AN APPRAISAL OF THE METHODS OF URINARY DIVERSION

Postgraduate Lecture delivered at the Royal College of Surgeons of England

on

16th April 1969

by

Peter F. Philip, M.S., F.R.C.S.

Consultant Surgeon and Urologist, Charing Cross,

Bolingbroke and Royal Masonic Hospitals

INITIALLY ONE MUST know whether the diversion is intended to be a
temporary or permanent state, and the reasons for the diversion. The
reasons are, first, to maintain renal function by relieving an obstruction
and perhaps as a result of this to assist in clearing renal infection; secondly,
to improve continence when lack of control may be due to fistulae,
incurable neurogenic disease, or to congenital defects; and, thirdly,
following removal of the lower urinary tract, usually for malignancy.
METHODS OF URINARY DIVERSION
At kidney level:
1. Nephrostomy or pyelostomy.
2. Ureterostomy in situ.
3. Ileal conduit, to skin or bladder.
At ureteric level:
1. Cutaneous ureterostomy.
2. Uretero-sigmoidostomy.
2 (a). Trigono-colostomy.
3. Rectal bladder and proximal colostomy.
3 (a). Rectal bladder and intersphincteric anal colostomy.
4. Ileal or colonic conduit.
At bladder level:
1. Suprapubic cystostomy.
2. Cutaneous vesicostomy.
3. Suprapubic displacement of the urethra.
(Urethrostomy will not be discussed in this lecture.)

Nephrostomy
Indications
1. In childhood renal function is best safeguarded with gross obstructions, as from posterior urethral valves, bilateral megaureters or megaureter-megacystis syndrome, by a nephrostomy, because ureteric function
may not be adequate. Also it is wiser to avoid surgery to the ureter
particularly when it is known that reflux is present, so that the whole
ureter undamaged by previous surgery can be available later if needed
for re-implantation procedures (Fig. 1).
2. In the adult when there is renal failure due to a large stone and
infection, particularly in the presence of bacteraemia from a pyonephrosis.
Extravasation following renal transplantation is an absolute indication
for nephrostomy.
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Method
Nephrostomy may be performed in many ways, and the precise method
will vary with the findings. If a sizeable stone is present, then a pyelotomy
should be performed, and the stone removed before establishing the
nephrostomy. There is some advantage in establishing a nephrostomy
without mobilization of the kidney, by introducing a trocar and cannula
through the substance of the kidney, having first established direction and
depth with a needle, and then passing a catheter along the cannula. However, it is probably less damaging to make a small pyelostomy opening,
pass a blunt probe (eye outwards) through the renal substance and then
draw back into the kidney a thin rubber Penrose drain through which a
catheter can then be introduced into the renal pelvis (Fig. 2a). The

(a1)
(h1)
Fig. 1. These X-rays show the improvement following nephrostomy drainage in a
child who had obstruction to the pelvic ureter of a single functioning kidney, the
other being dysplastic. The blood urea dropped from 250 to 80 mgm. per cent.
The ureter has not been interfered with, as it may well have to be re-implanted later.

Penrose drain is then pulled out along the catheter. The catheter should
have end and side holes.
Ureterostomy in situ

Indications
In most cases this is preferable to nephrostomy in adults who have a
rising blood urea from ureteric obstruction. This may be due to bladder
tumours or pelvic growths, or arise during radiotherapy for such lesions,
or it may be due to tuberculosis or retro-peritoneal fibrosis. In the
former, if a reasonable response to radiotherapy can be expected, then
bilateral ureterostomies can be performed under local anaesthesia if
necessary, and they have the advantage over nephrostomy in that they
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PETER F. PHILIP

are more comfortable for the patient because the tubes emerge in the
iliac fossae; there is less muscle trauma, and less strain on poor renal
function, and there is no disturbance of the kidney itself, and therefore
no risk of impairing renal function further.
Ureterostomy is not suitable for cases of pelvi-ureteric obstruction, or
where tuberculosis has affected the upper ureter.
Method
The ureter is exposed through an oblique, muscle splitting incision in
the iliac fossa. The wall is incised longitudinally, and a suitable polyethylene catheter, which passes easily through the pelvi-ureteric junction,
is inserted up into the renal pelvis and brought out in a smooth curve
through a small stab incision lower in the iliac fossa. This can be left
in position for three weeks, during which time a track will form enabling
tube changes to be made quite easily.
The only complication is that if too large a tube is used, pressure
necrosis of epithelium may occur at the pelvi-ureteric junction and later
result in stricture at this point.

Reproduced from Bailey and Love's ShortK.Practice

Lewis
of Surgery by kin permission of H.
&-Co. Ltd.

(b)
(a)
Fig. 2. (a) Method of performing nephrostomy (for details see text). (b) Stages
of Leadbetter anastomosis.

In both nephrostomy and ureterostomy in situ, tubes are an essential

part of the diversion. This is only acceptable where temporary diversion
is required, although in children ' temporary' nephrostomy may be
needed for a considerable period. The tubes must be changed regularly,
every two to three weeks, to minimize the risk of encrustation and
obstruction of the tube. If a St. Peter's catheter and flange are used to
drain a nephrostomy, daily changes are advocated. If possible the
urine should be kept acid to avoid phosphate deposition. Changes of
tubes can result in infection being carried in from the surface track, and
patients should be on long-term rotating chemotherapy or antibiotics.
The most important single factor is that a high urinary output must be
achieved at all times.
Permanent diversion at renal level may be needed occasionally when
both ureters have been destroyed, as may occur in tuberculosis, secondary
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operation for recurrent obstruction from retro-peritoneal fibrosis or

where gross recurrent stone formation has produced hydronephrosis
with impaired drainage from the lowest calyces. In these cases an ileal
conduit from the lowest calyx or the pelvis to the skin may be the best
method of maintaining renal function. The lower end of the loop may
be joined to the bladder in suitable cases, but absorption and biochemical
disturbances may occur in the long term.
Supra-pubic cystostomy
Indications: Temporary diversion by means of a supra-pubic catheter
is essential in cases of peri-urethral abscess secondary to stricture. It is
also advocated by the Bristol school in all cases of urethral damage in
which the patient fails to pass urine.
In the case of an impassable stricture presenting with retention it is
better to perform an external urethrotomy and the first stage of a
urethroplasty rather than insert a supra-pubic catheter. Permanent
supra-pubic catheter drainage is not preferable to an indwelling urethral
catheter.
Cutaneous vesicostomy and supra-pubic displacement of the urethra
These have been advocated in neurological conditions involving
bladder dysfunction as a means of enabling an appliance to be stuck to
a supra-pubic fistula which does not need an indwelling catheter. However, both these operations involve making scars in the region of the
spout, and consequently it is very difficult to gain a watertight fitting of
the collecting bag. Permanent bladder drainage by means of an indwelling
urethral catheter, or diversion of the ureters into an ileal conduit, are in
most cases preferable to these operations.
Diversion of the ureters
Ileal conduit
Turning now to the larger problem of diversion of the ureters, I consider
implantation of ureters into an ileal conduit as the most generally useful
form of diversion. The ureters are implanted with as little mobilization
as possible into an isolated short segment of ileum or colon which conducts
the urine onwards to a cutaneous stoma with a spout of 1 to 2 centimetres. Proper appliances can be fitted which are easy to manage and
they leak very infrequently if the stoma has been properly sited.
The site for any stoma must be chosen before operation, by selection
of an area free of scars and natural creases, supported by an accurately
located belt which is not disturbed by postural changes of the individual
during the performance of his usual work. Having selected the probable
site, an ileostomy bag filled with water is applied and the patient asked
to perform the type of movements which his work and general life will
entail. If satisfactory, this site is marked, and the stoma is formed at
this point at operation.
The other methods of ureteric diversion all have their place.
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Cutaneous ureterostomy
Normal ureters brought out on to the skin are very liable to stenosis,
and of course may require bilateral appliances. Mobilization of the
ureters, so that the ends can be joined to provide a single wider stoma,
has been advocated (ureters have even been brought forward through
the lesser sac), but particularly after radiotherapy the mobilization may
result in impairment of blood supply and sloughing, so these methods
have not achieved much popularity.
In grossly dilated megaureters or dilatation associated with lower
urinary tract obstruction in childhood, long term ' temporary' diversion
can be achieved by loop-ureterostomies, or where permanent diversion
is deemed necessary by terminal ureterostomy, with little risk of stenosis.
A single appliance can be achieved by swinging one ureter across the
posterior abdominal wall and anastomosing it end-to-side to the larger
ureter.
In such instances cutaneous ureterostomy can be most successful.
There is certainly no risk of biochemical disturbance from absorption,
and with care, providing stenosis does not occur, infection can be reduced
to a minimum. Ureteric function will improve, and the size of the renal
pelvis decrease.
Diversions into the colon
The advantages of this type of diversion over the conduit are that no
appliance is needed, the operation is shorter, no gut anastomosis is
involved, there is less ileus as the small gut mesentery is not handled,
and the urinary anastomosis can be totally extraperitonealized so the
risk of peritonitis is low. It must not be used in children because they
fail to grow properly; the total body potassium remains low and muscle
mass develops poorly.
The problems to be assessed in relation to diversions into the colon
are Continence, Infection, Pressure effects from the colon, Stenosis and
reflux, and Reabsorption.
Early in the 1950s reports began to appear, recognizing that urinary
diversion into the intact colon produced biochemical disturbances which
untreated could result in weakness, coma and death. These changes
are a hyperchloraemic acidosis, associated with low serum bicarbonate,
low serum potassium and low body water, aggravated by diarrhoea.
These changes are due to:
1. Diminished renal tubular function from pyelonephritis, back pressure
effects, and lowered water output.
2. Reabsorption of urea, chlorides and acids from the bowel. Reflux
up the colon and even round into the ileum can be seen to occur on
intravenous urography.
3. Excessive loss of water and potassium from irritation of the gut
by urine.
They are intimately related to the five problems listed above in italics,
but which I will consider separately:
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Continence: It is essential to prove that the patient can hold 6 to 8

ounces of fluid in the rectum for at least two hours while active, before
diverting the ureters into the sigmoid colon. However, after operation
patients must be discouraged from holding urine too long so as to limit
reflux round the colon and reabsorption of urea and chlorides.
Infection is inevitable where urine drains into intact large gut, and a
progressive pyelonephritis follows. A slow rate of progression depends
upon a high rate of urinary flow, and the absence of obstruction. The
prevention of frank reflux of colonic content is also of importance, but
less so than the other two factors.
Pressure effects from the colon: The importance of intra-colonic
pressures on renal function after transplantation of the ureters into the
colon has been stressed by Owen Daniel (1961). He describes a simple
method of assessing the resting colonic pressure, and suggests that if
the pressure is above 20 cm. of water, then a sigmoid myotomy (Reilly
1964) should be performed at the same time as the transplantation, from
the rectum to well above the site of the left uretero-sigmoidostomy.
Daniel and Ram (1965) describe the catastrophic results of high colonic
pressures in the period after transplantation. In two cases in which the
pressures rose to over 70 cm. water, acute ascending pyelonephritis
produced anuria and death within a few days. In another case with low
pre-operative pressures, post-operative levels of 50 cm. of water were
recorded, very little urine was passed in the first week, and progressive
renal failure resulted in death within a year.
Explosive expulsions of gas from nephrostomy tubes inserted into a
kidney, whose ureter had been transplanted into the colon, have been
reported by Whisenand and Moore (1951) and Rusche and Cook (1953);
and Dyke and Maybury (1924) showed the importance of high pressure
within the ureter and renal pelvis in the establishment of ascending
renal infection.
The most important single factor in the limitation of pyelonephritis
is to achieve a high urinary output, and this will not be attained in the
presence of back pressure.
Stenosis and reflux: Careful performance of the uretero-colonic
anastomosis employing the Leadbetter technique will reduce the risks
of stenosis and reflux (Fig. 2b). In order to prevent stenosis the ureter
should be cut obliquely, and if of normal calibre split for 1 centimetre.
The full thickness of the ureteric wall is then sewn with interrupted 4/0
chromic catgut to the edge of a mucosal hole of similar size after preparation of a mucosal bed obliquely across one of the taeniae. The muscle of
the bed is then sewn over the terminal 2 cm. of ureter to produce a tunnel
to limit reflux.
To prevent pressure rises in the ureter and pelvis after operation, the
ureter may be intubated with a small polyethylene tube, the end of which
is inserted into a rectal tube, and drawn out at the anus. Alternatively,
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a T-tube may be put into the ureter above the anastomosis and brought
out through a stab incision in the loin. If neither of these methods is
adopted, morphia should be avoided in the post-operative period unless
a sigmoid myotomy has been performed.
Trigono-colostomy, or Maydl's operation, is not applicable to malignant
cases, and in many cases of neurogenic dysfunction the normal ureterovesical competence may already have been lost, so the main advantage
of the procedure does not apply. However, the anastomosis is easy and
stenosis will not occur. The trigone should be left in place and the colon
mobilized and turned over on to the bladder base, so that as little disturbance as possible is made in the blood and nerve supply to the trigone.
Reabsorption of urine: Acids, chloride, and urea are reabsorbed from
the colonic mucosa, more particularly the upper reaches of the colon
and even, following reflux, from the terminal ileum. Reflux is probably
of more importance than time of contact with rectal mucosa, because if
a rectal bladder is formed, and the stool diverted by a left iliac colostomy,
biochemical problems rarely arise, even when urine is held in the rectal
stump for long periods. This lack of reflux is probably also helped by
absence of ascending infection. The difficulty in advising this type of
operation is my own reluctance to persuade a patient that, because his
bladder has to come out, he should have a permanent colostomy, which
in my opinion is more objectionable than having a urinary fistula, which
is relatively easy to keep free of odour.
Gersuny (1893) suggested, and Johnson (1953) and Lowsley and
Johnson (1955) have advocated, bringing the colostomy down through
the rectal sphincters and forming an anal colostomy behind the true anus.
Although the faecal and urinary streams are separated, the openings
adjoin, and infection must pass into the new bladder.
These factors almost invariably lead, as time passes and renal function
deteriorates, to a hyperchloraemic acidosis and a low body potassium.
Even though symptomless, patients should be kept on regular alkalis.
Potassium citrate and sodium bicarbonate, 2 grammes of each daily,
should be taken regularly. Any unusual tiredness, weakness, nausea or
diarrhoea should be reported and investigated by biochemical tests.
Patients must be told to empty their ' bladder' frequently, drink plenty
of fluid and avoid salt.
When considering the inter-relationship of these aspects of diversion
into the colon I am reminded of a grand old man I was asked to see with
a request for advice on his bladder extrophy. His age at this time was 75 !
As a child he had been taken to many of the London Teaching Hospitals,
but his parents had been advised that nothing could be done. He was
brought up at home with napkins and various rubber appliances, and in
due time joined his father as a carter in a large wine importing business.
Working underground much of the time in the cellars, it mattered little
if he wet his trousers or the floor. At the age of 40 he developed pneumonia
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and an empyema, for which he was treated in the Hammersmith PostGraduate Hospital. After recovery from this he was seen by Professor
Grey Turner and advised to have an operation. His ureters were transplanted one at a time into his colon. Unfortunately he had never been
continent, and had to wear a large rectal tube, joined by day to a leg
urinal and at night drained by a piece of garden hose into a bucket.
He had had no regular follow-up, but had attended several clinical
meetings. He cost the Hospital and later the Health Service only a few
pence each year for new rectal tubes and bags (he always bought his
own hose-pipe!). When I saw him, he still had some urothelium on the
anterior abdominal wall, but his blood urea was only 50 mgm. per cent,
chlorides 102 mEq. and bicarbonate 19 mEq./litre. He was reaching
the end of his days because of cardiac failure, but had never suffered
any biochemical imbalance of note because his rectum was only acting
as a conduit, and his incontinence had saved him from flow-back and the
consequences of reabsorption.
Ileal or colonic conduit diversions
These avoid many of the problems discussed above, and are undoubtedly
better from the point of view of preserving renal function. Reabsorption
is cut because contact time between urine and mucosa is limited, infection
is much reduced, but the problem of stenosis and reflux at the ureterointestinal anastomosis still remain. It is not easy to make a tunnel in
ileal wall, and I use a Cordonnier anastomosis. Advocates for the colonic
conduit point out the advantages of the Leadbetter anastomosis in
preventing reflux.
The main disadvantage of the operation is the need to wear an appliance
to collect the urine, and the occasional leaks which may occur. Clearly
the operation is undesirable in the blind, those who could not manage
the appliance because of severe rheumatoid arthritis or some other
defect of the hands, and in some who are psychologically incapable of
accepting a stoma of any kind. When laparotomy reveals incurable
disease, but palliative cystectomy is needed, then it seems better to avoid
an abdominal fistula if possible.
The preparation of the conduit involves an intestinal anastomosis,
with its consequent risk of leakage, and a stoma which may contract.
Although the operation is longer, I do not think the real risks are greater,
granted careful surgery and proper post-operative care. The ultimate
benefit to renal function far outweighs any slight increase in operative risk.
Technique of fashioning an ileal conduit
Preparation of the loop: This should be sited carefully, the distal point
of section must be at least a foot above the ileo-caecal valve to preserve
the absorption of Vit B12, and must leave a good blood supply to each
portion. The loop should ultimately be as short as possible. One should
prepare 24 cm. and later excise what is not required. The loop should, if
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PETER F. PHILIP

possible, have two arteries going into it; the proximal incision into the
mesentery can be quite short (Fig. 3).
The ileal continuity is re-established in front of the mesentery of the
conduit. The short incision proximally will prevent twisting of the root
of the conduit mesentery. All mesenteric gaps are carefully closed,
appendicectomy performed, and then the loop is routed from the promontory of the sacrum either retroperitoneally or across the peritoneum
to the site previously chosen for the stoma. The lateral gutter must be
closed if the loop crosses the abdominal cavity.
The ureters should be cut high: the blood supply to the lower ends
may be suspect after radiotherapy, and also because metaplasia of the
epithelium of the lower ends is not uncommon.
The ends may be split and joined together in front of the sacrum, and
inserted into the proximal end of the conduit, or the latter may be closed

DIVISION
Fig. 3. Preparation of ileal conduit. Division at the point marked X will assist
eversion of the gut wall and produce a better spout.

and the ureters inserted singly into the antimesenteric border of the loop.
It is vital that they should not be twisted or be angulated on their course
into the loop.
The stoma must have a spout of 1 to 2 cm. A disc of skin is cut out
at the chosen site, equal to the diameter of the ileum. The muscle wall
beneath is cut to allow free passage of the ileum. Eversion of the ileal
mucosa is maintained by suitable silk sutures. At the end of the operation
a colostomy bag is applied over the spout. Urine is aspirated hourly
from this by a catheter left in the top. Thus the colour of the ileal mucosa
is readily seen, and attention drawn rapidly to any sudden drop in
urinary output.
Post-operative care
If the gut is kept deflated until the paralytic ileus recovers, gut com302

AN APPRAISAL OF THE METHODS OF URINARY DIVERSION

plications are rare. The Ryles tube should be aspirated hourly, and
nothing is given by mouth until wind has been passed. Drains to the
site of the ureteric anastomosis should not be removed until all leakage
has ceased.
Complications
1. Of the stoma. Stenosis may occur at skin level but this is rare if
the spout is good. It is commoner in children. An alkaline dermatitis
may occur if the diaphragm fits badly.
2. Late stricture of the intestinal anastomosis, due to surgery in an area
of gut damaged by irradiation, may give rise to diarrhoea and a malmEq

tiC0O

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x=Urea o-Chloride

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100

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40

20

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'59

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Fig. 4. Effectiveness of an ileal conduit showing immediate fall of blood urea.

absorption syndrome. These may respond to steroids, but are best treated
by resection.
I will end this lecture with two examples of the effectiveness of an ileal
conduit. Figure 4 shows the slow rise in blood urea over the years following
a bilateral uretero-sigmoidostomy, and the immediate fall following
conversion to an ileal conduit, which was accompanied by a dramatic
change in well-being of the patient, and a rise in haemoglobin from
75 per cent to 96 per cent.
Finally, Figure 5 shows the beneficial results on renal function and
dilatation in a neurogenic bladder the result of paraplegia due to a
meningo-myelocele.
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PETER F. PHILIP

Fig. 5. Effect of ileal conduit on renal function in a patient with a neurogenic

bladder.
REFERENCES
DANIEL, 0. (1961) Ann. Roy. Coll. Surg. Engl. 29,205.
and RAM, R. S. (1965) Brit. J. Urol. 37, 664.
DYKE, S. C., and MAYBURY, A. C. (1924) Brit. J. Surg. 12, 106.
GERSUNY, R. (1893) quoted by HINMAN, F., and WEYRAUCH, H. M. (1936) Trans.
Amer. Ass. gen. -urin. Surg. 29, 15.
JOHNSON, T. H. (1953) J. Internat. Coll. Surg. 20, 464.
LOWSLEY, O. S., and JOHNSON, T. H. (1955) J. Urol. 73, 83.
REILLY, M. (1964) Proc. Roy. Soc. Med. 57, 556.
RUSCHE, C. F., and COOK, W. C. (1953) J. Urol. 70,447.
WHISENAND, J. M., and MOORE, U. (1951) J. Urol. 65, 564.

DONATIONS
DURING THE PAST few weeks the following generous donations have
been received:
21,000

The United Terminal Sugar Market Association (7-yr.

covenant, 3,000 p.a. less tax, towards funds of
Department of Dental Science).
1,000
The Yapp Education and Research Trust.
Cadbury Schweppes Limited (towards funds of Dental
Research Unit).
250
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105
The Toronto-Dominion Bank (further gift).
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In addition there have been a number of gifts under 100 which total 509 17s.
The following Fellows of the College, Fellow in Dental Surgery and Fellows in the
Faculty of Anaesthetists have generously given donations or entered into a covenant with
the College:
Sir Kenneth Adamson, C.M.G., F.D.S.R.C.S.
J. I. C. Mason, F.R.C.S.
L. S. A. Boothroyd, F.R.C.S.
A. G. Parks, F.R.C.S.
Mary Burnell, F.F.A.R.C.S.
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