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JU INSIGHT Should a Refluxing Internal Diversion Be Considered a Temporizing Procedure?
By: Adree Khondker, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada; Mandy Rickard, MN-NP, The Hospital for Sick Children, Toronto, Ontario, Canada; Jin Kyu Kim, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada; Juliane Richter, MD, The Hospital for Sick Children, Toronto, Ontario, Canada; Margarita Chancy, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada; Kay Rivera, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada; Joana Dos Santos, MD, The Hospital for Sick Children, Toronto, Ontario, Canada; Michael Chua, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada; Armando J. Lorenzo, MD, The Hospital for Sick Children, Toronto, Ontario, Canada, University of Toronto, Ontario, Canada | Posted on: 17 Jul 2024
Khondker A, Rickard M, Kim JK, et al. Should a refluxing internal diversion be considered a temporizing procedure? Extended follow-up and outcomes after side-to-side ureterovesicostomy for primary obstructive megaureter in young children. J Urol 2024;212(1):196-204. doi:10.1097/JU.0000000000003966
Study Need and Importance
Primary obstructive megaureter comprises up to 10% of all hydronephrosis cases in young children. For the select patients who will require surgery, current surgical options are technically challenging and often require a later staged surgery. In 2005, a primary side-to-end ureterovesicostomy was first described, and it was initially meant as a temporizing measure for later definitive reimplantation. We adapted this technique to side-to-side anastomosis and adopted a conservative follow-up approach in all patients, reserving a subsequent surgery for patients who had clinical or radiological worsening. Here, we describe our experience with our approach to determine if a subsequent surgery is mandatory.
What We Found
The median age of surgery was 9 months. Fifteen percent of children developed 30-day complications (retention, infection), and no children had 30-day major complications. Over follow-up (Figure), 30% of children developed a urine infection, and only 15% of children required a second surgery. There was a notable reduction in the percentage of patients exhibiting high-grade hydronephrosis, along with a decrease in the severity of both hydronephrosis and ureteral dilatation.
Limitations
Our study is limited by a single-institution experience and retrospective methodology, which limit generalizability. Next, we lack comparative data to contrast outcomes among patients undergoing ureterovesicostomy vs other surgical techniques. Lastly, our data show that there is a reassuring decrease in the proportion of patients with severe hydroureter, but we cannot ascertain complete resolution with the follow-up within this study.
Interpretation for Patient Care
Our experience demonstrates that creating a refluxing ureterovesicostomy is a safe and feasible procedure that offers reasonable rates of disease resolution, low complication rates, and acceptable rates of postoperative infections. We propose that primary refluxing ureterovesicostomy may not require subsequent surgery in all cases of primary obstructive megaureter.
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