Ureterosigmoidal transplantation for exstrophy of the bladder and complete epispadias with absent urinary sphincters

Abstract I am convinced that in children with exstrophy of the bladder or complete epispadias and urinary incontinence, the ureters are best transplanted into the rectosigmoid at different stages and that accurate submucosal transplantation, with the open end of the ureter carried into the lumen of the sigmoid, can be performed with a low mortality rate and with good results. In a study of 26 such cases in which I operated at The Mayo Clinic in the last six years, one patient died from calcareous pyonephrosis of the kidney opposite to the one of which the ureter was transplanted. The others made good operative recoveries. Cabot has operated in 20 consecutive cases, without a death. The absence of clinical evidence of serious infection in or about the ureterosigmoidal anastomosis in this group of cases would seem to be convincing evidence that the open end of the ureter can be placed accurately in the lumen of the bowel without particular fear of infection developing at the site of the anastomosis. This being the case, the advantage of the transfixion suture-necrosis technique which has been described as an aseptic method of anastomosis would appear to have no particular advantage. Furthermore, the possibility is real that the suture might not cause the necessary necrosis and that the anastomosis consequently would not establish itself, thus leading to hydronephrosis and destruction of the kidney; such results have been reported. In experimental animals the transfixion suture-necrosis technique was followed by immediate or remote hydronephrosis with considerable destruction of renal parenchyma in practically every case. The time of appearance of the urine in the rectum may vary from a few hours to several days subsequent to ureterosigmoidal transplantation, without effect on renal function. Cystectomy and plastic operations on the penis should be parts of every operation for exstrophy of the bladder. These procedures remove the chronically irritated bladder that is prone to undergo malignant degeneration and restore the penis to a reasonably normal contour. When the mortality statistics of bilateral, simultaneous ureteral transplantation with the use of catheters, are compared with the results obtained by the method used in the treatment of exstrophy of the bladder in 99 cases during the past twenty-one years at The Mayo Clinic, in which the ureters have been transplanted in separate stages and tubes or catheters have not been used; it is evident that the published risk of bilateral simultaneous transplantation is far in excess of that when the ureters are transplanted in stages without the use of catheters. Furthermore, particularly in children, the advantages of simultaneous bilateral transplantation are not apparent since the hospital morbidity in these cases and in cases in which the operation in two stages is used, is practically identical. Adding further weight to the argument in favor of ureteral transplantation in stages, is the fact that more severe and more prolonged reactions follow the operation of bilateral simultaneous ureteral transplantation.