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Reflux into the Unused Ureter
Vol. 115, March
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
REFLUX INTO THE UNUSED URETER RITA LITTLEWOOD TEELE,* ROBERT L. LEBOWITZ
AND
ARNOLD H. COLODNY
From the Departments of Radiology and Surgery, Children's Hospital Medical Center and Harvard Medical School, Boston, Massachusetts
ABSTRACT
Reflux occurs into unused ureters in patients with urinary diversion and renal tranplantation, and into the ipsilateral ureter in patients with renal agenesis or dysplasia. Efflux may prevent reflux in patients with normal ureterovesical anatomy. If urine begins to flow down the ureter again the reflux may cease. Thus, in patients undergoing urinary tract reconstruction, undiversion should be done before an antireflux operation is performed. Reimplantation can be done after undiversion on a normal capacity bladder if the reflux persists. There is a small but important group of patients with urinary diversion who do not have neurogenic bladder dysfunction. Some had the urinary diversion before the modern era of pediatric urologic surgery for problems that would not require diversion today. Others had temporary diversion, often as newborns, while awaiting definitive surgery. All of these patients are candidates for undiversion-reconstitution to normal urinary drainage. 1 • 3 Herein we report on 8 selected children with prior urinary diversion who have been undiverted. All patients demonstrated reflux into the unused ureters. This reflux occurred regardless of the presence or absence of reflux prior to diversion. The reflux persisted after an antireflux operation on the ureteral stumps but disappeared when continuity of the urinary tract was re-established and urine flowed normally down the distal ureter again. In these cases, the efflux of urine seemed to prevent reflux (fig. 1). CASE REPORTS
Case 1. L. H. was first seen at our hospital when she was 6, years old for persistent urinary tract infection. The first infection had been documented 10 months previously. Excretory urography (IVP) revealed mild bilateral hydroureteronephrosis and voiding cystourethrography demonstrated a markedly trabeculated bladder with an abnormal configuration but with no reflux. The patient was incontinent day and night and a cystometrogram showed a hyperreflexic high pressure bladder with a small capacity. She also had severe constipation and fecal incontinence. Symptoms and cystometric findings suggested that the underlying problem was neurogenic bladder dysfunction. Because of this and increasing hydroureteronephrosis, an ilea! loop was created. Two voiding cystourethrograms following urinary diversion showed reflux into both unused distal ureteral stumps. Undiversion was achieved 16 months later, after the bladder infection resolved, and it became clear that the diagnosis had been chronic interstitial cystitis. Voiding cystourethrograms 7 and 17 months after undiversion showed that the reflux had disappeared (fig. 2). Case 2. R. B., a 20-month-old boy, was admitted to our hospital with a febrile seizure and azotemia. Screening IVP showed bilateral hydroureteronephrosis. The urine was sterile. A voiding cystourethrogram showed massive (grade IV)' bilateral vesicoureteral reflux. Diagnosis was congenital reflux. A suprapubic cystostomy was performed and a catheter was left
in place for 7 months. A voiding cystourethrogram continued to show grade III reflux bilaterally. Urinary diversion via ilea! conduit was performed and the patient was followed for 14 years, undergoing 4 loop revisions during that period. He was then studied for undiversion. A voiding cystourethrogram showed a small bladder and bilateral reflux into the unused ureteral stumps. At cystoscopy, widely patent ureteral orifices were seen. Glenn-Anderson type ureteral advancements were performed. A voiding cystourethrogram 7 months later again demonstrated bilateral reflux and a small bladder. Because of the possibility that urinary flow down the ureter may participate as part of the antireflux mechanism, staged reconstruction was started despite the persistent reflux. A left ureteroureteral anastomosis was performed while the proximal right ureter remained draining into the conduit. Repeat voiding cystourethrograms showed no reflux into the left ureter, which had urine flowing down it but persistent reflux into the still unused right ureteral stump. Because the proximal right ureter was short, a right-to-left ureteroureterostomy was then performed. Followup voiding cystourethrograms have continued to show persistent reflux into the right, still unused, ureteral stump and none into the left ureter (fig. 3). Case 3. M. P. was first seen at our hospital as a newborn for ventricular septa! defect. Later, during evaluation for failure to thrive, an IVP revealed a non-functioning left kidney and right hydroureteronephrosis. A voiding cystourethrogram showed grade IV reflux on the right side and grade II reflux into a blind-ending left ureter (fig. 4). A high right end-cutaneous ureterostomy, right distal ureterectomy and left ureteral reimplant were performed. Reflux into the left ureter persisted. Because the phenomenon of reflux into the unused ureter was recognized at this time, reconstitution of the urinary tract
Accepted for publication June 20, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975. * Requests for reprints: Department of Radiology, The Children's Hospital Medical Center, 300 Longwood Ave., Boston, Massachusetts 02115. 310
REFLUX INTO UNUSED URETERS
FIG. 1. Reflux often occurs into unused ureters whether or not there was reflux before urinary diversion. Reflux will often persist despite antireflux operation but will disappear after undiversion once urine begins to flow down ureter again.
311
REFLUX INTO UNUSED URETER
B
C
J)
SEVERE INTERSTITIAL CYSTITIS NO REFLUX C? NEUROGENIC)
FIG. 2. Case 1. A, ilea! conduit, small unused bladder and reflux into unused ureteral stumps while diverted. B, voiding cystourethrogram prior to undiversion shows bilateral reflux (arrows). C, normal urinary drainage and normal bladder capacity after undiversion (bilateral ureteroureterostomies). D, voiding cystourethrogram after undiversion shows no reflux. A
B
C
D
MASSIVE CONGENITAL REFLUX
FIG. 3. Case 2. A, ilea! conduit, small unused bladder and reflux into unused ureteral stumps while diverted (before bilateral antireflux operation). B, voiding cystourethrogram prior to undiversion (after bilateral reimplants) shows bilateral reflux (arrows). C, all urine drains down left distal ureter after undiversion (left ureteroureterostomy and right-to-left transureteroureterostomy). Normal bladder capacity. D, voiding cystourethrogram after undiversion shows no reflux mto Jett ureter and persistent reflux mto right, still unused ureter (arrow).
Ureteroureteral anastomoses were performed bilaterally. A followup voiding cystourethrogram has not yet been done.
DISCUSSION
FIG. 4. Case 3. A, IVP shows massive right hydroureteronephrosis and no visualization of left kidney. B, voiding cystourethrogram shows massive (grade IV) reflux into right megaureter (arrow) and reflux (grade III) into blind-ending left ureter (arrow).
was planned despite the left ureteral reflux. A right-to-left transureteroureterostomy was performed. A followup voiding cystourethrogram showed no reflux into the left ureter (fig. 5). Case 4. N. F. had a high imperforate anus with rectourethral fistula. Non-refluxing, non-obstructed bilateral hydroureteronephrosis with sepsis occurred when he was a newborn. 5 Because this mimicked ureterovesical obstruction cutaneous ureterostomies were performed elsewhere to decompress the upper tracts. The phenomenon of reflux into unused ureters was recognized before undiversion. The ureters were not reimplanted despite reflux during the of diversion.
The 8 children in this series presented in a number of ways (see table). Two patients had congenital reflux and 1 had reflux related to contralateral ureterocele and/or infection. Of these children 2 underwent reimplantation of the distal unused ureters while the urinary streams were diverted. The technique used for reimplantation was the Glenn-Anderson or Leadbetter-Politano operation. The success rate for antireflux operations without megaureter repair at our hospital has been more than 97 per cent and this figure is reported by others.,, 7 Yet, all of these reimplants failed, that is reflux persisted postoperatively. In all patients the reflux ceased spontaneously after undiversion. Three children who had no reflux at the initial evaluation had reflux while they were diverted but the reflux stopped when normal urinary drainage was re-established. We have also noted reflux into unused ureters that disappeared after undiversion in l patient with prune belly syndrome and cutaneous ureterostomies, and in another patient with bilateral ureteropelvic junction obstruction and cutaneous pyelostomies. Reflux into the unused ureter is partially explained by animal experiments, which show that the ureter requires the flow of liquid to maintain normal peristalsis. 3 There is also evidence that the intact renal pelvis acts as a pacemaker for the initiation of peristalsis, which then continues down the ureter.•. 10 Our experience does not support an unfilled bladder theory, which would suggest that a contracted bladder means a short submucosal tunnel and associated vesicoureteral reflux. In case 2, despite eventual normal bladder capacity, the right unused ureter continues to have reflux while the reflux spon-
312
TEELE, LEBOWITZ AND COLODNY
taneously subsided on the left used side. Also, patients with transplanted kidneys often show reflux into the unused ureteral stumps once their own kidneys have been removed. 11 This occurs in the absence of infection (fig. 6). Furthermore, patients with a dysplastic non-functioning kidney or renal agenesis will often demonstrate reflux into the ipsilateral unused ureter (figs. 4 and 7). 12 • 13 In the future, an artificial urinary sphincter may enable some patients who have had an ileal conduit created because of neurogenic bladder dysfunction and incontinence to undergo urinary tract undiversion. 14 We predict that many of these patients will have reflux into their unused ureteral stumps whether or not they had reflux before diversion. In those patients with normal ureterovesical anatomy the reflux may disappear once urinary tract continuity has been re-established.
A
We have encountered 1 potential pitfall in evaluating patients after undiversion. The cessation of reflux on voiding cystourethrography after an antireflux operation may be owing to ureterovesical obstruction. This complication may be occult in the patient who has poor visualization of the urinary tract OB IVP. It is important to recognize the phenomenon of reflux into the unused ureter. Patients with ureteral stumps with reflux who are candidates for urinary tract reconstruction should undergo undiversion before an antireflux operation is performed. In many cases when the reflux is mold to moderate, it will cease when urine begins to flow down the ureter again. If the reflux persists, reimplantation can then be done under more favorable conditions. The bladder will often have regained normal capacity and the operation will be greatly simplified.
B
D
C
@, MASSIVE CONGENITAL REFLUX ([), AGENESIS, REFLUXING URETER
FIG. 5. Case 3. A, high right end-cutaneous ureterostomy, unused bladder and reflux into left blind-ending ureter while diverted (after right distal ureterectomy and left antireflux operation). B, voiding cystourethrogram prior to undiversion shows left reflux (arrow). C, after undiversion (right-to-left transureteroureterostomy). D, voiding cystourethrogram after undiversion shows no reflux.
While Diverted* Pt.
Original ProblemType of Diversion
Before Diversion Reflux
Reimplant
Rt.
Lt.
Rt.
Lt.
LH- Neurogenic bladder, severe cystitis-ilea! loop
No
No
No
No
Massive congenital reflux -ilea! loop Rt. hydronephrosis and refluxing megaureter, refluxing blind-ending It. ureter -rt. end-cutaneous ureterostomy
Yes
Yes
Yes
Yes
Yes
Yes
NF
Im perforate anus, pseudoureterovesical obstruction-cutaneous ureteros-
No
No
KW
Non-function rt. kidney, It. hydroureteronephrosis, It. ureterostomy-lt. jejuna! loop Bilat. ureteropelvic junction obstruction-cutaneous pyelostomies
No
No
Yes
No
Yes
Yes
No
No
No
No
Yes
Yes (lower unit)
No
RB MP
Reflux After Reim plant Rt.
Yes
Yes
No
Lt.
After Un diversion Reflux Rt.
Lt.
No
No
Yes
No
Yes
No
No
Bladder Capacity (cc) Miscellaneous
Reflux into both ureters while diverted Rt. unused ureter still refluxing
Diverted Undiverted
10
600
150
650
150
200
Bilat. reflux while diverted
20
No
Reflux into It. ureteral stump while diverted
60
250
No
No
30
250
No
No
Lt. ureter reimplanted (in retrospect unnecessarily) because of reflux only while diverted Bilat. reflux while diverted
100
400
25
400
tomies
PF
SH
Prune belly syndrome, hydroureteronephrosis-cuta-
ED
Bilat. duplication, It. ureterocele with subsequent nephrectomy and ureterectomy of both It. unitsilea! loop
Nephrectomy
No
Yes
Yes
neous ureterostomies
* All voiding cystourethrograms done while urine was sterile.
No
Reflux into rt. ureters while diverted
REFLUX INTO UNUSED URETER
313
F1G. 7. A, IVP in newborn with right multicystic dysplastic kidney (arrows). Left kidney is normal. B, voiding cystourethrogram shows reflux into blind-ending right ureter.
4. 5. 6. 7.
8.
9. FIG. 6. IVP in patient with renal transplant. Note reflux into
unused right ureteral stump (arrow). Patient has had bilateral nephrectomy and upper ureterectomy.
Ms. Andrea Kelton helped prepare this report and the Department of Visual Education, Children's Hospital Medical Center prepared the illustrations. REFERENCES
10. 11.
12.
1. Dretler, S. P., Hendren, W. H. and Leadbetter, W. F.: Urinary
tract reconstruction following ilea! conduit diversion. J. Urol., 109: 217, 1973. 2. Hendren, W. H.: Reconstruction of previously diverted urinary tracts in children. J. Pediat. Surg., 8: 135, 1973. 3. Colodny, A.H.: Reconstruction of the urinary stream 2 to 15 years following establishment of "permanent" ilea! loop diversion.
13.
14.
Read at annual meeting of American Urological Association, St. Louis, Missouri, May 19-23, 1974. Colodny, A. H. and Lebowitz, R. L.: A plea for grading vesicoureteric reflux. Urology, 4: 357, 197 4. Pais, V. M. and Retik, A. B.: Reversible hydronephrosis in the neonate with urinary sepsis. New Engl. J. Med., 292: 465, 1975. Hendren, W. H.: Reoperation for the failed ureteral reimplantation. J. Urol., Hl: 403, 1974. Willscher, M. K., Bauer, S. B., Zammuto, P. J. and Retik, A. B.: Renal growth and urinary infection following antireflux surgery in infants and children. J. Urol., in press. Yalla, V. S., Burros, H. M. and Zimskind, P. D.: Peristaltic behavior of disused ureteral stump. Urology, 1: 417, 1973. Wendel, R. M. and King, L. R.: Ureternl peristalsis. Further observations on the effects of flow reversal. Invest. Urol., IO: 354, 1973. Gosling, J. A. and Dixon, J. S.: Structural evidence in support of an urinary tract pacemaker. Brit. J. Urol., 44: 550, 1972. Uranga, V. M., Simmons, R. L., Kjellstrand, C. M., Buselmeier, T. J. and Najarian, J. S.: Autogenous ureteral reflux after transplant ureteroneocystostomy. Amer. J. Surg., 123: 639, 1972. Griscom, N. T., Vawter, G. F. and Fellers, F. X.: Pelvoinfundibular atresia: the usual form of multicystic kidney: 44 unilateral and 2 bilateral cases. Semin. Roentgen., W: 125, 1975. Limkakeng, A. C. and Retik, A. B.: Unilateral renal agenesis with hypoplastic ureter: observations on the contralateral urinary tract and report of 4 cases. J. Urol., 108: 149, 1972. Scott, F. B., Bradley, W. E. and Timm, G. W.: Treatment of urinary incontinence by an implantable prosthetic urinary sphincter. J. Urol., H2: 75, 1974.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
REFLUX INTO THE UNUSED URETER RITA LITTLEWOOD TEELE,* ROBERT L. LEBOWITZ
AND
ARNOLD H. COLODNY
From the Departments of Radiology and Surgery, Children's Hospital Medical Center and Harvard Medical School, Boston, Massachusetts
ABSTRACT
Reflux occurs into unused ureters in patients with urinary diversion and renal tranplantation, and into the ipsilateral ureter in patients with renal agenesis or dysplasia. Efflux may prevent reflux in patients with normal ureterovesical anatomy. If urine begins to flow down the ureter again the reflux may cease. Thus, in patients undergoing urinary tract reconstruction, undiversion should be done before an antireflux operation is performed. Reimplantation can be done after undiversion on a normal capacity bladder if the reflux persists. There is a small but important group of patients with urinary diversion who do not have neurogenic bladder dysfunction. Some had the urinary diversion before the modern era of pediatric urologic surgery for problems that would not require diversion today. Others had temporary diversion, often as newborns, while awaiting definitive surgery. All of these patients are candidates for undiversion-reconstitution to normal urinary drainage. 1 • 3 Herein we report on 8 selected children with prior urinary diversion who have been undiverted. All patients demonstrated reflux into the unused ureters. This reflux occurred regardless of the presence or absence of reflux prior to diversion. The reflux persisted after an antireflux operation on the ureteral stumps but disappeared when continuity of the urinary tract was re-established and urine flowed normally down the distal ureter again. In these cases, the efflux of urine seemed to prevent reflux (fig. 1). CASE REPORTS
Case 1. L. H. was first seen at our hospital when she was 6, years old for persistent urinary tract infection. The first infection had been documented 10 months previously. Excretory urography (IVP) revealed mild bilateral hydroureteronephrosis and voiding cystourethrography demonstrated a markedly trabeculated bladder with an abnormal configuration but with no reflux. The patient was incontinent day and night and a cystometrogram showed a hyperreflexic high pressure bladder with a small capacity. She also had severe constipation and fecal incontinence. Symptoms and cystometric findings suggested that the underlying problem was neurogenic bladder dysfunction. Because of this and increasing hydroureteronephrosis, an ilea! loop was created. Two voiding cystourethrograms following urinary diversion showed reflux into both unused distal ureteral stumps. Undiversion was achieved 16 months later, after the bladder infection resolved, and it became clear that the diagnosis had been chronic interstitial cystitis. Voiding cystourethrograms 7 and 17 months after undiversion showed that the reflux had disappeared (fig. 2). Case 2. R. B., a 20-month-old boy, was admitted to our hospital with a febrile seizure and azotemia. Screening IVP showed bilateral hydroureteronephrosis. The urine was sterile. A voiding cystourethrogram showed massive (grade IV)' bilateral vesicoureteral reflux. Diagnosis was congenital reflux. A suprapubic cystostomy was performed and a catheter was left
in place for 7 months. A voiding cystourethrogram continued to show grade III reflux bilaterally. Urinary diversion via ilea! conduit was performed and the patient was followed for 14 years, undergoing 4 loop revisions during that period. He was then studied for undiversion. A voiding cystourethrogram showed a small bladder and bilateral reflux into the unused ureteral stumps. At cystoscopy, widely patent ureteral orifices were seen. Glenn-Anderson type ureteral advancements were performed. A voiding cystourethrogram 7 months later again demonstrated bilateral reflux and a small bladder. Because of the possibility that urinary flow down the ureter may participate as part of the antireflux mechanism, staged reconstruction was started despite the persistent reflux. A left ureteroureteral anastomosis was performed while the proximal right ureter remained draining into the conduit. Repeat voiding cystourethrograms showed no reflux into the left ureter, which had urine flowing down it but persistent reflux into the still unused right ureteral stump. Because the proximal right ureter was short, a right-to-left ureteroureterostomy was then performed. Followup voiding cystourethrograms have continued to show persistent reflux into the right, still unused, ureteral stump and none into the left ureter (fig. 3). Case 3. M. P. was first seen at our hospital as a newborn for ventricular septa! defect. Later, during evaluation for failure to thrive, an IVP revealed a non-functioning left kidney and right hydroureteronephrosis. A voiding cystourethrogram showed grade IV reflux on the right side and grade II reflux into a blind-ending left ureter (fig. 4). A high right end-cutaneous ureterostomy, right distal ureterectomy and left ureteral reimplant were performed. Reflux into the left ureter persisted. Because the phenomenon of reflux into the unused ureter was recognized at this time, reconstitution of the urinary tract
Accepted for publication June 20, 1975. Read at annual meeting of American Urological Association, Miami Beach, Florida, May 11-15, 1975. * Requests for reprints: Department of Radiology, The Children's Hospital Medical Center, 300 Longwood Ave., Boston, Massachusetts 02115. 310
REFLUX INTO UNUSED URETERS
FIG. 1. Reflux often occurs into unused ureters whether or not there was reflux before urinary diversion. Reflux will often persist despite antireflux operation but will disappear after undiversion once urine begins to flow down ureter again.
311
REFLUX INTO UNUSED URETER
B
C
J)
SEVERE INTERSTITIAL CYSTITIS NO REFLUX C? NEUROGENIC)
FIG. 2. Case 1. A, ilea! conduit, small unused bladder and reflux into unused ureteral stumps while diverted. B, voiding cystourethrogram prior to undiversion shows bilateral reflux (arrows). C, normal urinary drainage and normal bladder capacity after undiversion (bilateral ureteroureterostomies). D, voiding cystourethrogram after undiversion shows no reflux. A
B
C
D
MASSIVE CONGENITAL REFLUX
FIG. 3. Case 2. A, ilea! conduit, small unused bladder and reflux into unused ureteral stumps while diverted (before bilateral antireflux operation). B, voiding cystourethrogram prior to undiversion (after bilateral reimplants) shows bilateral reflux (arrows). C, all urine drains down left distal ureter after undiversion (left ureteroureterostomy and right-to-left transureteroureterostomy). Normal bladder capacity. D, voiding cystourethrogram after undiversion shows no reflux mto Jett ureter and persistent reflux mto right, still unused ureter (arrow).
Ureteroureteral anastomoses were performed bilaterally. A followup voiding cystourethrogram has not yet been done.
DISCUSSION
FIG. 4. Case 3. A, IVP shows massive right hydroureteronephrosis and no visualization of left kidney. B, voiding cystourethrogram shows massive (grade IV) reflux into right megaureter (arrow) and reflux (grade III) into blind-ending left ureter (arrow).
was planned despite the left ureteral reflux. A right-to-left transureteroureterostomy was performed. A followup voiding cystourethrogram showed no reflux into the left ureter (fig. 5). Case 4. N. F. had a high imperforate anus with rectourethral fistula. Non-refluxing, non-obstructed bilateral hydroureteronephrosis with sepsis occurred when he was a newborn. 5 Because this mimicked ureterovesical obstruction cutaneous ureterostomies were performed elsewhere to decompress the upper tracts. The phenomenon of reflux into unused ureters was recognized before undiversion. The ureters were not reimplanted despite reflux during the of diversion.
The 8 children in this series presented in a number of ways (see table). Two patients had congenital reflux and 1 had reflux related to contralateral ureterocele and/or infection. Of these children 2 underwent reimplantation of the distal unused ureters while the urinary streams were diverted. The technique used for reimplantation was the Glenn-Anderson or Leadbetter-Politano operation. The success rate for antireflux operations without megaureter repair at our hospital has been more than 97 per cent and this figure is reported by others.,, 7 Yet, all of these reimplants failed, that is reflux persisted postoperatively. In all patients the reflux ceased spontaneously after undiversion. Three children who had no reflux at the initial evaluation had reflux while they were diverted but the reflux stopped when normal urinary drainage was re-established. We have also noted reflux into unused ureters that disappeared after undiversion in l patient with prune belly syndrome and cutaneous ureterostomies, and in another patient with bilateral ureteropelvic junction obstruction and cutaneous pyelostomies. Reflux into the unused ureter is partially explained by animal experiments, which show that the ureter requires the flow of liquid to maintain normal peristalsis. 3 There is also evidence that the intact renal pelvis acts as a pacemaker for the initiation of peristalsis, which then continues down the ureter.•. 10 Our experience does not support an unfilled bladder theory, which would suggest that a contracted bladder means a short submucosal tunnel and associated vesicoureteral reflux. In case 2, despite eventual normal bladder capacity, the right unused ureter continues to have reflux while the reflux spon-
312
TEELE, LEBOWITZ AND COLODNY
taneously subsided on the left used side. Also, patients with transplanted kidneys often show reflux into the unused ureteral stumps once their own kidneys have been removed. 11 This occurs in the absence of infection (fig. 6). Furthermore, patients with a dysplastic non-functioning kidney or renal agenesis will often demonstrate reflux into the ipsilateral unused ureter (figs. 4 and 7). 12 • 13 In the future, an artificial urinary sphincter may enable some patients who have had an ileal conduit created because of neurogenic bladder dysfunction and incontinence to undergo urinary tract undiversion. 14 We predict that many of these patients will have reflux into their unused ureteral stumps whether or not they had reflux before diversion. In those patients with normal ureterovesical anatomy the reflux may disappear once urinary tract continuity has been re-established.
A
We have encountered 1 potential pitfall in evaluating patients after undiversion. The cessation of reflux on voiding cystourethrography after an antireflux operation may be owing to ureterovesical obstruction. This complication may be occult in the patient who has poor visualization of the urinary tract OB IVP. It is important to recognize the phenomenon of reflux into the unused ureter. Patients with ureteral stumps with reflux who are candidates for urinary tract reconstruction should undergo undiversion before an antireflux operation is performed. In many cases when the reflux is mold to moderate, it will cease when urine begins to flow down the ureter again. If the reflux persists, reimplantation can then be done under more favorable conditions. The bladder will often have regained normal capacity and the operation will be greatly simplified.
B
D
C
@, MASSIVE CONGENITAL REFLUX ([), AGENESIS, REFLUXING URETER
FIG. 5. Case 3. A, high right end-cutaneous ureterostomy, unused bladder and reflux into left blind-ending ureter while diverted (after right distal ureterectomy and left antireflux operation). B, voiding cystourethrogram prior to undiversion shows left reflux (arrow). C, after undiversion (right-to-left transureteroureterostomy). D, voiding cystourethrogram after undiversion shows no reflux.
While Diverted* Pt.
Original ProblemType of Diversion
Before Diversion Reflux
Reimplant
Rt.
Lt.
Rt.
Lt.
LH- Neurogenic bladder, severe cystitis-ilea! loop
No
No
No
No
Massive congenital reflux -ilea! loop Rt. hydronephrosis and refluxing megaureter, refluxing blind-ending It. ureter -rt. end-cutaneous ureterostomy
Yes
Yes
Yes
Yes
Yes
Yes
NF
Im perforate anus, pseudoureterovesical obstruction-cutaneous ureteros-
No
No
KW
Non-function rt. kidney, It. hydroureteronephrosis, It. ureterostomy-lt. jejuna! loop Bilat. ureteropelvic junction obstruction-cutaneous pyelostomies
No
No
Yes
No
Yes
Yes
No
No
No
No
Yes
Yes (lower unit)
No
RB MP
Reflux After Reim plant Rt.
Yes
Yes
No
Lt.
After Un diversion Reflux Rt.
Lt.
No
No
Yes
No
Yes
No
No
Bladder Capacity (cc) Miscellaneous
Reflux into both ureters while diverted Rt. unused ureter still refluxing
Diverted Undiverted
10
600
150
650
150
200
Bilat. reflux while diverted
20
No
Reflux into It. ureteral stump while diverted
60
250
No
No
30
250
No
No
Lt. ureter reimplanted (in retrospect unnecessarily) because of reflux only while diverted Bilat. reflux while diverted
100
400
25
400
tomies
PF
SH
Prune belly syndrome, hydroureteronephrosis-cuta-
ED
Bilat. duplication, It. ureterocele with subsequent nephrectomy and ureterectomy of both It. unitsilea! loop
Nephrectomy
No
Yes
Yes
neous ureterostomies
* All voiding cystourethrograms done while urine was sterile.
No
Reflux into rt. ureters while diverted
REFLUX INTO UNUSED URETER
313
F1G. 7. A, IVP in newborn with right multicystic dysplastic kidney (arrows). Left kidney is normal. B, voiding cystourethrogram shows reflux into blind-ending right ureter.
4. 5. 6. 7.
8.
9. FIG. 6. IVP in patient with renal transplant. Note reflux into
unused right ureteral stump (arrow). Patient has had bilateral nephrectomy and upper ureterectomy.
Ms. Andrea Kelton helped prepare this report and the Department of Visual Education, Children's Hospital Medical Center prepared the illustrations. REFERENCES
10. 11.
12.
1. Dretler, S. P., Hendren, W. H. and Leadbetter, W. F.: Urinary
tract reconstruction following ilea! conduit diversion. J. Urol., 109: 217, 1973. 2. Hendren, W. H.: Reconstruction of previously diverted urinary tracts in children. J. Pediat. Surg., 8: 135, 1973. 3. Colodny, A.H.: Reconstruction of the urinary stream 2 to 15 years following establishment of "permanent" ilea! loop diversion.
13.
14.
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