The wide ureter and the small bladder. The cuff-nipple reimplantation rather than urinary diversion
Moneer K. Hanna, MD, FRCS1, Wael Abosena, MBBCh2.
1New York Presbyterian-Cornell, New York, NY, USA, 2Tanta university medical school, Tanta, Egypt.
BACKGROUND: Re-implantation of a dilated ureter into the infantile small capacity, represent a surgical challenge. The surgical options for reflux megaureters who develop break through urinary infections (UTI) while on prophylaxis are temporary diversion (vesicostomy for bilateral and ureterostomy for unilateral megaureters). In cases of obstructed megaureter the options are, ureterostomy and refluxing reimplantation. Our experience with the cuff-nipple ureteral reimplantation in the hostile thick bladder secondary to posterior urethral valves proved to be promising and successful in the majority of cases.
METHODS: Between 1995 and 2021, 46 infants (aged 3 and 12 months) were referred for surgical management following recurrent pyelonephritis while on prophylaxis (30 infants) and for worsening hydronephrosis (16 infants). There were 22 boys and 14 girls. The diagnosis was bilateral reflux megaureters in 18 and unilateral in 8 children. The other 20 children had bilateral obstructed megaureters in 9 and unilateral in 11 children. The radionuclide renal scan was performed in 43 children, and it showed reflux nephropathy in 35/ 44 renal units with VUR and reduced function of more than 20% in 9/11 obstructed kidneys. A total of 73 megaureters were operated on. The ureteral tortuosity was straightened, the caliber was reduced when indicated. Each ureter was reimplanted in a short (1cm) submucosal tunnel and cuff-nipple ureteral orifice was created in 62/73 ureters and simple cuff-nipple without tunneling in 11 ureters. Postoperatively, ultrasonography (US) and voiding cystourethrography (VCUG) in the 46 pts. were reviewed.
RESULTS: The postoperative course was uneventful in all children and the follow up was at 4 months when an US & VCUG were done and continued every 4 months for one year when the follow up continued by pediatric nephrology service. The postoperative US showed improved hydronephrosis in 59/73 kidneys and stable or unchanged in 14 units. The VCUG showed no evidence of VUR in 58/62 (93%) of the short tunnel and cuff-nipple reimplanted ureters and in 4 ureters the VUR was downgraded to grade II. 10/11 (91%) of the ureters with the cuff-nipple reimplantation showed no evidence of VUR and one ureter the VUR was downgraded to grade II. None of the reimplanted were obstructed postoperatively.4 children continued to develop UTI and were placed on prophylaxis and 7/46 eventually underwent renal transplantation as they outgrew their renal reserve.
CONCLUSIONS: The time-tested Paquin (1959) dogma of the tunnel length/width ratio of 5/1 was challenged by Lyons et. al. (1969), the latter contention was that the shape of the ureteral orifice (UO) is more important than the length of the tunnel, for correction of VUR, (the cuff-nipple create a volcano like UO.). Recently, Villanueva et al. performed a parametric simulation study of ureteral collapse (LS-DYNA finite-element software). They confirmed Lyons et. al observation and proposed that creation of a better UO, which the cuff-nipple does, would contribute to an efficient ureteral collapse i.e. reflux prevention. These observations would explain the high success rate which was achieved by the reported cuff-nipple technique
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