|Year : 2015 | Volume
| Issue : 1 | Page : 27-31
Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies
VVS Chandrasekharam, Harish Jayaram
Department of Pediatric Surgery, Pediatric Urology and MAS, Rainbow Children's Hospitals, Hyderabad, Telangana, India
|Date of Web Publication||27-Nov-2014|
Department of Pediatric Surgery, Pediatric Urology and MAS, Rainbow Children's Hospitals, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: Ipsilateral ureteroureterostomy is an established method for the treatment of duplication anomalies in children. With the advent of pediatric laparoscopy, many urologic procedures in children are being performed using minimal access techniques. We present our experience with laparoscopic ipsilateral ureteroureterostomy (LIUU) for duplex anomalies. Patients and Methods: The data of children who underwent LIUU was reviewed for demographic parameters, clinical and operative details, follow-up and results. Results: Over 3 years period, LIUU was performed in eight children (age 6-60 months). Five children had complete ipsilateral duplication with ectopic upper moiety ureter, one child each had ipsilateral incomplete duplication and bilateral duplex systems (with ipsilateral ectopic upper moiety ureter). One child had ipsilateral complete duplex with Grade V vesicoureteric reflux into the lower moiety ureter. Four children had antenatal diagnosis of hydronephrosis; three children had a urinary infection and two children presented with urinary incontinence. The surgical procedure consisted of cystoscopy, retrograde studies and cannulation of the recipient ureter. Then, LIUU was performed using three ports. The ectopic (donor) ureter was divided at the pelvic brim; the recipient ureter was opened and end-to-side LIUU was performed with 5/0 vicryl stitches over a double J (DJ) stent placed in the recipient ureter. Bladder catheter was removed after 2 days, and DJ stent was removed after 4 weeks. At a mean follow-up of 19 months (3-36), all children are asymptomatic and continent, with a significant reduction in hydroureteronephrosis on ultrasound. The cosmetic results were excellent. Conclusion: LIUU is a safe and effective technique in the management of duplication anomalies in children. It could be performed with minimal blood loss, minimal postoperative pain, excellent cosmesis and good success.
Keywords: Child, duplex, laparoscopy, ureteroureterostomy
|How to cite this article:|
Chandrasekharam V, Jayaram H. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies
. J Indian Assoc Pediatr Surg 2015;20:27-31
|How to cite this URL:|
Chandrasekharam V, Jayaram H. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies
. J Indian Assoc Pediatr Surg [serial online] 2015 [cited 2019 Dec 15];20:27-31. Available from: http://www.jiaps.com/text.asp?2015/20/1/27/145442
| Introduction|| |
Ipsilateral ureteroureterostomy (IUU) is an established method for the treatment of duplication anomalies in children. , Recent reports show that laparoscopic techniques are being increasingly utilized in pediatric reconstructive urologic surgery;  in particular, laparoscopic pyeloplasty has been demonstrated to be safe and effective in children across all age groups.  With increasing experience, there have been some reports of utilization of the laparoscopic reconstruction in children with duplication anomalies. , We present our experience and describe our technique with eight cases of laparoscopic IUU (LIUU) in children.
| Patients and methods|| |
Over a 3 years period, LIUU was performed in 8 children [Table 1]. Four children had antenatal diagnosis of right hydronephrosis. After birth, three children became symptomatic in infancy with urinary tract infection (UTI), while one child who was lost to follow-up after birth presented with abdominal pain at 3 years of age. Two children presented with urinary incontinence (with normal voiding also), while two children presented with febrile UTI. Ultrasound (USG) and micturating cystourethrography (MCUG) were performed in all cases. Intravenous pyelogram, computerized tomography or magnetic resonance urography confirmed the diagnosis. Six children had complete duplication of the right kidney; five of these had ectopic upper moiety ureter [Figure 1], one had Grade V vesicoureteric reflux (VUR) into the lower pole. One child (patient 7) had bilateral complete duplications with ectopic insertion of the right upper moiety ureter below the bladder neck, one child (patient 6) had incomplete duplication of the right kidney with midureteric obstruction of the lower moiety. The right lower moiety (upper moiety in patient 5 and 8) and left kidney were normal in all children; MCUG showed a normal bladder and urethra with no VUR in patients 1-7. The surgical procedure started with cystoscopy. In the seven children with complete duplication, the ipsilateral normal ureter was cannulated with 3F ureteric catheter. The ectopic upper moiety ureteric orifice was identified as a stenotic opening in the posterior urethra in the baby boy, below the bladder neck in one baby girl, in the vagina in two girls while it could not be identified in two girls. In patient 5, retrograde pyelography via the single right ureteric orifice revealed that it was an incomplete duplication with common lower ureter. In all children, LIUU was carried out in semi-lateral position with the right side elevated by 60°; three ports were used (5 mm umbilical telescope port and 2 × 3 mm working ports in right upper quadrant and hypogastrium). After confirming the anatomy, both the ipsilateral ureters were exposed at the pelvic brim (in seven children) and in the flank (in patient 5) by incising the peritoneum. It became evident at this point that patient 5 had a stenosis of the lower moiety ureter proximal to its junction with the upper moiety ureter. In the seven children with complete duplication, the dilated, abnormal (donor) ureter was transected at the pelvic brim after stabilizing it with a proximal stay (hitch) stitch. The distal ureteral stump was excised as low as possible and was left open, except in patient 8 where the refluxing stump was ligated. In patient 5, the dilated lower pole ureter was stabilized with a hitch stitch and transected proximal to the midureteric obstruction. In all children, a longitudinal ureterotomy was performed in the ipsilateral nondilated (recipient) ureter, with the length of the ureterotomy matching the diameter of the transected dilated ureter. End-to-side ureteroureterostomy was performed with two running 5/0 vicryl stitches. After the posterior wall suturing was completed, a DJ, (3/4 F) stent was placed in the nondilated (recipient) ureter before completing the anterior wall suturing. After completing the anastomosis, the hitch stitch was removed, and the anastomosis was retroperitonealized. Bladder was drained with a Foley catheter for 48 h. No intraperitoneal drainage was used. Intravenous antibiotics were continued for 2 days after which the bladder catheter was removed, and the children were discharged on prophylactic antibiotics. In seven children, the DJ stent was removed 4 weeks later, while in one child (patient 4), the DJ stent spontaneously extruded from the urethra 3 days after the surgery, with no adverse consequences. USG was done after 3 months and 1 year to assess the degree of hydronephrosis in the obstructed moiety.
|Figure 1: Magnetic resonance urography in patient 1 showing right duplex with hydroureteronephrosis of upper moiety|
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| Results|| |
The operative time was about 120 min (including cystoscopy). In two children, retrograde studies done at the time of DJ stent removal [Figure 2] demonstrated free flow into both the ureters with a reduced dilation of upper moiety ureter. At a mean follow-up of 19 months, all children are asymptomatic, and postoperative USG demonstrated significantly reduced hydroureteronephrosis in all children.
|Figure 2: Retrograde study at the time of double J stent removal showing both the ureters draining into a common lower ureter with a patent wide anastomosis and reduced HUN of previously dilated ureter|
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| Discussion|| |
Ipsilateral ureteroureterostomy has been shown to be a safe and effective approach to the treatment of duplication anomalies of the urinary tract, , both for managing obstructed and refluxing ureters. As laparoscopic procedures have become more popular in pediatric urology and were being increasingly utilized in different aspects of reconstructive surgery, it is possible to apply these techniques in the management of pediatric duplication anomalies. The basic principle of the surgery is to drain the abnormal ureter into the normal ipsilateral ureter.
Laparoscopic ipsilateral ureteroureterostomy for duplication anomalies in children was previously reported by a few surgeons. , Controversy exists in the case of complete duplication whether the ureteral anastomosis should be performed along the lower ureter at the level of iliac vessels  or in the proximal ureter.  Both techniques have been described with good results. We prefer the lower anastomosis because it may be technically easier. Moreover, transecting the dilated ureter at such a low level would leave only a short segment of defunctionalized distal ureter. Further, the "lower" anastamosis allowed us to accomplish the procedure with minimal mobilization of the colon without interfering with the gonadal vessels. On the other hand, Storm et al.  reported success in 7 patients with a proximal anastomosis, which they described was similar to performing a laparoscopic pyeloplasty. They concluded that the choice of proximal or distal anastomosis must be based on surgeon preference and experience.
Whether a proximal or distal approach, it is important to follow certain principles to achieve successful drainage through an LIUU. These include minimal dissection and handling of the nondilated recipient ureter, careful tissue handling, and an adequate-sized ureterotomy of the recipient ureter. It is important to perform initial cystoscopy and retrograde studies to ascertain the exact anatomy.  Cystoscopy also helps to place a ureteric catheter into the recipient ureter prior to laparoscopy. This help in two ways; first, it enables easy and quick identification of the nondilated recipient ureter with only minimal tissue handling. More importantly, it makes the longitudinal incision of the recipient ureter easy and safe by supporting the wall from inside and preventing injury to the back wall of the ureter.
Our technique differs from the technique used by Steyaert et al.  and Storm et al.  in some aspects. The former described fixing the recipient ureter to the abdominal wall while the latter described taking a "hitch stitch" on the recipient ureter to lift it up. This in our view poses a risk of injury to the nondilated normal recipient ureter. Hence, we prefer to place the hitch stitch on the donor ureter (which is usually dilated). The recipient ureter is left in situ so its handling is minimized, and the orientation is not altered. As Storm et al.  observed, the most difficult part of this operation is performing the ureterotomy in the recipient ureter. To achieve this, we first use a fine curved 3 mm laparoscopic scissors to make a small transverse cut on the recipient ureter involving only part of the wall. We then use a straight, single action 3 mm scissors (with one fixed and one mobile jaw) to perform the longitudinal ureterotomy. The fixed jaw is introduced into the ureter thru the transverse cut and then ureterotomy is carried out. This technique ensures a clean longitudinal ureterotomy and avoids a spiralling cut, similar to the technique of ureteric spatulation that we described for laparoscopic pyeloplasty.  The ability to perform intracorporeal suturing in the small abdomen of infants and children using fine sutures is essential to perform LIUU. The same ability is required for pediatric laparoscopic pyeloplasty; if one can complete the intracorporeal anastomosis required in a laparoscopic pyeloplasty, then using the principles we have described one may do the same with an LIUU.
We do not perform an IUU in children with reflux into the recipient ureter. Although other authors have reported the IUU was safe even in cases with low-grade reflux into the recipient ureter,  we have not considered IUU in this setting.
We chose to leave a double J stent in the recipient ureter for 4 weeks to support the anastomosis. Leaving stent serves multiple purposes. Firstly, it prevents obstruction of the recipient ureter due to edema in the immediate postoperative period. A nondilated ureter in small children may be prone to such obstruction. The stent also prevents urinary leakage from the suture line; we did not use a peritoneal drain in any of our cases, as we do not use it in our laparoscopic pyeloplasties. Lastly, the stent helps to fix the orientation of the anastomosis in the healing stage; otherwise there is a possibility (at least theoretical) that the dilated donor ureter may twist the suture line and the recipient ureter. However, in one of our patients, there was spontaneous stent expulsion only 3 days after the surgery with no adverse consequences.
The one theoretical concern over a low IUU has been the development of "yo-yo" reflux. However, this concern has not been substantiated in the literature.  Another concern is regarding removal of the entire distal donor ureter. We do not think this is necessary and previous studies have demonstrated that the distal ureter does not need to be removed since the overall complication rate with these retained stumps appears to be low. , Moreover, by performing a low IUU, we are minimizing the length of the defunctionalized distal donor ureter left in situ.
Some have advocated that hemi-nephrectomy, either via an open or laparoscopic approach, to remove the upper pole renal moiety in children with ectopic ureters and ureteroceles is preferred. , Previously, it was felt that the upper pole moiety should be removed secondary to a high degree of dysplasia and hypoplasia found upon pathologic analysis of these specimens. ,, However, further studies have demonstrated a decreased incidence of these histologic findings. , In addition, concern regarding the increased incidence of UTI, hypertension and malignant degeneration by leaving these renal moieties in place appears to be unfounded.  Furthermore, upper pole hemi-nephrectomy may be associated with a higher complication rate as compared to IUU and may also result in a loss of renal function. ,, Given these findings, it has been our approach to perform IUU when possible in these patients. In a recent article, Mcleod et al.  reviewed their experience with 43 ureteroureterostomies of which 12 were done by laparoscopy. They concluded that the ureteroureterostomy is a safe and effective technique for the reconstruction of duplex anomalies, even with a massively dilated and poorly functioning upper pole moiety, with no identifiable negative effect on the lower pole system.
| Conclusion|| |
In our experience, LIUU seems to be a good minimally invasive surgical option in infants and children with obstructed duplex ureters. It could be effectively performed with minimal blood loss, minimal postoperative pain, excellent cosmesis and good success.
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[Figure 1], [Figure 2]