Ureterocystoplasty: An alternative reconstructive procedure to enterocystoplasty in suitable cases

Ureterocystoplasty: An Alternative Reconstructive Procedure to Enterocystoplasty in Suitable Cases ¨ mer O ¨ ge, Kaan Bal, I˙lhan Erkan, and Mehmet Bakkalog˘lu By Serdar Tekgu¨l, O Ankara, Turkey

Purpose: The objective of the report is to present the results of ureterocystoplasty in 6 children with megaureters and low-capacity, high-pressure bladders. Methods: Of the 6 patients, 2 had valve bladders, 1 had Hinmann’s syndrome, 1 had neuropathic bladder, and the remaining 2 with ureterocutaneostomy were mainly diverted because of refluxing megaureters. Nephrectomy was performed in both of the boys with posterior urethral valve because of vesicoureteral reflux dysplasia (VURD) syndrome, and the ipsilateral ureter was used for the augmentation. In 2 patients with ureterocutaneostomy and in 1 with Hinmann’s syndrome, a transureteroureterostomy was carried out, and the distal part of the ureter was used to perform augmentation. The patient with neuropathic bladder had a nonfunctioning crossed ectopic left kidney with an associated ipsilateral,

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HEN NONOPERATIVE MANAGEMENT with anticholinergic agents and intermittent catheterization fail in the treatment of high-pressure, smallcapacity bladders, surgical bladder augmentation usually is required to achieve an adequate capacity and a safe pressure. Enterocystoplasty is the most preferred operation to treat the noncompliant bladders. Nearly every segment of gastrointestinal tract has been used successfully.1 However, serious complications have been reported in patients with gastrocystoplasty and enterocystoplasty, including metabolic disturbance,2 mucus production,3 stone formation,4 peptic ulceration,5 intractable diarrhea,5 and development of malignancy.6 Various nonintestinal materials have been used in bladder augmentation. Human tissue including free fascial grafts, lyophilized dura, pericardium and placental membranes, and synthetic materials such as polytetrafluoroethylene (Teflon) have been used.7 Nevertheless, these materials cause rejection, persistent infections, contracture, leakage, and stone formation at a high rate. Ureteral augmentation was popularized by Bellinger8 and Churchill et al9 as an ideal augmentation treating children with megaureters and small or noncompliant bladders. The goal of ureterocystoplasty is to use native nonsecreting and nonabsorbing urothelium, which eliminates metabolic disturbances, mucus production, and possible development of malignancy. Thus, it combines the benefits of enterocystoplasty without many of its drawbacks. Journal of Pediatric Surgery, Vol 35, No 4 (April), 2000: pp 577-579

refluxing megaureter, and the ureter was used for augmentation after the nephrectomy.

Results: All of the patients are continent, and 4 patients who are neurologically normal void spontaneously without requiring clean intermittent catheterization (CIC). The average increase in bladder capacity is 263% (range, 190% to 340%). Conclusions: Ureterocystoplasty is the bladder augmentation of choice for patients with a nonfunctioning kidney with an associated ipsilateral, refluxing megaureter and for patients with kidneys both in good function and megaureters suitable for a transureteroureterostomy. J Pediatr Surg 35:577-579. Copyright 娀 2000 by W.B. Saunders Company. INDEX WORDS: Bladder, ureter, cystoplasty.

MATERIALS AND METHODS Between March 1996 and January 1998, 6 children (4 boys and 2 girls) with a mean age of 7.6 years (range, 3 to 16 years) underwent ureterocystoplasty. The preoperative assessment included upper tract imaging, renal function tests, micturition cystourethrogram, and video-urodynamics. Of the 6 patients, 2 had valve bladders, 1 had Hinmann’s syndrome, 1 had neuropathic bladder, and the remaining 2 with ureterocutaneostomy were diverted mainly because of refluxing megaureters. Ureterocystoplasty was performed during the undiversion of ureterocutaneostomy in 2, and their blood creatinine levels were elevated slightly. The remaining 4 patients had normal renal function test results, and indications for reconstruction were urinary incontinence caused by low capacity and compliance and persistent urinary tract infections. All patients had bilateral vesicoureteral reflux except the 1 with neuropathic bladder. Both of the boys with posterior urethral valve had VURD syndrome on one side, and a nephrectomy was performed, and the ipsilateral ureter used for the augmentation. In 2 patients with ureterocutaneostomy and in 1 with Hinmann’s syndrome a transureteroureterostomy was carried out, and the distal part of the ureter was used to perform augmentation. The remaining patient with neuropathic bladder had a nonfunctioning crossed ectopic left kidney with an associated ipsilateral, refluxing megaureter, and the ureter was used for augmentation after the nephrectomy. After the ureter freed sufficiently, the bladder was opened and from the anterior incised obliquely over the dome down the posterior wall (Fig 1). The ureter was opened throughout its length along the

From the Department of Urology, Hacettepe University School of Medicine, Ankara, Turkey. ¨ niversitesi Address reprint requests to Serdar Tekgu¨l, MD, Hacettepe U ¨ roloji Anabilim Dalı, 06100 Sıhhiye, Ankara, Turkey. Tıp Faku¨ltesi, U Copyright 娀 2000 by W.B. Saunders Company 0022-3468/00/3504-0009$03.00/0 577

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Fig 3.

Fig 1.

Dilated ureter of the nonfunctioning kidney is mobilized.

anteromedial border, but the most distal part of the ureter and the orifice were kept intact, and any incision including the vesicoureteric junction was avoided to preserve its blood supply (Fig 2). The proximal ureteric flap was reconfigured, and the free edges of this flap were then sutured to the edges of the bivalved bladder, and a clam-type bladder augmentation was completed (Figs 3 and 4). A total of 3 simultaneous Mitrofanoff procedures were performed using the appendix in 2 and an ileum segment in 1. Reimplantation of the contralateral ureter was performed in all except the 1 with crossed ectopic kidney by the Cohen transtrigonal technique. An urethral or stoma catheter was left in situ and the abdominal wall closed.

RESULTS

There was no surgical mortality, and all patients made uneventful recoveries. Cystograms were obtained 10

Ureter is reconfigured into a U-shaped patch.

days postoperatively, and no urinary leakages were seen. Renal function remained stable in all patients. Preoperatively, 4 patients suffered from recurrent urinary infection, but all of the patients were free of infections postoperatively. All of the patients are continent, and of the 6 patients, 2 with ureterocutenostomy void to completion, 2 with posterior urethral valve void spontaneously with little residual bladder volumes but require no clean intermittent catheterization (CIC), and the remaining 2 with Hinmann’s syndrome and neuropathic bladder require CIC 2 and 4 times a day, respectively. Videourodynamic studies 6 months later showed good capacity and compliance in each case. The average increase in bladder capacity was 263% (range, 190% to 340%). All of the bladders were stable, and there was no evidence of vesicoureteral reflux in any patient. The outcomes in terms of clinical and videourodynamics are shown in Table 1. DISCUSSION

The complications with intestinal augmentation cystoplasty have initiated the search for alternative nonintestinal tissues. Of the many alternatives, ureterocystoplasty has gained much popularity in selected cases. The first report by Bellinger8 in 1993 described the technique and documented good results.

Fig 2. Ureter is detubularized, and the bladder is opened obliquely in clam shell type.

Fig 4.

Patch is anastamosed to the bladder.

URETEROCYSTOPLASTY

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Table 1. Outcomes Preoperative Patient No.

1 2 3 4 5 6

Postoperative

Age (yr)

Capacity (mL)

Compliance (mL/cm water)

Capacity (mL)

Compliance (mL/cm water)

Outcome

Medication

6 5 11 5 3 16

130 80 140 110 50 150

3 2 5 6 1 6

250 260 300 260 170 450

12 15 12 20 18 28

Dry, no need for CIC Dry, no need for CIC Dry, no need for CIC Dry, no need for CIC Dry, CIC twice a day Dry, CIC 4 times a day

Oxybutynin* No No Oxybutynin* Oxybutynin* No

*Administered only in the first postoperative 3 months.

In the largest series, Churchill et al9 reported twice as much increase in both capacity and compliance on 16 patients. They also compared their series with an age- and diagnosis-matched ileocystoplasty group and concluded that clinical and urodynamic results were identical in both groups.10 In our series we also had excellent increase both in capacity and compliance. There was no surgical complication, and all of the patients have significant clinical improvement. There is no question that ureterocystoplasty produces a reservoir with good capacity and compliance, and the results are identical with enterocystoplasty. It is technically easier to do than enterocystoplasty and avoids its metabolic complications, mucus production, and the risk for neoplastic metaplasia. The patients usually void to completion after ureterocystoplasty because many of them are neurologically normal. From the series reported previously, it seems that patients, especially with posterior urethral valves and those voiding spontaneously before the operation, void well after ureterocystoplasty.11,12 In our series all of the children with posterior urethral valves and with previously diverted bladders void to completion or with insignificant residual bladder volumes. Therefore, use of CIC is limited mainly to the ones who had neuropathic bladder originally. The avoidance of CIC is an important

benefit for patients especially in those with posterior urethral valves, in which CIC may be difficult to do. Currently, if there is no megaureter, it is not possible to perform an ureterocystoplasty, and this is the limitation of this procedure. Results of animal studies show that a normal-caliber ureter can be dilated enough for augmenting the bladder in a short period. In a rabbit model, the investigators obtained sufficient ureteral dilatation to perform a bladder augmentation within 30 days after dilatation with daily saline injections. They reported an average 260% increase in bladder capacity (190% to 380%) 3 to 6 months after the surgery.13 In an other study, it was achieved to acceptable dilatation to perform ureterocystoplasty, and the continuity of the ureter was restored by primary ureteroureterostomy.14 If animal models can be applied to clinical trials, ureterocystoplasty can replace the enterocystoplasty not only in patients with megaureters but also those with normal ureters. In our and previous experiences, ureterocystoplasty is the bladder augmentation of choice for patients with a nonfunctioning kidney with an associated ipsilateral, refluxing megaureter and for patients with kidneys both in good function and megaureters suitable for a transureteroureterostomy, which leaves the distal ureteral segment for use in augmentation of the bladder.

REFERENCES 1. Mitchell MC, Piser JA: Intestinocystoplasty and total bladder replacement in children and young adults: Follow-up in 129 cases. J Urol 138:579-583, 1987 2. McDougal WS: Metabolic complications of urinary intestinal diversion. J Urol 147:1199-1204, 1992 3. Murray K, Nurse DE, Mundy AR: Secreto-motor function of intestinal segments used in lower urinary tract reconstruction. Br J Urol 60:532-536, 1987 4. Blyth B, Ewalth DH, Duckett JW, et al: Lithogenic properties of enterocystoplasty. J Urol 148:575-577, 1992 5. Gonzales R, Cabral BPH: Rectal continence after enterocystoplasty. Dial Ped Urol 10:4, 1987 6. Filmer RB, Spencer JR: Malignancies in bladder augmentations and intestinal conduits. J Urol 143:671-678, 1990 7. Fishman IJ, Flores FN, Scott FB, et al: Use of fresh placental membranes for bladder reconstruction. J Urol 138:1291-1295, 1987

8. Bellinger MF: Ureterocystoplasty: A unique method for vesical augmentation in children. J Urol 149:811-813, 1993 9. Churchill BM, Aliabadi H, Landau EH, et al: Ureteral bladder augmentation. J Urol 150:716-719, 1993 10. Landau HE, Jayanthi VR, Khoury AE, et al: Bladder augmentation: Ureterocystoplasty versus ileocystoplasty. J Urol 152:716-719, 1994 11. Hitchcock RJI, Duffy PG, Malone PS: Ureterocystoplasty: the ‘‘bladder’’ augmentation of choice. Br J Urol 73:575-579, 1994 12. Reinberg Y, Allen RC, Vaughn M, et al: Nephrectomy combined with lower abdominal extraperitoneal ureteral bladder augmentation in the treatment of children with the vesicoureteral reflux dysplasia syndrome. J Urol 153:177-179, 1995 13. Lailas NG, Cilento B, Atala A: Progressive ureteral dilation for subsequent ureterocystoplasty. J Urol 156:1151-1153, 1996 14. Ikeguchi EF, Stifelman MD, Hensle TW: Ureteral tissue expansion for bladder augmentation. J Urol 159:1665-1667, 1998