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‘Wrap' Plication of a Megaureter Around the Normal-Sized Ureter In the Management of Complete Duplex System Reimplantation

Monday, October 22, 2012: 2:59 PM
Grand Ballroom B (Hilton Riverside)
M.M.C. van den Heijkant, MD, P. Dik, A.J. Klijn, R. Chrzan, C.F. Kuijper and T.P.V.M. de Jong, Pediatric Urology, Pediatric Renal Center, University Children's Hospitals UMC Utrecht and AMC, Utrecht, Netherlands

Abstract

“Wrap” plication of a megaureter around the normal- sized ureter in the management of complete duplex system reimplantations.

Purpose

A duplex collecting system (DCS) is a common congenital renal tract abnormality associated with different clinical problems. We describe our experience with ureteral reimplantations of a complete DCS where one megaureter, needing recalibration, and one normal sized ureter coexist. The recalibration of the megaureter has been done by a wrap plication around the normal sized ureter.

Methods

Operative logs and case notes were reviewed of consecutive children with a complete DCS treated with a wrap plication of the megaureter around the normal sized ureter and reimplantation between 1997 and 2010. Postoperative reoperation rates, vesicoureteral reflux (VUR) rates and obstruction rates were assessed. To assess severity of surgical complications, the Clavien-Dindo classification system was used.

Figure 1: Wrap plication of a megaureter around the normal-sized ureter in duplex collecting systems, with sufficient spatulation in the normal-sized ureter

Results

25 Children underwent a wrap plication and ureter reimplantation. Nineteen were completely successful (76%). Six out of 25 children (24%) needed a reoperation. Three children (12%) had persistent VUR, two children (8%) underwent endoscopic correction  and one (4%) a re-reimplantation of the duplex system. Three children (12%) had postoperative obstruction and two (8%) underwent endoscopic incision of the ureteral orifice. Another child (4%) developed a nonfunctioning lower moiety of the kidney and therefore underwent a heminephrectomy. The severity of surgical complications is shown in table 1.

Table 1 Reoperation rates after wrap plication and reimplantation of the duplex system.

Reoperation/N

                                                            Clavien-Dindo

6/25                     24%                         classification

EC persistent high-grade VUR lower pole ureter

Endoscopic incision ureteric orifices DCS

Re-reimplantation of the DCS

Heminephrectomy of non-functioning lower moiety kidney

2                            8%                               IIIb

2                            8%                               IIIb

1                            4%                               IIIb

1                            4%                              IVa

EC: endoscopic correction, VUR: vesicoureteral reflux, DCS: duplex collecting system

Conclusion

Wrap plication of a megaureter around the normal-sized ureter before reimplantation seems to be a relatively safe method in the surgical management of children with a complete duplex collecting system of the kidney. Sufficient spatulation of the lower pole ureter seems to be crucial.