Upsala J Med Sci 90: 119-125, 1985 Ureteral Reflux and Ileal Conduit Pressure Following Diversion with a Reflux-preventing Technique Kerstin Claesson, Lars Frodin and Lars-Erik Lorelius Department of Urology and Radiology, Universiv Hospital, Uppsala, Sweden ABSTRACT I l e a l c o n d u i t u r i n a r y d i v e r s i o n was p e r f o r m e d w i t h an a n t i r e f l u x t e c h n i q u e , w i t h n i p p l i n q o f t h e u r e t e r s i n t o t h e segment, i n 63 p a t i e n t s . The p a t i e n t s were t h e n f o l l o w e d up f o r 52 2 25 months c o n c e r n i n g u r o g r a p h i c f i n d i n g s , i n f e c t - i o n s and k i d n e y f u n c t i o n . U r e t e r o i l e a l s t e n o s i s d e v e l o p e d i n 3 o f 122 u r e t e r s and was s u r g i c a l l y c o r r e c t e d . R o e n t g e n o l o g i c e x a m i n a t i o n f o r u r e t e r a l r e f l u x was p e r f o r m e d a b o u t a y e a r p o s t o p e r a t i v e l y , and p r e s s u r e measurements were made i n t h e i l e a l segment. R e f l u x o f c o n t r a s t mediumwasseen i n 48 u r e t e r s a t p r e s s - u r e 5 1 2 30 mm Hg. When no r e f l u x was seen, t h e maximum i n f u s i o n p r e s s u r e was 62 2 34 mm Hg. The b a s a l p r e s s u r e ( p r e c e d i n g c o n t r a s t i n f u s i o n ) was 24 2 29 mn, Hg. R e g u l a r c o n t r a c t i o n waves w i t h p r e s s u r e r i s e i n t h e i l e a l segment were re- g i s t e r e d , w i t h d u r a t i o n 10-30 seconds. The s t u d y showed no c o n n e c t i o n between u r e t e r a l r e f l u x and p r e s s u r e i n t h e i l e a l segment. C o m p l i c a t i o n s a s s o c i a t e d w i t h t h e a n t i r e f l u x o p e r a t i n g t e c h n i q u e were few. INTRODUCTION I n l o n g - t e r m f o l l o w - u p a f t e r i l e a l c o n d u i t u r i n a r y d i v e r s i o n , h i g h i n c i d - ence o f c o m p l i c a t i o n s has been found, i n c l u d i n g c h r o n i c p y e l o n e p h r i t i s , s t o n e f o r m a t i o n and d e t e r i o r a t i o n o f k i d n e y f u n c t i o n (5,8,10). These c o m p l i c a t i o n s have been t h o u g h t t o have some c o n n e c t i o n w i t h u r e t e r a l r e f l u x ( 4 ) . V a r i o u s r e f l u x - p r e v e n t i n g p r o c e d u r e s have been used a t o p e r a t i o n (1). H i g h i n c i d e n c e o f u r e t e r o i l e a l s t e n o s i s has been a t t r i b u t e d t o r e f l u x - p r e v e n t i n g t e c h n i q u e s f o r u r e t e r o i l e a l a n a s t o m o s i s ( 2 ) . A s u r v e y o f s i x series w i t h a n t i - r e f l u x anastomosis showed s t e n o s i s i n c i d e n c e r a n g i n g from 3 t o 11 % ( 9 ) . The n i p p l e d u r e t e r o i l e a l anastomosing t e c h n i q u e d e s c r i b e d by P a t i l e t a l . ( 9 ) has been used a s a n t i r e f l u x p r o c e d u r e a t o u r c l i n i c . U r e t e r a l r e f l u x was e a r l i e r s t u d i e d t o g e t h e r w i t h r e c o r d i n g o f c o n d u i t p r e s s u r e , u s i n g s i m u l t a n e o u s l o o p o g r a p h y ( 2 ) . The aim o f t h e p r e s e n t s t u d y was 119 to register the ileal conduit pressure continuously during contrast infusion, for documentation of reflux to the ureters, and to compare the findings with the clinical features. MATERIAL AND METHODS Patients Sixty-three patients (45 male, 18 female, mean age 56.9 2 12.6 years) with ileal conduit were observed for 52 225 months postoperatively. The indication for urinary deviation was malignancy in 51 cases and benign, predominantly neurogenic disease in 12 cases. Preoperative radiotherapy was given the 51 patients with walignant disease. Three patients underwent salvage cyst- ectomy after irradiation (60 Gy). Postoperative irradiation was given in one case. Methods to 42 o f Operation. The antireflux technique with nippling o f the ureters into ileal conduit (9) was used in all cases. The technique is illustrated in the Fig.1. Fig. 1. The nippling ureteroileal anastomosis f o r prevention of reflux Intravenous uroqraphy. This exaDination was performed preoperatively and 3,6 and 12 months postoperatively, and then every 1 2 t h month. Infection control. Clinical analysis and culture of urine from the ileal segment , collected with a single-lumen catheter, were performed routinely 3, 6 and 12 months after diversion and then at least once yearly. 120 Kidney f u n c t i o n . S t u d i e s were made a t t h e above-mentioned i n t e r v a l s by measuring serum c r e a t i n i n e and Cr-EDTA clearance. Pressure s t u d i e s . Retrograde c o n t r a s t i n f u s i o n o f t h e i l i a c bladder was p e r - formed about one year p o s t o p e r a t i v e l y , u s i n g a m o d i f i e d Foley c a t h e t e r no 1 2 ( F i g . 2), f u n c t i o n i n g as a double-lumen c a t h e t e r . p r e s s u r e registration infusion F i g . 2. F o l e y c a t h e t e r w i t h t h e b a l l o o n c u t and a s i d e h o l e made i n t h e c a n a l f o r p r e s s u r e r e g i s t r a t i o n Under f l u o r o s c o p i c c o n t r o l t h e c a t h e t e r t i p was guided as c l o s e t o t h e u r e - t e r a l o r i f i c e s as p o s s i b l e . Through one o f t h e channels t h e i n t r a l u m i n a l p r e s s - u r e was c o n t i n u o u s l y r e g i s t e r e d ( t r a n s d u c e r Statham P 23 A C ) w i t h a l i n e a r w r i t e r (Mingograph 800, Elema-Schonander, Stockholm, Sweden). B e f o r e i n f u s i o n o f c o n t r a s t medium t h e b a s a l l u m i n a l p r e s s u r e was r e g i s t e r e d f o r 2 minutes. T h e r e a f t e r t h e c o n t r a s t medium (Isopaque 30 %, Nyegaard, Norway) was a d m i n i s t - ered as a d r i p i n f u s i o n from a b o t t l e p o s i t i o n e d 100 cm above t h e stoma. The i n f u s i o n v e l o c i t y was 10 ml/min f o r 3 minutes, 20 ml/min f o r 5 minutes and f r e e f l o w o f c o n t r a s t u n t i l 250 m l had been i n f u s e d , w i t h f r e e o u t f l o w from t h e stoma. The f i l m s were exposed over t h e i l i a c segment, u r e t e r s and k i d n e y s a t 3 and 8 minutes and a f t e r t h e i n f u s i o n . I f a pressure r i s e was recorded i n t h e segment, a supplementary f i l m was exposed. I l e a l c o n d u i t p r e s s u r e was d e f i n e d as t h e h i g h e s t p r e s s u r e d u r i n g 30 seconds preceding t h e exposure. 121 RESULTS U r o g r a p h y . Most u r e t e r s and r e n a l p e l v e s showed r e v e r s i b l e d i l a t i o n a t t h e u r o g r a p h y 3 months p o s t o p e r a t i v e l y , b u t i n o n l y 3 o f 1 2 2 u r e t e r s was t h e r e p e r - s i s t e n t d i s t a l o b s t r u c t i o n . R e a q a s t o m o s i s c o r r e c t e d t h e s t e n o s i s i n t h e s e t h r e e u r e t e r s . S t o n e s . R e n a l c a l c i f i c a t i o n s were o b s e r v e d i n f o u r p a t i e n t s p r e o p e r a t i v e l y a n d d e v e l o p e d i n n i n e p o s t o p e r a t i v e l y . None o f t h e s e p a t i e n t s h a d s i g n s o f u r e - t e r a l o b s t r u c t i o n . F o u r showed u r e t e r a l r e f l u x . F i v e p a t i e n t s were o p e r a t e d on f o r u r i n a r y c a l c u l i d u r i n g t h e o b s e r v a t i o n p e r i o d . R e f l u x s t u d i e s . R e f l u x was f o u n d i n 39 L o f t h e ureters. Hence t h e r e ap- p e a r e d t o b e no r e f l u x i n 61 %. P (mm Hg) 1 n F i g . 3. Maximum i n t r a l u r n i n a l p r e s s u r e ('f 1 SD) i n rnm Hg ( o r d i n a t e ) a t rest and i n r e l a t i o n t o t h e t o t a l c o n t r a s t volume i n m l ( a b s c i s s a ) i n 6 3 i l e a l c o n d u i t s ( u p p e r p a n e l ) . The r e l a t e d numbers o f u r e t e r s w i t h r e f l u x ( n ) a r e shown i n t h e l o w e r p a n e l . I n t r a l u r n i n a l p r e s s u r e . A l l t h e p a t i e n t s showed a l o w e s t b a s a l p r e s s u r e < 10 rnm Hg, w i t h i n t e r m i t t e n t p r e s s u r e p e a k s o f 10-30 s e c o n d s ' d u r a t i o n . The i l e a l c o n d u i t showed c o n t r a c t i o n d u r i n g p r e s s u r e p e a k s a n d was r e l a x e d a t b a s a l p r e s s - ure. I n t h r e e p a t i e n t s w i t h s t e n o s i s o f t h e c u t a n e o u s s t o m a , t h e p r e s s u r e d i d 122 n o t r e t u r n t o b a s a l l e v e l between t h e c o n t r a c t i o n s . The maximum p r e s s u r e r e g i s - t e r e d b e f o r e t h e s t a r t o f t h e i n f u s i o n was 24 2 29 (0-110) mm Hg. D u r i n g i n - f u s i o n t h e c o r r e s p o n d i n g f i g u r e s were 62 f 34 (15-150) mm Hg f o r p a t i e n t s w i t h - o u r r e f l u x and 5 1 ? 30 (30-110) mm Hg f o r t h o s e with r e f l u x ( d i f f e r e n c e n o t s t a - t i s t i c a l l y s i g n i f i c a n t ) . The maximum p r e s s u r e a t t h e o c c u r r e n c e o f r e f l u x was 28 25 (0-100) mm Hg ( F i g . 3 ) . A t y p i c a l pressure r e c o r d i n g i s shown i n F i g . 4 . t -r ~ 40s t I F i g . 4. P r e s s u r e r e c o r d i n g f r o m an i l e a l c o n d u i t : F i l m exposures a r e i n d i c a t e d b y v e r t i c a l b a r s I n f e c t i o n s . o f t h o s e w i t h o u t r e f l u x t h e r e was c l i n i c a l l y m a n i f e s t p y e l o n e p h r i t i s w i t h f e v e r and f l a n k p a i n . I m p a i r m e n t o f r e n a l f u n c t i o n , measured a s e l e v a t i o n o f serum c r e a t i n i n e , o c c u r r e d i n two o f t h e s e p a t i e n t s . F u n c t i o n was l o s t i n one k i d n e y , due t o u r e t e r a l s t e n o s i s , and nephrectomy was p e r f o r m e d . Another o f t h e n i n e p a t i e n t s had u r o g r a p h i c s i g n s o f p y e l o n e p h r i t i s . A l l 63 p a t i e n t s had p o s i t i v e u r i n e c u l t u r e on a t l e a s t one o c c a s i o n p o s t o p e r a t i v e l y , but o n l y t h e n i n e above-mentioned had c l i n i c a l p y e l o n e p h r i t i s . I n s i x (12.5 % ) o f t h e k i d n e y s with r e f l u x and i n t h r e e ( 4 7;) R e n a l f u n c t i o n . A t t h e end o f t h e f o l l o w - u p p e r i o d , 11 p a t i e n t s showed 9-858572 123 deterioration o f renal function. Six of these patients had had normal serum creatinine levels preoperatively. Two o f the six had unilateral reflux and four had no reflux. Three of the same six patients had had clinical pyelonephritis in the postoperative period. DISCUSSION Compared with results after other techniques of operation, the complication rate in this case series was relatively low ( 5 , 8 ) , although the follow-up time is short. Our investigations showed no reflux to the kidney in 61 7; of the patients, but in 39 7; the technique did not prevent reflux. The recordings in the ileal conduit showed that relatively high pressures were present locally at the site of ureteral implantation. These high pressures may be related to nonpulsatile contractions in the ileal conduit ( 3 ) . Reflux could possibly entail conduction of the elevated pressures to the renal pelvis, causing intermittently high pressure to the renal parenchyma. Theoretically the ureteral peristalsis might counteract this pressure r i s e , but dilation o f the ureter makes this peristalsis ineffective. Further, ureteral peristalsis has been shown to lack any coordination with the contractions of the conduit (3). Infections from the ileal conduit may be transferred to the renal pelvis in the same way. All o f our patients had at least one positive urinary culture from the ileal conduit during the observation time. Only nine, however, had clinically manifest signs of upper urinary tract infection. A possible explan- ation is that the anatomy of the renal pelvis is important for the developwent of pyelonephritis (6,7). The potential dangers of low-pressure contra high-pressure reflux are some- times debated. Since intermittently high pressures were registered in the con- duit in almost all of our patients, this distinction cannot be made (2). A l - though the incidence of pyelonephritis was slightly higher in the refluxing than in the nonrefluxing ureters, the series was too small to permit conclus- ions in this respect. We found no difference in stone formation related to re- flux. As, in comparison with other surgical techniques, no negative effects were found with the antireflux procedure, we are continuing to use this type of operation. REFERENCES 1. Ashken, M.H: Urinary reservoirs. In: Urinary Diversion, Ed. Ashken, M.H.. 2. Bergrnan, B., Nilsson, A.E., Pettersson, 5. & Sundin, T.: Ureteral reflux Springer Verlag, Berlin, Heidelberg, New York, 113-139,1982. from i l e a l conduit. Scand J Urol Nephrol 12:239-242,1976. 124 3 - 4. 5. 6. 7. 8 . 9. 10. 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