Ureteric Reimplantation with Tapering Bilateral

Bilateral ureteric reimplantation with tapering

A bilateral ureteric reimplantation with tapering is a surgical repair on both ureters in cases of abnormal ureteric width (dilated ureters) otherwise known as megaureter.

Tapering is used to reduce the diameter of the ureter, and reimplantation is done to form a new tunnel through which ureter enters the bladder to avoid reflux or obstruction.

The procedure is regularly carried out in children, although it may also be required in adults that are severely refluxing or have both-sided obstructive megaureter.

Indications

The given surgery is indicated in case of:

• Bilateral primary obstructive megaureter in an infant.
• Megaureter with high-grade VUR. 
• Frequent U.T.I. although it is treated.
• Both kidneys progressive hydronephrosis.
• Obstruction resulting in poor ureteral peristalsis.
• Previous ureteric surgeries performed previously and failed.
• Infants with worsening renal functioning have congenital megaureter.

Bilateral ureteric tapering and reimplantation surgery

Bilateral ureteric tapering and reimplantation is a reconstructive urological procedure carried out on both ureters in cases of megaureter and reflux, obstruction or hydronephrosis.

The operation re-establishes the regular ureteral size, and it forms a new bladder opening, to establish a one-way flow of urine.

The surgery is normally performed in children although it can be performed in adults as well.

Anaesthesia & Preparation

• General anaesthesia is administered on the patient.
• The placement of a urinary catheter is done to empty the bladder.
• The antibiotics are given prophylactically.
• The patient is positioned in the supine position with a draping of the lower abdomen.

Surgical Approach

The surgeon takes one of the following:

• Open surgery 
• Laparoscopic surgery
• Robotic-assisted surgery (preferred in centres having advanced setups)

Identification and Mobilization of Both ureters

• The surgeon operates the bladder and identifies every ureter.
• Blood supply is conserved by carefully moving ureters.
• The enlarged section is evaluated to check the extent to which some tapering is required.

Dilated Ureters Tapering

• Tapering makes the abnormal diameter of each ureter smaller.

Techniques of Tapering:

• Longitudinal Excision + Tubularization (the most widespread)
• A long incision is made along the length of the ureter.
• Excess tissue is removed.
• This is followed by rolling and suture of the ureter into a small tube.

Plication Technique

• The ureter is inverted and connected without the removal of tissue.
• Employed in case of moderate dilation.

Tailoring Over a Stent

• Stenting is done into the ureter.
• The surgeon stitches the area to form normal diameter.
• Objective: To normalize the ureteral diameter so that it is able to propel urine.

Designing of New Bladder Tunnels

• Every ureter must have a submucosal tunnel in order to avoid reflux.

Common techniques:

• Cohen Cross-Trigonal Reimplantation.
• Politano-Leadbetter Technique
• Lich-Gregoir Extravesical Technique.

Procedure:

• An incision is created in mucosa of the bladder.
• The bladder layers are made into a long and oblique tunnel.
• The tunnel is passed through the tapered ureter.

Tapered Ureters Reimplantation

Each ureter is:

• Introduced into the bladder by the new tunnel.
• Fixed on fine absorbable sutures.
• Placed such that there is a flap-valve system to keep back the reflux.

Placement of DJ Stents

• Each ureter has a Double J stent.
• It aids in recovery, and avoids the obstruction.
• The removal of stents occurs after 4 to 6 weeks.

Bladder & Abdominal Closure

• The bladder is sewn up two-layered.
• In layers the abdomen is closed.
• Drain may be placed if needed.

Acute Postoperative Care

• Inpatient: 2-5 days (depending on method)
• IV fluids & antibiotics
• Pain control
• Monitoring urine output
• Foley typically retained 2-3 days.

Recovery Timeline

• Normal diet within 24–48 hours
• 4-6 weeks of activity restriction.
• The post-stent removal ultrasound.
• It should be fully recovered in 4-8 weeks.

Success Rate

• The success rate associated with bilateral ureteric tapering and reimplantation is also 90 to 95 percent in the case of long-term kidney protection.

Robotic bilateral ureteric reimplantation with tapering

Robotic bilateral ureteric reimplantation and tapering is a state-of-the-art minimally invasive surgery that is utilized to repair both abnormally pathologically dilated ureters (megaureter) when they need reconstruction. The robotic system (usually Da Vinci robotic platform) has high precision, 3D vision, fine suturing capabilities and thus is suitable in delicate pediatric or adult ureteric surgery.

Core Objectives of Surgery

• Tapers dilate both ureters to normal size.
• Reposition the ureters in the bladder through new anti-reflux tunnels.
• Provide clear drainage of urine and inhibit reflux and obstruction.
• All this with minimum invasive robotic surgery with less pain and accelerated recovery.

Best hospital for bilateral ureteric reimplantation with tapering India

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

Recovery after bilateral ureteric reimplantation with tapering

The process of recovery is similar, however, recovery is quicker with open, laparoscopic and robotic. The recovery may also take a little longer than unilateral surgery due to the fact that both ureters are being reconstructed.

Hospital Stay

Open surgery

• 3–5 days

Laparoscopic surgery

• 1–3 days

During this time:

• The stay of bladder catheter is normally 2-3 days.
• IV fluids, pain medication and antibiotics are administered.
• Close monitoring of the urine production.

(First 1-2 weeks)

Activity

• The next day walking is promoted.
• No jogging, running, or strenuous activity.
• School/work can resume between 7-14 days with age and mode of surgery.

DJ Stent Period (4–6 weeks)

• During healing, both ureters are normally stented with Double J.

Precautions:

• Drink plenty of fluids
• Avoid strenuous activity
• Finish course of prescription antibiotics.
• Removal of the stents is normally performed after 4-6 weeks through cystoscopy (fast outpatient surgery).

Wound Care

• Keep incision clean and dry
• Sponge bath only till dressing removed.
• In 7-10 days Stitches (when non-absorbable) removed.
• Denies an abdominal pressure on the lower side.

Pain Control

• Painkillers taken orally 5-7 days.
• Spasms can be treated with bladder relaxants.
• Warm pack would be beneficial (do not place over incision)

Food & Fluid Intake

• Regular diet within 24–48 hours
• Encourage drinking fluids (to promote good urine flow)
• Non-carbonated drinks should not be taken when you have an upset stomach. 

Follow-Up Visits Schedule

Standard follow-up timetable 

• 1–2 weeks: wound review
• 4–6 weeks: DJ stent removal
• 6-12 weeks: ultrasound drainage and hydronephrosis.
• 1 to 2 times a year: Imagings follow up.
• Annual follow-up: chronic kidney disease surveillance.

Conclusion

A bilateral ureteric reimplantation involving tapering is one effective reconstructive operation that can be used to correct severe dilation or obstruction of the two ureters. The surgery restores normal urine flow, helps to avoid long-term kidney damage, and greatly decreases frequent urinary infections by decreasing the ureteral diameter and reconstructing a new anti-reflux pathway into the bladder. The procedure has great success rates and lasting results and whether carried out using an open, laparoscopic, or robotic procedure. Proper postoperative management, stent treatment, and follow-up imaging ensure that the majority of patients, particularly those in the pediatric population, will have a full recovery with normal renal functioning and sustained urinary health.

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FAQ

1. Why is a taper necessary in addition to reimplantation?

• Tapering is needed when the ureter is dilated (megaureter). A distended ureter can’t effectively propel urine flow and can lead to obstruction or reflux. Tapering returns the diameter to normal and reimplantation provides a one-way, reflux free path into the urinary bladder.

2. Are stents placed in both ureters, as a matter of course?

• Yes. Double J (DJ) stents are routinely inserted to support the narrowed ureters and to keep them open. They are taken out in 4–6 weeks.

3. Is the recovery painful?

• There is some degree of mild to moderate discomfort stents or no stents. Robotic and laparoscopic procedures cause significantly less pain than the open procedure. The pain is usually well controlled with medication.

4. Does hydronephrosis go right away?

• Not always. Improvement of hydronephrosis may take 3 to 12 months for it depends on how much the kidneys were swollen prior to the operation.

5. Can it come back after surgery?

• Obstruction or reflux rarely recurs. After this operation, the vast majority of children and adults have long-term normalization of urinary function.

6. Is robotic better for bilateral reconstruction?

• There are many advantages to robotic surgery, including smaller incisions, decreased pain, faster recovery and the ability to facilitate precise fastening of sutures which is particularly useful with bilateral repairs, when both ureters require careful reconstruction.