Symptomatic refluxing distal ureteral stumps after nephroureterectomy and heminephroureterectomy. What should we do?

We hypothesize that residual ureteral stumps following nephroureterectomy (NU) or heminephroureterectomy (HNU) are associated with an increased risk of urinary tract infection (UTI) that is decreased by distal ureterectomy.

We performed a retrospective review of 71 patients who underwent NU or HNU for reflux into a nonfunctioning system between 1990 and 2003. The indications for all renal surgery included recurrent UTIs in 44 patients, hypertension in 8 and a combination of these conditions in 19. Voiding cystourethrogram and urine cultures were performed in all patients with recurrent symptomatic UTIs.

Followup in all 71 patients averaged 52 months. A total of 11 patients who underwent laparoscopic NU or HNU to the hiatus of the bladder were excluded because they did not have a ureteral remnant. The remaining 60 patients all underwent an open procedure. Of these patients 32 (53%) had refluxing distal ureteral remnants. Six of these 32 patients with refluxing stumps (19%), all girls, became symptomatic during followup. Symptomatic UTIs recurred in these 6 patients an average of 12 times per year (range 8 to 21), which significantly decreased after distal ureterectomy.

If surgery is indicated in patients with reflux into a poorly functioning system, we recommend NU or HNU to the level of the bladder hiatus. If a symptomatic ureteral remnant is present, then distal ureterectomy decreases the rate of symptomatic UTIs in these patients. Laparoscopic distal ureterectomy is a viable surgical technique for this patient population.