Reimplantation of Double Ureters

Vol. 102, Aug. Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1969 by The Williams & Wilkins Co.

REIMPLANTATION OF DOUBLE URETERS G. RONALD REULE

AND

JULIAN S. ANSELL

From the Department of Urology, University of Washington School of Medicine and the Congenital Defects Clinic and Clinical Research Center, University Hospital, Seattle, Washington

Duplication of ureters will frequently be found in patients undergoing operation for reflux. Ambrose and Nicolson reported complete duplication in 12 to 22 per cent of their cases of reflux.1-3 Of 8 cases of reflux in children reported on by Hutch and associates, 3 patients had ureteral duplication (37 per cent). 4 We reviewed 32 cases of reflux and found 5 patients with complete ureteral duplication (15 per cent). In contrast, the over-all incidence of complete ureteral duplication is only 1 in 500. 5 Expressed another way, Ambrose and Ratner found that 50 to 60 per cent of patients with ureteral duplication had reflux.1· 6 Whenever possible, the most satisfactory correction of reflux in the presence of duplication is reimplantation of the double ureters as one within their common sheath. We prefer the PolitanoLeadbetter technique.7 This method of management in cases of reflux associated with duplicated ureters appears to be fairly common as judged by personal inquiry, yet reference to it is scarcely Accepted for publication August 1, 1968. Supported in part by National Foundation March of Dimes Grant CRCS-39 and in part through the Clinical Research Center, University of Washington Hospital on National Institutes of Health Grant FR-37. Read at annual meeting of Northwest Urological Society, Vancouver, British Columbia, Canada, December 2, 1967. 1 Ambrose, S. S. and Nicolson, W. P.: Ureteral reflux in duplicated ureters. J. Urol., 92: 439, 1964. 2 Ambrose, S.S. and Nicolson, W. P., III: The causes of vesicoureteral reflux in children. J. Urol., 87: 688, 1962. 3 Ambrose, S.S. and Nicolson, W. P., III: Vesicoureteral reflux secondary to anomalies of the ureterovesical junction: management and results. J. Urol., 87: 695, 1962. 4 Hutch, J. A., Bunge, R. G. and Flocks, R.H.: Vesicoureteral reflux in children. J. Urol., 74: 607, 1955. 5 Campbell, M. F.: Urology. Philadelphia: W. B. Saunders Co., vol. 2, 1963. 6 Ratner, I. A., Fisher, J. H. and Swenson, 0.: Double ureters in infancy and childhood. Pediatrics, 28: 810, 1961. 7 Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958.

found in the literature. 8 • 9 We herein emphasize the applicability of this approach and the details of technique. Four cases managed by us are reviewed. CASE SUMMARIES

All of our patients had a Politano-Leadbetter type ureteral reimplantation and in each case the double ureters were handled as one in a common sheath (fig. 1). • Case 1. L. D., a 6:\,-6-year-old girl with recurrent pyelonephritis, was found to have urethral stenosis, complete duplication of the right ureter and bilateral reflux with patulous orifices of the left ureter and the lower segment of the right ureter. The patient was free of reflux when checked 6 months after bilateral reimplantation and internal urethrotomy. Case 2. C. K., a 42-year-old woman, had had ureteral meatotomies in the past for bilateral hydronephrosis and recurrent urinary tract infection. She was known to have complete bilateral duplication, and our examination showed reflux into all 4 ureters. The patient underwent Y-V plasty of the bladder neck and a urethral meatotomy. Reflux persisted and, 2 years later, reimplantation was performed. One month postoperatively incomplete reflux was seen on the right side. Long-term evaluation will be made. Case 3. S. G., a 4-year-old girl, was enuretic since she was 17-6 years old and had a history of recurrent urinary tract infection. She had complete duplication of the right ureter and bilateral reflux. The right lower segment ureteral orifice and left orifice were patulous. The patient underwent bilateral reimplantation. She was free of reflux when evaluated 3 months later. Case 4. S. H., an 11-year-old girl, had had 8 Williams, D. I. and Eckstein, H.B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965. 9 Woods, F. M., Melvin, P. D., Coplan, M. M. and Raim, J. A.: Two case reports of Hutch-type vesicoureteroplasty on duplicated ureters. J. Urol., 81: 400, 1959.

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urinary tract infection since she was 5 years old. She was found to have partial ureteral duplication on the right side without reflux, but on the left side there was complete duplication with reflux. The degree of reflux was incomplete and it was uncertain into which orifice it occurred. Both left ureters were free of reflux 1 year postoperatively. TECHNIQUE

Our choice of procedure was essentially that of Politano and Leadbetter. A transverse lower abdominal incision is preferred. After the bladder is opened and the trigone is well exposed, both ureteral orifices are intubated with 5 or 8 Fr. polyvinyl pediatric feeding tubes to aid in dissection. A stay suture is placed at the 10 or 2 o'clock position of the more distal and medial of the duplicated orifices. With slight traction on this suture, the mucosa is incised 2 to 3 mm. from the margin of the orifice. The incision is completely carried around both orifices, leaving the small cuff of mucosa (fig. 2, A.). For this and much of tbe remainder of the dissection, we prefer Stevens

tenotomy scissors. After the initial sharp dissection to free the ureter from the bladder wall, blunt dissection with a Kuttner dissector will usually suffice to carry one deep behind the bladder, our desire being to reach close to the peritoneal reflection (fig. 2, B). Small vessels encountered during this part of the dissection are electrocoagulated before division. A right angle clamp is then put through this hiatus in the bladder wall and its tip is bluntly forced back into the bladder at a site a.bout 2 cm. above the hiatus (fig. 2, C). With the clamp in place, a submucosal tunnel is formed, joining the 2 site5. A. second clamp is then brought downward, following the first in its course outside the detrusor muscle. It is used to grasp the stay suture on the ureter and to pull it through the new hiatus into the bladder after removing the ureteral catheters (fig. 2, D). Next the bladder muscularis a.round the defect is approximated with 2 or 3 stitches of 3-zero chromic catgut and the mucosa of the margins of this defect is undermined and laterally for several millimeters to allow

174

REULE AND ANSELL

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REIMPLANTATION OF DOUBLE URETERS

easier approximation of the mucosa over the ureters (fig. 3, A.). A. clamp is then inserted from below into the submucosal tunnel to grasp the stay suture and to bring the ureters, in their common sheath, through this tunnel (fig. 3, B and C). The ureters are then laid over the stitched bladder muscularis and secured first with 1 or 2 stitches of 3-zero chromic catgut at the apex, placed deeply into the muscle of the trigone, then with several additional stitches of 4-zero chromic catgut to the mucosa! rim around the orifices to the bladder mucosa (fig. 3, D) Closure of the defect is completed by bringing together the lateral mucosa! edges over the ureters superior to the orifices. The mucosa! defect at the new site of ureteral entry through the bladder wall also closed. The ureteral catheters are replaced and brought through the urethra with a Foley catheter to which they are secured. In addition, we use a suprapubic catheter brought out through a separate stab incision and a Penrose drain is inserted to the pre-vesical space. The ureteral catheters are left in place for 5 clays. The drain is advanced in 4 clays and taken out in 6 clays. The suprapubic catheter is clamped 6 days postoperatively and removed the next day if void-· JS satisfactory. DISCUSSION

The single most clear-cut advantage of reim planting duplicate ureters is in the application to cases in which reflux occurs in only 1 ureter of the pair and is incomplete, so one knows not which orifice is incompetent. As mentioned, this was the case with one of our patients. There are, of course, alternatives to reimplanting double ureters by this method. Ureteroureterostomy has been advocated as a means of handling this situation. Though useful in some cases, occasionally it is not known in which ureter the reflux occurs and, therefore, cannot apply. Individual reimplantation of the double ureters simply adds to procedure time and disruption of the tissue. Harrow advised against it. 10 Our choice of the Politano-Leadbetter technique undoubtedly stems partly from our success and familiarity with it for single ureters. In addition seems to have some theoretical advantages 10

Harrow, R R.: How not to re-implant double

ureters into the bladder. J. Urol., 98: 345, 1967.

175

over other popular methods, For example, it would be difficult to apply those methods requiring a ureteral cuff. The Bischoff method of mucosa! tunnel construction would be technically difficult, requiring a much longer tunnel than usual, with increased tendency to fistula formation.11 The Lich method could be applied, but requires experienced judgment to create an ap· propriate tunnel-a step more difficult with a double ureter. 12 The original Hutch has been used successfully in this has a modification of that method. 9 • 13 • 14 However, since most of the proximal orifices in cation are higher and more widely placed than usual, kinking of the ureter at its entry into the bladder wall seems to be a likely complication. The Hutch advancement procedure more trigone than would usually be available in the presence of double ureters. 15 Paquin's procedure might well be Relected when one of the ureters is widely dilated but does require separate fixation and cuff formation for each ureter. 16 The Politano-Leadbetter technique also provides good latitude in choice of candidates. Although our patients had close orifices, this method would appear applicable in patients in whom there is greater distance between them, as well as in the presence of a ureterocele. Sacrifice of the distal portion of the upper ureteral seg,. rnent would readily adapt these variations to the described technique. CONCLUSION

In the presence of reflux and complete ureteral duplication, the simultaneous reimplantation of both ureters in their common sheath, by the Politano-Leadbetter technique, offers in most cases a simple and effective way of correcting the defect. 11

Bischoff, P.: Megaureter. Brit. J. Urol., 29:

416, 1957.

Lich, R., Jr., Howerton, L. W. and Davis, L.A.: Recurrent urosepsis in children. J. Urol., 86: 554, 1961. 13 Hutch, J. A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J. UroL, 68: 457, 1952. 14 Palken, M.: Personal communication. 15 Hutch, J. A.: U reteric advancement operation: anatomy, technique and early results. J. Urol., 89: 180, 1963. 16 Paquin, A. J., Jr.: Surgery of the ureteropelvic junction. In: Urologic Surgery. Edited by J . .F. Glenn and Yv. H. Boyce. New York: Harper & Row, p. 237, 1969. 12