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Fate of poorly functioning renal units managed by ureteral ligation: Longer follow up with reassuring clinical and sonographic assessment
Paul Bowlin, MD1, Fahad Alyami, MD1, Rodrigo Romao, MD2, Joseph Gleason, MD1, Armando Lorenzo, MD1.
1The Hospital for Sick Children, Toronto, ON, Canada, 2Dalhousie University, Halifax, NS, Canada.

BACKGROUND
In kidneys with impaired function and/or ectopic drainage, traditional management has involved reconstructive or extirpative surgery. These management options are guided by relevant anatomy (single vs. duplex system, ectopic drainage) and underlying indication for surgical intervention (such as infection or urinary incontinence). We recently described ureteral ligation as an alternative in selected cases with poorly functioning associated parenchyma, which has raised concerns regarding the fate of the obstructed system. Herein we present follow-up data on an updated prospective series of 17 patients managed with simple ligation of the ureter, focusing on clinical and sonographic outcomes.
METHODS
We conducted a review of 17 prospectively monitored patients who had undergone ureteral ligation at a single, tertiary care pediatric center. These patients have been monitored with serial clinical visits and ultrasound assessment since the procedure, focusing on complications, symptomatic worsening hydronephrosis, nephrolithiasis, or infection.
RESULTS
The indications for the procedure was an ectopic ureter or ureterocele associated with the upper pole of a duplex kidney in 11 patients and a poorly or nonfunctioning non-duplex kidney in 6 patients. Cases were performed via combination of pure laparoscopy, laparoscopic mobilization with open ligation, or open ligation via a small (<2cm) inguinal incision. Average length of follow up is 15 months (range 1-40 months). 11 of the cases were done purely laparoscopic, 4 lap/open, and 2 open. In 4 cases the degree of post-operative hydronephrosis/hydroureteronephrosis increased, it decreased in 2 cases, and remained unchanged in 7 cases. In 4 of the cases we do not have post-operative imaging due to a lack of follow up. 12 patients are completely asymptomatic, 2 have reports of dysuria without evidence of urinary tract infection, and 3 have no follow up to date. 1 patient required admission post-operatively for pain control, which resolved within 24 hours. There were no intra-operative or post-operative complications. There has not been any documented nephrolithiasis. No patients have had to undergo a secondary procedure to date.
CONCLUSIONS
Ureteral ligation appears to be a safe and effective strategy for the management of the poor/non-functioning kidney or renal moiety. It has the advantage of being minimally invasive, even when done via an open approach (<2cm inguinal incision). There is a very low theoretical risk of bleeding given that there isn’t any significant dissection or vascular ligation required. While there is always a risk to the functional moiety in a duplex system, in this approach the risk is minimized given that the lower pole isn’t involved in the procedure beyond mobilization to free it from the ureter being ligated. Concerns regarding leaving an obstructed system in place are thus far unfounded.


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