Bladder augmentation: Distal ureterocystoplasty with proximal ureteric reimplantation: A novel technique.

A novel technique of bladder augmentation is reported, wherein the distal dilated ends of tortuous ureters were used for ureterocystoplasty while proximal remaining ureters reimplanted back into the native bladder.

INTRODUCTION

Although ureterocystoplasty is the best choice among the available techniques of bladder augmentation, the surgeon has to opt either a trans ureteroureterostomy or nephrectomy of a non-functioning unit to enable this.[1-3] The current technique, similar to Perovic's technique[4] involves using bilateral distal ureters for augmentation while reimplanting the remaining proximal ureters back in to the bladder.

CASE REPORT

A 9-year-old boy with a past history of bilateral grade V primary vesico ureteric reflux (VUR), diagnosed at the age of two, underwent bilateral cutaneous ureterostomy, ureteric reimplantation and closure of ureterostomy between age 2 and 5 years, at a different center. He presented to us with recurrent urinary tract infections (UTI). At presentation he had urinary frequency of 15 days in addition to dribbling in between; the child was started on anti cholinergics at the referring center but there was no improvement. The clinical examination revealed palpable bladder; biochemical investigations revealed blood urea nitrogen of 24 mg/ dl and serum creatinine of 1.2 mg/dl. Urine showed 8-9 pus cells; specific gravity normal; urine culture was negative. An ultrasonography revealed bilateral gross hydroureteronephrosis with grossly dilated distal ureter and bladder wall thickening. Voiding cystourethrogram revealed bilateral grade V VUR [Figure 1a]; and a normal urethra; the bladder was irregular and of small capacity. Magnetic resonance imaging of the spine revealed no spinal abnormalities. Functional assessment with diuretic renogram revealed bilateral impaired drainage; a total glomerular filtration rate of 104.6 ml/min with a split renal function of, 31% right kidney and 69% left kidney.

Figure 1

(a) Voiding cystourethrogram shows bilateral grade V VUR and grossly dilated tortuous ureters; bladder irregular small capacity; Dotted lines show the level of division distal to which ureters were used for augmentation; proximal portion reimplanted back into the bladder. (b) Diagrammatic representation: Bladder was opened in coronal plane and ureters were detubularized by extending the bladder incision through the ureteric orifices in to the medial side of ureters

Cystoscopy revealed normal urethra, grossly trabeculated bladder and bilateral patulous ureteric orifices. Urodynamic evaluation (UDE) revealed a poorly compliant bladder with reduced functional capacity of 150 ml. In view of recurrent UTI, deteriorating renal function and poorly compliant bladder (non-neurogenic neurogenic bladder), we elected for reimplantation, along with bladder augmentation and Mitrofanoff. Since grossly dilated tortuous ureters were available, we decided to use the distal ureters from both sides for ureterocystoplasty [Figure 1a].

At surgery through a Pfannenstiel incision, the ureters were divided at a level high enough to use the distal part for augmentation and low enough for the proximal part to be reimplanted in to the bladder [Figure 1a]. The bladder was opened in coronal plane and ureters were detubularized by extending the bladder incision through the ureteric orifices in to the medial side of ureters [Figure 1b]. The detubularized ureters were reconfigured in to a patch and anastomosed first to the posterior lip of bladder [Figure 2a]. Ureterocystoplasty was completed by anastomosis of ureteric patch to anterior lip of bladder with 4-0 polyglactin [Figure 2b]. Appendicovesicostomy and reimplantation of proximal ureters (Politano Lead better type with excisional tapering) were completed before closure of ureterocystoplasty. Mitrofanoff and both ureters were stented with 5 F feeding tube for 2 weeks. Suprapubic catheter was left for 2 weeks. Post op cystogram performed at 2 weeks did not reveal any leak or reflux; the bladder capacity was 400 ml. Clean intermittent catheterization was started via Mitrofanoff after 4 weeks. Serum creatinine stabilized at 1.0 mg/dl and the child was able to perform clean intermittent catheterization through Mitrofanoff stoma. Repeat urodynamics at 6 months revealed a compliant bladder with functional capacity of 300 ml. There were no further episodes of febrile UTI at 12 months follow-up.

Figure 2

(a) The detubularized ureters were reconfigured in to a patch (arrow) and anastomosed first to the posterior lip of bladder. (b) Ureterocystoplasty was completed by anastomosis of ureteric patch to anterior lip of bladder with 4-0 polyglactin

DISCUSSION

Ureter is the best choice currently available for bladder augmentation as it is devoid of mucus related and metabolic complications.[1-3] However it cannot be performed frequently as it requires trans ureteroureterostomy or nephrectomy of a non-functioning unit as a prerequisite. Perovic et al.[4] addressed this issue by performing a variant of ureterocystoplasty with preservation of the kidney by dividing the megaureter and using the distal part for bladder augmentation and proximal part for reimplantation into the bladder. We have attempted a similar technique along with Mitrofanoff in our patient. Although vascularity of distal ureteric segment is a theoretical concern, in our patient it was not a problem, as the ureter was opened along the line of coronal bladder incision without any disconnection. Tandem ureterocystoplasty[5] and tea-pot ureterocystoplasty[6] are similar techniques preserving ureter bladder continuity and thereby its vascularity.

There are two requirements for this procedure to succeed: 1. Dilated tortuous ureters should be there on both sides 2. The bladder capacity should not be much reduced, as this procedure provides only a modest increase in capacity. When the bladder capacity is severely impaired, bowel augmentation would be an ideal choice for providing a good capacity. When the capacity is moderate but noncompliance is the main problem and tortuous megaureters are there, this procedure is ideal. The described technique is a novel modification of ureterocystoplasty and is a useful addition to the existing techniques as it enables the surgeon to perform ureterocystoplasty more frequently.