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Journal of Pediatric Urology (2015) xx, 1.e1e1.e4
Department of Pediatric
Urology, Sri Ramachandra
Medical College and Research
Institute, Porur, Chennai
600116, India
Correspondence to: R. Babu,
Pediatric Urology Unit, Sri
Ramachandra Medical College
and Research Institute, Porur,
Chennai 600116, India
drrameshbabu1@gmail.com
(R. Babu)
Keywords
Megaureter; Reimplantation;
Hydronephrosis; Children
Received 23 June 2015
Accepted 23 August 2015
Available online xxx
http://dx.doi.org/10.1016/j.jpurol.2015.08.017
1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Please cite this article in press as: Babu R, ‘Mini reimplantation’ for the management of primary obstructed megaureter, Journal of
Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.08.017
‘Mini reimplantation’ for the
management of primary obstructed
megaureter
Ramesh Babu
Summary
Introduction
The management of primary obstructed megaureter
(POM) ranges from temporary double-J stenting to
conventional ureteric reimplantation with tapering.
Of late, several authors have favored refluxing
reimplantation. In the present study the outcomes
of ‘mini reimplantation’, where no tapering or
advancement of the ureter was performed, have
been analyzed.
Methods
Records of all children (n Z 28) who underwent
reimplantation for POM from 2004 to 2014 were
retrospectively analyzed. During the initial 5 years,
a Cohen’s reimplantation with excisional tapering
was performed (Group 1, n Z 15). Due to compli-
cations, the technique was modified in the second 5
years (Group 2, n Z 13). In this group, after opening
the bladder, the distal narrow segment and grossly
dilated POM (around 3e5 cm) were excised (Figure).
After closing the detrusor behind the ureter, the
ureter was reimplanted again at the original position
without tapering or advancement. Bladder mucosa
was closed cranial to the new ureteric orifice,
providing a ureter:tunnel ratio of 1:2 (mini reim-
plantation). All patients underwent repeat ultra-
sonogram and MAG3 renogram, with indirect at 6
months and 1 year after stent removal to exclude
obstruction/vesicoureteral reflux (VUR).
Results
In Group 1, a significantly higher proportion
(P Z 0.04) of patients (5/15) had to undergo repeat
procedures for complications, compared with none
in Group 2. In Group 1, there were two redo reim-
plants for recurrent obstructions; two nephrec-
tomies for non-functioning kidneys; and one
ureterostomy for pyonephrosis. Postoperative Grade
2e3 VUR was encountered in 3/15 patients in Group
1, and 2/13 patients in Group 2. These patients
could be managed with antibiotic prophylaxis and no
intervention was required.
Discussion
Conventional management of POM involved initial
cutaneous ureterostomy, followed by reimplantation
with tapering of the ureter. Megaureter reimplan-
tation with and without tapering has been reported
to have no significant difference in outcomes be-
tween them. To avoid a potentially difficult opera-
tion in a small infant bladder, a refluxing
reimplantation has been proposed; however, there is
a high re-operation rate following this technique.
The author feels that the reported technique is
superior to the refluxing reimplantation, as there is
no need for re-operation. The limitations of this
study were the small numbers and short follow-up.
However, the proposed ‘mini reimplantation’ with
no tapering or advancement had good success rates
in this small series. Further larger studies are
required to support or negate the usefulness of this
technique.
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1.e2
Figure (a) Distal POM excised; (b) detrusor closed behind; (c) the ureter reimplanted; (d) mucosa closed over.
Introduction
Primary obstructed megaureter (POM) is diagnosed in the
presence of hydroureteronephrosis on ultrasonogram, stasis
with decreasing differential renal function (DRF) on nuclear
renogram, and absence of VUR on VCUG. The management
options include: temporary double-J stenting [1]; endo-
scopic dilatation/ureterotomy; cutaneous ureterostomy
and excision of distal adynamic segment followed by
tapering of the ureter and reimplantation [2]. Classical
reimplantation can be extremely difficult in a small infant
bladder, and of late, several authors have favored refluxing
reimplantation [2e4]. In the present study, the outcomes of
classical tapered Cohen’s reimplantation were compared
with ‘mini reimplantation’, where no tapering or
advancement of the ureter was performed.
Methods
Records of all children (n Z 28) who underwent reimplan-
tation for primary obstructed megaureter (POM) between
2004 and 2014 were retrospectively analyzed. Primary
obstructed megaureter was diagnosed after confirming
absence of VUR or PUV on VCUG, and the presence of
hydroureteronephrosis with megaureter (diameter
>10 mm) on ultrasonogram, and stasis on nuclear reno-
gram. All patients were conservatively managed up to the
age of 10 months with antibiotic prophylaxis, and rotation
of antimicrobial agent in those with recurrent UTI. In-
dications for surgery included >10% drop in DRF and break-
through infections. Those who underwent ureterostomy or
initial stenting due to intractable urosepsis were excluded.
During the initial 5 years, a classical Cohen’s reimplan-
tation with excisional tapering was performed (Group 1,
n Z 15). Due to complications in these patients, the
technique was modified in the second 5 years (Group 2,
n Z 13). In this group, after opening the bladder, the POM
Please cite this article in press as: Babu R, ‘Mini reimplantation’ for the management of primary obstructed megaureter, Journal of
Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.08.017
R. Babu
was dissected out, and the distal narrow segment and
grossly dilated distal segment (around 3e5 cm) were
excised (Fig. 1). A backing was provided to the ureter by
closing the detrusor behind the ureter. No attempt at
tapering was performed; the ureter was reimplanted again
at the original position without crossing or advancement
using 6-0 poly glycolic acid interrupted sutures; bladder
mucosa was closed cranial to the new ureteric orifice,
providing a ureter:tunnel ratio of 1:2. A double-J stent was
kept in all cases and removed after 6 weeks. This procedure
was called the ‘mini reimplantation’, as the tunnel length
was minimal.
All patients underwent repeat ultrasonogram and MAG3
renogram with indirect cystogram at 3 months, 6 months
and 1 year after stent removal to exclude obstruction/VUR.
The final outcomes were compared between the groups, and
the results were expressed as mean or percentage. After
confirming normal distribution of data, statistical analysis
was performed by Student’s t-test and Fishers exact test.
Results
Table 1 shows the characteristics and outcomes between
the groups. Male/left side preponderance was noted in both
of the groups, with no significant difference between mode
of presentation or age at surgery. None of the patients in
this group had bilateral POM. There was no significant dif-
ference between the mean initial/final DRF between the
groups.
In Group 1, a significantly higher proportion (P Z 0.04)
of patients (5/15) underwent repeat procedures for com-
plications, compared with none in Group 2. In Group 1, two
patients underwent redo reimplantation for recurrent py-
elonephritis with obstruction; two patients underwent ne-
phrectomy for persistent obstruction with severe
impairment of function (DRF 7% in one, 8% in the other);
one patient underwent ureterostomy for pyonephrosis.
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Management of primary obstructed megaureter 1.e3

Figure 1 Operative steps with illustration of ‘mini reimplantation’. (a) After opening the bladder, the POM is dissected out; the
distal narrow segment and grossly dilated distal segment (around 3e5 cm) are excised; (b) a backing is provided to the ureter by
closing the detrusor behind the ureter; (c) the ureter is reimplanted again at the original position without tapering or advancement
using 6-0 poly glycolic acid interrupted sutures; (d) the bladder mucosa is closed cranial to the new ureteric orifice, providing a
modest ureter:tunnel ratio of 1:2.

Postoperative Grade 2e3 VUR was encountered in 3/15
patients in Group 1 and 2/13 patients in Group 2. These
patients could be managed with antibiotic prophylaxis, and
no intervention was required.
Discussion
Conventional management of POM involved initial cuta-
neous ureterostomy, followed by excision of the adynamic
distal ureteric segment and reimplantation of the ureter
[1,2]. For preventing VUR during reimplantation, Paquin
proposed a tunnel length of five times the ureteric diam-
eter; however, achieving this in an infant bladder can be
extremely difficult. To enable this, multiple techniques
have been proposed to taper the megaureter: Starr plica-
tion, Kalcinsky plication, Hendren’s excisional tapering and
psoas hitch [2].
A tapered distal ureter in a long tunnel could theoreti-
cally provide a stiff segment. An associated dilated upper
tract could lead to stasis, recurrent infections, and loss of
renal function in the long run. In the present study, in

Table 1 The characteristics and outcomes between the groups DRF, differential renal function.
Group 1 (n Z 15) Group 2 (n Z 13) P-value
Tapered Cohen’s Untapered ‘mini
reimplantation reimplantation’
Antenatal diagnosis 12 11 1
Male:Female 11:4 10:3 1
Left:Right 13:2 9:4 0.3
Mean age (SD) [range] at surgery in months 13 (3.5) 14 (2.5) 0.39
[10e22] [10e19]
Mean % DRF (SD) [range] at presentation 33 (4.5) 36 (5.5) 0.12
[22e40] [28e36]
Mean % DRF (SD) [range] before surgery 28 (5.5) 31 (5.0) 0.14
[18e35] [24e40]
Mean % DRF (SD) [range] at 1-year follow-up 24 (7.5) 26 (5.5) 0.43
[7e31] [18e36]
VUR at 1-year follow-up 3 2 1
Re-operations 5 (2 redo reimplantation; 0 0.04
2 nephrectomies; 1 ureterostomy)

Please cite this article in press as: Babu R, ‘Mini reimplantation’ for the management of primary obstructed megaureter, Journal of
Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.08.017
 + MODEL
1.e4
Group 1, multiple complications were encountered with
tapered Cohen’s reimplantation. The authors felt that the
tapered segment with a stiff distal segment and a long
submucosal tunnel could be impeding drainage in mega-
ureters. This is usually not a problem in children with iso-
lated VUR, as the ureters often empty well, overcoming the
1:4e5 submucosal tunnel.
Ben Meir [5] compared the outcomes of megaureter
reimplantation with and without tapering, and found no
significant difference in outcomes between the groups.
Studies of primary VUR have shown that treatment does not
substantially alter the course of the condition. One infer-
ence from this is that isolated reflux does not lead to renal
injury. Extrapolating this concept leads to the conclusion
that it is unnecessary to obtain a non-refluxing anastomosis
when correcting a megaureter.
To avoid a potentially difficult reimplantation, refluxing
reimplantation was proposed by Lee, and further favored
by several authors [2e4]. However, this technique involved
extravesical anastomosis of the proximal end of the ureter
to the lateral wall of the bladder as a temporary internal
diversion. Kaefer [4] reported the outcomes of refluxing
reimplantation, and 14 out of 16 patients required re-
operations. De Jong [6] did not favor this intervention
when an obstructed megaureter was converted into a
refluxing one. Perovic [7] described an extravesical detru-
sor tunneling technique for reimplantation in megaureters.
In the present technique, ‘mini reimplantation’ of the
bladder is approached intravesically, the detrusor is
repaired behind the ureter, and the ureteric orifice is
placed at native position without tapering or advancement.
The bladder mucosa is closed cranial to the ureteric
opening, which sandwiches the ureter between the mucosa
and repaired detrusor, and provides a modest tunnel length
of twice the ureter diameter. Although this technique in-
volves opening the bladder, it is easier to perform than a
classical Cohen’s reimplantation, as there is no cross
trigonal tunnel. In cases of persistent VUR and pyelone-
phritis following ‘mini-reimplantation’, an extravesical
modified-Leich Gregoir technique or even a repeat Cohen’s
reimplantation is feasible. However, in the case of refluxing
reimplantation proposed by Lee, a repeat reimplantation
could be difficult, as there could be shortage of ureteric
length following extravesical disconnection of the distal
ureteric stump.
In the present study, a small proportion of children who
underwent ‘mini reimplantation’ had persistent VUR;
however, none encountered recurrent pyelonephritis
Please cite this article in press as: Babu R, ‘Mini reimplantation’ for the management of primary obstructed megaureter, Journal of
Pediatric Urology (2015), http://dx.doi.org/10.1016/j.jpurol.2015.08.017
R. Babu
during the follow-up. The consequences of persistent VUR
in the long run, particularly in female children, warrant
further study. Although this technique has not been per-
formed in bilateral POM, it should be technically possible.
Kim has reported a similar technique [8] with good success
rates. Although this has not been performed in infants <10
months of age, it should be technically feasible.
The limitations of this study were the small numbers and
short follow-up. However, the proposed ‘mini reimplanta-
tion’ for POM had good success rates, with none requiring
re-operation, as reported with refluxing reimplantation.
Further larger studies are required to support or negate the
usefulness of this technique.
Conflict of interest/Funding
None.
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