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Urinary Tract Reconstruction Patient 7: Strictured Ileal Loop

This 14-year-old boy was referred with an ileal loop in 1981.

At age 8 years, two bilateral reimplantation operations had been performed elsewhere and failed.

The kidneys and ureters were only moderately dilated. The bladder was small, being defunctioned for 6 years. The loop was strictured.

Our initial surgery was to stretch his small bladder by inserting a temporary suprapubic catheter embarking on a 13-hour reconstruction operation 6 months later when the bladder had increased to 200 ml, a volume which he could hold as well as void.

The strictured bowel was removed and discarded in order to not make a lower ureter of bowel and risk restricturing. Despite pexing the kidneys downward it was decided to autotransplant the right kidney based on the iliac vessels. A tension free long tunnel reimplant was done on the right and a transureteropyelostomy was performed on the left ureter. The right kidney was perfused with cold Lactated Ringer’s solution and Manitol. Slush ice was used for further cooling. The patient was hypotensive when the clamps were removed which was quickly remedied with more transfused blood. A psoas hitch was used to stabilize the right reimplant. Fluid replacement during the operation was enormous: requiring 13 liters of normal saline, 6 units of packed red cells, 250 ml of D5W, and 750 ml of albumen solution.

Anatomy (Select Image for High-quality Version). (Top) Before operation. (Bottom) After undiversion.

X-rays (Select Image for High-quality Version). (Left) Preop. (Right) Soon postop.

X-rays (Select Image for High-quality Version). 1 year postop.

Urinary Tract Reconstruction Patient 6: Prune Belly Syndrome

This 15-year-old male was referred in 1975 with the Prune Belly Syndrome. At age 2 weeks, bilateral nephrostomies had been performed and thereafter an ileal loop which was unfortunately placed in backwards and did not drain well. A second ileal loop was later performed but it drained poorly also.

The long defunctioned bladder would hold only 100 ml at age 15, even filling with a water pressure 4 feet above his bladder level. Cystoscopy disclosed a type 3 urethral valve which was opened endoscopically in 4 quadrants.

The bowel segment was usuable after reversing its orientation to flow left to right! There was ureteropelvic junction obstruction on both sides. The left colic artery was placed behind the new renal pelvic junction. Both renal pelves were trimmed. The loop was tapered. A psoas hitch was performed to stabilize the new “ureter” reimplant.

Operative time was 11 hours. Blood replacement was with washed red cells to minimize sensitization in view of future renal transplantation.

At 1.5 years after his undiversion surgery, his chemistries were: BUN 40, creatinine 2.0, CO2 19, creatinine clearance 61 liters.

Anatomy (Select Image for High-quality Version). (Top) Preoperative anatomy. (Bottom) Postoperative anatomy.

X-rays (Select Image for High-quality Version). (Left) Antegrade nephrostogram via needle in left kidney. Note small,smooth walled capacity bladder not in use since infancy. (Right) Anategrade study via left kidney 2 years after undiversion at age 15 years. Note now normal bladder size.

Urinary Tract Reconstruction Patient 5: Undiversion by Removing an Ileal Loop Done for Failed Ureteral Reimplants

This 13-year-old boy was referred in 1976 for reconstructive surgery of an ileal loop done after ureteral reimplantation had failed in two prior hospitals 5 years previously. As an infant, he had been treated successfully for HIrschsprung’s Disease by colon resection and pull through. It was presumed that he had a neuropathic bladder.

Preoperative evaluation showed a 100-ml bladder, with good sensation and ability to empty the bladder when it was filled with saline.

Several useful maneuvers are illustrated in this operation. First, is the use of transureteroureterostomy, which we have used extensively. Care must be taken to avoid wedging the crossing ureter beneath a mesenteric vessel, especially the left colic artery. The loop was tapered to substitute for loss of right ureter.

Comment from Dr. Hendren: Patients with small bowel in the urinary tract very commonly will develop one or more well defined strictures which may need dilatation or even cutting as he did. This will require careful long-term observation.

Anatomy (Select Image for High-quality Version). (Top) Before and (Bottom) after reconfiguring his urinary tract.

X-ray (Select Image for High-quality Version). Antegrade study via left kidney. Note discrete narrowing of tapered bowel loop just prior to its entry to bladder. He is allergic to I.V. contrast. Subsequent evaluations have been done by ultrasonography.

Urinary Tract Reconstruction Patient 4: Undiversion Using Gastric Augmentation

This 3-year-old girl was referred for reconstructive surgery in 1988. Born with severe bilateral obstructive megaureters with hydronephrosis, bilateral end ureterostomies had been performed at age 1 month. The ureterostomies did not drain well. Therefore, bilateral loop cutaneous ureterostomies were performed at age 1 year. Hydronephrosis improved; the ureterostomies were then closed, but severe hydronephrosis recurred.

Preoperative assessment showed a very small bladder volume of only 10 ml. When contrast was introduced through the end ureterostomy stomas, the ureters drained well, but contrast remained in the kidneys, indicating functional ureteropelvic junction obstruction bilaterally.

At reoperation the better ureter on the left was reimplanted with a long tunnel into her tiny bladder, together with a psoas hitch. The right side was drained by a transureteral ureterostomy to the left. Both upper ureters were obstructed from angulation at the site of the ureterostomy closures. Therefore, bilateral dismembering pyeloplasties were performed, maintaining adequate ureteral blood supply in the surrounding periureteral tissues. The bladder was augmented with a large segment of stomach based on the right gastric epiploic artery. This 13-hour operation was well tolerated. Bladder emptying was performed initially by intermittent catheterization by her mother. Gradually she learned to void completely, and catheterization was stopped.

Postoperative studies showed some reflux. Subureteric injection of Teflon paste beneath the single ureteral orifice stopped the reflux.

Comment from Dr. Hendren: Use of the stomach for bladder augmentation has some advantages over small bowel and colon. It is metabolically superior regarding chloride absorption and base loss, seen with segments of small bowel and colon. Those segments tend to lose bicarbonate and potassium and to a lesser extent sodium while resorbing chloride. If potassium loss is replaced as potassium chloride, bicarbonate loss can be accelerated, aggravating acidosis. Gastric mucosa secretes chloride and is therefore preferred in patients with poor renal function who cannot tolerate increased solute resorption with acidosis. The urine is usually sterile after gastrocystoplasty. The ureters are tunneled very easily into gastric mucosa which is durable and also compliant. The stomach may be the only reasonable means for reconstruction in certain patients with cloacal exstrophy who have little or no colon, and who have a short small bowel in particular. Its metabolic superiority probably makes it the augmentation of choice in patients with very poor renal function. These patients also do not have excess mucous in the urine, which is an added advantage because mucous provides a nidus for stones. Cutaneous ureterostomy was a common type of diversion in infants a few years ago. It can cause many complications however, as shown in this case.

Anatomy (Select Image for High-quality Version). (Top) Pre- and (Bottom) Postop anatomy.

X-rays (Select Image for High-quality Version). Preoperative x-ray studies. Both kidneys and ureters filled via end ureterostomies Small bladder filled via urethral catheter.(Left) Postoperative bladder studies after gastrocystoplasty. (Top Right) After filling. (Bottom Right) Voiding cystogram with good control.

X-rays (Select Image for High-quality Version). IVP 2 years postoperatively. Note: right ureter enters left just above bladder. Both ureters greatly improved in size and emptying.

Urinary Tract Reconstruction Patient 3: Male Infant with Horseshoe Kidney

This 1.5-year-old male baby was referred in February 1994 with multiple anatomic problems depicted below in the Before figure. Cutaneous vesicostomy had been performed elsewhere as an infant. Previous studies had shown a horseshoe kidney, the left side of which was dysplastic. The right ureter ended in a retrovesical “cyst.” Because of vesicoureteral reflux, he had been maintained since infancy on prophylactic antibiotics. Prolonged endoscopy, through duplex urethras, and the vesicostomy, plus appropriate radiology studies, disclosed the anatomy seen in the Before figure.

In a 10-hour operation the dysplastic right kidney was removed, together with the retro vesical “cyst” formed by the lower end of the right ureter, and the right seminal vesicle and vas. The right ureter was reimplanted, repairing the adjacent diverticulum as well. The perineal sinus tract connected with the prostatic urethra was excised. The septum between the two urethras was incised endoscopically.

At age 3 years, endoscopic cutting of the septum between his two penile urethras was performed, creating a single urethral meatus, and correcting his mild hypospadias.

Anatomy (Select Image for High-quality Version). (Top) Before undiversion. (Bottom) After undiversion.