British Association of Paediatric Urologists consensus statement on the management of the primary obstructive megaureter

IntroductionIt is well-known that the majority of congenital megaureters may be managed conservatively, but the indications and surgical options in patients requiring intervention are less well defined. Hence this topic was selected for discussion at the 2012 consensus meeting of the British Association of Paediatric Urologists (BAPU). Our aim was to establish current UK practice and derive a consensus management strategy.MethodsAn evidence-based literature review on a predefined set of questions on the management of the primary congenital megaureter was presented to a panel of 56 Consultant Surgeon members of the British Association of Paediatric Urologists (BAPU), and current opinion and practice established. Each question was discussed, and a show of hands determined whether the panel reached a consensus (two-thirds majority).ResultsThe BAPU defined a ureteric diameter over 7 mm as abnormal. The recommendation was for newborns with prenatally diagnosed hydroureteronephrosis to receive antibiotic prophylaxis and be investigated with an ultrasound scan and micturating cystourethrogram, followed by a diuretic renogram once VUR and bladder outlet obstruction had been excluded. Initial management of primary megaureters is conservative. Indications for surgical intervention include symptoms such as febrile UTIs or pain, and in the asymptomatic patient, a DRF below 40% associated with massive or progressive hydronephrosis, or a drop in differential function on serial renograms. The BAPU recommended a ureteral reimplantation in patients over 1 year of age but recognized that the procedure may be challenging in infancy. Proposed alternatives were the insertion of a temporary JJ stent or a refluxing reimplantation.ConclusionA peer-reviewed consensus guideline for the management of the primary megaureter has been established. The guideline is based on current evidence and peer practice and the BAPU recognized that new techniques requiring further studies may have a role in future management.     

气膀胱腹腔镜Cohen输尿管移植术治疗先天性膀胱输尿管连接部梗阻

目的 介绍应用气膀胱腹腔镜行膀胱内横向黏膜下推进抗返流输尿管膀胱再植术（Cohen术）治疗先天性膀胱输尿管连接部梗阻的方法和体会.方法 2008年8月至2009年4月本院收治8例先天性膀胱输尿管连接部梗阻患儿,年龄23个月至9岁,平均年龄4.1岁.男6例,女2例.左侧7例,右侧1例.均在气膀胱腹腔镜下行Cohen输尿管再植术.结果 7例手术获得成功,1例中转开放手术.手术时间150～360 min,平均213 min.9～10 d拔除导尿管,8例均痊愈出院.术后随访2～10个月,无尿路感染发生,尿常规检查正常,B超检查肾积水及输尿管扩张程度减轻,MCU（排尿性膀胱尿路造影）均发现膀胱输尿管反流.结论 在熟练掌握腹腔镜分离缝合技术的基础上,气膀胱腹腔镜Cohen输尿管再植术治疗先天性膀胱输尿管连接部梗阻可取得良好的手术效果.     

单纯上或下患肾部输尿管膀胱外再植治疗完全性重复肾畸形

目的 评价采用单纯上或下患肾部单根输尿管膀胱外再植治疗完全性重复肾畸形的疗效.方法 从2009年12月1日起至2014年12月31日间,我科采用单纯上或下患肾部单根输尿管膀胱外再植治疗完全性重复肾畸形患儿27例,均为单侧病变,女19例,男8例,年龄2个月至8岁.所有患儿经影像学检查明确诊断为完全性重复肾畸形且均为单根输尿管病变.其中上输尿管异位开口者9例;重复上肾上输尿扩张积水伴上输尿管末端囊肿者10例;重复下肾部输尿管单纯反流者8例.临床症状主要表现为正常排尿间歇性滴尿或发热性尿路感染.所有患儿术后随访观察11个月至6年,随访项目包括泌尿系统超声、同位素和膀胱造影等.结果 所有患儿手术过程顺利,平均手术时间63 min,术后平均住院时间为5d,术后所有患儿临床症状均消失.术后有1例患儿因血尿检查发现再植输尿管开口处结石形成,予以行膀胱镜下钬激光碎石术.术后6个月复查超声示患肾部积水均有好转,同位素示患肾部功能改善或稳定,正常肾部功能未见异常改变.7例患儿术后复查排泄性膀胱尿道造影检查未见膀胱输尿管反流等发生.结论 经腹股沟皮纹小切口单纯上或下患肾部单根输尿管膀胱外再植术治疗完全性重复肾畸形是一种安全、有效的方法,值得临床推广.     

Results of surgery for vesicoureteral reflux in children: 6 years' experience in an Asian country

From January 1990 to December 1995, a total of 181 patients underwent reimplantation of 318 ureters for primary vesicoureteral reflux (VUR); 87.8% received bilateral reimplantation. Surgical indications included breakthrough infection (35%), high-grade (≥IV) reflux (33%), or both (29%). The operative success rate was 99.4% at 3 months postoperatively and 100% ultimately. The complications included: contralateral sequential reflux in 3.9%, postoperative bladder diverticula in 1.1%, postoperative urinary infection in 1.1%, residual reflux in 0.3%, postoperative vesicoureteral stenosis in 0.3%, and slippage of the drainage tube in 0.3% of cases. Two patients had renal failure due to VUR that was proven by renal biopsy (one 4-year-old and one 8-year-old). The incidence of associated anomalies was higher than in the normal population. The average number of hospital admission days was 7.9 (3–63). After 1992, no ureteral stent was left in postoperatively. All patients received prophylactic antibiotics for 3 months postoperatively until the VUR disappeared. The surgical results were satisfactory in this series. Accepted: 4 February 1997     

Magnetic resonance urography for diagnosis of pediatric ureteral stricture

PurposeUreteral stricture is a rare cause of hydronephrosis in children and is often misdiagnosed on ultrasound (US) and diuretic renal scintigraphy (DRS), requiring intraoperative diagnosis. We evaluated ureteral strictures diagnosed by magnetic resonance urography (MRU) at our institution.Materials and methodsChildren with ureteral stricture who underwent MRU were identified. Patient demographics, prior imaging, MRU findings, and management were assessed. The efficacy of MRU in diagnosis of stricture was compared with US and DRS. Patients with ureteropelvic or ureterovesical junction obstruction were excluded.ResultsTwenty-eight ureteral strictures diagnosed by MRU between 2003 and 2013 were identified; 22% of strictures were diagnosed by DRS ± US. The mean age at MRU diagnosis was 2.4 years (range 4 weeks–15 years). Hydronephrosis was the most common presentation, accounting for 20 (71%) cases. Other etiologies included pain (3), incontinence (2), and urinary tract infection, cystic kidney, and absent kidney, present in one case each. A mean of 2.7 imaging studies was obtained prior to MRU diagnosis. Twenty-one (75%) ureteral strictures required surgical intervention, with the approach dependent upon location.ConclusionsMRU provides excellent anatomic and functional detail of the collecting system, leading to accurate diagnosis and management of ureteral stricture in children.     

儿童输尿管肿瘤的诊治分析

目的 总结儿童输尿管肿瘤的病理类型、临床表现、诊断、治疗和预后,提高对该病的认识.方法 回顾性分析2011年1月至2015年10月我院收治的5例输尿管肿瘤患儿的临床资料,结合文献总结儿童输尿管肿瘤的病理类型、临床表现、诊断、治疗及预后.5例患儿均为男性,输尿管炎性肌纤维母细胞瘤3例,2例以腹痛就诊,分别为6岁和10岁,肿瘤位于输尿管下段,均行输尿管下段肿物切除+输尿管端端(输尿管膀胱)吻合,1例以尿痛并血尿就诊,年龄1岁9月龄,肿物来源于下段输尿管,经输尿管膀胱连接部长入膀胱,继发膀胱输尿管积水,经输尿管和膀胱联合切除肿物+输尿管膀胱再植术.结果 术后随访5~48个月,未见肿瘤复发及转移.恶性横纹肌样瘤1例6岁,以左下腹痛2周就诊,输尿管肿瘤边界不清与腰大肌肉和后腹膜粘连,切除肿物行输尿管端端吻合,术后ICE方案化疗一疗程后局部复发,放弃治疗,术后233d死亡.尤文/原始神经外胚层瘤1例12岁,以右侧腰痛10d就诊,肿瘤位于输尿管髂血管水平,行输尿管肿瘤切除术+输尿管端端吻合术,术后予CAV+IE化疗12个月,随访56个月,未见转移及复发.结论 输尿管肿瘤在儿童发病率极低,文献曾报道的病理类型包括炎性肌纤维母细胞瘤、恶性横纹肌样瘤、尤文/原始神经外胚层瘤、横纹肌肉瘤,术前无特异方法诊断,手术完整切除肿瘤并重建输尿管是治疗的主要方法,确诊需要结合病理检查,根据病理类型决定是否化疗,治疗后均需要长期随访.     

气膀胱输尿管再植术治疗婴儿输尿管膀胱连接部梗阻临床分析

目的：总结气膀胱输尿管再植术治疗小婴儿输尿管膀胱交界处梗阻的临床经验。方法回顾性分析2006年2月至2013年3月本院收治的19例年龄小于1岁、行气膀胱输尿管再植术的输尿管膀胱交界处梗阻患儿临床资料,并与同期年长儿组32例进行对比。婴儿组单侧12例,双侧7例,22根输尿管行再植,4根行裁剪＋再植;年长儿组单侧25例,双侧7例,30根输尿管行再植,9根行裁剪＋再植。结果所有病例无中转开放手术,无输血。婴儿组手术时间长于年长儿组（P＜0.05）,术后泌尿道感染发生率高于年长儿组。年长儿组中1例出现吻合口梗阻急行手术置支撑管,拔管后吻合口引流通畅。共41例患儿获随访,随访率80．4％。B超示输尿管扩张较术前普遍好转;排尿性膀胱尿道造影（VCUG）发现3根输尿管存在低级别反流;除4例术前患肾功能严重受损之外,其余患儿分肾功能维持原有水平或轻度好转。随访情况两组间无明显差别。结论气膀胱输尿管再植术治疗输尿管末端梗阻,在小于1岁的小婴儿病例中手术难度大于年长儿,但通过熟练掌握腹腔镜技术可减少并发症,提高手术安全性,在小婴儿中同样能取得满意疗效。     

The effect of surgeon volume and hospital characteristics on in-hospital outcome after ureteral reimplantation in children

The aim of this study was to examine the association between surgeon and hospital characteristics on in-hospital outcome after ureteral reimplantation in children. Patients < 18 years undergoing vesicoureteral reimplantation (n = 3,109) were identified in Kids’ Inpatient Database, an administrative database containing discharge records from 27 states during 2000 in the US. Based on patient volume in 2000, surgeons were designated as low volume (< 11 procedures), medium volume (11–20 procedures) and high volume (> 20 procedures) surgeons. Length of stay and hospital charges were analyzed using multivariate linear regression analysis. A significant association between shorter length of stay and higher surgeon volume (p = 0.02) was observed that was independent of children’s hospital status, hospital volume and other hospital characteristics. Length of stay was 20% shorter when the procedure was performed by the highest volume surgeons compared to when performed by the lowest. No significant effect of surgeon volume on hospital charges, however, was observed. Higher surgeon volume was associated with shorter length of stay but no difference in hospital charges among children undergoing vesicoureteral reimplantation.     

经腹入路腹腔镜肾盂成形术治疗儿童肾盂输尿管连接部梗阻

目的探讨经腹腔入路腹腔镜肾盂成形术治疗儿童肾盂输尿管连接部梗阻（UPJO）的可行性、安全性及初步经验。方法本组9例患儿,共10侧手术,为2011年6月至2014年5月收治的1岁5个月至14岁以内肾积水儿童。年龄1岁5个月至14岁,平均年龄8岁。男性8例,女性1例。左侧7例,右侧3例。有腰痛症状8例,无症状2例（胎儿期 B 超检查发现肾积水）。其中肾重度积水5例,中度积水4例,轻度积水1例。先后行双侧肾盂成形术1例。输尿管狭窄扩张及置内支架管失败2例。所有患儿经 IVU 或 CTU 或 MRU 检查,确诊为 UPJO。均采用经腹腔入路腹腔镜离断式肾盂成形术。结果9例10侧患儿手术均获成功,无中转开腹手术或另外增加鞘管,无术中并发症。手术时间150～522 min,平均344.2 min。出血量10～100 mL,平均45 mL。术后肠道功能恢复时间1～3 d,平均2.1 d。术后住院7～10 d,平均8.5 d。术后采用超声,MRU 或 CT 三维重建、ECT 随访6～36个月,均显示肾实质有不同程度增厚,肾积水均明显减轻或消失,吻合口处较宽敞,术后无吻合口狭窄、尿漏及腹内脏器损伤等并发症。肾功能明显改善,患儿自觉症状消失。结论经腹腔入路腹腔镜肾盂输尿管成形术治疗儿童 UPJO 肾积水安全可行,效果良好,并发症少,对肠道干扰不大,美容效果良好,值得推广。选择手术病例应遵循由易到难过渡的原则。     

Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter

ObjectiveTo demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter.MethodsA 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO₂) laser.ResultsThe patient's vesicoureteral reflux was successfully corrected, and he is now asymptomatic.ConclusionSpecific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO₂ laser is advantageous for detrusorotomy.     

Ergebnisse der endoskopischen Refluxtherapie mit bovinem Kollagen

Purpose: This study has been conducted to evaluate the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injections for endoscopic treatment of vesicoureteral reflux (VUR). Methods: We prospectively studied 86 patients (mean age 8 years) with 128 refluxing ureteral units. All patients were treated with subureteral collagen injections and were followed up by voiding cystographies or videourodynamic evaluation. Results: 157 subureteral collagen injections have been performed on 128 ureteral units. This includes 27 second injections and 2 third injections. In 65 ureteral units a primary VUR was present, in 19 a secondary VUR. 28 ureteral units presented with secondary reflux due to neurogenic bladder dysfunction. 7 ureteral units were treated with subureteral collagen injections after the VUR persisted following open surgical reimplantation, in 9 ureteral units a double ureter was present. After a follow up of 24 months a reflux recurrence was observed in 83% of ureteral units with primary VUR, in 56% of ureteral units with secondary VUR, in 85% of ureteral units with VUR due to neurogenic bladder dysfunction, in 67% of ureteral units of double ureters and in 34% of ureteral units after open surgical reimplantation. After a second injection and a follow up of 24 months 35% of patients remained reflux free. Conclusion: Our results suggest, that endoscopic subureteral bovine collagen injections remain ineffective in the long term follow up to correct VUR.     

Robot-assisted laparoscopic ureteral reimplantation: A single surgeon comparison to open surgery

ObjectiveThe aim was to report a single surgeon's experience comparing open and robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) to treat vesicoureteral reflux (VUR).Subjects and methodsWe retrospectively reviewed the outcomes of RALUR and open extravesical ureteral reimplantations consecutively performed by a single surgeon between January 2008 and December 2010 using the da Vinci^® Surgical System. Both groups of patients were subjected to identical pre- and postoperative care protocols.ResultsDuring the defined study interval, 20 open and 20 RALUR procedures were completed by a single surgeon at our institution. Gender and VUR grade were similar in both cohorts. Operative times were longer in the RALUR group, but postoperative opioid use (morphine equivalents) was significantly lower in the RALUR group (RALUR: 0.14 mg/kg, open: 0.25 mg/kg, p = 0.021). There was no significant difference in estimated blood loss (EBL) or length of hospitalization (LOH). The overall rate of surgical complications was similar; however, the complications in the open group tended to be less severe than those occurring in the RALUR group. On follow-up, after a median of 52 months for open surgery and 39 months for RALUR, two children had developed a febrile urinary tract infection in both groups, of which one in the open group had persistent VUR.ConclusionThis single-surgeon experience of open and initial experience with RALUR performed with the same surgical technique on consecutive cohorts with identical post-surgical care protocol allows a comparative analysis of outcomes for a surgeon transitioning to RALUR. The RALUR reduces postoperative analgesic requirements while yielding similar clinical outcomes as the open technique.     

Refluxing ureteral reimplantation: A logical method for managing neonatal UVJ obstruction

ObjectiveAn obstructed megaureter can be managed using a number of techniques, with the primary goal being to minimize the potential for further injury to the affected kidney. Classically, these obstructed ureters have been treated using cutaneous ureterostomy. However, this technique has certain limitations including the potential for stenosis. We describe our experience with the refluxing ureteral reimplantation as a novel, yet technically simple, method for temporary internal diversion of the obstructed megaureter.MethodsTreatment consists of transecting the ureter proximal to the obstruction and performing an end-to-side anastomosis with the bladder in a freely refluxing fashion. Patients are placed on antibiotic suppression following surgery. Subsequent open definitive surgery is performed through the same incision site once the child is older than 1 year of age.ResultsSixteen patients identified with severe hydroureteronephrosis were found to have an obstructed megaureter(s) involving 19 ureteral moieties. Patients underwent internal diversion at an average age of 5 months. All patients demonstrated improved drainage of the affected kidney(s) following surgery. Three patients developed a febrile urinary tract infection. Definitive surgical treatment was undertaken in 18 of 19 ureters, and consisted of ureteral reimplantation with tapering or plication (13), ureteral reimplantation without tapering (3), and nephrectomy (2). One patient with multiple other congenital anomalies is not a candidate for further genitourinary reconstruction.ConclusionsRefluxing ureteral reimplantation is a safe and easy method of temporary internal urinary diversion. Simple in principle, the concept of creating a refluxing ureteral reimplantation is no different from that of incising an obstructing ureterocele. This technique allows time for the child to mature, while preserving renal function and awaiting definitive repair.     

Robotic-assisted laparoscopic extravesical ureteral reimplantation: an initial experience

ObjectiveThere are many emerging techniques using robotic-assisted laparoscopy (RAL) in pediatrics. We performed a retrospective review of our first patients who underwent RAL extravesical ureteral reimplantation.Materials/MethodsBetween October 2007 and May 2010, a single surgeon performed RAL extravesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplantation, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age 6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessed by voiding cystourethrogram.Results16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5 months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateral repair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgrading in one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3 days. No patients required postoperative catheterization at discharge.ConclusionsOutcomes for new procedures can be variable and unpredictable as the technique evolves. Given the high success rates of open reimplantation, a minimally invasive technique must show comparable results if it is to play a continuing role. Our initial results are encouraging, but prospective analyses are required to outline the future role of RAL ureteral reimplantation.     

Cohen再植术后反流影响因素的研究

目的 通过回顾性研究Cohen术围手术期各变量值,分析影响Cohen术后反流因素.方法 回顾性研究及追踪随访2008年1月至2013年12月我院收治的原发性膀胱输尿管反流(VUR)及原发性膀胱输尿管交界处梗阻(POM)患儿,排除继发反流及梗阻患儿,设置围手术期各个变量,对各变量进行统计学分析,找寻影响Cohen术后反流因素.结果 共随访218例原发VUR及POM,排除2例术中输尿管折叠再植术,1例术后出现对侧反流,1例术侧产生梗阻并发症.共纳入研究214例,其中VUR 74例,POM 140例.平均年龄3.7岁(7个月至17岁),平均手术时间72.3 min(60～95 min),平均出血5.5ml,随访时间6～53个月.19例患儿术后产生反流的并发症,其中11例通过保守治疗好转,8例通过再次Cohen术治愈,术后无反流率91.1％,最终手术成功率96.3％.经统计学检验发现在手术年龄7个月至17岁、输尿管黏膜下埋植长度与直径比2.5～7情况下,手术成功率与性别、年龄、病种、单双侧、反流度数、裁剪、埋植长度、埋植直径、埋植长度与直径比、支架管留置时间,导尿管留置时间、术前输尿管直径、术前泌尿系感染(UTI)无关(P＞0.05);输尿管黏膜下长度与直径比以≥5与＜5分成两组,两组手术成功率也无差异(P＞0.05).结论 在7个月至17岁、输尿管黏膜下埋植长度与直径比2.5～7情况下,Cohen术后反流与围手术期各个因素无关,即在此年龄段输尿管黏膜下埋植长度与直径比≥2.5即可起到抗反流作用.     

Iatrogenic ureteral injury: Can adult repair techniques be used on children?

ObjectiveIatrogenic ureteral injury in children is a rare occurrence, with sparse literature available regarding optimal repair techniques. We reviewed our experience in the management of iatrogenic pediatric ureteral injuries, particularly with respect to initial versus delayed diagnoses.MethodsAll pediatric iatrogenic ureteral injuries repaired by a single surgeon during 1986–2007 were reviewed.ResultsTen injuries were repaired over 20 years. Median patient age was 12 years. Injuries occurred during five open tumor resections, three laparoscopic procedures and two ureteroscopies. Diagnosis was immediate in four patients. Median ureteral defect length was 4 cm (range 2–5). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. Diagnosis was delayed in six patients by a median of 21 days. Five children (83%) were managed by temporary percutaneous nephrostomy tube and one (17%) by ureteral stent. Delayed repair was performed 1–3 months later. In the patients with laparoscopic or ureteroscopic injuries the median ureteral defect length was 4 cm (range 3–6). All underwent ureteral reimplantation and psoas hitch Boari flap. Median follow up was 1 year, with no obstruction noted. One child had a proximal ureteral defect 8 cm long; delayed ileal ureter was performed with good results 4 years postoperatively.ConclusionsPediatric iatrogenic ureteral injuries are rare and may be repaired by both immediate and delayed techniques as circumstances demand. Standard techniques used in the adult population may be employed in children with the expectation of good long-term results.     

利尿性肾图在小儿肾盂输尿管连接部梗阻致肾积水诊断中的作用

目的探讨以利尿性肾图替代静脉尿路造影对小儿肾盂输尿管连接部梗阻引起的肾积水进行诊断的可能性.方法对1995年8月至2001年10月间的52例同时行静脉尿路造影和利尿性肾图检查并进行了肾盂成形术的病例进行回顾性分析,男47例,女5例,年龄0.2～13岁(平均6.5岁).结果本组52例静脉尿路造影对梗阻部位判断有52例(100%)正确;利尿性肾图检查后,52例患儿梗阻部位的判断也都(100%)正确.静脉尿路造影和利尿性肾图在梗阻部位诊断上差异没有显著性意义(P＞0.05).结论在诊断小儿肾盂输尿管连接部梗阻上,以利尿性肾图来替代静脉尿路造影是可行的.     

一期手术矫治肾输尿管重复畸形合并异位输尿管囊肿

目的 探讨分析完全性肾输尿管重复畸形合并同侧上输尿管异位囊肿的病人，治疗时是否需要同时切除病变肾和输尿管囊肿。方法 对近8年来我院收治的10名完全性肾输尿臂重复畸形合并同侧上输尿管异位囊肿的病例予以总结。结果 发现其中6名初期治疗中仅切除患侧上半肾输尿管的儿童，平均术后1年都因为膀胱内囊肿增大而再次接受了输尿管囊肿切除术。另3例病人一期同时施行了上半肾输尿管切除术、膀胱内输尿管囊肿切除术和下半肾输尿管再植术，术后随访疗效良好。结论 我们认为对类似疾病应该在切除肾输尿管的同时一并切除异位输尿管囊肿。     

Management of vesicoureteral reflux secondary to neurogenic bladder

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH₂O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH₂O), reimplantation with bladder augmentation is recommended. Accepted: 6 January 1998     

The role of routine postoperative stentograms in the pediatric patient undergoing excisional tapered ureteral reimplantation

ObjectiveTo determine the usefulness of routine stentograms in postoperative management of pediatric patients undergoing excisional tapered ureteral reimplantation.Materials and methodsA retrospective review of all pediatric patients undergoing excisional tapered ureteral reimplantation from March 2003 to March 2008 at one center was performed. One hundred patients were identified. Seventeen had stentograms performed approximately 2 weeks (1–5 weeks) after surgery. The 83 without stentograms composed the control group.ResultsOf the 17 pediatric patients with postoperative stentograms, 10 (59%) had no contrast observed in the bladder. Ureteral stents were removed despite this finding. No anastamotic leaks were observed. In this group, not one had a postoperative complication at time of follow up (mean 25 months; range 4–52). Of the 83 patients without stentograms, not one had clinical signs of anastamotic leakage or obstruction at discharge. The stents were removed routinely 2 weeks (range 1–8) after surgery. Nine patients (10.8%) developed ureteral obstruction (mean 7 weeks; range 1–24) requiring intervention. Three of these patients required a second operation.ConclusionsSince routine stentograms rarely identify ureteral leak, and poor drainage on postoperative stentogram does not indicate a risk of obstruction, these studies are not required following routine excisional tapered ureteral reimplant.