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Contralateral Vesicoureteral Reflux After Simple and Tapered Unilateral Ureteroneocystostomy Revisited
Vol. 158, 1219-1220, September 1997 Printed in U.S.A.
CONTRALATERAL VESICOURETERAL REFLUX AFTER SIMPLE AND TAPERED UNILATERAL URETERONEOCYSTOSTOMY REVISITED ALAN C. McCOOL, LUIS M. PEREZ
AND
DAVID B. JOSEPH*
From the Division of Urology, University of Alabama at Birmingham. Children's Hospital, Birmingham, Alabama
ABSTRACT
Purpose: We reviewed our experience with contralateral vesicoureteral reflux following unilateral ureteroneocystostomy. Materials and Methods: We retrospectively identified 88 children who underwent unilateral ureteroneocystostomy from 1986 through 1995, including standard repair in 69 and tapered repair in 19. Cystoscopy was performed in all cases immediately before repair. Results: Grades IV to V vesicoureteral reflux was identified preoperatively in 34% of the patients, including 13 (19%)and 14 (74%) who underwent standard and tapered repair, respectively. Renal duplication was noted in 24% of the cases, including 18 standard (26%) and 3 tapered (16%) repairs. An abnormal contralateral nonrefluxing ureteral orifice was present in 8 of the 53 standard (15%)and 3 of the 14 (21%) tapered cases. Ipsilateral reflux was corrected in all children undergoing standard repair but it persisted in 4 (21%)in the tapered repair group. Postoperatively contralateral vesicoureteral reflux developed in 1 child (1.4%) in the standard and 1 (5.3%) in the tapered repair group. Conclusions: Contralateral vesicoureteral reflux is rare and does not appear to be influenced by preoperative reflux grade, a duplicated system or the endoscopic appearance of the ureteral orifice. KEY WORDS:vesico-ureteral reflux, bladder, ureter, cystoscopy
There has been renewed interest regarding the occurrence and mechanism of contralateral vesicoureteral reflux following unilateral ureteroneo~ystostomy.~-~ A review of the literature indicates a 10 to 25% incidence of contralateral reflux after various intravesical techniques, such as the Cohen, Politano-Leadbetter and Glenn-Anderson procedures.1-5 This high incidence of contralateral reflux prompted us to review our experience in the hope of identifylng factors that may influence the development of contralateral vesicoureteral reflux.
RESULTS
Grades IV to V vesicoureteral reflux was identified preoperatively in 34%' of the patients, including 13 (19%)in the standard and 14 (74%) in the tapered repair group. Renal duplication was noted in an average of 24% of the children, including 18 (26%)in the standard and 3 (16%)in the tapered repair group. Postoperatively there was no incidence of ureteral obstruction in the standard repair group. Obstruction requiring operative revision developed in 1 child in the tapered repair group. None of the 69 children who underwent standard reimplantation had persistent ipsilateral vesiPATIENTS AND METHODS coureteral reflux. Four of the 19 children (21%)who underWe retrospectively reviewed the records of 296 children went tapered reimplantation had ipsilateral reflux after rewho underwent standard (255) or tapered (41) ureteroneo- pair of whom 1 required revision. Contralateral vesicoureteral reflux was rare, identified in cystostomy from September 1986 through July 1995. Our technique and results have been previously reported.6 Of 1 child in the standard (1.4%) and 1 in the tapered (5.3%) these 296 cases 46 (38 standard and 8 tapered repairs) were repair group. The patient who underwent standard repair excluded from study because of secondary conditions, such a s remains asymptomatic, while contralateral reflux in the posterior urethral valves, neurogenic bladder or the triad other resolved within 2 years. In the standard repair group a syndrome. Of the remaining 250 children 88 underwent uni- contralateral ureteral orifice was described a t cystoscopy in lateral ureteroneocystostomy, including standard repair in 53 of the 69 children and an abnormal ureteral orifice, characterized by a lateral position or gaping appearance, was 69 and tapered repair in 19. Our operative protocol regarding unilateral versus bilat- reported in 8 (15%). In the tapered repair group the coneral ureteroneocystostomy is based on historical data per- tralateral orifice was described as abnormal in 3 of the 14 taining to voiding cystourethrography. When bilateral vesi- children (21%)in whom it was documented. coureteral reflux was previously identified, bilateral reimplantation was performed even if the most recent voidDISCUSSION ing cystourethrogram showed only unilateral reflux. CystosIn our series contralateral vesicoureteral reflux was rare copy was done in all cases immediately before repair. The decision to perform ureteral reimplantation was not based on after unilateral reimplantation. The small number of chilthe cystoscopic location or appearance of the ureteral orifice. dren with contralateral reflux postoperatively prevented us Postoperative evaluation included limited excretory urogra- from identifying any specific risk factor. Of the 2 patients phy 6 weeks and nuclear voiding cystourethrography 6 with contralateral disease reflux has resolved in 1 who underwent tapered repair, while 1 who underwent standard months after repair. repair remains asymptomatic. Recently Ross1 and Hoenig' e t a1 reported similar experi* Requests for reprints: Pediatric Urology, ACC-318, Children's ences with contralateral vesicoureteral reflux, noting that Hospital, 1600 Seventh Ave. South, Birmingham, Alabama 35233. 1219
1220
CONTRALATERAL REFLUX AFTER URETERONEOCYSTOSTOMY
contralateral reflux occurred in 17 and 19% of children, respectively. Ross et al subdivided their patients into those with and without previous contralateral reflux.' Postoperatively contralateral reflux developed in 5 of 11 children (45%) with a history of bilateral reflux compared to 4 of 42 (10%) without previous contralateral reflux. According to our protocol we selected out children with prior vesicoureteral reflux, which may have explained the low incidence of contralateral reflux. This finding supports the recommendation of Ross et al to perform bilateral repair when bilateral reflux has been previously reported. Our protocol for correcting previous contralateral reflux is not based on a novel approach. It is a perpetuation of practice accepted a s dogma and gained through training.' With our limited number of patients with contralateral reflux we are unable to determine any risk factors. Diamond et al suggested that the etiology may be elimination of a pop-off mechanism following repair of a duplicated system or high grade vesicoureteral r e f l ~ x We . ~ did not eliminate such children from this series, since 34% had grades IV to V reflux and 24% had a duplicated system. If a pop-off mechanism were a factor, we would have expected to observe a higher rate of contralateral reflux. Therefore, our data do not support this conclusion. Cystoscopy is beneficial immediately before ureteroneocystostomy but it does not influence our decision to perform contralateral ureteroneocystostomy. Cystoscopy is helpful for evaluating the mucosa of children with breakthrough urinary tract infections, locating the ureter if it is presumed to be ectopic, and visualizing ureteroceles and diverticula. In boys it allows direct visualization of t h e urethra. However, cystoscopy is not helpful in predicting the need for contralatera1 ureteroneocystostomy when there has been no previous radiographic documentation of vesicoureteral reflux. Our data on the location and appearance of the ureteral orifice are subjective with abnormalities noted in 15% of standard and 21% of tapered repairs. If the cystoscopic location and appearance of the ureteral orifice were predictive of contralateral reflux, a higher rate of contralateral reflux would
have been expected in our series. Our data support t h e decision to correct vesicoureteral reflux surgically based on dinical factors and radiographic findings, not on the cystoscopic appearance of the ureteral orifice. When treating contralateral vesicoureteral reflux, it is practical to follow a conservative course. Reflux has resolved in 1 of our 2 patients and the other remains asymptomatic. This rate is similar to t h a t of Hoenig e t al, who noted a 61% resolution rate for contralateral vesicoureteral reflux.2 CONCLUSIONS
Contralateral vesicoureteral reflux is rare and, when present, a conservative approach should be followed. A bilateral procedure should be performed if there is previous evidence of bilateral reflux. The cystoscopic appearance of the contralateral ureteral orifice does not determine t h e need for contralateral ureteroneocystostomy. REFERENCES
1. Ross. J. H.. Kav. R. and Nasrallah. P.: Contralateral reflux after .~ . - unilateral reimplantation in patients with a history of resolved contralateral reflux. J. Urol., 154: 1171, 1995. 2. Hoenig, D. M.. Diamond, D. A., Rabinowitz, R. and Caldarnone, A. A.: Contralateral reflux after unilateral ureteral reirnplantation. J. Urol., 156 196, 1996. 3. Diamond, D. A,, Rabinowitz, R., Caldamone, A. A. and Hoenig, D. M.: The mechanism of new onset contralateral reflux following unilateral ureteroneocystostomy. J . Urol., part 2, 156: 665, 1996. 4. Parrott, T. S. and Woodard, J . R.: Reflux in opposite ureter after successful correction of unilateral vesicoureteral reflux. Urology, 7: 276, 1976. 5. Ahmed, S. and Hock, T.: Complications of transverse advancement ureteral reimplantation: diverticulum formation. J. Urol., 127: 970, 1982. 6. McCool, A. C. and Joseph, D. B.: Postoperative hospitalization of children undergoing cross-trigonal ureteroneocystostomy. J. Urol., part 2, 154: 794, 1995. 7. Retik, A. B.: Personal communication, 1985. I
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CONTRALATERAL VESICOURETERAL REFLUX AFTER SIMPLE AND TAPERED UNILATERAL URETERONEOCYSTOSTOMY REVISITED ALAN C. McCOOL, LUIS M. PEREZ
AND
DAVID B. JOSEPH*
From the Division of Urology, University of Alabama at Birmingham. Children's Hospital, Birmingham, Alabama
ABSTRACT
Purpose: We reviewed our experience with contralateral vesicoureteral reflux following unilateral ureteroneocystostomy. Materials and Methods: We retrospectively identified 88 children who underwent unilateral ureteroneocystostomy from 1986 through 1995, including standard repair in 69 and tapered repair in 19. Cystoscopy was performed in all cases immediately before repair. Results: Grades IV to V vesicoureteral reflux was identified preoperatively in 34% of the patients, including 13 (19%)and 14 (74%) who underwent standard and tapered repair, respectively. Renal duplication was noted in 24% of the cases, including 18 standard (26%) and 3 tapered (16%) repairs. An abnormal contralateral nonrefluxing ureteral orifice was present in 8 of the 53 standard (15%)and 3 of the 14 (21%) tapered cases. Ipsilateral reflux was corrected in all children undergoing standard repair but it persisted in 4 (21%)in the tapered repair group. Postoperatively contralateral vesicoureteral reflux developed in 1 child (1.4%) in the standard and 1 (5.3%) in the tapered repair group. Conclusions: Contralateral vesicoureteral reflux is rare and does not appear to be influenced by preoperative reflux grade, a duplicated system or the endoscopic appearance of the ureteral orifice. KEY WORDS:vesico-ureteral reflux, bladder, ureter, cystoscopy
There has been renewed interest regarding the occurrence and mechanism of contralateral vesicoureteral reflux following unilateral ureteroneo~ystostomy.~-~ A review of the literature indicates a 10 to 25% incidence of contralateral reflux after various intravesical techniques, such as the Cohen, Politano-Leadbetter and Glenn-Anderson procedures.1-5 This high incidence of contralateral reflux prompted us to review our experience in the hope of identifylng factors that may influence the development of contralateral vesicoureteral reflux.
RESULTS
Grades IV to V vesicoureteral reflux was identified preoperatively in 34%' of the patients, including 13 (19%)in the standard and 14 (74%) in the tapered repair group. Renal duplication was noted in an average of 24% of the children, including 18 (26%)in the standard and 3 (16%)in the tapered repair group. Postoperatively there was no incidence of ureteral obstruction in the standard repair group. Obstruction requiring operative revision developed in 1 child in the tapered repair group. None of the 69 children who underwent standard reimplantation had persistent ipsilateral vesiPATIENTS AND METHODS coureteral reflux. Four of the 19 children (21%)who underWe retrospectively reviewed the records of 296 children went tapered reimplantation had ipsilateral reflux after rewho underwent standard (255) or tapered (41) ureteroneo- pair of whom 1 required revision. Contralateral vesicoureteral reflux was rare, identified in cystostomy from September 1986 through July 1995. Our technique and results have been previously reported.6 Of 1 child in the standard (1.4%) and 1 in the tapered (5.3%) these 296 cases 46 (38 standard and 8 tapered repairs) were repair group. The patient who underwent standard repair excluded from study because of secondary conditions, such a s remains asymptomatic, while contralateral reflux in the posterior urethral valves, neurogenic bladder or the triad other resolved within 2 years. In the standard repair group a syndrome. Of the remaining 250 children 88 underwent uni- contralateral ureteral orifice was described a t cystoscopy in lateral ureteroneocystostomy, including standard repair in 53 of the 69 children and an abnormal ureteral orifice, characterized by a lateral position or gaping appearance, was 69 and tapered repair in 19. Our operative protocol regarding unilateral versus bilat- reported in 8 (15%). In the tapered repair group the coneral ureteroneocystostomy is based on historical data per- tralateral orifice was described as abnormal in 3 of the 14 taining to voiding cystourethrography. When bilateral vesi- children (21%)in whom it was documented. coureteral reflux was previously identified, bilateral reimplantation was performed even if the most recent voidDISCUSSION ing cystourethrogram showed only unilateral reflux. CystosIn our series contralateral vesicoureteral reflux was rare copy was done in all cases immediately before repair. The decision to perform ureteral reimplantation was not based on after unilateral reimplantation. The small number of chilthe cystoscopic location or appearance of the ureteral orifice. dren with contralateral reflux postoperatively prevented us Postoperative evaluation included limited excretory urogra- from identifying any specific risk factor. Of the 2 patients phy 6 weeks and nuclear voiding cystourethrography 6 with contralateral disease reflux has resolved in 1 who underwent tapered repair, while 1 who underwent standard months after repair. repair remains asymptomatic. Recently Ross1 and Hoenig' e t a1 reported similar experi* Requests for reprints: Pediatric Urology, ACC-318, Children's ences with contralateral vesicoureteral reflux, noting that Hospital, 1600 Seventh Ave. South, Birmingham, Alabama 35233. 1219
1220
CONTRALATERAL REFLUX AFTER URETERONEOCYSTOSTOMY
contralateral reflux occurred in 17 and 19% of children, respectively. Ross et al subdivided their patients into those with and without previous contralateral reflux.' Postoperatively contralateral reflux developed in 5 of 11 children (45%) with a history of bilateral reflux compared to 4 of 42 (10%) without previous contralateral reflux. According to our protocol we selected out children with prior vesicoureteral reflux, which may have explained the low incidence of contralateral reflux. This finding supports the recommendation of Ross et al to perform bilateral repair when bilateral reflux has been previously reported. Our protocol for correcting previous contralateral reflux is not based on a novel approach. It is a perpetuation of practice accepted a s dogma and gained through training.' With our limited number of patients with contralateral reflux we are unable to determine any risk factors. Diamond et al suggested that the etiology may be elimination of a pop-off mechanism following repair of a duplicated system or high grade vesicoureteral r e f l ~ x We . ~ did not eliminate such children from this series, since 34% had grades IV to V reflux and 24% had a duplicated system. If a pop-off mechanism were a factor, we would have expected to observe a higher rate of contralateral reflux. Therefore, our data do not support this conclusion. Cystoscopy is beneficial immediately before ureteroneocystostomy but it does not influence our decision to perform contralateral ureteroneocystostomy. Cystoscopy is helpful for evaluating the mucosa of children with breakthrough urinary tract infections, locating the ureter if it is presumed to be ectopic, and visualizing ureteroceles and diverticula. In boys it allows direct visualization of t h e urethra. However, cystoscopy is not helpful in predicting the need for contralatera1 ureteroneocystostomy when there has been no previous radiographic documentation of vesicoureteral reflux. Our data on the location and appearance of the ureteral orifice are subjective with abnormalities noted in 15% of standard and 21% of tapered repairs. If the cystoscopic location and appearance of the ureteral orifice were predictive of contralateral reflux, a higher rate of contralateral reflux would
have been expected in our series. Our data support t h e decision to correct vesicoureteral reflux surgically based on dinical factors and radiographic findings, not on the cystoscopic appearance of the ureteral orifice. When treating contralateral vesicoureteral reflux, it is practical to follow a conservative course. Reflux has resolved in 1 of our 2 patients and the other remains asymptomatic. This rate is similar to t h a t of Hoenig e t al, who noted a 61% resolution rate for contralateral vesicoureteral reflux.2 CONCLUSIONS
Contralateral vesicoureteral reflux is rare and, when present, a conservative approach should be followed. A bilateral procedure should be performed if there is previous evidence of bilateral reflux. The cystoscopic appearance of the contralateral ureteral orifice does not determine t h e need for contralateral ureteroneocystostomy. REFERENCES
1. Ross. J. H.. Kav. R. and Nasrallah. P.: Contralateral reflux after .~ . - unilateral reimplantation in patients with a history of resolved contralateral reflux. J. Urol., 154: 1171, 1995. 2. Hoenig, D. M.. Diamond, D. A., Rabinowitz, R. and Caldarnone, A. A.: Contralateral reflux after unilateral ureteral reirnplantation. J. Urol., 156 196, 1996. 3. Diamond, D. A,, Rabinowitz, R., Caldamone, A. A. and Hoenig, D. M.: The mechanism of new onset contralateral reflux following unilateral ureteroneocystostomy. J . Urol., part 2, 156: 665, 1996. 4. Parrott, T. S. and Woodard, J . R.: Reflux in opposite ureter after successful correction of unilateral vesicoureteral reflux. Urology, 7: 276, 1976. 5. Ahmed, S. and Hock, T.: Complications of transverse advancement ureteral reimplantation: diverticulum formation. J. Urol., 127: 970, 1982. 6. McCool, A. C. and Joseph, D. B.: Postoperative hospitalization of children undergoing cross-trigonal ureteroneocystostomy. J. Urol., part 2, 154: 794, 1995. 7. Retik, A. B.: Personal communication, 1985. I
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