International Urology and Nephrology 24 (4), pp. 375-- 379 (1992)
Fifty Years of Antireflux Ureterovesicoplasty K. B. SrEFANOVId, N. S. BUKUROV Department of Urology, Institute of Urology and Nephrology, University of Belgrade School of Medicine, Belgrade, Yugoslavia (Accepted October 16, 1991)
In spite of the impressive progress in medical science, surgery remains an empirical skill. Surgery of the ureterovesical junction is a permanent challenge for all generations of urologists. Half a century of intensive development of modern surgery evidences the efforts to reestablish function by a perfect copy of natural anatomy.
Although Galen and Asclepiades demonstrated competency of the ureterovesical junction in animal experiments as early as the second century, surgical practice failed to establish an appropriate technical solution till the middle of this century (cit. [1 ]). Pioneers of the techniques of direct non-antireflux ureterovesical anastomosis have realized the problem. In his critical analysis of ureteral implants, Bovee [2] suggested that efforts should be made to mimic the normal, oblique ureteral passage through the bladder wall in order to prevent reflux. Nevertheless, the first experimental attempts at submucosal reimplantation of the ureters were carried out in the 1920s and 1930s. Thus, in t943 Stevens and Marshall [3] (Fig. 1) were the first to report the results of the procedure in 10 patients. They advocated extravesical dissection of the ureters, and via minor cystostomy a 2 cm long submucosal ureteral passage ending in a "fish mouth". The results were not encouraging. The first successful surgical correction of reflux was reported by Prather [4] a year later. In spite of relatively extensive application of ureterovesical anastomoses, urologic experience in this field was very limited, since the ureters were only reimplanted after excision of tumours either from the bladder or from the distal ureter. Ureteral damage in the course of pelvic surgery was usually corrected by general surgeons or gynaecologists responsible for the lesion. At the beginning of the 1940s urologists became increasingly consulted and asked for help in these situations. It was an encouragement and challenge for Dodson [5] to demonstrate surgical skill of a urologist in reestablishing continuity of the urinary tract. Following the principles of ureterosigmoidostomy suggested by Coffey [6, 7], Dodson implanted a ureter extravesically and formed a short submucosal tunnel. Smith (cit. [8]) also made similar attempts, but the idea of antireflux reimplantation of ureters still seemed unfeasible. The Second World War left behind a large number of patients with spinal cord lesions. Talbot and Bunts VSP, Utrecht Akaddmiai Kiad6, Budapest
376
Stefanovik, Bukurov : Antireflux ureterovesicoplasty
Stevensj Ma rsha II 1943
Hutch 1952
Polita no,Leadbetler 1958
Paquin 1959'
Girg'rs, Veenema 1965
Bischoff 1957
Williams, Scott Turner-Warwick 1961
Nutch 1963
Glenn Anderson 1966
Cohen 1975
Dodson
1946
Siephens 1977
Lich,Howerton, Vlatkovi~. Davis, 1961 1975 Gr~go it, Regemorter 1964
Gil~Vernei
198/.
Barry 1983
Fig. 1. Antireflux ureterovesicoplasty: Review of different techniques
[9] suggested reimplantation of the ureters in order to correct vesicoureteral reflux. Although neurogenic dysfunction of the urinary bladder is nowadays the least common indication for antireflux surgery, the idea actually induced introduction of the first surgical technique intended for a specific purpose reported in 1952 by John A. Hutch [10]. In 1957, Bischoff [11] offered a completely different surgical solution: prolongation of the intravesical ureter from a strip of vesical mucosa over the new ureter to create a submucosal tunnel for it. The approach failed to become applicable for routine use, since, similarly to Hutch's technique, it could not be performed in cases of ureteral obstruction. In such eases the distal part had to be resected, or when more severely dilated ureters had to be reshaped. In May 1957, at the International Urology and Nephroloyy 24, 1992
StefanoviO, Bukurov : Antireflux ureterovesicoplasty
377
Annual Meeting of the American Urologic Society in Pittsburg, Victor A. Politano and Wyland F. Leadbetter [12] reported a technique unrelated to any of the previously used ones. The operation was based on making a submucosal tunnel (3.5 times the ureteral diameter) on the firm musculature between the new and the old hiatus. Their technique has become one of the most popular and widely accepted procedures for ureteral reimplantation. Combination of the extra- and intra-vesical approaches with extensive dissection of the upper, lateral and posterior bladder wall associated with a long submucosal tunnel (5 times the ureteral diameter) and a cuff-like ureteral ending is the essence of antireflux ureteroneocystostomy suggested by Albert J. Paquin [13] only a year later. Although significantly modified, the technique has remained in general use to this day. Exposure of the ureter uncovered by the bladder mucosal tissue to intravesical pressure is common to the techniques of Dodson [5], Hutch [10] and Girgis and Veenema [14]. Hutch believed that strengthening of the detrusor muscle below the ureter is crucial for the whole operation. The exposed ureter entered the bladder lumen, while the junction of the orifice and the trigonum remained intact. Ureterovesicoplasty recommended by Girgis and Veenema is less known. They introduced the ureter through the new hiatus and formed the new orifice after dorsal incision of the distal ureteral end. A major improvement in extravesical formation of the submucosal tunnel was introduced by Lich, Howerton and Davis [15]. The whole surgery is performed without opening the bladder. The mobilized ureter is placed submucosally into the tunnel formed by vertical incision of the detrusor continuing circularly round the ureteral orifice. Gr6goir and Van Regemorter [16] introduced some technical improvements into the original extravesical antireflux technique. The extravesical approach has been recommended for reimplantation of a short ureter onto the detrusor roof for secondary and tertiary procedures [17]. Owing to minor opening of the urinary bladder, the technique of extravesical reimplantation of the ureter has been particularly convenient in renal transplantations. Recently Barry [18] improved the approach for renal transplantation purposes by forming a submucosal tunnel between two parallel extramucosal incisions on the detrusor. Nevertheless, completely transvesical procedures are preferred in surgical correction of reflux in children, where the same hiatus is preserved, and variations are related to submucosal prolongation and selecting a place for the new orifice. Williams, Scott and Turner-Warwick [19] displaced the ureter distally, mobilized it by a transvesical dissection from the inferior side, and used the "forgotten" part of the trigonum while a tiny tongue-shaped part of the tissue is excised from the trigonum to make a new orifice on the level of the lower part of the defect. The first modification of the method was suggested by Hutch [20]. A "U"-shaped incision with the top above the orifice and the arms on the bladder neck, with the intramural part of the ureter mobilized, established a new anastomosis on the distal part of the previously excised trigonal mucosal tissue. James F. Glenn and Everett E. Anderson [21] significantly simplified the technique of intravesical prolongation, making the method very popular in the International Uroloyy and Nephrolooy 24, 1992
378
Stefanovid, Bukurov." Antireflux ureterovesicoplasty
USA. The modified technique of intravesical ureteral prolongation was first applied by Anderson in an experimental study, while Glenn introduced it into clinical practice. The results on the first eight patients were reported in 1967. The following important variation was presented at the Paediatric Urologic Meeting in Liverpool in June 1973. Cohen [22] advocated transvesical prolongation of the ureter using a mildly curved submucosal tunnel on the bladder floor with the newly positioned orifice above the opposite one. The technique is widely used by European paediatric surgeons. Stephens [23] contributed to an improvement of intravesical ureteral prolongation. After elliptical cutting around the ureteral orifice and mobilizing the ureter from the periureteral sheath a vertical incision is made on the upper hiatal rim, displacing it, thus, 2 to 3 cm upwards. The detrusor muscle is closed afterwards. Elevation of the hiatus leaves more space for the submucosal tunnel and provides conditions for better exposure and intravesical modelling of a moderately dilated ureter. Jose Maria Gil-Vernet [26] introduced a new technique of antireflux plastic surgery of the ureterovesical junction. The technique comprises medial bilateral transposition of the ureteral orifices by plication of the trigonal musculature using a nonresorptive mattress suture. Although the author reported a t00 ~o success rate (in 38 surgically treated patients), others failed to confirm the results. This is the latest important improvement in open surgery of the ureterovesical junction. It should be remembered that Bazy [27] had introduced the term ureterocysto-neostomy as early as 1894. The terms ureterocystoneostomy and ureteroneocystostomy have been used ever since, and both actually describe a new hiatus in the bladder wall. More recent antireflux techniques do not necessarily create a new hiatus, and therefore ureterovesicoplasty is now a more preferred term.
References 1. Murphy, L. J. T.: The History of Urology. Charles C. Thomas Publisher, Springfield, Illinois 1972, p. 274. 2. Bovee, J. W.: A critical study of ureteral implantations. Ann. Surg., 32, 165 (1900). 3. Stevens, A. R., Marshall, V. F . : Reimplantation of the ureter into bladder: Report of a method applied to ten patients. Surg. Gynecol. Obstet., 77, 585 (1943). 4. Prather, G. C.: Vesicoureteral reflux. Report of a case cured by operation. J. Urol., 52, 437 (1944). 5. Dodson, A. I.: Some improvements in the technique of ureterocystostomy, aT. Urol., 55, 225 (1946). 6. Coffey, R. C.: Physiologic implantation of the severed ureter or common bile-duct into the intestine. JAMA, 56, 397 (1911). 7. Coffey R. C.: Transplantation of the ureter into the large intestine in the absence of a functioning bladder. Surg. Gynecol. Obstet., 32, 383 (1921). 8. Campbell, M.: Clinical Pediatric Urology. Operative Procedures. W. B, Saunders Company, Philadelphia-London 1951, pp. 921-923. 9. Talbot, H. S., Bunts, R. C.: Late renal changes in paraplegia: Hydronephrosis due to
vesicoureteral reflux. J. Urol., 61, 870 (1949). International Urology and Nephrology 24, 1992
Stefanovi6, Bukurov." Antireflux ureterovesicoplasty
379
10. Hutch, J. A. : Vesico-ureteral reflux in the paraplegic: Cause and correction. J. UroL, 68, 457 (1952). 11. Bischoff, P.: Megaureter. Br. J. UroL, 29, 416 (1957). 12. Politano, V. A., Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79, 932 (1958). 13. Paquin, A. J. : Ureterovesical anastomosis: The description and evaluation of a technique. J. UroL, 82, 573 (1959). 14. Girgis, A. S., Veenema, R. J.: Triangular flap ureterovesicoplasty: A new technique for the correction of ureteral reflux; A preliminary report. J. UroL, 94, 233 (1965). 15. Lich, R. Jr., Howerton, L. W., Davis, L. A. : Recurrent urosepsis in children. J. UroL, 86, 554 (1961). 16. Gr6goir, W., Van Regemorter, G. : Le reflux vesico-ureterale congenital. UroL Int., 18, 122 (1964). 17. Bradi6, I. Pasini, M., Vlatkovi6, G.: Antireflux ureterocystostomy at the vertex of the bladder. Br. J. Urol., 47, 525 (1975). 18. Barry, J. M.: Unstented extravesical ureteroneocystostomy in kidney transplantation. J. Urol., 129, 918 (1983). 19. Williams, D. I., Scott, J., Turner-Warwick, R. T.: Reflux and recurrent infection. Br. J. Urol., 33, 435 (1961). 20. Hutch, J. A.: Ureteric advancement operation: Anatomy, technique and early results. J. Urol., 69, 180 (1963). 21. Glenn, J. F., Anderson, E. E.: Distal tunnel ureteral reimplantation. Trans. Am. Assoc. Genitourin. Surg., 58, 37 (1966). 22. Cohen, S. J.: Ureterozystoneostomie. Eine neue Antirefluxtechnik. AktueL Urol., 6, 1 (1975). 23. Stephens, F. D.: A new technique of ureteral reimplantation based on anatomical principles. Presented at the Meeting of the Society for Pediatric Urology. Chicago, II1., April 23, 1977. 24. Tauffer, W. : Drei complicirte Ovariotomien, nebst Bemerkungen fiber die Drainage: die theilweise extraperitoneale Entwickelung derartiger Tumoren. Dtseh. Med. Wochenschr., 36, 425 (1877). 25. Murphy, L. J. T.: The History of Urology. Charles C. Thomas Publisher, Springfield, Illinois 1972, p. 297. 26. Gil-Vernet, J. M.: A new technique for surgical correction of vesicoureteral reflux. J. UroL, 131, 456 (1984). 27. Bazy, P. : De l'uretero-cysto-neostomie. Ann. Mal. Orig. Gen. Urin., 12, 481 (1894).
International Urology and Nephro!ogy 24 1992
Fifty Years of Antireflux Ureterovesicoplasty K. B. SrEFANOVId, N. S. BUKUROV Department of Urology, Institute of Urology and Nephrology, University of Belgrade School of Medicine, Belgrade, Yugoslavia (Accepted October 16, 1991)
In spite of the impressive progress in medical science, surgery remains an empirical skill. Surgery of the ureterovesical junction is a permanent challenge for all generations of urologists. Half a century of intensive development of modern surgery evidences the efforts to reestablish function by a perfect copy of natural anatomy.
Although Galen and Asclepiades demonstrated competency of the ureterovesical junction in animal experiments as early as the second century, surgical practice failed to establish an appropriate technical solution till the middle of this century (cit. [1 ]). Pioneers of the techniques of direct non-antireflux ureterovesical anastomosis have realized the problem. In his critical analysis of ureteral implants, Bovee [2] suggested that efforts should be made to mimic the normal, oblique ureteral passage through the bladder wall in order to prevent reflux. Nevertheless, the first experimental attempts at submucosal reimplantation of the ureters were carried out in the 1920s and 1930s. Thus, in t943 Stevens and Marshall [3] (Fig. 1) were the first to report the results of the procedure in 10 patients. They advocated extravesical dissection of the ureters, and via minor cystostomy a 2 cm long submucosal ureteral passage ending in a "fish mouth". The results were not encouraging. The first successful surgical correction of reflux was reported by Prather [4] a year later. In spite of relatively extensive application of ureterovesical anastomoses, urologic experience in this field was very limited, since the ureters were only reimplanted after excision of tumours either from the bladder or from the distal ureter. Ureteral damage in the course of pelvic surgery was usually corrected by general surgeons or gynaecologists responsible for the lesion. At the beginning of the 1940s urologists became increasingly consulted and asked for help in these situations. It was an encouragement and challenge for Dodson [5] to demonstrate surgical skill of a urologist in reestablishing continuity of the urinary tract. Following the principles of ureterosigmoidostomy suggested by Coffey [6, 7], Dodson implanted a ureter extravesically and formed a short submucosal tunnel. Smith (cit. [8]) also made similar attempts, but the idea of antireflux reimplantation of ureters still seemed unfeasible. The Second World War left behind a large number of patients with spinal cord lesions. Talbot and Bunts VSP, Utrecht Akaddmiai Kiad6, Budapest
376
Stefanovik, Bukurov : Antireflux ureterovesicoplasty
Stevensj Ma rsha II 1943
Hutch 1952
Polita no,Leadbetler 1958
Paquin 1959'
Girg'rs, Veenema 1965
Bischoff 1957
Williams, Scott Turner-Warwick 1961
Nutch 1963
Glenn Anderson 1966
Cohen 1975
Dodson
1946
Siephens 1977
Lich,Howerton, Vlatkovi~. Davis, 1961 1975 Gr~go it, Regemorter 1964
Gil~Vernei
198/.
Barry 1983
Fig. 1. Antireflux ureterovesicoplasty: Review of different techniques
[9] suggested reimplantation of the ureters in order to correct vesicoureteral reflux. Although neurogenic dysfunction of the urinary bladder is nowadays the least common indication for antireflux surgery, the idea actually induced introduction of the first surgical technique intended for a specific purpose reported in 1952 by John A. Hutch [10]. In 1957, Bischoff [11] offered a completely different surgical solution: prolongation of the intravesical ureter from a strip of vesical mucosa over the new ureter to create a submucosal tunnel for it. The approach failed to become applicable for routine use, since, similarly to Hutch's technique, it could not be performed in cases of ureteral obstruction. In such eases the distal part had to be resected, or when more severely dilated ureters had to be reshaped. In May 1957, at the International Urology and Nephroloyy 24, 1992
StefanoviO, Bukurov : Antireflux ureterovesicoplasty
377
Annual Meeting of the American Urologic Society in Pittsburg, Victor A. Politano and Wyland F. Leadbetter [12] reported a technique unrelated to any of the previously used ones. The operation was based on making a submucosal tunnel (3.5 times the ureteral diameter) on the firm musculature between the new and the old hiatus. Their technique has become one of the most popular and widely accepted procedures for ureteral reimplantation. Combination of the extra- and intra-vesical approaches with extensive dissection of the upper, lateral and posterior bladder wall associated with a long submucosal tunnel (5 times the ureteral diameter) and a cuff-like ureteral ending is the essence of antireflux ureteroneocystostomy suggested by Albert J. Paquin [13] only a year later. Although significantly modified, the technique has remained in general use to this day. Exposure of the ureter uncovered by the bladder mucosal tissue to intravesical pressure is common to the techniques of Dodson [5], Hutch [10] and Girgis and Veenema [14]. Hutch believed that strengthening of the detrusor muscle below the ureter is crucial for the whole operation. The exposed ureter entered the bladder lumen, while the junction of the orifice and the trigonum remained intact. Ureterovesicoplasty recommended by Girgis and Veenema is less known. They introduced the ureter through the new hiatus and formed the new orifice after dorsal incision of the distal ureteral end. A major improvement in extravesical formation of the submucosal tunnel was introduced by Lich, Howerton and Davis [15]. The whole surgery is performed without opening the bladder. The mobilized ureter is placed submucosally into the tunnel formed by vertical incision of the detrusor continuing circularly round the ureteral orifice. Gr6goir and Van Regemorter [16] introduced some technical improvements into the original extravesical antireflux technique. The extravesical approach has been recommended for reimplantation of a short ureter onto the detrusor roof for secondary and tertiary procedures [17]. Owing to minor opening of the urinary bladder, the technique of extravesical reimplantation of the ureter has been particularly convenient in renal transplantations. Recently Barry [18] improved the approach for renal transplantation purposes by forming a submucosal tunnel between two parallel extramucosal incisions on the detrusor. Nevertheless, completely transvesical procedures are preferred in surgical correction of reflux in children, where the same hiatus is preserved, and variations are related to submucosal prolongation and selecting a place for the new orifice. Williams, Scott and Turner-Warwick [19] displaced the ureter distally, mobilized it by a transvesical dissection from the inferior side, and used the "forgotten" part of the trigonum while a tiny tongue-shaped part of the tissue is excised from the trigonum to make a new orifice on the level of the lower part of the defect. The first modification of the method was suggested by Hutch [20]. A "U"-shaped incision with the top above the orifice and the arms on the bladder neck, with the intramural part of the ureter mobilized, established a new anastomosis on the distal part of the previously excised trigonal mucosal tissue. James F. Glenn and Everett E. Anderson [21] significantly simplified the technique of intravesical prolongation, making the method very popular in the International Uroloyy and Nephrolooy 24, 1992
378
Stefanovid, Bukurov." Antireflux ureterovesicoplasty
USA. The modified technique of intravesical ureteral prolongation was first applied by Anderson in an experimental study, while Glenn introduced it into clinical practice. The results on the first eight patients were reported in 1967. The following important variation was presented at the Paediatric Urologic Meeting in Liverpool in June 1973. Cohen [22] advocated transvesical prolongation of the ureter using a mildly curved submucosal tunnel on the bladder floor with the newly positioned orifice above the opposite one. The technique is widely used by European paediatric surgeons. Stephens [23] contributed to an improvement of intravesical ureteral prolongation. After elliptical cutting around the ureteral orifice and mobilizing the ureter from the periureteral sheath a vertical incision is made on the upper hiatal rim, displacing it, thus, 2 to 3 cm upwards. The detrusor muscle is closed afterwards. Elevation of the hiatus leaves more space for the submucosal tunnel and provides conditions for better exposure and intravesical modelling of a moderately dilated ureter. Jose Maria Gil-Vernet [26] introduced a new technique of antireflux plastic surgery of the ureterovesical junction. The technique comprises medial bilateral transposition of the ureteral orifices by plication of the trigonal musculature using a nonresorptive mattress suture. Although the author reported a t00 ~o success rate (in 38 surgically treated patients), others failed to confirm the results. This is the latest important improvement in open surgery of the ureterovesical junction. It should be remembered that Bazy [27] had introduced the term ureterocysto-neostomy as early as 1894. The terms ureterocystoneostomy and ureteroneocystostomy have been used ever since, and both actually describe a new hiatus in the bladder wall. More recent antireflux techniques do not necessarily create a new hiatus, and therefore ureterovesicoplasty is now a more preferred term.
References 1. Murphy, L. J. T.: The History of Urology. Charles C. Thomas Publisher, Springfield, Illinois 1972, p. 274. 2. Bovee, J. W.: A critical study of ureteral implantations. Ann. Surg., 32, 165 (1900). 3. Stevens, A. R., Marshall, V. F . : Reimplantation of the ureter into bladder: Report of a method applied to ten patients. Surg. Gynecol. Obstet., 77, 585 (1943). 4. Prather, G. C.: Vesicoureteral reflux. Report of a case cured by operation. J. Urol., 52, 437 (1944). 5. Dodson, A. I.: Some improvements in the technique of ureterocystostomy, aT. Urol., 55, 225 (1946). 6. Coffey, R. C.: Physiologic implantation of the severed ureter or common bile-duct into the intestine. JAMA, 56, 397 (1911). 7. Coffey R. C.: Transplantation of the ureter into the large intestine in the absence of a functioning bladder. Surg. Gynecol. Obstet., 32, 383 (1921). 8. Campbell, M.: Clinical Pediatric Urology. Operative Procedures. W. B, Saunders Company, Philadelphia-London 1951, pp. 921-923. 9. Talbot, H. S., Bunts, R. C.: Late renal changes in paraplegia: Hydronephrosis due to
vesicoureteral reflux. J. Urol., 61, 870 (1949). International Urology and Nephrology 24, 1992
Stefanovi6, Bukurov." Antireflux ureterovesicoplasty
379
10. Hutch, J. A. : Vesico-ureteral reflux in the paraplegic: Cause and correction. J. UroL, 68, 457 (1952). 11. Bischoff, P.: Megaureter. Br. J. UroL, 29, 416 (1957). 12. Politano, V. A., Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79, 932 (1958). 13. Paquin, A. J. : Ureterovesical anastomosis: The description and evaluation of a technique. J. UroL, 82, 573 (1959). 14. Girgis, A. S., Veenema, R. J.: Triangular flap ureterovesicoplasty: A new technique for the correction of ureteral reflux; A preliminary report. J. UroL, 94, 233 (1965). 15. Lich, R. Jr., Howerton, L. W., Davis, L. A. : Recurrent urosepsis in children. J. UroL, 86, 554 (1961). 16. Gr6goir, W., Van Regemorter, G. : Le reflux vesico-ureterale congenital. UroL Int., 18, 122 (1964). 17. Bradi6, I. Pasini, M., Vlatkovi6, G.: Antireflux ureterocystostomy at the vertex of the bladder. Br. J. Urol., 47, 525 (1975). 18. Barry, J. M.: Unstented extravesical ureteroneocystostomy in kidney transplantation. J. Urol., 129, 918 (1983). 19. Williams, D. I., Scott, J., Turner-Warwick, R. T.: Reflux and recurrent infection. Br. J. Urol., 33, 435 (1961). 20. Hutch, J. A.: Ureteric advancement operation: Anatomy, technique and early results. J. Urol., 69, 180 (1963). 21. Glenn, J. F., Anderson, E. E.: Distal tunnel ureteral reimplantation. Trans. Am. Assoc. Genitourin. Surg., 58, 37 (1966). 22. Cohen, S. J.: Ureterozystoneostomie. Eine neue Antirefluxtechnik. AktueL Urol., 6, 1 (1975). 23. Stephens, F. D.: A new technique of ureteral reimplantation based on anatomical principles. Presented at the Meeting of the Society for Pediatric Urology. Chicago, II1., April 23, 1977. 24. Tauffer, W. : Drei complicirte Ovariotomien, nebst Bemerkungen fiber die Drainage: die theilweise extraperitoneale Entwickelung derartiger Tumoren. Dtseh. Med. Wochenschr., 36, 425 (1877). 25. Murphy, L. J. T.: The History of Urology. Charles C. Thomas Publisher, Springfield, Illinois 1972, p. 297. 26. Gil-Vernet, J. M.: A new technique for surgical correction of vesicoureteral reflux. J. UroL, 131, 456 (1984). 27. Bazy, P. : De l'uretero-cysto-neostomie. Ann. Mal. Orig. Gen. Urin., 12, 481 (1894).
International Urology and Nephro!ogy 24 1992
