Laparoscopic management of obstructed partial duplex with Y ureteric configuration

An 11-year-old girl underwent a laparoscopic upper-to-lower moiety ureteropyelostomy for lower moiety pelviureteric junction obstruction associated with Y ureteric duplication. She presented with left flank pain and was noted to be hypertensive with microscopic haematuria on admission. An abdominal ultrasound scan revealed a duplex left kidney with gross lower moiety pelvicalyceal dilatation. A subsequent MAG-3 scan demonstrated reduced differential function in the left lower moiety. A laparoscopic transmesocolic approach confirmed a dilated lower moiety pelvis and revealed the Y ureteric duplication. An upper to lower moiety ureteropyelostomy and insertion of a JJ stent is described in the accompanying video. The child was discharged home on the second day post operation. Postoperative imaging showed good decompression and improved differential function. The child has been completely well and normotensive at 2 years' follow-up.     

Ureteroureterostomy irrespective of ureteral size or upper pole function: A single center experience

ObjectiveAlthough ureteroureterostomy (UU) is an established procedure for the treatment of duplex anomalies, there may be a reluctance to apply this approach to patients with poor upper pole function and/or marked degrees of ureteral dilation.MethodsAn institutional review board (IRB)-approved retrospective analysis of all patients undergoing UU between 2006 and present was performed. All patients underwent an end-to-side anastomosis with a double-J stent left in the lower pole ureter. Laparoscopic repairs were done ‘high’ and open repairs were done ‘low’. If the upper pole ureter remained massively dilated after transection, the ureter was partially closed to reduce the length of the anastomosis. Data collected included demographics, diagnosis, surgical interventions, imaging studies and outcomes.ResultsA total of 41 patients (43 renal units) were identified. There were 35 females and six males with an average age at surgery of 2.3 years (range 55 days to 15.9 years) and an average follow up of 2.8 years. Diagnosis included ureterocele (17), ectopic duplex ureter (25) and ureteral triplication (1). Thirty-six patients underwent UU only and five underwent UU with simultaneous lower pole reimplantation. Twelve of the 41 patients (29%) underwent laparoscopic repair. Twelve of the 43 renal units (28%) required ureteral tapering, of which three were performed laparoscopically. Preoperative median upper pole function was 17% (0–35%).Six patients had no measurable function and ten had < 15%. No patient developed lower pole hydronephrosis in the follow-up period. There were two complications: one patient was found to have a post-operative ureterovesical junction (UVJ) stricture and the second had an anastomotic stricture.ConclusionUreteroureterostomy 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, the concept of automatically removing ‘dysplastic’ upper pole segments can be challenged.     

Pelviureteric junction obstruction in duplex system

An unusual case of a PUJ obstruction in the upper moiety of a duplex kidney is presented. PUG obstruction in duplex moieties is commonly seen in the lower moiety ureter and is usually due to extrinsic compression by a crossing vessel. In our case there was a long stenotic segment of the ureter draining a functionally insignificant and infected segment of the kidney. The opposite kidney was hypoplastic and non functional. An upper polar hemi nephrectomy was performed.     

小儿输尿管膨出症的治疗--附91例分析

目的 选用创伤小，疗效好的术式治疗输尿管膨出症，减法二次手术。方法 91例输尿管膨出症，男25例，女66例，其中70例（76.9%)并发于重肾双输尿管畸形，其中左上输尿管膨出症40例，右上27例，双上3例，影像学检查；双上肾积水4例，患侧上肾积水52例，患侧上下肾积水10例，患侧上，下及对侧都有肾积水4例。21例单一系统输尿管膨出症中，左侧5例，右侧11例，双侧5例。影像学检查；患侧肾积水10例，双侧肾积水5例，患肾功能严重受损5例。上尿路正常1例。结果 78例（85.7%)术后平均随访2年。重肾组；（1）上肾部切除48例52侧，治愈36例，失访7例，需加做输尿管残留切除3例，需再经尿道戳穿输尿管膨出2例；（2）切除输尿管膨出及输尿管膀胱再吻合6例，治愈5例。术后加做上肾部切除1例；（3）经尿道戳穿输尿管膨出15例，治愈9例，失访4例。需加做上肾部切除2例；（4）输尿管膨出自行缩小，症状消失1例。单一系统21例中15例经尿道戳穿输尿管膨出，治愈12例，失访2例，需加做输尿管膀胱再植1例，1例经输尿管膨出切除，输尿管膀胱再植治愈，发育不良肾切除5例。治愈2例，有尿失禁症状2例，仍时有尿路感染1例。全组1次手术治愈65例。结论 输尿管膨出症的治疗须根据患肾功能决定，如患肾功能严重受损，首选患肾或肾部切除，反之则经尿道做膨出部下缘戳孔术，对单一系统肾发育不良并发异位输尿管膨出的女性，其位置低至尿道远端，因该处尿道肌肉缺损造成失禁，须进一步治疗。     

Upper pole pelviureteric junction obstruction

A case of neonatal hydronephrosis affecting the upper moiety of a duplex kidney is presented. In addition to the ectopic insertion of the upper-pole ureter into the urethra, the ureter was obstructed by the lower pole at its pelviureteric junction. Accepted: 26 February 1997     

重肾双输尿管合并肾盂输尿管交界部梗阻性肾积水的诊治分析

目的 探讨重肾双输尿管合并肾盂输尿管交界部梗阻性肾积水的诊断与处理方法。方法 回顾分析1986～2004年间收治重肾合并肾盂输尿管交界部梗阻肾积水8例的临床资料。男2例，女6例，年龄7个月～10岁，平均4．8岁。病变位于左侧3例，右侧5例；上肾积水2例，下肾积水5例，上下肾积水1例；3例为重肾完全型双输尿管，5例重肾Y型输尿管。结果 3例重肾完全型双输尿管中，上肾积水1例因肾实质薄无功能行上肾切除术，下肾积水伴上肾输尿管膨出症1例行上肾切除下肾离断性肾盂成形术，另1例下肾积水因临床症状轻微，IVP示积水半肾的肾盏变钝不明显，未行手术门诊随诊。5例重肾Y型输尿管中，上肾积水1例行上肾盂与下输尿管吻合，下肾积水3例行上肾输尿管下肾盂吻合 下肾离断性肾盂成形术，1例上下肾均积水行上下肾盂吻合 下肾盂成形术。术后3～6个月复查IVP肾积水明显好转。结论 重肾肾盂输尿管交界部梗阻肾积水发病率很低，术前不容易明确诊断或被误诊。腹部B超、IVP或MRU是有效的辅助检查手段。治疗应根据息肾功能、形态而定，如息肾功能严重受损，行患肾切除，反之，根据积水的部位、输尿管的形态选择手术方式。     

Experience with a novel approach to upper-pole nephrectomy and partial ureterectomy

The upper-pole moiety of a renal duplication anomaly associated with an ectopic ureter or ureterocele is often hydronephrotic and non-functioning. Thus, the treatment of choice is frequently upper-pole nephrectomy and partial ureterectomy. Previous surgical techniques have emphasized the initial removal of the upper pole followed by partial ureterectomy. The approach described here begins by identifying and dissecting the obstructed upper-pole ureter, dividing it distally, and performing the partial nephrectomy last. We have performed this procedure on 12 consecutive nonfunctioning and obstructed upper-pole moieties of duplicated kidneys. In 10 patients the obstructed upper pole was associated with an ectopic ureter or an ectopic ureterocele (bilateral in 1) and in 1 with uretero-pelvic junction obstruction of the upper-pole moiety. This anatomic approach has resulted in preservation of function in all 12 remaining lower renal and ureteral units as assessed by postoperative intravenous urography. Only 1 patient required an intraoperative blood transfusion. We believe that this safe and easy-to-teach approach should be included in the urologic armamentarium.     

Augmentation ureterocystoplasty in boys with valve bladder syndrome

ObjectiveChildren with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome.Patients and methodsEight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound.ResultsBladder capacity (as measured during cystometry at 30 cm H₂O) and compliance were significantly improved in all children following the procedure (P < 0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child.ConclusionUreterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.     

Spectrum of ectopic ureters in children

We reviewed the clinicopathological features, diagnosis, and surgical treatment of ectopic ureters (EU) in children in order to evaluate the anatomy, renal function, outcome, and the existence of any racial or regional difference in this abnormality. The records of 27 consecutive patients with 33 EU managed over a period of 7 years were analyzed. There were 25 female and two male patients. Their age ranged from 1 to 13 years, with an average of 4.5 years. The presenting features included history of continuous dribbling of urine with otherwise normal voiding in toilet-trained female patients, incontinence of urine, urinary tract infection, abdominal pain, and renal failure. The diagnostic work-up included ultrasonography (US) in all 27 patients, intravenous pyelography (IVP) in 23, micturating cystourethrogram (MCU) in 19, nuclear imaging (NI) in 16, and computed tomogram (CT) in five patients. All patients underwent examination under anesthesia (EUA) and cystourethrovaginoscopy immediately before the operation. Single-system ectopic ureter (SSEU) was present in 19 patients with 25 ureters (six bilateral), and duplex with ectopic ureter was present in eight cases. The left side was involved in 14 cases, the right side in seven, and the anomaly was bilateral in six cases. Abnormalities noted in the imaging studies were USG 23/27, IVP 23/23, MCU 11/19, NI 13/16, and CT 5/5 cases. EUA and cystourethrovaginocsopy helped in localization of the ectopic site and evaluation of the bladder. The surgical treatment included nephroureterectomy (NUT) for non-functioning kidney in 7 patients, heminephroureterectomy (HNUT) for non functioning upper pole of duplex kidney with EU in 6 patients, ureteric reimplantation (UTR) in 13 patients (19 ureters, 6 bilateral), and ureteropyelostomy (UTP) in one patient. In the follow-up period ranging from 1 to 5 years, 20 patients achieved continence; however, six cases with bilateral SSEU and one case of unilateral SSEU, who also had a patulous bladder neck, continued to dribble urine. SSEU was more common than duplex with ectopic ureter. A large number of functioning renal units associated with SSEU deserved preservation. The success of surgical treatment in terms of achievement of continence was high and depended on the integrity of the bladder neck.     

Ileal pedicle grafting for esophageal replacement in children

Reconstruction of the upper esophagus in small children remains a challenge. Free jejunal interposition as frequently used in adults is much less appropriate in children because of the limited vessel size. The use of a jejunal pedicle graft in children has been described, but gaining enough length may be a problem. A pedicle graft of terminal ileum may be a better option, but this technique has never been described. We report a child with esophageal atresia and distal fistula who had a very short upper esophageal pouch. Primary repair was impossible. The fistula was ligated and a gastrostomy created. A second attempt at anastomosis was not successful either, and a cervical esophagostomy was created. The child was fed by gastrostomy and received sham feeding orally. When the child was 10 months old, the upper esophagus was successfully reconstructed with a pedicle graft of terminal ileum. Postoperatively there was a limited leak of the proximal anastomosis, which healed spontaneously. The distal anastomosis had to be dilated on a few occasions. With a follow-up of 1 year, the child is eating well without gastrostomy supplementation. On imaging, the ileal pedicle graft looks somewhat tortuous but contracts nicely. We feel that ileal pedicle graft reconstruction of the esophagus should be part of the instrumentarium of pediatric surgeons dealing with esophageal reconstruction.     

Multiple fibroepithelial polyps of the upper ureter in a 17-year-old boy--case report and review of the literature.

Benign tumours and primary malignant tumours of the ureter are uncommon in adults and extremely rare in children. The clinical symptoms are flank pain, urinary tract infection, and macro/micro-haematuria. There is an incomplete ureteral obstruction and filling defect on intravenous urography (IVU). Optimum treatment of this lesion results in renal preservation. Uretero-renoscopy is currently the best method available for the identification and histological diagnosis of ureteral polyps. Recommended operative procedures are pyeloureteric junction (PUJ) resection with Anderson-Hynes pyeloplasty, ureteric resection with end-to-end anastomosis or with uretero-cysto-neoanastomosis (UCNA), ureteric resection with renal autotransplantation. Ureteronephrectomy is not indicated. A case of ureteral polyps in a 17-year-old boy with the chief complaint of left flank pain is reported here. The excretory urogram and renal scan showed left hydronephrosis. Resection of the pyeloureteral junction, partial resection of the upper ureter containing the lesions--multiple branching 30-40 mm long polyps with a common basis--and Anderson-Hynes pyeloplasty were performed. The pathological diagnosis was benign fibroepithelial polyps of the ureter. Convalescence was uneventful and after 4 years of follow-up, excretory urogram and ultrasonography showed good renal function and improvement of hydronephrosis.     

上位肾分肾功能<10%重复肾患者保留或不保留上肾手术的预后比较-单中心回顾性队列研究

目的比较上位肾分肾功能<10%的重复肾患者行保留或不保留上肾单位手术的预后情况。方法回顾性分析中国医科大学附属盛京医院2008年1月至2017年6月收治的49例上位肾分肾功能<10%的重复肾畸形患者临床资料,依据不同治疗方案分为保留上肾单位组(n=22)和不保留上肾单位组(n=27),对两组术后并发症发生率和再手术率进行统计学分析。结果与不保留上肾单位组相比,保留上肾单位组术后并发症发生率(22.7%vs.3.7%)和再手术率(9.1%vs.0.0%)更高,但差异无统计学意义(P>0.05)。与不保留上肾单位组相比,保留上肾单位组患者中位手术年龄更小(16.5个月vs.33.0个月),差异有统计学意义(P=0.006)。而两组间性别、侧别、术前是否存在输尿管末端膨出/异位、术前上位肾分肾功能和术前患侧上肾输尿管直径差异均无统计学意义(P>0.05)。结论上位肾分肾功能<10%重复肾患者如需手术治疗,初次手术方式可根据医生和患者家长意愿,选择较为简单的手术方式。     

Laparoscopic ureteral ligation (clipping): A novel,simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

ObjectiveA simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper.Materials and methodsProspectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy.ResultsMedian age was eight years (range 4–17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US.ConclusionLaparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.     

Endoscopic injection of dextranomer hyaluronic acid copolymer for the treatment of vesicoureteral reflux in duplex ureters

PurposeEndoscopic injection of dextranomer hyaluronic acid copolymer (DxHA) has been increasingly utilized for the treatment of complex cases of vesicoureteral reflux (VUR). We present our 6-year experience with the use of DxHA for the treatment of VUR in duplex ureters.Materials and methodsBetween July 2001 and April 2007, 52 children were identified retrospectively who had been treated by endoscopic injection of DxHA for VUR into duplex ureters. Mean age was 3 years (range 9 months–10 years) with a mean maximum grade of reflux of III (range 2–5). The refluxing lower pole ureter was injected using a subureteric injection technique (STING) or intraureteric injection technique (utilizing the hydrodistention implantation technique). The endpoint in all cases was the loss of hydrodistention of the ureteral orifice. Voiding cystourethrograms was obtained at 6 weeks–3 months to evaluate for the presence of VUR. Cure was defined as complete resolution of reflux in the treated moiety.ResultsAfter initial treatment, 38/52 (73%) patients were cured. Of the 14 failures, nine children underwent repeat endoscopic treatment with a 67% (6/9) resolution rate for repeat injection. Seven of the initial failures failed to grade I VUR. Overall, 85% (44/52) were cured after one or two treatments, 98% (51/52) were improved and only one (1.9%) with grade V VUR required open surgery. The treatment was well tolerated and there were no associated complications.ConclusionEndoscopic injection of DxHA copolymer corrected VUR in 85% of children with VUR into duplex ureters. This minimally invasive approach should be considered as a viable alternative to open surgery or antibiotic prophylaxis for the treatment of VUR associated with duplex ureters.     

A spectrum of segmental multicystic renal dysplasia

Background. Multicystic renal dysplasia (MCDK) is a common anomaly well described in the literature, but less well described when involving only a portion of a kidney. Objective. To present the imaging spectrum, natural history and associated anomalies of six kidneys with segmental MCDK. Materials and methods. Five children with segmental MCDK (one with bilateral segmental MCDK) referred to our hospital between 1989 and 1996 were reviewed. All had at least one ultrasound examination. Four had a voiding cystogram and three had renal scintigraphy. Results. Four children had antenatal diagnosis of cystic renal abnormality. In two, with obvious duplex kidneys and associated ureteroceles, the diagnosis of upper moiety MCDK was obvious either antenatally or immediately postnatally. In the other three there were diagnostic difficulties. One patient had bilateral widespread cysts obscuring the functioning renal portions. Another presented in utero with a large ureterocele and a cystic upper pole that had involuted by birth. The fifth had a nephrectomy at 3 years for a multiloculated cystic mass. Varying degrees of involution occurred in the five kidneys seen early. Reflux was demonstrated into the ipsilateral functioning lower moiety and midpole. Conclusion. In these children as in other studies, the commonest presentation of segmental MCDK is in the upper pole of a duplex kidney associated with a ureterocele at the end of the atretic ureter. Atypical segmental MCDK may present a diagnostic dilemma and should be included in the differential diagnosis of multiloculated cystic masses and cystic kidneys. Received: 16 June 1998 Accepted: 16 November 1998     

A new operative technique for a rare case of pyelic fusion

This case report presents the first documented case of pyelic fusion with two sites of obstruction. The patient was diagnosed following antenatal presentation and the operative technique described in this case report is the only way by which the obstructions could be treated with a single procedure. The left pelvicalyceal system was grossly dilated and was draining into the common pelvis via an obstructed calyx in the isthmus of the horse shoe. The common ureter also had a pelviureteric junction stenosis. Incisions were made in the left dilated pelvis and in the obstructed part of the pelviureteric junction and ureter. The two openings were sutured as a culp pyeloplasty using interrupted 6/0 PDS sutures over a 4F JJ stent.     

Cloacal malformation with solitary crossed renal ectopia and single-system vaginal ectopic ureter

A patient with a cloacal malformation and hydrocolpos underwent a colostomy and vaginostomy in the neonatal period and total reconstruction at 7 months of age. Associated upper-urinary-tract abnormalities included solitary crossed left renal ectopia and a non-functioning right kidney with a single-system vaginal ectopic ureter. Accepted: 12 August 1998     

Ureteral ectopia in infants and children

Ectopic ureter is a rare and obscure condition that affects both sexes. During the last decade we treated three children, all females, among 1,720 patients with urological disorders. They presented with dribbling and urinary tract infections. The ectopic ureter was draining a single pyelocalyceal system in two cases and the upper pole of a duplex kidney in the third. All patients were successfully operated upon and did well.     

Laparoscopic upper pole heminephroureterectomy in children: Seven-year experience

Background:

Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach.

Materials and Methods:

From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain.

Results:

The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2^nd to 4^th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously.

Conclusion:

The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.Key words: Duplex kidney, heminephrectomy, infants, laparoscopy     

Arteriovenous aneurysm of the left internal thoracic artery with hypertrophy of the left upper limb (author's transl)]

Case report on a 5 years old boy suffering from a congenital arteriovenous fistula of the left internal thoracic artery. At the age of 9 months hypertrophy of the left arm combined with dilated veins in this area developed. Diagnosis was made by clinical examination together with a density in the left upper chest on x-ray and was confirmed by phlebography and thoracic aortography. A dilatation of the left heart, which was marked at the age of 9 months vanished in childhood without any therapy. The child was operated successfully.