Background: There are different surgical strategies for the initial management of primary obstructive megaureter (POM), including cutaneous ureterostomy, tapered ureteral reimplantation, endoscopic balloon dilatation, and refluxing internal diversion. Here, we aim to describe longer-term outcomes, including urinary tract infections (UTIs) and need for reimplantation after a refluxing internal diversion (ureterovesicostomy [UV]) for children with POM.
Methods: Children referred to our institution between 2016 and 2023 who underwent refluxing UV were analyzed. POM was defined as hydroureteronephrosis with distal ureteral dilatation ≥ 7 mm and a negative workup for other aetiologies of hydronephrosis. We assessed for surgical outcomes, complications, rate of UTIs, and improvement in dilatation. Statistical analyses included multivariate regression and Kaplan-Meier survival curves for development of UTIs or need for secondary surgeries.
Results: Among 183 patients diagnosed with POM, 47 (24%) underwent UV. Median age of presentation, surgery, and follow-up was 2, 8, and 43 months, respectively. A total of 7 patients developed 30-day complications: Clavien-Dindo grade 1: 2 (urinary retention), and grade 2: 5 (UTIs). During monitoring 14 (30%) developed UTIs and 6 (15%) required ureteral reimplant or UV takedown. After surgery there was a significant decrease in the proportion of patients with high-grade hydronephrosis (96 vs. 49%, p<0.001) and proportion with ureteral dilatation ≥ 7 mm (100% vs. 66%, p<0.001).
Conclusion: Refluxing UV is a safe alternative to cutaneous diversion in POM. Most patients had improvement in upper tract dilatation with an acceptable complication rate and need for re-operation (versus routine later reimplantation). Our experience suggests that monitoring alone after UV is feasible, and that selective subsequent reconstruction is a reasonable strategy.
Figure: (a) Ultrasound metrics (max. ureteral dilation; APD = anteroposterior diameter) over study period with median +/- IQR. (b) Proportion of patients with hydroureter with at least grade 2 (≥ 7 mm) and grade 3 (>10 mm) over study period. (c) Proportion of patients with high-grade hydronephrosis (HN) over study period. In all panels, solid line at 8 months correspond to median age at surgery, and parentheses in x-axis correspond to median age at follow-up visit.
