The treatment options for vesicoureteral reflux (VUR) include medical management, endoscopic submucosal injection of a bioimplant, and ureteroneocystostomy. In children, ureteroneocystostomy is primarily used, for the treatment of VUR or obstructing megaureter. For VUR, operative indications for ureteroneocystostomy are recurrent febrile urinary tract infections (UTIs), and persistent high-grade (IV–V) VUR.
Ureteroneocystostomy offers the most definitive surgical management available for VUR. It may be performed via an intravesical or extravesical approach or through a combination of the two. Choice of technique is largely dependent on the location of the ureteral orifice as well as surgeon preference.
Ureteroneocystostomy is also indicated for the treatment of primary obstructive megaureter as a primary treatment or after cutaneous ureterostomy. In patients of any age, ureteroneocystostomy is indicated during renal transplantation and for the treatment of ureteral injury. In these patients, performance of a nonrefluxing ureterovesical anastomosis may not be required.
Successful ureteroneocystostomy, regardless of approach or procedure, depends on adherence to surgical principles. The ureter must be handled carefully: Initial mobilization and subsequent manipulation must be atraumatic to avoid devascularization and subsequent stricture formation. The ureter must be adequately mobilized to produce a sufficiently long submucosal tunnel and to avoid tension on the vesicoureteral anastomosis. To avoid postoperative VUR, the ratio of the submucosal tunnel to the ureteral diameter should be at least 5 to 1. The ureter must enter the bladder without significant angulation, twist, or kink to prevent postoperative obstruction. Additionally, before any surgical intervention for VUR, secondary causes must be aggressively investigated and treated.
Approach to the Bladder
Place the patient supine on the operating table with a bump under the pelvis. Prep the patient from the umbilicus to the midthighs, making sure to include the external genitalia in the prep so that access for urethral catheterization is available from the sterile field.
Make a Pfannenstiel incision along Langer’s lines, approximately 1 fingerbreadth above the symphysis pubis ( Fig. 33.1 ). Using blunt and electrocautery dissection, develop the underlying subcutaneous tissue, incise Scarpa fascia, and expose the external oblique aponeurosis
Incise the anterior rectus abdominis sheath (aponeurosis of the external and internal oblique muscles, which are fused medially) either longitudinally or transversely. (We prefer a transverse fascial incision in most cases. However, a longitudinal incision will allow more proximal access to the ureter, and this technique is used when needed.) Elevate fascial flaps laterally or cephalad and caudally using electrocautery to separate the fascia from the rectus abdominis muscle. Place a self-retaining Denis Browne retractor to retract the facial flaps. Identify the bilateral bellies of the rectus abdominis muscles and incise the midline transversalis fascia. Enter and develop the space of Retzius bluntly with lateral retraction of each belly of the rectus abdominis muscle. Retract the bilateral bellies of the rectus abdominis muscle with the Denis Browne retractor. Clear the bladder of perivesical fat.
Stabilize the bladder initially with either Allis clamps or 3-0 chromic stay sutures. Make a vertical cystotomy with electrocautery and empty the bladder. Place 3-0 chromic retraction sutures from the bladder, through the full thickness of the anterior wall lateral to the caudal apex of the cystotomy, to the skin or rectus fascia lateral to the midline. Pack the dome of the bladder with two or three moistened sponges and retract it with a deep blade of the Denis Browne retractor. Reposition the lateral blades of the Denis Browne retractor within the bladder to provide exposure of the posterior wall and trigone of the bladder.
Ureteral Mobilization ( Fig. 33.2 )
Intubate the ureter with a 3.5- or 5-Fr feeding tube and secure it to the adjacent bladder tissue with a 4-0 silk suture, initially placing the suture through the full thickness of the feeding tube. Score the bladder urothelium circumferentially around the ureteral orifice with electrocautery, leaving a rim of urothelium around the ureteral orifice. Begin sharp dissection of the ureter within Waldeyer’s sheath caudally, distal to the ureteral orifice. Mobilize the ureter with traction on the feeding tube by dissecting the bladder muscle fibers away from Waldeyer’s sheath using blunt and electrocautery dissection. After the ureter has been dissected away from the bladder muscle fibers, dissect the extravesical ureter away from the adjacent peritoneum using a combination of blunt and electrocautery dissection. Carefully cauterize the small branches of the superior vesical artery running along the peritoneal reflection.
Intraextravesical (Politano-Leadbetter) Technique ( Fig. 33.3 )
After mobilization of the intramural ureter, begin extraperitoneal blunt dissection of the extravesical ureter with a right-angle clamp. Mobilize the ureter initially in a plane between the posterior bladder wall and the anterior wall of the ureter, keeping caudal traction on the ureter with the feeding tube. After adequate ureteral mobilization has been accomplished, make a transmural incision through the posterior bladder wall with electrocautery at the intended site of the neohiatus over the tip of the right angle clamp. Transfer the distal ureter to the neohiatus. Close the original hiatus with running interrupted 2-0 polyglactin suture.
Dissect a submucosal tunnel from the neohiatus to the original hiatus sharply using tenotomy scissors. Transfer the distal ureter through this tunnel. Excise the most distal ureter sharply with heavy scissors, thereby dividing the feeding tube used initially to cannulate the ureter. Take care to apply external pressure to the ureter proximally and to the feeding tube to prevent cephalad migration of the feeding tube into the ureter.
Spatulate the distal anterior ureter sharply with tenotomy or Potts scissors. Anchor the distal posterior ureter to the neohiatus with 4-0 chromic sutures—place interrupted sutures at the 6-, 5-, and 7 o’clock positions approximating the transmural ureteral tissue and the ureteral orifice comprising deep muscular and urothelial bladder tissue. Approximate the urothelium of the orifice to the spatulated ureter at the 12 o’clock position with 5-0 chromic suture, making sure to incorporate the full thickness of the ureter. Approximate the intervening tissue with similar 5-0 chromic sutures. Close the urothelium overlying the ureter at the neohiatus with a running 5-0 chromic suture.
In some cases, it may be necessary to extend the length of the submucosal tunnel. This can be accomplished by creating a second submucosal tunnel toward the bladder neck. If a second tunnel is made caudally, the ureter is transferred to the location of the new orifice, and the ureterovesical anastomosis is performed as already described; the urothelium overlying the ureter at the original orifice is closed as well with 5-0 chromic suture. Intubate the ureteral orifice with a 3.5- or 5-Fr feeding tube and pass it proximal to the hiatus to ensure that there is no obstruction, either from kinking or twisting of the ureter along its course. Close the bladder in two layers using a running 3-0 absorbable suture for the urothelial layer and a running 2-0 absorbable suture for the seromuscular layer.
Modification of the Intraextravesical (Politano-Leadbetter) Technique
We typically perform a modified Politano-Leadbetter technique in which the original hiatus is opened sufficiently to allow for posterior dissection under direct vision. The neohiatus may then be created by further cephalad extravesical dissection under direct visualization or by opening the posterior wall of the bladder to the intended neohiatus. The floor of the bladder caudal (distal) to the neohiatus, as well as the original hiatus, is closed with either interrupted or running 2-0 polyglactin suture. Care must be taken to avoid closing the neohiatus too tightly to prevent obstruction of the ureter at this point.
Ureteral Advancement (Glenn-Anderson) Technique ( Fig. 33.4 )
After adequate ureteral mobilization has been accomplished, create a submucosal tunnel sharply toward the bladder neck. Incise a portion of the posterior wall of the bladder cephalad to the hiatus and transfer the ureter cephalad. Close the floor of the bladder with interrupted 2-0 absorbable sutures, beginning cephalad. Take care to avoid excessive compression of the ureter with these sutures. Transfer the distal ureter caudally through the submucosal tunnel. The ureterovesical anastomosis is performed as for the combined intraextravesical technique discussed earlier. Close the urothelium overlying the exposed ureter with running 5-0 chromic suture. Intubate the ureteral orifice with a 3.5- or 5-Fr feeding tube and pass it proximal to the hiatus to ensure that there is no obstruction, either from kinking or twisting of the ureter along its course. Close the bladder as described above.
Transtrigonal (Cohen) Technique
Unilateral Ureteroneocystostomy ( Fig. 33.5 )
Mobilize the ureter to be reimplanted and close any laxity of the hiatus with simple 2-0 absorbable sutures (chromic or polyglactin). Create a submucosal tunnel sharply from the hiatus of the ureter to be reimplanted to a point just cephalad to the contralateral ureteral orifice. Transfer the ureter across the trigone through the submucosal tunnel. Perform a ureterovesical anastomosis by approximating transmural ureteral tissue with urothelial bladder tissue using 5-0 chromic or 6-0 polyglactin simple interrupted sutures. Intubate the ureteral orifice with a 3.5- or 5-Fr feeding tube and pass it proximal to the hiatus to ensure that there is no obstruction, either from kinking or twisting of the ureter along its course. Close the bladder in two layers as described earlier.
Bilateral Ureteroneocystostomy ( Fig. 33.6 )
After mobilization of the bilateral ureters, close any laxity of the hiatuses with simple interrupted 2-0 absorbable sutures (chromic or polyglactin). Create a submucosal tunnel sharply from the hiatus of the left ureter to a point just cephalad to the right ureteral orifice. Transfer the left ureter across the trigone through the submucosal tunnel. Perform a ureterovesical anastomosis by approximating transmural ureteral tissue with urothelial bladder tissue using 5-0 chromic or 6-0 polyglactin simple interrupted sutures. Create a submucosal tunnel sharply from the hiatus of the right ureter to the location of the original left ureteral orifice. Transfer the right ureter across the trigone through the submucosal tunnel. Perform a ureterovesical anastomosis as already discussed. Close the urothelium overlying the exposed right ureter with running 5-0 chromic suture. Intubate each ureteral orifice with a 3.5- or 5-Fr feeding tube and pass it proximal to the hiatus to ensure that there is no obstruction, either from kinking or twisting of the ureter along its course. Close the remaining mucosa as described earlier.
Sheath Approximation (Gil Vernet) Technique
Make a transverse incision between the two laterally placed orifices to expose the underlying trigonal muscle. Catch the periurethral sheath at the inferior margin of the first ureter and then the other ureter with a single nonabsorbable mattress suture. Tie the suture to draw the ureters together in the midline.
Spatulated Nipple Technique ( Fig. 33.7 )
When bladder capacity is inadequate to provide an effective tunnel length to ureteral diameter ratio despite ureteral tailoring or tapering techniques, the spatulated nipple technique may be used, especially when delayed surgical intervention is contraindicated. Bring approximately 2 cm of ureter directly through the bladder. Fix the ureter to the neohiatus with simple interrupted 4-0 absorbable sutures that approximate seromuscular ureteral tissue to muscular bladder tissue. Spatulate the distal ureter and evert the distal ureteral lumen. Approximate the distal ureteral margin to the bladder urothelium surrounding the original ureteral orifice with simple interrupted 5-0 chromic or 6-0 polyglactin sutures. Reapproximate the spatulation, now over the more proximal ureter, with simple interrupted 5-0 chromic or 6-0 polyglactin sutures. Intubate the ureteral orifice with a 3.5- or 5-Fr feeding tube and pass it proximal to the hiatus to ensure that there is no obstruction, either from kinking or twisting of the ureter along its course. Close the bladder as described earlier.