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A 30-year female with history of ulcerative colitis and partial colectomy presented with rectal bleeding and fecal and urinary incontinence. She had active colitis with granulation tissue, crypt abscess formation, extensive regenerative changes, and lymphoid aggregate formation. She also had a contracted bladder and vesicovaginal fistula. She underwent total proctocolectomy and cystectomy. Simultaneous urinary and fecal diversion was achieved with a double-barreled wet ileostomy (DBWI). The anterior pelvic exenteration was technically challenging secondary to prior surgery, but no major complications were encountered. This is the second known reported case following development of the DBWI technique in 2005. The case shows that DBWI can be safely performed after total colectomy and pelvic exenteration, with no serious complications or morbidity in the first 19 months. This technique may be particularly advantageous for patients with fistulous intestinal tracts.
KEYWORDS: Pelvic exenteration; Urinary diversion
CORRESPONDENCE: Sertac Yazici, MD, Hacettepe University School of Medicine, Department of Urology, Sihhiye, Ankara 06100, Turkey ().
CITATION: Urotoday Int J. 2010 Jun;3(3). doi:10.3834/uij.1944-5784.2010.06.02
ABBREVIATIONS AND ACRONYMS: DBWI, double-barreled wet ileostomy; UC, ulcerative colitis.
Reconstruction of the urinary and gastrointestinal tracts after pelvic exenteration is a difficult procedure, even for experienced surgeons. The present complex case involves a patient who had a total proctocolectomy and cystectomy. This is the second known case reported in the literature where a double-barreled wet ileostomy (DBWI) was used.
A 30-year-old female with a history of ulcerative colitis (UC) presented with rectal bleeding and total fecal incontinence. She had undergone a partial colectomy 5 years previously because of the UC. She reported intensive rectal bleeding for the last 6 months, despite receiving sulfasalazine and steroid treatment for the previous 6 years. The bleeding was also resistant to cyclosporine and infliximab therapy. In addition, the patient reported total urinary incontinence for the last 6 months. She had a history of Fournier gangrene due to traumatic catheterization 3 years ago.
Colonoscopy demonstrated active ulcers and numerous pseudopolyps throughout the colon. Histological examination confirmed active colitis with granulation tissue, crypt abscess formation with eosinophilic infiltration, extensive regenerative changes, and lymphoid aggregate formation.
The urethral meatus was not visualized on physical examination. Cystoscopic examination under general anesthesia revealed that the external meatus was localized 2 cm inside the anterior vaginal wall. The bladder capacity was < 50 mL, and a fistula tract was seen between the bladder and vagina. Methylene blue injected into the bladder extravasated into the vagina. The fistula tract between the posterior bladder wall and the anterior fornix of the vagina was also seen on pelvic magnetic resonance imaging (MRI) (Figure 1).
The patient underwent total proctocolectomy and cystectomy. A DBWI was performed, with 15 cm of ileum sustained at the distal end. The ureters were spatulated for a distance equal to the diameter of ileum, and their posterior edges were joined side-by-side. Then, the joined ureters were anastomosed to the open ileal segment, as described previously by Wallace . The loop was exteriorized to the abdominal wall following the implantation of the ureters (Figure 1). Pigtail ureteral stents were placed bilaterally to prevent twisting and angulation. The stents were kept in the ureters for 3 weeks.
No perioperative or postoperative complications were encountered. The 1-year follow-up evaluation revealed no metabolic complications, with normal serum creatinine levels. The patient reported no difficulty maintaining the stoma bag. At the 19-month follow-up evaluation, bilateral grade 1 ureterohydronephrosis was observed on ultrasonographic imaging. However, the patient did not develop any electrolyte disturbances, deterioration in renal function, or pyelonephritis during the follow-up period.
Extensive surgical procedures such as anterior pelvic exenteration require the reconstruction of the urinary and gastrointestinal tracts, which may be a technical challenge for the surgeon. In such cases, 2 separate stomas are typically used for fecal and urinary diversion, and an ileal segment is used for the ureteral anastomoses . Simultaneous urinary and fecal diversion into a single stoma using the colon was first described by Carter et al . This procedure was called a double-barreled wet colostomy. The authors reported good results, with no serious metabolic problems or urinary tract infections. These successful results were later reproduced by other surgeons [3,4,5,6].
The double-barreled wet colostomy is surgically simple, provides patient comfort, and is reported to be safe. Operative morbidity is expected to be lower, because the surgery time is short when compared with the time needed to create separate stomas. The single stoma also decreases the amount of time that the patient needs to spend on daily care. Most importantly, the antireflux mechanism eliminates the risk of pyelonephritis.
For the patient in the present report, the surgeons used the ileal segment for both urinary and intestinal diversion because the patient needed complete resection of the colon. This DBWI procedure was first described by Guimaraes et al in 2005 . These authors performed the DBWI in a patient following neoadjuvant radiotherapy for a rectal tumor that was associated with familial adenomatous polyposis. They reported successful outcome at a 14-month follow-up evaluation.
In the present case, the possibility of short bowel syndrome was ruled out. Although the distal ileal segment in which the ureters were anastomosed was antiperistaltic in nature, the ureters were implanted into the distal segment of the loop ostomy using a nonreflux technique. Because the urinary and intestinal stream meet at the stoma level, the contact of intestinal output with the ureterointestinal anastomosis is decreased. The authors did not observe any upper urinary tract infection resulting from possible reflux. Assessment of the renal function 1 year after the procedure showed that serum creatinine level was normal, and ultrasonography revealed minimal dilatation of the upper urinary tract bilaterally. No metabolic changes were observed during the follow-up period.
The present report adds to the limited literature on this topic. This case shows that DBWI can be safely performed after total colectomy and pelvic exenteration, with no serious complications or morbidity in the first 19 months. This technique may be particularly advantageous for patients with fistulous intestinal tracts, such as those with ulcerative colitis or Crohn's disease. There appears to be a significant improvement in the patient's quality of life, probably due to the advantages of a single stoma. The DBWI technique was first reported 5 years ago. Therefore, additional long-term follow-up with more patients is needed to show if the risks of carcinoma, metabolic derangements, pyelonephreitis, or renal deterioration are increased for patients with this procedure, when compared with the more traditional ileal conduit and ileostomy.
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