Intravesical and extravesical ureteral reimplantation in children with bilateral refluxing megaureter: comparison of results

Introduction. Extravesical ureteral reimplantation is an accepted technique for the surgical treatment of high-grade vesicoureteral reflux. However, many surgeons continue to use an intravesical technique, including for the megaureter. We present our experience and outcomes with these techniques for primary bilateral refluxing megaureter.

Purpose of the study. To improve the results of surgical treatment of refluxing megaureter in children.

Materials and methods. A retrospective study was performed of 95 patients who underwent ureteral reimplantation between 2006 and 2019. The age of patients at the time of surgery was from 4 months to 13 years (median — 27.6 months), boys were 71 (74.7%), girls were 24 (25.3%). All patients are divided into 2 groups depending on the method of treatment. Group 1 consisted of 65 patients who underwent Cohen single-stage bilateral transvesical ureteral reimplantation. Group 2 included 30 children who underwent two-stage Barry extravesical ureteral reimplantation. The interval between operations was from 1 to 63 months (median — 5.2 months). Patient demographics, surgical technique and outcomes were recorded. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux.

Results. Median follow-up period was 3.2 years. The overall success rate was 80% for patients and 88% for ureters. Postoperative grade III – IV reflux had 15 patients (15,8%) and 16 ureters (8,4%). Persistent ureterohydronephrosis had 4 children (4,2%) and 6 ureters (3,2%). The effectiveness of treatment for patients in the Cohen group was 77%, in the Barry group — 87% (p = 0.408), for ureters — 86% and 93%, respectively (p = 0.223). The difference was not significant despite the higher effectiveness extravesical technique.

Conclusion. Extravesical and transvesical ureteral reimplantation are effective methods of treatment for bilateral refluxing megaureter in children.

1. Burbige KA, Miller M, Connor JP. Extravesical ureteral reimplantation: results in 128 patients. J Urol. 1996;155(5):1721‒1722. https://doi.org/10.1016/s0022-5347(01)66181-0

2. Shiryaev N.D., Kagantsov I.M., Rachkov E.B., Markov N.V. Is x-ray control always necessary after surgical correction of primary vesicoureteral reflux? Detskaja hirurgija. 2005;9(1):21‒23. (in Russ.). eLIBRARY ID: 17048115

3. Hjälmås K, Löhr G, Tamminen-Möbius T, Seppänen J, Olbing H, Wikström S. Surgical Results in the International Reflux Study in Children (Europe). J Urol. 1992;148(5Pt2):1657‒1661. https://doi.org/10.1016/s0022-5347(17)36996-3

4. Elder JS. Guidelines for consideration for surgical repair of vesicoureteral reflux. Curr Opin Urol. 2000;10(6):579‒585. https://doi.org/10.1097/00042307-200011000-00008

5. Markov N.V., Kagantsov I.M., Turabov I.A., Sablin D.E., Dubrov V.I., Logval A.A. The results of operative treatment of high grade vesicoureteral reflux in children. Jeksperimental’naja i klinicheskaja urologija. 2017;3:110‒113. (in Russ.). eLIBRARY ID: 30557004

6. Pavlov A.Y., Polyakov N.V., Moskaleva N.G., Krasyuk K.V. Extravesical ureterocystoanastomosis. Urologija. 2002;2:40‒43. (in Russ.).

7. Dubrov V.I., Bondarenko S.G., Kagantsov I.M. Modified single-sided laparoscopic extravesical antireflux operation. Rossijskij vestnik detskoj hirurgii, anesteziologii i reanimatologii. 2018;8(2):24‒32. (in Russ.). https://doi.org/10.30946/2219-4061-2018-8-2-24-32

8. Gander R, Asensio M, Royo GF, López M. Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and Secondary Megaureters: Preliminary Report of a New Simplified Technique. J Pediatr Surg. 2020;55(3):564‒569. https://doi.org/10.1016/j.jpedsurg.2019.05.028

9. Pirogov A.V., Sizonov V.V. Comparative analysis of the efficacy of ureteral reimplantation at vesicoureteral reflux and ureterovesical junction obstruction using vesicoscopic approach in children. Urology Herald. 2017;5(4):47‒57. (in Russ.). https://doi.org/10.21886/2308-6424-2017-5-4-47-57

10. Bi Y, Sun Y. Laparoscopic pneumovesical ureteral tapering and reimplantation for megaureter. J of Pediatr Surg. 2012:47(12):2285‒2288. https://doi.org/10.1016/j.jpedsurg.2012.09.020

11. Herz D, Fuchs M, Todd A, McLeod D, Smith J. Robotassisted laparoscopic extravesical ureteral reimplant: a critical look at surgical outcomes. J Pediatr Urol. 2016;12(6):402-e1‒ 402-e9. https://doi.org/10.1016/j.jpurol.2016.05.042

12. Chertin B, Pollack A, Koulikov D, Rabinowitz R, Shen O, Hain D, Hadas-Halpren I, Shenfeld OZ, Farkas A. Long-term follow up of antenatally diagnosed megaureters. J Pediatr Urol. 2008;4(3):188‒191. https://doi.org/10.1016/j.jpurol.2007.11.013

13. Paquin AJ. Ureterovesical anastomosis: the description and evaluation of a technique. J Urol. 1959;82:573‒583. https://doi.org/10.1016/s0022-5347(17)65934-2

14. Parrott TS, Woodard JR, Wolpert JJ. Ureteral tailoring: a comparison of wedge resection with infolding. J Urol. 1990;144(2):328‒329. https://doi.org/10.1016/s0022-5347(17)39445-4

15. Ben-Meir D, McMullin N, Kimber C, Gibikote S, Kongola K, Hutson J.M. Reimplantation of obstructive megaureters with and without tailoring. J Pediatr Urol. 2006;2 (3):178‒181. https://doi.org/10.1016/j.jpurol.2005.05.010

16. Perdzynski W, Kalicinski ZH. Long-term results after megaureter folding in children. J Pediatr Surg. 1996;31(9):1211‒1217. https://doi.org/10.1016/s0022-3468(96)90234-1

17. Mollard P, Foray P, De Godoy JL, Valignat C. Management of primary obstructive megaureter without reflux in neonates. Eur Urol. 1993;24(4):505‒510. https://doi.org/10.1159/000474359

18. DeFoor W, Minevich E, Reddy P, Polsky E, McGregor A, Wacksman J, Sheldon C. Results of Tapered Ureteral Reimplantation for Primary Megaureter: Extravesical Versus Intravesical Approach. J Urol. 2004;172(4 Pt 2):1640‒1643. https://doi.org/10.1097/01.ju.0000138529.43179.dd

19. McLorie GA, Jayanthi VR, Kinahan TJ, Khoury AE, Churchill BM. A modified extravesical technique for megaureter repair. Br J Urol. 1994;74(6):715‒719. https://doi.org/10.1111/j.1464-410x.1994.tb07112.x

20. Lee BR, Partin AW, Epstein JI, Quinlan DM, Gosling JA, Gearhart JP. A quantitative histological analysis of the dilated ureter of childhood. J Urol. 1992;148(5):1482‒1486. https://doi.org/10.1016/s0022-5347(17)36944-6