Initial Experience With LaparoscopicIpsilateral Ureteroureterostomy in Infants andChildren for Duplication Anomalies of the Urinary TractRicardo Gonzalez and Lisandro PiaggioFrom the Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, and Division of Urology, Alfred I. duPontHospital for Children, Wilmington, Delaware

Purpose: We report the feasibility of laparoscopic ipsilateral ureteroureterostomy for duplication anomalies of the urinarytract in infants and children, and the short-term results in 6 patients.Materials and Methods: Laparoscopic ipsilateral ureteroureterostomy was performed transperitoneally with 3 and 4 portsfor unilateral and bilateral cases, respectively. Cystoscopy, retrograde pyelogram and stent placement in the recipient ureterwere performed at the beginning of each case. The anastomosis was carried out with running or interrupted 6-zero sutures.An abdominal drain and Foley catheter were left indwelling in all cases. Demographic data, body measurements, type ofprocedure and indication, laterality, intraoperative and postoperative complications, analgesia requirement, length ofhospitalization and outcome were recorded.Results: Eight laparoscopic ipsilateral ureteroureterostomies were performed in 6 patients (2 males). Mean patient age was51 months. Diagnoses were bilateral lower pole vesicoureteral reflux (2 patients) and ectopic ureter (4). Mean operative timeincluding cystoscopy was 257 minutes (range 140 to 430) and estimated mean blood loss was 2.7 ml. There were nointraoperative complications. Mean morphine requirement was 0.13 mg/kg. Two cases required acetaminophen only for painmanagement. All patients were discharged home with no narcotics at a median of 3 days postoperatively (range 1 to 7). Therewere 2 postoperative febrile urinary tract infections. Followup renal ultrasound demonstrated no significant hydronephrosisof the moieties involved.Conclusions: In this initial experience laparoscopic ipsilateral ureteroureterostomy was done safely and effectively even insmall infants. Postoperative course was uneventful, with negligible blood loss and minimal analgesia requirement, and initialresults were comparable to those of open surgery.

Key Words: ureterostomy, ureter, vesico-ureteral reflux, laparoscopy, urinary incontinence

Ipsilateral ureteroureterostomy has been used to treatduplication anomalies of the urinary tract with 1 ob-structed system for the last 80 years.1 In addition, good

results have been reported when IUU is applied to treatlower pole reflux.2,3 Subsequently, several authors have re-ported the advantages of IUU as an alternative to partialnephrectomy or double barrel reimplantation in selectedcases.4,5 In the presence of a complete ureteral duplicationwith preserved function of a refluxing or obstructing moietyIUU is our approach of choice. Since laparoscopic surgerybecame our preferred approach for pediatric partial nephrec-tomy6 and pyeloplasty,7 it became logical to apply a laparo-scopic approach to IUU. Herein we describe the techniqueand our initial experience with laparoscopic ipsilateral ure-teroureterostomy.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients who un-derwent LIUU at our institution. Demographic data, bodymeasurements, type of procedure and indication, laterality,intraoperative and postoperative complications, analgesia

Submitted for publication October 17, 2006.Study received institutional review board approval.

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Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION

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requirement, length of hospitalization and outcome wererecorded.

In cases of reflux the indication for surgery was refluxconfined to the lower moiety on more than 1 voiding cysto-urethrogram and breakthrough urinary tract infections. Weperformed LIUU in the presence of a duplication anomalywith upper pole hydroureteronephrosis, no evidence of ure-terocele and a functioning upper pole on mercaptoacetyltri-glycine or dimercapto-succinic acid renogram.

In this procedure the child is admitted to the hospital onthe day of surgery. All except 1 patient weighed less than 21kg. The same technique was used in all patients. Undergeneral anesthesia the patients were placed supine andwere prepared from the nipples down to have the genitaliaincluded in the operating field. The feet were wrapped withwaterproof stockinettes to avoid excessive temperature loss(fig. 1). Cystoscopy, retrograde pyelogram and stent place-ment in the ureter to be anastomosed were performed ini-tially. Access to the peritoneum was gained using the Baileztechnique8 with a 5 mm trocar. Two and 3 (3 mm) workingports for unilateral and bilateral LIUU, respectively, wereplaced in the hypogastrium and the ipsilateral flank of therepair, adjusting the distance according to patient size(above or below the umbilical line for infants or older chil-

dren, respectively, fig. 1).

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DOI:10.1016/j.juro.2007.01.177

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The recipient ureter was easily identified at the pelvicbream even in cases of equal ureteral size, since it containedthe stent. The peritoneum was incised. The donor ureter wasdissected free at the level of the crossing of the iliac vessels,divided and ligated distally. The divided end was spatulatedon the lateral aspect. The recipient ureter was left in situand a longitudinal ureterotomy long enough to match thelumen of the donor ureter was performed with single actionscissors on its medial aspect. The anastomosis was carriedout with running or interrupted 6-zero reabsorbable mono-filament sutures. An abdominal drain was left indwelling inall but 1 case.

In 1 patient (a teenager) the procedure was started usingthe dorsal lithotomy position and the normal ureter wasstented cystoscopically. The patient was then placed supineand re-draped, and the laparoscopic procedure was carriedout.

The Foley catheter, drain and stent were removed at amedian (range) of 1.5 (1 to 2), 2 (1 to 3) and 21 (8 to 35) days,respectively. During the procedure patients were closelymonitored and hypercarbia was controlled by the anesthe-siologist by adjusting the ventilation rate.

RESULTS

There were 8 LIUUs performed in 6 patients (2 males).Mean patient age was 51 months (range 1 to 190). Diagnoseswere bilateral lower pole vesicoureteral reflux (2 patients)and ectopic ureter (4). Mean operative time for unilateraland bilateral cases was 211 minutes (range 140 to 338) and348 minutes (268 to 430), respectively. Cystoscopy, stentplacement and repositioning, if necessary, took a mean of 45minutes (range 21 to 73), and were recorded as part of thesurgical procedure. Blood loss was estimated at a mean of2.7 ml (range 1 to 5). There were no intraoperative compli-cations.

The end tidal CO2 typically remained at approximately40 mm Hg or less. In 1 patient it reached 50 mm Hg brieflywithout clinical consequences.

All patients were prescribed 15 mg/kg acetaminophen,

FIG. 1. a, patient is prepared from nipples down, with genitalia inLIUU in infant with ectopic ureter. Note working port on flank is p

0.5 mg/kg ketorolac and/or 0.1 mg/kg morphine, which they

could receive at intervals of 2 to 6 hours with the criteriadescribed previously.6 Two patients needed acetaminophenonly for pain control, 1 needed 2 doses of ketorolac and 3received a mean of 2.5 narcotic doses. All patients weredischarged home with no narcotics at a median of 3 days(range 1 to 7).

Postoperative course was uneventful in all patients ex-cept for a 15-year-old female who had pyelonephritis andneeded intravenous antibiotic therapy, prolonging the hos-pital stay. Another patient needed rehospitalization to treata febrile urinary tract infection. At the time of stent removal4 patients underwent assessment of the anastomoses viaretrograde pyelogram, which showed patency and no leak(fig. 2). At a mean followup of 10.7 months (range 5 to 16) allpatients were clinically well with subjectively perfect cos-metic results. Followup renal ultrasounds were performedat 1, 3 and 9 months postoperatively, and revealed decreas-ing or no significant hydronephrosis of the moieties involved(fig. 2).

DISCUSSION

Ipsilateral ureteroureterostomy is a time-honored techniqueto treat duplication anomalies of the urinary tract in whichonly 1 ureter is abnormal and there is function in the ab-normal moiety. Two recent series in which IUU was per-formed with an open technique demonstrated good long-term results and a low complication rate, comparable to thatof open double barrel ureteral reimplantation.5,9 In a studyby Choi and Oh 18 IUUs were performed in a group of 63patients with lower pole reflux, ureteral ectopia and ure-terocele.4 The relatively high reoperation rate reported was,as expected, mostly in patients with ureterocele, and wassimilar to the reoperation rate after partial nephrectomy.The series of Lashley et al includes 100 IUUs in 94 pa-tients operated on during a 23-year period, with a successrate of 94%.5

The question of whether the anastomosis should be donehigh or low has also been a matter of debate. Choi and Ohexplore the kidney to decide whether to do a partial nephrec-

d in operative field to allow cystoscopy. b, port placement in rightd high (above umbilical line).

tomy or an anastomosis.4 Therefore, they do most of their

mal

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IUUs high. We do not agree with this approach, since thefunction of the abnormal moiety should be evaluated byscintigraphy or magnetic resonance urography, and visualinspection is notoriously unreliable. Also, we have previ-ously reported a higher complication rate with ipsilateralureteropyelostomy compared to partial nephrectomy.10

One argument used in favor of high anastomosis is thefear of “yo-yo” reflux, which presumably would be detrimen-tal to the kidneys.4 However, others have not seen anydetrimental effect of low IUU.5,11 A relatively low anasto-mosis at the level of the iliac vessels is ideally suited to beperformed laparoscopically, since it can be accomplishedwith minimal or no mobilization of the colon and withoutinterfering with the gonadal vessels. When performing anopen IUU we create the anastomosis at the same level.

We believe that a stent in the recipient ureter is moreuseful to keep it open during the anastomosis and preventaccidental placement of sutures through the back wall, es-pecially if it is of normal caliber. We have used this approachin laparoscopic and open IUU cases, and found no problems.An alternative would be to place a stent across the anasto-mosis, which can easily be accomplished once the posteriorwall of the anastomosis is finished. For this purpose it isuseful to have the genitalia in the operative field.

The trunk of the patient should be on a table permeableto x-rays to confirm the position of the stent during theprocedure. The indwelling stent or wire can be redirectedfrom the recipient to the donor ureter laparoscopically. Tofacilitate advancing the stent, the distal coil can be straight-ened with a wire, retrieving the bladder coil cystoscopically.If one anticipates this maneuver, it is better to leave anindwelling wire or open-ended catheter in the recipient ure-ter at the beginning of the case. Lashley et al did not rou-tinely leave stents indwelling in their patients, and theoutcome of the ureteroureteral anastomosis was not alteredby the 13% incidence of urinary leak.5 In our small series weobserved no leaks.

The development of postoperative pyelonephritis in 2 ofour patients deserves special comment. In both cases we hadused a Double-J® stent with a transurethral string, whichmay have been a predisposing factor. We no longer use suchstents and, as in the laparoscopic pyeloplasties, we now relyon a second cystoscopy to remove the stent.

A concern regarding prolonged laparoscopic procedures in

FIG. 2. a, ultrasound of left kidney (sagittal view) in case of ectopictime of stent removal demonstrates patent anastomosis and proxinephrosis several months postoperatively.

infants is the development of hypercarbia and acidosis. In

our experience with the cases reported and more than 100renal and ureteral laparoscopic operations in infants andchildren CO2 absorption was always easily managed by theanesthesiologist.

CONCLUSIONS

This initial experience with LIUU to treat duplication anom-alies of the urinary tract is encouraging, and shows theexpanding applications of laparoscopy in reconstructiveurology. In the present series LIUU was performed safelyeven in small infants, with negligible blood loss, minimalanalgesia requirements and excellent short-term results.Ipsilateral ureteroureterostomy in selected cases is an idealapproach, providing a reliable repair with a low complica-tion rate and avoiding the morbidity associated with bladdersurgery. Because this is a small series and no comparisonwith open procedures was performed, we cannot state thatLIUU is superior to open IUU. However, the laparoscopicapproach adds to this surgery the benefits of magnification,excellent visualization and minimal invasiveness, makingthis operation even more appealing.

Abbreviations and Acronyms

IUU � ipsilateral ureteroureterostomyLIUU � laparoscopic ipsilateral

ureteroureterostomy

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