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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.

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.
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.
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.
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
Female9 (33.3%)18 (66.7%)
Male08 (100%)
Presentation (%)0.625
UTI5 (26.3%)14 (73.7%)
Antenatal hydronephrosis4 (33.3%)8 (66.7%)
Incidental finding02 (100%)
Incontinence02 (100%)
Associated pathology (%)0.348
Ectopic insertion4 (25%)12 (75%)
Intravesical ureterocele05 (100%)
Ectopic ureterocele4 (50%)4 (50%)0.074
Isolated LM VUR1 (16.7%)5 (83.3%)
Preoperative hydronephrosis (%)0.015
No or one moiety3 (12.5%)21 (87.5%)
Both moieties6 (55%)5 (45%)
Preoperative VUR0.774
Yes5 (27.8%)13 (72.2%)
No4 (23.5%)13 (76.5%)
Dilating VUR0.752
Yes4 (28.6%)10 (71.4%)
No5 (23.8%)16 (76.2%)
Mean ureteral diameter, mm (+SD)10.7 (2.1)11.4 (6.9)0.783
Concomitant reimplant (%)
Yes4 (44.4%)5 (55.6%)0.19
No5 (19.2%)21 (80.8%)

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