INTRODUCTION: The purpose of the study was to assess the effectiveness of a new antireflux technique that uses a peritoneal flap as a tunnel for the treatment of high-grade refluxing ureters.
METHODS: This was a prospective, nonrandomized trial involving15 patients with grade 4 or grade 5 vesicoureteral reflux, seen between 1998 and 2004. Their mean age was 41 years (range, 27-58 years). Of the 15 patients, 13 had a past history of ureteroneocystostomy without an antireflux procedure for the treatment of bilharzial ureteral stricture; 2 patients had reflux secondary to neurogenic bladder. A peritoneal flap was used to create an extravesical ureteral tunnel as an antireflux procedure that does not interrupt the ureterovesical junction. The effective tension of the tunnel and its ability to prevent reflux were tested using intraoperative fluoroscopy. Patients were followed at 6 and 12 months with urine cultures, creatinine measurement, voiding cystourethrogram, and renal ultrasound.
RESULTS: Voiding cystourethrogram showed that 10 of 12 patients without reflux during the procedure remained free of reflux during follow-up; the remaining 2 patients developed grade 1 and grade 2 reflux. For 3 patients with low-grade reflux during surgery, 2 remained at the same grade and 1 progressed to high grade. There were no major changes in serum creatinine from baseline to follow-up. After surgery, the frequency and severity of urinary tract infections and pyuria were appreciably diminished. There was no evidence of ureteral obstruction.
CONCLUSIONS: The new technique was effective in preventing or downgrading reflux in this small number of patients. By creating an extravesical tunnel from a peritoneal flap, the technique avoids interrupting the ureterovesical junction in the dilated unhealthy ureter and fibrosed bladder wall. It could be applied to cases with a severely fibrosed ureter and bladder when other surgical techniques cannot be safely used.
Mahmoud Ezzat Ibrahim,1 Mohamed Mahmoud Ezzat,2 Wael Mahmoud Ezzat3 1 Department of Urosurgery, Ain Shams University, Cairo, Egypt 2 Department of General Surgery, Ain Shams University, Cairo, Egypt 3 Department of Neurology, Cairo University Hospital, Cairo, Egypt Submitted September 29, 2010 - Accepted for Publication November 30, 2010
KEYWORDS: Antireflux surgical procedure; Secondary refluxing ureters.
CORRESPONDENCE: Mahmoud Ezzat Ibrahim, 37 El Hassan Street, Mail Box 12411, Dokki, Giza, Egypt ().
CITATION: UroToday Int J. 2011 Apr;4(2):art37. doi:10.3834/uij.1944-5784.2011.04.19
ABBREVIATIONS AND ACRONYMS: UTI, urinary tract infection.
The intrapelvic urinary organs are the primary sites for schistosomal infestation , which occurs mainly in the urinary bladder and pelvic part of the ureter . Dense fibrosis of the bladder wall results in diminished storage capacity . In the pelvic part of the ureters, intense bilharzial infestation causes long-segment stricture and obstructive uropathy, which is the most serious late complication [2,4]. Surgical excision of the strictured segment leaves a short, dilated ureter with a thickened wall. This eliminates the possibility of using any of the known antireflux measures during ureterovesical reimplantation. As a result, the patient has a high-grade refluxing ureter. When combined with superimposed bacterial infection, this leads to progressive deterioration of renal function [5,6].
We have developed a new antireflux technique for the treatment of high-grade refluxing ureters that uses a peritoneal flap as a tunnel. The purpose of the present study was to assess its effectiveness.
This was a prospective nonrandomized trial of patients seen between 1998 and 2004. The Urology Department Committee of Scientific Activities at Ain Shams University approved the protocol, in compliance with all regulations governing the protection of human participants. All of the patients were informed about the procedures and provided written informed consent.
The participants were 15 patients with dilated, high-grade (grade 4 or 5) refluxing ureters. There were 12 males and 3 females. Their mean age was 41 years (range, 27-58 years). In 13 patients, the high-grade reflux was a consequence of excision of the long bilharzial strictured segment of the lower ureter; these patients had ureterovesical reimplantation without an antireflux technique. In 2 patients, the dilated refluxing ureters were secondary to neurogenic bladder; the diagnosis was confirmed by neurological examination and urodynamic studies. These 2 patients had repeated courses of medical treatment for 1 year, including anticholinergic drugs and antibacterial agents. Regimens of interrupted, short courses of anticholinergic drugs and prolonged antibacterial agents were alternated, with no or minimal response.
Persistent heavy pyuria and positive urine cultures were present in all cases. The mean number of episodes of acute bacterial infection with general and urological manifestations was 5 attacks per year. Our management included an indwelling urethral catheter for an average of 7 days to drain the system and antimicrobial treatment for 10-15 days to help control the infection. However, eradication of infection was difficult and repeated attacks soon followed completion of the antibacterial course.
Serum creatinine measures, bacteriological studies, and ultrasonography measurement of the kidney, renal pelvis, and ureters were done before surgery. Excretory urography was done for patients with serum creatinine < 2 mg%; magnetic resonance urography (MRU) was done for patients with serum creatinine > 2 mg%. Patients with concomitant ureteral obstruction with reflux were excluded from the study. Cystoscopy was done to exclude patients with malignancy; uroflowmetry was done to exclude patients with infravesical obstruction.
A voiding cystourethrogram was used to grade the reflux before the procedure. A total of 9 patients had bilateral reflux, with high grade on 1 side and low grade on the other side (n = 5) or high grade on both sides (n = 4); 6 patients had unilateral reflux. Figure 1 shows a voiding cystourethrogram of a patient with a high-grade refluxing ureter.
For patients with bilateral reflux, 1 one side was treated with the extravesical peritoneal tunnel technique and the other side was treated with a Macroplastique injection protocol for reflux prevention. Patients with unilateral reflux received the extravesical peritoneal tunnel technique.
Patients received a suprapubic subumbilical incision. The peritoneum was carefully peeled off the ureter. The lower 10 cm of the ureter was exposed and dissected. We selected a rectangular sheet of the pelvic peritoneum near the posterior aspect of the bladder, measuring 10 cm in the transverse direction and 15-18 cm in the longitudinal direction. The lower attachment to the general peritoneum and the 2 lateral borders were incised sharply, releasing the flap base on its superior border that was attached to the peritoneum. As a prerequisite for a successful tunnel, the tensile properties of the peritoneal membrane should be maintained and the membrane should be of good quality (Figure 2). Very thin, easily torn membrane would not provide good material for the tunnel. In addition, 3-4 cm of the ureter should be available on the posterior aspect of the bladder for the creation of an effective tunnel.
The peritoneal cavity was closed either directly or after using expanded polytetrafluoroethylene (ePTFE) mesh. A Foley catheter was introduced to the bladder at the start of the operation. It was used to distend the bladder by saline during fixation of the peritoneal sheet and creation of the tunnel. The catheter was also used for instillation of dye inside the bladder (under X-ray control) to test the efficacy of the tunnel in preventing reflux. The tunnel was constructed from the peritoneal flap, 10 cm on the transverse axis and 8 cm on the longitudinal axis. The peritoneal sheet was stretched on its endothelial surface onto the posterior aspect of the ureter and urinary bladder and fixed in place on both the lateral and medial borders using interrupted stitches of 4-0 Prolene (Ethicon Inc, Somerville NJ, USA). The stitches were placed 1 cm apart while the bladder was fully distended. This created the 1st and 2nd rows of sutures. In order to construct the tunnel, the 3rd row of stitches was applied on the medial border of the ureter. The peritoneum was attached to the posterior aspect of the bladder using the same type of sutures (Figure 3a; Figure 3b). To select the proper tension of the tunnel that effectively prevents reflux, a temporary rigid tube (7 Ch ureteric catheter or Teflon ureteral dilator) was fixed on the lateral border of the ureter using 3 temporary stitches. The bladder was evacuated of saline and urine. This was followed by dye instilled inside the bladder that was sufficient to make it fully distended. Under X-ray control, any regurgitation of dye inside the ureter was observed. If no dye regurgitated into the ureter, the temporary tube and stitches were removed and a row of stitches was used to form the lateral border of the tunnel (4th row). However, if reflux was still seen in the ureter, the rigid catheter or dilator was shifted 2-3 mm medially and fixed temporarily; the test was then repeated. Figure 4 illustrates the mechanism of tunnel function during a full and empty bladder. Once the tunnel successfully prevented reflux, the temporary tube and stitches were removed and the 4th row of stitches was applied. The wound was closed in layers without drain and the Foley catheter was removed at the end of the operation.
Serum creatinine measures, bacteriological studies, ultrasonography measurement of the kidney, renal pelvis, and ureters, and voiding cystourethrogram were repeated at 6 months and 1 year after the antireflux procedure to detect any progressive dilatation and to determine the procedure's success. Changes from baseline in reflux grade, serum creatinine, and renal, pelvis and ureteral dimensions were summarized. Complications following surgery were described.
The tunnel was successful in preventing reflux in 12 out of the total 15 patients, as determined during the procedure under X-ray control. The reflux was downgraded from high grade to low grade in the remaining 3 patients. At the 6-month and 1-year follow-up examinations, the voiding cystourethrogram showed that 10 of the 12 patients without reflux during the procedure remained free of reflux; the remaining 2 patients had developed grade 1 and grade 2 reflux, respectively. Postoperative voiding cystourethrograms showing patients with no reflux and low-grade reflux are shown in Figure 5a and Figure 5b, respectively. For the 3 patients with low-grade reflux during surgery, 2 remained at the same grade and 1 progressed to high grade at follow-up. None of the patients required a nephrostomy tube either before or after surgery.
Preoperative serum creatinine values were within the normal range (< 1.4 mg%) for 4 patients, between 1.5 mg% and 2 mg% for 6 patients, and > 2 mg% for 5 patients. Serum creatinine values at 6 months and 1 year did not show any major changes. All of the patients presented with recurrent urinary tract infections (UTIs) and acute exacerbations. A frequent long course of urinary antiseptics was administered. After prevention or downgrading of the reflux, the frequency and severity of UTIs were appreciably diminished and pyuria decreased from a heavy to mild degree. Acute exacerbations were diminished from the mean of 5 episodes per year preoperatively to 1 attack per year postoperatively. Moreover, effective control of infection could be achieved using less frequent and shorter courses of urinary antiseptics, as seen on bacteriological examination through 1 year of postoperative follow-up.
Ultrasonography measurement data before and after 1 year of the antireflux procedure did not show any significant changes in renal, pelvis, or ureteral dimensions, which eliminated the possibility of obstruction. The X-ray exposure during the procedure was estimated. For 10 patients, the time was comparable to the average time of voiding cystourethrogram examination; for the other 5 patients it exceeded the average time of examination by 3-4 minutes.
The incidence of obstructive uropathy of schistosomal origin ranges between 5% and 50%  and is directly related to the severity of infection . Stricture of the ureter is the most important lesion because it produces severe symptoms that necessitate reimplantation . Surgical attempts for ureteroneocystostomy with an antireflux procedure are not recommended  and reimplantation in such pathological tissue with an antireflux procedure carries a high risk of restenosis [11,12].
In the present group of patients, ureterovesical reimplantation was done for treatment of bilharzial strictures of the lower ureter that had not been treated with antireflux measures. In Egypt, the frequency and intensity of schistosomal infestation has markedly declined through the last 3 decades. However, delayed sequels of the disease and its related surgery are still present. In addition to the superimposed bacterial infection , high-grade refluxing ureters can initiate rapid deterioration of renal function [5,6].
Prevention of reflux was mandatory to protect the kidney and stop any further damage. All types of antireflux procedures carry a high risk of restenosis or failure to cure reflux if performed in such pathological tissue . Using our new technique with 15 patients, we obtained a high rate of cure (n = 10) or improvement (n = 4) that remained 1 year after surgery. This indicated that the technique was highly successful and could be utilized in severely pathological tissues where other surgical alternates carry poor results and high rates of complication. The antireflux mechanism of this new technique depends on the 2 rows of sutures that form the tunnel (3rd - 4th row). These sutures were adjusted to exert a compression effect on the ureter during bladder distension to prevent reflux. When the bladder was empty the tension on the ureters was relieved, which allowed urine transport to the bladder. Serum values of creatinine were used as an index for renal function. Our results showed no deterioration in renal function in any case; no difference in presurgical serum creatinine values was reported 1 year after surgery. This finding indicated that the surgical technique effectively stopped further deterioration of renal function.
There were no appreciable differences in ultrasongraphy measurements of the kidney, renal pelvis, and ureter between baseline and 1-year follow-up. This finding indicated that the tunnel did not cause any ureteral obstruction.
The rate of bacterial infection and its severity markedly declined after cure or improvement of the reflux grade. Short, infrequent courses of urinary antiseptic were used to effectively control infection throughout the year following this technique.
Like previous reports, the present investigation is limited in the total number of patients and relatively short follow-up. Longer follow-up is required to determine whether or not the technique will stop the deleterious effects of high-grade reflux on the kidney and continue to minimize the severity and frequency of infection past a period of 1 year. Additionally, the patients were not randomly assigned to this surgical procedure with a control group for alternative techniques. The effect of the presence of the flap on future surgeries (eg, cystectomy and diversions; neobladders) is unknown. However, the successful results reported here indicate that future research is warranted. Generalization of this technique to patients with complicated reflux cases of detrusor instability with voiding problems is one possible extension of the present study.
The new antireflux technique presented in this study was highly successful, safe, and simple to complete. By creating an extravesical tunnel from a peritoneal flap, the technique avoids interrupting the ureterovesical junction in the dilated unhealthy ureter and fibrosed bladder wall. Therefore, it does not interrupt the ureterovesical anastomosis and could be applied to cases with a severely fibrosed ureter and bladder when other surgical techniques cannot be safely used.
Conflict of Interest: none declared.
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