Reoperative
Ureteral
Reimplantation:
ByJohn
Strategies
for Management
P. Gearhart and Michael P. Leonard
Baltimore, Maryland l Ureteral reimplantation is a procedure commonly performed by both urologists and pediatric surgeons. Although the vast majority are successful, there are some patients in whom technical considerations or bladder/ureteral abnormalities militate against success. We review our experience in 19 patients with multiple failed reimplants. The reasons for their failure, the investigations required to document such, and the management of these difficult problems will be discussed. In our hands, 95% of these patients ultimately became reflux-free and nonobstructed. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Vesicoureteral reflux; ureteral implantation, failure; ureteral implantation, reoperative.
R
EIMPLANTATION of the ureter is a commonly performed urological procedure. Success rates with various reimplant techniques are in the range of 98% to 99%.’ The management of patients who do not respond to ureteral reimplantation can be quite challenging. This article will discuss strategies of managing the failed reimplant, and describe selected cases for illustration. MATERIALS AND METHODS From 1984 through 1988, 19 patients who had failed ureteral reimplantation were examined by one of us (J.P.G.). There were 13 females and 6 males, with an age range of 2 to 42 years (median age, 7 years). The reasons for initial reimplantation were quite variable, and are illustrated in Table 1. The procedure used for the initial reimplant varied among the patients, and included such standard techniques as Leadbetter-Politano (5), Glenn-Anderson (4) Cohen (lo), and Paquin (1). The number of times the patients were previously reimplanted varied: once (3), twice (13) thrice (2) and four times (3). There were three main reasons for failure of previous reimplantations: a submucosal tunnel of inadequate length, a poorly compliant and/or hyperreflexic bladder, and ureteral obstruction. Table 2 correlates the initial reimplantation techniques with the reasons for failure. All patients were evaluated preoperatively by radiological studies including intravenous pyelography (IVP) and voiding cystourethrography (VCUG) (one patient who was diverted had a loopogram in addition to the above studies). The procedures used to remedy the situation of persistent reflux and/or obstruction varied greatly with the clinical demands. An appreciation of the variability
From the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD. Date accepted: October 6, 1989. Dr Leonard was a research fellow supported by the Kidney Foundation of Canada. Address reprint requests to John P. Gearhart, MD, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD 21205. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112601-0014$03.OOiO
58
of reconstruction may be gained by perusing Table 3. Reoperative Cohen reimplants were used in the setting of an inadequate tunnel, with a normal ureter and bladder. If the ureter was dilated (> 1 cm), a psoas hitch and/or ureteral tapering were used to assure an adequate reimplant. If only one of two ureters was suitable for reimplantation because of bladder and/or ureteral abnormalities, a transureteroureterostomy was mandated. In the setting of a poorly compliant, small volume bladder, which had been unresponsive to anticholinergic medication, bladder augmentation was performed. Of the patients who were augmented, the sources used to increase bladder capacity and compliance included ileum (3) cecum (1) and hindgut (1). Postoperatively, the need for intermittent self-catheterization (ISC) and anticholinergics (imipramine or oxybutinin) was recognized in some patients. Six patients were myelodysplastics, who had undergone bladder augmentation at the time of ureteral reimplantation. There was one undiversion patient, and two patients with primary reflux who also required these adjuncts. All patients were evaluated with IVP and VCUG at 3 months postsurgery. Particular attention was placed on whether or not reflux had been cured, and whether there was any ureteral obstruction.
Case Reports Case 1. (Date of birth, May 22, 1979.) At age 6 months this girl presented with urosepsis and was investigated with an IVP and VCUG. These studies documented high-grade reflux bilaterally, with poor renal function and gross ureteral dilatation. She underwent bilateral ureteral reimplantation (right Cohen, left GlennAnderson). Subsequent IVP showed improved renal function, and less ureteral dilatation bilaterally, but she had persistent highgrade reflux on the right. On April 7, 1980, a VCUG documented no reflux. She was followed conservatively until a series of breakthrough infections prompted reinvestigation. A VCUG (July 1983) documented left-sided reflux with a trabeculated and poorly emptying bladder. She underwent left ureteral reimplant (Cohen) and creation of a vesicostomy. Follow-up films showed no reflux or obstruction, and in October 1984 the vesicostomy was taken down. On June 6,1985, a VCUG documented grade V reflex on the right and ISC was begun. On August 14, 1985, she underwent psoas hitch and right ureteral reimplantation with ureteral tapering. Postoperatively she was maintained on ISC and anticholinergics. The subsequent follow-up films include: IVP, bilateral moderately severe hydronephrosis, lasix renogram, no obstruction; and VCUG, no reflux, heavily trabeculated bladder. Her current serum creatinine is 1.7 mg/dL and she is clinically well with no recent infections. Figure 1 shows representative urographic studies. Case 2. (Date of birth, December 19, 1966.) This woman was born with vaginal agenesis, and in the course of investigation was found to have massive bilateral vesicoureteral reflux. She then underwent bilateral tapered ureteral reimplants (LeadbetterPolitano) in July 1967. However, bilateral ureterovesical obstruction led to ileal loop diversion in 1969. She subsequently underwent a loop revision in 1969 for a ureterointestinal stricture, and another in 1979 for a dilated, poorly draining loop. She presented here in 1987 for consideration of undiversion. Investigations at that time included: IVP, moderate cahectasis and short ureters bilaterally; loopogram, short loop with bilateral reflux; DTPA scan, poor renal function on the left, normal renal function on the right; and
JournalofPediatric
Surgery, Vol26, No 1 (January), 1991: pp 58-63
59
FAILED URETERAL IMPLANTATION
Table 1. Etiology of Reflux and/or Obstruction Leading to
Table 3. Procedures Used in Definitive Reimplantation
Initial l?eimplant(s) Etiology
No. of
Patients(W)
No. of Ureters I%) Procedure
Primary reflux
4 (21)
5 (19)
Posterior urethral values Neurogenic bladder
3 (16) 6 (32)
3 (12) 10 (38)
Ureteral stricture Undiversion
1 (5)
1 (4)
t (5)
2 (8)
Obstructed megaureter
3 (16)
4(15)
Prune-belly syndrome
1 (5)
1 (4)
Cohen reimplant
RESULTS
All patients tolerated their reoperative reimplantation procedures well, without any significant postoperative complications. All patients were reflux-free on a VCUG done 3 months postoperatively, except for one with persistent reflux (grade IV/V) in a megaureter reimplanted for the third time. He has subsequently undergone subtrigonal injection of collagen with downgrading of his reflux to I/V. There was only one patient with documented obstruction postoperatively. This patient had a history of posterior urethral valves, and his obstruction was on the side that was not reimplanted. This was likely the result of poor bladder compliance, and the patient is currently being followed with a timed voiding regimen on anticholinergic medication. The final outcome, in terms of renal function, has been quite favorable in this group of patients. One and Reason for Failure
Reasonsfor Failure No. of Patients
Short TMVVZ?l
Bladder Noncompliance
Ureteral Obstruction
Leadbetter-Politano
5
3
1
Glenn-Anderson
4
1
2
1
10
6
4
0
Cohen Paquin Total
1
1
1
0
0
20
11
7
2
NOTE. One patient had a Cohen reimplantation Glenn-Anderson
on the other.
W)
W)
1 (5)
2 (7)
5 (26)
5 (18)
Psoas hitch and ureteral tapering
4w
4 (14)
Cohen reimplant and ureteral tapering
2(11)
3(11)
Psoas hitch and TUU
2(11)
4 (14)
Cohen reimplant and bladder augmentation
3 (15)
6 (22)
2 111)
4 (141
Psoas hitch and bladder augmentation and
VCUG, small (120 mL) bladder. Urodynamics showed cystometrogram, multiple unstable contractions, poor compliance, 100 mL capacity; uroflow, peak 3 mL/s, volume 100 mL; and urethral pressure profile, length 2.5 cm, maximum urethra1 pressure 100 cm H,O. She underwent a course of bladder cycling and was able to achieve a volume of 230 mL and a continence interval of 20 minutes. She underwent excision of her ileal conduit, right to left transureteroureterostomy, left ureteroneocystostomy with psoas hitch, and abdominal hysterectomy-right salpingooophorectomy on October 23, 1987. She was initiated on ISC with anticholinergics postoperatively. Follow-up VCUG (February 24, 1988) documented no reflux and her IVP showed moderate caliectasis (chronic) with good drainage bilaterally. She is currently continent and infection-free with a serum creatinine of 1.1 mg/dL. Figure 2 shows representative urographic studies.
Technique
No. of Ureters
Psoas hitch
TUU + bladder neck suspension
Table 2. Technique of Prior Reimplantation
No. of Patients
on one side and a
Abbreviation: TUU, transureteroureterostomy.
patient is currently in renal failure and on hemodialysis. This patient had a history of posterior urethral valves with documented renal dysplasia. His operation was successful in preventing reflux, but his meager renal reserve could not keep pace with somatic growth. Another patient requires oral bicarbonate to combat a chronic metabolic acidosis. She initially had primary reflux, but underwent four previous reimplant procedures with multiple episodes of intervening pyelonephritis. Her renal damage was likely a result of this stormy clinical course. Currently her serum creatinine is 1.4 mg/dL. The remaining patients have serum creatinines in the range of 0.5 to 1.7 mg/dL, with an average of 0.82 mg/dL (normal range, 0.4 to 1.5 mg/dL). DISCUSSION
Ureteral reimplantation is a common procedure in the surgeon’s armamentarium. With current techniques of antireflux surgery one can anticipate a successful outcome in 97%.’ However, what is to come of the minority who fail the reimplantation? In evaluating whether or not a patient is a true failure, one must be very cautious. In many cases, persistent low-grade reflux or ureteral obstruction on the initial postoperative films may simply be a reflection of surgical edema at the ureterovesical junction, and will resolve with time.’ In fact, there are documented cases of high-grade reflux after reimplantation resolving spontaneously.’ However, if the reflux and/or obstruction are persistent findings postoperatively, it is likely that the reimplant has failed. Aside from the IVP and VCUG, other studies may be useful in elucidating the cause for failure of reimplantation. Hendren has been an advocate of antegrade/retrograde pyelography to better delineate the anatomy of the faulty ureterovesical junction.’ Also, a Whitaker test may be done in conjunction with an antegrade pyelogram to ascertain whether a reimplant is obstructed.4 In addition, lasix renogram studies may be a less invasive means of assessing
GEARHART AND LEONARD
Fig 1. Representative imaging studies for case 1. (A) Initial VCUG illustrating high-grade reflux (V/V) bilaterally. (B) VCUG subsequent to initial reimplantation with persistent high-grade reflux on right. This reflux eventually resolved spontaneously. (C) VCUG after left ureteral reimplantation and veslcostomy takedown. Note high-grade reflux on the right (V/V) and trabeculated appearance of the bladder. (D) VCUG after definitive reimplantation documenting no reflux.
whether obstruction is present, but give less anatomical detail.* Cystoscopy is a useful adjunct to assess the adequacy of the submucosal tunnels and the degree of support at the ureterovesical junction.* Finally, if
one is suspicious of a poorly compliant hyperreflexic bladder as a cause of reimplant failure, urodynamics are useful for documentation, and planning the therapeutic course.’ We would recommend urodynamic
FAILED URETERAL IMPLANTATION
Fig 2. Representative imaging studies for case 2. (A) Preundiversion IVP documenting moderate caliectasis and short ureters bilaterally. The ileal loop is somewhat truncated. (6) Preoperative VCUG documenting smooth-wailed, small-capacity (120 mL) bladder with no reflux into ureteric stumps. (C) Postundiversion IVP illustrating good drainage of upper tracts (note right to left transureteroureterostomy). gladder distortion is due to psoas hftch. (D) Postoperative VCUG illustrating good-capacity, smooth-walled bladder with no reflux. Bladder is distorted secondary to psoas hitch.
61
62
evaluation in all patients after reimplantation failure,especially if the initial reimplant involved significant extravesical dissection. The causes of ureteral reimplantation failure are self-evident. Failure may be due to improper tunnel construction, abnormal ureters, or an abnormal bladder.’ Obstruction occurs in approximately 2% and may be suprahiatal, hiatal, or infrahiatal.’ Suprahiatal obstruction is due to placing the neohiatus too cephalolateral on the mobile part of the bladder, resulting in ureteral angulation with bladder filling-the “high reimplant syndrome.” Hiatal obstruction is usually due to creation of a neohiatus that is too snug, closure of the old detrusor defect too tightly, or angulation of the ureter as it crosses the lower edge of the neohiatus. Infrahiatal obstruction may be due to distal ureteral stenosis (ischemia), submucosal ureteral entrapment, or ureteral torsion within the submucosal tunnel. Aside from these technical misadventures, obstruction may be due to a poorly compliant and/or poorly emptying bladder, or ureteral atony.’ Persistent reflux has been documented to occur in less than 2% of patients.2 This may be due to the creation of an inadequate submucosal tunnel, reimplantation into a poorly compliant, poorly emptying bladder, or reimplantation of a large atonic ureter. A rare but recognized cause of persistent reflux has been the development of a ureterovesical fistula proximal to the neoorifice.’ In this series, the causes of reimplant failure were as follows: short submucosal tunnel (55%), poorly compliant bladder (35%), and ureteral obstruction (10%). The issue of contralateral reflux appearing after unilateral reimplantation should be addressed. This phenomenon has been documented to occur in 9% to 25% of cases.* Most authors, ourselves included, feel that both ureters should be reimplanted in cases of unilateral reflux if the contralateral nonrefluxing unit has had previously documented reflux, an endoscopitally poor tunnel/support mechanism, or a submucosal tunnel length < 0.5 cm.2 Other authors feel that bilateral reimplantation is only justified if there is bilateral reflux with one side grade III/V or more.6 The approach to the reoperative reimplant must be individualized. These reconstructive procedures are often long and tedious and should be performed in a setting of excellent pediatric anesthesia and supportive care. Hendren has masterfully outlined the basic principles of reoperative reimplantation.4 He advocates that these procedures be ,done through a lower midline incision, because it may be necessary to enter the peritoneum to adequately mobilize the ureter extravesically. The initial ureteral dissection is begun intravesically until the ureter is freed from the con-
GEARHART AND LEONARD
fines of the hiatus. In order to gain enough length for subsequent reimplantation, extravesical dissection to the level of the iliac vessels may be required. Hendren has emphasized the importance of sweeping all surrounding tissues (including the gonadal vessels) toward the ureter in order to preserve its blood supply. If the ureter is of normal caliber, and the bladder compliant with adequate volume, reoperative Cohen reimplantation,’ or creation of a neohiatus posteromedially on the bladder wall4 with subsequent ureteral reimplantation, are appropriate. If the ureter is significantly dilated (> 1 cm), ureteral tapering by either the Hendren4 or Kalicinski and Kan$ technique may be performed. Such tapering is usually only necessary for the lower ureter, because the ensuing improved ureteral peristalsis will allow upper tract dilatation to diminish.’ In the setting of ureteral tapering or a lack of ureteral length, the psoas hitch is a useful adjunct.4s9 In many cases only one ureter will be suitable for reimplantation because of bladder and/or ureteral abnormalities, and in this situation transureteroureterostomy may be used with reimplantation of the “best” ureter into the bladder.4 In some cases, the use of ileum to substitute for ureter may be advocated.4 We have not found it necessary to use ileal interposition in the patients we have managed, even those who have had up to four previous reimplantations. The topic of bladder augmentation, and the utility of ISC and anticholinergic medications is important. In many patients, the cause of reimplantation failure is a bladder abnormality. These patients often have overt neurological problems (eg, myelodysplasia), but may have subtle underlying abnormalities. In the present patient group, only three nonmyelodysplastic patients required anticholinergics and ISC postoperatively. Two of these patients initially had primary reflux, and both had undergone multiple previous reimplantations. Both girls acquired very poorly compliant and poorly emptying bladders, likely due to cystolysis from previous extravesical dissections. The third nonmyelodysplastic patient who required ISC and anticholinergics had a bladder that had been defunctional for nearly 20 years. The necessity for using ISC and anticholinergics may be determined preoperatively by clinical intuition, and supported with urodynamics. In some children, these adjuncts may actually abolish reflux and obviate the need for operation.‘“~ll However, in many, surgical intervention will be necessary. Jeffs et all2 have found that selection of myelodysplastic children with good bladder capacity and absence of trabeculations will often portend a good outcome after ureteral reimplantation. If there is any concern
FAILED URETERAL IMPLANTATION
63
about poor bladder compliance or hyperreflexia despite anticholinergics and ISC, bladder augmentation should be performed at the time of reimplantation. Many segments may be used for augmentation, but our preference is ileum. A caveat must be added here: the long-term metabolic consequences of the use of bowel in urinary tract reconstruction are uncertainI and will require careful follow-up.‘4 All patients undergoing reoperative reimplantations must undergo postoperative imaging to assess the outcome. Such studies are generally undertaken approximately 3 months postoperatively. In this study, 95% of patients had resolution of their reflux, and only one patient had an obstructed ureter (on the side that was not reimplanted). There is some concern over the length of follow-up required to rule out late complications. Broaddus et al feel that the 6-month follow-up IVP is adequate to rule out obstruction.” The recurrence of reflux up to 5 years after surgical “cure” has been documented in one study.‘” The important observation is that these children should be followed carefully throughout their childhood and adolescence. It is unlikely that routine x-rays are required more than 1 year postoperatively unless there are clinical indications, such as infection. Because these patients have underlying urological abnormalities, either iatrogenic or congenital, attention must also be focused on overall renal function. In this series, one patient is on hemodialysis. This patient had a history of posterior urethral valves and renal dysplasia. Even though his native kidneys func-
tion poorly, they produce erythropoeitin, and allow him greater latitude with respect to fluid intake. Because reflux is no longer a problem for this boy, he may undergo transplantation without the need for native nephrectomy. One patient who has had multiple reimplants for primary reflux is currently acidotic, with a creatinine of 1.4 mg/dL. She has suffered recurrent episodes of pyelonephritis due to persisting reflux. Her acidosis is well controlled with oral bicarbonate. The remaining patients all have good renal function without the need for dialysis or medical therapy. In conclusion, to assure a successful outcome with ureteric reimplantation, several important criteria must be met. First, the ureter must be reimplanted into a tunnel of adequate length, and must not be constricted or angulated anywhere along its course. Second, the ureter must be of normal diameter and tonus, and must have an adequate blood supply. Third, the bladder must be of adequate capacity and compliance. If the surgeon overlooks any of these factors, or does not correct them at the time of initial reimplantation, an operative failure will result. In the course of assessing a patient who has failed prior reimplantation, great pains must be taken to troubleshoot the system to document the reason for failure. Such evaluation is performed preoperatively with the aid of radiological investigations, cystoscopy, and urodynamics. In the process of reoperative reimplantation, these deficiencies are corrected according to need, in order to assure success.
REFERENCES 1. Hendren HW: Reoperation for the failed ureteral reimplantation. J Urol 111:403-411,1974 2. Gibbons MD, Gonzales ET Jr: Complications of antireflux surgery. Urol Clin North Am 10:489-501,1983 3. Siegelbaum MH, Rabinovitch HH: Delayed spontaneous resolution of high grade vesicoureteral reflux after reimplantation. J Urol 138:1205-1206,1987 4. Hendren WH: Reoperative ureteral reimplantation: Management of the difficult case. J Pediatr Surg 15:770-785,198O 5. Grechi G, Selli C, Pecori M, et al: Recurrent reflux caused by vesicoureteral fistula. Urology 17:360-361,198l 6. Quinlan D, O’Donnell B: Unilateral ureteric reimplantation for primary vesicoureteric reflux in children. Br J Urol57:406-409, 1985 7. Ahmed S: Revision of ureteral reimplantation by the transverse advancement technique. J Urol122:550-553,1979 8. Kalicinski ZH, Kansy J, Kotarbinska B, et al: Surgery of megaureters-Modification of Hendren’s operation. J Pediatr Surg 12:183-187, 1977 9. Gearhart JP, Woolfenden KA: The vesico-psoas hitch as an
adjunct to megaureter repair in childhood. J Urol 127:505-507, 1982 10. Brereton RJ, Narayanan R, Spitz L, et al: Ureteric reimplantation in the neuropathic bladder. Br J Surg 74:1107-1110,1987 11. Woodard JR, Anderson AM III, Parrott TM: Ureteral reimplantation in myeodysplasia children. J Urol126:387-388,198l 12. Jeffs RD, Jonas P, Schillinger JF: Surgical correction of vesicoureteral reflux in children with neurogenic bladder. J Urol 115:449-451, 1976 13. Heaton JPW, Leonard M: Long-term metabolic consequences of continent ileal diversion. J Urol 140:836, 1988 (letter) 14. Canning DA, Perman JA, Jeffs RD, et al: Nutritional consequences of bowel segments in lower urinary tract. J Urol 142:509-511, 1989 15. Broaddus SB, Zickerman PM, Morrisseau PM, et al: Incidence of late ureteral obstruction after antireflux surgery in infants and children. Urology 11:139-141, 1978 16. Amar AD: Delayed recurrence of reflux after initial success of antireflux operation. J Urol 119:131-133,1978
Ureteral
Reimplantation:
ByJohn
Strategies
for Management
P. Gearhart and Michael P. Leonard
Baltimore, Maryland l Ureteral reimplantation is a procedure commonly performed by both urologists and pediatric surgeons. Although the vast majority are successful, there are some patients in whom technical considerations or bladder/ureteral abnormalities militate against success. We review our experience in 19 patients with multiple failed reimplants. The reasons for their failure, the investigations required to document such, and the management of these difficult problems will be discussed. In our hands, 95% of these patients ultimately became reflux-free and nonobstructed. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Vesicoureteral reflux; ureteral implantation, failure; ureteral implantation, reoperative.
R
EIMPLANTATION of the ureter is a commonly performed urological procedure. Success rates with various reimplant techniques are in the range of 98% to 99%.’ The management of patients who do not respond to ureteral reimplantation can be quite challenging. This article will discuss strategies of managing the failed reimplant, and describe selected cases for illustration. MATERIALS AND METHODS From 1984 through 1988, 19 patients who had failed ureteral reimplantation were examined by one of us (J.P.G.). There were 13 females and 6 males, with an age range of 2 to 42 years (median age, 7 years). The reasons for initial reimplantation were quite variable, and are illustrated in Table 1. The procedure used for the initial reimplant varied among the patients, and included such standard techniques as Leadbetter-Politano (5), Glenn-Anderson (4) Cohen (lo), and Paquin (1). The number of times the patients were previously reimplanted varied: once (3), twice (13) thrice (2) and four times (3). There were three main reasons for failure of previous reimplantations: a submucosal tunnel of inadequate length, a poorly compliant and/or hyperreflexic bladder, and ureteral obstruction. Table 2 correlates the initial reimplantation techniques with the reasons for failure. All patients were evaluated preoperatively by radiological studies including intravenous pyelography (IVP) and voiding cystourethrography (VCUG) (one patient who was diverted had a loopogram in addition to the above studies). The procedures used to remedy the situation of persistent reflux and/or obstruction varied greatly with the clinical demands. An appreciation of the variability
From the James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD. Date accepted: October 6, 1989. Dr Leonard was a research fellow supported by the Kidney Foundation of Canada. Address reprint requests to John P. Gearhart, MD, James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, MD 21205. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112601-0014$03.OOiO
58
of reconstruction may be gained by perusing Table 3. Reoperative Cohen reimplants were used in the setting of an inadequate tunnel, with a normal ureter and bladder. If the ureter was dilated (> 1 cm), a psoas hitch and/or ureteral tapering were used to assure an adequate reimplant. If only one of two ureters was suitable for reimplantation because of bladder and/or ureteral abnormalities, a transureteroureterostomy was mandated. In the setting of a poorly compliant, small volume bladder, which had been unresponsive to anticholinergic medication, bladder augmentation was performed. Of the patients who were augmented, the sources used to increase bladder capacity and compliance included ileum (3) cecum (1) and hindgut (1). Postoperatively, the need for intermittent self-catheterization (ISC) and anticholinergics (imipramine or oxybutinin) was recognized in some patients. Six patients were myelodysplastics, who had undergone bladder augmentation at the time of ureteral reimplantation. There was one undiversion patient, and two patients with primary reflux who also required these adjuncts. All patients were evaluated with IVP and VCUG at 3 months postsurgery. Particular attention was placed on whether or not reflux had been cured, and whether there was any ureteral obstruction.
Case Reports Case 1. (Date of birth, May 22, 1979.) At age 6 months this girl presented with urosepsis and was investigated with an IVP and VCUG. These studies documented high-grade reflux bilaterally, with poor renal function and gross ureteral dilatation. She underwent bilateral ureteral reimplantation (right Cohen, left GlennAnderson). Subsequent IVP showed improved renal function, and less ureteral dilatation bilaterally, but she had persistent highgrade reflux on the right. On April 7, 1980, a VCUG documented no reflux. She was followed conservatively until a series of breakthrough infections prompted reinvestigation. A VCUG (July 1983) documented left-sided reflux with a trabeculated and poorly emptying bladder. She underwent left ureteral reimplant (Cohen) and creation of a vesicostomy. Follow-up films showed no reflux or obstruction, and in October 1984 the vesicostomy was taken down. On June 6,1985, a VCUG documented grade V reflex on the right and ISC was begun. On August 14, 1985, she underwent psoas hitch and right ureteral reimplantation with ureteral tapering. Postoperatively she was maintained on ISC and anticholinergics. The subsequent follow-up films include: IVP, bilateral moderately severe hydronephrosis, lasix renogram, no obstruction; and VCUG, no reflux, heavily trabeculated bladder. Her current serum creatinine is 1.7 mg/dL and she is clinically well with no recent infections. Figure 1 shows representative urographic studies. Case 2. (Date of birth, December 19, 1966.) This woman was born with vaginal agenesis, and in the course of investigation was found to have massive bilateral vesicoureteral reflux. She then underwent bilateral tapered ureteral reimplants (LeadbetterPolitano) in July 1967. However, bilateral ureterovesical obstruction led to ileal loop diversion in 1969. She subsequently underwent a loop revision in 1969 for a ureterointestinal stricture, and another in 1979 for a dilated, poorly draining loop. She presented here in 1987 for consideration of undiversion. Investigations at that time included: IVP, moderate cahectasis and short ureters bilaterally; loopogram, short loop with bilateral reflux; DTPA scan, poor renal function on the left, normal renal function on the right; and
JournalofPediatric
Surgery, Vol26, No 1 (January), 1991: pp 58-63
59
FAILED URETERAL IMPLANTATION
Table 1. Etiology of Reflux and/or Obstruction Leading to
Table 3. Procedures Used in Definitive Reimplantation
Initial l?eimplant(s) Etiology
No. of
Patients(W)
No. of Ureters I%) Procedure
Primary reflux
4 (21)
5 (19)
Posterior urethral values Neurogenic bladder
3 (16) 6 (32)
3 (12) 10 (38)
Ureteral stricture Undiversion
1 (5)
1 (4)
t (5)
2 (8)
Obstructed megaureter
3 (16)
4(15)
Prune-belly syndrome
1 (5)
1 (4)
Cohen reimplant
RESULTS
All patients tolerated their reoperative reimplantation procedures well, without any significant postoperative complications. All patients were reflux-free on a VCUG done 3 months postoperatively, except for one with persistent reflux (grade IV/V) in a megaureter reimplanted for the third time. He has subsequently undergone subtrigonal injection of collagen with downgrading of his reflux to I/V. There was only one patient with documented obstruction postoperatively. This patient had a history of posterior urethral valves, and his obstruction was on the side that was not reimplanted. This was likely the result of poor bladder compliance, and the patient is currently being followed with a timed voiding regimen on anticholinergic medication. The final outcome, in terms of renal function, has been quite favorable in this group of patients. One and Reason for Failure
Reasonsfor Failure No. of Patients
Short TMVVZ?l
Bladder Noncompliance
Ureteral Obstruction
Leadbetter-Politano
5
3
1
Glenn-Anderson
4
1
2
1
10
6
4
0
Cohen Paquin Total
1
1
1
0
0
20
11
7
2
NOTE. One patient had a Cohen reimplantation Glenn-Anderson
on the other.
W)
W)
1 (5)
2 (7)
5 (26)
5 (18)
Psoas hitch and ureteral tapering
4w
4 (14)
Cohen reimplant and ureteral tapering
2(11)
3(11)
Psoas hitch and TUU
2(11)
4 (14)
Cohen reimplant and bladder augmentation
3 (15)
6 (22)
2 111)
4 (141
Psoas hitch and bladder augmentation and
VCUG, small (120 mL) bladder. Urodynamics showed cystometrogram, multiple unstable contractions, poor compliance, 100 mL capacity; uroflow, peak 3 mL/s, volume 100 mL; and urethral pressure profile, length 2.5 cm, maximum urethra1 pressure 100 cm H,O. She underwent a course of bladder cycling and was able to achieve a volume of 230 mL and a continence interval of 20 minutes. She underwent excision of her ileal conduit, right to left transureteroureterostomy, left ureteroneocystostomy with psoas hitch, and abdominal hysterectomy-right salpingooophorectomy on October 23, 1987. She was initiated on ISC with anticholinergics postoperatively. Follow-up VCUG (February 24, 1988) documented no reflux and her IVP showed moderate caliectasis (chronic) with good drainage bilaterally. She is currently continent and infection-free with a serum creatinine of 1.1 mg/dL. Figure 2 shows representative urographic studies.
Technique
No. of Ureters
Psoas hitch
TUU + bladder neck suspension
Table 2. Technique of Prior Reimplantation
No. of Patients
on one side and a
Abbreviation: TUU, transureteroureterostomy.
patient is currently in renal failure and on hemodialysis. This patient had a history of posterior urethral valves with documented renal dysplasia. His operation was successful in preventing reflux, but his meager renal reserve could not keep pace with somatic growth. Another patient requires oral bicarbonate to combat a chronic metabolic acidosis. She initially had primary reflux, but underwent four previous reimplant procedures with multiple episodes of intervening pyelonephritis. Her renal damage was likely a result of this stormy clinical course. Currently her serum creatinine is 1.4 mg/dL. The remaining patients have serum creatinines in the range of 0.5 to 1.7 mg/dL, with an average of 0.82 mg/dL (normal range, 0.4 to 1.5 mg/dL). DISCUSSION
Ureteral reimplantation is a common procedure in the surgeon’s armamentarium. With current techniques of antireflux surgery one can anticipate a successful outcome in 97%.’ However, what is to come of the minority who fail the reimplantation? In evaluating whether or not a patient is a true failure, one must be very cautious. In many cases, persistent low-grade reflux or ureteral obstruction on the initial postoperative films may simply be a reflection of surgical edema at the ureterovesical junction, and will resolve with time.’ In fact, there are documented cases of high-grade reflux after reimplantation resolving spontaneously.’ However, if the reflux and/or obstruction are persistent findings postoperatively, it is likely that the reimplant has failed. Aside from the IVP and VCUG, other studies may be useful in elucidating the cause for failure of reimplantation. Hendren has been an advocate of antegrade/retrograde pyelography to better delineate the anatomy of the faulty ureterovesical junction.’ Also, a Whitaker test may be done in conjunction with an antegrade pyelogram to ascertain whether a reimplant is obstructed.4 In addition, lasix renogram studies may be a less invasive means of assessing
GEARHART AND LEONARD
Fig 1. Representative imaging studies for case 1. (A) Initial VCUG illustrating high-grade reflux (V/V) bilaterally. (B) VCUG subsequent to initial reimplantation with persistent high-grade reflux on right. This reflux eventually resolved spontaneously. (C) VCUG after left ureteral reimplantation and veslcostomy takedown. Note high-grade reflux on the right (V/V) and trabeculated appearance of the bladder. (D) VCUG after definitive reimplantation documenting no reflux.
whether obstruction is present, but give less anatomical detail.* Cystoscopy is a useful adjunct to assess the adequacy of the submucosal tunnels and the degree of support at the ureterovesical junction.* Finally, if
one is suspicious of a poorly compliant hyperreflexic bladder as a cause of reimplant failure, urodynamics are useful for documentation, and planning the therapeutic course.’ We would recommend urodynamic
FAILED URETERAL IMPLANTATION
Fig 2. Representative imaging studies for case 2. (A) Preundiversion IVP documenting moderate caliectasis and short ureters bilaterally. The ileal loop is somewhat truncated. (6) Preoperative VCUG documenting smooth-wailed, small-capacity (120 mL) bladder with no reflux into ureteric stumps. (C) Postundiversion IVP illustrating good drainage of upper tracts (note right to left transureteroureterostomy). gladder distortion is due to psoas hftch. (D) Postoperative VCUG illustrating good-capacity, smooth-walled bladder with no reflux. Bladder is distorted secondary to psoas hitch.
61
62
evaluation in all patients after reimplantation failure,especially if the initial reimplant involved significant extravesical dissection. The causes of ureteral reimplantation failure are self-evident. Failure may be due to improper tunnel construction, abnormal ureters, or an abnormal bladder.’ Obstruction occurs in approximately 2% and may be suprahiatal, hiatal, or infrahiatal.’ Suprahiatal obstruction is due to placing the neohiatus too cephalolateral on the mobile part of the bladder, resulting in ureteral angulation with bladder filling-the “high reimplant syndrome.” Hiatal obstruction is usually due to creation of a neohiatus that is too snug, closure of the old detrusor defect too tightly, or angulation of the ureter as it crosses the lower edge of the neohiatus. Infrahiatal obstruction may be due to distal ureteral stenosis (ischemia), submucosal ureteral entrapment, or ureteral torsion within the submucosal tunnel. Aside from these technical misadventures, obstruction may be due to a poorly compliant and/or poorly emptying bladder, or ureteral atony.’ Persistent reflux has been documented to occur in less than 2% of patients.2 This may be due to the creation of an inadequate submucosal tunnel, reimplantation into a poorly compliant, poorly emptying bladder, or reimplantation of a large atonic ureter. A rare but recognized cause of persistent reflux has been the development of a ureterovesical fistula proximal to the neoorifice.’ In this series, the causes of reimplant failure were as follows: short submucosal tunnel (55%), poorly compliant bladder (35%), and ureteral obstruction (10%). The issue of contralateral reflux appearing after unilateral reimplantation should be addressed. This phenomenon has been documented to occur in 9% to 25% of cases.* Most authors, ourselves included, feel that both ureters should be reimplanted in cases of unilateral reflux if the contralateral nonrefluxing unit has had previously documented reflux, an endoscopitally poor tunnel/support mechanism, or a submucosal tunnel length < 0.5 cm.2 Other authors feel that bilateral reimplantation is only justified if there is bilateral reflux with one side grade III/V or more.6 The approach to the reoperative reimplant must be individualized. These reconstructive procedures are often long and tedious and should be performed in a setting of excellent pediatric anesthesia and supportive care. Hendren has masterfully outlined the basic principles of reoperative reimplantation.4 He advocates that these procedures be ,done through a lower midline incision, because it may be necessary to enter the peritoneum to adequately mobilize the ureter extravesically. The initial ureteral dissection is begun intravesically until the ureter is freed from the con-
GEARHART AND LEONARD
fines of the hiatus. In order to gain enough length for subsequent reimplantation, extravesical dissection to the level of the iliac vessels may be required. Hendren has emphasized the importance of sweeping all surrounding tissues (including the gonadal vessels) toward the ureter in order to preserve its blood supply. If the ureter is of normal caliber, and the bladder compliant with adequate volume, reoperative Cohen reimplantation,’ or creation of a neohiatus posteromedially on the bladder wall4 with subsequent ureteral reimplantation, are appropriate. If the ureter is significantly dilated (> 1 cm), ureteral tapering by either the Hendren4 or Kalicinski and Kan$ technique may be performed. Such tapering is usually only necessary for the lower ureter, because the ensuing improved ureteral peristalsis will allow upper tract dilatation to diminish.’ In the setting of ureteral tapering or a lack of ureteral length, the psoas hitch is a useful adjunct.4s9 In many cases only one ureter will be suitable for reimplantation because of bladder and/or ureteral abnormalities, and in this situation transureteroureterostomy may be used with reimplantation of the “best” ureter into the bladder.4 In some cases, the use of ileum to substitute for ureter may be advocated.4 We have not found it necessary to use ileal interposition in the patients we have managed, even those who have had up to four previous reimplantations. The topic of bladder augmentation, and the utility of ISC and anticholinergic medications is important. In many patients, the cause of reimplantation failure is a bladder abnormality. These patients often have overt neurological problems (eg, myelodysplasia), but may have subtle underlying abnormalities. In the present patient group, only three nonmyelodysplastic patients required anticholinergics and ISC postoperatively. Two of these patients initially had primary reflux, and both had undergone multiple previous reimplantations. Both girls acquired very poorly compliant and poorly emptying bladders, likely due to cystolysis from previous extravesical dissections. The third nonmyelodysplastic patient who required ISC and anticholinergics had a bladder that had been defunctional for nearly 20 years. The necessity for using ISC and anticholinergics may be determined preoperatively by clinical intuition, and supported with urodynamics. In some children, these adjuncts may actually abolish reflux and obviate the need for operation.‘“~ll However, in many, surgical intervention will be necessary. Jeffs et all2 have found that selection of myelodysplastic children with good bladder capacity and absence of trabeculations will often portend a good outcome after ureteral reimplantation. If there is any concern
FAILED URETERAL IMPLANTATION
63
about poor bladder compliance or hyperreflexia despite anticholinergics and ISC, bladder augmentation should be performed at the time of reimplantation. Many segments may be used for augmentation, but our preference is ileum. A caveat must be added here: the long-term metabolic consequences of the use of bowel in urinary tract reconstruction are uncertainI and will require careful follow-up.‘4 All patients undergoing reoperative reimplantations must undergo postoperative imaging to assess the outcome. Such studies are generally undertaken approximately 3 months postoperatively. In this study, 95% of patients had resolution of their reflux, and only one patient had an obstructed ureter (on the side that was not reimplanted). There is some concern over the length of follow-up required to rule out late complications. Broaddus et al feel that the 6-month follow-up IVP is adequate to rule out obstruction.” The recurrence of reflux up to 5 years after surgical “cure” has been documented in one study.‘” The important observation is that these children should be followed carefully throughout their childhood and adolescence. It is unlikely that routine x-rays are required more than 1 year postoperatively unless there are clinical indications, such as infection. Because these patients have underlying urological abnormalities, either iatrogenic or congenital, attention must also be focused on overall renal function. In this series, one patient is on hemodialysis. This patient had a history of posterior urethral valves and renal dysplasia. Even though his native kidneys func-
tion poorly, they produce erythropoeitin, and allow him greater latitude with respect to fluid intake. Because reflux is no longer a problem for this boy, he may undergo transplantation without the need for native nephrectomy. One patient who has had multiple reimplants for primary reflux is currently acidotic, with a creatinine of 1.4 mg/dL. She has suffered recurrent episodes of pyelonephritis due to persisting reflux. Her acidosis is well controlled with oral bicarbonate. The remaining patients all have good renal function without the need for dialysis or medical therapy. In conclusion, to assure a successful outcome with ureteric reimplantation, several important criteria must be met. First, the ureter must be reimplanted into a tunnel of adequate length, and must not be constricted or angulated anywhere along its course. Second, the ureter must be of normal diameter and tonus, and must have an adequate blood supply. Third, the bladder must be of adequate capacity and compliance. If the surgeon overlooks any of these factors, or does not correct them at the time of initial reimplantation, an operative failure will result. In the course of assessing a patient who has failed prior reimplantation, great pains must be taken to troubleshoot the system to document the reason for failure. Such evaluation is performed preoperatively with the aid of radiological investigations, cystoscopy, and urodynamics. In the process of reoperative reimplantation, these deficiencies are corrected according to need, in order to assure success.
REFERENCES 1. Hendren HW: Reoperation for the failed ureteral reimplantation. J Urol 111:403-411,1974 2. Gibbons MD, Gonzales ET Jr: Complications of antireflux surgery. Urol Clin North Am 10:489-501,1983 3. Siegelbaum MH, Rabinovitch HH: Delayed spontaneous resolution of high grade vesicoureteral reflux after reimplantation. J Urol 138:1205-1206,1987 4. Hendren WH: Reoperative ureteral reimplantation: Management of the difficult case. J Pediatr Surg 15:770-785,198O 5. Grechi G, Selli C, Pecori M, et al: Recurrent reflux caused by vesicoureteral fistula. Urology 17:360-361,198l 6. Quinlan D, O’Donnell B: Unilateral ureteric reimplantation for primary vesicoureteric reflux in children. Br J Urol57:406-409, 1985 7. Ahmed S: Revision of ureteral reimplantation by the transverse advancement technique. J Urol122:550-553,1979 8. Kalicinski ZH, Kansy J, Kotarbinska B, et al: Surgery of megaureters-Modification of Hendren’s operation. J Pediatr Surg 12:183-187, 1977 9. Gearhart JP, Woolfenden KA: The vesico-psoas hitch as an
adjunct to megaureter repair in childhood. J Urol 127:505-507, 1982 10. Brereton RJ, Narayanan R, Spitz L, et al: Ureteric reimplantation in the neuropathic bladder. Br J Surg 74:1107-1110,1987 11. Woodard JR, Anderson AM III, Parrott TM: Ureteral reimplantation in myeodysplasia children. J Urol126:387-388,198l 12. Jeffs RD, Jonas P, Schillinger JF: Surgical correction of vesicoureteral reflux in children with neurogenic bladder. J Urol 115:449-451, 1976 13. Heaton JPW, Leonard M: Long-term metabolic consequences of continent ileal diversion. J Urol 140:836, 1988 (letter) 14. Canning DA, Perman JA, Jeffs RD, et al: Nutritional consequences of bowel segments in lower urinary tract. J Urol 142:509-511, 1989 15. Broaddus SB, Zickerman PM, Morrisseau PM, et al: Incidence of late ureteral obstruction after antireflux surgery in infants and children. Urology 11:139-141, 1978 16. Amar AD: Delayed recurrence of reflux after initial success of antireflux operation. J Urol 119:131-133,1978
