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Ipsilateral Ureteroureterostomy for Vesicoureteral Reflux in Duplicated Ureters
Vol. 118, November Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
IPSILATERAL URETEROURETEROSTOMY FOR VESICOURETERAL REFLUX IN DUPLICATED URETERS EVERETTE J. DUTHOY, JOHN A. SOUCHERAY
AND
BRIAN J. MCGROARTY
ABSTRACT
In most duplex systems reflux only occurs to the lower segment and these patients present with symptoms of recurrent pyelonephritis. We have treated 12 such cases by ipsilateral ureteroureterostomy with good results. Treatment of this condition in most major pediatric urologic centers consists of reimplanting the duplicated ureters but we recommend an ipsilateral ureteroureterostomy because of lower morbidity, relative lack of complications, ease of operation and excellent longterm results. Complete duplication of the ureter occurs in 0.75 per cent of the population. It has been found to occur in 1 of every 151 autopsies. Approximately 60 per cent of the duplex systems will have reflux. If both orifices are situated on the trigone reflux will occur to the lower segment. In rare instances there will be reflux to both segments. Reflux to the upper segment alone does not occur unless the orifice to that segment is ectopic. If the upper segment orifice is on the bladder neck or in the prostatic urethra there may be reflux only to the upper segment. The recommended treatment for reflux in a duplex system is to reimplant both ureters, although in 97 per cent reflux occurs only to the lower segment. i-3 While this method of treatment is acceptable the operation is not always successful. Barrett and associates reported 2 failures in 44 cases. 3 Amar reported 2 failures in 18 cases. 1 Belman and associates recommend a pyeloureterostomy when reflux occurs only to the lower segment. 4 This is technically difficult because of having to anastomose a dilated renal pelvis to a small upper segment ureter. This operation also leaves a long ureteral stump that may be symptomatic. It does have the advantage of allowing evaluation of the lower renal segment if a heminephrectomy would be indicated. In cases of bilateral involvement 2 flank incisions would be necessary. Several authors have reported on small series of cases in which the ureter to the lower pole with reflux was ligated and the proximal end was anastomosed to the normal upper pole ureter. 5- 7 In 1928 Foley performed a side-to-side ipsilateral ureteroureterostomy to bypass an impacted stone. 8 In 1952 Kuss 9 performed the operation for an ectopic orifice as did Buchtel in 1961. 10 Buchtel then reimplanted the remaining solitary ureter with poor results. Rothfeld also did a side-to-side anastomosis for reflux to the lower segment using a splint and a nephrostomy.11 In 1971 Bums and Palken, 5 and Lytton and associates6 reported 6 and 5 cases, respectively, without failures. They ligated the distal stump of the lower segment ureter and anastomosed the proximal ureter end-to-side to the normal upper segment ureter (fig. 1). Although their cases were successful the operation has not gained in popularity. Using this same procedure we would like to add 12 more cases to the literature. All are female patients and range in age from 20 months to 22 years. Four cases have been followed for more than 6 years and all are considered successful. Each patient presented with recurrent pyelonephritis. Five cases were bilateral. The 3 adult female patients have delivered 4 children since the operation. Pyelonephritis has not occurred Accepted for publication February 11, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976. 826
postoperatively. All x-rays have improved or remained stable. There were no complications. A postoperative urine leak in 1 of the 2-year-old patients closed spontaneously and a followup excretory urogram (IVP) was normal. The studies on these patients should include an IVP and a voiding cystogram. If the cortex overlying the lower pole with reflux is thin the IVP should be repeated with a Foley catheter in place. Without a catheter in the bladder the reflux to the lower segment could lead one to believe that there is good
Fm.1
IJPSU,ATERAL URETEROURETEROSTOIV.1:Y FOR VESICOURETERAL REFLUX IN DUPLICA'J:'EiJ URETERS
827
end-to-side anastomosis is using either 4 or interrupted catgut sutures. Caution should be exercised when separating the ureters near the bladder since they seem have a common wall in that location. No c,tt·onn,t is made to ligate the transected ureter near the bladder. This small stump with reflux that is not obstructed has not caused lems in any of our patients. This should not be confused with the long stump that is left after a ___ _,,- _,.._a,,t,,,rm, or the dilated obstructed stump in an frequently has to be removed. CASE REPORTS
FIG. 3. Case 2. A, preoperative IVP. B, IVP 7 days postopera-
tively. function in that segment when actually the function may be or non-existent and best treated by heminephrectomy. possible means to assess the function of the lower segment would be to perform a renal scan with a Foley catheter connected to straight drainage. Cystoscopy is done to rule out an ectopic orifice or a ureterocele. Criteria for an operation should include a normal upper pole segment on x-ray and good remaining cortex to the lower segment. Dilatation of the collecting system to the lower segment is not a contraindication. The orifice to the upper segment should be normal, not ectopic and without reflux. infection should be treated adequately preoperatively. presence of a ureterocele of either segment is best treated reimplantation of both ureters. TECHNIQUE
A low transverse suprapubic incision is made. The rectus muscles are retracted rather than divided. The exposure is excellent and bilateral procedures are done through the same incision. Cystoscopy is done immediately preoperatively and a small ureteral catheter is passed to the upper segment. This catheter serves to identify the diseased ureter from the normal one and also facilitates the anastomosis. If the ureter with reflux is not dilated the proximal end is spatulated. An
Case 1. M. R, an 18-year-old girl, was December 4, 1968 with a 2-week history of and fever. Examination revealed right flank tenderness a temperature of 104F. The IVP showed a uuvu.'"a"',u collecting system with dilatation of the lower segment A). History included recurrent urinary tract infection. copy and urethral dilatation were performed elsewhere when the patient was 10 years old. She improved on antibiotics. Cystourethroscopy revealed a single normal left ureteral orifice and 2 right orifices. The proximal (lower pole) orifice was patulous. The upper pole orifice appeared normaL The cystograrn failed to reveal reflux and the discharged from the hospital on long-term ~·L-rn~~,L-H"L',:·-,-ho, Pyuria and intermittent right flank pain persisted but she remained afebrile. A cystogram on February 17, 1969 failed to reveal reflux. Because of the persistent intermittent flank pain and suspected reflux another cystogram was made on June 2, 1969. This study revealed total reflux to the lower segment (fig. 2, B). A right ipsilateral ureteroureterostomy was done on June lL Convalescence was uneventfuL The patient has been off all medication for more than 7 years and has not had an infection. She has delivered 2 healthy children during this time. The last IVP was made in March 1976 (fig. 2, C). Case 2. P. M., a 5-year-old girl, was referred in October 1970 for definitive therapy. History revealed the presence of recurrent urinary tract infection since birth. Cystoscopy and urethral dilatation were done when she was 17 months old. At 24 months she had undergone repeat cystoscopy and an internal urethrotomy. IVPs at that time revealed cu,,u~,11:,.,e duplication on the right side and incomplete duplication on the left side. On continuous low-dose antimicrobial ....~·~"~, the patient continued to have clinical infections. Our confirmed the aforementioned radiologic findings (fig. 3, il.)
828
DUTHOY, SOUCHERAY AND MCGROARTY
A voiding cystogram revealed total reflux to the right lower segment. Cystourethroscopy revealed a single left normalappearing orifice and 2 orifices on the right side. The refluxing lower segment orifice was patulous. On October 29 a right ipsilateral ureteroureterostomy was done. Convalescence was uneventful. Before the patient was discharged from the hospital on November 5 a 20-minute function IVP was made (fig. 3, B). The mother and the referring urologist reported that the child has been without evidence of infection postoperatively. Followup x-rays in April 1976 were normal. Case 3. A 40-year-old woman had complete duplication of the left collecting system. After a hysterectomy a fistula developed from the upper segment ureter to the vagina. An ipsilateral ureteroureterostomy was done above the site of the original operation, thus eliminating the need to wait several months to repair the fistula. A followup IVP 5 years later was normal. CONCLUSION
We recommend an ipsilateral ureteroureterostomy rather than reimplanting a duplex system when there is only reflux to the lower segment. The operation requires less time than a reimplantation, is technically easier and has a low morbidity. There is no bladder incision and no splints or catheters are needed. The ureteral catheter inserted at the time of operation is removed immediately afterwards. A Penrose drain is left in place until one is certain that there is no urine leakage. Both sides can be done through 1 incision. The theoretical disadvantage of producing asynchronous peristalsis or the so-called "yo-yo" theory of Lenaghan 12 does not appear to be a problem. We would reserve reimplanting double ureters for those systems in which both ureters have reflux or 1 ureter is ectopic.
222 Central Medical Building, St. Paul, Minnesota 55104 (E.J.D.J. REFERENCES
1. Amar, A. D.: Reimplantation of completely duplicated ureters. J. Urol., 107: 230, 1972. 2. Johnston, J. H. and Heal, M. R.: Reflux in complete duplicated ureters in children: management and techniques. J. Urol., 105: 881, 1971. 3. Barrett, D. M., Malek, R. S. and Kelalis, P. P.: Problems and solutions in surgical treatment of 100 consecutive ureteral duplications in children. J. Urol., 114: 126, 1975. 4. Belman, A. B., Filmer, R. B. and King, L. R.: Surgical management of duplication of the collecting system. J. Urol., 112: 316, 1974. 5. Burns, A. and Palken, M.: Ureteroureterostomy for reflux in duplex systems. J. Urol., 106: 290, 1971. 6. Lytton, B., Weiss, R. M. and Berneike, R. R.: Ipsilateral ureteroureterostomy in the management of vesicoureteral reflux in duplication of upper urinary tract. J. Urol., 105: 507, 1971. 7. Gutierrez, J., Chang, C.-Y. and Nesbit, R. M.: Ipsilateral ureteroureterostomy for vesicoureteral reflux in duplicated ureter. J. Urol., 101: 36, 1969. 8. Foley, F. E. B.: Uretero-ureterostomy. As applied to obstructions of the duplicated upper urinary tract. J. Urol., 20: 109, 1928. 9. Kuss, R.: Chirurgie Plastique et Reparatrice de la Voie Excretrice du Rein. Indications et Telchniques Operatoires. Paris: Masson et Cie Editeurs, pp. 98-103, 1954. 10. Buchtel, H. A.: Uretero-ureterostomy. J. Urol., 93: 153, 1965. 11. Rothfeld, S. H.: Uretero-ureterostomy: a means of conservation of renal tissue. J. Urol., 84: 60, 1960. 12. Lenaghan, D.: Bifid ureters in children: an anatomical, physiological and clinical study. J. Urol., 87: 808, 1962.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
IPSILATERAL URETEROURETEROSTOMY FOR VESICOURETERAL REFLUX IN DUPLICATED URETERS EVERETTE J. DUTHOY, JOHN A. SOUCHERAY
AND
BRIAN J. MCGROARTY
ABSTRACT
In most duplex systems reflux only occurs to the lower segment and these patients present with symptoms of recurrent pyelonephritis. We have treated 12 such cases by ipsilateral ureteroureterostomy with good results. Treatment of this condition in most major pediatric urologic centers consists of reimplanting the duplicated ureters but we recommend an ipsilateral ureteroureterostomy because of lower morbidity, relative lack of complications, ease of operation and excellent longterm results. Complete duplication of the ureter occurs in 0.75 per cent of the population. It has been found to occur in 1 of every 151 autopsies. Approximately 60 per cent of the duplex systems will have reflux. If both orifices are situated on the trigone reflux will occur to the lower segment. In rare instances there will be reflux to both segments. Reflux to the upper segment alone does not occur unless the orifice to that segment is ectopic. If the upper segment orifice is on the bladder neck or in the prostatic urethra there may be reflux only to the upper segment. The recommended treatment for reflux in a duplex system is to reimplant both ureters, although in 97 per cent reflux occurs only to the lower segment. i-3 While this method of treatment is acceptable the operation is not always successful. Barrett and associates reported 2 failures in 44 cases. 3 Amar reported 2 failures in 18 cases. 1 Belman and associates recommend a pyeloureterostomy when reflux occurs only to the lower segment. 4 This is technically difficult because of having to anastomose a dilated renal pelvis to a small upper segment ureter. This operation also leaves a long ureteral stump that may be symptomatic. It does have the advantage of allowing evaluation of the lower renal segment if a heminephrectomy would be indicated. In cases of bilateral involvement 2 flank incisions would be necessary. Several authors have reported on small series of cases in which the ureter to the lower pole with reflux was ligated and the proximal end was anastomosed to the normal upper pole ureter. 5- 7 In 1928 Foley performed a side-to-side ipsilateral ureteroureterostomy to bypass an impacted stone. 8 In 1952 Kuss 9 performed the operation for an ectopic orifice as did Buchtel in 1961. 10 Buchtel then reimplanted the remaining solitary ureter with poor results. Rothfeld also did a side-to-side anastomosis for reflux to the lower segment using a splint and a nephrostomy.11 In 1971 Bums and Palken, 5 and Lytton and associates6 reported 6 and 5 cases, respectively, without failures. They ligated the distal stump of the lower segment ureter and anastomosed the proximal ureter end-to-side to the normal upper segment ureter (fig. 1). Although their cases were successful the operation has not gained in popularity. Using this same procedure we would like to add 12 more cases to the literature. All are female patients and range in age from 20 months to 22 years. Four cases have been followed for more than 6 years and all are considered successful. Each patient presented with recurrent pyelonephritis. Five cases were bilateral. The 3 adult female patients have delivered 4 children since the operation. Pyelonephritis has not occurred Accepted for publication February 11, 1977. Read at annual meeting of North Central Section, American Urological Association, Palm Beach, Florida, October 17-24, 1976. 826
postoperatively. All x-rays have improved or remained stable. There were no complications. A postoperative urine leak in 1 of the 2-year-old patients closed spontaneously and a followup excretory urogram (IVP) was normal. The studies on these patients should include an IVP and a voiding cystogram. If the cortex overlying the lower pole with reflux is thin the IVP should be repeated with a Foley catheter in place. Without a catheter in the bladder the reflux to the lower segment could lead one to believe that there is good
Fm.1
IJPSU,ATERAL URETEROURETEROSTOIV.1:Y FOR VESICOURETERAL REFLUX IN DUPLICA'J:'EiJ URETERS
827
end-to-side anastomosis is using either 4 or interrupted catgut sutures. Caution should be exercised when separating the ureters near the bladder since they seem have a common wall in that location. No c,tt·onn,t is made to ligate the transected ureter near the bladder. This small stump with reflux that is not obstructed has not caused lems in any of our patients. This should not be confused with the long stump that is left after a ___ _,,- _,.._a,,t,,,rm, or the dilated obstructed stump in an frequently has to be removed. CASE REPORTS
FIG. 3. Case 2. A, preoperative IVP. B, IVP 7 days postopera-
tively. function in that segment when actually the function may be or non-existent and best treated by heminephrectomy. possible means to assess the function of the lower segment would be to perform a renal scan with a Foley catheter connected to straight drainage. Cystoscopy is done to rule out an ectopic orifice or a ureterocele. Criteria for an operation should include a normal upper pole segment on x-ray and good remaining cortex to the lower segment. Dilatation of the collecting system to the lower segment is not a contraindication. The orifice to the upper segment should be normal, not ectopic and without reflux. infection should be treated adequately preoperatively. presence of a ureterocele of either segment is best treated reimplantation of both ureters. TECHNIQUE
A low transverse suprapubic incision is made. The rectus muscles are retracted rather than divided. The exposure is excellent and bilateral procedures are done through the same incision. Cystoscopy is done immediately preoperatively and a small ureteral catheter is passed to the upper segment. This catheter serves to identify the diseased ureter from the normal one and also facilitates the anastomosis. If the ureter with reflux is not dilated the proximal end is spatulated. An
Case 1. M. R, an 18-year-old girl, was December 4, 1968 with a 2-week history of and fever. Examination revealed right flank tenderness a temperature of 104F. The IVP showed a uuvu.'"a"',u collecting system with dilatation of the lower segment A). History included recurrent urinary tract infection. copy and urethral dilatation were performed elsewhere when the patient was 10 years old. She improved on antibiotics. Cystourethroscopy revealed a single normal left ureteral orifice and 2 right orifices. The proximal (lower pole) orifice was patulous. The upper pole orifice appeared normaL The cystograrn failed to reveal reflux and the discharged from the hospital on long-term ~·L-rn~~,L-H"L',:·-,-ho, Pyuria and intermittent right flank pain persisted but she remained afebrile. A cystogram on February 17, 1969 failed to reveal reflux. Because of the persistent intermittent flank pain and suspected reflux another cystogram was made on June 2, 1969. This study revealed total reflux to the lower segment (fig. 2, B). A right ipsilateral ureteroureterostomy was done on June lL Convalescence was uneventfuL The patient has been off all medication for more than 7 years and has not had an infection. She has delivered 2 healthy children during this time. The last IVP was made in March 1976 (fig. 2, C). Case 2. P. M., a 5-year-old girl, was referred in October 1970 for definitive therapy. History revealed the presence of recurrent urinary tract infection since birth. Cystoscopy and urethral dilatation were done when she was 17 months old. At 24 months she had undergone repeat cystoscopy and an internal urethrotomy. IVPs at that time revealed cu,,u~,11:,.,e duplication on the right side and incomplete duplication on the left side. On continuous low-dose antimicrobial ....~·~"~, the patient continued to have clinical infections. Our confirmed the aforementioned radiologic findings (fig. 3, il.)
828
DUTHOY, SOUCHERAY AND MCGROARTY
A voiding cystogram revealed total reflux to the right lower segment. Cystourethroscopy revealed a single left normalappearing orifice and 2 orifices on the right side. The refluxing lower segment orifice was patulous. On October 29 a right ipsilateral ureteroureterostomy was done. Convalescence was uneventful. Before the patient was discharged from the hospital on November 5 a 20-minute function IVP was made (fig. 3, B). The mother and the referring urologist reported that the child has been without evidence of infection postoperatively. Followup x-rays in April 1976 were normal. Case 3. A 40-year-old woman had complete duplication of the left collecting system. After a hysterectomy a fistula developed from the upper segment ureter to the vagina. An ipsilateral ureteroureterostomy was done above the site of the original operation, thus eliminating the need to wait several months to repair the fistula. A followup IVP 5 years later was normal. CONCLUSION
We recommend an ipsilateral ureteroureterostomy rather than reimplanting a duplex system when there is only reflux to the lower segment. The operation requires less time than a reimplantation, is technically easier and has a low morbidity. There is no bladder incision and no splints or catheters are needed. The ureteral catheter inserted at the time of operation is removed immediately afterwards. A Penrose drain is left in place until one is certain that there is no urine leakage. Both sides can be done through 1 incision. The theoretical disadvantage of producing asynchronous peristalsis or the so-called "yo-yo" theory of Lenaghan 12 does not appear to be a problem. We would reserve reimplanting double ureters for those systems in which both ureters have reflux or 1 ureter is ectopic.
222 Central Medical Building, St. Paul, Minnesota 55104 (E.J.D.J. REFERENCES
1. Amar, A. D.: Reimplantation of completely duplicated ureters. J. Urol., 107: 230, 1972. 2. Johnston, J. H. and Heal, M. R.: Reflux in complete duplicated ureters in children: management and techniques. J. Urol., 105: 881, 1971. 3. Barrett, D. M., Malek, R. S. and Kelalis, P. P.: Problems and solutions in surgical treatment of 100 consecutive ureteral duplications in children. J. Urol., 114: 126, 1975. 4. Belman, A. B., Filmer, R. B. and King, L. R.: Surgical management of duplication of the collecting system. J. Urol., 112: 316, 1974. 5. Burns, A. and Palken, M.: Ureteroureterostomy for reflux in duplex systems. J. Urol., 106: 290, 1971. 6. Lytton, B., Weiss, R. M. and Berneike, R. R.: Ipsilateral ureteroureterostomy in the management of vesicoureteral reflux in duplication of upper urinary tract. J. Urol., 105: 507, 1971. 7. Gutierrez, J., Chang, C.-Y. and Nesbit, R. M.: Ipsilateral ureteroureterostomy for vesicoureteral reflux in duplicated ureter. J. Urol., 101: 36, 1969. 8. Foley, F. E. B.: Uretero-ureterostomy. As applied to obstructions of the duplicated upper urinary tract. J. Urol., 20: 109, 1928. 9. Kuss, R.: Chirurgie Plastique et Reparatrice de la Voie Excretrice du Rein. Indications et Telchniques Operatoires. Paris: Masson et Cie Editeurs, pp. 98-103, 1954. 10. Buchtel, H. A.: Uretero-ureterostomy. J. Urol., 93: 153, 1965. 11. Rothfeld, S. H.: Uretero-ureterostomy: a means of conservation of renal tissue. J. Urol., 84: 60, 1960. 12. Lenaghan, D.: Bifid ureters in children: an anatomical, physiological and clinical study. J. Urol., 87: 808, 1962.