Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation

Ureterocystoplasty in pediatric patients with unilateral nonfunctioning kidney

OBJECTIVE

Bladder augmentation with uroepithelium lined material yields an absence of mucus production, with reduced possibility of urinary infection and lithiasis. The utilization of the ureter in augmentation cystoplasty results in a uroepithelium-lined neobladder with all of the appropriate histologic layers. The purpose of this study was to assess the efficacy and safety of ureterocystoplasty in children with a small bladder capacity and low bladder compliance.

MATERIAL AND METHODS

Between January 1992 and August 2011, six females and eight males who were 3 to 13 years old (median age 6 years) and had a low-capacity, poorly compliant bladder underwent augmentation cystoplasty using dilated ureters. Unilateral non-functioning renal moiety draining into a massively dilated ureter was present in every patient. The etiology of hydroureteronephrosis was a neurogenic bladder secondary to meningomyelocele in five patients, a posterior urethral valve in four patients, an obstructive megaureter in three patients and ectopic obstructive ureterocele in two patients.

RESULTS

Mean age was 6 years (3-13 y). Clinical improvement regarding the resolution of reflux, a better bladder capacity and improved compliance was achieved in every patient. The increase in bladder capacity ranged from 84 cc (30 to 200) to 235 cc (150 to 420), with a mean increase of 318% (210 to 500). Marked improvement in compliance was also observed (from 1.2 to 5.1 mL/cm H2O, mean 2.4, to 22 to 50 mL/cm H2O, mean 41). No uninhibited bladder contractions were detected during a urodynamic study at 12 months postoperatively.

CONCLUSION

In patients with a low-capacity, poorly compliant bladder, augmentation cystoplasty using the ureter seems to be a viable alternative. Ureterocystoplasty results in a large-capacity, high-compliance bladder, without metabolic and infective complications, compared with other techniques of augmentation cystoplasty.

Alternatives to conventional enterocystoplasty in children: a critical review of urodynamic outcomes

Alternatives to conventional enterocystoplasty have been developed in order to avoid the most common complications derived from contact of the urine with intestinal mucosa. In this article critically we review the literature on the topics: ureterocystoplasty, detrusorectomy, detrusorotomy, seromuscular gastroenterocystoplasty, use of off the shelf biomaterials, and bladder augmentation by bioengineering. Recognizing the difficulty of deciding when a child with a history of posterior urethral valves requires and augmentation and that the development of a large megaureter in cases of neurogenic dysfunction represents a failure of initial treatment, we conclude that ureterocystoplasty can be useful in selected cases when a large dilated ureter is available. Seromuscular colocystoplasty lined with urothelium (SCLU) has been urodynamically effective in several series when the outlet resistance is high and no additional intravesical procedures are necessary. Seromuscular gastrocystoplasty lined with urothelium seems to offer no distinct advantages and involves a much more involved operation. The use of seromuscular segments without urothelial preservation, with or without the use of an intravesical balloon has been reported as successful in two centers but strict urodynamic evidence of its effectiveness is lacking. The published evidence argues strongly against the use of detrusorectomy or detrusorotomy alone because of the lack of significant urodynamic benefits. Two recent reports discourage the use of small intestinal submucosa patches because of a high failure rate. Finally, research into the development of a bioengineered bladder constructed with cell harvested from the same patient continues but is fraught with technical and conceptual problems. In conclusion of the methods reviewed, only ureterocystoplasty and SCLU have been proven urodynamically effective and reproducible.

[Ureterocystoplasty in the treatment of "low-compliance" bladder in children]

In cases of inadequate or insufficient conservative treatment of non-compliant bladders the function of the upper urinary tract is jeopardized. We present our experience with ureterocystoplasty as one possible treatment option.A total of eight children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in five children, posterior urethral valves in two children, and in one child after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. Following nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE procedure was performed in three patients, antireflux surgery for the contralateral kidney in two patients, and one patient underwent stone removal in the remaining kidney. In one patient the ureter was used as a free transplant and was covered by an omental flap. In addition a simultaneous living donor kidney transplant was performed. The storage function could be improved in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years. Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.