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Journal of Indian Association of Pediatric Surgeons
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LETTER TO THE EDITOR
Year : 2016  |  Volume : 21  |  Issue : 2  |  Page : 92-93
 

Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies


Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospital, New Delhi, India

Date of Web Publication18-Feb-2016

Correspondence Address:
Sujit Kumar Chowdhary
Department of Pediatric Urology and Pediatric Surgery, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi - 110 044
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.158094

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How to cite this article:
Agarwal D, Kandpal DK, Chowdhary SK. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies. J Indian Assoc Pediatr Surg 2016;21:92-3

How to cite this URL:
Agarwal D, Kandpal DK, Chowdhary SK. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2019 Dec 8];21:92-3. Available from: http://www.jiaps.com/text.asp?2016/21/2/92/158094


Sir,

read with interest the article on "laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies." Chandrasekharam and Jayaram have reported excellent outcome for complex urological anomaly by minimally invasive approach, and we congratulate them for their meticulous technique. [1] However, we would like to make a few observations on the comment by the authors that, the distal ureter does not need to be removed since the overall complication rate with these retained stumps appears to be low.

There is a debate over complete resection of the distal ureteric stump with most studies favoring leaving behind the ureteric stump. The reluctance to completely resect the ureteric stump arises from the concerns regarding injury to the ipsilateral normal ureter and bladder neck resulting in incontinence, secondary neuropathic bladder, etc. Further, in days of open surgery it required two separate incisions. Most of the studies are retrospective with limited follow-up studies of uncontrolled patients.

De Caluwe et al. have reported a 10% residual stump excision rate after low excision of the ureter at a median follow-up of 6 years in a cohort of 50 patients. [2] Ade-Ajayi et al. also reported a reoperation rate of 8% for a redundant ureteric stump after upper pole heminephrectomy. [3] We report three cases in the last 5 years, two of our own follow-up, and one referred for symptoms secondary to retained distal stump. All three had serious complications, one presenting with pyuria from refluxing stump, another with palpable lump secondary to obstructed refluxing stump left behind after laparoscopic nephroureterectomy, and last one, with progressive inability to void and pyuria. The first two presented within 24 months after excision of nonfunctioning upper pole in one and nonfunctioning kidney with vesicoureteric junction obstruction in another child. The third was a 7-year-old child operated for bilateral duplex systems, both the ectopic ureter opening into the posterior urethra and bladder neck were re-implanted into the bladder leaving behind a long distal ureteric stump on one side. He remained asymptomatic for 3 years and developed progressive inability to void, dribbling incontinence and pyuria. After extensive investigation, it became obvious he had developed almost a pseudo bladder behind bladder obstructing the bladder from emptying. The prostatic ureteric opening was large enough to allow retrograde filling of the distal ureteric remnant [Figure 1]. The child has done well after excision of the ureteric stump down to posterior urethra and repair of the posterior urethra. He is voiding well but not to completion as he has an element of the secondary neuropathic bladder following extensive pelvic surgery.
Figure 1: Retrograde contrast study showing the dilated ureteric remnant opening in posterior urethra

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We believe that leaving behind the residual ureteric stump in these children keeps the door open for development of complications in the long-term follow-up. Parents must be aware that children who have surgery for duplex systems are candidates for lifelong follow-up. We cannot make conclusions about the incidence of complications in these surgical reconstructions with limited period follow-up.

 
   References Top

1.
Chandrasekharam V, Jayaram H. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies. J Indian Assoc Pediatr Surg 2015;20:27-31.  Back to cited text no. 1
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2.
De Caluwe D, Chertin B, Puri P. Fate of the retained ureteral stump after upper pole heminephrectomy in duplex kidneys. J Urol 2002;168:679-80.  Back to cited text no. 2
    
3.
Ade-Ajayi N, Wilcox DT, Duffy PG, Ransley PG. Upper pole heminephrectomy: Is complete ureterectomy necessary? BJU Int 2001;88:77-9.  Back to cited text no. 3
    


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