Elsevier

Journal of Pediatric Urology

Volume 11, Issue 5, October 2015, Pages 266.e1-266.e6
Journal of Pediatric Urology

Retrospective study to determine the short-term outcomes of a modified pneumovesical Glenn–Anderson procedure for treating primary obstructing megaureter

https://doi.org/10.1016/j.jpurol.2015.03.020Get rights and content

Summary

Introduction

Primary obstructive ureter (POM) is an upper urinary tract malformation in children. Transvesicoscopic ureteral reimplantation is increasingly being used as the first choice to correct POM, replacing the open extravesical approach. Although several procedures have been reported, there is no universally accepted technique for endoscopic ureteral reimplantation.

Objective

To report on several modifications of the Glenn–Anderson ureteral advancement technique to make it suitable for a laparoscopic pneumovesical approach to treatment of POM.

Patients and methods

From February 2006 to December 2013, 63 children with POM, 45 male and 18 female (median age 4.2 years; range 2 months–14 years), underwent modified transvesicoscopic ureteral implantation surgery. The technique was modified by repositioning of the hiatus proximally to afford greater “tunnel” length, and use of a trough rather than a tunnel, avoiding the challenges of more adherent mucosa in the trigone. Ureter diameter was followed over a 12-month period post surgery. Voiding cystourethrography (VCUG), intravenous urogram (IVU), or radionuclide imaging were conducted in patients who still had ureteral dilation at 6 months and 12 months after surgery.

Results

The procedure was successfully performed in 62/63 patients. The mean operating time was 105 min. Twelve months after surgery 90% of ureters were considered cured and 10% were considered improved. In patients who showed improvement ureters, the ureter diameter was significantly reduced from preoperative measurements as early as 1 month post surgery.

Discussion

The Glenn–Anderson technique advances the ureteral orifice distal to the trigone near the bladder neck and allows relatively easy access to the upper urinary tract. However, the submucosal tunnel produced is relatively short, and the surgery is not recommended for patients with a small trigone or megaureter because of anatomical considerations. This study made two major modifications to the traditional Glenn–Anderson procedure: (1) the bladder wall was incised superiorolaterally to move the hiatus proximally along the course of the ureter and the detrusor muscle was sutured to the seromuscular layer of the ureter, and (2) a mucosal groove rather than tunnel was used for advancement from the ureteral hiatus to the bladder neck. This approach preserves conventional endourologic access to the upper tracts; however, the stabilizing distal stitch does leave the suture line in proximity to the mucosal suture line, a theoretical disadvantage from the standpoint of ureterovesical fistula.

Conclusions

These preliminary results indicate that this modified transvesicoscopic ureteral implantation is an effective procedure with minimal morbidity.

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Figure. Transvesicoscopic ureteral reimplantation for an 11-month-old girl. After confirming the locations of trocars (left), we began the operation with a 5-mm trocar as the midline camera port and two 3-mm trocars as the working ports (right).

Introduction

Primary obstructive ureter (POM) is an upper urinary tract malformation in children, and has the potential to cause long-term kidney damage and pyelonephritis [1]. POM occurs in 0.36 of 1000 to 1 of 1500 live births [1], [2]. Treatment for POM is generally a “watchful-waiting” approach and/or antibiotic prophylaxis to prevent recurrent UTIs. However, 21–23% of POM patients [1], [2] will require surgical treatment for breakthrough infections and worsening dilation of ureters.

Ureteral reimplantation has a high success rate, over 90%, for effective treatment of urinary reflux [3]. However, there is no universally accepted technique for endoscopic ureteral reimplantation to treat POM and vesciouretal reflux (VUR). Various surgical techniques have been reported, including extravesical Lich-Gregoir technique [4], endoscopic trigonoplasty [5], Politano-Leadbetter technique [6], Glenn–Anderson reimplantation, and the Cohen procedure. The Cohen and Glenn–Anderson reimplantation procedures are the most widely accepted to correct POM or VUR [7], [8], [9], [10]. In the Cohen procedure, the ureter is rerouted so that it tunnels across the trigone to exit the contralateral half of the bladder. The Cohen procedure allows for ample bladder to be used for the tunnel with very little in terms of anatomic limitations in how far the tunnel can be extended. However, altering the normal anatomical alignment of the ureter makes retrograde access to the upper urinary tract difficult [11], [12]. Furthermore, cross-trigonal dissection is more likely to disturb the contralateral hemi-trigone and could result in a higher rate of contralateral reflux [13]. In contrast, the Glenn–Anderson technique advances the ureteral orifice distal to the trigone near the bladder neck and preserves the normal course of the ureter. There is a reduced risk for ureteral kinking or obstruction with this technique [8], it minimizes the impact on the hemi-trigone, and allows relatively easy access to the upper urinary tract. In fact, minimally invasive treatments for upper tract nephrolithiasis are more successful after the Glenn–Anderson surgery than after the Cohen procedure [14]. An additional advantage is that the muscular trigone would have to be considered an optimal backing for the ureter in prevention of reflux. However, the submucosal tunnel produced is relatively short, and the surgery is not recommended for patients with a small trigone or megaureter because of anatomical considerations [15].

Transvesicoscopic ureteral reimplantation is increasingly replacing open extravesical approach in the field of pediatric urology. Its potential benefits include reduction in postoperative bladder spasms, decreased incisional blood loss and pain, and improved cosmetics. Minimally invasive procedures using a laparoscopic technique and CO2 insufflation of the bladder (pneumovesicum) were introduced in 2005 [7]. Since then, there have been several advocates of transvesical reimplantation for POM in children. Although this technology has several advantages, it has never achieved widespread acceptance. Because of the extremely high level of skill required to perform the operation, laparoscopic techniques have been limited to a few select pediatric surgeries and centers. Herein, we describe a modified pneumovesical Glenn–Anderson technique that achieves adequate submucosal length of the ureter to treat POM in children.

Section snippets

Patient enrollment and characteristics

Sixty-three patients (45 male, 18 female) ranging in age from 2 months to 14 years (median age 4.2 years) were recruited at our hospital from February 2006 to December 2013. Preoperatively, patients were evaluated with at least two urinary system ultrasounds, VCUG, and either an IVP or radionucleotide (DMSA) study. Indications for surgery included recurrent urinary tract infections (9 cases), deterioration of split renal function (46 cases), and significant worsening dilation of ureters (24

Results

The mean operating time for the total cohort was 105 min (range 70–195 min). Patients who required unilateral surgery had a mean operating time of 92 min (range 70–170 min), bilateral operations required a mean of 175 min (range 110–195 min). To evaluate the learning curve for the operating surgeon, the operative time was compared between the first 15 unilateral patients and the following 41 unilateral patients. One patient was converted to an open surgery because of displacement of the port,

Discussion

The Glenn–Anderson procedure to treat VUR was first reported in 1967 by Glenn and Anderson [15]. In the original technique, the distal ureter was mobilized for 2–3 cm and the configuration of the ureterovesical hiatus was maintained, which avoided enlargement of this hiatus. The ureteral orifice was then advanced distally toward the trigone near the bladder neck to preserve the normal course of the ureter. Glenn and Anderson realized that the length of the submucosal tunnel created was too

Conflict of interest

None.

Funding

None.

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