British Journal of Urology (1978). 50, 383-386
Reimplantation of the Wide Ureter M. C. BISHOP, A. R. ASKEW and J. C. SMITH Nuffield Department of Surgery and Department of Urology, University of Oxford, Radcliffe Infirmary, Oxford
Summary-A modification of the technique of Politano and Leadbetter for reimplantation of wide ureters is described. Nine patients with obstructive megaureter (1 0 ureters) and 6 with gross vesicoureteric reflux (9ureters) were treated. A satisfactory result w a s obtained in 6 of the obstructed patients (7ureters) and ultimately, after re-operation, in 1 of the remaining ureters. Reflux w a s corrected in all 6 patients. This method requires less extravesical dissection than others involving extensive remodelling of the wide ureter. There is therefore less risk of damage t o the distal ureteric blood supply and the natural flap valve mechanism a t the ureteric orifice may be more effectively emulated.
Antireflux surgery on ureters of normal calibre is usually successful. The technique of Politano and Leadbetter (1958) is frequently used with one or other minor modification (Clark and Hosmane, 1976), though simple advancement (Cohen, 1977) is also often satisfactory. However, reimplantation of the wide ureter caused by vesicoureteric reflux or idiopathic obstruction has had a sinister reputation. A variety of techniques has been used to narrow the calibre. For example, Paquin (1959) constructed a cuff at the site of reimplantation. On the other hand, Hendren (1969) has adopted a more radical approach with extensive re-modelling of the ureter through most of its pelvic course. We present another technique which has the virtue of simplicity, avoids extensive dissection with possible damage to the blood supply to the ureter and attempts to reconstruct the natural flap valve mechanism at the ureteric orifice. Patients and Methods Fifteen patients (aged 9-52 years at presentation) were studied. They all had wide, tortuous ureters and the majority (9) were obstructed at the lower end whilst the remainder had vesicoureteric reflux. In 1 case this was due to tuberculosis, but the majority of patients with obstruction had a short narrow distal fibrotic segment with muscle hypertrophy and occasionally squamous metaReceived 13 December 1977. Accepted for publication 8 June 1978.
plasia of the mucosa. These features may be regarded as typical of primary idiopathic obstructive megaureter. The abnormality was bilateral in 1 patient. Most patients presented with loin pain. One 22-year-old male was investigated pre-operatively for severe hypertension. Another patient had bilateral obstruction with scarring of the kidneys and renal calculi. Of the 6 patients with reflux, 3 had bilateral megaureters. Overall renal function in 3 patients was poor (creatinine clearance < 20 m l h i n ) . One of the patients with unilateral reflux evidently acquired incompetence of the vesicoureteric junction after diathermy incision of a ureterocele. All patients with vesicoureteric reflux presented with recurrent urinary infections.
Technique (Figs. la-c) A combined intravesical and extravesical approach is used to mobilise the ureter. An umbilical catheter inserted and sutured into place in the ureter facilitates the intramural dissection. When present, the narrow distal segment found in idiopathic obstructive megaureter is resected. A long ‘V’ is then excised from the ureter. This is then sutured to narrow the ureter, leaving the terminal 1 to 2 cm to form a ‘Y’(Fig. la). Saline is injected to develop the submucosal plane in the bladder and facilitate formation of a tunnel. The reconstructed ureter is drawn through a new hiatus in the detrusor and the submucosal tunnel (Fig. lb). The lower edge is sutured to the bladder mucosa, leaving the defect in the distal ureter covered by
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Fig. l b Modified Politano-Leadbetter technique (intravesical and extravesical approach) for reimplantation of the reconstructed ureter.
to the orifice and due to kinking above the hiatus in the detrusor. Fig. la Technique for reconstruction of the lower end of the ureter. In patients with obstructive megaureter the distal segment is excised.
a bladder mucosal flap (Fig. lc). This acts as a flexible valve to prevent reflux. The neocystostomy is not usually splinted and the bladder is drained with a fine catheter for 5 days.
Results Obstruction All 9 patients were assessed post-operatively. A satisfactory result was obtained in 6: the excretion urogram showed definite improvement in terms of concentration and pelviureteric dilatation (Fig. 2); the micturating cystourethrogram showed no relux and the urine was sterile. There was no recurrence of symptoms. Of the remaining 3 patients, 1 had persistent hypertension and probably a degree of residual obstruction; 2 patients required re-exploration and further reimplantation but in 1 of these the ureteric anastomosis was healthy and intact, the obstruction being proximal
Reflux Reflux was corrected in all 6 patients. Postoperative X-rays showed improvement in pelviureteric dilatation in 3 patients. Two female patients had recurrent urinary infection; in 1 this had not been a feature of the pre-operative course. In 3 patients with poor renal function (creatinine clearance < 20 m l h i n ) deterioration was not affected by reimplantation and long-term dialysis treatment was ultimately required.
b
Fig. IC Completed ureterovesical anastomosis showing free flap of bladder mucosa.
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385
Fig. 2 Patient C.R. (a) IVU: 30 min after injection (40ml 45% Hypaque). Pre-operative film. (b) Left retrograde pyelogram. Pre-operative film. (c) IVU: 10 min after injection. Eighteen months after operation. (d) IVU: 45 min after injection. Eighteen months after operation.
Discussion Whether renal function will remain stable or will deteriorate in cases of vesicoureteric reflux or idiopathic obstructive megaureter is difficult to predict, particularly when presentation is in the
older child or adult. The interrelation between the urodynamic disorder of the upper tract and other factors such as infection is obscure and this has led to uncertainty about clinical management. In the past it was felt that a conservative approach
386 was justified (Nesbit and Withycombe, 1954) but with improved technique it is now clear that surgical treatment may be more appropriate (Johnston, 1967; Williams and Hulme-Moir, 1970). Broadly, the aim in surgical management has been to reduce the calibre and redundant length of the ureter and to reimplant it, after reconstruction, into the bladder (Hendren, 1969). Provided that a normal width of the terminal ureter has been achieved, the technique of Politano and Leadbetter (1958) is satisfactory. Their method depends upon construction of a submucosal tunnel of adequate length to maintain competence of the ureteroneocystostomy by reproducing the flap valve mechanism (Sampson, 1903). If the terminal ureter is too wide there may be difficulty in constructing a submucosal tunnel of adequate length. The preliminary tailoring and tapering of the supravesical ureter is therefore all-important. The risk of damage to the blood supply of the ureter during this process should not be underestimated. We have modified the standard technique so that less manipulation of the ureter is required. Sufficient ureteric wall is removed from the terminal segment to construct a long ‘V’. With the formation of a free flap of bladder mucosa acting as an antireflux mechanism in its own right, the length of the submucosal tunnel may be less critical. The results suggest that the antireflux effect was always satisfactory. Stenosis recurred in 2 patients who were reexplored. However, kinking of the ureter had occurred above the anastomosis and was probably due to excision of an insufficient length of distal ureter. In all cases the anastomosis appeared to be healthy and with an intact blood supply. A few patients had occasional episodes of urinary infection post-operatively but these were always easily treated and there was no evidence that the upper urinary tract was involved. In any case it is controversial whether antireflux surgery affects the incidence of urinary infection (Fair and Govan, 1976) and observations on sterility of post-operative urine may not necessarily reflect on the effectiveness of the surgical procedure. The slow deterioration in renal function in 3 patients, despite treatment of their vesicoureteric reflux (P.S., N.M., D.N.) probably indicated that renal parenchymal damage was irreversible and unlikely to be affected by surgery. Reimplantation of the ureter in patients with a
BRITISH JOURNAL OF UROLOGY
creatinine clearance below 20 ml/min is probably rarely indicated. The operative technique described here provides a free flap of bladder mucosa similar to the triangular flap ureteroplasty described in the experimental animal (Girgis and Veenema, 1965) and in the management of ureteric obstruction after antireflux surgery (Manley and Ferrell, 1975). We have found our results sufficiently encouraging to recommend its use in the primary treatment of megaureter.
References Clark, P. and Hosmane, R. U. (1976). Reimplantation of the ureter. British Journal of Urology, 48, 31-37. Cohen, S. (1977). In Operative Surgery, ed. Robb, C. and Smith, R. Third edition. Urology, ed. Williams, D. I., p. 131. London: Butterworths. Fair, W. R. and Covan, D. E. (1976). Influence of vesicoureteric reflux on the response to treatment of urinary tract infections in female children. Brirish Journal of Urology, 48, 111-117.
Cirgis, A. S. and Veenema, R. J. (1965). Triangular flap uretero-vesicoplasty: a new technique for correction of reflux-a preliminary report. Journal of Urology, 94, 233-237.
Hendren, W. H. (1969). Operative repair of megaureter in children. Journal of Urology, 101, 491-507. Johnston, J. H. (1967). Reconstructive surgery of megaureter in childhood. British Journal of Urology, 39, 17-21. Manley, C. 9. and Ferrell. J. M. (1975). Management of ureteric obstruction after an anti-reflux operation. Journal of Urology, 113, 121-124. Nesbit, R. M. and Wlthycombe, J. F. (1954). The problem of primary megaloureter. Journal of Urology, 72. 162-171. Paquin, A. J. (1959). Ureterovesical anastomosis: the description and evaluation of a technique. Journal of Urology,
82,573-583. Politano, V. A. and Leadbetter, W. F. (1958). An operative technique for the correction of vesicoureteral reflux. Journal of Urology, 79, 932-941. SPmpson, J. A. (1903). Ascending renal infection with special reference to the reflux of urine from the bladder into the ureters as an aetiological factor in its causation and maintenance. Bulletin of the Johns Hopkins Hospital, 14, 344-352. Williams, D. I. and Hulme-Moir, I. (1970). Primary obstructive megaureter. British Journal of Urology, 42, 140-149.
The Authors M. C. Bishop, MD, FRCS, formerly Clinical Lecturer, Nuffield Department of Surgery, Radcliffe Infirmary. Now Clinical Lecturer in Urology, Addenbrookes Hospital, Cambridge. A. R. Askew, FRCS, Surgical Registrar, Department of Surgery, Radcliffe Infirmary. J. C. Smith, MS. FRCS, Consultant Urological Surgeon, Department of Urology, Radcliffe Infirmary. Requests for reprints to: M. C. Bishop, Department of Urology, Addenbrookes Hospital, Hills Road, Cambridge CB2 2QQ.
Reimplantation of the Wide Ureter M. C. BISHOP, A. R. ASKEW and J. C. SMITH Nuffield Department of Surgery and Department of Urology, University of Oxford, Radcliffe Infirmary, Oxford
Summary-A modification of the technique of Politano and Leadbetter for reimplantation of wide ureters is described. Nine patients with obstructive megaureter (1 0 ureters) and 6 with gross vesicoureteric reflux (9ureters) were treated. A satisfactory result w a s obtained in 6 of the obstructed patients (7ureters) and ultimately, after re-operation, in 1 of the remaining ureters. Reflux w a s corrected in all 6 patients. This method requires less extravesical dissection than others involving extensive remodelling of the wide ureter. There is therefore less risk of damage t o the distal ureteric blood supply and the natural flap valve mechanism a t the ureteric orifice may be more effectively emulated.
Antireflux surgery on ureters of normal calibre is usually successful. The technique of Politano and Leadbetter (1958) is frequently used with one or other minor modification (Clark and Hosmane, 1976), though simple advancement (Cohen, 1977) is also often satisfactory. However, reimplantation of the wide ureter caused by vesicoureteric reflux or idiopathic obstruction has had a sinister reputation. A variety of techniques has been used to narrow the calibre. For example, Paquin (1959) constructed a cuff at the site of reimplantation. On the other hand, Hendren (1969) has adopted a more radical approach with extensive re-modelling of the ureter through most of its pelvic course. We present another technique which has the virtue of simplicity, avoids extensive dissection with possible damage to the blood supply to the ureter and attempts to reconstruct the natural flap valve mechanism at the ureteric orifice. Patients and Methods Fifteen patients (aged 9-52 years at presentation) were studied. They all had wide, tortuous ureters and the majority (9) were obstructed at the lower end whilst the remainder had vesicoureteric reflux. In 1 case this was due to tuberculosis, but the majority of patients with obstruction had a short narrow distal fibrotic segment with muscle hypertrophy and occasionally squamous metaReceived 13 December 1977. Accepted for publication 8 June 1978.
plasia of the mucosa. These features may be regarded as typical of primary idiopathic obstructive megaureter. The abnormality was bilateral in 1 patient. Most patients presented with loin pain. One 22-year-old male was investigated pre-operatively for severe hypertension. Another patient had bilateral obstruction with scarring of the kidneys and renal calculi. Of the 6 patients with reflux, 3 had bilateral megaureters. Overall renal function in 3 patients was poor (creatinine clearance < 20 m l h i n ) . One of the patients with unilateral reflux evidently acquired incompetence of the vesicoureteric junction after diathermy incision of a ureterocele. All patients with vesicoureteric reflux presented with recurrent urinary infections.
Technique (Figs. la-c) A combined intravesical and extravesical approach is used to mobilise the ureter. An umbilical catheter inserted and sutured into place in the ureter facilitates the intramural dissection. When present, the narrow distal segment found in idiopathic obstructive megaureter is resected. A long ‘V’ is then excised from the ureter. This is then sutured to narrow the ureter, leaving the terminal 1 to 2 cm to form a ‘Y’(Fig. la). Saline is injected to develop the submucosal plane in the bladder and facilitate formation of a tunnel. The reconstructed ureter is drawn through a new hiatus in the detrusor and the submucosal tunnel (Fig. lb). The lower edge is sutured to the bladder mucosa, leaving the defect in the distal ureter covered by
383
384
BRITISH JOURNAL OF UROLOGY
Fig. l b Modified Politano-Leadbetter technique (intravesical and extravesical approach) for reimplantation of the reconstructed ureter.
to the orifice and due to kinking above the hiatus in the detrusor. Fig. la Technique for reconstruction of the lower end of the ureter. In patients with obstructive megaureter the distal segment is excised.
a bladder mucosal flap (Fig. lc). This acts as a flexible valve to prevent reflux. The neocystostomy is not usually splinted and the bladder is drained with a fine catheter for 5 days.
Results Obstruction All 9 patients were assessed post-operatively. A satisfactory result was obtained in 6: the excretion urogram showed definite improvement in terms of concentration and pelviureteric dilatation (Fig. 2); the micturating cystourethrogram showed no relux and the urine was sterile. There was no recurrence of symptoms. Of the remaining 3 patients, 1 had persistent hypertension and probably a degree of residual obstruction; 2 patients required re-exploration and further reimplantation but in 1 of these the ureteric anastomosis was healthy and intact, the obstruction being proximal
Reflux Reflux was corrected in all 6 patients. Postoperative X-rays showed improvement in pelviureteric dilatation in 3 patients. Two female patients had recurrent urinary infection; in 1 this had not been a feature of the pre-operative course. In 3 patients with poor renal function (creatinine clearance < 20 m l h i n ) deterioration was not affected by reimplantation and long-term dialysis treatment was ultimately required.
b
Fig. IC Completed ureterovesical anastomosis showing free flap of bladder mucosa.
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385
Fig. 2 Patient C.R. (a) IVU: 30 min after injection (40ml 45% Hypaque). Pre-operative film. (b) Left retrograde pyelogram. Pre-operative film. (c) IVU: 10 min after injection. Eighteen months after operation. (d) IVU: 45 min after injection. Eighteen months after operation.
Discussion Whether renal function will remain stable or will deteriorate in cases of vesicoureteric reflux or idiopathic obstructive megaureter is difficult to predict, particularly when presentation is in the
older child or adult. The interrelation between the urodynamic disorder of the upper tract and other factors such as infection is obscure and this has led to uncertainty about clinical management. In the past it was felt that a conservative approach
386 was justified (Nesbit and Withycombe, 1954) but with improved technique it is now clear that surgical treatment may be more appropriate (Johnston, 1967; Williams and Hulme-Moir, 1970). Broadly, the aim in surgical management has been to reduce the calibre and redundant length of the ureter and to reimplant it, after reconstruction, into the bladder (Hendren, 1969). Provided that a normal width of the terminal ureter has been achieved, the technique of Politano and Leadbetter (1958) is satisfactory. Their method depends upon construction of a submucosal tunnel of adequate length to maintain competence of the ureteroneocystostomy by reproducing the flap valve mechanism (Sampson, 1903). If the terminal ureter is too wide there may be difficulty in constructing a submucosal tunnel of adequate length. The preliminary tailoring and tapering of the supravesical ureter is therefore all-important. The risk of damage to the blood supply of the ureter during this process should not be underestimated. We have modified the standard technique so that less manipulation of the ureter is required. Sufficient ureteric wall is removed from the terminal segment to construct a long ‘V’. With the formation of a free flap of bladder mucosa acting as an antireflux mechanism in its own right, the length of the submucosal tunnel may be less critical. The results suggest that the antireflux effect was always satisfactory. Stenosis recurred in 2 patients who were reexplored. However, kinking of the ureter had occurred above the anastomosis and was probably due to excision of an insufficient length of distal ureter. In all cases the anastomosis appeared to be healthy and with an intact blood supply. A few patients had occasional episodes of urinary infection post-operatively but these were always easily treated and there was no evidence that the upper urinary tract was involved. In any case it is controversial whether antireflux surgery affects the incidence of urinary infection (Fair and Govan, 1976) and observations on sterility of post-operative urine may not necessarily reflect on the effectiveness of the surgical procedure. The slow deterioration in renal function in 3 patients, despite treatment of their vesicoureteric reflux (P.S., N.M., D.N.) probably indicated that renal parenchymal damage was irreversible and unlikely to be affected by surgery. Reimplantation of the ureter in patients with a
BRITISH JOURNAL OF UROLOGY
creatinine clearance below 20 ml/min is probably rarely indicated. The operative technique described here provides a free flap of bladder mucosa similar to the triangular flap ureteroplasty described in the experimental animal (Girgis and Veenema, 1965) and in the management of ureteric obstruction after antireflux surgery (Manley and Ferrell, 1975). We have found our results sufficiently encouraging to recommend its use in the primary treatment of megaureter.
References Clark, P. and Hosmane, R. U. (1976). Reimplantation of the ureter. British Journal of Urology, 48, 31-37. Cohen, S. (1977). In Operative Surgery, ed. Robb, C. and Smith, R. Third edition. Urology, ed. Williams, D. I., p. 131. London: Butterworths. Fair, W. R. and Covan, D. E. (1976). Influence of vesicoureteric reflux on the response to treatment of urinary tract infections in female children. Brirish Journal of Urology, 48, 111-117.
Cirgis, A. S. and Veenema, R. J. (1965). Triangular flap uretero-vesicoplasty: a new technique for correction of reflux-a preliminary report. Journal of Urology, 94, 233-237.
Hendren, W. H. (1969). Operative repair of megaureter in children. Journal of Urology, 101, 491-507. Johnston, J. H. (1967). Reconstructive surgery of megaureter in childhood. British Journal of Urology, 39, 17-21. Manley, C. 9. and Ferrell. J. M. (1975). Management of ureteric obstruction after an anti-reflux operation. Journal of Urology, 113, 121-124. Nesbit, R. M. and Wlthycombe, J. F. (1954). The problem of primary megaloureter. Journal of Urology, 72. 162-171. Paquin, A. J. (1959). Ureterovesical anastomosis: the description and evaluation of a technique. Journal of Urology,
82,573-583. Politano, V. A. and Leadbetter, W. F. (1958). An operative technique for the correction of vesicoureteral reflux. Journal of Urology, 79, 932-941. SPmpson, J. A. (1903). Ascending renal infection with special reference to the reflux of urine from the bladder into the ureters as an aetiological factor in its causation and maintenance. Bulletin of the Johns Hopkins Hospital, 14, 344-352. Williams, D. I. and Hulme-Moir, I. (1970). Primary obstructive megaureter. British Journal of Urology, 42, 140-149.
The Authors M. C. Bishop, MD, FRCS, formerly Clinical Lecturer, Nuffield Department of Surgery, Radcliffe Infirmary. Now Clinical Lecturer in Urology, Addenbrookes Hospital, Cambridge. A. R. Askew, FRCS, Surgical Registrar, Department of Surgery, Radcliffe Infirmary. J. C. Smith, MS. FRCS, Consultant Urological Surgeon, Department of Urology, Radcliffe Infirmary. Requests for reprints to: M. C. Bishop, Department of Urology, Addenbrookes Hospital, Hills Road, Cambridge CB2 2QQ.
