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Acquired Intravesical Ureteral Diverticulum: An Unusual Late Complication of Ureteroneocystostomy
0022-534 7/89/1416-1420$02.00/0 Vol. 141, June
THE JOURNAL OF UROLOGY
Copyright © 1989 by Williams & Wilkins
Printed in U.S. A.
Case Reports ACQUIRED INTRAVESICAL URETERAL DIVERTICULUM: AN UNUSUAL LATE COMPLICATION OF URETERONEOCYSTOSTOMY FRANCESCO ARAGONA,* PIERFRANCESCO BASSI, GIACOMO PASSERINI GLAZEL AND FRANCESCO PAGANO From the Institute of Urology, University of Padua, Padova, Italy
ABSTRACT
An unusual case of late ureteral obstruction following a Politano-Leadbetter ureteroneocystostomy performed 11 years previously is reported. Fibrosis of the distal ureter associated with vascular compression of the extravesical ureter presumably led to development of a ureteral intramural diverticulum. This case illustrates the necessity of careful ureteral placement and emphasizes the importance of close followup for many years, even in asymptomatic patients. (J. Ural., 141: 14201421, 1989) Politano-Leadbetter ureteroneocystostomy1 is one of the most widely used techniques for correction of vesicoureteral reflux. The reported incidence of postoperative complications is only 3 to 4 per cent, mostly ureteral obstruction and persistent reflux. 2 - 9 The occurrence of an acquired ureteral diverticulum, which we have termed pseudoureterocele, subsequent to a Politano-Leadbetter reimplantation is an unusual complication that to our knowledge has not been reported to date. CASE REPORT
A 36-year-old woman had undergone bilateral PolitanoLeadbetter ureteroneocystostomy 11 years previously (May 1976). The patient was asymptomatic until July 1987, when she was hospitalized for recurrent urinary tract infection and gross hematuria during the preceding few months. An excretory urogram (IVP) showed 2 small ureteral calculi with moderate dilatation of the collecting system on the left side (fig. 1). The ureteral stones were contained in a saccular dilation of the juxtavesical ureter, which was separated from the bladder shadow by a nonopaque halo. These radiographic findings were impressively similar to those described for simple ureterocele. Cystoscopy revealed stenosis of the left ureteral orifice and a limited meatotomy was performed. Ureteropyeloscopy showed a saccular pouch, freely communicating with the ureteral lumen and containing the stones 4 cm. behind the ureteral meatus. All endoscopic maneuvers failed to extract the stones and a Double-Jt ureteral stent was left indwelling for 2 months without benefit. Urinary tract infection and gross hematuria persisted after removal of the ureteral stent. Followup renal sonography (March 1988) showed a significant increase in the degree of left hydroureteronephrosis and a temporary nephrostomy tube was placed to decompress the upper urinary tract. At operation (April) the intramural portion of the left ureter was markedly narrowed. Above the stenotic segment a round bulging of the vesical mucosa also was visible (fig. 2). Extravesical exploration showed the left ureter to be hooked on a branch Accepted for publication December 2, 1988. *Requests for reprints: Istituto di Urologia, Monoblocco Ospedaliero, Via Giustiniani, 2, 35100 Padova, Italy. t Medical Engineering Corp., New York, New York.
of the uterine artery just behind the ureteral hiatus. The compressing vessel and the umbilical artery were divided, and the distal 3 cm. of ureter were resected along with the pseudoureterocele. As a consequence, an SF ureteral catheter passed easily. The ureter then was mobilized completely and reimplanted into the bladder in a submucosal tunnel. The surgical specimen shows the relationship between the distal ureter and the pouch whose opening communicates freely with the ureteral lumen (fig. 3). Histological examination revealed flat metaplasia of the epithelial lining and marked fibrosis of the ureteral wall. Postoperatively, the patient is asymptomatic with negative urine culture and the left collecting system has returned to normal caliber.
FIG. 1. A, IVP 11 years after ureteroneocystostomy demonstrates moderate dilation of left collecting system with sacciform dilatation of intravesical ureter (pseudoureterocele). B, presumable pathogenetic mechanism of pseudoureterocele as consequence of fibrosis of terminal ureter coupled with extravesical compression.
1420
ACQUIRED INTRAVESICA.L URETERAL JIVERTICULU1vi DISCUSSION
The development of a ureteral intravesical submucosal diverticulum, strictly resembling ureterocele, has not been reported previously among the obstructive complications of transvesical ureteral reimplantation. Presumably, it occurred as a consequence of 3 causative factors acting simultaneously during a long period: 1) fibrosis of the terminal ureter (usually related to a compromised blood supply), 2) compression of the extravesical ureter between the bladder wall and blood vessels and 3) progressive weakening of the anterior ureteral wall distal to the vesical hiatus. The weakening probably involved a limited portion of the ureter, thus, explaining the existence of a saccular dilatation with a well defined opening similar to the neck of a diverticulum (if the entire ureteral wall is involved, the distal ureter should be uniformly dilated). The first consideration of this unusual complication of ureteral reimplantation regards the caution required to manipulate the ureter and its placement, especially when the procedure is done entirely extravesically. Creation of a periureteral hiatus as wide as possible is needed for meticulous and extensive ureteral detachment. Moreover, it is useful to obtain an ade-
FIG. 2. Operative photograph shows macroscopic appearance of pseudoureterocele. Mucosa surrounding left ureteral orifice has been incised and distal ureter is dissected in its tunnel.
1421
quate elevation of the bladder wall, mounting it on a vein retractor, for visual control of the dissected area and of the new ureteral location. Another consideration is the long interval (11 years) between reimplantation and development of the observed complication. Late developments of ureter al obstruction have been reported previously, 10- 12 which emphasize the importance of close followup for many years postc,peratively, even in patients in whom the immediate surgical result seems to be excellent. In a review of failed ureteroneocystostomy Kramer found that 20 per cent of the failures occurred between 4 and 10 years postoperatively. 13 These findings should suggest great caution in evaluation of the results of any new technique proposed for correction of vesicoureteral reflux. REFERENCES
1. Politano, V. A. and Leadbetter, W. F.: An operative technique for
the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. 2. Williams, D. I. and Eckstein, H. B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965. 3. Brannan, W., Ochsner, M. G., Rosencrantz, D. R., Whitehead, C. M., Jr. and Goodier, E. H.: Experiences with vesicoureteral reflux. J. Urol., 109: 46, 1973. 4. Hendren, W. H.: Reoperation for the failed ureteral reimplantation. J. Urol., lll: 403, 1974. 5. Tocci, P. E., Politano, V. A., Lynne, C. M. and Carrion, H. M.: Unusual complications of transvesical ureteral reimplantation. J. Urol., 115: 731, 1976. 6. Scott, J.E. S.: The management ofureteric reflux in children. Brit. J. Urol., 49: 109, 1977. 7. Marshall, S., Guthrie, T., Jeffs, R., Politano, V. and Lyon, R. P.: Ureterovesicoplasty: selection of patients, incidence and avoidance of complications. A review of 3,527 cases. J. Urol., 118: 829, 1977. 8. Carpentier, P. J., Bettink, P. J., Hop, W. G. J. and Schroder, F. H.: Reflux: a retrospective study of 100 ureteric reimplantations by the Politano-Leadbetter method and 100 by the Cohen technique. Brit. J. Urol., 54: 230, 1982. 9. Hoover, D. L.: Surgical management of vesicouretera! reflux. Sem. Urol., 4: 109, 1986. 10. Martin, D. C. and Kaufman, J. J.: Pitfalls in ureterovescioplasty for the prevention of reflux. J. Urol., 97: 846, 1967. 11. Weiss, R. M., Schiff, M., Jr. and Lytton, B.: Late obstruction after ureteroneocystostomy. J. Urol., 106: 144, 1971. 12. Filly, R. A., Friedland, S. W., Fair, W. R. and Goven, D. E.: Late ureteric obstruction following uretera! reimplantation for reflux: a warning. Urology, 4: 540, 1974. 13. Kramer, S. A.: Reflux: discussion. J. Urol., part 2, 138: 956, 1987.
FIG. 3. A, surgical specimen shows relationship between distal ureter and saccular pouch. B, section of ureter along its entire length demonstrates that pseudoureterocele opens freely into ureteral lumen. Arrowheads indicate ureteral meatus.
THE JOURNAL OF UROLOGY
Copyright © 1989 by Williams & Wilkins
Printed in U.S. A.
Case Reports ACQUIRED INTRAVESICAL URETERAL DIVERTICULUM: AN UNUSUAL LATE COMPLICATION OF URETERONEOCYSTOSTOMY FRANCESCO ARAGONA,* PIERFRANCESCO BASSI, GIACOMO PASSERINI GLAZEL AND FRANCESCO PAGANO From the Institute of Urology, University of Padua, Padova, Italy
ABSTRACT
An unusual case of late ureteral obstruction following a Politano-Leadbetter ureteroneocystostomy performed 11 years previously is reported. Fibrosis of the distal ureter associated with vascular compression of the extravesical ureter presumably led to development of a ureteral intramural diverticulum. This case illustrates the necessity of careful ureteral placement and emphasizes the importance of close followup for many years, even in asymptomatic patients. (J. Ural., 141: 14201421, 1989) Politano-Leadbetter ureteroneocystostomy1 is one of the most widely used techniques for correction of vesicoureteral reflux. The reported incidence of postoperative complications is only 3 to 4 per cent, mostly ureteral obstruction and persistent reflux. 2 - 9 The occurrence of an acquired ureteral diverticulum, which we have termed pseudoureterocele, subsequent to a Politano-Leadbetter reimplantation is an unusual complication that to our knowledge has not been reported to date. CASE REPORT
A 36-year-old woman had undergone bilateral PolitanoLeadbetter ureteroneocystostomy 11 years previously (May 1976). The patient was asymptomatic until July 1987, when she was hospitalized for recurrent urinary tract infection and gross hematuria during the preceding few months. An excretory urogram (IVP) showed 2 small ureteral calculi with moderate dilatation of the collecting system on the left side (fig. 1). The ureteral stones were contained in a saccular dilation of the juxtavesical ureter, which was separated from the bladder shadow by a nonopaque halo. These radiographic findings were impressively similar to those described for simple ureterocele. Cystoscopy revealed stenosis of the left ureteral orifice and a limited meatotomy was performed. Ureteropyeloscopy showed a saccular pouch, freely communicating with the ureteral lumen and containing the stones 4 cm. behind the ureteral meatus. All endoscopic maneuvers failed to extract the stones and a Double-Jt ureteral stent was left indwelling for 2 months without benefit. Urinary tract infection and gross hematuria persisted after removal of the ureteral stent. Followup renal sonography (March 1988) showed a significant increase in the degree of left hydroureteronephrosis and a temporary nephrostomy tube was placed to decompress the upper urinary tract. At operation (April) the intramural portion of the left ureter was markedly narrowed. Above the stenotic segment a round bulging of the vesical mucosa also was visible (fig. 2). Extravesical exploration showed the left ureter to be hooked on a branch Accepted for publication December 2, 1988. *Requests for reprints: Istituto di Urologia, Monoblocco Ospedaliero, Via Giustiniani, 2, 35100 Padova, Italy. t Medical Engineering Corp., New York, New York.
of the uterine artery just behind the ureteral hiatus. The compressing vessel and the umbilical artery were divided, and the distal 3 cm. of ureter were resected along with the pseudoureterocele. As a consequence, an SF ureteral catheter passed easily. The ureter then was mobilized completely and reimplanted into the bladder in a submucosal tunnel. The surgical specimen shows the relationship between the distal ureter and the pouch whose opening communicates freely with the ureteral lumen (fig. 3). Histological examination revealed flat metaplasia of the epithelial lining and marked fibrosis of the ureteral wall. Postoperatively, the patient is asymptomatic with negative urine culture and the left collecting system has returned to normal caliber.
FIG. 1. A, IVP 11 years after ureteroneocystostomy demonstrates moderate dilation of left collecting system with sacciform dilatation of intravesical ureter (pseudoureterocele). B, presumable pathogenetic mechanism of pseudoureterocele as consequence of fibrosis of terminal ureter coupled with extravesical compression.
1420
ACQUIRED INTRAVESICA.L URETERAL JIVERTICULU1vi DISCUSSION
The development of a ureteral intravesical submucosal diverticulum, strictly resembling ureterocele, has not been reported previously among the obstructive complications of transvesical ureteral reimplantation. Presumably, it occurred as a consequence of 3 causative factors acting simultaneously during a long period: 1) fibrosis of the terminal ureter (usually related to a compromised blood supply), 2) compression of the extravesical ureter between the bladder wall and blood vessels and 3) progressive weakening of the anterior ureteral wall distal to the vesical hiatus. The weakening probably involved a limited portion of the ureter, thus, explaining the existence of a saccular dilatation with a well defined opening similar to the neck of a diverticulum (if the entire ureteral wall is involved, the distal ureter should be uniformly dilated). The first consideration of this unusual complication of ureteral reimplantation regards the caution required to manipulate the ureter and its placement, especially when the procedure is done entirely extravesically. Creation of a periureteral hiatus as wide as possible is needed for meticulous and extensive ureteral detachment. Moreover, it is useful to obtain an ade-
FIG. 2. Operative photograph shows macroscopic appearance of pseudoureterocele. Mucosa surrounding left ureteral orifice has been incised and distal ureter is dissected in its tunnel.
1421
quate elevation of the bladder wall, mounting it on a vein retractor, for visual control of the dissected area and of the new ureteral location. Another consideration is the long interval (11 years) between reimplantation and development of the observed complication. Late developments of ureter al obstruction have been reported previously, 10- 12 which emphasize the importance of close followup for many years postc,peratively, even in patients in whom the immediate surgical result seems to be excellent. In a review of failed ureteroneocystostomy Kramer found that 20 per cent of the failures occurred between 4 and 10 years postoperatively. 13 These findings should suggest great caution in evaluation of the results of any new technique proposed for correction of vesicoureteral reflux. REFERENCES
1. Politano, V. A. and Leadbetter, W. F.: An operative technique for
the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. 2. Williams, D. I. and Eckstein, H. B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965. 3. Brannan, W., Ochsner, M. G., Rosencrantz, D. R., Whitehead, C. M., Jr. and Goodier, E. H.: Experiences with vesicoureteral reflux. J. Urol., 109: 46, 1973. 4. Hendren, W. H.: Reoperation for the failed ureteral reimplantation. J. Urol., lll: 403, 1974. 5. Tocci, P. E., Politano, V. A., Lynne, C. M. and Carrion, H. M.: Unusual complications of transvesical ureteral reimplantation. J. Urol., 115: 731, 1976. 6. Scott, J.E. S.: The management ofureteric reflux in children. Brit. J. Urol., 49: 109, 1977. 7. Marshall, S., Guthrie, T., Jeffs, R., Politano, V. and Lyon, R. P.: Ureterovesicoplasty: selection of patients, incidence and avoidance of complications. A review of 3,527 cases. J. Urol., 118: 829, 1977. 8. Carpentier, P. J., Bettink, P. J., Hop, W. G. J. and Schroder, F. H.: Reflux: a retrospective study of 100 ureteric reimplantations by the Politano-Leadbetter method and 100 by the Cohen technique. Brit. J. Urol., 54: 230, 1982. 9. Hoover, D. L.: Surgical management of vesicouretera! reflux. Sem. Urol., 4: 109, 1986. 10. Martin, D. C. and Kaufman, J. J.: Pitfalls in ureterovescioplasty for the prevention of reflux. J. Urol., 97: 846, 1967. 11. Weiss, R. M., Schiff, M., Jr. and Lytton, B.: Late obstruction after ureteroneocystostomy. J. Urol., 106: 144, 1971. 12. Filly, R. A., Friedland, S. W., Fair, W. R. and Goven, D. E.: Late ureteric obstruction following uretera! reimplantation for reflux: a warning. Urology, 4: 540, 1974. 13. Kramer, S. A.: Reflux: discussion. J. Urol., part 2, 138: 956, 1987.
FIG. 3. A, surgical specimen shows relationship between distal ureter and saccular pouch. B, section of ureter along its entire length demonstrates that pseudoureterocele opens freely into ureteral lumen. Arrowheads indicate ureteral meatus.