A Surgical Procedure Suggested for Certain Cases of Reduplicated Ureter

Vol.105,June Printed in U.S.A.

THE JOURNAL OF UROLOGY

Copyright © 1971 by The Williams & Wilkins Co.

A SURGICAL PROCEDURE SUGGESTED FOR CERTAIN CASES OF REDUPLICATED URETER CARL A. OLSSON AND RICHARD CHUTE From the Department of Urology, Boston Veterans Administration Hospital, Boston, Massachusetts

Incomplete ureteral duplication with peristaltic dysfunction causes renal pain. Herein we present a method of treating this problem with conservation of all renal tissue. CASE REPORT

J. R., BVAH 427446826, a 41-year-old black man, had a 3-year history of right flank pain. There were no urinary symptoms. Physical examination was unremarkable except for right flank tenderness. Laboratory data including complete blood count, urinalysis, blood urea nitrogen, liver function studies and serum amylase were normal. X-ray studies of the chest, gallbladder and gastrointestinal tract failed to reveal the source of pain. An excretory urogram (IVP) showed a partially reduplicated right ureter with alternating distention of the 2 ureteral segments (fig. 1). Thinking that ureteral dyskinesia might be the source of pain, we administered 50 mg. cthacrynic acid intravenously in an effort to reproduce the pain. Five minutes after diuretic injection the patient suffered exquisite right flank pain requiring narcotics for relief. Retrograde cine-pyelography revealed alternating dilatation of the upper and lower renal segments with "see-saw" peristalsis originating in each ureteral limb (fig. 2). This study again reproduced an identical pattern of renal pain. The reduplicated ureters were exposed through a right flank incision from the renal pelves down to their junction just above the iliac vessels. Peristaltic activity was observed initiating alternately in each ureteral limb, with urine advancing toward the branch point and then refluxing up the opposite limb. Electromanomctric studies showed that, in the absence of diuresis, the upper segment ureter peristalsis was much stronger than the lower (fig. 3). However, with mannitol diuresis, the peristaltic ability of the upper segment ureter became fatigued and the so-called "ilea!" type Accepted for publication November 1970.

of peristaltic activity became apparent in both limbs. 1 Since we were undecided as to which ureter to sacrifice if a pyelopyelostomy was to be considered, we decided to preserve both ureters. I3y spatulating each from the area of its renal pelvis clown to the branch point and anastomosing one to the other, we were left with a single ureter from the kidney down to the bladder. IVPs 5 and 8 months postoperatively revealed that the kidney had good drainage (fig. 4). Normal urinalysis and sterile urine culture were noted. To provoke renal pain, diuresis was produced with furoscmide. The patient suffered no recurrence of pain. DISCUSSI0)1

Physiology. l\Iost bifid ureters display refluxing peristalsis. 1-s In the absence of infection the condition seems to be well tolerated by the 1iatient. 2 , 3 However, the simple anatomic abnormality with resulting "see-saw" peristalsis may cause renal pain. 2, 7 The incidence of ureteroureteral reflux corresponds to the level at which the ureteral branches meet. In high-branching ureters regurgitant peristalsis is uncommon. In lowbranching ureters (mid or lower ureter) reversed peristalsis is present nearly 100 per cent of the time. 4 • 6 Furthermore, the lower the branch 1 Boyarsky, S. and Labay, P.: Ureteral motility. Ann. Rev. Med., 20: 383, 1969. 2 Swenson, 0. and Ratner, I. A.: Pyeloureterostomy for treatment of symptomatic ureteral duplications in children. J. Urol., 88: 184, 1962. 3 Campbell, J.E.: Ureteral peristalsis in duplex renal collecting systems. Amer. J. Roentgen., 99: 577, 1967. 4 Kaplan, N. and Elkin, M.: Bifid renal pelves and ureters. Radiographic and cinefluorographic observations. Brit. J. Urol., 40: 235, 1968. 5 Boyarsky, S., Labay, P. and Lenaghan, D.: Transureteroureterostomy, bificl ureters and ureteral dyskinesia. J. Urol., 99: 156, 1968. 6 Amar, A. D.: Reflux in duplicated ureters. Brit. J. Urol., 40: 385, 1968. 7 Lenaghan, D.: Bifid ureters in children: an anatomical, physiological and clinical study. J. Urol., 87: 808, 1962. 8 Pearson, H. H.: Results of pyelopyelostomy for bifid ureters. Brit. J. Urol., 40: 483, 1968.

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SURGICAL PROCEDURE FOR REDUPLICATED URETER

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FIG. 1. Sequential films from preoperative IVP. A, distention of both pelves. B, lower pelvis is further distended as upper pelvis empties.

Frn. 2. Sequential films from retrograde study. A, lower branch filled with coutrast medium. B, re-· flux has occurred filling upper branch.

point the more dilatation of one or both of the ureteral branches is seen radiographically. 4 Since the contraction wave of ureteral peristalsis originates in the renal calix and is trans-

rnitted from there across the pelvis and then on clownward,1 it is reasonable to assume that if there are 2 pelves and 2 ureters there will be asynchronous peristalsis. 1 • 5 This

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FIG. 3. Manometric studies of ureteral branch

peristalsis. Arrow indicates point at which upper ureter pressure begins to be transmitted to lower ureter.

peristalsis would not present a problem if it were not for the fact that the common stem ureter distal to the fork has a higher resting pressure than does either of the branches and resists the passage of urine toward the bladder. 7 Treatment. Therapy for patients with ureteroureteral peristalsis lies in the fashioning of a single drainage unit so that upper ureteral peristalsis will initiate a single peristaltic wave to the bladder. The ways a single drainage unit may be constructed are shown in figures 5 and 6. In figure

5, A a single urinary conduit is fashioned by heminephro-ureterectomy of the duplicated renal portion. This should be considered when there is unsalvagable renal tissue being drained by one of the 2 branch ureters. When the 2 portions of kidney are salvagable, the development of a single dr.ainage unit is achieved by pyelopyelostomy, sacrificing the ureteral branch that drains the smaller portion of kidney (fig. 5, B). However, when the 2 renal portions are equal in size one must decide which ureter to sacrifice in performing a pyelopyelostomy. A method for treating branch ureters coming from equal-sized renal portions was described by Turner-Warwick (fig. 6, B). 9 If the ureteral junction point is low, the 2 ureteral branches can be separately reimplanted into the bladder, which is hitched to the psoas muscle in the so-called "bladder horn" procedure. In our case the branch point of the bifid ureter was at the level of the iliac vessels, so that separate reimplantation of the branches into the bladder did not seem feasible. Operative manometry showed that without diuresis the ureteral branch draining the upper renal segment had much stronger peristalsis than did that draining the lower renal segment. To find out how the upper ureter would fare 9 Turner-Warwick, R. and Worth, P. H. L.: The psoas bladder-hitch procedure for the replacement of the lower third of the ureter. Brit. J. Urol.,

41: 701, 1969.

Fra. 4. A, IVP 5 months postoperatively. B, IVP 8 months postoperatively

SURGICAL PROCEDURE FOR REDUPLICATED URETER

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B

Unsalvageable

UNEQUAL

SIZE

Salvageable

SEGMENTS

Fm. 5. Methods of treating bifid kidneys with renal segments of dissimilar size. Shaded areas resected.

and its peristaltic wave became broadened due to regurgitating pressure from the lower ureteraI branch. Thus, we were faced with the dilemma of not knowing which ureteral branch to select pyefor the construction of a single conduit lopyelostomy. Following the example of others,2· 3 • 8 , 10 , H we wanted to conserve all renal tissue and therefore rejected the possibility of heminephro-ureterectomy, especially in that the renal segments drained by the 2 uretera! branches were ap proximately equal in size. We decided to combine the 2 branched ureters into a single conduit spatulating each on their opposing surfaces aud sewing the edges together so that a single ureteral conduit was fashioned (fig. 6, A). This preserved all ureternl musculature. allowed for a single urinary conduit through which peristalsis could be established and conserved the entire kidney. CONCLUSIONS

Our operation is not to be considered for the usual case of bifid ureter with refluxing The long anastomotic line may present in healing not present in pyelopyelostomy or heminephro-ureterectomy. However, in cases of equal-sized renal portions drained by each ureteral limb, when a decision is uot made as to vvhich ureteral limb is the better, we feel that this operation might be of use. SUMMARY

B

A Ureteral plica~ion EQUAL

SIZE

Reimplantation in bladder horn

SEGMENTS

Fm. 6. Methods of treating bifid kidneys with renal segments of equal. size. A, authors' procedure. B, Turner-Warwick's procedure. with perhaps twice as much urine flowing through it, we initiated mannitol diuresis during an operation and repeated the manometric studies. With diuresis, it became evident that the situation was now reversed. The ureteral branch draining the upper renal segment became fatigued easily

A case of partial reduplication of the ureter causing renal pain due to regurgitating is presented. A new procedure is described for fashioning a single drainage unit from the bifid ureter. 10 Diaz-Ball, F. L., Fink, A., Moore, C. A. and Gangai, M. P.: Pyeloureterostomy and ureteroureterostomy: alternative procedures to nephrectomy for duplication of the ureter one pathological segment. J. Urol., 102; G21, 11 Rothfeld, S. H.: Uretero-ureterostomy: a means of conservation of renal tissue. J. Urol., 84: 60, 1960.