Ureteric Reimplantation Bilateral

Bilateral ureteric reimplantation

Bilateral ureteric reimplantation: It is an operation done to correct the anomalies of both ureters at the time of entry into the bladder. The operation will entail the reposition and reattachment of the ureters to the bladder to regain a normal flow of urine and avoid the backflow (reflux).

Ureteric reimplantation surgery bilateral

Bilateral ureteric reimplantation is a surgical intervention performed on an abnormal area in which both the ureters enter the bladder. In the first, the ureters are moved so that they are better able to prevent urine from flowing backward (vesicoureteral reflux) or so that any blockage is relieved, allowing urine to drain normally from the kidneys to the bladder.

Indications

• Bilateral Vesicoureteral Reflux (VUR): Severe grade reflux with scarring on the kidney or frequent UTIs.
• Ureterovesical Junction (UVJ) Obstruction: Congenital or acquired obstruction on both ureteric orifices.
• Ectopic Ureters: Ureters that are implanted into the bladder or urethra. 
• Recurrent UTIs: Unresponsive to medical care particularly when there is renal scarring.
• Sphincter dysfunction or neurogenic bladder: This can be performed in conjunction with bladder augmentation or other reconstructive procedures. 

Surgical Techniques

There are various methods, which are based on the age, anatomy and preference of the surgeon:

This technique is identified as Cohen Cross-Trigonal (Intravesical):

• Common in children.
• The ureters were submitted submucosally through the bladder to avoid reflux.

Politano-Leadbetter Technique (Intravesical):

• Anti-reflux ureters implanted at an alternate angle and with a longer submucosal tunnel.

Lich-Gregoir Technique (Extravesical):

• Ureters inserted external to the bladder.
• Less bladder incision, minimally invasive, usually applied in older children or adults.

Bilateral ureteric reimplantation procedure

The following is a simple and step-by step description of the Bilateral Ureteric Reimplantation Procedure. This includes the procedure of the surgeon to enact the operation in both ureters to cure reflux or obstruction.

Anaesthesia and positioning

• General anaesthesia was given to the patient.
• Lay in a supine position (on the back). 
• The abdomen is draped and cleansed at the lower level.

Incision

Depending on technique:

Intravesical approach (Cohen / Politano-Leadbetter):

• Incision is made.
• The bladder is punctured (cystotomy). 

Extravesical technique (Lich-Gregoir):

• On both sides of the bladder there is a small muscle-parting cut without breaching it.

Identification of Both Ureters

• The surgeon also opens up the two ureters on their entry points into the bladder.
• The ureteric blood supply is observed and taken care of.

Mobilization of Ureters

• Both ureters are finally dissected and released of additional tissues.
• Sufficient length is manufactured to tunnel or re-position the ureter without any tension.
• Any fibroscars or obstruction of the ureterovesical junction (UVJ) is excised.

The formation of Submucokal Tunnel (Anti-reflux Mechanism)

The key part of the surgery:

• A new tunnel in the wall of the bladder is made around each ureter.

Length of tunnel by the principle:

• Length: Diameter = ~5:1
• (This prevents reflux.)    

Techniques:

• Cohen cross-trigonal technique: Ureters both reimplanted through the bladder floor.
• Politano-Leadbetter: Ureters reoperated with a new opening at the height of the first location.
• Lich-Gregoir (extravesical): Tunnel developed outside the bladder but does not open it.

Reimplantation of Ureters

Each ureter is:

• Spatuated (opened in a little at the end).
• Placed into the ready tunnel.
• Stitched tight in case of leakage.
• This forms a valve like system which helps in flow of urine into the bladder but not back.

Stenting (Optional)

• Surgeons can place the ureteric stents in each ureter to temporarily open them.
• The removal of stents is normally done in 2-6 weeks.

Bladder Closure

• The bladder (in case it is opened) is sewn two-layeredly using absorbable sutures.
• The urinary catheter is inserted and retained between 3-5 days.

Abdominal Closure

• The layers of muscles, fascia, and skin are stitched in a standard fashion.

Post-Procedure Care

• Hospital stay: 3–7 days.
• Catheter: Removed after 3–5 days.
• Stents: Stents removed at follow-up.
• Follow-up: to make sure it is successful, ultrasound or VCUG.

Outcome

• Success rate: 90-95 percent in reflux or obstruction.
• Renal preservation of functions: Good with early treatment.

Bilateral ureteric reimplantation surgery recovery

Owing to the use of both ureters, recovery time is a little bit longer and bladder irritation can be more evident compared with the unilateral cases.

Hospital Stay

• 3-7 days according to age and the method of the surgery.
• Intravesical (Cohen / Politano-Leadbetter) → typically prolonged residency.
• Extravesical (Lich-Gregoir) → shorter stay.

Immediately After Surgery

Urinary Catheter

• A catheter (Foley) stays up to 3 -5 days to enable the bladder to heal.

During this time:

• Blood-tinged urine is common
• Bladder spasms may occur
• Drain (optional)
• A urinary drain can be instilled next to the bladder and extracted after 24-48 hours.

Pain & Bladder Spasms

• 3-5 days mild to moderate pain.
• Bladder spasms (pain in the form of cramps) occur frequently after intravesical surgery.
• Drugs such as oxybutynin can be administered.

Ureteric Stents (if placed)

• Temporary stents make the ureters remain open.
• Removed within 2-6 weeks through the OPD procedure or cystoscopy.

Activity Restrictions

Children

• Normal play: 2–4 weeks
• Jumping, cycling, sports: 4-6 weeks.

Adults

• Light activity: 1 week
• Work (non-physical): 2–3 weeks
• Heavy work or strenuous work: 4-6 weeks.

Urine Appearance

• Light haematuria in urine is usual during few days.
• It may be 1-2 weeks of irritation or burning sensation.
• Urethritis symptoms are similar to those of a urinary tract infection (UTI) with both common early symptoms being more frequent and urgent urination.

Diet and Fluid Intake

• Clear liquids for first 12-24 hours. Graduate to normal diet.
• Dehydrate by taking lots of fluids in order to maintain clear urine.

Medications

• In some cases, 2-6 weeks of antibiotics (prophylaxis).
• Pain relievers for 3–5 days.
• Bladder spasm drugs when necessary.

Follow-Up Tests

Most surgeons perform:

Ultrasound:

• Evaluation at 2-6 weeks after surgery to confirm drainage of the kidney and healing of the ureter. 

VCUG (if reflux surgery):

• Typically at 3-6 months follow up to eliminate VUR (not mandatory in some centers).

Renal scan:

• Obstruction was severe or the symptoms persistent only.

Full Recovery Time

• Children: 3–6 weeks
• Adults: 4–8 weeks

Best hospital for bilateral ureteric reimplantation India

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

Conclusion

Bilateral ureteric reimplantation is a highly efficient surgery that is done to treat reflux or obstruction in both ureters that are considered to drain the urine properly in the kidneys to the bladder. The operation greatly minimizes the possibility of recurrent urinary tract infections, kidney damage, and urinary normal functioning. Most patients have great long term outcomes when the condition is managed at an early age with a success rate of 90-95. Recovery is usually three short hospital visits, catheter assistance in the meantime, and the need to resume normal functioning in a few weeks. A follow-up imaging also serves to check adequate healing and ureter functioning.

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FAQ

Do I need a catheter after surgery?

• Yes. A urinary catheter is kept in place for 3-5 days to enable the bladder to heal. 

Are ureteric stents used? 

• Yes. Temporary stents hold the ureters open while they heal. They will be taken out in 2-6 weeks.

How long until reflux or obstruction improves? 

• Reflux or obstruction is usually immediately corrected; however complete healing is confirmed by imaging at follow-up.

Is the surgery done laparoscopically or robotically?

• Exrtravesical reimplantation can be performed laparoscopically or robotically in selected centers especially in older children and adults.