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Challenging Concepts in Urological Surgery
Learning point Ureteric reimplantation
This approach has a high success rate of 92– 98%, despite multiple described surgical
techniques which have the principle of lengthening the intramural ureter. The most popular
and reliable is the Cohen cross- trigonal reimplantation. Other alternatives are suprahiatal
reimplantation (Politano– Leadbetter technique), infrahiatal reimplantation (Glenn– Anderson
technique), or extravesical (Lich– Gregoir technique). Though ureteric reimplantation is safe
and feasible in infants <1 year old,16 there is still some apprehension due to concerns about
iatrogenic bladder dysfunction.17 This was not undertaken due to the concerns about causing
worsening bladder dysfunction that could subsequently affect the much better functioning left
renal unit.
Expert comment Urinary diversion
Endoscopic treatment was not undertaken in this patient due to concerns regarding the
dysfunctional bladder with known reduced success rates in combination with high- grade VUR.
The right- sided VUR may have been protective for the left renal system and therefore attempted
correction of the right VUR may have compromised the left side without first resolving the
bladder dysfunction. The authors feel that endoscopic treatment is safe to perform for highgrade reflux in isolation in the absence of bladder dysfunction and also concomitant VUR with
obstruction.
The option of urinary diversion via a refluxing right ureterostomy was undertaken to allow
VUR secondary to bladder dysfunction to be easily drained from the urinary tract and thereby
avoid urinary stasis and reduce the risk of UTIs. Urinary diversion could also be achieved via
a vesicostomy; however, the refluxing ureterostomy allowed continued bladder cycling and
growth.
Expert comment Operative note: cutaneous loop ureterostomy
A transverse inguinal crease incision is made and the anterior abdominal muscles are split to gain
access to the extraperitoneal space. The approach to the ureter is entirely extraperitoneal and the
peritoneum is reflected medially. The obliterated umbilical artery is divided to demonstrate the
ureter. The ureter is carefully mobilized, preserving the blood supply, so that the ureter can reach the
skin. At times, the proximal ureter may need to be dissected and shorted to aid drainage if it is very
tortuous and dilated; however, the surgeon must keep in mind the ureteric length required for later
reconstruction.
The ureter is opened longitudinally to create the loop ureterostomy. The ureter is secured to the
external oblique aponeurosis with a 6/ 0 absorbable suture with the proximal limb secured laterally.
It is important to ensure a kink or stenosis is not created. The mucocutaneous anastomosis is
undertaken with a 6/ 0 absorbable suture.
The ureterostomy is easily covered by the nappy, which makes it easy to handle.
Subsequent serial ultrasounds demonstrated decreased dilatation on the right side
and no left- sided renal dilatation (Figure 47.4).
At 9 months of age, a non- invasive urodynamic study was performed but with
some difficulty due to urinary leakage via the ureterostomy despite the placement of a
balloon catheter to occlude the right VUJ. The study, however, demonstrated minimal
post- void residuals (<5 mL) but it was not possible to define bladder capacity.
A repeat DMSA scan performed at 17 months of age showed 10% differential function of right kidney (Figure 47.5).
Figure 47.4 Postoperative renal USS showing (a) decreased dilatation in the right kidney, longitudinal;
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(b) no hydronephrosis in the left kidney, longitudinal.
At 19 months, an open right nephroureterectomy including ureterostomy closure
was performed. At 3 years’ follow- up, the patient remains well, without urinary
prophylaxis and is UTI free. His estimated glomerular filtration rate is 86 mL/
min/ 1.73m2 and he has complete spontaneous bladder emptying as assessed by
ultrasonography.
Expert comment Ureterostomy closure
The rationale for closure of the ureterostomy was based on the clinical stability of the patient with
time and by demonstrating resolution of the immature infantile bladder with the urodynamic
investigation that confirmed complete bladder emptying. The benefit of reconstructive surgery for
the right dilated system with 10% function, including a ureteric reimplantation, did not outweigh the
risks, therefore a more straightforward total right nephroureterectomy was undertaken. At the time of
nephroureterectomy, it is important to remove the ureter as close to the bladder as possible to avoid
any future problems with a refluxing ureteral stump.
455Case 47 Vesicoureteral reflux in children
Figure 47.5 DMSA scan at 17 months showing a differential function of right 10% and left 90%.
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Challenging Concepts in Urological Surgery
A final word from the expert
This case is a good example of how sometimes we have to be innovative in our management.
The conventional management of this infant would most likely have been endoscopic
correction of the reflux once he reached an appropriate age. Due to the high grade of the
reflux and the young age of the child, endoscopic correction was likely to fail and in fact may
have resulted in worsening of the bladder dynamics and/ or back pressure changes in the
healthy left kidney. In this child, there was clear evidence of incomplete bladder emptying
which was most likely related to the right refluxing system but in addition there could also
have been a component of bladder immaturity/ dysfunction. The initial management was with
clean intermittent catheterization but when this became difficult, an alternative option had
to be sought. Formation of a vesicostomy would be an option but this has the disadvantage
of, at a later stage, not being able to accurately assess the bladder for capacity and efficacy
of emptying. An elegant alternative to a vesicostomy is a refluxing ureterostomy. This system
allows good decompression of the bladder, while still allowing for cycling of the bladder with
urine from the contralateral kidney, a factor which may be important in maturation of bladder
function. It is often seen that, over time, the quantity of refluxing urine from the ureterostomy
reduces, probably due to a combination of maturation of the vesicoureteric mechanism but
also due to linear growth of the child and changes in the angulation of the ureter at the level of
the bladder. The parents witness the increased passage of urine per urethra and by occluding
bladder function. Once it is established that bladder function and emptying is adequate, one
can then either close the ureterostomy, reimplant the refluxing ureter, or perform a complete
nephroureterectomy as in this case.
References
1. Nguyen HT, Benson CB, Bromley B, et al. Multidisciplinary consensus on the classification
of prenatal and postnatal urinary tract dilatation (UTD classification system). J Pediatr Urol.
2014;10(6):982– 998.
2. Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of
postnatal outcome: a metaanalysis. Pediatrics. 2006;118(2):586– 593.
3. Phan V, Traubici J, Hershenfield B, et al. Vesicoureteral reflux in infants with isolated antenatal hydronephrosis. Pediatr Nephrol. 2003;18(12):1224– 1228.
4. Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with
antenatally detected hydronephrosis and other renal abnormalities. Radiology.
1993;187(1):157– 160.
5. Sinha R, Saha S, Maji B, Tse Y. Antibiotics for performing voiding cystourethrogram: a randomised control trial. Arch Dis Child. 2018;103(3):230– 234.
6. Tekgül S, Riedmiller H, Hoebeke P, et al. European Association of Urology guidelines on
vesicoureteral reflux in children. Eur Urol. 2012;62(3):534– 542.
7. Lebowitz RL, Olbing H, Parkkulainen KV, et al. International system of radiographic
grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol.
1985;15(2):105– 109.
8. Paquin AJ. Ureterovesical anastomosis: the description and evaluation of a technique. J
Urol. 1959;82:573– 583.
9. Priti K, Rao KLN, Menon P, et al. Posterior urethral valves: incidence and progress of
vesicoureteric reflux after primary fulguration. Pediatr Surg Int. 2004;20(2):136– 139.
10. Sillén U. Bladder dysfunction and vesicoureteral reflux. Adv Urol. 2008;2008:815472.
11. Chandra M, Maddix H. Urodynamic dysfunction in infants with vesicoureteral reflux. J
Pediatr. 2000;136(6):754– 759.
12. Sillén U, Bachelard M, Hermanson G. Gross bilateral reflux in infants: gradual decrease of
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initial detrusor hypercontractility. J Urol. 1996;155(2):668– 672.
13. Weiss R, Tamminen- Möbius T, Koskimies O, et al. Characteristics at entry of children with
severe primary vesicoureteral reflux recruited for a multicenter, international therapeutic
trial comparing medical and surgical management. The International Reflux Study in
Children. J Urol. 1992;148(5 Pt 1):1644– 1649.
14. Wang HH, Gbadegesin RA, Foreman JW, et al. Efficacy of antibiotic prophylaxis in
children with vesicoureteral reflux: systematic review and meta- analysis. J Urol.
2015;193(3):963– 969.
15. Elder JS, Diaz M, Caldamone AA, et al. Endoscopic therapy for vesicoureteral reflux: a
meta- analysis, I: reflux resolution and urinary tract infection. J Urol. 2006;175(2):716– 722.
16. Jude E, Deshpande A, Barker A, Khosa J, Samnakay N. Intravesical ureteric reimplantation
for primary obstructed megaureter in infants under 1 year of age. J Pediatr Urol.
2017;13(47):47.e1– 47.e7.
17. Farrugia MK, Hitchcock R, Radford A, et al. British Association of Paediatric Urologists consensus statement on the management of the primary obstructive megaureter. J Pediatr Urol.
2014;10(1):26– 33.
18. Earp BD. Do the benefits of male circumcision outweigh the risks? A critique of the proposed CDC guidelines. Front Pediatr. 2015;3:18.
19. Singh- Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis
Child. 2005;90(8):853– 858.
20. Evans K, Asimakadou M, Nwankwo O, et al. What is the risk of urinary tract infection
in children with antenatally presenting dilating vesico- ureteric reflux? J Pediatr Urol.
2015;11(2):93.e1– 93.e6.
457Case 47 Vesicoureteral reflux in children
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SECTION 15
Urological radiology
Case 48 Acute interventional radiology procedures in urology
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48
(b)(a)
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CASE
Acute interventional radiology
procedures in urology
Yousef Shahin
Expert commentary Steven Kennish
Case history
An 81- year- old male patient first presented with a 6- week history of rectal bleeding
and change in bowel habit to the accident and emergency department. The patient
was found to have a large fixed rectal mass on examination by the general surgeons.
Following this, a computed tomography (CT) scan of the abdomen and pelvis confirmed the presence of a locally advanced rectal tumour infiltrating the prostate gland
and the bladder in addition to a suspicious liver lesion. On magnetic resonance imaging (MRI) of the pelvis, the tumour was confirmed to be locally advanced and measured 3 cm in diameter. It was staged as T4N1M1 due to localized vascular invasion and
confirmation of liver metastasis on liver MRI (Figure 48.1).
The patient was discussed at the multidisciplinary team meeting and started on
neoadjuvant chemotherapy and radiotherapy. Follow- up CT scanning demonstrated
tumour response with reduction in size. The patient underwent elective anterior pelvic
exenteration, ileal conduit, and end- colostomy formation. Two months after the operation the patient presented with abdominal pain to the accident and emergency department. A CT scan of the abdomen and pelvis (urographic phase) showed a defect in
the proximal posteromedial wall of the ileal conduit with contrast leaking out with an
associated urinoma (Figure 48.2). The urinoma was drained by inserting an 8- French
drain under ultrasound guidance.
Figure 48.1 MRI of the abdomen and pelvis (axial) showing (a) locally advanced rectal tumour with
invasion of the prostate; (b) single liver metastasis in the right lobe.
462 Challenging Concepts in Urological Surgery
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Figure 48.2 CT urogram showing a defect in the posteromedial wall of the ileal conduit and urinoma.
Learning point Pelvic exenteration and outcomes
Pelvic exenteration surgery for locally advanced rectal cancer is associated with variable outcomes.
The operation is radical and involves the removal of most of the pelvic organs including the urethra,
urinary bladder, rectum, and anus. The procedure leaves the person with a permanent colostomy and
urinary diversion. In women, the vagina, cervix, uterus, fallopian tubes, ovaries, and, in some cases, the
vulva are removed. In men, the prostate is removed.
In a recent multicentre study which included 1184 patients who underwent pelvic exenteration, the
median overall survival was 36 months following R0 resection, 27 months after R1 resection, and
16 months following R2 resection (p <0.001). Patients who received neoadjuvant chemotherapy had
more postoperative complications (unadjusted odds ratio (OR) 1.53), readmissions (unadjusted OR 2.33),
and radiological reinterventions (unadjusted OR 2.12). Bone resection (when required) was associated
with a longer median survival (36 vs 29 months; p <0.001). Node- positive patients had a shorter median
overall survival than those with node- negative disease (22 vs 29 months, respectively). Multivariable
Expert comment Ileal
conduit and complications
Ileal conduit formation involves
anastomosing both diverted ureters
to a length of mobilized small
bowel which is brought out of the
abdomen as a stoma. It is among
the most commonly performed
procedures for urinary diversion,
but attendant risks include
anastomotic leakage and stricture
formation as well as vulnerability
to ischaemia and subsequent
breakdown. Urinary diversion away
from any leak allows healing while
persistent urinary contamination
leads to wound breakdown
and urinoma formation with
subsequent infection.
analysis identified margin status and bone resection as significant determinants of long- term survival.
The patient was reviewed by the urologists and a decision was taken not to revise
the urostomy due to the expected complexity of the procedure and patient frailty. In
order to divert urine away from the leaking urostomy and allow the defect to close,
the patient underwent bilateral nephrostomy insertion by interventional radiologists
which was a challenging procedure due to non- dilated pelvicalyceal systems and the
patient’s inability to lie prone.
Clinical tip Percutaneous nephrostomy insertion
Percutaneous nephrostomy was first described in 1955 by Goodwin et al.2 as a minimally
invasive treatment for urinary obstruction causing hydronephrosis. It is now used in a wide
variety of clinical indications in dilated systems to relieve urinary tract obstruction or nondilated systems to provide urinary diversion away from distal leaks/ fistula or to relieve lower
urinary tract symptoms associated with bladder malignancy. The procedure is performed by
interventional radiologists under ultrasound and fluoroscopy guidance with local anaesthesia
and occasionally intravenous sedoanalgesia.
1
463Case 48 Acute interventional radiology procedures in urology
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Indications
1. Relief of urinary obstruction.
2. Urinary diversion.
3. Access for endourological procedure.
4. Diagnostic testing.
Complications
Most case series report combined immediate major and minor complication rates of approximately
3,4
10%.
Immediate major complications include injury to adjacent structures, severe bleeding, or
severe infection or sepsis and are uncommon. Injury to adjacent organs, most commonly the pleura
or colon, is exceptionally uncommon when careful consideration is given to patient anatomy and
periprocedural planning on CT and ultrasound scanning. Minor complications, including minor
bleeding and transient low- grade fever post insertion, are more often seen and generally unavoidable
in some clinical scenarios.
Late complications are mainly drain related such as displacement, blockage, and encrustation. Patients
with long- term nephrostomy tubes will have these drains exchanged every 3 months to prevent
blockage by encrustation.
Expert comment Nephrostomy in a non- dilated system
Nephrostomy insertion is commonly undertaken for urinary diversion but can be challenging
because the non- dilated target calyces are inherently very difficult to identify even with the most
modern high- end ultrasound equipment.
If covering internal– external ureteric stents have been left in place by the surgical team, these can
be utilized to retrogradely fill the pelvicalyceal systems with contrast to create target calyces visible
to both ultrasound and fluoroscopy. If the stents have been removed prior to the discovery of a
leak, other adjuncts include the intravenous administration of contrast to allow the draining renal
collecting system to be visualized fluoroscopically and an intravenous diuretic with saline to create
increased renal excretion and hopefully a visible calyx on ultrasound.
Retrogradely filling the conduit and ureters with contrast through a catheter is risky in the
context of an ongoing leak or collection because of the risk of driving pyelovenous backflow and
sepsis.
5
The patient was stabilized to allow time for antibiotic treatment and nutritional
support in preparation for a laparotomy, revision of ileal conduit, small bowel resection, and end ileostomy. Unfortunately, the proximal aspect of the ileal conduit was
too stuck down to access for revision surgery. Following this operation, he developed
acute kidney injury and sepsis. A CT of the abdomen and pelvis showed a 7 × 12
cm pelvic collection. This was drained by interventional radiology under CT guidance
(Figure 48.3) following which the patient improved clinically although renal replacement therapy (dialysis) was required.
A month later the patient presented with right- sided flank pain and had a CT scan
which showed right- sided pyelonephritis. A nephrostogram showed a leak close to
the ureteroileal anastomosis on the right and a stricture proximal to the ureteroileal
anastomosis on the left (Figure 48.4). Blood and nephrostomy urine cultures grew
Klebsiella.
Two weeks later, the right nephrostomy tube was not draining, and an unenhanced
CT scan showed the nephrostomy tube to be displaced. A new nephrostomy tube was
inserted on the same day by the interventional radiology team.
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