Common sheath reimplantation (for duplex ureters)

Common sheath reimplantation

Common sheath ureteral reimplantation is a surgery performed to treat the problems in duplicated ureters systems when the two ureters of the same kidney share a common sheath as they pass through the bladder. It is majority performed to treat vesicoureteral reflux (VUR) or ureterocele-obstruction. The ureters are lined by a common sheath hence they have to be reimplanted together to maintain the common blood supply.

Common sheath ureteral reimplantation

Usually used in children with a duplicated ureter system, where there are two ureters of the same kidney whose ends enter the bladder in one common sheath, common sheath ureteral reimplantation is a surgery to correct vesicoureteral reflux (VUR) or obstruction. The ureters cannot be separated, and have to be reimplanted, as they share blood and sufficient perfusion and avoid ischemia.

Guidelines to the Procedure

Common sheath ureteral reimplantation is suggested in:

Duplicating collecting system with:

• Grade III -V: Vesicoureteral reflux.
• Spill into one or both duplex system limbs.
• Reflux and obstruction ureterocele.
• Recurrent febrile UTIs
• Renal hydronephrosis or scarring.
• Endoscopic injection treatment (Deflux) failure.

Advantages of the Procedure

• Outstanding long-term results.
• Avoids reflux damage of kidneys.
• Corrections obstruction and frequent UTIs.
• Safe even among young children and infants.

Duplex ureter common sheath reimplantation surgery

With a duplex collecting system, the kidney contains two ureters which pass down and into the bladder, commonly wrapped in a shared sheath. Surgical intervention is required when these ureters are vesicoureteral refluxed (VUR) or blocked (usually because of ureterocele).

• Because the two ureters share a blood supply in their sheath, both are freed and reimplanted as a unit to prevent ischemia and loss of function.

Surgical Procedure 

Positioning & Anaesthesia

• General anaesthesia is administered to the child.
• Lying supine with the legs turned slightly abducted.
• Open surgery involves a lower abdominal incision

Bladder Exposure

• The bladder is revealed by splitting muscles of the rectus.
• The traction is provided by a stay suture.
• In the extravesical method, Bladder is left intact or opened (intravesical technique).

Identification of Duplex Ureters 

• Both ureters are identified by the surgeon into the bladder.
• Both the ureters are located in a shared sheath.
• They are rallied like one, maintaining:
• Shared periureteral tissue
• Blood supply

Moving of the Common Sheath

• Dissection is done in a non-aggressive manner.
• Enough mobilization is done so that tension free reimplantation is possible.
• The orifices of ureters can be cut in the wall of the bladder (in intravesical technique).

Establishment of New Submucosal Tunnel

The submucosal tunnel is made at the bladder wall through one of the following methods:

A. Cohen Cross-Trigonal Tunnel (most frequent)

• Across the trigone of the bladder is made a tunnel.
• It provides good length as well as anti-reflux action.

B. Leadbetter to Politano tunnel.

• Conventional strategy that is more vertical.

C. Glenn-Anderson Technique

• Applied in the cases of bladder capacity that is small.

Tunnel length:

• Good anti-reflux mechanism is assured by a length to diameter ratio of 5:1.

Reimplantation of the Duplex Ureters

• The ureters are both passed through the newly formed tunnel.
• A common opening, spatulated, with one wide, broad opening may be made, when necessary.

The ureteral orifices are located such that:

• Each drains smoothly
• Angulation and kinking is absent.
• The ureters are compressed sufficiently by the tunnel to avoid reflux in the process of filling the bladder.

Fixation & Closure

• Finest absorbable sutures are used to hold together the ureters.
• The ureters are covered with the submucosal tunnel.
• Bladder is closed in two layers.
• A urinary catheter is inserted between 1 and 3 days.
• Abdominal incision is sewn up.

Recovery After Surgery

• Hospital stay: 2–4 days
• Mild dysuria and spasms in the bladder are usual.
• Hematuria for 24–72 hours
• Catheter is taken out when the bladder heals.
• Postoperative Light activity at 1-2 weeks; recovery occurs after 3-4 weeks.
• Ultrasound at 4–6 weeks post-op

Common sheath reimplantation complications

Though the success rate of the procedure is 95-98 per cent, there are some complications that can arise. These can be classified into early, intermediate and late complications.

Early Complications (In Days to Week)

a. Hematuria (Blood in Urine)

• Very common 24–72 hours post-surgery. 
• Typically sorted out with hydration.

b. Bladder Spasms

• Due to irritation with catheters.
• Appear as pain, urgency, or squeezy pain.
• Treated using anticholinergics (oxybutynin).

c. Urinary Retention

• Acute acute problem of passing urine after removal of the catheter.
• More frequently observed in extravesical methods.
• Typically self-limited.

d. UTI Post-Operatively

• Pain, fever or burning.
• Needs antibiotic intervention.

e. Leakage of Bladder Suture Line (Uncommon)

• Urine drip into body tissues.
• Maintained on catheter drainage.

Intramuscular complications (Weeks to Months)

a. Stenosis of One or Both Ureters.

• Most critical complication in common sheath.

Causes:

• Edema at the new tunnel
• Narrow tunnel
• Kinking
• Excessive traction
• Ischemia due to excessive dissection.

Symptoms/Signs:

• On ultrasound, hydronephrosis is detected.
• Flank pain
• Recurrent UTIs
• May require stent surgery or revision surgery (unfrequent). 

b. These patients have persistent or recurrent vesicoureteral reflux (VUR). 

Reflux may continue if:

• Tunnel is too short
• There is poor tunnel geometry.
• There are high pressures of the bladder.
• Most likely non-severe and can be self-limiting.

c. Ureteral Ischemia (Uncommon but Dangerous)

• Brought about by hypermobility or division of the ureters.
• Causes strictures, difficulty in the flow of urine, or obstruction.
• Requires prompt evaluation.

Months to Years Late Complications

a. Ureteral Stricture

• At the reimplant site, scarring occurs.
• Obstructs and causes hydronephrosis.
• May require endoscopic dilation or revision surgery.

b. Recurrent UTIs

• You will have issues when there is a reflux or bladder problem.
• In the majority of cases, it can be treated with the help of medicine.

c. Bladder Dysfunction (Rare)

• Postoperative or catheter temporary overactivity.
• Rarely long-term.

Common sheath reimplantation success rate

Correctly carried out common sheath ureteral reimplantation is very successful particularly in children with duplexes. Regular series on pediatric urology report regularly:

• Success Rate: 95–98%

Best hospital for common sheath ureteral reimplantation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Common sheath ureteral reimplantation is a very effective and sound procedure that is employed in the correction of vesicoureteral reflux or obstruction in children having a duplex ureter system. The reimplantation of the two ureters into the same vascular sheath will maintain the blood supply and avoid ischemia as well as long-term ureteral activity. It is very efficient (95-98 success), gives superior resolution of reflux, minimizes frequent UTIs, and safeguards the functioning of the kidneys. The complication is rare and is generally manageable, and is a safe and proven scenario in pediatric urology where duplex systems are involved.

Affordable common sheath ureteral reimplantation India GetWellGo

GetWellGo is regarded as a leading supplier of healthcare services. We help our foreign clients choose the best treatment locations that suit their needs both financially and medically.

We offer:

• Complete transparency
• Fair costs.
• 24 hour availability.
• Medical E-visas
• Online consultation from recognized Indian experts.
• Assistance in selecting India's top hospitals for common sheath ureteral reimplantation treatment.
• Expert urosurgeon with a strong track record of success
• Assistance during and after the course of treatment.
• Language Support
• Travel and Accommodation Services
• Case manager assigned to every patient to provide seamless support in and out of the hospital like appointment booking
• Local SIM Cards
• Currency Exchange
• Arranging Patient’s local food

FAQ

Why is it necessary to reimplant both ureters together?

• Because both the ureters are enclosed in one vascular sheath. Dividing them endangers their blood supply, and may result in strictures or obstruction.

Will my child be in pain after the surgery?

• Moderate to mild pain is to be expected initially and bladder spasms may occur. They can both be well controlled by medications.

Do I need a catheter?

• Yes. The bladder is usually drained through a urinary catheter for 1-3 days to allow healing.

Will the reflux or obstruction come back?

• It's rare for it to come back. Continuous reflux or obstruction, which affects a small percentage (2-6%), is generally identified on follow-up ultrasound.