+ MODEL
Journal of Pediatric Urology (2015) xx, 1.e1e1.e6
Department of Urology,
Chongqing Children’s Hospital,
Chongqing Medical University,
Chongqing, China
Correspondence to: D.-W. He,
Department of Urology,
Children’s Hospital of
Chongqing Medical University,
136 Zhongshan Er Road,
Yuzhong District, Chongqing,
China
dw.he@163.com (D.-W. He)
Keywords
Ureter; Laparoscopy;
Reimplantation
Received 13 August 2014
Accepted 23 March 2015
Available online xxx
http://dx.doi.org/10.1016/j.jpurol.2015.03.020
1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
Retrospective study to determine the
short-term outcomes of a modified
pneumovesical GlenneAnderson
procedure for treating primary
obstructing megaureter
Xing Liu, Jun-Hong Liu, De-Ying Zhang, Yi Hua, Tao Lin,
Guang-Hui Wei, Da-Wei He
Summary
Introduction
Primary obstructive ureter (POM) is an upper urinary tract
malformation in children. Transvesicoscopic ureteral reim-
plantation is increasingly being used as the first choice to
correct POM, replacing the open extravesical approach.
Although several procedures have been reported, there is
no universally accepted technique for endoscopic ureteral
reimplantation.
Objective
To report on several modifications of the GlenneAnderson
ureteral advancement technique to make it suitable for a
laparoscopic pneumovesical approach to treatment of POM.
Patients and methods
From February 2006 to December 2013, 63 children with
POM, 45 male and 18 female (median age 4.2 years; range 2
monthse14 years), underwent modified transvesicoscopic
ureteral implantation surgery. The technique was modified
by repositioning of the hiatus proximally to afford greater
“tunnel” length, and use of a trough rather than a tunnel,
avoiding the challenges of more adherent mucosa in the
trigone. Ureter diameter was followed over a 12-month
period post surgery. Voiding cystourethrography (VCUG),
intravenous urogram (IVU), or radionuclide imaging were
conducted in patients who still had ureteral dilation at 6
months and 12 months after surgery.
Figure Transvesicoscopic ureteral reimplantation for an 11-month-old girl. After confirming the
locations of trocars (left), we began the operation with a 5-mm trocar as the midline camera port and
two 3-mm trocars as the working ports (right).
Results
The procedure was successfully performed in 62/63 patients.
The mean operating time was 105 min. Twelve months after
surgery 90% of ureters were considered cured and 10% were
considered improved. In patients who showed improvement
ureters, the ureter diameter was significantly reduced from
preoperative measurements as early as 1 month post surgery.
Discussion
The GlenneAnderson technique advances the ureteral
orifice distal to the trigone near the bladder neck and al-
lows relatively easy access to the upper urinary tract.
However, the submucosal tunnel produced is relatively
short, and the surgery is not recommended for patients
with a small trigone or megaureter because of anatomical
considerations. This study made two major modifications
to the traditional GlenneAnderson procedure: (1) the
bladder wall was incised superiorolaterally to move the
hiatus proximally along the course of the ureter and the
detrusor muscle was sutured to the seromuscular layer of
the ureter, and (2) a mucosal groove rather than tunnel
was used for advancement from the ureteral hiatus to the
bladder neck. This approach preserves conventional
endourologic access to the upper tracts; however, the
stabilizing distal stitch does leave the suture line in
proximity to the mucosal suture line, a theoretical disad-
vantage from the standpoint of ureterovesical fistula.
Conclusions
These preliminary results indicate that this modified
transvesicoscopic ureteral implantation is an effective
procedure with minimal morbidity.
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1.e2
Introduction
Primary obstructive ureter (POM) is an upper urinary tract
malformation in children, and has the potential to cause long-
term kidney damage and pyelonephritis [1]. POM occurs in
0.36 of 1000 to 1 of 1500 live births [1,2]. Treatment for POM is
generally a “watchful-waiting” approach and/or antibiotic
prophylaxis to prevent recurrent UTIs. However, 21e23% of
POM patients [1,2] will require surgical treatment for
breakthrough infections and worsening dilation of ureters.
Ureteral reimplantation has a high success rate, over 90%,
for effective treatment of urinary reflux [3]. However, there
is no universally accepted technique for endoscopic ureteral
reimplantation to treat POM and vesciouretal reflux (VUR).
Various surgical techniques have been reported, including
extravesical Lich-Gregoir technique [4], endoscopic trig-
onoplasty [5], Politano-Leadbetter technique [6], Glenn
eAnderson reimplantation, and the Cohen procedure. The
Cohen and GlenneAnderson reimplantation procedures are
the most widely accepted to correct POM or VUR [7e10]. In
the Cohen procedure, the ureter is rerouted so that it tunnels
across the trigone to exit the contralateral half of the
bladder. The Cohen procedure allows for ample bladder to be
used for the tunnel with very little in terms of anatomic lim-
itations in how far the tunnel can be extended. However,
altering the normal anatomical alignment of the ureter makes
retrograde access to the upper urinary tract difficult [11,12].
Furthermore, cross-trigonal dissection is more likely to
disturb the contralateral hemi-trigone and could result in a
higher rate of contralateral reflux [13]. In contrast, the
GlenneAnderson technique advances the ureteral orifice
distal to the trigone near the bladder neck and preserves the
normal course of the ureter. There is a reduced risk for ure-
teral kinking or obstruction with this technique [8], it mini-
mizes the impact on the hemi-trigone, and allows relatively
easy access to the upper urinary tract. In fact, minimally
invasive treatments for upper tract nephrolithiasis are more
successful after the GlenneAnderson surgery than after the
Cohen procedure [14]. An additional advantage is that the
muscular trigone would have to be considered an optimal
backing for the ureter in prevention of reflux. However, the
submucosal tunnel produced is relatively short, and the sur-
gery is not recommended for patients with a small trigone or
megaureter because of anatomical considerations [15].
Transvesicoscopic ureteral reimplantation is increasingly
replacing open extravesical approach in the field of pedi-
atric urology. Its potential benefits include reduction in
postoperative bladder spasms, decreased incisional blood
loss and pain, and improved cosmetics. Minimally invasive
procedures using a laparoscopic technique and CO2 insuf-
flation of the bladder (pneumovesicum) were introduced in
2005 [7]. Since then, there have been several advocates of
transvesical reimplantation for POM in children. Although
this technology has several advantages, it has never ach-
ieved widespread acceptance. Because of the extremely
high level of skill required to perform the operation, lapa-
roscopic techniques have been limited to a few select pe-
diatric surgeries and centers. Herein, we describe a
modified pneumovesical GlenneAnderson technique that
achieves adequate submucosal length of the ureter to treat
POM in children.
Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
X. Liu et al.
Materials and methods
Patient enrollment and characteristics
Sixty-three patients (45 male, 18 female) ranging in age
from 2 months to 14 years (median age 4.2 years) were
recruited at our hospital from February 2006 to December
2013. Preoperatively, patients were evaluated with at least
two urinary system ultrasounds, VCUG, and either an IVP or
radionucleotide (DMSA) study. Indications for surgery
included recurrent urinary tract infections (9 cases),
deterioration of split renal function (46 cases), and signif-
icant worsening dilation of ureters (24 cases).
Informed consent and treatment options were discussed
with parents and, if possible, the patients. The patients
underwent the modified pneumovesical GlenneAnderson
ureteral reimplantation to treat POM. Six cases were
bilateral and 57 were unilateral. The mean diameter of the
megaureter was 12 mm (range 8e22 mm). Patients with
dilating vesicoureteral reflux were not included in this
series.
Surgical procedure
The initial steps of this operation have been reported pre-
viously by Yeung et al. [7]. Briefly, the patient was placed in
the dorsal lithotomy position. A 5-mm trocar was used for
the midline camera port and two 5-mm trocars or 3-mm
trocars were used for the working ports. The operative
time was defined as the time from the start of cystoscopy to
skin closure. The bladder was drained by inserting a ure-
thral catheter, and CO2 insufflation to 10e12 mm Hg was
started. The ureteral orifice was circumscribed using hook
electrocautery. The ureter was mobilized with a hook using
a blunt grasper to retract the ureteral end, taking care not
to damage the main blood supply or the proximity of the vas
deferens in boys.
The following steps of the operation were our modifi-
cations. First, we made a 1e1.5 cm incision to the bladder
wall proximal to the original ureteral orifice with a hook
(Fig. 1B). Once adequate ureteral length was obtained, the
mobilized ureter was drawn cephalad to expose the
detrusor defect. The detrusor defect in the ureteral hiatus
and the seromuscular layer of the ureter were closed with
one interrupted 5e0 absorbable suture (Fig. 1C). An addi-
tional one to two interrupted sutures were used to close the
detrusor defect entirely. Second, we developed a groove of
musculature from the hiatus to near the bladder neck using
hook electrocautery. The length of hiatus to distal aspect of
the mucosal groove was equal to approximately five times
the ureteral diameter (Fig. 1D,E). The terminal portion of
the ureter was amputated to a suitable length where
appropriate. The tip of the neoureteral opening was su-
tured to the end of the groove to better fix the ureter for
tapering (seven patients) if needed. Excisional ureteral
tapering and ureterovesical anastomosis were performed
using 5e0 absorbable interrupted sutures, taking care to
reserve and not to damage the main longitudinal blood
supply as much as possible. The mucosal layer was closed
over the muscular groove with 5e0 absorbable running su-
 + MODEL
Primary obstructing megaureter 1.e3

Figure 1 Surgical procedure steps. (A) Prior to mobilizing the ureter. a-indicates the proximal point of the hiatus; b-indicates the
original ureteral orifice; c-indicates the new ureteral opening at the trigone. (B) During the ureter mobilization. (C) The hiatus is
closed distal to the point of entry of the seromuscular layer of the ureter indicated by d. (D) The length of the groove (intramural
ureter) and (E) the width of the ureter are measured using a ureteral catheter. (F) Postoperative view.

tures (Fig. 1F). The use of 6Fr stenting ureteral catheters is
optional for this surgery, but catheters were placed for all
the patients that required ureteral tapering. A transure-
thral Foley was inserted at the end of operation.
The stenting catheter was removed 6 days post surgery
and the patient was discharged the next day. The preop-
erative and postoperative anatomy is shown in Fig. 2.
ultrasonography was performed three times post-
operatively after 1 month, 6 months, and 12 months. The
diameter of the ureter was measured at the midureter level
before and after voiding to determine its dilation. VCUG,
DMSA scan, or IVU was conducted in patients who still had
ureteral dilation or no change at 6 months and 12 months
after surgery.

Follow-up procedure Statistical analysis

A successful result in all cases was defined as no detection Statistical analysis was conducted using SPSS13.0 (SPSS
of VUR or VUJ obstruction throughout the follow-up. Renal Inc., Chicago, IL, USA). Univariate analysis between mean

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
1.e4 X. Liu et al.

Figure 2 Sagittal views preoperation (left) and postoperation (right) of the vesicoureteral junction obstruction. The green lines
in left figure indicate the range of incisions. a, b, c, and d indicate the same points as in Fig. 1.

values was performed using a two-tailed t test for normally surgery was monitored over a 12-month period. The ma-
distributed data; p < 0.05 was considered statistically jority of the enrolled patients participated in follow-up
significant. procedures, although participation decreased over time
from 58 (93%) 1 month post surgery to 49 (79%) at 12 months
post surgery (Table 2). The surgical outcomes were quali-
Ethical approval
tatively described as “cured” Z no ureter found or diam-
eter  5 mm tested by ultrasonography;
Ethical approval was not required for this work. “improved” Z reduced dilation from preoperative mea-
sures but still present; “aggravated” Z increased dilation;
Results or “no change.” At 1 month post surgery, 38 (59%) ureters
were considered cured and 26 (41%) showed improvement
(Table 2). The percentage of ureters that were considered
The mean operating time for the total cohort was 105 min
cured increased at 6 months post surgery (44; 78%) and 12
(range 70e195 min). Patients who required unilateral sur-
months post surgery (48; 90%). There was a simultaneous
gery had a mean operating time of 92 min (range
decrease in the percentage of patients considered
70e170 min), bilateral operations required a mean of
175 min (range 110e195 min). To evaluate the learning
curve for the operating surgeon, the operative time was
compared between the first 15 unilateral patients and the
following 41 unilateral patients. One patient was converted Table 1 Demographic and intraoperative data.
to an open surgery because of displacement of the port, Age (median) 4.2 years
which resulted in gas leakage into the extravesical space. (range 2 monthse14 years)
This patient was excluded from the operative time analysis. Gender 18 female, 45 male
The surgeon required significantly longer to complete the Operative time (mins)
procedure in the first 15 unilateral patients Unilat ureter Mean 92 (range 70e170)
(113.2  38.7 min) than the following 41 unilateral patients Bilat ureters Mean 175 (range 110e195),
(80.6  19.2 min; p < 0.01, two-tailed t test) (Table 1). completed simultaneously
Blood loss was minimal in all cases. None of the patients First 15 unilat ureter Mean 113 (range 68e145)
developed postoperative wound infections. Of note, Last 41 unilat ureter Mean 80 (range 65e110)
bladder spasms were minimal, especially after removal of No. conversion to open 1/63 (1.6)
the urinary catheter. Pain medication, NSAIDs, was pre- surgery/total No. (%)
scribed as and when needed. No. laparoscopic 62/63 (98.4)
To evaluate the success of the modified laparoscopic success/total No. (%)
GlenneAnderson procedure, the clinical outcome of

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020

Primary obstructing megaureter
Table 2 Postoperative ureteral outcomes and comparison of ureteral diameter of improved ureters.
No. patients
No. cured ureters (%)
No. improved ureters (%)
Preoperative diameter (Mean  SD cm)
Postoperative diameter (Mean  SD cm)
p value (two-tailed t test)
No. no change/aggravated ureters
No. VCUG (reflux/tested)
No. DMSA scan or IVU (obstruction/tested)
Cured: No ureter was found or ureteral diameter  5 mm tested by ultrasonography.
Improved: Ureteral diameter was less than the postoperative value.
Aggravated: Increased ureteral diameter.
improved (Table 2). At no time post surgery did we detect
aggravation to the ureter or no change.
We also quantified the ureter diameter over the 12-
month follow-up period in only those patients who showed
improvement, but were not considered cured. As early as 1
month post surgery, the diameter of the ureter was signif-
icantly decreased from 1.29  0.30 cm prior to surgery to
0.65  0.04 cm post surgery (p Z 0.030). Ureter diameter
was also significantly reduced 6 months and 12 months post
surgery. In addition, where no postoperative VUR was
detected using VCUG, DMSA scans or IVU were also obtained
and provided evidence of the resolution of the obstruction
in these patients (Table 2).
Discussion
The GlenneAnderson procedure to treat VUR was first re-
ported in 1967 by Glenn and Anderson [15]. In the original
technique, the distal ureter was mobilized for 2e3 cm and
the configuration of the ureterovesical hiatus was main-
tained, which avoided enlargement of this hiatus. The
ureteral orifice was then advanced distally toward the
trigone near the bladder neck to preserve the normal
course of the ureter. Glenn and Anderson realized that the
length of the submucosal tunnel created was too short,
prohibiting the use of this procedure in infants and pa-
tients. In 1978, they reported their modified technique [8].
In the refined technique they deliberately enlarged the
hiatus to permit the ureter to move further and diminish
the necessary tunnel length distally on the trigone. They
believed that this modified technique also could be used to
correct ureterovesical junction obstructions. Retaining the
principles of adequate submucosal ureteral length and
preserving the normal course of the ureter, we have further
modified the GlenneAnderson procedure for trans-
vesicoscopic conditions or for open surgery as well.
In our procedure, the primary modification was creating
a ureteral hiatus that involved the proximal and distal sides
of the ureteral orifice. A submucosal tunnel five times the
length of the ureteral diameter is optimal for ureteral
reimplantation [16]. To achieve this, the bladder wall was
incised proximal to the original ureteral orifice for
1e1.5 cm as the ureter was being mobilized. The bladder
Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
+ MODEL
1.e5
1 month 6 months 12 months
58 52 49
38 (59%) 44 (78%) 48 (90%)
26 (41%) 12 (22%) 5 (10%)
1.29  0.30 1.18  0.42 1.43  0.33
0.65  0.04 0.72  0.18 0.79  0.15
0.030 0.015 0.005
0 0 0
e 0/9 0/5
e 0/8 0/4
musculature of the enlarged hiatus was then closed distal
to the point of entry of the seromuscular layer of the ure-
ter. As a result, the ureter was displaced to the proximal
portion of the hiatus and anchored on the bladder wall,
facilitating enough intramural ureteral length for the next
step. Another important modification in the laparoscopic
procedure is the creation of a groove, instead of a tunnel,
from the ureteral hiatus to the trigone. The muscle fibers of
the trigone are more compact than those of the detrusor,
and adhere firmly to the overlying mucosal layer [17]. His-
tological differences make it more difficult to create the
transverse submucosal tunnel in the trigone than in the
bladder, particularly under pneumovesical conditions.
In our series of operations, we achieved stable operative
skill level after 15 cases based on the time needed for
successful completion. Important skills are necessary for
adequate performance of this surgery. First, suturing the
tip of the neoureteral opening to the end of the groove
provides stability for the ureter during tapering. To girls, a
blunt grasper may be introduced through urethra to clamp
the ureteral end. Second, to avoid high tension across the
groove, the bladder insufflation pressure should be down-
regulated and the submucous layer may be slightly mobi-
lized before closing the mucosal layer with running sutures.
However, the stabilizing distal stitch does leave the suture
line in proximity to the mucosal suture line, a theoretical
disadvantage from the standpoint of ureterovesical fistula.
We did not find ureterovesical fistula in seven patients in
this study, but close attention should be paid to patients in
similar situations.
It has been suggested that pneumovesicoscopic trans-
trigonal ureteric reimplantation is not appropriate for
children under 6 months of age [18]. However, in our series,
five infants between 2 and 3 months of age were surgically
treated, recovered uneventfully, and remain well. This
experience leads us to believe that skilled surgeons could
use this modified procedure in younger patients with small
bladders. In our series, although the patients were all POM,
the surgical process and operating time were similar when
treating VUR and POM.
In the present study, we demonstrated that a modified
GlenneAnderson surgical technique resulted in favorable
outcomes for POM patients. Although there was no persis-
tent hydroureternephrosis observed, postoperative VUR or
 + MODEL
1.e6
ureteral stricture might occur later, with implications for
relevance of patients to the study and short-term follow-
up. We need to continue to explore the limits of our surgical
expertise.
Conflict of interest
None.
Funding
None.
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GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
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