Primary obstructive megaureter is dilatation of the ureter secondary to narrowing at the vesicoureteric junction (VUJ). Many (80%) require no intervention, however, a select number do for worsening hydroureteronephrosis, decreasing renal function, prolonged drainage time, recurrent urinary tract infections or stones. Surgical strategies include cutaneous ureterostomy, tapered ureteric reimplantation, endoscopic balloon dilatation or refluxing diversion. Lee and Kaefer described the refluxing internal diversion in 2005 (primary ureterovesicostomy), creating a freely refluxing end-to-side anastomosis between the transected ureter (proximal to the obstruction) and the bladder. This overcomes difficulties in infants and small children where there is a small bladder and a large calibre ureter (avoiding the need to taper or to form an incontinent stoma). Here, the authors studied patients undergoing a ureterovesicostomy between 2016 and 2023. Within 183 patients diagnosed with primary obstructive megaureter during this period, 47 (26%) were treated with a refluxing ureterovesicostomy. Median age at surgery was nine months. Operative time was approximately 1.5 hours and patient stay was approximately 20 hours (same day discharge in 40%). During postoperative follow-up, 14 (30%) developed a urinary tract infection. Seven children (15%) ultimately required additional procedures. Six children underwent ureteral reimplantation and in one, the anastomosis was simply reversed (having shown subsequent patency at the VUJ). After surgery there was a significant decrease in the proportion of patients with high-grade hydronephrosis, anteroposterior renal pelvis diameter, and maximum ureteral dilatation. The authors conclude that refluxing ureterovesicostomy is a safe alternative to cutaneous diversion in primary obstructive megaureter. Most patients had improvement in upper tract dilatation with an acceptable short-term complication rate and need for reoperation (in comparison to routine later reimplantation). The study adds evidence to the literature that monitoring alone after ureterovesicostomy is feasible, and that only a select number may require subsequent reconstruction.
Long term outcomes of primary ureterovesicostomy for the primary obstructive megaureter
Reviewed by Neil Featherstone
Should a refluxing internal diversion be considered a temporizing procedure? Extended follow-up and outcomes after side-to-side ureterovesicostomy for primary obstructive megaureter in young children.
CONTRIBUTOR
Neil Featherstone
Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).
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