Peadiatric transvesicoscopic dismembered ureteric reimplantation for ectopic upper ureter in duplication anomalies

Abstract

Introduction: Ectopic upper pole ureters in duplex kidneys can be managed surgically by ipsilateral distal ureteroureterostomy or reimplantation of both ipsilateral ureters when upper pole shows reasonable function.

Objective: This study aimed to evaluate the clinical outcomes of transvesicoscopic dismembered upper ureteric reimplantation for patients with ectopic upper pole ureters in duplication anomalies.

Patients and methods: Between July 2015 and January 2019, laparoscopic transvesicoscopic ureteral reimplantation was performed in 20 patients with ectopic upper pole ureters. An incision was made in the bladder wall at 1.0 cm proximal to the lower ureteral orifice of affected side. The upper pole ureter was recognized, and the terminal portion of the upper ureter was ligated and cut. Then the proximal portion of the upper ureter was mobilized, a transverse submucosal tunnel was created and upper ureteric reimplantation was performed with 6/0 absorbable sutures. Patients were followed up with renal ultrasonography and voiding cystourethrogram for clinical outcomes and hydronephrosis trends.

Results: Median (range) age at surgery was 22.5 (10-53) months. All of the 20 operations were successful, and none required conversion to an extravesical approach or open surgery. Four patients presented with worsening upper pole hydroureteronephrosis but recovered three to six months postoperatively. Resolution of symptoms and improving hydroureteronephrosis were achieved in all patients and VUR of the upper and lower ureters was not detected at postoperative follow-up.

Discussion: To our knowledge, dismembered reimplantation of upper pole ureters has been reported only in a small series through extravesical technique. In our study, we performed intravesicoscopic upper ureter Cohen reimplantation for duplex system ureteral ectopia. Compared with the extravesical approach, the transvesicoscopic approach leave most of the pelvic structures intact and the creation of a submucosal tunnel for prevention of ureteral reflux is more reliable; in addition, this approach avoids any manipulation of the lower pole ureter compared to ipsilateral ureteroureterostomy. But this method does not seem applicable to children under 6 months of age because of the small bladder capacity.

Conclusions: The laparoscopic intravesical technique of dismembered ureteral reimplantation was safe and feasible in our cases and may be an alternative surgical treatment for ectopic upper pole ureters in duplication anomalies.

Keywords: Duplex kidney; Ectopic ureter; Laparoscopic; Minimally invasive; Reimplantation.