Ureteroneocystostomy - treatment for vesicoureteral reflux (VUR)

Indications in VUR

• Breakthrough UTI on continuous antibiotic prophylaxis or unable to comply
• Persistent VUR/unlikely to have spontaneous resolution of VUR

Otherwise used in setting of ureteral injury

Principles

• Resect distal 2-3 cm of ureter (underdeveloped muscle)
• Create intravesical submucosal tunnel with length:diameter at least 3-5:1
• Tapering if needed
• Avoid kinking/obstruction

Reimplant types

• Intravesical: higher risk of bladder spasm, more difficult post-operative care. When mobilizing ureter at posterior bladder, be careful of peritoneum and the vas
• Politano-Leadbetter - more complex, but UO remains in anatomic position for future ureteroscopy. However ureter can kink when bladder is full
• Excise UO and mobilize distal ureter
• Re-implant into the bladder wall 3 cm above UO
• Create submucosal tunnel so that UO remains in same place
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• Cohen cross-trigonal - lengthens submucosal tunnel to opposite side of bladder; makes future endoscopy very difficult (use only select situations)
• Mobilize ureter and create submucosal tunnel to reimplant just cephalad to contralateral UO
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• Glenn-Anderson advancement - can use to correct an ectopic UO
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• Paquin - extravesical dissection of ureter, then intravesical reimplant similar to Politano-Leadbetter
• Extravesical: Not indicated for bilateral ureteral implant - damage to pelvic plexus on both sides can lead to urinary retention
• Lich-Gregoir
• Identify ureter just below medial umbilical ligament. Dissect detrusor flaps to create a submucosal tunnel.
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Complications

• Ureteral obstruction (< 1%) - presents 1-2 weeks post-op with abdominal pain, n/v.
• Diagnose with US showing hydroureteronephrosis
• Usually resolves spontaneously (ureteral edema) - manage conservatively (fluids, stent, neph tube)
• Persistent obstruction (> 3 wks) is due to ischemic stricture - usually reoperate
• Persistent reflux
• May occur up to 3 mo post-op while inflammation resolves
• Reflux that persists > 3 mo rearely resolves spontaneously
• Most commonly 2/2 unrecognized voiding dysfunction (BBD).
• Contralateral VUR may develop in 10% but wait at least 1 year for resolution before re-operation

Post-op management

• Valley - use "Pediatric Urology Post-op Admission" order set

 Other management

• Ureteral stents left in for ~ 1 mo
• Continue prophylactic antibiotics for 2 wks if uncomplicated, otherwise for 3 mo
• Renal and bladder US at 4-6 weeks to check for ureteral obstruction
• Optional VCUG at 3 mo to check for resolution of VUR
• If VCUG and ultrasound both negative - can stop abx