British Joirrnal of Urology (1976), 48, 31-37 0

Re-Implantation of the Ureter’ P H I L I P CLARK and R. u. HOSMANE

Drparrmenr of Urology, The General Infirmary and Leeds (Sr. James’s), University Hospital, Leeds

Is the mechanism whereby the ureterovesical junction prevents reflux active or passive? Since Galen in the 2nd century showed that there was no reflux from the bladders of living and dead normal animals and Sir Charles Bell at the beginning of the last century described the muscle fibres of the ureter passing down from the orifice to the bladder neck and prostate, people have been arguing whether the valvular mechanism is active or passive (Bell, 1812; Brock, 1916).

Sampson (1903) was the first person to put forward the case for a passive mechanism forcibly. He thought any intravesical tension would press the anterior lip of the orifice against the posterior ureteric wall, thus occluding the lumen of the ureter. The case for the passive mechanism rests on the fact that the ureterovesical junction of the intact, excised bladder is no less effective and sometimes even more effective, in preventing reflux than it was in the living body.

There is general agreement that in patients with reflux the ureteric orifice is often wider and situated farther from the bladder neck than normal. The submucosal segment of the ureter is therefore shorter than normal. However, Stephens and Lenaghan (1963) observed reflux in infants with duplex ureters, not in the normally sited ureter but in the ureter opening ectopically at the bladder neck. This ureter had a submucosal segment far longer than normal, yet it refluxed. Dissections of the ureterovesical junctions of infants with reflux showed a congenital absence of the submucosal segment, often with wedge-sector defects in the muscle. They postulated that the primary mechanism producing competence is the contraction of Bell’s muscle which occludes the ureteric lumen by a “longitudinal shearing action”. Tanagho and Hutch (1965) also suggested that the primary cause of reflux was a trigonal muscle deficiency. In addition, Tanagho examined 72 specimens of terminal ureter removed during operations to correct reflux and found that, compared with normal controls, they were deficient in muscle (Tanagho, Guthrie and Lyon, 1969).

The theoretical question, “Is it active or passive?” now becomes a practical one, for, if the lower end of the refluxing ureter is deficient in muscle and the mechanism for preventing reflux is an active one, should not the lower end of the ureter, as Tangaho suggests, be excised?

Operative Techoique

The one thing which all operations to correct reflux have in common is the creation of a long submucosal segment of the ureter. This is achieved with different degrees of mobilisation of the ureter. The most popular operation is that described by Politano and Leadbetter (1958), in which the ureter is completely detached and reintroduced into the bladder through a newly formed, long, submucosal tunnel. For 10 years we have used a modification of this operation.

Politano and Leadbetter performed the operation entirely by an intravesical approach but we have always used a combined extravesical and intravesical exposure which has several advantages (Table I). First the ureter is identified extravesically and mobilised from the point where it is crossed by the superior vesical artery to the point where it enters the bladder wall. No arteries need be divided. The bladder is then opened and the ureter is detached in the usual way by intravesical dissection. If there is any difficulty in freeing it at any point deeply, it can be pulled outside the bladder and the final separation can be completed with ease extravesically.

I Presented at the 28th Annual Meeting of the Urological Society of Australasia in Sydney, April 1975. 31

32 BRITISH JOURNAL OF UK0I.OGY

Fig. 1 . Ureter mobilised extravesically; one sling passed around superior vesical artery (a). another around ureter (b). Fig. 2. Bladder opened transversely (c). Mucosa slit to form cuff around ureteric orifice (d). Fig. 3. Ureter dissected up intravesically ( e ) ; about to be passed extravesically (f). Fig. 4. Hole in bladder muscle closed (g). Saline injected submucously to facilitate dissection of tunnel (h). Fig. 5 . Angled forceps passed up tunnel and pushed through bladder muscle (i). Ureter about to be passed intravesically (j). Fig. 6. Ureter sutured back to its original site (k). Final state (I).

RE-IMPLANTATION OF THE URETER 33

30n 1 Male 13 = Female 43 20

Q) .-

10

0 0 10 20 30 40 5 0 60

Age in years Fig. 7. Histogram showing age and sex of the patients.

Because of the combined exposure, it is unnecessary to incise the bladder mucosa at the upper end of the submucosal tunnel to make the new hole in the bladder muscle. Angled forceps may be passed up the tunnel, turned outwards and pushed through the bladder muscle so that they emerge accurately in line with the ureter and near to the point to which it has been mobil- ised. The combined exposure ensures that accidental perforation of the peritoneum or even of the intestine, which has been described, does not occur and that when the ureter is drawn back again through the new tunnel and into the bladder it is not angulated or twisted.

Other minor details of this technique are illustrated in Figures 1 to 6. The skin incision is made vertically in the midline. Figure la and b shows the ureter being mobilised extravesically. The bladder is opened transversely (Fig. 2c). Two monofilament stay sutures are inserted to elevate the orifice using sutures of different colours to identify the top and bottom end. The circular incision around the orifice is made well away from it and with a fine, straight scalpel by slitting the mucosa outwards (Fig. 2d). The ureter is detached in the normal way (Fig. 3e) and brought extravesically (Fig. 3f). The hole in the bladder muscle is closed with two interrupted stitches (Fig. 4g) and the submucosal tunnel is fashioned after lifting the mucosa off the bladder muscle with a submucous injection of saline (Fig. 4h). Angled forceps are passed up the tunnel, turned outwards and pushed through the bladder muscle in line with the ureter (Fig. 5 ) . The ureter is then brought back into the bladder (Fig. 5j). The ureteric orifice is only advanced towards the bladder neck if the submucosal tunnel would otherwise be too short. Usually it is sutured back into its original site and the lower stitches in the marked, bottom end of the ureter are made to take a firm bite of the underlying muscle to anchor the ureter and prevent retraction (Fig. 6k). Figure 61, shows the final state.

The ureter is not splinted. The bladder is drained with a fine, urethral catheter for between 2 and 7 days.

Results

In the last 10 years we have re-implanted 91 ureters i n 56 patients by this technique, which preserves the lower end of the ureter, after trying the classical intravesical and Paquin’s operation (Paquin, 1959).

13 of these patients were male and 43 female; their ages ranged from I to 60 and the majority were under 10 years old but notice that quite a number of adults had re-implantations (Fig. 7).

4 ureters were associated with Hutch diverticula. 4 other ureters were duplex and were treated just like single ureters (and counted as single ureters in the analysis). 12 ureters were advanced

4811-c

34 BRITISH JOURNAL OF UROLOGY

Table I Advantages of Combined Extravesical/Intra- vesical Approach

Can tinish freeing titcrer froin bladder extravesically Upper end of submucosal tunnel left intact Ureter re-enters bladder wall at correct place externally N o danger of perforating peritoneum or viscus No danger of angulating or twisting ureter

Table 111 Late Complications

Table IV Relief of Symptoms

Progressive renal failure 4 patients Persistent reflux 1 ureter Obstruction 2 ureters

Table V Advantages of Preserving the Lower End of the Ureter

Maximum length of ureter preserved no tension on anastomosis no need to rnobilise ureter far easy to advance orifice

Ureteric orifice+ cuff preserved stitches away from orifice

Table I1 Immediate Complications

Patients ~. ~~~ ~~

Haematorna of wound 2 Infection of wound 1 Pulmonary embolus 1

Patients Cured No change ~~ ~ ~ ~

Urinary infection 39 28 1 1 Loin pain 24 20 4 Incontinence: day 7 7

night 17 10 7 -

towards the bladder neck. There were no grossly dilated ureters in this series and no ureter was tailored or trimmed.

In 3 patients in whom reflux had been demonstrated up only 1 ureter and only that ureter had been re-implanted, reflux occurred up the other ureter postoperatively. Subsequently, because of this, even though reflux had been shown up only 1 ureter, if both ureteric orifices appeared equally gaping and equally displaced laterally, both ureters were re-implanted at the same operation. This was done in 13 patients. In 7 of these patients the intravenous pyelogram showed pyelonephritis or dilatation of the collecting system on both sides suggesting that bilateral reflux occurred.

There was no operative mortality. Postoperative recovery was usually remarkably uneventful (Table 11). 2 patients developed a haematoma and 1 an infection of the wound. One patient had a pulmonary embolus but recovered fully. Although the blood-urea level might rise transiently, significant ureteric obstruction did not occur, even though splints were not used.

The average follow-up period of these patients was over 4 years. 4 patients with bilateral pyelonephritis and a raise blood-urea level at the time of their operation

had progressive deterioration of renal function in the years following operation and 3 have died, presumably as the result of progressive fibrosis of their kidneys (Table 111). Operation was still probably worthwhile in that they had no further urinary symptoms and no further attacks of urinary infection, Altogether, there were I3 patients who had blood-urea levels of over 40 mg per 100 ml (7.1 mmol/l) at the time of their operation; of the other 9 patients, in 3 the level has remained static and in 6 it has returned to normal or near-normal levels. 5 of these 13 patients

RE-IMPLANTATION OF THE URETER 35

were hypertensive at the time of their operation. 2 had progressive deterioration of renal function and died; in 1 the blood-urea level remained static; in 2 it decreased.

One patient, who had leukoplakia involving the ureteric orifice and a urethral stricture requiring repeated dilatation (and was also the oldest patient in the series) has not been cured of reflux by re-implantation. Due perhaps to soft-heartedness, postoperative micturating cystograms were done on only 46 of the other 55 patients (a general anaesthetic would have been needed to catheterise some of the children) but there is no reason to believe reflux is occurring in any of the other 9 patients. This gives a reflux rate of I in 76 ureters, or 1 in 64 ureters in which reflux had been demonstrated preoperatively.

2 patients developed obstruction of a ureter and have been treated by re-implanting their obstructed ureter into a Boari flap. In 1 patient the cause of the obstruction was not apparent; in the other the cause was faulty technique, the angled forceps having been inadvertently pushed through a fold of bladder mucosa before perforating the bladder muscle. This resulted in the ureter crossing the lumen of the bladder and being angulated before it entered the submucosal tunnel-a fault which was subsequently easily avoided.

In the other patients the relief of symptoms by the operation was usually dramatic (Table IV). Often the patient would have no further attacks of urinary infection, no further loin pain and would become dry from the day of operation. A child, who before the operation had been listless, irritable and below average weight, would become active and happy and would put on a spurt of growth.

Several patients needed to be on antibiotic therapy for up to 2 months to eradicate urinary infection; 4 patients had 1 or 2 isolated attacks of urinary infection but recurrent attacks con- tinued in only I 1 patients; one of these had renal stones and 2 adult patients had urethral strictures requiring repeated dilatation. Loin pain was usually cured, though 4 patients have continued to have occasional twinges of pain. Diurnal incontinence has been cured but nocturnal enuresis persists in 7 out of 17 patients; 2 of these had a Y-V plasty of the bladder neck, an operation which is now generally thought to be rarely indicated.

Pyelograms were usually done on these patients every 2 years after operation. Dilatation of the collecting system sometimes took 1 or 2 years to disappear but unlike the dilatation caused by obstruction which may persist. When the dilatation disappeared, previously unnoticed pyelo- nephrotic changes sometimes became apparent. The radiological changes of pyelonephritis persisted.

Discussion

Is the mechanism which prevents reflux active or passive? The lower end of the ureter was carefully preserved in all these patients; if it was deficient in muscle as Tanagho suggests, it remained deficient. In the majority the ureteric orifice was carefully replaced in its original site; if the trigonal muscles were weak, they remained weak. Nevertheless, in all but 1 patient reflux was prevented. Reflux can be prevented by this or by any other operative procedure which creates a long submucosal segment of the ureter. The aim should be to restore the passive mechanism which prevents reflux.

How then can we explain the reflux described by Stephens and Lenaghan in ectopic ureters with very long submucosal segments? Figure 8 is the micturating cystogram of a boy with an ectopic duplex ureter ending at the bladder neck in a ureterocele. The actual orifice was very wide and admitted a panendoscope with ease. It would certainly have allowed urine to flow in and out. Is it too far-fetched to imagine that, trapped within the contracting bladder neck during micturi- tion, this ureterocele might have acted like a Higginson’s syringe and actually squirted urine up the ureter?

Should the lower end of the ureter be excised? The results presented show that it is unnecessary to excise the lower end of the ureter for possible muscular deficiency or for any of those curious

36 BRITISH JOUKNAL OF UKOLOCiY

Fig. 8. Micturating cystograin of boy with duplex ureter opening ectopically and with a ureterocele.

pathological conditions, such as dysembryoplasia, which are said to occur at its lower end. Indeed, there are many advantages in preserving it and therefore every reason to do so (Table V). Because the maximum length of ureter is available, there is no tension on the anastomosis and there is never any need to mobilise the ureter far; advancement of the orifice, if this is necessary, is easy to do; the original orifice is, of course, also preserved and, because the cuff of mucosa around it is much wider than the ureter itself, none of the stitches need ever encroach upon the orifice itself. There is, therefore, never any need to splint the ureter.

If the lower end of the ureter is preserved and a combined extravesical and intravesical approach is used, re-implantation of the ureter becomes a satisfying, workmanlike operation which i s easy to teach and gives consistently good results.

Summary

For 10 years a modified Politano-Leadbetter technique with extravesical as well as intravesical exposure has been used for re-implantation of the ureter.

The results suggest that the passive mechanism of prevention of reflux is more important than any active mechanism and that it is unnecessary to excise the lower end of the ureter.

We wish to thank Miss Mary Brown for the drawings of re-implantation of the ureter.

RE-IMPLANTATION OF THE URETER 37

References

BELL, C. (1812). Account of the muscles of the ureters. Medico-Chiritrgical Transactions, 3 (2nd ed., 1816), 171-190. BROCK, A. J . (1916). Galen: On the Natural Fucirlties. (Loeb’s Classical Series.) London: Heineinann, pp. 59 and 60. PAQUIN, A. J . (1959). Ureterovesical anastomosis: the description and evaluation of a technique. Journalof Urologj,,

POLITANO, V. A. and LEADBETTER, W. F. (1958). An operative technique for the correction of vesicoureteral reflux. Journal of’ Urology, 79, 932-941.

SAMPSON, J . A. (1903). Ascending renal infection; with special reference to the reflux of urine froiii the bladder into the ureters as an etiological factor in its causation and maintenance. Johns Hopk.ins Hospital Bulletin,

STEPHENS, F. D. and LENAGHAN, D. (1963). Congenital Maljormations of the Rectum, Airrrs mid Genitoririnar~~

TANAGHO, E. A., GUTHRIE, T. H. and LYON, R . P. (1969). The intravesical ureter in primary reflux. J V I W I I U ~ of

82, 573-583.

14, 334-352.

Tracts, edited by F. D. Stephens. Edinburgh: Livingstone, pp. 132-152.

Urology, 101, 824-832. TANAGHO, E. A. and HUTCH, J. A. (1965). Primary reflux. Joirrnalof Urology, 93, 158-164.

The Authors

Philip Clark, MD, MChir, FRCS, Consultant Urologist. K. U. Hosniane, FRCSE (now Resident in Urology, Philadelphia General Hospital, Philadelphia, Pennsylvania,

USA).