Ureterovesical anastomosis: a comparison of two principles

[Sacral hitch vesical pexy: a new ancillary technique for ureteroneocystostomy]

BACKGROUND

To describe the Sacral Hitch, vesical pexys to sacral promontory, an alternative technique to the Psoas Hitch when this is impossible to perform. We report intraoperative complications, and long-term functional results.

METHODS

From 1989 to date we performed 66 ureteroneocystostomies (UNCS) (transbladder technique and Politano-Leadbetter antireflux plasty): 51 with ancillary "Psoas Hitch" (11 Casati-Boari); 15 with "Sacral Hitch" because of the intraoperative finding of deficiency or lack of psoas tendon. Note of technique. Ureter and bladder are dissected as usual. Sacral Hitch: left lateralization of sigmoid and exposition of sacral promontory; longitudinal incision and divarication of peritoneum; smooth dissection of fat tissue, displacement of medium sacral vessels and visualization of neurovascular bundles. Direct fixation of the dome/posterior aspect of bladder to anterior longitudinal ligament above promontory.

RESULTS

Among the patients who underwent the Psoas Hitch technique, 3 (5.4%) showed hypoesthesia, acute pain and impossible flexion of the thigh on hip with EMG positive for femoral (1) and genito-femoral (2) neuropathy. The re-operation in 2 cases solved the symptoms. One case resolved conservatively with corticoids, tricyclic antidepressants (Amitriptyline) and antiepileptics (gabapentin). Mean follow-up was 115 months (8-252); two stenosis of anastomosis. Sacral Hitch: (15 pts), mean follow-up: 47 months (range 4-110), no stenosis of anastomosis 0%; transfusion rate 0%.

DISCUSSION

The psoas tendon deficiency or its congenital absence (children or women) requires the direct fixation to the muscle, an inadequate and weak target and housing of important sensitive-motor nerves (Genito-femoral, femoral and latero-cutaneous). A "Psoas-Syndrome" could be present in 5.1% and a re-operation could be necessary. The sacral promontory represents an affixation target already successfully adopted in other surgery specialties (Gynaecology, Orthopaedic and General Surgery) and gives to UNCS a stiffness plate and an effective bladder cranialization. CONCLUSIONS. Sacral Hitch Vesical Pexys represents an ancillary procedure to UNCS and surgeons should keep it in mind in cases of difficult finding of the psoas muscle tendon.

Management of Nephrolithiasis After Cohen Cross-Trigonal and Glenn-Anderson Advancement Ureteroneocystostomy

PURPOSE

Ureteroneocystotomy is frequently performed for ureteral injury or vesicoureteral reflux. The Glenn-Anderson technique advances the ureteral orifice distal to its native position, while the Cohen technique crosses the orifice to the opposite trigone. Each treatment can alter access to the upper genitourinary tracts. We report our experience with subsequent nephrolithiasis in these patients.

MATERIALS AND METHODS

We performed a retrospective chart review of all patients treated with ureteroneocystotomy since 1980 who had nephrolithiasis.

RESULTS

Nephrolithiasis developed in 9 patients with prior Cohen ureteroneocystotomy and in 15 with prior Glenn-Anderson ureteroneocystotomy. Stones size was 2 to 20 mm (mean 6.4). In the Cohen group ureteroscopy was attempted and failed in 2 patients, requiring percutaneous nephrolithotomy. Attempted shock wave lithotripsy failed in 2 patients, of whom 1 required percutaneous nephrolithotomy and 1 required observation. Primary percutaneous nephrolithotomy was performed in 1 patient. One patient required nephrectomy for chronic pyelonephritis related to nephrolithiasis. Two patients had active stone disease and were awaiting further treatment, while 1 passed the stone. In the Glenn-Anderson group ureteroscopy was successful in all 4 attempts. Attempted shock wave lithotripsy in 2 patients was successful in 1. The other patient required subsequent percutaneous nephrolithotomy. Primary percutaneous nephrolithotomy was required in 2 patients. All other patients were asymptomatic and under observation.

CONCLUSIONS

Treatment for upper tract nephrolithiasis is effected by prior ureteroneocystotomy. Minimally invasive treatments were less successful after Cohen ureteroneocystotomy than after Glenn-Anderson ureteroneocystotomy. In this study patients with prior cross-trigonal ureteroneocystotomy required more invasive therapies for symptomatic nephrolithiasis.

Vesicoureteral reflux: surgical approaches

The treatment of vesicoureteral reflux has evolved over the past half-century from primarily surgical to nonoperative treatments. Although the benefits of surgical correction versus medical management are debated, the surgical techniques that have evolved are highly effective in correcting vesicoureteral reflux. Recently, the US Food and Drug Administration has approved an injectable implant of dextranomer/hyaluronic acid copolymer for use in children, making the endoscopic treatment of reflux a potential alternative to open surgical correction. This article reviews the different surgical techniques,postoperative management, and complications, as well as the various implants used in the endoscopic correction of vesicoureteral reflux and their outcomes.

The functional anatomy of the ureterovesical junction

OBJECTIVE

To obtain a new insight into the anti-reflux mechanism of the ureterovesical junction by studying the topographical anatomy of the juxta- and intravesical ureter and its relationship to the surrounding bladder musculature.

MATERIALS AND METHODS

Fresh pig bladders were fixed, frozen and serially sectioned. Enzyme histochemistry was performed to demonstrate tissue acetyl- and butyryl- (non-specific) cholinesterase. Smooth muscle cells were identified by immunohistochemistry using a monoclonal anti-alpha actin smooth muscle antibody. Three-dimensional computer reconstructions of the different muscle groups of the bladder and ureterovesical junction were generated.

RESULTS

On the basis of expression patterns of the cholinesterase isozymes, five different groups of muscles were identified: the detrusor, the muscularis mucosae of the bladder, the muscle layer of the intravesical ureter and the separate inner and outer muscular layers of the pelvic ureter.

CONCLUSION

No separate ureteric sheath was identified. There appeared to be few or no (muscular) connections between the ureter and the bladder musculature. The muscle layer of the ureter ended beneath the mucosa of the bladder, without extension into the trigone. The submucosal section of the ureter was very short, although its length was thought to be of importance in the anti-reflux mechanism. Examination using enzyme histochemistry demonstrated a muscularis mucosae in the bladder which was absent from the trigone.

Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children

We performed an extravesical nondismembered reimplant to correct surgically primary vesicoureteral reflux in 45 patients (65 renal units) between April 1989 and September 1990. Of the units 6 had grade I reflux, 16 grade II, 23 grade III, 14 grade IV and 6 grade V. Only patients with primary reflux were included in this study. The success rate was 100% for grades I to III, 92.9% for grade IV and 66.7% for grade V. Overall, the reflux was cured in 62 of the 65 operated renal units (95.4%) or 95.6% of the patients (43 of 45). Postoperative morbidity and complications were minimal. No cases of postoperative obstruction were detected on excretory urography 6 weeks postoperatively. Seven children (16%) suffered from transient inadequate bladder emptying as assessed by post-void ultrasound residual evaluations. This problem resolved spontaneously after a maximum of 4 weeks of clean intermittent catheterization. Compared to conventional transvesical technique, the discomfort related to bladder spasms during the postoperative period was subjectively decreased and patients had no prolonged hematuria.

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.

Technical considerations in distal tunnel ureteral reimplantation

The advantages of a distal tunnel ureteral reimplantation have been elaborated upon previously. This method offers simplicity of transvesical explosure, rapidity of execution, excellent visibility of the terminal ureteral segments, minimal dissection and trauma in the paravesical space, the opportunity to advance the ureteral orifices to a physiologic position on the trigone and minimal risk of angulation, kinking or obstruction of the terminal ureter. It is now recognized that this method, with the modifications discussed herein, has wide applicability in the management of vesicoureteral reflux of all varieties and etiologies.

Reconstruction of previously diverted urinary tract in children

We tried to reconstruct partly or completely the urinary tract in nine patients who underwent, some years before, attempts at urinary diversion, for severe urinary tract diseases, using the intestine as an ureteral or a bladder subtitute. Our aim was to do a two-stage procedure, trying to reconstruct one normal side without the use of bowel, then within 6 mo to reevaluate the reconstructed side and, if correct, to do a transureteroureterostomy from the diverted side into the reconstructed side. Two patients were operated on this way and cured. We then advanced to a more aggressive approach with a one-stage procedure. Two more patients were operated on and cured. We then attempted reconstruction in patients when the ureter was no longer available. Two patients were operated on using a tapered and reimplanted piece of small bowel in the bladder and cured. Next we came to the patients in whom neither ureter nor bladder was available. Two patients were undiverted from an ileal loop and transformed into an ureterosigmoidostomy with transureterostomy, with achievement of continence. Finally, when neither ureter, nor bladder, nor even rectum was available, one patient on hemodialysis for a nonfunctioning Duhamel rectal bladder was converted into a functioning ileal loop and freed from dialysis. Technical points are discussed, focused on a two-stage procedure with one reimplantation and a transureteroureterostomy. When a permanent diversion must be done, today, for rare indications, we prefer to perform a sigmoid conduit.