Single distal ureter for ureterocystoplasty: a safe first choice tissue for bladder augmentation

Recently, the use of ureter for bladder augmentation has gained wide acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with 1 or both ureters mildly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients.

Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorly compliant bladder underwent ureterocystoplasty with a single distal dilated ureter. Diagnosis included myelomeningocele in 13 cases, central neurogenic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Variable degrees of hydronephrosis were observed in all patients. Vesicoureteral reflux was detected in 14 patients and was bilateral in 3. Five patients presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segments of ureter used for augmentation ranged from 9 to 14 cm. long (mean 11) and from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedures included transureteroureterostomy in all 22 patients, appendicovesicostomy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months postoperatively and yearly thereafter.

Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 have had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 14 patients, improved in 6 and remained unchanged in 2. On urodynamics median increase in capacity less than 30 cm. pressure was 177% (range 11% to 560%). When comparing capacity less than 30 cm. water to normal expected capacity for age and weight, 50% of the cases reached or exceeded theoretical capacity while the rest reached 63% to 89% (mean 76%). Long-term complications included persistent reflux in 1 case, deterioration of bladder function without clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty.

Although increase in bladder capacity is not always optimal with the use of a distal dilated ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval with a low complication rate in the long term, thus avoiding use of a piece of gut or stomach to perform bladder augmentation in nearly all patients.