POINT OF TECHNIQUE
|Year : 2002 | Volume
| Issue : 1 | Page : 89-92
Combined augmentation ileo-cystoplasty and ileal replacement of ureter in advanced genitourinary tuberculosis: Modified technique
PB Singh, Harbans Singh, Arif Hamid, Gopi Kishore, US Dwivedi
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
P B Singh
Department of Urology, Institute of Medical Sciences, BHU, Varanasi - 221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An advanced case of genitourinary tuberculosis presenting with small capacity bladder left ureteric stricture and nonfunctioning right kidney was managed with modified technique of combined augmentation ileo-cystoplasty and ileal replacement of left ureter This complex and extensive reconstruction can be done easily and successfully in a short time with our modified technique.
Keywords: Cvstonlasty: Tuberculosis
|How to cite this article:|
Singh P B, Singh H, Hamid A, Kishore G, Dwivedi U S. Combined augmentation ileo-cystoplasty and ileal replacement of ureter in advanced genitourinary tuberculosis: Modified technique. Indian J Urol 2002;19:89-92
|How to cite this URL:|
Singh P B, Singh H, Hamid A, Kishore G, Dwivedi U S. Combined augmentation ileo-cystoplasty and ileal replacement of ureter in advanced genitourinary tuberculosis: Modified technique. Indian J Urol [serial online] 2002 [cited 2020 Aug 13];19:89-92. Available from: http://www.indianjurol.com/text.asp?2002/19/1/89/20304
| Introduction|| |
Genitourinary tuberculosis is still prevalent in tropical countries and sometimes in advanced cases surgical reconstruction is required. These reconstructions pose challenge to the urologist not only due to the magnitude of surgery but also due to associated poor health and impaired renal function. Here we report a case of advanced genitourinary tuberculosis managed by a modified technique of combined ileal replacement of ureter with augmentation ileo-cystoplasty.
| Technique|| |
A 35-year-old lady presented with features of renal failure and irritative voiding symptoms. Serum creatinine was 5.5 mg/dl. Urine microscopy showed 8-10 RBCs, 6-8 pus cells and Ziehl-Nelson staining was positive for acid-fast bacilli. Ultrasonography revealed left moderate hydronephrosis and multiple areas of cortical hypoechogenicity in the right kidney. Differential renal function of right side was only 4% on DTPA scan. Left percutaneous nephrostomy was performed and antitubercular treatment was commenced. Only nephrostomy was draining without any urine output per urethra. After 6 weeks, serum creatinine came down to 1.8 mg/dl. Nephrostogram revealed complete ureteric stricture at mid ureter with narrow irregular upper ureter. Cystogram revealed bladder capacity of only 80 ml. After 2 months patient underwent augmentation ileo-cystoplasty and ileal replacement of left ureter with right nephroureterectomy. Abdominal exploration revealed putty kidney on right side and fibrotic narrow left ureter with small capacity bladder. Left kidney had reasonably good parenchyma. About 75 cm loop of distal ileum, 15 cm proximal of ileo-caecal junction was isolated on its pedicle and ileo-ileostomy was performed to maintain bowel continuity. After the loop of ileum was flushed, distal 50 cm segment of ileum was opened on its anti-mesenteric border. This was placed in form of "M" with five limbs of 10 cm each and remaining 25 can ileum was kept to replace left ureter [Figure - 1]a. The limbs were sutured side to side with continuous 2/0-vicryl suture to convert it into flat sheet of ileum with attached 25 cm of intact ileum at left end corner. This flat sheet was folded on itself horizontally from right to left side to that the loop of intestine to be anastomosed to the renal pelvis remained on the dome of augmented bladder. [Figure - 1]b Then the plate was sutured on the superior aspect and on the left side to make a cup patch which was anastomosed to the opened bladder. using continuous 2/0-vicryl suture. Ilea] loop was brought beneath sigmoid mesentery and was anastomosed to dissected left dilated ureter with interrupted 3/0vicryl suture [Figure - 1]c. Nephrostomy tube. antigrade ureteric stent, suprapubic catheter and urethral catheter ware maintained for 3 weeks. Postoperative nephrostogram revealed good drainage through replaced ileal loop and adequate bladder capacity [Figure - 2]a and b. Ureteric stent, nephrostomy tube, suprapubic catheter and urethral catheter were sequentially removed. Patient voided urine with the maximum flow rate of 15 ml/sec and serum creatinine remained stable at 2.0 mg/dl.
| Advantages|| |
Augmentation cystoplasty and ileal replacement of ureter individually are well established procedures and there are many techniques of such reconstructions. There are few reports of using both procedures in the same patient. Wong et al  combined cecocystoplasty with ileal ureter in 3 patients. Webster and Roman recommended hemikock augmentation of bladder and used intussuscepted afferent limb for replacement of ureter.  These techniques are complex in nature and time consuming. Studer et al  in their technique of ileal neobladder used afferent isoperistaltic limb for ureteroileal anastomosis without any antireflux procedure and showed that it does not influence renal functions. Carl and Stark  reported the combination of ileal ureter and augmentation ileo-cystoplasty without any antireflux procedure.Their case was similar to ours but detailed operative technique, except the principle that was based on neo-bladder reported by Wenderoth et al,  has not been published. In most of the augmentation procedures, detubularised ileal plate is folded vertically on itself to make the cup. We folded the `M' shaped multiple limb ileal plate as per requirement, horizontally so that the afferent ileal limb, to be used for ureteric replacement, remained at the dome of the reconstructed bladder, resulting in better dependent drainage. Further multiple limbs allow us to make a wide mouth cup as required. It prevents narrowing at the site of anastomosis. We also did not use any antireflux procedure and relied on long isoperistaltic ileal limb. Our technique is easy and can be done in short operative time.
| References|| |
|1.||Wong SH, Lau WY, Poon GP, Fan ST, Ho KK, Yin TF et al. The treatment of urinary tuberculosis. J Urol 1984; 131: 297. |
|2.||Webster GD. Roman J. Bladder Augmentation and Reconstruction. In: Droller ML (ed.). Surgical management of urologic diseases : an anatomical approach, Chapter 47. St Louis, Mosby Year Book 1992; 601-618. |
|3.||Studer UE, Spiegel T. Casanova AG. Springer J, Gerber E. Ackermann DK et al. Ileal bladder substitute : antireflux nipple or afferent tubular segment ? Eur Urol 1991; 20: 315. |
|4.||Carl P, Stark L. Heal bladder augmentation combined with ileal ureter replacement in advanced urogenital tuberculosis. J Urol 1994: 151: 1345. |
|5.||Wenderoth UK, Bachor R, Egghart G, Frohneberg D, Miller K. Hautmann RE. The ileal neobladder experience and results of more than 100 consecutive cases. J Urol 1990; 143: 492. |
[Figure - 1], [Figure - 2]