Ureteric Reimplantation with Tapering Unilateral

Unilateral ureteric reimplantation with tapering

Unilateral ureteric reimplantation with tapering Unilateral ureteric reimplantation with tapering is a surgery conducted when one of the ureters has been abnormally enlarged (megaureter) and requires resizing (tapering) and repositioning in the bladder so that it can adequately drain urine and avoid kidney damage.

This operation is usually performed on children but depending on the situation an adult may also be faced with the need to undergo this surgery.

Indication of Unilateral ureteric Reimplantation with tapering

The procedure is normally advised when:

• Primary obstructive megaureter (lateral condensation of the ureter at the ureterovesical junction) 
• Megaureter refluxing and substantially dilated.
• Conservative management failure.
• Constant urinary tract infections.
• Progressive hydronephrosis
• Obstructed renal failure.
• Dilation of the ureters to result in dysfunctional bladder drainage.

Tapering is performed in cases where the ureter is too large to create an anti-reflux tunnel in the process of reimplantation.

Ureteric reimplantation with tapering surgery

Reconstructive surgery involved in the treatment of an abnormally dilated ureter (megaureter) involves ureteric reimplantation with tapering, which is a procedure whereby the abnormally dilated ureter is tapered and reattached (reimplanted) back into the bladder to restore normal urine flow and eliminate kidney injury.

This operation may be carried out on children or adults, depending on the disease underlying.

Why Tapering Is Needed?

Tapering must be used when the ureter is:

• Pseudomonas too large to form an adequate anti-reflux tunnel.
• Weak ureter wall leads to poor draining.
• It causes chronic hydronephrosis.
• Reflux-related (VUR grade IV -V)
• Causing recurrent UTIs

In case the ureter diameter is usually higher than 10-12 mm, tapering is advisable prior to reimplantation.

Robotic ureteric tapering and reimplantation

• Robotic ureteric tapering and reimplantation is a minimally invasive reconstructive operation that involves the use of a robotic surgical system (mostly da Vinci robotic platform) to treat a dilated or obstructed ureter (megaureter).
• The process remodels (tapers) the broad ureter and reimplants it into the bladder through a robotized procedure that is very precise.
• It provides better visualization, precision and minimal invasive healing in comparison with open surgery.

Unilateral ureteral tapering and reimplantation procedure

Preoperative Evaluation:

• Ultrasound
• VCUG (if reflux suspected)
• MAG3/DTPA kidney scan to test drainage.
• Blood tests (renal function)
• Urine analysis and culture
• Sometimes MRI/CT urogram

Surgical Operation: Step-by-Step:

Anaesthesia & Positioning

• General anaesthetic procedure.
• The patient is in supine position.
• Urinary catheter is put in place.

Surgical Approach

There are three methods that can be employed:

Open surgery

• Old fashioned yet very powerful.

Laparoscopic surgery

• Less invasive operations; earlier healing.

Robotic-assisted surgery

• Extremely accurate tapering and suture.

Exposure and Mobilization of the Ureters

• The surgeon gets to the side that is affected.
• The ureter is cut off of the surrounding tissues.
• The amount of blood supply is only mobilized to the necessary length.

Ureteral Tapering (Key Step)

• Tapering is done on the already enlarged segment of the ureter to form a smaller and uniform tube.

Steps of tapering:

• An elongated cut is made on the enlarged distal ureter.
• An excisional (strip) of spare ureteral wall is excised (excisional tapering).
• Alternatively, excision is not necessary but folding tapering can be applied.
• The ureter will undergo re-shaping along a stent or catheter.
• New narrowed lumen of the ureter is made up of fine sutures.

Purpose of tapering:

• Prevent kinking and stasis
• Make it possible to create an appropriate anti-reflux tunnel.
• Enhance ureteral peristalsis.
• Maximize drainage into the bladder.

Ureteral Reimplantation

One of the following is then reinserted into the bladder; the tapered ureter.

1. Cohen Cross-Trigonal Technique

• Most common in children.
• Tunnel bladder floor to tunnel floor: to achieve an excellent anti-reflux effect.

2. Leadbetter -Politano Technique

• Conventional intravesical delivery in adults and older children.

3. Lich Gregoire Extravesical Technique.

• Less bladder opening.
• Ideally suited to unilateral repair particularly in minimally invasive surgery.

Goals of reimplantation:

• Establish a long submucosal tunnel.
• Avert retrograde pyelography (vesicoureteral reflux)
• Make certain of free drainage of urine.

Stent Placement

• A Double-J stent is inserted in the ureter.
• Spends 4-6 weeks to aid recovery.

Bladder & Wound Closure

• Bladder closed in layers.
• Abdominal incisions closed.
• Foley left in place at 3-5 days.

Duration of Surgery

• Depending on the complexity of the surgery, approximately 2 to 3 hours

Recovery After Surgery 

Hospital Stay

• Open operation: 3–5 days of hospital stay

• Laparoscopic / robotic surgery: 1-3 days. 

At Home

• Bladder spasms or mild pain can take place.
• Restricted activity of 3-4 weeks.
• Plenty of hydration needed.

Stent Removal

• Performed through cystoscopy within 4-6 weeks.

Follow-Up Imaging

• 6 weeks ultrasound, 3 months ultrasound, 6 months ultrasound. 
• Renogram if needed.

Pediatric unilateral ureteric tapering and reimplantation

Pediatric unilateral ureteric tapering and reimplantation is a reconstructive operation that is carried out when one of the ureters in a child is abnormally enlarged (megaureter) or blocked along the way to the bladder.

In order to fix the urine flow, prevent reflux, and preserve the kidney, the surgery tapers and reimplants the ureter into the bladder (reimplantation).

It is among the most successful and a widely used pediatric urology surgery to correct severe megaureter.

Indications in Children

The process is suggested in case a child has:

• Primary obstruction megaureter (POM)
• Ureterovesical obstruction (UVJ).
• Refluxing megaureter
• High grade VUR with highly dilated ureter.
• Distal obstruction/stenosis of ureters.

Leading to:

• Progressive hydronephrosis
• Recurrent UTIs
• Poor drainage on renogram
• Worsening of the impaired kidney.
• Conservative management failure.
• Persistent dilation >12 months

Worsening symptoms:

• More enlargement (>10-12 mm ureter diameter)
• The restructuring happens in only one of the sides (unilateral).

Best hospital for ureteric reimplantation with tapering India

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

Conclusion

Unilateral ureteric tapering and reimplantation is a surgical intervention which is applicable in the treatment of a megafixed ureter (megaureter) which cannot drain effectively due to excessive dilation of the ureter. The surgery, which involves a decrease in the diameter of the ureter and repositioning it back on the bladder after using a reflux-preventing procedure, restores normal urine flow, protects the kidney and prevents repeated infections. The success rates of the operation are high using modern surgical techniques so are long-term results such as open, laparoscopic, and robotic surgery. With proper post-operative management, follow up and imaging, most patients are well recovered with proper follow up.

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FAQ

1. Does it take place in children or in adults?

• It may be performed in both, although most often it may be performed in children who have congenital megaureters.

2. What is the success rate?

• The success rates are usually above 90-95 percent and that too, when the surgeons are experienced, either in pediatrics or urology.

3. Will a stent be used?

• Yes, a temporary internal stent (DJ stent) is usually inserted so that urine can pass through it and the wound may heal. It is cleared a couple of weeks after.

4. Should it be followed up long term?

Yes. Follow-up ultrasounds and in some cases renal scans assist in making sure that:

• Good drainage
• No obstruction
• Stable kidney function