End Cutaneous Ureterostomy Research Articles

Primary repair vs Delayed staged repair in infants with primary obstructive megaureters and their long term outcomes – A single centre experience

There is paucity of literature in the management of infants with primary obstructive megaureters undergoing upfront primary repair with an extravesical technique of ureteral re implantation (with or without ureteral tailoring). To compare 2 different approaches in the management of infants with unilateral primary obstructive megaureters. This was a retrospective analysis of a prospectively maintained data base between 2005 and 2021. Infants <1 year with unilateral primary obstructive megaureter were included. They were divided into 2 groups: those who underwent an upfront extravesical ureteric reimplantation with or without ureteral tailoring during infancy -Primary Repair (PR), and those who initially underwent a low end cutaneous ureterostomy during infancy followed by take down of ureterostomy and intravesical ureteric reimplantation after 1 year of age -Delayed staged repair (DSR). Children presenting with sepsis, in whom a diversion was imperative, were excluded. All children were followed up annually after their definitive repair with a renal ultrasound, diuretic renogram, estimated glomerular filtration rate and assessment of voiding dysfunction if present. The 1st year and 3rd year follow up details were collated and analysed. Failure was defined as persistent obstructive pattern on renogram with worsening differential renal function or presence of high grade reflux with recurrent breakthrough urinary tract infection; both of which necessitated a redo reimplantation following the definitive surgery. There were 18 infants in Primary repair and 16 infants in Delayed Staged Repair. Urinary tract infections was the commonest presenting symptom amongst both groups i.e. > 50%.The post operative complication rate was 11% in Primary repair and 31% in Delayed Staged Repair. One child in each of the groups (2 girls) required redo reimplantation (5.8%). At the end of the 3rd year follow up (from the definitive repair) there was significant reduction in the hydronephrosis, improvement in the differential renal function with no evidence of obstruction and improvement in the estimated glomerular filtration rate amongst all in both groups which was statistically significant i.e. p<0.05. The success rate was 94.4% in Primary Repair and 93.75% in Delayed Staged Repair. The mean follow up was 9.7 years amongst those undergone Primary Repair and 9 years amongst those undergone Delayed Staged Repair. Primary extravesical ureteral reimplantation may be considered as the preferred line of management of unilateral obstructed megaureters during infancy.

Laparoscopic robotic takedown ureterostomy with extravesical cross-trigonal reimplantation after end cutaneous ureterostomy

Introduction The main goal of managing an obstructed megaureter (OMU) is to preserve the function of the affected kidney. To preserve the upper urinary tract, end cutaneous ureterostomy (ECU) seems to be a promising temporizing option. We aimed to evaluate our experience with ECU in patients with primary and secondary OMU and to demonstrate an efficacy of robot-assisted laparoscopic takedown ureterostomy and subsequent extravesical ureteric reimplantation. Materials and methods Retrospective analysis of patients that underwent ECU due to primary or secondary megaureter between 2003 and 2020. Nineteen patients (12 males, 7 females) with a mean age of 4.2 ± 3.5 months (mean ± standard deviation) underwent ECU of 27 renal units. Of those, 11 (57.9%) had primary OMU and 8 (42.1%) had secondary OMU. Undiversion was performed in 16 (84%) out of 19 patients (20 renal units out of 27 [74%]). Results In the vast majority of the cases, we have observed improvement in the hydronephrosis and renal function after ureterostomy. After reimplantation ultrasonography showed either stable or further improvement in hydronephrosis in 80% of patients. Robot-assisted laparoscopic patients had shorter admission period and indwelling catheter time after the surgery. Conclusions End cutaneous ureterostomy is a safe and effective temporary procedure for the treatment of progressive primary and secondary megaureters. Robot-assisted laparoscopic takedown of ureterostomy with subsequent reimplantation seems to be a good alternative for undiversion and subsequent reimplantation in these patients.

An exceptionally rare cause of fetal megacystis in a male fetus

Megacystis in a male fetus is most commonly due to posterior urethral valves (PUV). Reported incidence ranges from 1:5000–1:8000 births. Other causes of megacystis in a male fetus include prune belly syndrome, neurogenic bladder, bilateral high grade V-U reflux etc. We are presenting a case of megacystis diagnosed at 27 weeks gestation, due to large tortuous ectopic ureter from a single system inserting into the prostatic urethra. This case highlights the interesting diagnostic and management challenges encountered with an exceptionally rare malformation causing bladder outlet obstruction. The antenatal ultrasound at 20 week gestation was normal. By 33 weeks, bilateral pelvicalyceal dilatation and bilateral hydroureter was seen; additionally, bladder appear enlarged. Ultrasound at 39 week gestation suspected the right ureteric insertion to be ectopic into the bladder neck. Follow up scans demonstrated worsening hydroureteronephrosis and megacystis. The amniotic fluid volume remained within normal limits. Working diagnosis was bladder outlet obstruction due to PUV. His post-natal ultrasounds, MCUG and MRU confirmed a single system on the right side with ectopic insertion into the prostatic urethra causing bladder outlet obstruction. On the left a low lying malrotated kidney & grade 4-5 vesicoureteric reflux was noted. Serum creatinine was high in the neonatal period. He underwent cystoscopy to confirm the ectopic right ureteric insertion. The right ureter was disconnected from prostatic urethra and an end cutaneous ureterostomy was performed to relieving bladder outlet obstruction and allowing better decompression of right ureter. At 9 months follow-up his renal function had normalized and he had a good urinary stream. The right ureter will be re-implanted to the bladder at 2 years of age. There are few similar cases of similar cases of megacystis in the literature. Ectopic ureters inserting into posterior urethra causing bladder outlet obstruction in all case reports are diagnostic conundrum and must be considered as rarer differential diagnoses to PUV.

Commentary on “Outcome of end cutaneous ureterostomy (EUC) as a non conservative option in the management of primary obstructive megaureters (POM)”

Commentary on “Outcome of end cutaneous ureterostomy (EUC) as a non conservative option in the management of primary obstructive megaureters (POM)”

Outcome of end cutaneous ureterostomy (ECU) as a non conservative option in the management of primary obstructive megaureters (POM)

Primary obstructive megaureters (POM) can be treated with one of the following options: conservative management with antibiotic chemoprophylaxis and active observation of the hydroureteronephrosis (HUN) until suspicion of renal deterioration; refluxing/non-refluxing ureteric reimplantation with antibiotic suppression; temporary double-J stenting; endoscopic balloon dilatation; endoureterotomy; and end cutaneous ureterostomy (ECU). To study the profile of patients with POM and assess the efficacy, safety and outcome of ECU as an interim procedure. A retrospective review was performed of patients who underwent ECU for POM between January 2004 and December 2014. Demographics, surgical details, and outcomes were studied. A total of 25 patients (19 males, six females) underwent ECU of 25 renal units for POM at a mean age of 7 months (range 23 days to 2.5 years). Of these, nine had presented with radiological worsening of antenatally detected HUN, 12 had symptoms (urosepsis in nine and palpable hydronephrosis in three), three had a solitary kidney in renal failure, and one had incidentally diagnosed renal cortical thinning as shown in Table below. Following diversion, renal failure had resolved in all, and febrile urinary tract infection (UTI) developed in one while awaiting reimplantation. Undiversion was performed in 21/25 patients at a mean duration of 12 months after diversion and a mean age of 19 months. In these, the ureteric size had decreased significantly at reimplantation. In 4/25, undiversion was not performed due to loss of follow-up in two and a subsequent nephrectomy in two. Two out of 21 developed febrile UTI after undiversion. The overall mean follow-up period was 34.2 months (n=25), while the mean follow-up after undiversion was 41.5 months (n=21). There was no incidence of stomal complications. End cutaneous ureterostomy was a safe and effective temporary procedure for the treatment of progressive primary obstructive megaureters.

Role of proximal drainage in obstruction in the urinary tract: an observational study

Background:Urinary tract obstruction may occur due to various causes at various levels. Proximal drainage implies drainage of the urinary tract proximal to the site of obstruction. This may be unilateral or bilateral and may be classified as follows: Renal- nephrostomy, pelvic-pyelostomy, ureteral-ureterostomy, vesical-cystostomy and urethral- urethrostomy. The aim of the present work would be to analyse the cases needed such drainage procedure in six months period in a tertiary care teaching hospital, Kolkata, India.Methods: Proximal drainage operations done in series of 35 cases were standard nephrostomy, U-tube nephrostomy, percutaneous needle nephrostomy, end cutaneous ureterostomy, T-tube ureterostomy and suprapubic cystostomy. In 4 cases the drainage operations were done as emergency and lifesaving procedure. Seven drainage operations were done for permanent diversion of urine, 22 as preparatory to subsequent corrective or palliative surgery and 8 as adjuvant with corrective surgery. Clinical findings, post-operative complaints and results of investigations were noted and both pre and post-operative findings were compared to assess the ultimate results of the surgical treatment.Results:Out of 9 cases of nephrostomy, 4 cases (44.44%) showed good result, 4 cases (44.44%) showed fair result and 1 case (11.11%) showed bad result. In 21 cases of T-tube ureterostomy, 15 cases (71.42%) showed good result, 3 cases (14.28%) showed fair result and 3 cases (14.28%) showed bad result. Out of the 6 cases of cutaneous ureterostomy, 4 cases (66.66%) showed good result, 1 cases (16.66%) showed fair result and 1 case (16.66%) showed bad result. The case had bad result (case no. 3) was a case of urinary tuberculosis with ureteric stricture at the lower third with hydroureteronephrosis and poorly functioning kidney on the other side. Out of the 3 cases of suprapubic cystostomy, 1 case showed good result and 2 cases showed fair result. Conclusions:Drainage operation was done as preparatory to subsequent corrective or palliative surgery in majority of the cases. Proximal drainage helps controlling infection, normalizing blood biochemistry, regression of back pressure changes, in a word improving renal function. Proximal drainage of urine should be done before irreversible damage to the renal parenchyma occurs.

Congenital giant megaureter associated with ipsilateral multicystic dysplastic kidney in newborn

Congenital giant megaureter presents as abdominal mass and impose diagnostic difficulties. It can be associated with other upper urinary tract anomalies. A female newborn with antenatal diagnosis of polycystic kidneys was admitted at birth due to lower abdominal mass. Ultrasound and CT scans diagnosed a multiloculated cystic lesion in the mid and lower abdomen along with right side multicystic kidney. At laparotomy, an extaperitoneal, lobulated cystic swelling was found due to rightside giant megaureter. Its lower end was of normal caliber and orthotopic. End cutaneous ureterostomy was done. Intravenous urogram and isotope renograms showed nonfunctioning right kidney. She also had grade II vesicoureteral reflux on left side. Child suffered urinary infection twice. At 9m age, right nephroureterectomy was done. Histopathologic examination was consistent with cystic renal dysplasia and dilated ureter. This is the first case report of giant megaureter associated with ipsilateral multicystic dysplastic kidney in newborn.

End Cutaneous Ureterostomy for the Management of Severe Hydronephrosis

Although rarely indicated, surgical treatment of severe megaureter can pose a formidable technical challenge, especially in the small infant. We present our experience and outcomes with end cutaneous ureterostomy as a temporizing adjunct to future ureteral reimplantation. We performed a retrospective cohort study of patients who underwent end cutaneous ureterostomy between 1993 and 2005. Patient demographics, surgical details and outcomes were recorded. A total of 29 patients (22 males, 7 females) underwent diversion of 34 renal units. Primary megaureter was diagnosed in 15 patients (17 renal units). Secondary megaureter was found in 10 patients (12 renal units). Postoperative megaureter was diagnosed in 4 patients (5 renal units). Mean patient age at time of diversion was 3.2 months for those with primary megaureter and 1.4 years overall. Bilateral diversion or diversion of a solitary functioning kidney was performed in 14 patients (48%), of whom 4 had renal insufficiency. Nine patients (31%) had a febrile urinary tract infection while awaiting undiversion, with no evidence of renal scarring on followup. Undiversion was performed in 12 patients (13 renal units) with primary megaureter at a mean age of 18 months. Overall, undiversion was performed in 21 patients (23 renal units), and ureteral tailoring was required in only 5 renal units (22%). Mean followup after undiversion was 4.2 years for primary megaureter and 3.9 years overall. End cutaneous ureterostomy is a safe and effective procedure to temporize massive hydronephrosis while awaiting definitive ureteral reimplantation.

Bilateral ureterocutaneostomy with modified stoma: long-term follow-up

Ileal conduit and orthotopic bladder substitution have been the preferred options for urinary diversion after cystectomy. Self-catheterisation has revolutionised the management of neuropathic bladder. However, ureterocutaneostomy (cutaneous ureterostomy) described as a means of supravesical urinary diversion 40 years ago still has a definite role for both temporary and permanent diversion particularly in the developing countries. We present a small series of cutaneous ureterostomies performed in four children who have now grown up to become adults without being undiverted. We discuss the technique that we used to modify the stoma, which helped prevent stomal complications over the long term. Our results we believe will rekindle the interest in cutaneous ureterostomy as a viable option for permanent urinary diversion. Four children between ages 2 and 16 years had bilateral side-to-side single stoma tubeless end cutaneous ureterostomy as a primary procedure for permanent urinary diversion. The stoma was modified to prevent retraction and stenosis. Long-term follow-up is presented. All the children have grown up to become adults with their ureterocutaneostomies functioning very well. There have been no biochemical or mechanical complications. Only one out of four stomas had to be refashioned. A simple collection device has proved successful in maintaining a watertight drainage system without apparent problems. Bilateral side-to-side single stoma end cutaneous ureterostomy with modification of the stoma by a plastic surgical technique can help achieve a non-retracting stoma on which a collection device can snuggly fit. It is a viable option for permanent urinary diversion without any significant complications. It is simple, easy and highly practical way of managing urinary diversion especially in the developing countries.

Current indications for cutaneousureterostomy

Objective To assess the current indications for cutaneous ureterostomy in children. Method A total of 32 children underwent cutaneous ureterostomy at Texas Children'sHospital from 1975 to 1990. Medical records were reviewed to determine the urologic diagnosis, the indication for urinary diversion, the type of ureterostomy performed, and the outcome for each patient. Results Twenty patients underwent loop cutaneous ureterostomy (LCU) or pyelostomy and 12 patients underwent end cutaneous ureterostomy (ECU). The main indication for LCU was obstructive uropathy unresponsive to lower urinary tract drainage, and the most common cause was posterior urethral valves. Other indications for LCU included obstruction requiring delayed surgical correction, high-grade reflux into a solitary kidney, and obstruction with infection. The children who required ECU were an older, more diverse group than those who underwent LCU. The main indication for ECU was poor bladder function secondary to a variety of congenital anomalies, including prune-belly syndrome, posterior urethral valves, bladder exstrophy, and urogenital sinus defect. Conclusion LCU is easy to perform and is an excellent method for achieving temporaryupper urinary tract drainage. ECU is suited for long-term or permanent urinary diversion in children with at least one dilated ureter, and can provide a socially acceptable stoma when delayed reconstruction is necessary. Many children who were “permanently” diverted by ECU may be undiverted using newer reconstructive techniques.

The Expanded Role of Transureteroureterostomy in Pediatric Urology

Transureteroureterostomy was used in 31 patients as a component in urinary undiversions, salvage procedures for failed reimplants/reconstructions and diversions with a sigmoid antirefluxing conduit or end cutaneous ureterostomy, as well as an adjunct to reimplantation procedures complicated by an abnormal bladder that precluded reimplantation of more than 1 ureter. Reconstruction in 29 patients involved procedures that changed the drainage of the recipient ureters for various reasons, including obstruction, reflux, undiversion and diversion. A neurogenic bladder was present in 26 patients and an additional 4 patients had a significant bladder pathological condition. Both ureters were dilated in 17 patients, while 1 was dilated in another 6. This series illustrates the versatility and confirms the success of transureteroureterostomy in high risk, complicated reconstructive urological procedures in children.

Application of a silicone stent following end cutaneous ureterostomy.

Application of a silicone stent following end cutaneous ureterostomy.

Surgical Management of Massive Neurogenic Hydronephrosis

Permanent urinary diversion has been the standard recommended treatment of massive dilatation of the upper tracts in the child with neurogenic vesical dysfunction. Reimplantation of relatively normal caliber ureters into neurogenic bladders has been shown to be effective. However, attempts to save urinary diversion in 39 neurogenic megaureters have been unrewarding, with the salvage rate of 15 per cent, and 64 per cent have been diverted permanently. Upper tract decompression by continuous or intermittent catheterization, nephrostomy or end cutaneous ureterostomy was used in this series. When ureteral caliber responded to decompression a reasonable success rate from non-tailored reimplantation may be anticipated. However, in those instances in which ureteral caliber failed to respond or when tailoring of ureteral caliber was done in conjunction with reconstruction the success rate was much lower.

Use of pre-existing ureterocutaneous anastomosis as conduit in renal allotransplantation

This report details 2 patients with unusable bladders whose renal allografts were anastomosed to an existent end cutaneous ureterostomy. The literature on renal allotransplants into intestinal conduits is reviewed. Use of existent, mature end cutaneous ureterostomies is suggested as an alternative to an intestinal conduit in patients with unusable bladders who require renal allografts.