Reoperative ureteroneocystostomy: review of 69 patients

Laparoscopic Ureteral Reimplantation after Failed Open Surgery: Incorporating the Psoas Hitch Maneuver for Sufficient Tunnel Length

BACKGROUND

 Failure after open ureteral reimplantation has been reported to occur in 2 to 7% of cases. While a second open reconstructive surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The objective of this study is to describe a modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation reinforced with a psoas hitch.

MATERIALS AND METHODS

 A retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between September 2012 and April 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications, and outcomes were reviewed. Either ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches or a cross-trigonal extravesical approach was utilized, depending on the length of the ureter. In all cases, a psoas hitch was performed to gain a longer submucosal tunnel and relieve tension, thus facilitating an efficient antireflux mechanism.

RESULTS

 Seventeen patients underwent a laparoscopic ureteral reimplantation after failed open surgery. Median age at second surgery was 106 months (interquartile range [IQR]: 53-122.5). Ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches was performed in 11 cases and cross-trigonal extravesical approach in 6 cases. Median ureteral diameter before the redo surgery was 16 mm (IQR: 14.5-18.5) and after surgery was 6 mm (IQR: 3.5-8.5) (p < 0.001). Postoperative mercaptoacetyltriglycine renal scan showed a nonobstructive pattern and stable renal function in all cases.

CONCLUSION

 Laparoscopic ureteral reimplantation with incorporation of a psoas hitch after failed open reimplantation is safe and effective.

A modified technique for ureteral reimplantation: intravesical detrusorrhaphy

PURPOSE

To describe the surgical procedure of intravesical detrusorrhaphy, a modified technique of ureteral reimplantation, and report our initial experience.

METHODS

From October 2007 to March 2012, 55 children with vesicoureteral reflux (VUR) and 13 children with obstructive megaureter (OM) underwent intravesical detrusorrhaphy. All surgical procedures were performed via an open intravesical approach. The ureter was mobilized, and the bladder mucosa was separated from the detrusor in a cephalad direction. The separated detrusor was incised vertically and repaired underneath the mobilized ureter to create the submucosal tunnel. The ureteral orifice was anastomosed to its orthotopic position.

RESULTS

Of 31 patients treated with bilateral intravesical detrusorrhaphy, no patient had postoperative urinary retention. Follow-up voiding cystourethrography was performed in 45 patients with 72 reimplanted ureters. VUR was resolved in 41 patients (91.1%) with 68 ureters (94.4%). Among 13 patients with 14 ureters treated for OM, hydroureteronephorosis improved in 11 patients (84.6%) with 12 ureters (85.7%).

CONCLUSIONS

Intravesical detrusorrhaphy is modified technique of ureteral reimplantation, which recreates the neo-ureteric orifice in the orthotopic position and does not produce postoperative urinary retention in bilateral cases. Intravesical detrusorrhaphy is safe and effective in treating patients with VUR or OM.

Vesicoureteral reflux

Vesicoureteral reflux, the abnormal flow of urine from the bladder into the ureter, is one of the most common congenital anomalies found in children. The association of vesicoureteral reflux with urinary tract infections and renal scarring has important clinical implications. New insights into pathogenesis and new surgical techniques are changing the approach to the management of this disorder.

Results of the Gil Vernet procedure in preventing contralateral reflux in unilateral ureteric reflux

OBJECTIVE

To evaluate whether contralateral meatal advancement based on the technique described by Gil Vernet decreases the risk of postoperative contralateral reflux, which may occur after a unilateral reimplantation.

PATIENTS AND METHODS

From January 1986 to 1997, 321 reimplantations were performed for unilateral vesico-ureteric reflux (VUR) using the Cohen procedure. In cases where the contralateral meatus was symmetrical or had a pathological appearance, preventive contralateral surgery with meatal advancement was performed.

RESULTS

Ureteric reimplantation was exclusively performed unilaterally in 254 patients and in 67 a contralateral meatal advancement was performed. There were 29 cases of contralateral reflux at the 4-month follow-up. In nine patients contralateral reimplantation was necessary for persistent symptomatic VUR, the reflux resolved spontaneously in 14 and a radiological examination was necessary in six. Reflux also appeared on the Gil Vernet side in only 6% of patients; there were no clinical symptoms and the outcome was favourable.

CONCLUSION

The advancement of the meatus using the Gil Vernet procedure is simple, with no surgical complications. We suggest that this technique constitutes a useful surgical alternative in the prevention of contralateral reflux.

Endoscopic treatment of vesicoureteric reflux in transplanted kidneys

Twenty-one patients underwent endoscopic subureteric injection of Polytef paste for the correction of secondary vesicoureteric reflux (VUR) in transplanted kidneys. Ureteroneocystotomy was performed in renal transplants using an extravesical technique in 19 patients and the Leadbetter-Politano technique in 2 cases. Success was achieved in only 6 patients, including the 2 ureters reimplanted according to the Leadbetter-Politano technique. No significant complication relating to the technique was observed. Despite the low success rate (30%), endoscopic treatment of VUR in transplanted kidneys is justified as a first attempt in view of the morbidity of VUR and the difficulties of repeated surgical reimplantation in this population.

Ureteral reimplantation: a comparison of results with the cross-trigonal and Politano-Leadbetter techniques in 120 patients

A review of 120 children who underwent ureteral reimplantation by the cross-trigonal or Politano-Leadbetter technique is presented. Over-all success rates (no postoperative reflux or ureteral obstruction) were 96.7% for the Politano-Leadbetter method and 97.8% for the cross-trigonal technique. There were no failures using either method in patients operated upon for primary vesicoureteral reflux.

Surgical management of vesicoureteral reflux by modified Gil-Vernet method

Modified antireflux Gil-Vernet technique was used in the surgical management of primary vesicoureteral reflux grades II and III in 62 patients (60 children, 2 adults). Reflux has been eliminated in 90.3% of the patients. In patients with persisting reflux it was of lower grade than before surgery and showed a tendency to spontaneous disappearance when treated conservatively. Taking into consideration also the late results of elimination of the reflux, the success rate is comparable to that in other antireflux methods. In none of our patients has obstruction or other more serious complication occurred. Advantages of this technique are stressed, first of all its simplicity, preservation of musculature of terminal ureters, possibility of management of both ureters and absence of complications, mostly of obstructive character.