|The mechanism of the transport of urine after the urinary diversion to ileal conduit
Urinary Bladder Neoplasms/surgery
|Since 1964 we have utilized the ileal conduit for the urinary d i v ersion, and the data for this report came from the study of 17 cases out of 34 patients who underwent the ileal conduit during the years from 1964 to 1970. Four modified techniques of the ileal conduit were performed, but there was no significant difference observed between them in the transport of urine. The ileum and the ureter, which are the main com ponents of the ileal conduit, have own different activity, but few investigations have been made whether the motion of ileal conduit itself has some untoward effects on the transport of urine in the upper urinary tracts or not. Cinefluorographic studies by the retrograde ileal conduitography (ileal loopography) and excretory urograms were chiefly used, in addition, routine intravenous pyelograms, the PSP excretion test, the manometric studies of ileal conduit, and the bacteriological examinations of urine were carried out. And the following results were obtained. 1) The frequency of systolic movements observed at the ureteropelvic junction was 2 to 3 times per minute in supine position, and 3 to 4 times per minute in erect position after the diversion to the ileal conduit. It remained within normal limits of the frequency observed in the normal persons. 2) Unle s s there was no obstruction of urine passage distal to the ureteroileostomy, the systolic movements of ileal conduit itself gave cinefluorographically little influence to the transport of urine in the upper urinary tracts. 3) The ureteral reflux was obs e r ved in 53 % of the renal units in the retrograde ileal conduitography. But it seems to be an artificial phenomenon, and from the following facts the spontaneous occurrence of ureteral reflux seems to be uncommon in the ileal conduit in ordinary life. A) No relationship was observed between the occurrence of reflux and the postoperative improvement of pyelograms, the pattern of PSP excretion curve, the frequency of systolic movements at the ureteropelvic junction, or the persistence of infected urine. B) Small air bubbles were sent to the renal pelvis with the contr a st medium in some cases of the retrograde ileal conduitography. In such cases the air bubbles were transported into the ureter after the removal of Foley catheter, but were never backflowed again. C) The occurrence of reflux from the conduit into the ureter was difficult t o observe in the excretory cinefluorography with the intravenous injection of large dose contrast medium. 4) All of five cases with advanced hydronephrosis were improved to normal or t o minimal hydronephrosis. Consequently, it is emphasized that the ileal conduit is a safe and adequate urinary diversion for the patients with advanced hydronephrosis if the duration of urinary stasis has not been so long and the renal parenchymal damage has not been so serious. 5) The systolic movements at the ureteropelvic junction were often observe d cinefluorographically in hydronephrosis which was improving to the lower grade after the urinary diversion. 6) The elevation of intraluminal pressure, induced by the obstruction of the stoma with a balloon catheter, was recorded by the electromanometer with the sensitive strain gauge. The resting pressure was 2 to 10 mmHg (the average was 5.9 mmHg). The maximum pressure, which was recorded at the onset of spike wave, was 38 to 100 mmHg (the average was 58 mm Hg). The interval of the spike waves was comparatively constant. Some patients complained of the colic flank pain suggesting the occurrence of ureteral reflux when the spike wave was recorded. 7) The PSP excretion curve gives a clue to see the change of the dead space and the state of renal function when comparing the curves monthly or annually after the urinary diversion. 8) The excretory cinefluorography of the ileal conduit and the cinefluoro-conduitography often showed the weak nonpropulsive movements Although the propulsive peristalsis were rarely noted, the stasis of urine in the ileal conduit was not so much and never increased. This means that the urine in the conduit is discharged little by little with the weak and nonpropulsive movements of the conduit. The urinary stasis was rare in the short and straight.
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