Pre-operative factors associated with the development of distal ureteral stump syndrome after upper pole heminephrectomy
Hansen Tang Lui, MD, Ifeanyi Onyeji, MD, Blythe Durbin-Johnson, PhD, Eric A. Kurzrock, MD.
University of California, Davis, Sacramento, CA, USA.
BACKGROUND: For children with duplex systems and severe hydroureteronephrosis of the upper pole, heminephrectomy is one of many suitable treatments, particularly if there is no associated lower pole reflux. Distal ureteral stump syndrome (DSS) is a very difficult complication and manifests as stump empyema, urinary tract infection and/or urethral discharge and can occur months to years later in 10 to 20 percent of patients. Secondary distal ureterectomy is an extremely difficult surgery due to the inflammation and adhesions. To avoid DSS, distal ureterectomy at the time of heminephrectomy can be performed laparoscopically but can further de-vascularize and injure the lower pole ureter. Current literature on DSS has shown possible associations with subtotal ureterectomy or long ureteral stumps. We hypothesized that there may be preoperative variables prior to heminephrectomy that are associated with the development of DSS. This can inform the selection of patients who would benefit from distal ureterectomy and conversely allow a majority of patients to avoid an unnecessary dissection.
METHODS: After IRB approval, a retrospective analysis of patients with a duplex kidney who underwent upper pole heminephrectomy at a single, academic institution was performed. Patients were sub-divided into those who did or did not develop DSS. Age was compared between groups using Wilcoxon rank sum tests and ureter debris, mucous, and the other pre-operative variables listed were compared between groups using Fischer's Exact Test.
RESULTS: No patients who had primary distal ureterectomy were found. Thirty-six patients were included in the study with a mean age of 19 months and female predominance (69%). All 5 patients (14%) who had signs or symptoms of DSS required secondary distal ureterectomy at a mean of 1.4 years after heminephrectomy. The presence of a ureterocele, ectopic ureter, preoperative UTI and/or use of prophylactic antibiotics were not associated with DSS. Preoperative variables such as reflux in the upper pole (60% vs 3.2 %, p = 0.005), sonographic ureteral debris (80% vs 0%, p = <0.001) and report of mucous discharge (100% vs 0%, p = <0.001) were significantly associated with DSS.
CONCLUSIONS: DSS is a well-known, latent complication of heminephrectomy. In this study, the presence of ureteral debris, mucous discharge and upper pole reflux prior to heminephrectomy were identified as preoperative factors that are significantly associated with DSS. The findings of this study are limited in their retrospective design but suggests a potential role for the selective use of primary distal ureterectomy in the surgical management of duplex systems.
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