0022-534 7/79/1216-0816$02. 00/0 Vol. 121, June Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
VESICOURETERAL REFLUX AND URETEROPELVIC JUNCTION OBSTRUCTION: LATE OCCURRENCE OF URETEROPELVIC OBSTRUCTION AFTER SUCCESSFUL URETERONEOCYSTOSTOMY DANIEL P. DEKLERK, WILLIAM G. REINER
AND
ROBERT D. JEFFS
From the James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland
ABSTRACT
Ureteropelvic junction obstruction occurred in 2 patients after successful correction of vesicoureteral reflux. The correction of vesicoureteral reflux does not always allow complete resolution of pelvioureteral tortuosity, kinking and periureteritis. In cases with a severe degree of these changes the possibility of ureteropelvic junction obstruction occurring either early or late after ureteroneocystostomy should be considered when unsatisfactory renal function is noted during followup. The ureteropelvic junction is the most common site of obstruction in the upper urinary tract in children. Nearly all obstructions at this level are congenital in origin, such as intrinsic ureteral musculature defects, obstructing fibrous bands or aberrant vessels. However, since the description of Gross and Sanderson, 1 and Hutch and associates2 it has been recognized that vesicoureteral reflux of a severe degree may cause secondary ureteropelvic obstruction. Usually, this has been regarded as owing to ureteral tortuosity, kinking and periureteritis from long-standing vesicoureteral reflux. Ureteropelvic junction obstruction associated with vesicoureteral reflux may be divided into 2 categories. First, as Williams has indicated, there may be an incidental association of ureteropelvic obstruction with minimal reflux and, as is usual with this degree of reflux, this may disappear spontaneously after the pyeloplasty. 3 Secondly, the ureteropelvic junction obstruction may be recognized during voiding cystourethrography when, with total reflux, the renal pelvis distends out of proportion to the ureteral dilatation. In this case the recommended therapy has been a primary approach to the ureterovesical junction with the expectation that the changes at the ureteropelvic junction will resolve spontaneously after correction of the reflux and treatment of the urinary tract infection. Herein we report 2 cases in which ureteropelvic junction obstruction developed after successful correction of vesicoureteral reflux. Undoubtedly, vesicoureteral reflux had brought about chronic inflammation, dilatation and kinking at the ureteropelvic junction but these were not manifest during the initial evaluation. Correction of the reflux by successful ureteroneocystostomy did not allow resolution of these changes at the ureteropelvic junction and, therefore, despite good drainage on the initial postoperative excretory urogram (IVP), late followup showed the occurrence of ureteropelvic junction obstruction. CASE REPORTS
Case 1 . A 3-year-old white girl was seen in 1972 with a history of documented urinary tract infection. An IVP was reported as normal but voiding cystourethrography demonstrated total left vesicoureteral reflux (fig. 1). Subsequently, she underwent bilateral ureteroneocystostomy. The patient was well for 2 years postoperatively but in 1974 she had recurrence of acute left pyelonephritis. An IVP revealed a left extrarenal pelvis but with no apparent obstruction (fig. 2, A). No voiding cystography was done. In 1976 she was rehospitalAccepted for publication July 21, 1978.
ized for left pyelonephritis and an IVP was interpreted as demonstrating decreased function on the left side, hydronephrosis with loss of cortex and non-visualization of the left ureter (fig. 2, B). A voiding cystourethrogram revealed the absence of reflux with a somewhat large bladder but a good detrusor contraction. Upon referral to this institution the urine was uninfected. Physical examination was unremarkable except for hypertension, with a blood pressure of 160/135, and a palpable left kidney. An IVP demonstrated massive left hydronephrosis. A differential renal scan revealed a poorly functioning left kidney with normal function on the right side. With the presumptive diagnosis of ureteropelvic junction obstruction selective arteriography was done in search of aberrant vasculature. A lower pole vessel was seen contributing to the ureteropelvic junction obstruction (fig. 3, A). Renal vein renins were collected and lateralized to the left side (right, 2.35 and left, 13.97 ng./ml. per hour). A left dismembered Y-V pyeloplasty was done. Convalescence was uneventful and blood pressure responded weJl. Blood pressure ranged from 90/60 to 115/65, 18 months postoperatively. An IVP showed remarkable improvement compared to the preoperative function (fig. 3, B). Followup urine cultures remain negative. Case 2. A 2-year-old girl was hospitalized in 1963 with a history of recurrent urinary tract infections, right pyelonephritis and failure to thrive. Urinalysis revealed 15 to 30 white blood cells per high power field and subsequent culture yielded enteric streptococci. Renal function was normal. An IVP revealed a poorly functioning right kidney and voiding cystourethrography demonstrated bilateral massive vesicoureteral reflux with prompt drainage from both collecting systems (fig. 4, A). After a trial of antibiotic therapy bilateral ureteral advancement was done. No reflux on either side was demonstrated on a voiding cystourethrogram 3 months postoperatively. An IVP showed that the left side was normal and that the drainage and function on the right side were improving. Although the patient remained asymptomatic weight gain was not satisfactory. A repeat IVP 6 months later revealed gross hydronephrosis of the right kidney. A right retrograde pyelogram showed a persistent obstruction at the ureteropelvic junction (fig. 4,B). At operation an aberrant vessel was found to cross the ureteropelvicjunction contributing to the obstruction. Further dissection revealed no demonstrable intrinsic ureteropelvic junction obstruction after release of the vessel and useful parenchyma was present. Drainage was improved by relocat-
816
_,.,_
VESICOURETERAL REFLUX AND URETEROPELVIC JUNCTION OBSTRUCTION
ing the aberrant vessel and performing a modified Hamilton Stewart4 nephroplasty to provide a dependent ureteropelvic junction with the main and aberrant vessels overlying each other at a higher level. Convalescence was essentially uneventful. A followup IVP revealed improvement of the function on the right side. DISCUSSION
The etiology of the ureteropelvic junction obstruction in association with vesicoureteral reflux has provoked some discussion. Occasionally, patients with ureteropelvic junction obstruction may have associated minimal degrees of vesicoureteral reflux. These patients may be treated primarily by
Fm. 1
817
pyeloplasty and the reflux disappears spontaneously, as in cases of minimal degrees of vesicoureteral reflux. However, the more common association is when ureteropelvic junction obstruction is secondary to a significant degree of vesicoureteral reflux. It is this latter group in which the mechanism of obstruction has been debated. Williams has proposed that the atonicity of the pelvic musculature is primarily to be implicated and that ballooning of the renal pelvis with massive reflux prevents adequate drainage. 3 Johnston has suggested that this sudden distension of the pelvis with reflux may allow angulation, obstruction and delayed drainage of the renal pelvis. 5 Recently, Whitaker has proposed that atonicity and dilatation of the renal pelvis do not allow for adequate bolus formation and propagation of the bolus through the ureteropelvic junction, and that the contracting circular fibers at the ureteropelvic junction may produce a functional obstruction. 6 In our cases ureteropelvic obstruction was not recognized during the initial evaluation but, subsequently, became apparent on followup by the late deterioration of renal function. It is noteworthy that in both cases an accessory vessel contributed to ureteropelvic junction obstruction. It is unlikely that the vessels were primarily responsible for the development of obstruction but probably merely accentuated the changes induced by the vesicoureteral reflux. In the child being evaluated for vesicoureteral reflux severe dilatation and angulation of the renal pelvis during voiding cystourethrography should raise the question as to the significance of the pelvic dilatation. Whether the dilatation is secondary to an associated ureteropelvic obstruction may be determined by fluoroscopy of the renal pelvis after the voiding phase of the voiding cystourethrogram. Usually, the pelvis will drain promptly but, occasionally, significant delay may be noted in the renal pelvis, suggesting obstruction. In the patient with persistent hydronephrosis after apparently successful correction of reflux the level of obstruction may be more difficult to determine, since a certain degree of persisting ureteral dilatation may be expected in patients with severe preoperative ureteral dilatation. In such cases we have found the percutaneous puncture of the renal pelvis with fluoroscopy and the Whitaker pressure flow studies7 to be of value. This procedure will allow accurate assessment of vesicoureteral and ureteropelvic junctions and demonstrates the capability of the ureter to peristalsis. It is apparent that in the child with vesicoureteral reflux and ureteropelvic junction obstruction the primary repair should be aimed at the area of most significant pathology. Therefore, should the reflux be of an insignificant degree the ureteropelvicjunction should first be approached in the expectation that the reflux will resolve spontaneously. However, should the reflux be of massive proportions ureteroneocystostomy should be done in the hope that the pelvic obstruction
Fm. 2
818
DEKLERK, REINER AND JEFFS
Fm. 3
Fm. 4
will improve spontaneously with the return of normal renal drainage raise the suspicion of an element of ureteropelvic pelvic tonicity and resolution of the urinary tract inflamma- junction obstruction. Unsatisfactory improvement in renal tion. Occasionally, when gross reflux is present there is poor function or general health indicates the necessity for redrainage of the renal pelvis immediately after a cystogram. In evaluation in these patients, these patients significant lesions are present at the ureteroREFERENCES vesical and ureteropelvic junctions, and surgical correction of 1. Gross, K. E. and Sanderson, S. S.: Cineurethrography and both lesions is indicated. Under these circumstances we prefer voiding cinecystography with special attention to vesico-urea staged approach with the initial procedure to the ureteropelteral reflux. Radiology, 77: 573, 1961. vic junction. 2. Hutch, J. A., Hinman, F., Jr. and Miller, E. R.: Reflux as a In conclusion, the advent of modern operative techniques cause of hydronephrosis and chronic pyelonephritis. J. U rol., for ureteroneocystostomy has produced a significant improve88: 169, 1962. ment in the salvage rate of children otherwise doomed to 3. Williams, D. I.: Vesico-ureteric reflux. In: Encyclopedia of progressive renal failure from massive hydroureteronephrosis Urology. Berlin: Springer, vol. 15 (suppl.), pp. 119-125, 1974. with severe degrees of vesicoureteral reflux. The experienced 4. Sunderland, H.: A review of experiences with the AndersonHynes plastic operation for hydronephrosis. Brit. J. Urol., 35: urologist may expect a
THE JOURNAL OF UROLOGY
Copyright © 1979 by The Williams & Wilkins Co.
VESICOURETERAL REFLUX AND URETEROPELVIC JUNCTION OBSTRUCTION: LATE OCCURRENCE OF URETEROPELVIC OBSTRUCTION AFTER SUCCESSFUL URETERONEOCYSTOSTOMY DANIEL P. DEKLERK, WILLIAM G. REINER
AND
ROBERT D. JEFFS
From the James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland
ABSTRACT
Ureteropelvic junction obstruction occurred in 2 patients after successful correction of vesicoureteral reflux. The correction of vesicoureteral reflux does not always allow complete resolution of pelvioureteral tortuosity, kinking and periureteritis. In cases with a severe degree of these changes the possibility of ureteropelvic junction obstruction occurring either early or late after ureteroneocystostomy should be considered when unsatisfactory renal function is noted during followup. The ureteropelvic junction is the most common site of obstruction in the upper urinary tract in children. Nearly all obstructions at this level are congenital in origin, such as intrinsic ureteral musculature defects, obstructing fibrous bands or aberrant vessels. However, since the description of Gross and Sanderson, 1 and Hutch and associates2 it has been recognized that vesicoureteral reflux of a severe degree may cause secondary ureteropelvic obstruction. Usually, this has been regarded as owing to ureteral tortuosity, kinking and periureteritis from long-standing vesicoureteral reflux. Ureteropelvic junction obstruction associated with vesicoureteral reflux may be divided into 2 categories. First, as Williams has indicated, there may be an incidental association of ureteropelvic obstruction with minimal reflux and, as is usual with this degree of reflux, this may disappear spontaneously after the pyeloplasty. 3 Secondly, the ureteropelvic junction obstruction may be recognized during voiding cystourethrography when, with total reflux, the renal pelvis distends out of proportion to the ureteral dilatation. In this case the recommended therapy has been a primary approach to the ureterovesical junction with the expectation that the changes at the ureteropelvic junction will resolve spontaneously after correction of the reflux and treatment of the urinary tract infection. Herein we report 2 cases in which ureteropelvic junction obstruction developed after successful correction of vesicoureteral reflux. Undoubtedly, vesicoureteral reflux had brought about chronic inflammation, dilatation and kinking at the ureteropelvic junction but these were not manifest during the initial evaluation. Correction of the reflux by successful ureteroneocystostomy did not allow resolution of these changes at the ureteropelvic junction and, therefore, despite good drainage on the initial postoperative excretory urogram (IVP), late followup showed the occurrence of ureteropelvic junction obstruction. CASE REPORTS
Case 1 . A 3-year-old white girl was seen in 1972 with a history of documented urinary tract infection. An IVP was reported as normal but voiding cystourethrography demonstrated total left vesicoureteral reflux (fig. 1). Subsequently, she underwent bilateral ureteroneocystostomy. The patient was well for 2 years postoperatively but in 1974 she had recurrence of acute left pyelonephritis. An IVP revealed a left extrarenal pelvis but with no apparent obstruction (fig. 2, A). No voiding cystography was done. In 1976 she was rehospitalAccepted for publication July 21, 1978.
ized for left pyelonephritis and an IVP was interpreted as demonstrating decreased function on the left side, hydronephrosis with loss of cortex and non-visualization of the left ureter (fig. 2, B). A voiding cystourethrogram revealed the absence of reflux with a somewhat large bladder but a good detrusor contraction. Upon referral to this institution the urine was uninfected. Physical examination was unremarkable except for hypertension, with a blood pressure of 160/135, and a palpable left kidney. An IVP demonstrated massive left hydronephrosis. A differential renal scan revealed a poorly functioning left kidney with normal function on the right side. With the presumptive diagnosis of ureteropelvic junction obstruction selective arteriography was done in search of aberrant vasculature. A lower pole vessel was seen contributing to the ureteropelvic junction obstruction (fig. 3, A). Renal vein renins were collected and lateralized to the left side (right, 2.35 and left, 13.97 ng./ml. per hour). A left dismembered Y-V pyeloplasty was done. Convalescence was uneventful and blood pressure responded weJl. Blood pressure ranged from 90/60 to 115/65, 18 months postoperatively. An IVP showed remarkable improvement compared to the preoperative function (fig. 3, B). Followup urine cultures remain negative. Case 2. A 2-year-old girl was hospitalized in 1963 with a history of recurrent urinary tract infections, right pyelonephritis and failure to thrive. Urinalysis revealed 15 to 30 white blood cells per high power field and subsequent culture yielded enteric streptococci. Renal function was normal. An IVP revealed a poorly functioning right kidney and voiding cystourethrography demonstrated bilateral massive vesicoureteral reflux with prompt drainage from both collecting systems (fig. 4, A). After a trial of antibiotic therapy bilateral ureteral advancement was done. No reflux on either side was demonstrated on a voiding cystourethrogram 3 months postoperatively. An IVP showed that the left side was normal and that the drainage and function on the right side were improving. Although the patient remained asymptomatic weight gain was not satisfactory. A repeat IVP 6 months later revealed gross hydronephrosis of the right kidney. A right retrograde pyelogram showed a persistent obstruction at the ureteropelvic junction (fig. 4,B). At operation an aberrant vessel was found to cross the ureteropelvicjunction contributing to the obstruction. Further dissection revealed no demonstrable intrinsic ureteropelvic junction obstruction after release of the vessel and useful parenchyma was present. Drainage was improved by relocat-
816
_,.,_
VESICOURETERAL REFLUX AND URETEROPELVIC JUNCTION OBSTRUCTION
ing the aberrant vessel and performing a modified Hamilton Stewart4 nephroplasty to provide a dependent ureteropelvic junction with the main and aberrant vessels overlying each other at a higher level. Convalescence was essentially uneventful. A followup IVP revealed improvement of the function on the right side. DISCUSSION
The etiology of the ureteropelvic junction obstruction in association with vesicoureteral reflux has provoked some discussion. Occasionally, patients with ureteropelvic junction obstruction may have associated minimal degrees of vesicoureteral reflux. These patients may be treated primarily by
Fm. 1
817
pyeloplasty and the reflux disappears spontaneously, as in cases of minimal degrees of vesicoureteral reflux. However, the more common association is when ureteropelvic junction obstruction is secondary to a significant degree of vesicoureteral reflux. It is this latter group in which the mechanism of obstruction has been debated. Williams has proposed that the atonicity of the pelvic musculature is primarily to be implicated and that ballooning of the renal pelvis with massive reflux prevents adequate drainage. 3 Johnston has suggested that this sudden distension of the pelvis with reflux may allow angulation, obstruction and delayed drainage of the renal pelvis. 5 Recently, Whitaker has proposed that atonicity and dilatation of the renal pelvis do not allow for adequate bolus formation and propagation of the bolus through the ureteropelvic junction, and that the contracting circular fibers at the ureteropelvic junction may produce a functional obstruction. 6 In our cases ureteropelvic obstruction was not recognized during the initial evaluation but, subsequently, became apparent on followup by the late deterioration of renal function. It is noteworthy that in both cases an accessory vessel contributed to ureteropelvic junction obstruction. It is unlikely that the vessels were primarily responsible for the development of obstruction but probably merely accentuated the changes induced by the vesicoureteral reflux. In the child being evaluated for vesicoureteral reflux severe dilatation and angulation of the renal pelvis during voiding cystourethrography should raise the question as to the significance of the pelvic dilatation. Whether the dilatation is secondary to an associated ureteropelvic obstruction may be determined by fluoroscopy of the renal pelvis after the voiding phase of the voiding cystourethrogram. Usually, the pelvis will drain promptly but, occasionally, significant delay may be noted in the renal pelvis, suggesting obstruction. In the patient with persistent hydronephrosis after apparently successful correction of reflux the level of obstruction may be more difficult to determine, since a certain degree of persisting ureteral dilatation may be expected in patients with severe preoperative ureteral dilatation. In such cases we have found the percutaneous puncture of the renal pelvis with fluoroscopy and the Whitaker pressure flow studies7 to be of value. This procedure will allow accurate assessment of vesicoureteral and ureteropelvic junctions and demonstrates the capability of the ureter to peristalsis. It is apparent that in the child with vesicoureteral reflux and ureteropelvic junction obstruction the primary repair should be aimed at the area of most significant pathology. Therefore, should the reflux be of an insignificant degree the ureteropelvicjunction should first be approached in the expectation that the reflux will resolve spontaneously. However, should the reflux be of massive proportions ureteroneocystostomy should be done in the hope that the pelvic obstruction
Fm. 2
818
DEKLERK, REINER AND JEFFS
Fm. 3
Fm. 4
will improve spontaneously with the return of normal renal drainage raise the suspicion of an element of ureteropelvic pelvic tonicity and resolution of the urinary tract inflamma- junction obstruction. Unsatisfactory improvement in renal tion. Occasionally, when gross reflux is present there is poor function or general health indicates the necessity for redrainage of the renal pelvis immediately after a cystogram. In evaluation in these patients, these patients significant lesions are present at the ureteroREFERENCES vesical and ureteropelvic junctions, and surgical correction of 1. Gross, K. E. and Sanderson, S. S.: Cineurethrography and both lesions is indicated. Under these circumstances we prefer voiding cinecystography with special attention to vesico-urea staged approach with the initial procedure to the ureteropelteral reflux. Radiology, 77: 573, 1961. vic junction. 2. Hutch, J. A., Hinman, F., Jr. and Miller, E. R.: Reflux as a In conclusion, the advent of modern operative techniques cause of hydronephrosis and chronic pyelonephritis. J. U rol., for ureteroneocystostomy has produced a significant improve88: 169, 1962. ment in the salvage rate of children otherwise doomed to 3. Williams, D. I.: Vesico-ureteric reflux. In: Encyclopedia of progressive renal failure from massive hydroureteronephrosis Urology. Berlin: Springer, vol. 15 (suppl.), pp. 119-125, 1974. with severe degrees of vesicoureteral reflux. The experienced 4. Sunderland, H.: A review of experiences with the AndersonHynes plastic operation for hydronephrosis. Brit. J. Urol., 35: urologist may expect a
