A nonrefluxing megaureter is a relatively common cause of antenatal hydronephrosis. Although nonoperative management is favored, surgical intervention is sometimes warranted. However, there is controversy regarding the best approach, particularly in young children. We describe our experience with nondismembered side-to-side refluxing ureterocystotomy as a simple option to address obstruction.Between January 2012 and January 2017, 32 patients underwent ureterocystotomy at 4 referral centers in North America. Demographics, surgical indications, complications, need for further interventions and change in hydronephrosis were captured. Patients were monitored clinically and with serial ultrasounds.Mean age at surgery was 3.7 months (range 0 to 33) and 25 (78%) patients were male. Unilateral procedures were performed in 29 patients. All patients were initially identified based on the presence of antenatal hydronephrosis and symptoms developed in 10. The procedure was conducted for primary nonrefluxing megaureter in 27 patients and to address secondary obstruction in the remainder. Mean followup was 34.3 months (range 6 to 58). At the most recent evaluation most children demonstrated significant improvement in dilation (86%). To date, 6 patients have undergone further procedures, including a circumcision and 2 ureteral reimplantations for recurrent infections.Our results suggest that side-to-side refluxing ureterocystotomy is a straightforward, minimally invasive alternative for the surgical management of nonrefluxing megaureter. Despite the trade-off of relieving obstruction and creating reflux, it can be considered a potentially definitive procedure in patients who remain infection-free, particularly circumcised boys. Extended followup with close monitoring is critical to document long-term results with this intervention.
Abstract Our study aims to assess the clinical implication of RAV / rBSA ratio in PRT as a predictor for attained renal function at 1 year post‐transplantation and its association with surgical complications. A retrospective cohort was performed for PRT cases from January 2000 to December 2015 in our institution. Extracted clinical information includes the recipient's demographics, donor type, renal allograft characteristics, arterial, venous and ureteral anastomoses, vascular anastomosis time while kidney off ice, overall operative time, and estimated blood loss. The RAV / rBSA was extrapolated and assessed for its association with renal graft function attained in 1 year post‐transplantation and surgical complications within 30‐day post‐transplantation. A total of 324 PRT s cases were analyzed. The cohort consisted of 187 (52.4%) male and 137 (42.3%) female recipients, with 152 (46.9%) living donor and 172 (53.1%) deceased donor renal transplants, and an overall median age of 155.26 months (IQR 76.70‐186.98) at time of renal transplantation. The receiver operating characteristic identified that a RAV / rBSA ratio of 135 was the optimal cutoff in determining the renal graft function outcome. Univariate and multivariate analyses revealed the relative OR for RAV / rBSA ≥ 135 ratio in predicting an eGFR ≥ 90 attained within 1 year post‐transplant was highest among younger pediatric recipients (<142.5 months) of deceased kidney donors ( OR = 11.143, 95% CI = 3.156‐39.34). Conversely, Kaplan‐Meier analysis revealed that RAV / rBSA ratio ≥ 135 is associated with lower odds of having eGFR <60 ( OR = 0.417, 95% CI = 0.203‐0.856). The RAV / rBSA ratio was not associated nor predictive of transplant‐related surgical complications. Our study determined that the RAV / rBSA ratio is predictive of renal graft function at 1‐year PRT , but not associated with any increased surgical complications.
We evaluated the appearance of the mound of failed endoscopic dextranomer microsphere injections at the time of reinjection or open ureteral reimplantation. We performed a multi-institutional study of 80 patients (97 ureters) who were diagnosed with vesicoureteral reflux and had failed endoscopic treatment with dextranomer microspheres. Observations of injected mound characteristics were made during the time of reinjection or at open ureteral reimplantation. Correlations were made with the pre-injection grade of reflux, volume of initial injection, number of punctures used for the initial injection and presence of symptoms of dysfunctional voiding. Examination of the failed injection sites before subsequent injections or open surgery revealed mound abnormalities in all but 13 of the 97 ureters. Of the cases 49% demonstrated a shifted mound, 22% an absent mound and 10% a loss of volume in the mound. Of the 13 patients with normal appearing mounds 7 had improved reflux grade, 3 had worsened grade and 3 had no change. Patients with dysfunctional voiding symptoms had a second injection failure rate of 44%, compared to a 13% rate in those without symptoms of voiding dysfunction. Most failures of endoscopic correction are associated with mound shifting. The presence of a perfect mound does not predict success. Dysfunctional voiding predicts a lower success rate after a second injection.
Use of autologous rectus fascia for urethral slings in the pediatric population has produced reliable and predictable results. However, the potential morbidity and complications associated with harvesting the autologous rectus fascia have driven efforts to find a reliable off-the-shelf material for urethral slings. Small intestinal submucosa is a collagen based material that has been shown to promote tissue specific regeneration in a variety of organs. We report the clinical experience at 4 institutions with small intestinal submucosa for urethral slings.A total of 20 patients 3 to 18 years old (mean age 8.7) received urethral slings using the commercially available form of small intestinal submucosa (STRATASIS, Cook Urologic Spencer, Indiana) via a sling suspension procedure from a suprapubic approach.The material was consistently uniform to work with and user-friendly. All 20 patients tolerated the procedure well with no intraoperative complications. Postoperative followup has ranged from 9 to 26 months (mean 13), and 14 (70%) patients are completely dry (85% in females and 43% in males). Of the 14 dry patients 13 are on intermittent catheterization and 1 female with epispadias voids spontaneously.This report is the largest and longest followup series using small intestinal submucosa as an "off the shelf" urethral sling material in children. These continence rates are equal to autologous fascia without additional morbidity of graft harvest.
