THE ]GURNAL OF U20LOGY
Copyright© 1976 by
Vo~. ll5, ,Jur'e
'Ni!liart:.s & \iViJ.l-r.i?1s Co,
UNUSUAL
_F·'rinted
U.S.A.
OIVlPLICATIONS OF TRANSVESICAL URETERAL REIMPLANTATION
PAULE. TOCCI, VICTOR A. POLITANO, CHARLES M. LYNNE AND HERMAN M. CARRION From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
Four of 8 cases that represent unusual and infrequent complications of the transvesicle PolitanoLeadbetter ureteral reimplantation technique are reported. Approximately 90 per cent of ureteral reimplantations for vesicoureteral reflux may be done satisfactorily as a transvesical procedure but combining it with an extravesical approach of the ureter when necessary or indicated will serve to correct any conceivable congenital, acquired or iatrogenic lesion of the lower ureteral segment. The extravesical approach should be used if there is any difficulty in performing the procedure transvesically or if the patient has undergone previous attempts at antireflux operation. Obstructive complications may occur in either the early or late postoperative period. When discovered, surgical correction is usually indicated. We strongly advocate strict adherence to the surgical technique involved and meticulous postoperative followup of these patients. Herein we report some infrequent and unusual complications of the Politano-Leadbetter ureteral reimplantation technique, how and why they occurred and ways to prevent their occurrence. The results of this technique for the correction of vesicoureteral reflux have been gratifying with the reported success rate in the range of 96 to 97 per cent. 1-4 The complication rate for the most part has been low, which can be attributed to the technical experience of the surgeons performing the procedure along with the refinement of the technique during the last several years. The most frequent complication is the persistence of vesicoureteral reflux in the reimplanted ureter. The rate of frequency increases in patients who have undergone previous attempts at antireflux operation and in those with fibrotic, dilated or rigid ureters. The most common cause for this complication is the positioning of the orifice too far lateral or too high on the floor of the bladder with an inadequate length of sub mucosa! tunnel. The tunnel length must bear approximately a 3 to 1 ratio to the anticipated diameter of the ureter for prevention of reflux. 5 The second most common complication is obstruction at the site of the ureterovesical junction with resultant hydroureteronephrosis. There are 2 basic causes of this complication: 1) angulation of the ureter proximal to its entry through the bladder wall, which can be avoided adequate mobilization of the ureter transvesically and creation of a large non-obstructing hiatus in the bladder wall at the new point of entry of the ureter, and 2) occurrence of periureteral fibrosis or scarring in the intramural or immediate perivesical area, which is usually related to injury of the ureteral adventitia with compromised vascular supply. This can be prevented by resection of the distal traumatized ureteral segment. Other complications include acute pyelonephritis, reflux in the contralateral ureter when only 1 side is reimplanted, perforation of the ureter leading to fistula formation and urinary extravasation, sloughing of the lower ureter with pelvic abscess formation and the development of a para-ureteral diverticulum causing compression and obstruction of the ureter. Martin and Kaufman reported a case of obstruction caused by compression and angulation of the ureter between the bladder and uterine artery on 1 side and compression of the other ureter by an obliterated superior vesical artery. 6 Recently, Kaufman and associates reported 1 ureter being reimAccepted for publication October 24, 1975. Read at annual meeting of Southeastern Section, American Urological Association, Atlanta, Georgia, April 13-16, 1975.
planted through a fallopian tube and another through a segment of small intestine. 7 During the last 13 years some 2,000 ureteral reimplantations have been performed by the residents and staff of our hospital. The ratio or percentage of unusual complications to ureters reimplanted is difficult to establish since several patients reported in this series were referred from elsewhere. We have collected 8 such cases during the last 12 years, 7 of which were ureters passing through an adjacent viscus. In 1 of these 7 cases the orifice had also become re-epithelialized. The eighth case was prolonged bleeding from the cut end of the ureter requiring transfusions and electrocoagulation. Herein we present 4 illustrative cases. CASE REPORTS
Case 1. G. S., a 15-month-old boy with recurrent urinary tract infections since he was 1 month old, had an excretory urogram (IVP) performed in December 1961, which revealed mild left ureterocaliectasis. Diagnosis was left ureterovesical junction obstruction and bladder neck obstruction. A wedge resection of the posterior bladder neck and revision of the left ureterovesical junction were performed but the patient continued to have recurrent urinary tract infections and, subsequently, was found to have massive left vesicoureteral reflux. He was then referred to this hospital. An IVP and cystogram in November 1962 again revealed left hydroureteronephrosis and reflux. A left transvesica! ureteral reimplantation and Y-V plasty of the bladder neck were performed, The ureteral catheter was removed 72 hours postoperatively, and fever and diarrhea developed, which responded to chloromycetin, An IVP 6 days postoperatively showed marked left hydroureteronephrosis (fig. 1, A). The patient was discharged from the hospital on antibiotics and Foley catheter drainage. The Foley catheter was removed 3 weeks later and an IVP the following week showed increased dilatation of the left upper collecting system. A cystogram 3 months postoperatively revealed no reflux. An IVP showed left hydronephrosis with ureteral dilatation down to the lower third of the ureter (fig. 1, B). The patient was rehospitalized and a ureteral catheter was easily passed to the left renal pelvis and left in place. The distal end of the catheter passed per rectum that night (fig. 2). A left retrograde pyelogram the following day revealed a ureterocolic fistula (fig. 3, A). Exploration revealed the left ureter traversing the sigmoid colon with an easily identifiable fistula between the ureter and
731
732
TOCCI AND ASSOCIATES
not bring about any improvement in the status of the left kidney. At surgical exploration the previously reimplanted left ureter was found coursing through the broad ligament and obviously obstructed by it. The broad ligament was divided and the ureter was dissected free. No ureteral reimplantation was necessary. An IVP 4 months later showed persistent calicectasis with normal ureteral caliber and no evidence of ureteral obstruction (fig. 5. B). Case 3. D. C., a 3-year-old girl, had a !-year history of recurrent urinary tract infections and known bilateral, massive
FIG. 1. Case 1. A, IVP after left transvesical ureteral reimplantation shows marked hydroureteronephrosis. B, IVP 3 months later shows persistent left hydroureteronephrosis down to lower third of ureter.
Fm. 3. Case 1. A, left retrograde pyelogram shows contrast material in sigmoid colon representing ureterocolic fistula. B, ureter is traversing sigmoid colon.
Fm. 2. Case 1. Distal end of ureteral catheter is protruding from anus
colon (fig. 3, B). The involved area of sigmoid colon was wedgeresected and anastomosed in 3 layers and the ureteral fistula was closed in 1 layer with 4-zero chromic catgut sutures. A ureteral reimplantation was not performed. Convalescence was uneventful. Prior to the patient's discharge from the hospital an IVP showed a dilated left upper collecting system. An IVP and cystogram 1 ½ years later as well as an IVP 11 years later (May 1974) showed no reflux with only mild calicectasis on the left side (fig. 4). Case 2. P.R., a 12-year-old girl, had a bilateral transvesical ureteral reimplantation performed 6 years previously. The patient was asymptomatic until 2 weeks before hospitalization when the sudden onset of left flank pain with nausea and vomiting developed. An IVP revealed delayed visualization on the left side with hydroureteronephrosis. The patient was then referred to this hospital. Urine culture yielded more than 100,000 colonies per cc Escherichia coli. At cystoscopy 2 ureteral catheters were easily passed up the left ureter and left in place for 3 days. A pull-out ureterogram showed dilatation proximal to the pelvic brim with non-visualization of the ureter below that level (fig. 5, A). The patient was discharged from the hospital on antibiotics. An IVP 4 months later again revealed left hydroureteronephrosis with narrowing of the lower third of the ureter. It was apparent that previous insertion of the ureteral catheters did
Fm. 4. Case 1. NP 11 years after repair ofureterocolic fistula shows mild calicectasis on left side.
TRANSVESICAL URETERAL REIMPLANTATION
FIG. 5. Case 2. A, left pull-out ureterogram shows dilatation proximal to pelvic brim with non-visualization of ureter below that level. B, IVP 4 months after left ureter was freed from broad ligament shows persistent calicectasis with normal ureteral caliber.
vesicoureteral reflux, which did not respond to a year of continuous antibiotic therapy. The patient was then referred to this hospital. An IVP showed fullness to both renal pelves with moderate ureteral dilatation and a cystogram revealed bilateral grade III to IV reflux (fig. 6, A and B). Cystoscopy revealed both ureteral orifices to be gapping and somewhat more laterally and superiorly placed than normal. A bilateral transvesical ureteral reimplantation was performed. An IVP 7 days postoperatively revealed a prolonged nephrogram on the right side through 2 hours and moderate left hydroureteronephrosis. The left side was considered compatible with the degree of postoperative changes usually seen. An early followup IVP obtained 3 weeks later (1 month postoperatively) revealed poor visualization on the right side with slight resolution of the hydronephrotic changes on the left side. A second followup film 1 month later again failed to show any resolution of the high grade obstruction on the right side and persistent left hydroureteronephrosis (fig. 6, C). Cystoscopy was performed. A ureteral catheter could not be passed through the right ureterovesical junction but one was passed up the left side with some difficulty encountered just outside the bladder. Exploration revealed the extravesical course of the right ureter through both walls of the distal ileum. The involved segment of ileum was excised with a wedge resection and an ileoileostomy was performed. The portion of ureter traversing the ilea! wall was excised. The remaining ureter was tailored and reimplanted into the bladder. Exploration of the left ureter revealed it to be angulated acutely by an adhesive band just outside the bladder. This band was lysed. An IVP 1 year later revealed prompt visualization bilaterally with satisfactory resolution of the previously noted obstructive changes (fig. 6, D). Case 4. E. N., a 4-year-old girl, had recurrent urinary tract infections since she was 18 months old. An IVP appeared normal (fig. 7, A) and a cystogram showed moderate bilateral vesicoureteral reflux (fig. 7, B). The blood urea nitrogen (BUN) was 12 mg. per cent, serum creatinine 0.5 mg. per cent and the
733
hemogram was normal. Urine culture yielded enterococcus. Initial cystoscopy revealed laterally placed, gapping orifices bilaterally. At this time, the urethra was dilated to 26F and the patient was placed on antibiotics. She continued to have recurrent infections while taking antibiotics and was shown radiographically to have persistent reflux. The patient underwent a bilateral transvesical ureteral reimplantation 10 months after the initiation of conservative therapy. An IVP 6 days postoperatively revealed dilatation of both collecting systems consistent with the postoperative status (fig. 7, C). The patient was asymptomatic while on antibiotics and 2 months later a repeat cystogram showed no reflux. However, an IVP revealed no improvement in the bilateral ureterocaliectasis (fig. 7, D). An acute urinary tract infection developed 3 months later and the patient was rehospitalized. Laboratory studies revealed a hemoglobin of 8.6 gm. per cent, hematocrit 25.3, BUN 64 mg. per cent and serum creatinine 3.7 mg. per cent. Electrolytes were normal. Cystoscopy revealed both ureteral orifices normal in position with adequate submucosal tunnels. Bilateral ureteral catheters were easily passed and left in place for several days, which resulted in improvement of the BUN and serum creatinine to 18 and 1.3 mg. per cent, respectively. Pull-out ureterograms showed both ureters dilated down to a point 1 to 2 cm. from the bladder. Exploration revealed both ureters coursing through the broad ligaments. They were dissected free and the ureters were reimplanted. The patient has done well postoperatively with only short-term followup.
FIG. 6. Case 3. A, IVP shows bilateral calicectasis and dilated ureters. B, cystogram reveals bilateral grade III to IV vesicoureteral reflux. C, IVP 2 months after bilateral transvesical ureteral reimplantation shows poor visualization on right side with left hydroureteronephrosis. D, IVP 1 year after second exploration reveals prompt visualization bilaterally with great improvement of previously noted obstructive changes.
734
TOCCI AND ASSOCIATES
the ureteral adventitia causing devascularization of the distal ureteral segment. If there is difficulty mo.bilizing the ureter one should not hesitate to go extravesically to make sure that the mobilization is complete. The submucosal tunnel is then formed. Next, a right angle clamp is passed through the bladder hiatus, behind the bladder with the point advancing gently and slowly against the base of the bladder, thus gradually dissecting away the peritoneal reflection. We stress that this should be done under direct vision with the use of a vein retractor or narrow Deaver retractor (fig. 8). Failure to do this properly may lead to perforation of peritoneum, ileum, broad ligament or sigmoid colon (fig. 9). At this point, a right angle clamp is passed through the full thickness of the bladder from outside in at the proximal end of the tunnel. The bladder wall is thin and if unusual resistance or thickness is
URETER
FIG. 7. Case 4. A, IVP appears normal. B, cystogram shows moderate bilateral vesicoureteral reflux. C, 10-minute postoperative IVP shows bilateral pyelocaliectasis consistent with operation. D, IVP 2 months after bilateral transvesical ureteral reimplantation reveals persistent bilateral ureterocaliectasis.
DISCUSSION
FIG. 8. Under direct vision, peritoneal reflection is dissected away from base of bladder.
The 8 cases encountered demonstrate that the PolitanoLeadbetter ureteral reimplantation technique is not a completely innocuous procedure, especially in more inexperienced hands. Although the complication rate is low and the success rate high, unusual and infrequent complications can occur and result in significant morbidity for the patient. Of the 8 patients in whom complications developed 7 did well after a corrective operation was performed, while 1 required a nephrectomy because of a technical error at the time of re-exploration. This technique of ureteral reimplantation was initially described as a transvesical procedure.• With time and experience, it became apparent that combining it with an extravesical approach of the ureter when indicated would serve to correct any conceivable congenital, acquired or iatrogenic lesion of the lower ureteral segment. Approximately 90 per cent of ureteral reimplantations for reflux may be done satisfactorily as a transvesical procedure. We believe that this is more advantageous because: 1) it decreases operative time, which is especially important when dealing with infants, 2) there is minimal bladder mobilization and dissection and 3) there is less dissection of the lower ureters minimizing the chance of devascularization with subsequent fibrosis and sloughing. These unusual complications are preventable if one adheres to the technique involved in performing the Politano-Leadbetter procedure. Once the ureter has been detached from the bladder it should be gently mobilized for a distance of at least 6 FIG. 9. A, course of ureter before and after ureteral reimplantation. to 8 cm. or more with gentle traction and blunt spreading of the B, ureter is passing through ileum. C, ureter is traversing broad ligatissues parallel to the ureter. Care must be taken not to injure ment. D, ureter is passing through sigmoid colon.
Trf.J,j_,,JSVESICAL UP,,ETERAL RE11Vi?LAt-rrA1'XON
encountered while the it is most likely that some other structure is between the ureter and bladder. Once the ureter has been reimplanted, a ureteral catheter should pass easily to the kidney without meeting any obstruction. If there is difficulty, the reimplant should be performed again or the ureter explored ext:ravesically. The case of postoperative bleeding after ureteral reimplantation is quite unusual. This child required several units of blood and did not respond to conventional means. Bleeding from a distal ureteral artery may occur more commonly than recognized and can be prevented by more careful hemostasis and meticulous suturing at the time of operation. If excessive bleeding persists postoperatively cystoscopy is indicated with fulguration of the bleeding point. Re-epithelialization of the ureteral orifice as seen in 1 case may have been owing to poor fixation of the bladder mucosa to the ureteral epithelium, thereby allowing regrowth of the bladder mucosa across the orifice. Careful approximation of the edge of the bladder mucosa to the distal ureter when suturing it in place may prevent this complication. Followup of these patients is perhaps as important as the actual operation. Minor degrees of ureteral obstruction can be recognized early, many of which can be resolved simply. A single 10-minute IVP is obtained 6 or 7 days postoperatively to rule out complete obstruction of the newly reimplanted ureter and to serve as a control for postoperative resolution. Usually, a moderate amount of ureterectasis is present. If the degree of reflux has been severe and there is considerable morphologic deformity, such as loss of renal parenchyma and hydronephrosis, these structural changes may persist indefinitely. At approximately 8 weeks postoperatively a cystogram and an IVP are obtained. By this time the urine is usually uninfected, reflux should be absent and there should be considerable improvement in the ureterocaliectasis. If the urine remains infected the patient is continued on a urinary antiseptic. If the ureterocaliectasis has not improved as expected or has become more severe cystoscopy is performed with ureteral catheterization to dilate the intramural ureter and rule out mechanical obstruction. Frequently, minor degrees of ureteral obstruction can be resolved by this method, much as one would leave a catheter indwelling to soften a urethral stricture. The catheters are left in place for a few days and then pull-out ureterograms are performed. If the obstruction persists, particularly above the level of the ureterovesical junction, exploration of the ureter should be seriously considered. If the ureter is found to traverse the intestine the intestine is opened, the ureter is removed and the bowel is closed in several layers or
a segment of bowel is resected and an end-to-end anastomosis is performed. It is interesting that the symptoms in our patients primarily referred to the genitourinary tract rather than gynecologic or gastrointestinal. Only 1 patient (case 1) had gastrointestinal symptoms but this was in the immediate postoperative period and quickly resolved with antibiotics. It is of further interest to note that the child who had 1 ureter reimplanted through the broad ligament was completely asymptomatic for 6 years and did not have problems until after menarche, while the other patient who had both ureters reimplanted through the broad ligaments had problems early. This may be explained either on the basis of a hormonal or physiological response that occurred during puberty or that the ureter became obstructed by the broad ligament with normal growth and development. This case illustrates another important point, that of late ureteral obstruction after ureteral reimplantation. This has been reported previously"· 10 and emphasizes the importance of close followup in these patients. Repeat cystograms and IVPs should be performed at 6-month intervals for the first year postoperatively. If the cystogram remains normal IVPs should still be performed at yearly intervals for the next several years, even in asymptomatic patients who have had previously normal radiographic findings. REFERENCES
1. Politano, V. A.: Review of 500 cases of ureteral reimplantations.
2. 3.
4. 5. 6. 7.
8. 9. 10.
Read at annual meeting of American Urological Association, Chicago, Illinois, May 16-20, 1971. Hendren, W. H.: Reoperation for the failed ureteral reimplantation. J. Urol., Hl: 403, 1974. Brannan, W., Ochsner, M. G., Rosencrantz, D.R., Whitehead, C. M., Jr. and Goodier, E. H.: Experiences with vesicoureteral reflux. J. Urol., 109: 46, 1973. Williams, D. I. and Eckstein, H.B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965. Politano, V. A.: Ureterovesical junction. J. Urol., 107: 239, 1972. Martin, D. C. and Kaufman, J. J.: Pitfalls in ureterovesicoplasty for the prevention of reflux. J. Urol., 97: 846, 1967. Kaufman, J. M., McGuire, E. J. and Baskin, A. M.: Viscus perforation: unusual complication of ureteroneocystostomy. Urology, 4: 728, 1974. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. Weiss, R. M., Schiff, M., Jr. and Lytton, B.: Late obstruction after ureteroneocystostomy. J. Urol., 106: 144, 1971. Filly, R. A., Friedland, G. W., Fair, W.R. and Goven, D. E.: Late ureteric obstruction following ureteral reimplantation for reflux: a warning. Urology, 4: 540, 1974.
Copyright© 1976 by
Vo~. ll5, ,Jur'e
'Ni!liart:.s & \iViJ.l-r.i?1s Co,
UNUSUAL
_F·'rinted
U.S.A.
OIVlPLICATIONS OF TRANSVESICAL URETERAL REIMPLANTATION
PAULE. TOCCI, VICTOR A. POLITANO, CHARLES M. LYNNE AND HERMAN M. CARRION From the Department of Urology, University of Miami School of Medicine and Jackson Memorial Hospital, Miami, Florida
ABSTRACT
Four of 8 cases that represent unusual and infrequent complications of the transvesicle PolitanoLeadbetter ureteral reimplantation technique are reported. Approximately 90 per cent of ureteral reimplantations for vesicoureteral reflux may be done satisfactorily as a transvesical procedure but combining it with an extravesical approach of the ureter when necessary or indicated will serve to correct any conceivable congenital, acquired or iatrogenic lesion of the lower ureteral segment. The extravesical approach should be used if there is any difficulty in performing the procedure transvesically or if the patient has undergone previous attempts at antireflux operation. Obstructive complications may occur in either the early or late postoperative period. When discovered, surgical correction is usually indicated. We strongly advocate strict adherence to the surgical technique involved and meticulous postoperative followup of these patients. Herein we report some infrequent and unusual complications of the Politano-Leadbetter ureteral reimplantation technique, how and why they occurred and ways to prevent their occurrence. The results of this technique for the correction of vesicoureteral reflux have been gratifying with the reported success rate in the range of 96 to 97 per cent. 1-4 The complication rate for the most part has been low, which can be attributed to the technical experience of the surgeons performing the procedure along with the refinement of the technique during the last several years. The most frequent complication is the persistence of vesicoureteral reflux in the reimplanted ureter. The rate of frequency increases in patients who have undergone previous attempts at antireflux operation and in those with fibrotic, dilated or rigid ureters. The most common cause for this complication is the positioning of the orifice too far lateral or too high on the floor of the bladder with an inadequate length of sub mucosa! tunnel. The tunnel length must bear approximately a 3 to 1 ratio to the anticipated diameter of the ureter for prevention of reflux. 5 The second most common complication is obstruction at the site of the ureterovesical junction with resultant hydroureteronephrosis. There are 2 basic causes of this complication: 1) angulation of the ureter proximal to its entry through the bladder wall, which can be avoided adequate mobilization of the ureter transvesically and creation of a large non-obstructing hiatus in the bladder wall at the new point of entry of the ureter, and 2) occurrence of periureteral fibrosis or scarring in the intramural or immediate perivesical area, which is usually related to injury of the ureteral adventitia with compromised vascular supply. This can be prevented by resection of the distal traumatized ureteral segment. Other complications include acute pyelonephritis, reflux in the contralateral ureter when only 1 side is reimplanted, perforation of the ureter leading to fistula formation and urinary extravasation, sloughing of the lower ureter with pelvic abscess formation and the development of a para-ureteral diverticulum causing compression and obstruction of the ureter. Martin and Kaufman reported a case of obstruction caused by compression and angulation of the ureter between the bladder and uterine artery on 1 side and compression of the other ureter by an obliterated superior vesical artery. 6 Recently, Kaufman and associates reported 1 ureter being reimAccepted for publication October 24, 1975. Read at annual meeting of Southeastern Section, American Urological Association, Atlanta, Georgia, April 13-16, 1975.
planted through a fallopian tube and another through a segment of small intestine. 7 During the last 13 years some 2,000 ureteral reimplantations have been performed by the residents and staff of our hospital. The ratio or percentage of unusual complications to ureters reimplanted is difficult to establish since several patients reported in this series were referred from elsewhere. We have collected 8 such cases during the last 12 years, 7 of which were ureters passing through an adjacent viscus. In 1 of these 7 cases the orifice had also become re-epithelialized. The eighth case was prolonged bleeding from the cut end of the ureter requiring transfusions and electrocoagulation. Herein we present 4 illustrative cases. CASE REPORTS
Case 1. G. S., a 15-month-old boy with recurrent urinary tract infections since he was 1 month old, had an excretory urogram (IVP) performed in December 1961, which revealed mild left ureterocaliectasis. Diagnosis was left ureterovesical junction obstruction and bladder neck obstruction. A wedge resection of the posterior bladder neck and revision of the left ureterovesical junction were performed but the patient continued to have recurrent urinary tract infections and, subsequently, was found to have massive left vesicoureteral reflux. He was then referred to this hospital. An IVP and cystogram in November 1962 again revealed left hydroureteronephrosis and reflux. A left transvesica! ureteral reimplantation and Y-V plasty of the bladder neck were performed, The ureteral catheter was removed 72 hours postoperatively, and fever and diarrhea developed, which responded to chloromycetin, An IVP 6 days postoperatively showed marked left hydroureteronephrosis (fig. 1, A). The patient was discharged from the hospital on antibiotics and Foley catheter drainage. The Foley catheter was removed 3 weeks later and an IVP the following week showed increased dilatation of the left upper collecting system. A cystogram 3 months postoperatively revealed no reflux. An IVP showed left hydronephrosis with ureteral dilatation down to the lower third of the ureter (fig. 1, B). The patient was rehospitalized and a ureteral catheter was easily passed to the left renal pelvis and left in place. The distal end of the catheter passed per rectum that night (fig. 2). A left retrograde pyelogram the following day revealed a ureterocolic fistula (fig. 3, A). Exploration revealed the left ureter traversing the sigmoid colon with an easily identifiable fistula between the ureter and
731
732
TOCCI AND ASSOCIATES
not bring about any improvement in the status of the left kidney. At surgical exploration the previously reimplanted left ureter was found coursing through the broad ligament and obviously obstructed by it. The broad ligament was divided and the ureter was dissected free. No ureteral reimplantation was necessary. An IVP 4 months later showed persistent calicectasis with normal ureteral caliber and no evidence of ureteral obstruction (fig. 5. B). Case 3. D. C., a 3-year-old girl, had a !-year history of recurrent urinary tract infections and known bilateral, massive
FIG. 1. Case 1. A, IVP after left transvesical ureteral reimplantation shows marked hydroureteronephrosis. B, IVP 3 months later shows persistent left hydroureteronephrosis down to lower third of ureter.
Fm. 3. Case 1. A, left retrograde pyelogram shows contrast material in sigmoid colon representing ureterocolic fistula. B, ureter is traversing sigmoid colon.
Fm. 2. Case 1. Distal end of ureteral catheter is protruding from anus
colon (fig. 3, B). The involved area of sigmoid colon was wedgeresected and anastomosed in 3 layers and the ureteral fistula was closed in 1 layer with 4-zero chromic catgut sutures. A ureteral reimplantation was not performed. Convalescence was uneventful. Prior to the patient's discharge from the hospital an IVP showed a dilated left upper collecting system. An IVP and cystogram 1 ½ years later as well as an IVP 11 years later (May 1974) showed no reflux with only mild calicectasis on the left side (fig. 4). Case 2. P.R., a 12-year-old girl, had a bilateral transvesical ureteral reimplantation performed 6 years previously. The patient was asymptomatic until 2 weeks before hospitalization when the sudden onset of left flank pain with nausea and vomiting developed. An IVP revealed delayed visualization on the left side with hydroureteronephrosis. The patient was then referred to this hospital. Urine culture yielded more than 100,000 colonies per cc Escherichia coli. At cystoscopy 2 ureteral catheters were easily passed up the left ureter and left in place for 3 days. A pull-out ureterogram showed dilatation proximal to the pelvic brim with non-visualization of the ureter below that level (fig. 5, A). The patient was discharged from the hospital on antibiotics. An IVP 4 months later again revealed left hydroureteronephrosis with narrowing of the lower third of the ureter. It was apparent that previous insertion of the ureteral catheters did
Fm. 4. Case 1. NP 11 years after repair ofureterocolic fistula shows mild calicectasis on left side.
TRANSVESICAL URETERAL REIMPLANTATION
FIG. 5. Case 2. A, left pull-out ureterogram shows dilatation proximal to pelvic brim with non-visualization of ureter below that level. B, IVP 4 months after left ureter was freed from broad ligament shows persistent calicectasis with normal ureteral caliber.
vesicoureteral reflux, which did not respond to a year of continuous antibiotic therapy. The patient was then referred to this hospital. An IVP showed fullness to both renal pelves with moderate ureteral dilatation and a cystogram revealed bilateral grade III to IV reflux (fig. 6, A and B). Cystoscopy revealed both ureteral orifices to be gapping and somewhat more laterally and superiorly placed than normal. A bilateral transvesical ureteral reimplantation was performed. An IVP 7 days postoperatively revealed a prolonged nephrogram on the right side through 2 hours and moderate left hydroureteronephrosis. The left side was considered compatible with the degree of postoperative changes usually seen. An early followup IVP obtained 3 weeks later (1 month postoperatively) revealed poor visualization on the right side with slight resolution of the hydronephrotic changes on the left side. A second followup film 1 month later again failed to show any resolution of the high grade obstruction on the right side and persistent left hydroureteronephrosis (fig. 6, C). Cystoscopy was performed. A ureteral catheter could not be passed through the right ureterovesical junction but one was passed up the left side with some difficulty encountered just outside the bladder. Exploration revealed the extravesical course of the right ureter through both walls of the distal ileum. The involved segment of ileum was excised with a wedge resection and an ileoileostomy was performed. The portion of ureter traversing the ilea! wall was excised. The remaining ureter was tailored and reimplanted into the bladder. Exploration of the left ureter revealed it to be angulated acutely by an adhesive band just outside the bladder. This band was lysed. An IVP 1 year later revealed prompt visualization bilaterally with satisfactory resolution of the previously noted obstructive changes (fig. 6, D). Case 4. E. N., a 4-year-old girl, had recurrent urinary tract infections since she was 18 months old. An IVP appeared normal (fig. 7, A) and a cystogram showed moderate bilateral vesicoureteral reflux (fig. 7, B). The blood urea nitrogen (BUN) was 12 mg. per cent, serum creatinine 0.5 mg. per cent and the
733
hemogram was normal. Urine culture yielded enterococcus. Initial cystoscopy revealed laterally placed, gapping orifices bilaterally. At this time, the urethra was dilated to 26F and the patient was placed on antibiotics. She continued to have recurrent infections while taking antibiotics and was shown radiographically to have persistent reflux. The patient underwent a bilateral transvesical ureteral reimplantation 10 months after the initiation of conservative therapy. An IVP 6 days postoperatively revealed dilatation of both collecting systems consistent with the postoperative status (fig. 7, C). The patient was asymptomatic while on antibiotics and 2 months later a repeat cystogram showed no reflux. However, an IVP revealed no improvement in the bilateral ureterocaliectasis (fig. 7, D). An acute urinary tract infection developed 3 months later and the patient was rehospitalized. Laboratory studies revealed a hemoglobin of 8.6 gm. per cent, hematocrit 25.3, BUN 64 mg. per cent and serum creatinine 3.7 mg. per cent. Electrolytes were normal. Cystoscopy revealed both ureteral orifices normal in position with adequate submucosal tunnels. Bilateral ureteral catheters were easily passed and left in place for several days, which resulted in improvement of the BUN and serum creatinine to 18 and 1.3 mg. per cent, respectively. Pull-out ureterograms showed both ureters dilated down to a point 1 to 2 cm. from the bladder. Exploration revealed both ureters coursing through the broad ligaments. They were dissected free and the ureters were reimplanted. The patient has done well postoperatively with only short-term followup.
FIG. 6. Case 3. A, IVP shows bilateral calicectasis and dilated ureters. B, cystogram reveals bilateral grade III to IV vesicoureteral reflux. C, IVP 2 months after bilateral transvesical ureteral reimplantation shows poor visualization on right side with left hydroureteronephrosis. D, IVP 1 year after second exploration reveals prompt visualization bilaterally with great improvement of previously noted obstructive changes.
734
TOCCI AND ASSOCIATES
the ureteral adventitia causing devascularization of the distal ureteral segment. If there is difficulty mo.bilizing the ureter one should not hesitate to go extravesically to make sure that the mobilization is complete. The submucosal tunnel is then formed. Next, a right angle clamp is passed through the bladder hiatus, behind the bladder with the point advancing gently and slowly against the base of the bladder, thus gradually dissecting away the peritoneal reflection. We stress that this should be done under direct vision with the use of a vein retractor or narrow Deaver retractor (fig. 8). Failure to do this properly may lead to perforation of peritoneum, ileum, broad ligament or sigmoid colon (fig. 9). At this point, a right angle clamp is passed through the full thickness of the bladder from outside in at the proximal end of the tunnel. The bladder wall is thin and if unusual resistance or thickness is
URETER
FIG. 7. Case 4. A, IVP appears normal. B, cystogram shows moderate bilateral vesicoureteral reflux. C, 10-minute postoperative IVP shows bilateral pyelocaliectasis consistent with operation. D, IVP 2 months after bilateral transvesical ureteral reimplantation reveals persistent bilateral ureterocaliectasis.
DISCUSSION
FIG. 8. Under direct vision, peritoneal reflection is dissected away from base of bladder.
The 8 cases encountered demonstrate that the PolitanoLeadbetter ureteral reimplantation technique is not a completely innocuous procedure, especially in more inexperienced hands. Although the complication rate is low and the success rate high, unusual and infrequent complications can occur and result in significant morbidity for the patient. Of the 8 patients in whom complications developed 7 did well after a corrective operation was performed, while 1 required a nephrectomy because of a technical error at the time of re-exploration. This technique of ureteral reimplantation was initially described as a transvesical procedure.• With time and experience, it became apparent that combining it with an extravesical approach of the ureter when indicated would serve to correct any conceivable congenital, acquired or iatrogenic lesion of the lower ureteral segment. Approximately 90 per cent of ureteral reimplantations for reflux may be done satisfactorily as a transvesical procedure. We believe that this is more advantageous because: 1) it decreases operative time, which is especially important when dealing with infants, 2) there is minimal bladder mobilization and dissection and 3) there is less dissection of the lower ureters minimizing the chance of devascularization with subsequent fibrosis and sloughing. These unusual complications are preventable if one adheres to the technique involved in performing the Politano-Leadbetter procedure. Once the ureter has been detached from the bladder it should be gently mobilized for a distance of at least 6 FIG. 9. A, course of ureter before and after ureteral reimplantation. to 8 cm. or more with gentle traction and blunt spreading of the B, ureter is passing through ileum. C, ureter is traversing broad ligatissues parallel to the ureter. Care must be taken not to injure ment. D, ureter is passing through sigmoid colon.
Trf.J,j_,,JSVESICAL UP,,ETERAL RE11Vi?LAt-rrA1'XON
encountered while the it is most likely that some other structure is between the ureter and bladder. Once the ureter has been reimplanted, a ureteral catheter should pass easily to the kidney without meeting any obstruction. If there is difficulty, the reimplant should be performed again or the ureter explored ext:ravesically. The case of postoperative bleeding after ureteral reimplantation is quite unusual. This child required several units of blood and did not respond to conventional means. Bleeding from a distal ureteral artery may occur more commonly than recognized and can be prevented by more careful hemostasis and meticulous suturing at the time of operation. If excessive bleeding persists postoperatively cystoscopy is indicated with fulguration of the bleeding point. Re-epithelialization of the ureteral orifice as seen in 1 case may have been owing to poor fixation of the bladder mucosa to the ureteral epithelium, thereby allowing regrowth of the bladder mucosa across the orifice. Careful approximation of the edge of the bladder mucosa to the distal ureter when suturing it in place may prevent this complication. Followup of these patients is perhaps as important as the actual operation. Minor degrees of ureteral obstruction can be recognized early, many of which can be resolved simply. A single 10-minute IVP is obtained 6 or 7 days postoperatively to rule out complete obstruction of the newly reimplanted ureter and to serve as a control for postoperative resolution. Usually, a moderate amount of ureterectasis is present. If the degree of reflux has been severe and there is considerable morphologic deformity, such as loss of renal parenchyma and hydronephrosis, these structural changes may persist indefinitely. At approximately 8 weeks postoperatively a cystogram and an IVP are obtained. By this time the urine is usually uninfected, reflux should be absent and there should be considerable improvement in the ureterocaliectasis. If the urine remains infected the patient is continued on a urinary antiseptic. If the ureterocaliectasis has not improved as expected or has become more severe cystoscopy is performed with ureteral catheterization to dilate the intramural ureter and rule out mechanical obstruction. Frequently, minor degrees of ureteral obstruction can be resolved by this method, much as one would leave a catheter indwelling to soften a urethral stricture. The catheters are left in place for a few days and then pull-out ureterograms are performed. If the obstruction persists, particularly above the level of the ureterovesical junction, exploration of the ureter should be seriously considered. If the ureter is found to traverse the intestine the intestine is opened, the ureter is removed and the bowel is closed in several layers or
a segment of bowel is resected and an end-to-end anastomosis is performed. It is interesting that the symptoms in our patients primarily referred to the genitourinary tract rather than gynecologic or gastrointestinal. Only 1 patient (case 1) had gastrointestinal symptoms but this was in the immediate postoperative period and quickly resolved with antibiotics. It is of further interest to note that the child who had 1 ureter reimplanted through the broad ligament was completely asymptomatic for 6 years and did not have problems until after menarche, while the other patient who had both ureters reimplanted through the broad ligaments had problems early. This may be explained either on the basis of a hormonal or physiological response that occurred during puberty or that the ureter became obstructed by the broad ligament with normal growth and development. This case illustrates another important point, that of late ureteral obstruction after ureteral reimplantation. This has been reported previously"· 10 and emphasizes the importance of close followup in these patients. Repeat cystograms and IVPs should be performed at 6-month intervals for the first year postoperatively. If the cystogram remains normal IVPs should still be performed at yearly intervals for the next several years, even in asymptomatic patients who have had previously normal radiographic findings. REFERENCES
1. Politano, V. A.: Review of 500 cases of ureteral reimplantations.
2. 3.
4. 5. 6. 7.
8. 9. 10.
Read at annual meeting of American Urological Association, Chicago, Illinois, May 16-20, 1971. Hendren, W. H.: Reoperation for the failed ureteral reimplantation. J. Urol., Hl: 403, 1974. Brannan, W., Ochsner, M. G., Rosencrantz, D.R., Whitehead, C. M., Jr. and Goodier, E. H.: Experiences with vesicoureteral reflux. J. Urol., 109: 46, 1973. Williams, D. I. and Eckstein, H.B.: Surgical treatment of reflux in children. Brit. J. Urol., 37: 13, 1965. Politano, V. A.: Ureterovesical junction. J. Urol., 107: 239, 1972. Martin, D. C. and Kaufman, J. J.: Pitfalls in ureterovesicoplasty for the prevention of reflux. J. Urol., 97: 846, 1967. Kaufman, J. M., McGuire, E. J. and Baskin, A. M.: Viscus perforation: unusual complication of ureteroneocystostomy. Urology, 4: 728, 1974. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. Weiss, R. M., Schiff, M., Jr. and Lytton, B.: Late obstruction after ureteroneocystostomy. J. Urol., 106: 144, 1971. Filly, R. A., Friedland, G. W., Fair, W.R. and Goven, D. E.: Late ureteric obstruction following ureteral reimplantation for reflux: a warning. Urology, 4: 540, 1974.
