Ipsilateral Ureteroureterostomy For Ureteral Duplication Anomalies: Predictors of Adverse Outcomes
Ahmed Abdelhalim, MD, Joshua D. Chamberlin, MD, Huy Truong, BS, Irene M. McAleer, MD, Kai-wen Chuang, MD, Elias Wehbi, MD, Heidi A. Stephany, MD, Antoine E. Khoury, MD.
The Department of Urology of the University of California-Irvine and the Children's Hospital of Orange County, Orange, CA, USA.
Background:
Ipsilateral ureteroureterostomy has demonstrated high success rates in patients with ureteral duplication associated with obstruction and/or vesico-ureteral reflux (VUR). Predictors of adverse outcomes are, however, not well studied. This study aims at identifying the predictors of adverse outcomes in children with ureteral duplication treated with ureteroureterostomy.
Methods:
A retrospective review of children with complete ureteral duplication treated with ureteroureterostomy at the study institution was performed. Clinical factors evaluated included presenting symptoms, imaging, surgical indications, operative technique and follow-up data. Adverse outcomes were defined as subsequent febrile urinary tract infection (fUTI), worsening hydronephrosis or the need for unplanned surgery.
Results:
Between 2009 and 2017, a total of 27 girls and 8 boys with complete ureteral duplication underwent ipsilateral ureteroureterostomy at a median age of 14.5 (1.5-134) months. UTI was the commonest presenting symptom in 54.3%. Surgical indications included: isolated upper moiety (UM) obstruction in 20 patients (14 ectopic ureters, 2 intravesical and 4 ectopic ureteroceles), lower moiety (LM) VUR in 5 and obstructed LM following Deflux® injection in one patient. Nine patients with both UM obstruction and LM reflux underwent combined ureteroureterostomy and LM ureteroneocystostomy (2 ectopic ureters, 3 intravesical and 4 ectopic ureteroceles). The median hospital stay was one day (IQR= 1-3 days).
After a median follow-up of 36.7 (6-78.1) months, 89.3% (25/28) of renal units with baseline hydronephrosis demonstrated improvement or resolution. Nine patients (25.7%) had adverse treatment outcomes: 4 required reoperation, 3 had progressive hydronephrosis and 7 suffered postoperative fUTI. None of them had anastomotic stricture or persistent/recurrent VUR. Adverse outcomes were associated with female gender (p=0.05) and preoperative hydronephrosis of both UM and LM (p=0.015). Adverse treatment outcomes were encountered in 4/8 patients with ectopic ureteroceles (p=0.074) and 4/9 who had a concomitant reimplant (p=0.19). The degree of ureteral dilation and the presence or grade of VUR were not associated with adverse treatment outcomes (table 1). No secondary surgery was required in 96.2% (25/26) when ureteroureterostomy was done in isolation and in 66.7% (6/9) when combined with ureteroneocystostomy.
Conclusions:
Ureteroureterostomy is a successful treatment option for ureteral duplication associated with ectopic ureters or intravesical ureteroceles with minimal morbidity and a short hospital stay. However, it should be cautiously considered in patients with ectopic ureteroceles, hydronephrosis of both moieties and when a concomitant LM reimplant is needed.
Table 1. Bivariable analysis for predictors of ureteroureterostomy adverse outcomes
| Adverse treatment outcomes (reoperation, worsening hydronephrosis or febrile UTI) (N=9) | Successful treatment (N=26) | p | |
| Gender (%) | 0.05 | ||
| Female | 9 (33.3%) | 18 (66.7%) | |
| Male | 0 | 8 (100%) | |
| Presentation (%) | 0.625 | ||
| UTI | 5 (26.3%) | 14 (73.7%) | |
| Antenatal hydronephrosis | 4 (33.3%) | 8 (66.7%) | |
| Incidental finding | 0 | 2 (100%) | |
| Incontinence | 0 | 2 (100%) | |
| Associated pathology (%) | 0.348 | ||
| Ectopic insertion | 4 (25%) | 12 (75%) | |
| Intravesical ureterocele | 0 | 5 (100%) | |
| Ectopic ureterocele | 4 (50%) | 4 (50%) | 0.074 |
| Isolated LM VUR | 1 (16.7%) | 5 (83.3%) | |
| Preoperative hydronephrosis (%) | 0.015 | ||
| No or one moiety | 3 (12.5%) | 21 (87.5%) | |
| Both moieties | 6 (55%) | 5 (45%) | |
| Preoperative VUR | 0.774 | ||
| Yes | 5 (27.8%) | 13 (72.2%) | |
| No | 4 (23.5%) | 13 (76.5%) | |
| Dilating VUR | 0.752 | ||
| Yes | 4 (28.6%) | 10 (71.4%) | |
| No | 5 (23.8%) | 16 (76.2%) | |
| Mean ureteral diameter, mm (+SD) | 10.7 (2.1) | 11.4 (6.9) | 0.783 |
| Concomitant reimplant (%) | |||
| Yes | 4 (44.4%) | 5 (55.6%) | 0.19 |
| No | 5 (19.2%) | 21 (80.8%) |
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