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|
|Female||9 (33.3%)||18 (66.7%)|
|UTI||5 (26.3%)||14 (73.7%)|
|Antenatal hydronephrosis||4 (33.3%)||8 (66.7%)|
|Incidental finding||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%)|
|Yes||5 (27.8%)||13 (72.2%)|
|No||4 (23.5%)||13 (76.5%)|
|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%)|
Back to 2018 Program