BJU International (1999), 83, 334–336

P O I NT OF TE C HN I QU E

Ureterocystoplasty: a variant of an operative techniqueZ.D. KRSTICUniversity Children’s Hospital, Belgrade, Yugoslavia

physiological solution provided little improvement, indi-Indications

cating bladder augmentation.Using the same Pfannenstiel incision, both cutaneousUreteric augmentation was popularized by Bellinger [1]

and Churchill et al. [2] as an ideal bladder augmentation. ureterostomies were taken down, i.e. both ureters weremobilized extraperitoneally for 7–8 cm, taking care toIt provides native nonsecreting transitional epithelium

with an elastic wall and muscle backing, which elimin- preserve ureteric vascularization. Considering the extens-ive ureteric dilatation, which persisted at 2–2.5 cm, andates the potential for metabolic disturbances, mucus

production and malignancy that may occur after aug- a very small bladder, bilateral reimplantation was con-sidered unreliable, even after tapering. The ureters werementation with gastrointestinal tract segments [3].

Ureterocystoplasty was successful even in children with opened anteromedially (Fig. 1b) and an antireflux mech-anism created by forming a 1.5 cm long nipple usingminimally dilated ureters [4]. However, the procedure

described previously requires the use of the extensively ureteric intussusception, secured with interrupted 4–0synthetic absorbable sutures in three rows (Fig. 1c). Thedilated ureter (and sometimes renal pelvis) of a nonfunc-

tional kidney or the mid- and distal ureter with preser- right ureter was wider, permitting the construction of a‘telescopic’ antireflux system with a double intussuscep-vation of the ipsilateral functioning renal unit; however,

this necessitates trans-ureteroureterostomy, which some- tion (Fig. 1d). Both nipples were then joined in themidline, as were the anterior and posterior edges of thetimes may endanger the second kidney [5,6].

The blood supply of the ureteric/renal pelvic patch is ureteric flaps, thus forming a 10×5×4 cm calotte(Fig. 1c). The bladder was opened transversally acrosscarried by branches of the renal, gonadal and iliac

vessels [1,7]. However, in such cases the essential vascu- the bladder dome and the calotte sutured as a ‘cap’ ontothe open bladder, with a continuous absorbable suture.larization is nevertheless based on the retrograde circu-

lation. The present variant of ureterocystoplasty involves To facilitate intermittent catheterization, a preputial con-tinent vesicostomy was formed [8]. The postoperativethe use of giant megaureters of the functioning kidney,

with no separation from the proximal urinary tract and course was uneventful and cystography showed anexcellent bladder capacity but with left VUR. The bladderproximal circulation.capacity was increased from 60 mL to 260 mL. Threeyears after ureterocystoplasty the child easily catheterizes

Methodthrough the stoma and, under socially inadequate con-ditions, can also urinate spontaneously with a 40 mLA 4-year-old boy was initially treated in 1992 for renal

failure caused by a neurogenic bladder, with bilateral residuum. Except for periodic bacteriuria, the boy hadno symptomatic infections and his renal function stabil-reflux grade 5/5 and mega-ureteric hydronephrosis. End

cutaneous ureterostomies (Fig. 1a) were constructed ized at the same level as that prevailing when he hadcutaneous ureterostomies.through a Pfannenstiel incision (the right ureter was

3.5–4 cm in diameter and the left 3 cm). This improvedand stabilized overall renal function (creatinine

Advantages and disadvantages80–90 mmol/L). His urological status was re-evaluatedin 1995, which revealed that the bladder was of low The greatest advantage of the technique is the bilateral

use of megaureters of the functioning kidney, with nocapacity and poor compliance. Daily dilatation with

Fig. 1. a, End cutaneous ureterostomies. b, Ureters mobilized extraperitoneally through the same Pfannesteiel incision and cutanteromedially (interrupted line). c, Antireflux mechanism created by forming a nipple by intussusception of the ureter, showing thesutured posterior edges of the ureteric flaps and Foley catheter in the open bladder. d, Formation of the nipple by double intussusception.

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336 Z.D. KRSTIC

separation from the proximal urinary tract and proximalDiYculties and complications

circulation. The technique therefore enables ureterocys-toplasty even after previous surgical interventions on There were no complications, except for unilateral reflux,

which 3 years after surgery has caused no deteriorationthe vesico-ureteric junction (ureterocystoneostomy, endcutaneous ureterostomy). In the present procedure the of renal function because the bladder created has a large

capacity and low pressure when voided using CISC. Thepatch receives most of its blood supply from above(longitudinal arterial inflow), unlike other methods of only remaining issue is how to stabilize the nipple and

whether double intussusception is a suBcient solution.ureterocystoplasty that rely on retrograde flow (vesicalarteries). The blood supply for the megaureteric patcharises from the renal and probably gonadal vessels,because the blood supply from the iliac vessels had beendisrupted by previous cutaneous ureterostomies. The use Referencesof the proximal blood supply of the ureter is very reliable, 1 Bellinger MF. Ureterocystoplasty: a unique method for vesicalas confirmed by its use in renal transplantation. augmentation in children. J Urol 1993; 149: 811–3

The whole procedure may be carried out extraperito- 2 Churchill BM, Aliabadi H, Landau EH et al. Ureteral bladderneally, which in patients with renal failure permits augmentation. J Urol 1993; 150: 716–20

3 Reinberg Y, Allen RC, Vaughn M, McKenna PH.preservation of the integrity of the peritoneal cavityNephrectomy combined with lower abdominal extraperito-for possible subsequent peritoneal dialysis, and thusneal ureteral bladder augmentation in the treatment ofavoids complications of intraperitoneal surgery. Thechildren with the vesicoureteral reflux dysplasia syndrome.presence of a ventriculoperitoneal shunt makes thisJ Urol 1995; 153: 177–9procedure even more advantageous. The procedure may

4 Hitchcock RJI, DuCy PG, Malone PS. Ureterocystoplasty: thebe applicable in chosen cases of unilateral mega-bladder augmentation of choice. Br J Urol 1994; 73: 575–9

ureterohydronephrosis and a functioning kidney, thus5 Gosalbez R, Kim CO. Ureterocystoplasty with preservation of

avoiding intraperitoneal transuretero-ureterostomy that ipsilateral renal function. J Ped Surg 1996; 31: 970–5may endanger the healthy kidney. 6 Noble IG, Lee KT, Mundy AR. Transuretero-ureterostomy.

The disadvantage of the technique is its limitation to A review of 253 cases. Br J Urol 1997; 79: 20–3enormously dilated ureters. The antireflux mechanism is 7 Churchill BM, Jayanthi VR, Landau EH, McLorie GA, Khoury

AE. Ureterocystoplasty: Importance of the proximal blooda separate issue; the reliability of the antireflux nipplesupply. J Urol 1995; 154: 197–8mechanism remains undetermined and presents the

8 Krstic ZD. Preputial continent vesicostomy. Preliminarymain problem of the procedure. However, in patientsreport of a new technique. J Urol 1995; 154: 1160–1with ureters dilated to such an extent, and with very

small contractible and noncompliant bladders, any otherantireflux mechanism would be probably also be suspect.In the present patient, no reflux occurred on the sidewhere double intussusception was used and where the Authornipple was 2.5 cm long, but developed on the side with Z.D. Krstic, MD, PhD, Associate Professor of Pediatric Surgery,

University Children’s Hospital, Tirsova 10, 11000 Belgrade,single intussusception where the nipple was 1.5 cm long;Serbia, Yugoslavia.cystoscopy showed that the nipple was lost.

© 1999 BJU International 83, 334–336