ILEAL CONDUIT CALCULI FROM STAPLER

ANASTOMOSIS: A LONG-TERM COMPLICATION?

MARK BRENNER, D.O. DOUGLAS E. JOHNSON, M.D.

From the Department of Urology, The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Texas

ABSTRACT-A long-term review of24 patients in whom ileal conduit diversions were constructed using surgical staples has shown calculi developing as a result of the staples in only 1 patient (4.2 % ). Experience suggests that calculi usually form within fourteen months of surgery, pass sponta- _ _ neously, and produce minimal symptoms.

Interest in constructing continent ileostomies in patients requiring supravesical urinary diver- sion has raised concern that, when the autosu- ture device is used to secure the nonrefluxing nipple valves, the result will be an increased in- cidence of calculi secondary to encrustations around the metal staples. However, to date, no other satisfactory method has been devised, and surgical staples remain the only method availa- ble to construct a Kock pouch or other conti- nent urinary diversion. As these procedures are utilized more often, will patients be increas- ingly subject to calculus formation in the urinary diversion? In an attempt to answer this question, we have reviewed our long-term follow-up of 24 patients in whom we used the autosuture device to construct a ureteroileocu- taneous urinary diversion between 1971 and 1973.

Material and Methods We reviewed the charts of all 34 patients

who, between November, 1971, and February, 1973, underwent ureteroileocutaneous urinary diversion employing surgical staples at The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston. The autosu- ture stapling instruments (TA-30, TA-55, and GIA) were used to close the proximal end of the ileal conduit and to form the ileoileostomy. This

series consisted of 28 men and 6 women ranging in age from seventeen to seventy-five years (me- dian age 64 years). Patient follow-up ranged from one to one hundred and sixty-one months (average 50 months). Ileal conduit urinary diversion was performed in conjunction with radical cystectomy for malignant disease of the bladder or prostate in 31 patients. The remain- ing 3 patients underwent only urinary diver- sion. In reviewing the patient charts, we re- corded all episodes of urolithiasis, paying specific attention to calculus formation within the ileal conduit. We also carefully examined the x-ray films of every patient to confirm the presence of stapled suture lines and to record any unreported calculi.

The technique of autosuturing for urinary diversion has been described previously. ’ Briefly, once the ileal segment has been isolated, the surgeon applies the TA-30 instrument to the proximal end of the ileal segment, thus creating a double row of staggered staples that close the butt end of the ileal conduit. In this series, the stapled proximal end of the ileal conduit of all patients was inverted with interrupted sero- muscular silk sutures. Bowel continuity was re- established by placing a limb of the GIA stapler into the open lumen of each of the two ileal seg- ments. The GIA was then locked into place op- posite the mesenteric border, and the staple

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FIGURE 1. Calculi containing stainless steel staples passed twenty months after ileal loop construction.

device and knife were pushed forward, forming an open-ended, serosa-to-serosa, side-to-side anastomosis. A mucosa-to-mucosa closure of the open double-barrel stump was then per- formed by using the TA-55, resulting in a func- tional end-to-end anastomosis of the ileum.

Results

Only in 1 patient in our series did stones de- velop in the ileal conduit secondary to encrusta- tion around the staples. Approximately twenty months after urinary diversion, she painlessly passed 3 small stones, each of which contained a stainless steel staple (Fig. 1). This same pa- tient also had a significant degree of stoma1 stenosis that ultimately required stoma1 revision approximately ten years after her original sur- gery*

Figure 2 indicates the length of follow-up of our 34 patients. Review of the literature reveals an average time to first conduit stone formation

0 1 2 3 4 5 6 7 8 9 1011121314

Years

FIGURE 2. Years of observation for entire series.

of approximately fourteen months. If we delete all those in our series followed less than four- teen months (10 patients), we are left with a long-term study population of 24 patients; in these, the adjusted incidence of conduit stone formation is 4.2 per cent. Eleven patients have been followed longer than five years; 4 have been followed longer than twelve years and are still alive and free of conduit calculi (including the 1 patient who formed 3 stones 20 months postoperatively).

Comment

Johnson and Fuerst, in 1973,’ reported their use of surgical staplers to construct ileal con- duits in 24 consecutive patients who had under- gone a ureteroileocutaneous urinary diversion for malignant disease of the bladder or pros- tate. Operative time had been shortened, post- operative paralytic ileus had resolved sooner, and postoperative complications related to the use of the stapling device were minimal. De- spite this report, urologists have been hesitant to use the autosuture technique, primarily be- cause of their concern that stones will develop in the ileal conduit secondary to encrustation around the staples.

The literature contains conflicting reports re- garding the actual incidence of this complica- tion. Early investigators who used the tech- nique for a few patients reported a high incidence of ileal conduit stone formation around surgical staples: Assadnia et uZ.,~ in 1972, reported that stones formed around metal staples in the ileal conduits of 2 of the 5 patients in whom they had performed a cystectomy plus ureteroileocutaneous urinary diversion using surgical staples. Bergman, Sears, and Javad- pour in 1978,3 reported conduit stone formation in 1 of 2 patients in whom they had used surgi- cal staples. These investigators concluded that surgical staplers have no place in urologic operations because the risk of stone formation is too high.

However, those who have used the autosu- ture device in large numbers of patients have placed the incidence of stone formation at 7.3 per cent or less. 4-7 Karamcheti et al. ,5 who have used metal staples to construct ileal conduits in 110 patients, published in 1978 a comparison of these patients and 55 others in whom they had used a conventional suture anastomosis. Con- duit stones formed on exposed staples in only 2 of the 110 patients with surgical staples, an inci- dence of only 1.8 per cent. No conduit stones

538 UROLOGY i DECEMRER 1985 i VOLUME XXVI. NUMRER 6

were reported in the 55 patients with conven- tionally sutured conduits. More important, the authors demonstrated that the stapling tech- nique reduced the average operating time by more than one hour, postoperative ileus by two to three days, and the average postoperative hospital stay by five to six days. They concluded that the surgical staplers represented an im- provement in the method of ileal conduit con- struction. Also in 1978 Heney et al6 reported their experience with 41 patients in whom they had closed the base of the urinary intestinal conduit with the autosuture device (12 colonic, 25 ileal, and 4 jejunal). Four of their patients passed stones through their conduit (2 colonic, 1 jejunal, and 1 ileal), but only 3 had embedded staples, resulting in an incidence of 7.3 per cent. All stones passed spontaneously, gross he- maturia did not occur, and discomfort during stone passage was minimal. While advising against inverting the stapled proximal end of the conduit, the authors conclude that the sta- pling device reduces operating time, bowel ma- nipulation, and peritoneal contamination.

By 1981, Wheeless and Dorseys had per- formed 52 urinary diversions (40 ileal, 12 co- ionic) in which they used metal surgical staples to close the proximal end of the urinary con- duit; in 2 patients conduit stones subsequently formed secondary to encrustation around sta- ples. Both patients’ stones were easily removed endoscopically. The predominant complication in these 2 patients was increased urinary tract infections. In 1982, Myers, Rife, and Barrett7 added 94 patients whose ileal conduits were constructed with surgical staplers. They com- pared the results of these operations with data from 199 ileal conduits and ileoileostomies con- structed with standard suture methods and con- cluded that stapling devices provide an effective alternative to standard suturing methods. Stones formed on conduit staples in 3 of 94 pa- tients, an incidence of 3.4 per cent. The calculi in all 3 patients passed spontaneously and asymptomatically. They determined stone for- mation in the ileal conduit secondary to encrus- tation around staples was a minor complica- tion, occurred infrequently, and should not deter one from using the surgical staplers to close the proximal end of the conduit.

Recently, Skinner, Boyd, and Lieskovskyg have reported their experience with the Kock continent ileal reservoir as a means of urinary diversion. They use the TA-55 stapler to form the nonrefluxing nipple valves and have ob-

served stone formation on exposed staples at the end of the intussuscepted nipple valves in 4 of 201 patients (D. G. Skinner, personal com- munication). They note that the only exposed metal staples are those near the tip of the nipple valve and point out that this is where the stones form. Since they have determined that the sta- ples at the end of the nipple do not contribute to maintenance of the intussusception, they now remove from the stapling instrument the 5 sta- ples closest to the end of the nipple, thus remov- ing the potential nidus for stone formation. The staples near the base of the intussuscepted nip- ple valve become buried in the mucosa, and no stones have been observed at that location. The authors conclude that stones that do form in the Kock pouch can be easily removed endoscopi- tally.

Absorbable staples* are now available as an alternative to metal ones. The Polysorb 55 Lac- tomer copolymer absorbable staple (lactide- glycolic copolymer) was developed in 1982 and fits the TA-55 stapler. These staples are ab- sorbed in tissue via hydrolysis rather than poly- nuclear phagocytosis, thus reducing necrosis in the tissues and improving wound healing. Wheeless4 recently reported using the TA-55 Polysorb staples to close cystostomies, the proxi- mal end of ileal loops, the vaginal cuff, and the tubo-ovarian round ligament in abdominal hys- terectomies. He suggests that using absorbable staples on the proximal end of the ileal loop would reduce the already low incidence of stone formation.

We recognize that an exposed metal staple can, indeed, serve as a nidus for stone forma- tion, but the incidence appears to be low: our 4-2 per cent rate is consistent with that reported in other larger series. 4-8 The majority of calculi form within the first fourteen months postoper- atively, and none has been reported occurring longer than twenty months postoperatively. Our experience, spanning twelve years, has re- vealed no long-term or chronic stone formers. Calculus formation appears to be a minor com- plication: all stones have been passed sponta- neously or been removed endoscopically, caus- ing minimal discomfort. Therefore, although we have expressed concern in the past over pos- sible calculus formation,1° we are again routinely using the autosuture technique to

*United States Surgical Corporation. Norwalk. Connecticut 068.50.

UROLOGI’ DECEMBER lSS5 VOLUME: XXVI. NUMBER 6 539

close the proximal end of the see few problems in using the struct other forms of urinary

conduit and fore- I technique to con-

. d iversion.

Department of Urology, Box 110 6723 Bertner Avenue

Houston, Texas 77030 (DR. JOHNSON)

References

1. Johnson DE, and Fuerst DE: Use of autosuture for construc- tion of ileal conduits, J Urol 109: 821 (1973).

2. Assadnia A, Lee CN. Petre JH, and Lyons RC: Two cases of stone formation in ileal conduits after using staple gun for closure of proximal end of isolated loop, ibid 108: 553 (1972).

3. Bergman SM, Sears HF, and Javadpour N: Complication with mechanical stapling device in creation of ileoconduit, Urol- ogy 12: 71 (1978).

4. Wheeless CR: Stapling techniques in operations for malig- nant disease of the female genital tract, Surg Clin North Am 64: 591 (1984).

5. Karamcheti A, et al: Autosuture ileal conduit construction: experience in 110 cases. J Urol 120: 545 (1978).

6. Heney NM, Dretler SP, Hensle TW, and Kerr WS: Autosu- turing device in intestinal urinary conduits, Urology 12: 650 (1978).

7. Myers RP, Rife CC, and Barrett DM: Experience with the bowel stapler for ileal conduit urinary diversion, Br J Uro154: 491 (1982).

8. Wheeless CR, and Dorsey JH: Use of the automatic surgical stapler for intestinal anastomosis associated with gymecologic ma- lignancy: review of 283 procedures, Gynecol On&l 11: l(1981).

9. Skinner DG. Bovd SD. and Lieskovskv G: Clinical exoe- , rience with the Kock continent ileal reservoir for urinary diver- sion, J Urol 132: 1101 (1984).

10. Costello AJ, and Johnson DE: Modified autosuture tech- nique for ileal conduit construction in urinary diversion, Aust NZJ Surg 54: 477 (1984).

540 UROLOGY i DECEMBER 1985 i VOLUME XXVI. NUMBER 6