The use of refluxing ureter in the creation of a Mitrofanoff channel in children undergoing bladder augmentation: is a formal reimplantation necessary?

Transureteroureterostomy as an adjunctive antireflux procedure in children undergoing bladder augmentation for neurogenic bladder with major reflux

INTRODUCTION

Transureteroureterostomy (TUU) provides urinary drainage of both renal systems to the bladder via a single ureter and is useful in selected situations of complex urological reconstructions. Herein we discuss its use, advantages and complications in children with neurogenic bladders and high-grade (4/5) reflux who have undergone augmentation cystoplasty.

PATIENTS AND METHODS

Children with neurogenic bladder complicated by unilateral or bilateral high-grade vesicoureteric reflux (VUR), who underwent TUU along with augmentation cystoplasty (BA), were selected from two institutions. Eighteen children with an average age of 5 years at presentation were identified from a retrospective chart review.

RESULTS

All had bilateral hydroureteronephrosis (HUN) of which there were 30 refluxing megaureters. While BA reduced bladder pressure, VUR was managed by refluxing to non-refluxing TUU in six cases with unilateral VUR and unilateral reimplantation with TUU to the reimplanted ureter in 12 cases of bilateral VUR, thus minimizing reimplantation to 12 of 30 ureters. The average time of follow-up was 51 months. Follow-up cystograms showed complete resolution of VUR in all. HUN improved/stabilized in all but one child. Serum creatinine remained normal in all but two cases. Other advantages of TUU include the use of the distal ureter as a catheterizable channel and ease of undiversion when the ureter has been diverted as a ureterostomy. An unusual complication of a TUU site stricture is discussed and the innovative technique of using a cecal patch to salvage the anastomosis is detailed.

CONCLUSION

We conclude that a TUU is a safe and useful adjunctive procedure in children undergoing BA for neurogenic bladder with high-grade VUR, minimizing the need for ureteric reimplant in an unhealthy bladder.

Umbilical rotation: a new technique for the cutaneous fixation of continent catheterizable vesicostomies

PURPOSE

For cutaneous fixation of the continent catheterizable vesicostomy we present a new technique, in which the umbilicus is rotated caudally by 180° and the catheterizable channel is sutured to the umbilical cone. This procedure reduces the distance between the stoma entrance and the bladder.

MATERIALS AND METHODS

Between 2001 and 2008, 67 patients underwent construction of a continent catheterizable vesicostomy. In 82% (n = 55), this was an appendicovesicostomy according to the Mitrofanoff principle. For 21 of these patients, later in the series (2005 onwards), the procedure involved rotation of the umbilicus. We evaluated cosmetic outcome and channel-related complication rates and compared the results between the two groups, with and without umbilical rotation.

RESULTS

The overall complication rate was 22.4% (n = 15); stoma stenosis occurred in eight cases. In the majority of cases with complications, endoscopic treatment was sufficient. The complication rate was significantly lower in the group with umbilical rotation compared to the other group (14.3% vs 26.1%, P < 0.02).

CONCLUSIONS

Umbilical rotation always enables cutaneous implantation of the vesicostomy in the umbilical pit and is a safe and straightforward procedure.