42 - Surgery of the Ureter in Children: Ureteropelvic Junction, Megaureter, and Vesicoureteral Reflux

Abstract

Dilation of the upper urinary tract in children is quite common and is mainly related to congenital conditions such as ureteropelvic junction obstruction, ureterovesical junction obstruction, and vesicoureteral reflux. Dilation is however not always synonymous with true obstruction, and the majority of dilations observed in infancy and childhood disappear or stabilize spontaneously. In cases of clinically significant obstruction at the ureteropelvic junction, dismembered pyeloplasty remains the gold standard procedure. This can be performed via the open technique, especially in infancy, or via minimally invasive techniques such as laparoscopic and robotic-assisted procedures in older children, with very high success rates and low operative morbidity. Likewise, megaureters resolve or stabilize spontaneously in the majority of cases, and the few that require intervention can be managed successfully with ureteral reimplantation with or without ureteral remodeling. In less severe dilations, management with balloon dilation and stenting of the ureterovesical junction for a period of 2 to 6 months is also viable. The same surgical principles apply to the refluxing ureter, for which open ureteral reimplantation remains the gold standard intervention, with success rates upward of 95%, although minimally invasive procedures such as laparoscopic and robotic-assisted ureteral reimplants are becoming more common. Endoscopic injection, especially that of dextranomer hyaluronic acid, is also in common use, with excellent long-term outcomes after one to three injections and is probably used as a first-line treatment at many centers because of its simplicity and relative noninvasiveness.