Complications of transverse advancement ureteral reimplantation: diverticulum formation

[Evidence-based medicine and vesicoureteral reflux]

Vesicoureteral reflux (VUR) remains one of the most controversial subjects in paediatric urology. Much literature has been published on VUR, making the understanding of this anomaly and its treatments quite opaque. Evidence-Based Medicine (EBM) should be helpful to clarify the various VUR approaches contained in the 6224 titles found on Medline using the keywords "vesicoureteral reflux" and "vesicoureteric reflux". These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. This review of VUR literature suggests that most of our knowledge is based on publications with a low level of evidence, and that EBM lacks arguments to support recommendations for VUR diagnostic and treatment. It appears yet that antenatal dilatation of the urinary tract and symptomatic urinary tract infections (UTI) justify VUR screening. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in case of persistent asymptomatic VUR regarding indication and duration of antibio-prophylaxis, and selection of radical treatment.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Is primary obstructive megaureter repair at risk for contralateral reflux?

PURPOSE

Contralateral vesicoureteral reflux occurs after successful unilateral reflux repair in a significant proportion of patients without correlation to the surgical approach. Unilateral congenital obstructive megaureter was compared to primary vesicoureteral reflux with regard to the risk of onset of contralateral reflux after unilateral ureteral reimplantation.

MATERIALS AND METHODS

Unilateral congenital obstructive megaureter was diagnosed in 58 consecutive patients 2 to 10 years old (mean age 3.2). Cross-trigonal ureteroneocystostomy was performed in 57 cases and longitudinal ureteral reimplantation, according to the Politano-Leadbetter technique was done in 1. Longitudinal tapering according to Hendren was performed in 44 ureters, and the Kalicinski folding was used to repair 11 ureters. All patients underwent serial renal ultrasound, diethylenetetraminepentaacetic acid nuclear scan, excretory urogram and voiding cystourethrogram. The control group was composed of 98 age matched children with unilateral vesicoureteral reflux who underwent unilateral reimplantation with or without tapering. Fisher's exact test and Student's t test were used for statistical analysis.

RESULTS

Followup ranged from 1 to 5 years. All patients in both groups underwent a voiding cystourethrogram at 6 months, and renal ultrasound at 3, 6 and 12 months postoperatively. Grade 2 reflux developed in 1 study group patient after contralateral Kalicinski ureteral folding and cross-trigonal reimplantation (1.7%). In the control group new onset contralateral reflux developed in 11 cases (11.2%). The difference was statistically significant (p <0.005, Fisher's exact test p = 0. 033).

CONCLUSIONS

Ureteral reimplantation for unilateral congenital obstructive megaureter is not correlated with the development of contralateral reflux. The occurrence of contralateral reflux after successful unilateral reflux repair is high (11.2%), and is not correlated with age, sex and technique of reimplantation or tapering. These results support the hypothesis that the functional anatomy of the trigone is preserved in congenital obstructive megaureter but is impaired on both sides in cases of unilateral vesicoureteral reflux. The surgical management of unilateral primary vesicoureteral reflux and congenital obstructive megaureter should be differentiated based on these results.

Contralateral vesicoureteral reflux after simple and tapered unilateral ureteroneocystostomy revisited

PURPOSE

We reviewed our experience with contralateral vesicoureteral reflux following unilateral ureteroneocystostomy.

MATERIALS AND METHODS

We retrospectively identified 88 children who underwent unilateral ureteroneocystostomy from 1986 through 1995, including standard repair in 69 and tapered repair in 19. Cystoscopy was performed in all cases immediately before repair.

RESULTS

Grades IV to V vesicoureteral reflux was identified preoperatively in 34% of the patients, including 13 (19%) and 14 (74%) who underwent standard and tapered repair, respectively. Renal duplication was noted in 24% of the cases, including 18 standard (26%) and 3 tapered (16%) repairs. An abnormal contralateral nonrefluxing ureteral orifice was present in 8 of the 53 standard (15%) and 3 of the 14 (21%) tapered cases. Ipsilateral reflux was corrected in all children undergoing standard repair but it persisted in 4 (21%) in the tapered repair group. Postoperatively contralateral vesicoureteral reflux developed in 1 child (1.4%) in the standard and 1 (5.3%) in the tapered repair group.

CONCLUSIONS

Contralateral vesicoureteral reflux is rare and does not appear to be influenced by preoperative reflux grade, a duplicated system or the endoscopic appearance of the ureteral orifice.

Contralateral ureteral meatal advancement in unilateral antireflux surgery

PURPOSE

Contralateral vesicoureteral reflux is a well-known development after successful unilateral ureteral reimplantation that is not apparently influenced by the reimplantation technique. We sought to determine whether bilateral reimplantation should be performed routinely in unilateral cases.

MATERIALS AND METHODS

From 1984 to 1995 we performed contralateral ureteral meatal advancement in 53 children 1 to 9.5 years old (mean age 2.5) undergoing surgery for unilateral grades II to V vesicoureteral reflux, including 12 with reflux in duplex systems. Ureteral meatal advancement involves a transverse Y shaped mucosal incision from the nonrefluxing orifice to the opposite hemitrigone. The inferior half of the ureteral orifice is then advanced toward the midline using 3 or 4 long-term resorbable sutures. The control group included 98 children who underwent unilateral surgery for grades II to V reflux from 1990 to 1995.

RESULTS

No evidence of vesicoureteral reflux was observed in the 53 children who underwent contralateral meatal advancement. There was no obstruction or other complications. At followup contralateral reflux was found in 11 controls after unilateral reimplantation.

CONCLUSIONS

Contralateral reflux has been reported in up to 27% of previously reported cases and in 11% of our control group after successful unilateral antireflux surgery. Contralateral ureteral meatal advancement has proved effective for preventing reflux in 100% of cases. It requires minimal invasion of the nonrefluxing ureter, and little additional operative time and cost.

Tumour in a giant bladder diverticulum: a case report and review of literature

We report an unusual case of a transitional cell carcinoma arising in a bladder diverticulum presenting as a giant abdominal mass and acute urinary retention. We have reviewed the literature and discuss the aetiology, diagnosis, and treatment of tumours arising in vesical diverticula.

The mechanism of new onset contralateral reflux following unilateral ureteroneocystostomy

PURPOSE

We studied a population of patients undergoing unilateral antireflux surgery to determine the mechanism of new onset contralateral reflux postoperatively.

MATERIALS AND METHODS

A total of 141 patients underwent unilateral antireflux surgery via the Cohen, Glenn-Anderson or extravesical technique. The 18% of patients who had new onset contralateral vesicoureteral reflux were analyzed according to grade of initial reflux, presence of a Hutch diverticulum or duplex system and surgical technique.

RESULTS

Surgical technique did not influence the development of contralateral reflux. As grade of corrected reflux increased, a significant trend toward development of contralateral reflux was noted. A Hutch diverticulum was not a risk factor for contralateral reflux but reflux into a duplicated system was a distinct risk factor (26 versus 12% in single system reflux).

CONCLUSIONS

Our study supports the concept that new onset contralateral reflux may result from elimination of a pop-off mechanism. Surgical distortion of the contralateral hemi-trigone appears not to be responsible. Correction of severe (grade V) reflux and reflux into duplex systems put patients at particular risk for development of contralateral reflux postoperatively.

Laparoscopic transperitoneal bladder diverticulectomy: surgical technique

A large bladder diverticulum causing poor emptying in an 84-year-old man was removed laparoscopically in a 6.5-h operation. The patient was discharged from the hospital on the third postoperative day, having had minimal analgesic requirements. A Council catheter and stylet in the diverticulum greatly facilitated identification of the sac with the laparoscope. Difficulties with intracorporeal knot tying were avoided by using the Lapra-Ty system. Experienced laparoscopic surgeons may find this method of diverticulectomy valuable. With experience, the operating time should be reduced.

Cecoureterocele: experience of three cases with special reference to the relevance of endoscopic incision

We report three cases of cecoureterocele to emphasize the salient features of this rare clinical entity. The differentiation of it from the usual ectopic ureterocele requires careful examination of the urethra by voiding cystourethrography and cystourethroscopy. We describe the management of these three cases with special reference to the endoscopic incision of the obstructing tissue.

Vesicoureteral reflux in complete ureteral duplication: surgical options

Vesicoureteral reflux is the most common abnormality seen with complete ureteral duplication. The majority of cases require surgical correction. The techniques used in 62 patients with 71 duplicated systems with reflux are reviewed. Reflux into the lower pole was encountered in 51 duplicated systems, both poles in 19 systems and the upper pole in 1. A total of 42 conjoint ureteral reimplantations was performed but in 8 cases only the lower pole ureter with reflux was reimplanted after it was separated from the nonrefluxing ureter. Ipsilateral ureteroureterostomy was performed in 19 cases of lower pole reflux. Two patients underwent lower pole heminephrectomy. Satisfactory results were obtained by all 3 reconstructive techniques. However, for lower pole reflux we recommend ipsilateral ureteroureterostomy unless a contralateral operation also is necessary. Ureteroureterostomy proved to be a simple and safe operation free of complications, with little morbidity and requiring a shorter hospitalization.

Management of vesico-ureteric reflux in myelodysplasia neurogenic bladder

During the period 1978-87, 22 patients with myelodysplasia had surgery for vesico-ureteric reflux (VUR) and seven patients with VUR were managed non-operatively. Clean intermittent catheterization was an integral part of the management in both the operated and non-operated cases. The majority of patients had reflux-related upper tract changes pre-operatively, but after operation the urinary tract was stabilized in all but one kidney which was lost. Transverse advancement ureteric reimplantation or the pull-through technique provided satisfactory results, giving a total of 29 refluxing units managed surgically.

Bilateral ureteral meatal obstruction after ureteroneocystostomy

Anuria due to complete obstruction at the level of the ureteral meatus was encountered after bilateral ureteral reimplantation. The cause was thought to be due, at least in part, to excessive length of distal ureter drawn into the submucosal tunnel. At reoperation, both ureteral meatus were found to be stenotic and to project intravesically. Bilateral ureteral meatotomy was performed and proved to be curative.

Operative treatment of bilateral vesicoureteral reflux by our own method of ureter reimplantation

The results of treatment of 50 patients with bilateral vesicoureteral reflux (VUR) are presented. In all patients our own method of reimplantation of the ureters consisting in making a single, common submucosal tunnel situated on the back wall of the bladder was employed. The observations made and the results obtained prove the usefulness of the described operative technique in the treatment of bilateral vesicoureteral reflux.

Follow-up of renal morphology and growth of 141 children operated for vesicoureteral reflux: a retrospective computerized study

This study relates the postoperative evolution after ureterovesical reimplantation for vesicoureteral reflux (VUR) in 141 children who were ten years old or younger at the time of surgery. Renal growth and morphology were evaluated 2 and 5 years after surgery. We estimated renal growth by measuring the ratio of the bipolar parenchymal thickness to the total length of the kidney. We noticed that whatever the degree of reflux might have been, most of the kidneys partially or totally compensated for their growth failure. This growth resumption required many years to be completed. Surgical correction of VUR had favorable consequences on the radiologic aspect of pyelonephritic scars only on some of the kidneys: in these cases, the child's age appeared to be the only factor that had a statistical importance affecting the postoperative evolution of pyelonephritic scarring: the younger the children were at the time of surgery, the better the results obtained.

Reoperative ureteroneocystostomy: review of 69 patients

Reoperative ureteroneocystostomy in 69 patients with primary vesicoureteral reflux was reviewed. Of the renal units 49 were obstructed and 48 had reflux. Postoperative obstruction was caused by mechanical factors in 61 per cent of the renal units, distal ureteral scarring in 31 per cent and a previously unrecognized functionally neurogenic bladder (without a neurological lesion) in 8 per cent. Persistent postoperative reflux was secondary to a short submucosal tunnel in 94 per cent of the renal units and occult neurogenic bladder in 6 per cent. Reoperative ureteroneocystostomy was successful in 79 per cent of the renal units, with a mean followup of 33 months. The modified Paquin technique (omitting the ureteral cuff) yielded consistently superior results in children undergoing reoperation for ureterovesical junction obstruction. In patients with postoperative vesicoureteral reflux a variety of techniques produced similar and gratifying results. That 52 per cent of our patients had no symptoms indicates clearly the absolute necessity of careful followup after ureteral reimplantation. Furthermore, 20 per cent of our patients had late failure (4 to 10 years after initial ureteroneocystostomy), which suggests the need for careful monitoring of the reimplanted ureter past puberty.

Application of the pull-through technique of transverse advancement ureteral reimplantation

In the pull-through technique of ureteral reimplantation the ureter is divided at the hiatus and pulled through into the bladder. It is then advanced transversely as described previously for megaloureter but the technique also may be used for routine cases. The technique is particularly suitable for ureteral reimplantation in patients with urethral valves and neurogenic bladder. Pull-through ureteral reimplantation also may be used to reimplant the orthotopic ureter in complete ureteral duplication with ectopic ureterocele or with orthotopic reflux.