| Abstract|| |
The evaluation of the complications of uretero-neocystostomy is very scant in the literature. The objectives of this study were to determine the indications for ureteroneocystostomy and to evaluate the complications of different techniques. This retrospective descriptive study was conducted in the Gezira Hospital for Renal Diseases and Surgery, Sudan between January 2001 and January 2004. A total of 65 patients were enrolled in this study. All of them underwent reimplantation of either one or both ureters for various indications. The methods of reimplantation were direct, Lich Gregoire, Cohen, Boari's and ileum substitution. The mean follow-up period was18 months. The 65 patients underwent a total of 77 reimplanted ureters. Of them, 39 ureters were gynecological ureters, 21 were renal transplant and 17 others had miscellaneous indications. The direct method was used for 25 transplanted cases (27.5%), Lich Gergoire for 40 patients (51.9%), Cohen for eight patients (10.4%) and Boari's for seven (9.0%). Leakage and lower urinary tract symptoms (LUTS) were diagnosed in four patients each (4.8%), two had hydronephrosis while one each had obstruction and necrosis. Our study indicates that gynecological ureter was the leading indication for ureteral reimplantation and the incidence of complications was comparable to the literature.
|How to cite this article:|
El Imam Mohammed M, Omram M, Nugud F, El Hassan M, Taha O. Evaluation of Ureteral Reimplantation in 65 Sudanese Patients. Saudi J Kidney Dis Transpl 2005;16:166-70
|How to cite this URL:|
El Imam Mohammed M, Omram M, Nugud F, El Hassan M, Taha O. Evaluation of Ureteral Reimplantation in 65 Sudanese Patients. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2015 Nov 28];16:166-70. Available from: http://www.sjkdt.org/text.asp?2005/16/2/166/32936
| Introduction|| |
Ureteral reimplantation is a procedure commonly performed by both urologists and pediatric surgeons. Although the vast majority is successful, there are patients in whom technical considerations and/or bladder or ureter abnormalities might mitigate against success. 
Reimplantation of the ureter into a groove of the bladder mucosa has been used to simplify the procedure of reimplantation and to over come problems of trabeculated bladder by obviating the creation of sub-mucosal tunnel. 
Anti-reflux ureteral reimplantation may be performed by a variety of techniques with consistently satisfactory results. Complications such as persistent reflux post-surgery and ureterovesical obstruction may be encountered.  The Politano and Leadbutter anti-reflux uretero-neocystostomy is the most accepted method for ureteral reimplantation. 
The evaluation of the complications of ureteroneocystostomy is varied based on the etiological factors such as malformations, gynecologic ureters and stenos of the lower ureter and reflux and the technique used. The Cohen technique has yielded the best success rate. Most of the failures are due to stenosis of the reimplanted ureter. 
Other methods for reimplantation were evaluated like psoas-bladder hitch confirming that this is a versatile procedure that suits a number of indications.  The modified Lich Gregoire technique of extravesical ureteral reimplantation is successful, simple to be performed and reproducible and associated with low morbidity requiring minimal hospital stay. ,
The use of laparoscopy in reimplantation was reviewed.  Two common techniques of ureteric reimplantation for kidney transplantations, the Politano-Leadbutter and the extravesical uretero-neostostomy with judicious use of double J stent are also emphasized to reduced urological complications which occur in about 7-15% in most series. 
The incidence of urological complications after renal transplantation, although are still a source of morbidity and mortality, are not very common. Uretero-neocystostomy with Lich Gregoire and Politano-Leadbutter techniques were evaluated with the frequent complications being early ureteral obstruction (3.6%), obstruction (1.8%), lithiasis (1.8%) and urinary extravasation (0.9%). 
Ureteral lesions due to endometriosis and gynecological surgery are common findings in urology. 
The present study was undertaken at the Gezira University in Sudan in order to determine the indications of uretero-neocystostomy at our center and to assess the complications of the different techniques used.
| Patients and Methods|| |
This is a retrospective cross-sectional study. It was carried out in the Gezira Hospital for Renal Diseases and Surgery. All patients who underwent ureteric reimplantation from January 2001 to January 2004 were enrolled in this study. A senior surgeon operated upon all the patients. Different methods of reimplantation were used.
Patients undergoing renal transplantation were the first group of patients to undergo ureteral reimplantation in this hospital. All these cases underwent reimplantation by direct method mucosa-to-mucosa anastamosis with double J stent left for a couple of weeks. Vicryl suture was used. In all these patients, the left kidneys of the donors were transplanted in the right iliac fossa and reimplantation was performed to the right side of the bladder.
All patients with urinary fistulae had high fistula with or without complications. Several cases were operated more than once. Reimplantation was considered when the fistula was involving the ureteric orifices or was expected to endanger the ureters. All cases were dealt with by the Lich Gregoire method with adequate anti-reflux procedure using a nasogastric tube sized 5 or 8 as stent for seven days.
The Cohen procedure was adopted for bilateral reflux in pediatric cases as well as bilateral direct trauma to the bladder during subtotal hysterectomy performed for uterine inertia and post-partum hemorrhage.
Boari's flap was used for patients who were discovered intra-operatively to have short ureters. The only case of reconstruction by the ileum was in a patient with a long stricture of the ureter, who underwent several dilatations that ultimately worsened the condition. A segment of the ileum was chosen and reimplanted in a tunnel at the urinary bladder.
Follow-up for all patients was done by regular clinical examination and ultrasound study. The mean follow-up duration was 18 months.
Leakage was detected by persistent continuous drain after surgery. If the drainage was minimal, we used to wait for spontaneous cure and if it continued we would interfere. Other complications were dealt with appropriately and revision was done for one case.
| Results|| |
The total number of patients studied was 65 who underwent a total of 77 ureteral reimplantations. Of them, 39 ureters were related to gynecological procedures or diseases, 21 were following renal transplantation and the other 17 included miscellaneous indications [Table - 1].
Reimplantation was performed by the direct method in 25 transplanted cases (27.5%), Lich Gergoire method in 40 patients (51.9%), Cohen method in eight patients and Boari's method in seven (9.0%) [Table - 2].
Following reimplantation, leakage and lower urinary tract symptoms (LUTS) were diagnosed in four patients each (4.8%). Two patients developed hydronephrosis and one each developed obstruction and ureteral necrosis [Table - 3].
| Discussion|| |
The principles of ureteric reconstruction are not different from those of other reconstructive urological procedures. The importance of ensuring good vascular supply, complete excision of pathological lesions, good drainage and a wide spatulated and tension-free anastamosis of mucosa-to-mucosa remain paramount, although the time of diagnosis is the most single most important factor affecting the outcome. 
Various techniques of ureteral reimplantation have been described for different indications which are numerous and varied including enterocystoplasty, inflammatory stenosis, renal transplantation, primary megaureter and stenosis.
Lich Gregoire is the ideal reimplantation technique for renal transplantation, LeducCamey method for ureterodigestive tract reimplantation and Leadbutter technique for megaureter and Cohen technique for reflux. 
In our series, we found that the leading indication of reimplantation was gynecology related lesions including pelvic endometriosis and gynecological surgery.  Various techniques of ureteral reimplantation were used for different indications.  Although the ureter is functionally a simple tube to transport urine, ureteric surgery requires detailed anatomical knowledge and advanced surgical skill because the ureter has a delicate blood supply. Therefore, the urological surgeon must have distinct strategies available to bridge ureteric defect with various sites and length. 
We used the direct method for all transplanted patients initially; we have changed to Lich Gergoire technique more recently. 
Two common techniques of ureteric reimplantation include the Leadbutter-Politano technique and extra-vesical uretero-neocystosomy with judicious use of double J stent so as to reduce the urological complications, which occur in 7% to 15% of the cases.  Cohen's technique was used for bilateral reflux and/or combined injury to the posterior bladder. The technique was found to be easy and safe with less use of a urethral catheter. Also, Cohen's transtrigonal ureteric reimplantation was known to decrease hospital stay and discomfort of the patient.  Boari's technique was used for a short ureter in seven patients and it was practically feasible.
Ureteral complications after renal transplantation include urine leakage, stenosis and vesicoureteral reflux.  Long-term results in patients operated upon for ureteral lesions following surgical gynecological procedures showed complete preservation of kidney function in 87% of the cases without the need of a permanent stent. 
We diagnosed leakage in four patients (4.5%) three of whom were cases of direct anastomosis in renal transplantation and were treated conservatively by stent that yielded gratifying results. One case (1.2%) in whom Cohen's technique was used for reflux was diagnosed as having stenosis with the aid of contrast study and treated endoscopically.
| Conclusion|| |
Our study suggests that gynecological ureters were the commonest causes of reimplantation. The incidence of complications was comparable to what is described in the literature. The Lich Gregoire technique was better than direct reimplantation for renal transplantation. LUTS as a sequel of reimplantation needs to be addressed in another study.
| References|| |
|1.||Geanhart JP, Leonard MP. Reoperative ureteral reimplantation. Strategies for management. J Pediatr Surg 1991;26(1):58-63. |
|2.||Keramidas DC. Reimplantation of the ureter in a transtrigonal mucosal groove. B J Urol 1993;72(6):962-4. |
|3.||Ahmed S. Revision of ureteral reimplantation by transverse advancement technique. J Urol 1979;122(4):550-3. |
|4.||Persky L, Hampel N. Simplified technique for ureteroneocystostomy: a modification of Politano-Leadbetter operation. Urol Int 1977;32(5):368-72. |
|5.||Puebla Cerverino M, Martinez Torres JL, de La Fuente Serrano A, et al. Ureterovesical reimplantation. Our results. Arch Esp Urol 1989;42(5):404-12. |
|6.||Staehler G, Schmeller N, Wieland W. Ureteral reimplantation using Psoas bladderhitch. Experience based on 111 operation in 100 patients. Urol Int 1984;39(3):143-6. |
|7.||Lapointe SP, Barrieras, Leblanc B, Williot P. Modified Lich-Gregoire Ureteral reimplantation. Experience of a Canadian Center. J Urol 1988;159(5):1662-4. |
|8.||Marberger M, Altwein JE, Straub E, Wulff SH, Hohenfellner R. The Lich Gregoir antireflux plasty: experiences with 371 children. J Urol 1978;120(2):216-9. |
|9.||Gill IS, Ponsky LE, Desai M, Kay R, Ross JH. Laparoscopic Cross-trigonal Cohen Ureteroneocystostomy: novel technique. J Urol 2001;166(5):1811-4. |
|10.||Tan EC, Lim SM, Rauff A. Techniques of ureteric reimplantation in kidney transplantation and its related urological complications. Ann Acad Med Singapore 1991; 20(4)524-8. |
|11.||Santiago-Delpin EA, Baquero A, Gonzalez Z. Low incidence of urologic complications after renal transplantation. Am J Surg 1986; 151(3):374-7. |
|12.||Rigatti P, Pompa P. Pathology of the gynecologic ureter. Arch Ital Urol Androl 2002;74(1):21-2. |
|13.||Png JC, Chapple CR. Principles of ureteric reconstruction. Curr Opin Urol 2000;10(3): 207-12. |
|14.||Aboutaieb R, Rabii R, Joual A, el Mrini M, Benjelloun S. Ureteral reimplantation. Ann Urol Paris 1996;30(5):240-3. |
|15.||Stief CG, Jonas U, Petry KU, et al. Ureteric reconstruction. B J U Int 2003;91(2):138-42. |
|16.||Anderson PD, Dewan PA. Catheter-less cohen transtrigonal ureteric reimplantation. BJU Int 2002;89(7):722-5. |
|17.||Cancarini G, Frego E, Simeone C, et al. Controversies concerning the treatment of ureteral complication following kidney transplantation. Arch Ital Urol Nefrol Androl 1993;65(1):59-62. |
Mohammed El Imam Mohammed
Gezira University, Faculty of Medicine, P.O. Box 20 Wad Medani
[Table - 1], [Table - 2], [Table - 3], [Table - 4]