BERKELEY, CA (UroToday Inc.) - Debate has existed for some time in the pediatric literature as to the appropriate management of the distal refluxing ureter during nephroureterectomy and heminephroureterectomy for a nonfunctioning moiety. With this large retrospective review of 71 patients, the importance of excision of the ureter to the level of the bladder hiatus becomes clear. At a mean age of 49 months, the 52 girls and 19 boys in this study underwent 60 open nephroureterectomies or heminephroureterectomies with ligation of the ureter at the pelvic brim or 11 laparoscopic nephroureterectomies or heminephroureterectomies with ligation of the ureter at the bladder hiatus. High grade reflux (IV or V) was present in 58 of the patients and moderate grade reflux (III) was noted in 13, in addition to their nonfunctioning moiety. With a mean follow up of 52 months, the 11 patients who underwent laparoscopic nephroureterectomy and heminephroureterectomy to the hiatus of the bladder remained asymptomatic during follow up.

In the 60 children who underwent an open procedure, 28 (47%) had the distal ureteral stump excised and also remained asymptomatic. These distal ureteral stump excisions were performed in conjunction with reimplantation of the contralateral refluxing system. In the remaining 32 patients (53%) with refluxing distal ureteral remnants, six (19%) became symptomatic, while 26 (81%) remained asymptomatic. These six patients all had reflux (grade IV or V in 5 and grade III in 1). These symptomatic urinary tract infections recurred on an average at least once a month in these six children. The authors point out that the removal of the distal ureter at the time of the nephroureterectomy or heminephroureterectomy is a straightforward laparoscopic procedure while the open approach usually necessitates an additional lower abdominal incision. They also recommend that the normal usually upper pole ureter be stinted to decrease the risk of iatrogenic injury during the dissection of the refluxing ureter to the bladder hiatus. The laparoscopic approach is readily applied to a solitary distal remnant, especially if the contralateral ureter is not reimplanted. It would certainly seem prudent to excise the entire ureter in a refluxing nonfunctioning moiety and eliminate the 19% risk of morbidity associated with a refluxing distal stump.

J Urol 2005;173:204-06