Surgery Section of Urology Emory University School of Medicine 1365 Clifton Road NE Atlanta, Georgia 30322 Chapter 5 Pablo J. Santamaria, M.D. Clinical Assistant Professor Section of Urology Emory University School of Medicine Atlanta, Georgia 30322, and Middle Georgia Urology Associates, PC Erin Office Park Suite 11 Dublin, Georgia 31021 Chapter 4 Richard P. Santarosa, M.D. J. Bentley Squier Urological Clinic Columbia University College of Physicians and Surgeons New York, New York 10032 Chapter 112 Anthony J. Schaeffer, M.D. Professor and Chairman Department of Urology Northwestern University Medical School Tarry Building 1-715 303 East Chicago Avenue Chicago, Illinois 60611-3008 Chapter 12 Bernd J. Schmitz-Dräger, M.D., Ph.D. Professor of Urology Department of Urology Heinrich-Heine-University Moorenstrasse 5 D-40225 Düsseldorf, Germany Chapter 20 Douglas Schow, M.D. Department of Urologic Surgery, University of Minnesota 360 Sherman Street, Suite 160 P.O. Box 394 UMHC 420 Delaware Street, SE Minneapolis, Minnesota 55455, and Center for Men’s Health and Infertility Reproductive Health Associates 360 Sherman Street, Suite 160 St. Paul, Minnesota 55102 Chapter 57 Daniela Schultz-Lampel, M.D. Adult Department of Urology and Pediatric Urology Klinikum Wuppertal GmbH University of Witten/Herdecke Medical School Heusnerstrasse 40 Wuppertal, Germany Chapter 82 Joseph W. Segura, M.D.

Professor of Urology Department of Urology Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 Chapter 115 Richard I. Silver, M.D. Assistant Professor of Urology and Pediatrics Department of Pediatric Urology Thomas Jefferson University Philadelphia, Pennsylvania 19107-5083 Chapter 106 Donald G. Skinner, M.D. Department of Urology University of Southern California/Norris Comprehensive Cancer Center 1441 Eastlake Avenue, Suite 7414 Los Angeles, California 90033 Chapter 83 Steven J. Skoog, M.D. Professor of Surgery and Pediatrics Division of Urology The Oregon Health Sciences University 3181 South West Sam Jackson Park Road Portland, Oregon 97201 Chapter 107 Arthur D. Smith, M.D. Professor Albert Einstein College of Medicine Bronx, New York 10461, and Chairman Department of Urology Long Island Jewish Medical Center 270-05 76th Avenue New Hyde Park, New York 11040 Chapter 117 Edwin A. Smith, M.D. Department of Surgery Emory University School of Medicine Egleston Children’s Hospital Atlanta, Georgia 30322 Chapter 97 Joseph A. Smith, Jr., M.D. Professor and Chairman Department of Urologic Surgery Vanderbilt University Medical Center A-1302 Medical Center North Nashville, Tennessee 37232-2765 Chapter 33 Warren Snodgrass, M.D. Methodist Children’s Hospital 3606 21st Street, Suite 207 Lubbock, Texas 79410 Chapter 101 John P. Stein, M.D. Department of Urology, MS 74 University of Southern California Norris Cancer Center 1441 Eastlake Avenue, Suite 7414 Los Angeles, California 90033 Chapter 83 Gary D. Steinberg, M.D. Clinical Assistant Professor Department of Surgery Section of Urology The University of Chicago Hospitals MC 6038 5841 South Maryland Avenue Chicago, Illinois 60637 Chapter 17 Marshall L. Stoller, M.D. Department of Urology University of California San Francisco Urology Clinic 400 Parnassus Avenue Room A605 San Francisco, California 94143 Chapter 119 Lynn Stothers, M.D., M.H.S.C. Department of Surgery St. Paul’s Hospital Vancouver, British Columbia V52 4E3, Canada Chapter 39

Stevan B. Streem, M.D. Head Section of Stone Disease and Endourology Department of Urology The Cleveland Clinic Foundation/A100 9500 Euclid Avenue Cleveland, Ohio 44195 Chapter 110 Urs E. Studer, M.D. Professor and Chairman Department of Urology University of Berne 3010 Bern, Switzerland Chapter 81 Ray E. Stutzman, M.D. Associate Professor of Urology Department of Urology The Johns Hopkins University 601 North Caroline Street Baltimore, Maryland 21287 Chapter 31 David A. Swanson, M.D., F.A.C.S. Professor and Chairman (Ad Interim) Department of Urology The University of Texas M.D. Anderson Cancer Center 1515 Holcombe Boulevard Box 110 Houston, Texas 77030 Chapter 62 Rodney J. Taylor, M.D. Professor of Surgery Section of Urologic Surgery University of Nebraska Medical Center 600 South 42nd Street Omaha, Nebraska 68198-2360 Chapter 15 H. Tazaki Department of Urology New York Medical College Valhalla, New York 10595 Chapter 132 Alexis E. Te, M.D. J. Bentley Squier Urological Clinic Columbia University College of Physicians and Surgeons New York, New York 10032 Chapter 112 Anthony J. Thomas, Jr., M.D. Head Section of Male Infertility Department of Urology The Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, Ohio 44195 Chapter 58 Joachim W. Thüroff, M.D. Professor and Chairman Department of Urology Johannes Gutenberg University Medical School Langenbeckstrasse 1 55131 Mainz, Germany Chapter 82 Paul J. Turek, M.D. Assistant Professor In-Residence Department of Urology University of California Box 0738, Room U-575 533 Parnassus Avenue San Francisco, California 94143-0738 Chapter 56 Toyoaki Uchida, M.D. Assistant Professor Kitasato University School of Medicine 1-15-1, Kitasato, Sagamihara Kanagawa 228, Japan Chapter 113 Jeffrey Wacksman, M.D. Associate Professor Department of Surgery University of Cincinnati Medical Center, and Division of Pediatric Urology Children’s Hospital Medical Center

3333 Burnet Avenue Cincinnati, Ohio 45229-3039 Chapter 88 R. Dixon Walker, M.D. Professor of Surgery and Pediatrics Department of Surgery Division of Urology University of Florida College of Medicine Box 100247 JHMHC Gainesville, Florida 32610 Chapter 93 George D. Webster, M.B., F.R.C.S. Professor of Urology Surgery Department of Surgery Division of Urology Duke University Medical Center Box 3146 Durham, North Carolina 27710 Chapters 51 and 77 O. Lenayne Westney, M.D. Division of Urology University of Texas Health Science Center 6431 Fannin, Suite 6.018 Houston, Texas 77030 Chapter 85 Howard N. Winfield, M.D. Chief of Urology Department of Urology VA Palo Alto Health Care System, and Palo alto, California 94304-1290, and Associate Professor Department of Urology, S-287 Stanford University School of Medicine Stanford University Medical Center Stanford, California 94305-5118 Chapters 123 and 130 J. Stuart Wolf, Jr., M.D. Chief Section of Urology Ann Arbor Veterans Affairs Medical Center, and Assistant Professor of Surgery (Urology) University of Michigan Hospital 2916 Taubman Center 1500 East Medical Center Drive Ann Arbor, Michigan 48109-0330 Chapter 129 E. James Wright, M.D. Assistant Professor of Surgery Department of Surgery Division of Urology University of Kentucky 800 Rose Street Lexington, Kentucky 40536 Chapter 51 Theodros Yohannes, M.D. Resident Division of Urology University of Louisville School of Medicine Louisville, Kentucky 40292 Chapter 75 Philippe E. Zimmern, M.D. Associate Professor Department of Urology University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard Dallas, Texas 75235-9110 Chapter 49

Preface It has been nearly 30 years since the first edition of Urologic Surgery was published in 1969. Since then, the field of urology has undergone massive transformation. We have witnessed advances and improvements in virtually every aspect of our surgical craft. An exhaustive survey of improved capabilities would include reconstructive techniques, endourology, laparoscopic surgery, mastery of multiple energy sources for transurethral surgery, and tremendous strides in pediatric urology. However, certain fundamentals remain constant. As stated in the preface to the first edition, “Urologists are—first and foremost—surgeons.” The second edition expressed the hope that the volume “constitute the basis for further advances and that it be rendered obsolete by progress in urology.” In the third edition, it was acknowledged that progress in urology was paralleled by “advances in anesthesia, antibiosis, medical techniques, and diagnostic capability.” The fourth edition reaffirmed that “although many textbooks of urology and a number of excellent atlases dealt with surgical procedures, no single volume combined the virtues of text and illustrations that amplify the fundamental considerations and technical aspects” of urologic surgery. In retrospect, these thoughts are verities. We are still seeing rapid advances in our specialty. Perhaps there is no greater compliment to a medical publication than to admit to obsolesence in only a matter of a few months or years, as the result of our expanding capabilities. However, it is our expressed hope that this volume will serve as a ready reference for medical students, residents in training, and even our colleagues with the most advanced surgical skills. On a personal note, it is with great satisfaction that the editorship of Urologic Surgery passes on to Sam D. Graham, Jr., M.D., my capable friend, respected colleague, and former resident. He has assembled an outstanding group of authors for the fifth edition, and I anticipate with pleasure the prospect of further editions. James F. Glenn, M.D. Lexington, Kentucky

Acknowledgments The editors would like to thank the following for their tireless efforts in bringing this book to completion: Tawn Edwards for organization and editing, Sandra Spruill for editing and formatting, and Jennifer Smith for editing the artwork. Finally, we are greatly indebted to Craig Percy at Lippincott–Raven Publishers for his guidance and help in bringing this project to fruition.

Chapter 1 Cushing's Disease and Syndrome Glenn’s Urologic Surgery

Chapter 1 Cushing's Disease and Syndrome David P. O'Brien III

D. P. O'Brien III: Section of Urology, Emory University School of Medicine, The Emory Clinic, Atlanta, Georgia 30322.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

The association of pituitary lesions in patients with hirsutism, proximal muscle weakness, round plethoric faces, increased supraclavicular and infrascapular fat pads, thin skin, and other less frequent signs such as acne, purple abdominal striae, and psychiatric symptoms (Cushing's syndrome) has been known as Cushing's disease since the original description relating the illness to pituitary lesions by Cushing in 1912. It was many years later that the syndrome was found to be caused by cortisol excess, and later still it was found that there were multiple etiologies for this excess, including ectopic production of ACTH in adrenal tumors and tumors arising in other organs, including some that may be ectopic sources for corticotropin-releasing factor. The first planned operation for adrenal tumor was performed in 1914, with removal of a 17-cm adrenal adenoma and subsequent cure of hyperadrenocorticism. Initial attempts at curative pituitary surgery for Cushing's disease were short lived for lack of the necessary technology, but with modern microsurgical techniques, transsphenoidal pituitary microsurgery has become the treatment of choice. Adrenal surgery for Cushing's syndrome has in the past varied from partial to total adrenalectomy, depending on the availability of supplemental glucocorticoids. The etiologies of Cushing's syndrome are summarized in Table 1-1 and Fig. 1-1. In general, the pathophysiology of these disorders involves the production of excessive ACTH from pituitary adenomas or from ectopic sources, benign adrenal tumors and macronodular and micronodular adrenal hyperplasia, which usually produce excessive glucocorticoids only, whereas many adrenal malignancies also produce excessive androgens and mineralocorticoids. Iatrogenic administration of glucocorticoids is also a common etiology of Cushing's syndrome.

TABLE 1-1. Etiology of Cushing's syndrome

FIG. 1-1. Causes of Cushing's syndrome: (A) adrenocortical tumor; (B) adrenocarotical hypertension of hypothalamic origin; (C) adrenocortical hyperplasia caused by ectopic ACTH production; and (D) exogenous cortisol administration.

DIAGNOSIS The sine qua non for the diagnosis of Cushing's syndrome is an abnormality of the plasma or urinary cortisol and/or ACTH. Because these studies are extremely variable, sometimes fluctuating daily and frequently negative, a high degree of suspicion usually leads the clinician to evaluate the patient with an overnight dexamethasone suppression test, a metapyrone stimulation test, or corticotropin-releasing factor stimulation. Imaging studies such as CT scanning, adrenal arteriography and venography, MRI (with and without gadolinium), and scintigraphy have also been used with some success. Because of the lack of sensitivity and specificity of these studies, it would also be common to perform repetitive evaluations in many patients.

INDICATIONS FOR SURGERY Indications for surgery of the adrenal gland in patients with Cushing's syndrome include adrenal adenoma, adrenal hyperplasia, and adrenal carcinoma. Bilateral adrenalectomy has been suggested for those patients with micronodular adrenal hyperplasia, macronodular hyperplasia, patients with unknown sources of ACTH, and those with incurable pituitary Cushing's syndrome. 3,6

ALTERNATIVE THERAPY Treatment of the aforementioned causes of Cushing's disease all require surgical management except for the iatrogenic administration of glucocorticoids.

SURGICAL TECHNIQUE The posterior approach to the adrenal glands is described here; the other surgical approaches to the adrenals are described in Chapter 2, Chapter 3, Chapter 4 and Chapter 132. The posterior approach to the adrenal gland was first described by Young in 1936. Most authors would reserve this technique for small adrenal

adenomas or adrenal hyperplasia, i.e., noncancerous states with small lesions. 1,6 It is also the ideal method for bilateral adrenal exploration because the patient does not have to be repositioned. The patient is placed in the prone position under general endotracheal anesthesia. Appropriate padding is used to pad the chest, anterior pelvis, and legs (Fig. 1-2).

FIG. 1-2. Posterior approach for total adrenalectomy showing position of patient on operating table and bilateral incisions over 11th ribs. The medial end of the incision should be extended superiorly along the paravertebral musculature.

Several incisions have been described, and we prefer the hockey-stick incision, which begins just lateral to the midline at the ninth or tenth rib and extends downward and then laterally over the 11th or 12th ribs. Alternatively, an 11th rib incision or supracostal incision is used. 4,6 In the supracostal incision, the rib is spared, the intercostal muscles are divided, the pleura is swept away from the rib, and the retroperitoneum is entered ( Fig. 1-3). In the other approaches, the latissimus dorsi and sacrospinalis muscles are divided and retracted medially. The incision is extended through the periosteum of the 12th rib, which is resected close to the vertebral body (Fig. 1-4). The deep periosteum is incised, avoiding the neurovascular bundle, while laterally the abdominal muscles are divided and the pleura dissected from the diaphagm, exposing Gerota's fascia. As an alternative, in the transthoracic approach, the exposed pleura and diaphragm are incised, again exposing Gerota's fascia. It should be noted that the decision on which rib space to utilize (10, 11, or 12) depends on the position of the adrenal as estimated by the imaging studies, and it would be rare to be too high with the placement of the incision. In bilateral adrenalectomy, a Finochetti retractor can be placed for exposure ( Fig. 1-5).

FIG. 1-3. (A) Mobilization of the rib in the supracostal approach. The intercostal muscle is divided, with a finger behind to protect the deep structures. (B) Extrapleural fascia dissects away from the posterior surface of the rib with exposure of the insertion of the diaphragm and the pleura.

FIG. 1-4. Rib resection in any of the surgical approaches to the adrenal involves incision and elevation of the periosteum (A) with mobilization and resection of the rib as medially as is convenient (B).

FIG. 1-5. Simultaneous bilateral exposure of the adrenals is facilitated by use of a self-retaining retractor.

Gerota's fascia is incised, and the perinephric fat is swept away or incised superiorly, exposing the adrenal. Inferior retraction 3,6 of the kidney aids this portion of the dissection (Fig. 1-6). On the left side, the resection of the adrenal proceeds from laterally and superiorly to medially and inferiorly, where the main veins are ligated, the largest draining into the renal vein while the major adrenal artery arises from the main renal artery. On the right, the dissection is similar, but care is taken medially where the short right adrenal vein (and occasional accessory veins) empties into the vena cava. The largest adrenal artery usually arises from the main renal artery.

FIG. 1-6. With the subcostal approach (A), the kidney must be retracted inferiorly (B) to give access to the adrenal, permitting application of metal clips (C) for control and division of vessels.

If the pleura is entered, a temporary “pull-out” Robinson catheter (14 to 18 F) is placed, the pleura sutured, and the musculature approximated. While deep inspiration is maintained by the anesthesiologist, and the catheter is placed in an underwater seal, the catheter is quickly removed after all air bubbling in the water ceases. The remainder of the wound closure is completed, and a dressing applied.

OUTCOMES Complications Surgical complications following adrenal surgery for Cushing's syndrome include not only those that pertain to routine retroperitoneal surgery, e.g., blood loss and infection, but also those complications specific to patients with hormonal imbalances. It should be mentioned that a chest x-ray in the recovery room is essential after any flank surgery in which the patient has been placed in the lateral or prone position, to evaluate the patient's pulmonary status for atelectasis and/or pneumothorax when the pleura has been violated. The occurrence of adrenocortical insufficiency should be kept uppermost in the clinician's mind even in the patient who has had a unilateral adrenalectomy. The use of supplemental glucocorticoids and mineralocorticoids is commonplace in these complex patients, whereas those in whom adrenalectomy is not curative need further evaluation, looking for ectopic sites of disease, either benign or malignant. Postoperative wound healing may be impaired, and the infection rate has been described to be between 4% and 21%. Other complications, e.g., thromboembolism, may be related to Cushing's syndrome or the associated obesity. Results The operative mortality for adrenalectomy in patients with Cushing's syndrome has been reported to be 2% to 6%, and the occurrence of Nelson's syndrome (the development of invasive pituitary tumors after adrenalectomy) seems minimal. Most patients with pituitary Cushing's syndrome who have poor results from pituitary surgery are cured with bilateral adrenalectomy, and a successful outcome should occur after adenalectomy in the patient with adrenal hyperplasia or an adrenal adenoma correctly diagnosed. In the small number of patients with adrenal malignancy, sugery may be curative if the tumor is localized, but metastatic disease responds poorly to the combination of adrenalectomy, radiation, and chemotherapy. It still remains, however, that management of these complicated endocrinologic patients is a continuing challenge for the urologic surgeon. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Angermeier KW, Montie JE. Perioperative complications of adrenal surgery. Urol Clin North Am 1989;16(3):597–606. Bennett AH, Cain JP, Dluhy RG, et al. Surgical treatment of adrenocortical hyperplasia: 20 year experience. J Urol 1973;109:321–324. Bertagna C, Orth DN. Clinical and laboratory findings and results of therapy in 58 patients with adrenocortical tumors admitted to a single medical center. Am J Med 1981;1:855–875. Bloom LS, Libertino JA. Surgical management of Cushing's syndrome. Urol Clin North Am 1989;16(3):547–565. Cushing H. The pituitary body and its disorders. Philadelphia: JB Lippincott, 1912. Glenn JF. Adrenal surgery. In: Glenn JF, ed. Urologic surgery, 4th ed. Philadelphia: JB Lippincott, 1993;1–21.

Chapter 2 Adrenal Adenoma and Carcinoma Glenn’s Urologic Surgery

Chapter 2 Adrenal Adenoma and Carcinoma Muta M. Issa and Thomas E. Keane

M. M. Issa: Department of Surgery, Division of Urology, Emory University School of Medicine, Atlanta, Georgia 30322. T. E. Keane: Department of Urology, Emory University Hospital, Atlanta, Georgia 30322.

Epidemiology and Natural History Diagnosis Biochemical Evaluation Radiologic Evaluation Fine Needle Aspiration Cytology Other Evaluation Indications for Surgery Surgical Technique Surgical Approaches to the Adrenal Gland General Considerations The Posterior, Modified Posterior, and Posterior Transthoracic Approaches Lateral Flank Approach Anterior Transabdominal and Thoracoabdominal Approaches Laparoscopic Approach Outcomes Complications Results Chapter References

Adrenal tumors present either as a result of their clinical symptoms or as incidental findings during radiologic imaging studies. The nomenclature “adrenal incidentaloma” describes adrenal tumors discovered inadvertently by radiologic imaging in the absence of clinical indication. The objectives of this chapter are to discuss the various aspects of adrenal incidentaloma and adrenocortical carcinoma with regard to the epidemiology, natural history, investigation, diagnosis, and treatment with particular emphasis on their surgical management. Aldo-steronoma, pheochromocytoma, Cushing's disease and syndrome, and laparoscopic adrenalectomy have been purposely excluded from this chapter because they are reviewed in detail in Chapter 1, Chapter 3, Chapter 4, and Chapter 132.

EPIDEMIOLOGY AND NATURAL HISTORY The prevalence of adrenal incidentalomas is estimated to approach 2%, 3 similar to the 1.9% figure of autopsy series, considering the increasing and widespread use of various radiologic images such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). 1,3,10 The incidence of adrenocortical carcinoma, on the other hand, is extremely rare, with an estimated annual rate of 0.00006% to 0.00017% in the population, i.e., approximately one in a million. 4 Because the majority of adrenal carcinomas present late, and approximately half are hormonally active, it is calculated that the chance of detecting an adrenocortical carcinoma is one in 1,700 adrenal incidentalomas. Adrenocortical carcinomas occur in all age groups but are most common in the fifth to seventh decades of life. The vast majority of adrenal incidentalomas are benign, remain asymptomatic, and have favorable outcome. On the other hand, the opposite is true in adrenocortical carcinoma, which is an aggressive malignant disease with ominous prognosis. The majority present late with local invasion, regional lymph node involvement, or distant metastases (stages III and IV) rather than early, i.e., confined to the adrenal gland (stages I and II). Approximately half of these tumors are hormonally active and release excessive secretions of glucocorticoids, estrogens, androgens, and, rarely, mineralocorticoids.

DIAGNOSIS Biochemical Evaluation Incidentally discovered adrenal tumors found by radiologic imaging can exhibit hormonal activity that initially may not be clinically apparent. Subsequent detailed endocrine clinical assessment may reveal, for the first time, clinical features suggestive of hormonal activity. In these patients, further evaluation with appropriate biochemical testing is indicated according to the clinical suspicion. On the other hand, 15% of adrenal incidentalomas may be totally asymptomatic in a setting of subclinical hormonal activity. Much debate currently exists regarding the recommended biochemical evaluation in this latter group. It is to be emphasized that before embarking on an extensive and exhaustive biochemical evaluation, one must consider the expected detection rate and cost/benefit ratio of such an empirical approach. The overall low prevalence of hormonal activity in these adrenal incidentalomas and the type of hormonal dysfunction likely to be encountered call for a more selective approach. The calculated possibility of uncovering a pheochromocytoma or aldosteronoma is one per 15 adrenal incidentalomas, and for a glucocorticoid-producing adenoma or adrenal carcinoma, it is one per 1,700 to 2,800. 9 It therefore seems reasonable to initiate biochemical screening for primary hyperaldosteronism with serum potassium first and for pheochromocytoma with urinary VMA, catecholamines, and metanephrines. Biochemical assessment for glucocorticoid and sex hormones should be reserved for patients with clinical features suggestive of such hormonal dysfunction. Radiologic Evaluation Computerized tomography (CT) is the standard radiologic imaging modality for adrenal tumors. It is utilized to delineate the anatomy and characterize the morphology of adrenal tumors. Although CT is reliable in the diagnosis of certain benign adrenal masses such as myelolipoma ( Fig. 2-1) and simple cysts, its dependability in accurately differentiating between benign and malignant tumors is limited. Certain CT features suggestive of a malignant process include a tumor >6 cm, inhomogeneity, irregular contours, thickened walls, and calcification, as illustrated in Fig. 2-2.

FIG. 2-1. Computerized tomography appearance of right myelolipoma (marked by white arrow), which has combined tissue characterization of muscle and fat.

FIG. 2-2. Computerized tomographic appearance of locally advanced left adrenocortical carcinoma (marked by white arrows), illustrating its huge size, irregular posterior borders, and inhomogeneity of its anteromedial portion.

Magnetic resonance imaging (MRI) is increasingly becoming a valuable radiologic tool in the evaluation of adrenal tumors. The MRI provides better visual clarity and resolution than CT imaging. Furthermore, the utilization of coronal planes in MRI ( Fig. 2-3 and Fig. 2-4) offers superior images for understanding anatomy and for assessing vena cava involvement. More recent advances in the MRI technique have revealed encouraging results in distinguishing between benign and malignant adrenal tumors. 2,5,6,7 and 8 This is achieved by the manipulation of fat and water MRI signals (chemical shift technique), which allows for the detection of microlipids within the tumor; these are a hallmark for benign adrenal adenomas. A significant subtraction of microlipids from the adrenal mass tissue on MRI as illustrated in Fig. 2-5 implies a benign adrenal adenoma. Conversely, lack of microlipid subtraction from the adrenal tissue, i.e., an area of hyperintensity, correlates with the presence of malignancy (Fig. 2-6). Further clinical experience and future refinements of this technique hold a real potential for MRI to become the imaging modality of choice in the evaluation of adrenal masses.

FIG. 2-3. Magnetic resonance imaging (coronal view) of a left adrenocortical carcinoma (marked by white arrow) illustrating its huge size, lobular contour, irregular borders, inhomogeneity, and invasion of the upper pole of the left kidney.

FIG. 2-4. Magnetic resonance imaging (coronal view) of a left adrenocortical carcinoma (marked by white arrow) illustrating its huge size, inhomogeneity, and local invasion both superiorly and inferiorly. The entire uninvolved length of the inferior vena cava (marked by black arrows) can be clearly visualized.

FIG. 2-5. (A) Magnetic resonance imaging appearance of an adrenal adenoma illustrating its isointense appearance on T 1-weighted image and (B) its hypointense appearance following the dramatic substraction of its microlipid signal. White arrows point to the adrenal mass, and the black arrow to the inferior vena cava. (Courtesy of Roger Y. Shifrin, M.D.)

FIG. 2-6. (A) Magnetic resonance imaging appearance of a small isointense malignant lesion (marked by white arrow) in a hypointense right adrenal adenoma. This image illustrates the value of MRI in accurately detecting a small metastatic deposit in an adenomatous gland. (B) Cross-section gross appearance of the adrenal gland following surgical excision illustrating the lesion (marked by black arrow). The lesion was a deposit from primary bronchogenic adenocarcinoma. (Courtesy of Roger Y. Shifrin, M.D.)

Fine Needle Aspiration Cytology When clinical, biochemical, and radiologic evaluation fail to provide sufficient diagnostic information for an appropriate management decision, fine needle aspiration (FNA) cytology may play a role. Difficulty in tissue sampling, preparation, and interpretation can lead to false-negative results and limit its reliability. Potential indications for FNA cytology include atypical adrenal cysts, i.e., with thick, irregular walls or inhomogeneous fluid content, and differentiation between primary and metastatic deposits in individual cases. Other Evaluation Recent advances in noninvasive radiologic imaging such as CT and MRI have replaced the need for scintigraphy as well as NP-59 and MIBG, venography, and arteriography. The previously recommended use of venography in the assessment of inferior vena caval involvement has been superseded by the less invasive MRI. In rare circumstances, preoperative arteriography may have a role in delineating the vascular supply of large adrenal masses to aid in planning surgical resection.

INDICATIONS FOR SURGERY Generally, there are two definitive indications for surgical excision: (a) symptomatic and hormonally active adrenal tumor and (b) adrenal carcinoma. The dilemma arises in patients with asymptomatic adrenal tumors and unconfirmed diagnosis despite extensive evaluation. These constitute a gray zone into which fall the majority (>80%) of adrenal incidentalomas. Conservative management of these patients by observation and serial imaging poses certain concerns about the possibility of delayed or missed diagnosis of a biologically active lesion. To date, the controversies continue with no clear answers to the primary concern of whether or not a tumor is malignant. As a result of the available epidemiologic data, the influence of radiologic features, and FNA cytology, certain guidelines are becoming available for management decisions in an attempt to minimize unnecessary surgical excisions without compromising the final outcome. Surgical resection continues to be the treatment of choice for adrenal masses with features suggestive of malignancy such as large size (>6 cm), inhomogeneity, irregular contours, thickened walls, calcification, regional lymphadenopathy, lack of microlipids on chemical-shift MRI, and suspicious FNA cytology. Conservative management with observation and serial imaging is recommended for small tumors (100 µg total catecholamines per 24 hours overall, with epinephrine >20 µg and norepinephrine >80 µg, per 24 hours, respectively) or catecholamine degradation products such as metanephrines (>1.3 mg per 24 hours) and vanillymandelic acid (>6.5 mg per 24 hours); a value of >9.0 mg/24 hours determines over 90% of patients with pheochromocytomas. 1 Total catecholamines, such as epinephrine, norepinephrine, and dopamine, can also be measured in the blood. Although urinary catecholamines have a higher specificity than plasma catecholamines, either may give misleadingresults because of other medical conditions (acute alco-holism, hypothyroidism, or volume depletion) or in-terfering medications. A combined free plasma norepinephrine and epinephrine level in excess of 950 pg/ml has a diagnostic sensitivity of 94% and a specificity of 97%. The radioenzymatic assay is sensitive to the circumstances in which the blood was collected, and this should be carefully controlled by having the patient in a fasting state and supine for at least 30 minutes before blood sampling through a large-bore needle placed at least 20 minutes beforehand to avoid a spurious catecholamine elevation caused by pain or apprehension. Baseline plasma norepinephrine and epinephrine levels of more than 2,000 pg/ml (norepinephrine >2,000pg/ml, epinephrine >200 pg/ml) indicate a pheochromocytoma. Failure of these levels to decline to less than 500 pg/ml after oral clonidine is also indicative of tumor. Stimulation or provocation tests of patients suspected of this diagnosis can be extremely hazardous and are not recommended. Despite the reliance on diagnostic measurements of urinary catecholamines and their degradation products, newer agents have been tried to delineate borderline patients. Plasma catecholamines are measured after administration of clonidine or pentolinium tartrate. Patients with pheochromocytoma experience no significant decrease in circulating catecholamines with either agent, as opposed to normal patients, who do. Imaging Techniques A variety of imaging techniques are available for the detection of pheochromocytoma. Several decades ago, angiography and venography were the imaging

techniques of choice. However, along with a low sensitivity, these modalities carried a significant morbidity and a risk of provoking a hypertensive crisis if the possibility of pheochromocytoma had not been considered. The most frequent initial diagnostic modality currently is the abdominal CT scan, which, as a result of its widespread usage, has led to a significant increase in the diagnosis of asymptomatic adrenal lesions. This test has an accuracy rate for diagnosis of pheochromocytomas of over 90% and can be performed in patients who have not previously undergone a blockade, although unenhanced CT has been recommended as the initial localizing study to avoid even the small risk of precipitating a hypertensive crisis during the intravenous injection of contrast medium. 9 Computed tomography has largely replaced nephrotomography, ultrasonography, selective angiography, and venography with venous sampling. However, CT does not differentiate among adrenal lesions and benign and malignant disease. Magnetic resonance imaging (MRI) appears to be as accurate as CT in identifying adrenal lesions and also has a characteristically bright, light bulb image on T2-weighted study (Fig. 4-2). It is also very useful in the detection of recurrent local tumors in patients with metal clips and may have indications in pregnant patients. Sagittal and coronal imaging can give excellent definition of the surrounding anatomic and vascular relationships.

FIG. 4-2. Magnetic resonance appearance of pheochromocytoma showing axial T 2-weighted, axial, sagittal, and coronal T 1-weighted images.

An alternative in the search for residual or multiple pheochromocytoma is the meta-iodobenzylguanidine scan ( 131I-MIBG). This compound is taken up by adrenergic granules and adrenal medulla cells and causesvirtually no pharmacologic effects. Because MIBG is concentrated in catecholamine storage vesicles, it is quite specific for pheochromocytoma rather than just an adrenal mass: MIBG scans have a 78.4% sensitivity in primary sporadic lesions, 92.4% in malignant lesions, and 94.3% in familial cases, giving an overall 87.4% sensitivity with 99% specificity. Although it provides no anatomic detail, this test is extremely useful when CT and MRI findings are confusing (Fig. 4-3).

FIG. 4-3. 131I-MIBG scan demonstrating bilateral adrenal lesions.

INDICATIONS FOR SURGERY Indications for surgery are an adrenal mass or extra-adrenal mass that meets the biochemical criteria for a pheochromocytoma. Additional indications include a positive MIBG scan or MRI with borderline biochemical criteria.

ALTERNATIVE THERAPY There is no acceptable alternative therapy to the management of pheochromocytoma except surgery. Alternative approaches to the adrenal would include laparoscopic surgery, though with the high perioperative risks associated with this procedure, open surgery is by far the preferred route. In pregnant patients, oral blocking agents may be utilized until the fetus has matured, and cesarean section and tumor excision can be safely performed as one procedure, avoiding the potential stress of vaginal delivery.

SURGICAL TECHNIQUE Preoperative Management The localization of a pheochromocytoma is essential in planning definitive therapy and is influenced by whether it is sporadic (80% solitary adrenal lesion) or familial (50% bilateral) and whether it occurs in children or in adults. Multiple or extra-adrenal lesions occur in 10% of cases in adults and up to 30% in children. Localization techniques usually involve one or more of the imaging techniques listed above. Adequate preoperative pharmacologic blockade provides a smoother and safer procedure for the surgeon, patient, and anesthesiologist. Phenoxybenzamine hydrochloride is an a-adrenergic blocker with both postsynaptic (a 1) and presynaptic (a 2) blocking capabilities. An initial divided dose of 30 to 60 mg orally is commenced. The dose is increased by 10 to 20 mg per day until the blood pressure has stabilized (maximum 100 mg/day). Recently, newer blocking agents have become available that are more selective and avoid some of the associated side effects. Patients are usually adequately blocked when they complain of postural hypotension and nasal stuffiness. b-Blockers protect against arrhythmias, control tachyphylaxis from a-blockers and permit a decrease in the amount of a-blocker necessary to control blood pressure. These agents should be used only after a-blockade has been established because, alone, they may precipitate a rise in total peripheral vascular resistance through unopposed a-adrenergic activity, and used only when cardiac arrhythmias are expected. a-Methylparatyrosine has been utilized in addition to phenoxybenzamine and/or propranolol. This agent decreases the rate of catecholamine synthesis and is particularly useful in patients who are resistant to a-blockers or have multiple paragangliomas. Preoperative preparation also requires intravenous fluid replacement to ensure adequate hydration because many patients will have a depleted intravascular volume. Unless active fluid expansion is planned, the pharmacologic blockade should be of at least 2 weeks' duration in order to allow the patient's own homeostatic

mechanisms to compensate for the recently expanded intravascular space. Crystalloids and in some cases blood transfusions may be required to accommodate the expanded intravascular volume produced by blockade, and an extra fluid load of 1 to 2 liters should be administered the night before surgery. Anesthesia The primary focus of anesthetic management of a pheochromocytoma patient is hemodynamic control. Close monitoring of the blood pressure, EKG, urinary output, and central venous pressure is essential in all phases of the procedure. An arterial line and Swan–Ganz catheter are frequently utilized. Sodium pentobarbital is usually used for induction, and virtually all inhalational agents have been administered for maintenance of anesthesia; these are usually combined with the neuromuscular blocking agents succinylcholine, d-tubocurarine, or pancuronium. The two inhalational agents of choice appear to be enflurane and isoflurane, with the latter decreasing myocardial contractility but being more resistant to metabolism and consequently less toxic. Either agent can also be combined with phentolamine or nitroprusside to control hypertension. Intraoperative arrhythmias can be controlled with either lidocaine or propranolol, although they frequently resolve following blood pressure normalization. Following interruption of the venous drainage of a pheochromocytoma, profound hypotension may ensue, and the surgeon should inform the anesthesiologist before performing this maneuver. Volume replacement is the treatment of choice, which may be augmented by the addition of vasopressors (Levophed) if necessary until the situation stabilizes. Surgical Approach There are numerous approaches to the adrenal gland, and the appropriate choice of access is governed by the size, multiplicity, and site of the lesion and the underlying pathology. In situations where a paraganglioma is a possibility, a midline abdominal incision allows a full assessment of the abdomen, retroperitoneum, and pelvis. The one essential is a detailed knowledge of the surgical anatomy of the adrenal glands ( Fig. 4-4 and Fig. 4-5). Other factors such as the body habitus of the patient and the preference and experience of the surgeon must also be considered. Therefore, in view of all these variables, it is apparent that each case should be approached individually, with account taken of the various preferred guidelines for individual diseases.

FIG. 4-4. When viewed anteriorly, the adrenals lie behind the colon, stomach, duodenum, and pancreas.

FIG. 4-5. Arterial blood supply of the adrenals may vary with multiple small arteries, whereas venous drainage is relatively constant.

The left adrenal gland is supplied by multiple small arteries superiorly originating from the inferior phrenic artery. Medially, multiple arteries arise directly from the aorta. Inferiorly, a constant artery arises either directly from the aorta just above the left renal artery or from the proximal renal artery itself. The venous drainage of the left gland is mainly through the inferior adrenal vein, which drains into the superior aspect of the left renal vein, usually just lateral to the aorta. There are virtually no blood vessels entering or draining the lateral aspect of the left adrenal under normal circumstances. Gerota's fascia can be dissected anteriorly off the posterior aspect of the pancreas and the splenic vein and artery. If an anterior approach is used, the splenorenal ligaments must be divided, and the colon reflected medially, before Gerota's fascia can be dissected, following which the spleen and pancreas can be elevated superiorly to expose the underlying anterior surface of the adrenal gland. A virtually avascular plane also exists posteriorly between Gerota's fascia and the paraspinous muscles such that the gland can be mobilized from the surrounding structures before its blood supply. The right adrenal gland is supplied superiorly by branches of the inferior phrenic artery that are often obscured by the overlying liver and inferior vena cava. Medially, small direct branches from the aorta course beneath the vena cava, and inferiorly a fairly constant branch of the proximal renal artery enters the gland. The venous drainage is again mainly through one vessel, which is short and enters directly into the vena cava just below the hepatic veins. Securing this vein is perhaps the most challenging aspect of adrenal surgery, as it is nearly always higher and shorter than expected, and adjacent vascular and fascial structures may have to be divided beforehand. In cases involving a large right-sided tumor, following reflection of the colon and duodenum it is not unusual to have to divide the caudate lobe veins entering directly into the vena cava in order to gain adequate exposure anteriorly. Once again, there are relatively avascular planes anteriorly, posteriorly, and laterally. Care should be exercised when freeing the inferior aspect of the gland, which can have vascular attachment to the upper pole of the kidney. Small well-localized adrenal lesions may be approached by either a posterior, modified posterior, or flank approach. Larger lesions including pheochromocytomas, both single and multiple, may be approached by either an abdominal or thoracoabdominal incision. These latter two options are dealt with below, and the other approaches are described elsewhere in this section. Thoracoabdominal and Transabdominal Approaches The thoracoabdominal eighth, ninth, or tenth intercostal approach is the incision preferentially utilized for large right-sided pheochromocytomas. 10 This approach offers the advantage of excellent adrenal exposure and an opportunity to palpate the thoracic sympathetic chain in the case of a rare associated paraganglioma metastasis. The peritoneal cavity may be widely opened for laparotomy, and in cases in which the contralateral gland must be explored, the incision is extended, though closure may be tedious. There is usually less requirement for this incision, with its extrapulmonary morbidity, when dealing with left-sided lesions. There is generally less vascularity to deal with, especially on the superior, lateral, and posterior aspects of the tumor, and the pancreas and spleen can be mobilized away from the lesion with ease. The patient is placed in a semioblique position on a bean bag that is rolled to elevate the relevant flank and hemithorax. For this description the lesion is assumed to be right-sided, but the approach is similar for left-sided lesions. The right arm is then draped across the chest over a Mayo stand with careful padding and positioning to avoid a stretch or pressure injury. The left axilla is protected with a pad. The pelvis should lie almost parallel, with the contralateral knee flexed 90 degrees and lying under the straight ipsilateral leg, with padding between the two g Figure 4-6). The table is then hyperextended, and the patient is fixed in position with adhesive tape. The incision is made in the eighth, ninth, or tenth intercostal space at the angle of the rib and extended across the costal margin to curve inferiorly to the

midpoint of the opposite rectus muscle. Once the latisimus dorsi, posterior inferior serratus, and the external oblique have been divided, the internal oblique is divided on the upper border of the rib itself, which need not be resected; the costvertebral ligament is divided, allowing the rib to swing down after division of the intercostal muscles. The pleura is then carefully entered, and the lung protected by a padded retractor. The diaphragm with overlying pleura will then be visualized and should be divided at the periphery about 2 cm from the chest wall in a circumferential pattern from anterior to posterior to allow for later reconstruction and to avoid damage to the phrenic nerve.

FIG. 4-6. Thoracoabdominal incision. (A) The patient is placed in a semirecumbent position using sandbags with the chest angled at 40 to 45 degrees and the pelvis almost flat. If the chest is entered through the ninth intercostal space, the incision extends from the midaxillary line across the costal margin at the intercostal space to the midline or across it just above the umbilicus. (B) The anterior rectus sheath and the external oblique and latissimus dorsi muscles are divided. (C) The intercostal muscles parallel the directions of the three abdominal layers and are divided. The costal cartilage and the internal oblique and rectus muscles are incised. (D) The pleural reflection (shaded areas) lies progressively closer to the costal margin in the more cephalic intercostal spaces. (E) The pleura, reflecting as the costophrenic sinus near the costal margin, is exposed beneath the intercostal muscles. The diaphragm can be seen inferior and dorsal to the pleura. The pleura is opened with care to avoid injuring the lung, which comes into view with inspiration. After the lung is packed away, the diaphragmatic surface of the pleura is seen. The diaphragm is incised avoiding damage to the phrenic nerve. (F) The transversus muscle is divided, exposing the peritoneum with the liver beneath it. (G) The peritoneum is divided, and a rib-spreading retractor is inserted, enabling upward displacement of the liver (or spleen on the left) into the thoracic cavity and giving wider access to the posterior peritoneum than in an anterior abdominal incision.

Heavy scissors are used to divide the costochondral junction, the peritoneum is opened, and the underlying liver can then be retracted upward. Because this incision is usually employed in large pheochromocytomas, the right triangular and coronary ligaments are divided, thus mobilizing the right lobe of the liver, which can be further retracted upward, providing excellent exposure of the suprarenal vena cava and the adjoining right adrenal vein. A fixed retractor (either Omnitract or Bookwalter) is preferred for this procedure. With the liver well protected and retracted into the chest, the posterior peritoneum lateral to the right colon is incised, and the incision is carried up along the vena cava to the level of the retracted liver edge (at the level of the hepatic veins) ( Fig. 4-7). The right colon and duodenum are mobilized medially, and the kidney is gently retracted downward to bring the adrenal into view. The attachment of the kidney to the adrenal should be preserved until the gland has been completely mobilized, as this facilitates exposure and prevents direct manipulation of the tumor. At this point care must be exercised to avoid trauma to the small veins draining directly into the vena cava from the caudate lobe. If necessary, these veins may be divided between Adson clamps and sutured below the clamps with 5-0 Proline. At this point, full retraction is instituted to expose the entire operative field.

FIG. 4-7. Anterior approach to the right adrenal gland. (A) The posterior peritoneum lateral to the right colon is incised, and the mobilization is carried along the vena cava to the level of the hepatic veins. (B) With the duodenum and colon reflected medially, the liver and gallbladder are retracted upward. Gentle downward retraction on the kidney brings the anterior surface of the right adrenal gland into view. Small veins draining the caudate lobe of the liver to the vena cava may be injured with excessive retraction, and a self-retaining ring retractor is ideal at this stage. (C) The adrenal vein should be ligated early in the procedure. In many cases, the vein may lie high and enter the cava posterolaterally. Extensive dissection of the arterial supply medially and laterally may be necessary to adequately expose the vein. Exposure is facilitated by medial and downward traction on the cava. The remaining lateral and inferior attachments are readily divided to complete the procedure. (D) In rare cases where the kidney is invaded, nephrectomy and adrenalectomy are the treatments of choice.

In pheochromocytomas, it is essential that the blood supply be isolated as soon as possible, with the adrenal vein ligated with either silver clips or 2-0 silk sutures. In cases where the vein lies far superior, extensive dissection and division of the arterial supply medially and inferiorly may be necessary to allow safe and satisfactory exposure of the vein. When there are large tumors extending medially below the vena cava, mobilization of the vena cava with division of the relevant lumbar veins, if necessary, facilitates exposure and ligation of the medial vessels between vascular clips. The vena cava can be retracted by passing vascular tapes below it to provide the necessary medial traction. If the tumor is confined to the adrenal gland, the remaining lateral and inferior attachments of the gland are mobilized and divided to complete the adrenalectomy. An alternative approach to large pheochromocytomas is the anterior transperitoneal approach. This approach also allows early vascular control and provides the opportunity for a thorough laparotomy. The optimal approach involves a bilateral subcostal or chevron incision. A midline incision is used only when an extra-adrenal pheochromocytoma is suspected in either the pelvis or retroperitoneum. This approach is particularly suitable for left-sided large pheochromocytomas. A number of approaches are available to expose the left adrenal gland. Exploration through the lesser sac or the avascular plane in the transverse mesocolon is ideal for small tumors. However, for large tumors, following laparotomy, the posterior peritoneum lateral to the left colon is incised, and the incision is extended to include the lienorenal ligament. Splenic injury is a risk during this maneuver. Once again, a fixed ring retractor is optimal in this procedure. The initial dissection involves exposure of the left adrenal vein, which is easier to approach on this side and is ligated at its entry into the renal vein with 2-0 silk ligatures. The anterior and posterior adrenal planes are then developed, and the spleen and pancreas are gently retracted superiorly. The left colon and duodenum are reflected medially. Leaving the distal ligature long permits the ligated adrenal vein to be utilized to provide retraction to facilitate ligation of the inferior adrenal artery ( Fig. 4-8). The gland is then mobilized with gentle blunt dissection on its lateral and posterior margins. Downward traction on the kidney facilitates exposure of the superior vascular ligaments, which may be tied with 3-0 silk or ligated with vascular clips. Lateral traction is then employed to expose the medial arteries and lymphatic vessels, which are ligated. Finally, the remaining inferior attachments are divided, and the adrenal gland is removed ( Fig. 4-9, Fig. 4-10 and Fig.4-11).

FIG. 4-8. Anterior approach for left adrenalectomy. (A) The adrenal vein is divided and can be used for traction, although excessive traction may provoke a sharp elevation in the blood pressure of even adequately blocked patients. (B) The kidney can be used to provide excellent traction of the adrenal, allowing the lateral attachments to be divided.

FIG. 4-9. (A) Intraoperative photograph showing IVC retraction with mobilization of the medial aspect of the right gland. (B) Postoperative appearance.

FIG. 4-10. (A) Intraoperative photograph showing ligation of the left adrenal vein as it enters the renal vein. (B) Postoperative appearance.

FIG. 4-11. Resected specimen, gross appearance, showing multiple areas of necrosis.

The adrenal fossa is carefully inspected for bleeding and, after electrocautery, packed while the surrounding viscera are carefully examined. Persistent oozing may be controlled with Surgicel or Gelfoam. The incisions are closed in a standard fashion, with no drainage utilized. Nasogastric suction may be employed for 48 hours to minimize postoperative distention. Postoperative Care and Specific Complications In the recovery room, vital signs and mental status are closely monitored. Patients with a flank, posterior, or thoracoabdominal incision should have a chest radiograph to rule out a pneumothorax or document proper positioning of a chest tube. Pain control is a major contributing factor to reduce atelectasis and promote early ambulation. Intensive care monitoring for the initial 24-hour period is prudent following removal of a pheochromocytoma.

OUTCOMES Complications Specific complications seen during both the intra- and postoperative period include profound hemodynamic instability, which requires precise monitoring and adequate preoperative preparation. Postoperatively, large boluses of intravenous fluids with pressor support may be necessary to maintain stability. Vasospasm sufficient to reduce enteral blood flow may be encountered and should be considered along with possible neurologic complications in inadequately blocked or unrecognized cases. When dealing with large lesions, the surgeon needs to bear in mind that the renal vascular anatomy may be distorted and out of position, putting it at risk of inadvertent injury. Significant hemorrhage secondary to vena caval or renal vein lacerations may occur and require repair with 4-0 or 5-0 Proline once adequate control has been established. Left-sided lesions may be associated with pancreatic or splenic injuries resulting in postoperative bleeding and hypotension (which may be attributed to metabolic causes) or a fistula. In cases where such an injury has occurred, placement of a drain may be prudent.

Results The Lahey Clinic reported a 0% mortality in 62 patients treated for pheochromocytoma and a 25% postoperative morbidity rate in the 41 patients whose records were available. 11 However, overall, convalescence of patients undergoing adrenal surgery is reasonably benign. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Chute R, Soutter L, Kerr WS. The value of the thoracoabdominal incision in the removal of kidney tumors. N Engl J Med 1949;241:951–960. Crout JR, Pisano JJ, Sjoerdsma A. Urinary excretion of catecholamines and their metabolites in pheochromocytoma. Am Heart J 1961;61:375–381. Malone MJ, Libertino JA, Tsapatsaris NP, Woods OB. Preoperative and surgical management of pheochromocytoma. Urol Clin North Am 1989;16(3):567–582. Mayo CH. Paroxysmal hypertension with tumor of retroperitoneal nerve. JAMA 1927;89:1047–1050. Radin DR, Ralls PW, Boswell WD, et al. Pheochromocytoma: detection by unenhanced CT. Am J Urol 1986;146:741–744. Roux C. Thesis Lausanne. Cited in Welbourne RB. Early surgical history of phaeochromocytoma. Br J Surg 1987;74:594–596. Samaan NA, Hickey RC, Shutts PE. Diagnosis, localization, and management of pheochromocytoma: pitfalls and follow up in 41 patients. Cancer 1988;62:2451–2460. Sheps SG, Jiang N-S, Klee GG. Diagnostic evaluation of pheochromocytoma. Endocrinol Metab Clin North Am 1988;17:397–414. St John Sutton MG, Sheps SG, Lie JT. Prevalence of clinically unsuspected pheochromocytoma: Review of a 50 year autopsy series. Mayo Clin Proc 1981;56:354–360. Stewart BM, Brevo EL, Haaga J. Localization of tumor by computed tomography. N Engl J Med 1978;299:460–461. Whalen RK, Althausen AF, Daniels GH. Extra-adrenal pheochromocytoma. J Urol 1992;147:1.

Chapter 5 Simple Nephrectomy Glenn’s Urologic Surgery

Chapter 5 Simple Nephrectomy W. Holt Sanders and Cragin Anderson

W. H. Sanders: Department of Surgery, Section of Urology, Emory University School of Medicine, Atlanta, Georgia 30322. C. Anderson: Atlanta Urological Institute, Riverdale, Georgia 30274.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Anatomy Preoperative Evaluation Subcostal Flank Incision Eleventh and 12th Rib Incision Subcostal Abdominal Incision Vertical Abdominal Incision Nephrectomy Subcapsular Approach Closure Outcomes Complications Results Chapter References

The term “simple nephrectomy” describes the technique of removing the kidney from within Gerota's fascia and in no manner is meant to indicate that the operation is technically easy. This procedure is usually performed in the setting of a nonneoplastic disease state but is the end operation after other therapies (including surgery) have failed, making this operation technically challenging.

DIAGNOSIS Usually the indications for simple nephrectomy are for (a) trauma that is so severe that reconstruction is not possible, (b) a nonfunctioning kidney associated with hypertension or nephrolithiasis, or (c) a severe infectious process that cannot be cleared medically. The diagnostic studies, therefore, will depend on the clinical setting. Renal trauma and the diagnostic studies are discussed in Chapter 13. The diagnosis of a nonfunctioning kidney is made by the absence of a nephrogram on excretory urogram or CT scan or by the absence of signal on a radionuclide scan in a kidney that is not obstructed. It is occasionally necessary to place a ureteral stent or a nephrostomy tube to relieve an obstruction so that lack of function can be documented by contrast or radionuclide study. Severe infections such as xanthogranulomatous pyelonephritis or emphysematous pyelonephritis are often treated with simple nephrectomy. Patients with xanthogranulomatous pyelonephritis, an uncommon form of chronic renal infection, present with flank pain, fever, persistent bacteriuria, and flank mass. The CT reveals a renal mass associated with a calcification in the renal pelvis. The parenchyma is replaced by small water-density masses. Xanthogranulomatous pyelonephritis is often misdiagnosed preoperatively as renal cell carcinoma and correctly identified only after nephrectomy, by the pathologist. Emphysematous pyelonephritis is a complication of acute pyelonephritis in patients with diabetes. Patients with this condition present with severe pyelonephritis that does not resolve within the first 3 days of treatment. The diagnosis is made by a plain abdominal radiograph, which reveals small gas bubbles radiating in a radial distribution through the renal parenchyma.

INDICATIONS FOR SURGERY Simple nephrectomy is indicated for nonneoplastic diseases of the kidney. The more common specific indications include severe trauma, renal infections (e.g., xanthogranulomatous pyelonephritis and emphysematous pyelonephritis), nonfunctioning kidneys with stru-vite stones or obstruction, renal vascular hypertension (when all attempts at medical and surgical therapy have failed), and renal fistula.

ALTERNATIVE THERAPY Alternatives to simple nephrectomy include partial nephrectomy, renal embolization, laparoscopic nephrectomy, and radical nephrectomy.

SURGICAL TECHNIQUE Anatomy The right kidney is lower than the left kidney in 90% of patients as a result of downward displacement by the liver. The renal arteries run posterior to the renal veins, and the right renal artery runs posterior to the inferior vena cava. The renal arteries divide into segmental branches at the junction of the middle and final third of their course. This anatomic point is important to keep in mind if the vessels are divided close to the renal hilus, as in a subcapsular nephrectomy. The left renal vein receives tributaries from the phrenic vein, the adrenal vein, the gonadal vein, and occasionally the lumbar vein. The right renal vein usually receives no tributaries. Anomalies of the renal vasculature are present in three-quarters of all patients. 2 Departures from the anatomy presented in the textbooks usually involve supernumerary arteries rather than the veins. These additional arteries commonly supply the lower pole of the kidney. 5 Preoperative Evaluation The preoperative evaluation has two purposes: to minimize risk and to determine the optimal incision. These two purposes are interrelated, and occasionally the primary reason for choosing one type of incision over another is to minimize risk to the patient. It is essential to document function in the contralateral kidney. For most cases, a serum creatinine and an IVP are adequate. In indeterminate cases, a nuclear renogram may be required to demonstrate sufficient renal function. The scout film of the IVP is useful for determining the level of a flank incision. Note which rib is superimposed on the middle of the lateral border of the kidney. An appropriate flank incision should be made at the level of this rib or above. The surgeon should inquire about a history of pulmonary disease. The decubitus position with an elevated kidney rest can decrease the vital capacity by 20%. In the decubitus position, there is also preferential ventilation of the upper lung and perfusion of the lower lung, creating a ventilation–perfusion mismatch. A history of severe pulmonary disease will therefore favor an abdominal approach. Exploration of the kidney in the setting of traumatic injury must be done through an abdominal approach. In an obese patient, a flank approach optimizes exposure and minimizes wound complications. Previous abdominal surgery also favors a flank approach. An extraperitoneal flank approach is preferable in a patient with a chronically infected kidney. In other cases, the choice of incision depends largely on the surgeon's preference.

Subcostal Flank Incision The patient is placed on the operating table so that the kidney rest is just cephalad to the anterior superior iliac spine. The patient is turned to the lateral decubitus position with his or her back toward the edge of the table. The contralateral leg is flexed and padded at the knee and ankle. The ipsilateral leg is appropriately padded with pillows and kept only gently flexed. The table is then flexed, and the kidney rest elevated. The patient should then be secured to the table with 2-inch tape over the patient's hip. The patient should have an axillary roll placed to avoid brachial plexus injury, and upper extremities should be secured to arm board and sling support or Mayo stand. Some find a bean bag to be useful in holding the patient's position. It is important to remember that the patient should be positioned with the table flexed before the bean bag is inflated. The incision is made approximately 2 cm inferior to the 12th rib starting posterior to the angle of the 12th rib or at the inferior border of the paraspinous muscles. The incision usually is gently curved toward the umbilicus to the lateral edge of the rectus muscle. The latissimus dorsi and external oblique are divided with cautery, exposing the serratus posterior inferior and the internal oblique, which are then divided Figure 5-1). Often the subcostal nerve emerges from the fibers of the lumbodorsal fascia to extend along a course that is superficial to the transversus muscle. Careful proximal and distal dissection of this nerve will minimize the risk of injury. A small incision in the lumbodorsal fascia provides access to the retroperitoneum. The peritoneum is dissected medially off the transversalis fascia with blunt dissection. The transversus can then be divided with cautery or bluntly divided between the muscle fibers. Gerota's fascia is identified beneath the paranephric fat and is then incised. The kidney is dissected free from the surrounding perinephric fat using blunt and sharp dissection. The renal pedicle can be approached anteriorly or posteriorly.

FIG. 5-1. (A) The subcostal incision begins below the tip of the 12th rib and extends toward the umbilicus, ending at the rectus and running parallel to the rib. (B) The external oblique edges of the latissimus dorsi muscles are divided in the direction of the incision. The 12th nerve usually is seen beneath this layer as it penetrates the lumbodorsal fascia. The nerve can be freed from its subcostal tunnel medially by sharp dissection until it is slack enough to be drawn out of the way (see D). (C) The internal oblique muscle is incised and can be seen to originate from the posterior layer of the lumbodorsal fascia. (D) The transversus abdominis muscle has the same origin and can be slit in the direction of its fibers. Care is taken to separate the peritoneum bluntly from the transversalis fascia, which limits the transversus internally. (E) Retroperitoneal (paranephric) fat lies under the lumbodorsal fascia. Beneath is a smooth envelope of paranephric fascia (Gerota's). Paranephric fat is less lobular and lighter yellow. The kidney can be dissected with Gerota's fascia widely opened. If a tumor is present, fat and fascia are taken with the kidney.

If additional exposure is required, the costovertebral ligament of the 12th rib can be divided bluntly or sharply, allowing for greater cephalad retraction. Eleventh and 12th Rib Incision If the kidney appears high in relation to the thoracic cage on preoperative radiographic studies, an 11th or 12th rib resection may be preferred. The patient is positioned as detailed above for the flank subcostal approach. The incision is made over the selected rib from the costovertebral angle over the tip of the rib medially to the edge of the rectus muscle (Figure 5-2).

FIG. 5-2. Technique of 11th-rib resection. (A and B) The incision is made over the 11th rib.

Once the rib is exposed, the periosteum is incised along the length of the rib. The periosteum is dissected off the rib using the periosteal elevator and the Alexander periosteotome. The Doyen periosteal elevator is guided beneath the rib to complete the dissection posteriorly. Once free, the rib can be divided with a rib cutter, and the edges smoothed with a rongeur (Fig. 5-3).

FIG. 5-3. Rib resection technique. (A) After exposure of the rib, the intercostal muscles are stripped from the upper and lower rib surfaces with an Alexander Farabeuf costal periosteotome. (B) The rib is freed from the periosteum by subperiosteal resection or from the pleura with a periosteum elevator. (C) A Doyen costal elevator is slipped beneath the rib to free it. The proximal and distal portions of the rib are immobilized with Kocher's clamps, and the rib is divided proximal to its angle with a right-angled rib cutter. (D) The costal cartilage is cut free with scissors. The cut surface of the rib is inspected for spicules, which are removed with a rongeur.

The posterior periosteum is divided, exposing the fascial attachments of the pleura to the diaphragm Figure 5-4). These attachments are sharply incised so that the pleura can be reflected superiorly. The peritoneum is bluntly dissected from the deep surface of the transversalis fascia by sweeping it medially with the fingers. The medial extent of the incision, including the external oblique, the internal oblique, and the transversus, can now be completed. Gerota's fascia is incised, and the kidney is dissected free from the surrounding peri-nephric fat using blunt and sharp dissection ( Fig. 5-5).The flank incisions enhance the ease of a posterior approach to the pedicle without increasing the difficulty of the anterior approach.

FIG. 5-4. (A) After division of the latissimus and external oblique muscles, subperiosteal resection of the rib is performed. (B) The incision is carried through the periosteum posteriorly and the internal oblique and transversus muscles medially, exposing the paranephric space. A tongue of pleura lies in the upper portion of the wound. Diaphragmatic slips that come into view are divided, and the pleura can be retracted upward. (C) The paranephric fat is dissected bluntly.

FIG. 5-5. (A) Gerota's fascia is incised and entered. In nephrectomy for renal donation, a sharp technique is used to dissect the paranephric fat. (B) The renal vein is exposed to its entrance into the vena cava anteriorly. The tissue between the ureter laterally and the vena cava medially is dissected free, with care taken to preserve the periureteral blood supply. The hilar region of the kidney is avoided in dissection. (C) The kidney is rotated anteromedially, and the renal artery is isolated as far as possible. The ureter is divided as far inferiorly as possible.

Subcostal Abdominal Incision The subcostal abdominal incision is preferred by some surgeons because of: 1. Early exposure of the renal pedicle 2. Lower risk of inadvertent pleurotomy 3. Decreased effect on ventilation in patients with pulmonary disease The patient is positioned with the table break at the level of the 12th rib, and the operative side is elevated with a rolled sheet. The table is then flexed to maximize exposure. The incision is typically two fingerbreadths below the costal margin with its medial extent being approximately two fingerbreadths below the xyphoid process. After the skin incision, the anterior rectus fascia is divided along with the rectus muscle and the external oblique. The superior epigastric artery is divided. The internal oblique is divided. The lumbodorsal fascia is incised laterally, and the peritoneum can be opened or bluntly stripped off the anterior abdominal wall. The transversus can then be divided with cautery or bluntly divided between the muscle fibers. If peritoneum is opened, one must reflect the colon medially to expose Gerota's fascia, which is then incised. The kidney is dissected free from the surrounding perinephric fat using blunt and sharp dissection. The anterior approach to the renal pedicle is easier than the posterior approach when a subcostal abdominal incision is used. Vertical Abdominal Incision If a vertical abdominal incision is required for the evaluation of intraperitoneal structures (such as in a patient who has had abdominal trauma) or for a combined procedure, a simple nephrectomy can be performed through a midline incision. This incision is typically from the xyphoid process to the pubic symphysis. After incision of the skin and subcutaneous fat, the linea alba is identified and incised. The peritoneum can be identified beneath preperitoneal fat and is incised sharply and carefully to avoid bowel injury. The colon is reflected medially to expose Gerota's fascia. In a patient who has suffered renal trauma, it is important to obtain early vascular control by dissecting along the aorta for a left renal injury and along the inferior vena cava for a right renal injury. The dissection is carried superiorly to the level of the renal vessels. Vessel loops are placed around the renal artery and vein before exploration of the injured kidney. The paramedian incision is helpful if an attempt will be made to stay extraperitoneal or if a two-layer closure is preferred. It is typically two fingerbreadths lateral to midline. The rectus muscle fibers are dissected off the linear alba and retracted laterally. If peritoneum is opened, one must reflect the colon medially. Gerota's fascia is then incised, and the kidney is dissected free from the surrounding perinephric fat using blunt and sharp dissection. Nephrectomy After Gerota's fascia is incised and the kidney is dissected free from surrounding perinephric fat, the renal artery should be identified. One must keep in mind possible aberrant vessels, particularly lower-pole branches. The renal artery can usually be identified during posterior dissection of the pedicle. Ligation of the artery before the vein prevents renal congestion and is thus preferred. Two size-0 silk ties are placed proximally, and a single silk is placed distally. The artery is divided with scissors; a scalpel is used when there is minimal distance between the proximal and distal ligatures. To minimize the possibility that the proximal tie will slip off the arterial stump, some surgeons place a suture ligature distal to the 0 silk ties. The ureter is quickly identified by blunt dissection in the fat inferior to the kidney. It is divided between ligatures or clips. The connective tissue and lymphatics are dissected off the kidney, revealing the renal vein. On the left, particular attention is paid to the gonadal vein, inferior adrenal vein, and lumbar venous branches. These branches are divided between silk ties if distal to the area dissected. The renal vein is doubly ligated, as was the artery. The adrenal gland can be dissected off with sharp dissection, taking care to clip all vessels. If the nephrectomy is secondary to an infectious process, a drain is left in

the posterior flank. Subcapsular Approach In patients undergoing simple nephrectomy for stone disease or for infection, previous surgery or chronic inflammation can make dissection very difficult. In these cases, it is advantageous to come down to the capsule, incise it, and continue the dissection under the capsule to the hilus. It is important to remember that the renal vessels have already divided into several branches once they reach the renal hilum and to continue searching for additional arterial branches once the apparent main branch has been divided. Closure There are differing opinions on the best technique for closure of a flank wound, although there is general agreement that the abdominal portion of a flank wound should be closed in two layers. The bean bag is deflated, the kidney rest is lowered, and the flexion is taken out of the table. The closure should be initiated at each end of the incision and continued toward the middle of the incision. Anteriorly, the internal oblique is closed with a running PDS suture. In the posterior portion of the wound, the inferiorly reflected periosteum is approximated to the periosteum and intercostal muscle of the superior rib. When the rib has been resected, the periosteum and intercostal muscles above and below the rib are approximated. The latissimus dorsi fascia is then closed in continuity with the external oblique fascia using a running PDS suture. A single-layer closure is often sufficient over the ribs. A single running PDS suture closing the fascia of the external oblique and continuing posterior to close the fascia of the latissimus dorsi has resulted in one hernia in approximately 700 donor nephrectomies at our institution.

OUTCOMES Complications The operative mortality of nephrectomy for benign disease is less than 1%. 4 The most common intraoperative problem is hemorrhage, especially of the renal vein and vena cava. It is important to avoid blind clamping and suture ligatures that can lead to an arteriovenous fistula. 6 The proper strategy is to gain control by direct pressure on the vena cava with sponge sticks, followed by optimization of exposure. The surgeon can then use a running 5-0 vascular suture to repair the vessel. Blind clamping can also lead to duodenal injury in a right nephrectomy. It is important to reflect the duodenum medially before division of the vessels from an anterior approach. The superior mesenteric artery is vulnerable to injury during a left nephrectomy. Unintentional laceration of the parietal pleura is common and can usually be repaired without placement of a chest tube. The edges of the pleura are approximated with a running absorbable suture. A red rubber catheter is placed through the laceration into the pleural cavity before the suture is tied. The end of the catheter is placed in a basin of water. The anesthesiologist gives the patient a deep breath; air is expelled from the pleural cavity; the catheter is removed; and the suture is tied. After such a maneuver, it is important to obtain a chest x-ray in the recovery room. A small pneumothorax will be reabsorbed without sequelae. A larger pneumothorax may benefit from aspiration of air from the pleural cavity using a large luer lock syringe, a stopcock, and an intravenous angiocath. Because the pulmonary parenchyma is not injured, it is rarely necessary to insert a chest tube. Inability to reapproximate the pleural edges in an airtight fashion may necessitate placement of a chest tube. Atelectasis is common after a simple nephrectomy even if the pleural cavity has not been entered. A flank bulge is common after a nephrectomy through the flank approach, especially if the subcostal nerve has been injured. The nerve lies below the internal oblique muscle and above the transversus abdominus muscle. Careful identification, proximal and distal dissection, and gentle retraction of the nerve can minimize this problem. Flank bulges must be distinguished from incisional hernias, which are rare. A fascial defect is usually palpable in patients with a hernia. Results Generally, the patients recover from simple nephrectomies uneventfully and remain in the hospital for less than a week, depending on the indication for the nephrectomy, the comorbidities, and the patient's preoperative status. Success rates with improved control of hypertension are as high as 86% in patients with unilateral atherosclerotic disease of the renal artery. 1 Many of these patients continue to require antihypertensive medications, although at lower doses. The success in the treatment of xanthogranulomatous pyelonephritis approaches 100%. In contrast, patients with emphysematous pyelonephritis have a mortality rate as high as 43% despite aggressive intervention with nephrectomy. 3 CHAPTER REFERENCES 1. Andersen GS, Gadsboll N, McNair A, et al. Treatment of renovascular hypertension by unilateral nephrectomy. A follow-up study in patients above 60 years of age. Scand J Urol Nephrol 1986;20:51–56. 2. Anson BJ, Kurth L. Common variations in the renal blood supply. Surg Gynecol Obstet 1955;100:157–160. 3. Freiha FS, Messing EM, Gross DM. Emphysematous pyelonephritis. J Contin Educ Urol 1979;18:9. 4. Scott RF Jr, Selzman HM. Complications of nephrectomy: review of 450 patients and a description of the modification of the transperitoneal approach. J Urol 1966;95:307–312. 5. Sykes D. The arterial supply of the human kidney with special reference to accessory renal arteries. Br J Surg 1963;50:368–370. 6. Yeates WK. Post-nephrectomy arteriovenous fistula. Proc R Soc Med 1967;60:112–115.

Chapter 6 Partial Nephrectomy Glenn’s Urologic Surgery

Chapter 6 Partial Nephrectomy Andrew C. Novick

A. C. Novick: Department of Urology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Anatomic Considerations Timing of Surgery in Bilateral Tumors General Operative Considerations Segmental Polar Nephrectomy Wedge Resection Transverse Resection Simple Enucleation Extracorporeal Partial Nephrectomy and Autotransplantation Partial Nephrectomy in Duplex Collecting Systems Postoperative Follow-Up Outcomes Complications Results Chapter References

Recent interest in partial nephrectomy or nephron-sparing surgery for renal cell carcinoma has been stimulated by advances in renal imaging, improved surgical techniques, the increasing number of incidentally discovered low-stage renal cell carcinomas, and good long-term survival in patients undergoing this form of treatment. Partial nephrectomy entails complete local resection of a renal tumor while leaving the largest possible amount of normal functioning parenchyma in the involved kidney.

DIAGNOSIS Evaluation of patients with renal cell carcinoma for partial nephrectomy should include preoperative testing to rule out locally extensive or metastatic disease. For most patients, preoperative renal arteriography to delineate the intrarenal vasculature aids in excising the tumor with minimal blood loss and damage to adjacent normal parenchyma. This test can be deferred in patients with small peripheral tumors. Selective renal venography is performed in patients with large or centrally located tumors to evaluate for intrarenal venous thrombosis secondary to malignancy. The latter, if present, implies a more advanced local tumor stage and also increases the technical complexity of tumor excision.

INDICATIONS FOR SURGERY Accepted indications for partial nephrectomy in malignancies include situations in which radical nephrectomy would render the patient anephric with subsequent immediate need for dialysis. 1 This encompasses patients with bilateral renal cell carcinoma or renal cell carcinoma involving a solitary functioning kidney. The latter circumstance may be present as a result of unilateral renal agenesis, prior removal of the contralateral kidney, or irreversible impairment of contralateral renal function and is seen in patients with unilateral renal cell carcinoma and a functioning opposite kidney, when the opposite kidney is affected by a condition that might threaten its future function such as calculus disease, chronic pyelonephritis, renal artery stenosis, ureteral reflux, or systemic diseases such as diabetes and nephrosclerosis. Partial nephrectomy is also indicated in selected patients with localized benign pathology of the kidney. The indications include (a) hydronephrosis with parenchymal atrophy or atrophic pyelonephritis in a duplicated renal segment, (b) calyceal diverticulum complicated by infection or stones or both, (c) calculus disease with obstruction of the lower-pole calyx or segmental parenchymal disease with impaired drainage, (d) renovascular hypertension from segmental parenchymal damage or noncorrectable branch renal artery disease, (e) traumatic renal injury with irreversible damage to a portion of the kidney, and (f) removal of a benign renal tumor such as an angiomyolipoma or oncocytoma.

ALTERNATIVE THERAPY Alternatives to partial nephrectomy include simple nephrectomy and radical nephrectomy.

SURGICAL TECHNIQUE Anatomic Considerations Figure 6-1 illustrates the normal renal arterial supply. The kidney has four constant vascular segments, which are termed apical, interior, posterior, and basilar. Each of these segments is supplied by one or more major arterial branches. Though the origin of the branches supplying these segments may vary, the anatomic positions of the segments are constant. All segmental arteries are end arteries with no collateral circulation; therefore, all branches supplying tumor-free parenchyma must be preserved to avoid devitalization of functioning renal tissue.

FIG. 6-1. Normal arterial supply for the right kidney with anterior and posterior views.

The normal renal venous anatomy is depicted in Fig. 6-2 (for the left kidney). The renal venous drainage system differs significantly from the arterial blood supply in that the intrarenal venous branches intercommunicate freely among the various renal segments. Ligation of a branch of the renal vein, therefore, will not result in segmental infarction of the kidney because collateral venous blood supply will provide adequate drainage. This is important clinically because it enables one to obtain surgical access safely to tumors in the renal hilus by ligating and dividing small adjacent or overlying venous branches. This allows major venous branches to be

completely mobilized and freely retracted in either direction to expose the tumor with no vascular compromise of uninvolved parenchyma ( Fig. 6-3).

FIG. 6-2. Renal venous anatomy depicted here for the left kidney.

FIG. 6-3. Mobilization of the left renal vein to obtain better exposure of the renal hilus by ligating and dividing small renal venous branches.

Timing of Surgery in Bilateral Tumors In patients with bilateral synchronous renal cell carcinoma, the kidney more amenable to a partial nephrectomy is usually approached first by the author. Then, approximately 1 month after a technically successful result has been documented, radical nephrectomy or a second partial nephrectomy is performed on the opposite kidney. Staging surgery in this fashion obviates the need for temporary dialysis if ischemic renal failure occurs following nephron-sparing excision of renal cell carcinoma. General Operative Considerations It is usually possible to perform partial nephrectomy for malignancy in situ by using an operative approach that optimizes exposure of the kidney and by combining meticulous surgical technique with an understanding of the renal vascular anatomy in relation to the tumor. We employ an extraperitoneal flank incision through the bed of the 11th or 12th rib for almost all of these operations; we occasionally use a thoracoabdominal incision for very large tumors involving the upper portion of the kidney. These incisions allow the surgeon to operate on the mobilized kidney almost at skin level and provide excellent exposure of the peripheral renal vessels. With an anterior subcostal transperitoneal incision, the kidney is invariably located in the depth of the wound, and the surgical exposure is simply not as good. In partial nephrectomy for benign disease, the preferred surgical approach is usually through an extraperitoneal flank incision except for cases of renal trauma, which are best approached anteriorly. When in situ partial nephrectomy is performed for malignancy, the kidney is mobilized within Gerota's fascia while the perirenal fat around the tumor is left intact. For small peripheral renal tumors, it may not be necessary to control the renal artery. In most cases, however, partial nephrectomy is most effectively performed after temporary renal arterial occlusion. This measure not only limits intraoperative bleeding but, by reducing renal tissue turgor, also improves access to intrarenal structures. In most cases, we believe that it is important to leave the renal vein patent throughout the operation. This measure decreases intraoperative renal ischemia and, by allowing venous back bleeding, facilitates hemostasis by enabling identification of small transected renal veins. In patients with centrally located tumors, it is helpful to occlude the renal vein temporarily to minimize intraoperative bleeding from transected major venous branches. When the renal circulation is temporarily interrupted, in situ renal hypothermia is used to protect against postischemic renal injury. Surface cooling of the kidney with ice slush allows up to 3 hours of safe ischemia without permanent renal injury. An important caveat with this method is to keep the entire kidney covered with ice slush for 10 to 15 minutes immediately after occluding the renal artery and before commencing the partial nephrectomy. This amount of time is needed to obtain core renal cooling to a temperature (approximately 20°C) that optimizes in situ renal preservation. During excision of the tumor, invariably large portions of the kidney are no longer covered with ice slush, and, in the absence of adequate prior renal cooling, rapid rewarming and ischemic renal injury can occur. Cooling of the kidney by perfusion with a cold solution instilled via the renal artery is not recommended because of the theoretical risk of tumor dissemination. Mannitol is given intravenously 5 to 10 minutes before temporary renal arterial occlusion. Systemic or regional anticoagulation to prevent intrarenal vascular thrombosis is not necessary. A variety of surgical techniques are available for performing partial nephrectomy in patients with malignancy. These include simple enucleation, polar segmental nephrectomy, wedge resection, transverse resection, and extracorporeal partial nephrectomy with renal autotransplantation. All of these techniques require adherence to basic principles of early vascular control, avoidance of ischemic renal damage, complete tumor excision with free margins, precise closure of the collecting system, careful hemostasis, and closure or coverage of the renal defect with adjacent fat, fascia, peritoneum, or Oxycel. Whichever technique is employed, the tumor is removed with a surrounding margin of grossly normal renal parenchyma. Special equipment that is utilized in partial nephrectomy may include intraoperative ultrasound which is very helpful in achieving accurate tumor localization, particularly for intrarenal lesions that are not visible or palpable from the external surface of the kidney. 3 The argon beam coagulator is a useful adjunct for achieving hemostasis on the transected renal surface. If possible, the renal defect created by the excision is closed as an additional hemostatic measure. A retroperitoneal drain is always left in place for at least 7 days. An intraoperative ureteral stent is placed only when major reconstruction of the intrarenal collecting system has been performed. In patients with renal cell carcinoma, partial nephrectomy is contraindicated in the presence of lymph node metastasis because the prognosis for these patients is poor. Enlarged or suspicious-looking lymph nodes should be biopsied before the renal resection is begun. When partial nephrectomy is performed, after excision of all gross tumor, absence of malignancy in the remaining portion of the kidney should be verified intraoperatively by frozen-section examinations of biopsy specimens obtained at random from the renal margin of excision. It is unusual for such biopsies to demonstrate residual tumor, but, if so, additional renal tissue must be excised. Segmental Polar Nephrectomy In a patient with malignancy confined to the upper or lower pole of the kidney, partial nephrectomy can be performed by isolating and ligating the segmental apical or basilar arterial branch while allowing unimpaired perfusion to the remainder of the kidney from the main renal artery. This procedure is illustrated in Fig. 6-4 for a tumor confined to the apical vascular segment. The apical artery is dissected away from the adjacent structures, ligated, and divided. Often, a corresponding venous branch is present, which is similarly ligated and divided. An ischemic line of demarcation will then generally appear on the surface of the kidney and will outline the segment to be excised. If this area is not obvious, a few milliliters of methylene blue can be directly injected distally into the ligated apical artery to better outline the

limits of the involved renal segment. An incision is then made in the renal cortex at the line of demarcation, which should be at least 1 cm away from the visible edge of the cancer. The parenchyma is divided by sharp and blunt dissection, and the polar segment is removed. In cases of malignancy, it is not possible to preserve a strip of capsule beyond the parenchymal line of resection for use in closing the renal defect.

FIG. 6-4. Technique of segmental polar nephrectomy for a tumor confined to the apical vascular renal segment.

Often a portion of the collecting system will have been removed with the cancer during a segmental polar nephrectomy. The collecting system is carefully closed with interrupted or continuous 4-0 chromic sutures to ensure a watertight repair. Small transected blood vessels on the renal surface are identified and ligated with shallow figure-of-eight 4-0 chromic sutures. The edges of the kidney are reapproximated as an additional hemostatic measure, using simple interrupted 3-0 chromic sutures inserted through the capsule and a small amount of parenchyma. Before these sutures are tied, perirenal fat or Oxycel can be inserted into the defect for inclusion in the renal closure. If the collecting system has been entered, a Penrose drain is left in the perinephric space. When an apical or basilar partial nephrectomy is performed for benign disease, the segmental apical or basilar arterial branch is secured, and the parenchyma is divided at the ischemic line of demarcation, without the need for temporary renal arterial occlusion. More complex transverse or wedge renal resections are best performed with temporary renal arterial occlusion and ice slush surface hypothermia. The technical aspects of partial nephrectomy for benign disease are otherwise the same as those described for malignancy, with adherence to the same basic principles of appropriate vascular control, avoidance of ischemic renal damage, precise closure of the collecting system, careful hemostasis, and closure or coverage of the renal defect. In benign conditions necessitating partial nephrectomy, however, the renal capsule is excised and reflected off the diseased parenchyma for subsequent use in covering the renal defect. Wedge Resection Wedge resection is an appropriate technique for removing peripheral tumors on the surface of the kidney, particularly ones that are larger or not confined to either renal pole. Because these lesions often encompass more than one renal segment, and because this technique is generally associated with heavier bleeding, it is best to perform wedge resection with temporary renal arterial occlusion and surface hypothermia. In performing a wedge resection, the tumor is removed with a 1-cm surrounding margin of grossly normal renal parenchyma ( Fig. 6-5). The parenchyma is divided by a combination of sharp and blunt dissection. Invariably, the tumor extends deeply into the kidney, and the collecting system is entered. Often, prominent intrarenal vessels are identified as the parenchyma is being incised. These may be directly suture-ligated at that time, while they are most visible. After excision of the tumor, the collecting system is closed with interrupted or continuous 4-0 chromic sutures. Remaining transected blood vessels on the renal surface are secured with figure-of-eight 4-0 chromic sutures. Bleeding at this point is usually minimal, and the operative field can be kept satisfactorily clear by gentle suction during placement of hemostatic sutures.

FIG. 6-5. Technique of wedge resection for a tumor on the midlateral aspect of the kidney.

The renal defect can be closed in one of two ways. The kidney may be closed upon itself by approximating the transected cortical margins with simple interrupted 3-0 chromic sutures, after placing a small piece of Oxycel at the base of the defect. If this is done, there must be no tension on the suture line and no significant angulation or kinking of blood vessels supplying the kidney. Alternatively, a portion of perirenal fat may simply be inserted into the base of the renal defect as a hemostatic measure and sutured to the parenchymal margins with interrupted 4-0 chromic. After closure or coverage of the renal defect, the renal artery is unclamped, and circulation to the kidney is restored. A Penrose drain is left in the perinephric space. Transverse Resection A transverse resection is done to remove large tumors that extensively involve the upper or lower portion of the kidney. This technique is performed using surface hypothermia after temporary occlusion of the renal artery ( Fig. 6-6). Major branches of the renal artery and vein supplying the tumor-bearing portion of the kidney are identified in the renal hilus, ligated, and divided. If possible, this should be done before temporarily occluding the renal artery to minimize the overall period of renal ischemia.

FIG. 6-6. Technique of transverse resection for a tumor involving the upper half of the kidney.

After the renal artery has been occluded, the parenchyma is divided by blunt and sharp dissection, leaving a 1-cm margin of grossly normal tissue around the tumor. Transected blood vessels on the renal surface are secured as previously described, and the hilus is inspected carefully for remaining unligated segmental vessels. An internal ureteral stent may be inserted if extensive reconstruction of the collecting system is necessary. If possible, the renal defect is sutured together with one of the techniques previously described. If this suture cannot be placed without tension or without distorting the renal vessels, a piece of peritoneum or perirenal fat is sutured in place to cover the defect. Circulation to the kidney is restored, and a Penrose drain is left in the perirenal space. Simple Enucleation Some renal cell carcinomas are surrounded by a distinct pseudocapsule of fibrous tissue. The technique of simple enucleation implies circumferential incision of the renal parenchyma around the tumor simply and rapidly at any location, often with no vascular occlusion, and with maximal preservation of normal parenchyma. Initial reports indicated satisfactory short-term clinical results after enucleation with good patient survival and a low rate of local tumor recurrence. However, most recent studies have suggested a higher risk of leaving residual malignancy in the kidney when enucleation is performed. These latter reports include several carefully done histopathologic studies that have demonstrated frequent microscopic tumor penetration of the pseudocapsule that surrounds the neoplasm. These data indicate that it is not always possible to be assured of complete tumor encapsulation before surgery. Local recurrence of tumor in the treated kidney is a grave complication of partial nephrectomy for renal cell carcinoma, and every attempt should be made to prevent it. Therefore, it is the author's view that a surrounding margin of normal parenchyma should be removed with the tumor whenever possible. This provides an added margin of safety against the development of local tumor recurrence and, in most cases, does not appreciably increase the technical difficulty of the operation. The technique of enucleation is currently employed only in occasional patients with von Hippel Lindau disease who have multiple low-stage encapsulated tumors involving both kidneys. Extracorporeal Partial Nephrectomy and Autotransplantation Extracorporeal partial nephrectomy for renal cell carcinoma with autotransplantation of the renal remnant was initially described to facilitate excision of large complex tumors involving the renal hilus. Reconstruction of kidneys with renal cell carcinoma as well as renal artery disease may also be facilitated with this approach. The advantages of an extracorporeal approach include optimum exposure, a bloodless surgical field, the ability to perform a more precise operation with maximum conservation of renal parenchyma, and a greater protection of the kidney from prolonged ischemia. Disadvantages of extracorporeal surgery include longer operative time with the need for vascular and ureteral anastomoses and an increased risk of temporary and permanent renal failure; the latter presumably reflects a more severe intraoperative ischemic insult to the kidney. Although some urologic surgeons (including the author) have found that almost all patients undergoing partial nephrectomy for renal cell carcinoma can be managed satisfactorily in situ, others have continued to recommend an extracorporeal approach for selected patients. Extracorporeal partial nephrectomy and renal autotransplantation are generally performed through a single midline incision. The kidney is mobilized and removed outside Gerota's fascia with ligation and division of the renal artery and vein as the last steps in the operation. Immediately after division of the renal vessels, the removed kidney is flushed with 500 ml of a chilled intracellular electrolyte solution and is submerged in a basin of ice slush saline solution to maintain hypothermia. Under these conditions, if warm renal ischemia has been minimal, the kidney can safely be preserved outside the body for as much time as is needed to perform extracorporeal partial nephrectomy. If possible, it is best to leave the ureter attached in such cases to preserve its distal collateral vascular supply, particularly with large hilar or lower renal tumors, in which complex excision may unavoidably compromise the blood supply to the pelvis, ureter, or both. When this procedure is done, the extracorporeal operation is performed on the abdominal wall. If the ureter is left attached, it must be occluded temporarily to prevent retrograde blood flow to the kidney when it is outside the body. Often, unless the patient is thin, working on the abdominal wall with the ureter attached is cumbersome because of the tethering and restricted movement of the kidney. If these are observed, the ureter should be divided, and the kidney placed on a separate workbench. This practice will provide better exposure for the extracorporeal operation, and, as this is being done, a second surgical team can be simultaneously preparing the iliac fossa for autotransplantation. If concern exists about the adequacy of ureteral blood supply, the risk of postoperative urinary extravasation can be diminished by restoring urinary continuity through direct anastomosis of the renal pelvis to the retained distal ureter. Extracorporeal partial nephrectomy is done with the flushed kidney preserved under surface hypothermia. The kidney is first divested of all perinephric fat to appreciate the full extent of the neoplasm ( Fig. 6-7A,B). Because such tumors are usually centrally located, dissection is generally begun in the renal hilus with identification of major segmental arterial and venous branches. Vessels clearly directed toward the neoplasm are secured and divided, and those supplying uninvolved renal parenchyma are preserved. The tumor is then removed by incising the capsule and parenchyma to preserve a surrounding margin of normal renal tissue (Fig. 6-7C,D). Transected blood vessels visible on the renal surface are secured, and the collecting system is closed as described for in situ partial nephrectomy.

FIG. 6-7. Technique for extracorporeal resection of large central renal neoplasm. (A) The kidney is removed to outside Gerota's fascia with its surrounding perinephric fat. (B) The flushed kidney is divested of all perinephric fat, and the gross margins of the tumor in relation to uninvolved renal parenchyma are defined. The dashed line indicates the area of tumor to be excised with a margin of surrounding normal renal tissue. (C) The capsule and parenchyma are incised, and vessels directed toward the neoplasm are secured and divided. (D) The renal remnant following extracorporeal excision of the tumor is shown. (E) The renal remnant is placed on the pulsatile perfusion unit and is alternatively perfused through the renal artery and vein. (F) The defect created by the partial nephrectomy is closed by suturing the kidney to itself.

At this point, the renal remnant may be reflushed or placed on the pulsatile perfusion unit to facilitate identification and suture ligation of remaining potential bleeding points (Fig. 6-7E). Alternatively, the kidney can be perfused through the renal artery and vein to ensure both arterial and venous hemostasis. Because the flushing solution and perfusate lack clotting ability, there may continue to be some parenchymal oozing, which can safely be ignored. If possible, the defect created by the partial nephrectomy is closed by suturing the kidney on itself to further ensure a watertight repair ( Fig. 6-7F). Autotransplantation into the iliac fossa is done employing the same vascular technique as that in renal allotransplantation. Urinary continuity may be restored with ureteroneocystostomy or pyeloureterostomy, leaving an internal ureteral stent in place. When removal of the neoplasm has necessitated extensive hilar dissection of vessels supplying the renal pelvis, an indwelling nephrostomy tube is also left for postoperative drainage. After autotransplantation, a Penrose drain is positioned extraperitoneally in the iliac fossa away from the vascular anastomotic sites. Partial Nephrectomy in Duplex Collecting Systems Occasionally, heminephrectomy in a kidney with a duplicated collecting system is indicated because of hydronephrosis and parenchymal atrophy of one of the two segments. In these cases, the demarcation of the tissue to be removed is usually very evident. The atrophic parenchyma lining the dilated system can be further

delineated by blue pyelotubular backflow if the ureter is ligated and the affected collecting system is distended by blue dye under pressure. In such cases, there is also often a dual arterial supply with distinct segmental branches to the upper and lower halves of the kidney. Segmental arterial and venous branches to the diseased portion of the kidney are ligated and divided. After preserving a strip of renal capsule, the parenchyma is divided at the observed line of demarcation. There is usually minimal bleeding from the renal surface, and temporary occlusion of the arterial supply to the nondiseased segment is often unnecessary. There should be no entry into the collecting system over the transected renal surface, which is then closed or covered as described above. Postoperative Follow-up Patients who undergo a partial nephrectomy for renal cell carcinoma are advised to return for initial follow-up 4 to 6 weeks postoperatively. At this time, a serum creatinine measurement and intravenous pyelogram are obtained to document renal function and anatomy; in patients with impaired overall renal function, a renal ultrasound study is obtained instead of an intravenous pyelogram.

OUTCOMES Complications Complications of partial nephrectomy include hemorrhage, urinary fistula formation, ureteral obstruction, renal insufficiency, and infection. Significant intraoperative bleeding can occur in patients who are undergoing partial nephrectomy. The need for early control and ready access to the renal artery is emphasized. Postoperative hemorrhage may be self-limiting if confined to the retroperitoneum, or it may be associated with gross hematuria. The initial management of postoperative hemorrhage is expectant with bed rest, serial hemoglobin and hematocrit determinations, frequent monitoring of vital signs, and blood transfusions as needed. Angiography may be helpful in some patients to localize actively bleeding segmental renal arteries, which may be controlled via angioinfarction. Severe intractable hemorrhage may necessitate reexploration with early control of the renal vessels and ligation of the active bleeding points. Postoperative urinary flank drainage after a partial nephrectomy is common and usually resolves as the collecting system closes with healing. Persistent drainage suggests the development of a urinary cutaneous fistula. This diagnosis can be confirmed by determination of the creatinine level of the drainage fluid or by intravenous injection of indigo carmine with subsequent appearance of the dye in the drainage fluid. The majority of urinary fistulas resolve spontaneously if there is no obstruction of urinary drainage from the involved renal unit. If the perirenal space is not adequately drained, a urinoma or abscess may develop. An intravenous pyelogram or retrograde pyelogram should be obtained to rule out obstruction of the involved urinary collecting system. In the event of hydronephrosis or persistent urinary leakage, an internal ureteral stent is placed. If this is not possible, a percutaneous nephrostomy may be inserted. The majority of urinary fistulas resolve spontaneously with proper conservative management, although this may take several weeks in some cases. A second operation to close the urinary fistula is rarely necessary. Ureteral obstruction can occur after partial nephrectomy because of postoperative bleeding into the collecting system with resulting clot obstruction of the ureter and pelvis. This obstruction can lead to temporary extravasation of urine from the renal suture line. In most cases, expectant management is appropriate, and the obstruction resolves spontaneously with lysis of the clots. When urinary leakage is excessive, or in the presence of intercurrent urinary infection, placement of an internal ureteral stent can help to maintain antegrade ureteral drainage. Varying degrees of renal insufficiency often occur postoperatively when partial nephrectomy is performed in a patient with a solitary kidney. This insufficiency is a consequence of both intraoperative renal ischemia and removal of some normal parenchyma along with the diseased portion of the kidney. Such renal insufficiency is usually mild and resolves spontaneously with proper fluid and electrolyte management. Also, in most cases, the remaining parenchyma undergoes compensatory hypertrophy that serves to further improve renal function. Severe renal insufficiency may require temporary or permanent hemodialysis, and patients should be made aware of this possibility preoperatively. Postoperative infections are usually self-limiting if the operative site is well drained and there was no preexisting untreated urinary infection at the time of surgery. Unusual complications of partial nephrectomy include transient postoperative hypertension and aneurysm or arteriovenous fistula in the remaining portion of the parenchyma. A recent study detailed the incidence and clinical outcome of technical or renal-related complications occurring after 259 partial nephrectomies for renal tumors at The Cleveland Clinic. 2 In the overall series, local or renal-related complications occurred after 78 operations (30.1%). The incidence of complications was significantly less for operations performed after 1988 and significantly less for incidentally detected versus suspected tumors. The most common complications were urinary fistula formation and acute renal failure. A urinary fistula occurred after 45 of 259 operations (17%). Significant predisposing factors for a urinary fistula included central tumor location, tumor size >4 cm, the need for major reconstruction of the collecting system, and ex vivo surgery. Only one urinary fistula required open operative repair, and the remainder resolved either spontaneously ( n=30) or with endoscopic management (n=14). Acute renal failure occurred after 30 of 115 operations (26%) performed on a solitary kidney. Significant predisposing factors for acute renal failure were tumor size >7 cm, >50% parenchymal excision, >60 minutes ischemia time, and ex vivo surgery. Acute renal failure resolved completely in 25 patients, nine of whom (8%) required temporary dialysis; five patients (4%) required permanent dialysis. Overall, only eight complications (3.1%) required repeat open surgery for treatment, and all other complications resolved with noninterventive or endourologic management. Surgical complications contributed to an adverse clinical outcome in only seven patients (2.9%). These data indicate that partial nephrectomy can be performed safely with preservation of renal function in most patients with renal tumors. Results We recently completed a detailed analysis of tumor recurrence patterns after partial nephrectomy for sporadic localized renal cell carcinoma (RCC) in 327 patients at The Cleveland Clinic. 4 The purpose of this study was to develop appropriate guidelines for long-term surveillance after partial nephrectomy for RCC. Recurrent RCC after partial nephrectomy occurred in 38 patients (1 1.6%) including 13 patients (4.0%) who developed local tumor recurrence (LTR) and 25 patients (7.6%) who developed metastatic disease (MD). The incidence of postoperative LTR and MD according to initial pathologic tumor stage was as follows: 0% and 4.4% for T1 RCC, 2.0% and 5.3% for T2 RCC, 8.2% and 11.5% for T3a RCC, and 10.6% and 14.9% for T3b RCC. The peak postoperative intervals for developing LTR were 6 to 24 months (in T3 RCC patients) and >48 months (in T2 RCC patients). The above data indicate that surveillance for recurrent malignancy after partial nephrectomy for RCC can be tailored according to the initial pathologic tumor stage. The recommended surveillance scheme is depicted in Table 6-1. All patients should be evaluated with a medical history, physical examination, and selected blood studies on a yearly basis. The latter should include serum calcium, alkaline phosphatase, liver function tests, blood urea nitrogen, serum creatinine, and electrolytes. A 24-hour urinary protein measurement should also be obtained in patients with a solitary remnant kidney to screen for hyperfiltration nephropathy. 9 Patients who have proteinuria may be treated with a low-protein diet and a converting enzyme inhibitor, which appears to be beneficial in preventing glomerulopathy caused by reduced renal mass.

TABLE 6-1. Recommended postoperative surveillance after NSS for sporadic localized RCC

The need for postoperative radiographic surveillance studies varies according to the initial pT stage. Patients who undergo partial nephrectomy for pT1 RCC do not require radiographic imaging postoperatively in view of the very low risk of recurrent malignancy. A yearly chest x-ray is recommended after partial nephrectomy for pT2 or pT3 RCC because the lung is the most common site of postoperative metastasis in both groups. Abdominal or retroperitoneal tumor recurrence is uncommon in pT2 patients, particularly early after partial nephrectomy, and these patients require only occasional follow-up abdominal CT scanning; we recommend that this be done every 2 years in this category. Patients with pT3 RCC have a higher risk of developing LTR, particularly during the first 2 years after partial nephrectomy, and they may benefit from more frequent follow-up abdominal CT scanning initially; we recommend that this be done every 6 months for 2 years and every 2 years thereafter. The technical success rate with partial nephrectomy for renal cell carcinoma is excellent, and several large studies have reported 5-year cancer-specific survival rates of 87% to 90% in such patients (Table 6-2). These survival rates are comparable to those obtained after radical nephrectomy, particularly for low-stage renal cell carcinoma. The major disadvantage of partial nephrectomy for renal cell carcinoma is the risk of postoperative local tumor recurrence in the operated kidney, which has been observed in 4% to 6% of patients. These local recurrences are most likely a manifestation of undetected microscopic multifocal renal cell carcinoma in the renal remnant. The risk of local tumor recurrence after radical nephrectomy has not been studied, but it is presumably very low.

TABLE 6-2. Results of partial nephrectomy for renal cell carcinoma

Recent studies have clarified the role of partial nephrectomy in patients with localized unilateral renal cell carcinoma and a normal contralateral kidney. The data indicate that radical nephrectomy and partial nephrectomy provide equally effective curative treatment for such patients who present with a single, small (4 cm) or multiple localized renal cell carcinomas, and radical nephrectomy remains the treatment of choice in such cases when the opposite kidney is normal. The long-term renal functional advantage of partial nephrectomy with a normal opposite kidney requires further study. CHAPTER REFERENCES 1. Butler B, Novick AC, Miller D, et al. Management of small unilateral renal cell carcinomas: Radical versus nephron-sparing surgery. Urology 1995;45:34–41. 2. Campbell SC, Novick AC, Streem SB, et al. Complications of nephron-sparing surgery for renal tumors. J Urol 1994;151:1177–1180. 3. Campbell SC, Fichtner J, Novick AC, et al. Intraoperative evaluation of renal cell carcinoma: Prospective study of the role of ultrasonography and histopathological frozen sections. J Urol 1996;155:1191. 4. Hafez KS, Novick AC, Campbell SC. Patterns of tumor recurrence and guidelines for follow-up after nephron-sparing surgery for sporadic renal cell carcinoma. J Urol 1997;157:2067–2071. 5. Lerner SE, Hawkins CA, Blute ML, et al. Disease outcome in patients with low-stage renal cell carcinoma treated with nephron-sparing or radical surgery. J Urol 1996;155:1868. 6. Licht MR, Novick AC, Goormastic M. Nephron-sparing surgery in incidental versus suspected renal cell carcinoma. J Urol 1994;152:39–42. 7. Licht MR, Novick AC. Nephron-sparing surgery for renal cell carcinoma. J Urol 1993;149:1–7. 8. Morgan WR, Zincke H. Progression and survival after renal-conserving surgery for renal cell carcinoma: Experience in 104 patients and extended follow-up. J Urol 1990;144:852–858. 9. Novick AC, Gephardt G, Guz B, et al. Long-term follow-up after partial removal of a solitary kidney. N Engl J Med 1991;325:1058–1062. 10. Steinbach F, Stockle M, Muller SC, et al. Conservative surgery of renal cell tumors in 140 patients: 21 years of experience. J Urol 1992;148:24–30.

Chapter 7 Radical Nephrectomy Glenn’s Urologic Surgery

Chapter 7 Radical Nephrectomy Michael S. Cookson

M. S. Cookson: Division of Urology, Department of Surgery, University of Kentucky, Lexington, Kentucky 40536.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Flank Incision Thoracoabdominal Incision Transabdominal (Chevron or Anterior Subcostal) Radical Nephrectomy Outcomes Complications Results Chapter References

Renal cell carcinoma (RCC) is the most common malignancy of the kidney and accounts for about 3% of all adult neoplasms. The estimated number of new cases of renal cell carcinoma in the United States in 1997 is 28,000 with a projected 11,300 deaths, and this incidence is expected to increase as a result of the expanded use of radiographic imaging. 7 Because renal cell carcinoma is relatively refractory to chemotherapy and radiation therapy, surgery in general and radical nephrectomy in particular has evolved as the primary treatment in patients with clinically localized and locally advanced disease. Radical nephrectomy is defined as resection of Gerota's fascia and its entire contents including the kidney, perinephric fat and lymphatics, and ipsilateral adrenal gland. In theory, complete surgical excision of all tumor with negative surgical margins would offer the best opportunity for cure in patients with renal cell carcinoma. This argument would favor radical nephrectomy over simple nephrectomy, given the frequent propensity of the tumor to extend microscopically outside of the renal capsule and into perinephric fat. Thus, although no randomized trial has demonstrated the superiority of radical nephrectomy over simple nephrectomy, multiple series have documented improved survival in patients with renal cell carcinoma treated with radical nephrectomy over the past 30 years. 2,3,4 and 8

DIAGNOSIS Between 85% and 90% of all solid renal masses are renal cell carcinoma, and, therefore, the diagnosis of renal cell carcinoma should be considered in all patients with a suspected solid renal mass. A renal mass detected on either intravenous pyelography or ultrasound is usually confirmed by computed tomography (CT scan). Typically, renal cell carcinomas are characterized on CT scan by a solid parenchymal mass with a heterogeneous density and enhancement with intravenous contrast injection (between 15 and 40 Hounsfield units). However, despite modern imaging, some benign tumors of the kidney may be indistinguishable and confirmed only after surgical excision. Additionally, metastatic deposits from a variety of malignancies including lung and breast cancers may involve the kidney and should be considered in patients with a known primary. The role of percutaneous biopsy or needle aspiration in differentiating an indeterminate renal mass remains controversial, and the absence of malignant cells on biopsy does not rule out the possibility of a neoplasm. For this reason, percutaneous renal biopsy for the purpose of diagnosis should be used only in selected cases. Clinical staging in patients suspected of renal cell carcinoma usually includes a contrast-enhanced CT scan of the abdomen; however, MRI is used occasionally and is particularly useful in patients with a history of a contrast allergy, renal insufficiency, or a suspected vena caval thrombus. From these imaging modalities, a number of factors can be determined, including the size and resectability of the primary, the presence or absence of lymphadenopathy or metastasis, involvement of adjacent structures, and the status of the contralateral kidney. A chest x-ray is obtained to rule out lung metastasis. Bone scans are performed in any patients with symptoms referable to the bone, as well as an elevation in serum alkaline phosphatase or hypercalcemia. In cases of suspected vena caval involvement, Doppler ultrasound is a useful screening tool. If results are equivocal, or if a vena caval thrombus is confirmed, a vascular phase MRI is usually able to determine the level of extension of the tumor thrombus, which allows the surgeon to properly plan an operative strategy.

INDICATIONS FOR SURGERY The indication for radical nephrectomy is a clinically localized solid renal mass in a patient with a normal contralateral kidney. Patients with solitary kidneys, renal insufficiency, and bilateral renal masses should be considered candidates for nephron-sparing surgery. A thorough preoperative history and physical examination should be performed before the procedure. If significant comorbidities are suspected, consultation with the appropriate physician is recommended. The patient should be expected to physically withstand the operation and have a reasonable overall performance status and a 5-year life expectancy. In general, radical nephrectomy in patients with metastatic disease is performed for palliation, such as those patients with intractable pain or life-threatening hemorrhage who fail conservative treatment. Also, radical nephrectomy may be performed in the setting of an approved investigational protocol. Radical nephrectomy as a potential adjunct to enhance the effectiveness of biological response modifiers in patients with metastatic renal cell carcinoma remains experimental. The role of radical nephrectomy in patients with a solitary metastatic site is controversial; however, 5-year survival rates of 30% have been reported in selected patients, with best results reported in patients with solitary pulmonary metastases. 2 Although local extension of primary renal cell carcinoma into the perinephric fat, vena cava, or ipsilateral adrenal gland may portend a worse prognosis, in the absence of metastatic disease these factors alone should not dissuade the surgeon from attempting a radical nephrectomy. Additionally, radical nephrectomy has been successfully performed in the setting of direct extension of the tumor into adjacent organs such as the liver, colon, or psoas muscle. However, surgical removal in this setting is technically difficult and is associated with a higher morbidity and a potentially poor prognosis. Therefore, it should be attempted only in selected patients without obvious nodal or metastatic disease and in cooperation with appropriate surgical consultants. The role of regional lymphadenectomy at the time of radical nephrectomy remains controversial, and presently most patients should undergo only a limited unilateral lymphadenectomy for the purpose of staging. 2

ALTERNATIVE THERAPY Surgery remains the only effective and potentially curative form of therapy for primary RCC. Along this line, the main challenge to radical nephrectomy in the near future appears to be from more conservative surgical approaches. Partial nephrectomy, enucleation, and wedge resection have recently been proposed in small, clinically localized RCC, with excellent early results ( Chapter 6).6 Arguments against partial nephrectomy include the potential for local recurrence, tumor multifocality, and the potential for increased complications. The routine removal of the ipsilateral adrenal gland at the time of radical nephrectomy has also been questioned, particularly in small tumors and tumors not involving the upper pole. 9 The use of laparoscopic techniques is currently expanding, and recently laparoscopic nephrectomy has been reported in patients with small tumors, although concerns over potential for tumor spillage and alteration of pathologic staging remain to be addressed. 5 Currently, chemotherapy and radiation therapy have proven to be inadequate treatment in primary renal cell carcinoma. 2

SURGICAL TECHNIQUE There are a variety of factors that influence the choice of incision during radical nephrectomy. These include location of the affected kidney, tumor size and characteristics, body habitus, and physician preference. There are advantages and disadvantages to each incision, and it is important to be familiar with several approaches to the kidney, as no one incision is appropriate in all settings. The most commonly used incisions for radical nephrectomy are the flank,

thoracoabdominal, and transabdominal (subcostal or chevron) ( Fig. 7-1).

FIG. 7-1. Types of incisions during radical nephrectomy.

Flank Incision The flank approach is an excellent choice for a variety of reasons. First, it allows direct access to the retroperitoneum and kidney, and the entire procedure can often be performed in an extrapleural and extraperitoneal fashion. Additionally, the incision is anatomic in that it follows the track of the intercostal nerves with minimal risk of denervation. However, in large tumors, tumors involving the upper pole, or in situations where vena cava access is critical, a flank approach may be suboptimal. Although a flank approach may be performed through a subcostal incision, an 11th or 12th rib incision is superior for exposure of the upper pole and ipsilateral adrenal gland during radical nephrectomy. The patient is positioned on an inflatable mattress in the lateral decubitus position with the upper chest at about a 45 degree angle. An axillary roll is placed under the patient to cushion against pressure on the brachial plexus, and the elbows are padded to prevent ulnar nerve injury. The upper arm is draped across the body and placed on a Mayo stand or a padded support. The lower leg is flexed at 90 degrees, and the upper leg is extended over one or two pillows. The kidney rest is raised and the table is flexed to elevate the flank, and the table is adjusted to make the flank horizontal to the floor. The inflatable mattress is then activated, and the patient is secured with wide tape. An 11th or 12th rib incision is made based on several factors including the kidney position, the cephalad extent of the tumor, and the patient's body habitus. A general rule is to incise over the rib that, when extended medially, will position the incision over the renal hilum. The incision is then made over the rib from the posterior axillary line to the tip and extended medially as far as necessary, which usually stops short of the lateral border of the rectus abdominis Figure 7-2). The latissimus dorsi is divided, and the upper portion of the incision is carried down to the rib. At this point a partial rib resection may be accomplished as shown in ( Fig. 7-3). An Alexander periosteal elevator is used to deflect the periosteum from the bone to avoid injury to the intercostal bundle located under the inferior portion of the rib. A Doyen elevator is then used to strip the periosteum from the entire undersurface of the rib to be resected. Next, a rib cutter is used to divide the proximal segment of the rib. Alternatively, the incision may be created between the ribs in the intercostal space.

FIG. 7-2. Technique of 11th-rib resection. (A and B) The incision is made over the 11th rib. (C) After division of the latissimus dorsi and external oblique muscles, subperiosteal resection of the rib is performed. (D) The incision is carried through the periosteum posteriorly and the internal oblique and transversus muscles medially, exposing the paranephric space. A tongue of pleura lies in the upper portion of the wound. Diaphragmatic slips that come into view are divided, and the pleura can be retracted upward. (E) The paranephric fat is dissected bluntly.

FIG. 7-3. Rib resection technique. (A) After exposure of the rib, the intercostal muscles are stripped from the upper and lower rib surfaces with an Alexander Farabeuf costal periosteotome. (B) The rib is freed from the periosteum by subperiosteal resection or from the pleura with a periosteum elevator. (C) A Doyen costal elevator is slipped beneath the rib to free it. The proximal and distal portions of the rib are immobilized with Kocher's clamps, and the rib is divided proximal to its angle with a right-angled rib cutter. (D) The costal cartilage is cut free with scissors. The cut surface of the rib is inspected for spicules, which are removed with a rongeur.

The posterior layer of the periosteum is then incised carefully, and the pleura is protected superiorly. Anteriorly, the external and internal oblique muscles are divided, and the transversus abdominis muscle is split in the direction of its fibers, taking care not to enter the peritoneum. The peritoneum is swept medially, and the intermediate stratum of the retroperitoneal connective tissue is incised sharply to expose the paranephric space. Approaching this in a posterior fashion with early identification of the psoas muscle helps to keep proper orientation. A self-retaining retractor such as a Finochetto or Balfour helps to maintain exposure. A radical nephrectomy is then performed. The wound is closed after checking to ensure that no injury to the pleura has occurred (see complications). The table flex is released, and the kidney rest is lowered. The posterior layer consisting of the fascia of the transversus abdominis and the internal oblique is closed in a running fashion with #1 PDS or Prolene. The anterior layer of external oblique fascia is closed with a running #1 PDS or Prolene. Alternatively, interrupted figure-of-eight sutures of #1 Vicryl can be used for both layers. The skin is closed in accordance with surgeon preference.

Thoracoabdominal Incision The thoracoabdominal approach allows for excellent exposure of large tumors as well as upper-pole tumors, particularly on the left. Additionally, it affords easy access to the adrenal gland and thoracic cavity. The patient is positioned with the hips flat and with the break of the table located just above the iliac crest. The pelvis can be torqued up to about 30 degrees if necessary. The patient's ipsilateral shoulder is rotated 45 degrees, and the ipsilateral arm is extended over the table and properly supported on a Mayo stand or padded arm rest Figure 7-4). It is important to properly pad all pressure points including between the legs and the contralateral shoulder. The kidney rest may be elevated to accentuate the proper extension, and the break in the table is made to optimize the incision. After positioning, the patient is secured with wide adhesive tape.

FIG. 7-4. Thoracoabdominal incision. (A) The patient is placed in a semirecumbent position using sandbags. If the chest is entered through the ninth intercostal space, the incision extends from the midaxillary line across the costal margin at the intercostal space to the midline or across it just above the umbilicus. (B) The anterior rectus sheath and the external oblique and latissimus dorsi muscles are divided. (C) The intercostal muscles parallel the direction of the three abdominal layers and are divided. The costal cartilage and the internal oblique and rectus muscles are incised. If more exposure is desired, the linea alba and opposite rectus can be divided. (D) The pleural reflection (shaded areas) lies progressively closer to the costal margin in the more cephalic intercostal spaces. (E) The pleura, reflecting as the costophrenic sinus near the costal margin, is exposed beneath the intercostal muscles. The diaphragm can be seen inferior and dorsal to the pleura. The pleura is opened with care to avoid injuring the lung, which comes into view with inspiration. After the lung is packed away gently, the diaphragmatic surface of the pleura is seen. The diaphragm is incised on its thoracic surface, avoiding the phrenic nerve. (F) The transversus abdominis muscle is divided, exposing the peritoneum with the liver lying beneath it. (G) The peritoneum is incised, and a rib-spreading retractor (Finochletto) is inserted, enabling upward displacement of the liver (or the spleen on the left) into the thoracic cavity and giving wider access to the posterior peritoneum than in an anterior abdominal incision.

The thoracoabdominal incision is made over the bed of the eighth, ninth, or tenth rib, depending on the surgeon's preference based on patient and tumor characteristics. The incision may be made between the ribs, or a portion of the rib may be removed. The incision is made over the rib beginning at the posterior axillary line. The incision is carried medially across the costal cartilage margin to the midline and then carried down the midline to the umbilicus. Alternatively, the medial portion of the incision may be carried across the midline or combined with a low midline to form a “T.” The latissimus dorsi is divided, and the upper portion of the incision is carried down to the rib. At this point, a rib resection can be performed as previously described ( Fig. 7-3). The peritoneum may be entered by incising the external and internal obliques, the transversus abdominis, and the ipsilateral rectus belly. Next, the costochondral cartilage at the inferior portion of the upper thoracic incision is divided, and the chest is entered along the entire length of the periosteal bed. The pleural space is entered, and care should be taken not to injure the lung. The lung is protected by pads, and the diaphragm is divided in the direction of the muscle fibers, which helps to avoid injury to the phrenic nerve. A self-retaining retractor such as a Finochetto or a Balfour is properly padded and placed to maintain exposure. A radical nephrectomy is then performed. After completion of the radical nephrectomy, the table flex is removed, and the diaphragm is closed with interrupted 2-0 silk sutures with knots placed on the inferior side. After a #32 chest tube has been inserted through a separate incision and properly positioned, the ribs are reapproximated with 2-0 chromic pericostal sutures. The thoracic portion of the incision is closed with interrupted figure-of-eight 1-0 Vicryl sutures through all layers of the chest wall. The medial portion of the intercostal muscle closure should include at least a small portion of the diaphragm. An intercostal nerve block is administered before closure and may be accomplished by injecting approximately 10 ml of 0.5% lidocaine or bupivicaine hydrochloride into the intercostal space of the incision and two interspaces above and below. The costal cartilage can be reapproximated with 0 chromic suture. The peritoneum is closed with a running 2-0 chromic, although this is optional. The posterior rectus fascia, the fascia of the transversus abdominis, and the internal oblique muscles are closed with a running or interrupted #1 PDS suture. The anterior rectus and the external oblique fascia are closed with either a running or interrupted #1 PDS or Maxon suture. Skin closure is determined by surgeon preference. The chest tube is secured in place with a 0 silk and taped securely in place. Transabdominal (Chevron or Anterior Subcostal) Anterior incisions offer several advantages including excellent exposure of the renal pedicle and access to the entire abdomen and contralateral retroperitoneum. With the patient in the supine position, the operative side is elevated slightly with a flank roll, and the patient hyperextended to accentuate the line of incision. An incision is made from near the tip of the 11th or 12th rib on the ipsilateral side two fingerbreadths below the costal margin and extended medially to the xyphoid process. The incision is then gently curved across the midline and as far laterally as necessary for exposure up to near the tip of the contralateral 11th rib. Occasionally, only a portion of the contralateral side will be incised just across the rectus abdominis. The incision is carried down to the anterior rectus fascia, which is then divided (Fig. 7-5). Next, the external and internal oblique fascia and muscles are divided, and the fibers of the transversus abdominis split. The rectus muscle and posterior rectus sheath are divided with electrocautery by placing a straight clamp or army–navy retractor underneath and gently elevating it. The superior epigastric artery is ligated with 2-0 silk and divided when encountered. The peritoneal cavity is then entered, and the falciform ligament is ligated between two Kelly clamps, divided, and tied with 0 silk suture. To facilitate exposure, the lower aspect of the incision is rotated caudally with a rolled towel placed underneath the skin, and the fascia sutured to the lower portion of the abdominal wall with two #2 nylon sutures. Use of a self-retaining retractor such as a Wishbone Omni-Tract is helpful. A radical nephrectomy is then performed.

FIG. 7-5. Transabdominal chevron incision. (A) With the patient in the supine position and slightly hyperextended, an incision is made two fingerbreadths below the costal margin to just below the xyphoid process and then curved gently down across to the tip of the opposite 11th rib. (B) Divide the subcutaneous tissue and the anterior rectus sheath bilaterally. Insinuate a Kelly or an army–navy retractor under the rectus muscle, and the muscle is divided with electrocautery. (C) Divide the external oblique and internal oblique muscles and split the transversus abdominis. Enter the peritoneal cavity in the midline by tenting up on the peritoneum and incising sharply with Metzenbaum scissors.

Closure of the wound is performed after the table is returned to the horizontal position. The wound is then closed in two layers. The posterior layer consisting of the fascia of the transversus abdominis and the internal oblique laterally along with the posterior rectus fascia medially is closed with two running #1 PDS sutures, each starting at the lateral aspect and running medially to the midline. The anterior layer of external oblique and anterior rectus fascia is closed in a similar fashion with #1 PDS. Alternatively, the layers can be closed with interrupted #1 Vicryl. Occasionally, it is helpful to place a U stitch of #1 Prolene at the apex of the chevron incision before closure, which includes the rectus fascia on either side of the midline, securing this suture after the anterior fascia has been approximated. The skin is then closed according to the surgeon's preference. Radical Nephrectomy Irrespective of the choice of incision, certain caveats are universal for the safe and successful completion of a radical nephrectomy. This includes a systematic approach with careful mobilization of Gerota's fascia and early vascular control. For a flank approach, the posterior peritoneum lateral to the colon is incised along the length of the descending colon (left side) or ascending colon (right side) and reflected medially. For left-sided exposure, the lienorenal ligament is incised to mobilize the spleen cephalad. On the right side, the hepatic flexure of the colon is mobilized. The ureter is identified and encircled with a vessel loop. The gonadal vein is ligated and divided. The plane between the mesentery of the colon and Gerota's fascia is then developed using a combination of sharp and blunt dissection. On the right side, the vena cava is exposed by Kocherizing the duodenum. Using blunt dissection, the retroperitoneal fat overlying the renal vessels is separated, exposing the renal hilum. It is often helpful to ligate and divide the ureter before this to allow for mobilization and upward displacement of the lower pole of the kidney. The dissection is then carried cephalad along the vena cava (right side) or aorta (left side). On the right side, the right renal vein is identified exiting from the vena cava, isolated, and encircled with a right-angle clamp and a 0 silk suture and tagged. After identification of the renal artery (exposure may be enhanced by the use of a vein retractor on the renal vein), the artery is dissected free and cleaned for a distance of approximately 2 to 3 cm. With a right-angle clamp, the renal artery is encircled, and 2-0 silk ties are passed ( Fig. 7-6). The sutures are then separated and tied, allowing a safe distance for division of the artery. A small hemoclip or a 3-0 silk suture ligature may be placed on the proximal aspect of the artery before division. A right-angle clamp is placed under the artery to be divided and gently elevated, and the artery is cut with either a knife (#15 blade) or Metzenbaum scissors. The right renal vein is then ligated in a similar fashion with 0 silk sutures.

FIG. 7-6. The right renal artery is identified by palpation beneath the vein. After identification with a right-angle clamp, the artery is cleaned in the same manner as the vein. With a right-angle clamp beneath the artery, a suture is passed on a tonsil clamp to the mouth of the right-angle clamp, and the suture is passed around the artery. (From Donohue RE. Radical nephroureterectomy for carcinoma of the renal pelvis and ureter. In: Crawford ED, Borden TA, eds. Genitourinary cancer surgery. Philadelphia: Lea & Febiger. 1982;101.)

On the left, the renal vein is isolated as it courses over the aorta. The left adrenal and gonadal veins are identified emanating from the left renal vein, and, if present, a posteriorly directed lumbar venous tributary is noted. A right-angle clamp is passed around the renal vein, followed by a 0 silk suture proximal to the tributaries, and tagged. The venous tributaries are then individually ligated and divided with 2-0 or 3-0 silk and small hemoclips where necessary, leaving the 2-0 silk suture on the main renal vein tagged ( Fig. 7-7). The left renal artery and vein are then ligated similarly to the technique described above for the right side.

FIG. 7-7. The same technique for ligation is employed on the left side. A suture is passed around the lumbar vein proximally and distally after the vein has been cleaned, and the vein is ligated. Sutures are passed around the main renal vein but are not tied until after the branches have been ligated. The artery is identified above the vein and cleaned, isolated, and ligated, and the proximal end is sutured with a 5-0 cardiovascular silk suture. (From Donohue RE. Radical nephroureterectomy for carcinoma of the renal pelvis and ureter. In: Crawford ED, Borden TA, eds. Genitourinary cancer surgery. Philadelphia: Lea & Febiger, 1982;101.)

Gerota's fascia is then mobilized posteriorly and superiorly using a combination of sharp and blunt dissection. Hemoclips along the superior and medial border are useful to control any potential bleeding during this portion of the procedure. The adrenal hilum is then dissected from caudal to cranial with the aid of either hemoclips or straight clamps and ties. On the right side, the short posteriorly located right adrenal vein should be anticipated as it exits directly from the vena cava. When encountered, the right adrenal vein is isolated, ligated, and divided. The specimen is then delivered, and meticulous hemostasis is achieved.

OUTCOMES Complications The potential for bleeding during radical nephrectomy necessitates careful patient preparation and preoperative planning to significantly reduce the chances. Any medications that interfere with platelet function or clotting should be discontinued, and patients should be type and cross matched for 2 units of packed red blood cells. The patient should have either two large-bore peripheral intravenous lines or a central venous line to allow for rapid infusion of fluids or blood products. Bleeding during radical nephrectomy may be from a variety of locations including the renal hilum, collateral tumor vessels, or adjacent structures. Venous bleeding is usually the most problematic. The first maneuver is to apply direct pressure to the area of bleeding. The point of bleeding is then carefully exposed and controlled by a suture ligature. In the case of venal caval injury, a Satinsky clamp is placed, and a vascular 5-0 or 6-0 Prolene suture is used to oversew the defect. Lumbar veins should be exposed by gentle retraction of the vena cava, appropriately clamped, ligated with vascular silk suture, and divided. Renal artery bleeding may be controlled by direct pressure on the aorta proximally until adequate exposure can be obtained, and the artery is then ligated. Only in rare circumstances will a pedicle

clamp or mass ligature be necessary. Adrenal tears may result in significant hemorrhage during radical nephrectomy, particularly on the right side, where the short adrenal vein enters into the vena cava directly posterior. Control of the right adrenal vein should be attempted only after control of the vena cava, adequate exposure, and proper suction. The vein is then ligated with a 2-0 or 3-0 silk tie or a vascular Prolene. Venous bleeding from a torn adrenal gland can be oversewn with a running suture or stopped by placement of surgical clips. However, removal of the ipsilateral adrenal may be the most expeditious method of controlling bleeding. Failure to recognize a rent in the pleura during flank incision will result in a pneumothorax. Small openings in the pleura may be recognized by filling the flank wound with sterile water and administering a deep inspiratory breath. Small tears recognized intraoperatively can be managed by closing the pleura with a 3-0 chromic pursestring suture over a 12 Fr or 14 Fr Robinson catheter. Before it is removed, all air is aspirated from the pleural cavity either by suction or by placing the Robinson catheter under water and administering a deep inspiratory breath. The air is evacuated from the pleural space, and the tube is removed while the pursestring suture is simultaneously tied in place. Alternatively, the Robinson catheter can be temporarily left in place with the chromic suture secured and the fascial layers closed around the catheter, which exits from the corner of the wound. Just before skin closure, after all air has been evacuated under water seal as described above, the catheter is removed. The latter technique is helpful when the pleura is attenuated or contains multiple small holes that are not easily closed. Alternatively, a 22 Fr or 24 Fr chest tube may be placed and left to suction. An upright end-expiratory chest x-ray is obtained after all flank incisions to ensure that no significant pneumothorax exists. A small (usually less than 15%), asymptomatic pneumothorax can be followed conservatively with serial chest x-rays and oxygen therapy. In a symptomatic or large pneumothorax, aspiration of the pleural space using a needle or a central venous catheter (Seldinger technique) introduced just over the rib in the anterior fourth or fifth interspace can be therapeutic. However, if these attempts are not successful, a chest tube should be inserted and placed on suction. Injuries to the colon during radical nephrectomy are uncommon. In locally advanced tumors suspected of extension into either the colon or mesentery, patients should undergo a mechanical and antibiotic bowel preparation. Segmental colon resection and primary anastomosis should be possible in most cases. Inadvertent injury to the colon during radical nephrectomy can usually be repaired primarily; however, in situations where there is gross spillage of fecal contents or a devascularized segment, a diverting colostomy should be considered, and a general surgery consultation is advisable. Defects in the mesentery of colon should be closed to prevent internal herniation of peritoneal contents. Right radical nephrectomy is also associated with the potential for injury to the duodenum and liver. The duodenum must be carefully mobilized, and care must be taken to properly pad retractors to prevent injury to the bowel and adjacent structures including the head of the pancreas. The second portion of the duodenum may be injured during a right radical nephrectomy. Duodenal hematomas should only be observed, but rapidly enlarging hematomas will require control of the bleeding, and an intraoperative general surgery consultation should be obtained. Duodenal lacerations should be repaired in multiple layers with interrupted nonabsorbable sutures for the mucosal and serosal layers. 10 When possible, an omental wrap may provide additional support, and all patients should be managed with a nasogastric tube during the postoperative period. Superficial liver lacerations are repaired with absorbable horizontal mattress sutures utilizing a Surgicel or Hemopad bolster. Deep liver lacerations, which may involve the hepatic ducts, could result in bile leakage and should be drained following repair. Direct invasion of the liver by renal cell carcinoma is rare; however, resection including en-bloc removal is possible in selected cases. If a major lobectomy or a partial hepatectomy is to be performed because of either direct extension or major hemorrhage, a general surgeon should be present. Splenic injury is one of the most common intraoperative complications during a left nephrectomy, with an incidence as high as 10% in some series. Most superficial lacerations or tears can be managed conservatively without the need for splenectomy. Although minor tears may require only some gentle pressure and the application of a Hemopad or Surgicel with Avitene application, closure of a moderate splenic capsular tear is facilitated through the use of nonabsorbable sutures over bolsters of Surgicel. Major hemorrhage secondary to severe splenic lacerations may require splenectomy. The splenic artery and vein are controlled by compressing these structures, located in the splenic hilum near the tail of the pancreas. Initially, this can be accomplished manually by compressing the tail of the pancreas between the thumb and the forefinger. Once bleeding has been temporarily controlled, the spleen is mobilized by dividing the splenocolic and splenorenal ligaments as well as taking down the peritoneal attachments to the diaphragm. The short gastric vessels are then ligated, and the hilum of the spleen is dissected free from the tail of the pancreas. The splenic artery and vein are ligated and divided. The pancreas should be inspected closely to rule out inadvertent injury. Following splenectomy, patients will have a reduced resistance to pneumococcal organisms and should receive Pneumovax and Hibtiter on a yearly basis. Results Surgical excision remains the only effective and potentially curative therapy for clinically localized RCC. Pathologic staging remains the best prognostic variable in terms of patient survival, and the two most commonly used staging systems are the Robson classification and the American Joint Committee on Cancer recommendations (TNM) classification. 1,8 Both staging systems have demonstrated an inverse relationship between survival and increasing stage, but the TNM is generally thought to be more accurate because it more precisely defines the extent of disease. In patients treated with radical nephrectomy and found to have tumors confined to the kidney (Robson stage I), the 5-year survival is between 60% and 90% compared with 47% to 67% in patients whose RCC is confined to Gerota's fascia (Robson stage II). Survival for patients with distant metastases is poor with 5-year survival of between 5% and 10%. 2 Under the TNM staging system, the 5-year survival for patients with organ-confined tumors treated with radical nephrectomy for T1N0M0 tumors is between 80% and 91%, whereas that for T 2N 0M0 tumors is 68% to 92%.3,4 For those patients with T 3aN0M0 (tumor invading into the adrenal gland) and T3bN0M0 (tumor invading into the renal vein) carcinomas, the 5-year survival is 77% and 59%, respectively. Finally, patients with node-positive disease (N 1–3M0) have a 5-year survival between 15% and 52%. Although radical nephrectomy remains the standard of care for unilateral renal cell carcinoma, more conservative surgical options have been proposed. Recently, excellent results have been seen in patients treated with nephron-sparing surgery, with 5-year cancer-specific survivals of greater than 90% for small, unilateral, stage I tumors.9 The ultimate choice of surgical treatment in patients with these favorable clinical features, and in particular the risk of local recurrence and cancer-specific survival, remains to be determined through long-term follow-up. Currently, radical nephrectomy remains the treatment of choice in patients with clinically localized renal cell carcinoma and the standard against which future alternative surgical strategies will be measured. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

American Joint Committee on Cancer. Manual for staging of cancer, 4th ed. Philadelphia: JB Lippincott, 1992. deKernion JB, Belldegrun A. Renal tumors. In: Walsh PC, Retik AB, Stamey AB, Vaughan ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;1053–1093. Giuliani L, Giberti C, Martorana G, Rovida S. Radical extensive surgery for RCC: long-term results and prognostic factors. J Urol 1990;143:468–474. Hermanek P, Schrott KM. Evaluation of a new tumor, nodes and metastases classification of RCC. J Urol 1990;144:238–242. Kerbl K, Clayman RV, McDougall EM, Kavoussi LR. Laparoscopic nephrectomy: the Washington University experience. Br J Urol 1994;73:231–236. Novick AC. Renal sparing surgery for RCC. Urol Clin North Am 1993;20:277–282. Parker S, Tong T, Bolden S, Wingo PA. Cancer statistics, 1997. CA 1997;47:5–27. Robson CJ, Churchill BM, Andersen W. The results of radical nephrectomy for RCC. J Urol 1969;101:297–301. Sagolowsky AI, Kadesky KT, Ewalt DM, Kennedy TJ. Factors influencing adrenal metastasis in RCC. J Urol 1994;151:1181–1184. Smith RB. Complications of renal surgery. In: Smith RB, Ehrlich RM, eds. Complications of urologic surgery: Prevention and management, 2nd ed. Philadelphia: WB Saunders, 1990;128–159.

Chapter 8 Intracaval Tumors Glenn’s Urologic Surgery

Chapter 8 Intracaval Tumors Thomas J. Polascik and Fray F. Marshall

T. J. Polascik, Central Medical Park, Durham, North Carolina 27704. F. F. Marshall: James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287.

Diagnosis Indications Alternative Therapy Surgical Technique Cardiopulmonary Bypass, Hypothermia, and Temporary Cardiac Arrest Outcomes Complications Results Chapter References

Tumor thrombus extending from the renal vein into the vena cava has been reported to occur in 4% to 10% of patients with renal cell carcinoma. 5 The extent of tumor thrombus involving the inferior vena cava can vary from involvement of the renal vein only to extension into the right atrium, which occurs in some of these patients. The majority of patients with vena caval tumors have right-sided renal primaries because of the short right renal vein. In the absence of metastatic disease, numerous centers have demonstrated long-term cancer-specific survival rates comparable to early-stage renal cell carcinoma following complete surgical excision. Improvements in surgical technique have allowed the surgeon to safely perform a radical nephrectomy and vena cavotomy. Several centers have documented reduced morbidity and mortality associated with these procedures. We have removed tumor from both renal veins, lumbar veins, hepatic veins, the right atrium, and the right ventricle. Technical difficulties and complications (excessive bleeding, coagulopathy, and postoperative renal failure) can accompany these procedures, especially with extensive intra- or suprahepatic caval neoplastic extension.

DIAGNOSIS Today, the majority of patients presenting with a renal mass and intracaval tumor extension are diagnosed with computerized tomography (CT). In the past, patients presenting with advanced disease had clinical signs and symptoms related to vena caval occlusion including bilateral lower extremity edema, a recently enlarging varicocele, or dilated abdominal wall veins. Patients may also present with proteinuria, hepatic dysfunction with hepatomegaly, or pulmonary embolus. Patients should have a thorough evaluation for metastatic disease because, if present, we do not typically recommend proceeding with surgery. Further radiologic imaging typically includes CT of the chest and abdomen and a bone scan if applicable. The renal vein and vena cava can be noninvasively imaged using magnetic resonance imaging (MRI). The MRI can usually define the superior limit of the caval thrombus unless the distal thrombus is mobile, thus limiting its accuracy. The MRI is also effective when total caval occlusion is present. Vena cavography can be used to define a caval tumor; however, its invasive nature, its false-positive and -negative results, and a decreased ability to define the superior extent of the tumor limit its use. To fully delineate the extent of a large caval tumor, the combination of MRI and intraoperative transesophageal sonography provides the best results. 8 All patients should have a complete medical evaluation and be deemed candidates to withstand an extensive surgery.

INDICATIONS The primary indication for nephrectomy and vena cavotomy is a renal mass with intracaval tumor extension in the absence of metastatic disease. The patient should also be medically able to tolerate an extensive surgical procedure.

ALTERNATIVE THERAPY To date, complete surgical excision of tumor is the only curative treatment. Expectant therapy or systemic protocols may be applicable if the patient is a candidate.

SURGICAL TECHNIQUE In addition to a general anesthetic, a thoracic epidural can be utilized and is often effective with postoperative pain management with most flank incisions. For the majority of tumors, standard intraoperative monitoring includes central venous pressure, arterial pressure tracings, electrocardiography, and urinary output. Additional monitoring is used for extensive vena cava tumors, including a Swan–Ganz catheter, esophageal and rectal temperature probes, oxygen and carbon dioxide measurements, and transesophageal sonography. A hypothermic blanket is used to maintain body temperature. Elastic stockings and sequential compression devices are placed to prevent lower extremity venous stasis. An intravenous cephalosporin is generally sufficient as prophylactic antibiotic coverage. The patient's body habitus and extent of both the primary and intracaval tumor direct the surgical approach. For renal tumors with neoplasm extending minimally into the inferior vena cava, a supra-11th-rib or standard thoracoabdominal approach with rib excision is ideal, especially in obese patients. For left-sided tumors and more extensive caval tumors, an anterior incision will provide good exposure. We have used a thoracoabdominal incision extending from the tip of the scapula across the costal margin to the midline halfway between the umbilicus and the xyphoid process for right-sided tumors with intrahepatic and supradiaphragmatic intracaval tumor extension. In this approach, the patient should be positioned with the right shoulder rotated toward the contralateral side; the hips remain in the supine position, and the table is slightly extended. Although this incision provides both intra-abdominal and intrathoracic exposure, the infradiaphragmatic dissection is easier for the urologist while cannulating the aortic arch for cardiopulmonary bypass is more difficult. We typically use a median sternotomy extending into either a midline abdominal or a chevron incision when the intracaval neoplasm extends into or beyond the liver and cardiopulmonary bypass is considered ( Fig. 8-1).2 The chevron incision is useful in patients with a wide abdominal girth. Although these extensive incisions provide excellent exposure, allowing for additional operations to be performed, we recommend limiting the procedure to nephrectomy and caval thrombectomy.

FIG. 8-1. Incision for radical nephrectomy with removal of vena caval thrombus. Reprinted with permission from Marshall FF, Reitz BA. Radical nephrectomy with excision of vena caval tumor thrombus. In: Marshall FF, Reitz BA (eds.), Marshall's textbook of operative urology. Philadelphia: WB Saunders, 1996.

The operation is commenced by utilizing the entire incision including the median sternotomy, as this approach gives the best exposure. The abdomen is inspected for metastatic disease, and if discovered, the procedure is usually stopped, as cancer-specific survival has not been demonstrated to be improved in the long term. In the absence of overt metastasis, the renal tumor is approached first. For a right renal tumor, the right colon is mobilized along the line of Toldt and retracted medially to gain access to the retroperitoneum. For significant tumors via a midline approach, incision of the root of the mesentery up to the ligament of Trietz with placement of the bowel into an intestinal bag retracted onto the chest provides additional exposure. We use the OmniTract retractor (Minnesota Scientific Inc.), as it provides excellent superficial and deep exposure of the surgical field. The kidney and Gerota's fascia are mobilized, first by a posterolateral approach developing the plane between the quadratus/psoas muscles and Gerota's fascia. After the kidney has been mobilized posteriorly, the renal artery is ligated early to keep blood loss to a minimum. Anteriorly, the mesocolon is then reflected medially from the anterior surface of Gerota's fascia until the vena cava is visualized. A Kocher maneuver provides additional medial exposure near the vena cava. Superiorly, dissection above the adrenal is undertaken with Ligaclips, and the adrenal vein is ligated. Inferiorly, the kidney is mobilized along with ligation of the gonadal vein and ureter. Mobilization of the primary tumor is complete when the kidney remains attached to the vena cava by the renal vein. A left-sided renal tumor with caval thrombus requires dissection on both sides of the abdomen to access both the vena cava and the left kidney. A midline incision usually provides sufficient exposure. The descending colon is reflected medially by incising the line of Toldt. In a dissection similar to that for a right-sided tumor, the kidney and Gerota's fascia is mobilized until only the left renal vein remains. The ascending colon is then mobilized medially by incising the line of Toldt, and the duodenum is reflected by the Kocher maneuver. Once adequate exposure to the vena cava is obtained, the remainder of the procedure is similar to that for a right-sided renal primary tumor. The extent of the intracaval tumor dictates the length the vena caval needs to be isolated. Dissection should proceed directly on the vena cava with care taken to prevent potential dislodgment of caval tumor. If the intracaval tumor extends slightly beyond the ostium of the renal vein into the vena cava, a Statinsky vascular clamp can be placed on the caval sidewall beyond the tumor. This segment of caval wall can be excised with the nephrectomy specimen en bloc, and the cava can be oversewn with a 4-0 polypropylene on a cardiovascular needle. With a more extensive infrahepatic intracaval tumor, control of the vena cava must be obtained above and below the extent of the caval tumor thrombus. During mobilization of the vena cava, one or more posterior lumbar veins may require ligation to prevent unexpected bleeding. Inferiorly, a Rummel tourniquet (umbilical tape passed through a 16-Fr red rubber catheter) is placed loosely below the tumor thrombus and both renal veins. For a right-sided tumor, a Rummel tourniquet is placed loosely around a segment of the left renal vein to secure control of this vessel. Additional exposure to the vena cava can be gained superiorly by dividing the posterior attachments of the liver and rotating the liver medially. Depending on the superior extent of the caval tumor, variable venous branches draining the caudate lobe of the liver may need to be ligated and divided ( Fig. 8-2). If these veins are short, they can be controlled using suture ligatures placed into the liver parenchyma. Cardiopulmonary bypass can be obviated when vascular control using a vascular clamp or Rummel tourniquet can be gained above the superior extent of the tumor. Division of the diaphragm may aid in gaining vascular control above the superior extent of the tumor thrombus.

FIG. 8-2. Ligation and division of venous tributaries of the caudate lobe of the liver. Reprinted with permission from Marshall FF, Reitz BA. Radical nephrectomy with excision of vena caval tumor thrombus. In: Marshall FF, Reitz BA (eds.): Marshall's textbook of operative urology. Philadelphia: WB Saunders, 1996.

After adequate mobilization of the vena cava superior and inferior to the tumor thrombus with ligation of any lumbar veins, all vascular clamps or Rummel tourniquets are secured. A narrow elliptical incision circumscribing the ostium of the involved renal vein is made. If the tumor is inseparable from the caval endothelium superior to the renal veins, the involved cava is excised. The renal primary and caval tumor is removed en toto under direct vision. On occasion, we have used a dental mirror to inspect the hepatic veins or the flexible cystoscope to inspect the cava to ensure complete removal of tumor. If additional verification is necessary, transesophageal echography can be used to evaluate the superior extent of the cava, or direct intraoperative sonography can be used to evaluate the extent of the cava. 8 To close the vena cava, a 4-0 or 5-0 cardiovascular polypropylene suture is used. Before the cavotomy closure is completed, the inferior tourniquet is released to allow trapped air to escape through the cavotomy site. If excision of the cava decreases the vascular diameter by more than 50%, reconstruction of the vena cava is recommended to prevent caval thrombosis (Fig. 8-3). We prefer to reconstruct the vena cava using pericardium because it is less thrombogenic, although prosthetic grafts can be employed.3 Venous drainage of the right kidney must always be preserved to prevent venous infarction. In some instances, the cava has been oversewn to prevent subsequent embolism if the thrombus below the renal veins is adherent to the caval endothelium.

FIG. 8-3. Reconstruction of the vena cava is recommended if the cross-sectional diameter of the vena cava is reduced by more than 50% after resection of the tumor thrombus and vena caval wall. Reprinted with permission from ref. 3.

Cardiopulmonary Bypass, Hypothermia, and Temporary Cardiac Arrest Cardiopulmonary bypass, hypothermia, and temporary cardiac arrest greatly facilitate the resection of a suprahepatic caval thrombus. 4 It is best to dissect as much of the kidney and the vena cava as possible before cardiac bypass. Following isolation of the renal tumor, the pericardium is opened and retracted with stay sutures. Typically, the right atrial appendage is cannulated with a 32-Fr venous cannula, and the aorta is cannulated with a 22-Fr Bardic cannula. Heparin is then administered to maintain an activated clotting time greater than 450 seconds. The patient is placed on bypass with flow rates maintained between 2.5 and 3.5 liters/min. A core temperature of 18° to 20°C is attained within 30 minutes while an 8° to 10°C gradient is maintained between the perfusion and the patient's core temperature. When a rectal temperature of 20°C is reached, the aorta is cross-clamped, and 500 cc of cardioplegic solution is administered. Once cardiac arrest is achieved, bypass is terminated, and the patient is temporarily exsanguinated into an oxygen reservoir. The patient's brain is protected by placing ice bags around the head. At this point

there is no anesthesia, ventilation, or circulation. To reduce the incidence of complications, circulatory arrest time is best limited to 45 minutes. An elliptical incision is made around the ostium of the renal vein and carried superiorly along the length of the vena cava. The incision can extend into the right atrium or ventricle, depending on the superior extent of the thrombus. Cardiopulmonary bypass and deep hypothermic circulatory arrest permit the thrombus to be removed in a bloodless field and the interior of the vena cava and heart to be inspected under direct vision ( Fig. 8-4). It is not uncommon to find some degree of adherence of the tumor to the endothelium. In this case, the tumor thrombus can be “endarterectomized” from the interior of the vena cava or atrium. Reconstruction of the vena cava is as previously described.

FIG. 8-4. (A) The ostium of the renal vein is circumferentially incised, and the right atrium is opened. (B) Following removal of the tumor thrombus, the atriotomy and vena cavotomy incisions are closed. Reprinted with permission from Novick AC, Montie JE. Surgery for renal cell carcinoma. In: Novick AC, Streem SB, Pontes JE (eds.), Stewart's operative urology, Vol. 1, 2nd ed. Baltimore: Williams and Wilkins, 1989.

Following closure of the vena cavotomy, cardiopulmonary bypass is begun. The patient is slowly warmed using a 10°C gradient between the bypass machine and a warming blanket. Mannitol (12.5 g) is given along with 1 g of CaCl 2 when core temperature reaches 25°C. Electrical defibrillation is necessary if the heart does not resume spontaneous beating. Following resumption of cardiac activity, blood is returned to the patient from the oxygen reservoir. Following the rewarming process, which can take up to 1 hour, heparin is neutralized with protamine. The patient is returned to the cardiac ICU intubated.

OUTCOMES Complications Intraoperative complications include excessive bleeding and coagulopathy. Coagulopathy is more common with prolonged cardiopulmonary bypass and cardiac arrest times. Intraoperatively, red blood cells, platelets, fresh frozen plasma, and calcium chloride are routinely administered. Furosemide and/or mannitol is given if urine output remains low. Transient hypotension can occur when the vena cava is clamped. This can be managed with volume expansion and is less of a problem if venous collaterals have developed with a completely occluded vena cava. Embolization of a segment of tumor thrombus can be a potentially lethal intraoperative complication, and extreme care should be taken when handling the vena cava to prevent such an occurrence. Postoperatively, several complications can occur because of the magnitude of the surgical procedure or the use of cardiopulmonary bypass. Potential complications include caval thrombosis, deep venous thrombosis, pulmonary embolus, postoperative bleeding, or coagulopathy. Patients may also develop hepatic dysfunction, renal failure, sepsis, or myocardial infarction. Although the mortality rate associated with this procedure is tolerable, most patients who die of complications within the first postoperative month succumb to multisystem organ failure. Results The 5-year survival rates in most reported large series vary from 14% to 68% following complete surgical removal of the renal tumor and caval extension. 1,6,7 Differences in reported survival may reflect several factors, including local extension of the primary tumor, presence of lymphatic or visceral metastases, level of caval tumor extension, or invasion into the vascular wall. lt is generally agreed that patients with metastatic disease and significant perinephric fat involvement tend to have a poor prognosis. The majority of patients eventually dying of their disease succumb to metastases, which suggests that occult metastatic disease is frequently present at the time of surgery. 6 We believe that patients with good performance status who have tumors confined to the renal capsule and are without evidence of metastatic disease are ideal candidates for this surgery and have improved long-term survival. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Glazer AA, Novick AC. Long-term follow up after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol 1996;155:448. Marshall FF, Dietrick DD, Baumgartner WA, Reitz BA. Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins. J Urol 1988;139:1166. Marshall FF, Reitz BA. Supradiaphragmatic renal cell carcinoma tumor thrombus: indications for vena caval reconstruction with pericardium. J Urol 1985;133:266. Marshall FF, Reitz BA. Technique for removal of renal cell carcinoma with suprahepatic vena caval tumor thrombus. Urol Clin North Am 1986;13:551–557. Marshall VF, Middleton RG, Holswade GR, Goldsmith EI. Surgery for renal cell carcinoma in the vena cava. J Urol 1970;103:414. Polascik TJ, Partin AW, Pound CR, Marshall FF. Radical nephrectomy with intrahepatic or supradiaphragmatic intracaval thrombectomy for renal cell carcinoma: long-term outcome analysis. (submitted) 7. Skinner DG, Pfeister RF, Colvin R. Extension of renal cell carcinoma into the vena cava: the rationale for aggressive surgical management. J Urol 1972;107:711. 8. Treiger BFC, Humphrey LS, Peterson JCV, et al. Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension. J Urol 1991;145:1138.

Chapter 9 Transplant Nephrectomy Glenn’s Urologic Surgery

Chapter 9 Transplant Nephrectomy J. Thomas Rosenthal

J. T. Rosenthal: Department of Urology, U.C.L.A. School of Medicine, Los Angeles, California 90095-1731.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Success rates for kidney transplantation continue to improve. Graft survival at 1 year is now 83% for all cadaver transplants done in the United States and 93% for living related transplants. 9 Some programs report greater than 90% survival even for cadaver grafts, and greater than 85% survival at 2 years. 1 Despite these good results, they are not yet 100%, so a percentage of patients transplanted will fail. The fate of the kidney after transplant failure is the subject of this chapter.

DIAGNOSIS The diagnosis of a failed renal transplant is not difficult because the patients are azotemic and require dialysis. The common causes of graft failure are technical, such as arterial or venous thrombosis, and rejection, acute or chronic. Irreversible rejection can occur despite optimum immune suppression. Sometimes rejection results from the necessity to reduce or stop immune suppression to treat a life-threatening infection. Acute rejections occurring more than 1 year after the transplant are often a result of patient noncompliance with drugs. In any of these situations, patients will usually have undergone some radiologic investigation such as Doppler ultrasound or renal scan to ascertain whether there was a treatable cause for graft dysfunction. Renal biopsy is often performed once it is clear that there is no technical cause of graft dysfunction to determine the degree of acute or chronic rejection present. Once it is certain that renal failure is irreversible, immune suppression is withdrawn, chronic dialysis is reinstituted, and a decision is made as to whether or not it is necessary to remove the allograft.

INDICATIONS FOR SURGERY Grafts failing within the first 12 months are almost always removed prophylactically regardless of the cause of graft loss and whether or not there are specific symptoms present. This is because if the graft is left in place, significant symptoms necessitating its removal will almost always occur. 3 Most of these are either technical failures, which occur in the first few weeks after transplant, or acute rejection, which is manifest in the first 2 to 3 months. Those grafts failing after 12 months are left in place initially, immunosuppression is stopped, and patients are followed. Approximately 50% of these patients will develop symptoms consistent with acute rejection such as fever, malaise, graft tenderness, or gross hematuria. These symptoms can be confused with an infection and can be difficult to distinguish from rejection. onetheless, these symptoms occurring in a patient who has recently had a failed kidney transplant are usually a result of rejection, and so a prolonged workup, searching for the source of fever, is not usually necessary or productive. These symptoms can occur many months after the patient is back on dialysis and many after the transplantation, which can make the diagnosis more difficult. Sometimes proceeding with nephrectomy is the only way to distinguish the symptoms. There has been some suggestion that repeat transplants may do worse in patients who have had the primary graft removed. 1 The data on this point are not absolutely convincing, although they further support the notion of doing the nephrectomy only for specific indications. A rare indication for allograft nephrectomy is the presence of a mass lesion of the transplant kidney. We have seen this twice in approximately 1,500 transplants. The diagnosis is usually made by ultrasound done for routine evaluation of the transplant, which detects the mass, followed by CT scan and biopsy to confirm the diagnosis. This may involve lesions unintentionally transmitted from the donor or lesions arising de novo in the transplant kidney. In the early era of transplantation, nephrectomy was often required because of technical complications such as urinary fistula or graft hemorrhage, which were not lethal to the kidney but could not be repaired. This almost never occurs now.

ALTERNATIVE THERAPY One alternative to allograft nephrectomy is watchful waiting, as described earlier. In those whose graft is lost beyond 1 year from the transplant, about half the time no symptoms occur, and the kidney shrinks and sometimes will calcify. In those chronic cases where symptoms do occur, a short course of oral steroids is sometimes given over a week or two with prednisone, 15 mg/day initially and quickly tapered. This will ameliorate symptoms and, in a rare case, may eliminate the need for nephrectomy. Another alternative is radiologic embolization, which we have performed in a few cases. The drawbacks are having a large kidney occluded and uncertainty as to whether this would make a subsequent transplant on that side more difficult in the future. Another drawback is that it may be hard to angiographically identify the renal artery(ies) and catheterize it (them) in the small chronic kidney, which commonly has significant intimal thickening from the rejection process. One group has reported the combination of ethanol and stainless steel coil transvenous catheter ablation in 14 patients. 4 Postembolization syndrome occurred in 11 of 14 patients, and one patient had an abscess develop in the graft.

SURGICAL TECHNIQUE The patient is placed on the operating room table in the supine position. In most cases the previous transplant incision is a lower quadrant incision ( Fig. 9-1). The nephrectomy incision is over that incision and extended laterally if necessary. If the transplant had been done through a midline transperitoneal incision, it may be necessary to reopen that incision and go transperitoneally to get to the kidney. When the transplant has been transperitoneal, it is often swollen and palpable in the lower abdomen, and thus, it is possible to make the incision directly over the kidney, incise the external and internal obliques, and reach the kidney capsule. Because the kidney is usually stuck to its surrounding structures, it is possible in this situation to stay extraperitoneal and remove the kidney. Routinely, in reopening a lower quadrant incision, the scars in the external and internal obliques are reincised. Once the internal oblique is incised, the kidney should be approached as laterally as possible because the peritoneum is often draped over the kidney in the line of the incision. If the peritoneum is opened and the patient is on peritoneal dialysis. this creates a problem to use the P-D catheter until the peritoneum reseals, necessitating temporary vascular access for dialysis. This is particularly problematic in children, and it is helpful to avoid this circumstance.

FIG. 9-1. The patient is positioned in the supine position, and the incision is made over the previous lower quadrant transplant incision.

In cases where the kidney has rejected, it is sometimes swollen to two to three times its normal size. The kidney is palpable superficially, but the bulk of the size is hidden in the flank. This may be the situation even where there has been chronic rejection because acute rejection is often superimposed. A very long incision may not create the amount of access needed to dissect the kidney under direct vision because of the lie of the kidney in the abdomen and flank. The subcapsular approach, in addition to helping with the kidney being stuck to surrounding structures, helps with these very large kidneys because it allows the mobilization of the kidney to be done blindly and delivers the large kidney into the incision so the pedicle can be dissected under direct vision. This is not unlike the dissection of the prostate in a retropubic or suprapubic prostatectomy for BPH. Kidneys that have been lost in the first few days after transplant for technical reasons can be removed in toto, including the whole capsule, because these kidneys are not usually stuck to the surrounding tissues. Kidneys that have undergone rejection are usually stuck to the pelvic side wall, iliac vessels, and peritoneum. Attempts to remove these extracapsularly can result in injury to vessels or bowel in addition to being very difficult to do. 6 A subcapsular approach simplifies the operation considerably, reducing risk of damage to adjacent structures. 7 The renal vessels are ligated well into the hilum. After the internal and external obliques are opened, the surface of the kidney can be balloted and often has a bluish tint. A tiny incision in the capsule is made with the knife, confirming the presence of renal parenchyma ( Fig. 9-2). The Metzenbaum scissors are used to dissect bluntly under the capsule and enlarge the capsulotomy. A finger sliding under the capsule should meet a plane that dissects easily ( Fig. 9-3). An exception is the rare circumstance where the kidney is small and partly calcified, where the subcapsular plane may be quite difficult to appreciate. In the more usual circumstance, the plane between capsule and parenchyma is extended around the entire kidney except the hilum, and the kidney is delivered into the wound. It may be necessary to extend the fascial incisions to allow this depending on the size of the kidney. The kidney will now be tethered by the vessels and the ureter. Care must be taken not to avulse these in delivering the kidney into the wound.

FIG. 9-2. The incision is carried through the external and internal oblique muscles to the capsule of the kidney, where a small capsular incision is made.

FIG. 9-3. The renal parenchyma is enucleated subcapsularly.

Breaking the connections between parenchyma and capsule will usually result in a moderate amount of bleeding from the raw internal capsular surface, and it is difficult to control this bleeding until the kidney is out. The reflected capsular surface overlying the hilum is then incised sharply on either the medial or lateral surface, depending on which is more accessible( Fig. 9-4).

FIG. 9-4. The hilar vessels are exposed by making an incision close to the renal parenchyma (A) and incising the overlying capsule (B).

The peritoneum can be entered here, so it is best to make this incision close to the renal parenchyma. The other advantage is that ligating the vessels well into the hilum minimizes the risk of damage to the iliac artery. A theoretical disadvantage to this approach is that donor material is left in situ. Blowout of this remnant is a possibility but appears to occur only if the suture line itself becomes infected. 8 Therefore, leaving this material in place usually causes no problem. The only other drawback is that if a third transplant is ever required on that side, it may be necessary to dissect this scar out at the time of the transplant. The potential problems that this presents are outweighed by the complexity of the nephrectomy and risk of trying to control the proximal and distal iliac artery and vein in the presence of a large, friable failed allograft and can sometimes be avoided by going higher on the vessels, to the common iliacs or aorta and vena cava. The hilar structures may be densely adherent to one another, but it is usually possible to dissect arteries, veins, and ureters free for individual ligation ( Fig. 9-5). It may be possible to obtain only enough length to handle the proximal vessels without ligating the kidney side. A finger over the kidney side may be sufficient until all the vessels have been ligated. Ligation plus suture ligation with 2-0 or 3-0 cardiovasculars wedged-on sutures provides security that there will be no major bleeding postoperatively. Silk, Prolene, or some other nonabsorbable suture can be used. The vessels themselves are often friable, and care must be taken not to saw through them. Occasionally a vessel is torn flush with the dense scar at the base of the kidney overlying the iliac artery or vein, which can not be seen. A figure-of-eight stitch can control it, but care must be taken not to pass the needle too deeply into the scar because the iliac vessels may be very superficial.

FIG. 9-5. The renal artery and vein are suture ligated (A) and divided (B).

In the event that it is elected to remove all the donor vessels, as might be done in the early technical failure case, it may be necessary to repair the defect left in the iliac artery using a saphenous vein patch or some nonautologous graft to avoid narrowing the iliac artery ( Fig. 9-6). Repair of the vein is not usually necessary other than to oversew the venotomy. Side-biting vascular clamps are helpful to control the iliacs for these repairs.

FIG. 9-6. If the renal allograft artery is completely removed, it may be necessary to cover the defect in the iliac artery with a patch graft.

Once all the hilar structures have been ligated, hemostasis of the capsule must be obtained. This can be done by using the flat part of the electrocautery or an argon-beam coagulator. The entire capsular surface should be inspected. The unacceptable alternative, unless it is absolutely impossible to obtain a dry field, is to drain the space, which runs the risk of potentiating infection of the space, even if a closed drain is used. Spray thrombin can be liberally applied after coagulation. Care should be taken not to rub off the carefully obtained surface hemostasis. Antibiotic irrigation is carried out, although the evidence that this prevents infection in this situation is lacking. The wound is closed in one or two layers, depending on what is possible. I prefer interrupted 2-0 Prolene, but absorbable and running sutures are possible. Usually there is no value in specifically closing the remaining renal capsule.

OUTCOMES Complications Complications reported in earlier series included major perioperative bleeding, wound infections, and intraoperative injury to adjacent structures. 5 The incidence of hemorrhage following transplant nephrectomy is 5% to 6%. 2 Routine use of the subcapsular approach can reduce these complications to less than 1%. 6 The other type of complication is less related to the operation than it is to immune suppression. Even though patients undergoing allograft nephrectomy have had their immune suppression stopped before the nephrectomy, it may have been only a few days before. The sequelae of immune oversuppression may take days or weeks to manifest themselves. In the UCLA series, two perioperative deaths were from B-cell lymphoma related to immune oversuppression. Persistent fever after nephrectomy should be carefully evaluated. Results Transplant nephrectomy can be performed with minimal morbidity, though it can be extremely challenging in the postrejection setting. The issue of the value of transplant nephrectomy to reduce the possibility of rejection of subsequent renal allografts remains controversial. CHAPTER REFERENCES 1. Abouljoud MS, Deiehoi MH, Hudson SLL, Diethelin AGL. Risk factors affecting second renal transplant outcome, with special reference to primary allograft nephrectomy. Transplantation 1995;60:138–144. 2. Chiverton SG, Mufic JA, Allen RD, Morris P. Renal transplant nephrectomy. Surg Gynecol Obstet 1987;164:324–328. 3. DiSesa VJ, Tilney NL. Conservative management of the failed renal allograft: indications for transplant nephrectomy. Curr Surg 1982;39:417–418. 4. Lorenzo V, Diaz F, Perez L, et al. Ablation of irreversibly rejected renal allograft by embolization with absolute ethanol. Am J Kidney Dis 1993;22:592–595. 5. O'Sullivan D, Murphy DM, McLean P, Donovan MG. Transplant nephrectomy over 20 years; factors involved in associate morbidity and mortality. J Urol 1994;151:855–858. 6. Rosenthal JT, Peaster ML, Laub D. The challenge of kidney transplant nephrectomy. J Urol 1993;149:1395–1397. 7. Sutherland DER, Simmons RL, Howurti R. Intracapsular technique of transplant nephrectomy. Surg Gynecol Obstet 1978;146:950–952. 8. Starnes HF, McWhinnie DL, Bradley JA, et al. Delayed major arterial hemorrhage after transplant nephrectomy. Transplant Proc 1984;16:1320–1323. 9. United Network for Organ Sharing. Center specific report. Richmond, VA: Author, 1997.

Chapter 10 Renovascular Disease Glenn’s Urologic Surgery

Chapter 10 Renovascular Disease John A. Libertino

J. A. Libertino: Department of Surgery, Harvard University Medical School, Boston, Massachusetts 02115, and Department of Urology, Tufts University School of Medicine, Lahey Clinic Medical Center, Burlington, Massachusetts 01805.

Diagnosis Indications for Surgery Alternative Therapy Surgical Techniques Aortorenal Bypass Graft Procurement of Saphenous Vein Technique of Insertion of Saphenous Vein Graft Alternative Arterial Bypass Grafts Splenorenal Arterial Bypass Hepatorenal Bypass Graft Renal Autotransplantation andEx Vivo Bench Surgery Techniques for Autotransplantation Outcomes Complications Results Conclusion Chapter References

Although the true incidence of renovascular hypertension is unknown, it is estimated that between 5% and 10% of all hypertensive patients suffer from renovascular hypertension. 4 During the past two decades, there have been dramatic changes in the diagnosis and treatment of renovascular hypertension. There is clearly a better understanding of the renin–angiotensin system, and newer, more potent antihypertensive medications are available. In addition, newer diagnostic radiologic procedures, such as digital subtraction angiography, captopril renal scans, balloon angioplasty, and newer surgical techniques, have dramatically changed the ways in which we diagnose and treat renovascular hypertension today.

DIAGNOSIS In the past, the clinician's task of identifying potentially curable patients in a safe, cost-effective, and reliable manner was difficult. Recently we have been given the means to reliably identify patients with a physiologically significant renal artery stenosis that, in the past, might have eluded the physician. A single-dose captopril test is reported by some investigators to be a reliable screening test and is well suited for outpatient use. Although it is less reliable in patients with a degree of renal insufficiency, the peripheral plasma renin response to a single dose of oral captopril has proved to be a simple and sensitive test. 7 In patients with a functional renal artery stenosis, ACE inhibitors lead to a disproportionate increase in peripheral plasma renin activity as a result of the disappearance of the inhibitory effect of angiotensin II on renin secretion. This phenomenon can be used diagnostically to detect unilateral renal artery stenosis. In cases of bilateral stenosis, however, the test cannot be used reliably as an indicator of renal artery stenosis. 1 However, Postma et al.8 have reported that the captopril test is not a reliable screening test, and as a consequence, the value of this procedure as a screening test in detection of renal artery disease is at present unsettled. Another test that has recently been analyzed for the detection of renal artery stenosis is the renal scintigram with isotopic nephrography following the administration of captopril.9 In a functional renal artery stenosis when ACE is inhibited, the glomerular infiltration rate decreases as a consequence of the decreased inhibition of angiotensin II on the vasa efferens. This can be demonstrated by technetium DTPA scintography. The sensitivity of this means of identifying renal artery stenosis varies from 71% to 92% with a specificity of 72% to 97%. In the hipuran scintigram, the patient with renal artery stenosis showed a continual enrichment of the isotope in the renal cortex, probably related to a decreased excretion of hipuran because of the ACE inhibitor. Digital venous subtraction angiography (DSA), in my opinion, remains the most definitive and reliable screening test available. It has a sensitivity and specificity of nearly 90%. Intravenous DSA is susceptible to artifacts such as crossing vessels and from intestinal motility. In these patients, digital arterial subtraction angiography achieves an excellent view of the renal circulation using less contrast dye than conventional angiography. Because this method uses a comparatively small 4- to 5-Fr catheter, groin hematoma is rare, and the technique can be used in an outpatient setting. Several other new modalities have appeared recently. Duplex Doppler ultrasound scanning is now a recognized way of demonstrating and locating focal renal artery stenosis. This noninvasive test is gaining acceptance in the diagnosis of both atherosclerosis and fi-bromuscular hyperplasia. In a recent study, Ferdinandi et al. 3 report the ability to detect renal artery stenosis with a success rate of over 90%. Further studies will be necessary to determine the ultimate role of duplex sonography and color Doppler evaluation of renal ar-tery stenosis. At present, digital subtraction angiography in conjunction with divided renal vein renin assays, which demonstrate contralateral suppression, remains the best screening test and predictor of treatment outcome. In those patients who have azotemia, in whom contrast is contraindicated, MRI angiography and CO 2 digital subtraction angiography are useful 12 These studies avoid the use of contrast and obviate the occurrence of contrast toxicity.

INDICATIONS FOR SURGERY The surgical management of renovascular hypertension has changed dramatically in the last two decades. In the early 1970s, we demonstrated that renal function could be preserved or restored by renal revascularization of nonfunctioning kidneys with totally occluded renal arteries. This contribution led to the notion that if patients who had totally occluded renal arteries and nonfunctioning kidneys could have restoration of renal function, then we could treat patients with renal artery stenosis who had azotemia with the expectation that they could also have preservation or improvement of renal function. 5 Progressive azotemia in the elderly atherosclerotic patient population is now one of the indications for renal revascularization. Secondly, based on our observations, the use of alternative bypass procedures has significantly reduced the morbidity and mortality of high-risk patients undergoing renovascular surgery. The use of the hepatic artery, the gastroduodenal artery, and other alternative procedures instead of the aortorenal saphenous vein bypass graft has not only reduced the morbidity and mortality of surgery but, in doing so, has dramatically changed the nature of our patient population.

ALTERNATIVE THERAPY Converting enzyme inhibitors prevent the conversion of angiotensin I to angiotensin II. These drugs in conjunction with calcium channel blockers have greatly improved the medical management of patients who suffer from renovascular hypertension. Unfortunately, even if adequate blood pressure control is maintained by pharmacologic means, progression of renal artery disease is not prevented, and renal ischemia and renal damage may clearly progress. 11 When medical management fails or azotemia progresses, then balloon angioplasty and surgical treatment must be considered. The choice between angioplasty and surgery relies on a well-defined set of criteria established by published results. Angioplasty is indicated in the treatment of fibrous dysplasia and atherosclerosis of the mid–main renal artery. Surgery is indicated for the treatment of osteal atherosclerosis and for branch lesions of the renal artery. Renal artery aneurysms are a different problem. Surgery is indicated when they are the cause of hypertension. Also aneurysms larger than 2 cm in diameter that are noncalcified, especially in gestational women, should be repaired, as they are prone to rupture during pregnancy.

It is our feeling that patients who develop recurrent disease following balloon angioplasty are probably best subjected to surgical management, as repeat balloon angioplasty is associated with a significant complication rate. Use of the thoracic aorta may also be a viable alternative on the left side because the thoracic aorta is usually less atherosclerotic than the abdominal aorta. 6

SURGICAL TECHNIQUES Aortorenal Bypass Graft The widespread popularity of the bypass graft for renal artery disease was attained by virtue of its technical ease of insertion and the favorable short- and long-term patency rates achieved. Bypass grafts are applicable to almost any disease process involving the main renal artery or its branches. This procedure also eliminates the more hazardous and tedious dissection of the juxtrarenal portion of the aorta required in endarterectomy. Bypass grafts are particularly suitable for fibrous lesions that affect long and multiple segments of the renal artery and its branches ( Fig. 10-1). Dacron, autogenous artery (hypogastric and splenic), and autogenous saphenous vein may be chosen as aortorenal bypass grafts in properly selected patients.

FIG. 10-1. (A) An aortogram shows a double right renal artery with stenoses at the ostia of both trunks. (B) A postoperative aortogram with the vein graft making a side-to-side anastomosis to the stenotic lower renal artery and an end-to-end anastomosis to the distal stump of the upper renal artery.

Dacron has been applied extensively in renal artery reconstruction but has been associated with a relatively high rate of early thrombosis. Excellent long-term patency rates have been reported with a segment of autogenous hypogastric artery. Such a graft matches the size of the renal artery and is sutured more simply than the Dacron prosthesis. Autogenous hypogastric artery is the most favorable graft material for children with renal artery disease because the saphenous vein is usually too small and is more prone to aneurysmal dilation than in adults. The major disadvantage is that the hypogastric artery is often the first to be involved with generalized atherosclerosis and therefore is not suitable graft material in older patients. It is also a short vessel and occasionally is technically more difficult to insert between the renal arteries and aorta. During the past two decades the autologous saphenous vein has emerged as our preferred graft material and is the most common source for restoration of renal blood flow at our hospital. Saphenous vein is readily available and closer in size to the lumen of the renal artery than other vascular conduits. Its intima is less thrombogenic than prosthetic material and accommodates the creation of a precise contoured anastomosis with a delicate thin-walled distal renal artery. Patent anastomoses can be achieved with the most challenging 2- to 3-mm-lumen branches beyond the major bifurcation. Because of its inherent properties and the favorable surgical results obtained, saphenous vein has become the conduit of choice for aortorenal bypass at most major renovascular centers. If the saphenous veins are not available, we use cephalic vein and Gore-Tex graft, in that order, as substitutes. Procurement of Saphenous Vein The procurement of an adequate segment of the long saphenous vein is critical to the success of the graft procedure. Meticulous technique in exposure and excision of the vein is essential to prevent mural trauma and ischemia. Improper harvesting of the vein may result in the delayed complications of stenosing intimal hyperplasia and aneurysmal dilation. Removal of the saphenous vein should be performed by an experienced surgeon. The saphenous vein is usually obtained from the thigh opposite the renal lesion so that two surgeons may simultaneously expose the renal vessels and mobilize the graft, shortening the operative time. The vein is mobilized through a single long incision in the upper thigh ( Fig. 10-2), which begins parallel to and below the groin crease over the palpable femoral pulses and is extended toward the knee after the junction of the saphenous and femoral veins has been exposed. The incision should be made directly over the vein to avoid producing devascularized skin flaps that can result in necrotic edges and wound sepsis. Finger dissection between the trunk of the vein and the skin is helpful to ensure accurate placement of the incision and, thus, to avoid development of these flaps (see Fig. 10-2). On the day before operation, the course of the saphenous vein is outlined with an indelible pen while the patient is standing.

FIG. 10-2. (A) Position of patient for harvesting of saphenous vein graft. (B) Line of incision for saphenous vein graft harvest. (C) Exposure of saphenous vein.

A 20-cm-long vein graft with an outside diameter of 4 to 6 mm is usually adequate for reconstruction of the renal artery. Excess vein should always be available for revision of any intraoperative technical problems that may occur during anastomosis. The vein is handled gently without stretching or tearing its branches. The tributaries are tied in continuity with fine silk before they are divided. The areolar tissue is dissected from the specimen, and the adventitia is left undisturbed. To decrease transmural ischemia, the vein graft remains4 in situ until the renal vessels are mobilized and it is ready to be used. If the graft is inadvertently removed prematurely, it is placed in cold Ringer's lactate solution or autologous blood, even if only a short period of time will ensue. The distal end of the vein is transected, cannulated with a Marks needle, and secured with a silk tie ( Fig. 10-3). A dilute heparinized solution of autologous blood distends the vein graft before the proximal is transected. This step helps to identify any untied tributaries or unrecognized leakage and washes out any residual blood clots. The vein is distended to a minimal diameter of 5 to 6 mm by exerting gentle pressure on the syringe. The proximal end of the vein is transected, and the vein graft is now ready for use. The thigh incision is not closed until the bypass procedure has been completed to ensure that any delayed bleeding caused by the heparinized state is identified and controlled.

FIG. 10-3. Harvest of saphenous vein graft.

Technique of Insertion of Saphenous Vein Graft Heparin is initially given systemically after the surgical dissection has been completed and approximately 30 minutes before the arteries are clamped. The saphenous vein graft should be oriented properly to avoid misalignment during implantation. Either an end-to-end or an end-to-side anastomosis can be accomplished, depending on the anatomic situation encountered. An end-to-end anastomosis is preferred under usual circumstances because it permits the best laminar flow. The aorta, which has already been mobilized and exposed from the renal arteries to the level of the inferior mesenteric artery, is carefully palpated to determine a suitable soft location for the anastomosis that is relatively free of atherosclerotic plaque. A medium-sized DeBakey clamp is placed on the anterolateral portion of the infrarenal aorta in a tangential manner. A vertical 13- to 16-mm aortotomy is made without excising any of the aortic wall or attempting to perform a localized endarterectomy (Fig. 10-4), which may dislodge intimal plaque fragments that can form emboli to the lower extremities when the clamp is released.

FIG. 10-4. The bypass graft is placed along the lateral aortic wall to determine the best position for its placement. (From Novick AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

Excision of the aortic wall is not necessary because intraluminal aortic pressure spreads the edge of the linear aortotomy to the appropriate dimensions when the clamp is released. The vein graft is anastomosed to the aorta with continuous 5-0 Proline suture after it has been satisfactorily spatulated ( Fig. 10-5). A microvascular Schwartz clamp is placed on the end of the saphenous vein graft, and the aortic clamp is released. The graft is allowed to lie anterior to the vena cava on the right side or anterior to the renal vein on the left side. Although it is preferable to leave the vein too long than too short, it should not be so long as to bend into an acute angle at any point. The renal artery is secured distally with a smooth-jawed Schwartz microvascular clamp placed on either the distal main renal artery or its branches. The proper site for the arterial anastomosis is selected. An end-to-end anastomosis is performed utilizing a continuous 6-0 Proline suture or interrupted sutures of the same material, depending on the diameter of the anastomosis (Fig. 10-6). When the saphenous vein graft is being anastomosed with two branches 3 mm or less in size, interrupted sutures are chosen. An interrupted suture line is also selected in children to prevent a pursestring effect with growth of the vessels when the patients become older. This effect may also occur with running synthetic monofilament sutures when too much tension is applied during the creation of the anastomosis. The pursestring effect can be avoided by placing sutures at four quadrants in the arterial wall before beginning the anastomosis. Operating loupe magnification and fiberoptic headlamps are very helpful at this point in the operation to allow precise placement of the sutures, particularly when exposure in the renal artery is difficult.

FIG. 10-5. Following partial aortic occlusion, an oval aortotomy is made for end-to-side anastomosis with the spatulated bypass graft. (From Novick AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

FIG. 10-6. (A) Anastomosis of the graft to the aorta is performed with interrupted vascular sutures. (B) After completion of the aortic anastomosis, the renal artery is prepared for anastomosis with the graft. (C) A spatulated end-to-end anastomosis of the graft and distal renal artery is performed. (From Novic AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

The single most important factor responsible for long-term patency is a wide flawless anastomosis with the renal artery. After completion of the anastomosis, the microvascular bulldog clamps are removed from the distal renal circulation and the saphenous vein graft, permitting reconstitution of the renal circulation ( Fig. 10-7).

FIG. 10-7. Completed aortorenal bypass operation. (From Novic AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

Alternative Arterial Bypass Grafts Extensive atherosclerosis, previous aortic surgery, and complete thrombosis of the aorta may preclude the use of the aortorenal bypass procedure for renal artery reconstruction. When the surgeon is treating a patient with stenosis of the right renal artery in association with these pathologic limitations on the aorta, a splenorenal or hepatic-to-renal artery saphenous vein bypass or gastroduodenal-to-renal artery bypass procedure can be selected. Splenorenal Arterial Bypass Splenorenal arterial bypass has many desirable features as a substitute for aortorenal bypass in patients with stenosis of the left renal artery. It is particularly suitable for patients who have diffuse atherosclerotic disease or thrombosis of the aortic lumen and for those who have previously undergone difficult aortic reconstructions. The splenic artery has the advantages of being an autogenous artery that has not been separated from its nutrient vaso vasorum, of being exposed without difficulty by a relatively uncomplicated anatomic dissection, and of requiring only one vascular anastomosis. Carefully monitored oblique and lateral angiography of the celiac axis is required to determine the patency of this artery because atherosclerosis can affect the arterial lumen early in the patient's life. Surgical exploration and intraoperative evaluation by palpation and measurement of splenic blood flow are also helpful in establishing its suitability for renal revascularization. If the blood flow is less than 125 ml/min, the splenic artery should probably not be utilized for renal artery bypass. We now prefer to expose the splenic artery through a supracostal 11th-rib flank incision ( Fig. 10-8). The dissection is continued along the upper border of the rib. The overlying latissimus dorsi, the serratus posterior inferior, and the intercostal muscles are divided. Division of the intercostal ligament permits the rib to move freely. The external, internal oblique, and transversus abdominis muscles are divided, and the intercostal muscle attachments on the distal 1 inch of the rib are divided carefully until the corresponding intercostal nerve is identified. The investing fascia around the nerve is entered. Dissection in this plane allows an extrapleural approach and generally avoids entry into the pleural cavity. This approach also allows excellent exposure, for the ribs are free to pivot downward in a “bucket-handle” fashion (Fig. 10-9).

FIG. 10-8. Supracostal 11th-rib incision: (A) posterior view; (B) anterior view. (C) The costovertebral ligament must be divided to allow the rib to pivot inferiorly. (D) Closure of incision, taking care to spare the intercostal nerves. The diaphragm is not incorporated in the closure.

FIG. 10-9. Bilateral subcostal “bucket handle” incision.

The plane between Gerota's fascia and the adrenal gland posteriorly and the pancreas anteriorly is entered. The splenic artery is identified at the upper border of the pancreas. Its enveloping fascia is entered, and the splenic artery is mobilized by a purely retroperitoneal approach. Several small pancreatic branches are identified, isolated, ligated, and divided. The splenic artery can usually be mobilized from the splenic hilum to the celiac axis without difficulty, and it provides sufficient length to reach the left renal artery. After the splenic artery is mobilized, a sponge soaked with papaverine is placed on it to permit it to dilate. The artery is divided just proximal to its primary bifurcation in the hilum of the spleen, after a suitable vascular clamp has been applied to the origin of the artery. If necessary, the artery may be dilated with a Gruntzig balloon or Fogarty catheter intraoperatively to obtain maximum caliber. Removal of the spleen is not necessary because it continues to receive adequate blood flow from the short gastric arteries. The left kidney is approached posteriorly, and the left renal artery is identified and mobilized ( Fig. 10-10). The renal artery is ligated at the aorta, and an end-to-end anastomosis between the splenic artery and the distal renal artery is carried out using continuous or interrupted 6-0 Proline sutures ( Fig. 10-10).

We have employed this approach in nearly 100 patients and now prefer it to the traditional transabdominal technique.

FIG. 10-10. Technique of splenorenal bypass. Note that the pancreas is lifted cephalad in order to expose the splenic artery.

On rare occasions, a sufficient length of splenic artery cannot be achieved. In this instance, an interposition saphenous vein graft from the splenic artery to the renal artery can be utilized. This maneuver enables the creation of a tension-free anastomosis ( Fig. 10-11).

FIG. 10-11. An aortogram shows a splenorenal end-to-side bypass.

Splenic artery disease, the risk of pancreatitis, and the formation of a pancreatic pseudocyst are some of the limitations that have restricted splenorenal bypass as a routine procedure in the management of disease of the left renal artery. Hepatorenal Bypass Graft Arising from the celiac axis and continuing along the upper border of the pancreas, the hepatic artery reaches the portal vein and divides into an ascending and a descending limb. The ascending limb is a continuation of the main hepatic artery upward within the lesser omentum; it lies in front of the portal vein and to the left of the biliary tree. The descending limb forms the gastroduodenal artery. In the porta hepatis, the hepatic artery ends by dividing into the right and left hepatic branches, which supply the corresponding lobes of the liver ( Fig. 10-12). The anatomic variations in the hepatic circulation must be appreciated before this procedure can be utilized. The right hepatic artery is more variable than the left. It may be anterior (24% of patients) or posterior (64% of patients) to the common bile duct, and in 12%, this artery arises from the superior mesenteric artery ( Fig. 10-13). The hepatic artery lies anterior (91% of patients) or posterior (9% of patients) to the portal vein. In addition, the left hepatic artery arises from the left gastric artery in 11.5% of patients.

FIG. 10-12. Normal course of the main hepatic artery and its various branches. (From Novick AC. Diminished operative risk and improved results following revascularization for atherosclerotic renal artery disease. Urol Clin North Am 1984;11:435.)

FIG. 10-13. Separate origins of the left and right hepatic arteries from the celiac and superior mesenteric arteries, respectively. (From Novick AC. Diminished operative risk and improved results following revascularization for atherosclerotic renal artery disease. Urol Clin North Am 1984;11:435.)

Careful dissection of the porta hepatis is essential, and the common hepatic, gastroduodenal, and right and left hepatic arteries should be identified before an anastomotic procedure is attempted. Vascular elastic loops are placed about these vessels, and the common bile duct and portal vein are identified. After careful dissection and mobilization of the renal artery, clamps are placed on the proximal portion of the common hepatic artery and its distal branches. The

gastroduodenal artery is divided ( Fig. 10-14). The inferior surface of the hepatic artery is mobilized from the underlying portal vein and the common bile duct. An arteriotomy, 10 to 12 mm in length, is made in the anterior inferior wall of the common hepatic artery, beginning at the ostium of the gastroduodenal artery. A reversed autogenous saphenous vein is inserted with an end-to-side anastomosis between the vein graft and the hepatic artery. This maneuver is usually accomplished with a continuous 6-0 Proline suture. A microvascular clamp is placed on the vein graft after it has been filled with heparin and after the proper alignment and length for the renal artery anastomosis has been determined. The clamps are removed from the hepatic circulation, and a small Schwartz microvascular clamp is placed on the distal renal artery. The vein graft is anastomosed to the right renal artery in an end-to-end fashion. When the gastroduodenal artery is used, it is divided, and an end-to-end anastomosis between the gastroduodenal artery and the renal artery is accomplished.

FIG. 10-14. Use of the gastroduodenal artery to perform hepatorenal revascularization through direct end-to-end anastomosis with the right renal artery. (From Novick AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

We have employed this procedure in approximately 50 patients with good results. Postoperative angiography has demonstrated the absence of a renal–hepatic steal syndrome. Liver function has not been compromised in any of our patients to date. We no longer advocate the use of the gastroduodenal artery in adult patients, but it is a perfectly acceptable bypass procedure in the pediatric patients. We have also utilized the superior mesenteric-to-renal artery saphenous vein bypass as a “bailout procedure” as well with good results ( Fig. 10-15). An iliac-to-renal bypass graft has been done as an alternative to the aortorenal bypass procedure in ten of our patients, with favorable results ( Fig. 10-16).

FIG. 10-15. Hepatorenal bypass performed with an interposition saphenous vein graft anastomosed end to side to the common hepatic artery and end to end to the right renal artery. (From Novick AC. Diminished operative risk and improved results following revascularization for atherosclerotic renal artery disease. Urol Clin North Am 1984;11:435.)

FIG. 10-16. Iliorenal bypass with a saphenous vein graft anastomosed end to side to the common iliac artery and end to end to the renal artery. (From Novick AC, Streem SB, Pontes JE, eds. Stewart's operative urology. Baltimore: Williams & Wilkins, 1989.)

Renal Autotransplantation and Ex Vivo Bench Surgery On rare occasions, kidneys with lesions of the renal artery or its branches are not amenable to in situ reconstruction. In these circumstances, temporary removal of the kidney, ex vivo preservation, microvascular repair (bench surgery), and autotransplantation may permit salvage. Autotransplantation developed as an outgrowth of the technique in renal transplantation. The simultaneous development of an apparatus that could preserve kidneys extracorporeally for long periods of time and of preservation solutions also led to the technique of extracorporeal renal repair. Autotransplantation and ex vivo repair should be considered in patients with traumatic arterial injuries, when disease of the major vessels extends beyond the bifurcation of the main renal artery into the segmental branches, and when multiple vessels supplying the affected kidney are involved. Bench surgery may also be required in patients who have very large aneurysms, arteriovenous fistulas, or malformations ( Fig. 10-17).

FIG. 10-17. (A) An arteriogram shows complex involvement of the right renal artery by disease extending into the primary branches. (B) A postoperative arteriogram shows patent anastomoses.

Other indications for autotransplantation that usually do not require ex vivo repair include abdominal aortic aneurysms that involve the origin of the renal arteries and extensive atheromatous aortic disease, when an operation on the aorta itself may prove hazardous. In the last case, the patients usually have extensive internal iliac artery disease that precludes utilization of this artery for autotransplantation. However, we have noted that in these instances, the external iliac artery is spared extensive atherosclerosis and is suitable for autotransplantation, with an end-to-side renal artery anastomosis or an iliac-to-renal bypass graft. Techniques for Autotransplantation Autotransplantation can be accomplished through a large single midline incision or two separate flank and iliac fossa incisions. When the kidney is removed, care is taken to preserve the maximum length of renal vessels and ureter. If the transabdominal approach is selected, ureteral continuity can be retained, necessitating only vascular anastomosis afer the kidney is flipped over. If ex vivo surgery requires transection of the ureter, ureteroneocystostomy is necessary in addition to vascular anastomosis. When ureteral continuity is preserved, autotransplantation is performed as illustrated in Fig. 10-18. When the kidney has been excised completely, the standard techniques for renal homotransplantation are used.

FIG. 10-18. Ipsilateral autotransplantation of the kidney with end-to-side anastomosis of renal vein to common iliac vein and end-to-end anastomosis of hypogastric artery to renal artery. Ureter is taking a redundant course to bladder, and kidney is placed in upside-down position.

During dissection of the iliac vessels, meticulous care is taken to ligate the lymphatics in this area to prevent the development of a lymphocele. The external iliac vein is freed to the point where it is crossed by the internal iliac artery ( Fig. 10-19A). The renal vein is anastomosed end-to-side to the external iliac vein using 5-0 Proline sutures (Fig. 10-19B). If the renal artery is free of atherosclerotic disease, it is then anastomosed end-to-end to the internal iliac artery, employing 6-0 Proline sutures (Fig. 10-19C,D). If the internal iliac artery is diseased, the renal artery is anastomosed end-to-side to the external iliac artery.

FIG. 10-19. (A) Dissection of lymphatic and areolar tissue from iliac vessels. (B) End-to-side anastomosis of renal vein to external iliac vein. (C) End-to-end anastomosis of renal artery to internal iliac artery.

When the ureter requires reimplantation, we prefer a modification of the Politano–Leadbetter ureteroneocystostomy. Saline solution, 2 to 3 ml, is injected submucosally, raising a mucosal bleb (Fig. 10-20A). A small segment of mucosa is removed from the inferior portion of the bleb ( Fig. 10-20B). A right-angle clamp is inserted into this opening, and a 3-cm-long submucosal tunnel is created ( Fig. 10-21A). At the apex of the tunnel, the right-angle clamp is rotated 180 degrees to pierce the detrusor muscle. The ureter is brought to lie in the submucosal tunnel ( Fig. 10-21B). The distal ureter is cut at a 45-degree angle, and the ureter is anastomosed to the bladder with interrupted 4-0 or 5-0 Dexon or Vicryl sutures ( Fig. 10-21C,D).

FIG. 10-20. (A) Injection of saline submucosally to dissect mucosa from muscularis before reimplantation. (B) Creation of tunnel.

FIG. 10-21. (A) Ureteroneocystostomy: opening in posterolateral bladder wall for ureter. (B) Submucosal tunnel for ureteroneocystostomy. (C) Ureter in position in submucosal tunnel. (D) Elliptic anastomosis of ureter to bladder wall.

In the future, the use of endovascular prostheses in maintaining the effect of luminal balloon dilatation is a very promising technique if long-term evaluation confirms the preliminary results.

OUTCOMES Complications Complications of renal vascular surgery can be classified as early or delayed. Early complications include bleeding, thrombosis of the artery, embolization of the branch vessels, subintimal dissection, false aneurysms, and loss of the kidney. Postoperative bleeding requiring operative intervention is to some extent a technical failure but may also be a function of the structural integrity of the arterial wall in diseased segments. It is important to recognize the enlarged perihilar vessels that are seen in high-grade stenosis and to be cognizant of the adrenal venous channels. Delayed bleeding may be the result of false aneurysm formation or erosion of the graft anastomosis into the duodenum or other bowel. Renal artery thrombosis is the most common complication of renal vascular reconstruction and is most common after either placement of a dacron graft or endarterectomy. Predisposing factors include small dacron grafts, renal atrophy associated with thin-walled diseased arteries and high intrarenal vascular resistance, hypotension, or hypovolemia. It has been shown that the thrombosis of both venous and synthetic grafts is partially affected by the adequacy of the peripheral runoff as well as the adequacy of resection of the endothelial plaques in atheroschlerotic vessels. Embolization of plaque to the distal extremities or aortic thrombosis is rare. Results Balloon angioplasty is primarily used to treat patients with mural dysplasia. 2,10 This modality of treatment is 80% to 85% effective in the management of these patients at our institution. Balloon angioplasty has a very limited role in the management of atherosclerotic renovascular disease at our institution. The combination of balloon angioplasty for the younger, healthier patients suffering from mural dysplasia, the advent of alternative bypass procedures, and the concept of revascularization for preservation and restoration of renal function have dramatically changed the nature of the patient population being referred to our institution for renal revascularization. We are now frequently being called on to revascularize more elderly, higher-risk patients with diffuse atherosclerosis who have failed aggressive antihypertensive therapy in order to improve their renal function. We have recently reported a series of more than 100 patients who have undergone renal revascularization for preservation and restoration of renal function with an 85% success rate in this very high-risk patient population. 5

CONCLUSION Renovascular disease is a rapidly changing clinical entity. Considerable progress is being made in screening and diagnosis, primarily as a result of the development of less- or noninvasive studies. Renovascular disease is a potentially curable cause of hypertension and one of the few curable or preventable causes of renal failure. The indications for angioplasty and surgical revascularization are better known, and interventional therapy is justified when anesthesia and surgery represent an acceptable risk. We look forward to the short- and long-term results of renal artery atherectomy and wall stenting with anticipation. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Distler A, Spies KP. Diagnostic procedures in renovascular hypertension. Clin Nephrol 1991;36(4):174–180. Englund R, Brown MA. Renal angioplasty for renovascular disease. J Cardiovasc Surg 1991;32:76–80. Ferdinandi A, Pavlica P, Lupattelli L, et al. Duplex sonography and color Doppler evaluation of renal artery stenosis—angiographic correlation. Scand J Urol Nephrol [Suppl] 1991;137:67–72. Libertino JA. Surgery for renovascular hypertension. In: Walsh PC, Retik AB, Stamey TA, Vaughan ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2521–2551. Libertino JA, Bosco PJ, Ying C, et al. Renal revascularization to restore and preserve renal function. J Urol 1992;147:1485–1487. Novick AC. Management of renovascular disease: a surgical perspective. Circulation 1991;83(Suppl 2):1167–1171. Pickering TG. Diagnosis and evaluation of renovascular hypertension: indications for therapy. Circulation 1991;83(Suppl 2):1147–1154. Postma CT, Dernout HA, Van Oljen MD, et al. The value of tests predicting renovascular hypertension in patients with renal artery stenosis treated by angioplasty. Arch Intern Med 1991;151:1531–1535. Setaro JF, Saddler MC, Chen CC, et al. Simplified captopril renography in diagnosis and treatment of renal artery stenosis. Hypertension 1991;18:289–298. Tegtmeyer CJ, Selby JB, Hartwell GD, et al. Results and complications of angioplasty in fibromuscular disease. Circulation 1991;83(Suppl 2):1155–1161. Tollefson DF, Ernst CB. Natural history of atherosclerotic renal artery stenosis associated with aortic disease. J Vasc Surg 1991;14:327–331. Weaver F, Pentecost MJ, Yellin AE, et al. Clinical applications of CO 2 digital subtraction angiography. J Vasc Surg 1991;13:266–273.

Chapter 11 Anatrophic Nephrolithotomy Glenn’s Urologic Surgery

Chapter 11 Anatrophic Nephrolithotomy Michael L. Paik and Martin I. Resnick

M. L. Paik and M. I. Resnick: Department of Urology, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, Ohio 44106.

Diagnosis Indications for Surgery Alternative Treatments Surgical Technique Outcomes Complications Results Chapter References

Anatrophic nephrolithotomy is a procedure that has been used by urologists for nearly 30 years in the removal of large renal calculi, specifically branched or staghorn calculi. These stones are often associated with urinary tract infections, and the coexistence of these two conditions makes it difficult to eradicate either. Definitive treatment of these stones is generally advocated because of the significant morbidity and mortality associated with untreated staghorn calculi. Blandy and Singh found that patient survival is reduced with untreated staghorn calculi, with a mortality rate of 28% at 10 years. 3 Since the early 1980s, with the development of less invasive approaches such as extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy, the role of anatrophic nephrolithotomy and other open stone operations has certainly diminished. 2 However, anatrophic nephrolithotomy remains the gold standard for the treatment of staghorn calculi and thus maintains a role in the treatment of these large complex stones. The original description of anatrophic nephrolithotomy was by Smith and Boyce in 1968. 9 The operation they described was based on the principle of placing the nephrotomy incision through a plane of the kidney that was relatively avascular. This approach would avoid damage to the renal vasculature with resulting atrophy of the renal parenchyma, hence the term anatrophic. The operation also involves reconstruction of the intrarenal collection system to eliminate anatomic obstruction, thus improving urinary drainage, reducing the likelihood of urinary tract infection, and preventing recurrent stone formation.

DIAGNOSIS The diagnosis of staghorn calculi is usually established in a similar fashion as other forms of urolithiasis. Patients may have the typical symptoms of flank pain, fever, and hematuria, or they may be asymptomatic. The diagnosis of chronic urinary tract infection is common in patients with these types of stones. Urine culture is often positive, and typical organisms include urea-splitting organisms such as Proteus, Klebsiella, Providencia, and Pseudomonas. Useful radiographic studies traditionally include plain abdominal radiographs, nephrotomograms, and excretory urograms to identify the stones, the collecting system, and, if present, to define the degree of obstruction. Computed tomography can be helpful for detection of radiolucent or poorly calcified stones. Retrograde pyelography is usually performed in cases of equivocal findings on excretory urography. Nuclear renal scans can help to determine differential renal function when such information might affect the surgical approach. Renal arteriography is usually not indicated unless there is suspicion of anomalous arterial anatomy such as in renal fusion anomalies. Before elective surgery, a metabolic evaluation is recommended to attempt to determine an etiology for stone formation and to aid in preventing a recurrence. For instance, it is important to determine the presence of hypercalciuria, hyperuricosuria, hyperoxaluria, cystinuria, hyperparathyroidism, and renal tubular acidosis. The measurement of serum and urine calcium, phosphorus, creatinine, uric acid, and electrolytes should be routine. A 24-hour urine collection for creatinine clearance as well as urinary calcium, phosphorus, oxalate, citrate, cystine, and uric acid is also an integral part of the workup.

INDICATIONS FOR SURGERY Anatrophic nephrolithotomy should be performed for the removal of branched or staghorn calculi, usually complete staghorn stones, or those associated with infundibular stenosis or other intrarenal anatomic obstruction, for the combined goals of removing all calculi and open surgical correction of the anatomical obstruction. This procedure may also be preferred in the treatment of a staghorn calculus in a kidney with a small intrarenal pelvis, making access to the renal pelvis difficult, or in a patient who has undergone prior renal surgery to avoid a more risky renal sinus dissection. This operation is also indicated for the treatment of staghorn calculi in patients who would benefit from or prefer a single therapeutic procedure versus multiple, less invasive, procedures such as extracorporeal shock wave lithotripsy and/or percutaneous nephrolithotomy. The goals of the procedure should be to remove all calculi and fragments, to improve urinary drainage of any obstructed intrarenal collecting system, to eradicate infection, to preserve and improve renal function, and to prevent stone recurrence. 10

ALTERNATIVE TREATMENTS Most staghorn calculi can now be preferentially treated with percutaneous nephrolithotomy, with or without extracorporeal shock wave lithotripsy. The stone-free rates reported are approaching comparability with traditional anatrophic nephrolithotomy, and there is probably an advantage to be gained in shorter convalescent periods following the less invasive methods. These alternative odalities can sometimes require multiple different procedures to accomplish a stone-free state. The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommended as a guideline that initial percutaneous nephrolithotomy followed by extracorporeal shock-wave lithotripsy and/or further percutaneous procedures should be the treatment for most standard patients with staghorn calculi. Open surgery is recommended as an appropriate option in unusual cases when a stone is not expected to be removed with a reasonable number of the less-invasive procedures. 8 Despite impressive advances with the less-invasive techniques, anatrophic nephrolithotomy remains a treatment option for large complete staghorn calculi or staghorn stones associated with anatomic obstruction and requiring open surgical correction.

SURGICAL TECHNIQUE After administration of general anesthesia and placement of a Foley catheter, the patient is placed in the standard flank position with elevation of the kidney rest and flexion of the operating table to achieve adequate spacing between the lower costal margin and the iliac crest. Three-inch-wide adhesive tape applied at the shoulders and hips can be used to secure the patient to the table. Adequate padding should be used to protect pressure points. A standard flank approach is used. The incision can be placed through the bed of either the 11th or 12th rib, depending on the estimated position of the kidney. If a previous flank incision has been made for renal surgery, it is preferable to place the incision above the old scar, ensuring that access to the kidney can be achieved through unscarred tissue. After rib resection, when access has been gained into the retroperitoneal space, Gerota's fascia is identified overlying the kidney. Gerota's fascia is incised in a cephalad–caudal direction, which facilitates returning the kidney to its fatty pouch at the end of the operation. The kidney is then fully mobilized, and the perinephric fat is carefully dissected off the renal capsule with care taken not to disrupt the renal capsule. Should the capsule become inadvertently incised, it can be closed at that time with chromic catgut sutures. The kidney is now free to be suspended in the operative field by utilizing two 1-inch umbilical tapes as slings. At this point a preliminary portable plain radiograph can be obtained. The renal hilar dissection is the next step. The main renal artery and its branches are carefully dissected and identified ( Fig. 11-1A). The avascular plane, or Brodel's line, can be identified by temporarily clamping the posterior segmental artery and injecting 20 ml of methylene blue intravenously, which results in the blanching of the posterior renal segment while the anterior portion turns blue 5 (Fig. 11-1B). This allows identification of this avascular plane. Placing the nephrotomy incision through this plane will achieve maximal renal parenchymal preservation and minimize blood loss. The avascular plane can also be identified with the use of a Doppler

stethoscope to localize the area of the kidney with minimal blood flow.

FIG. 11-1. Anatrophic nephrolithotomy. (A) Main renal artery and branches are isolated. (B) The posterior segmental artery is occluded, and methylene blue is administered intravenously. The resulting demarcation between pale ischemic and bluish perfused parenchyma defines a relatively avascular nephrotomy plane.

Extensive renal hilar dissection can be avoided by utilizing a modification of the original procedure described by Smith and Boyce. Redman and associates relied on the relatively constant segmental renal vascular supply in advocating placing the incision at the expected location of the avascular line after clamping the renal pedicle with a Satinsky clamp, seeking to prevent vasospasm of the renal artery and warm ischemia. 6 This modification can be time-saving and spare extensive dissection of the renal hilum. However, we continue to advocate precise identification of the avascular plane to minimize parenchymal loss. At this point, 25 g of intravenous mannitol is administered. This promotes a postischemic diuresis and prevents the formation of intratubular ice crystals by increasing the osmolarity of the glomerular filtrate. The main renal artery can now be occluded with a noncrushing bulldog vascular clamp ( Fig. 11-2). A bowel bag or barrier drape is placed around the kidney, and hypothermia is initiated with the placement of iced saline slush within the barrier surrounding the kidney. Dry laparotomy sponges are used to pack away the peritoneal contents and to protect and insulate them from hypothermia. The kidney should be cooled for 10 to 20 minutes before the nephrotomy incision is made. This should allow achievement of a core temperature in the 5° to 20°C range, which will allow safe ischemic times from 60 to 75 minutes and minimize renal parenchymal damage. 4

FIG. 11-2. The main renal artery is clamped and a bowel bag or rubber dam is placed around the kidney. Dry gauze packs are placed anterior to the kidney to protect the intra-abdominal organs from hypothermia.

The renal capsule is then incised sharply over the previously identified avascular plane, and the renal parenchyma can be bluntly dissected with the back of the scalpel handle (Fig. 11-3). Blunt dissection minimizes injury to the intrarenal arteries that are traversed. Small bleeding vessels can be controlled with 5-0 or 6-0 chromic catgut suture ligature. If renal back bleeding continues to be a problem despite these measures, the main renal vein can be occluded. As the incision is angled toward the midportion of the renal hilum, the nephrotomy should theoretically remain close to the avascular plane ( Fig. 11-4).

FIG. 11-3. A superficial incision is made in the renal capsule through the avascular plane.

FIG. 11-4. The parenchyma is bluntly dissected with the back of a scalpel handle. The incision closely approximates the avascular plane.

As the nephrotomy incision proceeds toward the renal hilum, the ideal location to enter the collecting system is at the base of the posterior infundibula. Occasionally, with large posterior calyceal calculi, a dilated posterior calyx will be entered initially. The remainder of the collecting system can then be identified and opened with a probe or stone forceps. If a posterior infundibulum is entered first, the incision is then carried toward the renal pelvis ( Fig. 11-5). The stone is palpated, and the

remainder of the infundibula are incised in a similar fashion. Attention is then turned towards the anterior infundibula. All of the calyceal extensions should be identified and incised. In order to minimize stone fragment formation and retained calculi, the stone should not be manipulated or removed until all of the calyceal and infundibular extensions are appropriately identified and incised, allowing for complete visualization and mobilization of the collecting system and calculi. Ideally, the stone or stones should be removed without fragmentation; however, often it is inevitable that there will be some piecemeal extraction ( Fig. 11-6). After removal of all stone fragments, the renal pelvis and calyces are copiously irrigated with cold saline and carefully inspected for retained fragments. A plain radiograph is obtained at this point to rule out residual calculi or fragments.

FIG. 11-5. The collecting system is carefully incised.

FIG. 11-6. After the collecting system is opened, calculi are extracted and total removal is confirmed radiographically.

At this time, a “double-J” stent is passed from the renal pelvis into the bladder ( Fig. 11-7). The routine use of internal ureteral catheters is encouraged. They provide good urinary drainage and protect the freshly reapproximated collecting system and minimize postoperative urinary extravasation. The stents also prevent intraoperative migration of smaller calculi into the ureter.

FIG. 11-7. A Silastic stent is passed in an antegrade fashion from the pelvis to the bladder. Traction sutures are placed to mark the walls of adjacent calyces before suturing them together with a running 6-0 chromic suture.

The next step in the procedure is the reconstruction of the intrarenal collecting system. Infundibular stenosis or stricture, which results in obstruction promoting urinary stasis and recurrent stone formation, should be corrected with calyorrhaphy or calycoplasty. The former is the repair of a single narrowed calyx, achieved by incising the calyx along its appropriate margin (anterior margin for posterior calyces and posterior margin for anterior calyces) and suturing those margins to the renal pelvis, resulting in a shorter, wider calyx ( Fig. 11-8). The infundibulum can also be incised longitudinally and then closed transversely in a Heinecke–Mickulicz fashion. Calycoplasty is the repair of adjacent stenotic calyces by suturing the adjacent walls of the neighboring calyces, thus forming a single structure ( Fig. 11-9 and Fig. 11-10). All intrarenal reconstructive suturing should be accomplished with 5-0 or 6-0 chromic catgut sutures. When suturing the mucosal edges, it is important to avoid incorporation of underlying interlobular arteries, thus preventing ischemia.

FIG. 11-8. Technique of repairing strictured infundibula. (1) Narrowed elongated infundibulum. (2) Incision into calyx forms an inverted Y. (3) Pelvic flap is advanced into infundibulotomy. (4) Incision in calyx is closed transversely.

FIG. 11-9. Adjacent infundibula are sutured together starting in the renal pelvis. Peripelvic fat is depressed during this closure.

FIG. 11-10. The collecting system is completely reconstructed.

The renal pelvis is then closed with a running 6-0 chromic catgut suture ( Fig. 11-11). The renal capsule is closed with a running 4-0 chromic suture ( Fig. 11-12). The use of mattress-type parenchymal sutures can lead to tissue ischemia and should be avoided if possible. One should inspect closely for further parenchymal bleeding points and ensure good hemostasis before closing the renal capsule. After the capsule is closed and hemostasis has been achieved, the slush surrounding the kidney is removed, and the renal artery unclamped. The kidney is observed for good hemostasis and return of pink color and good turgor after unclamping. The kidney is then returned into Gerota's fascia, and the kidney and proximal ureter are covered with some perirenal fat to minimize the postoperative scar formation. If Gerota's fascia is unavailable because of prior surgery, omentum can be mobilized through a peritoneal opening and wrapped around these structures. The peritoneal opening should be sutured to the omentum to prevent herniation of the abdominal viscera.

FIG. 11-11. The renal pelvis is closed with a running 6-0 chromic suture.

FIG. 11-12. The renal capsule is closed with a running 4-0 chromic suture.

A Penrose or suction-type drain is placed within Gerota's fascia and brought out through a separate stab incision. This drain is left in place until minimal drainage occurs, usually by the third or fourth postoperative day. Nephrostomy tubes are generally avoided because of their potential for causing infection or further renal damage. The flank musculature and skin are closed in the standard fashion. Postoperative management after anatrophic nephrolithotomy should follow the same principles that guide management after other major operations. Intravenous fluids are maintained to achieve brisk urine output and until the patient is able to tolerate a clear liquid diet. Broad-spectrum intravenous antibiotics are administered perioperatively and continued postoperatively. Antibiotic coverage is guided by preoperative urine culture and sensitivity results. The patient is usually converted to appropriate oral antibiotics and maintained on a 14-day course. The ureteral stent is removed cystoscopically at approximately 6 weeks after the operation in uncomplicated cases.

OUTCOMES Complications Pulmonary complications are perhaps the most common following anatrophic nephrolithotomy, especially atelectasis. Patients with a history of pulmonary disease should probably undergo preoperative evaluation with pulmonary function testing and initiation of vigorous pulmonary toilet prior to surgery. Postoperatively, patients should be encouraged to breathe deeply, and use of an incentive spirometer should be routine. Early ambulation will also be beneficial.

Pneumothorax should occur in fewer than 5% of patients. 10 Inadvertent opening of the pleura, usually during incision and resection of a rib, should be readily identified intraoperatively. The defect should be closed immediately with a running chromic catgut suture. The lung is hyperinflated just before the final suture is placed to ensure reexpansion of the lung. Chest tubes are not routinely used but may be necessary if any question remains regarding the reliability of the pleural closure. A chest radiograph should be obtained in the recovery room for any patient who undergoes repair of a pleural defect. Pulmonary embolism remains a potential complication of any major surgery. Routine use of elastic support hose and sequential-compression stockings can lower the risk of deep venous thrombosis. Encouragement of early ambulation is also an important preventative measure. Significant postoperative renal hemorrhage should occur in fewer than 10% of patients. Assimos and associates reported an incidence of 6.4%. 1 Bleeding usually occurs immediately or about a week postoperatively. Extensive intrarenal reconstruction, older age, worse renal function, and presence of blood dyscrasias were found to be significant risk factors. Slow bleeding will usually resolve on its own; management includes correction of any bleeding abnormalities and replacement with blood products as necessary. Oral e-aminocaproic acid can be successful in certain cases. Bleeding that is brisk or cannot be adequately treated conservatively will require a more aggressive approach. A renal arteriogram can help identify the lesion, and an attempt at arteriographic embolization can be considered. Reexploration may be required in the remainder of the cases, with reinstitution of hypothermia and suture ligation of the bleeding vessel(s). Persistent hematuria 1 to 4 weeks postoperatively should alert the clinician to the possibility of renal arteriovenous fistula formation. 1 Stone recurrence rates following anatrophic nephrolithotomy have been reported from 5% to 30%. 10 Inspection, intraoperative plain radiographs, intraoperative ultrasound, and nephroscopy can all aid in the identification and treatment of retained calculi. Recurrent calculi usually form in those with persistent urinary tract infections, persistent urinary drainage impairment, and those with previously unidentified or refractory metabolic disturbances. 7 Urinary drainage or extravasation should occur infrequently with the routine use of perinephric drains and internal ureteral catheter drainage. Should drainage recur or persist following removal of the drain and/or ureteral stent, replacement of the ureteral stent should be considered to decompress the system and relieve any obstruction. Results When performed for appropriate indications and with meticulous technique, anatrophic nephrolithotomy can achieve successful removal of all calculi, preservation of renal function, improved urinary drainage, and eradication of infection. Stone-free rates greater than 90% should be achieved. We believe that for large complex staghorn calculi and those associated with some anatomic abnormality leading to impaired urinary drainage, anatrophic nephrolithotomy remains superior to percutaneous nephrolithotomy or combination therapy with respect to both stone-free rates and the achievement of a stone-free state with a single operative procedure. In the long term, treatment of these staghorn calculi with anatrophic nephrolithotomy should preserve renal function in the involved kidney and, in a majority of patients, eradicate stone disease and chronic urinary infection. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Assimos DG, Boyce WH, Harrison LH, Hall JA, McCullough DL. Postoperative anatrophic nephrolithotomy bleeding. J Urol 1986;135:1153–1156. Assimos DG, Boyce WH, Harrison LH, McCullough DL, Kroovand RL, Sweat KR. The role of open stone surgery since extracorporeal shock wave lithotripsy. J Urol 1989;142:263–267. Blandy JP, Singh M. The case for a more aggressive approach to staghorn stones. J Urol 1976;115:505–506. McDougal WS. Renal perfusion/reperfusion injuries. J Urol 1988;140:1325–1330. Myers RP. Brodel's line. Surg Gynecol Obstet 1971;132:424–426. Redman JF, Bissada NK, Harper DL. Anatrophic nephrolithotomy: experience with a simplification of the Smith and Boyce technique. J Urol 1979;122:595–597. Russell JM, Harrison LH, Boyce WH. Recurrent urolithiasis following anatrophic nephrolithotomy. J Urol 1981;125:471–474. Segura JW, Preminger GM, Assimos DG, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. J Urol 1994;151:1648–1651. Smith MJV, Boyce WH. Anatrophic nephrotomy and plastic calyrhaphy. J Urol 1968;99:521–527. Spirnak JP, Resnick MI. Anatrophic nephrolithotomy. Urol Clin North Am 1983;10(4):665–675.

Chapter 12 Renal and Retroperitoneal Abscesses Glenn’s Urologic Surgery

Chapter 12 Renal and Retroperitoneal Abscesses J. Quentin Clemens and Anthony J. Schaeffer

J. Q. Clemens and A. J. Schaeffer: Department of Urology, Northwestern University Medical School, Chicago, Illinois 60611-3008.

Classification Pathogenesis Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Percutaneous Drainage Open Surgical Drainage Ancillary Procedures Subcapsular Nephrectomy Outcomes Complications Results Special Considerations Renal Tuberculosis Renal Echinococcosis Chapter References

Renal and retroperitoneal abscesses are uncommon clinical entities that often pose a significant diagnostic challenge. Nonspecific signs and symptoms frequently lead to a delay in diagnosis and treatment. Consequently, they are associated with significant morbidity, and mortality rates approaching 50% have been reported. An understanding of the anatomy of the retroperitoneal space is essential for classification, diagnosis, and management of renal and retroperitoneal abscesses.

CLASSIFICATION The retroperitoneal space is bounded by the posterior parietal peritoneum and transversalis fascia ( Fig. 12-1 and Fig. 12-2). It is divided into the perirenal space and the pararenal space.

FIG. 12-1. Right sagittal view showing the anterior pararenal, perirenal, posterior pararenal and retrofascial spaces. (From Simons GW, Sty JR, Starshak RJ. Retroperitoneal and retrofascial abscess. J Bone Joint Surg 1983;65A:1041.)

FIG. 12-2. The three retroperitoneal compartments. The striped and crosshatched areas correspond to the perirenal and posterior pararenal space, respectively. (From Meyers MA. Dynamic radiology of the abdomen. In: Normal and pathologic anatomy, 2nd ed. New York: Springer-Verlag, 1982;107–110.)

The perirenal space surrounds the kidney and is bounded by the renal (Gerota's) fascia. It contains a lemon-yellow layer of fat, which is thickest posteriorly and laterally. The anterior and posterior leaves of the renal fascia fuse above the adrenal gland, becoming continuous with the diaphragmatic fascia. 1 A thinner, more variable layer meets between the adrenal gland and the kidney. Laterally, the fascial layers join to form the lateroconal fascia, which becomes continuous with the posterior parietal peritoneum. Medially, the posterior layer fuses with the psoas muscle fascia, and the anterior layer fuses with the connective tissue surrounding the great vessels and organs of the anterior retroperitoneum (i.e., the pancreas, duodenum, and colon). Because the perirenal space rarely crosses the midline, perirenal abscesses usually remain unilateral. 16 Inferiorly, the renal fascial layers do not fuse but, rather, become continuous with the psoas and ureteral coverings. 1,11 This opening inferiorly allows spread of perirenal infections to the pararenal space, to the pelvis, to the psoas muscle, and, in some cases, to the contralateral retroperitoneum. The pararenal space is divided into two compartments: the anterior compartment, which is bounded by the posterior parietal peritoneum and the anterior renal fascia; and the posterior compartment, which is bounded by the posterior renal fascia and transversalis fascia. The pararenal space contains pale adipose tissue, which fills much of the retroperitoneal space. Because the anterior pararenal space extends across the midline, infection arising in one space may become bilateral. The posterior pararenal space does not cross the midline, and infection within it remains unilateral. 16 The retrofascial compartment lies posterior to the transversalis fascia. It is important only in development of the rare retrofascial abscess from abscesses of the psoas, iliacus, and quadratus muscles.

PATHOGENESIS Before the advent of antimicrobial therapy, most renal abscesses occurred as a result of hematogenous spread of gram-positive organisms, usually Staphylococcus aureus. These abscesses, which were called renal carbuncles, may still be seen in intravenous drug users and in patients with dermatologic disorders. They may

resolve with aggressive antimicrobial therapy if treated before frank suppuration. Presently, most renal and retroperitoneal abscesses are caused by retrograde ascent of gram-negative bacteria from the bladder. The most common organisms include Escherichia coli, Proteus, Klebsiella, and Pseudomonas.6,12 Anaerobes may be isolated in abscesses associated with gastrointestinal and respiratory infections. 2,4 Abscesses caused by opportunistic organisms such as Candida and Aspergillus may occur in immunosuppressed patients. Other uncommon pathogens include Mycobacterium tuberculosis and Echinococcus (see below). A renal abscess is generally preceded by pyelonephritis, which progresses to abscess formation in the presence of a virulent uropathogen, a damaged or obstructed urinary tract, or a compromised host. Renal abscesses have a predilection for the cortical medullary region and may drain spontaneously through the renal collecting system. When renal infection is complicated by obstruction, a purulent exudate collects in the renal collecting system. Pyonephrosis refers to infected hydronephrosis with suppurative destruction of the parenchyma of the kidney, with total or near total loss of renal function. The most frequent cause of obstruction is calculous disease. 3,20 A previous history of urinary tract infection or surgery is also common. Perirenal abscesses usually occur by erosion of abscesses or pyonephrosis into the perirenal space. 14 Because of gravity, the resulting perirenal suppuration tends to localize dorsolaterally to the lower pole of the kidney. Posterior pararenal abscesses may arise from perirenal abscesses or from anterior pararenal abscesses tracking into the pelvis, where the anterior and posterior pararenal spaces communicate. Occasionally they result from hematogenous spread. Anterior pararenal abscesses are rarely urologic in origin. They arise from infection involving the organs within the anterior pararenal space, namely the ascending and descending colon, appendix, duodenal loop, and the pancreas. Abscesses arising from the gastrointestinal tract usually harbor a mixture of microorganisms, of which E. coli is the most prevalent. Extension of anterior pararenal abscesses into the perirenal space is uncommon.

DIAGNOSIS The diagnosis of renal and retroperitoneal abscesses requires a high index of suspicion, as they typically present with insidious, nonspecific signs and symptoms. 6,17 Presenting symptoms may include fever, chills, abdominal or flank pain, irritative voiding symptoms, nausea, vomiting, lethargy, or weight loss. Symptoms have been present for more than 5 days in the majority of patients with renal and retroperitoneal abscesses, compared with 10% of patients with pyelonephritis. Over one-third of patients may be afebrile. The majority of patients diagnosed with renal and retroperitoneal abscesses have underlying, predisposing medical conditions. These include diabetes mellitus, urinary tract calculi, previous urologic surgery, urinary tract obstruction, polycystic kidney disease, and immunosuppression. A palpable flank or abdominal mass is present in about half of the cases. The mass may be better appreciated by examination of the patient in the knee–chest position. There may also be signs of psoas muscle irritation with flexion of the thigh. Laboratory tests are helpful but nondiagnostic. Leukocytosis, elevated serum creatinine, and pyuria are common. Blood and urine cultures are frequently negative; when positive, they usually correlate with culture results from the abscess. Excretory urography may aid in the diagnosis of renal or retroperitoneal abscesses by showing diminished mobility on inspiratory–expiratory films. A renal abscess causes a decrease in function and enlargement of the nephrogram during the acute phase. Retroperitoneal abscesses may cause displacement of the kidneys or ureters by a mass, scoliosis of the spine, and free air or fluid in the retroperitoneal space. Computed tomography (CT) is highly sensitive for the diagnosis of renal and retroperitoneal abscesses. It precisely localizes and assesses the size of an abscess so that the type of intervention and its anatomic approach can be determined. The presence of gas within a lesion is pathognomonic for an abscess. Additional CT findings characteristic of an abscess include a mass with low attenuation, rim enhancement of the abscess wall after contrast, obliteration of tissue planes, and displacement of surrounding structures. Ultrasonography is less sensitive than CT but useful for monitoring response to therapy. Arteriography and radioisotope scanning rarely add significant information.

INDICATIONS FOR SURGERY Renal and retroperitoneal abscesses are generally lethal if untreated. Therapeutic options include antimicrobial therapy, percutaneous catheter drainage, and open surgical drainage.

ALTERNATIVE THERAPY Antimicrobial therapy as the sole treatment is an option, yet most abscesses cannot be cured without drainage. Small renal abscesses may resolve, however, if they are treated early with aggressive antimicrobial therapy. Prolonged antimicrobial therapy without drainage is indicated only if favorable clinical response and radiologic confirmation of abscess resolution indicate that the therapy is effective. If antimicrobial therapy is not effective, prompt percutaneous or open surgical drainage of the pus is mandatory. Progression of a renal abscess leads to perinephric abscess or perforation into the collecting system and results in signs and symptoms of urinary tract infection. Antimicrobial therapy should be instituted after the urine has been Gram-stained and urine and blood cultures have been obtained. Broad-spectrum coverage should be guided by the presumptive diagnosis and the presumed pathogen. An aminoglycoside for gram-negative rods and ampicillin for gram-positive cocci are preferred. Anaerobic coverage with a drug such as clindamycin is warranted when Gram stain reveals a polymicrobial flora or when a gastrointestinal source is suspected. If the abscess may be of staphylococcal origin, a penicillinase-resistant penicillin, such as nafcillin, should be added. Antimicrobial therapy should be reevaluated when the results of culture and sensitivity tests are available. Unfortunately, urine and blood cultures are frequently sterile, and empirical therapy must be modified on the basis of clinical response and changes in imaging studies.

SURGICAL TECHNIQUE Percutaneous Drainage Most renal and retroperitoneal abscesses are treated with empirical antimicrobial therapy and immediate percutaneous drainage. When successful, minimally invasive therapy minimizes operative morbidity and allows for preservation of renal tissue. The abscess must be confirmed by CT-guided or ultrasonography-guided needle aspiration and must be drainable without injury to other organs. Immediate surgical drainage must be instituted if the procedure fails. After a multiport drainage catheter (8 to 12 Fr) is positioned, the abscess should be drained, and adequate evacuation should be confirmed by CT or ultrasonography. The catheter should then be connected to low intermittent suction, and drainage outputs should be monitored daily. If drainage stops abruptly, occlusion of the catheter should be suspected, and it should be irrigated gently with small amounts of normal saline. Computed tomography or ultrasonography should be performed periodically to monitor catheter position and size of the abscess. Direct instillation of contrast through the drainage tube may be helpful to confirm the catheter position or to rule out a fistula. To avoid bacteremia, prophylactic antimicrobial coverage should be given, and the contrast should be instilled under gravity or by gentle injection. Instillation of 2,500 units of urokinase in 50 ml of normal saline on a daily basis may be successful in evacuating an organizing infected hematoma. Routine abscess irrigation with antimicrobials is of questionable benefit and may promote overgrowth of resistant bacteria. The catheter should be withdrawn gradually as the abscess cavity shrinks and the drainage decreases. The usual duration of drainage is 1 to 3 weeks. The catheter is removed when drainage stops and CT and ultrasonography show complete resolution. Open Surgical Drainage The incision should be smaller than that used for routine nephrectomy, and usually a posterior flank muscle-splitting incision below the 12th rib is sufficient. When the retroperitoneal abscess is entered, the pus should be cultured, and the space gently but thoroughly explored to ensure that all loculated cavities are drained. Thorough irrigation of the cavity is essential. Multiple Penrose drains should be inserted into the space through separate stab wounds, and the ends of the drains should be sutured to the skin and tagged with safety pins. Fascial and muscular closure may be performed with chromic catgut suture, but skin and subcutaneous tissue should be left open to prevent the formation of a secondary body wall abscess. The wound can be left to heal from within, or skin sutures may be placed and left untied for dermal approximation 5 to 7 days postoperatively after drainage has ceased. The wound should be packed with gauze, and the packs should be changed daily. The drains should be left in place until purulent drainage has decreased, and then they can be removed slowly over several days.

ANCILLARY PROCEDURES

If a perinephric abscess is due to long-standing obstruction and there is no functioning renal tissue, a nephrectomy at the time of drainage is theoretically attractive. Drainage of a perinephric abscess should usually be performed as a primary procedure, however, with nephrectomy performed at a later date if necessary. Patients are frequently too ill for prolonged general anesthesia and surgical manipulation. Furthermore, nephrectomy is usually difficult to accomplish technically, and preoperative information is usually not sufficient to determine accurately the amount of functioning of salvageable renal tissue. After drainage of the abscess, removal of obstruction, and appropriate antimicrobial therapy, many kidneys may regain sufficient function to obviate future nephrectomy. Nephrectomy, if indicated, can be performed using a standard nephrectomy approach or a subcapsular nephrectomy technique outlined later. A small renal abscess confined to one pole of the kidney may be managed by partial nephrectomy. If the infection extends beyond the apparent line of cleavage, however, it is essential to remove all infection, and the line of excision should extend through healthy tissue. If multiple abscesses are present, internal drainage is difficult, and nephrectomy may be required. Subcapsular Nephrectomy When a kidney is so adherent to surrounding tissues that dissection is difficult and hazardous, a subcapsular nephrectomy is indicated. These conditions are usually seen after multiple or chronic infections or previous operations have caused scarring to adjacent organs. Blunt dissection results in tearing of structures such as bowel wall. Sharp dissection when there is no definable tissue plane often results in lacerations of the vena cava, aorta, duodenum, spleen, and other structures. In subcapsular nephrectomy, dissection beneath the renal capsule enables one to avoid these vital structures. Subcapsular nephrectomy should not be performed for malignant disease and is undesirable in tuberculosis. The main difficulty with subcapsular nephrectomy is that the capsule is adherent to the vessels in the hilum, and one usually must go outside the capsule to ligate the renal pedicle. In this setting, the renal hilum usually is involved in the inflammatory reaction, and separate identification of the vessels is difficult. Kidney exposure is accomplished through the flank using a 12th rib incision. For low-lying kidneys, a subcostal incision may be satisfactory. When the kidney is reached, the capsule is incised and is freed from the underlying cortex ( Fig. 12-3). The capsule is stripped from the surface of the kidney, and an incision is made carefully in the capsule where it is attached to the hilum ( Fig. 12-4). The vessels may be protected by placing a finger in front of the pedicle when cutting the capsule. The dense apron of capsule can usually be incised best on the anterior aspect. Control of bleeding can be difficult in this procedure. Frequently all landmarks are obscured, and the renal artery and vein cannot be identified. Sharp dissection is usually required, and major vessels may be entered before they are recognized. Fortunately, the dense fibrous tissue tends to prevent their retraction. Frequently, several chromic suture ligatures can be placed through the pedicle between a proximally placed pedicle clamp and the kidney. To avoid damage to the duodenum or major vessels, pieces of capsule may be left behind. However, prolonged drainage can ensue, and as much of the infected tissue should be removed as possible. After ligation and cutting of the pedicle, the ureter is identified and cut, and the distal end is ligated. If distal ureteral obstruction has caused pyonephrosis, a small, 8 to 10 Fr red Robinson catheter may be placed in the distal ureter to allow postoperative antimicrobial irrigation. Multiple drains should be placed and brought through separate stab wounds.

FIG. 12-3. Subcapsular secondary nephrectomy showing freeing of capsule from anterior surfaces of kidney.

FIG. 12-4. Subcapsular secondary nephrectomy showing incision in and removal of a portion of renal capsule to expose and ligate renal pedicle.

OUTCOMES Complications Complications associated with percutaneous drainage include the formation of additional abscesses that communicate with the renal collecting system and may require temporary urinary diversion via percutaneous nephrostomy drainage to affect a cure. Sepsis, the most frequent complication of percutaneous drainage, occurs in fewer than 10% of patients. Other complications, such as transpleural puncture, vascular or enteric injury, and cutaneous fistula, are rare. Additional complications to open or percutaneous drainage include prolonged purulent drainage, which may indicate a retained foreign body, calculus, or fistula. Results Cure rates for percutaneous drainage of renal and retroperitoneal abscesses range from 60% to 90%. 8,15 Multiloculated, viscous abscesses and abscesses in immunocompromised hosts are associated with lower cure rates. Large abscesses may require more than one percutaneous access procedure to completely drain them. In the past, mortality rates were reported to be as high as 50% in patients with retroperitoneal or perinephric abscesses. More recent reports indicate a significant improvement in mortality (approximately 10%), in large part because of more accurate diagnosis from improved imaging techniques, more effective antimicrobial therapy, and better supportive care. 4,6,17

SPECIAL CONSIDERATIONS

Renal Tuberculosis Renal tuberculosis is caused by hematogenous dissemination from an infected source somewhere else in the body. Both kidneys are seeded with tuberculosis bacilli in 90% of cases. Clinically apparent renal tuberculosis is usually unilateral, however. The initial lesion involves the renal cortex, with multiple small granulomas in the glomeruli and in the juxtaglomerular regions. In untreated patients who fail to heal spontaneously, the lesions may progress slowly and remain asymptomatic for variable periods, usually 10 to 40 years. As the lesions progress, they produce areas of caseous necrosis and parenchymal cavitation. Large tumor-like parenchymal lesions or tuberculomas frequently have fibrous walls and resemble solid mass lesions. Once cavities form, spontaneous healing is rare, and destructive lesions result, with spread of the infection to the renal pelvis and development of a parenchymal or peri-nephric abscess. Indications for Surgery Surgery was once commonly used in the treatment of renal tuberculosis, but since the advent of effective antituberculosis chemotherapy, it is reserved primarily for management of local complications, such as ureteral strictures, or for treatment of nonfunctioning kidneys. If surgery is warranted, it is wise to precede the operation with at least 3 weeks and preferably 3 months of triple-drug chemotherapy. Use of isoniazid, 300 mg/day; pyrazinamide, 25 mg/kg to a maximum of 2 g, once daily; and rifampicin, 450 mg/day is recommended. If segmental renal damage is obvious and salvage of the kidney is possible, a drainage procedure or cavernostomy can be performed. 7 Removal of a nonfunctioning kidney is usually indicated for advanced unilateral disease complicated by sepsis, hemorrhage, intractable pain, newly developed severe hypertension, suspicion of malignancy, inability to sterilize the urine with drugs alone, abscess formation with development of fistula or inability to have appropriate follow-up. 9,10,13 Alternative Therapy Prophylactic removal of a nonfunctioning kidney to prevent complications, remove a potential source of viable organisms, and shorten the duration of convalescence and requirement for chemotherapy is advocated by some authors. 5,19 Others, who followed a large series of patients treated with medical therapy alone, concluded that, because the frequency of late complications is only 6%, routine nephrectomy should not be performed for every nonfunctioning kidney. 9 These authors, however, treated patients for at least 2 years. The merits of short-term therapy and prophylactic nephrectomy versus long-term 2-year chemotherapy and selective nephrectomy warrant further study. Modern percutaneous drainage techniques have largely replaced open cavernostomy for treatment of closed pyocalyx. Surgical Technique Cavernostomy Renal tuberculosis sometimes results in caliceal infundibular scarring, causing a closed pyocalix. Unroofing of a pyocalix is called cavernostomy. If the calix still communicates with the renal pelvis, or if it is connected to significant functioning parenchyma, a cavernostomy should not be done because a urinary fistula or urinoma may result. To minimize wound contamination and tuberculous spread, thorough needle aspiration of purulent material and saline irrigation of the abscess cavity should be performed using a large-bore needle and syringe ( Fig. 12-5). The abscess cavity is then unroofed, and the edge is sutured with a running suture for hemostasis. Any unsuspected connection with the renal pelvis by an open infundibulum must be closed using 5-0 chromic catgut suture to prevent fistula or urinoma formation. After thorough wound irrigation, multiple drains are placed, and closure is undertaken. Drains are managed as previously described for perinephric abscess.

FIG. 12-5. Cavernotomy drainage of tuberculous renal abscess. (From Hanley HG. Cavernotomy and partial nephrectomy in renal tuberculosis. Br J Urol 1970;42:661.)

Nephrectomy When unilateral tuberculosis causes more extensive parenchymal destruction or nonfunction, a partial or total nephrectomy, respectively, should be performed. For partial nephrectomy, a guillotine incision is made 1 cm beyond the abscess. If the renal pedicle can be freed and polar vessel located and occluded, the incision can be made at the line of demarcation of the ischemia. In partial nephrectomy, it is important to try to save the capsule (if it is not involved with the infection) to cover the raw surface for hemostasis. Alternatively, fat can be used for hemostasis. The amputated calyx is carefully ligated with a 4-0 chromic catgut suture to prevent urinary fistula or urinoma formation. After nephrectomy, the distal ureter can be ligated and in most cases does not need to be brought to the skin because tuberculosis of the ureter generally heals with chemotherapy after nephrectomy. If renal tuberculosis is associated with severe tuberculosis cystitis, ureteral catheterization for 7 days postoperatively to minimize subsequent ureteral stump abscess formation should be considered. 18 Renal Echinococcosis Echinococcosis is a parasitic infection caused by the canine tapeworm E. granulosus. Echinococcal or hydatid cysts occur in the kidney in some 3% of patients with this disease. The hydatid cyst gradually develops at a rate of about 1 cm/year and is usually single and located in the cortex. Diagnosis The symptoms are those of a slowly growing tumor; most patients are asymptomatic or have a dull flank pain or hematuria. Excretory urography typically shows a thick-walled cystic mass, which is occasionally calcified. Ultrasonography and CT usually show a multicystic or multiloculated mass. Confirmation of the diagnosis is most reliably made by diagnostic tests using partially purified hydatid antigens in a double diffusion test. 13 Complement fixation and hemagglutination are less reliable. Diagnostic needle puncture is associated with significant risk of anaphylaxis as a result of leakage of toxic cyst contents. Indications for Surgery Cyst removal is indicated when an enlarging cyst threatens renal function or produces obstruction. Surgical Technique The cyst should be removed without rupture to reduce the chance of seeding and recurrence. In cases where cyst removal is impossible because of its size or involvement of adjacent organs, marsupialization is required. The contents of the cyst initially should be aspirated, and the cyst should be filled with a scolecidal agent

such as 30% sodium chloride, 2% formalin, or 1% iodide for about 5 minutes to kill the germinal portions. Complete evacuation of all hydatid tissue and thorough postmarsupialization irrigation are critical to preventing systemic effects. Penrose drains are left in the cystic cavity until drainage ceases. If large amounts of renal tissue have been damaged, partial or simple nephrectomy may be required. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Amin M, Blandford AT, Polk HC. Renal fascia of Gerota. Urology 1976;7:1–3. Brook I. The role of anaerobic bacteria in perinephric and renal abscesses in children. Pediatrics 1994;93:261–264. Doughney KB, Dineen MK, Venable DD. Nephrobronchial colonic fistula complicating perinephric abscess. J Urol 1986;135:765–767. Edelstein H, McCabe RE. Perinephric abscess: modern diagnosis and treatment in 47 cases. Medicine 1988;67(2):118–131. Flechner SM, Gow JG. Role of nephrectomy in the treatment of nonfunctioning or very poorly functioning unilateral tuberculous kidney. J Urol 1980;123:822–825. Fowler JE, Perkins T. Presentation, diagnosis and treatment of renal abscesses: 1972–1988. J Urol 1994;151:847–851. Hanley HG. Cavernostomy and partial nephrectomy in renal tuberculosis. Br J Urol 1970;42:661–666. Lambiase RE, Deyoe L, Cronan JJ, Durfman GS. Percutaneous drainage of 355 consecutive abscesses: results of primary drainage with 1-year follow-up. Radiology 1992;184:167–179. Lattimer JK, Wechsler MW. Editorial comment: surgical management of nonfunctioning tuberculous kidneys. J Urol 1980;124:191. Lorin MI, Hsu KHF, Jacob SC. Treatment of tuberculosis in children. Pediatr Clin North Am 1983;30:333–348. Mitchell GAG. The renal fascia. Br J Surg 1950;37:257–266. Patterson JE, Andriole VT. Bacterial urinary tract infections in diabetes. Infect Dis Clin North Am 1995;9:25–51. Schaeffer AJ. Urinary tract infections. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and pediatric urology. Chicago: Year Book Medical Publishers, 1996;289–351. Sheinfeld J, Ertuk E, Spataro RF, Cockett ATK. Perinephric abscess: current concepts. J Urol 1987;137:191–194. Siegel JF, Smith A, Moldwin R. Minimally invasive treatment of renal abscess. J Urol 1996;155:52–55. Simons GW, Sty JR, Starshak RJ. Retroperitoneal and retrofascial abscesses. J Bone Joint Surg 1983;65A:1041–1058. Thorley JD, Jones SR, Sanford JP. Perinephric abscess. Medicine 1974;53:441–451. Wechsler M, Lattimer JK. An evaluation of the current therapeutic regimen for renal tuberculosis. J Urol 1975;13:760–761. Wong SH, Lou WY. The surgical management of non-functioning tuberculous kidney. J Urol 1980;124:187–191. Yoder JC, Pfister RC, Lindfors KK, et al. Pyonephrosis: imaging and intervention. Am J Roentgenol 1983;141:735–739.

Chapter 13 Renal Trauma Glenn’s Urologic Surgery

Chapter 13 Renal Trauma Allen F. Morey and Jack W. McAninch

A. F. Morey: Department of Surgery (Urology Service), Uniformed Services University of the Health Sciences, and Brooke Army Medical Center, Fort Sam Houston, Texas 78258. J. W. McAninch: Urology Department, University of California, and San Francisco General Hospital, San Francisco, California 94110. The opinions expressed herein are those of the authors and are not to be construed as reflecting the views of the Armed Forces or the Department of Defense

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Renal injuries can be some of the most complex and challenging cases a urologist or trauma surgeon may face. The vast majority of renal injuries occur as a result of blunt trauma, and most of these are amenable to nonoperative management. Penetrating renal trauma usually occurs in conjunction with injuries to associated abdominal organs, which require urgent laparotomy. Systematic renal reconstruction at the time of laparotomy provides excellent functional results in the majority of cases.

DIAGNOSIS Signs, symptoms, and laboratory findings that suggest renal injury should prompt immediate radiologic evaluation in stable patients. Gross hematuria after blunt trauma should warrant renal imaging in all cases. Adults with microhematuria in the presence of shock, deceleration injuries, or signs of significant abdominal, flank, or chest injuries after blunt trauma should also be imaged. 3 Pediatric patients with significant microhematuria or signs of multiple injuries after blunt trauma should be radiographically evaluated. 4 Penetrating wounds of the abdomen or flank with any degree of hematuria also warrant urgent renal imaging. The best study for assessing the injured kidney in a stable patient is a renal CT scan. Renal images can be obtained in conjunction with an abdominal CT when trauma surgeons need this study to evaluate the extent of associated intra-abdominal injuries. When unstable patients are taken emergently for laparotomy and renal injuries are suspected, a one-shot intraoperative IVP is extremely useful. The intraoperative IVP consists of a high-dose (2 cc/kg) intravenous bolus injection of radiographic contrast; a single film is taken at 10 minutes. No scout film is necessary. This technique provides important information regarding the degree of injury of the kidney in question and the status of the contralateral kidney without delaying resuscitation. 4

INDICATIONS FOR SURGERY The decision to surgically repair the traumatized kidney is based on consideration of the patient's mechanism of injury, hemodynamic stability, associated injuries, and accurate radiographic staging of the injury. The vast majority of blunt traumatic renal injuries are clinically insignificant. At San Francisco General Hospital, fewer than 3% of patients with blunt renal trauma require renal exploration ( Fig. 13-1). Penetrating renal injuries, on the other hand, should usually be explored. Approximately 70% of patients with penetrating renal trauma are treated surgically at our trauma center. Only when radiographic staging clearly defines a penetrating injury as minor can a nonoperative approach be used successfully. 8

FIG. 13-1. Abdominal CT reveals left renal laceration after blunt trauma (grade 3). Even major renal lacerations occurring after blunt trauma are usually amenable to nonoperative management. Renal CT provides detailed information regarding the depth of laceration, size of perirenal hematoma, tissue viability, urinary extravasation, and the status of the contralateral kidney.

Persistent renal bleeding is an absolute indication for renal exploration. Relative indications for renal surgery include extensive urinary extravasation, nonviable renal tissue in association with a parenchymal laceration, incomplete clinical or radiographic staging, and arterial thrombosis. 3 Also, if a trauma surgeon elects to perform an exploratory laparotomy to manage an associated abdominal injury, we will usually repair significant renal injuries at that time in order to prevent late complications. Nearly all renal lacerations occurring from gunshot wounds require immediate repair. In the absence of severe vascular injury or hemodynamic instability, renal reconstruction may safely be attempted. Successful reconstruction can be undertaken despite spillage from bowel injury, pancreatic injury, or other associated injuries. 7

ALTERNATIVE THERAPY Nephrectomy, when required after renal trauma, usually occurs when an injury is deemed irreparable or in the setting of hemodynamic instability. Although nephrectomy is clearly a life-saving maneuver in these instances, it is only necessary in about 10% of cases. In general, patients requiring nephrectomy are much more seriously injured, are frequently in shock, and cannot be managed conservatively. 5 Renal stab wounds are successfully managed nonoperatively in about 50% of cases at San Francisco General Hospital. The types of stab wounds most amenable to an observational approach are those occurring posteriorly or in the flank, where intra-abdominal organs are unlikely to be involved. For those stab-wound patients in whom nonoperative management is being contemplated, renal CT provides excellent information regarding the depth of laceration, extent of urinary extravasation, and size of perirenal hematoma. 8

SURGICAL TECHNIQUE Renal exploration in the trauma setting should be carried out through a standard midline abdominal incision. This approach provides complete access to the intra-abdominal viscera and vasculature, and it also gives the greatest flexibility to assess and repair a variety of genitourinary injuries. Major bleeding noted on opening the abdominal cavity should be controlled immediately with laparotomy packs followed by surgical control and repair. Associated injuries to other abdominal organs are usually addressed before examination of the kidneys if the patient is stable. The bowel, liver, spleen, pancreas, and other organs should be inspected

systematically and carefully. The renal vasculature is routinely isolated before a retroperitoneal hematoma surrounding an injured kidney is entered. This creates a safety net for reconstruction and reduces the risk of uncontrolled renal bleeding and subsequent nephrectomy. To facilitate access to the retroperitoneum, the transverse colon is lifted out of the abdomen superiorly and placed on moist laparotomy packs. The small bowel is placed in a bowel bag and lifted anteriorly to the right. An incision is made in the retroperitoneum over the aorta from the level of the inferior mesenteric artery to the ligament of Treitz, which can be divided for additional exposure. If hemorrhage obscures the aorta, the inferior mesenteric vein is identified, and the retroperitoneal incision is placed just medial to this important landmark. Once the aorta is identified in the lower part of the incision, it is followed superiorly to the left renal vein, which reliably crosses anteriorly. The renal arteries can be found just posterior to the left renal vein on either side of the aorta. If the right renal vein is difficult to isolate through this approach, an alternative method of exposure is to mobilize the second portion of the duodenum off the vena cava. With lateral retraction on the vena cava, the right renal artery can then be isolated in its interaortocaval location. The ipsilateral renal artery and vein are individually isolated with vessel loops. These vessels are not occluded initially unless bleeding is heavy, which occurs in approximately 12% of cases in our experience. 1 Because the vessels are not routinely clamped, renal perfusion is continuous, and warm ischemia is avoided. Patients most likely to require temporary vascular occlusion are those in shock from active, uncontrolled renal bleeding. Vascular occlusion, when necessary for reconstruction, does not increase the incidence of postoperative complications when the warm ischemia time is kept around 30 minutes. After vascular control, the kidney is exposed by incising the retroperitoneum just lateral to the colon. The colon is reflected medially, and dissection through the hematoma allows renal exposure. After the kidney has been bluntly and sharply mobilized, the entire renal surface, renal vasculature, and upper ureter are routinely inspected for the presence of exit wounds or multiple injured areas ( Fig. 13-2 and Fig. 13-3). If heavy bleeding ensues, Rummel tourniquets can be applied to the vessel loops for vascular occlusion. First, the renal artery alone is occluded. If bleeding persists, the renal vein is then occluded to eliminate back bleeding.

FIG. 13-2. After preliminary vascular control, the colon is reflected, and the kidney explored. Here a small gunshot entrance wound on the anterior aspect of left kidney is identified.

FIG. 13-3. When a renal injury is identified, the entire kidney must be examined for associated wounds. Here, a complex gaping exit wound is identified on the posterior surface of the kidney. Nonviable tissue is debrided, the collecting system is closed, and segmental vessels are individually suture ligated with 4-0 chromic suture. Capsular sutures of 3-0 Vicryl are used to reapproximate wound edges.

For major polar injuries, partial nephrectomy offers the best management. Nonviable tissue is sharply debrided from the injured area. Manual compression of the adjoining normal renal parenchyma, rather than formal vascular occlusion, is extremely useful during partial nephrectomy as an adjunct during control of moderate renal hemorrhage. Arcuate arteries are individually suture-ligated with 4-0 chromic suture to control hemorrhage. The collecting system is then closed watertight with a running 4-0 Vicryl suture. Methylene blue may be injected into the renal pelvis with simultaneous compression of the ureter to elucidate any leaks in the collecting system, which may then be oversewn. The renal parenchymal defect should be covered with thrombin-soaked Gelfoam to enhance hemostasis and then covered with renal capsule, if possible. Typically, after partial nephrectomy for polar injuries, the remaining renal capsule is insufficient to allow for primary closure. In this case, an omental pedicle flap can be brought around the colon or through a window in the colon mesentery and attached with interrupted suture to the existing renal capsule for coverage of the defect. Its excellent vascular supply and lymphatic drainage make omentum an excellent tissue choice for coverage of renal injuries, especially in the setting of concomitant bowel or pancreatic injury. A retroperitoneal drain is placed routinely. Major injuries to the midportion of the kidney are more difficult to repair than polar injuries, but the same surgical principles apply. Nonviable tissue is removed sharply. Sites of bleeding are individually ligated with fine absorbable sutures, and the collecting system is closed watertight. Interrupted 3-0 chromic sutures placed superficially are ideal for renal capsule approximation. Capsular sutures are best placed without incorporating the underlying parenchyma, as that tissue is extremely friable. Thrombin-soaked Gelfoam bolsters in the defect enhance hemostasis, prevent urinary leakage, and stabilize capsular closure ( Fig. 13-4). Again, omentum should be used if primary capsular closure cannot be achieved. We frequently place a row of small titanium staples in the renal capsule near the closure to visualize the operative site on subsequent imaging studies. A retroperitoneal Penrose drain is brought out through a separate incision in most cases. Suction-type drains may initiate or prolong urinary leakage.

FIG. 13-4. Closure of parenchymal defect after central renal injury. Capsular sutures of 3-0 Vicryl may be used to sew gelatin foam bolsters into repair site. Titanium clips may be placed along the repair line to identify the area of reconstruction on subsequent imaging studies. Alternatively, if primary renal closure cannot be achieved, an omental flap may be tacked over the defect using small interrupted chromic sutures.

Renal stab wounds may be repaired using the same methods detailed above. As discussed, many may be amenable to nonoperative management. If laparotomy is performed for associated injuries, renal reconstruction should be done concomitantly. Tissue destruction is frequently much less than that seen with gunshot injuries. Frequently, entrance and exit wounds may be simply oversewn (Fig. 13-5 and Fig. 13-6).

FIG. 13-5. Technique of renorrhaphy after stab wound. Gelfoam bolsters are laid into the capsular defect, and overlying 3-0 chromic sutures are placed superficially to approximate the adjoining renal capsule, thus sealing the reconstructed area.

FIG. 13-6. Completed renal reconstruction after stab wound. The entire kidney has been mobilized and evaluated for associated wounds. Titanium clips along the capsular sutures denote the area of repair.

Renal vascular injuries are a major cause of renal loss and may coexist with parenchymal lacerations. Main renal artery or complex renal vein injuries frequently lead to total nephrectomy.5 Venous injuries may occur along the main renal vein or in segmental branches. In either case, the first step is to temporarily occlude the main renal artery. Vascular clamps are then placed proximal and distal to the venous laceration. A running suture of 5-0 vascular silk is then used to close the venous defect. Segmental arterial injuries are best repaired in a similar fashion. Smaller segmental veins can safely be ligated because of the internal collateral circulation of the venous system. Also, the left main renal vein may be ligated proximally because there is extensive collateral flow through the adrenal, lumbar, and gonadal branches. Gross blood in the urine usually clears within 24 hours, and patients should be observed at bed rest during this time. Ambulation is resumed once the urine is clear. Serial hematocrits should be monitored because delayed bleeding is possible. Renal angiography and selective embolization may be considered in the event of continued hemorrhage. Retroperitoneal drains are normally removed within 48 to 72 hours. If drainage is excessive, an aliquot may be checked for creatinine; a level similar to that of serum suggests peritoneal fluid rather than urine. Blood pressure is checked before discharge. A radionuclide study is usually obtained around the time of discharge to assess function, and a renal imaging study is again obtained at about 3 months.

OUTCOMES Complications Small amounts of urinary extravasation are usually not clinically significant as long as they do not become infected. Large urinomas are best treated with percutaneous drainage. Delayed renal hemorrhage is most likely within the first 2 weeks, and this complication is best treated initially with percutaneous embolization and supportive therapy. Hypertension occurs rarely after renal injuries, and it is usually easily controlled by medical therapy alone. Delayed urinary bleeding may be a sign of a vascular fistula to the collecting system: this complication is frequently difficult to reconstruct and may often be best treated with nephrectomy. Results Renal reconstruction has achieved adequate preservation of function in 83% of patients at our institution. concomitant bowel or pancreatic injuries. 7

6

We have found renal salvage to be safe in the presence of

CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Carroll PR, Klosterman P, McAninch JW. Early vascular control for renal trauma: a critical review. J Urol 1989;141:826–829. McAninch JW. Surgery for renal trauma. In: Novick AC, Streem SB, Pontes JE, eds. Stewart's operative urology, 2nd ed. Baltimore: Williams & Wilkins, 1989;237–245. Miller KS, McAninch JW. Radiographic assessment of renal trauma: our 15-year experience. J Urol 1995;154:352–355. Morey AF, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol 1996;156(6):2014–2018. Nash PA, Bruce JE, McAninch JW. Nephrectomy for traumatic renal injuries. J Urol 1995;153:609–611. Wessels HB, Deirmenjian JM, McAninch JW. Quantitative assessment of renal function after renal reconstruction for trauma: radiographic scintigraphy results in 52 patients. J Urol 1997;157:1583–1586. 7. Wessels HB, McAninch JW. Effect of colon injury on the management of simultaneous renal trauma. J Urol 1996;155:1852–1856. 8. Wessels HB, Meyer A, McAninch JW. Criteria for conservative management of penetrating renal trauma: comparison of non-operative and surgical treatment of grade 2–4 renal lacerations due to gunshot and stab wounds. J Urol 1997;157:24–27.

Chapter 14 Renal Allotransplantation Glenn’s Urologic Surgery

Chapter 14 Renal Allotransplantation Bruce A. Lucas

B. A. Lucas: Kidney Transplant Program, Transplant Section, Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky 40536.

Indications for Surgery Alternative Therapy Surgical Technique Preparation of the Patient Incision and Iliac Fossa Dissection Allograft Positioning and Vascular Anastomoses Multiple Renal Vessels Ureteroneocystostomy Pediatric Kidneys Pediatric Transplantation Wound Closure Chapter References

Transplantation of a kidney allograft and subsequent immunosuppression in patients with renal failure demand surgical precision and zero tolerance for errors of judgment or technique. The devastating consequences of vascular, urologic, and infectious wound complications in renal transplantation, with their associated morbidity, mortality, and graft loss, are well documented. Fortunately, strict adherence to techniques and principles outlined in this chapter can reduce the incidence of these problems to very low levels.

INDICATIONS FOR SURGERY Indications for surgery include patients with chronic renal failure. Contraindications to renal allograft transplantation include a history of cancer (especially hematopoietic, renal cell carcinoma, or melanoma), active infections, and patients who are a poor operative risk. Relative contraindications include oxalosis and other metabolic disorders, psychological instability, and focal glomerulosclerosis.

ALTERNATIVE THERAPY The alternative to renal allotransplantation is chronic dialysis.

SURGICAL TECHNIQUE Preparation of the Patient The prospective transplantation recipient should be in metabolic, fluid, and electrolyte balance to avoid perioperative hyperkalemia, unstable blood pressure, pulmonary edema, dehydration, or difficult operative hemostasis associated with inadequate dialysis. When dialysis can be scheduled in advance, as with living related donor transplantation, it should be performed on the day before surgery. The patient's cardiopulmonary status needs to be well documented, and central venous pressure monitoring is routine. Swan–Ganz monitoring is often useful. The entire abdomen is shaved and prepped after the induction of anesthesia and insertion of an indwelling 16 or 18 Fr Foley catheter. Any urine present in the bladder is submitted for culture. Then the bladder is distended with 150 ml or more of a saline solution containing Neosporin GU Irrigant. This greatly facilitates the anterior cystotomy later in the procedure and, in addition, protects against possible wound contamination when the bladder is opened. After instillation of the antibiotic solution, the catheter is clamped. The clamp is removed only after cystotomy closure is completed. Incision and Iliac Fossa Dissection A lower quadrant curvilinear incision is extended from the symphysis pubis passing 2 cm medial to the anterior superior iliac spine and up to about 4 to 5 cm below the lower costal margin (Fig. 14-1A). The upper half of the incision is extended through the external oblique, internal oblique, and transversus abdominis muscles; in the lower half of the incision, the anterior rectus fascia is incised. The rectus muscle can then be dissected inferiorly to its tendinous insertion on the symphysis pubis and retracted medially. In thin patients we prefer to keep the cephalad portion of the incision also within the lateral border of the rectus muscle, thereby obviating any transection of muscle and simplifying the closure. The inferior epigastric vessels are identified as they pass across the incision and are preserved for possible use later. Next, an anterolateral retroperitoneal fascial plane is developed, permitting extraperitoneal entry into the iliac fossa.

FIG. 14-1. (A) The incision is depicted for the right abdomen, and subsequent illustrations represent graft implantation in the right iliac fossa. The renal transplantation, however, can be performed on either the right or left side. (B) The iliac vessels are best exposed with a self-retaining retractor. Sequential separation, ligation, and division of perivascular tissue containing lymphatics are essential and must precede skeletonization on the iliac vessels.

With medial retraction of the peritoneum, the spermatic cord in the male patient or round ligament in the female patient is easily identified. In men, some of the connective tissue around the cord is freed to permit easier retraction. Usually, cord ligation should be avoided to prevent hydrocele formation, testicular atrophy, or infertility. In women, the round ligament is divided and ligated. Further development of the extraperitoneal space in the iliac fossa is accomplished with exposure of the distal common and external iliac artery. The insertion of a self-retaining retractor at this point assures adequate exposure for the subsequent iliac vessel dissection and vascular anastomoses. The dissection and skeletonization of the iliac vessels must be performed in a manner that allows secure ligation of the divided lymphatics passing along and across these vessels. Usually, this process is best approached on the medial aspect of the external iliac vein, working cephalad with a right-angle clamp toward the internal iliac artery, which crosses the vein. In some cases, especially when the donor kidney is large or has a short vein, the internal iliac artery must be sacrificed in order to achieve sufficient mobilization of the underlying vein. The iliac vein can be skeletonized as far cephalad as the vena cava if necessary. Posterior venous tributaries must be divided to permit maximum anterior mobility of the iliac vein. It is best to ligate all tributaries doubly with 2-0 or 3-0 silk in continuity before division because a

double-clamping maneuver may sometimes result in injury or avulsion of a poorly accessible stump during ligation. Hemostasis then can be achieved only with difficulty and with risk of obturator nerve injury. Unless the internal iliac artery already has been selected for an end-to-end allograft anastomosis, right-angle clamp dissection is used to partially skeletonize the common and external iliac arteries ( Fig. 14-1B). The tissue overlying the arteries and containing the lymphatics is sequentially separated, doubly ligated with 3-0 silk, and divided, a strategy that greatly reduces the incidence of lymphocele. Again, this tissue should be doubly ligated before it is incised, in contrast with double clamping and division of the tissue. Just as with the vein, the anterior separation of tissue over the iliac artery is more easily performed in a cephalad direction. At this point, palpation of the common iliac bifurcation and internal iliac artery determines the suitability of the internal iliac artery for an end-to-end anastomosis with the renal artery and the need for endarterectomy. If there is moderate or severe atherosclerosis extending into the bifurcation, or great size disparity, the internal iliac artery is usually not used. If an endarterectomy can be performed safely, or if there is little evidence of atheroma in the internal iliac vessel, skeletonization of this vessel prepares it for end-to-end anastomosis. Before skeletonization is begun, the lymphatics on the medial aspect of the iliac bifurcation should be doubly ligated and divided. If the internal iliac artery is to be used, it may be clamped proximally with a Fogarty clamp and divided distal to its bifurcation with appropriate ligation of the distal stumps deep in the pelvis. The mobilized internal iliac artery is irrigated with heparinized saline solution. Allograft Positioning and Vascular Anastomoses Before recipient vessel anastomotic sites are selected, visualization of the ultimate resting place for the allograft lateral or anterior to the iliac vessels should be considered, with all anatomic factors taken into account. The iliac vein is prepared for the end-to-side renal vein anastomosis by placement of clamps proximal and distal to the proposed venotomy. Fogarty clamps usually serve this purpose well. Excision of a thin ellipse of vein produces an ideal venotomy. The isolated segment of the iliac vein is irrigated with heparinized saline. After this, four 6-0 cardiovascular sutures are placed at the superior and inferior apices and at the midpoints of the medial and lateral margins of the venotomy. These sutures later are passed through corresponding points on the donor renal vein or vena cava patch for a four-quadrant end-to-side anastomosis. If a cadaveric kidney is used, the allograft is removed from cold storage or perfusion preservation at this point. With living related transplantation, the flushed and cooled graft is obtained from the live donor in an adjacent operating room. The kidney is secured in a sling or a 3-inch stockinette 4 containing ice slush and held in position for the vascular anastomosis by the assistant. A clamp is used to secure the sling to relieve the assistant from holding the kidney in position with the hands, which might accelerate warming of the kidney during the performance of the vascular anastomoses. The previously placed four sutures through the iliac vein are passed through the corresponding points of the donor renal vein, Carrel patch, or vena cava conduit and secured, bringing the renal vein into juxtaposition with the iliac vein ( Fig. 14-2A). The medial and lateral sutures are retracted to separate the venotomy opening and facilitate rapid anastomosis without inadvertent suturing of the back wall. With the table rotated laterally, the superior suture is used as a running suture down the medial side of the renal vein to meet the inferior suture running up. The lateral suture line is then run in similar fashion after the table has been rotated medially. The clamps on the iliac vein may be left in place until completion of the arterial anastomosis, but application of a finger Fogarty or a bulldog clamp across the renal vein at this time allows for removal of the iliac vein clamps and earlier restoration of venous return from the lower extremity.

FIG. 14-2. (A) The renal vein is brought into exact juxtaposition with the iliac vein phlebotomy by previously placed four-quadrant sutures. A running suture anastomosis will follow. (B) The renal artery is positioned to the end of the internal iliac artery by superior and inferior apical sutures. Subsequent placement of interrupted sutures completes the anastomosis. Note the occluding bulldog clamp on the renal vein. (C) The completed venous and arterial anastomoses are demonstrated.

If the internal iliac artery is to be used for the arterial anastomosis, an end-to-end anastomosis is then performed with the renal artery ( Fig. 14-2B). The two vessels are positioned to allow a gentle upward curve from the iliac bifurcation to the kidney by fixating the superior and inferior arterial apices with interrupted 6-0 cardiovascular suture. The anastomosis is completed with continuous or interrupted sutures. With the kidney resting in the iliac fossa or suspended in a sling, the initial interrupted suture may be placed midway between the apical sutures on the anterior vessel walls facing the operator, thus allowing better approximation of the opposing arterial margins, particularly when a discrepancy exists in the size of the vessels. Subsequently, the remaining sutures are placed to approximate each anterior quadrant. Next, the previously placed apical sutures are used to rotate the arteries so that the posterior vessel walls are now in the anterior position for subsequent interrupted or running suture placement. Just as before, a suture placed midway between the apical sutures again divides the rotated posterior vessel walls into quadrants for subsequent suture placement. A preference for interrupted sutures instead of a running suture in this end-to-end anastomosis prevails when one needs to avoid absolutely any pursestring effect that might occur from a running suture or to achieve optimal accommodation of the two vessels to each other when a size or thickness discrepancy exists. In most cases, the internal iliac artery is left intact to preserve potency in men as well as gluteal and pelvic blood supply in the elderly. Therefore, end-to-side anastomosis of the renal artery to the external or common iliac artery is chosen more commonly than the end-to-end procedure just described. This anastomosis usually is placed cephalad to the level of the venous anastomosis. The location of clamp placement must be carefully selected so as not to disrupt existing arteriosclerotic plaques and precipitate embolization or thrombosis. A longitudinal incision is made on the anterior or anterolateral portion of the iliac artery segment with a #11 blade knife, and a 4.8- or 5.6-mm aortic punch is used to prepare an ideal oval arteriotomy. After the incision is made, regional heparinization of the lower extremity may be accomplished by instilling about 80 to 100 ml of heparinized saline (1,000 units/100 ml) into the distal iliac limb. Systemic heparinization is usually not necessary. This anastomosis is also performed with 6-0 cardiovascular continuous or interrupted sutures after initial fixation of the end of the renal artery to an apex of the arteriotomy with suture cinched down by parachute technique. The previously placed sling around the kidney is removed. It is desirable to have obtained preoperative assessment of the recipient for existing cold agglutinins, because moderate to high titers of these agglutinins require warming of the kidney before the circulation is reestablished. 1 The vascular clamps are released after IV infusion of mannitol and methylprednisolone, venous clamps before arterial. At this point, the patient should be judiciously overhydrated with saline and albumin, and a dopamine drip should be ready to optimize renal blood flow if needed. Multiple Renal Vessels Although the Carrel patch may frequently be used with single arteries and veins, a cadaveric kidney with multiple renal arteries perfused through the aorta is especially well suited to an end-to-side anastomosis of a Carrel patch encompassing the multiple arteries ( Fig. 14-3).2 If the vessels are close to each other, a single Carrel patch is sufficient. If the vessels are more than 2 cm apart, we prefer two Carrel patches. The Carrel patch of donor aorta is fashioned to accommodate the multiple vessels, and its anastomosis to the common or external iliac artery is performed with continuous 5-0 or 6-0 cardiovascular sutures after an arteriotomy that accommodates the width and length of the Carrel patch. This anastomosis is best performed by fixating the patch at the superior and inferior apices of the arteriotomy or by parachute technique. Each suture limb runs away from the apex.

FIG. 14-3. A donor aorta Carrel patch encompassing two renal arteries is positioned by apical sutures to an iliac arteriotomy fashioned to accommodate the length and width of the patch.

The presence of multiple arteries in related donor transplantation is known in advance because all living related donors have preoperative arteriograms. Most donors have at least one kidney with a single artery, but, at times, a donor kidney with double arteries or triple arteries must be used. These arteries cannot be taken with a Carrel patch because of the risk to the donor. In these instances, several strategies for arterial anastomoses are possible: double end-to-side renal arteries to iliac artery, end-to-end superior renal artery to internal iliac artery with end-to-side inferior renal artery to external iliac artery, and implantation of an accessory artery end-to-side into the larger main renal artery, with the larger renal artery anastomosed to the internal, external, or common iliac artery. If two renal arteries are of similar diameter, the spatulation edges of the renal arteries can be joined with a running 6-0 or 7-0 cardiovascular suture to create a single bifurcating artery. 3 An accessory artery to main renal artery anastomosis should be performed with ex vivo bench technique in cold ice slush before the renal vein anastomosis is done. Finally, some recipients have a deep inferior epigastric artery that is suitable for end-to-end 7-0 suture interrupted anastomosis of a small lower-pole artery, which may be essential for ureteral viability. 8 Our experience in more than 30 cases with this technique has been excellent; no ureteral ischemia or necrosis has occurred. Ureteroneocystostomy Some patients are prepared for kidney transplantation by creation of an ileal loop or isolated ileal stoma to divert urine from a dysfunctional or absent bladder. These techniques are beyond the scope of this discussion. In addition, when the donor ureter is absent or damaged, the recipient ureter may be used for ureteroureterostomy or ureteropyelostomy to the allograft. 10 Various modifications of the Politano-Leadbetter, Paquin, and Lich techniques are used for allograft ureteral implantation into the bladder. In our experience, when the bladder is very small or the donor ureter is very short, an extravesical technique is best. 6 Otherwise, we prefer the ease and reliability of a transvesical approach without a formal submucosal tunnel. 7 In either case, previous filling of the bladder facilitates a longitudinal anterior cystotomy with minimal trauma to the bladder wall. In the transvesical approach, the bladder dome is packed and retracted cephalad, exposing the bas fond. An oblique tunnel is created in the bladder floor using a tonsil clamp directed toward the trigone from outside the bladder. This maneuver prevents subsequent angulation of the ureter when the bladder is distended. An 8 Fr Robinson catheter or heavy silk is passed through the tunnel in retrograde fashion and secured to the donor ureter ( Fig. 14-4A).

FIG. 14-4. Ureteroneocystostomy. (A) A small Robinson catheter or heavy silk suture with donor ureter attached is brought into the bladder through an oblique hiatus. (B) The completed transplant ureteroneocystostomy is demonstrated. Four interrupted sutures secure the spatulated ureteral orifice.

The ureter is pulled down and brought into position in the bladder by gentle traction. This maneuver avoids any handling of the ureter, which is important because the ureter of the transplanted kidney receives its blood supply exclusively from the renal vessel branches that course in its adventitia. In male patients, it is important to pass the ureter beneath the spermatic cord. Intravesically, the ureter is hemitransected about 4 cm from its entrance site into the bladder and spatulated about 1 cm. Four sutures of 4-0 chromic catgut are usually sufficient for an anastomosis incorporating bladder mucosa and muscularis ( Fig. 14-4B) as the ureteral transection is completed. When the apical stitch also catches ureteral adventitia 1 to 2 cm above the apex, a nice everted ureteral nipple may be produced. This eversion is especially desirable with patulous ureters. The ureter is not stented routinely. A no-touch technique is essential to avoid producing vascular insufficiency, ureteral necrosis, and urinary extravasation from injury to the adventitial vascular network of the ureter. The oblique bladder tunnel and muscle hiatus must accommodate the ureter comfortably to avoid postoperative obstruction from edema, and a gentle oblique course of the ureter must be ensured so that no kinks, twists, or obstructions occur. This attention is important because the ureter of a transplanted kidney crosses the iliac vessels in a much more caudal position than the native ureter. A little redundancy of the ureter is established outside the bladder to ensure that the ureteroneocystostomy is done without tension and that postoperative allograft swelling will not unduly stretch or angulate the ureter. Patency of the ureteroneocystostomy is confirmed by gently passing a 5 Fr feeding tube or an 8 Fr or smaller soft Robinson catheter toward the renal pelvis. Kidneys with a double ureter can also be transplanted successfully. These ureters should be dissected en bloc within their common adventitial sheath and periureteral fat so that the ureteral blood supply is protected. The technique of ureteroneocystostomy is essentially the same as with a single ureter, except that the ureters are brought through together side by side in a nonconstricting tunnel. The distal end of each ureter is spatulated, and the adjacent margins are approximated with 5-0 chromic catgut. To ensure a watertight closure, the cystotomy incision is closed in three layers. The first 3-0 chromic running suture secures the full thickness of the bladder near the bladder neck and closes the mucosal layer. The second 2-0 chromic running suture is an inverting layer of muscularis. The third 2-0 chromic layer inverts the adventitia. Each layer should overlap the immediately underlying layer about 0.5 cm at each end of the cystotomy closure to avoid urinary extravasation at these two points. Pediatric Kidneys Although en bloc transplantation of kidneys from very young children is often desirable, 5 it is not necessary to transplant both kidneys from young children en bloc each kidney can be used for a different recipient, as is the case with adult cadaveric donors, using Carrel patches of donor aorta and vena cava ( Fig. 14-5).9 A Carrel patch is mandatory in these cases because direct implantation of a small vessel into a much larger or diseased vessel may result in thrombosis or produce functional stenosis as the kidney grows. When the en bloc technique is used, the two ureters are implanted separately and stented. Pediatric kidneys have proven to be excellent donor grafts for carefully selected adults and children. Avoidance of older recipients or diabetics with advanced arteriosclerosis will minimize the potential for

thrombosis. Rapid growth and hypertrophy occur in the immediate posttransplantation period. If early rejection can be avoided, these allografts achieve adult size and function in adult recipients within several weeks.

FIG. 14-5. Small pediatric cadaver renal vessels are anastomosed to larger recipient iliac vessels using Carrel patches of donor aorta and vena cava.

Pediatric Transplantation In small children, the iliac fossa is not large enough to accommodate a kidney from an adult donor, and the pelvic vessels in a small child are so small that the disparity between the donor renal vessels and the recipient vessels precludes the technique described for adults. In these small children, graft implantation must use the recipient aorta and vena cava, which is best accomplished through a right-sided retroperitoneal or transperitoneal midline abdominal incision that provides ready access to the great vessels as well as the urinary bladder. After the right colon is reflected medially, the right kidney is usually removed to make room for the allograft. The vena cava is then freed from the level of the right renal vein inferiorly to its bifurcation or beyond. Posterior lumbar veins are doubly ligated with 5-0 silk and divided. Mobilization of the vena cava is important to facilitate the end-to-side anastomosis of the renal vein, which is performed with running 6-0 ardiovascular sutures, as described for the adult ( Fig. 14-6). Performing the venous anastomosis superiorly allows room for an end-to-side anastomosis of the renal artery to the inferior abdominal aorta. Aortic mobilization should be limited to its distal portion, from the level of the inferior mesenteric artery, and including both common iliac arteries. The segment of the aorta to be used for the end-to-side renal artery anastomosis can be isolated by a superior pediatric vascular clamp and by two inferior clamps or silastic loops on the common iliac arteries. The end-to-side anastomosis is performed with interrupted 6-0 cardiovascular sutures.

FIG. 14-6. Anatomic relationships of an adult donor kidney in a small child are shown with renal vessel anastomoses to the inferior vena cava and aorta.

Important to the revascularization of an adult kidney in small children is the need to anticipate the impending consumption of several hundred milliliters of effective blood volume by the renal allograft. Initiation of blood transfusion before beginning the vascular anastomoses will avoid hypotension after release of the vascular clamps. When the vascular anastomoses are completed, the superior aortic clamp must be kept loosely in place until it is clear that hypotension is not a problem. Immediately after establishing circulation in the graft, the anesthesiologist must obtain blood pressures at 30-second or 1-minute intervals until stabilization is assured. The ureteral implantation is carried out as described except that the ureter must be passed retroperitoneally behind the bladder near the midline. Wound Closure Except in unusual cases, the allograft ureter is not stented, and the space of Retzius and iliac fossa are not drained. Jackson–Pratt suction may be employed, but Penrose drains are never used. If good hemostasis has been obtained, and if the principles of implantation as outlined in this chapter have been followed, there is no need for postoperative drainage other than a urethral catheter. The optimal period of Foley catheter drainage is debatable. We prefer to remove the catheter within 48 hours unless the patient has worrisome hematuria, large diuresis, or poor bladder function. Before wound closure, the wound is thoroughly irrigated with saline. The wound is then closed using a 1 Maxon running suture to approximate transversus abdominis and internal oblique muscles in a single-layer closure; the adjacent fascia is included inferiorly at the tendinous insertion of the rectus muscle. Next, the rectus fascia anteriorly and the fascia of the external oblique are approximated with 1 Prolene running suture. The subcutaneous tissue is thoroughly irrigated with saline and then may be approximated with interrupted 2-0 or 3-0 sutures. These sutures are placed about 2 to 3 cm apart and include both Scarpa's fascia and the underlying fascia superficially. In this manner, one can obliterate dead space in the subcutaneous area in which a seroma in an immunosuppressed patient might become secondarily infected. The skin is approximated with interrupted fine nylon sutures or staples. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Belzer FO, Kountz SL, Perkins HA. Red cell cold autoagglutinins as a cause of failure of renal allotransplantation. Transplantation 1971;11:422–424. Belzer FO, Schweizer RT, Kountz SL. Management of multiple vessels in renal transplantation. Transplant Proc 1972;4:639–644. Codd JE, Anderson CB, Graff RJ, Gregory JG, Lucas BA, Newton WT. Vascular surgical problems in renal transplantation. Arch Surg 1974;108:876–878. Gill IBS, Munch LC, Lucas BA. Use of a cotton stockinette to minimize warm ischemia during renal transplant vascular anastomoses. J Urol 1994;152:2053–2054. Kinne DW, Spanos PK, DeShazo MM, Simmons RL Najarian JS. Double renal transplants from pediatric donors to adult recipients. Am J Surg 1974;127:292–295. Konnak JW, Herwig KR, Finkbeiner A, Turcotte JG, Freier DT. Extravesical ureteronecocystostomy in 170 renal transplant patients. J Urol 1975;113:299–301. Lucas BA, McRoberts JW, Curtis JJ, Luke RG. Controversy in renal transplantation: Antireflux versus non-antireflux ureteroneocystostomy. J Urol 1979;121:156–158. Merkel FK, Straus AK, Anderson O, Bannett AD. Microvascular techniques for polar artery reconstruction in kidney transplants. Surgery 1976;79:253–261. Salvatierra O Jr, Belzer FO. Pediatric cadaver kidneys: their use in renal transplantation. Arch Surg 1975;110:181–183 Welchel JD, Cosimi AB, Young HH, Russell PS. Pyeloureterostomy reconstruction in human renal transplantation. Ann Surg 1975;181:61–66.

Chapter 15 Ureteral Complications Following Renal Transplantation Glenn’s Urologic Surgery

Chapter 15 Ureteral Complications Following Renal Transplantation Rodney J. Taylor

R. J. Taylor: Section of Urologic Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198-2360.

Urinary Leaks Ureteral Obstruction Diagnosis Indications for Surgery Alternative Therapy Description of the Procedure Outcomes Complications Results Chapter References

Historically, the incidence of urologic complications following kidney transplantation, manifested primarily as ureteral leaks or obstruction, was as high as 10%. 1,5 The complications often resulted in significant morbidity, graft loss, and occasional patient death. Improvements in surgical techniques, immunosuppression, and methods for diagnosing and treating the complications have led to a significant decline in the rate of urologic complications to the current reported incidence of 2% to 2½%. 4,7,9 This has resulted in lower morbidity and rare loss of a kidney or patient to urologic complications. However, despite these changes, the need for diligence in diagnosing these complications and quickly addressing them remains as true today as in the past. The most common cause for ureteral complications following kidney transplantation is technical error. 1,5,7 Damage to the ureteral blood supply during graft harvest or transplantation can result in ureteral ischemia and subsequent leak or obstruction. Additional technical errors such as excessive tension at the ureteroneocystostomy site or hematoma development within the tunnel may also cause problems. 4,7 With careful attention to detail, most of these problems can be minimized, especially in the early postoperative setting. Long-term or delayed ureteral obstruction may be the result of ischemic changes secondary to chronic rejection or a continuation of the spectrum of damage associated with the organ harvest and transplantation, and although not all are preventable, the incidence can be markedly reduced with good surgical technique. 1,4

URINARY LEAKS In current practice most urinary leaks are the result of ureteral problems, s a majority of surgeons now employ an extravesical ureteroneocystostomy technique for implantation of the ureter. This results in a shorter ureter, decreased likelihood of ischemia, and a limited cystostomy that rarely leads to leakage from the bladder. 4,10 The majority of leaks occur early after transplantation and are manifested by either drainage from the wound, unexplained graft dysfunction, or a pelvic fluid collection. Signs and symptoms can also include fever, graft tenderness, and lower extremity edema. 8 Early urinary leaks can be divided into two types according to the timing of presentation. The first usually occurs within the first 1 to 4 days and is almost always related to technical problems with the implantation. In this case, the ureter has usually pulled out of a tunnel. This is likely caused by excessive tension at the anastomosis. This complication appears to be more common with the extravesical ureteroneocystostomies. 8 Some investigators have recommended use of a ureteral stent to lessen the likelihood of this complication. 4,5 The second type of early ureteral leak is associated with distal ureteral ischemia, which may be a consequence of injury during the donor recovery, technical causes such as tunnel hematoma, or distal stripping of the blood supply. This type usually presents between 5 and 10 days posttransplant. 7 To correct the early leak caused by excessive tension, it is often possible to do a repeat ureteroneocystostomy. In most other cases, especially with the current techniques of extravesical reimplantation, a different operative procedure is often more suitable. 5,7

URETERAL OBSTRUCTION Ureteral obstruction can also be the result of ureteral ischemia but occurs later than ureteral leaks and usually presents as graft dysfunction. It can occur years after the transplant and in this situation may represent vascular injury associated not only with the technical complications but also with chronic rejection. 1,7,8 The spectrum of ureteral ischemic injury extends from early necrosis and urinary leakage to delayed ureteral obstruction, presenting months to years after the actual transplantation.

DIAGNOSIS Urinary leaks are often suspected because of increased drainage from the wound. The fluid should be tested for BUN/creatinine to see if it is urine. Radiographic tests of help include an abdominal ultrasound and nuclear renal scan. A renal scan demonstrating extravasation is the most sensitive method to differentiate a urine leak from other fluid collections such as lymphoceles or hematomas. 2 A cystogram should be performed if a bladder leak is suspected. Ureteral obstruction, usually manifested by graft dysfunction, requires evaluation, and again an ultrasound and nuclear renal scan are the most common screening studies. Additional radiographic studies such as a CT scan may be of assistance in some cases. With both ureteral leaks and obstruction, endourologic techniques can be both diagnostic and therapeutic.

INDICATIONS FOR SURGERY Anything that causes graft dysfunction or results in disruption of the urinary tract in a renal transplant patient is of utmost concern and requires rapid diagnosis and treatment. In the case of ureteral leakage or obstruction, the goals of treatment include careful and accurate diagnosis of the exact cause and site. If the problem has a physical cause such as a leak or an obstruction and is not associated with an acute rejection episode, then treatment is directed at stabilization of the renal function, minimization of morbidity, and a restoration of the continuity and function of the urinary tract. If there is concomitant rejection, then definitive operative therapy is withheld pending the treatment of rejection. 7,8

ALTERNATIVE THERAPY The need for immediate open operative surgical intervention has been replaced, to a large extent, by early endourologic intervention. 1,6,7 and 8 The placement of a percutaneous nephrostomy can divert a leak or relieve obstruction and allow more definitive diagnosis. As described by Streem et al., endourologic management algorithms can select patients for whom the likelihood of successful nonoperative management is good. Depending on the selection criteria, the results of management of distal ureteral leaks with stenting and a nephrostomy tube show that approximately one-third of patients do well long term and require no additional treatment. For ureteral strictures or stenoses, approximately 45% of patients, carefully selected, will avoid an open operative repair. 8 For the other patients, percutaneous access can allow stabilization of renal function and a more critical assessment before open surgical repair is carried out. In a few cases, percutaneous access can offer long-term treatment with chronic stent management. This choice, in my opinion, is of limited application in most patients with a well-functioning graft because of the long-term risks (i.e., stone formation, infection, etc.) and inherent costs. However, in patients who are not operative candidates and for some patients with marginal graft function, chronic endourologic treatment can be an alternative to definitive repair. 5

DESCRIPTION OF THE PROCEDURE There are many procedures available to restore the continuity of the urinary tract. 1,2 and 3,5,6 and 7 In our experience dealing with a difficult ureteral stenosis or a leak from significant ureteral ischemic necrosis, we favor the use of the native ureter to replace the transplant ureter. Advantages of this repair include: the native ureter is usually nonrefluxing, the results are reliable, there is a low likelihood of recurrence of the primary problem, and a tension-free anastomosis with good blood supply is easily attained. The focus of this operative description is on that surgical choice. Surgical access to the transplanted kidney and ureters (transplant and native) is usually achieved by reopening the old incision. Occasionally, if extensive mobilization of transplanted kidney is anticipated or access to the contralateral native ureter is planned, a midline incision is an option. 7 Surgical access to repair an early ureteral leak is usually simplified because dense fibrosis has not yet occurred, the fascial layers are easily opened, the peritoneum and its contents are freely mobilized medially and cephalad, and the kidney and ureter are identified without much difficulty. A primary repair can often be performed, and in most cases, a repeat ureteroneocystostomy at a new site in the bladder is the best choice. Use of a mechanical retractor greatly simplifies exposure and allows excellent access to the pelvis. If the repair has been delayed because of attempted endourologic management or because of delay in presentation or diagnosis, then access to the ureter and kidney can be much more challenging and hazardous. In these cases, mandatory preoperative preparation includes a review of the operative note, especially if the operation was performed by someone else. It is important to know whether the kidney to be operated on was the donor's right or left kidney. It is critical to know the position of the ureter and renal pelvis in relation to the renal vessels (below or above), and this depends on which kidney was used and into which side of the recipient's pelvis it was transplanted. Additional information to be sought includes the type of vascular anastomosis performed (end-to-end versus end-to-side, etc.) and whether or not the iliac vessels (especially the iliac vein) were mobilized. All of this information can help to determine the likely position of the kidney in relation to the transplanted and native ureter and the anticipated ease in gaining access to these structures. Figure 15-1 demonstrates the relationship of the transplanted kidney, vessels, and ureter to the recipient's iliac vessels and ureter. Note that this depicts a donor right kidney on the right side, as the renal pelvis is posterior to the renal vessels.

FIG. 15-1. Relationship of the transplanted kidney and its vasculature to the recipient's iliac vessels and ureter.

In terms of the recipient, it is critical to know the status of the recipient's urinary tract. This is especially true if the recipient had a history of ureteral reflux or had undergone nephroureterectomy and might not have a suitable native ureter available to use for repair. Finally, the status of the recipient's urinary bladder in terms of capacity, compliance, and function can be important in determining which other repair options are available. Additional preoperative preparation involves stabilization of the patient and function of the graft. It is important to delay any open operative repair until concurrent rejection episodes have been adequately treated and renal function stabilized. All patients should be treated with preoperative antibiotics based on anticipated contaminants or cultures obtained from the urine. If there is a likelihood that bowel might be needed (a very unusual circumstance) to repair the urinary tract, then a full bowel prep is indicated. The goals of surgery are to repair the ureteral defect, reestablish continuity of the urinary system, get rid of all foreign bodies as quickly as possible, and avoid graft or patient loss. With a well-planned and executed procedure, these goals should be easily obtained in essentially all cases. Delayed surgical repair because of attempted endourologic management, delayed diagnosis, or late presentation of obstruction makes surgical exposure of the kidney and ureter very challenging. As noted earlier, access is almost always achieved through the old transplant incision, and cephalad extension of the incision is often needed in these cases because of perinephric fibrosis, the increased size of the kidney posttransplant, and to achieve access to the iliac vessels and native ureter. It is usually possible to extend the incision several centimeters cephalad. Additional exposure, if needed, can also be obtained by extending the inferior aspect of the incision across the midline, though this is rarely needed and should be delayed until the need is present. With delayed repair, the normal tissue planes are obliterated, and a dense fibrosis has occurred around the graft. This makes it very easy to violate the “renal capsule” and get into significant bleeding. As a routine, it is preferable to operate from a position of “known to unknown” with good exposure. The surgeon should also plan to gain vascular control proximally and distally if it appears that the kidney may need to be mobilized in order to permit access to the renal pelvis. A three-way Foley catheter should always be placed into the bladder before the start of the surgery to allow for irrigation and filling with an antibiotic solution. In order to assure a safe and adequate exposure, I usually open the peritoneum early in cases where there is dense fibrosis. This allows better cephalad exposure, protects the bowel, and gives good access to the bladder. Because the transplant ureter usually crosses the external iliac vessels below the renal vessels, one should take care to avoid these structures while gaining access to the ureter. This is a critical feature of this operative procedure because exact visualization of the renal vascular structures is often difficult, and many times one is operating based on the expected, not visualized, location of these structures. In some cases a percutaneous nephrostomy tube will be placed as well as a ureteral stent. If present, the nephrostomy tube should be accessible during a procedure as injection of saline or methylene blue may aid in identifying the ureter and renal pelvis. In some cases, because of the dense fibrosis, the ureter is identified only when it is actually cut. The routine placement of a ureteral stent is of limited value in most cases because the fibrosis is so dense, it is hard to discern the presence of the catheter. If the ureter is not in dense fibrosis, then access is usually easy. Once access to the bony pelvis is obtained, careful dissection along the lateral wall of the bladder usually leads to the ureter. Once it is identified, care must be used in mobilizing the ureter to avoid any further vascular injury. When the site of leakage and/or obstruction has been identified, the most commonly used repairs include (a) a repeat ureteroneocystostomy, (b) use of the bladder (Boari flap or bladder hitch) to help bridge the gap, or (c) use of a native ureter to perform a ureteroureterostomy or ureteropyelostomy. Repeat ureteroneocystostomies are indicated only to repair early leaks when the problem was from tension at the anastomosis or distal ureteral ischemia and a well-vascularized minimally fibrosed ureter is present. In most circumstances, especially late, with a lot of periureteral reaction or ischemia, the preferred option is the use of the ipsilateral native ureter if it is present and of adequate caliber. If not, then a Boari flap is an excellent choice. Access to the native ureter is obtained by identifying it as it crosses the common iliac vessels. Care must be used in mobilizing the ureter down into the pelvis to the level of the superior vesical artery to avoid injury to the ureter blood supply. The ureter is divided well above the iliac vessels, and the proximal end of the ureter is doubly ligated. In our experience of over 30 cases, this has not resulted in problems with the native kidney or ureter requiring any further intervention. Figure 15-2 shows the native ureter mobilized distally and doubly ligated proximally in preparation for a ureteropyelostomy.

FIG. 15-2. Mobilization of the native ureter distally with the proximal segment ligated.

The operative positioning of the native ureter depends on access to the transplant ureter and/or pelvis. In addition, whether a side-to-side ureteral anastomosis or a ureteropyelostomy is to be performed may make a difference to the exact positioning of the native ureter. All of these factors relate to the extent of fibrosis and the appearance of the transplant ureter. To prevent any additional future problem, a tension-free, widely spatulated anastomosis of well-vascularized ureter to either transplant ureter or renal pelvis is critical ( Fig. 15-3). The anastomosis is performed using 5-0 Maxon (Davis and Geck, Danbury, CT) or Polydioxanone (PDS, Ethicon, Somerville, NJ) in a watertight single layer. The critical aspect is to obtain a mucosa-to-mucosa approximation avoiding tension, devascularization, and urinary leak. A 12-cm 4.7 double-J stent is routinely used on all anastomoses. The anastomosis may be additionally wrapped in omentum or peritoneal flap, if available, to decrease further the risk of leak. The wound is well irrigated with antibiotic solution, and if no preoperative infection was present, we close the wound without a drain. If there is concern about urinary leak, lymphatic leak, or possible infection, one or two Jackson Pratt drains are indicated. The fascia is closed in layers with a 0 or #1 permanent monofilament suture. The subcutaneous tissue is not closed. The skin is usually closed with staples. A nephrostomy tube, if present, is removed at day 5 to 7 after an antegrade nephrostogram has been obtained to be sure that there is no leak. The ureteral catheter is left in for 4 to 6 weeks.

FIG. 15-3. Anastomosis of spatulated native ureter to (A) transplant ureter and to (B) transplant renal pelvis.

OUTCOMES Complications Complications that can occur postprocedure include infection, urinary leak, bleeding, recurrence of the stricture, and possible loss of graft. In all series, these are very uncommon complications. 1,7 Results We have performed over 30 native-to-transplant ureteroureterostomies or ureteropyelostomies to treat ureteral obstruction or ureteral leaks or to deal with damaged ureters at the time of the transplant. In our experience, all kidneys involved have been “salvaged,” and none lost to urologic complications. There have been no significant postoperative complications and no patient deaths. We have not had to repeat any procedures in any of the patients we have treated and have not had any recurrence of either leak or stricture. As noted earlier, we routinely tie off the proximal native ureter, do not do a nephrectomy, and have not had any problems related to the native kidney. We feel that routine native nephrectomy is not indicated, and if one is ever subsequently indicated, a laparoscopic nephrectomy would be our choice. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Banowsky LHW. Surgical complications of renal transplantation. In: Glenn JF, ed. Urologic surgery, 4th ed. Philadelphia: JB Lippincott, 1991;252–266. Bretan PN Jr, Hodge E, Streem SB, et al. Diagnosis of renal transplant fistulas. Transplant Proc 1989;21:1962–1966. Gerridzen RG. Complete ureteral replacement by Boari bladder flap after cadaveric renal transplant. Urology 1993;41:154–156. Gibbons WS, Barr JM, Hefty TR. Complications following unstented parallel incision extravesical ureteroneocystostomy in 1,000 kidney transplants. J Urol 1992;148:38–40. Khauli RB. Surgical aspects of renal transplantation: New approaches. Urol Clin North Am 1994;27:321–341. Martin DC, Mims MM, Kaufman JJ, Goodwin WE. The ureter in renal transplantation. J Urol 1969;101:680–687. Rosenthal JT. Surgical management of urological complications after kidney transplantation. Semin Urol 1994;XII(2):114–122. Streem SB. Endourological management of urological complications following renal transplantation. Semin Urol 1994;XII(2):123–133. Taylor RJ, Rosenthal JT, Schwentker FN, et al. Factors in urologic complications in 400 cadaveric renal transplants. J Urol 1984;131:336A. Thrasher JB, Temple DR, Spees EK. Extravesical versus Leadbetter–Politano ureteroneocystostomy: A comparison of urological complications in 320 renal transplants. J Urol 1990;144:1105–1109.

Chapter 16 Renal Autotransplantation Glenn’s Urologic Surgery

Chapter 16 Renal Autotransplantation Philip Ayvazian and Mani Menon

P. Ayvazian: Department of Urology, University of Massachusetts, Worcester, Massachusetts 01655. M. Menon: Department of Urology, Henry Ford Hospital, Detroit, Michigan 48202.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Nephrectomy Renal Preservation Autotransplantation Outcomes Complications Results Chapter References

Renal autotransplantation is a safe and effective procedure to reconstruct the urinary tract. The first successful surgery was performed by Hardy in 1963 in a patient with severe ureteral injury following aortic surgery. The advent of microvascular techniques and renal preservation extends the scope of the procedure, allowing for successful extracorporeal (bench) surgery and subsequent autotransplantation. Current indications of autotransplantation include renal-vascular disease, severe ureteral damage, tumors of the kidney and ureter, complex nephrolithiasis, and retroperitoneal fibrosis. The procedure is technically demanding and is contraindicated in the setting of severe occlusive atherosclerosis of the iliac arteries. The advantages of autotransplantation include optimal surgical exposure, bloodless surgical field, and hypothermic protection of the kidney from ischemia. In cases of malignancy, there is less risk of tumor spillage and better assessment of tumor margins than by in vivo renal reconstruction. It is possible that this procedure may be underutilized because a good proportion of urologists are unfamiliar with the principles of renal homotransplantation.

DIAGNOSIS Preoperative renal and pelvic arteriography should be performed to define the renal artery anatomy and ensure disease-free iliac vessels. In cases where autotransplantation is performed for the management of ureteral disease, ureteral involvement can be assessed by intravenous or retrograde pyelography. A CT scan of the pelvis may be beneficial in cases of retroperitoneal fibrosis to assess pelvic extension of disease.

INDICATIONS FOR SURGERY Renal autotransplantation is particularly attractive for a variety of vascular lesions affecting the aorta and renal artery. These include traumatic arterial injuries, renal artery stenosis with extension into the segmental branches (fibromuscular disease), large aneurysms, or arteriovenous fistulas. Other vascular indications include aortic aneurysms involving the renal arteries (Marfan's syndrome) and occlusive aortic disease. In patients with central, intrarenal tumors or multiple tumors in a solitary kidney, renal autotransplantation with extracorporeal surgery is a useful technique. Following radical nephrectomy and exterior hypothermic renal perfusion, the kidney is dissected beginning in the hilum. The vasculature to the tumor is ligated. After tumor-free margins are achieved, autotransplantation is carried out. Renal autotransplantation allows for a direct anastomosis of the renal pelvis to the bladder. Therefore, it can be used in cases of ureteral damage or long ureteral lesions such as iatrogenic ureteral injuries, ureteral strictures, ureteral tumors, ureteral tuberculosis, failed urinary diversions, and retroperitoneal fibrosis. The procedure can also be used to facilitate stone passage in patients with complex nephrolithiasis. Renal autotransplantation has been effective in controlling the symptoms related to loin-pain hematuria syndrome.

ALTERNATIVE THERAPY Replacement of the ureter for reconstruction of the urinary tract may be performed with a segment of ileum. The advantages of an ileal ureter over autotransplantation are threefold: (a) the procedure is technically less demanding; (b) vascular anastomosis is not necessary; and (c) bladder argumentation with bowel can be done simultaneously. Disadvantages include mucus production, metabolic and electrolyte imbalance, propensity for bacteriuria, and the need for indefinite radiologic surveillance of the ileal segment. Contraindications include intestinal diseases, hepatic dysfunction, and renal insufficiency (serum creatinine greater than 2.0 mg/dl). For severe renovascular disease, the first surgical options typically include in situ reconstruction. This may involve endarterectomy or aortic–renal or splenorenal bypass grafting. When these techniques are not possible and microvascular reconstruction is required, autotransplantation becomes the procedure of choice.

SURGICAL TECHNIQUE Perioperatively, a brisk diuresis should be induced by IV hydration and 12.5 g mannitol given 1 hour before surgery. This will minimize ischemic injury to the kidney and hasten restoration of renal function. A broad-spectrum antibiotic is also administered 1 hour before surgery. During the operation, an adequate central venous pressure should be maintained with fluid boluses as needed. Renal autotransplantation is a two-step procedure: first, the kidney is removed; then, it is transplanted. The surgical approach to removing the kidney is similar to that of living-donor nephrectomy. However, the operation may be complicated by the particular disease process necessitating the surgery. Typically, two incisions are needed: the first, either a subcostal transperitoneal or extrapleural–extraperitoneal flank to remove the kidney; and the second, a lower-quadrant curvilinear or midline incision to access the iliac fossa ( Fig. 16-1). In thin patients, an alternative approach is a single midline incision from the xiphoid to the symphysis pubis, although the exposure to the kidney is not optimal.

FIG. 16-1. Location of flank and inguinal incisions.

Nephrectomy After the peritoneum and colon are reflected medially, Gerota's facia is incised. The perinephric fat is sharply dissected off the renal capsule with minimal spreading using Metzenbaum scissors. Excessive retraction of the kidney should be avoided because that may result in subcapsular hematomas or capsular tears. The adrenal gland should be carefully separated from the upper pole of the kidney. In cases where ureteral continuity is not preserved, the distal ureter is isolated and transected before the dissection of the renal hilum. The ureteral stump can be tied with #0 chromic catgut suture. The ureter should be maintained with its vascularity and the gonadal vein. To maximize ureteral viability, the tissue between the lower pole of the kidney and the ureter should be kept intact. Urinary output can then be assessed before the renal pedicle is approached. On the right side, the vena cava is carefully isolated from the surrounding tissue. The gonadal vein can be ligated at its insertion on the vena cava. The renal vein should be identified anterior to the renal artery. Accessory renal veins can be ligated, but accessory renal arteries must be maintained. Careful dissection of the renal artery is performed toward the aorta by slightly retracting the vena cava with a closed forceps or vein retractor. After a further 12.5 g of mannitol has been given, a right-angle clamp is placed on the renal artery, and it is transected. A Satinski vascular clamp is then placed proximal to the renal vein ostium, and the renal vein is transected. The renal artery can be tied with #0 silk ties or, alternatively, one #0 silk tie and a #0 silk ligature. We have found that the renal vein retracts after transection and that placement of a second larger Satinski clamp behind the first allows for a less stressful closure of the renal ostium. A 5-0 Proline suture is tied at one end, run down to the other end, back to the first, and retied. On the left side, the artery is divided at the aorta; the vein is divided anterior to the aorta and tied with two #0 silk sutures. Renal Preservation Once the kidney is removed, it is immersed in ice-cold slush at 4°C. The renal artery is flushed with either a Collins intracellular electrolyte solution or a lactated renal solution with 10,000 units/liter of heparin and 50 mEq/liter of sodium bicarbonate. Flushing is continued until the effluent from the renal vein is clear. An adaptor is used to hold a good seal during flushing. Adequate flushing allows about 4 to 6 hours of renal preservation. If extracorporeal renal surgery is required, a second team can close the flank incision. In closure of the flank, a strong monofilament absorbable suture such #1 PDS or Maxon is used. Anteriorly, the transversus abdominis, internal oblique, and external oblique muscles are closed separately. Often the transversus and internal oblique are closed together. Closure should begin after flexion is removed from the operating room table. Posteriorly, the intercostal muscles and latissimus dorsi are closed as separate layers. Autotransplantation The patient is placed in the supine position and draped. A Foley catheter carries 150 cc of 1% neomycin sulfate solution into the bladder, and the catheter is clamped. A curvilinear incision is made, extending from one fingerbreadth above the pubis to two fingerbreadths above the anterior superior iliac spine. The incision is carried down to the rectus facia. The rectus facia, the external oblique, internal oblique, and transversus abdominis muscles are opened along the line of the incision. The lateral edge of the rectus muscle is transected off the pubis to get better exposure to the pelvis. The epigastric vessels are transected beneath the transversus abdominis muscle and tied with two 2-0 silk ties. The round ligament or the spermatic cord is doubly ligated. In young men, the spermatic cord is preserved and displaced inferomedially. The peritoneum is reflected medially to expose the iliac vessels and bladder. A Buckwalter retractor is placed into the wound to provide optimal exposure. The next part of the procedure is similar to that used for renal homotransplantation. The iliac vessels are evaluated for potential size for anastomosis with the renal artery. If the caliber of the internal iliac artery is sufficient, and there is not significant plaque formation, then this vessel is selected. It is mobilized from the common iliac to the first branch, the superior gluteal artery. A bulldog vascular clamp is placed just beyond the origin of the internal iliac artery, and a right-angle clamp is placed distally ( Fig. 16-2). After transection of the vessel, the distal portion is tied with #0 silk tie. The bulldog vascular clamp is opened to test for flow. The proximal portion of the vessel is flushed with 2,000 units of heparin mixed as follows: 10,000 units per 100 cc normal saline. If a plaque is discovered, it can be trimmed back, an endarterectomy can be performed, or it can be tacked down with 6-0 silk. Further dissection of the common iliac and external iliac artery is not required. The external iliac vein is mobilized for 5 to 7 cm with special care to ligate any lymphatic vessels with 4-0 silk to prevent lymphocele formation.

FIG. 16-2. (A) Ipsilateral autotransplantation of kidney with end-to-side anastomosis of renal vein to common iliac vein and end-to-end anastomosis of hypogastric artery to renal artery. (B) The completed venous and arterial anastomoses are demonstrated.

When the internal iliac artery is unavailable, the external iliac artery is selected. After the external iliac artery is mobilized for 4 to 5 cm, an end-to-side anastomosis is performed between it and the renal artery ( Fig. 16-3). Wide mobilization of the external iliac artery may result in kinking of the vessel. Vascular clamps are placed proximally and distally, and an arteriotomy is performed. Typically only a slit is needed, and an ellipse of the anterior wall need not be removed. The distal artery is flushed with 2,000 units of dilute heparin with a red rubber catheter. A Satinski vascular clamp is placed distally on the external iliac vein, and a bulldog is placed proximal to the venotomy. The iliac vein is then carefully incised with a #11 blade scalpel to accommodate the renal vein. Four 5-0 Proline sutures are placed on the external iliac vein in an outside-to-in fashion, one at each apex and one at the midpoint on each side of the venotomy.

FIG. 16-3. (A) Renal autotransplantation with end-to-side anastomoses of both renal and external iliac arteries and renal and external iliac veins. (B) Small pediatric cadaver renal vessels are anastomosed to larger recipient iliac vessels using Carrel patches of donor aorta and vena cava.

The kidney is placed in the operative field. An assistant holds the kidney with a surgical sponge in an anatomic position with the ureter inferiorly. To minimize warm ischemia while the anastomosis is accomplished, the kidney is irrigated with cold saline. The four Proline sutures in the external iliac vein are then brought through

the renal vein in an inside-to-out fashion. The kidney is lowered into the wound, and each suture is tied with the knots on the outside. The two apex sutures are used to close the venotomy. The midpoint sutures are placed with mild traction to keep the back wall from being incorporated in the running suture. The internal iliac artery is then anastomosed to the renal artery end to end with 6-0 siliconized silk suture. The artery should be placed posterior to the renal vein to preserve anatomic relationships. The first two sutures of the arterial anastomosis are placed at either apex with double-armed needles such that the knots are on the outside. The remainder are placed with single-armed needles. We prefer an anastomosis with interrupted sutures when the internal iliac artery is used. Sutures should be placed close enough to avoid any gaps, especially at the apex. After one side is complete, the apical sutures are rotated to give exposure to the back wall. If the external iliac artery is used, the arteriotomy should be staggered with the venotomy to avoid kinking of the vessels. The anastomosis is performed with two to four continuous 6-0 Proline sutures. After completion of the anastomosis, oxidized cellulose is wrapped in small pieces around the arteriotomy and venotomy. The venous clamps are then removed, followed by the arterial clamps. It is important to maintain adequate intravascular volume with colloid or blood, especially when the clamps are removed, so that the kidney is well perfused. If this produces an excessively elevated central venous pressure, intravenous furosemide (Lasix) should be administered. Occasionally, renal autotransplantation can be performed with the ureter left intact. Although it will follow a redundant course to the bladder, normal peristalsis will provide effective drainage from the kidney. Care must be taken to avoid positioning the kidney so as to produce an obstruction of the ureter. If the ureter is transected, the urinary system can be reconstructed by a ureteroneocystostomy, ureteroureterostomy, pyeloureterostomy, or a pyelovesicostomy ( Fig. 16-4 and Fig. 16-5). We prefer an extravesical ureteroneocystostomy when there is adequate length of nondiseased ureter for a tension-free anastomosis. The Buckwalter retractor is repositioned to provide better exposure to the lateral wall of the bladder. A 2- to 3-cm tunnel is made in the bladder wall by incising the posterior lateral serosa and detrusor muscle. After the margins of the detrusor are retracted with 3-0 chromic stay sutures, the mucosa is mobilized and allowed to bulge. An ellipse of the mucosa is removed from the apex of the tunnel, and the spatulated ureter is anastomosed with the bladder mucosa using a continuous 50 chromic catgut suture. Two sutures are used, each of which incorporates 180 degrees of the anastomosis, and are tied without tension. The anastomosis is performed over a 4.8 Fr double-J ureteric stent, which is positioned into the bladder after the bladder mucosa has been opened. The stent will be removed in the postoperative period.

FIG. 16-4. Lich extravesical ureteroneocystostomy. Gregoir and Campos Freire techniques are similar.

FIG. 16-5. Alternative options for reconstruction of urinary tract: ureteroureterostomy, pyeloureterostomy, or Boari flap to renal pelvis.

The detrusor is closed over the ureter with interrupted 3-0 chromic catgut suture. The tunnel should allow passage of a right-angle clamp between the ureter and overlying muscle. The wound is irrigated with a 1% neomycin solution. No external drains are required if the ureteral reimplantation is watertight. In cases where the upper ureter is diseased, the area is removed, and the proximal ureter or renal pelvis is anastomosed to the normal lower ureter. The ureteroureterostomy or pyeloureterostomy is performed over a ureteric double-J stent by end-to-end anastomosis of the spatulated lower ureter to either the spatulated upper ureter or the renal pelvis ( Fig. 16-5). If the entire ureter is not viable, or for recurrent stone disease, a pyelovesicostomy is performed. This technique can be performed with a Boari flap and end-to-end anastomosis of the renal pelvis to tubularized bladder. The Boari flap should be secured to the psoas muscle to avoid tension on the anastomosis. The wound is then closed in layers. The rectus muscle is approximated back to the tendinous insertion at the pubic bone with a #0 Proline suture. The internal oblique and transversus abdominis are closed with a #0 Proline suture. The external oblique is closed with continuous #0 Proline. The subcutaneous layer is closed with 3-0 Dexon and the skin is closed with 3-0 nonabsorbable suture or clips. For optimal renal perfusion during the immediate postoperative period, the central venous pressure should be maintained adequately, and the diastolic blood pressure kept at 85 mm Hg or higher. Mild hypertension is preferred over normotension or mild hypotension. Aspirin can be started postoperatively to reduce the risks of graft thrombosis. A renal scan is obtained on the first postoperative day to document renal perfusion and again about postoperative day 7. Broad-spectrum antibiotics are administered during the immediate postoperative period to maintain sterile urine and help prevent infection of the vascular grafts. The ureteral stent is left in place for 2 to 3 weeks and is removed during outpatient cystoscopy. The Foley catheter is removed on postoperative day 5. It may be removed sooner if a ureteroureterostomy or pyeloureterostomy is performed, but it should be kept in place for 5 days following a pyelovesicostomy or ureteroneocystostomy. An intravenous pyelogram or a cystogram is obtained 1 to 2 weeks after surgery to evaluate ureteral integrity.

OUTCOMES Complications Early postoperative complications include bleeding from the vascular anastomosis, renal artery or vein thrombosis, distal extremity embolization, or urinary extravasation. Bleeding from a disrupted anastomosis is a rare event but requires immediate exploration. It is usually associated with anastomosis to diseased vessels or errors in surgical technique. Peripheral collateral vessels from the renal hilum can attain significant size if there is stenosis of the renal artery or vein and can be a source of postoperative bleeding. Renal artery or vein thrombosis occurs in fewer than 2% of cases and should be ruled out in cases of oliguria following autotransplant of a solitary kidney. The diagnosis is made by renal scan; if it is made without delay, salvage of the autotransplant should be attempted. Any significant hypotension or hypovolemic event in the postoperative period or error in surgical technique can predispose to this threat. Distal extremity embolization as a result of dislodging of plaque during aortic clamping or unclamping can occur, especially with diseased blood vessels. Heparinization at the time the vessels are prepared aids in preventing this problem, but the distal pulses and color of the legs should be assessed after arterial clamps are opened. Deep venous thrombosis can result in propagation of clot from the renal vein. Intimal injury, low-flow states, and venous obstruction can predispose to

this condition. Urinary extravasation is the most common complication from autotransplantation. Placement of a ureteric double-J stent diminishes this risk. If a leak occurs, it should be treated by a percutaneous nephrostomy. In circumstances when these conservative measures fail, such as when the distal ureter is ischemic, operative repair is required. The most common late complications include renal artery stenosis, ureteral stricture, and ureterovesical reflux. Renal artery stenosis may be manifested by hypertension or impaired renal function. Diagnosis is made by renal scan and digital subtraction angiography. Initial management should be percutaneous angioplasty. Obstruction of the urinary system demonstrated by pain or impaired renal function can be managed by dilation and stenting. Results Bodie et al. reported on 24 autotransplanted kidneys in 23 patients in whom the primary indication was to replace all or a major portion of the ureter. There were no operative deaths reported. Of the 24 autografts, three were ultimately lost (12%). The function of the remaining grafts was stable or improved postoperatively. 1 Novick reported successful outcomes in 29 of 30 patients who underwent autotransplantation for the management of intrarenal branch arterial lesions. 7 Van der Valden reported on six cases of renal carcinoma treated by extracorporeal surgery and autotransplantation. Dialysis was not required, and the patients' blood pressure improved or remained within normal limits. Mean follow-up time was 54 months, with three patients dying during this period. 9 Zincke and Sen performed extracorporeal surgery and autotransplantation in 15 kidneys. Of these, 11 had renal cell carcinoma, and four had transitional cell carcinoma. Three autografts were lost because of venous and arterial thrombosis in two and necrosis of the renal pelvis and ureter in one. The remaining patients were dialysis-free with stable creatinine values. Other complications cited included a caliceal fistula requiring closure in one patient and an intimal injury requiring partial replacement of the external iliac artery with a Gore-Tex graft. 10 Novick et al. observed an increased incidence of temporary and permanent renal failure for extracorporeal compared to in situ partial nephrectomy for renal cell carcinoma. 8 Postoperative initial nonfunction occurred in five of 14 patients (36%) undergoing autotransplantation but in only two of 86 patients (2.3%) who underwent an in situ procedure. Permanent renal failure occurred in two of 14 (14.3%) autotransplanted patients and in one of 86 managed in situ(1.2%). 8 Renal autotransplantation is a rare procedure that is technically demanding with several potentially serious complications. However, in a variety of instances, it may be of great utility for organ salvage and should be included in the armamentarium of the urologist. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Bodie B, Novick AC, Rose M, Straffon RA. Longterm results with renal autotransplantation for ureteral replacement. J Urol 1986;136:1187–1189. Brunetti DR, Sasaki TM, Friedlander G, et al. Successful renal autotransplantation in a patient with bilateral renal artery thrombosis. Urology 1994;43(2):235–237. Khauli RB, Menon M. Ileal ureter and renal autotransplantation. In: Fowler JE Jr, ed. Mastery of surgery: Urologic surgery. Boston: Little, Brown, 1992;183–191. Libertino JA. Renovascular surgery. In: Walsh PC, et al, eds. Campbell's urology, 5th ed. Philadelphia: WB Saunders, 1986;2546–2551. Libertino JA, Zinman L. Renal transplantation and autotransplantation. In: Libertino JA, ed. Pediatric and adult reconstructive urologic surgery, 2nd ed. Baltimore: Williams & Wilkins, 1987;176–177. Novick AC. Technique of renal transplantation. In: Novick AC, et al, eds. Stewart's operative urology, 2nd ed. Baltimore: Williams & Wilkins, 1989;324–340. Novick AC. Microvascular reconstruction of complex branch renal artery disease. Urol Clin North Am 1984;11(3):465–475. Novick AC, Streem S, Montie JE, et al. Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients. J Urol 1989;141:835–839. Van der Valden JJ, Van Bockel JH, Zwartendijk J, Van Krieken JH, Terpstra JL. Longterm results of surgical treatment of renal carcinoma in solitary kidneys by extracorporeal resection and autotransplantation. Br J Urol 1992;69 Zincke H, Zen SE. Experience with extracorporeal surgery and autotransplantation for renal cell and transitional cell cancer of the kidney. J Urol 1988;140:25–27.

Chapter 17 Nephroureterectomy Glenn’s Urologic Surgery

Chapter 17 Nephroureterectomy Gary D. Steinberg

G. D. Steinberg: Department of Surgery, Section of Urology, The University of Chicago Hospitals, Chicago, Illinois 60637.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Two-Incision Approach Outcomes Complications Results Chapter References

Malignant tumors of the upper urinary tract are uncommon and account for only 5% to 10% of all urothelial malignancies. The peak incidence is in the sixth and seventh decade of life with a male predominance of 2:1. 3 Most upper tract tumors are transitional-cell carcinoma (TCC, 85% to 90%), with 10% to 15% squamous cell carcinoma or mixed TCC and squamous. Adenocarcinoma of the renal pelvis is extremely rare, accounting for only 1% of upper tract tumors. Cigarette smoking is the major risk factor for development of TCC of the renal pelvis. It has been reported that there is a three- to sevenfold increased risk of carcinoma associated with cigarette smoking and that cessation of smoking is associated with a decreased risk. Phenacetin abuse is also associated with an increased risk of TCC of the renal pelvis. Although the specific mechanism of tumorigenesis is unknown, the phenacetin metabolite 4-acetoaminoprophenol is thought to cause chronic inflammation and papillary necrosis. The combination of papillary necrosis and chronic inflammation has been associated with a 20-fold increased risk of cancer development. 5 Balkan nephropathy, also known as Danuvian endemic familial nephropathy, is a condition strictly associated with TCC of the upper tracts. This endemic disease is confined to the Balkan states that lie on the Danube river. Cancer of the renal pelvis in these states accounts for 42% of renal tumors. The specific cause is unknown, although the drinking water has been suggested. The tumors are typically low grade, multifocal, and slow growing. Bilateral tumors occur 10% of the time. Occupational risk factors have also been correlated with TCC of the renal pelvis, including exposure to chemicals in the rubber, petroleum, plastics, and aniline dye industries. Forty to eighty percent of patients with upper tract tumors will have urothelial carcinomas at some time elsewhere in the urinary tract, usually in the bladder. About 3% of patients with transitional cell cancer of the bladder develop upper tract tumors; however, patients with urothelial tract tumors of the prostate or urethra have approximately a 30% risk of developing upper tract tumors. 1

DIAGNOSIS Approximately 80% of patients present with hematuria. Some patients present with flank pain or constitutional symptoms. Intravenous pyelography (IVP) is the initial study of choice in the evaluation of a patient suspected of having a renal pelvic or ureteral tumor. Assessment of the entire urinary tract is important in evaluating patients diagnosed with a renal pelvic or ureteral tumor because the upper urinary tract has a high potential of developing multiple tumors as described by the field-change theory. Grabstald reported that approximately 50% of patients with renal tumors have coexisting tumors in the ipsilateral ureter and bladder, and 3% to 4% of those patients have tumors in the contralateral upper urinary system. A retrograde pyelogram is usually indicated if the collecting system of the affected kidney is not completely visualized or in the case of renal insufficiency or contrast allergy. Additional urothelial assessment may include renal pelvic and/or ureteral washing for cytology, brush biopsies, cystoscopy, and bladder washing for urinary cytology. The role of ureteroscopy in the diagnosis of upper tract tumors is complementary and may confirm the findings of the IVP, retrograde pyelography, and cytology. Ureteroscopy may aid in visual identification and biopsy of tumors for grading and staging. Additional staging evaluation for the detection of metastatic disease should include a chest radiograph and/or computed tomography (CT) of the chest, abdomen, and pelvis. A bone scan may be obtained in patients with an elevated serum calcium, alkaline phosphatase, or bony abnormalities seen on CT scan.

INDICATIONS FOR SURGERY Nephroureterectomy with excision of a cuff of bladder is the classic surgical procedure for carcinoma of the renal pelvis or ureter. However, conservative surgery may be indicated in those patients diagnosed with a small, solitary, well-differentiated papillary tumor. Current staging techniques, however, may make accurate preoperative staging and grading of tumors difficult. In addition, half of all cases of ureteral tumors involve at least the musculature. Furthermore, there is a high incidence of multiple ipsilateral tumors. Last, recurrent tumors in the remaining ureteral stump have been reported in more than 30% of patients treated by nephrectomy and partial ureterectomy. Although patients with solitary distal ureteral tumors may be successfully treated with distal ureterectomy and ureteroneocystostomy, in general, a conservative surgical approach should be reserved for the highly selected patient pop-ulation in whom nephron sparing is essential, i.e., pa-tients diagnosed with bilateral tumors, Balkan nephropathy, patients with a solitary kidney, renal insufficiency, and patients with comorbid health problems. Patients treated with a conservative approach are at increased risk of local recurrence and require frequent and careful follow-up including IVPs, retrograde pyelograms, and endoscopies.6

ALTERNATIVE THERAPY Alternatives to nephroureterectomy include (a) endoscopic resection and/or fulguration, in either a retrograde or antegrade fashion, (b) topical chemo- or immunotherapy via either a nephrostomy tube or ureteral stent, (c) external beam radiotherapy, or (d) laparoscopic nephroureterectomy. Lesions in the ureter may be treated with resection of the ureteral tumor and ureteroureterostomy, replacement with ileal interposition, and ureteral reimplantation. These operations require a careful assessment of the entire urothelium and careful follow-up. Because of the “field change” effect of the urothelium and multiplicity of tumors, these operations may not be appropriate in patients with high-grade or -stage tumors.

SURGICAL TECHNIQUE In performing a nephroureterectomy, technical considerations include the choice of incision, whether it is appropriate and to what extent the surgeon should perform a lymph node dissection, and excision of bladder cuff and distal ureter via an intravesical versus extravesical approach. Two-Incision Approach An intrathoracic, extrapleural, extraperitoneal approach, removing the kidney within Gerota's fascia without removing the adrenal gland, is our preferred procedure. In order to gain proper exposure, the incision can never be too high, and thus, a tenth interspace or supra-11th-rib incision is generally utilized. The patient is placed in a modified flank position (approximately 60 degrees rotated) with the table flexed and the kidney rest elevated. The patient is taped into position with wide adhesive tape, and an arm rest is utilized. The patient is adequately padded with an axillary roll, pillows, and sheets and is prepped and draped from nipples to the symphysis pubis in the usual sterile fashion. The 11th rib and the tenth intercostal space are identified, and a supra-11th-rib incision is made in the tenth intercostal space. The incision extends from the edge of the erector spinae muscle and courses obliquely and medially to the lateral border of the rectus fascia to incise the external and internal oblique muscles, exposing the transversalis fascia, and the latissimus dorsi and serratus muscles, exposing the intercostal muscles. The lumbodorsal fascia is then incised at the level of the tip of the 11th rib to avoid inadvertent division of the peritoneum or pleura ( Fig. 17-1).

FIG. 17-1. The patient is rotated on the table and flexed in the flank position. The incision is made through the transversalis abdominis muscle off the end of the 11th rib to avoid the pleura and peritoneum. The lower border of the pleura is shown. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

The peritoneum is mobilized off the posterior aspect of the transversalis muscle, moving the peritoneum medially and inferiorly. Primarily by use of blunt dissection with minimal sharp dissection, Gerota's fascia is mobilized superiorly from the diaphragm and posteriorly and inferiorly from the psoas and quadratus musculature (Fig. 17-2). The intercostal muscles are then incised, carefully avoiding the pleural membrane. The plane between the pleura and chest wall is identified with careful blunt dissection along the tenth rib using a Kitner dissector. The diaphragmatic attachments to the 11th and 12th rib are transected sharply down to their insertion between the quadratus and psoas muscles, avoiding the intercostal nerve and vessels. Sharp dissection is continued posteriorly until the intercostal ligament is divided, allowing the rib to hinge posteriorly ( Fig. 17-3).

FIG. 17-2. As the left radical nephrectomy continues, Gerota's fascia is mobilized off the abdominal side of the diaphragm. The diaphragm can be seen after the transversalis muscle has been divided. Pleura is identified in the space between the transversus abdominis muscle and the diaphragm. It can then be mobilized with the Kitner dissector superiorly. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

FIG. 17-3. The transverse costal (intercostal) ligament is divided after the pleura has been reflected superiorly and the diaphragm has been divided. Division of the intercostal ligament allows the 11th rib to hinge inferiorly and improves the exposure. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

A self-retaining retractor is placed into the wound for optimal exposure. A Balfour or Finochietto retractor may be used, but a multibladed ring retractor that is secured to the operating table such as a Buckwalter retractor is preferable. The renal mass within Gerota's fascia is rotated medially, and the dissection is carried posteriorly off the psoas and quadratus musculature. The iliohypogastric and ilioinguinal nerves and 12th thoracic neurovascular bundle can usually be identified ( Fig. 17-4).

FIG. 17-4. The transversalis fascia and Gerota's fascia are mobilized from the psoas and quadratus musculature posteriorly. The iliohypogastric and ilioinguinal nerves and 12th thoracic neurovascular bundle are seen. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

The colon is then held medially and superiorly, an avascular plane between the colonic mesocolon and Gerota's fascia is developed, and the renal mass is sharply separated from the peritoneum. By use of sharp and blunt dissection, the superior and inferior aspects of the kidney are dissected free of the adrenal gland and surrounding tissues, respectively. There may be several vessels between the adrenal gland and the kidney that should be ligated with ligaclips. The kidney is dissected posteriorly to the level of the renal hilum. Attention is directed to the main renal vessels. The pulsating renal artery is identified by palpation, double ligated

as it exits the aorta with 0 silk sutures and then divided ( Fig. 17-5).

FIG. 17-5. The aorta is located, and the renal artery can be identified, ligated, and divided. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

On the right side, especially with a large tumor mass, the artery may be approached anteriorly or in the interaortocaval region, though the preferred approach to the right renal artery is posteriorly. On the left side, the gonadal and adrenal veins are identified anteriorly, as is the renal vein. The gonadal and any lumbar veins are ligated before double ligating the renal vein with 2-0 silk suture ( Fig. 17-6 and Fig. 17-7). On the right side, the inferior vena cava is identified as well as the renal vein. Careful palpation for a second renal artery is important before ligation of the renal vein. The remaining soft tissue attachments to the kidney should be divided so that the only remaining attachment is to the ureter.

FIG. 17-6. The medial dissection includes mobilization of the colon and mesocolon from Gerota's fascia. Gerota's fascia remains with the specimen. The aorta is identified, and an en bloc periaortic node dissection is commenced. Care is taken not to injure the femoral branch of the genitofemoral nerve on the psoas muscle. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

FIG. 17-7. The gonadal vessels and ureter are ligated inferiorly. The regional node dissection is carried along the aorta, and the renal vein is ligated and divided. Additional vessels to the adrenal gland are ligated and divided. Adrenal gland is usually not removed with nephroureterectomy for renal pelvic or ureteral tumors. (From Marshall FF. Radical nephrectomy. In: Marshall FF, ed. Operative urology. Philadelphia: WB Saunders, 1991;18–25.)

Attention is then directed to the inferior aspect of the kidney. The ureter is identified and dissected free to a level distal to the bifurcation of the iliac vessels. The ureter is ligated distally with a 0 silk suture, making sure not to include any surrounding tissue in the ligature. A large straight clip is placed proximally to prevent urine spillage, and the ureter is divided. The specimen is then removed. Transitional-cell carcinoma may spread by direct extension or metastasis by hematogenous or lymphatic routes. Therefore, a regional lymphadenectomy should be performed as part of the surgical procedure. A lymph node dissection is performed by identifying the midline of the aorta for a left-sided tumor, and the vena cava for a right-sided tumor. Starting from just cephalad to the renal hilum to the level of the inferior mesenteric artery, the lymphatic tissue is dissected using a “split and roll technique” with ligaclips placed on the lymphatics to avoid a lymphocele. Hemostasis is obtained using electrocautery. The diaphragm is not repaired if only the lateral attachments have been taken down. If a pleurotomy has been made, a red rubber catheter with additional side holes cut out is placed into the pleural space, and the pleurotomy is closed with a running 3-0 chromic suture. The kidney rest is lowered, the table is taken out of flexion, and the wound is closed in two layers using a continuous suture of #1 PDS. The skin is closed using staples. The pleural cavity is then bubbled out with the red rubber catheter in a basin of saline. When fluid and bubbles cease to emerge from the catheter, it is removed, and additional skin staples are applied. Auscultation of the chest at the apex of the lung as well as a chest x-ray should be performed postoperatively to diagnose a pneumothorax. If there are any concerns, a temporary chest tube may be placed. The patient is taken out of flank position, placed in supine position over the break of the operating room table with the table flexed, and prepped and draped in the usual sterile fashion. A 20-Fr Foley catheter is passed into the bladder, and the bladder is then filled with 200 to 300 cc of normal saline. A lower midline abdominal incision is made and carried down through the rectus and transversalis fascia. A Balfour retractor is placed. The bladder is identified and opened longitudinally between two laterally placed 2-0 Vicryl stay sutures. Additional stay sutures are placed at the apex of the incision in the bladder. The ureteral orifices are identified, the bladder is packed with several sponges, and the bladder blade is placed in the dome of the bladder. A 5-Fr feeding tube is placed in the ipsilateral ureteral orifice and sewn in place with a 4-0 chromic suture. The ureteral orifice is circumscribed sharply, including a 1-cm cuff of bladder. The ureter is dissected from its orifice using a pinpoint electrocautery and sharp dissecting scissors ( Fig. 17-8).

FIG. 17-8. A catheter is placed in the left ureteral orifice and sutured. A wide circumferential incision around the ureteral orifice and periureteral dissection free the intravesical ureter. (From Lange PH. Carcinoma of the renal pelvis and ureter. In: Glenn JF, ed. Urologic surgery, 4th ed. Philadelphia: JB Lippincott, 1991;273.)

The entire distal ureter is dissected free to the level of the 0 silk tie, removed with a cuff of bladder, and passed off the table as a specimen. In most cases the remaining stump of distal ureter may be removed entirely with an intravesical approach; however, in some cases additional extravesical dissection is required in which the superior and middle vesicle pedicles are divided. A two-layer closure of the posterior bladder wall is performed using 2-0 Vicryl suture to close the muscle and serosa and 5-0 chromic to close the bladder mucosa. A 3-0 Vicryl continuous suture and subsequently 2-0 Vicryl figure-of-eight Lembert sutures are used to close the bladder incision in two layers. A Davol drain is placed in the pelvis and secured with a 3-0 nylon suture. The abdomen is closed with a continuous #1 PDS suture. The skin is closed with staples.

OUTCOMES Complications Early complications include hemorrhage, wound infection, pneumothorax, atelectasis, and pneumonia. Meticulous dissection around the renal vessels, aorta, and vena cava will aid in decreasing intraoperative blood loss. The supra-11th-rib incision provides excellent exposure to the great vessels and kidney, thus reducing the chance of inadvertent injury to the vasculature. Later complications include “flank sag,” which may be related to division of more than one intercostal nerve. Results The survival rate after nephroureterectomy is dependent on the stage and grade of the tumor. Superficial low-grade tumors rarely metastasize and when adequately treated rarely decrease life expectancy. Invasive lesions have a higher metastatic rate and are associated with a poorer prognosis. Patients with low-grade and high-grade tumors have approximately 80% and 20% survival at 5 years, respectively. 4 Patients with pT2–3a renal pelvic and ureteral tumors have a 75% and 15% survival at 5 years, respectively, and patients with pT3b–4, N+ tumors have approximately a 5% survival at 5 years. Interestingly, in patients with ureteral tumors, survival may be more dependent on the stage and grade of tumor than the surgical approach. 2 CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Abercrombie GF, Eardley I, Payne SR, et al. Modified nephroureterectomy: long-term follow-up with particular reference to subsequent bladder tumors. Br J Urol 1988;61:198. Badalament RA, O'Toole RV, Kenworthy P, et al. Prognostic factors in patients with primary transitional cell carcinoma of the upper urinary tract. J Urol 1990;144:859. Kleer E. Transitional cell carcinoma of the upper tracts. In: Soloway MS, ed. Problems in urology, vol 6, no. 3. Philadelphia: JB Lippincott, 1992;531. Nielson K, Ostri P. Primary tumors of the renal pelvis: evaluation of clinical and pathological features in a consecutive series of 10 years. J Urol 1988;140:19. Ross RK, Paganini-Hill A, Landolph J, et al. Analgesics, cigarette smoking, and other risk factors for cancer of the renal pelvis and ureter. Cancer Res 1989;49:1045. Teffens J, Nagel R. Tumors of the renal pelvis and ureter: observations in 170 patients. Br J Urol 1988;61:277.

Chapter 18 Pyelolithotomy Glenn’s Urologic Surgery

Chapter 18 Pyelolithotomy John M. Fitzpatrick

J. M. Fitzpatrick: Department of Surgery/Urology, Mater Hospital and University College Dublin, Dublin 7, Ireland.

Diagnosis Indications for Surgery Alternative Procedures Surgical Technique Surgical Access to the Kidney Access to the Renal Pelvis Simple Pyelolithotomy Extended Pyelolithotomy Additional Nephrotomies Wound Closure Outcomes Complications Results Chapter References

Pyelolithotomy is an operation that is now uncommonly performed. The advent of percutaneous nephrolithotomy with contact lithotripsy (PCN) and extracorporeal shockwave lithotripsy (ESWL) has reduced the indications for pyelolithotomy, which is a considerably more invasive procedure. It is interesting to note that when surgeons were first performing pyelolithotomy, there was considerable disagreement as to which was the preferred approach to stone removal. Clearly, people liked to argue even then, when one had to do so mainly by letter or book rather than by published article, conference, phone call, telefax, or Internet. Vincenz Czerny probably performed the first pyelotomy, with Sir Henry Morris performing a similar operation to remove a stone in the same year, 1880. Further developments took place over the years, with many incisions through the thorax and abdomen being introduced, and then many incisions through the renal pelvis and renal parenchyma following. The introduction of radiologic visualization of the kidney completed the picture. It is clear, however, that the landmark contributions to open surgical removal of stones from the kidney were made in recent years by Gil Vernet, 5 Marshall,7 Boyce,1 and Wickham. 9

DIAGNOSIS The usual presenting symptom for renal calculi is radiating colicky flank pain, usually associated with hematuria. Larger stones, however, may be relatively asymptomatic or present with persistent infection and/or hematuria. The diagnosis of renal calculi is generally made radiographically. Currently, the most common radiologic method of diagnosis is via a KUB and intravenous pyelography, though some centers are investigating the use of ultrasound and computed tomography.

INDICATIONS FOR SURGERY Although its use is limited because of this relative invasiveness, it sometimes has a role to play, particularly when the stone burden is large or when problems with body shape or habitus prevent percutaneous access to renal calculi or focusing on the stone by ESWL.

ALTERNATIVE PROCEDURES Alternatives to pyelolithotomy include ESWL, percutaneous stone extraction/destruction, ureteroscopic stone destruction, chemolysis (uric acid or struvite stones), or anatrophic nephrolithotomy.

SURGICAL TECHNIQUE Surgical Access to the Kidney The urologist may consider five possible approaches to the kidney for open stone removal: 1. Flank approach a. Subcostal b. Costal (11th or 12th rib) c. Intercostal (above the 11th or 12th rib) 2. Transabdominal 3. Posterior lumbotomy The advantages of the flank approach are described after I explain why, in my opinion, the transabdominal and posterior lumbotomy incisions are rarely required in what is, after all, a relatively uncommon procedure. Transabdominal and transperitoneal access may be required if the patient has spinal deformities and very occasionally after several previous surgical procedures. It is the most invasive of all the approaches, and recovery is delayed postoperatively. It should not be used as the standard approach for pyelolithotomy. The posterior lumbotomy incision ( Fig. 18-1) has its advocates, particularly because postoperative pain is minimal, and recovery is quick with shortened hospital stay. The patient is placed either in the lateral decubitus position or prone, with pillows under the upper abdomen. The incision is made about 2.5 cm lateral to the erector spinae muscle from the 12th rib down to the superior border of the iliac crest. The incision is extended through fat and fascia and then through the aponeurotic fibers of the latissimus dorsi. If further access is required, a small part of the 12th rib can be removed, or the lower end of the incision can be curved inferolaterally along the iliac crest. The advantages of this approach have been listed above, but a major disadvantage is that access to the upper pole is difficult, as is access to the ureter below its upper portion. I feel that when an open operation is being performed today for stone removal, it is unlikely to be a simple procedure but rather a more complex one for which greater exposure may be required than is afforded by this incision.

FIG. 18-1. Gil Vernet incision. (A) Line of posterior vertical lumbotomy with patient in Murphy's position. (B) Plane of dissection. (C) With sacrolumbar and quadratus lumborum muscles retracted, the kidney is rotated to present the hilar surface.

Of the flank incisions, I prefer the costal route of access. The subcostal approach is usually too low for renal surgery of any complexity. In considering the incision, it is worth remembering that although it is possible to be too low, preventing complete visualization of each step of the subsequent dissection, it is never possible to be too high. For this reason, the skin incision should be made on top of or superior to one of the ribs. In this way, damage to the subcostal or infracostal nerves is prevented, and the likelihood of a wound hernia is minimized. The intercostal approach requires division of the posterior costotransverse ligament in order to allow the rib to “bucket-handle.” Otherwise, access between the ribs may be suboptimal, and, indeed, the ribs may break when spread apart by a self-retaining retractor. When an incision is based on a rib (the costal approach), removal of the end of the rib is required. A careful review of the preoperative x-ray films and examination of the patient with the table broken will clarify whether the 12th, 11th, or even, on some occasions, the tenth rib should be the line of the skin incision. The patient should be placed on the table in the lateral decubitus position with the side to be operated on facing directly upward ( Fig. 18-2). The patient can be stabilized by inserting three T-pieces along the sides of the table or by fastening tape to the upper thorax and over the hip, thereby fixing the patient on the table. The table is broken, thus opening up the space between the ribs and the iliac crest, and then tilted 20 degrees laterally toward the surgeon. The surgeon and assistant are both positioned behind the patient, and the surgeon can sit down throughout the procedure.

FIG. 18-2. Classic loin approach. (A) Patient positioned and table flexed. (B) The entire table is tilted about 20 degrees toward the surgeon, who may then be seated for the operation.

The incision is made in the skin over the distal 6 cm of the rib, extending medially for another 10 to 12 cm. It should be deepened down to the rib before any muscles are cut. Once the rib can be clearly seen, the skin, fat, and fascial layers are retracted on both sides to give a better view. The intercostal muscles are divided above the rib with a knife until the diaphragm can be seen; this is then divided with a scissors until the distal 6 cm of rib is cleared. Then the same approach is made below the rib, with the intercostal muscles being divided if the 11th rib is being used, or the latissimus dorsi if it is the 12th. The diaphragm will not be divided inferior to the rib, but it is advisable to identify the nerve bundle and sweep it inferiorly. Once the rib has been dissected free of the surrounding muscles, the distal 6 cm is removed with a rib shears. I do not approach the rib subperiosteally, as leaving the periosteum does not confer any advantage. Once the rib has been removed, Gerota's fascia can be visualized, and through it the kidney can be palpated. Two fingers should be introduced under the abdominal muscles through this incision, and the peritoneum swept away from their under surface. The incision is then deepened through the external oblique, internal oblique, and transversus abdominus muscles using the knife or cutting diathermy. The incision should not extend as far medially as the rectus sheath. At this stage, a body wall retractor should be inserted, preferably the Wickham retractor, which is self-retaining and shaped to the body wall. Gerota's fascia is then opened, and this incision is extended upward toward the diaphragm and inferiorly toward the pelvic brim. The peritoneum can then be mobilized medially away from the ureter, which is visualized exiting from the perirenal fat, and the ureter is encircled with a loop or tape. The perirenal fat is then grasped over the lateral border of the kidney, elevated by two Babcock forceps, and incised, revealing the capsule of the kidney ( Fig. 18-3). The degree of mobilization of the kidney required depends on how large the stone is. If full mobilization is required, it can be performed easily but should always be carried out by sharp dissection with a Metzenbaum scissors under direct vision. Remember that the main renal vein is always best accessed from anterior to the kidney (although there may be tributaries lying posteriorly). The main renal artery is best approached from above and posterior to the kidney, although there may be other branches, particularly an upper pole or lower pole branch directly from the aorta. The artery need not be isolated in the unusual situation that small stones are being removed, unless a parenchymal incision is being contemplated. When it is isolated, a loop or tape should be put around it.

FIG. 18-3. Babcock clamps are used to grasp the perirenal fat, which is incised to reveal the renal capsule

In the case of surgical access after previous surgery and after many previous surgical procedures, great care must be taken ( Fig. 18-4). After incision of the muscles, the fascial and perirenal areas are likely to be greatly thickened and indurated. It is very helpful to isolate the ureter first (prestented if required) and to trace the ureter upward to the ureteropelvic junction. The kidney can then be dissected free from the surrounding tissues with the scissors. Care must be taken not to incise the renal capsule because considerable hemorrhage can occur under these circumstances. Because the kidney is likely to be encased in dense fibrous tissue, the perirenal anatomy will be difficult to define accurately, and upper and lower pole arteries can be damaged. In addition, identification of the renal artery can be somewhat more difficult; palpation of the tissues medial to the kidney will reveal its position.

FIG. 18-4. Standard pyelothotomy with sinus retraction.

Access to the Renal Pelvis In general terms, it is preferable to open the renal pelvis posteriorly rather than anteriorly. This approach will avoid the renal vein, which often runs along the upper part of the anterior surface of the pelvis. Damage to the renal parenchyma can be avoided if only the renal pelvis is incised. The degree of dissection around the renal pelvis will not affect renal function. 2 The subparenchymal and intrasinusal pyelotomy 5 has made easier the removal of even the most complex calculi. Simple Pyelolithotomy This method of opening the renal pelvis would only be considered if the stone to be removed is only 1 to 2 cm in diameter in the renal pelvis or in a calyx, or if there were a number of such sized calculi in several calyces. After opening Gerota's fascia and the perirenal fat and putting a tape around the upper ureter, as described above, the amount of dissection in the region of the renal pelvis that is required is not extensive. The ureteropelvic junction and the pelvis itself should be clearly defined, but a subparenchymal dissection is not required unless the pelvis is intrarenal ( Fig. 18-5). After placing two stay sutures of 4-0 polyglycolic acid or chromic catgut, make a longitudinal incision in the renal pelvis using a scalpel. The incision must not extend through or into the ureteropelvic junction because of the risk of subsequent scarring.

FIG. 18-5. Exposure of the renal sinus in the presence of severe inflammatory erection. (A) Dissection begins along the upper ureter and proceeds superiorly. (B) Peripelvic fat is mobilized and then incised. (C) Near the hilus, peripelvic tissue is dissected bluntly. (D) Excess adipose tissue may be excised. (E) With hilar retractors in place, intrasinusal fat is dissected away by blunt dissection using surgical gauze.

When the urologist is certain that all stones have been removed, the pelvis should be closed with continuous 4-0 polyglycolic acid or chromic catgut suture. The attempt is to make the closure watertight, but even making the suture continuous does not guarantee this, so the peripelvic tissues should be drained. Extended Pyelolithotomy In most cases, the reason for performing open pyelolithotomy will be the complexity of the stone in the renal pelvis and its multiple extensions into the calyces. In many cases it will be possible to remove the stone completely by extending the dissection under the parenchyma and exposing the renal pelvis and calyceal infundibula in the manner described by Gil Vernet. 5 In this way, incisions into the renal parenchyma can be avoided, thus reducing the potential for renal injury. The anatomy of the renal hilum allows for extensive exposure of the renal pelvis, but care must be taken that the correct planes of dissection are adhered to. There is a thin layer of connective tissue extending from the renal capsule into the fat in the renal hilum and then onto the renal pelvis. This closes off the renal hilum, and it is this layer that must be incised in order to gain access to the infundibula in carrying out an extended pyelolithotomy. Once this layer of connective tissue has been incised, the dissection is continued by inserting specially designed retractors under the parenchyma. The dissection is carried out by inserting and spreading a fine scissors or by the use of a Küttner dissector. This dissection is carried out between the fatty layer in the hilum and the pelvis itself ( Fig. 18-3). If, mistakenly, the surgeon enters the layer between the fat and the parenchyma, considerable hemorrhage can be encountered because of many venous channels in this area. Even if there is perihilar inflammation, or if there has been previous surgery, it is possible to develop this plane. Sharp dissection is required, but early insertion of Gil Vernet retractors moves the vessels in the hilum out of the way so that damage to important structures is avoided. Even if veins in this area are opened, they can be compressed by the insertion of small sponges between the retractors and the hilum, and bleeding kept to a minimum. The subparenchymal dissection can be extended to the infundibula without damaging the superior or inferior apical branches of the renal artery. An incision is then made with a scalpel into the renal pelvis, directly down onto the main bulk of the stone. It is extended in a curved fashion with angled scissors into the necks of the superior and inferior calyces. Alternatively, a straight incision is made in the parenchyma from side to side, and perpendicular extensions are made into the necks of the individual calyces ( Fig. 18-6).

FIG. 18-6. Alternative extended incisions of the renal pelvis.

In general, the large central bulk of the stone is removed first. The best way to do this is to pass a stone dissector around the stone and lever it out of the pelvis. This is preferable to grasping the stone with a forceps, as the stone may break. Once the main fragment is out, fine Turner–Warwick stone forceps, either straight or curved, can be inserted into the calyces, and individual fragments can be removed. After the surgeon feels that all of the stone has been removed, it is advisable to irrigate the renal pelvis and flush smaller fragments out of the calyces. This is done by inserting a wide-bore tube into the calyces, through which a high pressure jet of saline can be passed; the high flow of the saline is essential for effectiveness, and this is best induced by a pressure cuff around a bag of saline attached to an infusion cannula. Contact radiography should then be performed by putting a kidney film behind the kidney. It is helpful to put the kidney into an elastic net sling and then tie the sling to the retractor or to a gantry on the retractor. Ligaclips can then be clipped onto the sling, thereby facilitating the location of even small residual fragments on the x-ray film. The renal pelvis is then closed by using a continuous 4-0 polyglycolic acid or chromic catgut suture. Sometimes it may be easier to put one or two interrupted sutures in the apical parts of the necks of the infundibula, and this will facilitate closure. Again, the closure may not be watertight, and drainage of the area is thus required. Unless there is noticeable intrarenal hemorrhage, no nephrostomy tube is necessary. Additional Nephrotomies On some occasions, it may not be possible to remove the entire stone through a pyelotomy, and additional transparenchymal access is required; the anatrophic nephrolithotomy 1 would be excessive if the renal pelvis has been opened in the manner described above, and multiple radial paravascular nephrotomies 9 are a relatively atraumatic method of access. The method of doing this is to make a small (1 cm) radial incision over the stone, which can be localized either by palpation with a needle through the parenchyma or by intraoperative ultrasonography. The parenchyma is then separated by spreading with two MacDonald's stone dissectors until the calyx is opened and the stone removed. This can be done in a number of positions with a minimal effect on renal function. 2 The nephrotomies are closed with a continuous 4-0 polyglycolic acid or chromic catgut suture, which is placed superficially, incorporating only capsule and a thin layer of parenchyma. A nephrostomy tube should be placed into the most dependent calyx opened; a 12-Fr whistle-tip catheter is satisfactory. This should be brought out through a separate stab incision in the skin. If a radial paravascular incision is to be made, the renal artery must be located and either a silastic loop or a cotton tape passed around it in order to gain control. A single nephrotomy may not require vascular occlusion, and occlusion can be avoided altogether by the use of the Doppler ultrasound, which is especially valuable in kidneys with decreased function and thinned parenchyma. 4 If the renal artery must be occluded, renal function should be preserved during the period of ischemia. Renal hypothermia is achieved by surface cooling with sterile crushed ice 6 or by external cooling coils. 8 A less complex method of protecting against renal ischemic damage is the use of intravenous inosine. This can be injected into a peripheral vein and is valuable in protecting renal function, particularly if the ischemic period is less than 60 minutes and overall preoperative renal function is good. 3 Wound Closure After complete stone removal and adequate hemostasis are ensured, the wound is closed. A Robinson drain is brought out through a separate stab incision. A gravity drainage system such as this is preferable to a suction drain, which may cause a urinary fistula to develop. The wound is closed using a series of interrupted #1 polyglycolic acid sutures. These are passed through all muscular layers at 2-mm intervals and are left untied until all are placed. The table is then unbroken, which brings the wound edges closer together and allows the sutures to be tied without tension. A continuous layer of #1 polyglycolic acid suture is then passed through the outer layer of the external oblique muscle and the fascial layers. The skin can be closed with 3-0 monofilament nylon or with skin clips.

OUTCOMES Complications Complications from open renal stone surgery are significant and include hemorrhage, urinary fistula, recurrent stones, and actual or functional loss of the renal unit. The risk of these complications is dependent on the associated findings of chronic infection, prior surgery, and surgeon's expertise. There is a small chance that the pleura may be opened when a costal or intercostal incision is made, and the probability of this increases the higher the incision is made. A pleurotomy is readily identified by hearing the sound of air being sucked into the thorax and by seeing the lung on inspiration. The diaphragm should be dissected free from the ribs and used to strengthen the closure of the pleura, which is itself too thin and fragile to hold a suture. The 3-0 chromic catgut suture should include the diaphragm, pleura, and intercostal muscles, and the anesthesiologist should inflate the lung before the last suture is put in. This usually prevents a pneumothorax. A postoperative chest x-ray must be performed, and, in the relatively uncommon event of a persistent pneumothorax, a chest tube should be inserted. Results Stone-free rates in patients undergoing pyelolithotomy are variable, depending on the number of stones, the composition of the stone, and the presence of calyceal stones or obstruction. Solitary stones have virtually a 100% stone-free rate, whereas staghorn stones (stru-vite) or patients with multiple stones scattered among the calyces may have an incidence of retained stones of 10% or more. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Boyce WH, Elkins IB. Reconstructive renal surgery following anatrophic nephrolithotomy: follow-up of 100 consecutive cases. J Urol 1974;111:307. Fitzpatrick JM, Sleight MW, Braack A, Marberger M, Wickham JEA. Intrarenal access: effects on renal function and morphology. Br J Urol 1980;52:409. Fitzpatrick JM, Wallace DMA, Whitfield HN, Watkinson LE, Fernando AR, Wickham JEA. Inosine in ischaemic renal surgery: long-term follow-up. Br J Urol 1981;53:524. Fitzpatrick JM, Murphy DM, Gorey TF, Alken P, Thuroff J. Doppler localization of intrarenal vessels: an experimental study. Br J Urol 1984;56:614. Gil Vernet JM. New surgical concepts in removing renal calculi. Urol Int 1965;20:255. Graves FT. Renal hypothermia: an aid to partial nephrectomy. Br J Surg 1968;50:362. Marshall VF, Lavengood RW Jr, Kelly DG. Complete longitudinal nephrolithotomy and the Shorr regimen in the management of staghorn calculi. Ann Surg 1965;162:366. Wickham JEA. A simple method for regional renal hypothermia. J Urol 1968;99:246. Wickham JEA, Coe N, Ward JP. One hundred cases of nephrolithotomy under hypothermia. J Urol 1974;112:702.

Chapter 19 Ureterolithotomy Glenn’s Urologic Surgery

Chapter 19 Ureterolithotomy Michael Marberger

M. Marberger: Department of Urology, University of Vienna, Vienna A-1090, Austria.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Anterior Supracostal Approach Posterior Lumbotomy Suprainguinal Approach Ureterolithotomy Outcomes Complications Chapter References

For centuries, “cutting for stone” was synonymous with urology, and just over a decade ago it still made up at least one-fourth of the surgical activity in the field. The development of extracorporeal shockwave lithotripsy (SWL) and endoscopic stone surgery shattered this tradition, and the change becomes most obvious in the indications for ureterolithotomy. Once one of the most common procedures in urology, it all but vanished in the last years in spite of the fact that almost 50% of all patients with upper tract urolithiasis coming to treatment today have stones impacted in the ureter. 8 Specifically, the development of ultrathin semirigid and flexible ureteroscopes with effective laser, electrohydraulic, or ballistic lithotripsy, 1,3,5,8 laparoscopic ureterolithotomy, and third-generation lithotriptors with ultrasonic and fluoroscopic stone localization and small focal zones, which can be pinpointed onto ureteric stones even in infants, 9 have closed the last gaps in the spectrum of minimally invasive therapy of ureteric calculi.

DIAGNOSIS With less invasive methods of stone removal, a sudden change of the position of the calculus can be met without major problems, even when noticed only during the intervention. In open stone surgery, this could result in a catastrophe, with failure to remove the stone and the need for further procedures. The time-honored rule of precise delineation of the size, number, and shape of all calculi and their topography within the collecting system before an incisional procedure remains as valid as ever. In general, ureteric stones can be located precisely with a good intravenous pyelogram with appropriate oblique, delayed, and postvoiding films. To differentiate radiolucent stones from tumors, clots, or papillae, a nonenhanced abdominal computed tomography may be helpful, but significant stones may be missed with this technique, even when 5-mm cuts are obtained at the level of interest. Retrograde ureterography and, if needed, diagnostic ureteroscopy immediately before surgery will clarify the situation. Urinary infection should always be treated with appropriate antibiotics before surgery. With severe obstruction and any evidence of infection, it is prudent to first drain the kidney by percutaneous nephrostomy for about 48 hours until any pathogen is cultured and adequately treated. A plain abdominal roentgenogram is always obtained immediately before surgery, before anesthesia is initiated. Even the largest calculus seemingly incapable of changing its position may do so, and this may necessitate a completely different surgical strategy.

INDICATIONS FOR SURGERY In general, ureterolithotomy today becomes necessary only where ESWL or endoscopic techniques fail. Usually, these failures are concomitant with a complication of previous therapeutic interventions, in particular endoscopic manipulation. Urinary extravasation, an impacted ureteral basket, ureteral avulsion, and an obstructing stone are the typical scenarios. At the author's institution, incisional surgery was required in only six of 3,123 patients subjected to a therapeutic intervention to remove ureteric stones in a 7-year period. Two patients had suffered ureteric avulsion, one patient had a basket trapped around a stone, in two patients stones could not be reached endoscopically, and one patient, pregnant in the fourth week of gestation, required rapid removal of a very large stone impacted in the lumbar ureter. Ureteric reconstruction is beyond the scope of this chapter (see Chapter 20), but the latter three patients demonstrate that there is still an occasional, anecdotal need for ureterolithotomy. Stones can of course also be trapped above congenital or acquired ureteric strictures. Where these require surgical correction, the stone is removed at the time of reconstructive surgery, but the underlying pathology dictates the surgical strategy and technique.

ALTERNATIVE THERAPY Alternatives to open ureterolithotomy are observation, which is indicated in small ( 4.0 ng/ml but < 10.0 ng/ml had a positive biopsy; 53% of patients with a PSA > 10 ng/ml had a positive biopsy. Cooner's detection rate for transrectal ultrasound-guided biopsy in patients with a PSA > 4.0 ng/ml was 33%. Vallancien reported a detection rate of 26% with systematic sextant biopsies in men with a PSA > 4.0 ng/ml and a normal DRE.6 Smith reported a detection rate of 29% at the initial evaluation of men with PSA > 4.0 ng/ml and an overall detection rate of 45% when these same men were followed longitudinally and evaluated with repeat biopsies. 4 CHAPTER REFERENCES 1. Cooner WH, Mosley BR, Rutherford CL Jr, et al. Prostate cancer detection in a clinical urological practice by ultrasonography, digital rectal examination and prostate specific antigen. J Urol 1990;143:1146. 2. Lee F. Transrectal ultrasound: diagnosis and staging of prostatic carcinoma. Urology 1989;33:5–10. 3. Peller P, Young C, Marrnaduke D, Marsh W, Badalament R. Sextant prostate biopsies. Cancer 1995;75:530–538. 4. Smith DS, Catalona WJ, Herschman JD. Longitudinal screening for prostate cancer with prostate-specific antigen. JAMA 1996;276:1309. 5. Torp-Pedersen ST, Lee F. Transrectal biopsy of the prostate guided by transrectal ultrasound. Urol Clin North Am 1989;16:703–712. 6. Vallancien G, Prapotnich D, Veillon B, Brisset JM, Andre-Bougaran J. Systematic prostatic biopsies in 100 men with no suspicion of prostate cancer on digital rectal examination. J Urol 1991;146:1308.

Chapter 37 Stamey and Gittes Bladder Neck Suspension Glenn’s Urologic Surgery

Chapter 37 Stamey and Gittes Bladder Neck Suspension David A. Ginsberg, Eric S. Rovner, and Shlomo Raz

D. A. Ginsberg: Department of Urology, University of Southern California/Norris Cancer Center, Los Angeles, California 90033. E. S. Rovner: Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104. S. Raz: Department of Urology, U.C.L.A. School of Medicine, Los Angeles, California 90024.

Stamey Bladder Neck Suspension Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Gittes No-Incision Urethropexy Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Chapter References

STAMEY BLADDER NECK SUSPENSION Suspension of the bladder neck via a vaginal approach was initially described by Peyrera in 1959. Contemporary techniques of transvaginal bladder neck suspension have arisen as modifications of Peyrera's description. The endoscopic needle suspension of Stamey, described in 1973, contributed several concepts to the surgical technique of bladder neck suspension. This procedure was the first to utilize the cystoscope to precisely place sutures at the bladder neck and visualize closure of the bladder neck with elevation of the suspension sutures. In addition, the procedure incorporates a knitted dacron graft as a bolster to buttress either side of the urethra and aid in the prevention of suture pull-out. Diagnosis The complete evaluation and work-up for urinary incontinence is described in Chapter 38. Indications for Surgery The technique described by Stamey is indicated for correction of stress incontinence in the absence of a significant cystocele. We currently have abandoned simple bladder neck suspensions and perform vaginal wall slings for patients with stress incontinence and no significant cystocele. The choice between these techniques depends on the surgeon's training and experience with the different procedures. Alternative Therapy Alternatives to needle suspensions of the bladder for stress urinary incontinence include transabdominal suspensions, vaginal wall slings, fascial slings, periurethral injections of collagen or Teflon, and conservative measures such as pessaries, pelvic floor stimulation, behavior modification, biofeedback, a-agonist therapy, and urinary collection devices including pads or diapers. Surgical Technique Positioning and Retraction The patient is placed in the dorsal lithotomy position and prepped and draped in the standard fashion. A posterior weighted vaginal speculum and silk labial retraction sutures are placed to aid in exposure. A Foley catheter is placed, and the bladder is drained. Exposure of Bladder Neck A T-shaped incision is made in the anterior vaginal wall. The dissection is carried down to the glistening periurethral fascia and continues laterally until the surgeon is able to palpate the balloon of the catheter. This identifies the bladder neck and allows adequate exposure for later placements of the dacron pledgets. Needle Passage Two suprapubic stab wound incisions are made on each side of the lower abdomen, and the anterior rectus fascia is exposed. The single-pronged Stamey needle is then inserted into the medial edge of one of the suprapubic wounds and advanced, under fingertip control, into the vaginal incision ( Fig. 37-1). The needle passes through the rectus fascia, adjacent to the periosteum, alongside the bladder neck, and through the periurethral fascia as it traverses from the abdomen to the vagina. The Foley catheter is removed, and cystoscopy is performed to confirm correct positioning of the needle. An appropriately positioned needle, when moved medially, will indent the ipsilateral bladder neck ( Fig. 37-2). If the needle penetrates the bladder, it should be removed and repassed.

FIG. 37-1. The needle is guided along the posterior surface of the pubic symphysis under fingertip control to avoid injury to the bladder. (From Shortliffe LMD, Stamey TA. In: McDougal WS, ed. Operative urology. Kent, England: Butterworth, 1985.)

FIG. 37-2. The cystoscope is placed distal to the urethrovesical junction to evaluate needle positioning. An appropriately positioned needle will indent the ipsilateral bladder neck when moved medially (upper inset). If the needle penetrates the bladder ( lower inset), the needle is removed and repassed. (From Shortliffe LMD, Stamey TA. In: McDougal WS, ed. Operative urology. Kent, England: Butterworth, 1985.)

Suture Transfer and Dacron Graft One end of a #2 nylon suture is threaded through the needle and transferred suprapubically. The Stamey needle is passed a second time, 1 cm lateral to the first pass, and its position is again cystoscopically confirmed. The vaginal end of the nylon suture is threaded through a 10- by 5-mm dacron arterial graft, and the free vaginal end of the nylon suture is then placed in the needle holder and transferred suprapubically ( Fig. 37-3). During the transfer of this nylon, an Allis clamp may be used to visually maneuver the dacron graft into appropriate position at the urethrovesical junction as the Stamey needle is pulled suprapubically. The periurethral tissues are now suspended on one side of the bladder neck, and the procedure is repeated on the contralateral side.

FIG. 37-3. Stamey needle is passed a second time after the suture is passed through the dacron graft. (From Shortliffe LMD, Stamey TA. In: McDougal WS, ed. Operative urology. Kent, England: Butterworth, 1985.)

Cystoscopy and Closure Cystoscopy is performed to evaluate the placement of the needle sutures and to confirm adequate functional closure of the bladder neck with minimal tension placed on the nylon sutures. The vaginal incision and graft material are irrigated with an antibiotic solution and closed with a running, locking 2-0 polyglycolic acid suture. An antibiotic-impregnated vaginal pack is placed, and the suprapubic nylon sutures are tied, without tension, such that the knots rest against the rectus fascia. A suprapubic catheter is placed, and the suprapubic wounds are closed with a 4-0 polyglycolic acid suture following antibiotic irrigation. The vaginal packing may be removed 2 hours after surgery, and the patient may be discharged as early as 6 hours postoperatively. The suprapubic catheter is removed no earlier than 1 week after surgery once the postvoid residuals are less than 60 ml. Several important technical points have been outlined by Stamey. 9 The dacron graft should be positioned below the suture line to prevent graft erosion through the vaginal incision. Copious irrigation with an aminoglycoside solution should be performed before closing the vaginal incision to decrease the risk of dacron graft infection. The appropriate Stamey needle (0-, 15-, or 30-degree angle at the distal end containing the needle) should be used depending on the patient's anatomy.

OUTCOMES Complications Complications particular to the Stamey needle suspension include erosion of suture and bolster material into the urinary tract, which can occur up to 7 years following the procedure. Stamey reports a 0.3% incidence of dacron buttress erosion into the bladder as well as a 0.3% incidence of failure of the vaginal incision to completely heal, resulting in an exposed piece of dacron. In both circumstances the exposed tube and suture were removed (endoscopically if the tube eroded into the bladder), and continence was maintained with the single remaining suture on the contralateral side. 9 Sutures are removed in 1% to 2% of patients for pain or infection, and long-term retention may be resolved by loosening of the nylon loop under local anesthesia. Results Evaluation of the literature to determine the success rates of this operation is difficult. The majority of the studies with an adequate number of patients obtained their data in a retrospective manner without anonymous questionnaires to the patients (thus possibly introducing bias to their results), the follow-up in most studies was short (mean follow-up often 24 months or less), and the definition of success was different from author to author (completely dry versus improved). These provisos should be remembered as the literature is reviewed. Review of the English literature in the past 5 years reports cure rates that range from 53% to 80%. 1,3 Walker and Texler evaluated patients with a mail-in questionnaire and found 82% of 192 respondents improved and 65% of patients willing to undergo the procedure again. 10 Early success rates with the Stamey bladder neck suspension may not be durable. O'Sullivan et al. reported a dry rate of 70% immediately after surgery in 67 patients, which decreased to 31% dry at 1 year (58 patients) and further decreased to 18% dry at 5 years (22 patients). 8 Mills et al. found the cure rate in 30 patients decreased from an initial 67% to 33% over a 10-year period of time.7 Factors that may place patients at increased risk for postoperative failure include obesity, respiratory disease, number of pads used per day, prior Marshall–Marchetti–Krantz procedure and concomitant abdominal hysterectomy. 8,10

GITTES NO-INCISION URETHROPEXY The technique of Gittes and Loughlin was described in 1987. 2 Their simplified modification of the Peyrera needle suspension obviates the need for vaginal incisions (Fig. 37-4). This technique is based on the concept that as a monofilament suture pulls through the vaginal wall, it heals as an autologous pledget, creating an internal bolster that tethers the anterior vaginal wall and prevents rotational descent with Valsalva ( Fig. 37-5).

FIG. 37-4. Diagrammatic representation of just-tied no-incision urethropexy as monofilament sutures lift the vaginal wall under tension. (From Raz S, Little NA, Juma S. Female urology. In: Walsh PL, Retik AB, Stamey TA, Vaughan ED, Jr., eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992; 2782–2828.)

FIG. 37-5. Diagrammatic representation of no-incision urethropexy approximately 1 month after surgery. As the suture slowly cuts through the vaginal wall and fascia, a curtain of scar tissue is left and provides support to the vesical neck. (From Gittes RF. No-incision urethropexy. In: Raz S, ed. Female urology, 2nd ed. Philadelphia: WB Saunders, 1996;328–332.)

Diagnosis The complete evaluation and workup for urinary incontinence is described in Chapter 41. Indications for Surgery The technique described by Gittes is indicated for correction of stress incontinence in the absence of a significant cystocele. We currently have abandoned simple bladder neck suspension and perform vaginal wall slings ( Chapter 39) for patients with stress incontinence and no significant cystocele. The choice between these techniques depends on the surgeon's training and experience with the different procedures. Alternative Therapy Alternatives to needle suspensions of the bladder for stress urinary incontinence include transabdominal suspensions, vaginal wall slings, periurethral injections of collagen or Teflon, artificial urethral sphincters, and conservative measures such as pessaries, pelvic floor stimulaion, and urinary collection devices including pads. Surgical Technique Positioning and Retraction The patient is placed in the dorsal lithotomy position and prepped and draped in the standard fashion. A posterior weighted vaginal speculum and silk labial retraction sutures are placed to aid in exposure. A Foley catheter is placed, and the bladder is drained. Needle Passage Two suprapubic stab wound incisions, approximately 5 cm lateral to the midline, are made on each side of the lower abdomen at the upper border of the symphysis pubis, and the anterior rectus fascia is exposed. The single-pronged Stamey needle is then inserted into the medial edge of one of the suprapubic wounds such that the tip of the needle scrapes the posterior aspect of the pubic bone. The anterior vaginal wall is identified just lateral to the Foley catheter balloon and simultaneously elevated with the surgeon's second hand. The needle is then directed, from above, toward the intravaginal fingertip. Once the needle tip is palpable by the intravaginal fingertip, the needle is advanced through the anterior vaginal wall and out through the introitus. The Foley catheter is removed, and cystoscopy is performed to confirm correct positioning of the needle. An appropriately positioned needle, when moved medially, will indent the ipsilateral bladder neck. If the needle penetrates the bladder, it should be removed and repassed. Suture Transfer One end of a #2 Proline suture is threaded through the needle, transferred suprapubically, and secured with a hemostat. The Stamey needle is passed a second time, 1 to 2 cm lateral to the first pass, to provide a base of strong fascial support for the suspension. The second pass of the needle should perforate the vaginal tissue approximately 1 cm lateral to the initial pass to avoid tenting up a large amount of vaginal tissue at the completion of the procedure. The position of the Stamey needle is again confirmed with cystoscopy. The free end of the Proline is threaded through a Mayo needle, and two or three helical bites of vaginal tissue are taken between the first and second vaginal perforation. The Mayo needle is then unthreaded, and the free end of the Proline suture is then advanced through the eye of the previously positioned Stamey needle. The needle is withdrawn, and the two ends of the suspension suture are secured with a hemostat for later tying. The periurethral tissue is now suspended on one side of the bladder neck. Needle passage and suture transfer are then repeated on the contralateral side. Cystoscopy and Closure Cystoscopy is performed to evaluate the placement of the needle and sutures and to confirm adequate functional closure of the bladder neck with minimal tension placed on the Proline sutures. An antibiotic-impregnated vaginal pack is placed, and the suprapubic Proline sutures are tied, without tension, such that the knots rest against the rectus fascia. A suprapubic catheter is placed, and the suprapubic wounds are closed with a 4-0 polyglycolic acid suture following antibiotic irrigation. The vaginal packing may be removed 2 hours after surgery, and the patient may be discharged as early as 6 hours postoperatively. The suprapubic catheter is removed no earlier than 1 week after surgery once the postvoid residuals are less than 60 ml. Outcomes Complications

An overall complication rate of 9.8% for the Gittes no-incision urethropexy has been reported. 6 Potential complications include prolonged urinary retention (2% to 7%), suprapubic pain or cellulitis, genitofemoral or ilioinguinal nerve entrapment, vaginitis, and suture infection with abscess formation, which could require the removal of a suspension suture (and possibly lead to recurrent stress urinary incontinence). 4,5 and 6 Results Reported success rates in the English literature for cure of stress incontinence with the Gittes no-incision urethropexy vary between 81% and 94% depending on the length of follow-up and definition of cure. 4,5 and 6 There are no adequately done studies that have evaluated the long-term efficacy of the Gittes no-incision urethropexy. Kursh evaluated factors influencing the outcome of this procedure and found a significantly decreased cure rate in postmenopausal women and in patients with a greater degree of incontinence preoperatively. 4 As expected, women with type 1 stress incontinence had better outcomes than patients with type 3 stress incontinence (97% versus 45% cure rate, respectively). 4 CHAPTER REFERENCES 1. Ashken MH. Follow-up results with the Stamey operation for stress urinary incontinence of urine. Br J Urol 1990;65:168. 2. Gittes RF, Loughlin KR. No incison pubovaginal suspension for stress incontinence. J Urol 1987;138:568. 3. Hilton P, Mayne CJ. The Stamey endoscopic bladder neck suspension: a clinical and urodynamic investigation, including actuarial follow-up over four years. Br J Obstet Gynaecol 1991;98:1141. 4. Kursh ED. Factors influencing the outcome of a no incision endoscopic urethropexy. Surg Gynecol Obstet 1992;175:254. 5. Kursh ED, Angeli AH, Resnick MI. Evolution of endoscopic urethropexy: Seven-year experience with various techniques. Urology 1991;37:428. 6. Loughlin KR, Whitmore WF III, Gittes RF, Richie JP. Review of an 8-year experience with modifications of endoscopic suspension of the bladder neck for female stress urinary incontinence. J Urol 1990;143:44. 7. Mills R, Persad R, Ahsken MH. Long-term follow-up results with the Stamey operation for stress incontinence of urine. Br J Urol 1996;77:86. 8. O'Sullivan DC, Chilton CP, Munson KW. Should Stamey colposuspension be our primary surgery for stress incontinence? Br J Urol 1995;75:457. 9. Stamey TA. Urinary Incontinence in the Female: The Stamey Endoscopic Suspension of the Vesical Neck for Stress Urinary Incontinence. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2829–2850. 10. Walker GT, Texler JH Jr. Success and patient satisfaction following Stamey procedure for stress urinary incontinence. J Urol 1992;147:1521.

Chapter 38 Abdominal Approaches to Surgery for Female Incontinence Glenn’s Urologic Surgery

Chapter 38 Abdominal Approaches to Surgery for Female Incontinence E. P. Arnold and Peter Gilling

E. P. Arnold: Department of Urology, Christchurch Hospital, Christchurch, New Zealand. P. Gilling: Promed House, Tauranga, New Zealand.

Diagnosis Indications for Surgery Principles of Surgery Alternative Therapy Surgical Technique: Retropubic Cystourethropexies Burch Colposuspension Marshall-Marchetti-Krantz Procedure Suburethral Slings Laparoscopic Burch Colposuspension Outcomes Complications Results Chapter References

Urinary incontinence in women is common. Its incidence rises after vaginal delivery, apparently as a result of nerve stretch, which can also occur after prolonged straining from constipation. Denervation can lead to incompetence of urethral and anal sphincters and to prolapse of the pelvic floor. Incontinence and prolapse are common and often, but not always, coexist. It is clear that for incontinence to occur, the urethral sphincter must be deficient whether or not a prolapse is present. In some patients with prolapse and bladder base descent, however, rotational compression of the urethra from the prolapse stops any leakage. Following repair of such prolapse, these patients might then begin leaking when the underlying intrinsic sphincter deficiency is unmasked. The second major cause of urinary incontinence is detrusor instability, a diagnosis based on urodynamic studies and referring to the occurrence of detrusor contractions during the filling phase or provoked by coughing, posture change, etc. It is often associated with symptoms of frequency, nocturia, urgency, and urge incontinence. The presence of detrusor instability preoperatively has been demonstrated by some authors to have a negative prognostic influence on the outcome of surgery. The incidence of detrusor instability detected by continuous ambulatory monitoring is higher than that found on standard cystometry to the extent that some have considered it to be almost normal. In any case, where there are high-pressure overactive bladder contractions, these patients may well require a reduction in their bladder pressures by anticholinergic medication or, in severe cases, by augmentation cystoplasty to ensure adequate bladder capacity, particularly if there is a neurologic cause.

DIAGNOSIS The diagnosis of urinary incontinence can be made by clinical history and examination of the patient with a full bladder, observing the effects of coughing and straining. The severity of urinary incontinence can be graded ( Table 38-1).

TABLE 38-1. Severity of urinary incontinence

Urinary leakage can be quantified by standardized pad-weighing tests or by a bladder diary and can be further assessed by the performance of pressure-flow studies, preferably with video screening facilities to demonstrate bladder base and urethral hypermobility or rotational descent during coughing and straining. This will also outline any fistula or urethral diverticulum. The type of urinary incontinence can be classified on the basis of radiologic findings and the degree of bladder base descent (anatomic incontinence) or whether the urethra appeared wide open as a “stove pipe” (intrinsic sphincter deficiency, ISD) in an attempt to rationalize the type of procedure to be advised. Measurements of urethral pressures during coughing and straining and measurements of the pressure transmission ratio or assessment of the abdominal leak-point pressure during a Valsalva maneuver have been found useful by some clinicians. Low preoperative maximum urethral closure pressure (MUCP) is more likely to result in a postoperative failure to stop the leakage. 1 The abdominal leak-point pressure (ALPP) correlates with the degree of incontinence from the history and from pad-weighing tests; however, the pelvic floor is a complex mechanism, and precisely what happens to it during straining and coughing requires further study. The presence of detrusor instability is not easy to predict from the history of frequency, nocturia, urgency, and urge incontinence or from examination of the patient, and one must rely on urodynamic studies.

INDICATIONS FOR SURGERY Essentially, if conservative measures have not succeeded, patients who have genuine stress incontinence and who are bothered by the symptom and who are fit for surgery should be offered it. 3 The significance of detrusor instability detected preoperatively in predicting the outcome of surgery is controversial. Many have shown that preoperatively detected detrusor instability compromises the results of surgery. 10 Long-term ambulatory monitoring studies show a higher incidence of detrusor instability than conventional cystometry, and the detrusor instability correlated with an increased surgical failure. 2 Many patients with detrusor instability lose their urgency and frequency symptoms postoperatively, though preoperative detrusor instability may persist in 15% to 89% of cases (mean approximately 50%). 10 Principles of Surgery Continuous Compression of Urethra

Artificial urethral sphincters and injectable bulking agents produce a continuous compression of the urethra to stop leakage. Submucosal injections of bovine collagen, fat, silicone macroparticles, and other bulking agents have been used to produce coaptation of urethral walls and to increase urethral resistance to leakage; they seem to work best for ISD where there is minimal rotation of the bladder base. Intermittent Compression Exactly how other procedures work remains somewhat conjectural but is probably on the same principle of having a backboard behind the urethra that will prevent mobility during coughing and improve the pressure transmission ratio (PTR) of abdominal pressure to the urethra. 9 There is no intrinsic change in the maximum urethral closure pressure postoperatively; hence, nothing is done to improve the efficiency of the intrinsic sphincter mechanism. These operations produce a suburethral “sling”: Of vaginal wall and periurethral tissues and endopelvic fascia in situ, as in the Stamey, Gittes, Burch, Marshall–Marchetti–Krantz (MMK), and Raz–Peryera operations Of the vaginal wall as a buried strip as in the Raz vaginal sling Using a strip of rectus fascia or fascia lata Of synthetic materials The principal difference among these procedures is whether the “sling” is sutured to a fixed point, as in the iliopectineal ligament of the Burch procedure and as in the symphysis pubis in the MMK procedure, or to the mobile rectus sheath, as in the pubovaginal sling, Stamey, and Raz operations. The theoretical advantage of being fixed to the mobile rectus sheath is that it will allow for a loose sling at rest that tightens when the abdominal pressure rises and hence resists leakage when it is needed without obstructing voiding.

ALTERNATIVE THERAPY Conservative therapies including pelvic floor exercises, vaginal cones, and pelvic floor electrical stimulation achieve a success rate that varies between 30% and 70%.3 This improvement may avoid the need for surgery in some patients. It is usually worth trying as a first line of treatment. Success is less likely in the patient who has had previous surgery or radiotherapy and in those with grade 2 or 3 severity of leakage. Hormone replacement therapy may help frequency, urgency, and burning, but its use for incontinence has been disappointing.

SURGICAL TECHNIQUE: RETROPUBIC CYSTOURETHROPEXIES Burch Colposuspension Informed consent should follow only after a full explanation of the procedure ( Fig. 38-1), length of time of hospitalization and recovery, expected outcomes, and possible complications, as discussed below. Prophylactic antibiotics are administered. My preference is to use a cephalosporin with a spectrum against anaerobic organisms.

FIG. 38-1. Burch colposuspension. (A) Modified Lloyd–Davies position with hips abducted and minimally flexed and the patient slightly head-down. Pfannensteil incision. (B) Initial exposure of the retropubic space, with bladder swept off the back of the symphysis pubis and superior pubic rami, demarcating the iliopectineal ligament. (C) The vagina is tented up by the operator's second and third fingers placed vaginally, and using diathermy forceps the endopelvic fascia is buttonholed alongside the bladder neck and bladder base. (D) Sutures are placed on one side and then tied before being placed on the other. No attempt is made to approximate the vaginal wall to Cooper's ligament.

The fully anesthetized patient is placed in the modified Lloyd Davies position with hips abducted and minimally flexed. This allows access for preliminary cystoscopy if indicated and for bimanual manipulation intraoperatively. Skin preparation of the abdomen and vagina is performed using Betadine. A 16-Fr urethral catheter with 7 ml instilled into the balloon is placed on free drainage. Through a Pfannensteil incision 1 cm above the symphysis pubis, the rectus fascia is incised transversely, and the recti are separated. The bladder is swept off the back of the symphysis pubis and the iliopectineal ligament, exposing it and the obturator internus and levator ani muscles. Care is required to avoid damage to the abnormal obturator veins, if present. This dissection is easy in a first approach but can be difficult if adhesions are present following previous surgery. Care is required to avoid perforating a thin-walled bladder adherent to the bones. Keeping close to the bone helps to avoid this. Some surgeons advocate intravesical installation of methylene blue to detect any transgression into the lumen. With the two fingers of the operator's left hand in the vagina, the lateral fornix is tented up, and the endopelvic fascia overlying the vaginal fornix, well lateral to the bladder, is buttonholed; this allows the vagina and its plexus of veins to be mobilized medially. The dissection should start well laterally to avoid the ureter and the bladder. Blunt dissection with the Riches diathermy forceps develops the appropriate plane lateral to the bladder neck as defined by palpation of the Foley catheter balloon, and this exposes the pale white tissue of the vagina and allows any venous bleeding to be cauterized without changing instruments. Mobilization is done on both sides. A row of usually three nonabsorbable sutures (size 1 nylon) are placed full thickness of vagina up through the iliopectineal ligament. These are then tied before sutures are placed on the opposite side to enable correct positioning. It is important not to make the suspension too tight, and it is not necessary to approximate the vagina to the iliopectineal ligament. Often the sutures “bow-string,” particularly after previous vaginal repair or vaginal hysterectomy, as of course they always do in any of the needle suspension procedures. Where an enterocele is present, this can be surgically managed with a Muskowitz procedure in which the pouch of Douglas is obliterated intraperitoneally by encircling sutures at serial levels. In the prevention of this complication of the Burch procedure, some have advised plication of the round ligament or, if a hysterectomy has been previously undertaken, of tightening the uterosacral ligaments. A suction drain is left in the retropubic space, and a suprapubic catheter is inserted to enable measurements of postvoid residuals postoperatively ( Fig. 38-2). After balloon inflation, the catheter should be withdrawn against the vault of the bladder to avoid its tip irritating the trigone and causing postoperative urgency. 12 The rectus muscles are approximated with interrupted 2-0 synthetic absorbable sutures without tension, and the rectus fascia is closed transversely with continuous 0 suture.

FIG. 38-2. Placing suprapubic catheter. (A) With Allis tissue forceps, grasp both walls of the bladder onto the balloon of the urethral catheter to ensure avoiding the peritoneum. (B) Puncture both walls of the bladder with mosquito forceps. (C) Grasp the Foley catheter tip (14 Ch). (D) Pull catheter into the bladder and direct it downward. (E) Withdraw the forceps and close the puncture wound; inflate the catheter balloon. Pull back the catheter so that the balloon abuts on the inner vault of the bladder. 12

Postoperatively the suction drain is removed, usually by day 2; the suprapubic catheter is clamped, and a trial of voiding is commenced. It is removed when the residuals are less than 100 ml or less than one-third of the bladder capacity. Patients are discharged by day 5, and by then most are voiding satisfactorily; if there is any doubt, the patient is taught intermittent self-catheterization until voiding efficiency is restored. Marshall-Marchetti-Krantz Procedure This procedure (Fig. 38-3), described in 1949, involves retropubic dissection through a Pfannensteil incision as for the Burch procedure, and the edges of the urethra are sutured to the fibrocartilage of the symphysis pubis. Serially, the row of sutures is continued onto the anterior surface of the bladder in the perception that this would alleviate prolapse and descent of the bladder base. There is some risk of damage to the urethra as the sutures pass through its lateral wall, and most surgeons have modified the original procedure to take in the periurethral tissue rather than the edges of the urethra. There are also technical difficulties in some patients because of the very thin periosteum through which to place the sutures.

FIG. 38-3. Marshall–Marchetti–Krantz procedure. (A) Endopelvic fascia incised alongside the upper urethra and bladder neck. Space opened by blunt dissection using the diathermy forceps and developing the plane by counterpressure against the operator's second and third fingers placed within the vagina. Three sutures are placed on each side of the urethra through the endopelvic fascia and vaginal wall, but not including the urethral wall, and the sutures are then passed through the cartilage of the symphysis pubis. If the sutures are placed in the cartilage too medially, then this can compress and obstruct the urethra. (B) Lateral parasagittal view of symphysis showing approximation of the urethra and anterior bladder wall to the back of the symphysis pubis.

Suburethral Slings Patients with rotational descent and adequate vaginal capacity are suitable for either a Burch colposuspension or a pubovaginal sling, but if the vaginal capacity is reduced, a pubovaginal sling may be more appropriate. These retropubic procedures use a fascial strip from the rectus fascia as a suburethral sling with each end sutured to the rectus sheath (Fig. 38-4). This technique has been largely superseded by a vaginal approach to avoid the retropubic dissection and is described in Chapter 39 and Chapter 40. In the abdominal approach for this procedure, a strip of rectus fascia 1.5 cm wide is taken from the upper margin of the Pfannensteil incision. The bladder is mobilized, and a tunnel is developed between the vagina and bladder neck and upper urethra, using the balloon of the catheter as a guide. The sling is passed through this tunnel, each end of the strip is sutured with 1 nylon, and the sutures at each end are brought out and tied anterior to the rectus, 1 to 2 cm lateral to the midline, and low down, 1 cm above the symphysis. The length of the strip is probably not critical to the procedure, but it would seem reasonable to use a strip approximately 5 to 10 cm in length. The nylon sutures can be passed up to the appropriate site using the Stamey needle. It is important to ensure that the sling is not too tight, to avoid urethral compression.

FIG. 38-4. Suburethral sling: abdominal approach. (A) A 1.5-cm strip of anterior rectus sheath harvested from the line of the suprapubic Pfannenstiel incision, 5 to 10 cm in length. (B) Endopelvic fascia incised lateral to the proximal urethra and bladder neck. (C) Sutures at one end of the fascial strip grasped and pulled through the suburethral tunnel. (D) Stamey needle puncture of the anterior rectus sheath and one suture drawn through. A second pass with the Stamey needle is made 1 cm from the first in a vertical plane to draw through the second suture. The two sutures are then tied, fixing the one end. The process is repeated on the opposite side, ensuring minimal tension on the sling.

Laparoscopic Burch Colposuspension The patient is admitted in the morning of surgery, having had nothing by mouth from midnight of the night before. Below-knee compression stockings are fitted, and a shave is performed to just below the upper border of the pubic symphysis (midpubic shave). No bowel preparation is necessary for this procedure. A suitable premedication is given, and prophylactic antibiotics are given with the induction of anesthesia as a single dose.

A general anesthetic is preferred for complete relaxation. Pneumatic calf stimulators are placed once the patient is asleep. The low lithotomy position is employed with slight hip flexion and abduction. The lower abdomen and vagina are scrubbed and prepared in the usual manner, and a Foley catheter is placed on free drainage. Surgical drapes are placed to leave the abdomen below the umbilicus and perineum exposed. The surgeon stands on the patient's left, and the assistant and a scrub nurse on the patient's right. A Mayo table is placed between the patient's legs, and this contains the trocars and instruments necessary during the procedure. Two video monitors are generally employed, one each for the surgeon and assistant, at the foot of the bed. The instrumentation required is listed in Table 38-2.

TABLE 38-2. Instrumentation

The procedure (Fig. 38-5) commences with a 12-mm incision, which is placed midway between the umbilicus and the pubic symphysis. It is extended down to the fascia, which is cleared away by finger dissection. The fascia is penetrated with a fine arterial forceps, and the surgeon's index finger is used to clear the extraperitoneal space so that the pubic symphysis can be clearly felt. It is important to be careful not to puncture the peritoneum during this maneuver. Two stay-sutures are placed to the fascial opening; then the retroperitoneal dilating balloon on a catheter introducer is passed into the space created, and 600 ml of saline is placed in the balloon. This remains inflated for several minutes while the remainder of the laparoscopic instrumentation is set up, including the video camera. The balloon is then deflated, and the Hasson cannula placed and secured with stay-sutures. The space is then inspected with the laparoscope. The room is then darkened, and the light source turned up to the maximum. The remaining two trocars are placed in the left lower quadrant. It is important to avoid the vessels that are transilluminated during this maneuver. The 5-mm trocar is placed 2 cm above the symphysis at the lateral border of the left rectus abdominis muscle. The 10-mm trocar is placed between the two previous trocars avoiding obvious blood vessels.

FIG. 38-5. Laparoscopic Burch colposuspension. (A) Site of placement of port. (B) The percutaneous suture passer is placed via side punctures into the retropubic space and thence under laparoscopic vision through the iliopectineal ligament. One end of the suture is then passed through its eye, the passer is withdrawn out of the ligament, and its end is then delivered into the retropubic space and tied. (C) Laparoscopic procedure at completion. 4

With the assistant's finger in the vagina elevating the tissue adjacent to the bladder neck, which can easily be identified using the balloon of the Foley catheter as a guide, the endopelvic fascia is cleared of its fatty tissue. The grasping forceps are in the surgeon's left hand, and the endosurgical scissors in his or her right. Once this is completed, the needle holder is used to introduce the long length of 2-0 Ticron suture down the 10-mm port. The needle is grasped at an appropriate angle, and a large bite of this tissue adjacent to the bladder neck is obtained. The suture needle is then cut off. The percutaneous suture passer is then passed under direct vision into the extraperitoneal space just above Cooper's ligament. It is then placed through the ligament. The end of the suture is passed through the eye of this needle and drawn up through the ligament. Then, the suture material is freed from the suture passer, and this is withdrawn. The free end of the suture, which now passes through both the vaginal tissue and Cooper's ligament, is then grasped with the needle holder and drawn out through the 10-mm port. An extraperitoneal knot is then tied, and this is passed down to be placed snugly on Cooper's ligament. The suture material is then cut, and two further intracorporeal knots are tied to secure this extracorporeal knot. The assistant's finger elevates the tissues throughout this maneuver. Further fixation can be obtained with a 15-cm length of 2-0 Ticron suture on a needle that is passed through both Cooper's ligament and the vaginal tissues with the knots being tied intracorporeally. The procedure is then repeated on the patient's left side in an identical manner. An alternative to this technique involves a 15-cm length of suture, which is prepared by tying a small loop at the free end. The suture is then passed through the 10-mm port with a needle holder and then through the tissue at the level of the bladder neck. The needle is then passed through this loop at the end of the suture, and it is snugged down onto the tissues. A further bite of paravaginal tissue can then be taken to form a helical suture, and the needle is then passed through Cooper's ligament. A Lapra-Ty clip can then be placed onto the suture just as it exits the ligament. A second pass through Cooper's ligament and a second Lapra-Ty clip can also be placed for extra security. The patient is able to eat and drink once she recovers from the effects of the anesthetic. Analgesic and antiemetics are given as required, though opiates are usually unnecessary. The Foley catheter remains in the bladder on free drainage until 6 o'clock the next morning, at which time it is removed, and if the patient is able to void comfortably on several occasions following this, she is discharged from the hospital. Rarely, intermittent self-catheterization will be required for the first few days if voiding is not satisfactory. Residual urine volumes are not routinely measured. No further antibiotic prophylaxis is employed.

OUTCOMES Complications Urethral obstruction after successful surgery occurs in about 10% of cases. 5 To prevent it, care should be taken to avoid elevating the bladder neck too high or tying sutures with undue tension. Intermittent self-catheterization is best used in these cases, and generally, with time, voiding dysfunction usually resolves within about a week. It may persist longer. If dysfunction persists for more than 3 to 6 months, the sutures can be taken down, and, following cystolysis, a vagino-obturator shelf can be considered.11 Postoperative voiding difficulties may be predicted by preoperative voiding problems. However, some acontractile bladders at preoperative study can be shown to contract postoperatively. Those with low preoperative voiding pressures (less than 15 cm of water) were more likely to have problems. 7 Measurement of isometric pressure at the clinical stop test was not found to be helpful in predicting postoperative voiding dysfunction. De novo appearance of detrusor instability postoperatively has been observed in 10% to 20% of cases. Why this should occur is unclear, but ambulatory continuous monitoring studies show a higher preoperative incidence of detrusor instability, and perhaps the surgery unmasks this by changing afferent inputs from the pelvic

floor. In the patient with urgency and urge incontinence postoperatively, one should exclude infection and obstruction. Urodynamic studies should be performed to determine the presence of instability. Cystoscopy should be undertaken where the problem persists, as occasionally a stitch will erode into the bladder. In management, if instability is the only problem, then anticholinergics are often helpful. In the rare cases where this does not suffice and instability remains a problem, then a clam cystoplasty can be considered. Dyspareunia following pelvic floor surgery is not uncommon and is either downplayed or not included in the subjective symptomtology in most series. Where the vagina was narrow or shortened before the incontinence surgery, dyspareunia may occur as a result of the posterior ridge that mirrors the anterior suspension of the anterior vaginal wall. Usually this will settle in time. The question of whether vaginal delivery should be allowed after a successful incontinence surgery is often stated, but the evidence is lacking. This has led to most patients who have had a successful outcome from surgery being advised by their obstetrician to consider a cesarean section rather than risk breaking it down. The magnitude of this risk has never been properly substantiated. After the Burch procedure and needle suspension operations, pain occurs in around 10% and is usually caused by the tension of the sutures. Mostly it decreases with time, but occasionally it persists, and the sutures have to be removed. Another rarer cause of pain is osteitis pubis. Results There is a discrepancy between the results as told us by the patients and those obtained from objective tests of clinical examination, pad-weighing tests, or video pressure-flow studies postoperatively. Often it is not clear in the literature how the results are in fact assessed. In a collected series only 4,815 of 20,481 (23.5%) had had their results of surgery objectively assessed. 5 Results are probably best assessed by a health professional independent of the surgeon, as patients often unwittingly confound the results as stated. They often want to please the surgeon, the one whom they chose and whose advice they accepted. They might feel guilty about hurting the surgeon's feelings or fearful that if they complain of continuing problems, the surgeon might want to do all that again, or even something worse. Patients often enhance the results, and although they may indeed be dry, that might be at the expense of stopping jogging, aerobics, or golf, etc. These factors make comparison of outcomes from different procedures quite difficult. There is not a perfect operation for female urinary incontinence, but the results in achieving continence are quite good at 5 years. The results tend to diminish in time, although the Burch operation and pubovaginal slings tend to hold up as well as most others ( Table 38-3).5,7

TABLE 38-3. Success of urinary incontinence procedures

Patients with persistent or recurrent urinary incontinence should be thoroughly reassessed. This includes history, examination, bladder diary, pad-weighing tests, and urodynamic studies to detect any instability, fistula, etc. If genuine stress incontinence is the reason for failure, then the operation can be repeated. Or, if the urethra is “stove-pipe” and fixed, then there are the options of injecting a suburethral bulking agent such as collagen or of repeating the colposuspension or vaginal sling. In gross cases, some have advocated a reduction vesicourethroplasty. In some cases the artificial urethral sphincter can be considered. Causes of failure include incorrect placement of sutures too high or too low in relation to the bladder neck, sutures cutting out, atrophy of the periurethral and vaginal tissues contributing to the sling, or sphincter damage as might occur in the Marshall–Marchetti–Krantz procedure, where the sutures might have been placed in the wall of the urethra. The urethra may be held open by scar tissue following the first procedure, and a full urethrolysis needs to be considered at the second procedure to avoid this. A history of previous hysterectomy; obesity, but excluding morbid obesity; parity; or age had no apparent influence on the outcome, but results were slightly better in those who had no past history of prior incontinence surgery. 6 CHAPTER REFERENCES 1. Bown LW, Sand PK, Ostergard DR, Franti CE. Unsuccessful Burch retropubic urethropexy: A case-controlled urodynamic study. Am J Obstet Gynecol 1989;160:452–458. 2. Eckford SD, Bailey RA, Jackson SR, Shepherd AM, Abrams P. Occult pre-operative detrusor instability: an adverse prognostic feature in genuine stress incontinence surgery. Neurourol Urodyn 1995;14:487–488. 3. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical practice guidelines no. 2, AHCPR publication no. 96-0682. Rockville, MD: Agency for Health Care Policy and Research, 1996. 4. Gilling PG, Fraundorfer MR, Sealey C, et al. Laparoscopic extraperitoneal approaches to female urinary incontinence: the colposuspension and pubovaginal sling. J Urol 1994;153:344A. 5. Jarvis GJ. Surgery for genuine stress incontinence: Review. Br J Obstet Gynaecol 1994;101:371–374. 6. Kiilholma P, Makinen J, Chancellor MB, Pitkanen Y, Hirvonen T. Modified Burch colposuspension for stress urinary incontinence in females. Surg Gynecol Obstet 1993;176:111–115. 7. Lose G, Jorgenson L, Mortenson SO, Molsted-Pedersen L, Kristensen JK. Voiding diffilculties after colposuspension. Obstet Gynecol 1978;69:33–37. 8. McDougall E. Correction of stress urinary incontinence: retropubic approach. J Endourol 1996;10:247. 9. Theofrastous JP, Bump RC, Elser DM, Wyman JF, McClish DK. Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence. Am J Obstet Gynecol 1995;173:407–414. 10. Vierhout ME, Mulder AFP. Persistent detrusor instabilty after surgery for concomitant stress incontinence and detrusor instability: a review. Int Urogynecol J 1993;4:237–239. 11. Webster GD, Kreder KJ. Voiding dysfunction following cystourethropexy: its evaluation and measurement. J Urol 1990;144:670–673. 12. Woo HH, Rosario DJ, Chapple CR. A simple technique for the intra-operation placement of a suprapubic catheter. Br J Urol 1996;77:153–154.

Chapter 39 Anterior Vaginal Wall Sling Glenn’s Urologic Surgery

Chapter 39 Anterior Vaginal Wall Sling Lynn Stothers

L. Stothers: Department of Surgery, St. Paul's Hospital, Vancouver, British Columbia V52 4E3, Canada.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Preparation Suprapubic Cystostomy Anterior Vaginal Wall Sling Outcomes Complications Results Chapter References

The Raz anterior vaginal wall sling is a relatively new surgical procedure developed since 1992 at the University of California Los Angeles Medical Center. It creates a sling for the treatment of intrinsic sphincter dysfunction (ISD) or anatomic (hypermobility-related) incontinence without burying vaginal epithelium or using autologous fascial strips. Permanent sutures are placed into the periurethral supporting tissues to create a hammock of support from the naturally occurring anatomic structures adjacent to the bladder neck and urethra. To achieve improvement in continence status, two main surgical goals must be met: (a) provide support and increased coaptation to the urethra and (b) create a strong hammock of vaginal wall and underlying tissues to provide a backboard of support to the midurethra and bladder neck during times of increased intra-abdominal pressure.

DIAGNOSIS The presence of stress urinary incontinence should be confirmed objectively by the surgeon with physical examination, cystoscopy, and urodynamics. Epidemiologic studies have shown that 1% of patients who complain objectively of stress urinary incontinence actually have an alternative diagnosis such as profuse vaginal discharge or endocervical cysts, which may mimic incontinence. If incontinence can not be demonstrated objectively by the routine evaluation, then a pyridium pad test may be helpful in confirming the diagnosis. Before surgery, administration of a self-directed incontinence-specific quality-of-life score such as the Raz Quality-of-Life Score, the Incontinence Impact Questionnaire, or the Urogenital Distress Inventory will help to quantify the degree of clinical significance urinary incontinence is having on an individual patient. 2,5 Once incontinence is demonstrated, it is classified as intrinsic sphincteric dysfunction (ISD) or anatomic incontinence (AI). Because no pathognomonic test exists for ISD, the diagnosis is made by a combination of historical, physical, and urodynamic parameters. Factors typically associated with ISD include multiple prior surgeries, prior radiation exposure, direct urethral trauma, or neurologic dysfunction. The abdominal leak-point pressure is typically low. In contrast, patients with AI have hypermobility of the bladder neck and urethra, and the abdominal leak-point pressure is found to be higher than that in those with ISD. In addition to those patients who fit classically into either the ISD or AI categories, there exists a group of patients who may exhibit characteristics of both etiologies with an abdominal leak-point pressure in the gray zone between these two categories. Although patients with a broad range of intra-abdominal leak-point pressures have been treated with the anterior vaginal wall sling, we still continue to classify patients as ISD or AI types to aid in preoperative counseling. Patients with ISD may take longer to resolve postoperative urinary retention and have a lower incidence of resolution of preoperative instability symptoms than do patients with AI. 4

INDICATIONS FOR SURGERY This procedure is indicated for clinically significant female stress urinary incontinence secondary to bladder neck hypermobility or intrinsic sphincter dysfunction with little (grade 1) or no cystocele. Like any vaginal surgery, it is contraindicated in patients who can not adequately be placed in lithotomy position because of physical restrictions such as limited hip abduction. Modifications of this procedure can be made to treat incontinence associated with grade 2 or 3 cystocele (six-corner suspension). Grade 4 cystocele requires a more extensive procedure in which both central and lateral defects are corrected as described in Chapter 42, Chapter 43, Chapter 44 and Chapter 55.

ALTERNATIVE THERAPY In contrast to the Raz vaginal wall sling, which uses permanent sutures placed in the periurethral supporting tissues, a sling can be created from a variety of alternative materials. These can be classified as endogenous sources (fascia lata, rectus fascia, or harvested strips of anterior vaginal wall) or exogenous sources. The latter are either synthetics such as Marlex mesh or natural sources such as banked human dura. In addition to sling procedures, ISD may be treated surgically with injectable agents (collagen, fat, Teflon, silicon) or the artificial urinary sphincter. Alternative surgical treatments for anatomic or hypermobility-related incontinence are classified by the surgical approach—either abdominal, such as the Burch suspension, or vaginal, such as the Gittes or Stamey procedure. The Raz bladder neck suspension, which was previously used to treat anatomic incontinence, has now been replaced by the anterior vaginal wall sling at our institution.

SURGICAL TECHNIQUE Preparation In preparation for surgery, the patient should be given an oral stool softener to begin on the day before surgery. Broad-spectrum intravenous antibiotics such as an aminoglycoside plus a cephalosporin or a broad-spectrum DNA gyrase inhibitor are administered preoperatively. Following general or spinal anesthesia, the patient is placed in the lithotomy position with the buttocks just overhanging the edge of the operating table. This will allow the weighted vaginal speculum to hang freely without contact against the operating table. The feet should be adequately padded in protective boots and placed in leg-supporting stirrups. If the patient is obese, slight Trendelenburg positioning of the table will help to expose the suprapubic region. The skin is then painted with an iodine-based solution from the level of the umbilicus inferiorly to include the whole perineum. The vagina is also painted with an iodine-based solution. A speculum or long forceps should be used to aid in the skin preparation of the vagina to ensure that the entire vagina is adequately prepared to avoid bacterial contamination of the suture material. The drapes are placed to expose the suprapubic region and perineum, with the anus carefully excluded from the field. Several 3-0 silk sutures are used to anchor the drape covering the anus to ensure that it does not fall away during the procedure, thereby contaminating the field. To obtain maximum exposure, the 30-degree weighted vaginal speculum is placed in the vagina, following which single 3-0 silk labial retraction sutures are placed into the labia minora. Appropriate placement of these two retraction sutures will greatly aid in the exposure. Be sure they anchor the labia both laterally and superiorly to exposure the urethra and bladder neck region of the anterior vaginal wall. Always apply retraction sutures after the vaginal speculum is in place to avoid unnecessary tension or suture pull-out. Suprapubic Cystostomy A 14-Fr Foley catheter is used for suprapubic drainage. To place the suprapubic catheter, the closed curved Lowsley forcep is placed into the bladder by the surgeon and pressed against the anterior vaginal wall 2 cm above the symphysis pubis in the midline. The assistant feels for the tip of the forceps and makes a puncture wound with the scalpel blade cutting the skin and rectus fascia. The operator pushes the tip of the forceps through the wound, and the assistant positions the 14-Fr

Foley catheter into the jaws of the retractor. Do not lubricate the tip of the catheter or curved Lowsley retractor to ensure that the catheter does not slip out of the jaws of the retractor. Withdrawal of the retractor by the surgeon delivers the tip of the catheter out the urethra. A small forceps is used to hold the tip of the catheter inside the bladder while the assistant inflates the balloon with 10 cc of water and irrigates with 50 cc of normal saline to ensure correct positioning within the bladder. The suprapubic catheter is placed on traction, and the bladder is emptied with the suction and clamped off. A second 14-Fr Foley catheter with 10 cc of water in the balloon is placed per urethra and clamped off. Palpation of the balloon against the bladder neck is helpful in identifying this landmark vaginally. The assistant places three Allis clamps at the level of the midurethra (midway between the bladder neck and external meatus) on the anterior vaginal wall and retracts upward, exposing the anterior vaginal wall for the surgeon. Anterior Vaginal Wall Sling Before the vaginal incisions are made, 10 cc of saline is injected just beneath the vaginal wall along the anticipated suture lines to facilitate dissection. Two oblique incisions are made in the anterior vaginal wall, extending from the level of the midurethra to 2 cm below the bladder neck ( Fig. 39-1). Dissection is carried out laterally using the Metzenbaum scissors to expose the vaginal side of the urethropelvic ligament bilaterally. This dissection should be superficial. Deep dissection with perforation of the ligament can result in excess bleeding. The attachment of the urethropelvic ligament to the tendinous arc can be felt by the operator by placing a finger into the incision pointing toward the ipsilateral shoulder of the patient ( Fig. 39-2A). With gentle pressure, the curved Mayo scissors are placed into each wound against the tendinous arc and advanced until the retropubic space is entered. Opening the blades of the scissors helps to detach the urethropelvic ligament from the tendinous arc. The operator can now place a finger into the wound and feel the open retropubic space. Blunt finger dissection is used to detach any adhesions within the retropubic space from both sides. The space should feel freely open with the finger, and one should be able to palpate the urethra easily in the midline ( Fig. 39-2B).

FIG. 39-1. The patient is in the lithotomy position with the weighted vaginal speculum in place along with labial retraction sutures. The positions of the two oblique incisions in the anterior vaginal wall are shown by the dotted lines. Note that the incisions do not cross or meet in the midline.

FIG. 39-2. (A) Dissection is carried out over the glistening periurethral fascia. The curved Mayo scissors are shown entering the retropubic space. The scissors are pointed toward the shoulder of the patient. Misdirecting the scissors too far medially could result in bladder perforation. (B) The surgeon's finger is inserted into the open retropubic space through each vaginal incision, and adhesions are taken down. The inside of the pubic ramus is easily palpated. In patients with prior surgery, a Deaver retractor may be placed in the retropubic space, and sharp dissection under vision can be used to safely incise any dense urethral adhesions from the pubic bone.

Two pairs of #1 Proline suture on a half-circle tapered MO-5 needle are used to complete the sling. As each suture is passed to the surgeon, its free end is held with a small mosquito forceps, which can rest on the patient's abdomen while the surgeon completes suture placement. This keeps the free end of the suture well within the sterile field and prevents potential contamination. Begin with placement of the proximal pair of Proline sutures, which are similar to those used in the traditional Raz bladder neck suspension. A long forceps is placed into the retropubic space, and the urethra and bladder are retracted medially. A #1 Proline suture is placed in a helical fashion into the urethropelvic ligament, taking several passes. Then, with the needle kept parallel to the plane of the vagina, the suture is passed in the vaginal wall (excluding the epithelium) to incorporate a large surface area of the underlying vesicopelvic fascia. A similar procedure is carried out on the contralateral side ( Fig. 39-3).

FIG. 39-3. The first pair of Proline sutures are placed at the level of the bladder neck. On the patient's left, correct positioning of the left proximal Proline suture is shown incorporating several helical passes of the urethropelvic ligament and the underlying vesicopelvic fascia. This suture is placed in an identical fashion to the Raz bladder neck suspension.

To place the second, more distal pair of Proline sutures, the long forceps is placed into the open retropubic space. Opening the jaws of the forceps parallel to the floor and retracting inferiorly will create an open triangle in the retropubic space. At the apex of this triangle is the levator muscle as it inserts into the pubic symphysis and the midurethral segment. The urethropelvic ligament in the medial vaginal wall forms the lateral border of the triangle. The floor of the triangle is parallel to the cardinal ligaments.

Using a #1 Proline suture, incorporate several passes of the levator muscle and the edge of the urethropelvic ligament. In order to obtain an adequate amount of levator tissue, the needle must be placed deep into the retropubic space. The levator should be visualized on the arc of the needle. Reposition the forceps to put downward traction on the anterior vaginal wall in the area of the midurethra and incorporate several helical bites of the underlying periurethral fascia incorporating tissue up to but not crossing the midline. As in placing sutures into the vesicopelvic fascia it is important to keep the needle parallel with the vaginal wall to prevent suture material from entering the spongy tissue of the urethra itself. After all four Proline sutures are in place, one can visualize a rectangle of support for the bladder neck and midurethra (Fig. 39-4).

FIG. 39-4. The second more distal pair of Proline sutures is placed at the level of the midurethra. These sutures include the levator muscle, the edge of the urethropelvic ligament, and the underlying periurethral fascia. Once the four Proline sutures are in place, one can visualize the rectangle of support that will be given to the underlying urethra and bladder neck.

A clean blade is used to make a puncture wound the width of the double-pronged needle carrier in the midline, just above the superior margin of the pubic bone. If the incision is made too high, the sutures will be transferred over a mobile area of the anterior abdominal fascia, which can result in pain or incomplete support. The incision is carried down to, but not through, the rectus fascia. With a finger in the retropubic space serving as a guide, the double-pronged needle carrier is advanced through the suprapubic incision, the retropubic space, and out through the vaginal incision ( Fig. 39-5). As the needle passes into the retropubic space, it should hug the symphysis in the midline to ensure that the needle passes into the thick and less mobile area of the rectus fascia. The freed ends of one of the ipsilateral Proline sutures is placed through the needle holes in the double-pronged ligature carrier. Retraction of the needle carrier delivers both ends of the suture out through the suprapubic incision. A total of four passes are made, each suture being transferred individually. Do not attempt to transfer more than one suture at a time—this can result in tangling or knotting of the Proline sutures.

FIG. 39-5. Each Proline suture is transferred individually using the double-pronged needle carrier through a midline suprapubic stab wound the width of the double-pronged needle. Note that passage of the needle is done under fingertip control, passing the needle from the suprapubic region to the vaginal area as close to the pubic symphysis as possible. This maneuver is repeated for a total of four passes, transferring one Proline suture at a time to the suprapubic region.

Indigo carmine is injected intravenously, and cystoscopy is performed with 30- and 70-degree lenses. This ensures that (a) the suprapubic tube is in good position, (b) blue efflux is noted from both ureteral orifices, (c) no Proline suture material has entered the bladder, and (d) upward retraction on the suprapubic Proline sutures provides support to the bladder neck and midurethra. The urethral catheter is replaced, and the assistant provides upward retraction with the three Allis clamps, once again exposing the anterior vaginal wall. The two oblique incisions are closed with a running, locking absorbable suture of 2-0 polyglycolic acid on a tapered UR-5 needle. The shape of this needle allows better placement of sutures high in the vagina. A vaginal pack laden with antibiotic cream is inserted into the vagina, following which the weighted vaginal speculum is removed. Last, the Proline sutures are tied independently to their ipsilateral mates over the rectus fascia, creating the hammock of support ( Fig. 39-6). Excessive tension in the suspending sutures may lead to prolonged pain and is not necessary to achieve support. The skin edges of the suprapubic wound are freed, and the Proline knots are buried. Failure to adequately free the skin edges can result in dimpling of the skin over the Proline knots, which can cause patient discomfort. The suprapubic skin wound is closed with intradermic 4-0 absorbable sutures and Steri-strips.

FIG. 39-6. Lateral view of the pelvis demonstrating all four Proline sutures in place and tied in the midline; a hammock is created to provide support to the midurethra and bladder neck. A vaginal pack is shown in the vagina, and the suprapubic catheter is exiting the suprapubic region in the midline 2 cm superior to the Proline sutures.

Within 24 hours the vaginal pack and urethral catheter are removed. The suprapubic catheter is plugged, and the patient begins to record her voided volumes and the postvoid residual. The patient is discharged with an oral stool softener, an oral antibiotic, and analgesics. When the residual urine is consistently low, the suprapubic catheter is removed in the office.

OUTCOMES Complications A list of the potential complications related to the vaginal wall sling are listed in Table 39-1. The majority are preventable by (a) proper positioning of the patient, (b) careful dissection and identification of the important anatomic landmarks, and (c) routine performance of intraoperative cystoscopy for early identification and correction of potential problems. Patients at increased risk for complications include those with a history of prior bladder or pelvic surgery, endometriosis, pelvic infection, pelvic fracture, or significant pelvic prolapse. These factors may alter the typical pelvic anatomy. Although a detailed review of female pelvic anatomy is beyond the scope of this chapter, several excellent resources are available. 1,3

TABLE 39-1. Classification of the potential complications related to the anterior vaginal wall sling

Intraoperatively, minor bleeding most commonly results from dissection in the wrong fascial plane, such as perforation of the urethropelvic ligament rather than dissection over its glistening surface during exposure. Bleeding may also occur following opening of the retropubic space if entrance is made too close to the urethra with subsequent injury to the periurethral vessels. Temporary placement of a pack into the retropubic space will facilitate exposure and provide hemostasis until a suture ligature can be applied. Temporary packing is always preferable to the excessive use of electrocautery on the delicate tissues of the urethra and bladder. Rarely, arterial vessels are found within the vaginal wall and are encountered shortly after the vaginal wall incisions are made. Should this occur, an Allis clamp placed over the edge of the vaginal wall will secure hemostasis until a suture ligature is applied. Postoperatively, vaginal spotting of blood may be noticed by the patient within the first two postoperative weeks. If vaginal bleeding continues or is increasing, perform a vaginal examination and place a temporary vaginal pack. Misplaced Proline sutures occur when the anatomic landmarks are not clearly exposed and identified. This can potentially result in ureteral or bladder perforation or injury. Both of these complications may be diagnosed with the use of intraoperative indigo carmine and careful cystoscopy. If suture material is identified within the bladder, immediately remove the offending suture and ensure that the ureters are intact, performing retrograde pyelograms if necessary. Ureteral injuries may require stenting for minor injuries or reimplantation for complete ligations. Perforation of the bladder during dissection is exceedingly rare and should be repaired immediately intraoperatively by a multiple layered vaginal closure adhering to the principles of vesicovaginal fistula repair. P>Postoperative suprapubic pain may be related to suspension sutures and is often activity related, subsiding with several weeks of decreased physical activity. It is often idiopathic in nature but may also be caused by cellulitis, subcutaneous abscess formation, muscle entrapment, vigorous overtying of sutures, or placement of sutures through a mobile portion of the anterior abdominal wall. Transferring of sutures in such a site may create tension over the rectus muscle during activity. Passing the double-pronged needle in the midline, as close to the pubic bone as possible, and not tying sutures under tension will minimize this complication. Vaginal stenosis or shortening may result from excessive plication of the vaginal epithelium during closure or secondary scarring. When the vaginal wall is closed, the running suture is locked to aid in the prevention of excessive plication of the tissue. A history of new onset of dyspareunia or pelvic or vaginal pain and the finding of foreshortening on physical examination confirm the diagnosis. Mild shortening or stenosis may be treated with longitudinal relaxing incisions in the lateral vaginal wall with transverse closure. Voiding dysfunction in the early postoperative period is common following surgery for stress urinary incontinence. Before surgery, the patient should be informed of common potential changes in her voiding pattern, including temporary retention and mild bladder irritability. The majority of patients with the new onset of voiding dysfunction have resolution of their symptoms within a short period of time; however, persistent voiding dysfunction should be reevaluated with physical examination, cystoscopy, and videourodynamics. Urinary retention in the immediate postoperative period resolves in the majority of patients with the use of a suprapubic catheter or intermittent self-catheterization. Permanent retention has not been reported as a complication of this procedure. Persistent or recurrent stress incontinence requires complete urodynamic evaluation and usually reoperation if it is of a severity to affect the patient's quality of life. In this case, reoperation with proper suture placement should correct the problem. When the cause is recurrent intrinsic sphincteric dysfunction, alternative corrective measures including injection of urethral bulking agents or artificial urinary sphincters may be considered. Pain, redness, and swelling in the suprapubic area should alert the surgeon to a potential infection at the site of suspension suture knots, which may require drainage should antibiotic therapy be unsuccessful. Lower urinary tract infections are common in the first month following any vaginal surgery and generally respond to a short course of oral antibiotics. Results In 1995 the clinical outcome of the sling procedure was reported in 163 women ranging in age from 31 to 81 years. 4 The cohort was followed prospectively with a median follow-up of 17 months (range 6 to 32 months). Three patients were lost to follow-up. Of the 160, 95 had intrinsic sphincter dysfunction (ISD), and 65 anatomic incontinence (AI). One hundred fifty-two patients were considered cured of stress urinary incontinence at last follow-up. 4 Eleven of 163 patients were considered failures and had recurrent incontinence that was unrelated to bladder instability and required further therapy. Time to recurrent stress incontinence comparing ISD and AI patients, as modeled using Kaplan–Meier survival curves and the log-rank test, showed no significant difference between patients with preoperative anatomic incontinence and those with intrinsic sphincter dysfunction ( p > 0.05). Conditional logistic regression covariates revealed no significant predictive factors for postoperative failures. Seven percent of patients developed de novo instability. Pre- and postoperative within-patient changes of quality-of-life scores were found to be statistically significantly improved for both AI and ISD patients. 6 These initial results indicate that excellent continence was achieved in patients with both ISD and AI using the anterior vaginal wall sling. Advantages of this technique include the absence of a laparotomy incision, short hospital stay, lateral placement of permanent nonreactive sutures, and the ability to correct mild cystocele. The procedure has been shown to be safe and effective and allows for outpatient surgical management of bothintrinsic sphincter dysfunction and anatomic incontinence. CHAPTER REFERENCES 1. Raz S. The anatomy of pelvic support and stress incontinence. In: Raz S, ed. Atlas of transvaginal surgery. Philadelphia: WB Saunders, 1992;1–21. 2. Raz S, Erickson DR. SEAPI QMM incontinence classification system. Neurourol Urodyn 1992;1:187–199. 3. Raz S, Stothers L, Chopra A. Vaginal reconstructive surgery for incontinence and prolapse. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 7th ed. Philadelphia: WB Saunders, 1998;1059–1094. 4. Raz S, Stothers L, Young G, et al. Vaginal wall sling for anatomic incontinence and intrinsic sphincter damage-efficacy and outcome analysis. J Urol 1996;156:166–170. 5. Schumaker SA, Wyman SF, Uebersax JS, et al. Health related quality of life measures for women with urinary incontinence; the Incontinence Impact Questionnaire and the Urogenital Distress

Inventory. Quality Life Res 1994;3:291–306. 6. Stothers L, Raz S, Chopra A. Anterior vaginal wall sling. In: Raz S, ed. Female urology, 2nd ed. Philadelphia: WB Saunders, 1996;395–398.

Chapter 40 Pubovaginal Fascial Slings Glenn’s Urologic Surgery

Chapter 40 Pubovaginal Fascial Slings R. Duane Cespedes and Edward J. McGuire

R. D. Cespedes: Department of Urology/MKCU, Wilford Hall Medical Center, Lackland AFB, Texas 78236. E. J. McGuire: Division of Urology, University of Texas, Houston, Texas 77030. The opinions contained herein are those of the authors and are not to be construed as reflecting the views of the Air Force or the Department of Defense.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

The first urethral sling procedure was described by Von Giordano in 1907. 9 However, even after numerous technical improvements and application of many different materials, the pubovaginal sling (PVS) was rarely used until repopularized by McGuire and Lytton in 1978. 2 The pubovaginal sling has traditionally been used only when other incontinence procedures such as a bladder neck suspension or retropubic urethropexy have failed. In this regard, patients with type 3 stress urinary incontinence, also called intrinsic sphincter deficiency (ISD), have often been diagnosed by default. More recently, the preoperative diagnosis of ISD has been facilitated by use of the Valsalva or abdominal leak point pressure (ALPP) during incontinence evaluations. 3 Accordingly, the diagnosis of ISD can be made before surgery and a PVS performed as the primary incontinence procedure. Stress urinary incontinence in females is classified by the presence and degree of urethral mobility and functional status of the urethra. In types I and II stress urinary incontinence, the urethral sphincter functions normally; however, abdominal pressure can drive the sphincter to a position where it doesn't function normally. Stress incontinence due to urethral hypermobility can be successfully treated by a procedure that immobilizes it, such as a retropubic urethropexy or needle suspension procedure. Type III stress urinary tract incontinence, or ISD, is usually characterized by a minimally mobile urethra and incompetence of the urethral sphincter during increases in abdominal pressure. A few patients have incontinence due to coexisting ISD and urethral hypermobility. All patients with ISD are effectively treated with a PVS.

DIAGNOSIS The preoperative evaluation is directed to identifying ISD. The history can be helpful because patients with ISD usually have severe leakage with minimal activity or have a history of irradiation to the pelvis, a prior incontinence procedure, or are elderly (especially new onset in patients over 70 years old). The incidence of ISD increases after each failed incontinence procedure: 9% if no previous surgery, 25% after one failed procedure, and 75% after two failed procedures. 4 The physical exam is directed to demonstrating leakage, urethral hypermobility, and pelvic prolapse. Urinary leakage without significant hypermobility constitutes presumptive evidence of ISD. A careful evaluation for associated cystocele, rectocele, enterocele, and uterine prolapse is important for ALPP interpretation and in planning the appropriate operative procedures. Failure to repair associated pelvic prolapse conditions will put undue stress on any incontinence procedure, including a pubovaginal sling, which increases the failure rate. After the postvoid residual is determined, a cystometrogram is performed to exclude poor detrusor compliance and overt detrusor instability. To diagnose ISD, an ALPP is indispensable. The bladder is filled to a standard volume of 200 ml (children to one-half functional bladder capacity) and a slow Valsalva maneuver is performed with the patient in the upright position until leakage is noted. Performing this several times and determining an average improves accuracy. If a well-performed Valsalva maneuver fails to induce leakage, vigorous coughing may be required. If the ALPP is below 60 cm H 2O, then ISD is present. If the ALPP is greater than 90 cm H2O and minimal pelvic prolapse exists, pure urethral hypermobility is usually present. Patients with a significant pelvic prolapse condition may have a falsely elevated ALPP and reduction with a vaginal pack is helpful. ALPP values between 60 to 90 cm H 2O form a gray area in which hypermobility and ISD usually coexist. 3

INDICATIONS FOR SURGERY The most common indications for a PVS are urodynamically documented ISD with or without urethral hypermobility and a prior failed incontinence procedure. Additionally, because of the long-term success and durability of a pubovaginal sling, certain patients with stress urinary incontinence due to urethral hypermobility may be better served with a sling procedure. These include females who engage in vigorous athletic activities, are significantly obese, or who cough frequently due to pulmonary disease.

ALTERNATIVE THERAPY In selected female patients with ISD and minimal urethral hypermobility, collagen can be injected at the bladder neck with a success rate of 63% using a mean of 9.1 ml and 1.5 treatments.6 The vaginal wall sling introduced by Raz uses the in situ vaginal wall as the sling with a reported 93% short-term cure rate in patients with ISD.8

SURGICAL TECHNIQUE Patients with atrophic vaginitis should be treated with topical estrogens for 2 weeks before the procedure. It is helpful to teach the patient clean intermittent catheterization before the procedure since incomplete emptying is common for a few days postoperatively. One dose of intravenous antibiotics should be given preoperatively. General or regional anesthesia may be used without particular advantage to either technique. The procedure is performed in the low lithotomy position using Allen stirrups with feet squarely in the stirrups to avoid pressure on the calf areas. The legs should only be moderately flexed at the hips to allow simultaneous exposure to the vagina and the lower abdomen. A 16-Fr Foley catheter is placed and the balloon inflated with 5 mls to allow palpation of the bladder neck and urethra. A weighted vaginal speculum is placed. The labia may be sewn laterally if the view is obstructed. The rectus fascia is usually harvested first to minimize vaginal bleeding. In adults, an 8- to 10-cm Pfannenstiel incision is made approximately 2 to 3 cm above the pubis (Fig. 40-1). The subcutaneous tissue is cleared from the rectus fascia and a relatively scar-free area is selected. Even the most scarred and thickened rectus fascia is usually suitable as a sling. Incising parallel to the fibers, obtain a fascial sling approximately 8 to 10 cm in length with a center portion 1.5 to 2.0 cm wide, tapering the ends to 1 cm wide (Fig. 40-1 inset). Free the upper and lower fascial leaf from the rectus muscles superiorly and inferiorly for approximately 4 to 5 cm to allow a tension-free fascia closure. The sling sutures may be placed before or after transection. The size and type of suture used is a matter of personal preference but we currently use 1-0 polyglactin absorbable suture, which decreases postoperative suture pain and does not compromise durability. The sutures are placed perpendicular to the direction of the fibers approximately 0.5 cm from the ends incorporating all of the fibers in the bites.

FIG. 40-1. Harvesting of the rectus abdominis fascial sling. The sling is 8 to 10 cm long and 1.5 to 2.0 cm wide in the center, narrowing to 1 cm at the ends. The sling ends are sutured with 1-0 absorbable suture incorporating all of the fibers.

The vaginal procedure begins by placing an Allis clamp midway between the bladder neck and the urethral meatus with traction placed superiorly. It is very important to maintain this traction throughout the vaginal procedure. Injectable saline is infiltrated beneath the vaginal epithelium over the proximal urethra to facilitate the dissection. A 3-cm midline incision is made over the proximal urethra and the initial vaginal dissection is performed with a scalpel or Church scissors, which allows one to quickly find the proper plane superficial to the white periurethral fascia. Damage to the underlying urethra and bladder is minimized when dissection proceeds in this plane. The dissection is facilitated by maintaining outward traction (toward the operator) on the developing vaginal flap and by maintaining the tips of the scissors on this flap at all times. Carry the dissection laterally and enter the retropubic space inferior to the ischium, at the level of the bladder neck, by perforating the endopelvic fascia using curved Metzenbaum scissors with tips pointed laterally and slightly superiorly ( Fig. 40-2). Blunt finger dissection should not be used to perforate the endopelvic fascia as bladder injury may occur. Once the endopelvic fascia is entered, gently advance the closed scissors laterally and slightly upward for 1 to 2 cm before opening widely. Gentle blunt finger dissection of the retropubic space superiorly to the rectus muscle is performed ( Fig. 40-3). Through the abdominal incision, the lateral border of the rectus muscle is retracted medially to expose a defect just lateral to where the rectus muscle inserts onto the symphysis (Fig. 40-4). Gentle dissection in this area allows safe and easy access into the retropubic space. If finger dissection of the retropubic space is difficult, as is sometimes the case after prior procedures, place the tips of Metzenbaum scissors directly on the posterior pubis and slowly advance them with constant pressure against the pubic periosteum. After this is completed, no tissue should be palpable between fingers inserted into the retropubic space from above and the vaginal incision below. If some intervening tissue is found at the level of the pelvic floor, penetration of that tissue is safe. If the tissue is higher than the pelvic floor, it is often the bladder attached to the posterior pubis. The bladder can be carefully dissected off the pubis by keeping the scissors on the back of the pubis at all times. A similar procedure is performed on the other side. Extensive retropubic space dissection is unnecessary and may lead to excessive bleeding or bladder injury. A Sarot or Crawford clamp is placed in the retropubic space from above and directed into the vaginal incision using manual guidance ( Fig. 40-5). The tip of the clamp should remain in contact with the pubic periosteum and under the vaginal operator's finger at all times. After clamps have been passed bilaterally, cystoscopy is performed to ensure there has been no damage to the urethra or bladder. Each sling suture is pulled into the abdominal incision placing the sling under the urethra. Proper function and longevity of the sling does not depend on the sutures to hold tension indefinitely (since the sutures are absorbable) and thus it is critical that a good portion of the sling extend into the retropubic space to allow good fixation. One or two 3-0 absorbable sutures are placed through the edge of the sling and superficially through the periurethral fascia to secure it in place ( Fig. 40-6). The sling sutures are passed through the rectus fascia, directly above the retropubic “tunnel,” using a right angle clamp before the rectus fascia is closed. If a suprapubic tube needs to be placed (we do not recommend this), it is done under direct vision at this time. The vagina is closed with a running, locking 2-0 absorbable suture. The weighted speculum and all other instruments should be removed from the vagina. The sling sutures are gently pulled up to remove any slack and tied over the rectus ( Fig. 40-7). A shodded clamp can be used to hold tension on the untied sutures until the appropriate tension is obtained. The appropriate tension is the minimum amount required to stop urethral motion, which is tested by pulling on the urethral catheter. Also, one or two fingers should easily slide under the suture knot. If in doubt it is better to err on the side of too little tension. We do not place a vaginal pack before tying the sutures. We have not found it useful to judge how tight to pull the sling by visual assessment during cystoscopy nor by tightening the sling until leakage cannot be produced by compressing the bladder. In the situation where the patient does not void and permanent urinary retention is desired, increased tension can be applied. The skin is closed and a vaginal pack placed. When the abdominal and vaginal components are performed synchronously, the average operating time is 40 minutes with 50 ml average blood loss.

FIG. 40-2. The vaginal dissection is performed superficially to the white periurethral fascia. With the scissors parallel to the plane of the perineum and tips pointing superiorly and laterally, the retropubic space is entered and subsequently enlarged by further advancing the scissors 1 to 2 cm and then opening them.

FIG. 40-3. Blunt finger dissection creates a tunnel to the rectus muscles above. Wide dissection is unnecessary and may cause significant bleeding or bladder injury.

FIG. 40-4. The approach to the retropubic space from above is located below the rectus fascia and lateral to where the rectus muscles attach to the pubic symphysis. Minimal dissection in this area allows safe and easy access to the retropubic space previously dissected by the vaginal operator.

FIG. 40-5. Using manual guidance, a Crawford clamp is passed from above toward the vaginal incision with the tip of the clamp in contact with the pubic periosteum and the vaginal operator's finger. After the passage of clamps bilaterally, cystoscopy is performed to ensure that no injury to the bladder has occurred.

FIG. 40-6. The sling ends are pulled well into the retropubic space to allow good fixation. The sling is seated at the proximal urethra and sutured to the periurethral fascia using 3-0 absorbable suture.

FIG. 40-7. The sling sutures are passed through the rectus fascia before the fascia is closed. The vaginal mucosa is closed, the weighted speculum removed, and the sling sutures are tied down over the rectus fascia under minimal tension.

On postoperative day 1, the vaginal pack is removed; if the patient is ambulating well, the Foley catheter is removed. The patient performs clean intermittent catheterization after each void, or a minimum of every 4 hours if unable to void, until the postvoid residual is consistently under 60 ml. Patients are regularly discharged within 48 hours. Oral antibiotics are not routinely prescribed postoperatively. Patients should refrain from vigorous activities and sexual intercourse for 4 to 6 weeks to allow proper fixation of the sling.

OUTCOMES Complications When rectus fascia is used for the urethral sling, the most common complications include detrusor instability and urinary retention. Approximately 15% to 25% of patients will have residual urgency symptoms, with less than half demonstrating occasional urge incontinence. 1,2 Less than 10% will develop new onset detrusor instability. In a recent report by O'Connell and colleagues, 26% of patients had residual urgency symptoms and less than half of this group had mild urge incontinence.7 In most cases, these symptoms are responsive to anticholinergic medications and will subside over a period of 3 to 6 months. Persistent postoperative urinary retention, although believed to be a common complication, is not statistically more common after pubovaginal slings than after suspension procedures. In a recent series of 54 patients, no patient who could void preoperatively was in persistent retention postoperatively. 7 McGuire and colleagues reported a 3% incidence of prolonged retention in one series. 5 Superficial wound infections occur in approximately 4% of patients and significant blood loss occurs in 1% to 2%. 7 Wound infections have not resulted in sling failure. Although synthetic sling materials may be used, relatively high rates of infection and urethral erosion have been reported. Persistent postoperative pain is rare when absorbable suture is used. O'Connell and colleagues reported that no patient had to take analgesics chronically and no patient had a procedure to relieve pain. 7

Results In a recent series, 82% of patients were totally dry and another 11% had rare incontinence (once a week or less) for an overall 93% cured or significantly improved. Other long-term series have documented a greater than 80% cure and over 90% significantly improved rate. 1,2,5 Residual stress incontinence usually responds very well to injectable agents such as collagen. The pubovaginal fascial sling is the procedure of choice for treatment of females with urinary incontinence due to ISD. Even patients who had prior surgical failures can obtain excellent results with minimal morbidity, but such results are contingent on an accurate preoperative evaluation and careful placement of the sling at the proximal urethra without undue tension. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Blaivas JG, Jacobs BZ. Pubovaginal sling: long term results and prognostic indicators. J Urol 1993;149:292A, Abstract 313. McGuire EJ, Lytton B. The pubovaginal sling for stress urinary incontinence. J Urol 1978;119:82. McGuire EJ, Fitzpatrick CC, Wan J, et al. Clinical assessment of urethral sphincter function. J Urol 1993;150:1452. McGuire EJ. Urodynamic findings in patients after failure of stress incontinence operations. In: Zinner NR, Sterling AM, eds. Female incontinence. New York: Alan R. Liss, 1981;351–360. McGuire EJ, Bennett CJ, Konnak JA, Sonda LP, Savastano JA. Experience with pubovaginal slings for urinary incontinence at the University of Michigan. J Urol 1987;138:525. O'Connell HE, McGuire EJ, Aboseif S. Transurethral collagen injection therapy in women. J Urol 1995;154:1463. O'Connell HE, McGuire EJ, Usui A, Gudziak M. Pubovaginal slings in 1994. J Urol 1995;153:525A, abstr. 1186. Raz S, Stothers L, Young GPH, et al. Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction. Efficacy and outcome analysis. J Urol 1996;156:166. Ridley JH. The Goebell-Stoeckel sling operation. In: Mattingly RF, Thompson JD, eds. TeLinde's operative gynecology. 4th ed. Philadelphia: JB Lippincott, 1985;923–935.

7

Chapter 41 Injections for Incontinence in Women and Men Glenn’s Urologic Surgery

Chapter 41 Injections for Incontinence in Women and Men Rodney A. Appell and Randy A. Fralick

R. A. Appell: Section of Voiding Dysfunction and Female Urology, Department of Urology, The Cleveland Clinic Foundation, Cleveland, Ohio 44195. R. A. Fralick: Section of Voiding Dysfunction and Female Urology, Department of Urology, The Cleveland Clinic Foundation, Cleveland, Ohio, 44195, and Holy Family Memorial Medical Center, Manitowoc, Wisconsin 54220.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Technique of Injection in the Male Patient Technique of Injection in the Female Patient Outcomes Complications Results Chapter References

In evaluating patients for the use of intraurethral injections as a treatment of urinary incontinence, it is essential to identify the cause(s) of incontinence in order to recommend appropriate therapy. Intraurethral injections benefit patients with incontinence occurring at the level of the bladder outlet. Incontinence occurring at this level may be caused by anatomic displacement of a normally functioning urethra (anatomic genuine stress urinary incontinence) in women or intrinsic incompetence of the urethral closure mechanism (intrinsic sphincteric dysfunction) in women or men. Patients with intrinsic sphincteric dysfunction (ISD) commonly have had a previous surgical procedure on or near the urethra, a sympathetic neurologic injury, or myelodysplasia. Female patients with genuine stress urinary incontinence have normal urethral function but hypermobility of the bladder neck and proximal urethra resulting from a deficiency in pelvic support. These patients benefit from bladder neck elevation and stabilization. Patients with ISD have poor urethral function and require procedures to increase outflow resistance. Patients with a fixed, well-supported urethra in association with ISD are excellent candidates for periurethral injection. In men this is most commonly encountered following radical prostatectomy, whereas in women the primary cause of ISD is a residual effect of multiple surgical resuspension procedures for genuine stress urinary incontinence. 1

DIAGNOSIS Patients with ISD urodynamically display an open bladder outlet at rest in the absence of a detrusor contraction. However, standardization of a methodology to determine ISD has not yet been accepted. Because the incontinence of ISD is nonresistant (passive) urinary leakage, the goal of treatment should be only to coapt the urethra by passive occlusion. With respect to outlet function, maximum urethral closure pressure (UCP max) obtained during urethral pressure profilometry has been the test used to determine the presence of ISD in women. Those women with UCP max £ 20 cm H2O were said to have a “low-pressure urethra” or ISD, and these patients failed standard bladder neck suspension procedures. 9 One can infer that if urethral urinary loss can be induced by abdominal pressure, something must be wrong with the outlet. The abdominal leak-point pressure (LPP abd) is determined by direct measurement of the abdominal pressure required to overcome urethral resistance. This determination may be considered an indirect method of measuring the closure forces of the urethra during straining maneuvers. It is used primarily in women with stress urinary incontinence (SUI) to differentiate between anatomic displacement of a normal-functioning urethra (SUI caused by hypermobility) from poor outlet function (ISD). The leakage may be documented visually or fluoroscopically. At the point at which leakage occurs, LPP abd is recorded. Patients with ISD demonstrate minimal urethral resistance to straining, and therefore the urethral opening pressure is very low, whereas patients with an anatomic displacement of a normally functioning urethra have high urethral opening pressures, and therefore the LPP abd will be higher. However, no standardization of the technological methods to obtain LPP abd has been accepted. In summary, in evaluating leak-point pressures, until a universally accepted technique is established, a single mode with which the physician is comfortable should be used in the same manner on every patient whether for a preoperative evaluation or for the evaluation of a patient with an unsatisfactory result.

INDICATIONS FOR SURGERY During the multicenter investigation of collagen in the treatment of ISD, the patients selected with anatomic (type II vesicourethral hypermobility) incontinence did not fare well.7 Therefore, the recommendation currently is to perform intraurethral or periurethral injections on patients with a poorly functioning urethra (ISD) and good anatomic support. However, recent data suggest that injectables may be used for selected female patients with anatomic stress urinary incontinence. 6

ALTERNATIVE THERAPY The treatment of urinary incontinence related to the incompetent urethra has been a challenging problem and frequently involves surgical augmentation of intraurethral pressures by the use of slings made of autologous or synthetic materials, implantation of an artificial sphincter, or periurethral injection of bulk-enhancing agents.

SURGICAL TECHNIQUE The technique of injection of material is not difficult; however, it is essential to perform precise placement of the material in order to ensure an optimal result. The equipment required for injection depends on the bulk-enhancing agent injected. The injection can be performed either suburothelially through a needle placed directly through a cystoscope (transurethral injection) or periurethrally with a needle inserted percutaneously and positioned in the urethral tissues in the suburothelial space, with the manipulation observed by cystourethroscopy. 1 Men are injected predominantly by the transurethral approach, and women are injected by either technique. There is certainly a learning curve with any technique chosen, which ultimately results in using less injectable material to attain the desired result of continence. Injection techniques using glutaraldehyde-cross-linked collagen (Contigen) are presented, as this is currently the only injectable approved for incontinence. Technique of Injection in the Male Patient The patient is positioned in the semilithotomy position and prepped and draped in the usual fashion, and 10 ml of a 2% lidocaine jelly is placed intraurethrally and left in place 10 minutes before instrumentation. Cystourethroscopy with a zero-degree lens is employed. The injectable material is then delivered suburothelially by way of a transcystoscopic injection needle under direct vision. The needle is advanced under the mucosa with the beveled portion of the needle facing the lumen of the urethra. This is performed in a circumferential matter, employing four quadrant needle placements ( Fig. 41-1). The material is injected until a mucosal bleb is created in each quadrant. Gradually, after the circumferential injections, the urethral mucosa meets in the midline, although additional needle placements may be required for completion.

FIG. 41-1. Transurethral injection in a male patient.

In cases of ISD following a radical prostatectomy, a short segment of urethra remains above the external sphincter. If visualization of this segment of the urethra is difficult, the needle may be placed at the level of the external sphincter and advanced to ensure deposition of the material proximal to the external sphincter. To be effective, any injectable material must be injected in the urethra superior to the external sphincter, even if this means injecting into the actual bladder neck on the proximal side of the anastomosis. It is important to note that the material should not be injected directly into the external sphincter, as this can cause pudendal nerve irritation with resultant sphincter spasm and discomfort. The depth of injection is also critical. The materials must deform the urethral mucosa so that it closes the urethral lumen. Too deep an injection site is a waste of the material and is not effective. Injection is more difficult in patients with post-radical-prostatectomy incontinence resulting from the short segment of urethra above the level of the external sphincter and extensive scarring, which usually occurs in this area following surgery. This problem can be circumvented by using an antegrade approach. The technique is performed by passing a cystoscope with a 5-Fr working port through a small suprapubic cystotomy tract. The vesical neck and proximal urethra are then visualized, and subepithelial injections are performed until the bladder outlet is coapted ( Fig. 41-2). Frequently there is less scar tissue in this location, which results in better tissue coaptation. In early clinical trials, this technique seems to facilitate more precise injection of material, generating improved results with the use of less material. 4 In the authors' opinion this technique represents an exciting new method of implantation in male patients and should be considered in any postprostatectomy man not achieving adequate success by way of the standard transurethral approach. Post-radical-prostatectomy urothelium covers scar, and there is migration of any injectable substance distally along the urethra. Once this stops, there is a “wall” to abut the freshly injected material at the bladder neck. Therefore, this additional technique is not recommended as the primary method for an initial injection.

FIG. 41-2. (A) Beginning antegrade injection in a male patient. (B) Completion of antegrade injection.

A small subset of patients continue to have some degree of incontinence after the placement of a bulbous urethral artificial urinary sphincter. To date the only options to address this problem have been to place a more distal second (tandem) cuff around the bulbous urethra or to place a higher-pressure regulating balloon. Injectable agents have generally been avoided in this setting because of fear of damaging the sphincter cuff. The antegrade approach can be used for this situation without fear of damaging the cuff, although it remains important to know the location of the pressure-regulating balloon before performing the punch cystotomy. In cases of ISD following prostatic resection, a short segment of urethra remains below the veru montanum and yet is still proximal to the external sphincter. The injections should be made in this position circumferentially until urethral coaptation is visible. Extrusion of material into the urethral lumen from the needle holes may occur but can be minimized by not traversing the injected area with the distal end of the cystoscope once the material has been injected. In other words, do not enter the bladder. Technique of Injection in the Female Patient Women may be injected by way of a transcystoscopic technique, as described for the male patient, or by a periurethral approach. 1 The patient is placed in the lithotomy position and prepped and draped in the usual fashion. The introitus and vestibule are anesthetized with 20% topical benzocaine, and the urethra is anesthetized with 10 ml of 2% lidocaine jelly. Following this, a local injection of 1% plain lidocaine is performed periurethrally at the 3- and 9-o'clock positions using 2 to 4 ml on each side. Panendoscopy is performed with a 0- or 30-degree lens, and the needle is positioned periurethrally at the 4- or 8-o'clock position with the bevel of the needle directed toward the lumen (Fig. 41-3). The needle is then advanced into the urethral muscle into the lamina propria in an entirely suburothelial plane. Once the needle is positioned in the lamina propria, it usually advances with very little force. The needle may also be introduced between the urethral fascia and vaginal epithelium at the 6-o'clock position ( Fig. 41-4), and, again, needle placement is fully observed endoscopically. Bulging of the tip of the needle against the mucosa of the urethra is observed during advancement of the needle to ensure its proper placement. When the needle tip is properly positioned 0.5 cm below the bladder neck, the material is injected until swelling is visible on each side, creating the appearance of occlusion of the urethral lumen ( Fig. 41-3). Once the urethra is approximately 50% occluded, the needle is removed and reinserted on the opposite side, and additional material is injected until the urethral mucosa coapts in the midline, creating the endoscopic appearance of two lateral prostatic lobes.

FIG. 41-3. Technique of periurethral injection in a female patient. (A) Appearance of the urethra before treatment. (B) Needle positioned in proximal urethra below the bladder neck. (Note the submucosal location within the lamina propria.) (C) Urethra after completion of injection.

FIG. 41-4. Transvaginal injection of collagen.

Although urologists and urogynecologists are more familiar with transurethral than periurethral techniques, we prefer the periurethral approach, as this minimizes intraurethral bleeding and extravasation of the injectable substance. A useful “trick” described by Neal et al. is to add methylene blue to the injectable lidocaine to aid in the location of the needle tip before injecting the bulking agent. 8 Once the needle is located at the bladder neck position, the syringe of anesthetic/methylene blue is removed, and the syringe containing the bulking agent is engaged. When the desired appearance of the coapted mucosa is attained, have the patient stand and cough to see if there is any leakage, and, if there is, reposition the patient and reinject. Perioperative antibiotic coverage is continued for up to 3 days following the procedure. Most patients are able to void without difficulty following the procedure; however, if retention does develop, clean intermittent catheterization is begun with a 10- to 14-Fr catheter. An indwelling urethral catheter is to be avoided in patients, as this promotes molding of the material around the catheter. Although it is usually unnecessary, if longer-term catheterization is needed, suprapubic cystotomy should be performed in these patients. Patients are contacted 2 weeks postprocedure in order to determine their continence status. Repeat injections are scheduled as necessary and at a time interval appropriate for the injectable substance.

OUTCOMES Complications The perioperative complications associated with periurethral injections are uncommon ( Table 41-1). In the multicenter clinical trial using Contigen injections, transient retention developed in approximately 15% of patients, but only 1% of patients experienced irritative voiding symptoms, and 5% developed a urinary tract infection. 5 Hypersensitivity responses with Contigen are not a problem, as the possibility is assessed by skin testing (wheal and flare) with the more immunogenic and sensitizing non-cross-linked collagen prior to treatment. Those with a positive skin test are excluded from treatment. Regardless of the material, the use of periurethral injections has proven to be safe, eliciting only minor complications. All complications resolve rapidly, and a serious long-term complication from the use of periurethral injections has yet to be reported.

TABLE 41-1. Adverse events reported during multicenter study of 382 patients treated with GAX-collagen a

Results There are no controlled, long-term reports available on any injectable. In fact, it is difficult to glean information in any group reported as to etiology of the incontinence. For example, in women results of injectables are reported without differentiating among patients with hypermobility, those with ISD, and those with both; and men with prostatic resection for benign disease are not separated from those having had a radical prostatectomy. Thus, results have been a combination of anecdotal reporting mixed with conjecture, speculation, and the hope that the truth is involved. Having stated this, it appears that injectables are helpful for some incontinent patients, especially selected women. There are two major disadvantages to the use of injectables: (a) the inability to determine the quantity of material needed for an individual patient and (b) the safety of nonautologous products for injection with respect to migration, foreign body reaction, and immunologic effects. At this point in time only Contigen has been approved as an injectable for incontinence in the United States, and results presented are confined to this approved substance. Results of the North American Contigen Study Group of 134 postprostatectomy patients (17 postresection; 117 post-radical-prostatectomy) and 17 postradiation incontinent men demonstrated that only 22 men (16.5%) regained continence following injections of collagen, but 78.7% were dry or significantly improved at 1 year of follow-up, and 67% at 2 years following injections. 2,7 Use of the antegrade injection technique in men failing the standard retrograde, cystoscopic approach increased the “cured” rate at 1 year by another 37.5%. 4 Results of the North American Contigen Study Group of 127 women demonstrated 46% dry and 34% socially continent (patients requiring a single minipad/day) with 77% remaining dry once continence had been attained. 3 Worldwide independent studies have supported these findings. Patients with no anatomic hypermobility and ISD appear to be the most satisfactory candidates for intraurethral injections. In selected elderly and less mobile female patients with anatomic incontinence, recent data suggest that collagen may also be useful in this patient population. 6 Injectables are still in the developmental stages and their roles in the management of incontinence still need to be defined more precisely. Because the methods are less invasive and generally performed on an outpatient basis, medical costs should be reduced, and there should also be a more rapid return to the patient's normal activities. The ideal material is still sought and should combine ease of administration with minimal tissue reaction, lack of migration, and persistence over time. The physician considering injectables for his or her patient should consider that there is a learning curve in patient selection as well as method of delivery of the bulking agents to attain optimal results. CHAPTER REFERENCES 1. Appell RA. Collagen injection therapy for urinary incontinence. Urol Clin North Am 1994;21:177. 2. Appell RA, McGuire EJ, DeRidder PA, et al. Summary of effectiveness and safety in the prospective, open, multicenter investigation of contigen implant for incontinence due to intrinsic sphincteric deficiency in males. J Urol 1994;151(2):271A. 3. Appell RA, McGuire EJ, DeRidder PA, et al. Summary of effectiveness and safety in the prospective, open, multicenter investigation of contigen implant for incontinence due to intrinsic

4. 5. 6. 7. 8. 9.

sphincteric deficiency in females. J Urol 1994;151(2):418A. Appell RA, Vasavada SP, Rackley RR, et al. Percutaneous antegrade collagen injection therapy for urinary incontinence following radical prostatectomy. Urology 1996;48:769. Bard CR. PMAA submission to US Food and Drug Administration for IDE G850010, 1990. Faerber GJ. Endoscopic collagen injection therapy for elderly women with type I stress urinary incontinence. J Urol 1995;155(2):527A. McGuire EJ, Appell RA. Transurethral collagen injection for urinary incontinence. Urology 1994;43:413–415. Neal D Jr, Lahaye K, Lowe D. Improved needle placement technique in periurethral collagen injection. Urology 1995;45:865–866. Sand PK, Bowen LW, Panganiban R, et al. The low-pressure urethra as a factor in failed retropubic urethropexy. Obstet Gynecol 1987;69:399.

Chapter 42 Pelvic Floor Relaxation Glenn’s Urologic Surgery

Chapter 42 Pelvic Floor Relaxation David A. Ginsberg, Eric S. Rovner, and Shlomo Raz

D. A. Ginsberg: Department of Urology, University of Southern California School of Medicine/Norris Cancer Center, Los Angeles, California 90033. E. S. Rovner: Division of Urology, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104. S. Raz: Division of Urology, Department of Surgery, University of California, Los Angeles, Los Angeles, California 90024.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Positioning and Retraction Exposure of Perineal Body Exposure of Distal Vaginal Defect Exposure of Proximal Vaginal Defect Plication of Prerectal and Pararectal Fascia Repair of the Levator Hiatus Repair of the Perineal Body Outcomes Complications Results Chapter References

A rectocele is secondary to a defect in the supporting fascia of the rectum that results in a herniation of the anterior rectal and posterior vaginal wall into the lumen of the vagina. The true incidence of rectoceles is unknown. Wells et al. reported a 12% incidence of rectoceles on physical examination when evaluating patients complaining of urinary incontinence. 9 Concomitant rectocele or enterocele repair was performed in 35% of patients undergoing a Raz bladder neck suspension 7; however, 65% of patients who underwent repair of a grade IV cystocele required rectocele repair. 6 To understand the concepts underlying repair of pelvic floor relaxation, the anatomy of the normal pelvic floor support system should be briefly reviewed. The pelvic diaphragm is the superior shelf of the pelvic floor and consists of the levator ani and the coccygeus muscles ( Fig. 42-1). The urogenital diaphragm forms the second layer of the pelvic floor and consists of the bulbocavernosus, transverse perinei, and external anal sphincter muscles. These muscles join together with the anterior fibers of the levator ani to form the central tendon of the perineum ( Fig. 42-2).

FIG. 42-1. The pelvic diaphragm consisting of the levator ani and the coccygeus muscles and their investing fascia. The levator hiatus is an area of relative weakness. Prerectal fibers of the levator ani between the rectum and the vagina help to maintain a narrow hiatus that resists prolapse of pelvic organs. (From Raz S, Little NA, Juma S. Female urology. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2782–2828.)

FIG. 42-2. The urogenital diaphragm, consisting of the bulbocavernosus, superficial and deep transverse perinei, and external anal sphincter muscles, and their investing fascia, provides the second layer of pelvic support and is anchored in the middle by the central perineal tendon. (From Raz S, Little NA, Juma S. Female urology. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2782–2828.)

The fascial support of the rectum consists of the prerectal fascia and the pararectal fascia. The prerectal fascia runs anterior to the rectum from the pouch of Douglas to the central tendon and prevents protrusion of the rectum into the vagina. A virtual space exists between the posterior vaginal wall and the prerectal fascia, which offers a convenient plane of dissection during rectocele repair. The pararectal fascia originates from the lateral pelvic sidewall and sweeps posteromedially to the rectum, splitting into anterior and posterior sheets and forming a fibrous envelope around the rectum ( Fig. 42-3).

FIG. 42-3. The prerectal and pararectal fascia provide support to the posterior pelvic floor. (From Babiarz JW, Raz S. Pelvic floor relaxation. In: Raz S, ed. Female urology, 2nd ed. Philadelphia: WB Saunders, 1996;442–456.)

The normal vaginal axis that is seen in the well-supported pelvic floor conveniently protects against rectocele formation and further pelvic prolapse. Two distinct areas of the vagina are seen if a normal vaginal axis is maintained. The proximal vagina lies at a 110- to 120-degree angle to the horizontal. The distal vagina, with the sling-like support provided by the levators, forms an angle of 45 degrees from the vertical. This results in a midvaginal angle of 110 to 130 degrees ( Fig. 42-4). In women with significant pelvic floor prolapse, levator plate laxity and widening of the levator hiatus result in a disappearance of the normal curvature of the vagina and a near-vertical vaginal axis, which facilitates rectocele formation ( Fig. 42-5).

FIG. 42-4. Lateral view of the pelvis. The distal vagina forms an angle of 45 degrees from the vertical. The proximal half of the vagina lies on top of the levator plate, forming an angle of 110 degrees from the diatal vagina. (From Raz S, Little NA, Juma S. Female urology. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2782–2828.)

FIG. 42-5. Levator plate laxity and forward pressure from a rectocele result in a near-vertical vaginal axis, which facilitates the downward prolapse of the pelvic organs. (From Babiarz JW, Raz S. Pelvic floor relaxation. In: Raz S, ed. Female urology, 2nd ed. Philadelphia: WB Saunders, 1996;442–456.)

The high incidence of concomitant rectocele and cystocele relates to the pathophysiology of pelvic floor weakness and subsequent rectocele formation. Childbirth results in several events that weaken the pelvic floor support system: (a) passage of the child's head through the vagina stretches the prerectal and pararectal fascia and detaches the prerectal fascia from the perineal body; (b) the levator musculature and its fascia are weakened, which allows the levator hiatus to widen; (c) the normal narrowing of the vaginal opening is rendered ineffective secondary to widening of the anogenital hiatus and damage to the UG diaphragm. The changes wrought by childbirth are further enhanced by aging, loss of estrogen stimulation, obesity, smoking, strenuous work/physical activity, and chronic abdominal straining, which is often seen in patients with chronic respiratory diseases and cough, constipation, and bladder outlet obstruction. Furthermore, loss of the normal vaginal axis, which is seen with pelvic floor relaxation (and may be accentuated after cystocele repair and/or anti-incontinence surgery), results in ineffective transmission of intra-abdominal pressures. This may lead to a worsening of preexisting pelvic prolapse and an increased risk of stress incontinence. Defects of the perineal body are often a result of injuries sustained during vaginal delivery or episiotomy.

DIAGNOSIS The majority of rectoceles are asymptomatic. If symptomatic, rectocele-related complaints are often related to bowel dysfunction and include constipation, the need to digitalize the vagina to facilitate stool passage, a feeling of blockage at the outlet, and a sensation of stool pocketing. Interestingly, although problems with constipation are often correlated with a rectocele, many patients report continued difficulties with constipation after rectocele repair. 1 Patients may also complain of dyspareunia and symptoms attributable to prolapse such as the feeling of a bulge or sitting on a ball. Defects of the perineal body are usually asymptomatic, but patients may complain of incontinence of liquid stool or flatus or loss of sensation during sexual intercourse secondary to a widened introitus. The diagnosis of a posterior wall defect is made on physical examination. Examination of the posterior compartment is best accomplished using a Sims retractor or half of the vaginal speculum to displace the anterior vaginal wall anteriorly. Perineal body defects are associated with a widened introitus and a decreased distance between the anus and the posterior aspect of the vagina and are graded as follows: I, a tear in the hymenal ring; II, a tear involving the perineal body but not the anal sphincter; III, a tear involving the anal sphincter; IV, a tear extending into the anal mucosa. A rectocele will manifest as a bulge extending from the posterior wall of the vagina and is graded as follows: I, protrusion of the posterior vaginal wall at the level of the hymenal ring; II, protrusion at the level of the hiatus; III, protrusion beyond the introitus. Rectoceles may further be classified according to their position in the vagina as low, medium, or high ( Table 42-1). Rectovaginal examination will reveal attenuation of the fascia and helps rule out coincidental enterocele, which should be suspected in the patient with a high rectocele. With posterior wall defects, loss of the normal banana-like axis of the lower and upper vagina is seen, as the vagina will assume a straight orientation. Finally, defecography and dynamic rectal radiologic examinations are used by some authors in the diagnosis and classification of posterior vaginal vault defects. 8,10

TABLE 42-1. Classification of rectoceles by position

INDICATIONS FOR SURGERY Patients with symptomatic posterior vaginal wall defects should undergo surgical correction. The repair of asymptomatic defects coincident with other vaginal surgery is controversial. Arguments against repair of an asymptomatic rectocele include postoperative coital dysfunction and rectal injury. Jeffcoate described a 30% rate of discontinued coitus or dyspareunia after anterior and posterior repair 3; however, recent reviews evaluating outcomes using present-day techniques describe a 0% to 9% incidence of coital dysfunction. 2,4,5 Rectal injury has not been a concern with current surgical techniques. Arguments favoring repair of asymptomatic pelvic floor relaxation during concomitant vaginal surgery include the risk of larger and symptomatic pelvic prolapse (i.e., rectocele, enterocele, uterine prolapse) if repair is not accomplished and the possibility that results of simultaneous anti-incontinence surgery are improved if repair is done. Anti-incontinence procedures orient the vagina in a vertical axis; however, pelvic floor relaxation repair helps restore the normal near-horizontal axis of the vagina. Restoration of this axis decreases the incidence of postoperative prolapse, results in more effective transmission of intraabdominal pressure to the pelvis, and should improve the results of anti-incontinence surgery by helping to provide a strong backboard against which the bladder neck and urethra (which are secondarily supported by the pelvic floor) can be compressed. These arguments, combined with the ability to accomplish this surgery without introducing significant perioperative morbidity, leads us to strongly favor simultaneous repair of even asymptomatic moderate pelvic floor weakness at the time of concurrent vaginal procedures.

ALTERNATIVE THERAPY Alternatives to repair of pelvic floor relaxation include observation and intravaginal pessaries.

SURGICAL TECHNIQUE The essential goals of rectocele repair include (a) plication of the prerectal and pararectal fascia, (a) narrowing of the levator hiatus by reapproximating the prerectal levator fibers; 3) repair of the perineal body. Two days before surgery, the patient begins a clear liquid diet and begins oral laxatives. Broad-spectrum intravenous antibiotics to cover anaerobes, gram-negative bacilli, and group D enterococcus are administered preoperatively. Positioning and Retraction The patient is placed in the dorsal lithotomy position, and a Betadine-soaked rectal packing is placed to aid in identification of the rectum and to avoid rectal injury. The patient is draped (the rectal packing is isolated from the operative field with double draping), and a Foley catheter is placed. Anti-incontinence surgery, cystocele repair, enterocele repair, and vaginal hysterectomy, if indicated, are accomplished first. A ring retractor with hooks, applied to the perineum, aids in lateral exposure of the vaginal vault. The anterior vaginal wall is retracted upward with a Haney or right-angle retractor to improve visualization and help prevent excessive narrowing of the vagina. Exposure of Perineal Body The rectocele repair begins with the placement of two Allis clamps to the posterior margin of the introitus at the 5- and 7-o'clock positions. A V-shaped incision is made, and a triangular segment of perineal skin with the base of the triangle at the mucocutaneous junction is excised between the Allis clamps, exposing the attenuated perineal body ( Fig. 42-6).

FIG. 42-6. (A) Overlying triangle represents site of incision for this step. (B) Pelvic floor repair begins with excision of triangle of skin at the mucocutaneous junction of posterior vaginal wall and perineum.

Exposure of Distal Vaginal Defect The Allis clamps are then placed in the midline of the posterior vaginal wall, grasping and elevating the rectocele at its midpoint. Saline is injected along the posterior vaginal wall to facilitate dissection. With the use of a scalpel, a second triangular incision is made in the posterior vaginal wall with the base of the triangle at the site of the previous incision and the apex of the triangle above the levator plate 2 to 3 inches inside the hymenal ring ( Fig. 42-7). This is a superficial incision through the vaginal wall only; a deeper dissection at this point risks injury to the rectum. Metzenbaum scissors are then used to sharply develop a plane from the lateral margins of the triangle, dissecting between the herniated rectal wall and the vaginal wall. Staying as close as possible to the vaginal wall to avoid injury to the rectum, the dissection extends laterally, exposing the attenuated prerectal fascia distally. The triangular island of posterior vaginal wall that was created by the inverted V-shaped incision is sharply excised off the prerectal levator fascia and fibers. This redundant skin is not discarded until the rectocele is entirely repaired; if the repair is accidentally too tight and/or excessively narrows the vagina, the excised piece of vaginal wall may be used as a free graft.

FIG. 42-7. (A) Overlying triangle represents site of incision along posterior vaginal wall. (B) With lateral dissection and excision of the vaginal wall, the underlying

pararectal and prerectal fascia is exposed.

Exposure of Proximal Vaginal Defect The prerectal fascia is exposed by sliding the Metzenbaum scissors under the posterior vaginal wall from the apex of the previous triangular incision to the cuff of the vagina. The posterior vaginal wall is then incised along the midline. This incision is made from the apex of the previous triangular incision to the vaginal cuff. An appropriately sized rectangular strip of posterior vaginal wall is excised (a greater severity of prolapse necessitates a wider resection of posterior vaginal wall), exposing the attenuated pararectal and prerectal fascia proximally ( Fig. 42-8). Use of a Haney or right-angle retractor on the anterior vaginal wall at this point helps prevent resection of an excessive amount of posterior vaginal wall, thus decreasing the risk of vaginal stenosis postoperatively. Inadequate resection of sufficient vaginal wall risks a weak repair and the formation of painful ridges during reconstruction.

FIG. 42-8. (A) Overlying vertical line represents site of incision along posterior vaginal wall, extending from previous triangular apex to vaginal cuff. (B) A rectangular strip of posterior vaginal wall is excised, exposing the attenuated pararectal and prerectal fascia proximally.

Plication of Prerectal and Pararectal Fascia At this point attention is turned toward repair of the rectocele. The anterior vaginal wall is retracted upward, and the distal rectum is retracted downward with a Haney or right-angle retractor. This protects the rectum, reduces the rectocele, and facilitates reapproximation of the pararectal and prerectal fascia. Reconstruction begins at the apex of the rectocele and is carried out to the level of the levator hiatus with a running, locking 2-0 polyglycolic acid suture. Each needle passage incorporates the edge of the vaginal wall and generous bites of the prerectal fascia and the pararectal fascia bilaterally ( Fig. 42-9). We attempt to reapproximate the sacrouterine/cardinal ligament complex with the initial bite of this portion of the repair to decrease the risk of subsequent enterocele formation.

FIG. 42-9. (A) A running, locking, absorbable suture is used to reapproximate the vaginal wall and prerectal and pararectal fascia up to the level of the levators. (B) Schematic diagram demonstrates layers incorporated with repair.

Repair of the Levator Hiatus Two or three interrupted figure-of-eight 2-0 polyglycolic acid sutures are placed, closing the distal posterior vaginal wall to the level of the perineum ( Fig. 42-10). This suture incorporates the same layers as previously described. As the reconstruction continues, each side of the vaginal wall should proportionally come together such that the most distal aspect of the repair, at the mucocutaneous junction, is reapproximated evenly. Reapproximation of the prerectal levator fascia at this level restores the normal axis of the vagina. Therefore, examination of the repair at this point should reveal a well-supported posterior vaginal wall with a concavity (corresponding to the normal midvaginal axis of 110 degrees) to the repair proximally. Finally, a smooth contour without ridges should be noted along the suture line.

FIG. 42-10. The prerectal levator fibers are reapproximated with interrupted absorbable sutures placed in a figure-of-eight fashion.

Repair of the Perineal Body Several vertical mattress sutures of 2-0 polyglycolic acid are used to approximate the bulbocavernosus, transverse perineal, and external anal sphincter muscles ( Fig. 42-11). This brings together the muscles of the UG diaphragm, reconstructing and providing support to the central tendon. The perineal skin is closed with a running 4-0 polyglycolic acid suture ( Fig. 42-12), and an antibiotic-impregnated vaginal packing is placed.

FIG. 42-11. Vertical mattress sutures are placed to reconstruct the perineum.

FIG. 42-12. The repair is completed with reapproximation of the perineal skin with a running 4-0 absorbable suture. (From Raz S, Little NA, Juma S. Female urology. In: Walsh PC, Retik AB, Stamey TA, Vaughn ED Jr, eds. Campbell's urology, 6th ed. Philadelphia: WB Saunders, 1992;2782–2828.)

This procedure is performed as an outpatient surgery. The Foley catheter and vaginal packing are removed several hours after surgery, and patients are prepared for discharge within 6 to 20 hours postoperatively. Patients are sent home with oral antibiotics and are maintained on stool softeners for 1 month. Finally, patients are encouraged to resume early postoperative coitus to ensure normal resumption of sexual function.

OUTCOMES Complications Urinary retention is the most frequent complication of rectocele repair and occurs in 12.5% of patients. 1 Retention in these patients is temporary and rarely lasts more than several days. Rectovaginal fistula was not seen in our series but has been reported in up to 5% of patients undergoing pelvic floor repair. 5 Dyspareunia can be averted by not excessively narrowing the vagina, avoiding suture placement directly into the levators, and by not leaving uneven, painful ridges along the repair. Other complications of vaginal surgery include infection, bleeding, vaginal shortening, vaginal wall inclusion cyst formation, and fistula. Results Recurrent rectocele is very uncommon and has not occurred in any of the 95 patients we recently reviewed. However, recurrent pelvic prolapse can be expected in as many as 7.5% of patients postoperatively. Constipation is not resolved in up to 50% of patients undergoing rectocele repair for this complaint; this is likely a result of the multifactorial etiology of constipation in many patients. 1 CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Arnold MW, Stewart WR, Aguilar PS. Rectocele repair: Four years experience. Dis Col Rect 1990;33:684. Haase P, Skibsted L. Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand 1988;67:659. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol 1958;77:490 Nichols DH. Posterior colporrhaphy and perineorrhaphy: Separate and distinct operations. Am J Obstet Gynecol 1991;164:714. Pratt JH. Surgical repair of rectocele and perineal lacerations. Clin Obstet Gynecol 1972;15:1160. Raz S, Little NA, Juma S, Sussman EM. Repair of severe anterior vaginal wall prolapse (grade IV cystourethrocele). J Urol 1991;146:988 Raz S, Sussman EM, Erickson DB, Bregg KJ, Nitti VW. The Raz bladder neck suspension: Results in 206 patients. J Urol 1992;148:845. Sentovich SM, Rivela LJ, Christensen MA, Blatchford GJ. Simultaneous dynamic proctography and peritoneography for pelvic floor disorders. Dis Col Rect 1995;38:912. Wells TJ, Brink CA, Diokno AC. Urinary incontinence in elderly women: Clinical findings. J Am Geriatr Soc 1987;35:933. Wiersma TG, Mulder CJ, Reeders JW, Tytget GN, Van Waes PF. Dynamic rectal examination (defecography). Ballieres Clin Gastroenterol 1994;8:729.

Chapter 43 Rectus Muscle Sling Procedure for Severe Stress Urinary Incontinence Glenn’s Urologic Surgery

Chapter 43 Rectus Muscle Sling Procedure for Severe Stress Urinary Incontinence Niall T. M. Galloway

N. T. M. Galloway: Section of Urology, Department of Surgery, Emory University School of Medicine, The Emory Clinic, Atlanta, Georgia 30322.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complication Results Chapter References

Type III stress urinary incontinence results from intrinsic dysfunction of the urethra and bladder neck incompetence. Effective repair must restore closure of the deficient urethra. Current surgical techniques include the use of fascial slings, vaginal island slings, artificial urinary sphincter, or periurethral injections. A variety of natural materials have been used for sling procedures, the most popular being fascia lata or rectus fascia. Synthetic materials are convenient but are more prone to problems of erosion or infection. The narrow dimensions of a traditional sling make it important that the surgeon position the sling accurately at the proximal urethra. A more distal location can produce outflow obstruction or problems with recurrent infection or voiding difficulty. The rectus muscle provides a broad platform of support for the bladder neck and urethra, and accurate placement seems to be less of a problem. 1

DIAGNOSIS There is a clinical pattern of sacral neurogenic deficit that is characterized by flat feet and loss of intrinsic muscle function of the toes (inability to abduct the toes), and the lateral toes may be hypoplastic. On perineal examination, there is loss of two-point discrimination (4 cm) in the postanal (S5) or perianal (S4) dermatomes, and anal examination reveals loss of anal tone and anal grip that is weak and not sustained. The severity of urinary leakage will give a clue to intrinsic urethral weakness. If the patient leaks with a flood in the supine position on the first or second cough, one should suspect type III stress urinary incontinence. Correction of bladder neck displacement with the examining finger will usually fail to correct the leakage. It is often difficult to assess urethral function in the presence of severe vaginal vault prolapse or procidentia because the prolapsing bladder base may obstruct the urethra. Surgical correction of the prolapse may reveal moderate or severe stress incontinence. Objective urodynamic findings are essential to distinguish the patient who will require a sling procedure. Selection criteria for rectus muscle sling procedure were Valsalva leak-point pressures of less than 60 cm H 2O and/or maximum urethral pressure (Brown and Wickam) of less than 20 cm H 2O and/or a urethral length of less than 1.5 cm.

INDICATIONS FOR SURGERY Traditional indications would reserve sling procedures for those who have failed a primary surgical repair. In contemporary practice, the sling is also used as a primary procedure for patients with severe stress urinary incontinence. Clinical features would include leakage with a flood that occurs instantly with the first cough in a supine position, in a patient with a comfortably full bladder, or leaks while standing without provocation. Cystoscopic features include open bladder neck and short urethral length (1.5 cm width) or dilated ejaculatory ducts (>2.3 mm) in association with a cyst, calcification, or stones along the duct. Recently, high-resolution TRUS has virtually replaced the more invasive vasography in the diagnosis of ejaculatory duct obstruction. With TRUS, it is also possible to determine precisely the level of obstruction in the ejaculatory duct in order to more accurately assess the feasibility of transurethral surgery. To complete the evaluation in patients presenting with infertility, it is important that the serum FSH and testosterone be normal and that a testis biopsy confirms ongoing sperm production. Indications for Surgery Patients with ejaculatory duct obstruction sufficient to cause coital discomfort, recurrent hematospermia, or infertility should be considered as candidates for transurethral treatment. Infertility with duct obstruction can present with low ejaculate volume and azoospermia or low ejaculate volume with decreased sperm density (CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Catalona WJ. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results. J Urol 1988;140:306–310. Catalona WJ. Re: Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results. Editorial. J Urol 1988;140:836. Connell CF, Berger NA. Management of advanced squamous cell carcinoma of the penis. Urol Clin North Am 1994;21(4):745–756. Daseler EH, Hanson BJ, Reimann AF. Radical excision of the inguinal and iliac lymph glands. Surg Gynecol Obstet 1948;87:679–694. Ekstrom T, Edsmyr F. Carcinoma of the penis. A clinical study of 229 cases. Acta Chir Scand 1958;115:25. Frew IDO, Jefferies JD, Swiney J. Carcinoma of the penis. Br J Urol 1967;39:398. Kattan J, Culine S, Drop JP, et al. Penile cancer chemotherapy: twelve years experience at Institut Gustave-Roussy. Urology 1993;42:559–562. McDougal WS. Carcinoma of the penis: improved survival by early regional lymphadenectomy based on the histological grade and depth of invasion of the primary lesion. J Urol 1995;154:1364–1366. McDougal WS, Kirchner FK Jr, Edwards RN, Killian LT. Treatment of carcinoma of the penis: the case for primary lymphadenectomy. J Urol 1986;136:38. Mukamel E, deKernion JB. Early versus delayed lymph-node dissection versus no lymph-node dissection in carcinoma of the penis. Urol Clin North Am 1987;14:707–711. Pedrick TJ, Wheeler W, Riemenschneider H. Combined modality therapy for locally advanced penile squamous cell carcinoma. Am J Clin Oncol 1993;16:501–505. Shammas FV, Ous S, Fossa SD. Cisplatin and 5-fluorouracil in advanced cancer of the penis. J Urol 1992;147:630–632. Skinner DG, Leadbetter WF, Kelley SB. The surgical management of squamous cell carcinoma of the penis. J Urol 1972;107:273. Theodorescu D, Russo P, Zhang A-F, et al. Outcomes of initial surveillance of invasive squamous cell carcinoma of the penis and negative nodes. J Urol 1996;155:1626–1631.

Chapter 68 Peyronie's Disease Glenn’s Urologic Surgery

Chapter 68 Peyronie's Disease Kenneth S. Nitahara and Tom F. Lue

K. S. Nitahara and T. F. Lue: Department of Urology, University of California, San Francisco, California 94143–0738.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Multiple Parallel Plication Plaque Incision and Venous Graft Outcomes Complications Results Chapter References

Peyronie's disease is a fibrous thickening in the tunica of the penis causing abnormal curvature or narrowing in the erect state. The relative inelasticity of the fibrous plaque precludes normal elongation of the tunica albuginea during the transition from the flaccid to the erect state. The plaque is usually located on the dorsal surface of the tunica albuginea, causing curvature in that direction. However, the scar may also be located laterally or ventrally, causing curvature in the direction of the scar. Circumferential scarring of the tunica or involvement of the septum may cause a shortening of the entire erect penis. The severity of curvature may be mild, such that it has no impact on sexual intercourse, or it may be more severe such that sexual intercourse is painful or even physically impossible.

DIAGNOSIS The evaluation of such patients should begin with a thorough history and physical examination with emphasis on erectile function. Information on specific sexual or traumatic events leading to Peyronie's disease should be identified, as well as the duration of symptoms. In the acute phase, an inflammatory reaction may persist for 6 months or more, causing changes in the severity and even direction of angulation; surgical treatment should be postponed until this dynamic phase is complete. Other causes of penile scarring should be identified such as chronic penile intracavernosal injections for impotence. Also, a family history of Peyronie's disease or of Dupuytren's contracture should be identified. Finally, changes in libido or emotional stress related to impotence should be discussed. Although the psychological impact of such a change in sexual function may vary among men, reassurance will always help to establish rapport and confidence in the urologist. The focused physical evaluation begins with home photos of the erect penis. This allows the urologist to assess the character of curvature in the most natural setting. Palpating the stretched penis enables the physician to identify the extent and location of scarring. Plain films or sonography may also be helpful in identifying calcifications within scars. Duplex ultrasonography measures the vascular supply, collateral circulation, and venous drainage before and after intracavernous injection of vasodilators. 1 This also helps to characterize the angulation of the erect penis. Patients with adequate erections after pharmacologic injections are candidates for surgical repair. If venous leakage is suggested, cavernosometry and pharmacocavernosography may be indicated. Patients with identified venous leakage may undergo simultaneous repair.

INDICATIONS FOR SURGERY The indications for surgery in Peyronie's disease include: (a) persistent pain or deformity for more than 12 months after the onset of the disease; (b) poor response to conservative therapy; (c) severe curvature, narrowing, shortening, or distal softening of the penis with or without erectile dysfunction. In the surgical treatment of Peyronie's disease we prefer multiple parallel plication (MPP) on the opposite side of the curvature or plaque incision with venous grafting. Incising rather than excising the fibrous plaque, we have found, results in a stronger repair with a lower incidence of impotence. During informed consent, patients are advised about both procedures. The MPP has the advantages of a relatively short and minimally invasive procedure; however, the penis may be shortened. Conversely, whereas the plaque incision with venous graft procedure is longer and more invasive, the length of the penis is usually maintained. The deep dorsal and saphenous veins are usually used as the venous graft; for the latter, the lower portion is usually chosen because of its superficial location.

ALTERNATIVE THERAPY Alternative therapy to the MPP and incision and venous graft procedure would include observation, which is indicated in mild and evolving Peyronie's disease, medical management (vitamin E 400 to 1,000 IU/day, protaba, or colchicine 2.4 mg/day), or intralesional injections (steroid, verapamil, or a-interferon). Radiation therapy may damage penile erectile tissue and is indicated only in patients with severe penile pain that is resistant to other therapies. There are several approaches to the operative treatment of Peyronie's disease, such as Nesbit wedge resection, in which ellipsoids of tunica albuginea are excised on the side opposite the plaque. The cut edges of the tunica are then closed primarily to decrease the shaft length on the opposite side of the curved penis to allow a straightened penis. 8 For curvatures from Peyronie's disease, the plication procedure can be performed as long as the patient accepts the consequence of a shorter penis. Plaque incision and graft placement are a better procedure for the patient with severe curvature, a short penis, an hourglass deformity, distal flaccidity, penile narrowing or shortening without curvature, and persistent penile pain. Plaque excision and dermal graft placement have also been described; this technique involves excising the tunica involved by scar, followed by grafting a section of dermal tissue on to the surgically created defect. 5 Other autologous tissue and inert substances have been used as grafts. 2,3 and 4 Also, placement of a penile prosthesis has been described by some authors as an option for treating such patients. 6

SURGICAL TECHNIQUE Multiple Parallel Plication This procedure (MPP) is performed under local anesthesia with the patient in the supine position. After the genitalia are prepped and draped in a sterile fashion, an artificial erection is induced with 10 µg of PGE 1 or 30 mg of papaverine using a 28-gauge needle. For dorsal curvature, a longitudinal ventral incision is made to the level of Buck's fascia so that the corpus spongiosum and cavernosum are identified ( Fig. 68-1). Using 2-0 Ticron nonabsorbable braided sutures, full-thickness stitches are placed 2 to 3 mm away from either side of the spongiosum at a point opposite the maximal curvature. Two to three pairs of sutures are usually needed along the length of the shaft. It is important not to grasp too much tissue in each suture because this will result in bunching of the tissue.

FIG. 68-1. Dorsal curve plication. After the tunica has been exposed, place sutures 2 to 3 mm away from the spongiosum in a location opposite the point of maximal curvature. Multiple parallel sutures are recommended because grasping large lengths of tissue in a single bite may cause tissue bunching.

For ventral curvature, a circumcising incision is followed by reflecting the skin of the penis to its base ( Fig. 68-2). With special care taken not to injure the neurovascular bundle, 2-0 Ticron sutures are placed opposite the maximal point of curvature between the deep dorsal vein and the dorsal arteries. Multiple bites of tissue with each suture are used to avoid bunching of the tissue about the suture. If the penis becomes flaccid during the procedure, 0.9% normal saline may be infused with the base of the penis compressed to assess curvature. If the penis remains rigid at the end of the procedure, detumescence with aspiration and/or instillation of phenylephrine HCl (250 to 500 µg) should be performed. The skin is reapproximated with 4-0 chromic sutures, and the penis is wrapped with a lightly compressive dressing, with care taken not to occlude blood flow to and from the glans.

FIG. 68-2. Ventral curve plication. After the tunica and neurovascular structures have been identified, carefully place sutures between the dorsal vein and artery on either side opposite the point of maximal curvature. This should be done under magnified vision.

Plaque Incision and Venous Graft Before surgery, the patient's lower extremities should be evaluated for quality of lower saphenous vein. The decision over which side to use should also be based on size of the vein, history of lower extremity surgery, and chronic pain or edema. The procedure may be performed under local, regional, or general anesthesia in the supine position. After a circumcising incision is made, the skin is reflected to the base of the penis. For patients with a dorsal curvature, the neurovascular bundle is identified, followed by mobilization of the deep dorsal vein along the length of the shaft ( Fig. 68-3). Small tributary veins should be ligated with 3-0 or 4-0 silk sutures and then sharply divided. Perforating veins left unligated will cause troublesome bleeding at the end of the procedure. Mobilization of the dorsal vein should be limited proximally to within about 1 cm of the pubis; more aggressive mobilization will result in postoperative scarring and shortening of the penis. Next, the dorsal vein is ligated with a 2-0 silk suture and sharply divided at the ends of the dissected portions; this portion of vein is saved in normal saline.

FIG. 68-3. Mobilization of the deep dorsal vein. After the neurovascular structures have been identified, incise Buck's fascia directly over the dorsal vein. Further mobilization of the vein with ligation and division of its branches will allow it to be removed and preserved in saline.

The next and most critical part of the procedure is dissection and mobilization of the neurovascular bundle ( Fig. 68-4); this should be done under loupe or magnifying scope vision. The bundle is separated from the surface of the tunica albuginea, with care taken to avoid piercing the tunica. In nonaffected areas of the tunica there is normally a clear plane allowing dissection of the bundle off of the tunica; this plane is routinely obliterated at the area of Peyronie's plaque, making dissection more difficult. Mobilization of the neurovascular bundles should be sufficient that there is some slack with the penis stretched; this is the limiting factor to the eventual length of the penis.

FIG. 68-4. Mobilization of the neurovascular bundle. Using magnified vision, carefully dissect the neurovascular bundles on either side off of the tunica albuginea. These bundles should be mobilized sufficiently that there is some slack when the penis is pulled in the stretched position.

With a 21-gauge needle, normal saline solution is infused into the corpora via a lateral tunical puncture to characterize the abnormal curvature. With this anatomic site noted, the tunica overlying the point of maximal curvature is marked and sharply incised ( Fig. 68-5). The initial incision is transverse through the middle of the scar. These are connected by perpendicular incisions at either end of the initial incision to form an “H” configuration. Cases in which there is concomitant narrowing of the corporal body from scar contracture may require an extra incision at each tip of the “H” configuration; this allows side grafts to be placed to widen the penis. After the incision is made, the size of the defect to be covered is measured by pulling the penis to the stretched position longitudinally and transversely.

FIG. 68-5. Tunical incision. Sharply incise the marked area directly across from the scarred area in an “H” fashion. This will increase the length of the incised side of the penis. Vein graft anastomosis. After the venous segments have been harvested and incised lengthwise, place them side by side with their endothelial side down. These are then anastomosed in a watertight fashion either with 5-0 Maxon or staples. After the graft has been created, it is placed over the defect and sewn into place with a continuous 4-0 Maxon suture.

With this measured area as a guide, the venous graft may now be considered. In general, one length of vein opened lengthwise will provide a stretched width of 1 cm. The preserved dorsal vein may be considered for use, but this is often not sufficient. Additional vein may be obtained from the previously prepped lower saphenous vein by sharply incising the skin directly overlying the vein and then mobilizing the vein and dividing its branches. Be careful with the peripheral nerve branch that runs alongside the vein; blunt injury to this may cause pain, and division may cause numbness. After a sufficient length of vein has been harvested, it can be cut into pieces to fit the specifications. Sharply incise each vein segment lengthwise to create a rectangle of tissue. With the endothelial sides faced down, the pieces of vein are lined up side by side and connected with either a vascular stapler or a 5-0 Maxon suture in a running, locking fashion ( Fig. 68-5). This graft is then sutured to the surgically created defect in the tunica using 4-0 Maxon in a running, locking fashion (Fig. 68-5). This should create a watertight closure. To test the adequacy of repair, inject normal saline into the cavernosal bodies as described above. It is occasionally necessary to make another incision in the tunica and apply a second vascular graft. Placing plication sutures on the ventral surface of the tunica may also be helpful during the healing process, but this is generally not necessary. The neurovascular bundles are repositioned in the dorsal midline with 5-0 Maxon. For ventral plaques, it is important to identify the neurovascular bundles, but their dissection is generally not necessary. Exposure of the plaque mandates dissection of the spongiosum off of the cavernosum. Troublesome bleeding may be encountered if the spongiosum is entered; this is usually resistant to electrocoagulation but may be more easily controlled with suture ligation with 5-0 Maxon. Penile skin closure is done in two layers using 4-0 Vicryl for fascia and 4-0 chromic for skin in an interrupted, simple fashion. A Foley catheter is left to drain the bladder. Xeroform gauze covers the incision, and Coban tape is used as a light compression dressing for control of swelling and hematoma. A scrotal support and ice pack are also helpful in this regard. The leg incision is closed in two layers, using 4-0 Vicryl for both fascia and skin. A dry sterile dressing is used to cover this incision. Patients who have undergone vein grafting are usually admitted to the hospital for an overnight stay. On the first post operative day, Foley catheters are removed, and the patients are discharged to home after demonstrating the ability to urinate. Patients are taught to change their penile dressing at home by reapplying Coban tape in a lightly compressive fashion daily for 10 days. They are specifically instructed to avoid wrapping too tightly, which might compromise blood flow to the glans and penile skin. They are also instructed to abstain from sexual relations for at least 5 weeks.

OUTCOMES Complications Immediate complications may include bleeding and hematoma from the incision sites, persistent edema, wound infection, and necrosis of tissue from excessively tight dressings. The risks of these complications may be minimized by careful attention to basic principles of operative and perioperative antisepsis and postoperative care. Keeping the surgical sites clean is essential, as is maintaining a lightly compressive but not constrictive dressing around the penis for 10 days. We have not found that use of antibiotics for longer than the perioperative period has been of any increased benefit. Patients may also describe a painful erection for up to 2 months and penile numbness for as long as 6 months. These findings are normal in the postoperative period, and patients should be reassured that normal sexual relations will return after the tissue has healed. Patients should also be informed that about 2% of cases have recurrence of Peyronie's disease after this procedure. Finally, erectile dysfunction following surgery may occur in patients who have marginally poor vascular supply to the penis. This is predictable, and at-risk patients should be identified with preoperative evaluation including duplex ultrasonography so that additional management may be planned. Results We have performed more than 50 MPP and 200 plaque incisions combined with venous grafts in the past 6 years. Worsening curvature at the same site was noted in two patients who underwent MPP 6 months and 1 year after surgery, respectively. Three patients had new curvature after plaque incision and venous graft. Interestingly, the sites of deformity were away from the venous graft, suggesting a recurrence rather than progression of the disease. From our animal experiments and histologic studies, we have noted that the venous graft thickened and transformed into a fibroelastic structure similar to the tunica after 3 months. After surgery, all patients had a straight penis or curvature of less than 15 degrees during erection with the exception that less than a handful of cases still had curvature of approximately 30 degrees. Penile narrowing is more difficult to correct. However, many patients still had mild indentations after surgery. In conclusion, Peyronie's disease may be functionally and emotionally disabling to men. An understanding of the concepts and familiarity with the surgical options are important for urologists because up to 1% of the United States population may be affected by this. 7 For patients who are operative candidates, surgical repair may enable them to resume normal sexual activity without pain. We think that the continued use of these surgical techniques is warranted. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.

Brock G, Nunes L, von Heyden B, Martinez-Pineiro L, Hsu GL, Lue TF. Can a venous patch graft be a substitute for the tunica albuginea of the penis? J Urol 1993;150:1306. Das S. Peyronie's disease: excision and autografting with tunica vaginalis. J Urol 1980;124:818. Fallon B. Cadaveric dura mater graft for correction of penile curvature in Peyronie's disease. Urology 1990;35:127. Ganabathi K, Dmochowski R, Zimmern P, Leach GE. Peyronie's disease: surgical treatment based on penile rigidity. J Urol 1995;153:662. Jordan GH, Devine PC, Schlossberg SM, Gilbert DA, Horton CE, Devine CJ Jr. The dermal graft procedure for Peyronie's disease. J Urol 1987;137:220A. Knoll LD. Use of penile prosthetic implants in patients with penile fibrosis. Urol Clin North Am 1995;22:857. Lindsay MB, Schain DM, Grambsch P, et al. The incidence of Peyronie's disease in Rochester, Minnesota, 1950 through 1984. J Urol 1991;146:1007. Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol 1965;93:230.

Chapter 69 Priapism Glenn’s Urologic Surgery

Chapter 69 Priapism Kenneth S. Nitahara and Tom F. Lue

K. S. Nitahara and T. F. Lue: Department of Urology, University of California, San Francisco, California 94143–0738.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Glans–Cavernosal Shunt Al-Ghorab Procedure Quackles Cavernosum–Spongiosum Shunt Cavernosal–Venous Shunts Cavernosum–Dorsal Vein Shunt Postoperative Considerations High-Flow Priapism Outcomes Complications Results Chapter References

Priapism is a persistent, often painful erection that does not subside after ejaculation. Priapism is considered a surgical emergency until proven to be otherwise; in low-flow or ischemic states, patients must be treated immediately. Untreated cases will lead to ischemia, necrosis, and severe scarring of the erectile tissue. After 24 hours there is evidence of irreversible smooth muscle necrosis, destruction of epithelium, and exposure of the basement membrane with thrombocytes adherent to it.

5

Priapism may be classified as high flow or low flow, depending on its etiology. High-flow priapism is often caused by an arteriovenous fistula circulating well-oxygenated blood; this may not need urgent surgical attention. Low-flow priapism is caused by a trapping of poorly oxygenated blood in the cavernosal tissue with associated ischemic damage; these patients must be decompressed as soon as possible.

DIAGNOSIS On initial evaluation, patients should have a complete history and physical, with emphasis on possible causative factors. Physical examination should assess for subtle neurologic defects, pelvic masses, and perineal abnormalities as well as the characteristics of the penis. Patients with significant pain are more likely to have low-flow priapism, but this is certainly not diagnostic. Laboratory tests should include complete blood count, urinalysis, and sickle cell screen as well as evaluation for coagulopathy if indicated. Before any therapeutic attempts, informed consent should be obtained. Patients should understand that there is about a 50% chance of erectile dysfunction regardless of duration of priapism or method of management. Diagnosis of the type of priapism and the management of it should commence as soon as possible ( Fig. 69-1). Aspiration of penile blood may be diagnostic and therapeutic; acidotic, hypoxic blood is likely to indicate veno-occlusion.

FIG. 69-1. Algorithm for the diagnosis and management of priapism.

INDICATIONS FOR SURGERY If medical management is unsuccessful in allowing detumescence of the penis, surgical management should be considered. The immediate goal is to allow blood to flow readily in and out of the penis to prevent ischemic damage.

ALTERNATIVE THERAPY Occasionally, aspirating blood will allow resolution of the erection. a-Adrenergic therapy is often needed and may be used if the priapism has lasted less than 36 hours; after that, damaged smooth muscle will no longer respond to the pharmacologic stimulus. A variety of a agonists have been used; we have had the most success with aspiration plus diluted phenylephrine, 250 to 500 µg every 3 to 5 minutes until detumescence. This therapy is not recommended for high-flow priapism; it is ineffective and may have systemic side effects because the venous channels are wide open.

SURGICAL TECHNIQUE Surgical correction involves connecting the engorged cavernosal tissue with the glans, corpus spongiosum, or dorsal or saphenous vein. This surgically created fistula will allow blood to drain from the corpora cavernosa until the pathologic process has resolved. Ideally, the surgically created fistula will spontaneously close after the priapism-causing factors have resolved. On the basis of these principles, many techniques have been used for the urgent treatment of priapism. We describe the procedures with which we have been most successful, including glans–cavernosum, spongiosum–cavernosum, and cavernosum–venous anastomoses. Distal shunts are attempted first and are followed by more proximal ones if penile detumescence is not achieved. Any shunt used must be tested intraoperatively to assess its success. This is best done by assessing the intracavernosal pressure for 10 to 15 minutes after the completion of the shunt. Placing a pressure-monitoring needle within the corpora will measure the pressure ( Fig. 69-2). A pressure of less than 40 mm Hg for longer than 10 minutes is necessary for a successful shunt. If this is not achieved, then a more invasive procedure must be performed.

FIG. 69-2. After multiple glans–cavernosal shunts, monitoring intracavernosal pressure for 10 minutes after closure to ensure a pressure of 50 ml/min of saline to maintain a rigid erection at an intracorporeal pressure of at least 90 mm Hg is indicative of corporal veno-occlusive dysfunction. A maintenance flow rate between 30 and 50 ml/min is considered to be borderline for venous leakage. Contrast material is infused into the corpora at the defined maintenance flow rate, and then AP and oblique radiographs of the penis are taken. The most common sites of venous leakage seen in patients with veno-occlusive dysfunction are the deep dorsal vein, the cavernosal veins, and the circumflex veins at the base of the penis.

FIG. 71-1. Penile venous anatomy.

INDICATIONS FOR SURGERY Patients must meet strict criteria to be selected for venous surgery. Candidates must first have a history that is consistent with venous leak impotence, corroborated by duplex Doppler sonography and intracavernosal test injection findings. Other causes of impotence should be ruled out. Normal penile arterial inflow must also be documented in response to an intracavernosal injection agent because patients with concomitant arterial disease often have a poor outcome after venous surgery. Cavernosometry and cavernosography must confirm veno-occlusive dysfunction and outline the sites of leakage. Patients should have no medical contraindications to surgery. There is no strict age limit, but we prefer to perform venous surgery on patients less than 65 years old. Patients need to eliminate all tobacco use at least 6 months before surgery. Finally, patients must select venous surgery after presentation of alternative forms of therapy and discussion of expected success rates. We also perform venous surgery in conjunction with penile arterial revascularization in select patients with both focal arterial disease and veno-occlusive dysfunction. 8

ALTERNATIVE THERAPY Patients with venous leak impotence have some effective surgical and nonsurgical options to consider along with penile venous dissection and ligation. Vacuum erection devices create an adequate erection by drawing blood into the penis with negative pressure in the vacuum tube. A constriction band placed at the base of the penis prevents outflow of blood and substitutes for a faulty veno-occlusive mechanism. Self-injection of intracavernosal vasodilating agents at high doses can often produce a functional erection in patients with mild to moderate venous leak. Patients with severe leakage, however, will most often not respond to injection therapy. Combining self-injection with a constriction band is also helpful in maintaining an erection in some patients. Implantation of a penile prosthesis effectively replaces the natural veno-occlusive mechanism with a mechanical device capable of producing a sufficiently rigid erection. A goal-directed approach is used to help the patient select an appropriate form of therapy.

DESCRIPTION OF PROCEDURE Patients are admitted to the hospital on the day of surgery. They receive a dose of intravenous cephalosporin antibiotic 1 hour before surgery. Surgery is performed under either general intubated or spinal anesthesia. Patients are positioned supine with legs abducted to allow easy access to the perineum. If crural ligation and banding are planned as part of the operative procedure, then a dorsal lithotomy position is preferred. A lighted suction device can facilitate illumination of the deep

infrapubic dissection. An intraoperative Doppler probe can be helpful in localizing small arteries in this region. We do not routinely use optical magnification for the dissection. The operative field is prepped and draped in a sterile fashion from the umbilicus to the perineum, and an 18-Fr Foley catheter is placed for the purpose of bladder drainage and improved urethral identification. An infrapubic curvilinear anterior peripenile scrotal incision is made with a #15 blade ( Fig. 71-2). The superior extent of the incision is the inferior border of the pubis, and the inferior extent is the median raphe of the scrotum below the penile shaft. Superficial tissue is dissected free of the corporal bodies with sharp and blunt dissection. Communicating veins joining the deep and superficial drainage systems are isolated, ligated with 3-0 plain gut suture on a reel, and divided. The penile skin is then stripped away from the shaft, and the penis is inverted into the wound to gain exposure to the superficial and deep venous systems ( Fig. 71-3). Any other venous trunks of the superficial system that receive tributaries from the corpora are ligated with absorbable suture material and divided at this time ( Fig. 71-4).

FIG. 71-2. Peripenile scrotal incision for penile venous surgery.

FIG. 71-3. Inversion of the penile shaft into the wound.

FIG. 71-4. Ligation of superficial veins with connections to the corpora.

A 19-gauge butterfly needle is placed into the base of the corpus cavernosum and fixed in place to the tunica albuginea with a 3-0 chromic suture ( Fig. 71-5). The cavernosal tissue receives an injection of 30 mg of papaverine, followed 10 minutes later by indigo-carmine-colored saline (12 ml in 250 ml of saline) to help visualize abnormally effluxing veins. The butterfly needle tubing is clamped for the duration of the procedure and is used again after the dissection to perform intraoperative cavernosometry. A $-inch Penrose drain is looped around the penile shaft between the corpora. The penile skin near the glans is clamped to the Mayo stand to retract the penile skin, elongate and stabilize the penile shaft, and afford exposure for the proximal dissection. The superficial fundiform ligament is identified at the base of the penis and is divided to expose the suspensory ligament. The suspensory ligament is then sharply divided close to the underside of the pubic symphysis ( Fig. 71-6). The suspensory ligament must be completely taken down to expose the deep infrapubic region. Care is taken to identify and divide small veins emanating from the underside of the pubis and joining the superficial drainage system as well as veins perforating Buck's fascia to connect the deep and superficial systems at this level. Failure to ligate these vessels can lead to significant bleeding, which can be difficult to control and can obscure exposure for the proximal portion of the venous dissection.

FIG. 71-5. Placement of a butterfly needle for intraoperative cavernosometry.

FIG. 71-6. The suspensory ligament is divided to expose the base of the penis.

Deep in the infrapubic region, Buck's fascia is opened in the midline over the deep dorsal vein. The vein usually has a single large main trunk at this level. The deep dorsal vein is dissected free of the tunica albuginea, ligated with 0 silk ties, and divided ( Fig. 71-7). Inferior to the deep dorsal vein, the cavernosal veins can be identified in the penile hilum at this time. They may be divided if they are a major source of leakage. Great care is taken to preserve the cavernosal arteries and nerve trunks that lie lateral to these veins. If the deep dorsal vein is a significant source of abnormal penile drainage, then it is dissected from the infrapubic region along the penile dorsal midline under Buck's fascia distally toward the glans. It is important to stay in the midline during the dissection to avoid the laterally located dorsal arteries and nerves. Circumflex and emissary veins encountered on either side of the deep dorsal vein are ligated with 3-0 plain gut suture and divided ( Fig. 71-8). Bipolar electrocoagulation on low setting can be used to cauterize some small vessels along the shaft. Sometimes the deep dorsal vein is composed of two trunks along the penile shaft, and each must be dissected separately. Dissection continues until several fanning tributaries constitute the deep dorsal vein approximately 1 cm from the glans. Rarely, a large vein arises from the tunica albuginea and penetrates Buck's fascia to join the deep dorsal vein. Ligation of this vein creates a sinusoidal defect in the tunica, which must be closed with a 3-0 chromic figure-of-eight suture ligature. The junction between the corpora cavernosa and the spongiosum is carefully inspected as well, and circumflex veins connecting the two structures are ligated and divided.

FIG. 71-7. Division of the deep dorsal vein in the infrapubic region.

FIG. 71-8. Division of circumflex and emissary veins on both sides of the deep dorsal vein.

After vein dissection and ligation are completed, 30 mg of papaverine is injected into the corpora via the butterfly needle, and cavernosometry is performed 10 minutes later. If the abnormal draining veins have been eliminated, then a rigid erection is easily maintained at a flow of saline considerably less than 5 ml/min ( Fig. 71-9). Following this, the suspensory ligament is reapproximated with a 0 silk suture ligature between the infrapubic periosteum and the penile shaft. A #10 Jackson-Pratt fenestrated bulb suction drain is then placed in the wound with the tubing exiting via a separate stab incision lateral to the surgical incision. The subcuticular tissue is closed with a running 3-0 chromic suture, with care taken to approximate equal tissue planes to minimize the chance of scar formation resulting in fixation of the base of the penis. The skin edges are then reapproximated with a running subcuticular 3-0 Monocryl suture. The wound is covered with a standard sterile dressing, and the penis is snugly wrapped with a self-adherent Coban wrap. Care is taken to avoid glanular edema from a dressing that is too tight. The Foley catheter and the dressing are removed the day after surgery. The drain is removed as soon as drainage is negligible, usually in 24 to 48 hours. Patients are discharged from the hospital on the second or third postoperative day. They are advised against engaging in intercourse for 6 weeks.

FIG. 71-9. Cavernosometry after completion of the dissection confirms correction of the venous leak.

If the crural veins are found to be the only source of major venous leakage by cavernosography, we perform a crural banding procedure. The crura are exposed near the bulb of the urethra via a perineal incision, and a $-inch Mersilene ribbon (Ethicon, Inc.) is used to band the crura ( Fig. 71-10). Veins draining from the edge of the crura are ligated as well. Crural banding is not routinely performed at the time of deep dorsal vein ligation and is usually a secondary procedure. Another secondary

procedure that is rarely employed is spongiolysis. Via a penile scrotal incision, the corpus spongiosum is exposed and stripped away from the ventral surface of the corpora cavernosa. All communications between the two structures are ligated or coagulated.

FIG. 71-10. Crural banding to correct venous leakage from crural veins.

OUTCOMES Complications Table 71-1 lists the complications that have been encountered after penile venous surgery. 9 Complications can be divided into immediate and long-term. Most patients experience some superficial bruising of the shaft and scrotum. Penile edema is usually moderate and resolves within 2 to 3 weeks. The incidence of penile edema has decreased since our use of a compression dressing and a closed wound drainage system. Painful nocturnal rections often occur for the first 24 to 48 hours after surgery. Infrequently, they may last for longer than 1 week. Wound infection and true hematoma rarely occur. Care taken during the infrapubic portion of the dissection can eliminate the risk of postoperative hematoma.

TABLE 71-1. Complications of penile venous surgery

Despite careful reapproximation of the suspensory ligament after the vein dissection is complete, approximately 20% of patients complain of penile shortening. The amount of perceived loss of length, however, is rarely clinically or functionally significant. Hypoesthesia or numbness of the glans or shaft of the penis is a common occurrence after surgery. Patients who report a loss of sensation often experience a diminished ability to achieve orgasm as well. In most cases, though, penile sensation returns completely within 7 to 9 months. Infrequently, wound scar contractures occur that lead to true penile tethering. In these cases, revision surgery is necessary, consisting of release of scar tissue and skin Z-plasty. Results Although individual reports of successful vein ligation procedures date back to the early 1900s, the modern era of penile venous surgery did not begin until the development of accurate and appropriate diagnostic and surgical techniques. A number of surgeons have since reported on the initial and long-term success rates for this procedure. Donatucci and Lue reported on 100 patients operated on between 1986 and 1988. 2 Forty-four patients (44%) had an excellent result, defined as a complete return of spontaneous erections rigid enough for penetration, and 24 patients (24%) noted some improvement in rigidity. All patients were followed for longer than 1 year after surgery. Knoll et al. reported a 46% excellent response to surgery in 41 patients followed for an average of 28 months. 4 Claes and Baert similarly reported a return of normal erectile function in 30 of 72 patients (42%) and a partial response in 23 others (32%). 1 Patients were all followed for more than 1 year. Lewis recently reported on 60 patients, of whom 16 (27%) initially had return of normal erections. 8 Seventeen other patients (28%) experienced improved rigidity and were able to have intercourse with the aid of intracavernosal pharmacologic injections for a combined success rate of 55%. All patients were followed for at least 2 years. Over time, 13 of the 33 patients (39%) who initially experienced a successful result later reported failure of the procedure. Kropman et al. also reported a 40% late failure rate at a mean follow up of 28 months in 10 of 20 patients who initially experienced a successful result from surgery. 5 Several different factors can account for the approximately 40% failure rate of penile venous surgery. Inability to accurately diagnose concomitant arterial disease and less extensive venous dissection probably account for many of the early patient failures in the series reported above. With the use of stricter diagnostic inclusion criteria and a more aggressive surgical approach, many of these early failures could have been avoided. The development of collateral venous circulation is the most likely cause of late failure in patients who experience immediate postoperative success. Collateralization has limited the long-term success rates of other types of venous surgery as well. A final reason for failure is that the ligation of penile veins may not address the true underlying pathologic disorder in many patients. Sinus smooth muscle disease that prohibits the expansion of the tunica albuginea and the subsequent compression of subtunical venules have been postulated as a major cause of veno-occlusive dysfunction. 10 To date, though, no practical test is available to accurately diagnose this entity. Penile venous surgery remains a reasonable surgical option for highly selected patients with venous leak impotence. CHAPTER REFERENCES 1. Claes H, Baert L. Cavernosometry and penile vein resection in corporeal incompetence: An evaluation of short-term and long-term results. Int J Impotence Res 1991;3:129. 2. Donatucci CF, Lue TF. Venous surgery: Are we kidding ourselves? In: Lue TF, ed. World book of impotence. London: Smith-Gorthdon and Co, 1992;221–227. 3. King BF, Lewis RW, McKusick MA. Radiologic evaluation of impotence. In: Bennett AH, ed. Impotence. Diagnosis and management of erectile dysfunction. Philadelphia: WB Saunders, 1994;52–91. 4. Knoll LD, Furlow WL, Benson RC. Penile venous ligation surgery for the management of cavernosal venous leakage. Urol Int 1992;49:33. 5. Kropman RF, Nijeholt AABL, Giespers AGM, Swarten J. Results of deep penile vein resection in impotence caused by venous leakage. Int J Impotence Res 1990;2:29. 6. Lewis RW. Diagnosis and management of corporal veno-occlusive dysfunction. Semin Urol 1990;8:113. 7. Lewis RW. Venogenic impotence. Diagnosis, management, and results. Probl Urol 1991;5:567. 8. Lewis RW. Venous surgery in the patient with erectile dysfunction. Atlas Urol Clin North Am 1993;1:21. 9. Petrou S, Lewis RW. Management of corporal veno-occlusive dysfunction. Urol Int 1992;49:48. 10. Wespes E, Moreira De Goes P, Sattar AA, Schulman C. Objective criteria in the long-term evaluation of penile venous surgery. J Urol 1994;152:888.

Chapter 72 Penile Arterial Reconstruction (Penile Revascularization) Glenn’s Urologic Surgery

Chapter 72 Penile Arterial Reconstruction (Penile Revascularization) John Mulhall and Irwin Goldstein

J. Mulhall: Department of Urology, Loyola University Medical Center, Maywood, Illinois 60153. I. Goldstein: Boston Medical Center, Boston, Massachusetts 02118.

Diagnosis Indications for Surgery Operative Technique Dorsal Artery Dissection Penile Inversion Preparation of Recipient Dorsal Arteries Harvesting of the Inferior Epigastric Artery Microvascular Anastomosis Outcomes Complications Results Chapter References

Erectile dysfunction is defined as the consistent inability to obtain or maintain a penile erection satisfactory for sexual relations. Community epidemiologic studies have revealed that 52% of men age 40 to 70 years have self-reported (17%), moderate (25%), and complete (10%) forms of impotence. Nonsurgical treatment options for impotence include psychotherapeutic, hormonal, pharmacologic, and external device interventions. 4 Surgical treatment options consist primarily of penile prosthesis insertion, microvascular arterial bypass surgery, and, until recently, surgery for corporovenous occlusive dysfunction. 1 This latter surgery has been demonstrated to have poor long-term success rates and we no longer perform venous leak surgery. Penile revascularization is currently the only modality of therapy that has the potential to permanently cure patients, i.e., allow return of spontaneously developing erections without the necessity for any internal or external devices. This procedure has undergone many refinements since its first description by Michal in 1973. 5,6 Many variations have been described by workers such as Virag, Hauri, Crespo, and Goldstein. 3 We are currently utilizing one primary procedure involving anastomosis of the inferior epigastric artery to one or both dorsal arteries of the penis. The overall goal of penile revascularization surgery is to bypass obstructive arterial lesions in the hypogastric-cavernous arterial bed. The specific objective of the surgery is to increase the cavernosal arterial perfusion pressure and blood inflow in patients with vasculogenic erectile dysfunction secondary to pure arterial insufficiency. Young men, without other vascular risk factors, who have erectile dysfunction of a pure arteriogenic nature represent the ideal patient population for this procedure, and the investigation and preoperative evaluation of these patients are aimed at ensuring adequacy of hormonal status, neurologic function, and corporovenous occlusive function.

DIAGNOSIS The diagnostic algorithm is aimed at ensuring that this operation is performed on the ideal candidate, i.e., one in whom there is erectile dysfunction purely on the basis of arterial insufficiency. All young patients with a history suggestive of trauma-associated impotence (pelvic fractures and perineal trauma) undergo a comprehensive history and physical examination. They have a routine endocrinologic evaluation to ensure adequate circulating levels of testosterone. These patients undergo a nocturnal penile tumescence test in an attempt to rule out neurogenic and psychogenic erectile dysfunction. Finally, they are required to have hemodynamic assessment by dynamic infusion cavernosometry/cavernosography (DICC), although other workers have used duplex Doppler ultrasonography for the same purpose. The criteria for the definition of pure arteriogenic erectile dysfunction are beyond the scope of this chapter and have been outlined elsewhere. 2 The purpose of the testing is to rule out corporovenous occlusive dysfunction. Following hemodynamic diagnosis, if the patient has pure arterial insufficiency, a selective internal pudendal arteriogram is performed to define the arterial anatomy and confirm the location of the obstructive lesion, which is generally in the common penile or cavernosal artery(ies). Only following this complete evaluation do we perform a penile revascularization procedure.

INDICATIONS FOR SURGERY The success of this operation is based on the selection of the correct candidate and the microsurgical capabilities of the surgeon. To this end, we have developed a list of criteria that the patient and surgeon must meet to ensure optimum results. The criteria are as follows: The patient's history is characterized by (a) strong libido, (b) a consistent reduction in erectile rigidity during sexual activity, (c) increased erection rigidity during morning erections, (d) variable sustaining capability with the best maintenance of the rigidity during early morning erections, and (e) poor spontaneity of erections, taking much effort and excessive time to achieve the poorly rigid erectile response. Normal hormonal evaluation. Normal neurologic evaluation. Increased arterial gradients during cavernosal artery occlusion pressure determination at the time of DICC, indicative of arterial insufficiency. Normal venoocclusive parameters (flow-to-maintain values, pressure decay values) during DICC. The presence of an occlusive lesion in one or both hypogastric-cavernous arterial beds, located in the common penile artery or cavernosal artery that is amenable to distal bypass. The presence of an inferior epigastric artery of sufficient length to allow anastomosis to the dorsal artery. The presence of a communication branch(es) between the dorsal artery and the cavernosal artery distal to the occlusion that will allow the inflow of new blood flow and the development of increased intracorporal pressure. The development of surgical skills allowing strict adherence to operative microsurgical principles, namely, (a) avoidance of any mechanical trauma to the donor or recipient arteries due to twisting or excessive stretching; (b) avoidance of any thermal changes due to electrocautery, exposure to cold irrigants, or drying from exposure to air; (c) avoidance of ischemia resulting from compression or excessive adventitial dissection; and (d) meticulous microsurgical anastomotic technique. Avoidance of any penile trauma, such as may occur during masturbation or a sexual encounter, for a period of 6 weeks postoperatively to avoid disruption of the anastomosis. As this is elective surgery, options include observation and continued impotence or the insertion of penile prostheses.

OPERATIVE TECHNIQUE As the candidates are young men, there is no necessity for preoperative testing other than that outlined above. In the operating room, the patients are placed supine on the operating table and their legs are placed in the frog-leg position. As this operation may last in excess of 6 hours, great care must be taken in the positioning and padding of the limbs, particularly the neurovascular points on the upper limbs. We have had one patient who developed a transient postoperative ulnar palsy due to protracted pressure on his medial epicondylar area. It is our policy now to instruct the anesthesiologist to move the arms around and alternate the position of the blood pressure cuff periodically throughout the procedure. Either general endotracheal or regional anesthesia may be used. It is our policy also to have the arteriograms in the operating room so that we can refer to them intraoperatively if necessary. Once in the operating room the patient's abdomen and genitalia are carefully shaved and he is given one dose of preoperative antibiotics. Once the patient is prepped and draped, a 16-Fr Foley catheter is placed using sterile technique and the bladder is drained of urine. From a technical standpoint, the operation can be divided into three stages: dorsal artery dissection, inferior epigastric artery harvesting, and microsurgical

anastomosis. Dorsal Artery Dissection A curvilinear incision is made, generally on the side opposite to the planned abdominal incision for inferior epigastric artery harvesting ( Fig. 72-1). The incision is made 2 fingerbreadths from the base of the penis, from a point opposite the ventral root of the penis, to the scrotal median raphe. This incision is carried down through the dartos layer using cautery. The advantages of this incision are that it offers (a) excellent proximal and distal exposure of the penile neurovascular bundle, (b) the ability to preserve the fundiform and suspensory ligaments, and (c) the absence of unsightly postoperative scars on the penile shaft or at the base of the penis. Use of a ring retractor with its elastic hooks maximizes operative exposure of the penis with a minimum of assistance.

FIG. 72-1. Inguinoscrotal incision.

Penile Inversion The ipsilateral tunica albuginea is subsequently identified at the midpenile shaft. With the penis stretched, blunt finger dissection along the tunica albuginea is performed in a distal direction deep to the spermatic cord structures along the lateral aspect of the penile shaft avoiding injury to the fundiform ligament. The penis is then inverted through the skin incision, with care taken to push the glans in fully ( Fig. 72-2). The penis must not be tumesced during this maneuver. If a partial erection is present, intracavernosal a-adrenergic agonist (100 µg phenylephrine) should be administered. Blunt finger dissection around the distal penile shaft enables a plane to be established between Buck's fascia and Colles' fascia, and a Penrose drain is secured in this plane.

FIG. 72-2. Penile inversion.

Preparation of Recipient Dorsal Arteries Exposure of the neurovascular bundle and, in particular, the right and left dorsal penile arteries is now performed. The arteries are usually obvious, located on either side of the deep dorsal vein. Isolation of the dorsal penile arteries for such arterial bypass surgery requires limited dissection at this time in the procedure; thus ischemic, mechanical, and thermal trauma to the dorsal penile arteries may be minimized. To avoid injurious vasospasm, topical papaverine hydrochloride irrigation is applied frequently. In this way, reservation of endothelial and smooth muscle cell morphology during dorsal artery preparation is ensured. This is very critical as the room temperature of the operating room, the use of room temperature irrigating solution, and even the skin incision can induce vasoconstriction, spasm, and possible endothelial cell damage. For intraluminal irrigation, we utilize a dilute papaverine, heparin, and electrolytic solution believed to be capable of inhibiting the early development of myointimal proliferative lesions during surgical preparation. The right and left dorsal penile arteries are identified first in the midpenile shaft. Their course is followed proximally underneath the fundiform ligament, with care being taken to leave the fundiform ligament intact. A fenestration is fashioned in the fundiform ligament proximally, usually near the junction of the fundiform and suspensory ligaments at a location where the pendulous penile shaft becomes fixed proximally ( Fig. 72-3). Blunt dissection is performed under the proximal aspect of the fundiform ligament above the pubic bone toward the external ring. This dissection enables the inferior epigastric artery to pass from its abdominal location to the appropriate location in the penis while simultaneously preserving the fundiform ligament.

FIG. 72-3. Fenestration of the fundiform ligament.

Harvesting of the Inferior Epigastric Artery Abdominal Incision The inguinoscrotal incision is temporarily closed with staples. A unilateral abdominal incision is made and can be transverse or paramedian in its disposition ( Fig. 72-4). The transverse incision provides excellent operative exposure of the inferior epigastric artery and heals with a more cosmetic scar compared to those observed

with paramedian skin incisions. The starting point of the transverse incision is approximately three-quarters of the total distance from the pubic bone to the umbilicus in the midline. It extends laterally along the skin lines for approximately 4 fingerbreadths. The rectus fascia is incised vertically. The junction between the rectus muscle and underlying preperitoneal fat is identified and the preperitoneal space is entered. The rectus muscle is reflected medially.

FIG. 72-4. Abdominal incision for harvesting epigastric artery.

Inferior Epigastric Artery Dissection The inferior epigastric artery and its two accompanying veins are located beneath the rectus muscle in the preperitoneal plane. The ring retractor is again utilized to optimize operative exposure. It is critical to harvest an inferior epigastric artery of sufficient length to prevent tension on the microvascular anastomosis. Application of topical papaverine is utilized on the inferior epigastric artery throughout the dissection. Thermal injury is avoided using low current microbipolar cautery set at the minimum level necessary for adequate coagulation and the vasa vasora are preserved by dissecting the artery en bloc with its surrounding veins and fat. Dissection of the inferior epigastric is required from its origin at the level of the external iliac artery to a point at the level of the umbilicus ( Fig. 72-5). It is at this point that the artery bifurcates. We make every effort to use the bifurcation where possible to allow anastomoses to both dorsal arteries.

FIG. 72-5. Inferior epigastric artery dissection.

Inferior Epigastric Artery Transfer The transfer route of the neoarterial inflow source is prepared from the abdominal perspective prior to transecting the vessel distally (the penile transfer route has previously been dissected) ( Fig. 72-6). The temporary scrotal staples are removed and the penis is reinverted. The internal ring on the side of the harvested artery is identified lateral to the origin of the inferior epigastric artery. Using blunt finger dissection through the inguinal canal, a long fine vascular clamp is passed through the fenestration in the fundiform ligament, the external and internal inguinal rings, and a Penrose drain is placed to protect this transfer route.

FIG. 72-6. Inferior epigastric artery transfer.

The donor vascular bundle is transected at the level of the umbilicus between two Ligaclips and is carefully inspected for any proximal bleeding points. The long fine vascular clamp is brought through the internal inguinal ring again, this time to grasp the end of the transected inferior epigastric artery. The inferior epigastric vascular bundle is transferred to the base of the penis. It should be briskly pulsating and of adequate length. The origin of the inferior epigastric artery should be inspected for kinking or twisting. Following the achievement of complete hemostasis, closure of the abdominal wound is performed in two layers. The rectus fascia is closed utilizing a running 0 polyglycolic acid suture, one suture started at either end of the incision. The skin edges are apposed using skin staples. Microvascular Anastomosis Vessel Preparation A ring retractor and the associated elastic hooks are utilized once again on the inguinoscrotal incision and the fenestration of the fundiform ligament to gain exposure of the proximal dorsal neurovascular bundle. The pulsating inferior epigastric artery is placed against the recipient dorsal penile arteries and a convenient location is selected for the vascular anastomosis. The anastomosis (or anastomoses) is(are) created based on the arteriographic findings. An end-to-side anastomosis is best under conditions whereby dorsal penile artery communications exist to the cavernous artery. Furthermore, an end-to-side anastomosis protects arterial blood flow in the distal direction to the glans penis. It has been our experience, however, that ligation of both dorsal penile arteries to perform bilateral proximal end-to-end anastomoses has not ever caused ischemic injury to the glans penis. The appropriate dorsal penile artery segment is freed from its attachments to the tunica albuginea, with care being taken to avoid injury to any communicating branches to the cavernosal artery. Vascular hemostasis of this segment of the dorsal penile artery may be achieved with either gold-plated (low-pressure) ( Fig. 72-7) aneurysm vascular clamps or vessel loops under minimal tension for the minimal of operating time. The only location where the adventitia must be carefully removed

is at the site of the vascular anastomosis, i.e., the distal end of the inferior epigastric artery and the selected region of the dorsal penile artery, in order to avoid causing subsequent thrombosis. If segments of adventitia enter the anastomosis patency of the anastomosis is in jeopardy, as adventitia activates clotting factors from the extrinsic clotting system. The remaining adventitia should be preserved in the vessels as the vasa vasorum provide a nutritional role to the vessel wall. The preservation of the adventitia is additionally important in terms of vessel innervation.

FIG. 72-7. Preparation of vessel for microvascular anastomosis.

Anastomotic Technique Under microscopic control at 5–10× magnification, a 10-0 suture (single-armed, 100-µm, 149 degree curved needle) is placed along the longitudinal axis of the dorsal penile artery in a 1-mm segment in the region of the intended anastomosis. After placing tension on the suture, an oval section of the artery wall is excised with curved microscissors resulting in a 1.2- to 1.5-mm horizontal arteriotomy ( Fig. 72-8). We use a plastic colored background material to aid in vessel visualization under the microscope. A temporary 2-Fr silastic stent is placed within the arteriotomy for clearer definition of the vessel lumen.

FIG. 72-8. Microsurgical anastomosis with sutures in place.

An end-to-side anastomosis is performed between the inferior epigastric artery and the dorsal artery using interrupted 10-0 nylon sutures under the 5-10× magnification. The sutures are placed initially at each apex of the anastomosis and then subsequently three to five interrupted sutures are placed into each side wall (Fig. 72-8). All sutures used to complete the anastomosis are inserted equidistant from each other to avoid an uneven anastomosis. One side of the anastomosis is completed prior to commencing the other side. If a temporary vascular stent is used, it is removed following placement of all sutures. The use of a temporary vascular stent enables careful inspection of the vessel back wall. Following release of the temporary occluding vascular clamps (or vessel loops) on the dorsal penile artery, the anastomosed segment should reveal arterial pulsations along its length and retrograde into the inferior epigastric artery. Such an observation implies a patent anastomosis. At this time, the inferior epigastric artery gold-plated aneurysm clamp may be removed. The intensity of the arterial pulsations in the anastomosis usually increases. Occasionally, the application of a small amount of hemostatic material may be needed to aid in promoting hemostasis from suture needle holes in the vessel walls. After complete hemostasis has been achieved and correct instrument and sponge counts are assured, closure of the inguinoscrotal incision may begin. The dartos layer is reapproximated using a 3-0 polyglycolic acid suture in a running fashion. The skin edges are closed with skin staples. The Foley catheter is left to closed-system gravity drainage overnight. Modifications of the above-described procedure may be utilized. The most common alternative arterial anastomosis is an end-to-end anastomosis between the inferior epigastric artery and the ligated proximal end of the dorsal penile artery. Depending on the site of the arterial communication from the dorsal penile artery to the cavernosal artery, the end-to-end anastomosis may also be anastomosed to the distal ligated end of the dorsal penile artery. It is also most common to anastomose the opposite dorsal penile artery to the inferior epigastric artery. This can be done with an appropriately sized distal branch of the inferior epigastric artery end-to-side as previously described.

OUTCOMES Complications Mechanical disruption of the microvascular anastomosis and subsequent uncontrolled arterial hemorrhage may occur from blunt trauma in the first few postoperative weeks following coitus, masturbation, or from accidents. We recommend abstention from sexual activities involving the erect penis until 6 weeks postoperatively. Other complications include penile pain and diminished penile sensation from injury to the nearby dorsal nerve. 7 Loss of compliance of the suspensory and fundiform ligaments postoperatively may lead to diminished penile length. Preserving the two ligaments has markedly minimized those complications in our series. Glans hyperemia, once a complication seen when inferior epigastric artery to deep dorsal vein anastomoses (dorsal vein arterialization) were performed, is no longer seen because we no longer perform this form of anastomosis.3 Results We have reported on the objective postoperative hemodynamic status including steady-state equilibrium intracavernosal pressures, venoocclusive and arterial function testing parameters, in patients who experienced successful as well as unsuccessful clinical results following microvascular arterial bypass surgery for impotence. Of the 226 patients who underwent penile microvascular arterial bypass surgery from 1985 to 1992, 68 (30%) (mean age 34 ± 10 years) underwent both preoperative and postoperative pharmacocavernosometry/graphy. The mean duration between the bypass procedure and follow-up postoperative testing was 8 ± 6 months. Surgical bypasses in these 68 patients included 65 inferior epigastric artery to dorsal penile artery including 30 with dual dorsal arterial anastomoses. There were, in addition, 9 artery-to-deep-dorsal-vein anastomoses including 6 performed in conjunction with an arterial anastomosis. Forty-nine patients (72%) had concomitant venous surgery for venoocclusive dysfunction (46 deep dorsal vein excisions, 35 crural placation, 19 cavernosal vein ligations, and 3 spongiolyses). Twelve patients (21%) with pure arteriogenic impotence had a postoperative mean increase in steady-state equilibrium intracavernosal pressure of 25 ± 12.3 mm Hg (range 13 ± 45 mm Hg). Of the remaining 56 patients, 49 had concomitant venous surgery. In this latter group, there was no significant change in mean steady-state

equilibrium intracavernosal pressure (38 ± 20 mm Hg preoperative and 43 ± 17 mm Hg postoperative), mean pressure decay in 30 seconds (67 ± 9 mm Hg preoperative versus 64 ± 26 mm Hg postoperative) or mean flow-to maintain values (38 ± 36 ml/min preoperative versus 28 ± 28 mm Hg postoperative). The remaining 7, who did not have venous surgery, had normal venoocclusive function pre- and postoperatively; however, the postoperative intracavernosal pressure did not increase (54 ± 22 mm Hg preoperatively; 58 ± 27 mm Hg postoperatively). 3 On review of the recent literature, there has been reported a variable success rate following penile revascularization, ranging from 30% to 74%. One of the problems in interpreting these data is that there exists no standardization of the definition of success following this operation. Success has been variably defined by questionnaire, patient interview, and hemodynamic evaluation. Furthermore, the patient populations have been heterogeneous with varying numbers of patients with venogenic impotence. We no longer offer this operation to patients with venous leak. The third problem with the literature to date is the inclusion in reported series of dorsal vein arterialization procedures, which we believe to have success rates inferior to procedures utilizing pure arterial anastomoses. Finally, most of the studies have involved short periods of follow-up ranging from 16 to 36 months. The most recent study had a short-term success rate of 80% and long-term (up to 5 years) success rate of 64%, utilizing strict patient selection criteria. To evaluate this operation as a valid management strategy, prospective analysis of patient outcomes is essential. There should be a standardization of success definition, follow-up techniques, and patients need to be followed long-term postoperatively. The goal of the operation is to restore natural, spontaneously occurring erections without the aid of any internal or external means to young men with erectile dysfunction. Much research is needed to define why a significant number of men continue to fail to respond to penile revascularization. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Goldstein I. Arterial revascularization procedures. Semin Urol 1986;4:25.2. Goldstein I. Vascular diseases of the penis. In: Pollack HM, ed. Clinical urography. 3rd ed. Philadelphia: WB Saunders, 1990;2231–2252. Hatzichristou DG, Goldstein I. Arterial bypass surgery for impotence. Curr Opin Urol 1991;1. Krane RJ, Goldstein I, Saenz de Tejada I. Impotence. N Engl Med J 1989;321:1648–1659. Michal V, Kramer R, Popischal J, Hejhal L. Direct arterial anastomosis on corporal cavernosa penis in therapy of erectile dysfunction. Rozhl Chir 1973;52:587–590. Michal V, Kramer R, Popischal J. Femoropudendal bypass, internal iliac thrombendarterectomy and direct arterial anastomosis to the cavernous body in the treatment of erectile impotence. Bull Soc Int Chir 1974;33:341–345. 7. Zorgniotti AW, Lizza EF. Complications of penile revascularization. In: Zorgniotti AW, Lizza EF, eds. Diagnosis and management of impotence. Philadelphia: BC Decker, 1991.

Chapter 73 Penile Trauma Glenn’s Urologic Surgery

Chapter 73 Penile Trauma David M. Nudell, Allen F. Morey, and Jack W. McAninch

D. M. Nudell: Department of Urology, University of California, San Francisco, California 94140. A. F. Morey: Department of Surgery (Urology Service), Uniformed Services University of the Health Sciences, and Brooke Army Medical Center, San Antonio, Texas 78258. J. W. McAninch: Department of Urology, University of California, and San Francisco General Hospital, San Francisco, California 94110. The opinions expressed herein are those of the authors and are not to be construed as reflecting the views of the Armed Forces or the Department of Defense.

Penile Rupture Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Penile Skin Loss Indications for Surgery Alternative Therapy Surgical Technique Outcomes Penetrating Penile Trauma Diagnosis Indications for Surgery and Alternative Treatments Surgical Technique Outcomes Chapter References

Trauma to the penis occurs from both blunt and penetrating injury. Such injuries present unique and difficult management problems to the urologic surgeon, including overall cosmesis, micturition, and future potency. Major blunt penile injuries include penile rupture and skin loss from strangulation or degloving injuries. Penetrating penile trauma seldom occurs in the absence of associated genital or major organ injury, except in the event of bites and self-inflicted wounds.

PENILE RUPTURE The most common blunt injury involving the penis is rupture of the corpora cavernosa, or penile fracture. This almost invariably occurs when the erect penis is forced to bend in an irregular fashion, such as when it accidentally impinges on the pubis or perineum after slipping out of the vagina during sexual intercourse. 9 The remainder of cases are caused by falls out of bed with an erect penis, masturbation, or manipulation of the erect penis. The patient often reports a cracking or popping noise at the time of injury, leading to immediate detumescence and rapid onset of discoloration and swelling over the site of injury. Diagnosis The diagnosis of penile rupture is easily made by physical examination along with the appropriate history. Swelling and discoloration may or may not be limited to the penis, depending on the integrity of Buck's fascia. If Buck's fascia is intact, the hematoma will be contained and will not usually spread below the base of the penis, resulting in the typical “eggplant” deformity ( Fig. 73-1). However, if the laceration in the tunica albuginea involves Buck's fascia, extravasation will be contained by Colles' fascia, and ecchymosis will extend in a “butterfly” distribution over the perineum, scrotum, and lower abdomen. Examination may reveal angulation of the penis away from the side of rupture because of the mass effect of the hematoma. In addition, focal tenderness and a palpable defect in the tunica albuginea may help localize the fracture site.

FIG. 73-1. Fractured penis displaying the pathognomonic “eggplant deformity” with swelling and discoloration extending to the base of the shaft. The penis usually bends away from the side of injury because of the hematoma.

Penile rupture can occur anywhere along the shaft including the base of the penis, where the corpora are fixed by the penile suspensory ligament. Generally, only one corporal body is injured, although both corpora and the corpus spongiosum can be affected, depending on the severity of the injury. Most patients are able to urinate normally. Failure to void spontaneously may signify compression of the urethra by hematoma but should lead to evaluation of urethral injury by retrograde urethrography (RUG). Urethral injury occurs in approximately 20% of cases and usually consists of partial disruption, although complete transection can result. 8 Retrograde urethrography is mandatory in all patients with blood at the urethral meatus, hematuria of any extent, or inability to void. 9 However, because RUG is easy to perform and provides reliable results, we perform it routinely in all cases of suspected penile rupture. Imaging of the corporal bodies is generally not necessary because prompt surgical exploration is usually advised when penile rupture is suspected. Although magnetic resonance imaging has recently been shown to be highly sensitive in the diagnosis of rupture, cost and inaccessibility limit routine use of MRI in this setting. 7,9 Indications for Surgery Although penile fractures can be managed nonoperatively, the literature shows a clear advantage to early operative repair. evacuation of hematoma and primary repair of the laceration.

8,9

Alternative Therapy Conservative treatment consists of cool compression dressings, anti-inflammatory agents, and sedatives to reduce erections. Surgical Technique

The goals of acute exploration are

The patient is placed in a supine position, and a Foley catheter is placed to facilitate identification of the urethra and urinary drainage. Exposure is usually obtained through a subcoronal circumferential incision, and the penile skin is degloved down to the base. The distal circumferential incision is favored because it allows both exposure of the ruptured corpus and adequate assessment of the contralateral corpus and corpus spongiosum. The corpus spongiosum is carefully inspected to evaluate for potential urethral injury. Inspection of the fracture site usually reveals a transverse laceration, between 0.5 and 2.0 cm long, in the tunica albuginea of the proximal penile shaft. 4 After evacuation of the hematoma and irrigation, minimal debridement of nonviable wound edges may be necessary before closure with interrupted 4-0 Maxon sutures (Fig. 73-2). The surgeon should not probe the exposed cavernous tissue unnecessarily, as this may elicit troublesome bleeding. A tourniquet may be used intraoperatively to control hemorrhage. Lacerations may run directly under the dorsal neurovascular bundle located on the dorsal surface of the corpora at approximately the 10- and 2-o'clock positions ( Fig. 73-3). This necessitates careful dissection of these structures off the corpora to allow a safe, watertight closure. Division of the deep dorsal vein facilitates unilateral dissection of the neurovascular bundle off the underlying corpus cavernosum. The penile skin is then replaced, and the subcoronal incision is closed with interrupted 4-0 chromic sutures. Postoperatively, a loose compression dressing (Coban) is gently placed, and the urethral catheter may be removed on the first postoperative day. Systemic antibiotics, anti-inflammatory agents, and fibrinolytics are unnecessary. Most patients can be discharged home within 1 to 2 days of surgery. Sexual activity can be resumed at about 4 to 6 weeks.

FIG. 73-2. Identification and repair of penile fracture. A distal circumferential subcoronal incision is made, and skin and soft tissue are mobilized off the underlying corporal bodies down to the base of the penis. This maneuver exposes the transverse laceration in the tunica albuginea. The laceration is repaired using interrupted 4-0 Maxon with the knots buried. Exposed corporal erectile tissue should not be probed or explored, as this may cause troublesome bleeding.

FIG. 73-3. Penile fracture extending beneath dorsal neurovascular bundles. Elevation of the ipsilateral dorsal neurovascular bundle facilitates repair of lacerations and protects these structures from inadvertent injury. Division of the deep dorsal vein in the midline provides access to the correct surgical plane beneath the ipsilateral neurovascular bundle.

When urethral transection occurs in the context of penile rupture, we advocate primary repair with interrupted 5-0 or 6-0 Maxon sutures over a 16-Fr silicone catheter. In cases of complete urethral transection, additional urinary diversion through a percutaneous suprapubic cystostomy tube may be prudent. 9 Outcomes Complications Many patients treated conservatively or with delayed repair have some form of sexual dysfunction, such as painful erection, curvature, or even impotence secondary to cavernous–venous occlusive disease. 1,10 Results Patients who have operative repair within 48 hours of the injury have excellent functional results. In two relatively large studies, none of the patients with early operative repair experienced impotence, penile curvature on erection, or pain at coitus. 4,9

PENILE SKIN LOSS Penile skin loss can occur from infection, burns, constrictive bands, or degloving injuries from blunt or penetrating trauma. When the skin loss is secondary to infection, repeated debridement with antibiotics and moist dressing changes must be instituted to prepare the underlying tissue for delayed reconstruction. Avulsions are most often caused by power tool injuries or motor vehicle accidents. 1 Immediate repair is frequently possible in cases of traumatic skin loss. Indications for Surgery Partial penile skin loss, especially in the distal shaft, is best managed by rotational mobilization of a local skin flap. Extensive skin loss, whether from the injury itself or surgical debridement, usually requires tissue transfer for repair. In impotent patients, the penis can be buried under a scrotal flap with the glans left exposed to allow micturition (Fig. 73-4).3 In sexually active patients, a thick (0.016 to 0.018 inch), nonmeshed split-thickness skin graft is used. Thick split-thickness grafts are preferred because they are not hair-bearing, have minimal contraction, and offer excellent cosmesis and viability. In impotent patients, a thinner or meshed split-thickness graft, despite a higher rate of contraction, may be preferred to increase the chance of graft survival. Avulsed skin that is still attached on a viable pedicle can be gently washed and reapplied with the knowledge that it may need to be debrided at a later time. Skin that is no longer attached is usually unsuitable for free tissue graft. 6

FIG. 73-4. Scrotal tunnel maneuver for penile skin coverage. The penis shaft may be buried beneath a flap of scrotal skin to provide skin coverage, leaving the glans exposed. This is a viable option in older patients who either were impotent before their injury or who have sustained severe associated injuries.

Alternative Therapy There are no alternatives to surgery. Surgical Technique The patient is placed supine, and both the genitals and a carefully chosen donor site are prepped into the field. The anterolateral thigh provides thickness, texture, and color resembling penile skin and is therefore the preferred donor site. A Foley catheter is placed to prevent postoperative urinary contamination. The shaved donor site is coated with sterile mineral oil, and a Brown or Paget dermatome (10 cm wide strip) is used to harvest the graft in standard fashion. Once the graft is harvested, the donor site is covered with fine mesh gauze under gentle pressure. The penile wound is sharply debrided of all devitalized tissue and any chronic granulation tissue. It is imperative to prepare the recipient site so that the graft will have adequate blood supply. Debridement of the glans should be avoided, but penile skin left distal to the site of planned skin grafting should be excised up to the coronal sulcus to prevent chronic lymphostasis in this area. Hemostasis at the graft site is essential to prevent hematoma formation under the graft. Once prepared, the penis is stretched, and the graft applied circumferentially such that the seam is in the midline ventrally, providing the cosmetic appearance of a midline raphe ( Fig. 73-5). Chordee formation has generally not been a problem because the graft will have minimal longitudinal contraction. The graft is secured to itself and along the shaft with interrupted 5-0 chromic sutures. The proximal and distal margins are secured with 4-0 silk sutures, some of which are left long to fashion a bolster dressing. A Xeroform dressing is placed directly on the graft, followed by cotton soaked in mineral oil and fluffs. The whole dressing is secured in place using the bolster sutures, leaving the glans visible for inspection. To keep the penis in a vertical position, a splint is placed around the bolstered dressing.

FIG. 73-5. Penile split-thickness skin graft. A thick (0.016 to 0.018 inch) split-thickness skin graft is applied to the denuded penile shaft. The distal skin is discarded to just beneath the corona when a circumferential graft is indicated. The graft is placed with the seam in the midline ventrally and secured with 5-0 chromic sutures to itself and along the shaft, while 4-0 silk sutures placed proximally and distally are left long to secure a bolster dressing.

Postoperatively, the patient is kept at strict bed rest until the dressing is removed, usually after 5 days, when the Foley catheter is also removed. The operatively placed fine mesh gauze is allowed to separate from the donor site wound on its own, which usually occurs within 7 to 10 days. Once the penile dressing is removed, twice-daily sitz baths can be started. We do not discourage erections, as they provide natural tissue expansion and may reduce the rate of graft contracture. Outcomes Complications The common causes of early failure are infection, shearing forces during the critical first 5 postoperative days, and underlying hematoma. It is imperative that the graft bed be free of infected granulation tissue and any necrotic tissue. Shearing forces disrupt the blood supply to the new graft and are prevented by the penile splint, provided the patient is cooperative with strict bed rest for 5 days. Hematoma causes failure by creating poor contact between the graft and the recipient bed. Meshed grafts allow better dissipation of hematoma fluid but are discouraged in potent patients because of their increased degree of contraction. Long-term results of reconstruction have been excellent. Patients may lose superficial sensation but maintain deep touch sensation and potency. Results Graft take exceeds 90%. Most patients have satisfactory intercourse after reconstruction. Cosmetic and functional results of nonmeshed, thick split-thickness penile grafts are superior.

PENETRATING PENILE TRAUMA Penetrating trauma to the penis is most often caused by firearms but can also result from stab wounds, industrial accidents, self-mutilation attempts, and bites. In all cases, general principles of management include hemo-stasis, judicious wound debridement, and assessment of urethral and corporal injury. Most civilian penile gunshot wounds are caused by low-velocity missiles, which cause damage only in the path of the bullet. Associated wounds of the thigh and pelvis are common. Diagnosis Genital injury is determined by careful physical examination, with special attention paid to the trajectory of the bullet and initial hemostasis. The exam should include a vascular (glanular capillary refill) and penile sensory assessment. 7 Urethral injury, which occurs in 25% to 40% of penetrating injuries to the penis, should be excluded with retrograde urethrography (RUG) in all cases. 5 The triad of no blood at the meatus, absence of hematuria, and normal voiding suggests that there is no urethral injury; however, penetrating trauma can cause urethral injury without clinical signs of damage. Cystography, intravenous pyelography, and scrotal ultrasonography may be necessary to evaluate associated urologic injuries. Indications for Surgery and Alternative Treatments

Penetrating injury to the penis most often requires surgical exploration. The exceptions are single pellet wounds with small entrance sites and superficial stab wounds in which there is no active bleeding or hematoma. 2 In addition, patients with unstable major organ injury will be unable to undergo immediate exploration. In these cases, initial treatment consists of hemostasis and packing of major wounds. Penetrating injury causing major skin loss will require tissue transfer for satisfactory coverage, but associated corporal and urethral injuries must be repaired before the skin grafting. Immediate primary closure or reconstruction should take place only with a clean wound that is generally less than 8 hours old. Surgical Technique Operation consists of judicious debridement of devitalized tissue and hemostasis. The wound must be copiously irrigated to remove all foreign bodies, including powder from shotgun pellets and pieces of clothing. Bleeding almost always occurs from a lacerated corporal body but may also be from disrupted superficial veins. The corpora are well vascularized, and extensive debridement is usually unnecessary and will hinder future potency. Hemostasis is obtained by gentle compression and watertight closure of the tunica albuginea alone, usually with interrupted 4-0 Maxon sutures. Deep sutures or clamping within the corpora is discouraged, as delicate erectile tissue is damaged and bleeding is usually exacerbated. Urethral injuries are repaired with 5-0 Vicryl suture over a silicone catheter. Devitalized urethra must be carefully debrided, and primary repair with a tension-free anastamosis can usually be accomplished. Associated scrotal and spermatic cord injuries are treated with debridement and, if necessary, orchiectomy or ligation of the vas deferens. The skin can be closed primarily unless viable skin edges cannot be approximated. In contaminated wounds or those encountered after 8 hours, immediate skin closure or grafting is not recommended, and the wound is packed instead. Once the wound is clean, delayed primary closure, staged reconstruction, or healing by secondary intention may be selected. Penile bites deserve special mention, as they can rapidly progress to severe infection. Wounds should be copiously irrigated, and all devitalized tissue debrided. All wounds should be left open, and prophylactic antibiotics administered. Antibiotic treatment should cover gram-positive and gram-negative organisms as well as anaerobic gram-negative rods. Hospitalization with frequent wound inspection and intravenous antibiotics is necessary in those with delayed presentation or with increased risk factors such as steroid use, diabetes, or immunodeficiency syndromes. Close follow-up is mandatory in all outpatients. Outcomes Complications Early complications of penetrating penile trauma include rebleeding and infection. Because the corpora are heavily vascularized, breakdown of repair in the tunica albuginea is rare. A small minority will report superficial sensory loss, pain with erection, and rapid detumescence. Results Excellent functional results can be expected except in those cases of high-velocity injuries where massive tissue destruction has occurred. Most patients report retained potency without penile curvature and with satisfactory cosmetic results. 3,6 CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Armenakas NA, McAninch JW. Use of skin grafts in external genital reconstruction. In: McAninch JW, ed. New techniques in reconstructive urology. New York: Igaku-Shoin, 1996;127–141. Goldman HB, Dmochowski RR, Cox CE. Penetrating trauma to the penis: functional results. J Urol 1996;155:551. Gomez RG. Genital skin loss: reconstructive techniques. In: McAninch JW, ed. Problems in urology. Philadelphia: JB Lippincott, 1994;290–301. Gomez RG. Genital injuries: presentation and management. In: McAninch JW, ed. Problems in urology. Philadelphia: JB Lippincott, 1994;279–289. Gomez RG, Castanheira AC, McAninch JW. Gunshot wounds to the male external genitalia. J Urol 1993;150:1147. McAninch JW. Management of genital skin loss. Urol Clin North Am 1989;16:387. Miller KS, McAninch JW. Penile fracture and soft tissue injury. In: McAninch JW, ed. Traumatic and reconstructive urology. Philadelphia: WB Saunders, 1996;693–698. Nicolaisen GS, Melamud A, Williams RD, McAninch JW. Rupture of the corpus cavernosum: surgical management. J Urol 1983;130:917. Orvis BR, McAninch JW. Penile rupture. Urol Clin North Am 1989;16:369. Volz LR, Broderick GA. Conservative management of penile fracture may cause cavernous-venous occlusive disease and permanent erectile dysfunction. J Urol 1994;151(5):358A.

Chapter 74 Penile Replantation Glenn’s Urologic Surgery

Chapter 74 Penile Replantation Farhad Parivar, Allen F. Morey, and Jack W. McAninch

F. Parivar: Department of Urology, University of California, San Francisco, California 94140. A. F. Morey: Department of Surgery, Uniformed Services University of the Health Sciences, and Brooke Army Medical Center, San Antonio, Texas 78258. J. W. McAninch: Department of Urology, University of California, and San Francisco General Hospital, San Francisco, California 94110. The opinions expressed herein are those of the authors and are not to be construed as reflecting the views of the Armed Forces or the Department of Defense.

Diagnosis Indications for Surgery Surgical Technique Outcomes Complications Results Chapter References

Traumatic amputation of the penis is an uncommon injury. Its incidence is not well known, as it is believed to be underreported. There are approximately 100 reported cases of injury in the English literature. By far the most common cause of injury is genital self-mutilation in men with psychiatric disorders. The incidence of psychiatric disease has been reported to be 65% to 87%. 1,2,3,4 and 5 Patients with a history of substance abuse or those with gender misidentification (transvestites, homosexuals, and transsexuals) constitute the remainder of the population. Other causes of genital mutilation include accidental injuries such as dog bites, ballistic wounds, and industrial injuries. Because of the nature of the injury, these usually carry a worse prognosis than self-inflicted wounds. Partial amputations in general have better surgical outcome than complete amputations.

DIAGNOSIS The diagnosis of penile amputation is self-evident. No radiologic study is necessary to evaluate the urethra or penile vasculature. A plain x-ray of genitalia may be necessary in patients with shrapnel or shotgun blast injuries to evaluate for the presence of foreign bodies.

INDICATIONS FOR SURGERY Because of the reported good cosmetic and functional results of reconstructive surgery, attempt at replantation is recommended in all cases of penile amputation. There is no consensus on the timing of surgery after complete amputation. The majority of reported series have not documented the time elapsed between injury and surgery, but replantation up to 8 hours after amputation has been reported. 3 The amputated distal penis should be wrapped in a saline/water-soaked gauze and placed in a plastic bag, which is in turn placed in a second ice-containing plastic bag and transported to the hospital as soon as possible (“bag-in-a-bag” technique).

SURGICAL TECHNIQUE Following partial or complete amputation of the penis, there is often profuse blood loss, and therefore blood should be obtained for cross-match. General or continuous regional anesthesia is necessary. For the surgeon, optical magnification and familiarity with microvascular techniques are mandatory. Broad-spectrum antibiotics and tetanus immunization are instituted. After preparation of the surgical field, a tourniquet is placed on the penile stump to prevent further blood loss. The overlying blood clot is then removed. It is usually at this stage that a thorough examination can be carried out and the extent of injury assessed. Dorsal arteries, veins, and nerves are identified at this stage and tagged with bulldogs and sutures ( Fig. 74-1). The amputated part is separately cleaned with saline and appropriate antiseptic solution and examined on the field. The dorsal arteries, veins, and nerves are similarly identified.

FIG. 74-1. The replantation procedure begins with identification and isolation of the neurovascular structures, corpora, and urethral mucosa on the penile stump.

A 16-Fr silastic Foley catheter is passed per meatus and through the stump into the bladder ( Fig. 74-2). Urethral anastomosis is first carried out over this Foley. We prefer an end-to-end anastomosis using 10 to 12 sutures of 5-0 polydeoxanon (Maxon). The cut edges may need to be trimmed, and some urethral mobilization may be necessary to achieve a tension-free anastomosis. When possible, the corpus spongiosum should be closed with interrupted sutures of 5-0 Maxon as a second layer. However, these injuries usually occur in the region of pendulous urethra where a one-layer urethral anastomosis is more practical. The corpora cavernosa are next sutured with interrupted sutures of 3-0 polyglycolic acid (Dexon/Vicryl) starting from the septum. It is not necessary to anastomose the central cavernous arteries. The deep dorsal vein and artery are next anastomosed under magnification using interrupted sutures of 9-0 nylon. For best results, at least one vein and artery should be anastomosed to provide both adequate blood supply and venous drainage of the distal segment. If a large segment of the artery or vein is missing, vascular interposition using saphenous vein will be necessary. Use of synthetic grafts is not recommended. The dorsal nerve is finally anastomosed using sutures of 9-0 nylon. The Buck's fascia is closed with interrupted sutures of 3-0 chromic, and penile skin with interrupted sutures of 4-0 chromic.

FIG. 74-2. A 16-Fr Foley catheter is placed through the urethral meatus and then through the stump into the bladder. Repair of the urethra with interrupted 5-0 Maxon sutures is the first anastomosis to be completed.

If penile skin is inadequate for closure, the penile shaft may be temporarily covered with vaselinated gauze in preparation for skin grafting at a later stage. Furthermore, if there is inadequate tissue to cover the vascular anastomoses, the denuded shaft may be temporarily buried under the scrotal skin in the midline. The bladder is then filled with saline through the Foley, and a percutaneous suprapubic tube is inserted for urinary diversion until the Foley is removed in 3 weeks. At the end of the procedure, the penis needs to be elevated and immobilized to enhance venous and lymphatic drainage ( Fig. 74-3). This can be accomplished by wrapping the penis in loose gauze and placing it in a plastic irrigation fluid bottle cut and well padded on both ends. The glans and distal penis should be inspected regularly for evidence of venous congestion and skin loss. Five days of bed rest is prescribed, during which patients should have some form of prophylaxis against thromboembolism.

FIG. 74-3. The reconstructed phallus is immobilized in a plastic housing that allows inspection of the glans. Urethral and suprapubic catheters are placed.

OUTCOMES Complications Common to most reports of penile replantation is the high incidence of partial or complete skin necrosis. This in turn is a function of extent of injury, delay in repair, and success of vascular anasomosis. Restoration of venous return is extremely important, as venous congestion of the distal penis may lead to eventual necrosis and graft loss. Loss of distal cutaneous sensation is invariable if dorsal nerve is not anastomosed. Urethral stricture and urethrocutaneous fistula have been reported in some of the earlier cases, but in most of these, urethral anastomosis was done using chromic sutures. We believe stronger, longer-lasting, monfilament sutures such as Maxon or PDS facilitate better results. Reduction in penile rigidity may require subsequent intervention. Results In general, all patients with penile amputation should be considered for replantation unless the distal segment is completely mutilated. Microvascular techniques attain the best results, but even simple reimplantation results in adequate cosmetic and functional restoration of the penis in a majority of cases. 4,6 Nearly all patients undergoing either form of reconstruction are capable of subsequent intromission. Surgical repair is thus a worthwhile exercise whenever possible. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Aboseif S, Gomez R, McAninch J. Genital self-mutilation. J Urol 1993;150:1143. Bhanganada K, Chayavatana T, Pongnumkul C, et al. Surgical management of an epidemic of penile amputation in Siam. Am J Surg 1983;146:376. Bux R, Carroll P, Berger M, Yarbrough W. Primary penile reanastomosis. Urology 1978;11:500. Carroll PR, Lue TF, Schmidt RA, Trengrove-Jones G, McAninch JW. Penile replantation: Current concepts. J Urol 1985;133:281. Greilsheimer H, Groves JE. Male genital self-mutilation. Arch Gen Psychiatry 1979;36:441. Heymann AD, Bell-Thomson J, Rathod DM, Heller LE. Successful reimplantation of the penis using microvascular techniques. J Urol 1977;118:879.

Chapter 75 Hydrocele and Spermatocele Glenn’s Urologic Surgery

Chapter 75 Hydrocele and Spermatocele Theodros Yohannes and James I. Harty

T. Yohannes and J. I. Harty: Division of Urology, University of Louisville School of Medicine, Louisville, Kentucky 40292.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique: Hydrocele Lord Procedure Jaboulay Procedure Surgical Technique: Spermatocele Outcomes Complications Results Chapter References

A hydrocele is an abnormal accumulation of serous fluid between the layers of the tunica vaginalis. Embryologically, the tunica vaginalis is an extension of the peritoneal sac that has a serous surface that secretes and absorbs fluid. The fluid collection that occurs is thought to be due to an imbalance between production and absorption within the layers of the tunica vaginalis. Hydroceles may be congenital or acquired. Congenital hydroceles result from persistence of the processus vaginalis (peritoneal sac) and are treated by ligation of the sac at the internal inguinal ring through an inguinal incision if they persist after 1 year of life. Most acquired hydroceles are idiopathic, although some are related to trauma, infection, testicular tumors, or inguinal operations that cause lymphatic obstruction, such as ipsilateral renal transplantation. A spermatocele is a cystic structure that usually arises from the head of the epididymis and rete testis. It is usually filled with a milky fluid that contains spermatozoa. Spermatoceles are usually located on the superior aspect of the testicle but can occur anywhere on the epididymis. Although the exact etiology is unknown, obstruction and trauma have been implicated. Spermatoceles are found most commonly in middle-aged men, and their incidence increases with age.

DIAGNOSIS The patient with a hydrocele usually presents with a smooth scrotal swelling, which may be painful or cause embarrassment due to its appearance. Upon examination, the swelling is confined to the scrotum distinguishing it from an inguinal hernia. A hydrocele will transilluminate to varying degrees, depending on the thickness of the wall. The testis is not usually palpable within the hydrocele. In this instance, or when there is any suspicion that there may be an underlying testicular tumor, a scrotal ultrasound should be performed. The patient with a spermatocele also usually presents with a scrotal mass. Physical examination reveals a mass superior to and separate from the testicle. This gives the impression that the patient has three testes, the so-called pawnbroker's sign. The spermatocele transilluminates and may give a Chinese lantern appearance due to septae within the spermatocele.

INDICATIONS FOR SURGERY No surgery is indicated unless the hydrocele or spermatocele is causing pain, social embarrassment, or a tumor is suspected based on the ultrasonographic findings.

ALTERNATIVE THERAPY Transcrotal needle aspiration, with or without instillation of sclerosing agents such as tetracycline, may be indicated in elderly patients with severely symptomatic hydroceles who may be poor surgical risks. This form of therapy is contraindicated in younger, healthier patients because of the high recurrence rate and the risk of persistent discomfort after sclerosis. Occasionally, the spermatocele may also be aspirated and injected with a sclerosing agent, such as tetracycline, though this is rarely required.

SURGICAL TECHNIQUE: HYDROCELE The surgery can be performed under local, spinal, or general anesthesia. The entire scrotum is shaved immediately prior to the procedure, but the pubic hair is left intact. The scrotum and penis are cleaned with betadine and the area is draped with sterile towels, including one beneath the scrotum to elevate it. The incision in the scrotum can be made along the median raphe or transversely in an avascular area between the blood vessels that run transversely in the scrotal wall, while an assistant grasps the scrotum and compresses the hydrocele against the skin. The incision in the skin is made with a knife while the remainder of the incision through the subcutaneous layers and dartos muscle is made with the electrocautery in order to achieve satisfactory hemostasis. Once the parietal layer of the tunica vaginalis is exposed, a decision is made as to which type of procedure should be performed, i.e., Jaboulay or Lord. 1,2 The Jaboulay procedure is preferred in cases involving a thick-walled sac, whereas the Lord procedure is more suitable for thin-walled hydroceles. With either procedure, the testicle and appendages should be examined carefully for pathology. Hydrocele fluid is not usually sent for examination unless the fluid appears purulent or bloody. Lord Procedure The Lord procedure is performed by directly opening the parietal layer of the hydrocele sac without dissecting it free from the dartos layer. The testicle is then extruded into the surgical field and examined. The parietal layer of the tunica vaginalis is then plicated using a 3-0 chromic catgut suture by taking small bites at 1-cm intervals (Fig. 75-1A). Eight to 10 of these sutures are placed approximately 1 cm apart, and then all are tied so as to accordion the sac into a collar surrounding the testis and epididymis ( Fig. 75-1B).

FIG. 75-1. (A) The Lord operation. The testis is extruded through a small incision in the middle of the sac. (B) The sac is plicated with multiple sutures.

Jaboulay Procedure In the Jaboulay procedure (Fig. 75-2), the hydrocele is freed from the dartos layer using blunt dissection with a dry gauze sponge before the sac is opened and the testicle delivered. The excess sac is excised leaving a 2- to 3-cm remnant around the testicle, and the edges are oversewn with a running locked 3-0 chromic suture. The remnant of the sac is then wrapped posteriorly around the spermatic cord and sutured with a 3-0 chromic catgut suture, with care being taken not to strangulate the cord.

FIG. 75-2. Jaboulay technique. Most of the sac is excised and a running suture closes the free edges loosely about the cord. This is a rapid method of controlling troublesome bleeding.

SURGICAL TECHNIQUE: SPERMATOCELE The skin preparation and incision is identical to that described above for a hydrocele repair. The tunica vaginalis is opened and the testicle is delivered with the spermatocele. The spermatocele is dissected from the epididymis using electrocautery ( Fig. 75-3), and if the attachment of the spermatocele to the epididymis can be found, it is ligated with a 4-0 chromic catgut suture. Using this technique, the spermatocele can usually be removed intact. The edge of the tunica vaginalis is sutured with a running 4-0 chromic catgut suture for hemostatic purposes, and the tunica vaginalis is left open to avoid the formation of a hydrocele. The scrotal incision is then approximated in two layers, as outlined for the hydrocele closure.

FIG. 75-3. Spermatocelectomy. The spermatocele is being separated from the head of the epididymis with electrocautery.

After either type of repair has been carried out, drains are not usually necessary. However, if hemostasis is difficult to attain, a Penrose drain should be placed and brought out through a separate stab incision in the inferior aspect of the scrotum. The incision is then closed in two layers using 3-0 chromic catgut sutures, with the first layer approximating the dartos muscle in a running fashion, and the second layer closing the skin with interrupted horizontal mattress sutures tied loosely without tension. A fluff dressing is applied and held in place with a scrotal support. An ice pack is kept on the scrotum for the first 24 hours to reduce pain and swelling, and appropriate oral analgesics are prescribed. Antibiotics are not routinely used.

OUTCOMES Complications The most common complication is usually a hematoma. A wound infection, scrotal abscess, and recurrent hydrocele or spermatocele are less common. These complications are seen less frequently when the Lord procedure is performed. 3 Results The success rate of hydrocelectomy or spermatocelectomy should approach 100%. 3 CHAPTER REFERENCES 1. Jaboulay M. In: Chirurgie des Centres Nerveux, des Viscres et des Membres. Vol. 2. Lyon: Storck, 1902;192. 2. Lord PH. A bloodless operation for the radical cure of idiopathic hydrocele. Br J Surg 1964;51:914. 3. Rodriguez WC, Rodriguez DD, Fortuno RF. The operative treatment of hydrocele: a comparison of four basic techniques. J Urol 1981;125:804.

Chapter 76 Ureterosigmoidostomy and the Mainz Pouch II Glenn’s Urologic Surgery

Chapter 76 Ureterosigmoidostomy and the Mainz Pouch II Margit Fisch and Rudolf Hohenfellner

M. Fisch and R. Hohenfellner: Department of Urology, Johannes Gutenberg University Medical School, 55131 Mainz, Germany.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Ureterosigmoidostomy Rectosigmoid Pouch (Mainz Pouch II) Serous Lined Extramural Tunnel Surgical Tricks for the Recto Sigmoid Pouch Outcomes Complications Results Chapter References

Since the introduction of internal urinary diversion 140 years ago by Simon, more than 60 modifications of ureterosigmoidostomy have been published. 2,7 Critics of ureterosigmoidostomy tend to quote publications dealing with complications in patients operated on before the 1950s. 3 The development of new absorbable suture material, modern ureteric stents, antibiotics, and alkalinizing drugs served in solving many of the traditional shortcomings of ureterosigmoidostomy and rekindled the interest in this technique. However, high intraluminal pressures caused by circular bowel contractions toward the anus during peristalsis can result in anal incontinence and dilation of the upper tract. Implantation into the so-called false loop, especially when the sigmoid colon is extremely mobile, may result in kinking and dilation of the ureters. Fixation of the sigmoid colon after ureteral implantation might be difficult and can damage the blood supply of the mesentery. Pertaining to these points, the technique of the rectosigmoid pouch (Mainz pouch II) optimizes classical ureterosigmoidostomy and has replaced it at our institution. 4,5 Dilated ureters, a contraindication for classical ureterosigmoidostomy, can also be implanted into a rectosigmoid pouch, preferably by the technique of the serous lined extramural tunnel. 1,2

DIAGNOSIS A competent anal sphincter is prerequisite for ureterosigmoidostomy/rectosigmoid pouch. This can be checked by a tap water enema (rectal instillation of 200 to 300 ml saline), which the patient should keep at least for 3 hours without leakage. Also, a rectodynamic investigation should show no incontinence during measurement and an anal sphincter profile of a baseline closure pressure greater than 60 cm H 2O and a closure pressure under stress greater than 100 cm H 2O.

INDICATIONS FOR SURGERY Indications for a sigma rectum pouch include the need for a primary urinary diversion, a revision of ureteral implantation after ureterosigmoidostomy, or a conversion of an incontinent diversion with a nonrefluxing ureteral implantation (colon conduit). Contraindications include an incompetent anal sphincter, prior irradiation of the pelvis, sigmoid diverticula or polyposis, or a creatinine concentration greater than 1.5 mg %.

ALTERNATIVE THERAPY Alternatives to the Mainz pouch II include other forms of continent urinary diversion, ileal conduit or other incontinent diversions, or ureterosigmoidostomy.

SURGICAL TECHNIQUE Instruments and suture material required include a basic kidney set, additional instruments for abdominal surgery, suction, and a basin containing prepared iodine solution for disinfection. Additionally, disposable supplies will include two ureteral stents (6 Fr), one rectal tube, and suture material. We prefer chromic catgut 5-0 for the mucosa and polyglycolic acid 4-0 in the seromuscular layer of the bowel and pouch walls, and we recommend 5-0 and 6-0 chromic catgut for the ureteral reimplantation. Ureterosigmoidostomy The initial incision is a median laparotomy. An incision is made in the peritoneum lateral to the ascending and descending colon, allowing identification of the right and left ureters, respectively. Both ureters are dissected, taking care to avoid injury to the longitudinal vessels running inside the Waldeyer's sheath down to the ureterovesical junction. At this point, the ureters are divided as distally as possible and a stay suture placed at the 6 o'clock position while the ureteral stumps are ligated. The colon is slightly elevated at the rectosigmoid junction by 4 stay sutures and a 4-cm incision is made in the anterior sigmoid wall in the area of the taenia libera to facilitate ureteral reimplantation. Four mucosal stay sutures are placed and an incision is made in the mucosa between the proximal stay sutures ( Fig. 76-1). A buttonhole of musculature is removed and a straight or slightly curved hemostat advanced into the opening ( Fig. 76-2). A 3-cm tunnel is created by blunt dissection just below the visceral peritoneum of the mesosigmoid and the ureter is pulled into the lumen of the intestine through this tunnel, with care taken to avoid torsion of the ureter (Fig. 76-3). The anterior wall of the ureter is spatulated for a length of 1 cm ( Fig. 76-4A). The final anastomosis is performed by first placing a 5-0 chromic catgut anchor suture at the 6 o'clock position (incorporating intestinal mucosa and musculature) and mucosa-to-mucosa sutures of 6-0 chromic catgut. A 6-Fr silastic stent is inserted and fixed to the mucosa by a 5-0 catgut suture ( Fig. 76-4B).

FIG. 76-1. Open transcolonic ureterosigmoidostomy: both ureters have been cut at their entrance into the bladder and mobilized. The site of the planned left ureteral implantation in the posterior sigmoid wall is outlined by stay sutures.

FIG. 76-2. After incision of the mucosa and excision of a buttonhole from the musculature at the point where the ureter will be brought through the intestinal wall, a tunnel is modeled bluntly from this point to the left incision in the peritoneum. The hemostat is advanced precisely below the peritoneum.

FIG. 76-3. The ureter has been pulled into the bowel and through a submucosal tunnel reaching from the proximal to the distal stay suture.

FIG. 76-4. Spatulation of the anterior wall of the ureter (A) and mucosa-mucosal anastomosis between ureter and intestinal wall. The ureter is stented (B).

The contralateral ureter is reimplanted in the same technique about 3 cm lateral and proximal or distal to the first anastomosis ( Fig. 76-5). The ureteral stents are led out perianally with the rectal tube and the anterior sigmoid incision is closed by seromuscular single stitches of 4-0 polyglycolic acid or two-layer running suture (5-0 chromic catgut for the mucosa and 4-0 polyglycolic acid for the seromuscularis). The peritoneal incisions are then closed. At the end of the operation, a rectal tube is reinserted and separately fixed from the ureteral stents near the anus with a suture of nonabsorbable material.

FIG. 76-5. Identical implantation of the right ureter 3 cm lateral and proximal or distal of the first anastomosis.

Rectosigmoid Pouch (Mainz Pouch II) The abdomen is entered via a median laparotomy and the ureters are prepared as for a ureterosigmoidostomy. The left ureter is pulled through the sigmoid mesentery above the inferior mesenteric artery ( Fig. 76-6). The junction between the sigmoid colon and rectum is identified and the intestine is opened at the taenia libera starting from the recto-sigmoid junction over a total length of 20 to 24 cm distal and proximal of this point. Two stay sutures are placed at the summit of the rectosigmoid, giving the split intestine the shape of an upside-down U ( Fig. 76-7). A side-to-side anastomosis of the medial margins of the U is created by a two-layer running suture of 4-0 polyglycolic acid for the seromuscular layer and 4-0 chromic catgut for the mucosa ( Fig. 76-8).

FIG. 76-6. Opening of the rectosigmoid at the taenia libera starting from the rectosigmoid junction over a total length of 20 to 24 cm distal and proximal of this point. By placing two stay sutures at the summit of the rectosigmoid the split intestine receives the shape of an upside-down U.

FIG. 76-7. Side-to-side anastomosis of the medial margins of the U by two-layer running sutures using 4-0 polyglycolic acid for the seromuscular layer and 4-0 chromic catgut for the mucosa.

FIG. 76-8. The left ureter is pulled through retromesenterically to the right side.

The ureteral reimplantation is performed by placing 4 mucosal stay sutures parallel to the right and left of the medial running suture. The mucosa and the seromuscular layers are excised to create a wide buttonhole between the two cranial stay sutures as an entrance of the ureter into the pouch. A submucosal tunnel is dissected starting from this incision over a length of 2 to 2.5 cm. The mucosa is incised at its distal end of the tunnel to allow a pull-through of the ureter. The ureter is resected to an adequate length and the reimplantation is completed by placing two anchor sutures at the 5 o'clock and 7 o'clock position and several single-stitch mucosa-mucosal sutures. The cranial mucosal incision is closed by a running suture of 6-0 chromic catgut ( Fig. 76-9). The contralateral ureter is reimplanted in an identical fashion. Then 8-Fr ureteral stents are placed to secure the ureteral implantation and are led out via the rectal tube.

FIG. 76-9. Creation of a wide buttonhole as an entrance of the ureter into the pouch and preparation of a submucosal tunnel (2 to 2.5 cm in length). Incision of the mucosa at its distant end and pull-through of the ureter. Ureteral implantation by two anchor sutures at the 5 o'clock and 7 o'clock positions and single-stitch mucosa-mucosal sutures. Closure of the cranial mucosal incision by a running suture with chromic catgut 6-0.

The pouch is fixated to the anterior longitudinal cord of the sacral promontory by two Bassini sutures in the area of the proximal end of the medial running suture ( Fig. 76-10). The anterior pouch wall is closed by two-layer sutures of 5-0 polyglycolic acid for the seromuscular and 4-0 chromic catgut for the mucosal layer. Alternatively, seromuscular single stitches can be used. The peritoneal incisions are closed and the anastomotic site of the pouch is covered by omentum ( Fig. 76-11). The ureteral stents and rectal tube are fixed as for ureterosigmoidostomy.

FIG. 76-10. After having placed two 8-Fr ureteral stents, which are led out with the rectal tube, the pouch is fixed to the anterior longitudinal cord of the promontory in the area of the proximal end of the medial running suture to by two Bassini sutures.

FIG. 76-11. Closure of the anterior pouch wall by seromuscular single stitches with polyglycolic acid 4-0. Closure of the peritoneal incisions.

Serous Lined Extramural Tunnel In cases of a short sigmoid colon, a left paracolonic incision is made mobilizing the descending colon including the left colonic flexure. The left ureter is identified and dissected free. A right paracolonic incision is made and continued along the root of the mesentery of the small bowel, allowing the right ureter to be identified and dissected free (Fig. 76-12). The ureters are divided to maximize the length and the left ureter is pulled through the sigmoid mesentery to the right side ( Fig. 76-13). An S-shaped sigmoid segment is marked by stay sutures, with each limb of 10 to 12 cm length resulting in a total length of 30 to 36 cm. An antimesenteric incision is made in the tenia libera of the S-shaped pouch ( Fig. 76-14). A side-to-side adaptation of the limbs is created by two serous running sutures close to the mesentery (non-absorbable suture, e.g., 4-0 silk or prolene) forming two serous-lined grooves.

FIG. 76-12. Right and left paracolonic incision, identification of the ureters.

FIG. 76-13. The ureters are cut and the left ureter is pulled through retromesenterically to the right side.

FIG. 76-14. An S-shaped sigmoid segment is marked by stay sutures, length 2 times 10 to 12 cm starting at the rectosigmoid junction (standard technique) plus additional 10 to 12 cm of the ascending colon and opened in the area of the taenia libera. Excision of a mesenteric window to pull the left ureter through.

On the right side an entrance for the right ureter is left at the cranial aspect of the running suture. The mesentery is incised cranial to the left running suture and the left ureter is pulled through the hiatus. The ureters are then brought into their respective grooves ( Fig. 76-15) and the respective borders of the bowel are anastomosed over the ureter by a running suture grasping all layers of the bowel wall. The length of the tunnel should be approximately 4 times the diameter of the ureter. The ureter is cut at its required length and spatulated. Four 4-0 chromic catgut anchor sutures are placed at the 11 o'clock and 1 o'clock and the 5 o'clock and 7 o'clock position grasping all layers of the ureter as well as all layers of the bowel wall. Mucosa-mucosal stitches of 5-0 chromic catgut are placed between the anchor sutures to complete the anastomosis ( Fig. 76-16). Two ureteral stents are inserted and led out with the rectal tube after being fixed to the bowel mucosa with 5-0 catgut. The anterior pouch wall is closed by seromuscular single sutures of 4-0 polyglycolic acid ( Fig. 76-17).

FIG. 76-15. Side-to-side adaptation of the limbs of the S by two serous running sutures close to the mesentery (nonabsorbable suture 4-0). Thereby two serous lined grooves are created. On the right side an entrance for the right ureter is left at the cranial aspect of the running suture and the ureter is pulled through. The ureters are laid down in the respective groove.

FIG. 76-16. Definitive ureteral implantation in the area of the continuous suture line. Anastomosis is secured by means of ureteral stents.

FIG. 76-17. The stents are led out transanally and the pouch is closed.

Surgical Tricks for the Recto Sigmoid Pouch When the anastomosis reaches deep down to the rectum, it is easier to suture the pouch starting caudally, as the deepest point of the anastomosis is the most critical part and can be reached easier at the beginning of the anastomosis. To facilitate fixation of the pouch to the promontory, one sutured end of the dorsal running suture can be pulled through dorsally outside of the pouch and be tied with the fixation suture placed in the anterior chord of the promontory. A Bassini needle facilitates placement of the fixation suture into the anterior chord. During ureteral implantation extensive spatulation of the ureters is of utmost importance to avoid a cuff-like protrusion of the ureteral borders. To avoid a hematoma of the submucosal tunnel, the mucosa over the tunnel can be carefully incised at different points.

OUTCOMES Complications At our institution, we have long-term follow-up (more than 5 years) in 46 children who have undergone ureterosigmoidostomy. The indication for ureterosigmoidostomy had been bladder exstrophy in 40 patients, incontinent epispadias in 5, and neurogenic bladder dysfunction in 1. Seven early postoperative complications occurred: severe pyelonephritis developed in one patient resulting in nephrectomy. Three patients with unilateral dilation required reimplantation within 3 months after the initial operation. Three patients underwent late conversion of ureterosigmoidostomy because of upper urinary tract problems. One patient underwent a percutaneous stone operation on one kidney and nephrectomy of the infected contralateral kidney had to be performed 20 years after ureterosigmoidostomy. Episodes of pyelonephritis developed in five patients with nondilated upper tracts. Between 1990 and July 1994 a rectosigmoid pouch was performed in 87 patients (69 adults and 18 children). Mean age was 40.2 years. Indications were malignancy (n = 65), bladder exstrophy and incontinent epispadias ( n = 17), trauma (n = 4), and a sinus urogenitalis ( n = 1). Of the 87 patients, 83 were followed with a mean follow-up of 26.4 months (5 months to 4.3 years). Seven patients died during follow-up due to their primary malignant tumor. Seven early complications were encountered in 6 patients (6.9%): one dislodged ureteral stent requiring temporary nephrostomy, one pulmonary embolism, two pneumoniae, one suture dehiscence, and one ileus requiring operative intervention. One patient developed severe complications as suture insufficiency and leakage required revision and ended with a colostomy due to a pouch fistula. Eight late complications occurred followed by an intervention (9.6%), with stenosis at ureteral implantation site being the most common complication (7.2%). During follow-up eight patients developed pyelonephritis (9.6%). Results In the patients with ureterosigmoidostomies, the daytime continence rate was 97.4% and the complete continence rate was 92.3%. In the patients undergoing the rectosigmoid pouch, 76 of the 83 patients were completely continent postoperatively; 2 children are still too young for final judgment (daytime continence 93.8%). Four of the five patients suffered from stress incontinence grade I–II. Five patients are incontinent during the night (nighttime continence 93.8%). Thirteen patients irregularly lose some drops of urine during the night; seven of them use pads prophylactically. The majority of the patients take alkalinizing drugs to avoid metabolic acidosis.

CHAPTER REFERENCES 1. Abol-Enein H, Ghoneim MA. A novel uretero-ileal reimplantation technique: the serous lined extramural tunnel. Preliminary report. J Urol 1993;1193–1197. 2. Abol-Enein H, Ghoneim MA. Optimization of uretero-intestinal anastomosis in urinary diversion: an experimental study in dogs. III. A new antireflux technique for ureterointestinal anastomosis: a serous-lined extramural tunnel. Urol Res 1993;21:135–139. 3. Connor JP, Hensle TW, Lattimer JK, Burbige KA. Long-term follow-up of 207 patients with bladder exstrophy: an evolution in treatment. J Urol 1989;142:793. 4. Fisch M, Hohenfellner R. Der Sigma-Rektum Pouch: Eine Modifikation der Harnleiterdarmimplantation. Akt Urol 1991;22:I–IX. 5. Fisch M, Wammack R, Miller SC, Hohenfellner R. The Mainz pouch II (sigma rectum pouch). J Urol 1993;149:258–263. 6. Hinman F, Weyrauch HM Jr. A critical study of the different principles of surgery which have been used in uretero-intestinal implantation. Trans Am Assoc Genitourin Surg 1036;29:15. 7. Simon J. Ektropia vesica (absence of the anterior wall of the bladder and pubic abdominal parieties): operation for directing the orifices of the ureters into the rectum; temporary success; subsequent death; autopsy. Lancet 1852;2:568.

Chapter 77 Conduit Urinary Diversion Glenn’s Urologic Surgery

Chapter 77 Conduit Urinary Diversion Lesley K. Carr and George D. Webster

L. K. Carr: Department of Surgery Division of Urology, University of Toronto, Wellesley Hospital, Toronto M4Y IJ3, Ontario, Canada. G. D. Webster: Department of Surgery, Division of Urology, Duke University Medical Center, Durham, North Carolina 27710.

Diagnosis Indications for Surgery Alternative Therapy Description of Procedure Patient Preparation Surgical Technique Postoperative Care Outcomes Complications Results Chapter References

The ileal conduit, as first described by Bricker in 1950, continues to be the most common form of urinary diversion performed worldwide. Although continent urinary diversion to a catheterizable abdominal stoma and orthotopic bladder replacement are gaining popularity and may offer the patient greater freedom to continue social and leisure aspects of their life, circumstances exist when simple conduit diversion is optimal.

DIAGNOSIS This procedure is done as part of a reconstruction following functional or actual loss of the urinary bladder, and all diagnostic studies are directed to the underlying pathology in the bladder.

INDICATIONS FOR SURGERY Patients should be thoroughly counseled regarding options for diversion, both continent and incontinent. Coexistent medical illness such as renal compromise (serum creatinine more than 2.5 mg %) predicting electrolyte disturbance or bowel disease (inflammatory bowel, malignancy) may mitigate against continent diversion. In very elderly or infirm patients who would tolerate additional operative time or possible revisions of the diversion poorly, a simple conduit may be wise. Finally, preoperative confirmation of the ability and reliability of the patient to perform self-catheterization is an essential requirement for any continent diversion.

ALTERNATIVE THERAPY When a conduit diversion is selected, options exist for the segment of intestine used and the type of ureteroenteric anastomosis. Other potential conduit segments include colon and jejunum, the latter of which is associated with a high incidence of metabolic disturbances. The most commonly employed alternative to the ileal conduit is some form of continent diversion or orthotopic neobladder.

DESCRIPTION OF PROCEDURE Patient Preparation Proper stoma siting is critical for a successful outcome in appliance-dependent urostomy surgery. The entero-stomal therapist should examine the patient in the supine, erect, and sitting positions and will consider preferred clothing styles. The stoma site is generally in the right lower quadrant just medial to the rectus on a line between the umbilicus and anterior superior iliac spine. The site should avoid these landmarks, along with scars and creases to enable face plate adherence. Bowel preparation should begin 2 days prior to surgery with clear fluids. Polyethylene glycol electrolyte solutions taken by mouth the day before surgery will achieve an adequate preparation in most cases. Volumes of 4 L are generally sufficient and may be augmented by tap water enemas per rectum until efflux is clear. Intravenous hydration during this final phase of preparation may be advisable to avoid dehydration. The addition of oral antibiotics is debatable but broad-spectrum intravenous antibiotic coverage is indicated at the time of surgery. Surgical Technique Incision and Preparation of the Field A long midline incision is optimal for dissection and an abdominal ring retractor (Bookwalter type) facilitates exposure. The ureters should be mobilized with care to protect their blood supply and transacted distally as close to the bladder as possible. This is especially important on the left side where the ureter must have adequate length to traverse a hiatus beneath the sigmoid mesocolon and approximate the right ureter for ureteroenteric anastomosis. Isolation of the Intestinal Segment The terminal ileum remains the standard bowel segment for conduit urinary diversion. Relative contraindications to the use of ileum are significant radiation changes, coexistent bowel disease such as active Crohn's disease, short bowel syndrome, and insufficient mesenteric length to allow proper delivery of the loop through the abdominal wall for stoma creation. In the patient with a normal body habitus, a 15-cm length of ileum is usually sufficient. Conduits that are too short jeopardize proper stoma formation and conduits that are excessively long may aggravate metabolic and electrolyte abnormalities and empty poorly. The distal mesenteric incision is made in the avascular area between the ileocolic artery and the right colic artery ( Fig. 77-1). This location, which is generally 15 cm from the ileocecal valve, allows for a long distal mesenteric incision facilitating mobility of the bowel for its transfer through the abdominal wall yet maintains sufficient terminal ileum to avoid bile salt malabsorption. At least four vascular arcades should supply the loop to avoid ischemic complications.

FIG. 77-1. (A) Selection of the ileal segment. Note distal mesenteric window located in the watershed area between the right colic artery and the ileal branch of the ileocolic artery. (B) Bowel anastomosis performed cephalad to the isolated ileal segment with mesenteric defect closed.

Ileoileal reanastomosis is performed cephalad to the conduit using either standard staple or suture techniques. The mesenteric window is closed to avoid internal bowel herniation. The isolated ileal loop is then irrigated free of fecal contents using antibiotic solution and a sump suction. Use of Colon There are several theoretical advantages to the use of colon for urinary conduits. The colon is more amenable to tunneled antireflux ureteroenteric anastomosis, is less prone to stomal stenosis, and is potentially less likely to result in electrolyte disturbances. Despite this, colon conduits generally only find their use in patients with pathology of the small intestine or heavy prior pelvic irradiation. The transverse and sigmoid colon are the most commonly employed segments. The transverse colon has the advantage of being out of the field of pelvic irradiation, having good mobility, and occupying a more cephalad position for use with short ureters. The segment of colon is isolated in a similar fashion to that described for the ileum ( Fig. 77-2). Leadbetter-type tunneled antireflux ureteroenteric anastomosis or simple end-to-side anastomosis is then performed.

FIG. 77-2. Transverse colon conduit. The large bowel is anastomosed and intestinal continuity is restored. The ureters are brought intraperitoneally below the duodenum next to the proximal portion of the colon conduit. Anastomoses of ureters to bowel are accomplished in a routine manner. Stents may be employed.

Use of Jejunum Jejunum has been recommended for use as a urinary conduit when the stoma must be placed higher on the abdominal wall or when high diversion is needed because of lower ureteral pathology. It may also be less affected by prior pelvic irradiation than ileum. The disadvantage of jejunum is its marked absorptive capacity, which is associated with large fluid shifts and a syndrome characterized by hyponatremic, hypochloremic, hyperkalemic metabolic acidosis. The situation is aggravated by compromised renal function. Ureteroenteric Anastomosis A good outcome from ureteroenteric anastomosis is dependent on intact blood supply to the conduit and distal ureter along with avoidance of tension. If cystectomy was performed for malignancy, frozen sections of the ureteral margins should be free of tumor, carcinoma in situ, and severe dysplasia. A surgical clip or ligature left on the distal ureter from the time of its transection will allow the ureter to dilate gently and facilitate anastomosis. The most commonly used anastomotic techniques are the Bricker end-to-side and the Wallace conjoined spatulated end-to-side anastomosis, both of which are freely refluxing. Alternatively, a split-cuff nipple or the technique of Le Duc may be used to prevent reflux. When colon is used, Leadbetter antirefluxing tunneled implants through the tenia are generally advocated. The true value of nonrefluxing ureteroenteric anastomosis remains unknown, and it may be that the potential advantages of reflux avoidance are offset by the increased risk of ureteral obstruction. Atraumatic handling of the ureter and careful suture placement using 4-0 or 5-0 absorbable material are essential for a good outcome. Urinary leakage with resulting fibrosis may be minimized with the use of stents. Silastic single J stents may be brought out through the conduit stoma and offer the additional benefit of preventing poor conduit drainage from early bowel edema. Regardless of anastomotic technique, it is customary to retroperitonealize the proximal conduit end and the region of the ureteroenteric anastomosis by fixing the cut edges of the peritoneum to the conduit. This also limits future risk to the anastomotic area from intraperitoneal surgery or pathology, and may contain any postoperative anastomotic urine leak. Most surgeons advocate the use of closed suction drains placed alongside the ureteroenteric anastomosis during the initial preoperative period. Bricker End-to-Side Ureteroileal Anastomosis With this technique, the butt (proximal) end of the conduit is closed using two layers of absorbable suture. A small full-thickness plug of ileal wall is sharply excised at a site where the end of the ureter naturally lies. The mucosal defect need not be as large as the seromuscular defect. The terminal ureter is spatulated and a single-layer anastomosis is performed using interrupted sutures of absorbable 4-0 or 5-0 material. Sutures should encompass the full thickness of the ureteral and bowel wall. Further sutures approximating ureteral adventitia and bowel serosa will act to reinforce the anastomosis but must not cause kinking ( Fig. 77-3).

FIG. 77-3. Ileal conduit showing the ureters sutured from beneath the isolated segment into the antimesenteric border of the loop. The reconstituted mesentery is demonstrated.

Wallace Anastomosis With this technique, the proximal end of the conduit is left open for anastomosis to the conjoined ureters. The ureters are spatulated over a length of 2 to 3 cm and the adjacent sides arc approximated using a running 4-0 absorbable suture. The open ureteral plate is then anastomosed end-to-end to the open proximal end of the ileal

conduit using running absorbable suture. The advantages of this technique are its speed and the wide ureteral anastomosis, which is less prone to obstruction. A suggested disadvantage when diversion is being performed for bladder malignancy is the possibility of ureteral recurrence causing bilateral obstruction ( Fig. 77-4).

FIG. 77-4. Wallace technique with anastomosis of the conjoined ureteral plate to the proximal end of the ileal conduit.

Leadbetter Tunneled Reimplant into Colon For tunneled anastomosis, the ureter is spatulated and a 2- to 3-cm trough is made in an antimesenteric tenia. The grove is full-thickness through the serosa and muscularis but leaves the mucosa intact. A small opening is made in the mucosa at the inferior end of the trough and the ureter is anastomosed in this location using fine absorbable suture. The seromuscular layer is then approximated over the proximal ureter, thus creating a submucosal tunnel to prevent reflux. The groove must be wide enough that the ureter is not obstructed by reapproximation of the muscular layer ( Fig. 77-5).

FIG. 77-5. Leadbetter ureterocolic nonrefluxing anastomosis. A submucosal tunnel is created along an antimesenteric tenia and reapproximated in a nonobstructing fashion over the ureter.

Construction of the Stoma A circular plug of skin and subcutaneous fat is excised at the preoperatively marked site. A cruciate incision in the anterior rectus fascia is made and the rectus muscle bluntly split. The hiatus created into the peritoneal cavity should readily admit two fingers. This will avoid compression of the conduit mesentery and reduce the risk of parastomal hernia formation. The distal conduit is grasped and delivered through the abdominal wall defect, ensuring that the mesentery is not twisted or stripped. The conduit is secured by fixing the anterior rectus fascia to the serosa of the bowel in four quadrants. The border of the stoma is matured to the skin edge using three-way bites incorporating dermis, serosa 2 cm from the edge, and full-thickness bowel margin ( Fig. 77-6). Four such sutures are generally sufficient to achieve eversion of the stoma and additional sutures may be placed between the dermis and bowel edge, as needed.

FIG. 77-6. A rosebud stomal nipple is created by using interrupted absorbable stitches between subcutaneous tissue, lateral bowel wall, and the terminal edge of the segment. This avoids puckering of the skin and permits a smooth surface for the appliance.

In cases where the bowel has insufficient mobility or the patient is morbidly obese, a Turnbull loop stoma may offer benefit ( Fig. 77-7).9 In this technique, the distal end of the conduit is closed using two-layer absorbable suture. A knuckle of the terminal loop is delivered through the stomal defect and the bowel is incised on the antimesenteric border. The serosa is secured to the anterior rectus fascia and the cut edge of the bowel is matured to the skin edge. The blind end of the stoma should be positioned cephalad.

FIG. 77-7. The modified Turnbull loop stoma.

Postoperative Care The major factor dictating duration of hospital admission is return of bowel function. Nasogastric or percutaneous gastrostomy bowel decompression may be advocated during the initial postoperative period of ileus depending on the magnitude of the associated surgical procedures. Ureteral stents are maintained for approximately 7 days or longer. The suction drain may be removed once drainage is negligible or shown to be serous based on a low-drain fluid creatinine. Before discharge the patient should be taught about all aspects of stoma care by an enterostomal therapist. Routine follow up is generally at 4 to 6 weeks and then 3 months postoperatively. An intravenous pyelogram and serum renal profile is obtained at the 3-month visit. Unless problems arise, annual surveillance of the upper urinary tract, renal and metabolic profile, and periodic serum B 12 and folate are levels sufficient thereafter. If the reason for cystectomy was malignancy, urine cytology is also indicated.

OUTCOMES Complications The perioperative mortality and morbidity for patients undergoing ileal conduit urinary diversion has reduced remarkably as a result of improved surgical technique along with better supportive care both intraoperatively and postoperatively. Current mortality rates including cystectomy can be expected between 1% and 3%. The most common urology-specific early postoperative complications are ureteroenteric anastomotic urine leak or obstruction and urosepsis. With the availability of percutaneous nephrostomy drainage, surgical intervention for ureteral anastomotic obstruction due to edema is rarely required. Delayed complications of conduit urinary diversion are common, but generally are mild and do not require surgical revision. Urinary colonization can be expected in at least 65% of patients, but perhaps as few as 20% develop pyelonephritis as a result of reflux of this colonized urine. Antibiotic therapy is usually warranted only for recurrent pyelonephritis or if Proteus becomes chronic. Approximately 10% of patients will develop renal calculi but their management has been dramatically facilitated by percutaneous and lithotripsy techniques. Stomal complications, namely, stenosis, prolapse, or parastomal hernias combined, may occur in up to 25% of cases with prolonged surveillance. These complications generally require operative revision. Ureteral obstruction has been reported with an incidence of 5% to 10%. 7 Most commonly it is a result of fibrosis, but recurrent malignancy and stones may be contributing factors. Endoscopic or fluoroscopic balloon dilation of the strictured area is often successful at relieving the obstruction. Deterioration in renal function must be monitored on a lifelong basis. In some cases it is chronic and progressive with no identifiable cause, but in many cases an etiology may be identified and corrected. Results Conduit urinary diversion will continue to enjoy a major role even with increasing popularity of continent options. The simplicity of surgical technique and postoperative stoma care renders conduit diversion the most appropriate choice in many instances. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am 1950;30:1511. Golimbu M, Morales P. Jejunal conduits: technique and complications. J Urol 1975;112:787. Leadbetter WF, Clarke BG. Five years experience with ureteroenterostomy by the “combined” technique. J Urol 1954;73:67. Leduc A, Camey M, Teillac P. An original antireflux ureteroileal implantation technique: long-term follow up. J Urol 1987;137:1156. Morales P, Golimbu M. Colonic urinary diversion: 10 years of experience. J Urol 1975;113:302. Regan JB, Barrett DM. Stented versus non stented ureteroileal anastomoses: is there a difference with regard to leak and stricture? J Urol 1985;134:1101. Schmidt JD, Hawtrey CE, Flocks R, Culp DA. Complications, results and problems of ileal conduit diversion. J Urol 1973;109:210. Stone AR, Macdermott JPA. The split-cuff ureteral nipple reimplantation technique: reliable reflux prevention from bowel segments. J Urol 1989;142:707. Turnbull RB, Fazia V. Advances in surgical technique in ulcerative colitis surgery. In: Nyhus L, ed. Surgery annual. New York: Appleton-Century Crofts, 1975;315. Wallace DM. Ureteric diversion using a conduit: a simplified technique. Br J Urol 1968;38:522.

Chapter 78 Kock Pouch Continent Urinary Diversion Glenn’s Urologic Surgery

Chapter 78 Kock Pouch Continent Urinary Diversion John A. Freeman

J. A. Freeman: Division of Urology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599–7235.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Preoperative Preparation Operative Technique Postoperative Care Outcomes Complications Results Chapter References

Innovative surgeons have struggled for centuries with the question of how best to replace a diseased bladder. During this time the technique of urinary diversion has evolved along three themes: cutaneous fistulas (nephrostomy, pyelostomy, and ureterostomy), implantation of ureters into segments of bowel in continuity with the fecal stream (ureterosigmoidostomy), and implantation of ureters into segments of bowel isolated from the fecal stream (bowel conduits and continent diversion). While all of these forms of diversion are successful in eliminating urine, they do not achieve similar success in recapitulating the detrusor's inherent properties of providing a large-capacity, low-pressure reservoir that is continent and nonrefluxing, allows volitional voiding, and prevents significant resorption of urinary electrolytes. These properties are best mimicked by continent forms of urinary diversion. Modern advances in surgical technique, perioperative care, and anesthesia have lessened the morbidity of exenterative surgery, allowing the surgeon and patient to consider reconstructive options. In 1982, Nils Kock reported his results with a continent cutaneous ileal reservoir for urinary diversion in 12 patients. 4 This was the first documentation of the simultaneous use of the preeminent concepts of modern continent urinary diversion, which must now be considered to be the gold standard in urinary reconstruction: (a) detubularization of the bowel to provide a low-pressure, large-capacity reservoir; (b) an antireflux mechanism to protect the upper urinary tract; and (c) urinary continence. With more than a decade of experience with continent diversion, reconstructive surgeons have proven that continent forms of diversion can replace conduit diversion in most cases, are technically sound and durable, and are clearly the preferred choice of most patients who are given the option.

DIAGNOSIS The use of this procedure is as an adjunct for reconstruction of the urinary tract, usually following cystectomy. The diagnostic modalities therefore are relevant only as to the primary diagnosis that resulted in the plan for the cystectomy.

INDICATIONS FOR SURGERY Any patient who requires removal of the bladder or diversion of the urinary stream away from the bladder is a potential candidate for a Kock pouch cutaneous urinary reservoir. Today, however, the number of patients undergoing cutaneous diversion (continent or incontinent) continues to decline. This is a function primarily of the success and utilization of orthotopic urinary diversion, which is applicable to approximately 90% of male bladder cancer patients and 75% to 85% of female bladder cancer patients. 2,10 To be a candidate for continent cutaneous diversion, the patient should have the intelligence, maturity, and manual dexterity to manage the urinary diversion, as well as a life expectancy great enough to recover from the operation and enjoy the lifestyle benefits of the reconstructive surgery. Some patients are less than ideal candidates. Morbid obesity presents significant technical difficulties in forming the pouch, securing the cutaneous continence limb, and achieving catheterization. Patients with prior small bowel resections, bowel symptoms, or neurogenic bowel dysfunction are at risk for development of bowel dysfunction following surgery. Impaired renal function, unless severe (serum creatinine more than 2.5–3.0), is not a contraindication to continent urinary diversion. Initial concerns over electrolyte disturbances caused by urine resorption in the face of compromised renal function have not proven clinically significant. Only rarely does a patient develop a clinically significant metabolic acidosis requiring therapy because the bowel mucosa loses much of its absorptive capacity after chronic exposure to urine.

ALTERNATIVE THERAPY The alternatives to continent cutaneous urinary diversion are incontinent cutaneous urinary diversion (percutaneous nephrostomy, pyelostomy, ureterostomy, and bowel conduit urinary diversion), ureterosigmoidostomy, and orthotopic urinary diversion (neobladder construction). The patient must understand that the choice of a particular form of urinary diversion consists primarily of a quality-of-life decision and has essentially no impact on the course of the disease necessitating bladder replacement. It is the responsibility of the surgeon who undertakes urinary reconstruction to fully educate the patient of all available forms of reconstruction, and their relative benefits and risks. Having been so educated, the patient is prepared to make a truly informed decision. Currently, continent urinary diversion is the gold standard against which any other form of urinary diversion must be measured.

SURGICAL TECHNIQUE Preoperative Preparation The patient is admitted 1 day prior to surgery for bowel preparation, intravenous hydration, and antibiotics. The modified Nichols bowel preparation, which has been previously described, consists of a clear liquid diet and 120 cm 3 of oral castor oil emulsion (Neoloid) administered on arrival, followed by oral neomycin and erythromycin base over the course of the day. 8 This is a well-tolerated regimen that gently and reliably cleanses and sterilizes the small bowel. The enterostomal therapist marks an appropriate abdominal stoma site and reinforces patient education concerning reconstruction alternatives. If the patient is undergoing conversion of an existing ileal conduit to a cutaneous Kock ileal reservoir, it is important to radiographically assess the patency of the ureteroileal anastomoses. If free reflux is demonstrated, the ileal conduit can be incorporated into the afferent antireflux segment of the reservoir. If obstruction is demonstrated, the ureteroileal anastomoses should be revised prior to incorporation of the conduit into the antireflux segment. Intravenous hydration overnight prevents dehydration, which can complicate any cathartic bowel preparation. Operative Technique The patient is placed in the hyperextended supine position. A midline incision from the pubis is carried left of the umbilicus and extended to the epigastrium. Construction of the urinary reservoir is begun after completion of the exenterative portion of the operation. The small bowel is divided distally in a freely mobile portion of the mesentery, 15 to 20 cm proximal to the cecum in the avascular plane of Treves between the terminal branch of the superior mesenteric artery and the ileocolic artery. If small bowel has been resected previously, then the enteroenterostomy site should be utilized if at all possible. Locating the distal division in a mobile portion of the mesentery is critical because this will later be secured to the abdominal wall as the cutaneous continence mechanism. The length of small bowel to be used for the reservoir must be measured initially. Segments of ileum to be utilized for specific components of the reservoir are measured and marked with silk sutures as one moves proximally along the 78 cm of small intestine that will be required for the reservoir: 17 cm distally for the efferent cutaneous continence nipple mechanism, two 22-cm segments for the reservoir, and a second 17-cm segment for the proximal antireflux nipple mechanism ( Fig. 78-1). A shallower mesenteric division is made at the proximal end of the bowel, assuring a broad vascular pedicle to the segment for the reservoir. An additional 5-cm segment of bowel is discarded proximal to this proximal mesenteric division to allow free mobility of the reservoir separate from the remaining small bowel. Continuity of the gastrointestinal tract is restored by performing an enteroenterostomy. The use of a stapled or hand-sewn anastomosis is the operating surgeon's

choice. If staples are utilized, the staples at the proximal end of the segment of intestine to be utilized for the reservoir should be excised and the bowel should be closed with absorbable suture (3-0 chromic Parker-Kerr stitch), reinforced with 4-0 silk Lembert sutures to prevent stone formation within the reservoir. The mesenteric window is closed with running, locking 3-0 chromic suture, with care taken not to compromise the blood supply to the reservoir.

FIG. 78-1. A 78-cm segment of small bowel is isolated for the Kock pouch. The distal 17 cm is utilized for the cutaneous continence valve, two 22-cm segments are used for the lumen of the reservoir, and a proximal 17-cm segment is used for the antirefluxing valve mechanism. A 5-cm segment of small bowel is excised proximal to the isolated segment to ensure adequate mobility between the reservoir segment and the small bowel reanastomosis. The proximal mesenteric division should be shallow to provide a broad vascular pedicle to the reservoir segment. The distal mesenteric division is normally located in the avascular plane between the terminal branch of the superior mesenteric artery and the ileal colic artery.

The small bowel segment to be utilized for the reservoir is then isolated in the right lower quadrant ( Fig. 78-2). It is easiest to lay the bowel into a U shape in the right lower quadrant on top of a sterile towel and drape a second towel over the remaining bowel above the reservoir segment. This leaves only the reservoir segment visible in the surgeon's field. The serosal surfaces of the inner edges of the two 22-cm segments that form the U are then apposed to each other 0.5 cm above the mesentery with a running 3-0 polyglycolic acid (PGA) suture, with care taken not to damage the mesentery or move too far away from the mesenteric edge ( Fig. 78-2). The 22-cm segments are then opened along the antimesenteric edge of the 3-0 PGA suture line, exposing the lumen of the bowel and “back wall” of the reservoir. It is important to continue these incisions some 2 to 3 cm onto the 17-cm segments so that when the nipple valves are later constructed they will be separated along the back wall of the reservoir (Fig. 78-3). The raw mucosal edges of the back wall resulting from incising the serosa adjacent to the original 3-0 PGA suture are then anastomosed with two layers of running, locking 3-0 PGA suture ( Fig. 78-4).

FIG. 78-2. The 78-cm segment is isolated in the right lower quadrant with the two 22-cm segments forming a U directed into the right lower quadrant. The 17-cm segments lie as wings at the top of the U. The serosal surfaces of the 22-cm segments are sewn together with 3-0 polyglycolic acid suture 0.5 cm above the mesenteric junction.

FIG. 78-3. The reservoir segments are incised with electrocautery adjacent to the polyglycolic acid suture line. The incisions are extended 2 to 3 cm along the 17-cm wings, allowing the nipple valves to be separated on the back wall of the reservoir.

FIG. 78-4. The back wall of the reservoir is closed in water tight fashion with a running, locking two-layer 3-0 polyglycolic acid suture.

The next task is to create the nipple valve mechanisms responsible for continence in the efferent (distal) segment and preventing reflux in the afferent (proximal) segment. Both nipple mechanisms are constructed in similar fashion, although the proximal antireflux nipple can be shorter than the distal continence nipple. Beginning where the 17-cm segments join the 22-cm segments, the mesentery of the 17-cm wings of ileum is divided for 7 to 8 cm (windows of Deaver) with electrocautery adjacent to the ileum without injuring the bowel serosa ( Fig. 78-5). Limiting adherent mesenteric fat on the bowel serosa facilitates the intussusception required for nipple construction and prevents later extussusception. Three vascular arcades are spared and a separate small window of Deaver is made in the

mesentery to allow passage of a 2- to 3-cm doubled strip of PGA mesh soaked in tetracycline (250 mg in 10 cm 3 normal saline). Marlex mesh (as originally described) should not be used because it can erode into the bowel, causing infection, stone formation, and incontinence. The PGA mesh is used to fix and stabilize the nipple, and will assist in anchoring the efferent limb to the abdominal fascia.

FIG. 78-5. To allow intussusception of the nipple valve mechanisms, the mesentery adjacent to the 17-cm segments must be mobilized. An 8-cm mesenteric window is developed using electrocautery for hemostasis. One centimeter of mesentery is spared where each 17-cm segment joins the 22-cm segments. A second 1-cm window in the mesentery is created one or two vascular arcades beyond the 8-cm mesenteric window to accommodate the polyglycolic acid mesh collars.

The nipple valves are created by intussuscepting bowel from the 17-cm segments into the lumen of the reservoir. The intussusception is performed by passing two Allis clamps two-thirds of the way into the lumen of the 17-cm segment toward the PGA mesh, grasping the mucosa, and withdrawing the Allis clamps. A third Allis clamp on the cut edge of the ileum facilitates this maneuver ( Fig. 78-6). The resulting nipple valve should be at least 5 cm long, and it is important to leave a lip of bowel serosa (where the third Allis clamp is located) to facilitate closure of the reservoir. The nipple intussusception is secured by stapling of the intussuscepted bowel. This can be performed with a standard TA-55 stapler, but I prefer a custom gastrointestinal anastomosis (GIA) device that has no knife. The TA-55 that aligns with a pin in the stapling head occasionally leads to a pinhole fistula in the valve mechanism and should be avoided. Pinless TA-55 devices are available. Two rows of staples are applied in the anterior 180 degrees of the nipple, making sure to utilize the entire length of the stapling device to achieve a 5-cm nipple mechanism ( Fig. 78-7). Since the staples at the tip of the nipple do not significantly contribute to its stability, the distal six staples can be removed from the cartridge prior to firing. This eliminates redundant staples that are exposed at the tip of the nipple and contribute to stone formation.

FIG. 78-6. Tetracycline-soaked mesh is positioned in each distal mesenteric window. The nipple valves are intussuscepted into the lumen of the reservoir by passing two Allis clamps two-thirds of the way into the lumen of the 17-cm segment, grasping the mucosa, and pulling the limb 5 cm into the reservoir.

FIG. 78-7. The nipple valve mechanisms are secured by stapling the anterior 180° of the valve mechanism with two staple lines from a pinless TA-55 or knifeless GIA. The distal 6 staples at the tip of the nipple are removed prior to firing the stapler.

To prevent extussusception of the valve, with resultant incontinence and reflux, a third full-length row of staples secures the nipple to the back wall of the reservoir. The easiest and most reliable method to do this is by passing the customized GIA (without a knife) or a TA-55 device along the serosal surface of the intussusception. Firing the device in this way attaches the back wall of the reservoir to a single thickness of the nipple with a full row of staples ( Fig. 78-8). The nipple is further secured to the pouch wall by scoring the apposing mucosal surfaces with electrocautery and suturing the nipple tip to the back wall with 2-0 chromic suture ( Fig. 78-9). Finally, the tetracycline-soaked PGA mesh is secured circumferentially to the ileal serosa with 2-0 chromic suture, and additionally to the base of the reservoir where the intussusception enters the reservoir. Care is taken not to narrow the lumen of the ileum by performing the fixation over a 30-Fr Medina (ileostomy) catheter (Fig. 78-10). Careful construction and fixation of the valves is crucial to maintain continence, prevent reflux, avoid fistulas, and allow easy catheterization; this portion of the operation cannot be rushed.

FIG. 78-8. The valves are secured to the back wall of the reservoir by passing a pinless TA-55 or knifeless GIA along the serosal surface of the back wall and serosal surface of the intussuscepted ileum, adjacent to the mesentery. This fixes one fold of the intussusception to the back wall of the reservoir. Alternatively, a hole can be

made in the back wall of the reservoir adjacent to the tip of the valve and the arm of the stapler can then be passed inside the lumen of the valve. This then fixes all three serosal layers of the bowel (two from the intussusception and one from the back wall). If this technique is used, the hole in the back wall needs to be oversewn with 3-0 polyglycolic acid suture.

FIG. 78-9. The tips of the nipples are secured to the back wall of the reservoir with 2-0 chromic after scoring the mucosal surface of the nipple and the reservoir to increase scar formation and nipple fixation.

FIG. 78-10. The polyglycolic acid mesh collars are sutured to the 17-cm segments and base of the 22-cm segments over a 30-Fr catheter.

The reservoir is then closed by folding the bottom of the U up to the free mucosal edge near the base of the valve mechanisms. The center portion of the bottom of the U is attached to the midpoint of the free edge between the nipples, creating a spherical reservoir. Running 3-0 PGA suture closes this anterior wall in two layers ( Fig. 78-11). Closely placed sutures that invert the mucosa prevent urinary leaks.

FIG. 78-11. The reservoir is closed in spherical fashion with two layers of a running, locking 3-0 polyglycolic acid suture.

The ureters are spatulated and anastomosed to the reservoir in end-to-side fashion on opposite sides of the afferent limb using interrupted 4-0 PGA sutures ( Fig. 78-12). The base of the afferent segment is secured to the sacral promontory. The ureteroileal anastomoses are stented with radiolucent no. 8 infant feeding tubes that are passed proximally into the renal pelvis. The distal ends are passed across the antireflux valve into the lumen of the reservoir. When the ureteroileal anastomoses are completed, the sigmoid mesenteric trap is closed by suturing the edge of the mesentery to the PGA collar at the base of the afferent limb. In this way, the left ureter is left in a retroperitoneal location.

FIG. 78-12. The ureters are anastomosed to the afferent limb in end-to-side fashion, and the base of the efferent limb is secured to the sacral promontory. The stoma site is selected and three horizontal mattress sutures of no. 1 polyglycolic acid (PGA) are fixed to the lateral, medial, and inferior aspects of the anterior fascial opening. These are secured to the corresponding sites of the PGA mesh collar on the efferent limb. A 1-cm Marlex mesh sling is passed through the mesenteric window of Deaver on the superior aspect of the fascial opening. The cutaneous continence limb is pulled through the stoma, the PGA sutures are tied, and the Marlex sling is secured to the posterior abdominal fascia.

Finally, the efferent limb is prepared for cutaneous anastomosis. It is my preference to taper the efferent limb segment over an 18-Fr catheter down to the PGA mesh. This removes some of the redundancy that can make catheterization difficult at times. The tapering is easily performed by excising the antimesenteric border of the

ileum with a standard GIA stapler. The location of the stoma site is chosen to allow the efferent limb to rise to the skin in an essentially perpendicular fashion, preventing angulation which may later make catheterization difficult. A small skin plug is excised using the flat end of a 10-cm 3 syringe plunger as a template. The anterior rectus fascia is incised vertically for 2 to 3 cm and the muscle fibers retracted. Three no. 1 PGA horizontal mattress sutures are placed through the anterior rectus fascia on the lateral, inferior, and medial portions of the incision, and affixed in their corresponding spots on the PGA collar of the efferent limb. Care must be taken to ensure that the efferent limb is not twisted when the sutures are placed and that the sutures do not become crossed while being passed through the abdominal wall and secured to the collar. A narrow 2- to 3-cm strip of Marlex mesh is secured with no. 1 PGA to the abdominal wall superior and lateral to the cephalad extent of the fascial incision. This is then passed through the mesenteric window of the efferent limb (window of Deaver) which accommodates the PGA mesh collar, forming a sling that supports the mesentery to the efferent limb. A Babcock clamp guides the free distal end of the efferent limb through the stomal opening, with care taken not to cross sutures or wrap the ileum in suture. The PGA sutures are tied, fixing the PGA mesh to the anterior rectus fascia. The medial free edge of the Marlex “strut” is then sutured to the abdominal wall medial to the mesentery, completing a four-quadrant fixation of the efferent limb of the reservoir that facilitates catheterization and prevents parastomal herniation. The catheterizable ileal limb is stretched to the skin level to guarantee a straight catheterization channel, and the redundant ileum above skin level is excised. A flush stoma is constructed circumferentially with 3-0 PGA suture. Drainage of the reservoir during the healing phase can be performed in several ways. A 30-Fr Medina tube through the stoma into the reservoir has been traditional. In a tapered efferent limb, a 30-Fr tube is precluded and instead a capped 18-Fr catheter is left through the stoma to fix the efferent limb in a straight position during the scar formation of the early postoperative period. The ureteral stents are sutured to a 22-Fr catheter that is exteriorized through the skin and anterior pouch wall, draining the reservoir. Alternative methods of managing the distal ureteral stents include exteriorization by bringing them through the anterior wall of the reservoir and through a skin stab wound, creating a dry reservoir during the healing process or leaving them within the lumen of the reservoir for later endoscopic retrieval. Mucous irrigation can be performed in an in-and-out fashion if needed between the two catheters. The catheters are secured to the skin with nonabsorbable suture after assuring easy irrigation of the reservoir prior to, and subsequent to, abdominal closure. A doubled 1-in. Penrose drain is placed through a separate stab wound in the lower abdomen and is positioned in a dependent portion of the pelvis. The drain should not lie on suture lines of the reservoir because it may migrate into the lumen of the pouch. Fixing it to the psoas muscle or peritoneum with a 4-0 chromic will prevent migration of the drain. Postoperative Care The most important aspect of early postoperative care is adequate, unobstructed drainage. The reservoir is irrigated with 60 to 120 cm 3 of normal saline every 4 hours to prevent mucous obstruction of the catheters. Patients learn to manage their catheters, Penrose drain, and irrigation and are discharged when bowel function returns. They return 3 weeks after surgery for removal of catheters and drains if intravenous pyelogram and reservoir x-rays reveal no leakage. The initial catheterization regimen is every 2 hours, increasing by 1 hour each week until the goal of every 6-hour catheterization is achieved. A small absorbent pad worn over the stoma site prevents mucous soiling of clothing.

OUTCOMES Complications The early complication rate (10% to 15%) is similar for patients undergoing single-stage cystectomy and Kock pouch construction, conversion of an ileal conduit to a Kock pouch, or construction of an ileal conduit at the time of cystectomy. The overall incidence of late complications related to the reservoir is 10% to 15%. 6,7 It is convenient to segregate reservoir-related complications into those related to the cutaneous continence limb, the reservoir itself, and the afferent antireflux limb. The most common and confounding problem associated with the cutaneous continence limb remains incontinence. With all of the modifications to nipple construction over the years, incontinence can be expected to occur in 5% to 10% of patients due to an extussuscepted nipple, a fistula, a nipple of inadequate length, or other rare causes. Parastomal herniation rarely occurs if the four-quadrant technique described here is utilized. The problem of Marlex erosion described in the early literature has disappeared since Marlex mesh is no longer used to stabilize the valves. Difficult catheterization remains a problem in the obese patient, but tapering the catheterization limb should minimize this difficulty. Problems related to the storage portion of the reservoir can be divided into metabolic and nonmetabolic. Metabolic complications include solute absorption disorders due to urine coming into contact with the absorptive bowel mucosa for long periods between catheterizations, and metabolic alterations related to the removal of segments of bowel from the gastrointestinal tract. Although these topics are beyond the scope of this discussion, they have been well reviewed. 5 The bowel mucosa atrophies over chronic exposure to urine so that long-term metabolic disturbances, such as metabolic acidosis with its potential demineralizing effects on bone, are rare if renal function is normal. Vitamin B 12 replacement may be necessary after 5 years. The most common nonmetabolic complication associated with the reservoir is calculus formation, seen in 5% to 10% of patients. Vigilance is needed to diagnose these calculi, and they can be managed by outpatient endoscopic techniques. 3 Spontaneous rupture has been reported, and this uncommon complication can be fatal if not recognized. Complications associated with the afferent antireflux limb includes ureteroileal anastomotic stricture in 3%, stenosis of the valve in 3%, and asymptomatic reflux. afferent valve, however, has been remarkably free of significant complications.

9

The

Results Patients are encouraged to return to a normal lifestyle with minimal restrictions after complete healing has occurred. Patient satisfaction has been tremendous but depends on realistic expectations from the outset. 1 Patient counseling should include a discussion that makes clear that the choice of urinary diversion is a lifestyle choice unlikely to significantly impact survival (which will be determined by the disease necessitating bladder replacement). The patient should not expect the reservoir to perform like a native bladder. Nonetheless, quality-of-life surveys demonstrate an advantage for patients with continent diversion compared to conduit diversion in terms of body image, sexual life, and personal satisfaction. A properly motivated patient with realistic expectations is likely to benefit most from the procedure. CHAPTER REFERENCES 1. Boyd SD, Feinberg SM, Skinner DG, Lieskovsky G, Baron D, Richardson J. Quality of life survey of urinary diversion patients: comparison of ileal conduits versus continent Kock ileal reservoirs. J Urol 1987;138:1386–1389. 2. Elmajian DA, Stein JP, Esrig D, et al. The Kock ileal neobladder: updated experience in 295 male patients. J Urol 1996;156:920–925. 3. Ginsberg D, Huffman JL, Lieskovsky G, Boyd SD, Skinner DG. Urinary tract stones: a complication of the Kock pouch urinary diversion. J Urol 1991;145:956–959. 4. Kock NG, Nilson AE, Nilsson LO, Noden LJ, Philipson BM. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol 1982;128:469–475. 5. McDougal WS. Metabolic implications and electrolyte disturbances. In: Webster GD, Goldwasser G, eds. Urinary diversion: scientific foundations and clinical practice. 1st ed. Oxford: Isis Medical Media, 1995;32–44. 6. Skinner EC, Lieskovsky G, Boyd SD, Skinner DG. Continent cutaneous diversion and total bladder replacement using the Kock principles. Rec Adv Urol Androl 1991;5:135–147. 7. Skinner DG. Intussuscepted ileal nipple valve; development and present status. Scand J Urol Nephrol (Suppl) 1992;142:63–65. 8. Skinner DG, Lieskovsky G. Technique of radical cystectomy. In: Skinner DG, Lieskovsky G, eds. Diagnosis and management of genitourinary cancer. Philadelphia: WB Saunders, 1988;607. 9. Stein JP, Freeman JA, Esrig D, et al. Complications of the afferent antireflux valve in the Kock ileal reservoir. J Urol 1996;155:1579–84. 10. Stein JP, Stenzl A, Esrig D, et al. Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience. J Urol 1994;152:1404–1408.

Chapter 79 Right Colon Reservoir Glenn’s Urologic Surgery

Chapter 79 Right Colon Reservoir Jorge L. Lockhart

J. L. Lockhart: Division of Urology, Harborside Medical Center, Tampa, Florida 33606.

Anatomic, Physiologic, and Urodynamic Considerations Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Preoperative Care Reservoir Preparation Ureteral Intestinal Reimplantation Antiincontinence Mechanism Conversion From an Ileal Conduit to A Continent Urinary Reservoir Postoperative Care Outcomes Complications Results Chapter References

Attempts to develop a continent urinary reservoir have been studied since 1950, when Gilchrist and Merricks described their original cecal bladder. 2 An important step for the popularization of continent urinary reservoirs followed Lapides's experience with intermittent catheterization, demonstrating both safety and patient acceptance.4 Following the original report of 12 patients undergoing the Kock procedure, Skinner and colleagues focused on improvement of the surgical technique. Ten other authors, including ourselves, adopted other modified techniques utilizing the ileocecal segment (Indiana, Mainz, Florida, Miami).

ANATOMIC, PHYSIOLOGIC, and URODYNAMIC CONSIDERATIONS The extended right colonic segment includes the cecum, ascending colon, hepatic flexure, and right half of transverse colon. The blood supply is provided by branches of the superior mesenteric artery. These arteries are the middle colic (midtransverse colon), right colic (hepatic flexure), and ileocolic (cecum and distal ileum). The venous drainage is characterized by veins that accompany the arteries and drain into the portal system (superior mesenteric vein). This colonic segment has two primary functions: storage of chyme and water, and electrolyte absorption. The amount of water absorbed represents a small amount of the total absorbed in the intestinal tract. The motility of the right colon is characterized by both a segmental and a mass type of activity; however, the transit time is much slower than in the small bowel, which emphasizes the value of right colon as a storage organ. This organ harbors a large number of bacteria, among which the Bacteroides fragilis (anaerobe) and Escherichia coli (aerobe) are the most common, emphasizing the need of an adequate bowel preoperative preparation. Postoperative urinary continence depends on a suitable balance between reservoir pressure and outlet resistance. Incontinence occurs if there is an imbalance between both systems and ensues if there is a high-pressure, small-capacity reservoir or an inadequate outlet resistance. For the above reasons, detubularized intestine should be used to create a large-capacity reservoir and decrease its intraluminal pressure. In our patients, the long-term follow-up of reservoir pressure recording has demonstrated that involuntary bowel contractions tend to diminish in amplitude. Therefore, incontinence can improve with time if these patients are properly followed provided there is adequate resistance at the antiincontinence segment level.

DIAGNOSIS The right colonic reservoir is usually performed in conjunction with a cystectomy and as such the diagnostic modalities relate to the indications for cystectomy (see Chapter 23 and Chapter 24). All physiologic and medical abnormalities should be diagnosed and treated preoperatively. The patient should completely understand the magnitude and risks of the procedure and should be assessed for their compliance and dexterity. The rigors of time, intermittent catheterization and periodic pouch irrigation should be explained.

INDICATIONS FOR SURGERY Indications for a right colonic reservoir include the absolute or functional loss of the bladder. Contraindications for the procedure include the following: (a) poor understanding of or compliance with the procedure; (b) inability to properly maneuver upper extremities; (c) high risk from the surgical point of view; (d) inflammatory bowel disease, large bowel malignancy, or previous history of multiple bowel ablative procedures; (e) low-weight myelomeningocele, with history of bowel ablative procedures, with or without history of diarrhea. In adult patients with bowel disease or previous bowel resection, I obtain a gastroenterology consultation for colonoscopy and occasionally for a barium enema. A patient with an ileal conduit diversion, without another bowel segment previously resected, can be converted to a continent colonic diversion. 2,4,8,10 I do not routinely perform a barium enema on children unless there is a specific indication. Children with myelomeningocele and low body weight or young adults with previous bowel ablation procedures associated with the elimination of the ileocecal valve present a well-known risk for the development of postoperative diarrhea with utilization of the ileocecal segment. In some of these patients we have recommended diversion utilizing a composite gastrointestinal segment. 6

ALTERNATIVE THERAPY Alternatives to the right colonic reservoir include other forms of urinary diversion including ureterosigmoidostomy ( Chapter 76), ileal or colonic conduits ( Chapter 77), continent urinary diversions ( Chapter 78, Chapter 80), or orthotopic bladders (Chapter 81, Chapter 82 and Chapter 83).

SURGICAL TECHNIQUE Preoperative Care The patient should arrive at the operating suite in a satisfactory nutritional and hydroelectrolytic balance. An intravenous central line should be initiated the night before the surgical procedure. Bowel preparation should include a low-residue diet, antibiotics (neomycin, erythromycin), and a mechanical clean-out. Golytely solution the day prior to surgery accomplishes the latter function. Preoperative stomal position is not as essential as with an incontinent appliance diversion. An area where the patient would perform intermittent catheterization without difficulty should be selected for stomal placement. Reservoir Preparation With the patient in the supine position, a midline incision should be made between 5 cm above the umbilicus and the symphysis pubis. The incision may be extended

upward if difficulties are encountered with the colonic mobilization or if changes due to multiple adhesions or radiation therapy in the lower abdomen exist. After exploration of the abdominal contents, any necessary pelvic cavity ablative procedure should be performed first. Both ureters should be isolated and mobilized, taking special care to preserve the adventitia. The left ureter is brought behind and above the mesosigmoid to the right hemiabdomen; it is important to avoid bringing the ureter below the sigmoid vessels to prevent its kinking. This maneuver is facilitated if a 4-0 silk suture is left attached to its lower end. Attention is then focused on the cecum and distal ileum, where 10 to 12 cm of distal ileum is freed from adhesions while the bowel is transacted proximally utilizing GIA-60 nonabsorbable staples. The blood supply of the distal ileum is provided by the ileal branch of the ileocecal artery. This intestinal segment is used for the construction of the antiincontinence mechanism. The right colon, hepatic flexure, and right half of transverse colon are mobilized after the incision of the parietal peritoneum and gastrocolic ligament. Care should be taken to preserve its blood supply while transecting the right colon (ileocolic and right colic arteries) with similar GIA-60 staples. The middle colic artery should remain with the left transverse mesocolon to prevent ischemia in the left half of the transverse and the splenic flexure in the event of future need of left colon resection ( Fig. 79-1). The bowel stream is reconstituted through a laterolateral ileotransversostomy using routine stapling techniques. Care should be taken to suture the mesentery to the transverse mesocolon to prevent internal hernias postoperatively.

FIG. 79-1. Division of transverse colon. Care is taken to preserve middle colic artery.

The end of the transected transverse colon is folded toward the right gutter and shaped as an inverted U. Both bowel limbs can be grasped with Allis clamps or approximated with silk sutures as depicted in Figure 79-2. The staple line from the transverse colon end is removed and an opening of approximately 3 in. is created in the cecum (Fig. 79-3). A Polysorb 75 (absorb-able) stapler is utilized to suture both bowel limbs together ( Fig. 79-4).7 With the reservoir mucosa exposed, a small incision (2 cm) is made at the end of the staple lines to allow the insertion of the absorbable stapler and continue the bowel limbs suturing ( Fig. 79-5). The Polysorb 75 stapler is again inserted and the suturing between both bowel limbs is completed. As a rule, three Polysorb staplers are utilized to complete the detubularization of the reservoir (Fig. 79-6 and Fig. 79-7). With the reservoir open at its lower end, the ureters are brought in for reimplantation.

FIG. 79-2. Approximation of limbs of bowel as part of detubularization.

FIG. 79-3. Opening in bowel approximately 3 in. from cecum.

FIG. 79-4. Stapling of bowel limbs with Polysorb GIA stapler.

FIG. 79-5. A small incision must be made at the end of the staple line to allow further stapling.

FIG. 79-6. Usually three Polysorb staplers are utilized to complete detubularization.

FIG. 79-7. Completion of detubularization.

Ureteral Intestinal Reimplantation Authors differ on the ureteral intestinal reimplantation technique. The main concern is ureteral intestinal obstruction, which can occur after pouch distention, lower ureteral stretching, and fibrosis in the weeks following surgery. Reflux has proven to be non-deleterious in these large-capacity, low-pressure reservoirs. 3 In one of the larger series, the Leadbetter combined technique is recommended. 9 The technique is extraintestinal and combines a direct mucosa-to-mucosa anastomosis with a submucosal tunnel. We have utilized a direct transintestinal reimplantation as described by Goodwin. 3 In some situations, however, the extraintestinal approach can be utilized at the discretion of the surgeon. For creation of a direct anastomosis, and with the bowel mucosa exposed, the reservoir wall is perforated with a small hemostatic clamp. The ureter is brought intraluminally (Fig. 79-8). Care should be taken to avoid ureteral kinking or twisting, mainly during the left ureteral manipulation. The ureter is spatulated for at least 2 cm and fixed to the submucosa with four quadrant sutures using 5-0 absorbable material. Four or five sutures are placed between the end of the ureter and the bowel mucosa (Fig. 79-9). Single-J ureteral stents, 7.5 mm in diameter, are placed in both ureters. Both catheters are fixed to the bowel mucosa with 3-0 absorbable sutures. A 22-Fr Malecot catheter is left indwelling in the reservoir and is brought out through a separate incision in the reservoir's anterior wall. The purpose of leaving a Malecot catheter is for postoperative irrigation of clots and mucus, and for urine drainage until the reservoir suture lines are completely healed. A purse string suture with 3-0 chromic material is placed where the Malecot exits from the pouch. The ureteral catheters can be brought out through the same Malecot catheter opening, through the stoma, or can be transected at 4 cm from the exit from the ureteral orifices and sutured to the Malecot catheter with nonabsorbable suture material. This maneuver would eliminate the need for postoperative care of the ureteral stents. However, in some difficult cases in which renal failure occurs, the lack of access to the ureteral catheter prevents injection of contrast to determine the real cause for the problem. The reservoir can be closed as shown on Figure 79-10 or with a running and locking 3-0 Vicryl suture.

FIG. 79-8. Reimplantation of ureter.

FIG. 79-9. Anastomosis of ureter to bowel mucosa.

FIG. 79-10. Closure of reservoir (absorbable staples).

Antiincontinence Mechanism The Indiana group pioneered the bowel plication concept as an antiincontinence mechanism for continent urinary reservoirs. 9 The main idea is to reinforce the ileocecal valve using bowel wall infolding sutures. Using a similar concept, we reported our plication technique. 5 Similar to Rowland's technique, the last 10 cm of ileum is left attached to the reservoir and plicated around a 10- or 12-Fr Robinson catheter. In our procedure, the bowel infolding is performed with interrupted, nonabsorbable sutures placed longitudinally in the ileum, ileocecal valve, and cecal wall ( Fig. 79-11). A second plicating suture row is placed in the opposite bowel side at 12 o'clock from the first one ( Fig. 79-12). A 10- or 12-Fr Robinson catheter is passed several times to test the ease of intubation and the catheter is withdrawn. An alternative preparation of the antiincontinence mechanism utilizing staples has been reported. 1 With a red Robinson no. 14 Fr catheter in place, the antimesenteric bowel edge is grasped with Allis clamps; two GIA-60 stapling devices are utilized to transect the bowel between catheter and clamps leaving the catheterizable segment around the red Robinson catheter ( Fig. 79-13 and Fig. 79-14). Other alternatives to strengthen the ileocecal valve have been utilized by different authors. Rowland et al. utilized plicating sutures in the cecum and opposite to the stapled antiincontinence segment ( Fig. 79-15). When this technique is utilized, we also place infolding sutures at the base of the antiincontinence segment in an attempt to further reinforce the ileocecal valve ( Fig. 79-16 and Fig. 79-17).

FIG. 79-11. Bowel infolding technique to achieve continence. A layer of nonabsorbable sutures is placed longitudinally in the ileum, ileocecal valve, and cecal wall.

FIG. 79-12. A second plication layer is placed opposite to the first.

FIG. 79-13. Allis clamps are used to guide GIA stapling of catheterizable segment over a red Robinson catheter.

FIG. 79-14. Construction of tubular segment of catheterizable segment using GIA stapler.

FIG. 79-15. Completion of catheterizable segment with red Robinson catheter in place.

FIG. 79-16. Plication of cecum over catheterizable segment.

FIG. 79-17. Completion of plication.

More recently, we initiated an ileocecal valve reinforcing technique in reoperations for a variety of failed antiincontinence systems (appendix, reimplanted and tapered ileum, ileocecal valve). Following the stapling of the antiincontinence mechanism, a small window is created in the mesentery for a distance of approximately 2 to 3 in. (Fig. 79-18). The cecum is grasped at both sides of the base of the tapered ileal segment with Allis clamps and is brought around the ileocecal valve ( Fig. 79-19). Then both ends are sutured with four 3-0 silk sutures ( Fig. 79-20). This technique has been utilized in reoperations and is now routinely performed in the new cases with excellent results.

FIG. 79-18. Window in mesentery created 2 to 3 in.

FIG. 79-19. Cecal segment brought through mesenteric window.

FIG. 79-20. Cecal segments sewn to encircle catheterizable segment.

The integrity of the antiincontinence mechanism is tested after pouch filling through the Malecot with 250 to 300 ml of saline. The ileal segment is brought out through the skin through the abdominal wall. Some surgeons prefer to bring out the ureteral stents through the stoma in order to facilitate postoperative care because urine will be collected in an urostomy bag. The ileal segment is brought out to the skin through the rectus sheath or umbilicus ( Fig. 79-21). Bringing out the ileal segment through the abdominal wall weak area (lateral to the rectus sheath through Spiegel's line) increases the incidence of parastomal hernias. Patients with a wide, well-vascularized distal ileal opening can be brought out to the skin through a circular stoma. If the distal ileum's diameter is relatively small or suspected to be poorly vascularized, the bowel is spatulated and the stoma is constructed utilizing a Y-V plasty technique. A laterally based skin triangle is elevated and defatted ( Fig. 79-22 and Fig. 79-23). The antiincontinence mechanism construction is completed with both ureteral stents coming out per stoma ( Fig. 79-24 and Fig. 79-25).

FIG. 79-21. Possible sites for stoma.

FIG. 79-22. Anatomic landmark relations to location of stoma in the right lower quadrant.

FIG. 79-23. Skin triangle developed for stoma.

FIG. 79-24. Catheterizable segment brought through the stoma site.

FIG. 79-25. Completed stoma.

Conversion from an Ileal Conduit to a Continent Urinary Reservoir A similarly prepared detubularized right colonic segment is positioned on top of the conduit and is sutured to the conduit utilizing Polyabsorb 75 GIAs as needed. Figure 79-26 shows the colon already stapled to the conduit and the antiincontinence mechanism to be brought to the abdominal wall. Figure 79-27 shows the final coloileal preparation.

FIG. 79-26. Conversion of ileal conduit to continent reservoir, with colon stapled to conduit.

FIG. 79-27. Conversion of ileal conduit to continent reservoir. Completed configuration.

Postoperative Care Immediately after surgery the patient is admitted to the intensive care unit. Precautions are taken to maintain circulating volume, hemoglobin levels, and hydroelectrolytic balance, which are essential in the immediate postoperative period. Prophylaxis for pulmonary infections and venous embolism are carried out. Intravenous antibiotics are maintained until the initiation of oral feedings; then they are switched to oral antimicrobials. I prefer to use third-generation cephalosporins with adequate gram-negative and anaerobe coverage. Patients undergoing a simultaneous cystectomy, who are expected to have a greater morbidity from the procedure, are initiated on patyrenteral hyperalimentation. The Malecot and ureteral catheters are irrigated twice daily to facilitate urine drainage. It is essential to irrigate the mucus from the reservoir cavity in the next two or three postoperative weeks. After return of bowel function, the ureteral stents are removed. Patients who live in our community are sent home and readmitted in 1 week for pouch activation. Other patients are maintained in the hospital until they perform intermittent catheterization satisfactorily. Pouch activation represents Malecot catheter clamping and initiation of intermittent catheterization. A baseline pouchogram and intravenous pyelogram are obtained. This is initially performed by well-trained nurses who also begin the patient's follow-up instruction. The next day, the Malecot catheter is removed and the patient is discharged from the hospital.

OUTCOMES Complications The most ominous complication with this procedure has been the development of ureteral-intestinal obstruction. When this complication occurs, initial percutaneous nephrostomy and internal stenting for 6 to 8 weeks is all that is required in approximately 50% of cases. The rest will need re-reimplantation, and in this situation a

trans-reservoir approach facilitates the procedure. Prior radiation therapy to the pelvis, though not a contraindication to this procedure, is associated with a higher incidence of wound infection and ureteral obstruction. Other postoperative complications include persistent postoperative diarrhea and metabolic abnormalities. Patients with persistent diarrhea will generally require gastroenterologic assistance for its management. The presence of intermittent acidosis has required treatment with Bicitra solution. Problems specific to the reservoir found in long-term follow-up include parastomal hernias and stone formation. Parastomal hernias require surgical correction and for that purpose we have achieved better results with takedown of the antiincontinence segment, internal closure of the hernia, and stoma repositioning to the abdominal wall. Stone disease in the reservoir can be managed better with percutaneous lithotripsy and, in the case of large stones, through an open lithotomy. Results We reported our initial results in 1990. A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series, 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1200 cm3 (average 747 cm3). Maximal reservoir pressures ranged from 10 to 58 cm H 2O (average 35 cm H2O). Of the 127 ureterocolonic reimplantations, 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach, and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the three techniques (absence of reflux and obstruction) were 75%, 88.6%, and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and three of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir whereas the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the overall rate of complication was comparable to previous series with ileal conduits. The double-row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours, and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or another complication. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Bejany DE, Politano VA. Stapled and non-stapled tapered distal ileum for construction of a continent colonic urinary reservoir. J Urol 1988;140:491–494. Gilchrist RK, Merricks JW, Hamlin HH, Rieger IT. Construction of substitute bladder and urethral. Surg Gynecol Obstet 1950;90:752–760. Helal MA, Pow-Sang JM, Lockhart JL, Sanford EJ, Figueroa TE. Direct (non-tunnelled) uretero-colonic reimplantation in association with continent reservoirs. J Urol 1993;150:835–837. Lapides J, Diokno AC, Gould FR, Lowe BS. Further observations on self catheterization. J Urol 1976;116:169–171. Lockhart, JL. An alternative method for continent supravesical diversion. Soc Pediatr Urol Newslett 1987;3:18–20. Lockhart JL, Davies R, Cox C, McAllister E, Helal M, Figueroa TE. The gastroileal pouch: an alternative continent urinary reservoir for patients with short bowel, acidosis and/or extensive pelvic radiation. J Urol 1993;150(l):46–50. Olsson CA, Kirsch AJ, Whang MIS. Rapid construction of right colonic pouch. Curr Surg Tech Urol 1993;6:3:1–7. Pow-Sang JM, Helal MA, Figueroa TE, Sanford EJ, Persky L, Lockhart JL. Conversion from external appliance wearing or internal urinary diversion to continent urinary reservoir (Florida Pouch I and II): surgical technique, indications and complications. J Urol 1992;147:356. Rowland RG, Mitchell ME, Birhle R. The cecoileal continent urinary reservoir. World Urol 1985;3:185–188. Skinner DG, Boyd SD, Lieskovsky G. Clinical experience with the Kock continent ileal reservoir for urinary diversion. J Urol 2985;132:1101–1107.

Chapter 80 Mitrofanoff Continent Urinary Diversion Glenn’s Urologic Surgery

Chapter 80 Mitrofanoff Continent Urinary Diversion Hubertus Riedmiller and Elmar Werner Gerharz

H. Riedmiller: Department of Urology, Julius Maximilians-University Medical School, 97080 Wurzburg, Germany. E. W. Gerharz: Department of Urology, Julius Maximilians-University Medical School, 97080 Wurzburg, Germany, and The Institute of Urology and Nephrology, University College London Medical School, London W1P 7PN, United Kingdom.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

In 1980 the French urologist Paul Mitrofanoff rediscovered the vermiform appendix as a catheterizable channel for emptying a urinary reservoir and for the first time described its attachment with a flap-valve antirefluxing technique to the bladder in children with meningomyeloceles. With its vascular mesenteric pedicle preserved, the proximal end of the isolated appendix was brought out to the skin, allowing clean intermittent catheterization (CIC). 7 But Mitrofanoff not only initiated an up-to-date persisting renaissance of the appendix in urologic reconstructive surgery; he also lent his name to a far-extended, well-defined concept applicable to a wide variety of urologic conditions. 13 The Mitrofanoff principle encompasses two distinct requirements: 1. A small-caliber supple conduit, most frequently the appendix, is brought to the skin as a catheterizable stoma facilitating catheterization by avoiding kinking and coiling catheters. 2. An antirefluxing connection of this conduit to the reservoir with a portion of the conduit placed in a submucosal tunnel provides continence by a highly effective flap-valve mechanism. To allow an adequate function those requirements have to be combined with the factors formulated by Snyder including a low-pressure urinary reservoir with adequate storage volume, nonrefluxing ureteral reimplantation, and successful emptying of the reservoir by CIC. The high-capacity reservoir is important to maintain a socially acceptable interval between catheterizations and is created using detubularized gastrointestinal segments for either augmentation cystoplasty or de novo construction if the native bladder is inadequate or absent. The nonrefluxing ureteral implantation is important for protection of the upper urinary tract integrity and renal function. Reliable low-pressure and complete evacuation of the reservoir by CIC permits the storage cycle to recommence. 11 Only 6 years after Mitrofanoff's report the original Mainz pouch technique was presented, 12 and the introduction of the submucosally embedded in situ appendix as the continent outlet since 1990 has simplified the surgical technique. This has greatly increased the acceptance of the Mainz procedure, developing it into an almost ideal realization of the above-described reconstructive “philosophy.” 6 Being the most intriguing modification of the Mainz pouch, its appendiceal configuration finally contributes to the wide array of successful Mitrofanoff variations: shorter excluded bowel segments, significant reduction of operation time (simple procedure), minimized risk of stone formation (no staples), and perfect continence with easy catheterization. 8 With a significant decrease of specific morbidity and mortality, continent intestinal reservoirs with cathe-terizable cutaneous stoma are no longer surgical curiosities but rather standardized indispensable constituents of the reconstructive urologist's armamentarium with large personal and institutional series throughout the world. 1,9,13

DIAGNOSIS As this technique is for urinary diversion, it is usually an adjunct to the treatment of the underlying pathology that resulted in the loss of the bladder and/or sphincteric function. The diagnostic modalities therefore should be directed at the underlying pathology and definitive treatment. Since in every case one should attempt to use any previously existing material, such as conduits or native bladder remnants, preoperative anatomic evaluation must result in a maximum of information. Excretory urography, voiding cystourethrography, loopogram, urethrography, endoscopy, and retrograde injection of ureteral stumps (if feasible) are therefore mandatory investigations especially in children with complex abnormalities and in patients with multiple prior surgeries. The functional assessment should include isotope renography, filling and voiding cystometrography, and upright cystography. An overall assessment of intelligence, manual dexterity, education, and social support is of paramount importance.

INDICATIONS FOR SURGERY Avoiding the need for external collection devices, continent urinary reservoirs have proved to be advantageous with respect to all issues directly related to the stoma, when compared to a conduit diversion. Significant superiority of continent diversion in the patients' global self-assessment of their quality of life, physical strength, mental capacity, leisure time activities, and social competence as indicators of enhanced vital power support our understanding that especially younger women and men do benefit from a Mitrofanoff solution and therefore should be offered this surgical option. 3 The appendix seems to be the most satisfactory structure for the creation of a catheterizable stoma and the placement in the umbilicus is recommended for cosmetic and functional reasons. 1,2,7,8,10,12,13 Whereas the most common indication for continent urinary reconstruction in adults has been in bladder replacement after anterior pelvic exenteration for malignant disease with curative intent, the predominant applications of the Mitrofanoff principle in children are inaccessible urethral orifice, discomfort in catheterization, or difficult incontinence due to simple or complex genitourinary abnormalities. 2,9,13 Moreover, continent urinary diversion increasingly becomes a consideration for patients in whom an abnormality of the lower urinary tract has resulted in renal failure or a functioning bladder is lacking for other reasons. 4 We use the Mitrofanoff principle as the continence mechanism in a primary therapeutic approach as well as in conversion and salvage maneuvers after failure of previous reconstructive surgery. The major advantage of the submucosally embedded in situ appendix, highly effective continence, may turn out to be its main drawback: once the bladder outlet is closed the patient is entirely dependent on CIC of the reservoir. If not emptied in a timely fashion, sufficiently high pressures may be generated within the reservoir to cause rupture with potentially fatal consequences. To achieve satisfactory results careful patient selection, continuing education, and meticulous compliance on the patient's part are essential. It is therefore desirable to have highly motivated patients with realistic expectations and normal intelligence who are physically and emotionally capable of dealing with the strict regimen of CIC.

ALTERNATIVE THERAPY The appendix may not be available, if surgically removed beforehand or unsuitable for use in reconstructive surgery. In these cases the surgeon must be familiar with appropriate alternative methods. In 6 cases out of our 95 nonappendectomized patients (6.3%), the vermiform appendix could not be used to create a continence mechanism due to complete fibrotic obliteration or insufficient diameter. Other authors observed higher rates of unsuitability (17% to 31%). In these cases, several alternatives have been described including ureter, tapered ileum, and fallopian tube. 13 In the ileocecal reservoir there are basically two surgical options: forming an isoperistaltic ileoileal intussusception valve ( Chapter 78), a technique with a long individual learning curve and a relatively high complication rate. Another option would be to mimic the appendix by construction of either a seromuscular bowel flap tube (pedicled island flap of large bowel) or a full-thickness bowel flap tube as described by Lampel et al. 6

SURGICAL TECHNIQUE In contrast to Mitrofanoff's original technique, in the appendiceal configuration of the Mainz pouch the appendix is left in situ. The excluded bowel segment is divided on the antimesenteric border leaving the lower 5 cm of the cecum (cecal pole) tubularized and intact. The opened bowel loops are sewn together thus creating a low-pressure and high-capacity reservoir. Both ureters are implanted in the large bowel segment of the pouch plate, forming long submucosal tunnels for reflux prevention. In some cases the appendix must be dilated to accommodate a 16- to 18-Fr catheter to assure sufficient postoperative drainage of mucus. After cutting of the distal end of the appendix, dilation is easily achieved using a set of slightly curved bougies. Analogous to the Lich-Gregoir procedure for vesicoureteral reflux, the seromuscular layer of the intact cecal pole is incised along the tenia libera for approximately 5 cm in length down to the mucosa. The incision should reach directly to the appendicular base and is extended like an inverted Y to both sides of the appendix, thus creating small seromuscular flaps. By careful dissection of the seromuscular tissue with small scissors, a broad submucosal bed (2 to 2.5 cm wide) for the appendix is created. The appendicular mesentery is freed of its excessive fatty tissue. Windows in the mesoappendix are created between the branches of the appendicular artery without compromising the blood supply ( Fig. 80-1). Anatomic variations of the appendicular artery ( Fig. 80-2) have to be respected and an additional branch of the anterior or posterior cecal artery supplying the base of the appendix should be preserved. After the appendix is correctly positioned into its submucosal bed the seromuscular layer is closed over the embedded in situ appendix through the mesoappendicular windows with interrupted 4-0 polydioxanone sutures ( Fig. 80-3 and Fig. 80-4). The seromuscular flaps described above are closed over the appendicular base and guarantee a safe and firm coverage. A short, mobile portion of the distal appendix remains for creation of the appendicoumbilical stoma (Fig. 80-5). The free portion of the appendix is pulled through the abdominal wall via a small incision at the umbilical area, where even in obese patients the thickness of the ventral abdominal wall is minimal. Anastomosis to the deepest point of the umbilical funnel is performed with six interrupted 4-0 polydioxone sutures on a cutting needle. If no umbilicus is present (as in the case of exstrophy), it is created by tubularizing a V-shaped cutaneous flap connected to the appendicular stump. The pouch is carefully attached to the abdominal wall with nonreabsorbable sutures to prevent the appendix from rotating and kinking and to keep the ileocecal pouch in its original position.

FIG. 80-1. Seromuscular incision along the tenia libera. Creation of the mesenteric windows in the mesoappendix.

FIG. 80-2. Anatomic variations of the appendicular blood supply.

FIG. 80-3. Closure of the seromuscular layer through the mesenteric windows over the embedded in situ appendix.

FIG. 80-4. Intraoperative view of the ileocecal reservoir with continent appendix outlet (mobile portion still has to be shortened).

FIG. 80-5. Correctly embedded in situ appendix with short mobile portion for creation of the appendicoumbilical anastomosis.

Placement of the stoma within the umbilicus is cosmetically very satisfactory and obviates the need of much length of an appendix to bridge a thick abdominal wall. In comparison to other variations of the Mitrofanoff principle in ileocecal reservoirs, submucosal embedding of the in situ appendix avoids excision, reimplantation, and especially 180 degrees rotation of the appendix with the risk of compromising the blood supply. Preserving the anatomic connection between appendix and cecal pole and positioning of the continence mechanism inside the pouch with an extremely short appendicular portion (less than 0.5 cm) outside the reservoir ensures ease of catheterization. In children, of course, one must minimize the use of bowel by appropriately scaling down the length of the intestinal segments recommended for adults.2,9

OUTCOMES Complications In 93 patients with appendiceal continence mechanisms in a continent urinary pouch followed for a mean of 36.1 months (2.9 to 67.8 months), two major stoma-related complications (2.1%) were observed: due to complete necrosis the appendix had to be replaced by an intussuscepted ileal nipple. Stomal stenosis was observed in 14 patients (15.1%). Although the intermittent passage of the catheter through the conduit dilates the lumen repetitively and may successfully prevent, decrease, or delay encroachment of the appendiceal lumen, it has been recognized that stomal stenosis at the appendicoumbilical junction may be troublesome, especially in the absence of a natural umbilicus such as in patients with bladder exstrophy. In most cases, a gradually stenosing stoma requires simple revision (see below) and remains of adequate caliber. In these patients 20 reinterventions—either simple removal of scar tissue or star-shaped incision (Sachse appendicotomy)—were required. All procedures could be performed with local anesthesia on an outpatient basis. An indwelling catheter was left in place for 1 to 3 days. Although these simple revisions usually lead to good results, the prevention of recurrence is desirable, particularly in patients with a neoumbilical stoma. For that reason, we have developed a cone-shaped metal dilator with a maximum caliber of 24 to 26 Fr. 5 The effective length was chosen to cover only the known critical segment of the tunnel. It is currently applied by 14 of our patients, including 2 men with a neoumbilicus. Directly before inserting the catheter for evacuating the low-pressure reservoir the stoma is gently dilated for a few minutes once or twice per day. With a mean follow-up of 18 months, none of these patients has suffered from recurrent stenosis. A modification of the stomal implantation, described by Woodhouse, avoids stomal stenosis by creation of an oval anastomosis using a V-shaped flap of the umbilical funnel instead of the original circular anastomosis. The long-term complications inherent in continent urinary diversion lined with enteric epithelium are well described. This issue, however, is gaining importance with the number of years a patient has to cope with the physical and mental consequences of an artificial nonphysiologic combination of the gastrointestinal and urinary tract. Whereas in the adult population survival is often determined by the underlying malignant condition, except for a genitourinary abnormality healthy children are facing a close to normal life expectancy. Only a minority of the cancer patients will experience the whole range of late complications of urinary diversion, but in many of the children those complications are perhaps inevitable and may involve serious physical and psychological morbidity, or, even in the worst case, become a limiting factor quo ad vitam. Results At the Department of Urology in Marburg within the last 5 years, 375 patients (352 adults and 23 children) underwent urinary diversion with creation of continent reservoirs in more than 70%. The spectrum of applied techniques included orthotopic bladder substitution, sigma rectum pouch, and ileal or colonic conduits. In 193 patients an ileocecal pouch with umbilical stoma was fashioned. As a continence mechanism the submucosally embedded in situ appendix could be utilized in 93 cases; in 100 cases an ileal intussusception valve was established. In terms of outcome, 97.9% patients with appendicoumbilical stoma are completely continent day and night; easy CIC was initially achieved in 100%. In 11 patients with functional or morphologic bladder loss, a continent urinary reservoir has been created in preparation of kidney transplant. Five patients (aged 11, 14, 16, 31, and 52 years) received a cadaveric donor kidney 5, 6, 8, 9, and 17 months after urinary reconstruction with excellent renal function (creatinine 0.9 to 1.7 mg/dl) at a follow-up of 1 to 48 months (mean 13.8 months). Performed as a staged procedure with urinary diversion as the first step, this strategy successfully combines the advantages of two clinically well-established therapeutic principles obviating external urine collecting devices and chronic hemodialysis. Both in situ appendix and intussuscepted ileum valve are very satisfactory techniques for providing continence in an ileocecal urinary reservoir. Besides the known advantages of the appendix in the primary reconstructive approach—easy and relatively quick procedure, minimized risk of stone formation, and reduced loss of bowel—the treatment of subsequent complications usually is simple. Thus, whenever an appropriate appendix is encountered it should be the intestinal segment of choice in forming a continence mechanism. CHAPTER REFERENCES 1. Duckett JW, Lofti AH. Appendicovesicostomy (and variations) in bladder reconstruction. J Urol 1993;149:567–569. 2. Dykes EH, Duffy PG, Ransley PG. The use of the Mitrofanoff principle in achieving clean intermittent catheterisation and urinary continence in children. J Pediatr Surg 1991;26:535–538. 3. Gerharz EW, Weingärtner K, Dopatka TH, Köhl U, Basler HD, Riedmiller H. Quality of life following cystectomy and urinary diversion: results of an interdisciplinary retrospective study. Urol 1997;158:778–785. 4. Gerharz EW, Köhl U, Melekos MD, Weingärtner K, Riedmiller H. Kidney transplantation into continent urinary reservoirs in patients with absent or non-functioning bladder. Abstracts of the 31st Congress of the European Society for Surgical Research, Southampton, United Kingdom, March 3–4, 1996. 5. Köhl U, Gerharz EW, Weingärtner K, Riedmiller H. Point of technique: a simple device in the prevention of recurrent appendico-umbilical stenosis. Br J Urol 1996;77:603–604. 6. Lampel A, Hohenfellner M, Schultz-Lampel D, Thüroff JW. In situ tunneled bowel flap tubes: two new techniques of a continent outlet for Mainz pouch cutaneous diversion. J Urol 1995;153:308–315. 7. Mitrofanoff P. Cystostomie continente transappendiculaire dans le traitement des vessies neurologiques. Chir Pediatrics 1980;21:297–305. 8. Riedmiller H, Bürger R, Müller SC, Thüroff J, Hohenfellner R. Continent appendix stoma: a modification of the Mainz pouch technique. J Urol 1990;143:1115–1117. 9. Riedmiller H, Gerharz EW. The in situ-appendix modification of the Mitrofanoff principle in ileocecal reservoirs. Dialog Pediatr Urol 1996;19:3–5. 10. Riedmiller H, Gerharz EW. The Mitrofanoff principle in continent urinary diversion. In: Webster GD, Goldwasser B, eds. Urinary diversion. 1st ed. Oxford: Isis Medical Media, 1995;236–243. 11. Snyder HM. Principles of pediatric urinary tract reconstruction: a synthesis. In: Gillenwater JY, Grayhack JT, Howards SS, Duckett JW, eds. Adult and pediatric urology. Vol. 2. Chicago: Year Book, 1987;1726–1781. 12. Thüroff J, Alken P, Riedmiller H, Jacobi G, Hohenfellner R. 100 cases of Mainz pouch: continuing experience and evolution. J Urol 1988;140:283–288. 13. Woodhouse CRJ, MacNeily AE. The Mitrofanoff principle: expanding upon a versatile technique. Br J Urol 1995;74:447–453.

Chapter 81 Orthotopic Urinary Diversion Using an Ileal Low-Pressure Reservoir with an Afferent Tubular Segment Glenn’s Urologic Surgery

Chapter 81 Orthotopic Urinary Diversion Using an Ileal Low-Pressure Reservoir with an Afferent Tubular Segment Hansjörg Danuser and Urs E. Studer

H. Danuser and U. E. Studer: Department of Urology, University of Berne, 3010 Bern, Switzerland.

Diagnosis Indications Alternative Therapy Surgical Technique Cystectomy Preparation of the Ileal Segment for the Bladder Substitute Construction of the Bladder Substitute and Anastomosis to the Urethra Postoperative Education Outcomes Complications Results Chapter References

This form of orthotopic bladder substitution offers several significant advantages over other forms of diver-sion. One is the ease of surgery, which can be done by any urologist experienced in performing a radical prostatectomy or a cystectomy and ileal conduit. Anatomically, the terminal ileum as well as the ileocecal valve is preserved. The reservoir is spheric, thus achieving a maximum volume/surface area ratio with maximum capacity from a given bowel segment. To avoid metabolic disturbances from reabsorption of urine metabolites, a small surface of intestinal mucosa and a short contact time of the urine with the neobladder mucosa is important. The short ileum segment, 54 to 60 cm long, used to construct this bladder substitute minimizes intestinal malabsorption. On the other hand, according to Laplace's law, a certain reservoir size is mandatory to reduce tension on the neobladder wall and to keep intraluminal pressure low, aiding patients to achieve continence. Another advantage of this bladder substitute is the isoperistaltic tubular afferent segment with the ureteroileal anastomosis at its proximal end. It allows a resection of the distal ureters, including the paraureteral lymphatics, at a safe distance from the bladder cancer and reduces the risk of leaving behind distal ureters that may contain carcinoma in situ. The shorter the ureters are the better the blood supply can be preserved and the lower is the risk of ischemic stricture of the distal ureter. The peristalsis of the afferent ileal segment acts as a dynamic antireflux mechanism. In addition, the simple end-to-side technique of the ureteroileal anastomosis and the omission of an additional antireflux mechanism with a potentially high rate of strictures keeps this risk low. Even if a stricture occurs, the distensibility of the afferent tubular segment allows for bridging unilateral ureteral strictures or necrosis by reanastomosis to the more proximal ureter. In the case of complicated urethral strictures or tumor recurrence in the urethra, the afferent tubular segment can easily be transformed into an ileal conduit.

DIAGNOSIS In patients with invasive bladder cancer the workup includes bladder biopsies, CT scan of the pelvis and abdomen, chest x-ray, and bone scan to exclude lymph node or systemic metastasis. Urography is done to detect possible tumors of the upper urinary tract. Endoscopy of the urethra should exclude strictures or tumors and verify a normally functioning external urethral sphincter. In addition, biopsies from the prostatic urethra beneath the verumontanum are taken to exclude carcinoma in situ of the urethra, which would force one to perform a urethrectomy and choose another type of urinary diversion. Independent of the indication to cystectomy, renal function must be sufficient with a serum creatinine below 150 to 200 µmol/L (or when it can be expected to fall below this level after cystectomy in cases of obstruction of the upper urinary tract). Otherwise severe metabolic acidosis will occur.

INDICATIONS The most common indication to use the orthotopic bladder substitute is in patients after radical cystectomy for invasive bladder cancer. This reservoir, with slight modifications, is also useful for bladder augmentation after subtotal cystectomy in patients with a contracted bladder due to neurologic disorders or to replace a shrunken bladder and ureter after radiotherapy, particularly in female patients. Patients who want this orthotopic bladder substitute should be willing to cooperate and to accept and follow the postoperative education instructions. Only then will they achieve urinary continence, void without residual urine, and avoid urinary infections and metabolic disturbances.

ALTERNATIVE THERAPY Alternative therapies include other types of continent bladder substitutes and pouches, the ureterosigmoidostomy, and the ileal conduit.

SURGICAL TECHNIQUE All patients receive peri- and postoperative antibiotic prophylaxis consisting of an aminoglycoside and ornidazol for 48 hours and amoxicillin/clavulanate given until all drains are removed 12 to 14 days postoperatively. Heparin is given subcutaneously peri- and postoperatively as thrombosis prophylaxis. Cystectomy Pelvic lymphadenectomy and cystectomy are performed according to standard technique with slight modifications. 3 The external iliac vessels, the obturator fossa, and the hypogastric vessels are freed of all lymphatic, fatty, and connective tissue. Having divided the dorsolateral bladder pedicles containing the superior and inferior vesical vessels along the hypogastric arteries, the pelvic floor fascia is incised and Santorini's plexus is ligated. The ureters are divided where they cross the iliac vessels. This allows en bloc removal of the distal ureters and paraureteral lymphatic vessels, together with the cystectomy specimen. The dorsome-dial pedicle is resected along the pararectal/presacral plane on the tumor-bearing side. Whenever possible, however, care is taken to preserve the hypogastric fibers and the pelvic plexus situated dorsolaterally to the seminal vesicle on the contralateral non-tumor-bearing side. On this side the dissection along the dorsolateral wall of the seminal vesicle is stopped at the base of the prostate. Santorini's plexus is then divided and the membranous urethra transected as close as possible to the apex of the prostate by excavating it from the donut-shaped apex. The neurovascular bundles dorsolateral to the prostate are also preserved. Preparation of the Ileal Segment for the Bladder Substitute For construction of the reservoir, an ileal segment 54 to 60 cm long is isolated approximately 25 cm proximal to the ileocecal valve and bowel continuity is restored (Fig. 81-1). The length of the ileal segment is measured with a ruler in portions of 10 or 15 cm along the border of the mesoileum without stretching the bowel. Irritation of the bowel as well as peridural anesthesia can increase smooth muscle tone and activity and “shorten” the length of the bowel, which will then be too long after muscle relaxation. The distal mesoileum incision transects the main vessels, whereas the proximal mesoileum incision must be short in order to preserve the main vessels perfusing the future reservoir segment ( Fig. 81-1). The mesoileal borders are adapted with a running suture (2-0 polyglycolic acid) in which the mesoileum of the bladder substitute is included ( Fig. 81-2). The stitches must be applied superficially, with care taken to preserve the blood supply to the bladder substitute. Both ends of the isolated ileal segment are closed by seromuscular running sutures (4-0 polyglycolic acid). The distal end of the ileal segment, approximately 40 to 44 cm long, is opened along its antimesenteric border ( Fig. 81-2).

FIG. 81-1. Preparation of the 54- to 60-cm-long ileum segment for the bladder substitute. Note the different incision depth of the mesoileum proximally and distally, in order to preserve the circulation.

FIG. 81-2. Closure of the mesoileum incision. Avoid deep sutures in the area joining the mesoileum of the terminal ileum to the mesoileum of the bladder substitute in order not to compromise circulation.

Ureteroileal End-to-Side Anastomosis The ureters are split over a length of 1.5 to 2 cm and anastomosed by two running sutures using the Nesbit technique in an open end-to-side fashion to two longitudinal 1.5- to 2-cm-long incisions along the paramedian antimesenteric border of the afferent tubular ileal segment, which is 14 to 16 cm long ( Fig. 81-3). The ureters are stented with 7-Fr or 8-Fr catheters. To prevent dislocation of the stents, a rapidly absorbable suture (4-0 polyglycolic acid) is placed through the ureter and stent together 3 to 4 cm proximal to the anastomosis. It is tied very slackly, not compromising the ureteral vasculature. The most distal periureteral tissue is sutured to the afferent ileal segment to neutralize tension on the anastomosis and to cover it. The ureteral stents are passed through the wall of the most distal end of the afferent tubular segment, where it is covered by some meso-ileum. This provides a “covered” canal in the reservoir wall when withdrawing the ureteral stents 5 to 7 days postoperatively.

FIG. 81-3. Ureteroileal anastomosis using a simple end-to-side Nesbit technique with a 4-0 running suture assures a low stricture rate.

Construction of the Bladder Substitute and Anastomosis to the Urethra To construct the reservoir itself, the two medial borders of the opened U-shaped distal part of the ileal segment are oversewn with a single-layer seromuscular continuous 2-0 polyglycolic acid suture ( Fig. 81-4). The bottom of the U is folded over between the two ends of the U (Fig. 81-4 and Fig. 81-5), resulting in a spherical reservoir consisting of four cross-folded ileal segments. After closure of the lower half of the anterior wall and part of the upper half ( Fig. 81-5), the surgeon's finger is introduced through the remaining opening to determine the most caudal part of the reservoir. There a hole, 8 to 10 mm in diameter, is cut out of the pouch wall, outside the suture line (Fig. 81-6). Six polyglycolic acid 2-0 seromuscular sutures are placed between the hole in the reservoir wall and the membranous urethra ( Fig. 81-7). An 18-Fr urethral catheter is inserted before tying the six sutures ( Fig. 81-8). Before complete closure of the pouch, a 10-Fr cystostomy tube is passed through the wall of the pouch where it is covered by some mesoileum ( Fig. 81-9). The cystostomy tube is withdrawn 10 days postoperatively after exclusion of any leakage by pouch radiography. The indwelling catheter is left on continuous drainage for 2 more days before removal to allow for closure of the cystostomy canal in the reservoir wall.

FIG. 81-4. The two medial antimesenteric borders of the opened U-shaped distal ileum segment are oversewn with a single-layer seromuscular running suture. The bottom of the U is folded over and tied between the two ends of the U.

FIG. 81-5. The caudal half of the remaining reservoir opening is closed completely, the cranial half partially by a running seromuscular suture.

FIG. 81-6. A hole is cut into the most caudal part of the reservoir, close to the mesoileum and 2 to 3 cm away from the edge that resulted from cross-folding the ileum segment.

FIG. 81-7. Six seromuscular sutures are placed between the reservoir and the membranous urethra.

FIG. 81-8. The six prelayed sutures are tied after inserting an 18-Fr urethral catheter.

FIG. 81-9. After insertion of a cystostomy tube into the reservoir, the pouch is closed completely.

Postoperative Education Meticulous postoperative surveillance and teaching of the patient are paramount for good long-term results. After catheter removal, any bacteriuria is treated until the urine is sterile. Patients are instructed to void every 2 hours, first while sitting, by relaxing the pelvic floor and, if necessary, by abdominal straining. 2 Patients are encouraged to drink 2 to 3 L of fluid per day and to take additional dietary salt. The reservoir will secrete sodium and chloride if the urine is hypoosmolar. The additional salt intake prevents a salt-losing syndrome that might result in hypovolemia and acidosis. 5 Therefore, body weight and blood gases are controlled regularly. Patients without metabolic acidosis (negative base excess of more than 4 mmol/L), or with metabolic acidosis compensated by oral intake of sodium bicarbonate, are then instructed to retain the urine for 3 and later for 4 hours (even if they become incontinent earlier) until the maximal voiding volume is increased to 500 ml. Patients must be told that when the reservoir is full, increased reservoir pressure may cause urinary incontinence, but that it is essential to maintain the elevated pressure in order to expand the reservoir to the desired capacity. If a patient voids as soon as he or she becomes incontinent the reservoir will hardly ever expand; nighttime

incontinence in particular will be inevitable due to lack of capacity and the unfavorable pressure characteristics of a low-capacity reservoir. Residual urine is repeatedly ruled out and any bacteriuria treated.

OUTCOMES Complications Early complications are dehydration due to salt loss syndrome and/or metabolic acidosis, as well as those of extended abdominal surgery. complications of the bladder substitute such as intestinal obstruction, pouch necrosis, ureteral strictures, or necrosis are rare.

5,6,9

Specific late

Results Capacity The median functional capacity of the bladder substitute increases from 120 ml immediately postoperatively to 350 ml after 6 months and 500 ml after 12 months postoperatively by extending the micturition interval from 2 to 4 hours. 2,5,6 With the advice to maintain regular voiding intervals of 4 to 6 hours and to avoid micturition volumes exceeding 500 ml, overdistention of the reservoir will be prevented and its capacity will remain stable for years. Spontaneous voiding with abdominal straining is possible in 98% of patients. The necessity of intermittent self-catheterization is rare (1%). 5,6 Continence Urinary continence is poor just after removal of the catheter 10 to 14 days postoperatively but improves within 3 months with the increase of functional bladder capacity. Younger patients and those in whom a nerve-sparing cystectomy was performed achieve continence faster than older patients and patients with previous radiation therapy of the pelvis. 11 Daytime continence is achieved in 92% of the patients 1 year postoperatively, nighttime continence in 80% of the patients 2 years postoperatively. 1,2,5,6 Urinary Infection Positive urinary cultures 6 months postoperatively are found in 12% of patients, usually in combination with residual urine. The risk of pyelonephritis within a year is less than 2% for patients with this bladder substitute. 6 Ureteral Obstruction Ureteral strictures, usually on the left side distal ureter, occur in 2% of patients. 1,6. This low stricture rate is the result of a simple end-to-side anastomosis with short ureters and preservation of the ureter circulation, and absence of any additional antireflux mechanism. 7,8 An antireflux nipple valve in this type of bladder substitute is not necessary for the following reasons: 1. The bladder substitute is a low-pressure reservoir. 2. During voiding, abdominal straining simultaneously produces the same pressure increase in the bladder substitute, the abdomen, and the renal pelvis. Without pressure differences retrograde urinary flow is impossible. 7,8 3. The peristalsis of the afferent tubular ileal segment and the peristalsis of the ureter provide a dynamic antireflux mechanism, as has been demonstrated in a video showing simultaneous pressure recordings in the bladder substitute and in the renal pelvis. 7,8 4. The long-term results of a randomized prospective study including 70 patients with either an antireflux mechanism or an afferent isoperistaltic ileal segment support the hypothesis that an antireflux nipple is not necessary. There were no major differences between these two groups except for an increased rate of upper urinary tract obstruction in the patients with antireflux nipples. 7 Metabolic Disturbances The incidence of postoperative metabolic acidosis is related to the length of ileum used to construct the reservoir, excluding the length of ileum used for the afferent tubular segment. Metabolic acidosis occurs predominantly within the first 3 months postoperatively. If the problem is recognized, resolution is made easy by draining the bladder and administering saline infusions and sodium bicarbonate if necessary. Permanent sodium bicarbonate substitution is only necessary in acidotic patients with reservoirs constructed from ileum segments 50 to 60 cm long. 5,6 A major risk of long-term acidosis would be impaired bone metabolism with osteopenia and/or osteomalacia. However, those patients with a 5- to 8-year follow-up still have bone densities in the normal range. 10 In summary, this orthotopic bladder substitute constructed from 40- to 44-cm ileum with a 14- to 16-cm-long afferent tubular ileal segment is a low-pressure urinary reservoir with excellent urodynamic properties providing good daytime and nighttime continence. It has a low stricture rate of the ureteroileal anastomosis and an adequate dynamic antireflux mechanism, preventing kidney damage. Furthermore, this urinary diversion is well accepted by the patients and promises good results, provided that the patients are carefully selected, well instructed, and meticulously followed. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Benson MC, Seaman EK, Olsson CA. The ileal ureter neobladder is associated with a high success and low complication rate. J Urol 1996;155:1585. Casanova GA, Springer JP, Gerber E, Studer UE. Urodynamic and clinical aspects of ileal low pressure bladder substitutes. Br J Urol 1993;72:728. Skinner DG. Technique of radical cystectomy. Urol Clin North Am 1981;8:353. [Deleted in proofs.] Studer UE, Danuser H, Hochreiter W, Springer JP, Turner WH, Zingg EJ. Summary of ten years experience with a ileal low-pressure bladder substitute combined with an afferent tubular isoperistaltic segment. World J Urol 1996;14:29. Studer UE, Danuser H, Merz VW, Springer JP, Zingg EJ. Experience in 100 patients with an ileal low pressure bladder substitute combined with an afferent tubular isoperistaltic segment. J Urol 1995;154:49. Studer UE, Danuser H, Thalmann GN, Springer JP, Turner WH. Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: long term results of a prospective randomized trial. J Urol 1996;156:1913. Studer UE, Spiegel T, Casanova GA, et al. Ileal bladder substitute: antireflux nipple or afferent tubular segment? Eur Urol 1991;20:315. Studer UE, Thalmann G, Springer JP, Zingg EJ. Complications and functional results in 100 patients with an ileal bladder substitute. J Urol 1993;149:326. Tschopp AB, Lippuner K, Jaeger P, Merz VW, Danuser H, Studer UE. No evidence of osteopenia 5 to 8 years after ileal orthotopic bladder substitution. J Urol 1996;155:71. Turner WH, Danuser HJ, Moehrle K, Studer UE. The effect of nerve sparing cystectomy technique on postoperative continence after orthotopic bladder substitution. J Urol 1997;158:2118.

Chapter 82 Orthotopic Urinary Diversion Using a Colonic Segment Glenn’s Urologic Surgery

Chapter 82 Orthotopic Urinary Diversion Using a Colonic Segment Daniela Schultz-Lampel and Joachim W. Thüroff

D. Schultz-Lampel: Adult Department of Urology and Pediatric Urology, Klinikum Wuppertal GmbH, University of Witten/Herdecke Medical School, Wuppertal, Germany. J. W. Thüroff: Department of Urology, Johannes Gutenberg University Medical School, 55131 Mainz, Germany.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique The Mainz Pouch Le Bag Right Colon for Orthotopic Bladder Substitution Left Colon for Orthotopic Bladder Substitution Outcomes Complications Results Chapter References

Orthotopic urinary diversion refers to total replacement of the bladder with bowel and preservation of transurethral voiding, with an attempt to restore the storage capacity and volitional control of emptying. 13 For patients with benign diseases of the bladder and for selected cases of bladder cancer, orthotopic bladder substitution can achieve normal functional control of urinary storage and emptying and can contribute to a tremendous improvement of quality of life in patients who must undergo total cystectomy. For successful restoration of function, surgical reconstruction of a urinary bladder from bowel must achieve the following: 1. Creation of a reservoir with adequate capacity and storage pressures less than 40 cm H 2O 2. Ureteral reimplantation avoiding reflux and obstruction 3. Reliable control of continence and emptying of the reservoir A variety of surgical techniques have been developed whereby almost all segments of the gastrointestinal tract are used in different configurations to reconstruct a neobladder: stomach, ileum, ileocecum, ascending colon, sigmoid colon, and rectum. 9 Each surgical technique addresses certain advantages but the variety of available techniques obviates the ability to gain widespread and broad experience by a standardized approach. We prefer the large bowel for orthotopic bladder substitution because it has several advantages over small bowel: 1. 2. 3. 4.

A larger diameter requires a bowel segment of limited length. The length of the ileocecal artery allows transfer of the reservoir into the pelvis. A standard technique of antirefluxive ureteral implantation using a submucosal tunnel can be applied. Metabolic complications are fewer than after isolation of long segments of small bowel.

DIAGNOSIS Urinary diversion is generally done in situations in which there is an actual or functional loss of bladder. The diagnostic modalities utilized are more specific to the cause of the operation (e.g., cystectomy for cancer) than the type of urinary diversion utilized.

INDICATIONS FOR SURGERY Patient selection for orthotopic bladder replacement is critical and remains controversial. 10 Generally, an intact urethra and urethral sphincter mechanism as well as the feasibility of transurethral self-catheterization are regarded as prerequisites for orthotopic urinary diversion. Impaired renal function constitutes a contraindication for orthotopic bladder substitution because those patients may suffer from severe water and electrolyte imbalance. According to the literature, the main indication for orthotopic bladder substitution is bladder cancer in male patients requiring radical cystoprostatectomy. However, in our practice we apply a restricted indication for orthotopic total bladder substitution in malignant disease. Since patients with bladder cancer demonstrate an involvement of the urethra in 11% to 48% of all cases and the urethral recurrence rates are 6% to 15% in patients in whom the urethra is preserved as part of the cystectomy, we developed the following philosophy with regard to orthotopic bladder substitution: We regard transitional cell carcinoma in the urethra, prostate, or bladder neck as well as multifocal tumor occurrence or carcinoma in situ as contraindications for orthotopic bladder replacement. In females, the feasibility of an orthotopic bladder replacement has to consider not only the 40% incidence of primary tumor invasion of the urethra but also possible difficulties in transurethral self-catheterization. Despite recent promising results of orthotopic bladder replacement in females, urethrectomy with cutaneous urinary diversion must be considered the standard approach for females requiring cystectomy for bladder cancer. 9,10 On the other hand, orthotopic urinary diversion is an alternative to cutaneous urinary diversion in a variety of benign diseases, such as bladder contracture due to interstitial cystitis, tuberculosis, bilharziasis, or irradiation damage. In addition, orthotopic bladder substitution to the bladder neck is a therapeutic option for a functionally reduced bladder capacity in severe cases of detrusor hyperreflexia, bladder hypersensitivity, or low-compliance bladder, if these conditions do not respond to conservative therapy and if subtrigonal cystectomy with ureteral reimplantation is required. In patients with neurogenic bladder dysfunction, bladder substitution to the bladder neck can be an alternative to continent cutaneous diversion. This would be the case when intermittent self-catheterization through the urethra is feasible, standard bladder augmentation is not suitable, and ureteral reimplantation is required. However, pharmacotherapy and less invasive surgical techniques, such as neuromodulation and sacral deafferentation with implantation of an anterior sacral root nerve stimulator, should be considered first. 9 Orthotopic bladder substitution may also be applied for undiversion in selected patients who had previously undergone supravesical diversion.

ALTERNATIVE THERAPY As ileum, ileocecum, cecum, and different segments of the colon have been used for orthotopic bladder replacement with similar results, any of these surgical techniques may be used. Usually, the individual preference of the surgeon will determine the choice of the bowel segment. Most frequently, orthotopic bladder replacement is performed by using the ileum. 8 Such ileal reservoirs include the Camey II procedure for total bladder replacement, the Hautmann ileal neobladder, the Melchior ileal neobladder, the orthotopic Kock pouch, the Studer cross-folded ileal reservoir, the ileal S pouch, and other procedures. The variety of techniques indicates that there is no standardization regarding how to perform an ileal neobladder. The main differences between these techniques are the length of the ileum used and the antireflux technique of ureter implantation. The main problem after ileal neobladder over all techniques is a nighttime incontinence rate of at least 30%.8,10 In all patients with contraindications for orthotopic bladder replacement and especially in females, continent cutaneous urinary diversion should be considered as an alternative to orthotopic bladder substitution. 9,10 Incontinent urinary diversion may be reserved for patients with severely impaired renal function and patients with

impaired general health conditions who would not tolerate continent urinary diversion. In patients with benign diseases, bladder augmentation is an alternative for those in whom sparing of the bladder is possible.

9

SURGICAL TECHNIQUE The Mainz Pouch The ileocecal region and appendix was first utilized experimentally for supravesical urinary diversion by Verhoogen in 1908. Since that time different authors have successfully performed continent cutaneous urinary diversion and bladder substitution using the ileocecal region. 9 Since 1983, the Mainz pouch technique has combined detubularized cecum, ascending colon, and two ileal loops to create a spherical reservoir. 11,12 Light and Engelmann7 used a slightly modified pouch (“Le Bag”) for complete bladder substitution after cystoprostatectomy. The Mainz pouch technique of constructing a spherical pouch from 10 to 15 cm detubularized cecum and ascending colon and two ileal loops of the same length has been used since 1983 without major changes. A high-capacity reservoir with low pressures, a standard technique of ureteral implantation, and a universal applicability for bladder augmentation, bladder substitution, and continent cutaneous diversion are main advantages of this procedure. Diagnostic procedures for evaluation of the urinary tract include urodynamic studies of the bladder and the urethral sphincter mechanism in those patients with functional loss of bladder capacity. Evaluation of the colon by radiologic (contrast enema) and/or endoscopic (colonoscopy) examinations is performed to exclude polyposis, diverticulosis, and other bowel pathology. The bowel is rinsed the day before surgery by antegrade irrigation with 8 to 10 L of saline via a nasogastric tube. Intraoperatively the nasogastric tube is substituted by a gastrostomy catheter, and a rectal drainage tube is inserted in addition. Serum electrolyte concentrations are checked immediately after irrigation and, if necessary, are substituted intravenously. Prophylactic antibiotics are started the day before surgery and continued for at least 6 days postoperatively, e.g., piperacillin/tazobactam (Tazobac) 3 × 450 mg. After a median laparotomy, the cecum, ascending colon, and right colic flexure are detached from the abdominal wall and mobilized. The mesentery is divided between the right colic and the ileocolic arteries ( Fig. 82-1A). 10- to 15-cm of cecum and ascending colon and two segments of terminal ileum of same length each are isolated. Bowel continuity is restored by spatulated end-to-end ileoascendostomy using a single row of running 4-0 polyglyconate (Maxon) sutures of the seromuscularis layer only. Recently, reconstruction of the ileocecal valve has been introduced as a choice for selected cases. 2 As the appendix is not needed as a continent outlet for continent cutaneous urinary diversion, appendectomy is performed.

FIG. 82-1. Operative technique of Mainz pouch bladder substitution. (A) Intestinal segment to be isolated for the Mainz pouch procedure. (B) Antimensenteric splitting of intestine. (C) Side-to-side anastomosis of terminal and next proximal ileal loop. Line at antimesenteric splitting of the cecum for completing the posterior wall (pouch plate). (D) Antirefluxive implantation of ureters through a submucosal tunnel of 3 to 5 cm in length. (E) Buttonhole incision and anastomosis of the cecal pole to the membranous urethra for complete bladder substitution after radical cystoprostatectomy. (F) Completed Mainz pouch bladder substitution after radical cystoprostatectomy. Two 6- to 8-French ureteral stents and a 10-Fr pigtail cystostomy catheter are brought out through the abdominal wall. A transurethral 20-Fr Foley catheter is used for drainage and stenting of the urethral anastomosis.

The isolated bowel segment is irrigated clean with neomycin dissolved in saline. To create the reservoir, the isolated bowel segments are opened antimesenterically (Fig. 82-1B) and anastomosed side-to-side, connecting colon with terminal ileum and the latter with the next proximal segment of ileum, by a single row of running sutures of all layers using a straight needle and 4-0 polyglyconate (Maxon) sutures to create the posterior pouch plate ( Fig. 82-1C). For ureteral implantation, the left ureter is tunneled to the right side retroperitoneally and both ureters are implanted at the open end of the large bowel via a 3- to 5-cm-long submucosal tunnel with 6-0 polyglycolic acid (Dexon) sutures. The ureters are stented with 8-Fr ureteral catheters ( Fig. 82-1D). If the ureters are grossly dilated, implantation of the ureters in a serous-lined extramural tunnel in the Abol-Enein technique is preferable ( Fig. 82-2).3

FIG. 82-2. Operative technique of ureteral implantation in Mainz pouch bladder substitution through a serous-lined extramural tunnel (Abol-Enein technique). (A) Two times 12 to 15 cm of cecum and ascending colon and one ileum segment of the same length are isolated and incised antimesenterically. The lateral limbs are joined together by seromuscular continuous suture to create two serous-lined intestinal troughs. The right ureter is pulled through an opening of the seromuscular trough; the left ureter is pulled through a window of the mesentery. (B) Ureters are inlayed within the corresponding trough and the tunnel is closed over the ureters. (C) Ureters are spatulated and anastomosed to the intestinal mucosa. (D) Completion of ureteral implantation. (Modified from Fisch M, Abol-Enein H, Hohenfellner R. Ureterimplantation mittels serösem extramuralem Tunnel in Mainz-Pouch I und Sigma-Rektum-Pouch (Mainz-Pouch II): Akt Urol 1995;26:I–X.)

For the urethral anastomosis, a buttonhole incision of approximately 0.5 cm in diameter is made at the lowest aspect of the cecal pole and the mucosa is everted by 4 to 5 catgut sutures to ensure mucosal adaption with the urethral stump. Closure of the anterior wall of the pouch is completed by running 4-0 polyglyconate (Maxon) sutures. At the site of ureteral implantation, the mucosa only is sutured to prevent ureteral obstruction at the entry into the pouch. The pouch is then anastomosed to the membranous urethra by six everting 5-0 polyglycolic (Dexon) sutures ( Fig. 82-1E, F). The reservoir is tested for leakage by filling the reservoir through the catheter. A 20 F transurethral Foley catheter and an additional 10-Fr pouchostomy tube are used for stenting the urethral anastomosis and drainage. Two 20-Fr silicone drains are placed into the pelvis and at the site of ureteral implantation. Beginning with the second postoperative day, the pouch is irrigated twice daily to prevent mucous retention. The ureteral stents are removed after 10 to 12 days and

an intravenous pyelogram (IVP) is performed. The transurethral catheter is removed after 4 weeks, when a pouchogram confirms absence of extravasation. The cystostomy catheter is removed when the patient is able to reliably empty the pouch spontaneously or by self-catheterization. Le Bag Another variant of a detubularized ileocolonic pouch is called “Le Bag,” which was first described by Light and Engelmann in 1986 7 for bladder augmentation and total substitution in four patients (three male and one female) after cystectomy due to neuropathic bladder and bladder cancer. This ileocolonic pouch also offers a low-pressure reservoir for orthotopic replacement of the bladder in selected patients, but it also has the disadvantage of a relatively high incontinence rate and is often associated with hyperchloremic metabolic acidosis. 5,9 After a midline abdominal incision, the cecum and ascending colon are mobilized up to the hepatic flexure and an appendectomy is performed. A segment of at least 20 cm of ascending colon and a corresponding segment of terminal ileum are isolated on a common vascular pedicle. Bowel continuity is restored between the ileum and transverse colon ( Fig. 82-3A).

FIG. 82-3. Operative technique of ileocolonic bladder substitution Le Bag. (A) Selection of ileocolonic segment with single vascular pedicle. (B) Incision along antimesenteric border to create two flat sheets of bowel. (C) Suturing of ileal and colonic segments. (D) Completion of pouch for anastomosis to the urethral stump. (E) Pouch rotated 180 degrees into the pelvis for anastomosis to the urethral stump, leaving an opening for later ureteral implantation. (F) Ureteral implantation into colonic segment of the pouch through hiatus in anterior wall. (From Light JK, Engelmann UH. Reconstruction of the lower urinary tract. Observations on bowel dynamics and the artificial urinary sphincter. J Urol 1985;135:215–224.)

For bladder substitution to the urethra, the ileocecal segment is opened along the antimesenteric border commencing at the terminal ileum 2 in. distal to the cut end and continuing through the ileocecal valve and into the anterior tenia of the ascending colon ( Fig. 82-3B). In this way, two flat sheets of small and large bowel are obtained that are in continuity at the incised ileocecal valve. The two outermost incisions of the large and small bowel segments are joined with horizontal mattress sutures of 1-0 chromic catgut (Fig. 82-3C). The ileocolonic pouch is rotated 180 degrees into the pelvis. Thus, the initial anterior wall, which has already been sutured, comes to lie posteriorly ( Fig. 82-3D). Similarly, the open posterior wall then lies anteriorly and is closed in a similar fashion from the inferior to the superior aspect, leaving an opening for later implantation of the ureters ( Fig. 82-3E). The short tubular segment of intact ileum allows end-to-end anastomosis to the urethra. The urethral remnant is mobilized and anastomosed to the ileal loop with 6 all-layer sutures of 1-0 chromic catgut ( Fig. 82-3E). Implantation of the ureters into the colon is performed once the ileocolonic pouch is situated and sutured in the pelvis from inside the pouch through the defect left previously at a convenient site. A submucosal tunnel is created from inside the pouch for a length of approximately 1 in., the ureters are pulled through, and the ureteral end is spatulated and sutured to the colonic mucosa with 4-0 catgut sutures ( Fig. 82-3F). Stenting of the ureters is not performed routinely but is recommended if there is any concern regarding tension at the ureteral implantation. The remaining portion of the anterior wall of the pouch is closed with a running horizontal mattress suture of 1-0 chromic catgut. A large catheter is placed through the urethra into the completed pouch, and the pouch is filled with water to estimate capacity and examine for leaks. The indwelling catheter is maintained for 3 weeks and a cystogram is performed before removal to ensure that there is no urinary leakage. Right Colon for Orthotopic Bladder Substitution The use of the detubularized right colon for bladder replacement was first described by Goldwasser et al. in 1980. According to the authors' opinion, the main advantage of the use of the right colon is the long vascular pedicle that allows easy mobilization of the bowel segment to the urethra. 4 The construction of the bladder substitution is commenced with division of the posterior peritoneum lateral to the right colon, around the cecum and along the root of the small bowel mesentery up to the ligament of Treitz. After incision of the hepatocolic ligament, the entire right colon including cecum, ascending and right transverse colon can be mobilized on their mesentery. At that stage of the operation, the surgeon must decide whether the lowermost part of the cecum can reach the pelvic floor. If this is not possible, the procedure should be changed to a technique using an alternative bowel segment. After identification of the ileocolic, the right colic, and middle colic arteries by palpation and transillumination, the right colon is isolated by incision of the ileal and colonic mesenteries ( Fig. 82-4A). Intestinal continuity is reestablished by an ileocolostomy.

FIG. 82-4. Operative technique of right colonic bladder substitution. (A) Isolation of right colon with vascular pedicle: ICA = ileocolic, RCA = right colic arteries, MCA = middle colic artery, SMA = superior colic arteries. (B) Splitting of bowel segment through anterior tenia. Resection of ileal stump and closure of ileocecal valve. Resection of appendix if present. (C) Approximately 5 cm of proximal cecum remains tubular-shaped. Antirefluxive implantation of the ureters through submucosal tunnels in the proximal half of the segment. Buttonhole incision is performed at the cecal pole. (D) Urethrocecal anastomosis over a urethral catheter. (E) Suprapubic catheter and ureteral stents are passed through anterior wall of the neobladder. (F) Distal opened bowel segment is folded over to become the anterior wall of the neobladder. (From Goldwasser B, Mor Y. Bladder replacement using the detubularized right colon. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;166–174.)

The isolated bowel segment is then irrigated clean with saline. Taking care of the ileocolic artery, the ileal stump is resected completely and the opening of the ileocecal valve is closed with two layers of 3-0 polyglactin (Vicryl) sutures. If present, the appendix is removed ( Fig. 82-4B). The right colonic segment is then opened through the anterior tenia, leaving the distal 3 to 5 cm of the cecum tubularized.

The ureters are implanted through submucosal tunnels of 3 to 4 cm length according to Goodwin's antireflux technique into the proximal half of the bowel segment (Fig. 82-4C). The ureters are stented with 5- to 8-Fr feeding tubes. A 4-0 chromic catgut suture between the ureteral serosa and the bowel wall at the site of entry into the neobladder preserves the intended length of the submucosal tunnel. A buttonhole is incised at the lowest pole of the cecum, which later allows anastomosis to the urethra (Fig. 82-4D). The mucosa of the bowel is everted by a few interrupted 4-0 chromic catgut sutures. The distal opened bowel segment is folded over to become the anterior wall of the neobladder ( Fig. 82-4E). If this is difficult, the right colonic artery may be sacrificed. The pouch is closed over the two ureteral stents and a 20-Fr Foley cystostomy catheter, which are brought through separate openings in the anterior wall of the neobladder, with two layers of running 3-0 Vicryl sutures leaving an opening of 3-4 cm in length at the right upper corner of the cystoplasty. For anastomosis to the urethra, six 2-0 chromic catgut sutures are placed. These sutures are then tied over a transurethral 20-Fr silastic Foley catheter. The remaining opening of the neobladder is closed ( Fig. 82-4F). Finally, the bowel used for bladder replacement is retroperitonealized and omentum is wrapped over the suture lines. Two suction drains are placed behind and anterior to the neobladder. The urethral catheter and the suprapubic tube are flushed with 20 ml of sterile saline every 4 hours for the first week. Thereafter, irrigation is performed twice daily. If the cystogram performed after 10 days does not show any extravasation, the ureteral stents are removed. The urethral catheter remains in place for 21 days and the cystostomy is removed when the patient can void spontaneously without significant residual urine. Left Colon for Orthotopic Bladder Substitution The use of the left colon (detubularized sigmoid colon) for total bladder substitution was described by Reddy and co-workers in 1991 and an update of the surgical technique was published in 1995. 1 Candidates for bladder substitution using the left colon have to undergo a barium enema or colonoscopy. Whereas detection of an occult malignancy is an absolute contraindication for using the left colon for bladder replacement, diverticula of the sigmoid colon are not. However, chronic diverticulitis usually leaves the left colon unsuitable for reconstructive applications. The left colon is mobilized up to the splenic flexure to allow the bowel segment to reach the pelvic floor. A 30- to 35-cm segment of sigmoid and descending colon is then isolated on a broad mesenteric pedicle of the sigmoid arterial branch of the inferior mesenteric artery ( Fig. 82-5). Colonic continuity is reestablished by end-to-end anastomosis of the colon with a single layer of interrupted 3-0 Vicryl sutures or recently by using the Valtract BAR biofragmented anastomosis ring (Davis and Geck, Medical Device Division, American Cynamid Corp, Wayne, NJ). 1 The isolated colonic segment is irrigated with antibiotic solution and positioned in a U shape in the pelvis. The lowermost part of the U is marked for later anastomosis to the urethral stump. The segment is completely detubularized by incision of the medial tenia close to the mesenteric border ( Fig. 82-6A). The posterior layer of the colon segment is aligned by a few interrupted 3-0 Vicryl sutures and then closed by a single continuous suture of 3-0 Vicryl ( Fig. 82-6B). After ureteral implantation, the anterior layer is closed in a similar way. A 24-Fr Malecot catheter is placed in the reservoir and the cephalad opening of the reservoir is closed with a single layer of 3-0 Vicryl. For further reduction of reconstruction time, recently the Auto Suture Poly GIA 75-060 (United States Surgical Corp., Norwalk, CT) disposable surgical stapler is used for detubularization and simultaneous placement of the posterior and anterior suture lines. 1

FIG. 82-5. Operative technique of left colonic bladder substitution. Isolation of left colon on a broad vascular pedicle based on the sigmoid arteries. (From Goldwasser B, Mor T: Bladder replacement using the dehulularized right colon. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;175–182.)

FIG. 82-6. Operative technique of left colonic bladder substitution. (A) Colon segment folded in a U shape. Most dependent part is marked for later anastomosis to the urethral stump. (B) Ureteral implantation anteriorly into the lateral tenia. (C) Splitting colonic segment along the medial tenia. Ureteral implantation posteriorly through submucosal tunnels. (D) Approximation of posterior walls of the sigmoid. (E) Completion of anterior wall of the neobladder. (F) Anastomosis of the neobladder to the urethral stump over a Foley catheter. (From Bernard PH, Iseri A, Reddy PK. Sigmoid bladder. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;175–182.)

Implantation of the ureters into the reservoir can be performed either from an external anterior approach using a seromuscular technique or from inside by a submucosal technique and a posterior approach. In the first technique, the ureters are implanted before detubularization of the colonic segment. The ureters are implanted along the lateral tenia on either side by the Leadbetter technique using 5-0 Vicryl sutures ( Fig. 82-6B). The ureters are stented with 8-Fr infant feeding tubes. In the alternative technique, the colonic segment is already detubularized and the posterior pouch plate is formed. The ureters are implanted through submucosal tunnels in the posterior colonic wall using 5-0 Vicryl sutures and stented with 8-Fr feeding tubes ( Fig. 82-6C, D). For anastomosis to the urethra, a small opening is made into the lowest aspect of the colonic reservoir and the neobladder is sutured to the urethral stump over a 20-Fr Foley catheter using 6 interrupted 2-0 Vicryl sutures ( Fig. 82-6E, F). The neobladder is irrigated with saline every 8 hours to prevent mucus obstruction. Ureteral stents are removed on days 13 and 14. If a cystogram on day 14 does not reveal extravasation, the transurethral catheter is removed. Urinary drainage via the Malecot catheter is continued until day 21 and the catheter is removed when successful voiding has been achieved without major amounts of residual urine.

OUTCOMES Complications

Mainz Pouch Among all 561 patients treated with the Mainz pouch I procedure, early and late complications were encountered in 12% and 37%, respectively. 6 Most of the complications (9%) were general surgical ones, such as thrombosis, pulmonary embolism, or pneumonia, whereas pouch-related early complications only occurred in 17 of 561 patients (3%). Complications that were specifically related to the technique of orthotopic bladder substitution occurred in 3 of 61 patients (5%), all of whom had leakage at the urethral anastomosis ( Table 82-1). Of the late complications, 50% were related to the continence mechanism in continent cutaneous diversion. 6 Eleven of 61 patients with orthotopic bladder substitution (18%) developed stenosis at the urethral anastomosis, which could easily be managed by endoscopic incision or resection of the anastomosis ( Table 82-2). Surprisingly, in one patient resection of the stenosis at the urethral anastomosis revealed tumor recurrence at the site of the anastomosis. In this patient, urethrectomy and conversion into a continent cutaneous urinary diversion was performed.

TABLE 82-1. Early complications of orthotopic bladder substitution using a colonic segment

TABLE 82-2. Late complications of orthotopic bladder substitution using a colonic segment

Le Bag In the early series, renal function and electrolyte balance remained normal, 7 but later series revealed hyperchloremic metabolic acidosis in most of the patients, which was related to the pouch length (Table 82-1 and Table 82-2).5 Right Colon Early complications occurred in 10 of 41 patients (24%). Four patients developed cardiovascular complications, which were fatal in two patients. Three patients had prolonged intestinal obstruction which was successfully treated by conservative means. Three patients had extravasation of urine from the neobladder after 12 to 14 days, which stopped spontaneously after prolonged transurethral drainage ( Table 82-1). Late complications occurred in only four patients (10%) who developed ureteral obstruction. In one patient ureteral obstruction occurred at the site where the left ureter was passed through the sigmoid mesentery and nephrectomy was performed because of poor kidney function. In the other case, fibrous tissue caused right ureteral obstruction that necessitated ureterolysis. Two patients developed urethral strictures that were successfully treated by dilation ( Table 82-2). Left Colon Early complications occurred in 2 of 27 patients (7%) ( Table 82-2). These were a pulmonary embolism in one patient and urinary extravasation in another. Late complications in 8 of 27 patients (30%) comprised ureteroenteric obstruction requiring ureteral reimplantation (1), progressive renal failure (1), grade I reflux (3), and asymptomatic urinary tract infection (3) (Table 82-2). Results The Mainz Pouch From 1983 to July 1994, a Mainz pouch procedure has been performed in 561 patients in Mainz and Wuppertal. 6 Sixty patients underwent Mainz-pouch procedure for bladder augmentation or bladder substitution to the bladder neck, 61 for bladder substitution to the urethra, and 440 for continent cutaneous urinary diversion. The mean follow-up for all patients is 57 months (range: 3 to 127 months); in the group with substitution to the urethra follow-up is 46.3 months (range: 3 to 90 months). Fifty-eight of 61 male patients (95%) with orthotopic bladder substitution to the urethra after radical cystoprostatectomy are continent during daytime. Eight of 58 patients (14%) have leakage during the night if they do not empty the bladder at regular 4-hour intervals. Another 8 of 61 patients (13%) are not able to void spontaneously and have to perform clean intermittent catheterization ( Table 82-3).

TABLE 82-3. Results of orthotopic bladder substitution using a colonic segment

Postoperative urodynamic studies in the patients with orthotopic bladder substitution revealed approximately the same pressure/volume characteristics as measured under the same conditions in the normal urinary bladder. Mean capacity of the bladder substitutes was 500 ml (range: 250 to 1000 ml). The residual volume ranged from 0 to 80 ml (mean: 30 ml). Total reservoir pressures in sitting position ranged from 28 cm H 2O (50% filling) to 45 cm H 2O (100% filling). Peristaltic contractions were recorded in the early postoperative phase in most of patients with filling volumes ranging from 130 to 570 ml (mean: 317 ml) and a mean maximum amplitude of 10 cm H2O. After follow-up periods exceeding 6 months, contraction waves subsided in the majority of cases or shifted to the right on the cystometric curve to non-physiologic high filling volumes. Le Bag In an early series, 6 weeks postoperatively three patients were continent, two of whom were assisted by the placement of an artificial sphincter. Water cystometry revealed high compliance and adequate bladder capacity in all four patients. Two patients showed low-amplitude contractions at maximum capacity with total pressures staying below 45 cm H2O.7 In a later series of 11 patients, 5 of 9 men achieved continence, whereas the remaining required implantation of an artificial sphincter (Table 82-3).9 In a recent series of 38 cases with Le Bag orthotopic bladder substitution to the urethra, daytime continence was 91%, whereas only 46% achieved nighttime continence. 5 Right Colon Between 1985 and 1993, 41 men underwent orthotopic urinary diversion using the right colonic segment after radical cystoprostatectomy for invasive transitional cell carcinoma of the bladder. 4 During the follow-up, 38 of 41 patients (93%) were completely continent during the day. However, 2 of 41 patients (5%) suffered from severe daytime and nighttime incontinence that was successfully treated by implantation of an artificial urinary sphincter, and 1 patient had mild diurnal stress incontinence. Continence at night was not so favorable in that 13 of 41 patients (32%) had nocturnal incontinence using protective pads at night and the other two-thirds achieved nighttime continence if they emptied their bladders every 2 to 3 hours ( Table 82-3). Large amounts of residual urine or voiding difficulties were not a problem in any of the patients. Urodynamic studies were performed in the first nine patients at least 3 months after surgery. The capacity ranged from 500 to 1600 ml and residual urine ranged from 0 to 70 ml. Sensation of bladder fullness was present in about half of the patients. At 500 ml capacity, the mean basal pressure was 11 cm H 2O (range: 6 to 20 cm H2O) and the maximum reservoir pressure was 22 cm H2O (range: 12 to 49 cm H2O). Peristaltic contractions occurred in about 70% of patients at a filling volume between 100 and 900 ml (mean 270 ml) with a maximum amplitude of less than 40 cm H2O. The maximum urethral closure pressure ranged between 35 and 60 cm H 2O (mean 48 cm H2O). Left Colon All 27 patients with a sigmoid orthotopic bladder substitution were completely continent during the day and 18 of 27 (67%) also achieved nighttime continence after a follow-up period of 26.5 months (range: 13 to 38 months). 1 The remaining nine patients (33%) have to get up more than twice each night to maintain continence or have urinary leakage at night requiring pads or condom catheter ( Table 82-3). Capacity after 3 months was 450 ml (range: 230 to 720 ml) and increased to 600 ml (380 to 780 ml) after 12 months, allowing mean voiding intervals of 4.5 hours (range: 3 to 6 hours). After 12 months, reservoir pressure during filling was 12 cm H 2O (range: 10 to 16 cm H2O) and at capacity 16 cm H 2O (range: 10 to 22 cm H2O). Residual urine was 40 ml (range: 4 to 80 ml) and no patient required intermittent catheterization. Recurrence of Tumor The incidence of recurrence of the cancer can be seen from our experience with the right colon orthotopic bladders, in which we performed the procedure in 41 patients with cancer. Eleven of 41 patients (27%) died during the follow-up period of 30 months (range: 6 to 42 months). Two patients died in the early postoperative period and 1 patient died of myocardial infarction 6 months after surgery. An additional 8 patients died from disseminated disease or local recurrence. However, none of these patients had recurrence in the urethra. Orthotopic bladder substitution is a highly appreciated therapeutic modality for reconstruction of the urinary tract after total removal of the bladder when certain prerequisites are fulfilled. The colonic segments fulfill all requirements of an intestinal urinary reservoir for orthotopic bladder substitution. Complications relate to general risks of major surgery or to the specific surgical techniques and are comparable to techniques using ileum for bladder substitution. As in some cases the final choice of the bowel segment to be used for construction of a neobladder can only be made at the time of surgery, it is useful to be able to use both small and large bowel segments in different techniques. CHAPTER REFERENCES 1. Bernard PH, Iseri A, Reddy PK. Sigmoid bladder. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;175–182. 2. Fisch MM, Wammack RE, Hohenfellner R. The Mainz pouch procedure (mixed augmentation, ileum and cecum). In: Webster G, Kirby R, King L, Goldwasser B, eds. Reconstructive urology. Vol. 1. London: Blackwell Scientific, 1993;459–475. 3. Fisch M, Abol-Enein H, Hohenfellner R. Ureterimplantation mittels serösem extramuralem Tunnel in Mainz-Pouch I und Sigma-Rektum-Pouch (Mainz-Pouch II): Akt Urol 1995;26:I–X. 4. Goldwasser B, Mor Y. Bladder replacement using the detubularized right colon. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;166–174. 5. Kolettis PN, Klein EA, Novick AC, Winters JC, Appell RA. The Le Bag orthotopic urinary diversion. J Urol 1996;156:926–930. 6. Lampel A, Fisch M, Stein R, et al. Continent diversion with the Mainz pouch. World J Urol 1996;14:85–91. 7. Light JK, Engelmann UH. Reconstruction of the lower urinary tract. Observations on bowel dynamics and the artificial urinary sphincter. J Urol 1985;135:215–224. 8. Mark SD, Webster GD. Ileal reservoirs (Camey II, Hautmann, Kock, Studer). In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;140–147. 9. Schultz-Lampel D, Lampel A, Thüroff JW. Ileocolonic reservoir (Mainz, Le Bag). In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;148–165. 10. Seemann O, Jünemann KP, Alken P. Patient selection criteria for orthotopic bladder replacement. In: Webster GD, Goldwasser B, eds. Urinary diversion: scientific foundation and clinical practice. Oxford: Isis Medical Media, 1995;128–139. 11. Thüroff JW, Alken P, Engelmann U, Riedmiller H, Jacobi GH, Hohenfellner R. The Mainz pouch (mixed augmentation ileum and coecum) for bladder augmentation and continent urinary diversion. Eur Urol 1985;11:152–160. 12. Thüroff JW, Alken P, Riedmiller H, Jacobi GH, Hohenfellner R. 100 cases of Mainz pouch: continuing experience and evolution. J Urol 1988;140:283–288. 13. Thüroff JW, Mattiasson A, Andersen JT, et al. Standardization of terminology and assessment of functional characteristics of intestinal reservoirs. Neurourol Urodynam 1996;15:499–511.

Chapter 83 Orthotopic Bladder Replacement in Women Glenn’s Urologic Surgery

Chapter 83 Orthotopic Bladder Replacement in Women John P. Stein and Donald G. Skinner

J. P. Stein and D. G. Skinner: Department of Urology, University of Southern California/Norris Comprehensive Cancer Center, Los Angeles, California 90033.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Preoperative Evaluation Radical Cystectomy Construction of the Kock Ileal Neobladder Urethral Anastomosis Outcome Complications Results Chapter References

Since the early 1900s innovative surgeons have persistently pursued how best to replace the original bladder removed for either benign or malignant disease. Currently, the ultimate goals of lower urinary tract reconstruction have become more than simply a means to divert urine and to protect the upper urinary tracts. Contemporary objectives of lower urinary tract reconstruction should include eliminating the need for a cutaneous stoma, urostomy appliance, or the need for intermittent catheterization, while maintaining a more natural voiding pattern that allows volitional micturition through the intact native urethra. These advances in urinary diversion have been made in an effort to provide patients a more normal lifestyle, with an improved self-image following removal of the bladder. Over the past 45 years the evolution of urinary diversion has developed along three distinct paths: a noncontinent cutaneous form of urinary diversion; a continent cutaneous form of urinary diversion; and, most recently, an orthotopic form of diversion to the native urethra. In 1950, Bricker introduced the ileal conduit, which established a reliable form of urinary diversion. This form of urinary diversion remained, even until the early 1990s, the gold standard to which all other forms of urinary diversion were compared. Concurrent with Bricker's introduction of the ileal conduit, Gilchrist independently reported on the concept of a continent cutaneous form of diversion, utilizing the ileocecal valve as the continence mechanism and the distal ileum as a catheterizable stoma. However, Gilchrist's ileocecal reservoir garnered little support, whereas the Bricker ileal conduit became the urinary diversion of choice for the next several decades. The concept of a continent cutaneous diversion was eventually popularized in the 1980s at several large institutions. 9 This revolutionized lower urinary tract reconstruction to a continent cutaneous form. Patients were relieved from the problems of an external collection device but still required catheterization of an abdominal stoma. In 1979, Camey and Le Duc reported their pioneering work with orthotopic neobladders to the native urethra. This landmark accomplishment demonstrated the feasibility of lower urinary tract reconstruction to the urethra, with reasonable continence rates, in carefully selected male patients following cystectomy. From 1982 to 1986, the continent cutaneous Kock ileal reservoir was the procedure of choice in all patients requiring urinary diversion at our institution. Beginning in 1986 we began to perform orthotopic reconstruction to the urethra in carefully selected male patients undergoing cystectomy with excellent functional results. 10 However, prior to 1990, orthotopic reconstruction was limited to male patients and considered to be a contraindication in the female subject undergoing cystectomy. It was previously thought necessary to remove the urethra during cystectomy in order to provide an adequate surgical cancer margin in women. In addition, it was believed that the female patient would be unable to maintain a continence mechanism if orthotopic diversion was performed following cystectomy. However, based on an extensive pathologic review of female cystectomy specimens removed for transitional cell carcinoma of the bladder, it was shown that the urethra could be safely preserved in the majority of women undergoing cystectomy.13 This study provided sound pathologic criteria that helped to safely identify appropriate female candidates for orthotopic diversion following cystectomy for bladder cancer. In addition, elegant anatomic dissection of the female pelvis provided a better understanding of the continence mechanism in women, suggesting that continence could be maintained in women following cystectomy. 2 These important discoveries provided a foundation on which to offer women lower urinary tract reconstruction to the urethra. Our initial clinical experience in women demonstrated outstanding functional results. 14 This achievement marked another significant step forward in the evolution of lower urinary tract reconstruction. It is our firm opinion that the orthotopic neobladder currently represents the most ideal form of urinary diversion available today and should be considered the gold standard to which other forms of diversion are compared. In fact, in 1993 at the Fourth International Consensus Conference on Bladder Cancer in Antwerp, Belgium, consensus opinion was that in the properly selected bladder cancer patient, lower urinary tract reconstruction to the urethra is the procedure of choice in most centers worldwide. We believe that this form of diversion can be safely performed in nearly 80% of women undergoing cystectomy for bladder cancer. This chapter will focus on the indications and the technique of the orthotopic diversion in women.

DIAGNOSIS This reconstructive technique is performed following cystectomy, usually for malignant disease. As such, proper diagnostic studies for the underlying disease are important and are discussed in Chapter 24.

INDICATIONS FOR SURGERY Indications for orthotopic urinary diversion in women are following actual or functional loss of the bladder. These modifications are further modified by patient selection criteria specific to orthotopic diversion, which include the following: (a) the external sphincter must remain functionally intact to provide continence and to allow for volitional voiding per urethra and (b) the cancer operation must under no circumstance be compromised by the orthotopic reconstruction at the ure-throenteric anastomosis, the retained urethra, or the surgical margins. If these two criteria can be safely maintained, the patient may then be considered for orthotopic diversion following cystectomy. In general, the majority of women undergoing cystectomy are potential candidates for orthotopic reconstruction. Contraindications to this form of diversion include (a) a noncompliant patient with a mental or physical handicap, (b) patients with impaired renal function whose serum creatinine is greater than 2.5 mg/dl, and (c) those patients with inflammatory bowel disease. However, patients with an elevated serum creatinine secondary to ureteral obstruction should undergo upper urinary tract decompression (via a percutaneous nephrostomy tube) allowing recovery, and determination of the true baseline renal function prior to urinary diversion. Although controversial, patient age alone should not be a contraindication to orthotopic diversion. A differentiation between physiologic and chronologic age should be made. In a recent review of 295 male patients undergoing orthotopic diversion, the overall percentage of patients with good and satisfactory continence was statistically similar in older (more than 70 years) and younger age groups ( p < 0.001).4 These findings, at least in male patients, underscore the notion that patient age alone should not preclude orthotopic urinary diversion. Furthermore, body habitus has not been an exclusive factor for orthotopic reconstruction. In fact, the obese patient is an ideal candidate for this form of diversion, as the need to negotiate a thick abdominal wall for intermittent catheterization is eliminated. Currently, most patients requiring lower urinary tract reconstruction undergo cystectomy for transitional cell carcinoma of the bladder. Despite progress in chemotherapeutic regimens, radical cystectomy remains the treatment of choice for high-grade, invasive bladder cancer. Furthermore, as the incidence of bladder cancer rises, the number of patients requiring cystectomy and subsequent urinary diversion for transitional cell carcinoma of the bladder can also be expected to increase. A critical issue in women undergoing cystectomy and orthotopic diversion for a pelvic malignancy is ensuring that the cancer operation is not compromised by the

reconstruction. Concerns for orthotopic diversion in the female patient arise from the fact that the pathologic implications of sparing the female urethra had not been well studied previously. In addition, urethrectomy was routinely performed in women without sound scientific data. In contrast to male patients with prostatic tumor involvement, risk factors that may predict for urethral tumor involvement in women have only recently been identified. In an extensive retrospective analysis of female cystectomy specimens we have helped define the incidence of carcinoma involving the bladder neck and urethra in women with transitional cell carcinoma of the bladder. 13 This pathologic study identified important risk factors for urethral tumor involvement in women that could help select appropriate candidates for orthotopic diversion following cystectomy for bladder cancer. A total of 67 consecutive female cystectomy specimens removed for biopsy proven transitional cell carcinoma of the bladder between 1982 and 1990 were pathologically reviewed. 13 Histologic evidence of tumor (carcinoma in situ or invasive carcinoma) involving the urethra was present in 9 cystectomy specimens (13%). In all cases, tumor was confined to the proximal or midurethra, and in no patient was the distal urethra involved with tumor. Most importantly, all patients with carcinoma involving the urethra had concomitant tumor involving the bladder neck. A total of 17 patients (25%) had tumor involvement of the bladder neck; all patients with an uninvolved bladder neck also had an uninvolved urethra. Tumor involving the bladder neck and urethra was more commonly associated with high-grade and high-stage tumors, as well as lymph node–positive disease. In addition to bladder neck involvement, anterior vaginal wall involvement with tumor was also identified as a major risk factor for urethral tumor involvement in these female cystectomy specimens. All patients with tumor extending into the anterior vaginal wall were also found to have bladder neck involvement, and 50% of these specimens also demonstrated urethral tumor involvement. However, if the bladder neck was histologically free of tumor, then no patient demonstrated any urethral or vaginal wall tumor. This pathologic study suggested that female patients without tumor involvement of the bladder neck and anterior vaginal wall may be considered appropriate candidates for orthotopic diversion. However, not all specimens with tumor involving the bladder neck demonstrated urethral tumor involvement. This is an important issue because although bladder neck involvement with tumor is a risk factor for urethral tumor involvement, approximately 50% of patients with tumor involving the bladder neck will have a urethra free of tumor. Accordingly, these female patients could be considered appropriate candidates for orthotopic diversion. Therefore, although bladder neck involvement with tumor is a risk factor for concomitant urethral tumor involvement, pathologic evaluation of the proximal urethra appears to be the most critical determinant for orthotopic diversion. These initial pathologic guidelines were subsequently evaluated prospectively in 29 consecutive women undergoing orthotopic diversion following cystectomy for transitional cell carcinoma of the bladder. 12 A total of 23 cystectomy specimens were without evidence of tumor involvement of the bladder neck and were also free of tumor at the urethra. Overall, 6 specimens demonstrated tumor involvement at the bladder neck, with only one of these demonstrating any urethral tumor involvement. These results appear to support our previously established pathologic criteria that identify bladder neck tumor involvement as a risk factor for urethral tumor involvement. In addition, in our clinical series of 29 women undergoing orthotopic diversion, we found intraoperative frozen section analysis of the distal surgical margin (proximal urethra) to be an accurate and reliable method to evaluate the proximal urethra for urethral tumor involvement. Intraoperative frozen section analysis accurately evaluated the proximal urethra in all 29 specimens removed for transitional cell carcinoma, including 28 cases without tumor involvement and 1 specimen with carcinoma in situ involving the proximal urethra. In all 29 cases the frozen section analysis was correctly confirmed on permanent section of the cystectomy specimen. Currently, we believe that intraoperative frozen section of the proximal urethra is the most decisive method to determine if a female patient is an appropriate candidate for orthotopic diversion. Furthermore, because of the potential risk of injuring the continence mechanism with preoperative biopsy of the bladder neck and urethra, coupled with a confirmed method to reliably evaluate the proximal urethra (intraoperatively), we now rely on intraoperative frozen section analysis of the proximal urethra for proper patient selection in women considering orthotopic lower urinary tract reconstruction.

ALTERNATIVE THERAPY Alternatives to orthotopic diversion include any other form of urinary diversion including ileal conduit or other bowel conduit, ureterosigmoidostomy, varied forms of continent urinary diversion, and varied segments of bowel described for orthotopic diversion.

SURGICAL TECHNIQUE Although the ideal bladder substitute remains to be developed, the orthotopic neobladder most closely resembles the original bladder in both location and function. The orthotopic neobladder eliminates the need for a cutaneous stoma or cutaneous collection device. This form of diversion relies on the intact rhabdosphincter continence mechanism, eliminating the need for the often-plagued efferent continence mechanism of most continent cutaneous reservoirs and need for intermittent catheterization. The majority of patients undergoing orthotopic reconstruction are continent and able to void to completion without the need for intermittent catheterization. 4,14 Certain principles of all orthotopic urinary reservoirs should include a large-capacity, low-pressure, nonrefluxing (to protect upper urinary tract), nonabsorptive surface that allows the patient to volitionally void per urethra. The continence mechanism is maintained by the external striated sphincter muscle (rhabdosphincter muscle) of the pelvic floor, whereas voiding is accomplished by concomitantly increasing intraabdominal pressure (Valsalva), along with relaxation of the pelvic floor. The literature is replete with particular opinions on which bowel segment and/or reservoir is optimal for construction of the orthotopic neobladder. The small intestine, terminal ileum and cecum, large intestine, or a combination of these have all been utilized to construct a urinary reservoir. It is the authors' preference to use the small bowel (ileal reservoir) as it appears to offer less contractility, greater compliance, and improved continence rates compared to large bowel neobladders. There is evidence to suggest that the muscular-walled colon is less compliant than ileum and may store urine at higher pressures than ileum. 7 In addition, several clinical studies have demonstrated that the urodynamic characteristics of ileum appear superior to those of the colon. 1,3,8 Furthermore, mucosal atrophy with less reabsorption of urinary constituents appears to be more reliable in small bowel than in large bowel reservoirs. For these reasons, in addition to the ease with which the small bowel can be surgically manipulated, it is our preference to use ileum in the construction of the neobladder. Preoperative Evaluation All women considering orthotopic diversion should have the understanding that if the bladder or pelvic tumor involves the proximal urethra (diagnosed on intraoperative frozen section analysis), then lower urinary tract reconstruction should not be performed. In this case, a cutaneous form of diversion should be performed based on the patient's desires, as discussed preoperatively. It is therefore important to involve the enterostomal therapy nurse in the preoperative period, to mark for an appropriate cutaneous stoma, and to instruct the patient on how to self-catheterize should it be necessary. Radical Cystectomy The technique of en bloc radical cystectomy (anterior exenteration) with bilateral pelvic lymphadenectomy has remained standard and is described in Chapter 24.11 However, preparation of the anterior urethra in women undergoing orthotopic diversion deserves specific mention. This portion of the procedure is critical in maintaining the continence mechanism, and to the successful outcome of the procedure. Elegant neuroanatomic and histologic studies of the female pelvis and urethra in fetal specimens have provided a better understanding of the female urethra and continence mechanism.2 These anatomic dissections have identified three layers of smooth muscle in the proximal two-thirds of the urethra. The innervation of this proximal urethral segment can be traced back to the pelvic plexus coursing along the lateral aspect of the uterus, vagina, and bladder neck. A gradual transition with intermingling smooth muscle to striated pelvic floor muscle can be identified in the mid- to lower third portion of the urethra. This striated pelvic floor muscle, the so-called rhabdosphincter muscle, with its major portion on the ventral aspect of the urethra, is innervated from branches off the pudendal nerve that course along the pelvic floor posterior to the levator muscles. These findings suggest that preservation of the distal half of the urethral musculature, together with the corresponding nerve supply, is crucial in maintaining the continence mechanism in females. Furthermore, a properly performed cystectomy with en bloc removal of the uterus and cervix effectively denervates the bladder neck and proximal urethral sphincter mechanism, rendering them ineffective as a continence mechanism. This unique anatomic study supports the complete removal of the bladder neck with transection of the proximal urethra just beyond the urethrovesical junction because continence is maintained solely by the rhabdosphincter muscle of the lower urethra. In addition, minimal dissection should be performed anterior to the

proximal urethra, which could injure the pudendal innervation to the rhabdosphincter and possibly damage the continence mechanism. When developing the posterior vascular pedicles during the cystectomy in women, the posterior vagina is incised at the apex just distal to the cervix. This incision is carried anteriorly along the lateral and anterior vaginal wall forming a circumferential incision. The anterior lateral vaginal wall is then grasped with a curved Kocher clamp. This provides countertraction and facilitates dissection between the anterior vaginal wall and the bladder specimen. Development of this posterior plane and vascular pedicle is best performed sharply with the use of hemoclips and carried just distal to the vesicourethral junction. Palpation of a previously placed Foley catheter balloon in the bladder assists in identifying this region. This dissection effectively maintains a functional vagina. Furthermore, an intact anterior vaginal wall may help support the proximal urethra through a complex musculofascial support system that extends from the anterior vagina. The vagina is then closed at the apex and suspended to Cooper's ligament to prevent vaginal prolapse or the development of an enterocele postoperatively ( Fig. 83-1).

FIG. 83-1. View of the female pelvis from above. Note that no dissection is performed anterior to the urethra along the pelvic floor. This helps prevent injury to the rhabdosphincter region and corresponding innervation, which are critical to the continence mechanism in women undergoing orthotopic diversion.

Alternatively, in the case of a deeply invasive posterior bladder tumor with concern of an adequate surgical margin, the anterior vaginal wall can be removed en bloc with the cystectomy specimen. After dividing the posterior vaginal apex, the lateral vaginal wall subsequently serves as the posterior pedicle and is divided distally. This leaves the anterior vaginal wall attached to the posterior bladder specimen. Again, the Foley catheter balloon facilitates identification of the vesicourethral junction. The surgical plane between the vesicourethral junction and the anterior vaginal wall is then developed distally at this location. Dissection is carried downward just distal to the proximal urethra, while the remaining urethra distally is left intact with the anterior vaginal wall. Vaginal reconstruction by a clam shell (horizontal) or side-to-side (vertical) technique is required. Other means of vaginal reconstruction may include a rectus myocutaneous flap, detubularized cylinder of ileum, a peritoneal flap, or an omental flap. Regardless, a well-vascularized omental pedicle graft is placed between the reconstructed vagina and neobladder, and secured to the levator ani muscles to separate the suture lines and prevent fistulization ( Fig. 83-2).

FIG. 83-2. Sagittal section of the female pelvis. Note that a well-vascularized omental pedicle graft is placed between the reconstructed vagina and the neobladder. This pedicle graft is secured to the levator ani muscles to separate the suture lines and prevent fistulization. Note also that the vagina is closed at the apex and will be suspended to Cooper's ligament to prevent vaginal prolapse or the development of an enterocele postoperatively (not shown).

It is critical that no dissection be performed anterior to the urethra along the pelvic floor in women undergoing orthotopic diversion. This prevents injury to the rhabdosphincter region and corresponding innervation, which are necessary in maintaining the continence mechanism. Any dissection performed anteriorly may injure these nerves and compromise the continence status. Some reports suggest that a sympathetic nerve–sparing cystectomy is important in maintaining continence in these women. We have routinely sacrificed the autonomic nerves coursing along the lateral aspect of uterus and vagina and relied on the pudendal innervation of the rhabdosphincter region. With this approach we have observed excellent continence results in women undergoing orthotopic diversion. 12 In fact, extensive urodynamic studies in women undergoing orthotopic diversion have identified this rhabdosphincter region as the area that provides the continence mechanism in these women. 5 Furthermore, it is possible that preservation of the sympathetic nerves may contribute to the high incidence of hypercontinence and urinary retention requiring continuous intermittent catheterization reported by Hautmann and associates. 6 Following completion of the posterior dissection (ensuring dissection just distal to the vesicourethral junction), a large Statinsky vascular clamp is placed across the bladder neck. With gentle traction the proximal urethra is divided anteriorly for 270 degrees circumferentially just distal to the bladder neck and clamp. Approximately 6 to 8 anterior urethral sutures (2-0 polyglycolic acid) are then placed. The distal portion of the catheter is then drawn into the wound through the urethrostomy and divided. The Statinsky vascular clamp placed across the catheter at the bladder neck prevents any tumor spill from the bladder. Gentle cephalad tract on the clamped catheter allows placement of 2 to 4 posterior urethral sutures. The posterior urethra is then transected and the specimen is removed. Frozen section analysis is performed on the distal urethral margin of the cystectomy specimen to exclude tumor. Construction of the Kock Ileal Neobladder The Kock ileal neobladder is constructed from approximately a 61-cm segment of terminal ileum ( Fig. 83-3). The reservoir portion of the neobladder is constructed from two 22- to 25-cm segments of distal ileum, whereas a single 17-cm segment of more proximal ileum is used to form the antireflux afferent nipple valve. The distal mesenteric division of the terminal ileum is performed along the avascular plane of Treves, between the ileocolic artery and the terminal ileal branches of the superior mesenteric artery, extending to the base of the small bowel mesentery. The proximal mesenteric division is short to ensure a broad vascular supply to the proximal ileal segment. Usually a 5-cm portion of proximal ileum is discarded proximal to the overall segment in order to ensure adequate mobility of the pouch and the small bowel anastomosis. The proximal end of the isolated ileal segment is closed with a running Parker-Kerr suture (3-0 chromic) and imbricated with a layer of 3-0 silk sutures. The small bowel continuity is reestablished with a standard small bowel anastomosis and the mesenteric trap closed.

FIG. 83-3. The ileal segment used to construct the orthotopic Kock ileal neobladder. The distal mesenteric division is made approximately 20 cm proximal to the cecum along the avascular plane of Treves. A total length of 61 cm of ileum is required in the construction of the neobladder, two 22-cm segments for the reservoir portion of the pouch, and a proximal 17-cm segment for the intussuscepted afferent nipple valve.

The two isolated 22-cm ileal segments are positioned adjacent to one another in a U fashion with the apex directed caudally ( Fig. 83-4A). These 22-cm ileal segments are sewn together along the serosa (side-to-side) approximately 1 cm from the mesentery with a 3-0 polyglycolic acid running suture. The ileum is opened just lateral to this serosal basting suture with electrocautery, The incised mucosa is approximated and oversewn the entire length with a 3-0 polyglycolic acid suture in two layers (Fig. 83-4B). This suture line forms the posterior wall of the reservoir.

FIG. 83-4. Creation of the pouch. (A) The two 22-cm segments are approximated in a U formation (directed to the right lower quadrant) with a serosal basting suture 1 cm from the mesentery (bottom). The ileum is then opened with electrocautery adjacent to the basting suture line. (B) The posterior wall of the reservoir is then sutured in two layers with a continuous 3-0 polyglycolic acid suture ( top). (C) A 5- to 7-cm antireflux valve is created by intussusception of the afferent limb with Allis forcep clamps.

Attention is then directed to the 17-cm ileal segment and construction of the intussuscepted afferent nipple valve. Windows of Deaver are developed alone, with the afferent limb mesentery adjacent to the serosa of this proximal 17-cm segment. The mesentery is divided away from the pouch, extending for 5 to 6 cm. This is best performed with electocautery. This maneuver effectively strips the mesentery from the serosa of the ileum, ensuring that the mesentery is not incorporated into the intussuscepted nipple valve. Furthermore, this also helps prevent future prolapse or extussusception of the afferent nipple valve. One additional window of Deaver is created beyond the previously stripped mesentery, while preserving at least one vascular arcade in between. A 2.5-cm strip, tetracycline-soaked, of doubled polyglycolic acid mesh is then brought through this smaller window. This mesh will serve as an anchoring collar at the base of the nipple valve. The intussuscepted antireflux afferent nipple valve is then created ( Fig. 83-4C). The afferent nipple is intussuscepted by passing two Allis forcep clamps toward the anchoring collar, grasping the mucosa, and inverting the ileum into the pouch. This positions the mesh adjacent to the wall of the pouch at the base of the intussuscepted nipple. Next, two single rows of parallel 4.8-mm nonhemostatic staples (applied with a custom no-knife GIA 50 stapler), with the proximal four staples removed from each row, are applied to the medial and anterior aspect of the nipple ( Fig. 83-5A). A third parallel staple line is applied from outside the pouch between the posterior wall of the pouch along the mesenteric border and one layer of the intussuscepted nipple (applied with a TA-55 stapling device; Fig. 83-5B). The pinhole created by the TA-55 is oversewn from within the pouch to prevent formation of a fistula. This maneuver effectively fixes the afferent nipple valve to the posterior wall of the reservoir.

FIG. 83-5. Fixation of the afferent limb. (A) Two rows of staples (with the distal 4 to 6 staples removed) are placed within the limb to stabilize the two leaves of the valve. (B) The valve is then fixed to the back wall from outside the reservoir. This fixes the intraluminal valve, which becomes more efficient as the reservoir fills, thus preventing reflux.

The anchoring mesh collar is fixed to the base of the afferent nipple valve. The mesh is circumferentially sutured to the serosa at the base of the nipple with 2-0 chromic. This helps prevent prolapse of the nipple valve. The reservoir is closed by folding the ileum in the opposite direction back onto itself, creating a totally detubularized reservoir ( Fig. 83-6). The anterior aspect of the pouch is closed in two layers with 3-0 polyglycolic acid sutures in a water-tight fashion. It should be noted that the anterior suture line is stopped just prior to reaching the end of the right side, allowing easy entry of one finger. This is the most mobile and dependent portion of the reservoir and will be the portion of the reservoir anastomosed to the native urethra.

FIG. 83-6. After the afferent valve is constructed, the reservoir is completed by folding the ileum upon itself and suturing it with a 3-0 polyglycolic acid. The most dependent comer is left open for the urethral anastomosis. The urethroileal anastomosis is completed in a tension-free, mucosa-to-mucosa fashion with interrupted 2-0 polyglycolic acid. Note that the ureteroileal anastomosis is completed prior to the urethral anastomosis.

The ureteroileal anastomosis is then performed end-to-side with interrupted 4-0 polyglycolic acid sutures. We routinely stent the ureters with 8-Fr pediatric feeding tubes. These feeding tubes will be sutured to a 24-Fr hematuria catheter that is passed per urethra and positioned in the pouch. Urethral Anastomosis Following completion of the neobladder, the urethral sutures are placed in the neobladder and tied down to form a tension-free, mucosa-to-mucosa, urethroileal anastomosis (Fig. 83-6). The pelvis is drained by a 1-in. Penrose drain for 3 weeks; the drain is removed along with the urethral catheter at that time.

OUTCOME Complications Since 1990, 34 women aged 31 to 86 years (median age 66) have undergone orthotopic lower urinary tract reconstruction following cystectomy at our institution. 5 The median follow-up in this group of patients was 21 months (range 7 to 53). The indication for cystectomy in 29 women (85%) was for transitional cell carcinoma of the bladder. There were no perioperative deaths. Three patients (9%) suffered a total of 4 early com-plications: 1 pouch-related (3%, urine leak) and 3 pouch-unrelated. Late complications requiring rehospitalization or reoperation occurred in 3 patients (9%). However, only 1 of these late complications was pouch-related in a woman who developed a Kock pouch stone. To date, there have been no urethral recurrences in this group of female patients. Results Continence status was evaluable in 33 of 34 patients. Complete daytime continence is reported in 28 of 33 (85%) women, whereas complete nighttime continence is reported in 27 (82%) women. The ability to void to completion by Valsalva and relaxation of the pelvic floor is reported in 28 (85%) patients. Only 5 patients require some form of intermittent catheterization to empty their neobladder. All patients are completely sat-isfied. The key to a successful outcome with orthotopic diversion in women is appropriate patient selection and attention to surgical detail with minimal dissection performed along the anterior urethra. Overall, most women undergoing orthotopic diversion are continent, have the luxury of voiding every 4 to 6 hours with excellent voided volumes, retain a more routine micturition pattern, avoid the need for a cutaneous stoma or external urostomy appliance, and live a more normal lifestyle with an improved self-image. Careful preoperative counseling in all female patients considering orthotopic lower urinary tract reconstruction should include the possible need for clean intermittent catheterization in the rare patient unable to void with pelvic floor relaxation and Valsalva. In addition, patients should understand the potential risk of a urethral recurrence and the need for continued long-term surveillance of the retained urethra. Careful follow-up will be necessary to define the true risk of urethral or vaginal wall recurrence in women and to diagnose urethral recurrences in all patients at an early curable stage. Presently, meticulous monitoring of the retained urethra includes careful palpation of the urethroenteric anastomosis on vaginal examination. In addition, voided urine cytology should be performed on a regular basis in all patients at each follow-up visit. The development of orthotopic lower urinary tract reconstruction has been a significant step in the continued progression of urinary diversion. We believe that the orthotopic reservoir should now be considered the gold standard to which other forms of diversion are compared. Orthotopic diversion can now be safely offered to female patients undergoing cystectomy. With this form of diversion we hope that patients with bladder cancer, as well as their physicians, may be encouraged toward an earlier and more aggressive form of therapy with cystectomy, when cure and ultimately survival are greatest. CHAPTER REFERENCES 1. Berglund B, Kock NG, Norlen L, Philison BM. Volume capacity and pressure characteristic of the continent ileal reservoir used for urinary diversion. J Urol 1987;137:29. 2. Colleselli K, Strasser H, Moriggl B, Stenzl A, Poisel S, Bartsch G. Hemi-Kock to the female urethra: anatomical approach to the continence mechanism to the female urethra. J Urol 1994;part 2, 151:500A, Abstract 1089. 3. Davidsson T, Poulsen AL, Hedlund H, et al. A comparative urodynamic study of the ileal and the colonic neobladder. Scand J Urol Nephrol 1992;142 (Suppl.):143. 4. Elmajian DA, Stein JP, Esrig D, et al. The Kock ileal neobladder: update experience in 295 male patients. J Urol 1996;156:920. 5. Grossfeld GD, Stein JP, Bennett CJ, et al. Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of continence results and fluorourodynamic findings. Urology 1996;48:383. 6. Hautmann RE, Paiss T, Petriconi R. The ileal neobladder in women: 9 years of experience with 18 patients. J Urol 1996;155:76. 7. Hinman F Jr. Selection of intestinal segments for bladder substitution: physical and physiological characteristics. J Urol 1988;139:519. 8. Lytton B, Green DF. Urodynamic studies in patients undergoing bladder replacement surgery. J Urol 1989;141:1394. 9. Rowland RG, Mitchell ME, Bihrle R. The cecoileal continent urinary reservoir. World J Urol 1985;3:185. 10. Skinner DG, Boyd SD, Lieskovsky G, Bennett C, Hopwood B. Lower urinary tract reconstruction following cystectomy: experience and results in 126 patients using the Kock ileal reservoir with bilateral ureteroileal urethrostomy. J Urol 1991;146:756. 11. Skinner DG, Lieskovsky G. Technique of radical cystectomy. In: Skinner DG, Lieskovsky G, eds. Diagnosis and management of genitourinary cancer. Vol. 1. Philadelphia: WB Saunders, 1988;605–621. 12. Stein JP, Grossfeld G, Freeman JA, et al. Orthotopic lower urinary tract reconstruction in women using the Kock ileal neobladder: updated experience in 27 patients. J Urol 1996;155(2):399A, Abstract 353. 13. Stein JP, Cote RJ, Freeman JA, et al. Lower urinary tract reconstruction in women following cystectomy for pelvic malignancy: a pathological review of female cystectomy specimens. J Urol 1995;part 2, 154:1329. 14. Stein JP, Stenzl A, Esrig D, et al. Lower urinary tract reconstruction following cystectomy in women using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: initial clinical experience. J Urol 1994;152:1404.

Chapter 84 Neuroblastoma Glenn’s Urologic Surgery

Chapter 84 Neuroblastoma Yves L. Homsy and Paul F. Austin

Y. L. Homsy: Department of Pediatric Urology, University of South Florida College of Medicine, Tampa, Florida 33607. P. F. Austin: Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis, Indiana 46202.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Neuroblastoma represents the most common extracranial malignant solid neoplasm of childhood. The first successful excision of a neuroblastoma was performed in 1916. Surgical therapy remained the primary mode of treatment despite a poor prognosis until adjuvant treatment modalities were later added. Radiation therapy was introduced in 1928 and chemotherapy in 1951; however, little improvement in survival was achieved. Each modality has evolved in its influence and impact on prognosis, but surgery remains the best mode of therapy for localized, nonadvanced disease. For locally advanced or metastatic disease, the role of surgery is not as clear. Nevertheless, total or near-total resection of the primary tumor has recently been shown to be of prognostic significance. 1,20 Neuroblastoma arises along the sympathetic ganglia or from neuroblasts that may have migrated from the mantle layer of the developing spinal cord. Neuroblastomas exhibit a wide spectrum of morphologic differentiation and may be quite primitive (neuroblastoma), more differentiated (ganglioneuroblastoma), or well differentiated (ganglioneuroma). Two-thirds of these tumors present in the retroperitoneum with the majority occurring in the adrenal medulla (more than 65%). Cervical and mediastinal lesions tend to present in younger patients less than 1 year of age. Half of the patients present in the first 2 years of life with the peak incidence occurring between 12 to 18 months of age. The clinical presentation of neuroblastoma is dependent on the site of the primary tumor, presence of metastatic disease, and production of metabolically active substances.6 The catecholamine urinary metabolites vanillylmandelic acid (VMA) and homovanillic acid (HVA) are elevated in more than 80% of neuroblastoma patients. An increased VMA/HVA ratio has been shown to have a better prognosis in localized disease. 3 Other metabolic products that may be elevated include lactate dehydrogenase (LDH), serum ferritin, and serum neuron-specific enolase (NSE), and these have been associated with a poor prognosis. Typically children with neuroblastoma appear more ill than children with Wilms' tumor. At least half of the children with neuroblastoma will have metastatic disease, particularly to the bone, bone marrow, liver, and skin, at the time of diagnosis. Because of the multiple sites of potential origin and involvement, the presentation may vary from paresis/paralysis to Horner's syndrome to numerous subcutaneous tumor deposits (“blueberry muffin babies”).

DIAGNOSIS A complete history and physical should be performed as well as a meticulous diagnostic workup that should include the tests in Table 84-1. Of particular importance is the presence of multiple copies of the N- myc oncogene (genomic amplification) because N- myc amplification is associated with an unfavorable tumor and poor prognosis. 6 Other molecular studies such as ploidy and chromosome analysis may be performed as well but are optional as the role they play in diagnosis and staging is not yet well defined.

TABLE 84-1. Neuroblastoma diagnostic/staging workup

Multiple staging systems have evolved in the management of neuroblastoma. The Evans-D Angio staging system consists of a clinical assessment that describes the initial tumor distribution and whether the tumor crosses the midline. Both the St. Jude Children's Research Hospital (SJCRH) and the Pediatric Oncology Group (POG) staging systems are based on surgical resectability of the primary tumor and the findings at the time of surgery. The International Neuroblastoma Staging System (INSS) incorporates many of the important criteria from each of the staging systems and includes initial tumor distribution as well as its surgical resectability (Table 84-2). It is important to realize that accurate staging cannot be determined until the time of surgical exploration.

TABLE 84-2. International staging system (INSS)

INDICATIONS FOR SURGERY If the patient has stage I or II disease, then surgical resection can be undertaken with reasonable success. In a prospective study by the POG in 1988, an 89% 2-year

disease free survival was obtained in 100 patients with localized neuroblastoma when treated by surgery. chemotherapy or radiation even in the presence of residual disease. 10

14

In addition, no advantage is gained by the addition of

A multimodal approach utilizing chemotherapy, radiation, and surgery is used for advanced disease. Patients with stage IV disease and older than 1 year of age unfortunately have a poor outlook; however, intensive multiagent chemotherapy has increased the 5-year survival for patients less than 1 year of age to 75%. 16 Radiation has also been shown to be of benefit in advanced disease and has been demonstrated to give superior initial and long-term disease control when administered together with chemotherapy rather than treating with chemotherapy alone. 4 After chemotherapy is administered, surgical intervention is usually performed 13 to 18 weeks afterward. 1 Surgical resection seems to be somewhat easier around vital structures and major blood vessels because the tumors tend to have become smaller and more firm. This rubbery consistency also decreases the risk of rupture and spillage of tumor that would otherwise be encountered. Radiation therapy may then be delivered to the tumor bed and regional lymph node areas. Intraoperative radiation may be utilized and is helpful in reducing the exposure to adjacent normal structures. Supralethal chemotherapy and total body irradiation followed by bone marrow transplantation has shown promise and a 72% 3-year disease-free survival has been reported in advanced neuroblastoma. 12 The role of surgery is controversial, particularly regarding the extent of surgical resection. Some reports have been unfavorable 10,17 whereas others have reported significant improvement in survival with gross complete resection or near-total (95%) resection. 5,20 Stage IV-S patients may be followed conservatively due to their high rate of spontaneous regression and 60% to 90% survival rate. Resection of the primary tumor has been associated with a survival of 96%, 9 though in the current philosophy operative intervention is felt to be diagnostic and supportive in nature rather than therapeutic. Respiratory insufficiency may develop in these infants with massive hepatomegaly and the use of a silastic pouch to enlarge the abdomen has been recommended. Chemotherapy and radiation have also been advocated for extensive metastatic disease in these patients. Stage IV-S patients have been stratified into high- and low-risk groups based on the patient's age and the pattern of metastatic sites. Low-risk patients benefit more from a conservative approach that includes primary tumor resection when possible followed by careful observation. Because of their poorer prognosis, high-risk patients may benefit more from an aggressive approach that includes multimodal therapy. 18

ALTERNATIVE THERAPY Due to the extraordinarily complex therapy involved and the relative rarity of this tumor, patients should be managed according to the protocols established by the POG. The therapy is multimodal and there is no accepted alternative therapy available.

SURGICAL TECHNIQUE Unlike pheochromocytoma where choice of general anesthetic plays an important role in the operative case, no specific optimal anesthetic regimen is recommended and intraoperative hypertension is rare. 7 The patient is placed in the supine position and at the discretion of the surgeon an appropriate incision is made that should provide adequate exposure of the abdomen and retroperitoneum. We prefer an upper abdominal transverse incision, although a chevron incision may also be used for tumors involving the upper abdomen/retroperitoneum. The viscera are reflected to the midline and placed in an intestinal bag. Exploration of the abdomen and retroperitoneum is performed with particular attention to the relationship of the primary tumor to the surrounding vital structures ( Fig. 84-1). Regional lymph nodes are assessed and the liver is biopsied.

FIG. 84-1. CT scan (A) and operative view (B) of a stage I neuroblastoma. Note relationship of the tumor with the sympathetic chain ( small arrow) and the inferior vena cava (large arrow). The vena cava can be seen to be compressed on the CT scan.

Neuroblastoma often invades the tunica adventitia of large blood vessels and consequently resection of these tumors should be regarded as a vascular procedure with appropriate instrumentation and sutures. 8 After adequate exposure of the surrounding vasculature, the dissection begins distal to the tumor typically along the external or common iliac artery. The adventitia is incised longitudinally and once the subadventitial plane is entered, the dissection proceeds proximally to encounter the tumor. Utilization of bipolar cautery as well as the Cavitron Ultrasonic Surgical Aspirator (CUSA) is beneficial during the dissection. The CO 2 laser has likewise been reported to be helpful in the resection of neuroblastoma but the cytotoxic effect seems to be related to its increased tumor immunogenicity rather than to increased tumor kill. 11 Maintaining the subadventitial plane dissection proximally, the anterior aorta is cleared and the origins of the inferior mesenteric, superior mesenteric, and celiac arteries are identified and cleared as well. The renal artery is similarly dissected; when there is tumor present deep in the hilum, nephrectomy is sometimes necessary. The main attachments to the tumor are then divided and the tumor is removed. The surgical management is determined at the time of this staging laparotomy. If primary tumor resection cannot be adequately accomplished, then an open wedge biopsy is obtained for histopathologic and genetic analysis. Neuroblastomas are hypervascular and therefore adequate control of hemorrhage at the biopsy site as well as avoidance of tumor spillage is essential. Tissue should be placed in saline prior to freezing and should be of adequate volume for histopathology, immunohistochemistry, and genetic studies.

OUTCOMES Complications The morbidity associated with surgical intervention for neuroblastoma has primarily been related to vascular injuries occurring during the dissection. Any major branch originating from the aorta might be injured, as might tributaries of the inferior vena cava. Other reported injuries include a splenic injury, brachial plexus injury, and a chylothorax.2 Acute renal failure has also been reported secondary to renal artery spasm. This may be induced by excessive traction on the renal vessels during the dissection or by stimulation of the autonomic nerve plexi surrounding the origin of the renal arteries with resultant vasospasm. 15 Intravenous digital subtraction arteriography utilizing a central venous catheter has been used to evaluate renal blood flow following surgery. 19 If renal blood flow is compromised, then vasodilator drips such as lidocaine, papaverine, or prostaglandin may be initiated locally to reverse the vasospasm. Results Neuroblastoma is a unique tumor that violates many of the treatises of surgical oncology, being one of the few tumors where a surgeon may violate the capsule or pseudocapsule leaving residual tumor yet still achieve a good overall outcome. Even though surgical therapy has been reported to affect the prognosis of advanced neuroblastoma, it is the biological and immunologic properties that determine much of the eventual outcome. Low-risk tumors tend to occur in lower stage patients

whereas higher risk tumors tend to occur in the more advanced staged patients and henceforth have a poorer prognosis. Although as surgeons we prefer to believe that we provide a significant impact with our intervention, it most likely is the intrinsic properties of the tumor itself that seems to be a greater determinant of the eventual outcome in neuroblastoma. CHAPTER REFERENCES 1. Azizkhan RG, Haase GM. Current biological and therapeutic implications in the surgery of neuroblastoma. Semin Surg Oncol 1993;9:493. 2. Azizkhan RG, Shaw A, Chandler JG. Surgical complications of neuroblastoma resection. Surgery 1985;97:514. 3. Berthold F, Hunneman DH, Harms D, Kaser H, Zieschang J. Serum vanillylmandelic acid/homovanillic acid contributes to prognosis estimation in patients with localized but not with metastatic neuroblastoma. Eur J Pediatr Surg 1992;28A:1950. 4. Castleberry RP, Kun LE, Shuster JJ, et al. Radiotherapy improves the outlook for patients older than 1 year with Pediatric Oncology Group stage C neuroblastoma. J Clin Oncol 1991;9:789. 5. DeCou JM, Bowman LC, Rao BN, et al. Infants with metastatic neuroblastoma have improved survival with resection of the primary tumor. J Pediatr Surg 1995;30:937. 6. Grosfeld JL. Neuroblastoma in infancy and childhood. In: Hays DM, ed. Pediatric surgical oncology. Orlando: Grune and Stratton, 1986;63–85. 7. Kain ZN, Shamberger RS, Holzman RS. Anesthetic management of children with neuroblastoma. J Clin Anesth 1993;5:486. 8. Kiely EM. The surgical challenge of neuroblastoma. J Pediatr Surg 1994;29:128. 9. Martinez DA, King DR, Ginn-Pease ME, Haase GM, Wiener ES. Resection of the primary tumor is appropriate for children with stage IV-S neuroblastoma: an analysis of 37 patients. J Pediatr Surg 1992; 27:1016. 10. Matthay KK, Sather HN, Seeger RC, Haase GM, Hammond GD. Excellent outcome of stage II neuroblastoma is independent of residual disease and radiation therapy. J Clin Oncol 1989;7:236. 11. McCormack CJ, Naim JO, Rogers DW, Ziegler MM, Hinshaw JR. Beneficial effects following carbon dioxide laser excision on experimental neuroblastoma. J Pediatr Surg 1989;24:201. 12. Mugishima H, Iwata M, Okabe I, et al. Autologous bone marrow transplantation in children with advanced neuroblastoma. Cancer 1994;74:972. 13. Nakagawara A, Ikeda K, Tsuda T, Higashi K. N-myc oncogene amplification and prognostic factors of neuroblastoma in children. J Pediatr Surg 1987;22:895. 14. Nitschke R, Smith EI, Shochat S, et al. Localized neuroblastoma treated by surgery: a Pediatric Oncology Group study. J Clin Oncol 1988;6:1271. 15. Ogita S, Tokiwa K, Takahashi T. Renal artery spasm: a cause of acute renal failure following abdominal surgery for neuroblastoma. J Pediatr Surg 1989;24:215. 16. Paul SR, Tarbell NJ, Korf B, Kretschmar CS, Lavally B, Grier HE. Stage IV neuroblastoma in infants. Long-term survival. Cancer 1991;67:1493. 17. Shorter NA, Davidoff AM, Evans AE, Ross AJ III, Zeigler MM, O'Neill JA Jr. The role of surgery in the management of stage IV neuroblastoma: a single institution study. Med Pediatr Oncol 1995;24:287. 18. Stephenson SR, Cook BA, Mease AD, Ruymann FB. The prognostic significance of age and pattern of metastases in stage IV-S neuroblastoma. Cancer 1986;58:372. 19. Yamagiwa I, Obata K, Saito H, Washio M. Intravenous digital subtraction angiography for the evaluation of renal artery blood flow following the removal of a neuroblastoma. Surg Today 2994;24:973. 20. Yokoyama J, Ikawa H, Endow M, et al. The role of surgery in advanced neuroblastoma. Eur J Pediatr Surg 1995;5:23.

Chapter 85 Wilms' Tumor Glenn’s Urologic Surgery

Chapter 85 Wilms' Tumor O. Lenayne Westney and Michael L. Ritchey

O. L. Westney: Division of Urology, University of Texas Health Science Center, Houston, Texas 77030. M. L. Ritchey: Division of Surgery and Pediatrics, University of Texas Medical School, Houston, Texas 77030.

Diagnosis Indications for Surgery Surgical Technique Bilateral Tumors Postoperative Treatment Results Complications Results Chapter References

Wilms' tumor, or nephroblastoma, represents 5% to 6% of all childhood cancers in the United States and is the most common primary malignant renal tumor of childhood. The incidence rate of Wilms' tumor is 1 in 10,000 children with a new case rate of 450 to 500 annually in the United States. 1 The mean age at diagnosis for unilateral nephroblastoma is 36.5 months for males and 42.5 months for females. The age of peak incidence for bilateral tumors is lower for both sexes: 29.5 months for males and 32.6 months for females. Children with Wilms' tumor may have associated anomalies, including aniridia, hemihypertrophy, and genitourinary tract malformations (hypospadias, cryptorchidism, and renal fusion anomalies). 3 The constellation of Wilms' tumor, aniridia, genitourinary malformations, and mental retardation (WAGR syndrome) occurs in association with a constitutional deletion of chromosome 11. About one-third of sporadic Wilms' tumors show tumor-specific loss of heterozygosity for polymorphic DNA markers on 11p13.6 The sequence of this putative Wilms' tumor gene, WT1, has now been determined. Mutations of WT1 have also been found in patients with the Denys-Drash syndrome. The Denys-Drash syndrome is of particular relevance to urologists due to the association of male pseudohermaphroditism and renal mesangial sclerosis. Wilms' tumor also has an increased incidence in children with Beckwith-Wiedemann, hemihypertrophy, and Perlman syndromes. Beckwith-Wiedemann syndrome (BWS), which consists of macroglossia, omphalocele, and visceromegaly, is associated with a 10% to 20% risk of tumor development, including nephroblastoma, adrenocortical neoplasms, and hepatoblastoma. This syndrome has also been linked to a second Wilms' tumor locus ( WT2) 11p15.5.6.

DIAGNOSIS More than 90% of children with Wilms' tumor present with an abdominal mass found incidentally by a family member or physician. The mass may be extremely large relative to the child and not necessarily confined to one side. Approximately 25% of children will have hematuria at diagnosis. However, gross hematuria is less common and warrants further evaluation to rule out tumor extension into the collecting system. Children may present more acutely with abdominal pain, leading to exploration for assumed appendicitis. Tumor rupture into the peritoneal cavity or bleeding within the tumor are the common reasons for presentation with an acute abdomen. A persistent varicocele in the supine position or hepatomegaly may be reflective of inferior vena caval obstruction from tumor thrombus. 8 The preoperative evaluation of a child with an abdominal mass can be accomplished in 24 to 48 hours in most medical centers. The laboratory evaluation should include a complete peripheral blood count, differential white blood cell count, platelet count, liver function tests, and renal function tests. There is an 8% incidence of acquired von Willebrand's disease in newly diagnosed Wilms' tumor patients. 4 This defect can be corrected preoperatively with the administration of 1-desamino-8-D-argiuine-vasopressin (DDAVP). Serum calcium should also be checked as this can be elevated in both congenital mesoblastic nephroma and rhabdoid tumor of the kidney. Children with abdominal masses require radiographic evaluation. The first study that should be obtained is an abdominal ultrasound, which can differentiate between solid and cystic masses. 1 For children with renal tumors, real-time ultrasonography of the inferior vena cava is necessary to exclude intracaval tumor thrombus, which occurs in 4% of patients with Wilms' tumor. 8 If this study is inconclusive, magnetic resonance imaging (MRI) is an excellent modality to assess the venous system. There is controversy regarding the need for additional imaging studies if ultrasound yields the information listed above. 1 Additional data required in a patient suspected of having Wilms' tumor is the presence of a contralateral functioning kidney and detection of pulmonary metastases. The question is whether advanced imaging studies, e.g., computed tomography (CT) or MRI, can provide useful staging information. Definition of local tumor extent and assignment of tumor stage is determined by surgical and pathologic findings. CT can suggest extrarenal extension into the perirenal fat or adjacent organs (e.g., liver) and regional adenopathy, but must be confirmed at surgery. Lungs represent the most common site of metastases and plain chest radiographs should be obtained to exclude pulmonary lesions.

INDICATIONS FOR SURGERY The initial management of a child with Wilms' tumor is abdominal exploration. In most cases, a radical nephrectomy can be performed. Histopathology and tumor stage have been demonstrated to be the key determinants of prognosis in patients with Wilms' tumor. Assignment of tumor stage ( Table 85-1) is based on intraoperative and pathologic findings. Therefore, the surgeon has an essential role in determining the treatment.

TABLE 85-1. Staging system of the National Wilms Tumor Study

The International Society of Pediatric Oncology (SIOP) advocates primary hemotherapy for all patients with Wilms' tumor regardless of extent of disease. Preoperative treatment can produce dramatic reduction in the size of the primary tumor facilitating surgical excision. The SIOP trials have utilized preoperative treatment for Wilms' tumor since the early 1970s, and their studies have demonstrated that the incidence of tumor rupture is lower after preoperative therapy. 10 It should be noted that there was no survival advantage over a primary surgical approach. One notable difference between SIOP and the National Wilms' Tumor Study Group (NWTSG) is that SIOP investigators use the postchemotherapy stage to determine the amount of postoperative therapy, which may inadequately define the risk of intraabdominal

recurrence in unirradiated patients. The NWTSG recommends preoperative chemotherapy only in children with bilateral tumors, tumors inoperable at surgical exploration, and inferior vena cava extension above the hepatic veins. All other patients should undergo primary excision of the tumor. This will allow precise staging of patients with modulation of treatment for each individual, thereby decreasing the intensity of treatment when possible while maintaining excellent overall survival.

SURGICAL TECHNIQUE Nephrectomy is routinely performed via a generous transverse abdominal incision. The patient is positioned in a supine fashion with some flexion of the lumbar spine to facilitate the exposure of retroperitoneal structures. The incision is made approximately 2 fingerbreadths above the umbilicus. The incision begins in the midaxillary line on the side of the neoplasm. The extent to which the incision is extended across the midline will vary with the size of the tumor and amount of exposure needed. The incision may be extended into a thoracoabdominal approach by continuing through the bed of the 9th or 10th rib, if necessary. The muscle layers are divided sequentially to facilitate exposure. The peritoneal space should be opened very carefully. The tumor will compress the colon and/or small bowel up against the anterior abdominal wall, which can inadvertently lead to enterotomy. A thorough exploration of the abdomen is then performed. The peritoneal cavity is assessed for evidence of preoperative tumor rupture, tumor implants, or drop metastases in the pelvis. The liver is carefully examined, as many of the liver metastases are not identified on preoperative imaging studies, and an assessment of tumor extent is then performed, including palpation of the inferior vena cava, assessment of regional lymphadenopathy, perinephric extension, and tumor mobility. Prior to proceeding with nephrectomy, the contralateral kidney is examined. The colon is reflected medially by incising the white line of Toldt. Gerota's fascia is opened to allow inspection as well as palpation of the anterior and posterior surfaces of the kidney. Any suspicious lesions should be biopsied for frozen section to exclude Wilms' tumor or nephrogenic rests. The nephrectomy now proceeds by reflection of the colon in a similar fashion as to expose the contralateral kidney. The colonic mesentery is mobilized with care taken to preserve the colonic vessels that are draped over the tumor. The colon can then be retracted medially to expose the renal vessels ( Fig. 85-1). For right-sided tumors, the posterior peritoneum can be incised up to the base of the mesentery. This will allow reflection of the entire colon and small bowel, which provides excellent exposure of the retroperitoneal vessels.

FIG. 85-1. Descending colon retracted medially after incising of the line of Toldt and mobilizing of the mesocolon off the anterior surface of the tumor.

If possible, the renal vessels should be ligated at the beginning of the operation. Once the renal vein has been identified, a vessel loop is placed around the vein. Any nodal tissue around the renal vein may be sent as part of the permanent specimen. The renal vein and inferior vena cava should be carefully palpated for the presence of tumor thrombus. The artery can be identified with careful retraction of the vein. Prior to ligation of the vessels, the contralateral renal vessels and superior mesenteric artery are identified to avoid injury to these structures. The vessels are then doubly ligated and divided. An alternative for management of the renal vein is to place a Satinsky clamp on the vena cava just proximal to the insertion of the renal vein. This is of great value when the vein is short or if there is tumor extension through the renal vein. The venous stump in the Satinsky is oversewn with continuous 5-0 prolene in two layers after the vein is divided ( Fig. 85-2A, B).

FIG. 85-2. Mobilization of left Wilms' tumor by blunt dissection after ligation and division of the renal artery (A) and vein (B).

If a tumor thrombus is present in the inferior vena cava, additional surgical exposure is necessary. In order to extract tumor thrombus from within the vena cava, both proximal and distal vascular control are necessary. For minimal extension well below the hepatic veins, the inferior edge of the liver can be retracted to expose the infrahepatic vena cava. For a tumor that extends more cephalad, mobilization of the liver is required. Division of the triangular and coronary ligaments of the liver allows rotation and exposure of the retrohepatic vena cava. Additional exposure can be gained by dividing the lesser hepatic veins. The contralateral renal vein and infrarenal IVC are controlled with vessel loops. The vena cava is then vertically incised just medial to the entrance of the renal vein. If the thrombus is free-floating, it may easily be milked out at this point. In many cases, however, the thrombus is adherent to the wall of the inferior vena cava. A Fogarty or Foley balloon catheter is passed beyond the level of the hepatic veins, the balloon inflated and pulled inferiorly, displacing the thrombus into the cavotomy. The vena cava is allowed to fill by releasing the vessel loops on the distal cava and contralateral renal vein. This will displace the air from within the cava. The cavotomy is then clamped with a Satinsky and oversewn in a continuous fashion with a 5-0 prolene suture (Fig. 85-3).

FIG. 85-3. Surgical technique to manage tumor extension through the renal vein. (A) Into the vena cava (limited to the infrahepatic level). (B) After exposure of the vessels, the infrarenal vena cava and contralateral renal vein are controlled with vessel loops and the vena cava is incised vertically at the intersection with the renal vein. (C) A Fogarty catheter is passed superior to the tumor thrombus and the balloon inflated. (D) The vena cava is flushed of air and a Satinsky clamp is placed to allow closure of the cavotomy.

After the vessels are controlled, a dissection plane is established outside of Gerota's fascia by sharp and blunt dissection. The perforating vessels can be quite large and should be ligated individually. Gentle handling of the tumor is needed to avoid rupture of the tumor during this dissection. Wilms' tumors are very soft, and it is easy to enter the tumor resulting in either local or diffuse tumor spill. The ureter is divided as low as possible after palpation of the ureter to rule out intraureteral extension. The lymphatic tissue in the renal hilum and adjacent precaval and preaortic area is generally removed with the specimen. Formal lymph node dissection is not required, but all suspicious lymph nodes should be biopsied. After removal of the tumor, the wound is irrigated with saline and hemostasis is assessed. A drain is not routinely left in place unless a portion of the pancreas or liver has been resected. The displaced colon is placed back in the tumor bed. Bilateral tumors Radical nephrectomy should not be performed at the initial operation of a child with bilateral Wilms' tumors. Children treated with preoperative chemotherapy have an equivalent survival to those undergoing initial radical surgery, but more renal units can be preserved in those given preoperative chemotherapy and partial nephrectomy(ies).7 Initial exploration of the abdomen and biopsy of both kidneys are performed to verify the histologic type of each tumor, although sampling errors may still occur. Partial nephrectomy or wedge excision can be employed at the initial operation only if all tumor can be removed with preservation of the majority of renal parenchyma on both sides. Grossly abnormal lymph nodes or other lesions suggestive of extrarenal spread should be biopsied and a surgical stage assigned to each kidney. The patient is given preoperative chemotherapy appropriate to the stage and histology of the tumor. The response of the tumors is evaluated by CT after week 5. This can assess the reduction in tumor volume and the feasibility of partial resection. At the time of the second-look procedure, partial nephrectomy or wedge excision of the tumor is performed, but only if it will not compromise tumor resection and negative margins can be obtained. If complete excision of tumor from one kidney can be performed leaving a viable and functioning kidney, then radical nephrectomy is performed to remove the contralateral kidney with extensive tumor involvement. Enucleation of the tumor should be considered in lieu of a formal partial nephrectomy only if removal of a margin of renal tissue would compromise the vascular supply to the kidney. If the tumor is not amenable to partial resections, repeat biopsies should be performed. Patients with persistent viable tumor that cannot be resected should be treated with a different chemotherapeutic regimen. The patient should be reassessed after an additional 12 weeks of chemotherapy to determine the feasibility of resection. If there is extensive tumor involvement precluding partial resection in a solitary kidney, radiation therapy can then be instituted to effect tumor shrinkage. Postoperative Treatment Current recommendations have been given for treatment to be utilized in the recently opened intergroup study NWTS-5 ( Table 85-2) in which biological features of the tumors will be assessed in patients who will not be randomized for therapy. This study will attempt to verify the preliminary findings that (LOH) for chromosomes 16q and 1p are useful markers in identifying patients who will relapse. 6 If these variables are found to be predictive of clinical behavior, then this information will be used in subsequent clinical trials to further stratify patients for therapy.

TABLE 85-2. Protocol for National Wilms' Tumor Study–5

The treatment for patients with stage I or II favorable histology (FH) and stage I anaplastic Wilms' tumor is the same. They will receive a pulse-intensive regimen of vincristine (VCR) and dactinomycin (AMD) for 18 weeks. A select group of patients under two years of age with stage I FH tumors weighing under 550 g will be selected for management with surgery alone in NWTS-5. 5 Careful postoperative surveillance of this group of children will be necessary so that any relapses can be detected early. Patients with stage III FH and stage II–III focal anaplasia are treated with AMD, VCR, and doxorubicin (DOX) and 1080 cGy abdominal irradiation. Patients with stage IV FH tumors receive abdominal irradiation based on the local tumor stage and 1200 cGy to both lungs.

RESULTS Complications Despite improvements and refinement of surgical technique, the removal of a large nephroblastoma is still prone to intraoperative and postoperative complications. Review of the charts of 1910 children with unilateral Wilms' tumor enrolled in NWTS-3 revealed a complication rate of 19.8%. 9 The most common complication was intestinal obstruction (6.9%) secondary to intestinal adhesions or intussusception. This was followed closely by extensive hemorrhage (5.9%), defined as intraoperative blood loss exceeding 50 ml/kg of body weight ( Table 85-3).

TABLE 85-3. National Wilms' Tumor Study–3: Most commonly reported surgical complications after unilateral nephrectomy

A mortality rate of 0.5% (intraoperative 0.05%) related to surgical complications is reported from NWTS-3. However, a higher intraoperative mortality rate of 1.5% has been reported from other centers. The risk factors associated with surgical complications are higher tumor stage, tumor size greater than 10 cm, incorrect preoperative diagnosis, thoracoabdominal incision, extrarenal intravascular tumor extension, and resection of other visceral organs. Results With current multimodal therapy, the overall 4-year survival for patients with favorable histology is approximately 90%. However, the regimens have not been as successful, with clear cell sarcoma of the kidney and rhabdoid tumor of the kidney patients demonstrating 4-year survival rates of 75% and 25%, respectively. Children with stage II–IV diffuse anaplasia and stage I–IV clear cell sarcoma and rhabdoid tumor of the kidney will be treated with new chemotherapeutic regimens in an attempt to further improve the survival of these high-risk groups. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Babyn P, Owens C, Gyepes M, D'Angio GJ. Imaging patients with Wilms' tumor. Hematol Oncol Clin North Am 1995;9:1217–1252. Breslow N, Olshan A, Beckwith JB, Green DM. Epidemiology of Wilms' tumor. Med Pediatr Oncol 1993;21:172–181. Clericuzio CL. Clinical phenotypes and Wilms' tumor. Med Pediatr Oncol 1993;21:182–187. Coppes MJ, Zandvoort SWH, Sparling CR, et al. Acquired von Willebrand disease in Wilms' tumor patients. J Clin Oncol 1993;10:1–7. Green DM, Beckwith JB, Weeks DA, et al. The relationship between microsubstaging variables, tumor weight, and age at diagnosis of children with stage I/favorable histology Wilms' tumor. A report from the National Wilms' Tumor Study. Cancer 1994;74:1817–1820. Grundy P, Coppes MJ, Haber DA. Molecular genetics of Wilms' tumor. Hematol Oncol Clin North Am 1995;9:1201–1216. Horwitz J, Ritchey ML, Moksness J, et al. Renal salvage procedures in patients with synchronous bilateral Wilms' tumors: a report of the NWTSG. J Pediatr Surg. 1996;31:1020–1025. Ritchey ML, Kelalis PP, Breslow N, et al. Intracaval and atrial involvement with nephroblastoma: review of National Wilms' Tumor Study–3. J Urol 1988;140: 1113–1118. Ritchey ML, Kelalis PP, Breslow N, et al. Surgical complication following nephrectomy for Wilms' tumor: a report of National Wilms' Tumor Study–3. Surg Gynecol Obstet 1992;175:507–514. Tournade MF, Com-Nougue C, Voute PA, et al. Results of the Sixth International Society of Pediatric Oncology Wilms' Tumor Trial and Study: a risk-adapted therapeutic approach in Wilms' tumor. J Clin Oncol 1993;11:1014–1023.

Chapter 86 Renal Fusion and Ectopia Glenn’s Urologic Surgery

Chapter 86 Renal Fusion and Ectopia Ross M. Decter

R. M. Decter: Department of Surgery, Section of Urology, Pennsylvania State Geisinger Health System, Hershey, Pennsylvania 17033.

Embryology Horseshoe Kidney Renal Ectopia Diagnosis Ectopic Kidney Indications for Surgery Alternative Therapy Surgical Technique Pyeloplasty Ureterocalicostomy Surgery for Tumors Stone Surgery in the Horseshoe Kidney Surgical Options for the Ectopic Kidney Outcomes Complications Results Chapter References

Although clinical problems associated with abnormali-ties of renal fusion and ectopia present infrequently in urologic practice, because these anomalies predispose to infection, hydronephrosis, stone disease, and, in some instances, neoplasia, a clear understanding of these anatomic variants and the deviation from standard urologic techniques to address them is important.

EMBRYOLOGY The ureteral bud branches from the Wolffian duct and extends toward the metanephric blastema during the fourth and fifth week of gestation, inducing the metanephric blastema to form the functioning kidney. The exact mechanism of renal ascent is not known but during normal development the kidneys ascend and rotate. The renal pelvis rotates from an initial anterior position 90 degrees toward the midline until it reaches its final medial position. Migration and rotation occur simultaneously between the fourth and eighth or ninth week of gestation. During renal ascent, the blood supply to the kidney is derived from successively higher levels of the aorta and its branches. The most common anomaly of renal position is incomplete rotation of the kidney to its final position. The renal pelvis in these malrotated kidneys generally lies anterior to the parenchyma as opposed to its normal medial location. Malrotation may be seen in kidneys that are otherwise normally positioned and malrotation is commonly observed in ectopic kidneys. Simple malrotation of a normally positioned kidney is often an incidental finding. These pyelocaliceal systems are morphologically abnormal, but functionally they usually drain without impairment. Close approximation of the proliferating renal blastemas prior to significant ascent is a normal embryologic finding. 5 If there is any disturbance of separation of the closely approximated renal blastemas, fusion anomalies of the kidneys may develop. The most common fusion anomaly is the horseshoe kidney. It is unknown as to whether this is caused by an abnormality of the arterial supply to the developing kidney, abnormal unfolding of the tail of the embryo, or some teratogenic agent. The horseshoe kidney generally ascends until the upper border of the isthmus is at the level of the inferior mesenteric artery. The second most common fusion anomaly is crossed-fused ectopia. This occurs when the developing kidney crosses from one side to the other during its ascent or when the ureteral bud from one side crosses to the contralateral side and induces abnormal development of that metanephric blastema. Crossed ectopia with fusion may occur in a variety of forms (Fig. 86-1). Although crossed ectopia occurs most frequently with fusion, the anomaly may occur without fusion ( Fig. 86-2).

FIG. 86-1. Six types of crossed renal ectopia with fusion. (A) Ectopic kidney superior. (B) Sigmoid or S-shaped kidney. (C) Lump kidney. (D) L-shaped kidney. (E) Disk kidney. (F) Ectopic kidney inferior. (Modified from McDonald JH, McClellan DS. Crossed renal ectopia. Am J Surg 1957;93:995.)

FIG. 86-2. Types of crossed renal ectopia. (A) Fused. (B) Nonfused. (C) Solitary. (D) Bilateral. (Modified from McDonald JH, McClellan DS. Crossed renal ectopia. Am J Surg 1957;93:995.)

HORSESHOE KIDNEY Horseshoe kidney is the most common of the fusion anomalies. It occurs in 1 n 400 to 1 in 1800 births. 8 There is a male predominance for the condition. 10 The fusion in horseshoe kidney almost always occurs at the lower poles. Only rare cases of upper pole fusion are recorded. 10 The isthmus of the horseshoe kidney lies as

mentioned above, just below the inferior mesenteric artery at the L4 vertebral level. The blood supply to these kidneys is often variable ( Fig. 86-3).

FIG. 86-3. Three common variants of blood supply in horseshoe kidney. (A) Single renal arteries arising from the aorta. (B) Multiple aortic arteries. (C) Multiple aortic and iliac arteries.

Horseshoe kidney is associated frequently with abnormalities of other systems, suggesting that a teratogenic factor causing widespread abnormalities may be etiologically important. About one-third of patients with these kidneys have such anomalies. Predominant among these are nonrenal genitourinary problems, including hypospadias and undescended testicles. These occur in about half of the patients with associated anomalies. Abnormalities of the musculoskeletal and cardiovascular systems each occur in about one-third of patients who have associated anomalies. Cardiovascular anomalies include ventriculoseptal defect (VSD). Musculoskeletal anomalies include spina bifida occulta, polydactyly, cleft lip and palate, hemivertebra, and scoliosis. Gastrointestinal anomalies include anorectal imperforation, rectosigmoid duplication, and malrotation of the kidney. In addition, horseshoe kidney is clearly associated more frequently with certain neurologic conditions including myelodysplasia. Chromosomal abnormalities have been associated with an increased risk of horseshoe kidneys. In Turner's syndrome, horseshoe kidney is a common occurrence and the diagnosis of a horseshoe kidney in a female suggests the need for a karyotype. Horseshoe kidneys are seen more frequently in patients who have trisomy 18 and in patients with long-arm deletions of chromosome 18. 1 The horseshoe kidney seems to be at no greater risk for renal malignancies than an orthotopically positioned kidney, but the distribution of the types of renal tumors in these kidneys is remarkably different from that of normal kidneys. In horseshoe kidneys, the proportion of transitional cell carcinoma and Wilms' tumor is much higher than expected. In fact, in one series of renal tumors occurring in horseshoe kidneys, 20% were transitional cell tumors, 25% Wilms', and only 50% were renal cell carcinomas. 2 It seems reasonable to suggest serial ultrasonographic follow-up in children with horseshoe kidneys to allow for early detection of a Wilms' tumor.

RENAL ECTOPIA An ectopic kidney lies outside of its normal position in the renal fossa. In simple ectopia, the kidney lies in the ipsilateral retroperitoneal space at a position that is generally lower than normal ( Fig. 86-4). It may be pelvic, iliac, lumbar, or thoracic. In crossed ectopia, the kidney crosses the midline and it is frequently fused to its contralateral mate. The autopsy incidence of renal ectopia is about 1 in 1000 cases. In screening studies, these kidneys were discovered in about 1 of 5000 cases and ectopic kidneys become clinically recognized in about 1 of 10,000 patients. Therefore, the condition often is totally asymptomatic. 6

FIG. 86-4. Location of lumbar and pelvic ectopically positioned kidneys in relation to the normally positioned kidney.

Reviews of renal ectopia show that the left and right kidneys are ectopic with close to equal frequency. Ectopic kidneys occur bilaterally around 10% of the time. The most common position of the ectopic kidney is pelvic. Pelvic ectopia was found in about 55% of the patients in one series; crossed-fused ectopia occurred in 27%; lumbar ectopia in 12%; noncrossed fused ectopia about 5% of the time; and thoracic kidney about 1% of the time. 6 Rarely, a solitary pelvic kidney occurs. This kidney suffers the risk of injury during pelvic surgical procedures and occasionally has been reported as an unusual cause of giant hydronephrosis. Ectopic kidneys are smaller than their contralateral mates. 3 The blood supply to the pelvic kidney, the commonest of the ectopic kidneys, is variable. The arterial supply may arise from the distal aorta or bifurcation, the ipsilateral common iliac, or the hypogastric vessels. In general, the lower the kidney is in its pelvic location, the greater the likelihood that multiple arterial vessels are supplying it. 4 Patients with renal ectopia frequently have a variety of other associated conditions. Musculoskeletal anomalies including vertebral abnormalities and nonrenal genitourinary conditions including hypospadias, undescended testicles, and anomalies of the vagina and Müllerian ducts occur in about a quarter of patients. Appropriate gynecologic evaluation is therefore mandated. 3 Significant cardiovascular conditions including tetralogy of Fallot, patent ductus arteriosus, VSD, and aortic coarctation have been recorded in association with renal ectopia. In addition, gastrointestinal tract anomalies including imperforate anus, cloacal anomalies, and Bochdalek's hernia are described. 6

DIAGNOSIS Patients with horseshoe kidneys seem to present in two groups. The first group consists of neonates or stillborns who have severe anomalies of other organ systems. Death in these children results from the anomalies in other systems. 10,11 The second group of patients comprises those who survive beyond the newborn period. The horseshoe kidney is asymptomatic in between a quarter and a third of these patients. 10 In children, typical symptoms leading to presentation include urinary tract infection in half; an abdominal mass, hematuria, or abdominal pain each occurring in about 10%; and other assorted causes in the remainder. The diagnostic evaluation of the clinical problem presenting in the horseshoe kidney generally proceeds along standard lines. Most children will have been evaluated initially with an ultrasound and many subsequently have intravenous pyelography (IVP). Most adults have IVP as their initial study. The intravenous pyelographic features of the horseshoe kidney are typical. One observes the abnormality of the renal axis with the more vertical orientation or lateral tilt of the renal axis. The renal pelves tend to be located anteriorly and the ureters course ventral to the isthmus. The lower calyces are oriented caudally or even medially as opposed to laterally. Kidneys with fusion anomalies are subject to a high incidence of reflux, variably reported between 20% and 50%. Voiding cystourethrography (VCUG) is therefore mandated during the evaluation of these patients. At times the diagnosis of ureteropelvic junction (UPJ) obstruction in a horseshoe kidney is straightforward; the patient's symptoms and IVP that reveals significant pyelocaliectasis can lead to the diagnosis. In other instances, with less severe dilation and especially when there is coexistent stone disease, we find the diuretic

renal scan valuable in helping to assess the drainage of these systems and deciding whether the hydronephrosis should be surgically addressed. Ectopic Kidney Patients who are symptomatic from their ectopic kidney frequently present with urinary tract infection. An ectopic kidney may also be discovered in the evaluation of abdominal pain. The workup of a palpable abdominal mass and discovery of the abnormal renal position in the workup of other associated anomalies each occur in about one-fifth of the cases. Hematuria, incontinence, renal insufficiency, and nephrolithiasis are less common presenting complaints. It is important to emphasize that the majority of patients who have ectopic idneys will be asymptomatic. The evaluation of the presenting symptoms generally proceeds along standard lines. Often in children an ultrasound evaluation leads to the recognition of the condition. In older patients, IVP is frequently performed. The ectopic kidney can be difficult to detect on the intravenous pyelogram as the pyelocaliceal system often overlies the bony pelvis. Special scrutiny needs to be directed to these areas to observe these systems. Functional evaluation of the ectopically positioned kidney is routinely performed with a diuretic renal scan. We find this testing very helpful in trying to assess whether or not a hydronephrotic ectopic kidney is truly obstructed. Ectopic kidneys have a high incidence of vesicoureteral reflux and consequently VCUG should be a routine part of the evaluation of these patients. Reviews of symptomatic patients with ectopic kidneys reveal that over half of patients present with hydronephrosis. The hydronephrosis is due to obstruction, most frequently at the UPJ but at times at the ureterovesical junction. In about one-quarter of cases the hydronephrosis in ectopic kidneys is a consequence of reflux; in a similar number, it is due to the configuration of extrarenal calyces that are neither obstructive nor refluxing. 6 The extrarenal calyces seen with ectopic kidneys look clubbed on IVP, as if they are affected by obstruction or chronic infection. In most instances, however, they are not affected by these processes but are simply an anatomic variant seen in association with the abnormal position of the kidney. 3

INDICATIONS FOR SURGERY The indications for surgical intervention in the horseshoe kidney are similar to those in the normally positioned kidney. Pyeloplasty is required in patients with symptomatic UPJ obstruction or when it is considered that the abnormality at the UPJ may impact on ultimate renal function. Symptomatic stone disease needs to be cleared by either open, endoscopic, or extracorporeal technique. The evaluation of infections in horseshoe kidney includes a VCUG and ureteral reimplantation may be mandated if reflux is of high grade, persists, or if prophylaxis fails to prevent infection.

ALTERNATIVE THERAPY The alternative to surgical intervention is nonoperative management, usually including no active therapy and antibiotics. In cases of severe obstruction, stones, and tumors, surgery is the only viable option. Endopyelotomy has recently been utilized to treat UPJ obstruction in horseshoe kidneys. The initial results of endo-pyelotomy performed by experienced surgeons are encouraging; however, we currently prefer pyeloplasty as the initial procedure on UPJ obstructions. Whereas pyelolithotomy has in past decades been utilized to clear calculi from horseshoe kidneys, more recently percutaneous and extracorporeal techniques have been employed. Extracorporeal shock wave lithotripsy (ESWL) in horseshoe kidneys has not enjoyed the success rates that it provides in orthotopically positioned kidneys. Most series note utilization of an increased number of shocks, the need for an increased retreatment rate, and an overall decreased stone clearance rate in horseshoe kidneys as compared to stones in conventionally positioned kidneys. One series recorded a 73% stone-free rate using ESWL after multiple treatments in horseshoe kidneys. 9 One of the reasons for difficulties treating stones with ESWL is that the anterior position of the stone makes it harder to position the stone at the F2 focus; often the surgeon will have to employ the blast path to try to fragment the stone. Some investigators have used prone positioning to overcome this problem. Percutaneous access to the horseshoe kidney seems readily achievable by most experienced percutaneous surgeons. Most investigators note that the use of a midto posterior calyx allows good access to the renal pelvis and state that the percutaneous access is not generally problematic. 7 Reports comparing ESWL of stones in horseshoe kidneys to percutaneous nephrostolithotomy suggest that the latter procedure provided superior stone clearance rates.

SURGICAL TECHNIQUE Pyeloplasty Pyeloplasty is the most common procedure performed on the horseshoe kidney. Division of the isthmus with nephropexy was thought in the past to be an important part of the procedure, but recent experience suggests that isthmus division or symphysiotomy is rarely necessary in the correction of UPJ obstruction. The surgical exposure of the horseshoe kidney can be achieved through a midline transperitoneal, anteriorly positioned flank extraperitoneal, or transverse transperitoneal approach. The transverse transperitoneal exposure seems to provide the widest exposure with a cosmetically acceptable scar and so we prefer it for pyeloplasty. The incision extends from the anterior axillary line on the affected side crossing the midline several centimeters below the umbilicus. It can be extended laterally in either direction if necessary. Depending on the position of the affected UPJ, the posterior peritoneum may be incised medial to the inferior mesenteric vein up to the ligament of Treitz, inferior and laterally along the small bowel mesentery around the cecum, and up along the line of Toldt on the right side. The small bowel and cecum can then be reflected upward out of the operative field and packed in the upper abdomen. Exposure is maintained with a ring retractor. Repair of UPJ obstruction in the horseshoe kidney can be performed by a Foley Y-V plasty or a dismembered pyeloplasty. Although the Foley Y-V repair is nicely suited to the typical high-insertion obstruction seen in horseshoe kidneys ( Fig. 86-5), we prefer the dismembered technique because it seems to provide more flexibility. During conduct of the pyeloplasty care must be taken to avoid inadvertent division of small vessels to the parenchyma and excessive dissection of the ureter or pelvis. In general, as much adventitial tissue is left on the ureter as possible and no vessels to the ureter are sacrificed unless their division is absolutely necessary to provide for adequate mobilization.

FIG. 86-5. The Foley Y-V technique is illustrated in A–C, the dismembered technique in D–G. (A) Dashed lines indicate inverted Y-shaped incision. Stay sutures of 5-0 chromic help define the margins of the incision. (B) A¢ indicates the tip of the renal pelvic flap. A indicates the inferior margin of the ureteral incision. (C) A and A¢ are sutured together with 7-0 Vicryl, creating a dependent, widely patent anastomosis. (D) The ureter is divided distal to the ureteropelvic junction after stay stitches are positioned. The inverted V, indicating the outline of the pelvic incision, is indicated by a dashed line. (E) The ureter has been spatulated and the pelvic flap developed. The initial stitch of 7-0 Vicryl is positioned at the heel of the anastomosis. (F) The interrupted sutures around the heel are completed. (G) The running locking sutures extending between the spatulated ureter and pelvis are completed creating a widely patent anastomosis.

After the proximal ureter and renal pelvis are adequately exposed using sharp dissection, two stay stitches of 5-0 chromic are positioned in the ureter just below the UPJ (Fig. 86-5). The ureter is divided between these stitches and carefully mobilized. A flap is then created by orienting an inverted V-shaped incision on the renal pelvis with the apex of the inverted V at the UPJ. The flap is designed so that when it is opened it will provide an adequate dependent portion of pelvis for the ureteral anastomosis. It is important that the base of the V be wide to avoid ischemia of the flap. The flap is opened with Wescott tenotomy scissors and the tip is trimmed

minimally to smooth the point of the V. The ureter is then positioned so that one can judge the length of the spatulation. The fact that the ureter is dismembered allows one to position it in such a way that the ureteral spatulation can extend in a relatively wide portion of the ureter and simultaneously orient it so that there is no redundancy that might kink the ureter below the UPJ repair. In addition, the anastomosis seems technically easier than the Foley Y-V as the ureter is not fixed at two points. The spatulation is created using Potts scissors on the posterior aspect of the ureter such that when it is laid on the dependent pelvic flap it will not be twisted. The anastomosis and dissection are performed with the aid of 2.5 power optical magnification. The anastomosis is performed using 7-0 Vicryl in children; in adults, 5-0 chromic or polydioxunone suture (PDS) is employed. We begin the anastomosis at its heel, suturing the most dependent portion of the V-shaped incision to the apex of the ureteral spatulation. The initial portion of the anastomosis is performed using interrupted sutures, generally one at the apex and two on either side of the apex. Each stitch must be precisely positioned to avoid postoperative leakage and/or stricturing. After the apex is anastomosed, the remainder of the pyeloplasty is performed using a running locking 7-0 Vicryl suture up one side of the spatulated ureter and then up the other side. Prior to complete closure, the anastomosis is tested for patency with five and eight feeding tubes. A double-J stent is placed in adults; no stent or diversion is generally employed in children. A Penrose drain is positioned near the anastomosis and made to exit extraperitoneally through a separate stab wound. The posterior peritoneum is approximated over the repair and the abdominal wall closure is performed using running 3-0 or larger PDS. We generally close the skin with a subcuticular pull-out stitch of 3-0 prolene. Most children are discharged 1 or 2 days after surgery. The skin suture is removed between 5 and 7 days postoperatively and the drain is removed at that time if drainage is minimal. Ureterocalicostomy A ureterocalicostomy may be performed to salvage a failed prior pyeloplasty, to correct UPJ obstruction when there is a small intrarenal collecting system, or in other instances when the lower pole parenchyma is extremely thinned ( Fig. 86-6). The ureter is separated from the pelvis as described above. The parenchyma over the lower pole calyx is incised and is resected to allow adequate exposure of the calyx. After hemostasis is achieved using cautery and/or sutures of 3-0 or 4-0 chromic through the edge of the resected parenchyma, the pelvis is incised from the region of the UPJ down into the exposed lower pole calyx. The ureter is spatulated and the anastomosis between the ureter and the opened calyx and pelvis is performed as previously described. It is important to resect enough parenchyma so that it does not impinge on the anastomosis. In these instances, diversion by either a nephrostomy tube (a 10- or 12-Fr Malecot) and a stent (usually a 5-Fr feeding tube) or a double-J stent are employed.

FIG. 86-6. Ureterocalicostomy for correction of ureteropelvic obstruction complicated by a small extrarenal pelvis. (A) Incision in the proximal ureter, through the stenotic junction into a wider portion of the ureter. (B) The 3-0 chromic sutures compress the resected renal parenchyma. (C) The opened edges of the ureter sutured to the cut edges of the calyx with 4-0 or 7-0 absorbable sutures. (D) Completed closure. A nephrostomy tube and ureteral stent should be used.

Surgery for Tumors Wilms' tumor commonly presents in the horseshoe kidney. In general, the involved kidney and isthmus are resected in the course of removal of the tumor. If the tumor occurs in the isthmus, some authors have recommended bilateral lower pole heminephrectomy. If the Wilms' tumor is bilateral at presentation, it is managed the same as bilateral Wilms' tumors in orthotopically positioned kidneys. Tumor surgery in the isthmus of the horseshoe kidney deserves special mention because this will involve division of the isthmus. If the isthmus is composed of a band of fibrous tissue it can be readily divided using cautery; however, if it is functioning parenchyma it must be carefully addressed to avoid excessive blood loss and necrosis of remaining parenchyma with risk of secondary bleed and urinary fistula. The area must be carefully dissected and arteries to the isthmus sequentially occluded with bulldogs to assess the line of demarcation. Once this line is established the capsule is divided sharply and the parenchyma divided. Bleeding from the cut parenchyma is controlled with 4-0 chromic suture ligation. Any exposed calyces are closed with running locking 4-0 or 5-0 chromic, and the capsule and parenchyma are closed with carefully positioned horizontal mattress suture of 1-0 or 2-0 chromic ( Fig. 86-7).

FIG. 86-7. Division of the isthmus of a horseshoe kidney with a right-sided renal tumor. The isthmus blood supply is from the left iliac. (A) After identification of the line of demarcation an incision is made around the capsule of the isthmus. (B) The capsule is peeled back. (C) The parenchyma of the isthmus is transected in a wedge fashion to facilitate closure. (D) Horizontal mattress sutures of absorbable 2-0 material are used to close the parenchyma for hemostasis. (E) The capsule is closed over the retained parenchyma with a continuous absorbable suture.

Stone Surgery in the Horseshoe Kidney When calculus disease complicates obstruction of the UPJ in a horseshoe kidney the stone is removed at the time of pyeloplasty. In these instances, there may be considerably more reaction around the pelvis and ureter, so that the use of a nephrostomy tube and ureteral stent is prudent. An antegrade study can be performed 10 to 12 days postoperatively prior to nephrostomy tube removal to confirm drainage through the UPJ and integrity of the repair. Surgical Options for the Ectopic Kidney The ectopic kidney can be affected by any of the processes that occur in a normally positioned kidney. Overall, the evaluation and surgical management of these conditions will follow the lines of those discussed with horseshoe kidney. Reflux, if it mandates treatment, is generally dealt with by a standard Cohen ureteral reimplantation.

Occasionally, one has to address the problem of a failed pyeloplasty in a patient who has an ectopic pelvic kidney. Ureterocalicostomy is one alternative in management of this problem; another is the use of a pyelovesicostomy. Pyelovesicostomy has been performed in renal transplant recipients after ureteral loss due to ischemia and/or rejection, and has proven to be a viable salvage procedure.

OUTCOMES Complications Problems common to UPJ repair regardless of kidney position, such as prolonged urine leakage and poor anastomotic drainage, occur more frequently in the horseshoe kidney. The risk of renal ischemia caused by damage of a aberrant vessel is increased in the horseshoe or ectopic kidney. Results Pyeloplasty in the horseshoe kidney is generally a successful procedure, although surgery on this anatomic variant does have a somewhat higher rate of complications than in normally positioned kidneys especially if division of the isthmus is employed. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Boatman DL, Kölln CP, Flocks RH. Congenital anomalies associated with horseshoe kidney. J Urol 1982;107:205. Buntley D. Malignancy associated with horseshoe kidney. Urol, VIII:146, 1976. Dretler SP, Olsson C, Pfister RC. The anatomic, radiologic and clinical characteristics of the pelvic kidney: an analysis of 86 cases. J Urol 1971;105:623. Dretler SP, Pfister R, Hendren WH. Extrarenal calyces in the ectopic kidney. J Urol 1970;103:406. Friedland GW, DeVries P. Renal ectopia and fusion: embryologic basis. Urology 1975;5:698. Gleason PE, Kelalis PP, Husmann DA, Kramer SA. Hydronephrosis in renal ectopia: incidence, etiology and significance. J Urol 1994;151:1660. Jones DJ, Wickham JEA, Kellett MJ. Percutaneous nephrolithotomy for calculi in horseshoe kidneys. J Urol 1991;145:481. Kölln CP, Boatman DL, Schmidt JD, Flocks RH. Horseshoe kidney: a review of 105 patients. J Urol 1972;107:203. Locke DR, Newman RC, Steinbock GS, Finlayson B. Extracorporeal shock-wave lithotripsy in horseshoe kidneys. Urology 1990;35:407. Pitts WR Jr, Muecke EC. Horseshoe kidneys: a 40-year experience. J Urol 1975;113:743. Segura JW, Kelalis PP, Burke EC. Horseshoe kidney in children. J Urol 1972;108:333.

Chapter 87 Transureteroureterostomy Glenn’s Urologic Surgery

Chapter 87 Transureteroureterostomy Anthony J. Casale

A. J. Casale: Department of Urology, Indiana University School of Medicine, and Pediatric Urology Division, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Transureteroureterostomy (TUU) is a renal salvage procedure necessitated by severe disease or injury of the lower half of the ureter. TUU was first performed clinically by Charles Higgins in 1934. Conditions that disable the distal ureter are rare and include trauma, malignancy, severe reflux, and distal ureteral obstruction. 6 As a rule, a ureteroureterostomy or ureteroneocystostomy are preferable procedures, but when the loss of ureter exceeds the ability of the surgeon to reanastomose the two ends of the ureter and the proximal ureter is too short to reach the bladder even with the aid of nephropexy and Boari bladder flap, then TUU is a useful option. TUU is occasionally utilized in complex reconstruction when the distal ureter is harvested to be used as a urethral replacement, for a catheterizable continent stoma, or for ureterocystoplasty. 3 Patients with advanced pelvic malignancies and a dilated ureter may be diverted utilizing a TUU and a cutaneous ureterostomy. 5

DIAGNOSIS Transureteroureterostomy is used as a salvage reconstructive procedure in conditions that would require resection or loss of the distal ureter. Any unilateral pelvic malignancy or trauma may result in unilateral ureteral loss. Complex reconstruction for congenital urologic anomalies and neurogenic bladder conditions may also require harvesting and re-use of a distal ureteral segment.

INDICATIONS FOR SURGERY Conditions that should be present to consider TUU include a salvageable kidney with a viable upper ureter of at least one-half its original length and a viable contralateral ureter with adequate drainage. The contralateral kidney is not necessary; in fact, the absence of the contralateral kidney facilitates the procedure and allows for an end-to-end anastomosis. A long segment of proximal ureter on the affected side will make the anastomosis easier and more successful by allowing a tension-free, straight anastomosis. Contraindications to TUU include impediments such as inadequate length of the donor ureter, a previous injury to either ureter from surgery or radiation, genitourinary tuberculosis, urothelial tumors, chronic pyelonephritis of either kidney, and a large size disparity between ureters. 7 A history of renal stones is considered to be a relative contraindication. In general, if one kidney is subject to a pathologic process that has spared the contralateral kidney and there is any possibility that the process can affect the uninvolved kidney via the shared ureter, then the procedure should not be performed.

ALTERNATIVE THERAPY Nephrectomy, nephrostomy, ureterostomy or pyelostomy; ureteral replacement with bowel; Boari bladder flaps and nephropexy to allow ureteroneocystostomy or ureteroureterostomy; and autotransplantation all stand as alternatives to TUU. Our preferences in reconstruction include keeping the drainage of each kidney into the bladder separate and the use of only urothelium in the urinary tract. Obviously, these goals cannot always be realized.

SURGICAL TECHNIQUE The surgical position for transureteroureterostomy is supine with the patient flat or with the back slightly flexed to elevate the retroperitoneum. The Trendelen-berg position will aid the surgeon by keeping the bowels out of the lower abdominal cavity during the procedure. If feasible, a preliminary cystoscopy may allow the urologist to place ureteral catheters in one or both ureters, which may aid in identifying the ureters and be used for postoperative stenting. A midline incision is best for this procedure, and because the ureters are closest to one another just above the bifurcation of the aorta the incision should afford the best visibility in this area. 4 The ureters must be easily visualized as they pass over the iliac vessels and into the pelvis in order to facilitate adequate mobilization of the donor ureter. Upon entering the peritoneal cavity, the bowel is packed into the upper abdomen or, if necessary, placed in a bowel bag. There are two options in opening the retroperitoneum. Two vertical incisions 5 cm long may be made over the distal ureters where they cross the iliac vessels and extending cephalad opening a window in the posterior peritoneum on each side ( Fig. 87-1). Alternately, a single curved incision may be used that opens the retroperitoneum from over the left distal ureter and extends across the midline along the small bowel mesentery and the cecum and up the right side along the line of Toldt (Fig. 87-2). This incision allows the bowels to be mobilized in an upward direction and exposes the retroperitoneum widely. On the left side the inferior mesenteric artery is a potential impediment to exposure of the distal ureter. If the blood supply of the left colon is otherwise normal, the inferior mesenteric artery can be ligated safely; however, this is seldom necessary.

FIG. 87-1. Transureteroureterostomy (TUU) using two posterior peritoneal incisions. (A) Plan for a left-to-right TUU. (B) The donor left ureter is spatulated and aligned with an incision made in the medial aspect of the recipient right ureter. (C, D) The anastomosis of the ureters may be performed with either interrupted or running (illustrated) absorbable sutures. (E, F) A catheter may be used during the anastomosis to separate the front and back wall of the anastomosis and removed at the last stitch. (G) Finished anastomosis visible through the right retroperitoneal window.

FIG. 87-2. Exposure of the retroperitoneal space using a circular self-retaining retractor and a curvilinear incision in the posterior peritoneum for mobilization of the bowel and mesentery.

It is advisable to expose and examine both ureters prior to beginning dissection. The recipient ureter should be mobilized only enough to allow an easy end-to-side anastomosis. Two 4-0 chromic stay sutures, one proximal and one dista to the anastomotic site, may be used to elevate and stabilize the ureter. Alternatively, small vessel loops may be carefully passed around the ureter at the same positions. Surgeons agree that dissection of the recipient ureter must be kept at a minimum to protect its blood supply. The donor ureter must be extensively mobilized to allow it to swing across the midline and lie in a gradually curved and tension-free course. It is important to maintain the ureter's associated blood supply and dissection should include mobilization of the gonadal vessels and periureteral adventitia along with the ureter. The dissection should begin just lateral to the gonadal artery and vein, and sweep all of the adventitia lying anterior to the psoas muscle with the ureter medially. The ureter should be divided and ligated with 3-0 chromic as distal as possible. The gonadal vessels should be divided and ligated with 3-0 silk near the length of the associated donor ureter. A long 4-0 chromic stay suture on the distal end of the divided donor ureter will allow it to be handled with minimal injury and facilitate its being passed through the retroperitoneal tunnel. Once the ureter has been mobilized the tunnel can be created through the retroperitoneal space. The tunnel should course beneath the posterior peritoneum, anterior to the great vessels, and superior to the inferior mesenteric artery to avoid trapping the ureter in the angle between the artery and the aorta. This is best done by dissecting medially from each side under direct vision. The midline portion of the tunnel may need to be created blindly with blunt dissection to connect the two sides. The surgeon's finger should pass through the tunnel to assure that it is wide enough for the ureter. A hemostat may then be used to grasp the stay suture on the end of the donor ureter and pull the ureter into position. Care must be taken to prevent twisting or kinking of the donor ureter. The donor ureter should easily reach the recipient ureter and lie in position against it without tension. The donor ureter should then be trimmed obliquely and may be spatulated if necessary to provide a wide anastomosis. The recipient ureter should be opened on its medial wall facing the donor ureter for a distance of at least 1.5 cm. The exact method of sewing the anastomosis may vary and either interrupted or running suture techniques are appropriate. We prefer to place a 5-0 chromic suture at each end of the anastomosis and to tie the two ureters in position ( Fig. 87-3). The sutures then can be sewn in a simple continuous running stitch to the opposite end and tied to the tail of the other end suture. The end sutures hold the ureters straight in position and allow some retraction during the anastomosis. We sew the back wall first, and once this step is done the ureteral catheter or stent can be placed under direct vision through the anastomosis.

FIG. 87-3. Ureteroureteral anastomosis may be performed with interrupted sutures. (A) After spatulating the donor ureter a suture is placed at the apex of each end of the anastomosis. (B) Once these sutures are tied the ureteral alignment should be straight. (C) Additional sutures are placed on each side of the anastomosis by dividing the distance between previous sutures evenly in half. (D) The finished anastomosis. (E) The TUU should not significantly alter the course of the recipient ureter.

Stenting of the transureteroureterostomy offers many options. We prefer to leave a stent across the newly created anastomosis and two ureteral catheters or double-J stents would be optimal. This is not often possible, however, because of the size of the recipient ureter especially at the ureterovesical junction. Stents may be placed in an antegrade fashion through the kidneys and the ends left in the distal ureter below the anastomosis and above the bladder. Finally, a single ureteral catheter or stent may be left in place that passes up the distal recipient ureter, passes through the anastomosis, and ends in the donor kidney. It is important that the stent have multiple side holes to facilitate drainage from both kidneys. All urologists agree that retroperitoneal drainage should be established. Dissection laterally from the ret-roperitoneal window over the anastomosis to the body wall allows placement of a drain to the skin through a separate stab incision. Some urologists prefer suction drains but we have used Penrose drains with success. The correct placement of the drains is more important than their type. The posterior peritoneum is then closed with a running 4-0 chromic so that any urine drainage cannot enter the peritoneal cavity. The peritoneal cavity is not drained. A Foley catheter is left in place unless bladder surgery was also performed and a suprapubic tube is utilized. If double-J stents are used the bladder is drained for 5 days and the stents left in place for 3 to 4 weeks. If ureteral catheters or antegrade stents are utilized, then the catheters or stents may be injected with contrast in x-ray to check for the patency and intactness of the anastomosis at 5 days and the tubes removed if the x-rays are acceptable. The bladder catheter may be removed 1 day after the ureteral catheters or antegrade stents. The retroperitoneal drains may be removed 5 days later. Patients often go home and return to have catheters and drains removed in clinic. Patients remain on prophylactic antibiotics until all tubes are removed and the urine is sterile.

OUTCOMES Complications Ureteral obstruction due to stricture may occur in 1% to 3% of patients and is the most serious possible complication. Therefore, it is imperative to carefully follow the patient with a transureteroureterostomy with imaging studies on a frequent basis. We prefer an IVP or Lasix renogram 2 weeks after stent removal. These studies should be repeated at 6 and 12 months after surgery, and then every 12 months. In addition, interval ultrasounds may be used in between these functional studies. Strictures may present either silently with gradually increasing hydronephrosis or with symptoms such as flank pain or infection. While the donor ureter is most at risk

because of mobilization, the recipient ureter may also be injured. Ureterocutaneous fistula might also occur and will become obvious when urine continues to drain from the Penrose site. Like strictures, fistulas may result from poor healing due to diminished vascular supply to the ureters or from inflammation, tumor, or distal obstruction. The initial management of both strictures and fistulas is long-term stenting and may include nephrostomy drainage in some cases. Finally, the most serious result of transureteroureterostomy occurs when both kidneys become obstructed due to a process at or below the anastomosis. The most common problem is an impacted stone in the distal ureter, but tumors or structure can also be to blame. In this instance the patient may become anuric and a true urologic emergency is present. Often use of percutaneous nephrostomy tubes is the best initial management to establish adequate drainage of urine until the primary obstruction can be evaluated and definitively treated. Results Transureteroureterostomy has been a highly useful technique with success rates of over 90%. In order to achieve these high levels of success, however, it is important to follow well-documented principles, such as (a) adequate mobilization of the donor and minimal mobilization of the recipient ureter, (b) spatulation of the donor ureter and anastomosis to the medial aspect of the recipient ureter, and (c) adequate drainage and prevention of urinary extravasation. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7.

Ehrlich RM, Skinner DG. Complications of transureteroureterostomy. J Urol 1975;113:467–473. Higgins CC. Transuretero-ureteral anastomosis. Report of a clinical case. J Urol 1935;34:349. Mitrofanoff P. Cystostomie Continent Trans-appendiculaire dans le Traitement des Vessaies Neurologiques. Chir Pediatrics 1980;21:297. Netto NR Jr. Transureteroureterostomy. In: Glenn JF, ed. Urologic surgery. 4th ed. Philadelphia: JB Lippincott, 1993;306–310. Rainwater LM, Leary FJ, Rife CC. Transureteroureterostomy with a cutaneous ureterostomy: a 25-year experience. J Urol 1991;146:13. Rushton HG, Parrott TS, Woodard JR. The expanded role of transureteroureterostomy in pediatric urology. J Urol 1987;138:357. Sandoz IL, Paull DP, Macfarlane CA. Complications with transureteroureterostomy. J Urol 1977;117:39.

Chapter 88 Pyeloplasty Glenn’s Urologic Surgery

Chapter 88 Pyeloplasty Eugene Minevich and Jeffrey Wacksman

E. Minevich and J. Wacksman: Department of Surgery, University of Cincinnati College of Medicine, and Division of Pediatric Urology, Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique: Dismembered Pyeloplasty Outcomes Complications Results Chapter References

The ureteropelvic junction (UPJ) is the most common site of obstruction in the upper urinary tract. The pelvis is usually a single hollow structure forming a cone-like transition to the upper ureter, which is fortunate for the performance of most surgical procedures. Urine is collected in the pelvis and transmitted through the UPJ to the upper ureter, where it travels via a peristaltic wave down the ureter to the bladder. Histologically, the renal pelvis is composed of three main layers: an inner transitional cell mucosal lining, a middle smooth muscle layer oriented in circular fashion (with a few internal and external bundles), and an outer fibrous coat. The renal vessels are usually situated superior and anterior to the UPJ. Contained within the outer layer of the renal pelvis is a rich arterial and venous anastomosis that provides an abundant blood supply to the pelvis. The blood supply of the upper ureter is contained within the surrounding adventitial layer of the ureter and outer ureteral wall. Therefore, skeletonizing of the ureter during dissection may cause devascularization of this segment. Lesions causing obstruction to the UPJ are divided into those resulting from intrinsic or extrinsic causes. Of the intrinsic factors (calculus, ureteral valve, fibroepithelial polyp, primary carcinomas), the adynamic segment is associated most often with classical UPJ obstruction. This obstruction is thought to be a congenital absence or abnormal arrangement of the muscular fiber at the transition zone of the upper ureter and renal pelvis. Extrinsic causes include fibrous bands, aberrant accessory vessels, and various organ-compressing factors (e.g., retroperitoneal fibrosis, carcinomatous nodal disease, inflammatory bowel disease).

DIAGNOSIS Prior to the advent of widespread ultrasonic screening during pregnancy, most children presented with abdominal or flank pain, hematuria, urinary tract infection (UTI), or gastrointestinal symptoms. Currently, most cases of UPJ obstruction are diagnosed in utero, although such patients are initially asymptomatic. Ultrasound is the test of choice to determine the degree of renal pelvic dilation, parenchymal thickness, and associated abnormalities of the bladder and ureter. The voiding cystourethrogram (VCUG) and occasional excretory urogram (IVP) provide necessary anatomic details. We use the diuretic renogram (MAG3) and occasional Whitaker antegrade pressure perfusion studies to define UPJ obstruction. 6 Retrograde pyelography is used occasionally to rule out other causes of obstruction and is usually performed just before surgery. 5

INDICATIONS FOR SURGERY In our institution, indications for surgery comprise the following: 1. Symptomatic UPJ obstruction with intermittent flank pain 2. Hematuria or pyelonephritis. 3. Renogram Lasix clearance T ½ (the time taken to clear half of the accumulated radioactive agent from the renal pelvis following Lasix administration) in excess of 20 minutes. 4. Renal pelvis pressure exceeding 20 cm H 20. 5. Differential renal function of the obstructed kidney less than 40%

ALTERNATIVE THERAPY Alternative treatments, including endopyelotomy (percutaneous or retrograde) and laparoscopic pyeloplasty, are beyond the scope of this chapter but are discussed in Chapter 116 and Chapter 128 of this book.

SURGICAL TECHNIQUE: DISMEMBERED PYELOPLASTY Although many repair techniques are available, we prefer a dismembered Anderson-Hynes pyeloplasty ( Fig. 88-1) for obstructed UPJ repair because it allows the removal of an adynamic segment and reduces the renal pelvis, thereby creating a more efficient pelvis. 1 Optical magnification (×3.5) is beneficial in ensuring precise suture placement and a watertight anastomosis. We have successfully used a standard subcostal extraperitoneal flank approach for several decades.

FIG. 88-1. Dismembered pyeloplasty after subtotal resection of an excessively large renal pelvis. (A) The line of excision provides an adequate margin of pelvis to enable closure without tension. (a) A vertical incision is made in the lateral aspect of the ureter to spatulate it. (B) The apical sutures are carefully placed. (C) Approximation and closure of the pelvis are completed.

The procedure starts with careful but limited mobilization of the upper ureter, being certain to keep all periureteral tissue attached to the ureter. In most cases this can be done without placing any type of tape around the ureter, which could damage the blood supply coming up through its adventitia. Next, a 4-0 or 5-0 chromic traction suture on a small taper needle is placed at the UPJ. A second suture is usually placed above this and the upper ureter transected. The transected ureter with its traction suture is carefully mobilized for a short distance. With use of the traction suture through the UPJ, the pelvis is completely mobilized and prepared for reduction. Next, the renal pelvis is incised (usually below the UPJ) and excess pelvis is trimmed away. At this point, the surgeon should be careful not to cut across

any extrarenal calyces. A 5-0 chromic traction suture is used to mark the most dependent position of the UPJ. We prefer to close the trimmed upper pelvis next, which usually is accomplished with a 4-0 or 5-0 chromic running, interlocking suture placed halfway down the renal pelvis, in a watertight fashion. The ureter-to-pelvis anastomosis is performed next. The suture on the upper ureter is placed on traction and the upper ureter is spatulated for 2 to 3 cm on either the posterior or the lateral aspect of the ureter. Care is taken not to twist or spiral this incision. Next, the spatulated end of the ureter is anastomosed to the dependent portion of the renal pelvis with interrupted 6-0 monofilament polyglyconate (Maxon) sutures, or 6-0 or 7-0 Vicryl sutures. These are usually through-and-through inverting sutures, with knots secured on the outside of the anastomosis. After placement of 4 or 5 sutures, the KISS catheter (Kidney Internal Split-Stent, Cook Urological) is placed. 4 The remainder of both sides of the anastomosis is closed, with either a running suture of 6-0 Maxon or 6-0 or 7-0 Vicryl. An external drain (Penrose or Jackson-Pratt) should be placed after the anastomosis is completed. The type of suture material used is not critical, but the type of surgical dissection and mobilization are most important. If the ureter is compressed against a distended pelvis by crossing polar vessels, we prefer to divide the UPJ and bring the pelvis and ureter anterior to the crossing vessel (Fig. 88-2). Having accomplished this, the rest of the procedure is similar to the dismembered pyeloplasty.

FIG. 88-2. Dismembered pyeloplasty with accessory polar vessels. (A) Vessels compressing the ureteropelvic junction. (B) Ureter divided from renal pelvis. (C) Reduction pyeloplasty with ureter brought anterior to polar vessels for anastomosis.

The most common site of UPJ obstruction in a duplicated kidney is usually the lower pole segment ( Fig. 88-3). Since the upper pole is separate and not obstructed, we usually perform a simple dismembered pyeloplasty to the lower pole. On occasion, we have anastomosed the lower pole renal pelvis to the upper ureter, especially in long-segment disease. For obstruction of the upper pole segment alone, either a routine pyeloplasty to the upper pole or, in this case, a pyeloplasty to the lower pole pelvis can be performed ( Fig. 88-4).

FIG. 88-3. Ureteropelvic junction obstruction of the lower pole ureter in a duplicated system. (A) Ureteropelvic stenosis of lower pole. (B) Dismembered pyeloplasty with resection of stenotic segment. (C) Reduction pyeloplasty and anastomosis of lower pole pelvis to upper ureter.

FIG. 88-4. Pyelopyelostomy. (A) Adjacent surfaces of the unobstructed normal lower segment of pelvis and the obstructed (abnormal) upper segment of pelvis. (B) A window is created between the two pelves, and the posterior margins are joined. (C) Anastomosis is completed. An optional resection of a portion of the upper segment of the ureter is illustrated.

The anatomies of the horseshoe kidney and pelvic or ectopic kidney with a UPJ obstruction are similar. In both, the renal pelvis is usually anterior, with several crossing vessels. In patients with horseshoe kidneys, we usually recommend a transabdominal approach. Although not absolutely necessary, we prefer to divide the renal isthmus to try to establish a more inferior and dependent position to the new UPJ. After this, a standard dismembered pyeloplasty is preferred over a flap procedure.

OUTCOMES Complications Urinary leakage may occur during the first few postoperative days. Usually a minor amount of leakage is not problematic if the area is drained adequately. Therefore the drain should only be removed after one has made sure that the anastomosis is intact. If intraoperative drainage of the renal pelvis was not performed, leakage can be handled by percutaneously placed nephrostomy or by ureteral stent. With the use of meticulous technique and a KISS catheter, immediate postoperative excess urinary leakage is virtually non-existent. Obstruction at the UPJ is usually secondary to traumatic dissection, devascularization of the ureter, excessive traction on the ureter resulting in ischemia or creation of an anastomosis that is too tight, or extravasation from an undrained anastomotic leak with subsequent fibrosis. This can be managed initially by intubation or balloon dilation of the strictured area and formal reoperation (open or endoscopic) if the initial step fails. Postoperative bleeding (usually from the nephrostomy tract) can jeopardize the repair by the formation of obstructive clots. Other postoperative problems include

acute pyelonephritis, wound infection, or incisional hernia. Results Experimental and clinical data clearly support our view that obvious obstruction at the UPJ should be surgically corrected expeditiously, even in the neonatal period. Dismembered pyeloplasty with careful attention to the details outlined is successful in more than 95% of cases. 2 Surgical complications are rare and can be managed conservatively in most cases. In our 15-year experience of more than 200 pyeloplasties with nephrostomy tube or KISS catheter drainage, no patient required reoperation for persistent obstruction, increased hydronephrosis, or decreased split renal function. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6.

Anderson JC, Hynes W. Retrocaval ureter: case diagnosed preoperatively and treated successfully with plastic operator. Br J Urol 1949;21:209. Bernstein GT, Mandell J, Lebowitz RL, Bauer SB, Colodny AH, Retik AB. Ureteropelvic junction abstraction in the neonate. J Urol 1988;140:1216. Conway J. Well tempered diuresis renography. Semin Nucl Med 1992;22:74. Ritchie E, Reisman EM, Zaontz MR, Hatch DA, Wacksman J, Maizels M. Use of kidney internal split/stent (KISS) catheter in urinary diversion after pyeloplasty. Urology 1993;42(l):55. Rushton HG, Salem Y, Belman AB, Maid M. Pediatric pyeloplasty: is routine retrograde pyelography necessary? J Urol 1994;152(2 part2):604. Whitaker RH. The Whitaker test. Urol Clin North Am 1979;6:529.

Chapter 89 Megaureter Glenn’s Urologic Surgery

Chapter 89 Megaureter Edmond T. Gonzales, Jr.

E. T. Gonzales, Jr.: Scott Department of Urology, Baylor College of Medicine, Houston, Texas 77030-2399.

Diagnosis Indications for Surgery Surgical Technique Outcomes Complications Chapter References

A megaureter is, simply stated, a ureter that is wider than normal. By convention, this is usually a ureter greater than 7 mm in diameter. 3 However, the extent of dilation varies considerably and in some cases the ureter may be as wide as 3 cm or more in cross-section diameter. In nearly all cases, the dilation is present along the entire length of the ureter. In the past, most patients with megaureter presented because of urinary tract infection, pain, palpable abdominal or flank mass, or were found incidentally when an intravenous urogram or renal ultrasound was obtained for unassociated symptomatology. Today most children with megaureter are found on prenatal ultrasound, before associated symptoms or infections develop. There are multiple causes for megaureter and the abnormalities are considerably more varied than the pathology associated with ureteropelvic junction (UPJ) obstruction. Megaureter may be acquired or congenital. Acquired abnormalities might include a postsurgical stricture, ureteral calculus, or ureteral occlusion associated with an inflammatory process or a tumor. In the pediatric age group, acquired causes for megaureter are distinctly uncommon. Almost all children with megaureter have some form of congenital anomaly associated with the development of the ureter, the ureterovesical junction, or abnormally high intravesical pressures. Megaureter is generally classified as (a) obstructed megaureter, (b) nonobstructed, nonrefluxing megaureter, or (c) refluxing megaureter. Each of these categories is subclassified into primary and secondary disorders. Primary causes for megaureter involve anomalies of the ureterovesical junction or the ureter itself. Secondary causes would result from abnormally high intravesical pressures or abnormally high urinary flow rates (e.g., diabetes insipidus). This classification emphasizes the observation that all widened ureters are not associated with obstruction at the ureterovesical junction. It behooves the surgeon contemplating an operative repair to evaluate all aspects of urinary pathophysiology that might be associated with a megaureter. For instance, high intravesical pressures associated with posterior urethral valves, neurogenic dysfunction, or dysfunctional voiding can result in substantial dilation of the ureter, which would resolve if the bladder pathology were corrected. In most cases, if the primary pathology is associated with high intravesical pressures, one expects bilateral ureteral changes as well as some degree of detrusor thickening. However, the degree of ureteral dilation is not always symmetric. A voiding cystourethrogram is, therefore, essential as part of the initial screening evaluation of any child with a megaureter. In some children, vesical urodynamics will also be necessary to fully elucidate the possibility of bladder pathology. In other cases, massive vesicoureteral reflux will be found at the time of voiding cystourethrography. If there is no obvious bladder pathology and no findings to suggest high intravesical pressures, this confirms the diagnosis of a primary refluxing megaureter. In this situation, it is likely that the extreme dilation of the ureter represents some form of primary ureteral muscle abnormality in association with the reflux. Ureteral dilation can be associated with ureteral abnormalities without reflux or obstruction. Examples of primary ureteral dysfunction are most obvious and exaggerated in the prune belly syndrome. Isolated examples of this form of ureteral dilation, though, are also thought to exist and have been described in the past as a forme fruste of the prune belly syndrome. Primary obstructive megaureter is about one-sixth as common as primary UPJ obstruction. Truly obstructive megaureter will ultimately require surgical repair and is the primary topic of this discussion. In a primary obstructed megaureter, the most distal portion of ureter for 1 to 2 cm just outside of the bladder is usually of normal or slightly smaller caliber. This is the obstructing portion. The obstruction appears to result from faulty peristalsis of this segment, and histologic studies have demonstrated increased circular muscle and fibrosis in that segment. 7 In the refluxing megaureter, the ureter is generally dilated all the way to the detrusor and the typical changes seen in the obstructed megaureter are not present. There is also a histologic difference between the obstructed and refluxing megaureter. Whereas the ureteral wall in obstructed megaureter may be thickened and hypertrophied, the smooth muscle-to-collagen ratio is similar to normal control ureters. In the refluxing megaureter there is an increased percentage of collagen to smooth muscle in the ureter, suggesting that there is an inherent developmental abnormality in the refluxing megaureter. 5

DIAGNOSIS The confirmation of significant ureterovesical junction obstruction as a cause for megaureter is not always straightforward. Evaluation and assessment of the child with hydroureteronephrosis must consider the extent of renal function in the involved kidney, the degree of dilation, level of bladder function, and presenting symptoms. Diagnostic evaluation might include renal ultrasonography, intravenous urography, radioisotope renal scan, percutaneous nephrostomy for temporary diversion that would allow evaluation of specific renal function and for antegrade pressure flow studies (Whitaker test), 13 as well as a thorough bladder evaluation (cystography, urodynamics) as discussed above. In most situations, the initial evaluation will consist of a renal ultrasound, voiding cystourethrogram, and diureticenhanced (Lasix) renal scan. The renal scan will provide an estimate of comparative renal function and washout times.

INDICATIONS FOR SURGERY Indications for surgery would include evidence of deterioration (such as increasing ureteral dilation on subsequent ultrasounds or decreasing renal function on follow-up renal scans) or development of urinary infection or pain consistent with the obstruction. If the hydroureter was identified incidentally (e.g., prenatally or during a bone scan for evaluation of joint pain), and renal function is normal or near-normal on the side of the abnormality, an argument could be convincingly made to follow this child. This presentation differs significantly from the child who presents with pain and/or urinary infection. Perhaps the most controversial aspect of managing a child with megaureter and ureterovesical obstruction is the current increased recognition of the disorder in the fetus. Initially, this observation was met with great surgical enthusiasm on the expectation that progressive deterioration and loss of renal function will undoubtedly result. However, increasing experience has shown that a considerable number of newborns with hydroureter will maintain stable renal function and show substantial, gradual improvement in the degree of dilation, ultimately regaining near-normal renal and ureteral anatomy. 2,6,9 In one study reported by Baskin and associates, 25 neonates with primary megaureter (without reflux) and good ipsilateral renal function were followed for an average of more than 8 years. 1 In half of the patients, the hydronephrosis improved spontaneously, whereas in another 20% it remained stable. None of these children demonstrated loss of renal function as measured by radionuclide renal scanning.

SURGICAL TECHNIQUE

Surgical techniques for correction of obstructive anomalies at the ureterovesical junction involve a variation of ureteral reimplantation. If ureteral dilation is only mild to moderate, a simple ureteral reimplantation may be all that is necessary. The segment of abnormal ureter is usually short and must be excised in its entirety. The procedure can be done either intravesically or extravesically by any standard ureteral reimplantation technique as described elsewhere in this text and can be chosen at the surgeon's preference. More often, however, some degree of remodeling of the lower ureter is indicated during correction of a megaureter. The lower ureter is approached through a Pfannenstiel incision. The procedure can be performed intravesically or extravesically. If the ureteral diameter is substantial, my preference is to expose the ureter extravesically before opening the bladder. The principle of remodeling the lower ureter for correction of a megaureter anomaly is to reduce the circumference sufficiently to allow a more near-normal-caliber ureter to be implanted. The goal is to achieve a homogeneous caliber of lower ureter for the entire segment of submucosal tunnel as well as for a short distance outside of the detrusor. It is not necessary to extensively reduce the caliber of the ureter more proximally. Since these are obstructed ureters, once the obstruction is satisfactorily relieved the proximal dilation will resolve substantially. It is especially important to respect the blood supply when mobilizing the ureter. The blood supply to the lower portion of the ureter will be coming into the ureter laterally from the superior vesical artery as well as small branches that may still be coming from the umbilical vessels. These vessels will usually have to be sacrificed. The first significant medial branch is encountered coming off of the common iliac or internal iliac (hypogastric) artery, and every effort must be made to identify and preserve this vessel (Fig. 89-1). During dissection, a visible layer of adventitia is left along the ureter to minimize damage to the delicate blood supply that encompasses the ureter. Special care is taken to identify and preserve any longitudinal blood supply along the ureter.

FIG. 89-1. Diagrams of the major arterial supply to the ureter. It is not necessary to sacrifice any medially based blood supply for primary megaureter repair.

In most cases, the discarded segment of ureter will be a lateral wedge. However, the basic principle is to respect obvious intrinsic blood supply, and at times the resection may follow a more circuitous path if a clearly defined longitudinal vessel is evident. At this point, a choice is made regarding whether a formal surgical excision and reduction ureteroplasty is to be performed or whether a plication procedure would be satisfactory. This decision is generally based on the caliber and thickness of the ureter as well as the preference of the surgeon to some extent. Plicating a very large, thick-walled ureter leaves a considerable bulk of defunctionalized ureter that can be difficult to bring through a submucosal tunnel and results in considerable edema that may require a lengthy period of ureteral diversion in some instances. From a practical point of view, postoperative management is similar for a plication versus a reduction ureteroplasty in my hands, and I do not feel that there is a substantial difference between the two procedures. Formal excision and reduction ureteroplasty will be described first, followed by techniques for plication of the ureter. After adequate dissection and mobilization of the ureter in the perivesical space, a 12-Fr catheter is passed up to the renal pelvis (in a newborn or very young infant, the catheter would be 10-Fr). Occlusive clamps are placed loosely around the catheter, visually preserving longitudinal blood supply along the course of the segment to be preserved. As the clamps are placed proximally, the length of segment needed for passage into the bladder and through the submucosal tunnel is kept at a homogeneous caliber. As soon as this length is felt to be sufficient, more proximal clamps are gradually moved farther and farther away from the catheter so that a gentle tapering of this portion of the ureter results. The clamps are placed so that the discarded segment is what is secured by the clamps. Every effort is made to avoid damage to the small vessels of the preserved ureteral strip ( Fig. 89-2). The ureter is closed in two layers. The musculomucosal layer is closed with a running, locking 7-0 chromic catgut suture. The thin adventitia that was preserved at the time of ureteral mobilization is then closed as a second layer with running, nonlocking, 7-0 Vicryl or 7-0 PDS suture. Near the distal portion of the ureteral strip, for a length of about 1.5 cm, interrupted sutures are placed. This is because a segment of ureter may have to be excised at the time of reimplantation and this prevents cutting back into the running suture line. At this point, care is taken to inspect the blood supply and extent of bleeding at the tip of the ureter.

FIG. 89-2. (A, B) The wedge of ureter to be excised is secured with Allis or Hendren clamps. (C) The outlined segment of ureteral wall is excised sharply. (D, E) The ureter is closed in two layers. Distally, interrupted sutures are placed to allow for trimming of the end of the ureter at the time of reimplantation.

The bladder is then opened anteriorly. A suitable location on the posterolateral side of the bladder is chosen for creation of a new ureteral hiatus, usually just cephalad to the original ureteral meatus. The ureter is brought into the bladder. A cross-trigonal tunnel is then fashioned, and the tapered segment of the ureter is brought into the tunnel and secured distally in the usual fashion. The mucosa overlying the location of the neohiatus is closed with submucosal sutures to evert the mucosal edges. This is done to reduce the likelihood that a ureteral bladder fistula could result that would subsequently eliminate the length of tunnel that was created. A 7-Fr silastic single-J catheter is placed in the ureter and secured just at the meatus with a single 4-0 chromic catgut suture. The catheter is then brought out through the bladder and through a separate puncture wound in the skin for external diversion and drainage. Vesical diversion is accomplished by a small urethral catheter in girls or a small suprapubic tube in boys. The wound is closed in layers in the routine fashion, and the perivesical space is drained with a small Penrose drain. The ureteral stent is generally left in place for 10 days. There are two techniques for ureteral plication: the Starr technique and the Kalicinski technique. The Starr technique involves imbrication and plication of the ureter along the course to be reimplanted as demonstrated in Figure 89-3.12 The Kalicinski technique differs by isolating the ureteral lumen from a defunctionalized portion by a running horizontal mattress suture and then folding this defunctionalized segment around the ureter to maintain a more homogeneous ureteral caliber ( Fig. 89-4).4 Respect for the ureteral blood supply is identical to what was emphasized for formal excision ureteroplasty. In both cases, reimplantation is accomplished in a similar fashion and a ureteral stent is similarly left in place. If the amount of tissue folded is not extensive, then the catheter is generally taken out after several days.

FIG. 89-3. (A) Starr plication of the ureter suture to infold the ureter. (B) Cross-section to show placement of Lembert-type suture. (C) Cross-section after ligation of suture.

FIG. 89-4. Kalicinski technique of ureteral imbrication. (A) Placement of cobbler's stitch to exclude a major portion of the ureteral lumen. (B) Same in cross-section. (C) After ligation. (D) Excluded portion of ureter is folded over and wrapped around the intubated ureter. (E) Final appearance in cross-section.

A totally extravesical approach for the management of a megaureter has been described, but it is not as popular as the transvesical approach.

8

OUTCOMES Complications Reduction ureteroplasty is a very safe, reproducible, and successful procedure. 10 The major complications are those associated with any ureteral reimplantation: the development of ureteral obstruction (about 5% of cases) or vesicoureteral reflux (about 10% of cases). As suggested previously, one abnormality that can result in postoperative reflux is the development of a fistula along the tunnel fashioned for the reimplantation. Although a two-layer ureteral closure offers some additional assurance to avoid this complication, care should be taken to handle the mucosa during the development of the submucosal tunnel carefully and to keep it full thickness throughout the course of dissection. In most cases, obstruction is probably a result of ischemia of the preserved ureteral strip. Initial efforts at managing this complication would be by percutaneous dilation of the stricture, but many such instances will ultimately require formal open surgical revision. Many clinicians have experienced more difficulties when reconstructing a refluxing megaureter than a primary obstructed megaureter. 11 The specific reasons for the observation have not been clearly elucidated, although it is generally accepted that refluxing ureters are inherently more abnormal than primary obstructed systems and therefore are less likely to recover fully. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Baskin LS, Zderic SA, Snyder HM, Duckett JW. Primary dilated megaureter: long term follow-up. J Urol 1994;152:918–921. Cozzie F, Madonna L, Maggi E, et al. Management of primary megaureter in infancy. J Pediatric Surgery 1993; 28:1031–1033. Cussen LJ. Dimensions of the normal ureter in infancy and childhood. Invest Urol 1997;5:194–199. Kalicinski ZH, Kansy J, Kotarbinska B, Joszt W. Surgery of megaureters: modification of Hendren's operation. J Pediatr Surg 1977; 12:183–188. Lee BR, Partin AW, Epstein JI, Quinlan DM, Gosling JA, Gearhart JP. A quantitative histological analysis of the dilated ureter of childhood. J Urol 1992; 148:1482–1489. Liu HY, Dhillon HK, Young CK, Diamond DA, Duffy PG, Ransley PG. Clinical outcome and management of prenatally diagnosed primary megaureter. J Urol 1994;152:914–917. McLaughlin AP III, Pfister RC, Leadbetter WF, Salzstein SL, Kessler WO. The pathophysiology of primary megaloureter. J Urol 1973; 109:805–811. McLorie GA, Jayonthi VR, Kinaham TJ, Khoury AE, Churchill BM. A modified extravesical technique for megaureter repair. Br J Urol 1994;74:715–719. Mollard P, Foray P, Degoday JL, Valignat C. Management of primary obstructive megaureter without reflux in neonates. Eur Urol 1993;24:505–510. Peters CA, Mandell J, Lebowitz RL, et al. Congenital obstructed megaureters in early infancy: diagnosis and treatment. J Urol 1989;142:641–645. Rabinowitz R, Barkin M, Schillinger JF, Jeffs RD, Cook GT. The influence of etiology on the surgical management and prognosis of the massively dilated ureter in children. J Urol 1978;119:808–813. 12. Starr A. Ureteral plication: a new concept in ureteral tailoring for megaureter. Invest Urol 1979;17:153–157. 13. Whitaker RH. Methods of assessing obstruction in dilated ureters. Br J Urol 1973;45:15–22.

Chapter 90 Triad Syndrome Glenn’s Urologic Surgery

Chapter 90 Triad Syndrome David B. Joseph

D. B. Joseph: Division of Urology, Children's Hospital of Alabama, and Department of Surgery, The University of Alabama, Birmingham, Alabama 35233.

Diagnosis Presentation Evaluation Indications for Surgery Urinary Tract Reconstruction Urinary Diversion Definitive Urinary Reconstruction Reduction Cystoplasty Abdominal Wall Reconstruction Orchiopexy Outcomes Complications Results Chapter References

Triad syndrome—the clinical association of a thin flaccid abdominal wall, undescended testes, and bladder hypertrophy with hydroureters—was originally described in 1895 by Parker. 9 Shortly thereafter, Osler presented a similar constellation of findings in a child he described as having the appearance of a wrinkled prune. 8 From that point, prune belly has unfortunately become synonymous with this syndrome. This clinical manifestation is also known as the Eagle-Barrett syndrome and the abdominal muscular deficiency syndrome. By classic description, the triad syndrome occurs in boys. However, 5% are girls presenting with similar physical findings with the obvious exception of the gonadal abnormality. The incidence of triad syndrome occurs in 1 of every 30,000 to 50,000 live births. Most cases are sporadic, although a familial occurrence has been described. There is no single theory that incorporates all aspects of the triad syndrome. Early theories were founded on a primary mesodermal defect or a primary obstructive process.3 The mesodermal defect theory is based on an abnormality occurring in embryonic mesoderm during the third week of gestation that results in an abnormally developed abdominal wall and urinary system. The obstructive theory is based on a lesion occurring in the region of the membranous urethra. This causes back pressure, which leads to dilation of the bladder, urinary ascites, and abdominal distention. The result is degeneration of abdominal wall musculature. The increased abdominal pressure is transmitted to the upper urinary tract resulting in hydroureteronephrosis and renal dysplasia. The presence of intra-abdominal testes with either of these theories has not been supported by experimental investigation. Approximately three-quarters of the children with classic triad syndrome will have associated anomalies. Most often there is a thoracic deformity resulting in protrusion of the upper sternum, depressed lower sternum, and splayed ribs. Other skeletal deformities include talipes equinovarus, congenital hip dislocation, calcaneus valgus, polydactyly, syndactyly, arthrogryposis, scoliosis, and lordosis. Midgut malformations, most often due to defective fixation or malrotation of the midgut, have been noted in approximately one-third of children. Cardiac problems (atrial and ventricular septal defects) have been reported in approximately 15% of children.

DIAGNOSIS Presentation Fetal sonography has had a major impact on early identification of genital urinary abnormalities. With sophisticated equipment and operator expertise, the identification of a child with the triad syndrome can often be established in utero. A similar constellation of findings can be seen in a fetus with posterior urethral valves or the megacystis-megaureters syndrome. Close inspection of the abdominal wall musculature will often hedge the differential diagnosis to that of the triad syndrome. In utero diagnosis allows for a planned neonatal investigation spear-headed by the pediatric urologist. At birth, the diagnosis of triad syndrome is often obvious based on the pathognomonic physical findings of a loose, lax, wrinkled abdominal wall, flared chest, and undescended testes. Several classifications of the triad syndrome have been established based on severity and clinical presentation. There is no single classification system that incorporates the total spectrum of this syndrome. For practical purposes, children can be grouped into severe, moderate, or mild presentations. With a severe presentation, survival is often limited by significant respiratory compromise due to pulmonary immaturity and dysplasia, as well as extensive renal dysplasia, resulting in a Potter-like syndrome. Children described with moderate involvement have combined renal and respiratory insufficiency mandating close observation and early intervention to minimize the sequelae of pulmonary and renal compromise. Monitoring of the urinary system is necessary in order to prevent progressive renal deterioration due to stagnation of urinary flow, urinary tract infections, and possible urinary tract obstruction. Children with mild involvement do not suffer from respiratory or renal compromise. While long-term follow-up is necessary, operative intervention is often limited to orchiopexy and abdominal wall reconstruction. Evaluation A team approach consisting of a pediatric urologist, neonatologist, nephrologist, pulmonologist, and cardiologist is required in order to maximize the outcome. The initial cardiorespiratory status of the neonate must be established. The baby should undergo a chest x-ray and, when indicated, cardiac sonography. Treatment may be required to maintain adequate pulmonary toilet for oxygenation and prevention of upper respiratory tract infections. Urologic evaluation commences with abdominal sonography. Both the upper and lower urinary tract should be assessed. Attention should be placed on the degree of hydronephrosis, the volume of renal parenchyma, and its echogenicity. Oftentimes there will be a disproportionate degree of lower ureteral and urinary tract dilation when compared to the proximal ureter and kidney. On occasion a marked transition of ureteral dilation is noted. If the infant is clinically stable and voiding per urethra or draining through a patent urachus, further diagnostic testing can be placed on hold. Children with renal insufficiency must undergo further testing, which may include a voiding cystourethrogram, to determine whether the insufficiency is related to renal dysplasia, stagnant urine flow or true obstruction. It is of utmost importance that any invasive lower urinary tract imaging be performed in a sterile environment with the child receiving pre- and postprocedural antibiotics. The abnormally dilated urinary system in a child with triad syndrome results in stagnant urine flow that is very susceptible to bacteriuria and often difficult to clear. When functional renal information is needed, renal scintigraphy provides greater objective information than conventional intravenous urography.

INDICATIONS FOR SURGERY There is no other pediatric urologic pathologic process that requires as much individualized patient care as the triad syndrome. Each child presents with a unique constellation of problems resulting in its own set of considerations. Therefore, no one treatment plan is appropriate for all children. In general, operative management can be divided into three broad areas: 1. Reconstruction of the urinary system 2. Reconstruction of the abdominal wall 3. Transfer of the intraabdominal testes to the scrotum

These three areas of operative management are not exclusive of each other, but for simplicity's sake each will be described independently. H4>Urinary Tract Reconstruction Controversy surrounds the need for aggressive urinary tract reconstruction. Early aggressive operative intervention in all cases is countered by the fact that renal dysplasia may be inherent, thus preventing any intervention from improving the functional status. In addition, imaging studies depicting significant hydroureteronephrosis do not correlate with obstruction. Hydroureteronephrosis does not by itself mandate reconstruction. Urinary tract reconstruction is beneficial in a child who has a component of obstructive uropathy and has been shown to have improved renal function with decompression of the urinary system. Reconstruction is also of benefit in the child who has progressive hydroureteronephrosis associated with increasing renal compromise and in the child who has urinary tract infections due to stagnant urine flow. Urinary Diversion Urinary diversion can play a temporary initial role in the management of acute renal failure or sepsis. Oftentimes children with urethral atresia or obstruction will present with a patent urachus, effectively emptying their lower tract. Infants with associated urethral abnormalities resulting in obstruction or poor bladder decompression, who are not candidates for intermittent catheterization, benefit from a vesicostomy. A vesicostomy, however, may not adequately drain the upper urinary tract due to a relative obstruction of the ureter at the level of the bladder or poor urinary transport due to a highly compliant adynamic ureter. Temporary diversion of the upper urinary tract may be undertaken with nephrostomy tube drainage. When formal upper urinary tract diversion is necessary, there is a theoretical advantage in performing the diversion as proximal as possible. This should maximally relieve stress to the kidney and limit stagnation of urine in a dilated tortuous ureter. However, there is often a disproportionate degree of proximal versus distal ureteral dilation that prevents easy access of the proximal ureter. When there is minimal proximal dilation, a low distal cutaneous ureterostomy provides adequate decompression with relief of stagnated urine flow and stabilization of renal function. The ureter can be approached from a small (2.5-cm) incision placed in a lower inguinal location. The muscles are split to enter the retroperitoneum. The ureter can have the appearance of bowel due to its large size. When in doubt, a 21-gauge needle should be passed, aspirating contents to confirm urine. Once identified, the ureter is sacrificed at the level of the obliterated umbilical artery. The size of the ureter usually prevents postoperative stenosis, allowing for either an end or loop ureteral anastomosis. When definitive urinary reconstruction is undertaken following a distal ureterostomy, the proximal urinary system will have remained uncompromised allowing for easier mobilization and greater flexibility if tailoring of the ureter is required. Definitive Urinary Reconstruction When definitive urinary reconstruction is necessary, the initial approach to the ureter can be extravesical. The ureter is isolated at the level of the bladder and proximal dissection ensues. If a transitional phase exists between the dilated distal ureter and the normal proximal ureter, the dissection should be continued proximal past that point, taking care not to devascularize the ureter. All of the distal ureter is excised when there is adequate length for the proximal ureter to be reimplanted in the bladder in a standard fashion or with the assistance of a psoas hitch. If total proximal and distal ureteral tailoring is necessary, full mobilization of the ureter is required, which can be accomplished via a retroperitoneal approach. However, it is often helpful to enter the peritoneum and reflect either the descending or ascending colon along the white line of Toldt. The dilated ureter is often exceedingly redundant and tortuous. Straightening of the ureter without devascularization is required. The functional capability of the ureter for peristalsis and transmission of urine into the bladder parallels the degree of hydroureter. Therefore, ureteral tapering may enhance urinary flow into the bladder. Multiple techniques exist for ureteral tailoring that include ureteral imbrication and formal ureteral excision 4,5,11 (Fig. 90-1). Ureteral imbrication is appropriate for marginally dilated ureters. But when massive ureteral dilation is present, formal excision is preferred, eliminating the bulky tissue that results from the large imbricated ureter.

FIG. 90-1. (A) The tortuous dilated ureter is carefully straightened without compromising blood supply. The redundant portion is excised and the remaining distal segment tapered if necessary. (B) Ureteral folding over a 10- or 12-Fr ureteral catheter. (C) Formal ureteral tapering with excision and closure. Note: The continuous running closure stops 1 to 2 cm from the end of the segment, followed by interrupted suture placement allowing for excision of the distal end of the ureter without compromise of the running closure.

The ureter should be tapered loosely over either a 10- or 12-Fr catheter depending on the child's age and size. With excision, the excised ureteral segment might take an unconventional course in order to preserve adequate blood supply to the tailored ureter. After excision, the ureter is closed in a two-layer technique. The first running suture line of 5.0 or 6.0 chromic gut directly opposes the mucosa and muscularis of the ureter. The second layer reapproximates the adventitial tissue with the same suture material. Both running layers are discontinued a few centimeters from the distal end of the ureter. The very distal portion of the ureter is closed with interrupted sutures. This allows for excision of the distal ureter without interruption of the running suture line. Having enough ureteral length should not be a problem, allowing for a tunneled antirefluxing ureteroneocystostomy in all cases. Ureteral stents remain in place for 5 to 10 days for postoperative management. If a large, redundant, renal pelvis is present in association with a dilated proximal ureter, a reduction pyeloplasty should be performed in line with the ureteral excision. Preservation of the proximal ureteral blood supply is mandatory. Reduction Cystoplasty Reduction cystoplasty is a very compelling component to urinary reconstruction in a child with triad syndrome. However, long-term follow-up in children having undergone reduction cystoplasty has shown no objective advantage. 1,6 With time the bladder will regain its large size, lose its tone, and lead to inadequate emptying. For these reasons it is not practical to proceed with reductive cystoplasty as the primary indication for urinary reconstruction. If a large, poorly contracting bladder results in inadequate urinary emptying, intermittent catheterization would be a more appropriate form of management. However, when formal urinary reconstruction is required for ureteral tailoring, reductive cystoplasty can be performed and may provide limited improved bladder emptying. Reductive cystoplasty should incorporate the urachus and majority of the dome of the bladder (Fig. 90-2). A 2- to 3-cm strip of mucosa is removed from one side of the bladder wall, allowing for a reinforced overlapping suture line. The bladder is closed in three independent layers using a running suture of 3.0 chromic gut. A suprapubic tube is inserted for postoperative monitoring regarding the effectiveness of bladder emptying.

FIG. 90-2. Reduction cystoplasty. The dome of the bladder, including any urachal remnant, is removed. A 2- to 3-cm mucosal strip is then removed from one portion of the bladder allowing for an overlapping suture line.

Abdominal Wall Reconstruction Several techniques have been devised to maximize the cosmetic benefits of abdominal wall reconstruction in children with triad syndrome. 2,10 There is evidence indicating that the muscular defect is more pronounced centrally and caudally. Initial reconstructive efforts were based on removal of this abnormal tissue. While the appearance of the abdomen was improved, it was not ideal and resulted in loss of the umbilicus. Monfort originally described preservation of the umbilicus. 7 Based on this approach, abdominal wall reconstruction now allows for an excellent cosmetic and functional outcome. The benefit of abdominal wall reconstruction is dependent on the degree of abdominal wall laxity. The timing for this procedure should be based on the need for other operative intervention. If it is obvious that the child will not require upper urinary tract reconstruction, abdominal wall reconstruction can be undertaken at any time. If, however, there is the potential for upper urinary tract reconstruction, abdominal wall reconstruction should be deferred until the time of that intervention. The Monfort approach begins with a midline incision from the tip of the xyphoid process carried inferiorly, circumscribing the umbilicus, leaving an adequate margin of umbilical tissue, and ending at the symphysis pubis ( Fig. 90-3). A full-thickness skin flap is created bilaterally, elevating the subcutaneous fat from the underlying fascia. The dissection is carried laterally to the anterior axillary line. Oftentimes there will be variability and asymmetry of muscular development. Care must be taken not to enter the peritoneum while mobilizing the skin flaps, particularly in areas where the fascia is relatively thin. A lateral incision is then made through the fascia entering the peritoneum. The first incision is made lateral to the superior epigastric artery. Once entrance has been made into the peritoneum, the superior epigastric artery is located and the incision is continued lateral and parallel to its course from the costal margin to the symphysis pubis. Having entered the peritoneum on one side, the fascia is elevated and the contralateral superior epigastric artery identified. A second lateral parallel incision can then be made. The central fascial bridge with the umbilical island is supported by the superior epigastric arteries. The two lateral incisions provide excellent exposure for orchiopexy and major urinary tract reconstruction.

FIG. 90-3. (A) An incision is begun at the xyphoid, circumscribing the umbilicus, and carried down to the pubis. (B) Skin flaps are then elevated, dissecting between the subcutaneous fat and the fascial layer. The lateral extension is the anterior auxiliary line. (C, D) The umbilicus is supported by the central fascial bridge. Incisions will be made into the peritoneum lateral to the epigastric vessels. The central fascial bridge is easily manipulated to allow for excellent intraabdominal exposure. (E) At the time of closure, a line is scored on the peritoneal surface of the fascia. (F) The central fascial strip is then secured laterally to the scored fascia line with a running suture of 2-0 or 3-0 polyglactin. (G) The lateral fascia is then secured in the midline above and below the umbilicus with 2-0 or 3-0 polyglactin. Centrally, the fascia is secured directly to the umbilicus. This allows for an overlapping reinforced fascial wall closure. Subcutaneous tissue is closed with 3-0 or 4-0 plain gut and the skin with a running subcuticular 4-0 or 5-0 polyglactin.

At the time of closure, the lateral fascia wall is secured to the central fascial strip with a running 2-0 or 3-0 polyglactin. The suture line is scored on the peritoneal side of the lateral fascia to enhance adherence. The lateral fascia is then secured in the midline with figure-of-8 suture placement using 2-0 or 3-0 polyglactin. This pants-over-vest closure provides additional ventral support. Two flat 7-Fr suction drains are placed between the fascia and the subcutaneous space. The skin flap is then tailored, removing the excess, allowing for a midline and periumbilical closure. The skin flap is closed in multiple layers, securing the subcutaneous tissue with 4-0 plain gut sutures. The epithelial edge is reapproximated with a running subcuticular suture of 5-0 polyglactin. The drains remain in place for 2 or 3 days for decompression of the dead space. Orchiopexy The timing for orchiopexy can be individualized based on the child's need for urinary reconstructive surgery. If urinary reconstructive surgery is required, orchiopexy can be performed in the same procedure. If urinary reconstructive surgery is not required, then timing is variable. Placement of the testes in the scrotum is obviously important for psychological and hormonal factors but, unfortunately, fertility does not appear to be improved. Biopsies of testes have shown a Sertoli-cell-only feature prohibiting future fertility. 12 Sacrifice of the gonadal artery may be required to obtain adequate length for the testicle to be delivered in the scrotum as described by Fowler and Stephens. 3 If orchiopexy is undertaken early, particularly within the first year of life, there is often adequate vascular length to deliver the testicle directly into the scrotum without transection of the testicular artery. A staged approach, using laparoscopic-assisted ligation of the gonadal artery, followed by a 6-month delay in delivering the testicle in the scrotum, has also recently been described. It appears appealing if urinary reconstruction and abdominal wall reconstruction are unnecessary. Exposure for the orchiopexy is often dependent on other urinary or abdominal wall reconstructive efforts. When the gonad is first identified it may be found closely associated with a dilated distal ureter. To determine whether the testicle can be delivered into the scrotum without sacrifice of the gonadal artery, the testicle should be released from the ureter. A lateral peritoneal incision can be made to the proximal gonadal artery. The incision is continued medial to the artery and carried down inferiorly. It is important to not disrupt the vascular supply of the peritoneal pedicle running on both sides of the vas deferens. After mobilization, if it becomes apparent that the testes will not reach into the scrotum, the gonadal artery is sacrificed. The blood supply to the testes is maintained by the vasal artery and small anastomotic channels in the peritoneal flap. A tunnel is then made into the scrotum and an incision placed inferiorly in the scrotum to create a dartos pouch. A clamp is passed from the scrotum to the inguinal canal. The testicle is grasped, pulled down through the tunnel, and delivered to the scrotum. Care must be taken not to twist or place the peritoneal pedicle on tension. If desired, the testicle can be secured to the dartos tissue with 5-0 PDS suture.

OUTCOMES

Complications Ureteral devascularization resulting in ischemia and subsequent obstruction can occur if attention has not been paid to the ureteral blood supply. The risk of bowel obstruction is present as in any intraabdominal procedure. Testicular ischemia and atrophy due to a Fowler-Stephens procedure has been reported to occur in 15% of children. Results The results of urologic reconstruction can be very gratifying in the initial postoperative period, particularly with removal of significant redundancy and relief of stagnated urine. However, with time, there can be an increase in both bladder size and ureteral dilation. This is often due to ineffective voiding and is independent of bladder reduction. For those reasons, the urinary tract must be closely monitored for an extended period. Patients should be prepared for the potential need for intermittent catheterization. Because of normal sensation, children are often unwilling to cooperate with urethral catheterization. If catheterization appears to be a realistic possibility at the time of urinary reconstruction, placement of an appendicovesicostomy should be considered. This provides a very easy mechanism for catheterization if required. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Bukowski TM, Perlmutter AD. Reduction cystoplasty in the prune-belly syndrome: a long term follow up. J Urol 1994;152:2113–2116. Ehrlich RM, Lesavoy MA, Fine RN. Total abdominal wall reconstruction in the prune-belly syndrome. J Urol 1986;136:282–285. Fowler R, Stephens FD. The role of testicular vascular anatomy in the salvage of high undescended testis. Aust N Z J Surg 1959;29: 92–106. Hendren WH. Operative repair of megaureter in children. J Urol 1969;101:491. Kalicinski ZH, Kansy J, Kotarbinska B, et al. Surgery of megaureters modification of Hendren's operation. J Pediatr Surg 1977;12:183. Kinahan TJ, Churchill BM, McLorie GA, et al. The efficiency of bladder emptying in the prune-belly syndrome. J Urol 1992;148:600–603. Montfort G, Guys JM, Boccoardo, et al. A novel technique for reconstruction of the abdominal wall in the prune belly syndrome. J Urol 1991;146:639–640. Osler W. Congenital absence of the abdominal muscles with distended and hypertrophied urinary bladder. Bull Johns Hopkins Hosp 1901;12:331–333. Parker RW. Absence of abdominal muscles in an infant. Lancet 1895;1:1252–1254. Randolph JG. Total surgical reconstruction for patients with abdominal muscular deficiency (“prune-belly”) syndrome. J Pediatr Surg 1977;12:1033–1043. Starr A. Ureteral plication. A new concept in ureteral tailoring for megaureter. Invest Urol 1979;17:153. Uehling DT, Zadina SP, Gilbert E. Testicular histology in triad syndrome. Urology 1984;23:364. Wheatley JM, Stephens FD, Hutson JM. Prune-belly syndrome: ongoing controversies regarding pathogenesis and management. Semin Pediatr Surg 1996;5:95–106.

Chapter 91 Supravesical Urinary Diversions Glenn’s Urologic Surgery

Chapter 91 Supravesical Urinary Diversions Byron Joyner and Antoine Khoury

B. Joyner: Division of Urology, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada. A. Khoury: University of Toronto, and Department of Surgery, Division of Urology, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Cutaneous Pyelostomy and High Cutaneous Ureterostomy Pelvioureterostomy-En-Y (Sober Loop Ureterostomy) Closure of Pyelostomies and Ureterostomies End-Cutaneous Ureterostomies Outcomes Complications Results Chapter References

Over the last century, various forms of cutaneous urinary diversions have been developed. The inception of these developments began in the mid-1800s when Rayer described the association between hydronephrosis and renal failure. Surgical intervention for this problem was not documented until the 19th century when percutaneous drainage of a distended renal pelvis was performed. In 1878, Robert Weir performed the first open drainage of a hydronephrotic kidney. Twenty years later, the nephrotomy was espoused by Henry Morris whose patient with a solitary kidney drained for 6 years postoperatively. These seminal attempts at urinary diversion have inspired multiple techniques that have all been neatly categorized as either intubated or nonintubated urinary diversions. Intubated diversions typically are employed in the acute setting of urinary obstruction or difficulty voiding. The tube remains in place for brief periods of time to facilitate urinary drainage. Intubated diversions can be divided further into vesical or supravesical diversions. The Foley catheter and suprapubic tube account for the majority of intubated vesical diversions. A variety of nephrostomy tubes and nephrovesical (double-J ureteral) stents account for the supravesical diversions. Nonintubated, vesical urinary diversions are surgically constructed in situations requiring prolonged periods of diversion. These would include perineal urethrostomies or cutaneous vesicostomies. The non-intubated, supravesical diversions include cutaneous pyelostomies, loop ureterostomies, and end-cutaneous ureterostomies.

DIAGNOSIS Indications for nonintubated urinary diversions and, specifically, supravesical urinary diversions have been better defined and are performed rarely now compared to 20 years ago. New technical advances in radiology and urology have resulted in fewer temporary urinary diversions and more definitive reconstructive surgery for those children with obstructive uropathies. The increased use and clarity of ultrasonography has had a significant impact on the detection of antenatal hydronephrosis, as well as the subsequent management of its postnatal course. Refined endoscopic equipment for the treatment of posterior urethral valves, improved anesthesia, standardized intensive care, and better operative techniques have made extensive reconstructive efforts more common earlier in infancy. The most effective management of these children is to progress through a logical algorithm in order to establish adequate urinary drainage ( Fig. 91-1). Initially, when posterior urethral valves are suspected, a 5-Fr pediatric feeding tube is inserted into the urethra to drain the bladder. The response to catheter drainage will be determined by the level of the serum creatinine. This response, in association with the physical examination and radiographic findings, will direct further management. Radiographic studies may provide further insight into the quality of the bladder. A good bladder has a normal capacity (ml) for age (in infants: weight in kg × 7) and normal compliance. In contrast, a bad bladder is characterized as thick and noncompliant. The detrusor muscle hypertrophies in response to infravesical obstruction, with subsequent trabeculation and sacculation. These distinct findings are extremely useful in managing the infant who may need some type of urinary diversion.

FIG. 91-1. Management algorithm for infravesical urinary obstruction.

INDICATIONS FOR SURGERY Despite new technical advances and earlier reconstructive surgery, supravesical urinary diversions are still occasionally indicated. They are, however, typically restricted to newborns with infravesical obstruction who subsequently have progressive hydroureteronephrosis, poor urinary drainage, and renal compromise, despite initial urethral intubation. In this situation, the most common diagnoses are posterior urethral valves associated with a thickened, stiff bladder; high-grade vesicoureteral reflux; or obstructive megaureter. These babies require stabilization in an intensive care unit where their fluid and electrolyte status can be optimized, their acid–base problems corrected, and sepsis addressed. The next step is to decide on the best method of urinary diversion. The first diagnostic, as well as therapeutic, step in the posterior urethral valve management algorithm is to insert a 5-Fr urethral catheter. If the urethral catheter causes the creatinine to decrease daily by 10% to a nadir of less than 80 mol/L by day 5, then transurethral resection of the posterior urethral valves is performed. Primary valve ablation is the preferred treatment of choice. But temporary urinary diversion may be necessary if the creatinine continues to rise after valve ablation. Children who may be too small (FIG. 129-8. Completed repair with well-supported bladder neck.

Cystoscopy Indigo carmine is administered intravenously as the suture placement is being completed. The Foley catheter is removed and a flexible cystoscope inserted in the bladder. After inspection of the bladder to confirm no transgression of the bladder or urethra by suture material, the cystoscope is withdrawn to the bladder neck to confirm that it has been well supported (the light from the cystoscope is easily visible laparoscopically, even with the laparoscopic light source on maximal illumination). Both ureteral orifices should be observed to confirm efflux of blue urine. The cystoscope is removed and the Foley catheter replaced. Exiting the Operative Site After reducing the insufflation pressure to 5 mm Hg and inspecting the operative site for hemostasis, the two lateral ports are removed under direct vision. With the assistant holding fingers over these port sites to maintain the pneumoretroperitoneum, the laparoscope is withdrawn to the tip of the midline cannula and the fixation sutures released. The cannula and laparoscope are slowly pulled out, as a unit, inspecting the tract for hemostasis as the equipment is removed. The midline fascial defect is closed by tying together of the fixation sutures. Being extraperitoneal, neither of the lateral port sites require fascial closure. The skin incisions are reapproximated with 4-0 absorbable subcuticular stitches and sterile tape. Postoperative care The Foley catheter is removed the following morning and a postvoid residual is obtained after the first voiding. If the residual is less than 90 cm 3, then the patient is discharged without the catheter. If, however, the postvoid residual is more than 90 cm 3, then the patient is taught self-administered intermittent catheterization and discharged. Catheterization must be performed 4 times daily until the postvoid residual is less than 90 cm 3. Patients usually leave the hospital the morning after surgery, although in elderly patients an extra day in the hospital may be necessary if intermittent self-catheterization is required. Surgery on an outpatient basis is considered in young, healthy patients because the Foley catheter can either be removed by the patient at home or by a nurse in the physician's office. We have found postoperative analgesics with oral medication to be sufficient for most patients. Oral antibiotics are continued for 5 to 7 days postoperatively.

OUTCOMES Complications Potential complications of laparoscopic bladder neck suspension include: 1. 2. 3. 4. 5.

Physiologic complications associated with the anesthetic or use of gas insufflation (cardiac, pulmonary, venous gas embolism, etc.) Complications due to laparoscopic/surgical manipulation (bleeding, nerve injury, visceral injury including bladder injury, etc.) Wound complications (infection, skin separation, dehiscence, hernia formation) Prolonged urinary retention Failure of the procedure to correct incontinence

In the series illustrated in Table 129-1, complications occurred in 12% of the laparoscopically treated patients, 20% of the open group, and 3% of the Raz group (not including prolonged urinary retention and failure of the procedure). 3,5,7 In the series of McDougall and associates, the only two complications were a bladder laceration that occurred during the balloon dilation of the retropubic space and a pelvic hemorrhage requiring a 2-unit blood transfusion. 5

TABLE 129-1. Three studies comparing laparoscopic Burch colposuspension to contemporaneous Raz vaginal needle suspension and/or open Burch colposuspension

Results In terms of surgical efficacy, the short-term (less than 1 year) success rates of laparoscopic bladder neck suspension are promising (82% to 100%). Only three reports to date describe patients with a mean follow-up in excess of one year (all three utilizing a laparoscopic Burch colposuspension). The cure rates range from 71% to 85%, with mean follow-ups from 17 to 24 months.5,7,8 Since approximately one-quarter of treatment failures occur more than 2 years after anti-incontinence surgery, longer follow-up is mandatory to assess the effectiveness of this newly introduced procedure. 9 Until such long-term data become available, the most useful studies are three reports comparing laparoscopic bladder neck suspension to vaginal and/or open retropubic procedures (Table 129-1).3,5,7 Although the groups were similar within each study with regard to patient characteristics and date of operation, these investigations were nonrandomized. Thus, they may be subject to significant bias. Several differences between the groups are striking nonetheless. Compared to the open or vaginal procedures, the requirement for pain medication and hospital stay following the laparoscopic procedures was less. Although the time required to resume spontaneous voiding did not differ greatly between the laparoscopic and open groups, patients in the former group voided much sooner than did patients undergoing the Raz procedure. Not surprisingly, operative times were longest in the laparoscopic group. With limited follow-up, the success rates within each study did not differ greatly. In conclusion, the technique outlined above for laparoscopic Burch colposuspension employs principles and anatomy that are familiar to most urologists. Suturing is the most difficult aspect of the procedure. Alternatives to suturing during laparoscopic Burch colposuspension include staple fixation of mesh and the use of fibrin

tissue adhesive. In our opinion, the potential for problems associated with staples in the vaginal wall outweighs any technical expediency of this approach. Fibrin tissue adhesive for this application has been assessed only in short-term studies. For the time being, then, suturing is required for optimal results with laparoscopic Burch colposuspension. It appears that the laparoscopic approach to stress urinary incontinence produces less pain than either the open or the vaginal approach. The laparoscopic procedure offers a much shorter hospital stay than the open approach and a much shorter duration of catheterization than the vaginal procedure. Problems with operating time and complication rates will hopefully be reduced with further experience. This has been the case with most other laparoscopic procedures. The final key factor—the long-term success rate—is yet to be determined but preliminary findings are promising. Prospective randomized trials are presently being instituted. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Bergman A, Ballard CA, Koonings PP. Comparison of three different surgical procedures for genuine stress incontinence: prospective randomized study. Am J Obstet Gynecol 1989;160:1102. Bergman A, Koonings PP, Ballard CA. Primary stress incontinence and pelvic relaxation: prospective randomized comparison of three different operations. Am J Obstet Gynecol 1989;161:97. Das S, Palmer JK. Laparoscopic colpo-suspension. J Urol 1995;154:1119. Jarvis GL. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994;101:371. McDougall EM, Klutke CG, Cornell T. Comparison of transvaginal versus laparoscopic bladder neck suspension for stress urinary incontinence. Urology 1995;45:641. McGuire EJ, Cespedes RD. Proper diagnosis: a must before surgery for stress incontinence. J Endourol 1996;3:201. Polascik TJ, Moore RG, Rosenberg MT, Rosenberg LRK. Comparison of laparoscopic and open retropubic urethropexy for treatment of stress urinary incontinence. Urology 1995;45:647. Radomski SB, Herschorn S. Laparoscopic Burch bladder neck suspension: early results. J Urol 1996;155:515. Rodriguez R, Partin AW, Mostwin JL, Kavoussi LR. Long term follow-up of surgically treated stress urinary incontinence (Abstract 810). J Urol 1995;153 (Suppl):431. Vancaillie TG, Schuessler W. Laparascopic bladderneck suspension. J Laparoendosc Surg 1991;1:169.

Chapter 130 Laparoscopic Management of Lymphoceles Glenn’s Urologic Surgery

Chapter 130 Laparoscopic Management of Lymphoceles Blake D. Hamilton and Howard N. Winfield

B. D. Hamilton: Division of Urology, University of Utah, Salt Lake City, Utah 84132. H. N. Winfield: Department of Urology, VA Palo Alto Health Care System, Palo Alto, California 94304–1290, and Department of Urology, Stanford University School of Medicine, Stanford University Medical Center, Stanford, California 94305-5118.

Diagnosis Indications for Surgery Alternative Therapy Surgical Procedure Preoperative Preparation Operative Technique Outcomes Complications Results Chapter References

P>Pelvic lymphocele is a known complication of renal transplantation with an incidence reported between 1% and 18%. 2,5 It may also occur after 1% to 2% of pelvic lymph node dissections for staging of urologic malignancies. Many pelvic lymphoceles are small and asymptomatic, but lymphocele size and location may result in clinical sequelae ranging from minor lower extremity and genital lymphedema to loss of a transplanted kidney to sepsis and death. The laparoscopic treatment of pelvic lymphoceles was first reported by McCullough et al. in 1991. 7 This was a natural application of new surgical technology, providing the patient with the most effective procedure without the attendant morbidity of a laparotomy. In the ensuing 5 years, the laparoscopic technique has been reported by numerous surgeons with minor variations. It is now widely accepted as a first-line treatment for pelvic lymphoceles. It requires a modest level of laparoscopic skill and is well tolerated by the patient, generally requiring a brief (less than 24 hours) hospital stay and accompanied by a return to baseline activity within a week.

DIAGNOSIS Lymphocele is most frequently diagnosed by ultrasound or CT scan. Occasionally, ultrasound-directed aspiration may be needed to differentiate a true lymphocele from urinoma, hematoma, seroma, or abscess.

INDICATIONS FOR SURGERY The vast majority of lymphoceles are asymptomatic and in the absence of any specific symptoms do not require intervention. In the posttransplant patient, the lymphocele may cause oliguria, hydronephrosis, renal insufficiency, lower extremity swelling, or abdominal discomfort. After radical prostatectomy, extremity swelling or abdominal discomfort may be the presenting complaint.

ALTERNATIVE THERAPY Traditional techniques for treating lymphoceles have distinct disadvantages. Simple needle aspiration carries minimal risk, but an unacceptable recurrence rate of 50% to 100%. Sclerosing agents (e.g., tetracycline, povidone-iodine, ethanol) improve these success rates but result in dense fibrosis around the transplanted kidney and ureter that may prove hazardous in the long term 8. External drainage requires prolonged treatment with the risk of infection, especially in the immunosuppressed patient. The most effective treatment has been open surgical exploration and marsupialization of the lymphocele into the peritoneal cavity through the transplant incision or a low midline incision. This treatment, however, is not free of morbidity, particularly in the immunosuppressed patient.

SURGICAL PROCEDURE Preoperative Preparation With transplant-related lymphoceles, it is imperative to know the location of the ureter relative to the lymphocele in order to avoid ureteral injury during the dissection. If the serum creatinine is less than 2.0 mg/dl, a computed tomography (CT) scan with intravenous contrast should demonstrate the position of the ureter above or below the lymphocele (Fig. 130-1).

FIG. 130-1. CT scan demonstrating the close proximity of the transplant ureter (with stent in place), anterior to the lymphocele.

If the serum creatinine is greater than 2.0 mg/dl, then a 5-Fr end-hole angiographic catheter is placed in the transplant ureter with a flexible cystoscope in the office and a CT scan is obtained. The catheter demonstrates the position of the ureter and is removed after the CT scan. In addition, the patient is given a preoperative mechanical bowel preparation on the day prior to surgery, and the patient's blood is typed and screened. Operative Technique Standard transperitoneal laparoscopy preparation is used ( Chapter 122). Pneumoperitoneum is established as previously described, with a Veress needle or with the open laparoscopy technique (Hasson, Chapter 124). We prefer the Hasson technique because of the location of the transplant kidney ( Fig. 130-2). In addition, many transplant patients have had peritoneal dialysis catheters with some degree of peritonitis resulting in adhesions that increase the risk of injury with blind needle placement. Once the primary port is secured, a 10-mm, 0 or 30 degrees laparoscope is used to survey the intraperitoneal structures. Two additional ports are placed in the midline or contralateral quadrant with the exact position determined by the size and location of the lymphocele.

FIG. 130-2. Suggested port placement for laparoscopic drainage of posttransplant lymphocele.

Localization of the lymphocele is clearly the most critical and often the most difficult part of the operation. If the lymphocele is large enough, it can be readily seen bulging into the peritoneum. Smaller lymphoceles, or those hidden deep in the pelvis, may be more difficult to locate. Several maneuvers are useful to assist with identification of the lymphocele. If the Foley catheter is kept on the sterile field, the bladder may be filled and emptied repeatedly so that the bladder and an adjacent lymphocele can be identified laparoscopically. Laparoscopic ultrasonography with a 5- to 7.5-MHz probe (if available) may identify the lymphocele. A previously placed pigtail catheter, or a percutaneous needle placed into the lymphocele intraoperatively with external ultrasound guidance, may be used to empty and fill the lymphocele with dilute indigo carmine. These techniques, alone or in combination, should facilitate identification of the lymphocele while minimizing inadvertent injury to adjacent structures. Once the lymphocele is identified, a 5-mm laparoscopic needle is used to aspirate the fluid and confirm its identity. This fluid should be typical, straw-colored lymph, although it may be blood-tinged. The wall of the lymphocele is now grasped and incised with a cautery hook or laparoscopic scissors. A window is created by excising a substantial portion of the lymphocele wall that abuts the peritoneum. The size of this window is dictated by the size and position of the lymphocele, but should include most of the visible wall. The edges of the cut lymphocele wall are meticulously cauterized, and internal loculations are thoroughly disrupted. As the window is extended, great care must be taken to avoid injury to the ureter and bladder. In general, the peritoneal window should be extended laterally. With video magnification, the ureter may actually be more easily avoided. If the course of the ureter seems problematic, as judged by preoperative images, a temporary stent placed at the beginning of the case may help preserve the ureter. An omental flap may be brought through the peritoneal window to reduce the likelihood of postoperative recurrence and to minimize the risk of internal herniation of a bowel loop. The lower free edge of the omentum is gently drawn down to the lymphocele site. Any adhesions are divided for full mobilization. The omental flap is pushed through the peritoneal window and fixed to the free peritoneal edges with clips. If no omentum is available for this purpose, an alternative method of fixation is to place 3 to 5 interrupted sutures through the cut peritoneal edges and lymphocele wall. External drains are not normally placed. Free fluid is evacuated and the abdomen is exited in the standard fashion. We prefer to close the fascia of any sites accommodating 10-mm or larger ports. The Carter-Thomason port closure device (Inlet Medical, Minneapolis, MN) can achieve a rapid and secure closure with 0 polydioxanone sutures. The skin is approximated with an absorbable subcuticular suture and the incision is covered with a transparent, permeable dressing. The patient is admitted for a brief (usually less than 24 hours) hospital stay.

OUTCOMES Complications There are scattered reports of ureteral, bladder, and other injuries. In Gill's series, there was one complication—a bladder injury—that was repaired laparoscopically without further sequelae. 3 Winfield et al. reported two complications that required open surgical repair: a bladder injury and a transplant ureter transection. 9 Gruessner et al. attempted 14 procedures and converted to open surgery in 5 patients. 4 Two patients with initially successful laparoscopic drainage required open laparotomy 3 and 12 weeks later, respectively. Gruessner et al. had no inadvertent injuries. Therefore, they concluded that laparoscopic drainage of lymphoceles is safe but technically more difficult if the lymphocele is posterior and inferior to a transplanted kidney. Results Many groups have reported their results with small numbers of patients. 1,5,6 There are few larger series. Gill et al. reported on three cohorts of patients with lymphoceles treated by laparoscopic or open marsupialization. 3 The latter was group divided into a contemporary and an historical group ( n = 12, 12, and 13, respectively). There were no recurrences in the laparoscopic group (4 and 3 in the other two groups). These patients experienced the expected quick discharge and return to activity. In only 1 of the 12 laparoscopic patients was an omentoplasty performed. Winfield et al. reported on 11 patients with laparoscopic marsupialization. One patient had recurrence at 3 months and required a repeat laparoscopic drainage procedure, which was successful. All of their patients were recurrence-free at 6 to 27 months follow-up. Laparoscopic drainage of a pelvic lymphocele is an excellent application of new technology, providing the patient with the most effective treatment while causing minimal morbidity. The procedure can be performed reliably and safely by most laparoscopists, with the reminder that localization of the lymphocele is the crux of the operation. Lymphoceles that are deep in the pelvis, or posterior and inferior to a transplant kidney, are a greater laparoscopic challenge. While some la-paroscopic procedures continue to require scrutiny, we believe that this procedure has become a first-line approach for the definitive treatment of pelvic lymphoceles. CHAPTER REFERENCES 1. Ancona E, Rigotti P, Zaninotto G, Comandella MG, Morpugo E, Costantini M. Treatment of lymphocele following renal transplantation by laparoscopic surgery. Int Surg 1991;76:261–263. 2. Braun WE, Banowsky LH, Straffon RA, et al. Lymphoceles associated with renal transplantation: a report of fifteen cases and review of the literature. Am J Med 1974;57:714. 3. Gill IS, Hodge EE, Munch LC, Goldfarb DA, Novick AC, Lucas BA. Transperitoneal marsupialization of lymphoceles: a comparison of laparoscopic and open techniques. J Urol 1995;153:706–711. 4. Gruessner RW, Fasola C, Benedetti E, et al. Laparoscopic drainage of lymphoceles after kidney transplantation: indications and limitations. Surgery 1995;117:288–295. 5. Kay R, Fuchs E, Barry JM. Management of postoperative pelvic lymphoceles. Urology 1980;15:345. 6. Khauli RB, Stoff JS, Lovewell T, Ghavamian R, Baker S. Post-transplant lymphoceles: a critical look into the risk factors, pathophysiology and management. J Urol 1993;150:22–26. 7. McCullough CS, Soper NJ, Clayman RV, So SSK, Jendrisak MD, Hanto DW. Laparoscopic drainage of a post-transplant lymphocele. Transplantation 1991;51:725–727. 8. Teruel JL, Escobar ME, Quereda C, Mayayo T, Ortuno J. A simple and safe method for management of lymphoceles after renal transplantation. J Urol 1983;130:1058. 9. Winfield HN, Hochstetler J, Terrell RB, Brown BP. Laparoscopic marsupialization of post-renal transplant lymphoceles (Abstract). J Urol 1996;155:657A.

9

Chapter 131 Laparoscopic Management of the Impalpable Undescended Testicle Glenn’s Urologic Surgery

Chapter 131 Laparoscopic Management of the Impalpable Undescended Testicle Gerald H. Jordan

G. H. Jordan: Department of Urology, Eastern Virginia Medical School, Norfolk, Virginia 23510.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Diagnostic Laparoscopy Laparoscopic Orchiopexy Outcomes Complications Results Chapter References

An undescended testis is defined as a testis that resides in an extrascrotal position. Those testicles can be either truly maldescended or ectopic. Maldescended testicles would imply that the testicle is arrested some place along a normal path from its origination at the nephrogonadal ridge to its target, the scrotum. An ectopic testicle implies that somewhere along the path of descent the testicle is led to a position that is not truly in the line of normal descent. Undescended testicles may be palpa-ble or impalpable. A palpable undescended testicle can either be retractile or truly undescended within the canal or in an extraabdominal ectopic position. Impalpable testicles are truly undescended (high cannicular or intraabdominal location), ectopic, (abdominal), or absent. 8,10,11

DIAGNOSIS The diagnosis of undescended testicle can be made by physical examination, imaging techniques, provocative hormonal tests, and laparoscopy. By definition, physical examination fails to show any testicle in the impalpable testis, but may be of help in diagnosing ectopic, retractile, or testes within the inguinal canal. Venography shows one the location of the pampiniform plexus only. The determination, of whether there is associated gonadal tissue or not, is not made. Ultrasound in some cases images the undescended testicle; however, many an orchiopexy has been undertaken when an ultrasound has shown an “inguinal gonad” that turns out to be a lymph node. Although magnetic resonance imaging (MRI) is better, it is not as accurate as laparoscopy. There are some who in the face of the findings of bilateral impalpable testicles would proceed with a challenge of b-human chorionic gonadotropin (HCG) in order to see if a response in the serum testosterone is noted. A major problem has been the reports from a number of centers advising varying challenge protocols, the varying protocols inevitably arising from those cases in which a given protocol was utilized, “no response noted,” and yet undescended gonadal tissue was eventually found. Thus the question remains, Does the HCG challenge diagnose with complete accuracy all cases of bilateral testicular loss? Many, myself included, do not feel that an absent response with HCG stimulation obviates the need for further investigation in these cases. Laparoscopy has been found useful for both the diagnosis of the impalpable undescended gonad and the management of the impalpable undescended gonad, especially in children. 2,4,6,7 and 8 Diagnostic laparoscopy has been found to consistently yield a definitive diagnosis, to be useful in the assessment of the testicular mobility, and has been found by many to be useful in the planning of the surgical approach. While laparoscopy is invasive and requires general anesthesia, the advantages by most are felt to far outweigh the disadvantages, particularly now that the laparoscopy can be part of the management, as opposed to just the preparation. The goal of diagnostic laparoscopy is to determine if there is gonadal tissue in the clinical setting of an impalpable testis and whether the gonad is suitable for orchiopexy or better removed. Any diagnostic test that is utilized for the diagnosis of the impalpable undescended testicle must uniformly fulfill these goals; and, to my knowledge, only laparoscopy uniformly accomplishes these goals. 4,12

INDICATIONS FOR SURGERY The indication for diagnostic laparoscopy is the finding on physical examination of an impalpable undescended gonad, either unilateral or bilateral. The goal of therapeutic laparoscopy for the undescended testicle is either removal of the undescended gonad or permanent fixation of the testis in the scrotum. Hormonal therapy has promoted testicular descent in some cases. To my knowledge, the use of hormonal therapy in an attempt to promote descent in no way complicates either open orchiopexy or laparoscopic orchiopexy. The indications for orchiopexy are as follows: (a) possible improved fertility; (b) relocation of the testis to a site amenable for examination; (c) correction of associated hernias; (d) prevention of testicular torsion; and (e) alleviation of psychological trauma resulting from an empty hemiscrotum. Some of these goals are aimed at the removal or arrest of the histologic abnormalities encountered in undescended gonads. 5,10 The indications for laparoscopic orchiopexy are the same as for orchiopexy in general. As already mentioned, the procedure has been found effective, in one modification or another, for the management of all testicles from high cannicular, associated with hernias, to high abdominal. However, the higher the testicle, the more profound the anatomic aberrancies. The issue then surrounds the advocacy of performing orchiopexy for the severely dysmorphic abdominal testicle. That issue has been extensively argued and will continue to be; however, the development of sperm aspiration techniques associated with various applications of assisted fertilization seems to favor a try at orchiopexy. Timing of orchiopexy is important. It is now clear that spontaneous descent of testicles can occur during the first year of life. However, after the first year of life, it would appear that permanent histologic changes can occur and, optimally, orchiopexy should be performed at or just before the first birthday. This approach maximizes the opportunity for those few testicles that will descend during the first year of life, while preventing the histologic changes that occur in those testicles that remain maldescended beyond the first year of life. We have adopted the following algorithm, which illustrates the approach to management of the impalpable undescended testicle ( Fig. 131-1).

FIG. 131-1. Working protocol for management of the impalpable undescended testicle incorporating laparoscopy.

A variant of the abdominal testicle has been found and has been designated the medial ectopic abdominal testicle. These testicles during descent come to rest medial to their respective medial umbilical ligament. Associated with these testicles are readily apparent vascular gubernacular structures that extend to the respective location of a normal internal ring, usually closed, i.e., no patent processus vaginalis. The vas deferens is quite short; most of these testicles have not been noted to

have looping vas or dissociation of the paratesticular tubular structures; and, by definition, the spermatic vessel leash is short. These testicles appear to be quite “ovarian.” The prominent gubernacular vessels are very similar in appearance to a round ligament. There is often a very prominent peritoneal fold, reminiscent of the broad ligament. The testicles, as opposed to having a vertical orientation, appear to have a horizontal orientation. While these testicles can be placed in the scrotum using laparoscopic techniques, such testicles are very difficult to correctly place in the scrotum. Because they are already medial to the obliterated umbilical artery, the advantages of medial transposition are negated. Because the testicles are not associated with looping of the vas, the advantages of spermatic vessel division, either primary or staged, are likewise negated. If unilateral, I would consider orchiectomy as opposed to orchiopexy. If associated with bilateral maldescensus, aggressive mobilization can be attempted. Another option to the case of bilaterality would be the microscopic free transfer of these testicles.

ALTERNATIVE THERAPY A number of surgical approaches have been used for the impalpable undescended testicle: inguinal (extended inguinal), primary open abdominal, staged laparoscopic first stage and open second stage, staged laparoscopic (both stages), and primary laparoscopic. Laparoscopic orchiopexy, either primary or staged, should be viewed as a minimally invasive alternative to primary abdominal orchiopexy or extended inguinal orchiopexy. Intraabdominal testicles occur anywhere in the retroperitoneum; however, they are most commonly found just inside the inguinal ring. For the higher testicle, the staged approach has been employed. Division of the spermatic vessels to “aid” with orchiopexy was advocated as early as 1903 by Bevan. 1 The staged approach based on collateralization along the long loop of the vas deferens was an extension of the technique described by Fowler and Stephens. Originally, a long looping vas was felt to be a prerequisite for the Fowler-Stephens procedure; however, intraabdominal testicles with non-long looping vas deferens have been successfully addressed. The staged approach has been likened to other forms of delay, a term in the reconstructive literature that implies the transposition of tissue at a first stage, with division of the axial blood supply at a second stage, thus allowing the transfer tissue to survive on random collateralization occurring between the first and second stages. Clearly, the staged orchiopexy does not accomplish this. Instead, the axial blood supply or at least part of it is divided at the first stage. There remains a second axial blood supply, but one is led to believe that the second blood supply enhances during the period between first stage and second stage. Whether this enhancement truly occurs has recently been called to question by Koff and Associates. 9 Clinically, most would agree that the paravasal blood supply, after division of the spermatic vessel leash and a waiting period, does appear to be more prominent. After a 6-month wait following the initial ligation of the spermatic vessels, using either laparoscopic techniques or an open technique, the testicle is brought to the scrotum based on the paravasal vascular supply. Some authors have suggested that testicles that have been managed with staged division of the spermatic vessel leash be evaluated with color Doppler in an effort to evaluate the viability of the testicle prior to undertaking the second stage. Realistically, however, even if by Doppler the testicle does not appear to be viable, the remaining gonadal tissue should be removed as atrophy by ultrasound criteria cannot be felt to be pathognomonic of complete atrophy of the gonadal tubular structures. Ostensibly, these structures could continue to carry the risk of malignant transformation.

SURGICAL TECHNIQUE Diagnostic Laparoscopy A number of approaches have been used with regard to diagnostic laparoscopy for the undescended testicle. The most commonly employed approach is to place a cannula at a supra- or an infraumbilical position, and to visualize the pelvis looking for the spermatic vessels and the vas deferens. In most cases, diagnostic laparoscopy per se requires the placement of a single cannula only. This cannula can be quite small with 4- or 5-mm cannulas readily available, and cannulas as small as 2.5 mm available from some manufacturers. The size of the initial access cannula depends on the intent of the surgeon (i.e., diagnostic laparoscopy followed by open surgery versus followed by laparoscopic surgery to correct the defect). In some cases, it is also useful to have a manipulating instrument such as a Veress needle; other small probes have been used for this purpose that do not require a formal secondary cannula placement. The umbilical cannula position allows for complete examination of the abdomen, in particular detailed examination of the pelvis. In the case of the unilateral impalpable undescended testicle, the exam can begin on the side of the normally descended testicle. Those vessels should be readily visualized. If there is difficulty locating them, traction on the descended testicle causes the cord structures to move and very easily defines their location. Attention is then switched to an identical location on the side of the impalpable testicle. Potential findings include the following: 1. A normal-appearing vas and vessels merging at the position of a closed internal ring ( Fig. 131-2)

FIG. 131-2. The laparoscopic appearance of a normal right groin; the spermatic vessel leash can be seen joined by the vas deferens passing through a closed internal ring. Traction is on the testicle, emphasizing the location of the ring.

2. Normal vas and vessels merging at an open internal ring, i.e., patent processes or hernia ( Fig. 131-3)

FIG. 131-3. The laparoscopic appearance of the right groin in which there is a patent processus vaginalis (hernia).

3. Normal vas and vessels merging at an open internal ring which, with palpation of the groin, reveals an emerging or peeping high cannicular testicle ( Fig. 131-4)

FIG. 131-4. (A) Laparoscopic appearance of the right groin. The spermatic vessel leash joined by the vas can be seen passing adjacent to the open internal ring (patent processus vaginalis). (B) With gentle pressure on the groin, the testicle can be seen delivered to the abdomen. Notice the bubbles created by the insufflation mixed with peritoneal fluid.

4. A true low abdominal testicle (Fig. 131-5)

FIG. 131-5. The laparoscopic appearance of the low right abdominal testicle. The laparoscopic grasper is elevating the testicle.

5. Blind-ending spermatic vessels, often within proximity of a blind-ending vas deferens ( Fig. 131-6)

FIG. 131-6. The laparoscopic appearance of the left groin: classic blind-ending vas and blind-ending vessels in proximity to each other.

In the case of the impalpable undescended gonad with normal vessels merging at either an open or a closed ring, these findings warrant further inguinal exploration. In virtually all cases, that inguinal exploration can be accomplished from above (i.e., laparoscopically). In the case of a high cannicular testicle, laparoscopic orchiopexy has been shown to be extremely effective. For higher testicles, many would consider staged orchiopexy. 3,13 In the vast majority of cases of true low abdominal testicles, primary laparoscopic orchiopexy is most effective. Laparoscopic Orchiopexy The technique of laparoscopic orchiopexy begins with careful patient positioning on the operating table. The patient must be fixed to the table to allow the table to be manipulated through the extremes of Trendelenburg, reverse Trendelenburg, and rolled positions. The arms should be tucked at the side. Preparation and draping must be suitable for an open abdominal procedure, be it planned or necessary. The skin is prepared nipple to midthigh, table side to table side. A urethral catheter and an oral gastric tube are inserted. Children can readily lose body heat during laparoscopic procedures due to the fact that the insufflation gases are not heated and warming devices must be used. With the availability of high-intensity illumination and three-chip camera technology, virtually all pelvic surgery in children can be accomplished using 5-mm or smaller optics. The cannula placement schema for laparoscopic orchiopexy is illustrated ( Fig. 131-7).

FIG. 131-7. Illustration of the cannula placement schema for right laparoscopic orchiopexy.

I do not favor closed Veress needle access and thus initially a small transverse incision is created in the infraumbilical crease. The incision is carried sharply down to the fascia, which is identified and tagged with Vicryl sutures. These sutures allow the fascia to be elevated. The fascia is then opened and, with the use of skin hooks, the deep abdominal wall structures are elevated, eventually allowing a small peritoneotomy to be made. Through that small incision, a 5-mm cannula is placed with a screw fixation device that achieves excellent gas seal. Specialized open access cannulas are not needed. For the diagnostic portion of the procedure, an examination of the pelvis is begun. Once the inspection of the pelvis is complete, a decision is made concerning the therapeutic intervention and secondary cannulas are placed.

For an impalpable testicle that is found to be in the high inguinal region (“emerging” or “peeping”), or a testicle that is found immediately proximate to the internal ring with vessels that allow mobilization, single-stage laparoscopic orchiopexy is undertaken. In addition, primary laparoscopic orchiopexy has recently been advocated for the management of the high palpable inguinal testicle. The procedure begins with the patient in the Trendelenburg position, the table tilted away from the undescended gonad. In the case of a true abdominal testicle, a peritoneal incision is made lateral to the spermatic cord at the upper pole of the testicle and continued in a rostral direction. The spermatic cord is rolled medially and elevated from the retroperitoneal tissues using blunt dissection. Adjacent to the patent processus vaginalis, if it is present, the gubernaculum is divided ( Fig. 131-8). Care must be taken with this maneuver as a loop of the vas deferens can be seen in these structures ( Fig. 131-9), making it imperative to define the caudal extent of looping of the vas prior to dividing the gubernaculum. These gubernaculum attachments are vascular and must be adequately cauterized before being divided. These inferior attachments retract caudally when divided, and significant bleeding in the groin is possible. In the high inguinal testicle, the initial incision is made adjacent to the patent processus, thus allowing the hernia sac to be dissected from the spermatic vessels. This allows for delivery of the testicle to the abdomen and for division of the inferior attachments.

FIG. 131-8. Laparoscopic appearance and accompanying diagram of right testicle—gubernacular attachments being divided.

FIG. 131-9. Laparoscopic appearance of the left groin; testicle is retracted into the abdomen and a looping vas is seen extending adjacent to the inferior (gubernacular) attachment.

Dissection is then carried to the peritoneum overlying the vas deferens, medial to the testicle. That peritoneum is opened, and the vas is carefully elevated, taking care to avoid injury to the paravasal structures ( Fig. 131-10). The vas is mobilized sufficiently to allow placement of the testicle in the scrotum, but vigorous mobilization of the vas deferens is purposefully avoided as the incidence of testicular atrophy has been attributed by some to be associated with vigorous mobilization of the vas. The vas, however, must be sufficiently mobilized so that when the testicle is brought into the scrotum there is not tenting of the paravasal attachments next to the ureter creating ureteral obstruction.

FIG. 131-10. (A) Photograph and accompanying diagram of a right testicle, having been freed from the adjacent hernia sac, being retracted into the abdomen. (B) Diagram showing the right testicle, retracted into the abdomen, the gubernacular attachments being divided using a combination of sharp and electrocautery dissection.

The two peritoneal incisions are connected, creating a triangular shaped flap of peritoneum. This flap of peritoneum ostensibly may preserve some of the collateral vessels between distal spermatic vessels and the paravasal vasculature. Realistically, however, this is simply the easiest way to accomplish the dissection. Likewise, including this peritoneal flap does allow one the opportunity to fall back on division of the spermatic vessel leash and primary Stephens-Fowler orchiopexy. After the spermatic cord, testicle, and vas have been sufficiently mobilized ( Fig. 131-11), the surgeon's attention is directed to the respective hemiscrotum. Fixation of the testicle and scrotum can be accomplished by whatever maneuver is the surgeon's preference; I generally create a subdartos pouch. A small transverse skin incision is made and carried to the dartos fascia. The dartos pouch is created; tacking sutures of 6-0 prolene are placed on the fascia; the fascia is then opened and the canal between the scrotum and the pubic tubercle created. At that point, the fascia is penetrated with a clamp, the tips of the clamp being readily detected from within. This allows for dilation of the “fascial window,” at which point a 5-mm rod is introduced via the developed canal. As the indentation of the rod is observed, the rod is guided into the peritoneal cavity under direct vision just medial to the obliterated umbilical ligament. The rod should literally “melt its way” into the abdominal cavity. If significant pressure is required to pass the rod, one must fear that the rod could be passing through the medial structures (i.e., the bladder) or perhaps passing through the vascular structures of the umbilical ligament. With the rod in the abdominal cavity, a threaded dilator is passed, dilating the canal to 10 mm, allowing for placement of a 10-mm cannula (Fig. 131-12).

FIG. 131-11. (A) Photograph with (B) accompanying diagram of a right testicle totally mobilized from its attachments to the right groin suspended in the intraabdominal cavity. Note the peritoneal reflection between the spermatic vessels and the vas deferens.

FIG. 131-12. (A) Diagram illustrat-bing the passage of a 5-mm rod medial to the medial umbilical ligament. The canal has then been dilated with a threaded 10-mm dilator. Laparoscopic cannula is passed over the dilator. (B) The appearance of laparoscopic cannula passed through the right hemiscrotum into the abdomen.

Testicular grasping forceps are introduced. The testicle is positioned into the forceps, and the testicle is then delivered into the scrotum via the cannula ( Fig. 131-13). As the vessels or vas come under tension, the attachments can be further freed. Lucent cannulas have been found to be very useful here as these cannulas allow one to visualize the testicle as it descends to what will be its eventual position, well placed in the scrotum. When there, the grasper is removed from the testicle; the testicle is secured with the previously placed prolene sutures and placed in the dartos pouch.

FIG. 131-13. (A) Photograph showing an intraabdominal testicle being pulled into the laparoscopic cannula using testicular grasping forceps. The testicle is then delivered to the right hemiscrotum. (B) Photograph illustrating the outside appearance with the testicle delivered to the level of the scrotum within the lucent cannula.

The scrotal skin is closed and insufflation pressures are dropped; the areas of dissection are checked for hemostasis. Early in my series, I attempted to reoppose the parietal peritoneum; however, it has been found that with dutiful dissection of the hernia sac, closure of the parietal peritoneum is not necessary; the area readily reperitonealizes without recurrences of hernia found to date. 6,7 With regard to the application of laparoscopic techniques for the Fowler-Stephens procedure, Bloom 2 described the first stage occlusion of the spermatic vessels using pelvioscopic clipping. In his series, the testicle was later located using an open technique. Vascular clips can be used for ligating the cord structures. Some centers have merely coagulated the spermatic vessels. With the advent of better operative laparoscopic procedures, this center, along with others, has performed the second stage laparoscopically. In terms of technique, the second-stage staged laparoscopic orchiopexy is not unlike the procedure already described for primary orchiopexy. Obviously, the extended dissection of the spermatic vessels is not required. It cannot be overemphasized that the undescended testicle is found proximate to the blind-ending vessels, not necessarily the blind-ending vas. If one finds a blind-ending vas deferens, only in the pelvis, one cannot declare the testicle “vanished” without further exploration and the findings of blind-ending vessels. The author recently encountered a case that caused him to question the certainty of the previous statement; however, in that case, a patient was found to have a normal-appearing vas deferens passing through an open internal ring. Merging with that vas deferens were structures that appeared to be normal spermatic vessels. On dissecting these structures during an attempt at orchiopexy, the hernia sac was dissected, the vessels and vas deferens were dissected, but a true undescended gonad was not found. Instead there was found only a prominence associated with the vas deferens/epididymis that was felt to possibly represent viable gonadal tissue. Fortunately, the decision was made to continue orchiopexy; and as these structures were freed up, beneath the cecum a testis was found. It is clear that the true spermatic vessels went to the testis. However, prominence of the vessels extending to the open ring (i.e., gubernacular attachments) were such that one could easily have been led astray by the findings of these vessels ending proximate to what ended up being only an epididymis. Had one explored via an extended inguinal approach, I believe a misdiagnosis would have been made. Likewise, had I not decided to attempt orchiopexy, the true high abdominal testicle would not have been found, at least not at that procedure. In children, all of the cannula sites, no matter how small, must be closed. At this center, closure of the cannula site is with 3-0 Vicryl suture on a strong circular needle. These children do profit from adjuvant caudal anesthesia using bupivacaine (Marcaine). Additionally, injection of the cannula sites with bupivacaine has also been found advantageous. The children are awakened, recover from anesthesia, and are discharged. In most cases, the diet is advanced rapidly. With the exception of instructions to keep the child from playing on straddle implements, virtually no physical restrictions are imposed. Most parents report that the child is “a little bit slow” on the day of surgery. If surgery is performed in the afternoon, on the following morning the child might remain a little slow. However, within 24 hours of surgery the vast majority of parents report that the child “suddenly awakens” and from that point on is seemingly unimpeded by the laparoscopic procedure.

OUTCOMES Complications Complications have almost all been associated with blind cannula placement used in association with Veress needle insufflation. To the author's knowledge, the only

other complication encountered using diagnostic laparoscopy was a single case of gas embolism, and the details of this case are not known. The complications that have been reported with laparoscopic orchiopexy have been acute testicular atrophy, a case of hernia with bowel incarceration at the site of the closure of the parietal peritoneum, a case of bladder injury occurring at the time of passing the testicle medial to the obliterated umbilical artery, and a case of avulsion of the testicle during the orchiopexy and with that case the testicle was salvaged by converting to microorchiopexy. Results Diagnostic laparoscopy is regarded as a highly effective and safe procedure to localize and diagnose the nature of the impalpable testicle. In most series, a large number of procedures have been done with virtually 100% accuracy and, in most series, no complications. Studies by both Body and Koyle 4,11,12 have shown the superior accuracy of laparoscopic “exploration” over open exploration. The literature supports diagnostic laparoscopy as the single most accurate modality for the diagnosis and localization of the impalpable undescended gonad. Our experience and the experiences of others have shown laparoscopic orchiopexy to be a valid and effective alternative to open orchiopexy ( Fig. 131-14). At this center, approximately 45 testicles have been brought to the scrotum using laparoscopic techniques, with only one case of possible acute atrophy. In that case the testicle was extremely small when brought down; however, with longer follow-up, the testicle has not shown much, if any, growth. In another case, the child developed a small hematoma in the “neoinguinal” canal that resolved without sequelae.

FIG. 131-14. Postoperative appearance at 6 months showing a patient following laparoscopic right orchiopexy for a right intraabdominal testicle. Note the complete normal appearance of the right hemiscrotum. A penny is placed on the child's abdomen for reference. Note that the laparoscopic cannula sites are virtually invisible. Drawn on the child's abdomen are what could have been the abdominal incisions for an open abdominal orchiopexy.

CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Bevan A. The surgical treatment of undescended testicle: a further contribution. JAMA 1903;41:718. Bloom DA. Two-step orchiopexy with pelvioscopic clip ligation of the spermatic vessels. J Urol 1991;145:1030. Bloom DA, Ritchey ML, Jordan GH. Pediatric peritoneoscopy (laparoscopy). Clin Pediatrics 1993;32(2):100–104. Boddy SA, Corkery JJ, Gornall P. The place of laparoscopy in the management of the impalpable testis. Br J Surg 1985;72(11):918–919. Giarola A, Agostini G. Undescended testis and male fertility. In: Bierich JR, Giarola A, eds. Cryptorchidism. London: Academic Press, 1979. Jordan GH, Bloom DA. Laparoscopic genitourinary surgery in children. In: Gomella LG, Kozminski M, Winfield HN, eds. Laparoscopic urologic surgery. New York: Raven Press, 1994;223. Jordan GH, Robey EL, Winslow BH. Laparoendoscopic surgical management of the abdominal/transinguinal undescended testicle. J Endourol 1992;6:157. Jordan GH, Winslow BH. Laparoscopic single stage and staged orchiopexy. J Urol 1994;152:1249–1252. Koff SA, Sephic PS. Treatment of high undescended testes by low spermatic vessel ligation. J Urol 1992;156(2):799–803 Kogan SJ. Cryptorchidism. In: Kelalis PP, King LR, Belman B, eds. Clinical pediatric urology. 2nd ed. Vol. 2. Philadelphia: WB Saunders, 1985;86 Koyle MA, Rajfer J, Ehrlich RM. Undescended testis. Pediatr Ann 1988;17(1):39, 42–46 Koyle MA, Pfister RR, Jordan GH, Winslow BH, Ehrlich RM. The role of laparoscopy in the patient with previous negative inguinal exploration for impalpable testis (Abstract 35). J Urol 1994;151:236A 13. Ransley PG, Vordermark JS, Caldamone AA, Bellinger MF. Preliminary ligation of the gonadal vessels prior to orchiopexy for the intra-abdominal testicle: a staged Fowler-Stephens procedure. World J Urol 1984;2:266.

Chapter 132 Laparoscopic Adrenalectomy Glenn’s Urologic Surgery

Chapter 132 Laparoscopic Adrenalectomy H. Tazaki

H. Tazaki: Department of Urology, New York Medical College, Valhalla, New York 10595.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Instruments Preparation Anterior Transperitoneal Approach Posterior Retroperitoneal Approach Postoperative Management Outcomes Complications Results Chapter References

In urologic surgery, laparoscopic surgery is most commonly utilized for pelvic lymphadenectomy as a staging diagnostic technique in patients with prostate cancer. Indications for laparoscopy in other malignant diseases are still controversial. Though most adrenal masses are benign, surgical intervention is generally indicated whether the mass is functioning 1 or nonfunctioning. On the other hand, location of adrenal glands is deep in retroperitoneal space and surgical approach is often difficult, even by open surgery. While the laparoscopic approach to the kidney is becoming common by either intra- or extraperitoneal routes, it is now possible to use this approach to the adrenal. The advantages of laparoscopic adrenal surgery are the reduced morbidity and shortened hospital stay that has been confirmed by the number of successful cases reported since 1993. 2,3,4,5

DIAGNOSIS The diagnosis of adrenal lesions is discussed in detail in Chapter 1, Chapter 2, Chapter 3 and Chapter 4.

INDICATIONS FOR SURGERY The indications for surgery are any functioning adrenal mass or any adrenal mass that is larger than 2 cm.

ALTERNATIVE THERAPY Alternative therapy is open surgery.

SURGICAL TECHNIQUE Instruments Standard instruments for urologic laparoscopic surgery can be used for laparoscopic adrenalectomy. These instruments include trocars, clamps, scissors, and hemoclips. Laser coagulators and ultrasound aspirators are helpful for a bloodless approach to the adrenal. 8 Rigid and flexible endoscopes can be used. We prefer to remove the adrenal with an endopouch, which accommodates the adrenal following its excision and allows the tissue to be taken out through a port at the final stage of surgery. The advantage of laparoscopic adrenalectomy is that it is less invasive with lower postoperative morbidity and quicker recovery. This is balanced by the increased time required in the operating room compared to open surgery and higher cost per procedure partly due to the increased operative time. However, recent reports show a remarkable improvement in operating time by introducing new instruments designed for smooth dissection and controlling hemorrhage from small vessels. An example of the new technology is the coagulation shears (Harmonic Scalpel, Ultra Cision), which reduces the use of hemoclips resulting in shortened operating time. Preparation Laparoscopic adrenalectomy is performed under intubated general anesthesia. A combination of general anesthesia with epidural anesthesia is recommended especially for obese patients due to the prolonged anesthesia time. Positioning of patients on operating table is extremely important. The operating table must be rotatable from flat to oblique positions as well as from flat to head-up positions. Positioning the patient for surgery varies according to the approach chosen for the adre-nalectomy. These approaches are transperitoneal an-terior, extra- or intraperitoneal flank, and posterior. Except for the gasless technique to explore the operating field, a pneumoperitoneum with CO 2 gas is used to obtain the adequate operating space for handling the instruments. Monitoring of end-tidal CO 2 and arterial blood gas throughout surgery is extremely important. Laparoscopic approaches to the adrenal gland are classified as those of open surgery. Anterior and flank approaches are more common than the posterior approach. Even in these two common approaches, there are many technical variations described. Therefore, the most basic techniques are described in the following paragraphs. Anterior Transperitoneal Approach The patient is placed in supine position under general anesthesia. A blind laparotomy using Veress needle is not recommended, especially in the obese patient ( Fig. 132-1 and Fig. 132-2). An open laparotomy is made at the umbilicus by the Hasson method and the pneumoperitoneum is established with the insufflation of CO 2, as described in Chapter 122. This pneumoperitoneum creates a space for additional trocar insertion and subsequent port placement for the laparoscope and other instruments. At this time, position of the patient is changed from supine to hemilateral position with the diseased side up. Care must be taken when a trocar is inserted along the midaxillary line or its posterior side because the ascending or descending colon may be injured. It is therefore important to have the preinserted camera watching these puncture sites during trocar placement.

FIG. 132-1. Positions of trocar ports for anterior transperitoneal adrenalectomy (left side). MCL, midclavicular line; MAL, middle axillary line; (1) Umbilicus (for open laparoscopy); (2, 3) Ports for 10/12-mm trocars; (4) port for 5-mm trocar.

FIG. 132-2. Positions of trocar ports for anterior transperitoneal adrenalectomy (right side): (1) Umbilicus (for open laparoscopy. (2, 3) Ports for 10/12-mm trocars on MCL. (4) Port for 5-mm trocar on MAL.

The right side allows better exploration of the adrenal than the left. The dissection begins by pushing the fatty tissue of the omentum laterally. The line between the lower lateral end of the liver and the colon is confirmed and an incision is made at the hepatic flexure. The incision is extended from the lateral colon to the lower surface of the liver along the duodenum. Gerota's fascia is opened and the upper pole of the right kidney is exposed. As the kidney is pushed down the adrenal is visualized. The adipose tissues around the adrenal are bluntly divided from lateral to medial until the vena cava and right renal vein are in sight. The inferior adrenal vein and other small vessels are clipped and divided until the right adrenal vein is identified attached to the vena cava ( Fig. 132-3). The right adrenal vein is usually very short and it is necessary to double-clip the vein prior to division. The excised mass is placed in the endopouch and removed through a trocar port.

FIG. 132-3. Laparoscopic view of anterior transperitoneal adrenalectomy (right side). Right adrenal vein is short, draining directly into vena cava. Sweep the fatty tissues and expose the adrenal vein, which is then double-clipped.

The left adrenal is located higher and in a narrow space between the descending colon and the spleen. The anterior surface of the left adrenal is covered by the stomach and omentum and the left colonic flexure, which is higher than the right side. Therefore, selection of port positions for left adrenalectomy should be higher than for the right side. In the left lateral position, along the lateral line of the descending colon, the peritoneum is incised and the dissection is carried to the upper pole of the kidney without entering Gerota's fascia. Care should be taken not to encounter bleeding when the splenocolonic ligament is incised and divided. Thus the splenic flexure of the colon can be replaced medially as the peritoneal wall along lateral of the descending colon is incised to the level of the lower pole of the kidney. Using a Babcock clamp inserted through an 11-mm port near the midline, the colon should be kept outside of sight. Gerota's fascia is incised at the level of upper pole of the left kidney as the lower surface of the spleen is pushed cranially. The phrenic branch vessels must be carefully clipped or fulgurated. Then anterolateral surface of the adrenal is divided bluntly by pushing the tail of the pancreas in a cranioventral direction. The renal hilum is exposed and the central vein and the left renal vein are identified. The central vein is doubly clipped and divided ( Fig. 132-4). As the dissection proceeds along the cranial side of the adrenal, the left inferior phrenic vein is identified, clipped, and divided. The adrenal is placed in a pouch and removed through a trocar port. After assuring complete hemostasis, all instruments are removed. It is recommended that a Penrose drain be left in the retroperitoneal space.

FIG. 132-4. Laparoscopic view of anterior transperitoneal adrenalectomy (left side). Left adrenal vein drains into the left renal vein. The adrenal vein is double clipped and divided.

Posterior Retroperitoneal Approach

Balloon dilation of the retroperitoneal space using techniques described by Gaur and subsequent pneumo-retroperitoneum can allow an approach to the adrenal without entering the peritoneal cavity and may reduce incidence of intraperitoneal complications. 4 However, some disadvantages to endoscopic retroperitoneal surgery are less visibility due to a darker operating field and a lack of landmarks due to scattering of light against the adipose tissue in the retroperitoneal space. The patient is placed in a flank position on the table ( Fig. 132-5). A 1.5-cm skin incision is made near tip of the 12th rib at the midaxillary line and the muscle layers are bluntly separated ( Fig. 132-6). A balloon dilation trocar (Preperitoneal Distention Balloon System, Origin Medsystems, Inc., Menlo Park, CA) is inserted into the hole and the balloon is inflated with 800 ml of air, creating a space for endoscopic manipulation. The Origin balloon trocar is changed to an 11-mm trocar and the laparoscope is introduced for observation. Two more operating trocars are introduced extraperitoneally on the line along the 12th rib.

FIG. 132-5. Patient's positioning for posterior retroperitoneal adrenalectomy by the flank approach. Special care should be taken for protection of arms and legs to avoid complications.

FIG. 132-6. Positions of trocar's for posterior retroperitoneal adrenalectomy. (right side AAL, anterior axillary line; PAL, posterior axillary line. (1) Trocar for balloon dilatation in retroperitoneal space right under the 12th rib. (2, 3) On AAL and PAL for 10/12-mm trocars. (4) Port for 5-mm trocar.

Another technique for the posterior approach is to place the patient in an extended abdominal position ( Fig. 132-7) and make a small incision at the midscapular line 2 cm below the 12th rib. The fascia of quadratus lumborum muscle is bluntly opened and the balloon dilation technique is applied. Two more ports are then created, avoiding damage to the iliolumbar muscle, for a direct approach to the upper pole of the kidney and the adrenal. The pressure in the retroperitoneal space is controlled at 12 to 15 mm Hg throughout the surgery.

FIG. 132-7. Patient positioning for posterior retroperitoneal adrenalectomy via the extended abdominal position. Balloon dilation of retroperitoneal space through a port on middle scapular line 2 cm below the 12th rib.

For a right adrenalectomy, Gerota's fascia is opened at the level of the upper pole of the kidney, allowing a direct approach to the right adrenal. The advantages are an operating field not disturbed by the liver or the intestines but the trade-off is that only the upper pole of the kidney can be used as a landmark. Clipping vessels from this approach is relatively easier ( Fig. 132-8).

FIG. 132-8. Laparoscopic view of posterior retroperitoneal approach. Upper pole of the kidney is a landmark for the adrenal. Laser coagulation shears (LCS) are a useful tool.

Left adrenalectomy, direct approach to the adrenal in the retroperitoneal space, is similar to adrenalectomy of the right side, though identifying the tail of the pancreas

is often difficult. Clipping the adrenal vein is the final stage of a left adrenalectomy from the retroperitoneal approach. Postoperative Management A chest x-ray is obtained on postoperative day 1 if there are any signs of suspected pulmonary complications. Patients are discharged on postoperative day 2.

OUTCOMES Complications Complications from laparoscopic adrenalectomy include disease-specific and technique-specific adverse events. Disease-specific events would include adrenal insufficiency in patients with Cushing's disease and are addressed in Chapter 1, Chapter 2, Chapter 3 and Chapter 4. Technique-specific events include hemorrhage, hypercarbia, pneumothorax, and pneumomediastinum, which can be avoided by careful attention to detail and close cooperation and monitoring by the anesthesiologist. Results As this is a relatively new approach to the adrenal, most reports are anecdotal. 7,8 However, results indicate that the procedure is technically feasible, offers quicker recovery and lower morbidity, and with more experience will become the most common approach to adrenal lesions. CHAPTER REFERENCES 1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma (letter to the editor). N Engl J Med 1992;327:1033. 2. Gaur DD. Laparoscopic operative retroperitoneoscopy. Use of new device. J Urol 1992;148:1137–1139. 3. Guazzoni G, Momtorsi F, Bocciardi A, et al. Transperitoneal laparoscopic versus open adrenalectomy for benign hyperfunctioning adrenal tumors. A comparative study. J Urol 1995;153:1597–1600. 4. Kelly M, Jorgensen J, Magarey C, Delbridge L. Extraperitoneal laparoscopic adrenalectomy. Aust NZ J Surg 1994;64:498–500. 5. Nakagawa K, Murai M, Deguchi N, et al. Laparoscopic adrenalectomy: clinical results in 25 patients. J Endourol 1995;9:265–267. 6. Rassweiler JJ, Henkel TO, Potempa DM, Copcoat M, Aiken P. The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy. Eur Urol 1993;23:425–430. 7. Suzuki K, Kageyama S, Ueda D, et al. Laparoscopic adrenalectomy: the initial 3 cases. J Urol 1993;149:973–976. 8. Tazaki H, Baba S, Murai M. Technical improvement in laparoscopic adrenalectomy. Tech Urol 1995;1:222–226.

Chapter 133 Renal Cysts Glenn’s Urologic Surgery

Chapter 133 Renal Cysts Michael P. O'Leary

M. P. O'Leary: Department of Surgery, Division of Urology, Harvard University Medical School, and Division of Urology, Brigham and Women's Hospital, Boston, Massachusetts 02115.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Cystic disease of the kidney may be divided into genetic and nongenetic categories. Genetically determined disorders include autosomal recessive (infantile) polycystic kidneys, autosomal dominant (adult) polycystic kidneys, and juvenile nephronophthisis, which is also autosomal recessive. Nongenetically determined cystic malformations include multicystic kidneys, multilocular cystic kidneys, and simple cysts. This chapter focuses on simple renal cysts. Renal cysts are believed to develop in tubular segments and Bowman's capsule, with simple cysts developing from the convoluted tubule, whereas the acquired and genetic forms may develop anywhere along the nephron and collecting duct. 3 Regardless of their origin, most are lined with a single epithelial layer. Simple cysts are extremely common, occurring in up to 50% of individuals over the age of 50. 9 The majority are asymptomatic and are found incidentally at the time of radiographic imaging for nonrenal conditions. Most are unilocular and, because they arise from the cortex, they distort the normal renal contour. They may enlarge somewhat with time, although most probably remain stable in size and appearance. Multicystic dysplastic kidneys may represent an extreme form of hydronephrosis and are generally encountered in infants, whereas multilocular cysts occur in young children and are believed to be part of a spectrum of neoplasia, associated with Wilms' tumor. 5 Cysts may also develop in end-stage kidneys and are present in 50% of patients on chronic dialysis. 2

DIAGNOSIS The diagnosis of renal cysts used to be made during intravenous urography with tomography. Today ultrasound (US) and computed tomography (CT) are the principal diagnostic tools, and most cysts are found incidentally. Occasionally a patient with a very large simple cyst may present with vague abdominal or flank discomfort and fullness on physical exam, though most patients are asymptomatic. The sonographic criteria for simple cysts are absence of internal echoes, increased through transmission of sound, and a sharply defined wall. On CT, cysts are sharply marginated, with attenuation values in the range of water (–10 to –20 Hounsfield units) ( Fig. 133-1). They do not enhance after administration of contrast material. Further elucidation may be obtained using magnetic resonance imaging (MRI) in which cysts appear as round, homogeneous, and low intensity (dark) on T1-weighted images and increased intensity (lighter) on T2-weighted images.

FIG. 133-1. CT scan of a renal cyst (arrow).

Complex renal cysts present a greater challenge both diagnostically and therapeutically because 15% of renal tumors may present this way. classification system using CT to aid in diagnosis ( Table 133-1).1

4

Bosniak has proposed a

TABLE 133-1.

INDICATIONS FOR SURGERY Surgery for the Bosniak type I simple renal cyst is rarely warranted. Occasionally, patients who present with flank pain are discovered to have no other etiology on radiographic evaluation for their complaint other than a large simple cyst, and may be candidates for therapy.

ALTERNATIVE THERAPY These patients may be candidates for cyst aspiration under CT or ultrasound guidance. Although such cysts will almost certainly recur, it is reasonable to conclude that if the patient's pain resolves after cyst aspiration, then some definitive form of therapy may be warranted and justifiable. The use of percutaneously injected sclerosing solutions has limited value in our experience. Open surgical approaches have been favored in the past 9 but the potential morbidity of the procedure must

be weighed against the benefits. A minimally invasive approach offers a reasonable alternative.

SURGICAL TECHNIQUE Our favored approach for treating renal cysts, either simple or multiple, has been laparoscopic marsupialization. This technique has also been reported to treat symptomatic polycystic kidneys.7 This is done under general endotracheal anesthesia with the patient placed in a 45 degree lateral flank position. An infraumbilical minilaparotomy incision is made and the blunt-tipped Hasson trochar is inserted in the peritoneal cavity. A purse string fascial suture of 2-0 Vicryl is used to secure the trochar and later to close the fascial defect. Carbon dioxide is insufflated to create the pneumoperitoneum, which is maintained at a pressure of 10 to 15 mm Hg. A 10-mm port is placed under laparoscopic guidance approximately 5 cm lateral and inferior to the umbilicus ( Fig. 133-2). A third 5-mm trochar is placed below the costal margin in the anterior axillary line. A fourth port is advocated by some but is rarely necessary in our experience. The white line of Toldt is incised and the colon is reflected medially. Gerota's fascia is then incised. The cysts are then generally readily visualized. Using an Orandi-type needle the cyst can be punctured and cyst fluid sent for cytologic diagnosis. The cyst can then be unroofed with laparoscopic shears and its walls carefully inspected to rule out malignancy, which, while extremely rare, has been reported. 8 No attempt is made to fulgurate the cyst wall, but generally the cyst wall is at least partially resected. Then, using endoscopic clip appliers, we have clipped a portion of the peritoneum to the cyst wall to ensure communication with the peritoneal cavity and decrease the likelihood of recurrence. Bleeding is minimal. No drains are necessary. The ports are removed under direct vision, the pneumoperitoneum is evacuated, and the trochar sites are closed with 2-0 polyglactin suture for the fascia and 4-0 for the skin in a subcuticular fashion.

FIG. 133-2. Laparoscopic port sites.

OUTCOMES Complications The overall complication rate for laparoscopic renal surgery has been reported to be in the range of 15% to 20%, with the majority of these being minor and occurring in the postoperative period. 6 These procedures have generally been nephrectomies. Intraoperative complications are similar to those of any laparoscopic procedure. The surgeon must be prepared (and likewise the patient well informed preoperatively) to convert to an open procedure in the rare event it becomes necessary. Results Immediate relief of flank discomfort is usually noted if indeed the cyst was the true etiology of the pain. It is therefore imperative to clearly inform the patient preoperatively of the possibility of continued discomfort postoperatively. It is always wise to remember that the surgeon who operates for pain alone embarks on a perilous journey. CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Bosniak MA. The small (less than 3.0 cm) renal parenchymal tumor: detection, diagnosis, and controversies. Radiology 1991; 179(2):307–318. Glassberg KI. Campbell's urology. 6th ed. Philadelphia: WB Saunders, 1992;1443. Grantham JJ. Pathogenesis of renal cyst expansion: opportunities for therapy. Am J Kidney Dis 1994;23(2):210–218. Hartman DS, Aronson S, Frazer H. Current status of imaging indeterminate renal masses. Radiol Clin North Am 1991;29(3):475–96. Kissaine JM, Smith MG. Pathology of infancy and childhood. 2nd ed. St. Louis: CV Mosby, 1975;587. Moore RG, Kavoussi LR. Laparoscopic nephrectomy. In: Loughlin KR, Brooks DC (Eds.), Principles of endosurgery. Cambridge: Blackwell Scientific, 1996;127–139. Segura JW, Brown JA, Torres VE, King BF. Laparoscopic marsupialization of symptomatic polycystic kidney disease. J Urol 1996;156:22–27. Stenling R, Ljungberg B, Holmberg G, Sjodin J, Hietala S. Renal cell carcinoma in a renal cyst: a case report and review of the literature. J Urol 1990;143:797–799. Walton KN. Urologic surgery. 4th ed. Philadelphia: JB Lippincott, 1991;138.

Chapter 134 Robotics, Telepresence, and Virtual Reality in Urologic Surgery Glenn’s Urologic Surgery

Chapter 134 Robotics, Telepresence, and Virtual Reality in Urologic Surgery Roland N. Chen and Louis R. Kavoussi

R. N. Chen: Department of Urology, The Cleveland Clinic Florida, Fort Lauderdale, Florida 33309. L. R. Kavoussi: Department of Urology, The James Buchanan Brady Urological Institute, and Department of Urology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224.

Robotics in Urologic Surgery Telepresence Surgery Virtual Reality Conclusion Chapter References

Rapid advances in telecommunication and computer technology have thrust mankind headlong into the information age, forever altering the way we communicate and do business. The early effects of such changes are now becoming apparent on the surgical landscape. Robotics, telepresence, and virtual reality are making their way from manufacturing and entertainment to the operating room. These new tools will soon enhance our ability to perform surgery quickly and skillfully. Because of their expense and dependence on the rapid processing and transfer of data, these disciplines remain in their infancy. However, continued improvements in optical fiber, silicon microchip, superconductor, and supercomputer technology will soon allow these barriers to be overcome. Future challenges lie not only in developing useful technologies but in making them practical and cost-effective. Robotics in Urologic Surgery The term “robot” is derived from the Czechoslovakian word robota, which denotes obligatory servitude. Although robots have been used extensively in industrial manufacturing, undersea applications, and space exploration over the past four decades, they have only recently been introduced in the operating room. A robot consists of a computer control system and a mechanical component which, for a surgical robot, is usually an arm that conveys motion to an attached instrument ( Fig. 134-1). A robotic arm can have multiple joints that translate or rotate. A robot's dexterity is determined by the total number of motions that the joints allow, described as degrees of freedom. For example, the human elbow has 1 rotational degree of freedom, whereas the shoulder and wrist each have 3 rotational degrees of freedom. Therefore, the human palm has 7 degrees of freedom, or a sum of the degrees of freedom provided by the shoulder, elbow, and wrist. A minimum of 6 degrees of freedom is necessary for an attached instrument to have complete freedom of motion. The computer and accompanying software that control the robot's motions can coordinate complex movements of multiple joints. Each software package is uniquely dedicated to a specific application.

FIG. 134-1. Illustration of a surgical robotic arm.

There are several advantages of utilizing robots in surgery. Robots are capable of performing tasks with great precision and without fatigue, thereby improving the efficacy, reducing the potential morbidity, and decreasing the length of a procedure. They also may potentially replace costly personnel by alleviating the need for a surgical assistant. Several important factors must be considered in the design of a robot for medical applications. Surgical robots must be cost-effective, intuitive to use, and ergonomic with respect to the patient, as well as the operating room equipment and personnel. In addition, redundant built-in safeguards are necessary to minimize the risk of inadvertent patient injury by the robot. Because of technological limitations and safety issues, the application of robots in surgery remains relatively limited. Their role in surgery will undoubtedly expand as improvements and innovations in software and hardware are achieved. Robots have initially been employed as assistants in procedures performed on tissues that provide fixed landmarks as reference points. Neurosurgeons, for example, have utilized robots that provide a three-dimensional road map based on computed tomography (CT) and magnetic resonance imaging (MRI) data as localizers and navigators for performing stereotactic neurosurgery. Orthopedic surgeons have employed robots to drill the femoral shaft in preparation for uncemented hip prostheses. Using similar concepts, a group of investigators at the Imperial College in London 6 developed a robotic system that is capable of performing rapid and accurate transurethral resection of the prostate ( Fig. 134-2). This system was first introduced in 1989 and continues to evolve. The most recent design employs a robotic arm that controls a 24-Fr resectoscope that is mounted on a constraining safety frame. Prior to initiation of the procedure, cystoscopy is performed and the resectoscope loop placed at the verumontanum. The prostatic size and shape based on transurethral ultrasound measurements are then input into the computer, allowing a three-dimensional model of the prostate to be constructed. Once the cutting limits are established, the robot performs a series of programmed cuts, removing one or more cones of tissue from within the prostatic fossa. The procedure is monitored by the surgeon via the attached endoscopic camera. Because the cutting sequence is preprogrammed, the resection process can be completed in less than 5 minutes. The significantly shortened procedure time allows hemostasis to be achieved following completion of the procedure, reduces the anesthetic risk, and minimizes intraoperative bleeding.

FIG. 134-2. Imperial College robotic system for transurethral resection of the prostate. (A) Pattern of resection performed by the robot. (B) Robotic safety frame.

In a trial of 30 patients in whom manual resection was performed using the safety frame, these authors have reported results comparable to standard transurethral resection of the prostate at 1 year following treatment. Five patients were treated successfully in an initial clinical trial using the unaided robotic system. This trial demonstrated that transrectal ultrasonography is inaccurate for measuring the prostatic dimensions. A modified system using transurethral ultrasonography as the imaging modality is currently being developed. The Imperial College group in London has also investigated the use of a robot for acquiring percutaneous renal access. 8 This group developed a system that employs a passive robot mounted to the operating table. Two-dimensional images of the intrarenal collecting system are obtained intraoperatively via a mobile C-arm fluoroscopic unit. These images are processed by a microcomputer, which in turn provides three-dimensional coordinates to the robot. The system allows the surgeon to select the trajectory of the access needle. Experiments evaluating system performance have demonstrated a targeting accuracy of within 1.5 mm. No in vitro or in vivo experiments have been performed to date. A group at Johns Hopkins have also developed a robotic system for acquiring percutaneous renal access. 1 Two-dimensional images are obtained via biplanar fluoroscopy and processed by a microcomputer. Once the needle trajectory is selected by the surgeon, the active robot positions, orients, and drives the access needle into the desired calyx. Experiments evaluating the performance of this system have demonstrated a targeting accuracy of within 1.0 mm. Ex vivo experiments in porcine kidneys demonstrated entry into the selected calyx in 10 of 12 attempts (83% accuracy) using this system. Robots designed as assistants for general laparoscopic surgery have also found use in urology. The AESOP (Automated Endoscopic System for Optimal Positioning, Computer Motion, Inc, Goleta, CA) robot, an FDA-approved device, has been used with considerable success as an assistant in laparoscopic surgery. 7 The robotic arm is controlled by a foot pedal or hand controller and is used to hold the laparoscope and/or a laparoscopic retracting device. Partin et al. evaluated the use of the AESOP robot in a series of 17 laparoscopic urologic procedures including nephrectomy, pyeloplasty, retroperitoneal lymph node dissection, and bladder neck suspension.7 The laparoscopic procedures were performed successfully in all cases and independently of additional human assistance in 14 of the 17 cases. These authors also found that laparoscopic cases performed with or without the robot did not differ significantly in terms of setup or breakdown time. In a blind study comparing the AESOP robot to human laparoscope holders, Kavoussi et al. found that the AESOP robot made significantly fewer inadvertent movements and rotations and came into contact with other instruments or adjacent organs a significantly fewer number of times than human assistants. 4 The next generation of robots to hold laparoscopic instruments will be more intelligent. They will be designed with voice recognition and will respond to the surgeon's vocal commands. Such robots may also be designed to recognize specific images such as the tip of a laparoscopic instrument. Using such a system, the surgeon holds the tip of the instrument in the field of interest and instructs the robot to center the image around the tip, bringing the field of interest into center view. Future designs may incorporate retinal motion detectors that track the movements of the surgeon's eyes, obviating the need for the surgeon to provide verbal commands. Telepresence Surgery As the term implies, telepresence brings the surgeon via global telecommunications from a remote location to the operative site to participate in a surgical procedure. The implementation of telepresence systems would improve patient access to specialty care and consultation for difficult cases by obviating the need for travel by the patient to the surgeon. Such systems would also facilitate the introduction of novel procedures into the community and allow physicians to provide remote specialty health care to patients who live overseas or in rural areas, and to patients in outer space or on the battlefield. Ideally, complete operative information is transmitted to the surgeon at the remote site in real time, providing the surgeon with the perception of actually being present at the operative site. At the most basic level, the task of the surgeon at the remote site may be to perform a consultation with a patient or to advise a less experienced surgeon during a procedure (telementoring) by giving instructions or recommendations via the telepresence system. The surgeons at the remote and surgical sites may communicate by verbal or written means. For example, the advisor at the remote site can speak directly to the surgeon and simultaneously draw an arrow on the video screen in order to indicate where the surgeon at the operative site should dissect or cut (telestration). At the next level of complexity for telepresence surgery, the surgeon (master) works at a computer workstation at the remote site and controls one or more robotic manipulators (slaves) at the operative site that perform or assist in the procedure. The potential applications for such systems include not only telementoring but also performing surgery on patients in very distant or potentially dangerous locations such as outer space or on the battlefield. Kavoussi et al. evaluated the use of a telepresence operative system in laparoscopic urologic surgery 3 (Fig. 134-3). In this study, a remote surgeon, who operated the robotically controlled laparoscope via a control pad, telementored an inexperienced primary surgeon and assistant as they performed a laparoscopic nephrectomy, cholecystectomy, and splenectomy in a swine model. A similar arrangement was then utilized to perform laparoscopic procedures in three human patients including a laparoscopic cholecystectomy, varix ligation, and bladder neck suspension. All of the procedures were performed successfully with the aid of the telementoring system.

FIG. 134-3. A laparoscopic telementoring system.

Moore et al. evaluated the feasibility of telementoring in a series of 23 laparoscopic urologic procedures including nephrectomy, bladder neck suspension, and pelvic lymphadenectomy.5 Experienced remote surgeons telementored inexperienced laparoscopic surgeons using real-time video images, a two-way audio communication system, a remotely controlled AESOP robot laparoscope holder, and a telestration system. The remote site and the operating room were in adjacent buildings connected via a hard-wired system. These authors found that telementoring allowed the procedures to be performed successfully in 22 of the 23 cases (96%). When the telementored cases were compared to matched procedures in which the experienced surgeon worked side by side with the inexperienced surgeon, telementoring resulted in longer operative times for complex cases. However, there were no differences in terms of complication rate, postoperative analgesic requirement, length of hospital stay, or number of days to full activity. These authors concluded that telementoring is safe, feasible, and may be useful in surgical training. Schulam et al. employed a similar telementoring system linking two sites separated by approximately 3.5 miles via an existing telephone line. 11 All seven laparoscopic urologic procedures were performed successfully with this system. This study demonstrated that, using current technology such as personal computers and a single high-bandwidth telecommunications link, an effective and safe telementoring system is feasible even today. There are currently highly complex prototype telepresence surgery systems that have been used successfully in ex vivo and animal models. Green et al. have designed a telepresence surgery system that allows open surgery to be performed from a remote site. 2 The patient and robots are positioned and the operative field is prepared by a technician at the surgical site. The surgeon sits at a remote workstation and manipulates instruments that are interfaced with a computer system that controls the robots at the operative site. These dexterous robots, with 6 degrees of freedom, hold and manipulate the instruments that actually perform the surgery. A pair of CCD video cameras at the operative site provides the surgeon with three-dimensional vision that is displayed in real time at the remote site on a 120-frame-per-second stereographic video monitor with a liquid crystal shutter. The instrument hand controllers are designed with responsive, force-reflecting servomotors that provide the surgeon with force and tactile feedback. With these features, for example, the surgeon can feel resistance as a needle is driven through tissues or as a vessel is cut with scissors. The surgeon communicates verbally with the surgical assistant and nurses at the operative site via two-way audio channels. Experiments have demonstrated that this telepresence system provides sufficient dexterity to slice a grape into 1-mm sections. Simple ex vivo and in vivo animal

experiments have been performed successfully using this system. The Zeus Telepresence Surgery System (Computer Motion, Inc., Goletas, CA) is another working prototype system that was designed specifically to allow surgeons to perform remote laparoscopic surgery 12 (Fig. 134-4). Again, the operative field is prepared by a technician at the operative site. The technician places the laparoscopic ports and positions the robots, laparoscope, and instruments. The surgeon operates from the remote workstation and is provided with a two-dimensional laparoscopic view of the operative field. The human–machine interface consists of instrument handles manipulated by the surgeon that control dexterous robotic manipulators at the operative site. This system has been used successfully in ex vivo laparoscopic surgery on animal viscera.

FIG. 134-4. A laparoscopic telepresence surgery system. Flexible ureteroscopy simulator. (Courtesy of HT Medical, Rockville, MD.)

Telepresence surgery has the potential to vastly improve surgical techniques in the future. Because the robot mimics the surgeon's movements and can potentially be programmed to reduce large, tremulous movements into fine, smooth motions, telesurgery could become invaluable for performing microsurgical procedures. Indeed, NASA's Jet Propulsion Laboratory has developed a robot that can scale down movements by a factor of up to 100:1. 10 These advances are a prelude to the possibility of someday performing complex surgery at the cellular or nuclear level. Virtual Reality The concept of virtual reality involves the creation of an artificial site in cyberspace that appears via human–computer interfaces to be so convincing that it approaches reality. Participants enter an imaginary three-dimensional world in which they can move around and interact with the environment. Although most current virtual reality systems have been designed primarily for entertainment, one of the most successful applications of such technology is the flight simulator. Pilots and astronauts practice taking off, flying, and landing on such simulators and, perhaps more importantly, they learn how to react to adverse situations before they are encountered in actual flight. Current virtual reality surgical systems are simulators intended to be used as training devices as well. Because of technological limitations, however, these systems often provide cartoon-like video images that often do not appear to be realistic. High Techsplanations (HT Medical, Inc., Rockville, MD) has been at the forefront of virtual reality medical and surgical simulation technology. This company employs supercomputers to simulate real-time procedures such as subclavian line placement, cardiac catheterization, and bronchoscopy. HT Medical has developed a real-time laparoscopic pelvic lymph node dissection simulator. A pair of laparoscopic instrument handles are used to perform the procedure in which deformable soft tissue structures such as blood vessels can be grasped, manipulated, or cut. HT Medical has also recently developed a virtual reality system that allows urologists to practice flexible ureteroscopy ( Fig. 134-5). The human–computer interface is a small, flexible ureteroscope that can be advanced into a black box. The surgeon watches a video image of the view from the tip of the ureteroscope as it is advanced through the ureter and into the intrarenal collecting system. A deflection mechanism provides the surgeon the ability to manipulate the tip of the ureteroscope into each of the calyces where stones, intrarenal tumors, and air bubbles may be seen.

FIG. 134-5. Prototype of virtual reality technology that can be used with a ureteroscope (courtesy of HT Medical, Inc., Rockville, MD).

The next generation of virtual reality systems will not only provide more accurate detail, but they will also become significantly more interactive. Very high-resolution three-dimensional images will be displayed with smooth and life-like motion. Pulsating vessels will bleed when cut and tissue planes can be bluntly dissected. The surgeon will experience tactile sensation and force feedback. The purpose of virtual reality surgical simulators is to provide surgical residents with practical operative experience, just as pilots and astronauts learn to fly on sophisticated flight simulators today. They will also learn how to cope with adverse situations such as intraabdominal bleeding and renal lacerations in cyberspace prior to confronting them in actual situations. Future surgeons may also be tested on such virtual reality systems in order to demonstrate a certain level of technical proficiency for certification purposes.

CONCLUSION Robots, telepresence, and virtual reality are evolving technologies that will continue to become integrated into surgical practice. Continued improvements in telecommunications and computer technology are vital for the continued development of these disciplines. With increasing speed and volume of data transmission, computer graphics for virtual reality systems will improve dramatically. Not only will images be significantly more life-like, but movements will be rapid and smooth. More sophisticated human–machine interfaces will allow robots to follow surgeons' commands more faithfully and to dampen or filter out unintentional movements such as tremors. The cost of such systems will fall dramatically as their use becomes widespread and as the necessary technology becomes widely available. With increasing sophistication and resolution of non-invasive imaging modalities, three-dimensional digital images from CT, MRI, or ultrasound may be integrated onto the surgeon's real-time video image in order to provide the surgeon with a greater intraoperative understanding of anatomic and pathologic detail. This would essentially be a detailed, superimposed road map for the surgeon and robot to follow. With increasing sophistication in both software and hardware, robots will gain increasing independence until perhaps someday much of a procedure will be performed by robots independently, with the role of the surgeon focusing on surgical indications and monitoring the progress and safety of the procedure. Indeed, through continued development of nanotechnology and micromachines, robots may one day be miniaturized to the point where automated microrobots with built-in end effectors can be placed into the body and directed to the site of pathology where surgery is performed at the cellular level. CHAPTER REFERENCES 1. Bzostek A, Schreiner S, Barnes A, et al. An automated system for precise percutaneous access of the renal collecting system. Unpublished data, 1996.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Green P, Satava R, Hill J, Simon I. Telepresence: advanced teleoperator technology for minimally invasive surgery (Abstract). Surg Endosc 1992;6:91. Kavoussi LR, Moore RG, Partin AW, Bender JS, Zenilman ME, Satava RM. Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience. Urology 1994;44:15. Kavoussi LR, Moore RG, Adams JB, Partin AW. Comparison of robotic versus human laparoscopic camera control. J Urol 1995;154:2134. Moore RG, Adams JB, Partin AW, Docimo SG, Kavoussi LR. Telementoring of laparoscopic procedures: initial clinical experience. Surg Endosc 1996;10:107. Nathan MS, Davies B, Hibberd R, Wickham JEA. Devices for automated resection of the prostate. Proc First Int Symp MRCAS. Pittsburgh, 1994;342–344. Partin AW, Adams JB, Moore RG, Kavoussi LR. Complete robot-assisted laparoscopic urologic surgery: a preliminary report. J Am Coll Surg 1995;181:552. Potamianos P, Davies BL, Hibberd RD. Intraoperative registration for percutaneous surgery. Proc 2nd Int Symp Med Rob Comput Assist Surg 1995;156. Sackier JM, Wang Y. Robotically assisted laparoscopic surgery. Surg Endosc 1994;8:63. Satava RM. Robotics, telepresence, and virtual reality: a critical analysis of the future of surgery. Min Inv Ther 1992;1:357. Schulam PG, Docimo SG, Saleh W, Breitenbach C, Moore RG, Kavoussi LR. Telesurgical mentoring: Initial clinical experience. Surg. Endosc 1997;11:1001–1005. Wang Y. Zeus Telepresence Surgery System. Computer Motion, Inc., Goletas, CA, personal communication, 1996.

Chapter 135 Cryosurgical Ablation of the Prostate Glenn’s Urologic Surgery

Chapter 135 Cryosurgical Ablation of the Prostate Harry S. Clarke

H. S. Clarke: Division of Urology, Emory University School of Medicine, Atlanta, Georgia 30322.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Cryosurgical ablation of the prostate was first investigated more than 30 years ago. The initial approach was transurethral freezing reported by Gonder, Soans, and Smith in which the indications for cryoablation was prostatic obstruction either from benign prostatic hyperplasia or adenocarcinoma. 3 From these initial studies, Flocks et al. developed a treatment of prostate cancer, utilizing a perineal approach. 2 Once the prostate was isolated in the surgical field, the cryoprobes were inserted and freezing was accomplished by the circulation of liquid nitrogen through the hollow probes. The procedure was open and the extent of freezing required was determined by direct visual inspection. While the 10-year survival was similar stage for stage with both radiation therapy and radical prostatectomy, the procedure was largely abandoned due to the technical difficulties and the complications encountered. 1 There was no accurate means of assessing the extent of freezing and patients suffered the consequences of thermal injury to the bladder, ureters, and rectum. Further reports on outflow obstruction due to sloughing of necrotic debris, urinary tract infection, hemorrhagic cystitis, and urethrocutaneous fistulas severely dampened the initial enthusiasm for this therapy as a means of treating the elderly and poor-risk surgical candidate. Cryosurgery for the treatment of prostate cancer has currently received renewed enthusiasm due in large part to the technological advances that have allowed circumvention of the morbidity previously described. The significant innovations included a new liquid nitrogen delivery system, which allows the delivery of super cooled liquid nitrogen or argon gas through small (3-mm) probes; percutaneous access technique; and the ability to evaluate the extent of freezing by transrectal ultrasound imaging.4

DIAGNOSIS The diagnosis of prostate cancer is made by direct biopsy of the prostate, usually under ultrasound guidance. This is covered more extensively in Chapter 36.

INDICATIONS FOR SURGERY The ideal candidate for cryosurgical ablation of the prostate is an individual with local recurrence after treatment with radiation therapy because there is no other successful definitive therapy, other than palliation, for these patients. Other patients without prior treatment for T1 to T3 prostate cancer may also benefit from this therapy; however, these patients should be well informed of the investigational nature of this procedure and it should be done only in the setting of a properly controlled study.

ALTERNATIVE THERAPY Alternatives to cryotherapy include observation, hormonal deprivation, radiation therapy (in patients who have not had prior radiation), and radical prostatectomy. In patients who have had prior radiation therapy, neither additional radiation nor radical prostatectomy is generally indicated. Salvage prostatectomy in our institution was associated with no patient having an undetectable prostate-specific antigen (PSA) beyond 18 months and a 75% rate of incontinence.

SURGICAL TECHNIQUE The technique of the procedure as initially described by Onik et al. begins with the establishment of suprapubic drainage via a punch using a nephrostomy tube with a coil on one end, guided by flexible cystoscopy. 4 A guidewire is inserted through the flexible cystoscope and the cystoscope is removed. A urethral warming catheter is then inserted over the guidewire, and the guidewire is removed. The warming catheter is connected to inflow and outflow tubing from a fluid pump that circulates normal saline for urethral warming at 44°C. A Bookwalter retractor is attached to the table at the patient's right side. The large ring is used to hold the flexible cystoscope and for support of loose guidewire ends and the cryoprobes, so that they do not have to be hand-held during application of the energy. The scrotum is elevated utilizing a gauze sling stapled in position and then secured to the retractor as well. Attention is then directed to the ultrasound machine. This begins with testing of the alignment to assure coordination between the needle guide and the screen guideline in a pan of water. The sonographic probe is inserted into the rectum, and the gland is examined in transaxial and longitudinal views. Five needles are inserted sequentially percutaneously in the perineum, two anterolaterally, two posterolaterally, and one posterior to the urethra under sonographic guidance (Fig. 135-1). Each needle is visualized first in the transaxial plane until it penetrates the scan plane about midprostate. The view is then switched to longitudinal, and the needle is advanced to the cephalad margin of the gland. A guidewire is then advanced through the needle until its floppy end can be visualized at the cephalad tip of the needle. The needle is then withdrawn and the skin is incised with a fascial incisor needle that slides over the guidewire.

FIG. 135-1. Placement of the needles for cryoablation of the prostate.

Once the skin is incised, a fascial dilator with the proximal end split for about 4 cm is then inserted over the guidewire to dilate the channel. A small amount of saline is then injected with a syringe and a spinal needle into the dilator channel in order to facilitate its visibility with ultrasound. The guidewire is removed, and the cryoprobe is inserted to the cephalad most part of the dilator, and the dilator is then pulled back using the split in its proximal end, leaving the cryoprobe in direct contact with the tissue. The cryoprobe is then turned on at –70°C in order to “stick” the probe to the tissue and the remaining four probes are inserted in similar fashion, taking care to

insert the anterior probes first, in order not to have shadowing from the posterior probes. Figure 135-2 is a transaxied view of the prostate with the fine cryoprobes and urethral warmer in position. Each cryoprobe is supported from the retractor ring by a rubber strap (a urinary leg bag strap), and after all have been inserted, they are tied together with an opened 4 × 4 sponge to keep them from moving. Figure 135-3 is a photograph of a patient with the probes in position secured to the buckwatter retractor.

FIG. 135-2. Ultrasonographic image of prostate with cryoprobes (p) in position, two anterior and three posterior. The urethra is shown in the center (u).

FIG. 135-3. A patient with probes in position secured to the buckwatter retractor.

The anterior cryoprobes are turned on first, taking the temperature down to about –190°C, and formation of the ice ball is monitored easily as a very hyperechoic acoustic interface line that develops at the junction of the ice ball and the unfrozen tissue. As the line progresses posteriorly, the two posterolateral probes are turned on, and further progress of the ice ball toward the rectum can be monitored with precision. Last, the probe posterior to the urethra is turned on. When the freezing process is complete, with care taken to monitor progression of the ice ball toward the rectum very carefully, the cryoprobes are turned off and the tissue is allowed to thaw. Once thawed a second freeze is performed in the same fashion as the first. The active portion of the cryoprobe extends from the tip up the probe for 4 cm. If the prostate length is greater than this, then the cryoprobes once thawed are pulled back the appropriate length to cover the untreated area and the freezing sequence is repeated to cover this tissue at the apex. Similarly the diameter of the active freeze zone for each cryoprobe is 4 cm, and care must be taken to ensure that there is adequate overlap of the freeze zones of the five probes to guarantee complete freezing of the entire prostate gland. The seminal vesicles can be treated by insertion of cryoprobes directly into those structures. Care must be taken to avoid freezing the distal ureter when this is done. Additional probes can be placed as needed for larger prostate glands. Thermocouples may be placed at the level of the neurovascular bundle on either side and at the level of Demonulli's fuscia in the suburethral area to monitor the temperature as the ice ball advances. After thawing is complete, the cryoprobes are removed along with the sheaths. Gentle pressure is applied to the perineum for 5 minutes to prevent hematoma formation. Each perineal puncture is closed with a stitch of 3-0 chromic suture. The urethral warming catheter is then removed as the last step in the procedure. The procedure is carried out under general or regional anesthesia. The patient goes home on the first postoperative day with the suprapubic tube in place. He is instructed to clamp the suprapubic tube after 1 week for a trial of voiding, and the tube is removed when the residual urine falls below 100 cm 3. There is almost always some scrotal and perineal edema and ecchymosis, but this resolves spontaneously in all patients.

OUTCOMES Complications In addition to the edema and ecchymosis encountered by all patients undergoing cryoablation of the prostate, many will experience some sloughing of urethral tissue. This comes out as a rather fine and homogeneous material, and in most instances with the use of the urethral warming device it does not cause obstruction. If significant obstruction does occur it can usually be managed with a period of intermittent catheterization, but in some instances it may require transurethral resection of necrotic material. If resection is necessary, then care must be taken to avoid resection of distal viable tissue as incontinence may ensue. Incontinence has been reported in as many as 5% of patients after cryoablation. The majority of this resolves without intervention in most patients. Urinary tract infection, both with typical urinary tract pathogens as well as some less typical organisms, such as Staphylococcus epidermidis and Candida albicans, have been reported, especially in patients who are experiencing significant amounts of sloughing of urethral tissue. Treatment with the appropriate antibiotics rapidly resolves these infections and the accompanying symptoms. The occurrence of urethrorectal fistula is less than 1%. The first symptom of this may be some mild watery diarrhea. This may be managed conservatively with several weeks of Foley catheter drainage being all that is required. More significant fistulas may require laparoscopic diversion and primary repair. Impotence has been reported in patients undergoing cryoablation; however, this has not been well established or studied in a series of men with documented potency prior to undergoing the procedure. Results When cryoablation has been successfully performed, the PSA in patients drops rapidly to the undetectable level (less than 0.1) and remains there. Those patients whose PSA does not nadir to the undetectable range often will have positive biopsies, or the presence of persistent benign glands in their biopsy specimens, and will have subsequent rises in their PSA and positive biopsies at a later date. Should this be the case, the patient may have the procedure repeated, undergo teletherapy, or undergo radical prostatectomy in some instances. The results of cryoablation of the prostate, while short term, have been very promising. The majority of centers performing the procedure report similar results, with negative biopsy results of 70% to 80% 6 months after the procedure. The results have held up with similar findings on subsequent biopsies at 2 and 3 years. The

longest current follow-up is just now approaching 5 years, and further studies will be pivotal in determining the long-term utility of this procedure. CHAPTER REFERENCES 1. 2. 3. 4.

Bonney WW, Fallon B, Gerber WI. Cryosurgery in prostatic cancer: survival. Urology 1982;19:37–42. Flocks R, Nelson C, Boatman D. Perineal cryosurgery for prostatic carcinoma. J Urol 1972;108:933–935. Gonder MJ, Soanes WA, Smith V. Experimental prostate cryosurgery. Invest Urol 1964;1:610–619. Onik GM, Cohen JK, Reyes GD, Rubinsky B, Chang ZH, Baust J. Transrectal ultrasound–guided percutaneous radical cryosurgical ablation of the prostate. Cancer 1993;72:1291–1299.

Chapter 136 Transurethral Microwave Thermotherapy Glenn’s Urologic Surgery

Chapter 136 Transurethral Microwave Thermotherapy Aaron P. Perlmutter

A. P. Perlmutter: Brady Prostate Center, Department of Urology, New York Hospital–Cornell Medical Center, New York, New York 10021.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Pretreatment Considerations Treatment Posttreatment Outcomes Complications Results Chapter References

Transurethral microwave thermotherapy is a treatment for symptomatic benign prostatic hyperplasia (BPH). This noncancerous enlargement of the prostate gland can begin as early as 30 years of age, is histologically identifiable in half of men age 60, and approaches 90% by age 85. However, the prevalence of clinical symptomatic BPH has been estimated at approximately 40% over age 60. The risk factors for development of symptomatic BPH include increasing age, the presence of androgens, and family history. Simplistically, the enlargement of the periurethral transition zone tissue creates a physical obstruction to urine flow, and this increase in outflow resistance results in changes in bladder function that are noticed by the patient. However, the pathophysiologic interactions are not well understood and are most likely multifactorial because there is poor correlation between prostate size, the severity of symptoms, and the urodynamic determination of obstruction. The sequelae of the natural history of untreated BPH include the following: Urinary retention Upper tract deterioration Bladder calculi Recurrent infections Gross hematuria However, the cumulative occurrence of these events during 3 to 5 years of observation is at most 10%. 2,10 Treatment of BPH is usually initiated because of the bothersome obstructive and irritative symptoms that interrupt normal daytime lifestyle patterns and reduce sleep. It is in the area of improvement of symptoms caused by prostatic outflow obstruction that transurethral microwave thermotherapy has had its greatest impact.

DIAGNOSIS BPH describes a histologic process, and this process can create bladder outflow obstruction (BOO). The patient usually seeks treatment for lower urinary tract symptoms (LUTS). The diagnosis of BPH is the means that connects this growth process to the symptoms of voiding dysfunction experienced by the patient. The diagnosis of BPH is made by history, physical examination, and symptom score assessment. The examination allows for palpation of a distended bladder and for detection of an enlarged or abnormal prostate. Interestingly, patients with BPH by exam and symptoms only have urodynamic proven BOO 60% to 70% of the time. 1 Urine flowmetry, residual urine volume, and imaging are sometimes used as adjunctive tests. Bladder pressure–flow studies provide the most definitive diagnosis. Although urethrocystoscopy is not necessary for the diagnosis of BPH, it identifies patients with intravesical middle lobes, high median bars, bladder neck stenosis, and very asymmetric prostates. Urethrocystoscopy is indicated in the pretreatment evaluation for transurethral thermotherapy since the above subgroups are unlikely to respond to treatment. Not all patients empirically treated with symptomatic prostatism have BOO from BPH. There are patients with the symptoms of “prostatism” without bladder outlet obstruction from BPH (i.e., neurologic diseases, primary bladder diseases, or urethral stricture), and there is a subset of patients with histologic BPH and obstruction who are without symptoms (“silent prostatism”). In order to maximize the likelihood that a patient will respond to transurethral microwave thermotherapy, nonprostatic causes of LUTS should be excluded.

INDICATIONS FOR SURGERY Transurethral thermotherapy is indicated for the treatment of symptomatic prostatic outflow obstruction. The goal of the treatment is heat-mediated alteration of the adenoma, which results in a decrease in symptomatology and, depending on the temperatures achieved, a decrease in outflow obstruction through tissue necrosis. 6,8 Patients with urinary retention, upper tract deterioration, bladder calculi, and recurrent infections or gross hematuria are better treated with surgical prostatectomy. The most commonly presenting patient for transurethral thermotherapy is a man with symptomatic prostatism who wishes to avoid prostatectomy and has had either no response or an adverse response to medical therapy, or does not wish to take medication on a regular basis. Because the microwave antenna must be safely located in the prostatic fossa, there are certain prostatic size and shape criteria for safe treatment. A intravesical middle lobe or high median bar has the tendency to displace the catheter balloon away from the bladder neck, thus moving the antenna away from proper placement in the middle of the fossa. In addition, the prostatic urethral length must be sufficient to safely accommodate the antenna and the lateral lobes must be of sufficient thickness to safely contain the heat. Manufacturer recommendations vary, but in general the bladder neck to verumontanum length should be at least 3 cm and the total prostatic volume greater than 25 cm 3. Most studies have excluded patients with prostatic volumes greater than 100 cm 3; therefore outcome data in this size range are limited and many investigators consider this to be a relative contraindication. Although bladder neck treatment is generally avoided and thus antegrade ejaculation usually maintained, there can be coagulative necrosis of the ejaculatory ducts and patients should be counseled accordingly. Anticoagulated patients have been safely treated. There is little experience treating patients with previous pelvic irradiation. The radiation-induced cellular changes will likely alter the response to the microwave treatment, and the safety and efficacy are unknown. Exclusion criteria related to the treatment manipulation and microwave and heat safety are listed in Table 136-1.

TABLE 136-1. Patient selection for transurethral microwave thermotherapy

ALTERNATIVE THERAPY Transurethral microwave thermotherapy is a new, minimally invasive therapy for the treatment of BPH. The goal of such a therapy is to provide symptom improvement without the hospitalization and side effects from transurethral prostatectomy (TURP). Transurethral thermotherapy occupies a unique niche because of its ability to treat symptomatic BPH in an office setting without the need for general or regional anesthesia. Using local anesthesia, the procedure can be performed in approximately 1 hour requiring only flexible instrumentation. Other new minimally invasive therapies that require rigid endoscopy and slightly more patient discomfort include prostatic stents and radiofrequency transurethral needle ablation. These procedures generally require more anesthesia than transurethral thermotherapy. The role for prostatic stenting is more limited than transurethral thermotherapy, and the outcome data for transurethral needle ablation are not as mature as those for transurethral thermotherapy. Two surgical approaches that require at least regional anesthesia but have much less morbidity than TURP are laser prostatectomy and transurethral incision of the prostate (TUIP). Laser prostatectomy retains the efficacy of TURP, although the onset of symptom improvement is not as rapid. TUIP is limited to prostate volumes less than 30 cm3 and may cause bleeding.

SURGICAL TECHNIQUE The major transurethral thermotherapy devices currently in use include: The Prostatron (EDAP Technomed, Cambridge, MA) The T3 (Urologix Inc, Minneapolis, MN) The Urowave (Dornier MedTech, Marietta, GA) The Prostatron obtained FDA clearance for use in the United States in October 1996; FDA approval for the T3 and Urowave is currently pending. The devices differ in microwave antenna design, irradiation wavelength, wattage generated, and target temperatures. Like lithotriptors, since these different devices vary, one should be chosen after the details of the specific strengths and weaknesses are appreciated. A schematic of a thermotherapy unit and the treatment catheter is shown in Fig. 136-1. The sophisticated nature of this system is mandated by safety considerations and differences in prostate size and configuration, tissue characteristics, and tissue vascularity from patient to patient. Varying amounts of energy may be needed in different patients to generate and maintain the same temperatures.

FIG. 136-1. (A) Each device used for microwave treatment of the prostate has several basic components. A power generator is responsible for microwave emission. A coaxial cable within the treatment applicator serves as the microwave antenna, and an impedance matching network allows for efficient transfer of power from generator to antenna. In addition, a thermometry system allows for the monitoring of temperatures attained during treatment. These components are coordinated by a central computer control system that allows for the maintenance of an integrated system in which power delivered to the prostate may be regulated by temperature feedback. (B) An enlarged view of the intraprostatic placement of the microwave antenna and an idealized heating pattern.

Transurethral thermotherapy is applied by a microwave antenna located in the intraprostatic portion of a modified urethral catheter. The microwave power delivered, maximum urethral and rectal temperatures allowed, and treatment time are determined by the software provided with the device by the manufacturer. When the software program is initiated after proper catheter placement, the heating occurs automatically. The heating results from computer-controlled stepwise increases in power until a maximum power limit is reached or the machine resets because a safety temperature limit is reached in the urethra or rectum. Thermotherapy requires temperatures of greater than 45°C, and all software programs are designed to reach this temperature threshold. Some devices and softwares are able to reach the 50° to 60°C range; this is typical of Prostasoft 2.5 for the Prostatron and is referred to as higher temperature software. These higher temperatures are aimed to create actual cavitation in the prostatic urethra. The responsibilities of the surgeon include patient selection, pretreatment patient preparation, the treatment itself including catheter placement monitoring, and posttreatment management of voiding. Pretreatment Considerations In addition to the above-mentioned selection criteria, other patient characteristics have been identified which allow the selection of a patient most likely to benefit from transurethral microwave thermotherapy. 7 Once a patient elects transurethral thermotherapy, sterile urine is verified prior to treatment. The patient is instructed to use an enema at home before coming for the therapy because the rectal thermosensor can be uncomfortable if the rectal vault contains stool. In addition, the patient is asked to restrict fluid intake the day of the therapy because many of the thermotherapy catheters do not drain, and if the bladder becomes uncomfortably distended during treatment, the treatment might need to be aborted to drain the bladder. Treatment When the patient arrives for the office treatment, an oral antibiotic is administered. The use of pain medication and sedation depends on the temperature limit of the software being used and the temperament of the patient. Even with the lower temperature softwares, the patient perceives the need to void often with a sensation of urge. Oral Valium, Ativan, or Restoril are commonly used to reduce patient anxiety and discomfort. Since many patients experience bladder spasms during the treatment, a rapidly absorbed sublingual anticholinergic can be routinely given before therapy or be available for postprandial dosing. If a higher temperature software program is used, then more anesthesia and a monitored setting may by required. Most patients find that the 1-hour treatment time is easier if a headset for music or a television screen is available for distraction. The patient is placed in a dorsal lithotomy position and sterilely prepped in the same manner as for cystoscopy. This allows use of transrectal sonography to verify catheter placement and the placement of transperineal thermosensors in the research setting. Depending on the device being used, the supine treatment can be used. Lidocaine jelly, 2%, is instilled per urethra and left indwelling for 5 to 10 minutes. A small catheter is passed to drain the bladder completely. The treatment catheter is then passed into the bladder and the anchor balloon is inflated. Since some of these catheters can be stiff, it is helpful to observe the catheter pass through the prostate using transrectal ultrasound. This also allows visualization when the balloon is inflated, and can verify that the catheter is properly positioned and the balloon is at the bladder neck. Balloon placement can also be confirmed by transvesical ultrasound if preferred. The catheter, with the anchor balloon against the bladder neck, is taped in place to prevent migration during the procedure.

The rectal thermosensors are then placed and secured if necessary to the drapes, and the device tested and connected as per the manufacturer instructions. The therapy software is then initiated. The software program will then test all components and automatically perform the treatment. Monitoring during the procedure is important for safety. Patient movements can cause catheter migration, and the catheter can be visually inspected and a transvesical ultrasound can verify balloon placement. Although the devices have many internal safety features, the temperature profiles should be monitored. Sudden patient pain should raise the possibility of a problem and the surgical field should be inspected. Some bleeding around the catheter is normal for some of the devices. At the termination of the procedure, the treatment catheter and other monitoring equipment are removed. If a software program has been used that will likely result in urinary retention, then a Foley catheter is left and the patient discharged with a leg bag. Depending on the software, most patients are ready to void in 3 to 5 days. This seems to be dependent on prostate size, and patients with prostate volumes greater the 50 cm 3 may require 5 to 7 days. This is dependent on the software and temperatures achieved, and each surgeon eventually develops a workable algorithm. Patients discharged with indwelling urethral catheters often have bladder spasms that respond to oral anticholinergic medication. Posttreatment Patients discharged without a catheter usually take oral antibiotics for 3 more days. Since there is edema in the prostatic fossa, the use of alpha blockade, if tolerated by the patients, can be beneficial for the first few postprocedure weeks. Acetaminophen is sufficient for the small number of patients who complain of discomfort. Many patients notice a worsening of symptoms for several weeks until there is improvement. Persistently worse symptoms should prompt an office visit with a postvoid residual determination and urine culture. Unexplained symptoms at 3 to 6 months that have not resolved should prompt a cystoscopy. Even at this time period after treatment, depending on the temperatures achieved, necrotic tissue may be present in the prostatic fossa.

OUTCOMES Complications One of the great advantages of transurethral microwave thermotherapy is the low incidence of complications. Some events are dependent on the energy dose delivered. Whereas urinary retention is expected in up to 25% of those treated with lower temperature software, it is universal in those treated with high-temperature software.6 Table 136-2 summarizes the range of post treatment events reported in sham controlled studies ( n = 335) using the Prostasoft 2.0 (lower temperature) for the Prostatron, Urowave, and the T3. 3,4 and 5,9 These procedures can be performed in the office using local anesthesia. Common TURP events including transfusion, bladder neck contracture, and retrograde ejaculation were absent.

TABLE 136-2. Transurethral thermotherapy outcomes

Results The results of new therapies are usually measured by changes in voiding symptoms and peak urinary flow rate. These values are reported means; therefore, some patients have minimal response, whereas others are above the mean. It is difficult to obtain an accurate indication, but reported studies indicate that between 6% and 12% of patients treated with the Prostasoft 2.0, T3, or the Urowave find no improvement in symptom score, and between 16% and 23% have no flow rate improvement. Therefore, there is a group of patients who will undergo the treatment without improvement and may be worse. Blute has reported that 1527 patients, 3 months after treatment with the Prostasoft 2.0, found a 61% (13.2 to 5.2) improvement in Madsen symptom score and a 41% (9.2 to 12.9 cm 3/sec) improvement in flow rate.4 Although the response is durable for many patients, there is a decrease of effect with time. For up to 4 years after treatment, 52% of patients required no further treatment; 36% had added medical therapy; and 11% required TURP. 4 The end of the 1990s will bring new technological improvements to transurethral microwave thermotherapy. Catheter design changes will allow better energy direction and deposition. Means for temperature monitoring will allow better dosimetry. This office-based therapy for BPH, first used clinically by Devonec and his colleagues in 1989, offers a very good chance of durable symptom relief for the patient with prostatism with a low chance of complications. CHAPTER REFERENCES 1. Abrams P. Objective evaluation of bladder outlet obstruction. Br J Urol 1995;76:11–16. 2. Ball AJ, Feneley RCL, Abrams PH. The natural history of untreated prostatism. Br J Urol 1981;53:613–616. 3. Blute ML, Bruskewitz R, Larsen TR, Mayer R, Utz W. U.S. multi-center randomized trial of a new high temperature office-based microwave system (T3) for the treatment of BPH. J Urol 1996;155:708A. 4. Blute ML, de Wildt M. Transurethral microwave thermotherapy for BPH. Contemp Urol 1996;Oct:66–80. 5. Blute ML, Patterson DE, Segura JW, Tomera KM, Hellerstein DK. Transurethral microwave thermotherapy v sham treatment: double-blind randomized study. J Endourol 1996;10:565573. 6. de la Rosette JJMCH, de Wildt MJAM, Hofner K, et al. Pressure-flow study analysis in patients treated with high energy thermotherapy. J Urol 1996;156:1428–1433. 7. de Wildt MJAM, Tubaro A, Hofner K, Carter SStC, de la Rosette JJMCH, Devonec M. Responders and nonresponders to transurethral microwave thermotherapy: a multicenter retrospective analysis. J Urol 1995;154:1775–1778. 8. Larsen TR, Bostwick DG, Corica A. Temperature-controlled correlated histopathologic changes following microwave thermoablation of obstructive tissue in patients with BPH. Urology 1996;47:463–469. 9. Ogden CW, Reddy P, Johnson H, Ramsey JWA, Carter SStC. Sham versus transurethral microwave thermotherapy in patients with symptoms of benign prostatic bladder outflow obstruction. Lancet 1993;341:14–17. 10. Wasson JH, Read DJ, Bruskewitz RC, et al. A comparison of transurethral surgery and watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med 1995;332:75–79.

Chapter 137 Interstitial Laser Therapy of Benign Prostatic Hyperplasia Glenn’s Urologic Surgery

Chapter 137 Interstitial Laser Therapy of Benign Prostatic Hyperplasia Rolf Muschter

R. Muschter: Department of Urology, Grosshadern Hospital of Ludwig-Maximilians University of Munich, D-83177 Munich, Germany.

Diagnosis Indications for Surgery Alternative Therapy Surgical Technique Outcomes Complications Results Chapter References

Interstitial laser coagulation (ILC) of benign prostatic hyperplasia (BPH) achieved with fibers specifically designed for this purpose was first mentioned by Hofstetter in 1991,3 with the basic experiments and initial clinical results published by Muschter et al. in 1992. 9 Since then, several variations and technical and procedural devel-opments have been introduced and tested in clinical trials 2,5,7,8,12,14 (Fig. 137-1).

FIG. 137-1. Interstitial laser coagulation of the prostate.

The objective of ILC of BPH is to achieve a marked volume reduction, and to decrease urethral obstruction and both obstructive and irritative symptoms. Coagulation necrosis is generated well inside the adenoma, rather than at its urethral surface. Because the applicator can be inserted as deeply and as often as necessary, it is possible to coagulate any amount of tissue at any desired location. Post-procedurally, the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes, rather than sloughing of necrotic tissue 6,7,8 and 9 (Fig. 137-1).

DIAGNOSIS The common diagnostic procedures usually required for transurethral resection of the prostate (TURP) are sufficient for ILC. Special radiologic or endoscopic examinations are not necessary. For monitoring the success of ILC during follow-up, American Urological Association (AUA) symptom score, and quality of life index, urinary flow rate, residual urine volume, and prostate volume should be measured before therapy. Pressure–flow studies can avoid treating patients with, for example, predominantly neurogenic bladder problems. ILC does not provide tissue for pathologic examination. Therefore, evaluation with digital rectal exam-ination and serum prostate-specific antigen level is essential. Patients presenting with active urinary tract infection, acute epididymitis, or acute prostatitis must be treated with appropriate antibiotics until complete recovery is achieved before having ILC.

INDICATIONS FOR SURGERY Candidates for ILC are all patients with moderate and severe voiding symptoms due to mechanical obstruction of the bladder outlet due to BPH who are otherwise candidates for surgical intervention, either transurethral or open. In principle, there is no limit to the prostate volume; the middle lobe can be treated too. Concomitant diseases, such as strictures of the urethra or bladder calculi, can be treated in the same session. Because ILC has essentially no major morbidity and can be performed with local anesthesia, even high-risk patients who are not candidates for TURP need not be excluded from treatment. Recurrent or residual BPH after previous prostate surgery, laser treatment, or microwave treatment can also be treated by ILC. Patients presenting with bladder cancer close to or at the bladder neck, or with possible invasion of the prostate, should not receive ILC. It is also contraindicated in cases of acute prostatitis or epididymitis and in the case of prostate abscess. Chronic prostatitis, however, which is frequently present in BPH patients, is no contraindication to ILC. Patients with symptomatic BPH who are suspected to have prostate cancer but not apt for curative treatment can be treated with ILC. If a curative therapy would be possible, however, screening biopsies should be done and examined before the planned laser treatment. If positive, these patients should not receive interstitial laser therapy.

ALTERNATIVE THERAPY ILC was initially designed as a treatment option for patients with BPH of a severe degree unfit for surgery as an alternative to life-long catheterization. 3,9 Due to the very promising results of the first series of such patients, the indication was expanded. 7,8 Today, ILC should be seen as an alternative to any surgical or minimally invasive procedure to treat BPH.

SURGICAL TECHNIQUE Because of their relatively deep penetration in water, efficient volumetric heating permitting necrotic temperatures deep into tissues, and the ability to be delivered with flexible optical fibers, neodymium/yttrium-aluminum-garnet (Nd:YAG) lasers (1064 nm) or diode lasers (approximately 800–1000 nm) are used for interstitial laser coagulation.9,10 and 11 Recent preliminary experiments demonstrated that the holmium-YAG (Ho:YAG) laser (2120 nm) is also suitable to generate interstitial lesions. Fibers employed for ILC must emit laser radiation at a relatively low power density. The currently most commonly used fiber emits the laser radiation circumferentially forward directed with a ring/cone-shaped beam profile (e.g., ITT Light Guide, Dornier, Germering, Germany and Kennesaw, GA; Fig. 137-2). Another type of fiber is a cylindrical diffuser tip emitting in all directions from the whole length of the applicator (e.g., Diffusor-Tip, Indigo, Cincinnati, OH; Fig. 137-3).

FIG. 137-2. Radiation pattern of the ITT Light Guide (Dornier, Germering, Germany and Kennesaw, GA) in water, laser fiber 600 microns, applicator 1.9 mm in diameter, 2 cm in length.

FIG. 137-3. Diffusor-Tip (Indigo, Cincinnati, OH); laser fiber 400 microns, applicator 2 mm in diameter, 2 cm in length, homogeneous diffuse radiation over 1 cm.

The optimal radiation parameters vary for different laser wavelength and applicator combinations. 10,11 Using constant laser power in the 5- to 7-W range, the maximal coagulation volume can be expected within approximately 10 minutes irradiation time without the risk of carbonization. 9 More rapid heating by using higher laser power reduces irradiation time but increases the risk of carbonization. 10 For short irradiation times, however, high powers are tolerable. In this type of laser energy application, irradiation starts with a relatively high power to rapidly heat the tissue and coagulate the blood vessels (e.g., 20 W for 30 seconds or 50 W for 10 seconds).7,12 The laser power is then reduced repeatedly to maintain the temperature in the center of the lesion at a high level just below the carbonization threshold and to allow further lesion growth ( Fig. 137-4, top). On-line temperature monitoring by use of an integrated thermocouple allows further optimization by use of a feedback control (Fig. 137-4, bottom).2 Optical feedback systems can also detect any carbonization. If this occurs at the applicator, laser irradiation is automatically terminated. This prevents overheating and therefore potential thermal fiber damage.

FIG. 137-4. (top) Standard irradiation program for ILC (for Nd:YAG laser and ITT Light Guide. (bottom) Various examples of possible laser power patterns in different individual applicator positions (for 830-mm diode laser and Diffusor-Tip.)

ILC can be performed with a local (e.g., periprostatic block), regional (e.g., spinal), or systemic (e.g., analgosedation) anesthetic. The procedure is suitable for the treatment of outpatients. ILC can be performed using the transurethral approach, in which the laser fiber is introduced from a cystoscope within the urethra, or the percutaneous (perineal) approach, in which the laser applicator is introduced through hollow needles in the perineum, guided by transrectal ultrasound. For the latter approach, an aiming device, as is used for the perineal placement of seeds for local radiation therapy of prostate cancer, is helpful. For penetrating the skin and guiding the fiber into position into the prostate, a special cannula large enough to accommodate the applicator is used. With an outer diameter of approximately 2.1 mm and sharpened tip, this cannula can be inserted without dilation. The commonly used transurethral ILC requires a rigid cystoscope with a working channel large enough to accommodate the fiber, which is usually between 5 and 6 Fr. The viewing angle of the telescope can be any in the range from 0 to 30 degrees. An ideal instrument has a small separate working channel that ends at the level of the telescope for optimal stabilization of the fiber during puncture ( Fig. 137-5). For cooling, continuous irrigation is not required throughout the procedure, but it will optimize visualization of the prostate and laser fiber.

FIG. 137-5. Standard cystoscope with special working element for interstitial laser coagulation for optimal fiber stabilization.

The goal of ILC is to treat a sufficient volume in each lateral lobe and in the median lobe (if needed) to produce therapeutic results while preserving healthy tissues. The total number of fiber placements is dictated by the total prostate volume and configuration. Any number of placements can be used. Generally it is better to treat one extra site than one too few. A general guideline would be a minimum of one to two applicator placements for each estimated 5 to 10 cm 3 of BPH tissue. Individual placements of the laser fiber can be spaced by about 0.5 to 1 cm and/or be performed at different angles and depths ( Fig. 137-6) to minimize substantial overlap of treatment volumes, which is not harmful but wastes time, but should be close enough that there are no gaps of untreated tissue. Fiber placement is basically limited by proximity of the produced treatment volume to the prostatic urethra, prostatic capsule, and points along the prostatic urethra distal to the bladder neck and proximal to the external sphincter.

FIG. 137-6. Scheme of possible applicator placements.

In general, the sites for fiber placement should be chosen where the mass or bulk of hyperplastic tissue is found. In the sagittal plane, fiber penetration should be in the direction of the urethra. With the patient in the lithotomy position, the direction of the prostatic urethra in most cases is approximately parallel to the operation table at the apex, turning ventrally near the bladder ( Fig. 137-7). Therefore in the apical zone it is best to puncture the lateral lobes at the 3 o'clock and 9 o'clock positions and penetrate parallel to the operation table. When closer to the bladder neck, it is suitable to penetrate more ventrally at the 2 o'clock and 10 o'clock positions. In larger prostates, multiple punctures at different fan-shaped angles are required.

FIG. 137-7. Applicator penetration orientations along the prostatic urethra.

In ILC, it is desired to preserve the urethra. If it is coagulated, however, ordinary tissue sloughing may occur and is not harmful (the treatment effect is then much like that of deep transurethral free beam coagulation). Avoiding coagulation of the urethra requires both a minimum depth and angle of fiber penetration. The applicator should be inserted at least to a depth of 0.5 cm beyond the irradiating part. In most types of applicators this corresponds to their proximal end or to a fiber depth marker. The fiber penetration angle in relation to the longitudinal axis of the urethra should be the maximum achievable. In the apical zone, this is approximately 30 to 40 degrees. Closer to the bladder neck it is often less because of the convex shape of the lobe. For effective treatment of this part of the lobe it is also possible to insert the fiber at a point closer to the apex at a lower angle and then carefully penetrate deeper toward the bladder neck ( Fig. 137-6). Fiber penetration of the capsule is almost impossible because of the limited penetration angle and depth achievable. In addition, the highly vascular nature of the prostate capsule acts as a heat sink and contributes to preventing potential coagulation of the capsule itself and adjacent structures. However, one should avoid advancing the applicator dorsally because there is little or no BPH tissue to treat and yet there is a potential risk of affecting structures adjacent to the prostate (neurovascular bundles and rectum) or inducing subtrigonal lesions with subsequent bladder neck strictures. All puncture points must be within the length of the prostatic urethra between the external sphincter and the bladder neck. The most apical puncture should be in the prostatic urethra just in front of the proximal end of the external sphincter so that no apical tissue goes untreated ( Fig. 137-8). The puncture closest to the bladder neck should not penetrate into the bladder. Accidental penetration of the applicator through the prostate into the bladder can be detected by a feeling of resistance to fiber penetration. If this occurs the fiber can simply be pulled back into the prostate and that site can be treated. When the median lobe is being treated, the fiber should always be advanced in the direction of the bladder to prevent subtrigonal penetration. A large median lobe should be treated with more than one puncture ( Fig. 137-7). Depending on its size and shape, punctures can be made at different levels and angles.

FIG. 137-8. Endoscopy during interstitial laser coagulation of the right apex, applicator in situ.

Postoperative (transurethral and/or suprapubic) catheterization is recommended. Bladder irrigation is usually not required but can be useful in individual cases to prevent clot retention. Sufficient voiding can be expected within 1 to 2 weeks in patients with normal detrusor function.

OUTCOMES

Complications No study reported any occurrence of impotence or sustained incontinence. Retrograde ejaculation occurred occasionally, with reported rates varying from 0 to 11.9%. The need for repeat BPH treatment because of treatment failure occurred at varying rates between 0% and 15.4% ( Table 137-1). Transient irritative symptoms, such as urgency, occurred in 0 to 12.6% of cases. Transient urge or stress incontinence was rare (less than 1%). Urethral strictures or bladder neck strictures were reported in a frequency of approximately 5% for the first series of patients but were not observed in subsequent series ( Table 137-2 ). Uncomplicated urinary tract infections occurred relatively frequently.

TABLE 137-1. Failure rate of ILC

Most complications, in particular the more serious ones, became less common or absent with increasing experience ( Table 137-2).

TABLE 137-2. Complications of ILC

Results Several studies indicated the effectiveness of interstitial laser coagulation of BPH regarding all of the three characteristics of the disease: symptoms, obstruction, and enlargement. All studies reported marked improvements in AUA score, peak flow rate, residual urine volume, and prostate volume 1,2,4,5,7,8,12,13 and 14 (Table 137-3 and Table 137-4). The latter was also demonstrated in studies using magnetic resonance imaging for volume measurements during follow-up. 1,6 Multivariate analysis was performed on the largest of the studies. 8 It showed no factors predicting final success or failure, such as initial symptoms, flow rates, residual volumes or prostate volumes, endoscopic or perineal access, etc., except the number of previous cases performed (effect of the learning curve). The latter can also be concluded from the results of consecutive multicentric studies of the same group of authors. 2,15 Some authors demonstrated in their multivariate analysis that the results correlated with the number of punctures per prostate volume, with less than one application per 5 to 7 ml of prostate volume the results were less good. 1

TABLE 137-3. Clinical results of ILC

TABLE 137-4. Decrease of prostate volume after ILC

Studies were also performed to compare the results with ILC to those of other laser techniques 4 and primarily TURP. 6,15 In one series, 48 patients were interstitially treated with standardized instrumentation (Nd:YAG laser, ITT Light Guide), application technique (transurethral application with an integrated cystoscope), and laser

parameters (power stepwise reduced from 20 to 7 W, 3 minutes total irradiation time per single-fiber placement), and compared prospectively with 49 TURP patients. 6 On average, within 12 months AUA score improved from 31.0 to 2.3 points (TURP: 31.1 to 3.5 points), life quality index from 4.7 to 0.6 points (TURP: 4.7 to 1.3 points), peak flow rate ( Fig. 137-9) from 9.4 ml/sec to 19.7 ml/sec (TURP: 8.9 ml/sec to 25.6 ml/sec), residual urine volume from 128 ml to 17 ml (TURP: 167 ml to 7 ml), and prostate volumes from 47.1 ml to 27.5 ml (TURP: 40.2 ml to 21.2 ml). Four laser patients were not completely satisfied and retreated by transurethral resection. The persistence of obstruction in these patients was caused by small tissue residues in unfavorable locations such as the apex or the bladder neck. In a prospectively randomized multicenter study a 10-W diode laser system was used. 15 Six months follow-up in 166 patients showed marked improvements in both groups; TURP, however, was significantly better (AUA score improving from 22.4 to 6.5 versus ILC from 21.5 to 9.7; peak flow rate improving from 8.3 ml/sec to 20.3 ml/sec versus ILC from 8.3 ml/sec to 14 ml/sec). The number of applications, however, was only 6.7 in average in an average prostate volume of approximately 50 ml.

FIG. 137-9. TURP versus interstitial laser coagulation. Urinary peak flow before and 12 months after treatment.

Urodynamic measurements were done in a limited number of patients before and after treatment. Pressure–flow studies demonstrated a sufficient decrease of intravesical/detrusor pressure, urethral opening pressure, and urethral resistance 4 (Table 137-5).

TABLE 137-5. Decrease of prostate volume after ILC

CHAPTER REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Arai Y, Ishitoya S, Okubo K, Suzuki Y. Transurethral interstitial laser coagulation for benign prostatic hyperplasia: treatment outcome and quality of life. Br J Urol 1996;77:93–98. De La Rosette JJMCH, Muschter R, Lopez MA. Interstitial laser coagulation in the treatment of BPH using a tissue adaptive laser system. J Endourol 1996;10(Suppl 1):S93. Hofstetter A. Interstitielle Thermokoagulation (ITK) von Prostatatumoren. Lasermedizin 1991;7:179. Horninger W, Janetschek G, Pointner J, Watson G, Bartsch G. Are TULIP, interstitial laser and contact laser superior to TURP? J Urol 1995;153:413A. McNicholas T, Alsudani M. Interstitial laser coagulation therapy for benign prostatic hyperplasia. SPIE Proc 1996;2671:300–308. Muschter R. Interstitial laser therapy. Curr Opin Urol 1996;6:33–38. Muschter R, Hofstetter A. Technique and results of interstitial laser coagulation. World J Urol 1995;13:109–114. Muschter R, Hofstetter A. Interstitial laser therapy outcomes in benign prostatic hyperplasia. J Endourol 1995;9:129–135. Muschter R, Hofstetter A, Hessel S, Keiditsch E, Rothenberger K-H, Schneede P, Frank F. Hi-tech of the prostate: interstitial laser coagulation of benign prostatic hypertrophy. In: Anderson RR, ed. Laser surgery: advanced characterization, therapeutics, and systems. SPIE Proc 1992;1643(111):25–34. Muschter R, Perlmutter AP. The optimization of laser prostatectomy. II. Other lasing techniques. Urology 1994;44:856–861. Muschter R, Perlmutter AP, Anson K, et al. Diode lasers for interstitial laser coagulation of the prostate. In: Anderson RR, ed. Lasers in surgery: advanced characterization, therapeutics, and systems. SPIE Proc 1995;2395(5):77–82. Muschter R, Sroka R, Perlmutter AP, Schneede P, Hofstetter A. High power interstitial laser coagulation of benign prostatic hyperplasia. J Endourol 1996;10 (Suppl 1):S197. Orovan WL, Whelan JP. Neodynium YAG laser treatment of BPH using interstitial thermotherapy: a transurethral approach. J Urol 1994;151:230A. Roggan A, Handke A, Miller K, Moller G. Laser induced interstitial thermotherapy of benign prostatic hyperplasia: basic investigations and first clinical results. Min Invas Medizin 1994;5:55–63. Whitfield N. A randomized prospective multicenter study eval-uating the efficacy of interstitial laser coagulation. J Urol 1996;155:318A.

Color Plate Glenn’s Urologic Surgery

Color Plate

COLOR PLATE 1. Normal appearance of the bladder urothelium before hydrodistention in a patient with symptoms consistent with interstitial cystitis. (B) Same patient following hydrodistention. The urothelium is abnormal, revealing minimal to moderate glomerulation. (C) Cystoscopic appearance of a patient with moderate glomerulations and submucosal hemorrhage. (D) Hunner's ulcer with marked hemorrhage surrounding the ulcer. This patient was successfully treated with focal Nd:YAG laser ablation therapy. (see Fig. 30-1.)

COLOR PLATE 2. Gangrene of the right testicle in a boy 16 years old who had undergone a 720-degree twist of the cord. (See Fig. 64-1.)

COLOR PLATE 3. Color Doppler sonography: avascular pattern of the testis 10 hours after torsion in a 16-year-old boy. (See Fig. 64-5.)