Reimplantation of Ureters into the Bladders of Children

Trrn

VoL gg, May Printed in U.S.A.

JouRMAL OF UnoLOGY

Copyright © 1968 by The Williams & Wilkins Co.

REIMPLANTATION OF URETERS INTO THE BLADDERS OF CHILDREN JOHN H. McGOVERN

VICTOR F. MARSHALL

AND

From the Department of Surgery (Urology), James Buchanan Brady Foundation of th8 New York Hospital and the Department of Surgery (Urology), Cornell University Medical College, New York, New York

From 1954 to 1965, 226 children at our hospital have had 327 ureters reimplanted into the bladder by Paquin's technique. 1 There were 168 girls and 58 boys ranging from 2 weeks to 14 years old (an average age of 5.1 years). The right and left ureters were attacked with equal frequency a.nd bilateral operations were performed in 82 children (36 per cent). Y-V plastic revision of the vesical outlet was done in conjunction with ureteral reimplantation in 185 children (82 per cent). A preliminary nephrostomy was performed upon 150 kidneys, or in more than 35 per cent of the reimplanted ureters; 51 ureters required straightening, excision of redundancy and reduction of caliber (16 per cent). Previous unsuccessful operations had been done on 32 of the 226 vesical outlets (14 per cent) and 22 ureters (7 per cent). Vesicoureteral regurgitation was present in 271 of the 327 ureters (83 per cent). RESULTS

The results were considered successful in 203 patients or 294 ureters (90 per cent). Success is defined as no reflux and no obstruction at the involved ureterovesical junction. The incidence of success differed distinctly between boys and girls and seemed to correlate well with the extent of the disease; that is, the boys had n10re severe pathologic changes (table 1). That the successful group was not a highly favorable one is revealed by its size and by certain characteristics which will be discussed (table 2). A previous enlargement of the vesical outlet was seen in 21 patients (10 per cent). In 15 cases (5 per cent) the ureters had been previously reimplanted unsuccessfully by various methods. More than 6 months of periodic urethral dilatation without significant improvement had been done Accepted for publication August 15, 1967. Read at annual meeting of American Association of Genito-Urinary Surgeons, Rye, New York, May 24-26, 1967. 1 Paquin, A. J ., Jr.: Ureterovesical anastomosis: The description and evaluation of a technique. J. Urol., 82: 573, 1959.

in 25 cases (12 per cent). Both ureters were reimplanted in 52 girls and 20 boys (35 per cent). Preliminary nephrostomy was advised in 93 cases (32 per cent). At the time of nephrostomy 7 pyeloplasties, 8 partial nephrectomies and 2 nephrolithotomies were carried out. The caliber of the ureter was reduced by wedge resection in 39 cases (11 per cent). The diameters were 1 cm. or more in 93 cases (32 per cent). Reflux was demonstrated preoperatively in 250 ureters (85 per cent). The other ureters were operated on for obstruction without reflux. In 215 cases (74 per cent) reflux was only seen at low pressure (less than 15 cm. water by gravity). Hydronephrosis was demonstrated on preoperative excretory urograms in 206 specific sides (70 per cent). Massive dilatation (grades 3 and 4) was seen in 21 cases (8 per cent). Postoperatively hydronephrosis was present in 100 units (34 per cent); however, this was massive in only 2 per cent and absent in 66 per cent of the cases. This objective pyelographic change was impressive to us (table 3). The ureter which was not originally reimplanted displayed reflux before operation in 52 ureters, 23 of these at low pressure. Postoperatively, regurgitation could not be shown in 30 of these 52 ureters. Thirteen of the 23 ureters (60 per cent) that refluxed under low pressure no longer exhibited reflux, while 17 of 19 ureters with only high pressure reflux exhibited reflux. The prognostic therapeutic value of knowing the pressures at which reflux occurred seems evident. The reader may profitably remember that a Y-V plasty on the anterior vesical outlet was also performed in 168 cases under consideration (82 per cent). During this time 82 patients (36 per cent) had bilateral (not necessarily simultaneous) reimplantations. Reflux was, of course, eliminated and without the price of obstruction in all of the 203 patients with 294 reimplanted ureters. Failure in 23 of 226 patients (10 per cent) or in 33 ureters was demonstrated by persistent reflux or increased dilatation, or both. Only 6 girls with 9 ureters (4 per cent of the 189 girls) had poor 572

!"''!'/')•

REli\IPLANTA"rION OF URETERS INTO BLADDERS OF CHILDREN

l. Successful results in 327 ureteral reimplantations by Paquin's technique in 226 children followed 1 year or more (ave.,

TABLE

4.5 yrs.)* Total

i

Girls

Boys

- - - - I-------1----- ____.,__ ------Patients Ureters

i90o/cO ~'. 2226} o3 \ i

196

I

I 39,r 10 !

294 ) /

\ 327 I

j

! !

07 /O

f_.lt\!j 168 2.31

95c10 •

240

71°/O1

1

41

58 )

I 7')01 . 63 ) ~ ;o 87 1

i

•

* No reflux and no increased obstruction. results within this limited definition; while 17 boys with 24c ureters per cent of the 58 boys) did not have successful outcome. As previously mentioned, the pathologic changes were more generally severe in the boys than in the girls. A preliminary nephrostomy was used in 96 per cent of the failures, and in the same percentage of failures the ureter was extensively straightened,

side would probably have avoided thc;;e 2 fatalities. That experience has been a strong stimu-lus toward nephrostomiPs. The third death occurred in a 3-year-old boy 7 alter a ureteral reimplantation, excision of a ureteroccle and a vesical diverticulectomy. He bled into the bladder 5 days postoperatively but seemed sta.bilized with a normal hemoglobin when a 250 c:c transfusion was administered. Later he was found in shock and convulsions ensued. He may have aspirated vomitus. Autopsy disclosed no cleru cause of death but 80 cc of dotted blood was present in the operative area. Therefore, 14 patients (3 girb and 11 boys) had 22 ureters reimplanted into the bladder and wern failures because of obstruction in the oper · ative area, deteriorating renal function. 01 persistent reflux. These 14 patients unclcrwem; urinary diversion, 7 by means of ileo-conduit and 7 by cutaneous ureterostomy. All of thC'se pa-· tients were well 1 to 9 years (ave., 4

Total

Hydronephrosis: Absent Present Preliminary nephrostomy Previous unsuccessful ureteral operation Reduction in ureteral ca.liber Previous bladder outlet op. Bilateral operation Permanent cystostomy (1 yr. or more) Vesicouretera.l reflux wedge resectcd to reduce caliber and redundancy excised. vVhilc this rn.ight be construed as condemning nephrostomies and ureteral revisions, we feel confident that the real indication is that the degrees of renal damage and ureteral deformity were excessive (that is we tried too hard in the face of poor prospects, certainly in retrospect, in these particular instances). Three children died in the hospital after operation (1.3 per cent). Two were infants with prune belly syndrome and both died of massive sepsis originating in the unoperatcd, undrained upper urinary tract. 2 A nephrostomy in the undrained 2 McGovern, J. and llfarshall, V. F.: Congenital deficiency of the abdominal muscLilature and obstructive uropathy. Surg., Gynec. & Obst., 108:

289., 19.59.

t_),: t)

88 239 115 22 51 32 82 5 271

Failure

Success

(27%) (73%) (35%) (7%) (16%) (14%) (36%)

88 206 9''i} 15 39

(82%)

250

21 72 2

(29%) (70%) (32%) (5%) (11%) (10%) (35%) (1%) (85%)

0

33 .22 (9fi%)

7 (30%) 12 (52%) 11 (47%) 10 (43%) 3 (13%) 21 (93%)

3. Success.fv.l reimplanlation of 294 ureters in 203 children followed 1 to 11 yea.rs (ave., 4.li yrs.)

TABLE

Ip

.

Preoperative . ~ ostoperat.J.v·e .· - - - - - - 1-------··--·-'1

.

.

Hydronephrosis* None

29c•· ( 88 lo 294

Moderate (l+, 2+)

6r10 (~~ 294

Severe (2+, 3+)

1

21 3% ( 294

0 Vesicoureteral reflux 860! ( 250 ,O 294.· 22 ureters C. ontralateral reflux I 52 ureters ') . 1000·· I n f ect1011 / 0 (203) . 203 34a•!o (_tl~ \ 203 / 1

* Measm·ed by excretory m:ography.

574

MCGOVERN AND MARSHALL

following urinary diversion. Six patients (3 boys and 3 girls) were considered failures because of persistent reflux. In 2 boys, although asymptomatic and free of infection, reflux was seen at high pressure only and 1 boy who underwent bilateral operations had 1 success and 1 failure (the failure occurred with a severely hydronephrotic upper urinary tract which was removed when the contralateral side became normal). In 2 girls the failures occurred in repeat operations on double ureters. Both continue to be infected. The third girl, although asymptomatic and free of infection, refluxes at voiding pressure only. Three patients died in the immediate postoperative period. Sixty-nine children with successful results of the reimplantation proper had evidence of recurrent or persistent infection at 1-year followup (34 per cent). Normal excretory urograms and no reflux were recorded in 29 of these 69 children (42 per cent). The remaining 40 patients had contralateral reflux or residual hydronephrosis. Therefore, hrn-thirds of the patients who underwent rein1plantation of the ureters into the bladder and usually a plasty on the vesical outlet were asymptomatic and free of infection while off drugs 1 year postoperatively. There were 169 patients (130 girls and 39 boys) available for followup studies by means of excretory urography, voiding cystourethrography, historical review and, in 1nost instances, bacterial colony counts, hvo or more years following operation (ave., 4 years). Two girls had died of renal failure after discharge from the hospital. Doth had had advanced pyelonephritis and had required preliminary nephrostomy. One of these girls had a solitary kidney. Of the remaining 167 patients 29 (17 per cent) continue to have infected urine. Only one of these 29

children had at that time a normal excretory urogram and no evidence of reflux; the rest had readily detectable reasons for the persistence. DISCUSSION

This experience with reimplantation of the ureters into the bladder of children utilizing the technique described by Paquin indicates that operative correction of the reflux and obstruction was successful in 90 per cent of the cases. Nevertheless, the results in the boys were not nearly so successful as in the girls, no doubt largely because of more advanced changes in the former. As the degree of dilatation increased, the number of successful operative results decreased. Some of the early failures might have been prevented if preliininary nephroston1y had been used, as exemplified in two of 3 fatalities. Accordingly, we now use nephrostomy in most cases of severe hydronephrosis. We are also now inclined to resect a redundant upper ureter at the time of preliminary nephrostomy, since this eliminates the later necessity of dissecting the ureter from the bladder to the renal pelvis in order to relieve intrinsic obstructions. It was discouraging to find 34 per cent of the children with infection at the 1-year followup, particularly since almost half of the group had norma.l excretory urograms and no evidence of reflux. However, on longer followup, only 17 per cent of the patients continue to have evidence of infection and only one with infection has a radiographically normal urinary tract. Therefore, operative correction of vesicoureteral reflux and/or obstruction at the ureterovesical junction by Paquin's technique and usually enlarging the vesical outlet by means of a Y-V plasty was highly successful and, in our opinion, the method of choice.